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This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.

Anatomy & Pathophysiology¶

Bony Anatomy¶

• The hip is a multiaxial joint formed by the articulation between the pelvis and femur, connecting the axial skeleton and the lower extremity [8].
• The hemipelvis comprises three bones: the ilium, ischium, and pubis, which unite at the triradiate cartilage within the concave acetabulum [8].
• The acetabulum comprises an articular crescent-moon–shaped lunate surface and a nonarticular central fossa that serves as the attachment point for the ligamentum teres [8].
• The acetabulum is incomplete inferiorly, forming a notch through which vital blood vessels and nerves pass to supply the joint [8].
• The femoral head forms two-thirds of a sphere, with a small depression at its center from which the ligamentum teres extends to connect to the acetabular notch [8].
• The neck-shaft angle of the femur averages 125° [8].
• Normal version, defined as the head-neck angle in the frontal plane, averages 15 to 20° [8].
• The acetabulum is normally anteverted 15 degrees and obliquely oriented in the coronal plane 45 degrees caudally [14].
• The posterosuperior articular surface of the acetabulum is thickened to accommodate weight bearing [14].
• The inferior surface of the acetabulum contains the acetabular (cotyloid) notch, which is bound by the transverse acetabular ligament [14].
• The femoral neck is normally anteverted approximately 14 degrees in relation to the femoral condyles, with a range of 1–40 degrees [14].
• The femoral neck-shaft angle averages 127 degrees, beginning at 141 degrees in the fetus [14].
• The ilium is a large flat bone forming the majority of the coxal bone, with the iliac crest terminating anteriorly at the anterior superior iliac spine (ASIS) and posteriorly at the posterior superior iliac spine (PSIS) [8].
• The ischium is a small L-shaped bone forming the posteroinferior margin of the pelvis, with the ischial tuberosity serving as a large attachment site for multiple muscle groups [8].
• The pubis bone consists of a body and two rami that connect superiorly to the ilium and inferiorly to the ischium to form the obturator foramen [8].
• The obturator foramen is covered by a strong membrane that provides surface area for muscle attachments [8].
• The hemipelvises unite anteriorly at the pubic symphyses and articulate posteriorly with the sacral ala to form the sacroiliac (SI) joint [8].
• The iliac crest is a palpable rim of the ilium and an important site for bone graft harvest, specifically the iliac tubercle 5 cm posterior to the ASIS [14].
• The ASIS is palpable at the lateral edge of the inguinal ligament and serves as the origin of the sartorius muscle and transverse and internal abdominal muscles [14].
• The AIIS is less prominent and serves as the origin of the direct head of the rectus femoris and the iliofemoral ligament [14].
• The PSIS is located 4–5 cm lateral to the S2 spinous process and is an important landmark for posterior iliac crest bone graft harvest [14].
• The ischial tuberosity serves as the origin of the hamstrings [14].
• The iliopsoas muscle/tendon traverses a groove between the iliopectineal eminence and the AIIS [14].

