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

The Evaluation of the Balance Test and MuscleLab Test for the Early Detection of Femoroacetabular Impingement

Femoroacetabular impingement (FAI) is a common source of hip pain affecting a wide range of subjects. In this work, we assessed two tests, namely the balance test and the MuscleLab test, in comparison with the flexion-abduction-external rotation (FABER) and flexion-adduction-internal rotation (FADIR) tests, in order to evaluate the functionality of the neural-musculoskeletal system of the subjects affected by FAI based on the measurement of biomechanical parameters. Our goal was to investigate the early detection of an altered hip joint and to monitor pathology progression over time. A total of 52 subjects, 29 females and 23 males, with an average age of 42 ± 13 years presenting hip impingement diagnosed using X-ray, were enrolled. Twenty-eight patients without signs of hip impingements were used as the control group. The balance test, which evaluates the capacity of a person to keep the orthostatic position against terrestrial gravity, and the MuscleLab test, which measures the force and power generated by active muscles during a movement, as well as FABER and FADIR tests, were performed in each subject. The balance and MuscleLab tests presented 100% sensitivity and higher sensitivity in FAI diagnosis, with 72.9% and 70.4%, respectively, in comparison with those obtained using FABER and FADIR tests, with 59.6% and 67.3%, respectively. The evaluation of the neural-musculoskeletal system using the balance and MuscleLab tests can help in the early detection of the severity of hip impingements and the assessment of non-operative treatments used over time.

The revision hip arthroscopy complex: capsular deficiency, labral deficiency, femoral over-resection and adhesions can result in good survivorship with revision hip arthroscopy

To evaluate the patient-reported outcomes (PROs) and survivorship of combined arthroscopic hip labral reconstruction/augmentation, capsular reconstruction, femoral neck remplissage and lysis of adhesions. Patients ≥18 years old who underwent this combination of procedures during revision hip arthroscopy and were eligible for minimum 2-year follow-up were identified. PRO scores including Hip Outcome Score (HOS)-Activities of Daily Living scale, HOS-Sports scale, modified Harris Hip Score, Short Form 12, and Western Ontario & McMaster Universities Osteoarthritis Index, patient satisfaction and failure rates were analyzed. Seven patients (5 females and 2 males) with average age of 45.0 ± 5.2 (range: 40-54 years) met inclusion criteria. Patients had a median of 1 (range: 1-3) prior hip surgery at an outside institution. All patients had previously undergone femoral osteoplasty, and 85% (6/7) of patients had a labral repair performed. Four patients had no capsule closure performed in their prior procedures. Six patients were available for minimum 2-year follow-up. Two patients converted to total hip arthroplasty: one patient with four prior hip arthroscopies and the other had advanced osteoarthritis with outerbridge grade 3/4 defects requiring microfracture. Mean patient satisfaction was 7 (range: 2-9). At mean follow-up of 3 years, most patients who underwent the combination of labral reconstruction, capsular reconstruction, femoral neck remplissage and lysis of adhesions during revision hip arthroscopy demonstrated improved PROs. This salvage procedure has the potential to restore hip function in patients who have failed an initial hip arthroscopy procedure. In patients with these pathologies present and concomitant joint space narrowing, a total hip arthroplasty may be a more appropriate salvage option.

Validity and Reliability of a Novel Smartphone Tele-Assessment Solution for Quantifying Hip Range of Motion

BACKGROUND

Tele-health has become a major mode of delivery in patient care, with increasing interest in the use of tele-platforms for remote patient assessment. The use of smartphone technology to measure hip range of motion has been reported previously, with good to excellent validity and reliability. However, these smartphone applications did not provide real-time tele-assessment functionality. We developed a novel smartphone application, the TelePhysio app, which allows the clinician to remotely connect to the patient's device and measure their hip range of motion in real time. The aim of this study was to investigate the concurrent validity and between-sessions reliability of the TelePhysio app. In addition, the study investigated the concurrent validity, between-sessions, and inter-rater reliability of a second tele-assessment approach using video analysis.

