Skip to main content

The Etiology of Osteoarthritis of the Hip

An Integrated Mechanical Concept

Abstract

The etiology of osteoarthritis of the hip has long been considered secondary (eg, to congenital or developmental deformities) or primary (presuming some underlying abnormality of articular cartilage). Recent information supports a hypothesis that so-called primary osteoarthritis is also secondary to subtle developmental abnormalities and the mechanism in these cases is femoroacetabular impingement rather than excessive contact stress. The most frequent location for femoroacetabular impingement is the anterosuperior rim area and the most critical motion is internal rotation of the hip in 90° flexion. Two types of femoroacetabular impingement have been identified. Cam-type femoroacetabular impingement, more prevalent in young male patients, is caused by an offset pathomorphology between head and neck and produces an outside-in delamination of the acetabulum. Pincer-type femoroacetabular impingement, more prevalent in middle-aged women, is produced by a more linear impact between a local (retroversion of the acetabulum) or general overcoverage (coxa profunda/protrusio) of the acetabulum. The damage pattern is more restricted to the rim and the process of joint degeneration is slower. Most hips, however, show a mixed femoroacetabular impingement pattern with cam predominance. Surgical attempts to restore normal anatomy to avoid femoroacetabular impingement should be performed in the early stage before major cartilage damage is present.

Level of Evidence: Level V, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

This is a preview of subscription content, access via your institution.

Fig. 1A–D
Fig. 2
Fig. 3A–C
Fig. 4A–D
Fig. 5A–B

References

  1. 1.

    Armfield DR, Towers JD, Robertson DD. Radiographic and MR imaging of the athletic hip. Clin Sports Med. 2006;25:211–239, viii.

    PubMed  Article  Google Scholar 

  2. 2.

    Beall DP, Sweet CF, Martin HD, Lastine CL, Grayson DE, Ly JQ, Fish JR. Imaging findings of femoroacetabular impingement syndrome. Skeletal Radiol. 2005;34:691–701.

    PubMed  Article  Google Scholar 

  3. 3.

    Beaule PE, Zaragoza E, Motamedi K, Copelan N, Dorey FJ. Three-dimensional computed tomography of the hip in the assessment of femoroacetabular impingement. J Orthop Res. 2005;23:1286–1292.

    PubMed  Google Scholar 

  4. 4.

    Beck M, Kalhor M, Leunig M, Ganz R. Hip morphology influences the pattern of damage to the acetabular cartilage: femoroacetabular impingement as a cause of early osteoarthritis of the hip. J Bone Joint Surg Br. 2005;87:1012–1018.

    PubMed  Article  CAS  Google Scholar 

  5. 5.

    Beck M, Leunig M, Clarke E, Ganz R. Femoroacetabular impingement as a factor in the development of nonunion of the femoral neck: a report of three cases. J Orthop Trauma. 2004;18:425–430.

    PubMed  Article  Google Scholar 

  6. 6.

    Beck M, Leunig M, Parvizi J, Boutier V, Wyss D, Ganz R. Anterior femoroacetabular impingement: part II. Midterm results of surgical treatment. Clin Orthop Relat Res. 2004;418:67–73.

    PubMed  Article  Google Scholar 

  7. 7.

    Bharam S. Labral tears, extra-articular injuries, and hip arthroscopy in the athlete. Clin Sports Med. 2006;25:279–292, ix.

    PubMed  Article  Google Scholar 

  8. 8.

    Blankenbaker DG, Tuite MJ. The painful hip: new concepts. Skeletal Radiol. 2006;35:352–370.

    PubMed  Article  Google Scholar 

  9. 9.

    Bredella MA, Stoller DW. MR imaging of femoroacetabular impingement. Magn Reson Imaging Clin N Am. 2005;13:653–664.

    PubMed  Article  Google Scholar 

  10. 10.

    Clohisy JC, McClure JT. Treatment of anterior femoroacetabular impingement with combined hip arthroscopy and limited anterior decompression. Iowa Orthop J. 2005;25:164–171.