Ligaments and Capsule¶

• The hip is surrounded by a dense fibrous capsule extending from the periphery of the acetabulum to the intertrochanteric line of the femoral neck [8].
• The capsule enhances joint stability by preventing translation of the femoral head in the acetabulum [8].
• The hip capsule attaches anteriorly and posteriorly along the periphery of the acetabulum outside the labrum [9].
• Inferiorly, the hip capsule is attached to the acetabular labrum [9].
• The capsule is attached to the femur anteriorly along the intertrochanteric crest [9].
• On the posterior side, the capsule attaches only partially, such that the basicervical region of the femoral neck and the intertrochanteric region of the femur are not intracapsular [9].
• The iliofemoral ligament is also known as the Y ligament of Bigelow; it originates at the AIIS and inserts at the intertrochanteric line [9].
• The iliofemoral ligament is the thickest and strongest of the three main ligaments supporting the hip [8].
• The medial portion of the iliofemoral ligament connects the anterior inferior iliac spine to the anterior intertrochanteric line, while the lateral portion originates slightly superior to the medial arm and attaches to the anterior greater trochanter [8].
• The iliofemoral ligament functions to limit external rotation, while in isolation, the lateral arm limits extension of the joint [8].
• The iliofemoral ligament becomes taut in full extension, preventing anterior dislocation and hyperextension of the hip [9].
• The ischiofemoral ligament extends from the ischial margin of the acetabulum to the greater trochanter of the femur [8].
• The ischiofemoral ligament provides support posteriorly and restricts internal rotation motion [8].
• The pubofemoral ligament extends from the obturator crest of the pubic bone to the femoral neck and acts to limit abduction of the joint [8].
• Deep fibers from the iliofemoral, ischiofemoral, and pubofemoral ligaments merge to form the zona orbicularis, which circumvents the femoral neck [8].
• The twisted orientation of the hip ligaments provides a screw mechanism for the hip in full extension [9].
• The ligamentum teres originates in the cotyloid fossa and attaches on the fovea of the femoral head [9].
• The ligamentum teres transmits an arterial branch of the posterior division of the obturator artery to the femoral head, which is less significant in adults [5].
• The sacrospinous ligament creates the upper border of the lesser sciatic foramen and the lower border of the greater sciatic foramen [9].
• The sacrotuberous ligament creates the inferior border of the lesser sciatic foramen [9].
• The piriformis muscle and the sciatic nerve exit from the greater sciatic foramen [9].
• The short external rotator muscles exit from the lesser sciatic foramen [9].

Labrum¶

• The acetabular labrum is a fibrocartilaginous ring attached to the rim of the acetabulum that extends the articulating surface area and increases femoral head coverage [8].
• The labrum is triangular in cross section, which contributes to its ability to create a pressurized seal of the central compartment of the hip during loading [8].
• Only the external one-third of the labrum contains blood vessels, leaving the majority of the structure avascular and limiting its healing ability following injury [8].
• The labrum is highly innervated, with the presence of both mechanoreceptors and nociceptors [8].
• The labrum is absent in the area of the inferior acetabular notch, where the transverse acetabular ligament serves as the continuation of the labrum, connecting the anterior and posterior lunate surfaces of the acetabulum [8].
• Labral functions include load transmission, maintenance of vacuum seal, regulation of synovial fluid hydrodynamics, and joint lubrication [5].

Muscular Anatomy¶

• The abductors of the hip are predominantly the gluteus medius and minimus muscles [16].
• The gluteus medius has three different components: anterior, middle, and posterior [16].
• The gluteus medius and minimus muscles function together to maintain and abduct the femur during the stance phase of gait [16].
• A Trendelenburg lurch is an attempt by the body to compensate for abductor weakness by bringing the center of gravity closer to the hip center, forcing the patient to lean toward the affected side [16].
• The gluteus maximus originates from the sacrum, the coccyx, and the sacrotuberous ligaments and inserts into the lateral intramuscular septum [16].
• The hamstring muscles originate on the ischial tuberosity [16].
• The primary hip flexor muscles are the iliopsoas, rectus femoris, and sartorius muscles [16].
• The iliopsoas muscle has a large origin along the iliac crest, the iliac fossa, the sacra ala, the iliolumbar ligaments, and the sacroiliac ligaments [16].
• The rectus femoris crosses the hip joint and the knee joint, with the straight head originating from the AIIS and the reflected head originating from the supra-acetabular tubercle [16].
• The sartorius muscle originates on the ASIS, crosses the hip and knee joints, and inserts on the medial aspect of the tibia and the pes anserine complex [16].
• The tensor fasciae latae muscle originates laterally on the anterolateral edge of the iliac crest and its fibers combine with the fasciae latae to form the iliotibial band [16].
• The action of the tensor fasciae latae is to flex, abduct, and rotate the hip [16].
• The external rotators of the hip include the obturator internus and externus, superior and inferior gemelli, quadratus femoris, and piriformis muscles [16].
• The piriformis forms the reference structure for the posterior part of the hip, with structures identified by whether they originate above or below it [16].
• The superior gluteal nerve and artery exit the pelvis above the piriformis muscle [16].
• The pudendal nerve, internal pudendal artery, nerve to the obturator internus, posterior femoral cutaneous nerve, sciatic nerve, inferior gluteal nerve, inferior gluteal artery, and nerve to the quadratus femoris all exit the pelvis below the piriformis [16].
• In 10% of cases, the common peroneal component of the sciatic nerve can pass through the division in the piriformis [16].
• The most consistent internal rotators of the hip joint are the gluteus medius and tensor fascia latae muscles [16].
• Lateral-sided hip pain is a conglomerate of conditions including snapping hip, trochanteric bursitis, and gluteal tendinopathy lumped together as greater trochanteric pain syndrome (GTPS) [20].
• The largest bursa in the lateral hip is found between the gluteus maximus muscle and the gluteus medius tendon, which is located directly lateral to the greater trochanter [20].
• The muscular sheaths and tendinous attachments of the gluteus maximus, ITB, tensor fascia lata, gluteus medius, and gluteus minimus contribute to a complex local environment susceptible to overuse injuries, direct trauma, and gait alterations [20].

