The Warwick Agreement on femoroacetabular impingement syndrome (FAI syndrome): an international consensus statement

Altered Hip Flexor and Extensor Activation During Progressive Inclined Walking in Individuals With Femoroacetabular Impingement Syndrome

CONTEXT

Femoroacetabular impingement syndrome (FAIS) is a movement-related condition associated with pain and impaired function; yet the evidence for level ground walking hip biomechanics is limited and inconsistent. Challenging the hip with inclined walking for individuals with FAIS might be important for elucidating mechanically driven function loss and informing tailored rehabilitation. The purpose of this study was to determine the effects of progressive inclined walking on sagittal hip biomechanics and hip flexor and extensor activity in individuals with FAIS.

DESIGN

Cross-sectional.

METHODS

Fourteen participants (7 individuals with FAIS and 7 asymptomatic individuals) underwent motion capture and electromyographic analysis during 3 treadmill walking conditions (0°/5°/10°). Statistical parametric mapping was used to compare the sagittal hip kinematic waveforms and hip flexor (rectus femoris) and extensor (gluteus maximus) waveforms between groups and walking conditions.

RESULTS

Hip flexion was significantly increased throughout the gait cycle in individuals with FAIS compared with asymptomatic individuals (P < .01) but was not dependent on incline. Rectus femoris activation was significantly increased throughout stance in individuals with FAIS compared with asymptomatic individuals (P < .01). Gluteus maximus activity significantly increased with progressive inclination in asymptomatic individuals (P < .01), with no significant change in activity for individuals with FAIS.

CONCLUSIONS

Hip biomechanics and muscle activity during inclined walking mirrored that of arthrogenic muscle inhibition, highlighted by a prominent flexor role and lack of hip extensor activity in individuals with FAIS. Future research investigating discordant activity between hip flexors and extensors during complex functional tasks may help identify rehabilitation targets.

Long-term outcomes of arthroscopic management of femoroacetabular impingement syndrome: a systematic review

INTRODUCTION

Femoroacetabular impingement (FAI) syndrome is a condition characterised by irregularities in the femur or acetabular rim, leading to hip pain, increased risk of osteoarthritis (OA), and potential need for total hip arthroplasty (THA). Non-surgical treatments are the first-line approach. However, arthroscopic surgery has become more prevalent due to its promising short- and medium-term outcomes. Recent meta-analyses suggest that hip arthroscopy may offer superior results compared to non-operative treatments, though follow-up periods in these studies have been limited to 12 months. This systematic review aims to evaluate the long-term effectiveness of arthroscopic management for FAI syndrome, hypothesising that it will significantly improve patient-reported outcomes (PROMs) over a follow-up period exceeding ten years.

METHODS

The review focused on studies published in peer-reviewed journals with a minimum follow-up of 120 months and assessed outcomes such as PROMs and complication rates. It adhered to PRISMA guidelines and used the PICOT algorithm to evaluate the literature. Data extraction covered study characteristics, PROMs, and complications. Statistical analyses were conducted using IBM SPSS software to summarise continuous and dichotomous data.

RESULTS

Of 1,245 identified articles, 7 were included after rigorous screening. Risk of bias assessment with the ROBINS-I tool revealed a serious or moderate risk of bias due to confounding, although overall methodological quality was acceptable. Data from 478 patients showed significant improvements in PROMs from baseline to follow-up.

CONCLUSION

This systematic review indicates that arthroscopic management for FAI syndrome significantly improves PROMs with a mean follow-up of approximately 130 months. Nevertheless, 32% of patients required THA within ten years, underscoring the importance of careful patient selection and consideration of factors like OA and age. While conservative treatments such as physical therapy may yield comparable short-term outcomes, recent evidence suggests that arthroscopy provides superior results, particularly for younger patients and those without preoperative OA.

LEVEL OF EVIDENCE

Level II, systematic review and meta-analysis.

Conservative treatment versus hip arthroscopy in patients with femoroacetabular impingement : a multilevel meta-analysis of randomized controlled trials

Aims

Femoroacetabular impingement (FAI) is a serious cause of hip pain with loss of function, and development of osteoarthritis of the hip. The aim of this multilevel meta-analysis of randomized controlled trials (RCTs) was to evaluate the outcomes of FAI patients treated conservatively compared with those treated with hip arthroscopy (HAS).

Methods

A systematic literature search of PubMed, CENTRAL of the Cochrane Library, Epistemonikos, and Embase databases was conducted up to 30 June 2024. In a frequentist multilevel meta-analysis with random effects model, means with 95% CIs were calculated separately in the conservative treatment subgroup and the HAS subgroup. A test for subgroup differences in meta-analysis was then performed to determine whether there was a statistically significant difference between the means of the two subgroups. Clinical assessment was based on Harris Hip Score (HHS), the International Hip Outcome Tool (iHOT), the Hip disability and Osteoarthritis Outcome Score (HOOS), the Hip Outcome Score Activities of Daily Living (HOS-ADL), and visual analogue scale (VAS) for pain.

Results

A total of 21 RCTs, including 674 patients in the conservative treatment subgroup and 1,125 patients in the HAS subgroup, met the inclusion criteria. The test for subgroup differences showed that the HAS subgroup had a statistically significant 6.5-point higher HHS ≤ 12 months post-intervention (F = 12.8; df = 1.5; p = 0.016) and a statistically significant 9.8-point higher iHOT ≤ 24 months post-intervention (F = 5.3; df = 1.1; p = 0.035) than the conservative treatment subgroup. Other functional (HOOS, HOS) and pain (VAS, NRS) outcome parameters analyzed did not show statistically significant differences.

Conclusion

This multilevel meta-analysis of 21 RCTs with a total of 1,799 FAI patients showed a statistically significant higher HHS ≤ 12 months post-intervention and iHOT ≤ 24 months post-intervention, favouring the HAS subgroup compared to the conservative treatment subgroup, without reaching minimal clinically important differences (MCIDs).

Deep learning and conventional hip MRI for the detection of labral and cartilage abnormalities using arthroscopy as standard of reference

OBJECTIVES

To evaluate the performance of high-resolution deep learning-based hip MR imaging (CSAI) compared to standard-resolution compressed sense (CS) sequences using hip arthroscopy as standard of reference.

METHODS

Thirty-two patients (mean age, 37.5 years (± 11.7), 24 men) with femoroacetabular impingement syndrome underwent 3-T MR imaging prior to hip arthroscopy. Coronal and sagittal intermediate-weighted TSE sequences with fat saturation were obtained using CS (0.6 × 0.8 mm) and high-resolution CSAI (0.3 × 0.4 mm), with 3 mm slice thickness and similar acquisition times (3:55-4:12 min). MR scans were independently assessed by three radiologists and a hip arthroscopy specialist for labral and cartilage abnormalities. Sensitivity, specificity, and accuracy were calculated using arthroscopy as reference standard. Statistical comparisons between CS and CSAI were performed using McNemar's test.

RESULTS

Labral abnormality detection showed excellent sensitivity for radiologists (CS and CSAI: 97-100%) and the surgeon (CS: 81%, CSAI: 90%, p = 0.08), with 100% specificity. Overall cartilage lesion sensitivity was significantly higher with CSAI versus CS (42% vs. 37%, p < 0.001). Highest sensitivity was observed in superolateral acetabular cartilage (CS: 81%, CSAI: 88%, p < 0.001), while highest specificity was found for the anteroinferior acetabular cartilage (CS and CSAI: 99%). Sensitivity was lowest for the assessment of the anteroinferior and posterior acetabular zones, and inferior and posterior femoral zones (CS and CSAI < 6%).

CONCLUSION

CS and CSAI MR imaging showed excellent diagnostic performance for labral abnormalities. Despite CSAI's improved cartilage lesion detection, overall diagnostic performance for cartilage assessment remained suboptimal.

KEY POINTS

Question Accurate preoperative detection of labral and cartilage lesions in femoroacetabular impingement remains challenging, with current MRI protocols showing variable diagnostic performance. Findings High-resolution deep learning-based and standard-resolution compressed sense MRI demonstrate comparable diagnostic performance, with high accuracy for labral defects but limited sensitivity for cartilage lesions. Clinical relevance Current MRI protocols, regardless of resolution optimization, show persistent limitations in cartilage evaluation, indicating the need for further technical advancement to improve diagnostic confidence in presurgical planning.

Sport Participation Is Associated with Superior 10-Year Patient Acceptable Symptom State Achievement Following Contemporary Hip Arthroscopy for Femoroacetabular Impingement

BACKGROUND

Sport participation has been associated with favorable outcomes following hip arthroscopy (HA) for femoroacetabular impingement (FAI) at short- and mid-term follow-up; however, few studies have evaluated the 10-year outcomes in this population. The purpose of this study was to compare patient-reported outcome measures (PROMs), the achievement of clinically significant outcomes, and reoperation-free survivorship between patients with and without regular preoperative sport participation who underwent HA for FAI and had a minimum of 10 years of follow-up.

METHODS

Data were prospectively collected for patients who underwent primary HA for FAI between January 2012 and September 2013. Patients who participated in weekly sport participation at the time of surgery ("athletes") were matched 1:1 to patients who denied sport participation ("nonathletes"), controlling for age, sex, and body mass index (BMI). Preoperative and 10-year postoperative PROMs were collected, including the Hip Outcome Score Activities of Daily Living (HOS-ADL) and Sports (HOS-Sports) subscales, the modified Harris hip score (mHHS), and the visual analog scale for pain (VAS Pain) and satisfaction (VAS Satisfaction). Patient acceptable symptom state (PASS) achievement and reoperation-free survivorship were compared between the groups.

RESULTS

Sixty-four athletes were matched to 64 nonathletes of similar age, sex, and BMI (p ≥ 0.411). In the athlete group, 85.9% were recreational-level athletes. The groups had similar preoperative PROMs, except for the HOS-ADL subscale, where the athlete group demonstrated a higher preoperative score (67.8 ± 16.7 versus 59.9 ± 21.1, p = 0.029). Both groups demonstrated a significant improvement in all PROMs (p < 0.001) at the minimum 10-year follow-up10.3 ± 0.4 years). At the time of the final follow-up, the athlete group demonstrated significantly higher scores across all of the measured PROMs (p ≤ 0.036). Athletes showed a higher cumulative PASS achievement compared with nonathletes for the HOS-ADL subscale (73% versus 50%, p = 0.033), the HOS-Sports subscale (85% versus 61%, p = 0.010), the mHHS (69% versus 43%, p = 0.013), and the VAS Pain (78% versus 51%, p = 0.006). Reoperation-free survivorship frequencies were 87.5% and 82.8%, respectively (p = 0.504).

CONCLUSIONS

Athletes who underwent contemporary HA for FAI showed superior PROMs and PASS achievement compared with nonathletes at the 10-year follow-up. Athletes and nonathletes showed reoperation-free survivorship frequencies of 87.5% and 82.8%, respectively.

