Cam-type deformities: Concepts, criteria, and multidetector CT features

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A y B)Varón de 58 años. C y D)Varón de 78 años. Ambos asintomáticos. TC multidetector con reconstrucción 3D anteroposterior (A y C) y multiplanar axial oblicua (B y D). Placas reactivas, de perfil plano (A y B) y de perfil convexo (C y D) (flechas)." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J.M. Mellado, N. Radi" "autores" => array:2 [ 0 => array:2 [ "nombre" => "J.M." "apellidos" => "Mellado" ] 1 => array:2 [ "nombre" => "N." 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Mellado, N. Radi" "autores" => array:2 [ 0 => array:4 [ "nombre" => "J.M." "apellidos" => "Mellado" "email" => array:1 [ 0 => "jmellado@comz.org" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "N." 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On the anterior–posterior plane, (A) focal prominence; (B) diffuse prominence with decrease of superior offset, and (C) superior offset loss, substituted by a convex profile (pistol grip deformity). On the axial plane, (D) focal prominence without offset loss; (E) offset loss without focal prominence (nearly flat contour, sometimes with a crest and medial depression), and (F) anterior convexity diffuse prominence, with epiphyseal retroversion." ] ] ] "textoCompleto" => "IntroductionIn 1965, Murray<a class="elsevierStyleCrossRef" href="#bib0315">1</a> suggested that some minor variants or deformities of the proximal femur can accelerate hip arthrosis. New terms were coined for these deformities (head tilt, pistol grip, post-slip), based on their radiographic appearance and the possible relation with epiphysiolysis.<a class="elsevierStyleCrossRefs" href="#bib0315">1–3</a> The concept femoroacetabular impingement arises from these and other observations, a controversial entity that has contributed to popularizing the variability of proximal femur in orthopedics and radiology forums.<a class="elsevierStyleCrossRef" href="#bib0330">4</a> Within femoroacetabular impingement (FAI) two subgroups are distinguished, the cam type and the pincer type, each with specific radiologic findings and differentiated surgical treatments.The cam type deformity, described in 2001, is an anatomical variant of the proximal femur. The word cam refers to a mechanical element, usually oval, which is attached to an axis at a point that is not its geometric center. The term cam is used in medical literature to describe a lack of sphericity in the femur head, occasionally associated with other minor deformities. Our understanding of the deformity comes from radiologic and intraoperative observations. The surgical hip luxation and arthro-resonance in multiple radial planes have turned out to be of great help in this sense. However, the variable appearance of the cam type deformity in the different modalities or projections makes its characterization complex.On the other hand, the variants of proximal femur have been studied thoroughly by anatomists and anthropologists for over a century. Research in cadavers has generated a large number of descriptive terms.<a class="elsevierStyleCrossRefs" href="#bib0335">5–7</a> Most of these variations correspond to three basic typologies: the prominent one (Poirier accessory facet), the flat or hardly prominent one (Angel's reactive plate) and the excavated one (Allen's cervical fossa). In their clarifying revision, Villotte and Knüsel<a class="elsevierStyleCrossRef" href="#bib0350">8</a> group the two latter terms, plate and fossa, suggesting that many cam type deformities could correspond to the accessory facet. More recently, Radi et al.<a class="elsevierStyleCrossRef" href="#bib0355">9</a> sub-categorized the plate and the fossa and proposed a simplified terminology based on the review of an identified wide skeletal collection.Our goal is to review the defining criteria of cam type deformities, illustrating the concepts with diagrams and diagnostic images. We focused our attention on multidetector computed tomography (MDCT), effective to assess it qualitative and quantitatively, with usual applications and specific programs (such as Clinical Graphics).<a class="elsevierStyleCrossRefs" href="#bib0360">10–18</a> Also the MDCT generates extremely realistic 3D reconstructions that can be compared with the specimens from the osteological medical literature. Ultimately we tried to illustrate the variability inherent to the deformity itself, seeking its potential correspondence with some of the concepts described in the osteological medical literature (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Cam-type deformities in orthopedic and radiologic medical literatureFAI is an entity typical of young, active adults that occurs with hip pain, limitation of movement range, suggestive physical examination and early hip arthrosis. In cam type FAI an anterior femoral neck with prominent contour repeatedly impacts the acetabular notch during hip flexion in abduction and internal rotation causing anterosuperior labral and chondral damage (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>). In pincer type FIA both the acetabular retroversion and the deep coxa originate anterosuperior labrum lesions, and in advanced stages, labral and chondral lesions are present in the posteroinferior quadrant. In addition, in pincer type FIA there is sclerosis or cortical excavation in the anterosuperior side of the femoral neck. The cam and pincer FAI types often coexist.<elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia>Ganz et al.<a class="elsevierStyleCrossRefs" href="#bib0330">4,11,19–30</a> have established the theoretical and practical foundations of FAI. Many other researchers have taken up the challenge of sub-categorizing and validating the most diverse aspects of FAI.<a class="elsevierStyleCrossRefs" href="#bib0360">10,12–18,31–59</a> In spite of great academic efforts, FAI continues to pose a number of uncertainties. The exact cause of cam type deformity is unknown, as well as its actual prevalence, its actual usefulness as a FAI radiological marker, the optimal surgical indication, the natural history of non-operated FAI or the possible effectiveness of preventive surgery in asymptomatic patients with this deformity.<a class="elsevierStyleCrossRefs" href="#bib0445">27,30,41,49,53</a>The idiopathic cam type deformity is an extension of the epiphysis towards the anterosuperior portion of the femoral neck.<a class="elsevierStyleCrossRef" href="#bib0420">22</a> In its most common manifestation, it is an osseous prominence lacking epiphyseal sphericity (cam) and a decrease of head–neck offset. Both features are closely linked to each other, but they are not equivalent and they do not occur necessarily in constant proportions.<a class="elsevierStyleCrossRef" href="#bib0490">36</a> The cam type FAI hypothesis suggests that there is an anomalous FAI when the curvature radius of the femoral head surpasses the curvature radius of the acetabulum. This can happen with several types of femoral deformity though the shape of the acetabular contour also plays a role. In a simplified manner, it can be claimed that there are 3 cam type deformities: (a) predominance of prominence; (b) predominance of offset loss, and (c) prominence with offset loss and epiphyseal retroversion (pistol grip deformity) (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). The latter has a shape similar to that of epiphysiolysis, but with less accentuated features. These three categories do not cover the whole spectrum of possible variations or represent a validated classification, but they serve the purpose of drawing the attention to the most relevant parameters.<elsevierMultimedia ident="fig0015"></elsevierMultimedia>Characterizing the cam type deformity requires a standardized radiographic technique and systematic evaluation.<a class="elsevierStyleCrossRef" href="#bib0490">36</a> Anterior–posterior and axial projections (conventional or Lauenstein) can prove useful (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). However, lateral projections with horizontal rays (cross-table, at a 15° internal rotation), Dunn at 90° and Dunn at 45° are more effective because they split the greater trochanter, broadening the view of the femoral neck.<a class="elsevierStyleCrossRef" href="#bib0430">24</a> In any case, regular normal radiographies do not rule out the deformity.<a class="elsevierStyleCrossRef" href="#bib0510">40</a> Characterization must be attempted in the anterior–posterior plane (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a> and <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>) and the lateral or axial plane (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a> and <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>). Some criteria are extrapolated from one modality or projection to others. Nevertheless, both the deficit of sphericity and the decrease of offset can show different reference values and manifestations depending on the modalities and projections chosen.<elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia>The most commonly used measurements are the alpha angle,<a class="elsevierStyleCrossRef" href="#bib0465">31</a> described in MRI to assess the femoral sphericity deficit, and Eijer's ratio,<a class="elsevierStyleCrossRef" href="#bib0405">19</a> described in lateral radiography to assess offset loss. The alpha angle identifies the potentially relevant cam type deformity from the clinical point of view when it reaches values above a specific cut point on an adequate plane. The alpha angle is optimally assessed in planned MR images with double obliquity (parallel to the cervical axis, but with a 45° radial orientation, equivalent to the 1:30h point) (<a class="elsevierStyleCrossRef" href="#fig0030">Fig. 6</a>). The ideal cut point to characterize the deformity is still under discussion, although values >60° improve significantly the effectiveness for identification purposes of the prominences clinically associated with FAI.<a class="elsevierStyleCrossRef" href="#bib0550">48</a> In any case, the alpha angle is hard to measure,<a class="elsevierStyleCrossRef" href="#bib0505">39</a> it cannot be estimated subjectively and it is influenced by several geometric factors. Measuring the Eijer ratio is also difficult because the distances assessed are small.<a class="elsevierStyleCrossRef" href="#bib0585">55</a> For all the above, it is recommended to combine the quantitative and qualitative criteria.<elsevierMultimedia ident="fig0030"></elsevierMultimedia>During the last few years new quantitative parameters or modifications from the existing ones have been proposed. In the coronal plane, the triangular index stands out, too complex to be used clinically (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>C). The anatomical alpha angle has been proposed for the axial plane, which takes into account epiphyseal retroversion on tracing the reference lines (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>B).<a class="elsevierStyleCrossRef" href="#bib0585">55</a> The beta angle, measured in 90° Dunn projection, assesses the relation of sphericity deficit with the anterior acetabular lip (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>A).<a class="elsevierStyleCrossRefs" href="#bib0590">56,57</a> The angle of torsion specifically quantifies epiphyseal retroversion with respect to the axis of the femoral neck with higher values in the cam type deformity associated with FAI<a class="elsevierStyleCrossRef" href="#bib0545">47</a> (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>C). On the other hand, femoral neck anteversion with respect to the posterior bicondylar line shows significantly lower values in patients with cam type FAI than in patients suffering from pincer type FAI.<a class="elsevierStyleCrossRef" href="#bib0560">50</a> The profusion of new indexes, angles and measurements in recent publications seem to reflect not only the limitations of the original criteria, but also the deformity's intrinsic variability. In this same line some authors suggest that the cam type deformity is much more than just a protuberance. According to this view, the deformity would entail a multiplicity of dimorphic traits, including large, spheroid femoral head, broad, short femoral neck, increase of the head–neck ratio, decrease of the anterior and posterior offset and occasional epiphyseal retroversion.<a class="elsevierStyleCrossRef" href="#bib0375">13</a>MDCT allows us to study cam type deformities quantitatively and qualitatively. It discriminates between cam type deformities with anterior prominence as a predominating feature (<a class="elsevierStyleCrossRef" href="#fig0035">Fig. 7</a>) and those with a more flat profile (<a class="elsevierStyleCrossRef" href="#fig0040">Fig. 8</a>). Also it shows the lateral extension of the joint surface, whose outer limit often surpasses the fissure line (<a class="elsevierStyleCrossRefs" href="#fig0035">Figs. 7 and 8</a>). MDCT's quantitative study options include densitometries. In cam type deformities, an increase of underlying trabecular bone density has been demonstrated which presupposes an increase in subchondral rigidity that can accelerate chondral degeneration.