Conflitto femoro-acetabolare

Body:

Il conflitto femoro-acetabolare colpisce in prevalenza maschi giovani-adulti, spesso sportivi, probabilmente perchè l’attività fisica richiede la ripetizione dei gesti responsabili del conflitto e quindi rende sintomatica una condizione che in soggetti sedentari potrebbe rimanere a lungo silente. Da considerare inoltre la possibilità che l’attività sportiva reiterata può comportare degli squilibri o vizzi posturali che sono la causa di squilibri delle forze cinetiche muscolari e pertanto di allterazioni della dinamica articolare. In queste situazioni, soprattutto in soggetti con una precisa predisposizione anatomica si instaurano dei contatti anomali tra le strutture osteo-capsulari capsulo-muscolari.

Il conflitto femoro-acetabolare è caratterizzato dal dolore inguinale e talvolta gluteo, che esordisce in genere in modo subdolo, episodico, dopo uno sforzo fisico (una partita di calcio, una giornata sugli sci).

Dapprima il disturbo viene avvertito solo nei movimenti di flessione e rotazione internadell’anca (ad es. quando si accavallano le gambe o quando ci si piega in avanti da seduti per calzare una scarpa), ma con il tempo esso diventa sempre più frequente, fino a determinare l’abbandono delle attività sportive.

Successivamente il dolore inizia a manifestarsi già con la camminata veloce. Inconsapevolmente il paziente accorcia il passo (per ridurre la flessione dell’anca) e porta la punta del piede verso l’esterno (per evitare la rotazione interna dell’anca). In assenza di trattamento, il paziente giunge in breve alla claudicatio.

Le cause del conflitto femoro-acetabolare sono da ricervare in malformazioni dell’anca che si sviluppano già nelle prime età della vita. Tali malformazioni riducono l’escursione articolare che il femore può eseguire prima di urtare i bordi dell’acetabolo. In altre parole l’anca ammalata entra in conflitto per movimenti di ampiezza “ordinaria”, laddove un anca sana entrerebbe in conflitto solo per gesti estremi, che difficilmente vengono richiesti anche nelle attività più impegnative.

Il conflitto prende il nome di pincer FAI (figura sottostante), ovvero di conflitto a “tenaglia”, quando la causa è un acetabolo troppo coprente, ovvero che avvolge eccessivamente la testa femorale, limitandone il movimento come nel disegno sottostante:

Il conflitto viene invece definito cam FAI (fig sottostante), ovvero conflitto a “camma”, quando la causa è una testa femorale non perfettamente sferica, che provoca una vera e propria abrasione del cotile quando la porzione asferica entra nel gioco articolare, come sotto rappresentato:

Il labbro acetabolare, sorta di “guarnizione” che riveste il bordo osseo dell’acetabolo, è ovviamente la prima struttura che viene logorata da questo meccanismo.

La diagnosi di FAI (e soprattutto la sua classificazione) può essere correttamente eseguita già sulla base di una radiografia standard: essa permette di identificare i segni tipici del cam FAI (deformità asferica della testa femorale) e del pincer FAI (cotile retroverso o coxa profunda).

Ecco un esempio di cam FAI, dove viene indicato lo sperone cefalico che si discosta dal profilo sferico ideale (punteggiato):

…e un esempio di pincer FAI, nella fattispecie un esempio di acetabolo troppo profondo (coxa profunda), che limita l’arco di movimento (in rosso) per conflitto tra il bordo acetabolare (tratteggiato) e il collo femorale:

Accertata l’esistenza di una sindrome conflittuale, è possibile ricorrere ad esami più specifici (TAC, artro-RMN), che hanno un reale significato per confermare la patologia, per evidenziare il grado di sofferenza articolare , per la pianificazione dell’eventuale  intervento chirurgico correttivo.
Valutazione con Risonanza Magnetica

Oltre a dimostrare le anomalie strutturali ossee visibili sulle radiografie come sopra descritto, tra cui deformità di tipo cam, copertura acetabolare o retroversione acetabolare, la risonanza magnetica (o artrografia RM) consente una migliore visualizzazione delle lesioni antero-superiori e fornisce un’importante valutazione per lacrime labrali e ialina perdita di cartilagine.

La valutazione della risonanza magnetica è diretta a cause di impingement sia femorali che acetabolari. Il femore prossimale deve essere esaminato su più piani di imaging con particolare attenzione agli aspetti anteriore e anterosuperiore della giunzione testa-collo del femore.

Una o più caratteristiche (che spesso coesistono) sono ricercate per identificare una deformità di tipo a camma:

  • protuberanza ossea focale o protuberanza nella parte anteriore o anterosuperiore della giunzione testa-collo femorale
  • testa femorale asferica in corrispondenza della giunzione testa-collo del femore (come un margine della testa del femore laterale appiattito)
  • riduzione dell’offset del collo della testa del femore (noto anche come “deficit della vita del femore” o “deformità dell’impugnatura della pistola” se osservato su immagini coronali).

Inoltre, piccole cisti nella giunzione testa-collo femorale sono un utile indicatore del FAI. Sono stati trovati nel 33% dei pazienti con FAI 13 e c’è un’alta probabilità di una relazione causale.

Altro esempio: particolare di una radiografia del bacino in anteroposteriore vera che mostra un retroversione acetabolare con “crossover sign” e cioè l’incrociarsi dei margini acetabolari anteriore e posteriore. In basso a sinistra e destra all’esame TC si evidenziano anomalie delle misurazione della retroversione acetabolare e dell’angolo alfa.

