1/22/2019

1

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

1/22/2019

2

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

1/22/2019

3

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

1/22/2019

4

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.

1/22/2019

5

Women’s Sports Medicine