hip pain and hip osteoarthritis

1. FEMORO-ACETABULARFEMORO-ACETABULAR
IMPINGEMENTIMPINGEMENT
CAMPBELL’S OPRATIVE ORTHOPAEDICSCAMPBELL’S OPRATIVE ORTHOPAEDICS
20132013
By: Dr Hamid HejratiBy: Dr Hamid Hejrati
Resident of Orthopedic SurgeryResident of Orthopedic Surgery
Iran, Mashhad university of medical scienceIran, Mashhad university of medical science

2. Anatomic variation of the hip causesAnatomic variation of the hip causes
impingement between theimpingement between the femoral head-femoral head-
neck junctionneck junction andand the acetabular rimthe acetabular rim
during functional range of motion.during functional range of motion.
believed to be one of the primary causesbelieved to be one of the primary causes
of osteoarthritis.of osteoarthritis.

3. Two basic types of impingement haveTwo basic types of impingement have
been described.been described.
Cam impingementCam impingement
Pincer impingementPincer impingement

4. Cam impingementCam impingement
occurs when the anterosuperior femoraloccurs when the anterosuperior femoral
head-neck junction ishead-neck junction is prominentprominent or theor the
femoral neck has afemoral neck has a diminished offsetdiminished offset fromfrom
the adjacent femoral headthe adjacent femoral head

6. A typical injury patternA typical injury pattern  aa tear at thetear at the
base of the labrumbase of the labrum at the labral-chondralat the labral-chondral
junction.junction.

7. The adjacentThe adjacent articular cartilagearticular cartilage thenthen
becomes injured because ofbecomes injured because of compressioncompression
from the femoral head with its relativelyfrom the femoral head with its relatively
larger radius of curvature rotating into thelarger radius of curvature rotating into the
acetabulum.acetabulum.
Frequently, the articular cartilageFrequently, the articular cartilage
delaminatesdelaminates from the underlyingfrom the underlying
subchondral bone, progressing from thesubchondral bone, progressing from the
acetabular rimacetabular rim

9. Cam morphology is more common inCam morphology is more common in
young athletic malesyoung athletic males..

10. TheThe etiologyetiology of the deformity isof the deformity is
unknownunknown, although some authors, although some authors 
may be a mildmay be a mild variant of slipped capitalvariant of slipped capital
femoral epiphysisfemoral epiphysis OROR developmentaldevelopmental
abnormality of the lateral femoralabnormality of the lateral femoral
physisphysis..

11. Pincer impingementPincer impingement
occurs when the acetabular rim has anoccurs when the acetabular rim has an
area ofarea of overcoverageovercoverage causingcausing
impingement against the femoral neckimpingement against the femoral neck
with functional motionwith functional motion

12. Overcoverage can beOvercoverage can be globalglobal, as in coxa, as in coxa
profunda or protrusio acetabuli, or can beprofunda or protrusio acetabuli, or can be
localizedlocalized to the anterior acetabulum asto the anterior acetabulum as
with acetabular retroversion.with acetabular retroversion.

14. Combined mechanism hip impingementCombined mechanism hip impingement
occurs when cam and pincer morphologyoccurs when cam and pincer morphology
coexist in the same hip.coexist in the same hip.

15. According to some authors,According to some authors, most hipsmost hips
treatedtreated for femoroacetabular impingementfor femoroacetabular impingement
havehave combinedcombined morphology.morphology.

17. Accurate diagnosisAccurate diagnosis of the source of pain inof the source of pain in
young adults or adolescents is crucial inyoung adults or adolescents is crucial in
obtaining optimal surgical outcomes withobtaining optimal surgical outcomes with
FAI surgery.FAI surgery.
The diagnosis of FAI is primarily madeThe diagnosis of FAI is primarily made
clinicallyclinically from the patient's history andfrom the patient's history and
physical examination and then correlatedphysical examination and then correlated
with thewith the radiographic findingsradiographic findings..

