Download Medical Approach to Pre-Arthritic Hip Disease Cara Beth

MedicalApproachtoPre-ArthriticHipDisease
CaraBethLee,MD
September30,2016
LayeredApproachtotheHip1,2
1Osteochondrallayer-pelvis,acetabululm,andfemur
• Responsibleforjointcongruenceandnormalkinematics
• Abnormalities
o Staticoverload(AcetabularDysplasia)
o DynamicImpingement(Femoroacetabularimpingement,FAI)
o DynamicInstability
2Inertlayer-labrum,capsule,ligamentumteres
• Responsibleforstaticstabilityofthejoint
• Susceptibletoinjuryfromlayer1morphologyandmechanics,e.g.camlesion!labraltear
3Contractilelayer-lumbosacral,pelvicandpelvicfloormusculature
• Responsiblefordynamicstabilityofthejointandmuscularbalanceofthehip,pelvis,andtrunk
• Alteredmechanicsinlayer1affectlumbarspineandpelvicmuscularattachments
4Neuromechanicallayer-integrationofanatomicstructure,neuralelementsandkinematicchain
• Responsibleforpostureandpelvicposition
• Affectedbylocalmechanoreceptorsandnociceptors
• Examstartsatlayer1andmovesoutward
• Treatmentstartsatlayer4andmovesinward
• Criticaltodistinguishstructuralpathologyinlayers1and2fromissuesinlayers3and4
Pre-ArthriticHipDisease
• AcetabularDysplasiaandFAI(Layers1and2)
o Demographicsandpathomechanics
o Radiographicfeatures
o Surgicaltreatment
• Importance
o PrimaryTHAinpts<50yearsoldfrom3centers,between1975–20053
o 604patients(710hips)
o 52%male,48%female,aveage40
" 47.5%‘idiopathic’OA
› 89.6%duetostructuralpathologyofFAI(41.2%)ordysplasia(48.4%)
• PioneerReinholdGanz
o Describedperiacetabularosteotomy(PAO)techniquetotreatacetabulardysplasia5
o DefinedpathomechanicsofFAI7
" “cam”and“pincer”
o Preliminaryworktoprotectfemoralheadperfusion9
o Surgicalhipdislocationtechnique11
1
AcetabularDysplasia
• Shallow,steeplysloped,orimproperlydirectedacetabulum
• Associatedwithincreasedfemoralanteversion
• Presentsinadolescenceoradulthood
• Female:Male,4.5:1
• Groinpain,trochantericpain
• Givingwayepisodes,abductorfatigue
• X-raysdiagnostic
• Imaging
" APpelvis,falseprofile
o Center-edgeangle–normal25º-35ºor~80%coverageoffemoralhead
o Tönnisacetabularroofangle–normal0º-10ºor~horizontal
o Shenton’sLinedisruption=dysplasia
o FemoralVersion
" Determinesfemoralrotationalalignment
" RequiresCTorMRItoquantify
" Normal:10º-25º(?)
• TreatmentdeterminedbyseverityandOA
o PAO-triplepelvicosteotomy(ilium,ischium,superiorpubicramus)
" Preservesposteriorcolumn
" Preservesacetabularbloodsupply
" Preservesbirthcanaldimensions
• SurgicalResults
o ReturntosportsafterPAO12
" 41patients(46hips),ages13-41,median3.1yr.follow-up
" 80%returntosportsatmedian9months
" 73%atpriorlevel(58%competitive,89%recreational)
o Abductorstrength13
" 21patients(24hips),aveage16yrs.
