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Lerch TD, Kaim T, Grob V, Hanke M, Schmaranzer F, Steppacher SD, Busch JD, Ziebarth K. MR-based Bony 3D models enable radiation-free preoperative patient-specific analysis and 3D printing for SCFE patients. J Child Orthop 2024; 18:162-170. [PMID: 38567038 PMCID: PMC10984152 DOI: 10.1177/18632521241229618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 01/12/2024] [Indexed: 04/04/2024] Open
Abstract
Objectives Slipped capital femoral epiphyses (SCFE) is a common pediatric hip disease with the risk of osteoarthritis and impingement deformities, and 3D models could be useful for patient-specific analysis. Therefore, magnetic resonance imaging (MRI) bone segmentation and feasibility of 3D printing and of 3D ROM simulation using MRI-based 3D models were investigated. Methods A retrospective study involving 22 symptomatic patients (22 hips) with SCFE was performed. All patients underwent preoperative hip MR with pelvic coronal high-resolution images (T1 images). Slice thickness was 0.8-1.2 mm. Mean age was 12 ± 2 years (59% male patients). All patients underwent surgical treatment. Semi-automatic MRI-based bone segmentation with manual corrections and 3D printing of plastic 3D models was performed. Virtual 3D models were tested for computer-assisted 3D ROM simulation of patients with knee images and were compared to asymptomatic contralateral hips with unilateral SCFE (15 hips, control group). Results MRI-based bone segmentation was feasible (all patients, 100%, in 4.5 h, mean 272 ± 52 min). Three-dimensional printing of plastic 3D models was feasible (all patients, 100%) and was considered helpful for deformity analysis by the treating surgeons for severe and moderate SCFE. Three-dimensional ROM simulation showed significantly (p < 0.001) decreased flexion (48 ± 40°) and IR in 90° of flexion (-14 ± 21°, IRF-90°) for severe SCFE patients with MRI compared to control group (122 ± 9° and 36 ± 11°). Slip angle improved significantly (p < 0.001) from preoperative 54 ± 15° to postoperative 4 ± 2°. Conclusion MRI-based 3D models were feasible for SCFE patients. Three-dimensional models could be useful for severe SCFE patients for preoperative 3D printing and deformity analysis and for ROM simulation. This could aid for patient-specific diagnosis, treatment decisions, and preoperative planning. MRI-based 3D models are radiation-free and could be used instead of CT-based 3D models in the future.
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Affiliation(s)
- Till D Lerch
- Department of Diagnostic, Interventional and Paediatric Radiology, Inselspital, University of Bern, Bern, Switzerland
- Department of Orthopaedic Surgery, Child and Young Adult Hip Preservation Program at Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Tilman Kaim
- Department of Diagnostic, Interventional and Paediatric Radiology, Inselspital, University of Bern, Bern, Switzerland
- Graduate School for Health Sciences, University of Bern, Switzerland
| | - Valentin Grob
- Department of Diagnostic, Interventional and Paediatric Radiology, Inselspital, University of Bern, Bern, Switzerland
| | - Markus Hanke
- Department of Orthopedic Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - Florian Schmaranzer
- Department of Diagnostic, Interventional and Paediatric Radiology, Inselspital, University of Bern, Bern, Switzerland
| | - Simon D Steppacher
- Department of Orthopedic Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - Jasmin D Busch
- Department of Diagnostic, Interventional and Paediatric Radiology, Inselspital, University of Bern, Bern, Switzerland
| | - Kai Ziebarth
- Department of Pediatric Surgery, section of pediatric orthopedic surgery, Inselspital, University of Bern, Bern, Switzerland
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Hoch A, Liebmann F, Farshad M, Fürnstahl P, Rahm S, Zingg PO. Augmented reality-guided pelvic osteotomy of Ganz: feasibility in cadavers. Arch Orthop Trauma Surg 2024; 144:1077-1089. [PMID: 38133802 PMCID: PMC10896923 DOI: 10.1007/s00402-023-05167-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 11/25/2023] [Indexed: 12/23/2023]
Abstract
INTRODUCTION The periacetabular osteotomy is a technically demanding procedure with the goal to improve the osseous containment of the femoral head. The options for controlled execution of the osteotomies and verification of the acetabular reorientation are limited. With the assistance of augmented reality, new possibilities are emerging to guide this intervention. However, the scientific knowledge regarding AR navigation for PAO is sparse. METHODS In this cadaveric study, we wanted to find out, if the execution of this complex procedure is feasible with AR guidance, quantify the accuracy of the execution of the three-dimensional plan, and find out what has to be done to proceed to real surgery. Therefore, an AR guidance for the PAO was developed and applied on 14 human hip cadavers. The guidance included performance of the four osteotomies and reorientation of the acetabular fragment. The osteotomy starting points, the orientation of the osteotomy planes, as well as the reorientation of the acetabular fragment were compared to the 3D planning. RESULTS The mean 3D distance between planned and performed starting points was between 9 and 17 mm. The mean angle between planned and performed osteotomies was between 6° and 7°. The mean reorientation error between the planned and performed rotation of the acetabular fragment was between 2° and 11°. CONCLUSION The planned correction can be achieved with promising accuracy and without serious errors. Further steps for a translation from the cadaver to the patient have been identified and must be addressed in future work.
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Affiliation(s)
- Armando Hoch
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland.
| | - Florentin Liebmann
- Research in Orthopaedic Computer Science, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Mazda Farshad
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Philipp Fürnstahl
- Research in Orthopaedic Computer Science, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Stefan Rahm
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Patrick O Zingg
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
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Hoch A, Grossenbacher G, Jungwirth-Weinberger A, Götschi T, Fürnstahl P, Zingg PO. The periacetabular osteotomy: angulation of the supraacetabular osteotomy for quantification of correction. Hip Int 2023; 33:934-940. [PMID: 35672882 DOI: 10.1177/11207000221103079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Malcorrection of the acetabular fragment in periacetabular osteotomy (PAO) is associated with inferior outcomes. 2-dimensional radiographic parameters are being used for intraoperative verification of a satisfactory result. After reorientation of the fragment, the acetabular version must be verified with an intraoperative radiograph. In the case of an unsatisfactory correction, a reorientation would be required. A slim and radiation-free intraoperative navigation method to directly quantify the correction is highly desirable. AIM To find out whether the measurable angulation of the supraacetabular osteotomy can be used for this purpose. METHODS To determine the angulation, 13 consecutive patients who underwent a PAO were investigated. The preoperative and postoperative standard radiographs as well as CT scans were available. The surgically produced alteration of radiographic parameters was correlated to tilting and spreading of the supraacetabular osteotomy planes. RESULTS Tilting of the supraacetabular osteotomy planes correlates strongly to alteration of the lateral centre-edge angle (LCEA) and the acetabular index (ACI), whereas spreading of the same planes showed also a strong correlation, but to the LCEA only. 1° of tilting resulted in a 0.2° alteration of the LCEA and a 0.5° alteration of the ACI, whereas 1° of spreading resulted in a 0.5° alteration of the LCEA. CONCLUSIONS This study shows that the measurable angulation of the supraacetabular osteotomy planes can be used to monitor the three-dimensional reorientation of the acetabular fragment in PAO. As long as sophisticated modalities are lacking, this technique offers an easy way to intraoperatively navigate the correction in PAO.
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Affiliation(s)
- Armando Hoch
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Switzerland
| | | | | | - Tobias Götschi
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Switzerland
- Institute for Biomechanics, ETH Zurich, Zurich, Switzerland
| | - Philipp Fürnstahl
- Research in Orthopaedic Computer Science, Balgrist University Hospital, University of Zurich, Switzerland
| | - Patrick O Zingg
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Switzerland
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Heimann AF, Brouze IF, Zheng G, Moosmann AM, Schwab JM, Tannast M, Zurmühle CA. Pelvic tilt after Bernese periacetabular osteotomy-a long-term follow-up study. J Hip Preserv Surg 2023; 10:214-219. [PMID: 38162264 PMCID: PMC10757412 DOI: 10.1093/jhps/hnad030] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 08/23/2023] [Indexed: 01/03/2024] Open
Abstract
Patients with developmental dysplasia of the hip (DDH) are believed to present with increased anterior pelvic tilt to compensate for reduced anterior femoral head coverage. If true, pelvic tilt in dysplastic patients should be high preoperatively and decrease after correction with periacetabular osteotomy (PAO). To date, the evolution of pelvic tilt in long-term follow-up after PAO has not been reported. We therefore asked the following questions: (i) is there a difference in pelvic tilt between patients with DDH and an asymptomatic control group? (ii) How does pelvic tilt evolve during long-term follow-up after Bernese PAO compared with before surgery? This study is a therapeutic study with the level of evidence III. We retrospectively compared preoperative pelvic tilt in 64 dysplastic patients (71 hips) with an asymptomatic control group of 20 patients (20 hips). In addition, immediate postoperative and long-term follow-up (at 18 ± 8 [range 7-34 years) pelvic tilt was assessed and compared. Dysplastic patients had a significantly higher mean preoperative pelvic tilt than controls [2.3 ± 5.3° (-11.2° to 16.4°) versus 1.1 ± 3.0° (-4.9 to 5.9), P = 0.006]. Mean pelvic tilt postoperatively was 1.5 ± 5.3° (-11.2 to 17.0º, P = 0.221) and at long-term follow-up was 0.4 ± 5.7° (range -9.9° to 20.9°, P = 0.002). Dysplastic hips undergoing PAO show a statistically significant decrease in pelvic tilt during long-term follow-up. However, given the large interindividual variability in pelvic tilt, the observed differences may not achieve clinical significance.
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Affiliation(s)
- Alexander F Heimann
- Department of Orthopaedic Surgery and Traumatology, HFR—Cantonal Hospital, Chemin des Pensionnats 2-6, Fribourg 1700, Switzerland
- Department of Medicine, University of Fribourg, Chemin du Musée, Fribourg 1700, Switzerland
| | - Iris F Brouze
- Department of Orthopaedic Surgery, Valais Hospital, Avenue Grand-Champsec 80, Sitten 1951, Switzerland
| | - Guoyan Zheng
- Institute of Medical Robotics, School of Biomedical Engineering, Shanghai Jiao Tong University, Minhang District, 东川路 邮政编码, Shanghai 200240, China
| | - Angela M Moosmann
- Department of Orthopaedic Surgery and Traumatology, HFR—Cantonal Hospital, Chemin des Pensionnats 2-6, Fribourg 1700, Switzerland
- Department of Medicine, University of Fribourg, Chemin du Musée, Fribourg 1700, Switzerland
| | - Joseph M Schwab
- Department of Orthopaedic Surgery and Traumatology, HFR—Cantonal Hospital, Chemin des Pensionnats 2-6, Fribourg 1700, Switzerland
| | - Moritz Tannast
- Department of Orthopaedic Surgery and Traumatology, HFR—Cantonal Hospital, Chemin des Pensionnats 2-6, Fribourg 1700, Switzerland
- Department of Medicine, University of Fribourg, Chemin du Musée, Fribourg 1700, Switzerland
| | - Corinne A Zurmühle
- Department of Orthopaedic Surgery and Traumatology, HFR—Cantonal Hospital, Chemin des Pensionnats 2-6, Fribourg 1700, Switzerland
- Department of Medicine, University of Fribourg, Chemin du Musée, Fribourg 1700, Switzerland
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Pruneski JA, Chan JJ, Wang KC, Matheney T, Bharam S. Acetabular Rim Disorders: Epidemiology, Etiology, Management, and Outcomes. JBJS Rev 2023; 11:01874474-202308000-00005. [PMID: 37549243 DOI: 10.2106/jbjs.rvw.23.00058] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
» Anatomic disorders of the acetabular rim are a common, correctable source of hip pain in younger patients.» Some common conditions of involving abnormal acetabular rim morphology include developmental dysplasia of the hip, pincer-type femoroacetabular impingement, acetabular protrusion, and acetabular retroversion.» Treatment option for these conditions were historically limited to open osteotomy and osteoplasty procedures; however, there is increasing use of arthroscopic intervention for these patients.» Arthroscopic intervention has demonstrated short-term success in a variety of focal acetabular rim disorders; however, further research is needed to determine the long-term outcomes of these procedures and their utility in more global pathology.
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Affiliation(s)
- James A Pruneski
- Tripler Army Medical Center, Honolulu, Hawaii
- Boston Children's Hospital, Boston, Massachusetts
| | - Jimmy J Chan
- Boston Children's Hospital, Boston, Massachusetts
- Mount Sinai Health System, New York, New York
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Jones AC, Stewart TD, Maher N, Holton C. Can a Computational Model Predict the Effect of Lesion Location on Cam-type Hip Impingement? Clin Orthop Relat Res 2023; 481:1432-1443. [PMID: 36724209 PMCID: PMC10263218 DOI: 10.1097/corr.0000000000002565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 01/03/2023] [Indexed: 02/02/2023]
Abstract
BACKGROUND The Warwick consensus defined femoroacetabular impingement syndrome as a motion-related clinical disorder of the hip with a triad of symptoms, clinical signs, and imaging findings representing symptomatic premature contact between the proximal femur and acetabulum. Several factors appear to cause labral and cartilage damage, including joint shape and orientation and patient activities. There is a lack of tools to predict impingement patterns in a patient across activities. Current computational modeling tools either measure pure ROM of the joint or include complexity that reduces reliability and increases time to achieve a solution. QUESTIONS/PURPOSES The purpose of this study was to examine the efficacy of a low computational cost approach to combining cam-type hip shape and multiple hip motions for predicting impingement. Specifically, we sought to determine (1) the potential to distinguish impingement in individual hip shapes by analyzing the difference between a cam lesion at the anterior femoral neck and one located at the superior femoral neck; (2) sensitivity to three aspects of hip alignment, namely femoral neck-shaft angle, femoral version angle, and pelvic tilt; and (3) the difference in impingement measures between the individual activities in our hip motion dataset. METHODS A model of the shape and alignment of a cam-type impinging hip was created and used to describe two locations of a cam lesion on the femoral head-neck junction (superior and anterior) based on joint shape information available in prior studies. Sensitivity to hip alignment was assessed by varying three aspects from a baseline (typical alignment described in prior studies), namely, femoral neck-shaft angle, femoral version, and pelvic tilt. Hip movements were selected from an existing database of 18 volunteers performing 13 activities (10 male, eight female; mean age 44 ± 19 years). A subset was selected to maximize variation in the range of joint angles and maintain a consistent number of people performing each activity, which resulted in nine people per activity, including at least three of each sex. Activities included pivoting during walking, squatting, and golf swing. All selected hip motion cases were applied to each hip shape model. For the first part of the study, the number of motion cases in which impingement was predicted was recorded. Quantitative analyses of the depth of penetration of the cam lesion into the acetabular socket and qualitative observations of impingement location were made for each lesion location (anterior and superior). In the second part of the study, in which we aimed to test the sensitivity of the findings to hip joint orientation, full analysis of both cam lesion locations was repeated for three modified joint orientations. Finally, the results from the first part of the analysis were divided by activity to understand how the composition of the activity dataset affected the results. RESULTS The two locations of cam lesion generated impingement in a different percentage of motion cases (anterior cam: 56% of motion cases; superior cam: 13% of motion cases) and different areas of impingement in the acetabulum, but there were qualitatively similar penetration depths (anterior cam: 6.8° ± 5.4°; superior cam: 7.9° ± 5.8°). The most substantial effects of changing the joint orientation were a lower femoral version angle for the anterior cam, which increased the percentage of motion cases generating impingement to 67%, and lower neck-shaft angle for the superior cam, which increased the percentage of motion cases generating impingement to 37%. Flexion-dominated activities (for example, squatting) only generated impingement with the anterior cam. The superior cam generated impingement during activities with high internal-external rotation of the joint (for example, the golf swing). CONCLUSION This work demonstrated the capability of a simple, rapid computational tool to assess impingement of a specific cam-type hip shape (under 5 minutes for more than 100 motion cases). To our knowledge, this study is the first to do so for a large set of motion cases representing a range of activities affecting the hip, and could be used in planning surgical bone removal. CLINICAL RELEVANCE The results of this study imply that patients with femoroacetabular impingement syndrome with cam lesions on the superior femoral head-neck junction may experience impinging during motions that are not strongly represented by current physical diagnostic tests. The use of this tool for surgical planning will require streamlined patient-specific hip shape extraction from imaging, model sensitivity testing, evaluation of the hip activity database, and validation of impingement predictions at an individual patient level.
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Affiliation(s)
- Alison C. Jones
- Leeds Institute of Medical and Biological Engineering, University of Leeds, UK
| | - Todd D. Stewart
- Leeds Institute of Medical and Biological Engineering, University of Leeds, UK
| | - Niall Maher
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Colin Holton
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
- National Institute for Health Research Leeds Biomedical Research Centre, Leeds, UK
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Slullitel PA, Holc F, Buljubasich M, Latorre M, Comba F, Zanotti G, Marquesini M, Grammatopoulos G, Buttaro MA. Anterior Center-Edge Angle Is Less Reliable Than Anterior Wall Index to Predict Anterior Coverage of the Femoral Head. Am J Sports Med 2023; 51:2151-2160. [PMID: 37227132 DOI: 10.1177/03635465231168902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
BACKGROUND No consensus is available regarding which radiographic measurement most accurately correlates with anterior coverage of the femoral head. PURPOSE (1) To determine the correlation between 2 measurements of anterior wall coverage: total anterior coverage (TAC) calculated from radiographs and equatorial anterior acetabular sector angle (eAASA) calculated from computed tomography (CT) scans; (2) to define the correlation between anterior center-edge angle (ACEA) and anterior wall index (AWI) with TAC and eAASA; and (3) to investigate what other radiographic metrics may help predict anterior coverage. STUDY DESIGN Cohort study (Diagnosis); Level of evidence, 3. METHODS The authors retrospectively reviewed 77 hips (48 patients) for which radiographs and CT scans were obtained for reasons other than hip-related pain. Mean age of the population was 62 ± 22 years; 48 (62%) hips were from female patients. Two observers measured lateral center-edge angle (LCEA), AWI, Tönnis angle, ACEA, CT-based pelvic tilt, and CT-based acetabular version, with all Bland-Altman plots within 95% agreement. Correlation between intermethod measurements was estimated with a Pearson coefficient. Linear regression was used to test the ability of baseline radiographic measurements to predict both TAC and eAASA. RESULTS Pearson coefficients were r = 0.164 (ACEA vs TAC; P = .155), r = 0.170 (ACEA vs eAASA; P = .140), r = 0.58 (AWI vs TAC; P = .0001), and r = 0.693 (AWI vs eAASA; P < .0001). Multiple linear regression model 1 showed that AWI (β = 17.8; 95% CI, 5.7 to 29.9; P = .004), CT acetabular version (β = -0.45; 95% CI, -0.71 to -0.22; P = .001), and LCEA (β = 0.33; 95% CI, 0.19 to 0.47; P = .001) were useful to predict TAC. Multiple linear regression model 2 revealed that AWI (β = 25; 95% CI, 15.67 to 34.4; P = .001), CT acetabular version (β = -0.48; 95% CI, -0.67 to -0.29; P = .001), CT pelvic tilt (β = 0.26; 95% CI, 0.12 to 0.4; P = .001), and LCEA (β = 0.21; 95% CI, 0.1 to 0.3; P = .001) accurately predicted eAASA. Model-based estimates and 95% CIs using 2000 bootstrap samples from the original data were 6.16 to 28.6 for AWI in model 1 and 15.1 to 34.26 for AWI in model 2. CONCLUSION There was a moderate to strong correlation between AWI and both TAC and eAASA, whereas ACEA correlated weakly with the former measurements, thus not being useful to quantify anterior acetabular coverage. Other variables such as LCEA, acetabular version, and pelvic tilt may also help predict anterior coverage in asymptomatic hips.
