The Development and validation of a self-administered quality-of-life outcome measure for young, active patients with symptomatic hip disease: the International Hip Outcome Tool (iHOT-33)

Evaluation and management of greater trochanter pain syndrome

Greater trochanteric pain syndrome is an enigmatic but common cause of lateral hip symptoms in middle-aged active women. The most common manifestation of this syndrome is a degenerative tendinopathy of the hip abductors similar to the intrinsic changes seen with rotator cuff pathology in the shoulder. There are no definitive tests to isolate the underlying pathology and palpation is a non-specific means by which to differentiate the source of the pain generator. The physical examination must comprehensively evaluate for a cluster of potential impairments and contributing factors that will need to be addressed to effectively manage the likely functional limitations and activity challenges the syndrome presents to the patient. Compressive forces through increased tension in the iliotibial band should be avoided. Intervention strategies should include education regarding postural avoidance, activity modifications, improvement of lumbopelvic control, and a patient approach to resolving hip joint restrictions and restoring the tensile capabilities of the deep rotators and abductors of the hip. A number of reliable and validated hip-specific self-report outcome tools are available to baseline a patient's status and monitor their progress. Further investigations to identify the epidemiological risk factors, establish effective treatment strategies, and predict prognosis are warranted.

Causes and risk factors for revision hip preservation surgery

BACKGROUND

Identifying causes and risk factors for failure of hip preservation surgery is critical to properly address residual pathological abnormalities in the revision setting and improve outcomes in this subset of patients.

PURPOSE

To identify the structural causes of failure in both open and arthroscopic hip preservation procedures and to identify demographic and radiographic risk factors that correlate with the need for revision surgery.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

A single-center hip preservation registry was reviewed (N = 1898 procedures in 1600 patients) to identify 147 patients (n = 152 procedures) who had undergone previous pelvic surgery. Exclusion criteria included residual deformity from pediatric hip disease (n = 5 patients). Preoperative demographics, intraoperative findings, radiographic data, and clinical outcome scores were compared between cohorts with and without revision surgery in the registry. Postoperative, short-term patient-reported outcome scores for the revision cohort were described.

RESULTS

The most common reason for revision was residual intra-articular femoroacetabular impingement (74.8%), followed by extra-articular impingement (9.5%). The majority of revision cases (78.9%) could be addressed with arthroscopic surgery, with the exception of extra-articular impingement or residual acetabular dysplasia, which necessitated open approaches. Patients who underwent revision were more likely to be female, were younger in age, and had worse preoperative outcome scores than did those in the primary cohort. Abnormal femoral version and the presence of acetabular dysplasia were not significantly different between the revision and primary cohorts. Short-term improvements in patient-reported outcome scores were found in the revision cohort at a mean of 15.0 months from the last revision surgery.

CONCLUSION

Residual intra- and extra-articular impingement were the most common reasons for revision in this cohort. Patients who underwent revision tended to be younger in age, were female, and had worse preoperative hip functional outcomes than did those in the primary cohort. Abnormal femoral version or acetabular coverage was not increased in our revision cohort.

Improved outcomes after hip arthroscopic surgery in patients undergoing T-capsulotomy with complete repair versus partial repair for femoroacetabular impingement: a comparative matched-pair analysis

BACKGROUND

Hip capsular management after hip arthroscopic surgery for femoroacetabular impingement (FAI) is controversial.

PURPOSE/HYPOTHESIS

To compare the clinical outcomes of patients undergoing hip arthroscopic surgery for FAI with T-capsulotomy with partial capsular repair (PR; closed vertical incision, open interportal incision) versus complete capsular repair (CR; full closure of both incisions). The hypothesis was that there would be improved clinical outcomes in patients undergoing CR compared with those undergoing PR.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Consecutive patients undergoing hip arthroscopic surgery for FAI by a single fellowship-trained surgeon from January 2011 to January 2012 were prospectively collected and analyzed. Inclusion criteria included all patients between ages 16 and 65 years with physical examination and radiographic findings consistent with symptomatic FAI, with a minimum 2-year follow-up. For analysis, patients were matched according to sex and age ±2 years. Primary clinical outcomes were measured via the Hip Outcome Score Activities of Daily Living (HOS-ADL) and Sport-Specific (HOS-SS) subscales, the modified Harris Hip Score (mHHS), patient satisfaction (measured on a visual analog scale), and clinical improvement at baseline, 6 months, 1 year, and 2 years. Statistical analysis was performed utilizing Student paired and unpaired t tests, with P < .05 considered significant.

RESULTS

A total of 64 patients were included in the study, with 32 patients (12 male, 20 female) in each group. The average follow-up was 29.9 ± 2.6 months. There were no significant demographic differences between the groups. The CR group demonstrated significantly superior outcomes in the HOS-SS at 6 months (PR: 63.8 ± 31.1 vs CR: 72.2 ± 16.1; P = .039), 1 year (PR: 72.7 ± 14.7 vs CR: 82.5 ± 10.7; P = .006), and 2.5 years (PR: 83.6 ± 9.6 vs CR: 87.3 ± 8.3; P < .0001) after surgery. Patient satisfaction at final follow-up was significantly better in the CR group (PR: 8.4 ± 1.0 vs CR: 8.6 ± 1.1; P = .025). Both groups demonstrated significant improvements in the HOS-ADL (PR: 64.6 ± 17.0 to 90.7 ± 8.4 [P < .0001]; CR: 66.1 ± 15.7 to 92.1 ± 7.9 [P < .0001]) and HOS-SS (PR: 39.4 ± 23.9 to 83.6 ± 9.6 [P < .0001]; CR: 39.1 ± 24.2 to 87.3 ± 8.3 [P < .0001]) at final follow-up. There were no significant differences between the groups in the HOS-ADL at any time point. There were no significant differences in the mHHS between the groups at final follow-up (PR: 82.5 ± 5.0 vs CR: 83.0 ± 4.4; P = .364). The overall revision rate was 6.25%; all patients (n = 4) who required revision arthroscopic surgery were in the PR group (13% of 32 patients), while no patients in the CR group required revision surgery.

