Femoroacetabular impingement

Outcomes of Isolated Endoscopic Gluteal Tendon Repair Compared With Concomitant Endoscopic Gluteal Tendon Repair and Arthroscopic Hip Labral Repair: A Propensity-Matched Analysis With Minimum 2-Year Follow-up

Background

Both gluteal and labral tears are common sources of hip pain, but no studies have evaluated how concomitant arthroscopic labral repair and correction of femoroacetabular impingement syndrome (FAIS) affect outcomes after endoscopic gluteus/minimus repair.

Purpose

(1) To compare patient-reported outcomes (PROs) and clinically significant outcomes achievements between patients who underwent endoscopic gluteus medius/minimus and arthroscopic hip labral repair with correction of FAIS versus endoscopic gluteus medius/minimus repair without labral repair and (2) to define threshold scores required to achieve the minimal clinically important difference (MCID) and the Patient Acceptable Symptom State (PASS) for the Hip Outcome Score-Activities of Daily Living, Hip Outcome Score-Sports Specific, modified Harris Hip Score (mHHS), 12-item international Hip Outcome Tool, and visual analog scale for pain in these patients.

Study Design

Cohort study; Level of evidence, 3.

Methods

Patients who underwent primary endoscopic gluteus medius/minimus repair between 2012 and 2020 were identified. Those who underwent concomitant arthroscopic labral repair and correction of FAIS with femoroplasty or acetabuloplasty as indicated were propensity matched in a 1 to 1 ratio by sex, age, and body mass index to patients who underwent gluteus medius/minimus repair without labral repair. Patients who completed the study PROs were assessed preoperatively and at 2 years postoperatively. Threshold scores required to achieve the MCID and PASS thresholds were calculated.

Results

A total of 32 patients who underwent simultaneous gluteal and labral repair (G+L) were matched to 32 patients who underwent gluteal repair without labral repair (G); 75% of patients in the G cohort underwent labral debridement, while 25% in this cohort received no labral treatment. A significant difference was observed between groups in preoperative mHHS scores (G+L, 54.4 ± 12.9 vs G, 46.3 ± 14; P = .048) but no differences in any other PRO scores (P≥ .207). The MCID/PASS thresholds were as follows: Hip Outcome Score-Activities of Daily Living (11.14/83.82), Hip Outcome Score-Sports Specific (16.07/59.72), mHHS (11.47/70.95), 12-item international Hip Outcome Tool (13.73/45.49), and visual analog scale for pain (14.30/22). There were no significant differences in MCID or PASS achievement rates between the 2 groups (P≥ .108).

Conclusion

Patients who underwent combined G+L demonstrated comparable PROs and clinically significant outcomes achievement rates to patients who underwent G, highlighting sustained successful outcomes for patients with gluteal tendon pathology and concomitant FAIS and labral tears.

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.

Effects of joint loading on the development of capital femoral epiphysis morphology

INTRODUCTION

The deleterious influence of increased mechanical forces on capital femoral epiphysis development is well established; however, the growth of the physis in the absence of such forces remains unclear. The hips of non-ambulatory cerebral palsy (CP) patients provide a weight-restricted (partial weightbearing) model which can elucidate the influence of decreased mechanical forces on the development of physis morphology, including features related to development of slipped capital femoral epiphysis (SCFE). Here we used 3D image analysis to compare the physis morphology of children with non-ambulatory CP, as a model for abnormal hip loading, with age-matched native hips.

MATERIALS AND METHODS

CT images of 98 non-ambulatory CP hips (8-15 years) and 80 age-matched native control hips were used to measure height, width, and length of the tubercle, depth, width, and length of the metaphyseal fossa, and cupping height across different epiphyseal regions. The impact of age on morphology was assessed using Pearson correlations. Mixed linear model was used to compare the quantified morphological features between partial weightbearing hips and full weightbearing controls.

RESULTS

In partial weightbearing hips, tubercle height and length along with fossa depth and length significantly decreased with age, while peripheral cupping height increased with age (r > 0.2, P < 0.04). Compared to normally loaded (full weightbearing) hips and across all age groups, partially weightbearing hips' epiphyseal tubercle height and length were smaller (P < .05), metaphyseal fossa depth was larger (P < .01), and posterior, inferior, and anterior peripheral cupping heights were smaller (P < .01).

CONCLUSIONS

Smaller epiphyseal tubercle and peripheral cupping with greater metaphyseal fossa size in partial weightbearing hips suggests that the growing capital femoral epiphysis requires mechanical stimulus to adequately develop epiphyseal stabilizers. Deposit low prevalence and relevance of SCFE in CP, these findings highlight both the role of normal joint loading in proper physis development and how chronic abnormal loading may contribute to various pathomorphological changes of the proximal femur (i.e., capital femoral epiphysis).

Two Novel Clinical Tests for the Diagnosis of Hip Labral Tears

BACKGROUND

There are few well-studied clinical tests for the diagnosis of hip labral tears. As the differential diagnosis for hip pain is broad, accurate clinical examination is important in guiding advanced imaging and identifying patients who may benefit from surgical management.

PURPOSE

To determine the diagnostic accuracy of 2 novel clinical tests for the diagnosis of hip labral tears.

STUDY DESIGN

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

METHODS

Clinical examination findings including the Arlington, twist, and flexion-adduction-internal rotation (FADIR)/impingement tests as performed by a fellowship-trained orthopaedic surgeon specializing in hip arthroscopy were obtained from retrospective chart review. The Arlington test ranges the hip from flexion-abduction-external rotation to FADIR while applying subtle internal rotation and external rotation motion. The twist test involves internal rotation and external rotation of the hip while weightbearing. Diagnostic accuracy statistics for each of the tests were calculated using magnetic resonance arthrography as the reference standard.

RESULTS

A total of 283 patients were included in the study with a mean age of 40.7 years (range, 13-77 years) and 66.4% were women. The Arlington test was found to have a sensitivity of 0.94 (95% CI, 0.90-0.96), specificity of 0.33 (95% CI, 0.16-0.56), positive predictive value (PPV) of 0.95 (95% CI, 0.92-0.97), and negative predictive value (NPV) of 0.26 (95% CI, 0.13-0.46). The twist test was found to have a sensitivity of 0.68 (95% CI, 0.62-0.73), specificity of 0.72 (95% CI, 0.49-0.88), PPV of 0.97 (95% CI, 0.94-0.99), and NPV of 0.13 (95% CI, 0.08-0.21). The FADIR/impingement test was found to have a sensitivity of 0.43 (95% CI, 0.37-0.49), specificity of 0.56 (95% CI, 0.34-0.75), PPV of 0.93 (95% CI, 0.87-0.97), and NPV of 0.06 (95% CI, 0.03-0.11). The Arlington test was significantly more sensitive than both the twist and FADIR/impingement tests (P < .05), while the twist test was significantly more specific than the Arlington test (P < .05).

CONCLUSION

The Arlington test is more sensitive than the traditional FADIR/impingement test, while the twist test is more specific than the FADIR/impingement test in diagnosing hip labral tears in the hands of an experienced orthopaedic surgeon.

Patient-Perceived Outcomes Improve Faster Than Hip Strength in Recovery After Surgical Correction for Symptomatic Femoroacetabular Impingement

Background: Patients with symptomatic femoroacetabular impingement (FAI) have hip strength deficits, instability, and increased risk for concomitant injury. While surgical intervention is an effective method of treatment for FAI, more information is needed about the recovery process. Purposes: We sought to understand how patients with FAI recover from surgical correction in the short term. Do patients' perceptions of improvement correspond with measured improvements in hip strength? Methods: We conducted a prospective cohort study of 17 patients (11 male, age range: 16-38 years) who were diagnosed with symptomatic FAI at a single surgeon's practice. Hip strength (flexion, extension, and abduction) was measured preoperatively and at 14, 26, and 52 weeks postoperatively. Patient-reported outcomes using the modified Harris Hip Score (mHHS) and Hip Outcome Osteoarthritis Score (HOOS) subscales were measured at the same time points and at 2 weeks postoperatively. Results: Compared with preoperative values, there was a significant increase in postoperative values at 26 and 52 weeks in normalized isokinetic hip extension (29% and 38%, respectively) and normalized hip abduction (48% and 55%, respectively). No differences in strength were observed at 14 weeks. Modified Harris Hip Score and all HOOS subscales were decreased by 2 weeks postoperatively, and by 14 weeks mHHS improved by 21%, and HOOS subscales improved as well (activities of daily living by 18%, pain by 34%, quality of life by 69%, sport and recreation by 36%, and symptoms by 28%). Conclusion: We observed that patient-reported outcomes including symptoms, function, and satisfaction improved at 14 weeks, while objective measures of hip strength improved at 26 weeks following surgical correction of FAI. More rigorous study is indicated.

Spinopelvic Parameters Do Not Influence Outcomes Following Primary Hip Arthroscopy for the Treatment of Femoroacetabular Impingement Syndrome

Purpose

To evaluate the influence of spinopelvic parameters on short-term postoperative patient-reported outcomes (PROs) following primary hip arthroscopy for the treatment of femoroacetabular impingement syndrome (FAIS).

Methods

Patients undergoing primary hip arthroscopy between January 2012 and December 2015 were retrospectively reviewed. Hip Outcome Score - Activities of Daily Living, Hip Outcome Score - Sports-Specific Subscale, modified Harris Hip Score, International Hip Outcome Tool-12, and visual analog scale pain were recorded preoperatively and at final follow-up. Lumbar lordosis (LL), pelvic tilt (PT), sacral slope, and pelvic incidence (PI) were measured on lateral radiographs in standing position. Patients were split into subgroups for individual analyses based on previous literature cutoffs: |PI-LL|> or <10°, PT> or <20°, and PI <40°, 40° < PI < 65°, and PI >65°. PROs and rate of achievement of patient acceptable symptom state (PASS) were compared between subgroups at final follow-up.

Results

Sixty-one patients who underwent unilateral hip arthroscopy were included in the analysis, and 66% of patients were female. Mean patient age was 37.6 ± 11.3 years, whereas mean body mass index was 25.0 ± 5.7. Mean follow-up time was 27.6 ± 9.0 months. No significant difference in preoperative nor postoperative PROs were appreciated in patients with spinopelvic mismatch (|PI-LL| >10°) versus those without, whereas patients with mismatch achieved PASS according to the modified Harris Hip Score (P = .037) and International Hip Outcome Tool-12 (P = .030) at greater rates. When we compared patients with a PT ≥20° versus PT <20°, no significant differences in postoperative PROs were present. When we compared patients in the following pelvic incidence groups: PI <40°, 40° < PI <65°, and PI >65°, no significant differences in 2-year PROs or rates of PASS achievement for any PRO were appreciated (P > .05 for all).

Conclusions

In this study, spinopelvic parameters and traditional measures of sagittal imbalance did not influence PROs in patients undergoing primary hip arthroscopy for FAIS. Patients with sagittal imbalance (|PI-LL|> 10° or PT >20°) achieved a greater rate of PASS.

Level of Evidence

IV; Prognostic case series.

Patients With Femoroacetabular Impingement Obtain Information From Low-Quality Sources Online and Are Most Interested in Conservative Treatment and Expected Recovery

Purpose

To investigate the type of questions patients undergoing hip arthroscopy for femoroacetabular impingement (FAI) are searching online and determine the type and quality of the online sources from the top results to each query by the "people also ask" Google algorithm.

