The prevalence of radiographic findings of structural hip deformities in female collegiate athletes

Evaluating Return to Sports Following Total Hip Arthoplasty With Custom Stems in Professional and Recreational Table Tennis Players

Background

Table tennis players execute short explosive movements, along with continuous hip flexion, abduction, and rotation, increasing their risk of injury. Previous studies reported a rate of return to sports (RTS) of 20% to 80% in athletes following total hip arthroplasty (THA). There are no studies reporting RTS in table tennis players following THA.

Purpose

To evaluate the clinical outcomes and RTS following custom THA in professional, ex-professional, and recreational table tennis players.

Study design

Case series; Level of evidence, 4.

Methods

Patients who underwent primary THA between April 2013 and January 2022 were retrospectively reviewed (n = 2977). Table tennis players of any level that received a custom femoral stem were included in the study (N = 17). At a minimum follow-up of 2 years, all players were assessed using the Oxford Hip Score (OHS), Forgotten Joint Score (FJS), and the University of California Los Angeles (UCLA) activity score, as well as with a sports-specific questionnaire that included questions related to their table tennis practice. Descriptive statistics, including medians and interquartile ranges, were used to summarize the data.

Results

All 17 players (22 hips) were available at ≥2 years, of which 3 were professional (5 hips), 4 were ex-professional (6 hips), and 10 were recreational (11 hips). The median OHS was 44.0 (IQR, 44.0-48.0) in professional, 48.0 (IQR, 48.0-48.0) in ex-professional, and 48.0 (IQR, 45.0-48.0) in recreational players. The median FJS was 92.0 (IQR, 88.0-98.0) in professional, 98.0 (IQR, 98.0-98.0) in ex-professional, and 100.0 (IQR, 93.0-100.0) in recreational players. The median UCLA activity score was 10.0 (IQR, 9.0-10.0) in professional, 9.0 (IQR, 9.0-9.8) in ex-professional, and 8.0 (IQR, 5.5-9.0) in recreational players. The rate of RTS was 100% for professional and ex-professional players, and 80% for recreational players. The hours played before onset of symptoms was higher than following surgery for professional (30.0 [IQR, 25.0-30.0] vs 20.0 [IQR, 16.0-22.5] h/week) and ex-professional players (19.5 [IQR, 11.0-29.3] vs 3.0 [IQR, 2.0-5.5] h/week), while it was constant for recreational players (4.0 [IQR, 2.3-4.0] vs 4.0 [IQR, 3.8-4.5] h/week).

Conclusion

Our retrospective analysis demonstrated that at a minimum follow-up of 2 years THA using custom stems provided good to excellent clinical outcomes in professional, ex-professional, and recreational table tennis players. All professional and ex-professional players, as well as 80% of recreational players, were able to return to play table tennis, although both professional and ex-professional players reduced their number of hours of play compared with before surgery. These findings could be used to help set expectations for table tennis players who are scheduled to undergo THA.

Altered Joint Forces Found in Symptomatic Dysplastic Hips in Women During Sport-Specific Activities

Background

Many patients with developmental dysplasia of the hip (DDH) are young and highly active but often become limited by activity-induced pain. Characterizing how the abnormal bony geometry of DDH affects hip joint loading and multiplanar kinematics during sport-specific motions relevant to active patients may provide insight into injury mechanisms and inform optimal treatment options.

Purpose/Hypothesis

The purpose of this study was to determine how hip joint loading and kinematics are altered in DDH during 2 common sport activities: running and multidirectional hop-cutting. It was hypothesized that superior and medial joint-reaction forces (JRFs) would be elevated during running and that medial JRFs would be elevated during hop-cutting when compared with controls.

Study Design

Controlled laboratory study.

Methods

Using patient-specific musculoskeletal modeling, both running and hop-cutting motions were analyzed for female patients with symptomatic DDH (DDH group) and female controls without hip disorders who were enrolled from October 2017 to August 2022. Hip joint angles, JRFs, and muscle forces were compared between the groups using 1-dimensional statistical parametric mapping.

Results

Overall, 19 women in the DDH group and 19 female controls were included in the running analysis, and 13 women in the DDH group and 10 female controls were included in the hop-cutting analysis. During the running motion, medial hip JRFs and gluteal muscle forces were significantly elevated in the DDH group, while rectus femoris muscle forces were reduced. During the hop-cutting motion, medial hip JRFs, gluteus minimus, and gluteus medius muscle forces were elevated, while gluteus maximus forces were reduced in the DDH group. There were no significant group differences in hip joint angles for either activity.

Conclusion

The lack of kinematic differences between women with symptomatic DDH and controls suggests that the JRF differences between groups stemmed from the abnormal joint geometry in the DDH group. These activities may have greater damaging potential than previously studied lower impact activities such as walking.

Clinical Relevance

Better understanding of how loading varies from activity to activity can help patients with DDH, and clinicians understand the mechanistic causes of DDH-related hip pain and damage and plan appropriate intervention strategies.

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.

Painful Borderline Acetabular Dysplasia: What's New?

Developmental dysplasia of the hip (DDH) is a complex static-dynamic condition resulting in chronic joint instability and osteoarthritis. Borderline acetabular dysplasia refers to slightly abnormal patterns in the acetabular shape and coverage that are not within the dysplastic range. However, they can predispose to mechanical dysfunction and hip instability. Diagnosis and treatment remain controversial topics in hip preservation, with little current comparative literature to guide accurate diagnosis and treatment decision-making. Historically, the diagnosis of borderline DDH relied on assessments of the acetabular anatomy on anteroposterior pelvic radiography, most commonly the lateral central-edge angle (LCEA), with normal values ranging from 20 to 25° or, in some more recent studies, 18 to 25°. Surgical treatment decision-making debates the use of isolated hip arthroscopy or periacetabular osteotomy, considering the difficulty in determining a fundamental mechanical diagnosis (instability versus femoroacetabular impingement) in subjects with borderline DDH. Therefore, for effective surgical decision-making, the evaluation of additional bone anatomy characteristics, instability, and patients' features is essential.

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.

Sex-related functional outcome after periacetabular osteotomy in mild to severe hip dysplasia

Aims

Periacetabular osteotomy (PAO) is well established for acetabular reorientation and has shown successful improvement in patient-reported outcome measures (PROMs). Nevertheless, studies focusing on postoperative outcomes related to patient individual factors are still underrepresented. Therefore, this study aimed to analyze the functional outcome and activity level in relation to patient sex with a minimum follow-up of two years after PAO for mild to severe hip dysplasia.

Methods

A single-centre study was conducted, enrolling patients undergoing PAO and completing a preoperative and postoperative radiological and clinical outcome assessment. The PROMs were assessed using the modified Harris Hip Score (mHHS), the Hip disability and Osteoarthritis Outcome Score (HOOS) with the subscales for pain, sport, activities of daily living (ADL), and quality of life (QoL), and the University of California, Los Angeles (UCLA) activity score. Kendall's tau were calculated for correlation analyses.

Results

In total, 145 patients (28 male, 117 female) were included. The PROMs improved significantly across males and females at the latest follow-up. Female patients had significantly lower preoperative PROMs: mHHS (47 vs 57.4; p = 0.002); HOOS pain (44.9 vs 60; p = 0.003), sport (47 vs 57.4; p = 0.002), ADL (58.9 vs 69.3; p = 0.032), and QoL (26.8 vs 39.3; p = 0.009); and UCLA (5.6 vs 6.7, p = 0.042) scores. Males showed higher postoperative UCLA scores (7.5 vs 6.7; p = 0.03). Kendall's tau showed significant negative correlation between BMI and UCLA scores in females and males (-0.21 to -0.29; p = 0.002/0.048), while BMI and HOOS sport (-0.16; p = 0.015) and ADL (-0.2; p = 0.003), as well as QoL (-0.14; p = 0.031) and preoperative acetabular inclination (-0.13; p = 0.049) were only significantly negatively correlated in females.

Conclusion

Patient sex affects PROMs before and after PAO. Female patients experience higher improvement in hip function and activity level, due to poorer preoperative PROMs than males. Thus, these data are particularly interesting in providing preoperative guidance regarding postoperative outcome expectations.

Greater anterior pelvic tilt and lumbar mobility in females compared to males undergoing periacetabular osteotomy: A matched cohort study

Purpose

The functional hip-spine interaction is increasingly noted in hip preservation by periacetabular osteotomy (PAO), while potentially affecting the impingement-free acetabular reorientation. However, the clinically relevant sex-related differences in lumbopelvic alignment have been poorly studied. Thus, the purpose of this study was to evaluate a matched PAO patient cohort for sex-related differences in lumbopelvic alignment.

Methods

Out of 138 patients undergoing PAO between January 2024 and September 2024 at one high-volume centre, there were 68 data sets (34 male, 34 female) included. The data sets of this diagnostic cohort study were prospectively collected, and the patients were matched in a 1:1 ratio for sex, age and acetabular morphology (hip dysplasia, borderline hip dysplasia, acetabular retroversion). Lumbopelvic alignment was assessed with serial sagittal lumbopelvic radiographs in standing, relaxed-seated and deep-seated positions. Each radiograph was reviewed for pelvic tilt (PT), lumbar lordosis and sacral slope.

