ArticleLiterature Review

Hip Pathology in the Adolescent Athlete

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Abstract

Hip injuries in young athletes are being diagnosed with increasing frequency. Improvements in diagnostic imaging and surgical technologies have helped facilitate the diagnosis of intra- and extra-articular derangements that were previously untreated in this age group. Athletic injuries of the hip in the young athlete encompass both osseous and soft-tissue etiologies, which can be the result of a single traumatic event or repetitive microtrauma or may be associated with an underlying pediatric hip disorder. Without accurate diagnosis and management, these injuries may result in debilitating consequences. This article will review the more common causes of hip and groin pain in the adolescent athlete, as well as advances in diagnostic and therapeutic interventions.

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... adult population [4], adolescents, particularly those engaged in athletic activity, are more frequently seeking surgical procedures to treat hip pain and dysfunction [5][6][7]. With the increase in training and participation of adolescents in competitive sports, the identification and diagnosis of intraarticular conditions of the hip joint have become more common in the young, athletic population [8][9][10]. Several centres have demonstrated the efficacy of arthroscopic hip surgery for this patient group, with high reported return-to-sport rates in small groups of adolescent patients [5][6][7]. ...
... While intra-articular hip injury rates for adolescents have continued to increase [8], there is limited understanding of the relative risk for hip injury that requires hip arthroscopy in adolescents participating in competitive sports as has been described for other regions of the lower extremity. Previous injury prevention efforts for anterior cruciate ligament (ACL) injury requiring surgical treatment established risk stratification for injury based upon the amount of contact and lateral motion risk during particular sports activities [11][12][13]. ...
... Although hip arthroscopy has been primarily performed in the adult population, the identification and diagnosis of intraarticular conditions have become more common in young athletes [8][9][10]. This study represents the growing number of adolescent athletes being evaluated and treated by hip arthroscopists in a large multicentre cohort. ...
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PurposeThe purpose of the current study was to establish a risk stratification for hip injury by presenting the classification of sports among adolescent athletes undergoing hip arthroscopy.MethodsA multicentre registry was queried to examine the incidence of adolescent athletes undergoing hip arthroscopy. Patients were identified and grouped according to their sport-specific risk classification (level I–III). Chi-square analysis was performed to determine the relationship of classification of sport and gender in adolescent athletes to hip arthroscopy. A second chi-square analysis was performed to determine the relationship of classification of sport and number of sports the adolescent athlete was participating in prior to arthroscopic hip surgery.ResultsA total of 297 adolescent athletes were included in the study with 129 (43.4%) participating in level I sports compared with 84 (28.3%) in level II and 84(28.3%) in level III sports. Chi-square testing demonstrated a significant effect on gender and sport classification, X2 (2, N = 297) = 31.18, p < 0.01. There was a greater percentage of athletes participating in a single sport (65.3%) compared with multiple sports (34.6%), but was not statistically significant, X2 (1, N = 297) = 1.88, p = 0.17.Conclusion The current study was successful in stratifying a large, multicentre cohort of adolescent athletes requiring hip arthroscopy based on classification levels of sport. There were more male athletes participating in level I sports, while more female athletes participated in level II and level III sports.
... Femoroacetabular impingement (FAI) is a common cause of hip pain due to abnormal joint morphology, leading to aberrant contact between the proximal femur (cam) and acetabular rim (pincer). 1,3,4,11,13 This can lead to decreased function and performance in elite athletes. 11,14 Overhead athletes are at particular risk for developing symptoms because of the significant rotational forces across the hip while throwing. ...
... 1,3,4,11,13 This can lead to decreased function and performance in elite athletes. 11,14 Overhead athletes are at particular risk for developing symptoms because of the significant rotational forces across the hip while throwing. 8 During the phases of throwing, the lower extremity generates energy that is transferred through the kinetic chain to the upper extremity before ball release. ...
