Article

Clinical Outcomes Analysis of Conservative and Surgical Treatment of Patients With Clinical Indications of Prearthritic, Intra-articular Hip Disorders

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Abstract

To describe outcomes of the conservative treatment of patients who had the clinical presentation of a prearthritic, intra-articular hip disorder, including acetabular labral tears, developmental hip dysplasia, and femoroacetabular impingement. Prospective observational clinical outcomes study. Outpatient orthopedic clinic at a tertiary university hospital. Patients presenting with prearthritic, intra-articular hip disorders were recruited. Fifty-eight consecutive patients were enrolled; 6 were lost to follow-up, and 52 subjects completed the study. Patients were recruited on the basis of symptoms, distribution of pain, and the findings of a physical examination. Radiographic measurements of the hip were obtained for all subjects to describe the presence or absence and extent of deformity and/or osteoarthritis. All subjects completed a directed course of conservative treatment. After 3 months of conservative care, subjects with continued limitations, reduction of symptoms with a diagnostic intra-articular hip injection, and a surgically amenable lesion found on a magnetic resonance arthrogram proceeded to surgery. Numeric Pain Score (0-10), Short Form-12, Modified Harris Hip Score, Western Ontario and McMaster Universities Osteoarthritis Index, Nonarthritic Hip Score, Baecke Questionnaire of Habitual Activity, and patient choice to have surgery. Fifty-eight patients (9 men and 49 women) with a mean age of 35 ± 11 years (range, 18-50 years) enrolled in the study. Fifty-two subjects completed the study. Twenty-three subjects (44%) reported satisfaction with conservative care. Twenty-nine subjects (56%) chose to have surgery. Both groups demonstrated equally significant improvement (P value ranges: P = .03 to P = .0001) in all outcome measures from baseline to 1-year follow-up. Subjects who chose surgery had higher baseline activity scores compared with the conservative treatment group (P = .02). All subjects with signs and symptoms of prearthritic, intra-articular hip disorders who were treated with conservative treatment alone and with conservative treatment followed by surgery demonstrated significant improvement in pain and functioning from baseline to 1 year. Forty-four percent of patients improved with conservative care alone, and 56% chose to have surgery after receiving conservative care. Persons with more active lifestyles were more likely to choose surgery. These data suggest that a trial of conservative management for persons with prearthritic, intra-articular hip disorders should be considered before engaging in surgical intervention.

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... [8][9][10][11][12][13][14] However, there are limited data regarding appropriate conservative treatment for FAI. 15,16 Conservative treatment for FAI is controversial. 17,18 Patient education, activity and sport modification, and physical therapy seem to be beneficial. ...
... 17,18 Patient education, activity and sport modification, and physical therapy seem to be beneficial. 16,17 However, there are no high level of evidence studies to substantiate this. Wall et al 17 stated that nonoperative treatment regimens need to be evaluated more extensively and rigorously, preferably compared with operative care, to determine true clinical effectiveness. ...
... The rehabilitation protocol consisted of patient education including activity modification and the control of gluteal muscles, based on prior reports of conservative treatment. 16,28,29 Before the beginning of intervention, 5 patients in the control group and 7 patients in the trunk training group had refrained from sports activities because of groin pain. All patients were instructed to modify activities of daily living, including avoidance of squatting, prolonged sitting, and cessation of any athletic activities causing groin pain during the intervention period. ...
Article
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Objective: To assess the efficacy of conservative management of women with femoroacetabular impingement (FAI) using trunk stabilization. Design: Randomized controlled trial (level of evidence: I). Subjects: Twenty FAI female patients who met the inclusion FAI criteria. Methods: A prospective, randomized, controlled study was performed on 20 female patients with symptomatic FAI comprising 2 groups (10 hips in trunk stabilization exercise group vs 10 hips in control group). We evaluated hip range of motion, isometric muscle strength using a handheld dynamometer (μ-TasMF-01; Anima, Co), and patient-reported outcome measures, including modified Harris hip score, Vail hip score, and international hip outcome tool 12 (iHOT12) before and at 4 weeks and 8 weeks after the intervention. Results: There was a significant improvement in the range of motion of hip flexion in the trunk training group detected as early as 4 weeks after the intervention compared with the control group (P < 0.05). Hip abductor strength significantly improved in the trunk training group at 4 weeks after the intervention, whereas it did not improve in the control group (P < 0.05). Vail hip score and iHOT12 were significantly increased at 8 weeks after the intervention in the trunk training group compared with the control group (iHOT12: 78.7 ± 22.4 vs 53.0 ± 22.3; P < 0.01, Vail hip score: 81.6 ± 18.5 vs 61.1 ± 11.6; P < 0.05). There was no significant difference in the modified Harris hip score between both the groups at 4 and 8 weeks after the intervention. Conclusions: The addition of trunk stabilization exercise to a typical hip rehabilitation protocol improves short-term clinical outcomes and may augment nonoperative and postoperative rehabilitation.
... Future larger studies should, however, consider sex differences for exercise therapy effectiveness due to different clinical (33) and functional characteristics (13,34) presented by female and male patients with FAIS. The responsiveness to exercise therapy found in our study (52%) was similar or better compared with that observed in earlier studies (35,36) and similar to the outcomes reported for hip surgery for FAIS at short-term follow-up (20). Hunt et al (35) observed that only 33% of their patients with FAIS could benefit from a trial of exercise therapy, while Wright et al (36) and Impellizzeri et al (20) had 60% of their patients reporting good outcomes after 6 weeks of exercise therapy, and at 6 months after hip surgery, respectively. ...
... The responsiveness to exercise therapy found in our study (52%) was similar or better compared with that observed in earlier studies (35,36) and similar to the outcomes reported for hip surgery for FAIS at short-term follow-up (20). Hunt et al (35) observed that only 33% of their patients with FAIS could benefit from a trial of exercise therapy, while Wright et al (36) and Impellizzeri et al (20) had 60% of their patients reporting good outcomes after 6 weeks of exercise therapy, and at 6 months after hip surgery, respectively. The relatively poor outcomes reported by Hunt et al may be the result of the low and variable amount of therapy provided to the patients (i.e., a mean of 6 sessions, range 1-19) (35). ...
... Hunt et al (35) observed that only 33% of their patients with FAIS could benefit from a trial of exercise therapy, while Wright et al (36) and Impellizzeri et al (20) had 60% of their patients reporting good outcomes after 6 weeks of exercise therapy, and at 6 months after hip surgery, respectively. The relatively poor outcomes reported by Hunt et al may be the result of the low and variable amount of therapy provided to the patients (i.e., a mean of 6 sessions, range 1-19) (35). In the current study, 8 patients (25%) decided to have hip surgery, followed up for 1 year, during which they chose to have surgery. ...
Article
Objective To investigate the responsiveness to exercise therapy of patients with femoroacetabular impingement syndrome (FAIS), and differences in hip function, strength and morphology between responders vs. non‐responders. Methods Patients with FAIS underwent 12 weeks of semi‐standardized and progressive exercise therapy. Good therapy outcome (responders) vs. poor therapy outcome (non‐responders) was determined at week 18 with the Global Treatment Outcome for hip pain. Hip function was evaluated using the Hip Outcome Score (HOS) activities of daily living (ADL) and Sport at baseline, week 6, 12 and 18. Hip muscle strength and dynamic pelvic control were evaluated using dynamometry and video analysis, respectively, at baseline, week 12 and 18. Hip morphology was evaluated with imaging at baseline. Results Thirty‐one patients (mean age: 24 years) were included. Sixteen (52%) patients were responsive and 15 (48%) were not responsive to exercise therapy. Only responders improved HOS ADL and HOS Sport by 10 (95% CI: 7 to 14, P<0.001) and 20 points (95%CI: 15 to 25, P<0.001), respectively, and hip abductor strength by 0.27 Nm/kg (95%CI: 0.18 to 0.36, P<0.001). The prevalence of patients showing good dynamic pelvic control only increased in responders (44%, P=0.029). The prevalence of severe cam morphology was higher in non‐responders than responders (40% vs. 6%, P=0.037). Conclusion Half of patients with FAIS benefits from exercise therapy at short term. Responsiveness to hip abductor strength and dynamic pelvic control improvements is associated with good therapy outcome, whereas presence of severe cam morphology is associated with poor therapy outcome. This article is protected by copyright. All rights reserved.
... Conservative management typically offers a quicker return to play than surgical management, 35,39 and it has proven to be effective in some athletes. 22 However, athletes who do not improve sufficiently with an extensive trial of conservative care and proceed to surgery anyway have an even more protracted return to play than if they had pursued surgery earlier in their course. 22 To our knowledge, the proportion of competitive athletes who pursue surgery over continued conservative management is unknown. ...
... 22 However, athletes who do not improve sufficiently with an extensive trial of conservative care and proceed to surgery anyway have an even more protracted return to play than if they had pursued surgery earlier in their course. 22 To our knowledge, the proportion of competitive athletes who pursue surgery over continued conservative management is unknown. Furthermore, identification of athlete-specific variables that are associated with progression to surgery rather than continued conservative management may assist providers in counseling patients and directing them to appropriate treatment options that will expedite their recovery and return to play. ...
... Our results build on the findings by Hunt et al, 22 in which patients with PAHD completed a standardized conservative management protocol and then were given the option of surgical management if their symptoms were not controlled. Similar to our results, the cohort was predominantly female, and only 56% of those patients chose to have surgery. ...
Article
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Background Prearthritic hip disorders (PAHD), such as femoroacetabular impingement (FAI), acetabular dysplasia, and acetabular labral tears, are a common cause of pain and dysfunction in adolescent and young adult athletes, and optimal patient-specific treatment has not been defined. Operative management is often recommended, but conservative management may be a reasonable approach for some athletes. Purpose To identify (1) the relative rate of progression to surgery in self-reported competitive athletes versus nonathletes with PAHD and (2) baseline demographic, pain, and functional differences between athletes who proceeded versus those who did not proceed to surgery within 1 year of evaluation. Study Design Cohort study; Level of evidence, 3. Methods An electronic medical record review was performed of middle school, high school, and college patients who were evaluated for PAHD at a single tertiary-care academic medical center between June 22, 2015, and May 1, 2018. Extracted variables included patients’ self-reported athlete status, decision to choose surgery within 1 year of evaluation, and baseline self-reported pain and functional scores on Patient-Reported Outcomes Measurement Information System (PROMIS) domains, the Hip disability and Osteoarthritis Outcome Score (HOOS), and the modified Harris Hip Score. Results Of 260 eligible patients (289 hips), 203 patients (78%; 227 hips) were athletes. Athletes were no more likely to choose surgery than nonathletes (130/227 hips [57%] vs 36/62 hips [58%]; relative risk [RR], 0.99 [95% CI, 0.78-1.25]). Among athletes, those who proceeded to surgery over conservative care were more likely to be female (81% vs 69%; RR, 1.34 [95% CI, 0.98-1.83]) and had more known imaging abnormalities (FAI: 82% vs 69%, RR, 1.47 [95% CI, 1.09-1.99]; dysplasia: 48% vs 27%, RR, 1.44 [95% CI, 1.16-1.79]; mixed deformity: 30% vs 10%, RR, 2.91 [95% CI, 1.53-5.54]; known labral tear: 84% vs 40%, RR, 2.79 [95% CI, 2.06-3.76]). Athletes who chose surgery also reported worse baseline hip-specific symptoms on all HOOS subscales (mean difference, 10.8-17.7; P < .01 for all). Conclusion Similar to nonathletes, just over half of athletes with PAHD chose surgical management within 1 year of evaluation. Many competitive athletes with PAHD continued with conservative management and deferred surgery, but more structural hip pathology and worse hip-related baseline physical impairment were associated with the choice to pursue surgery.
... Discussion and/or review articles, experimental studies, and randomized control feasibility and protocol studies addressing management of individuals with FAI, acetabular labral tears, dysplasia, structural instability, chondral damage, and ligamentum teres tears were evaluated. From these studies, several concepts were identified that should be considered when beginning all non-operative management plans including: patient education, [26][27][28] symptom control (with the use of non-steroidal anti-inflammatory drugs), 29-32 identification of aggravating activities, 31,33 modification of these activities with a focus on limiting extreme ranges of motion, [29][30][31]34,35 and initiation of therapeutic interventions within a physical therapy protocol. 33,36,37 Therapeutic interventions should consist of addressing neuromuscular deficits with training of the hip and lumbopelvic regions. ...
... Three experimental studies addressed non-operative management of intra-articular disorders including FAI, acetabular labral tears, dysplasia, chondral lesions and ligamentum teres partial tears. 27,28,62 Two of these studies provided specifics of non-operative management including the case series by Yazbek et al. 28 demonstrating a decrease in pain, improvement in functional movement, and increased lower extremity muscular balance in four individuals. This was achieved by correcting abnormal joint movement by emphasizing muscular strengthening and sensory motor training. ...
... When the muscle imbalance was corrected, the participants were progressed to a sports-specific functional training regimen and successfully returned to activity over a 12-week period. 28 The case series performed by Hunt et al. 27 demonstrated a successful management plan in 23 of 52 (44%) individuals with FAI, LT, and dysplasia over a 12-week period. All participants were taken through an individualized physical therapy protocol that emphasized femoral head motion by decreasing the anterior glide within the acetabulum through muscle training and postural positioning of the pelvis. ...
Article
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Background: Non-arthritic hip pain is defined as being related to pathologies of the intra-articular structures of the hip that can be symptomatic. A trial of non-operative management is commonly recommended before consideration of surgery for individuals with non-arthritic hip conditions. There is a need to describe a non-operative or conservative treatment plan for individuals with non-arthritic hip pain. Purpose: The purpose of this literature review was to systematically examine the literature in order to identify and provide evidence for non-operative or conservative management of individuals with non-arthritic hip pain. A proposed home exercise program will be provided for individuals with non-arthritic hip pain. Study design: Review of the Literature. Materials/methods: A literature search of PubMed, Medline, SPORTSDiscus, and CINAHL was conducted. Keywords included: "hip" AND "femoroacetabular impingement" OR "labral tear." Studies were included if they described non-operative management for individuals with non-arthritic hip pain. Studies were excluded if they recommended a trial of conservative treatment without specific management or interventions and/or activity modification without specific details for intervention. Results: A total of 49 studies met the eligibility criteria and were included in the review. Rehabilitation recommendations were identified from manuscripts including clinical trials, case series, discussion articles, or systematic reviews related to the non-operative or conservative management of non-arthritic hip pain. Rehabilitation interventions focused on patient education, activity modification, limitation of aggravating factors, an individualized physical therapy protocol, and use of a home exercise program. Conclusions: Rehabilitation should address biomechanical deficiencies with neuromuscular training of the hip and lumbopelvic regions. While the current literature on non-operative management is limited, future randomized control trials will establish the effectiveness of specific physical therapy protocols for individuals with non-arthritic hip pain. Level of evidence: 3b.