Results

Females showed a significantly lower PT in standing (7.8 vs. 14.3°, p < 0.001), relaxed-seated (28.1 vs. 34.9°, p = 0.012) and deep-seated (3.7 vs. 11.0°, p = 0.013) positions. Furthermore, females had a significantly increased lumbar mobility (Δ relaxed-seated - deep-seated position - 35.4° vs. 27.0°, p = 0.003), while there was no sex-related difference in sacral mobility (p > 0.05).

Conclusion

There are sex-related differences in functional lumbopelvic alignment across various positions of daily living in patients undergoing PAO. With a greater anterior PT, females are at risk of an anterior hip impingement. Thus, the intraoperative anterior and posterior wall reorientation by PAO should be adapted to the sex-related lumbopelvic alignment to ensure an impingement-free surgical outcome.

Level of Evidence

Level IV, case series.

Late-Onset Femoroacetabular Impingement Syndrome Following Knee Arthroscopy in a Retrospective Cohort

Background/Objectives: Hip-knee coupling is a well-documented phenomenon, and interventions to one joint can alter biomechanics at the other. The purpose of this study was to investigate if knee surgery is associated with later onset of femoroacetabular impingement syndrome (FAIS). Methods: A retrospective chart review was conducted regarding patients at a single academic institution who underwent hip arthroscopy for FAIS between January 2011-October 2021. Patient charts were queried for past surgical history of knee arthroscopy before hip arthroscopy. Patients who previously underwent hip arthroscopy with no history of knee arthroscopy served as controls. Details about demographics and the onset of hip symptoms were abstracted from patient charts. Statistical analysis was conducted using Mann-Whitney testing and binary logistic regression. Results: Of the 1569 patients identified, 127 had a history of knee arthroscopy and reported no hip symptoms at or prior to the time of surgery. Patients who had undergone prior knee arthroscopy were significantly older at onset of initial hip symptoms (42.15 ± 11.80 years versus 34.62 ± 12.49 years, p < 0.001) and at the time of hip arthroscopy (44.12 ± 11.85 years versus 36.90 ± 12.14 years, p < 0.001) when controlling for age, sex, and BMI. These patients first developed hip symptoms at a mean of 8.57 ± 8.53 years following knee arthroscopy (median 6.10 years) and underwent operative treatment 1.76 ± 1.96 years later. Conclusions: Patients with a history of prior knee arthroscopy are older at the time of hip symptom onset and subsequent hip arthroscopy for the treatment of FAIS.

Increased asphericity of the femoral head-neck junction in professional breakers compared to hobby athletes - a retrospective case-control study

OBJECTIVE

Breaking has gained public attention as a form of sports activity. The associated intense movements of the hip joints are possibly linked to the development of femoroacetabular impingement (FAI). Therefore, this study aimed to assess clinical and radiographic FAI measures in professional breakers compared to hobby athletes.

METHODS

The study cohort consisted of professional breakers with persisting hip pain who were 1:1 matched to a cohort of FAI patients without professional sports careers from our outpatient clinic. The primary endpoint assessed on standardized plain radiographs was the alpha angle (AA). Further measures were the acetabular index (AI), lateral center-edge angle (LCEA), crossover sign, ischial spine sign, and femoral head extrusion index (FHEI). The modified Harris Hip Score (mHHS) and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score were used to obtain patient-reported measures.

RESULTS

We recruited ten professional breakers and matched them to ten hobby athletes. The median AA was significantly higher in the breakers compared with the hobby athletes (73° [IQR 66.5°, 84.2°]) vs. 61.8° [IQR 59.5°, 64.8°], p = 0.0004). There was a significant reduction in weekly training hours in breakers after diagnosis (13.0 hours [interquartile range [IQR] 9.5, 32.4] to 1.5 hours [IQR 0, 4.8], p = 0.0039). There were no inter-group differences regarding mHHS, WOMAC, and additional radiographic measurements.

CONCLUSION

Breakers have higher AA in cam-type FAI compared to nonprofessional athletes. The corresponding hip pain significantly reduced training hours and caused the end of their breaking career. The potentially high prevalence of FAI in breakers and the corresponding consequences need to be considered early when athletes present with hip pain.

Periacetabular osteotomy with and without concomitant arthroscopy: a systematic review of evidence on post-operative activity levels and return to sport

The purpose of this systematic review is to (i) compare post-operative activity levels after periacetabular osteotomy (PAO) versus PAO + HA (concomitant PAO and hip arthroscopy) using patient-reported outcomes that specifically assess activity and sports participation [Hip Disability and Osteoarthritis Outcome Score-Sport and Recreation subscale (HOOS-SR), University of California Los Angeles (UCLA) activity score, Hip Outcome Score-Sport-Specific Subscale (HOS-SSS)] and (ii) compare post-operative return to sport (RTS) data between PAO and PAO + HA groups. A systematic review of literature was conducted on 1 June 2023, utilizing PubMed, Cochrane and Embase (OVID). Articles were screened for inclusion using specific inclusion and exclusion criteria. Twenty-six out of 1610 articles met all inclusion criteria, without meeting any exclusion criteria. In the 12 studies containing only subjects who underwent PAO alone, 11 demonstrated an average score improvement in UCLA, HOOS-SR or HOS-SSS post-operatively (P < 0.05). In the three studies containing subjects who underwent PAO with concomitant HA, significant improvements were seen in the HOS-SS and UCLA scores (P < 0.05). In the five studies that directly compared UCLA, HOS-SSS and HOOS-SSS scores between PAO groups and PAO + HA groups, all demonstrated statistically significant improvement post-operatively (P < 0.05). The rate of RTS ranged from 63% to 90.8% among PAO studies and was found to be 81% in the single PAO + HA study that assessed RTS. When performed in patients with intra-articular pathology, concomitant PAO + HA may provide similar sport-related outcomes to PAO alone in patients without intra-articular pathology.

A New Clinical Examination Algorithm to Prescribe Conservative Treatment in People with Hip-Related Pain

Hip-related pain is a common issue in active adults affecting their quality of life, mobility, and overall function, and it can lead to persistent disability. However, diagnosing hip-related pain is challenging due to the many potential sources and causes, including intra-articular and extra-articular pathology, and referred pain from other areas (lumbar or groin related pain). To address this, there is a need for a clinical algorithm based on the best available evidence and expert consensus. This algorithm could guide healthcare professionals in assessing and managing patients with hip-related pain, during the diagnosis, test selection, intervention, monitoring, and promoting collaboration among various healthcare providers. This clinical algorithm for hip-related pain is a comprehensive, flexible, adaptable to different settings, and regularly updated to incorporate new research findings. This literature review aims to establish a clinical algorithm specifically for prescribing exercise treatment to patients with hip-related pain, addressing their individual needs and enhancing their overall care.

Does hip muscle strength and functional performance differ between football players with and without hip dysplasia?

OBJECTIVE

To compare hip muscle strength and functional performance in football players with and without hip dysplasia and investigate if the relationships were modified by sex.

DESIGN

Cross-sectional study.

METHODS

This study compared football players with hip dysplasia (HD group) and without hip dysplasia (control group). Hip muscle strength (Nm/kg) and functional task performance were assessed in both groups. Linear regression with generalized estimating equations were used to assess differences between groups. Sex was assessed as a potential effect modifier.

RESULTS

101 football players were included (HD group, n = 50, control group, n = 51). There was no difference in hip muscle strength or functional performance between the HD group and the control group. Results ranged from hip extension strength (Estimate -0.13.95%CI: 0.29 to 0.02, P = 0.087) to hip external rotation strength (Estimate 0.00.95%CI: 0.05 to 0.05, P = 0.918). No relationships were modified by sex or age.

CONCLUSIONS

Similar levels of hip muscle strength and functional performance were found in active football players with and without hip dysplasia. These findings differ from other studies. This may be due to our cohort having less advanced hip dysplasia than the surgical populations that have been previously investigated, or due to a beneficial effect of football participation on muscle strength and functional performance in people with hip dysplasia.

Progression of Osteoarthritis at Long-term Follow-up in Patients Treated for Symptomatic Femoroacetabular Impingement With Hip Arthroscopy Compared With Nonsurgically Treated Patients

BACKGROUND

Femoroacetabular impingement (FAI) is a common cause of hip pain, especially in young patients. When left untreated, it has been demonstrated to be a risk factor for the onset or progression of osteoarthritis (OA) and has been identified as one of the main contributors leading to the need for total hip arthroplasty (THA) at a young age. While the short-term therapeutic potential of hip arthroscopy is widely recognized, little is known regarding its potential mid- to long-term preventive effect on the progression of hip OA.

PURPOSE

To (1) report clinical outcomes of arthroscopically treated FAI syndrome with a minimum 5-year follow-up and compare the results to a cohort with FAI treated nonsurgically and (2) determine the influence of hip arthroscopy on the onset and progression of hip OA in patients diagnosed with FAI.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients who had hip pain and were diagnosed with FAI were included. Exclusion criteria were (1) previous or concomitant hip surgery, (2) <5 years of follow-up, and (3) insufficient radiographs. Patients treated with hip arthroscopy were compared with a cohort of patients with FAI who were treated nonsurgically. Kaplan-Meier estimates of failure (defined as conversion to THA) were performed. Bivariate analysis and Cox regression were used to identify factors associated with inferior clinical and radiographic outcomes.

