Femoroacetabular impingement (FAI) is a significant cause of osteoarthritis in young active individuals but the pathophysiology remains unclear. Increasing mechanistic studies point toward an inflammatory component in OA. This study aimed to characterise inflammatory cell subtypes in FAI by exploring the phenotype and quantification of inflammatory cells in FAI versus OA samples. Ten samples of labrum were obtained from patients with FAI (confirmed pathology) during open osteochondroplasty or hip arthroscopy. Control samples of labrum were collected from five patients with osteoarthritis undergoing total hip arthroplasty. Labral biopsies were evaluated immunohistochemically by quantifying the presence of macrophages (CD68 and CD202), T cells (CD3), mast cells (mast cell tryptase) and vascular endothelium (CD34). Labral biopsies obtained from patients with FAI exhibited significantly greater macrophage, mast cell and vascular endothelium expression compared to control samples. The most significant difference was noted in macrophage expression (p<0.01). Further sub typing of macrophages in FAI using CD202 tissue marker revealed and M2 phenotype suggesting that these cells are involved in a regenerate versus a degenerate process. There was a modest but significant correlation between mast cells and CD34 expression (r=0.4, p<0.05) in FAI samples. We provide evidence for an inflammatory cell infiltrate in femoroacetabular impingement. In particular, we demonstrate significant infiltration of mast cells and macrophages suggesting a role for innate immune pathways in the events that mediate hip impingement. Further mechanistic studies to evaluate the net contribution and hence therapeutic utility of these cellular lineages and their downstream processes may reveal novel therapeutic approaches to the management of early hip impingement

Background. Femoroacetabular impingement due to a reduced femoral head-neck-offset or excessive acetabular coverage will lead to early cartilage lesions of the hip joint. The purpose of the present study was to analyze the relationship between the extent of bony deformity and the presence and extent of cartilage lesions in femoroacetabular impingement. Methods. On the radiographs of 92 hip joints in 86 patients with a mean age of 36.5 ± 9.2 years who were operated on for with femoroacetabular impingement by surgical hip dislocation, the acetabular index of the weight-bearing zone, the center-edge-angle, the inclination of the acetabulum, the lateral-head-extrusion-index, retroversion signs of the acetabulum, the neck-shaft-angle, asphericity, superior and anterior alpha angles, and superior and anterior offset and offset ratios were assessed and correlated to the presence and extent of chondromalazia. Results. Acetabular chondromalazia was found in 60 hip joints. Full-thickness delamination of the acetabular cartilage was present in 42 of these hips with an average size of 1.1 ± 0.5 cm2. Femoral-sided chondromalazia was found in 9 hip joints. Hip joints with chondromalazia had a lower center-edge-angle (p = 0.014) and anterior offset ratio (p = 0.028) and a higher lateral-head-extrusion-index (p = 0.029). Hip joints with acetabular cartilage delamination had a significantly lower center-edge-angle (p = 0.012) and anterior offset (p = 0.03) and a significantly higher lateral-head-extrusion-index (p = 0.001) and superior (p = 0.006) and anterior alpha angles (p = 0.003). Conclusions. Marked cam-type femoral deformity and lesser coverage of the femoral head are associated with the acetabular cartilage lesions, arousing suspicion to the assumption that a large lateral aperture of the acetabulum abets proximal femora with cam-type deformity to inflict cartilage damage in femoroacetabular impingement

Historically avoidance of avascular necrosis (AVN) has been the primary objective in the management of an acute unstable slipped upper femoral epiphysis (SUFE). When achieved through pinning in situ it was invariably associated with significant malunion. With increasing appreciation of the consequences of femoroacetabular impingement, modern techniques aim to correct deformity and avoid AVN. Exactly what constitutes an acute unstable SUFE is a source of debate but should represent 5–10% of all cases. This audit reviewed cases over the past 25 years treated in one region. Of 89 patients with 113 slips, 21 hips were recorded as unstable. During this period the management has evolved from closed reduction and stabilization through pinning in situ, to open reduction. Radiographic outcomes following these three treatment methods were compared with record of any subsequent surgery in the form of osteotomy or total hip arthroplasty. Currently the lowest reported incidence of AVN in patients with an acute unstable slip is associated with the Parsch technique which combines open arthrotomy, digital reduction and screw fixation. Early outcomes with this technique are in accordance with those reported in the literature and represents a significant improvement in outcome when compared to earlier techniques used in the management of the severe unstable SUFE

