The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 93, Issue Supplement 2

Scientific Articles | May 04, 2011

Impingement Between the Acetabular Cup and the Femoral Neck After Hip Resurfacing Arthroplasty

Myung Chul Yoo, MD, PhD¹; Yoon Je Cho, MD, PhD²; Young Soo Chun, MD, PhD¹; Kee Hyung Rhyu, MD, PhD¹

¹ Department of Orthopaedic Surgery, Kyung Hee University Hospital at Gangdong, School of Medicine, Kyung Hee University, #149, Sangil-dong, Gangdong-gu, Seoul 134-727, South Korea. E-mail address for Y.S. Chun: mozart13@khu.ac.kr
² Department of Orthopaedic Surgery, Kyung Hee University Hospital, School of Medicine, Kyung Hee University, #1, Hoeki-dong, Dongdaemoon-gu, Seoul 130-702, South Korea

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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 Department of Orthopaedic Surgery, Kyung Hee University Hospital at Gangdong, School of Medicine, Kyung Hee University, Seoul, South Korea

J Bone Joint Surg Am, 2011 May 04;93(Supplement 2):99-106. doi: 10.2106/JBJS.J.01771

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Abstract

Background:

Loosening, femoral neck fracture, and metal ion release have been well documented after hip resurfacing arthroplasty, but impingement between the acetabular cup and the femoral neck has not. The goal of this study was to analyze radiographic findings that were presumed to represent impingement of the neck after hip resurfacing arthroplasty, and to describe the mechanism of impingement.

Methods:

Of the 635 hips (579 patients) that underwent hip resurfacing arthroplasty between September 1998 and May 2008, forty hips (6.3%) with positive radiographic findings were available for this study. The mean age of the patients was 34.9 years and there were thirty-five men and five women. The average follow-up was sixty-eight months (twenty-four to 132 months). Radiographic evaluation included an analysis of neck-shaft angle, inclination of the acetabular cup, head-neck ratio, lateral protrusion of the cup, anterior protrusion of the cup, and stem angle to the axis of the femoral neck.

Results:

Impingement between the acetabular cup and the femoral neck occurred in 6.3% of hips and appeared at an average of seven months after surgery. There was no further change two years postoperatively. The impingement findings did not correlate with the clinical outcome, but all instances of impingement were located in the lateral or anterolateral part of the femoral neck along the arc from the center of the femoral head to the lateral edge of the socket. No significant factors were found to be related to the occurrence of impingement.

Conclusions:

Femoral-neck impingement should be differentiated from notching, narrowing, stress-shielding, or osteolysis of the femoral neck. Although we found no significant factors to explain the impingement found in the hips in our study, it appears that repetitive extreme motion of the involved hip and malposition of the implants can cause impingement after hip resurfacing arthroplasty.

Level of Evidence:

Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Figures in this Article

Introduction

Introduction | Materials and Methods | Results | Discussion | References

Total hip arthroplasty is one of the most effective treatments for end-stage hip disease^1,2. However, there is an increasing need for a new type of hip replacement that resembles a normal human hip joint and performs physiological functions. Although the newly developed alternative bearing surfaces have reduced the prevalence of osteolysis and related risks, patients with total hip arthroplasty usually have some limitation of normal activities. Many surgeons ask their patients who have undergone total hip arthroplasty to refrain from high-contact, high-impact sports and to change some aspects of their lifestyle and/or patterns of activity. Metal-on-metal hip resurfacing arthroplasty represents an alternative to total hip arthroplasty in young, active patients with end-stage arthritis³. The proposed advantages of hip resurfacing arthroplasty over conventional total hip arthroplasty are bone conservation, reproduction of anatomic biomechanics, greater implant stability, and easier revision surgery⁴. Encouraging midterm results have been reported with regard to hip resurfacing arthroplasty^1,2,5-7. Patients who have had hip resurfacing arthroplasty are able to engage in normal activities with a wider range of hip motion (due to the low risk of dislocation) and less impingement between the acetabular cup and the femoral neck. Reports of impingement between the acetabular component and the femoral neck are rare after hip resurfacing arthroplasty⁸. However, little is known about the nature, incidence, and clinical relevance of impingement between the acetabular cup and the femoral neck after hip resurfacing arthroplasty. The purpose of this study was to evaluate the clinical and radiographic findings presumed to be secondary to impingement of the femoral neck after hip resurfacing arthroplasty.

