Background

Magnetic resonance arthrography is the current method of choice for investigating patients with a clinical diagnosis of femoroacetabular impingement prior to performing hip arthroscopy. The aim of our study was to assess the efficacy of this investigation by comparing the findings of MR arthrogram with those found at arthroscopy, with reference to labral tears and chondral damage.

Aims

Our retrospective analysis reports the outcome of patients operated for slipped capital femoral epiphysis using the modified Dunn procedure. Results, complications, and the need for revision surgery are compared with the recent literature.

Introduction: Resurfacing arthroplasty is rapidly gaining popularity, the patients are in many cases very satisfied with the result. However some patients continue to complain about persistent groin pain, which is not clearly understood and attruibuted to different causes. We identified femoro-acetabular impingement as a source of pain, which promptly disappeared after surgical off-set restoration. Method: Since 2002 we implanted 390 hip resurfacing systems. At a one-year follow-up 16 patients complained about groin pain, especially when starting to walk. In 6 patients the clinical examination and the rx could demonstrate femoro-acetabular impingement. In four cases this was due to anterior osteophytes of the femoral neck, in two cases it was due to retroversion of the femoral implant. These 6 patients were revised. Results: During surgery femoro-acetabular impingement between these osteophytes on the femoral neck and the acetabular rim or the implant could be demonstrated. The head-neck off-set was restored with a high-speed burr. Interestingly rapid bleeding of the femoral neck was noted in all cases confirming the presence of vital bone. After surgery five of the six patients were painfree after 6–12 weeks. One patient did not experience a difference until now. There were no femoral neck fractures seen after this procedure. Conclusion: Femoro-acetabular impingement seems to be a common source of persistent groin pain after hip resurfacing. Care has to be taken to restore the head-neck offset during implantation

Radiodense structures resembling ossicles at the acetabular rim have received multiple names including “Os acetabuli, Os supertilii, Os marginale superius acetabuli, and Os coxae quartum”. Various theories regarding their origin have been postulated. These structures commonly are observed in dysplastic hips and hips suffering from femoro-acetabular impingement and represent fractures of the acetabular rim. In our series we observed acetabular rim fragments in 4.9% of the dysplastic hips and in 6.4% of the hips with femoro-acetabular impingement. Two different pathomechanics are responsible for the occurrence of these rim fragments. In dysplasia the short acetabular roof reduces the amount of available loading surface which leads to an overload on the lateral margin of the acetabulum, propagating the development of a fatigue fracture. However, as in all hips additional cysts were visible, it must be postulated, that cysts have to be present additionally and act as stress risers through which the rim bone eventually will fail. In hips with femoro-acetabular impingement the mode of failure is different. The relative anterior overcover in retroverted hips is subjected to stress during flexion of the hip, which is further increased by the frequent presence of an non-spheric extension of the femoral head as seen in cam impingement. The nonspheric femoral head-neck junction is jammed into the rim area. By repetitive traumatization the anterior rim eventually will fracture. The clinical importance of acetabular rim fractures in the dysplastic hip is readily understood even by an unexperienced observer. However, it has to be considered as a sign that the hip has decompensated and it usually goes with significant articular cartilage damage. Because the radiographic appearance of the hip with femoro-acetabular impingement seems normal at first sight, the mechanism leading to anterior rim fracture may be overlooked. However, recognition and adequate treatment is important to prevent further degeneration of the hip

