ArticleLiterature Review

Relationship of Acetabular Dysplasia and Femoroacetabular Impingement to Hip Osteoarthritis: A Focused Review

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Abstract

Hip osteoarthritis (OA) leads to significant functional limitations and economic burden. If modifiable risk factors for hip OA are identified, it may be possible to implement preventative measures. Bony abnormalities associated with acetabular dysplasia (AD) and femoroacetabular impingement have been recently implicated as risk factors for hip OA. The purpose of this focused review is to summarize the available evidence describing the relationship between bony abnormalities and hip OA. A librarian-assisted database search with PubMed, Embase, and CENTRAL was performed. Relevant articles were identified and assessed for inclusion criteria. The authors reviewed cohort and case-control studies that reported on the association between abnormal hip morphology and hip OA. The available literature suggests that an association exists between bony abnormalities found in AD and femoroacetabular impingement and hip OA, and preliminary evidence suggests that AD is a risk factor for OA; however, these conclusions are based on limited evidence. Prospective, longitudinal studies are needed to confirm the causal relationship between abnormal hip morphology and the future development of hip OA.

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... This concept is well recognized as a factor in the development of future hip osteoarthritis (OA). 10,15 Multiple studies have shown that the athletic population appears to have a higher prevalence of FAI, specifically cam-type deformities, than do nonathletes. 1,6,11,17,21 The demands of the dance athlete are such that they are expected to attain supraphysiologic hip joint range of motion to meet the requirements of both simple and advanced maneuvers. ...
... Single sport participation >1 sport listed (n=167) issues such as OA in the long term. 10,15 To date, the majority of studies on FAI have focused on male athletes and the increased prevalence of cam-type deformities in sports such as soccer and ice hockey. 1,5,11,21 Data on the female athlete with FAI are lacking, specifically on the young female dance athlete. ...
... The overall number of subjects was relatively low (N ¼ 56) but was comparable to other contemporary studies. 15,21 In our study, 1 reviewer was used when determining radiographic angles, and while some studies have shown high interobserver reliability for measurement of radiographic findings of FAI, 3 others have found that accuracy does not necessarily increase with multiple reviewers. 23 The reviewer was blinded to the underlying diagnosis regarding type of FAI. ...
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Background Femoroacetabular impingement (FAI) is a painful and limiting condition of the hip that is often seen in young athletes. Previous studies have reported a higher prevalence of this disorder in male athletes, but data on the structural morphology of adolescent and young adult female athletes, specifically those involved in dance, are lacking. Purpose (1) To investigate the radiographic morphology of FAI deformities in adolescent and young adult female single-sport dance and nondance athletes and (2) to examine the differences in the radiographic findings between these 2 groups. Study Design Cross-sectional study; Level of evidence, 3. Methods A retrospective chart review of 56 female single-sport athletes 10 to 21 years of age with a diagnosis of FAI within a single-sports medicine division of a pediatric academic medical center was performed. Acetabular index (AI), lateral center-edge angle (LCEA), crossover sign, and ischial spine sign were measured bilaterally on anteroposterior radiographs; alpha angle (AA) was measured on lateral films, and anterior center-edge angle (ACEA) was measured on false-profile films. Independent t tests and Mann-Whitney U tests were used to compare mean angle measurements between dance and nondance athletes. Dichotomized categorical variables and crossover and ischial spine signs were analyzed between dance and nondance athletes by applying a chi-square test. Statistical significance was set as P < .05 a priori. Results Significant differences in angle measurements were noted. AA was significantly lower in the dancers compared with the nondance athlete group (49.5° ± 6.0° vs 53.9° ± 7.3°, P = .001). The LCEA and ACEA of dance athletes were significantly greater compared with nondance athletes (33.8° ± 6.7° vs 30.9° ± 5.8° [P = .016] and 36.0° ± 8.1° vs 32.3° ± 7.0° [P = .035], respectively). No significant difference in AI was seen between the 2 cohorts (5.0° ± 4.0° for dancers vs 5.9° ± 3.4° for nondancers, P = .195). Conclusion Significant differences existed in the radiographic bony morphology of young female single-sport dance athletes compared with nondance athletes with FAI. In dance athletes, symptoms were seen in the setting of normal bony morphology.
... Developmental dysplasia of the hip (DDH) and femoroacetabular impingement syndrome (FAIS) are two common hip pathologies that may lead to early onset of hip pain [1][2][3][4]. High activity levels are recognized as a common factor among young individuals diagnosed with FAIS [1][2][3]5]. Similarly, risk factors such as increased activity level and severity of DDH, have been shown to correlate with a younger age of presentation for periacetabular osteotomy (PAO) in symptomatic DDH [6]. ...
... These variables were selected based on the results of previously published findings that have been associated with symptomatic DDH and FAIS. The pool of potential variables selected included: Sex, BMI (> 30 kg/m2 vs. ≤30 kg/ m2) [6] history of hip surgery [6], laterality [6], Tonnis grade [20,21], Tonnis angle [21], anterior center edge angle [6,20,21], lateral center edge angle [5,15,16], alpha Dunn angle [20,21], alpha frog angle [5,16], International Hip Outcome Tool (iHOT) total score [22], Hip Outcome Score [22,23], the UCLA activity score [6,23], Pain Catastrophizing Scale (PCS) Total score [7,8,24], SF-12 Physical Functioning (activity level) subscale score, SF-12 ...
... These variables were selected based on the results of previously published findings that have been associated with symptomatic DDH and FAIS. The pool of potential variables selected included: Sex, BMI (> 30 kg/m2 vs. ≤30 kg/ m2) [6] history of hip surgery [6], laterality [6], Tonnis grade [20,21], Tonnis angle [21], anterior center edge angle [6,20,21], lateral center edge angle [5,15,16], alpha Dunn angle [20,21], alpha frog angle [5,16], International Hip Outcome Tool (iHOT) total score [22], Hip Outcome Score [22,23], the UCLA activity score [6,23], Pain Catastrophizing Scale (PCS) Total score [7,8,24], SF-12 Physical Functioning (activity level) subscale score, SF-12 ...
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Background: Age of onset in symptomatic developmental dysplasia of the hip (DDH) and femoroacetabular impingement syndrome (FAIS) varies. The purpose of this study was to investigate whether psychological factors, radiographic, and clinical variables were related to age of onset of hip pain in DDH and FAIS. Methods: We collected demographic, clinical, and radiographic data on 56 DDH and 84 FAIS patients. Each was diagnosed based on radiographic findings and clinical history. Age of onset was operationalized by subtracting patient reported duration of symptoms from patient age at presentation. Pain catastrophizing (PCS) and depression were assessed with the pain catastrophizing scale and hospital anxiety and depression scale (HADS), respectively. Multiple linear regression modeling, with Lasso variable selection, was implemented. Results: Pain catastrophizing, anxiety, and depression were not significantly related to age of DDH onset (p-values > 0.27) or age of FAIS onset (p-values > 0.29). LASSO-penalized linear regression revealed alpha Dunn angle, Tonnis grade, prior hip surgery, WOMAC pain score, and iHOT total score were associated with age of onset in FAIS (Adjusted R2 = 0.3099). Lateral center edge angle (LCEA), alpha frog angle, Tonnis grade, SF12 physical functioning, and body mass index (BMI) were associated with age of DDH onset (Adjusted R2 = 0.3578). Conclusions: Psychological factors, as measured by PCS and HADS, were not associated with age of onset in DDH or FAIS. Functional impairment as measured by WOMAC pain and impaired active lifestyle as measured by iHOT were found to affect age of FAIS onset. For DDH, impaired physical functioning and increasing BMI were found to be associated with age of onset. Severity of the disease, as measured radiographically by LCEA and alpha Dunn angle, was also found to be associated with earlier age of onset in DDH and FAIS, respectively. A patient's radiographic severity may have more of a relationship to the onset of pain than physiologic factors.
... Excessive acetabular coverage typically exhibits itself as partial or complete osseous metaplasia. 3 This can lead to increased contact and friction between the femoral head-neck junction and acetabular rim. This can lead to damage of the underlying acetabular cartilage resulting in labral tears and eventually arthritis of the hip joint. ...
... This repeated contact between the enlarged acetabular rim and proximal femur has been termed pincer type femoro acetabular impingement (FAI). 3 On CT, acetabular coverage can be measured by using the anterior and posterior acetabular sector angles, AASA and PASA respectively (Fig. 1). 4 On the axial CT, at the slice of maximum sphericity of the femoral heads, a line is formed by joining the centre of the femoral heads. AASA is the angle between this and line joining the anterior edge of the anterior column of acetabulum and centre of femoral head and PASA is angle between the line joining the centre of head to posterior edge of the posterior column of acetabulum with the line joining the centre of both femoral heads. ...
Article
Purpose: To evaluate the correlation between trochlear dysplasia and acetabular coverage. Materials and methods: 109 retrospective CT studies referred from the young adult knee clinic were independently reviewed by two observers. Anterior acetabular (AASA) and posterior acetabular (PASA) sector angles were calculated bilaterally on axial CT. Trochlear dysplasia was graded using the Dejour classification (A-D). ANOVA test was used. Results: Dejour types A, B and D trochlear dysplasia were associated with a significantly increased AASA (P value = 0.0011). Conclusion: Our results demonstrate a significant relationship between trochlear dysplasia and anterior acetabular coverage, as measured by AASA.
... Acetabular dysplasia (AD) is a common cause of hip pain in adolescents. Furthermore, compared to a normally shaped acetabulum, AD results in increased contact stresses due to the smaller weight bearing surface (1). These increased contact stresses are thought to contribute to damage to the labrum and cartilage, thus, increasing the chance of developing osteoarthritis later in life (1)(2)(3). ...
... Furthermore, compared to a normally shaped acetabulum, AD results in increased contact stresses due to the smaller weight bearing surface (1). These increased contact stresses are thought to contribute to damage to the labrum and cartilage, thus, increasing the chance of developing osteoarthritis later in life (1)(2)(3). In order to prevent this long term sequela, osteotomies have been used to treat AD (4). ...
Article
Acetabular dysplasia (AD) is a common cause of hip pain in adolescents. Furthermore, compared to a normally shaped acetabulum, AD results in increased contact stresses due to the smaller weight bearing surface (1). These increased contact stresses are thought to contribute to damage to the labrum and cartilage, thus, increasing the chance of developing osteoarthritis later in life (1-3). In order to prevent this long term sequela, osteotomies have been used to treat AD (4). Two of these osteotomies include the Salter (5) innominate osteotomy and the Pemberton (6) pericapsular osteotomy (7,8). The salter osteotomy consists of stabilizing the reduced hip in the position of function by averting the acetabulum, whereas, the pericapsular osteotomy involves reshaping the dysplastic acetabulum. These two procedures have demonstrated good long-term results (8); however, there is the potential for overcorrection leading to iatrogenic pincer femoroacetabular impingement (FAI). With the development of FAI, some have proposed that this will lead to compression and shear stresses between the labrum and the cartilage, eventually also leading to articular degeneration and ultimately global hip OA (1). This question outlines the importance in publishing mid to long-term results following osteotomies to treat AD.
... 2,[5][6][7][8][9][10][11] Early treatment of dysplastic hips prevents premature hip osteoarthritis 2,3 and DDH-related mechanical dysfunction. [6][7][8][12][13][14] The most common non-surgical treatment of DDH in infants whose hips are not yet fully ossified is by Pavlik harness (PH). 2,3 Successful PH treatment causes spontaneous reduction of a subluxed/dislocated hip into correct anatomic position and eventually leads to functional healing of DDH. 15 Resolution of hip dysplasia strongly depends on the presence of the femoral head in the acetabulum. ...
Article
In dysplastic infant hips undergoing abduction harness treatment, cartilage contact pressure is believed to have a role in therapeutic cartilage remodeling and also in the complication of femoral head avascular necrosis. To improve our understanding of the role of contact pressure in the remodeling and the complication, we modeled cartilage contact pressure in cartilaginous infant hips undergoing Pavlik harness treatment. In subject‐specific finite element modeling, we simulated contact pressure of normal and dysplastic hips in Pavlik harness at 90° flexion and gravity‐induced abduction angles of 40°, 60° and 80°. We demonstrated that morphologies of acetabulum and femoral head both affected contact pressure distributions. The simulations showed that in Pavlik harness, contact pressure was mainly distributed along anterior and posterior acetabulum, leaving the acetabular roof only lightly loaded (normal hip) or unloaded (dysplastic hip). From a mechanobiological perspective, these conditions may contribute to therapeutic remodeling of the joint in Pavlik harness. Furthermore, contact pressure increased with the angle of abduction, until at the extreme abduction angle (80°), the lateral femoral head also contacted the posterior acetabular edge. Contact pressure in this area could contribute to femoral head avascular necrosis by reducing flow in femoral head blood vessels. The contact pressure we simulated can plausibly account for both the therapeutic effects and main adverse effect of abduction harness treatment for developmental dysplasia of the hip. This article is protected by copyright. All rights reserved
... Determined by making a line from the lateral sourcil to the upper corner of the ipsilateral pubic symphysis. The distance from this line to the deepest part of the acetabulum is then measured [20]. >38% [22] Later subluxation (L) (mm) ...
