MR-guided focused ultrasound therapy of extra-abdominal desmoid tumors: a multicenter retrospective study of 105 patients

OBJECTIVE

To assess the safety and efficacy of magnetic resonance-guided focused ultrasound (MRgFUS) for the treatment extra-abdominal desmoids.

METHODS

A total of 105 patients with desmoid fibromatosis (79 females, 26 males; 35 ± 14 years) were treated with MRgFUS between 2011 and 2021 in three centers. Total and viable tumors were evaluated per patient at last follow-up after treatment. Response and progression-free survival (PFS) were assessed with (modified) response evaluation criteria in solid tumors (RECIST v.1.1 and mRECIST). Change in Numerical Rating Scale (NRS) pain and 36-item Short Form Health Survey (SF-36) scores were compared. Treatment-related adverse events were recorded.

RESULTS

The median initial tumor volume was 114 mL (IQR 314 mL). After MRgFUS, median total and viable tumor volume decreased to 51 mL (95% CI: 30-71 mL, n = 101, p < 0.0001) and 29 mL (95% CI: 17-57 mL, n = 88, p < 0.0001), respectively, at last follow-up (median: 15 months, 95% CI: 11-20 months). Based on total tumor measurements (RECIST), 86% (95% CI: 75-93%) had at least stable disease or better at last follow-up, but 50% (95% CI: 38-62%) of remaining viable nodules (mRECIST) progressed within the tumor. Median PFS was reached at 17 and 13 months for total and viable tumors, respectively. NRS decreased from 6 (IQR 3) to 3 (IQR 4) (p < 0.001). SF-36 scores improved (physical health (41 (IQR 15) to 46 (IQR 12); p = 0.05, and mental health (49 (IQR 17) to 53 (IQR 9); p = 0.02)). Complications occurred in 36%, most commonly 1st/2nd degree skin burns.

CONCLUSION

MRgFUS reduced tumor volume, reduced pain, and improved quality of life in this series of 105 patients with extra-abdominal desmoid fibromatosis.

CLINICAL RELEVANCE STATEMENT

Imaging-guided ablation is being increasingly used as an alternative to surgery, radiation, and medical therapy for the treatment of desmoid fibromatosis. MR-guided high-intensity focused ultrasound is an incisionless ablation technique that can be used to reduce tumor burden effectively and safely.

KEY POINTS

• Desmoid fibromatosis was treated with MR-guided high-intensity focused ultrasound in 105 patients. • MR-guided focused ultrasound ablation reduced tumor volume and pain and improved quality of life. • MR-guided focused ultrasound is a treatment option for patients with extra-abdominal desmoid tumors.

Patterns of local recurrence and risk of skin recurrence in soft tissue sarcomas after surgical resection

PURPOSE/OBJECTIVE(S)

Soft tissue sarcomas (STSs) are rare, heterogeneous tumors primarily managed surgically with radiotherapy (RT) added to improve local control. Although there is a theoretical risk of skin seeding at the time of surgery, current ASTRO Clinical Practice Guidelines recommend against routine use of bolus during pre-operative or post-operative radiotherapy for STS due to increased risk of skin toxicity without clear benefit. However, in the modern era with contemporary treatment planning techniques, the risk of skin recurrence has not been assessed. We performed a detailed analysis of the patterns of local recurrence (LR) in patients with STS treated with surgical resection with or without RT.

MATERIALS/METHODS

We performed a retrospective analysis of 206 adult patients with extremity or trunk STSs evaluated in the Department of Radiation Oncology at our institution over 14 years (2007-2021) and identified all patients with LR. The depth of the recurrence and location relative to the radiation field in patients treated with radiotherapy was evaluated. Progression free survival (PFS) and overall survival (OS) were analyzed using the Kaplan-Meier method, and cumulative incidence of distant metastasis (CIDM) was calculated with competing risk analysis from the date of LR.