Methods

Three search strings pertaining to FAI were carried out through Google. The webpage information was manually collected from the "People also ask" Google algorithm. Questions were categorized using Rothwell's classification method. Each website was assessed using Journal of the American Medical Association Benchmark Criteria for source quality.

Results

A total of 286 unique questions were collected with their associated webpages. The most common questions included: "How do you treat femoroacetabular impingement and labral tears without surgery?" "What is the recovery process after hip arthroscopy and are there limitations after surgery?" and "How do you diagnose hip impingement and differentiate from other causes of hip pain?" The Rothwell Classification of questions were fact (43.4%), policy (34.3%), and value (20.6%). The most common webpage categories were Medical Practice (30.4%), Academic (25.8%), and Commercial (20.6%). The most common subcategories were Indications/Management (29.7%) and Pain (13.6%). Government websites had the highest average Journal of the American Medical Association score (3.42), whereas Single Surgeon Practice websites had the lowest (1.35). Conclusions: Commonly asked questions on Google regarding FAI and labral tears pertain to the indications and management of pathology as well as pain control and restrictions in activity. The majority of information is provided by medical practice, academic, and commercial sources, which have highly variable academic transparency.

Clinical Relevance

By better understanding which questions patients ask online, surgeons can personalize patient education and enhance patient satisfaction and treatment outcomes after hip arthroscopy.

Noninvasive shape-fitting method quantifies cam morphology in femoroacetabular impingement syndrome: Implications for diagnosis and surgical planning

There are considerable limitations associated with the standard 2D imaging currently used for the diagnosis and surgical planning of cam-type femoroacetabular impingement syndrome (FAIS). The aim of this study was to determine the accuracy of a new patient-specific shape-fitting method that quantifies cam morphology in 3D based solely on preoperative MRI imaging. Preoperative and postoperative 1.5T MRI scans were performed on n = 15 patients to generate 3D models of the proximal femur, in turn used to create the actual and the virtual cam. The actual cams were reconstructed by subtracting the postoperative from the preoperative 3D model and used as reference, while the virtual cams were generated by subtracting the preoperative 3D model from the virtual shape template produced with the shape-fitting method based solely on preoperative MRI scans. The accuracy of the shape-fitting method was tested on all patients by evaluating the agreement between the metrics of height, surface area, and volume that quantified virtual and actual cams. Accuracy of the shape-fitting method was demonstrated obtaining a 97.8% average level of agreement between these metrics. In conclusion, the shape-fitting technique is a noninvasive and patient-specific tool for the quantification and localization of cam morphology. Future studies will include the implementation of the technique within a clinically based software for diagnosis and surgical planning for cam-type FAIS.

Arthroscopic surgery for femoroacetabular impingement has limited effect in patients with Tönnis grade-2 at 4-year follow-up

INTRODUCTION

This study evaluated intraoperative findings and outcomes in Tönnis grade-2 patients after hip arthroscopy and compared these results with patients with Tönnis grade-0 and grade-1.

MATERIALS AND METHODS

Retrospective cohort study of patients undergoing hip arthroscopy between January 2013 and December 2017. Patients were divided into either Tönnis grade-2, grade-1, and grade-0 osteoarthritis groups. Labral and chondral status were evaluated. Radiographic analysis, modified Harris hip score (mHHS), a self-administered Hip Outcome Score (HOS) questionnaire, with activity of daily living (ADL) and sports subscale (SSS), and a self-administered short version of the International Hip Outcome Tool (IHOT-12) were assessed at 6, 12 months, and then yearly. Clinical meaningful outcomes were measured with the minimal clinical important difference (MCID), patient acceptable symptom state (PASS), and substantial clinical benefit (SCB) for mHHS, HOS-ADL and HOS-SSS, and IHOT-12.

RESULTS

A total of 264 hip arthroscopic procedures met the inclusion criteria. There were 38 patients Tönnis grade-2, 91 patients Tönnis grade-1, and 135 patients Tönnis grade-0. Mean follow-up was 48.7 months in Tönnis grade-2 group, 48.6 months in Tönnis grade-0 group, and 48.1 months in Tönnis grade-1 group. Tönnis grade-2 patients had more extensive rim chondral damage, and a higher rate of labral debridement was performed in this group. There were no statistically significant differences in preoperative PROs among the groups. Tönnis grade-2 group had statistically significant improvement in mHHS, but not in HOS-AVD, HOS-SSS and IHOT-12. Between T1 and T2 groups there were no statistically significant differences in outcomes. Lower significant percentage values of Tönnis grade-2 patients achieved MCID, PASS, and SCB threshold.

CONCLUSION

Improvements in PROs and rates of achieving clinical meaningful outcomes were limited for patients with Tönnis grade-2 after HA at 4-year follow-up. The outcomes of the Tönnis grade-2 cohort deteriorate over mid-term follow-up. Our results could be used in orthopedic practice to inform patients about the limited role of hip arthroscopy as a joint preservation procedure in these selected patients.

LEVEL OF EVIDENCE

Cohort study, level 3.

Outcomes of Staged Bilateral Hip Arthroscopic Surgery in the Context of Femoroacetabular Impingement Syndrome: A Nested Matched-Pair Control Study Focusing on the Effect of Time Between Procedures

BACKGROUND

Bilateral hip symptoms from femoroacetabular impingement syndrome (FAIS) are a common finding in patients regardless of athletic involvement. Oftentimes, patients and surgeons choose to stage bilateral hip arthroscopic surgery.

PURPOSE/HYPOTHESIS

The purpose of this study was (1) to compare minimum 2-year outcomes between patients who underwent staged bilateral hip arthroscopic surgery for FAIS to a propensity score-matched control group that underwent unilateral hip arthroscopic surgery and (2) to investigate the effect of time between bilateral procedures on patient-reported outcomes (PROs). We hypothesized that, after bilateral hip arthroscopic surgery, the improvement in outcomes would be similar to that after unilateral hip arthroscopic surgery and the time duration between bilateral procedures would not affect the final outcome.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data were retrospectively reviewed on a consecutive series of patients who underwent primary hip arthroscopic surgery at our institution between June 2008 and November 2017. Patients who underwent bilateral hip arthroscopic surgery with minimum 2-year PROs for the modified Harris Hip Score (mHHS), the Nonarthritic Hip Score (NAHS), the Hip Outcome Score-Sports Specific Subscale (HOS-SSS), patient satisfaction, and a visual analog scale (VAS) for pain were included. The study group was matched 1:1 based on age, sex, and body mass index to a control group that only required unilateral hip arthroscopic surgery. Additionally, a subanalysis was performed on the study group to determine the effect of time between arthroscopic procedures. Rates of achieving the minimal clinically important difference (MCID) and Patient Acceptable Symptom State (PASS) for the mHHS and HOS-SSS were determined. The P value was set at <.05.

RESULTS

A total of 205 patients (410 hips) were included. The mean age and body mass index of the study group were 32.3 ± 13.2 years and 25.0 ± 5.1, respectively. All 410 hips that met the inclusion criteria were matched. There were no significant differences in patient, radiographic, or procedural data. A significant and comparable improvement was reported for all PRO measures and the VAS (P < .0001) in both groups. Similarly, rates of achieving the MCID and PASS were comparable. After dividing the study group based on whether the contralateral procedure was performed <3 months or >3 months after the first procedure, it was determined that patients had a significant improvement and favorable outcomes regardless of time between bilateral procedures.

CONCLUSION

Patients who underwent unilateral and bilateral hip arthroscopic surgery for FAIS had a significant and comparable improvement in PROs at a minimum 2-year follow-up. A time interval of <3 months or >3 months between bilateral procedures did not affect PROs.

Osteoarthritis Risks and Sports: An Evidence-based Systematic Review

PURPOSE

Regular sports activities are associated with multiple physical and psychological health benefits. However, sports also may lead to injuries and the development of osteoarthritis (OA). This systematic review investigated the association between sports activity, sports type, and the risk of developing OA.

METHODS

A systematic review was performed by assessing studies that have investigated the risk of OA development in sports. Data extracted included general information, study design, number of participants, related body mass index, sports type, and assessment of OA. The methodological quality of the studies was assessed using the Newcastle-Ottawa Scale.

RESULTS

A total of 63 studies were included in this systematic review. The overall Newcastle-Ottawa Scale score was 6.46±1.44 demonstrating a good methodological quality of the articles included in the present study. A total of 628,036 participants were included, with a mean follow-up of 8.0±8.4 years. The mean age of the included athletes was 45.6±15.8, with a mean body mass index of 24.9±2.3 kg/m 2 .

CONCLUSION

Football and soccer players seem to be at higher risk for the development of OA, although the injury status of the joint should be considered when assessing the risk of OA. High equipment weight and increased injury risk also put military personnel at a higher risk of OA, although elite dancing leads to more hip labral tears. Femoroacetabular impingement was also often diagnosed in ice-hockey players and ballet dancers.

Assessment of Femoral Torsion on Magnetic Resonance Imaging is More Reliable Using Axial-Oblique Sequences Compared With Standard Axial Slices in Patients With Femoroacetabular Impingement Syndrome

PURPOSE

To determine the agreeability of femoral torsion measurements on axial and oblique axial magnetic resonance imaging (MRI) sequences in patients with femoroacetabular impingement syndrome (FAIS).

METHODS

Patients who underwent primary hip arthroscopy for FAIS between January 2012 to January 2019 were identified. Inclusion criteria were all patients with an MRI scan containing the pelvis and knee imaging. MRI-based measurements of femoral torsion were performed on axial and oblique-axial slices by 2 raters, and inter-rater and intrarater reliability was assessed. Bland Altman plots were constructed to evaluate the agreeability between femoral torsion measurements performed using axial and oblique-axial slices. Bivariate correlation analyses were performed to assess the relationship between measurement methods on each respective scan. A linear regression was performed between measurements performed using axial and oblique-axial sequences.

RESULTS

A total of 164 patients were included. The mean true-axial and oblique axial femoral torsion were 12.2° ± 9.9° and 11.1° ± 9.2°, respectively. The intrarater reliability for axial and oblique-axial measurements were 0.993 and 0.997, respectively. The inter-rater reliability for axial and oblique-axial measurements were 0.925 and 0.965, respectively. The number of differences within the limits of agreement for axial and oblique-axial femoral torsion measurements was 58.54%. On Pearson correlation analysis, strong positive correlations were found between oblique-axial measurements at multiple time points (r = 0.994, P < .001), as well as axial measurements at multiple time points (r = 0.986, P < .001). A strong positive correlation was found between axial and oblique-axial measurements (r = 0.894, P < .001). A significant regression equation indicated that for each additional increase in axial femoral torsion, the oblique-axial femoral torsion increased 0.837 (95% confidence interval 0.772-0.901).

CONCLUSIONS

Femoral torsion values measured on oblique-axial sequences are smaller than on true-axial sequences. Femoral torsion measurements on axial and oblique-axial MRI sequences exhibit poor agreement. Oblique-axial sequences demonstrated greater measurement consistency at multiple timepoints. When evaluating torsional measurements, it is important to delineate which axial sequence was used, especially in patients with suspected severe femoral antetorsion. Standardization of MRI femoral version protocols within one's practice can ensure more consistent decision-making, especially in patients with suspected femoral antetorsion.

LEVEL OF EVIDENCE

Retrospective cohort, level III.