Introduction. Ascertaining the etiology of hip pain in young patients can be challenging. Osteoid osteoma about the hip has only been described in case reports and small case series in this sub-population. This study assessed the clinical course, radiologic findings, and treatment approaches in a large series of pediatric osteoid osteoma cases about the hip. Potential diagnostic and treatment pitfalls were identified. Methods. A single-center tertiary care departmental database was queried for all cases of osteoid osteoma seen between Jan 1, 2003 and December 31, 2015. Medical records were reviewed to identify those with lesions identified within or around the hip joint. Clinical, demographic, and radiologic data were analyzed. Results. Fifty children and adolescents (56% female, mean age 12.4 years, range 3–19 years) were identified with osteoid osteoma about the hip. The femoral neck was the most common lesion location (38%), and pain in the hip was the most common presenting chief complaint (60%). Night pain (90%) and symptom relief with NSAIDs (88%) were extremely common, though not universally reported. Sclerosis and/or cortical thickening was visible in 58% of radiographs, though a lucent nidus was visible in only 42%. Thirty patients (60%) underwent MRI, 27 of which were available for review, with focal peri-lesional edema as a universal finding. Amongst intracapsular lesions (n=17, 63%), common findings included medial retinacular thickening (33%), synovitis (45%) and effusion (76%). In the 43 patients (48%) who underwent CT, a diagnostic lucent nidus was a universal finding. Initial alternative diagnoses were recorded in 46% of cases, including, in order of decreasing frequency, femoro-acetabular impingement, minor trauma, hip synovitis, ‘growing pain’, stress fracture, and infection. Abnormal hip range of motion, positive impingement signs, and global synovitis on MRI scan were found to be associated with alternative diagnosis. On multivariate regression analysis, only abnormal hip ROM was independently predictive of alternative diagnosis. Delay in diagnosis of >6 months was seen in 43% of patients. Three patients underwent preceding operative procedures for other hip diagnoses, but had persistent hip pain until the osteoid osteoma was treated. Forty-one patients (82%) ultimately underwent radiofrequency ablation (RFA), and 1 open osteoid osteoma resection was performed. Of those who underwent RFA, 93% achieved complete symptom resolution, with 2 of 3 patients without symptom resolution undergoing revision RFA procedure, 1 of which led to symptom resolution. Complications of treatment included 1 case of deep infection along an RFA track, requiring operative debridement, 1 case of transient weakness and paresthesias in the involved extremity, and 1 case of fracture at the RFA site, requiring ORIF. Conclusions. Alternative andelayed diagnoses are common in osteoid osteoma about the hip, with femoro-acetabular impingement representing the most common alternative initial diagnosis in our series. While varying presenting complaints and nonspecific MRI findings may contribute to diagnostic uncertainty, night pain was present in the vast majority of cases and CT scans provided definitive diagnosis in all patients who received them. As increasing numbers of young, active patients are being evaluated for various causes of hip pain, such as femoro-acetabular impingement, osteoid osteoma should not be overlooked in the differential diagnosis of pain about the hip

Femoro-acetabular impingement involves a deformity of the hip joint and is associated with hip osteoarthritis. Although 15% of the asymptomatic population exhibits a deformity, it is not clear who will develop symptoms. Current diagnostic imaging measures have either low specificity or low sensitivity and do not consider the dynamic nature of impingement during daily activities. The goal of this study is to determine stresses in the cartilage, subchondral bone and labrum of normal and impinging hips during activities such as walking and sitting down. Quantitative CT scans were obtained of a healthy Control and a participant with a symptomatic femoral cam deformity (‘Bump’). 3D models of the hip were created from automatic segmentation of CT scans. Cartilage layers were added so the articular surface was the mid-line of the joint. Finite element meshes were generated in each region. Bone elastic modulus was assigned element-by-element, calculated from CT intensity converted to bone mineral density using a calibration phantom. Cartilage was modelled as poroelastic, E=0.467 MPa, v=0.167, and permeability 3×10. -16. m. 4. /N s. The pelvis was fixed while rotations and contact forces from Bergmann et al. (2001) were applied to the femur over one load cycle for walking and sitting in a chair. All analyses were performed in FEBio. High shear stresses were seen near the acetabular cartilage-labrum junction in the Bump model, up to 0.12 MPa for walking and were much higher than in the Control. Patient-specific modelling can be used to assess contact and tissue stresses during different activities to better understand the risk of degeneration in individuals, especially for activities that involve high hip flexion. The high stresses at the cartilage labrum interface could explain so-called bucket-handle tears of the labrum

