Coxa Profunda Research Articles

The correlation between femoroacetabular impingement and superior retinacular artery interruption.

The aim of this study was to investigate the relationship between femoroacetabular impingement (FAI) and superior retinacular artery interruption using plain radiographs and digital subtraction angiography (DSA).Sixty-one patients included in this study were divided into 2 groups based on the superior retinacular artery integrity as evaluated on DSA images. Group A included intact arteries: 33 patients (24 men, 9 women,); group B included interrupted arteries: 28 patients (21 men, 7 women). The parameters of abnormal radiographic findings thought to be associated with FAI, including positive crossover or figure-of-eight sign of acetabulum, lateral center edge angle (LCEA) >40°, Tönnis angle <0°, positive posterior wall sign, alpha angle >50°, and coxa profunda, were evaluated in all patients through plain radiographs.The cross-over sign (Group A: 0, Group B: 8, P = .0035), LCEA (Group A: 1, Group B: 7, P = .0190), Tönnis angle (Group A: 3, Group B: 13, P = .0026), and alpha angle (Group A: 7, Group B: 17, P = .0039) differed significantly between both groups. However, there were no statistically significant differences in posterior wall sign (Group A: 9, Group B: 12, P = .3143) or coxa profunda (Group A: 12, Group B: 8, P = .7096).Patients with interrupted blood supply of the superior retinacular arteries displayed more parameters of abnormal radiographic findings associated with FAI thereby indicating potential correlation between FAI and the interruption of superior retinacular arteries.

Preoperative Use of a 3D Printed Model for Femoroacetabular Impingement Surgery and Its Effect on Planned Osteoplasty.

The purpose of this study was to determine the effect that preoperative use of 3D printed models has on planned osteoplasty for femoroacetabular impingement (FAI) surgery. This experimental study utilizing retrospective data included 10 consecutive patients from July 1, 2013, to January 1, 2015, with a clinical diagnosis of FAI and imaging consisting of radiographs, CT scans, and MR images. Three-dimensional models of each patient's affected hip were printed to scale from CT data. Two orthopedic surgeons evaluated each patient in a routine preoperative manner. The effect of the 3D models in altering the planned osteoplasty was then determined. Proportions of osteoplasty change were calculated at various positions, and categoric variables were assessed with the chi-square test for independence. Proportions of osteoplasty changes ranged from 20% to 55% at femoral positions (greatest at lateral and depth positions) and 35-75% at acetabular positions (greatest at anterior and depth positions). More osteoplasty changes occurred in patients with alpha angles of 60° or more (p = 0.00030) and without a radiographic crossover sign (p = 0.0075). We found no difference in the proportion of osteoplasty changes when stratifying by lateral center edge angle and coxa profunda (p = 0.190 and 0.109, respectively). The planned osteoplasty was changed for at least one reader in 9/10 (90%) femurs and 10/10 (100%) acetabula. Use of 3D models in preoperative planning can change both the extent and location of planned osteoplasty for FAI surgery and is particularly influential in patients with alpha angles of 60° or more and without a radiographic crossover.

The Correlation Between Hip Morphology and Hip Osteoarthritis: A Cross- Sectional Study

Background: Osteoarthritis (OA) is a highly prevalent chronic degenerative joint disease with different risk factors, which need to be investigated in order to perform more appropriate interventions in earlier phases of Osteoarthritis. Objectives: Therefore, the aim of this study was to determine the correlation between hip morphology and hip Osteoarthritis. Methods: This cross-sectional study was conducted on patients aged 15 to 60 years old with hip problems, diagnosed with hip Osteoarthritis, compared with healthy individuals as the control group. Then radiographic parameters, such as alpha angle, acetabular angle of sharp (AA), lateral center-edge angle (LCEA), femoral neck-shaft angle (FNA), coxa profunda, acetabular protrusio, crossover sign, posterior wall sign, and the ischial sign were measured by pelvic (AP) X-ray, using PACS systems in both groups. Results: This study found that alpha angle and AA were significantly greater in OA patients as compared to healthy individuals (P 0.05). By grouping studied angles, it was found that the frequency of alpha angle > 55°, AA > 38°, and LCEA > 40° were significantly higher in the OA group as compared to the control group (P < 0.05). Furthermore, the researchers observed that the frequency of acetabular protrusio (P = 0.013) and posterior wall sign were significantly higher in the OA group as compared to healthy individuals (P < 0.05). Conclusions: The current results showed that the higher Body Mass Index (BMI), greater alpha and acetabular angles, sharp, lateral center-edge angle center-edge angle, the higher rate of a posterior wall sign, and acetabular protrusio increased the risk of OA, which support that these structural changes are major contributors to OA development.