Association of Radiographic Markers of Hip Instability and Worse Outcomes 2 to 4 Years After Hip Arthroscopy for Femoroacetabular Impingement in Female Patients

BACKGROUND

Reported outcomes of patients undergoing hip arthroscopy for femoroacetabular impingement (FAI) with underlying borderline acetabular dysplasia are mixed. This may in part be the result of mixed-sex reporting.

PURPOSE

To determine the effect of radiographic measures of acetabular dysplasia and hip instability on outcomes of female patients undergoing hip arthroscopy for FAI.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

This was a retrospective study of female patients undergoing arthroscopic surgery for FAI. All patients had preoperative radiographs including a standing anteroposterior pelvic view on which lateral center-edge angle (LCEA), anterior wall index (AWI), posterior wall index (PWI), and femoroepiphyseal acetabular roof (FEAR) index were measured. Patient outcomes were quantified by preoperative and postoperative 12-Item International Hip Outcome Tool (iHOT-12) scores. All patients had follow-up at 2 to 4 years postoperatively. Published values for minimal clinically important difference (MCID), substantial clinical benefit (SCB), Patient Acceptable Symptom State (PASS), and a normal (iHOT-12 > 86 points) or abnormal (iHOT-12 < 56 points) hip were used to determine outcome, as well as the final iHOT-12 score and iHOT-12 preoperative to postoperative difference.

RESULTS

The cohort consisted of 249 female patients (83% follow-up) with iHOT-12 scores at 2 to 4 years after surgery (mean, 34.6 months). Female patients with combined LCEA ≤25° and AWI <0.35 had lower final iHOT-12 score and iHOT-12 difference and were less likely to meet MCID, SCB, and PASS and have a normal hip and were more likely to have an abnormal hip as determined by iHOT-12 cutoffs when compared with those patients who had an LCEA >25° and an AWI ≥0.35 (all P < .05). There was no effect of PWI on outcomes. Similarly, female patients with combined LCEA ≤25° and a laterally oriented (positive) FEAR index were less likely to meet MCID, SCB, and PASS and have a normal hip and were more likely to have an abnormal hip compared with those patients who had an LCEA >25° and a negative (medial) FEAR index (all P < .05). In multivariate regression, an LCEA between 18° and 25° was an independent predictor of worse outcomes.

CONCLUSION

An LCEA of 18° to 25°, in combination with an AWI of <0.35 or a laterally opening FEAR index, was predictive of worse outcomes in female patients undergoing hip arthroscopy for FAI.

Hip joint motion does not change one year after arthroscopic osteochondroplasty in patients with femoroacetabular impingement evaluated with dynamic radiostereometry

Purpose

Dynamic radiostereometric analysis (dRSA) enables precise non-invasive three-dimensional motion-tracking of bones for assessment of joint kinematics. Hereby, the biomechanical effects of arthroscopic osteochondroplasty of the hip (ACH) can be evaluated in patients with femoroacetabular impingement (FAI).

The aim was to investigate the pre- and postoperative range of motion (ROM) and the CT bone volume removed (BV) after ACH. We hypothesize increase in ROM 1 year after surgery.

Methods

Thirteen patients (6 female) with symptomatic FAI were included prospectively. The patient’s hips were CT-scanned and CT-bone models were created. Preoperative dRSA recordings were acquired during passive flexion to 90°, adduction, and internal rotation (FADIR). ACH was performed, CT and dRSA were repeated 3 months and 1 year postoperatively. Hip joint kinematics before, and 3 months and 1 year after ACH were compared pairwise. The bone volume removal was quantified and compared to change in ROM.

Results

Mean hip internal rotation, adduction and flexion were all unchanged after ACH at 1-year follow-up (p > 0.84). HAGOS scores revealed improvement of quality of life (QOL) from 32 to 60 (p = 0.02). The BV was between 406 and 1783 mm³ and did not correlate to post-operative ROM.

Conclusions

ACH surgery in FAI patients had no impact of ROM at 1-year follow-up. QOL improved significantly. This indicates that the positive clinical effects reported after ACH might be a result of reduced labral stress and cartilage pressure during end-range motion rather than increased ROM.

Level of evidence

Therapeutic prospective cohort study, level II.

Acetabular labral tear is associated with high pelvic incidence with or without femoroacetabular impingement morphology

PURPOSE

The aim of this study was to investigate the association between pelvic sagittal parameters and acetabular labral tears.

METHODS

Three-hundred and sixty-five patients (449 hips) who underwent magnetic resonance imaging (MRI) or magnetic resonance arthrogram (MRA) for hip pain were enrolled in this study. Pelvic sagittal parameters, including the pelvic incidence, pelvic tilt, and sacral slope, were measured with a standing lumbosacral lateral radiograph. All subjects were divided into two groups according to the presence or absence of radiologic acetabular labral tears and compared. Furthermore, the two groups were divided into subgroups according to whether femoroacetabular impingement (FAI) morphology was present or not and compared.

RESULTS

Pelvic incidence was greater in the labral tear group than in the non-labral tear group (52.3° ± 8.2° versus 47.1° ± 6.8°, p < 0.001). After accounting for potentially confounding variables, we found that higher age (odds ratio 1.04, 95% confidence interval [CI] 1.02 to 1.06, p = 0.001), FAI (odds ratio 15.11, 95% CI 7.43 to 30.75, p < 0.001), and high pelvic incidence (odds ratio 1.13, 95% CI 1.09 to 1.17, p < 0.001) were independently associated with acetabular labral tear. When only the patients without FAI (308 hips) were divided into groups with and without acetabular labral tear, we found that higher age (odds ratio 1.03, 95% CI 1.01 to 1.06, p = 0.008) and high pelvic incidence (odds ratio 1.15, 95% CI 1.11 to 1.19, p < 0.001) were independently associated with acetabular labral tear.

CONCLUSION

Acetabular labral tear is associated with high pelvic incidence with or without FAI morphology.

LEVEL OF EVIDENCE

III.

Return to Sport in Athletes With Borderline Hip Dysplasia After Hip Arthroscopy for Femoroacetabular Impingement Syndrome

BACKGROUND

Data on outcomes in patients with borderline hip dysplasia (BHD) who undergo hip arthroscopy remain limited, particularly in regard to return to sport (RTS).

PURPOSE

To evaluate outcomes in patients with BHD and their ability to RTS after hip arthroscopy for treatment of femoroacetabular impingement syndrome (FAIS).

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Consecutive patients with self-reported athletic activity and radiographic evidence of BHD, characterized by a lateral femoral center-edge angle (LCEA) between 18° and 25° and a Tönnis angle >10°, who underwent hip arthroscopy for FAIS between November 2014 and March 2017 were identified. Patient characteristics and clinical outcomes including the Hip Outcome Score-Activities of Daily Living (HOS-ADL), Hip Outcome Score-Sports Subscale (HOS-SS), modified Harris Hip Score (mHHS), international Hip Outcome Tool (iHOT-12), and visual analog scale (VAS) for pain and satisfaction were analyzed at minimum 2-year follow-up. In addition, all patients completed an RTS survey.

RESULTS

A total of 41 patients with a mean age and body mass index (BMI) of 29.6 ± 13.4 years and 25.3 ± 5.6, respectively, were included. Mean LCEA and Tönnis angle for the study population were 22.7°± 1.8° and 13.3°± 2.9°, respectively. A total of 31 (75.6%) patients were able to RTS after hip arthroscopy at a mean of 8.3 ± 3.2 months. A total of 14 patients (45.2%) were able to RTS at the same level of activity, 16 patients (51.6%) returned to a lower level of activity, and only 1 (3.2%) patient returned to a higher level of activity. Of the 11 high school and collegiate athletes, 10 (90.9%) were able to RTS. All patients demonstrated significant improvements in all patient-reported outcome measures (PROMs) as well as in pain scores at a mean of 26.1 ± 5.4 months after surgery. Patients who were able to RTS had a lower preoperative BMI than patients who did not RTS. Analysis of minimum 2-year PROMs demonstrated better HOS-ADL, HOS-SS, mHHS, iHOT-12, and VAS outcomes for pain in patients able to RTS versus those who did not RTS (P < .05).

CONCLUSION

Of the patients with BHD studied here, 75.6% of patients successfully returned to sport at a mean of 8.3 ± 3.2 months after hip arthroscopy for FAIS. Of the patients who successfully returned to sport, 45.2% returned at the same level, and 3.2% returned at a higher activity level.

Automated Risk Stratification of Hip Osteoarthritis Development in Patients With Femoroacetabular Impingement Using an Unsupervised Clustering Algorithm: A Study From the Rochester Epidemiology Project

Background:

Studies evaluating the natural history of femoroacetabular impingement (FAI) are limited.

Purpose:

To stratify the risk of progression to osteoarthritis (OA) in patients with FAI using an unsupervised machine-learning algorithm, compare the characteristics of each subgroup, and validate the reproducibility of staging.

Study Design:

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

Methods:

A geographic database from the Rochester Epidemiology Project was used to identify patients with hip pain between 2000 and 2016. Medical charts were reviewed to obtain characteristic information, physical examination findings, and imaging details. The patient data were randomly split into 2 mutually exclusive sets: train set (70%) for model development and test set (30%) for validation. The data were transformed via Uniform Manifold Approximation and Projection and were clustered using Hierarchical Density-based Spatial Clustering of Applications with Noise.

Results:

The study included 1071 patients with a mean follow-up period of 24.7 ± 12.5 years. The patients were clustered into 5 subgroups based on train set results: patients in cluster 1 were in their early 20s (20.9 ± 9.6 years), female dominant (84%), with low body mass index (<19 ); patients in cluster 2 were in their early 20s (22.9 ± 6.7 years), female dominant (95%), and pincer-type FAI (100%) dominant; patients in cluster 3 were in their mid 20s (26.4 ± 9.7) and were mixed-type FAI dominant (92%); patients in cluster 4 were in their early 30s (32.7 ± 7.8), with high body mass index (≥29 ), and diabetes (17%); and patients in cluster 5 were in their early 30s (30.0 ± 9.1), with a higher percentage of males (43%) compared with the other clusters and with limited internal rotation (14%). Mean survival for clusters 1 to 5 was 17.9 ± 0.6, 18.7 ± 0.3, 17.1 ± 0.4, 15.0 ± 0.5, and 15.6 ± 0.5 years, respectively, in the train set. The survival difference was significant between clusters 1 and 4 (P = .02), 2 and 4 (P < .005), 2 and 5 (P = .01), and 3 and 4 (P < .005) in the train set and between clusters 2 and 5 (P = .03) and 3 and 4 (P = .01) in the test set. Cluster characteristics and prognosis was well reproduced in the test set.

Conclusion:

Using the clustering algorithm, it was possible to determine the prognosis for OA progression in patients with FAI in the presence of conflicting risk factors acting in combination.

Hip muscle activity in male football players with hip-related pain; a comparison with asymptomatic controls during walking

OBJECTIVES

Compare muscle activity between male football players with and without hip-related pain. Morphological and intra-articular features of hip-related pain are proposed pre-cursors to hip osteoarthritis. Altered muscle activity is a feature of severe hip osteoarthritis, but it is not known whether differences exist earlier in the pathological spectrum.

DESIGN

Cross-sectional; SETTING: University laboratory; PARTICIPANTS: Forty-two male football players with hip-related pain; and 19 asymptomatic controls.