MCID and PASS are thresholds driven from PROMS to reflect clinical effectiveness. Statistical significance can be derived from a change in PROMS, whereas MCID and PASS reflect clinical significance. Its role has been increasingly used in the world of young adult hip surgery with several publications determining the thresholds for Femoro-acetabular impingement FAI. To our knowledge MCID and PASS for patient undergoing PAO for dysplasia has not been reported. 593 PAOs between 1/2013 and 7/2023 were extracted from the Northumbria Hip Preservation Registry. Patients with available PROMS at 1year and/or 2years were included. PAOs for retroversion, residual Perthes and those combined with FO were excluded. MCID was calculated using the distribution method 0.5SD of baseline score(1). PASS was calculated using anchor method, ROC analysis performed, and value picked maximizing Youden index. A Logistic Regression analysis was performed to determine which independent variables correlated with achieving MCID and PASS. The MCID threshold for iHOt12 was 8.6 with 83.4 and 86.3 % of patients achieved it at 1 and 2 years respectively. The PASS score at 1 and 2 year follow up was 43 and 44 respectively, with 72.6 and 75.2% achieving it at 1 and 2 year postop. At 2 years a Higher preop iHOT 12 was associated with not achieving MCID and PASS (p<0.05). Preop acetabular version was negatively correlated with achieving MCID and previous hip arthroscopy was negatively correlated with PASS. The % of patients achieving MCID and PASS mimics that of FAI surgery (2). The negative correlation with preop iHOT12 reaffirms the importance of patient selection. The negative correlation of hip arthroscopy highlights the importance of having a high index of suspicion for dysplasia prior to hip arthroscopy and poorer outcomes of patients with mixed CAM and dysplasia pathology

The purpose of this study was to investigate whether patients who had had excision of the Ligamentum Teres as part of a surgical hip dislocation for femoro-acetabular impingement exhibited symptoms of acute Ligamentum Teres rupture post-operatively. Recent reports in the literature suggest that injury to the Ligamentum Teres can cause instability, severe pain and inability to walk. We present the results of a postal questionnaire to 217 patients who had undergone open surgical hip dislocation for femoro-acetabular impingement where the LT was excised. This included seven patients who had undergone bilateral surgery. The questionnaire was designed to enquire about specific symptoms attributed to LT injuries in the literature; gross instability, incomplete reduction, inability to bear weight and mechanical symptoms. 161 patients responded (75%), with a total of 168 (75%) questionnaires regarding 224 hips completed. There were 104 females and 64 males. Median age was 34 and median follow-up was 52 months. All patients were found to have cam deformities, 72% (n=121) had associated labral tears. All patients were able to fully weight bear after surgery. 77% experienced no groin pain and 61% experienced no pain on exercise. 35% of patients experienced popping and locking in their operated hip and 24% had subjective feeling of their hip giving way. Oxford Hip scores and Nonarthritic Hip scores improved by 12 and 28 points respectively (n=47). Our results show that the symptoms of pain and instability described with LT pathology can be present but are by no means universal. This leads us to conclude that their symptoms may be attributed to labral pathology which is frequently noted to coexist

Since 2003 we have adopted an aggressive approach to the management of slipped upper femoral epiphysis (SUFE) deformity, an important cause of femoro-acetabular impingement and associated with the development of early adult hip arthritis. Sixteen patients aged 16.7 years (range 11–20), 13 male, have undergone surgery to manage their SUFE deformity. Nine underwent primary surgery using a Ganz approach (7) or in-situ pinning with femoral neck resection via a Smith-Peterson approach (2). Seven had previously undergone in-situ pinning 26 months earlier (range 4–44 months) of whom two had acetabular chondral flap tears with eburnated bone and six had significant labral degenerative changes associated with calcification or tears. Only one of the nine patients who underwent primary aggressive management of their SUFE, had a labral tear. Four patients underwent mobilisation of the femoral head on its vascular pedicle, followed by anatomical realignment. At an average follow-up of 22.3 months (range 1–41 months) 15 remained well with excellent function. Leg lengths remained equal in 12, with average shortening of 2 cm in the remaining four. Segmental AVN occurred in the first patient after damage to the vascular pedicle during drilling of the neck; the technique has been modified to prevent this. Despite having performed over 400 surgical hip dislocations, the authors continue to find the management of this condition challenging; nevertheless, having seen the consequences of femoro-acetabular impingement in these young patients, we believe that aggressive management to correct anatomical alignment is essential for the future well being of the hip

