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Hip preservation

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DOI: 10.1302/2058-5241.5.190074

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5.1900EOR0010.1302/2058-5241.5.190074
research-article2020

EOR | volume 5 | October 2020

Instructional Lecture: Hip DOI: 10.1302/2058-5241.5.190074
www.efortopenreviews.org

Hip preservation
Markus S. Hanke1
Florian Schmaranzer2
Simon D. Steppacher1
Till D. Lerch1
Klaus A. Siebenrock1

„„ Classical indications for hip preserving surgery are: including developmental dysplasia of the hip, femoro-
femoro-acetabular impingement (FAI) (intra- and extra- acetabular impingement, slipped capital femoral epiphy-
articular), hip dysplasia, slipped capital femoral epiphysis, sis, residual deformities after Perthes disease, avascular
residual deformities after Perthes disease, avascular necro- necrosis of the femoral head, together with the develop-
sis of the femoral head. ment of new surgical approaches and procedures, have
„„ Pre-operative evaluation of the pathomorphology is cru- revolutionized the field of hip-preserving surgery.
cial for surgical planning including radiographs as the
basic modality and magnetic resonance imaging (MRI) Pre-operative workup
and/or computed tomography (CT) to evaluate further
intra-articular lesions and osseous deformities. Conventional radiographs remain the basis of the diagnos-
tic workup in patients eligible for joint-preserving hip sur-
„„ Two main mechanisms of intra-articular impingement
gery. These should include supine anteroposterior (AP)
have been described:
pelvic views to assess radiographic joint degeneration, cov-
(1) Inclusion type FAI (‘cam type’). erage and version of the acetabulum and gross anatomy of
(2) Impaction type FAI (‘pincer type’). the pelvis.1 An axial view is needed to detect cam deformi-
„„ Either arthroscopic or open treatment can be performed ties which are typically located anterosuperiorly.1 In the
depending on the severity of deformity. absence of severe joint space narrowing, magnetic reso-
„„ Slipped capital femoral epiphysis often results in a cam- nance imaging (MRI) of the hip should be performed in all
like deformity of the hip. In acute cases a subcapital re- patients evaluated for joint-preserving surgery. At first,
alignment (modified Dunn procedure) of the femoral fluid-sensitive images with a large field of view should be
epiphysis is an effective therapy. obtained to screen for associated inflammatory or neoplas-
tic conditions surrounding the hip joint.2 Fast axial images
„„ Perthes disease can lead to complex femoro-acetabular
of the pelvis and the distal femoral condyles should be
deformity which predisposes to impingement with/with-
acquired to assess femoral torsion.3 Then dedicated high-
out joint incongruency and requires a comprehensive
resolution images of the hip at field strengths of 1.5 T or 3
diagnostic workup for surgical planning.
T in the coronal, axial-oblique/axial and sagittal orientations
„„ Developmental dysplasia of the hip results in a static over- should be performed to assess intra-articular lesions.4 Acqui-
load of the acetabular rim and early osteoarthritis. Surgical sition of radial images is essential to provide a circumferen-
correction by means of periacetabular osteotomy offers tial assessment of the femoral head neck junction.5,6
good long-term results. Although promising results have been demonstrated for
Keywords: femoro-acetabular impingement; hip arthros- non-contrast MRI of the hip at 3 T, direct MR arthrography
copy; hip dysplasia; periacetabular osteotomy; surgical hip is still the current diagnostic gold-standard in the detection
dislocation of chondrolabral lesions.7–9 MR arthrograms provide crucial
prognostic information as extensive cartilage defects, ace-
Cite this article: EFORT Open Rev 2020;5:630-640. tabular cysts and osteophyte formations indicate a higher
DOI: 10.1302/2058-5241.5.190074 risk for failure of femoro-acetabular impingement (FAI) sur-
gery in the long-term.10 Injection of intra-articular contrast
agent further enables application of leg traction to achieve
Over the past two decades, substantial increases in the joint distraction and has shown promising early results to
knowledge of pre-arthritic conditions of the hip joint, improve the visualization of intra-articular lesions.11–14
 Hip preservation