18. frog-leg lateral,frog-leg lateral,
cross-table lateral,cross-table lateral,
45-degree modified Dunn view of the hip.45-degree modified Dunn view of the hip.
The modified Dunn view is obtained withThe modified Dunn view is obtained with
thethe patient supinepatient supine with thewith the hip in 45hip in 45
degrees of flexiondegrees of flexion,, 20 degrees of20 degrees of
abductionabduction, and, and neutral rotationneutral rotation..
anteroposterior pelvic viewanteroposterior pelvic view

20. thethe femoral head-neck junctionfemoral head-neck junction isis
evaluatedevaluated at different degrees of femoralat different degrees of femoral
rotationrotation for the presence offor the presence of head-neckhead-neck
offset abnormalityoffset abnormality andand anterolateralanterolateral
prominence of the femoral neckprominence of the femoral neck that canthat can
cause cam impingement.cause cam impingement.

22. The Alpha AngleThe Alpha Angle
alpha angle is used to assess the femoralalpha angle is used to assess the femoral
head-neck junction on the lateral andhead-neck junction on the lateral and
modified Dunn views.modified Dunn views.

23. Alfa angleAlfa angle  1.line drawn from the center1.line drawn from the center
of the femoral neck to the center of theof the femoral neck to the center of the
femoral head 2.line drawn from the centerfemoral head 2.line drawn from the center
of the femoral headof the femoral head to the point on theto the point on the
anterior head-neck junctionanterior head-neck junction where thewhere the
contour of thecontour of the femoral head diverges fromfemoral head diverges from
the spherical contourthe spherical contour determined moredetermined more
medially on the head.medially on the head.

25. Larger alpha angles do, however, appearLarger alpha angles do, however, appear
to correlate with greater injury to the hipto correlate with greater injury to the hip
observed at the time of surgery.observed at the time of surgery.
correlated higher alpha angles withcorrelated higher alpha angles with
increasing amounts of chondral injury atincreasing amounts of chondral injury at
the time of arthroscopic FAI surgery.the time of arthroscopic FAI surgery.

26. The alpha angle probably is related to itsThe alpha angle probably is related to its
radial position on the femoral neckradial position on the femoral neck and theand the
associatedassociated geometry of the adjacentgeometry of the adjacent
acetabulumacetabulum..
An alpha angle of more than 60 degreesAn alpha angle of more than 60 degrees
was a predictor of hip pain in anotherwas a predictor of hip pain in another
studystudy

27. Lateral center edgeLateral center edge
(LCE) angle(LCE) angle
< 20 degrees is< 20 degrees is
indicative of hipindicative of hip
dysplasiadysplasia withwith
inadequate coverage ofinadequate coverage of
the femoral head by thethe femoral head by the
lateral dome of thelateral dome of the
acetabulum.acetabulum.
20 to 24 degrees have20 to 24 degrees have
borderline dysplasiaborderline dysplasia..
>40 degrees display>40 degrees display
overcoverageovercoverage..

28. The anterior head-The anterior head-
neck offset rationeck offset ratio thethe
cross-table lateralcross-table lateral
view with the hip in 10view with the hip in 10
degrees of internaldegrees of internal
rotation.rotation.

29. TheThe offset of the femoral headoffset of the femoral head is determined byis determined by
measuring the distance between two lines drawnmeasuring the distance between two lines drawn
parallel to the axis of the femoral neck. The firstparallel to the axis of the femoral neck. The first
line is drawn through the most anterior portion ofline is drawn through the most anterior portion of
the femoral neck, and the second line is drawnthe femoral neck, and the second line is drawn
through thethrough the most anterio portion of the femoralmost anterio portion of the femoral
headhead. The. The ratioratio is determined by dividing thisis determined by dividing this
distance by the diameter of the femoral head.distance by the diameter of the femoral head.
A value of less than 0.15 has a 95% positiveA value of less than 0.15 has a 95% positive
predictive value of diagnosing femor acetabularpredictive value of diagnosing femor acetabular
impingement.impingement.