Article
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Ptosis is a newly described phenomenon appearing on AP radiographs of patients undergoing femoroacetabular osteoplasty (FAO), and refers to a reverse break down in Shenton’s Line. Thorough characterization of this phenomenon is needed to better understand the hip morphology and pathologic ramifications. Our goal was to define the radiographic hip parameters accompanying a break down in Shenton’s Line and to determine how these values compare with standard values in normal hips. Using two independent readers, we retrospectively reviewed the medical records and preoperative supine radiographs of 630 patients (1260 hips) who underwent FAO by a single surgeon between 2003 and 2016. Prevalence of hip pathology and 28 radiographic parameters in ptosis hips was measured, as well as a comparison between unilateral ptosis hips and contralateral normal hips. Of the 53 patients (106 hips) who fulfilled the criteria for the study, 94 hips had a Shenton’s Line break down of at least 5 mm. Sixty-nine percent of ptosis hips had femoroacetabular impingement (FAI), 70.2% had coxa profunda, and 52.1% had partial joint space narrowing. Ptosis hips had 1.05 mm less lateral subluxation (P = 0.012), 2.28° larger Center-edge angle (P = 0.046), 2.59° smaller Sharp angle (P = 0.011) and 2.49% smaller extrusion index (P = 0.016) compared with contralateral normal hips. FAI is prevalent in patients with a positive ptosis sign. The high prevalence of partial joint space narrowing could suggest eventual osteoarthritis. We believe our results demonstrate the importance of further investigation of a positive ptosis sign on AP pelvic radiographs.
... 6 Harris-Hayes and Royer, in a review evaluating 20 studies assessing the correlation between AD and osteoarthritis, found that there was a correlation between AD and osteoarthritis development. 20 When we examine the relationship between CE angle and age, statistically there is a significant difference between the mean age of patients with hip dysplasia and those without hip dysplasia. Significantly, as CE angle decreases, the arthrosis age also decreases. ...
Article
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Introduction: Hip osteoarthritis is an important orthopedic problem frequently observed in the elderly. Acetabular dysplasia (AD) is one of the pathologies that cause coxarthrosis. Nearly 20-45% of primary or idiopathic hip osteoarthritis is linked to AD. In our country, there are few studies on this topic. We measured the center-edge (CE) angle, Sharp's angle, acetabular depth, and femoral head coverage ratio on pelvis anteroposterior radiographs of patients with primary coxarthrosis and calculated the dysplasia rates. Patients and method: Age at surgery and sex of the patients; and CE angle, Sharp's angle, acetabular depth, and femoral head coverage ratio for both operated and opposite hips were evaluated in 223 total hip prosthesis-performed patients with coxarthrosis. Also the distribution of mean age at surgery, sex of patients, dysplasia rates of operated hips, and bilateral dysplasia rates were calculated. Results: The right to left ratio of operated hips was 104/119. Female to male ratio was 163/60 (2.7/1), for those with CE angle below 20° it was 123/30 (4.1/1), and it was 40/30 (1.3/1) with CE angle above 20°. Mean age of patients at surgery was 56.9 (±11.4) years. CE angle less than 20° was found in 68.6% of patients, acetabulum depth less than 9 mm was found in 75.3%, Sharp's angle was more than 45° in 65.9%, and femoral head coverage ratio was less than 70% in 70.3% of patients. Conclusions: We identified a high rate of AD in primary coxarthrosis patients undergoing total hip arthroplasty in the study population.
... The anterior and lateral part of the femoral head is usually covered incompletely by the dysplastic acetabulum. 1 The deficiency of contact coverage on the dysplastic hip brings about an increase on contact pressure during daily activities, 2,3 which consequently not only gives rise to instability and dislocation of hip joint, 4 but also has a bearing on the development of the osteoarthritis and some other complications. 5,6 To rectify this abnormal situation, total hip arthroplasty (THA) is one of the options to ease pain and restore the function of the hip for patients who have advanced osteoarthritis. ...
... Hip disorders in young-and middle-aged adults are characterized by bony deformity with or without labral injury and are known to be a precursor to the development of osteoarthritis. [44] Studies of characteristics of patients with hip pain related to DDH and FAI with or without labral tears describe an insidious onset of pain that, on average, can take years to arrive at the appropriate diagnosis and treatment intervention. [1][2][3] This suggests patients with hip pain and no to minimal radiographic arthritis are at risk for cofounding sleep and anxiety disorders. ...
Article
Background: Hip pain in young and middle- aged adults with and without hip deformity receive treatment focused primarily related to hip structure. Because their hip pain may be chronic, these patients develop other modifiable co-existing disorders related to pain that go undiagnosed in this young and active population including insomnia and anxiety. Objective: The objective is to compare assessments of insomnia and anxiety in young and middle-aged adults presenting with hip pain with no greater than minimal osteoarthritis (OA) compared to asymptomatic (healthy) controls.Comparisons between types of hip deformity and no hip deformity in hip pain patients were performed to assess if patients with specific hip deformities were likely to have insomnia or anxiety as a cofounding disorder to their hip pain. Design: Prospective case series with control comparison. Setting: Two tertiary university physiatry outpatient clinics. Participants: Fifty hip pain patients aged 18-40 years and 50 gender and aged matched healthy controls. Methods: Patients were enrolled if: 2 provocative hip tests were found on physical examination and hip radiographs had no or minimal OA. Radiographic hip deformity measurements were completed by an independent examiners. Comparisons of insomnia and anxiety were completed between: 1) 50 hip pain patients and 50 controls and 2) patients with different types of hip deformity. Main outcome measures: Insomnia severity Index (ISI) and Pain anxiety Symptom Scale (PASS) RESULTS: Fifty hip pain patients (11 male, 39 female) with mean age of 31.2+8.31 years enrolled. Hip pain patients slept significantly less (p=.001) per night than controls. Patients experienced significantly greater insomnia (p=.0001) and anxiety (p=.0001) compared to controls. No differences were found in insomnia and anxiety scores between hip pain patients with and without hip deformity or between types of hip deformity. Conclusion: Hip pain patients with radiographs demonstrating minimal to no hip arthritis with and without hip deformity experience significant cofounding yet modifiable disorders of sleep and anxiety. If recognized early in presentation, treatment of insomnia and anxiety ultimately will improve outcomes for hip patients treated conservatively or surgically for their hip disorder.
... During hip flexion the femoral head-neck repeatedly abuts the acetabulum. The repeated microtrauma to the anterior acetabular margins causes labral tears and articular cartilage damage, eventually leading to OA [4,7]. In cam-type FAI the abnormality is an aspherical femoral head as well as reduced cranial offset of the femoral head-neck junction, often secondary to extra bone formation ( Fig. 1) [4,6]. ...
Article
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Sports participation can be an integral part of adolescent development with numerous positive short and long-term effects. Despite these potential benefits very high levels of physical activity, during skeletal maturation, have been proposed as a possible cause of cam-type femoroacetabular impingement (FAI). The influence of physical activity on the developing physis has been previously described both in animal studies and epidemiological studies of adolescent athletes. It is therefore important to determine whether the development of FAI is secondary to excessive physical activity or a combination of a vulnerable physis and a set level of physical activity. A review of the current literature suggests that adolescent males participating in ice-hockey, basketball and soccer, training at least three times a week, are at greater risk than their non-athletic counterparts of developing the femoral head-neck deformity associated with femoroacetabular impingement.
... Developmental dysplasia of the hip (DDH) is a structural disease characterized by a shallow acetabulum, insufficient femoral coverage, and abnormal intraarticular loading (Leunig et al. 2001;Henak et al. 2014;Gala et al. 2016). Abnormal hip loads may contribute to acetabular labrum and articular cartilage damage (Cooperman 2013), which often progresses to early osteoarthritis (Jessel et al. 2009;Harris-Hayes and Royer 2011). Reliable quantification of hip loads, including joint reaction forces (JRFs) and muscle forces, may improve our understanding of tissue damage and the pathogenesis of osteoarthritis among patients with DDH. ...
Article
Optimizing the geometric complexity of musculoskeletal models is important for reliable yet feasible estimation of joint biomechanics. This study investigated the effects of subject-specific model geometry on hip joint reaction forces (JRFs) and muscle forces in patients with developmental dysplasia of the hip (DDH) and healthy controls. For nine DDH and nine control subjects, three models were created with increasingly subject-specific pelvis geometry, hip joint center locations and muscle attachments. Hip JRFs and muscle forces during a gait cycle were compared among the models. For DDH subjects, resultant JRFs from highly specific models including subject-specific pelvis geometry, joint locations and muscle attachments were not significantly different compared to models using generic geometry in early stance, but were significantly higher in late stance (p = 0.03). Estimates from moderately specific models using CT-informed scaling of generic pelvis geometry were not significantly different from low specificity models using generic geometry scaled with skin markers. For controls, resultant JRFs in early stance from highly specific models were significantly lower than moderate and low specificity models (p ≤ 0.02) with no significant differences in late stance. Inter-model JRF differences were larger for DDH subjects than controls. Inter-model differences for JRF components and muscle forces were similar to resultant JRFs. Incorporating subject-specific pelvis geometry significantly affects JRF and muscle force estimates in both DDH and control groups, which may be especially important for reliable estimation of pathomechanics in dysplastic hips. © 2019
... Poor coverage may lead to deleterious hip contact mechanics, including elevated load support by the acetabular labrum (Henak et al., 2011). Altered hip contact mechanics may, in turn, accelerate osteoarthritis (OA) development (Harris-Hayes and Royer, 2011). Surgeons seek to normalize contact mechanics by correcting hip anatomy (Sanchez-Sotelo et al., 2002). ...
... These motions were chosen because they are known to be altered in patients with hip deformity 6,12 and OA. 21,55 In a previous study, 43 the authors demonstrated excellent intrarater reliability (intraclass correlation coefficient = 0.76-0.97) and good to excellent interrater reliability (intraclass correlation coefficient = 0.63-0.87) ...
Article
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Study Design Prospective cohort study, cross-sectional design. Background The hip-spine syndrome is described in patients with known arthritis of the hip. This study describes the hip examination findings of people presenting with low back pain (LBP). Objectives (1) report examination findings of the hip in patients with LBP, (2) compare pain and function of patients with positive hip examination findings to those without. Methods An examination and validated questionnaires of spine and hip pain and function were completed. Pain and function scores were compared between patients with and without hip findings. Results Consecutive patients (68 women, 33 men) with a mean age 47.6 years (range 18.4-79.8). On physical examination: 1) 81(80%) had reduced hip flexion (HF), 76 (75%) had reduced hip internal rotation (HIR), 2) 25 (25%) had 1, 32 (32%) had 2 and 23 (23%) had 3 positive provocative hip tests. Patients with reduced HF had less LBP -related (mean mODI 25.6 vs. 33.5, p=0.04) and hip-related function (mean mHHS 82.0 vs. 66.0, p=0.03). Patients with reduced HIR had less LBP-related function (mean RMQ 8.2 vs. 12.4, p=0.003). A positive provocative hip test(s) was coupled with more intense pain (median 7 vs. 9, p=0.05); and less LBP-related (mean RMQ 8.5 vs. 12.1, p=0.02) and hip-related function (mean mHHS 89.7 vs. 65.8, p=0.005). Conclusion Physical examination findings indicating hip dysfunction are common in patients presenting with LBP. Patients with LBP and positive hip examination findings have more pain and less function compared to patients with LBP without positive hip examination findings. Level of Evidence Symptom prevalence, Level 1b. J Orthop Sports Phys Ther, Epub 3 Feb 2017. doi:10.2519/jospt.2017.6567.
... Reports of the utilization of hip arthroscopy to treat a variety of pre-arthritic conditions have supported its continued use thus far [12,13]. Proponents of non-operative management (NOM) for pre-arthritic disease note the lack of long term evidence that surgical intervention alters the natural course of disease progression [14]. Additionally, the presence of asymptomatic cam lesions and labral tears leads some to further question the need for surgery in these settings [15][16][17][18][19][20][21]. ...
Article
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Hip arthroscopy (HA) is an established treatment option to address intra-articular pathology of the hip. However, some clinicians encourage non-operative management (NOM). Non-operative management may include active measures such as physiotherapy and intra-articular steroid injections, or NOM may involve so called watchful waiting with no active intervention. These approaches, along with surgery have been detailed recently in the Warwick Agreement, a Consensus Statement regarding diagnosis and treatment of Femoroacetabular Impingement Syndrome The aim of this study is to compare the change in clinical outcome scores of waitlisted patients with intra-articular hip pathology who receive no active treatment with matched controls that have undergone HA. Patients less than 60 years of age were identified from a HA waiting list in a single hospital in the Australian public hospital system. Patient reported outcomes (PRO) were collected whilst patients waited for surgery. During this waiting period no specific treatment was offered. A separate group of patients who had previously undergone HA were matched based on age, sex, body mass index and baseline non-arthritic hip scores (NAHS). The groups were compared using the NAHS as the primary outcome measures. Modified Harris Hip Scores were also collected and compared. Thirty-six patients were included in each group, with a mean follow up of 19 months (12–36). There were no significant differences in age, sex, BMI and NAHS between groups at baseline. At final follow up, mean NAHS scores after HA were significantly higher than scores after NOM, 82.1 (36.4–100.0) versus 48.9 (11.3–78.8), respectively (P < 0.001) with a large effect size for mean change in scores between groups (d = 1.77, 95% CI 1.21–2.30). Mean mHHS after HA were significantly higher than scores after NOM, 84.3 (15.4–100.0) versus 48.1 (21.0–66.0) respectively (P < 0.001), with a large effect size for mean change in scores between groups (d = 1.92, 95% CI 1.34–2.46). HA may lead to significant improvements in PRO when compared to non-operative management of waitlisted patients with intra-articular pathology of the hip at 18 months follow-up.
... Moreover, the von Mises stress on the acetabulum in the DDH-3 model (anterosuperior defect) barely improved (the maximum value decreased from 33.89 MPa pre-PAO to 27.48 MPa post-PAO). Therefore, stress concentration might be a crucial reason for the development of osteoarthritis in some DHH patients post-PAO [25,28]. ...