RESULTS

Of the 206 patients evaluated, 20 experienced a LR after surgical resection with or without RT. Among patients with a LR, 5 patients (25.0%) were treated with surgery alone and 15 patients (75.0%) received surgery and RT. In patients treated with RT, 46.7% had pre-operative RT, 53.3% had post operative RT, and bolus was used in 5 patients (33.3%). Surgical margins were close (<1mm) in 4 patients (20.0%) and positive in 10 patients (50.0%). Tumor grade was intermediate/high in 15 patients (75%) and the median tumor size was 9 cm (range 5-12). LR occurred in the muscle in 8 patients (40%), subcutaneous tissue in 11 patients (55.0%), and skin in 1 patient (5.0%). The patient with a skin recurrence was treated with surgery alone and the tumor involved the skin at presentation. In the patients treated with RT, LR occurred within radiation field in 10 patients (66.7%). Median follow up time after local recurrence was 12.9 months. At 3 years after LR, PFS was 43.9%, OS was 81.7%, and CIDM was 16.7%.

CONCLUSION

Skin recurrences were exceedingly rare after surgical resection of STSs, and only occurred in a tumor that involved the skin at initial presentation. Due to the increased dose to the normal skin and subcutaneous tissues when bolus is used, which increases risk of toxicity, these findings support current recommendations against routine use of bolus in STSs not involving the skin at presentation.

PET/MR of pediatric bone tumors: what the radiologist needs to know

Integrated 2-deoxy-2-[fluorine-18]fluoro-D-glucose (18F-FDG) positron emission tomography (PET)/magnetic resonance (MR) imaging can provide "one stop" local tumor and whole-body staging in one session, thereby streamlining imaging evaluations and avoiding duplicate anesthesia in young children. 18F-FDG PET/MR scans have the benefit of lower radiation, superior soft tissue contrast, and increased patient convenience compared to 18F-FDG PET/computerized tomography scans. This article reviews the 18F-FDG PET/MR imaging technique, reporting requirements, and imaging characteristics of the most common pediatric bone tumors, including osteosarcoma, Ewing sarcoma, primary bone lymphoma, bone and bone marrow metastases, and Langerhans cell histiocytosis.

Postinterview Communication in Orthopaedic Surgery Residency Interviews: A Survey of Match Applicants

Background:

To maintain the integrity of the match, postinterview communication (PIC) from programs to applicants is monitored and discouraged. The most recent report on the prevalence of PIC in orthopaedics found that 64% of surveyed applicants in 2014 and 2015 had received some form of PIC during their match cycle. In July 2019, the American Orthopaedic Association’s Council of Orthopaedic Residency Directors (AOA/CORD) released a guideline recommending the elimination of all PIC in any form. The goal of this follow-up study was to determine the current prevalence of PIC with orthopaedic surgery applicants and assess the perspectives of medical students who recently applied for orthopaedic surgery residency positions.

Methods:

A 35-question survey was e-mailed to all orthopaedic surgery residency applicants of 4 geographically diverse residency programs in postmatch March 2020. The survey was open for 1 month, and the responses were reported using descriptive statistics.

Results:

Of the 229 respondents (21% response rate), 91 (39.7%) received PIC during the 2019 to 2020 residency match cycle. The program director was most commonly identified (80.2%) as the person who communicated with the applicants. At the interview day, 198 respondents (86.5%) were told that programs would not be contacting the applicants with PIC. However, over a quarter of respondents (25.3%) who received PIC answered that those programs contacted applicants after announcing they would not. Nearly half of the respondents (48.5%) agreed or strongly agreed that PIC causes added stress on applicants, and over half (52.9%) agreed or strongly agreed that all programs should stop participating in any form of PIC.

Conclusions:

Although the prevalence of PIC seems to have decreased since the 2014 and 2015 match, there is still room for improvement toward eliminating PIC. The AOA/CORD position statement from July 2019 should be disseminated to all members of the residency selection team to ensure consistency from all programs. The primary limitation of this study was the 21% response rate.

Level of Evidence:

Level IV (survey study)

Ferumoxytol magnetic resonance imaging detects joint and pleural infiltration of bone sarcomas in pediatric and young adult patients

BACKGROUND

The diagnosis of joint infiltration by a malignant bone tumor affects surgical management. The specificity of standard magnetic resonance imaging (MRI) for diagnosing joint infiltration is limited. During our MRI evaluations with ferumoxytol nanoparticles of pediatric and young adult patients with bone sarcomas, we observed a surprising marked T1 enhancement of joint and pleural effusions in some patients but not in others.

OBJECTIVE

To evaluate if nanoparticle extravasation differed between joints and pleura with and without tumor infiltration.

