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This case report describes the evaluation, surgical intervention, and postoperative outcome of a 36-year-old male patient with chronic left hip pain following a rectus femoris injury which persisted despite conservative management and intra-articular steroid injection. Imaging revealed prominent ossification extending from the anterior inferior iliac spine at the proximal rectus femoris insertional, a femoral cam lesion, and tearing of the superior through anterior labrum, compatible with both subspine and femoroacetabular impingement. Subsequent arthroscopic femoroplasty, acetabuloplasty, labral repair, and excision of rectus femoris ossification provided lasting symptomatic relief. Identification of lesions resulting in subspine impingement is essential in the preoperative work up of patients with hip pain to ensure appropriate surgical management and optimize postoperative outcomes.
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AIMS: Femoroacetabular impingement (FAI) patients report exacerbation of hip pain in deep flexion. However, the exact impingement location in deep flexion is unknown. The aim was to investigate impingement-free maximal flexion, impingement location, and if cam deformity causes hip impingement in flexion in FAI patients. METHODS: A retrospective study involving 24 patients (37 hips) with FAI and femoral retroversion (femoral version (FV) < 5° per Murphy method) was performed. All patients were symptomatic (mean age 28 years (SD 9)) and had anterior hip/groin pain and a positive anterior impingement test. Cam- and pincer-type subgroups were analyzed. Patients were compared to an asymptomatic control group (26 hips). All patients underwent pelvic CT scans to generate personalized CT-based 3D models and validated software for patient-specific impingement simulation (equidistant method). RESULTS: Mean impingement-free flexion of patients with mixed-type FAI (110° (SD 8°)) and patients with pincer-type FAI (112° (SD 8°)) was significantly (p < 0.001) lower compared to the control group (125° (SD 13°)). The frequency of extra-articular subspine impingement was significantly (p < 0.001) increased in patients with pincer-type FAI (57%) compared to cam-type FAI (22%) in 125° flexion. Bony impingement in maximal flexion was located anterior-inferior at femoral four and five o'clock position in patients with cam-type FAI (63% (10 of 16 hips) and 37% (6 of 10 hips)), and did not involve the cam deformity. The cam deformity did not cause impingement in maximal flexion. CONCLUSION: Femoral impingement in maximal flexion was located anterior-inferior distal to the cam deformity. This differs to previous studies, a finding which could be important for FAI patients in order to avoid exacerbation of hip pain in deep flexion (e.g. during squats) and for hip arthroscopy (hip-preservation surgery) for planning of bone resection. Hip impingement in flexion has implications for daily activities (e.g. putting on shoes), sports, and sex.Cite this article: Bone Joint Res 2023;12(1):22-32.
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PURPOSE: The purpose of this multicenter, multinational study is to evaluate the agreement level of the Hetsroni's classification system across high-volume hip surgeons who specialize in hip preservation surgeries. METHODS: Four surgeons from three countries reviewed a digital survey that included 93 3D CT images of the hip from 53 patients. The population was composed of individuals who had undergone a pelvis CT scan in a tertiary hospital between 2000 and 2016. Each rater reviewed the images and classified each image according to AIIS subtype I, II, or III. After a minimum of two months, the raters repeated the survey. The inter-rater and intra-rater agreement was then assessed. The kappa values were calculated to determine variability. RESULTS: Inter-rater agreement levels yielded fair agreement for both sessions (Kappa = 0.4, p value < 0.001 in the first and Kappa = 0.27, p value < 0.001 in the second). Inter-rater agreement levels separating non-pathological Type I from pathological Types II and III yielded moderate to fair inter-rater agreement levels (K = 0.47, p value < 0.001 in the first session and k = 0.32, p value < 0.001 in the second). Intra-rater reliability displayed moderate agreement (average K = 0.53). CONCLUSION: The current 3D CT-based AIIS classification system shows fair-to-moderate inter- and intra-rater agreement among high-volume hip surgeons. According to this study, the agreement of the Hetsroni classification system is not able to be sufficiently reproduced. Since accurate classification of the AIIS morphology is imperative in establishing proper treatment for SSI, this classification system there is therefore limited in its clinical value. LEVEL OF EVIDENCE: III.
