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Noebauer-Huhmann IM, Vanhoenacker FM, Vilanova JC, Tagliafico AS, Weber MA, Lalam RK, Grieser T, Nikodinovska VV, de Rooy JWJ, Papakonstantinou O, Mccarthy C, Sconfienza LM, Verstraete K, Martel-Villagrán J, Szomolanyi P, Lecouvet FE, Afonso D, Albtoush OM, Aringhieri G, Arkun R, Aström G, Bazzocchi A, Botchu R, Breitenseher M, Chaudhary S, Dalili D, Davies M, de Jonge MC, Mete BD, Fritz J, Gielen JLMA, Hide G, Isaac A, Ivanoski S, Mansour RM, Muntaner-Gimbernat L, Navas A, O Donnell P, Örgüç Ş, Rennie W, Resano S, Robinson P, Sanal HT, Ter Horst SAJ, van Langevelde K, Wörtler K, Koelz M, Panotopoulos J, Windhager R, Bloem JL. Soft tissue tumor imaging in adults: European Society of Musculoskeletal Radiology-Guidelines 2023-overview, and primary local imaging: how and where? Eur Radiol 2024; 34:4427-4437. [PMID: 38062268 PMCID: PMC11213759 DOI: 10.1007/s00330-023-10425-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 09/08/2023] [Accepted: 09/26/2023] [Indexed: 06/29/2024]
Abstract
OBJECTIVES Early, accurate diagnosis is crucial for the prognosis of patients with soft tissue sarcomas. To this end, standardization of imaging algorithms, technical requirements, and reporting is therefore a prerequisite. Since the first European Society of Musculoskeletal Radiology (ESSR) consensus in 2015, technical achievements, further insights into specific entities, and the revised WHO-classification (2020) and AJCC staging system (2017) made an update necessary. The guidelines are intended to support radiologists in their decision-making and contribute to interdisciplinary tumor board discussions. MATERIALS AND METHODS A validated Delphi method based on peer-reviewed literature was used to derive consensus among a panel of 46 specialized musculoskeletal radiologists from 12 European countries. Statements were scored online by level of agreement (0 to 10) during two iterative rounds. Either "group consensus," "group agreement," or "lack of agreement" was achieved. RESULTS Eight sections were defined that finally contained 145 statements with comments. Overall, group consensus was reached in 95.9%, and group agreement in 4.1%. This communication contains the first part consisting of the imaging algorithm for suspected soft tissue tumors, methods for local imaging, and the role of tumor centers. CONCLUSION Ultrasound represents the initial triage imaging modality for accessible and small tumors. MRI is the modality of choice for the characterization and local staging of most soft tissue tumors. CT is indicated in special situations. In suspicious or likely malignant tumors, a specialist tumor center should be contacted for referral or teleradiologic second opinion. This should be done before performing a biopsy, without exception. CLINICAL RELEVANCE The updated ESSR soft tissue tumor imaging guidelines aim to provide best practice expert consensus for standardized imaging, to support radiologists in their decision-making, and to improve examination comparability both in individual patients and in future studies on individualized strategies. KEY POINTS • Ultrasound remains the best initial triage imaging modality for accessible and small suspected soft tissue tumors. • MRI is the modality of choice for the characterization and local staging of soft tissue tumors in most cases; CT is indicated in special situations. Suspicious or likely malignant tumors should undergo biopsy. • In patients with large, indeterminate or suspicious tumors, a tumor reference center should be contacted for referral or teleradiologic second opinion; this must be done before a biopsy.
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Affiliation(s)
- Iris-Melanie Noebauer-Huhmann
- Department of Biomedical Imaging and Image Guided Therapy, Division of Neuroradiology and Musculoskeletal Radiology, Medical University of Vienna, Vienna, Austria.
