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Protrusio Acetabuli

Protrusio acetabuli is a distortion of the hip where the acetabulum and femoral head migrate into the pelvic cavity. The disease can be idiopathic (primary) or can be secondary to a number of conditions, such as trauma, inflammation or other diseases. The cornerstone of diagnosis is anteroposterior radiography and the treatment varies by age. For the skeletally immature youth, a fusion of the triradiate cartilage may be recommended but is not frequently carried out because the protrusion does not always deteriorate. For young adults, valgus intertrochanteric osteotomy is performed. For older patients, total joint replacement is the procedure of choice.


Presentation

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].

Anemia
  • The authors conclude that sickle-cell anemia can predispose to development of protrusio acetabuli.[ncbi.nlm.nih.gov]
  • Protrusion of the acetabulum is relatively frequent in patients with sickle cell anemia.[rrnursingschool.biz]
Asymptomatic
  • […] protrusio acetabuli Causes include: may be present bilaterally in paget's, marfan's, RA, AS, & osteomalacia; Femoral head prosthesis Cup arthroplasty Septic arthritis Central fracture dislocation Total hip replacement surgery Signs and Symptoms May be asymptomatic[wikidoc.org]
  • It is usually asymptomatic except for slight limitation of movements at the hip joint. There may be the development of secondary osteoarthritis in later life, and it is only when this occurs that treatment is required.[gpnotebook.co.uk]
  • […] young to middle-aged Bilateral in 1/3 to 2/3 of patients No underlying causative mechanism is demonstrated Secondary form Rheumatoid arthritis Paget disease Central fracture-dislocation Hip implants Marfan Syndrome Osteomalacia Clinical Findings May be asymptomatic[learningradiology.com]
  • Protrusio acetabuli may be asymptomatic. Limitation of joint range of movement is the earliest sign, along with pain. Protrusio acetabuli is divided into two types, primary and secondary.[en.wikipedia.org]
Disability
  • CONCLUSIONS: These cases represent severe and disabling primary hip disease with considerable clinical and investigational inflammatory features.[ncbi.nlm.nih.gov]
  • Early diagnosis and treatment reduce long-term disability and secondary osteoarthritis in patients. References 1.[link.springer.com]
  • These cases represent severe and disabling primary hip disease with considerable clinical and investigational inflammatory features.[academic.oup.com]
  • If left untreated, it causes significant disability, including pain and functional limitations.[researchgate.net]
Reiter's Syndrome
  • The prevalence and characteristics of PA were studied in 50 adults and 25 children with SNSA (40 ankylosing spondylitis, 24 psoriatic arthropathy, and 11 Reiter's syndrome).[ncbi.nlm.nih.gov]
  • The prevalence and characteristics of PA were studied in 50 adults and 25 children with SNSA (40 ankylosing spondylitis, 24 psoriatic arthropathy, and 11 Reiter's syndrome}.[kundoc.com]
  • The main inflammatory conditions that cause protrusio acetabuli are rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, acute idiopathic chondrolysis, and Reiter’s syndrome.[symptoma.com]
  • ’s syndrome ü Osteolysis following hip Replacement Metabolic ü Paget’s disease ü Osteogenesis imperfecta ü Ochronosis ü Acrodysostosis ü Osteomalacia (very high incidence –50%) ü Hyperparathyroidism Traumatic ü Sequalae of acetabular fracture ü Surgical[orthopaedicprinciples.blogspot.com]
Marfanoid Habitus
  • A wide range of musculoskeletal involvement occurs including marfanoid habitus, kyphosis, scoliosis, slipped epiphyses, joint laxity and degenerative arthritis. Congenital myopia and micrognathia are the most characteristic non-skeletal features.[ncbi.nlm.nih.gov]
Pelvic Mass
  • BACKGROUND: The differential diagnosis in an elderly woman with a complex pelvic mass includes benign and malignant diseases. CASE: A woman in her ninth decade was discovered to have both a breast mass and a pelvic mass at examination.[ncbi.nlm.nih.gov]
  • Conclusion: Protrusio Acetabuli Prosthetica can present as pelvic mass without any other associated symtoms. Although a rare complication, with noted morbidity, it might still be reconstructable.[jocr.co.in]
  • The presence of any pelvic mass in association with total hip replacement should prompt consideration of presence of protrusio acetabuli and associated vascular pathology. CT can highlight any associated pelvic mass and thrombosis within vessels.[docksci.com]
  • And the case for arthroscopic treatment of global pincer impingement. ( 22551946 ) Matsuda D.K. 2012 15 Protrusio Acetabuli Prosthetica - a cause of a Pelvic Mass Presenting to the Gynaecologist. ( 27298861 ) 2012 16 Protrusio acetabuli and total hip[malacards.org]
Thrombosis
  • We present a case of severe prosthetic migration with the formation of haematoma and impingement on iliac vessels leading to thrombosis and subsequent pulmonary embolus.[ncbi.nlm.nih.gov]
  • CT can highlight any associated pelvic mass and thrombosis within vessels. The prevention of further deep vein thrombosis requires treatment of the prosthetic abnormality and removal of associated mass.[docksci.com]
  • Post-operatively he developed a large right-sided ilio-femoral deep venous thrombosis.[researchgate.net]
Ectopia Lentis
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]
Osteophyte
  • 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]
  • […] acquired deformities of limbs ( Valgus deformity, Varus deformity, Wrist drop, Foot drop, Flat feet, Club foot, Unequal leg length, Winged scapula) patella (Luxating patella, Chondromalacia patellae ) Protrusio acetabuli - Hemarthrosis - Arthralgia - Osteophyte[bionity.com]
  • In each coxofemoral joint X-ray the presence or absence of osteoporosis, joint narrowing erosions, cysts, alignment alterations, subchondral sclerosis, osteophytes, periostitis, subluxation, buttressing, bone ankylosis and PA were determined.[slideheaven.com]
Osteopenia
  • We have described a patient with sickle cell anemia who had this complication probably as a result of osteopenia. Thus sickle cell anemia should be added to the list of potential causes of protrusio acetabuli.[ncbi.nlm.nih.gov]
  • Observe also osteopenia and bilateral coxa valga. (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]
Flexion Contracture
  • Abstract The family of a child who developed symptoms and flexion contractures with protrusio acetabuli rapidly between the age of 8 and 11 was examined.[ncbi.nlm.nih.gov]
  • (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]
Thigh 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]
  • This results in preserved femoral bone stock and avoidance of thigh pain. The surgical technique is different from a standard total hip replacement. Round the corner broaching is done.[hipsurgery.in]
Breast Mass
  • CASE: A woman in her ninth decade was discovered to have both a breast mass and a pelvic mass at examination. After diagnostic breast biopsy results that confirmed invasive breast carcinoma, pelvic examination and ultrasonography were performed.[ncbi.nlm.nih.gov]
Stroke
  • Author information 1 Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea. 2 Division of Cardiology, Department of Medicine, Heart Vascular Stroke[ncbi.nlm.nih.gov]
  • Unusual association of diseases/symptoms CASE REPORT Protrusio acetabuli: a rare cause of pulmonary embolus Colm Murphy,1 Barry James O’Neill,2 John Francis Quinlan,2 Ronan Collins1 1 Stroke Unit and Department of Gerontology, Adelaide & Meath Hospital[docksci.com]
Neglect
  • These pathological alterations are responsible for neglecting MLD 46 in most studies on the postcranium of A. africanus.[researchgate.net]

