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Assessment of Femoral Torsion on Magnetic Resonance Imaging is More Reliable Using Axial-Oblique Sequences Compared With Standard Axial Slices in Patients With Femoroacetabular Impingement Syndrome

Published:November 25, 2021DOI:https://doi.org/10.1016/j.arthro.2021.11.026

      Purpose

      To determine the agreeability of femoral torsion measurements on axial and oblique axial magnetic resonance imaging (MRI) sequences in patients with femoroacetabular impingement syndrome (FAIS).

      Methods

      Patients who underwent primary hip arthroscopy for FAIS between January 2012 to January 2019 were identified. Inclusion criteria were all patients with an MRI scan containing the pelvis and knee imaging. MRI-based measurements of femoral torsion were performed on axial and oblique-axial slices by 2 raters, and inter-rater and intrarater reliability was assessed. Bland Altman plots were constructed to evaluate the agreeability between femoral torsion measurements performed using axial and oblique-axial slices. Bivariate correlation analyses were performed to assess the relationship between measurement methods on each respective scan. A linear regression was performed between measurements performed using axial and oblique-axial sequences.

      Results

      A total of 164 patients were included. The mean true-axial and oblique axial femoral torsion were 12.2° ± 9.9° and 11.1° ± 9.2°, respectively. The intrarater reliability for axial and oblique-axial measurements were 0.993 and 0.997, respectively. The inter-rater reliability for axial and oblique-axial measurements were 0.925 and 0.965, respectively. The number of differences within the limits of agreement for axial and oblique-axial femoral torsion measurements was 58.54%. On Pearson correlation analysis, strong positive correlations were found between oblique-axial measurements at multiple time points (r = 0.994, P < .001), as well as axial measurements at multiple time points (r = 0.986, P < .001). A strong positive correlation was found between axial and oblique-axial measurements (r = 0.894, P < .001). A significant regression equation indicated that for each additional increase in axial femoral torsion, the oblique-axial femoral torsion increased 0.837 (95% confidence interval 0.772-0.901).

      Conclusions

      Femoral torsion values measured on oblique-axial sequences are smaller than on true-axial sequences. Femoral torsion measurements on axial and oblique-axial MRI sequences exhibit poor agreement. Oblique-axial sequences demonstrated greater measurement consistency at multiple timepoints. When evaluating torsional measurements, it is important to delineate which axial sequence was used, especially in patients with suspected severe femoral antetorsion. Standardization of MRI femoral version protocols within one’s practice can ensure more consistent decision-making, especially in patients with suspected femoral antetorsion.

      Level of Evidence

      Retrospective cohort, level III.
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      References