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

Of 635 hips (579 patients) that underwent hip resurfacing arthroplasty during the period from September 1998 through May 2008 and for which the follow-up period was at least two years, forty hips (forty patients) (6.3%) had radiographic findings of erosion in the femoral neck due to femoral-neck impingement and were included in our study. The average age of the forty patients was 34.9 years (range, sixteen to sixty-seven years). There were thirty-five male hips and five female hips in the forty hips with impingement, resulting in a male-to-female ratio of 7 to 1 in that group; in comparison, the male-to-female ratio in the total group of 635 hips was 3.1 to 1 (481 male hips and 154 female hips). The preoperative diagnosis included osteonecrosis of the femoral head in thirty-five cases (87.5%), secondary osteoarthritis in four cases (10.0%), and ankylosing spondylitis in one case (2.5%). The average postoperative follow-up period was sixty-eight months (range, twenty-four to 132 months). The average body mass index of the patient was 22.4 kg/m² (range, 19.0 to 27.8 kg/m²) (Table I). Surgery was performed with the patient under general anesthesia and through a posterolateral surgical approach with the patient in the lateral position. In all cases, the gluteal sling was incised and the femoral head and neck were completely exposed to minimize tissue damage. After the acetabulum was exposed and reamed, the acetabular cup was press-fit without cement. The centerline of the femoral neck was marked on the cartilage of the femoral head in the coronal and sagittal planes with an electrocautery. Based on the point of intersection of these lines, the guide pin was inserted; the femoral head was cut with use of the cylindrical reamer, which is one size larger in diameter than that of the planned femoral implant. The junction between the femoral head and neck was trimmed with use of a rongeur and was cut to the planned size without notching. When osteonecrosis of the femoral head was present, the necrotic portion of the femoral head was completely removed by curettage but the sclerotic interface between the necrotic portion and normal bone was left. After cutting and removing the necrotic bone, the remaining bone was reevaluated to determine if treatment with hip resurfacing arthroplasty was still appropriate. As an appropriate indication for hip resurfacing arthroplasty in osteonecrosis of the femoral head, patients whose hips were at Ficat stage⁹ IIB or III and patients who had a minor (stage-III) collapse according to the classification system of the Association Research Circulation Osseous (ARCO)¹⁰ that was at least 5 mm above the head-neck junction and had <10% of rim defect after head implantation with cement augmentation were included. The extent of femoral-head necrosis was calculated with use of Yoo's method ([A+B]/2, where A represents the percentage of necrotic area on a midcoronal magnetic resonance imaging [MRI] scan and B represents the necrotic area on a midsagittal MRI scan); <50% necrosis was also included as an indication. The prostheses used included the Birmingham Hip Resurfacing prosthesis (MMT, Birmingham, United Kingdom) in thirty-five hips, the Durom Hip Resurfacing prosthesis (Zimmer, Warsaw, Indiana) in three hips, and the Conserve Plus prosthesis (Wright Medical, Arlington, Tennessee) in two hips (Table I). The acetabular cup was uncemented and the femoral component was fixed with use of low-viscosity bone cement (Surgical Simplex-P; Stryker Orthopaedics, Allendale, New Jersey). Most of the patients were allowed to walk with the aid of crutches two to three days postoperatively. Partial weight-bearing with the assistance of crutches was then allowed for two months, and full weight-bearing ambulation was allowed thereafter. Clinical evaluation included the preoperative and postoperative Harris hip score, the presence of pain in the hip joint and thigh, the range of motion of the hip joint, and body mass index. Radiographic evaluation included radiographs immediately postoperatively, at three and six months postoperatively, and after each one-year period thereafter, and the radiographic features analyzed included the neck-shaft angle; the stem angle to the axis of the neck; the inclination, lateral protrusion, and anterior protrusion of the acetabular cup; and the head-neck ratio (Figs. 1 and 2).

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TABLE I Demographic and Clinical Data of Patients Who Underwent Hip Resurfacing Arthroplasty*

		Clinical Data†
Parameter	Demographic Data	Preoperative	Postoperative
Sex (men:women) (no.)	35:5
Mean follow-up (range) (mo)	68 (24 to 132)
Diagnosis (ONFH:OA:AS) (no. of pts)	35:4:1
Prosthesis (BHR:Durom:CP) (no. of hips)	35:3:2
Mean body mass index and standard deviation (kg/m2)	22.4 ± 8.17
Flexion contracture (deg)		0	0.48 ± 2.0
Flexion (deg)		102.1 ± 15.83	125.8 ± 29.4
Internal rotation (deg)		15.2 ± 9.95	21.3 ± 22.1
External rotation (deg)		35.0 ± 10.27	36.3 ± 20.9
Abduction (deg)		40.9 ± 11.6	35.8 ± 8.9
Adduction (deg)		21 ± 10.1	27.1 ± 12.1
Harris hip score (points)		79.3 ± 16.05	98.9 ± 1.5
UCLA score (points)		4.8 ± 2.7	8.3 ± 1.9

*ONFH = osteonecrosis of the femoral head, OA = secondary osteoarthritis, AS = ankylosing spondylitis, BHR = Birmingham hip resurfacing prosthesis, Durom = Durom Hip Resurfacing prosthesis, CP = Conserve Plus prosthesis.
†Values are given as the mean and standard deviation.