... In particular, sports such as football that include repetitive hip flexion may cause the development of FAI and chondrolabral damage [38]. Although definitive treatment of FAI requires surgical intervention, many studies recommend a trial of non-operative management first [68]. ...
... The goals of physiotherapy in the management of FAI can be to increase the pain-free range of motion (ROM) of the hip, to optimize the balance between muscle strength and length, and to reduce anterior femoral glide [68,72]. ...
Chapter
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Groin pain represents a frequent cause of disability among footballers. Groin pain in footballers is most commonly due to overuse injury as opposed to traumatic injury. Athletic groin pain presents a diagnostic and therapeutic challenge for the sports medicine physician. The complex anatomy of the hip and groin region gives rise to an extensive list of possible pathologies that all may present very similarly. Adductor pathology represents the most common cause of groin pain in footballers, but other pathologies such as abdominal, intra-articular, inguinal, and iliopsoas-related pathologies may also cause groin pain in footballers. Although the majority of groin pain pathologies can be treated with an initial trial of conservative management, the evidence for non-operative management currently available is limited. Athletes who fail conservative treatment options may ultimately require operative management. This chapter discusses return to play in footballers following non-operative management of hip and groin pain.
... 13,36 Despite these surgical interventions to address FAI, some patients may still need total hip arthroplasty. 21 evidence for the conservative treatment of FAI is limited to case series 12,22 (level 4 evidence) and is affected by patient demand for surgical treatment as well as a paucity of effective exercises. 47 In these studies, however, a staged physical therapy approach with activity modification and exercise led to improved patient-reported outcomes. ...
... 47 In these studies, however, a staged physical therapy approach with activity modification and exercise led to improved patient-reported outcomes. 12,22 The use of conservative treatment in patients with FAI could be a strategy for avoiding surgery to ease hip pain. ...
Article
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Background Cam-type femoroacetabular impingement (FAI) is a femoral head-neck deformity that causes abnormal contact between the femoral head and acetabular rim, leading to pain. However, some individuals with the deformity do not experience pain and are referred to as having a femoroacetabular deformity (FAD). To date, only a few studies have examined muscle activity in patients with FAI, which were limited to gait, isometric and isokinetic hip flexion, and extension tasks. Purpose To compare (1) hip muscle strength during isometric contraction and (2) lower limb kinematics and muscle activity of patients with FAI and FAD participants with body mass index–matched healthy controls during a deep squat task. Study Design Controlled laboratory study. Methods Three groups of participants were recruited: 16 patients with FAI (14 male, 2 female; mean age, 38.5 ± 8.0 years), 18 participants with FAD (15 male, 3 female; mean age, 32.5 ± 7.1 years), and 18 control participants (16 male, 2 female; mean age, 32.8 ± 7.0 years). Participants were outfitted with electromyography electrodes on 6 muscles and reflective markers for motion capture. The participants completed maximal strength tests and performed 5 deep squat trials. Muscle activity and biomechanical variables were extrapolated and compared between the 3 groups using 1-way analysis of variance. Results The FAD group was significantly stronger than the FAI and control groups during hip extension, and the FAD group had greater sagittal pelvic range of motion and could squat to a greater depth than the FAI group. The FAI group activated their hip extensors to a greater extent and for a longer period of time compared with the FAD group to achieve the squat task. Conclusion The stronger hip extensors of the FAD group are associated with greater pelvic range of motion, allowing for greater posterior pelvic tilt, possibly reducing the risk of impingement while performing the squat, and resulting in a greater squat depth compared with those with symptomatic FAI. Clinical Relevance The increased strength of the hip extensors in the FAD group allowed these participants to achieve greater pelvic mobility and a greater squat depth by preventing the painful impingement position. Improving hip extensor strength and pelvic mobility may affect symptoms for patients with FAI.
... 18 Contrasting results have been reported in terms of the efficiency of non-surgical treatment, ranging from favorable to less favorable. [18][19][20][21] The main purpose of this case report is to present the successful management of bilateral FAI syndrome in a patient who underwent different treatment regimens on each side. ...
... 19 Contrasting results have been published by Hunt et al, who reported that, of 18 patients undergoing physiotherapy and activity modifications, eleven patients eventually underwent surgical treatment as they did not experience any temporary relief or improvement in function. 20 Moreover, Jäger et al reported that nine of nine patients with FAI syndrome treated with physiotherapy and NSAIDs continued to experience significant pain and hip dysfunction. 21 This patient's history illustrates FAI syndrome, treated both surgically and non-surgically. ...
Article
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Purpose: The purpose of this case report is to present the successful management of symptomatic bilateral femoroacetabular impingement (FAI) syndrome in a patient who underwent surgical treatment on one side and non-surgical treatment on the other side. Methods: We evaluated the treatment outcome of a young female presenting with bilateral FAI syndrome of cam morphology. A follow-up was performed at 5 years following surgical treatment on the right hip and 2 years following non-surgical treatment on the left hip. The evaluation included a clinical examination, patient-reported outcome measurements (PROM), plain radiographs, and magnetic resonance imaging (MRI). Results: The patient experienced subjective improvements bilaterally. The clinical examination revealed differences in range of motion between the surgically treated and the non-surgically treated sides, with internal rotation differing the most (20° vs almost 0°). Flexion was, however, the same on both sides (125°). The PROM results were satisfactory on both sides, with slightly better results for the surgically treated side (the short version of the International Hip Outcome Tool [iHOT-12]: 96.9 vs 90, the Copenhagen Hip and Groin Outcome Score [HAGOS]: 90-100 vs 65-100). On the surgically treated side, the alpha angle decreased by 19° postoperatively. An MRI did not reveal any injury to the cartilage or labrum on either side. Conclusion: This patient with bilateral FAI syndrome treated with arthroscopic surgery on one side and physiotherapy together with reduced physical activity on the other side, presented with good results bilaterally at follow-up.
... Guideline recommendations vary for the duration of exercise management of hip pain, with the most consistent recommendation being 12 weeks as a minimum [3,9,10]. Exercise is recommended even when there is an increased probability of proceeding to surgery [19,20]. At present, no clinical practice guidelines recommend specific exercise protocols for the management of hip pain, however it appears common practice that exercise protocols are aimed at improving hip range of movement, strength and function [1,[6][7][8]20]. ...
... Of the seven cases who proceeded to surgery (all with a structural diagnoses aligned to hip joint pathology), only two had pre-operative exercise. This conflicts with recommendations for pre-operative exercise intervention [19]. Although the research around surgery on compensable cases is limited, some findings have identified that when surgery is performed on a compensable worker, the risk of a negative outcome is doubled compared to non-compensable patients [13]. ...
Article
Background: Guidelines recommend early referral for exercise for hip pain. It is unclear if this occurs in the Australian workers' compensation environment. Objective: To investigate referral for exercise in workers with a compensable hip claim. Methods: Retrospective audit of closed compensation files for workers with hip pain was performed. Exercise commencement was indicated by billing codes for physiotherapy or exercise specific consultations. Time to exercise commencement was calculated. Associations were analysed between time to exercise commencement with claim duration and diagnostic category. Results: Exercise management occurred for 33/44 cases. Median time to commence exercise for those cases that had exercise was 14 days post-injury, with 33% commencing beyond 4 weeks. Longer time to commence exercise was associated with a longer claim duration (Spearman's rho = 0.70). Workers with a diagnosis of hip joint pain had a longer time to exercise commencement (median 49.5 days) compared to those with a diagnosis of lateral hip pain (median 14 days) or non-specific hip pain (median 4.5 days). Conclusion: Findings indicate practice behaviours in the workers' compensation environment for the management of hip pain with exercise. Further investigation is warranted to see if improved adherence to guideline recommendations improves outcomes for people with compensable hip pain.
... 3,4 Intra-articular injections also have a role in the treatment of nonarthritic disorders, including femoroacetabular impingement. [5][6][7] Other therapeutic intraarticular modalities include viscosupplementation and an expanding role for orthobiologics such as plateletrich plasma. 4,8 The purpose of this report is to describe a technique of ultrasound-guided intra-articular injection of the hip (the Nashville Sound), which was developed with a minimal learning curve and has proven to be safe and effective based on the outcomes of thousands of procedures (Tables 1 and 2). ...
... Corticosteroid is most commonly the treatment of choice. [3][4][5][6][7] Results of injections of viscosupplements and orthobiologics, especially platelet-rich plasma, have been published as well. 4,8 The scientific data behind e386 these alternative injections are mixed and sometimes inconsistent. ...
Article
Full-text available
Ultrasound-guided intra-articular injection has become a mainstay in the diagnosis and treatment of a variety of hip disorders. It is the single greatest adjunct to history and examination in the clinical assessment of hip problems and has substantial therapeutic value in the conservative management of symptomatic disorders, especially when used in conjunction with supervised physical therapy.
... This may be of particular relevance in those athletes whose bony anatomy is consistent with joint morphology associated with femoroacetabular impingement syndrome (FAIS), as this has been purported as a risk factor for developing intra-articular hip injury such as acetabular labral tears (ALT) and osteoarthritis. 4,6 Successful treatment of hip-related pain and injury is facilitated by accurate diagnosis, after which recovery can be expedited by prompt treatment or management of symptoms. One aspect affecting the time to treatment is how long it takes to reach a diagnosis. ...
... This is consistent with current trends showing an increase in the use of surgical treatment for the hip. 6,17,20 These results may lead to the conclusion that surgery may be an expected result for patients with the diagnosis of FAIS or chondrolabral pathology. However, the results should not be interpreted to mean that surgery is the preferred course of treatment, as comparative studies investigating outcomes between surgical and conservative treatments are lacking. ...
Article
Background: Hip-related pain and pathology can have an overall negative impact on healthrelated quality of life. Prompt diagnosis and treatment of symptoms at the hip may expedite the recovery process and allow for an earlier return to normal activity. Knowing the prevalence of a condition can help facilitate the diagnostic process. However, the prevalence of hip diagnoses and associated courses of treatment have not been described. Methods: A retrospective study was performed on patients presenting to a sports medicine clinic. Information on demographics, duration of pain, course of treatment, history of previous injury or surgery, and mechanism of injury was collected. Multivariate linear regression and multivariate logistic regression were utilized to describe differences in course of treatment between diagnostic groups. Results: Six hundred eighteen patients were included in this study, with 641 hips analyzed. Femoroacetabular impingement syndrome (FAIS) was the most frequent diagnosis (212 hips), followed by "musculotendinous pain" and "hip pain, not otherwise specified." Of those diagnosed with FAIS, 30.1% had secondary diagnoses in other categories. Home exercise programs were the most commonly prescribed treatment, followed by injections and physical therapy. Having a diagnosis of FAIS or chondrolabral pathology increased the odds of surgery. Conclusion: Femoroacetabular impingement syndrome was the most common diagnosis in our cohort and had the highest frequency of concurrent diagnoses. A combination of a home exercise program, injection, and physical therapy made up the typical course of treatment, while surgery was utilized less frequently.
... Historically, physical therapy treatment for NAHD has been focused on stretching, strengthening and joint mobility [5][6][7], but more recent physical therapy protocols have incorporated movement training [8,9]. Because patients with NAHD often present with abnormal movement patterns during functional tasks [10][11][12][13][14][15][16][17][18][19][20], physical therapy assessment specifically focused on posture and movement may be a crucial step to identify patients who stand to benefit from movement-focused treatment. ...
Article
Background: Non-arthritic hip disease (NAHD) is a clinical condition often accompanied by painful movement. Current literature is lacking regarding how movement abnormalities are evaluated and treated in this population, which may be key to identifying which patients may respond to non-operative versus operative treatment. Combining the expertise of a hip arthroscopist and physical therapist may better inform treatment decisions for persons with NAHD. The primary objective of this study is to identify the extent to which an interdisciplinary evaluation between a physical therapist and surgeon influences treatment decisions of persons presenting to a hip preservation clinic. Rationale for study design: A prospective, randomized controlled trial provides the ability to identify cause and effect of this new evaluation type. Methods: Ninety-six adults with unilateral, NAHD presenting to a hip preservation clinic for initial evaluation will be randomized to receive either a standard evaluation with a surgeon or an interdisciplinary evaluation by a physical therapist and surgeon. Regardless of group, the surgeon conducts a standard-care examination. For participants in the interdisciplinary group, the physical therapist conducts an assessment of 6 postures and movements to identify asymmetrical, abnormal, or painful strategies. Treatment selection(s) and decisional conflict will be compared between groups after the evaluations. Discussion: Persons with NAHD may experience considerable decisional conflict because of prolonged duration of symptoms and minimal evidence to compare operative and non-operative treatment for this population. The findings of this study have the potential to improve patient experience and produce more informed and supported treatment decisions for persons considering surgical treatment for NAHD.
... 17 FAI can present insidiously, with mild to severe pain most often with activities requiring hip flexion such as plyometric workouts. 18,19 Pain can also be reported at rest with activities such as sitting at a desk. While location of pain is often variable, most often it involves the groin, but can include the lateral and posterior hip, anterior and posterior thigh, and the lumbar spine. ...