... 19,31 Disruption anywhere along the chain can lead to decompensation in athletic performance, as seen in baseball players with FAI. 11 Radiographic findings of FAI have been found in between 51% and 66% of high-level athletes. 23 Specifically in baseball players, 1 study found a radiographic prevalence of 76.6%. ...
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Background Femoroacetabular impingement (FAI) is a common cause of hip pain that may lead to decreased performance in Major League Baseball (MLB) players. Purpose To determine the (1) return-to-sport (RTS) rate in MLB players after hip arthroscopic surgery for FAI; (2) postoperative career length, innings pitched (IP) (pitchers), and plate appearances (PA) (position players); (3) preoperative and postoperative performance; and (4) postoperative performance compared with control players matched by position, age, years of experience, and performance. Study Design Cohort study; Level of evidence, 3. Methods MLB athletes who underwent hip arthroscopic surgery for FAI and matched controls were identified. Demographic and performance data were collected. RTS was defined as playing in at least 1 MLB game after surgery. Continuous variables of each group were compared using a 2-tailed paired-samples Student t test for normally distributed data. The chi-square test was used to analyze categorical data. The Bonferroni correction was used to control for multiple comparisons, with statistical significance defined by a P value of ≤.007. Results A total of 50 players (57 surgeries) were analyzed (mean age, 30.4 ± 3.9 years; mean MLB experience at the time of surgery, 7.0 ± 4.6 years). Pitchers (31 surgeries; 54.4%) represented the largest proportion of players analyzed. Of these players, 42 (47 surgeries; 82.5%) were able to RTS at a mean of 8.3 ± 4.1 months. The overall 1-year MLB career survival rate of players undergoing FAI surgery was 78.9%. Players in the control group were in MLB a similar number of years (4.0 ± 2.9 years) to players who underwent surgery (3.3 ± 2.4 years) (P > .007). There was no significant decrease in IP or PA per season after surgery (P > .007). There was no significant difference in performance for pitchers and nonpitchers compared with matched controls after surgery (P > .007). Conclusion The RTS rate for MLB athletes after hip arthroscopic surgery for FAI was high. There were similar IP, PA, and career lengths postoperatively compared with preoperatively and with matched controls. There was no significant difference in performance for pitchers and nonpitchers compared with matched controls after surgery.
... Abdominal wall weakness, athletic pubalgia, and frank hernias are also a common source of groin pain in active patients. 19 ...
... Most of the traumatic dislocations in children are posterior in nature, but may be anterior in rare circumstances. 19,27,28 Care must be taken when discussing injuries with the patient and family as there are a large number of potential pathologies that can cause pain in and around the hip joint. 19 All associated injuries including labral tears, cartilage damage, femoral head fractures, acetabular fractures, and loose bodies should be addressed in a comprehensive fashion. ...
... 19,27,28 Care must be taken when discussing injuries with the patient and family as there are a large number of potential pathologies that can cause pain in and around the hip joint. 19 All associated injuries including labral tears, cartilage damage, femoral head fractures, acetabular fractures, and loose bodies should be addressed in a comprehensive fashion. ...
... Hip pain is a common presentation in the adolescent athletic population [1]. The hip itself has a complex regional anatomy, often exhibiting similar symptoms for different injury patterns originating from intra-articular, extra-articular or intra-pelvic etiologies. ...
... The hip itself has a complex regional anatomy, often exhibiting similar symptoms for different injury patterns originating from intra-articular, extra-articular or intra-pelvic etiologies. Age, sex, sport/activity level, previous injury, genetics and environmental factors all play an important role in determining the type of injury incurred [1][2][3][4]. As such, the treating clinician must be able to perform a thorough history and physical examination while maintaining a broad differential of potential diagnoses. ...
... While most injuries such as muscle strain may be treated with rest and analgesics, more serious causes of hip pain such as stress fractures may have similar presentations with negative radiographs, making early diagnosis challenging [5][6][7][8][9][10]. Common pain presentations which do not resolve in the expected course should alert the treating clinician to evaluate with more advanced studies such as ultrasound, magnetic resonance imaging (MRI) and/or computed tomography (CT) in select cases [1,11,12]. ...
