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

Serotonergic Antidepressants Are Associated With Higher Rates of Hematoma After Anterior Cervical Spine Surgery: A Large Propensity-Matched Cohort Analysis

STUDY DESIGN

Large database propensity-matched retrospective cohort analysis.

OBJECTIVE

This study aimed to investigate the potential effects of serotonergic antidepressants on outcomes after anterior cervical spine surgery. It was hypothesized that the perioperative use of serotonergic antidepressants would be associated with higher rates of hematoma formation and worse outcomes after anterior cervical spine surgery.

BACKGROUND

Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) have been associated with worse outcomes after orthopedic procedures.

MATERIALS AND METHODS

A retrospective cohort analysis was performed using TriNetX, an aggregated and de-identified electronic health record platform. Patients who underwent anterior cervical surgery were included through Current Procedural Terminology codes and the International Classification of Disease, 10th Revision, encounter diagnosis codes. Cohorts were 1:1 propensity-matched across 7 demographic and medical comorbidity parameters, and outcomes were compared. The incidence of adverse outcomes, as well as health care utilization, within 14 days, 30 days, 90 days, and 2 years postoperatively was evaluated.

RESULTS

Following propensity matching, each cohort consisted of 9249 patients, for a total of 18,498 patients included in the final statistical analysis. SSRIs/SNRIs were associated with higher odds of hematoma formation within 7 days [0.69% vs . 0.46%, odds ratio (OR): 1.5 (95% CI: 1.02-2.2), P = 0.04] and within 14 days postoperatively [0.81% vs . 0.52%, OR: 1.6 (95% CI: 1.1-2.3), P = 0.01]. Within 30 and 90 days, SSRIs/SNRIs were associated with a higher risk of emergency department utilization [30 d, OR: 1.30 (1.1-1.4); 90 d, OR: 1.3 (1.2-1.4)] and irrigation & debridement (I&D; 30 d, OR: 1.9 (1.2-3.0)]. SSRIs/SNRIs were also associated with a significantly higher risk of I&D within 2 years [OR: 1.3 (1.1-1.6)].

CONCLUSION

The use of serotonergic antidepressants perioperatively was associated with higher odds and risk of numerous outcomes, including hematoma formation, emergency department utilization, and the need for irrigation and debridement. Future prospective studies are required to confirm these results.

LEVEL OF EVIDENCE

Level III-retrospective cohort analysis.

PLGA Conical Nail Fixation for Acetabular Chondrolabral Delamination in Femoroacetabular Impingement Promotes Cartilage and Labrum Regeneration in a Porcine Model

BACKGROUND

Acetabular chondrolabral delamination (ACD) is one of the most common hip cartilage injuries. However, there are very limited clinical treatments for this injury.

PURPOSE

To evaluate the effectiveness of poly (lactic-co-glycolic acid) (PLGA) conical nail fixation in the treatment of acute and chronic ACD in a porcine model.

STUDY DESIGN

Controlled laboratory study.

METHODS

In this study, 24 pigs underwent surgically induced delamination of the chondrolabral junction. Pigs were randomly divided into 3 groups: the control group (delaminated chondrolabral junction without treatment), ACD acute refixation (ACDA) group (delaminated chondrolabral junction fixed with a PLGA nail), and ACD chronic refixation (ACDC) group (placement of a nonabsorbable spacer at the stripped chondrolabral junction for 6 weeks before fixation with a PLGA nail). Porcine specimens underwent magnetic resonance imaging (MRI), hematoxylin and eosin staining, safranin O/fast green (SO/FG) staining, immunohistochemistry examination (collagen 1, collagen 2, and collagen 10), and immunofluorescence examination (SOX9 and aggrecan) to evaluate the chondrolabral regeneration at 6 and 12 weeks postoperatively.

RESULTS

MRI showed focal discontinuity of cartilage and fluid located between the acetabular cartilage and subchondral bone plate in the control group. The acetabular cartilage stained with SO/FG showed significantly more proteoglycan deposition at 12 weeks in the ACDA group than in the control group (P = .0109) and ACDC group (P = .0484). In accordance with the results of the SO/FG and collagen 10 staining, the aggrecan of the femoral head at 6 and 12 weeks was upregulated in the ACDA group (P < .0001) and downregulated in the ACDC group (P < .0001).

CONCLUSION

PLGA conical nail fixation achieved a good treatment outcome on MRI and histological evaluations. Early treatment upregulated the expression levels of SOX9 and aggrecan and promoted proteoglycan deposition.

CLINICAL RELEVANCE

The PLGA conical nail fixation technique may be a viable and effective treatment approach for patients with ACD in clinical practice.

Management of Labral Tears in the Hip: A Consensus Statement

Background

Inconsistencies in the workup of labral tears in the hip have been shown to result in a delay in treatment and an increased cost to the medical system.

Purpose

To establish consensus statements among Canadian nonoperative/operative sports medicine physicians via a modified Delphi process on the diagnosis, nonoperative and operative management, and rehabilitation and return to play (RTP) of those with labral tears in the hip.

Study Design

A consensus statement.

Methods

A total of 40 sports medicine physicians (50% orthopaedic surgeons) were selected for participation based on their level of expertise in the field. Experts were assigned to 1 of 4 balanced working groups defined by specific subtopics of interest. Consensus, strong consensus, and unanimous consensus were defined as achieving 80% to 89%, 90% to 99%, and 100% agreement with a proposed statement, respectively.

Results

There was a unanimous consensus that several prognostic factors-including age, pain severity, dysplasia, and degenerative changes-should be taken into consideration with regard to the likelihood of surgical success. There was strong agreement that the cluster of symptoms of anterior groin pain, pain in hyperflexion, and sharp catching pain with rotation make a diagnosis of a labral tear more likely, that radiographs-including a minimum of a standing anteroposterior pelvis and 45° Dunn view-should be obtained in all patients presenting with a suspected labral tear, that a diagnostic injection should be performed if there is uncertainty that the pain is intra-articular in origin, and that a minimum of 6 months should elapse after surgical treatment before reinvestigation for persistent symptoms.