<a class="elsevierStyleCrossRef" href="#bib0605">59</a><elsevierMultimedia ident="fig0035"></elsevierMultimedia><elsevierMultimedia ident="fig0040"></elsevierMultimedia>Cam type deformities are highly prevalent in asymptomatic individuals. In fact the overlapping of alpha angles in asymptomatic individuals and in FAI patients has spurred scientific controversy,<a class="elsevierStyleCrossRefs" href="#bib0370">12,18,35,42,44,45,48,52,54</a> moderate skepticism<a class="elsevierStyleCrossRef" href="#bib0515">41</a> and sarcastic opinions.<a class="elsevierStyleCrossRef" href="#bib0575">53</a> For the advocates of the FAI concept, we are talking about predisposed individuals that may require specialized orthopedic attention.<a class="elsevierStyleCrossRef" href="#bib0445">27</a> For the most reticent ones, the broad angle overlapping between cases and controls could question the theoretical pillars of FAI.<a class="elsevierStyleCrossRef" href="#bib0575">53</a>Cam type deformities are more prevalent among males, especially in physically active individuals. They are likely to develop before the fissure closure, as an adaptational expression to a repeated mechanical overload.<a class="elsevierStyleCrossRef" href="#bib0450">28</a> Many authors claim that the deformity results from a clinically silent epiphysiolysis,<a class="elsevierStyleCrossRefs" href="#bib0325">3,51</a> although this has not been entirely verified and it can occur only in a small proportion of the cases. Cam type deformities can also have a racial and genetic component.<a class="elsevierStyleCrossRef" href="#bib0525">43</a>Recent publications suggest that the deformity has multiple causes, and the patient's age, sex, bodily habits, exercises and evolutionary patterns, among other factors are influential.<a class="elsevierStyleCrossRef" href="#bib0540">46</a> The deformity can be sub-categorized into: (a) primary; (b) secondary to development, related to epiphysiolysis, Perthes’ disease and interventional congenital hip dysplasia, and (c) acquired–Identified with remodeling associated with hip arthrosis, post-traumatic deformity or a previous osteotomy.<a class="elsevierStyleCrossRef" href="#bib0540">46</a> Therefore, cam type deformities can cause and also be the consequence of arthrosis.<a class="elsevierStyleCrossRef" href="#bib0610">60</a> And it can be secondary to epiphysiolysis or have nothing to do with it. There seem to be several types of deformity. But if that is the case, maybe not all of them cause FAI and then it would be necessary to discriminate them with renewed criteria.Proximal femur variations in osteological medical literatureThe osteological medical literature contains a large variety of descriptive terms for the proximal femur, many of which have fallen into disuse.<a class="elsevierStyleCrossRefs" href="#bib0335">5–9</a> The three basic forms described by anatomists and anthropologists are Poirier's accessory facet, Angel's reactive plate and Allen's cervical fossa, with a variable expression in the anterior–posterior and lateral or axial planes (<a class="elsevierStyleCrossRef" href="#fig0045">Fig. 9</a>).<elsevierMultimedia ident="fig0045"></elsevierMultimedia>In the anterior–posterior plane, the distinction between Poirier's accessory facet and Angel's reactive plate is based on its outer contour; being a priori the facet more circumscribed (<a class="elsevierStyleCrossRef" href="#fig0045">Fig. 9</a>A) and the plate more extensive and lateral (<a class="elsevierStyleCrossRef" href="#fig0045">Fig. 9</a>B). When loss of superior offset is associated (<a class="elsevierStyleCrossRef" href="#fig0045">Fig. 9</a>C), the variant is similar to the cam type deformity. Systematization in the lateral or axial plane distinguishes between concave or non-elevated (<a class="elsevierStyleCrossRef" href="#fig0045">Fig. 9</a>D), flat (<a class="elsevierStyleCrossRef" href="#fig0045">Fig. 9</a>E) and prominent variants (<a class="elsevierStyleCrossRef" href="#fig0045">Fig. 9</a>F) being the prominent variant closer to cam type morphology.Poirier's accessory facet was defined as a lateral extension of the epiphysis towards the anterosuperior region of the neck (<a class="elsevierStyleCrossRef" href="#fig0045">Fig. 9</a>A).<a class="elsevierStyleCrossRefs" href="#bib0335">5–9</a> It is usually covered by hyaline cartilage. Its prevalence is unknown because the data published are inconsistent.<a class="elsevierStyleCrossRefs" href="#bib0335">5,9</a> The accessory facet has a smooth contour, with a profile continuing to the joint surface of the epiphysis in the femoral neck region without apparent transition. It can present a triangular or oval configuration, and it can be hard to identify when it coexists with other variations or degenerative changes. When described like this the facet can correspond to the classical cam type deformity (<a class="elsevierStyleCrossRefs" href="#fig0015">Figs. 3A,D and 7</a>).<a class="elsevierStyleCrossRefs" href="#bib0350">8,9</a>Angel's reactive plate, a fairly more recent concept than that of accessory facet, introduces the idea of adaptational or occupational trait.<a class="elsevierStyleCrossRef" href="#bib0335">5</a> It is identified in up to 87% of the specimens. It is more prevalent among males, especially in elderly males.<a class="elsevierStyleCrossRef" href="#bib0355">9</a> The reactive plate extends more laterally and inferiorly than Poirier's facet (<a class="elsevierStyleCrossRef" href="#fig0045">Fig. 9</a>B).<a class="elsevierStyleCrossRefs" href="#bib0335">5,8,9</a> It can be covered by fibrocartilage<a class="elsevierStyleCrossRef" href="#bib0335">5</a> and it often presents sclerosis and cortical irregularity of a variable-profile (<a class="elsevierStyleCrossRef" href="#fig0045">Fig. 9</a>D–F). In MDCT, the reactive plate often adopts a slightly sclerotic appearance not elevated or associated with a minimal decrease of the anterior offset (<a class="elsevierStyleCrossRef" href="#fig0050">Fig. 10</a>). When the reactive plate is prominent, it can be similar to the accessory facet. In fact, they can both reflect variable degrees of the same phenomenon.<a class="elsevierStyleCrossRef" href="#bib0355">9</a> On the other hand, MDCT allows us to compare reactive plates in individuals of different ages (<a class="elsevierStyleCrossRef" href="#fig0055">Fig. 11</a>). The prominent plate, frequent in old age, seems to exaggerate a superficial trait that is present in the early decades of life.<elsevierMultimedia ident="fig0050"></elsevierMultimedia><elsevierMultimedia ident="fig0055"></elsevierMultimedia>The outer contour of the reactive area can be outlined by an osseous lip or crest<a class="elsevierStyleCrossRefs" href="#bib0335">5–9</a> (<a class="elsevierStyleCrossRef" href="#fig0045">Fig. 9</a>D–F) which is generally easy to identify with MDCT (<a class="elsevierStyleCrossRef" href="#fig0055">Fig. 11</a>). When the crest is prominent, the plate takes on an excavated appearance (fossa). Also the plate can present a patent aspect in dry cadaver specimens<a class="elsevierStyleCrossRef" href="#bib0355">9</a> possibly unnoticed in MDCT. In its extreme version, cortical patency also transforms into cervical fossa.<a class="elsevierStyleCrossRefs" href="#bib0335">5–9</a>Some cortical pores in the reactive area communicate with a small juxtacortical cyst, known as herniation pit.<a class="elsevierStyleCrossRefs" href="#bib0600">58,61</a> Such a cyst–a concept of radiological origins is recognizable by its radio-lucid appearance with sclerotic edges. Its prevalence ranges between 5 and 12%. Its meaning is controversial, and it can represent a synovial hernia or an intraosseous ganglion. Similar fibrocystic changes have been found in 33% of FAI patients,<a class="elsevierStyleCrossRef" href="#bib0425">23</a> although its relevance as FAI radiographic markers is still under discussion. In any case, the pits often appear closely related to the reactive plate focused on the utmost superior and medial margins of the femoral neck (<a class="elsevierStyleCrossRef" href="#fig0060">Fig. 12</a>).<elsevierMultimedia ident="fig0060"></elsevierMultimedia>Most authors talk about the existence of a direct relation between these skeletal variants of the proximal femur and habits associated with exercise or rest. It is hypothesized that there is a repetitive friction of the femoral neck with contiguous soft tissue structures, such as lower fasciculus of the iliofemoral capsular ligament<a class="elsevierStyleCrossRef" href="#bib0620">62</a> or the psoas tendon.<a class="elsevierStyleCrossRefs" href="#bib0335">5–9</a>ConclusionsCam type deformities can have 3 basic configurations: prominent, flat and with epiphyseal retroversion. On the other hand, the variants described in descriptive osteology are summarized in 2: Poirier's accessory facet (<a class="elsevierStyleCrossRef" href="#fig0065">Fig. 13</a>) and Angel's reactive plate (<a class="elsevierStyleCrossRef" href="#fig0070">Fig. 14</a>). The accessory facet is equivalent to the classical cam type deformity.<a class="elsevierStyleCrossRefs" href="#bib0350">8,9</a> However, the facet and the plate can look like each other, and they can be associated to crests, fossas, pores and pits. As a matter of fact we do not know if the accessory facet and the reactive plate are different entities or extreme versions of a continuous spectrum of variability that is still far from being fully understood.<elsevierMultimedia ident="fig0065"></elsevierMultimedia><elsevierMultimedia ident="fig0070"></elsevierMultimedia>Ethical responsibilitiesProtection of people and animalsAuthors confirm that no experiments have been performed on human beings or animals.Data confidentialityAuthors confirm that the protocols of their institution have been followed on the publication of data from patients.Right to privacy and informed consentAuthors declare that in this article no data from patients have been published.Authors<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">1.Manager of the integrity of the study: JMM.</li><li class="elsevierStyleListItem" id="lsti0010">2.Original idea of the Study: NR.</li><li class="elsevierStyleListItem" id="lsti0015">3.Study design: JMM.</li><li class="elsevierStyleListItem" id="lsti0020">4.Data mining: JMM, NR.</li><li class="elsevierStyleListItem" id="lsti0025">5.Data analysis and interpretation: JMM, NR.</li><li class="elsevierStyleListItem" id="lsti0030">6.Statistical analysis: N/A.</li><li class="elsevierStyleListItem" id="lsti0035">7.Reference search: JMM, NR.</li><li class="elsevierStyleListItem" id="lsti0040">8.Writing: JMM, NR.</li><li class="elsevierStyleListItem" id="lsti0045">9.Critical review of the manuscript with intellectually relevant remarks: JMM, NR.</li><li class="elsevierStyleListItem" id="lsti0050">10.Approval of final version: JMM, NR.</li></ul>Conflict of interestsAuthors declared no conflicts of interests." "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:3 [ "identificador" => "xres490312" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec512385" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres490311" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec512384" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Cam-type deformities in orthopedic and radiologic medical literature" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Proximal femur variations in osteological medical literature" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusions" ] 8 => array:3 [ "identificador" => "sec0025" "titulo" => "Ethical responsibilities" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Protection of people and animals" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Data confidentiality" ] 2 => array:2 [ "identificador" => "sec0040" "titulo" => "Right to privacy and informed consent" ] ] ] 9 => array:2 [ "identificador" => "sec0045" "titulo" => "Authors" ] 10 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflict of interests" ] 11 => array:2 [ "identificador" => "xack155074" "titulo" => "Acknowledgement" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-06-04" "fechaAceptado" => "2014-11-03" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec512385" "palabras" => array:5 [ 0 => "Anatomic variants" 1 => "Multidetector computed tomography" 2 => "Magnetic resonance imaging" 3 => "Femur" 4 => "Femoroacetabular impingement" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec512384" "palabras" => array:5 [ 0 => "Variantes anatómicas" 1 => "Tomografía computarizada multidetector" 2 => "Resonancia magnética" 3 => "Fémur" 4 => "Choque femoroacetabular" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Interpreting imaging studies of a painful hip requires detailed knowledge of the regional anatomy. Some variants of the proximal femur, such as cam-type deformities, can course asymptomatically or cause femoroacetabular impingement. The principal numerical criterion for defining cam-type deformities, the alpha angle, has some limitations. In this article, we review the anatomic variants of the anterior aspect of the proximal femur, focusing on cam-type deformities. Using diagrams and multidetector CT images, we describe the parameters that are useful for characterizing these deformities in different imaging techniques. We also discuss the potential correspondence of imaging findings of cam-type deformities with the terms coined by anatomists and anthropologists to describe these phenomena." