Surgery to correct cam femoroacetabular impingement (FAI) is increasingly popular. Despite this, no known study has used motion analysis and ground reaction forces to quantify the outcome of surgery for FAI. The goal of this study was to compare the preoperative and postoperative lower-extremity joint kinematic and kinetic measurements of cam FAI patients during activities of daily living with use of a high-speed motion capture system and force platforms. We hypothesized that the lower-extremity joint mechanics of FAI patients during level walking and maximal squatting would resemble more those of healthy control subjects, after surgery. Ten patients with unilateral symptomatic cam FAI, who underwent corrective surgery using an open or combined technique, performed walking and maximal depth squatting trials preoperatively and postoperatively. Thirteen healthy control subjects, matched for age, sex and body mass index, provided normative data. Results showed that postoperatively, FAI patients had reduced hip ROM in the frontal and sagittal planes, produced smaller peak hip abduction and external rotation moments, and generated less peak hip power compared to the control group during level walking. During maximal squatting, postoperative FAI patients squatted to a greater depth, and had larger knee flexion and ankle dorsiflexion angles, as well as the sum of all joint angles of the affected limb at maximal depth compared to the preoperative values. The lower-extremity joint and pelvic mechanics of FAI patients did not fully return to normal after surgery. Although surgery seemed to reduce hip pain and restore a normal femoral head-neck offset, it further impaired muscle function as a result of muscle incisions. More research is needed to determine the effects of muscle incisions, which could help improve surgical techniques and develop better rehabilitation programs for FAI patients.

Surgery to correct cam femoroacetabular impingement (FAI) is increasingly popular. Despite this, no known study has used motion analysis and ground reaction forces to quantify the outcome of surgery for FAI. The goal of this study was to compare the preoperative and postoperative lower-extremity joint kinematic and kinetic measurements of cam FAI patients during activities of daily living with use of a high-speed motion capture system and force platforms. We hypothesized that the lower-extremity joint mechanics of FAI patients during level walking and maximal squatting would resemble more those of healthy control subjects, after surgery. Ten patients with unilateral symptomatic cam FAI, who underwent corrective surgery using an open or combined technique, performed walking and maximal depth squatting trials preoperatively and postoperatively. Thirteen healthy control subjects, matched for age, sex and body mass index, provided normative data. Results showed that postoperatively, FAI patients had reduced hip ROM in the frontal and sagittal planes, produced smaller peak hip abduction and external rotation moments, and generated less peak hip power compared to the control group during level walking. During maximal squatting, postoperative FAI patients squatted to a greater depth, and had larger knee flexion and ankle dorsiflexion angles, as well as the sum of all joint angles of the affected limb at maximal depth compared to the preoperative values. The lower-extremity joint and pelvic mechanics of FAI patients did not fully return to normal after surgery. Although surgery seemed to reduce hip pain and restore a normal femoral head-neck offset, it further impaired muscle function as a result of muscle incisions. More research is needed to determine the effects of muscle incisions, which could help improve surgical techniques and develop better rehabilitation programs for FAI patients.

Surgery to correct cam femoroacetabular impingement (FAI) is increasingly popular. Despite this, no known study has used motion analysis and ground reaction forces to quantify the outcome of surgery for FAI. The goal of this study was to compare the preoperative and postoperative lower-extremity joint kinematic and kinetic measurements of cam FAI patients during activities of daily living with use of a high-speed motion capture system and force platforms. We hypothesized that the lower-extremity joint mechanics of FAI patients during level walking and maximal squatting would resemble more those of healthy control subjects, after surgery. Ten patients with unilateral symptomatic cam FAI, who underwent corrective surgery using an open or combined technique, performed walking and maximal depth squatting trials preoperatively and postoperatively. Thirteen healthy control subjects, matched for age, sex and body mass index, provided normative data. Results showed that postoperatively, FAI patients had reduced hip ROM in the frontal and sagittal planes, produced smaller peak hip abduction and external rotation moments, and generated less peak hip power compared to the control group during level walking. During maximal squatting, postoperative FAI patients squatted to a greater depth, and had larger knee flexion and ankle dorsiflexion angles, as well as the sum of all joint angles of the affected limb at maximal depth compared to the preoperative values. The lower-extremity joint and pelvic mechanics of FAI patients did not fully return to normal after surgery. Although surgery seemed to reduce hip pain and restore a normal femoral head-neck offset, it further impaired muscle function as a result of muscle incisions. More research is needed to determine the effects of muscle incisions, which could help improve surgical techniques and develop better rehabilitation programs for FAI patients.