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TABLE I Demographic and Clinical Data of Patients Who Underwent Hip Resurfacing Arthroplasty*

		Clinical Data†
Parameter	Demographic Data	Preoperative	Postoperative
Sex (men:women) (no.)	35:5
Mean follow-up (range) (mo)	68 (24 to 132)
Diagnosis (ONFH:OA:AS) (no. of pts)	35:4:1
Prosthesis (BHR:Durom:CP) (no. of hips)	35:3:2
Mean body mass index and standard deviation (kg/m2)	22.4 ± 8.17
Flexion contracture (deg)		0	0.48 ± 2.0
Flexion (deg)		102.1 ± 15.83	125.8 ± 29.4
Internal rotation (deg)		15.2 ± 9.95	21.3 ± 22.1
External rotation (deg)		35.0 ± 10.27	36.3 ± 20.9
Abduction (deg)		40.9 ± 11.6	35.8 ± 8.9
Adduction (deg)		21 ± 10.1	27.1 ± 12.1
Harris hip score (points)		79.3 ± 16.05	98.9 ± 1.5
UCLA score (points)		4.8 ± 2.7	8.3 ± 1.9

Fig. 1

A: The neck-shaft angle is the angle formed by the intersection of a line drawn through the axis of the femoral shaft and a line drawn through the long axis of the femoral stem on an anteroposterior radiograph of the hip. B: The stem angle to the axis of the femoral neck is measured on a cross-table lateral radiograph and is the angle (d) between the longitudinal axis of the stem and that of the femoral neck.

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Fig. 2

A: The inclination of the acetabular cup is the angle between the face of the cup and the line connecting both acetabular teardrops, which is the transverse axis of the pelvis. B: Lateral protrusion of the acetabular cup is measured on an anteroposterior hip radiograph and is described as either the distance (a) or the angle (?) between the acetabular end and the edge of the laterally protruded cup. C: Anterior protrusion of the acetabular cup is measured on a cross-table lateral radiograph and is the angle (?) between the inferior margin of the cup and the line connecting the anterosuperior iliac spine and ischial tuberosity. The plus sign indicates a more anteverted direction, and the minus sign indicates a retroverted or less anteverted direction. D: The head-neck ratio (A/B) is the ratio of the diameter (A) of the implant head to the distance (B) formed by the intersection of a line drawn through the circular outline of femoral implants and the cortical line of the femoral neck.

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Results

Introduction | Materials and Methods | Results | Discussion | References

The Harris hip score was 98.9 at the time of the final follow-up, which represented an improvement from the score of 79.3 points preoperatively. No patients complained of hip joint and/or thigh pain. At the time of the preoperative examination, the mean (and standard deviation) range of motion in the forty hips included a mean flexion contracture of 0°, flexion to 102.1° ± 15.83°, internal rotation to 15.2° ± 9.95°, external rotation to 35.0° ± 10.27°, adduction to 21° ± 10.1°, and abduction to 40.9° ± 11.6°; at the time of final follow-up, there was a mean flexion contracture of 0.48° ± 2.0°, flexion to 125.8° ± 29.4°, internal rotation to 21.3° ± 22.1°, external rotation to 36.3° ± 20.9°, adduction to 27.1° ± 12.1°, and abduction to 35.8° ± 8.9° (Table I). At the time of the last follow-up, the University of California at Los Angeles (UCLA) hip score¹¹ was improved to 8.3 from a preoperative score of 4.8 and 92.5% had resumed a high level of sports activity. All patients were able to sit in a cross-legged position and a squatting position and had returned to their original jobs. The radiographic findings that were presumed to be an impingement of the femoral neck started at an average of 7.6 months (range, three to twelve months) after surgery. No progression of these findings was present later (at an average of 23.2 months [range, twelve to thirty-six months]). These radiographic findings did not affect the clinical outcome. The erosion was well defined with a sclerotic border, and all of the erosion developed along the diameter of the acetabular cup. The erosion was located in the lateral part of the femoral neck in thirty-six hips (90.0%); the posterior part, in two hips (5.0%); and the anterior part, in two hips (5.0%). On the radiographs, the mean neck-shaft angle was 133.4° preoperatively and 133.6° postoperatively. Mean lateral protrusion of the acetabular cup was 6.9° and 2.5 mm, and the mean inclination of the acetabular cup was 44.5°. The mean postoperative head-neck ratio was 1.42. Mean anterior protrusion of the acetabular cup was 2.9°. The mean stem angle to the axis of the femoral neck was 4.2° (Table II). Fluoroscopic examination showed that there was contact between the lateral end of the acetabular component and the head-neck junction of the femoral neck at the erosion site during hyperflexion, abduction, and external rotation of the hip (Fig. 3).