Slipped capital femoral epiphysiolysis (SCFE) is a rare condition with a unknown aetiopathogenesis. An early diagnosis and treatment is essential to minimize premature degeneration of the joint. The authors reviewed the cases treated between 1980 and 2005 in our institution. This study was aimed at evaluating patients with hip epiphysiolysis surgically treated by canullated screws or pinning and previously controlled by short-term follow-up, in order to evaluate radiographic medium/ long term evolution, looking for evidence of degenerative arthritis or femoroacetabular impingement. We performed a retrospective review of the clinical notes and radiographs of all patients with slipped upper femoral epiphysis who were surgically treated at our institution between January 1980 and December 2005. These patients performed radiographs to detect evidence of osteonecrosis, chondrolysis, degenerative arthritis or femoroacetabular impingment. To grade the radiological osteoarthritic changes the grading system of Kellgren and Lawrence was used. These changes were correlated with the existence of femoroacetabular impingement. The radiological results were correlated with the Loder'sclassification of stability and the morphological classification. 43 patients were reviewed, corresponding to 47 treated hips. AP and Lowenstein x-ray views were taken in all patients. The alfa angle and the head-shaft angle were measured in the Lowenstein view (frog-leg). Of 16 patients with impingement only 1 patient didn't present pistol grip deformity. 4 contralateral hips also presented the deformity. The mean alfa angle was 99,4. 43% of the patients with unstable hips have impingment. In stable hips this percentage is of 35%. The Patrick test was positive in 30% of the hips with SCFE and only 17% of the unafected hips. The Kellgren and Lawrence scale was very diferent between trhe SCFE and control groups, with 43% grade 2, 17% grade 3 and 6% grade 4, versus 30% grade 2, 6% grade 3 and 0% grade 4. Some patients show bilateral pistol grip deformity and clinical signs of impingment, despite only having one hip with SCFE

Aims

Malreduction of the syndesmosis has been reported in up to 52% of patients after fixation of ankle fractures. Multiple radiological parameters are used to define malreduction; there has been limited investigation of the accuracy of these measurements in differentiating malreduction from inherent anatomical asymmetry. The purpose of this study was to identify the prevalence of positive malreduction standards within the syndesmosis of native, uninjured ankles.

Femoroacetabular impingement (FAI) is a pathologic condition of the hip that leads to osteoarthrosis. The goal of the surgical hip dislocation is to correct the bony malformations to prevent the progression of osteoarthrosis. We investigated the topographical cartilage thickness variation in patients with FAI and early stage osteoarthrosis using an ultrasonic probe during surgical hip dislocation. We performed a prospective case-series of 38 patients (41 hips) that underwent surgical hip dislocation. The mean age at operation was 30.6 (range, 18–48) years. Indication for surgery was symptomatic FAI with 4 hips (10%) with pincer-type, 7 hips (17%) with cam-type, and 20 hips (73%) with mixed-type of FAI. Cartilage thickness was measured intraoperatively using an A-mode 22 MHz ultrasonic probe at 8 locations on the acetabular cartilage. The thickest acetabular cartilage was found in the weight bearing zone (range 2.8–3.5mm), whereas the thinnest cartilage was in the posterior acetabular horn (1.0–2.2 mm). In all hips, cartilage was thicker in the periphery area compared to the central area. In the anterior and posterior acetabular horn, the anterior area, and the superior area (central parts) a significantly decreased cartilage thickness in pincer-type compared to cam-type of FAI was found (p<0.05). Cartilage thickness shows topographical differences in all types of FAI with pincer-type of FAI having generally thinner cartilage than cam-type FAI. This is the first study measuring in vivo cartilage thickness in the human hip