Article
Full-text available
Scott Buzin, Dhruv Shankar, Kinjal Vasavada, Thomas Youm Department of Orthopaedic Surgery, NYU Langone Health, New York, NY, USACorrespondence: Thomas Youm, Department of Orthopaedic Surgery, NYU Langone Health, New York, NY, USA, Tel +1 212-348-3636, Email thomas.youm@nyulangone.orgAbstract: Femoroacetabular impingement (FAI) has emerged as a common cause of hip pain, especially in young patients. While the exact cause of FAI is unknown, it is thought to result from repetitive microtrauma to the proximal femoral epiphysis leading to abnormal biomechanics. Patients typically present with groin pain that is exacerbated by hip flexion and internal rotation. Diagnosis of FAI is made through careful consideration of patient presentation as well as physical exam and diagnostic imaging. Use of radiographs can help diagnose both cam and pincer lesions, while the use of MRI can diagnose labral tears and cartilage damage associated with FAI. Both non-operative and surgical options have their role in the treatment of FAI and its associated labral tears; however, hip arthroscopy has had successful outcomes when compared with physical therapy alone. Unfortunately, chondral lesions associated with FAI have had poorer outcomes with a higher conversion rate to arthroplasty. Capsular closure following hip arthroscopy has shown superior clinical outcomes and therefore should be performed if possible. More recently, primary labral reconstruction has emerged in the literature as a good option for irreparable labral tears. While non-operative management may have its role in treating patients with FAI, hip arthroscopy has developed a successful track record in being able to treat cam and pincer lesions, chondral damage, and labral injuries.Keywords: femoroacetabular impingement, cam lesion, pincer lesion, labral tear, hip arthroscopy, labral reconstruction
... Ud over ovenstående randomiserede undersøgelser, har man i flere prospektive studier undersøgt effekten af fysioterapi som behandling af FAIS [20,27]. Der er indikationer på, at en subgruppe af patienter responderer positivt på fysioterapeutisk behandling, men det skal bemaerkes, at der er stor variation i den diagnostiske proces, og det er således uvist, om der er tale om intraartikulaere problemer eller blot koeksisterende hofte-lyske-smerter og aendret morfologi. ...
Article
Full-text available
Femoroacetabular impingement syndrome (FAIS) is defined as a motion-related disorder of the hip joint, consisting of a triad of symptoms, clinical findings, and imaging findings. Hip morphology related to FAIS is developed during skeletal growth and seems to be related to sports participation. Treatment for FAIS may include physiotherapy and/or surgery, but recent evidence suggests, that surgery is more effective in improving symptoms. No literature exists on the prevention of FAIS, and prophylactic surgery is not recommended.
... This can lead to chondral abrasion and labral detachment, causing pain in the groin and the development of early adult hip osteoarthritis [1,2]. Patients are initially treated through conservative nonsurgical methods, but osteochondroplasty of the femoral head-neck junction is often required [3][4][5]. The surgery can be done through either open [6,7] or arthroscopic [8,9] approaches, with both producing high level of patient satisfaction [10][11][12]. ...
Article
Background In order to reduce the development of hip osteoarthritis related to cam-type femoroacetabular impingement syndrome (FAIS), corrective surgery has evolved to become a safe and effective treatment. Although corrective surgery produces high level of patient satisfaction, it is still unclear how it affects muscle and hip contact forces during level walking. Research question The purpose was to compare the muscle force contributions and hip contact forces in patients before and after surgical correction for cam FAIS with healthy control (CTRL) individuals during level walking. Methods Eleven male patients with symptomatic cam-type morphology, who underwent hip osteochondroplasty, had their level walking recorded pre- and at 2-year postoperatively. The patients were sex-, age-, BMI-matched to 11 CTRL individuals. Sagittal and frontal hip kinematics and kinetics were computed and, subsequently, muscle and hip contact forces were estimated using musculoskeletal modelling and static optimization. Results Patient-reported outcomes improved postoperatively. The pre- and postoperative FAIS walked slower and with shorter steps than the CTRL. Postoperative biceps femoris (CTRL: 0.35 ± 0.13 N/BW; pre-op: 0.28 ± 0.11 N/BW; post-op: 0.20 ± 0.07 N/BW) and semimembranosus forces (CTRL: 0.77 ± 0.24 N/BW; pre-op: 0.66 ± 0.24 N/BW; post-op: 0.41 ± 0.14 N/BW) were lower at ipsilateral foot-strike. Postoperative rectus femoris force (CTRL: 1.73 ± 0.35 N/BW; pre-op: 1.44 ± 0.24 N/BW; post-op: 1.18 ± 0.23 N/BW) was lower than the other two groups, and the pre- and postoperative FAIS had lower iliacus (CTRL: 1.17 ± 0.18 N/BW; pre-op: 0.93 ± 0.16 N/BW; post-op: 0.94 ± 0.21 N/BW) and psoas (CTRL: 1.55 ± 0.24 N/BW; pre-op: 1.14 ± 0.38 N/BW; post-op: 1.10 ± 0.46 N/BW) muscle forces at contralateral foot-strike compared with the CTRL. Pre- and postoperative FAIS demonstrated lower peak hip contact loading resultant than the CTRL. Significance The altered gait parameters observed in the preoperative FAIS was not restored after surgery, and was still away from the CTRL. It is possible that the reduced dynamic muscle forces of the biceps femoris, semimembranosus and rectus femoris postoperatively were associated with the protected mechanism that involved the iliopsoas preoperatively. This is an indication that the gait adaptations affected by the FAIS do not restore to normal after surgical correction at the 2-years follow-up.
... FAIS symptoms are first treated with conservative methods [12][13][14][15]; however, once conservative methods are exhausted, surgical correction, an osteochondroplasty of the femoral head-neck junction [16], is often required [12,17,18]. The surgery for FAIS is done through either open [19][20][21] or arthroscopic [22][23][24][25][26] procedures. ...
Article
Full-text available
Femoroacetabular impingement syndrome (FAIS) surgery can produce improvements in function and patient satisfaction; however, data on muscle assessment and kinematics of high mobility tasks of post-operative patients is limited. The purpose of this study was to evaluate kinematics and muscle activity during a deep squat task, as well as muscle strength in a 2-year follow-up FAIS corrective surgery. Eleven cam morphology patients underwent motion and electromyography capture while performing a squat task prior and 2-years after osteochondroplasty and were BMI-, age- and sex-matched to 11 healthy control (CTRL) participants. Isometric muscle strength, flexibility and patient-reported outcome measures (PROMs) were also evaluated. Post-operative FAIS was significantly weaker during hip flexion (23%) and hip flexion-with-abduction (25%) movements when compared with CTRL, no improvements in squat depth were observed. However, post-operative FAIS increased the pelvic range of motion during the squat descent (P = 0.016) and ascent (P = 0.047). They had greater peak activity for the semitendinosus and total muscle activity for the gluteus medius, but decreased peak activity for the glutei and rectus femoris during squat descent; greater total muscle activity for the tensor fascia latae was observed during squat ascent (P = 0.005). Although not improving squat depth, post-operative patients increased pelvic ROM and showed positive PROMs. The muscle weakness associated with hip flexion and flexion-with-abduction observed at the follow-up can be associated with the alterations in the muscle activity and neuromuscular patterns. Rehabilitation programs should focus on increasing pelvis and hip muscles flexibility and strength.
... Because having the pelvis in a more posteriorly tilted position may help in avoiding pain and impingement, focusing on greater activity of the hip extensors and the rectus abdominis muscle during lunge movements could potentially help decrease activity-related symptoms. Indeed, movement retraining has been shown to improve symptoms and function in individuals with FAIS (Hunt et al., 2012). ...
Article
Background Femoroacetabular impingement is a patho-mechanical hip condition that can lead to restrictions in hip motion, particularly in end-range hip flexion, adduction and/or internal rotation. Radiographic evidence of femoroacetabular impingement – cam and/or pincer morphology - is prevalent in the general and athletic populations. There is, however, a lack of studies that have analyzed the performance of sport-specific movements in people possessing these morphologies. Therefore, the purpose of this study was to compare cross-body lunge biomechanics between individuals with and without painful cam and/or pincer morphology. Methods This was an exploratory, cross-sectional study where nine participants with cam and/or pincer morphology and symptoms, thirteen participants with asymptomatic cam and/or pincer morphology, and eleven pain-free controls performed the cross-body lunge during a single session. Trunk, pelvis, hip, knee and ankle kinematics, as well as hip, knee and ankle kinetics and vertical ground reaction forces were examined. Findings Overall, the groups performed the movement similarly, with most variables statistically similar between groups. However, pelvis sagittal plane excursion throughout the entire cross-body lunge was significantly larger in those with cam and/or pincer morphology and symptoms compared to those with asymptomatic cam and/or pincer morphology (P = .046, effect size = 0.98). Interpretation The results of this study show that cross-body lunge performance is similar across individuals with and without painful cam and/or pincer morphology. However, future research should aim to better understand pelvis biomechanics during sporting activities, as pelvis sagittal plane excursion may have important implications in rehabilitation and sport performance.
... 2,7 Recommendations for the prescription of opioids, if necessary, are found in older literature and did not evaluate the influence of said medications on hip pain or function. 8 Studies evaluating opioid use in the perioperative period are limited to small case series. 9 Opioid pain medications are not currently recommended for symptomatic management of FAI syndrome. ...
Article
Full-text available
Purpose: To determine the prevalence of preoperative opioid use in patients with femoroacetabular impingement (FAI) syndrome and to define how opioid use influences preoperative hip pain and function at a single center. Methods: Between February 2015 and September 2016, patients undergoing hip arthroscopy at a single Midwest institution for FAI syndrome were retrospectively reviewed. Patients undergoing arthroscopy for non-FAI conditions and those with undocumented preoperative opioid use were excluded. Baseline validated measures (Hip Disability and Osteoarthritis Outcome Score [HOOS] pain and physical function; University of California, Los Angeles, activity scores; Veterans RAND 12 Item Health Survey) of health were collected at the time of surgery. Articular cartilage status was documented at the time of surgery. Opioid use was extracted from the electronic medical record retrospectively, and patients were designated current users, past users, or nonusers. Analysis of variance and 2-tailed Student's t-tests were used to detect differences between groups according to preoperative opioid use, and significance was set to P < .05. Results: During the study period 321 patients underwent arthroscopic hip surgery for FAI and met the inclusion criteria (75 were excluded). Preoperatively, 55 patients (17%) were current opioid users, 89 (28%) were past users (not within 3 months of surgery), and 177 (55%) were opioid naive. Current opioid use was associated with significantly worse measures of joint and general health including HOOS-Pain (15.3 point difference, P < .001), HOOS-Physical Function (13.6 point difference, P < .001), University of California, Los Angeles, activity score (1.7 point difference, P < .001), and Veterans RAND 12 Item Health Survey mental component score (5.5 point difference, P < .001). Outerbridge cartilage grading and presence or length of labral tears were not worse in opioid users (P = .2-.61). Conclusions: Preoperative opioid use is common prior to arthroscopy for FAI and has detrimental impacts on hip pain and function. The present data also suggest cessation of opioid medication for 3 months prior to surgery may have meaningful impacts on baseline measures of hip and general health. Level of evidence: Level III, prognostic.
... Rehabilitation for CHJP has previously focused primarily on strengthening or flexibility exercises targeting muscle weakness or extensibility deficits. 8,9,17 Although patients in our study demonstrated muscle weakness, 14 muscle strength was not associated with improvements in pain and function. Because of these relationships, we believe improvements in pain and function primarily were due to the training component of MPT that incorporated decreasing excessive hip adduction angle into task-specific activities rather than the hip strengthening exercises. ...
Article
Full-text available
Study Design Ancillary analysis, time-controlled randomized clinical trial. Background Movement pattern training (MPT) has been shown to improve function among patients with chronic hip joint pain (CHJP). Objective Determine the association among treatment outcomes and mechanical factors associated with CHJP. Methods Twenty-eight patients with CHJP, 18-40 years, participated in MPT, either immediately after assessment or after a wait-list period. MPT included task-specific training to reduce hip adduction motion during functional tasks and hip muscle strengthening. Hip-specific function was assessed using modified Harris Hip Score (MHHS) and Hip disability and Osteoarthritis Outcome Score (HOOS). 3D kinematic data were used to quantify hip adduction motion, dynamometry to quantify abductor strength, and magnetic resonance imaging to measure femoral head sphericity using alpha angle. Paired t-tests assessed change from pre- to post-treatment. Spearman correlations assessed associations. Results There was significant improvement in MHHS and HOOS (P<.02), adduction motion (P=.045) and abductor strength (P=.01) between pre- and post-treatment. Reduction in hip adduction motion (r=-0.67, P<.01) and lower body mass index (r=-0.38, P=.049) correlated with MHHS improvement. Alpha angle and abductor strength change were not correlated with change in MHHS or HOOS. Conclusion After MPT, patients reported improvements in pain and function that was associated with their ability to reduce hip adduction motion during functional tasks. Level of Evidence Therapy, level 2b. J Orthop Sports Phys Ther, Epub 16 Mar 2018. doi:10.2519/jospt.2018.7810.
... Agreement between raters occurred on 54 out of 70 items, where κ=0.65, which represents moderate agreement. 29 [30][31][32] seven studies had a moderate risk of bias 7 33-38 and four studies had a low risk of bias. 8 39-41 In the included studies, the overall risk of performance bias (blinding of participants and personnel) and detection bias (blinding of outcome assessors) was high (high in ≥nine studies); the risk of attrition bias (incomplete outcome data) and the risk of selection bias (random sequence generation and allocation concealment) was moderate (high in six to eight studies) and the risk of reporting bias (selective reporting of outcomes) was low (high in <six studies). ...
Article
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Objective To report the effectiveness of physiotherapist-led interventions in improving pain and function in young and middle-aged adults with hip-related pain. Design Systematic review and meta-analysis. Data sources A comprehensive, reproducible search strategy was performed on five databases in May 2019. Reference lists and grey literature were also searched. Eligibility criteria for selecting studies Population: people aged ≥18 years with hip-related pain (with or without a diagnosis of femoroacetabular impingement syndrome). Intervention(s): physiotherapist-led interventions for hip pain. Comparators: sham treatment, no treatment or other treatment (eg, hip arthroscopic surgery). Outcomes: primary outcomes included patient-reported hip pain and function. Secondary outcomes included physical function measures. Results 1722 papers were identified. After exclusion criteria were applied, 14 studies were included for analysis. They had varied risk of bias. There were no full-scale placebo-controlled randomised controlled trials (RCTs) of physiotherapist-led treatment. Pooled effects ranged from moderate effects (0.67 (95% CI 0.07 to 1.26)) favouring physiotherapist-led intervention over no treatment post-arthroscopy, to weak effects (−0.32 (95% CI 0.57 to 0.07)) favouring hip arthroscopy over physiotherapist-led treatment. Conclusion Physiotherapist-led interventions might improve pain and function in young and middle-aged adults with hip-related pain, however full-scale high-quality RCT studies are required. PROSPERO registration number CRD42018089088.
