EP4.2 Femoral Head Divot - A Sign of Instability or Impingement?

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ID: 331150
2026
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Abstract
Abstract The femoral head divot is a rare radiographic finding in young adults with hip pain. While previous reports have hypothesized association with instability, there is limited literature describing the epidemiology and etiology of this feature. The purpose of this study was to describe the incidence of the femoral head divot, its topographical location on the femoral head, and likely etiology accounting for radiological characteristics and modelling. This is a retrospective, consecutive, multi-surgeon, cohort study from a tertiary referral centre. All patients reviewed in a hip preservation clinic between 2021 and 2025 were included. Exclusion criteria were age <18 or >55, no pre-operative CT, and previous hip surgery. Radiographic parameters were measured using standardized X-rays (LCEA, AI, AWI, PWI, crossover sign/ratio, alpha angle). CTs were assessed for acetabular and femoral version. Divot locations were identified using 3D CT reconstruction models. Collision modelling was performed on pre-operative CTs accounting for labrum, active hip ROM, and location of the divot; positions with contact between the divot and labrum were referenced to common positions of impingement. Non-parametric tests were used to compare hips with a divot to the contralateral hip and to symptomatic hips with no divot. Of 633 included patients, 33 (5%) had a femoral head divot. Patients with a divot were younger (36±9 vs 70±28, p<0.001), with no difference in gender proportion. Divots were unilateral in most cases (31/33). There were no differences in radiographic parameters between hips with divot and the contralateral hip, whereas LCEA (36.1±5.9 vs 27.2±8.1) and AWI (0.54±0.17 vs 0.45±0.15) were greater compared the group without a divot (p<0.001). All divots were located between 2 – 5 o’clock on the femoral head. Positions associated with the divot coming in contact with the rim included kneeling plantar- or dorsi-flexed, sitting with standard leg-cross, or being in a cross-legged/monk position. There were no anatomical differences in collisions between hips with a divot and the contralateral side. Femoral head divot is a rare finding on the antero-inferior surface of the femoral head caused by femoroacetabular impingement in functional positions of daily living, mostly occurring unilaterally despite symmetrical anatomy. These findings highlight the need for assessing version and impingement as an underlying diagnosis to guide surgical decision-making and management. Further studies are needed to investigate impact of the femoral head divot on patient outcomes.
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Authors Megha Rao, Andrew Speirs, Meaghan Dufresne, Jennifer MacDonald, Kawan S Rakhra, Paul E. Beaulé, George A. Grammatopoulos
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Journal Journal of hip preservation surgery
Year 2026
DOI
10.1093/jhps/hnag043.336
URL
https://doi.org/10.1093/jhps/hnag043.336
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