Surgery to correct cam femoroacetabular impingement (FAI) is increasingly popular. Despite this, no known study has used motion analysis and ground reaction forces to quantify the outcome of surgery for FAI. The goal of this study was to compare the preoperative and postoperative lower-extremity joint kinematic and kinetic measurements of cam FAI patients during activities of daily living with use of a high-speed motion capture system and force platforms. We hypothesized that the lower-extremity joint mechanics of FAI patients during level walking and maximal squatting would resemble more those of healthy control subjects, after surgery. Ten patients with unilateral symptomatic cam FAI, who underwent corrective surgery using an open or combined technique, performed walking and maximal depth squatting trials preoperatively and postoperatively. Thirteen healthy control subjects, matched for age, sex and body mass index, provided normative data. Results showed that postoperatively, FAI patients had reduced hip ROM in the frontal and sagittal planes, produced smaller peak hip abduction and external rotation moments, and generated less peak hip power compared to the control group during level walking. During maximal squatting, postoperative FAI patients squatted to a greater depth, and had larger knee flexion and ankle dorsiflexion angles, as well as the sum of all joint angles of the affected limb at maximal depth compared to the preoperative values. The lower-extremity joint and pelvic mechanics of FAI patients did not fully return to normal after surgery. Although surgery seemed to reduce hip pain and restore a normal femoral head-neck offset, it further impaired muscle function as a result of muscle incisions. More research is needed to determine the effects of muscle incisions, which could help improve surgical techniques and develop better rehabilitation programs for FAI patients.

Femoroacetabular impingement (FAI) is a hip condition which can limit hip motion and cause pain particularly in young and athletic patients. It is considered as a patho-mechanical process leading to progressive and degenerative damage of the joint. Surgical treatment for femoroacetabular impingement focuses on improving the clearance for hip motion, reducing the femoral impact against the acetabular labrum. The procedure involves the surgical resection of the cause of impingement which consists of trimming the acetabular rim and/or the femoral head-neck offset. Currently, there are no comprehensive tools available for pre-operative planning of FAI surgery and so the area and depth of bone resection are identified based on the skill and experience of the surgeon. This means that it is difficult to predict the degree to which the procedure will be successful, in terms of reducing pain and increasing the range of motion (RoM) of the hip, prior to surgery. In addition, resection can lead to increased stress in the remaining bone which in some cases can result in post-operative femoral neck fracture, a recognized risk of FAI surgery which is increased if the bone is osteoporotic. This thesis describes the development of a framework that will enable a tool to be created that can be used for the diagnosis, preoperative planning and selection of treatment for patients with cam-type FAI. The framework consists of a number of complementary 3-dimensional finite element (FE) models. The models are created from computer tomography (CT) data from actual patients with cam-type FAI. The first FE model was developed in order to predict the stress distribution in the head-neck region of the femur following resection surgery for FAI enabling the effect of resection depth to be investigated under loading conditions corresponding to typical daily activities. The model demonstrates that resection depth should be kept to less than one third of the diameter of the neck in order to ensure structural integrity. The second finite element model developed utilises a quasi-brittle damage plasticity material formulation to investigate the mechanism and risk of femoral neck fracture following femoral osteochondroplasty in osteoporotic and non osteoporotic hips. Predictions indicate that fracture can occur in osteoporotic hips during typical daily activities. Also, the likelihood of fracture increases when patients are subjected to high load conditions and activities, even in non-osteoporotic patients. The third FE model was developed to assess the reduction in the internal rotation movement in hips with cam-type FAI and identify and examine the areas where impingement occurs. The model shows that FAI can result in a significant reduction in hip motion and that impingement area and RoM are patient dependant. All three FE models were validated with results from experimental studies. The three models combined provide the framework for a virtual osteochondroplasty tool. The procedure for using the tool involves undertaking a virtual resection of a FAI hip based on the areas of impingement identified by the RoM analysis provided by the third FE model. Finite element models one and two are employed to ensure that the virtual resection remains within safe limits and stress does not elevate in the remaining bone to levels that would significantly increase the risk of femoral neck fracture. The framework was validated by comparing the RoM predicted following a virtual osteochondroplasty undertaken on a model of a hip from an actual patient with FAI with the results from a model of the same hip created from CT scan data taken after an actual osteochondroplasty had been performed on the patient using a resection area and depth identified in the conventional way by a surgeon.