| | - Filip M Vanhoenacker
- Department of Radiology AZ Sint Maarten Mechelen, University Hospital Antwerp, Antwerp, Belgium
- Faculty of Medicine and Health Sciences, University of Ghent, Ghent, Belgium
| | - Joan C Vilanova
- Department of Radiology, Clínica Girona, Institute of Diagnostic Imaging (IDI) Girona, University of Girona, Girona, Spain
| | - Alberto S Tagliafico
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
- Department of Radiology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Marc-André Weber
- Institute of Diagnostic and Interventional Radiology, Pediatric Radiology and Neuroradiology, University Medical Center Rostock, Rostock, Germany
| | - Radhesh K Lalam
- Department of Radiology, Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, UK
| | - Thomas Grieser
- Dept. for Diagnostic and Interventional, Radiology University Hospital Augsburg, Augsburg, Germany
| | - Violeta Vasilevska Nikodinovska
- Medical Faculty, Ss. Cyril and Methodius University, Skopje, Macedonia
- Department of Radiology, University Surgical Clinic "St. Naum Ohridski" Skopje, Skopje, Macedonia
| | - Jacky W J de Rooy
- Department of Imaging, Radiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Olympia Papakonstantinou
- 2Nd Department of Radiology, Attikon Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Catherine Mccarthy
- Oxford Musculoskeletal Radiology and Oxford University Hospitals, Oxford, UK
| | - Luca Maria Sconfienza
- IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
- Dipartimento Di Scienze Biomediche Per La Salute, Università Degli Studi Di Milano, Milan, Italy
| | | | | | - Pavol Szomolanyi
- High Field MR Center, Department of Biomedical Imaging and Image-Guided Therapy, Medical University Vienna, Vienna, Austria
- Department of Imaging Methods, Institute of Measurement Science, Slovak Academy of Sciences, Bratislava, Slovakia
| | - Frédéric E Lecouvet
- Department of Radiology and Medical Imaging, Cliniques Universitaires Saint Luc, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain (UCLouvain), Brussels, Belgium
| | - Diana Afonso
- Hospital Particular da Madeira, and Hospital da Luz Lisboa, Lisbon, Portugal
| | - Omar M Albtoush
- Department of Radiology, University of Jordan, Ammam, Jordan
| | - Giacomo Aringhieri
- Academic Radiology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Remide Arkun
- Ege University Medical School Izmir, Izmir, Turkey Star Imaging Center Izmir, Izmir, Turkey
| | - Gunnar Aström
- Department of Immunology, Genetics and Pathology (Oncology) and Department of Surgical Sciences (Radiology), Uppsala University, Uppsala, Sweden
| | - Alberto Bazzocchi
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Rajesh Botchu
- Department of Musculoskeletal Radiology, Royal Orthopedic Hospital, Birmingham, UK
| | | | | | - Danoob Dalili
- Academic Surgical Unit, South West London Elective Orthopaedic Centre (SWLEOC), London, UK
| | - Mark Davies
- Department of Musculoskeletal Radiology, Royal Orthopedic Hospital, Birmingham, UK
| | - Milko C de Jonge
- Department of Radiology, St. Antonius Hospital, Utrecht, The Netherlands
| | - Berna D Mete
- Department of Radiology School of Medicine, Izmir Demokrasi University, Izmir, Turkey
| | - Jan Fritz
- Department of Radiology, NYU Grossman School of Medicine, New York, USA
- Diagnostic and Interventional Radiology, Eberhard Karls University Tuebingen, University Hospital Tuebingen, Tübingen, Germany
| | - Jan L M A Gielen
- Department of Radiology and Medical Imaging, University Hospital Antwerp, Edegem, Belgium
| | - Geoff Hide
- Department of Radiology, Freeman Hospital, Newcastle Upon Tyne, UK
| | - Amanda Isaac
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Slavcho Ivanoski
- St. Erasmo Hospital for Orthopaedic Surgery and Traumatology Ohrid, Ohrid, Macedonia
| | | | | | - Ana Navas
- Department of Radiology, Division of Musculoskeletal Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | | | - Winston Rennie
- Clinical MSK Radiology, Loughborough University, Leicester Royal Infirmary, Leicester, UK
| | | | - Philip Robinson
- Musculoskeletal Radiology Department Chapel Allerton Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
- NIHR Leeds Biomedical Research Centre, Leeds, UK
| | - Hatice T Sanal
- Radiology Department, University of Health Sciences, Gülhane Training and Research Hospital, Istanbul, Turkey
| | - Simone A J Ter Horst
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands Department of Radiology and Nuclear Medicine, University Medical Centre Utrecht, Utrecht, The Netherlands
| | | | - Klaus Wörtler
- Musculoskeletal Radiology Section, Klinikum Rechts der Isar, Technical University of Munich - TUM School of Medicine, Munich, Germany
| | - Marita Koelz
- Clinical Institute of Pathology, Medical University of Vienna, Vienna, Austria
| | - Joannis Panotopoulos
- Departement of Orthopaedics and Traumatology, Division of Orthopaedics, Medical University of Vienna, Vienna, Austria
| | - Reinhard Windhager
- Departement of Orthopaedics and Traumatology, Medical University of Vienna, Vienna, Austria
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Fernandes DA, Martins EC, Melo G, Locks R, Adam GP, Neves FS. Diagnostic Capability of Intra-Articular Injections for Femoroacetabular Impingement Syndrome: A Systematic Review. Clin J Sport Med 2024:00042752-990000000-00192. [PMID: 38810122 DOI: 10.1097/jsm.0000000000001229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Accepted: 04/28/2024] [Indexed: 05/31/2024]
Abstract
OBJECTIVE To review and critically appraise available literature concerning the diagnostic capability of intra-articular injections for femoroacetabular impingement (FAI) syndrome. DESIGN Systematic review. SETTING N/A. PARTICIPANTS N/A. INTERVENTIONS N/A. MAIN OUTCOME MEASURES Studies assessing pain relief following intra-articular injections for the diagnosis of FAI syndrome, compared with arthroscopy as diagnostic reference standard, were considered eligible. Searches were performed across 8 databases, and the risk of bias was evaluated through the Quality Assessment of Diagnostic Accuracy Studies tool. RESULTS From 489 articles identified, 4 were included for analysis. Intra-articular injections were composed of anesthetic agents (such as lidocaine, bupivacaine, and ropivacaine), combined or not with corticosteroids (triamcinolone and betamethasone). All studies were judged as "at risk of bias", and a substantial heterogeneity was found considering assessment methods and pain relief thresholds for a positive response to intra-articular injections. Overall, 2 studies reported that intra-articular injections presented a high accuracy in determining the presence of FAI syndrome. However, the remaining 2 studies indicated that intra-articular injections might present restricted diagnostic capability to discriminate FAI syndrome from healthy individuals or those with other hip pathologies. CONCLUSIONS Based on limited evidence, the diagnostic capability of intra-articular injections for FAI syndrome cannot be supported. It remains unclear which pain relief thresholds are related to a higher diagnostic capability. The combination of anesthetics with corticosteroids should also be further explored, including multiple pain assessments for evaluation of prolonged effects.