CONCLUSION

While significant improvements were seen at 6 months, 1 year, and 2.5 years of follow-up regardless of the closure technique, patients who underwent CR of the hip capsule demonstrated superior sport-specific outcomes compared with those undergoing PR. There was a 13% revision rate in the PR group, but no patients in the CR group required revision surgery. While longer term outcome studies are needed to determine if these results are maintained over time, these data suggest improved outcomes after CR compared with PR at 2.5 years after hip arthroscopic surgery for FAI.

Asymptomatic hip/groin pathology identified on magnetic resonance imaging of professional hockey players: outcomes and playing status at 4 years' follow-up

PURPOSE

The purpose of this study was to evaluate the clinical outcomes and playing status of professional hockey players 4 years after they underwent bilateral magnetic resonance imaging (MRI) of asymptomatic hips.

METHODS

Twenty-one professional hockey players with no previous hip/groin pain underwent hip/pelvis MRI. Each MRI study was evaluated by 3 subspecialty-trained musculoskeletal radiologists for alpha-angle measurement and the presence of adductor-abdominal rectus abnormalities, acetabular labral tears, osteochondral lesions of the femoral head or acetabulum, hip effusion, adjacent muscle contusions or strain injury, and stress fractures. The MRI findings of the players were previously published. In the present study, each athlete was followed up by (1) completion of a questionnaire assessing hip/groin dysfunction at 1 and 2 years' follow-up and (2) number of games played over the course of the next 4 years. A significant difference in the number of games played was considered when a player missed more than 5 games compared with the index year.

RESULTS

We enrolled 21 players in the study. Of these players, 4 had no abnormality bilaterally, 10 had muscle strain and/or tendinosis in 1 or both hips, and 15 had labral tears identified in 1 or both hips. Eight players had a combination of labral tears and muscle strain/tendinosis. Of 21 professional hockey players, 16 (76%) and 14 (67%) were available at 1 and 2 years' follow-up, respectively. Nineteen of 21 players (90%) continued to play professional hockey at 4 years' follow-up. The development of any hip and/or pelvis symptoms occurred in only 3 players (14%) within 4 years. Only 1 of the 3 players missed any games because of hip and/or pelvis symptoms. The affected player missed several games because of proximal iliotibial band symptoms that occurred in the third year after MRI.

CONCLUSIONS

Hip/pelvis pathology is commonly uncovered on MRI of asymptomatic hockey players; however, this pathology does not produce symptoms or result in missed games within 4 years in most players.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Surgery for treating hip impingement (femoroacetabular impingement)

BACKGROUND

Surgery is sometimes recommended for femoroacetabular impingement where non-operative interventions have failed.

OBJECTIVES

To determine the benefits and safety of surgery for femoroacetabular impingement.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2013, Issue 11); MEDLINE (Ovid) (1946 to 19 November 2013); and EMBASE (Ovid) (1980 to 19 November 2013) for studies, unrestricted by language.

SELECTION CRITERIA

Randomised and quasi-randomised clinical trials assessing surgical intervention compared with placebo treatment, non-operative treatment or no treatment in adults with femoroacetabular impingement.

DATA COLLECTION AND ANALYSIS

Two authors independently selected trials for inclusion, assessed risk of bias and extracted data.

MAIN RESULTS

There were no studies that met the inclusion criteria, with 11 studies that were excluded following detailed review. There were four ongoing studies identified that may meet the inclusion criteria when they are completed; the results from these ongoing studies may begin to become available within the next five years. Three of the four ongoing studies are comparing hip arthroscopy versus non-operative care. The fourth study is comparing hip arthroscopy versus a sham arthroscopic hip procedure. All of the ongoing studies are recording at least one of our preferred clinical outcome measures for benefit and safety.

AUTHORS' CONCLUSIONS

There is no high quality evidence examining the effectiveness of surgery for femoroacetabular impingement. There are four ongoing studies, which may provide evidence for the benefit and safety of this type of surgery in the future.

[Hip arthroscopy in males younger than 40 with femoroacetabular impingement: short-term outcomes]

INTRODUCTION AND OBJECTIVES

Femoroacetabular impingement is probably the most common mechanism that leads to the development of early cartilage and labral damage in the non-dysplastic hip. The objective was to evaluate the outcomes of hip arthroscopy as a treatment for femoroacetabular impingement in patients with high level of function.

MATERIAL AND METHODS

A prospective study was performed on 41 patients younger than 40 years old undergoing hip arthroscopy for femoroacetabular impingement. Modified Harris Hip Score and HOS and IHOT questionnaires were used for clinical assessment. Radiological evaluation was made for joint space and alpha angle.

RESULTS

The mean age of patients was 32.7 years. Labrum injury was detected in 78%, and acetabular cartilage injury in 56% of cases. The average follow-up was 31.3 months. There was a significantly improvement in the mean score in the clinical questionnaires. Radiologically there was no change in the mean joint space, with significantly reduction to normal values of the alpha angle. All patients returned to sports at their pre-injury level of function.

DISCUSSION

Hip arthroscopy resulted in improvement in hip functional outcomes with correction of the underlying osseous deformity and treatment of the associated labral and cartilage pathology, with the return of patients to their pre-injury sports. Further follow-up is essential to confirm the stability of the clinical and radiological outcomes.