Osteoarthritis of the hip frequently occurs in the absence of osteoarthritis in other large joints, suggesting that local factors are important in its pathogenesis. Hip morphology has been recognised as a potential local biomechanical risk factor for the development of hip osteoarthritis. There are no adequate studies examining osteoarthritis development in the hip. Historical cohorts are either limited by a short follow up or by small numbers. This thesis explores the natural history of hip osteoarthritis in a large population cohort with particular attention to hip morphology as a predictor of osteoarthritis development. Software was developed which allows objective measurements of hip morphology in a reproducible manner. Hip morphology was then measured in a 1000 subject cohort. A detailed description of hip morphology is presented in this thesis, with interesting observations of wide variation and a bimodal distribution for alpha angle (a measure of cam-type femoroacetabular impingement). This is suggestive of a discrete pathological entity, which was associated with osteoarthritis in the cross-sectional analysis. No significant changes exist in terms of morphology during the course of the study and no significant relationship exists between age and hip morphology. Longitudinal analysis of hip morphology with radiographic osteoarthritis and total hip replacement revealed a significant association between cam-type femoroacetabular impingement and acetabular dysplasia with both outcome measures. Measurements of hip morphology were independently predictive of outcome when controlling for baseline age, BMI and joint space width, and significantly increased our ability to predict osteoarthritis and total hip replacement. Similar associations were seen when considering hip pain and symptomatic osteoarthritis as the outcome measures of interest. Pincer-type femoroacetabular impingement was not significantly associated with any of the outcome measures of interest and pain remains relatively poorly explained by both hip morphology and/or radiographic change. The understanding of hip morphology and its role in the natural history of osteoarthritis is significantly improved by this research. Further research is now required to determine whether these morphological abnormalities represent modifiable risk factors for osteoarthritis progression.