    PubMed  Google Scholar 

  11. 11.

    Crawford JR, Villar RN. Current concepts in the management of femoroacetabular impingement. J Bone Joint Surg Br. 2005;87:1459–1462.

    PubMed  Article  CAS  Google Scholar 

  12. 12.

    Eijer H, Myers SR, Ganz R. Anterior femoroacetabular impingement after femoral neck fractures. J Orthop Trauma. 2001;15:475–481.

    PubMed  Article  CAS  Google Scholar 

  13. 13.

    Eijer H, Podeszwa D, Ganz R, Leunig M. Evaluation and treatment of young adults with femoro-acetabular impingement secondary to Perthes’ disease. Hip Int. 2006;16:273–280.

    PubMed  CAS  Google Scholar 

  14. 14.

    Espinosa N, Rothenfluh DA, Beck M, Ganz R, Leunig M. Treatment of femoro-acetabular impingement: preliminary results of labral refixation. J Bone Joint Surg Am. 2006;88:925–935.

    PubMed  Article  Google Scholar 

  15. 15.

    Ganz K, Krügel N. Die Arteria circumflexa femoris lateralis. Topographischer Verlauf, Anastomosen. Berne, Switzerland: Department of Orthopaedic Surgery, University of Berne; 1997.

  16. 16.

    Ganz R, Gill TJ, Gautier E, Ganz K, Krugel N, Berlemann U. Surgical dislocation of the adult hip: a technique with full access to the femoral head and acetabulum without the risk of avascular necrosis. J Bone Joint Surg Br. 2001;83:1119–1124.

    PubMed  Article  CAS  Google Scholar 

  17. 17.

    Ganz R, Parvizi J, Beck M, Leunig M, Notzli H, Siebenrock KA. Femoroacetabular impingement: a cause for osteoarthritis of the hip. Clin Orthop Relat Res. 2003;417:112–120.

    PubMed  Google Scholar 

  18. 18.

    Gautier E, Ganz K, Krugel N, Gill T, Ganz R. Anatomy of the medial femoral circumflex artery and its surgical implications. J Bone Joint Surg Br. 2000;82:679–683.

    PubMed  Article  CAS  Google Scholar 

  19. 19.

    Guanche CA, Bare AA. Arthroscopic treatment of femoroacetabular impingement. Arthroscopy. 2006;22:95–106.

    PubMed  Article  Google Scholar 

  20. 20.

    Harris WH. Primary osteoarthritis of the hip: a vanishing diagnosis. J Rheumatol. 1983;Suppl 9:64.

    Google Scholar 

  21. 21.

    Harris WH. Etiology of osteoarthritis of the hip. Clin Orthop Relat Res. 1986;213:20–33.

    PubMed  Google Scholar 

  22. 22.

    Harris WH, Bourne RB, Oh I. Intra-articular acetabular labrum: a possible etiological factor in certain cases of osteoarthritis of the hip. J Bone Joint Surg Am. 1979;61:510–514.

    PubMed  CAS  Google Scholar 

  23. 23.

    Ito K, Leunig M, Ganz R. Histopathologic features of the acetabular labrum in femoroacetabular impingement. Clin Orthop Relat Res. 2004;429:262–271.

    PubMed  Article  Google Scholar 

  24. 24.

    Ito K, Minka MA 2nd, Leunig M, Werlen S, Ganz R. Femoroacetabular impingement and the cam-effect: a MRI-based quantitative anatomical study of the femoral head-neck offset. J Bone Joint Surg Br. 2001;83:171–176.

    PubMed  Article  CAS  Google Scholar 

  25. 25.

    Jager M, Wild A, Westhoff B, Krauspe R. Femoroacetabular impingement caused by a femoral osseous head-neck bump deformity: clinical, radiological, and experimental results. J Orthop Sci. 2004;9:256–263.

    PubMed  Article  Google Scholar 

  26. 26.