30. Special Tests
FADIR impingement test: flexion, adduction, IR
Sensitivity=75%, specificity=43% in identifying patients
with labral tears
FABER
88% sensitive for intra-articular hip pathology
Resisted SLR – assesses labral loading
Log Roll
Interrater reliability=0.63

31. Log Roll Test
The examiner passively
moves the patient’s lower
extremity through the
maximal available range of
hip external (A) and internal
rotation (B).
Eliciting a clicking or popping
sensation may indicate an
acetabular labral tear, while
increased total range of
motion when compared to the
opposite side may indicate
ligament or capsular laxity

32. TREATMENT OPTIONSTREATMENT OPTIONS
SURGICAL DISLOCATION OF THE HIPSURGICAL DISLOCATION OF THE HIP
COMBINED HIP ARTHROSCOPY ANDCOMBINED HIP ARTHROSCOPY AND
LIMITED OPEN OSTEOCHONDROPLASTYLIMITED OPEN OSTEOCHONDROPLASTY
PERIACETABULAR OSTEOTOMYPERIACETABULAR OSTEOTOMY
HIP ARTHROSCOPYHIP ARTHROSCOPY

35. Activities CAUSING FAIActivities CAUSING FAI
Ice HockeyIce Hockey
Horseback RidingHorseback Riding
YogaYoga
Football (American)Football (American)
SoccerSoccer
Ballet/Dance/AcrobaticsBallet/Dance/Acrobatics
GolfGolf
TennisTennis
BaseballBaseball
Field HockeyField Hockey
RugbyRugby
Bike Riding/CyclingBike Riding/Cycling
Martial ArtsMartial Arts
Deep squatting activities such as power liftingDeep squatting activities such as power lifting

36. EtiologyEtiology
Significant athletic activity before skeletalSignificant athletic activity before skeletal
maturity increases the risk of FAI.maturity increases the risk of FAI.
Prior Biomechanical theories suggest thatPrior Biomechanical theories suggest that
cartilage damage is initiated by Concentric orcartilage damage is initiated by Concentric or
Eccentric overload.Eccentric overload.
- Eccentric overload- Eccentric overload
- easily explained by- easily explained by
non-congruent articulations caused bynon-congruent articulations caused by
developmental dysplasias and post-traumaticdevelopmental dysplasias and post-traumatic
anatomyanatomy
- Concentric overload- Concentric overload
- not as easy to explain- not as easy to explain

37. Ganz et al. CORR. 2003Ganz et al. CORR. 2003
-- Summarized the concept of FAISummarized the concept of FAI
- Mechanism for development of- Mechanism for development of
osteoarthritis based on subtle aberrant bony morphologyosteoarthritis based on subtle aberrant bony morphology
-- Acetabular Retroversion / CoxaAcetabular Retroversion / Coxa
ProfundaProfunda
-- Femoral Head non-sphericityFemoral Head non-sphericity
-- Abnormal ContactAbnormal Contact in Normal / Nearin Normal / Near
Normal Appearing HipsNormal Appearing Hips
-- Abutment of the Proximal FemurAbutment of the Proximal Femur
on the Acetabular Rim during terminal motion of the hipon the Acetabular Rim during terminal motion of the hip
leading to lesions of the labrum and/or the adjacentleading to lesions of the labrum and/or the adjacent
cartilagecartilage
-- Chondral and Labral lesionsChondral and Labral lesions progressprogress
and result in degenerative diseaseand result in degenerative disease

38. FAI FormsFAI Forms
Generally occurs as two Cam and Pincer.Generally occurs as two Cam and Pincer.
TheThe Cam formCam form (Cam comes from the(Cam comes from the
Dutch word meaning “cog”) describes theDutch word meaning “cog”) describes the
femoral head and neck relationship asfemoral head and neck relationship as
aspherical.aspherical.
This loss of roundness contributes toThis loss of roundness contributes to
abnormal contact between the head andabnormal contact between the head and
socket.socket.

39. CAM ImpingementCAM Impingement
-- AnatomyAnatomy
- Abnormal Femoral Head/Neck- Abnormal Femoral Head/Neck
junction with increased radius at the waistjunction with increased radius at the waist
- Motion- Motion
- Impingement occurs primarily during- Impingement occurs primarily during
flexion, adduction, IRflexion, adduction, IR
-- MechanicsMechanics
- Contact between the femoral neck- Contact between the femoral neck
and acetabular rim induces compressionand acetabular rim induces compression
- Shear stress generated at the junction- Shear stress generated at the junction
between the labrum and the cartilage and at thebetween the labrum and the cartilage and at the
subchondral tidemarksubchondral tidemark
- Outward avulsion of the labrum- Outward avulsion of the labrum
and/or an inward compression of the articular cartilageand/or an inward compression of the articular cartilage
at Anterosuperior Rimat Anterosuperior Rim
--

