hip-problems--is-there-really-a-sex-difference-caitlin...
TRANSCRIPT
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Hip Problems: Is There Really a Sex Difference?CAITLIN CHAMBERS, MD
Outline
� Discuss sex-based differences in:
� Differential diagnoses
� FAI
� Anatomy/Pathoanatomy
� Prevalence
� Presentation
� Treatment
� Outcomes
Disclosures
� None
Differential Diagnosis of Groin Pain:
The Layered Approach1
� Layer 1: Osseous
� Femur, pelvis, acetabulum
� Layer 2: Capsuloligamentous
� Labrum, joint capsule, ligamentum teres
� Layer 3: Myotendinous
� Muscles of pelvis, lumbosacral, pelvic floor
� Layer 4: Neurokinetic
� Lumbosacral plexus, lumbopelvic tissues
� Ilioinguinal, iliohypogastric, genitofemoral nerves
Layer 1 : Osseous
Hip Joint:
female (77%) > male (45%)2
� Static overload
� OA: female = male2
� Femoral neck stress fx: female > male4
� Pubic bone stress injury: male > female2,3
� Dynamic impingement (FAI)
� Male (45.0%) > Female (20.7%) 2
� Dynamic instability (FAI, dysplasia, ligamentous laxity)
� Dysplasia: female > male5
� Ligamentous laxity: female > male6
Layer 2: Capsuloligamentous
� Labrum:
� Female (47.7%) > male (29.5%)2
� Ligamentum teres
� Female (19.3%) > male (7.2%)7
� Capsular laxity
� Females: ↑ capsular volume : femoral head volume ratio8
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Layer 3 : Myotendinous
� Core muscle injury: male > female2,9
� Adductor injury: male > female10
� Iliopsoas injury: female > male11
� Pelvic floor injury: female >> male
Layer 4 : Neurokinetic
Hernias – Seen in combination w/ FAI in 41% of cases12
� Inguinal hernia: men > women
� Femoral hernia: women > men
� “Sports Hernia” / Core Muscle Injury / Athletic Pubalgia: men > women
� Weakened posterior wall of inguinal ring
� Transversalis fascia, conjoined tendon, rectus abdominis insertion, internal/external
abdominal obliques
Femoroacetabular Impingement (“Hip Impingement” / FAI)
� FAI: Abnormal contact between the femoral head and acetabulum � damages labrum between the two
� Pincer: extra bone on the acetabulum
� Cam: extra bone on the femoral head/neck
� Mixed: cam + pincer
https://www.moveforwardpt.com/SymptomsConditionsDetail.aspx?cid=ded8ddca-4386-4d42-bf62-78129e04bd12
Radiographic FAI
Cam
Pincer
FAI Classification: Men vs Women
� CAM: male (84-100%) > female (60-88%)13,14
� Isolated cam: female (47-68%) > male (38-44%) 13
� Larger CAM in men 13,15,16
� Mean alpha: males 63.6-70.8, females 47.8-57.6 13,15
� Alpha >70: 50% males, 16% females
� Pincer: Male (56%) = female (47%) (p=0.464) 13
� Coxa profunda and protrusio: Female (19.7%) > male (7.0%)
� Mixed: Male > Female
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Acetabular / Proximal Femur Anatomy in FAI
� Acetabular Version
� Females:
� ↑ Anteversion (17.3º-22.2º vs 13.9º-19.1º) 13,15,17
� Males:
� ↑ Retroversion (62.7% M vs 55.4% F) 14
� Femoral Version, etc
� Females:
� ↑ Anteversion (14.4º-15.5º vs 11.3º-12.1º) 15,16
� ↑ Femoral neck-shaft angle13
� 134.1º vs 131.2º (p=0.012)
� Combined Version� Females:
� ↑ McKibbin Index (4-6º > than men) 15
Acetabular Dysplasia: Men vs Women
� Infantile DDH: 98% Female18
� Adolescent/Adult-Diagnosed Dysplasia: 88% Female
Sport-Specific Risk of FAI19
� Contact
� Football, rugby, wrestling
� Impingement:
� Ice hockey, crew/rowing, baseball catcher, water polo, equestrian polo, breaststroke swimmer