LEVEL OF EVIDENCE

Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Muscle contribution to hip contact force during walking is lower in individuals with femoroacetabular impingement syndrome, compared with controls

Altered hip loading and biomechanics in individuals with femoracetabular impingement syndrome (FAIS) may affect the joint's habitual mechanical environment, potentially increasing the risk of osteoarthritis . Examining differences in contributions of muscle and external loads (i.e., gravitational and intersegmental-inertial forces) to hip contact forces, compared with controls, may aid our understanding of FAIS pathomechanics and assist with the development of more effective treatments. Whole-body motion and electromyograms of 14 lower limb muscles were acquired from 41 participants with FAIS and 24 healthy controls whilst walking overground at self-selected speed. Contributions made by muscle and external (gravitational and intersegmental-inertial) forces to hip contact force during the stance phase of walking were estimated using an electromyogram-assisted neuromusculoskeletal model and compared between-groups using statistical parametric mapping. Throughout stance, muscle contributed ∼80% of hip contact force for both participants with FAIS and controls. Compared with controls, participants with FAIS generated ∼20% lower total muscle force (mean difference: -0.75 N·BW-1, 95% CI -1.13 to - 0.35, p < 0.001) primarily due to lower adductor (-0.27 N·BW-1, 95% CI -0.48 to - 0.06, p = 0.001), extensor (-0.40 N·BW-1, 95% CI - 0.65 to -0.16, p < 0.001) and flexor (-0.71 N·BW-1, 95% CI -1.07 to -0.35, p < 0.001) muscle group forces at different stages of stance. Compared with controls, lower hip contact force in participants with FAIS during the stance phase of walking were the result of lower flexor, extensor and adductor muscle forces and could be targeted in non-operative interventions (e.g., physiotherapy).

Impact of contralateral pelvic drop and femoral adduction on the femoral head acetabular coverage: A study on the reproducibility of a new radiographic measurement method

Purpose

Traditional radiographic measurements for acetabular dysplasia and femoroacetabular impingement syndrome (FAIS) are typically done in static positions, overlooking dynamic behaviours. This study investigated the reproducibility of a new radiographic method that incorporates pelvic and femoral motion during running.

Methods

This cross-sectional retrospective study included 10 patients (5 males/5 females; Mean 42.4, SD: 3.0 years) with symptomatic unilateral FAIS. Participants underwent three-dimensional running analysis and standard supine anteroposterior (AP) pelvis radiographs. Using specialised software, the femur and pelvis were rotated in the coronal plane according to peak angles of contralateral pelvic drop and femoral adduction from the running analysis, preserving the original hip joint centre. Two experienced physicians measured the lateral centre edge angle (LCEA), acetabular index (AI), sharp angle (SA), extrusion index (EI), and femoro-epiphyseal acetabular roof index (FEAR INDEX) on both standard and manipulated (M) radiographs in two rounds, with a 15-day interval. Differences between the original and manipulated measurements (VAR) were also calculated. Intra- and inter-rater reliability were assessed using the intraclass correlation coefficient (ICC) and Bland-Altman method, with a significance level of 5%.

Results

The average contralateral pelvic drop and femoral adduction used for image manipulation were 4.7° (SD: 2.7) and 6.2° (SD: 2.4), respectively. Of the 15 radiographic measurements, 14 showed good to excellent inter-rater reliability in the first assessment (range: 0.76-0.98), which decreased to 11 in the second assessment (range: 0.80-0.96). Intra-rater reliability showed 13 and 12 measurements with good or excellent reliability for raters 1 (range: 0.75-0.97) and 2 (range: 0.79-0.97), respectively.

Conclusion

This study demonstrates that incorporating dynamic motion into femoral head acetabular coverage radiographic measurements provides potential reliable assessments for most parameters. Integrating motion analysis with radiography could improve understanding of acetabular coverage in active individuals and support surgical decision-making.

Level of evidence

Diagnostic Study, Level III.

Femoroacetabular Impingement: Critical Analysis Review of Current Nonoperative Treatments

» Femoroacetabular impingement (FAI) is the premature contact of the femoral head-neck junction with the superior acetabular rim during hip range of motion, which may further damage intra-articular soft tissue structures and lead to the accelerated development of osteoarthritis.» FAI syndrome is diagnosed by a triad of symptoms, clinical signs, and imaging findings, and is a common cause of hip pain in young patients that have a significant impact on patient hip-related function and quality of life.» The treatment of FAI syndrome begins with noninvasive nonoperative modalities such as patient education and supervised exercise-based physical therapy. For recalcitrant symptoms, various injections have been explored for both diagnostic and therapeutic purposes; however, the efficacy of these interventions have generally not been demonstrated outside of the short term» In this article, we examine the available literature regarding the nonoperative treatment of FAI and provide insight into the effectiveness of current treatment modalities.

The Impact of Hip Arthroscopy on the Progression of Hip Osteoarthritis in Patients With Femoroacetabular Impingement Syndrome: A Systematic Review and Meta-analysis

Background

Hip arthroscopy (HA) for the surgical management of femoroacetabular impingement syndrome (FAIS) provides reliable improvements in pain and function; however, debate remains regarding the impact of HA on the progression of osteoarthritis (OA).

Purpose

To determine whether HA for FAIS reduces the progression of OA and the risk of conversion to total hip arthroplasty (THA).

Study Design

Systematic review; level of evidence, 4.

Methods

A systematic electronic search of articles in Medline, Embase, and ClinicalTrials.gov databases was performed under the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, with 5046 articles remaining after duplicates were removed. All papers addressing HA for FAIS that reported radiographic progression of hip OA with a follow-up of ≥2 years were eligible for inclusion. Studies assessing labral reconstruction, revision HA, case reports, studies with <10 patients, and patients with hip dysplasia or rheumatoid arthritis were excluded. A total of 322 studies progressed to full text, and 16 studies were ultimately included in this review. Studies were divided based on short-term (ST) (2 to <5 years), mid-term (MT) (5 to <10 years), and long-term (LT) (>10 years) follow-ups. A meta-analysis of homogenous studies and outcomes was performed, otherwise, descriptive statistics were presented.

Results

Sixteen studies (2278 hips) with FAIS were included, in which 1196 hips underwent HA and 1082 hips were treated nonoperatively. There were 8 ST studies, 4 MT studies, and 4 LT studies. A meta-analysis of 2 comparative studies found 32% (P = .002) less risk of progression of radiographic OA (any increase in grading) with HA compared with nonoperative management. In addition, there was a nonsignificant 23% (P = .35) decreased risk of conversion to THA/hip resurfacing with HA. For all studies, there was a progression of hip OA ranging from 0% to 37.1% for ST studies, 11.5% to 23% for MT studies, and 4.3% to 28% for LT studies.

Conclusion

Our systematic review demonstrated that studies of patients undergoing HA for FAIS demonstrated increased radiographic progression of hip OA over time. Although significantly limited by only 2 retrospective cohort studies, subgroup analysis comparing operative versus nonoperative management demonstrated a 32% reduction in the radiographic progression of OA (any increase in grading) at the LT follow-up. However, there were no significant differences in the risk of THA/hip resurfacing. Future long-term, high-level controlled studies are needed to help further understand this important clinical question.

Expert consensus on early orthodontic treatment of class III malocclusion

The prevalence of Class III malocclusion varies among different countries and regions. The populations from Southeast Asian countries (Chinese and Malaysian) showed the highest prevalence rate of 15.8%, which can seriously affect oral function, facial appearance, and mental health. As anterior crossbite tends to worsen with growth, early orthodontic treatment can harness growth potential to normalize maxillofacial development or reduce skeletal malformation severity, thereby reducing the difficulty and shortening the treatment cycle of later-stage treatment. This is beneficial for the physical and mental growth of children. Therefore, early orthodontic treatment for Class III malocclusion is particularly important. Determining the optimal timing for early orthodontic treatment requires a comprehensive assessment of clinical manifestations, dental age, and skeletal age, and can lead to better results with less effort. Currently, standardized treatment guidelines for early orthodontic treatment of Class III malocclusion are lacking. This review provides a comprehensive summary of the etiology, clinical manifestations, classification, and early orthodontic techniques for Class III malocclusion, along with systematic discussions on selecting early treatment plans. The purpose of this expert consensus is to standardize clinical practices and improve the treatment outcomes of Class III malocclusion through early orthodontic treatment.

Hip-focused strengthening and task-specific movement training for an individual with chronic, recurrent femoroacetabular impingement syndrome

OBJECTIVES

Examine the effects of hip-focused strengthening and task-specific movement training for a female who has undergone multiple surgical procedures yet continues to experience chronic, recurrent FAIS-related symptoms.

STUDY DESIGN

Case Report.

METHODS

A 23-year-old active female with an eleven-year history of FAIS and two previous surgical procedures recently experienced a third recurrence of symptoms brought on by increased physical activity levels. The patient performed progressive exercises focused on improving hip extension, abduction, and external rotation strength. The patient also received task-specific movement training aimed at minimizing hip adduction and internal rotation during movement that provoked her symptoms.

RESULTS

Following treatment, the patient's self-reported hip pain during movement improved 2.2 points and was abolished during four of the five activities examined. The patient exhibited strength gains for the hip extensors (22 %), abductors (36 %), and external rotators (20 %). The patient exhibited decreased hip adduction during all activities (mean difference = 10.6°) and decreased hip internal rotation during three of the five activities (mean difference = 3.7°).

CONCLUSION

This case report highlights the effects of hip-focused strengthening and task-specific movement training for a patient with longstanding FAIS and multiple surgical procedures.

Clinical assessment and treatment of patients presenting with longstanding hip and groin pain in primary care: a survey study among physical therapists and general practitioners in Sweden

BACKGROUND

Methods of assessment, treatment and referral rates of patients presenting with longstanding hip and groin pain (LHGP) are not well documented. The aim of this study was to investigate assessment and treatment of patients with LHGP among general practitioners (GPs) and physical therapists (PTs) in primary care.

METHODS

An anonymous web-based survey was developed specifically for this study and distributed to GPs and PTs at primary care centers in the southern part of Sweden. The survey covered the use of different methods of assessment and treatment for LHGP, the perceived importance these methods, and referral rates to orthopedic care. Responses from clinicians were reported in frequencies and percentages, and differences in assessment methodology between professions were examined with chi-square tests.

RESULTS

PTs (n = 104) and GPs (n = 62) referred less than 25% of patients with LHGP to orthopedic care. Both professions used clinical assessments as range of motion tests, but PTs were more likely to use specific clinical tests (PTs 76% vs. GPs 19%, p = < 0.001), GPs used more imaging (GPs 98% vs. PTs 58%, p = < 0.001) and neither profession used validated patient-reported outcome measures (GPs 2% vs. PTs 11%, p = 0.134). GPs and PTs ranked patient history and range of motion as the most important factors for diagnosis. GPs and PTs both reported providing patient education and advice on physical activity as part of the treatment. GPs commonly prescribed pain medication, including NSAIDs (97%), paracetamol (100%), and opioids (69%). 77% of PTs reported treatment duration less than 3 months, with treatment consisting of combinations of exercise therapy and manual therapy.

CONCLUSIONS

GPs and PTs in primary care referred 25% or less of patients with LHGP to orthopedic care. Both professions generally used assessment for LHGP in line with clinical recommendations. However, some assessment methods differed between GPs and PTs, and neither used validated patient-reported outcome measures. Treatment strategies mainly included pain medication (GPs), exercise and manual therapy (PTs), and education (both professions). Inconsistent with clinical recommendations, GPs commonly prescribed opioids as part of pain management, and PTs report treatment duration of less than 3 months.