    Kalberer F, Sierra RJ, Madan SS, Ganz R, Leunig M. Projection of the ischial spine into the pelvic cavity: a new sign for acetabular retroversion on plain radiographs. Clin Orthop Relat Res. 2008; doi:10.1007/s11999-007-0058-6.

  27. 27.

    Kassarjian A, Yoon LS, Belzile E, Connolly SA, Millis MB, Palmer WE. Triad of MR arthrographic findings in patients with cam-type femoroacetabular impingement. Radiology. 2005;236:588–592.

    PubMed  Article  Google Scholar 

  28. 28.

    Kelly BT, Weiland DE, Schenker ML, Philippon MJ. Arthroscopic labral repair in the hip: surgical technique and review of the literature. Arthroscopy. 2005;21:1496–1504.

    PubMed  Article  Google Scholar 

  29. 29.

    Kim YT, Azuma H. The nerve endings of the acetabular labrum. Clin Orthop Relat Res. 1995;320:176–181.

    PubMed  Google Scholar 

  30. 30.

    Lavigne M, Kalhor M, Beck M, Ganz R, Leunig M. Distribution of vascular foramina around the femoral head and neck junction: relevance for conservative intracapsular procedures of the hip. Orthop Clin North Am. 2005;36:171–176, viii.

    PubMed  Article  Google Scholar 

  31. 31.

    Lavigne M, Parvizi J, Beck M, Siebenrock KA, Ganz R, Leunig M. Anterior femoroacetabular impingement: part I. Techniques of joint preserving surgery. Clin Orthop Relat Res. 2004;418:61–66.

    PubMed  Article  Google Scholar 

  32. 32.

    Leunig M, Beck M, Dora C, Ganz R. Femoroacetabular impingement: etiology and surgical concept. Oper Tech Orthop. 2005;15:247–255.

    Article  Google Scholar 

  33. 33.

    Leunig M, Beck M, Dora C, Ganz R. Femoroacetabuläres Impingement als Auslöser der Koxarthrose. Orthopade. 2006;35:77–84.

    PubMed  Article  CAS  Google Scholar 

  34. 34.

    Leunig M, Beck M, Kalhor M, Kim YJ, Werlen S, Ganz R. Fibrocystic changes at anterosuperior femoral neck: prevalence in hips with femoroacetabular impingement. Radiology. 2005;236:237–246.

    PubMed  Article  Google Scholar 

  35. 35.

    Leunig M, Beck M, Stauffer E, Hertel R, Ganz R. Free nerve endings in the ligamentum capitis femoris. Acta Orthop Scand. 2000;71:452–454.

    PubMed  Article  CAS  Google Scholar 

  36. 36.

    Leunig M, Beck M, Woo A, Dora C, Kerboull M, Ganz R. Acetabular rim degeneration: a constant finding in the aged hip. Clin Orthop Relat Res. 2003;413:201–207.

    PubMed  Article  Google Scholar 

  37. 37.

    Leunig M, Casillas MM, Hamlet M, Hersche O, Nötzli H, Slongo T, Ganz R. Slipped capital femoral epiphysis: early mechanical damage to the acetabular cartilage by a prominent femoral metaphysis. Acta Orthop Scand. 2000;71:370–375.

    PubMed  Article  CAS  Google Scholar 

  38. 38.

    Leunig M, Fraitzl CR, Ganz R. Early damage to the acetabular cartilage in slipped capital femoral epiphysis: therapeutic consequences [in German]. Orthopade. 2002;31:894–899.

    PubMed  Article  CAS  Google Scholar 

  39. 39.

    Leunig M, Ganz R. Femoroacetabuläres Impingement: Häufige Ursache von zur Arthrose führenden Hüftbeschwerden. Unfallchirurg. 2005;108:9–10, 12–17.

    PubMed  Article  CAS  Google Scholar 

  40. 40.

    Leunig M, Parvizi J, Ganz R. Nonarthroplasty surgical treatment of hip osteoarthritis. Instr Course Lect. 2006;55:159–166.

    PubMed  Google Scholar 

  41. 41.