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Stress fractures are common injuries associated with repetitive high-impact activities, often in high-level athletes and military recruits. Although predominantly occurring in the lower extremities, stress fractures may occur wherever there is a sudden increase in frequency or intensity of activity, thereby overloading the yield point of the local bone environment. Ischial stress fractures are a rarely diagnosed cause of pain around the hip and pelvis. Often, patients present with buttock pain with activity, which can be misdiagnosed as proximal hamstring tendonitis or avulsion. Here, we report a case of a college football player who was diagnosed with an ischial stress fracture which went on to symptomatic non-union after extensive conservative management. We treated his ischial non-union with open reduction internal fixation utilizing a tension band plate and screws. This interesting case highlights an uncommon cause of the relatively common presentation of posterior hip pain and describes our technique for addressing a stress fracture non-union in the ischium.
... A stress fracture may be most accurately defined as a complication derived from abnormal bone homeostasis due to the repetitive mechanical impact, which in turn leads to an increased osteoclastic-mediated bone resorption. [1][2][3][4][5][6][7][8] Mostly uncommon, stress fractures amount to 10% of all sports-related injuries, femoral neck stress fractures being 3%-5% of the whole. [2][3][4][5][6][7] It is mainly observed among military recruits and young female athletes due to constant exposure of the bone to repetitive loading in a specific area, which in turn predisposes for microfracture accumulation. ...
... [1][2][3][4][5][6][7][8] Mostly uncommon, stress fractures amount to 10% of all sports-related injuries, femoral neck stress fractures being 3%-5% of the whole. [2][3][4][5][6][7] It is mainly observed among military recruits and young female athletes due to constant exposure of the bone to repetitive loading in a specific area, which in turn predisposes for microfracture accumulation. 1-4 9 Stress fractures most frequently appear in: the tibia (33%), tarsal bones (20%), metatarsals (20%), femur (11%), fibula (7%) and pelvis (7%). ...
... 4 6 During the early stages, femoral neck stress fractures can present themselves only when the subject is actively exercising and it is characterised by the onset of deep pain in the hip or anterior groin regions, an inability to carry weight, presenting antalgic gait and a limited motion range. [1][2][3][4][5][6][7] When unrecognised, untreated or mistreated, it may lead to the onset of acute pain in resting periods, which in turn denotes the possible presence of a displaced femoral fracture, a severe surgical emergency because of the high risk of avascular necrosis of the femoral head and late osteoarthritis of the hip joint, solved only by a total hip arthroplasty, it may also lead to delayed union or even non-union of fractures. 1-9 ...
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A 16-year-old female patient showed up at the orthopaedics unit complaining of intolerable pain on her left hip. While being questioned and her clinical history written down, she shared that as part of her daily exercise routine, she ran 10 miles (16 km) daily at a speed of 9.5–10.5 mph (15–17 km/hour). MRI was consequently ordered, confirming the presence of a stress fracture. Therefore, immediate suspension of physical activity was indicated, followed by the prescription of crutches as well as restricted weight bearing. Gradually, she recovered complete functionality and approximately a month after she had entirely healed. While on a skiing trip, again she abruptly developed an acute pain on her right hip. Another MRI was ordered; its result confirmed a new stress fracture. Her previous treatment has proved so successful, a conservative approach was once again prescribed for her, showing optimum results 6 months later.
... Femoroacetabular impingement (FAI) syndrome is a common cause of hip pain due to abnormal joint morphology leading to aberrant contact between the proximal femur (cam) and acetabular rim (pincer) [1][2][3][4]. This can lead to pain, decreased function and underperformance in elite athletes [4,5]. ...
... Femoroacetabular impingement (FAI) syndrome is a common cause of hip pain due to abnormal joint morphology leading to aberrant contact between the proximal femur (cam) and acetabular rim (pincer) [1][2][3][4]. This can lead to pain, decreased function and underperformance in elite athletes [4,5]. Hockey players are at particular risk with these players 15 times more likely to develop FAI compared with the general population [6][7][8][9][10][11]. ...