RESULTS

A total of 957 patients (650 female, 307 male; 1114 hips) (mean age, 28.03 ± 8.9 years [range, 6.5-41.0 years]) with FAI were included. A total of 132 hips underwent hip arthroscopy and 982 hips were nonoperatively treated. The mean follow-up was 12.5 ± 4.7 years (range, 5.0-23.4 years). At the final follow-up, the rate of OA progression was 26.5% in the operative group and 35.2% in the nonoperative cohort (P < .01). Conversion to THA was performed in 6.8% of the surgical patients and 10.5% of the initially nonsurgical patients (P = .19). Additionally, there was no significant difference in the risk of failure between the operatively and nonoperatively treated patients. Male sex, increased age at initial diagnosis, presence of cam morphology, and increased initial Tönnis grade were risk factors for failure (male sex: hazard ratio [HR], 2.3; P < .01; per year of increased age: HR, 1.1; P < .01; presence of cam: HR, 3.5; P < .01; per Tönnis grade: HR, 4.0; P < .01).

CONCLUSION

At a mean follow-up of nearly 13 years, 7% of patients of the surgical group experienced progression to THA, compared with 11% of the nonoperative control group. While most of the operative group showed little to no OA at final follow-up, moderate OA (Tönnis grade 2) was present in 12% of the cohort compared with 22% of nonsurgical patients. Increased age at diagnosis, male sex, presence of a cam morphology, and presence of initial arthritic joint changes were found to be risk factors for failure. The results of this study demonstrated evidence for a preventive effect of hip arthroscopy on the development and progression of OA in young patients with FAI at mid- to long-term follow-up.

The association between statistical shape modeling-defined hip morphology and features of early hip osteoarthritis in young adult football players: Data from the femoroacetabular impingement and hip osteoarthritis cohort (FORCe) study

Objective

To explore the relationship between radiographic hip shape and features of early hip osteoarthritis (OA) on magnetic resonance imaging (MRI) in young male and female football players without radiographic hip OA.

Design

We used baseline data from a cohort of symptomatic and asymptomatic football players aged 18-50 years. Hip shape was assessed on anteroposterior radiographs with statistical shape modeling (SSM) for men and women separately. Cartilage defects and labral tears were graded using the Scoring Hip Osteoarthritis with MRI (SHOMRI) system. We used logistic regression with generalized estimating equations to estimate associations between each hip shape variant, called shape modes, and cartilage defects or labral tears.

Results

We included 229 participants (446 hips, 77.4% male). For each sex, 15 shape modes were analyzed. In men, three shape modes were associated with cartilage defects: adjusted odds ratios (aOR) 0.75 (95%CI 0.58-0.97) per standard deviation (SD) for mode 1; 1.34 (95%CI 1.05-1.69) per SD for mode 12; and 0.61 (95%CI 0.48-0.78) per SD for mode 15; and one also with labral tears: aOR 1.30 (95%CI 1.01-1.69) per SD for mode 12. These modes generally represented variations in the femoral neck and subtypes of cam morphology, with and without pincer morphology. For women, there was no evidence for associations with the outcomes.

Conclusions

Several hip shape variants were associated with cartilage defects on MRI in young male football players. Specifically, one subtype of cam morphology was associated with both cartilage defects and labral tears. Hip shape was not associated with early OA features in women.

Extent of Cam Resection Relative to Epiphyseal Line and Its Association With Clinical Outcomes After Arthroscopic Treatment for Femoroacetabular Syndrome

Background:

Inadequate resection of cam lesions can cause inferior outcomes after hip arthroscopy and result in revision surgery for femoroacetabular impingement syndrome (FAIS).

Purpose:

To evaluate the association between postoperative cam lesions measured using the proximal boundaries of resection area (PBRE) relative to the epiphyseal line and 2-year outcomes after hip arthroscopy.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Included were patients with FAIS who had undergone primary hip arthroscopy between 2016 and 2018. The PBRE was calculated by measuring the linear distance from the PBRE to the epiphyseal line, dividing it by the diameter of the femoral head, and multiplying by 100; PBRE measurements were made at the 12-, 1-, and 2-o’clock positions on postoperative hip computed tomography. Within each clockface position, patients were divided into subgroups depending on whether their postoperative PBRE was greater than a half standard deviation above the mean (adequate resection) or less than or equal to a half standard deviation above the mean (inadequate resection). Patient-reported outcomes (PROs; Hip Outcome Score–Activities of Daily Living [HOS-ADL], International Hip Outcome Tool–Short Form [iHOT-12], modified Harris Hip Score [mHHS], and pain visual analog scale [VAS]) and rates of achieving the minimal clinically important difference (MCID) and patient-acceptable symptomatic state (PASS) were compared among the subgroups.

Results:

Included were 80 pairs of hips at 12 o’clock, 81 pairs of hips at 1 o’clock, and 80 pairs of hips at 2 o’clock. All subgroups demonstrated significant improvements in PRO scores at a minimum 2-year follow-up compared with preoperatively. At the 12-o’clock position, the subgroup with adequate resection had significantly superior HOS-ADL ( P = .004), iHOT-12 ( P < .001), and mHHS ( P < .001) scores and were more likely to achieve the MCID for the iHOT-12 score ( P = .035) and the PASS for the HOS-ADL ( P = .003), iHOT-12 ( P = .007), and mHHS ( P < .001) scores compared with the matched subgroup. There were no significant differences in PRO scores or rates of MCID and PASS for the 1- or 2-o’clock groups.

Conclusion:

The epiphyseal line may be a useful and reproducible landmark measurement for cam-type deformity. Patients considered to have inadequate resection at 12 o’clock had lower outcome scores at a minimum 2-year follow-up.

External Validation of the FEAR Index in Borderline Acetabular Dysplasia

Background

Given the lack of established, externally validated criteria for the diagnosis of unstable hips, the Femoro-Epiphyseal Acetabular Roof (FEAR) index has been proposed as a useful tool for identifying hips with instability in the setting of borderline acetabular dysplasia.

Purposes

To (1) determine the external performance of the FEAR index in identifying hips with a clinical diagnosis of instability in the setting of borderline dysplasia and (2) assess the performance of the FEAR index compared with acetabular inclination or physeal scar angle alone.

Study Design

Cohort study (diagnosis); Level of evidence, 3.

Methods

The authors reviewed 176 patients with borderline acetabular dysplasia (lateral center-edge angle, 20°-25°). A positive FEAR index was defined as ≥5°. An alternative threshold ≥2° was also assessed. Significant instability was determined by the senior surgeon based on the combination of patient and radiographic features; unstable hips were treated with periacetabular osteotomy (with or without hip arthroscopy), and stable hips were treated with isolated hip arthroscopy.

Results

Only 18% of borderline hips had a positive FEAR index. The ≥5° positive FEAR index threshold had a sensitivity of 33% (23/70) and specificity of 92% (98/106) in predicting the clinical diagnosis of instability. The ≥2° FEAR index threshold had a sensitivity of 39% (27/70) and specificity of 89% (94/106) in predicting the clinical diagnosis of instability. No alternative threshold for the FEAR index resulted in high levels of sensitivity and specificity. A threshold of -5° was required to reach an adequate sensitivity of 74%. The FEAR index remained a significant predictor of hip instability even after controlling for acetabular inclination (odds ratio, 1.12; P < .001) or physeal scar angle (odds ratio, 1.6; P < .001).

Conclusion

In the current study, a positive FEAR index was generally indicative of the presence of clinical instability, but the FEAR index alone remained inadequate to fully define the instability of a given hip, as it demonstrated low sensitivity (only 33%) in the external validation. The FEAR index is best used in the context of other clinical and radiographic features.

Does the Type of Sport Influence Morphology of the Hip? A Systematic Review

BACKGROUND

Femoroacetabular impingement (FAI) has been extensively investigated and is strongly associated with athletic participation.

PURPOSE

To assess (1) the prevalence of cam-type FAI across various sports; (2) whether kinematic variation among sports influences hip morphology; and (3) whether performance level, duration, and frequency of participation or other factors influence hip morphology in a sporting population.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic search of Embase, PubMed, and the Cochrane Library was undertaken following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Prospective and retrospective case series, case reports, and review articles published after 1999 were screened, and those that met the inclusion criteria decided a priori were included for analysis.

RESULTS

The literature search identified 58 relevant articles involving 5683 participants. A total of 49 articles described a higher prevalence of FAI across various "hip-heavy" sports, including soccer, basketball, baseball, ice hockey, skiing, golf, and ballet. In studies including nonathlete controls, a greater prevalence of FAI was reported in 66.7% of studies (n = 8/12). The highest alpha angle was identified at the 1-o'clock position (n = 9/9) in football, skiing, golf, ice hockey, and basketball. The maximum alpha angle was located in a more lateral position in goalkeepers versus positional players in ice hockey (1 vs 1:45 o'clock). A positive correlation was also identified between the alpha angle and both age and activity level (n = 5/8 and n = 2/3, respectively) and between prevalence of FAI and both age and activity level (n = 2/2 and n = 4/5).

CONCLUSION

Hip-heavy sports show an increased prevalence of FAI, with specific sporting activities influencing hip morphology. There is some evidence to suggest that a longer duration and higher level of training also result in an increased prevalence of FAI.