" Decreasedisokineticabductorstrengthat6monthspost-op,recoveredatoneyear
" Hipflexionstrengthpersistentlydecreased
o Decreasedpeakhipextensionandhipflexionmomentinpatientswithdysplasiacomparedtocontrols,
improvedatoneyearpost-op14
o SurvivorshipofnativehipafterPAO(158hips)
" 96%survivorshipat5yrs.,84%at10yrs.15
" 74%at18years16
› 21%THAatave9years
› 53%asymptomatic;26%failurebasedonpain(WOMAC>10)
› Age>25,jointspace<2mmor>5mm,poorcongruenceassociatedwithearlyfailure
" Ageover40,88%survivorshipat5yrs.ingrades0-1OA17
" 20yearfollow-upafterPAO
› 75%survivorshipat20years(>200hips)ifpre-opOAgrade0-118
2
APPelvisRadiograph
• Pelvictiltaffectsacetabularmeasures
• Alignmentandinclination
o Coccyxinlinewithsymphysis
o Iliacwings,obturatorforaminaandteardropssymmetric
4
o Symphysistosacrococcygealjointdistance2-5cm
§ ave47mm♀,32mm♂ o Or,symphysistotipofcoccyxdistance0-2cm6
• Anterioracetabularwall
o continuationofthesuperiorpubicramus
• Posterioracetabularwall
o extendsfromlateralischium
o alignswithcenteroffemoralhead
• Acetabularwallsshouldmeetatlateralrim
• Cross-overSign 8
o Indicativeofacetabularretroversionorfocalanteriorovercoverage
o Positiveifanteriorwallprojectslateraltoposteriorwall
o Falselypositivewithincreasedpelvicinclination
• IschialSpineSign10
o Positiveifspineprojectsmedialtoiliopectinealline
o Correlateswithcross-over,lessaffectedbytilt
• PosteriorWallSign
o Posteriorwallmedialtocenteroffemoralhead
o Suggestsposterioracetabularinsufficiency
FalseProfileView
• Standing,lateralviewoftheacetabulum
• Givestangentialviewofanteriorrim
• CanshowOAnotevidentonotherviews
o AnteriorCenter-Edge(CE)angle
§ Normal:25º-35º
§ Dysplastic:<20º
45ºDunnview
• Supine,45ºhipflexion,slightabduction
• Tangentialtoanterosuperiorhead-neckjunction
• Bestviewtoscreenforcamlesion
FemoroacetabularImpingement(FAI)
• HistoricalBackground
o Femoralbumpfirstdescribedin189919
o BumpectomyinSCFEdeformities20,21
o Acetabuloplasty22
o Anatomicvariantsassociatedwith‘idiopathic’osteoarthritis3,23-26
o Murray,1965–mildanatomicalvariationsexplainthemajorityof‘idiopathic’osteoarthritisofthehip
" 200patientswithprimaryOA
" 40%‘tilt’deformitysimilartomildslippedepiphysis
" 25%acetabulardysplasia
3
Stulberg,1975–compared‘idiopathic’OAptstothosewithSCFEandPerthes
" 40%ofOApatientswith‘pistolgrip’deformity
Pathomechanics
o Abnormalcontactbetweenfemurandacetabulum
" Cam–asphericalfemoralhead-neckjunctionimpactslabrochondraljunction
" Pincer–excessiveanterioracetabularcoveragecompresseslabruminflexion
" Femoralretroversion
o Cametiologyuncertain
" Subclinicalslippedcapitalfemoralepiphysis27
" Abnormalityofgrowthplateclosure28
" Relationtoathleticsinskeletallyimmature29,3031-33
o AcetabularPathology
" “Coxaprofunda”-rimossification–focalanterior/lateralovercoverage
" Acetabularretroversion
" Protrusioacetabuli
o Functionalimpingement
o Extra-articularimpingement
" “Sub-spine”impingement
› AIISimpingesagainstdistalfemoralneck
