This biographical sketch of M. N. Smith-Petersen corresponds to the historic text, The Classic: Treatment of Malum Coxae Senilis, Old Slipped Upper Femoral Epiphysis, Intrapelvic Protrusion of the Acetabulum, and Coxa Plana by Means of Acetabuloplasty, available at DOI 10.1007/s11999-008-0670-0

Eijer

Ganz

Heyman

Leunig

Myers

Richard A. Brand

Semb

Siebenrock

Smith-Petersen

Wagner

Whitman

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Femoroacetabular Impingement: Current Status of Diagnosis and Treatment: Marius Nygaard Smith-Petersen, 1886–1953

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SYMPOSIUM: FEMOROACETABULAR IMPINGEMENT: CURRENT STATUS OF DIAGNOSIS
AND TREATMENT
Femoroacetabular Impingement: Current Status of Diagnosis
and Treatment
Marius Nygaard Smith-Petersen, 1886–1953
Richard A. Brand MD
Published online: 9 January 2009
 The Association of Bone and Joint Surgeons 2008
Abstract This biographical sketch of M. N. Smith-
Petersen corresponds to the historic text, The Classic:
Treatment of Malum Coxae Senilis, Old Slipped Upper
Femoral Epiphysis, Intrapelvic Protrusion of the Acetabu-
lum, and Coxa Plana by Means of Acetabuloplasty,
available at DOI 10.1007/s11999-008-0670-0.
Marius Nygaard Smith-Petersen was born in 1886 of a
merchant marine family on the coastal town of Grimstad,
southwest of Oslo, Norway [1, 17]. In brief, he emigrated
with his mother to Milwaukee in 1903, completing high
school there in 1906. He attended the University of
Chicago and graduated from the University of Wisconsin.
Smith-Petersen then moved to Boston where he lived the
rest of his life: medical school at Harvard College,
internship at the Peter Bent Brigham Hospital, and further
training at the Massachusetts General hospital, his base
until his death in 1953 (an event noted with sadness
internationally [1, 6–8, 11]).
Smith-Peterson was among the most prominent [17] and
innovative of orthopaedic surgeons of the first half of the
20th century. (Readers are directed to his works on a new
approach to treating fractures of the neck of the femur [15],
mould arthroplasty [14], osteotomy of the spine [16], and
continuous irrigation for osteomyelitis [17], all republished
as Classics in CORR as examples of his innovative spirit.)
In this issue of CORR, we republish yet another of
his innovations related to this month’s symposium on
femoroacetabular impingement. Smith-Petersen was per-
haps the first to recognize and describe in detail an
approach to treating impingement [13]:
In February 1935 a patient, aged 55, was admitted to
the Orthopaedic Ward of the Massachusetts General
Hospital with a diagnosis of ‘‘bilateral intrapelvic
protrusion of the acetabulum’’. The case was dis-
cussed on ward rounds and the general opinion was
that nothing could be done for this patient, and that
she would have to adapt her life to the hip-joint
condition. This did not seem a constructive attitude,
and the patient was allowed to stay on the ward in the
hope that some operative procedure might be devel-
oped which would give her relief from her pain.
The question to be answered was this: ‘‘What was the
source of this patient’s pain?’’ The answer was: ‘‘The
impingement of the femoral neck on the anterior
acetabular margin’’. Such impingement would result
in ‘‘traumatic arthritis’’ with characteristic changes of
the joint surfaces as well as the synovia. Since the
joint surfaces have no nerve endings, their function in
itself cannot be the source of the pain; as they slide
over one another, even though the hyaline cartilage is
markedly thinned, they will not give rise to symp-
toms. What does give rise to pain? The impingement
of two surfaces—one covered by synovial, the other
by cartilage—will give rise to congestion of the
synovia, synovitis, and, because of the periosteal
irritation, hypertrophic changes.
Smith-Petersen recognized in this case impingement
could be relieved either on the acetabular or femoral side.
R. A. Brand (&)
Clinical Orthopaedics and Related Research, 1600 Spruce Street,
Philadelphia, PA 19103, USA
e-mail: dick.brand@clinorthop.org
123
Clin Orthop Relat Res (2009) 467:605–607
DOI 10.1007/s11999-008-0671-z
He chose the former in his first case: ‘‘To eliminate the
impingement by a plastic procedure on the neck of the
femur would be impossible, since this would sacrifice too
large a portion of the neck.’’ Therefore he advocated
removing the anterosuperior portion of the acetabular rim.
He concluded it important to also remove a portion of the
anterosuperior capsule since that would remove a source of
innervated tissue causing symptoms. However, he also
identified situations where the problem existed on the
femoral side: ‘‘If the anterior femoral head and neck are
very prominent, it may at times be advisable to do a plastic
operation on these as well as the acetabulum’’ and
‘‘…when they have been the seat of advance proliferative
changes.’’ He emphasized the importance of checking the
range of motion intraoperatively to ensure correction of the
impingement. Smith-Petersen had performed the proce-
dures in 11 patients: ‘‘They have all done well; the relief
from pain is the outstanding feature; gain in motion is
definite but not marked.’’ He recognized impingement
could arise from a number of sources (as implied in the title
of our republished article), and emphasized, ‘‘The surgeon
must be radical in performing this plastic procedure, but he
must not remove so much of the superior aspect of the
acetabulum as to allow the head of the femur to become
displaced anteriorly.’’ As always, Smith-Petersen advised
caution, ‘‘Sufficient time has not elapsed to obtain true end
results, but the author feels justified in rendering this pre-