� Cutting:
� Soccer, basketball, lacrosse, field hockey
� Asymmetric/Overhead:
� Baseball, softball, tennis, golf, volleyball, field events
� Endurance:
� Track, x-country, cycling, swimming
� Flexibility:
� Dance, gymnastics, yoga, cheer, figure skating, martial arts
0% Female0% Female0% Female0% Female
25% Female25% Female25% Female25% Female
38% Female38% Female38% Female38% Female
44% 44% 44% 44% FemaleFemaleFemaleFemale
59% Female59% Female59% Female59% Female
90% Female90% Female90% Female90% Female
Alpha AngleAlpha AngleAlpha AngleAlpha Angle
*66.65*66.65*66.65*66.65º
*67.49*67.49*67.49*67.49º
61.47º
63.54º
*55.87º*55.87º*55.87º*55.87º
*57.91º*57.91º*57.91º*57.91º
Demands of Sport on the Female Hip
� Jump landing mechanics20
� Females:
� Erect at initial contact
� ↑ ROM after contact (force dissipation)
� Hip ROM: 57.9º (50.4º in males)
� Peak hip angular velocity: -579.4 º/sec (-443.6 º/sec in males)
� Supraphysiologic ROM
� MRI of dancers in splits21
� ~2mm femoral head subluxation
� ↑ in dynamic activities
� Labral tears, cartilage thinning, herniation pits (superior and posterosuperior)
� Controls: anterosuperior labral tears, ↓ cartilage lesions/pits
Presentation Differences: ROM
� Normal Hip ROM22
Female Male
� Flexion: 122.0 115.8 (p<0.001)
� IR @ 90 34.7 26.9 (p<0.001)
� IR @ 0 38.9 29.0 (p<0.001)
� ER @ 90 49.7 44.7 (p<0.001)
� ER @ 0 37.0 39.8 (p=0.06)
� FAI Hip ROM13
Female Male
� Flexion: 97.6 94.4 (p=0.003)
� IR @ 90 16.4 6.9 (p<0.001)
� IR @ 0 12.6 8.1 (p<0.001)
� ER @ 90 39.1 27.1 (p<0.001)
� ER @ 0 33.1 28.1 (p=0.08)
� Generalized Joint Hypermobility6
� 36.7% females / 13.7% males
Clinical Presentation13
� Pain Severity
� ↑ Females
� Pain Location
� Anterior groin pain
� Female (86%) = male (94%) (p=0.182)
� Beyond anterior groin
� Female (58%) > Male (32%) (p=0.009)
� Lateral trochanteric
� Female (19%) > Male (10%) (p=0.047)
� Pre-Op PROS
� ↓ Females
mHHS and WOMAC gender differences > MCID
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Significantly more in men:
� Labral detachment length
� 28.4mm vs 22.1mm
� Posterior tear extension
� 24% vs 5%
� Advanced cartilage changes (Beck 4-5)
� 56% vs 24%
� Microfracture (75.8% male) 23
� Cartilage defect size
� 280mm2 vs 208mm2
� Posterior extension of cartilage injury
� 14% vs 0%
Intraoperative Findings13
No gender difference:
� Labral pathomorphology
� Labral repair (76%) vs
debridement (24%)
Significantly more in
women:
� Early cartilage changes
(Beck 1-3)
� 70% vs 44%
Technique Differences
� Stronger caution against iatrogenic destabilization
� Labral preservation
� Capsular plication
� Respect secondary stabilizers
� Iliopsoas
� LT
� Minimal necessary acetabuloplasty (<3mm)
Outcomes: PROS Improvements
� Poorly studied
� Some show equal PROS, others show ↓ scores in females23-28
� Older women (>45) = worst PROS25
Outcomes: Revision Rates
� ↑ ↑ Females23,29-31
� 64% revisions are female compared to 52% primaries
� Reasons for revision30
� Residual intra-articular FAI (74.8%)
� Extra-articular impingement (9.5%)
� Residual acetabular dysplasia (8.2%)
� Other (psoas tendinopathy, capsular adhesions, microinstability, osteochondral lesion) (7.5%)
� Why Females??
� Inadequate functional decompression
� Know that these patients do worse pre-op with lesser pathology
� Hormones & adhesion formation?