Assessing Performance in Shoulder Arthroscopy: The Imperial Global Arthroscopy Rating Scale (IGARS)

BACKGROUND

Surgical training is undergoing major changes with reduced resident work hours and an increasing focus on patient safety and surgical aptitude. The aim of this study was to create a valid, reliable method for an assessment of arthroscopic skills that is independent of time and place and is designed for both real and simulated settings. The validity of the scale was tested using a virtual reality shoulder arthroscopy simulator.

METHODS

The study consisted of two parts. In the first part, an Imperial Global Arthroscopy Rating Scale for assessing technical performance was developed using a Delphi method. Application of this scale required installing a dual-camera system to synchronously record the simulator screen and body movements of trainees to allow an assessment that is independent of time and place. The scale includes aspects such as efficient portal positioning, angles of instrument insertion, proficiency in handling the arthroscope and adequately manipulating the camera, and triangulation skills. In the second part of the study, a validation study was conducted. Two experienced arthroscopic surgeons, blinded to the identities and experience of the participants, each assessed forty-nine subjects performing three different tests using the Imperial Global Arthroscopy Rating Scale. Results were analyzed using two-way analysis of variance with measures of absolute agreement. The intraclass correlation coefficient was calculated for each test to assess inter-rater reliability.

RESULTS

The scale demonstrated high internal consistency (Cronbach alpha, 0.918). The intraclass correlation coefficient demonstrated high agreement between the assessors: 0.91 (p < 0.001). Construct validity was evaluated using Kruskal-Wallis one-way analysis of variance (chi-square test, 29.826; p < 0.001), demonstrating that the Imperial Global Arthroscopy Rating Scale distinguishes significantly between subjects with different levels of experience utilizing a virtual reality simulator.

CONCLUSIONS

The Imperial Global Arthroscopy Rating Scale has a high internal consistency and excellent inter-rater reliability and offers an approach for assessing technical performance in basic arthroscopy on a virtual reality simulator.

CLINICAL RELEVANCE

The Imperial Global Arthroscopy Rating Scale provides detailed information on surgical skills. Although it requires further validation in the operating room, this scale, which is independent of time and place, offers a robust and reliable method for assessing arthroscopic technical skills.

Position-Specific Hip and Knee Kinematics in NCAA Football Athletes

BACKGROUND

Femoroacetabular impingement is a debilitating hip condition commonly affecting athletes playing American football. The condition is associated with reduced hip range of motion; however, little is known about the range-of-motion demands of football athletes. This knowledge is critical to effective management of this condition.

PURPOSE

To (1) develop a normative database of game-like hip and knee kinematics used by football athletes and (2) analyze kinematic data by playing position. The hypothesis was that kinematics would be similar between running backs and defensive backs and between wide receivers and quarterbacks, and that linemen would perform the activities with the most erect lower limb posture.

STUDY DESIGN

Descriptive laboratory study.

METHODS

Forty National Collegiate Athletic Association (NCAA) football athletes, representing 5 playing positions (quarterback, defensive back, running back, wide receiver, offensive lineman), executed game-like maneuvers while lower body kinematics were recorded via optical motion capture. Passive hip range of motion at 90° of hip flexion was assessed using a goniometer. Passive range of motion, athlete physical dimensions, hip function, and hip and knee rotations were submitted to 1-way analysis of variance to test for differences between playing positions. Correlations between maximal hip and knee kinematics and maximal hip kinematics and passive range of motion were also computed.

RESULTS

Hip and knee kinematics were similar across positions. Significant differences arose with linemen, who used lower maximal knee flexion (mean ± SD, 45.04° ± 7.27°) compared with running backs (61.20° ± 6.07°; P < .001) and wide receivers (54.67° ± 6.97°; P = .048) during the cut. No significant differences were found among positions for hip passive range of motion (overall means: 102° ± 15° [flexion]; 25° ± 9° [internal rotation]; 25° ± 8° [external rotation]). Several maximal hip measures were found to negatively correlate with maximal knee kinematics.

CONCLUSION

A normative database of hip and knee kinematics utilized by football athletes was developed. Position-specific analyses revealed that linemen use smaller joint motions when executing dynamic tasks but do not demonstrate passive range of motion deficits compared with other positions.

CLINICAL RELEVANCE

Knowledge of requisite game-like hip and knee ranges of motion is critical for developing goals for nonoperative or surgical recovery of hip and knee range of motion in the symptomatic athlete. These data help to identify playing positions that require remedial hip-related strength and conditioning protocols. Negative correlations between hip and knee kinematics indicated that constrained hip motion, as seen in linemen, could promote injurious motions at the knee.

Nonarthritic hip joint pain

The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability, and Health (ICF). The purpose of these clinical practice guidelines is to describe the peer-reviewed literature and make recommendations related to nonarthritic hip joint pain.

A standardised outcome measure of pain, symptoms and physical function in patients with hip and groin disability due to femoro-acetabular impingement: cross-cultural adaptation and validation of the international Hip Outcome Tool (iHOT12) in Swedish

PURPOSE

There is a lack of standardised outcome measures in Swedish for active, young and middle-aged patients with hip and groin disability. The purpose of this study was to adapt the English version of the international Hip Outcome Tool (iHOT12) patient-reported outcome instrument for use in Swedish patients and evaluate the adaptation according to the consensus-based standards for the selection of health status measurement instruments checklist.

METHODS

Cross-cultural adaptation was performed in several steps, including translation, back-translation, expert review and pre-testing. The final version was evaluated for reliability, validity and responsiveness in a clinical study of patients [median age 37 (range 15-75)], undergoing surgery for femoro-acetabular impingement.