Workup

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].

HLA-B27
  • None were considered to have a specific subtype of juvenile idiopathic arthritis (JIA) and all tested were negative for HLA-B27. Elevation of serum inflammatory markers was variable. Protrusio acetabuli was the predominant radiological feature.[ncbi.nlm.nih.gov]
  • Cases would be excluded if found to be HLA-B27-positive, to fulfil criteria for other forms of JIA (other than oligoarthritis), or to have a family history of HLA-B27-associated disease or psoriasis or psoriatic arthritis.[academic.oup.com]

Treatment

  • TREATMENT • Adolescent or Young Adult Patients: VITO by Pauwels 8.[slideshare.net]
  • A detailed history and physical examination revealed previous radiation treatment of prostate cancer requiring extensive preoperative workup and consultation.[ncbi.nlm.nih.gov]
  • 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]

Prognosis

  • 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]
  • 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]

Etiology

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

Epidemiology

  • 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]
Sex distribution
Age distribution

Pathophysiology

  • 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]

Prevention

  • Early operation on those patients showing rapid development of protrusio may prevent complications.[ncbi.nlm.nih.gov]
  • 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]
  • 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]
  • 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]
  • Consequently, we believe that surgery should be offered to patients as a way of relieving symptoms but not as an osteoarthritis prevention tool. The pincer effect in FAI may be more complex than previously thought.[jxym.amegroups.com]

References

Article

  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.

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Last updated: 2019-07-11 21:20