Neurovascular Anatomy¶

• The medial femoral circumflex artery is the main blood supply to the femoral head in adults [18].
• The lateral femoral circumflex artery gives rise to the anterior aspect of the extracapsular arterial ring [18].
• The superior and inferior gluteal arteries also contribute branches to the extracapsular arterial ring [18].
• The ascending cervical arteries originate from the extracapsular arterial ring and are divided into lateral, medial, posterior, and anterior groups [18].
• The lateral group of ascending branches is the main blood supply to the femoral head [18].
• The lateral epiphyseal artery penetrates the femoral head and is believed to be the dominant blood supply to the femoral head from this system [18].
• Fractures that disrupt the ascending blood flow to the lateral epiphyseal vessel have an increased risk of osteonecrosis [18].
• The artery of the ligamentum teres arises from either the obturator or medial femoral circumflex artery and does not provide sufficient blood supply to maintain the viability of the femoral head [18].
• The common femoral artery arises from the external iliac artery as it passes underneath the inguinal ligament [21].
• The common femoral artery passes anterior and medial to the hip capsule [21].
• The common femoral vessels are the most commonly reported extrapelvic vascular structures injured during total hip arthroplasty [21].
• The most common mechanism of injury to the common femoral vessels is errant retractor placement anterior to the acetabulum [21].
• The profundus or deep femoral artery arises from the lateral aspect of the common femoral artery approximately 3.5 cm below the inguinal ligament [21].
• The lateral circumflex artery arises from the lateral side of the proximal profundus femoris artery [21].
• The medial circumflex artery most commonly comes from the posteromedial profundus femoris artery but may also come directly from the femoral artery [21].
• The superior gluteal vessels are branches of the posterior division of the internal iliac artery and are closest to the hip as they exit from the sciatic notch [21].
• Superior gluteal artery injury can occur with the placement of screws in the region of the sciatic notch [21].
• The inferior gluteal vessels and internal vessels are branches of the anterior division of the internal iliac artery and exit the pelvis between the piriformis and coccygeus muscles [21].
• The inferior gluteal vessels can be injured by screws in the posterior column that are at least 5 mm past the bony margin [21].
• The lateral femoral cutaneous nerve is at risk when using the anterior portal for hip arthroscopy, with less risk associated with the midanterior portal [3].
• The sciatic nerve is the main structure at risk with the posterior (Southern) approach to the hip [18].
• The superior gluteal nerve can be damaged if the intermuscular plane of the anterior lateral (Watson Jones) approach is extended to the iliac crest [18].