MATERIALS AND METHODS

We retrospectively identified 15 pediatric and young adult patients (mean age: 16±4 years) with bone sarcomas who underwent 18 MRI scans at 1 h (n=7) or 24 h (n=11) after intravenous ferumoxytol infusion. Twelve patients also received a gadolinium-enhanced MRI. We determined tumor invasion into the joint or pleural space based on histology (n=11) and imaging findings (n=4). We compared the signal-to-noise ratios (SNR) and contrast-to-noise ratios (CNR) of the joint or pleural fluid for tumors with and without invasion using a Mann-Whitney U test.

RESULTS

MRI scans 24 h after intravenous ferumoxytol infusion demonstrated a positive T1 enhancement of the effusion in all joints and pleural spaces with tumor infiltration and no joint or pleural space without infiltration. Corresponding SNR (P=0.004) and CNR (P=0.004) values were significantly higher for joints and pleural spaces with tumor infiltration than without. By contrast, unenhanced MRI, gadolinium-enhanced MRI and 1-h post-contrast ferumoxytol MRI did not show any enhancement of the joint or pleural effusion, with or without tumor infiltration.

CONCLUSION

This pilot study suggests that 24-h post-contrast ferumoxytol MRI scans can noninvasively differentiate between joints with and without tumor infiltration.

Education research - Understanding the factors involved in inpatient communication for orthopedic trainees

BACKGROUND

"Interpersonal and Communication Skills" (ICS) is a core competency set forth by the ACGME. No structured curriculum exists to train orthopedics residents in ICS.

METHODS

Twenty-four out of thirty-five orthopedics residents completed the survey (69%). The survey had the following domains: [1] Demographics, [2] Communication Needs/Goals, and [3] Communication Barriers.

RESULTS

Eighty-three percent of respondents wanted to improve their communication skills and their patient's experience. Interns-PGY4s wanted to improve on similar specific communication skills. All residents desired training in conflict management.

CONCLUSION

There is a need among orthopedics residents for a communication skills curriculum early in residency training, specifically in conflict management.

Ferumoxytol Does Not Impact Standardized Uptake Values on PET/MR Scans

PURPOSE

Tumor response assessments on positron emission tomography (PET)/magnetic resonance imaging (MRI) scans require correct quantification of radiotracer uptake in tumors and normal organs. Historically, MRI scans have been enhanced with gadolinium (Gd)-based contrast agents, which are now controversial due to brain deposition. Recently, ferumoxytol nanoparticles have been identified as an alternative to Gd-based contrast agents because they provide strong tissue enhancement on MR images but are not deposited in the brain. However, it is not known if the strong T1- and T2-contrast obtained with iron oxide nanoparticles such as ferumoxytol could affect MR-based attenuation correction of PET data. The purpose of our study was to investigate if ferumoxytol administration prior to a 2-deoxy-2-[¹⁸F]fluoro-D-glucose [¹⁸F]FDG PET/MR scan would change standardized uptake values (SUV) of normal organs.

PROCEDURES

Thirty pediatric patients (6-18 years) with malignant tumors underwent [¹⁸F]FDG-PET/MR scans (dose 3 MBq/kg). Fifteen patients received an intravenous ferumoxytol injection (5 mg Fe/kg) prior to the [¹⁸F]FDG-PET/MR scans (group 1). Fifteen additional age- and sex-matched patients received unenhanced [¹⁸F]FDG-PET/MR scans (group 2). For attenuation correction of PET data, we used a Dixon-based gradient echo sequence (TR 4.2 ms, TE 1.1, 2.3 ms, FA 5), which accounted for soft tissue, lung, fat, and background air. We used a mixed linear effects model to compare the tissue MRI enhancement, quantified as the signal-to-noise ratio (SNR), as well as tissue radiotracer signal, quantified as SUVmean and SUVmax, between group 1 and group 2. Alpha was assumed at 0.05.

RESULTS

The MRI enhancement of the blood and solid extra-cerebral organs, quantified as SNR, was significantly higher on ferumoxytol-enhanced MRI scans compared to unenhanced scans (p < 0.001). However, SUVmean and SUVmax values, corrected based on the patients' body weight or body surface area, were not significantly different between the two groups (p > 0.05).

CONCLUSION

Ferumoxytol administration prior to a [¹⁸F]FDG PET/MR scan did not change standardized uptake values (SUV) of solid extra-cerebral organs. This is important, because it allows injection of ferumoxytol contrast prior to a PET/MRI procedure and, thereby, significantly accelerates image acquisition times.