MAIN OUTCOME MEASURES

Hip muscle activity (Gluteus maximus, gluteus medius, tensor facia latae, adductor longus and rectus femoris) was recorded during walking using surface electromyography (EMG).

RESULTS

Men with hip-related pain had sustained rectus femoris activity prior to toe-off (47-51% of the gait cycle) (p = 0.01, ES = 0.51) unlike controls who had reduced activity. In men with severe hip-related pain, gluteus maximus EMG was sustained into mid-stance (12-20% of the gait cycle) (F = 6.15, p < 0.01) compared to controls.

CONCLUSIONS

Differences in rectus femoris and gluteus maximus activity were identified between male footballers with and without hip-related pain. The pattern of gluteus maximus EMG relative to peak, approaching mid-stance in severe hip-related pain, is consistent with observations in severe hip osteoarthritis. This supports the hypothesis that symptom severity may influence muscle activity across the spectrum of hip degeneration.

Hip Strength Before and After Arthroscopic Femoroacetabular Impingement Surgery

Femoroacetabular impingement (FAI) and labral pathology are associated with pain, decreased function, and hip strength deficits. Existing data are in conflict regarding when hip strength normalizes following arthroscopic treatment of FAI. The objective of this study was to identify preoperative hip strength relative to the contralateral hip not undergoing surgery as well as when postoperative strength in 4 functional muscle groups normalizes following arthroscopic treatment of FAI. Ninety-eight individuals with radiographic evidence of FAI and labral pathology underwent arthroscopic labral repair. Pre-surgical hip strength testing was performed in the symptomatic "surgical hip" and the contralateral "non-surgical hip." Hip strength measurements were repeated at 8 and 16 weeks postoperatively. Significant preoperative hip strength deficits were noted in the surgical hip compared with the non-surgical hip in flexion, extension, and adduction. At 8 weeks postoperatively, hip strength in the surgical hip improved to being equivalent to that in the non-surgical hip in adduction and extension, remained equivalent to that of the non-surgical hip in abduction, and decreased in flexion relative to the non-surgical hip. At 16 weeks, hip strength remained equivalent in the surgical hip and the non-surgical hip in abduction and adduction, but the surgical hip exceeded the non-surgical hip in extension. While flexion strength improved between 8 and 16 weeks postoperatively for the surgical hip, it had not fully recovered to that of the non-surgical hip. Using a structured postoperative rehabilitation protocol, abduction strength was maintained at 8 weeks postoperatively, while adduction and extension strength had improved to those of the non-surgical hip. At 16 weeks postoperatively, hip abduction and adduction had strength equivalent to those of the non-surgical hip. Despite preoperative improvement, flexion of the surgical hip lagged behind that of the non-surgical hip 16 weeks postoperatively. [Orthopedics. 2021;44(3):148-153.].

Sex differences in the prevalence of radiographic findings of structural hip deformities in patients with symptomatic femoroacetabular impingement

The purpose of this study was to determine the sex differences in the overall prevalence of radiographic femoroacetabular impingement (FAI) deformity patients presenting with hip pain and to identify the most common radiographic findings in male and female patients. A geographic database was used to identify patients between the age of 14 and 50 years with hip pain from 2000 to 2016. A chart and radiographic review was performed to identify patients with cam, pincer and mixed-type FAI. A total of 374 (449 hips) out of 612 (695 hips) male patients and 771 (922 hips) out of 1281 (1447 hips) female patients had radiographic features consistent with FAI. Ninety-four male hips (20.9%) and 45 female hips (4.9%) had cam type, 20 male hips (4.5%) and 225 female hips (24.4%) had pincer type and 335 male hips (74.6%) and 652 female hips (70.7%) had mixed type. The overall prevalence of radiographic findings consistent with FAI in male and female patients with hip pain was 61.1% and 60.2%, respectively. Mixed type was the most prevalent. The most common radiographic finding for cam-type FAI was an alpha angle >55°, and the most common radiographic finding for pincer-type FAI was a crossover sign. Male patients were found to have a higher prevalence of cam-type deformities, whereas female patients were found to have a higher prevalence of pincer-type deformities.

Does the Capital Femoral Physis Bony MorphologyDiffer in Children with Symptomatic Cam-type Femoroacetabular Impingement

BACKGROUND

The epiphyseal tubercle, the corresponding metaphyseal fossa, and peripheral cupping are key stabilizers of the femoral head-neck junction. Abnormal development of these features in the setting of supraphysiologic physeal stress under high forces (for example, forces that occur during sports activity) may result in a cam morphology. Although most previous studies on cam-type femoroacetabular impingement (FAI) have mainly focused on overgrowth of the peripheral cupping, little is known about detailed morphologic changes of the epiphyseal and metaphyseal bony surfaces in patients with cam morphology.

QUESTIONS/PURPOSES

(1) Does the CT-based bony morphology of the peripheral epiphyseal cupping differ between patients with a cam-type morphology and asymptomatic controls (individuals who did not have hip pain)? (2) Does the CT-based bony morphology of the epiphyseal tubercle differ between patients with a cam-type morphology and asymptomatic controls? (3) Does the CT-based bony morphology of the metaphyseal fossa differ between patients with a cam-type morphology and asymptomatic controls?

METHODS

After obtaining institutional review board approval for this study, we retrospectively searched our institutional database for patients aged 8 to 15 years with a diagnosis of an idiopathic cam morphology who underwent a preoperative CT evaluation of the affected hip between 2005 and 2018 (n = 152). We excluded 96 patients with unavailable CT scans and 40 patients with prior joint diseases other than cam-type FAI. Our search resulted in 16 patients, including nine males. Six of 16 patients had a diagnosis of bilateral FAI, for whom we randomly selected one side for the analysis. Three-dimensional (3-D) models of the proximal femur were generated to quantify the size of the peripheral cupping (peripheral growth of the epiphysis around the metaphysis), epiphyseal tubercle (a beak-like prominence in the posterosuperior aspect of the epiphysis), and metaphyseal fossa (a groove on the metaphyseal surface corresponding to the epiphyseal tubercle). A general linear model was used to compare the quantified anatomic features between the FAI cohort and 80 asymptomatic hips (aged 8 to 15 years; 50% male) after adjusting for age and sex. A secondary analysis using the Wilcoxon matched-pairs signed rank test was performed to assess side-to-side differences in quantified morphological features in 10 patients with unilateral FAI.

RESULTS

After adjusting for age and sex, we found that patients with FAI had larger peripheral cupping in the anterior, posterior, superior, and inferior regions than control patients who did not have hip symptoms or radiographic signs of FAI (by 1.3- to 1.7-fold; p < 0.01 for all comparisons). The epiphyseal tubercle height and length were smaller in patients with FAI than in controls (by 0.3- to 0.6-fold; p < 0.02 for all comparisons). There was no difference in tubercle width between the groups. Metaphyseal fossa depth, width, and length were larger in patients with FAI than in controls (by 1.8- to 2.3-fold; p < 0.001 for all comparisons). For patients with unilateral FAI, we saw similar peripheral cupping but smaller epiphyseal tubercle (height and length) along with larger metaphyseal fossa (depth) in the FAI side compared with the uninvolved contralateral side.

CONCLUSION

Consistent with prior studies, we observed more peripheral cupping in patients with cam-type FAI than control patients without hip symptoms or radiographic signs of FAI. Interestingly, the epiphyseal tubercle height and length were smaller and the metaphyseal fossa was larger in hips with cam-type FAI, suggesting varying inner bone surface morphology of the growth plate. The docking mechanism between the epiphyseal tubercle and the metaphyseal fossa is important for epiphyseal stability, particularly at early ages when the peripheral cupping is not fully developed. An underdeveloped tubercle and a large fossa could be associated with a reduction in stability, while excessive peripheral cupping growth would be a factor related to improved physeal stability. This is further supported by observed side-to-side differences in tubercle and fossa morphology in patients with unilateral FAI. Further longitudinal studies would be worthwhile to study the causality and compensatory mechanisms related to epiphyseal and metaphyseal bony morphology in pathogenesis cam-type FAI. Such information will lay the foundation for developing imaging biomarkers to predict the risk of FAI or to monitor its progress, which are critical in clinical care planning.

LEVEL OF EVIDENCE

Level III, prognostic study.

Transition to Telehealth Physical Therapy After Hip Arthroscopy for Femoroacetabular Impingement: A Pilot Study With Retrospective Matched-Cohort Analysis

Background

Telehealth use has increased significantly of late. However, outside of total hip and knee arthroplasty, there is minimal evidence regarding its efficacy in orthopaedics and postoperative rehabilitation.

Purpose

To determine the efficacy and cost-effectiveness of a transition to postoperative telehealth physical therapy in patients undergoing hip arthroscopy for femoroacetabular impingement (FAI).

Study Design

Cohort study; Level of evidence, 3.

Methods

Included were 51 patients undergoing postoperative physical therapy after hip arthroscopy for FAI. The intervention group consisted of patients undergoing initial in-person visits followed by a transition to telehealth physical therapy for 3 months postoperatively (group 1; n = 17). Comparison groups included patients undergoing in-person physical therapy with the same physical therapy team as the telehealth group (group 2; n = 17) and patients undergoing in-person therapy with a different therapy team at the same facility (group 3; n = 17). All groups were matched 1-to-1 by patient age and sex. All patients completed the short version of the International Hip Outcome Tool (iHOT-12) both preoperatively and at 3 months postoperatively. At 3 months postoperatively, it was determined whether patients met the minimally clinically important difference (MCID; ≥13 points) or substantial clinical benefit (SCB; ≥28 points) or whether they reached a Patient Acceptable Symptomatic State (PASS; ≥64 points). Billed charges were recorded as a measure of cost.

Results

The overall mean age of the study patients ranged from 33 to 34 years. Among the 3 groups, there was no significant difference in the preoperative, postoperative, or pre- to postoperative change in iHOT-12 scores or in the percentage of patients meeting MCID, SCB, or PASS at 3 months. Group 1 had significantly lower mean costs ($1015.67) compared with group 2 ($1555.62; P = .011) or group 3 ($1896.38; P < .001).

Conclusion

In this pilot study, telehealth physical therapy after hip arthroscopy was found to lead to similar short-term outcomes and was cost-effective compared with in-person physical therapy.

Functional improvement in hip pathology is related to improvement in anxiety, depression, and pain catastrophizing: an intricate link between physical and mental well-being

Background

Pain catastrophizing, anxiety, and depression are risk factors for poor functional outcomes and worse post-treatment pain that can be treated alongside physical care given to orthopedic patients. While these factors have been shown to be common in patients with hip pathology, there is limited literature that follows these conditions throughout treatment. The purpose of this study was to track psychological factors in patients with various hip pathology to determine if they improved alongside functional measures following treatment.

Methods

Patients presenting to a specialist hip clinic were prospectively evaluated for outcomes of pain catastrophizing, anxiety, depression, and hip function. Pre- and post-treatment assessments were undertaken: Pain Catastrophizing Scale, the Hospital Anxiety Depression Scale, the Hip Outcome Survey, and Hip Disability and Osteoarthritis Outcome Score (HOOS). Patient characteristics were recorded. A correlation analysis, using the Spearman partial correlation coefficient (r_s), was conducted to evaluate the relationship between change in psychological factors with change in functional outcomes.