Hip malformation is a very common finding in young patients scheduled for total hip arthroplasty.

In Denmark, 20% of all registered total hip arthroplasties (THA) from 1995 to 2014 has been patients younger than 60years with primary idiopathic osteoarthritis (OA). It is speculated that hip malformations may be a major contributor to early OA development. It has been shown that hip malformation may compromise implant position and, therefore, identifying and knowing the incidence of malformations is important. Our aim was to assess the prevalence and type of hip malformations in a cohort of younger patients undergoing THA. In this prospective two center cohort study, 95 consecutive patients (106 hips) met the inclusion criteria. One observer performed radiographic measurements for malformations and radiographic OA. Inter- and intraobserver variability was assessed. From 95 patients (male n = 52 and female n = 43) age ranged from 35 to 59years and prevalences of hip malformations were; CAM-deformity 50.9 and 25.5%, coxa profunda 33 and 27.4%, acetabular retroversion 33 and 29.2%, and acetabular dysplasia 10.4 and 3.8%. All patients showed minimum of one malformation. Prevalences of Tönnis grade 0-1 were 22.6% and 2-3 were 77.4%. All patients showed malformations, especially high prevalences were found for CAM-deformity, coxa profunda and acetabular retroversion. Identifying these malformations is fairly simple and recognizing the high prevalence may help surgeons avoid pitfalls during implant positioning in THA surgery. Further, focus on hip malformations may facilitate correct referral to joint-preserving surgery before OA develops.

Minimum 2-Year Outcomes of Hip Arthroscopic Surgery in Patients With Acetabular Overcoverage and Profunda Acetabulae Compared With Matched Controls With Normal Acetabular Coverage

Background: Advancements in instrumentation and techniques have extended the scope of hip arthroscopic surgery to treat complex osseous deformities that were previously best addressed with an open approach. Global pincer-type femoroacetabular impingement is an example of an abnormality requiring osseous correction with a technically challenging access point. Purpose: To report on the patterns of clinical presentation and intra-articular derangements, radiological associations, and minimum 2-year outcomes after hip arthroscopic surgery in patients with a lateral center edge angle (LCEA) >40° and profunda acetabulae in comparison with matched controls with normal acetabular coverage. Study Design: Cohort study; Level of evidence, 3. Methods: Data were collected on all patients undergoing hip arthroscopic surgery during the study period from April 2008 to April 2013. All patients who had undergone hip arthroscopic surgery for symptomatic labral tears not responsive to a minimum of 3 months of physical therapy with both an LCEA >40° and profunda acetabulae, as defined by the ilioischial line lateral to the medial border of the teardrop, and without a history of hip surgery or hip conditions were included. This group was matched in a 1-to-1 ratio with a control group that had also undergone the arthroscopic management of symptomatic labral tears refractory to a minimum of 3 months of physical therapy with an LCEA between 25° and 40° according to age within 3 years, sex, body mass index category, Tönnis grade, labral treatment, and capsular treatment. Range of motion, impingement signs, and radiographic indices of coverage and version were recorded for each group. Four patient-reported outcome (PRO) scores, the visual analog scale (VAS) for pain, patient satisfaction, revision hip arthroscopic surgery, and conversion to total hip arthroplasty (THA) were also recorded. Results: Thirty-nine patients met the inclusion criteria for the study (overcoverage) group, of which 36 (92.3%) patients had a minimum 2-year follow-up; 215 patients satisfied the inclusion criteria for the control (normal coverage) group, of which 183 (85.1%) had a minimum 2-year follow-up. Thirty-six patients were matched in each group using the above criteria. There was no difference with respect to range of motion and impingement signs between the groups. The study group had significantly higher radiological markers of overcoverage but not retroversion compared with the control group. The study group had a significantly higher incidence of Seldes type 2 tears compared with the control group: 50.0% versus 19.4%, respectively (P = .013). Both groups demonstrated significant improvements in the mean scores of all PROs, but the study group had a lower magnitude of improvement for all the PROs compared with the control group, with the modified Harris Hip Score (mHHS) achieving statistical significance: 13.5 versus 21.7 points, respectively (P = .032). The study group had a significantly lower mean patient satisfaction score compared with the control group: 6.61 versus 7.91, respectively (P = .019). The study group also had a significantly higher incidence of conversion to THA compared with the control group: 4 versus 0, respectively (P = .040). Conclusion: Hip arthroscopic surgery for the management of symptomatic labral tears in patients with combined overcoverage and coxa profunda is associated with improvements in patient outcomes and pain at a minimum 2-year follow-up. However, the degree of improvement is of lower magnitude compared with a matched cohort with normal coverage undergoing the arthroscopic management of symptomatic labral tears. While hips with lateral overcoverage combined with coxa profunda may have a smaller potential for improvement compared with hips with normal coverage, this type of osseous morphology is still repairable with arthroscopic treatment.

