Abstract
Femoral version abnormalities have been increasingly recognized as a key factor in the pathogenesis of nonarthritic hip pain. Excessive femoral anteversion (EFA), defined as femoral anteversion greater than 20°, has been postulated to create unstable alignment of the hip, which is exacerbated in patients with concomitant borderline hip dysplasia (BHD). The optimal treatment algorithm for hip pain in EFA-BHD patients remains debated, with some surgeons advocating against arthroscopic procedures in isolation owing to the combined instability due to the femoral and acetabular abnormalities. When determining the treatment approach for an EFA-BHD patient, clinicians should discern whether the patient is presenting with symptoms due to femoroacetabular impingement versus hip instability. When addressing symptomatic hip instability, clinicians are encouraged to evaluate for the Beighton score and additional radiographic factors (other than the lateral center-edge angle) suggestive of instability, such as a Tönnis angle greater than 10°, coxa valga, and deficient anterior or posterior acetabular wall coverage. Because the combination of these additional instability findings with EFA-BHD may portend an inferior outcome after arthroscopic treatment in isolation, an open procedure such as periacetabular osteotomy can be a more reliable treatment option for symptomatic hip instability in this cohort.
Seventeenth-century philosopher Baruch Spinoza proposed, “Nothing in nature is random. A thing appears random only through the incompleteness of our knowledge.” This is often evident in our growing understanding of patients with borderline hip dysplasia (BHD). This cohort can present with a wide spectrum of complaints and examination findings, ranging from femoroacetabular impingement syndrome (FAIS) to hip instability symptoms.
1- Saks B.R.
- Fox J.D.
- Owens J.S.
- et al.
One bony morphology, two pathologic entities: Sex-based differences in patients with borderline hip dysplasia undergoing hip arthroscopy.
Furthermore, the optimal treatment approach remains debated, with varying outcomes reported after arthroscopic surgery, as well as open procedures such as periacetabular osteotomy.
2- Murata Y.
- Fukase N.
- Martin M.
- et al.
Comparison between hip arthroscopic surgery and periacetabular osteotomy for the treatment of patients with borderline developmental dysplasia of the hip: A systematic review.
,3- Nepple J.J.
- Fowler L.M.
- Larson C.M.
Decision-making in the borderline hip.
Although differences in clinical presentation and outcomes between hips with BHD may seem “random,” these discrepancies may instead be attributed to an “incompleteness” in our understanding of the multitude of factors affecting BHD patients.
In the past decade, femoral version abnormalities have garnered increased attention as an additional factor that can exacerbate FAIS or hip instability.
4- 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.
,5- Sinkler M.A.
- Magister S.J.
- Su C.A.
- Salata M.J.
Femoral version may impact hip arthroscopy outcomes in select patient populations: A systematic review.
This concept has been elegantly investigated by Marland, Horton, Smythe, West, and Wylie
6- Marland J.D.
- Horton B.S.
- Smythe J.J.
- West H.S.
- Wylie J.D.
Combined borderline acetabular dysplasia and increased femoral anteversion is associated with worse outcomes in female patients undergoing hip arthroscopy for femoroacetabular impingement.
in their article “Combined Borderline Acetabular Dysplasia and Increased Femoral Anteversion Is Associated With Worse Outcomes in Female Patients Undergoing Hip Arthroscopy for Femoroacetabular Impingement.” They observed that excessive femoral anteversion (EFA), defined as femoral anteversion greater than 20°, with BHD was associated with significantly worse iHOT-12 (International Hip Outcome Tool, short version) scores compared with control patients at 2 to 4 years’ follow-up after hip arthroscopy. Notably, patients with EFA or BHD in isolation also exhibited inferior outcomes, although to a lesser extent, compared with the EFA-BHD cohort. We commend these authors for a well-designed study that demonstrates the importance of recognizing the multiple factors that can contribute to hip symptoms.
Chaharbakhshi et al.
7- 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.
observed a significant improvement in all patient-reported outcomes in EFA-BHD patients after hip arthroscopy. Although patient-reported outcomes in this group were lower than those in the control group both preoperatively and postoperatively, the EFA-BHD patients experienced a similar magnitude of improvement after surgery compared with the control group. Moreover, Chaharbakhshi et al. observed higher iHOT-12 scores at most recent follow-up in comparison to the findings of Marland et al.
6- Marland J.D.
- Horton B.S.
- Smythe J.J.
- West H.S.
- Wylie J.D.
Combined borderline acetabular dysplasia and increased femoral anteversion is associated with worse outcomes in female patients undergoing hip arthroscopy for femoroacetabular impingement.
Rather than attributing this discrepancy to an element of “randomness” seen in clinical research, we believe that these differences between studies, once again, highlight the “incompleteness” in our understanding of the complex interplay of factors in this patient population. Some of these factors may be discernible on a closer look at these studies, with Marland et al. observing a higher average age and body mass index in EFA-BHD patients, applying a lower alpha angle threshold of 50° rather than 60° to define a cam deformity, and performing a T-capsulotomy rather than an interportal capsulotomy. However, other contributing factors that affect preoperative decision making were not reported in either of these studies, such as the Beighton score or additional radiographic factors of instability other than the lateral center-edge angle.