Article
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Background Different extents and locations of acetabular cartilage defect have been supposed to be a major cause of undesirable outcomes of periacetabular osteotomy (PAO) in patients with developmental dysplasia of the hip (DDH). This study aimed to verify whether different locations of cartilage deficiency affect the biomechanical environment in a three-dimensional model utilizing finite element analysis (FEA). Material/Methods We developed 3 DDH models – DDH-1 (normal shape), DDH-2 (superior defect), and DDH-3 (anterosuperior defect) – by deforming from a normal hip model. We also developed 3 PAO models – PAO-1, PAO-2, and PAO-3 – through rotating osteotomized fragments. Results The maximum von Mises stress in the normal hip was 13.06 MPa. In the DDH-1 model, the maximum value on the load-bearing area decreased from 15.49 MPa pre-PAO to 14.28 MPa post-PAO, while stresses in the DDH-2 and DDH-3 models were higher than in the DDH-1 model, both pre-PAO and post-PAO (30.46 MPa to 26.04 MPa for DDH-2; 33.89 MPa to 27.48 MPa for DDH-3). Conclusions This study shows that, both pre- and post-PAO, different types of cartilage deficiency affect the biomechanical environment. Furthermore, in dysplastic hips, obtaining accurate three-dimensional information about the acetabular cartilage can contribute substantially to PAO decision making.
... Epidemiologic studies have identified several risk factors predisposing to hip OA, including increasing age, male sex (after age 55 years, hip OA is more common in women), excess body weight (which has a stronger association with knee OA), trauma, mechanical workload (occupational) and leisure-time physical activity, and gross bony abnormalities (i.e., congenital hip dislocation, Legg-Calv e-Perthes disease, or slipped capital femoral epiphysis) (1)(2)(3). Moreover, a review study (4) showed an association between bony abnormalities (e.g., acetabular dysplasia and cam deformity) and hip OA, although the conclusions drawn were based on limited prospective evidence (based on 110 individuals in 1 study of cam deformity, and a total of 1,365 individuals in 5 studies of dysplasia) (5)(6)(7)(8)(9)(10). ...
Article
Objective: Cam deformity and acetabular dysplasia have been recognized as relevant risk factors for hip osteoarthritis (OA) in a few prospective studies with limited sample sizes. To date, however, no evidence is available from prospective studies regarding whether the magnitude of these associations differs according to sex, body mass index (BMI), and age. Methods: Participants in the Rotterdam Study cohort including men and women ages 55 years or older without OA at baseline (n = 4,438) and a mean follow-up of 9.2 years were included in the study. Incident radiographic OA was defined as a Kellgren/Lawrence grade of ≥2 or a total hip replacement at follow-up. Alpha and center-edge angles were measured to determine the presence of cam deformity and acetabular dysplasia/pincer deformity, respectively. Odds ratios (ORs) were calculated to assess the associations between both deformities and the development of OA. Results: Subjects with cam deformity (OR 2.11, 95% confidence interval [95% CI] 1.55-2.87) and those with acetabular dysplasia (OR 2.19, 95% CI 1.50-3.21) had a 2-fold increased risk of developing OA compared with subjects without deformity, while pincer deformity did not increase the risk of OA. Stratification analyses showed that the associations of cam deformity and acetabular dysplasia with OA were driven by younger individuals, whereas BMI did not influence the associations. Female sex appears to modify the risk of hip OA related to acetabular dysplasia. Conclusion: Individuals with cam deformity and those with acetabular dysplasia are predisposed to OA; these associations were independent of other well-known risk factors. Interestingly, both deformities predisposed to OA only in relatively young individuals. Therefore, early identification of these conditions is important.
... Femoroacetabular impingement (FAI) has been increasingly recognized as a major contributor of hip osteoarthritis (OA) (Ganz et al. 2003;Beck et al. 2005;Harris-Hayes & Royer 2011;Bedi & Kelly 2013). Cam-type FAI is caused by decreased concavity of the anterosuperior femoral head-neck junction, which results in a jamming of the aspherical femoral head into the acetabulum and leads to cartilage damage (Ganz et al. 2003). ...
Article
Three dimensional finite element models of cam-type FAI with alpha angles of 60°, 70°, 80°, and 90° were created to investigate the cartilage contact mechanics in daily activities. Intra-articular cartilage contact pressures during routine daily activities were assessed and cross-compared with a normal control hip. Alpha angles and hip range of motion were found to have a combined influence on the cartilage contact mechanics in hips with cam-type FAI, thereby resulting in abnormally high pressures and driving the cartilage damage. In particular, alpha angles of 80° or greater contribute to substantial pressure increase under certain types of daily activities.
... While a wide range of this variability is considered normal, two structural abnormalities commonly noted today can generally be described as undercoverage and over-coverage of the acetabulum on the femur. Although these abnormal structures are thought to contribute to hip pain, the exact point at which these structures vary enough to be termed pathologic is not well established (Harris-Hayes and Royer, 2011;Anderson et al., 2012;Nepple et al., 2013;Diesel et al., 2015). Under-coverage and over-coverage are clinically referred to as acetabular dysplasia and pincer femoroacetabular impingement (FAI), respectively. ...
Article
The shift to habitual bipedalism 4–6 million years ago in the hominin lineage created a morphologically and functionally different human pelvis compared to our closest living relatives, the chimpanzees. Evolutionary changes to the shape of the pelvis were necessary for the transition to habitual bipedalism in humans. These changes in the bony anatomy resulted in an altered role of muscle function, influencing bipedal gait. Additionally, there are normal sex-specific variations in the pelvis as well as abnormal variations in the acetabulum. During gait, the pelvis moves in the three planes to produce smooth and efficient motion. Subtle sex-specific differences in these motions may facilitate economical gait despite differences in pelvic structure. The motions of the pelvis and hip may also be altered in the presence of abnormal acetabular structure, especially with acetabular dysplasia. Anat Rec, 300:633–642, 2017. © 2017 Wiley Periodicals, Inc.
... The centre -edge (CE) angle of Wiberg is a measure of depth of acetabulum and of the cover of formal head. 1,2 The (CE) angle increases very gradually though adult life. 3 Large number of patients with primary osteoarthritis is in reality secondary to pre-existing asymptomatic anatomical abnormality, such as mild acetabular dysplasia. ...
Article
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Objective: To measure the depth of acetabulum [the Centre edge (CE) angle] in adult normal Jordanian population. Design: Descriptive Case – Series Study. Setting: King Abdullah University hospital, Jordan University of Science and Technology, during the period May 2012 to May 2016. Participants: Antero – posterior (AP) radiographs of (400 hips) taken for adult non-orthopedic patients of various age groups, 105 were men and 95 were women. Main Outcome Measurements: The centre – edge (CE) angles of 400 hips were measured by Wiberg method. Results: The (CE) angle increased with age. There is no significant difference between men and women, nor is a significant difference between right and left. The distribution of (CE) angles is similar to other studies in Indians, Caucasians and Africans. Conclusion: The acetabular depth measured by the (CE) angle (acetabular dysplasia) could not be the main factor in etiology of osteoarthritis and congenital dislocation of the hip. Key words: CE angle, hip, and normal Jordanian adult.
... 1,4 When left unaddressed, FAI, dysplasia, and structural instability can lead to the progression of acetabular labral tears, chondropathy, and potentially osteoarthritic change. [5][6][7][8][9][10][11] Arthroscopic surgical procedures to address structural abnormalities, decrease pain, and improve function have significantly increased over the past decade. [12][13][14][15][16] However, a recent systematic review found that there is a high prevalence of structural deformities in asymptomatic individuals. ...
Article
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Background: Non-arthritic hip pain is defined as being related to pathologies of the intra-articular structures of the hip that can be symptomatic. A trial of non-operative management is commonly recommended before consideration of surgery for individuals with non-arthritic hip conditions. There is a need to describe a non-operative or conservative treatment plan for individuals with non-arthritic hip pain. Purpose: The purpose of this literature review was to systematically examine the literature in order to identify and provide evidence for non-operative or conservative management of individuals with non-arthritic hip pain. A proposed home exercise program will be provided for individuals with non-arthritic hip pain. Study design: Review of the Literature. Materials/methods: A literature search of PubMed, Medline, SPORTSDiscus, and CINAHL was conducted. Keywords included: "hip" AND "femoroacetabular impingement" OR "labral tear." Studies were included if they described non-operative management for individuals with non-arthritic hip pain. Studies were excluded if they recommended a trial of conservative treatment without specific management or interventions and/or activity modification without specific details for intervention. Results: A total of 49 studies met the eligibility criteria and were included in the review. Rehabilitation recommendations were identified from manuscripts including clinical trials, case series, discussion articles, or systematic reviews related to the non-operative or conservative management of non-arthritic hip pain. Rehabilitation interventions focused on patient education, activity modification, limitation of aggravating factors, an individualized physical therapy protocol, and use of a home exercise program. Conclusions: Rehabilitation should address biomechanical deficiencies with neuromuscular training of the hip and lumbopelvic regions. While the current literature on non-operative management is limited, future randomized control trials will establish the effectiveness of specific physical therapy protocols for individuals with non-arthritic hip pain. Level of evidence: 3b.
... Moreover, FAI is considered a cause of hip osteoarthritis. [2,3] However, the optimal treatment of symptomatic FAI is still controversial. There are 2 broad treatment strategies for symptomatic FAI: surgical and nonsurgical interventions. ...
Article
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Background: Presently, hip arthroscopy is a widely adopted surgical intervention for the treatment of femoroacetabular impingement (FAI). However, there is insufficient evidence regarding which between arthroscopy and nonoperative treatment is more optimal for symptomatic FAI. Methods: MEDLINE, Embase, Web of Science, and the Cochrane Library were systematically searched for studies that compared arthroscopy and nonoperative interventions for FAI treatment from inception to August 4, 2020. We included studies that directly compared surgical and nonsurgical treatment for symptomatic FAI and excluded those that did not use arthroscopic treatment as a surgical technique and studies performed on patients with concomitant diagnoses instead of pure FAI. We compared the following clinical outcome scores at 6 and 12 months of follow-up: International Hip Outcome Tool 33 (iHOT-33), hip outcome score (HOS), EuroQol-visual analog scale (EQ-VAS), modified Harris hip score (mHHS), and nonarthritic hip score (NAHS). Results: Five studies totaling 838 patients were included in the qualitative and quantitative synthesis; 382 patients underwent hip arthroscopy, and 456 patients were treated by nonoperative interventions. At 6 months of follow-up, there were no statistically significant differences in iHOT-33 ratings (mean difference [MD] = 7.92, P = .15), HOS (MD of HOS-ADL = 5.15, P = .26 and MD of HOS-Sports = 2.65, P = .79, respectively), and EQ-VAS (MD = 1.22, P = .76) between the 2 treatment strategies. At 12 months of follow-up, the arthroscopy group had a greater mean improvement in iHOT-33 score than the conservative treatment group (MD = 8.42, P = .002), but there was no difference between the groups in terms of mHHS rating (MD = -0.24, P = .83) and NAHS (MD = -2.08, P = .09). Conclusion: Despite arthroscopy being associated with significantly superior iHOT-33 scores after 12 months of follow-up, we were unable to discern the difference between the treatment strategies using other scoring methods, such as HOS, EQ-VAS, mHHS, and NAHS. Further studies will be needed to conclusively determine if 1 strategy is superior to the other for treating FAI.
... Coverage deficiency of the femoral head results in hip instability, as well as altered joint reaction forces (JRF) and contact stresses on the articular cartilage (Clohisy et al., 2009a;Harris et al., 2017;Henak et al., 2011). Without treatment, the abnormal geometries predispose affected patients to degenerative joint changes over time, including hip osteoarthritis (OA) (Harris-Hayes and Royer, 2011;Reijman et al., 2005). ...
Article
Acetabular dysplasia is primarily characterized by an altered acetabular geometry that results in deficient coverage of the femoral head, and is a known cause of hip osteoarthritis. Periacetabular osteotomy (PAO) is a surgical reorientation of the acetabulum to normalize coverage, yet its effect on joint loading is unknown. Our objective was to establish how PAO, simulated with a musculoskeletal model and probabilistic analysis, alters hip joint reaction forces (JRF) in two representative patients of two different acetabular dysplasia subgroups: anterolateral and posterolateral coverage deficiencies. PAO reorientation was simulated within the musculoskeletal model by adding three surgical degrees of freedom to the acetabulum relative to the pelvis (acetabular adduction, acetabular extension, medial translation of the hip joint center). Monte Carlo simulations were performed to generate 2000 unique PAO reorientations for each patient; from which 99% confidence bounds and sensitivity factors were calculated to assess the influence of input variability (PAO reorientation) on output (hip JRF) during gait. Our results indicate that reorientation of the acetabulum alters the lines of action of the hip musculature. Specifically, as the hip joint center was medialized, the moment arm of the hip abductor muscles was increased, which in turn increased the mechanical force-generating capacity of these muscles and decreased joint loading. Independent of subgroup, hip JRF was most sensitive to hip joint center medialization. Results from this study improve understanding of how PAO reorientation affects muscle function differently dependent upon acetabular dysplasia subgrouping and can be used to inform more targeted surgical interventions.
... B oth acetabular dysplasia and femoroacetabular impingement (FAI) have been associated with hip pain and early-onset osteoarthritis. [1][2][3][4] Early diagnosis and treatment of these morphologies in symptomatic patients may reduce or eliminate symptoms and may reduce arthritic deterioration. In the management of FAI, both arthroscopic and open procedures have shown to successfully improve patient-reported outcomes (PROs) in the mid-term follow-up. ...