liminary report because the method is non-destructive and
seems effective in relieving pain in conditions for which
there is no other adequate treatment.’’
Heyman, Herndon, and Strong [4], in 1957, reported 20
patients (21 hips), ages 12 to 16, with slipped capital femoral
epiphysis in whom they recognized impingement. Their first
operation was performed in 1935, the same year as that of
Smith-Petersen, but their next case, which they described in
detail, was not performed until 1942. At the time of surgery
they noted, ‘‘The obstruction to motion was identified as a
large bony prominence at the anterosuperior aspect of the
neck of the femur at its junction with the displaced epiph-
ysis, which was seen to impinge against the rim of the
acetabulum.’’ Rather than performing the planned cervical
osteotomy, they chose the more conservative approach of
removing the prominence, after which ‘‘The patient’s hip
could then be moved freely in all ranges, except for some
limitation of abduction.’’ At the time of their report, 14 of
the 20 patients had followup of 2 to 14 years. While these
patients were functioning well, they also cautioned readers:
‘‘A true end result cannot really be before middle age, for it
cannot be determined before then if the hips treated by this
conservative operative method will stand up under the
stresses and strains of years of physically active life.’’
Herndon and his colleagues acknowledged they were
not the first to try this approach, although they had been
unaware of the brief earlier descriptions. Whitman, in
1909, had performed this sort of operation rather than an
osteotomy in one out of 11 patients with coxa vara [20]. A
few years later, Vulpius and Sto¨ffel had a brief reference to
a procedure on the femoral neck in 1913 [18].
Thus, the concepts of impingement and the principles of
treatment are nearly a century old, if largely forgotten in
the latter part of the 20th century. Ganz and his colleagues
from Bern reintroduced these ideas in the 1990s in a series
of papers reporting impingement in various conditions
[2, 9, 10, 12]. They have refined the concepts [5] and
proposed many patients with previously undiagnosed hip
pain had more or less subtle deformities of the anterior
femoral neck causing impingement and early osteoarthritis
[3, 19]. This symposium includes a variety of papers
addressing the concepts, the diagnosis, and the treatment of
femoroacetabular impingement. We should, however,
recall the words of caution of Smith-Petersen and Heyman
and colleagues. While current procedures clearly relieve
pain and restore function and to a lesser degree restore
motion in large portion of patients, we do not know
whether these procedures will delay the development of
osteoarthrosis in middle age and beyond.
References
1. Dr. M. N. Smith-Petersen, 1886–1953. J Bone Joint Surg Br.
1953;35:482–484.
2. Eijer H, Myers SR, Ganz R. Anterior femoroacetabular
impingement after femoral neck fractures. J Orthop Trauma.
2001;15:475–481.
3. Ganz R, Parvizi J, Beck M, Leunig M, Notzli H, Siebenrock KA.
Femoroacetabular impingement: a cause for osteoarthritis of the
hip. Clin Orthop Relat Res. 2003;417:112–120.
4. Heyman CH, Herndon CH, Strong JM. Slipped femoral epiphysis
with severe displacement; a conservative operative treatment.
J Bone Joint Surg Am. 1957;39:293–303.
5. Ito K, Minka MA, 2nd, Leunig M, Werlen S, Ganz R. Femoro-
acetabular impingement and the cam-effect. A MRI-based
quantitative anatomical study of the femoral head-neck offset.
J Bone Joint Surg Br. 2001;83:171–176.
6. Leunig M, Casillas MM, Hamlet M, Hersche O, Notzli H, Slongo
T, Ganz R. Slipped capital femoral epiphysis: early mechanical
damage to the acetabular cartilage by a prominent femoral
metaphysis. Acta Orthop Scand. 2000;71:370–375.
7. Marius Nygaard Smith-Petersen. Lancet. 1953;265:145–146.
8. Marius Nygaard Smith-Petersen, 1886–1953. N Engl J Med.
1953;249:210–211.
9. M.N. Smith-Petersen. Br Med J. 1953;2:48.
10. Myers SR, Eijer H, Ganz R. Anterior femoroacetabular
impingement after periacetabular osteotomy. Clin Orthop Relat
Res. 1999;363:93–99.
11. Semb C. [Professor Marius Nygaard Smith-Petersen in memo-
riam.]. Tidsskr Nor Laegeforen. 1953;73:605.
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123
13. Smith-Petersen MN. Treatment of malum coxae senilis, old
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Joint Surg Am. 1936;18:869–880.
14. Smith-Petersen M. The Classic: Evolution of mould arthroplasty
of the hip joint. 1948. Clin Orthop Relat Res. 2006;453:17–21.
15. Smith-Petersen M. The Classic: treatment of fractures of the neck
of the femur by internal fixation. Clin Orthop Relat Res. 1967;
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16. Smith-Petersen M, Larson C, Aufranc OE. The Classic: Osteot-
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rheumatoid arthritis. Clin Orthop Relat Res. 1969;66:6–9.
17. Smith-Petersen M, Larson C, Cochran W. The Classic: Local
chemotherapy with primary closure of septic wounds by means of
drainage and irrigation cannulae. Clin Orthop Relat Res. 2008;
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18. Vulpius O, Sto¨ffel A. Orthopa¨dische Operationslehre. Suttgart,
Germany: F. Enke; 1913.
19. Wagner S, Hofstetter W, Chiquet M, Mainil-Varlet P, Stauffer E,
Ganz R, Siebenrock KA. Early osteoarthritic changes of human
femoral head cartilage subsequent to femoro-acetabular
impingement. Osteoarthritis Cartilage. 2003;11:508–518.
20. Whitman R. Further observations on injuries of the neck of the
femur in early life. Med Rec. 1909;75:1–8.
Volume 467, Number 3, March 2009 Marius Nygaard Smith-Petersen, 1886–1953 607
123