Conclusion

Overall, 76% of statements reached a unanimous/strong consensus, thus indicating a high level of agreement between nonoperative sports medicine physicians and orthopaedic surgeons on the management of labral tears in the hip. The statements that achieved unanimous consensus included the timing of RTP after surgery, prognostic factors affecting surgical success, and the timing to begin sport-specific training after nonoperative management. There was no consensus on the use of orthobiologics for nonoperative management, indications for bilateral surgery, whether the postoperative range of motion and weightbearing restrictions should be employed, and whether postoperative hip brace usage is required.

ChatGPT Can Often Respond Adequately to Common Patient Questions Regarding Femoroacetabular Impingement

OBJECTIVE

This study aims to analyze the ability of ChatGPT to answer frequently asked questions (FAQs) regarding FAI. We hypothesize that ChatGPT can provide accurate and thorough responses when presented with FAQs regarding FAI.

DESIGN

Ten FAQs regarding FAI were presented to ChatGPT 3.5 and initial responses were recorded and analyzed against evidence-based literature. Responses were rated as "excellent response requiring no further clarification," "satisfactory response requiring minimal clarification," "satisfactory response requiring moderate clarification," or "unsatisfactory response requiring substantial clarification."

SETTING

Institutional.

INDEPENDENT VARIABLES

Frequently asked questions regarding femoroacetabular impingement.

MAIN OUTCOME MEASURES

Accuracy and thoroughness of ChatGPT responses to FAQs. Hypothesis was formulated before data collection.

RESULTS

Most responses from ChatGPT were rated as satisfactory and required only minimal clarification. Two responses received an excellent rating and required no further clarification, while only 1 response from ChatGPT was rated unsatisfactory and required substantial clarification.

CONCLUSIONS

ChatGPT provided largely accurate and thorough responses to FAQs regarding FAI while appropriately reiterating the importance of always consulting a medical professional.

Postoperative femoral head cartilage injury after hip arthroscopic treatment for femoroacetabular impingement syndrome and labral tear

BACKGROUND

Postoperative femoral head cartilage injury (FHCI) is a rare condition that can be observed in a certain proportion of patients undergoing hip arthroscopy. However, the prevalence and associated factors of FHCI, and the effect of this condition on clinical outcomes still remain unknown.

PATIENTS AND METHODS

Consecutive patients who were diagnosed with femoroacetabular impingement syndrome (FAIS) and labral tear and underwent hip arthroscopic treatment in our institute between July 2020 and July 2021 were retrospectively evaluated. Supine anteroposterior hip radiographs, cross-table lateral radiographs, magnetic resonance imaging (MRI), and computed tomography (CT) were obtained preoperatively. Postoperative MRI, at least 6 months after arthroscopy, was performed. Postoperative FHCI was evaluated by two surgeons through MRI. Preoperative patient-reported outcomes (PROs) including visual analog scale (VAS) for pain, and modified Harris Hip Score (mHHS) before surgery and at final followup were obtained.

RESULTS

A total of 196 patients were included. Postoperative FHCI was identified in 21 (10.7%) patients. The intraobserver reliability of the observer A and B for detecting postoperative FHCI using 3.0-T MRI was high (k = 0.929, and k = 0.947, respectively). The interobserver reliability between the two observers for detecting FHCI using 3.0-T MRI was high (k = 0.919). There was no significant difference in preoperative and postoperative mHHS, VAS, and percentage of patients who surpassed minimal clinically important difference (MCID) and achieved patient acceptable symptom state (PASS) between patients with and without postoperative FHCI (P > 0.05).

CONCLUSION

Although postoperative FHCI was observed in 10.7% of patients, which was associated with larger labrum, this condition did not result in inferior clinical outcomes. Level of evidence IV, retrospective case series. Trial registration The Chinese Clinical Trial Registry approved the registration (ChiCTR2200061166). The date of registration is 2022-06-15.

Diagnostic Capability of Intra-Articular Injections for Femoroacetabular Impingement Syndrome: A Systematic Review

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.

Arthroscopic Treatment of Femoroacetabular Impingement Syndrome: An Updated Review

Treatment strategies for femoroacetabular impingement (FAI) syndrome have evolved in tandem with increased comprehension of FAI's impact on hip joint health. Early intervention, including arthroscopic surgery, has gained popularity due to its potential to delay the progression of osteoarthritis. Arthroscopic surgery has demonstrated significant efficacy in treating FAI syndrome, with robust evidence from randomized controlled trials and systematic reviews supporting its use. Despite arthroscopic surgery's success, complications and reoperations are not uncommon. The incidence ranges from 1% to 31% and 4% to 13%, respectively. Adjunctive biologic treatments, such as bone marrow aspirate concentrates and platelet-rich plasma, have shown promise in chondral lesion management. However, robust evidence supporting their routine use in FAI syndrome is currently lacking. Among conservative treatment methods, intra-articular injections offer diagnostic and therapeutic benefits for FAI patients. While they may provide pain relief and aid in prognosis, their long-term efficacy remains a subject of debate. Comparative studies between conservative and arthroscopic treatments highlight the importance of personalized approaches in managing FAI syndrome. In conclusion, recent advancements in FAI syndrome management have illuminated various treatment modalities. Arthroscopic surgery stands as a pivotal intervention, offering substantial benefits in pain relief, function, and quality of life. However, careful patient selection and postoperative monitoring are crucial for optimizing outcomes. Adjunctive biologics and intra-articular injections show promise but require further investigation. Tailoring treatment to individual patient characteristics remains paramount in optimizing FAI syndrome management.