    Leunig M, Podeszwa D, Beck M, Werlen S, Ganz R. Magnetic resonance arthrography of labral disorders in hips with dysplasia and impingement. Clin Orthop Relat Res. 2004;418:74–80.

    PubMed  Article  Google Scholar 

  42. 42.

    Mardones RM, Gonzalez C, Chen Q, Zobitz M, Kaufman KR, Trousdale RT. Surgical treatment of femoroacetabular impingement: evaluation of the effect of the size of the resection. J Bone Joint Surg Am. 2005;87:273–279.

    PubMed  Article  Google Scholar 

  43. 43.

    Mardones RM, Gonzalez C, Chen Q, Zobitz M, Kaufman KR, Trousdale RT. Surgical treatment of femoroacetabular impingement: evaluation of the effect of the size of the resection. Surgical technique. J Bone Joint Surg Am. 2006;88(Suppl 1 Pt 1):84–91.

    PubMed  Article  Google Scholar 

  44. 44.

    Meyer DC, Beck M, Ellis T, Ganz R, Leunig M. Comparison of six radiographic projections to assess femoral head/neck asphericity. Clin Orthop Relat Res. 2006;445:181–185.

    PubMed  Google Scholar 

  45. 45.

    Murphy S, Tannast M, Kim YJ, Buly R, Millis MB. Débridement of the adult hip for femoroacetabular impingement: indications and preliminary clinical results. Clin Orthop Relat Res. 2004;429:178–181.

    PubMed  Article  Google Scholar 

  46. 46.

    Murray RO. The aetiology of primary osteoarthritis of the hip. Br J Radiol. 1965;38:810–824.

    PubMed  CAS  Article  Google Scholar 

  47. 47.

    Nork SE, Schar M, Pfander G, Beck M, Djonov V, Ganz R, Leunig M. Anatomic considerations for the choice of surgical approach for hip resurfacing arthroplasty. Orthop Clin North Am. 2005;36:163–170, viii.

    PubMed  Article  Google Scholar 

  48. 48.

    Peters CL, Erickson JA. Treatment of femoro-acetabular impingement with surgical dislocation and débridement in young adults. J Bone Joint Surg Am. 2006;88:1735–1741.

    PubMed  Article  Google Scholar 

  49. 49.

    Philippon MJ, Schenker ML. A new method for acetabular rim trimming and labral repair. Clin Sports Med. 2006;25:293–297, ix.

    PubMed  Article  Google Scholar 

  50. 50.

    Philippon MJ, Schenker ML. Arthroscopy for the treatment of femoroacetabular impingement in the athlete. Clin Sports Med. 2006;25:299–308, ix.

    PubMed  Article  Google Scholar 

  51. 51.

    Sampson TG. Arthroscopic treatment of femoroacetabular impingement: a proposed technique with clinical experience. Instr Course Lect. 2006;55:337–346.

    PubMed  Google Scholar 

  52. 52.

    Siebenrock KA, Schoeniger R, Ganz R. Anterior femoro-acetabular impingement due to acetabular retroversion: treatment with periacetabular osteotomy. J Bone Joint Surg Am. 2003;85:278–286.

    PubMed  Google Scholar 

  53. 53.

    Siebenrock KA, Wahab KH, Werlen S, Kalhor M, Leunig M, Ganz R. Abnormal extension of the femoral head epiphysis as a cause of cam impingement. Clin Orthop Relat Res. 2004;418:54–60.

    PubMed  Article  Google Scholar 

  54. 54.

    Solomon L. Patterns of osteoarthritis of the hip. J Bone Joint Surg Br. 1976;58:176–183.

    PubMed  CAS  Google Scholar 

  55. 55.

    Solomon L. Studies on the pathogenesis of osteoarthritis of the hip. Trans Coll Med South Africa. 1981:104–124.

    Google Scholar 

  56. 56.

    Solomon L. Geographical and anatomical patterns of osteoarthritis. Br J Rheumatol. 1984;23:177–180.

    PubMed  Article  CAS  Google Scholar 

  57. 57.