40. Etiology of CAM ImpingementEtiology of CAM Impingement
- Elliptical Femoral Head- Elliptical Femoral Head
- Slipped Capital Femoral- Slipped Capital Femoral
Epiphysis -Epiphysis - SCFESCFE
-- Legg Calve PerthesLegg Calve Perthes
-- Adult OsteonecrosisAdult Osteonecrosis
- Malunited Femoral Neck- Malunited Femoral Neck
FracturesFractures

41. The Pincer FormThe Pincer Form
Pincer comes from the French word meaning “toPincer comes from the French word meaning “to
pinch”pinch”
describes the situation where the socket ordescribes the situation where the socket or
acetabulum has too much coverage of femoralacetabulum has too much coverage of femoral
head.head.
This over-coverage typically exists along theThis over-coverage typically exists along the
front-top rim of the acetabulum,front-top rim of the acetabulum,
results in the labral cartilage being “pinched”results in the labral cartilage being “pinched”
between the rim and the anterior femoral head-between the rim and the anterior femoral head-
neck junction.neck junction.

42. Pincer form of the ImpingementPincer form of the Impingement
Secondary to “retroversion”, or “profunda”,Secondary to “retroversion”, or “profunda”,
Most of the time, the Cam and PincerMost of the time, the Cam and Pincer
forms exist together.forms exist together.

43. Pincer ImpingementPincer Impingement
-- AnatomyAnatomy
- Excessive Acetabular Coverage- Excessive Acetabular Coverage
- Motion- Motion
- Dependent on acetabular morphology- Dependent on acetabular morphology
-- MechanicsMechanics
- Linear Contact between the labrum and femoral- Linear Contact between the labrum and femoral
head/neck junctionhead/neck junction
- Anterior = Acetabular Retroversion- Anterior = Acetabular Retroversion
- Circumferential = Coxa Profunda- Circumferential = Coxa Profunda
- Force from the femoral neck is transferred through the- Force from the femoral neck is transferred through the
labrum to the acetabular cartilagelabrum to the acetabular cartilage Results is chronic degeneration ofResults is chronic degeneration of
anterior labrum and subsequent ossificationanterior labrum and subsequent ossification Further deepens theFurther deepens the
cup.cup.
Resultant leverage of head in acetabulum with excessiveResultant leverage of head in acetabulum with excessive
ROM can result in contre-coup lesion in posteroinferior acetabulumROM can result in contre-coup lesion in posteroinferior acetabulum
and posteromedial femoral headand posteromedial femoral head
- Leading to Circumferential involvement- Leading to Circumferential involvement

44. EtiologyEtiology
- Acetabular Retroversion- Acetabular Retroversion
- Coxa Profunda- Coxa Profunda
- Protrusio Acetabuli- Protrusio Acetabuli
- Iatrogenic- Iatrogenic
overcorrection forovercorrection for
retroversion/dysplasiaretroversion/dysplasia
- Coxa Vara- Coxa Vara
- Os Acetabuli- Os Acetabuli

45. ASSOCIATED CARTILAGEASSOCIATED CARTILAGE
FAI is associated with cartilage damage,FAI is associated with cartilage damage,
labral tears,labral tears,
early hip arthritis,early hip arthritis,
hyperlaxity,hyperlaxity,
sports hernias, andsports hernias, and
low back pain.low back pain.
FAI is common in high level athletes, butFAI is common in high level athletes, but
also occurs in active individualsalso occurs in active individuals

46. DiagnosisDiagnosis
Most patients can be diagnosed with aMost patients can be diagnosed with a
good history,good history,
AA patient’s historypatient’s history ..
TheThe physical examphysical exam
TheThe plain x-rayplain x-ray filmsfilms

47. EXAMINATIONEXAMINATION
Gait should be closely scrutinized looking forGait should be closely scrutinized looking for
an abductor lurch,an abductor lurch,
a shortened stance phase,a shortened stance phase,
circumduction, or steppage.circumduction, or steppage.
Leg lengths should be measured using accurateLeg lengths should be measured using accurate
methods.methods.
The patient's posture should be noted, includingThe patient's posture should be noted, including
examination of the back for scoliosis.examination of the back for scoliosis.