Radiographic Diagnosis of Pincer-Type Femoroacetabular Impingement: A Systematic Review.

Background:Femoroacetabular impingement (FAI) is a well-recognized condition that causes hip pain and can lead to early osteoarthritis if not managed properly. With the increasing awareness and efficacy of operative treatments for pincer-type FAI, there is a need for consensus on the standardized radiographic diagnosis.Purpose:To perform a systematic review of the evidence regarding imaging modalities and radiographic signs for diagnosing pincer-type FAI.Study Design:Systematic review; Level of evidence, 4.Methods:A literature review was performed in 2016 using the Cochrane, PubMed, and Embase search engines. All articles focusing on a radiographic diagnosis of pincer-type FAI were reviewed. Each of the included 44 articles was assigned the appropriate level of evidence, and the particular radiographic marker and/or type of imaging were also summarized.Results:There were 44 studies included in the final review. Most of the articles were level 4 evidence (26 articles), and there were 12 level 3 and 6 level 2 articles. The crossover sign was the most commonly used radiographic sign (27/44) followed by the lateral center-edge angle (22/44). Anteroposterior (AP) pelvis plain radiographs were the most commonly used imaging modality (33 studies). Poor-quality evidence exists in support of most currently used radiographic markers, including the crossover sign, lateral center-edge angle, posterior wall sign, ischial spine sign, coxa profunda, acetabular protrusion, and acetabular index. There is poor-quality conflicting evidence regarding the use of the herniation pit to diagnose pincer-type FAI. Some novel measurements, such as β-angle, acetabular roof ratio, and acetabular retroversion index, have been proposed, but they also lack support from the literature.Conclusion:No strong evidence exists to support a single best set of current radiographic markers for the diagnosis of pincer-type FAI, largely due to the lack of better quality trials (levels 1 and 2) that compare conventional radiographic findings with the gold standard, which is the intraoperative findings. More sophisticated imaging modalities such as computed tomography and magnetic resonance arthrography are often needed to diagnose pincer-type FAI, and these investigations are relatively accurate in assessing labral pathology or cartilage damage.

Minimum 2-Year Outcomes of Arthroscopic Management of Symptomatic Hip Labrum Tears in Patients With Global Acetabular Overcoverage

To report minimum 2-year patient-reported outcomes (PROs) after hip arthroscopy (HA) for symptomatic labral tears in patients with global acetabular overcoverage. This study was a retrospective case series of patients who underwent HA from April 2008 to April 2013. The inclusion criteria were patients with global acetabular overcoverage, defined as a lateral center-edge angle greater than 40°, and with coxa profunda, defined radiologically by the ilioischial line lateral to the acetabular floor. Only patients with minimum 2-year follow-up and no history of hip conditions or surgery were included. We recorded demographic, examination, radiologic, and intraoperative findings; intraoperative procedures performed; and the following PROs: modified Harris Hip Score (mHHS), Non-Arthritic Hip Score, Hip Outcome Score-Activities of Daily Living (HOS-ADL), Hip Outcome Score-Sports-Specific Subscale (HOS-SSS), visual analog scale, and patient satisfaction. The inclusion criteria were met by 39 patients, of whom 35 (89.7%) had 2-year follow-up. There was no distinct pattern of examination findings. The study population had a mean acetabular inclination of-1.19° and an anterior center-edge angle of 35°. There was no association with measures of acetabular retroversion. Intrasubstance tearing of the labrum occurred in 75% of patients (mean tear size, 2.68 hours on acetabular clock face; mean location, 11.5 to 3 on acetabular clock face). There were significant improvements in the mean scores for all PROs: mHHS, 13.5 ± 17.7 points (P < .01); Non-Arthritic Hip Score, 14.3 ± 21.3 (P < .001); HOS-ADL, 11.6± 19.7 (P < .001); HOS-SSS, 17.1 ± 35.1 (P < .001); and visual analog scale,-2.77 ± 2.58 (P < .001). The mean patient satisfaction rating was 6.61. The improvements in mHHS, HOS-ADL, and HOS-SSS did not reach the minimal clinically important difference. The incidence of secondary procedures was 17% (4 patients underwent conversion to total hip arthroplasty and 2 required revision HA). HA in patients with global acetabular overcoverage was associated with improvements in PROs and pain at minimum 2-year follow-up. However, these improvements did not reach the minimal clinically important difference for the mHHS, HOS-ADL, and HOS-SSS. The incidence of secondary procedures was 17%. The pattern of labral injury is predominantly intrasubstance labral damage with a narrow rim of adjacent chondral injury. Level IV, therapeutic case series.