Patient Preferences for Shared Decision Making: Not All Decisions Should Be Shared

INTRODUCTION

To assess bounds of shared decision making in orthopaedic surgery, we conducted an exploratory study to examine the extent to which patients want to be involved in decision making in the management of a musculoskeletal condition.

METHODS

One hundred fifteen patients at an orthopaedic surgery clinic were asked to rate preferred level of involvement in 25 common theoretical clinical decisions (passive [0], semipassive [1 to 4], equally shared involvement between patient and surgeon [5], semiactive [6 to 9], active [10]).

RESULTS

Patients preferred semipassive roles in 92% of decisions assessed. Patients wanted to be most involved in scheduling surgical treatments (4.75 ± 2.65) and least involved in determining incision sizes (1.13 ± 1.98). No difference exists in desired decision-making responsibility between patients who had undergone orthopaedic surgery previously and those who had not. Younger and educated patients preferred more decision-making responsibility. Those with Medicare desired more passive roles.

DISCUSSION

Despite the importance of shared decision making on delivering patient-centered care, our results suggest that patients do not prefer to share all decisions.

Comparison of ferumoxytol- and gadolinium chelate-enhanced MRI for assessment of sarcomas in children and adolescents

OBJECTIVES

We compared the value of ferumoxytol (FMX)- and gadolinium (Gd)-enhanced MRI for assessment of sarcomas in paediatric/adolescent patients and hypothesised that tumour size and morphological features can be equally well assessed with both protocols.

METHODS

We conducted a retrospective study of paediatric/adolescent patients with newly diagnosed bone or soft tissue sarcomas and both pre-treatment FMX- and Gd-MRI scans, which were maximal 4 weeks apart. Both protocols included T1- and T2-weighted sequences. One reader assessed tumour volumes, signal-to-noise ratios (SNR) of the primary tumour and adjacent tissues and contrast-to-noise ratios (CNR) of FMX- and Gd-MRI scans. Additionally, four readers scored FMX- and Gd-MRI scans according to 15 diagnostic parameters, using a Likert scale. The results were pooled across readers and compared between FMX- and Gd-MRI scans. Statistical methods included multivariate analyses with different models.

RESULTS

Twenty-two patients met inclusion criteria (16 males, 6 females; mean age 15.3 ± 5.0). Tumour volume was not significantly different on T1-LAVA (p = 0.721), T1-SE (p = 0.290) and T2-FSE (p = 0.609) sequences. Compared to Gd-MRI, FMX-MRI demonstrated significantly lower tumour SNR on T1-LAVA (p < 0.001), equal tumour SNR on T1-SE (p = 0.104) and T2-FSE (p = 0.305), significantly higher tumour-to-marrow CNR (p < 0.001) on T2-FSE as well as significantly higher tumour-to-liver (p = 0.021) and tumour-to-vessel (p = 0.003) CNR on T1-LAVA images. Peritumoural and marrow oedema enhanced significantly more on Gd-MRI compared to FMX-MRI (p < 0.001/p = 0.002, respectively). Tumour thrombi and neurovascular bundle involvement were assessed with a significantly higher confidence on FMX-MRI (both p < 0.001).

CONCLUSIONS

FMX-MRI provides equal assessment of the extent of bone and soft tissue sarcomas compared to Gd-MRI with improved tumour delineation and improved evaluation of neurovascular involvement and tumour thrombi. Therefore, FMX-MRI is a possible alternative to Gd-MRI for tumour staging in paediatric/adolescent sarcoma patients.

KEY POINTS

• Ferumoxytol can be used as an alterative to gadolinium chelates for MRI staging ofpaediatric sarcomas. • Ferumoxytol-enhanced MRI provides equal assessment of tumour size and other diagnostic parameters compared to gadolinium chelate-enhanced MRI. • Ferumoxytol-enhanced MRI provides improved delineation of sarcomas from bone marrow, liver and vessels compared to gadolinium chelate-enhanced MRI.

