Protrusio acetabuli is the protrusion of the acetabulum into the pelvic cavity. With the medial movement of the acetabulum, the femoral head also shifts into the pelvis. Although the condition was first recognized in 1816, it was not until 120 years later that it was classified into primary (idiopathic) and secondary disease[1]. By today, a large number of conditions are known to cause secondary protrusio acetabuli [1]; the category of primary protrusio acetabuli is maintained for cases whose origins cannot be attributed to other diseases. As diagnostic techniques keep improving, the number of primary cases keeps decreasing [2].

Infections by gonoccous and echinococcus as well as tuberculosis were found early on to cause protrusio acetabuli. The main inflammatory conditions that cause protrusio acetabuli are rheumatoid arthritis [3], ankylosing spondylitis [4], psoriatic arthritis, acute idiopathic chondrolysis, and Reiter’s syndrome. A number of metabolic diseases are also associated with protrusio acetabuli. Among these are osteogenesis imperfecta, osteoporosis, hyperparathyroidism, and Paget’s disease. Some genetic ailments associated with protrusio acetabuli are sickle cell disease [5], trisomy 18, Ehlers-Danlos syndrome, and Marfan’s disease. Neoplastic disease and trauma to the bone, such as fractures, can also result in protrusio acetabuli [6].

Primary protrusio acetabuli is caused by deficiency or destruction of the bone structure or developmental abnormalities. It can be the source of osteoarthritis; senile patients with protrusio acetabuli almost always report with osteoarthritis [7]. Primary protrusio acetabuli is most frequently bilateral and affects women more than men. Several familial cases have been reported which were compatible with an autosomal dominant inheritance pattern [2]. Primary protrusio acetabuli showcases mainly with stiffness, limitation of movement, and possibly pain [2].

• Pain

  On hip had thigh pain attributable to a loose femoral component. No patient had groin pain at follow-up examination. [ncbi.nlm.nih.gov]

  […] in a teenager -Common in younger women -Present with pain and stiffness, rarely with knee pain -Arising from a seated position is a frequent cause of exacerbation X-Rays:. [orthopaedicprinciples.blogspot.com]

  (Radiculopathy, Neck pain, Sciatica, Low back pain ) Soft tissue disorders muscle : Myositis - Myositis ossificans ( Fibrodysplasia ossificans progressiva ) synovium and tendon : Synovitis - Tenosynovitis (Stenosing tenosynovitis, Trigger finger, DeQuervain's [bionity.com]

  Treatment Joint replacement surgery is indicated for severe pain or substantial joint restriction References J Am Acad Orthop Surg, Vol 9, No 2, March/April 2001, 79-88. de:Protrusio acetabuli [wikidoc.org]

• Surgical Procedure

  Make optimal use of the latest imaging techniques, surgical procedures, equipment, and implants available. [books.google.ro]

• Fatigue

  One 25-year old female had osteogenesis imperfecta with limited ROM until a fatigue fracture of the acetabular fossa (Fig. 7 A). [ncbi.nlm.nih.gov]

  Sometimes we feel ready physically, but there is still a fatigue factor, mentally and physically, that can linger for several months. On the average, if all goes well, 8-12 weeks is the recommendation, if you can possibly spare that much. [bonesmart.org]

  Hip pain related to static overload stresses may also be localized to the anteromedial groin, but compensatory dysfunction of the periarticular musculature may lead to muscular fatigue and associated pain throughout the hip. [researchgate.net]

• Arthritis

  posttraumatic arthritis, and protrusion acetabulum. [mjdrdypu.org]

  The condition can mimic juvenile chronic arthritis, septic arthritis, transient osteoporosis of the hip, os-teonecrosis of the femoral head, and pigmented vil-lonodular synovitis (Resnick and Niwayama 1995; Sherlock 1995). [rrnursingschool.biz]