Since 2003 we have adopted an aggressive approach to the management of the SUFE deformity, an important cause of anterior femoro-acetabular impingement, associated with the development of early adult hip arthritis. 16 patients aged 16.7 years (range 11–20, 3 female, 13 male, 8 right, 8 left hips) underwent surgery to manage their SUFE deformity. 7 patients had secondary correction of deformity after previous in-situ pinning and 9 underwent primary surgical management using a Ganz approach (7) or primary in-situ pinning with femoral neck resection via a Smith-Peterson approach (2). Of the 7 patients who had primary in-situ pinning 26 months (range 4–44 months) earlier, 2 had acetabular chondral flap tears with eburnated bone and 6 had significant labral degenerative changes associated with calcification or tears. Only one of the nine patients who underwent primary aggressive management of their SUFE, had a labral tear. 4 patients underwent mobilisation of the femoral head on its vascular pedicle followed by anatomical realignment. At an average follow-up of 22.3 months (range 1–41 months) 15 remained well with excellent function. Leg lengths remained equal in 12, with an average shortening of 2cm in the remaining 4 patients. Segmental AVN occurred in the first patient after damage to the vascular pedicle during drilling of the neck; the technique has been modified to prevent further occurrences. Removal of the trochanteric osteotomy screws has been performed in 4 cases. Despite having performed over 400 surgical hip dislocation, the authors continue to find the management of this condition challenging; nevertheless, having seen the direct consequences of femoro-acetabular impingement at an early stage in these young patients, we believe that aggressive management to correct anatomical alignment is essential for the future well being of the hip

Introduction and Aims: There is a relationship between the anatomy of the hip joint and the development of arthritis. A common cause of hip pain in the young adult that can lead to arthritis is acetabular dysplasia. More recently, femoroacetabular impingement has been described as another cause of hip pain. The purpose of our study was to evaluate the applicability of pelvic computed tomography (CT) with three-dimensional surface rendering to evaluate femoro-acetabular impingement. Method Thirty-six hips (30 patients; 17 males; 13 females) with persistent hip pain, mean age 41 (37–52), underwent three-dimensional CT of the pelvis, as well as MRI arthrography with gadolinium enhancement. On 3D CT, the concavity of the femoral head-neck junction (offset), alpha angle as described by Notzli was calculated to depict the anterior femoral neck contour. The concavity of the posterior aspect of the head neck junction was measured as the beta angle. The same measurements were made in 20 hips, consisting of randomly selected patients with no prior history of hip pathology or pain (mean age 37; 13 males; eight females). Results The mean alpha angle for the symptomatic group was 66.4 (39–94) and 43.8 (39.3–48.3) for the control group (p=0.001). All symptomatic hips had abnormal findings on MRA: labral tears in all; cartilage delamination/ulceration in 14 hips; herniation pits in six hips. The majority of labral tears and delamination were located in the antero-superior quadrant. In the surgical treated group, all MRA findings were confirmed. The mean beta angle was significantly smaller (increase concavity) in the symptomatic versus the controls: 40.2 versus 43.8 (p=0.011). Interestingly in the symptomatic group the beta angle was significantly lower than the alpha angle (p< 0.02), but not in the controls. Conclusion: 3D CT with surface rendering and multiplanar reformation is useful to determine degree of bone buttressing of the anterior femoral head-neck junction quantitatively assessed by alpha angle measurement, which is elevated in patients with femoro-acetabular impingement. With a greater posterior concavity i.e. small beta angle in the symptomatic group versus the control, subclinical slipped femoral epiphysis remains a plausible cause of this deformity