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Affiliation(s)
| | - Fernando Holc
- Hospital Italiano Buenos Aires, Buenos Aires, Argentina
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Heimann AF, Zurmühle CA, Stetzelberger VM, Galley J, Schwab JM, Tannast M. [Definition of hip dysplasia in 2023 : Signs of macro and micro instability]. ORTHOPADIE (HEIDELBERG, GERMANY) 2023; 52:261-271. [PMID: 36881127 PMCID: PMC10063496 DOI: 10.1007/s00132-023-04353-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 01/30/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND Hip dysplasia is a complex static-dynamic pathology leading to chronic joint instability and osteoarthritis. Because our understanding of the underlying pathomorphologies of hip dysplasia, both on the macro and micro levels, has evolved, an updated definition is needed. QUESTION What is the definition of hip dysplasia in 2023? METHODS By summarizing and reviewing relevant literature, we provide an up-to-date definition of hip dysplasia with a guide to appropriately making the diagnosis. RESULTS In addition to the pathognomonic parameters, supportive and descriptive indicators, as well as secondary changes are used to fully characterize instability inherent in hip dysplasia. The primary diagnostic tool is always the plain anteroposterior pelvis radiograph, which can be supplemented by additional investigations (MRI of the hip with intraarticular contrast agent; CT) if necessary. CONCLUSION The complexity, subtlety, and diversity of the pathomorphology of residual hip dysplasia requires careful, multilevel diagnosis and treatment planning in specialized centers.
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Affiliation(s)
- Alexander Frank Heimann
- Klinik für Orthopädische Chirurgie und Traumatologie, HFR Kantonsspital Freiburg, Universität Freiburg, Chemin des pensionnats 2-6, 1700, Freiburg, Schweiz
| | - Corinne Andrea Zurmühle
- Klinik für Orthopädische Chirurgie und Traumatologie, HFR Kantonsspital Freiburg, Universität Freiburg, Chemin des pensionnats 2-6, 1700, Freiburg, Schweiz
| | - Vera Marie Stetzelberger
- Klinik für Orthopädische Chirurgie und Traumatologie, HFR Kantonsspital Freiburg, Universität Freiburg, Chemin des pensionnats 2-6, 1700, Freiburg, Schweiz
| | - Julien Galley
- Klinik für Radiologie, HFR Kantonsspital Freiburg, Universität Freiburg, Freiburg, Schweiz
| | - Joseph M Schwab
- Klinik für Orthopädische Chirurgie und Traumatologie, HFR Kantonsspital Freiburg, Universität Freiburg, Chemin des pensionnats 2-6, 1700, Freiburg, Schweiz
| | - Moritz Tannast
- Klinik für Orthopädische Chirurgie und Traumatologie, HFR Kantonsspital Freiburg, Universität Freiburg, Chemin des pensionnats 2-6, 1700, Freiburg, Schweiz.
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Lerch TD, Schmaranzer F. [Preoperative MR imaging for hip dysplasia : Assessment of associated deformities and intraarticular pathologies]. ORTHOPADIE (HEIDELBERG, GERMANY) 2023; 52:300-312. [PMID: 36976331 PMCID: PMC10063507 DOI: 10.1007/s00132-023-04356-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Accepted: 02/02/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND Developmental dysplasia of the hip (DDH) is a known reason for hip pain for adolescents and young adults. Preoperative imaging is increasingly recognized as an important factor due to the recent advances in MR imaging. OBJECTIVES The aim of this article is to give an overview of preoperative imaging for DDH. The acetabular version and morphology, associated femoral deformities (cam deformity, valgus and femoral antetorsion) and intraarticular pathologies (labrum and cartilage damage) and cartilage mapping are described. METHODS After an initial evaluation with AP radiographs, CT or MRI represent the methods of choice for the preoperative evaluation of the acetabular morphology and cam deformity, and for the measurement of femoral torsion. Different measurement techniques and normal values should be considered, especially for patients with increased femoral antetorsion because this could lead to misinterpretation and misdiagnosis. MRI allows analysis of labrum hypertrophy and subtle signs for hip instability. 3D MRI for cartilage mapping allows quantification of biochemical cartilage degeneration and yields great potential for surgical decision-making. 3D-CT and, increasingly, 3D MRI of the hip to generate 3D pelvic bone models and subsequent 3D impingement simulation can help to detect posterior extraarticular ischiofemoral impingement. RESULTS AND DISCUSSION Acetabular morphology can be divided in anterior, lateral and posterior hip dysplasia. Combined osseous deformities are common, such as hip dysplasia combined with cam deformity (86%). Valgus deformities were reported in 44%. Combined hip dysplasia and increased femoral antetorsion can occur in 52%. Posterior extraarticular ischiofemoral impingement between the lesser trochanter and the ischial tuberosity can occur in patients with increased femoral antetorsion. Typically, labrum damage and hypertrophy, cartilage damage, subchondral cysts can occur in hip dysplasia. Hypertrophy of the muscle iliocapsularis is a sign for hip instability. Acetabular morphology and femoral deformities (cam deformity and femoral anteversion) should be evaluated before surgical therapy for patients with hip dysplasia, considering the different measurement techniques and normal values of femoral antetorsion.
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Affiliation(s)
- Till D Lerch
- Universitätsinstitut für diagnostische, interventionelle und pädiatrische Radiologie, Inselspital Bern, Universität Bern, Freiburgstr. 8, 3010, Bern, Schweiz.
| | - Florian Schmaranzer
- Universitätsinstitut für diagnostische, interventionelle und pädiatrische Radiologie, Inselspital Bern, Universität Bern, Freiburgstr. 8, 3010, Bern, Schweiz
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Boschung A, Antioco T, Novais EN, Kim YJ, Kiapour A, Tannast M, Steppacher SD, Lerch TD. Large Hip Impingement Area and Subspine Hip Impingement in Patients With Absolute Femoral Retroversion or Decreased Combined Version. Orthop J Sports Med 2023; 11:23259671221148502. [PMID: 36846812 PMCID: PMC9950619 DOI: 10.1177/23259671221148502] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 09/26/2022] [Indexed: 02/25/2023] Open
Abstract
Background It remains unclear if femoral retroversion is a contraindication for hip arthroscopy in patients with femoroacetabular impingement (FAI). Purpose 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. Study Design Cross-sectional study; Level of evidence, 3. Methods 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. Results 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). Conclusion 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.
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Affiliation(s)
- Adam Boschung
- Department of Diagnostic, Interventional and Pediatric Radiology,
Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland.,Department of Orthopedic Surgery and Traumatology, Fribourg Cantonal
Hospital, University of Fribourg, Fribourg, Switzerland
| | - Tiziano Antioco
- Department of Diagnostic, Interventional and Pediatric Radiology,
Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Eduardo N. Novais
- Department of Pediatric Orthopedic Surgery, Boston Children’s
Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Young-jo Kim
- Department of Pediatric Orthopedic Surgery, Boston Children’s
Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ata Kiapour
- Department of Pediatric Orthopedic Surgery, Boston Children’s
Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Moritz Tannast
- Department of Orthopedic Surgery and Traumatology, Fribourg Cantonal
Hospital, University of Fribourg, Fribourg, Switzerland
| | - Simon D. Steppacher
- Department of Orthopedic Surgery, Inselspital, University Hospital
Bern, University of Bern, Switzerland
| | - Till D. Lerch
- Department of Diagnostic, Interventional and Pediatric Radiology,
Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland.,Department of Pediatric Orthopedic Surgery, Boston Children’s
Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Till D. Lerch, MD, PhD, Department of Diagnostic, Interventional
and Pediatric Radiology, Inselspital, Freiburgstrasse, 3010 Bern, Switzerland
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11
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Meier MK, Schmaranzer F, Kaim T, Tannast M, Novais EN, Siebenrock KA, Steppacher SD, Lerch TD. Combined femoral and acetabular version is sex-related and differs between patients with hip dysplasia and acetabular retroversion. Eur J Radiol 2023; 158:110634. [PMID: 36462225 DOI: 10.1016/j.ejrad.2022.110634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 11/23/2022] [Accepted: 11/24/2022] [Indexed: 11/30/2022]
Abstract
AIMS Frequency 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 METHODS A 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. RESULTS Mean 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°. CONCLUSION Patients 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.
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Affiliation(s)
- Malin K Meier
- Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Florian Schmaranzer
- Department of Diagnostic, Interventional and Paediatric Radiology, University of Bern, Inselspital, Bern University Hospital, Bern, Switzerland.
| | - Tilman Kaim
- Department of Diagnostic, Interventional and Paediatric Radiology, University of Bern, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Moritz Tannast
- Department of Orthopaedic Surgery and Traumatology, Fribourg Cantonal Hospital, University of Fribourg, Fribourg, Switzerland.
| | - Eduardo N Novais
- Department of Pediatric Orthopedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Klaus A Siebenrock
- Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Simon D Steppacher
- Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Till D Lerch
- Department of Diagnostic, Interventional and Paediatric Radiology, University of Bern, Inselspital, Bern University Hospital, Bern, Switzerland.
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12
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Hassan MM, Farooqi AS, Feroe AG, Lee A, Cusano A, Novais E, Wuerz TH, Kim YJ, Parisien RL. Open and arthroscopic management of femoroacetabular impingement: a review of current concepts. J Hip Preserv Surg 2022; 9:265-275. [PMID: 36908557 PMCID: PMC9993460 DOI: 10.1093/jhps/hnac043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 08/09/2022] [Accepted: 10/05/2022] [Indexed: 03/14/2023] Open
Abstract
Femoroacetabular impingement (FAI) is a common femoral and/or acetabular abnormality that can cause progressive damage to the hip and osteoarthritis. FAI can be the result of femoral head/neck overgrowth, acetabular overgrowth or both femoral and acetabular abnormalities, resulting in a loss of native hip biomechanics and pain upon hip flexion and rotation. Radiographic evidence can include loss of sphericity of the femoral neck (cam impingement) and/or acetabular retroversion with focal or global overcoverage (pincer impingement). Operative intervention is indicated in symptomatic patients after failed conservative management with radiographic evidence of impingement and minimal arthritic changes of the hip, with the goal of restoring normal hip biomechanics and reducing pain. This is done by correcting the femoral head-neck relationship to the acetabulum through femoral and/or acetabular osteoplasty and treatment of concomitant hip pathology. In pincer impingement cases with small lunate surfaces, reverse periacetabular osteotomy is indicated as acetabular osteoplasty can decrease an already small articular surface. While surgical dislocation is regarded as the traditional gold standard, hip arthroscopy has become widely utilized in recent years. Studies comparing both open surgery and arthroscopy have shown comparable long-term pain reduction and improvements in clinical measures of hip function, as well as similar conversion rates to total hip arthroplasty. However, arthroscopy has trended toward earlier improvement, quicker recovery and faster return to sports. The purpose of this study was to review the recent literature on open and arthroscopic management of FAI.
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Affiliation(s)
- Mahad M Hassan
- TRIA Orthopedic Center, 8100 Northland Dr, Bloomington, MN 55431, USA.,Department of Orthopaedic Surgery, University of Minnesota Medical School, 2450 Riverside Ave, Suite R200, Minneapolis, MN 55454, USA
| | - Ali S Farooqi
- Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Aliya G Feroe
- Department of Orthopedic Surgery, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, USA.,Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Alexander Lee
- Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Antonio Cusano
- University of Connecticut School of Medicine, 200 Academic Way, Farmington, CT 06032, USA
| | - Eduardo Novais
- Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Thomas H Wuerz
- Boston Sports & Shoulder Center, 840 Winter St, Waltham, MA 02451, USA
| | - Young-Jo Kim
- Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Robert L Parisien
- Department of Orthopaedic Surgery and Sports Medicine, 5 East 98th Street, Mount Sinai, New York, NY 10029, USA
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13
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Curley AJ, Ruh ER, Shah A, Disantis AE, Krivoniak A, Mauro CS, McClincy MP. A systematic approach to CT evaluation of non-arthritic hip pain. EFORT Open Rev 2022; 7:653-662. [PMID: 36125004 PMCID: PMC9624481 DOI: 10.1530/eor-22-0051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Bone morphology has been increasingly recognized as a significant variable in the evaluation of non-arthritic hip pain in young adults. Increased availability and use of multidetector CT in this patient population has contributed to better characterization of the osseous structures compared to traditional radiographs. Femoral and acetabular version, sites of impingement, acetabular coverage, femoral head–neck morphology, and other structural abnormalities are increasingly identified with the use of CT scan. In this review, a standard CT imaging technique and protocol is discussed, along with a systematic approach for evaluating pelvic CT imaging in patients with non-arthritic hip pain.
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Affiliation(s)
- Andrew J Curley
- Department of Orthopedics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ethan R Ruh
- Department of Orthopedics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Amisha Shah
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ashley E Disantis
- Department of Orthopedics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - April Krivoniak
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Craig S Mauro
- Department of Orthopedics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Michael P McClincy
- Department of Orthopedics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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14
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Lerch TD, Antioco T, Boschung A, Meier MK, Schmaranzer F, Novais EN, Tannast M, Steppacher SD. Hip Impingement Location in Maximal Hip Flexion in Patients With Femoroacetabular Impingement With and Without Femoral Retroversion. Am J Sports Med 2022; 50:2989-2997. [PMID: 36037094 DOI: 10.1177/03635465221110887] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
- Till D Lerch
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Tiziano Antioco
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Adam Boschung
- Department of Orthopedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Malin K Meier
- Department of Orthopedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Florian Schmaranzer
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Eduardo N Novais
- Department of Orthopedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Moritz Tannast
- Department of Orthopedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Department of Orthopedic Surgery and Traumatology, Fribourg Cantonal Hospital, University of Fribourg, Fribourg, Switzerland
| | - Simon D Steppacher
- Department of Orthopedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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15
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Ruckli AC, Schmaranzer F, Meier MK, Lerch TD, Steppacher SD, Tannast M, Zeng G, Burger J, Siebenrock KA, Gerber N, Gerber K. Automated quantification of cartilage quality for hip treatment decision support. Int J Comput Assist Radiol Surg 2022; 17:2011-2021. [PMID: 35976596 PMCID: PMC9515031 DOI: 10.1007/s11548-022-02714-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 06/30/2022] [Indexed: 11/30/2022]
Abstract
Purpose Preservation surgery can halt the progress of joint degradation, preserving the life of the hip; however, outcome depends on the existing cartilage quality. Biochemical analysis of the hip cartilage utilizing MRI sequences such as delayed gadolinium-enhanced MRI of cartilage (dGEMRIC), in addition to morphological analysis, can be used to detect early signs of cartilage degradation. However, a complete, accurate 3D analysis of the cartilage regions and layers is currently not possible due to a lack of diagnostic tools. Methods A system for the efficient automatic parametrization of the 3D hip cartilage was developed. 2D U-nets were trained on manually annotated dual-flip angle (DFA) dGEMRIC for femoral head localization and cartilage segmentation. A fully automated cartilage sectioning pipeline for analysis of central and peripheral regions, femoral-acetabular layers, and a variable number of section slices, was developed along with functionality for the automatic calculation of dGEMRIC index, thickness, surface area, and volume. Results The trained networks locate the femoral head and segment the cartilage with a Dice similarity coefficient of 88 ± 3 and 83 ± 4% on DFA and magnetization-prepared 2 rapid gradient-echo (MP2RAGE) dGEMRIC, respectively. A completely automatic cartilage analysis was performed in 18s, and no significant difference for average dGEMRIC index, volume, surface area, and thickness calculated on manual and automatic segmentation was observed. Conclusion An application for the 3D analysis of hip cartilage was developed for the automated detection of subtle morphological and biochemical signs of cartilage degradation in prognostic studies and clinical diagnosis. The segmentation network achieved a 4-time increase in processing speed without loss of segmentation accuracy on both normal and deformed anatomy, enabling accurate parametrization. Retraining of the networks with the promising MP2RAGE protocol would enable analysis without the need for B1 inhomogeneity correction in the future.