REGISTRATION

CRD4202018001 (PROSPERO).

Incidence of Symptomatic Femoroacetabular Impingement: A 4-Year Study at a National Collegiate Athletic Association Division I Institution

Background:

Femoroacetabular impingement (FAI) is an increasingly recognized cause of hip pain in young athletes. Although there are multiple studies that describe the radiographic prevalence of FAI in athletes, its true incidence within this population is unknown.

Purpose:

To report on the overall and sport-specific incidence of symptomatic FAI in National Collegiate Athletic Association (NCAA) Division I athletes. Return-to-sport times were reported for patients treated operatively.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

A retrospective review was conducted to identify all reported hip injuries within a large, multisport NCAA Division I institution. Hip injuries were stratified into FAI, general pain/dysfunction, musculotendinous, ligament, bursitis, bone stress, contusion, and other. FAI was diagnosed based on history, physical examinations, imaging, and symptomatic relief after a diagnostic injection. Descriptive statistics were used to calculate the overall and sport-specific incidence, and chi-square analysis was performed to identify contingency data.

Results:

In a 3-year period, a total of 5319 musculoskeletal injuries occurred in 1072 athletes. There were 491 (9.2%) hip injuries that occurred in 288 athletes, of which 40 injuries were FAI. The overall incidence of symptomatic FAI was 3.0% of the total population, 3.7% of all injured athletes, and 13.9% of athletic hip injuries. There were no statistically significant differences in FAI rates among male and female athletes overall or among male and female athletes within similar sports. Of the 19 athletes who were treated nonoperatively, 2 failed to return to play: 1 secondary to multiple musculoskeletal injuries and 1 related to cardiac issues. There were 21 hips in 20 patients that were treated operatively, with 1 athlete failing to return to sport. Return to play occurred at a mean of 202 days (range, 81-360 days) after hip arthroscopic surgery.

Conclusion:

In this large, multisport NCAA Division I cohort, the overall incidence of symptomatic FAI was 3.0% and represented 13.9% of hip injuries. The successful management of FAI with return to play was achieved by both nonoperative and operative treatment methods. The relatively low incidence of symptomatic FAI, despite reports of a high prevalence of FAI morphology in athletes, serves to emphasize the importance of clinical evaluations in treating patients with FAI.

Predictors of Achieving the Patient Acceptable Symptomatic State at Minimum 5-Year Follow-up Following Primary Hip Arthroscopy in the Adolescent Athlete

BACKGROUND

Predictors of outcomes in adolescent athletes undergoing hip arthroscopy have not been established. The purpose of this study was to identify factors correlated with achieving the Patient Acceptable Symptomatic State (PASS) for the Hip Outcome Score-Sports Specific Subscale (HOS-SSS) at a minimum 5-year follow-up in adolescent athletes undergoing primary hip arthroscopy.

METHODS

Data were reviewed on adolescent (below 18 y old) athletes who underwent primary hip arthroscopy for femoroacetabular impingement syndrome between March 2008 and October 2015. Patients were included if they participated in sport within 1 year before surgery and had preoperative, 2-year, and minimum 5-year postoperative patient-reported outcome (PRO) scores for the modified Harris Hip Score, HOS-SSS, Visual Analog Scale for pain (VAS), and Non-Arthritic Hip Score (NAHS). Patients were divided into 2 groups based on whether they achieved PASS for HOS-SSS. Demographics, intraoperative findings, radiographic variables, surgical treatments, and PRO were compared. Multivariate logistic regression with corresponding odds ratios (ORs) quantified the correlation between variables and achievement of the PASS.

RESULTS

A total of 123 athletes with a mean age of 16.2±1.1 years were included. These athletes demonstrated significant imrpovement from preoperative to minimum 5-year follow-up for all recorded PROs (P<0.001). The multivariate logistic regression model identified preoperative NAHS (P=0.019, OR: 1.033), 2-year postoperative HOS-SSS (P=0.014, OR: 1.037), and 2-year postoperative VAS (P=0.003, OR: 0.590) as statistically significantly correlated with achieving the PASS. Athletes with a 2-year postoperative VAS pain score ≤2 achieved PASS at a rate of 81.9%, while those with a score >2 achieved PASS at a rate of 24.1% (P<0.001, OR: 14.2, 95% confidence interval: 5.23-38.7).

CONCLUSIONS

Favorable outcome were achieved at mid-term follow-up in adolescent athletes undergoing primary hip arthroscopy. Preoperative NAHS, 2-year postoperative HOS-SSS, and 2-year postoperative VAS pain scores were correlated with achieving the PASS for HOS-SSS at a minimum 5-year follow-up. Patients with 2-year postoperative VAS ≤2 were significantly more likely to achieve the PASS at 5-year follow-up than those with scores >2.

LEVEL OF EVIDENCE

Level III-case-control study.

[Femoroacetabular impingement syndrome in adolescents-How to adivse? How to treat?]

Hintergrund

Das Femoroazetabuläre Impingement-Syndrom (FAIS) ist eine relevante Ursache für Leistenschmerzen beim Jugendlichen. Insbesondere sind Sportler betroffen.

Ziel der Arbeit

Die Arbeit soll einen evidenzbasierten Hintergrund für Beratung und Therapie des FAIS beim Adoleszenten bieten.

Material und Methoden

Anhand der aktuellen Literatur wurde eine Übersicht zu Prävalenz und Pathogenese, Abklärung und Diagnostik sowie therapeutischen Empfehlung des FAIS beim Adoleszenten erarbeitet.

Ergebnisse und Diskussion

Das FAIS beim Jugendlichen betrifft vor allem sportlich aktive Patienten. Bestimmte Sportarten begünstigen die Entstehung eines FAIS. Cam-Impingement, Pincer-Impingement und kombiniertes FAIS sind die häufigsten Entitäten in dieser Altersgruppe. Die Cam-Morphologie entsteht kurz vor Schluss der proximalen Femurwachstumsfuge. Beim Cam-Impingement muss die Epiphyseolysis capitis femoris (ECF) von der primären Cam-Morphologie unterschieden werden. Die ECF verlangt eine rasche operative Versorgung mit Stabilisierung der Epiphyse, während das primäre Cam-Impingement elektiv abgeklärt werden kann und ein konservativer Behandlungsversuch sinnvoll ist. Schäden an Labrum und Knorpel werden regelhaft beobachtet. Eine systematische radiologische Abklärung mittels Projektionsröntgen und MRT ist obligat, um einen adäquaten Therapieplan zu entwickeln. Bei jugendlichen Patienten mit FAIS sollte immer ein konservativer Therapieversuch erfolgen. Ist dieser nicht erfolgreich, ist die operative Sanierung mit Hüftarthroskopie indiziert. Die postoperativen Ergebnisse zeigen bei Jugendlichen sehr gute Erfolge mit rascher Besserung der Beschwerden, geringen Komplikationen und einer hohen „Return-to-sport“-Rate.

Prevalence of Borderline Acetabular Dysplasia in Symptomatic and Asymptomatic Populations: A Systematic Review and Meta-analysis

Background:

Patients with borderline acetabular dysplasia are a controversial patient population in hip preservation, as some have primarily impingement-based symptoms and others have instability-based symptoms. Borderline dysplasia is most commonly defined as a lateral center-edge angle (LCEA) of 20° to 25°. However, its prevalence has not been well established in the literature.

Purpose:

To (1) define the prevalence of borderline hip dysplasia in the general population as well as in populations presenting with hip pain using a systematic review and meta-analysis of the literature and (2) describe differences between male and female patients as well as differences in prevalence from that of classic acetabular dysplasia.

Study Design:

Systematic review; Level of evidence, 3.

Methods:

A systematic review of the literature was performed using search terms to capture borderline dysplasia, or studies reporting prevalence by LCEA. The search yielded 1932 results, of which 11 articles met inclusion criteria and were included in the final systematic review. Studies were grouped by patient cohort as (1) asymptomatic general population, (2) asymptomatic targeted population (eg, athletes in a specific sport), and (3) symptomatic hip pain population. The reporting of prevalence rates by subject or by hip was recorded. In a study, the rates of borderline dysplasia were compared with those of classic acetabular dysplasia (LCEA, <20°).

Results:

The 11 studies included 19,648 hips (11,754 patients). In the asymptomatic general population, the pooled estimate of the prevalence of borderline dysplasia was 19.8% by subject and 23.3% by hip (range, 16.7%-46.0%). The targeted subpopulation group included 236 athletes with subgroups in ballet, football, hockey, volleyball, soccer, and track and field with prevalence ranging from 17.8% to 51.1%. The prevalence of borderline dysplasia in groups presenting with hip pain was 12.8% (range, 12.6%-16.0%). Borderline acetabular dysplasia was 3.5 times more common than classic acetabular dysplasia in the asymptomatic general population.

Conclusion:

This study demonstrated a prevalence of borderline dysplasia of 19.8% to 23.3% in the asymptomatic general population. Additionally, an estimated prevalence of 12.8% of hips in symptomatic patients highlights the common decision-making challenges in this population.