� Microinstability
Summary
� Differential Diagnoses: more common in women -
- - Femoral neck stress injury - Dysplasia - Ligamentous laxity
- - Ligamentum heres injury - Iliopsoas injury - Femoral hernia
�
XRs:
� Isolated CAM more common in women
� Smaller CAMs
� ↑ Anteversion (femoral, acetabular, combined)
� Presentation: ↑ pain, ↓ PROS, ↑ ROM
� Intraoperative: Smaller labral tears, less severe cartilage defects
� Outcomes: ↑ Revision
� Beware of iatrogenic instability!
References1. Lynch TS, Bedi A, Larson CM. Athletic Hip Injuries. J Am Acad Orthop Surg 2017;25: 269-279
2. Rankin AT, Bleakley CM, Cullen M. Hip Joint Pathology as a Leading Cause of Groin Pain in the Sporting Population: A 6-Year Review of 894 Cases. Am J Sports Med. 2015;43(7):1698-1703.
3. Birmingham PM, Kelly BT, Jacobs R, McGrady L, Wang M. The effect of dynamic femoroacetabular impingement on pubic symphysis motion: a cadaveric study. Am J Sports Med. 2012;40(5):1113-1118.
4.Brukner P, Bennell K. Stress fractures in female athletes. Diagnosis, management and rehabilitation. Sports Med. 1997;24(6):419-429.
5. Lee CB, Mata-Fink A, Millis MB, Kim YJ. Demographic differences in adolescent-diagnosed and adult-diagnosed acetabular dysplasia compared with infantile developmental dysplasia of the hip. J Pediatr Orthop. 2013;33(2):107-111.
6. Russek LN, Errico DM. Prevalence, injury rate and, symptom frequency in generalized joint laxity and joint hypermobility syndrome in a "healthy" college population. Clin Rheumatol. 2016;35(4):1029-1039.
7. Chahla J, Soares EA, Devitt BM, et al. Ligamentum Teres Tears and Femoroacetabular Impingement: Prevalence and Preoperative Findings. Arthroscopy. 2016;32(7):1293-1297.
8. Frank JM, Lee S, McCormick FM, et al. Quantification and correlation of hip capsular volume to demographic and radiographic predictors. Knee Surg Sports Traumatol Arthrosc. 2016;24(6):2009-2015.
9. Zoland MP, Iraci JC, Bharam S, Waldman LE, Koulotouros JP, Klein D. Sports Hernia/Athletic Pubalgia Among Women. Orthop J Sports Med. 2018;6(9):2325967118796494.
10. Eckard TG, Padua DA, Dompier TP, Dalton SL, Thorborg K, Kerr ZY. Epidemiology of Hip Flexor and Hip Adductor Strains in National Collegiate Athletic Association Athletes, 2009/2010-2014/2015. Am J Sports Med. 2017;45(12):2713-
2722.
11. Babst D, Steppacher SD, Ganz R, Siebenrock KA, Tannast M. The iliocapsularis muscle: an important stabilizer in the dysplastic hip. Clin Orthop Relat Res. 2011;469(6):1728-1734.
12. Naal FD, Dalla Riva F, Wuerz TH, Dubs B, Leunig M. Sonographic prevalence of groin hernias and adductor tendinopathy in patients with femoroacetabular impingement. Am J Sports Med. 2015;43(9):2146-2151.
13. Nepple JJ, Riggs CN, Ross JR, Clohisy JC. Clinical presentation and disease characteristics of femoroacetabular impingement are sex-dependent. J Bone Joint Surg Am. 2014;96(20):1683-1689.
Prospective study of 50 consecutive men + 50 consecutive women undergoing hip ax for Sy FAI
14. Larson CM, Safran MR, Brcka DA, Vaughn ZD, Giveans MR, Stone RM. Predictors of Clinically Suspected Intra-articular Hip Symptoms and Prevalence of Hip Pathomorphologies Presenting to Sports Medicine ad Hip Preservation
Orthopaedic Surgeons. Arthroscopy. 2018;34(3):825-831.