Treatment of Low-Flow Vascular Malformations of the Extremities Using MR-Guided High Intensity Focused Ultrasound: Preliminary Experience

Five patients with painful vascular malformations of the extremities that were refractory to standard treatment and were confirmed as low-flow malformations on dynamic contrast-enhanced magnetic resonance (MR) imaging were treated with MR imaging-guided high intensity focused ultrasound. Daily maximum numeric rating scale scores for pain improved from 8.4 ± 1.5 to 1.6 ± 2.2 (P = .004) at a median follow-up of 9 months (range, 4-36 mo). The size of the vascular malformations decreased on follow-up MR imaging (median enhancing volume, 8.2 mL [0.7-10.1 mL] before treatment; 0 mL [0-2.3 mL] after treatment; P = .018) at a median follow-up of 5 months (range, 3-36 mo). No complications occurred.

Changes in health status among aging survivors of pediatric upper and lower extremity sarcoma: a report from the childhood cancer survivor study

OBJECTIVE

To evaluate health status and participation restrictions in survivors of childhood extremity sarcomas.

DESIGN

Members of the Childhood Cancer Survivor Study cohort with extremity sarcomas who completed questionnaires in 1995, 2003, or 2007 were included.

SETTING

Cohort study of survivors of extremity sarcomas.

PARTICIPANTS

Childhood extremity sarcoma survivors (N=1094; median age at diagnosis, 13y (range, 0-20y); current age, 33y (range, 10-53y); 49% male; 87.5% white; 75% had lower extremity tumors) who received their diagnosis and treatment between 1970 and 1986.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Prevalence rates for poor health status in 6 domains and 5 suboptimal social participation categories were compared by tumor location and treatment exposure with generalized estimating equations adjusted for demographic/personal factors and time/age.

RESULTS

In adjusted models, when compared with upper extremity survivors, lower extremity survivors had an increased risk of activity limitations but a lower risk of not completing college. Compared with those who did not have surgery, those with limb-sparing (LS) and upper extremity amputations (UEAs) were 1.6 times more likely to report functional impairment, while those with an above-the-knee amputation (AKA) were 1.9 times more likely to report functional impairment. Survivors treated with LS were 1.5 times more likely to report activity limitations. Survivors undergoing LS were more likely to report inactivity, incomes <$20,000, unemployment, and no college degree. Those with UEAs more likely reported inactivity, unmarried status, and no college degree. Those with AKA more likely reported no college degree. Treatment with abdominal irradiation was associated with an increased risk of poor mental health, functional impairment, and activity limitation.

CONCLUSIONS

Treatment of lower extremity sarcomas is associated with a 50% increased risk for activity limitations; upper extremity survivors are at a 10% higher risk for not completing college. The type of local control influences health status and participation restrictions. Both of these outcomes decline with age.

Successful surgical and medical treatment of rhizopus osteomyelitis following hematopoietic cell transplantation

Mucormycosis has been reported in otherwise healthy individuals; however, it is primarily seen in immunocompromised patients, such as those with diabetes mellitus, malignancy, or chronic graft-versus-host disease, and has a high mortality rate. Because most cases of mucormycosis are associated with contiguous rhinocerebral infection, only 5 cases of isolated musculoskeletal Rhizopus infection have been reported in the literature. One patient underwent hematopoietic cell transplant, which resulted in a fatal outcome.This article describes the successful treatment of isolated Rhizopus osteomyelitis in a patient who underwent hematopoietic cell transplant using a combined surgical and medical approach. A 33-year-old woman with pre-B cell acute lymphoblastic leukemia underwent hematopoietic cell transplant with few complications but developed chronic graft-versus-host disease 8 months posttransplant. She was treated with high-dose steroids for 6 weeks before she was admitted for severe right tibial pain in the absence of trauma. Early detection, aggressive therapies, and a multidisciplinary surgical and medical team allowed for the microbiologically confirmed resolution of the infection. Treatment included multiagent antimicrobial therapy with amphotericin B, daptomycin, and ertapenem. Several surgical irrigation and debridement procedures were also performed, with the eventual placement of amphotericin-impregnated polymethylmethacrylate cement beads and small fragment titanium screws. The patient continued taking postoperative antifungal treatment for 7 months after discharge. Six months following the discontinuation of antifungal therapy, the team's multidisciplinary approach achieved a continued resolution of the patient's infection and a return to a fully ambulatory and radiographically proven recovery without limb loss.