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Femoroacetabular impingement (FAI) syndrome is a common cause of hip pain in National Hockey League (NHL) players that may lead to decreased performance. The purpose of this study was to determine the (i) return to sport (RTS) rate in NHL players following hip arthroscopy for FAI, (ii) post-operative career length and games per season, (iii) pre- and post-operative performance and (iv) post-operative performance compared with control players. NHL athletes who underwent hip arthroscopy for FAI and matched controls were identified based on position, age (±1 year), years of experience (±1 year) and performance data prior to the surgery date. Demographic and performance data were collected. RTS was defined as playing in at least one NHL game after surgery. A Bonferroni correction was used to control for multiple comparisons with statistical significance defined by a P-value ≤ 0.007. Seventy players (77 surgeries) were analysed (mean age 29.4 ± 4.5 years; mean 8.8 ± 4.7 years NHL experience at the time of surgery). Sixty-three players (70 surgeries, 90.9%) RTS at an average of 6.8 ± 4.1 months. The 1-year NHL career survival rate for players undergoing surgery was 84.4%. Players in the control group (4.4 ± 2.7 years) had longer careers (P = 0.00002) than players that underwent surgery (3.3 ± 2.5 years). There was no significant (P > 0.007) decrease in post-operative performance compared with pre-operatively and with matched controls. The RTS rate for NHL athletes after hip arthroscopy for FAI is above 90% at less than 1 year. Following surgery, if a player returns to the NHL, then their post-operative performance is similar to pre-operatively and controls, but their careers are approximately one season less than controls.
... Level of evidence: Level III casecontrol study F emoroacetabular impingement (FAI) syndrome is a common cause of hip pain due to abnormal joint morphology leading to aberrant contact between the proximal femur and acetabular rim. [1][2][3][4] This can lead to decreased function and performance in elite athletes. 4,5 Multiple previous investigations have demonstrated a significant increase in the risk of cam morphology development in adolescent athletes playing a high-intensity sport. ...
... [1][2][3][4] This can lead to decreased function and performance in elite athletes. 4,5 Multiple previous investigations have demonstrated a significant increase in the risk of cam morphology development in adolescent athletes playing a high-intensity sport. 6,7 In turn, there is a significantly greater rate of cam morphology in athletes versus nonathletes. ...
Article
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Purpose: To determine: (1) return to sport (RTS) rate in National Basketball Association (NBA) players following hip arthroscopy, (2) postoperative career length and games per season, (3) pre- and postoperative performance, and (4) postoperative performance compared with control players. Methods: NBA athletes who underwent hip arthroscopy and matched controls were identified. RTS was defined as playing in at least 1 game after surgery. Player efficiency ratings were used for performance evaluation. Continuous variables of each group were compared using a 2-tailed paired samples Student t test for normally distributed data. χ2 was used to analyze categorical data. RTS was used as the primary outcome with statistical significance defined by a P value < .05. A Bonferroni correction was used to control for the remaining multiple comparisons with statistical significance defined by a P value ≤.008. Results: Twenty-three players (24 hips) were analyzed (mean age 27.5 ± 3.1 years; mean experience in the NBA 5.8 ± 2.8 years at time of surgery). Small forwards (n = 8, 33.3%) represented the largest proportion of players that underwent hip arthroscopy. Twenty players (21 surgeries, 87.5%) were able to RTS in NBA at an average of 5.7 ± 2.6 months. The overall 1-year NBA career survival rate of players undergoing hip arthroscopy was 79.2%. Players in the control group (5.2 ± 3.5 years) had a similar career length as (P = .068) players who underwent surgery (4.4 ± 3.0 years). There was no significant (P = .045) decrease in games per season following surgery. There was no significant difference in performance postoperatively compared with preoperatively (P = .017) and compared with matched controls following surgery (P = .570). Conclusions: The RTS rate for NBA athletes after hip arthroscopy is high. There was no decrease in games played, career lengths, or performance following hip arthroscopy in NBA players versus preoperatively and matched controls. Level of evidence: Level III case-control study.
