Femoral Retroversion Research Articles

8주간의 발 각도 설정을 적용한 플라이오메트릭 훈련이 대퇴골 후경을 가진 대학 구기 종목 동아리 학생의 점프 능력 및 하지 근기능에 미치는 영향

8주간의 발 각도 설정을 적용한 플라이오메트릭 훈련이 대퇴골 후경을 가진 대학 구기 종목 동아리 학생의 점프 능력 및 하지 근기능에 미치는 영향

Association of Idiopathic Cam Morphology With Femoral and Acetabular Version: Analysis of 986 Cadaveric Hips.

Studies have correlated symptomatic femoroacetabular impingement (FAI) with femoral retroversion and cam lesions. To investigate any association between femoral and acetabular versions with cam deformity in a largely asymptomatic population. Descriptive laboratory study. A total of 986 cadaveric hips were selected from a historical osteologic collection. Each hip was assessed to determine the femoral and acetabular versions, anterior offset, and alpha angle. Cam morphology was defined as an alpha angle >60°. Multiple regression analysis was performed to determine the relationship between age, femoral version, acetabular version, and either alpha angle or anterior femoral offset. The mean alpha angle and anterior offset for the sample population were 48.1°± 10.4° and 0.77 ± 0.17 cm, respectively, with cam morphology in 149 of the 986 (15.1%) specimens. No significant difference was observed between hips with and without cam morphology with respect to the femoral (10.8°± 10° vs 10.3°± 9.6°; P = .58) or acetabular versions (17.4°± 6° vs 18.2°± 6.3°; P = .14). Multiple regression analysis did not demonstrate an association between the femoral or acetabular versions and the alpha angle, and it showed a small association between the increasing femoral and acetabular versions and a decreased anterior femoral offset (both P < .01). In a large random sample of cadaveric hips, cam morphology was not associated with femoral or acetabular retroversion. Combined with the existing literature, these findings suggest that retroversion is not associated with cam development. This study provides insight into the development of cam morphology, which may eventually aid in the evaluation and treatment of FAI.

Proximal femoral derotation osteotomy formanagement offemoral malversion: a systematic review.

Femoral malversion is an under-recognized contributor to hip pain in younger adults. Under treatment is often a contributor to poor outcomes in hip preservation surgery. We reviewed the literature to analyse the outcomes of proximal femoral derotation osteotomy as a treatment for femoral malversion as well as propose our own management algorithm for treating such patients. A systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines searching four databases (PubMed, CINALH, MEDLINE and EMBASE) for studies investigating the outcomes of derotation osteotomy in treating malversion. Nine studies were found encompassing 229 hips. At a mean follow-up of 39.9 months across the studies, there were only two conversions (1%) to total hip arthroplasty and four revision cases in total. Seven of the nine studies reported improved functional outcomes in their cohorts, with the mean Harris hip score improved from 63.7 to 87.3 where reported. There is a paucity of literature around the outcomes of proximal femoral derotation osteotomy. However, both the evidence available and the authors' experience suggest that consideration of femoral malversion is an essential component of hip preservation surgery, improving functional outcomes in cases of excessive femoral anteversion and femoral retroversion.

Poster 214: The Effect of Femoral Retroversion on Hip Range of Motion – A 3D Computational Analysis

Objectives: A subset of patients undergoing hip arthroscopy suffers from persistent pain and dysfunction which can be secondary to a number of factors. Femoral rotational deformities are often overlooked and/or providers are unsure when to address femoral deformities. Currently, there is limited to no data guiding surgeons when to consider a femoral osteotomy at the time of hip arthroscopy for FAI. Through previously validated computer-assisted 3D modeling software, this study sought to answer two questions: 1) How much femoral retroversion is too much to render cam femoroplasty ineffective in improving range of motion (ROM)? 2) In the setting of an osteotomy, what degree of femoral version correction would be sufficient to improve impingement free ROM? Methods: Ten patients were selected with symptomatic focal cam impingement lesions who underwent hip arthroscopy and had pre- and post-operative computed tomography (CT) scans. These patients were screened for normal acetabular morphology and demonstrated no radiographic signs of osteoarthritis. Pre- and post-operative 3D modeling of the involved hip was performed and subsequently dynamized with the femoral version set at (15, 5, -5 and -15 degrees) to define the impingement free ROM and location of impingement with maximum hip flexion and maximum hip internal rotation (IR) at 90 degrees of hip flexion. Results: Mean alpha angle pre and post cam resection were 66°±7.6 ° and 44°±4.9° respectively and were significantly different (p=0.003). Location of impingement shifted during hip flexion from the medial to anterior femoral neck with decreasing femoral version while the IR impingement location remained on the anterior femoral neck and was unaffected by femoral version. Kruskal-Wallis testing demonstrated decreasing femoral version significantly decreased hip flexion and IR ROM in both the pre and post cam resection groups (p&lt;0.0003). Impingement free ROM, as defined by hip flexion and IR greater than 90° and 10° respectively, was only identified in the 5 and 15 degree femoral anteversion models irrespective of whether cam femoroplasty had been performed. In the post cam resection group, hip IR ROM was significantly less with any level of decreasing femoral version (p&lt;0.002) while hip flexion ROM was significantly less with any level of decreased femoral version when compared to 15 degrees of anteversion (p&lt;0.04). When assessing the degree of change in ROM between the pre and post cam resection groups, femoral version had contrasting effects on hip ROM with decreasing femoral version showing less improvement with hip IR ROM while the femoral retroversion models had significantly greater improvements in hip flexion ROM when compared to the 15 degree anteversion model (p=0.02). Conclusions: Decreasing femoral version demonstrates significantly decreased hip flexion and IR both in the presence and absence of a CAM lesion. After cam femoroplasty, any level of decreased femoral version has a significant effect on hip ROM when compared to normal femoral anteversion. Femoral version seems to be the predominant factor in determining the amount of hip IR ROM in flexion and to a certain extent hip flexion ROM irrespective of the cam FAI. Impingement free ROM was only identified within the femoral anteversion models even after cam femoroplasty suggesting that recurrent mechanical collision and intra-articular damage seen with FAI may still be present with any level of true femoral retroversion. This study provides insight into the changes in hip flexion and IR that can be expected following both cam resection and simulated femoral osteotomy. [Table: see text]