        • Amanatullah D.F.
        • Antkowiak T.
        • Pillay K.
        • et al.
        Femoroacetabular impingement: current concepts in diagnosis and treatment.
        Orthopedics. 2015; 38: 185-199
        • Ghaffari A.
        • Davis I.
        • Storey T.
        • Moser M.
        Current Concepts of Femoroacetabular Impingement.
        Radiol Clin North Am. 2018; 56: 965-982
        • Griffin J.W.
        • Weber A.E.
        • Kuhns B.
        • Lewis P.
        • Nho S.J.
        Imaging in hip arthroscopy for femoroacetabular impingement: A comprehensive approach.
        Clin Sports Med. 2016; 35: 331-344
        • Bedi A.
        • Kelly B.T.
        Femoroacetabular impingement.
        J Bone Joint Surg Am. 2013; 95: 82-92
        • Lerch T.D.
        • Todorski I.A.S.
        • Steppacher S.D.
        • et al.
        Prevalence of femoral and acetabular version abnormalities in patients with symptomatic hip disease: A controlled study of 538 hips.
        Am J Sports Med. 2018; 46: 122-134
        • Kunze K.N.
        • Alter T.D.
        • Newhouse A.C.
        • Bessa F.S.
        • Williams J.C.
        • Nho S.J.
        Association between orientation and magnitude of femoral torsion and propensity for clinically meaningful improvement after hip arthroscopy for femoroacetabular impingement syndrome: A computed tomography analysis.
        Am J Sports Med. 2021; 49: 2466-2474
        • Fabricant P.D.
        • Bedi A.
        • De La Torre K.
        • Kelly B.T.
        Clinical outcomes after arthroscopic psoas lengthening: The effect of femoral version.
        Arthroscopy. 2012; 28: 965-971
        • Krishnamoorthy V.P.
        • Kunze K.N.
        • Beck E.C.
        • et al.
        Radiographic prevalence of symphysis pubis abnormalities and clinical outcomes in patients with femoroacetabular impingement syndrome.
        Am J Sports Med. 2019; 47: 1467-1472
        • Chahla J.
        • Nwachukwu B.U.
        • Beck E.C.
        • et al.
        Influence of acetabular labral tear length on outcomes after hip arthroscopy for femoroacetabular impingement syndrome with capsular plication.
        Am J Sports Med. 2019; 47: 1145-1150
        • Malloy P.
        • Stone A.V.
        • Kunze K.N.
        • Neal W.H.
        • Beck E.C.
        • Nho S.J.
        Patients with unilateral femoroacetabular impingement syndrome have asymmetrical hip muscle cross-sectional area and compensatory muscle changes associated with preoperative pain level.
        Arthroscopy. 2019; 35: 1445-1453
        • Krishnamoorthy V.P.
        • Beck E.C.
        • Kunze K.N.
        • et al.
        Radiographic prevalence of sacroiliac joint abnormalities and clinical outcomes in patients with femoroacetabular impingement syndrome.
        Arthroscopy. 2019; 35: 2598-2605 e2591
        • Kraeutler M.J.
        • Chadayammuri V.
        • Garabekyan T.
        • Mei-Dan O.
        Femoral version abnormalities significantly outweigh effect of cam impingement on hip internal rotation.
        J Bone Joint Surg Am. 2018; 100: 205-210
        • Lerch T.D.
        • Boschung A.
        • Todorski I.A.S.
        • et al.
        Femoroacetabular impingement patients with decreased femoral version have different impingement locations and intra- and extraarticular anterior subspine FAI on 3D-CT-based impingement simulation: Implications for hip arthroscopy.