LF

A) B) C)

D) E) F)

Fig. 1 (A) Schematic drawing, (B) direct MR arthrography with traction at 3T of a 27-year-old man with mixed FAI who underwent
(B) surgical hip dislocation. (A–C) Dynamic abutment leads to an ‘outside-in lesion’ shearing of the chondrolabral complex. (A)
In severe cases this can lead to a fatigue fracture of the osseous rim (dashed line). (B) Radial PD-w image shows contrast agent
undermining the delaminated cartilage from the labral-chondral transition zone towards the joint cavity. (C) The surgical probe
is advanced beneath the delaminated cartilage (arrowhead). (D–F) conventional X-rays: Pre-operative AP X-ray (D) showing slight
‘pistol-grip’ deformity and on the cross-table view (F: upper image) the cam deformity is clearly visible. (E and F: lower image) post-
operative X-rays after surgical hip dislocation and femoral osteochondroplasty.
Note. MR, magnetic resonance; FAI, femoro-acetabular impingement; PD-w, proton density weighted; AP, anteroposterior; L, labrum; LF, lunate facies.
Images A–C reprinted with permission from Schmaranzer et al.4

In addition, new biochemical cartilage MRI techniques such carpet-like delamination of cartilage and detachment of
as delayed gadolinium-enhanced MRI of cartilage (dGEM- the labrum (Fig. 1);2 impaction type FAI (‘pincer type’) in
RIC) or T2* imaging offer the ability to evaluate chondral which the femoral head abuts against an excessively prom-
defects more accurately before surgical therapy.15,16 3D CT inent acetabulum leading to cartilage thinning and degen-
scans enable exact visualization of the bony deformities, erative labrum tears (Fig. 2).4,22–24
and specific software for dynamic range of motion simula- The asphericity at the femoral head neck junction
tion can be very effective to identify the dominant osseous reflects a pattern of distinct osseous variants. Most fre-
deformity and plan surgical correction.17 This is especially quently (~ 80% cases) an ‘idiopathic’ cam type deformity
true for surgical planning in cases with suspected extra- can be found which typically arises from an excessively lat-
articular FAI.18 3D MRI has great potential to replace 3D CT eral extension of the epiphysis.25 Less frequently a slip-
for rendering of 3D models of the hip joint and further anal- like morphology resembling sequelae of slipped capital
ysis for a non-invasive improved surgical decision-making femoral epiphysis (SCFE) or post-slip morphologies are
in these mostly young patients.19–21 observed.25,26 The cam deformity is typically located
anterosuperiorly. The head-neck sphericity can be quanti-
fied with the alpha angle (Fig. 3) A normal alpha angle is
Femoro-acetabular impingement (FAI) less than 50°, and an alpha angle exceeding 50° classically
The concept of FAI was first described in 2003.22 It was defines a cam type morphology.27 Evidence for a threshold
defined as a condition of abnormal femoral abutment of > 60° is mounting due to previously published data,
against the acetabular rim arising as a result of abnormal showing that an alpha angle exceeding 60° is associated
morphological features involving the proximal femur and/ with clinical symptoms and the development of incident
or the acetabulum.22 osteoarthritis.28,29 During flexion, internal rotation and
Two main mechanisms of intra-articular impingement adduction, the eccentric part of the femoral-neck junction
have been described:1 inclusion type FAI (‘cam type’) in slides into the anterosuperior acetabulum. The first struc-
which the aspherical femoral head protrudes into the ace- ture to fail is the chondrolabral transition zone due to the
tabulum and induces shear forces which lead to the typical induced shear stress. Chondrolabral separation reflects the

631
 L

LF

A) B) C)

D) E) F)