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Ílio , Cirurgiões , Humanos , Reprodutibilidade dos Testes , Variações Dependentes do Observador , Ílio/diagnóstico por imagem , Ílio/patologia , Tomografia Computadorizada por Raios X/métodosRESUMO
BACKGROUND: Subspine impingement (SSI) does not have effective diagnostic criteria, especially in patients who also have femoroacetabular impingement (FAI). The classification of anterior inferior iliac spine (AIIS) morphology via three-dimensional CT is controversial. PURPOSE: To propose a method for ultrasound-guided AIIS injection as a way to diagnose SSI and evaluate the accuracy of radiography methods, including 3-D CT and MRI, as well as intraoperative findings. METHODS: Patients diagnosed with FAI between September 2020 and December 2021 were evaluated in this prospective study. Those who met the criteria were included in the ultrasound-guided AIIS injection test. Whether the pain was relieved after injection was recorded in the radiology report. Patients who experienced significant relief of the anterior groin pain (more than 50%) after the AIIS injection were considered positive responders. Among these patients, radiography materials, including AIIS morphology as measured by 3-D CT as well as superior capsular oedema on MRI, were compared. The presence of congestion or bruising on the capsule side of the labrum corresponding to the AIIS during hip arthroscopy was recorded. RESULTS: A total of 73 patients with FAI underwent the ultrasound-guided AIIS injection test. Prevalence rates of 13.70% (10/73), 58.90% (43/73), 23.29% (17/73) and 4.11% (3/73) were recorded for Type I, Type IIA, Type IIB and Type III AIISs, respectively. Thirty-six patients had positive responses to injection, and 37 patients had negative responses to injection. None of the patients with Type I, 23 (53.49%) patients with Type IIA, 11 (64.71%) patients with Type IIB and 2 (66.7%) patients with Type III AIISs had positive responses to the injection. A total of 57.14% of patients with Type II or Type III AIIS had positive responses to the injection. The proportions of patients with superior capsular oedema on MRI in the Type I, Type IIA, Type IIB, and Type III AIIS groups was 0, 30.23, 29.41 and 0%, respectively. Among non-Type I AIIS patients, those who reported positive responses to the injection had a higher incidence of superior capsular oedema (38.89% vs. 14.81%, P = 0.036), but they had no significant differences in the proportion of congestion or bruising of the labrum (47.22% vs. 37.04%, P = 0.419). The results showed that no pairs of methods-ultrasound-guided injection, MRI, and intraoperative findings-achieved good consistency (κ = 0.222, κ = 0.098 and κ = - 0.116). CONCLUSIONS: Radiographic methods including 3-D CT and MRI as well as the intraoperative findings of the labrum cannot be considered an accurate and reliable basis for the diagnosis and treatment of SSI in FAI patients. It is suggested that ultrasound-guided AIIS injections be combined with radiography to better diagnose SSI. LEVEL OF EVIDENCE: IV, case series.
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Impacto Femoroacetabular , Humanos , Estudos Prospectivos , Estudos Retrospectivos , Impacto Femoroacetabular/cirurgia , Radiografia , Artroscopia/métodos , Dor , Articulação do Quadril/cirurgiaRESUMO
Background: Subspine impingement, or anterior inferior iliac spine (AIIS) impingement, is a type of extra-articular pathology associated with femoroacetabular impingement syndrome and often requires subsequent arthroscopic surgery. Purpose: To examine the diagnostic accuracy, prevalence, and clinical outcomes of arthroscopic treatment for AIIS impingement. Study Design: Systematic review; Level of evidence, 4. Methods: The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 checklist was applied. We searched for studies on the prevalence, diagnostic accuracy, and results of surgical treatment for AIIS impingement. For each included study, data synthesis and statistical analysis were performed to identify pooled prevalence, calculate clinical outcome scores, and estimate adverse events. The QUADAS (a quality assessment tool for diagnostic accuracy studies) was used to assess the quality of the diagnostic accuracy studies, and the Risk of Bias Assessment tool for Nonrandomized Studies was used to assess the quality of the studies on arthroscopic treatment efficacy. Results: Out of an initial 791 studies, 23 were included. AIIS impingement was diagnosed by plain radiography with 76% to 86% sensitivity, 3-dimensional computed tomography with 80% to 81.8% sensitivity, magnetic resonance imaging with 80% sensitivity, and ultrasound with 92.5% sensitivity. For patients who underwent hip arthroscopy, the pooled prevalence of AIIS impingement was 18%. Significant improvement between pre- and postoperative clinical outcomes was observed: 25.75 points for the modified Harris hip score (mHHS), 46.88 points for the Hip Outcome Score-Sport subscale, 20.85 points for the Nonarthritic Hip Score, and -2.92 points for the pain visual analog scale. The minimal clinically important difference on the mHHS was exceeded by 94% of patients. The pooled incidence of surgical complications was 1%. Of 6 included studies on diagnostic accuracy, 2 were identified as having a low risk of bias, and 4 included >2 factors with a high risk of bias. All 9 included studies on treatment outcomes had at least 1 factor with a high risk of bias. Conclusion: Several imaging modalities assist in the diagnosis of AIIS impingement. The overall prevalence of AIIS impingement in patients that underwent hip arthroscopy was 18%. Clinical outcomes after arthroscopic AIIS decompression were generally favorable, with a relatively low rate of surgical complications.
