An algorithmic approach to mechanical hip pain

The association between hip adductor and extensor strength, and hip-related patient-reported outcomes in patients with longstanding hip and groin pain: An exploratory cross-sectional study

OBJECTIVE

The objective of this study was to assess the association between hip muscle strength and hip-related patient-reported outcome measures (PROMs) in patients with longstanding hip and groin pain (LHGP).

DESIGN

Cross-sectional design.

SETTING

Orthopedic care.

PARTICIPANTS

Eighty-one patients with LHGP were consecutively recruited.

MAIN OUTCOME MEASURES

Hip muscle strength was measured in adduction and extension. Hip-related PROMs was measured with the Copenhagen Hip and Groin Outcome Score (HAGOS) which includes six subscales (Symptoms, Pain, Activity in Daily Living (ADL), Physical Function in Sports and Recreation (Sport/Rec), Participation in Physical Activities (PA), and Quality of Life (QoL). Linear regression examined the association between hip muscle strength and each HAGOS subscale.

RESULTS

Greater isometric hip muscle strength in adduction was associated with better HAGOS score for Pain and ADL (p ≤ 0.037), but not for Symptoms, Sport/Rec, PA, or QoL (p ≥ 0.154). Greater isometric hip muscle strength in extension was associated with better HAGOS score for Symptoms, Pain, and ADL (p ≤ 0.034), but not for Sport/Rec, PA, or QoL (p ≥ 0.084).

CONCLUSIONS

In patients with LHGP, greater isometric hip muscle strength seems to be associated with less symptoms and pain, and better function in ADL. No association was found for Sport/Rec, PA, or QoL.

Borderline Developmental Dysplasia of the Hip With Osseous Impingement as Distinct From Femoroacetabular Impingement and Developmental Dysplasia of the Hip

Background

Borderline developmental dysplasia of the hip (BDDH) accompanied by cam deformity and subspinous impingement has been found to benefit from arthroscopic surgery. However, the research comparing BDDH combined with osseous impingement to femoroacetabular impingement (FAI) without borderline dysplasia remains limited.

Purpose/Hypothesis

To compare the clinical symptoms, intraoperative findings, and outcomes of hip arthroscopy in patients with BDDH and osseous impingement versus cam-type FAI. It was hypothesized that BDDH with osseous impingement could be classified as a distinct entity between FAI and developmental dysplasia of the hip (DDH).

Study Design

Cohort study; Level of evidence, 3.

Methods

Data were collected from patients 18 to 50 years old who underwent primary hip arthroscopy between September 2016 and October 2020. Patients were divided based on preoperative lateral center-edge angle (LCEA) into 2 groups: (1) BDDH group (LCEA 18°-25°; n = 67); and (2) cam-type FAI group without BDDH (FAI group; LCEA 25°-40° and alpha angle >55°; n = 145). Disparities in symptoms, preoperative examination, intraoperative findings and procedures, and patient-reported outcome (PRO) scores were compared.

Results

Follow-up was available for 61 (91.0%) patients in the BDDH group and 125 (86.2%) patients in the FAI group. The incidence of cam deformity in BDDH patients was 91.8%. The preoperative characteristics and intraoperative findings were similar between the groups; however, preoperative internal and external hip rotation, Tönnis angle, femoroepiphyseal acetabular roof index, labral size, capsule thickness, and percentage of ligamentum teres tear were significantly higher in the BDDH group than the FAI group, and the percentage of pain aggravating factor, cam deformity, and anterior inferior iliac spine types 2 and 3 were also significantly different between groups (P < .05 for all). The percentage of intraoperative minimal acetabuloplasty, subspinous decompression, labral repair, ligamentum teres debridement, and capsular closure was significantly higher in the BDDH group than the FAI group, while the percentage of femoroplasty was higher in the FAI group (P < .05). Pre- to postoperative improvement on PRO scores was seen in both groups.

Conclusion

Given the differences in etiology and surgical procedures between the 2 conditions, it is suggested that BDDH with osseous impingement be classified as an entity distinct from FAI and DDH (and separate from BDDH without impingement) while excluding joint instability.

Arthroscopic Subspine Decompression Is Commonly Reported in a Heterogenous Patient Population With Concomitant Procedures: A Systematic Review

PURPOSE

To systematically review the evaluation, management, and surgical outcomes of arthroscopic subspine decompression in conjunction with other intra-articular hip preservation procedures.

METHODS

Two databases (PubMed and Embase) were searched from 2010 to 2021, in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, for articles investigating arthroscopic subspine decompression using the key words: "subspine impingement", "AIIS impingement", and "extra-articular impingement." Exclusion criteria included diagnostic studies, failure to report postoperative outcomes, and case series of less than 10 hips. Studies were assessed for patient demographics, diagnostic criteria, clinical findings, concomitant procedures, outcomes, and postoperative complications. The quality of the studies was analyzed by 2 independent reviewers (A.J.C. and A.E.J.) using the Methodological Index for Non-randomized Studies (MINORS).

RESULTS

Ten studies consisting of 438 patients (460 hips, 48.6% female) met the inclusion criteria, with average ages and follow-up ranging from 24.9 to 34.7 years and 6.0 to 44.4 months, respectively. There was 1 Level II study, 3 Level III studies, and 6 Level IV studies. The MINORS criteria yielded an average quality assessment of 13.0 (range: 7-22), with 3 methodological domains demonstrating mean scores of less than 1: unbiased assessment of the study endpoint (.25), loss of follow up less than 5% (.25), and prospective calculation of the study size (.7). The most common exam maneuver used was the subspine impingement test (9 studies). Most subspine decompressions were performed in addition to traditional femoroacetabular impingement syndrome (FAIS) procedures, with only one study (33 hips) reporting solely on isolated subspine osteoplasty. Average preoperative and postoperative modified Harris Hip Score (mHHS) values ranged from 44.93 to 75.7 and 79.5 to 98.0, respectively. Three studies noted improved hip flexion in the postoperative period. Five surgical complications were reported.

CONCLUSIONS

Arthroscopic subspine decompression is commonly reported in a heterogenous patient population with intra-articular hip pathology. A combination of the subspine impingement test and anterior inferior iliac spine (AIIS) morphology on imaging is frequently used for diagnosis. While improved patient-reported outcomes (PROs) are consistently observed following arthroscopic decompression, conclusions are limited by study methodology and concurrent procedures performed at the time of surgery.

LEVEL OF EVIDENCE

IV, systematic review of Level II through Level IV studies.

Review of Extraosseous Applications of Thermal Ablation in the Treatment of Moderate to Severe Large Joint Osteoarthritis

Osteoarthritis (OA) is the most common joint disease worldwide, leading to significant pain, restricted range of motion, and disability. A gap exists between short- and long-term symptom-relieving therapies. Although arthroplasty is an effective treatment for symptomatic end-stage disease, most patients ultimately do not receive a joint replacement due to suboptimal surgical qualifications, comorbidities, or an aversion to surgery. The lack of additional treatment options in this setting makes opioid agonists a commonly used pharmacologic agent, contributing to the addiction epidemic that greatly afflicts our communities. Cooled radiofrequency ablation (CRFA) has arisen as a treatment modality in the setting of moderate to severe OA among patients refractory to conservative management, generally showing greater efficacy compared with other existing strategies. This review focuses on the benefits of CRFA and its technical feasibility as a management option among patients experiencing debilitating large joint OA with limited clinical options.