        Am J Sports Med. 2019; 47: 3120-3132
        • Fabricant P.D.
        • Fields K.G.
        • Taylor S.A.
        • Magennis E.
        • Bedi A.
        • Kelly B.T.
        The effect of femoral and acetabular version on clinical outcomes after arthroscopic femoroacetabular impingement surgery.
        J Bone Joint Surg Am. 2015; 97: 537-543
        • Murphy S.B.
        • Simon S.R.
        • Kijewski P.K.
        • Wilkinson R.H.
        • Griscom N.T.
        Femoral anteversion.
        J Bone Joint Surg Am. 1987; 69: 1169-1176
        • Beebe M.J.
        • Wylie J.D.
        • Bodine B.G.
        • et al.
        Accuracy and reliability of computed tomography and magnetic resonance imaging compared with true anatomic femoral version.
        J Pediatr Orthop. 2017; 37: e265-e270
        • Sutter R.
        • Dietrich T.J.
        • Zingg P.O.
        • Pfirrmann C.W.
        Assessment of femoral antetorsion with MRI: Comparison of oblique measurements to standard transverse measurements.
        Am J Roentgenol. 2015; 205: 130-135
        • Schmaranzer F.
        • Lerch T.D.
        • Siebenrock K.A.
        • Tannast M.
        • Steppacher S.D.
        Differences in femoral torsion among various measurement methods increase in hips with excessive femoral torsion.
        Clin Orthop Relat Res. 2019; 477: 1073-1083
        • Kaiser P.
        • Attal R.
        • Kammerer M.
        • et al.
        Significant differences in femoral torsion values depending on the CT measurement technique.
        Arch Orthop Trauma Surg. 2016; 136: 1259-1264
        • Fuller C.B.
        • Farnsworth C.L.
        • Bomar J.D.
        • et al.
        Femoral version: Comparison among advanced imaging methods.
        J Orthop Res. 2018; 36: 1536-1542
        • Frank R.M.
        • Lee S.
        • Bush-Joseph C.A.
        • Kelly B.T.
        • Salata M.J.
        • Nho S.J.
        Improved outcomes after hip arthroscopic surgery in patients undergoing T-capsulotomy with complete repair versus partial repair for femoroacetabular impingement: A comparative matched-pair analysis.
        Am J Sports Med. 2014; 42: 2634-2642
        • Harris J.D.
        • Slikker 3rd, W.
        • Gupta A.K.
        • McCormick F.M.
        • Nho S.J.
        Routine complete capsular closure during hip arthroscopy.
        Arthrosc Tech. 2013; 2: e89-e94
        • Beck E.C.
        • Alter T.
        • Mehta N.
        • et al.
        Contemporary hip capsular management and closure using a suture passing device.
        Arthrosc Tech. 2019; 8: e947-e952
        • Hernandez R.J.
        • Tachdjian M.O.
        • Poznanski A.K.
        • Dias L.S.
        CT determination of femoral torsion.
        Am J Roentgenol. 1981; 137: 97-101
        • Sugano N.
        • Noble P.C.
        • Kamaric E.
        A comparison of alternative methods of measuring femoral anteversion.
        J Comput Assist Tomogr. 1998; 22: 610-614
        • Tonnis D.
        • Heinecke A.
        Acetabular and femoral anteversion: relationship with osteoarthritis of the hip.
        J Bone Joint Surg Am. 1999; 81: 1747-1770
        • Jarrett D.Y.
        • Oliveira A.M.
        • Zou K.H.
        • Snyder B.D.
        • Kleinman P.K.
        Axial oblique CT to assess femoral anteversion.
        Am J Roentgenol. 2010; 194: 1230-1233
      1. Cohen J. The Effect Size Index: D. Statistical Power Analysis for the Behavioral Sciences. 2 ed1988.