Female Athlete Hip Injuries: A Narrative Review

OBJECTIVE

In this narrative review, we highlight sex-specific anatomic and biomechanical features of the hip region in female athletes, as well as the potential impact of these characteristics on observed disparities in both intra-articular and extra-articular injury patterns between female and male athletes. It is our goal to broaden the scope of knowledge related to hip pathology in active female athletes among sports medicine providers with the hope of better optimizing sport participation and performance in female athletes.

DATA SOURCES

A literature review was conducted using PubMed database and Google Scholar search engine. Search terms included sport, female, athlete, sex differences, injury, hip, and all diagnoses discussed in this review. Cross-reference of these articles identified additional resources.

MAIN RESULTS

Sex-specific differences in both static design and dynamic function contribute to disparities in hip injury patterns between female and male athletes. Intra-articular injuries, including labral and ligamentum teres pathology, as well as extra-articular injuries, including iliopsoas tendon dysfunction, gluteal and proximal hamstring tendinopathy, ischiofemoral impingement, bone stress injuries, and certain nerve entrapment syndromes, seem to affect female athletes more commonly than male counterparts.

CONCLUSIONS

Given unique anatomic and functional considerations, the growing population of female athletes worldwide warrants specialized care and consideration. Potential predisposition to specific hip injuries should be taken into consideration during diagnostic evaluation of hip pain in the female athlete.

Activity Level and Sport Type in Adolescents Correlate with the Development of Cam Morphology

The purpose of this study was to evaluate the influence of the volume and type of sport on the development of cam-type femoroacetabular impingement and acetabular dysplasia.

Return to Sports and Minimum 2-Year Outcomes of Bilateral Hip Arthroscopy in High-Level Athletes With a Propensity-Matched Benchmarking Against a Unilateral Control Group

BACKGROUND

Return to sports (RTS) and patient-reported outcomes (PROs) for high-level athletes after bilateral hip arthroscopy have not been well established.

PURPOSE

(1) To report minimum 2-year PROs and RTS rates in high-level athletes who underwent staged bilateral primary hip arthroscopies and (2) to compare clinical results against a propensity-matched control group of high-level athletes who underwent unilateral primary hip arthroscopy.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data were prospectively collected and retrospectively reviewed for high-level athletes (professional, college, or high school) who underwent staged bilateral hip arthroscopy for femoroacetabular impingement syndrome between September 2009 and October 2018. Inclusion criteria were preoperative and minimum 2-year follow-up for modified Harris Hip Score, Non-arthritic Hip Score, Hip Outcome Score-Sports Specific Subscale (HOS-SSS), and visual analog scale for pain. Exclusion criteria were Tönnis grade >1, hip dysplasia (lateral center-edge angle <18°), and previous ipsilateral hip surgery/conditions. Rates of achieving the minimal clinically important difference (MCID), patient acceptable symptomatic state (PASS), and maximum outcome improvement satisfaction threshold were recorded in addition to RTS. These athletes were then propensity matched in a 1:3 ratio to high-level athletes who underwent unilateral arthroscopy for comparison. Outcomes were compared among the first hip of the study group, the second hip of the study group, and the control group.

RESULTS

A total of 74 high-level athletes who underwent bilateral hip arthroscopy met the inclusion criteria, and follow-up was available for 68 (91.9%) at 58.9 ± 24.5 months (mean ± SD). Athletes undergoing bilateral hip arthroscopy returned to sports at a high rate (81.7%), demonstrated significant improvements in all recorded PROs, and achieved the MCID and PASS for the HOS-SSS at rates of 80.9% and 64.7%, respectively. PROs, RTS rate, and rates of achieving the MCID and PASS for the HOS-SSS were similar when the bilateral study group was compared with the unilateral control group (P > .05).

CONCLUSION

High-level athletes who undergo staged bilateral primary hip arthroscopy for femoroacetabular impingement syndrome may expect favorable PROs and RTS rates at minimum 2-year follow-up. These results were comparable with those of a propensity-matched control group of high-level athletes who underwent unilateral primary hip arthroscopy.

No Association Between Intrauterine Contraceptive Devices and Musculoskeletal Hip Joint Pain

Purpose

To investigate the association between intrauterine device (IUD) use and hip pain, orthopaedic visits for hip pain, and arthroscopic hip surgery.

Methods

This was a retrospective cohort study of patients aged 18-44 years old using either IUDs or subdermal implants for contraception in a large commercial claims database (MarketScan) from 2012 to 2015. All patients had at least 12 months of continuous enrollment both before and after contraceptive placement. Patients with a history of hip pain or surgery were excluded. The primary outcome was new hip pain. Secondary outcomes included visiting an orthopaedic or sports medicine provider for a hip complaint, intra-articular hip injection, and arthroscopic hip surgery. Outcomes were analyzed with Cox proportional-hazard models.

Results

We identified a total of 242,383 patients, including 216,541 (89.3%) with IUDs and 25,842 (10.7%) with subdermal contraceptive implants. In time-to-event analysis, IUDs (vs implants) were not associated with increased risk of new hip pain diagnoses (hazard ratio [HR] 0.95, 95% confidence interval [CI] 0.87-1.03, P = .21). In contrast, both age (P < .001) and region (P < .001) were associated with increased risk of new hip pain. Similar results were seen for the secondary outcomes, including risk of orthopaedic visits for hip complaints (HR 1.06, 95% CI 0.83-1.35, P = .63), intra-articular injections of the hip (HR 0.94, 95% CI 0.63-1.41, P = .77), and hip arthroscopy procedures (HR 1.13, 95% CI 0.53-2.40, P = .75).

Conclusions

In this study, we found no evidence that IUDs were associated with hip pain or surgery.

Level of Evidence

Level III, retrospective cohort.

Patient-Reported Outcome Scores and Rate of Return to Sport After Hip Arthroscopic Surgery: A Sex-Based Comparison in Professional and Collegiate Athletes

BACKGROUND

No studies have compared outcomes and return to sport (RTS) after hip arthroscopic surgery between matched groups of male and female athletes with a minimum 2-year follow-up.

PURPOSE

(1) To report minimum 2-year postoperative patient-reported outcome (PRO) scores and the RTS rate for elite female athletes undergoing hip arthroscopic surgery for femoroacetabular impingement (FAI) and (2) to compare clinical results with a matched control group of elite male athletes.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data on all consecutive female athletes who underwent primary hip arthroscopic surgery performed at our institution between March 2009 and July 2018 were collected. Patients were eligible if they underwent hip arthroscopic surgery for labral tears or FAI and participated in collegiate or professional athletics within 1 year of surgery. Minimum 2-year postoperative PRO scores were collected for the modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), Hip Outcome Score-Sport-Specific Subscale (HOS-SSS), and visual analog scale (VAS) for pain as well as RTS status. The percentages of patients achieving the minimal clinically important difference (MCID) and patient acceptable symptomatic state were recorded. These patients were matched to elite male athletes for comparison.

RESULTS

A total of 73 female hips were included, with a mean follow-up of 65.1 ± 27.9 months. They demonstrated a significant improvement from preoperatively to latest follow-up on the mHHS, NAHS, HOS-SSS, and VAS (P < .05). When outcomes were compared with a control group of male athletes, female athletes demonstrated lower preoperative scores, similar postoperative scores, and a significantly greater magnitude of improvement (delta value) on the mHHS, NAHS, and VAS. Female athletes also achieved the MCID at higher rates than did male athletes for the HOS-SSS (85.1% vs 70.0%, respectively; P = .035) and NAHS (79.1% vs 62.9%, respectively; P = .037). RTS rates among patients who attempted were similar between the 2 groups (female: 75.4%; male: 83.1%; P = .409).

CONCLUSION

Elite female athletes undergoing primary hip arthroscopic surgery for FAI demonstrated a significant improvement in PRO scores and a high RTS rate. Female athletes exhibited a greater improvement in PRO scores (mHHS, NAHS, VAS) and achieved the MCID (HOS-SSS, NAHS) at higher rates compared with a control group of male athletes.

The association of lumbosacral transitional vertebral anomalies with acetabular dysplasia in adult patients with hip-spine syndrome : a cross-sectional evaluation of a prospective hip registry cohort

AIMS

Some patients presenting with hip pain and instability and underlying acetabular dysplasia (AD) do not experience resolution of symptoms after surgical management. Hip-spine syndrome is a possible underlying cause. We hypothesized that there is a higher frequency of radiological spine anomalies in patients with AD. We also assessed the relationship between radiological severity of AD and frequency of spine anomalies.

METHODS

In a retrospective analysis of registry data, 122 hips in 122 patients who presented with hip pain and and a final diagnosis of AD were studied. Two observers analyzed hip and spine variables using standard radiographs to assess AD. The frequency of lumbosacral transitional vertebra (LSTV), along with associated Castellvi grade, pars interarticularis defect, and spinal morphological measurements were recorded and correlated with radiological severity of AD.

RESULTS

Out of 122 patients, 110 (90.2%) were female and 12 (9.8%) were male. We analyzed the radiographs of 122 hips (59 (48.4%) symptomatic left hips, and 63 (51.6%) symptomatic right hips). Average age at time of presentation was 34.2 years (SD 11.2). Frequency of LSTV was high (39% to 43%), compared to historic records from the general population, with Castellvi type 3b being the most common (60% to 63%). Patients with AD have increased L4 and L5 interpedicular distance compared to published values. Frequency of pars interarticularis defect was 4%. Intraclass correlation coefficient for hip and spine variables assessed ranged from good (0.60 to 0.75) to excellent (0.75 to 1.00). Severity of AD did not demonstrate significant correlation with frequency of radiological spine anomalies.