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BACKGROUND: Subspine impingement is considered a source of residual hip symptoms after primary hip arthroscopy, and the role of the subspine space and soft tissue is not clear. The purpose of this study was to analyze the relationship between the subspine space and labrum size in subspine impingement patients. METHODS: We performed a retrospective study of patients with femoroacetabular impingement between July 2016 and July 2020. Sixteen patients without hip symptom relief after primary hip arthroscopic treatment of femoroacetabular impingement and undergoing revision surgery for anterior inferior iliac spine compression were included as the study group. Forty-eight matched patients who underwent only primary surgery and whose hip discomfort was relieved without a diagnosis of subspine impingement were included as the control group. The patients' preoperative computerized tomography data were reviewed, and the anterior inferior iliac spine dimensions and the size of the subspine space were measured. The size of the labrum at the 11:30, 1:30, and 3 o'clock positions was measured with the use of magnetic resonance imaging. The ratio of the subspine space to the labrum was also calculated. RESULTS: There was no significant difference in anterior inferior iliac spine dimensions between these two groups (p > 0.05). A relatively narrow subspine space was found in the study group, especially in the direction of the anterior inferior iliac spine. Compared with the control group, subspine impingement patients were identified with larger labrums at 11:30 (8.20 ± 1.95 mm vs. 6.81 ± 0.50 mm, p = 0.016), 1:30 (7.83 ± 1.61 mm and 6.25 ± 0.78 mm, p = 0.001) and 3:00 (9.50 ± 1.73 mm vs. 7.48 ± 0.99 mm, p = 0.001). A relative mismatch between the subspine space and the labrum was also identified in the study group. The ratios of the labrum width to the subspine area were significantly larger in the study group than in the control group. CONCLUSION: This study reported potential additional criteria for subspine impingement-a large labrum and a relatively narrow subspine space-instead of abnormal anterior inferior iliac spine dimensions. For those with a large labrum and narrow subspine space, the diagnosis of subspine impingement should be carefully made, and arthroscopic anterior inferior iliac spine decompression may be important.
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Impacto Femoroacetabular , Humanos , Impacto Femoroacetabular/diagnóstico por imagem , Impacto Femoroacetabular/cirurgia , Estudos de Casos e Controles , Estudos Retrospectivos , Artroscopia/métodos , Ílio/cirurgiaRESUMO
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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Impacto Femoroacetabular , Estudos Transversais , Impacto Femoroacetabular/diagnóstico por imagem , Impacto Femoroacetabular/cirurgia , Articulação do Quadril/diagnóstico por imagem , Articulação do Quadril/cirurgia , Humanos , Dor , Estudos RetrospectivosRESUMO
BACKGROUND: Patient-reported outcomes (PROs) and return to sports (RTS) have not been established in athletes undergoing primary hip arthroscopy and subspine decompression for femoroacetabular impingement syndrome (FAIS) and subspine impingement (SSI). PURPOSE: (1) To report minimum 2-year PROs and RTS in competitive athletes undergoing primary hip arthroscopy for treatment of FAIS with subspine decompression for treatment of SSI and (2) to compare clinical results with a matched control group of athletes without SSI. STUDY DESIGN: Cohort study, Level of evidence, 3. METHODS: Data were reviewed for professional, collegiate, and high school athletes undergoing primary hip arthroscopy for FAIS with arthroscopic subspine decompression for SSI between February 2011 and October 2018. Inclusion criteria included preoperative and minimum 2-year follow-up scores for the modified Harris Hip Score, Nonarthritic Hip Score, Hip Outcome Score-Sport Specific Subscale, and visual analog scale for pain. Rates of achieving the minimal clinically important difference (MCID) were also calculated. For comparison, athletes in the SSI group were propensity matched according to age at the time of surgery, sex, body mass index, lateral center-edge angle, alpha angle, sport level, acetabular labrum articular disruption grade, and sport type to a control group of athletes without SSI. RESULTS: A total of 30 SSI athletes were included in the study, with a mean plus or minus standard deviation follow-up of 32.1 ± 7.1 months and age of 20.9 ± 5.7 years. The SSI cohort demonstrated significant improvement in all recorded PROs (P < .001), returned to sports at high rates (88.5%), and achieved the MCID for the Hip Outcome Score-Sport Specific Subscale at a high rate (80.0%). Furthermore, these patients had a low rate of undergoing revision surgery (6.7%). When compared with a propensity-matched control group of 59 athletes, the SSI group demonstrated similar rates of RTS, revision, and achieving the MCID for all PROs. CONCLUSION: Competitive athletes with FAIS and SSI who underwent primary hip arthroscopy and subspine decompression had favorable outcomes and high RTS rates at minimum 2-year follow-up. These results were comparable with those of a control group of athletes without SSI undergoing primary hip arthroscopy.