Outcomes After Management of Subspine and Femoroacetabular Impingement Using a Direct Anterior Mini-Open Approach

Background

Subspine impingement (SSI) has been commonly managed with arthroscopic decompression. However, arthroscopic decompression is a demanding technique, as under- or over-resection of the anterior inferior iliac spine (AIIS) could lead to inferior outcomes. An anterior mini-open approach has also been used in the management of femoroacetabular impingement (FAI), and it could provide adequate visualization of the anterior hip joint without a long learning curve.

Purpose/Hypothesis

The objective of the current study was to compare the outcomes of SSI patients with FAI who underwent arthroscopic subspine decompression and osteoplasty with a group undergoing subspine decompression and osteoplasty using a modified direct anterior mini-open approach. It was hypothesized that there would be no significant difference in outcomes between the groups.

Study Design

Cohort study; Level of evidence, 3.

Methods

We reviewed the records of SSI patients who underwent decompression surgery (arthroscopic or mini-open) at our institution from June 1, 2015 to December 31, 2016. Both groups underwent the same postoperative rehabilitation protocol. Preoperative and 2-year postoperative patient-reported outcomes were compared using the modified Harris Hip Score (mHHS), International Hip Outcome Tool-33 (iHOT-33), and Hip Outcome Score-Activities of Daily Living (HOS-ADL). Major and minor complications as well as reoperation rates were recorded.

Results

Included were 47 patients (49 hips) who underwent subspine decompression using an anterior mini-open approach and 35 patients (35 hips) who underwent arthroscopic subspine decompression. There were no differences in demographic and radiological parameters between the groups, and patients in both groups showed significant improvement in all outcome scores at follow-up. The pre- to postoperative improvement in outcome scores was also similar between groups (mini-open vs arthroscopy: mHHS, 26.30 vs 27.04 [P = .783]; iHOT-33, 35.76 vs 31.77 [P = .064]; HOS-ADL, 26.09 vs 22.77 [P = .146]). In the mini-open group, 10 of the 47 patients had temporary meralgia paresthetica, and fat liquefaction was found in 1 female patient. There were no reoperations in the mini-open group.

Conclusion

Subspine decompression using the anterior mini-open approach had similar outcomes to arthroscopic decompression in the management of SSI. The lateral femoral cutaneous nerve should be protected carefully during use of the anterior mini-open approach.

Validation of the French version of the self-administered international hip outcome tool-33 questionnaire

INTRODUCTION

To evaluate the effectiveness of new treatments, whether conservative or surgical, a self-administered questionnaire for hip pain targeted at physically active patients 18 to 60 years of age, named the international Hip Outcome Tool-33 (iHOT-33), was developed and validated in 2012. Since there is no French version available and we are acutely aware of transcultural variations, we conducted a prospective study to: 1) translate, and then 2) validate this questionnaire into international French.

HYPOTHESIS

The iHOT-33-Fr questionnaire is a valid and reliable tool for evaluating hip pain in a young, francophone population.

MATERIALS AND METHODS

Translation of the questionnaire was done according to the standardized method described by Beaton and the final version of the iHOT-33-Fr was validated using the COSMIN methodology. The data were collected prospectively at multiple sites. The reliability of the iHOT-33-Fr questionnaire was evaluated using the intraclass correlation coefficient (ICC) and its internal consistency using Cronbach's alpha. The standard error of measurement and minimum detectable change were calculated. The construct validity was evaluated using Pearson's correlation coefficient by comparing the iHOT-33-Fr with the Hip disability and Osteoarthritis Outcome Score (HOOS-Fr) and Nonarthritic Hip Score (NAHS-Fr).

RESULTS

In all, 101 patients filled out the questionnaires. The ICC was 0.87. The Cronbach alpha was 0.95. The standard error of measurement was 6.4 and the minimum detectable change was 1.8. The correlation between the iHOT-33-Fr and the HOOS-Fr was 0.86, while the correlation between the iHOT-33-Fr and the NAHS-Fr was 0.75.

DISCUSSION

Our results show that the metrological qualities of the iHOT-33-Fr are comparable to those of the original version and the versions translated into other languages. This study demonstrates that the iHOT-33-Fr is valid, reproducible and comparable to the original iHOT-33. It can be used by francophone surgeons treating symptomatic hip disease in young, active patients.

LEVEL OF EVIDENCE

IV.

The Use of Biologics for Hip Preservation

PURPOSE OF REVIEW

A wide array of nonoperative modalities to treat hip pain are aimed at restoring and maintaining the structural and physiologic characteristics of the joint. The purpose of this review is to describe the current understanding of biologics in hip pathology by providing an evidence-based overview of treatment modalities available for orthopedic surgeons.

RECENT FINDINGS

The use of biologics as a primary treatment or adjunct to traditional management has shown encouraging results for the treatment of hip pain. Studies have demonstrated safety with minimal complications when using platelet rich plasma, hyaluronic acid, or stem cells to treat hip pain caused by osteoarthritis, femoroacetabular impingement syndrome, tendinopathy, or osteonecrosis of the femoral head. Several studies have been able to demonstrate meaningful clinical results that can improve treatment standards for hip pain; however, more work must be performed to better delineate the appropriate protocols, indications, and limitations of each modality. Recent advances have inspired renewed interest in biologics for patients with hip pain. We present a concise review of platelet rich plasma, hyaluronic acid, stem cells, and matrix metalloprotease inhibitors and their applicability to hip preservation surgery.

Ultrasound and Ultrasound-Guided Hip Injection Have High Accuracy in the Diagnosis of Femoroacetabular Impingement With Atypical Symptoms

PURPOSE

To evaluate the diagnostic value of ultrasound and ultrasound-guided hip injection in the diagnosis of femoroacetabular impingement (FAI) with atypical symptoms.

METHODS

We evaluated consecutive patients diagnosed with FAI and with atypical symptoms who underwent ultrasound-guided hip injection between January 2017 and February 2019. All patients underwent systematic physical examination, ultrasound examination, magnetic resonance imaging (MRI) examination, and ultrasound-guided injection before surgery. Patients with positive response to ultrasound-guided hip injection were recommended to undergo arthroscopic surgery to treat intra-articular pathology. Sensitivity, specificity, accuracy, and positive predictive value (PPV) of ultrasound and MRI were calculated by using arthroscopic surgery as the gold standard. The accuracy of ultrasound-guided hip injection was recorded. Preoperative and postoperative patient-reported outcomes included visual analog scale for pain and modified Harris Hip Score.