CLINICAL TRIAL NUMBER

NA.

The Relationship Between Tensor Fascia Latae and Gluteus Maximus Has the Potential to Indicate Early Intra-articular and Degenerative Pathologies of the Femoral-Acetabular Joint: A Narrative Review

Intra-articular and degenerative hip pathologies have become common place with the number of total hip replacements rising year on year in the United Kingdom (UK). Pathology is identified by clinicians using special tests which are researched maneuvers used by clinicians to rule in or rule out specific musculoskeletal pathologies. Special tests used for hip pathology usually have high specificity to exclude degenerative and intraarticular pathology but vary in sensitivity. These special tests are usually only conducted when a person is symptomatic and typically require radiological confirmation to diagnose. The aim of this review was to appraise research to determine whether functional changes in the TFL and UGM muscle complex could indicate degenerative and/or intra articular pathology, with a specific focus on the utility of the ratio in strength of TFL and UGM to assist clinical diagnosis. The hypothesis was that the ratio of the strength of Tensor Fascia Latae (TFL) and the upper fibres of Gluteus Maximus (UGM) could suggest early intra-articular hip pathology, and that changes to this ratio could indicate deterioration of the hip joint before symptoms present/progress.

Level of Evidence

5.

More is not always better-association between hip range of motion and symptom severity in patients with femoroacetabular impingement syndrome: A cross-sectional study

BACKGROUND

Restricted hip range of motion (ROM) is a common finding in patients with femoroacetabular impingement (FAI) syndrome. However, the association between hip ROM and symptom severity in these individuals is unclear.

OBJECTIVE

Explore associations between symptom severity and hip flexion and rotation ROM in patients with FAI syndrome and determine if ROM measures can discriminate those with worse symptoms.

METHODS

Data from 150 participants with FAI syndrome were analysed. A digital inclinometer was used to measure hip flexion, internal rotation, and external rotation ROM. Symptom severity was quantified using the symptoms subscale of the international Hip Outcome Tool questionnaire (iHOT-Symptoms). Multivariable fractional polynomial analyses explored associations between hip ROM measures and symptom severity. Receiver operator characteristic curves explored the ability of ROM measurements to discriminate participants with different symptomatic states.

RESULTS

Smaller hip flexion ROM values were associated with worse iHOT-Symptoms scores (p < 0.01; R2=0.242); with the polynomial concave association attenuated at approximately 120° of hip flexion ROM. Hip internal rotation was weakly associated with iHOT-Symptoms score (p = 0.01; R2=0.033). Hip external rotation ROM was not associated with iHOT-Symptoms score (p = 0.06). A hip flexion value of 107° best discriminated mild to moderate and severe symptom states (sensitivity 92%, specificity 52%).

CONCLUSION

Less hip flexion ROM was associated with worse symptoms in patients with FAI syndrome. Patients with hip flexion ROM ≥ 107° had a 15-fold decrease in the likelihood of having severe symptoms. Hip rotation ROM measures do not have a clinically meaningful association with symptom severity.

Hip Arthroscopic Management for Patients With Subchondral Stress Fractures of the Femoral Head: A Case-Control Study

Background

A subchondral stress fracture of the femoral head (SSFFH) is managed with nonoperative treatment. There is a lack of knowledge regarding whether hip arthroscopic management is effective for active patients with SSFFHs.

Purpose

To elucidate whether arthroscopic management of SSFFHs enables active patients to return to sports activity.

Study Design

Cohort study; Level of evidence, 3.

Methods

A total of 22 patients undergoing hip arthroscopic management (labral repair/reconstruction and fragment fixation with hydroxyapatite and poly-L-lactic acid [HA/PLLA]-threaded pins) were enrolled and divided into 2 groups. The active group was defined as patients who participated in any kind of sports, regardless of the level of competition. The inactive group was defined as patients who did not participate in sports or any activity. Patient-reported outcome measure (PROM) scores, including the modified Harris Hip Score (mHHS) and Non-Arthritic Hip Score (NAHS), were collected preoperatively and at 6 months, 12 months, and the final follow-up (mean, 70.0 ± 36.6 months [range, 24-144 months]) after surgery. The authors performed chi-square and Mann-Whitney U tests to compare the PROM scores between the 2 groups.

Results

There were 10 patients in the active group and 12 patients in the inactive group in the final analysis. Overall, 14 SSFFHs underwent internal fixation with HA/PLLA-threaded pins. The PROM scores significantly improved from preoperatively to the final follow-up. The active group had significantly better PROM scores than the inactive group at 6 months (mHHS: 96.6 ± 5.0 vs 85.3 ± 13.6, respectively [P = .033]; NAHS: 74.3 ± 6.4 vs 57.0 ± 15.6, respectively [P = .008]) and 1 year (mHHS: 98.8 ± 1.8 vs 92.7 ± 8.6, respectively [P = .040]; NAHS: 78.0 ± 2.1 vs 65.9 ± 11.7, respectively [P = .007]). Additionally, 9 of 10 patients in the active group returned to their sports activity.

Conclusion

The study showed that arthroscopic management (femoroacetabular impingement correction, labral preservation, and stabilization with HA/PLLA-threaded pins) provided favorable clinical outcomes and a high rate of return to sports activity in active patients with SSFFHs. Active patients with SSFFHs had better postoperative results than inactive patients.

Arthroscopic treatment for femoroacetabular impingement yields favourable patient-reported outcomes and method survivorship at 10-year follow-up

PURPOSE

To compare the outcomes of hip arthroscopy for femoroacetabular impingement syndrome (FAIS) preoperatively and at minimum 10-year follow-up using patient-reported outcome measures (PROMs).

METHODS

A total of 128 patients with FAIS were prospectively included. The patients underwent arthroscopic surgery for FAIS between 2011 and 2013 and had a minimum of 10-year follow-up. The International Hip Outcome Tool short version (iHOT-12) was the primary outcome. Secondary outcomes were the Copenhagen Hip and Groin Outcome Score (HAGOS), the European Quality of Life-5 Dimensions Questionnaire (EQ-5D), the European Quality visual analogue scale (EQ VAS), the Hip Sports Activity Scale (HSAS) for physical activity level, the Visual Analogue Scale (VAS) for overall hip function and a single question regarding overall satisfaction with the surgery. The Wilcoxon signed rank test was used to compare pre- and postoperative PROMs.

RESULTS

There was a significant improvement (p < 0.001) of iHOT-12, HAGOS subscales, EQ-5D, EQ VAS and VAS for overall hip function. A total of 83% of the patients were satisfied with their surgery. The survivorship of hip arthroscopy, defined as nonconversion to total hip arthroplasty (THA), at the end of the follow-up period was 77%.

CONCLUSION

Patients undergoing arthroscopic treatment for FAIS reported statistically significant and clinically relevant improved outcomes at 10-year follow-up.

LEVEL OF EVIDENCE

Level IV, case series.

In Vitro Ovine Cam Impingement Model and Its Effect on Acetabular Cartilage

Background

Femoroacetabular impingement syndrome is a condition where abnormal contact occurs between the femoral head and the acetabulum, leading to chondral damage and hip osteoarthritis. To better understand and treat femoroacetabular impingement syndrome, it is crucial to establish in vitro models that mimic the condition and assess potential interventions.

Purpose

To establish an in vitro ovine cam impingement model and assess the effectiveness of cam excision in reducing the incidence of type 3 acetabular labrum articular disruption (ALAD) (chondral flap) lesions.

Study Design

Controlled laboratory study.

Methods

Utilizing an ovine in vitro cam impingement model, 40 hips were subjected to testing across 5 groups (n = 8 per group): group 1 (control group), 750 N for 200 cycles; group 2 (cycle decrease), 750 N for 100 cycles; group 3 (load decrease), 500 N for 200 cycles; group 4 (cam excision), cam excision followed by 750 N for 200 cycles; and group 5 (halfway cam excision), 750 N for 100 cycles followed by cam excision under an additional 750 N for 100 cycles loading. Each specimen was subsequently assessed for chondral damage according to the ALAD classification, both macroscopically and microscopically.

Results

The control group (group 1) demonstrated the highest ALAD scores (2.7 ± 0.4, 2.8 ± 0.3) compared with other groups, whereas the cam excision group (group 4) exhibited lower scores (0.5 ± 0.5, 0.7 ± 0.4) than both the cycle decrease group (group 2) (1.6 ± 0.5, 1.6 ± 0.5) and the halfway cam excision group (group 5) (1.8 ± 0.6, 2 ± 0.5) (P < .05) in both macroscopic and microscopic gradings (P < .05). The load decrease group (group 3) (1 ± 0.5) also displayed lower scores compared with group 5 (2 ± 0.5) at histological grading (P < .05).

Conclusion

An in vitro sheep model was established that reliably induces mechanical chondrolabral damage in the hip joint. The findings show that reducing the load results in less chondrolabral damage compared with reducing the number of cycles. Furthermore, this model emphasizes the protective effect of cam excision in the management of chondral flap lesions (ALAD type 3).

Assessing hip joint-related structure and patient-reported outcomes in people with Marfan syndrome

OBJECTIVE

People with Marfan syndrome (MFS) have clinical symptoms of hip pain, but to date, there is limited knowledge about hip-related structural abnormalities in these patients. Therefore, the purpose of this cross-sectional study was to assess hip-related structural abnormalities and patient-reported outcomes (PRO) in a cohort of patients with MFS compared to healthy controls.

METHODS

Nineteen individuals with MFS (17 females, 39.8±11.5 years) and 19 age, sex, and body mass index-matched healthy, asymptomatic individuals (17 females, 36.2±12.5 years) underwent radiographic imaging and unilateral hip MRI. The Scoring Osteoarthritis with MRI (SHOMRI) technique was used to assess hip-related morphological abnormalities between the MFS and control groups. All participants completed the Hip disability and Osteoarthritis Outcome Score (HOOS) to assess hip-related symptoms, pain, and function during activities of daily living (ADL) and quality of life (QOL).

RESULTS

The MFS group exhibited higher lateral center edge angles (p < .001). Despite similar severity of femoral cartilage damage (p = 1.0), the MFS group exhibited a higher severity (p = 0.046) of acetabular cartilage degeneration (1.21±1.08) compared to the controls (0.53±1.02). There were no between-group differences in severity of labral pathology, subchondral cysts, or edema. Individuals with MFS also self-reported significantly lower HOOS symptoms (p = 0.003), pain (p = 0.014), ADL (p = 0.028), and QOL (p = 0.014) sub-scores, indicating worse hip-related PRO in MFS.

CONCLUSION

Our study results suggest that individuals with MFS exhibit early signs of acetabular cartilage degeneration and poor hip-related clinical outcomes compared to healthy individuals. Future work should investigate the underlying biomechanical mechanisms associated with hip joint degeneration in the MFS population.

Running biomechanics in people with femoroacetabular impingement syndrome: A cross-sectional analysis of sex differences and relationships with patient reported outcome measures

OBJECTIVES

(i) Investigate if lower-limb running biomechanics differ between women and men with femoroacetabular impingement syndrome, and (ii) explore whether sex-specific relationships between lower-limb running biomechanics and symptom severity and sport-related concerns exist.