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Impacto Femoroacetabular , Adolescente , Adulto , Artroscopia , Atletas , Estudos de Coortes , Descompressão , Impacto Femoroacetabular/cirurgia , Seguimentos , Articulação do Quadril/cirurgia , Humanos , Estudos Retrospectivos , Volta ao Esporte , Resultado do Tratamento , Adulto JovemRESUMO
PURPOSE: To systematically review the evaluation, management, and surgical outcomes of arthroscopic subspine decompression in conjunction with other intra-articular hip preservation procedures. METHODS: Two databases (PubMed and Embase) were searched from 2010 to 2021, in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, for articles investigating arthroscopic subspine decompression using the key words: "subspine impingement", "AIIS impingement", and "extra-articular impingement." Exclusion criteria included diagnostic studies, failure to report postoperative outcomes, and case series of less than 10 hips. Studies were assessed for patient demographics, diagnostic criteria, clinical findings, concomitant procedures, outcomes, and postoperative complications. The quality of the studies was analyzed by 2 independent reviewers (A.J.C. and A.E.J.) using the Methodological Index for Non-randomized Studies (MINORS). RESULTS: Ten studies consisting of 438 patients (460 hips, 48.6% female) met the inclusion criteria, with average ages and follow-up ranging from 24.9 to 34.7 years and 6.0 to 44.4 months, respectively. There was 1 Level II study, 3 Level III studies, and 6 Level IV studies. The MINORS criteria yielded an average quality assessment of 13.0 (range: 7-22), with 3 methodological domains demonstrating mean scores of less than 1: unbiased assessment of the study endpoint (.25), loss of follow up less than 5% (.25), and prospective calculation of the study size (.7). The most common exam maneuver used was the subspine impingement test (9 studies). Most subspine decompressions were performed in addition to traditional femoroacetabular impingement syndrome (FAIS) procedures, with only one study (33 hips) reporting solely on isolated subspine osteoplasty. Average preoperative and postoperative modified Harris Hip Score (mHHS) values ranged from 44.93 to 75.7 and 79.5 to 98.0, respectively. Three studies noted improved hip flexion in the postoperative period. Five surgical complications were reported. CONCLUSIONS: Arthroscopic subspine decompression is commonly reported in a heterogenous patient population with intra-articular hip pathology. A combination of the subspine impingement test and anterior inferior iliac spine (AIIS) morphology on imaging is frequently used for diagnosis. While improved patient-reported outcomes (PROs) are consistently observed following arthroscopic decompression, conclusions are limited by study methodology and concurrent procedures performed at the time of surgery. LEVEL OF EVIDENCE: IV, systematic review of Level II through Level IV studies.