RESULTS

A total of 78 patients with atypical symptoms were diagnosed with FAI. Among these 78 patients, 50 patients had positive responses to injection and 28 patients had negative responses to injection. A total of 36 patients finally underwent arthroscopic surgery. Response to the ultrasound-guided intra-articular injection was 91.7% accurate for detecting the presence of intra-articular abnormality. There were no complications of injection in any of the patients. The sensitivity, PPV, and accuracy by ultrasound diagnosis of cam impingement were 82.9%, 96.7%, and 80.6%, respectively. The sensitivity and accuracy by ultrasound diagnosis of anterosuperior labral tear were both 72.2%. For MRI diagnosis of cam impingement, the sensitivity, PPV and accuracy were 72.2%, 96.3%, and 74.3%, respectively. For MRI diagnosis of labral tear, the sensitivity and accuracy were both 88.9%. Thirty-four patients (94.4%) surpassed the minimal clinically important difference, and 33 patients (91.7%) achieved the patient acceptable symptomatic state.

CONCLUSIONS

Ultrasound and ultrasound-guided hip injection have high accuracy in the diagnosis of femoroacetabular impingement with atypical symptoms.

LEVEL OF EVIDENCE

IV, case series.

Total extraperitoneal laparoscopic inguinal hernia repair with adductor tenotomy: a 10-year experience in the treatment of athletic pubalgia

BACKGROUND

Athletic pubalgia, commonly referred to as a "sports hernia," is a disease process characterized by groin pain produced by physical exertion often occurring in patients whose athletic activities require them to make rapid changes in direction. The groin pain is due to the traction-countertraction relationship between the adductor muscles and the weaker abdominal muscles. Hence, a few studies have shown inguinal hernia repair with adductor tenotomy to be an effective treatment for this pathology (Brody in Hernia 21:139-147, 2016, https://doi.org/10.1007/s10029-016-1520-8 ; Rossidis et al. in Surg Endosc 29:381-386, 2015, https://doi.org/10.1007/s00464-0143679-3 ). However, these studies are small and few in quantity but have demonstrated promising results. Thus, we sought to further study this combined surgical approach as a treatment for this multifactorial disease to improve our understanding and outcomes.

METHODS

With IRB approval, we retrospectively reviewed the charts of all patients who underwent adductor tenotomy and inguinal hernia repair for the treatment of athletic pubalgia at Mount Sinai Medical Center, Miami Beach FL. Parameters gathered included basic demographics, past medical and surgical history, athletic activity, length of surgery, length of time between surgery and follow-up, intraoperative and postoperative complications, and time to return to athletic activities.

RESULTS

A total of 93 patients underwent inguinal hernia repair with adductor tenotomy. These procedures were all performed by a single surgeon at two academic institutions. The average age of patients was 23.4 years. Athletic activities reported by the patients were as follows: American football (n = 36), soccer (n = 18), triathlon (n  = 11), track and field (n = 8), and baseball (n = 5). Less-represented activities included swimming (n = 3), tennis (n = 2), lacrosse (n = 1), golf (n = 1), and other (n = 8). Mean operative time was 72.4 min. Most patients were found to return to athletic activity in 28 days following a standardized physical therapy regimen (92.5%). Postoperative complications included recurrence of pain/symptoms (7.5%, n = 7), urinary retention (2.2%, n = 2), pain along the adductor magnus/brevis muscle group with more extraneous activity (1.1%,  n = 1), and adductor brevis hematoma 3 months following surgery and rehabilitation (1.1%, n = 1). Of the patients with recurrent pain, 2/7 reported contralateral pain.

CONCLUSIONS

Total extraperitoneal laparoscopic inguinal hernia repair with adductor tenotomy appears to be a relatively quick and safe procedure with few postoperative complications. The majority of treated athletes are able to return to full athletic activities within 28 days of operation. While a return of symptoms has been seen in some patients, it is frequently observed on the contralateral side.

Arthroscopic anterior inferior iliac spine decompression does not alter postoperative muscle strength

PURPOSE

The purpose of this study was to assess the additional effect of anterior inferior iliac spine (AIIS) decompression on knee extensor and hip flexor strength and compare functional outcomes after arthroscopic FAI correction with and without AIIS decompression.

METHODS

Sixty patients who underwent arthroscopic FAI correction surgery were divided into two groups matched for AIIS morphology: 31 patients who underwent arthroscopic FAI surgery only (without AIIS decompression) (FAI group) (AIIS Type I; n = 5, Type II; n = 26, Type III; n = 0) and 29 patients who underwent arthroscopic FAI surgery with AIIS decompression (AIIS group) (AIIS Type I; n = 5, Type II; n = 24, Type III; n = 0). Knee extensor and hip flexor strength were evaluated preoperatively and at 6 months after surgery. Patient-reported outcome (PRO) scores using the modified Harris hip score (MHHS), the nonarthritic hip score (NAHS) and iHOT-12 were obtained preoperatively and at 6 months after surgery.

RESULTS

In the AIIS group, there was no significant difference between knee extensor strength pre- and postoperatively (n.s.). In the AIIS group, hip flexor strength was significantly improved postoperatively compared to preoperative measures (p < 0.05). In the FAI group, there were no significant improvements regarding muscle strength (n.s.). While there were no significant differences of preoperative and postoperative MHHS and NAHS between both groups (MHHS; n.s., NAHS; n.s.), the mean postoperative iHOT-12 in the FAI group was inferior to that in the AIIS group. (p < 0.01). The revision surgery rate for the AIIS group was significantly lower compared with that in the FAI group (p < 0.05).

CONCLUSION

Anterior inferior iliac spine decompression, as a part of an arthroscopic FAI corrective procedure, had a lower revision surgery rate and did not compromise knee extensor and hip flexor strength, and it improved clinical outcomes comparable to FAI correction without AIIS decompression. AIIS decompression for FAI correction improved postoperative PRO scores without altering the muscle strength of hip flexor and knee extensor.

LEVEL OF EVIDENCE

III.

Functional Results of Arthroscopic Treatment in Patients With Femoroacetabular and Subspine Impingement Diagnosed With a 3-Dimensional Dynamic Study

Purpose

To describe the functional results of arthroscopic treatment in patients with femoroacetabular impingement (FAI) and subspine impingement (SSI) evaluated with a 3-dimensional (3D) dynamic study.

Methods

This was a retrospective observational study of patients with a diagnosis of FAI and SSI, evaluated with a 3D dynamic computed tomography scan with Move Forward software, who underwent hip arthroscopy between February 2015 and December 2017. Measurements of the alpha angle, femoral anteversion, acetabular anteversion, lateral center-edge angle, and Tönnis angle were extracted from the 3D dynamic study. Functionality was evaluated using the Western Ontario McMaster Universities Osteoarthritis Index before and 12 months after surgery.

Results

We analyzed 22 hips in 17 patients (9 female and 8 male patients) with an average age of 34.6 ± 14.3 years. Of the 22 hips, 15 had cam morphology, 6 had mixed morphology, and 1 had pincer morphology. Of the hips, 11 had a type I spine, 10 had type II, and 1 had type III. The average alpha angle, Tönnis angle, femoral anteversion, and acetabular anteversion were 61.9° ± 11.1°, 2.5° ± 6.4°, 8.8° ± 6.8°, and 15.1° ± 7.1°, respectively. The median lateral center-edge angle was 38.1° (interquartile range, 32.6°-43.5°). At 1-year follow-up, a decrease in the Western Ontario McMaster Universities Osteoarthritis Index score (P = .001) and an increase in the flexion angle (P < .001) were observed. No cases needed posterior surgical revision because of persistent pain.

