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Age-Related Differences in Radiographic Parameters for Femoroacetabular Impingement in Hip Arthroplasty Patients Geoffrey S

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Age-Related Differences in Radiographic Parameters for Femoroacetabular Impingement in Hip Arthroplasty Patients Geoffrey S Age-Related Differences in Radiographic Parameters for Femoroacetabular Impingement in Hip Arthroplasty Patients Geoffrey S. Van Thiel, M.D., M.B.A., Joshua D. Harris, M.D., Richard W. Kang, M.D., M.S., Jaskarndip Chahal, M.D., Craig J. Della Valle, M.D., Charles A. Bush-Joseph, M.D., and Shane J. Nho, M.D., M.S. Purpose: To compare the prevalence of femoroacetabular impingement (FAI) radiographic findings between patients aged younger than 50 years and those aged 50 years or older who underwent total hip arthroplasty. Methods: Total hip arthroplasty patients aged younger than 50 years and those aged 50 years or older were identified retrospectively from a facility medical record database. Fifty patients from each group were randomly selected, and preoperative radiographs were collected. Dysplastic, inflammatory, post-traumatic, and osteonecrosis patients were excluded. Radiographs were evaluated for FAI-specific findings. Intraobserver and interobserver reliability was evaluated with k statistics for categorical variables and intraclass correlation coefficients for continuous variables. An independent t test was used to compare continuous variables, c2 analysis was used for discrete variables, and a z ratio was used to analyze proportions. Results: The mean age between the subgroups of patients aged younger than 50 years and those aged 50 years or older (43 years and 68 years, respectively) was significantly different (P < .05). Findings in the subgroup aged younger than 50 years included significantly more men (P < .001), decreased lateral joint space with maintained medial joint space (P < .05), significantly greater alpha angle on both the anteroposterior view and the frog-leg lateral view (P < .05), significantly higher Tönnis and Sharp angles (P < .01), and significantly lower center-edge angle (P < .001). Conclusions: This retrospective case series shows an increased prevalence of FAI findings (specifically cam pathology) in a patient population aged younger than 50 years undergoing total hip arthroplasty when compared with a cohort aged 50 years or older. Level of Evidence: Level III, retrospective comparative study. here are multiple etiologies leading to end-stage anteriorly and laterally that reduces head-neck offset, Tdegenerative joint disease of the hip in young creating head asphericity. This equates to an osseous patients. Dysplasia, osteonecrosis, Perthes disease, post- bump on radiographs, a pistol-grip deformity, and flat- traumatic deformity, and inflammatory arthropathies are tening of the lateral head. Pincer abnormalities are among the common causes.1 However, there are a large observed at the acetabulum, with relative overcoverage of number of young patients who appear to have a primary the femoral head. This equates to a crossover sign, arthritic process. Femoroacetabular impingement (FAI) a posterior wall sign, and excessive acetabular over- has been proposed as a significant cause of premature hip coverage. The pathomechanics of an aspherical head in degeneration in the young patient.1-5 The impingement a spherical acetabulum or a mechanical block to motion may take the form of cam, pincer, or combined/mixed due to overcoverage may lead to abnormal contact, lesions.4 Cam abnormalities are observed at the femoral leading to premature degeneration.4 Advancements in head-neck junction, with excessive bone and cartilage the diagnosis and understanding of FAI have led to the development of new treatment algorithms and modali- From the Rush University Medical Center (G.S.V.T., J.D.H., R.W.K., J.C., ties. This is clearly seen in the exponential increase of C.J.D.V., C.A.B.-J., S.J.N.), Chicago, and Rockford Orthopedic Associates, Ltd arthroscopic hip procedures that are performed in (G.S.V.T.), Rockford, Illinois, U.S.A.; and University of Toronto (J.C.), Tor- contemporary orthopaedic surgery.6 However, the ques- onto, Ontario, Canada. The authors report that they have no conflicts of interest in the authorship tion still remains as to what is the cause, effect, and rela- and publication of this article. tion of FAI to early degeneration of the hip. Furthermore, Received October 10, 2012; accepted April 16, 2013. it is unknown whether surgical correction of radiographic Address correspondence to Joshua D. Harris, M.D., Midwest Orthopaedics FAI abnormalities halts progression to osteoarthritis. at Rush, Rush University Medical Center, 1611 W Harrison St, Chicago, IL Clohisy et al.2 recently reported that 35% of patients 60612, U.S.A. E-mail: [email protected] Ó 2013 by the Arthroscopy Association of North America aged younger than 50 years who underwent a total 0749-8063/12664/$36.00 hip arthroplasty with a diagnosis of osteoarthritis had http://dx.doi.org/10.1016/j.arthro.2013.04.013 radiographic evidence of FAI. They also found a 73% rate 1182 Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 