48. Anterior femoral-acetabularAnterior femoral-acetabular
impingementimpingement
the affected hip is flexed to ninty degrees and the leg isthe affected hip is flexed to ninty degrees and the leg is
internally rotated and adducted.internally rotated and adducted.
If there is abnormal contact between the anterior-If there is abnormal contact between the anterior-
superior acetabular rim and femoral neck, pain may besuperior acetabular rim and femoral neck, pain may be
elicited.elicited.
Posterior impingement may be tested by having thePosterior impingement may be tested by having the
patient dangle their legs off the end of an examinationpatient dangle their legs off the end of an examination
table,table,
with the affected leg externally rotated by the examiner,with the affected leg externally rotated by the examiner,
and the opposite limb held flexed by the patient. In aand the opposite limb held flexed by the patient. In a
positive exam, the femur contacts the posteriorpositive exam, the femur contacts the posterior
acetabular rim eliciting pain.acetabular rim eliciting pain.

49. EXAMINATIONEXAMINATION
The range of motionThe range of motion
A decreased range of motion of the hip,A decreased range of motion of the hip,
especially in cases of an external rotationespecially in cases of an external rotation
contracture, can point to an intra-articular causecontracture, can point to an intra-articular cause
of the pain.of the pain.
Patients with hip pathology often also develop aPatients with hip pathology often also develop a
flexion contracture. The Thomas test is a helpfulflexion contracture. The Thomas test is a helpful
maneuver.maneuver.
A thorough neurovascular exam should beA thorough neurovascular exam should be
conducted to rule out spine and other neuralconducted to rule out spine and other neural
causes of the patient's pain.causes of the patient's pain.

50. RADIOLOGYRADIOLOGY
The AP pelvis X-ray must be well centeredThe AP pelvis X-ray must be well centered
and well developed as to show a clearand well developed as to show a clear
outline of the acetabulum.outline of the acetabulum.
The coccyx should point toward theThe coccyx should point toward the
symphysis pubis, and there should besymphysis pubis, and there should be
about 1-2 cm between them.about 1-2 cm between them.
The anterior and posterior walls, the tearThe anterior and posterior walls, the tear
drop and the lateral edge of thedrop and the lateral edge of the
acetabulum should be noted.acetabulum should be noted.

51. MeasurementsMeasurements
may be taken to evaluate for hip dysplasiamay be taken to evaluate for hip dysplasia
including theincluding the Tönnis angleTönnis angle (abnormal < 10(abnormal < 10
degrees),degrees),
the lateral center-edge angle of Wibergthe lateral center-edge angle of Wiberg
(abnormal < 25 degrees), and(abnormal < 25 degrees), and
thethe Anterior center-edge angle of LequesneAnterior center-edge angle of Lequesne
(abnormal < 25 degrees) as measured on a(abnormal < 25 degrees) as measured on a
false-profile radiograph.false-profile radiograph.
The neck shaft angleThe neck shaft angle of the proximal femur isof the proximal femur is
considered normal between 120 and 140considered normal between 120 and 140
degrees.degrees.

52. Coxa ProfundaCoxa Profunda
When the floor of the acetabular fossa is inWhen the floor of the acetabular fossa is in
line with the ilioischial line;line with the ilioischial line;
Protrusio is present when the medial mostProtrusio is present when the medial most
femoral head overlaps the ilioischial line.femoral head overlaps the ilioischial line.
The crossover signThe crossover sign is a sensitive and specificis a sensitive and specific
indicator of native acetabular version.indicator of native acetabular version.
On anOn an AP pelvis radiographAP pelvis radiograph, the outlines of, the outlines of
the edges of the anterior and posterior wallsthe edges of the anterior and posterior walls
of the acetabulum should meet superiorlyof the acetabulum should meet superiorly
and laterally.and laterally.