Can intra-articular hip injections predict arthroscopy outcomes for femoroacetabular impingement syndrome? A systematic review

Background

Femoroacetabular Impingement (FAI) syndrome represents a prevalent aetiology of hip discomfort observed among both adolescent and adult populations. It is initially managed conservatively with oral anti-inflammatories and physiotherapy; some patients proceed to receiving an intra-articular (IA) hip injection, but ultimately, the gold-standard treatment is hip arthroscopy.

Study design

Systematic Review.

Purpose

To systematically investigate the relationship between response to IA anaesthetic or steroid hip injections and arthroscopy outcomes for FAI syndrome.

Methods

A systematic search of PubMed, Medline, CINAHL, SCOPUS, and Cochrane was conducted in line with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines.

Results

Seven studies (Level II-IV) were identified that met our inclusion and exclusion criteria. These studies collectively included 637 patients, demonstrating an average age of 37.5 years (and a range of 14-72 years). Two of the seven studies reported a statistically significant positive correlation between response to IA injections and arthroscopy outcomes. The remaining five studies found that although a positive IA injection response increased the odds of a good outcome post arthroscopy (defined across various studies as a post-operative modified Harris Hip score of >70 points, >79 points or an improvement by 8 or more points), this correlation was not statistically significant.

Conclusion

IA hip injections can be a useful prognostic tool, though they are not a consistently reliable predictor of which patients will have good arthroscopic outcomes.

Team Approach: Hip Preservation Surgery

The evaluation and treatment of adolescents and young adults with hip pain has seen tremendous growth over the past 20 years. Labral tears are well established as a common cause of hip pain but often occur because of underlying bony abnormalities. Femoroacetabular impingement (FAI) and acetabular dysplasia are now well-established causes of hip osteoarthritis and are increasingly treated in the prearthritic stage in hopes of improving symptoms and prolonging the longevity of the native hip. Beyond FAI and acetabular dysplasia, this patient population can present with a complex and variable group of underlying conditions that need to be taken into account. Expertise in the conservative management of this population, including physical therapy, is valuable to maximize the success. Preoperative, surgical, and postoperative decision-making and care in this population is complex and evolving. A comprehensive, multidisciplinary approach to the care of this patient population has been used for over 20 years by our institution with great success. The purpose of this article is to review the "team-based approach" necessary for successful management of the spectrum of adolescent and young adult hip disorders.

Does response to preoperative intra-articular anesthetic injections predict outcomes of femoroacetabular impingement syndrome?

INTRODUCTION

Some patients with femoroacetabular impingement syndrome (FAIS) who undergo surgery do not show satisfactory outcomes. Reliable tests that can inform prognosis of FAIS surgery are needed for optimized indications and contraindications to surgery. We aimed to review and critically appraise available literature on the capability of patient response to preoperative intra-articular anesthetic injections (PIAI) to predict post-surgical outcomes in patients with FAIS.

MATERIALS AND METHODS

This study was conducted in accordance with the PRISMA statement. Studies that assessed the patient pain response to PIAI and post-surgical outcomes in patients with FAIS were considered eligible. Study selection and data collection were performed by three independent reviewers. Main outcomes evaluated were those measured by hip outcome scales often used in assessing postoperative pain and functional recovery, such as the modified Harris Hip Score (mHHS) and international Hip Outcome Tool (iHOT). The likelihood ratio of achieving satisfactory postoperative outcomes at the mHHS (LHR) was extracted or calculated-for patients with significant response to PIAI and for those without a significant response to PIAI. The risk of bias was assessed using the Quality In Prognosis Studies (QUIPS) tool.

RESULTS

Six studies were considered eligible for analysis. Five studies indicated that patient response to PIAI are associated to surgical outcomes for patients with FAIS, with a greater reduction in pain typically indicating a better surgical outcome. Additionally, the LHR ranged from 1.15 to 1.92 for patients with significant response to PIAI (I2 = 90.6%). For patients without a significant response, the LHR ranged from 0.18 to 0.65 (I2 = 87.5). An overall high risk of bias was observed for all studies included in the analysis. Study attrition, the prognostic factor measurement and the presence of confounding factors were the main sources of bias.

CONCLUSIONS

Greater reductions in pain with preoperative intra-articular anesthetic injections were found to be associated to better outcomes after FAIS surgery, but all available studies contain a high risk of bias.

Ultrasound Assessment of Hip Subspine Bone Morphology Soft-tissue Correlates with Clinical Diagnosis of Impingement

PURPOSE

To determine the ultrasound imaging manifestations associated with subspine impingement (SSI), including the osseous and soft-tissue injuries adjacent to anterior inferior iliac spine (AIIS) and to investigate the diagnostic value of ultrasound for SSI.

METHODS

We retrospectively evaluated patients who attended the sports medicine department of our hospital and underwent arthroscopic treatment for femoroacetabular impingement (FAI) between September 2019 and October 2020, with preoperative hip joint ultrasound and computed tomography (CT) examination within 1 month before surgery. All of the FAI patients were divided into the SSI group and non-SSI group, according to the clinical and intraoperative findings. The preoperative ultrasound and CT findings were assessed. The sensitivity, specificity, and positive predictive value (PPV) of some indicators were calculated and compared. Multivariable logistic regression and receiver operating characteristic curve (ROC) were also used.

RESULTS

A total of 71 hips were included, with a mean age of 35.4 ± 10.4 years, 56.3% were women. Of these, 40 hips had clinically confirmed SSI. The bone morphology type III, heterogeneous hypoecho in anterosuperior joint capsule and the direct head of rectus femoris (dRF) tendon adjacent to AIIS on the Standard Section of the dRF in ultrasound were associated with SSI. Among them, the heterogeneous hypoecho in the anterosuperior joint capsule had the best diagnostic value for the SSI (85.0% sensitivity, 58.1% specificity, AUC = 0.681). The AUC of the ultrasound composite indicators was 0.750. The AUC and PPV of CT low-lying AIIS for the SSI diagnosis was 0.733 and 71.7%, which could be improved when CT was combined with the ultrasound composite indicators with AUC = 0.831 and PPV = 85.7%.