  Protrusio acetabuli: Radiographic appearance in arthritis and other conditions. Arthritis Rheum. 1983;26:1511–1516. PubMed CrossRef Google Scholar 3. Hubbard MJ. The measurement of progression in protrusio acetabuli. [link.springer.com]

• Fracture

  Multiple fractures involving the left acetabular fossa and ischial and pubic rami of both sides are apparent. [rrnursingschool.biz]

  Abstract This case report presents the case of a patient with a history of rheumatoid arthritis and protrusio acetabuli progressing to a medical wall acetabular fracture. [ncbi.nlm.nih.gov]

  Over 500 line drawings and photographs analyze and explain the various types of hip fractures including fractures of the femoral neck, intertrochanteric fractures and subtrochanteric fractures. [books.google.ro]

• Hip Pain

  (From Leroy et al. 1998) lescence or adulthood, and range from none to severe hip pain, limitation of hip motion, flexion contracture, and abnormal gait. [rrnursingschool.biz]

  (accessed on 02 Nov 2022) https://doi.org/10.53347/rID-50092 Case of the day: 18 Jan 2017 Inclusion in quiz mode: Included Presentation Severe right hip pain. Limited capacity to walk unaided. [radiopaedia.org]

  Abstract Eight children, aged 9 to 15, referred to a juvenile rheumatology service on account of undiagnosed hip pain, were ultimately found to have idiopathic protrusio acetabuli (IPA). [ncbi.nlm.nih.gov]

• Hip Dislocation

  […] acetabular rim trimming through a surgical hip dislocation for patients with this condition. [ncbi.nlm.nih.gov]

  A postoperative radiograph of a surgical hip dislocation secured with screws. Extensive literature has shown good to excellent outcomes following surgical hip dislocation for FAI. [frontiersin.org]

  In these cases, surgical dislocation with acetabular rim trimming is preferred to the arthroscopic technique ( 1 ). Hanke et al. ( 2 ), an expert group, performed over 1,300 surgical hip dislocations in the past 20 years. [jxym.amegroups.com]

  Osteoporosis of the hip causes weak bones that break easily. Both of these are common in older people. Another problem is hip dysplasia, where the ball at the end of the femur is loose in the hip socket. It can cause hip dislocation. [icdlist.com]

  Severe global deformities are often treated with open surgical dislocation of the hip. [researchgate.net]

• Coxa Vara

  Observe intense osteoporosis, severe coxa vara deformity, and dislocated fracture of the right femoral shaft Fig. 4.19. Osteogenesis imperfecta in a 16-year-old girl. [rrnursingschool.biz]

  vara and decreased femoral anteversion Treatment Depends on age and degree of degenerative changes Medial wall bone grafts Joint replacement surgery may be necessary Acetabular Protrusio. [learningradiology.com]

• Suggestibility

  It is suggested that this prosthesis offers a simple and effective method of treating painful protrusion into the pelvis; it allows healing of the medial wall of the acetabulum while avoiding many of the hazards of other methods of treatment. [ncbi.nlm.nih.gov]

  Hastings (9) et al. suggest always using titanium cups for closing the defect and so, improving the rotational center. [scielo.br]

• Irritability

  Examples include infection-related aetiologies such as irritable hip (a form of reactive arthritis) and septic arthritis, and juvenile idiopathic arthritis (JIA). [academic.oup.com]

Workup has to start with a thorough history (including family history), and careful physical examination of the hip. Blood tests (such as complete blood count, the presence of C-reactive protein) and synovial biopsy will aid in the diagnosis. An anteroposterior radiogram is the most usual diagnostic tool, using plain radiography. Some investigators advocate the use of the false profile view, which reveals excessive cartilage destruction [8]. Magnetic resonance arthrography is useful for the detection of structural changes in the early stages of the disease.