... F emoroacetabular Impingement (FAI) syndrome is a common cause of hip pain characterized by abnormal joint morphology leading to aberrant contact between the proximal femur (cam) and acetabular rim (pincer). [1][2][3][4] In patients experiencing symptoms, this often results in significant functional disability and impaired performance. 3,5,6 In patients dissatisfied with their hip condition despite nonsurgical treatment, hip arthroscopy with correction of cam and/or pincer morphology and labral preservation is successful in reducing pain, improving function, and enabling return to activities, including sports. ...
... [1][2][3][4] In patients experiencing symptoms, this often results in significant functional disability and impaired performance. 3,5,6 In patients dissatisfied with their hip condition despite nonsurgical treatment, hip arthroscopy with correction of cam and/or pincer morphology and labral preservation is successful in reducing pain, improving function, and enabling return to activities, including sports. [7][8][9] Previous studies have examined the epidemiology and outcomes of corrective surgery for FAI syndrome in professional athletes. ...
Article
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PURPOSE: To determine (1) return-to-sport rates for National Football League, Major League Baseball, National Basketball Association, and National Hockey League (NHL) athletes after hip arthroscopy for femoroacetabular impingement syndrome, (2) postoperative return-to-sport rate differences between sports, (3) differences in postoperative career length and games per season, (4) differences in preoperative and postoperative performance, and (5) postoperative performance compared with that of matched control players. METHODS: Professional athletes who underwent hip arthroscopy for femoroacetabular impingement syndrome were identified. Matched control players were identified by position, age, experience, and performance. Return to sport was defined as playing in at least 1 game after surgery. Continuous variables for each group were compared by using a 2-tailed paired-samples Student t test or χ2 test. A Bonferroni correction was used to control for multiple comparisons with statistical significance defined by a P value < .002. RESULTS: One hundred seventy-two players (86.4%) (mean age, 28.8 ± 5.2 years) were able to return to sport at an average of 7.1 ± 4.1 months. Athletes played 3.5 ± 2.4 years after surgery without significant differences between sports (P > .002). NHL players who underwent surgery played significantly fewer years (4.4 vs 3.3 years) (P < .001) and fewer games per season (4 fewer games) (P <.001) after surgery compared with control players. NHL players also had a significant decrease in performance after surgery compared with their performance before surgery (P < .001). In National Football League, Major League Baseball, and National Basketball Association athletes, no significant differences were found in games per season, career length, or preoperative performance compared with postoperative performance and performance of matched control players (P > .002). CONCLUSION: The RTS rate for professional athletes after surgery for femoroacetabular impingement syndrome is high. Only NHL athletes had significantly shorter careers and played significantly fewer games per season compared with matched control players, with no difference between sports. NHL athletes had significantly worse postoperative performance compared with preoperative performance, with all other sports demonstrating a career-related decline similar to that of matched control players.
... Similarly a high prevalence of hip pain has been reported in young elite athletes [18,26]. Hip pain may include extra-and intra-articular pathology or a combination of both that results in clinical signs and symptoms such as buttock, lateral, anterior and posterior thigh, groin, knee and LBP [13,14]. Extra-articular hip pain may relate to soft tissue pathologies such as tendinopathy, bursitis, hernia and muscle strain [13]. ...
... Hip pain may include extra-and intra-articular pathology or a combination of both that results in clinical signs and symptoms such as buttock, lateral, anterior and posterior thigh, groin, knee and LBP [13,14]. Extra-articular hip pain may relate to soft tissue pathologies such as tendinopathy, bursitis, hernia and muscle strain [13]. Moreover, intra-articular hip joint pain is also shown to be common [30], with Femoroacetabular impingement syndrome (FAI) reported as a frequent cause of pain and shown to have a prevalence of up to 89% in elite athletes [9,10,28,[30][31][32]. ...