METHODS

Fifteen participants (nfemales = 6) were assessed in our laboratory (session 1) and at their home (session 2). We assessed maximum voluntary active hip flexion in supine and hip internal and external rotation, in both prone and sitting positions. TelePhysio and video analysis were validated against the laboratory's 3-dimensional motion capture system in session 1, and evaluated for between-sessions reliability in session 2. Video analysis inter-rater reliability was assessed by comparing the analysis of two raters in session 2.

RESULTS

The TelePhysio app demonstrated high concurrent validity against the 3D motion capture system (ICCs 0.63-0.83) for all hip movements in all positions, with the exception of hip internal rotation in prone (ICC = 0.48, p = 0.99). The video analysis demonstrated almost perfect concurrent validity against the 3D motion capture system (ICCs 0.85-0.94) for all hip movements in all positions, with the exception of hip internal rotation in prone (ICC = 0.44, p = 0.01). The TelePhysio and video analysis demonstrated good between-sessions reliability for hip external rotation and hip flexion, ICC 0.64 and 0.62, respectively. The between-sessions reliability of hip internal and external rotation for both TelePhysio and video analysis was fair (ICCs 0.36-0.63). Inter-rater reliability ICCs for the video analysis were 0.59 for hip flexion and 0.87-0.95 for the hip rotation range.

CONCLUSIONS

Both tele-assessment approaches, using either a smartphone application or video analysis, demonstrate good to excellent concurrent validity, and moderate to substantial between-sessions reliability in measuring hip rotation and flexion range of motion, but less in internal hip rotation in the prone position. Thus, it is recommended that the seated position be used when assessing hip internal rotation. The use of a smartphone to remotely assess hip range of motion is an appropriate, effective, and low-cost alternative to the face-to-face assessments. This method provides a simple, cost effective, and accessible patient assessment tool with no additional cost. This study validates the use of smartphone technology as a tele-assessment tool for remote hip range of motion assessment.

Hip Range of Motion Is Increased After Hip Arthroscopy for Femoroacetabular Impingement: A Systematic Review

Purpose

To investigate the impact of arthroscopic correction of symptomatic femoroacetabular impingement on postoperative hip range of motion (ROM), as an objectively measured postoperative clinically reported outcome.

Methods

A systematic review of the current literature was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, OVID/MEDLINE, EMBASE, and Cochrane databases were queried in November 2020. Studies not reporting pre- to postoperative ROM measurements were excluded. Methodologic quality was assessed using the MINORS assessment, and certainty of evidence was assessed using the GRADE approach. Effect size using standardized mean differences assessed magnitude of change between pre- and postoperative ROM.

Results

In total, 23 studies were included evaluating 2,332 patients. Mean age ranged from 18 to 44.2 years. Flexion, internal rotation (IR), and external rotation (ER) were the predominantly measured ROMs reported in 91%, 100% and 65% of studies, respectively. Observed change following hip arthroscopy was considered significant in 57.1% (flexion), 74% (IR), and 20% (ER). Effect size of change in significantly improved ROMs were weak (16.7% flexion, 33.3% ER), moderate (58.3% flexion, 29.4% IR), and large (25% flexion, 64.7% IR, 66.7% ER). For goniometric assessment mean observed changes ranged as follows: flexion: 0.1° to 12.2°; IR: 3.6° to 21.9°; ER: –2.6° to 12.8°. For computed tomography–simulated assessment, the mean observed change ranged as follows: flexion: 3.0° to 8.0°; IR 9.3° to 14.0°.

Conclusions

Outcome studies demonstrate overall increased range of flexion and IR post-hip arthroscopy, with a moderate and large effect respectively. Change in ER is less impacted following hip arthroscopy. Certainty of evidence to support this observation is low. Current research evaluating changes in this functional ability is limited by a lack of prospective studies and non-standardized measurement evaluation techniques.

Level of Evidence

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

Physical Examination of the Hip: Assessment of Femoroacetabular Impingement, Labral Pathology, and Microinstability

Purpose of Review

Determining the correct diagnosis can be challenging in patients presenting with hip pain. The physical examination is an essential tool that can aid in diagnosis of hip pathology. The purpose of this review is to provide an updated summary of recent literature on the physical exam of the hip, particularly as it relates to diagnosis of femoroacetabular impingement (FAI) syndrome, labral injury, and hip microinstability.