Derotational femoral osteotomy locations and their influence on joint reaction forces in dysplastic hips.

Femoral version (FV) deformities are common in patients with developmental dysplasia of the hip (DDH) and may contribute to cartilage damage due to abnormal joint loading. Derotational femoral osteotomy (DFO) surgery corrects FV deformities. However there is little consensus about the femoral transection location for DFO, and its influence on joint loads is unknown. The purpose of this study was to compare the effects of two common DFO locations on muscle forces and hip joint reaction forces (JRFs) in patients with DDH. DFO was simulated in nine patients with DDH and abnormal FV using patient-specific musculoskeletal models. Femoral transection for DFO was separately simulated proximal and distal to the lesser trochanter and FV values were corrected to an idealized 15°. JRFs during early and late stance of gait were compared between the two simulated transection locations. Most changes to JRFs were similar between proximal and distal DFO, however, statistically significant differences were found for the medial JRF component during late stance among patients with femoral anteversion (p = 0.01). Force changes from five hip muscles were significantly different between DFO locations, however, changes were minimal. Most changes after DFO in patients with femoral retroversion were opposite of those with femoral anteversion, with anteroposterior and superior JRFs increasing after retroversion correction. After DFO correction, superior and medial JRFs in DDH patients remained elevated compared to controls. Understanding the influence of DFO location on muscle-generated hip forces can help surgeons justify decisions and potentially standardize surgical correction of FV deformities in patients with DDH.

Assessment of femoral retroversion on preoperative hip magnetic resonance imaging in patients with slipped capital femoral epiphysis: Theoretical implications for hip impingement risk estimation.

Slipped capital femoral epiphysis is a common pediatric hip disease and was associated with femoral retroversion, but femoral version was rarely measured. Therefore, mean femoral version, mean femoral neck version, and prevalence of femoral retroversion were analyzed for slipped capital femoral epiphysis patients. A retrospective observational study evaluating preoperative hip magnetic resonance imaging of 27 patients (49 hips) was performed. Twenty-seven untreated slipped capital femoral epiphysis patients (28 slipped capital femoral epiphysis hips and 21 contralateral hips, age 10-16 years) were evaluated (79% stable slipped capital femoral epiphysis, 22 patients; 43% severe slipped capital femoral epiphysis, 12 patients). Femoral version was measured using Murphy method on magnetic resonance imaging (January 2014-December 2021, rapid bilateral 3-dimensional T1 water-only Dixon-based images of pelvis and knee). All slipped capital femoral epiphysis patients underwent surgery after magnetic resonance imaging. Mean femoral version of slipped capital femoral epiphysis patients (-1° ± 15°) was significantly (p < 0.001) lower compared to contralateral side (15° ± 14°). Femoral version of slipped capital femoral epiphysis patients had significantly (p < 0.001) wider range from -42° to 35° (range 77°) compared to contralateral side (-5° to 44°, range 49°). Mean femoral neck version of slipped capital femoral epiphysis patients (6° ± 15°) was lower compared to contralateral side (11° ± 12°). Fifteen slipped capital femoral epiphysis patients (54%) had absolute femoral retroversion (femoral version < 0°). Six of the 12 hips (50%) with severe slips and 4 of the 8 hips (50%) with mild slips had absolute femoral retroversion (femoral version < 0°). Ten slipped capital femoral epiphysis patients (40%) had absolute femoral neck retroversion (femoral neck version < 0°). Although slipped capital femoral epiphysis patients showed asymmetrically lower femoral version compared to contralateral side, there was a wide range of femoral version, underlining the importance of patient-specific femoral version analysis on preoperative magnetic resonance imaging. Absolute femoral retroversion was prevalent in half of slipped capital femoral epiphysis patients, in half of severe slipped capital femoral epiphysis patients, and in half of mild slipped capital femoral epiphysis patients. This has implications for anterior hip impingement and for surgical treatment with in situ pinning or femoral osteotomy (e.g. proximal femoral derotation osteotomy) or other hip preservation surgery.