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Affiliation(s)
- Daniel Araujo Fernandes
- Department of Surgery, Federal University of Santa Catarina (UFSC), Biomechanical Engineering Laboratory (LEBm-UFSC), Postgraduate Program in Medical Sciences (PPGCM-UFSC), Florianópolis, Santa Catarina, Brazil
| | - Eduardo Campos Martins
- Medical School, Federal University of Santa Catarina (UFSC), Florianópolis, Santa Catarina, Brazil
| | - Gilberto Melo
- Department of Public Health, Federal University of Santa Catarina (UFSC), Florianópolis, Santa Catarina, Brazil
| | - Renato Locks
- Department of Orthopaedics, Regional Hospital of São José Dr Homero de Miranda Gomes, Florianópolis, Santa Catarina, Brazil
| | | | - Fabrício Souza Neves
- Internal Medicine Department, Federal University of Santa Catarina (UFSC), Florianópolis, Santa Catarina, Brazil
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Hamel C, Avard B, Gorelik N, Heroux M, Mai D, Sheikh A, Vo A, Watson ML, Rakhra K. Canadian Association of Radiologists Musculoskeletal System Diagnostic Imaging Referral Guideline. Can Assoc Radiol J 2024; 75:269-278. [PMID: 37635274 DOI: 10.1177/08465371231190807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023] Open
Abstract
The Canadian Association of Radiologists (CAR) Musculoskeletal System Expert Panel consists of musculoskeletal radiologists, a family physician, a sports and exercise medicine physician, emergency medicine physicians, a patient advisor, and an epidemiologist/guideline methodologist. After developing a list of 25 musculoskeletal clinical/diagnostic scenarios, a systematic rapid scoping review was undertaken to identify systematically produced referral guidelines that provide recommendations for 1 or more of these clinical/diagnostic scenarios. Recommendations from 41 guidelines (50 publications) and contextualization criteria in the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) for guidelines framework were used to develop 124 recommendation statements across the 25 scenarios related to the evaluation of the musculoskeletal system. This guideline presents the methods of development and the recommendations for imaging in the context of musculoskeletal pain, infection, tumors, arthropathies, metabolic bone disease, stress injuries, orthopedic hardware, avascular necrosis/bone infarction, and complex regional pain syndrome.
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Affiliation(s)
- Candyce Hamel
- Canadian Association of Radiologists, Ottawa, ON, Canada
| | - Barb Avard
- North York General Hospital, Toronto, ON, Canada
| | - Natalia Gorelik
- Department of Radiology, McGill University Health Centre, Montreal, QC, Canada
| | | | | | - Adnan Sheikh
- Vancouver General Hospital, Vancouver, BC, Canada
| | | | | | - Kawan Rakhra
- The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
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Noebauer-Huhmann IM, Koenig FRM, Chiari C, Schmaranzer F. [Femoroacetabular impingement in adolescents]. RADIOLOGIE (HEIDELBERG, GERMANY) 2023; 63:749-757. [PMID: 37698653 PMCID: PMC10522737 DOI: 10.1007/s00117-023-01197-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/28/2023] [Indexed: 09/13/2023]
Abstract
Femoroacetabular impingement syndrome (FAIS) is caused by a repetitive mechanical conflict between the acetabulum and the proximal femur, occurring in flexion and internal rotation. In cam impingement, bony prominences of the femoral head-neck junction induce chondrolabral damage. The acetabular type of FAIS, termed pincer FAIS, may be either due to focal or global retroversion and/or acetabular overcoverage. Combinations of cam and pincer morphology are common. Pathological femoral torsion may aggravate or decrease the mechanical conflict in FAI but can also occur in isolation. Of note, a high percentage of adolescents with FAI-like shape changes remain asymptomatic. The diagnosis of FAIS is therefore made clinically, whereas imaging reveals the underlying morphology. X‑rays in two planes remain the primary imaging modality, the exact evaluation of the osseous deformities of the femur and chondrolabral damage is assessed by magnetic resonance imaging (MRI). Acetabular coverage and version are primarily assessed on radiographs. Evaluation of the entire circumference of the proximal femur warrants MRI which is further used in the assessment of chondrolabral lesions, and also bone marrow and adjacent soft tissue abnormalities. The MRI protocol should routinely include measurements of femoral torsion. Fluid-sensitive sequences should be acquired to rule out degenerative or inflammatory extra-articular changes.