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Impacto Femoroacetabular , Articulação do Quadril , Artroscopia/métodos , Descompressão/efeitos adversos , Feminino , Impacto Femoroacetabular/cirurgia , Articulação do Quadril/cirurgia , Humanos , Masculino , Estudos Prospectivos , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: Subspine impingement (SSI) has been commonly managed with arthroscopic decompression. However, arthroscopic decompression is a demanding technique, as under- or over-resection of the anterior inferior iliac spine (AIIS) could lead to inferior outcomes. An anterior mini-open approach has also been used in the management of femoroacetabular impingement (FAI), and it could provide adequate visualization of the anterior hip joint without a long learning curve. PURPOSE/HYPOTHESIS: The objective of the current study was to compare the outcomes of SSI patients with FAI who underwent arthroscopic subspine decompression and osteoplasty with a group undergoing subspine decompression and osteoplasty using a modified direct anterior mini-open approach. It was hypothesized that there would be no significant difference in outcomes between the groups. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: We reviewed the records of SSI patients who underwent decompression surgery (arthroscopic or mini-open) at our institution from June 1, 2015 to December 31, 2016. Both groups underwent the same postoperative rehabilitation protocol. Preoperative and 2-year postoperative patient-reported outcomes were compared using the modified Harris Hip Score (mHHS), International Hip Outcome Tool-33 (iHOT-33), and Hip Outcome Score-Activities of Daily Living (HOS-ADL). Major and minor complications as well as reoperation rates were recorded. RESULTS: Included were 47 patients (49 hips) who underwent subspine decompression using an anterior mini-open approach and 35 patients (35 hips) who underwent arthroscopic subspine decompression. There were no differences in demographic and radiological parameters between the groups, and patients in both groups showed significant improvement in all outcome scores at follow-up. The pre- to postoperative improvement in outcome scores was also similar between groups (mini-open vs arthroscopy: mHHS, 26.30 vs 27.04 [P = .783]; iHOT-33, 35.76 vs 31.77 [P = .064]; HOS-ADL, 26.09 vs 22.77 [P = .146]). In the mini-open group, 10 of the 47 patients had temporary meralgia paresthetica, and fat liquefaction was found in 1 female patient. There were no reoperations in the mini-open group. CONCLUSION: Subspine decompression using the anterior mini-open approach had similar outcomes to arthroscopic decompression in the management of SSI. The lateral femoral cutaneous nerve should be protected carefully during use of the anterior mini-open approach.
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OBJECTIVE: To compare the difference of anterior inferior iliac spine (AIIS) and subspine hypertrophic deformity between symptomatic and asymptomatic hips in patients traditionally diagnosed with femoroacetabular impingement (FAI), and investigate the correlation of subspine decompression with AIIS variation and subspine hypertrophic deformity. METHODS: We retrospectively reviewed 70 patients with unilateral symptomatic FAI who underwent hip arthroscopy. The operative hips and contralateral hips naturally formed the symptomatic groups and asymptomatic control groups, respectively. The morphometric comparison of the hip joint was performed between the operative and contralateral sides of each patient. Radiological assessment was performed by two observers (an experienced musculoskeletal radiologist and an experienced surgeon). Three-dimensional (3D)-CT images of each patient were blindly reviewed to determine the AIIS variation and subspine hypertrophic deformity. Reformatted two-dimensional (2D)-CT images and anterior-posterior (AP) pelvic plain radiographs were blindly reviewed to determine FAI-related morphological measurements. Moreover, the surgical assessment was reviewed by one experienced surgeon to interpret whether subspine decompression was performed. The correlation of subspine decompression with AIIS variation and subspine hypertrophy was analyzed. RESULTS: Out of 70 patients with unilateral symptomatic FAI, 37 were males (52.9%) and 23 (32.9%) had symptoms involving the left hip. The mean age was 39.3 ± 10.4 years and the mean BMI was 24.3 ± 3.6. The distribution of AIIS variants in symptomatic hips did not differ significantly from that in asymptomatic hips (χ2 = 3.092, P = 0.213). Twenty-nine hips in the symptomatic group (41.4%) and 12 hips in the asymptomatic group (17.1%) were identified as positive for subspine hypertrophy. The incidence of positive subspine hypertrophy was significantly higher in the symptomatic hips compared to the asymptomatic hips (χ2 = 9.968, P = 0.002). FAI-related morphological parameters including α angle, lateral center-edge angle, acetabular anteversion, crossover sign, and Tonnis grade were highly symmetrical and did not show significant differences between symptomatic and asymptomatic hips. Fifty-four of 70 hips (77.1%) had labral tears extended to the acetabular rim corresponding to the AIIS. Forty-seven hips of 70 hips (67.1%) underwent subspine decompression, which was significantly correlated with AIIS variation and subspine hypertrophic deformity (P = 0.019 and 0.001, respectively). CONCLUSION: Subspine hypertrophic deformity was found to be more common in symptomatic side vs asymptomatic side in patients with unilateral symptomatic femoroacetabular impingement. Subspine hypertrophy may be considered as an underlying indication for subspine decompression besides low-lying AIIS.