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "Para interpretar correctamente los estudios radiológicos de una cadera dolorosa se requiere conocer detalladamente la anatomía regional. Algunas variantes del fémur proximal, como las deformidades tipo cam, pueden cursar de forma asintomática o causar un síndrome de choque femoroacetabular. El ángulo alfa, principal exponente numérico de estas deformidades, tiene algunas limitaciones. Nuestro objetivo es revisar las variantes anatómicas en la vertiente anterior del fémur proximal, centrando la atención en las deformidades tipo cam. Describimos los parámetros útiles para caracterizarla con métodos de imagen, utilizando diagramas e imágenes de tomografía computarizada multidetector. Exponemos además la correspondencia potencial de las deformidades tipo cam con términos descriptivos previamente acuñados por anatomistas y antropólogos." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Mellado JM, Radi N. Deformidades tipo cam: conceptos, criterios y apariencia en TC multidetector. Radiología. 2015;57:213–224." ] ] "multimedia" => array:17 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 636 "Ancho" => 1301 "Tamanyo" => 76896 ] ] "descripcion" => array:1 [ "en" => "Cam type femoral acetabular impingement syndrome. 38-year-old man with a positive test for right hip FAI. (A) Right hip anterior–posterior X-ray showing alteration of epiphyseal sphericity, with lateral flattening (yellow arrow), lateral prolongation fissure scar (arrow head) and cervical prominence with loss of head–neck superior offset (blue arrow). (B) The axial X-ray shows the characteristic prominence of the anterior–superior femoral neck (red arrow) with anterior offset loss. The reader can see this figure in color in the electronic version of the article." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 530 "Ancho" => 1950 "Tamanyo" => 154248 ] ] "descripcion" => array:1 [ "en" => "Cam type femoral acetabular impingement syndrome. 49-year-old man with a positive impingement test. Right hip MRI (3D gradient sequence) in oblique coronal (A), oblique axial (B) and sagittal oblique planes (C) showing cam type deformity (red arrow), contiguous to the lower iliofemoral ligament band (yellow arrow); anterior–superior chondral thinning (green arrow); signal alteration of anterior-lateral acetabular notch (blue arrow); and small geodes in the acetabular margin. The reader can see this figure in color in the electronic version of the article." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 977 "Ancho" => 871 "Tamanyo" => 84090 ] ] "descripcion" => array:1 [ "en" => "Basic modalities of cam type deformity. On the anterior–posterior plane, (A) focal prominence; (B) diffuse prominence with decrease of superior offset, and (C) superior offset loss, substituted by a convex profile (pistol grip deformity). On the axial plane, (D) focal prominence without offset loss; (E) offset loss without focal prominence (nearly flat contour, sometimes with a crest and medial depression), and (F) anterior convexity diffuse prominence, with epiphyseal retroversion." ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 771 "Ancho" => 3337 "Tamanyo" => 169545 ] ] "descripcion" => array:1 [ "en" => "Characterization of cam type deformity in an anterior–posterior projection. (A) Alpha angle. (B) Murray's ratio a/b and neck/head ratio c/d. (C) Triangular index, where e is the short radius, f is half the short radius, g is perpendicular to f, and h is calculated through Pythagoras’ theorem. When in an anterior–posterior X-ray (magnification≤1.2) the long radius h is greater than or equal to the short radius e plus 2, we usually speak of femoral asphericity. (D) Neck length of i; depth of superior j and inferior offset k." ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 314 "Ancho" => 1950 "Tamanyo" => 96908 ] ] "descripcion" => array:1 [ "en" => "Characterization of a cam type deformity in an axial projection. (A) Nötzli's alpha angle and Wyss’ beta angle. (B) Bouma's anatomical alpha angle (αa) and posterior displacement of epiphyseal center a. (C) Epiphyseal torsion angle. (D) Lateral (b) and posterior (c) extension of anterior epiphysis. Depth of anterior d and posterior e offset and Eijer's ratio d/f." ] ] 5 => array:7 [ "identificador" => "fig0030" "etiqueta" => "Figure 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 703 "Ancho" => 1400 "Tamanyo" => 121830 ] ] "descripcion" => array:1 [ "en" => "(A and B) Characterization of a cam type deformity on radial planes. The measurement of the alpha angle can be obtained on the oblique axial plane with a 3:00h orientation (blue line) though the plane with 1:30 radial orientation (red line), equivalent to 45° better discriminates those patients with FAI patients.<a class="elsevierStyleCrossRef" href="#bib0560">50</a> The reader can see this figure in color in the electronic version of the article." ] ] 6 => array:7 [ "identificador" => "fig0035" "etiqueta" => "Figure 7" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr7.jpeg" "Alto" => 1193 "Ancho" => 1327 "Tamanyo" => 221673 ] ] "descripcion" => array:1 [ "en" => "Cam type deformity (prominent). 53-year-old asymptomatic man. MDCT with 3D reconstructions (A) anterior–posterior, (B) oblique anterior–posterior and (C) cranio-caudal reconstructions, followed by (D) axial oblique multiplane reconstruction. Prominent cam type deformity with convex contour and regular surface, whose external limit (red arrow) extends the lateral contour of the epiphysis yet it is far from the fissure scar (green arrow). The reader can see this figure in color in the electronic version of the article." ] ] 7 => array:7 [ "identificador" => "fig0040" "etiqueta" => "Figure 8" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr8.jpeg" "Alto" => 1021 "Ancho" => 1335 "Tamanyo" => 199566 ] ] "descripcion" => array:1 [ "en" => "Cam type deformity (flat). 49-year-old asymptomatic man. MDCT with 3D reconstructions. (A) Anterior–posterior, (B) oblique anterior–posterior and (C) cranio-caudal reconstructions followed by (D) axial oblique multiplane reconstruction. Cam type deformity with predominantly flat contours, with erased anterior offset and small medial depression (blue arrow). The outer limits of the deformity (red arrow) extends the lateral contour of the epiphysis yet it is far from the fissure scar (green arrow). The reader can see this figure in color in the electronic version of the article." ] ] 8 => array:7 [ "identificador" => "fig0045" "etiqueta" => "Figure 9" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr9.jpeg" "Alto" => 878 "Ancho" => 886 "Tamanyo" => 78572 ] ] "descripcion" => array:1 [ "en" => "Variability of the anterior facet of the proximal femur based on the existing osteological medical literature. On the anterior–posterior plane, (A) Poirier's accessory facet; (B) Angel's reactive plate, and (C) facet or plate with superior offset loss, similar to cam type deformity. On the axial plane, (D) not-elevated Angel's reactive plate, with crest (lateral) and fossa (medial); (E) flat reactive plate, with crest (lateral) and herniation pit (medial), and (F) prominent plate or facet, similar to the cam type deformity." ] ] 9 => array:7 [ "identificador" => "fig0050" "etiqueta" => "Figure 10" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr10.jpeg" "Alto" => 1094 "Ancho" => 1300 "Tamanyo" => 199870 ] ] "descripcion" => array:1 [ "en" => "Reactive plate. 40-year-old asymptomatic man. MDCT with 3D reconstructions. (A) Anterior–posterior, (B) oblique anterior–posterior and (C) oblique axial, and (D) multiplane axial oblique reconstructions. Slightly sclerotic hardly appreciable reactive area. The plate's external limit (red arrow) is far from the fissure scar (green arrow). The reader can see this figure in color in the electronic version of the article." ] ] 10 => array:7 [ "identificador" => "fig0055" "etiqueta" => "Figure 11" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr11.jpeg" "Alto" => 780 "Ancho" => 1293 "Tamanyo" => 159492 ] ] "descripcion" => array:1 [ "en" => "Reactive plates in individuals of different ages. (A and B) 58-year-old man. (C and D) 78-year-old man. Both asymptomatic. MDCT with anterior–posterior 3D (A and C) and multiplane axial oblique reconstructions (B and D). Reactive plates with flat profile (A and B) and convex profile (C and D) (arrows)." ] ] 11 => array:7 [ "identificador" => "fig0060" "etiqueta" => "Figure 12" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr12.jpeg" "Alto" => 510 "Ancho" => 1950 "Tamanyo" => 145328 ] ] "descripcion" => array:1 [ "en" => "Reactive plate and herniation pit. 47-year-old asymptomatic man. MDCT with (A and B) 3D anterior–posterior and (C) multiplane axial oblique reconstructions. Reactive area with slightly elevated profile (green arrows) and underlying herniation pit (red arrows). The reader can see this figure in color in the electronic version of the article." ] ] 12 => array:7 [ "identificador" => "fig0065" "etiqueta" => "Figure 13" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr13.jpeg" "Alto" => 532 "Ancho" => 1297 "Tamanyo" => 124957 ] ] "descripcion" => array:1 [ "en" => "Cam type deformity. Specimen from the cadaver of a 59 year-old male. Views (A) frontal and (B) cranio-caudal showing a deformity typical of the cam type (between arrows). Lateral extension of the epiphysis, with a prominent profile, with epiphyseal retroversion and short neck. Source: Identified skeletal collection. La Certosa Cemetery. Museum of Anthropology of the University of Bologna. Bologna, Italy." ] ] 13 => array:7 [ "identificador" => "fig0070" "etiqueta" => "Figure 14" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr14.jpeg" "Alto" => 521 "Ancho" => 1298 "Tamanyo" => 129468 ] ] "descripcion" => array:1 [ "en" => "Reactive plate. Specimen from the cadaver of a 66 year-old male. (A) Frontal and (B) cranio-caudal views showing a reactive plate with concave profile (between arrows). Preservation of the anterior offset and the epiphyseal sphericity without any indications of retroversion. Source: Identified skeletal collection. La Certosa Cemetery. Museum of Anthropology of the University of Bologna. Bologna, Italy." ] ] 14 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Orthopedic and radiologic terminology \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Anatomic and anthropologic terminology \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Simplified terminology<a class="elsevierStyleCrossRef" href="#bib0335">5</a> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " rowspan="3" align="left" valign="top">Head tilt (Murray, 1965)Pistol grip deformity (Stulberg, 1975)Post-slip (Goodman, 1997)lack of sphericity in the femur head (Ito, 2001)Decrease of the head–neck offset (Ito, 2001)Increase of the alpha angle (Nötzli, 2002)Lateral epiphyseal extension (Siebenrock, 2004)Head–neck bulge (Jäger, 2004)Exostosis of femoral neck (Fritz, 2010)Lateral epiphyseal flattening (Laborie, 2011)Posterior epiphyseal displacement (Ellis, 2011)Epiphyseal retrotorsion (Schaeffeler, 2012)</td><td class="td" title="table-entry " align="left" valign="top">Anterior facet of femoral neck(Parsons, 1914)Alpha-type Poirier facet (Pearson, 1919)Poirier facet (Odgers, 1931)Joint eminence of femoral neck(Meyer, 1934)Cervical torus (Meyer, 1934)Cervical eminence (Kostick, 1963)Anterior bone bar (Angel, 1964) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Accessory facet \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Irregular trace of elevated contour (Bertaux, 1891)Iliac trace (Regnault, 1898)Anterior eminence (Walmsley, 1915)Gamma Poirier's facet (Pearson, 1919)Irregular elevated facet (Meyer, 1934)Reactive plate (Angel, 1964) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Elevated plate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Bone notch (Poirier, 1911)Capsular crest (Walmsley, 1915)Cervical crest (Meyer, 1934) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Crest \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="2" align="left" valign="top">Herniation pit (Pitt, 1982)Fibrocystic changes (Leunig, 2005)The notch sign (Petchprapa, 2012)</td><td class="td" title="table-entry " rowspan="2" align="left" valign="top">Cervical fossa (Allen, 1882)Irregular depression (Parsons, 1914)Capsular sulcus (Walmsley, 1915)Beta-type Poirirer's facet (Pearson, 1919)Irregular fossa (Meyer, 1934)Trace (Schofield, 1959)Anterior cervical trace (Kostick, 1963)Allen's fossa (Angel, 1964)</td><td class="td" title="table-entry " align="left" valign="top">Excavated plate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Patent variants: pores, erosions, trabecular exposition \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab779474.