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Femoral Neck Fracture After Arthroscopic Management of Femoroacetabular ImpingementA Case Report
Olufemi R. Ayeni, MD1; Asheesh Bedi, MD2; Dean G. Lorich, MD; Bryan T. Kelly, MD
1 Department of Orthopaedic Surgery, McMaster University, 1200 Main Street West, Hamilton, ON L8N 3Z5, Canada. E-mail address: femiayeni@gmail.com
2 Department of Orthopaedic Surgery, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI 48109. E-mail address: abedi@umich.edu
View Disclosures and Other Information
Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

Investigation performed at the Hospital for Special Surgery, New York, NY

Copyright © 2011 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2011 May 04;93(9):e47 1-8. doi: 10.2106/JBJS.J.00792
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Extract

Ganz and colleagues recently identified femoroacetabular impingement as the predominant cause of labral tears in nondysplastic hips1. Structural abnormalities of the hip can limit motion and result in repetitive impact of the proximal part of the femoral neck against the acetabular labrum and adjacent cartilage. Osseous impingement as a result of a decrease in femoral head-neck offset or an aspherical femoral head is termed cam impingement. On the acetabular side, pincer impingement results from various degrees of overgrowth of the osseous acetabulum and excessive acetabular retroversion2. Pincer impingement can be subdivided into coxa profunda or protrusio, anterosuperior overcoverage, and true acetabular retroversion.
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    Atil Atilla, Cemil Yildiz, Ibrahim Yanmis
    Posted on October 11, 2012
    What is the real indication for osteochondroplasty due to femoroacetabular impingement; do we overtreat?
    Sarikamis Military Hospital Department of Orthopedics and Traumatology ; Gulhane Military Medical Academy Department of Orthopedics and Traumatology

    We read the article about the case who had a femoral neck stress fracture due to arthroscopic osteochondroplasty for FAI with great interest[1]. We have a few questions to the authors about indication of the operation and the explanation of the fracture mechanism.

    We know that most of the cases with femoroacetabular impingement (FAI) involve both pincer and cam impingement because of the interaction of acetabulum and femoral neck while impinging, but mostly the main pathology can be defined[2]. Impingement due to one side of the hip joint might cause some secondary anatomic and radiologic changes at the counterside like os acetabulum, ossification or delamination of the labrum at the acetabular site and like herniation pits due to pincer impingement at the femoral site[2]. We think in this case with the radiologic evidence there is a pincer impingement with the focal retroversion of the acetabulum and herniation pits at the counter femoral site but there is not a large enough osteochondral bump of the femoral site for an indication of osteochondroplasty (alpha angle 46º). One study states the minimal alpha angle threshold for cam impingement is 50º [3]; a growing number of studies offer higher alpha angle threshold values for the diagnosis of cam impingement[4-5]. If there is femoral site impingement under the threshold value of alpha angle as indicated in the article, do we have to use new combined impingement values which look for the interaction, like beta angle for indication of osteochondroplasty, and utilize this value for routine intraoperative usage[6-7]?

    According to the article, there is retroversion of the acetabulum. Retroversion of the acetabulum is a reason for increased risk of a stress fracture of the femoral column by itself [8]. Femoral neck fracture after osteochondroplasty in the article is a stress fracture.  The study of by Mardones et al. which is cited as a relevant article is a cadaver study and not a stress fracture assessment study, so it may not be an appropriate reference for osteochondroplasty size[9]. May overtreatment of the CAM FAI and retroversion of the acetabulum together be a reason for this stress fracture ?

    And the last question, for the preoperative assessment of the patient, a triple phase bone scan was performed for the assessment of any active inflammatory process and/ or potential stress fracture of the hip. If the authors have MRI for the assessment of FAI and relevant soft tissue disorders of the hip, why did they also get a triple-phase bone scan, which radiates too much x-ray?

    References

    1. Ayeni, O.R., et al., Femoral neck fracture after arthroscopic management of femoroacetabular impingement: a case report. J Bone Joint Surg Am, 2011. 93(9): p. e47.

    2. Tannast, M., K.A. Siebenrock, and S.E. Anderson, Femoroacetabular impingement: radiographic diagnosis--what the radiologist should know. AJR Am J Roentgenol, 2007. 188(6): p. 1540-52.

    3. Notzli, H.P., et al., The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement. J Bone Joint Surg Br, 2002. 84(4): p. 556-60.

    4. Clohisy, J.C., et al., The frog-leg lateral radiograph accurately visualized hip cam impingement abnormalities. Clin Orthop Relat Res, 2007. 462: p. 115-21.

    5. Pollard, T.C., et al., Femoroacetabular impingement and classification of the cam deformity: the reference interval in normal hips. Acta Orthop, 2010. 81(1): p. 134-41.

    6. Wyss, T.F., et al., Correlation between internal rotation and bony anatomy in the hip. Clin Orthop Relat Res, 2007. 460: p. 152-8.

    7. Brunner, A., et al., The plain beta-angle measured on radiographs in the assessment of femoroacetabular impingement. J Bone Joint Surg Br, 2010. 92(9): p. 1203-8.

    8. Kuhn, K.M., et al., Acetabular retroversion in military recruits with femoral neck stress fractures. Clin Orthop Relat Res, 2010. 468(3): p. 846-51.

    9. Mardones, R.M., et al., Surgical treatment of femoroacetabular impingement: evaluation of the effect of the size of the resection. J Bone Joint Surg Am, 2005. 87(2): p. 273-9.

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