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Purpose: To investigate the prevalence between back and hip pain in young Elite skiers. Methods: Sample group (n = 102), consisted of young Elite skiers (n = 75) and age-matched non-athletes (n = 27), all completed a three-part back and hip pain questionnaire, Oswestry Disability Index and EuroQoL to evaluate general health, activity level, back and hip pain prevalence. Results: No significant differences were shown for lifetime prevalence of back pain in the skiers (50%) compared with controls (44%) (n.s.). Duration of back pain for the skiers showed (30%) > 1 year, whilst (46%) > 5 years. A significant difference was shown with increased Visual Analogue Scale back pain levels for skiers 5.3 (SD 3.1) compared with controls 2.4 (SD 1.9, p = 0.025). No significant differences were shown for lifetime prevalence of hip pain in skiers (21%) compared with controls (8%) (n.s.). Conclusion: Young Elite skiers are shown not to have increased lifetime prevalence for back and hip pain compared with a non-athletic control group. Level of evidence: II.
... Similarly a high prevalence of hip pain has been reported in young elite athletes [18,26]. Hip pain may include extraand intra-articular pathology or a combination of both that results in clinical signs and symptoms such as buttock, lateral, anterior and posterior thigh, groin, knee and LBP [13,14]. Extra-articular hip pain may relate to soft tissue pathologies such as tendinopathy, bursitis, hernia and muscle strain [13]. ...
... Hip pain may include extraand intra-articular pathology or a combination of both that results in clinical signs and symptoms such as buttock, lateral, anterior and posterior thigh, groin, knee and LBP [13,14]. Extra-articular hip pain may relate to soft tissue pathologies such as tendinopathy, bursitis, hernia and muscle strain [13]. Moreover, intra-articular hip joint pain is also shown to be common [30], with Femoroacetabular impingement syndrome (FAI) reported as a frequent cause of pain and 1 3 shown to have a prevalence of up to 89% in elite athletes [9,10,28,[30][31][32]. ...
... There has been an increase in diagnosis and treatment of hip injuries among adolescents. Treatment for pediatric hip disorders such as dysplasia, perthes and slipped capital femoral epiphysis (SCFE) have been well established; however, the diagnosis and treatment of conditions such as femoroacetabular impingement (FAI) and labral tears has limited long-term evidence [1,2]. Hip pain secondary to FAI and/or labral tear has been described as a common phenomenon among adolescent athletes [1,2]. ...
... Treatment for pediatric hip disorders such as dysplasia, perthes and slipped capital femoral epiphysis (SCFE) have been well established; however, the diagnosis and treatment of conditions such as femoroacetabular impingement (FAI) and labral tears has limited long-term evidence [1,2]. Hip pain secondary to FAI and/or labral tear has been described as a common phenomenon among adolescent athletes [1,2]. The workup and diagnosis typically includes a physical exam and radiographic evaluation with X-rays and/or magnetic resonance imaging (MRI). ...
Article
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Intra-articular injection of corticosteroid and anesthetic (CSI) is a useful diagnostic tool for hip pain secondary to labral tears or femoroacetabular impingement (FAI). However, the effectiveness of CSI as a stand-alone treatment for hip pain in adolescents is unknown. The purpose of this study is to evaluate the use of CSI for the treatment of hip pain and determine factors that may affect outcomes after injection. Retrospective analysis of 18 patients and 19 hips that underwent fluoroscopic guided hip injection for the treatment of pain at a single institution from 2012 to 2015 was carried out in this study. Mean age at the time of injection was 15.1 years (range 13–17) with mean follow-up of 29.4 months. Fifty-two percent (10/19 hips) went on to surgery after the injection. Average time to surgical conversion was 12.8 months after CSI. Cam or pincer morphologies were present in 90% (9/10 hips) of the operative group. Patients with FAI were more likely to need surgery than patients without bony abnormalities (RR= 10, 95% CI 1.6–64.2, P = 0.0001). There was no difference in the presence of labral tears in the operative and non-operative groups (100% versus 89%, P = 0.47). For adolescents without bony abnormalities, 90% improved with CSI alone and did not require further treatment within 2.4 years. Fluoroscopic guided corticosteroid hip injection may have limited efficacy for the treatment of hip pain secondary to FAI in adolescents. However, for patients without osseous deformity, CSI may offer prolonged improvement of symptoms even in the presence of labral tears.