CONCLUSION

Patients with AD have increased frequency of spinal anomalies seen on standard hip radiographs. However, there exists no correlation between radiological severity of AD and frequency of spine anomalies. In managing AD patients, clinicians should also assess spinal anomalies that are easily found on standard hip radiographs. Cite this article: Bone Joint J 2021;103-B(8):1351-1357.

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

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

Hip and Groin Pain in Soccer Players

Purpose  The aim of this article is to illustrate the recent framework necessary to standardize studies on groin pain and review the existing literature on groin pain in football. Methods  The common pathological processes underlying groin pain such as muscle, tendon or ligament strain, bone injury or fracture, sport hernia, bursitis, osteitis pubis, and hip-related diseases have been reviewed and current management options have been considered. Results  Groin pain is considered a pain in pubic or lower abdominal or adductors region which can be monolateral or bilateral. It is common in high-intensity team sports and can negatively affect an athlete's professional carrier, causing serious disruption in the performance. Despite a high prevalence of groin pain in athletes, diagnosis and management of the underlying pathological processes remain a challenge for surgeons, radiologists, and physiotherapists alike. Conclusion  A multidisciplinary approach is essential for patients with groin pain allowing prompt diagnosis and initiation of treatment thus facilitating more rapid return to play and preventing potential long-term sequelae of chronic groin pathology.

Decision-making in the Borderline Hip

Borderline acetabular dysplasia represents a "transitional acetabular coverage" pattern between more classic acetabular dysplasia and normal acetabular coverage. Borderline dysplasia is typically defined as a lateral center-edge angle of 20 to 25 degrees. This definition of borderline dysplasia identifies a relatively narrow range of lateral acetabular coverage patterns, but anterior and posterior coverage patterns are highly variable and require careful assessment radiographically, in addition to other patient factors. Treatment decisions between isolated hip arthroscopy (addressing labral pathology, femoroacetabular impingement bony morphology, and capsular laxity) and periacetabular osteotomy (improving osseous joint stability; often combined with hip arthroscopy) remain challenging because the fundamental mechanical diagnosis (instability vs. femoroacetabular impingement) can be difficult to determine clinically. Treatment with either isolated hip arthroscopy or periacetabular osteotomy (with or without arthroscopy) appears to result in improvements in patient-reported outcomes in many patients, but with up to 40% with suboptimal outcomes. A patient-specific approach to decision-making that includes a comprehensive patient and imaging evaluation is likely required to achieve optimal outcomes.

The Size and Prevalence of Bony Hip Morphology Do Not Differ Between Football Players With and Without Hip and/or Groin Pain: Findings From the FORCe Cohort

OBJECTIVE

To compare the size and prevalence of bony hip morphology in football players with and without hip and/or groin pain.

DESIGN

Case-control.

METHODS

We recruited 184 soccer and Australian football players with self-reported hip and/or groin pain of greater than 6 months in duration and a positive flexion, adduction, and internal rotation (FADIR) test (290 hips, 21% women), and 55 football players with no pain and a negative FADIR test (110 hips, 26% women) as a control group. Bony hip morphology was identified by the alpha angle and lateral center-edge angle (LCEA) on anteroposterior pelvis and Dunn 45° radiographs. The alpha angle and LCEA were analyzed as continuous measures (size) and dichotomized using threshold values to determine the presence of bony hip morphology (cam, large cam, pincer, and acetabular dysplasia). Regression analyses estimated differences in the size and prevalence of bony hip morphology between football players with and without pain.

RESULTS

In all football players and in men, the size and prevalence of bony hip morphology did not differ between those with and without hip and/or groin pain. Cam morphology was evident in 63% of hips in players without pain and 71% of symptomatic hips in players with hip and/or groin pain. In female football players with hip and/or groin pain compared to those without pain, larger alpha angle values were observed on the Dunn 45° view (5.9°; 95% confidence interval: 1.2°, 10.6°; P = .014).

CONCLUSION

The size and prevalence of bony hip morphology appear to be similar in football players with and without hip and/or groin pain. J Orthop Sports Phys Ther 2021;51(3):115-125. Epub 25 Dec 2020. doi:10.2519/jospt.2021.9622.

Incidence of Femoroacetabular Impingement and Surgical Management Trends Over Time

BACKGROUND

Femoroacetabular impingement (FAI) is a well-known cause of hip pain in adolescents and young adults. However, the incidence in the general population has not been clearly defined.

PURPOSE

To (1) define the population-based incidence of diagnosis of FAI in patients with hip pain, (2) report the trends in diagnosis of FAI over time, and (3) determine the changes in the rate and type of surgical management over time.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A geographic database was used to identify patients who were 14 to 50 years old with hip pain between the years 2000 and 2016. Chart and radiographic review was performed to determine which patients had FAI. To be included, patients had to have a triad of clinical symptoms, physical examination signs, and imaging findings consistent with FAI. Medical records were reviewed to obtain demographic information, clinical history, physical examination findings, imaging details, and treatment details. Statistical analysis determined the overall age- and sex-adjusted annual incidence of FAI diagnosis and trends over time.

RESULTS

There were 1893 patients evaluated with hip pain, and 716 (38%; 813 hips) had diagnosed FAI. The mean ± SD age was 27.2 ± 8.4 years, and 67% were female. The incidence of FAI diagnosis was 54.4 per 100,000 person-years. Female patients had a higher incidence than male patients (73.2 vs 36.1 per 100,000 person-years; P < .01). Incidence of FAI diagnosis were higher from 2010 to 2016 (72.6 per 100,000 person-years; P < .01) as compared with 2005 to 2009 (45.3) and 2000 to 2004 (40.3). Hip arthroscopy, surgical hip dislocation, and periacetabular osteotomy utilization increased from the 2000-2004 to 2010-2016 periods, respectively: 1 (1%) to 160 (20%; P = .04), 2 (1%) to 37 (5%; P = .01), and 1 (1%) to 22 (3%; P = .58).

CONCLUSION

The overall incidence of FAI diagnosis was 54.4 per 100,000 person-years, and it consistently increased between 2000 and 2016. Female patients had a higher incidence than male patients. The utilization of joint preservation operations, including hip arthroscopy, surgical hip dislocation, and anteverting periacetabular osteotomy, increased over time.

A Comparative Cohort Study With a 20-Year Age Gap: Hip Resurfacing in Patients Aged ≤35 Years and Patients Aged ≥55 Years

Background

This single-center retrospective cohort study aimed to evaluate and compare implant survival and patient-reported outcome measures in 2 distinct age groups separated by 20 years who underwent hip resurfacing arthroplasty (HRA).

Methods

Between 2005 and 2014, 2042 HRAs were performed by a single-surgeon, and 75 and 377 hips from patients aged ≤35 years and ≥55 years, respectively, were included in this study. Implant survival was determined for all available hips. Clinical features and patient-reported outcome measures were collected.

Results

Seven hips were revised, 4 for aseptic loosening of one or both components, one for infection, one for accelerated wear and metallosis, and one for femoral neck fracture. There was no difference in all-cause 10-year revision, with 97.1% (95% confidence interval 80.9 to 99.6) and 99.6% (95% confidence interval: 97 to 99.9) survivorship in younger and older patients, respectively (P = .246). Preoperatively, younger patients were less active than older patients on the Lower Extremity Activity Scale (LEAS) or University of California, Los Angeles, activity scale, but at follow-up, younger patients outpaced older ones.

Conclusion

Original to our study was the isolation and comparison of 2 distinct age groups. With excellent results in disparate age groups, HRA can be applied to a broad patient demographic and is suitable for those patients who want to achieve a high activity level as defined by Lower Extremity Activity Scale or University of California, Los Angeles, scores.

Classifying Cam Morphology by the Alpha Angle: A Systematic Review on Threshold Values

Background

The alpha angle is the most often used measure to classify cam morphology. There is currently no agreement on which alpha angle threshold value to use.

Purpose

To systematically investigate the different alpha angle threshold values used for defining cam morphology in studies aiming to identify this threshold and to determine whether data are consistent enough to suggest an alpha angle threshold to classify cam morphology.

Study Design

Systematic review; Level of evidence, 3.

Methods

The Embase, Medline (Ovid), Web of Science, Cochrane Central, and Google Scholar databases were searched from database inception to February 28, 2019. Studies aiming at identifying an alpha angle threshold to classify cam morphology were eligible for inclusion.

Results

We included 4 case-control studies, 10 cohort studies, and 1 finite-element study from 2437 identified publications. Studies (n = 3) using receiver operating characteristic (ROC) curve analysis to distinguish asymptomatic people from patients with femoroacetabular impingement syndrome consistently observed alpha angle thresholds between 57° and 60°. A 60° threshold was also found to best discriminate between hips with and without cam morphology in a large cohort study based on a bimodal distribution of the alpha angle. Studies (n = 8) using the upper limit of the 95% reference interval as threshold proposed a wide overall threshold range between 58° and 93°. When stratified by sex, thresholds between 63° and 93° in male patients and between 58° and 94° in female patients were reported.