RESULTS

Cronbach's alpha was 0.89, and significant correlations were obtained with the Copenhagen Hip and Groin Outcome Score (Spearman's r 0.10-0.70; p < 0.05) and the EuroQol, EQ-5D average score (Spearman's r 0.27-0.56; p < 0.01). Test-retest reliability (intraclass correlation coefficient) ranged from 0.59 to 0.93 for the individual items. The smallest detectable change ranged from 17.1 to 44.9 at individual level and 3.6 to 9.4 at group level. Factor analysis revealed one factor of pain and symptoms and another factor of physical function. Effect sizes were generally medium or large.

CONCLUSION

The Swedish version of the iHOT12 is a valid, reliable and responsive instrument that can be used both for research and in the clinical setting.

Complications in hip arthroscopy: necessity of supervision during the learning curve

PURPOSE

The aim of this study was to determine whether the learning curve of arthroscopic treatment of femoroacetabular impingement (FAI) could be verified by analyzing the complication rate of this procedure. Additionally, it was investigated whether supervision by an experienced surgeon leads to a steeper learning curve (lower number of complications) when starting to perform arthroscopic FAI treatment.

METHODS

The complications occurring in 317 consecutive patients treated with the sole diagnosis of FAI were analyzed. 256 patients (collective A) were treated by surgeon A between June 2005 and January 2010. Sixty-one patients (collective B) were treated by surgeon B between August 2008 and December 2009. From January to June 2008, surgeon B performed many hip arthroscopies under supervision of surgeon A. Complications were recorded in a central complication register. Statistic analysis of the complication rates was performed using Fischer's exact T test.

RESULTS

Subdividing collective A chronologically into thirds a significant decline of complications (p = 0.0044) was found with growing experience of the surgeon. Comparing the first 61 patients of both surgeons a significantly lower complication rate was discovered in the patients of surgeon B (p = 0.0375). In total there were 21 complications (6.6 %; CI 4.4-9.9 %). The observed complication rate was 7.0 % in collective A and 4.9 % in collective B.

CONCLUSION

The learning curve can be comprehended by the distribution of complications in collective A. Having spent 6 months performing under supervision of surgeon A, surgeon B has a lower complication rate than surgeon A when comparing the first 61 patients each surgeon operated on. This implies that surgeon B benefits from the experience of surgeon A. According to this analysis, beginners in arthroscopic FAI treatment should be taught at a specialized centre to reduce the number of complications.

Modest mid-term outcomes after isolated arthroscopic debridement of acetabular labral tears

PURPOSE

Currently, there is a paucity of literature regarding outcomes after isolated labral debridement. The purpose of this study was to (1) report the reoperation rate following isolated labral debridement, (2) report clinical and functional outcomes after labral debridement with a minimum 2-year follow-up and (3) identify risk factors for worse clinical and functional outcomes. It was hypothesized that inferior outcomes are associated with an increasing Tönnis grade and those with untreated femoral acetabular impingement (FAI).

METHODS

The records of patients undergoing hip arthroscopy between 1998 and 2005 were reviewed. Patients with labral tears who underwent isolated arthroscopic labral debridement were identified. Kaplan-Meier estimate of failure (defined as subsequent surgery) was performed for all patients. Patients with minimum 2-year follow-up were assessed with Modified Harris Hip Score (MHHS) and Hip Outcome Score (HOS). Univariate analysis was then performed to assess which factors were associated with worse clinical and functional outcomes.

RESULTS

Fifty-nine hips in 57 patients met our inclusion criteria (39 females, 18 males) with a mean age of 46 ± 14 years and mean follow-up of 5 (range 2-14) years. Overall, 45 % of the hips failed for repeat surgery (20 %) or rating for hip function as abnormal or severely abnormal (25 %). Twelve hips (20 %) required subsequent surgical intervention at a mean 23 (range 6-60) months (7 total hip arthroplasties, 2 open revisions, 3 arthroscopic revisions). Of the remaining hips, mean MHHS was 83.4 ± 19.7, mean HOS ADL score was 83.8 ± 21.3 and mean HOS sport score was 70.6 ± 32.9, with 33 of 41 (75 %) reporting normal or nearly normal current level of function. Univariate analysis revealed that hips with untreated bony impingement (p = 0.01) or requiring concomitant chondroplasty (p = 0.03) had inferior clinical outcome scores.

CONCLUSIONS

Isolated arthroscopic labral debridement for hip labral tears had 45 % combined poor results when strictly defining failure as repeat surgery or abnormal hip rating. Untreated FAI and concomitant chondroplasty were risk factors for inferior outcome. We recommend concomitant treatment for bony impingement lesions and preservation of the labrum whenever possible.

Ischiofemoral impingement of the hip: a novel approach to treatment

Ischiofemoral impingement (IFI) is an uncommon source of hip pain recently described in the non-surgical hip, associated with decreased space between the lesser trochanter and the ischium. There are no reports in the English literature of surgical treatment of this problem. We describe a case of IFI in a 19-year-old female who failed conservative management and underwent endoscopic surgical intervention to increase the space between her ischium and proximal femur. More than 2 years later, the patient is doing very well with an improvement of her iHOT score of 53 points to 85.

Hip arthroscopy: from the beginning to the future--an innovator's perspective

Hip arthroscopy is one of the fastest-growing areas of orthopaedic surgery. There are many reasons for this, including a better understanding of the pathophysiology of damage to the hip joint, improvements in imaging and technology advancements in arthroscopic instrumentation. This manuscript documents the historical development of hip arthroscopy, in general, as well as advances and ideas that have led to common techniques with regard to portal placement, traction and instrumentation. These advances have led to expanding indications for hip arthroscopy. This manuscript ends with some thoughts about the future of hip arthroscopy from the perspective of one of the leaders who helped shape hip arthroscopy, as it is performed today.

Hip arthroscopy with labral repair for femoroacetabular impingement: short-term outcomes

PURPOSE

The purpose of this study was to examine the progression of clinical outcomes 3, 6 and 12 months after hip arthroscopy with labral repair for femoroacetabular impingement (FAI).