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TABLE II Radiographic Results After Hip Resurfacing Arthroplasty*

Parameter	Preoperative Values	Postoperative Values
Neck-shaft angle (deg)	133.4 ± 5.65	133.6 ± 16.8
Head-neck ratio	1.39 ± 0.11	1.42 ± 0.12
Stem angle to the axis of the neck (deg)	NA	4.2 ± 2.3
Cup side
Inclination (deg)	NA	44.5 ± 14.8
Anterior protrusion (deg)	NA	2.9 ± 3.5
Lateral protrusion (deg)	NA	6.9 ± 5.5
Lateral protrusion (mm)	NA	2.5 ± 2.3

*Values are given as the mean and standard deviation. NA = not applicable.

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TABLE II Radiographic Results After Hip Resurfacing Arthroplasty*

Parameter	Preoperative Values	Postoperative Values
Neck-shaft angle (deg)	133.4 ± 5.65	133.6 ± 16.8
Head-neck ratio	1.39 ± 0.11	1.42 ± 0.12
Stem angle to the axis of the neck (deg)	NA	4.2 ± 2.3
Cup side
Inclination (deg)	NA	44.5 ± 14.8
Anterior protrusion (deg)	NA	2.9 ± 3.5
Lateral protrusion (deg)	NA	6.9 ± 5.5
Lateral protrusion (mm)	NA	2.5 ± 2.3

*Values are given as the mean and standard deviation. NA = not applicable.

Fig. 3

Fluoroscopic examination showed contact between the lateral end of the acetabular component and the head-neck junction of the femoral neck at the erosion site (arrow) during hyperflexion, abduction, and external rotation of the hip joint. From the left side to the right side of Figure 3, the degree of flexion, abduction, and external rotation is increased gradually.

