In many papers, the diagnosis of pincer-type femoroacetabular impingement (FAI) is attributed to the presence of coxa profunda. However, little is known about the prevalence of coxa profunda in the general population and its clinical relevance.

In order to ascertain its prevalence in asymptomatic subjects and whether it is a reliable indicator of pincer-type FAI, we undertook a cross-sectional study between July and December 2013. A total of 226 subjects (452 hips) were initially screened. According to strict inclusion criteria, 129 asymptomatic patients (257 hips) were included in the study. The coxa profunda sign, the crossover sign, the acetabular index (AI) and lateral centre–edge (LCE) angle were measured on the radiographs. The median age of the patients was 36.5 years (28 to 50) and 138 (53.7%) were women.

Coxa profunda was present in 199 hips (77.4%). There was a significantly increased prevalence of coxa profunda in women (p < 0.05) and a significant association between coxa profunda and female gender (p < 0.001) (92% vs 60.5%). The crossover sign was seen in 36 hips (14%), an LCE > 40° in 28 hips (10.9%) and an AI < 0º in 79 hips (30.7%). A total of 221 normal hips (79.2%) (normal considering the crossover) had coxa profunda, a total of 229 normal hips (75.5%) (normal considering the LCE) had coxa profunda and a total of 178 normal hips (75.3%) (normal considering AI) had coxa profunda.

When the presence of all radiological signs in the same subject was considered, pincer-type FAI was found in only two hips (one subject). We therefore consider that the coxa profunda sign should not be used as a radiological indicator of pincer-type FAI. We consider profunda to be a benign alteration in the morphology of the hip with low prevalence and a lack of association with other radiological markers of FAI. We suggest that the diagnosis of pincer-type FAI should be based on objective measures, in association with clinical findings.

Cite this article: Bone Joint J 2015; 97-B:478–83.

Aims. Periacetabular osteotomy (PAO) is widely recognized as a demanding surgical procedure for acetabular reorientation. Reports about the learning curve have primarily focused on complication rates during the initial learning phase. Therefore, our aim was to assess the PAO learning curve from an analytical perspective by determining the number of PAOs required for the duration of surgery to plateau and the accuracy to improve. Methods. The study included 118 consecutive PAOs in 106 patients. Of these, 28 were male (23.7%) and 90 were female (76.3%). The primary endpoint was surgical time. Secondary outcome measures included radiological parameters. Cumulative summation analysis was used to determine changes in surgical duration. A multivariate linear regression model was used to identify independent factors influencing surgical time. Results. The learning curve in this series was 26 PAOs in a period of six months. After 26 PAO procedures, a significant drop in surgical time was observed and a plateau was also achieved. The mean duration of surgery during the learning curve was 103.8 minutes (SD 33.2), and 69.7 minutes (SD 18.6) thereafter (p < 0.001). Radiological correction of acetabular retroversion showed a significant improvement after having performed a total of 93 PAOs, including anteverting PAOs on 35 hips with a retroverted acetabular morphology (p = 0.005). Several factors were identified as independent variables influencing duration of surgery, including patient weight (β = 0.5 (95% confidence interval (CI) 0.2 to 0.7); p < 0.001), learning curve procedure phase of 26 procedures (β = 34.0 (95% CI 24.3 to 43.8); p < 0.001), and the degree of lateral correction expressed as the change in the lateral centre-edge angle (β = 0.7 (95% CI 0.001 to 1.3); p = 0.048). Conclusion. The learning curve for PAO surgery requires extensive surgical training at a high-volume centre, with a minimum of 50 PAOs per surgeon per year. This study defined a cut-off value of 26 PAO procedures, after which a significant drop in surgical duration occurred. Furthermore, it was observed that a retroverted morphology of the acetabulum required a greater number of procedures to acquire proficiency in consistently eliminating the crossover sign. These findings are relevant for fellows and fellowship programme directors in establishing the extent of training required to impart competence in PAO. Cite this article: Bone Joint J 2024;106-B(4):336–343