Results

A total of 201 patients (78 male, 123 female) with a mean age of 53.75 ± 18.97 years were included, with diagnoses of hip dysplasia (n = 35), femoroacetabular impingement (n = 35), lateral trochanteric pain syndrome (n = 9), osteoarthrosis (n = 109), and avascular necrosis of the hip (n = 13). Statistical analysis revealed a significant negative relationship between change in function level (as measured by HOOS ADL) and change in pain catastrophizing (r_s = − 0.373, p < 0.0001), depression (r_s = − 0.363, p < 0.0001), and anxiety (r_s = − 0.264, p = 0.0002). Pain catastrophizing, depression, and anxiety improved with function. Spearman correlation coefficients also revealed that pain catastrophizing, HADS anxiety, and HADS depression improved with improvement in other patient-reported functional outcomes.

Conclusions

Patients with hip pathology often exhibit pain catastrophizing, anxiety, and depression, but improvements in hip functionality are associated with decreased severity of these psychological comorbidities. Exploring this connection demonstrates the correlation between musculoskeletal impairment and psychosocial outcomes and mental health. Perioperative multidisciplinary assessment may be a beneficial part of comprehensive orthopaedic hip care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04001-5.

Preparation Methods and Clinical Outcomes of Platelet-Rich Plasma for Intra-articular Hip Disorders: A Systematic Review and Meta-analysis of Randomized Clinical Trials

Background:

Despite its increasing use in the management of musculoskeletal conditions, questions remain regarding the preparation methods of platelet-rich plasma (PRP) and its clinical applications for intra-articular hip disorders, including femoroacetabular impingement syndrome (FAIS), labral pathology, and osteoarthritis (OA).

Purpose:

To systematically review and assess the preparation methods and clinical outcomes from randomized clinical trials (RCTs) on the use of PRP for intra-articular hip disorders.

Study Design:

Systematic review; Level of evidence, 2.

Methods:

A systematic review in accordance with the 2009 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was performed in September 2019. The Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, PubMed, Ovid Medline, and Embase were queried for studies regarding the use of PRP to treat intra-articular hip disorders. Qualifying articles were English-language RCTs describing the use of PRP for intra-articular hip disorders, either as standalone treatment or surgical augmentation. Two authors independently assessed article eligibility. Data pertaining to patient characteristics, indication for treatment, PRP preparation method, follow-up period, and clinical outcomes were extracted. Study results were qualitatively reported and quantitatively compared using meta-analysis when appropriate.

Results:

Seven RCTs met inclusion criteria. Four studies described the use of PRP for hip OA and 3 utilized PRP at arthroscopy for FAIS and labral tears. Outcomes after PRP for OA demonstrated improvement in validated patient-reported outcome measures for up to 1 year; however, pooled effect sizes found no statistically significant difference between PRP and hyaluronic acid (HA) regarding pain visual analog scale scores at short-term (≤2 months; P = .27), midterm (4-6 months; P = .85), or long-term (1 year; P = .42) follow-up. When injected at arthroscopy, 1 study reported improved outcomes, 1 reported no difference in outcomes, and 1 reported worse outcomes compared with controls. The meta-analysis demonstrated no statistically significant difference on the modified Harris Hip Score (mHHS) between PRP and control cohorts at a minimum 1-year follow-up. There were considerable deficiencies and heterogeneity in the reporting of PRP preparation methods for both indications.

Conclusion:

Treatment of OA with PRP demonstrated reductions in pain and improved patient-reported outcomes for up to 1 year. However, there was no statistically significant difference between PRP and HA in pain reduction. Likewise, for FAIS and labral surgery there was no statistically significant difference in mHHS outcomes between patients treated with PRP and controls. Given the limited number of studies and variability in PRP preparations, additional high-quality randomized trials are warranted.

Risk Factors for Long-term Hip Osteoarthritis in Patients With Femoroacetabular Impingement Without Surgical Intervention

BACKGROUND

Femoroacetabular impingement (FAI) is a common cause of hip pain and a known risk factor for hip osteoarthritis (OA) and total hip arthroplasty (THA) at a young age. Unfortunately, little is known about the specific factors associated with an increased risk of OA.

PURPOSE

To (1) report the overall rate of symptomatic hip OA and/or THA in patients with FAI without surgical intervention and (2) identify radiographic features and patient characteristics associated with hip OA.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

A geographic database was used to identify all patients with hip pain and radiographs between 2000 and 2016. Chart review was performed to identify patients with FAI. Patient medical records were reviewed to obtain demographic information, clinical history, physical examination findings, imaging details, and treatment details. Kaplan-Meier analysis was used to determine the rate of hip OA. Univariate and multivariate proportional hazard regression models were performed to determine risk factors for OA.

RESULTS

The study included 952 patients (649 female; 303 male; 1104 total hips) with FAI. The majority of hips had mixed type (n = 785; 71.1%), 211 (19.1%) had pincer type, and 108 (9.8%) had cam type. Mean age at time of presentation was 27.6 ± 8.7 years. Mean follow-up time was 24.7 ± 12.5 years. The rate of OA was 13.5%. THA was performed in 4% of patients. Male sex, body mass index (BMI) greater than 29, and increased age were risk factors for OA (male sex: hazard ratio [HR], 2.28; P < .01; BMI >29: HR, 2.11; P < .01; per year of increased age: HR, 1.11; P < .01.). Smoking and diabetes mellitus were not significant risk factors. No radiographic morphological features were found to be significant risk factors for OA.

CONCLUSION

At mean follow-up of 24.7 years, 14% of hips had symptomatic OA and 4% underwent THA. BMI greater than 29, male sex, and increased age at the time of presentation with hip pain were risk factors for hip OA. The cohort consisted of a large percentage of mixed-type FAI morphologies, and no specific radiographic risk factors for OA were identified.

Arthroscopic management with labral preservation, femoral osteoplasty, and capsular plication in patients with borderline hip dysplasia. Results of a matched-cohort study at minimum two year follow-up

PURPOSE

The purpose of this study was to assess intra-operative findings, surgical procedures, and outcomes in a cohort of patients with borderline hip dysplasia treated with arthroscopic labral repair, femoral osteoplasty, and capsular plication, and compare these outcomes with those of a rigorously matched control group without dysplasia.

METHODS

Data were prospectively collected and retrospectively reviewed for patients with a lateral center-edge angle between 20 and 24° who underwent hip arthroscopy surgery between 2014 and 2018. Labral, chondral status, psoas impingement, ligamentum teres, and cam morphology were evaluated. Patient-reported outcomes (PROs) scores included modified Harris Hip Score (mHHS), Hip Outcome Score Activities of Daily Living Subscale (HOS-AVD) and Hip Outcome Score Sport-Specific Subscale (HOS-SSS), and International Hip Outcome Tool-12 (IHOT-12). Clinical relevance was measured with the minimal clinical important difference (MCID), patient acceptable symptom state (PASS), and substantial clinical benefit (SCB).

RESULTS

Twenty patients met the inclusion criteria. An age- and sex-matched control group of 40 patients was also selected. Arthroscopic intra-operative findings were similar between cohorts. At a mean follow-up of 50 months in the borderline hip dysplasia cohort, and 52 months in the control cohort, there was a significant improvement in PROs in both cohorts, and no significant differences could be detected at the latest follow-up. The difference in frequency of patients achieving the MCID, PASS, and SCB was not statistically significant between cohorts.

CONCLUSION

With strict patient selection criteria, hip arthroscopy may be a beneficial approach in patients with borderline hip dysplasia.

Hip Arthroscopy for Femoroacetabular Impingement and Concomitant Labral Tears: A Minimum 2-Year Follow-Up Study

PURPOSE

The present study investigated the minimum 2-year outcomes of hip arthroscopy for femoroacetabular impingement (FAI) and concomitant labral tears in Asian patients.

METHODS

Patients who underwent hip arthroscopy for both FAI and concomitant labral tears between January 2012 and December 2017 were included. Patients with hip osteoarthritis of Tönnis grade ≥2, previous hip surgery, or followed for less than 2 years were excluded. Clinical assessments were performed using the modified Harris Hip Score, Western Ontario and McMaster Universities Osteoarthritis Index, and the rates of achieving threshold values of the minimal clinically important difference and patient acceptable symptomatic state at the latest follow-up. Plain radiographs were acquired pre- and postoperatively for radiologic assessments.

RESULTS

A total of 73 patients (90 hips, 58 male, 15 female; mean age 34.4 years) who underwent hip arthroscopy for FAI and concomitant labral tears were enrolled. Forty-three hips (47.8%) had cam-type, 7 (7.8%) had pincer-type, and 40 (44.4%) had mixed-type FAI. The mean follow-up duration was 5.2 years. In cam- and mixed-type FAI hips, the mean α angle significantly decreased from 66.7 ± 8.28° preoperatively to 44.9 ± 3.78° postoperatively (95% confidence interval [CI] 19.6°-22.8°; P < .001). The mean modified Harris Hip Score and Western Ontario and McMaster Universities Osteoarthritis Index increased from 74.8 ± 13.2 and 75 ± 12.7 preoperatively to 93 ± 8.1 (95% CI 15.4-20.9; P = .001) and 89.4 ± 8.4 postoperatively (95% CI 11.8-17; P = .001), respectively. Seventy-four hips (82.2%) crossed the minimal clinically important difference, and 85 hips (94.4%) had achieved the patient acceptable symptomatic state. There were 2 cases of pudendal nerve palsy and 1 case of sciatic nerve palsy. No additional surgeries were required.

CONCLUSIONS

Hip arthroscopy can be an effective treatment for FAI and concomitant labral tears in Asian patients as demonstrated in this study, with improved PRO scores and reoperation rates. Longer-term studies with larger cohorts are necessary.

LEVEL OF EVIDENCE

Level IV, case series.

Anterior inferior iliac spine avulsion fracture post hip arthroscopy for Femoroacetabular impingement

FAI (Femoroacetabular Impingement) is an uncommon yet reported pathology of the hip joint, especially in the young athletic population. If left untreated, it predisposes for premature osteoarthritis of the hip. FAI treatment modalities consists of either open or arthroscopic surgery, the latter becoming the most adapted modality. We present a case of a young male athlete found to have FAI, treated arthroscopically. His post operative follow up was complicated by anterior inferior iliac spine avulsion fracture due to post op protocol non compliance which was treated with ORIF, with satisfactory non symptomatic outcome.

Recreational Sports and Intra-articular Hip Injuries in Patients Undergoing Hip Arthroscopy for Femoroacetabular Impingement

Purpose

We aimed to determine the relationship between recreational sports and intra-articular hip injuries in an active population that had undergone hip arthroscopy for femoroacetabular impingement syndrome.

Methods

A retrospective review was performed of prospectively collected data from patients undergoing hip arthroscopy between January 2015 and December 2016. Inclusion criteria included patients between 18 and 50 years of age who had participated in recreational sports prior to surgery and had a minimum of a 2-year follow-up. Labral injury was evaluated using the Multicenter Arthroscopic Hip Outcome Research Network classification, and rim chondral injuries were evaluated using the Acetabular Labral Articular Disruptions system. Ligamentum teres tear and psoas impingement were also recorded. Sports were classified as rotational running (soccer, basketball, handball), flexibility (martial arts, dance), asymmetric-overhead (racquet), or endurance (running, swimming, cycling). Primary univariate analysis of sports’ independent associations, demographic characteristics, intra-articular hip injuries, and outcomes was performed.