Conclusion

Based on the available evidence, mostly based on studies using ROC curve analysis, an alpha angle threshold of ≥60° is currently the most appropriate to classify cam morphology. Further research is required to fully validate this threshold.

Return to Sport After Femoroacetabular Impingement Surgery and Sport-Specific Considerations: a Comprehensive Review

PURPOSE OF REVIEW

Recent advancements in surgical technology and techniques have improved functional results for operative treatment of femoroacetabular impingement syndrome (FAIS). Few studies have comprehensively evaluated the literature regarding return to sport criteria, timing, level, and rates. The purpose of this study was to review recent studies regarding return to play after surgical correction of FAIS. We will specifically evaluate the level of return to play and look to compare pre- and postoperative competition levels when available. We will also analyze timing of return to play from injury to surgery. Additionally, we will elucidate any sport-specific criteria that may determine readiness for return.

RECENT FINDINGS

Athletes with FAIS treated non-operatively have a low rate of return to sport and are often functionally limited in their level of performance. Surgical management of FAIS includes hip arthroscopy as well as open techniques. Current literature suggests a high rate of return to sport after contemporary surgery for FAIS at 87-93% overall. Rate of return to the same level of competition following surgery for FAIS is 55-83% in pooled studies. Limited evidence is available comparing postoperative rehabilitation protocols and timing of return among different sports. Operative treatment of FAIS results in high rates of return to sport and functional performance. The results of this study may help educate patients preoperatively in regard to the likelihood of functional return to sport and sport-specific considerations. Further research evaluating rehabilitation protocols and return criteria may better elucidate timing intervals for patients to maximize function while limiting complications.

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

Background:

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

Purpose:

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

Study Design:

Case series; Level of evidence, 4.

Methods:

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

Results:

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

Conclusion:

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

Young elite Alpine and Mogul skiers have a higher prevalence of cam morphology than non-athletes

PURPOSE

To investigate the prevalence of cam morphology in (1) a group of young elite Mogul and Alpine skiers compared with non-athletes and (2) between the sexes.

METHOD

The hip joints of 87 subjects [n = 61 young elite skiers (29 females and 32 males) and n = 26 non-athletes (17 females and 9 males)] were examined using MRI, for measurements of the presence of cam morphology (α-angle ≥ 55).

RESULTS

The skiers had a significantly higher prevalence of cam morphology compared with the non-athletes (49% vs 19%, p = 0.009). A significant difference (p < 0.001) was also found between females and males, where 22% of the females and 61% of the males had cam morphology. Among the skiers, there was also a significant difference (p < 0.001) between the sexes, where 28% of the females and 68% of the males had cam morphology. This difference between the sexes was not found in the non-athletic group. No significant differences were found between Mogul and Alpine skiers.

CONCLUSION

Young male elite skiers have a higher prevalence of cam morphology of the hips compared with non-athletes.

LEVEL OF EVIDENCE

II.

[Footballer's hip]

Although complaints and injuries in the knee and ankle joints are very prevalent in football, the hip has so far been given very little attention. Complaints in this area are often attributed to pathological changes in the inguinal region. However, intraarticular differential diagnoses are often not taken into consideration. This article gives an overview of possible hip pathology in footballers, as well as its diagnosis and treatment.

Acetabular Version Increases During Adolescence Secondary to Reduced Anterior Femoral Head Coverage

BACKGROUND

Acetabular version influences joint mechanics and the risk of impingement. Cross-sectional studies have reported an increase in acetabular version during adolescence; however, to our knowledge no longitudinal study has assessed version or how the change in version occurs. Knowing this would be important because characterizing the normal developmental process of the acetabulum would allow for easier recognition of a morphologic abnormality.

QUESTIONS/PURPOSES

To determine (1) how acetabular version changes during adolescence, (2) calculate how acetabular coverage of the femoral head changed during this period, and (3) to identify whether demographic factors or hip ROM are associated with acetabular development.

METHODS

This retrospective analysis of data from a longitudinal study included 17 volunteers (34 hips) with a mean (± SD) age of 11 ± 2 years; seven were male and 10 were female. The participants underwent a clinical examination of BMI and ROM and MRIs of both hips at recruitment and at follow-up (6 ± 2 years). MR images were assessed to determine maturation of the triradiate cartilage complex, acetabular version, and degree of the anterior, posterior, and superior acetabular sector angles (reflecting degree of femoral head coverage provided by the acetabulum anteriorly, posteriorly and superiorly respectively). An orthopaedic fellow (GG) and a senior orthopaedic resident (PJ) performed all readings in consensus; 20 scans were re-analyzed for intraobserver reliability. Thereafter, a musculoskeletal radiologist (KR) repeated measurements in 10 scans to test interobserver reliability. The intra- and interobserver interclass correlation coefficients for absolute agreement were 0.85 (95% CI 0.76 to 0.91; p < 0.001) and 0.77 (95% CI 0.70 to 0.84), respectively. All volunteers underwent a clinical examination by a senior orthopaedic resident (PJ) to assess their range of internal rotation (in 90° of flexion) in the supine and prone positions using a goniometer. We tested investigated whether the change in anteversion and sector angles differed between genders and whether the changes were correlated with BMI or ROM using Pearson's coefficient. The triradiate cartilage complex was open (Grade I) at baseline and closed (Grade III) at follow-up in all hips.

RESULTS

The acetabular anteversion increased, moving caudally further away from the roof at both timepoints. The mean (range) anteversion angle increased from 7° ± 4° (0 to 18) at baseline to 12° ± 4° (5 to 22) at the follow-up examination (p < 0.001). The mean (range) anterior sector angle decreased from 72° ± 8° (57 to 87) at baseline to 65° ± 8° (50 to 81) at the final follow-up (p = 0.002). The mean (range) posterior (98° ± 5° [86 to 111] versus 97° ± 5° [89 to 109]; p = 0.8) and superior (121° ± 4° [114 to 129] to 124° ± 5° [111 to 134]; p = 0.07) sector angles remained unchanged. The change in the anterior sector angle correlated with the change in version (rho = 0.5; p = 0.02). The change in version was not associated with any of the tested patient factors (BMI, ROM).

CONCLUSIONS

With skeletal maturity, acetabular version increases, especially rostrally. This increase is associated with, and is likely a result of, a reduced anterior acetabular sector angle (that is, less coverage anteriorly, while the degree of coverage posteriorly remained the same). Thus, in patients were the normal developmental process is disturbed, a rim-trim might be an appropriate surgical solution, since the degree of posterior coverage is sufficient and no reorientation osteotomy would be necessary. However, further study on patients with retroversion (of various degrees) is necessary to characterize these observations further. The changes in version were not associated with any of the tested patient factors; however, further study with greater power is needed.

LEVEL OF EVIDENCE

Level II, prognostic study.

Prevalence of Femoroacetabular Impingement Syndrome among Young and Middle-aged White Adults

Objective.

The purpose of the study was to determine the prevalence of femoroacetabular impingement syndrome (FAIS) in white adults 20 to 49 years of age.

Methods.

Participants were white men and women aged 20–49 years, recruited through random digit dialing from the population of Metro Vancouver, British Columbia, Canada. Participants filled out a self-administered questionnaire and underwent a physical examination and radiographs of both hips. FAIS was defined as a combination of hip symptoms, physical signs of impingement, and radiological findings of cam or pincer morphology as recommended by the Warwick Agreement. All analyses were weighted to reflect the population from which the sample was drawn.

Results.

Data were obtained for 500 participants. In the study population, 48.9% were males and the age distribution was 32.2%, 31.4%, and 36.4% in the groups 20–29, 30–39, and 40–49 years, respectively. The physical signs of impingement correlated significantly with symptoms, but there was no significant association between either symptoms or physical examination with radiographic findings. FAIS on either side was found in 3.0% (95% CI 1.5–4.5) of the population.

Conclusion.

In this study, FAIS was present in 3% of whites aged 20–49 years. Further research is needed to develop consistent criteria for assessing hip symptoms, physical signs, and hip joint morphology, and to better understand the relationships between them.

Reported Prevalence of Radiographic Cam Deformity Based on Sport: A Systematic Review of the Current Literature

Background

Repetitive loading and shear stress across the proximal femur account for the high prevalence of cam deformity in athletes.

Purpose

To systematically review the literature to identify the reported number, age, mean alpha angle measurements, and differences between male and female athletes with radiographic cam deformity based on sport.

Study Design

Systematic review; Level of evidence, 4.

Methods

A systematic review was conducted of studies in the literature between January 1990 and March 2018 that reported on athletes with radiographic cam deformity based on sport. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed, and PubMed, Biosis Previews, SPORTDiscus, PEDro, and EMBASE databases were used. Inclusion criteria included studies documenting radiographic cam deformity based on alpha angle measurements categorized according to the athlete's primary sport and according to sex. Exclusion criteria were (1) studies not documenting primary sport, (2) studies not reporting total number of athletes with radiographic cam deformity, and (3) studies not separating cam deformity based on sex or using alpha angle measurements. Statistical analysis was used to compare mean reported age and alpha angle measurements between males and females.

