Cadera/Hip: Pubalgia y choque fémoroacetabular unidos en deportistas jóvenes

The Role of Femoroacetabular impingement in Core Muscle injury/ Athletic Pubalgia: Diagnosis and Management

David S. Strosberg, Thomas J. Ellis and David B. Renton

Front. Surg. 3:6.  doi: 10.3389/fsurg.2016.00006.
OPEN ACCESS

Chronic groin pain in athletes represents a major diagnostic and therapeutic challenge in sports medicine. Two recognized causes of inguinal pain in the young adult athlete are core muscle injury/athletic pubalgia (CMI/AP) and femoroacetabular impingement (FAI). CMI/AP and FAI were previously considered to be two distinct entities; however, recent studies have suggested both entities to frequently coincide in the athlete with groin pain. This article briefly discusses the role of FAI in CMI/AP and the diagnosis and management of this complex disease.

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El dolor crónico inguinal en los deportistas representa un importante reto diagnóstico y terapéutico en medicina deportiva. Dos causas reconocidas de dolor inguinal del deportista joven adulto son las lesiones de la musculatura abdominal central /pubalgia del deportista (LMAC / PD) y el choque fémoroacetabular (CFA). LMAC / PD y el CFA anteriormente parecían ser dos entidades distintas. Sin embargo, estudios recientes han sugerido que ambas entidades coinciden con frecuencia en el deportista con dolor en la ingle. En este artículo se analiza brevemente el papel del CFA en LMAC / PD y el diagnóstico y tratamiento de esta compleja enfermedad

Cadera/Hip/Hüfte/Hanche: Tratar el choque femoroacetabular en pacientes muy jóvenes

Femoroacetabular Impingement in Skeletally Immature Patients: A Systematic Review Examining Indications, Outcomes, and Complications of Open and Arthroscopic Treatment
Author(s): Darren de SA , Stephanie Cargnelli , Michael Catapano , Asheesh Bedi , Nicole Simunovic , Sarah Burrow , Olufemi R. Ayeni
Source:Arthroscopy: The Journal of Arthroscopic & Related Surgery. Publication date: Available online 26 September 2014

Purpose
Improvements in physical examination and radiographic appreciation of symptomatic femoroacetabular impingement (FAI) has increased the focus on early diagnosis and treatment in an adolescent population. This systematic review aimed to establish specific indications, outcomes, and complications of surgical management of adolescent FAI.

Methods
The Medline, Embase, and PubMed online databases were searched from inception until April 21, 2014, for English-language studies that addressed open and/or arthroscopic treatment of FAI in patients aged 10 to 19 years inclusively. The studies were systematically screened and data abstracted in duplicate, with qualitative findings presented.

Results
There were 6 eligible case series (4 with arthroscopic and 2 with open technique) and 2 conference abstracts examining 388 patients in total (435 hips), 81% of which were treated with hip arthroscopy. Overall, patients were followed up for a mean of 23.4 months postoperatively (range, 3 to 75 months). The main indication for surgery was a confirmed diagnosis of FAI with persistent pain and impaired function refractory to nonoperative interventions (activity modification, intra-articular injections, and so on). Specific contraindications included Tönnis grade 2, 3, or 4 chondral changes and acetabular dysplasia. All studies reported significant improvements in patient pain, function (e.g., no patients were “abnormally” or “severely abnormally” impaired), and satisfaction rates (84% to 100% with arthroscopic technique v 79% with open technique). Improvements also were observed in range of motion and alpha angle correction, as well as across a variety of patient-reported functional scores, with all but 7 of 388 patients (1.8%) returning to activity/sport. No major complications were reported, with only 13 of 354 hips (3.7%) treated by arthroscopy requiring revision arthroscopy for lysis of adhesions and 1 of 81 open surgical dislocation hips (1%) having asymptomatic heterotopic ossification not requiring additional management. No cases of avascular necrosis, physeal arrest or growth disturbance, or iatrogenic deformity were reported.

Conclusions
Both arthroscopic and open surgical dislocation approaches for the treatment of adolescent FAI appear to be safe and effective options for patients with persistent pain and limited function after an appropriate trial of nonoperative therapy.

Level of Evidence
Level IV, systematic review of Level IV studies.

Cadera / Hip: el ángulo alfa puede que no refleje bien el cam

Correlations between the alpha angle and femoral head asphericity: Implications and recommendations for the diagnosis of cam femoroacetabular impingement.

Harris MD Kapron AL Peters CL Anderson AE

Eur J Radiol 2014 Feb 14.

Abstract

OBJECTIVE

To determine the strength of common radiographic and radial CT views for measuring true femoral head asphericity.

PATIENTS AND METHODS

In 15 patients with cam femoroacetabular impingement (FAI) and 15 controls, alpha angles were measured by two observers using radial CT (0°, 30°, 60°, 90°) and digitally reconstructed radiographs (DRRs) for the: anterior-posterior (AP), standing frog-leg lateral, 45° Dunn with neutral rotation, 45° Dunn with 40° external rotation, and cross-table lateral views. A DRR validation study was performed. Alpha angles were compared between groups. Maximum deviation from a sphere of each subject was obtained from a previous study. Alpha angles from each view were correlated with maximum deviation.