[Professor Marius Nygaard Smith-Petersen in memoriam.]. Tidsskr Nor Laegeforen.

Anterior femoro-acetabular impingement due to acetabular retroversion. Treatment with periacetabular osteotomy.

Anterior femoroacetabular impingement after femoral neck fractures.

Anterior femoroacetabular impingement after periacetabular osteotomy. Clin Orthop Relat Res.

Early osteoarthritic changes of human femoral head cartilage subsequent to femoro-acetabular impingement. Osteoarthritis Cartilage.

Femoroacetabular impingement and the cam-effect. A MRI-based quantitative anatomical study of the femoral head-neck offset.

Femoroacetabular impingement: a cause for osteoarthritis of the hip. Clin Orthop Relat Res.

Further observations on injuries of the neck of the femur in early life.

Slipped capital femoral epiphysis: early mechanical damage to the acetabular cartilage by a prominent femoral metaphysis. Acta Orthop Scand.

Slipped femoral epiphysis with severe displacement; a conservative operative treatment.

Sto ¨ffel A. Orthopa ¨dische Operationslehre.

The Classic: Evolution of mould arthroplasty of the hip joint.

The Classic: Local chemotherapy with primary closure of septic wounds by means of drainage and irrigation cannulae. Clin Orthop Relat Res.

The Classic: Osteotomy of the spine for correction of ﬂexion deformity in rheumatoid arthritis. Clin Orthop Relat Res.

The Classic: treatment of fractures of the neck of the femur by internal ﬁxation. Clin Orthop Relat Res.

Treatment of malum coxae senilis, old slipped upper femoral epiphysis, intrapelvic protrusion of the acetabulum, and coxa plana by means of acetabuloplasty.

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Femoroacetabular Impingement: Current Status of Diagnosis and Treatment: Marius Nygaard Smith-Petersen, 1886–1953

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