Detection of Acetabular and Proximal Femoral Radiographic Abnormalities Showed by Hip Digital Tomosynthesis in Special Functional Position Compared with Conventional Radiography

Background: The acetabular and proximal femoral bone abnormalities are very common in the clinical practice. Conventional radiography has some difficulties in detecting early osseous changes. Digital tomosynthesis (DT) can remove the overlap of the anatomical structures, which improves the detection of early osseous changes. A special functional position can simulate the status of clinical symptoms; provide more evidence for clinical study of the acetabular and proximal femoral bone abnormalities and improve the accuracy. Objectives: To evaluate the diagnostic value of hip digital tomosynthesis at special functional position (DT-SFP) in detecting acetabular and proximal femoral radiographic abnormalities compared with conventional radiography. Patients and Methods: Ninety-four consecutive patients with discomfort around the hip joint underwent DT-SFP and conventional radiography. The imaging features of the acetabular and proximal femoral bone abnormalities were analyzed and the detection rate of the two methods was compared by chi-square test. Results: The herniation pits (HPs) of the femoral neck, acetabular/labral ossification, femoral head-neck junction bone protrusion, acetabular cysts, and acetabular osteophytes were detected by DT-SFP and conventional radiography. The detection rates of DT-SFP were 35%, 21%, 33%, 17% and 40% respectively, which were significantly higher than conventional radiography (21%, 9%, 10%, 7% and 31% respectively) (P = 0.000, 0.000, 0.000, 0.000, 0.001). The detection rate of coxa profunda, posterior wall sign and hip joint space narrowing showed no significant difference between using DT-SFP and conventional radiography (41%, 8% and 6% respectively) (P = 1.000, 1.000, 1.000). Conclusion: DT-SFP can improve the detection of relatively early bone abnormalities in acetabular and proximal femur compared with conventional radiography. DT-SFP can also observe the abnormal impact between acetabular and proximal femur.

Treatment of mixed type femoroacetabular impingement using safe surgical hip dislocation in adults

This study aims to assess the experience gained in a single institution in the treatment of mixed type femoroacetabular impingement (FAI) using safe surgical hip dislocation (SSHD) technique. In this study, 22 hips of 21 patients (7 males, 14 females; mean age 33.8±10.6 years; range 19-52 years) treated by SSHD technique in our clinic between October 2009 and October 2014 were retrospectively evaluated. Preoperative and final Harris hip scores (HHS) and alpha angles were compared. Age, gender, laterality, impingement tests, preoperative HHS, cam and pincer type FAI radiographic indicators and intraoperative articular findings were assessed in terms of their influence to the final functional outcomes. Mean duration of the symptoms was 29.5 months. Groin pain, activated by flexion and internal rotation of the hip, was the main symptom. A radiographic diagnosis of "mixed type FAI" was made in all hips. Mean follow-up duration of 22 hips was 48 months. The difference between the mean preoperative and latest HHS was statistically significant (60.0 vs. 87.6 points, p<0.001). The treatment was considered satisfactory in 17 of 22 hips (77%) having a mean HHS of 95.0 points. Hips having a preoperative HHS of less than 60 points were more prone to unsatisfactory outcome. Among the investigated patient-dependent, clinical, radiographic variables and intraoperative articular findings, coxa profunda sign in a plain radiograph was found correlated with a higher rate of unsatisfactory outcome (p=0.040). Safe surgical hip dislocation procedure has a success rate of 77% after a mean follow-up of four years. Coxa profunda sign is associated with the unsatisfactory clinical outcome. Preoperative HHS of less than 60 points seems to be a negative predictive variable on the clinical outcome.

How common it is? How often we miss it????