8- McClincy M.P.
- Wylie J.D.
- Yen Y.M.
- Novais E.N.
Mild or borderline hip dysplasia: Are we characterizing hips with a lateral center-edge angle between 18° and 25° appropriately?.
,9Dornacher D, Lutz B, Fuchs M, Zippelius T, Reichel H. Acetabular deficiency in borderline hip dysplasia is underestimated by lateral center edge angle alone [published online October 22, 2022]. Arch Orthop Trauma Surg. doi:10.1007/s00402-022-04652-6
In our approach to EFA-BHD patients, we strive to take all the aforementioned factors into consideration prior to proceeding with arthroscopic treatment. We have a lower threshold for performing hip arthroscopy in EFA-BHD patients with a clinical picture consistent with FAIS, consisting of larger cam deformities (alpha angle > 60°), positive impingement test findings, and limitations in hip internal rotation. However, more caution is used for EFA-BHD hips presenting with clinical signs of instability, including positive apprehension test results, a large arc of movement from internal to external rotation, and laterally based pain consistent with abductor fatigue. In the presence of additional osseous and soft-tissue instability factors, such as a Tönnis angle greater than 10°, coxa valga, deficient anterior and posterior acetabular wall coverage (as measured by wall indices), or a Beighton score greater than 6, we may be more inclined to perform a periacetabular osteotomy to provide stability. In EFA-BHD patients with few or none of these additional instability factors, hip arthroscopy can be performed with caution, with the use of labral preservation techniques and judicious capsular management.
10- Domb B.G.
- Chaharbakhshi E.O.
- Perets I.
- Yuen L.C.
- Walsh J.P.
- Ashberg L.
Hip arthroscopic surgery with labral preservation and capsular plication in patients with borderline hip dysplasia: Minimum 5-year patient-reported outcomes.
The complexity of our treatment algorithm for EFA-BHD patients illustrates the challenge facing hip preservation surgeons in the current era, with numerous diagnostic tools and countless data points readily available. Clinicians must account for these abundant factors while also not becoming entangled in the minutiae. According to a maxim attributed to Albert Einstein, “Everything should be made as simple as possible. But not simpler.”
References
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- Fox J.D.
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- et al.
One bony morphology, two pathologic entities: Sex-based differences in patients with borderline hip dysplasia undergoing hip arthroscopy.
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- Martin M.
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Comparison between hip arthroscopic surgery and periacetabular osteotomy for the treatment of patients with borderline developmental dysplasia of the hip: A systematic review.
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Decision-making in the borderline hip.
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Prevalence of femoral and acetabular version abnormalities in patients with symptomatic hip disease: A controlled study of 538 hips.
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Combined borderline acetabular dysplasia and increased femoral anteversion is associated with worse outcomes in female patients undergoing hip arthroscopy for femoroacetabular impingement.
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Is hip arthroscopy effective in patients with combined excessive femoral anteversion and borderline dysplasia? A match-controlled study.
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Mild or borderline hip dysplasia: Are we characterizing hips with a lateral center-edge angle between 18° and 25° appropriately?.
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Hip arthroscopic surgery with labral preservation and capsular plication in patients with borderline hip dysplasia: Minimum 5-year patient-reported outcomes.
Am J Sports Med. 2018; 46: 305-313
Article info
Footnotes
See related article on page 971
The authors report the following potential conflicts of interest or sources of funding: B.G.D. reports that the American Orthopedic Foundation provides grant support that pays staff and expenses related to all research. In addition, B.G.D. receives royalties from Amplitude, Arthrex, DJO Global, Medacta, Stryker, and Orthomerica; receives research and education support from Arthrex, Medacta, and Stryker; receives consulting fees from Arthrex, Medacta, and Stryker; receives speaking fees from Arthrex; receives travel and lodging support from Arthrex, Medacta, Stryker, and Prime Surgical; receives educational support from Arthrex, Breg, Medwest Associates, St. Alexius Medical Center, and Ossur; receives food/beverage payments from Arthrex, DJO Global, Medacta, Stryker, Zimmer Biomet, DePuy Synthes Sales, Medtronic, and Trice Medical; receives honoraria from Medacta; receives non-consulting fees from Stryker; receives research support from ATI Physical Therapy; and has a medical directorship at St. Alexius Medical Center, outside the submitted work. Moreover, B.G.D. has patents issued and receives royalties for the following: method and instrumentation for acetabular labrum reconstruction (8920497), licensed by Arthrex; adjustable multi-component hip orthosis (8708941), licensed by Orthomerica and DJO Global; and knotless suture anchors and methods of suture repair (9737292), licensed by Arthrex. Finally, B.G.D. is a board member of the American Hip Institute Research Foundation, AANA Learning Center Committee, Journal of Hip Preservation Surgery, and Arthroscopy and has had ownership interests in the American Hip Institute, Hinsdale Orthopedic Associates, Hinsdale Orthopedic Imaging, SCD#3, North Shore Surgical Suites, and Munster Specialty Surgery Center. Full ICMJE author disclosure forms are available for this article online, as supplementary material.
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