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Cam-type deformities: terminology and correspondences." ] ] 15 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Parameter \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Orientative reference \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Lateral sphericity deficit \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Lateral epiphyseal prominence (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A)Lateral epiphyseal flattening (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A)Lateral physeal extension (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A)Radiographic alpha angle (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>A)Murray ratio (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>B)Triangular index (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>C) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Exceeds the circumferential morphology>2mm<a class="elsevierStyleCrossRef" href="#bib0490">36</a>Rectifies the usual curved contour<a class="elsevierStyleCrossRef" href="#bib0535">45</a>The fissure scar extends horizontally towards the femoral neck<a class="elsevierStyleCrossRef" href="#bib0420">22</a>In controls the reference values are 62° (males) and 52° (females)<a class="elsevierStyleCrossRef" href="#bib0580">54</a>In epiphysiolysis the cut value is >1.35<a class="elsevierStyleCrossRef" href="#bib0315">1</a>In cam, long radius≥short radius+2<a class="elsevierStyleCrossRef" href="#bib0480">34</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Superior offset decrease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Pistol grip deformity (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>C)Depth of superior offset (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>D) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Disappearance of superior offset (convex contour)<a class="elsevierStyleCrossRef" href="#bib0345">7</a>Comparison with inferior offset (less useful than the anterior offset)<a class="elsevierStyleCrossRef" href="#bib0480">34</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Other associated traits \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Head–neck ratio (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>B)Neck length (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>D)Cervical-diaphyseal angle \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">In cam, average value 1.59±0.11, lower than in controls<a class="elsevierStyleCrossRef" href="#bib0375">13</a>Cut value<1.27 associates arthrosis<a class="elsevierStyleCrossRef" href="#bib0485">35</a>In cam, average value 24.9±2.9mm (short wide neck<a class="elsevierStyleCrossRef" href="#bib0375">13</a>In cam, cut value<125°<a class="elsevierStyleCrossRef" href="#bib0435">25</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab779475.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Characterization of cam type deformity based on anterior–posterior projections." ] ] 16 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Parameter \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Orientative reference \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Anterior sphericity deficit \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Anterior–superior prominence (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B)Radiographic alpha angle (Frog axial Rx)Radiographic alpha angle (Lateral Rx)Tomographic alpha angle (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>A)Anatomic alpha angle (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>B)Beta angle (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>A)Lateral epiphyseal extension (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>D) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Exceeds the circumferential contour (>2mm)<a class="elsevierStyleCrossRef" href="#bib0490">36</a>In controls average value of 47° (males) and 42° (females)<a class="elsevierStyleCrossRef" href="#bib0580">54</a>In controls average value of 48° (males) and 47° (females) with a reference interval for both genes (95%) of 32–62°<a class="elsevierStyleCrossRef" href="#bib0520">42</a>In cam, cut value (at 45°)>60°<a class="elsevierStyleCrossRef" href="#bib0550">48</a>In cam, cut value>66°<a class="elsevierStyleCrossRef" href="#bib0585">55</a>In cam, average value 15.6° (38.7° in controls)<a class="elsevierStyleCrossRef" href="#bib0605">59</a>In cam, anterior distance exceeds the posterior distance<a class="elsevierStyleCrossRefs" href="#bib0420">22,29</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Anterior offset decrease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Depth of the anterior offset (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>D)Radiographic Eijer ratio (Lateral Rx)Tomographic Eijer ratio (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>D) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Comparison with posterior offset (same, lesser or absent)<a class="elsevierStyleCrossRef" href="#bib0490">36</a>In cam, cut value<8mm<a class="elsevierStyleCrossRef" href="#bib0370">12</a>In controls average value of 0.19,<a class="elsevierStyleCrossRef" href="#bib0520">42</a> with a reference interval for both genres (95%) of 0.14–0.24<a class="elsevierStyleCrossRef" href="#bib0520">42</a>In cam, ratio<0.18<a class="elsevierStyleCrossRef" href="#bib0405">19</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Other associated traits \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Posterior epiphyseal displacement (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>B)Epiphyseal retroversion with respect to the neck (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>C)Femoral anteversion with respect to the bicondylar line \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">With clinical significance cut value>2mm<a class="elsevierStyleCrossRef" href="#bib0375">13</a>In cam, cut value >20°<a class="elsevierStyleCrossRef" href="#bib0545">47</a>Similar values in controls and FAI<a class="elsevierStyleCrossRef" href="#bib0560">50</a>Lower averages values of cam (10±9) to those of pincer (18±10)<a class="elsevierStyleCrossRef" href="#bib0560">50</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab779473.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Characterization of cam type deformity base don axial or lateral projections." ] ] ] 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Update in Radiology

Deformidades tipo cam: conceptos, criterios y apariencia en TC multidetector

J.M. Melladoa,

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jmellado@comz.org

Corresponding author.

, N. Radib

a Hospital Royo Villanova, Zaragoza, Spain

b Laboratorio de Bioarqueología y Osteología Forense, Departamento de Ciencias Biológicas, Geológicas y Medioambientales, Universidad de Bolonia, Bolonia, Italy

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two subgroups are distinguished&#44; the <span class="elsevierStyleItalic">cam</span> type and the <span class="elsevierStyleItalic">pincer</span> type&#44; each with specific radiologic findings and differentiated surgical treatments&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The cam type deformity&#44; described in 2001&#44; is an anatomical variant of the proximal femur&#46; The word <span class="elsevierStyleItalic">cam</span> refers to a mechanical element&#44; usually oval&#44; which is attached to an axis at a point that is not its geometric center&#46; The term cam is used in medical literature to describe a lack of sphericity in the femur head&#44; occasionally associated with other minor deformities&#46; Our understanding of the deformity comes from radiologic and intraoperative observations&#46; The surgical hip luxation and arthro-resonance in multiple radial planes have turned out to be of great help in this sense&#46; However&#44; the variable appearance of the cam type deformity in the different modalities or projections makes its characterization complex&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">On the other hand&#44; the variants of proximal femur have been studied thoroughly by anatomists and anthropologists for over a century&#46; Research in cadavers has generated a large number of descriptive terms&#46;<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">5&#8211;7</span></a> Most of these variations correspond to three basic typologies&#58; the prominent one &#40;Poirier accessory facet&#41;&#44; the flat or hardly prominent one &#40;Angel&#39;s reactive plate&#41; and the excavated one &#40;Allen&#39;s cervical fossa&#41;&#46; In their clarifying revision&#44; Villotte and Kn&#252;sel<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">8</span></a> group the two latter terms&#44; plate and fossa&#44; suggesting that many cam type deformities could correspond to the accessory facet&#46; More recently&#44; Radi et al&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">9</span></a> sub-categorized the plate and the fossa and proposed a simplified terminology based on the review of an identified wide skeletal collection&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Our goal is to review the defining criteria of cam type deformities&#44; illustrating the concepts with diagrams and diagnostic images&#46; We focused our attention on multidetector computed tomography &#40;MDCT&#41;&#44; effective to assess it qualitative and quantitatively&#44; with usual applications and specific programs &#40;such as <span class="elsevierStyleItalic">Clinical Graphics</span>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0360"><span class="elsevierStyleSup">10&#8211;18</span></a> Also the MDCT generates extremely realistic 3D reconstructions that can be compared with the specimens from the osteological medical literature&#46; Ultimately we tried to illustrate the variability inherent to the deformity itself&#44; seeking its potential correspondence with some of the concepts described in the osteological medical literature &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030"><span class="elsevierStyleItalic">Cam</span>-type deformities in orthopedic and radiologic medical literature</span><p id="par0025" class="elsevierStylePara elsevierViewall">FAI is an entity typical of young&#44; active adults that occurs with hip pain&#44; limitation of movement range&#44; suggestive physical examination and early hip arthrosis&#46; In cam type FAI an anterior femoral neck with prominent contour repeatedly impacts the acetabular notch during hip flexion in abduction and internal rotation causing anterosuperior labral and chondral damage &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a>&#41;&#46; In pincer type FIA both the acetabular retroversion and the deep coxa originate anterosuperior labrum lesions&#44; and in advanced stages&#44; labral and chondral lesions are present in the posteroinferior quadrant&#46; In addition&#44; in pincer type FIA there is sclerosis or cortical excavation in the anterosuperior side of the femoral neck&#46; The cam and pincer FAI types often coexist&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Ganz et al&#46;<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">4&#44;11&#44;19&#8211;30</span></a> have established the theoretical and practical foundations of FAI&#46; Many other researchers have taken up the challenge of sub-categorizing and validating the most diverse aspects of FAI&#46;<a class="elsevierStyleCrossRefs" href="#bib0360"><span class="elsevierStyleSup">10&#44;12&#8211;18&#44;31&#8211;59</span></a> In spite of great academic efforts&#44; FAI continues to pose a number of uncertainties&#46; The exact cause of cam type deformity is unknown&#44; as well as its actual prevalence&#44; its actual usefulness as a FAI radiological marker&#44; the optimal surgical indication&#44; the natural history of non-operated FAI or the possible effectiveness of preventive surgery in asymptomatic patients with this deformity&#46;<a class="elsevierStyleCrossRefs" href="#bib0445"><span class="elsevierStyleSup">27&#44;30&#44;41&#44;49&#44;53</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The idiopathic cam type deformity is an extension of the epiphysis towards the anterosuperior portion of the femoral neck&#46;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">22</span></a> In its most common manifestation&#44; it is an osseous prominence lacking epiphyseal sphericity &#40;<span class="elsevierStyleItalic">cam</span>&#41; and a decrease of head&#8211;neck offset&#46; Both features are closely linked to each other&#44; but they are not equivalent and they do not occur necessarily