Surgical intervention of nonvertebral osseous metastasis

BACKGROUND

Nonvertebral osseous metastases can result in pain and disability. The goals of surgical intervention are to reduce pain and to improve function if nonsurgical treatment fails. The indications for proceeding with surgical intervention depend on anatomic location, amount of local destruction, extent of skeletal and visceral disease and, most important, the patient's performance status and life expectancy.

METHODS

This article reviews the evaluation and treatment of metastatic nonvertebral osseous lesions from the perspective of the orthopedic surgeon, based mainly on an assessment of the surgical literature.

RESULTS

This article summarizes the approaches to preoperative evaluation, patient selection, and medical optimization. Guidelines for estimating osseous stability and fracture risk are discussed, and surgical implants and their relation to postoperative outcomes are examined. This review also describes less invasive ablative procedures currently available.

CONCLUSIONS

The surgical management of nonvertebral osseous metastases involves multidisciplinary collaboration. The surgical construct must be a stable, reliable, and durable intervention that is individually tailored and matched to a patient's prognosis and performance status.

Factors associated with recurrence of primary aneurysmal bone cysts: is argon beam coagulation an effective adjuvant treatment?

BACKGROUND

Our goal was to assess the effectiveness and safety of argon beam coagulation as an adjuvant treatment for primary aneurysmal bone cysts, to reevaluate the adjuvant effectiveness of the use of a high-speed burr alone, and, secondarily, to identify predictors of aneurysmal bone cyst recurrence.

METHODS

We retrospectively reviewed the records of ninety-six patients with primary aneurysmal bone cysts who were managed at our institution from January 1, 1983, to December 31, 2008. Forty patients were managed with curettage, a high-speed burr, and argon beam coagulation; thirty-four were managed with curettage and a high-speed burr without argon beam coagulation; and the remaining twenty-two were managed with curettage with argon beam coagulation alone, curettage with no adjuvant treatment, or resection of the entire lesion. Demographic, clinical, and radiographic data were viewed comparatively for possible predictors of recurrence. Kaplan-Meier survival analysis with a log-rank test was performed to measure association and effectiveness.

RESULTS

The median age at the time of diagnosis was fifteen years (range, one to sixty-two years). The median duration of follow-up was 29.5 months (range, zero to 300 months). The overall rate of recurrence of aneurysmal bone cyst after surgical treatment was 11.5%. The rate of recurrence was 20.6% after curettage and high-speed-burr treatment alone and 7.5% after curettage and high-speed-burr treatment plus argon beam coagulation. The five-year Kaplan-Meier survival estimate was 92% for patients managed with curettage and adjuvant treatment with a high-speed burr and argon beam coagulation, compared with 73% for patients managed with curettage and a high-speed burr only (p = 0.060).

CONCLUSIONS

Surgical treatment of aneurysmal bone cyst with curettage and adjuvant argon beam coagulation is effective. Postoperative fracture appears to be a common complication of this treatment and needs to be studied further. Treatment with curettage and high-speed burr alone may not reduce recurrence.

Solitary osteochondroma of the proximal femur and femoral acetabular impingement

Although osteochondromas can be present within the context of multiple hereditary exostosis, these tumors are overwhelmingly found as isolated lesions. Increased exostotic load associated with multiple hereditary exostosis can lead to limb-length discrepancy, increased femoral anteversion, valgus angulation, and acetabular dysplasia. Despite these observations, the relationship of more common isolated exostoses near the proximal femur and their role in femoral acetabular impingement has never been depicted. Although solitary osteochondromas have been linked with bursal inflammation and pain, compression on neurovascular structures, and malignant degeneration, they have not previously been associated with femoral acetabular impingement. This article presents a novel case of a proximal femoral osteochondroma of the greater trochanter leading to the development and associated symptoms and radiographic findings consistent with hip impingement. A 24-year-old man presented with groin and lower extremity pain thought to be due to an exostosis of the proximal femur. Following surgical excision and persistence of anterior groin pain, the patient was found to display a presentation and radiographic findings consistent with femoral acetabular impingement. He successfully underwent a hip arthroscopy, femoroacetabular osteochondroplasty, and labral repair. Postoperatively, his symptoms improved significantly, and he returned to normal activity. The presence of a proximal femoral exostosis can be associated with the development of femoral acetabular impingement. Awareness of this relationship may lead to a better understanding of patient symptoms and expectations associated with treatment.