Aims. Acetabular retroversion is a recognized cause of hip impingement and can be influenced by pelvic tilt (PT), which changes in different functional positions. Positional changes in PT have not previously been studied in patients with acetabular retroversion. Methods. Supine and standing anteroposterior (AP) pelvic radiographs were retrospectively analyzed in 69 patients treated for symptomatic acetabular retroversion. Measurements were made for acetabular index (AI), lateral centre-edge angle (LCEA), crossover index, ischial spine sign, and posterior wall sign. The change in the angle of PT was measured both by the sacro-femoral-pubic (SFP) angle and the pubic symphysis to sacroiliac (PS-SI) index. Results. In the supine position, the mean PT (by SFP) was 1.05° (SD 3.77°), which changed on standing to a PT of 8.64° (SD 5.34°). A significant increase in posterior PT from supine to standing of 7.59° (SD 4.5°; SFP angle) and 5.89° (SD 3.33°; PS-SI index) was calculated (p < 0.001). There was a good correlation in PT change between measurements using SFP angle and PS-SI index (0.901 in the preoperative group and 0.815 in the postoperative group). Signs of retroversion were significantly reduced in standing radiographs compared to supine: crossover index (0.16 (SD 0.16) vs 0.38 (SD 0.15); p < 0.001), crossover sign (19/28 hips vs 28/28 hips; p < 0.001), ischial spine sign (10/28 hips vs 26/28 hips; p < 0.001), and posterior wall sign (12/28 hips vs 24/28 hips; p < 0.001). Conclusion. Posterior PT increased from supine to standing in patients with symptomatic acetabular retroversion. The features of acetabular retroversion were less evident on standing radiographs. The low PT angle in the supine position is a factor in the increased appearance of acetabular retroversion. Patients presenting with symptoms of hip impingement should be assessed by supine and standing pelvic radiographs to highlight signs of acetabular retroversion, and to assist with optimizing acetabular correction at the time of surgery. Cite this article: Bone Joint J 2022;104-B(7):786–791

Aims. Periacetabular osteotomy (PAO) is an established treatment for acetabular dysplasia. It has also been proposed as a treatment for patients with acetabular retroversion. By reviewing a large cohort, we aimed to test whether outcome is equivalent for both types of morphology and identify factors that influenced outcome. Methods. A single-centre, retrospective cohort study was performed on patients with acetabular retroversion treated with PAO (n = 62 hips). Acetabular retroversion was diagnosed clinically and radiologically (presence of a crossover sign, posterior wall sign, lateral centre-edge angle (LCEA) between 20° and 35°). Outcomes were compared with a control group of patients undergoing PAO for dysplasia (LCEA < 20°; n = 86 hips). Femoral version was recorded. Patient-reported outcome measures (PROMs), complications, and reoperation rates were measured. Results. The mean Non-Arthritic Hip Score (NAHS) preoperatively was 58.6 (SD 16.1) for the dysplastic hips and 52.5 (SD 12.7) for the retroverted hips (p = 0.145). Postoperatively, mean NAHS was 83.0 (SD 16.9) and 76.7 (SD 17.9) for dysplastic and retroverted hips respectively (p = 0.041). Difference between pre- and postoperative NAHS was slightly lower in the retroverted hips (18.3 (SD 22.1)) compared to the dysplastic hips (25.2 (SD 15.2); p = 0.230). At mean 3.5 years’ follow-up (SD 1.9), one hip needed a revision PAO and no hips were converted to total hip arthroplasty (THA) in the retroversion group. In the control group, six hips (7.0%) were revised to THA. No differences in complications (p = 0.106) or in reoperation rate (p = 0.087) were seen. Negative predictors of outcome for patients undergoing surgery for retroversion were female sex, obesity, hypermobility, and severely decreased femoral anteversion. Conclusion. A PAO is an effective surgical intervention for acetabular retroversion and produces similar improvements when used to treat dysplasia. Femoral version should be routinely assessed in these patients and when extremely low (< 0°), as an additional procedure to address this abnormality may be necessary. Females with signs of hypermobility should also be consulted of the likely guarded improvement. Cite this article: Bone Jt Open 2021;2(9):757–764