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Discussion

Introduction | Materials and Methods | Results | Discussion | References

Compared with conventional total hip arthroplasty, hip resurfacing arthroplasty is associated with less risk of dislocation because the hip resurfacing prosthesis has a large-diameter femoral head that is similar to the anatomic femoral head in size^5,6,12,13. Patients who undergo hip resurfacing arthroplasty also have considerably more joint motion until reaching the point at which dislocation will occur, and they are more likely than patients who undergo conventional total hip arthroplasty to return to their original jobs and participate in high-impact sports activities such as soccer, baseball, and tae kwon do. Hip resurfacing arthroplasty can preserve the femoral neck and some portion of the femoral head and form a shape that is similar to the preoperative shape of the anatomic bone so that more physiological load transfer can be achieved^14,15. Recent studies have reported high success rates for hip resurfacing arthroplasty at short to midterm follow-up^{7,12,14,16-19}. Despite these excellent early outcomes, femoral-neck fracture, femoral-neck narrowing, neck impingement, and metal hypersensitivity have been reported as complications after hip resurfacing arthroplasty^{8,13,14,19-25}. Restoration of normal hip motion is proposed as one of the advantages associated with hip resurfacing arthroplasty as compared with total hip arthroplasty. The head-neck diameter ratio is an important parameter governing motion of the hip joint. Greater motion is anticipated with a higher diameter ratio and is one of the main advantages of using large-diameter heads in total hip arthroplasty²⁶. However, in hip resurfacing arthroplasty, the retained anatomic femoral neck is much larger than the prosthetic femoral neck of a conventional total hip replacement²⁷. Kluess et al., who used three-dimensional computer-aided design (CAD) models of the natural hip implanted (in a virtual sense) with eight designs of hip-resurfacing prostheses, reported that the average range of motion that could be achieved with the hip resurfacing prostheses was 31° to 48° narrower than what could be achieved with a model of a stemmed total hip replacement with a 32-mm head diameter²⁸. The large diameter of the femoral neck in the hip resurfacing models led to early impingement in all maneuvers analyzed. Simulation of hip resurfacing arthroplasty resulted in a decrease in head-neck ratio of 5% compared with the natural hip joint. In hip resurfacing, the neck diameter should not be reduced surgically since a lesion of the supporting cortical bone increases the risk of femoral-neck fracture^17,19. The stresses appearing at the impingement site can lead to further complications, including fracture of the femoral neck and implant loosening¹⁷. Subluxation caused by impingement can damage the bearing surfaces and initiate high wear rates²⁹. However, in a study of fifty-seven hips with a minimum follow-up period of two years, Ball and Schmalzried⁸ reported that impingement between the acetabular cup and the femoral neck occurred in about 20% of the cases, occurred at a mean of fifteen months, and did not progress after two years. They considered the lesion as a small, corticated, and nonprogressive erosion caused by femoral acetabular impingement and concluded that lesions tended to occur posteriorly in active patients, with no adverse effect on clinical outcomes. In our patients, the lesion occurred frequently in the lateral or anterolateral portion of the femoral neck (attributed to Korean cultural habits of hyperflexion and external rotation) and all of the erosion developed along the circle of the diameter of the acetabular cup (Fig. 3). Our findings were observed from 7.6 months through 23.2 months postoperatively, and the lesion did not progress with time (Figs. 4 and 5). The time period when the lesion occurred was slightly different from that reported by Ball and Schmalzried, but the lesion did not show any progression two years postoperatively in either study. In patients with a hip resurfacing prosthesis, hip motion is greater than it is in patients with a conventional total hip prosthesis, but this increased range of motion likely caused the impingement. In this study, although the patients with impingement of the femoral neck did not exhibit clinical symptoms, long-term follow-up is required to identify whether the small, cortical, nonprogressive lesions seen on radiographs will eventually produce complications such as loosening of the acetabular cup, loosening of the femoral component, femoral-neck narrowing, and femoral-neck fracture. These complications are characteristic of male patients who enjoy high-level activities with strenuous hip movements in which there is repetitive contact of the acetabular cup and the femoral neck. Beaulé et al.³⁰ reported that appropriate femoral head-neck offset is important to minimize the risk of impingement, and they further stated that correction of femoral head-neck offset is important to avoid impingement, loosening, and abnormal wear. The study of component positioning must take into account the limitations of radiographs. Computed tomography has greater accuracy in measuring component position, such as acetabular cup anteversion and true femoral anteversion, after hip resurfacing arthroplasty³¹. We suggest that hyperflexion and external rotation of the hip joint, decreased head-neck ratio compared with what can be achieved with conventional total hip arthroplasty, and the lifestyle of the patient can lead to impingement. Although we did not find any significant contributing factors, we believe that repetitive extreme hip motion after hip resurfacing arthroplasty and malposition of the implants are both factors in causing impingement after hip resurfacing arthroplasty.

Fig. 4

Anteroposterior radiographs of the hip of a twenty-four-year-old man, showing the appearance of the hip preoperatively, immediately postoperatively, and at six months, two years, three years, and seven years postoperatively (Po). Erosion of the femoral neck along the circle of the diameter of the acetabular cup was first seen on the six-month radiograph and continued to progress until three years after surgery. The erosion margin was sclerotic and well defined. No progression was seen after three years postoperatively.

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Fig. 5

Anteroposterior radiographs of the hip of a thirty-two-year-old woman, showing the appearance of the hip preoperatively, immediately postoperatively, and at six months, two years, three years, and six years postoperatively (Po). Erosion of the femoral neck along the circle of the diameter of the acetabular cup was first seen on the six-month radiograph and continued to progress until two years after surgery. No progression was seen after two years postoperatively.

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References

Introduction | Materials and Methods | Results | Discussion | References

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Kluess D; Zietz C; Lindner T; Mittelmeier W; Schmitz K-P; Bader R. Limited range of motion of hip resurfacing arthroplasty due to unfavorable ratio of prosthetic head size and femoral neck diameter. Acta Orthop. 2008;79:748-54.[CrossRef][PubMed]

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Topics

neck ; neck of femur ; hip joint ; radiography of hip ; erosion ; hip resurfacing arthroplasty

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Myung Chul Yoo, Yoon Je Cho, Young Soo Chun, Kee Hyung Rhyu; Impingement Between the Acetabular Cup and the Femoral Neck After Hip Resurfacing Arthroplasty. The Journal of Bone & Joint Surgery. 2011 May;93(Supplement_2):99-106.

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