... The lower scores obtained with the iHOT-33 (»30 points) may give the impression that the FAI syndrome causes a greater burden to a patient than when considering the mHHS or HOS scores. However, patients with FAI syndrome have shown increments of »9 points in the mHSS and HOS in response to non-surgical treatment, 11,39 while the improvement in iHOT-33 score was of »14 points 9 (note that the minimal clinically important difference for mHSS, HOS, and iHOT-33 are »8, »9, and »6 points, respectively 40,41 ). In other words, despite the lower baseline scores, there is a greater score change in response to treatment when patients are assessed with iHOT-33 compared to the other two questionnaires. ...
Article
Background The International Hip Outcome Tool (iHOT-33) is a reference instrument among the Patient-Reported Outcome Measures (PROMs) to assess people with hip disorders, including femoroacetabular impingement (FAI) syndrome. Older questionnaires such as the Harris Hip Score, or its modified version (mHHS), and the Hip Outcome Score (HOS), through the full version or its subscales (Activities of Daily Living-ADL; and Sports) are still used in the clinical setting and their construct validity is so far underexplored. Objective To assess the construct validity of mHHS and HOS-ADL compared with iHOT-33 by hypothesis testing in a large sample of patients with FAI syndrome. Methods This retrospective study was conducted with data records from patients with FAI syndrome seeking care at a private physical therapy clinic between 2013 and 2018. All participants completed the three questionnaires (mHHS, HOS-ADL, and iHOT-33) during the physical therapy initial assessment. Results From the 523 patients with FAI syndrome found in the clinic's database, 373 were eligible for this study. An acceptable agreement (r>0.70) was found between HOS-ADL and iHOT-33 (r = 0.77, 95%CI: 0.73, 0.81), but not between mHHS and iHOT-33 (r = 0.68, 95%CI: 0.62, 0.73). HOS-ADL score presented an acceptable agreement with iHOT-Symptoms subscale score (r = 0.78, 95%CI: 0.73, 0.81), while mHHS score did not (r = 0.68, 95%CI: 0.62, 0.73). Neither HOS-ADL or mHHS presented an acceptable agreement with iHOT-Sport, iHOT-Job, or iHOT-Social scores. Conclusion The HOS-ADL score, but not mHSS score, is an acceptable measure of health-related quality of life in patients with FAI syndrome.
... 10 However, the vast majority of patients have relapsing pain and functional impairments and thus progress to surgical intervention. 11,12 At an average of 2 years following hip arthroscopy, 1 in 4 individuals report persistent hip pain and 1 in 3 report unacceptable sports function. 13,14 One potential barrier to decreasing pain and improving functional outcomes for individuals with FAIS is poor mental health. ...
Article
Full-text available
Context: Femoroacetabular impingement syndrome (FAIS) is a painfully debilitating hip condition disproportionately affecting active individuals. Mental health disorders are an important determinant of treatment outcomes for individuals with FAIS. Self-efficacy, kinesiophobia, and pain catastrophizing are psychosocial factors that have been linked to inferior outcomes for a variety of orthopedic conditions. However, these psychosocial factors and their relationships with mental health disorders, pain, and function have not been examined in individuals with FAIS. Objective: (1) To examine relationships between self-efficacy, kinesiophobia, pain catastrophizing, pain, and function in patients with FAIS and (2) to determine if these variables differ between patients with and without a self-reported depression and/or anxiety. Design: Cross-sectional. Setting: University health center. Participants: Fifty-one individuals with FAIS (42 females/9 males; age 35.7 [11.6] y; body mass index 27.1 [4.9] kg/m2). Main outcome measures: Participants completed the Pain Self-Efficacy Questionnaire, Tampa Scale for Kinesiophobia, Pain Catastrophizing Scale, visual analog scale for hip pain at rest and during activity, and the 12-item International Hip Outcome Tool. Self-reported depression and/or anxiety were recorded. The relationships between psychosocial factors, pain, and function were examined using Spearman rank-order correlations. Independent t tests and Mann-Whitney U tests were used to evaluate the effect of self-reported depression and/or anxiety on psychosocial factors, pain and function. Results: The 12-item International Hip Outcome Tool was correlated with pain during activity (ρ = -.57, P ≤ .001), Tampa Scale for Kinesiophobia (ρ = -.52, P ≤ .001), and Pain Self-Efficacy Questionnaire (ρ = .71, P ≤ .001). The Pain Self-Efficacy Questionnaire was also correlated with pain at rest (ρ = -.43, P = .002) and pain during activity (ρ = -.46, P = .001). Individuals with self-reported depression and/or anxiety (18/51; 35.3%) had worse self-efficacy and pain catastrophizing (P ≤ .01). Conclusion: Self-reported depression and/or anxiety, low self-efficacy, and high kinesiophobia were associated with more hip pain and worse function for patients with FAIS. These findings warrant further examination including psychosocial treatment strategies to improve the likelihood of a successful clinical outcome for this at-risk population.
... Patients with FAIS have altered hip muscle strength, range of motion (ROM) and gait biomechanics, and these offer potential targets for treatment through physiotherapy. However, limited articles with a high quality of evidence 19,20 suggested that conservative treatment was beneficial for FAI patients. Until recently, both AHS and conservative therapy can be the option for FAIS while the most suitable choice for FAIS patients is still controversial due to the limited evidence. ...
Article
Full-text available
To determine the outcome and differences between arthroscopic hip surgery and conservative therapy in patients suffering from femoroacetabular impingement syndrome, we searched articles from PubMed, Embase, Cochrane, Web of Science and Clinicaltrials.gov using a Boolean search algorithm. Only randomized controlled trials comparing arthroscopic hip surgery and conservative therapy were included in this meta-analysis of femoroacetabular impingement syndrome management. Two authors determined eligibility, extracted the needed data and assessed the risk of bias of eligible studies independently. Then we meta-analyzed three articles to assess pooled estimate size (ES) and 95% confidence interval for Hip Outcome Score of activities of daily living (HOS ADL subscale), Hip Outcome Score sport (HOS sports subscale) and International Hip Outcome Tool (iHOT-33) analyses were performed by using STATA version 14.0 MP (STATA, College Station, TX, USA) with the principal summary measures are mean between group difference, sample size, and standard deviation. We collected 52 articles in total after removing duplicates and screened by titles and abstracts. A total of three RCTs were included finally. There was definite evidence of additional benefit of arthroscopic hip surgery against conservative therapy in the field of improving quality of life (three trials, 575 participants, ES = 2.109, 95% CI: 1.373 to 2.845, I² = 42.8%, P = 0.000) and activity of daily living (two trials, 262 participants, ES = 9.220, 95% CI: 5.931 to 12.508, I² = 16.5%, P = 0.000). However, no significant difference could be seen in sports function improvement (two trials, ES = 7.562, 95% CI: −2.957 to 18.082, I² = 60.1%, P = 0.159). In conclusion, this meta-analysis suggests that arthroscopic hip surgery provided essential benefit compared with conservative therapy in improving activity of daily living and quality of life.
... Therefore, long-term follow-up of patients with a labral tear is likely necessary. Those with ongoing symptoms and especially patients who are more active at baseline may choose to pursue surgical intervention [123]. In addition, a [103] recent study of adolescent athletes demonstrated the high risk of progressing to surgical intervention when bony FAI is present in addition to a labral tear. ...
Article
Full-text available
Purpose of Review This paper aims to assess the pathophysiology, diagnosis, and latest evidence-based treatment of acetabular labral tears. Recent Findings The acetabular labrum contributes to the stability of the hip. Labral tears may lead to significant pain and disability, although many are asymptomatic. Imaging and intra-articular injections are often required in addition to standard history and physical examination for accurate diagnosis. Most patients will benefit from initial conservative treatment, but those requiring surgical intervention may have better outcomes with labral repair over debridement. If the labral tear is irreparable, reconstruction is favored. There is still conflicting evidence regarding the efficacy of surgical versus non-surgical treatment likely due to heterogeneity of pathology, patient activity, and lack of long-term follow up. Summary The approach to management of acetabular labral tears starts with confirming the labrum as the primary pain generator. Most patients benefit from initial conservative treatment. Ultimately, the decision for surgical treatment is dependent on correct patient selection. Those patients who are youger, with bony morphologic changes, a higher activity level, an isolated labral tear without significant cartilage degeneration, and good response to intra-articular diagnostic injection will likely have better outcomes with surgical treatment.
... 16 Evidence suggests that PT of at least 12 weeks duration is recommended to correct chronic biomechanical dysfunction. [17][18] Individualized exercise-based programs including proximal hip and core strengthening, hip and lumbopelvic mobility, and neuromuscular exercises should be included. A well-designed therapy regimen for chronic, non-arthritic hip pain can help alleviate symptoms, postponing or negating the need for hip surgery. ...
Article
Background: Comprehensive conservative care prior to arthroscopic hip surgery is recommended, but not all patients pursue a course of physical therapy (PT) prior to consulting a hip surgeon. The purpose of this study is to investigate the incidence and type of PT administered to patients with hip pain prior to consulting a hip surgeon. Methods: We conducted a single-center, questionnaire-driven study at a young adult hip preservation clinic that exclusively treats patients with hip pain. Thirty (88%) of thirty-four consecutive new patients answered the 15-item questionnaire. The questionnaire was designed to inquire about the reason for the visit, type of formal PT received (hip strengthening, leg strengthening etc.), and additional treatments received prior to the visit (electric stimulation, narcotics etc.). Descriptive statistics were utilized to quantify the reason for visit, PT prior to the visit, and type of exercises performed during physical therapy. Results: Overall, 21 (70%) patients received physical therapy prior to consulting with a hip surgeon. Of those who received PT, 91% (n=19) did hip strengthening exercises, 76% (n=16) did focused hip stretching exercises, 62% (n=13) did leg strengthening exercises, 57% (n=12) did joint mobilization exercises, and 52% (n=11) did focused core strengthening exercises. Only 48% (n=10) reported improvement in symptoms with PT. Of those who received additional treatments, 77% (n=20) took anti-inflammatory medications regularly, 50% (n=13) underwent electric stimulation, 31% (n=8) had chiropractic manipulation, 19% (n=5) underwent soft tissue mobilization, 15% (n=4) received steroid injections, and 12% (n=3) were prescribed narcotics for hip pain. Conclusion: The present study offers insight into the incidence and type of formal PT patients with hip pain receive before consulting a hip surgeon. Treatment methods during PT visits are variable, which makes determining outcomes of conservative care difficult to assess in this population.Level of Evidence: IV.
... Corticosteroids are frequently used in the nonoperative treatment of chondral and meniscal pathology and have proven efficacious in pain relief. 11,25,26 When nonoperative treatment fails, some surgeons advocate for intra-articular CSI at the time of arthroscopy, as the anti-inflammatory properties of corticosteroids are thought to mitigate the pain of inflamed synovial tissue and contribute to hemostasis. 10 This practice has been shown to reduce postoperative analgesic consumption and pain scores and hasten recovery. 13,14,20 Although intra-articular CSI does provide demonstrable clinical benefit, there remains concern that perioperative injection increases the risk of postoperative infection. ...
Article
Full-text available
Background Recent evidence suggests that there may be an increased risk of infection for patients undergoing a corticosteroid injection before, during, or after knee arthroscopy. Purpose To systematically review the literature to evaluate the risk of postoperative infection in patients undergoing intra-articular corticosteroid injections (CSI) before, during, or after knee arthroscopy. Study Design Systematic review; Level of evidence, 3. Methods A systematic review was performed by searching the PubMed, Cochrane Library, and Embase databases to identify studies that evaluated the rate of postoperative infection in patients undergoing knee arthroscopy who received an intra-articular CSI during the perioperative period. The search phrase used was “knee AND arthroscopy AND injection AND (infection OR revision).” A subanalysis was also performed to analyze infection rates based on the timing of the corticosteroid injection in relation to arthroscopy. Results Four studies met the inclusion criteria, representing 11,925 patients undergoing knee arthroscopy with an intra-articular CSI administered during the perioperative period (mean follow-up, 5.3 months) and 247,329 patients without a corticosteroid injection during the perioperative period (mean follow-up, 5.9 months). Patients who received an injection experienced a statistically significantly higher rate of postoperative infection (2.2%) when compared with patients who did not receive an injection (1.1%; P < .001). When analyzed by the timing of the injection, patients receiving an injection preoperatively or intraoperatively experienced a statistically significantly higher rate of postoperative infection (3% and 2.6%, respectively) when compared with patients receiving an injection postoperatively (1.4%; P = .001 for both). Conclusion Patients undergoing knee arthroscopy who receive an intra-articular CSI during the perioperative period can be expected to experience significantly higher postoperative infection rates when compared with patients not receiving an injection. Furthermore, patients receiving a corticosteroid injection pre- or intraoperatively may experience significantly higher rates of postoperative infection when compared with patients receiving an injection postoperatively.
... 27 The success rates of nonoperative treatment for FAI have ranged from 39% to 82%. 13,20 Rigorous comparative research between outcomes of PT and FAI surgery has been previously lacking. The National Institutes of Healthsponsored American Academy of Orthopaedic Surgeons/ Orthopaedic Research Society (AAOS/ORS) FAI Research Symposium of international leaders in 2012 concluded, "an urgent need exists for a randomized clinical trial that could compare the surgical and nonsurgical management of symptomatic FAI to justify definitively the need for surgical intervention in these patients." ...
Article
Full-text available
Background Both physical therapy (PT) and surgery are effective in treating femoroacetabular impingement (FAI), but their relative efficacy has not been well established until recently. Several randomized controlled trials (RCTs) comparing the early clinical outcomes of these treatments have been published, with contradictory results. Purpose/Hypothesis The purpose of this study was to perform a meta-analysis of RCTs that compared early patient-reported outcomes (PROs) of hip arthroscopy versus PT in patients with symptomatic FAI. The hypothesis was that surgical treatment of FAI leads to better short-term outcomes than PT. Study Design Systematic review; Level of evidence, 1. Methods In March 2019, a systematic review was performed to identify RCTs comparing hip arthroscopy and PT in patients with symptomatic FAI. A total of 819 studies were found among 6 databases; of these, 3 RCTs met eligibility (Griffin et al, 2018; Mansell et al, 2018; and Palmer et al, 2019). All 3 RCTs reported international Hip Outcome Tool--33 (iHOT-33) scores, and 2 reported Hip Outcome Score (HOS)–Activities of Daily Living (ADL) and HOS-Sport results. In a random-effects meta-analysis, between-group differences in postintervention scores were assessed according to intention-to-treat and as-treated approaches. Quality was assessed with CONSORT, CERT, TiDieR, and the Cochrane Collaboration tool. Results The 3 RCTs included 650 patients with FAI; the mean follow-up ranged from 8 to 24 months. All studies reported PRO improvement from baseline to follow-up for both PT and surgery. The quality of the Griffin and Palmer studies was good, with minimal bias. In the Mansell study, a 70% crossover rate from PT to surgery increased the risk of bias. The meta-analysis demonstrated improved iHOT-33 outcomes with surgery compared with PT for intention-to-treat (mean difference [MD], 11.3; P = .046) and as-treated (MD, 12.6; P = .007) analyses. The as-treated meta-analysis of HOS-ADL scores favored surgery (MD, 12.0; P < .001), whereas the intention-to-treat analysis demonstrated no significant difference between groups for HOS-ADL (MD, 3.9; P = .571). Conclusion In patients with FAI, the combined results of 3 RCTs demonstrated superior short-term outcomes for surgery versus PT. However, PT did result in improved outcomes and did not appear to compromise the surgical outcomes of patients for whom therapy failed and who progressed to surgery.