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Affiliation(s)
- Iris-M Noebauer-Huhmann
- Universitätsklinik für Radiologie und Nuklearmedizin, Abteilung für Neuroradiologie und Muskuloskelettale Radiologie, Medizinische Universität Wien, Wien, Österreich.
| | - Felix R M Koenig
- Universitätsklinik für Radiologie und Nuklearmedizin, Abteilung für Neuroradiologie und Muskuloskelettale Radiologie, Medizinische Universität Wien, Wien, Österreich
| | - Catharina Chiari
- Universitätsklinik für Orthopädie und Unfallchirurgie, Klinische Abteilung für Orthopädie, Medizinische Universität Wien, Wien, Österreich
- Abteilung für Kinderorthopädie und Fußchirurgie, Orthopädisches Spital Speising, Wien, Österreich
| | - Florian Schmaranzer
- Universitätsklinik für Diagnostische‑, Interventionelle- und Pädiatrische Radiologie, Inselspital Bern, Universität Bern, Bern, Schweiz
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Meier MK, Wagner M, Brunner A, Lerch TD, Steppacher SD, Vavron P, Schmaranzer E, Schmaranzer F. Can gadolinium contrast agents be replaced with saline for direct MR arthrography of the hip? A pilot study with arthroscopic comparison. Eur Radiol 2023; 33:6369-6380. [PMID: 37042981 PMCID: PMC10415454 DOI: 10.1007/s00330-023-09586-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 02/08/2023] [Accepted: 02/10/2023] [Indexed: 04/13/2023]
Abstract
OBJECTIVE To compare image quality and diagnostic performance of preoperative direct hip magnetic resonance arthrography (MRA) performed with gadolinium contrast agent and saline solution. METHODS IRB-approved retrospective study of 140 age and sex-matched symptomatic patients with femoroacetabular impingement, who either underwent intra-articular injection of 15-20 mL gadopentetate dimeglumine (GBCA), 2.0 mmol/L ("GBCA-MRA" group, n = 70), or 0.9% saline solution ("Saline-MRA" group, n = 70) for preoperative hip MRA and subsequent hip arthroscopy. 1.5 T hip MRA was performed including leg traction. Two readers assessed image quality using a 5-point Likert scale (1-5, excellent-poor), labrum and femoroacetabular cartilage lesions. Arthroscopic diagnosis was used to calculate diagnostic accuracy which was compared between groups with Fisher's exact tests. Image quality was compared with the Mann-Whitney U tests. RESULTS Mean age was 33 years ± 9, 21% female patients. Image quality was excellent (GBCA-MRA mean range, 1.1-1.3 vs 1.1-1.2 points for Saline-MRA) and not different between groups (all p > 0.05) except for image contrast which was lower for Saline-MRA group (GBCA-MRA 1.1 ± 0.4 vs Saline-MRA 1.8 ± 0.5; p < 0.001). Accuracy was high for both groups for reader 1/reader 2 for labrum (GBCA-MRA 94%/ 96% versus Saline-MRA 96%/93%; p > 0.999/p = 0.904) and acetabular (GBCA-MRA 86%/ 83% versus Saline-MRA 89%/87%; p = 0.902/p = 0.901) and femoral cartilage lesions (GBCA-MRA 97%/ 99% versus Saline-MRA 97%/97%; both p > 0.999). CONCLUSION Diagnostic accuracy and image quality of Saline-MRA and GBCA-MRA is high in assessing chondrolabral lesions underlining the potential role of non-gadolinium-based hip MRA. KEY POINTS • Image quality of Saline-MRA and GBCA-MRA was excellent for labrum, acetabular and femoral cartilage, ligamentum teres, and the capsule (all p > 0.18). • The overall image contrast was lower for Saline-MRA (Saline-MRA 1.8 ± 0.5 vs. GBCA-MRA 1.1 ± 0.4; p < 0.001). • Diagnostic accuracy was high for Saline-MRA and GBCA-MRA for labrum (96% vs. 94%; p > 0.999), acetabular cartilage damage (89% vs. 86%; p = 0.902), femoral cartilage damage (97% vs. 97%; p > 0.999), and extensive cartilage damage (97% vs. 93%; p = 0.904).