METHODS

From May 2009 to December 2011, 87 consecutive patients [55 females (median age 38, range 17-63) and 32 males (median age 38, range 15-59)] underwent hip arthroscopy and labral repair, by the same experienced surgeon. Standardised, but unstructured, post-operative rehabilitation instructions were provided. Function and pain were evaluated using modified Harris Hip Score (mHHS) and visual analogue scale (VAS) pre-operatively and post-operatively at 3, 6, and 12 months.

RESULTS

A main effect of time was seen for mHHS and pain (VAS) at 3, 6, and 12 months (p < 0.001). Mean (SE) mHHS improved significantly from 59.9 (1.9) pre-operatively to 74.5 (1.9) after 3 months (p < 0.001), and again from 3 to 6 months from 74.5 (1.9) to 80.1 (1.9) (p = 0.004), with no additional changes from 6 to 12 months [80.1 (1.9)-78.7 (1.9), (n.s.)]. Also, the mean (SE) VAS improved significantly from pre-operative 57.9 (2.6) to 30.0 (2.6) after 3 months (p < 0.001), and from 30.0 (2.6) to 22.6 (2.6) (p = 0.017), after 6 months with no additional changes from 6 to 12 months [22.6 (2.6)-27.9 (2.6), (n.s.)].

CONCLUSIONS

Improvements in function (mHHS) and pain (VAS) were seen in patients after hip arthroscopy with labral repair for FAI at 3, 6, and 12 months. While significant improvements occurred from 3 to 6 months, no further improvements were seen from 6 to 12 months.

Hip chondropathy at arthroscopy: prevalence and relationship to labral pathology, femoroacetabular impingement and patient-reported outcomes

BACKGROUND

This study aimed to describe chondropathy prevalence in adults who had undergone hip arthroscopy for hip pain. The relationships between chondropathy severity and (1) participant characteristics; and (2) patient-reported outcomes (PROs) at initial assessment (∼18 months postsurgery) and over a further 12 months (∼30 months postsurgery) were evaluated. Finally, the relationships between chondropathy and coexisting femoroacetabular impingement (FAI) and labral pathology at the time of surgery were evaluated.

METHODS

100 consecutive patients (36±12 years) who underwent hip arthroscopy 18 months previously participated. Hip Osteoarthritis and Disability Outcome Score (HOOS) and International Hip Outcome Tool (iHOT-33) data were collected prospectively at 18 months postsurgery and at 30 months postsurgery. Surgical data were collected retrospectively. Participants were grouped: Outerbridge grade 0, no chondropathy; Outerbridge grade I-II, mild chondropathy; Outerbridge III-IV, severe chondropathy. The presence of FAI or labral pathology was noted.

RESULTS

The prevalence of chondropathy (≥grade I) at hip arthroscopy was 72%. Participants with severe chondropathy were significantly worse for all HOOS subscales and the iHOT-33 at 18 months postsurgery (HOOS-symptoms (p=0.017); HOOS-pain (p=0.024); HOOS-activity (p=0.009); HOOS-sport (p=0.004); HOOS-quality-of-life (p=0.006); iHOT-33 (p=0.013)) than those with no chondropathy. At 12-month follow-up, HOOS-quality-of-life in those without chondropathy was the only PRO that improved. Relative risk of coexisting chondropathy with labral pathology or FAI was 40%.

CONCLUSIONS

Chondropathy was prevalent, and associated with increasing age, coexisting labral pathology or FAI. Severe chondropathy was associated with worse pain and function at 18 months postsurgery. Little improvements were observed in participants over a further 12 months, regardless of chondropathy status.

Efficacy of a physiotherapy rehabilitation program for individuals undergoing arthroscopic management of femoroacetabular impingement - the FAIR trial: a randomised controlled trial protocol

Background

Femoroacetabular impingement is a common cause of hip/groin symptoms and impaired functional performance in younger sporting populations and results from morphological abnormalities of the hip in which the proximal femur abuts against the acetabular rim. Many people with symptomatic femoroacetabular impingement undergo arthroscopic hip surgery to correct the bony abnormalities. While many case series over the past decade have reported favourable surgical outcomes, it is not known whether formal rehabilitation is needed as part of the management of patients undergoing this surgical procedure. This randomised controlled trial will investigate the efficacy of a progressive physiotherapist-supervised rehabilitation program (Takla-O’Donnell Protocol) in improving health-related quality of life, physical function and symptoms in individuals undergoing arthroscopic management of femoroacetabular impingement.

Methods/design

100 people aged 16–35 years undergoing hip arthroscopy for symptomatic femoroacetabular impingement will be recruited from surgical practices in Melbourne, Australia and randomly allocated to either a physiotherapy or control group. Both groups will receive written information and one standardised post-operative physiotherapy visit whilst in hospital as per usual care. Those in the physiotherapy group will also receive seven individual 30-minute physiotherapy sessions, including one pre-operative visit (within 2 weeks of surgery) and six post-operative visits at fortnightly intervals (commencing two weeks after surgery). The physiotherapy intervention will incorporate education and advice, manual techniques and prescription of a progressive rehabilitation program including home, aquatic and gym exercises. The control group will not receive additional physiotherapy management. Measurements will be taken at baseline (2 weeks pre-operatively) and at 14 and 24 weeks post-surgery. Primary outcomes are the International Hip Outcome Tool and the sports subscale of the Hip Outcome Score at 14 weeks post-surgery. Secondary outcomes include the Copenhagen Hip and Groin Outcome Score, the activities of daily living subscale of the Hip Outcome Score, the Heidelberg Sports Activity Score, a modified Tegner Activity Scale and participant-perceived overall change.