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Affiliation(s)
- Adrian C Ruckli
- sitem Center for Translational Medicine and Biomedical Entrepreneurship, Personalised Medicine, University of Bern, Bern, Switzerland
| | - Florian Schmaranzer
- Department of Diagnostic-, Interventional- and Pediatric Radiology, Inselspital, University Hospital of Bern, Bern, Switzerland
| | - Malin K Meier
- Department of Orthopaedic Surgery and Traumatology, Inselspital, University Hospital of Bern, Bern, Switzerland
| | - Till D Lerch
- Department of Diagnostic-, Interventional- and Pediatric Radiology, Inselspital, University Hospital of Bern, Bern, Switzerland
| | - Simon D Steppacher
- Department of Orthopaedic Surgery and Traumatology, Inselspital, University Hospital of Bern, Bern, Switzerland
| | - Moritz Tannast
- Department of Orthopaedic Surgery and Traumatology, Fribourg Cantonal Hospital, University of Fribourg, Fribourg, Switzerland
| | - Guodong Zeng
- sitem Center for Translational Medicine and Biomedical Entrepreneurship, Personalised Medicine, University of Bern, Bern, Switzerland.,Department of Orthopaedic Surgery and Traumatology, Fribourg Cantonal Hospital, University of Fribourg, Fribourg, Switzerland
| | - Jürgen Burger
- sitem Center for Translational Medicine and Biomedical Entrepreneurship, Personalised Medicine, University of Bern, Bern, Switzerland
| | - Klaus A Siebenrock
- Department of Orthopaedic Surgery and Traumatology, Inselspital, University Hospital of Bern, Bern, Switzerland
| | - Nicolas Gerber
- sitem Center for Translational Medicine and Biomedical Entrepreneurship, Personalised Medicine, University of Bern, Bern, Switzerland.
| | - Kate Gerber
- sitem Center for Translational Medicine and Biomedical Entrepreneurship, Personalised Medicine, University of Bern, Bern, Switzerland
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16
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Becker LD, Floerkemeier T, Derksen A, Schwarze M, Budde S, Windhagen H, Wirries N. Analysis of factors affecting the time for implantation of a total hip arthroplasty in patients with symptomatic primary and secondary hip osteoarthritis. Hip Int 2022:11207000221114618. [PMID: 35876182 DOI: 10.1177/11207000221114618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Many studies have identified factors associated with an unfavourable clinical outcome or an early conversion to total hip arthroplasty (THA) after joint-preserving treatment. We analysed the effect and reliability of different factors on the age at which THA becomes necessary. METHODS Hip joint radiographs of 2485 cases were evaluated using the lateral centre-edge angle (LCEA) and acetabulum angle (ACA) as well as the alpha angle to describe the femoral head shapes. Regressions were performed using patient's age at the time of THA and body mass index (BMI) as well as LCEA and ACA. Multiple linear regressions were used to create a formula comprising factors that significantly correlated with patient age at the time of joint replacement surgery. RESULTS The BMI, LCEA, and ACA showed significant correlations with the age of THA implantation (p < 0.001). Multiple linear regressions produced the following formula: age (THA) = 72.40-0.40 × BMI + 0.20 × LCEA-0.18 × ACA. BMI showed a stronger impact on the age of end-stage osteoarthritis than the ACA. The formula explained 12.1% of the distributing data (r2). Surprisingly, the alpha angle did not show an impact on the age of THA surgery. CONCLUSIONS BMI had the greatest impact on patient's age at the time of THA, followed by the characteristic radiological angles for hip dysplasia. The resulting formula could emphasise and visualise the significant impact of these factors. However, despite the calculation being based on 2485 cases, the calculated validity of 12.1% was limited.
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Affiliation(s)
- Leon D Becker
- Department of Orthopaedic Surgery at Diakovere Annastift (Hannover Medical School), Hannover, Germany
| | | | - Alexander Derksen
- Department of Orthopaedic Surgery at Diakovere Annastift (Hannover Medical School), Hannover, Germany
| | - Michael Schwarze
- Laboratory for Biomechanics and Biomaterials, Hannover Medical School, Hannover, Germany
| | - Stefan Budde
- Department of Orthopaedic Surgery at Diakovere Annastift (Hannover Medical School), Hannover, Germany
| | - Henning Windhagen
- Department of Orthopaedic Surgery at Diakovere Annastift (Hannover Medical School), Hannover, Germany
| | - Nils Wirries
- Department of Orthopaedic Surgery at Diakovere Annastift (Hannover Medical School), Hannover, Germany
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17
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Meier MK, Reche J, Schmaranzer F, von Tengg-Kobligk H, Steppacher SD, Tannast M, Novais EN, Lerch TD. How frequent is absolute femoral retroversion in symptomatic patients with cam- and pincer-type femoroacetabular impingement? Bone Jt Open 2022; 3:557-565. [PMID: 35819309 PMCID: PMC9350700 DOI: 10.1302/2633-1462.37.bjo-2022-0049.r1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Aims The 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. Methods A 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. Results A 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°). Conclusion Patients 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.
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Affiliation(s)
- Malin K. Meier
- Department of Orthopaedic Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jelena Reche
- Department of Orthopaedic Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Florian Schmaranzer
- Department of Diagnostic, Interventional and Paediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Hendrik von Tengg-Kobligk
- Department of Diagnostic, Interventional and Paediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Simon D. Steppacher
- Department of Orthopaedic Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Moritz Tannast
- Department of Orthopaedic Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Orthopaedic Surgery and Traumatology, Fribourg Cantonal Hospital, University of Fribourg, Fribourg, Switzerland
| | - Eduardo N. Novais
- Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Till D. Lerch
- Department of Diagnostic, Interventional and Paediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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18
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Vuillemin N, Steppacher SD, Meier MK, Büchler L. [Treatment strategies for the combination of hip dysplasia, femoroacetabular impingement and malrotation of the proximal femur : How much should be corrected?]. ORTHOPADIE (HEIDELBERG, GERMANY) 2022; 51:438-449. [PMID: 35925372 DOI: 10.1007/s00132-022-04252-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/06/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Hip dysplasia, FAI and femoral malrotation often occur together, resulting in mixed symptoms and severe biomechanical limitations of the hip. OBJECTIVES To report on the current recommendations for the best possible diagnosis and treatment strategies of combination pathologies in hip-preserving surgery. METHODS Review and discussion of the relevant literature with consideration of own experience in the treatment of complex combined pathomorphologies of the hip. RESULTS Patient history and a thorough clinical examination are key for determining the predominant pathomorphologies causing the symptoms. Standardized conventional ap pelvic and axial images of the hip are the basis for the radiological assessment of the hip, supplemented with MRI, CT and animations of the hip, depending on the case. As the pathologies influence each other functionally, a stepwise approach to treatment is recommended. The functionally most relevant pathology is treated first, followed by further corrections as needed. The primary goal is to achieve a stable hip with normal acetabular coverage, followed by an impingement-free range of motion and normalized musculoskeletal function. Care must be taken in the choice of surgical method to ensure that all pathologies can be adequately treated. CONCLUSION Complex, combined pathologies of the hip can be treated sufficiently with hip-preserving surgery. A thorough diagnosis is important in order to recognize the functional interaction of the different pathologies. The goal of the surgical therapy is a correctly covered, stable hip with a normal range of motion.
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Affiliation(s)
- Nicolas Vuillemin
- Department für Orthopädie und Traumatologie, Inselspital, Universitätsklinik Bern, Bern, Schweiz
| | - Simon D Steppacher
- Department für Orthopädie und Traumatologie, Inselspital, Universitätsklinik Bern, Bern, Schweiz
| | - Malin K Meier
- Department für Orthopädie und Traumatologie, Inselspital, Universitätsklinik Bern, Bern, Schweiz
| | - Lorenz Büchler
- Department für Orthopädie und Traumatologie, Inselspital, Universitätsklinik Bern, Bern, Schweiz.
- Klinik für Orthopädie und Traumatologie, Kantonsspital Aarau, Tellstrasse 25, 5001, Aarau, Schweiz.
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Lerch TD, Antioco T, Meier MK, Boschung A, Hanke MS, Tannast M, Siebenrock KA, Schmaranzer F, Steppacher SD. Combined abnormalities of femoral version and acetabular version and McKibbin Index in FAI patients evaluated for hip preservation surgery. J Hip Preserv Surg 2022; 9:67-77. [PMID: 35854804 PMCID: PMC9291377 DOI: 10.1093/jhps/hnac016] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 02/20/2022] [Accepted: 03/07/2022] [Indexed: 01/04/2023] Open
Abstract
Frequencies of combined abnormalities of femoral version (FV) and acetabular version (AV) and of abnormalities of the McKibbin index are unknown. To investigate the prevalence of combined abnormalities of FV and AV and of abnormalities of the McKibbin index in symptomatic patients with femoroacetabular impingement (FAI), a retrospective, Institutional Review Board (IRB)-approved study of 333 symptomatic patients (384 hips) that were presented with hip pain and FAI was performed. The computed tomography/magnetic resonance imaging based measurement of central AV, cranial AV and FV was compared among five subgroups with distinguished FAI subgroups and patients that underwent a hip preservation surgery. The allocation to each subgroup was based on AP radiographs. Normal AV and FV were 10–25°. The McKibbin index is the sum of central AV and FV. Of patients that underwent a hip preservation surgery, 73% had a normal McKibbin index (20–50°) but 27% had an abnormal McKibbin index. Of all patients, 72% had a normal McKibbin index, but 28% had abnormal McKibbin index. The prevalence of combined abnormalities of FV and AV varied among subgroups: a higher prevalence of decreased central AV combined with decreased FV of patients with acetabular-retroversion group (12%) and overcoverage (11%) was found compared with mixed-type FAI (5%). Normal AV combined with normal FV was present in 41% of patients with cam-type FAI and in 34% of patients with overcoverage. Patients that underwent a hip preservation surgery had normal mean FV (17 ± 11°), central AV (19 ± 7°), cranial AV (16 ± 10°) and McKibbin index (36 ± 14°). Frequency of combined abnormalities of AV and FV differs between subgroups of FAI patients. Aggravated and compensated McKibbin index was prevalent in FAI patients. This has implications for open hip preservation surgery (surgical hip dislocation or femoral derotation osteotomy) or hip arthroscopy or non-operative treatment.
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Affiliation(s)
| | - Tiziano Antioco
- Department of Diagnostic, Interventional and Paediatric Radiology, University of Bern, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Malin K Meier
- Department of Orthopaedic Surgery, University of Bern, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Adam Boschung
- Department of Orthopaedic Surgery, University of Bern, Inselspital, Bern University Hospital, Bern, Switzerland
- Department of Orthopaedic Surgery and Traumatology, Fribourg Cantonal Hospital, University of Fribourg, Fribourg, Switzerland
| | - Markus S Hanke
- Department of Orthopaedic Surgery, University of Bern, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Moritz Tannast
- Department of Orthopaedic Surgery, University of Bern, Inselspital, Bern University Hospital, Bern, Switzerland
- Department of Orthopaedic Surgery and Traumatology, Fribourg Cantonal Hospital, University of Fribourg, Fribourg, Switzerland
| | - Klaus A Siebenrock
- Department of Orthopaedic Surgery, University of Bern, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Florian Schmaranzer
- Department of Diagnostic, Interventional and Paediatric Radiology, University of Bern, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Simon D Steppacher
- Department of Orthopaedic Surgery, University of Bern, Inselspital, Bern University Hospital, Bern, Switzerland
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20
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Wirries N, Posselt C, Ettinger M, Derksen A, Budde S, Windhagen H, Floerkemeier T. Sports activity after pelvic osteotomy for treatment of developmental dysplasia of the hip : A comparative study between the triple pelvic and periacetabular osteotomy techniques. DER ORTHOPADE 2022; 51:775-780. [PMID: 35394145 DOI: 10.1007/s00132-022-04249-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/08/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Symptomatic dysplasia of the hip represents an indication for a bony correction of the acetabulum. In the last decades several operative procedures were established. OBJECTIVE The aim of the current study was to analyze whether the level of sports activity is higher in patients after periacetabular osteotomy (PAO) according to Ganz as a technique which preserves the posterior column compared to classical triple pelvic osteotomy (TPO) for treatment of developmental hip dysplasia. MATERIAL AND METHODS The study group included 102 patients treated with the classical TPO with already published clinical results, who were compared to 34 patients treated with PAO between 2012 and 2016. The clinical outcome scores included the modified Harris Hip Score, the Hip Osteoarthritis Outcome Score, the University of California, Los Angeles activity score and the visual analog scale. RESULTS After a mean follow-up of 4.4 years the clinical parameters improved significantly after PAO (p < 0.05). In comparison to the TPO group the clinical scores of the PAO group had inferior baseline values and a tendency to inferior follow-up results in the mHHS (p < 0.05) and HOOS (p > 0.05). After surgery, the PAO group showed a shift to medium and high impact sport activities. CONCLUSION The shorter time of postoperative partial weight bearing after PAO due to the preservation of the posterior column seemed not to have a positive impact on the clinical results or the sports activity compared to the TPO treated patients.
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Affiliation(s)
- Nils Wirries
- Department of Orthopaedic Surgery, Diakovere Annastift (Hannover Medical School), Hannover, Germany
| | - Corinna Posselt
- Department of Orthopaedic Surgery, Diakovere Annastift (Hannover Medical School), Hannover, Germany
| | - Max Ettinger
- Department of Orthopaedic Surgery, Diakovere Annastift (Hannover Medical School), Hannover, Germany
| | - Alexander Derksen
- Department of Orthopaedic Surgery, Diakovere Annastift (Hannover Medical School), Hannover, Germany
| | - Stefan Budde
- Department of Orthopaedic Surgery, Klinikum Bethel, Bielefeld, Germany
| | - Henning Windhagen
- Department of Orthopaedic Surgery, Diakovere Annastift (Hannover Medical School), Hannover, Germany
| | - Thilo Floerkemeier
- go:h Gelenkchirurgie Orthopädie: Hannover, Bertastraße 10, 30159, Hannover, Germany.
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21
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Yang F, Huang HJ, He ZY, Xu Y, Zhang X, Wang JQ. Central acetabular osteophytes (CAO) are more prevalent in the borderline developmental dysplastic hip (BDDH) patients: a propensity-score matched CT study. J Orthop Surg Res 2022; 17:158. [PMID: 35279180 PMCID: PMC8917739 DOI: 10.1186/s13018-022-03056-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 03/03/2022] [Indexed: 11/17/2022] Open
Abstract
Background The acetabular fossa often showing the first signs of degeneration, Central acetabular osteophytes (CAO) have been increasingly recognized during hip arthroscopy. The purpose of this study was to investigate the condition of CAO in BDDH hips and compare cotyloid fossa size between the BDDH and the non-BDDH hips on CT images. Methods We performed a retrospective analysis of prospectively collected data of hip CT images of FAI or labral injury patients. A 1:2 propensity-score matched observational study comparing the linear length of cotyloid fossa was analyzed. Cotyloid fossa width (CFW) and cotyloid notch width (CNW) were measured on axial images, cotyloid fossa height (CFH) and cotyloid fossa depth (CFD) were measured on coronal images. Within the CAO patients, we performed central acetabular decompression (CAD) and then observed the morphology change in fossa. Results Propensity-score matching yielded 61 BDDH hips and 122 non-BDDH hips. BDDH hips had a higher prevalence of CAO and a decreased linear length of cotyloid fossa (CFW, CFH and CNW). In the BDDH group, 33 hips underwent CAD, postoperative CFW, CFH and CNW were significantly increased (p < .001 for all), and had no statistical difference compared with the non-BDDH hips (p = .193, p = .132, p = .421, respectively). Conclusion BDDH hips had a significantly higher prevalence of CAO than adequate acetabular coverage hips. After the procedure of CAD, BDDH hips were found to have acetabular parameters (CFW, CFH, CNW) and were restored to that of the control hips.
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22
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[Imaging in joint-preserving hip surgery]. Radiologe 2022; 62:271-284. [PMID: 35238995 PMCID: PMC8894169 DOI: 10.1007/s00117-022-00973-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/20/2022] [Indexed: 11/25/2022]
Abstract
Instabilität und Impingement stellen die Hauptpathomechanismen dar, die bereits bei jungen Patienten durch erhöhten mechanischen Stress zu chondrolabralen Schäden, schmerzhafter Bewegungseinschränkung und frühzeitiger Coxarthrose führen können. Ziele der gelenkerhaltenden Chirurgie an der Hüfte sind die Korrektur der knöchernen Deformitäten und chondrolabraler Schäden sowie die Wiederherstellung der Gelenkfunktion. Voraussetzung dafür ist die Identifikation der ursächlichen Pathologien an der Hüfte, welche zudem in Kombination auftreten können. Die dezidierte Röntgen- und Magnetresonanzbildgebung der knöchernen Morphologie und der degenerativen Gelenkbinnenläsionen liefern einen essenziellen Beitrag für die Behandlungsindikation und die Behandlungsplanung. Der vorliegende Artikel soll einen kurzen Überblick über die Hüftdeformitäten mit deren Prävalenz, Pathomechanismus und indizierter Therapie sowie detaillierte Empfehlungen über die spezifische radiologische Abklärung geben.
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23
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Sobau C, Steimer O. Stellenwert der Arthroskopie bei Hüftgelenkdysplasie? ARTHROSKOPIE 2022. [DOI: 10.1007/s00142-021-00507-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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24
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Lerch TD, Meier MK, Boschung A, Steppacher SD, Siebenrock KA, Tannast M, Schmaranzer F. Diagnosis of acetabular retroversion: Three signs positive and increased retroversion index have higher specificity and higher diagnostic accuracy compared to isolated positive cross over sign. Eur J Radiol Open 2022; 9:100407. [PMID: 35242888 PMCID: PMC8885617 DOI: 10.1016/j.ejro.2022.100407] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 02/13/2022] [Accepted: 02/17/2022] [Indexed: 11/28/2022] Open
Abstract
Objectives The crossover-sign (COS) is a radiographic sign for diagnosis of acetabular-retroversion(AR) in patients with femoroacetabular-impingement (FAI) but overestimates AR. Three signs combined with retroversion-index (RI) could potentially improve diagnostic-accuracy. Aims To calculate central acetabular-version (AV, CT/MRI) in patients with isolated positive COS and in patients with three radiographic signs for AR on radiographs (AP). To calculate diagnostic performance of positive COS and of three signs combined with retroversion-index (RI) > 30% on radiographs (AP) to detect global AR (AV < 10°, CT/MRI).