... However, because HD does not necessarily require surgery, other modalities such as physical therapy, injections, and exercise rehabilitation may be beneficial. In a previous study, 56% of the participants opted for surgery and 44% preferred conservative treatment; the results were satisfactory in both groups [10]. In addition, it was reported that flexion strength, pain scale, and subjective hip joint score in patients with HD significantly improved after 8 weeks of strength training [11]. ...
Article
Full-text available
Hip dysplasia (HD) is a typical developmental abnormality of the hip joint, and discomfort is often found in adulthood. This study compared patients with symptomatic HD in muscle strength, dynamic balance, and range of motion (ROM) with healthy individuals. Patients included those who complained of unilateral pain although the lateral center edge angle (LCEA) exhibited bilateral abnormality. Participants (n = 95; men: 46, women: 49) were divided into symptomatic and asymptomatic sides, and a healthy group without a history of hip joint disease (n = 70; men: 30, women: 40) was compared. Hip flexion, extension, abduction, and adduction were performed at an angular velocity of 30°/s using an isokinetic strength test device. The Y-balance test was conducted to measure dynamic balance, and ROM was measured using an electronic goniometer to evaluate flexion, extension, adduction, abduction, and internal and external rotations. In addition, the pain visual analog scale (VAS) and hip and groin outcome scale (HAGOS), a subjective evaluation of the hip joint, were evaluated. ROM (flexion, abduction, internal rotation, and external rotation) was significantly decreased in the HD symptomatic sides of men and women compared to those of the healthy group and the asymptomatic side, and the dynamic balance, flexion, and abduction muscle strength were also lower on the symptomatic sides. Although the LCEA of the HD asymptomatic side was lower than that of the healthy group, there were no significant differences in VAS, flexion, extension, abduction ROM, and extension strength compared to those of healthy individuals. In conclusion, patients with HD were mostly bilateral, and on the symptomatic side, there was a decrease in ROM, dynamic balance, and muscle strength; however, on the asymptomatic side, the function was relatively close to normal.
... I ntra-articular corticosteroid injections (CSIs) are a key component in the nonoperative management of a range of hip pathologies. In the setting of labral injuries and other prearthritic sources of hip symptoms, CSIs may reduce pain, improve rehabilitation and strengthening, and/or delay the need for hip arthroscopy [1][2][3][4] . In the setting of osteoarthritis (OA), corticosteroids are the gold-standard injectate for reducing pain and improving short-term function 5,6 . ...
Article
Background: Although intra-articular corticosteroid injections (CSIs) are a cornerstone in the nonoperative management of hip pathology, recent reports have raised concerns that they may cause osteonecrosis of the femoral head (ONFH). However, these studies might have been limited by nonrepresentative patient samples. Therefore, the purpose of this study was to assess the incidence of ONFH after CSI and compare it with the incidence in a similar patient population that received a non-CSI injection. Methods: This was a retrospective propensity-matched cohort study of patients in the MarketScan database who underwent an intra-articular hip injection from 2007 to 2017. Patients receiving hip CSIs were matched 4:1 with patients receiving hip hyaluronic acid injections (HAIs) based on age, sex, geographic region, comorbidities, type of hip pathology, injection year, and baseline and follow-up time using propensity scores. The patients' first injections were identified, and the time to development of ONFH was analyzed using Kaplan-Meier curves and Cox proportional-hazards models. Patients with a history of osteonecrosis or those who received both types of injections were excluded. Results: A total of 3,710 patients undergoing intra-articular hip injection were included (2,968 CSIs and 742 HAIs; mean [standard deviation] age, 53.1 [9.2] years; 55.4% men). All baseline factors were successfully matched between the groups (all p > 0.57). The estimated cumulative incidence (95% confidence interval [CI]) of ONFH for CSI and HAI patients was 2.4% (1.8% to 3.1%) versus 2.1% (1.1% to 3.5%) at 1 year and 2.9% (2.2% to 3.7%) versus 3.0% (1.7% to 4.8%) at 2 years (hazard ratio, 1.05; 95% CI, 0.59 to 1.84; p = 0.88). The results held across a range of sensitivity analyses. Conclusions: The incidence of ONFH after intra-articular hip injection was similar between patients who received CSIs and those who received HAIs. Although this study could not determine whether intra-articular injections themselves (regardless of the drug that was used) lead to ONFH, the results suggest that ONFH after CSI often may be due, in part, to the natural course of the underlying disease. Future randomized controlled trials are needed to definitively answer this question; in the interim, clinicians may be reassured that they may continue judicious use of CSIs as clinically indicated. Level of evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
... Other studies have also found that those who had symptoms for >12 months have worse outcomes and are more likely to undergo additional intervention. [36][37][38][39] Additionally, given the high incidence of grade 3 and 4 chondromalacia noted at the time of surgery in some studies, one could argue that FAI corrective surgery might be more beneficial if performed earlier in some instances. 40 In our study, 93.8% of the patients that underwent FAI surgery had at least 6 months of symptoms prior to surgery. ...
Article
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Background: With the rapidly growing body of FAI literature in the last decade, improved evidence exists to support FAI surgery. However, it remains unclear how well third-party insurance company's FAI policies have adapted over time to improved evidence. The purpose of this study was (1) to compare the 2020 FAI surgery criteria of four major insurance companies utilizing a multi-center cohort of FAI patients undergoing surgery to identify rates and causes of ineligibility, and (2) to compare the rates of approval based on changes in policy from 2012 to 2020. Methods: Four major insurance companies' coverage policies with specific criteria for the surgical treatment of FAI were applied to this population at two time points (2012 and 2020). The policies listed various combinations of age, symptom duration, radiographic signs of FAI, radiographic signs of osteoarthritis, and physical exam findings. A prospective, multi-center cohort of 712 patients (including 45.5% males and 54.5% females with a mean age of 28.7 years) undergoing surgical treatment of FAI was utilized for analysis of insurance policies. Results: Based on 2020 FAI policies across 4 insurers, 22.5% (range 18.4-28.4%) of FAI patients would be deemed ineligible. In 2012, the average percent exclusion of the four companies was 23.7%. The most likely reason to be excluded was either failure to meet imaging criteria (alpha angle >50° or positive cross-over sign) [13%, n=94]) or the absence of an impingement sign (9%, n=65). Other causes of exclusion were <6-month symptom duration (6%, n=44), age <15 years (4%, n=28), or skeletally immaturity (3%, n=23). Conclusion: Our study shows that despite a six-year span of growing literature and updated policies, nearly 1 in 5 patients diagnosed with FAI would still potentially be denied coverage. This highlights a continued divide between surgeons and insurance companies. There is a major need for improved consensus regarding the diagnosis of FAI and appropriate indications for surgical intervention.Level of Evidence: IV.
... At the time of the rst medical examination, patients began a 6-month trial of nonsurgical management consisting of patient education, activity modi cation, physical therapy, and/or anti-in ammatory medications [7]. ...
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Background: Repeated microtrauma often causes damage to the periarticular soft tissues. This damage, together with the lack of acetabular bony coverage, such as developmental dysplasia of the hip (DDH), can contribute to various degrees of dynamic instability of the hip joint and cause progressive osteoarthritic changes The purpose of this study was to use an image-matching procedure to compare dynamic instability of the hip joint in patients with DDH who did or did not undergo periacetabular osteotomy (PAO). Methods: Six patients (6 hips) with symptomatic DDH were enrolled. A 6-month trial of nonsurgical management was initiated at the first visit. PAO was performed in 3 patients who experienced persistent pain after conservative treatment. The dynamic instability of all 6 hips was evaluated. Results: Japanese Orthopaedic Association hip scores improved significantly in all hips regardless of PAO. At the first visit, the center-edge angle, Sharp angle, vertical-center-anterior angle, and acetabular head index were not significantly different between the PAO and non-PAO groups. Dynamic instability was defined as the 3D translation of the femoral head center for the acetabular center at hip abduction angles from 0° to 30°. In the non-PAO group, the mean sagittal, axial, and coronal translations were 2.4 mm, 2.2 mm, and 1.1 mm, respectively, and in the PAO group they were 2.4 mm, 7.2 mm, and 2.7 mm, respectively. There was a significant difference in axial translation between the 2 groups. Conclusion: Dynamic instability leads to periarticular soft tissue damage and insufficient bony coverage, and causes progressive osteoarthritic changes. Dynamic instability in the axial plane induces persistent hip pain after nonsurgical management. Affected patients should undergo PAO as soon as possible.
... Because having the pelvis in a more posteriorly tilted position may help in avoiding pain and impingement, focusing on greater activity of the hip extensors and the rectus abdominis muscle during lunge movements could potentially help decrease activity-related symptoms. Indeed, movement retraining has been shown to improve symptoms and function in individuals with FAIS (Hunt et al., 2012). ...
Article
Background Hip dysplasia belongs to the most frequent hip deformities and is a relevant risk factor for osteoarthritis.Objectives What is the influence of dysplasia on hip osteoarthritis? What is the indication for conservative treatment and surgical intervention?Material and MethodsA literature analysis up to 2021 providing data about the natural course of hip dysplasia and osteoarthritis was performed. In addition, publications were screened for the presence of criteria regarding patient selection as well as optimal timing of surgical interventions.ResultsMost publications show an association between hip dysplasia and osteoarthritis. Decreasing acetabular coverage and instability (i.e. subluxation) increase the risk for the development of hip osteoarthritis. Surgical correction of hip dysplasia should be considered mainly for patients without relevant osteoarthritis. Concommittant other hip deformities should be corrected as well.Conclusion In adolescent and adult patients with symptomatic hip dysplasia and limited degenerative changes pelvic osteotomies should be considered as primary treatment option. Conservative treatment is restricted to asymptomatic patients, patients with relevant degenerative changes who are not suitable for joint preserving surgery and an age above 50 years. If performed in young patients with hip pain, it should be considered only for a limited time, not risking the right moment for the operation and it’s protective influence.
Article
Objective: To review the literature guiding all aspects of the use of injectable corticosteroids for painful musculoskeletal conditions, with a focus on the treatment of athletes. Data sources: An extensive search of the literature was completed including search terms of corticosteroid, steroid, athlete, and injection, among others. Additional articles were used after being identified from previously reviewed articles. Main results: Injections of corticosteroids for a variety of painful conditions of the extremities and the axial spine have been described. Numerous minor and major complications have been reported, including those with a high degree of morbidity. There is a dearth of published research on the use of corticosteroid injections in athletes, with most of the research on this topic focused on older, nonathlete populations. Generally, these injections are well tolerated and can provide short-term pain improvement with little or no long-term benefits. Conclusions: Corticosteroid injections should be used cautiously in athletes and only after a full consideration of the pharmacology, pathogenesis of disease, potential benefits, complications, factors specific to the athlete, and rules of athletic governing bodies. Corticosteroid injections are just one component of a comprehensive rehabilitation plan available to the physician providing care to athletes.
Article
Background: The diagnosis and treatment of femoroacetabular impingement (FAI) have increased steadily within the past decade, and research indicates clinically significant improvements after treatment of FAI with hip arthroscopy. Purpose: This study examined the societal and economic impact of hip arthroscopy by high-volume surgeons for patients with FAI syndrome aged <50 years with noncontroversial diagnosis and indications for surgery. Study design: Economic and decision analysis; Level of evidence, 2. Methods: The cost-effectiveness of hip arthroscopy versus nonoperative treatment was evaluated by calculating direct and indirect treatment costs. Direct cost was calculated with Current Procedural Terminology medical codes associated with FAI treatment. Indirect cost was measured with the patient-reported data of 102 patients who underwent arthroscopy and from the reimbursement records of 32,143 individuals between the ages of 16 and 79 years who had information in a private insurance claims data set contained within the PearlDiver Patient Records Database. The indirect economic benefits of hip arthroscopy were inferred through regression analysis to estimate the statistical relationship between functional status and productivity. A simulation-based approach was then used to estimate the change in productivity associated with the change in functional status observed in the treatment cohort between baseline and follow-up. To analyze cost-effectiveness, 1-, 2-, and 3-way sensitivity analyses were performed on all variables in the model, and Monte Carlo analysis evaluated the impact of uncertainty in the model assumptions. Results: Analysis of indirect costs identified a statistically significant increase of mean aggregate productivity of $8968 after surgery. Cost-effectiveness analysis showed a mean cumulative total 10-year societal savings of $67,418 per patient from hip arthroscopy versus nonoperative treatment. Hip arthroscopy also conferred a gain of 2.03 quality-adjusted life years over this period. The mean cost for hip arthroscopy was estimated at $23,120 ± $10,279, and the mean cost of nonoperative treatment was estimated at $91,602 ± $14,675. In 99% of trials, hip arthroscopy was recognized as the preferred cost-effective strategy. Conclusion: FAI syndrome produces a substantial economic burden on society that may be reduced through the indirect cost savings and economic benefits from hip arthroscopy.