    Solomon L, Beighton P. Osteoarthrosis of the hip and its relationship to pre-existing in an African population. J Bone Joint Surg Br. 1973;55:216–217.

    Google Scholar 

  58. 58.

    Solomon L, Schnitzler CM, Browett JP. Osteoarthritis of the hip: the patient behind the disease. Ann Rheum Dis. 1982;41:118–125.

    PubMed  CAS  Google Scholar 

  59. 59.

    Sozen YV, Ozkan K, Goksan SB, Ciftci F, Mutlu S, Uzer G. Arthroscopic diagnosis and treatment of an acetabular labrum bucket handle tear: a case report. Arch Orthop Trauma Surg. 2005;125:649–652.

    PubMed  Article  Google Scholar 

  60. 60.

    Strehl A, Ganz R. Anterior femoroacetabular impingement after healed femoral neck fractures [in German]. Unfallchirurg. 2005;108:263–273.

    PubMed  Article  CAS  Google Scholar 

  61. 61.

    Stulberg SD. Acetabular dysplasia, development of osteoarthritis of the hip. In: Harris WH, ed. The Hip: Proceedings of the Second Open Scientific Session of the Hip Society. St Louis, MO: CV Mosby; 1974:82–93.

  62. 62.

    Stulberg SD. Unrecognized childhood hip disease: a major cause of idiopathic osteoarthritis of the hip. In: Cordell LD, Harris WH, Ramsey PL, MacEwen GD, eds. The Hip: Proceedings of the Third Open Scientific Meeting of the Hip Society. St Louis, MO: CV Mosby; 1975:212–228.

  63. 63.

    Tanzer M, Noiseux N. Osseous abnormalities and early osteoarthritis: the role of hip impingement. Clin Orthop Relat Res. 2004;429:170–177.

    PubMed  Article  Google Scholar 

  64. 64.

    Theumann N, Wettstein M. Clinical and radiological aspects of femoro-acetabular impingement [in French]. Rev Med Suisse. 2006;2:1741–1746.

    PubMed  CAS  Google Scholar 

  65. 65.

    Tschauner C, Fock C, Hofmann S. Femoro-acetabular impingement: an underestimated pathogenetic factor in coxarthrosis [in German]. Z Orthop Ihre Grenzgeb. 2001;139:M88–M91.

    PubMed  CAS  Google Scholar 

  66. 66.

    Wagner S, Hofstetter W, Chiquet M, Mainil-Varlet P, Stauffer E, Ganz R, Siebenrock KA. Early osteoarthritic changes of human femoral head cartilage subsequent to femoro-acetabular impingement. Osteoarthritis Cartilage. 2003;11:508–518.

    PubMed  Article  CAS  Google Scholar 

  67. 67.

    Werlen S, Leunig M, Ganz R. Magnetic resonance arthrography of the hip in femoroacetabular impingement: technique and findings. Oper Tech Orthop. 2005;15:191–203.

    Article  Google Scholar 

  68. 68.

    Wettstein M, Dienst M. Hip arthroscopy for femoroacetabular impingement [in German]. Orthopade. 2006;35:85–93.

    PubMed  Article  CAS  Google Scholar 

  69. 69.

    Wisniewski SJ, Grogg B. Femoroacetabular impingement: an overlooked cause of hip pain. Am J Phys Med Rehabil. 2006;85:546–549.

    PubMed  Article  Google Scholar 

Download references

Author information

Affiliations

Authors

Corresponding author

Correspondence to Michael Leunig MD.

Additional information

Each author certifies that he or she has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article.

About this article

Cite this article

Ganz, R., Leunig, M., Leunig-Ganz, K. et al. The Etiology of Osteoarthritis of the Hip. Clin Orthop Relat Res 466, 264–272 (2008). https://doi.org/10.1007/s11999-007-0060-z

Download citation

Keywords

  • Femoral Head
  • Slip Capital Femoral Epiphysis
  • Diffuse Idiopathic Skeletal Hyperostosis
  • Femoroacetabular Impingement
  • Multiple Epiphyseal Dysplasia