Methods A retrospective, IRB-approved, controlled diagnostic study comparing radiographic signs for AR (AP radiographs) with MRI/CT-based measurement of central AV was performed. 462 symptomatic patients (538 hips) with FAI or hip-dysplasia were compared to control-group (48 hips). Three signs for AR(on radiographs) were analyzed: COS, posterior-wall-sign and ischial-spine-sign. RI (synonym cross-over-index) quantifies overlap of anterior and posterior wall in case of positive COS. Diagnostic performance for COS and for three signs combined with RI > 30% to detect central AV < 10° (global AR) was calculated. Results Central AV was significantly (p < 0.001) decreased (13 ± 6°, CT/MRI) in patients with three signs for AR and RI > 30% on radiographs compared to patients with positive COS (18 ± 7°). Sensitivity and specificity of three signs combined with RI > 30% on radiographs was 85% and 63% (87% and 23% for COS). Negative-predictive-value (NPV) was 94% (93% for COS) to rule out global AR (AV < 10°, CT/MRI). Diagnostic accuracy increased significantly (p < 0.001) from 31% (COS) to 68% using three signs.
Conclusion Improved specificity and diagnostic accuracy for diagnosis of global AR can help to avoid misdiagnosis. Global AR can be ruled out with a probability of 94% (NPV) in the absence of three radiographic signs combined with retroversion-index < 30% (e.g. isolated COS positive).
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25
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Zeng G, Degonda C, Boschung A, Schmaranzer F, Gerber N, Siebenrock KA, Steppacher SD, Tannast M, Lerch TD. Three-Dimensional Magnetic Resonance Imaging Bone Models of the Hip Joint Using Deep Learning: Dynamic Simulation of Hip Impingement for Diagnosis of Intra- and Extra-articular Hip Impingement. Orthop J Sports Med 2021; 9:23259671211046916. [PMID: 34938819 PMCID: PMC8685729 DOI: 10.1177/23259671211046916] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 06/23/2021] [Indexed: 11/26/2022] Open
Abstract
Background: Dynamic 3-dimensional (3D) simulation of hip impingement enables better
understanding of complex hip deformities in young adult patients with
femoroacetabular impingement (FAI). Deep learning algorithms may improve
magnetic resonance imaging (MRI) segmentation. Purpose: (1) To evaluate the accuracy of 3D models created using convolutional neural
networks (CNNs) for fully automatic MRI bone segmentation of the hip joint,
(2) to correlate hip range of motion (ROM) between manual and automatic
segmentation, and (3) to compare location of hip impingement in 3D models
created using automatic bone segmentation in patients with FAI. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: The authors retrospectively reviewed 31 hip MRI scans from 26 symptomatic
patients (mean age, 27 years) with hip pain due to FAI. All patients had
matched computed tomography (CT) and MRI scans of the pelvis and the knee.
CT- and MRI-based osseous 3D models of the hip joint of the same patients
were compared (MRI: T1 volumetric interpolated breath-hold examination
high-resolution sequence; 0.8 mm3 isovoxel). CNNs were used to
develop fully automatic bone segmentation of the hip joint, and the 3D
models created using this method were compared with manual segmentation of
CT- and MRI-based 3D models. Impingement-free ROM and location of hip
impingement were calculated using previously validated collision detection
software. Results: The difference between the CT- and MRI-based 3D models was <1 mm, and the
difference between fully automatic and manual segmentation of MRI-based 3D
models was <1 mm. The correlation of automatic and manual MRI-based 3D
models was excellent and significant for impingement-free ROM
(r = 0.995; P < .001), flexion
(r = 0.953; P < .001), and internal
rotation at 90° of flexion (r = 0.982; P
< .001). The correlation for impingement-free flexion between automatic
MRI-based 3D models and CT-based 3D models was 0.953 (P
< .001). The location of impingement was not significantly different
between manual and automatic segmentation of MRI-based 3D models, and the
location of extra-articular hip impingement was not different between CT-
and MRI-based 3D models. Conclusion: CNN can potentially be used in clinical practice to provide rapid and
accurate 3D MRI hip joint models for young patients. The created models can
be used for simulation of impingement during diagnosis of intra- and
extra-articular hip impingement to enable radiation-free and
patient-specific surgical planning for hip arthroscopy and open hip
preservation surgery.
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Affiliation(s)
- Guodong Zeng
- Sitem Center for Translational Medicine and Biomedical Entrepreneurship, University of Bern, Switzerland
| | - Celia Degonda
- Department of Orthopedic Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - Adam Boschung
- Department of Orthopedic Surgery, Inselspital, University of Bern, Bern, Switzerland.,Department of Diagnostic, Interventional and Paediatric Radiology, University of Bern, Inselspital, Bern, Switzerland
| | - Florian Schmaranzer
- Department of Orthopedic Surgery, Inselspital, University of Bern, Bern, Switzerland.,Department of Diagnostic, Interventional and Paediatric Radiology, University of Bern, Inselspital, Bern, Switzerland
| | - Nicolas Gerber
- Sitem Center for Translational Medicine and Biomedical Entrepreneurship, University of Bern, Switzerland
| | - Klaus A Siebenrock
- Department of Orthopedic Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - Simon D Steppacher
- Department of Orthopedic Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - Moritz Tannast
- Department of Orthopedic Surgery, Inselspital, University of Bern, Bern, Switzerland.,Department of Orthopaedic Surgery and Traumatology, Cantonal Hospital, University of Fribourg, Fribourg, Switzerland
| | - Till D Lerch
- Department of Orthopedic Surgery, Inselspital, University of Bern, Bern, Switzerland.,Department of Diagnostic, Interventional and Paediatric Radiology, University of Bern, Inselspital, Bern, Switzerland
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Lerch TD, Boschung A, Schmaranzer F, Todorski IAS, Vanlommel J, Siebenrock KA, Steppacher SD, Tannast M. Lower pelvic tilt, lower pelvic incidence, and increased external rotation of the iliac wing in patients with femoroacetabular impingement due to acetabular retroversion compared to hip dysplasia. Bone Jt Open 2021; 2:813-824. [PMID: 34619033 PMCID: PMC8558448 DOI: 10.1302/2633-1462.210.bjo-2021-0069.r1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
AIMS The effect of pelvic tilt (PT) and sagittal balance in hips with pincer-type femoroacetabular impingement (FAI) with acetabular retroversion (AR) is controversial. It is unclear if patients with AR have a rotational abnormality of the iliac wing. Therefore, we asked: are parameters for sagittal balance, and is rotation of the iliac wing, different in patients with AR compared to a control group?; and is there a correlation between iliac rotation and acetabular version? METHODS A retrospective, review board-approved, controlled study was performed including 120 hips in 86 consecutive patients with symptomatic FAI or hip dysplasia. Pelvic CT scans were reviewed to calculate parameters for sagittal balance (pelvic incidence (PI), PT, and sacral slope), anterior pelvic plane angle, pelvic inclination, and external rotation of the iliac wing and were compared to a control group (48 hips). The 120 hips were allocated to the following groups: AR (41 hips), hip dysplasia (47 hips) and cam FAI with normal acetabular morphology (32 hips). Subgroups of total AR (15 hips) and high acetabular anteversion (20 hips) were analyzed. Statistical analysis was performed using analysis of variance with Bonferroni correction. RESULTS PI and PT were significantly decreased comparing AR (PI 42° (SD 10°), PT 4° (SD 5°)) with dysplastic hips (PI 55° (SD 12°), PT 10° (SD 6°)) and with the control group (PI 51° (SD 9°) and PT 13° (SD 7°)) (p < 0.001). External rotation of the iliac wing was significantly increased comparing AR (29° (SD 4°)) with dysplastic hips (20°(SD 5°)) and with the control group (25° (SD 5°)) (p < 0.001). Correlation between external rotation of the iliac wing and acetabular version was significant and strong (r = 0.81; p < 0.001). Correlation between PT and acetabular version was significant and moderate (r = 0.58; p < 0.001). CONCLUSION These findings could contribute to a better understanding of hip pain in a sitting position and extra-articular subspine FAI of patients with AR. These patients have increased iliac external rotation, a rotational abnormality of the iliac wing. This has implications for surgical therapy with hip arthroscopy and acetabular rim trimming or anteverting periacetabular osteotomy (PAO). Cite this article: Bone Jt Open 2021;2(10):813-824.
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Affiliation(s)
- Till Dominic Lerch
- Department of Orthopedic Surgery and Traumatology, Inselspital Bern, University Hospital of Bern, University of Bern, Bern, Switzerland.,Department of Diagnostic, Interventional and Paediatric Radiology, Inselspital Bern, University Hospital of Bern, University of Bern, Bern, Switzerland
| | - Adam Boschung
- Department of Orthopedic Surgery and Traumatology, Inselspital Bern, University Hospital of Bern, University of Bern, Bern, Switzerland
| | - Florian Schmaranzer
- Department of Orthopedic Surgery and Traumatology, Inselspital Bern, University Hospital of Bern, University of Bern, Bern, Switzerland.,Department of Diagnostic, Interventional and Paediatric Radiology, Inselspital Bern, University Hospital of Bern, University of Bern, Bern, Switzerland
| | - Inga A S Todorski
- Department of Orthopedic Surgery and Traumatology, Inselspital Bern, University Hospital of Bern, University of Bern, Bern, Switzerland.,Department of Diagnostic, Interventional and Paediatric Radiology, Inselspital Bern, University Hospital of Bern, University of Bern, Bern, Switzerland
| | - Jan Vanlommel
- Department of Orthopaedic Surgery and Traumatology, Orthoclinic, Bruges, Belgium
| | - Klaus A Siebenrock
- Department of Orthopedic Surgery and Traumatology, Inselspital Bern, University Hospital of Bern, University of Bern, Bern, Switzerland
| | - Simon D Steppacher
- Department of Orthopedic Surgery and Traumatology, Inselspital Bern, University Hospital of Bern, University of Bern, Bern, Switzerland
| | - Moritz Tannast
- Department of Orthopedic Surgery and Traumatology, Inselspital Bern, University Hospital of Bern, University of Bern, Bern, Switzerland.,Department of Orthopaedic Surgery and Traumatology, Fribourg Cantonal Hospital, University of Fribourg, Fribourg, Switzerland
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Roth T, Rahm S, Jungwirth-Weinberger A, Süess J, Sutter R, Schellenberg F, Taylor WR, Snedeker JG, Widmer J, Zingg P. Restoring range of motion in reduced acetabular version by increasing femoral antetorsion - What about joint load? Clin Biomech (Bristol, Avon) 2021; 87:105409. [PMID: 34144389 DOI: 10.1016/j.clinbiomech.2021.105409] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 06/04/2021] [Accepted: 06/04/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Acetabular retroversion results in reduced range of motion, and is thought to contribute to femoroacetabular impingement. Severe retroversion can be corrected with a periacetabular osteotomy, which is a technically demanding intervention. In this study, we investigated whether increasing femoral antetorsion is a potential alternative to restore the range of motion and how this approach would affect hip joint loading. METHODS Six different finite element models of the same subject were built from MRI and used to simulate different load scenarios during stance phase, including healthy and pathological configurations with different acetabular version and femoral torsion angles. The subject's gait was analysed in our gait lab and motion data as well as joint reaction forces were integrated into the model. Hip range of motion, hip abductor muscle forces as well as localization and magnitude of hip joint loads were determined. FINDINGS The negative effects of acetabular retroversion on hip range of motion including flexion and internal rotation can be reversed by increasing femoral anteversion. The rotation of the femur furthermore affected muscular functionality by shortening the moment arms of the hip abductor muscles, resulting in increased abductor muscle forces, joint reaction forces and hip joint loading. INTERPRETATION Even though increased femoral antetorsion can compensate for the loss of hip range of motion due to reduced acetabular version, rotational ostotomy of the proximal femur is likely to alter muscular moment arms and therefore increase hip joint load, conflicting the goal of a long-term healthy joint.
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Affiliation(s)
- Tabitha Roth
- Institute for Biomechanics, ETH Zurich, Rämistrasse 101, 8092 Zurich, Switzerland; Department of Orthopedics, Balgrist University Hospital, Forchstrasse 340, 8008 Zurich, Switzerland.
| | - Stefan Rahm
- Department of Orthopedics, Balgrist University Hospital, Forchstrasse 340, 8008 Zurich, Switzerland.
| | - Anna Jungwirth-Weinberger
- Department of Orthopedics, Balgrist University Hospital, Forchstrasse 340, 8008 Zurich, Switzerland.
| | - Janine Süess
- Institute for Biomechanics, ETH Zurich, Rämistrasse 101, 8092 Zurich, Switzerland; Department of Orthopedics, Balgrist University Hospital, Forchstrasse 340, 8008 Zurich, Switzerland.
| | - Reto Sutter
- Radiology, Balgrist University Hospital, Forchstrasse 340, 8008 Zurich, Switzerland.
| | - Florian Schellenberg
- Institute for Biomechanics, ETH Zurich, Rämistrasse 101, 8092 Zurich, Switzerland.
| | - William R Taylor
- Institute for Biomechanics, ETH Zurich, Rämistrasse 101, 8092 Zurich, Switzerland.
| | - Jess G Snedeker
- Institute for Biomechanics, ETH Zurich, Rämistrasse 101, 8092 Zurich, Switzerland; Department of Orthopedics, Balgrist University Hospital, Forchstrasse 340, 8008 Zurich, Switzerland.
| | - Jonas Widmer
- Institute for Biomechanics, ETH Zurich, Rämistrasse 101, 8092 Zurich, Switzerland; Department of Orthopedics, Balgrist University Hospital, Forchstrasse 340, 8008 Zurich, Switzerland.
| | - Patrick Zingg
- Department of Orthopedics, Balgrist University Hospital, Forchstrasse 340, 8008 Zurich, Switzerland.
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Pun SY, Hosseinzadeh S, Dastjerdi R, Millis MB. What Are the Early Outcomes of True Reverse Periacetabular Osteotomy for Symptomatic Hip Overcoverage? Clin Orthop Relat Res 2021; 479:1081-1093. [PMID: 33296152 PMCID: PMC8052029 DOI: 10.1097/corr.0000000000001549] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 10/06/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Acetabular overcoverage is associated with pincer-type femoroacetabular impingement (FAI). A subtype of acetabular overcoverage is caused by a deep acetabulum with a negatively tilted acetabular roof, in which acetabular reorientation may be a preferable alternative to rim trimming to uncover the femoral head. We introduced the true reverse periacetabular osteotomy (PAO) in 2003, which in contrast to an anteverting PAO, also flexes and abducts the acetabulum relative to the intact ilium to decrease anterior and lateral femoral head coverage and correct negative tilt of the acetabular roof. To our knowledge, the clinical results of the true reverse PAO have not been evaluated. QUESTIONS/PURPOSES For a group of patients who underwent reverse PAO, (1) Do patients undergoing reverse PAO demonstrate short-term improvement in pain, function, and hip ROM, and decreased acetabular coverage, as defined by lateral and anterior center-edge angle and Tönnis angle? (2) Are there identifiable factors associated with success or adverse outcomes of reverse PAO as defined by reoperation, conversion to THA, or poor patient-reported outcome scores? (3) Are there identifiable factors associated with early complications? METHODS Between 2003 and 2017, two surgeons carried out 49 reverse PAOs in 37 patients. Twenty-five patients had unilateral reverse PAO and 12 patients had staged, bilateral reverse PAOs. To ensure that each hip was an independent data point for statistical analysis, we chose to include in our series only the first hip in the patients who had bilateral reverse PAOs. During the study period, our general indications for this operation were symptomatic lateral and anterior acetabular overcoverage causing FAI that had failed to respond to previous conservative or surgical treatment. Thirty-seven hips in 37 patients with a median (range) age of 18 years (12 to 41; interquartile range 16 to 21) were included in this retrospective study at a minimum follow-up of 2 years (median 6 years; range 2 to 17). Thirty-four patients completed questionnaires, 24 patients had radiographic evaluation, and 23 patients received hip ROM clinical examination. However, seven patients had not been seen in more than 5 years. The clinical and radiographic parameters of all 37 hips that underwent reverse PAO in 37 patients from a longitudinally maintained institutional database were retrospectively studied preoperatively and postoperatively. Adverse outcomes were considered conversion to THA or a WOMAC pain score greater than 10 at least 2 years postoperatively. Patient-reported outcomes, radiographic measurements, and hip ROM were evaluated preoperatively and at most recent follow-up using a paired t-test or McNemar test, as appropriate. Linear regression analysis was used to assess for identifiable factors associated with clinical outcomes. Logistic regression analysis was used to assess for identifiable factors associated with adverse outcomes and surgical complications. All tests were two-sided, and p values less than 0.05 were considered significant. RESULTS At a minimum of 2 years after reverse PAO, patients experienced improvement in WOMAC pain (-7 [95% CI -9 to -5]; p < 0.001), stiffness (-2 [95% CI -3 to -1]; p < 0.001), and function scores (-18 [95% CI -24 to -12]; p < 0.001) and modified Harris Hip Score (mHHS) (20 [95% CI 13 to 27]; p < 0.001). The mean postoperative hip ROM improved in internal rotation (8° [95% CI 2° to 14°]; p = 0.007). Acetabular coverage, as defined by lateral center-edge angle (LCEA), anterior center-edge angle (ACEA), and Tönnis angle, improved by -8° (95% CI -12° to -5°; p < 0.001) for LCEA, -12° (95% CI -15° to -9°; p < 0.001) for ACEA, and 9° (95% CI 6° to 13°; p < 0.001) for Tönnis angle. The postoperative severity of radiographic arthritis was associated with worse WOMAC function scores such that for each postoperative Tönnis grade, WOMAC function score increased by 12 points (95% CI 2 to 22; p = 0.03). A greater postoperative Tönnis grade was also correlated with worse mHHS, with an average decrease of 12 points (95% CI -20 to -4; p = 0.008) in mHHS for each additional Tönnis grade. Presence of a positive postoperative anterior impingement test was associated with a decrease in mHHS score at follow-up, with an average 23-point decrease in mHHS (95% CI -34 to -12; p = 0.001). Nineteen percent (7 of 37) of hips had surgery-related complications. Four hips experienced adverse outcomes at final follow-up, with two patients undergoing subsequent THA and two with a WOMAC pain score greater than 10. We found no factors associated with complications or adverse outcomes. CONCLUSION The early clinical and radiographic results of true reverse PAO compare favorably to other surgical treatments for pincer FAI, suggesting that reverse PAO is a promising treatment for cases of pincer FAI caused by global acetabular overcoverage. However, it is a technically complex procedure that requires substantial training and preparation by a surgeon who is already familiar with standard PAO, and it must be carefully presented to patients with discussion of the potential risks and benefits. Future studies are needed to further refine the indications and to determine the long-term outcomes of reverse PAO. LEVEL OF EVIDENCE Level IV, therapeutic study.