Article
Introduction Extensive literature has described surgical outcomes for pre-arthritic hip pain, but the proportion of patients who progress to surgery remains unknown. Objective To determine the proportion of patients who present to a tertiary referral center for pre-arthritic hip pain and progress to surgery at minimum one year follow-up. Design Retrospective cohort study. Setting Single tertiary care academic medical center. Patients Thirteen to 40-year-olds who presented for initial evaluation to a conservative or surgical orthopedic specialist and were diagnosed with pre-arthritic hip pain (n=713 patients, 830 hips). Intervention Not applicable. Main Outcome Measures The primary outcome was the rate of progression to surgery at minimum one year follow-up for the entire cohort. Predictors of progression to surgery were determined for the entire cohort and for radiographically defined subgroups using multiple logistic regression. Candidate predictors included baseline demographic, radiographic, clinical diagnosis, and patient-reported outcome measures. Results In a cohort with mean age 25.4 (SD 8.1) years, 72.7% female, and mean follow-up 2.6 (range 1.0-4.8) years, 429/830 hips (51.7% [95% CI 48.2%-55.1%]) progressed to surgery. Predictors of surgical progression in the entire cohort included younger age (OR 0.95/year [95% CI 0.93-0.98]), pain duration longer than six months (OR 1.87-2.03, p≤.027), worse physical function (OR 0.96/Patient-Reported Outcomes Measurement Information System (PROMIS) point [0.92-0.99]), and a clinical diagnosis of femoroacetabular impingement (FAI) (OR 3.47 [2.05-5.89]), acetabular dysplasia (OR 2.75 [1.73-4.35]), and/or labral tear (OR 10.71 [6.98-16.47]). Radiographic dysplasia (lateral center edge angle<20⁰) increased the likelihood of surgery in all subgroups (OR 2.05-8.47, p≤.008). Increasing maximum α angle increased the likelihood of surgery in patients with severe cam FAI (α>63⁰) (OR 1.03/degree [1.00-1.06]). Conclusion Almost half of patients with pre-arthritic hip pain did not progress to surgery at minimum one year follow-up. A trial of conservative management is likely worthwhile in most patients. This article is protected by copyright. All rights reserved.
Article
This statement summarises and appraises the evidence on diagnostic tests and clinical information, and non-operative treatment of femoroacetabular impingement (FAI) syndrome and labral injuries. We included studies based on the highest available level of evidence as judged by study design. We evaluated the certainty of evidence using the Grading of Recommendations Assessment Development and Evaluation framework. We found 29 studies reporting 23 clinical tests and 14 different forms of clinical information, respectively. Restricted internal hip rotation in 0° hip flexion with or without pain was best to rule in FAI syndrome (low diagnostic effectiveness; low quality of evidence; interpretation of evidence: may increase post-test probability slightly), whereas no pain in Flexion Adduction Internal Rotation test or no restricted range of motion in Flexion Abduction External Rotation test compared with the unaffected side were best to rule out (very low to high diagnostic effectiveness; very low to moderate quality of evidence; interpretation of evidence: very uncertain, but may reduce post-test probability slightly). No forms of clinical information were found useful for diagnosis. For treatment of FAI syndrome, 14 randomised controlled trials were found. Prescribed physiotherapy, consisting of hip strengthening, hip joint manual therapy techniques, functional activity-specific retraining and education showed a small to medium effect size compared with a combination of passive modalities, stretching and advice (very low to low quality of evidence; interpretation of evidence: very uncertain, but may slightly improve outcomes). Prescribed physiotherapy was, however, inferior to hip arthroscopy (small effect size; moderate quality of evidence; interpretation of evidence: hip arthroscopy probably increases outcome slightly). For both domains, the overall quality of evidence ranged from very low to moderate indicating that future research on diagnosis and treatment may alter the conclusions from this review.
Article
Background:: The literature has given little attention to the nonoperative management of femoroacetabular impingement (FAI) syndrome despite a rapidly expanding body of research on the topic. Purpose:: To perform a prospective study utilizing a nonoperative protocol on a consecutive series of patients presenting to our clinic with FAI syndrome. Study design:: Cohort study; Level of evidence, 2. Methods:: Between 2013 and 2016, patients meeting the following criteria were prospectively recruited in a nonoperative FAI study: no prior hip surgery, groin-based pain, a positive impingement test, and radiographic FAI syndrome. The protocol consisted of an initial trial of rest, physical therapy, and activity modification. Patients who remained symptomatic were then offered an image-guided intra-articular steroid injection. Patients with recurrent symptoms were then offered arthroscopic treatment. Outcome scores were collected at 12 and 24 months. Statistical analysis was performed to identify risk factors for the need for operative treatment and to determine patient outcomes based on FAI type and treatment. Results:: Ninety-three hips (n = 76 patients: mean age, 15.3 years; range, 10.4-21.4 years) were included in this study and followed for a mean ± SD 26.8 ± 8.3 months. Sixty-five hips (70%) were managed with physical therapy, rest, and activity modification alone. Eleven hips (12%) required a steroid injection but did not progress to surgery. Seventeen hips (18%) required arthroscopic management. All 3 groups saw similar improvements in modified Harris Hip Score ( P = .961) and nonarthritic hip score ( P = .975) with mean improvements of 20.3 ± 16.8 and 13.2 ± 15.5, respectively. Hips with cam impingement and combined cam-pincer impingement were 4.0 times more likely to meet the minimal clinically important difference in modified Harris Hip Score ( P = .004) and 4.4 times more likely to receive surgical intervention ( P = .05) than patients with pincer deformities alone. Participants in team sports were 3.0 times more likely than individual sport athletes to return to competitive activities ( P = .045). Conclusion:: A majority (82%) of adolescent patients presenting with FAI syndrome can be managed nonoperatively, with significant improvements in outcome scores at a mean follow-up of 2 years. Clinical relevance:: A nonoperative approach should be the first-line treatment for young active patients with symptomatic FAI syndrome.
Article
Background:: Acetabular labral tears are increasingly recognized as a source of hip pain in a younger active population. Given the significant focus on surgical intervention, there has been limited investigation on the nonsurgical management and natural history of such injuries. Hypothesis:: Patients undergoing nonsurgical treatment for symptomatic acetabular labral tears experience functional improvement based on patient-reported outcome measures over the course of 1 year. Study design:: Case series; Level of evidence, 4. Methods:: Seventy-one patients were identified who had acetabular labral injuries confirmed by magnetic resonance imaging or arthrography, received a minimum of 1 year of nonsurgical treatment, and completed baseline functional outcome questionnaires: modified Harris Hip Score (mHHS), Hip Outcome Score (HOS)-Activities of Daily Living, HOS-Sports, and iHOT-33 (International Hip Outcome Tool-33). Of these, 52 (73.2%) completed the minimum 1-year follow-up questionnaires. Chart review was conducted to obtain demographic information. Statistical significance ( P < .05) was determined by paired t test, independent samples t test, and chi-square test. Results:: Twenty-two male and 30 female patients completed 1-year follow-up questionnaires. Mean ± SD follow-up time was 16.2 ± 3.1 months. The cohort had a mean age of 38.9 ± 9.3 years. Baseline radiographs demonstrated minimal arthritis (Tönnis grades 0-2). Mean alpha angle differed significantly between men and women at 52.9°± 8.6° and 46.3°± 8.5°, respectively. At 1-year follow-up, patients experienced a significant improvement in all 4 functional outcome measures (mHHS: 72.6 vs 81.8, HOS-Activities of Daily Living: 78.6 vs 86.4, HOS-Sports: 56.0 vs 71.1, iHOT-33: 47.5 vs 67.9). Patients with and without femoroacetabular impingement demonstrated a significant improvement in the mHHS. However, 48.1% reported no improvement in their pain; 69.2% were limited in their activities; and 40.4% were still considering surgery. Overall, 71.2% were satisfied with nonsurgical treatment. Conclusion:: Patients with symptomatic labral tears can experience functional improvement after a minimum 1 year of nonsurgical treatment in the presence and absence of femoroacetabular impingement. However, many report residual pain, alteration of their activities, and interest in surgery. This information is important when patients are counseled in the treatment options for this injury. Identifying the population that responds best to nonsurgical management and comparing outcomes with those undergoing surgical management should be the focus of future research. Longer-term follow-up may be necessary to reevaluate pain, function, and return to activities.
Article
Introduction Physical therapy and hip arthroscopy are two viable treatment options for patients with non-arthritic hip pain(NAHP); however, patients may experience considerable decisional conflict when making a treatment decision. Interdisciplinary evaluation with a physical therapist and surgeon may better inform the decision-making process and reduce decisional conflict. Objective Identify the extent to which an interdisciplinary evaluation between a surgeon, physical therapist, and patient influences treatment plans and decisional conflict of persons with NAHP. Design Randomized controlled trial. Setting Hip preservation clinic. Participants Adults with primary NAHP. Interventions Participants were randomized to receive a standard (surgeon) or interdisciplinary (surgeon+physical therapist) evaluation. Surgeon evaluations included patient interview, strength and range-of-motion examination, palpation, gross motor observation, and special testing. Interdisciplinary evaluations started with the surgeon evaluation, then a physical therapist evaluated movement impairments during sitting, sit-to-stand, standing, single-leg stance, single-leg squat, and walking. All evaluations concluded with treatment planning with the respective provider(s). Outcome Measures Treatment plan and decisional conflict were collected pre- and post-evaluation. Inclusion of physical therapy(PT) in participants' post-evaluation treatment plans and post-evaluation decisional conflict were compared between groups using chi-squared tests and Mann Whitney U tests, respectively. Results 78 participants (39 in each group) met all eligibility criteria and were included in all analyses. Sixty-six percent of participants who received an interdisciplinary evaluation included PT in their post-evaluation treatment plan, compared to 48% of participants who received a standard evaluation (P = 0.10). Participants who received an interdisciplinary evaluation reported 6.3 points lower decisional conflict regarding their post-evaluation plan (100-point scale; P = 0.04). The interdisciplinary and standard groups reduced decisional conflict on average 24.8 ± 18.9 and 23.6 ± 14.6 points, respectively. Conclusions Adding a physical therapist to a surgical clinic increased interest in PT treatment, but this increase was not statistically significant. The interdisciplinary group displayed lower post-evaluation decisional conflict; however, both groups displayed similar reductions in decisional conflict from pre- to post-evaluation. This study also demonstrated the feasibility of an interdisciplinary evaluation in a hip preservation clinic. This article is protected by copyright. All rights reserved.
Article
Background: Ultrasound-guided intra-articular hip injections have become a mainstay in the diagnosis and treatment of various hip disorders. Concern arises with regard to the chronological proximity of an injection to subsequent arthroscopy. Thus, the purpose of this study was to report the risk of postoperative infections among patients who have undergone an intra-articular corticosteroid injection within 3 months of hip arthroscopy. Methods: In-office, ultrasound-guided, intra-articular hip injections were first performed at this center in 2011. Corticosteroid is used for therapeutic purposes in the presence of painful hip conditions to reduce joint symptoms, either to allow for more effective supervised physical therapy or simply as a last line of nonoperative management. A retrospective review of patient records was performed, identifying all patients who had undergone arthroscopy and had received an intra-articular injection of corticosteroid at this institution within 3 months of the surgical procedure. Results: Five hundred patients underwent an ultrasound-guided intra-articular injection of corticosteroid within 3 months of a hip arthroscopy. The mean age was 37.6 years (range, 14 to 74 years), with 112 male patients and 388 female patients. The mean time between the injection and the arthroscopy was 59 days (range, 15 to 92 days). There were no postoperative infections. Conclusions: When both the injection and the procedure are performed in a tertiary referral center, an ultrasound-guided intra-articular injection of corticosteroid within 3 months prior to arthroscopy, at a mean time of 59 days, resulted in no postoperative infections among 500 cases and can represent an acceptably low rate of complication. To our knowledge, this is the largest reported series on this subject. Level of evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Article
Acetabular dysplasia represents a structural pathomorphology associated with hip pain, instability, and osteoarthritis. The wide spectrum of dysplasia anatomically refers to a 3-dimensional volumetric- and surface area-based insufficiency in coverage and is classified based on the magnitude and location of undercoverage. Borderline dysplasia has been variably defined and leads to management challenges. In symptomatic dysplasia, treatment addresses coverage with periacetabular osteotomy. Concomitant simultaneous or staged hip arthroscopy has significant advantages to address intra-articular pathology. In nonarthritic individuals, there is evidence PAO alters the natural history of dysplasia and decreases the risk of hip arthritis and total hip arthroplasty.
Article
Introduction: This study aimed to clarify the relationship of individual radiographic parameters and features with the patient-reported outcome measurements (PROMs) of patients with developmental dysplasia of the hip (DDH) in a hospital-referred cross-sectional analysis. Methods: This cross-sectional study included 108 Japanese DDH patients (female, n = 88; male, n = 20; mean age, 43.4 years). We recorded the CE angle, angle of Sharp, ARO, ADR, AHI, crossover sign, pistol grip deformity, and femoral head-neck ratio, which were measured on the AP view, and the α-angle, which was measured on the Lauenstein view. We also recorded cyst formation and osteophytes on either view. We used the Japanese Orthopaedic Association hip disease evaluation questionnaire (JHEQ) to assess the PROMs. The PROMs of patients with and without cysts or osteophytes and those of patients with or without cam or pincer deformity were compared. The relationships between specific PROMs and radiographic features were evaluated with a linear regression analysis and independent associations between PROMs and radiographic features were assessed with a multiple regression analysis using various independent variables. Results: The JHEQ movement and mental values in patients with cyst formation were significantly lower in comparison to those in patients without cyst formation. The JHEQ subscale values did not differ according to the presence or absence of osteophytes, cam deformity or pincer deformity. The CE angle was found to be associated with the JHEQ movement score in the linear regression analysis. To identify radiographic features that were independently associated with each of the JHEQ subscale scores, we performed a multiple regression analysis with age, body mass index, sex and the number of affected hip joints (bilateral or unilateral) included as independent variables. The CE angle was found to be independently associated with JHEQ movement. Conclusion: The CE angle was independently associated with the JHEQ movement value.