› AIIScanbemistakenforanteriorwall
› Visibleonfalseprofile
" Ischiofemoralimpingement–contactbetweenischiumandlessertrochanter
› Increasedfemoralvalgusandanteversion
› Decreasedfemoraloffset
Imaging
o StandingAPpelvis,Falseprofile,45ºDunn
o Subtledeformityeasilymissedontypicalviews
› 35%‘normal’x-raysin58cases34
o Femoralfindings
" Asphericalorflatfemoralhead-neckjunction
" ‘Pistolgrip’onAP
" Increasedalphaangle(normal<43°)35
" Cystsorsclerosisinfemoralneck
o Acetabularfindings
" Overcoverage
› LateralandAnteriorCEangles>40º
› Tönnisanglenegative(downslopingsourcil)
" ProtrusioAcetabuli
› Femoralheadmedialtoilioischialline
" Retroversion
› Positivecross-overandischialspinesigns
MRI
o Labralpathologycommonwithbonyabnormality36
" Arthrogramunnecessary37
o Radialviewsdelineatehead-neckjunction
o Femoralversionassessment
Radiographicabnormalitiescommoninasymptomaticsubjects
o
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•
•
•
4
•
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o 20-25%prevalenceofcamlesionsinmales,9%females38
o Labraldamagecommon
o NotallwilldevelopsymptomsorOA
Treatment
o Activitymodification
" Avoiddeepflexion–squats,bicycling
o Surgery
" SurgicalHipDislocation(SHD)
" HipArthroscopy
› 90%ofFAItreatedarthroscopically
SurgicalResults
o Alltechniques(ifOAminimal)39-42
" decreasedpain
" improvedfunction
" safe
o Arthroscopy!equivalentoutcomes,fewercomplications40,41
o Level3and4studies,difficulttocompareduetodifferentoutcomemeasures
o Resultsbetterwithlabralrepairoverdebridement43,44
o ReturntosportsafterFAIsurgery
" Systematicreview18studies,caseseries,level4evidence45
› 87%returntosport,82%samesportandlevelpriortosymptoms
› Higherreturnforprofessionalathletesvs.collegiateandrecreational
o ConversiontoTHAwithin2years
" Populationbasedanalysis46
› 7351arthroscopiesinCAandFL2005-12
› Meanage43.9,58.5%female
› 11.7%THAwithin2years
› 35%60–69agegroup
› 3%lessthanage40
o Resultsbygenderandage47
" 150patients,25peragegroup:<30,30-45,>45
" Minimum2yearfollow-upHOS-ADLandsport,modifiedHarrisHipScore
" Ageover45years!loweroutcomescorescomparedtoothergroupsbygenderandcombined
› femalesover45lowestoverallsatisfaction
CapsularFunction
• Allowsuprightstancewithmaximalmuscleefficiency48
• Iliofemoralligamentextremelystiffandstrong49
o Superiorbandcheckreinforexternalrotation50
o Inferiorbandtautinextension
• Zonacapsularisencircleshead-neckjunction
o Limitsdistraction51
• ConfluenceofZO/IFLadjacenttocamlesion
• ‘Eminentia’functionsaspulleybarforcapsule52
• Possibleroleinformationofcamlesionwithopenphysis53
• LossofERafteranteriorprocedures
5
LabralFunction
• Gasket–createsasuctionseal54
o Modulatesfluidflowandpressurizationofcartilage55,56
• Highlyinnervated
• Labral“tears”commoninasymptomaticvolunteers
o 45subjects,aveage38years(15-66)57
" Labraltears69%
" Paralabralcysts13%
" >35yearsold
› Chondraldefect13.7xmorelikely
› Subchondralcysts16.7xmorelikely