Large Hip Impingement Area and Subspine Hip Impingement in Patients With Absolute Femoral Retroversion or Decreased Combined Version.

It remains unclear if femoral retroversion is a contraindication for hip arthroscopy in patients with femoroacetabular impingement (FAI). To compare the area and location of hip impingement at maximal flexion and during the FADIR test (flexion, adduction, internal rotation) in FAI hips with femoral retroversion, hips with decreased combined version, and asymptomatic controls. Cross-sectional study; Level of evidence, 3. Twenty-four symptomatic patients (37 hips) with anterior FAI were evaluated. All patients had femoral version (FV) <5° according to the Murphy method. Two subgroups were analyzed: 13 hips with absolute femoral retroversion (FV <0°) and 29 hips with decreased combined version (McKibbin index <20°). All patients were symptomatic and had anterior groin pain and a positive anterior impingement test ; all had undergone pelvic computed tomography (CT) scans to measure FV. The asymptomatic control group consisted of 26 hips. Dynamic impingement simulation of maximal flexion and FADIR test at 90° of flexion was performed with patient-specific CT-based 3-dimensional models. Extra- or intra-articular hip impingement area and location were compared between the subgroups and with control hips using nonparametric tests. Impingement area was significantly larger for hips with decreased combined version (<20°) versus combined version (≥20°) (mean ± SD; 171 ± 140 vs 78 ± 55 mm2; P = .012) and was significantly larger for hips with FV <0° (absolute femoral retroversion) vs FV >0° (P = .025). Hips with absolute femoral retroversion had a significantly higher frequency of extra-articular subspine impingement versus controls (92% vs 0%; P < .001), compared to 84% of patients with decreased combined version. Intra-articular femoral impingement location was most often (95%) anterosuperior and anterior (2-3 o'clock). Anteroinferior femoral impingement location was significantly different at maximal flexion (anteroinferior [4-5 o'clock]) versus the FADIR test (anterosuperior and anterior [2-3 o'clock]) (P < .001). Patients with absolute femoral retroversion (FV <0°) had a larger hip impingement area, and most exhibited extra-articular subspine impingement. Preoperative FV assessment with advanced imaging (CT/magnetic resonance imaging) could help to identify these patients (without 3-dimensional modeling). Femoral impingement was located anteroinferiorly at maximal flexion and anterosuperiorly and anteriorly during the FADIR test.

Femoral impingement in maximal hip flexion is anterior-inferior distal to the cam deformity in femoroacetabular impingement patients with femoral retroversion

Femoroacetabular impingement (FAI) patients report exacerbation of hip pain in deep flexion. However, the exact impingement location in deep flexion is unknown. The aim was to investigate impingement-free maximal flexion, impingement location, and if cam deformity causes hip impingement in flexion in FAI patients. A retrospective study involving 24 patients (37 hips) with FAI and femoral retroversion (femoral version (FV) < 5° per Murphy method) was performed. All patients were symptomatic (mean age 28 years (SD 9)) and had anterior hip/groin pain and a positive anterior impingement test. Cam- and pincer-type subgroups were analyzed. Patients were compared to an asymptomatic control group (26 hips). All patients underwent pelvic CT scans to generate personalized CT-based 3D models and validated software for patient-specific impingement simulation (equidistant method). Mean impingement-free flexion of patients with mixed-type FAI (110° (SD 8°)) and patients with pincer-type FAI (112° (SD 8°)) was significantly (p < 0.001) lower compared to the control group (125° (SD 13°)). The frequency of extra-articular subspine impingement was significantly (p < 0.001) increased in patients with pincer-type FAI (57%) compared to cam-type FAI (22%) in 125° flexion. Bony impingement in maximal flexion was located anterior-inferior at femoral four and five o'clock position in patients with cam-type FAI (63% (10 of 16 hips) and 37% (6 of 10 hips)), and did not involve the cam deformity. The cam deformity did not cause impingement in maximal flexion. Femoral impingement in maximal flexion was located anterior-inferior distal to the cam deformity. This differs to previous studies, a finding which could be important for FAI patients in order to avoid exacerbation of hip pain in deep flexion (e.g. during squats) and for hip arthroscopy (hip-preservation surgery) for planning of bone resection. Hip impingement in flexion has implications for daily activities (e.g. putting on shoes), sports, and sex.Cite this article: Bone Joint Res2023;12(1):22-32.