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Impacto Femoroacetabular/diagnóstico por imagem , Impacto Femoroacetabular/cirurgia , Ílio/diagnóstico por imagem , Ílio/cirurgia , Adulto , Artroscopia/métodos , Feminino , Humanos , Hipertrofia , Incidência , Masculino , Pessoa de Meia-Idade , Radiografia , Estudos Retrospectivos , Tomografia Computadorizada por Raios XRESUMO
PURPOSE: To compare ultrasound examination to false profile radiographs in identification and classification of AIIS morphology. The study hypothesis stated that sonographic imaging of the AIIS correlates well to AIIS morphology seen on false profile radiographs. METHODS: Fifty-three hips in 30 consecutive patients met the inclusion criteria. A single, fellowship trained, orthopedic surgeon performed an ultrasound on all of the patients to evaluate the AIIS morphology. The patients underwent standing false profile radiographs. The US and radiographic images were independently reviewed and classified according to Hetsroni classification of AIIS morphology by two senior, fellowship trained, orthopedic surgeons. Agreement between the two raters was calculated for each imaging modality (inter-rater agreement) as well as the agreement between the rating in each modality by the same rater ("inter-method" agreement). RESULTS: The agreement between the raters (inter-rater agreement) for morphologic evaluation of the AIIS by means of FP view was 88.8% (p < 0.001) and that by means of US was 81.5%(p < 0.001). The overall accuracy of the US compared to the FP view was 92.3% (48/52) for both rater 1 and 2. CONCLUSION: This study showed near-perfect agreement in analyzing the morphology of the AIIS in a group of patients with hip pathology. Office sonographic evaluation of the AIIS is reliable and, therefore, may be routinely utilized in the clinic setting avoiding unnecessary radiation exposure to the patient. LEVEL OF EVIDENCE: Level II.
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Impacto Femoroacetabular/diagnóstico por imagem , Articulação do Quadril/diagnóstico por imagem , Ílio/diagnóstico por imagem , Ultrassonografia/métodos , Adolescente , Adulto , Idoso , Feminino , Articulação do Quadril/patologia , Humanos , Ílio/patologia , Masculino , Pessoa de Meia-Idade , Cirurgiões Ortopédicos , Radiografia/métodos , Sensibilidade e Especificidade , Tomografia Computadorizada por Raios X/métodos , Adulto JovemRESUMO
Purpose: Subspine impingement occurs due to a morphologically abnormal anterior inferior iliac spine (AIIS), capable of causing impingement against the distal femoral neck. The purpose of this investigation was to determine the prevalence of AIIS dysmorphism based on specimen sex, race, and age, while introducing a novel anatomic-based classification system. Methods: A total of 1,797 adult cadaveric specimens (n = 3,594 hemipelvises) were analyzed. AIIS with the potential for subspine impingement (SSI) was recorded in each specimen by two independent authors. Specimens with AIIS dysmorphism were then reexamined to determine SSI subtype using a novel descriptive anatomic classification system. Results: AIIS dysmorphism was present in 6.4% (n = 115 of 1,797 specimens) of specimens and 5.2% (n = 186 of 3,594) of hemipelvises. Dysmorphism was significantly more common in male specimens (p = 0.04) and African-American specimens (p = 0.04). No significant overall difference in prevalence was appreciated based on specimen age (p = 0.89). Subtype classification found that 67% of hemipelvises possessed a columnar type AIIS, 30% were bulbous and 3% hook type. Males possessed a significantly higher prevalence of columnar type AIIS dysmorphism (p < 0.001). No significant overall differences in anatomic classification were appreciated based on race (p = 0.12) or when analyzed based on age (p = 0.34). Conclusion: AIIS dysmorphism was present in 6.4% of the 1,797 cadaveric specimens evaluated. African-American and male specimens possessed significantly higher prevalence of AIIS dysmorphism, with no significant difference based on specimen age. Columnar type AIIS dysmorphism was most common. Anatomic classification was not significantly different based on specimen race or age. Level of Evidence: Case Series, Level IV.
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Femoroacetabular impingement syndrome is classically thought of as either a cam or pincer deformity causing abnormal bony contact resulting in labral pathology. However, alternate patterns of hip impingement can occur, but tend to be less commonly recognized or studied. Collectively termed 'extra-articular impingement', four subgroups of impingement can contribute to non-arthritic hip pain and disability: iliopsoas impingement, subspine impingement, ischiofemoral impingement and trochanteric-pelvic impingement. The purpose of this review article is to highlight the pertinent points to aid in proper clinical and radiographic evaluation to allow appropriate diagnosis. Additionally, a review of potential surgical treatment options and resultant outcomes will also be provided.