Article
Introduction: Outcomes for operative and non-operative management of femoroacetabular impingement syndrome (FAIS) are variable. Understanding factors that inform patients' treatment decisions may optimize their outcomes. Objective: Identify factors that predict which patients with FAIS proceed to surgery within 90 d of their initial evaluation by an orthopaedic surgeon. We explored potential predictors of surgical intervention, including: demographic factors, activity level, symptom duration, previous treatment, hip function, pain, presence of labral tear, and patient interest in surgical and physical therapy(PT) treatment. Design: Prospective cohort. Setting: Single-site academic medical center. Patients: 77 individuals with FAIS. Intervention: After evaluation in a hip preservation clinic, participants reported activity level, symptom duration, treatment history, hip function [Hip Outcome Score Activities of Daily Living(HOS-ADL)], pain severity and location, and treatment interests. These variables were evaluated based on univariate analysis for entry into a multiple binomial logistic regression to identify predictors of surgery within 90 d. Adjusted marginal prevalence ratios and 95% confidence interval estimates(PR [95%CI]) were reported (P ≤ 0.05). Main outcome measure(s): 90-d treatment (surgery or not). Results: Participants indicated initial interest in surgery(n = 27), PT(n = 22), both(n = 18), or neither(n = 10). Those interested in PT-only had lower prevalence of diagnosed labral tear (P < 0.001) and previous PT for the hip (P < 0.001). Prevalence of previous injection was higher for those interested in surgery-only than those with any interest in PT (P < 0.001). Thirty-six of 77 participants (46%) underwent surgery within 90 d. Surgical interest (3.56 [1.57, 5.46]), previous hip injection (3.06 [1.73, 3.89]), younger age (0.95 [0.92, 0.98]), and worse hip function (0.97 [0.95, 0.99]) were significant (P ≤ 0.02) predictors of surgery. Conclusions: Treatment interest and history, patient function, and age were significantly related to participants' decision to pursue surgical intervention within 90 d. Patient engagement in the decision-making process should include considerations of patient knowledge of and experience with the various treatment options. This article is protected by copyright. All rights reserved.
Article
Objective To summarize the effects of surgical treatment compared to conservative treatment in femoroacetabular impingement syndrome in the short, medium, and long term. Study Design Systematic review Methods The following databases were searched on 14/09/2020: MEDLINE, EMBASE, CENTRAL, Web of Science, and PEDro. There were no date or language limits. The methodological quality assessment was performed using the PEDro scale and the quality of the evidence followed the GRADE recommendation. The outcomes pain, disability, and adverse effects were extracted. Results Of 6264 initial studies, three met the full-text inclusion criteria. All studies were of good methodological quality. Follow up ranged from six months to two years, with 650 participants in total. The meta-analyses found no difference in disability between surgical versus conservative treatment, with a mean difference (MD) between groups of 3.91 points (95% CI –2.19 to 10.01) at six months, MD of 5.53 points (95% CI –3.11 to 14.16) at 12 months and 3.8 points (95% CI –6.0 to 13.6) at 24 months. The quality of the evidence (GRADE) varied from moderate to low across all comparisons. Conclusion There is moderate-quality evidence that surgical treatment is not superior to conservative treatment for femoroacetabular impingement syndrome in the short term, and there is low-quality evidence that it is not superior in the medium term. Level of evidence Therapy, level 1a. Registration number PROSPERO CRD42019134118
Chapter
Young adults with pre-arthritic hip pain and underlying hip dysplasia have traditionally been treated with reconstructive surgery, with a limited role for conservative/non-surgical management. This chapter briefly focuses on understanding the pathophysiology of non-arthritic pain in patients with hip dysplasia and indications for various conservative modalities in the same. Non-operative modalities described in detail include activity modifications, oral analgesics and anti-inflammatory medications, physical therapy, orthotics, and injections. A detailed discussion is also presented regarding the current status of orthobiologics, regenerative medicine, and emerging therapeutics in the field of cartilage regeneration and symptom improvement.
Article
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Impingement by prominence at the femoral head-neck junction on the anterior acetabular rim may cause early osteoarthritis. Our aim was to develop a simple method to describe concavity at this junction, and then to test it by its ability to distinguish quantitatively a group of patients with clinical evidence of impingement from asymptomatic individuals who had normal hips on examination. MR scans of 39 patients with groin pain, decreased internal rotation and a positive impingement test were compared with those of 35 asymptomatic control subjects. The waist of the femoral head-neck junction was identified on tilted axial MR scans passing through the centre of the head. The anterior margin of the waist of the femoral neck was defined and measured by an angle (α). In addition, the width of the femoral head-neck junction was measured at two sites. Repeated measurements showed good reproducibility among four observers. The angle α averaged 74.0° for the patients and 42.0° for the control group (p < 0.001). Significant differences were also found between the patient and control groups for the scaled width of the femoral neck at both sites. Using standardised MRI, the symptomatic hips of patients who have impingement have significantly less concavity at the femoral head-neck junction than do normal hips. This test may be of value in patients with loss of internal rotation for which a cause is not found.
Article
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The Bernese periacetabular osteotomy is commonly used to treat symptomatic acetabular dysplasia. Although periacetabular osteotomy is becoming a more common surgical intervention to relieve pain and improve function, the strength of clinical evidence to support this procedure for these goals is not well defined in the literature. We therefore performed a systematic review of the literature to define the level of evidence for periacetabular osteotomy, to determine deformity correction, clinical results, and to determine complications associated with the procedure. Thirteen studies met our inclusion criteria. Eleven studies were Level IV, one was Level III, and one was Level II. Radiographic deformity correction was consistent and improvement in hip function was noted in all studies. Most studies did not correlate radiographic and clinic outcomes. Clinical failures were commonly associated with moderate to severe preoperative osteoarthritis and conversion to THA was reported in 0% to 17% of cases. Major complications were noted in 6% to 37% of the procedures. These data indicate periacetabular osteotomy provides pain relief and improved hip function in most patients over short- to midterm followup. The current evidence is primarily Level IV. Level of Evidence: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
Article
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Femoroacetabular impingement (FAI) is considered a cause of labrochondral disease and secondary osteoarthritis. Nevertheless, the clinical syndrome associated with FAI is not fully characterized. We determined the clinical history, functional status, activity status, and physical examination findings that characterize FAI. We prospectively evaluated 51 patients (52 hips) with symptomatic FAI. Evaluation of the clinical history, physical exam, and previous treatments was performed. Patients completed demographic and validated hip questionnaires (Baecke et al., SF-12, Modified Harris hip, and UCLA activity score). The average patient age was 35 years and 57% were male. Symptom onset was commonly insidious (65%) and activity-related. Pain occurred predominantly in the groin (83%). The mean time from symptom onset to definitive diagnosis was 3.1 years. Patients were evaluated by an average 4.2 healthcare providers prior to diagnosis and inaccurate diagnoses were common. Thirteen percent had unsuccessful surgery at another anatomic site. On exam, 88% of the hips were painful with the anterior impingement test. Hip flexion and internal rotation in flexion were limited to an average 97° and 9°, respectively. The patients were relatively active, yet demonstrated restrictions of function and overall health. These data may facilitate diagnosis of this disorder. Level of Evidence: Level II, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.
Article
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Impingement by prominence at the femoral head-neck junction on the anterior acetabular rim may cause early osteoarthritis. Our aim was to develop a simple method to describe concavity at this junction, and then to test it by its ability to distinguish quantitatively a group of patients with clinical evidence of impingement from asymptomatic individuals who had normal hips on examination. MR scans of 39 patients with groin pain, decreased internal rotation and a positive impingement test were compared with those of 35 asymptomatic control subjects. The waist of the femoral head-neck junction was identified on tilted axial MR scans passing through the centre of the head. The anterior margin of the waist of the femoral neck was defined and measured by an angle (alpha). In addition, the width of the femoral head-neck junction was measured at two sites. Repeated measurements showed good reproducibility among four observers. The angle alpha averaged 74.0 degrees for the patients and 42.0 degrees for the control group (p < 0.001). Significant differences were also found between the patient and control groups for the scaled width of the femoral neck at both sites. Using standardised MRI, the symptomatic hips of patients who have impingement have significantly less concavity at the femoral head-neck junction than do normal hips. This test may be of value in patients with loss of internal rotation for which a cause is not found.
Article
The construct validity and the test-retest reliability of a self-administered questionnaire about habitual physical activity were investigated in young males (n = 139) and females (n = 167) in three age groups (20 to 22, 25 to 27, and 30 to 32 yr) in a Dutch population. By principal components analysis three conceptually meaningful factors were distinguished. They were interpreted as: 1) physical activity at work; 2) sport during leisure time; and 3) physical activity during leisure time excluding sport. Test-retest showed that the reliability of the three indices constructed from these factors was adequate. Further, it was found that level of education was inversely related to the work index, and positively related to the leisure-time index in both sexes. The subjective experience of work load was not related to the work index, but was inversely related to the sport index, and the leisure-time index in both sexes. The lean body mass was positively related to the work index, and the sport index in males, but was not related to the leisure-time index in either sex. These differences in the relationships support the subdivision of habitual physical activity into the three components mentioned above.
Conference Paper
Advancement in diagnostic and therapeutic applications for hip arthroscopy have dispelled previous myths about early hip disease. Arthroscopic findings have established the following facts: Acetabular labral tears do occur; acetabular chondral lesions do exist; tears are most frequently anterior and often associated with sudden twisting or pivoting motions; and labral tears often occur in association with articular cartilage lesions of the adjacent acetabulum or femoral head, and if present for years, contribute to the progression of delamination process of the chondral cartilage. Magnetic resonance arthrography represents an improvement over conventional magnetic resonance imaging, it does have limitations when compared with direct observation. Although indications for hip arthroscopy are constantly expanding, the most common indications include: labral tears, loose bodies, chondral flap lesions of the acetabular or femoral head, synovial chondromatosis, foreign body removal, and crystalline hip arthropathy (gout, pseudogout, and others). Contraindications include conditions that limit the potential for hip distraction such as joint ankylosis, dense heterotopic bone formation, considerable protrusio, or morbid obesity. Complication rates have been reported between 0.5 and 5%, most often related to distraction and include sciatic or femoral nerve palsy, avascular necrosis, and compartment syndrome. Transient peroneal or pudendal nerve effects and chondral scuffing have been associated with difficult or prolonged distraction. Meticulous consideration to patient positioning, distraction time and portal placement are essential. Judicious patient selection and diagnostic expertise are critical to successful outcomes. Candidates for hip arthroscopy should include only those patients with mechanical symptoms (catching, locking, or buckling) that have failed to respond to conservative therapy. The extent of articular cartilage involvement has the most direct relationship to surgical outcomes. Improvements in technique and instrumentation have made hip arthroscopy an efficacious way to diagnose and treat a variety of intra-articular problems.
Article
Background: The clinical presentation of a labral tear of the acetabulum may be variable, and the diagnosis is often delayed. We sought to define the clinical characteristics associated with symptomatic acetabular labral tears by reviewing a group of patients who had an arthroscopically confirmed diagnosis. Methods: We retrospectively reviewed the records for sixty-six consecutive patients (sixty-six hips) who had a documented labral tear that had been confirmed with hip arthroscopy. We had prospectively recorded demographic factors, symptoms, physical examination findings, previous treatments, functional limitations, the manner of onset, the duration of symptoms until the diagnosis of the labral tear, other diagnoses offered by health-care providers, and other surgical procedures that these patients had undergone. Radiographic abnormalities and magnetic resonance arthrography findings were also recorded. Results: The study group included forty-seven female patients (71%) and nineteen male patients (29%) with a mean age of thirty-eight years. The initial presentation was insidious in forty patients, was associated with a low-energy acute injury in twenty, and was associated with major trauma in six. Moderate to severe pain was reported by fifty-seven patients (86%), with groin pain predominating (sixty-one patients; 92%). Sixty patients (91%) had activity-related pain (p < 0.0001), and forty-seven patients (71%) had night pain (p = 0.0006). On examination, twenty-six patients (39%) had a limp, twenty-five (38%) had a positive Trendelenburg sign, and sixty-three (95%) had a positive impingement sign. The mean time from the onset of symptoms to the diagnosis of a labral tear was twenty-one months. A mean of 3.3 health-care providers had been seen by the patients prior to the definitive diagnosis. Surgery on another anatomic site had been recommended for eleven patients (17%), and four had undergone an unsuccessful operative procedure prior to the diagnosis of the labral tear. At an average of 16.4 months after hip arthroscopy, fifty-nine patients (89%) reported clinical improvement in comparison with the preoperative status. Conclusions: The clinical presentation of a patient who has a labral tear may vary, and the correct diagnosis may not be considered initially. In young, active patients with a predominant complaint of groin pain with or without a history of trauma, the diagnosis of a labral tear should be suspected and investigated as radiographs and the history may be nonspecific for this diagnosis. Level of Evidence: Diagnostic Level IV. See Instructions to Authors for a complete description of levels of evidence.
Article
An end-result analysis is presented of thirty-nine mold arthroplasties performed at the Massachusetts General Hospital between 1945 and 1965 in thirty-eight consecutive private patients for arthritis of the hip following fractures of the acetabulum or dislocations of the hip. Of the nineteen unilateral cases in the second half of the series, sixteen were rated good or excellent. Results in the second half of the series were significantly better statistically than those in the first half of the series. Possible reasons for this improvement are discussed. No significant deterioration occurred with the passage of time. Among the thirty-nine hips, three revisions were required. One patient had postoperative sepsis after arthroplasty. Four patients who had had intra-articular sepsis prior to arthroplasty showed no evidence of sepsis postoperatively. Factors influencing the choice between hip fusion and hip arthroplasty in these cases are presented. A new system for rating hip function is proposed and is compared with the systems of Larson and Shepherd.
Article
The purpose of the current study was to assess the validity, internal consistency, and reproducibility of a short, self-administered hip score designed for use in younger patients with higher demands and expectations than older patients with degenerative joint disease. Validity and internal consistency was studied with 48 consecutive patients with a mean age of 33 years with intractable hip pain and normal plain radiographs. Reproducibility was assessed from data on an additional random sample of 17 patients with hip pain. The Pearson correlation coefficients were 0.82 and 0.59 between the nonarthritic hip score and the Harris hip score and Short Form-12, respectively showing validity. Cronbach's coefficient alpha measuring the internal consistency within each of the score's four domains ranged from 0.69 to 0.92. The test and retest reproducibility ranged from 0.87 to 0.95 for the four subsets and was 0.96 overall. This short, self-administered questionnaire regarding hip pain in young patients with increased activity demands and high treatment expectations is valid compared with previous measures of hip performance, is internally consistent, and is reproducible.
Article
There is an evolving body of knowledge regarding the acetabular labrum. Labral tears are most frequently anterior and often are associated with sudden twisting or pivoting motions. High clinical suspicion in association with positive physical findings are fundamental for the clinician to properly determine treatment for the suspected tear. Labral tears, especially those present for years, may contribute to the progression of hip osteoarthritis. Patients at risk include those with developmental dysplasia, those with tears greater than 5 years, and those with associated chondral full-thickness lesions. Chondral injuries may occur in association with a multitude of hip conditions including labral tears, loose bodies, osteonecrosis, slipped capital femoral epiphysis, dysplasia, and degenerative arthritis. Labral tears occurring at the watershed zone may destabilize the adjacent acetabular conditions. Arthroscopic observations support the concept that labral disruption, acetabular chondral lesions, or both frequently are part of a continuum of degenerative joint disease.