CONCLUSIONS

Bone morphology abnormalities and soft-tissue injuries adjacent to the AIIS through sonographic evaluation were associated with SSI. Ultrasound could be used as a feasible method to predict SSI. The diagnostic value for SSI could be improved when ultrasound is combined with CT.

LEVEL OF EVIDENCE

Level IV, case series.

The Role of Ultrasonography in Hip Impingement Syndromes: A Narrative Review

Hip pain is indubitably a frequent clinical problem deriving from copious etiologies. Hip impingement syndromes are one of the most prevalent causes of persistent groin pain, especially in young and active patients. Diligent imaging of the hip region is indispensable to discern femoroacetabular impingement, as the differential diagnosis of hip pain can be exceedingly arduous. Despite hip radiography being plain and broadly attainable, it offers narrow information concerning soft tissue pathologies around the hip joint (extra-articular hip impingement syndromes). Magnetic resonance imaging and arthrography remain the gold standard examination for detecting intra-articular pathologies; however, they are widely considered expensive, time-consuming and characterized by confined. Consequently, ultrasonography has emerged as an alternative valuable diagnostic tool for distinguishing the underlying abnormalities that trigger femoroacetabular impingement. Proper hip ultrasound examination provides dynamic assessment, while also beneficial for guided intervention around the hip joint. Ultrasound hip examination is exacting due to its complex regional anatomy and deep location. It is capable of providing detailed information about various hip quadrants. An adept operator can identify both intra-articular and extra-articular pathologies. In addition, with ultrasonography, hip injections have been rendered relatively undemanding, aiding in therapeutic and diagnostic purposes. This paper aims to provide a succinct and compendious review of the existing literature, accentuating the crucial role of ultrasonography in diagnosing hip impingement syndromes and determining whether an additional examination is required regarding distinguishing between intra-articular and extra-articular syndromes.

Ultrasound-guided joint interventions of the lower extremity

The purpose of this article is to better understand the role ultrasound plays in lower extremity joint interventions. Ultrasound is an important and reliable tool diagnostically and therapeutically. Real-time feedback, lack of ionizing radiation, and dynamic maneuverability make ultrasound an important tool in the proceduralist's armament. This article will touch upon the important anatomic considerations, clinical indications, and technical step-by-step details for lower extremity ultrasound interventions. Specifically, we will look at interventions involving the hip, knee, ankle, and foot. In addition, this article will discuss the roles corticosteroid and platelet-rich plasma may play in certain interventions.

Gadolinium injected concurrently with anesthetic can result in false-negative diagnostic intra-articular hip injections

PURPOSE

The purpose of this paper was to evaluate the response to intra-articular hip injections with and without concurrent gadolinium administration. Our secondary outcome was to compare post-operative outcomes between patients with an initial false-negative gadolinium-containing injection and a matched control group.

METHODS

Patients receiving a series of two hip diagnostic intra-articular injections (DIAI), the first with gadolinium for concurrent MRA and the second without gadolinium, were retrospectively identified. Pain response to DIAI, injectate volume, local anesthetic volume, inclusion of corticosteroids, and method of injection were compared between injections. False-negative injection was defined as < 50% pain relief with concurrent gadolinium, but ≥ 50% pain relief with subsequent anesthetic injection without gadolinium. False-negative injections in patients that ultimately underwent primary hip arthroscopy were identified from this cohort and matched in a 3:1 ratio to a control cohort to compare short-term post-operative single assessment numerical evaluation (SANE) outcomes.

RESULTS

Forty-three patients underwent a series of anesthetic injections with and without gadolinium and met inclusion and exclusion criteria. Pain response was significantly different in injections performed with and without gadolinium (18% vs. 81%; p < 0.001). There were significant differences in total injectate volume, local anesthetic volume, corticosteroid use, and method of injection between injections, but these variables were not correlated with pain response. Fifteen patients with false-negative responses to injection underwent primary hip arthroscopy and were matched in a 3:1 ratio to a control cohort. There was no difference in short-term post-operative SANE scores between the gadolinium-sensitive and control groups (81.6 vs. 80.0, n.s.).

CONCLUSION

Concurrent administration of intra-articular gadolinium with DIAI may result in a false-negative response to anesthetic. Additionally, in patients with initial false-negative DIAI with gadolinium, short-term post-operative outcomes after hip arthroscopy are similar to a matched cohort.

LEVEL OF EVIDENCE

Level III.

Effect of Changes in Iliocapsularis Cross-sectional Area on Hip Arthroscopy Outcomes: Clinical and Magnetic Resonance Imaging Follow-up

Background

The function of the iliocapsularis (IC) muscle is still unclear. Previous studies have reported that the cross-sectional area of the IC may be useful in identifying borderline developmental dysplasia of the hip (BDDH).

Purpose

To evaluate the pre- to postoperative changes in IC cross-sectional area in patients with femoroacetabular impingement (FAI) and to determine if there are any associations with clinical outcomes after hip arthroscopy.

Study Design

Cohort study; Level of evidence, 3.

Methods

The authors retrospectively evaluated patients who underwent arthroscopic surgery for FAI at a single institution between January 2019 and December 2020. Patients were divided into 3 groups according to lateral center-edge angle: BDDH group (20°-25°), control group (25°-40°), and pincer group (>40°). Supine anteroposterior hip radiographs, 45° Dunn view radiographs, computed tomography scans, and magnetic resonance imaging (MRI) scans were obtained for all patients preoperatively and postoperatively. The cross-sectional areas of the IC and the rectus femoris (RF) were measured on an axial MRI slice at the level of the femoral head center. Preoperative and final follow-up scores on the visual analog scale for pain and the modified Harris Hip Score (mHHS) were compared between groups with the independent-samples t test.

