Capital Femoral Growth Plate Extension Predicts Cam Morphology in a Longitudinal Radiographic Study

Morris, William Z.; Weinberg, Douglas S.; Gebhart, Jeremy J.; Cooperman, Daniel R.; Liu, Raymond W.

doi:10.2106/jbjs.15.01028

Cited by 30 publications

(37 citation statements)

References 38 publications

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“… 10 A theoretical model suggested that recurrent mechanical impingement could lead to growth plate alterations and development of cam, 11 findings which have been reinforced by recent studies demonstrating that adolescents develop concurrent growth plate changes and cam morphology. 12 - 14 Although we have no kinematic data from our cadaveric subjects, this hypothesis is consistent with the increased incidence of cam morphology seen in the cohort with decreased pelvic incidence.…”

Section: Discussionsupporting

confidence: 71%

“… 11 Growth plate alterations have subsequently been identified prior to cam development in adolescents. 12 - 14 Relative anterior acetabular overcoverage (as a consequence of low pelvic incidence) would similarly increase the risk for repetitive mechanical impingement, and could subsequently lead to cam formation through this mechanism. A preliminary study supported this theory as it demonstrated that patients with bilateral cam morphology had lower PI than matched controls.…”

Section: Introductionmentioning

confidence: 99%

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Decreasing pelvic incidence is associated with greater risk of cam morphology

Morris

Fowers

Yuh

et al. 2016

Bone & Joint Research

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ObjectivesThe spinopelvic relationship (including pelvic incidence) has been shown to influence pelvic orientation, but its potential association with femoroacetabular impingement has not been thoroughly explored. The purpose of this study was to prove the hypothesis that decreasing pelvic incidence is associated with increased risk of cam morphology.MethodsTwo matching cohorts were created from a collection of cadaveric specimens with known pelvic incidences: 50 subjects with the highest pelvic incidence (all subjects > 60°) and 50 subjects with the lowest pelvic incidence (all subjects < 35°). Femoral version, acetabular version, and alpha angles were directly measured from each specimen bilaterally. Cam morphology was defined as alpha angle > 55°. Differences between the two cohorts were analysed with a Student’s t-test and the difference in incidence of cam morphology was assessed using a chi-squared test. The significance level for all tests was set at p < 0.05.ResultsCam morphology was identified in 47/100 (47%) femurs in the cohort with pelvic incidence < 35° and in only 25/100 (25%) femurs in the cohort with pelvic incidence > 60° (p = 0.002). The mean alpha angle was also greater in the cohort with pelvic incidence < 35° (mean 53.7°, sd 10.7° versus mean 49.7°, sd 10.6°; p = 0.008).ConclusionsDecreased pelvic incidence is associated with development of cam morphology. We propose a novel theory wherein subjects with decreased pelvic incidence compensate during gait (to maintain optimal sagittal balance) through anterior pelvic tilt, creating artificial anterior acetabular overcoverage and recurrent impingement that increases risk for cam morphology.Cite this article: W. Z. Morris, C. A. Fowers, R. T. Yuh, J. J. Gebhart, M. J. Salata, R. W. Liu. Decreasing pelvic incidence is associated with greater risk of cam morphology. Bone Joint Res 2016;5:387–392. DOI: 10.1302/2046-3758.59.BJR-2016-0028.R1.

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Section: Discussionsupporting

confidence: 71%

Section: Introductionmentioning

confidence: 99%

Decreasing pelvic incidence is associated with greater risk of cam morphology

Morris

Fowers

Yuh

et al. 2016

Bone & Joint Research

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“…Excessive epiphyseal extension into the metaphysis has been shown to be a precursor off Cam FAI morphology in adolescent athletes . However, it remains unclear whether the increased epiphyseal extension is a pathologic response of the proximal femoral epiphysis to the increased mechanical stress associated with vigorous sports or if it is an adaptive response that would protect the epiphysis from slip at the cost of leading to a Cam morphology as suggested by Morris et al In our study it was evident that the more mature hips depended upon the peripheral cupping for epiphyseal stability in comparison to the young hip in which the large tubercle was the area with higher stress concentration. The transition from a tubercle‐based model towards a peripheral cupping‐based model of epiphyseal stability demonstrated in our study confirms that during skeletal growth, increased repetitive forces to the capital femoral epiphysis lead to a higher concentration of stress in the periphery.…”

Section: Discussionsupporting

confidence: 51%

“…Those studies also indicated a concomitant peripheral growth of the epiphysis around the metaphysis, described as epiphyseal cupping. Increased epiphyseal cupping or extension of the epiphysis into the metaphysis has been described as a precursor of cam‐type morphology associated with femoroacetabular impingement (FAI) . Abnormal extension of the capital femoral epiphysis has been suggested as a pathological response to recurrent stress to the growth plate observed in adolescents involved in vigorous sports activities .…”

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confidence: 99%

Relative contribution of epiphyseal tubercle and peripheral cupping to capital femoral epiphysis stability during daily activities