o 42subjects,aveage34years(27-43)58
" Labraltears81%
" Paralabralcysts21%
o 208subjectsoverage5059
" Labralpathology93.3%
• Veryrealtreatmentdilemma
Layer3–Contractilelayer
• Lumbosacral,pelvicandpelvicfloormusculature
o Dynamicstabilityandmuscularbalanceofthehip,pelvisandtrunk
• Alteredmechanicsinlayer1affectlumbarspineandpelvicmuscularattachments
o Anterior–iliopsoasandhipflexorstrain
o Medial–adductorandrectusabdoministendinopathy
o Posterior–proximalhamstring,externalrotatorstrains
o Lateral–gluteusmedius,minimus,trochantericbursitis,ITB
60
(IllustrationsfromNeumann,JOrthopSportsPhysTher,2010 )
6
AnteriorHipPain
• Anteriorhipforceincreasedwith:61
o Hipextension
o Glutealweaknessinextension
o Iliopsoasweaknessinflexion
• DelayedonsetofTAinathleteswithchronicgroinpain62
• Iliopsoas/hipflexorirritability
o Canmimicimpingement–eveninpatientswithnolabrum,suchasafterhipreplacement
o Snapping
" Iliopsoassnapsoveriliopectinealeminenceorfemoralhead
" Presentin90%ofdancers63
o Surgicalreleasecontroversial,particularlywithincreasedfemoralanteversion64
MedialHip/AnteriorPelvicPain
• Osteitispubis,AthleticPubalgia(‘SportsHernia’)65-69
• Dysfunctionofthe‘Pubicjoint’68
o PubicJoint=entiremusculoskeletonaroundsymphysis
o Rectusabdominisdisruptionatpubictubercle
" concomitantadductorinjury
o Inguinalcanalposteriorwallweakness70
" Leadstogenitofemoralnerveirritation
• Predominantlymen,teens–30s
• Classicmechanismofinjury
o hyperextensionofrectusabdominis,hyperabductionofadductors
o Associatedwithsoccer,icehockey,football
• FAIandAthleticPubalgia
o “SportsHipTriad”71
" Rectus,adductorandhipjointpathology
o Cadavericstudy72
" SimulatedcamFAI!Increasedpubicsymphysismotion
o Combinedproceduresmaybenecessaryifbothpathologiesconfirmed
" In37hips,returntosports89%withbothproceduresvs.25%and50%ifisolatedsurgical
treatmentforathleticpubalgiaorhiparthroscopyforFAI,respectively73
• Imaging
o MRI
" Athleticpubalgiaprotocol
" Disruptionofaponeuroticplateatsymphysis
" Edema(osteitispubis)
• Treatment
o Activitymodification–corestabilityprogram
o Surgicalreferral(GeneralSurgeon)
7
(IllustrationfromMeyers,OperTechSportsMed,201268)
LateralHipPain
• GreaterTrochantericPainSyndrome
o Spectrumofglutealoverload(notbursitis)
o Muchhigherprevalenceinwomen
o Associationwithspinedisease,hipOA,kneeOA,obesity
o Surgicaltreatmentunpredictable
• Consequenceofevolution
o Pelvicadaptationsofbipedalismandencephalization74,75
" Iliumshortenedandrotatedtosagittalplane
" Sacrumwiderandmorecaudal
" Inletdiameterwidened
" Gluteusmaximusenlargedtostabilizeuprightstance
" Gluteusmediusandminimusalteredfromhipextensorstoabductors
o Sexualdimorphisminpelvicdimensions76
(CourtesyWorldwideFistulaFund)
8
•
Alteredbiomechanicsfromlumbopelvicchanges
o Inequilibrium,rotationaltorquesareequal
" MxD=WxD1
" Increasebodyweight(W)!increaseabductorforce(M)
" Increasebodyweightleverarm(D1),e.g.,widerfemalepelvis/interacetabulardistance)!