Article
Acetabular dysplasia is recognized as a cause of early degenerative hip osteoarthritis. The purpose of this study was to prospectively determine the early clinical presentation of symptomatic acetabular dysplasia in skeletally mature patients. Fifty-seven consecutive skeletally mature patients with a total of sixty-five symptomatic hips were diagnosed with symptomatic acetabular dysplasia on the basis of the history, physical examination, and radiographs. These fifty-seven patients were enrolled in this study and were followed prospectively for a minimum of twenty-four months postoperatively. The study group included forty-one female patients (72%) and sixteen male patients (28%) with a mean age of twenty-four years. All were treated with a periacetabular osteotomy and were followed for a minimum of twenty-four months. The initial presentation was insidious in 97% of the hips, and the majority (77%) of the hips were associated with moderate-to-severe pain on a daily basis. Pain was most commonly localized to the groin (72%) and/or the lateral aspect of the hip (66%). Activity-related hip pain was common (88%), and activity restriction frequently diminished hip pain (in 75% of the cases). On examination, thirty-one hips (48%) were associated with a limp; twenty-five (38%), with a positive Trendelenburg sign; and sixty-three (97%), with a positive impingement sign. The mean time from the onset of symptoms to the diagnosis of hip dysplasia was 61.5 months. The mean number of health-care providers seen prior to the definitive diagnosis was 3.3. The mean Harris hip score improved from 66.4 points preoperatively to 91.7 points at a mean of 29.2 months after the periacetabular osteotomy. The diagnosis of symptomatic acetabular dysplasia is commonly delayed, and procedures other than a pelvic reconstructive osteotomy are frequently recommended. The diagnosis of developmental dysplasia of the hip should be suspected and investigated when a skeletally mature, young, active patient has a predominant complaint of insidious activity-related groin pain and/or lateral hip pain. Prognostic Level IV. See Instructions to Authors for a complete description of levels of evidence.
Article
The past decade has seen unprecedented growth in the number of hip arthroscopies. Acetabular labral tears are the leading indication for arthroscopy of this joint. However, labral anatomy and function, as well as the effects of labral tears and surgical outcomes, have only recently been studied. Labral tears may cause pain and microinstability of the hip joint. They also may increase friction within the joint, cartilage consolidation, and strain within the articular cartilage, thereby possibly resulting in accelerated degeneration of the joint. Partial labrectomy and labral repair are the current surgical options, and basic science data suggest that labral repairs can heal and subsequently restore function. However, a good, validated outcomes measure to adequately assess active patients with a painful nonarthritic hip is needed to determine the efficacy of such repair and aid in managing patient expectations.
Article
The surgical treatment of femoroacetabular impingement has become more common, yet the strength of clinical evidence to support this surgery is debated. We performed a systematic review of the literature to (1) define the level of evidence regarding hip impingement surgery; (2) determine whether the surgery relieves pain and improves function; (3) identify the complications; and (4) identify modifiable causes of failure (conversion to total hip arthroplasty). We searched the literature between 1950 and 2009 for all studies reporting on surgical treatment of femoroacetabular impingement. Studies with clinical outcome data and minimum two year followup were analyzed. Eleven studies met our criteria for inclusion. Nine were Level IV and two were Level III. Mean followup was 3.2 years; range (2–5.2 years). Reduced pain and improvement in hip function were reported in all studies. Conversion to THA was reported in 0% to 26% of cases. Major complications occurred in 0% to 18% of the procedures. Current evidence regarding femoroacetabular impingement surgery is primarily Level IV and suggests the various surgical techniques are associated with pain relief and improved function in 68–96% of patients over short-term followup. Long-term followup is needed to determine survivorship and impact on osteoarthritis progression and natural history. Level of Evidence: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
Article
To determine whether posterior pelvic pain is associated with intra-articular hip abnormalities (labral tears and early degenerative changes) in patients with minimal-to-no radiographic abnormalities. A retrospective observational study of prospectively collected data collected from patients with an arthroscopy-confirmed diagnosis of acetabular labral tear or femoral and/or acetabular chondrosis, without severe deformity. An academic orthopedic clinic at a tertiary hospital. All patients, having failed to respond to conservative treatment, required surgical intervention for definitive structural diagnosis and treatment because of pain and dysfunction. Within this group, patients with posterior pelvic pain were included. One hundred thirty consecutive patients, 93 women and 37 men with mean age 31.16 years (range, 10-65.5 years), entered the study, and observational findings were reported. University instructional review board approval was obtained before conducting the study. Patients completed medical information questionnaires, pain diagrams, severity of pain, and validated hip questionnaires that focused on symptoms and function. Postoperatively, patients who had posterior pelvic pain before surgery completed a phone interview regarding their clinical progress. MAIN OUTCOMES MEASUREMENT: A numeric pain scale, description of location of continued pain, Modified Harris Hip Score, and satisfaction with the procedure were recorded. Twenty-six (20%) of the 130 patients complained of posterior pelvic pain as a component of their clinical presentation. Of these patients, the mean duration of symptoms was 29.5 months. A total of 92% related that their pain was moderate or marked. The preoperative mean modified Harris Hip Score was 61.6 (range, 27-85) and showed postoperative improvement with a mean of 84.5 (range, 45-100; P < .001). The Modified Harris Hip Score was completed a mean 15.9 months postoperatively. Pain diagrams and questionnaires revealed that of the 26 patients with posterior pelvic pain, 92.3% (24/26) also had associated groin pain (P < .001), 57.7% (15/26) had lateral thigh pain, and 7.7% (2/26) had anterior thigh pain (P < .001). A total of 12 of 26 patients with an initial presentation including posterior pelvic pain agreed to a phone interview. The mean time after surgery in this group of patients was 56.9 months (range, 39-65 months). Five of 12 patients reported no pain and no activity limitations. The Visual Analog Scale representing their self-reported average daily pain was 1.4 (range, 0-3). The mean Modified Harris Hip Score was 10.4 (range, 8-13). All 7 patients with continued pain described the pain in more than one location. Ten of 12 patients were very satisfied with hip arthroscopy, 1 of 12 was somewhat satisfied, and 1 of 12 was dissatisfied. This latter patient went on to have total hip arthroplasty and was very satisfied with that procedure. All 12 patients would recommend the procedure to a friend. Twenty percent of patients at the authors' institution who required surgical intervention to treat their pain after not responding to conservative management had posterior pelvic pain in addition to groin or lateral and anterior hip pain. Of those respondents, 33% had complete resolution of symptoms at 4.75 years after surgery, and all had reduction in pain as compared with completion of conservative care. Patients with early intra-articular hip pathology, such as acetabular labral tears with no or mild hip deformity, and patients with arthrosis and mild hip deformity may experience groin and posterior pelvic pain as part of their clinical presentation.
Article
The hip labrum has many functions, including shock absorption, joint lubrication, pressure distribution, and aiding in stability, with damage to the labrum associated with osteoarthritis. The etiology of labral tears includes trauma, femoroacetabular impingement (FAI), capsular laxity/hip hypermobility, dysplasia, and degeneration. Labral tears present with anterior hip or groin pain, and less commonly buttock pain. Frequently, there are also mechanical symptoms including clicking, locking, and giving way. The most consistent physical examination finding is a positive anterior hip impingement test. Because of the vast differential diagnosis and the need for specialized diagnostic tools, labral tears frequently go undiagnosed during an extended period of time. Evaluation usually begins with plain radiographs to assess for dysplasia, degeneration, and other causes of pain. While magnetic resonance imaging (MRI) and computed tomography scans are unreliable for diagnosis, magnetic resonance arthrography (MRA) is the diagnostic test of choice, with arthroscopy being the gold standard. Typically, treatment begins conservatively with relative rest and non-steroid anti-inflammatory agents, with physical therapy (PT) being controversial. Often, surgical treatment is necessary, which entails, arthroscopic debridement of labral tears and surgical repair of associated structural problems.
Article
Hip dysplasia leads to abnormal loading of articular cartilage, which results in osteoarthritis. The purpose of this study was to investigate the anatomic and demographic factors associated with the early onset of osteoarthritis in dysplastic hips by utilizing the delayed gadolinium-enhanced magnetic resonance imaging of cartilage (dGEMRIC) index as a marker of the disease. Ninety-six symptomatic dysplastic hips in seventy-four patients were assessed with standard radiographs and a dGEMRIC scan. The lateral center-edge angle of Wiberg, the acetabular index of Tönnis, and the break in the Shenton line were measured on a standing anteroposterior radiograph. Anterior undercoverage was assessed by measuring the anterior center-edge angle on a Lequesne false-profile view. A labral tear was considered to be present when contrast agent was seen through the entire thickness of the labrum on magnetic resonance arthrography. Osteoarthritis was defined as a dGEMRIC value of <390 msec (two standard deviations below the dGEMRIC index in normal hips). The mean dGEMRIC index (and standard deviation) for this cohort (473 +/- 104 msec) was significantly lower than that of a morphologically normal hip (570 +/- 90 msec). The anterior center-edge angle, the joint space width, and the presence of a labral tear were all found to be associated with osteoarthritis in the univariate analysis. Multivariate analysis identified age, the anterior center-edge angle, and the presence of a labral tear as independent factors associated with osteoarthritis. A second model was fitted with omission of the anterior center-edge angle because the lateral and anterior center-edge angles were highly correlated and the lateral center-edge angle is a more common clinical measure. This model identified age, the lateral center-edge angle, and the presence of a labral tear as significant independent factors associated with osteoarthritis. As has been demonstrated in previous studies of the hip, this investigation showed osteoarthritis to be associated with increasing age and the severity of dysplasia, as demonstrated both by the Wiberg lateral center-edge angle and the Lequesne anterior center-edge angle. Additionally, we identified a labral tear as being a risk factor for osteoarthritis.
Article
Femoroacetabular impingement (FAI) is a pathologic condition of the hip joint in young adults that, if untreated, leads to end-stage osteoarthritis. It is characterized by early pathologic contact between primary osseous prominences of the acetabular rim (so-called pincer FAI) and/or the femoral head-neck junction (cam FAI). Conventional radiographs are often considered normal because classic radiographic signs of osteoarthritis are not present initially. The physician should be aware of the radiographic features for both types of impingement to recognize subtle pathologies.
Article
Orthopaedic evaluation of hip pain in the young adult population has undergone a rapid evolution over the past decade1,2. This is in large part due to enhanced awareness of structural hip disorders, including developmental dysplasia of the hip and femoroacetabular impingement1-5. Surgical treatment for these disorders continues to be refined6-9, and our ability to identify patients along the spectrum of disease continues to improve10-15. Yet, despite our advances, obtaining an accurate diagnosis can remain challenging, especially in the setting of mild structural abnormalities. Therefore, radiographic examination is a critical component of the diagnostic evaluation and treatment decision-making process. It is essential that physicians have common and reliable radiographic views as well as parameters for plain radiographic assessment that can serve as a foundation for accurate diagnosis, disease classification, and surgical decision-making. Many different radiographic measurements have been described as indicators of structural disease. In particular, measurements such as the lateral center-edge angle of Wiberg16, the anterior center-edge angle of Lequesne17, the acetabular index of depth to width described by Heyman and Herndon18, the femoral head extrusion index19, and the Tonnis angle20 have been used as markers for acetabular dysplasia. Similarly, measurements of acetabular version21, the headneck offset (initially described by Eijer)3,22, and the alpha angle19 have been used in the diagnosis of femoroacetabular impingement. Nevertheless, there is limited literature that provides comprehensive information regarding the details of radiographic evaluation in the young patient with hip symptoms. This paper summarizes the recommendations of the ANCHOR (Academic Network for Conservational Hip Outcomes Research) study group regarding the most important aspects of radiographic technique and image interpretation to evaluate the symptomatic, …
Article
In eight patients with so-called idiopathic degenerative arthritis of the hip the acetabular labrum, at surgery, was found to lie in the articulation between the femoral head and the acetabulum. In none of the patients was there a history or roentgenographic evidence of congenital dysplasia or congenital dislocation. None of the patients had had a closed reduction or manipulation of the hip during infancy, childhood, or adolescence. No patient had had a traumatic dislocation. The findings suggest that the intra-articular labrum was a developmental abnormality and we postulate that this abnormality was the cause of the degenerative arthritis.
Article
Within the context of a double blind randomized controlled parallel trial of 2 nonsteroidal antiinflammatory drugs, we validated WOMAC, a new multidimensional, self-administered health status instrument for patients with osteoarthritis of the hip or knee. The pain, stiffness and physical function subscales fulfil conventional criteria for face, content and construct validity, reliability, responsiveness and relative efficiency. WOMAC is a disease-specific purpose built high performance instrument for evaluative research in osteoarthritis clinical trials.
Article
Current methods of clinical assessment in osteoarthritis show a high degree of variability. By contrast, patients with rheumatoid arthritis may be evaluated using a number of standardised and validated indices. One hundred patients with primary osteoarthritis of the hip and knee were interviewed in order to determine the dimensionality of their discomfort and disability and to define the clinical importance of each component item. The symptomatology of osteoarthritis was captured by five pain, one stiffness, twenty-two physical, eight social and eleven emotional items. In spite of a high degree of variability in the frequency of involvement of the individual items, their clinical importance was similar both within as well as across dimensions. Further studies are indicated to determine the reliability, validity and responsiveness of each of the items identified as a prelude to developing a standardized method of assessing patients with osteoarthritis of the hip and knee.
Article
Eleven patients with tears of the acetabular labrum are discussed and the syndrome of the torn labrum is defined. In all cases the lesion was associated with acetabular dysplasia, and a constant early radiological sign was a cyst in the lateral aspect of the acetabulum. The diagnosis was confirmed by arthrography. It is suggested that these tears are degenerative, occurring as a consequence of abnormal stresses imposed by the uncovered lateral portion of the femoral head. Once a tear is present a localised stress point occurs on the femoral head, leading rapidly to degenerative arthritis.
Article
Of 285 total hip arthroplasties (260 patients) performed for primary osteoarthritis during a six-year period, 135 were resurfaced using a Tharies prosthesis (total hip articular replacement with internal eccentric shells) and 150 were tre