Background: Coxa profunda or deep acetabular socket is a variant of cam type of femoroacetabular impingement (FAI). It is a common radiographic finding in patients with painful hip which is often missed. The diagnosis of this condition plays a vital role in the approach towards the treatment and functional outcome of the treatment. The purpose of this study is to determine the prevalence of coxa profunda. Materials and Methods: In this study a total of 117 pelvis with bilateral radiographs out of which 77 patients with positive radiographic findings for coxa profunda are analysed retrospectively. The study was done at R.L. Jalappa Hospital and Research Centre, Tamaka. Kolar. Patients with positive radiographic findings are called and taken thorough history and examination done to know whether patients are symptomatic or not. Results: Among 117 patient radiographs taken for the study 77 patients are diagnosed with coxa profunda. The results were analysed on clinical findings like positive stress test for pincer type of femoroacetabular index and also parameters like medialization of floor of fossa acetabuli, increase in lateral centre edge angle(CE), decrease in acetabular index (tonni’s angle),decrease in femoral head extrusion index, femoral acetabular over coverage are taken into consideration for the diagnosis of this condition. Conclusion: Coxa profunda is a common variation of pincer type of femoroacetabular impingement which is often missed.

Arthroscopic treatment of global pincer-type femoroacetabular impingement.

Few studies have evaluated the role of hip arthroscopy in patients with coxa profunda. The purposes of this study are to (1) report functional hip outcomes after arthroscopic treatment of patients with femoroacetabular impingement (FAI) associated with radiographic coxa profunda and (2) evaluate factors associated with poor hip function at minimum 2years following surgery in this specific cohort. This retrospective review included patients with radiographic sign of coxa profunda who underwent hip arthroscopy to treat FAI. Preoperative and post-operative radiographs were reviewed to determine changes in lateral centre-edge angle (CEA), the presence and correction of Cam deformity, and Tönnis grade of osteoarthritis. Hip functional scores, including modified Harris Hip Score, Hip Outcome Score, and IHOT score, were obtained at a minimum of 2years following surgery. The study cohort included 46 patients with a mean preoperative CEA of 39.9 (±2.4)° which decreased to a mean of 30.8 (±1.8)° post-operatively. At a mean follow-up of 2.5years (±0.5), the mean mHHS and IHOT scores were 79.5 (±20.2) and of 69.7 (±28.3), respectively. Increased preoperative (p=0.02) and post-operative (p=0.001) Tönnis Osteoarthritis Grade was associated with a lower mHHS. Patients with coxa profunda can achieve similar functional scores to more traditional FAI cohorts after arthroscopic treatment. Baseline osteoarthritis is predictive of lower hip function after hip arthroscopy. This study demonstrates that patients with global over-coverage can benefit from hip arthroscopy and may influence surgeons to treat these patients with less invasive arthroscopic techniques which avoid the morbidity of open surgical procedures. Retrospective case series, Level IV.

The prevalence of radiographic signs of pincer type morphology in a population based cohort study of asymptomatic Japanese.

This study was designed to document the prevalence of radiographic findings of pincer-type morphology in an asymptomatic population and determine any relationship to age. A total of 2,104 hips in 1,052 patients (mean age 38.9 years [10-59]), who underwent abdominal/pelvic computed tomography for other conditions, were identified retrospectively. Anteroposterior scout radiographs were used to detect the acetabular crossover sign (COS), prominent ischial spine (PRIS), coxa profunda (CP), and posterior wall sign (PWS). Subgroup analyses of signs were performed by age (group 1: 532 hips in &lt;30-year-old patients; group 2: 1,572 hips in ≥30-year-old patients). COS and PRIS was observed significantly more often in group 1 vs. group 2: COS was 73.1% vs. 29.3% in group 2, p&lt;0.001; PRIS was 23.9% vs.7.4% in group 2, p&lt;0.001. CP and PWS was observed significantly less frequently in group 1 vs. group 2: CP 3.4% vs. 21.2% in group 2, p&lt;0.001; PWS was 4.7% vs. 11.0% in group 2, p&lt;0.001. Radiographic pincer-type findings were common in an asymptomatic population and their prevalence was dependent upon a patient's age, indicating a diagnosis using radiographic parameters should also take into account a patient's age.

Measures of hip morphology are related to development of worsening radiographic hip osteoarthritis over 6 to 13 year follow-up: the Johnston County Osteoarthritis Project

We sought to describe the effect of alterations in hip morphology with respect to worsening hip OA in a community-based sample including African American (AA) and white men and women. This nested case-control study defined case hips as Kellgren Lawrence grade (KLG) <3 on baseline supine pelvis radiographs and KLG ≥3 or THR for OA at the 1st or 2nd follow-up visit (mean 6 and 13 years, respectively); control hips had KLG <3 at both visits, with gender/race distribution similar to cases. Hip morphology was assessed using HipMorf software (Oxford, UK). Descriptive means and standard errors were obtained from generalized estimating equation (GEE) models. Sex-stratified GEE regression models (accounting for within-person correlation), adjusted for age, race, BMI, and side were then employed. A total of 120 individuals (239 hips; 71 case/168 control) were included (25% male, 26% AA, mean age 62 years, BMI 30 kg/m(2)). Case hips tended to have greater baseline AP alpha angles, smaller minimum joint space width (mJSW) and more frequent triangular index signs. Adjusted results among men revealed that higher AP alpha angle, Gosvig ratio, and acetabular index were positively associated with case hips; coxa profunda was negatively associated. Among women, greater AP alpha angle, smaller mJSW, protrusio acetabuli, and triangular index sign were associated with case hips. We confirmed an increased risk of worsening hip OA due to baseline features of cam deformity among men and women, as well as protrusio acetabuli among women, and provide the first estimates of these measures in AAs.