Conclusions

Arthroscopic treatment provides symptom relief and good functional results in patients with FAI and SSI.

Level of Evidence

Level IV, therapeutic case series.

Role of arthroscopy for the diagnosis and management of post-traumatic hip pain: a prospective study

The current published literature regarding the role of hip arthroscopy in the diagnosis and management of post-traumatic hip pain is still limited. Therefore, we conducted the present prospective study to determine the value of hip arthroscopy in the diagnosis and management of various causes of hip pain after traumatic conditions. The present study included a prospective cohort of 17 patients with symptomatic post-traumatic hip pain. It was conducted between July 2013 and May 2018. The mean age was 22 (19-29) years and the mean follow-up was 24 (r: 7-36) months. Prior to surgery, every eligible patient underwent assessment of functional status using the Modified Harris Hip Score, Oxford hip score (OHS) and Western Ontario and McMaster Universities Arthritis Index (WOMAC) score. All patients underwent arthroscopic management for their diagnosed pathologies. The most commonly encountered diagnosis was labral tear (58.8%), followed by ligamentum teres tear (35.3%) and loose intra-articular fragments (29.4%). In addition, 52.9% of the patients had associated CAM lesion and 11.8% had associated Pincer lesion. The mHSS, OHS and WOMAC score showed significant improvement in the post-operative period (P < 0.001), all the 17 patients had 100% Patient Acceptable Symptomatic State; only one patient did not achieve minimal clinical importance difference. One case underwent labral debridement for failed labral repair (5.8%), another patient developed maralgia paraesthetica (5.8%). In conclusion, hip arthroscopy is a useful and effective minimally invasive procedure for the diagnosis and management of selected patients with post-traumatic hip pain. Moreover, hip arthroscopy was safe technique with no reported serious adverse events.

Mid-term outcomes of arthroscopic-assisted Core decompression of Precollapse osteonecrosis of femoral head-minimum of 5 year follow-up

Background

Osteonecrosis of the femoral head (ONFH) is a progressive disease that leads to collapse and the development of secondary arthritis. The preferred management of ONFH remains controversial. Arthroscopic-assisted management of ONFH is a new and evolving approach for hip preservation. We hypothesis that arthroscopy is able to improve ONFH outcomes by achieving accurate and minimally invasive decompression while successfully addressing concomitant intraarticular pathologies resulting in reliable mid-term outcomes.

Methods

This was a retrospective cohort analysis. All patients had atraumatic ONFH with a precollapse lesion and a minimum follow-up of 5 years.

Results

A total cohort of 11 hips (8 patients) was identified. The mean patient follow-up was 7 years ±1.48 years (range, 64—118 months). The Ficat-Alret classification found on preoperative imaging was Stage I—3 (27.2%), IIa—4 (36.4%), and IIb—4 (36.4%) hips. Four (36.4%) hips experienced mechanical issues, including locking, catching, and buckling. The most common concomitant pathology addressed at the time of arthroscopy, was labral repair/debridement—8 (73%), followed by microfracture—7 (64%). At final follow-up, 6 hips (54.5%) had not converted to THA. Upon further stratification, Stage I—100%, Stage IIa—75%, for a combined 87%, had not converted to THA, in contrast, 100% of hips categorized as Stage IIb had converted to THA. Ficat-Alret staging, especially Stage IIb, was significantly associated with conversion to THA. (p-value = 0.015) There were 0% major or minor complications.

Conclusions

To our knowledge, this is the longest reported follow-up of arthroscopic-assisted management of ONFH. Arthroscopic-assisted management is a promising surgical approach that provides safe, accurate, and minimally invasive decompression, resulting in reliable results with an acceptable conversion rate to THA.

Level of evidence

Level IV, Case Series.

MRI Assessment of Subspine Impingement: Features beyond the Anterior Inferior Iliac Spine Morphology

Background The MRI manifestations of subspine impingement (SSI) other than morphologic features of anterior inferior iliac spine (AIIS) have not been extensively explored and validated. Purpose To determine the MRI findings associated with SSI, including AIIS morphologic features, femoral distal cam, and associated soft-tissue injuries. Materials and Methods This is a retrospective study of symptomatic patients who underwent arthroscopic treatment for femoroacetabular impingement between December 2014 and March 2017, with preoperative MRI within 6 months before surgery. The SSI group included patients with clinical and intraoperative findings of SSI; the remaining patients comprised the non-SSI group. Preoperative MRI findings were independently assessed by two radiologists who were blinded to clinical information. Interreader agreement was assessed, and multivariable logistic regression was also used. Results A total of 62 patients (mean age ± standard deviation, 42.1 years ± 11.9; 38 women) were included. SSI was diagnosed in 20 of the 62 patients (32%) (mean age, 43 years ± 12); 42 patients (68%) did not have SSI (mean age, 41 years ± 10). Reader 1 detected distal cam in 16 of the 20 patients with SSI (80%) and eight of the 42 patients without SSI (19%), and reader 2 detected distal cam in 15 of the 20 patients with SSI (75%) and eight of the 42 patients without SSI (19%) (P < .001 for both). Reader 1 detected signs of impingement on the distal femoral neck (IDFN) in 18 of the 20 patients with SSI (90%) and seven of the 42 patients without SSI (16%), and reader 2 detected signs of IDFN in 13 of the 20 patients with SSI (65%) and nine of the 42 patients without SSI (21%) (P < .001 and P = .001, respectively). Reader 1 detected superior capsular edema in 15 of 20 patients with SSI (75%) and three of 42 patients without SSI (7%), and reader 2 detected superior capsular edema in 17 of 20 patients with SSI (85%) and 22 of 42 patients without SSI (52%) (P < .001 and P = .02, respectively). Distal cam was a predictor of SSI after adjustment for IDFN. Interreader agreement was substantial for distal cam (κ = 0.80) and moderate for IDFN (κ = 0.50). Conclusion Soft-tissue injuries and osseous findings other than morphologic features of the anterior inferior iliac spine were associated with subspine impingement. © RSNA, 2019 See also the editorial by Guermazi in this issue.

Extra-articular hip impingement: clinical presentation, radiographic findings and surgical treatment outcomes

Femoroacetabular impingement syndrome is classically thought of as either a cam or pincer deformity causing abnormal bony contact resulting in labral pathology. However, alternate patterns of hip impingement can occur, but tend to be less commonly recognized or studied. Collectively termed 'extra-articular impingement', four subgroups of impingement can contribute to non-arthritic hip pain and disability: iliopsoas impingement, subspine impingement, ischiofemoral impingement and trochanteric-pelvic impingement. The purpose of this review article is to highlight the pertinent points to aid in proper clinical and radiographic evaluation to allow appropriate diagnosis. Additionally, a review of potential surgical treatment options and resultant outcomes will also be provided.

Effectiveness of Active Rehabilitation Program on Sports Hernia: Randomized Control Trial

Objective

To determine whether an active rehabilitation program that involves repetitive effortful muscle contractions, including core stability, balancing exercises, progressive resistance exercises, and running activities, after a sports hernia, is effective.

