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Review

Radiological variables associated with progression of femoroacetabular impingement of the hip: A systematic review Alexis A. Wright a,∗ , Garrett S. Naze b , Alicia Emerson Kavchak c , Danielle Paul d , Brianna Kenison e , Eric J. Hegedus a a

High Point University, School of Health Sciences, Department of Physical Therapy, High Point, USA Carroll University, Department of Physical Therapy, Waukesha, USA c Department of Physical and Occupational Therapy, University of Illinois Hospital and Health Sciences System, Chicago, USA d Exercise Science Program, High Point University, High Point, USA e Biology and Exercise Science Programs, High Point University, High Point, USA b

a r t i c l e

i n f o

Article history: Received 6 August 2013 Received in revised form 26 February 2014 Accepted 6 March 2014 Available online xxx Keywords: Femoroacetabular impingement Hip Prognosis Osteoarthritis, Hip

a b s t r a c t Objectives: Femoroacetabular impingement is gaining increased recognition as a cause of hip dysfunction. Of great concern is its potential association with labral tears and osteoarthritis. This systematic review examines the evidence regarding radiographic variables associated with the progression of femoroacetabular impingement. Design: Systematic review. Methods: Articles were selected following a comprehensive search of PubMed, CINAHL, SportDiscus, Embase, and Medline databases from database inception through October 2012. Inclusion criteria involved (1) estimates of the association between prognostic variables and progression of femoroacetabular impingement, (2) prospective or retrospective design, (3) patients diagnosed with femoroacetabular impingement based on established criteria, (4) the outcome of interest was radiologic and/or clinical progression of femoroacetabular impingement, and (5) access to the full text. Two independent reviewers assessed the methodological quality of each study and the association between prognostic variables and femoroacetabular impingement progression. Results: Thirteen articles met the inclusion criteria; nine were considered to be of high quality. Moderate evidence of progression of femoroacetabular impingement to labral pathology was associated with increased alpha angle. Moderate evidence for their lack of association with progression of FAI was associated with alpha angle with respect to development of osteoarthritis, acetabular index, center edge angle, coxa profunda, coxa vara, and pistol grip deformity. Conclusions: There is moderate evidence that increased alpha angle at baseline is associated with progression of femoroacetabular impingement to labral tear. Moderate evidence suggests a lack of association between other radiographic variables and progression of femoroacetabular impingement. © 2014 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.

1. Introduction Femoroacetabular impingement (FAI) has been identified as a common source of hip pain and dysfunction, and the leading cause of acetabular labral tears in active, young adults.1 Previous literature has reported an estimated 10–15% prevalence rate of FAI in the general population,2,3 although estimates range anywhere from

∗ Corresponding author. E-mail address: [email protected] (A.A. Wright).

10% to 39% depending upon the criteria used to diagnose FAI.4,5 In recent years, convincing evidence has emerged to support the theory that FAI may be a precursor of early hip osteoarthritis (OA) in up to 40% of patients with a prior diagnosis of idiopathic OA of the hip.1,6–8 In patients 50◦ being the most common.27–29,33–35,38 The alpha angle is defined as a measure of femoral head asphericity which quantifies the anterosuperior bulge of the femoral head over the neck eliminating

Table 1 Levels and grades of evidence for prognostic factors on femoroacetabular impingement. Level of evidence 1 2 3 4 5

Prospective, high-quality inception cohort study; CDR validated in a single population Retrospective, high-quality cohort study or follow-up of untreated control patients in an RCT; Derivation of CDR or validated on split sample only Individual case control studies Case Series and poor quality prognostic cohort studies Expert Opinion without explicit critical appraisal, or based on physiology, bench research, or “first principles”

Grades of recommendation A B

Strong evidence Moderate evidence

C D

Weak evidence Conflicting evidence

Consistent findings (≥75%) in at least two level 1 studies Consistent findings (≥75%) in at least one level 1 or 2 study and ≥1 level 3 or 4 study or consistent findings (≥75%) in ≥ two level 2 or 3 studies Findings in one level 1 or 2 study or consistent findings (≥75%) in ≥ two level 4 studies Inconsistent or inconclusive studies of any level or a single level 4 study