15. Hetsroni I, Dela Torre K, Duke G, Lyman S, Kelly BT. Sex differences of hip morphology in young adults with hip pain and labral tears. Arthroscopy. 2013;29(1):54-63.
16. Yanke AB, Khair MM, Stanley R, et al. Sex Differences in Patients With CAM Deformities With Femoroacetabular Impingement: 3-Dimensional Computed Tomographic Quantification. Arthroscopy. 2015;31(12):2301-2306.
17.Tannenbaum EP, Zhang P, Maratt JD, et al. A Computed Tomography Study of Gender Differences in Acetabular Version and Morphology: Implications for Femoroacetabular Impingement. Arthroscopy. 2015;31(7):1247-1254.
18. Lee CB, Mata-Fink A, Millis MB, Kim YJ. Demographic differences in adolescent-diagnosed and adult-diagnosed acetabular dysplasia compared with infantile developmental dysplasia of the hip. J Pediatr Orthop. 2013;33(2):107-111.
19. Nawabi DH, Bedi A, Tibor LM, Magennis E, Kelly BT. The demographic characteristics of high-level and recreational athletes undergoing hip arthroscopy for femoroacetabular impingement: a sports-specific analysis. Arthroscopy.
2014;30(3):398-405.
20. Decker MJ, Torry MR, Wyland DJ, Sterett WI, Richard Steadman J. Gender differences in lower extremity kinematics, kinetics and energy absorption during landing. Clin Biomech (Bristol, Avon). 2003;18(7):662-669.
21. Duthon VB, Charbonnier C, Kolo FC, et al. Correlation of clinical and magnetic resonance imaging findings in hips of elite female ballet dancers. Arthroscopy. 2013;29(3):411-419.
22. Czuppon S, Prather H, Hunt DM, et al. Gender-Dependent Differences in Hip Range of Motion and Impingement Testing in Asymptomatic College Freshman Athletes. Pm r. 2017;9(7):660-667.
23. Sardana V, Philippon MJ, de Sa D, et al. Revision Hip Arthroscopy Indications and Outcomes: A Systematic Review. Arthroscopy. 2015;31(10):2047-2055.
24. Joseph R, Pan X, Cenkus K, Brown L, Ellis T, Di Stasi S. Sex Differences in Self-Reported Hip Function Up to 2 Years After Arthroscopic Surgery for Femoroacetabular Impingement. Am J Sports Med. 2016;44(1):54-59.
25. Frank RM, Lee S, Bush-Joseph CA, Salata MJ, Mather RC, 3rd, Nho SJ. Outcomes for Hip Arthroscopy According to Sex and Age: A Comparative Matched-Group Analysis. J Bone Joint Surg Am. 2016;98(10):797-804.
26. Malviya A, Stafford GH, Villar RN. Impact of arthroscopy of the hip for femoroacetabular impingement on quality of life at a mean follow-up of 3.2 years. J Bone Joint Surg Br. 2012;94(4):466-470.
27. Cvetanovich GL, Weber AE, Kuhns BD, et al. Clinically Meaningful Improvements After Hip Arthroscopy for Femoroacetabular Impingement in Adolescent and Young Adult Patients Regardless of Gender. J Pediatr Orthop. 2018;38(9):465-
470.
28. Philippon MJ, Ejnisman L, Ellis HB, Briggs KK. Outcomes 2 to 5 years following hip arthroscopy for femoroacetabular impingement in the patient aged 11 to 16 years. Arthroscopy. 2012;28(9):1255-1261.
29. Heyworth BE, Shindle MK, Voos JE, Rudzki JR, Kelly BT. Radiologic and intraoperative findings in revision hip arthroscopy. Arthroscopy. 2007;23(12):1295-1302.
30. Ricciardi BF, Fields K, Kelly BT, Ranawat AS, Coleman SH, Sink EL. Causes and risk factors for revision hip preservation surgery. Am J Sports Med. 2014;42(11):2627-2633.
31.Clohisy JC, Nepple JJ, Larson CM, Zaltz I, Millis M; Academic Network of Conservation Hip Outcome Research (ANCHOR) Members. Persistent structural disease is the most common cause of repeat hip preservation surgery. Clin Orthop
Relat Res. 2013 Dec;471(12):3788-94.
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Women’s Sports Medicine