Results

A total of 141 patients (mean age, 38.5 years; 64 male, 77 female) were included. The preoperative IC-to-RF ratio of the BDDH group was significantly higher than that of the pincer group (P < .05). In the BDDH group, there was significant pre- to postoperative decrease in IC cross-sectional area and the IC-to-RF ratio (P < .05 for both) as well as a significant correlation between the preoperative IC cross-sectional area and the postoperative mHHS (r = 0.434; P = .027).

Conclusion

Patients with BDDH had a significantly higher preoperative IC-to-RF ratio than patients with pincer morphology. A higher preoperative IC cross-sectional area was associated with better postoperative patient-reported outcomes after arthroscopy for the treatment of FAI combined with BDDH.

Changes in Hip Labral Size Two Years After Arthroscopic Repair Are Correlated With Preoperative Measurements on Magnetic Resonance Imaging

PURPOSE

The purposes of our study were 1) to investigate the potential change of labral size after arthroscopic repair and 2) to analyze the relationship between acetabular labral size and functional outcomes.

METHODS

In this retrospective study, patients diagnosed with labral tear and undergoing hip arthroscopic repair in our institution between September 2016 and December 2018 were included. Magnetic resonance imaging was obtained preoperatively and postoperatively, and the labral length and labral height were measured in three anatomic sites: 11:30, 1:30, and 3:00 positions. All patients completed at least 2-year follow-up. Patients whose preoperative labral size in any position wider than 2 standard deviation away from the mean were identified as the hypertrophic labrum group and were compared with the control in radiographic variables and patient-reported outcomes (PROs), including the visual analog scale (VAS), modified Harris Hip Score (mHHS), the International Hip Outcome Tool-12 (iHOT-12) and the Hip Outcome Score-Activities of Daily Living (HOS-ADL).

RESULTS

A total of 82 patients (82 hips) were included, and the mean follow-up period was 39.54 ± 8.48 months. Significant improvement in PROs was determined before and after surgeries. Twelve patients were identified with labral hypertrophy and had higher postoperative mHHS scores, higher postoperative iHOT-12 scores, and greater improvement in HOS-ADL compared with the control group. Patients with larger preoperative anterosuperior labral height exhibited more favorable clinical outcomes. Meanwhile, no significantly morphologic change in labral size was determined.

CONCLUSION

There is no significantly morphologic change in labral size of superior, anterosuperior, and anterior labrum after arthroscopic repair. Patients with hypertrophic labrum achieved more favorable clinical outcomes compared with those with normal-sized labrum.

LEVEL OF EVIDENCE

Level III, retrospective comparative prognostic trial.

Update on contribution of hip labral tears to hip pain: A narrative review

Hip labral tears are found in 22-55% of individuals with hip pain, but labral tears without cysts are usually not responsible for hip pain, which originates mostly from other structures than the torn labrum, like osteochondral, but also tendinous injuries (rectus femoris, gluteus minimus, iliopsoas) or capsulo-ligamentous tears (iliofemoral ligaments, ligament teres). Those lesions are mainly the consequences of underlying unrecognized functional acetabular dysplasia, and/or femoroacetabular impingements. Although the early repair of labral tears in young sportsmen induces a marked and lasting relief, and might delay the onset of osteoarthritis, the microinstability fostered by labral damages seems less important than underlying dysplasias/impingements. This narrative review details recent findings on: (i) the various mechanisms of pain associated with labral tears; (ii) few evidence for hip microinstability induced by isolated labral tears; (iii) how to best detect labral tears, both clinically (including through IROP test) and on imaging (MRI, MRA, computed tomography arthrography, ultrasound). Some authors suggested to use pull-out tests during surgery, but pulling of hips do not seem to increase much diagnostic performances of ultrasounds. Ultrasound-guided intra-articular and peri-articular injections may tell how often hip pain is exclusively induced by peri-capsular injuries secondary to the acetabular dysplasia/femoro-acetabular impingements already responsible for labral tears. Further works could tell whether labral repair, tendinous debridement, plication of capsule, and/or focal denervation, may induce lasting reliefs of pain induced by the chronic contraction of surrounding muscles (rectus femoris, gluteus minimus, psoas), whose deep aponeuroses mix with the superficial fibres of the thick hip capsule.

A comparison between ultrasound-guided AIIS injection and radiography in the diagnosis of subspine impingement in patients with FAI

BACKGROUND

Subspine impingement (SSI) does not have effective diagnostic criteria, especially in patients who also have femoroacetabular impingement (FAI). The classification of anterior inferior iliac spine (AIIS) morphology via three-dimensional CT is controversial.

PURPOSE

To propose a method for ultrasound-guided AIIS injection as a way to diagnose SSI and evaluate the accuracy of radiography methods, including 3-D CT and MRI, as well as intraoperative findings.

METHODS

Patients diagnosed with FAI between September 2020 and December 2021 were evaluated in this prospective study. Those who met the criteria were included in the ultrasound-guided AIIS injection test. Whether the pain was relieved after injection was recorded in the radiology report. Patients who experienced significant relief of the anterior groin pain (more than 50%) after the AIIS injection were considered positive responders. Among these patients, radiography materials, including AIIS morphology as measured by 3-D CT as well as superior capsular oedema on MRI, were compared. The presence of congestion or bruising on the capsule side of the labrum corresponding to the AIIS during hip arthroscopy was recorded.