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Impacto Femoroacetabular/diagnóstico , Impacto Femoroacetabular/cirurgia , Impacto Femoroacetabular/etiologia , HumanosRESUMO
OBJECTIVE: The objective of our study was to compare anterior inferior iliac spine (AIIS) morphology in symptomatic hips with femoroacetabular impingement (FAI) and in asymptomatic hips, determine the prevalence of impingement morphology in patients with a radiographic "crossover" sign, and identify potential risk factors for having impingement morphology. MATERIALS AND METHODS: For this retrospective study, we identified consecutive symptomatic hips with FAI (n = 54) and asymptomatic hips (n = 35) in patients who underwent CT from 2015 to 2017. Two radiologists blindly and independently evaluated 3D CT images of each hip and graded the AIIS morphology according to the Hetsroni classification scheme. The prevalence of AIIS morphology types was calculated. Associations of AIIS morphology types with symptoms and the crossover sign were evaluated with a chi-square test. A multivariable logistic regression determined risk factors for abnormal AIIS morphology (i.e., type 2 or 3). RESULTS: There was no difference in the prevalence of AIIS morphology types for symptomatic hips with FAI versus asymptomatic hips (p = 0.44) or for hips with a positive versus those with a negative crossover sign (p = 0.21). There was moderate interobserver agreement (κ = 0.44) and good-to-excellent intraobserver agreement (κ = 0.67 and 0.90) for grading AIIS morphology. Age, sex, femoral version, acetabular version, alpha angle, lateral center edge angle, and the crossover sign were not significant risk factors for abnormal AIIS morphology in patients with FAI (p = 0.11-0.79). CONCLUSION: There is no difference in AIIS morphology between symptomatic hips with FAI versus asymptomatic hips or between hips with and those without the radiographic crossover sign. Age, sex, and other FAI parameters are not risk factors for developing AIIS impingement morphology.
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Impacto Femoroacetabular/diagnóstico por imagem , Ílio/diagnóstico por imagem , Tomografia Computadorizada por Raios X/métodos , Adulto , Doenças Assintomáticas , Feminino , Humanos , Imageamento Tridimensional , Masculino , Reprodutibilidade dos Testes , Estudos Retrospectivos , Fatores de RiscoRESUMO
Hip and groin pain is a common clinical problem. Multiple causes can generate hip or groin pain, often sharing clinical and demographic characteristics. Diagnostic imaging tests play an important role in the etiological diagnosis. New forms of extra-articular hip impingement have recently been recognized as a cause of hip pain and limited function especially in young active patients. These conditions include ischiofemoral impingement, anterior inferior iliac spine and subspine impingement, iliopsoas impingement and greater trochanteric-pelvic impingement. In general, they are caused by a mechanical conflict with an abnormal or excessive contact between the proximal femur and pelvis and/or soft tissue between them. In this manuscript we review the physiopathology, clinical presentation, the most common radiologic findings and treatment of these forms of extra-articular hip impingement.
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Impacto Femoroacetabular , Impacto Femoroacetabular/diagnóstico por imagem , Impacto Femoroacetabular/etiologia , HumanosRESUMO
BACKGROUND: Femoroacetabular hip impingement (FAI) is now well recognized; however, anterior inferior iliac spine (AIIS; or subspine) impingement is a form of hip impingement that is underrecognized and can be an important source of hip disability and functional limitation. PURPOSE: To investigate the outcomes after arthroscopic treatment of AIIS/subspine-related hip impingement in the absence of FAI surgery. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A prospective institutional hip preservation registry was reviewed to identify patients who underwent arthroscopic AIIS decompression without concurrent treatment of FAI. Primary outcome tools captured in the registry included the modified Harris Hip Score (mHHS), the Hip Outcome Score (HOS), and the International Hip Outcome Tool-33 (iHOT-33). Patients with minimum 1-year follow-up were included. Meaningful outcome improvement was determined per minimal clinically important difference (MCID). Statistical analyses were primarily descriptive. RESULTS: Thirty-three patients with a mean follow-up of 19.1 months (range, 12-44 months) were identified. All patients were female, with a mean ± SD age of 26.1 ± 10.3 years. All patients were found to have an associated labral tear, and the mean acetabular version was increased at 2 and 3 o'clock (14.5° and 19.8°, respectively). Mean preoperative outcome scores on the mHHS, HOS ADL (activities of daily living), HOS sport, and iHOT-33 were 57.2 ± 15.3, 66.9 ± 18.8, 43.9 ± 23.6, and 33.5 ± 18.3, respectively. At final available follow-up, mean scores on these outcome measures were 79.5 ± 19.0, 86.8 ± 15.8, 70.4 ± 32.8, and 65.0 ± 31.0, respectively. By the 1-year follow-up, MCID had been achieved in the majority of patients across all 4 tools. CONCLUSION: There is a paucity of outcomes evidence on AIIS/subspine-related hip impingement. This study demonstrates that isolated subspine impingement can be a cause of hip disability, even in the absence of FAI. Patients with isolated subspine impingement are more likely to be women and to present with low patient-reported outcome scores. However, meaningful outcome improvement can be achieved with arthroscopic AIIS decompression.