Methods

Forty soccer players with sports hernias were randomly divided into two equal groups: group A (active rehabilitation program) and group B (conventional treatment). The methods of assessment included a visual analog scale (VAS) and hip internal and external range of motion assessments. Group A received conventional treatment (heat, massage, transcutaneous electrical nerve stimulation, and mobilization) plus an active rehabilitation program, while group B received only conventional treatment. Three treatment sessions were given each week for 2 months. Evaluations were performed pre- and post-treatment.

Results

A decrease in VAS was seen in both groups at the end of treatment, 80.25% in group A and 41.93% in group B. The difference between the two groups was statistically significant (p=0.0001), whereas there were no statistical differences in internal and external rotation between the groups at the end of treatment (p>0.05). After treatment, an improvement in outcome measures of group A compared to group B (p=0.01) was seen. Thirteen patients in group A and only three patients in group B returned to sports activities without groin pain.

Conclusion

Active rehabilitation was effective for sports hernia management measured by a decrease in pain and the return to sports.

Labral hypertrophy correlates with borderline hip dysplasia and microinstability in femoroacetabular impingement: a matched case-control analysis

PURPOSE:

The goal of this study was to: (1) investigate the association between labral hypertrophy and radiographic and computed tomography (CT) imaging measurements of dysplasia in a femoroacetabular impingement (FAI) cohort; (2) evaluate the association between physical examination parameters suggestive of microinstability and labral hypertrophy.

METHODS:

A retrospective case-control study was performed. Labral hypertrophy was defined as intraoperative labral width measuring greater >4 mm. A control cohort (NL) was matched to the cases. Physical examination parameters and preoperative radiographic and CT imaging studies were reviewed.

RESULTS:

231 hip arthroscopies for FAI were reviewed from which 42 cases of labral hypertrophy were identified (LH). In the LH group there was significantly increased hip internal rotation at 90° hip flexion compared to normal controls (13.6° ± 1 0.7° LH vs. 9.3° ± 6.2° NL; p = 0.04). On plain radiographs, the mean lateral centre-edge angle was smaller in the LH group compared to the NL group (27.6° ± 6.00° LH vs. 31.6° ± 6.59° NL; p < 0.001) and the acetabular index was larger in the LH group compared to the NL group (6.61 ± 4.18 LH vs. 4.14 ± 6.13 NL; p = 0.04). On CT imaging coronal sagittal CEA was significantly lower in LH cases compared to NL control (31.8° ± 5.30° LH vs. 35.1° ± 7.67° NL; p = 0.01).

CONCLUSIONS:

We found that patients with labral hypertrophy have radiographic and CT measurements consistent with subtle but not absolute dysplasia and physical examination findings suggestive of microinstability. We propose that labral hypertrophy can be a useful clinical tool for identifying FAI patients on the dysplasia spectrum.

Hip Arthroscopic Management Can Improve Osteitis Pubis and Bone Marrow Edema in Competitive Soccer Players With Femoroacetabular Impingement

BACKGROUND

There is a dearth of knowledge regarding the correlation between femoroacetabular impingement (FAI) and osteitis pubis (OP) among symptomatic soccer players.

PURPOSE

To elucidate whether arthroscopic FAI correction is effective for young competitive soccer players with FAI combined with OP or perisymphyseal pubic bone marrow edema (BME).

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A total of 577 consecutive patients who underwent arthroscopic FAI correction were retrospectively reviewed with a minimum 2-year follow-up. Competitive soccer players who were professional, college, and high school athletes were included. The authors assessed the modified Harris Hip Score and Nonarthritic Hip Score preoperatively and at 6 months, 1 year, and 2 years after surgery. In addition, players were divided into groups according to radiographic evidence of OP and BME (2 groups each). Clinical outcomes, return to play, and radiographic assessments were compared between groups.

RESULTS

Twenty-eight hips met the inclusion criteria. The median modified Harris Hip Score significantly improved after hip arthroscopy (81.4, preoperatively; 95.7 at 6 months, P = .0065; 100 at 1 year, P = .0098; 100 at 2 years, P = .013). The median Nonarthritic Hip Score also significantly improved (75.0, preoperatively; 96.3 at 6 months, P = .015; 98.8 at 1 year, P = .0029; 100 at 2 years, P = .015). Furthermore, 92.0% of players returned to play soccer at the same or higher level of competition at a median 5.5 months (range, 4-15 months); 67.8% had radiological confirmation of OP; and 35.7% had pubic BME. The alpha angle was significantly higher in pubic BME group than the no-pubic BME group (64.8° vs 59.2°, P = .027), although there was no significant difference between the OP and no-OP groups. The prevalence of tenderness of the pubic symphysis significantly decreased preoperatively (32.1%) to postoperatively (3.6%). Magnetic resonance imaging findings confirmed that pubic BME disappeared in all players at a median 11 months (range, 6-36) after initial surgery.

CONCLUSIONS

Arthroscopic management for FAI provides favorable clinical outcomes, a high rate of return to sports, and, when present, resolution of pubic BME among competitive soccer players.

Causes of Chronic Hip Pain Undiagnosed or Misdiagnosed by Primary Physicians in Young Adult Patients: a Retrospective Descriptive Study

BACKGROUND

Hip pain is a common musculoskeletal complaint in general practice. Although comprehensive diagnostic approach on hip pain is mandatory for adequate treatment, un- or mis-diagnosis is not rare in primary care. The aim of this study was to analyze descriptively un- or mis-diagnosed hip pain cases referred from primary care to a tertiary hospital, especially in young adults ≤ 50 years old.

METHODS

We retrospectively analyzed a consecutive cohort of 150 patients (≤ 50 years old) with chronic hip pain (≥ 6 weeks), which was not diagnosed or misdiagnosed based on the information provided on the referral form.

RESULTS

Overall an average 32 cases/month were referred due to hip pain without a diagnosis or with an incorrect diagnosis. Among them, 150 patients were enrolled in this study and 146 (97.3%) could be allocated to a specific disease by using data from routine clinical practice. Four common final diagnoses were femoroacetabular impingement (FAI) syndrome (55.3%), hip dysplasia (HD, 13.3%), referred pain from the lumbar spine (9.3%), and spondyloarthritis (SpA, 7.3%). In patients with FAI syndrome, 37 (44.0%) had pincer-type FAI and 33 (39.8%) had combined-type. Although the pain site or gender was not tightly clustered, the distribution of final diagnosis was significantly different according to hip pain location or gender. Especially, SpA or HD was not observed in younger women subgroup or elder men subgroup, respectively, when stratified by the mean age of participants.

CONCLUSION

Most (> 80%) young patients with hip pain, a difficult issue to diagnosis for many primary physicians, had FAI syndrome, HD, spine lesions, and SpA. This study could give a chance to feedback information about cases with un- or mis-diagnosed hip pain, and it suggests that primary physicians need to be familiar with the diagnostic approach for these 4 diseases.