Discussion

The findings from this randomised controlled trial will provide evidence for the efficacy of a specific physiotherapist-supervised rehabilitation program in improving outcomes following arthroscopic management of symptomatic femoroacetabular impingement.

Trial registration

Australian New Zealand Clinical Trials Registry reference number: ACTRN12613000282785.

Translation and cross-cultural adaptation of the International Hip Outcome Tool (iHOT) into Portuguese

OBJECTIVE

iHOT12/33 is an outcome tool designed for young patients with hip problems. The objective of this study is to translate and establish a cross-cultural adaptation of this questionnaire to Portuguese.

METHOD

The Guillemin guidelines were followed for the translation and cross-cultural adaptation consisting on: translation, back-translation, prefinal version, administration of the Questionnaire, and editing of the final version.

RESULTS

The prefinal version was applied to 30 young patients with hip problems. Some difficulties in understanding some of the words and expressions were noted, and these were replaced with simpler ones, achieving the patient's full acceptability in the final version of the Questionnaire.

CONCLUSION

The creation of the Brazilian version of the International Hip Outocome Tool (iHOT) 12/33 enables this questionnaire to be used in the evaluation of patients with hip problems in Brazil, and was clearly understood, with good acceptance by the patients tested. Level of evidence II - Development of diagnostic criteria on consecutive patients (with universally applied reference "gold" standard).

Development and validation of a pediatric sports activity rating scale: the Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS)

BACKGROUND

Having simple and reliable validated outcome measures is vital to conducting high-quality outcomes research in the field of orthopaedic surgery. Activity level is a key prognostic variable for patients with sports injuries. There is a paucity of such activity scales for children and adolescents who are otherwise healthy and athletically active. In addition to frequency and intensity of athletic activity, level of play and coach/trainer supervision are important variables unique to children and adolescents that are not captured in available adult scoring systems.

PURPOSE

To create and validate a concise and comprehensive activity rating scale for athletically active children and adolescents 10 to 18 years of age.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 2.

METHODS

Item generation was performed with a panel of orthopaedic surgeons and adolescent athletes. Item reduction, pilot testing and scale refinement resulted in a final 8-item instrument, the Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS). Existing methods were used to determine reliability and validation. The Flesch-Kincaid score was calculated at a 6.6th-grade reading level (approximately 13 years old); therefore, although all subjects provided their own answers, parents were allowed to assist children younger than 13 years with reading the questionnaire.

RESULTS

Scale reliability was excellent (test-retest reliability, intraclass correlation coefficient = 0.91; internal consistency, Cronbach alpha = .914), and there were no floor or ceiling effects. There was also robust construct validity: Convergent validity testing revealed positive correlations between the HSS Pedi-FABS and level of competition in athletic activity, number of reported hours of athletic activity per week, and existing comparable adult and pediatric scales. Discriminant validity was shown with age, body mass index, and type of sport as measured by the Daniel scale.

CONCLUSION

The 8-item HSS Pedi-FABS can be used to reliably and accurately evaluate activity level as a prognostic variable for clinical research studies. It is a simple, reliable, and valid metric to assess activity in children and adolescents 10 to 18 years of age. This instrument will lead to better evaluation of posttreatment outcomes and patient-reported activity for child and adolescent athletes.

Treatment of femoroacetabular impingement: a systematic review

The purpose of this review is to determine if there is a difference in outcomes after: (1) nonsurgical vs surgical treatment of FAI; (2a) surgical dislocation with greater trochanteric osteotomy, (2b) anterior mini-open, (2c) arthroscopic plus mini-open, and (2d) arthroscopic surgery for FAI; (3) difference in complication and re-operation rates; and (4a) labral refixation and (4b) labral debridement for labral injuries. A systematic review of multiple databases was performed after PROSPERO registration and using PRISMA guidelines. Level I-IV evidence clinical studies with minimum 2-year follow-up were included. Data were compared using 2-sample and 2-proportion Z-test calculators. Study methodological quality was analyzed using Modified Coleman Methodology Score (MCMS). Recommendations were made using SORT (Strength Of Recommendation Taxonomy). Twenty-nine studies were included (2369 subjects; 2507 hips). MCMS was poor. Mean subject age was 34.4+/-8.4 years and mean follow-up was 3.1+/-0.9 years. Statistically significant differences were observed following both nonsurgical and surgical treatment, with greater (P < 0.05) improvements following surgery (SORT B), without consistent significant differences observed between different surgical techniques (SORT C). There was a greater (P < 0.05) reoperation and complication rate following surgical dislocation vs mini-open and arthroscopic techniques (SORT A). Clinical outcomes were significantly better (P < 0.05) following labral refixation vs debridement (SORT B). Outcomes of operative treatment of femoroacetabular impingement are significantly better than nonsurgical management. Surgical treatment significantly improves outcomes, with no consistent significant differences exhibited between open and arthroscopic techniques. Open surgical dislocation has significantly greater reoperation and complication rates vs mini-open and arthroscopic techniques. Outcomes of labral refixation are significantly better than debridement in patients with labral injuries.

Psychometric properties of patient-reported outcome measures for hip arthroscopic surgery

BACKGROUND

Patient-reported outcomes (PROs) are considered the gold standard when evaluating outcomes in a surgical population. While the psychometric properties of some PROs have been tested, the properties of newer PROs in patients undergoing hip arthroscopic surgery remain somewhat unknown.

PURPOSE

To evaluate the reliability, validity, responsiveness, and interpretability of 5 PROs (Copenhagen Hip and Groin Outcome Score [HAGOS], Hip Disability and Osteoarthritis Outcome Score [HOOS], Hip Outcome Score [HOS], International Hip Outcome Tool [iHOT-33], and Modified Harris Hip Score [MHHS]) in a population undergoing hip arthroscopic surgery and also to provide a recommendation of the best PROs in patients undergoing hip arthroscopic surgery.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 2.