in constant proportions&#46;<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">36</span></a> The cam type FAI hypothesis suggests that there is an anomalous FAI when the curvature radius of the femoral head surpasses the curvature radius of the acetabulum&#46; This can happen with several types of femoral deformity though the shape of the acetabular contour also plays a role&#46; In a simplified manner&#44; it can be claimed that there are 3 cam type deformities&#58; &#40;a&#41; predominance of prominence&#59; &#40;b&#41; predominance of offset loss&#44; and &#40;c&#41; prominence with offset loss and epiphyseal retroversion &#40;pistol grip deformity&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; The latter has a shape similar to that of epiphysiolysis&#44; but with less accentuated features&#46; These three categories do not cover the whole spectrum of possible variations or represent a validated classification&#44; but they serve the purpose of drawing the attention to the most relevant parameters&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Characterizing the cam type deformity requires a standardized radiographic technique and systematic evaluation&#46;<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">36</span></a> Anterior&#8211;posterior and axial projections &#40;conventional or Lauenstein&#41; can prove useful &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; However&#44; lateral projections with horizontal rays &#40;<span class="elsevierStyleItalic">cross-table</span>&#44; at a 15&#176; internal rotation&#41;&#44; Dunn at 90&#176; and Dunn at 45&#176; are more effective because they split the greater trochanter&#44; broadening the view of the femoral neck&#46;<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">24</span></a> In any case&#44; regular normal radiographies do not rule out the deformity&#46;<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">40</span></a> Characterization must be attempted in the anterior&#8211;posterior plane &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a> and <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41; and the lateral or axial plane &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a> and <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; Some criteria are extrapolated from one modality or projection to others&#46; Nevertheless&#44; both the deficit of sphericity and the decrease of offset can show different reference values and manifestations depending on the modalities and projections chosen&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">The most commonly used measurements are the alpha angle&#44;<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">31</span></a> described in MRI to assess the femoral sphericity deficit&#44; and Eijer&#39;s ratio&#44;<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">19</span></a> described in lateral radiography to assess offset loss&#46; The alpha angle identifies the potentially relevant cam type deformity from the clinical point of view when it reaches values above a specific cut point on an adequate plane&#46; The alpha angle is optimally assessed in planned MR images with double obliquity &#40;parallel to the cervical axis&#44; but with a 45&#176; radial orientation&#44; equivalent to the 1&#58;30<span class="elsevierStyleHsp" style=""></span>h point&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>&#41;&#46; The ideal cut point to characterize the deformity is still under discussion&#44; although values &#62;60&#176; improve significantly the effectiveness for identification purposes of the prominences clinically associated with FAI&#46;<a class="elsevierStyleCrossRef" href="#bib0550"><span class="elsevierStyleSup">48</span></a> In any case&#44; the alpha angle is hard to measure&#44;<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">39</span></a> it cannot be estimated subjectively and it is influenced by several geometric factors&#46; Measuring the Eijer ratio is also difficult because the distances assessed are small&#46;<a class="elsevierStyleCrossRef" href="#bib0585"><span class="elsevierStyleSup">55</span></a> For all the above&#44; it is recommended to combine the quantitative and qualitative criteria&#46;</p><elsevierMultimedia ident="fig0030"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">During the last few years new quantitative parameters or modifications from the existing ones have been proposed&#46; In the coronal plane&#44; the triangular index stands out&#44; too complex to be used clinically &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>C&#41;&#46; The anatomical alpha angle has been proposed for the axial plane&#44; which takes into account epiphyseal retroversion on tracing the reference lines &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>B&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0585"><span class="elsevierStyleSup">55</span></a> The beta angle&#44; measured in 90&#176; Dunn projection&#44; assesses the relation of sphericity deficit with the anterior acetabular lip &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>A&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0590"><span class="elsevierStyleSup">56&#44;57</span></a> The angle of torsion specifically quantifies epiphyseal retroversion with respect to the axis of the femoral neck with higher values in the cam type deformity associated with FAI<a class="elsevierStyleCrossRef" href="#bib0545"><span class="elsevierStyleSup">47</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>C&#41;&#46; On the other hand&#44; femoral neck anteversion with respect to the posterior bicondylar line shows significantly lower values in patients with cam type FAI than in patients suffering from pincer type FAI&#46;<a class="elsevierStyleCrossRef" href="#bib0560"><span class="elsevierStyleSup">50</span></a> The profusion of new indexes&#44; angles and measurements in recent publications seem to reflect not only the limitations of the original criteria&#44; but also the deformity&#39;s intrinsic variability&#46; In this same line some authors suggest that the cam type deformity is much more than just a protuberance&#46; According to this view&#44; the deformity would entail a multiplicity of dimorphic traits&#44; including large&#44; spheroid femoral head&#44; broad&#44; short femoral neck&#44; increase of the head&#8211;neck ratio&#44; decrease of the anterior and posterior offset and occasional epiphyseal retroversion&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">13</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">MDCT allows us to study cam type deformities quantitatively and qualitatively&#46; It discriminates between cam type deformities with anterior prominence as a predominating feature &#40;<a class="elsevierStyleCrossRef" href="#fig0035">Fig&#46; 7</a>&#41; and those with a more flat profile &#40;<a class="elsevierStyleCrossRef" href="#fig0040">Fig&#46; 8</a>&#41;&#46; Also it shows the lateral extension of the joint surface&#44; whose outer limit often surpasses the fissure line &#40;<a class="elsevierStyleCrossRefs" href="#fig0035">Figs&#46; 7 and 8</a>&#41;&#46; MDCT&#39;s quantitative study options include densitometries&#46; In cam type deformities&#44; an increase of underlying trabecular bone density has been demonstrated which presupposes an increase in subchondral rigidity that can accelerate chondral degeneration&#46;<a class="elsevierStyleCrossRef" href="#bib0605"><span class="elsevierStyleSup">59</span></a></p><elsevierMultimedia ident="fig0035"></elsevierMultimedia><elsevierMultimedia ident="fig0040"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">Cam type deformities are highly prevalent in asymptomatic individuals&#46; In fact the overlapping of alpha angles in asymptomatic individuals and in FAI patients has spurred scientific controversy&#44;<a class="elsevierStyleCrossRefs" href="#bib0370"><span class="elsevierStyleSup">12&#44;18&#44;35&#44;42&#44;44&#44;45&#44;48&#44;52&#44;54</span></a> moderate skepticism<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">41</span></a> and sarcastic opinions&#46;<a class="elsevierStyleCrossRef" href="#bib0575"><span class="elsevierStyleSup">53</span></a> For the advocates of the FAI concept&#44; we are talking about predisposed individuals that may require specialized orthopedic attention&#46;<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">27</span></a> For the most reticent ones&#44; the broad angle overlapping between cases and controls could question the theoretical pillars of FAI&#46;<a class="elsevierStyleCrossRef" href="#bib0575"><span class="elsevierStyleSup">53</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Cam type deformities are more prevalent among males&#44; especially in physically active individuals&#46; They are likely to develop before the fissure closure&#44; as an adaptational expression to a repeated mechanical overload&#46;<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">28</span></a> Many authors claim that the deformity results from a clinically silent epiphysiolysis&#44;<a class="elsevierStyleCrossRefs" href="#bib0325"><span class="elsevierStyleSup">3&#44;51</span></a> although this has not been entirely verified and it can occur only in a small proportion of the cases&#46; Cam type deformities can also have a racial and genetic component&#46;<a class="elsevierStyleCrossRef" href="#bib0525"><span class="elsevierStyleSup">43</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Recent publications suggest that the deformity has multiple causes&#44; and the patient&#39;s age&#44; sex&#44; bodily habits&#44; exercises and evolutionary patterns&#44; among other factors are influential&#46;<a class="elsevierStyleCrossRef" href="#bib0540"><span class="elsevierStyleSup">46</span></a> The deformity can be sub-categorized into&#58; &#40;a&#41; primary&#59; &#40;b&#41; secondary to development&#44; related to epiphysiolysis&#44; Perthes&#8217; disease and interventional congenital hip dysplasia&#44; and &#40;c&#41; acquired&#8211;Identified with remodeling associated with hip arthrosis&#44; post-traumatic deformity or a previous osteotomy&#46;<a class="elsevierStyleCrossRef" href="#bib0540"><span class="elsevierStyleSup">46</span></a> Therefore&#44; cam type deformities can cause and also be the consequence of arthrosis&#46;<a class="elsevierStyleCrossRef" href="#bib0610"><span class="elsevierStyleSup">60</span></a> And it can be secondary to epiphysiolysis or have nothing to do with it&#46; There seem to be several types of deformity&#46; But if that is the case&#44; maybe not all of them cause FAI and then it would be necessary to discriminate them with renewed criteria&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Proximal femur variations in osteological medical literature</span><p id="par0075" class="elsevierStylePara elsevierViewall">The osteological medical literature contains a large variety of descriptive terms for the proximal femur&#44; many of which have fallen into disuse&#46;<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">5&#8211;9</span></a> The three basic forms described by anatomists and anthropologists are Poirier&#39;s accessory facet&#44; Angel&#39;s reactive plate and Allen&#39;s cervical fossa&#44; with a variable expression in the anterior&#8211;posterior and lateral or axial planes &#40;<a class="elsevierStyleCrossRef" href="#fig0045">Fig&#46; 9</a>&#41;&#46;</p><elsevierMultimedia ident="fig0045"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">In the anterior&#8211;posterior plane&#44; the distinction between Poirier&#39;s accessory facet and Angel&#39;s reactive plate is based on its outer contour&#59; being a priori the facet more circumscribed &#40;<a class="elsevierStyleCrossRef" href="#fig0045">Fig&#46; 9</a>A&#41; and the plate more extensive and lateral &#40;<a class="elsevierStyleCrossRef" href="#fig0045">Fig&#46; 9</a>B&#41;&#46; When loss of superior offset is associated &#40;<a class="elsevierStyleCrossRef" href="#fig0045">Fig&#46; 9</a>C&#41;&#44; the variant is similar to the cam type deformity&#46; Systematization in the lateral or axial plane distinguishes between concave or non-elevated &#40;<a class="elsevierStyleCrossRef" href="#fig0045">Fig&#46; 9</a>D&#41;&#44; flat &#40;<a class="elsevierStyleCrossRef" href="#fig0045">Fig&#46; 9</a>E&#41; and prominent variants &#40;<a class="elsevierStyleCrossRef" href="#fig0045">Fig&#46; 9</a>F&#41; being the prominent variant closer to cam type morphology&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Poirier&#39;s accessory facet was defined as a lateral extension of the epiphysis towards the anterosuperior region of the neck &#40;<a class="elsevierStyleCrossRef" href="#fig0045">Fig&#46; 9</a>A&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">5&#8211;9</span></a> It is usually covered by hyaline cartilage&#46; Its prevalence is unknown because the data published are inconsistent&#46;<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">5&#44;9</span></a> The