DESIGN

Cross-sectional.

SETTING

Gait laboratory.

PARTICIPANTS

Twenty women and 22 men enrolled in a clinical trial of physiotherapist-led treatments for femoroacetabular impingement syndrome.

MAIN OUTCOME MEASURES

Kinematics and kinetics of hip, knee, and ankle joints during the stance phase (calculated from three-dimensional biomechanics data) were compared using statistical parametric mapping. The International Hip Outcome Tool-33 and Copenhagen Hip and Groin Outcomes Score quantified hip-related symptom severity and sport-related concerns.

RESULTS

Women had larger hip adduction angles (34%-44% of stance,p = 0.045) than men. For kinetics, women displayed larger external hip extension moments (77%-100%,p = 0.001), smaller knee extension moments (80%-100%,p = 0.007), and smaller ankle dorsiflexion moments (26%-67%,p < 0.001) than men. Worse sport-related concern was associated with a larger peak hip extension angle (0.18, 95%CI 0.05,0.31) and smaller hip flexion moment impulse (0.14∗10-2, 95% CI 0.02∗10-2,0.25∗10-2) in women, and smaller hip external rotation moment impulse in men (0.06∗10-2, 95% CI 0.01∗10-2,0.11∗10-2).

CONCLUSIONS

Women and men with FAI syndrome display differences in lower-limb running biomechanics and relationships between symptom severity and running biomechanics are sex-dependent, warranting consideration in future analyses.

Evaluating Outcomes and Survivorship of Revision Arthroscopic Surgery for Femoroacetabular Impingement Compared With Matched Primary Cases

Background

The exponential rise in arthroscopy for femoroacetabular impingement (FAI) has led to increased revision surgery rates, although this is often an exclusion criterion from arthroscopy literature.

Purpose

To examine the midterm (minimum 5-year follow-up) outcomes after revision arthroscopic correction of FAI compared with a matched control group of primary surgical cases.

Study Design

Cohort study; Level of evidence, 3.

Methods

Prospective outcome data, collected in a consecutive series of patients undergoing revision arthroscopic FAI correction, was retrospectively reviewed. Revision procedures were compared with a matched group of primary surgical cases. Survivorship was defined as the avoidance of total hip replacement (THR) and assessed using a Kaplan-Meier curve with the log-rank test. Regression analysis was conducted to identify predictors of THR conversion. Patient-reported outcomes (PROs) including modified Harris Hip Score (mHHS), University of California, Los Angeles (UCLA), 36-Item Short Form Health Survey (SF36), and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) preoperatively and at 5 years postoperatively were compared between the groups. The proportion of patients across groups achieving the minimal clinically important difference (MCID) was compared for each PRO. Finally, a subgroup analysis was performed to compare the outcomes of those who had their index surgery at our clinic and those who had an index procedure elsewhere.

Results

A total of 124 revision cases were compared with 268 primary cases. The most common indication for revision surgery was residual bony deformity. Both groups had high survivorship rates at 5 years (>90%) although revision cases did have a statistically higher conversion to THR than did primary cases (6.5% vs 1.5%; P = .008). Increasing age and revision surgery were identified in regression analysis as predictors for THR conversion. Where THR was avoided, improvements in PROs were observed in both groups (P < .05 for all). Before surgery, revision cases reported lower scores for all PROs. At 5 years, the only statistical difference between the groups was in the distribution of mHHS scores. There were no differences in the rate of MCID achievement between groups.

Conclusion

Residual bony deformity is the most common indication for revision arthroscopy. Revision procedures may have a lower survival than primary cases, although overall survivorship at midterm follow-up is high. Of the revision cases, 17% required further arthroscopy. Where THR is avoided, improvements in pain and function can be expected that are similar to primary surgical cases.

Doctor when can I drive? A systematic review and meta-analysis of brake reaction time in patients returning to driving after hip arthroscopy for femoroacetabular impingement (FAI)

BACKGROUND

A common question from patients undergoing hip arthroscopy for femoroacetabular impingement (FAI) is when they may return to driving.

PURPOSE

We aimed to perform a formal systematic review and meta-analysis to address this issue.

METHODS

A systematic review and meta-analysis followed PRISMA guidelines. Databases searched included OVID, EMBASE, and COCHRANE through July 2024 for articles with keywords and MeSH terms like "Hip arthroscopy," "Femoroacetabular Impingement," "total brake response time," and "reaction time" related to driving. Titles and full articles were reviewed for quality and relevance. Statistical analysis was done using Review Manager Version 5.4.A total of 39 articles were reviewed, with 5 meeting inclusion criteria. All selected articles used brake reaction time (BRT) as an outcome measure. A meta-analysis compared pre- and postoperative BRT values. Data were analysed for the right and left hips combined, followed by a subgroup analysis by laterality. BRT values were divided into preoperative and 2, 4, 6, and 8 weeks postoperative periods.

RESULTS

The studies assessed 160 patients, with 142 undergoing hip arthroscopy for FAI. The mean age was 32.75 ± 9.4 years, with a male-to-female ratio of 73:69. The right hip was affected in 68% of patients. Preoperative BRT ranged from 566 to 1960 milliseconds, while postoperative BRT ranged from 567 to 1860 milliseconds between week 2 and week 12.

CONCLUSIONS

BRTs returned to baseline or control values and continued to improve 4 weeks post-surgery for FAI. It is safe to recommend a return to driving at 4 weeks after hip arthroscopy for FAI.

Arthroscopic Management of Femoroacetabular Impingement: Current Concepts

Background: Femoroacetabular impingement (FAI) is a common cause of hip pain and dysfunction, especially in young and active individuals, and it may require surgical management for associated labral tears and cartilage damage. The management of FAI has advanced radically over the last few years, and hip arthroscopy has gained a leading role. However, despite the increasing number of published research and technological advancements, a comprehensive systematic review summarising current evidence is still missing. Methods: All the clinical studies investigating the arthroscopic management of FAI were accessed. Only studies with a minimum of six months of follow-up were considered. The 2020 PRISMA guidelines were followed. In December 2024, PubMed, Web of Science, and Embase were accessed without time constraints. Results: The present systematic review included 258 clinical investigations (57,803 patients). The mean length of follow-up was 34.2 ± 22.7 months. The mean age was 34.7 ± 5.3, and the mean BMI was 25.1 ± 2.0 kg/m2. Conclusions: The present systematic review updates current evidence on patients who have undergone arthroscopic surgery for FAI, updating and discussing current progress in managing labral injuries and patient selection, emphasising outcomes and pitfalls. Progress in surgery and improvement in eligibility criteria, as well as current controversies and prospects, were also discussed.

Patients Requiring Revision Surgery After Primary Hip Arthroscopy for Femoroacetabular Impingement Syndrome Show a Small Reduction of Postoperative Labral Size: A Propensity-Matched Controlled Study

PURPOSE

To compare the changes in labral size after primary hip arthroscopy between patients requiring revision surgery and those did not.

METHODS

Data collected between August 2016 and September 2021 were retrospectively reviewed. Patients diagnosed with femoroacetabular impingement syndrome and undergoing primary and revision hip arthroscopy at our institute were included in the revision group. Exclusion criteria were Tönnis grade >1, concomitant hip conditions, and incomplete magnetic resonance imaging (MRI) data. Patients who did not undergo revision surgery or conversion to total hip arthroplasty at minimum 2-year follow-up were matched in a 1:2 ratio and included in the control group. The labral size (width and height at 11:30, 1:30, and 3:00) on MRI (noncontrast, 3.0 T) before and after 12 months of primary surgery was compared.

RESULTS

Twenty-one patients were included in the revision group, and 42 patients were matched in the control group. In the revision group, significant reduction in labral width and height at 11:30 and 1:30, and labral width at 3:00 was observed at 12 months after primary hip arthroscopy (all with P < .05), whereas the control group did not show significant difference of changes in labral size (all with P > .05). Smaller postoperative labral width at 1:30 and 3:00 was observed in the revision group compared with the control group (all with P < .05). The revision group presented with greater reduction of labral width at all 3 positions and labral height at 1:30 compared with the control group (all with P < .05).

CONCLUSIONS

Patients requiring revision surgery after primary hip arthroscopy for femoroacetabular impingement syndrome presented with smaller postoperative labral size (less than 1 mm difference) and greater reduction of labral size (at or less than 1mm difference) on MRI 12 months after primary surgery compared with those patients that did not require later revision surgery.

LEVEL OF EVIDENCE

Level III, retrospective case control.

No Significant Differences in Clinical Outcomes Were Observed Between Healed and Unhealed Hip Joint Capsules in Femoroacetabular Impingement Syndrome After Arthroscopy

PURPOSE

To explore the healing status of interportal capsulotomies without repair after arthroscopy in patients with femoroacetabular impingement syndrome (FAIS) and to examine its correlation with clinical outcomes, including the relationship with age and sex subgroups.

METHODS

Data collected between August 2015 and January 2022 were reviewed. Patients with FAIS aged 18 to 65 years who underwent hip arthroscopy with interportal capsulotomies without repair with a minimum 2-year follow-up were included. Patients with a lateral center-edge angle of less than 25°, Tönnis grade greater than 1, Perthes disease, slipped upper femoral epiphysis, avascular necrosis, prior ipsilateral hip injury or surgery, and absence of magnetic resonance imaging at final follow-up were excluded. Patients were divided into healed and unhealed capsule groups according to magnetic resonance imaging evaluation. The primary patient-reported outcome (PRO) was the modified Harris Hip Score (mHHS). The secondary PROs were the Hip Outcome Score-Activities of Daily Living subscale, Hip Outcome Score-Sport Specific subscale, University of California at Los Angeles score, and visual analog scale pain score at final follow-up. The percentages of patients achieving the minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) for the PROs were also calculated.

RESULTS

The cohort comprised 69 patients (72 hips), with 28 hips (38.89%) in the unhealed capsule group and 44 hips (61.11%) in the healed capsule group. The cohort comprised 32 male and 37 female patients, and the mean age of the patients was 44.15 years. Within each group, there were significant preoperative-to-postoperative increases in the mHHS, Hip Outcome Score-Activities of Daily Living, Hip Outcome Score-Sport Specific subscale, and University of California at Los Angeles score and decreases in the visual analog scale pain score (all P < .001). There were no significant differences between the healed and unhealed groups in the PROs and the achievement rates of the MCID and PASS (all P > .05). In addition, compared with the healed group, the unhealed group showed worse mHHS values in patients older than 40 years (P = .003) and female patients (P = .036) on subgroup analysis by age and sex, respectively.

CONCLUSIONS

At a minimum 2-year follow-up, 38.89% of patients with FAIS who underwent arthroscopic surgery with interportal capsulotomy without repair had unhealed hip capsules. There were no significant differences in PROs or achievement rates of the MCID and PASS between the healed and unhealed groups. Subgroup analysis showed that age older than 40 years and female sex may be associated with worse efficacy in patients with unhealed capsules.

LEVEL OF EVIDENCE

Level III, retrospective case-control study.