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Affiliation(s)
- Malin K Meier
- Department of Orthopedic Surgery, Inselspital Bern, University Hospital, University of Bern, Freiburgstrasse, 3010, Bern, Switzerland
| | - Moritz Wagner
- Department of Orthopaedic Surgery, District Hospital St. Johann in Tirol, Bahnhofstrasse 14, 6380, St. Johann in Tirol, Austria
| | - Alexander Brunner
- Department of Orthopaedic Surgery, District Hospital St. Johann in Tirol, Bahnhofstrasse 14, 6380, St. Johann in Tirol, Austria
| | - Till D Lerch
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010, Bern, Switzerland
| | - Simon D Steppacher
- Department of Orthopedic Surgery, Inselspital Bern, University Hospital, University of Bern, Freiburgstrasse, 3010, Bern, Switzerland
| | - Peter Vavron
- Department of Orthopaedic Surgery, District Hospital St. Johann in Tirol, Bahnhofstrasse 14, 6380, St. Johann in Tirol, Austria
| | - Ehrenfried Schmaranzer
- Department of Radiology, District Hospital St. Johann in Tirol, Bahnhofstrasse 14, 6380, St. Johann in Tirol, Austria
| | - Florian Schmaranzer
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010, Bern, Switzerland.
- Department of Radiology, District Hospital St. Johann in Tirol, Bahnhofstrasse 14, 6380, St. Johann in Tirol, Austria.
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Ebert JR, Raymond AC, Aujla RS, D'Alessandro P. The Effect of a Formal Nonoperative Management Program Combining a Hip Injection With Structured Adjunctive Exercise Rehabilitation in Patients With Symptomatic Femoroacetabular Impingement Syndrome. Am J Sports Med 2023; 51:694-706. [PMID: 36752689 DOI: 10.1177/03635465221148744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
BACKGROUND Although the initial treatment recommendations for femoroacetabular impingement syndrome (FAIS) may include nonsurgical therapies such as injections and rehabilitation, many patients undergo isolated injections or a rudimentary exercise regimen. PURPOSE To investigate the benefit of an intra-articular hip injection and concomitant structured exercise rehabilitation program in patients with symptomatic FAIS ≥6 months. STUDY DESIGN Case series; Level of evidence, 4. METHODS For this study we recruited 49 patients with a mean age of 32.8 years (range, 16-56 years) and symptoms ≥6 months (range, 6-250 months) associated with FAIS, as confirmed via magnetic resonance imaging and radiography. After a guided intra-articular injection of corticosteroid and local anesthetic, patients underwent a structured 12-week rehabilitation program. Patients were assessed before and after injection (8 weeks and 4, 6, 12, and 24 months) with a range of patient-reported outcome measures (PROMs), including the 33-item International Hip Outcome Tool, Hip Outcome Score, modified Harris Hip Score, the Tegner Activity Score, a visual analog scale assessing the frequency and severity of hip pain, and a Global Rating of Change scale. Range of motion, peak isometric hip strength, and hop tests were assessed. Absolute scores and limb symmetry indices were calculated. The percentage of patients transitioning toward surgery over the period was evaluated. RESULTS Of the 44 patients who underwent the injection and completed the initial 8-week rehabilitation component, 14 (31.8%) progressed toward surgical intervention over the 24-month postinjection period owing to dissatisfaction and/or symptom recurrence. Patients who progressed toward surgery, as compared with those who did not, reported significantly worse (P < .05) PROMs presurgery and more pain within the first 4 weeks after injection. In the nonoperative cohort, a significant improvement (P < .05) in all PROMs was observed, with 93% of these patients satisfied overall. The Global Rating of Change did not improve, although this was measured only after the injection, reflecting no further significant perceived global change from 8 weeks to 24 months. A significant increase (P < .05) in all hip range of motion and most isometric strength measures was observed at 8 weeks after injection, with these improvements largely sustained until 24 months. Bilateral improvements in hop capacity were observed, with hop test LSIs significantly improving for the single (p = 0.009), triple (p = 0.029) and triple crossover (p = 0.005) hop tests for distance. CONCLUSION Although 32% of patients progressed toward surgery, significant improvement in hip pain, symptoms, and physical function was observed in the majority of patients with symptomatic FAIS as a result of a targeted nonoperative management pathway consisting of an intra-articular injection and a structured exercise program.