Pathophysiology¶

• Femoroacetabular impingement (FAI) is recognized as a common cause of hip dysfunction and secondary osteoarthritis [3].
• In FAI, distinct structural abnormalities produce repetitive impingement between the acetabulum and the femoral head-neck junction [3].
• Three types of FAI are recognized: cam, pincer, and combined cam/pincer [3].
• Cam impingement involves femoral-based abnormalities such as an aspherical femoral head and reduced head-neck offset, resulting in repetitive abutment of the acetabular rim and femoral head-neck junction [3].
• Pincer impingement involves acetabular-based disorders such as acetabular retroversion, global overcoverage, and acetabular protrusio, creating abnormal abutment of the acetabular rim and femoral head-neck junction [3].
• Impingement abnormalities can cause labral tears, degeneration, or ossification [3].
• Impingement abnormalities can cause acetabular cartilage delamination [3].
• Impingement abnormalities can cause secondary osteoarthritis [3].
• The hip is a complex multiaxial joint capable of producing large forces and moving the thigh through large ranges of motion [1].
• Any alteration to joint morphology or function can place the hip at risk for pathology [1].
• The anatomic structures of the hip and pelvis are described in layers: Layer 1 is osseous morphology, Layer 2 is soft tissue including labrum, capsule, and ligaments, Layer 3 is the contractile layer including adductors, abductors, flexors/extensors, and rotators, and Layer 4 is neurovascular structures [12].
• Patients with extra-articular hip pathology can have concomitant femoroacetabular impingement (FAI) or intra-articular hip pathology [12].
• DDH is a gradually progressive disorder associated with distinct anatomic changes, many of which are initially reversible [13].
• In unstable hips at birth, the posterosuperior rim of the acetabulum loses its sharp margin and becomes flattened and thickened in the area over which the femoral head slides [13].
• A ridge of thickened articular cartilage called the neolimbus arises along the posterosuperior acetabular wall as the head rides in and out of the socket [13].
• In dislocated hips, the fatty tissue known as the pulvinar thickens in the depths of the acetabulum and may impede reduction [13].
• The ligamentum teres elongates and thickens in dislocated hips, taking up valuable space within the acetabulum [13].
• The transverse acetabular ligament is often hypertrophic in dislocated hips and may impede reduction [13].
• The inferior capsule of the hip assumes an hourglass shape in dislocated hips, eventually presenting an opening smaller in diameter than the femoral head [13].
• The iliopsoas tendon is pulled tight across the capsular isthmus, contributing to narrowing and acting as a barrier to closed reduction [13].
• Excessive pressure on the cartilaginous upper femur can cause a loss of vascular perfusion, resulting in necrosis of the chondrocytes [11].
• Muscle imbalance can significantly affect the growth and morphology of the upper femur, with excessive adductor pull or inadequate abductor muscle function resulting in a valgus deformity [11].

Investigations¶

Clinical Examination¶

• A thorough understanding of normal anatomy and biomechanics is necessary to identify pathology and determine the appropriate course of treatment for hip conditions [1].
• A comprehensive clinical examination is required to determine a differential diagnosis because many hip conditions present with similar symptoms [1].
• A thorough history is essential to differentiating between common causes of hip pain [1].
• Clinical examination tests and imaging findings should be used to confirm a suspected clinical diagnosis [1].

Radiography¶

• Conventional radiographs remain critical in the initial imaging evaluation of the hip [2].
• Radiographs can be used to diagnose fractures, developmental dysplasia of the hip (DDH), femoroacetabular impingement (FAI), and osteoarthritis [2].
• A complete hip series usually consists of an anterior-posterior (AP) pelvis, a centered AP hip, a lateral view (frog-leg, cross-table, Dunn 45° or 90°), and a false-profile (Lequesne) view [2].
• The Dunn 45° view may be more accurate for determining the alpha angle measurement than CT or MRI [2].
• The alpha angle is used to assess femoral head-neck junction morphology, with normal values generally considered less than 50°–55° [2].
• The Tönnis angle is defined by the angle of the acetabular sourcil and a line parallel to the transverse pelvis axis, with values between 0° and 10° considered normal [2].
• The lateral center-edge angle (Wiberg) is the angle between a line from the center of the femoral head perpendicular to the transverse pelvis axis and a second line from the center of the femoral head to the superolateral most point of the acetabulum [2].
• Center-edge angles of 20°–40° are considered normal, while angles from 20° to 25° are considered borderline [2].
• The femoral head extrusion index is defined by the length of the femoral head that lies beyond the acetabulum as a percentage of the total horizontal width of the femoral head [2].
• Femoral head extrusion index values greater than 25% are considered abnormal [2].
• Coxa profunda is diagnosed when the fossa line touches or is medial to the ilioischial line on an AP pelvis radiograph [2].
• The "crossover" sign on an AP pelvis radiograph indicates acetabular retroversion related to lateralization of the anterior acetabular wall relative to the posterior acetabular wall [2].
• Pelvic tilt or rotation may lead to false-positive and false-negative "crossover" signs on AP pelvis radiographs [2].
• For neutral pelvic tilt on an AP pelvis radiograph, the sacrococcygeal joint should be between 3 and 5 cm above the superior border of the symphysis pubis [2].
• Radiographs can serially assess hardware positioning and evaluate symptomatic hardware related to open reduction and internal fixation and total hip arthroplasty [2].
• The AP pelvis view is used to assess acetabular anatomy, including version, acetabular coverage, and femoral head sphericity [3].
• Various lateral views, most commonly the 45° Dunn view and frog-leg lateral, can be used to assess femoral head sphericity and head-neck offset [3].