Article
Purpose: To analyse the current approaches and clinical outcomes in the surgical management of concomitant mild acetabular dysplasia and femoroacetabular impingement (FAI). Methods: Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) method, the PubMed and Medline databases were searched in March 2019 for studies that reported on surgical outcomes in hips with concomitant mid acetabular dysplasia and FAI. Studies published in English that focused on the surgical outcomes after hip arthroscopy, open surgery or periacetabular osteotomy of concomitant acetabular dysplasia and FAI, in which the lateral centre-edge angle (LCEA) of all subjects was between 15° and 25°, were included. Articles that included subjects with LCEA <15°, with a minimum follow-up duration < 1 year, had <5 subjects, or were not original articles were excluded. Results: The initial search yielded 748 studies, and 5 studies met the inclusion criteria. All these 5 studies focused on hip arthroscopic treatment for patients with concomitant mild acetabular dysplasia and FAI. Three studies had level III evidence, while 2 studies had level IV evidence. The mean patient age range across the studies was 29.8-49.6 years, and the female to male ratio was 1.14. Improved patient-reported outcomes (HOS-ADL, HOS-Sport, mHHS, SF-12 PCS, WOMAC) at a minimum 2-year follow-up were obtained in 4 of the 5 studies. Two of these 4 studies had a comparative cohort of patients with FAI with normal acetabular coverage, and there was no significant difference in the postoperative outcomes and secondary procedure rate between patients with mild acetabular dysplasia and those with normal acetabular coverage. Conclusions: This systematic review indicates that improved patient-reported outcomes can be obtained with hip arthroscopy in the treatment of concomitant mild acetabular dysplasia and FAI at a minimum 2-year follow-up.
Article
Background: The age when patients present for treatment of symptomatic developmental dysplasia of the hip with periacetabular osteotomy (PAO) varies widely. Modifiable factors influencing age at surgery include preexisting activity level and body mass index (BMI). The severity of the hip dysplasia has also been implicated as a factor influencing the age at arthritis onset. The purpose of this study was to determine whether activity level, BMI, and severity of dysplasia are independent predictors of age of presentation for PAO. Methods: A retrospective, institutional review board-approved review of prospectively collected data from a multicenter study group identified 708 PAOs performed for developmental dysplasia of the hip. Demographic factors that were considered in the analysis included age at surgery, BMI, history of hip disorder or treatment, and duration of symptoms. The severity of the developmental dysplasia of the hip was assessed by radiographic measurement of the lateral and anterior center-edge angles and acetabular inclination. Activity level was assessed with the University of California, Los Angeles (UCLA) activity score. Spearman correlations and t tests were used for univariable analysis. Multivariable regression analysis using generalized estimating equations was applied to determine independent predictors of age at PAO. Results: Univariable analysis indicated that age at presentation for treatment of PAO correlated with the lateral and anterior center-edge angles (p < 0.001), UCLA score (p < 0.001), and BMI (p = 0.04). Since the lateral and anterior center-edge angles were similarly correlated (Spearman rho = 0.61, p < 0.001), the lateral center-edge angle alone was used to classify the severity of the developmental dysplasia of the hip. Multivariable linear regression confirmed that a high UCLA score and severe hip dysplasia were independent predictors of age at PAO (p < 0.001). Conclusions: A high activity level and severe dysplasia lead to the development of symptoms and presentation for PAO at significantly younger ages. The combination of these two factors has an even greater effect on decreasing the age at presentation for hip-preserving surgery. An increased BMI was not independently associated with a younger age at surgery. Modifying activity level may be beneficial in terms of delaying the onset of symptoms from developmental dysplasia of the hip. Level of evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Article
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Study Design Feasibility randomized clinical trial. Background Rehabilitation may be an appropriate treatment strategy for patients with chronic hip joint pain (CHJP), however the evidence related to the effectiveness of rehabilitation is limited. Objectives Assess feasibility of performing a randomized clinical trial to investigate the effectiveness of movement pattern training (MPT) to improve function in people with CHJP. Methods Thirty-five patients with chronic CHJP were randomized into two groups, treatment (MPT) or wait-list control (Wait-list). The MPT program included six, one hour supervised sessions and incorporated: 1) task-specific training for basic functional tasks and symptom-provoking tasks; and 2) strengthening of hip musculature. The Wait-list group received no treatment. Primary outcomes for feasibility were patient retention and adherence. Secondary outcomes to assess treatment effects were patient-reported function (Hip disability and Osteoarthritis Outcome Score [HOOS]), lower extremity kinematics, and hip muscle strength. Results Retention rates did not differ between MPT (89%) and Wait-list groups (94%, P = 1.0). Sixteen of the 18 patients (89%) in the MPT group attended at least 80% of the treatment sessions. For the home exercise program, 89% of patients reported performing their home program at least once per day. Secondary outcomes support the rationale for conduct of a superiority RCT. Conclusion Based on retention and adherence rates, a larger RCT appears feasible and warranted to assess treatment effects more precisely. Data from this feasibility study will inform our future clinical trial. Level of Evidence Therapy, Level 2b. J Orthop Sports Phys Ther, Epub 26 Apr 2016. doi:10.2519/jospt.2016.6279.
Article
Objectives Compare muscle activity between male football players with and without hip-related pain. Morphological and intra-articular features of hip-related pain are proposed pre-cursors to hip OA. Altered muscle activity is a feature of severe hip OA, but it is not known whether differences exist earlier in the pathological spectrum. Design Cross-sectional; Setting University laboratory; Participants Forty-two male football players with hip-related pain; and 19 asymptomatic controls. Main outcome measures Hip muscle activity (Gluteus maximus, gluteus medius, tensor facia latae, adductor longus and rectus femoris) was recorded during walking using surface electromyography EMG. Results Men with hip-related pain had sustained rectus femoris activity prior to toe-off (47–51% of the gait cycle) (p = 0.01, ES = 0.51) unlike controls who had reduced activity. In men with severe hip-related pain, gluteus maximus EMG was sustained into mid-stance (12–20% of the gait cycle) (F = 6.15, p < 0.01) compared to controls. Conclusions Differences in rectus femoris and gluteus maximus activity were identified between male footballers with and without hip-related pain. The pattern of gluteus maximus EMG relative to peak, approaching mid-stance in severe hip-related pain, is consistent with observations in severe hip OA. This supports the hypothesis that symptom severity may influence muscle activity across the spectrum of hip degeneration.
Article
The purpose of this exploratory analysis was to compare the impact of movement pattern training (MoveTrain) and standard strength and flexibility training (Standard) on muscle volume, strength and fatty infiltration in patients with hip-related groin pain (HRGP). We completed a secondary analysis of data collected during an assessor-blinded randomized control trial. Data was used from 27 patients with HRGP, 15 to 40 years, who were randomized into MoveTrain or Standard groups. Both groups participated in their training protocol (MoveTrain, n = 14 or Standard, n = 13) which included 10 supervised sessions over 12 weeks and a daily home exercise program. Outcome measures were collected at baseline and immediately after treatment. Magnetic resonance images (MRI) data was used to determine muscle fat index (MFI) and muscle volume. A hand-held dynamometer was used to assess isometric hip abductor and extensor strength. The Standard group demonstrated a significant post-treatment increase in gluteus medius muscle volume compared to the MoveTrain group. Both groups demonstrated an increase in hip abductor strength and reduction in gluteus minimus and gluteus maximus MFI. The magnitude of change for all outcomes were modest. Statement of Clinical Significance: Movement pattern training or a program of strength/flexibility training may be effective at improving hip abductor strength and reducing fatty infiltration in the gluteal musculature among those with HRGP. Further research is needed to better understand etiology of strength changes and impact of muscle volume and MFI in HRGP and the effect of exercise on muscle structure and function. This article is protected by copyright. All rights reserved.
Article
Developmental dysplasia of the hip (DDH) is a common condition predisposing to osteoarthritis. Especially since DDH is best identified and treated in infancy before bones ossify, there is surprisingly a near-complete absence of literature examining mechanical behavior of infant dysplastic hips. We sought to identify current practice in finite element modeling (FEM) of DDH, to inform future modeling of infant dysplastic hips. We performed multi-database systematic review using PRISMA criteria. Abstracts (n=126) fulfilling inclusion criteria were screened for methodological quality, and results were analyzed and summarized for eligible articles (n=12). The majority of the studies modeled human adult dysplastic hips. Two studies focused on etiology of DDH through simulating mechanobiological growth of prenatal hips; we found no FEM-based studies in infants or children. Finite element models used either patient-specific geometry or idealized average geometry. Diversities in choice of material properties, boundary conditions, and loading scenarios were found in the finite-element models. FEM of adult dysplastic hips demonstrated generally smaller cartilage contact area in dysplastic hips than in normal joints. Contact pressure may be higher or lower in dysplastic hips depending on joint geometry and mechanical contribution of labrum. FEM of mechanobiological growth of prenatal hip joints revealed evidences for effects of the joint mechanical environment on formation of coxa valga, asymmetrically shallow acetabulum and malformed femoral head associated with DDH. Future modeling informed by the results of this review may yield valuable insights into optimal treatment of DDH, and into how and why osteoarthritis develops early in DDH.
Chapter
Successful development and maturation of the hip involves ongoing integration of various congenital, environmental and morphological stimuli over a period of time. The development of the proximal femur and acetabulum are interdependent and changes in either component affect the development of the other and abnormal morphology of the hip can predispose the joint to particular patterns of injury and development of osteoarthritic changes. Some of the anatomical shapes seen in the young adults with mechanical problems of the hip might be related to the evolutionary demand of upright posture and running. The ossification process within the proximal femur and the acetabulum is complex and susceptible to various insults depending upon the stage of development. The identification of various aetiological factors associated with abnormal hip development is important as some can be modified. There is strong evidence suggesting the role of certain physical activities during skeletal maturation may influence the growth and development of the hip joint.
Article
Objective To appraise the highest evidence on hip morphology as a risk factor for developing hip osteoarthritis (OA). Design We searched for studies evaluating the association between radiological hip morphology parameters and the prevalence, incidence or progression of hip OA (based on different radiographic and clinical criteria) in the MEDLINE, EMBASE, Web of Science, Scopus, Cochrane Library and PEDro databases from inception until June 2020. Prospective and cross-sectional studies were separately evaluated. Data are presented as odds ratios (OR) with 95% confidence intervals (CI). Results We included 9 prospective and 21 cross-sectional studies in the meta-analysis, and evaluated 42,831 hips from 25,898 individuals (mean age: 59 years). Prospective studies showed that, compared with control hips, hips with cam morphology (alpha angle >60°; OR=2.52, 95% CI: 1.83 to 3.46, P<0.001) or hip dysplasia (lateral center-edge angle (LCEA) <25°; OR=2.38, 95% CI: 1.84 to 3.07, P<0.001), but not hips with pincer morphology (LCEA >39°; OR=1.08, 95% CI: 0.57 to 2.07, P=0.810), were more likely to develop hip OA than hips without these morphologies. Cross-sectional studies showed a greater prevalence of pincer morphology (LCEA >39°, OR=3.71, 95% CI: 2.98 to 4.61, P<0.001) and acetabular retroversion (crossover sign; OR=2.65, 95% CI: 1.17 to 6.03, P=0.020) in hips with OA than in control hips. Conclusion Cam morphology and hip dysplasia were consistently associated with the development of hip OA. Pincer morphology was associated with hip OA in cross-sectional but not in prospective studies. The heterogeneous quantification of pincer morphology on radiographs limits a clear conclusion on its association with hip OA.
Article
Objectives The purpose of this study was to measure the indices of radiographic developmental dysplasia of the hip (DDH) in a cross-sectional study of an elderly Japanese population. Methods Hip radiographs of 427 informed, voluntary Japanese community-dwelling individuals (279 female and 148 male) aged 50 to 96 years-old were obtained from Miyagawa village in Japan through a health screening. The hip radiographs were measured by a custom-written, semi-automated MATLAB program. The center edge (CE) angle, acetabular roof obliquity (ARO), acetabular head index (AHI), and minimum joint space width (mJSW) were measured. We examined the associations between gender, side-of-hip, and age group on radiographic DDH and hip osteoarthritis (OA). Results The mean CE angle was 31.0°. The mean ARO was 5.8°. The mean AHI was 88.2%. The mean mJSW was 4.0 mm. Of the total population, 29.9% had DDH and 4.0% had hip OA. Of those who had hip OA, 41.2% were secondary OA, and 58.8% were primary OA. The relationship between DDH and OA was not significant. Conclusion DDH is unlikely to be an important cause of hip OA in the present population-based study.
Article
Background Developmental dysplasia of the hip is characterized by abnormal acetabular and femoral geometries that alter joint loading and increase the risk of hip osteoarthritis. Current understanding of biomechanics in this population remains isolated to the hip and largely focused on level-ground walking, which may not capture the variable loading conditions that contribute to symptoms and intra-articular damage. Methods Thirty young adult females (15 with dysplasia) underwent gait analysis during level, 10° incline, and 10° decline walking while whole-body kinematics, ground reaction forces, and electromyography (EMG) were recorded. Low back, hip, and knee joint kinematics and internal joint moments were calculated using a 15-segment model and integrated EMG was calculated within the functional phases of gait. Dependent variables (peak joint kinematics, moments, and integrated EMG) were compared across groups with a one-way ANOVA with multiple comparisons controlled for using the Benjamini-Hochberg method (α = 0.05). Findings During level and incline walking, patients with developmental dysplasia of the hip had significantly lower trunk flexion angles, lumbar and knee extensor moments, and erector spinae activity than controls. Patients with developmental dysplasia of the hip also demonstrated reduced rectus femoris activity during loading of level walking and increased gluteus maximus activity during mid-stance of decline walking. Interpretation Patients with developmental dysplasia of the hip adopt compensations both proximal and distal to the hip, which vary depending on the slope of walking. Furthering the understanding of multi-joint biomechanical compensations is important for understanding the mechanism of osteoarthritis development as well as secondary conditions.