Cam Morphology and Sex-Based Differences in the Proximal Femur Anatomy of Collegiate Athletes Without Hip Pain: A 3-Dimensional Statistical Shape Modeling Analysis

Background

Radiographic studies have reported a high prevalence of cam morphology in athletes, especially in male athletes, suggesting these individuals are at an elevated risk of developing femoroacetabular impingement syndrome (FAIS). However, recent research has shown that 2-dimensional measurements do not accurately characterize cam deformities, motivating the need for 3-dimensional (3D) analyses.

Purpose

To develop a 3D statistical shape model of the proximal femur to evaluate cam morphology in collegiate athletes through (1) quantifying shape variation, (2) establishing sex-based shape differences, and (3) comparing shapes between male athletes and male cam FAIS patients.

Study Design

Cross-sectional study; Level of evidence, 3.

Methods

Double-echo steady-state magnetic resonance images were prospectively acquired of the hips of Division I collegiate athletes (28 male, 23 female). An existing data set of computed tomography scans of cam FAIS patients (26 male) and morphologically screened controls (30 male, 17 female) was also evaluated. The proximal femur was segmented, reconstructed into a 3D surface, and analyzed to generate a correspondence model using ShapeWorks. Principal component analysis, parallel analysis, and linear discriminant analysis quantified variation in proximal femoral shape.

Results

Variation in the full cohort primarily occurred in the head-neck junction, femoral offset, and location of the greater trochanter relative to the head/neck (mode VIII, adjusted P = .01; modes I and IV, adjusted P = .002 and adjusted P = .003, respectively; modes IV and VIII, adjusted P = .0003 and adjusted P = .0007, resepctively. P < .001). Modes represented anatomic variation significantly different between pairs within a group. Variation between male and female athletes occurred in the concavity of the head at the head-neck junction, length of the femur, and length of the femoral offset (modes I and II, adjusted P = .006 and adjusted P = .009, respectively). Variation between male athletes and male patients and between male patients and male controls occurred in the concavity of the head at the head-neck junction and femoral torsion (mode IV, adjusted P = .02 and adjusted P = .003, respectively). Shape scores, which represented a generalized value of the entire shape, were significantly different between athletes and patients (adjusted P = .003) and patients and controls (adjusted P < .0001).

Conclusion

Athletes in our study had a proximal femur shape more similar to morphologically screened controls than FAIS patients. Sex-based differences occurred in athletes in regions where cam morphology typically occurs.

Clinical outcomes of arthroscopic surgical intervention in femoroacetabular impingement amongst the Asian population: A meta-analysis

IMPORTANCE

In Asian populations, increased prevalence of hip dysplasia as well as activities of daily living which require increased hip range of motion, such as squatting, may impact outcomes of arthroscopic surgery for femoroacetabular impingement (FAI) when compared to their Western counterparts. Existing literature lacks a comprehensive review and synthesis of knowledge focusing on outcomes of arthroscopic intervention for FAI in the Asian population.

OBJECTIVE

To conduct the first systematic review and meta-analysis that examines outcomes of arthroscopic intervention in Asian patients with FAI.

EVIDENCE REVIEW

PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Scopus, and Cochrane Library databases were reviewed. Case series or cohort studies assessing outcomes of arthroscopic intervention in FAI were included. Pooled analysis of modified Harris Hip Score (mHHS), Visual Analogue Scale (VAS), and adverse events were conducted. Rate of revision surgery and conversion to total hip arthroplasty (THA) were analysed as well.

FINDINGS

Six studies (5 case series, 1 cohort study) of high methodological quality involving 498 patients were included. Age of patients ranged from 20s to 70s, with a balanced gender ratio. Pooled patient-reported outcomes improved significantly postoperatively. VAS at the last follow-up mark improved by -4.28 (95 ​% CI, -4.49 to -4.08, P ​< ​0.00001), and VAS at the 12-month post-operation mark improved by -4.11 (95 ​% CI, -4.34 to -3.88, P ​< ​0.00001). The mHHS at the last follow-up mark improved by 23.37 (95 ​% CI, 20.29-26.45, P ​< ​0.00001). Revision surgery rate was low at 2.8 ​% and conversion to THA rate was 0.3 ​%.

CONCLUSIONS AND RELEVANCE

Arthroscopic intervention in FAI provides favorable outcomes in the Asian population that is comparable with outcomes seen in the Western population.

LEVEL OF EVIDENCE

Meta-analysis; Level of evidence, IV.

Asymptomatic female softball pitchers have altered hip morphology and cartilage composition

Few studies have explored hip morphology and cartilage composition in female athletes or the impact of asymmetric repetitive loading, such as occurs during softball pitching. The current cross-sectional study assessed bilateral bony hip morphology on computed tomography imaging in collegiate-level softball pitchers ('Pitch1', n = 25) and cross-country runners ('Run', n = 13). Magnetic resonance imaging was used to assess cartilage relaxation times in a second cohort of pitchers ('Pitch2', n = 10) and non-athletic controls ('Con', n = 4). Pitch1 had 52% greater maximum alpha angle than Run (p < 0.001) and were 21.3 (95% CI 2.4 to 192.0) times more likely to have an alpha angle ≥ 60° within at least one hip. Pitch2 had longer T2 relaxation times in the superior femoral cartilage of the drive leg (same side as the throwing arm) and stride leg than Con (all p < 0.02). The drive leg in Pitch2 had longer T1ρ and T2 relaxation times in the superior femoral cartilage compared to the stride leg (all p ≤ 0.03). Asymptomatic softball pitchers exhibit altered bony hip morphology and cartilage composition compared to cross-country runners and non-athletic controls, respectively. They also exhibit asymmetry in cartilage composition. Further studies with larger sample sizes are warranted and any potential long-term consequences of the changes in terms of symptom and osteoarthritis development requires investigation.

Medium-term results of arthroscopic hip surgery compared with physiotherapy and activity modification for the treatment of femoroacetabular impingement syndrome: a multi-centre randomised controlled trial

OBJECTIVE

To report a 3-year follow-up from the FemoroAcetabular Impingement Trial, comparing arthroscopic surgery with physiotherapy in the management of femoroacetabular impingement (FAI) syndrome for the dual primary outcomes of radiographic hip osteoarthritis (OA) and patient-reported outcome measures of activities of daily living.

METHODS

Two-group parallel, assessor-blinded, pragmatic randomised controlled trial across seven sites. 222 participants aged 18-60 years with FAI syndrome confirmed clinically and radiologically were randomised (1:1) to receive arthroscopic hip surgery (n=112) or physiotherapy (n=110). Dual primary outcome measure was minimum joint space width (mJSW) on anteroposterior radiograph at 38 months post-randomisation and Hip Outcome Score ADL (HOS ADL) (higher score indicates superior outcomes). Secondary outcome measures were Scoring Hip Osteoarthritis with MRI (SHOMRI) (lower score indicates less pathology).

RESULTS

mJSW, HOS ADL and MRI data were available for 45%, 77% and 62% of participants at 38 months, respectively. No significant difference in mJSW was seen between groups at 38 months. HOS ADL was higher in the arthroscopy group (mean (SD) 84.2 (17.4)) compared with the physiotherapy group (74.2 (21.9)), difference 8.9 (95% CI 7.0, 10.8)). SHOMRI score total at 38 months was lower in the arthroscopy group (mean (SD) 9.22 (11.43)) compared with the physiotherapy group (22.76 (15.26)), differences (95% CIs) -15.94 (-18.69, -13.19).

CONCLUSIONS

No difference was seen between groups on radiographic measures of OA progression. Patients with FAI syndrome treated surgically may experience superior pain and function outcomes, and less MRI-measured cartilage damage compared with physiotherapy.

TRIAL REGISTRATION NUMBER

NCT01893034.

Evaluation of Outcomes Following Arthroscopic Treatment of Femoroacetabular Impingement Syndrome Across Different Surgeons, Surgical Techniques, and Postoperative Protocols: A Multi-institutional Study

Background

Femoroacetabular impingement syndrome (FAIS) is frequently treated arthroscopically with osteoplasty and labral repair. Surgical preferences vary in terms of equipment, technique, and postoperative protocol. Patient-reported outcome measures (PROMs) are valuable tools to assess outcomes across different institutions.

Purpose

To compare PROMs after FAIS arthroscopy and evaluate the impact on postoperative outcomes with independent surgeons utilizing different surgical techniques and postoperative protocols.

Study Design

Cohort study; Level of evidence, 2.

Methods

Prospective data were collected from patients with a 2-year follow-up after arthroscopic FAIS treatment by 2 orthopaedic surgeons from different states, each attending different sports medicine fellowships. Patients were matched according to age, sex, and body mass index. Data included patient characteristics, surgical findings, and the Hip disability and Osteoarthritis Outcome Score (HOOS) preoperatively and 2 years postoperatively. Patients with revision surgery, concomitant procedures, or incomplete pre- and postoperative data were excluded. Surgeon A utilized interportal capsulotomy, capsular repair, all-suture anchors, and a postoperative hip brace. Surgeon B employed periportal capsulotomy without repair, polyether ether ketone suture anchors, and no brace. The 2 high-volume arthroscopists (>100 hips/year) performed osteoplasty and labral repair and used a large perineal post. Cohorts were analyzed with appropriate t tests, with significance set at P < .05. The percentage of patients achieving minimal clinically important difference (MCID) was calculated using Pearson chi-square tests.

Results

A total of 176 hips (100 women, 76 men) were included, with 88 matched patients from each institution. The mean age was 33.7 years and the body mass index was 26.3 kg/m2. Both cohorts significantly improved in all 5 HOOS subscales 2 years after surgery. When comparing the mean change in PROMs and the percentage of patients achieving the MCID, differences were only observed in the HOOS-Sports subscale (cohort A: 25.3 ± 29.7 vs cohort B: 34.3 ± 29.7; P = .048; MCID achieved in 57% of patients vs 76%; P = .01).

Conclusion

This prospective cohort study on arthroscopic FAIS treatment indicates that matched patient cohorts from different institutions show similarly improved PROMs at 2 years. This study suggests consistent patient outcomes across sites despite geography, surgeon, training, surgical technique, implants, and postoperative protocol.

Strength, mobility, and functional outcomes 2.5 months after hip arthroscopy for femoroacetabular impingement syndrome: A Cross-sectional Study

OBJECTIVE

Short-term deficits after hip arthroscopy for femoroacetabular impingement syndrome (FAIS) remain poorly understood. We assessed muscle strength, hip range of motion, and functional task performance 2.5 months after surgery and analyzed their association with self-reported function.

DESIGN

Cross sectional study.

PARTICIPANTS

52 patients.

MAIN OUTCOME MEASURES

Maximal isometric strength (hip flexion with both straight and flexed hip/knee, abduction and external rotation), hip range of motion (flexion, external and internal rotation), and functional tasks (bipodal/unipodal squat, bilateral vertical jump, single-leg distance hop). Between-limb differences were analyzed using paired t-tests, and the Limb Symmetry Index (LSI) was calculated.

RESULTS

The operated hip showed lower hip flexion strength (LSI = 88.4%; ES = -0.549; p < 0.001) and reduced range of motion (LSI = 75.4-92.4%; ES = -0.479 to -1.02; all p < 0.01) compared to the non-operated hip. Functional task performance did not differ between operated and non-operated hips (all p > 0.05).