Introdução: As alterações anatômicas do fêmur proximal ou do acetábulo, como as decorrentes das sequelas da epifisiólise do fêmur proximal, da displasia do quadril da doença de Legg-Perthes-Calvé, podem levar ao desenvolvimento da artrose do quadril. No entanto, em torno de 80% dos indivíduos que desenvolvem essa doença têm uma anatomia óssea considerada normal. Ainda assim, surgiu a hipótese que alterações sutis do fêmur proximal ou do acetábulo, denominadas, respectivamente, cam e pincer, poderiam gerar um contato anormal entre essas estruturas ósseas, desencadear lesão condral e, como consequência, a artrose do quadril. Esse mecanismo foi denominado impacto fêmoro-acetabular. No entanto, a comprovação da relação entre o impacto e a artrose do quadril depende da uniformização dos critérios diagnósticos do cam e do pincer, ainda escassa e variável na literatura. Dessa forma, será possível a definição da prevalência e história natura do impacto fêmoro-acetabular e da sua relação com a artrose do quadril. Objetivo: Avaliar a prevalência do impacto fêmoro-acetabular tipo cam e tipo pincer em uma amostra de indivíduos assintomáticos. Pacientes e Métodos: Foram estudados 106 indivíduos assintomáticos (65 homens e 41 mulheres), com idade entre 20 e 40 anos. A condição determinante para a inclusão no estudo foi à ausência de história de dor no quadril ao longo da vida. Foram obtidas radiografias em ântero-posterior e Dünn 45°. A presença de cam foi determinada por um ângulo alfa, arbitrado, de 55° e a presença de pincer, quando observado o sinal da parede posterior e/ou o sinal de crossover. Resultados: Foi observada prevalência de cam de 29%; o sinal do crossover e da parede posterior ocorreram, respectivamente, em 20% e 29% dos indivíduos estudados. Pelo menos uma das imagens de impacto fêmoro-acetabular estava presente em 65% dos indivíduos da amostra. Conclusão: A prevalência encontrada das imagens de impacto fêmoro-acetabular (65%) está acima daquelas relatadas na literatura. É necessária a ampliação do estudo para confirmar os resultados encontrados e a realização de estudos prospectivos bem controlados para avaliar o papel do cam e do pincer no desenvolvimento da artrose do quadril. / Background: Anatomical abnormalities of the proximal femur or the acetabulum, such as those resulting from the consequences of slipped epiphyses of the proximal femur, the hip dysplasia of Legg-Calve-Perthes disease, could lead to the development of hip osteoarthrosis. Nevertheless, around 80% of individuals who develop this condition have a bone anatomy considered normal. Still, the hypothesis arose that subtle alterations of the proximal femur or the acetabulum, called, respectively, cam and pincer, could generate an abnormal contact between these bony structures, triggering chondral lesion and as a consequence, arthritis of the hip. This mechanism has been named femoroacetabular impingement. Nevertheless, evidence of the relationship between the impact and osteoarthritis of the hip depends on the standardization of diagnostic criteria of cam and pincer, still scarce and variable in the literature. Thus it will be possible to define the prevalence and natural history of femoroacetabular impingement and its relationship with hip osteoarthrosis. Aim: To determine the prevalence of cam-type and pincer-type femoroacetabular impingements in asymptomatic subjects. Patients and Methods: Were studied 106 asymptomatic subjects (65 males and 41 females) aged between 20 and 40 years. The determining condition for inclusion in the study was the absence of history of hip pain throughout life. Radiographs were obtained in anteroposterior pelvic view and Dunn 45° view. The presence of cam was determined by an angle alpha, arbitrated, 55 ° and the presence of pincer when the observed the posterior wall and / or crossover signs. Results: A prevalence of 29% of cam, and 20% and 29% of crossover sign and posterior wall sign respectively was found. At least, one of those radiographic signs of femoroacetabular impingement was found in 65% (68) of the cases. Conclusion: In conclusion, the prevalence of images of femoroacetabular impingement (65%) is above those reported in the literature. Increase of the study is necessary to verify the results found, and the performance of well-controlled prospective studies to evaluate the role of the cam and pincer in the development of osteoarthritis of the hip.