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Objective To summarize available evidence on the association between hip shape as quantified by statistical shape modeling (SSM) and the incidence or progression of hip osteoarthritis. Design We conducted a systematic search of five electronic databases, based on a registered protocol (available: PROSPERO CRD42020145411). Articles presenting original data on the longitudinal relationship between radiographic hip shape (quantified by SSM) and hip OA were eligible. Quantitative meta-analysis was precluded because of the use of different SSM models across studies. We used the Newcastle-Ottawa Scale (NOS) for risk of bias assessment. Results Nine studies (6,483 hips analyzed with SSM) were included in this review. The SSM models used to describe hip shape ranged from 16 points on the femoral head to 85 points on the proximal femur and hemipelvis. Multiple hip shape features and combinations thereof were associated with incident or progressive hip OA. Shape variants that seemed to be consistently associated with hip OA across studies were acetabular dysplasia, cam morphology, and deviations in acetabular version (either excessive anteversion or retroversion). Conclusions Various radiographic, SSM-defined hip shape features are associated with hip OA. Some hip shape features only seem to increase the risk for hip OA when combined together. The heterogeneity of the used SSM models across studies precludes the estimation of pooled effect sizes. Further studies using the same SSM model and definition of hip OA are needed to allow for the comparison of outcomes across studies, and to validate the found associations.
Article
This article is the fourth of five in a series on the effects of age-related changes in impairment evaluations as defined by the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth and Sixth Editions. The present article addresses the musculoskeletal system and differs from the first three articles, which focused on apportionment of an impairment rating between aging and other causes. The medical literature supports the notion that age-related osteoarthritis (OA) changes in the hand and digits frequently are associated with injury and/or repetitive motion. Thus, apportionment is indicated, but deciding which came first, the imaging abnormality or the injury, requires consummate skill on behalf of the rating physician. OA also occurs in the knees and hips of older individuals. Diffuse idiopathic skeletal hyperostosis (DISH) is a noninflammatory disorder characterized by calcification and ossification of spinal ligaments and entheses and is unique, in the authors’ opinion, because of a positive correlation between aging and back pain caused by this condition. The article also addresses the association—or the lack thereof—between pathology and aging, as well as degenerative changes and symptoms, to facilitate causation analysis. For a fuller discussion of causation analysis for the spine, readers can consult the AMA Guides to the Evaluation of Disease and Injury Causation, Second Edition.
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Introduction: The role of proximal femur morphology to the development of certain proximal femur fracture types both femoral neck and trochanteric fractures has been observed. However, the relavance of acetabular morphology to the development of proximal femur fractures is not extensively questioned. Therefore the aim of the study was to determine whether there is a correlation between acetabular morphology and pathogenesis of 2 different hip fracture types after low energy trauma. Method: This retrospective study includes 60 cases (41 women, 19 men) with a proximal femoral fracture after a low energy trauma between July 2012 and December 2014. Acetabular depth and acetabular index were measured on pelvic radiographs. Neck shaft angle, hip axis length and cortical index were measured on pelvic computed tomography scans. All measurements were performed on the contralateral hip. Results: Mean age was 77.56 ± 8.99 years (range 61-92 years). No statistically significant difference was found with regard to neck shaft angle, acetabular depth or cortical index measurements between patients with femoral neck fracture and patients with trochanteric femoral fractures (p>0.05). Acetabular index measurement was higher (p = 0.001) and hip axis length measurement was lower (p = 0.001) in trochanteric fracture group as compared to femoral neck fracture. Conclusions: The rate of trochanteric femur fractures is higher in patients with high acetabular index, whereas the rate of femoral neck fractures is higher in patients with increased hip axis length.
Article
Résumé Objectif Évaluer les effets de la morphologie de la hanche sur la prévalence, la sévérité clinique et la progression de l’arthrose de la hanche. Méthodes De 2007 à 2009, nous avons mené une étude sur 242 patients âgés de 40 à 75 ans ayant une arthrose des membres inférieurs symptomatique, inclus dans une étude de cohorte de sujets arthrosiques en France. Des radiographies standards des deux hanches furent obtenues à l’inclusion et au bout de trois ans. La progression de la coxarthrose a été évaluée selon le score radiologique de Kellgren-Lawrence (KL) et la sévérité clinique par les scores de douleur sur une échelle visuelle analogique (EVA) enregistrés chaque année. Cinq mesures ont été utilisées pour décrire la morphologie de la hanche : l’angle de couverture externe, l’indice acétabulaire (IA), l’angle de couverture antérieure, la profondeur du cotyle et l’angle céphalo-cervico-diaphysaire. Résultats Sur les 484 hanches étudiées, 205 (42 %) montraient des signes d’arthrose à l’inclusion et 16 (11 à droite et 5 à gauche) eurent une prothèse totale au cours du suivi. L’indice acétabulaire (IA) était la mesure morphologique le plus constamment et fortement associée à l’arthrose radiographique à l’inclusion (odds ratio = 1,05, IC à 95 % : 1,01 à 1,08 par degré de changement d’angle), la sévérité clinique (coefficient de corrélation avec l’EVA pendant les 3 ans = 0,15 ; p = 0,004), la progression radiographique (odds ratio = 1,05, IC 95 % : 1,00–1,10 par degré) et la mise en place d’une prothèse (hazard ratio = 1,18, IC à 95 % : 1,07 à 1,29 par degré). Conclusions L’obliquité acétabulaire et surtout l’IA sont fortement, et probablement de manière causale associées à l’existence, la sévérité et la progression de la coxarthrose.
Article
Background: The aim of this study was to evaluate the influence of total hip arthroplasty on axial alignment of the lower limb in adults with unilateral developmental hip dysplasia (Crowe type IV). Methods: We retrospectively reviewed medical records of 50 adults who underwent total hip arthroplasty, in which the acetabular cup was placed in the anatomical position. The following parameters were measured before surgery, immediately after surgery, and two years later: mechanical axis deviation (MAD), tibiofemoral angle (TFA), femoral offset, hip-knee-ankle angle (HKA), mechanical lateral distal femoral angle (LDFA), mechanical medial proximal tibial angle, height of medial femoral condyle, height of lateral femoral condyle, and leg lengthening. Length of the resected femoral segment was also recorded from medical records. Results: Preoperative MAD, TFA, HKA, and LDFA of the ipsilateral lower limb showed significant valgus deformity. MAD of the ipsilateral lower limb and valgus inclination were significantly smaller immediately after surgery than before, while TFA, HKA, femoral offset, and LDFA were significantly larger (P < 0.05). These parameters did not differ significantly between immediately after surgery and two years later (P > 0.05). Ipsilateral extremities were extended by a mean of 2.54 cm (range, 0 to 5.35 cm). The mean length of the femoral resected segment was 3.56 cm (range, 2.03 to 5.74 cm). The contralateral lower limb showed marginally smaller MAD and medial proximal tibial angle after surgery than before, but larger LDFA, TAF, and HKA. Conclusions: In patients with developmental hip dysplasia who underwent total hip arthroplasty with placement of the acetabular component at the level of the anatomic hip center, axial alignment of the ipsilateral lower limb was immediately altered, and valgus inclination was significantly reduced. The procedure only slightly altered the axial alignment of the contralateral lower limb.
Article
Aims: Recently, there has been considerable interest in quantifying the associations between bony abnormalities around and in the hip joint and osteoarthritis (OA). Our aim was to investigate the relationships between acetabular undercoverage, acetabular overcoverage, and femoroacetabular impingement (FAI) with OA of the hip, which currently remain controversial. Materials and methods: A total of 545 cadaveric skeletons (1090 hips) from the Hamann-Todd osteological collection were obtained. Femoral head volume (FHV), acetabular volume (AV), the FHV/AV ratio, acetabular version, alpha angle and anterior femoral neck offset (AFNO) were measured. A validated grading system was used to quantify OA of the hip as minimal, moderate, or severe. Multiple linear and multinomial logistic regression were used to determine the factors that correlated independently with the FHV, AV, and the FHV/AV ratio. Results: Female cadavers had smaller FHVs (standardised beta -0.382, p < 0.001), and AVs (standardised beta -0.351, p < 0.001), compared with male patients, although the FHV/AV ratio was unchanged. Every 1° increase in alpha angle increased the probability of having moderate OA of the hip compared with minimal OA by 7.1%. Every 1 mm decrease in AFNO increased the probability of having severe or moderate OA of the hip, compared with minimal OA, by 11% and 9%, respectively. The relative risk ratios of having severe OA of the hip compared with minimal OA were 7.2 and 3.3 times greater for acetabular undercoverage and overcoverage, respectively, relative to normal acetabular cover. Conclusion: Acetabular undercoverage and overcoverage were independent predictors of increased OA of the hip. The alpha angle and AFNO had modest effects, supporting the hypothesis that bony abnormalities both in acetabular dysplasia and FAI are associated with severe OA. Cite this article: Bone Joint J 2017;99-B:432-9.
Article
Objective To summarize the effects of surgical treatment compared to conservative treatment in femoroacetabular impingement syndrome in the short, medium, and long term. Study Design Systematic review Methods The following databases were searched on 14/09/2020: MEDLINE, EMBASE, CENTRAL, Web of Science, and PEDro. There were no date or language limits. The methodological quality assessment was performed using the PEDro scale and the quality of the evidence followed the GRADE recommendation. The outcomes pain, disability, and adverse effects were extracted. Results Of 6264 initial studies, three met the full-text inclusion criteria. All studies were of good methodological quality. Follow up ranged from six months to two years, with 650 participants in total. The meta-analyses found no difference in disability between surgical versus conservative treatment, with a mean difference (MD) between groups of 3.91 points (95% CI –2.19 to 10.01) at six months, MD of 5.53 points (95% CI –3.11 to 14.16) at 12 months and 3.8 points (95% CI –6.0 to 13.6) at 24 months. The quality of the evidence (GRADE) varied from moderate to low across all comparisons. Conclusion There is moderate-quality evidence that surgical treatment is not superior to conservative treatment for femoroacetabular impingement syndrome in the short term, and there is low-quality evidence that it is not superior in the medium term. Level of evidence Therapy, level 1a. Registration number PROSPERO CRD42019134118
Article
Purpose: To develop and evaluate an automatic measurement model for hip joints based on anteroposterior (AP) pelvic radiography and a deep learning algorithm. Methods: A total of 1260 AP pelvic radiographs were included. 1060 radiographs were randomly sampled for training and validation and 200 radiographs were used as the test set. Landmarks for four commonly used parameters, such as the center-edge (CE) angle of Wiberg, Tönnis angle, sharp angle, and femoral head extrusion index (FHEI), were identified and labeled. An encoder-decoder convolutional neural network was developed to output a multi-channel heat map. Measurements were obtained through landmarks on the test set. Right and left hips were analyzed respectively. The mean of each parameter obtained by three radiologists was used as the reference standard. The Percentage of Correct Key points (PCK), intraclass correlation coefficient (ICC), Pearson correlation coefficient (r), root mean square error (RMSE), mean absolute error (MAE), and Bland-Altman plots were used to determine the performance of deep learning algorithm. Results: PCK of the model at 3 mm distance threshold range was from 87 % to 100 %. The CE angle, Tönnis angle, Sharp angle and FHEI of the left hip generated by the model were 29.8°±6.1°, 5.6°±4.2°, 39.0°±3.5° and 19 %±5 %, respectively. The parameters of the right hip were 30.4°±6.1°, 7.1°±4.4°, 38.9°±3.7° and 18 %±5 %. There were good correlation and consistency of the four parameters between the model and the reference standard (ICC 0.83-0.93, r 0.83-0.93, RMSE 0.02-3.27, MAE 0.02-1.79). Conclusions: The new developed model based on deep learning algorithm can accurately identify landmarks on AP pelvic radiography and automatically generate parameters of hip joint. It will provide convenience for clinical practice of measurement.
Article
Structural abnormalities of the hip including developmental dysplasia (DDH) and femoroacetabular impingement (FAI) are a predominant cause of primary osteoarthritis. While affected patients may have significant pain and functional limitations, many may remain asymptomatic and will likely incur intra-articular damage over time. The objective of this review is to explore the natural history of DDH, FAI, and the current outcomes of hip preservation surgery including peri-acetabular osteotomy, hip arthroscopy, and surgical hip dislocation.
Article
This is the protocol for a review and there is no abstract. The objectives are as follows: To determine the benefits and safety of surgical interventions for treating FAI.
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Study design Pilot, multicentre randomised clinical trial (RCT). Objectives Assess viability of performing a definitive RCT and compare preliminary effects of movement pattern training (MoveTrain) and strengthening/flexibility (Standard) to improve function in people with chronic hip-related groin pain (HRGP). Background To determine the best physical therapist-led intervention for patients with HRGP, we must understand treatment effects of different treatment modes. Methods Forty-six patients (17M:29F; 29±5.3 years; body mass index 25.6±6.3 kg/m ² ) with HRGP were randomised. MoveTrain included task-specific training to optimise biomechanics during daily tasks. Standard included strengthening/flexibility. Treatment included 10 visits/12 weeks and home exercise programme (HEP). Primary outcomes for feasibility were recruitment, retention, treatment adherence and treatment fidelity. Secondary outcomes were patient-reported function (Hip disability and Osteoarthritis Outcome Score (HOOS)), lower extremity kinematics and hip muscle strength. Results We achieved target recruitment, and retention was excellent (91%). Patient session attendance was high (93%); however, reported HEP adherence (62%) was lower than expected. Physical therapists’ adherence to treatment protocols was high (90%). Patients demonstrated high treatment receipt; 91% of exercises performed were rated independent. Both groups demonstrated clinically important improvements in function (HOOS) and muscle strength; however, there were no between-group differences (HOOS subscales, p≥0.13, strength, p≥0.34). Compared with Standard, MoveTrain demonstrated greater reductions in hip adduction (p=0.016) and pelvic drop (p=0.026) during a single leg squat. No adverse events were noted. Conclusion Our experience in completing this RCT confirmed that a larger, multicentre RCT is feasible and highlighted modifications we will implement to optimise the future RCT. Trial registration number NCT02913222 .