Modified from Oxford Centre for Evidence-Based Medicine.26

Please cite this article in press as: Wright AA, et al. Radiological variables associated with progression of femoroacetabular impingement of the hip: A systematic review. J Sci Med Sport (2014), http://dx.doi.org/10.1016/j.jsams.2014.03.004

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4 Table 2 Results of the methodological assessment. Cohort name

A

B

C

D

E

F

G

H

I

J

K

L

M

N

O

P

Q

R

Quality score

Agricola et al. (2012)27 Horisberger et al. (2010)35 Bardakos & Villar (2008)30 Gosvig et al. (2010)32 Hartofilakidis et al. (2011)33 Johnston et al. (2008)37 Kappe et al. (2011)39 Anderson et al. (2009)28 Kang et al. (2009)38 Heyworth et al. (2012)34 Audenaert et al. (2012)29 Beck et al. (2005)31 Jessel et al. (2009)36

1 1 0 1 1 1 1 1 1 1 0 1 0

1 1 1 1 1 1 1 1 1 1 0 1 1

1 0 1 1 0 1 1 0 0 0 0 1 0

1 1 0 1 0 1 1 1 1 1 0 0 0

1 1 1 0 1 0 0 0 0 0 0 0 0

1 1 1 0 1 0 0 0 0 0 0 0 0

0 1 1 1 1 1 1 1 1 1 1 0 1

1 1 0 0 0 1 1 0 0 0 1 0 0

1 1 1 1 0 0 0 1 1 0 1 0 1

1 1 1 1 1 1 1 1 1 1 1 1 1

1 1 1 1 1 1 1 1 1 1 1 1 1

1 1 1 1 1 1 1 1 1 1 1 1 0

1 1 1 1 1 1 1 1 1 1 1 1 1

1 1 1 1 1 1 1 1 1 1 1 1 0

1 1 1 1 1 1 1 1 1 1 1 1 1

0 0 0 0 0 0 1 0 0 0 0 0 0

0 0 1 0 1 0 0 1 0 0 0 0 0

1 0 0 1 1 1 0 0 1 1 0 0 1

15 14 13 13 13 13 13 12 12 11 9 9 8

the head–neck offset.40 Four studies defined progression of FAI as development of osteoarthritis, although the studies varied in their definition of progression (joint space narrowing, Kellgren/Lawrence grades, Tonnis classification, and joint space width ≤2 mm).27,30,32,33 Two studies defined FAI progression as THA (total hip arthroplasty) or hip arthroscopy alone.29,35 The remaining 7 studies used labral tears or chondral defects to define FAI progression.28,31,34,36–39 Most frequently reported prognostic variables were presence of extra bone formation in the anterolateral head–neck junction (cam type deformity), pincer lesion, and crossover sign. The results of the quality assessment are presented in Table 2. The two primary reviewers (AAW, EJH) demonstrated a kappa of 0.70 (0.60, 0.79). This finding represents substantial agreement.41 Disagreements between raters were resolved with consensus. The studies were ranked in descending order by methodological quality score. The overall quality score ranged from 8 to 15 points out of 18 and 9/13 (69%) studies were classified as high-quality studies. The median score was 13/18 points (72.2%). Most methodological shortcomings concerned the following items: inadequate description of inclusion and exclusion criteria, follow up 40◦ demonstrated weak (Level 2C) evidence of a relationship to reduced progression of FAI.28 Inconclusive evidence – Level D The following variables were assigned the score of Level D evidence because each was reported in a single, poor quality study or study results were reported with wide confidence intervals or crossed 1 or only a single p-value statistical association was reported. Two variables demonstrated inconclusive (Level 1D) evidence in support of being predictive for the progression of FAI: alpha angle >83◦27 and the combination of alpha angle >83◦ and hip internal rotation ≤20◦ .27 Six variables demonstrated inconclusive (Level 2D) evidence in support of being predictive for the progression of FAI: male sex,28,39 anterior asphericity,39 anterior offset 50◦ ,39 anterior alpha angle >50◦ ,39 acetabular risk score,28 anterior offset

Radiological variables associated with progression of femoroacetabular impingement of the hip: a systematic review.

Femoroacetabular impingement is gaining increased recognition as a cause of hip dysfunction. Of great concern is its potential association with labral...
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