Risk of impingement after total hip resurfacing arthroplasty may be great because femoral head-neck unit is preserved and there is little flexibility to adjust limb length and femoral offset, but this potentially worrisome phenomenon has been rarely reported. Impingement between femoral neck and acetabular cup was observed in a cohort of patients who underwent contemporary total hip resurfacing arthroplasty. We then questioned whether patient demographics, component features or suboptimal position of components would be risk factors for impingement. We reviewed a consecutive series of 51 patients (61 hips) who underwent contemporary total hip resurfacing arthroplasty. The mean age at the time of the index arthroplasty was 38 years (18 to 64). The most common diagnosis leading to the total hip resurfacing arthroplasty was osteonecrosis of the femoral head in 41 hips (67%). All the procedures were performed by single surgeon through an anterolateral approach. All the patients were assessed clinically and radiographically at a mean of 32 months (24 to 53) postoperatively. Femoro-acetabular cup impingement, defined as the presence of bony spur at the femoral neck corresponding to abutment site of the metallic cup, was observed in seven of the 61 hips (11.5%). Of these, five patients reported limitation of activities due to groin pain. The average postoperative Harris hip score of impingement hips was inferior to those of non-impingement hips (p = 0.004). No significant difference was detected between the impingement hips and non-impingement hips with regard to of patient demographics, component features and radiographic measurements including cup inclination, cup version, femoral component version, anterior femoral offset, stem-shaft angle, femoral offset and limb length discrepancy. Our multivariate analysis revealed that only acetabular cup uncoverage ratio had a significant association with femoro-acetabular cup impingement (p = 0.04, odds ratio 1.385 [95% CI, 1.014 – 1.891]). There was no aseptic loosening of components or femoral neck fracture. We found a high incidence of impingement between retained femoral neck and metallic acetabular cup after contemporary total hip resurfacing arthroplasty in association with an increased acetabular cup uncoverage ratio. As patients with femoro-acetabular cup impingement showed inferior clinical results, it is crucial to avoid excessive protrusion of acetabular cup beyond bony margin by proper selection of acetabular component size and appropriate positioning

Introduction. Acetabular and spino-pelvic (SP) morphological parameters are important determinants of hip joint dynamics. This study aims to determine whether acetabular and SP morphological differences exist between hips with and without cam morphology and between symptomatic and asymptomatic hips with cam morphology. Patients/Materials & Methods. A prospective cohort of 67 patients/hips was studied. Hips were either asymptomatic with no cam (Controls, n=18), symptomatic with cam (n=26) or asymptomatic with cam (n=23). CT-based quantitative assessments of femoral, acetabular, pelvic and spino-pelvic parameters were performed. Measurements were compared between controls and those with a cam deformity, as well as between the 3 groups. Morphological parameters that were independent predictors of a symptomatic Cam were determined using a regression analysis. Results. Hips with cam deformity had slightly smaller subtended angles superior-anteriorly (87° Vs 84°, p=0.04) and greater pelvic incidence (53° Vs 48°, p=0.003) compared to controls. Symptomatic Cams had greater acetabular version (p<0.01), greater subtended angles superiorly and superior-posteriorly (p=0.01), higher pelvic incidence (p=0.02), greater alpha angles and lower femoral neck-shaft angles compared to asymptomatic cams (p<0.01) and controls (p<0.01). The four predictors of symptomatic cam included antero-superior alpha angle, femoral neck-shaft angle, acetabular depth and pelvic incidence. Discussion. Symptomatic hips had a greater amount of supero-posterior coverage; which would be the contact area between a radial cam and the acetabulum, when the hip is flexed to 90°. Furthermore, individuals with symptomatic cam morphology had greater PI. Acetabular- and SP parameters should be part of the radiological assessment of femoro-acetabular impingement. Conclusion. Because of the association between a high PI and an increased risk of hip OA (also shown to be increased with c-FAI), the relationship between the PI and FAI should be taken into consideration in prospective longitudinal studies looking at factors influencing the formation of cam morphology as well as those at risk of developing symptoms and degenerative changes