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Study Design Ancillary analysis, time-controlled randomized clinical trial. Background Movement pattern training (MPT) has been shown to improve function among patients with chronic hip joint pain (CHJP). Objective Determine the association among treatment outcomes and mechanical factors associated with CHJP. Methods Twenty-eight patients with CHJP, 18-40 years, participated in MPT, either immediately after assessment or after a wait-list period. MPT included task-specific training to reduce hip adduction motion during functional tasks and hip muscle strengthening. Hip-specific function was assessed using modified Harris Hip Score (MHHS) and Hip disability and Osteoarthritis Outcome Score (HOOS). 3D kinematic data were used to quantify hip adduction motion, dynamometry to quantify abductor strength, and magnetic resonance imaging to measure femoral head sphericity using alpha angle. Paired t-tests assessed change from pre- to post-treatment. Spearman correlations assessed associations. Results There was significant improvement in MHHS and HOOS (P<.02), adduction motion (P=.045) and abductor strength (P=.01) between pre- and post-treatment. Reduction in hip adduction motion (r=-0.67, P<.01) and lower body mass index (r=-0.38, P=.049) correlated with MHHS improvement. Alpha angle and abductor strength change were not correlated with change in MHHS or HOOS. Conclusion After MPT, patients reported improvements in pain and function that was associated with their ability to reduce hip adduction motion during functional tasks. Level of Evidence Therapy, level 2b. J Orthop Sports Phys Ther, Epub 16 Mar 2018. doi:10.2519/jospt.2018.7810.
Article
Objective: Femoroacetabular impingement (FAI) and hip dysplasia (HD) are frequently evaluated by isotropic CT (3DCT) for preoperative planning at the expense of radiation. The aim was to determine if isotropic MRI (3DMR) imaging can provide similar quantitative and qualitative morphological information as 3DCT. Methods: 25 consecutive patients with a final diagnosis of FAI or HD were retrospectively selected from December 2016-December 2017. Two readers (R1, R2) performed quantitative angular measurements on 3DCT and 3DMR, blinded to the diagnosis and each other's measurements. 3DMR and 3DCT of the hips were qualitatively and independently evaluated by a radiologist (R3), surgeon (R4), and fellow (R5). Interobserver and intermodality comparisons were performed. Results: The ICC was good to excellent for all measurements between R1 and R2 (ICC:0.60-0.98) and the majority of intermodality measurements for R1 and R2. Average inter-reader and inter-modality PABAK showed good to excellent agreement for qualitative reads. On CT, all alpha angles (AA) were significantly lower in dysplasia patients than in cam patients (p < 0.05). All lateral center-edge angle (LCEA) were significantly lower in dysplasia than in cam patients (p < 0.05). On MR, AA at 12, 1, and 2 o'clock, and LCEA at center were significantly lower in dysplasia patients than in cam patients (p < 0.05). Conclusion: 3DMR offers similar qualitative and quantitative analysis as 3DCT in adult painful hip conditions. Advances in knowledge: 3DMR has good potential to replace 3DCT and serve as a one-stop modality for bone and soft tissue characterizations in the pre-operative evaluation of FAI and HD.
Article
Objective To determine if hip 3D-MR imaging can be used to accurately demonstrate femoral and acetabular morphology in the evaluation of patients with femoroacetabular impingement. Materials and methods We performed a retrospective review at our institution of 17 consecutive patients (19 hips) with suspected femoroacetabular impingement who had both 3D-CT and 3D-MRI performed of the same hip. Two fellowship-trained musculoskeletal radiologists reviewed the imaging for the presence and location of cam deformity, anterior–inferior iliac spine variant, lateral center-edge angle, and neck–shaft angle. Findings on 3D-CT were considered the reference standard. The amount of radiation that was spared following introduction of 3D-MRI was also assessed. Results All 17 patients suspected of FAI had evidence for cam deformity on 3D-CT. There was 100% agreement for diagnosis (19 out of 19) and location (19 out of 19) of cam deformity when comparing 3D-MRI with 3D-CT. There were 3 type I and 16 type II anterior–inferior iliac spine variants on 3D-CT imaging with 89.5% (17 out of 19) agreement for the anterior–inferior iliac spine characterization between 3D-MRI and 3D-CT. There was 64.7% agreement when comparing the neck–shaft angle (11 out of 17) and LCEA (11 out of 17) measurements. The use of 3D-MRI spared each patient an average radiation effective dose of 3.09 mSV for a total reduction of 479 mSV over a 4-year period. Conclusion 3D-MR imaging can be used to accurately diagnose and quantify the typical osseous pathological condition in femoroacetabular impingement and has the potential to eliminate the need for 3D-CT imaging and its associated radiation exposure, and the cost for this predominantly young group of patients.
Article
Background: A common claim in the orthopaedic literature is that acetabular dysplasia (AD) exists when the center-edge angle of Wiberg (CE angle) is <20 degrees and that AD leads to osteoarthritis (OA). Our purpose is to evaluate the validity of the linkage between AD and OA. Methods: We assess and discuss the theories and the empirical evidence relating AD to OA. Moreover, we test the rule that hips with a CE angle <20 degrees will develop OA by 65 years of age, by looking for exceptions to this rule. Results: Wiberg and Cooperman and colleagues present 30 ideal patients for assessing the relationship between AD and OA. Each was arthritis free, with stable AD, CE angle <20 degrees, without signs of subluxation. They were all followed and all developed OA. In the studies by Stulberg and colleagues, and Jacobsen and colleagues, every patient presented with OA, making it difficult to be certain about the appearance of the hip before the onset of OA. In the study by Murphy and colleagues, we have the same problem, as an unknown number of patients already had OA at first assessment. All of these studies used different schemes for diagnosing OA, making the studies difficult to compare. Most of the patients in the studies were of Northern European ancestry, making the results difficult to generalize to other populations. Four patients had CE angles <20 degrees and did not develop severe arthritis by 65 years of age. Conclusions: Our conclusions apply directly to patients of Northern European ancestry. A few patients with stable, mild AD (CE angle 15 to 19 degrees) will be arthritis free at 65 years of age. Almost all patients with stable AD develop OA by 65 years of age. Unstable AD (CE angle <20 degrees, with subluxation) always leads to OA by 65 years of age. It is probably reasonable to extend these conclusions to other populations, but the reader must be prepared to re-evaluate them, as more data accumulates.
Article
Background: Subchondral insufficiency fracture of the femoral head (SIFFH) occurs in elderly patients and might be confused with osteonecrosis of the femoral head (ONFH). Subchondral insufficiency fracture of the femoral head is an insufficiency fracture at the dome of the femoral head and has been known to be associated with osteoporosis, hip dysplasia, and posterior pelvic tilt. This study's aims were to evaluate (1) surgical complications, (2) radiological changes, (3) clinical results, and (4) survivorship of THA in patients with SIFFH. Methods: From November 2010 to June 2017, 21 patients (23 hips); 5 men (5 hips) and 16 women (18 hips) underwent cementless THA due to SIFFH at our institution. Their mean age was 71.9 years (range, 57 to 86) at the time of surgery, and mean T-score was -2.2 (range, -4.2 to 0.2). The mean lateral center-edge angle, abduction, and anteversion of the acetabulum were 29.9° (range, 14.8° to 47.5°), 38.5° (range, 31° to 45°), and 20.0° (range, 12° to 25°), respectively. The mean pelvic incidence, lumbar kyphotic angle and posterior pelvic tilt were 56.4° (range, 39° to 79°), 14.7° (range, -34° to 43°), and 13.0° (range, 3° to 34°), respectively. Results: An intraoperative calcar crack occurred in 1 hip. The mean anteversion and abduction of cup were 29.0° (range, 17° to 43°) and 43.3° (range, 37° to 50°), respectively. One patient sustained a traumatic posterior hip dislocation 2 weeks after the procedure, and was treated with open reduction. At a mean follow-up of 35.4 months (range, 24 to 79 months), no hip had prosthetic loosening or focal osteolysis. At the latest follow-up, the mean modified Harris hip score was 79.1 (range, 60 to 100) points, and mean UCLA activity score was 4.2 (range, 2 to 7) points. The survivorship was 95.7% (95% CI, 94.9% to 100%) at 6 years. Conclusions: Cementless THA is a favorable treatment option for SIFFH in elderly patients. Level of evidence: 3.
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Impingement by prominence at the femoral head-neck junction on the anterior acetabular rim may cause early osteoarthritis. Our aim was to develop a simple method to describe concavity at this junction, and then to test it by its ability to distinguish quantitatively a group of patients with clinical evidence of impingement from asymptomatic individuals who had normal hips on examination. MR scans of 39 patients with groin pain, decreased internal rotation and a positive impingement test were compared with those of 35 asymptomatic control subjects. The waist of the femoral head-neck junction was identified on tilted axial MR scans passing through the centre of the head. The anterior margin of the waist of the femoral neck was defined and measured by an angle (α). In addition, the width of the femoral head-neck junction was measured at two sites. Repeated measurements showed good reproducibility among four observers. The angle α averaged 74.0° for the patients and 42.0° for the control group (p < 0.001). Significant differences were also found between the patient and control groups for the scaled width of the femoral neck at both sites. Using standardised MRI, the symptomatic hips of patients who have impingement have significantly less concavity at the femoral head-neck junction than do normal hips. This test may be of value in patients with loss of internal rotation for which a cause is not found.
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Introduction Hip dysplasia (HD) is assumed to be an etiological factor in the development of premature hip osteoarthrosis (OA). We established the prevalences of HD and OA in adults according to qualified radio-graphic discriminators, and investigated the relationship between HD and OA. Methods Wiberg's CE angle (CE), Sharp's angle, the femoral head extrusion index, the acetabular depth ratio (ADR), the radiographic OA discriminators of Croft, and of Kellgren and Lawrence, and also minimum joint space width (JSW) ≤ 2 mm were applied to the standing, standardized pelvic radiographs of 1 429 men (22–93 years), and 2 430 women (22–92 years). Results The 4 HD discriminators were interrelated. A negligible sex-related difference in acetabular morphology was found, male acetabulae being slightly more dysplastic than female acetabulae. However, differences between the sexes for right and left CE angles were within 1.0°, and within 1.4° for right and left Sharp's angles. There were no cases of hip subluxation (breakage of Shenton's line ≥ 5 mm). Average CE angle was 34° in men (SD 7.3°), and 35° in women (SD 7.6°). Applying a CE cutoff value of 20° for designation of definite hip dysplasia, we found a prevalence of hip dysplasia of 3.4%. Approximately 2% of cases were unilateral and 1.4% of cases were bilateral. We found significant relationships between radiographic OA discriminators and the CE angle, femoral head extrusion index and ADR. Odds ratios ranged from 1.0 to 6.2. Compared to subjects with OA in morphologically normal hips, a trend towards younger age in subjects with HD and OA was noted, but this was not strictly significant.
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To determine whether mild variation in acetabular depth (AD) and shape is a risk factor for osteoarthritis (OA) of the hip. The unaffected contralateral hip of patients with unilateral hip OA was compared with hips of asymptomatic controls without hip OA, derived from the Nottingham Genetics Osteoarthritis and Lifestyle case-control study. Standardised anteroposterior x-rays of the pelvis were used to measure centre edge (CE) angle and AD. Cut-off points for narrow CE angle and shallow AD were calculated from the control group (mean -1.96 × SD). The relative risk of hip OA associated with each feature was estimated using OR and 95% CI and adjusted risks were calculated by logistic regression. In controls, both the CE angle and the AD were lower in the left hip than in the right hip. The CE angle related to age in both hips, and AD of the right hip was lower in men than in women. The contralateral unaffected hip in patients with unilateral hip OA had a decreased CE angle and AD compared with controls, irrespective of side. The lowest tertile of the CE angle in contralateral hips was associated with an eightfold risk of OA (aOR 8.06, 95% CI 4.87 to 13.35) and the lowest tertile of AD was associated with a 2.5-fold risk of OA (aOR 2.53, 95% CI 1.28 to 5.00). Significant increases in the risk of OA were also found as the CE angle and AD decreased. Constitutional mild acetabular dysplasia appears to increase the risk of hip OA.
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The acetabular rim syndrome is a pathological entity which we illustrate by reference to 29 cases. The syndrome is a precursor of osteoarthritis of the hip secondary to acetabular dysplasia. The symptoms are pain and impaired function. All our cases were treated by operation which consisted in most instances of re-orientation of the acetabulum by peri-acetabular osteotomy and arthrotomy of the hip. In all cases, the limbus was found to be detached from the bony rim of the acetabulum. In several instances there was a separated bone fragment, or 'os acetabuli' as well. In acetabular dysplasia, the acetabular rim is subject to abnormal stress which may cause the limbus to rupture, and a fragment of bone to separate from the adjacent bone margin. Dysplastic acetabuli may be classified into two radiological types. In type I there is an incongruent shallow acetabulum. In type II the acetabulum is congruent but the coverage of the femoral head is deficient.
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In a population sample health survey, body mass, previous trauma and physical stress were studied for associations with coxarthrosis. A sample of 8,000 persons representative of the Finnish population aged 30 or over was invited for examination, and 90 percent participated. On the basis of a standardized clinical examination, a physician diagnosed coxarthrosis in 6 percent of the women and 4 percent of the men. The prevalence rose with age. In persons with a past traumatic lower-limb injury, the odds ratio of unilateral coxarthrosis was 2.1 and of bilateral coxarthrosis 1.5, as adjusted for sex, age and other determinants using logistic regression. The sum index reflecting self-reported features of physical stress in present or previous occupations was directly proportional to the prevalence of coxarthrosis. Body mass index (kg/m2) was closely associated with bilateral coxarthrosis; the adjusted odds ratio (95 percent confidence intervals) for indices > 35, compared to those < 25, was 2.8 (1.4-5.7). In terms of the population attributable fraction, prior trauma, physical stress and body mass were estimated to explain 59 percent of the prevalence of coxarthrosis. The potential for primary prevention may be great, but longitudinal population studies are necessary to elucidate causal significance of the risk factors.