METHODS

Study participants were adults (mean age, 37 ± 11 years) who had undergone hip arthroscopic surgery 12 to 24 months previously and pain-free, healthy age-matched controls (mean age, 35 ± 11 years). Baseline characteristics including age, height, weight, waist girth, physical activity, and occupation were collected for both groups. The hip arthroscopic surgery group completed the 5 PRO questionnaires on 3 occasions, while the healthy control group completed the PRO questionnaires on 1 occasion. The reliability (test-retest reliability [intraclass correlation coefficient, or ICC] and minimal detectable change [MDC]), validity (construct validity, ability to detect a difference between groups, acceptability including floor and ceiling effects), responsiveness, and interpretability (minimal important change [MIC]) of each measure were calculated.

RESULTS

The test-retest reliability of PROs was excellent (ICC, 0.91-0.97), with an MDC of <20%. The HOOS, HAGOS, and iHOT-33 had acceptable content validity. All PROs demonstrated construct validity and were able to detect a difference between the hip arthroscopic surgery and control groups. No measures demonstrated a floor effect; however, the MHHS and subscales relating to activities of daily living of the HOOS, HOS, and HAGOS demonstrated a ceiling effect. The HOOS, iHOT-33, and MHHS demonstrated adequate responsiveness, and the MIC for all measures was <11 points of a possible 100 points.

CONCLUSION

The PROs of the HOOS and iHOT-33 demonstrate psychometric properties that may enable researchers and clinicians to use them with confidence in a population undergoing hip arthroscopic surgery. The psychometric properties of the MHHS, HOS, and some subscales of the HAGOS are reduced, and these PROs may be less valuable in this group.

History and physical examination of the hip: the basics

The history and physical examination of the hip is the key component for evaluation of patients presenting with hip pain. As our understanding of the anatomy and biomechanics of the normal hip vs the pathologic hip advances, the physical examination progresses as well. As with the shoulder and knee examinations, there are critical steps that form the basis of the examination of the hip joint. This hip examination contains 21 steps, which compares well with the shoulder 20 step exam and the knee 33 step exam. Consideration should be given for the hip as comprised of 4 layers: the osseous, capsulolabral, musculotendinous, and neurovascular. The hip represents the link between the upper body and lower body, therefore the fifth layer, the kinematic chain, plays an essential role in treatment recommendations. A clinical evaluation of the hip that incorporates this multifactor thought process will lead to an accurate diagnosis in a timely manner. This paper is a description of the 21 core examinations of a standardized clinical evaluation of the hip.

Descriptive epidemiology of femoroacetabular impingement: a North American cohort of patients undergoing surgery

BACKGROUND

Symptomatic femoroacetabular impingement (FAI) is associated with hip pain, functional limitations, and secondary osteoarthritis. There is limited information from large patient cohorts defining the specific population affected by FAI. Establishing a large cohort will facilitate the identification of "at-risk" patients and will provide a population for ongoing clinical research initiatives. The authors have therefore established a multicenter, prospective, longitudinal cohort of patients undergoing surgery for symptomatic FAI.

PURPOSE

To report the clinical epidemiology, disease characteristics, and contemporary surgical treatment trends in North America for patients with symptomatic FAI.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

Upon approval of the institutional review boards at 8 institutions, 12 surgeons enrolled consecutive patients undergoing surgical intervention for symptomatic FAI. Patient demographics, physical examination data, radiographic data, diagnoses, operative data, and standardized patient-reported outcome measures were collected. The first 1130 cases are summarized in this study.

RESULTS

A total of 1076 consecutive patients (1130 hips) were enrolled; 55% (n = 622) were female, and 45% (n = 508) were male, with an average age of 28.4 years and average body mass index (BMI) of 25.1. Demographics revealed that 88% of patients who were predominantly treated for FAI were white, 19% reported a family history of hip surgery, 47.6% of hips had a diagnosis of cam FAI, 44.5% had combined cam/pincer FAI, and 7.9% had pincer FAI. Preoperative clinical scores (pain, function, activity level, and overall health) indicated a major dysfunction related to the hip. Surgical interventions were arthroscopic surgery (50.4%), surgical dislocation (34.4%), reverse periacetabular osteotomy (9.4%), limited open osteochondroplasty with arthroscopic surgery (5.8%), and limited open by itself (1.5%). More than 90% of the hips were noted to have labral and articular cartilage abnormalities at surgery; femoral head-neck osteochondroplasty was performed in 91.6% of the surgical procedures, acetabular rim osteoplasty in 36.7%, labral repair in 47.8%, labral debridement in 16.3%, and acetabular chondroplasty in 40.1%.

CONCLUSION

This multicenter, prospective, longitudinal cohort is one of the largest FAI cohorts to date. In this cohort, FAI occurred predominantly in young, white patients with a normal BMI, and there were more female than male patients. The disease pattern of cam FAI was most common. Contemporary treatment was predominantly arthroscopic followed by surgical hip dislocation.

Consistency of reported outcomes after arthroscopic management of femoroacetabular impingement

PURPOSE

The purpose of this systematic review is to evaluate the consistency of the reporting of clinical and radiographic outcomes after arthroscopic management of femoroacetabular impingement (FAI).

METHODS

Two databases (Medline and EMBASE) were screened for clinical studies involving the arthroscopic management of FAI. A full-text review of eligible studies was conducted, and the references were searched. Inclusion and exclusion criteria were applied to the searched studies, and a quality assessment was completed for included studies.