Management of the young adult hip pathologies is a special entity in orthopaedic surgical practice that needs special emphasis and consideration. A wide range of pathological and traumatic conditions occur in the young adult hip that lead to functional disability and the development of premature osteoarthritis. Proper surgical interference when the hip is still in the pre-arthritic stage restores function to the young hip and protects it from early degenerative changes, and hence the anticipated need for future joint replacement surgery is prevented. Accurate estimation of the biomechanical error combined with careful understanding of the hip joint biology is the cornerstone of success of any hip preservation surgery ever performed to save the young adult hip. Safe surgical hip dislocation approach was adopted as one of the tools in the hands of the hip preservation surgeon to treat a broad spectrum of intra-articular hip pathologies like Perthes disease and severe forms of slipped capital femoral epiphysis (SCFE). Osteo-chondroplasty at the head-neck junction with relative femoral neck lengthening for Perthes disease, and Subcapital re-orientation of severe SCFE based on its retinacular vascular pedicle are often performed via the surgical hip dislocation approach. The approach is also useful with certain types of acetabular fractures that enables fixation of dual-column fractures via single approach with intra-articular visualization for the accuracy of reduction and hardware placement. The 4 cm mini-open direct anterior approach is ideal for the surgical treatment of cases with cam and/or pincer types of femoro-acetabular impingement. Peri-articular osteotomies performed either on the acetabular or the femoral sides of the hip joint are extremely useful in the correction of the biomechanical error that led to an existing hip pathology. Periacetabular osteotomies are commonly performed to treat dysplasia of the young hip. Proximal femoral osteotomies are commonly performed to treat a wide range of hip pathologies including non-unions of femoral neck fractures in the young adult. Correction of the biomechanical error at the proper timing ensures normalization of the hip joint loading conditions and range of motion that leads to reversal of the pathologic process and prevention of osteoarthritis. A hip joint replacement would have an unknown but certainly a finite life, whereas a young hip that has healed after hip preservation surgery would definitely last for a lifetime

Perthes disease often leaves young adults with hip joint incongruency due to femoral head asphericity, (extra-articular extrusion and superior flattening). This causes femoro-acetabular impingement, a reduced range of movement and early degenerative change. We report a novel method for restoration of femoral head sphericity and femoro-acetabular congruency. Two males (aged 21 and 22 years) presented with groin pain and severe hip stiffness after childhood Perthes disease. Imaging confirmed characteristic saddle shaped deformities of the femoral head, with cartilage loss overlying a central depression in the superior section of the head. A new method of treatment was proposed. Both cases were treated in the same manner. A surgical dislocation was performed with a trochanteric flip osteotomy. The extra-articular bump was removed with osteotomes and a burr to reduce femoro- acetabular impingement. The sphericity of the femoral head was restored using a HemiCap partial re-surfacing (Arthrosurface, MA, USA). The radius of the implant was selected to match that of the acetabulum. Restoration of the height of the flattened portion of the weight-bearing surface of the femoral head reduces abnormal loading of the acetabular articular cartilage by improving congruency of the joint. Both patients recovered without incident and were mobilised with crutches, restricted to touch weight-bearing for six weeks to protect union of the trochanteric osteotomy. At a minimum of three year follow-up both patients had sustained improved range of movement, pain and Oxford hip score. Repeated imaging shows no evidence of joint space narrowing or loosening at this stage. We conclude that this novel treatment functions well in the short term. Further surveillance is on-going to confirm that this treatment results in improved long term durability of the natural hip joint after Perthes disease