Acetabular retroversion (ARV) is a cause of femoroacetabular impingement leading to hip pain and reduced range of motion. We aimed to describe the radiological criteria used for diagnosing ARV in the literature and report on the outcomes of periacetabular osteotomy (PAO) and hip arthroscopy (HA) in its management. A systematic review using PRISMA guidelines was conducted on the MEDLINE, CINAHL, EMBASE, COCHRANE database in December 2022. English-language studies reporting outcomes of PAO, or open or arthroscopic interventions for ARV were included. From an initial 4203 studies, 21 non-randomised studies met the inclusion criteria. Eleven studies evaluated HA for ARV, with average follow-up ranging from 1 to 5 years, for a cumulative number of 996 patients. Only 3/11 studies identified ARV using AP standardized pelvic radiographs. The most frequent signs describing ARV identified were: Ischial Spine Sign (98% of patients), Posterior Wall Sign (PWS, 94%) and Crossover Sign (COS, 64%); with mean Acetabular Retroversion Index (ARI) ranging from 33% to 35%. 39% of HA patients had all three radiographic signs. Clinically significant outcomes were reached by 33–78% of patients. Eight studies evaluated PAO for ARV, with a follow-up ranging from 2 to 10 years, for a cumulative number of 379 patients. Five of the eight studies identified ARV using standardized radiographs. ISS, COS and PWS were positive in 54%, 97% and 81% of patients, respectively with 52% of PAO patients having all three radiographic signs. Mean ARI ranged from 36–41%. Clinically significant results were reported in 71%–78% of patients. The diagnostic criteria for ARV is poorly defined in the literature, and the quality of evidence is low. Studies on HA are more likely to have used lenient diagnostic criteria. It remains difficult to recommend which cases maybe more suitable for treatment by HA rather than PAO

Aims. What represents clinically significant acetabular undercoverage in patients with symptomatic cam-type femoroacetabular impingement (FAI) remains controversial. The aim of this study was to examine the influence of the degree of acetabular coverage on the functional outcome of patients treated arthroscopically for cam-type FAI. Patients and Methods. Between October 2005 and June 2016, 88 patients (97 hips) underwent arthroscopic cam resection and concomitant labral debridement and/or refixation. There were 57 male and 31 female patients with a mean age of 31.0 years (17.0 to 48.5) and a mean body mass index (BMI) of 25.4 kg/m. 2. (18.9 to 34.9). We used the Hip2Norm, an object-oriented-platform program, to perform 3D analysis of hip joint morphology using 2D anteroposterior pelvic radiographs. The lateral centre-edge angle, anterior coverage, posterior coverage, total femoral coverage, and alpha angle were measured for each hip. The presence or absence of crossover sign, posterior wall sign, and the value of acetabular retroversion index were identified automatically by Hip2Norm. Patient-reported outcome scores were collected preoperatively and at final follow-up with the Hip Disability and Osteoarthritis Outcome Score (HOOS). Results. At a mean follow-up of 2.7 years (1 to 8, . sd. 1.6), all functional outcome scores significantly improved overall. Radiographically, only preoperative anterior coverage had a negative correlation with the improvement of the HOOS symptom subscale (r = -0.28, p = 0.005). No significant difference in relative change in HOOS subscale scores was found according to the presence or absence of radiographic signs of retroversion. Discussion. Our study demonstrated the anterior coverage as an important modifier influencing the functional outcome of arthroscopically treated cam-type FAI. Cite this article: Bone Joint J 2018;100-B:831–8

Acetabular retroversion is a recognised cause of hip impingement. Pelvic tilt influences acetabular orientation and is known to change in different functional positions. While previously reported in patients with developmental dysplasia of the hip, positional changes in pelvic tilt have not been studied in patients with acetabular retroversion. We retrospectively analysed supine and standing AP pelvic radiographs in 22 patients with preoperative radiographs and 47 with post-operative radiographs treated for symptomatic acetabular retroversion. Measurements were made for acetabular index (AI), lateral centre-edge angle (LCEA), crossover index, ischial spine sign, and posterior wall sign. The change in pelvic tilt angle was measured both by the Sacro-Femoral-Pubic (SFP) angle and the Pubic Symphysis to Sacro-iliac (PS-SI) Index. In the supine position, the mean calculated pelvic tilt angle (by SFP) was 1.05° which changed on standing to a pelvic tilt of 8.64°. A significant increase in posterior pelvic tilt angle from supine to standing of 7.59° (SFP angle) and 5.89° (PS –SI index) was calculated (p<0.001;paired t-test). There was a good correlation in pelvic tilt change between measurements using SFP angle and PS-SI index (rho .901 in pre-op group, rho .815 in post-op group). Signs of retroversion were significantly reduced in standing x-rays compared to supine: Crossover index (0.16 vs 0.38; p<0.001) crossover sign (19/28 vs 28/28 hips; p<0.001), ischial spine sign (10/28 hips vs 26/28 hips; p<0.001) and posterior wall sign (12/28 vs 24/28 hips; p<0.001). Posterior pelvic tilt increased from supine to standing in patients with symptomatic acetabular retroversion, in keeping with previous studies of pelvic tilt change in patients with hip dysplasia. The features of acetabular retroversion were much less evident on standing radiographs. The low pelvic tilt angle in the supine position is implicated in the appearance of acetabular retroversion in the supine position. Patients presenting with symptoms of hip impingement should be assessed by supine and standing pelvic radiographs so as not to miss signs of retroversion and to assist with optimising acetabular correction at the time of surgery