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Affiliation(s)
- Stephanie Y Pun
- S. Y. Pun, Department of Orthopaedic Surgery, The Stanford Child and Adult Hip Preservation Center, Stanford University School of Medicine, Stanford, CA, USA
- S. Hosseinzadeh, R. Dastjerdi, M. B. Millis, Department of Orthopaedic Surgery, The Child and Adult Hip Program, Boston Children's Hospital, Boston, MA, USA
| | - Shayan Hosseinzadeh
- S. Y. Pun, Department of Orthopaedic Surgery, The Stanford Child and Adult Hip Preservation Center, Stanford University School of Medicine, Stanford, CA, USA
- S. Hosseinzadeh, R. Dastjerdi, M. B. Millis, Department of Orthopaedic Surgery, The Child and Adult Hip Program, Boston Children's Hospital, Boston, MA, USA
| | - Roya Dastjerdi
- S. Y. Pun, Department of Orthopaedic Surgery, The Stanford Child and Adult Hip Preservation Center, Stanford University School of Medicine, Stanford, CA, USA
- S. Hosseinzadeh, R. Dastjerdi, M. B. Millis, Department of Orthopaedic Surgery, The Child and Adult Hip Program, Boston Children's Hospital, Boston, MA, USA
| | - Michael B Millis
- S. Y. Pun, Department of Orthopaedic Surgery, The Stanford Child and Adult Hip Preservation Center, Stanford University School of Medicine, Stanford, CA, USA
- S. Hosseinzadeh, R. Dastjerdi, M. B. Millis, Department of Orthopaedic Surgery, The Child and Adult Hip Program, Boston Children's Hospital, Boston, MA, USA
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Stetzelberger VM, Leibold CS, Steppacher SD, Schwab JM, Siebenrock KA, Tannast M. The Acetabular Wall Index Is Associated with Long-term Conversion to THA after PAO. Clin Orthop Relat Res 2021; 479:1052-1065. [PMID: 33605631 PMCID: PMC8052033 DOI: 10.1097/corr.0000000000001641] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 12/17/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Periacetabular osteotomy (PAO) has been shown to be a valuable option for delaying the onset of osteoarthritis in patients with hip dysplasia. Published studies at 30 years of follow-up found that postoperative anterior overcoverage and posterior undercoverage were associated with early conversion to THA. The anterior and posterior wall indices are practical tools for assessing AP coverage on standard AP radiographs of the pelvis pre-, intra-, and postoperatively. However, no study that we know of has evaluated the relationship between the postoperative anterior and posterior wall indices and survivorship free from arthroplasty. QUESTIONS/PURPOSES In a study including patients after PAO for developmental dysplasia of the hip (DDH), we evaluated whether the acetabular wall index is associated with conversion to THA in the long-term after PAO. We asked: (1) Is an abnormal postoperative anterior wall index associated with conversion to THA after PAO? (2) Is an abnormal postoperative posterior wall index associated with conversion to THA after PAO? (3) Are there other factors associated with joint replacement after PAO? METHODS This retrospective study involved pooling data of PAO for DDH from two previously published sources. The first series (1984-1987) comprised the very first 75 PAOs for symptomatic DDH performed at the inventor's institution. The second (1997-2000) comprised a series of PAOs for symptomatic DDH completed at the same institution 10 years later. No patient was lost to follow-up. Fifty hips (44 patients) were excluded for predefined reasons (previous surgery, substantial femoral pathomorphologies, poor-quality radiographs), leaving 115 hips (102 patients, mean age 29 ± 11 years, 28% male) for analysis with a mean follow-up of 22 ± 6 years. One observer not involved in patient treatment digitally measured the anterior and posterior wall indices on postoperative AP pelvic radiographs of all patients. All patients were contacted by mail or telephone to confirm any conversion to THA and the timing of that procedure relative to the index procedure. We performed univariate and multivariate Cox regression analyses using conversion to THA as our endpoint to determine whether the anterior and posterior wall indices are associated with prosthetic replacement in the long-term after PAO. Thirty-one percent (36 of 115) of hips were converted to THA within a mean of 15 ± 7 years until failure. The mean follow-up duration of the remaining patients was 22 ± 6 years. RESULTS A deficient anterior wall index was associated with conversion THA in the long-term after PAO (adjusted hazard ratio 10 [95% CI 3.6 to 27.9]; p < 0.001). Although observed in the univariate analysis, we could not find a multivariate association between the posterior wall index and a higher conversion rate to THA. Grade 0 Tönnis osteoarthritis was associated with joint preservation (adjusted HR 0.2 [95% CI 0.07 to 0.47]; p = 0.005). Tönnis osteoarthritis Grades 2 and 3 were associated with conversion to THA (adjusted HR 2.3 [95% CI 0.9 to 5.7]; p = 0.08). CONCLUSION A deficient anterior wall index is associated with a decreased survivorship of the native hip in the long-term after PAO. Intraoperatively, in addition to following established radiographical guidelines, the acetabular wall indices should be measured systematically to ascertain optimal acetabular fragment version to increase the likelihood of reconstructive survival after PAO for DDH. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Vera M Stetzelberger
- V. M. Stetzelberger, M. Tannast. Department of Orthopaedic Surgery and Traumatology, Hôpital Fribourgeois HFR Cantonal Hospital, University of Fribourg, Fribourg, Switzerland
- C. S. Leibold, S. D. Steppacher, K. A. Siebenrock, Department of Orthopaedic Surgery, Inselspital Bern, University of Bern, Bern, Switzerland
- J. M. Schwab, Department of Orthopaedic Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Christiane S Leibold
- V. M. Stetzelberger, M. Tannast. Department of Orthopaedic Surgery and Traumatology, Hôpital Fribourgeois HFR Cantonal Hospital, University of Fribourg, Fribourg, Switzerland
- C. S. Leibold, S. D. Steppacher, K. A. Siebenrock, Department of Orthopaedic Surgery, Inselspital Bern, University of Bern, Bern, Switzerland
- J. M. Schwab, Department of Orthopaedic Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Simon D Steppacher
- V. M. Stetzelberger, M. Tannast. Department of Orthopaedic Surgery and Traumatology, Hôpital Fribourgeois HFR Cantonal Hospital, University of Fribourg, Fribourg, Switzerland
- C. S. Leibold, S. D. Steppacher, K. A. Siebenrock, Department of Orthopaedic Surgery, Inselspital Bern, University of Bern, Bern, Switzerland
- J. M. Schwab, Department of Orthopaedic Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Joseph M Schwab
- V. M. Stetzelberger, M. Tannast. Department of Orthopaedic Surgery and Traumatology, Hôpital Fribourgeois HFR Cantonal Hospital, University of Fribourg, Fribourg, Switzerland
- C. S. Leibold, S. D. Steppacher, K. A. Siebenrock, Department of Orthopaedic Surgery, Inselspital Bern, University of Bern, Bern, Switzerland
- J. M. Schwab, Department of Orthopaedic Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Klaus A Siebenrock
- V. M. Stetzelberger, M. Tannast. Department of Orthopaedic Surgery and Traumatology, Hôpital Fribourgeois HFR Cantonal Hospital, University of Fribourg, Fribourg, Switzerland
- C. S. Leibold, S. D. Steppacher, K. A. Siebenrock, Department of Orthopaedic Surgery, Inselspital Bern, University of Bern, Bern, Switzerland
- J. M. Schwab, Department of Orthopaedic Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Moritz Tannast
- V. M. Stetzelberger, M. Tannast. Department of Orthopaedic Surgery and Traumatology, Hôpital Fribourgeois HFR Cantonal Hospital, University of Fribourg, Fribourg, Switzerland
- C. S. Leibold, S. D. Steppacher, K. A. Siebenrock, Department of Orthopaedic Surgery, Inselspital Bern, University of Bern, Bern, Switzerland
- J. M. Schwab, Department of Orthopaedic Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
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Lerch TD, Ambühl D, Schmaranzer F, Todorski IAS, Steppacher SD, Hanke MS, Haefeli PC, Liechti EF, Siebenrock KA, Tannast M. Biochemical MRI With dGEMRIC Corresponds to 3D-CT Based Impingement Location for Detection of Acetabular Cartilage Damage in FAI Patients. Orthop J Sports Med 2021; 9:2325967120988175. [PMID: 33816640 PMCID: PMC7988263 DOI: 10.1177/2325967120988175] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 09/30/2020] [Indexed: 01/20/2023] Open
Abstract
Background Anterior femoroacetabular impingement (FAI) is associated with labral tears and acetabular cartilage damage in athletic and young patients. Delayed gadolinium-enhanced magnetic resonance imaging of cartilage (dGEMRIC) is an imaging method for detecting early damage to cartilage. Purpose We evaluated the following questions: (1) What is the sensitivity and specificity of morphological magnetic resonance imaging (MRI) and dGEMRIC for detecting cartilage damage? Do the mean acetabular and femoral dGEMRIC indices differ between (2) superior acetabular clock positions with and without impingement and (3) between cam- and pincer-type FAI? Study Design Cohort study (diagnosis); Level of evidence, 2. Methods This was a retrospective comparative study of 21 hips (20 patients with symptomatic anterior FAI) without osteoarthritis on anteroposterior radiographs. Morphological MRI and dGEMRIC (3.0-T, 3-dimensional [3D] T1 maps, dual-flip angle technique) of the same hip joint were compared. Intraoperative acetabular cartilage damage was assessed in patients who underwent surgical treatment. Computed tomography (CT)-based 3D bone models of the same hip joint were used as the gold standard for the detection of impingement, and dGEMRIC indices and zones of morphologic damage were compared with the CT-based impingement zones. Results Of the 21 hips, 10 had cam-type FAI and 8 had pincer-type FAI according to radiographs. The mean age was 30 ± 9 years (range, 17-48 years), 71% were female, and surgical treatment was performed in 52%. We found a significantly higher sensitivity (69%) for dGEMRIC compared with morphological MRI (42%) in the detection of cartilage damage (P < .001). The specificity of dGEMRIC was 83% and accuracy was 78%. The mean peripheral acetabular and femoral dGEMRIC indices for clock positions with impingement (485 ± 141 and 440 ± 121 ms) were significantly lower compared with clock positions without impingement (596 ± 183 and 534 ± 129 ms) (P < .001). Hips with cam-type FAI had significantly lower acetabular dGEMRIC indices compared with hips with pincer-type FAI on the anterosuperior clock positions (1 to 3 o'clock) (P = .018). Conclusion MRI with dGEMRIC was more sensitive than morphological MRI, and lower dGEMRIC values were found for clock positions with impingement as detected on 3D-CT. This could aid in patient-specific diagnosis of FAI, preoperative patient selection, and surgical decision making to identify patients with cartilage damage who are at risk for inferior outcomes after hip arthroscopy.
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Affiliation(s)
- Till D Lerch
- Department of Orthopaedic Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Dimitri Ambühl
- Department of Orthopaedic Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Florian Schmaranzer
- Department of Orthopaedic Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Inga A S Todorski
- Department of Orthopaedic Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Simon D Steppacher
- Department of Orthopaedic Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Markus S Hanke
- Department of Orthopaedic Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Pascal C Haefeli
- Department of Orthopaedic Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Emanuel F Liechti
- Department of Orthopaedic Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Klaus A Siebenrock
- Department of Orthopaedic Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Moritz Tannast
- Department of Orthopaedic Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Department of Orthopaedic Surgery, Fribourg Cantonal Hospital, University of Fribourg, Fribourg, Switzerland
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Abstract
BACKGROUND Abnormalities in size and position of the acetabulum have been linked to both developmental dysplasia of the hip and femoroacetabular impingement. Owing to its 3-dimensional (3D) complexity, plain radiography and cross-sectional studies [computed tomography (CT) and magnetic resonance imaging] have limitations in their ability to capture the complexity of the acetabular 3D anatomy. The goal of the study was to use 3D computed tomography reconstructions to identify the acetabular lunate cartilage and measure its size at varying ages of development and between sexes. METHODS Patients aged 10 to 18 years with asymptomatic hips and a CT pelvis for appendicitis were reviewed. Patients were stratified by sex and age: preadolescent (10 to 12), young adolescent (13 to 15), and old adolescent (16 to 18) in equal proportions. Materialise 3-matic was used to generate a 3D pelvic model, and the acetabular lunate cartilage surface area was calculated. The lunate cartilage was divided into anatomic segments: superior (11:00 to 1:00), anterior (1:00 to 4:00), and posterior (8:00 to 11:00). The femoral head surface area was calculated to control for patient size. Mixed effects models were generated predicting segment size where side was treated as a repeated measure. Absolute and relative (lunate cartilage to femoral head) models were generated. RESULTS Sixty-two patients (124 hips) were included. Females showed a significant decrease in femoral head coverage as age increased overall and in the 3 subsegments. The majority of changes occurred between the preadolescent and young adolescent groups. Males did not show an overall change, but the superior and anterior anatomic subgroups showed a significant decrease in coverage between the young and old adolescent groups. Male lunate cartilages were absolutely, but not relatively, larger than females. No clinically significant side-to-side differences were noted. CONCLUSIONS The relative femoral head coverage by the acetabular lunate cartilage reduced with increasing age, suggesting the growth of the femoral head outpaces the acetabular lunate cartilage's growth. This was more prominent in females. This study has important implications for expected acetabular coverage changes in the latter aspects of pediatric and adolescent development. LEVEL OF EVIDENCE Level III-diagnostic study.
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Abstract
OBJECTIVE. Imaging plays a critical role in the assessment of patients with femoroacetabular impingement (FAI). With better understanding of the underlying pathomechanics and advances in joint-preserving surgery, there is an increasing need to define the most appropriate imaging workup. The purpose of this article is to provide guidance on best practices for imaging of patients with FAI in light of recent advances in corrective FAI surgery. CONCLUSION. Pelvic radiography with dedicated hip projections is the basis of the diagnostic workup of patients with suspected FAI to assess arthritic changes and acetabular coverage and to screen for cam deformities. Chondrolabral lesions should be evaluated with unenhanced MRI or MR arthrography. The protocol should include a large-FOV fluid-sensitive sequence to exclude conditions that can mimic or coexist with FAI, radial imaging to accurately determine the presence of a cam deformity, and imaging of the distal femoral condyles for measurement of femoral torsion. CT remains a valuable tool for planning of complex surgical corrections. Advanced imaging, such as 3D simulation, biochemical MRI, and MR arthrography with application of leg traction, has great potential to improve surgical decision-making. Further research is needed to assess the added clinical value of these techniques.
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Zeng G, Schmaranzer F, Degonda C, Gerber N, Gerber K, Tannast M, Burger J, Siebenrock KA, Zheng G, Lerch TD. MRI-based 3D models of the hip joint enables radiation-free computer-assisted planning of periacetabular osteotomy for treatment of hip dysplasia using deep learning for automatic segmentation. Eur J Radiol Open 2020; 8:100303. [PMID: 33364259 PMCID: PMC7753932 DOI: 10.1016/j.ejro.2020.100303] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 11/27/2020] [Accepted: 11/28/2020] [Indexed: 11/02/2022] Open
Abstract
Introduction Both Hip Dysplasia(DDH) and Femoro-acetabular-Impingement(FAI) are complex three-dimensional hip pathologies causing hip pain and osteoarthritis in young patients. 3D-MRI-based models were used for radiation-free computer-assisted surgical planning. Automatic segmentation of MRI-based 3D-models are preferred because manual segmentation is time-consuming.To investigate(1) the difference and(2) the correlation for femoral head coverage(FHC) between automatic MR-based and manual CT-based 3D-models and (3) feasibility of preoperative planning in symptomatic patients with hip diseases. Methods We performed an IRB-approved comparative, retrospective study of 31 hips(26 symptomatic patients with hip dysplasia or FAI). 3D MRI sequences and CT scans of the hip were acquired. Preoperative MRI included axial-oblique T1 VIBE sequence(0.8 mm3 isovoxel) of the hip joint. Manual segmentation of MRI and CT scans were performed. Automatic segmentation of MRI-based 3D-models was performed using deep learning. Results (1)The difference between automatic and manual segmentation of MRI-based 3D hip joint models was below 1 mm(proximal femur 0.2 ± 0.1 mm and acetabulum 0.3 ± 0.5 mm). Dice coefficients of the proximal femur and the acetabulum were 98 % and 97 %, respectively. (2)The correlation for total FHC was excellent and significant(r = 0.975, p < 0.001) between automatic MRI-based and manual CT-based 3D-models. Correlation for total FHC (r = 0.979, p < 0.001) between automatic and manual MR-based 3D models was excellent.(3)Preoperative planning and simulation of periacetabular osteotomy was feasible in all patients(100 %) with hip dysplasia or acetabular retroversion. Conclusions Automatic segmentation of MRI-based 3D-models using deep learning is as accurate as CT-based 3D-models for patients with hip diseases of childbearing age. This allows radiation-free and patient-specific preoperative simulation and surgical planning of periacetabular osteotomy for patients with DDH.