Combined femoral and acetabular version is sex-related and differs between patients with hip dysplasia and acetabular retroversion

AimsFrequency of abnormal femoral and acetabular version (AV) and combinations are unclear in patients with developmental dysplasia of the hip (DDH). This study aimed to investigate femoral version (FV), the proportion of increased FV and femoral retroversion, and combined-version (CV, FV+AV) in DDH patients and acetabular-retroversion (AR). Patients and methodsA retrospective IRB-approved observational study was performed with 78 symptomatic DDH patients (90 hips) and 65 patients with femoroacetabular-impingement (FAI) due to AR (77 hips, diagnosis on AP radiographs). CT/MRI-based measurement of FV (Murphy method) and central AV were compared. Frequency of increased FV(FV > 25°), severely increased FV (FV > 35°) and excessive FV (FV > 45°) and of decreased FV (FV < 10°) and CV (McKibbin-index/COTAV-index) was analysed. ResultsMean FV and CV was significantly (p < 0.001) increased of DDH patients (mean ± SD of 25 ± 11° and 47 ± 18°) compared to AR (16 ± 11° and 28 ± 13°). Mean FV of female DDH patients (27 ± 16°) and AR (19 ± 12°) was significantly (p < 0.001) increased compared to male DDH patients (18 ± 13°) and AR (13 ± 8°). Frequency of increased FV (>25°) was 47% and of severely increased FV (>35°) was 23% for DDH patients.Proportion of femoral retroversion (FV < 10°) was significantly (p < 0.001) higher in patients AR (31%) compared to DDH patients (17%). 18% of DDH patients had AV > 25° combined with FV > 25°. Of patients with AR, 12% had FV < 10° combined with AV < 10°. ConclusionPatients with DDH and AR have remarkable sex-related differences of FV and CV. Frequency of severely increased FV > 35° (23%) is considerable for patients with DDH, but 17% exhibited decreased FV, that could influence management. The different combinations underline the importance of patient-specific evaluation before open hip preservation surgery (periacetabular osteotomy and femoral derotation osteotomy) and hip-arthroscopy.

Coxa valga and antetorta increases differences among different femoral version measurements : potential implications for derotational femoral osteotomy planning.

To evaluate how abnormal proximal femoral anatomy affects different femoral version measurements in young patients with hip pain. First, femoral version was measured in 50 hips of symptomatic consecutively selected patients with hip pain (mean age 20 years (SD 6), 60% (n = 25) females) on preoperative CT scans using different measurement methods: Lee et al, Reikerås et al, Tomczak et al, and Murphy et al. Neck-shaft angle (NSA) and α angle were measured on coronal and radial CT images. Second, CT scans from three patients with femoral retroversion, normal femoral version, and anteversion were used to create 3D femur models, which were manipulated to generate models with different NSAs and different cam lesions, resulting in eight models per patient. Femoral version measurements were repeated on manipulated femora. Comparing the different measurement methods for femoral version resulted in a maximum mean difference of 18° (95% CI 16 to 20) between the most proximal (Lee et al) and most distal (Murphy et al) methods. Higher differences in proximal and distal femoral version measurement techniques were seen in femora with greater femoral version (r > 0.46; p < 0.001) and greater NSA (r > 0.37; p = 0.008) between all measurement methods. In the parametric 3D manipulation analysis, differences in femoral version increased 11° and 9° in patients with high and normal femoral version, respectively, with increasing NSA (110° to 150°). Measurement of femoral version angles differ depending on the method used to almost 20°, which is in the range of the aimed surgical correction in derotational femoral osteotomy and thus can be considered clinically relevant. Differences between proximal and distal measurement methods further increase by increasing femoral version and NSA. Measurement methods that take the entire proximal femur into account by using distal landmarks may produce more sensitive measurements of these differences.Cite this article: Bone Jt Open2022;3(10):759-766.

Abnormal Spinopelvic Motion and Spine Deformity are Associated With Native Femoral Retroversion in the Setting of Total Hip Arthroplasty