increaseabductorforce(M)
" Decreaseabductorleverarm(D),e.g.,femoralvalgus!increaseabductorforce(M)
" Decreasebodyweightleverarm(D1),e.g.,Trendelenburggait!decreaseabductorforce(M)
o Jointreactionforcescounterbalancemuscularandbodyweightforces
" Inequilibrium,forcevectorsumiszero(M+W+J=0)
" Anyincreaseinbodyweightorabductorforceleadstoincreasejointreactionforce
" Increasedjointreactionforce!increasedjointcontactpressure!increasedriskofOA
› Women77
› Dysplasia78
W
J
M
(IllustrationfromGenda,JBiomech,2001)
(Neumann,JOrthopSportsPhysTher,2010)
Layer4-Neuromechanicallayer
o “Theoretical”layercomprisedofanatomicstructure,neuralelementsandkinematicchain
" Postureandpelvicposition
" Localmechanoreceptorsandnociceptors
o Abnormalitiesduetoalteredmovementpatterns
" Chronicanklesprainsassociatedwithdelayedgluteusmaximusactivation79
" Recurrentbackpainrelatedtomultifidusandtransverseabdominisrecruitmentandthickness80,81
" Groinpainassociatedwithdelayedtransverseabdominisfiringanddecreasedabductor/adductor
activation62,82
9
History
• Pain–duration,location,severity,nature,exacerbating,alleviatingfactors
• Medical/SurgicalHistory
• Sports/activityhistoryduringdevelopment
o Physealovergrowthfromphysicalactivityspeculatedascauseofcamlesion30
o Sportsassociatedwithcamlesions:
" Soccer31,83-85,Basketball86,Icehockey32,87-89,Football90-92
• Familyhistory93-95
• PresentingsymptomsofFAIandacetabulardysplasia96,97
• Datadrawnfromasinglesurgeonhippreservationpractice
FAI97
AcetabularDysplasia96
n=51
n=57
Age
35years
24years
Gender
57%male
72%female
GroinPain
88%
72%
LateralHipPain
67%
66%
InsidiousOnset
65%
97%
Mod-severePain
81%
77%
SleepDisturbance
79%
59%
Snapping/Popping
65%
80%
Painwhilesitting
65%
44%
Painwithstanding
44%
70%
Painwithwalking
57%
81%
Painwithpivoting
63%
45%
Painwithrunning
69%
80%
ANCHORgroupFAIepidemiology
• 1076patients(1130hips)
o Averageage28.4years(majority11-19.9)
o 88%Caucasian
o AverageBMI25.1
o 55%female;45%male
o 19%positivefamilyhistoryofhipdisease
o 89%idiopathicFAI
o 48%cam,45%combinedcam/pincer,8%pincer
• Highlyactive
o UCLAscoreaverage7,(29%10)
• Highlylimited
o mHHS60.1
o HOOSpain55%,symptoms54%,Sports/rec43%,QOL31%
PhysicalExam
• Standing
o Gait
" Antalgic,Trendelenburggait,shortenedstride
" Footprogressionangle(indicatoroffemoralversionandtibialtorsion)
10
Increasedfemoralanteversion
FemoralRetroversion
o Trendelenburgsign-whenstandingononeleg,thepelvisdropsontheoppositesideindicating
abductorinsufficiencyonthestanceside
o Pelvicobliquity-observewhetherposteriorsuperioriliacspinesarelevel
o Spineexam-notestiffness,scoliosis,lordosis
o Flexibility/jointlaxity
" Beighton9-pointscale98-palmsflattofloorwithforwardbending,hyperextensionatthekneeand
elbows(1ptperside),thumbtoforearmwithwristflexion(1ptperside),>90ºextensionofsmall
fingerMPjoints(1ptperside)
Supine
o HipROM-watchforpelvicandlumbarmotion
" Neutralflexion-normalisapproximately95º,painwithdeepneutralflexionmayindicatesubspine
impingement99(distalfemoralneckcontactwithAIIS)
" Flexionat90ºwithinternalrotation-normalis20ºormore35,100,101
" Flexionat90ºwithexternalrotation
" FADIR-flexion,adduction,internalrotation(Impingementtest)102
› Loadslabrumbetweenfemoralhead-neckjunctionandanterosuperioracetabularrim