In the congenital hip dysplasia, patients treated with total hip replacement (THR) often report persistent disability and pain, with unsatisfactory function and quality of life. A major challenge is to restore the center of rotation of the hip and a satisfactory abduction function [1]. The position of the acetabular cup during THR might be crucial, as it affects abduction moment and motor function. Recently, several software systems have been developed for surgical planning of endoprostheses. Previously developed software called HipOp [2], which is routinely used in clinics, allows surgeons to properly position the prosthetic components into the 3D space of CT data. However, this software did not allow to simulate the articular range of motion and the condition of the abductor muscles. Our aim is to present HipOpCT, an advanced version of the software that includes 3D musculoskeletal planning, through the application to hip dysplasia patients to add knowledge in the diagnosis and treatment of such patients who need THR. 40 hip dysplasia patients received pre-operative CT scanning of pelvis and thighs and had their THR surgery planned using HipOpCT. The base planning includes import of CT data, positioning of prosthetic components interactively through multimodal display, as well as geometrical measurements of the implant and the host bone. The advanced planning additionally includes evaluation of femoro-acetabular impingement and calculation of leg lengths, abductor muscle lengths and lever arms through the automatic creation of a musculoskeletal model. The musculoskeletal parameters in all patients were calculated during the surgical planning, and the data were processed to evaluate pre- and post-operative differences in leg length discrepancy, length and lever arm of the abductor muscles, and how these parameters correlated. The surgical planning led to an increase in the operated leg length of 7.6 ± 5.7 mm. The variation in abductors lever arm was −0.9% ± 4.8% and significantly correlated with the variation in the operated leg length (r = −0.49), pre-operative leg length discrepancy (r = 0.32) and variation in abductors length (r = −0.32). The variation in abductors length was 6.6% ± 5.5%, and significantly correlated with the variation in the operated leg length (r = 0.92), post-operative leg length discrepancy (r = 0.37), pre-operative abductors length (r = −0.37) and variation in abductors lever arm (r = −0.32). The increase in the operated leg length was strongly correlated to the increase in abductor muscle length. Conversely, abductor lever arms slightly decreased on average, and were inversely correlated to leg length variation and abductors lengths. This interactive technology for surgical planning represent a powerful tool for orthopaedic surgeons to consider the best muscle reconstruction, and for rehabilitation specialists to achieve the best functional recovery based on biomechanical outcomes. In a parallel study, we are investigating how these advanced planning is reflected onto the function, pain and biomechanical outcome after a rehabilitation protocol is completed

Heterotopic ossification is a recognised complication of surgery on the hip joint that can adversely affect the outcome. The aim of this study was to determine the incidence of heterotopic ossification following surgical hip dislocation and debridement for femoro-acetabular impingement using Ganz trochanteric flip osteotomy approach. We also compared the incidence of heterotopic ossification between two subgroups of patients; in the first group, a shaver burr was used to reshape the femoral head and in the second group, an osteotome was used. Methods: We reviewed postoperative radiographs of all patients who underwent surgical hip dislocation and debridement during the period between March 2003 and July 2007. We excluded patients with radiographic follow-up of less than one year. Brooker classification was used to grade heterotopic ossifications. Results: Ninety eight patients (mean age 35 years, range 12–65 years) were included with a mean radiological follow-up of 23 months (range 12–61 months). The overall incidence of heterotopic ossification was 31%. None of the patients developed Brooker grade III or IV heterotopic ossifications. The incidence of heterotopic ossifications in the shaver burr group (n=57) and in the osteotome group (n=41) was 30% and 32%, respectively. Conclusions: Heterotopic ossification of minor grade is a common complication of surgical hip dislocation using trochanteric flip osteotomy approach. The use of a shaver burr did not result in higher rates of heterotopic ossifications despite the formation of large amounts bone debris

Rotational acetabular osteotomy (RAO) for developmental dysplasia of the hip (DDH) may not restore normal hip range of motion (ROM) due to the inherent deformity of the hip and it may lead to femoro-acetabular impingement. The purpose of this study was to investigate morphological factors of the pelvis and femur influencing on simulated ROM after RAO with a fixed target for femoral head coverage. We retrospectively reviewed CT images of 52 DDHs with an average lateral centre edge angle (CEA) of 7.9° (−12° to 19°). After virtual RAO with 30° of lateral CEA and 55° of anterior CEA producing femoral head coverage similar to that of the normal hips, we measured simulated flexion ROM using pelvic and femoral computer models reconstructed from the CT images. Pelvic sagittal inclination, acetabular anteversion, lateral CEA, femoral neck anteversion, femoral neck shaft angle (FNSA), alpha angle and the position of the anterior inferior iliac spine (AIIS) were investigated as morphological factor. When the most prominent point of the AIIS existed more distally than the cranial tip of the acetabular joint line in a lateral view of the pelvis model in supine position, the subjects were defined as AIIS-Type1; the remaining subjects were defined as Type 2. There were 10 hips with Type 1 and 42 hips with Type 2 AIIS. The Kappa value of inter-observer reproducibility to classify AIIS was 0.82. Multiple regression analyses were performed to analyse the relationship between ROM and the morphological parameters. We also analysed the relationship between the probability of flexion ROM being less than 110° and the factors which influenced on flexion ROM. FNSA and AIIS-Type independently influenced on simulated flexion ROM after RAO (standard regression coefficient: −0.51 and 0.37, respectively. p&lt; 0.001). The multiple correlation coefficient was 0.68. Flexion ROM after RAO with a fixed femoral head coverage similar to that of the normal hips ranged from 95° to 141° with an average of 121°±8°. The probability of ROM being less than 110° was significantly higher in subjects with AIIS-Type 1 than in those with Type 2 (odds ratio: 13.3, p&lt;0.01). It was also significantly higher in subjects with more than 135° of FNSA than in those with less than 135° of FNSA (odds ratio: 9.5, p&lt;0.05). FNSA and the type of AIIS influenced on flexion ROM after RAO with approximately 40° of variation in spite of a fixed target for femoral head coverage. A large FNSA and a distal positioning of AIIS were independently associated with smaller flexion ROM after RAO