29, No 7 (July), 2013: pp 1182-1187 AGE-RELATED RADIOGRAPHIC PARAMETERS IN FAI 1183 of arthroplasty or advancement in osteoarthritis grade in the contralateral hip with bilateral findings of FAI. These results suggest a distinct relation between impingement and end-stage hip degeneration. However, in a prospec- tive study of asymptomatic volunteers, Laborie et al.7 found a 35% rate of cam deformities and a 34% rate of pincer lesions in men (the rates were 10% and 17%, respectively, in women). Moreover, Register et al.8 found a high prevalence of 3.0-T magnetic resonance imagingediagnosed FAI findings in asymptomatic vol- unteers, including a 20% prevalence of osseous bumps. Furthermore, male patients were 8.5 times more likely Fig 1. Standing AP pelvis radiograph. The center-edge angle fi (95% con dence interval, 1.2 to 56 times) to have an (CEA) is calculated by first drawing a line connecting the osseous bump than female patients. This calls into inferior tips of the radiographic pelvic teardrops. A vertical question the pathologic relation by showing a high rate of line perpendicular to the first line is then drawn through the impingement findings in patients without hip disease. center of the femoral head (by use of the Mose circle). Next, Ganz and colleagues4,5,9 have also proposed that struc- a line is drawn through the center of the femoral head and the tural abnormalities associated with cam and pincer lateral acetabular edge. The CEA is the angle subtended by the impingement can lead to advanced arthrosis. Nonethe- vertical line and the latter. The Sharp angle (S) is calculated by fi less, a direct relation between FAI and end-stage hip rst drawing a line connecting the inferior tips of the radio- graphic pelvic teardrops. Next, a line is drawn connecting the degeneration has not been established and represents the inferior tip of the teardrop to the lateral edge of the acetab- crux of current hip research in the young patient. ulum. The Sharp angle is the angle subtended by these 2 lines. The purpose of this study was to compare the prev- The Tönnis angle (T) is calculated by first drawing a line fi alence of FAI radiographic ndings between patients parallel to the transverse line connecting the radiographic aged younger than 50 years and those aged 50 years or teardrops. Next, a line is drawn connecting the inferior and older who underwent total hip arthroplasty. We lateral margins of the sourcil. The Tönnis angle is the angle hypothesized that FAI would be significantly more subtended by these 2 lines. common in a patient population aged younger than 50 years who required hip arthroplasty than an older patient subset. acceptable range for men was between 8 and 50 mm, Methods and for women, it was between 15 and 72 mm.11 Patients who underwent a total hip arthroplasty Two blinded independent observers analyzed the between January 2007 and June 2009 were retro- preoperative radiographs. Measurements were made spectively identified from a facility repository database. on the anteroposterior (AP) pelvis (Fig 1) and frog-leg Fifty patients each were then randomly selected from 1 lateral (Fig 2) radiographs of the affected hip. The of 2 subgroups, and all preoperative radiographs were following parameters were determined12,13: center of collected. One subgroup consisted of all patients who the femoral head, which was identified with the use of were aged younger than 50 years (mean, 43 years; SD, Mose circles14; alpha angle on the AP and lateral views; 5.6 years), whereas the other subgroup contained neck-shaft angle; Tönnis angle; center-edge angle; patients who were aged 50 years or older (mean, 68 Sharp angle15; presence of osteophytes; medial/lateral years; SD, 8.3 years). Both subgroups were chosen with joint space; congruency; presence of herniation pits; specific inclusion/exclusion criteria. Exclusion criteria lateral head-neck offset ratio; and femoral head extru- included the presence of osteonecrosis, developmental sion. The center-edge angle was defined as the angle dysplasia of the hip, inflammatory arthritides, and post- formed by a vertical line and a line through the center traumatic arthritis. of the femoral head and the lateral acetabular edge on Inclusion criteria included adequate available radio- an AP pelvis radiograph.15,16 This equates to the native graphs with appropriate pelvic tilt and rotation. We acetabulum in a radiographically normal hip and an assessed rotation by qualitatively assessing the obtu- osteophyte in an osteoarthritic hip. The Sharp angle rator foramen for symmetry, as well as quantitatively used 2 reference points on an AP pelvis radiograph15: by drawing a plumb line from the lumbar spinous one was the lateral edge of the acetabular roof, and the processes through the pelvis.10 A distance between the other was the inferior tip of the pelvic teardrop. By use plumb line and the pubic symphysis of less than 16 mm of a line connecting bilateral teardrops and the lateral was considered adequate.10,11 Pelvic tilt was deter- edge of the acetabular roof, the angle of inclination, or mined by measuring the distance between the sacro- Sharp angle, can be measured (Fig 1).
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