Magnetic Resonance Imaging (MRI)¶

• MRI is the modality of choice for patients suspected of soft tissue or intra-articular pathology, given its superior sensitivity and specificity [25].
• Conventional MRI is effective at identifying osteochondral injuries, musculotendinous pathologies, and inflammation [25].
• Magnetic resonance arthrography (MRA) is more appropriate than conventional MRI to determine injuries to the labrochondral structures and the ligamentum teres [25].
• MRA is useful for identifying the presence of loose bodies and synovial chondromatosis [25].
• The utility of MRA in the accurate detection and staging of articular cartilage lesions is reduced, with sensitivity reported to be less than 50% compared with arthroscopic findings [25].
• Recent advances in MRI techniques, such as delayed gadolinium-enhanced MR imaging and T2* mapping, allow for a more in-depth analysis of the structure of articular cartilage [25].
• Delayed gadolinium-enhanced MR imaging and T2* mapping were effective at detecting early changes to the articular cartilage surfaces of patients with hip dysplasia and femoroacetabular impingement [25].
• MRI provides information regarding the integrity of the acetabular labrum and articular cartilage [3].
• MRI can assess the anatomy of the proximal femur as well as the version of the acetabulum and femur [3].
• The sensitivity of MRI to acetabular rim chondral lesions is limited [3].
• Noncontrast MRI at 3T is generally adequate for diagnosing intra-articular pathology [28].
• If 3T imaging is unavailable, MRA can be considered at 1.5T for increased diagnostic accuracy [28].
• A prospective study found similar accuracies between noncontrast 3T MRI and 1.5T MRA in femoroacetabular impingement [26].
• In a retrospective study evaluating noncontrast 3T MRI versus hip arthroscopy, the accuracy for labral tears was 98% and for acetabular cartilage lesions was 90% [26].
• MRI is helpful in identifying femoral neck stress fracture in athletes and predicting patients that may require surgical intervention [28].
• MRI is useful for assessing complications of conventional and resurfacing hip arthroplasties, particularly those with metal-on-metal bearing systems [28].
• Major MRI findings that help predict histologic ALVAL scores include synovial thickening, synovitis, synovial volume, abductor disruption, and soft-tissue edema [28].
• MRI is more sensitive than bone scan for ruling out occult nondisplaced stress fractures if the injury is less than 24 hours old [22].

Computed Tomography (CT)¶

• CT scans are effective for examining cortical and cancellous bone and can be used to create three-dimensional reconstructions of the hip for use in surgical planning [25].
• Measurements of femoral head coverage and acetabular and femoral impingement can be performed reliably using CT images [25].
• Low-dose CT with three-dimensional reformats is particularly useful in surgical planning of complex or borderline deformities [3].
• CT overcomes the limitations of radiography by providing three-dimensional assessment of bony morphology and, to some degree, assessment of soft-tissue abnormalities [10].
• Combined with arthrography, CT can evaluate chondrolabral abnormalities, specifically in patients with contraindications to MRI [10].
• CT is helpful in fracture evaluation, particularly in the setting of negative radiographs or for further defining fracture morphology in patients requiring surgical reduction [10].
• The multiplanar and 3D capabilities of CT make it an invaluable tool for assessing bone morphology, but at higher cost and radiation dose [28].
• 3D volume renderings are useful to aid in preoperative planning in FAI and subspine impingement [28].
• CT is performed after reduction of hip dislocations to evaluate for associated acetabular and/or femoral head fracture and loose bodies in the joint [22].
• CT is used to evaluate the location and size of femoral head fracture fragments and rule out associated acetabular fracture [22].