accessory facet has a smooth contour&#44; with a profile continuing to the joint surface of the epiphysis in the femoral neck region without apparent transition&#46; It can present a triangular or oval configuration&#44; and it can be hard to identify when it coexists with other variations or degenerative changes&#46; When described like this the facet can correspond to the classical cam type deformity &#40;<a class="elsevierStyleCrossRefs" href="#fig0015">Figs&#46; 3A&#44;D and 7</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0350"><span class="elsevierStyleSup">8&#44;9</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Angel&#39;s reactive plate&#44; a fairly more recent concept than that of accessory facet&#44; introduces the idea of adaptational or occupational trait&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">5</span></a> It is identified in up to 87&#37; of the specimens&#46; It is more prevalent among males&#44; especially in elderly males&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">9</span></a> The reactive plate extends more laterally and inferiorly than Poirier&#39;s facet &#40;<a class="elsevierStyleCrossRef" href="#fig0045">Fig&#46; 9</a>B&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">5&#44;8&#44;9</span></a> It can be covered by fibrocartilage<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">5</span></a> and it often presents sclerosis and cortical irregularity of a variable-profile &#40;<a class="elsevierStyleCrossRef" href="#fig0045">Fig&#46; 9</a>D&#8211;F&#41;&#46; In MDCT&#44; the reactive plate often adopts a slightly sclerotic appearance not elevated or associated with a minimal decrease of the anterior offset &#40;<a class="elsevierStyleCrossRef" href="#fig0050">Fig&#46; 10</a>&#41;&#46; When the reactive plate is prominent&#44; it can be similar to the accessory facet&#46; In fact&#44; they can both reflect variable degrees of the same phenomenon&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">9</span></a> On the other hand&#44; MDCT allows us to compare reactive plates in individuals of different ages &#40;<a class="elsevierStyleCrossRef" href="#fig0055">Fig&#46; 11</a>&#41;&#46; The prominent plate&#44; frequent in old age&#44; seems to exaggerate a superficial trait that is present in the early decades of life&#46;</p><elsevierMultimedia ident="fig0050"></elsevierMultimedia><elsevierMultimedia ident="fig0055"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">The outer contour of the reactive area can be outlined by an osseous lip or crest<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">5&#8211;9</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0045">Fig&#46; 9</a>D&#8211;F&#41; which is generally easy to identify with MDCT &#40;<a class="elsevierStyleCrossRef" href="#fig0055">Fig&#46; 11</a>&#41;&#46; When the crest is prominent&#44; the plate takes on an excavated appearance &#40;fossa&#41;&#46; Also the plate can present a patent aspect in dry cadaver specimens<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">9</span></a> possibly unnoticed in MDCT&#46; In its extreme version&#44; cortical patency also transforms into cervical fossa&#46;<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">5&#8211;9</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Some cortical pores in the reactive area communicate with a small juxtacortical cyst&#44; known as <span class="elsevierStyleItalic">herniation pit</span>&#46;<a class="elsevierStyleCrossRefs" href="#bib0600"><span class="elsevierStyleSup">58&#44;61</span></a> Such a cyst&#8211;a concept of radiological origins is recognizable by its radio-lucid appearance with sclerotic edges&#46; Its prevalence ranges between 5 and 12&#37;&#46; Its meaning is controversial&#44; and it can represent a synovial hernia or an intraosseous ganglion&#46; Similar fibrocystic changes have been found in 33&#37; of FAI patients&#44;<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">23</span></a> although its relevance as FAI radiographic markers is still under discussion&#46; In any case&#44; the <span class="elsevierStyleItalic">pits</span> often appear closely related to the reactive plate focused on the utmost superior and medial margins of the femoral neck &#40;<a class="elsevierStyleCrossRef" href="#fig0060">Fig&#46; 12</a>&#41;&#46;</p><elsevierMultimedia ident="fig0060"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">Most authors talk about the existence of a direct relation between these skeletal variants of the proximal femur and habits associated with exercise or rest&#46; It is hypothesized that there is a repetitive friction of the femoral neck with contiguous soft tissue structures&#44; such as lower fasciculus of the iliofemoral capsular ligament<a class="elsevierStyleCrossRef" href="#bib0620"><span class="elsevierStyleSup">62</span></a> or the psoas tendon&#46;<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">5&#8211;9</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusions</span><p id="par0110" class="elsevierStylePara elsevierViewall">Cam type deformities can have 3 basic configurations&#58; prominent&#44; flat and with epiphyseal retroversion&#46; On the other hand&#44; the variants described in descriptive osteology are summarized in 2&#58; Poirier&#39;s accessory facet &#40;<a class="elsevierStyleCrossRef" href="#fig0065">Fig&#46; 13</a>&#41; and Angel&#39;s reactive plate &#40;<a class="elsevierStyleCrossRef" href="#fig0070">Fig&#46; 14</a>&#41;&#46; The accessory facet is equivalent to the classical cam type deformity&#46;<a class="elsevierStyleCrossRefs" href="#bib0350"><span class="elsevierStyleSup">8&#44;9</span></a> However&#44; the facet and the plate can look like each other&#44; and they can be associated to crests&#44; fossas&#44; pores and <span class="elsevierStyleItalic">pits</span>&#46; As a matter of fact we do not know if the accessory facet and the reactive plate are different entities or extreme versions of a continuous spectrum of variability that is still far from being fully understood&#46;</p><elsevierMultimedia ident="fig0065"></elsevierMultimedia><elsevierMultimedia ident="fig0070"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Ethical responsibilities</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Protection of people and animals</span><p id="par0115" class="elsevierStylePara elsevierViewall">Authors confirm that no experiments have been performed on human beings or animals&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Data confidentiality</span><p id="par0120" class="elsevierStylePara elsevierViewall">Authors confirm that the protocols of their institution have been followed on the publication of data from patients&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Right to privacy and informed consent</span><p id="par0125" class="elsevierStylePara elsevierViewall">Authors declare that in this article no data from patients have been published&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Authors</span><p id="par0130" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0135" class="elsevierStylePara elsevierViewall">Manager of the integrity of the study&#58; JMM&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0140" class="elsevierStylePara elsevierViewall">Original idea of the Study&#58; NR&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</span><p id="par0145" class="elsevierStylePara elsevierViewall">Study design&#58; JMM&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4&#46;</span><p id="par0150" class="elsevierStylePara elsevierViewall">Data mining&#58; JMM&#44; NR&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5&#46;</span><p id="par0155" class="elsevierStylePara elsevierViewall">Data analysis and interpretation&#58; JMM&#44; NR&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">6&#46;</span><p id="par0160" class="elsevierStylePara elsevierViewall">Statistical analysis&#58; N&#47;A&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">7&#46;</span><p id="par0165" class="elsevierStylePara elsevierViewall">Reference search&#58; JMM&#44; NR&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">8&#46;</span><p id="par0170" class="elsevierStylePara elsevierViewall">Writing&#58; JMM&#44; NR&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">9&#46;</span><p id="par0175" class="elsevierStylePara elsevierViewall">Critical review of the manuscript with intellectually relevant remarks&#58; JMM&#44; NR&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">10&#46;</span><p id="par0180" class="elsevierStylePara elsevierViewall">Approval of final version&#58; JMM&#44; NR&#46;</p></li></ul></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conflict of interests</span><p id="par0185" class="elsevierStylePara elsevierViewall">Authors declared no conflicts of interests&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
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        0 => array:3 [
          "identificador" => "xres490312"
          "titulo" => "Abstract"
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              "identificador" => "abst0005"
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          "identificador" => "xpalclavsec512385"
          "titulo" => "Keywords"
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          "titulo" => "Resumen"
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          "titulo" => "Palabras clave"
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        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
        ]
        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Cam-type deformities in orthopedic and radiologic medical literature"
        ]
        6 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Proximal femur variations in osteological medical literature"
        ]
        7 => array:2 [
          "identificador" => "sec0020"
          "titulo" => "Conclusions"
        ]
        8 => array:3 [
          "identificador" => "sec0025"
          "titulo" => "Ethical responsibilities"
          "secciones" => array:3 [
            0 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Protection of people and animals"
            ]
            1 => array:2 [
              "identificador" => "sec0035"
              "titulo" => "Data confidentiality"
            ]
            2 => array:2 [
              "identificador" => "sec0040"
              "titulo" => "Right to privacy and informed consent"
            ]
          ]
        ]
        9 => array:2 [
          "identificador" => "sec0045"
          "titulo" => "Authors"
        ]
        10 => array:2 [
          "identificador" => "sec0050"
          "titulo" => "Conflict of interests"
        ]
        11 => array:2 [
          "identificador" => "xack155074"
          "titulo" => "Acknowledgement"
        ]
        12 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2014-06-04"
    "fechaAceptado" => "2014-11-03"
    "PalabrasClave" => array:2 [
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec512385"
          "palabras" => array:5 [
            0 => "Anatomic variants"
            1 => "Multidetector computed tomography"
            2 => "Magnetic resonance imaging"
            3 => "Femur"
            4 => "Femoroacetabular impingement"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec512384"
          "palabras" => array:5 [
            0 => "Variantes anat&#243;micas"
            1 => "Tomograf&#237;a computarizada multidetector"
            2 => "Resonancia magn&#233;tica"
            3 => "F&#233;mur"
            4 => "Choque femoroacetabular"
          ]
        ]
      ]
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      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Interpreting imaging studies of a painful hip requires detailed knowledge of the regional anatomy&#46; Some variants of the proximal femur&#44; such as cam-type deformities&#44; can course asymptomatically or cause femoroacetabular impingement&#46; The principal numerical criterion for defining cam-type deformities&#44; the alpha angle&#44; has some limitations&#46; In this article&#44; we review the anatomic variants of the anterior aspect of the proximal femur&#44; focusing on cam-type deformities&#46; Using diagrams and multidetector CT images&#44; we describe the parameters that are useful for characterizing these deformities in different imaging techniques&#46; We also discuss the potential correspondence of imaging findings of cam-type deformities with the terms coined by anatomists and anthropologists to describe these phenomena&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Para interpretar correctamente los estudios radiol&#243;gicos de una cadera dolorosa se requiere conocer detalladamente la anatom&#237;a regional&#46; Algunas variantes del f&#233;mur proximal&#44; como las deformidades tipo <span class="elsevierStyleItalic">cam</span>&#44; pueden cursar de forma asintom&#225;tica o causar un s&#237;ndrome de choque femoroacetabular&#46; El &#225;ngulo alfa&#44; principal exponente num&#233;rico de estas deformidades&#44; tiene algunas limitaciones&#46; Nuestro objetivo es revisar las variantes anat&#243;micas en la vertiente anterior del f&#233;mur proximal&#44; centrando la atenci&#243;n en las deformidades tipo <span class="elsevierStyleItalic">cam</span>&#46; Describimos los par&#225;metros &#250;tiles para caracterizarla con m&#233;todos de imagen&#44; utilizando diagramas e im&#225;genes de tomograf&#237;a computarizada multidetector&#46; Exponemos adem&#225;s la correspondencia potencial de las deformidades tipo <span class="elsevierStyleItalic">cam</span> con t&#233;rminos descriptivos previamente acu&#241;ados por anatomistas y antrop&#243;logos&#46;</p></span>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Mellado JM&#44; Radi N&#46; Deformidades tipo <span class="elsevierStyleItalic">cam</span>&#58; conceptos&#44; criterios y apariencia en TC multidetector&#46; Radiolog&#237;a&#46; 2015&#59;57&#58;213&#8211;224&#46;</p>"