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Affiliation(s)
- Guodong Zeng
- Sitem Center for Translational Medicine and Biomedical Entrepreneurship, University of Bern, Switzerland
| | - Florian Schmaranzer
- Department of Orthopedic Surgery, Inselspital, University of Bern, Bern, Switzerland.,Department of Diagnostic, Interventional and Paediatric Radiology, University of Bern, Inselspital, Bern, Switzerland
| | - Celia Degonda
- Department of Orthopedic Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - Nicolas Gerber
- Sitem Center for Translational Medicine and Biomedical Entrepreneurship, University of Bern, Switzerland
| | - Kate Gerber
- Sitem Center for Translational Medicine and Biomedical Entrepreneurship, University of Bern, Switzerland
| | - Moritz Tannast
- Department of Orthopedic Surgery, Inselspital, University of Bern, Bern, Switzerland.,Department of Orthopaedic Surgery and Traumatology, Cantonal Hospital, University of Fribourg, Switzerland
| | - Jürgen Burger
- Sitem Center for Translational Medicine and Biomedical Entrepreneurship, University of Bern, Switzerland
| | - Klaus A Siebenrock
- Department of Orthopedic Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - Guoyan Zheng
- Institute for Medical Robotics, School of Biomedical Engineering, Shanghai Jiao Tong University, China
| | - Till D Lerch
- Department of Orthopedic Surgery, Inselspital, University of Bern, Bern, Switzerland.,Department of Diagnostic, Interventional and Paediatric Radiology, University of Bern, Inselspital, Bern, Switzerland
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Lerch TD, Liechti EF, Todorski IAS, Schmaranzer F, Steppacher SD, Siebenrock KA, Tannast M, Klenke FM. Prevalence of combined abnormalities of tibial and femoral torsion in patients with symptomatic hip dysplasia and femoroacetabular impingement. Bone Joint J 2020; 102-B:1636-1645. [PMID: 33249913 DOI: 10.1302/0301-620x.102b12.bjj-2020-0460.r1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
AIMS The prevalence of combined abnormalities of femoral torsion (FT) and tibial torsion (TT) is unknown in patients with femoroacetabular impingement (FAI) and hip dysplasia. This study aimed to determine the prevalence of combined abnormalities of FT and TT, and which subgroups are associated with combined abnormalities of FT and TT. METHODS We retrospectively evaluated symptomatic patients with FAI or hip dysplasia with CT scans performed between September 2011 and September 2016. A total of 261 hips (174 patients) had a measurement of FT and TT. Their mean age was 31 years (SD 9), and 63% were female (165 hips). Patients were compared to an asymptomatic control group (48 hips, 27 patients) who had CT scans including femur and tibia available for analysis, which had been acquired for nonorthopaedic reasons. Comparisons were conducted using analysis of variance with Bonferroni correction. RESULTS In the overall study group, abnormal FT was present in 62% (163 hips). Abnormal TT was present in 42% (109 hips). Normal FT combined with normal TT was present in 21% (55 hips). The most frequent abnormal combination was increased FT combined with normal TT of 32% (84 hips). In the hip dysplasia group, 21% (11 hips) had increased FT combined with increased TT. The prevalence of abnormal FT varied significantly among the subgroups (p < 0.001). We found a significantly higher mean FT for hip dysplasia (31°; SD 15)° and valgus hips (42° (SD 12°)) compared with the control group (22° (SD 8°)). We found a significantly higher mean TT for hips with cam-type-FAI (34° (SD 6°)) and hip dysplasia (35° (SD 9°)) compared with the control group (28° (SD 8°)) (p < 0.001). CONCLUSION Patients with FAI had a high prevalence of combined abnormalities of FT and TT. For hip dysplasia, we found a significantly higher mean FT and TT, while 21% of patients (11 hips) had combined increased TT and increased FT (combined torsional malalignment). This is important when planning hip preserving surgery such as periacetabular osteomy and femoral derotation osteotomy. Cite this article: Bone Joint J 2020;102-B(12):1636-1645.
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Affiliation(s)
- Till D Lerch
- Department of Orthopaedic Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,University Institute of Diagnostic, Interventional and Paediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Emanuel F Liechti
- Department of Orthopaedic Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Inga A S Todorski
- Department of Orthopaedic Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,University Institute of Diagnostic, Interventional and Paediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Florian Schmaranzer
- Department of Orthopaedic Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,University Institute of Diagnostic, Interventional and Paediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Simon D Steppacher
- Department of Orthopaedic Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Klaus A Siebenrock
- Department of Orthopaedic Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Moritz Tannast
- Department of Orthopaedic Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Department of Orthopaedic Surgery and Traumatology, Fribourg Cantonal Hospital, University of Fribourg, Fribourg, Switzerland
| | - Frank M Klenke
- Department of Orthopaedic Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Abstract
As our understanding of hip function and disease improves, it is evident that the acetabular fossa has received little attention, despite it comprising over half of the acetabulum’s surface area and showing the first signs of degeneration. The fossa’s function is expected to be more than augmenting static stability with the ligamentum teres and being a templating landmark in arthroplasty. Indeed, the fossa, which is almost mature at 16 weeks of intrauterine development, plays a key role in hip development, enabling its nutrition through vascularization and synovial fluid, as well as the influx of chondrogenic stem/progenitor cells that build articular cartilage. The pulvinar, a fibrofatty tissue in the fossa, has the same developmental origin as the synovium and articular cartilage and is a biologically active area. Its unique anatomy allows for homogeneous distribution of the axial loads into the joint. It is composed of intra-articular adipose tissue (IAAT), which has adipocytes, fibroblasts, leucocytes, and abundant mast cells, which participate in the inflammatory cascade after an insult to the joint. Hence, the fossa and pulvinar should be considered in decision-making and surgical outcomes in hip preservation surgery, not only for their size, shape, and extent, but also for their biological capacity as a source of cytokines, immune cells, and chondrogenic stem cells. Cite this article: Bone Joint Res 2020;9(12):857–869.
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Affiliation(s)
- Pablo A Slullitel
- 'Sir John Charnley' Hip Surgery Unit, Institute of Orthopaedics 'Carlos E. Ottolenghi', Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Daniel Coutu
- Regenerative Medicine Program, The Ottawa Hospital Research Institute, Ottawa, Canada
| | - Martin A Buttaro
- 'Sir John Charnley' Hip Surgery Unit, Institute of Orthopaedics 'Carlos E. Ottolenghi', Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Paul Edgar Beaule
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Canada
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36
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Abstract
Classical indications for hip preserving surgery are: femoro-acetabular impingement (FAI) (intra- and extra-articular), hip dysplasia, slipped capital femoral epiphysis, residual deformities after Perthes disease, avascular necrosis of the femoral head. Pre-operative evaluation of the pathomorphology is crucial for surgical planning including radiographs as the basic modality and magnetic resonance imaging (MRI) and/or computed tomography (CT) to evaluate further intra-articular lesions and osseous deformities. Two main mechanisms of intra-articular impingement have been described:
(1) Inclusion type FAI (‘cam type’). (2) Impaction type FAI (‘pincer type’).
Either arthroscopic or open treatment can be performed depending on the severity of deformity. Slipped capital femoral epiphysis often results in a cam-like deformity of the hip. In acute cases a subcapital re-alignment (modified Dunn procedure) of the femoral epiphysis is an effective therapy. Perthes disease can lead to complex femoro-acetabular deformity which predisposes to impingement with/without joint incongruency and requires a comprehensive diagnostic workup for surgical planning. Developmental dysplasia of the hip results in a static overload of the acetabular rim and early osteoarthritis. Surgical correction by means of periacetabular osteotomy offers good long-term results.
Cite this article: EFORT Open Rev 2020;5:630-640. DOI: 10.1302/2058-5241.5.190074
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Affiliation(s)
- Markus S Hanke
- Department of Orthopaedic and Trauma Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - Florian Schmaranzer
- Department of Diagnostic, Interventional and Pediatric Radiology, University Hospital of Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Simon D Steppacher
- Department of Orthopaedic and Trauma Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - Till D Lerch
- Department of Orthopaedic and Trauma Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - Klaus A Siebenrock
- Department of Orthopaedic and Trauma Surgery, Inselspital, University of Bern, Bern, Switzerland
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Bastian JD, Näf DR, Cullmann JL, Keel MJ, Giannoudis PV. Does increased acetabular depth affect safe infra-acetabular screw placement in acetabular fracture fixation? Eur J Trauma Emerg Surg 2020; 47:1319-1326. [PMID: 32728900 PMCID: PMC8476395 DOI: 10.1007/s00068-020-01455-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 07/21/2020] [Indexed: 11/24/2022]
Abstract
Background Infra-acetabular screws enhance the fixation strength in acetabular fractures with separation of both columns. Placement without iatrogenic femoral head violation is challenging. Purpose To assess the impact of the acetabular configuration, the patients’ age and gender on safe infra-acetabulum screw insertion. Methods In 112 patients (69 females; mean age: 34 years, range 17–88; n = 200 hips), the lateral center–edge angle (LCE) was measured on radiographs. Using corresponding axial CT scans the residual distance from (the lateral border) of the screw to (the medial border of) the femoral head (“Screw-to-Femoral Head distance”; “RD_SFH”) was determined. Statistical analysis was carried out using linear regression, multiple linear regression and normal distribution estimation. Results The mean (range) LCE angle was 30° (7°–51°) and the mean (range) “RD_SFH” was 5 mm (1–14 mm). The linear regression model shows a significant linear relation between LCE and “RD_SFH” with a slope parameter of − 0.15 (p value < 0.0001), the Pearson correlation between LCE and “RD_SFH” is − 0.56 (CI [− 0.71, [− 0.40]). Age did not have a significant impact on the relation between LCE and “RD_SFH” (p value 0.85). Compared to male patients, in females, the intercept is 4.62 mm (p value 0.0005) less, the slope parameter is 0.09 (p value 0.029) larger. Conclusion The virtual possibility to place an infra-acetabular screw was given in all patients. An increasing depth of the acetabulum correlated with a decrease in residual distances. As hip joint cartilage thickness was not considered in measurements, intraoperative rule-out of screw mispositioning especially in deep acetabular sockets and females is still of utmost importance.
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Affiliation(s)
- Johannes Dominik Bastian
- Department of Orthopaedic Surgery and Traumatology, Inselspital Bern, Bern University Hospital, University of Bern, Freiburgstrasse 18, 3010, Bern, Switzerland.
| | - David Riccardo Näf
- Department of Orthopaedic Surgery and Traumatology, Inselspital Bern, Bern University Hospital, University of Bern, Freiburgstrasse 18, 3010, Bern, Switzerland
| | - Jennifer Larissa Cullmann
- Department of Diagnostic, Interventional and Paediatric Radiology, University of Bern, Inselspital, Bern, Switzerland
| | - Marius Johann Keel
- Department of Orthopaedic Surgery and Traumatology, Inselspital Bern, Bern University Hospital, University of Bern, Freiburgstrasse 18, 3010, Bern, Switzerland
| | - Peter V Giannoudis
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Leeds, UK
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Mascarenhas VV, Castro MO, Rego PA, Sutter R, Sconfienza LM, Kassarjian A, Schmaranzer F, Ayeni OR, Dietrich TJ, Robinson P, Weber MA, Beaulé PE, Dienst M, Jans L, Lalam R, Karantanas AH, Sudoł-Szopińska I, Anderson S, Noebauer-Huhmann I, Vanhoenacker FM, Dantas P, Marin-Peña O, Collado D, Tey-Pons M, Schmaranzer E, Llopis E, Padron M, Kramer J, Zingg PO, De Maeseneer M, Afonso PD. The Lisbon Agreement on Femoroacetabular Impingement Imaging-part 1: overview. Eur Radiol 2020; 30:5281-5297. [PMID: 32405754 DOI: 10.1007/s00330-020-06822-9] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 02/28/2020] [Accepted: 03/18/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Imaging assessment for the clinical management of femoroacetabular impingement (FAI) syndrome remains controversial because of a paucity of evidence-based guidance and notable variability in clinical practice, ultimately requiring expert consensus. The purpose of this agreement is to establish expert-based statements on FAI imaging, using formal techniques of consensus building. METHODS A validated Delphi method and peer-reviewed literature were used to formally derive consensus among 30 panel members (21 musculoskeletal radiologists and 9 orthopaedic surgeons) from 13 countries. Forty-four questions were agreed on, and recent relevant seminal literature was circulated and classified in five major topics ('General issues', 'Parameters and reporting', 'Radiographic assessment', 'MRI' and 'Ultrasound') in order to produce answering statements. The level of evidence was noted for all statements, and panel members were asked to score their level of agreement with each statement (0 to 10) during iterative rounds. Either 'consensus', 'agreement' or 'no agreement' was achieved. RESULTS Forty-seven statements were generated, and group consensus was reached for 45 (95.7%). Seventeen of these statements were selected as most important for dissemination in advance. There was no agreement for the two statements pertaining to 'Ultrasound'. CONCLUSION Radiographic evaluation is the cornerstone of hip evaluation. An anteroposterior pelvis radiograph and a Dunn 45° view are recommended for the initial assessment of FAI although MRI with a dedicated protocol is the gold standard imaging technique in this setting. The resulting consensus can serve as a tool to reduce variability in clinical practices and guide further research for the clinical management of FAI. KEY POINTS • FAI imaging literature is extensive although often of low level of evidence. • Radiographic evaluation with a reproducible technique is the cornerstone of hip imaging assessment. • MRI with a dedicated protocol is the gold standard imaging technique for FAI assessment.
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Affiliation(s)
- Vasco V Mascarenhas
- Musculoskeletal Imaging Unit, Imaging Center, Radiology Department, Hospital da Luz, Grupo Luz Saúde, Av. Lusiada 100, 1500-650, Lisbon, Portugal.
| | - Miguel O Castro
- Department of Radiology, Centro Hospitalar Universitário do Algarve, Portimão, Portugal
| | - Paulo A Rego
- Department of Orthopaedic Surgery, Hospital da Luz, Lisbon, Portugal
| | - Reto Sutter
- Radiology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Luca Maria Sconfienza
- IRCCS Istituto Ortopedico Galeazzi, Milan, Italy.,Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Milan, Italy
| | | | - Florian Schmaranzer
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern, University of Bern, Bern, Switzerland
| | - Olufemi R Ayeni
- Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | | | - Philip Robinson
- Radiology Department, Leeds Teaching Hospitals, Chapel Allerton Hospital, Leeds, UK.,University of Leeds, Leeds, UK.,NHIR Leeds Musculoskeletal Biomedical Research Unit, Chapel Allerton Hospital, Leeds, UK
| | - Marc-André Weber
- Institute of Diagnostic and Interventional Radiology, Pediatric Radiology and Neuroradiology, University Medical Center, Rostock, Germany
| | - Paul E Beaulé
- Division of Orthopaedic Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Lennart Jans
- Department of Radiology, Ghent University Hospital, Gent, Belgium
| | - Radhesh Lalam
- The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Gobowen, Oswestry, UK
| | - Apostolos H Karantanas
- Medical School, University of Crete, Heraklion, Greece.,Computational BioMedicine Laboratory, ICS/FORTH, Heraklion, Greece
| | - Iwona Sudoł-Szopińska
- Department of Radiology, National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland
| | - Suzanne Anderson
- Institute of Radiology, Kantonsspital Baden, Baden, Switzerland.,Sydney School of Medicine, The University of Notre Dame Australia, Sydney, Australia
| | - Iris Noebauer-Huhmann
- Department of Biomedical Imaging and Image Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Filip M Vanhoenacker
- Department of Radiology, Ghent University Hospital, Gent, Belgium.,Department of Radiology, Antwerp University Hospital, Edegem, Belgium.,Department of Radiology, AZ Sint-Maarten, Mechelen, Belgium
| | | | - Oliver Marin-Peña
- Orthopedic and Traumatology Department, Hip Unit, University Hospital Infanta Leonor, Madrid, Spain
| | - Diego Collado
- Cirugía Ortopédica y Traumatología, Centro Médico Teknon, Barcelona, Spain
| | - Marc Tey-Pons
- Department of Orthopedic Surgery and Traumatology, University Hospital del Mar, Barcelona, Spain
| | | | - Eva Llopis
- Department of Radiology, Hospital de la Ribera, Valencia, Spain
| | - Mario Padron
- Department of Radiology, Clínica Cemtro, Madrid, Spain
| | - Josef Kramer
- Röntgeninstitut am Schillerpark, Rainerstrasse, Linz, Austria
| | - Patrick O Zingg
- Department of Orthopaedics, Balgrist University Hospital, Zurich, Switzerland
| | | | - P Diana Afonso
- Musculoskeletal Imaging Unit, Imaging Center, Radiology Department, Hospital da Luz, Grupo Luz Saúde, Av. Lusiada 100, 1500-650, Lisbon, Portugal
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Trinh TQ, Leunig M, Larson CM, Clohisy J, Nepple J, Zaltz I, Kelly BT, Naimark MB, Bedi A. Lateral Center-Edge Angle Is Not Predictive of Acetabular Articular Cartilage Surface Area: Anatomic Variation of the Lunate Fossa. Am J Sports Med 2020; 48:1967-1973. [PMID: 32520593 DOI: 10.1177/0363546520924038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Surgical treatment of symptomatic femoroacetabular impingement (FAI) and dysplasia requires careful characterization of acetabular morphology. The lateral center-edge angle (LCEA) is often used to assess lateral acetabular anatomy. Previous work has questioned the LCEA as a surrogate for acetabular contact/articular cartilage surface area because of the variable morphology of the lunate fossa. HYPOTHESIS We hypothesized that weightbearing articular cartilage of the acetabulum would poorly correlate with LCEA secondary to significant variation in the size of the lunate fossa. STUDY DESIGN Cohort study (Diagnosis); Level of evidence, 3. METHODS Patients with 3D CT imaging undergoing either hip arthroscopy or periacetabular osteotomy for FAI or symptomatic hip instability were retrospectively identified. The LCEA and femoral head diameter were measured on an anteroposterior pelvis radiograph. Patients were grouped according to their lateral acetabular coverage as undercoverage (LCEA, <25°), normal coverage (LCEA, 25°-40°), or overcoverage (LCEA, >40°). Patients were randomly identified until each group contained 20 patients. The articular surface area was measured from preoperative 3D CT data. Linear regression analysis was performed to examine the relationship between articular surface area and LCEA. Continuous and categorical data were analyzed utilizing analysis of variance and chi-square analysis. Statistical significance was set at P < .05. RESULTS No difference in age (P = .52), body mass index (BMI) (P = .75), or femoral head diameter (P = .66) was noted between groups. A significant difference in articular surface area was observed between patients with undercoverage and those with overcoverage (20.4 cm2 vs 24.5 cm2; P = .01). No significant difference was identified between the undercoverage and normal groups (20.4 cm2 vs 23.3 cm2; P = .09) or the normal and overcoverage groups (23.3 cm2 vs 24.5 cm2; P = .63). A moderate positive correlation was observed between LCEA and articular surface area across all patients (r = 0.38; P = .002) but not when patients with undercoverage were excluded (r = 0.02; P = .88). Significant variation in surface area was observed within each group such that no patient in any group was outside of 2 SDs of the means of the other groups. When patients were categorized into quartiles established by the articular surface area for the entire population, 40% of patients with overcoverage were observed in the first or second quartile (lower area). CONCLUSION Lateral acetabular undercoverage based on the LCEA (<25°) correlates with decreased acetabular surface area. Normal or increased acetabular coverage (LCEA, >25°), however, is not predictive of increased, normal, or decreased acetabular surface area.