Radiographic Prevalence of Dysplasia, Cam, and Pincer Deformities in Elite Ballet

Background: The demands of hip strength and motion in ballet are high. Hip disorders, such as cam and pincer deformities or dysplasia, may affect dance performance. However, the prevalence of these radiographic findings is unknown. Purpose: To determine the prevalence of radiographic cam and pincer deformities, borderline dysplasia, and dysplasia in a professional ballet company. Study Design: Cross-sectional study; Level of evidence, 3. Methods: An institutional review board–approved cross-sectional investigation of a professional ballet company was undertaken. Male and female adult dancers were eligible for inclusion. Four plain radiographs were obtained (standing anteroposterior pelvis, bilateral false profile, and supine Dunn 45°) and verified for adequacy. Cam and pincer deformities, dysplasia, borderline dysplasia, and osteoarthritis were defined. All plain radiographic parameters were measured and analyzed on available radiographs. Student t test, chi-square test (and Fisher exact test), and Spearman correlation analyses were performed to compare sexes, groups, and the effect of select radiographic criteria. Results: A total of 47 dancers were analyzed (21 males, 26 females; mean age (±SD), 23.8 ± 5.4 years). Cam deformity was identified in 25.5% (24/94) of hips and 31.9% (15/47) of subjects, with a significantly greater prevalence in male dancers than females (48% hips and 57% subjects vs 8% hips and 12% subjects; P < .001 and P = .001, respectively). Seventy-four percent of subjects had at least 2 of 6 radiographic signs of pincer deformity. Male dancers had a significantly greater prevalence of both prominent ischial spine and posterior wall signs (P = .001 and P < .001, respectively), while female dancers had a significantly greater prevalence of coxa profunda (85% female hips vs 26% male hips; P < .001). Eighty-nine percent of subjects had dysplasia or borderline dysplasia in at least 1 hip (37% dysplastic), with a significantly greater prevalence of dysplasia or borderline dysplasia in female versus male dancers (92% female hips vs 74% male hips; P < .022). Further, in those with dysplasia or borderline dysplasia, 92% of female and 82% of male dancers had bilateral findings. Conclusion: In this professional ballet company, a high prevalence of radiographic abnormalities was found, including cam and pincer deformity and dysplasia. The results also revealed several sex-related differences of these abnormalities in this unique population. The long-term implications of these findings in this group of elite athletes remain unknown, and this issue warrants future investigation.

Acetabular Labral Base Repair Versus Circumferential Suture Repair: A Matched-Paired Comparison of Clinical Outcomes

To determine whether an acetabular labral repair technique would be superior to another repair technique based on clinical outcomes measured by patient-reported outcome (PRO) scores. We identified 465 patients who underwent labral base repair or circumferential suture repair from February 2008 to February 2012. The type of repair performed was based on labral size and tear type. The 2 groups were pair matched for age within 5 years, sex, crossover sign within 15%, coxa profunda, Workers' Compensation status, and microfracture (femur, acetabulum, or none). Data were prospectively collected and retrospectively reviewed. PROs included a visual analog scale score and the modified Harris Hip Score, Non-Arthritic Hip Score, Hip Outcome Score-Activities of Daily Living, and Hip Outcome Score-Sports-Specific Subscale. One hundred ten patients met the inclusion criteria for labral base repair and were pair matched on a 1:1 basis with 110 patients who underwent circumferential suture repair. The mean follow-up period was 30 months for both groups, with a range of 19.2 to 60 months for the labral base repair group and 19.2 to 67 months for the circumferential suture repair group. Radiographic data were similar between groups with respect to the lateral center-edge angle (P = .906), acetabular inclination (P = .329), anterior center-edge angle (P = .208), alpha angle (P = .387), and joint space width (P = .388). All preoperative PRO scores were statistically similar. Both groups showed significant improvements in all PROs. There were no statistical differences in postoperative PRO scores at latest follow-up (modified Harris Hip Score, P = .215; Hip Outcome Score-Activities of Daily Living, P = .839; Hip Outcome Score-Sports-Specific Subscale, P = .561; Non-Arthritic Hip Score, P = .333; visual analog scale score, P = .373; and satisfaction, P = .483). There were similar rates of revision (n = 10 for both groups) and conversion to arthroplasty (n = 2 for both groups). On the basis of PRO scores at 2 years' follow-up, there is no difference in outcomes based on the type of labral repair performed. Level III, retrospective comparative study.