Fig. 2 (A) Schematic drawing, (B) direct MR arthrography with traction at 3T of a 26-year-old female with impaction type FAI due to
severe acetabular retroversion who underwent (E) anteverting PAO. (A–C) Early dynamic abutment due to overgrowth of the anterior
acetabular wall (in red) leads to impaction against the chondrolabral complex and typically a narrow and circumferential strip with
labral damage and degenerative tearing within the labrum visible on (B) the radial PD-w image. (C) Correlating intra-operative image
(arrowhead) in a different patient who underwent surgical hip dislocation in case of acetabular retroversion. (D–F) conventional
X-rays: pre-operative AP X-ray (D) showing acetabular retroversion with positive cross-over sign, ischial spine and positive posterior
wall sign. Cross-table view (F: upper image) no additional cam deformity is visible. (E and F: lower image) post-operative X-rays after
anteverting periacetabular osteotomy.
Note. MR, magnetic resonance; FAI, femoro-acetabular impingement; PAO, periacetabular osteotomy; PD-w, proton density weighted; AP, anteroposterior;
L, labrum; LF, lunate facies.

precursor lesion, which progresses to acetabular cartilage

delamination and avulsion of the labrum from the acetab-
ular rim. Even fatigue fractures of the rim can occur and are
referred to as ‘os acetabuli’.4 Damage secondary to inclu-
sion FAI is typically focal but pronounced (Fig. 1).4,24
Either arthroscopic or open treatment by means of a sur-
gical hip dislocation (SHD) with recreation of the femoral a
head-neck offset can be performed.30–33 For open treat- C
ment of the cam deformity, hemispherical plastic templates
are used to intra-operatively identify the location and extent
of the cam deformity. The femoral head-neck offset is
restored using chisels and a high-speed burr. Intra-operative
dynamic evaluation of hip range of motion (ROM) deter-
mines the extent of the surgical correction. The torn labrum
is trimmed to stable substance and re-attached. To achieve
a good clinical outcome, labrum preservation or recon- Fig. 3 Alpha angle: angle formed by the femoral head-neck axis
struction of the labrum should be achieved whenever pos- (a) and line through the centre of the femoral head (C) and the
point where the anterior head-neck contour exceeds the head
sible.34,35 Autologous fascia lata or ligamentum teres grafts
radius.
can be used for labral reconstruction.36–39
In hips with impaction type morphology, acetabular
over-coverage restricts the impingement-free range of retroversion or osteophytes),40 or 2 generalized over-
motion. Different pathomorphologies of over-coverage coverage of the entire acetabulum (e.g. protrusio ace-
can be defined: 1 localized as an anterior osseous acetab­ tabuli representing the most severe form of pincer
ular prominence (e.g. with anterosuperior acetabular impingement) or severe acetabular retroversion.41

632
 Hip preservation

PW
IS
AW
PB

A) B)

PW PW

AW

a
b
C

C) D)

Fig. 4 (A) ‘Ischial spine sign’: positive if the ischial spine (IS) is projected medially to the pelvic brim (PB). (B) ‘Cross-over’ sign:
positive if the anterior wall (AW) crosses the posterior wall (PW). (C) Posterior wall sign: positive if the posterior wall (PW) runs
medially to the centre (C) of the femoral head. (D) Retroversion index: percentage of the retroverted acetabular opening (a) divided
by the entire opening (b).