RESULTS

A total of 73 patients with FAI underwent the ultrasound-guided AIIS injection test. Prevalence rates of 13.70% (10/73), 58.90% (43/73), 23.29% (17/73) and 4.11% (3/73) were recorded for Type I, Type IIA, Type IIB and Type III AIISs, respectively. Thirty-six patients had positive responses to injection, and 37 patients had negative responses to injection. None of the patients with Type I, 23 (53.49%) patients with Type IIA, 11 (64.71%) patients with Type IIB and 2 (66.7%) patients with Type III AIISs had positive responses to the injection. A total of 57.14% of patients with Type II or Type III AIIS had positive responses to the injection. The proportions of patients with superior capsular oedema on MRI in the Type I, Type IIA, Type IIB, and Type III AIIS groups was 0, 30.23, 29.41 and 0%, respectively. Among non-Type I AIIS patients, those who reported positive responses to the injection had a higher incidence of superior capsular oedema (38.89% vs. 14.81%, P = 0.036), but they had no significant differences in the proportion of congestion or bruising of the labrum (47.22% vs. 37.04%, P = 0.419). The results showed that no pairs of methods-ultrasound-guided injection, MRI, and intraoperative findings-achieved good consistency (κ = 0.222, κ = 0.098 and κ = - 0.116).

CONCLUSIONS

Radiographic methods including 3-D CT and MRI as well as the intraoperative findings of the labrum cannot be considered an accurate and reliable basis for the diagnosis and treatment of SSI in FAI patients. It is suggested that ultrasound-guided AIIS injections be combined with radiography to better diagnose SSI.

LEVEL OF EVIDENCE

IV, case series.

Hip-Spine Syndrome in the Nonarthritic Patient

Hip-spine syndrome refers to concurrent hip and spine pathology with overlapping symptoms. Most of the literature has studied it in relation to total hip arthroplasty literature and has been shown to increase dislocation risk. Lumbar spine and pelvic mobility have been studied less frequently in relation to nonarthritic pathologic hip states. Understanding the biomechanical relationship between the lumbar spine, pelvis, and hip can help elucidate how hip-spine syndrome affects the nonarthritic hip and how it impacts outcomes of hip arthroscopy. Changes in lumbar spine motion may be the reason certain predisposed patients develop symptomatic femoroacetabular impingement (FAI) or ischiofemoral impingement. Some athletes may be "hip users" with a low pelvic incidence, making them more reliant on hip motion due to less-intrinsic lumbopelvic motion. When these patients have FAI morphology, their increased reliance on hip motion makes them prone to experiencing femoroacetabular contact and concurrent symptoms. Other athletes may be "spine users," with larger pelvic incidence and more baseline lumbopelvic motion, making them less reliant on hip motion and therefore less prone to experiencing hip impingement even with hip FAI morphology. Hip-spine syndrome also appears to have an impact on patient selection, role of nonoperative treatment, and hip arthroscopy surgical outcomes. Identifying patients with concurrent pathology may allow surgeons to recommend targeted physical therapy or counsel patients better on their expectations after surgery.

Accuracy of Magnetic Resonance Imaging in the Diagnosis of Acetabular Chondral Delamination in Femoroacetabular Impingement

Background

Currently, there is no consensus regarding the accuracy of magnetic resonance imaging (MRI) in the detection of acetabular chondral delamination (ACD) in patients with femoroacetabular impingement (FAI), and, correspondingly, the preoperative diagnosis of ACD remains challenging.

Hypothesis

It was hypothesized that MRI would have relatively high accuracy in detecting ACD in patients with FAI.

Study Design

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

Methods

We retrospectively evaluated patients who attended the sports medicine clinic of our department and underwent arthroscopic surgery for the diagnosis of FAI between January 2018 and December 2020. All patients underwent preoperative 3.0-T MRI. ACD was evaluated by 2 raters on 3.0-T MRI scans, and interrater and intrarater reliability was assessed. Sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) of MRI for diagnosis of ACD were calculated, using arthroscopic surgery as the standard.

Results

A total of 233 patients (mean age, 37.4 years; 99 male and 134 female) were included in this study. The presence of ACD in 101 (43.3%) patients was confirmed during hip arthroscopy. The intraobserver reliability of both of the observers in detecting ACD using 3.0-T MRI scans was almost perfect (observer 1, kappa coefficient [κ] = 0.909 [95% CI, 0.854-0.964]; observer 2, κ = 0.937 [95% CI, 0.890-0.984]), and the interobserver reliability between the observers (κ = 0.801 [95% CI, 0.723-0.879]) was substantial. The overall sensitivity, specificity, PPV, and NPV of preoperative MRI to detect ACD were 83.7%, 82%, 74.2%, and 89.1%, respectively.

Conclusion

It was found that 3.0-T MRI had a relatively high sensitivity, specificity, PPV, and NPV for diagnosis of ACD in patients with FAI and could be a reliable method of diagnosing ACD preoperatively.

Healing of joint capsule after hip arthroscopy using interportal capsulotomy and capsular closure influences clinical outcomes

Background

Hip arthroscopy for treatment of femoroacetabular impingement (FAI) has developed rapidly and has been shown to significantly decrease pain and improve hip function. However, the relationship between hip capsule characteristics and healing after arthroscopic surgery and changes in patient-reported outcomes scores (PROs) for postoperative pain, function, and symptoms is still uncertain.

Methods

We retrospectively evaluated consecutive patients who were diagnosed with FAI and underwent hip arthroscopy for treatment in our hospital between May 2018 and November 2020. All patients had preoperative MRI and postoperative MRI at least 6 months after arthroscopy. Hip capsular thickness was measured at the proximal, middle, and distal site of the capsule. PROs and PROs at final follow-up were obtained, including visual analog scale (VAS) for pain and modified Harris Hip Score (mHHS).