CONCLUSION

Patients showed alterations in hip flexion strength and range of motion post-surgery, but functional task performance was unaffected. Targeted assessment and intervention may be needed to improve outcomes after surgery for FAIS.

Early Impact of Hip Arthroscopy on the Resolution of Symptom Burden in Athletes With Femoroacetabular Impingement

Background

Coexisting symptoms can confound outcomes after arthroscopic correction of femoroacetabular impingement (FAI). Symptom burden (SB) represents the cumulative load of patient-reported symptoms.

Purpose

To quantify the prevalence of symptoms in athletes before and after arthroscopic correction of FAI and evaluate the impact of independent and cumulative SB resolution on outcomes.

Study Design

Case series; Level of evidence, 4.

Methods

Included were 509 hips of 386 athletes (89% men; age, 26.4 ± 6.1 years) who underwent primary hip arthroscopy for FAI between 2011 and 2020. Symptom prevalence was assessed preoperatively and 1 year postoperatively using a 15-item SB survey, with the total number of symptoms reported as the SB score. Minimal clinically important difference (MCID-SB) and substantial clinical benefit (SCB-SB) thresholds according to the proportional pre- to postoperative resolution of SB were calculated, and 1- and 2-year postoperative patient-reported outcome measures (PROMs)-including the modified Harris Hip Score and 36-Item Short Form Survey-were compared relative to MCID-SB and SCB-SB achievement. Multivariable stepwise regression was used to evaluate the ability of individual symptom resolution for MCID and SCB achievements on PROMs.

Results

The SB score was 6 ± 2.9 preoperatively, improving to 2.8 ± 2.7 at 1 year postoperatively (P < .001). A proportional reduction in symptoms by 48.5% and 70.3% defined the MCID-SB and SCB-SB, respectively; this was achieved by 63.6% and 43.8% of the hips, respectively. Postoperatively, PROMs were superior where clinically meaningful SB resolution thresholds were achieved (P < .001). A significantly higher proportion of these cases returned to their main sport (79.4% vs 63.1% achieved MCID-SB; 83.8% vs 65.2% achieved SCB-SB) (P < .001). Odds ratios for symptoms associated with achieving the MCID on PROMs included resolution of groin pain (2.6-5.5), side hip pain (3.4), pain during (3.1) and after (2.6-3.5) activity, hamstring tightness (2.6), and limping after activity (2.6). Symptom resolution associated with achieving SCB included groin pain (3.0-3.1), pain during (3.3) and after (2.7-4.2) activity, and limping after activity (3-6.8).

Conclusion

Achieving thresholds of clinically important SB resolution was associated with superior postoperative PROM scores and higher rates of return to sports for this athletic cohort. Resolution of groin pain, pain during/after activity, hamstring tightness, and limping after activity increased the odds of achieving clinically important improvement on PROMs.

Patients With Lateral and Anterolateral Cam Morphology Have Greater Deformities Versus Typical Anterolateral Deformity Alone but No Differences in Postoperative Outcomes: A Propensity-Matched Analysis at Minimum 5-Year Follow-Up

PURPOSE

To compare pre- and postoperative findings between patients undergoing hip arthroscopy for femoroacetabular impingement syndrome with lateral impingement versus those without lateral impingement METHODS: Patients who underwent primary hip arthroscopy for femoroacetabular impingement syndrome between 2012 and 2017 with minimum 5-year follow-up were included. Alpha angle (AA) was measured on preoperative anteroposterior (AP) and 90° Dunn radiographs. Patients with AA >60° on Dunn view but not AP view (no lateral impingement) were propensity matched by sex, age, and body mass index in a 1:3 ratio to patients with AA >60° on both views (lateral impingement). Demographic characteristics, radiographic and intraoperative findings, reoperation rates, and patient-reported outcomes (PROs) were compared between groups. Categorical variables were compared using the Fisher exact testing and continuous variable using 2-tailed Student t tests.

RESULTS

Sixty patients with lateral impingement (65.0% female, age: 35.3 ± 13.0 years) were matched to 180 patients without lateral impingement (65.0% female, age: 34.7 ± 12.5 years, P ≥ .279). Patients with lateral impingement had larger preoperative AAs on both Dunn (71.0° ± 8.8° vs 67.6° ± 6.1°, P = .001) and AP radiographs (79.0° ± 12.1° vs 48.2° ± 6.5°, P < .001). However, there were no differences in postoperative AAs on either view (Dunn: 39.0° ± 6.1° vs 40.5° ± 5.3°, AP: 45.8° ± 9.0° vs 44.9° ± 7.0°, P ≥ .074). Labral tears began more superiorly in patients with lateral impingement (12:00 ± 0:49 vs 12:17 ± 0:41, P = .030), and they demonstrated greater rates of acetabular and femoral cartilage damage (P = .030 for both); however, there were no differences in PROs or reoperation rates between the groups at 5-year follow-up.

CONCLUSIONS

Although cam deformities located laterally and anterolaterally are larger than those located anterolaterally alone, both can be resected adequately, resulting in similar postoperative radiographic measurements, PROs, and survivorship.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Management of Labral Tears in the Hip: A Consensus Statement

Background

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

Purpose

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

Study Design

A consensus statement.

Methods

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

Results

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

Conclusion

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

Current understanding of articular cartilage lesions in femoroacetabular impingement syndrome

The concept of femoroacetabular impingement syndrome (FAIS) has received much attention over the past 20 years. Currently, it is believed that FAIS can lead to intra-articular pathologies such as labral tears and articular cartilage lesions, resulting in clinical symptoms and subsequent poor clinical outcomes. FAIS-related articular cartilage lesions are common but unique, and their natural course always leads to early osteoarthritis of the hip. However, despite these cartilage lesions having gradually gained considerable attention, limited consensus has been reached on key aspects, such as diagnosis, mechanisms, classification, and management strategies, which limits clinical and research advances. Hence, an intensive comprehensive overview based on the existing evidence is necessary. The purpose of this review was to introduce the general consensus, controversial issues, and recent advances in FAIS-related articular cartilage lesions.

The ligamentum teres and its role in hip arthroscopy for femoroacetabular impingement: a systematic review

BACKGROUND

The ligamentum teres (LT) has received attention in patients undergoing hip arthroscopy (HA) for femoroacetabular impingement (FAI). Indeed, a better understanding of the function of the LT and its implications for clinical outcomes in the presence of a torn LT is required. This systematic review analyses the patient-reported outcome measures (PROMs) and the complication rate when an intact or torn LT is encountered during HA for FAI.

METHODS

Studies that compared patients with an intact to those with a torn LT managed with debridement during hip arthroscopy for FAI were identified from the Web of Science, PubMed, and Embase. The minimum follow-up for inclusion was 24 months. The Risk of Bias in Non-randomised Studies of Interventions (ROBINS-I) tool was used to assess the risk of bias. Patient characteristics and PROMs were assessed at the baseline and last follow-up.

RESULTS

The systematic review identified two studies comprising 611 patients. No statistically significant difference was found in pain, Harris Hip Score, and the activities of daily living and sports subscales of the Hip Outcome Score between patients with an intact LT and those with a torn LT treated with debridement, both of whom underwent HA for FAI.

CONCLUSIONS

In patients undergoing arthroscopic management for FAI, an intact or torn ligamentum teres managed with debridement does not influence postoperative PROMs. Given the importance of the LT as a structure of the hip joint and the increasing interest in HA for FAI, further standardised studies will be a valuable source for surgeons encountering this pathology.

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

BACKGROUND

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Demographic Disparities and Outcomes Following Hip Arthroscopy: Exploring the Impact of Social Determinants of Health in Femoroacetabular Impingement Syndrome

BACKGROUND

The purpose of this study was to explore the impact of social deprivation on preoperative characteristics and postoperative outcomes following hip arthroscopy (HA) for femoroacetabular impingement syndrome (FAIS).

METHODS

Patients undergoing primary HA for FAIS were identified, and their social deprivation index (SDI) score was assigned on the basis of the provided ZIP code. Quartiles (Q1 to Q4) were established using national percentiles, with Q4 representing patients from the areas of greatest deprivation. Patient-reported outcomes (PROs) were collected preoperatively and at a minimum follow-up of 2 years. Achievement rates for clinically meaningful outcomes, including the minimal clinically important difference (MCID), patient acceptable symptom state (PASS), and substantial clinical benefit (SCB), were determined. The incidences of revision HA and conversion to total hip arthroplasty (THA) were recorded. SDI groups were compared with respect to preoperative characteristics and postoperative outcome measures. Predictors of MCID, PASS, and SCB achievement; revision HA; and conversion to THA were identified with use of multivariable logistic regression.

RESULTS

In total, 2,060 hips were included, which had the following SDI distribution: Q1 = 955, Q2 = 580, Q3 = 281, and Q4 = 244. The composition of the included patients with respect to race and/or ethnicity was 85.3% Caucasian, 3.8% African American, 3.7% Hispanic, 1.7% Asian, and 5.4% "other." Patients with more social deprivation presented at a later age and with a higher body mass index (BMI), a longer duration of preoperative hip pain, and greater joint degeneration (p ≤ 0.035 for all). The most socially deprived groups had higher proportions of African American and Hispanic individuals, less participation in physical activity, and greater prevalences of smoking, lower back pain, and Workers' Compensation (p ≤ 0.018 for all). PRO scores and achievement of the PASS and SCB were worse among patients from areas of greater social deprivation (p ≤ 0.017 for all). Age, BMI, activity status, race and/or ethnicity classified as "other," SDI quartile, Workers' Compensation, preoperative back pain, duration of preoperative hip pain, and Tönnis grade were independent predictors of clinically meaningful outcome achievement, revision arthroscopy, and/or THA conversion (p ≤ 0.049 for all).

CONCLUSIONS

Individuals with more social deprivation demonstrated inferior postoperative outcome measures. This was driven primarily by preoperative characteristics such as SDI, hip pain duration, joint degeneration, and overall health at presentation. Despite differential outcomes, patients still showed clinical improvement regardless of SDI quartile.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Revision hip arthroscopy for hip synovial chondromatosis is effective despite inferior postoperative clinical outcomes compared to patients undergoing primary hip arthroscopy: a matched control study with minimum 2-year follow-up

PURPOSE

(1) To determine the clinical outcomes following revision arthroscopy for patients with hip synovial chondromatosis (SC), and (2) to compare the clinical outcomes between patients undergoing revision hip arthroscopy and primary hip arthroscopy.

METHODS

Patients undergoing hip arthroscopy between December 2014 and January 2021 was reviewed. Patients treated for SC and confirmed by postoperative pathology were included. Exclusion criteria were age less than 18 years old, hip osteoarthritis (Tönnis grade > 1), history of autoimmune disease, avascular necrosis, and Legg-Calve-Perthes disease. Patients undergoing revision surgery were included in the revision group, while those undergoing primary surgery were matched in a 1:4 ratio and included in the primary group. Preoperative and postoperative patient-reported outcome (PRO) scores including Visual Analog pain Scale (VAS), modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), and international Hip Outcome Tool, 12-component form (iHOT-12) were collected and compared. The PROs and percentage of achieving minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) of mHHS, iHOT-12, and NAHS were compared between the two groups.