Introduction. Femoroacetabular impingement (FAI) is a relatively recent recognised condition and a potential cause of anterior hip pain in the young military adult population. Both Cam and Pincer type FAI may lead to inflammation, labral tears, and or damage to the smooth articular cartilage of the acetabulum leading potentially to early osteoarthritis of the hip. Open Surgical hip dislocation using the Ganz Trochanteric Flip approach is an accepted technique allowing osteoplasty of the femoral neck and acetabular rim combined with labral repair if required. We present our results of this technique used in military personnel. Methods. All Military personnel who underwent FAI surgery in our unit since August 2006 were included in the study. Functional outcome was measured using the Oxford hip and McCarthy non-arthritic hip scores pre and post-operatively. Results: 13 hips in 11 patients with an average age of 36 years (21–45) underwent surgical hip dislocation for treatment of FAI. Average time of downgrading prior to surgery was 9.3(3-18) months. 6 out of the 11 patients have been upgraded to P2. Average time to upgrading was 6.8(3-17) months. There were no infections, dislocations, or neurovascular complications. Mean Oxford Hip Score improved from 22.8(range 8–38) to 39.5(11–48) and mean McCarthy hip score from 49.6(33.75–80) to 79.2(36.25–100) with an average follow up of 19.4 months (range 4– 42 months). Discussion. The early results of surgical hip dislocation in military personnel are encouraging. Long-term follow-up is required to see if this technique prevents the natural progression to osteoarthritis

Background. Femoroacetabular impingement (FAI) may be a predisposing factor in progression of osteoarthritis. The use of hip arthroscopy is in its infancy with very few studies currently reported. Early reports show favourable results for treatment of young patients with FAI. This prospective study over a larger age spectrum represents a significant addition to this expanding field of minimally invasive surgery. Methods. Over a twenty-two month period all patients undergoing interventional hip arthroscopy were recorded on a prospective database. Patient demographics, diagnosis, operative intervention and complications were noted. Patients were scored pre-operatively and postoperatively at 6 months and 1 year using the McCarthy score. Results. 94 patients met the criteria for inclusion in this study. Median age was 39 (15–66) years with 57.4% female, 16 patients were over the age of 50 years. At operation, 50 patients had a labral tear, 70 had cam impingement and 62 had chondral damage, with 21 of these deemed severe (grade 3 or 4). For all patients a mean increase in the McCarthy score of 14.6 (p=<0.0001) was seen at 6 months and 19.1 (p=0.0002) at 1 year postoperatively. For those over 50 years, at 6 months an increase of 11.9 (p=0.08) was seen, improving to 33.8 (p=<0.0001) at 1 year. Eight patients underwent THR, of these, 2 were over 50 years of age. All of this group of patients had chondral damage (50% judged as severe at arthroscopy). At 6 months postoperatively these patients had severe pain and their mean score worsened by −16.3 (p=0.2). Few complications were seen, 7 patients had tight access (5 males), 3 of which received chondral scuffing and 1 had the procedure abandoned, 1 patient had groin labral bruising and 2 patients had transient parasthesia. Conclusions. Patients see a gradual and significant improvement post hip arthroscopy, with symptoms continuing to improve until 1 year. This is a well-tolerated procedure with a low complication rate and the opportunity for treatment of a range of hip pathology. Patients over the age of 50 gain a significant improvement from this procedure. Two groups of patients who gain no improvement are those with inflammatory arthropathy and those with dysplastic acetabulae