BackgroundThe effect of spinopelvic pathology on femoral version is unclear. This study investigated variability in native femoral anteversion in patients undergoing total hip arthroplasty (THA) and its relationship to the patient’s underlying spinopelvic pattern. MethodsA retrospective chart review was performed to include in the study all patients undergoing robot-assisted THA over a 3-year period. Native femoral version was measured for each patient using a preoperative computed tomography scan and categorized as excessive, normal, or retroverted. Additionally, a subset analysis was performed for all patients with sit-to-stand dynamic pelvic radiographs available, and cases were classified by spinopelvic pattern. ResultsA total of 119 patients were included in the study with a mean age of 68.6 years; 61 (51%) were female. The median femoral anteversion for the entire study group was 6.0° (−32° to 40°, interquartile range 13.5°). Eleven patients (9.2%) had excessive femoral anteversion, 54 of the 119 (45.4%) had normal femoral version, and 54 of the 119 (45.4%) had native retroversion. Forty-two patients (35.3%) had sit-to-stand radiographs available and were subclassified by femoral version type and spinopelvic parameters. Welch’s analysis of variance demonstrated a significant difference in femoral version among spinopelvic patterns (F = 7.826, P = .003), with Games-Howell post hoc analysis showing increased retroversion in deformity-stiff patients compared to deformity-normal mobility patients (P = .003). ConclusionsThis study demonstrates that native femoral retroversion is present in a significant number of patients undergoing THA and is more common in patients with stiff spine deformities. Based on this observation, currently available spinopelvic classification systems should be modified to account for native femoral version.

Hip Impingement Location in Maximal Hip Flexion in Patients With Femoroacetabular Impingement With and Without Femoral Retroversion

Background: Symptomatic patients with femoroacetabular impingement (FAI) have limitations in daily activities and sports and report the exacerbation of hip pain in deep flexion. Yet, the exact impingement location in deep flexion and the effect of femoral version (FV) are unclear. Purpose: To investigate the acetabular and femoral locations of intra- or extra-articular hip impingement in flexion in patients with FAI with and without femoral retroversion. Study Design: Cross-sectional study; Level of evidence, 3. Methods: An institutional review board–approved retrospective study involving 84 hips (68 participants) was performed. Of these, symptomatic patients (37 hips) with anterior FAI and femoral retroversion (FV <5°) were compared with symptomatic patients (21 hips) with anterior FAI (normal FV) and with a control group (26 asymptomatic hips without FAI and normal FV). All patients were symptomatic, had anterior hip pain, and had positive anterior impingement test findings. Most of the patients had hip/groin pain in maximal flexion or deep flexion or during sports. All 84 hips underwent pelvic computed tomography (CT) to measure FV as well as validated dynamic impingement simulation with patient-specific CT-based 3-dimensional models using the equidistant method. Results: In maximal hip flexion, femoral impingement was located anterior-inferior at 4 o’clock (57%) and 5 o’clock (32%) in patients with femoral retroversion and mostly at 5 o’clock in patients without femoral retroversion (69%) and in asymptomatic controls (76%). Acetabular intra-articular impingement was located anterior-superior (2 o’clock) in all 3 groups. In 125° of flexion, patients with femoral retroversion had a significantly (P < .001) higher prevalence of anterior extra-articular subspine impingement (54%) and anterior intra-articular impingement (89%) compared with the control group (29% and 62%, respectively). Conclusion: Knowing the exact location of hip impingement in deep flexion has implications for surgical treatment, sports, and physical therapy and confirms previous recommendations: Deep flexion (eg, during squats/lunges) should be avoided in patients with FAI and even more in patients with femoral retroversion. Patients with femoral retroversion may benefit and have less pain when avoiding deep flexion. For these patients, the femoral location of the impingement conflict in flexion was different (anterior-inferior) and distal to the cam deformity compared with the location during the anterior impingement test (anterior-superior). This could be important for preoperative planning and bone resection (cam resection or acetabular rim trimming) during hip arthroscopy or open hip preservation surgery to ensure that the region of impingement is appropriately identified before treatment.

How frequent is absolute femoral retroversion in symptomatic patients with cam- and pincer-type femoroacetabular impingement?

AimsThe frequency of severe femoral retroversion is unclear in patients with femoroacetabular impingement (FAI). This study aimed to investigate mean femoral version (FV), the frequency of absolute femoral retroversion, and the combination of decreased FV and acetabular retroversion (AR) in symptomatic patients with FAI subtypes.MethodsA retrospective institutional review board-approved observational study was performed with 333 symptomatic patients (384 hips) with hip pain due to FAI evaluated for hip preservation surgery. Overall, 142 patients (165 hips) had cam-type FAI, while 118 patients (137 hips) had mixed-type FAI. The allocation to each subgroup was based on reference values calculated on anteroposterior radiographs. CT/MRI-based measurement of FV (Murphy method) and AV were retrospectively compared among five FAI subgroups. Frequency of decreased FV < 10°, severely decreased FV < 5°, and absolute femoral retroversion (FV < 0°) was analyzed.ResultsA significantly (p < 0.001) lower mean FV was found in patients with cam-type FAI (15° (SD 10°)), and in patients with mixed-type FAI (17° (SD 11°)) compared to severe over-coverage (20° (SD 12°). Frequency of decreased FV < 10° was significantly (p < 0.001) higher in patients with cam-type FAI (28%, 46 hips) and in patients with over-coverage (29%, 11 hips) compared to severe over-coverage (12%, 5 hips). Absolute femoral retroversion (FV < 0°) was found in 13% (5 hips) of patients with over-coverage, 6% (10 hips) of patients with cam-type FAI, and 5% (7 hips) of patients with mixed-type FAI. The frequency of decreased FV< 10° combined with acetabular retroversion (AV < 10°) was 6% (8 hips) in patients with mixed-type FAI and 5% (20 hips) in all FAI patients. Of patients with over-coverage, 11% (4 hips) had decreased FV < 10° combined with acetabular retroversion (AV < 10°).ConclusionPatients with cam-type FAI had a considerable proportion (28%) of decreased FV < 10° and 6% had absolute femoral retroversion (FV < 0°), even more for patients with pincer-type FAI due to over-coverage (29% and 13%). This could be important for patients evaluated for open hip preservation surgery or hip arthroscopy, and each patient requires careful personalized evaluation.Cite this article: Bone Jt Open 2022;3(7):557–565.