Femoroacetabular impingement (FAI) has been increasingly recognized as a cause of early hip osteoarthritis. FAI is characterized by pathologic contact between the femur and acetabular rim during hip join movement, caused by morphological abnormalities. Arthroscopic technique has become increasingly popular for FAI surgical treatment because of its minimal invasiveness. However, it involves cumbersome procedures and over- or under-resection are likely to occur. To tackle this issue, robot-assisted FAI arthroscopy is a well suited approach because it results in high accuracy and reproducible surgical outcomes. This dissertation provides new approaches and methods for the current challenges in the development of robot-assisted FAI arthroscopy. The study has three objectives: 1) to develop a robust calibration method for the A-mode ultrasound probe used for noninvasive bone registration, 2) to develop a bone registration simulator for verifying the registration accuracy and consistency for any given registration point-pattern, and 3) to develop a hip range of motion simulation system that returns the virtual range of motion and determines the bone resection volume. Carefully designed calibration procedures and simulation experiments have been conducted during the study of this research. From the experimental results, the developed ultrasound calibration method successfully reduces the registration errors and is proved to be robust. The results from the registration simulator indicate that the pattern with widely distributed points lead to better registration accuracy and consistency. The hip range of motion simulation system results in acceptable accuracy and successfully generates the resection volume. With further modifications, the ultrasound probe can be successfully calibrated with the developed method, and will be applied for noninvasive bone registration. The registration simulator can also be served as a useful tool for determining the optimized registration point-pattern, which can lead to reduced surgical trauma and registration time. Finally, the developed range of motion simulation system can allow the surgeon to evaluate the surgical outcome and to determine the resection volume even before the surgery begins. To conclude, this dissertation provides useful approaches, methods, and software for developing robot-assisted FAI arthroscopy.

Femoroacetabular impingement (FAI) is a hip joint deformity that causes joint pain, decreases joint range of motion and results in abnormal kinematic and kinetic characteristics. It is not known whether these biomechanical variations are caused by the actual mechanical impingement aspect of hip deformity or neuromuscular adaptations and soft tissue damage associated with pain. The purpose of this study was to investigate the effects of femoroacetabular cam deformity (FAD) during daily functional tasks. This was accomplished by measuring and comparing the hip joint biomechanics of symptomatic FAI (sFAI), asymptomatic FAD, and control (CON) subjects. Fifty one subjects volunteered to the study (n = 51; CON = 17, FAD = 18, sFAI = 16) and they performed 6 simulated activities of daily living: stair ascent and descent, sit-to-stand and stand-to-sit, dynamic range of motion, maximum depth squats and level walking tasks while motion ground reaction force and muscle activity were recorded. However, only the squat and level walking tasks were analyzed for this thesis. For each task, three-dimensional kinematics and kinetics were recorded and analyzed. Qualitative questionnaires (HOOS and WOMAC) and physical exams were also part of the testing protocol, and maximum voluntary isometric contractions (MVIC) were collected as part of a separate EMG protocol. The EMG results were not analyzed but the MVIC results were and the moments of force were determined. The sFAI group had significantly reduced scores for all HOOS and WOMAC metrics compared to FAD and CON. The sFAI group had significantly reduced external rotation, internal rotation, and a trend indicating reduced hip flexion compared to FAD and CON groups. The FAD group had a trend indicating reduced internal rotation compared to CON. There were no differences in the moments of force between groups for the MVICs. No statistically significant differences were observed between groups for the squat trials, however, the sFAI group showed biomechanical variations. Both the CON and FAD groups were able to squat deeper, had greater pelvic range of motion and a larger maximum hip and knee flexion angle compared to sFAI. Similarly, the walking tasks did not elucidate any between group differences in biomechanical characteristics. Yet, there was a noticeable trend of decreased peak hip abduction angle in the sFAI group compared to CON. This result may be indicative of a gait adaptation based on the pain that sFAI subjects endure over a long period of time. Interestingly, the FAD group did not have obvious gait patterns similar to either the CON or sFAI, making it unclear if the asymptomatic cam deformity has any gait adaptation effects. Since no differences were observed between FAD and CON in squatting and walking, the actual bone deformity may not be the cause of restricted motion during daily activities as previously thought. Internal rotation physical examination appears to indicate potential restrictions in the FAD compared to CON, and may be the best parameter to assess differences between groups and predict the presence of cam deformity. It is suggested that the presence of pain, caused by soft tissue damage over time, may be confounding factors leading to the biomechanical and neuromuscular discrepancies observed in sFAI, and should be the next avenue of study.