In young patients, the condition is difficult to diagnose because the radiological signs are not characteristic. The difficulty also lies in differentiating protrusio acetabuli from acute idiopathic chondrolysis. With complaints of stiffness and pain – and with secondary causes, such as inflammation and trauma excluded –young people would be diagnosed with idiopathic chondrolysis if they display loss of joint space. If they also exhibit signs of an acetabular protrusion in addition to the loss of joint space, the diagnosis is protrusio acetabuli. Some investigators regard protrusio acetabuli and idiopathic chondrolysis as the same condition [9]; however, for various reasons, this view is not universally accepted. For example, idiopathic chondrolysis does not show a female preponderance [2].

A critical measurement for diagnosis deduced from radiographs is the center-edge angle of Wiberg [2], which is between 25 and 40 degrees in normal hips. An angle of more than 46 degrees indicates protrusio acetabuli. However, several authors find the angle measurement inadequate for diagnosis; for example, angles greater than 46 degrees can also be found in the general population [10]. Another important indication of protrusio acetabuli is the extent to which the medial wall of the acetabulum shifts medially in relation to the ilioischial line (Kohler’s line). Some investigators require the acetabular wall to reach the ilioischial line, while others call for the line to be crossed to establish the diagnosis. Yet another widely used criterion is the arrangement of the teardrop. Using the above criteria for diagnosis requires the careful centering of radiographic images. Other anatomical criteria can be used. A grading of the protrusion is provided by determination of the distance of the acetabulum from the upper margin of the superior pubic ramus [11].

• Joint Space Narrowing

  Preoperatively, joint space narrowing and osteophytes were more frequent posteroinferior (joint space narrowing 18% versus 2%, p = 0.008; osteophytes 21% versus 4%, p = 0.007), medial (joint space narrowing 33% versus 5%, p < 0.001) and anterior (osteophytes [ncbi.nlm.nih.gov]

  Patient Data Age: 70 years Gender: Female Severe deformity of the right femoral head with joint space narrowing and subchondral sclerosis. Protuberance of the femoral head giving rise to protrusio acetabuli. [radiopaedia.org]

  Radiographs show joint space narrowing, irregular and eroded subchondral bone, regional osteoporosis, and mild protrusio acetabuli (Hughes 1985). [rrnursingschool.biz]

TREATMENT • Adolescent or Young Adult Patients: VITO by Pauwels 8. [de.slideshare.net]

Treatment Arthroscopic surgery (or open joint surgery) is an effective treatment. Joint replacement surgery may be necessary in the case of severe pain or substantial joint restriction. [ipfs.io]

Protrusio is certainly an unsolved treatment dilemma. [arthroscopyjournal.org]

Treatment[edit] Arthroscopic surgery (or open joint surgery) is an effective treatment. Joint replacement surgery may be necessary in the case of severe pain or substantial joint restriction. [en.wikipedia.org]

TREATMENT DISCUSSION Even though it is difficult to discuss the subject given there were few reports in the last years, the treatment of choice of protrusio acetabuli was surgical, as recommended in the literature (4,10,13, 17,23,26). [scielo.br]

It is concluded that PA is a frequent complication in SNSA; however, its presence does not seem to modify the functional prognosis of these patients. [ncbi.nlm.nih.gov]

Prognosis[edit] The protrusio may progress until the femoral neck impinges against the pelvis. Treatment[edit] Arthroscopic surgery (or open joint surgery) is an effective treatment. [en.wikipedia.org]

It is concluded that PA is a frequent complication in SNSA, however, its presence does not seem to modify the functional prognosis of these patients. Copyright 9 1993 by W.B. [kundoc.com]

The prognosis in untreated dysplasia of the hip. A study of radiographic factors that predict the outcome. J Bone Joint Surg Am (1995) 77 (7):985–9. Google Scholar 24. Nunley RM, Prather H, Hunt D, Schoenecker PL, Clohisy JC. [frontiersin.org]

A genetic etiology has been proposed in developmental dysplasia of the hip, while the etiology of primary protrusio acetabuli is widely debated. [ncbi.nlm.nih.gov]