Recent Findings

Physical exam findings consistent with the diagnosis of FAI include reduced supine hip internal rotation and positive flexion-adduction-internal rotation maneuvers. Labral tears can be detected on exam with the Scour test. Studies demonstrate altered hip biomechanics in patients with FAI during activities such as walking and squatting. Those with FAI have slower squat velocities, slower sit-to-stand tests, and increased hip flexion moments during ambulation. Hip microinstability is a dynamic process, which can occur after prior hip arthroscopy. For hip microinstability, the combination of the three following positive tests (anterior apprehension, abduction-extension-external rotation, and prone external rotation) is associated with a 95% likelihood of microinstability as confirmed by examination under anesthesia at the time of surgery.

Summary

A comprehensive hip physical exam involves evaluation of the hip in multiple positions and assessing hip range of motion, strength, as well as performing provocative testing. A combination of physical exam maneuvers is necessary to accurately diagnose FAI syndrome and labral pathology as individual tests vary in their sensitivity and specificity. While an elevated level of suspicion is needed to diagnose hip microinstability, the provocative tests for microinstability are highly specific.

‘Mini-Max’ knotless acetabular labrum repair: repair construct rationale and allocation in a consecutive case series with minimum 1-year clinical outcomes

To describe the ‘mini-Max’ approach to labrum repair using non-absorbable 2.4-mm knotless suture anchors and report objective clinical outcomes with a large single-surgeon cohort. Level 3 retrospective case series. A retrospective review was conducted to report the use and allocation of non-absorbable 2.4-mm knotless suture anchors during ‘mini-Max’ labral repair from 2015 to 2018. Descriptive analysis of the labral damage severity, size and number of anchors used to arthroscopically repair the acetabular labrum was performed. Paired-samples t-tests were performed to evaluate whether preoperative and 1-year follow-up patient-reported outcomes (PROs) were statistically significant. An analysis of variance was performed comparing PROs with categorized number of labral anchors. A total of 390 patients were queried in this study, with 330 (85%) diagnosed intraoperatively with acetabular labral tears. A total of 245 patients (137 females and 108 males) with a mean age of 30.1 ± 11.6 years (mean ± SD) at the time of surgery underwent ‘mini-Max’ labral refixation. Of the 245 labral tears, 88 (35.9%) were graded as mild, 113 (46.1%) as moderate and 44 (18.0%) as severe. Labral repairs required an average of 2.1 ± 0.67 anchors across all patients included. Forty-one repairs (16.7%) required one anchor, 139 (56.7%) required two anchors, 63 (25.7%) required three anchors and 2 (0.8%) required four anchors. Significant improvements were reported for all PROs (P ≤ .001) at a minimum of 1-year follow-up. Arthroscopic ‘mini-Max’ labral repair using non-absorbable knotless suture anchors is a safe and effective technique for improving the lives of patients suffering from symptomatic acetabular labrum tears.

Excision of Heterotopic Ossification around the Hip: Arthroscopic and Open Techniques

Heterotopic ossification (HO) can occur as a complication of various pathologies affecting the hip including trauma, tendon avulsions, chronic injury, spinal cord injury, and soft-tissue disruption caused by surgery. When HO is present alongside intra-articular hip pathology such as femoroacetabular impingement syndrome (FAIS) or labral pathology, consideration should be made to combine the surgical excision of the HO with the FAIS decompression or labral repair if the location and size of the HO is appropriate for arthroscopic excision. Often times, the HO is located in such a position that any central compartment work can be completed before turning to the HO excision. If an open approach is required, the modified Gibson approach can be used for lateral hip access, whereas the Smith-Petersen approach provides anterior hip access. In this Technical Note we discuss arthroscopic techniques for excision of HO in the setting of concomitant FAIS, with discussion of when HO excision occurs in relation to cam decompression and labral repair, and mention tips on how to approach HO excision through an open approach.