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Affiliation(s)
- Thai Q Trinh
- Genesis Healthcare, Genesis Neuroscience and Orthopedic Center, Zanesville, Ohio, USA
| | - Michael Leunig
- Department of Orthopedic Surgery, University of Bern, Inselspital, Switzerland
| | - Christopher M Larson
- Minnesota Orthopedic Sports Medicine Institute at Twin City Orthopedics, Minneapolis, Minnesota, USA
| | - John Clohisy
- Department of Orthopedic Surgery, Washington University, St Louis, Missouri, USA
| | - Jeff Nepple
- Department of Orthopedic Surgery, Washington University, St Louis, Missouri, USA
| | - Ira Zaltz
- William Beaumont Hospital, Royal Oak, Michigan, USA
| | - Bryan T Kelly
- Sports Medicine Service, Hospital for Special Surgery, New York, New York, USA
| | | | - Asheesh Bedi
- Department of Orthopedic Surgery, University of Michigan, Ann Arbor, Michigan, USA
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40
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Spiker AM, Fabricant PD, Wong AC, Suryavanshi JR, Sink EL. Radiographic and clinical characteristics associated with a positive PART (Prone Apprehension Relocation Test): a new provocative exam to elicit hip instability. J Hip Preserv Surg 2020; 7:288-297. [PMID: 33163214 PMCID: PMC7605765 DOI: 10.1093/jhps/hnaa021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 04/08/2020] [Accepted: 04/18/2020] [Indexed: 12/13/2022] Open
Abstract
Hip instability due to mild dysplasia can be a diagnostic challenge. The physical exam is an important adjunct to radiographic evaluation for the clinical diagnosis of hip instability. Herein, we describe a new maneuver to replicate hip instability pain, called the PART (Prone Apprehension Relocation Test). We retrospectively identified patients in our institution’s hip preservation registry who presented for evaluation of hip pain. We divided patients into ‘positive’ or ‘negative’ PART and analyzed associated clinical and radiographic findings. Ninety patients (159 hips) were included, 83 female and 7 male, average age 27.3 ± 9.1 years. Thirty-four hips (21.4%) had a positive PART. There were no significant differences in hip range of motion, lateral center edge angle, or in acetabular depth. There was, however, a significant difference in acetabular version at 3 o’clock between the two test groups (18.5 ± 6.9° in negative, 21.2 ± 4.9° in positive, P = 0.045). There was no association between PART and previously described anterior apprehension testing. Historical methods of diagnosing hip dysplasia may not adequately identify patients with clinical hip instability. We describe a new provocative exam, the PART, which may be helpful in replicating hip instability symptoms in patients with anterior acetabular undercoverage. PART positive patients had significantly more acetabular anteversion at the 3 o’clock position, which is measured on computed tomography and is not visible on standard anteroposterior (AP) pelvis or false profile radiographs. We believe that the PART is a valuable supplement to clinical examination and radiographic measurements to identify patients with symptomatic hip instability.
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Affiliation(s)
- Andrea M Spiker
- Department of Orthopedic Surgery, University of Wisconsin - Madison, UW Health at The American Center, 4602 Eastpark Blvd, Madison, WI 53718, USA
| | - Peter D Fabricant
- Department of Orthopedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Alexandra C Wong
- Department of Orthopedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Joash R Suryavanshi
- Department of Orthopedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Ernest L Sink
- Department of Orthopedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
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Lerch TD, Siegfried M, Schmaranzer F, Leibold CS, Zurmühle CA, Hanke MS, Ryan MK, Steppacher SD, Siebenrock KA, Tannast M. Location of Intra- and Extra-articular Hip Impingement Is Different in Patients With Pincer-Type and Mixed-Type Femoroacetabular Impingement Due to Acetabular Retroversion or Protrusio Acetabuli on 3D CT-Based Impingement Simulation. Am J Sports Med 2020; 48:661-672. [PMID: 31961701 DOI: 10.1177/0363546519897273] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Diagnosis and surgical treatment of hips with different types of pincer femoroacetabular impingement (FAI), such as protrusio acetabuli and acetabular retroversion, remain controversial because actual 3-dimensional (3D) acetabular coverage and location of impingement cannot be studied via standard 2-dimensional imaging. It remains unclear whether pincer hips exhibit intra- or extra-articular FAI. PURPOSE (1) To determine the 3D femoral head coverage in these subgroups of pincer FAI, (2) determine the impingement-free range of motion (ROM) through use of osseous models based on 3D-computed tomography (CT) scans, and (3) determine the osseous intra-and extra-articular 3D impingement zones by use of 3D impingement simulation. STUDY DESIGN Cross-sectional study; Level of evidence, 3. METHODS This is a retrospective, comparative, controlled study involving 70 hips in 50 patients. There were 24 patients (44 hips) with symptomatic pincer-type or mixed-type FAI and 26 patients (26 hips) with normal hips. Surface models based on 3D-CT scans were reconstructed and compared for hips with acetabular retroversion (30 hips), hips with protrusio acetabuli (14 hips), and normal asymptomatic hips (26 hips). Impingement-free ROM and location of impingement were determined for all hips through use of validated 3D collision detection software based on CT-based 3D models. No abnormal morphologic features of the anterior iliac inferior spine were detected. RESULTS (1) Mean total femoral head coverage was significantly (P < .001) increased in hips with protrusio acetabuli (92% ± 7%) and acetabular retroversion (71% ± 5%) compared with normal hips (66% ± 6%). (2) Mean flexion was significantly (P < .001) decreased in hips with protrusio acetabuli (104°± 9°) and acetabular retroversion (116°± 6°) compared with normal hips (125°± 13°). Mean internal rotation in 90° of flexion was significantly (P < .001) decreased in hips with protrusio acetabuli (16°± 12°) compared with normal hips (35°± 13°). (3) The prevalence of extra-articular subspine impingement was significantly (P < .001) higher in hips with acetabular retroversion (87%) compared with hips with protrusio acetabuli (14%) and normal hips (0%) and was combined with intra-articular impingement. The location of anterior impingement differed significantly (P < .001) between hips with protrusio acetabuli and normal hips. CONCLUSION Using CT-based 3D hip models, we found that hips with pincer-type and mixed-type FAI have significantly larger femoral head coverage and different osseous ROM and location of impingement compared with normal hips. Additionally, intra- and extra-articular subspine impingement was detected predominantly in hips with acetabular retroversion. Acetabular rim trimming during hip arthroscopy or open surgical hip dislocation should be performed with caution for these hips. Patient-specific analysis of location of impingement using 3D-CT could theoretically improve diagnosis and planning of surgical treatment.
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Affiliation(s)
- Till D Lerch
- Department of Orthopaedic Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - Mathias Siegfried
- Department of Orthopaedic Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - Florian Schmaranzer
- Department of Orthopaedic Surgery, Inselspital, University of Bern, Bern, Switzerland.,University Institute of Diagnostic, Interventional and Paediatric Radiology, University of Bern, Inselspital, Bern, Switzerland
| | - Christiane S Leibold
- Department of Orthopaedic Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - Corinne A Zurmühle
- Department of Orthopaedic Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - Markus S Hanke
- Department of Orthopaedic Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - Michael K Ryan
- American Sports Medicine Institute, Andrews Orthopaedic and Sports Medicine Center, Birmingham, Alabama, USA
| | - Simon D Steppacher
- Department of Orthopaedic Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - Klaus A Siebenrock
- Department of Orthopaedic Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - Moritz Tannast
- Department of Orthopaedic Surgery, Inselspital, University of Bern, Bern, Switzerland.,Department of Orthopaedic Surgery and Traumatology, Fribourg Cantonal Hospital, University of Fribourg, Fribourg, Switzerland
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Flecher X, Wettstein M, May O. Limitations of arthroscopy for managing coxa profunda. Orthop Traumatol Surg Res 2019; 105:S267-S274. [PMID: 31672415 DOI: 10.1016/j.otsr.2019.09.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 09/20/2019] [Indexed: 02/02/2023]
Abstract
Coxa profunda is a complex entity that can result in femoro-acetabular impingement (FAI). A meticulous evaluation of the type of acetabular overcoverage is essential to determine which treatment is best suited to each individual patient. Focal overcoverage with no posterior impingement can be treated by arthroscopic recontouring of the disproportionate acetabular wall. Any femoral deformities should be managed during the same procedure. General overcoverage, with predominant postero-inferior impingement, requires open surgery to obtain access to the entire acetabular rim. Rim resection should be sparing, to avoid removing an excessive proportion of the joint surface, yet sufficient to eliminate the impingement. In the event of protrusio acetabuli, which is the extreme form of coxa profunda, reverse peri-acetabular osteotomy should be considered, particularly if the acetabular roof angle is reversed. In some patients, chiefly those with coxa vara, valgus femoral osteotomy should be considered as a means of redirecting the loads towards the acetabular roof, thereby diminishing the forces that tend to drive the femoral head deeper into the socket.
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Affiliation(s)
- Xavier Flecher
- CNRS, ISM, Department of orthopaedics and Traumatology, Aix-Marseille université, Sainte-Marguerite hospital, Institute for Locomotion, AP-HM, 13009 Marseille, France.
| | - Michaël Wettstein
- Institut de traumatologie et d'orthopédie du Léman-Suisse, clinique de Genolier, 1272 Genolier, Switzerland
| | - Olivier May
- Centre de chirurgie de la hanche, clinique du sport, Medipôle Garonne, 31036 Toulouse, France
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43
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CORR Insights®: Does Acetabular Coverage Vary Between the Supine and Standing Positions in Patients with Hip Dysplasia? Clin Orthop Relat Res 2019; 477:2467-2469. [PMID: 31567708 PMCID: PMC6903831 DOI: 10.1097/corr.0000000000000966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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44
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Lerch TD, Boschung A, Todorski IAS, Steppacher SD, Schmaranzer F, Zheng G, Ryan MK, Siebenrock KA, Tannast M. Femoroacetabular Impingement Patients With Decreased Femoral Version Have Different Impingement Locations and Intra- and Extraarticular Anterior Subspine FAI on 3D-CT-Based Impingement Simulation: Implications for Hip Arthroscopy. Am J Sports Med 2019; 47:3120-3132. [PMID: 31539275 DOI: 10.1177/0363546519873666] [Citation(s) in RCA: 74] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND It remains unclear whether decreased femoral version (FV) causes anterior intra- or extra-articular femoroacetabular impingement (FAI). Therefore, we evaluated symptomatic hips with decreased FV, with and without cam and pincer FAI, by using computed tomography (CT)-based virtual 3-dimensional (3D) impingement simulation and compared this group with patients with normal FV and with asymptomatic hips. PURPOSE To investigate (1) the osseous range of motion, (2) the osseous femoral and acetabular impingement zones, and (3) whether hip impingement is extra- or intra-articular in symptomatic hips with FAI. STUDY DESIGN Cross-sectional study; Level of evidence, 3. METHODS An institutional review board-approved, retrospective comparative analysis was performed on a total of 84 hips in 68 participants. Of these, 37 hips in 24 symptomatic patients with FAI had decreased FV. These hips were compared with 21 hips of 18 symptomatic patients with anterior FAI with normal FV (10°-25°) and 26 asymptomatic hips with no FAI and normal FV. All patients with FAI were symptomatic and had anterior hip pain and a positive anterior impingement test. They underwent pelvic CT scans to measure FV. Decreased FV was defined as FV less than 5°. The 37 hips with decreased FV presented both with and without cam and pincer FAI. All 84 hips were evaluated by use of CT-based 3D models and a validated 3D range of motion and impingement simulation. Asymptomatic hips were contralateral normal hips imaged in patients undergoing total hip arthroplasty. RESULTS Hips with FAI combined with decreased FV had a significantly (P < .001) lower mean flexion (114°± 8° vs 125°± 13°) and internal rotation (IR) at 90° of flexion (18°± 6° vs 32°± 9°, P < .001) compared with the asymptomatic control group. Symptomatic patients with FAI and normal FV had flexion of 120°± 16° and IR at 90° of flexion of 23°± 15°. In a subgroup analysis, we found a significantly (P < .001) lower IR in 90° of flexion in hips with FV less than 5° combined with mixed-type FAI compared with hips with FV less than 5° without a cam- or pincer-type deformity. The maximal acetabular impingement zone for hips with decreased FV was located at the 2-o'clock position and ranged from 1 to 3 o'clock. In hips with decreased FV, most of the impingement locations were intra-articular but 32% of hips had combined intra- and extra-articular FAI in internal rotation in 90° of flexion. During the flexion-adduction-IR test performed in 10° and 20° of adduction, extra-articular subspine FAI had significantly (P < .001) higher prevalence (68% and 84%) in hips with decreased FV compared with normal hips. CONCLUSION Hips with FAI and decreased FV had less flexion and internal rotation in 90° of flexion compared with the asymptomatic control group. The majority of hip impingement due to low FV was intra-articular, but one-third of samples had combined intra- and extra-articular subspine FAI. Anterior extra- and intra-articular hip impingement can be present in patients who have FAI with decreased FV. This could be important for patients undergoing hip arthroscopy.
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Affiliation(s)
- Till D Lerch
- Department of Orthopaedic Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - Adam Boschung
- Department of Orthopaedic Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - Inga A S Todorski
- Department of Orthopaedic Surgery, Inselspital, University of Bern, Bern, Switzerland.,Department of Radiology, Inselspital, University of Bern, Bern, Switzerland
| | - Simon D Steppacher
- Department of Orthopaedic Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - Florian Schmaranzer
- Department of Orthopaedic Surgery, Inselspital, University of Bern, Bern, Switzerland.,Department of Radiology, Inselspital, University of Bern, Bern, Switzerland
| | - Guoyan Zheng
- ISTB, Institute for Surgical Techniques and Biomechanics, University of Bern, Bern, Switzerland
| | - Michael K Ryan
- American Sports Medicine Institute, Andrews Orthopaedic and Sports Medicine Center, Birmingham, Alabama, USA
| | - Klaus A Siebenrock
- Department of Orthopaedic Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - Moritz Tannast
- Department of Orthopaedic Surgery, Inselspital, University of Bern, Bern, Switzerland.,Department of Orthopaedic Surgery and Traumatology, Fribourg Cantonal Hospital, University of Fribourg, Fribourg, Switzerland
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Lerch TD, Eichelberger P, Baur H, Schmaranzer F, Liechti EF, Schwab JM, Siebenrock KA, Tannast M. Prevalence and diagnostic accuracy of in-toeing and out-toeing of the foot for patients with abnormal femoral torsion and femoroacetabular impingement: implications for hip arthroscopy and femoral derotation osteotomy. Bone Joint J 2019; 101-B:1218-1229. [PMID: 31564157 DOI: 10.1302/0301-620x.101b10.bjj-2019-0248.r1] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Abnormal femoral torsion (FT) is increasingly recognized as an additional cause for femoroacetabular impingement (FAI). It is unknown if in-toeing of the foot is a specific diagnostic sign for increased FT in patients with symptomatic FAI. The aims of this study were to determine: 1) the prevalence and diagnostic accuracy of in-toeing to detect increased FT; 2) if foot progression angle (FPA) and tibial torsion (TT) are different among patients with abnormal FT; and 3) if FPA correlates with FT. PATIENTS AND METHODS A retrospective, institutional review board (IRB)-approved, controlled study of 85 symptomatic patients (148 hips) with FAI or hip dysplasia was performed in the gait laboratory. All patients had a measurement of FT (pelvic CT scan), TT (CT scan), and FPA (optical motion capture system). We allocated all patients to three groups with decreased FT (< 10°, 37 hips), increased FT (> 25°, 61 hips), and normal FT (10° to 25°, 50 hips). Cluster analysis was performed. RESULTS We found a specificity of 99%, positive predictive value (PPV) of 93%, and sensitivity of 23% for in-toeing (FPA < 0°) to detect increased FT > 25°. Most of the hips with normal or decreased FT had no in-toeing (false-positive rate of 1%). Patients with increased FT had significantly (p < 0.001) more in-toeing than patients with decreased FT. The majority of the patients (77%) with increased FT walk with a normal foot position. The correlation between FPA and FT was significant (r = 0.404, p < 0.001). Five cluster groups were identified. CONCLUSION In-toeing has a high specificity and high PPV to detect increased FT, but increased FT can be missed because of the low sensitivity and high false-negative rate. These results can be used for diagnosis of abnormal FT in patients with FAI or hip dysplasia undergoing hip arthroscopy or femoral derotation osteotomy. However, most of the patients with increased FT walk with a normal foot position. This can lead to underestimation or misdiagnosis of abnormal FT. We recommend measuring FT with CT/MRI scans in all patients with FAI. Cite this article: Bone Joint J 2019;101-B:1218-1229.
