Cam type Femoroacetabular Impingement associated with Marker for Hyperandrogenism in Women

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1 Cam type Femoroacetabular Impingement associated with Marker for Hyperandrogenism in Women Andrew B. Wolff, MD a Torie Plowden, MD b Alexandra Napoli, BA a Benjamin McArthur, MD a Erin F. Wolff, MD b a Washington Orthopaedics and Sports Medicine, Washington DC; b Program in Reproductive and Adult Endocrinology, NICHD, National Institutes of Health, Bethesda, MD

2 Andrew B. Wolff, MD I have the following financial relationships to disclose: Consulting: Arthrex, Pivot medical

3 Etiology of Cam Type FAI Remains undefined, but evidence shows: Develops during adolescence 1,2,3 More common in males 4 Associated with vigorous sporting activities 3 Can be result of silent slipped capital femoral epiphysis 5,6 More common in males 5,6 Associated with endocrine disorders 7

4 Polycystic Ovary Syndrome Polycystic Ovary Syndrome (PCOS) Important cause of androgen excess in women Affects percent of women Associated with menstrual irregularity, hirsutism, obesity, glucose intolerance, dyslipidemia, obstructive sleep apnea

5 Polycystic Ovary Syndrome Polycystic Ovary Syndrome (PCOS) Characterized and diagnosed in part by increased number and size of antral follicles on imaging 8,9

6 Cam-type FAI and PCOS Both develop in the peri-pubertal period Both associated with or defined by endocrine dysfunction Cam-type FAI seen more in men than in women PCOS characterized by hyperandrogenism

7 Hypothesis Cam-type FAI will be associated with marker for PCOS (hyperandrogenism)

8 Methods Prospective cohort of reproductive aged women who were indicated for arthroscopic hip surgery were assessed. Presence or absence of cam morphology was determined by measurement of alpha angles on 45 degree Dunn lateral radiographs. Cam FAI was defined as an angle of >55 degrees 10

9 Methods Antral follicles were assessed by MRI. As only one ovary was frequently seen on MRI, the average number of antral follicles per ovary were recorded.

10 Results Fifteen women with cam FAI and 13 without were found to have median alpha angle of 62 (range 56-72) and 46 (range 40-54), respectively (P<0.0001). Average ages were similar between groups ( vs , P=0.30). Antral follicle counts per ovary were significantly higher in women with cam FAI than controls, respectively ( vs , P=0.004). Univariate analysis revealed a statistically significant correlation between alpha angle measurements and antral follicle counts per ovary (R=0.30, P=0.03), indicating that cam type FAI appears to be more consistent with a continuum rather than cut-point with respect to antral follicle counts.

11 Results Fifteen women with cam FAI and 13 without were found to have median alpha angle of 62 (range 56-72) and 46 (range 40-54), respectively (P<0.0001). Average ages were similar between groups ( vs , P=0.30). Antral follicle counts per ovary were significantly higher in women with cam FAI than controls, respectively ( vs , P=0.004). Univariate analysis revealed a statistically significant correlation between alpha angle measurements and antral follicle counts per ovary (R=0.30, P=0.03), indicating that cam type FAI appears to be more consistent with a continuum rather than cut-point with respect to antral follicle counts.

12 Discussion and Conclusion Cam-type FAI was found to be strongly associated with increased antral follicle numbers--a marker for PCOS and hyperandrogenism. Further study is needed to assess hormonal influence such as PCOS and hyperandrogenism on development of the proximal femur during adolescence

13 References 1. The Otto Aufranc Award. On the etiology of the cam deformity: a cross-sectional pediatric MRI study. Carsen, S et al. CORR The cam-type deformity of the proximal femur arises in childhood in response to vigorous sporting activity. Siebenrock, KA et al. CORR Prevalence of cam-type deformity and hip pain in elite ice hockey players before and after the end of growth. Siebenrock, KA et al. Am J Sports Med The alpha angle in cam-type femoroacetabular impingement: new reference intervals based on 2038 healthy young adults. Laborie LB et al. Bone Joint J Radiological findings that may indicate a prior silent slipped capital femoral epiphysis in a cohort of 2072 young adults. Lehmann TG et al. Bone Joint J The frequency of sequelae of slipped upper femoral epiphysis in cam-type femoroacetabular impingement. Murgier J et al. Bone Joint J Slipped capital femoral epiphysis and its association with endocrine, metabolic and chronic diseases: a systematic review of the literature. Witbreuk M et al. J Child Orthop Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome (PCOS). Rotterdam ESHRE/ASRM-Sponsored PCOS consensus workshop group. Hum Reprod Ovarian morphology assessed by magnetic resonance imaging in women with and without polycystic ovary syndrome and associations with antimüllerian hormone, free testosterone, and glucose disposal rate. Leonhardt H. Fertil Steril Femoral head-neck offset measurements in 339 subjects: distribution and implications for femoroacetabular impingement. Fraitzl CR et al. Knee Surg Sports Traumatol Arthrosc