Outcomes and Return-to-Sport Rates for Elite Athletes With Femoral Retroversion Undergoing Hip Arthroscopy: A Propensity-Matched Analysis With Minimum 2-Year Follow-up.

Background:Return to sports (RTS) and patient-reported outcomes (PROs) for elite athletes with femoral version abnormalities undergoing hip arthroscopy have not been well established.Purposes:To (1) report minimum 2-year PROs and RTS rates in elite athletes with femoral retroversion who underwent primary hip arthroscopy and (2) compare clinical results to those of a propensity-matched control group of elite athletes with normal femoral version who underwent primary hip arthroscopy.Study Design:Cohort study; Level of evidence, 3.Methods:Data were prospectively collected and retrospectively reviewed for elite (professional and collegiate) athletes with femoral version <5°, as measured on magnetic resonance imaging scans, who underwent hip arthroscopy for femoroacetabular impingement syndrome between March 2010 and April 2018. Inclusion criteria were preoperative and minimum 2-year follow-up PROs for the modified Harris Hip Score, Nonarthritic Hip Score, Hip Outcome Score–Sports Specific Subscale (HOS-SSS), and visual analog scale for pain. Exclusion criteria were Tönnis grade >1, hip dysplasia, and previous ipsilateral hip surgery or conditions. Rates of achieving the minimal clinically important difference (MCID), Patient Acceptable Symptom State (PASS), and maximum outcome improvement satisfaction threshold were recorded in addition to RTS. Athletes with retroversion were propensity matched in a 1:2 ratio to elite athletes with normal femoral version (5°-20°) for comparison.Results:A total of 33 elite athletes (33 hips) with femoral retroversion who underwent hip arthroscopy met the inclusion criteria, and follow-up was available for 30 hips in 30 athletes (90.9%) at an average of 36.1 ± 25.6 months. Elite athletes with femoral retroversion demonstrated significant improvements in all recorded PROs, achieved the MCID and PASS for the HOS-SSS at high rates (86.7%), and returned to sports at a rate of 83.3%. PROs, rates of achieving MCID and PASS for the HOS-SSS, and RTS rates were similar between the study and propensity-matched control group.Conclusion:Elite athletes with femoral retroversion undergoing primary hip arthroscopy demonstrated favorable PROs and high RTS rates at a minimum 2-year follow-up. These results were comparable with those of a propensity-matched control group of elite athletes with normal femoral version.

Less in-toeing after femoral derotation osteotomy in adult patients with increased femoral version and posterior hip impingement compared to patients with femoral retroversion.

ABSTRACTIn-toeing of the foot was associated with high femoral version (FV), while Out-toeing was associated with femoral-retroversion. Therefore, we report on (i) foot-progression-angle (FPA), (ii) prevalence of In-toeing and Out-toeing, and (iii) clinical outcome of patients treated with femoral-derotation-osteotomy (FDO). We performed a retrospective analysis involving 20 patients (20 hips) treated with unilateral FDO (2017–18). Of them, 14 patients had increased FV, 6 patients had femoral-retroversion. Follow-up time was mean 1 ± 1 years. All patients had minimal 1-year follow-up and the mean age was 29 ± 8 years. Patients with increased FV (FV > 35°) presented with positive posterior-impingement-test and mean FV was 49 ± 11° (Murphy method). Six patients with femoral-retroversion (FV < 10°) had positive anterior impingement test and mean FV of 5 ± 4°. Instrumented gait analysis was performed preoperatively and at follow-up using the Gaitrite system to measure FPA and was compared to a control group of 18 healthy asymptomatic volunteers (36 feet, mean age 29 ± 6 years). (i) Mean FPA increased significantly (P = 0.006) from preoperative 1.3 ± 7° to 4.5 ± 6° at follow-up for patients with increased FV and was not significantly different compared to the control group (4.0 ± 4.5°). (ii) In-toeing decreased from preoperatively (five patients) to follow-up (two patients) for patients with increased FV. Out-toeing decreased from preoperatively (two patients) to follow-up (no patient) for patients with femoral-retroversion. (iii) Subjective-hip-value of all patients increased significantly (P < 0.001) from preoperative 21 to 78 points at follow-up. WOMAC was 12 ± 8 points at follow-up. Patients with increased FV that underwent FDO walked with less In-toeing. FDO has the potential to reduce In-toeing and Out-toeing and to improve subjective satisfaction at follow-up.