Acetabular retroversion is a recognised cause of hip impingement. Pelvic tilt influences acetabular orientation and is known to change in different functional positions. While previously reported in patients with developmental dysplasia of the hip, positional changes in pelvic tilt have not been studied in patients with acetabular retroversion. We retrospectively analysed supine and standing AP pelvic radiographs in 22 patients with preoperative radiographs and 47 with post-operative radiographs treated for symptomatic acetabular retroversion. Measurements were made for acetabular index (AI), lateral centre-edge angle (LCEA), crossover index, ischial spine sign, and posterior wall sign. The change in pelvic tilt angle was measured both by the Sacro-Femoral-Pubic (SFP) angle and the Pubic Symphysis to Sacro-iliac (PS-SI) Index. In the supine position, the mean calculated pelvic tilt angle (by SFP) was 1.05° which changed on standing to a pelvic tilt of 8.64°. A significant increase in posterior pelvic tilt angle from supine to standing of 7.59° (SFP angle) and 5.89° (PS –SI index) was calculated (p<0.001;paired t-test). The mean pelvic tilt change of 6.51° measured on post-operative Xrays was not significantly different (p=.650). There was a good correlation in pelvic tilt change between measurements using SFP angle and PS-SI index (rho .901 in pre-op group, rho .815 in post-op group). Signs of retroversion were significantly reduced in standing x-rays compared to supine: Crossover index (0.16 vs 0.38; p<0.001) crossover sign (19/28 vs 28/28 hips; p<0.001), ischial spine sign (10/28 hips vs 26/28 hips; p<0.001) and posterior wall sign (12/28 vs 24/28 hips; p<0.001). Posterior pelvic tilt increased from supine to standing in patients with symptomatic acetabular retroversion, in keeping with previous studies of pelvic tilt change in patients with hip dysplasia. The features of acetabular retroversion were much less evident on standing radiographs. The low pelvic tilt angle in the supine position is implicated in the appearance of acetabular retroversion in the supine position. Patients presenting with symptoms of hip impingement should be assessed by supine and standing pelvic radiographs so as not to miss signs of retroversion and to assist with optimising acetabular correction at the time of surgery

The purpose of this study was to examine a cohort of patients with minor acetabular dysplasia features in order to identify the preoperative clinical characteristics and imaging findings that differentiate patients with hip instability from patients with impingement. A retrospective cohort study of patients with borderline acetabular dysplasia was performed. All patients were identified by prospective radiographic evaluation with an LCEA between 20° and 25°. Multivariate statistical analyses were used to identify independent predictors of disease type. Of the 143 hips in the cohort, 39.2% (n=56) had the diagnosis of instability, while 60.8% (n=87) had the diagnosis of impingement. The cohort included 109 females (76.2%) and 34 males (23.8%). Hips with instability had a lower LCEA (21.8° vs. 22.8°; p<0.001), lower ACEA (23.3° vs. 26.6°; p=0.002), a higher AI (11.8° vs. 8.5°; p<0.001), and a lower maximum alpha angle (54.4° vs. 61.1°; p=0.001). The odds of instability increased 1.7 times for each one-degree decrease in LCEA, 1.4 times for each one-degree decrease in ACEA, and 1.1 times for each one-degree increase in acetabular inclination (all p0.003). Female sex was strongly associated with instability. The instability subgroup had greater range of motion (IRF, 22.7° vs. 12.4°, p<0.001) and total arc of motion (IRF+ERF, 61.2° vs. 47.4°, p<0.001). We identified predictors of diagnosis including: acetabular inclination (1.49, p<0.001), ACEA (0.89, p=0.007), crossover sign (0.27, p=0.014), preoperative mHHS (0.96, p=0.014), IRF (1.10, p=0.001), and age (0.88, p=0.001). Patients with symptomatic instability tend to have increased acetabular inclination, decreased ACEA, greater functional limitations, younger, greater IRF, while hips with impingement demonstrate the opposite trends