Introduction. In recent years, there has been a significant advancement in our understanding of femoro-acetabular impingement and associated labral and chondral pathology. Surgeons worldwide have demonstrated the successful treatment of these lesions via arthroscopic and open techniques. The aim of this study is to validate a simple and reproducible classification system for acetabular chondral lesions. Methods. In our classification system, the acetabulum is first divided into 6 zones as described by Ilizalithurri VM et al [Arthroscopy 24(5) 534-539]. The cartilage is then graded as 0 to 4 as follows: Grade 0 – normal articular cartilage lesions; Grade 1 softening or wave sign; Grade 2 - cleavage lesion; Grade 3 - delamination and Grade 4 –exposed bone. The site of the lesion is further typed as A, B or C based on whether the lesion is 1/3 distance from acetabular rim to cotyloid fossa, 1/3 to 2/3 distance from acetabular rim to cotyloid fossa and > 2/3 distance from acetabular rim to cotyloid fossa. For validating the classification system, six surgeons reviewed 14 hip arthroscopy video clips. All surgeons were provided with written explanation of our classification system. Each surgeon then individually graded the cartilage lesion. A single observer then compared results for observer variability using kappa statistics. Results. We observed a high inter-observer reliability of the classification system with a kappa coefficient of 0.89 (range 0.78 to 0.91) and high intra-observer reliability with a kappa coefficient of 0.91 (range 0.89 to 0.96). In conclusion we have developed a simple reproducible classification system for acetabular cartilage lesions seen at hip arthroscopy

Introduction: In recent years, there has been a significant advancement in our understanding of femoro-acetabular impingement and associated labral and chondral pathology. Surgeons worldwide have demonstrated the successful treatment of these lesions via arthroscopic and open techniques. The aim of this study is to validate a simple and reproducible classification system for acetabular chondral lesions. Methods: In our classification system, the acetabulum is first divided into 6 zones as described by Ilizalithurri VM et al [Arthroscopy 24(5) 534–539]. The cartilage is then graded as 0 to 4 as follows: Grade 0 – normal articular cartilage lesions; Grade 1 softening or wave sign; Grade 2 – cleavage lesion; Grade 3 – delamination and Grade 4 -exposed bone. The site of the lesion is further typed as A, B or C based on whether the lesion is 1/3 distance from acetabular rim to cotyloid fossa, 1/3 to 2/3 distance from acetabular rim to cotyloid fossa and > 2/3 distance from acetabular rim to cotyloid fossa. For validating the classification system, six surgeons reviewed 14 hip arthroscopy video clips. All surgeons were provided with written explanation of our classification system. Each surgeon then individually graded the cartilage lesion. A single observer then compared results for observer variability using kappa statistics. Results: We observed a high inter-observer reliability of the classification system with a kappa coefficient of 0.89 (range 0.78 to 0.91) and high intra-observer reliability with a kappa coefficient of 0.91 (range 0.89 to 0.96). Discussion: In conclusion we have developed a simple reproducible classification system for acetabular cartilage lesions