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Affiliation(s)
- Jay R Ebert
- School of Human Sciences (Exercise and Sport Science), University of Western Australia, Crawley, Australia
- HFRC Rehabilitation Clinic, Nedlands, Australia
- Orthopaedic Research Foundation of Western Australia, Bethesda Hospital, Claremont, Australia
| | | | | | - Peter D'Alessandro
- Orthopaedic Research Foundation of Western Australia, Bethesda Hospital, Claremont, Australia
- Coastal Orthopaedics, Bethesda Hospital, Claremont, Australia
- Fiona Stanley and Fremantle Hospitals Group, South Metropolitan Health Service, Murdoch, Australia
- School of Surgery, University of Western Australia, Crawley, Australia
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Dijkstra HP, Mc Auliffe S, Ardern CL, Kemp JL, Mosler AB, Price A, Blazey P, Richards D, Farooq A, Serner A, McNally E, Mascarenhas V, Willy RW, Oke JL, Khan KM, Glyn-Jones S, Clarke M, Greenhalgh T. Oxford consensus on primary cam morphology and femoroacetabular impingement syndrome: part 1-definitions, terminology, taxonomy and imaging outcomes. Br J Sports Med 2022; 57:bjsports-2022-106085. [PMID: 36588401 PMCID: PMC9985727 DOI: 10.1136/bjsports-2022-106085] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2022] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Primary cam morphology is a mostly benign bony prominence that develops at the femoral head-neck junction of the hip, but it is highly prevalent in many athlete populations. In the small proportion of athletes for whom it is not benign, the resulting hip osteoarthritis can be debilitating. Clinicians, athletes, patients and researchers do not yet agree on important primary cam morphology elements. We aimed to ascertain and improve the level of agreement on primary cam morphology definitions, terminology, taxonomy and imaging outcome measures. METHODS To collect and aggregate informed opinions, an expert panel-the Young Athlete's Hip Research Collaborative-rated primary cam morphology definition, terminology, taxonomy and imaging outcome statements through an online Delphi exercise followed by an online meeting to explore areas of tension and dissent. Reporting followed Conducting and REporting DElphi Studies. RESULTS A diverse and inclusive Delphi panel (n=65 for rounds 1 and 2, representing 18 countries; 6 stakeholder groups; 40% women) agreed on 35 of 47 statements in 4 domains, while surfacing areas of tension and dissent. This Delphi panel agreed on four key issues essential to moving research and clinical care forward around primary cam morphology. They agreed on: (1) definition, confirming its conceptual attributes (tissue type, size, location, shape and ownership); (2) terminology-use 'morphology' and not terms with a negative connotation like 'lesion', 'abnormality' or 'deformity'; (3) taxonomy, distinguishing between primary and secondary cam morphology, and (4) imaging outcomes, a continuous bone/cartilage alpha angle on radial femoral head-neck MRI for primary cam morphology aetiology research. CONCLUSION This consensus provides athletes, patients, clinicians and researchers with a strong foundation to guide more precise communication, better clinical decision-making and higher value research about primary cam morphology and its natural history.
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Affiliation(s)
- H Paul Dijkstra
- Department of Medical Education, Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Qatar
- Department for Continuing Education, University of Oxford, Oxford, UK
| | - Sean Mc Auliffe
- Department of Physical Therapy & Rehabilitation Science, Qatar University, Doha, Qatar
- Department of Physiotherapy, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Clare L Ardern
- Department of Family Practice, The University of British Columbia, Vancouver, British Columbia, Canada
- La Trobe Sport and Exercise Medicine Research Centre; Australian IOC Research Centre, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia
| | - Joanne L Kemp
- La Trobe Sport and Exercise Medicine Research Centre; Australian IOC Research Centre, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia
| | - Andrea Britt Mosler
- La Trobe Sport and Exercise Medicine Research Centre; Australian IOC Research Centre, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia
| | - Amy Price
- Department of Anesthesia, Informatics and Media Lab, Stanford University School of Medicine, Stanford, California, USA
| | - Paul Blazey
- Center for Hip Health and Mobility, The University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Abdulaziz Farooq
- FIFA Medical Centre of Excellence, Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Qatar
| | - Andreas Serner
- FIFA Medical, Federation Internationale de Football Association, Zurich, Switzerland
| | | | - Vasco Mascarenhas
- Advanced Imaging Research Consortium UIME, Hospital da Luz, Lisboa, Portugal
| | - Richard W Willy
- Physical Therapy and Movement Science, University of Montana, Missoula, Montana, USA
| | - Jason L Oke
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Karim M Khan
- Family Practice & Kinesiology, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Sion Glyn-Jones
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Mike Clarke
- Northern Ireland Methodology Hub, Queen's University Belfast, Belfast, UK
| | - Trisha Greenhalgh
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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8
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Dijkstra HP, Mc Auliffe S, Ardern CL, Kemp JL, Mosler AB, Price A, Blazey P, Richards D, Farooq A, Serner A, McNally E, Mascarenhas V, Willy RW, Oke JL, Khan KM, Glyn-Jones S, Clarke M, Greenhalgh T. Oxford consensus on primary cam morphology and femoroacetabular impingement syndrome: part 2-research priorities on conditions affecting the young person's hip. Br J Sports Med 2022; 57:bjsports-2022-106092. [PMID: 36588402 PMCID: PMC9985764 DOI: 10.1136/bjsports-2022-106092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2022] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Primary cam morphology is highly prevalent in many athlete populations, causing debilitating hip osteoarthritis in some. Existing research is mired in confusion partly because stakeholders have not agreed on key primary cam morphology elements or a prioritised research agenda. We aimed to inform a more rigorous, inclusive and evidence-based approach to research on primary cam morphology and its natural history by working towards agreement on a set of research priorities for conditions affecting the young person's hip. METHODS An international expert panel-the Young Athlete's Hip Research (YAHiR) Collaborative-rated research priority statements through an online two-round Delphi exercise and met online to explore areas of tension and dissent. Panellists ranked the prioritised research statements according to the Essential National Health Research (ENHR) ranking strategy. Reporting of results followed REPRISE (REporting guideline for PRIority SEtting of health). RESULTS A diverse Delphi panel (n=65, Delphi rounds 1 and 2; three ENHR strategy surveys: n=49; n=44; n=42) from 18 countries representing six stakeholder groups, prioritised and ranked 18 of 38 research priority statements. The prioritised statements outlined seven research domains: (1) best practice physiotherapy, (2) rehabilitation progression and return to sport, (3) exercise intervention and load management, (4) primary cam morphology prognosis and aetiology, (5) femoroacetabular impingement syndrome prognosis and aetiology, (6) diagnostic criteria, and (7) screening. The panel recommended areas of tension and dissent for the research community to focus on immediately. CONCLUSION While informing more rigorous, inclusive and evidence-based research, this consensus is a roadmap for researchers, policy-makers and funders to implement research dedicated to reducing the cost and burden of hip disease related to primary cam morphology.