Results

Patients included 185 people with a mean age of 36.7 years. Patients participating in rotational running sports and flexibility sports had a significantly greater proportion of rim chondral injuries than those participating in endurance sports or asymmetric overhead sports (P = 0.02). Ligamentum teres tears were significantly associated with flexibility sports (P < 0.001). A total of 84.7%, 67.7%, 67.2%, and 71.2% of patients met minimal clinically important difference levels for the modified Harris Hip Score (mHHS), the Hip Outcome Score (HOS)¹⁰ questionnaire with activities of daily living (HOS-ADL), the sports subscale (HOS-SSS), and the International Hip Outcome Tool (iHOT-12), respectively; 94.9%, 66.2% and 62.7% met the patient acceptable symptom state for mHHS, HOS-ADL, and HOS-SSS, respectively; 86.7%, 48.5%, 47.8%, and 32.4% found substantial clinical benefit for mHHS, HOS-ADL, HOS-SSS, and iHOT-12, respectively.

Conclusions

Rotational running sports were significantly associated with rim chondral injuries. Flexibility sports were significantly associated with rim chondral injuries and ligamentum teres tears. Athletes participating in these sports are more likely to have intra-articular hip injuries than those in the other sports categories.

Level of Evidence

Level IV, prognostic case series.

Pericapsular hip muscle activity in people with and without femoroacetabular impingement. A comparison in dynamic tasks

OBJECTIVES

Compare anterior pericapsular muscle activity between individuals with and without femoroacetabular impingement syndrome (FAIS) during dynamic tasks, to investigate whether muscle activity is consistent with a role in retracting the capsule to prevent impingement and active restraint of the femoral head in walking.

DESIGN

Cross-sectional.

SETTING

University-laboratory.

PARTICIPANTS

Thirteen athletes with FAIS and 13 pain-free controls.

MAIN OUTCOME MEASURES

Muscle activity was recorded using fine-wire (Iliocapsularis, iliacus and anterior gluteus minimus) and surface (rectus femoris) electromyography (EMG), during three hip flexion tasks (active and assisted hip flexion; squatting) and four walking trials.

RESULTS

Iliocapsularis EMG amplitude was no different between active and assisted hip flexion tasks around 90° of hip flexion in FAIS. There was no difference in EMG between groups in squatting. The pattern of burst activity preceding peak hip extension in iliacus, iliocapsularis, and anterior gluteus minimus was similar in both groups during walking.

CONCLUSION

In FAIS, similar activation of iliocapsularis during active and assisted hip flexion, despite reduced flexion torque demand in the latter, suggests a role in capsular retraction or enhanced hip joint protection. Pericapsular muscle activity in advance of peak hip extension during walking is consistent with a proposed contribution to femoral head control.

Return to Sport After Hip Arthroscopy for Femoroacetabular Impingement Syndrome in NCAA Division I Athletes: Experience at a Single Institution

Background:

The rate of return to sport after surgical treatment of femoroacetabular impingement (FAI) syndrome (FAIS) has been studied in high-level athletes. However, few studies examining this rate have focused exclusively on National Collegiate Athletic Association (NCAA) Division I athletes.

Purpose:

To evaluate the return-to-sport rate after hip arthroscopy for FAIS and to examine the influence of sport type on the clinical presentation of FAIS in collegiate athletes.

Study Design:

Case series; Level of evidence, 4.

Methods:

Included in this study were NCAA Division I student-athletes who underwent hip arthroscopy for FAIS at our institution between 2010 and 2017. Exclusion criteria were history of previous hip pathology, pediatric hip disease, radiographic evidence of osteoarthritis (Tönnis grade >0), prior lower extremity procedure, history of chronic pain, osteoporosis, or history of systemic inflammatory disease. Athletes were categorized into 6 subgroups based on the type of sport (cutting, contact, endurance, impingement, asymmetric/overhead, and flexibility) by using a previously reported classification system. Patient characteristics and preoperative, intraoperative, and return-to-sport variables were compared among sport types.

Results:

A total of 49 hip arthroscopies for FAIS were performed in 39 collegiate athletes (10 females, 29 males; mean age, 19.5 ± 1.3 years). A total of 1 (2.6%) cutting athlete, 15 (38.5%) contact athletes, 8 (20.5%) impingement athletes, 6 (15.4%) asymmetric/overhead athletes, and 9 (23.1%) endurance athletes were included in the study. There were no differences among sports groups with respect to the FAI type. Endurance athletes had lower rates of femoral osteochondroplasty (45.5%) and labral debridement (0.0%) (P < .0001). Contact sport athletes had higher rates of labral debridement (50.0%; P < .0001). Patients were evaluated for return to sport at an average of 1.96 ± 0.94 years. Overall, the return-to-sport rate was 89.7%. There were no differences in return-to-sport rates based on the sport type except for endurance athletes, who returned at a lower rate (66.6%; P < .001). No differences in return-to-sport rate (P = .411), duration after return (P = .265), or highest attempted level of sport resumed (P = .625) were found between patients who underwent labral repair versus debridement.

Conclusion:

Collegiate-level athletes who underwent hip arthroscopy for FAIS returned to sport at high and predictable rates, with endurance athletes possibly returning to sport at lower rates than all other sport types. Surgical procedures may be influenced by sport type, but the rate of return to sport between athletes who underwent labral debridement versus labral repair was similar.

Expression profile of matrix metalloproteinases in the labrum of femoroacetabular impingement

Aims

Femoroacetabular impingement (FAI) is a potential cause of hip osteoarthritis (OA). The purpose of this study was to investigate the expression profile of matrix metalloproteinases (MMPs) in the labral tissue with FAI pathology.

Methods

In this study, labral tissues were collected from four FAI patients arthroscopically and from three normal hips of deceased donors. Proteins extracted from the FAI and normal labrums were separately applied for MMP array to screen the expression of seven MMPs and three tissue inhibitors of metalloproteinases (TIMPs). The expression of individual MMPs and TIMPs was quantified by densitometry and compared between the FAI and normal labral groups. The expression of selected MMPs and TIMPs was validated and localized in the labrum with immunohistochemistry.

Results

On MMP arrays, most of the targeted MMPs and TIMPs were detected in the FAI and normal labral proteins. After data normalization, in comparison with the normal labral proteins, expression of MMP-1 and MMP-2 in the FAI group was increased and expression of TIMP-1 reduced. The histology of the FAI labrum showed disorderly cell distribution and altered composition of thick and thin collagen fibres. The labral cells expressing MMP-1 and MMP-2 were localized and their percentages were increased in the FAI labrum. Immunohistochemistry confirmed that the percentage of TIMP-1 positive cells was reduced in the FAI labrum.

Conclusion

This study established an expression profile of MMPs and TIMPs in the FAI labrum. The increased expression of MMP-1 and MMP-2 and reduced expression of TIMP-1 in the FAI labrum are indicative of a pathogenic role of FAI in hip OA development.

Cite this article:Bone Joint Res. 2020;9(4):173–181.

Identifying the Most Successful Procedures in Hip Arthroscopy

Hip arthroscopy for femoral and acetabular pathologies has increased dramatically. However, there is little literature analyzing procedures as predictors of revision arthroscopy or arthroplasty. From February 2008 to November 2015, patients undergoing hip arthroscopy for a labral tear with minimum 2-year follow-up and between 18 and 60 years old were retrospectively reviewed. Those with previous surgeries, Tönnis grade greater than 1, and previous hip conditions were excluded. Follow-up was obtained for 1118 patients (1249 hips; 81.7%) with a mean age of 38.7 years (range, 18.0-60.0 years), mean body mass index of 26.4 kg/m² (range, 16.3-48.9 kg/m²), and mean follow-up of 50.2 months (range, 24.0-111.9 months). A total of 122 (9.8%) patients converted to total hip arthroplasty (mean, 35.3 months; range, 1.4-95.2 months). Multivariate analysis for predictors of total hip arthroplasty found age at surgery (hazard ratio, 1.064/y; P<.05), body mass index (nonlinear; P<.05), labral debridement (HR, 1.558; P=.03), and notchplasty (HR, 2.128; P<.05), with trochanteric bursectomy (HR, 0.367; P<.05) identified as associated with higher survivorship. A total of 124 (9.9%) patients underwent revision hip arthroscopy at a mean of 21.7 months (range, 0.10-83.3 months). Multivariate analysis for predictors of revision surgery found workers' compensation (HR, 3.352; P<.05), capsular repair (HR, 1.950; P<.05), and femoral head microfracture (HR, 2.844; P=.04) to be significant, with age at date of surgery (HR, 0.973/y; P<.05) and femoral head chondroplasty (HR, 0.241; P=.05) associated with higher survivorship. Understanding risk factors for conversion to total hip arthroplasty or revision is paramount during discussions with patients. [Orthopedics. 2020;43(3):173-181.].

Pelvic incidence in a femoroacetabular impingement population

Objective

We aim to determine if pelvic incidence (PI) differed between a symptomatic femoroacetabular impingement (FAI) population and a control.

Methods

We retrospectively identified a cohort of symptomatic FAI patients and compared measured PI to a control group.

Results

The PI was significantly lower in the FAI group compared to the control (51.32±1.07 vs. 55.63±1.04; P < 0.01).

Conclusion

The mean PI was significantly decreased in the FAI population compared to a control.

The Prevalence of Radiographic Findings of Structural Hip Deformities for Femoroacetabular Impingement in Patients With Hip Pain

BACKGROUND

Radiography is the initial imaging modality used to evaluate femoroacetabular impingement (FAI), and diagnostic radiographic findings are well-established. However, the prevalence of these radiographic findings in patients with hip pain is unknown.

PURPOSE

The purpose was 3-fold: (1) to determine the overall prevalence of radiographic FAI deformities in young patients presenting with hip pain, (2) to identify the most common radiographic findings in patients with cam-type FAI, and (3) to identify the most common radiographic findings in patients with pincer-type FAI.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

A geographic database was used to identify patients aged 14 to 50 years with hip pain between the years 2000 to 2016. The following were evaluated on radiographs: cam type: typical pistol grip deformity, alpha angle >55°; pincer type: crossover sign (COS), coxa profunda or protrusio acetabuli, lateral center edge angle (LCEA) ≥40°, Tönnis angle <0°; and mixed type: both cam- and pincer-type features. Posterior wall sign (PWS) and ischial spine sign (ISS) were also evaluated. The prevalence of each was determined. Descriptive statistics were performed on all radiographic variables.

RESULTS

There were 1893 patients evaluated, and 1145 patients (60.5%; 1371 hips; 374 male and 771 female; mean age, 28.8 ± 8.4 years) had radiographic findings consistent with FAI. Of these hips, 139 (10.1%) had cam type, 245 (17.9%) had pincer type, and 987 (72.0%) had mixed type. The prevalence of a pistol grip deformity and an alpha angle >55° was 577 (42.1%) and 1069 (78.0%), respectively. The mean alpha angle was 66.9°± 10.5°. The prevalence of pincer-type radiographic findings was the following: COS, 1062 (77.5%); coxa profunda, 844 (61.6%); ISS, 765 (55.8%); PWS, 764 (55.7%); Tönnis angle <0°, 312 (22.8%); LCEA ≥40°, 170 (12.4%); and protrusio acetabuli, 7 (0.5%).

CONCLUSION

The overall prevalence of radiographic findings consistent with FAI in young patients with hip pain was 60.5%. Radiographic findings for mixed-type FAI were the most prevalent. The most common radiographic finding for cam-type FAI was an alpha angle >55°. The most common radiographic finding for pincer-type FAI was the COS.