RESUMO
PURPOSE: Extra-articular hip impingement syndromes encompass a group of conditions that have previously been an unrecognised source of pain in the hip and on occasion been associated with intra-articular hip impingement as well. As arthroscopic techniques for the hip continue to evolve, the importance of these conditions has been recognised recently and now form an important part of the differential of an individual presenting with hip pain. The aim of this article, therefore, is to provide the reader with an evidence-based and comprehensive update of these syndromes. METHODS: By reviewing past literature, the anatomy, pathophysiology, clinical features and the management of the five common extra-articular hip impingement syndromes were described. RESULTS: The common extra-articular impingement syndromes are: 1) Ischiofemoral impingement: quadratus femoris muscle becomes compressed between the lesser trochanter and the ischial tuberosity. 2) Subspine impingement: mechanical conflict occurs between an enlarged or malorientated anterior inferior iliac spine and the distal anterior femoral neck. 3) Iliopsoas impingement: mechanical conflict occurs between the iliopsoas muscle and the labrum, resulting in distinct anterior labral pathology. 4) Deep gluteal syndrome: pain occurs in the buttock due to the entrapment of the sciatic nerve in the deep gluteal space. 5) Pectineofoveal impingement: pain occurs when the medial synovial fold impinges against overlying soft tissue, primarily the zona orbicularis. Knowledge for these syndromes still remains limited for reasons mostly relating to their low prevalence and their co-existence with typical femoro-acetabular impingement. CONCLUSIONS: The knowledge of extra-articular hip impingement syndromes is essential and should form a part of the differential diagnoses alongside intra-articular pathology including femoro-acetabular impingement particularly in the younger patient with a non-arthritic hip.
Assuntos
Impacto Femoroacetabular/diagnóstico , Articulação do Quadril , Dor Musculoesquelética/etiologia , Diagnóstico Diferencial , Humanos , Artropatias/diagnóstico , SíndromeRESUMO
INTRODUCTION: A hypertrophic AIIS has been identified as a cause for extraarticular hip impingement and is classified according to Hetsroni using 3D-CT reconstructions. The role of the conventional AP pelvis X-ray, which is the first standard imaging step for the evaluation of hip pain, has not been investigated yet. MATERIALS AND METHODS: AP pelvis X-rays and 3D-CT reconstructions of patients were evaluated regarding their morphology of the AIIS. The conventional X-rays were categorized into three groups according to the projection of the AIIS: above (A) or below (B) the acetabular sourcil or even exceeding the anterior acetabular rim (C). They were compared to the morphologic types in the 3D-CT reconstruction (Hetsroni type I-III). RESULTS: Ninety patients with an equal distribution of type A, B or C projection in the AP pelvis were evaluated and compared to the morphology in the 3D-CT reconstruction. The projection of the AIIS below the acetabular sourcil (B + C) showed only moderate sensitivity (0.76) and specificity (0.64) for a hypertrophic AIIS (Hetsroni type II + III), but if the AIIS exceeds the anterior rim, all cases showed a hypertrophic AIIS in the 3D-CT reconstructions (Hetsroni type II + III). CONCLUSIONS: Distinct differentiation of the AIIS morphology in the AP pelvis is not possible, but the projection of the AIIS below the anterior acetabular rim represented a hypertrophic AIIS in all cases and should, therefore, be critically investigated for a relevant AIIS impingement.
Assuntos
Impacto Femoroacetabular/fisiopatologia , Ílio/fisiopatologia , Adulto , Feminino , Impacto Femoroacetabular/diagnóstico por imagem , Impacto Femoroacetabular/cirurgia , Humanos , Ílio/diagnóstico por imagem , Ílio/cirurgia , Imageamento Tridimensional , Masculino , Interpretação de Imagem Radiográfica Assistida por Computador , Sensibilidade e Especificidade , Tomografia Computadorizada por Raios XRESUMO
This article presents a brief review of pincer impingement pathomechanics and the current methods of diagnosis, followed by a discussion of many of the current controversies in addressing pincer morphology. These controversies include controversial surgical indications such as global acetabular retroversion and the role of prophylactic surgery, controversial surgical techniques to address the acetabular labrum, as well as the best methods for intraoperative evaluation of the arthroscopic acetabuloplasty.