Ultrasonography¶

• Ultrasonography provides real-time dynamic assessment of the hip and is useful in diagnosing soft-tissue abnormalities about the hip joint [10].
• Ultrasonography is particularly useful in providing real-time guidance during diagnostic and therapeutic procedures [10].
• Ultrasonography can be an effective modality to identify musculotendinous disruptions, effusions associated with intra-articular pathology, or inflammatory conditions, such as bursitis [25].
• Ultrasonography is increasingly used for targeted injections into muscles, tendons, or intra-articularly around the hip for use with corticosteroids or biologic treatments [25].
• Ultrasonography allows bedside evaluation of the hip and can be used to guide interventions in the office setting [28].
• Ultrasonography provides dynamic assessment of structures such as tendon and nerve subluxation [29].
• Higher frequency ultrasonographic beams can provide higher resolution images of superficial structures such as tendons and ligaments [29].
• Ultrasonography cannot image inside bone because bone cortex reflects almost all sound waves [29].
• Internal joint structures are not well visualized by ultrasonography unless they are in a superficial location [29].
• Image quality and interpretation of ultrasonography depend on the experience of the ultrasonography technician and the radiologist [29].
• The utility of ultrasonography in evaluating the adult hip is limited, although it is a valuable tool to examine pediatric hip conditions [25].

References¶

[1] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Anatomy and Biomechanics, Evaluation, Clinical Examination, and Imaging of the Hip > Summary.

[2] Orthopaedic Knowledge Update Sports Medicine 6. Imaging of the Hip > Radiography.

[3] Aaos Comprehensive Orthopaedic Review 3. Nonarthroplasty Surgical Treatment of the Hip > I. Femoroacetabular Impingement.

[5] Miller S Review Of Orthopaedics. Genetics of musculoskeletal conditions and abnormalities are summarized in Table 1.27 > 2. Arthrology > Hip (Fig. 2.49).

[8] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Anatomy and Biomechanics, Evaluation, Clinical Examination, and Imaging of the Hip > Osseous and Ligamentous Anatomy.

[9] Aaos Comprehensive Orthopaedic Review 3. Surgical Anatomy of the Hip > IV. Hip Capsule and Ligaments.

[10] Orthopaedic Knowledge Update Sports Medicine 6. Imaging of the Hip > Introduction.

[11] Tachdjian S Pediatric Orthopaedics From The Texas Scottish Rite Hospital For Children E Book. Associated Conditions > Pathophysiology.

[12] Orthopaedic Knowledge Update Sports Medicine 6. Core Muscle Injury/Athletic Pubalgia and Groin Pathology > Introduction.

[13] Tachdjian S Pediatric Orthopaedics From The Texas Scottish Rite Hospital For Children E Book. Hip Development With Developmental Dysplasia of the Hip.

[14] Miller S Review Of Orthopaedics. SECTION 16 PATELLAR TRACKING IN TOTAL KNEE ARTHROPLASTY > LOWER EXTREMITY.

[16] Aaos Comprehensive Orthopaedic Review 3. Surgical Anatomy of the Hip > V. Hip Joint Muscles.

[18] Aaos Comprehensive Orthopaedic Review 3. Fractures of the Hip > I. General Considerations.

[20] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Muscular, Neurovascular, and Soft-­Tissue Conditions of the Hip > Muscular Conditions About the Hip > Hip Bursitis.

[21] Aaos Comprehensive Orthopaedic Review 3. Surgical Anatomy of the Hip > VI. Neurovascular Structures Surrounding the Hip.

[22] Miller S Review Of Orthopaedics. SECTION 16 PATELLAR TRACKING IN TOTAL KNEE ARTHROPLASTY > YOUNG ADULT PROXIMAL FEMUR INJURIES.

[25] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Anatomy and Biomechanics, Evaluation, Clinical Examination, and Imaging of the Hip > Imaging.

[26] Orthopaedic Knowledge Update Sports Medicine 6. Imaging of the Hip > Annotated References.

[28] Orthopaedic Knowledge Update Sports Medicine 6. Imaging of the Hip > Summary.

[29] Aaos Comprehensive Orthopaedic Review 3. Musculoskeletal Imaging* > IV. Ultrasonography.