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Affiliation(s)
- Till D Lerch
- Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Patric Eichelberger
- Bern University of Applied Sciences Health, Physiotherapy, Bern, Switzerland
| | - Heiner Baur
- Bern University of Applied Sciences Health, Physiotherapy, Bern, Switzerland
| | - Florian Schmaranzer
- Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Emanuel F Liechti
- Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Joe M Schwab
- Department of Orthopaedic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Klaus A Siebenrock
- Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Moritz Tannast
- Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Department of Orthopaedic Surgery and Traumatology, Fribourg Cantonal Hospital, University of Fribourg, Fribourg, Switzerland
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Fritz B, Agten CA, Boldt FK, Zingg PO, Pfirrmann CWA, Sutter R. Acetabular coverage differs between standing and supine positions: model-based assessment of low-dose biplanar radiographs and comparison with CT. Eur Radiol 2019; 29:5691-5699. [PMID: 30903332 DOI: 10.1007/s00330-019-06136-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 02/16/2019] [Accepted: 03/07/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVES To evaluate the feasibility of 2D and 3D acetabular coverage assessments based on low-dose biplanar radiographs (BPR) in comparison with CT, and to demonstrate the influence of weight-bearing position (WBP) on anterior and posterior acetabular coverages. METHODS Fifty patients (21 females, 29 males) underwent standing BPR and supine CT of the pelvis. Using dedicated software, BPR-based calculations of anterior and posterior 2D coverages and anterior, posterior, and global 3D coverages were performed in standardized anterior pelvic plane (APP) and WBP. CT-based anterior and posterior 2D coverages and global 3D coverage was calculated in APP and compared with BPR-based data. Statistics included intraclass correlation coefficients (ICC) and Bland-Altman plots. RESULTS Mean anterior 2D coverage was 21.2% (standard deviation, ± 7.4%) for BPR and 23.8% (± 8.4%) for CT (p = 0.226). Mean posterior 2D coverage was 54.2% (± 9.8%) for BPR and 61.7% (± 9.7%) for CT (p = 0.001). Mean global 3D coverage was 46.5% (± 3.0%) for BPR and 45.6% (± 3.6%) for CT (p = 0.215). The inter-method reliability between CT and BPR and inter-reader reliability for BPR-based measurements were very good for all measurement (all ICC > 0.8). Based on BPR, mean anterior and posterior 3D coverages were 20.5% and 26.0% in WBP and APP, while 25 patients increased anterior and 24 patients increased posterior 3D coverage from APP to WBP with a relative change of coverage of up to 11.9% and 10.0%, respectively. CONCLUSIONS 2D and 3D acetabular coverages can be calculated with very good reliability based on BPR. The impact of standing position on acetabular coverage can be quantified with BPR on an individual basis. KEY POINTS • 2D and 3D acetabular coverages can be calculated with very good reliability based on biplanar radiographs in comparison with CT. • The impact of standing position on anterior and posterior acetabular coverages can be quantified with BPR on an individual basis.
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Affiliation(s)
- Benjamin Fritz
- Department of Radiology, University Hospital Balgrist, Forchstrasse 340, CH-8008, Zurich, Switzerland. .,Faculty of Medicine, University of Zurich, Zurich, Switzerland.
| | - Christoph A Agten
- Department of Radiology, University Hospital Balgrist, Forchstrasse 340, CH-8008, Zurich, Switzerland.,Faculty of Medicine, University of Zurich, Zurich, Switzerland
| | - Franca K Boldt
- Department of Radiology, University Hospital Balgrist, Forchstrasse 340, CH-8008, Zurich, Switzerland.,Faculty of Medicine, University of Zurich, Zurich, Switzerland
| | - Patrick O Zingg
- Faculty of Medicine, University of Zurich, Zurich, Switzerland.,Department of Orthopedics, University Hospital Balgrist, Forchstrasse 340, Zurich, Switzerland
| | - Christian W A Pfirrmann
- Department of Radiology, University Hospital Balgrist, Forchstrasse 340, CH-8008, Zurich, Switzerland.,Faculty of Medicine, University of Zurich, Zurich, Switzerland
| | - Reto Sutter
- Department of Radiology, University Hospital Balgrist, Forchstrasse 340, CH-8008, Zurich, Switzerland.,Faculty of Medicine, University of Zurich, Zurich, Switzerland
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Lerch TD, Degonda C, Schmaranzer F, Todorski I, Cullmann-Bastian J, Zheng G, Siebenrock KA, Tannast M. Patient-Specific 3-D Magnetic Resonance Imaging-Based Dynamic Simulation of Hip Impingement and Range of Motion Can Replace 3-D Computed Tomography-Based Simulation for Patients With Femoroacetabular Impingement: Implications for Planning Open Hip Preservation Surgery and Hip Arthroscopy. Am J Sports Med 2019; 47:2966-2977. [PMID: 31486679 DOI: 10.1177/0363546519869681] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Femoroacetabular impingement (FAI) is a complex 3-dimensional (3D) hip abnormality that can cause hip pain and osteoarthritis in young and active patients of childbearing age. Imaging is static and based on 2-dimensional radiographs or computed tomography (CT) scans. Recently, CT-based 3D impingement simulation was introduced for patient-specific assessments of hip deformities, whereas magnetic resonance imaging (MRI) offers a radiation-free alternative for surgical planning before hip arthroscopic surgery. PURPOSE To (1) investigate the difference between 3D models of the hip, (2) correlate the location of hip impingement and range of motion (ROM), and (3) correlate diagnostic parameters while comparing CT- and MRI-based osseous 3D models of the hip in symptomatic patients with FAI. STUDY DESIGN Cohort study (Diagnosis); Level of evidence, 2. METHODS The authors performed an institutional review board-approved comparative and retrospective study of 31 hips in 26 symptomatic patients with FAI. We compared CT- and MRI-based osseous 3D models of the hip in the same patients. 3D CT scans (slice thickness, 1 mm) of the entire pelvis and the distal femoral condyles were obtained. Preoperative MRI of the hip was performed including an axial-oblique T1 VIBE sequence (slice thickness, 1 mm) and 2 axial anisotropic (1.2 × 1.2 × 1 mm) T1 VIBE Dixon sequences of the entire pelvis and the distal femoral condyles. Threshold-based semiautomatic reconstruction of 3D models was performed using commercial software. CT- and MRI-based 3D models were compared with specifically developed software. RESULTS (1) The difference between MRI- and CT-based 3D models was less than 1 mm for the proximal femur and the acetabulum (median surface distance, 0.4 ± 0.1 mm and 0.4 ± 0.2 mm, respectively). (2) The correlation for ROM values was excellent (r = 0.99, P < .001) between CT and MRI. The mean absolute difference for flexion and extension was 1.9°± 1.5° and 2.6°± 1.9°, respectively. The location of impingement did not differ between CT- and MRI-based 3D ROM analysis in all 12 of 12 acetabular and 11 of 12 femoral clock-face positions. (3) The correlation for 6 diagnostic parameters was excellent (r = 0.98, P < .001) between CT and MRI. The mean absolute difference for inclination and anteversion was 2.0°± 1.8° and 1.0°± 0.8°, respectively. CONCLUSION Patient-specific and radiation-free MRI-based dynamic 3D simulation of hip impingement and ROM can replace CT-based 3D simulation for patients with FAI of childbearing age. On the basis of these excellent results, we intend to change our clinical practice, and we will use MRI-based 3D models for future clinical practice instead of CT-based 3D models. This allows radiation-free and patient-specific preoperative 3D impingement simulation for surgical planning and simulation of open hip preservation surgery and hip arthroscopic surgery.
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Affiliation(s)
- Till D Lerch
- Department of Orthopedic Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - Celia Degonda
- Department of Orthopedic Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - Florian Schmaranzer
- Department of Orthopedic Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - Inga Todorski
- Department of Orthopedic Surgery, Inselspital, University of Bern, Bern, Switzerland
| | | | - Guoyan Zheng
- Institute for Surgical Technology and Biomechanics, University of Bern, Bern, Switzerland
| | - Klaus A Siebenrock
- Department of Orthopedic Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - Moritz Tannast
- Department of Orthopedic Surgery, Inselspital, University of Bern, Bern, Switzerland.,Department of Orthopaedic Surgery and Traumatology, Fribourg Cantonal Hospital, University of Fribourg, Fribourg, Switzerland
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Automatic MRI-based Three-dimensional Models of Hip Cartilage Provide Improved Morphologic and Biochemical Analysis. Clin Orthop Relat Res 2019; 477:1036-1052. [PMID: 30998632 PMCID: PMC6494340 DOI: 10.1097/corr.0000000000000755] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The time-consuming and user-dependent postprocessing of biochemical cartilage MRI has limited the use of delayed gadolinium-enhanced MRI of cartilage (dGEMRIC). An automated analysis of biochemical three-dimensional (3-D) images could deliver a more time-efficient and objective evaluation of cartilage composition, and provide comprehensive information about cartilage thickness, surface area, and volume compared with manual two-dimensional (2-D) analysis. QUESTIONS/PURPOSES (1) How does the 3-D analysis of cartilage thickness and dGEMRIC index using both a manual and a new automated method compare with the manual 2-D analysis (gold standard)? (2) How does the manual 3-D analysis of regional patterns of dGEMRIC index, cartilage thickness, surface area and volume compare with a new automatic method? (3) What is the interobserver reliability and intraobserver reproducibility of software-assisted manual 3-D and automated 3-D analysis of dGEMRIC indices, thickness, surface, and volume for two readers on two time points? METHODS In this IRB-approved, retrospective, diagnostic study, we identified the first 25 symptomatic hips (23 patients) who underwent a contrast-enhanced MRI at 3T including a 3-D dGEMRIC sequence for intraarticular pathology assessment due to structural hip deformities. Of the 23 patients, 10 (43%) were male, 16 (64%) hips had a cam deformity and 16 (64%) hips had either a pincer deformity or acetabular dysplasia. The development of an automated deep-learning-based approach for 3-D segmentation of hip cartilage models was based on two steps: First, one reader (FS) provided a manual 3-D segmentation of hip cartilage, which served as training data for the neural network and was used as input data for the manual 3-D analysis. Next, we developed the deep convolutional neural network to obtain an automated 3-D cartilage segmentation that we used as input data for the automated 3-D analysis. For actual analysis of the manually and automatically generated 3-D cartilage models, a dedicated software was developed. Manual 2-D analysis of dGEMRIC indices and cartilage thickness was performed at each "full-hour" position on radial images and served as the gold standard for comparison with the corresponding measurements of the manual and the automated 3-D analysis. We measured dGEMRIC index, cartilage thickness, surface area, and volume for each of the four joint quadrants and compared the manual and the automated 3-D analyses using mean differences. Agreement between the techniques was assessed using intraclass correlation coefficients (ICC). The overlap between 3-D cartilage volumes was assessed using dice coefficients and means of all distances between surface points of the models were calculated as average surface distance. The interobserver reliability and intraobserver reproducibility of the software-assisted manual 3-D and the automated 3-D analysis of dGEMRIC indices, thickness, surface and volume was assessed for two readers on two different time points using ICCs. RESULTS Comparable mean overall difference and almost-perfect agreement in dGEMRIC indices was found between the manual 3-D analysis (8 ± 44 ms, p = 0.005; ICC = 0.980), the automated 3-D analysis (7 ± 43 ms, p = 0.015; ICC = 0.982), and the manual 2-D analysis.Agreement for measuring overall cartilage thickness was almost perfect for both 3-D methods (ICC = 0.855 and 0.881) versus the manual 2-D analysis. A mean difference of -0.2 ± 0.5 mm (p < 0.001) was observed for overall cartilage thickness between the automated 3-D analysis and the manual 2-D analysis; no such difference was observed between the manual 3-D and the manual 2-D analysis.Regional patterns were comparable for both 3-D methods. The highest dGEMRIC indices were found posterosuperiorly (manual: 602 ± 158 ms; p = 0.013, automated: 602 ± 158 ms; p = 0.012). The thickest cartilage was found anteroinferiorly (manual: 5.3 ± 0.8 mm, p < 0.001; automated: 4.3 ± 0.6 mm; p < 0.001). The smallest surface area was found anteroinferiorly (manual: 134 ± 60 mm; p < 0.001, automated: 155 ± 60 mm; p < 0.001). The largest volume was found anterosuperiorly (manual: 2343 ± 492 mm; p < 0.001, automated: 2294 ± 467 mm; p < 0.001). Mean average surface distance was 0.26 ± 0.13 mm and mean Dice coefficient was 86% ± 3%. Intraobserver reproducibility and interobserver reliability was near perfect for overall analysis of dGEMRIC indices, thickness, surface area, and volume (ICC range, 0.962-1). CONCLUSIONS The presented deep learning approach for a fully automatic segmentation of hip cartilage enables an accurate, reliable and reproducible analysis of dGEMRIC indices, thickness, surface area, and volume. This time-efficient and objective analysis of biochemical cartilage composition and morphology yields the potential to improve patient selection in femoroacetabular impingement (FAI) surgery and to aid surgeons with planning of acetabuloplasty and periacetabular osteotomies in pincer FAI and hip dysplasia. In addition, this validation paves way to the large-scale use of this method for prospective trials which longitudinally monitor the effect of reconstructive hip surgery and the natural course of osteoarthritis. LEVEL OF EVIDENCE Level III, diagnostic study.
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Lerch TD, Vuilleumier S, Schmaranzer F, Ziebarth K, Steppacher SD, Tannast M, Siebenrock KA. Patients with severe slipped capital femoral epiphysis treated by the modified Dunn procedure have low rates of avascular necrosis, good outcomes, and little osteoarthritis at long-term follow-up. Bone Joint J 2019; 101-B:403-414. [PMID: 30929481 DOI: 10.1302/0301-620x.101b4.bjj-2018-1303.r1] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
AIMS The modified Dunn procedure has the potential to restore the anatomy in hips with severe slipped capital femoral epiphyses (SCFE). However, there is a risk of developing avascular necrosis of the femoral head (AVN). In this paper, we report on clinical outcome, radiological outcome, AVN rate and complications, and the cumulative survivorship at long-term follow-up in patients undergoing the modified Dunn procedure for severe SCFE. PATIENTS AND METHODS We performed a retrospective analysis involving 46 hips in 46 patients treated with a modified Dunn procedure for severe SCFE (slip angle > 60°) between 1999 and 2016. At nine-year-follow-up, 40 hips were available for clinical and radiological examination. Mean preoperative age was 13 years, and 14 hips (30%) presented with unstable slips. Mean preoperative slip angle was 64°. Kaplan-Meier survivorship was calculated. RESULTS At the latest follow-up, the mean Merle d'Aubigné and Postel score was 17 points (14 to 18), mean modified Harris Hip Score was 94 points (66 to 100), and mean Hip Disability and Osteoarthritis Outcome Score was 91 points (67 to 100). Postoperative slip angle was 7° (1° to 16°). One hip (2%) had progression of osteoarthritis (OA). Two hips (5%) developed AVN of the femoral head and required further surgery. Three other hips (7%) underwent implant revision due to screw breakage or change of wires. Cumulative survivorship was 86% at ten-year follow-up. CONCLUSION The modified Dunn procedure for severe SCFE resulted in a low rate of AVN, low risk of progression to OA, and high functional scores at long-term follow-up. The slip deformities were mainly corrected but secondary impingement deformities can develop in some hips and may require further surgical treatment. Cite this article: Bone Joint J 2019;101-B:403-414.
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Affiliation(s)
- T D Lerch
- Department of Orthopaedic Surgery, Inselspital, University of Bern, Freiburgstrasse, Bern, Switzerland
| | - S Vuilleumier
- Department of Orthopaedic Surgery, Inselspital, University of Bern, Freiburgstrasse, Bern, Switzerland
| | - F Schmaranzer
- Department of Orthopaedic Surgery, Inselspital, University of Bern, Freiburgstrasse, Bern, Switzerland
| | - K Ziebarth
- Department of Paediatric Surgery, Inselspital, University of Bern, Freiburgstrasse, Bern, Switzerland
| | - S D Steppacher
- Department of Orthopaedic Surgery, Inselspital, University of Bern, Freiburgstrasse, Bern, Switzerland
| | - M Tannast
- Department of Orthopaedic Surgery, Inselspital, University of Bern, Freiburgstrasse, Bern, Switzerland
| | - K A Siebenrock
- Department of Orthopaedic Surgery, Inselspital, University of Bern, Freiburgstrasse, Bern, Switzerland
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Damopoulos D, Lerch TD, Schmaranzer F, Tannast M, Chênes C, Zheng G, Schmid J. Segmentation of the proximal femur in radial MR scans using a random forest classifier and deformable model registration. Int J Comput Assist Radiol Surg 2019; 14:545-561. [PMID: 30604143 DOI: 10.1007/s11548-018-1899-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 12/10/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND Radial 2D MRI scans of the hip are routinely used for the diagnosis of the cam type of femoroacetabular impingement (FAI) and of avascular necrosis (AVN) of the femoral head, both considered causes of hip joint osteoarthritis in young and active patients. A method for automated and accurate segmentation of the proximal femur from radial MRI scans could be very useful in both clinical routine and biomechanical studies. However, to our knowledge, no such method has been published before. PURPOSE The aims of this study are the development of a system for the segmentation of the proximal femur from radial MRI scans and the reconstruction of its 3D model that can be used for diagnosis and planning of hip-preserving surgery. METHODS The proposed system relies on: (a) a random forest classifier and (b) the registration of a 3D template mesh of the femur to the radial slices based on a physically based deformable model. The input to the system are the radial slices and the manually specified positions of three landmarks. Our dataset consists of the radial MRI scans of 25 patients symptomatic of FAI or AVN and accompanying manual segmentation of the femur, treated as the ground truth. RESULTS The achieved segmentation of the proximal femur has an average Dice similarity coefficient (DSC) of 96.37 ± 1.55%, an average symmetric mean absolute distance (SMAD) of 0.94 ± 0.39 mm and an average Hausdorff distance of 2.37 ± 1.14 mm. In the femoral head subregion, the average SMAD is 0.64 ± 0.18 mm and the average Hausdorff distance is 1.41 ± 0.56 mm. CONCLUSIONS We validated a semiautomated method for the segmentation of the proximal femur from radial MR scans. A 3D model of the proximal femur is also reconstructed, which can be used for the planning of hip-preserving surgery.
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Affiliation(s)
- Dimitrios Damopoulos
- Institute for Surgical Technology and Biomechanics, University of Bern, Stauffacherstrasse 78, 3014, Bern, Switzerland.
| | - Till Dominic Lerch
- Department of Orthopaedic Surgery and Traumatology, Inselspital, University of Bern, Freiburgstrasse, 3010, Bern, Switzerland
| | - Florian Schmaranzer
- Department of Orthopaedic Surgery and Traumatology, Inselspital, University of Bern, Freiburgstrasse, 3010, Bern, Switzerland
| | - Moritz Tannast
- Department of Orthopaedic Surgery and Traumatology, Inselspital, University of Bern, Freiburgstrasse, 3010, Bern, Switzerland
| | - Christophe Chênes
- School of Health Sciences - Geneva, HES-SO University of Applied Sciences and Arts Western Switzerland, Avenue de Champel 47, 1206, Geneva, Switzerland
| | - Guoyan Zheng
- Institute for Surgical Technology and Biomechanics, University of Bern, Stauffacherstrasse 78, 3014, Bern, Switzerland.
| | - Jérôme Schmid
- School of Health Sciences - Geneva, HES-SO University of Applied Sciences and Arts Western Switzerland, Avenue de Champel 47, 1206, Geneva, Switzerland
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