Splenic injuries secondary to colonoscopy: Rare but serious complication

BACKGROUND

Colonoscopy is a safe and routine diagnostic and therapeutic procedure for evaluation of large bowel diseases. Most common procedure related complications include bleeding and perforation but rarely a splenic Injury.

AIM

To investigate the reason for colonoscopy, presentation of patient with spleen injury, types of injury, diagnosis, management and outcomes of patients

METHODS

A structured search on four databases was done and 45 articles with 68 patients were selected. The reason for colonoscopy, presentation of patient with spleen injury, types of injury, diagnosis, management and outcomes of patients were identified and analyzed using SPSS.

RESULTS

The mean age of the patients was 62.7 years with 64% females. Twenty two percent had a complete splenic rupture with colonoscopy while 63% had subcapsular hematoma, spleen laceration and spleen avulsion. The most common reason for colonoscopy was screening (46%) followed by diagnostic colonoscopy (28%). Eighty seven percent of patients presented with abdominal pain. Patients with spleen rupture mostly required splenectomy (47%), while minor spleen hematomas and lacerations were managed conservatively (38%). Six percent of the patients were managed with proximal splenic artery splenic embolization and 4% were managed with laparoscopic repair. The overall mortality was 10% while 77% had complete recovery. The reason of colonoscopy against presentation specifically, abdominal pain showed no statistical significance P = 0.69. The indication of colonoscopy had no significant impact on incidence of splenic injury (P = 0.89). Majority of the patients (47%) were managed with splenectomy while the rest were managed conservatively (P = 0.04). This association was moderately strong at a cramer’s V test (0.34). The Fisher exact test showed a higher mortality with spleen rupture (P = 0.028).

CONCLUSION

Spleen rupture due to colonoscopy is a significant concern and is associated with high mortality. The management of the patients can be individualized based on clinical presentation.

Pediatric Hip and Pelvis

The most common pediatric orthopedic conditions of the hip and pelvis involve abnormal architecture of the joint leading to pain and dysfunction. Developmental dysplasia of the hip and femoroacetabular impingement are 2 common and distinct forms of structural pathology in the pediatric hip. The authors also discuss 2 of the more common, and often questioned, pediatric hip disorders-slipped capital femoral epiphysis and Legg-Calvé-Perthes disease. Future investigations are aimed at identifying risk factors to provide pediatric orthopedists tools to risk stratify their patients and understand when conservative approaches such as close observation versus surgical interventions are more appropriate.

Return to Play in Amateur Soccer Players Undergoing Hip Arthroscopy: Short- to Mid-Term Follow-Up

PURPOSE

To describe patient-reported outcomes (PROs) and return to play at any level in amateur soccer players undergoing hip arthroscopy for femoroacetabular impingement syndrome at short- to mid-term follow-up.

METHODS

Data were prospectively collected and retrospectively reviewed for patients who underwent hip arthroscopy between March 2009 and June 2014. Patients who participated in amateur soccer within 1 year prior to surgery and intended to return to their sport after hip arthroscopy for femoroacetabular impingement syndrome were considered for inclusion in our study. Patients were excluded if they had a preoperative Tönnis osteoarthritis grade of 2 or greater, previous ipsilateral hip conditions or hip surgical procedures, or Workers' Compensation status. The patients from the initial group who had preoperative and minimum 2-year postoperative measures for the modified Harris Hip Score, Non-Arthritic Hip Score, Hip Outcome Score-Sports Specific Subscale, and visual analog scale for pain were included in our final group. In addition to PROs, data regarding the patients' return to soccer, surgical complications, and secondary surgical procedures were collected.

RESULTS

A total of 41 patients were eligible for inclusion in our study, of whom 34 (82.9%) had a mean follow-up period of 47.4 months. Five patients were not eligible because they did not intend to return to soccer. There were 15 male hips (44.1%) and 19 female hips (55.9%). The mean age at surgery was 20.8 ± 7.4 years. All PROs and the visual analog scale score improved significantly from preoperatively to latest follow-up. Of the 34 patients, 27 (79.4%) returned to soccer. Of the patients who returned to soccer, 19 (70.4%) were competing at the same level or a higher level compared with their highest level within 1 year of surgery. Regardless of competitive level, 21 patients (77.8%) reported that their athletic ability was the same as or higher than it was within 1 year of surgery.

CONCLUSIONS

Hip arthroscopy was associated with significant improvements in PROs for amateur soccer players. There was a high level of return to soccer and a high proportion of patients whose competitive level was similar or improved. As such, hip arthroscopy is a good option for soccer players, in the absence of underlying osteoarthritis, presenting with hip pathology.

LEVEL OF EVIDENCE

Level IV, case series.

Corrections in alpha angle following two different operative approaches for CAM-type femoral acetabular impingement - Ganz surgical hip dislocation vs anterior mini-open

BACKGROUND

Femoroacetabular impingement (FAI) is a predisposing factor for secondary osteoarthritis of the hip joint. The two extensively described impingement mechanisms of FAI are CAM and Pincer-type. Initially managed conservatively, operative intervention should be offered to the persistently symptomatic patient. The measurement of the alpha angle is considered a standard method of assessing the severity of pathology in Cam-type FAI on pre-operative plain radiographs. The radiological correction of the alpha angle has not been previously compared between different surgical approaches. We hypothesize that there is no difference in alpha angle correction between Ganz surgical hip dislocation and the anterior mini-open approach.

AIM

To compare the magnitude of alpha angle correction achieved by using the Ganz surgical hip dislocation and the anterior mini-open approach.

METHODS

This is a retrospective study assessing seventy-nine patients identified in a 5-year period. These patients had preoperative radiographic evidence of FAI and underwent surgery by a single surgeon at our institution, a tertiary care center. Patients with missing radiographic documentation, radiographs with insufficient quality which then precluded accurate measurement of the angle α, a diagnosed congenital condition, isolated type II pathology (Pincer), and history of prior surgery were excluded from the study. Either the Ganz surgical hip dislocation or the anterior mini open approach was used. Postoperative radiographic evaluation of the alpha angle between the two surgical methods was done and corrected for age and gender using two-sample t-tests and Chi-square analyses.

RESULTS

A total of 79 patients met the inclusion and exclusion criteria. Forty-seven males (mean age of 35.3, range 16-53) and 32 females (mean age 36.7, range 16-60) were enrolled. Forty-seven patients underwent the anterior mini-open approach, and 32 underwent the Ganz surgical hip dislocation. There were no significant differences in age between the two surgical groups or in pre- and post-operative alpha angles based on patient gender. The mean pre-operative alpha angle for the Ganz surgical hip dislocation group was 88.0 degrees (SD 12.3) and 99.4 degrees (SD 7.2) for the anterior mini-open group. Mean post-operative angles were 49.9 degrees (SD 4.3) for the Ganz surgical hip dislocation and 43.8 (SD 4.3) degrees for the anterior mini-open group. There was a statistically significant difference in patient’s pre-operative and post-operative angles (P = 0.000) with both surgical approaches.

CONCLUSION

Statistically significant decreases in alpha angle were noted for both surgical techniques, with larger decreases seen in the anterior mini-open group.

Comparison of the open versus the arthroscopic approach in the treatment of femoroacetabular shock

OBJECTIVE

To compare clinical and imaging results and complications between patients treated for femoroacetabular impingement who underwent either open surgery or an arthroscopic approach.

METHODS

This retrospective study included patients who underwent femoroacetabular impingement surgical treatment between June 2009 and January 2018. Patients treated with open surgery were compared with those treated with arthroscopy. Patients were radiographically and clinically assessed by alpha angle, degree of arthritis, Harris Hip Score, hospital stay and complications, as well as progression to total hip arthroplasty.

RESULTS

57 patients with FAI were included; 27 (45.6%) underwent open surgery and 31 (54.4%) underwent arthroscopy. Statistically significant differences were observed in hospital stay, where the patients who underwent arthroscopic surgery showed better outcomes. There were no other statistically significant differences, the results were similar in both groups.

CONCLUSIONS

Arthroscopy and open surgery treatments for femoroacetabular impingement provided comparable clinical and radiographic results. However, the latter surgery provides better results in surgery time, hospital stay and postoperative recovery.

How Useful Is the Flexion-Adduction-Internal Rotation Test for Diagnosing Femoroacetabular Impingement: A Systematic Review

OBJECTIVE

Clinicians use the flexion, adduction, and internal rotation (FADIR) test in the diagnosis of femoroacetabular impingement (FAI). However, the diagnostic utility of this test remains unclear. The purpose of this review was to determine the utility of the FADIR test in diagnosing FAI.

DATA SOURCES

MEDLINE, EMBASE, and PubMed were searched using relevant key terms and study screening was performed in duplicate. Patient demographics, diagnostic imaging, and summary measures (eg sensitivity, specificity, etc.) of the FADIR test in patients with FAI were recorded.

MAIN RESULTS

Eight studies of levels III (87.5%) and IV (12.5%) evidence were included. Four hundred fifty-two patients (622 hips) with a mean age of 27.0 ± 9.0 were examined. Alpha (75.1%) and/or center-edge (26.8%) angles were used to diagnose hips with FAI. X-ray (78.9%), magnetic resonance imaging (MRI) (16.2%), and computed tomography (CT) (4.8%) were used to confirm the diagnosis of FAI. The sensitivity when confirmed by x-ray, MRI, or CT was 0.08 to 1, 0.33 to 1 and 0.90, respectively. The specificity when confirmed by x-ray and MRI was 0.11 and 1, respectively.

CONCLUSIONS

Although the overall utility of the FADIR test in diagnosing FAI remains unclear given its moderate sensitivity and specificity, it may be a useful screening tool for FAI because of its low risk. Clinicians should consider the variability in sensitivity and specificity values reported and the low quality of literature available. Future studies should use large sample sizes and consistent radiographic measurements to better understand the usefulness of this physical examination maneuver in diagnosing FAI.

LEVEL OF EVIDENCE

Level IV, Systematic Review of Level III and IV studies.

An Anatomical Study of the Anterosuperior Capsular Attachment Site on the Acetabulum

BACKGROUND

Despite the fact that many surgeons perform partial capsular detachment from the anterosuperior aspect of the acetabulum to correct acetabular deformities during hip arthroscopy, few studies have focused on whether these detachments influence hip joint stability. The aim of this study was to investigate the capsular attachment on the anterosuperior aspect of the acetabulum. We hypothesized that the attachment on the inferior aspect of the anterior inferior iliac spine (AIIS) is wide and fibrocartilaginous and might have a substantial role in hip joint stability.

METHODS

Fifteen hips from 9 cadavers of Japanese donors were analyzed. Eleven hips were analyzed macroscopically, and the other 4 were analyzed histologically. In all specimens, the 3-dimensional morphology of the acetabulum and AIIS was examined using micro-computed tomography (micro-CT).

RESULTS

Macroscopic analysis showed that the widths of the capsular attachments varied according to the location, and the attachment width on the inferior edge of the AIIS was significantly larger than that on the anterosuperior aspect of the acetabulum. Moreover, the capsular attachment on the inferior edge of the AIIS corresponded with the impression, which was identified by micro-CT. Histological analysis revealed that the hip joint capsule on the inferior edge of the AIIS attached to the acetabulum adjacent to the proximal margin of the labrum. In addition, the hip joint capsule attached to the inferior edge of the AIIS via the fibrocartilage.