        • Lin L.J.
        • Akpinar B.
        • Bloom D.A.
        • Youm T.
        Age and outcomes in hip arthroscopy for femoroacetabular impingement: A comparison across 3 age groups.
        Am J Sports Med. 2021; 49: 82-89
        • Knapik D.M.
        • Clapp I.M.
        • Wichman D.
        • Nho S.J.
        Use of younger patient age and greater anterior center-edge angle to predict the need for bilateral hip arthroscopy in patients with bilateral femoroacetabular impingement-related hip pain.
        Am J Sports Med. 2021; 49: 2110-2116
        • Beck E.C.
        • Drager J.
        • Nwachukwu B.U.
        • Jan K.
        • Rasio J.
        • Nho S.J.
        Gender and age-specific differences observed in rates of achieving meaningful clinical outcomes 5-years after hip arthroscopy for femoroacetabular impingement syndrome.
        Arthroscopy. 2021; 37: 2488-2496 e2481
        • Kunze K.N.
        • Polce E.M.
        • Nwachukwu B.U.
        • Chahla J.
        • Nho S.J.
        Development and internal validation of supervised machine learning algorithms for predicting clinically significant functional improvement in a mixed population of primary hip arthroscopy.
        Arthroscopy. 2021; 37: 1488-1497
        • Parvaresh K.
        • Rasio J.P.
        • Wichman D.
        • Chahla J.
        • Nho S.J.
        The influence of body mass index on outcomes after hip arthroscopy for femoroacetabular impingement syndrome: Five-year results in 140 patients.
        Am J Sports Med. 2021; 49: 90-96
        • Beck E.C.
        • Nwachukwu B.U.
        • Jan K.
        • et al.
        The effect of postoperative opioid prescription refills on achieving meaningful clinical outcomes after hip arthroscopy for femoroacetabular impingement syndrome.
        Arthroscopy. 2020; 36: 1599-1607
        • Matsuda D.K.
        • Gupta N.
        • Martin H.D.
        Closed intramedullary derotational osteotomy and hip arthroscopy for cam femoroacetabular impingement from femoral retroversion.
        Arthrosc Tech. 2014; 3: e83-e88
        • Hartigan D.E.
        • Perets I.
        • Walsh J.P.
        • Domb B.G.
        Femoral derotation osteotomy technique for excessive femoral anteversion.
        Arthrosc Tech. 2017; 6: e1405-e1410
        • Nelitz M.
        Femoral Derotational Osteotomies.
        Curr Rev Musculoskelet Med. 2018; 11: 272-279
        • Chaharbakhshi E.O.
        • Hartigan D.E.
        • Perets I.
        • Domb B.G.
        Is hip arthroscopy effective in patients with combined excessive femoral anteversion and borderline dysplasia? A match-controlled study.
        Am J Sports Med. 2019; 47: 123-130
        • Botser I.B.
        • Ozoude G.C.
        • Martin D.E.
        • Siddiqi A.J.
        • Kuppuswami S.
        • Domb B.G.
        Femoral anteversion in the hip: comparison of measurement by computed tomography, magnetic resonance imaging, and physical examination.
        Arthroscopy. 2012; 28: 619-627
        • Marcovigi A.
        • Ciampalini L.
        • Perazzini P.
        • Caldora P.
        • Grandi G.
        • Catani F.
        Evaluation of native femoral neck version and final stem version variability in patients with osteoarthritis undergoing robotically implanted total hip arthroplasty.
        J Arthroplasty. 2019; 34: 108-115
        • Dolan M.M.
        • Heyworth B.E.
        • Bedi A.
        • Duke G.
        • Kelly B.T.
        CT reveals a high incidence of osseous abnormalities in hips with labral tears.
        Clin Orthop Relat Res. 2011; 469: 831-838
        • Lall A.C.
        • Battaglia M.R.
        • Maldonado D.R.
        • et al.
        Does Femoral Retroversion Adversely Affect Outcomes After Hip Arthroscopy for Femoroacetabular Impingement Syndrome? A midterm analysis.
        Arthroscopy. 2019; 35: 3035-3046
        • Chadayammuri V.
        • Garabekyan T.
        • Bedi A.
        • et al.
        Passive hip range of motion predicts femoral torsion and acetabular version.
        J Bone Joint Surg Am. 2016; 98: 127-134
        • Gorelik N.
        • Boily M.
        • Lafreniere A.S.
        • et al.
        Impact of the T2-weighted axial oblique MRI sequence in the assessment of peroneal tendons.
        Clin Radiol. 2020; 75: 642 e615-642 e623
        • Ziegert A.J.
        • Blankenbaker D.G.
        • De Smet A.A.
        • Keene J.S.
        • Shinki K.
        • Fine J.P.
        Comparison of standard hip MR arthrographic imaging planes and sequences for detection of arthroscopically proven labral tear.
        Am J Roentgenol. 2009; 192: 1397-1400
        • Woo S.
        • Moon M.H.
        • Cho J.Y.
        • Kim S.H.
        • Kim S.Y.
        Diagnostic performance of MRI for assessing parametrial invasion in cervical cancer: A head-to-head comparison between oblique and true axial T2-weighted images.
        Korean J Radiol. 2019; 20: 378-384
        • Tonnis D.
        • Heinecke A.
        Diminished femoral antetorsion syndrome: A cause of pain and osteoarthritis.
        J Pediatr Orthop. 1991; 11: 419-431
        • Lansdown D.A.
        • Cvetanovich G.L.
        • Verma N.N.
        • et al.
        Automated 3-dimensional magnetic resonance imaging allows for accurate evaluation of glenoid bone loss compared with 3-dimensional computed tomography.
        Arthroscopy. 2019; 35: 734-740
        • Malloy P.
        • Gasienica J.
        • Dawe R.
        • et al.
        1.5 T magnetic resonance imaging generates accurate 3D proximal femoral models: Surgical planning implications for femoroacetabular impingement.
        J Orthop Res. 2020; 38: 2050-2056
      2. Guidetti M, Malloy P, Alter TD, et al. MRI- and CT-based metrics for the quantification of arthroscopic bone resections in femoroacetabular impingement syndrome [online ahead of print June 30, 2021]. J Orthop Res. doi: 10.1002/jor.25139.