Kiapour

Maranho

et al. 2019

Journal Orthopaedic Research

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Epiphyseal tubercle and peripheral cupping can influence the development of slipped capital femoral epiphysis (SCFE) and Cam morphology. During normal skeletal growth, epiphyseal tubercle shrinks while the peripheral cupping grows. We hypothesized that epiphyseal tubercle act as the primary stabilizer of the head-neck junction at early stages and this role is gradually transferred to epiphyseal cupping as the tubercle shrinks and cupping grows. From a cohort of 80 boys and girls (8-15 years old) with normal hips, CT scans of 5 subjects corresponding to minimum, 25th percentile, median, 75th percentile and maximum relative tubercle and cupping height were used to develop 3D finite element models. In vivo measured hip loads were used to study load sharing between the tubercle and peripheral cupping under combined and uniaxial loads exerted on femoral head during a range of daily activities. Lower epiphyseal tubercle height, larger epiphyseal cupping height and bigger differences in tubercle and cupping heights were strongly associated with increased epiphyseal cupping to epiphyseal tubercle stress ratios (R 2 > 0.7). We found lower peripheral cupping stresses relative to the tubercle (cupping to tubercle stress ratio <1) in hips with larger tubercle and smaller cupping. The relative decreases in tubercle size along with increased in peripheral cupping in our models gradually shifted the load distribution to higher stresses in the periphery compared to the epiphyseal tubercle area (cupping to tubercle stress ratio >1). Both tubercle and

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“…Previous studies suggested that this transition in the mechanism that regulates epiphyseal stability may establish a mechanical environment susceptible for the development of SCFE or cam morphology. 15 , 19 – 21 Participation in vigorous sports activities may increase shear stress across the growth plate and has been associated with supraphysiologic epiphyseal extension into the anterosuperior metaphysis. 1 , 26 – 29 Although some authors have suggested that supraphysiologic epiphyseal extension is a pathologic response to increased recurring mechanical stress at the femoral head-neck junction, 1 , 24 , 26 , 29 others have proposed that excessive extension is an adaptive response to protect the growth plate from increased mechanical stress that could lead to SCFE.…”

Section: Discussionmentioning

confidence: 99%

Age- and Sex-Specific Morphologic Variations of Capital Femoral Epiphysis Growth in Children and Adolescents Without Hip Disorders

Novais

Maranho

Kim

et al. 2018

Orthopaedic Journal of Sports Medicine

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Background:Understanding the development of the capital femoral epiphysis is essential to identify pathologic variations that may lead to cam morphology.Purpose/Hypothesis:The purpose of this study was to investigate the development of the capital femoral epiphysis during childhood and adolescence, with specific morphologic analysis of the peripheral growth and the metaphyseal surface of the growth plate. We hypothesized that age- and sex-dependent morphologic variations of the peripheral growth (cupping) and surface anatomy (epiphyseal tubercle) of the epiphysis would be evident with increasing age.Study Design:Cross-sectional study; Level of evidence, 3.Methods:Pelvic computed tomography scans of 80 children and adolescents (range, 8-15 years; n = 10 per age group; 50% male), imaged because of suspected appendicitis, were used to reformat the proximal femur. All patients had asymptomatic hips with no signs or history of hip disorder. We measured the peripheral cupping of the epiphysis and the epiphyseal tubercle dimensions from 3-dimensional models. All measurements were normalized to the epiphyseal diameter. The effect of age on these parameters was evaluated by use of linear regression analysis. A 2-way analysis of variance (ANOVA) was used to compare these parameters between males and females.Results:The mean epiphyseal cupping increased with increasing age (R2 = 0.54; P < .001). The mean normalized epiphyseal cupping was consistently higher in the anterior and posterior directions compared with the inferior and superior locations. Male patients aged 10 and 11 years had lower (P = .002) mean epiphyseal cupping compared with female patients of the same age. We observed no difference between male and female participants after 12 years of age (P > .3). The normalized epiphyseal tubercle height (R2 = 0.08; P = .009), width (R2 = 0.13; P = .001), and length (R2 = 0.45; P < .001) decreased with increasing age, with no differences between male and female patients. On average, a 2.6-fold increase was found in epiphyseal cupping from 8 to 15 years of age, whereas normalized tubercle height decreased by 0.4-fold.Conclusion:Peripheral cupping of the epiphysis over the metaphysis increases with age, while the relative epiphyseal tubercle dimensions decrease. Females have an earlier onset of rapid increase in the peripheral cupping compared with males; however, no differences in epiphyseal tubercle dimensions were found between male and female patients. These findings may guide future studies investigating the development of cam morphology, which should consider the surface morphologic characteristics of the capital femoral epiphysis, the growth plate, and the differences in morphologic characteristics according to age and sex.

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Capital Femoral Growth Plate Extension Predicts Cam Morphology in a Longitudinal Radiographic Study

Cited by 30 publications

References 38 publications

Decreasing pelvic incidence is associated with greater risk of cam morphology

Decreasing pelvic incidence is associated with greater risk of cam morphology

Relative contribution of epiphyseal tubercle and peripheral cupping to capital femoral epiphysis stability during daily activities

Age- and Sex-Specific Morphologic Variations of Capital Femoral Epiphysis Growth in Children and Adolescents Without Hip Disorders

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