Effect of posture and femoral neck osteochondroplasty on femur‐acetabulum clearance in patients with cam‐type femoroacetabular impingement

Wilson, David R.; Zhang, Honglin; Jones, Carly E.; Gilbart, Michael K.; Masri, Bassam A.

doi:10.1002/jor.25037

Cited by 3 publications

(3 citation statements)

References 42 publications

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“…The results of the current study are in line with another recent study of patients with cam or pincer morphologies, which evaluated hip impingement conflict in flexion using open MRI, 44 scanning hips in active squatting and passive sitting position. However, another study found that cam resection (femoral neck osteochondroplasty) improved postoperative flexion by 8° in a sitting posture, 45 analyzing a small sample size.…”

Section: Discussionmentioning

confidence: 97%

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

Boschung

Faulhaber

Kiapour

et al. 2023

Bone & Joint Research

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Aims 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. Methods 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). Results 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. Conclusion 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 Res 2023;12(1):22–32.

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Section: Discussionmentioning

confidence: 97%

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

Boschung

Faulhaber

Kiapour

et al. 2023

Bone & Joint Research

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“…30 Diagnosis of posterior hip impingement for all patients was based on the current recommendations of a positive correlation among symptoms, findings during physical examination, and radiographic findings, 44,52 as recommended by the Warwick agreement. 14 Routine clinical examination included the anterior impingement test (pain in forced flexion, IR, and adduction, also called the FADIR 55 [flexion, adduction, internal rotation] test), the posterior impingement test (pain in forced extension and ER, also called the HEER 18 [hyperextension and external rotation] test), and the FABER (flexion, abduction, external rotation) test. A positive posterior impingement test and/or positive FABER test was used as an indicator for hip instability.…”

Section: Methodsmentioning

confidence: 99%

Limited External Rotation and Hip Extension Due to Posterior Extra-articular Ischiofemoral Hip Impingement in Female Patients With Increased Femoral Anteversion: Implications for Sports, Sexual, and Daily Activities

et al. 2023

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Background: Posterior femoroacetabular impingement (FAI) is poorly understood. Patients with increased femoral anteversion (FV) exhibit posterior hip pain. Purpose: To correlate hip impingement area with FV and with combined version and to investigate frequency of limited external rotation (ER) and hip extension (<40°, <20°, and <0°) due to posterior extra-articular ischiofemoral impingement. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Osseous patient-specific three-dimensional (3D) models based on 3D computed tomography scans were generated of 37 female patients (50 hips) with positive posterior impingement test (100%) and increased FV >35° (Murphy method). Surgery was performed in 50% of patients (mean age, 30 years; 100% female). FV and acetabular version (AV) were added to calculate combined version. Subgroups of patients (24 hips) with increased combined version >70° and patients (9 valgus hips) with increased combined version >50° were analyzed. The control group (20 hips) had normal FV, normal AV, and no valgus. Bone segmentation was performed to generate 3D models of every patient. Validated 3D collision detection software was used for simulation of impingement-free hip motion (equidistant method). Impingement area was evaluated in combined 20° of ER and 20° of extension. Results: Posterior extra-articular ischiofemoral impingement occurred between the ischium and the lesser trochanter in 92% of patients with FV >35° in combined 20° of ER and 20° of extension. Impingement area in combined 20° of ER and 20° of extension was larger with increasing FV and with higher combined version; correlation was significant ( P < .001, r = 0.57, and r = 0.65). Impingement area was significantly ( P = .001) larger (681 vs 296 mm2) for patients with combined version >70° (vs <70°, respectively) in combined 20° of ER and 20° of extension. All symptomatic patients with increased FV >35° (100%) had limited ER <40°, and most (88%) had limited extension <40°. The frequency of posterior intra- and extra-articular hip impingement of symptomatic patients (100% and 88%, respectively) was significantly ( P < .001) higher compared with the control group (10% and 10%, respectively). The frequency of patients with increased FV >35° with limited extension <20° (70%) and patients with limited ER <20° (54%) was significantly ( P < .001) higher compared with the control group (0% and 0%, respectively). The frequency of completely limited extension <0° (no extension) and ER <0° (no ER in extension) was significantly ( P < .001) higher for valgus hips (44%) with combined version >50° compared with patients with FV >35° (0%). Conclusion: All patients with increased FV >35° had limited ER <40°, and most of them had limited extension <20° due to posterior intra- or extra-articular hip impingement. This is important for patient counselling, for physical therapy, and for planning of hip-preservation surgery (eg, hip arthroscopy). This finding has implications and could limit daily activities (long-stride walking), sexual activity, ballet dancing, and sports (eg, yoga or skiing), although not studied directly. Good correlation between impingement area and combined version supports evaluation of combined version in female patients with positive posterior impingement test or posterior hip pain.