› Recreationofgroinpainisapositivefinding
› Non-specificforlabralirritabilitybutnotnecessarily‘impingement’
Normal
•
ImpingementTest
ApprehensionTest
(IllustrationsfromLeunig,Siebenrock,Ganz,JBJS,2001103)
FABER-flexion,abduction,externalrotation
› Groinpainmaybefromtransversestraininthelabrum104
› Lateralhippainmaybefromthelabrumorlateralimpingement
› SIjointpain
Palpation
" ASIS/TFL-maybepainfulfromcompensatoryinjury
" AIIS-painfulinsubspineimpingement99
" Inguinalcrease,iliopsoas,adductors
"
o
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•
•
•
" Pubictubercle-painfulinathleticpubalgia
o Straightlegraiseagainstresistance(Stinchfieldtest)
" Maybetendonitisoriliopsoasimpingementinwhichpainisduetocompressionofthelabrum
withiliopsoasactivation105
" Multiplemusclesrecruitedinactivestraight-legraisetest106
o Resistedsit-uptest
o Adductionagainstresistance
o Apprehension/PosteriorImpingementtest(illustrationabove)-flexcontralateralkneetochest,
hyperextendandexternallyrotatesymptomatichip
" Anteriordiscomfortsuggestsanteriorinstabilityandlabralstrain104
" Posteriorpainindicativeofposteriorimpingement
Side-lyingLateralExam
o Palpationfortrochantericorshortexternalrotatortenderness
o Abductionstrengthagainstresistance
Prone
o Femoralversion-assesssymmetryofinternalandexternalrotation
o Quadricepstightness(Elytest)-passivelyflexkneeuntilpelviselevatesfromtable
" Quadricepstightnesscombinedwithcore/abdominalmuscleweaknesscanresultindynamic
anteriorimpingementfromanteriorpelvictilt
DiagnosticInjection
o 90%accuracytodetectarthroscopically-confirmedintra-articularabnormality107
o Negativeresponsetoinjectionassociatedwithpoorshort-termsurgicalresult108
PositivesignsofFAIandacetabulardysplasiaonphysicalexam
FAI97
AcetabularDysplasia96
n=51
n=57
Trendelenburgsign
33%
38%
Limp
85%
FADIR/Impingement
88%
97%
FABER
69%
Ave.Flexion
97º
Ave.IRat90ºflexion
9º
• AmericanPhysicalTherapyAssociation(APTA)ClinicalPracticeGuidelines109
o ExtensivereviewofdiagnostictestsandcorrelationwithICD-10coding
• APTADiagnosticCriteriaforFAI
o Anteriorand/orlateral/trochantericpain
o Paindescribedasachingorsharp
o Painaggravatedbysitting
o PainreproducedbyFADIRtest
o IRlessthan20°at90°flexion
o "Conflictingclinicalfindingsnotpresent"
o RadiographiccorrelationwithFAImeasures
• APTADiagnosticCriteriaStructuralInstability
o Anterior,lateralorgeneralizedhippain
o PainreproducedbyFADIRandFABERtests
o Positiveapprehensionsign
12
o IRgreaterthan30°at90°flexion
o Mechanicalsymptoms
o "Conflictingclinicalfindingsnotpresent"
o Radiographiccorrelationwithdysplasiameasures
• Distinguishingfeaturesofathleticpubalgia(vs.FAI)
o Nopainatrest
o Painwithstraining,coughing,sneezing
o Tenderatpubictubercle
o Painelicitedwithresistedsit-up,resistedhipadduction,valsalva
o Nohernia
Summary
• Thepelvisisindeedabusyplace
• Manycomponentsofthekineticchaincancause'hip'pain
• Consistenthistoryandphysicalexamarekeytodetermineprimarypainsource
• Structuraldeformityandlabraltearsarecommonandnotnecessarilypathologic
13
RadiographicEvaluationoftheNon-arthriticHip
ScreeningImages:
• APPelvis
• 45ºDunnlateral(bilateral)
• Falseprofile110(bilateral)
• ForAcetabularDysplasia,addvonRosen111(maximalabduction/internalrotation)view
1.Assessalignment