Results

A total of 28 studies consisting of 1160 male and 53 female athletes with radiographic cam deformity were identified. Cam lesions were most commonly reported in soccer athletes among both males and females, followed by hockey and American football. Male athletes had significantly higher mean alpha angle measurements (59.9° ± 5.5°) compared with female athletes (48.3° ± 6.9°) (P = .001). No significant difference in age was appreciated between males (21.1 ± 4.0 years) and females (21.7 ± 3.0 years) (P = .62).

Conclusion

Radiographic cam deformity is most commonly reported in athletes participating in soccer and hockey. Males possessed significantly greater mean alpha angle measurements compared with females, whereas no significant difference in mean age at the time of diagnosis was appreciated between sexes.

Capital Femoral Epiphyseal Extension May Confer Physeal Stability in Slipped Capital Femoral Epiphysis

BACKGROUND

Factors including obesity and morphologic parameters around the hip that increase physeal stress are associated with an increased risk of slipped capital femoral epiphysis (SCFE). Recent evidence suggests that superior epiphyseal extension may confer stability to the physis and help protect against SCFE. The purpose of this study is to investigate the relationship between epiphyseal extension and SCFE using an age-matched and sex-matched cohort study.

METHODS

We generated 2 separate cohorts for comparison: 89 patients with unilateral SCFE and 89 healthy subjects with no evidence of hip disease or deformity. We utilized the anterior-posterior and lateral films of the hip to measure the Southwick angle and the epiphyseal extension ratio (EER), defined as the ratio of extension of the capital femoral epiphysis down the femoral neck relative to the diameter of the femoral head. We then compared these measurements between cohorts and in subgroup analysis based on slip stability and whether subjects progressed to a contralateral slip.

RESULTS

The SCFE cohort demonstrated a decreased superior epiphyseal extension ratio compared with control (superior EER 0.71 vs. 0.68, P=0.002). There was also a significant downward trend in superior EER from the control subjects (0.71±0.07) to the stable slips (0.69±0.06) to the unstable slips (0.65±0.04) with an overall difference between the groups (P=0.001). Eighteen of 44 (41%) subjects with unilateral stable slips and at least 6 months of follow-up went on to develop SCFE of the contralateral limb. The subjects who developed contralateral slips were younger (11.6±1.2 vs. 12.7±1.4 y, P=0.008); however, there was no difference in superior or anterior epiphyseal extension (P=0.75 and 0.23, respectively). There was no significant linear correlation between Southwick angle and superior or anterior EER (r=0.13 and 0.17, respectively, P>0.05 for both).

CONCLUSIONS

Increasing capital femoral epiphyseal extension may confer physeal stability in the setting of SCFE. We propose that this epiphyseal extension reflects an adaptive response to limit physeal stress and reduce the risk for progression to SCFE.

LEVEL OF EVIDENCE

Level III-prognostic study.

Prevalence of CAM deformity and its influence on therapy success in patients with osteonecrosis of the femoral head

Osteonecrosis of the femoral head (ONFH) and CAM-type femoroacetabular impingement (FAI) present two different pathologies of the hip joint. The aim of this study is to describe the prevalence of CAM-FAI in a collective of ONFH hips and to evaluate its influence on ONFH therapy outcome. A cohort of 86 ONFH hips with a mean follow-up of 46.7 months (±20.5) after advanced core decompression (ACD) was evaluated regarding CAM deformity by measuring the alpha angle (α) and head-neck offset. The influence of CAM-type FAI was investigated using the Kaplan-Meier estimator and the Cox regression model. The mean α was 60.4° (±13.8) with 41 hips (47.7%) being ≥60°. The mean head-neck offset was 4.5 mm (±3.2), with 78 hips (90.7%) being ≤9 mm. Survival analysis indicated noticeably better ACD results for α < 60° versus α ≥ 60° (p = 0.07). Treatment failure within the first 2 years was statistically estimated as 27.7% for α < 60° versus 40.7% for α ≥ 60°: The hazard ratio for α ≥ 60° was 1.94. Head-neck offset-dependent survival showed better, though not significant, results for offset >9 mm (p = 0.38, hazard ratio 1.89 for offsets ≤9 mm). The prevalence of CAM-type deformity is greatly increased in patients with concomitant ONFH. There is a strong indication that CAM-type FAI has a negative influence on ONFH therapy outcome. The risk that ONFH treatment will fail seems to be twice as high for α ≥ 60° as for α < 60°. We recommend cotreatment of pathological head-neck offset in patients with ONFH.

Preoperative Symptom Duration Is Associated With Outcomes After Hip Arthroscopy

BACKGROUND

Prolonged disease chronicity has been implicated as a cause of suboptimal clinical outcomes after hip arthroscopy for femoroacetabular impingement syndrome (FAIS), possibly due to disease progression, deconditioning, and the development of compensatory pathomechanics.

PURPOSE

To evaluate the effect of increasing duration of preoperative symptoms on patient-reported outcomes, reoperation, and clinical failure of hip arthroscopy for FAIS.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A retrospective cohort study was performed to identify all patients undergoing primary hip arthroscopy between January 1, 2012, and July 30, 2014, by a single surgeon, with minimum follow-up of 2 years. Patient demographics, comorbid medical conditions, and preoperative outcome scores were compared between patients with preoperative symptoms lasting less than 2 years and those with symptoms lasting 2 years or longer. Multivariate regressions were used to compare Hip Outcome Score Activities of Daily Living (HOS-ADL), Hip Outcome Score Sport-Specific (HOS-SS), and modified Harris Hip Score (mHHS) between the 2 cohorts at 2 years of follow-up.

RESULTS

A total of 624 patients were included, with an average age of 34.0 ± 13.5 years; 235 (37.7%) patients had experienced preoperative symptoms 2 years or longer. Patients with symptoms lasting less than 2 years had statistically significant higher outcome scores than those with symptoms lasting 2 or more years for the HOS-ADL (86.3 ± 16.4 vs 80.3 ± 19.9, respectively), HOS-SS (75.0 ± 25.3 vs 65.1 ± 29.0), and mHHS (79.1 ± 16.6 vs 74.0 ± 18.8), as well as higher satisfaction (82.1 ± 30.7 vs 71.1 ± 31.6) and lower pain scores (2.6 ± 2.3 vs 3.5 ± 2.6). On multivariate analysis, patients with symptoms 2 years or longer had significantly higher visual analog scale-Pain score (β = 0.6, P = .039) and lower HOS-ADL (β = -3.4, P = .033), HOS-SS (β = -6.3, P = .012), and satisfaction (β = -6.7, P = .028) at 2-year follow-up. Patients with longer duration of symptoms also demonstrated less improvement in HOS-SS (β = -10.3, P = .001) at 2 years after surgery. Patients with symptoms for 2 years or longer were significantly less likely to achieve a patient acceptable symptomatic state for HOS-ADL (relative risk [RR] = 0.8, P = .024) and HOS-SS (RR = 0.8, P = .032) at 2 years of follow-up. Patients with symptoms 2 years or longer also demonstrated significantly higher rates of revision arthroscopy (RR = 10.1, P = .046).

CONCLUSION

Patients with untreated, FAIS-related symptoms lasting 2 years or longer before arthroscopic management had significantly worse patient-reported outcomes and higher rates of reoperation at 2 years after surgery when compared with those patients with a shorter duration of preoperative symptoms.

Relationship Between Hip Morphology and Hip-Related Patient-Reported Outcomes in Young and Middle-Aged Individuals: A Population-Based Study

Objective

Radiographic measurements of the alpha angle and the lateral center edge (LCE) angle in the hip joint are important for the diagnosis of femoroacetabular syndrome, a potential risk factor for hip osteoarthritis. Our objective was to determine whether these measurements are associated with hip‐related patient‐reported outcomes in young and middle‐aged individuals.

Methods

A stratified random sample of white men and women ages 20–49 years, with and without hip pain, was selected using random digit dialing from the population of metro Vancouver, Canada. The alpha and LCE angles were measured bilaterally on radiographs using Dunn and anteroposterior views, respectively. Patient‐reported outcomes were measured by the Copenhagen Hip And Groin Outcome Score (HAGOS), which has scales for symptoms, pain, daily activities, sports, physical activity, and quality of life (QoL). We performed descriptive analyses and a regression analysis with restricted cubic splines, adjusted for age and sex and weighted for the sampling design.

Results

Data were obtained for 500 subjects. The alpha angle distribution was strongly skewed, with a mean of 54°. The LCE angle distribution was symmetric, with a mean of 34°. In the restricted cubic splines analysis, the relationship between the alpha angle and HAGOS scores was nonlinear, with higher alpha angles generally associated with worse HAGOS scores for alpha >60°. The associations were statistically significant for symptoms, sports, and QoL. No association was found between the LCE angle and HAGOS scales.

Conclusion

In a general population sample ages 20–49 years, we have found an association between the alpha angle and hip‐related patient‐reported outcomes.

Sex-based Differences in Common Sports Injuries

The patient's sex plays an important role in mediating the risk for, and experience of, disease. Injuries of the musculoskeletal system are no exception to this phenomenon. Increasing evidence shows that the incidence, clinical presentation, and treatment outcomes for male and female patients with common sports injuries may vary widely. Stress fracture, which is associated with the female athlete triad, is a sports injury with known sex-based differences. Other common sports-related injuries may also have distinct sex-based differences. Understanding these differences is important to optimize each patient's musculoskeletal care.