Arthroscopic Capsular Management of the Hip: A Comparison of Indications for and Clinical Outcomes of Periportal Versus Interportal Capsulotomy

PURPOSE

To compare the clinical outcomes of periportal capsulotomy versus interportal capsulotomy with closure using a standard clinical algorithm at a minimum of 2 years after hip arthroscopy.

METHODS

A retrospective cohort study of patients treated from July 2015 to October 2017 was conducted to determine the effects of 2 capsular management approaches on clinical outcomes. When patient pathology limited adequate exposure via periportal capsulotomy, an interportal capsulotomy was performed. The capsular management approaches were correlated with the following patient-reported outcomes (PROs) at 2 years: Hip Outcome Score (HOS), 12-item International Hip Outcome Tool, visual analog scale for pain, and patient satisfaction. Preoperative comparisons between the 2 groups were analyzed using t tests or the Fisher exact test, depending on the category of data. Two-tailed independent t tests were performed to evaluate whether preoperative and follow-up outcome scores were significantly different between patients treated with a periportal capsulotomy and those treated with an interportal capsulotomy.

RESULTS

Overall, patients in both groups experienced significant improvements in all PROs on postoperative comparisons at 2-year follow-up (P < .001). The mean changes in the PROs were as follows: HOS-Activities of Daily Living, 24.7 in the periportal group and 23.5 in the interportal group (P = .484); HOS-Sport-Specific Subscale, 30.2 and 31.3, respectively (P = .895); 12-item International Hip Outcome Tool score, 41.9 and 40.2, respectively (P = .564); and visual analog scale pain score, -40.9 mm and -34.5 mm, respectively (P = .791). Additionally, no statistically significant difference in patient satisfaction at 2-year follow-up was found between patients who underwent interportal capsulotomy and those who underwent periportal capsulotomy (P = .604).

CONCLUSIONS

At 2-year follow-up, patients who underwent a periportal capsulotomy reported statistically and clinically significant improvements in PROs and satisfaction with the surgical intervention. This study confirms that the use of a simple clinical algorithm for selection of periportal capsulotomy or interportal capsulotomy with closure results in acceptable management decisions as defined by 2-year PROs.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Pre-operative comparisons for a return to running protocol in recreational athletes following hip arthroscopy

The purpose of the current study was to present pre-operative comparisons for recreational athletes attempting a return to running following hip arthroscopy, and the return to running progression protocol used to guide them. A prospective, non-randomized cohort study was conducted to evaluate recreational athletes that returned to running following hip arthroscopy. Return to running was the primary outcome measure and defined as the ability to run at least one mile three times weekly while maintaining patient-reported relief of pre-operative symptoms. Patients included were correlated with the following pre-operative patient-reported outcome measures: hip outcome score (HOS), 12-item international outcome tool (iHOT-12), visual analog scale for pain (VAS) and the Short-Form Health Survey (SF-12). Of the 99 included patients, 94 (95%) returned to running successfully with an average return of 4.8 months. There was no statistical difference in pre-operative comparisons between patients that returned to running and did not return to running (P ≥ 0.154). Evaluation of pre-operative clinical outcomes demonstrated no statistical difference between individuals that returned and did not return to running (P ≥ 0.177), but a large difference between the two groups was identified for HOS-ADL (64.8 versus 53.7, returned versus did not return), iHOT-12 (33.8 versus 25.4) and VAS (58.6 versus 69.3). Patients who returned to running demonstrated similar intraoperative procedures as those that did not return to running (P ≥ 0.214). The current study successfully establishes a management plan and progression protocol for patients identifying a return to recreational running following hip arthroscopy. Level of evidence: 3.

Editorial Commentary: Revision Hip Surgery After Arthroscopy-What Went Wrong? Are There Second Chances?

Hip arthroscopy allows minimally invasive treatment of femoroacetabular impingement (FAI) with labral tears. Over the last 2 decades, the indications and techniques for treatment of FAI have evolved, and complex pathology can now be treated arthroscopically. Short- and medium-term patient-reported outcomes demonstrate the reliability of hip arthroscopy for treatment of FAI, although a subset of patients fail to achieve desired results and require revision surgery. The indications for revision surgery after a primary hip arthroscopy are not well described in a large series, and most reviews focus on revision arthroscopy at the exclusion of open surgery (notably periacetabular osteotomy and total hip arthroplasty). Furthermore, patient-reported outcomes after these revision procedures have not been recently summarized.