Hip Arthroscopy: Where We Are, and Where We Are Going.

Hip Arthroscopy: Where We Are, and Where We Are Going.

Coxa profunda in the diagnosis of pincer-type femoroacetabular impingement and its prevalence in asymptomatic subjects.

In many papers, the diagnosis of pincer-type femoroacetabular impingement (FAI) is attributed to the presence of coxa profunda. However, little is known about the prevalence of coxa profunda in the general population and its clinical relevance. In order to ascertain its prevalence in asymptomatic subjects and whether it is a reliable indicator of pincer-type FAI, we undertook a cross-sectional study between July and December 2013. A total of 226 subjects (452 hips) were initially screened. According to strict inclusion criteria, 129 asymptomatic patients (257 hips) were included in the study. The coxa profunda sign, the crossover sign, the acetabular index (AI) and lateral centre-edge (LCE) angle were measured on the radiographs. The median age of the patients was 36.5 years (28 to 50) and 138 (53.7%) were women. Coxa profunda was present in 199 hips (77.4%). There was a significantly increased prevalence of coxa profunda in women (p < 0.05) and a significant association between coxa profunda and female gender (p < 0.001) (92% vs 60.5%). The crossover sign was seen in 36 hips (14%), an LCE > 40° in 28 hips (10.9%) and an AI < 0º in 79 hips (30.7%). A total of 221 normal hips (79.2%) (normal considering the crossover) had coxa profunda, a total of 229 normal hips (75.5%) (normal considering the LCE) had coxa profunda and a total of 178 normal hips (75.3%) (normal considering AI) had coxa profunda. When the presence of all radiological signs in the same subject was considered, pincer-type FAI was found in only two hips (one subject). We therefore consider that the coxa profunda sign should not be used as a radiological indicator of pincer-type FAI. We consider profunda to be a benign alteration in the morphology of the hip with low prevalence and a lack of association with other radiological markers of FAI. We suggest that the diagnosis of pincer-type FAI should be based on objective measures, in association with clinical findings.

Femoral Neck Stress Fractures and Imaging Features of Femoroacetabular Impingement

BackgroundPrior literature has suggested an association between the radiographic signs of femoroacetabular impingement (FAI) and femoral neck stress fractures (FNSF) or femoral neck stress reactions (FNSR). At the time of the writing of this article, no study has described the association of FAI and FNSF/FNSR along with the need for surgical intervention and outcomes. ObjectiveTo determine the prevalence of radiographic features of FAI in patients diagnosed with FNSF. DesignRetrospective case series. SettingTertiary care, institutional setting. PatientsA medical records search program (Stanford Translational Research Integrated Database Environment, Stanford University, California) was used to retrospectively search for patients 18-40 years old with a history of FNSF or FNSR. The records were obtained from the period July 25, 2003, to September 23, 2011. MethodsFor assessment of risk factors, plain radiographs and magnetic resonance imaging studies were reviewed for features of cam or pincer FAI. Medical records were reviewed to determine whether patients required operative intervention. Main Outcome MeasuresIncidence of abnormal alpha (α) angle, abnormal anterior offset ratio, abnormal femoral head-neck junction, coxa profunda, positive crossover sign, and abnormal lateral center-to-edge angle. ResultsTwenty-one female and 3 male participants (mean age 27 years, range 19-39 years) were identified with magnetic resonance imaging evidence of femoral neck stress injury. Cam morphology was seen in 10 patients (42%). Pincer morphology could be assessed in 18 patients, with coxa profunda in 14 (78%) and acetabular retroversion in 6 (14%). Features of combined pincer and cam impingement were observed in 4 patients (17%). Seven patients (29%) had operative intervention, with 3 (12%) requiring internal fixation of their femoral neck fractures, and all had radiographic evidence of fracture union after surgery. Four patients (17%) had persistent symptoms after healing of their FNSF with conservative treatment and eventually required surgery for FAI, 3 had no pain at final follow-up 1 year post-surgery, and one patient was lost to follow-up. ConclusionThe results of the current study suggest that patients in the general population with femoral neck stress injuries have a higher incidence of bony abnormalities associated with pincer impingement, including coxa profunda and acetabular retroversion, although it is unclear whether pincer FAI is a true risk factor in the development of FNSF.