RETROVERSIONE ACETABOLARE

Si calcola sulle immagini assiali RM o TC valutando l’angolo tra la linea orizzontale che unisce i

ANGOLO ALFA

Viene calcolato sia in TC che in RM su un piano di scansione assiale obliquo tracciato sul piano coronale seguendo l’asse del collo femorale (fig in basso a sinistra). Su questo piano si calcola l’angolo formato dalla linea centrale dell’asse del collo femorale e la linea che lo interseca unendo il primo punto che sul profilo anteriore supera il contorno dell’ipotetico cerchio della testa femorale, il quale rappresenta il potenziale bump o cam della testa. Normalmente l’angolo alfa è minore di 55 gradi. Quando è minore indica potenziale condizione predisponente all’impingement.

OFFSET FEMORALE

E’ la distanza tra 2 linee parallele tracciate lungo il profilo più prominete anteriore della testa femorale ed il profilo corticale anteriore del collo femorale. Si puo ottenere oltre che in TC e RM anche da una corretta proiezione radiografica (CROSS-TABLE O ASSIALE VERA DELL’ANCA o proiezione di Dunn a 90 gradi; vedi articolo relativo alle proiezioni dell’anca).

Considerazione personale:

L’impingement femoro-acetabolare è quasi sempre una condizione predisponente all’artrosi dell’anca ma negli sportivi assume maggior importanza clinica in quanto limita la prestazione sportiva. I rilievi che nascono dalla Diagnostica per Immagini richiedono sempre un’attenta correlazione clinica in quanto in alcuni casi sono riscontrati in pazienti asintomatici. Vanno peratanto escluse con certezza altre patologie o condizioni associate. Attualmente viene spesso proposta la soluzione artroscopica che deve assolutamente essere proposta in casi selezionati. Glie esami radiografici e di secondo livello (RM e TC) vanno eseguiti da esperti radiologici del settore perche se mal eseguiti possono essere mal interpretati.

Qualsiasi esame per immagini deve essere esclusivamente richiesto con specifica motivazione dello specialista ortopedico ed inviato al radiologo di riferimento.

a cura di Sergio De Bac

ad breath is a deal breaker both in business and in personal life of ours. And while breath fresheners or candies hide it, they do not cure the very problem at hand…

So, most importantly, the bad breath is caused by a lack of oral hygiene. It includes sleeping with an open mouth at night. This makes mouth dry and bacterias began to flourish there and cause that smell…

Bad breath has a medical name “halitosis”. This kind of condition can stem from poor oral hygiene habits. It also may be a telling sign of other health problems. What you’re eating can cause this disease to progress much faster. So how healthy your menu is directly correlated with any oral hygiene problems.

So, how your diet and dishes choice affects the smell of your breath?

Essentially, everything you’re consuming begins to be broken down into parts in your mouth. As dishes are digested and absorbed into the blood system, foods eventually get carried to your lungs. Then it reveals in your breath. This is even more true in case you like foods with strong odors (such as garlic or onions). Then teeth brushing and flossing, even mouthwash and any other breath freshening liquids are redundant. They merely disguise that kind of odor temporarily. The odor will not go away completely until the foods have passed through your body completely…

How damaging abundant amount of sugar is for your teeth health?

John Doe
Which poor oral hygiene habits lead to the bad breath?

First off, ask yourself do you regularly follow basic oral hygiene routines? This, of course, includes such morning musts as brushing your teeth twice a day. Keep in mind, that each brushing should be lasting for at least 5 minutes. It’s not limited to that. Teeth flossing after each eating is also strongly recommended. Because when you eat and don’t follow these methods, food particles stay in your mouth. They get stuck in between the teeth, on gums and the tongue. Then it decays and absorbs there, causing various oral bacteria to flourish. All this results in a bad breath. Antibacterial mouth rinsers, instead of simple breath fresheners, may be of a big help here.

It will not simply disguise the smell by replacing it with a nicer aroma. These antibacterial mouth rinsers will eventually fight off and kick out the bacteria from your mouth. As well as off the teeth, gums and tongue.

To add to that you must keep an especially attentive eye on your dentures, if you have any. They are critically vulnerable towards the odor-causing bacteria. If the dentures are not cleaned properly, and even more importantly, regularly, it will get covered with invisible bacteria. This will be causing bad smells, that will be obvious to absolutely everyone around. There’s also no better way to hazard you oral hygiene and health than smoking or chewing tobacco. Besides irritating the sensitive gums and making teeth yellow, this makes the bacterias prosper. It adds up to a smell too…

 Are there any specific health issues that are connected to a bad breath?

Such a thing as the periodontal disease may be an essential cause of the bad breath. So if smell and unpleasant taste in your mouth are a lasting issue, you’d better check with your dentist. Specifically on the matter of whether you have periodontal disease or not. Gum disease is caused by the appearance of plaque on teeth. Bacteria cause the formation of toxins to form, which irritate the gums and enamel. If such a gum disease carries on without any treatment to it provided, it can damage the gums and jawbone. Other dental causes of bad breath include poorly fitting dental appliances, yeast infections of the mouth, and denta

The medical condition of the dry mouth (also called xerostomia) also can cause a bad smell. Saliva is necessary to moisten the mouth. It neutralizes acids produced by plaque and piles away the dead cells off the tongue, gums, and cheeks’ insides. If not removed, these cells begin to decay and can cause bad breath. Dry mouth may be a side effect of various medications. Also salivary gland problems or breathing with your mouth open can be an additional cause. Many other general diseases and illnesses may cause bad breath. Here are some to be aware of: respiratory tract infections such as pneumonia or bronchitis, chronic sinus infections, postnasal drip, diabetes, chronic acid reflux, and liver or kidney problems.

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