To measure the acetabular coverage the lateral centre- that the outer margin of the acetabulum rim and size of the
edge (LCE) angle is the most important angle. An LCE lunate surface are essentially normal in retroverted acetab-
angle of less than 23° is defined as dysplastic, an angle ula.45 Therefore cases with substantial acetabular retrover-
exceeding 33° is considered as an acetabular over-cover- sion present with a combination of radiographic findings:
age, and an angle exceeding 39° is considered as a severe a positive cross-over sign (with a retroversion index exceed-
acetabular over-coverage.41 The acetabular index (AI) is ing 30%), a positive posterior wall sign, and a positive
used to measure the inclination of the acetabular roof. An ischial spine sign (Fig. 4). Long-term outcome data sup-
AI of > 14° is defined as dysplastic and an AI of ≤ 2° is con- ports acetabular re-orientation by means of an anteverting
sidered as an acetabular over-coverage, and an AI < –8° is PAO (periacetabular osteotomy) over acetabular rim trim-
considered as a severe acetabular over-coverage.41 ming.47–49 In contrast to the re-orientation in DDH, an
In hips with acetabular over-coverage, cartilage dam- internal rotation of the acetabular fragment is performed
age is usually restricted to a narrow and circumferential to achieve a rotational correction of the acetabulum.50
strip with labral damage usually co-located, and typically For arthroscopic treatment of FAI less favourable out-
presents as ossification and degenerative tearing within comes have been reported for patients of older age groups
the labrum (Fig. 2).4,24 (> 45 years), female sex, with elevated BMI, osteoarthritic
Either arthroscopic or open acetabular rim trimming is changes, decreased joint space (< 2 mm), chondral defects,
performed until impingement-free ROM is achieved fol- increased LCE angle, and labral debridement compared
lowed by re-attachment of the labrum.30–32 with labral repair.51 Comparable predictive factors associ-
There is mounting evidence that severe acetabular ret- ated with decreased long-term survivorship are reportedly
roversion represents a rotational abnormality of the entire associated with over- or under-treatment of the acetabular
hemipelvis rather than a prominent overgrowth of the rim, age > 40 years, and elevated BMI (> 30 kg/m2) for
anterior acetabular wall.42–46 Further, it has been shown patients undergoing surgical hip dislocation.31,32

633
 L

LF

A) B) C)

D) E) F)

Fig. 5 (A) Schematic drawing, (B) direct MR arthrography at 3T of a 23-year-old female with a posterior, extra-articular impingement
due to increased femoral torsion who underwent (B) surgical hip dislocation and an additional de-rotational osteotomy. (A) The
dynamic posterior abutment leads to an anterior leverage mechanism and causes a dynamic overload of the anterior chondrolabral
complex. (B) Radial PD-w image shows a hypertrophied labrum with hyper-intense signal alterations corresponding to an intra-
substance tear. (C) The surgical probe is advanced within the labrum and the adjacent acetabular cartilage is thinned. (D–F)
conventional X-rays: pre-operative AP X-ray (D) showing the typical morphology of a coxa valga antetorta and on the cross-table
view (F: upper image) a slight cam deformity is visible. (E and F: lower image) post-operative X-rays after surgical hip dislocation,
subtrochanteric de-rotational osteotomy and femoral osteochondroplasty.
Note. MR, magnetic resonance; PD-w, proton density weighted; AP, anteroposterior; L, labrum; LF, lunate facies.
Images A–C reprinted with permission from Schmaranzer et al.4

Extra-articular impingement cam resection and resection of the intertrochanteric region

and/or resection of the anterior iliac inferior spine. We use
Recently, extra-articular hip impingement has been recog- intra-operative dynamic evaluation of hip ROM for testing
nized as an additional but less frequent cause of impinge- of impingement-free motion. In cases with persisting
ment. Extra-articular impingement can occur anteriorly or anterior FAI after the aforementioned resection, a rota-
posteriorly. Anterior, ‘subspine’ impingement is typically tional femoral osteotomy to increase femoral torsion
located between the anterior iliac inferior spine (AIIS) and should be considered if an internal rotation of at least 30°
the intertrochanteric region of the proximal femur.52 This in 90° flexion is not present.54
condition can be caused by low femoral torsion (even Posteriorly, ischiofemoral impingement is typically
without concomitant cam or pincer morphologies),53 located between the ischial tuberosity and the lesser tro-
severe acetabular retroversion or after avulsion fractures chanter.18 Excessive high femoral torsion (> 35 degrees)
of the AIIS. This has been described using CT-based 3D combined with a valgus deformity (neck-shaft angle
reconstructions of the pelvis and femur and is probably > 139°) predisposes to this conflict in extension with or
underestimated. The use of intra-articular corticosteroid without external rotation in the hip joint. The posterior
injections can help to differentiate between anterior intra- osseous abutment supposedly leads to a levering mech-
and extra-articular hip impingement. Because clinical anism and de-centralization or dynamic hip instability
diagnosis is difficult, the use of CT-based 3D reconstruc- (Fig. 5).2 Consequently the femoral head subluxates
tions of the pelvis and femur and dynamic simulation of anteriorly and leads to an inside-out avulsion of the ace-
hip impingement for diagnosis and pre-operative plan- tabular labrum and tearing of the labral body.4 Clinical
ning in these cases is helpful.18 This is particularly due to diagnosis is established by a positive posterior impinge-
the fact that most patients show combined intra- and ment test or the FABER test. Especially in the presence of
extra-articular impingement.53 a cam deformity and in the presence of acetabular over-
Surgical treatment for these hips is performed arthro- coverage it can be challenging to diagnose ischiofemo-
scopically or by means of a surgical hip dislocation for ral impingement. CT-based 3D reconstructions of the