Results

A total of 194 patients were included in this study. The mean MRI follow-up time was 14.3 (range, 6–37) months, and the mean clinical follow-up time was 26.1 (range, 12–43) months. Postoperative capsular thickness or net change were not correlated with postoperative PROs and VAS (P > .05). Capsular defect was observed in 17 (8.8%) patients. Patients with capsular defect had a relatively higher BMI (P < .05). Patients with capsular defect had a significant lower mHHS and higher VAS compared with patients with continuous capsule (P < .05). Ninety-one percentage of patients with continuous capsule surpassed minimal clinically important difference (MCID) and 80.8% achieved PASS, but only 58.8% of patients with capsular defect surpassed MCID and 47.1% achieved patient acceptable symptom state (PASS).

Conclusions

Postoperative capsular thickness may not have influence on the clinical outcomes of hip arthroscopy for treatment of FAI. Some capsule of patients who underwent arthroscopic interportal capsulotomy and repair could not heal. Postoperative capsular continuity had a great impact on the clinical outcomes of hip arthroscopy for FAI. Patients with higher BMI may be more likely to have capsule failure to heal.

Pre- and intraoperative decision-making challenges in hip arthroscopy for femoroacetabular impingement

There has been a marked increase in the number of hip arthroscopies performed over the past 16 years, primarily in the management of femoroacetabular impingement (FAI). Insights into the pathoanatomy of FAI, and high-level evidence supporting the clinical effectiveness of arthroscopy in the management of FAI, have fuelled this trend. Arthroscopic management of labral tears with repair may have superior results compared with debridement, and there is now emerging evidence to support reconstructive options where repair is not possible. In situations where an interportal capsulotomy is performed to facilitate access, data now support closure of the capsule in selective cases where there is an increased risk of postoperative instability. Preoperative planning is an integral component of bony corrective surgery in FAI, and this has evolved to include computer-planned resection. However, the benefit of this remains controversial. Hip instability is now widely accepted, and diagnostic criteria and treatment are becoming increasingly refined. Instability can also be present with FAI or develop as a result of FAI treatment. In this annotation, we outline major current controversies relating to decision-making in hip arthroscopy for FAI. Cite this article: Bone Joint J 2022;104-B(5):532-540.

Diagnosis and Simultaneous Treatment of Musculoskeletal Injury Using H2O2-Triggered Echogenic Antioxidant Polymer Nanoparticles in a Rat Model of Contusion Injury

Ultrasound is clinically used for diagnosis and interventions for musculoskeletal injuries like muscle contusion, but contrast of ultrasonography still remains a challenge in the field of the musculoskeletal system. A level of hydrogen peroxide (H₂O₂) is known to be elevated during mechanical tissue damage and therefore H₂O₂ can be exploited as a diagnostic and therapeutic marker for mechanical injuries in the musculoskeletal system. We previously developed poly(vanillin-oxalate) (PVO) as an inflammation-responsive polymeric prodrug of vanillin, which is designed to rapidly respond to H₂O₂ and exert antioxidant and anti-inflammatory activities. The primary aim of this study is to verify whether PVO nanoparticles could serve as contrast agents as well as therapeutic agents for musculoskeletal injuries simultaneously. In a rat model of contusion-induced muscle injury, PVO nanoparticles generated CO₂ bubbles to enhance the ultrasound contrast in the injury site. A single intramuscular injection of PVO nanoparticles also suppressed contusion-induced muscle damages by inhibiting the expression of pro-inflammatory cytokines and inflammatory cell infiltration. We, therefore, anticipate that PVO nanoparticles have great translational potential as not only ultrasound imaging agents but also therapeutic agents for the musculoskeletal disorders such as contusion.

The imaging evaluation of acetabular labral lesions

The acetabular labrum is an important structure that contributes to hip joint stability and function. Diagnosing labral tears involves a comprehensive assessment of clinical symptoms, physical examinations, imaging examinations, and arthroscopic confirmation. As arthroscopy is an invasive surgery, adjuvant imaging of the acetabular labrum is increasingly imperative for orthopedists to diagnose and assess labral lesions prior to hip arthroscopy for surgical management. This article reviews the current imaging strategies for the evaluation of labrum lesions.

Image-Guided Intra-articular Hip Injections and Risk of Infection After Hip Arthroscopy

BACKGROUND

Although intra-articular injections are important in the management of patients who may later undergo hip arthroscopy, conflicting data are available regarding the safety of such injections when administered within 3 months of surgery. Furthermore, despite the increasing use of image-guided intra-articular hip injections, it is unknown whether the type of imaging modality used is associated with infection after hip arthroscopy.

PURPOSE

To assess the risk of infection associated with image-guided intra-articular injections before hip arthroscopy and, secondarily, compare that risk between ultrasound (US) and fluoroscopic (FL) guidance.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

This was a retrospective cohort study of patients in a large national insurance database who underwent hip arthroscopy between 2007 and 2017. Patients were required to have continuous enrollment from at least 1 year before to 6 months after hip arthroscopy. Patient age, sex, geographic region, medical history, surgical details, and hip injections were collected. Patients who underwent injection ≤3 months preoperatively and >3 to ≤12 months preoperatively were compared with patients who did not undergo preoperative injection. Bivariate analyses and multivariable logistic regressions were used to assess the association between ipsilateral preoperative hip injection and surgical site infection within 6 months of surgery.

RESULTS

We identified 17,987 patients (36.3% female; mean ± SD age, 37.6 ± 14.0 years) undergoing hip arthroscopy, 2276 (12.7%) of whom had an image-guided hip injection in the year preceding surgery (53.0% FL). Patients who underwent intra-articular injection ≤3 months preoperatively had similar infection rates to patients who did not undergo preoperative injection in the year before surgery for both the FL (0.46% vs 0.46%; P≥ .995) and the US cohorts (0.50% vs 0.46%; P = .76). Results persisted in adjusted analysis (FL ≤3 months: OR, 1.04; 95% CI, 0.32-3.37; P = .94; US ≤3 months: OR, 1.19; 95% CI, 0.36-3.90; P = .78). Similar results were seen for patients undergoing injections >3 to ≤12 months preoperatively.