RESULTS

A total of 12 patients were included in the revision group, while 48 patients were included in the primary group. No significant difference was found in baseline characteristics (all with P > .05). No significant difference was found in the arthroscopic findings and procedures (all with P > .05). Both groups presented significant improvement of postoperative PROs compared to the preoperative PROs (all with P < .001). No significant difference was found in preoperative PROs between the two groups (all with P > .05). Postoperatively, the revision group presented inferior VAS (P = .007), mHHS (P = .007), iHOT-12 (P = .004), and NAHS (P = .028), as well as lower rate of achieving MCID of NAHS (P = .038), and PASS of mHHS (P = .003) compared to the primary group.

CONCLUSION

Patients undergoing revision arthroscopy for hip SC presented favorable clinical outcomes at minimum of 2-year follow-up, although the postoperative PROs, rate of achieving MCID, and PASS were lower compared to patients undergoing primary arthroscopy.

LEVEL OF EVIDENCE

III.

Preoperative versus postoperative nonsteroidal anti-inflammatory drugs in femoroacetabular impingement patients undergoing hip arthroscopy surgery: analgesic effect, joint function, patients' satisfaction, and quality of life

BACKGROUND

Nonsteroidal anti-inflammatory drugs (NSAIDs) have analgesic effects on femoroacetabular impingement (FAI) patients undergoing hip arthroscopy surgery (HAS). However, the influence of medication time on the analgesic effect of NSAIDs is uncertain. This study aimed to compare the analgesic effect, joint function, quality of life (QoL), and patients' satisfaction between preoperative and postoperative NSAIDs in these patients.

METHODS

In this prospective, observational study, 165 FAI patients undergoing HAS with NSAIDs (celecoxib, meloxicam, and nimesulide) for analgesia were divided into preoperative (PRE-A) and postoperative analgesia (POST-A) groups according to their actual medication.

RESULTS

The visual analog scale (VAS) pain scores on the 1st (P < 0.001) and 3rd (D3) (P = 0.015) days after the operation were lower in the PRE-A group versus the POST-A group but not preoperatively (P = 0.262) or on the 7th day after the operation (D7) (P = 0.302). The proportion of patients receiving rescue analgesia decreased in the PRE-A group versus POST-A group (P = 0.041). However, the modified Harris hip score (mHHS), proportion of patients with an mHHS ≥ 70, and EuroQol-5-dimensional score at preoperative, 1st month (M1), and 3rd month (M3) after the operation were similar between the groups (all P > 0.050). The VAS score on D7 was greater in the PRE-A group compared to the POST-A group (P = 0.014), but the scores at M1 and M3 and the satisfaction and very satisfaction rates at D7, M1, and M3 did not differ between the groups (all P > 0.050). Subgroup analysis revealed that the type of NSAID did not affect most outcomes.

CONCLUSION

Preoperative NSAIDs elevate analgesic effect and patients' satisfaction, but not joint function or QoL compared to postoperative NSAIDs in FAI patients undergoing HAS.

Clinical presentation of anterior pelvic tilt and trunk muscle endurance among patients with femoroacetabular impingement syndrome: a cross-sectional study

BACKGROUND

Femoroacetabular impingement syndrome (FAIS) significantly affects the physical function and quality of life of the young and middle-aged population. Pelvic tilt and trunk muscle endurance are physical features poorly studied in FAIS.

AIM

This study aimed to compare the anterior pelvic tilt and anterior, lateral, and posterior trunk muscles endurance between people with FAIS and healthy individuals, within FAIS sub types and between the symptomatic and asymptomatic hip in people with FAIS.

DESIGN

Cross-sectional study.

SETTINGS

Participants were recruited and screened for potential eligibility at the Rehabilitation, Sports Medicine, and Physiotherapy Unit between April 2021 and February 2022.

POPULATION

Sixty-nine patients with FAIS and 69 controls.

METHODS

A study adhering to STROBE guidelines recruited 138 participants (69 FAIS, 69 controls). The degree of pelvic tilt was measured by the palpation meter (PALM) tool. To assess trunk musculature endurance, isometric trunk tests described by McGill were performed (extension resistance test, flexion resistance test, and side plank test). Cases were classified based on FAIS subtypes. Differences between groups and subgroups were performed using t-tests and ANCOVA, respectively.

RESULTS

Significant differences in anterior pelvic tilt were observed between the control and FAIS groups (P<0.001, d=0.72). Participants with FAIS exhibited greater pelvic tilt (MD=1.57, 95% CI=0.83 to 2.3). Trunk muscle endurance showed statistically significant differences (P<0.001, d=0.72) for posterior muscles. In comparisons between symptomatic and asymptomatic hips, significant differences were found in pelvic tilt (P<0.001, d=0.26) and lateral trunk muscle endurance (P<0.001, d=0.43). FAIS subtypes demonstrated significant differences in lateral trunk muscle endurance (P=0.002, ηp2=0.209).

CONCLUSIONS

This study found that patients with FAIS present large anterior pelvic tilt and lower posterior trunk muscle endurance. Although anterior pelvic tilt was comparable for all FAIS subtypes, Pincer-type with or without labral tear exhibited lower lateral trunk muscle endurance compared with Cam-type with or without labral tear. In addition, the symptomatic hip of FAIS patients showed lower lateral trunk muscle endurance compared to the asymptomatic hip.

CLINICAL REHABILITATION IMPACT

Incorporating rehabilitation strategies that address pelvic tilt and trunk muscle strengthening in individuals with FAIS might be considered as a potential means to improve these physical impairments, pending careful evaluation of their effectiveness.

Osteochondroplasty with or without labral repair is more cost-effective than arthroscopic lavage with or without labral repair for treatment of young adults with femoroacetabular impingement: A cost-utility analysis based on data from a randomized controlled trial

OBJECTIVES

The objective of this study was to conduct a cost-utility analysis of osteochondroplasty with or without labral repair compared to arthroscopic lavage with or without labral repair for femoroacetabular impingement (FAI) from a Canadian public payer perspective.

METHODS

A Markov model was constructed to compare the lifetime quality-adjusted life years (QALYs) and costs of the two treatment strategies. The target population was surgical FAI patients aged 36 years. The primary data source was patient-level data from the Femoroacetabular Impingement Randomised Controlled Trial, which evaluated the efficacy of the surgical correction of FAI via arthroscopic osteochondroplasty with or without labral repair compared to arthroscopic lavage with or without labral repair in Canada. Long-term data were extrapolated using a generalized gamma model. The primary outcome was the incremental cost-effectiveness ratio, calculated by dividing the difference in costs by the difference in QALYs between osteochondroplasty and lavage, with or without labral repair. Probabilistic sensitivity analyses and one-way sensitivity analyses were used to characterize uncertainty of model parameters and assumptions.

RESULTS

Over a lifetime horizon, osteochondroplasty, with or without labral repair, had a greater expected benefit (0.63 QALYs gained per patient) and lower costs ($955.89 saved per patient), as compared with lavage with or without labral repair. Probabilistic sensitivity analyses demonstrated that the probability of osteochondroplasty, with or without labral repair, being cost-effective was 90.5% at a commonly used willingness-to-pay threshold of $50,000/QALY in Canada. Across all one-way sensitivity analyses, osteochondroplasty with or without labral repair remained a cost-effective option.

CONCLUSION

Over a lifetime time horizon, osteochondroplasty, with or without labral repair, is a cost-effective treatment strategy for young adults with FAI. Future research involving real-word data is needed to further validate these findings.

LEVEL OF EVIDENCE

III.

Review of femoroacetabular impingement syndrome

Femoroacetabular impingement syndrome (FAIS) is a common condition of the hip that can cause significant damage to the joint, leading to degeneration and osteoarthritis. FAIS constitutes an abnormal and dynamic contact between the femoral head-neck junction and the acetabular rim, resulting from altered bone morphology at one or both sites. Repetitive trauma at the site of impingement generates progressive damage to the acetabular labrum, chondrolabral junction, and articular cartilage. Proper diagnosis based on patient symptoms, specific clinical signs, and imaging findings will guide treatment and ultimately allow preservation of the native hip joint. Common symptoms in patients with FAIS include pain, clicking, catching, buckling, stiffness, giving way, and a limited range of motion of the hip. Specific clinical maneuvers can aid diagnosis, such as flexion adduction internal rotation and flexion abduction external rotation tests. Imaging diagnosis includes orthogonal hip and pelvis X-ray views, as well as magnetic resonance imaging/magnetic resonance arthrogram imaging. Initial treatment of FAIS can be conservative and include physical therapy, intra-articular injections, and activity modification. Currently, the preferred surgical management consists of hip arthroscopy, which aims to correct bony abnormalities, repair or reconstruct labral lesions and address other intra-articular and extra-articular derangements as needed.

The association between cam morphology and hip pain in males and females within 10 years: A national prospective cohort study (CHECK)

OBJECTIVES

To determine the association between baseline cam morphology and self-reported hip pain assessed at annual visits over a 10-year follow-up period stratified by biological sex. The secondary aim was to study the association between the magnitude of cam morphology and the severity of pain in symptomatic hips.

METHODS

The nationwide prospective Cohort Hip and Cohort Knee (CHECK) study includes 1,002 participants aged 45-65 years. Logistic regression with generalized estimating equations were used to determine the strength of the associations between (1) baseline cam morphology (both alpha angle ≥60° and as a continuous measure) and the presence of hip pain at 10 annual follow-up visits and (2) the alpha angle (continuous) and the severity of pain as classified by Numerical Rating Scale at 5-,8-, 9-, and 10-years. The results are expressed as odds ratios (OR), adjusted for age, biological sex (only in the sex-combined group), body mass index, and follow-up Kellgren and Lawrence grade.

RESULTS

In total, 1,658 hips were included at baseline (1,335 female hips (79.2%)). The prevalence of cam morphology was 11.1% among all hips (29.1% in males; 6.4% in females). No association was found between cam morphology at baseline and the presence of hip pain at any follow-up in the female or sex-combined group. In males, only at 5-year follow-up, significant adjusted ORs were observed for the presence of cam morphology (1.77 (95%CI: 1.01-3.09)) and the alpha angle (1.02 (95%CI:1.00-1.04)). No evidence of associations was found between the alpha angle and the severity of hip pain in any of three groups.

CONCLUSION

Within this study, no consistent associations were found between cam morphology and hip pain at multiple follow-ups. There might be a weak relationship between cam morphology and hip pain in males, while no such relation was found in females. We did not identify an association between the alpha angle and severity of hip pain.

Interleukin-6 and Interleukin-8 Gene Expressions Differ Between Male and Female Patients at Time of Hip Arthroscopy for Femoroacetabular Impingement Syndrome

Purpose

To identify key molecular components within the femoroacetabular impingement hip and compare the findings between male and female patients across varying age groups.

Methods

All patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS) without hip dysplasia were included. During hip arthroscopy, performed at University of Wisconsin Health, loose articular cartilage, excess synovium, damaged labral tissue, and minimal adipose tissue were debrided only as needed for visualization and tissue repair purposes and collected. Tissue was processed and used for quantitative polymerase chain reaction (qPCR). Genes were selected for qPCR on the basis of their associated function in inflammation and/or extracellular matrix remodeling during the progression of osteoarthritis.