Introdução: As alterações anatômicas do fêmur proximal ou do acetábulo, como as decorrentes das sequelas da epifisiólise do fêmur proximal, da displasia do quadril da doença de Legg-Perthes-Calvé, podem levar ao desenvolvimento da artrose do quadril. No entanto, em torno de 80% dos indivíduos que desenvolvem essa doença têm uma anatomia óssea considerada normal. Ainda assim, surgiu a hipótese que alterações sutis do fêmur proximal ou do acetábulo, denominadas, respectivamente, cam e pincer, poderiam gerar um contato anormal entre essas estruturas ósseas, desencadear lesão condral e, como consequência, a artrose do quadril. Esse mecanismo foi denominado impacto fêmoro-acetabular. No entanto, a comprovação da relação entre o impacto e a artrose do quadril depende da uniformização dos critérios diagnósticos do cam e do pincer, ainda escassa e variável na literatura. Dessa forma, será possível a definição da prevalência e história natura do impacto fêmoro-acetabular e da sua relação com a artrose do quadril. Objetivo: Avaliar a prevalência do impacto fêmoro-acetabular tipo cam e tipo pincer em uma amostra de indivíduos assintomáticos. Pacientes e Métodos: Foram estudados 106 indivíduos assintomáticos (65 homens e 41 mulheres), com idade entre 20 e 40 anos. A condição determinante para a inclusão no estudo foi à ausência de história de dor no quadril ao longo da vida. Foram obtidas radiografias em ântero-posterior e Dünn 45°. A presença de cam foi determinada por um ângulo alfa, arbitrado, de 55° e a presença de pincer, quando observado o sinal da parede posterior e/ou o sinal de crossover. Resultados: Foi observada prevalência de cam de 29%; o sinal do crossover e da parede posterior ocorreram, respectivamente, em 20% e 29% dos indivíduos estudados. Pelo menos uma das imagens de impacto fêmoro-acetabular estava presente em 65% dos indivíduos da amostra. Conclusão: A prevalência encontrada das imagens de impacto fêmoro-acetabular (65%) está acima daquelas relatadas na literatura. É necessária a ampliação do estudo para confirmar os resultados encontrados e a realização de estudos prospectivos bem controlados para avaliar o papel do cam e do pincer no desenvolvimento da artrose do quadril. / Background: Anatomical abnormalities of the proximal femur or the acetabulum, such as those resulting from the consequences of slipped epiphyses of the proximal femur, the hip dysplasia of Legg-Calve-Perthes disease, could lead to the development of hip osteoarthrosis. Nevertheless, around 80% of individuals who develop this condition have a bone anatomy considered normal. Still, the hypothesis arose that subtle alterations of the proximal femur or the acetabulum, called, respectively, cam and pincer, could generate an abnormal contact between these bony structures, triggering chondral lesion and as a consequence, arthritis of the hip. This mechanism has been named femoroacetabular impingement. Nevertheless, evidence of the relationship between the impact and osteoarthritis of the hip depends on the standardization of diagnostic criteria of cam and pincer, still scarce and variable in the literature. Thus it will be possible to define the prevalence and natural history of femoroacetabular impingement and its relationship with hip osteoarthrosis. Aim: To determine the prevalence of cam-type and pincer-type femoroacetabular impingements in asymptomatic subjects. Patients and Methods: Were studied 106 asymptomatic subjects (65 males and 41 females) aged between 20 and 40 years. The determining condition for inclusion in the study was the absence of history of hip pain throughout life. Radiographs were obtained in anteroposterior pelvic view and Dunn 45° view. The presence of cam was determined by an angle alpha, arbitrated, 55 ° and the presence of pincer when the observed the posterior wall and / or crossover signs. Results: A prevalence of 29% of cam, and 20% and 29% of crossover sign and posterior wall sign respectively was found. At least, one of those radiographic signs of femoroacetabular impingement was found in 65% (68) of the cases. Conclusion: In conclusion, the prevalence of images of femoroacetabular impingement (65%) is above those reported in the literature. Increase of the study is necessary to verify the results found, and the performance of well-controlled prospective studies to evaluate the role of the cam and pincer in the development of osteoarthritis of the hip.