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To examine the association of acetabular dysplasia and osteoarthritis (OA) of the hip among elderly white women. Pelvic radiographs from a sample of 165 white women aged 65 and above with radiographic hip OA and 88 white women aged 65 and above without radiographic changes of hip OA were read for evidence of acetabular dysplasia by a single trained investigator. Acetabular dysplasia was assessed using measurements of the centre edge angle and the acetabular depth, which are both reduced in this condition. Odds ratios for the association between acetabular dysplasia and hip OA were estimated using logistic regression analysis. Fourteen (3.4%) hips had a centre edge angle < 25 degrees, 46 (11.2%) hips had an acetabular depth of < 9 mm, and 54 (13.2%) hips had acetabular dysplasia defined as either of the above. Hips with OA had a small, but not statistically significant, increased prevalence of abnormal centre edge angle (odds ratio: 1.43; 95% confidence intervals: 0.46, 4.46), abnormal acetabular depth (1.47; 0.78, 2.77) and acetabular dysplasia (1.33; 0.74, 2.40). These results do not support the hypothesis that mild acetabular dysplasia accounts for a substantial proportion of hip OA in elderly white women. A study with a much larger sample size would be required to rule out a weak association between dysplasia and hip OA of the magnitude actually observed in our study.
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We describe a little-known variety of hip dysplasia, termed ‘acetabular retroversion’, in which the alignment of the mouth of the acetabulum does not face the normal anterolateral direction, but inclines more posterolaterally. The condition may be part of a complex dysplasia or a single entity. Other than its retroversion, the acetabulum is sited normally on the side wall of the pelvis, and its articular surface is of normal extent and configuration. The retroverted orientation may give rise to problems of impingement between the femoral neck and anterior acetabular edge. We define the clinical and radiological parameters and discuss pathological changes which may occur in the untreated condition. A technique of management is proposed.
Article
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We describe a little-known variety of hip dysplasia, termed ‘acetabular retroversion’, in which the alignment of the mouth of the acetabulum does not face the normal anterolateral direction, but inclines more posterolaterally. The condition may be part of a complex dysplasia or a single entity. Other than its retroversion, the acetabulum is sited normally on the side wall of the pelvis, and its articular surface is of normal extent and configuration. The retroverted orientation may give rise to problems of impingement between the femoral neck and anterior acetabular edge. We define the clinical and radiological parameters and discuss pathological changes which may occur in the untreated condition. A technique of management is proposed.
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: To determine ethnic variations of acetabular morphology, and to delineate their relationship with hip osteoarthritis (OA). : Radiographs of 283 French men, 118 French women, 414 Japanese men and 368 Japanese women, aged 20-79 yr, who underwent intravenous urography were assessed by a single observer for morphometric measurement and hip OA scoring. : The standardized morbidity ratio (SMR) for hip OA was highest in French men and lowest in Japanese men, whereas the SMR for acetabular dysplasia was highest in Japanese women and lowest in French men. French men and women had the highest centre-edge angle, followed by Japanese men then Japanese women. : In a large number of subjects assessed by a single observer, this study confirms other previous reports that the relationship between acetabular dysplasia and risk of hip OA is negative.
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To study the influence of genetics on the development of hip osteoarthritis as determined by structural change on plain radiographs. Sibling study. Nottinghamshire, England. 392 index participants with hip osteoarthritis of sufficient severity to warrant total hip replacement, 604 siblings of the index participants, and 1718 participants who had undergone intravenous urography. Odds ratios for hip osteoarthritis in siblings. The age adjusted odds ratios in siblings were 4.9 (95% confidence interval, 3.9 to 6.4) for probable hip osteoarthritis and 6.4 (4.5 to 9.1) for definite hip osteoarthritis. These values were not significantly altered by adjusting for other risk factors. Siblings have a high risk of hip osteoarthritis as shown by structural changes on plain radiographs. One explanation is that hip osteoarthritis is under strong genetic influence.
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Impingement by prominence at the femoral head-neck junction on the anterior acetabular rim may cause early osteoarthritis. Our aim was to develop a simple method to describe concavity at this junction, and then to test it by its ability to distinguish quantitatively a group of patients with clinical evidence of impingement from asymptomatic individuals who had normal hips on examination. MR scans of 39 patients with groin pain, decreased internal rotation and a positive impingement test were compared with those of 35 asymptomatic control subjects. The waist of the femoral head-neck junction was identified on tilted axial MR scans passing through the centre of the head. The anterior margin of the waist of the femoral neck was defined and measured by an angle (alpha). In addition, the width of the femoral head-neck junction was measured at two sites. Repeated measurements showed good reproducibility among four observers. The angle alpha averaged 74.0 degrees for the patients and 42.0 degrees for the control group (p < 0.001). Significant differences were also found between the patient and control groups for the scaled width of the femoral neck at both sites. Using standardised MRI, the symptomatic hips of patients who have impingement have significantly less concavity at the femoral head-neck junction than do normal hips. This test may be of value in patients with loss of internal rotation for which a cause is not found.
Article
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To determine the prevalence of acetabular dysplasia in subjects presenting with hip pain to primary care and its relationship with radiographic osteoarthritis (OA) of the hip. Cross sectional analysis of a prospective cohort. 35 general practices across the UK. 195 patients (63 male, 132 female) aged 40 years and over presenting with a new episode of hip pain The prevalence of acetabular dysplasia in this study of new presenters with hip pain was high (32%). There was no significant relationship between acetabular dysplasia and radiographic OA overall. The high prevalence of acetabular dysplasia across all grades of OA severity suggests that dysplasia itself may be an important cause of hip pain ("symptomatic adult acetabular dysplasia").
Article
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It has been suggested that in some patients with primary hip osteoarthritis (OA), the disease occurs as a consequence of acetabular dysplasia or hip dysplasia (HD). To carry out a systematic review to investigate the association between acetabular dysplasia and hip OA. A database search of Medline, Embase, and the Cochrane library was carried out, and articles that aimed at studying the relationship between HD and hip OA were identified. The methodological quality of the selected studies was assessed using a standardised set of criteria, and a best evidence synthesis was used to summarise the results from the individual studies. Five cohort studies and four case-control studies were included in this review. One cohort study had the correct design to answer the question and was considered to be a high quality study. This study reported a positive association between HD and hip OA. Overall, limited evidence was found for a positive association between HD and hip OA. Most studies included older people. In younger age groups the relation between HD and OA or hip complaints may be much higher. The evidence for the influence of HD on the occurrence of hip OA, at age 50-60 or older, is limited.
Article
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Labrum pathology may contribute to early joint degeneration through the alteration of load transfer between, and the stresses within, the cartilage layers of the hip. We hypothesize that the labrum seals the hip joint, creating a hydrostatic fluid pressure in the intra-articular space, and limiting the rate of cartilage layer consolidation. The overall cartilage creep consolidation of six human hip joints was measured during the application of a constant load of 0.75 times bodyweight, or a cyclic sinusoidal load of 0.75+/-0.25 times bodyweight, before and after total labrum resection. The fluid pressure within the acetabular was measured. Following labrum resection, the initial consolidation rate was 22% greater (p=0.02) and the final consolidation displacement was 21% greater (p=0.02). There was no significant difference in the final consolidation rate. Loading type (constant vs. cyclic) had no significant effect on the measured consolidation behaviour. Fluid pressurisation was observed in three of the six hips. The average pressures measured were: for constant loading, 541+/-61kPa in the intact joint and 216+/-165kPa following labrum resection, for cyclic loading, 550+/-56kPa in the intact joint and 195+/-145kPa following labrum resection. The trends observed in this experiment support the predictions of previous finite element analyses. Hydrostatic fluid pressurisation within the intra-articular space is greater with the labrum than without, which may enhance joint lubrication. Cartilage consolidation is quicker without the labrum than with, as the labrum adds an extra resistance to the flow path for interstitial fluid expression. However, both sealing mechanisms are dependent on the fit of the labrum against the femoral head.
Article
To help to determine the natural history of residual dysplasia of the hip after skeletal maturity, we followed the status of the contralateral hip in 286 patients who had had a total hip replacement for osteoarthrosis secondary to dysplasia. The initial radiographic findings in seventy-four patients in whom advanced osteoarthrosis later developed in the contralateral hip were compared with those in forty-three patients who had reached the age of sixty- five years without having had severe osteoarthrosis. No patient in whom the hip functioned well until the age of sixty-five years had had a center-edge angle of less than 16 degrees, an acetabular index of depth to width of less than 38 per cent, an acetabular index of the weight-bearing zone of more than 15 degrees, uncovering of the femoral head of more than 31 per cent, or an acetabulum in which the most proximal point of the dome had been at the lateral edge (zero peak-to-edge distance).
Article
SUMMARY Objective. Geographic diVerences in the prevalence of hip osteoarthritis (OA) have been ascribed to diVerences in the frequency of acetabular dysplasia among diVerent ethnic groups. However, there are few data on the shape of the acetabulum in various populations around the world. We examined this issue in samples of pelvic radiographs from Britain and Japan. Methods. Measurements were made on the pelvic radiographs of 1303 men and 195 women, aged 60‐75 yr, who attended for i.v. urography in two British centres. These were compared with 99 men and 99 women aged 60‐79 yr who were included in a population-based study in a rural community in Japan, and who agreed to undergo standardized pelvic radiography. Acetabular dysplasia was assessed by morphometric measurement of the centre‐edge (CE ) angle and acetabular depth. Results. The mean CE angle among men was 36° (95% CI 35‐37°) in Britain and 31° (95% CI 29‐32°) in Japan; that in women was 37° (95% CI 36‐38°) in Britain and 31° (95% CI 29‐33°) in Japan. The mean values of acetabular depth were also significantly (P< 0.001) lower in Japan than in Britain. However, the prevalence of hip OA was lower in Japan (0% in men, 2% in women) than in Britain (11% in men, 4.8% in women). In a random eVects model, there were negative relationships between measures of acetabular dysplasia and minimum joint space among individuals. Conclusions. We conclude that there are marked diVerences in pelvic morphometry between Britain and Japan. The acetabular dimensions of Japanese subjects are considerably shallower than those of their British counterparts of similar age and sex. Nevertheless, hip OA is more frequent in Britain than in Japan. Further studies are required on the risk factors for hip OA in Oriental populations, in order that the aetiology of this disorder can be better understood.
Article
Objectives: To study the influence of genetics on the development of hip osteoarthritis as determined by structural change on plain radiographs. Design: Sibling study. Setting: Nottinghamshire, England. Participants: 392 index participants with hip osteoarthritis of sufficient severity to warrant total hip replacement, 604 siblings of the index participants, and 1718 participants who had undergone intravenous urography. Main outcome measure: Odds ratios for hip osteoarthritis in siblings. Results: The age adjusted odds ratios in siblings were 4.9 (95% confidence interval, 3.9 to 6.4) for probable hip osteoarthritis and 6.4 (4.5 to 9.1) for definite hip osteoarthritis. These values were not significantly altered by adjusting for other risk factors. Conclusion: Siblings have a high risk of hip osteoarthritis as shown by structural changes on plain radiographs. One explanation is that hip osteoarthritis is under strong genetic influence.
Article
The purpose of this study was to establish that anterior hip impingement, secondary to an anterior femoral offset deficiency from a pistol-grip deformity, was a common etiology of hip disorders. This impingement results in a spectrum of injury ranging from anterior hip pain, labral tears, damage to the acetabular articular cartilage and idiopathic arthritis. This was accomplished through three separate but closely related studies: (1) an arthroscopic labral tear study of 38 patients who had hip arthroscopy for a labral tear (2) a hip cheilectomy study of 10 patients who had a cheilectomy for anterior femoroacetabular impingement and (3) an idiopathic arthritis study of 200 consecutive patients having THA. In all three studies, a common etiology was identified. Repetitive anterior femoroacetabular impingement resulted in anterior groin pain, labral tears, chondral damage and eventually arthritis. This impingement was caused by a pistol-grip deformity of the proximal femur in 97% of the cases in the arthroscopic labral study and 100% of the cases in the idiopathic arthritis study. The identification of anterior hip impingement as a cause of labral tears and idiopathic arthritis may allow surgeons to correct it early in its natural history and delay or prevent end-stage arthritis.
Article
Background: Acetabular retroversion can result from posterior wall deficiency in an otherwise normally oriented acetabulum or from excessive anterior coverage secondary to a malpositioned acetabulum, or both. Theoretically, a retroverted acetabulum, which adversely affects load transmission across the hip, may occur more frequently in hips with degenerative arthritis. The aim of this study was to assess the prevalence of acetabular retroversion in normal hips and in hips with osteoarthritis, developmental dysplasia, osteonecrosis, and Legg-Calvé-Perthes disease. Methods: We retrospectively examined anteroposterior radiographs of the pelvis of 250 patients (342 hips). Fifty-six patients (112 hips) had normal findings; sixty-six patients (seventy hips) had osteoarthritis; sixty-four (seventy-four hips), developmental dysplasia; thirty (thirty-six hips), osteonecrosis of the femoral head; and thirty-four (fifty hips), Legg-Calvé-Perthes disease. The sole criterion for a diagnosis of acetabular retroversion was the presence of a so-called cross-over sign on the anteroposterior radiograph of the pelvis. Results: The prevalence of acetabular retroversion was 6% (seven of 112 hips) in the normal group, 20% (fourteen of seventy hips) in the osteoarthritis group, 18% (thirteen of seventy-four hips) in the developmental dysplasia group, 6% (two of thirty-six hips) in the group with osteonecrosis of the femoral head, and 42% (twenty-one of fifty hips) in the group with Legg-Calvé-Perthes disease. In patients with Legg-Calvé-Perthes disease, the prevalence of acetabular retroversion was 68% in twenty-five hips with Stulberg class-III, IV, or V involvement. In contrast, only four (16%) of twenty-five hips with Stulberg class-I or II involvement had acetabular retroversion. The difference was significant (p = 0.0002). Patients with osteoarthritis, developmental dysplasia, or Legg-Calvé-Perthes disease are significantly more likely to have acetabular retroversion than are normal subjects (p < 0.05). Conclusions: Acetabular retroversion occurs more commonly in association with a variety of hip diseases, in which the prevalence of subsequent degenerative arthritis is increased, than has been previously noted.