• Inclination/Reclination4affectacetabularmeasures
• Inletappearancemaybeduetoanteriorhipcapsuletightness/lumbarlordosis
2.Evaluateacetabularmorphology
• Center-edge(CE)angle112:measureoffemoralheadcoverage
o lateralCEanglemeasuredonAPpelvisimage
o anteriorCEangleobtainedonfalseprofileview
• Acetabularroof/Tönnisangle113:indicatesobliquityoftheweight-bearingacetabulum(sourcil)
• Shenton'sline114:detectssubtleinstabilityifdisrupted
• Cross-oversign8:suggestsanteriorovercoverageoracetabularretroversion
o sensitivetopelvicposition
• IschialSpinesign10:alsoassociatedwithacetabularretroversion,lessaffectedbypelvictilt
• PosteriorWallsign:indicativeofposterioracetabulardeficiency
o whenseenwithcross-oversign=>globaldeficiency
• Ilioischialline
o teardropmedialtoilioischialline=>coxaprofunda(incontext)
o femoralheadmedialtoilioischialline=>protrusioacetabuli
• TönnisOsteoarthritis(OA)Grade
• JointSpaceNarrowing:lessthan2mmpoorcandidateforjointpreservation
• JointCongruity
3.Evaluateproximalfemur
• 45ºDunnlateralbestforevaluatingcamlesions115
• Examinehead/neckshape,offset,
• αangle(≤55°normal)35
4.MRI
• Radialviewsvaluabletodetectandquantifycamlesions116
• LabralpathologynearlyalwayspresentinFAI
• BiochemicalimaginghelpfultoquantifyOAinacetabulardysplasia
5.Caveats
• Normalx-raysdonotexcludeFAI
• Abnormalx-raysdonotequatetoFAI--highprevalenceofcamlesionsinasymptomaticpopulation
• Femoralretroversioncanpredisposetoimpingement
• Asymmetryoffemoralhead/acetabulumhaspoorprognosisforarthroscopy,Tönnisgrades0and1
bestcandidatesforFAIsurgery
14
APPelvisMeasures
AlignmentandInclination
• Coccyxinlinewithsymphysis
• Iliacwings,obturatorforaminaandteardropssymmetric
• Symphysistosacrococcygealjointdistance2-5cm(ave47mm♀,32mm
♂)4
• Or,symphysistotipofcoccyxdistance2cm6
LateralCEAngle
Theangleformedbytheintersectionofalinefromthecenterofthefemoralheadtothe
lateralrimoftheacetabularsourcilandasecondlinethatisperpendiculartoaline
connectingthecenterofthefemoralheads.
Normal:25º-35º
Dysplastic:<20º
Overcovered:>40º
TönnisAngle
Theangledeterminedbyalinebetweenthefemoralheadcenters(orparalleltoit)anda
secondlinethatconnectsthemostmedialandlateralmarginsofthesourcil.
Normal:0-10º
Dysplastic:>12º
Overcovered:negativeangle/downslopingsourcil
Shenton'sLine
Themeasuredescribesthecurvedlineextendingfromthetopoftheobturator
foramentothemedial,inferiorfemoralneck.Inanormalhip,thisarcmaintainsa
smoothcontour.DisruptionofShenton'slineindicatesdysplasiawithfemoral
headsubluxation.
15
Cross-oversign
Theanterioracetabularwallisacontinuationofthesuperiorpubicramusand
ismorehorizontallyoriented.Theposteriorwallextendsfromthelateral
ischiumandismorevertical.Inanormalhip,theanteriorandposterior
acetabularwallsmeetatthelateralrimonanAPx-ray.Thecross-oversignis
anindicatorofacetabularretroversionorfocalanteriorovercoverage;itis
positiveiftheanterioracetabularwallprojectslateraltotheposteriorwall.
Thismeasuremaybefalselypositivewithincreasedpelvicinclination.
PosteriorWallsign
Therimoftheposteriorwalloftheacetabulumshouldbein
linewithorlateraltothecenterofthefemoralheadonanAP
x-ray.Theposteriorwallsignispositiveiftherimismedialto
thecenterofthehead,whichdenotesinsufficientposterior
coveragethatoccurswithacetabularretroversionorglobal
acetabulardysplasia.