The Effect of Femoral and Acetabular Version on Outcomes Following Hip Arthroscopy: A Systematic Review.

Torsional hip deformities are common among patients undergoing hip arthroscopy. However, recent studies have suggested conflicting outcomes following arthroscopy in the setting of abnormal hip version. The purpose of this study was to systematically evaluate the literature and determine the impact of femoral and acetabular version on patient-reported outcomes following primary arthroscopic hip surgery. This study was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. Studies investigating femoral and acetabular version in primary hip arthroscopy with clinical outcomes were identified, and data were extracted in duplicate. Overall, 11 studies met inclusion criteria and comprised 1,297 hips (726 femora and 571 acetabulae), with a mean patient age of 29.2 years (range, 14 to 74.7 years). In patients with acetabular retroversion, there was no significant difference, when compared with the normal acetabular version group, in the modified Harris hip score (mHHS), the Hip Outcome Score-Sports Specific Subscale (HOS-SSS), and visual analog scale (VAS) pain scores postoperatively. Among patients with femoral retroversion, in 2 of 3 studies, the authors reported no difference in mHHS postoperatively compared with patients with normal femoral version. In patients with high femoral anteversion, in 2 of 3 studies, the authors reported a significant difference in postoperative mHHS favoring patients with normal femoral version. Studies examining high femoral anteversion included patients with borderline hip dysplasia and patients who underwent concurrent psoas-lengthening procedures. Although the definition of the normal version of the hip varied within the literature, hip arthroscopy in patients with acetabular retroversion resulted in no difference in functional outcomes compared with patients with normal version. Postoperative functional outcomes in patients with femoral retroversion and high femoral anteversion were mixed, although the procedure was possibly less effective in high femoral anteversion combined with specific clinical scenarios. Further prospective studies based on standardized definitions and version analysis techniques would be useful in identifying the precise surgical indications for safe arthroscopic surgical procedures in patients with version abnormalities of the femur and acetabulum, particularly those with high femoral anteversion and retroversion. Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Custom 3D-Printed Cutting Guides for Femoral Osteotomy in Rotational Malalignment Due to Diaphyseal Fractures: Surgical Technique and Case Series.

Femoral shaft fractures are one of the most common injuries in trauma patients. The gold standard treatment consists of closed reduction and intramedullary nailing, providing a high fracture healing rate and allowing early mobilization. However, rotational malalignment is a well-known complication following this procedure, and excessive femoral anteversion or femoral retroversion can trigger functional complaints. In order to achieve the ideal degree of femoral rotation, a 3D planning and printing cutting guides procedure was developed to correct femoral malrotation. A patient series with malalignment after a femoral diaphyseal fracture was operated on with the customized guides and evaluated in this study. Computed tomography scans were performed to accurately determine the number of degrees of malrotation, allowing the design of specific and personalized surgical guides to correct these accurately. Once designed, they were produced by 3D printing. After surgery with the customized guides to correct femoral malrotation, all patients presented a normalized anteversion angle of the femur (average −10.3°, range from −5° to −15°), according to their contralateral limb. These data suggest that the use of customized cutting guides for femoral osteotomy is a safe and reproducible surgical technique that offers precise results when correcting femoral malrotation.

Introducing the Impingement Index: A study of the combined effect of alpha angle and femoral version on outcomes after hip arthroscopy for femoral acetabular impingement