634
 Hip preservation

pelvis and femur followed by a dynamic simulation Residual deformities after Perthes disease
of hip impingement considerably facilitate surgical
decision-making in patients with suspected posterior As the result of an abnormal development of the growth
extra-articular FAI.18 plate, Legg-Calvé-Perthes disease (LCPD) results typically
The causal treatment for this condition represents a in an aspherical, mushroom-shaped femoral head.68 In
proximal femoral de-rotational osteotomy.54 In our insti- flexion and internal rotation the aspherical portion of the
tution, this procedure typically is combined with a SHD head-neck junction may protrude into the acetabulum
for an anterior cam resection and for intra-operative and create shear forces perpendicular to the acetabular
dynamic evaluation of hip ROM. A de-rotational osteot- cartilage,24 resulting in cartilage avulsion from the labrum
omy will increase the range of external rotation while and/or abrasions on the acetabular cartilage. To restore
impairing the range of internal rotation. Thus, a concomi- ROM the surgical treatment of choice is resection of the
tant anterior cam resection is performed on a nearly regu- aspherical portion of the head.68 A high-riding trochanter
lar basis in these hips (Fig. 5). is another typical deformity in LCPD, causing extra-articular
impingement between the greater trochanter and the
supra-acetabular region and impairment of abductor
Slipped capital femoral epiphysis (SCFE) strength.68,69 Relative femoral neck lengthening70 is neces-
SCFE is the most common adolescent hip disorder.55 The sary to improve the lever arm and restore abductor func-
association between deformities from SCFE and the tion.71 In cases in which the deformed and enlarged
development of FAI and early osteoarthritis of the hip has femoral head is not contained by the acetabulum, intra-
been shown in multiple studies.56–58 It is suspected that articular impingement between the femoral head and the
multiple factors lead to a weakened physis no longer acetabulum, also referred to as ‘hinged abduction’, results
restraining the forces acting upon the epiphysis, result- in levering out of the head in abduction.72,73 Via a surgical
ing in a slip of the epiphysis over the metaphysis in a hip dislocation, a semi-circumferential femoral osteochon-
postero-inferior direction.55 Historically, in situ pinning droplasty can be safely performed. A further femoral head
had the lowest risk for avascular necrosis and became the reduction osteotomy can be considered in selective cases
treatment of choice in many institutions. The downside if containment of the femoral head cannot be achieved
of in situ fixation is that even large deformations are left with femoral osteochondroplasty alone.74 As a result of a
uncorrected overall resulting in an abutment of the ante- premature fusion of the tri-radiate cartilage, the acetabu-
rior metaphyseal flare against the acetabular rim, caus- lum becomes dysplastic concomitant with severe femoral
ing chondrolabral damage59–61 and exposing young head deformities75,76 presenting with an increased radius,
patients to the risk of early hip dysfunction.62 In many a decreased depth and a more vertically orientated ace-
centres severe or unstable SCFE is nowadays treated tabular roof.75,77 Overall this results in joint instability
open using surgical hip dislocation with development of leading to acetabular rim overload and concurrent chon-
a retinacular soft tissue flap to perform a subcapital re- drolabral lesions78 requiring a periacetabular osteotomy
alignment of the slipped epiphysis, the so-called ‘modi- to manage the dysplastic component of these hips.68
fied Dunn’ procedure.63 The femoral head is stepwise
mobilized respectively and separated from the femoral Avascular necrosis (AVN) of the
epiphysis. The callus formation of the metaphysis is
femoral head
resected and the epiphyseal scar is cleaned. The epiphy-
sis is then manually reduced on the metaphyseal stump AVN typically leads to femoral head collapse and subse-
and fixed with anterograde Kirschner wires.63 Of the quent rapid progression of osteoarthritis. Mainly young
hips, 93% presented with no progression of osteoarthri- and active patients in the third and fourth decades of life
tis, good clinical scores and no subsequent total hip are affected.79 Apart from idiopathic aetiologies, osteone-
arthroplasty (THA) at 10-year follow-up64 following a crosis of the femoral head occurs secondary to corticoster-
modified Dunn procedure. Different rates of avascular oid use, alcohol abuse, sickle cell disease, radiation, and
necrosis (AVN) are reported for the modified Dunn pro- cytotoxic agents.80 There is no consensus on the optimal
cedure in the literature with low rates of 4–6%65,66 or surgical treatment for this challenging condition accord-
high rates of up to 26%.67 In contrast to the modified ing to a recent systematic review of the literature.79
Dunn procedure, devastating long-term results were Depending on the localization, extension and stage of the
shown for in situ pinning with almost 75% of hips dem- osteonecrosis, multiple therapeutic options are available
onstrating degenerative changes on X-rays or requiring such as rotational osteotomies, bone grafting, core decom-
conversion to THA in a series with a mean follow-up of pression and varus/flexion femoral osteotomy aiming
23 years.62 to preserve the joint in these mostly young and active