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Affiliation(s)
- H Paul Dijkstra
- Department of Medical Education, Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Qatar
- Department for Continuing Education, University of Oxford, Oxford, UK
| | - Sean Mc Auliffe
- Department of Physical Therapy and Rehabilitation Science, Qatar University, Doha, Qatar
- Department of Physiotherapy, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Clare L Ardern
- Department of Family Practice, The University of British Columbia, Vancouver, British Columbia, Canada
- La Trobe Sport and Exercise Medicine Research Centre; Australian IOC Research Centre, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia
| | - Joanne L Kemp
- La Trobe Sport and Exercise Medicine Research Centre; Australian IOC Research Centre, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia
| | - Andrea Britt Mosler
- La Trobe Sport and Exercise Medicine Research Centre; Australian IOC Research Centre, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia
| | - Amy Price
- Department of Anesthesia, Informatics and Media Lab, Stanford University School of Medicine, Stanford, California, USA
| | - Paul Blazey
- Center for Hip Health and Mobility, The University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Abdulaziz Farooq
- FIFA Medical Centre of Excellence, Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Qatar
| | - Andreas Serner
- FIFA Medical, Federation Internationale de Football Association, Zurich, Switzerland
| | | | - Vasco Mascarenhas
- Advanced Imaging Research Consortium UIME, Hospital da Luz, Lisboa, Portugal
| | - Richard W Willy
- School of Physical Therapy, University of Montana, Missoula, Montana, USA
| | - Jason L Oke
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Karim M Khan
- Family Practice & Kinesiology, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Sion Glyn-Jones
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Mike Clarke
- Northern Ireland Methodology Hub, Queen's University Belfast, Belfast, UK
| | - Trisha Greenhalgh
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Scholes MJ, Kemp JL, Mentiplay BF, Heerey JJ, Agricola R, Semciw AI, Souza RB, Link TM, Majumdar S, King MG, Lawrenson PR, Crossley KM. Does Femoroacetabular Impingement Syndrome Affect Self-Reported Burden in Football Players With Hip and Groin Pain? Sports Health 2022; 14:920-931. [PMID: 35321607 PMCID: PMC9631050 DOI: 10.1177/19417381221076141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND It is unknown if football players with femoroacetabular impingement (FAI) syndrome report worse burden than those with other causes of hip/groin pain, and to what extent this is mediated by cartilage defects and labral tears. HYPOTHESIS Football players with FAI syndrome would report worse burden than other symptomatic players, with the effect partially mediated by cartilage defects and/or labral tears. STUDY DESIGN Cross-sectional study. LEVEL OF EVIDENCE Level 4. METHODS Football (soccer and Australian football) players (n = 165; 35 women) with hip/groin pain (≥6 months and positive flexion-adduction-internal rotation test) were recruited. Participants completed 2 patient-reported outcome measures (PROMs; the International Hip Outcome Tool-33 [iHOT-33] and Copenhagen Hip and Groin Outcome Score [HAGOS]) and underwent hip radiographs and magnetic resonance imaging (MRI). FAI syndrome was determined to be present when cam and/or pincer morphology were present. Cartilage defects and labral tears were graded as present or absent using MRI. Linear regression models investigated relationships between FAI syndrome (dichotomous independent variable) and PROM scores (dependent variables). Mediation analyses investigated the effect of cartilage defects and labral tears on these relationships. RESULTS FAI syndrome was not related to PROM scores (unadjusted b values ranged from -4.693 (P = 0.23) to 0.337 (P = 0.93)) and cartilage defects and/or labral tears did not mediate its effect (P = 0.22-0.97). CONCLUSION Football players with FAI syndrome did not report worse burden than those with other causes of hip/groin pain. Cartilage defects and/or labral tears did not explain the effect of FAI syndrome on reported burden. CLINICAL RELEVANCE FAI syndrome, cartilage defects, and labral tears were prevalent but unrelated to reported burden in symptomatic football players.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Kay M. Crossley
- Kay M. Crossley, PT, PhD,
La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health,
Human Services and Sport, La Trobe University, Bundoora, Victoria 3806,
Australia ()
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10
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Curley AJ, Ruh ER, Shah A, Disantis AE, Krivoniak A, Mauro CS, McClincy MP. A systematic approach to CT evaluation of non-arthritic hip pain. EFORT Open Rev 2022; 7:653-662. [PMID: 36125004 PMCID: PMC9624481 DOI: 10.1530/eor-22-0051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Bone morphology has been increasingly recognized as a significant variable in the evaluation of non-arthritic hip pain in young adults. Increased availability and use of multidetector CT in this patient population has contributed to better characterization of the osseous structures compared to traditional radiographs. Femoral and acetabular version, sites of impingement, acetabular coverage, femoral head–neck morphology, and other structural abnormalities are increasingly identified with the use of CT scan. In this review, a standard CT imaging technique and protocol is discussed, along with a systematic approach for evaluating pelvic CT imaging in patients with non-arthritic hip pain.