Objectives:Many studies within the recent literature have sought to identify the effect of femoral version and other morphologic characteristics on outcomes after primary hip arthroscopy for femoral acetabular impingement (FAI). In addition to femoral version and combined version, our group has recently begun to use the impingement index to stratify patients undergoing this procedure. We define the impingement index as the alpha angle minus the femoral version. The purpose of the current study is to determine the impact of femoral version, combined version and impingement index on patient reported outcomes after primary hip arthroscopy for FAI.Methods:A retrospective chart review of a prospectively collected data was conducted from 2010-2016 to identify consecutive patients who underwent primary hip arthroscopy for treatment of FAI. Inclusion criteria are pre-operative CT scan,Results:A total of 456 hips (200 males, 256 females) met the inclusion criteria. The mean age at time of surgery was 28.2 (+/- 10). Average follow-up was 2.6 years (range 23-59 months). The cohort experienced clinical improvement (p<0.001) in all patient-reported outcome measures. The mean improvement was 21.4 points for HHS, 17.4 for HOS ADL, 29.5 for HOS Sport, and 34.3 for QOL. There was no significant difference in outcomes scores when stratified by femoral version (<5°, 5-20°, >20°), including at the extremes of femoral version (<-5°, >30°). There was also no significant difference in outcomes scores when patients were stratified by Mckibbin Index (<25°, 25-40, >40°). The net change in mean HOS Sport for impingement index >75 was significantly lower than any other category (14.5 (>75°) vs. 28.1 (45°-75°) vs. 25.7 (<45°).Conclusions:Clinically significant improvements can be expected for all femoral version values when a thoughtful algorithm is employed for indicating patients for hip arthroscopy with version abnormalities. However, patients with significant femoral retroversion and large cam lesions may experience less overall improvement compared with normal or increased version. The impingement index may be a valuable tool for predicting outcomes of primary hip arthroscopy for FAI. An elevated impingement index in the setting of femoral retroversion may portend less improvement in patient reported outcomes. This finding warrants further investigation and informs the preoperative decision-making process when indicating a patient for hip arthroscopy for FAI.

Dependency of lower limb joint reaction forces on femoral version.

Musculoskeletal (MSK) models based on literature data are meant to represent a generic anatomy and are a popular tool employed by biomechanists to estimate the internal loads occurring in the lower limb joints, such as joint reaction forces (JRFs). However, since these models are normally just linearly scaled to an individual's anthropometry, it is unclear how their estimations would be affected by the personalization of key features of the MSK anatomy, one of which is the femoral version angle. How are the lower limb JRF magnitudes computed through a generic MSK model affected by changes in the femoral version? We developed a bone-deformation tool in MATLAB (shared at https://simtk.org/projects/bone_deformity) and used it to create a set of seven OpenSim models spanning from 2˚ femoral retroversion to 40˚ anteversion. We used these models to simulate the gait of an elderly individual with an instrumented prosthesis implanted at their knee joint (5th Grand Challenge dataset) and quantified both the changes in JRFs magnitude due to varying the skeletal anatomy and their accuracy against the correspondent in vivo measurements at the knee joint. Hip and knee JRF magnitudes were affected by the femoral version with variations from the unmodified generic model up to 17.9 ± 4.5% at the hip and 43.4 ± 27.1% at the knee joint. The ankle joint was unaffected by the femoral geometry. The MSK models providing the most accurate knee JRFs (root mean squared error: 0.370 ± 0.068 body weight, coefficient of determination: 0.757 ± 0.104, peak error range: 0.09-0.42 body weight) were those with femoral anteversion angle closer to that measured on the segmented bone of the individual. Femoral version substantially affects hip and knee JRFs estimated with generic MSK models, suggesting that personalizing key MSK anatomical features might be necessary for accurate estimation of JRFs with these models.

The distal femur trochlear groove appears to compensate for tibial deformity but not femoral deformity in an investigation of five-hundred and seventy-nine cadaveric skeletons

The etiology of patellofemoral disorders is multifactorial. Preoperative patellofemoral anatomy evaluation is of great importance in patients undergoing surgery for patellofemoral disorders. Although anatomical risk factors of patellofemoral disorders have been thoroughly investigated in clinical and radiological studies, there are sparse data regarding the association between trochlear dysplasia with other anatomical parameters. This study sought to explore those associations using a large osteological collection. Five-hundred and seventy-nine cadaveric skeletons were obtained from the Hamann-Todd osteological collection. Mechanical lateral distal femoral angle (mLDFA), medial proximal tibial angle (MPTA), femoral version, tibial torsion, lateral position of the tibial tubercle, and femoral length were modeled as predictors of medial and lateral flange height of the distal femur trochlea at various degrees of knee flexion. The average age and standard deviation for the 1158 lower extremities analyzed was 55.9 ± 10.2years. There were 500 males (86%) and 79 females. Increasing MPTA or tibial valgus predicted increasing lateral femoral flange height at 0, 30, and 50 degrees of knee flexion [(standardized beta 0.111, p = 0.01), (standardized beta 0.129, p < 0.001), and (standardized beta 0.186, p < 0.001), respectively]. Increasing internal tibial torsion predicted increased medial flange height at 30 and 50° [(standardized beta - 0.114, p = 0.006), (standardized beta - 0.108, p = 0.006), respectively]. Increased femoral retroversion predicted increasing lateral flange height at 0 and 30 degrees [(standardized beta - 0.105, p = 0.005), (standardized beta - 0.098, p = 0.004), respectively]. To maintain the equilibrium necessary for effective patellar tracking, the depth of trochlear groove appears to effectively compensate for some of the anatomical parameters of the proximal tibia associated with patellofemoral disorders, and appears to be less influenced by femoral alignment. The clinical relevance of these findings warrants further investigation, and emphasizes the importance of carefully assessing the lower limb alignment in the management of patellofemoral disorders.