Advanced Concepts in Hip Morphology, Associated Pathologies, and Specific Rehabilitation for Athletic Hip Injuries

Hip and groin injuries comprise up to 17% of athletic injuries and can pose rehabilitation challenges for many athletes. Injuries involving abnormal femoral acetabular morphology, reduced range of motion, and decreased lumbopelvic strength and endurance also may increase the risk of injury to lower extremities and delay return to play if proper rehabilitation does not take place. The rehabilitation of athletic hip injuries requires a multifaceted interdisciplinary approach that manages the interplay of multiple factors to restore preinjury function and facilitate return to play. Emphasis should be placed on activity modification, preservation of the arcs of range of motion, functional strengthening of the lumbopelvic core, and optimization of proprioceptive and neuromechanical strategies. Communication between providers and the injured athlete also is crucial to ensure that proper therapeutic approaches are being applied.

Gluteus maximus contraction velocity assessed by tensiomyography improves following arthroscopic treatment of femoroacetabular impingement

PURPOSE

Muscular impairment, particularly for the gluteus maximus (GM), has been observed in femoroacetabular impingement (FAI). The purpose of this study was to evaluate the tensiomyographic changes of the GM, rectus femoris (RF) and adductor longus (AL) before and after arthroscopic surgery for FAI. It was hypothesized that arthroscopic treatment of FAI would improve the preoperative muscular impairment.

METHODS

All patients undergoing arthroscopic treatment of FAI between January and July 2015 were approached for eligibility. Patients included had a tensiomyography (TMG) evaluation including maximal displacement (Dm) and contraction time (Tc) of these muscles in both lower extremities. TMG values between the injured and healthy sides were compared at the preoperative and post-operative (3, 6 and 12 months after surgery) periods.

RESULTS

There were no significant differences for the RF and AL, and Dm of the GM for any of the comparisons (n.s.). However, GM Tc was significantly lower at 3 (p = 0.016), 6 (p = 0.008), and 12 (p = 0.049) months after surgery in the injured side compared to preoperatively. GM Tc of the healthy side was significantly lower than the injured side at the preoperative period (p = 0.004) and at 3 (p = 0.024) and 6 (p = 0.028) months after surgery, but these significant differences were no longer observed at 12 months after surgery (n.s.). There was a significant reduction of pain in the GM area at 1 year after surgery compared to preoperatively (p < 0.0001).

CONCLUSIONS

Arthroscopic treatment of FAI and the subsequent rehabilitation improves contraction velocity of the GM of the injured side. Despite Tc is elevated in the GM of the injured compared to the healthy side preoperatively and at 3 and 6 months after surgery, differences in Tc between both sides are no longer significant at 12 months. Athletes with FAI participating in sports with great involvement of GM may benefit from arthroscopic treatment and its subsequent rehabilitation. TMG can be used as an objective measurement to monitor muscular improvements of the GM after surgery in these patients.

LEVEL OF EVIDENCE

II.

Hip and Groin Injuries in Baseball Players

PURPOSE OF REVIEW

To discuss the clinical significance of the most common hip and groin injuries in baseball players, as well as an algorithmic approach to diagnosis and treatment of these injuries.

RECENT FINDINGS

(a) Limitations in throwing velocity, pitch control, and bat swing speed may be secondary to decreased mobility and strength within the proximal kinetic chain, which must harness power from the lower extremities and core. (b) Approximately 5.5% of all baseball injuries per year involve the hip/groin and may lead to a significant amount of time spent on the disabled list. Injuries involving the hip and groin are relatively common in baseball players. Our knowledge of the mechanics of overhead throwing continues to evolve, as does our understanding of the contribution of power from the lower extremities and core. It is paramount that the team physician be able to accurately diagnose and treat injuries involving the hip/groin, as they may lead to significant disability and inability to return to elite levels of play. This review focuses on hip- and groin-related injuries in the baseball player, including femoroacetabular impingement, core muscle injury, and osteitis pubis.

Endoscopic shelf acetabuloplasty can improve clinical outcomes and achieve return to sports-related activity in active patients with hip dysplasia

PURPOSE

To investigate clinical outcomes and return to sports-related activity following endoscopic shelf acetabuloplasty combined with labral repair in the treatment of the active patients with developmental dysplasia of the hip (DDH).

METHODS

Between 2011 and 2013, 32 patients (36 hips; 11 males and 21 females; 11 right 17 left 4 bilateral; median age 28.5, range 12-51 years), who underwent endoscopic shelf acetabuloplasty combined with labral repair and met the inclusion criteria were enrolled in this study. There was a minimum follow-up of 2 years (average 32.3 ± 3 months, range 24-48 months). Patient-reported outcome (PRO) scores including the modified Harris Hip Score (MHHS) and Non-Arthritis Hip Score (NAHS) were obtained preoperatively and at final follow-up for the assessment of surgical outcomes.

RESULTS

The mean MHHS significantly improved from 68.4 ± 14.3 (range 23.1-95.7) preoperatively to 94.5 ± 8.5 (range 66-100) at final follow-up (p = 0.001). Similarly, the NAHS also significantly improved from 51.3 ± 11.9 (range 23-76) preoperatively to 73.0 ± 7.4 (range 44-80) at final follow-up (p = 0.001). The mean LCE angle significantly increased postoperatively but partially decreased at final follow-up (mean preoperative versus postoperative versus final follow-up: 16.0 range 5-24, versus 40.1 range 27-58, versus 30.1 range 20-41. p = 0.001, respectively). There were 3 patients who returned to a higher activity level, 20 patients who returned to the same activity level, and 6 patients who returned to a lower activity level. The mean period from surgery to return to play was 9.0 ± 3.5 months (range 5-18).

CONCLUSION

Endoscopic shelf acetabuloplasty provides promising clinical outcomes and return to sports-related activity for active patients with DDH.

LEVEL OF EVIDENCE

Level IV.

Comprehensive Clinical Evaluation of Femoroacetabular Impingement: Part 1, Physical Examination

A thorough evaluation of the hip must include a comprehensive medical and surgical history focused on the hip joint, surrounding soft tissues, and the associated structures of the spine, pelvis, and lower extremities. These details can guide the physical examination and provide insight into the cause of the patient's chief complaints. A proper examination includes physical examination while the patient is in the upright, supine, prone, and lateral position, as well as an evaluation of gait. Guided by a thorough history, the physical examination enables the surgeon to distinguish between intra-articular and extra-articular contributors to hip pain, selection of appropriate imaging modalities, and ultimately supports medical decision making.

Outcomes for Arthroscopic Treatment of Anterior Inferior Iliac Spine (Subspine) Hip Impingement

BACKGROUND

Femoroacetabular hip impingement (FAI) is now well recognized; however, anterior inferior iliac spine (AIIS; or subspine) impingement is a form of hip impingement that is underrecognized and can be an important source of hip disability and functional limitation.

PURPOSE

To investigate the outcomes after arthroscopic treatment of AIIS/subspine-related hip impingement in the absence of FAI surgery.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A prospective institutional hip preservation registry was reviewed to identify patients who underwent arthroscopic AIIS decompression without concurrent treatment of FAI. Primary outcome tools captured in the registry included the modified Harris Hip Score (mHHS), the Hip Outcome Score (HOS), and the International Hip Outcome Tool-33 (iHOT-33). Patients with minimum 1-year follow-up were included. Meaningful outcome improvement was determined per minimal clinically important difference (MCID). Statistical analyses were primarily descriptive.