Its etiology in childhood is attributed to changes in triradiated cartilage ossification. It can also come from osteoconditis, asthenia, congenital deep acetabulum and rheumatic diseases. [scielo.br]

Parker Medicine Clinical orthopaedics and related research 1975 Early operation on those patients showing rapid development of protrusio may prevent complications, and Adrenal cortical steroids may play a significant role in the etiology of this condition [semanticscholar.org]

It is important to consider all etiologic possibilities before evaluating treatment options. [doi.org]

In addition, this book covers epidemiology and mechanisms of injury, diagnosis, treatment principles, avoidance of pitfalls, rehabilitation, outcome assessment, economics of hip fracture treatment and prevention. [books.google.ro]

INCIDENCE AND EPIDEMIOLOGY It is more frequent in female (10:1), and bilateral; is very common in advanced rheumatoid arthritis patients (1). [scielo.br]

Fundamentally, myositis ossificans can be categorized into nonhereditary and hereditary types, with the latter being a distinct entity with a separate pathophysiology and treatment approach. [researchgate.net]

These terms are essentially descriptive and ambiguous in the sense that they do not impart information regarding the likely pathophysiology of the disease. [academic.oup.com]

Gel foam strips were then placed around the periphery of the graft to prevent interposition of cement between it and the articular surface. [mjdrdypu.org]

Eight year follow up of patients with permanent vena cava filters in the prevention of pulmonary embolism: the PREPIC (Prevention du Risque d’Embolie Pulmonaire par Interruption Cave) randomized study. [docksci.com]

Early operation on those patients showing rapid development of protrusio may prevent complications. [ncbi.nlm.nih.gov]

[…] progressive medialization of the component; - peripherally placed screws may also prevent medialization; - ref: Incomplete seating of press-fit porous-coated acetabular components: the fate of zone 2 lucencies. - Surgical Technique: (see THR surgical [wheelessonline.com]

1. Leunig M, Nho SJ, Turchetto L, Ganz R. Protrusio acetabuli: new insights and experience with joint preservation. Clin Orthop Relat Res. 2009 Sep;467(9):2241-2250.
2. Dunlop CC, Jones CW, Maffulli N. Protrusio acetabuli. Bull Hosp Jt Dis. 2005;62:105-114.
3. Vaishya R. Bilateral protrusio acetabuli of the hip. BMJ Case Rep. 2014 Mar 17;2014.
4. Dwosh IL, Resnick D, Becker MA. Hip involvement in ankylosing spondylitis. Arthritis Rheum. 1976 Jul-Aug;19(4):683-692.
5. Martinez S, Apple JS, Baber C, Putman CE, Rosse WF. Protrusio acetabuli in sickle-cell anemia. Radiology. 1984 Apr;151(1):43-44.
6. Gillard AJ, Deyle GD. Acetabular fracture and protrusio acetabuli in an elderly patient following a fall. J Orthop Sports Phys Ther. 2009 Sep;39(9):703.
7. Hooper JC, Jones EW. Primary protrusion of the acetabulum. J Bone Joint Surg Br. 1971 Feb;53(1):23-29.
8. Lequesne MG, Laredo JD. The faux profil (oblique view) of the hip in the standing position. Contribution to the evaluation of osteoarthritis of the adult hip. Ann Rheum Dis. 1998 Nov;57(11):676-681.
9. Sherlock DA. Acute idiopathic chondrolysis and primary acetabular protrusio may be the same disease. J Bone Joint Surg Br. 1995 May;77(3):392-395.
10. Armbuster TG, Guerra J Jr, Resnick D, et al. The adult hip: an anatomic study. Part I: the bony landmarks. Radiology. 1978 Jul;128(1):1-10.
11. Sotelo-Garza A, Charnley J. The results of Charnley arthroplasty of hip performed for protrusio acetabuli. Clin Orthop Relat Res. 1978 May;(132):12-18.