Article
As the most common form of joint disease, osteoarthritis (OA) is associated with an extremely high economic burden. This burden is largely attributable to the effects of disability, comorbid disease, and the expense of treatment. Although typically associated with less severe effects on quality of life and per capita expenditures than rheumatoid arthritis, OA is nevertheless a more costly disease in economic terms because of its far higher prevalence. At the same time, the burden of OA is increasing. While direct and indirect per capita costs for OA have stabilized in recent years, the escalating prevalence of the disease-partly a function of the rapid increase in 2 major risk factors: aging and obesity-has led to much higher overall spending for OA. Approximately one-third of direct OA expenditures are allocated for medications, much of which goes toward pain-related agents. Hospitalization costs comprise nearly half of direct costs, although these expenditures are consumed by only 5% of OA patients who undergo knee or hip replacement surgery. However, while these surgeries are costly, they also appear to be quite cost-effective in the long term. Indirect costs for OA are also high, largely a result of work-related losses and home-care costs. Despite the need for wide-ranging and up-to-date data on the economics of OA treatment to clarify the most effective treatments and the best use of resources, this area of study has received insufficient research attention.
Article
Hip osteoarthritis is a major cause of pain and disability. The authors explored individual risk factors for hip osteoarthritis in a population-based case-control study. The study was performed in two English health districts (Portsmouth and North Staffordshire) from 1993 to 1995. A total of 611 patients (210 men and 401 women) listed for hip replacement because of osteoarthritis over an 18-month period were compared with an equal number of controls selected from the general population and individually matched for age, sex, and family practitioner. Information about suspected risk factors was obtained by a questionnaire administered at interview and a short physical examination. Obesity (odds ratio (OR) = 1.7, 95% confidence interval (CI) 1.3-2.4; highest vs. lowest third of body mass index), previous hip injury (OR = 4.3, 95% CI 2.2-8.4), and the presence of Heberden's nodes (OR = 1.6, 95% CI 1.2-2.2) were independent risk factors for hip osteoarthritis among men and women. Hip injury was more closely related to unilateral as compared with bilateral disease. There were a negative association between cigarette smoking and osteoarthritis among men and a weak positive association with prolonged regular sporting activity. Obesity and hip injury are important independent risk factors for hip osteoarthritis, which might be amenable to primary prevention. Hip osteoarthritis may also arise as part of the polyarticular involvement found in generalized osteoarthritis.
Article
To create a comprehensive evaluation of checklists and scales used to evaluate observational studies that examine incidence or prevalence and risk factors for diseases. We did a literature search of several databases to abstract format, content, development, and validation of the tools. We identified 46 scales and 51 checklists. Forty-seven of these tools were created for therapeutic studies, 48 for risk factors, and 5 for incidence studies. Forty-seven percent were modifications of previously published peer-reviewed appraisals, 18% were developed based on methodological standards, and 35% did not report development. Twenty-two percent reported reliability and 10% the validation procedure. Tools did not discriminate poor reporting vs. methodological quality of studies or external vs. internal validity; 35% categorize quality by the presence of predefined major flaws in design or by total score from the scale. Level of evidence was proposed in 22% of the tools by criteria of causality or internal validity of the studies. Evaluation required different degrees of subjectivity. Format, length, and content varied substantially across available checklists and scales. Development, validation, and reliability were not consistently reported. Transparent objective quality assessments should be developed in the future.
Article
Although the clinical consequences of femoroacetabular impingement have been well described, little is known about the prevalence of the anatomical malformations associated with this condition in the general population, the natural history of the condition, and the risk estimates for the development of osteoarthritis. The study material was derived from a cross-sectional population-based radiographic and questionnaire database of 4151 individuals from the Copenhagen Osteoarthritis Substudy cohort between 1991 and 1994. The subjects were primarily white, and all were from the county of Østerbro, Copenhagen, Denmark. The inclusion criteria for this study were met by 1332 men and 2288 women. On the basis of radiographic criteria, the hips were categorized as being without malformations or as having an abnormality consisting of a deep acetabular socket, a pistol grip deformity, or a combination of a deep acetabular socket and a pistol grip deformity. Hip osteoarthritis was defined radiographically as a minimum joint-space width of <or=2 mm. The male and female prevalences of hip joint malformations in the 3620 study subjects were 4.3% and 3.6%, respectively, for acetabular dysplasia; 15.2% and 19.4% for a deep acetabular socket; 19.6% and 5.2% for a pistol grip deformity; and 2.9% and 0.9% for a combination of a deep acetabular socket and pistol grip deformity. The male and female prevalences of a normal acetabular roof were 80.5% and 77.0%. We found no significantly increased prevalence of groin pain in subjects whose radiographs showed these hip joint malformations (all p > 0.13). A deep acetabular socket was a significant risk factor for the development of osteoarthritis (risk ratio, 2.4), as was a pistol grip deformity (risk ratio, 2.2). Acetabular dysplasia and the subject's sex were not found to be significant risk factors for the development of hip osteoarthritis (p = 0.053 and p = 0.063, respectively). The prevalence of hip osteoarthritis was 9.5% in men and 11.2% in women. The prevalence of concomitant malformations was 71.0% in men with hip osteoarthritis and 36.6% in women with hip osteoarthritis. In our study population, a deep acetabular socket and a pistol grip deformity were common radiographic findings and were associated with an increased risk of hip osteoarthritis. The high prevalence of osteoarthritis in association with malformations of the hip joint suggests that an increased focus on early identification of malformations should be considered.
Article
To investigate the prevalence of hip osteoarthritis (OA) in a community-based elderly Korean population and to identify its risk factors. Radiographs of hip and knee were evaluated in 288 men and 386 women (age>or=65 years) that participated in the Korean Longitudinal Study on Health and Aging (KLoSHA). Minimum joint space widths (JSW), center-edge angles (CEA), and neck-shaft angles were measured on hip radiographs, and tibio-femoral angles on knee radiographs. Hip OA was defined as minimum JSW of <or=2mm or <or=2.5mm. The following potential risk factors of OA were examined; demographic data, acetabular dysplasia, large CEA (>or=40 degrees) and deformities of femoral neck and knee joint. Multivariate analysis with generalized estimating equation (GEE) model was performed to exclude confounding factors. When hip OA was defined as JSW<or=2mm, the overall prevalence of the disease was 2.1% (95% confidence interval [CI], 1.0-3.2%), and only older age (>or=70 years) was identified as a significant risk factors with an odds ratio (OR) of 10.0. However, when hip OA was defined as a JSW of <or=2.5mm, the overall prevalence of the disease was 13.1% (95% CI, 10.5-15.6%), and older age (>or=70 years), female, large CEA (>or=40 degrees), and acetabular dysplasia (CEA<20 degrees) were identified as significant risk factors with ORs of 2.1, 2.1, 2.3, and 10.2, respectively. The prevalence of hip OA in elderly Korean was 2.1% (JSW<or=2mm) in community-based population. Older age (>or=70 years), female, large CEA (>or=40 degrees), and acetabular dysplasia (CEA<20 degrees) appeared to be significant risk factors of hip OA.
Article
Hip dysplasia leads to abnormal loading of articular cartilage, which results in osteoarthritis. The purpose of this study was to investigate the anatomic and demographic factors associated with the early onset of osteoarthritis in dysplastic hips by utilizing the delayed gadolinium-enhanced magnetic resonance imaging of cartilage (dGEMRIC) index as a marker of the disease. Ninety-six symptomatic dysplastic hips in seventy-four patients were assessed with standard radiographs and a dGEMRIC scan. The lateral center-edge angle of Wiberg, the acetabular index of Tönnis, and the break in the Shenton line were measured on a standing anteroposterior radiograph. Anterior undercoverage was assessed by measuring the anterior center-edge angle on a Lequesne false-profile view. A labral tear was considered to be present when contrast agent was seen through the entire thickness of the labrum on magnetic resonance arthrography. Osteoarthritis was defined as a dGEMRIC value of <390 msec (two standard deviations below the dGEMRIC index in normal hips). The mean dGEMRIC index (and standard deviation) for this cohort (473 +/- 104 msec) was significantly lower than that of a morphologically normal hip (570 +/- 90 msec). The anterior center-edge angle, the joint space width, and the presence of a labral tear were all found to be associated with osteoarthritis in the univariate analysis. Multivariate analysis identified age, the anterior center-edge angle, and the presence of a labral tear as independent factors associated with osteoarthritis. A second model was fitted with omission of the anterior center-edge angle because the lateral and anterior center-edge angles were highly correlated and the lateral center-edge angle is a more common clinical measure. This model identified age, the lateral center-edge angle, and the presence of a labral tear as significant independent factors associated with osteoarthritis. As has been demonstrated in previous studies of the hip, this investigation showed osteoarthritis to be associated with increasing age and the severity of dysplasia, as demonstrated both by the Wiberg lateral center-edge angle and the Lequesne anterior center-edge angle. Additionally, we identified a labral tear as being a risk factor for osteoarthritis.
Article
The relation between acetabular dysplasia and osteoarthritis of the hip was examined in a series of 1516 pelvic radiographs taken for non-skeletal indications. Osteoarthritis was assessed by measuring joint space, and dysplasia by the centre-edge angle and acetabular depth. In contrast with previous studies of patients with symptomatic osteoarthritis of the hip, no evidence that dysplasia predisposes to osteoarthritis was found. Possible reasons for the discrepancy are discussed. It was concluded that although acetabular dysplasia may lead to osteoarthritis of the hip in some subjects, it is unlikely to be an important cause of the disease in men.
Article
In most reports on osteoarthritis of the hip approximately half the patients have presented in adult life with no relevant antecedent history. In order to assess, in such cases of so-called primary osteoarthritis, the presence of any minor pre-existing anatomical abnormality, the pelvic radiographs of 200 cases of this type were examined. No case in which the changes could be attributed to symptomatic disorder earlier in life was accepted. In this connection a few cases showing a protrusio acetabuli deformity were arbitrarily regarded as being secondary to inflammatory change of a rheumatoid nature and were therefore excluded. The cases were divided by visual assessment into those arising in the presence of (a) normal anatomy; (b) abnormal anatomy. The variations in the latter group included imperfect acetabular development—acetabular dysplasia—and an abnormal relationship of the femoral head to the femoral neck, comparable to the residual adult deformity of epiphysiolysis in adolescence. This abnormality was designated the tilt deformity. These different types showed somewhat different radiological features. Each hip, together with a control series of 100 hips, was then subjected to geometrical measurement. To assess acetabular dysplasia, the well recognised C E angle of Wiberg was used, but this was supplemented by a new measurement, the acetabular depth, which is considered to be simpler and more reliable when the joint architecture is disturbed by osteoarthritis. The tilt deformity required a new measurement—the femoral head ratio (FHR). The techniques for these measurements are described. These measurements, compared with the control series, were statistically significant (P<0·001) in the case of each of these anatomical abnormalities. Osteoarthritis arising in the presence of normal anatomy, here described as idiopathic, was found in 35 per cent with a female to male preponderance of approximately 4:1. The average age of onset of symptoms was 57·7 years. Osteoarthritis arising in the presence of abnormal anatomy accounted for the remaining 65 per cent. That associated with acetabular dysplasia represented 25·5 per cent of the whole series and also showed a female to male preponderance of approximately 4:1 with a rather earlier average age of onset of symptoms—50·8 years. This type appears to be a forme fruste of congenital dislocation of the hip. The tilt deformity was found in 39·5 per cent with a marked variation in sex incidence, approximately six males being affected for every female. The age of onset of symptoms in this group was 51·5 years. The balance of evidence suggests that this anatomical variation results from minor and unrecognised trauma in adolescence. It is considered that these minor anatomical variations can be recognised from more critical examination of pelvic radiographs and that their presence should indicate joint incongruity and potential osteoarthritic change. Conversely a normal adult pelvic radiograph makes the subsequent development of osteoarthritis of the hip much less likely. Earlier recognition of degenerative change may permit earlier treatment by osteotomy and arrest of the process of deterioration.
Article
Twenty adults (32 hips) with acetabular dysplasia were followed up for an average of 22 years to determine the natural history of the disorder. Initially, all hips had a center-edge (CE) angle of Wiberg of 20 degrees or less and an essentially intact Shenton's line with no roentgenographic evidence of osteoarthritis. Average patient age initially was 43 years (range, 27-57 years) and at final follow-up examination, 65 years. Various parameters of hip integrity were measured, including the CE angle of Wiberg, acetabular angle of Sharp, percentage of the femoral head covered by the acetabulum, acetabular depth, and inclination of the lateral lip of the acetabulum. None of these indicators proved a reliable prognostic aid for predicting the rate at which the osteoarthritis process supervened in any one case.
Article
To help to determine the natural history of residual dysplasia of the hip after skeletal maturity, we followed the status of the contralateral hip in 286 patients who had had a total hip replacement for osteoarthrosis secondary to dysplasia. The initial radiographic findings in seventy-four patients in whom advanced osteoarthrosis later developed in the contralateral hip were compared with those in forty-three patients who had reached the age of sixty-five years without having had severe osteoarthrosis. No patient in whom the hip functioned well until the age of sixty-five years had had a center-edge angle of less than 16 degrees, an acetabular index of depth to width of less than 38 per cent, an acetabular index of the weight-bearing zone of more than 15 degrees, uncovering of the femoral head of more than 31 per cent, or an acetabulum in which the most proximal point of the dome had been at the lateral edge (zero peak-to-edge distance).