Aims. Femoroacetabular impingement (FAI) has been highlighted and well documented primarily in Western countries and there are few large studies focused on FAI-related morphological assessment in Asian patients. We chose to investigate this subject. Patients and Methods. We assessed the morphology of the hip and the prevalence of radiographic FAI in Japanese patients by measuring predictors of FAI. We reviewed a total of 1178 hips in 695 men and 483 women with a mean age of 58.2 years (20 to 89) using CT images that had been obtained for reasons unrelated to symptoms from the hip. We measured the lateral centre edge angle, acetabular index, crossover sign, alpha angle and anterior femoral head-neck offset ratio. Results. A total of 441 hips (37.4%) had pincer-type deformity (41.7% men, 31.3% women) and 534 (45.3%) had cam-type deformity (54.4% men, 32.3% women). Moreover, 773 hips (65.6%) had at least one parameter that predisposes to FAI (74.0% men, 53.6% women) and 424 hips (36.0%) had two or more parameters (43.6% men, 25.0% women). Conclusion. The prevalence of radiographic FAI was common in Japanese patients who are generally considered to have dysplastic hips. Cite this article: Bone Joint J 2016;98-B:1167–74

Aims

Hip arthroscopy has gained prominence as a primary surgical intervention for symptomatic femoroacetabular impingement (FAI). This study aimed to identify radiological features, and their combinations, that predict the outcome of hip arthroscopy for FAI.

Aims

The aim of this study was to determine the clinical outcomes and factors contributing to failure of transposition osteotomy of the acetabulum (TOA), a type of spherical periacetabular osteotomy, for advanced osteoarthritis secondary to hip dysplasia.

Aims

The aim of this study is to evaluate whether acetabular retroversion (AR) represents a structural anatomical abnormality of the pelvis or is a functional phenomenon of pelvic positioning in the sagittal plane, and to what extent the changes that result from patient-specific functional position affect the extent of AR.

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?

Aims

Psychological status may be an important predictor of outcome after periacetabular osteotomy (PAO). The aim of this study was to investigate the influence of psychological distress on postoperative health-related quality of life, joint function, self-assessed pain, and sports ability in patients undergoing PAO.

Aims

Femoroacetabular impingement (FAI) patients report exacerbation of hip pain in deep flexion. However, the exact impingement location in deep flexion is unknown. The aim was to investigate impingement-free maximal flexion, impingement location, and if cam deformity causes hip impingement in flexion in FAI patients.

Aims

The primary aim of this study was to determine the ten-year outcome following surgical treatment for femoroacetabular impingement (FAI). We assessed whether the evolution of practice from open to arthroscopic techniques influenced outcomes and tested whether any patient, radiological, or surgical factors were associated with outcome.

Aims

Cam and pincer morphologies are potential precursors to hip osteoarthritis and important contributors to non-arthritic hip pain. However, only some hips with these pathomorphologies develop symptoms and joint degeneration, and it is not clear why. Anterior impingement between the femoral head-neck contour and acetabular rim in positions of hip flexion combined with rotation is a proposed pathomechanism in these hips, but this has not been studied in active postures. Our aim was to assess the anterior impingement pathomechanism in both active and passive postures with high hip flexion that are thought to provoke impingement.

Aims

Some patients presenting with hip pain and instability and underlying acetabular dysplasia (AD) do not experience resolution of symptoms after surgical management. Hip-spine syndrome is a possible underlying cause. We hypothesized that there is a higher frequency of radiological spine anomalies in patients with AD. We also assessed the relationship between radiological severity of AD and frequency of spine anomalies.

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.