RESULTS

Thirty-three patients with a mean follow-up of 19.1 months (range, 12-44 months) were identified. All patients were female, with a mean ± SD age of 26.1 ± 10.3 years. All patients were found to have an associated labral tear, and the mean acetabular version was increased at 2 and 3 o'clock (14.5° and 19.8°, respectively). Mean preoperative outcome scores on the mHHS, HOS ADL (activities of daily living), HOS sport, and iHOT-33 were 57.2 ± 15.3, 66.9 ± 18.8, 43.9 ± 23.6, and 33.5 ± 18.3, respectively. At final available follow-up, mean scores on these outcome measures were 79.5 ± 19.0, 86.8 ± 15.8, 70.4 ± 32.8, and 65.0 ± 31.0, respectively. By the 1-year follow-up, MCID had been achieved in the majority of patients across all 4 tools.

CONCLUSION

There is a paucity of outcomes evidence on AIIS/subspine-related hip impingement. This study demonstrates that isolated subspine impingement can be a cause of hip disability, even in the absence of FAI. Patients with isolated subspine impingement are more likely to be women and to present with low patient-reported outcome scores. However, meaningful outcome improvement can be achieved with arthroscopic AIIS decompression.

Imaging of impingement syndromes around the hip joint

Impingement syndromes are increasingly recognised as significant causes of hip pain and dysfunction. A broad spectrum of intraarticular and extraarticular conditions has been implicated in their pathophysiology. Physical examination is often inconclusive as clinical findings may be unclear or misleading, often simulating other disorders. With current improvements in imaging techniques and better understanding of hip impingement related pathomechanisms, these entities can be accurately diagnosed. In addition, preoperative imaging has allowed for targeted treatment planning. This article provides an overview of the various types of hip impingement, including femoroacetabular impingement, ischiofemoral impingement, snapping hip syndrome, greater trochanteric-pelvic and subspine impingement. Current literature data regarding their pathogenesis, clinical manifestation and imaging work-up are discussed.

Athletic Hip Injuries

Historically, athletic hip injuries have garnered little attention; however, these injuries account for approximately 6% of all sports injuries and their prevalence is increasing. At times, the diagnosis and management of hip injuries can be challenging and elusive for the team physician. Hip injuries are seen in high-level athletes who participate in cutting and pivoting sports that require rapid acceleration and deceleration. Described previously as the "sports hip triad," these injuries consist of adductor strains, osteitis pubis, athletic pubalgia, or core muscle injury, often with underlying range-of-motion limitations secondary to femoroacetabular impingement. These disorders can happen in isolation but frequently occur in combination. To add to the diagnostic challenge, numerous intra-articular disorders and extra-articular soft-tissue restraints about the hip can serve as pain generators, in addition to referred pain from the lumbar spine, bowel, bladder, and reproductive organs. Athletic hip conditions can be debilitating and often require a timely diagnosis to provide appropriate intervention.

Effect of General Anesthesia on Preoperative Hip Range of Motion in Patients Undergoing Hip Arthroscopy

The purpose of this study was to investigate the effect of general anesthesia on preoperative passive hip range of motion (ROM) in patients undergoing hip arthroscopy for various indications. A total of 260 consecutive patients undergoing hip arthroscopy were included in this study. Passive hip ROM was evaluated bilaterally in the clinic and subsequently under general anesthesia immediately preoperatively. Demographic variables, including age, height, weight, and clinical diagnosis, were recorded for all patients. Hips with pincer-type femoroacetabular impingement (FAI) and hips with acetabular dysplasia showed a mean increase of 4° and 6°, respectively, in hip external rotation at 90° of hip flexion (ER-90) with induction of anesthesia (P=.018 and P=.021, respectively). In contrast, a statistically significant reduction in hip abduction (2°) and hip flexion (4°) was observed following induction of anesthesia in healthy contralateral hips of patients presenting with unilateral hip pathology (P=.01 and P<.001, respectively). Hip ROM does not change to a clinically significant extent with induction of general anesthesia. Small increases in external rotation in patients with FAI or acetabular dysplasia are within the standard error for ROM measurements. [Orthopedics. 2016; 39(6):e1165-e1169.].

Core Muscle Injury/Sports Hernia/Athletic Pubalgia, and Femoroacetabular Impingement

Core muscle injury/sports hernia/athletic pubalgia is an increasingly recognized source of pain, disability, and time lost from athletics. Groin pain among athletes, however, may be secondary to various etiologies. A thorough history and comprehensive physical examination, coupled with appropriate diagnostic imaging, may improve the diagnostic accuracy for patients who present with core muscular injuries. Outcomes of nonoperative management have not been well delineated, and multiple operative procedures have been discussed with varying return-to-athletic activity rates. In this review, we outline the clinical entity and treatment of core muscle injury and athletic pubalgia. In addition, we describe the relationship between athletic pubalgia and femoroacetabular impingement along with recent studies that have investigated the treatment of these related disorders.

Gluteus maximus impairment in femoroacetabular impingement: a tensiomyographic evaluation of a clinical fact

INTRODUCTION

the aim of the present study is to evaluate the mechanical and contractile properties of the gluteus maximus (GM) muscle in patients with femoroacetabular impingement (FAI). Our hypothesis is that the clinical observation of GM pain would be evidenced by tensiomyographic impairment in muscle function.

MATERIALS AND METHODS

A prospective, cross-sectional, intra-group comparative study was conducted to assess the neuromuscular changes of lower extremity muscles in patients with FAI. Fifty-one patients with clinical and radiographic diagnosis of FAI for at least 3 months were included. The rectus femoris (RF), adductor magnus (AM), and GM of both lower extremities of all patients were evaluated with tensiomyography (TMG). The values of TMG of the affected lower extremity were compared to those of the healthy contralateral side. The parameters obtained in this study were maximal displacement (Dm), and contraction time (Tc).

RESULTS

The Tc of the injured GM was significantly higher compared to the healthy side (p = 0.01). There were no significant side-to-side differences in the Dm of the GM (p = 0.13), either in the Tc and Dm of the RF (p = 0.15 and p = 0.8, respectively) and AM (p = 0.25 and p = 0.75, respectively).

CONCLUSIONS

FAI is associated with impairment of contraction time in the GM of the injured compared to the healthy side. Impairment of the GM may be monitored to evaluate response to conservative or surgical treatment.

Extra-articular hip impingement: a narrative review of the literature

There is growing subgroup of patients with poor outcomes after hip arthroscopy for intra-articular pathology suggesting unrecognized cause(s) of impingement may exist. Extra-articular hip impingement (EHI) is an emerging group of conditions that have been associated with intra-articular causes of impingement and may be an unrecognized source of pain. EHI is caused by abnormal contact between the extra-articular regions of the proximal femur and pelvis. This review discusses the most common forms for EHI including: central iliopsoas impingement, subspine impingement, ischiofemoral impingement, and greater trochanteric-pelvic impingement. The clinical presentation of each pathology will be discussed since EHI conditions share similar clinical features as the intra-articular pathology but also contain some unique characteristics.