      ]
    ]
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Cam type femoral acetabular impingement syndrome&#46; 38-year-old man with a positive test for right hip FAI&#46; &#40;A&#41; Right hip anterior&#8211;posterior X-ray showing alteration of epiphyseal sphericity&#44; with lateral flattening &#40;yellow arrow&#41;&#44; lateral prolongation fissure scar &#40;arrow head&#41; and cervical prominence with loss of head&#8211;neck superior offset &#40;blue arrow&#41;&#46; &#40;B&#41; The axial X-ray shows the characteristic prominence of the anterior&#8211;superior femoral neck &#40;red arrow&#41; with anterior offset loss&#46; The reader can see this figure in color in the electronic version of the article&#46;</p>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Cam type femoral acetabular impingement syndrome&#46; 49-year-old man with a positive impingement test&#46; Right hip MRI &#40;3D gradient sequence&#41; in oblique coronal &#40;A&#41;&#44; oblique axial &#40;B&#41; and sagittal oblique planes &#40;C&#41; showing cam type deformity &#40;red arrow&#41;&#44; contiguous to the lower iliofemoral ligament band &#40;yellow arrow&#41;&#59; anterior&#8211;superior chondral thinning &#40;green arrow&#41;&#59; signal alteration of anterior-lateral acetabular notch &#40;blue arrow&#41;&#59; and small geodes in the acetabular margin&#46; The reader can see this figure in color in the electronic version of the article&#46;</p>"
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Basic modalities of cam type deformity&#46; On the anterior&#8211;posterior plane&#44; &#40;A&#41; focal prominence&#59; &#40;B&#41; diffuse prominence with decrease of superior offset&#44; and &#40;C&#41; superior offset loss&#44; substituted by a convex profile &#40;pistol grip deformity&#41;&#46; On the axial plane&#44; &#40;D&#41; focal prominence without offset loss&#59; &#40;E&#41; offset loss without focal prominence &#40;nearly flat contour&#44; sometimes with a crest and medial depression&#41;&#44; and &#40;F&#41; anterior convexity diffuse prominence&#44; with epiphyseal retroversion&#46;</p>"
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Characterization of cam type deformity in an anterior&#8211;posterior projection&#46; &#40;A&#41; Alpha angle&#46; &#40;B&#41; Murray&#39;s ratio <span class="elsevierStyleItalic">a</span>&#47;<span class="elsevierStyleItalic">b</span> and neck&#47;head ratio <span class="elsevierStyleItalic">c</span>&#47;<span class="elsevierStyleItalic">d</span>&#46; &#40;C&#41; Triangular index&#44; where <span class="elsevierStyleItalic">e</span> is the short radius&#44; <span class="elsevierStyleItalic">f</span> is half the short radius&#44; <span class="elsevierStyleItalic">g</span> is perpendicular to <span class="elsevierStyleItalic">f</span>&#44; and <span class="elsevierStyleItalic">h</span> is calculated through Pythagoras&#8217; theorem&#46; When in an anterior&#8211;posterior X-ray &#40;magnification<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>1&#46;2&#41; the long radius <span class="elsevierStyleItalic">h</span> is greater than or equal to the short radius <span class="elsevierStyleItalic">e</span> plus 2&#44; we usually speak of femoral asphericity&#46; &#40;D&#41; Neck length of <span class="elsevierStyleItalic">i</span>&#59; depth of superior <span class="elsevierStyleItalic">j</span> and inferior offset <span class="elsevierStyleItalic">k</span>&#46;</p>"
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Characterization of a cam type deformity in an axial projection&#46; &#40;A&#41; N&#246;tzli&#39;s alpha angle and Wyss&#8217; beta angle&#46; &#40;B&#41; Bouma&#39;s anatomical alpha angle &#40;&#945;a&#41; and posterior displacement of epiphyseal center <span class="elsevierStyleItalic">a</span>&#46; &#40;C&#41; Epiphyseal torsion angle&#46; &#40;D&#41; Lateral &#40;<span class="elsevierStyleItalic">b</span>&#41; and posterior &#40;<span class="elsevierStyleItalic">c</span>&#41; extension of anterior epiphysis&#46; Depth of anterior <span class="elsevierStyleItalic">d</span> and posterior <span class="elsevierStyleItalic">e</span> offset and Eijer&#39;s ratio <span class="elsevierStyleItalic">d</span>&#47;<span class="elsevierStyleItalic">f</span>&#46;</p>"
        ]
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        "descripcion" => array:1 [
          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">&#40;A and B&#41; Characterization of a cam type deformity on radial planes&#46; The measurement of the alpha angle can be obtained on the oblique axial plane with a 3&#58;00<span class="elsevierStyleHsp" style=""></span>h orientation &#40;blue line&#41; though the plane with 1&#58;30 radial orientation &#40;red line&#41;&#44; equivalent to 45&#176; better discriminates those patients with FAI patients&#46;<a class="elsevierStyleCrossRef" href="#bib0560"><span class="elsevierStyleSup">50</span></a> The reader can see this figure in color in the electronic version of the article&#46;</p>"
        ]
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Cam type deformity &#40;prominent&#41;&#46; 53-year-old asymptomatic man&#46; MDCT with 3D reconstructions &#40;A&#41; anterior&#8211;posterior&#44; &#40;B&#41; oblique anterior&#8211;posterior and &#40;C&#41; cranio-caudal reconstructions&#44; followed by &#40;D&#41; axial oblique multiplane reconstruction&#46; Prominent cam type deformity with convex contour and regular surface&#44; whose external limit &#40;red arrow&#41; extends the lateral contour of the epiphysis yet it is far from the fissure scar &#40;green arrow&#41;&#46; The reader can see this figure in color in the electronic version of the article&#46;</p>"
        ]
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        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Cam type deformity &#40;flat&#41;&#46; 49-year-old asymptomatic man&#46; MDCT with 3D reconstructions&#46; &#40;A&#41; Anterior&#8211;posterior&#44; &#40;B&#41; oblique anterior&#8211;posterior and &#40;C&#41; cranio-caudal reconstructions followed by &#40;D&#41; axial oblique multiplane reconstruction&#46; Cam type deformity with predominantly flat contours&#44; with erased anterior offset and small medial depression &#40;blue arrow&#41;&#46; The outer limits of the deformity &#40;red arrow&#41; extends the lateral contour of the epiphysis yet it is far from the fissure scar &#40;green arrow&#41;&#46; The reader can see this figure in color in the electronic version of the article&#46;</p>"
        ]
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        "etiqueta" => "Figure 9"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
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        "figura" => array:1 [
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            "imagen" => "gr9.jpeg"
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Variability of the anterior facet of the proximal femur based on the existing osteological medical literature&#46; On the anterior&#8211;posterior plane&#44; &#40;A&#41; Poirier&#39;s accessory facet&#59; &#40;B&#41; Angel&#39;s reactive plate&#44; and &#40;C&#41; facet or plate with superior offset loss&#44; similar to cam type deformity&#46; On the axial plane&#44; &#40;D&#41; not-elevated Angel&#39;s reactive plate&#44; with crest &#40;lateral&#41; and fossa &#40;medial&#41;&#59; &#40;E&#41; flat reactive plate&#44; with crest &#40;lateral&#41; and <span class="elsevierStyleItalic">herniation pit</span> &#40;medial&#41;&#44; and &#40;F&#41; prominent plate or facet&#44; similar to the cam type deformity&#46;</p>"
        ]
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      9 => array:7 [
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        "etiqueta" => "Figure 10"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
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        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Reactive plate&#46; 40-year-old asymptomatic man&#46; MDCT with 3D reconstructions&#46; &#40;A&#41; Anterior&#8211;posterior&#44; &#40;B&#41; oblique anterior&#8211;posterior and &#40;C&#41; oblique axial&#44; and &#40;D&#41; multiplane axial oblique reconstructions&#46; Slightly sclerotic hardly appreciable reactive area&#46; The plate&#39;s external limit &#40;red arrow&#41; is far from the fissure scar &#40;green arrow&#41;&#46; The reader can see this figure in color in the electronic version of the article&#46;</p>"
        ]
      ]
      10 => array:7 [
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        "etiqueta" => "Figure 11"
        "tipo" => "MULTIMEDIAFIGURA"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Reactive plates in individuals of different ages&#46; &#40;A and B&#41; 58-year-old man&#46; &#40;C and D&#41; 78-year-old man&#46; Both asymptomatic&#46; MDCT with anterior&#8211;posterior 3D &#40;A and C&#41; and multiplane axial oblique reconstructions &#40;B and D&#41;&#46; Reactive plates with flat profile &#40;A and B&#41; and convex profile &#40;C and D&#41; &#40;arrows&#41;&#46;</p>"
        ]
      ]
      11 => array:7 [
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        "descripcion" => array:1 [
          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Reactive plate and <span class="elsevierStyleItalic">herniation pit</span>&#46; 47-year-old asymptomatic man&#46; MDCT with &#40;A and B&#41; 3D anterior&#8211;posterior and &#40;C&#41; multiplane axial oblique reconstructions&#46; Reactive area with slightly elevated profile &#40;green arrows&#41; and underlying <span class="elsevierStyleItalic">herniation pit</span> &#40;red arrows&#41;&#46; The reader can see this figure in color in the electronic version of the article&#46;</p>"
        ]
      ]
      12 => array:7 [
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          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Cam type deformity&#46; Specimen from the cadaver of a 59 year-old male&#46; Views &#40;A&#41; frontal and &#40;B&#41; cranio-caudal showing a deformity typical of the cam type &#40;between arrows&#41;&#46; Lateral extension of the epiphysis&#44; with a prominent profile&#44; with epiphyseal retroversion and short neck&#46; <span class="elsevierStyleItalic">Source</span>&#58; Identified skeletal collection&#46; La Certosa Cemetery&#46; Museum of Anthropology of the University of Bologna&#46; Bologna&#44; Italy&#46;</p>"
        ]
      ]
      13 => array:7 [
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          "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Reactive plate&#46; Specimen from the cadaver of a 66 year-old male&#46; &#40;A&#41; Frontal and &#40;B&#41; cranio-caudal views showing a reactive plate with concave profile &#40;between arrows&#41;&#46; Preservation of the anterior offset and the epiphyseal sphericity without any indications of retroversion&#46; <span class="elsevierStyleItalic">Source</span>&#58; Identified skeletal collection&#46; La Certosa Cemetery&#46; Museum of Anthropology of the University of Bologna&#46; Bologna&#44; Italy&#46;</p>"
        ]
      ]