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“…32 For all hips, the diagnosis was based on the current recommendations of a positive correlation among symptoms, findings during physical examination, and radiographic findings, 46,53 as recommended by the Warwick Agreement. 20 Routine clinical examination included the anterior impingement test (pain in forced flexion, IR, and adduction; also called the FADIR 57 [flexion-adduction-IR] test), posterior impingement test (pain in forced extension and ER; also called the HEER 22 [hyperextension and ER] test), and anterior pain during the FABER (flexion-abduction-ER) test. A positive posterior impingement test and/or positive FABER was used as signs of potential anterior hip instability because some patients exhibited anterior hip pain during the FABER test.…”

Section: Methodsmentioning

confidence: 99%

Posterior Hip Impingement at Maximal Hip Extension in Female Patients With Increased Femoral Version or Increased McKibbin Index and Its Effect on Sports Performance

Boschung

Antioco

Steppacher

et al. 2023

Orthopaedic Journal of Sports Medicine

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Background: The location of posterior hip impingement at maximal extension in patients with posterior femoroacetabular impingement (FAI) is unclear. Purpose: To investigate the frequency and area of impingement at maximal hip extension and at 10° and 20° of extension in female patients with increased femoral version (FV) and posterior hip pain. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Osseous patient-specific 3-dimensional (3D) models were generated of 50 hips (37 female patients, 3D computed tomography) with a positive posterior impingement test and increased FV (defined as >35°). The McKibbin index (combined version) was calculated as the sum of FV and acetabular version (AV). Subgroups of patients with an increased McKibbin index >70° (24 hips) and FV >50° (20 hips) were analyzed. A control group of female participants (10 hips) had normal FV, normal AV, and no valgus deformity (neck-shaft angle, <139°). Validated 3D collision detection software was used for simulation of osseous impingement-free hip extension (no rotation). Results: The mean impingement-free maximal hip extension was significantly lower in patients with FV >35° compared with the control group (15° ± 15° vs 55° ± 19°; P < .001). At maximal hip extension, 78% of patients with FV >35° had osseous posterior extra-articular ischiofemoral hip impingement. At 20° of extension, the frequency of posterior extra-articular ischiofemoral impingement was significantly higher for patients with a McKibbin index >70° (83%) and for patients with FV >35° (76%) than for controls (0%) ( P < .001 for both). There was a significant correlation between maximal extension (no rotation) and FV ( r = 0.46; P < .001) as well as between impingement area at 20° of extension (external rotation [ER], 0°) and McKibbin index (0.61; P < .001). Impingement area at 20° of extension (ER, 0°) was significantly larger for patients with McKibbin index >70° versus <70° (251 vs 44 mm2; P = .001). Conclusion: The limited hip extension found in our study could theoretically affect the performance of sports activities such as running, ballet dancing, or lunges. Therefore, although not examined directly in this study, these activities are not advisable for these patients. Preoperative evaluation of FV and the McKibbin index is important in female patients with posterior hip pain before hip preservation surgery (eg, hip arthroscopy).

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Effect of posture and femoral neck osteochondroplasty on femur‐acetabulum clearance in patients with cam‐type femoroacetabular impingement

Cited by 3 publications

References 42 publications

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

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

Limited External Rotation and Hip Extension Due to Posterior Extra-articular Ischiofemoral Hip Impingement in Female Patients With Increased Femoral Anteversion: Implications for Sports, Sexual, and Daily Activities

Posterior Hip Impingement at Maximal Hip Extension in Female Patients With Increased Femoral Version or Increased McKibbin Index and Its Effect on Sports Performance

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