Pelvic Tilt and Range of Motion in Hips With Femoroacetabular Impingement Syndrome

INTRODUCTION

Physiotherapy is a management option for the treatment of femoroacetabular impingement (FAI) syndrome. This study examines the influence of changes in pelvic tilt and hip adduction on the range of motion (ROM) of the hip.

METHODS

Ten FAI hips were used to simulate impingement at two positions: (1) 20° internal rotation (IR) with 100° flexion and 10° adduction and (2) 40° IR with 35° flexion and 10° adduction; the amount of IR was measured at the point of bony impingement or to the defined limit. Each simulation was performed at neutral and 5° and 10° anterior and posterior pelvic tilt. Then, the hip was placed in 10° of abduction, and all simulations were repeated.

RESULTS

With neutral pelvic tilt, impingement occurred at 4.3 ± 8.4° of IR at the high-flexion position. An increase in anterior pelvic tilt led to a loss of IR, that is, earlier occurrence of FAI, whereas an increase in posterior pelvic tilt led to an increase in IR, that is, later occurrence of FAI. At the high-flexion position, abduction provided more IR before impingement (neutral: 9.1 ± 5.7°, P < 0.01; 10° anterior tilt: 14.6 ± 5.2°, P < 0.01; 10° posterior tilt: 4.2 ± 3.7° IR, P = 0.01). Placing the hip in abduction and posteriorly tilting the pelvis produce a combined effect that increased IR relative to the neutrally tilted pelvis (5° posterior tilt: 11.4 ± 7.6°, P = 0.01; 10° posterior tilt: 12.8 ± 7.6°, P < 0.01). The ROM in the mid-flexion position was not affected by any combination of pelvic tilt and hip abduction or adduction (average IR: 37.4 ± 5.0°, P > 0.05).

CONCLUSIONS

Abduction and posterior pelvic tilt increased the impingement-free ROM in the hips with FAI. Thus, rehabilitation aimed at altering the tilt of the pelvis may reduce the frequency of impingement and limit further joint damage.

THE ROLE of a BIKE FIT in CYCLISTS with HIP PAIN. A CLINICAL COMMENTARY

Hip pathology is common amongst athletes and the general population. The mechanics of cycling have the potential to exacerbate symptomatic hip pathology and progress articular pathology in patients with morphologic risk factors such as femoroacetabular impingement. A professional fit of the bicycle to the individual which aims to optimize hip joint function can allow patients with hip pathology to exercise in comfort when alternative high impact exercise such as running may not be possible. Conversely improper fit of the bicycle can lead to hip symptoms in otherwise healthy individuals who present with risk factors for hip pain. Accordingly a bike fit can form part of the overall management strategy in a cyclist with hip symptoms. The purpose of this clinical commentary is to discuss hip pathomechanics with respect to cycling, bicycle fitting methodology and the options available to a physical therapist to optimize hip mechanics during the pedaling action.

Hip Joint Torsional Loading Before and After Cam Femoroacetabular Impingement Surgery

BACKGROUND

Surgical management of cam femoroacetabular impingement (FAI) aims to preserve the native hip and restore joint function, although it is unclear how the capsulotomy, cam deformity, and capsular repair influence joint mechanics to balance functional mobility.

PURPOSE

To examine the contributions of the capsule and cam deformity to hip joint mechanics. Using in vitro, cadaveric methods, we examined the individual effects of the surgical capsulotomy, cam resection, and capsular repair on passive range of motion and resistance of applied torque.

STUDY DESIGN

Descriptive laboratory study.

METHODS

Twelve cadaveric hips with cam deformities were skeletonized to the capsule and mounted onto a robotic testing platform. The robot positioned each intact hip in multiple testing positions: (1) extension, (2) neutral 0°, (3) flexion 30°, (4) flexion 90°, (5) flexion-adduction and internal rotation (FADIR), and (6) flexion-abduction and external rotation. Then the robot performed applicable internal and external rotations, recording the neutral path of motion until a 5-N·m of torque was reached in each rotational direction. Each hip then underwent a series of surgical stages (T-capsulotomy, cam resection, capsular repair) and was retested to reach 5 N·m of internal and external torque again after each stage. During the capsulotomy and cam resection stages, the initial intact hip's recorded path of motion was replayed to measure changes in resisted torque.