IschialSpinesign
Thissignstronglycorrelateswiththecross-oversignas
anotherindicatorofacetabularretroversion,butitisless
affectedbypelvictilt.Itisconsideredpositiveiftheischial
spineprojectsmedialtotheiliopectineallineintothepelvis.
IlioischialLine
Thepositionofthefemoralheadandtheflooroftheacetabularfossa,whichcorrespondsradiographicallyto
theacetabularteardrop,shouldbeexaminedrelativetotheilioischiallineasadditionalmeasuresof
acetabulardepthinpatientswithahighlateralCEangleornegativeroofangle.Incoxaprofunda,theteardrop
touchesorismedialtotheilioischialline.Theteardropcanbemedialtotheilioischiallineindysplastichips;
therefore,thisradiographicsignmustbeinterpretedincontext.Inprotrusioacetabuli,thefemoralheadis
medialtothisline.
Coxaprofunda:fossaacetabuli(B)touchesorismedial
totheilioischialline(A)
Protrusioacetabuli:medialaspectoffemoral
headismedialtoilioischialline
16
TönnisOsteoarthritisGrade
Asubjectivecategorizationofthepresenceofarthritisinthehipjoint.Tönnisgrades0-1arebestcandidates
forhippreservationprocedures.
Grade0:Normal,nojointspacenarrowingorothersignsofOA
Grade1:Sclerosis,slightjointspacenarrowingorlossofheadsphericity,minimalosteophytes
Grade2:Smallcysts,moderatejointspacenarrowingorlossofheadsphericity
Grade3:Largecysts,severebutlocalizedjointspacenarrowing,severefemoralheaddeformity
Grade4:Extensive,severelossofjointspace
JointCongruity
Thismeasureisasubjectiveassessmentofthecurvatureofthefemoralheadandacetabulum.Fair-poor
congruenceisassociatedwithworseoutcomesafterperiacetabularosteotomy(PAO).
Excellent:curvatureoftheacetabulumandthefemoralheadisalmostidentical.
Good:curvatureoftheacetabulumandthefemoralheadarenotidenticalbutjoinspacemaintained.
Fair:partialnarrowingofthejointspace.
Poor:focallossofjointspace.
45ºDunnLateralView
AlphaAngle(αangle)
Thisangleisusedtoquantifythefemoralhead-neckjunction.Itwasoriginallydescribed
fromobliqueaxialMRimagesbutisnowcommonlymeasuredonlateralradiographs.
Theangleisformedbytheintersectionofalinealongtheaxisofthecenterofthe
femoralneck(orparalleltoit)passingthroughthecenterofthefemoralheadanda
secondlinefromthecenterofthefemoralheadtothepointonthefemoralhead-neck
junctionwheretheheadceasestobespherical.Anαangleof55ºormoreisconsidered
abnormalwhensupportedbyotherclinicalfindingsofFAI.
FalseProfileView
AnteriorCEAngle(obtainedonfalseprofileview)
Theangleformedbytheintersectionofaverticallinefromthecenterof
thefemoralheadtotheanteriorrimoftheacetabularsourcil.Canbe
sensitiveforOAnotevidentinotherviews.
Normal:25º-35º
Dysplastic:<20º
Overcovered:>40º
17
vonRosenView
ThevonRosenviewisafunctionalradiographthatisusefulforpre-operativeplanningforaPAO,aswellasa
screeningtooltoidentifypatientswithincongruenceoradvancedOAwhomayfarepoorlywithjointpreservingprocedures.Theimageisobtainedwithbothlegsinmaximalabductionandinternalrotation,
whichreflectsthejointcongruencethatcanbeachievedwithrotationoftheacetabularfragmentfromaPAO.
MRIRadialViews
Theimageplaneofradialviewsisperpendiculartothecentral,longitudinalaxisofthefemoralneckinaround
360ºlikea'clockface'.Mostcamlesionsarealongtheanterosuperiorfemoralhead-neckjunction,which
correspondsto1-3o'clock(lefthip).
Formattingradialviews
'Clockface'planeofimages
Sampleradialview
18
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