Passive Hip Range of Motion Predicts Femoral Torsion and Acetabular Version

BACKGROUND

Orientation abnormalities of the acetabulum and femur have been implicated in early-onset coxarthrosis. The purpose of this study was to identify clinical examination findings predictive of such hip morphologies.

METHODS

A consecutive cohort of 221 patients (442 hips) undergoing hip arthroscopy was included. Demographic characteristics including age, diagnosis, sex, height, weight, body mass index (BMI), and physical activity level were recorded. Passive range of motion was measured for all hips. Preoperative computed tomography scans were utilized to measure femoral torsion and central acetabular version, and a combined femoral torsion-acetabular version (COTAV) index was defined as their sum.

RESULTS

The study cohort comprised 221 patients (sixty-four males, 157 females) with a mean age of 32.5 years and mean BMI of 24.2 kg/m(2). Overall, hips with femoral antetorsion and acetabular anteversion exhibited the greatest internal rotation range of motion at a neutral hip position (mean, 44.2°), whereas hips with femoral retrotorsion and acetabular retroversion demonstrated the lowest corresponding value (20.1°; p < 0.001). Femoral torsion was significantly associated with female sex (p < 0.001), BMI (p < 0.001), and presence of pathology corresponding to cam-type femoroacetabular impingement (FAI) (p = 0.044). Central acetabular version was significantly associated with age (p = 0.021), female sex (p < 0.001), and absence of mixed-type FAI pathology (p = 0.025). Increasing age and internal rotation range of motion at a neutral hip position were the most significant predictors of an increased COTAV index.

CONCLUSIONS

This study confirmed that passive hip range of motion significantly predicts combined femoral torsion and central acetabular version. Accurate clinical assessment of the COTAV index may inform surgical decision-making in hip preservation surgery.

Clinical and Radiographic Predictors for Worsened Clinical Outcomes After Hip Arthroscopic Labral Preservation and Capsular Closure in Developmental Dysplasia of the Hip

BACKGROUND

Patients with developmental dysplasia of the hip (DDH) have a greater risk of acetabular labral tearing and joint instability, which predispose them to developing osteoarthritis. The arthroscopic management of DDH, however, remains controversial.

HYPOTHESIS

Specific clinical characteristics and radiographic parameters correlate with and predict a worsened clinical outcome after hip arthroscopic surgery for DDH.

STUDY DESIGN

Case control study; Level of evidence, 3.

METHODS

Of patients with DDH who underwent an arthroscopic procedure between March 2009 and June 2011, there were 28 hips in 28 patients (6 male and 22 female) that met the inclusion criteria. The mean patient age was 28.4 years. Clinical and radiographic follow-up evaluations up to a minimum of 2 years after surgery were performed for all patients. Failure of the procedure was defined as conversion to subsequent surgery or having a Tönnis osteoarthritis grade of 2 and modified Harris Hip Score (mHHS) that remained <85, and success was defined as patients who did not need subsequent surgery and had an mHHS >85. Univariate analysis and Cox hazard proportional analysis were performed on the 2 subpopulations.

RESULTS

There were 9 patients in the failure group (including 3 hips with T nnis grade 2) and 19 patients in the success group. In 22 of 28 patients, the mean mHHS significantly improved from 61.6 ± 18.8 (range, 12.0-85.0) preoperatively to 94.3 ± 7.0 (range, 73.7-100.0) at final follow-up, and the mean Non-Arthritic Hip Score (NAHS) improved from 56.2 ± 13.9 (range, 35.0-81.3) preoperatively to 92.7 ± 9.5 (range, 65.0-100.0) at final follow-up (P < .001, Wilcoxon signed-rank test). Univariate analysis showed that a broken Shenton line was significantly more prevalent in the failure group compared with the success group (8/9 [89%] vs 3/19 [16%] patients, respectively; P < .001). High-grade cartilage delamination (Multicenter Arthroscopy of the Hip Outcomes Research Network [MAHORN] grades 3-5) was significantly higher in the failure group than in the success group (8/9 [89%] vs 3/19 [16%] patients, respectively; P < .001). The median femoral neck-shaft (FNS) angle in the failure group was significantly higher than that in the success group (139° vs 134°, respectively; P = .01). Further, Cox hazard proportional analysis of the failure group showed that the predictors for a poor clinical outcome were the presence of a broken Shenton line, FNS angle >140°, center-edge (CE) angle <19°, body mass index (BMI) >23 kg/m(2), acetabular cartilage damage (MAHORN grades 3-5), and cartilage damage of the femoral head (International Cartilage Repair Society grades 2-4). The most important predictors for a poor clinical outcome at the time of surgery were a broken Shenton line and an FNS angle >140°.

CONCLUSION

Patients with a broken Shenton line, FNS angle >140°, CE angle <19°, or BMI >23 kg/m(2) at the time of surgery are not good candidates for the arthroscopic management of DDH.

Conservative management of sports hernia in a professional golfer: a case report

STUDY DESIGN

Case Report.

BACKGROUND

Activity-limiting groin pain is relatively common in athletes who participate in sports which involve rapid or repetitive twisting, cutting, and/or kicking. Despite the reported prevalence of this condition in athletes, there is still much controversy as to the anatomical structures involved and most effective treatment approach. There is limited evidence favoring conservative management of sports hernia as opposed to surgical intervention in professional athletes, and there are no reports of sports hernia management in the professional golf population. The purpose of this case report is to describe the conservative management and decision making used with a professional golfer with symptoms consistent with a sports hernia which allowed for successful return to prior level of sport participation.

CASE PRESENTATION

The subject of this case report is a professional golfer who developed lower abdominal and groin pain after changes in conditioning routine. Clinical presentation was consistent with a diagnosis of sports hernia. Rehabilitation of this athlete included a structured core muscle retraining program which utilized a step wise progression through the neurodevelopmental sequence in order to allow for development of neuromuscular control and stability required for return to golf.

OUTCOME

This athlete was able to return to full golf participation after 13 physical therapy visits over 4 weeks.

DISCUSSION

The available evidence supports surgical intervention over conservative management in the treatment of sports hernia in the athletic population. A structured and comprehensive rehabilitation program addressing core muscle weakness and contributing impairments adjacent to injury may be a beneficial treatment option prior to surgical repair potentially allowing return to sport in some athletes.

LEVELS OF EVIDENCE

4.

A less-invasive technique for capsular management during hip arthroscopy for femoroacetabular impingement

The aim of this work is to describe a new arthroscopic technique for the treatment of femoroacetabular impingement that allows a complete articular joint view with maximum protection of the capsuloligamentous complex. This arthroscopic technique avoids injury to the capsuloligamentous complex, preventing the risk of postoperative instability. The diagnosis of femoroacetabular impingement was based on clinical and radiographic grounds. An alpha angle greater than 50° was considered pathologic. In this technique, the use of intra-articular devices (retractors) allows us to separate the capsular tissue from the femoral head-neck junction and mobilize the capsule, achieving an adequate joint view without performing a capsulotomy and, consequently, avoiding the complications of capsular damage.