Cam type femoroacetabular impingement (FAI) is due to an aspheric femoral head, which is best quantified by the alpha angle described on MRI and CT-scan. Radiographic measurement of the alpha angle is not well codified and studies from the literature cannot conclude on the best view to measure it. Most authors also describe a mixed type FAI which associates an aspheric femoral head with an excessive anterior acetabular coverage of the femoral head. Anterior center edge (ACE) angle has been described on the false profile view to measure anterior acetabular coverage in hip dysplasia and has never been evaluated in FAI. In this study, we developed a new lateral hip view which associates a lateral view of the femoral neck and a false profile view of the acétabulum, which we called profile view in impingement position (PVIP). Twenty six patients operated for FAI had CT-scan, the PVIP and the false profile view of one or two hips according to pain. A control group of 19 patients who did not suffer from the hip had the PVIP. Alpha angles were measured twice on 17 CT scan of FAI patients by two observers and compared with the alpha angles measured on the corresponding hip PVIP by a correlation analysis. Alpha angles were measured twice on 45 PVIP in FAI patient and on 19 PVIP in the control group by three observers. ACE angles were measured once on 15 PVIP and on 15 false profile views. Means were compared by two tail paired t-tests, intra- and inter-observer reliability were measured by intraclass correlation coefficient. Mean alpha angle on CT scan was 65.8° and 65.6° for observers 1 and 2 respectively (p>0.05). It was 63.6° and 64.3° on the PVIP (p>0.05). No significant difference was found between CT scan and radiographic measurements, and Pearson's correlation coefficients were good at 0.74 and 0.8. ICC was 0.86 for inter-rater reliability, and 0.91 for intra-rater reliability for CT-scan alpha angle measures. ICC for PVIP measures varied from 0.82 to 0.9 for intra-rater reliability and from 0.6 to 0.9 for inter-rater reliability. Mean alpha angle measured on PVIP in FAI patients was 63.3° and was 44.9° in control subjects and the difference was significant (p<0.001) for the three observers. None of the FAI patients and 88% of the control subjects had an alpha angle < 50°. Mean ACE angle was 26.8° on PVIP and 32.8° on the false profile view, the difference was significant (p=0.015), and the Pearson's correlation coefficient was moderate (r=0.58). The PVIP is a reliable radiographic view to measure the alpha angle. It allows a good quantification of the alpha angle comparable to CT-scan measurements and permits to differentiate patients from control subjects. PVIP is not a good view to quantify anterior edge angle probably because of acetabular retroversion due to the hip flexion needed in this view. Mean ACE angle measured on the false profile view in FAI patient was comparable to ACE angle in general population reported in the literature

In the time since Letournel popularised the surgical treatment of acetabular fractures, more than 25 years ago, there have been many changes within the field, related to patients, surgical technique, implants and post-operative care. However, the long-term outcomes appear largely unchanged. Does this represent stasis or have the advances been mitigated by other negative factors? In this article we have attempted to document the recent changes within the surgery of patients with a fracture involving the acetabulum, outline contemporary management, and identify the major problem areas where further research is most needed.

Cite this article: Bone Joint J 2017;99-B:1125–31

Surgical dislocation of the hip in the treatment of acetabular fractures allows the femoral head to be safely displaced from the acetabulum. This permits full intra-articular acetabular and femoral inspection for the evaluation and potential treatment of cartilage lesions of the labrum and femoral head, reduction of the fracture under direct vision and avoidance of intra-articular penetration with hardware. We report 60 patients with selected types of acetabular fracture who were treated using this approach. Six were lost to follow-up and the remaining 54 were available for clinical and radiological review at a mean follow-up of 4.4 years (2 to 9).

Substantial damage to the intra-articular cartilage was found in the anteromedial portion of the femoral head and the posterosuperior aspect of the acetabulum. Labral lesions were predominantly seen in the posterior acetabular area. Anatomical reduction was achieved in 50 hips (93%) which was considerably higher than that seen in previous reports. There were no cases of avascular necrosis. Four patients subsequently required total hip replacement. Good or excellent results were achieved in 44 hips (81.5%). The cumulative eight-year survivorship was 89.0% (95% confidence interval 84.5 to 94.1). Significant predictors of poor outcome were involvement of the acetabular dome and lesions of the femoral cartilage greater than grade 2. The functional mid-term results were better than those of previous reports.

Surgical dislocation of the hip allows accurate reduction and a predictable mid-term outcome in the management of these difficult injuries without the risk of the development of avascular necrosis.