53. COXA PROFUNDACOXA PROFUNDA
In cases ofIn cases of acetabular retroversionacetabular retroversion, this, this
crossover of the anterior and posteriorcrossover of the anterior and posterior
acetabular wall outlines is more distal.acetabular wall outlines is more distal.
Changes in the acetabular rim may alsoChanges in the acetabular rim may also
be noted.be noted.
AA 'double line'double line' is seen in labral' is seen in labral
ossification.ossification.
AnAn os acetabulios acetabuli may also be an indicatormay also be an indicator
of pathologyof pathology

54. Alterations of the proximal femoral anatomy, such asAlterations of the proximal femoral anatomy, such as
head neck offset and bump formation can be observed inhead neck offset and bump formation can be observed in
addition to acetabular and labral pathology.addition to acetabular and labral pathology.
A pistol grip deformity of the femoral head is often seenA pistol grip deformity of the femoral head is often seen
in Cam Type impingement.in Cam Type impingement.
In this situation the superior-lateral head neck junction isIn this situation the superior-lateral head neck junction is
convex instead of concave.convex instead of concave.
A high fovea can also indicate asphericity of the femoralA high fovea can also indicate asphericity of the femoral
head that is not able to be appreciated on the AP films.head that is not able to be appreciated on the AP films.
A cross table lateral may show an abnormality in theA cross table lateral may show an abnormality in the
anterior head neck junction in cases of impingement.anterior head neck junction in cases of impingement.

55. ALPHA ANGLEALPHA ANGLE

56. TONNIS ANGLE

57. LCA
CROSS
OVER

58. PROFUNDA
ACEA

59. MRIMRI
Often an MRI of the hip is used to confirmOften an MRI of the hip is used to confirm
a labral tear or damage to the jointa labral tear or damage to the joint
surface.surface.
The MRI is most helpful in eliminatingThe MRI is most helpful in eliminating
certain causes of non FAI hip paincertain causes of non FAI hip pain
including avascular necrosis (dead bone)including avascular necrosis (dead bone)
and tumors.and tumors.

60. DIFFRENTIAL DIAGNOSISDIFFRENTIAL DIAGNOSIS
Hip Dysplasia (Adult Form)Hip Dysplasia (Adult Form)
Lumbar Spine Pain (Low Back Pain)Lumbar Spine Pain (Low Back Pain)
Lumbar Radiculopathy Low Back Facet Disease)Lumbar Radiculopathy Low Back Facet Disease)
SacroiliitisSacroiliitis
Trochanteric BursitisTrochanteric Bursitis
Piriformis SyndromePiriformis Syndrome
Psychosomatic Pain DisorderPsychosomatic Pain Disorder
Iliopsoas Tendinitis/Tendonitis/TendinosisIliopsoas Tendinitis/Tendonitis/Tendinosis
Groin PullGroin Pull
Sports Hernia (abdominal muscle strain)Sports Hernia (abdominal muscle strain)
Iliac ApophysitisIliac Apophysitis
Quadriceps Hernia/Strain Chronic Pain SyndromesQuadriceps Hernia/Strain Chronic Pain Syndromes

61. TreatmentTreatment
Non-operativeNon-operative
A course of non-operative treatment forA course of non-operative treatment for
most hip pathology may be tried first.most hip pathology may be tried first.
Patients presenting with femoroacetabularPatients presenting with femoroacetabular
impingement or labral disease may tryimpingement or labral disease may try
modification of activitymodification of activity
avoiding excessive hip movementavoiding excessive hip movement
regular non-steroidal anti-inflammatoryregular non-steroidal anti-inflammatory
medicationmedication

62. ArthroscopyArthroscopy
Arthroscopic assessment of the hip can includeArthroscopic assessment of the hip can include
examination of both the central and peripheralexamination of both the central and peripheral
compartments.compartments.
The central compartment includes the labrum and allThe central compartment includes the labrum and all
structures located further medially.structures located further medially.
Tearing of the labrum anterolaterally and damage to theTearing of the labrum anterolaterally and damage to the
acetabular cartilage is characteristic.acetabular cartilage is characteristic.
The lesions of the labrum and any areas of chondralThe lesions of the labrum and any areas of chondral
damage are debrided.damage are debrided.
Labral repair may be possible for specific tears.Labral repair may be possible for specific tears.
For areas of exposed subchondral bone a microfractureFor areas of exposed subchondral bone a microfracture
technique may be performed.technique may be performed.