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Affiliation(s)
- Andrew J Curley
- Department of Orthopedics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ethan R Ruh
- Department of Orthopedics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Amisha Shah
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ashley E Disantis
- Department of Orthopedics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - April Krivoniak
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Craig S Mauro
- Department of Orthopedics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Michael P McClincy
- Department of Orthopedics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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11
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[Imaging in joint-preserving hip surgery]. Radiologe 2022; 62:271-284. [PMID: 35238995 PMCID: PMC8894169 DOI: 10.1007/s00117-022-00973-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/20/2022] [Indexed: 11/25/2022]
Abstract
Instabilität und Impingement stellen die Hauptpathomechanismen dar, die bereits bei jungen Patienten durch erhöhten mechanischen Stress zu chondrolabralen Schäden, schmerzhafter Bewegungseinschränkung und frühzeitiger Coxarthrose führen können. Ziele der gelenkerhaltenden Chirurgie an der Hüfte sind die Korrektur der knöchernen Deformitäten und chondrolabraler Schäden sowie die Wiederherstellung der Gelenkfunktion. Voraussetzung dafür ist die Identifikation der ursächlichen Pathologien an der Hüfte, welche zudem in Kombination auftreten können. Die dezidierte Röntgen- und Magnetresonanzbildgebung der knöchernen Morphologie und der degenerativen Gelenkbinnenläsionen liefern einen essenziellen Beitrag für die Behandlungsindikation und die Behandlungsplanung. Der vorliegende Artikel soll einen kurzen Überblick über die Hüftdeformitäten mit deren Prävalenz, Pathomechanismus und indizierter Therapie sowie detaillierte Empfehlungen über die spezifische radiologische Abklärung geben.
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Vasileff WK. Editorial Commentary: Low-Radiation Dose 3-Dimensional Computed Tomography Scan Reconstruction Is the Best Way to Visualize the Anterior Inferior Iliac Spine-For Now. Arthroscopy 2022; 38:799-801. [PMID: 35248230 DOI: 10.1016/j.arthro.2021.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 08/16/2021] [Indexed: 02/02/2023]
Abstract
Femoroacetabular impingement comes in several anatomic variations that may coexist, and subspine impingement is a commonly discussed cause of indirect extra-articular hip pathology. Although a classification system to identify and understand anterior inferior iliac spine morphology has been in place for some time, attempts have been made to visualize and understand the anatomy based on other imaging modalities. Standard radiographs are a common part of the initial patient evaluation pathway, along with thorough history taking and physical examination findings. Magnetic resonance imaging scans are obtained typically to evaluate the soft tissue, muscle, ligaments, articular cartilage, and labrum for pathology. For many hip preservation surgeons, a computed tomography scan with 3-dimensional reconstruction is standard protocol for patients who progress along the treatment pathway toward a surgical procedure because understanding the complex hip anatomy is key to successful surgical treatment. Many hip arthroscopy patients are in their young adult years, and we always attempt to reduce the amount of radiation exposure. Eliminating this computed tomography scan and using standard-of-care magnetic resonance imaging to simplify patient care, reduce radiation, and reduce health care costs would certainly be beneficial to our hip preservation patients.
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Felsing C, Schröder J. Update Bildgebung beim Femoroazetabulären Impingement-Syndrom. DER ORTHOPADE 2022; 51:176-186. [DOI: 10.1007/s00132-022-04223-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/01/2022] [Indexed: 10/19/2022]
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Clinical relevance of MR arthrography to classify the types of femoro-acetabular impingement. Jpn J Radiol 2021; 40:226-227. [PMID: 34374942 DOI: 10.1007/s11604-021-01188-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 08/03/2021] [Indexed: 10/20/2022]
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