RESULTS

There were no significant differences between alpha angles measured on radiographs and the corresponding DRRs (p=0.72). Alpha angles were significantly greater in patients for all views (p≤0.002). Alpha angles from the 45° Dunn with 40° external rotation, cross-table lateral, and 60° radial views had the strongest correlations with maximum deviation (r=0.831; r=0.823; r=0.808, respectively). The AP view had the weakest correlation (r=0.358).

CONCLUSION

DRRs were a validated means to simulate hip radiographs. The 45° Dunn with 40° external rotation, cross-table lateral, and 60° radial views best visualized femoral asphericity. Although commonly used, the AP view did not visualize cam deformities well. Overall, the magnitude of the alpha angle may not be indicative of the size of the deformity. Thus, 3D reconstructions and measurements of asphericity could improve the diagnosis of cam FAI.

Cadera / Hip: peores resultados postartroscopia en caso de choque femoroacetabular con espacio articular reducido

The Effect of Joint Space on Midterm Outcomes After Arthroscopic Hip Surgery for Femoroacetabular Impingement.

Skendzel JG, et al. Show all Am J Sports Med. 2014 Mar 7

Abstract

BACKGROUND: Excellent short-term results have been reported after hip arthroscopic surgery to address femoroacetabular impingement (FAI).

Purpose/ HYPOTHESIS: The purpose of this study was to determine if patients with narrow joint spaces had inferior outcomes at a postoperative minimum of 5 years and if they had a higher conversion rate to total hip arthroplasty (THA). The hypothesis was that patients with ≤2-mm joint spaces would report inferior outcomes and that patients with >2-mm joint spaces would have improved survivorship (no conversion to THA). 

STUDY DESIGN: Cohort study; Level of evidence, 3. 

METHODS: Between March 2005 and January 2008, prospectively collected data were analyzed for patients older than 18 years of age undergoing hip arthroscopic surgery for FAI. Radiographic measurements of joint space were collected, and hips were grouped as having preserved (>2 mm) or limited (≤2 mm) joint space. Outcome measures included the Western Ontario and McMaster Universities Arthritis Index (WOMAC), modified Harris Hip Score (MHHS), Hip Outcome Score (HOS) for activities of daily living and sports, and Short Form-12 (SF-12). 

RESULTS: There were 559 patients included, 466 (83%) of whom were contacted. Fifty-four patients with limited joint spaces (86%) converted to THA, while only 63 patients with preserved joint spaces (16%) converted to THA. The mean survival time for patients with preserved joint spaces was 88 months (95% CI, 85-91 months), and the mean survival time for patients with limited joint spaces was 40.0 months (95% CI, 33.7-46.3 months) (P = .0001). Complete follow-up outcome data were available on 323 patients, none of whom had THA, with a mean follow-up of 73 months. The mean postoperative HOS for activities of daily living and sports were significantly better in patients with preserved joint spaces (82 vs 62 [P = .012] and 77 vs 47 [P = .003], respectively) compared with those with limited joint spaces at a mean of 73 months postoperatively (range, 60-97 months). 

CONCLUSION: Hip arthroscopic surgery for FAI resulted in significantly better outcomes and activity levels at minimum 5-year follow-up in patients with preserved joint spaces. Hips with limited joint spaces converted to THA earlier than did those with preserved joint spaces.

Cadera / Hip: El choque fémoroacetabular más allá de lo pensado

The Critical Corner of Cam Femoroacetabular Impingement: Clinical Support of an Emerging Concept

Author(s): Dean K. Matsuda , Charito P. Schnieder , Bantoo Sehgal

Source:Arthroscopy: The Journal of Arthroscopic & Related Surgery

Publication date: Available online 12 March 2014

Purpose

The purpose of this study was to evaluate the concept of cam femoroacetabular impingement (FAI) occurring medial to the classic anterolateral (AL) quadrant.

Methods

Forty-four patients met the inclusion criteria of cam FAI and underwent arthroscopic AL femoroplasty. Goniometric measurements of intraoperative hip internal rotation (HIR) in 90° of hip flexion and 0° of adduction were obtained. Thirty patients (14 male and 16 female), comprising the substance of this study, exhibited HIR of less than 40° after AL femoroplasty and underwent further anteromedial (AM) femoroplasty with subsequent repeat measurement of HIR. Nonparametric statistical analysis was performed.

Results

Preoperative HIR averaged 20.8° (range, 10° to 29°); intraoperative HIR averaged 29.5° (range, 18° to 39°) after AL femoroplasty and 42.7° (range, 32° to 61°) after additional AM femoroplasty. The gain in HIR after AL femoroplasty was 8.7° (range, 2° to 23°) (P < .0001). The further gain in HIR after AM femoroplasty was 13.2° (range, 2° to 22°) (P < .0001). The overall gain in HIR after AL and AM femoroplasty was 21.9° (range, 13° to 38°) (P < .0001). A consistent landmark termed the resident's ridge of the hip accompanied all cases of AM cam impingement.

Conclusions

Femoroplasty of the AM “critical corner” may improve cam decompression and supports the concept of cam impingement extending beyond the classic AL quadrant of the proximal femur.

Level of Evidence

Level IV, therapeutic case series.