Does radiographic coxa profunda indicate increased acetabular coverage or depth in hip dysplasia?

Although radiographic coxa profunda has been considered an indicator of acetabular overcoverage, recent studies suggest that radiographic coxa profunda is a nonspecific finding seen even in hip dysplasia. The morphologic features of coxa profunda in hip dysplasia and the frequency with which the two overlap are not well defined. We determined (1) the prevalence of radiographic coxa profunda in patients with hip dysplasia; (2) the morphologic differences of the acetabulum and pelvis between patients with hip dysplasia and control subjects; and (3) the morphologic differences between hip dysplasia with and without coxa profunda. We retrospectively reviewed the pelvic radiographs and CT scans of 70 patients (70 hips) with hip dysplasia. Forty normal hips were used as controls. Normal hips were defined as those with a lateral center-edge angle between 25° and 40°. Coxa profunda was defined as present when the acetabular fossa was observed to touch or was medial to the ilioischial line on an AP pelvic radiograph. CT measurements included acetabular version, acetabular coverage, acetabular depth, and rotational alignment of the innominate bone. The prevalence of coxa profunda was 44% (31 of 70 hips) in dysplastic hips and 73% (29 of 40 hips) in the control hips (odds ratio, 3.32; 95% CI, 1.43-7.68). Dysplastic hips had a more anteverted and globally shallow acetabulum with inwardly rotated innominate bone compared with the control hips (p<0.001). Dysplastic hips with coxa profunda had a more anteverted acetabulum (p<0.001) and inwardly rotated innominate bone (p<0.002) compared with those without coxa profunda, whereas the acetabular coverage and depth did not differ between the two groups, with the numbers available. Radiographic coxa profunda was not a sign of increased acetabular coverage and depth in patients with hip dysplasia, but rather indicates classic acetabular dysplasia, defined by an anteverted acetabulum with anterolateral acetabular deficiency and an inwardly rotated pelvis. Thus, the presence of coxa profunda does not indicate a disease in addition to hip dysplasia, and the conventional maneuvers during periacetabular osteotomy are adequate for these patients. Level IV, diagnostic study.

Can combining femoral and acetabular morphology parameters improve the characterization of femoroacetabular impingement?

Femoroacetabular impingement (FAI) presupposes a dynamic interaction of the proximal femur and acetabulum producing clinical symptoms and chondrolabral damage. Currently, FAI classification is based on alpha angle and center-edge angle measurements in a single plane. However, acetabular and femoral version and neck-shaft angle also influence FAI. Furthermore, each of these parameters has a reciprocal interaction with the others; for example, a shallow acetabulum delays impingement of the femoral head with the acetabular rim. We introduce the new parameter "omega zone," which combines five parameters into one: the alpha and center-edge angles, acetabular and femoral version, and neck-shaft angle. We sought to determine whether the omega zone could differentiate patients with FAI from (1) normal control subjects (alpha < 55°), but also from (2) control subjects with elevated alpha angles (≥ 55°). We evaluated CT data of 20 hips of male patients with symptomatic cam-type FAI and of 35 male hips extracted from 110 anonymized CT scans for vascular diagnosis. We excluded hips with osteoarthritis, developmental dysplasia, or coxa profunda (center-edge angle 20°-45° on AP pelvic view or corresponding coronal CT views). With dedicated software, femoral and pelvic orientation was standardized; we tested the omega zone in four hip positions in three distinct groups: patients with cam-type FAI (alpha > 60°) and control subjects with normal (< 55°) and high alpha angles (≥ 55°). The omega zone was smaller in patients with cam-type FAI than normal control subjects (alpha angle < 55°) at 60° and 90° of flexion (mean, 12%; 95% confidence interval [CI], 7-17; p = 0.008; Cohen's d = 9%; 95% CI, 4-13; p = 0.003). Furthermore, the omega zone was smaller in all positions in patients with cam-type FAI than control subjects with high alpha angles (0° p = 0.017, 30° p = 0.004, 60° p = 0.004, 90° p = 0.007). In contrast, the omega zone did not differ between control subjects with normal or high alpha angles. In all hips, the omega zone decreased with flexion, corresponding to a decrease in remaining impingement-free motion with flexion. The omega zone visualizes and quantifies the interaction of the proximal femur and acetabulum. The omega zone differed between patients with cam-type FAI and control subjects with high alpha angles (≥ 55°), who could not be distinguished based on alpha angle alone. For hip-preserving surgery, it can help surgeons decide whether to address the femur, the acetabulum, or both.