RESULTS

We identified 29 eligible studies involving 2,816 patients. There was a lack of consensus with regard to reported outcomes (clinical and radiographic) after arthroscopic treatment of FAI. Clinical outcomes reported include the Harris Hip Score (45%) and the Non-Arthritic Hip Scale (28%), range of motion (34%), pain scores (24%), and patient satisfaction (28%). The most commonly reported radiographic outcomes included the alpha angle (38%), head-neck offset (14%), and degenerative changes (21%).

CONCLUSIONS

There is significant variation in reported clinical and radiographic outcomes after arthroscopic treatment of FAI. This study highlights the need for consistent outcome reporting after arthroscopic FAI surgery.

LEVEL OF EVIDENCE

Level IV, systematic review of Level II, III, and IV studies.

Risk factors for infection and amputation following open, combat-related calcaneal fractures

BACKGROUND

High-energy open calcaneal fractures are severe injuries complicated by high rates of infection, uncertain functional outcomes, and frequent need for later amputation.

METHODS

We conducted a retrospective review of 102 consecutive combat-related open calcaneal fractures. Patient demographics, injury mechanisms, fracture and wound characteristics, associated fractures, and methods of fracture fixation were reviewed to determine risk factors for eventual amputation or infection.

RESULTS

Eighty-nine patients, with a mean age of twenty-six years, sustained 102 open calcaneal fractures (thirteen bilateral). After a mean follow-up of four years (range, five to ninety-two months), 42% (forty-three limbs) underwent amputation. A delayed amputation (more than twelve weeks from the time of injury) was performed in 15% (fifteen) of 102 open calcaneal fractures. In a multivariate Cox proportional-hazards survival model with time to amputation as the end point, the blast mechanism of injury, plantar wound location, larger size of open wound (in square centimeters), and escalating Gustilo and Anderson classification types (p < 0.05 for all) were predictive of eventual amputation. At the time of the final follow-up, patients who had undergone amputation had lower visual analogue scale scores for pain (2.1 compared with 4.0; p < 0.0001) and higher Tegner activity levels (5.4 compared with 3.5; p < 0.0001) than limb salvage patients.

CONCLUSIONS

Lower-extremity amputation following open calcaneal fractures is predicted by the injury mechanism, wound location and size, and open fracture type and severity. After short-term follow-up, patients with open calcaneal fractures eventually requiring amputation exhibit improved pain and activity levels compared with patients with continued, ostensibly successful limb salvage.

Clinical outcomes assessment in clinical trials to assess treatment of femoroacetabular impingement: use of patient-reported outcome measures

Patient-reported outcome measures are an important component of outcomes assessment in clinical trials to assess the treatment of femoroacetabular impingement (FAI). This review of disease-specific measures and instruments used to assess the generic quality of life and physical activity levels of patients with FAI found no conclusive evidence to support a single disease-specific questionnaire. Using a systematic review of study methodology, the Copenhagen Hip and Groin Outcome Score and the 33-item International Hip Outcome Tool scored the best. Nevertheless, both of these instruments were developed recently and have not been established in the literature. Although currently used generic and activity-level measures have limitations, as well, they should be considered, depending on the specific goals of the study. Additional research is needed to assess the properties of these measures fully when used to evaluate patients with FAI.

Health-related quality of life after total knee or hip replacement for osteoarthritis: a 7-year prospective study

OBJECTIVE

To assess health-related quality of life (HRQOL) in a prospective study with 7 years of follow-up in 49 consecutive patients who underwent a total joint replacement because of osteoarthritis.

METHODS

Generic HRQOL was assessed with the short-form 36 (SF-36) and specific HRQOL with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC).

RESULTS

Out of the 39 subjects who have completed the 7 years of follow-up of this study, 22 (56.4 %) underwent a hip replacement surgery and the other 17 (43.6 %) a knee replacement. Six months after surgery, a significant improvement, compared to preoperative scores, was observed in two of the eight dimensions of the SF-36 (i.e. physical function and pain). The same dimensions, pain and physical function, at the same time, 6 months after surgery, measured by the WOMAC, showed a significant improvement as well, but there was no significant change in the stiffness score. From 6 months to the end of follow-up, changes in SF-36 scores showed a significant improvement in physical function (p = 0.008), role-physical (p = 0.004) and role-emotional (p = 0.01) while all scores of the WOMAC improved (p < 0.001 for pain, p < 0.001 for stiffness and p < 0.01 for physical function).

CONCLUSION

The improvements observed in HRQOL at short term after surgery, are at least maintained over a 7-year follow-up period.

A short version of the International Hip Outcome Tool (iHOT-12) for use in routine clinical practice

PURPOSE

The purpose of this study was to develop and validate a shorter version of the 33-item International Hip Outcome Tool (iHOT-33) that could be easily used in routine clinical practice to measure both health-related quality of life and changes after treatment in young, active patients with hip disorders.

METHODS

A development dataset (104 patients) was explored with forward-selection linear regression analysis to choose a reduced item set for the new scale. This was tested in a validation dataset (1,833 patients) and responsiveness subset (80 patients) to measure agreement between the shorter and longer versions and to test the sensitivity of the shorter instrument to change after treatment.

RESULTS

Twelve items were chosen for a short version of the International Hip Outcome Tool (iHOT-12). The iHOT-12 showed excellent agreement with the long version (iHOT-33). It captured 95.9% (95% confidence interval, 95.0% to 96.8%) of the variation of the iHOT-33 and showed equivalent sensitivity to change with a standardized effect size of 0.98 (95% confidence interval, 0.67 to 1.28).

CONCLUSIONS

A short version of the International Hip Outcome Tool (iHOT-12) has been developed. It has very similar characteristics to the original rigorously validated 33-item questionnaire, losing very little information despite being only one-third the length. It is valid, reliable, and responsive to change. We suggest that it be used for initial assessment and postoperative follow-up in routine clinical practice.