Results

A total of 91 male (M) and female (F) patients 15 to 58 years old were included in the study. qPCR results indicated that Interleukin-6 (P < .05, 95% confidence interval [CI] 0.047-0.083 F, 0.070-0.12 M) and Interleukin-8 (P = .04, 95% CI 0.059-0.10 F, 0.082-0.18 M) were significantly greater in male patients compared with female patients regardless of age, and IL6 (P = .02, 95% CI [0.026-0.070] F, [0.067-0.17] M), Interleukin-1ß (P < .01 95% CI [0.013-0.063] F, [0.073-0.25] M), and Matrix metalloproteinase-13 (P = .047, 95% CI [0.0051-0.017] F, [0.0084-0.052] M) were significantly greater in male patients younger than 20 years old compared with female patients younger than 20 years old.

Conclusions

In patients with FAIS, there are significant differences between male and female patients in the biomarkers present in the affected hip at the time of surgery. Male patients have greater levels of IL6 and IL8 and male patients younger than 20 years of age have greater levels of IL1β, IL6, and MMP13 compared with age-matched female patients.

Clinical Relevance

A better understanding of the molecular markers present during varying stages of FAIS and in patients of different ages will help characterize the pathologic process behind FAIS. This may also help define future methods of targeted treatment and prevention of disease progression.

Radiomics features outperform standard radiological measurements in detecting femoroacetabular impingement on three-dimensional magnetic resonance imaging

Femoroacetabular impingement (FAI) is a cause of hip pain and can lead to hip osteoarthritis. Radiological measurements obtained from radiographs or magnetic resonance imaging (MRI) are normally used for FAI diagnosis, but they require time-consuming manual interaction, which limits accuracy and reproducibility. This study compares standard radiologic measurements against radiomics features automatically extracted from MRI for the identification of FAI patients versus healthy subjects. Three-dimensional Dixon MRI of the pelvis were retrospectively collected for 10 patients with confirmed FAI and acquired for 10 healthy subjects. The femur and acetabulum were segmented bilaterally and associated radiomics features were extracted from the four MRI contrasts of the Dixon sequence (water-only, fat-only, in-phase, and out-of-phase). A radiologist collected 21 radiological measurements typically used in FAI. The Gini importance was used to define 9 subsets with the most predictive radiomics features and one subset for the most diagnostically relevant radiological measurements. For each subset, 100 Random Forest machine learning models were trained with different data splits and fivefold cross-validation to classify healthy subjects versus FAI patients. The average performance among the 100 models was computed for each subset and compared against the performance of the radiological measurements. One model trained using the radiomics features datasets yielded 100% accuracy in the detection of FAI, whereas all other radiomics features exceeded 80% accuracy. Radiological measurements yielded 74% accuracy, consistent with previous work. The results of this preliminary work highlight for the first time the potential of radiomics for fully automated FAI diagnosis.

No Effect of Cigarette Smoking in the Outcome of Arthroscopic Management for Femoroacetabular Impingement: A Systematic Review

Background: The impact of smoking in arthroscopic surgery for femoroacetabolar impingement (FAI) is controversial. This systematic review updates and discusses current evidence on the influence of cigarette smoking on the outcome of arthroscopic management of FAI. The outcomes of interest were to compare patient-reported outcome measures (PROMs) and complications. Methods: The present systematic review followed the PRISMA guidelines. Embase, Web of Science, and PubMed were accessed in June 2024 without additional filters or temporal constraints. All the clinical investigations comparing smokers versus nonsmokers in patients who underwent arthroscopic management for FAI were considered. The risk of bias in nonrandomised controlled trials was assessed using the Risk of Bias in Nonrandomised Studies of Interventions (ROBINS-I). Results: Data from 368 patients were retrieved. The mean length of follow-up was 34.1 ± 7.1 months. The mean age was 40.4 ± 4.0 years and the mean BMI was 27.1 ± 1.6 kg/m2. No significant difference was evidenced in the visual analogue scale, Harris hip score, Hip Outcome Score-Sport subscale, and Non-Arthritic Hip Score. No difference was observed in the complication rate: reoperation (p = 0.6) and progression to THA (p = 0.4). Conclusions: Tobacco smoking does not appear to influence the outcomes of arthroscopic management for FAI. At approximately 34 months of follow-up, no difference was found in pain, PROMs, reoperation rate, and progression to THA.

Assessment of hip abductor and adductor muscle strength with fixed-frame dynamometry: Considerations on the use of bilateral and unilateral tasks

OBJECTIVE

To examine the specificities and limitations of bilateral and unilateral tasks for the assessment of hip abductor and adductor strength with a commercially-available fixed-frame dynamometer.

DESIGN

Correlational/validity study.

METHODS

Maximal voluntary isometric strength of hip abductors and adductors was evaluated in 130 healthy participants using unilateral and bilateral tasks. Surface EMG activity of agonist and stabilizer muscles was concomitantly recorded in a subgroup of 15 participants.

RESULTS

For both muscle groups, bilateral tasks resulted in higher strength values than unilateral tasks (∼25%; p < 0.001). The correlation between left- and right-side data was higher for bilateral than unilateral tasks (p < 0.05), thereby resulting in lower interlimb asymmetries (p < 0.001). Agonist EMG activity was lower for unilateral than bilateral tasks (p < 0.01). Stabilizer EMG activity (external abdominal oblique) was higher for unilateral than bilateral tasks (p < 0.05) on the ipsilateral and contralateral side for hip abductors and adductors, respectively.

CONCLUSIONS

A large (25%) and quasi-systematic bilateral facilitation of strength was observed for both hip abductors and adductors. Bilateral testing led to an underestimation of interlimb asymmetries, due to higher side equivalence than unilateral tasks. Unilateral testing resulted in lower agonist EMG activity and higher stabilizer activity than bilateral tasks, especially in weaker subjects.

Acetabular retroversion and cam morphology are contributing risk factors for posterior hip dislocation independent of the trauma mechanism

INTRODUCTION

A high-energy trauma impact is generally considered the crucial factor causing native hip dislocation. However, femoroacetabular variations are assumed to contribute to low-energy posterior hip dislocations, especially in adolescent athletes. The study aimed to analyze the femoroacetabular morphology of adults who sustained traumatic posterior hip dislocations, comparing high-energy, sports-related, and low-energy trauma mechanisms.

MATERIALS AND METHODS

One hundred forty-one patients with traumatic posterior hip dislocations were analyzed and matched to a control group of 141 patients with high-energy trauma mechanisms without hip or pelvic injury, matched for age, gender, and Body Mass Index (BMI). The trauma mechanism was analyzed, and the femoroacetabular morphology and concomitant femoral head or posterior acetabular wall fractures were assessed using computed tomography (CT) scans. Acetabular version, coverage, and pincer morphology were evaluated by measuring the lateral center-edge angle, acetabular index, acetabular depth/width ratio, cranial and central acetabular version angles, and the anterior and posterior acetabular sector angles (AASA, PASA). The caput-collum-diaphyseal (CCD) angle and coronal and axial alpha angles were measured to detect cam morphology.

RESULTS

A high-energy trauma caused posterior hip dislocations in 79.4%, sports-related mechanisms in 7.8%, and a low-energy impact in 12.8%. Patients with high-energy and sports-related dislocations exhibited a higher disposition for acetabular retroversion (p < 0.001). However, the acetabular version in low-energy mechanisms did not differ from the control group (p ≥ 0.05). Acetabular retroversion was associated with isolated dislocation, while acetabular overcoverage correlated with concomitant posterior acetabular wall fractures (p < 0.05). Alpha angles were significantly increased in patients with hip dislocations, independent of the trauma mechanism (p < 0.001).

CONCLUSION

Acetabular retroversion contributes to posterior hip dislocation in high-energy and sports-related trauma mechanisms and decreases the likelihood of sustaining concomitant fractures. Acetabular morphology was subordinate to causing hip dislocation following a low-energy impact. Increased alpha angles were identified as a risk factor contributing to posterior hip dislocations, regardless of the trauma mechanism.

Prevalence of Asymptomatic Changes in the Groin Region Among Adult Professional Soccer Players and Their Association With Limb Dominance

OBJECTIVE

To investigate the prevalence of asymptomatic radiologic groin region findings in adult professional soccer players using magnetic resonance imaging (MRI) and examine the influence of age and limb dominance on their occurrences.

DESIGN

Cross-sectional trial.

SETTING

Soccer club medical service, private practice.

PARTICIPANTS

Forty-seven male professional soccer players.

INTERVENTIONS

Players underwent a groin presigning MRI scan with a magnetic field induction of 1.5 Tesla. Image analysis of their pubic bones was performed according to The Copenhagen Standardized MRI protocol to assess the pubic symphysis and adductor regions of players.

MAIN OUTCOME MEASURES

The prevalence of various changes in the symphysis, pubic bone, and adjacent areas.

RESULTS

Fifty images of pubic bones and adjacent regions (53.2%) highlighted 1 to 4 changes, while another 44 images (46.8%) demonstrated 5 or more changes. The most frequent changes observed in the pubic bone were joint surface irregularities (100%), symphyseal sclerosis (93.6%), pubic bone swelling (56.3%), parasymphyseal high-intensity line (55.3%), fatty infiltration in bone marrow (38.3%), and adductor tendinopathy (34%). When comparing the prevalence of different changes in the dominant and nondominant limbs, no statistically significant differences were found.

CONCLUSIONS

In adult professional soccer players with no prior groin pain complaints in recent history (12 months), asymptomatic changes are extremely common in the pubic joint and adjacent areas, including those that are very likely to be considered the main cause of pain when investigated in soccer players with groin pain. None of these changes were associated with limb dominance.

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

OBJECTIVE

To review and critically appraise available literature concerning the diagnostic capability of intra-articular injections for femoroacetabular impingement (FAI) syndrome.

DESIGN

Systematic review.

SETTING

N/A.

PARTICIPANTS

N/A.

INTERVENTIONS

N/A.

MAIN OUTCOME MEASURES

Studies assessing pain relief following intra-articular injections for the diagnosis of FAI syndrome, compared with arthroscopy as diagnostic reference standard, were considered eligible. Searches were performed across 8 databases, and the risk of bias was evaluated through the Quality Assessment of Diagnostic Accuracy Studies tool.

RESULTS

From 489 articles identified, 4 were included for analysis. Intra-articular injections were composed of anesthetic agents (such as lidocaine, bupivacaine, and ropivacaine), combined or not with corticosteroids (triamcinolone and betamethasone). All studies were judged as "at risk of bias", and a substantial heterogeneity was found considering assessment methods and pain relief thresholds for a positive response to intra-articular injections. Overall, 2 studies reported that intra-articular injections presented a high accuracy in determining the presence of FAI syndrome. However, the remaining 2 studies indicated that intra-articular injections might present restricted diagnostic capability to discriminate FAI syndrome from healthy individuals or those with other hip pathologies.

CONCLUSIONS

Based on limited evidence, the diagnostic capability of intra-articular injections for FAI syndrome cannot be supported. It remains unclear which pain relief thresholds are related to a higher diagnostic capability. The combination of anesthetics with corticosteroids should also be further explored, including multiple pain assessments for evaluation of prolonged effects.