      14 => array:7 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Orthopedic and radiologic terminology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Anatomic and anthropologic terminology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Simplified terminology<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">5</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " rowspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Head tilt</span> &#40;Murray&#44; 1965&#41;Pistol grip deformity &#40;Stulberg&#44; 1975&#41;<span class="elsevierStyleItalic">Post-slip</span> &#40;Goodman&#44; 1997&#41;lack of sphericity in the femur head &#40;Ito&#44; 2001&#41;Decrease of the head&#8211;neck offset &#40;Ito&#44; 2001&#41;Increase of the alpha angle &#40;N&#246;tzli&#44; 2002&#41;Lateral epiphyseal extension &#40;Siebenrock&#44; 2004&#41;Head&#8211;neck bulge &#40;J&#228;ger&#44; 2004&#41;Exostosis of femoral neck &#40;Fritz&#44; 2010&#41;Lateral epiphyseal flattening &#40;Laborie&#44; 2011&#41;Posterior epiphyseal displacement &#40;Ellis&#44; 2011&#41;Epiphyseal retrotorsion &#40;Schaeffeler&#44; 2012&#41;</td><td class="td" title="table-entry  " align="left" valign="top">Anterior facet of femoral neck&#40;Parsons&#44; 1914&#41;Alpha-type Poirier facet &#40;Pearson&#44; 1919&#41;Poirier facet &#40;Odgers&#44; 1931&#41;Joint eminence of femoral neck&#40;Meyer&#44; 1934&#41;Cervical torus &#40;Meyer&#44; 1934&#41;Cervical eminence &#40;Kostick&#44; 1963&#41;Anterior bone bar &#40;Angel&#44; 1964&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Accessory facet&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Irregular trace of elevated contour &#40;Bertaux&#44; 1891&#41;Iliac trace &#40;Regnault&#44; 1898&#41;Anterior eminence &#40;Walmsley&#44; 1915&#41;Gamma Poirier&#39;s facet &#40;Pearson&#44; 1919&#41;Irregular elevated facet &#40;Meyer&#44; 1934&#41;Reactive plate &#40;Angel&#44; 1964&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Elevated plate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Bone notch &#40;Poirier&#44; 1911&#41;Capsular crest &#40;Walmsley&#44; 1915&#41;Cervical crest &#40;Meyer&#44; 1934&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Crest&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Herniation pit</span> &#40;Pitt&#44; 1982&#41;Fibrocystic changes &#40;Leunig&#44; 2005&#41;The notch sign &#40;Petchprapa&#44; 2012&#41;</td><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Cervical fossa &#40;Allen&#44; 1882&#41;Irregular depression &#40;Parsons&#44; 1914&#41;Capsular sulcus &#40;Walmsley&#44; 1915&#41;Beta-type Poirirer&#39;s facet &#40;Pearson&#44; 1919&#41;Irregular fossa &#40;Meyer&#44; 1934&#41;Trace &#40;Schofield&#44; 1959&#41;Anterior cervical trace &#40;Kostick&#44; 1963&#41;Allen&#39;s fossa &#40;Angel&#44; 1964&#41;</td><td class="td" title="table-entry  " align="left" valign="top">Excavated plate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Patent variants&#58; pores&#44; erosions&#44; trabecular exposition&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Cam-type deformities&#58; terminology and correspondences&#46;</p>"
        ]
      ]
      15 => array:7 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Parameter&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Orientative reference&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Lateral sphericity deficit&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Lateral epiphyseal prominence &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#41;Lateral epiphyseal flattening &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#41;Lateral physeal extension &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#41;Radiographic alpha angle &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>A&#41;Murray ratio &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>B&#41;Triangular index &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>C&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Exceeds the circumferential morphology<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>2<span class="elsevierStyleHsp" style=""></span>mm<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">36</span></a>Rectifies the usual curved contour<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">45</span></a>The fissure scar extends horizontally towards the femoral neck<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">22</span></a>In controls the reference values are 62&#176; &#40;males&#41; and 52&#176; &#40;females&#41;<a class="elsevierStyleCrossRef" href="#bib0580"><span class="elsevierStyleSup">54</span></a>In epiphysiolysis the cut value is &#62;<span class="elsevierStyleHsp" style=""></span>1&#46;35<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">1</span></a>In <span class="elsevierStyleItalic">cam</span>&#44; long radius<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>short radius<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>2<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">34</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Superior offset decrease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pistol grip deformity &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>C&#41;Depth of superior offset &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>D&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Disappearance of superior offset &#40;convex contour&#41;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">7</span></a>Comparison with inferior offset &#40;less useful than the anterior offset&#41;<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">34</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Other associated traits&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Head&#8211;neck ratio &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>B&#41;Neck length &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>D&#41;Cervical-diaphyseal angle&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">In <span class="elsevierStyleItalic">cam</span>&#44; average value 1&#46;59<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;11&#44; lower than in controls<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">13</span></a>Cut value<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>1&#46;27 associates arthrosis<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">35</span></a>In <span class="elsevierStyleItalic">cam</span>&#44; average value 24&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;9<span class="elsevierStyleHsp" style=""></span>mm &#40;short wide neck<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">13</span></a>In <span class="elsevierStyleItalic">cam</span>&#44; cut value<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>125&#176;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">25</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Characterization of cam type deformity based on anterior&#8211;posterior projections&#46;</p>"
        ]
      ]
      16 => array:7 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Parameter&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Orientative reference&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Anterior sphericity deficit&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Anterior&#8211;superior prominence &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#41;Radiographic alpha angle &#40;Frog axial Rx&#41;Radiographic alpha angle &#40;Lateral Rx&#41;Tomographic alpha angle &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>A&#41;Anatomic alpha angle &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>B&#41;Beta angle &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>A&#41;Lateral epiphyseal extension &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>D&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Exceeds the circumferential contour &#40;&#62;2<span class="elsevierStyleHsp" style=""></span>mm&#41;<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">36</span></a>In controls average value of 47&#176; &#40;males&#41; and 42&#176; &#40;females&#41;<a class="elsevierStyleCrossRef" href="#bib0580"><span class="elsevierStyleSup">54</span></a>In controls average value of 48&#176; &#40;males&#41; and 47&#176; &#40;females&#41; with a reference interval for both genes &#40;95&#37;&#41; of 32&#8211;62&#176;<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">42</span></a>In <span class="elsevierStyleItalic">cam</span>&#44; cut value &#40;at 45&#176;&#41;<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>60&#176;<a class="elsevierStyleCrossRef" href="#bib0550"><span class="elsevierStyleSup">48</span></a>In <span class="elsevierStyleItalic">cam</span>&#44; cut value<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>66&#176;<a class="elsevierStyleCrossRef" href="#bib0585"><span class="elsevierStyleSup">55</span></a>In <span class="elsevierStyleItalic">cam</span>&#44; average value 15&#46;6&#176; &#40;38&#46;7&#176; in controls&#41;<a class="elsevierStyleCrossRef" href="#bib0605"><span class="elsevierStyleSup">59</span></a>In <span class="elsevierStyleItalic">cam</span>&#44; anterior distance exceeds the posterior distance<a class="elsevierStyleCrossRefs" href="#bib0420"><span class="elsevierStyleSup">22&#44;29</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Anterior offset decrease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Depth of the anterior offset &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>D&#41;Radiographic Eijer ratio &#40;Lateral Rx&#41;Tomographic Eijer ratio &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>D&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Comparison with posterior offset &#40;same&#44; lesser or absent&#41;<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">36</span></a>In <span class="elsevierStyleItalic">cam</span>&#44; cut value<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>8<span class="elsevierStyleHsp" style=""></span>mm<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">12</span></a>In controls average value of 0&#46;19&#44;<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">42</span></a> with a reference interval for both genres &#40;95&#37;&#41; of 0&#46;14&#8211;0&#46;24<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">42</span></a>In <span class="elsevierStyleItalic">cam</span>&#44; ratio<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;18<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">19</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Other associated traits&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Posterior epiphyseal displacement &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>B&#41;Epiphyseal retroversion with respect to the neck &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>C&#41;Femoral anteversion with respect to the bicondylar line&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">With clinical significance cut value<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>2<span class="elsevierStyleHsp" style=""></span>mm<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">13</span></a>In <span class="elsevierStyleItalic">cam</span>&#44; cut value &#62;<span class="elsevierStyleHsp" style=""></span>20&#176;<a class="elsevierStyleCrossRef" href="#bib0545"><span class="elsevierStyleSup">47</span></a>Similar values in controls and FAI<a class="elsevierStyleCrossRef" href="#bib0560"><span class="elsevierStyleSup">50</span></a>Lower averages values of <span class="elsevierStyleItalic">cam</span> &#40;10<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9&#41; to those of <span class="elsevierStyleItalic">pincer</span> &#40;18<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&#41;<a class="elsevierStyleCrossRef" href="#bib0560"><span class="elsevierStyleSup">50</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Characterization of cam type deformity base don axial or lateral projections&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:62 [
            0 => array:3 [
              "identificador" => "bib0315"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The aetiology of primary osteoarthritis of the hip"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "R&#46;O&#46; Murray"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1259/0007-1285-38-455-810"
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Radiol"
                        "fecha" => "1965"
                        "volumen" => "38"
                        "paginaInicial" => "810"
                        "paginaFinal" => "824"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/5842578"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0320"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
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Article information

ISSN: 21735107
Original language: English

DOI:10.1016/j.rxeng.2014.11.002

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Year/Month	Html	Pdf	Total

2024 October	1	0	1
2024 July	1	0	1
2024 June	1	0	1
2024 May	1	0	1
2024 March	2	0	2
2023 December	1	0	1
2023 September	1	0	1
2023 August	1	0	1
2023 March	7	2	9
2023 January	1	0	1
2018 May	30	0	30
2018 April	91	9	100
2018 March	73	4	77
2018 February	174	5	179
2018 January	136	5	141
2017 December	191	10	201
2017 November	135	9	144
2017 October	76	8	84
2017 September	63	14	77
2017 August	65	15	80
2017 July	76	11	87
2017 June	119	44	163
2017 May	141	20	161
2017 April	85	19	104
2017 March	103	30	133
2017 February	123	11	134
2017 January	61	7	68
2016 December	78	12	90
2016 November	81	15	96
2016 October	126	21	147
2016 September	68	13	81
2016 August	83	9	92
2016 July	100	3	103
2016 June	105	15	120
2016 May	84	20	104
2016 April	86	19	105
2016 March	99	21	120
2016 February	64	20	84
2016 January	58	16	74
2015 December	33	12	45
2015 November	19	11	30
2015 October	1	0	1
2015 September	0	2	2
2015 July	0	1	1
2015 June	0	3	3
2015 May	2	4	6
2015 April	1	0	1

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