635
 L

LF

A) B) C)

D) E) F)

Fig. 6 (A) Schematic drawing, (B) direct MR arthrography with traction at 3T of a 17-year-old woman with hip dysplasia who
underwent (B) surgical hip dislocation and subsequent periacetabular osteotomy. (A–C) Static axial overload leads to ‘inside-
out lesion’ of the chondrolabral complex. (A) In severe cases this can lead to a fatigue fracture of the osseous rim (dashed
line). (B) Coronal PD-w image and (C) intra-operative image shows a cartilage sleeve which extends from centrally into the
chondrolabral transition zone and the hypertrophied labrum. (D–F) conventional X-rays of a 23-year-old woman: pre-operative
AP X-ray (D: showing hip dysplasia with LCE angle of 17° and acetabular index of 14°. On the cross-table view (F: upper image) a
concomitant cam deformity is apparent. (E and F: lower image) post-operative X-rays after periacetabular osteotomy and femoral
osteochondroplasty.
Note. MR, magnetic resonance; PD-w, proton density weighted; AP, anteroposterior; LCE, lateral centre-edge; L, labrum; LF, lunate facies.
Images A–C reprinted with permission from Schmaranzer et al.4

patients.79 Combined surgical dislocation with flexion/ labrum from the acetabular rim together with a sleeve of
varus osteotomy and direct treatment of the necrosis with cartilage (Fig. 6). Furthermore, progressive thinning of the
subchondral drilling or cartilage repair followed by curet- acetabular cartilage occurs finally resulting in full-thick-
tage of the necrotic lesion has shown promising early ness defects at the peripheral acetabular rim due to static
results in hips with advanced AVN.81 If joint preservation is overload.86 This chondrolabral damage is typically located
not possible THA should be performed.79,80 superiorly.87
Surgical treatment of acetabular under-coverage aims
to re-orientate the acetabulum to normalize joint contact
Developmental dysplasia of the hip (DDH) pressure by optimizing the femoral containment and pre-
Acetabular under-coverage (development dysplasia of vention of subluxation.82,88 Different studies have shown
the hip) produces a different pathomechanism leading that joint contact pressure can be reduced through ace-
to degenerative hip arthritis and is defined by a lateral tabular re-orientation.89,90
centre-edge angle of less than 22°.41 Further prognostic Various acetabular osteotomies have been described.
values are an acetabular index > 14° and a femoral head At our institution the Bernese periacetabular osteotomy
extrusion index > 27%. Typically, the entire innominate (PAO) (Fig. 6) is the standard of care.91 This approach
bone is internally rotated.46 Different studies have shown gives the advantage of enabling the surgeon to perform
that dysplastic hips have a decrease in size of the lunate corrections in a large tri-dimensional fashion, producing
surface45,82 compared with normal hips and increased an inherent stability of the acetabular fragment due to
contact pressures (e.g. 23% increased pressure in mid- the polygonal cuts and furthermore the preservation of
stance phase of gait).82 An up to four times increased load the posterior column. Patients can proceed with partial
to the labrum results in a reactive labral hypertrophy.83–85 weight-bearing directly after the surgery. Furthermore,