63. SAFE Surgical Hip Dislocation-SAFE Surgical Hip Dislocation-
OsteoplastyOsteoplasty
Surgical dislocation of the hip has been described.Surgical dislocation of the hip has been described.
A posterior incision (Kocher-Langenbeck) as this approachA posterior incision (Kocher-Langenbeck) as this approach
usually provides better access to posterior parts of the jointusually provides better access to posterior parts of the joint
after the hip is dislocated.after the hip is dislocated.
A trochanteric flip osteotomy is performed. The trochanter isA trochanteric flip osteotomy is performed. The trochanter is
osteotomized from a posterior to anterior direction, the cutosteotomized from a posterior to anterior direction, the cut
exits superficial to the piriformis fossa superiorly and at theexits superficial to the piriformis fossa superiorly and at the
vastus ridge inferiorly.vastus ridge inferiorly.
The gluteus minimus muscle is dissected carefully off theThe gluteus minimus muscle is dissected carefully off the
capsule starting at the piriformis interval.capsule starting at the piriformis interval.
The capsulotomy is Z-shaped (for the right hip), with theThe capsulotomy is Z-shaped (for the right hip), with the
superior limb located along the posterior acetabular rim, andsuperior limb located along the posterior acetabular rim, and
the inferior limb located at the level of the anteromedialthe inferior limb located at the level of the anteromedial
femoral neckfemoral neck

64. After dislocation of the hip, the acetabular labrum andAfter dislocation of the hip, the acetabular labrum and
the adjacent articular cartilage are assessed, and thethe adjacent articular cartilage are assessed, and the
identified lesions are tested for partial or completeidentified lesions are tested for partial or complete
avulsions from the acetabular rim.avulsions from the acetabular rim.
The severity, extent, and location of these lesions shouldThe severity, extent, and location of these lesions should
be defined, and their association with FAI should bebe defined, and their association with FAI should be
confirmed by provocative maneuvers in flexion andconfirmed by provocative maneuvers in flexion and
internal rotation with the head relocated.internal rotation with the head relocated.
The combination of anterior over coverage and theThe combination of anterior over coverage and the
status of the labrum and the acetabular articular cartilagestatus of the labrum and the acetabular articular cartilage
will determine the type of treatment of the acetabularwill determine the type of treatment of the acetabular
rim.rim.
In cases of anterior over coverage contributing to FAI,In cases of anterior over coverage contributing to FAI,
as is frequent with acetabular retroversion, a resectionas is frequent with acetabular retroversion, a resection
osteoplasty of the anterosuperior rim is done.osteoplasty of the anterosuperior rim is done.

65. Periacetabular OsteotomyPeriacetabular Osteotomy
Reorientation of the articulating surfaces of theReorientation of the articulating surfaces of the
hip joint is an attractive procedure in the patienthip joint is an attractive procedure in the patient
with hip dysplasia.with hip dysplasia.
Increased joint congruity after reorientation ofIncreased joint congruity after reorientation of
the osteotomized fragment allows loadthe osteotomized fragment allows load
transmission through a broader area subjectedtransmission through a broader area subjected
to less pressure.to less pressure.
These changes can be expected to reduce painThese changes can be expected to reduce pain
and possibly protect the articular cartilage fromand possibly protect the articular cartilage from
degenerative changesdegenerative changes

66. Pelvic OsteotomyPelvic Osteotomy
Corrects the major anatomic abnormalityCorrects the major anatomic abnormality
and has the further advantage overand has the further advantage over
femoral osteotomy of not creating afemoral osteotomy of not creating a
secondary femoral deformity.secondary femoral deformity.
Femoral osteotomy may be added toFemoral osteotomy may be added to
pelvic osteotomy when coexistent femoralpelvic osteotomy when coexistent femoral
anatomic abnormalities are significant.anatomic abnormalities are significant.

67. Bernese Periacetabular OsteotomyBernese Periacetabular Osteotomy
The is indicated for patients with hipThe is indicated for patients with hip
symptoms of mechanical overload,symptoms of mechanical overload,
impingement, or hip instability as a resultimpingement, or hip instability as a result
of insufficient acetabular coverage.of insufficient acetabular coverage.