CONCLUSIONS

The capsular attachment on the inferior edge of the AIIS was characterized by an osseous impression, large attachment width, and distributed fibrocartilage.

CLINICAL RELEVANCE

It appeared that the capsular attachment on the inferior edge of the AIIS was highly adaptive to mechanical stress, on the basis of its osseous impression, attachment width, and histological features. Anatomical knowledge of the capsular attachment on the inferior edge of the AIIS provides a better understanding of the pathological condition of hip joint instability.

Prevalence and Clinical Implications of Chondral Injuries After Hip Arthroscopic Surgery for Femoroacetabular Impingement Syndrome

BACKGROUND

Studies on the effect of partial- and full-thickness chondral damage of the hip on outcomes and the ability to achieve meaningful clinical outcomes are limited.

PURPOSE

To determine the effect of full- and partial-thickness chondral injuries on 2-year outcomes in patients undergoing hip arthroscopic surgery for femoroacetabular impingement syndrome (FAIS) compared with patients without chondral damage, and to identify significant predictors of achieving the patient acceptable symptomatic state (PASS) and minimal clinically important difference (MCID).

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Data from consecutive patients with evidence of chondromalacia at the time of primary hip arthroscopic surgery with routine capsular closure for the treatment of FAIS by a single fellowship-trained surgeon between January 2012 and September 2016 were reviewed. Patients were divided into groups with partial-thickness (grade I-III) or full-thickness (grade IV) chondral defects and matched by age and body mass index (BMI) to patients without chondral injuries. Preoperative and postoperative outcomes were compared among the 3 groups, and a binary logistic regression analysis was utilized to identify significant predictors of achieving the MCID and PASS.

RESULTS

There were 634 patients included in the analysis, with a mean age of 34.5 ± 10.9 years and a mean BMI of 25.2 ± 4.7 kg/m². A total of 493 (77.8%) patients had no evidence of chondral damage, 92 (14.5%) patients had partial-thickness chondral defects, and 49 (7.7%) patients had full-thickness chondral defects. There were statistically significant differences in the Hip Outcome Score (HOS)-Activities of Daily Living, HOS-Sports Subscale, modified Harris Hip Score, pain, and satisfaction (P < .01) among the 3 groups. Patients with grade IV chondromalacia experienced the poorest outcomes and lowest percentage of achieving the PASS. Predictors for achieving any PASS threshold included preoperative alpha angle (odds ratio [OR], 0.96; P = .016), absence of preoperative limping (OR, 7.25; P = .002), absence of preoperative chronic pain (OR, 5.83; P = .019), primary hip arthroscopic surgery (OR, 0.17; P = .050), patients who self-identified as runners (OR, 2.27; P = .037), and Tönnis grade 0 (OR, 2.86; P = .032). Male sex (OR, 2.49; P = .015) was the only predictor of achieving any MCID threshold.

CONCLUSION

Patients with grade IV chondral defects experienced worse functional outcomes, lower satisfaction, and increased pain when compared with both patients without chondral damage or grade I-III chondromalacia at 2-year follow-up. Several predictors were associated with achieving clinically significant function in patients undergoing hip arthroscopic surgery for FAIS.

A Sport-specific Analysis of the Epidemiology of Hip Injuries in National Collegiate Athletic Association Athletes From 2009 to 2014

PURPOSE

To describe the injury rates, mechanisms, time loss, and rates of surgery for hip/groin injuries in National Collegiate Athletic Association (NCAA) athletes across 25 collegiate sports during the 2009/10 to 2013/14 academic years.

METHODS

Data from the 2009/10 to 2013/14 academic years were obtained from the NCAA Injury Surveillance Program (ISP). Rates of hip/groin injuries, mechanism of injury, time lost from competition, and surgical treatment were calculated. Differences between sex-comparable sports were quantified using rate ratios and injury proportion ratios. A sport-specific biomechanical classification system, which included cutting, impingement, overhead/asymmetric, endurance, and flexibility sports, was applied for subgroup analysis.

RESULTS

In total, 1,984 hip injuries were reported in 25 NCAA sports, including 9 male and female sports, 3 male-only sports, and 4 female-only sports between the years 2009/10 and 2013/14, resulting in an overall hip injury rate of 53.1/100,000 athletic exposures (AEs). In sex-comparable sports, (basketball, cross-country, lacrosse, ice hockey, indoor track, outdoor track, soccer, swimming, and tennis), men were more commonly affected than women (59.53 vs 42.27 per 100,000 AEs respectively; rate ratio, 1.41; 95% confidence interval, 1.28-1.55). Subgroup analysis demonstrated that the highest rate of hip injuries per 100,000 AEs occurred in impingement sports (96.9). Endurance sports had the highest proportion of injured athletes with time lost >14 days (9.5%). For impingement-type sports, the most common mechanism of injury was no apparent contact (48.2%). The rate of athletes undergoing surgery per 100,000 AEs was highest in impingement-type sports (2.0).

CONCLUSIONS

We have identified that impingement-type sports are most frequently associated with hip injuries. Additionally, this study demonstrates that hip injuries sustained in athletes who played impingement-type sports had a significantly higher rate of surgical intervention than other sport classifications.

LEVEL OF EVIDENCE

Level III, prognostic study.

Management of femoroacetabular impingement syndrome: current insights

Since the description of femoroacetabular impingement (FAI) by Ganz in 2003, our understanding of the pathophysiology, management options, and outcomes has evolved and literature continues to be generated on this condition at a rapid rate. FAI has been identified as a primary source of hip pain as well as a generator of secondary osteoarthritis. Improvements in the radiographic detection of cam and pincer morphologies as well as a better understanding of the structural impact of these morphologies have led to improved preoperative planning. Advancements in hip arthroscopy techniques have also led to a higher rate of arthroscopic management of this condition over the initially described open surgical dislocation technique. While arthroscopic management of this condition has become the most common form of surgical management for FAI, inadequate bony resection has been shown to be a frequent source of revision surgery. Therefore, roles for open surgical dislocation and combined mini-open approaches remain, particularly in cases where concern for the inability to fully access the morphology arthroscopically exists.

Reliability of the Arthroscopic Classifications of Hip Chondral Lesions

Objective  To evaluate the inter- and intraobserver reliability of the Outerbridge, Beck, and Haddad classifications for acetabular joint cartilage lesions through the arthroscopic procedure. Methods  A total of 60 hip arthroscopy videos were evaluated twice by 4 surgeons at 2 different times to assess the inter- and intraobserver reproducibility of the classifications, and the data was analyzed by means of the weighted Cohen Kappa index. Results  The mean weighted Kappa values in the interobserver assessment of the Outerbridge, Beck, and Haddad classifications were, respectively, 0.72, 0.78, and 0.68. The three classifications were considered as presenting good interobserver agreement. Regarding the intraobserver assessment of the Outerbridge, Beck, and Haddad classifications, the weighted Kappa values were, respectively, 0.9, 0.9, and 0.93. The three classifications were considered as presenting excellent intraobserver agreement. Conclusion  In the present series, the Outerbridge, Beck, and Haddad classifications presented good interobserver reproducibility and excellent intraobserver reproducibility when evaluating acetabular chondral lesions by the arthroscopic approach.

Treatment of cam-type femoroacetabular impingement using anterolateral mini-open and arthroscopic osteochondroplasty

BACKGROUND

Femoroacetabular impingement (FAI) is associated with decreased hip function and early hip osteoarthritis. Surgical treatment is often required to halt the process of mechanical degeneration. The study investigated the short-to-midterm results of using a modified anterolateral mini-open and arthroscopic osteochondroplasty in the treatment of cam-type FAI.

METHODS

Thirty-six patients (39 hips), with the mean age of 43.6 years, who had cam-type FAI, were operated by a mini-open and arthroscopy-assisted osteochondroplasty via the Watson-Jones interval between 2002 and 2016. Radiographic parameters and Harris hip scores were retrospectively analyzed after a mean follow-up of 44 months.

RESULTS

Of the 39 hips, the mean Harris hip score significantly improved from 61.1 preoperatively to 84.2 postoperatively (P < 0.01). There were nine hips (23%) undergoing total hip arthroplasty (THA) at a mean of 22 months (range, 3~64 months) due to progression of hip osteoarthritis. The 5-year survival for hip preserving was 74.9%. Cox proportional-hazards model showed that age ≥ 55 years (P = 0.03) and preoperative Tönnis stage II (P = 0.02) were independent risk factors for conversion to THA.

CONCLUSIONS

The mini-open and arthroscopic approach allowed direct visualization and improved quality of the osteochondroplasty of FAI hip while avoiding the need for surgical dislocation. This technique could be a safe and viable option for symptomatic cam-type FAI patients to relieve symptoms and improve hip function.

Pain catastrophizing, anxiety, and depression in hip pathology

AIMS

Psychological factors play a critical role in patient presentation, satisfaction, and outcomes. Pain catastrophizing, anxiety, and depression are important to consider, as they are associated with poorer outcomes and are potentially modifiable. The aim of this study was to assess the level of pain catastrophizing, anxiety, and depression in patients with a range of hip pathology and to evaluate their relationship with patient-reported psychosocial and functional outcome measures.

PATIENTS AND METHODS

Patients presenting to a tertiary-centre specialist hip clinic were prospectively evaluated for outcomes of pain catastrophizing, anxiety, and depression. Validated assessments were undertaken such as: the Pain Catastrophizing Scale (PCS), the Hospital Anxiety Depression Scale (HADS), and the 12-Item Short-Form Health Survey (SF-12). Patient characteristics and demographics were also recorded. Multiple linear regression modelling, with adaptive least absolute shrinkage and selection operator (LASSO) variable selection, was used for analysis.

RESULTS

A total of 328 patients were identified for inclusion, with diagnoses of hip dysplasia (DDH; n = 50), femoroacetabular impingement (FAI; n = 55), lateral trochanteric pain syndrome (LTP; n = 23), hip osteoarthrosis (OA; n = 184), and avascular necrosis of the hip (AVN; n = 16) with a mean age of 31.0 years (14 to 65), 38.5 years (18 to 64), 63.7 years (20 to 78), 63.5 years (18 to 91), and 39.4 years (18 to 71), respectively. The percentage of patients with abnormal levels of pain catastrophizing, anxiety, or depression was: 22.0%, 16.0%, and 12.0% for DDH, respectively; 9.1%, 10.9%, and 7.3% for FAI, respectively; 13.0%, 4.3%, and 4.3% for LTP, respectively; 21.7%, 11.4%, and 14.1% for OA, respectively; and 25.0%, 43.8%, and 6.3% for AVN, respectively. HADS Anxiety (HADSA) and Hip Disability Osteoarthritis Outcome Score Activities of Daily Living subscale (HOOS ADL) predicted the PCS total (adjusted R² = 0.4599). Age, HADS Depression (HADSD), and PCS total predicted HADSA (adjusted R² = 0.4985). Age, HADSA, patient's percentage of perceived function, PCS total, and HOOS Quality of Life subscale (HOOS QOL) predicted HADSD (adjusted R² = 0.5802).

CONCLUSION

Patients with hip pathology may exhibit significant pain catastrophizing, anxiety, and depression. Identifying these factors and understanding the impact of psychosocial function could help improve patient treatment outcomes. Perioperative multidisciplinary assessment may be a beneficial part of comprehensive orthopaedic hip care. Cite this article: Bone Joint J 2019;101-B:800-807.