The labrum is torn along with a part of the adjacent carti- the birth canal is not affected. If needed, femoral osteo-
lage due to subluxation of the femoral head that tears the chondroplasty is performed additionally if an internal

636
 Hip preservation

rotation of less than 30° in 90° flexion is apparent after the Licence
acetabular re-orientation. © 2020 The author(s)
As these patients are often very young at the time of This article is distributed under the terms of the Creative Commons Attribution-Non
surgery, long-term follow-up and identification of factors Commercial 4.0 International (CC BY-NC 4.0) licence (https://creativecommons.org/
associated with osteoarthritis progression, poor clinical licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribu-
outcome, and conversion THA will help to improve patient tion of the work without further permission provided the original work is attributed.
selection. Recently a study presented 30-year follow-up
results.92 Advanced age > 40 years, a pre-operative Merle References
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Author Information 9. Chopra A, Grainger AJ, Dube B, et al. Comparative reliability and diagnostic
1Department of Orthopaedic and Trauma Surgery, Inselspital, University of Bern,
performance of conventional 3T magnetic resonance imaging and 1.5T magnetic resonance
Bern, Switzerland. arthrography for the evaluation of internal derangement of the hip. Eur Radiol 2018;28:963–971.
2Department of Diagnostic, Interventional and Pediatric Radiology, University 10. Hanke MS, Steppacher SD, Anwander H, Werlen S, Siebenrock KA,
Hospital of Bern, Inselspital, University of Bern, Bern, Switzerland. Tannast M. What MRI findings predict failure 10 years after surgery for femoroacetabular
impingement? Clin Orthop Relat Res 2017;475:1192–1207.
Correspondence should be sent to: Markus S. Hanke, Department of Orthopaedic
11. Schmaranzer F, Klauser A, Kogler M, et al. Improving visualization of the
and Trauma Surgery, Inselspital, University of Bern, Freiburgstrasse, 3010 Bern,
central compartment of the hip with direct MR arthrography under axial leg traction: a
Switzerland.
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Email: [email protected]
12. Schmaranzer F, Klauser A, Kogler M, et al. Diagnostic performance of
direct traction MR arthrography of the hip: detection of chondral and labral lesions with
ICMJE Conflict of interest statement
arthroscopic comparison. Eur Radiol 2015;25:1721–1730.
FS reports grants/grants pending from the Swiss National Science Foundation, out-
side the submitted work. 13. Schmaranzer F, Klauser A, Kogler M, et al. MR arthrography of the hip with
The other authors declare no conflict of interest relevant to this work. and without leg traction: assessing the diagnostic performance in detection of ligamentum
teres lesions with arthroscopic correlation. Eur J Radiol 2016;85:489–497.
Funding statement 14. Schmaranzer F, Lerch TD, Strasser U, Vavron P, Schmaranzer E, Tannast
No benefits in any form have been received or will be received from a commercial M. Usefulness of MR arthrography of the hip with and without leg traction in detection of
party related directly or indirectly to the subject of this article. intra-articular bodies. Acad Radiol 2019;26:e252–e259.

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