RESULTS

Regarding changes in motion, external rotation increased substantially after capsulotomies, but internal rotation only further increased at flexion 90° (change +32%, P = .001, d = 0.58) and FADIR (change +33%, P < .001, d = 0.51) after cam resections. Capsular repair provided marginal restraint for internal rotation but restrained the external rotation compared with the capsulotomy stage. Regarding changes in torque, both internal and external torque resistance decreased after capsulotomy. Compared with the capsulotomy stage, cam resection further reduced internal torque resistance during flexion 90° (change -45%, P < .001, d = 0.98) and FADIR (change -37%, P = .003, d = 1.0), where the cam deformity accounted for 21% of the intact hip's torsional resistance in flexion 90° and 27% in FADIR.

CONCLUSION

Although the capsule played a predominant role in joint constraint, the cam deformity provided 21% to 27% of the intact hip's resistance to torsional load in flexion and internal rotation. Resecting the cam deformity would remove this loading on the chondrolabral junction.

CLINICAL RELEVANCE

These findings are the first to quantify the contribution of the cam deformity to resisting hip joint torsional loads and thus quantify the reduced loading on the chondrolabral complex that can be achieved after cam resection.

NON-OPERATIVE MANAGEMENT OF INDIVIDUALS WITH NON-ARTHRITIC HIP PAIN: A LITERATURE REVIEW

BACKGROUND

Non-arthritic hip pain is defined as being related to pathologies of the intra-articular structures of the hip that can be symptomatic. A trial of non-operative management is commonly recommended before consideration of surgery for individuals with non-arthritic hip conditions. There is a need to describe a non-operative or conservative treatment plan for individuals with non-arthritic hip pain.

PURPOSE

The purpose of this literature review was to systematically examine the literature in order to identify and provide evidence for non-operative or conservative management of individuals with non-arthritic hip pain. A proposed home exercise program will be provided for individuals with non-arthritic hip pain.

STUDY DESIGN

Review of the Literature.

MATERIALS/METHODS

A literature search of PubMed, Medline, SPORTSDiscus, and CINAHL was conducted. Keywords included: "hip" AND "femoroacetabular impingement" OR "labral tear." Studies were included if they described non-operative management for individuals with non-arthritic hip pain. Studies were excluded if they recommended a trial of conservative treatment without specific management or interventions and/or activity modification without specific details for intervention.

RESULTS

A total of 49 studies met the eligibility criteria and were included in the review. Rehabilitation recommendations were identified from manuscripts including clinical trials, case series, discussion articles, or systematic reviews related to the non-operative or conservative management of non-arthritic hip pain. Rehabilitation interventions focused on patient education, activity modification, limitation of aggravating factors, an individualized physical therapy protocol, and use of a home exercise program.

CONCLUSIONS

Rehabilitation should address biomechanical deficiencies with neuromuscular training of the hip and lumbopelvic regions. While the current literature on non-operative management is limited, future randomized control trials will establish the effectiveness of specific physical therapy protocols for individuals with non-arthritic hip pain.

LEVEL OF EVIDENCE

3b.

Comprehensive Clinical Evaluation of Femoroacetabular Impingement: Part 3, Magnetic Resonance Imaging

Radiologic imaging is an essential supplement to the physical examination in the evaluation of a patient with femoroacetabular impingement. Plain radiographs are the initial modality of choice for the evaluation of bony anatomy and pathology. Magnetic resonance imaging supplements the physical examination and standard radiographs by enabling qualitative and quantitative evaluation of both articular cartilage and soft tissues about the hip. Magnetic resonance imaging also provides improved 3-dimensional characterization of the bony anatomy owing to the multiplanar nature of this technique. This article describes a comprehensive approach to interpretation of magnetic resonance examination of the hip.