CONCLUSION

Postoperative infection was rare in patients undergoing intra-articular hip injection ≤3 months before hip arthroscopy and was no more common than in patients not undergoing preoperative injection. Moreover, no differences were seen in infection risk between US and FL guidance. Although intra-articular hip injections should always be administered with careful consideration, these results do not suggest that these injections are uniformly contraindicated in the 3 months preceding hip arthroscopy.

Genes associated with inflammation and bone remodeling are highly expressed in the bone of patients with the early-stage cam-type femoroacetabular impingement

BACKGROUND

Recent studies have shown high expression levels of certain inflammatory, anabolic, and catabolic genes in the articular cartilage from the impingement zone of the hips with femoroacetabular impingement (FAI), representing an increased metabolic state. Nevertheless, little is known about the molecular properties of bone tissue from the impingement zone of hips with FAI.

METHODS

Bone tissue samples from patients with early-stage cam-type FAI were collected during hip arthroscopy for treatment of cam-type FAI. Control bone tissue samples were collected from six patients who underwent total hip replacement because of a femoral neck fracture. Quantitative real-time polymerase chain reaction (PCR) was performed to determine the gene expression associated with inflammation and bone remodeling. The differences in the gene expression in bone tissues from the patients with early-stage cam-type FAI were also evaluated based on clinical parameters.

RESULTS

In all, 12 patients with early-stage cam-type FAI and six patients in the control group were included in this study. Compared to the control samples, the bone tissue samples from patients with FAI showed higher expression levels of interleukin-6 (IL-6), alkaline phosphatase (ALP), receptor activator of nuclear factor-kB ligand (RANKL), and osteoprotegerin (OPG) (P < 0.05). IL-1 expression was detected only in the control group. On the other hand, there was no significant difference in IL-8 expression between the patients with FAI and the control group. The patients with FAI having a body mass index (BMI) of >24 kg/m² showed higher ALP expression (P < 0.05). Further, the expression of IL-6 and ALP was higher in the patients with FAI in whom the lateral center-edge angle was >30° (P < 0.05).

CONCLUSIONS

Our results indicated the metabolic condition of bone tissues in patients with early-stage cam-type FAI differed from that of normal bone in the femoral head-neck junction. The expression levels of the genes associated with inflammation and bone remodeling were higher in the bone tissue of patients with early-stage cam-type FAI than in the patients with normal bone tissue.

Hip arthroscopy has good clinical outcomes in the treatment of osteoid osteoma of the acetabulum

BACKGROUND

Osteoid osteoma (OO) of the acetabulum is a relatively rare disease. However, the the clinical outcomes of hip arthroscopy for treatment of OO of the acetabulum are still uncertain.

METHODS

We evaluated consecutive patients who were diagnosed with OO of the acetabulum and who underwent hip arthroscopy at our hospital between January 2013 and March 2020. All patients underwent a preoperative physical examination. Preoperative supine anteroposterior hip radiography, cross-table lateral radiographs, computed tomography (CT), and magnetic resonance imaging were performed in all patients. The alpha angle and lateral center-edge angle were measured before surgery. Supine anteroposterior hip radiography and CT were performed in all patients postoperatively. Preoperative patient-reported outcomes (PROs), including Visual Analog Scale (VAS), the International Hip Outcome Tool-12 (iHOT-12) and modified Harris Hip Score (mHHS), and PROs at final follow-up were evaluated.

RESULTS

A total of 6 patients (mean age, 18.7 years; age range, 6-31 years; 5 males and 1 females) were included in this study. The average follow-up period after surgery was 28.3 months (range, 6-90 months). Before surgery, the mean mHHS was 45.2 ± 10.5 (range, 33-56), the mean iHOT-12 was 33.3 ± 14.5 (range, 13-49), and mean VAS was 8.2 ± 1.0 (range, 7-9). At one month after surgery, mean mHHS was 78.7 ± 1.9 (range, 77-81), iHOT-12 was 71.0 ± 4.5 (range, 68-80), and mean VAS was 0. At the final post-operative follow-up, mean mHHS was 89.2 ± 2.1 (range, 86-91), iHOT-12 was 93.5 ± 5.0 (range, 88-98), and mean VAS was 0. All results, except VAS between one month after surgery and at final follow-up, demonstrated statistically significant improvement (P < 0.05). One patient underwent revision surgery.

CONCLUSIONS

Hip arthroscopy has good clinical outcomes in the treatment of OO of the acetabulum. Further study on the mechanism of secondary femoroacetabular impingement (FAI) caused by OO of the acetabulum is needed. More cases of arthroscopic excision and longer follow-up are also needed to better prove the clinical outcomes of hip arthroscopy for OO of the acetabulum.

Editorial Commentary: Ultrasound-Guided Injection With Dynamic Assessment Could Improve Outcomes in Atypical and Revision Hip Arthroscopy Patients: But Today, Few Are Trained to Hear at Such High Frequencies

Imaging modalities for hip disorders all have their strengths and weaknesses. Magnetic resonance imaging is superior for evaluating soft tissue pathology, computerized tomography best characterizes osseous morphology, and plain radiographs can accurately depict 2-dimensional anatomy and are familiar to most clinicians. Ultrasound-guided injections have become commonplace in the musculoskeletal arena. Ultrasound evaluation of musculoskeletal anatomy has received increased attention, has the ability to image soft tissue and osseous structures, and more importantly, has the ability to dynamically evaluate these structures in real time. A noninvasive dynamic assessment of the hip region could be an absolute game changer for the hip preservation/sports medicine community in the diagnosis of atypical hip pain, femoroacetabular impingement, and labral tears. Widespread ability and expertise to perform these dynamic ultrasound assessments, however, is not in place at this time. We need more training and studies to best harness the potential benefits of these sound waves.