... The hip and groin are sites of multiple injuries and inflammatory conditions, including intra-articular and extraarticular pathology, giving rise to an extensive differential diagnosis for hip and groin pain [1,2]. Pain originating from different anatomical areas such as lumbar spine, knee and pelvis can also be referred to the hip and groin. ...
Article
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Hip and groin pain often presents a diagnostic and therapeutic challenge. The differential diagnosis is extensive, comprising intra-articular and extra-articular pathology and referred pain from lumbar spine, knee and elsewhere in the pelvis. Various ultrasound-guided techniques have been described in the hip and groin region for diagnostic and therapeutic purposes. Ultrasound has many advantages over other imaging modalities, including portability, lack of ionising radiation and real-time visualisation of soft tissues and neurovascular structures. Many studies have demonstrated the safety, accuracy and efficacy of ultrasound-guided techniques, although there is lack of standardisation regarding the injectates used and long-term benefit remains uncertain.
... Physical examination should consist of range of motion testing along with specific tests for impingement and labral pathology. Log roll, FABER, FADIR, and Stinchfield's test can all illicit pain in patients with labral tears, but cannot exclude many other potential etiologies (26). Extra-articular etiologies of hip pain should be ruled out. ...
... Prior studies have examined the biomechanical demands placed on athletes to determine which sports are more likely to cause athletic hip injuries. 7,14,18,20,43 There have also been epidemiological studies of hip injuries in athletes in all 4 of the major American sports (baseball, football, basketball, and ice hockey). 9,15,16,28 To our knowledge, however, a large epidemiological study of hip injuries in college athletes in the United States has not been previously undertaken. ...
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Background Hip and groin pain is a common complaint among athletes. Few studies have examined the epidemiology of hip and groin injuries in collegiate athletes across multiple sports. Purpose To describe the rates, mechanisms, sex-based differences, and severity of hip/groin injuries across 25 collegiate sports. Study Design Descriptive epidemiology study. Methods Data from the 2009-2010 through 2013-2014 academic years were obtained from the National Collegiate Athletic Association Injury Surveillance Program (NCAA ISP). The rate of hip/groin injuries, mechanism of injury, time lost from competition, and need for surgery were calculated. Differences between sex-comparable sports were quantified using rate ratios (RRs) and injury proportion ratios (IPRs). Results In total, 1984 hip/groin injuries were reported, giving an overall injury rate of 53.06 per 100,000 athlete-exposures (AEs). An adductor/groin tear was the most common injury, comprising 24.5% of all injuries. The sports with the highest rates of injuries per 100,000 AEs were men’s soccer (110.84), men’s ice hockey (104.90), and women’s ice hockey (76.88). In sex-comparable sports, men had a higher rate of injuries per 100,000 AEs compared with women (59.53 vs 42.27, respectively; RR, 1.41 [95% CI, 1.28-1.55]). The most common injury mechanisms were noncontact (48.4% of all injuries) and overuse/gradual (20.4%). In sex-comparable sports, men had a greater proportion of injuries due to player contact than women (17.0% vs 3.6%, respectively; IPR, 4.80 [95% CI, 3.10-7.42]), while women had a greater proportion of injuries due to overuse/gradual than men (29.1% vs 16.7%, respectively; IPR, 1.74 [95% CI, 1.46-2.06]). Overall, 39.3% of hip/groin injuries resulted in time lost from competition. Only 1.3% of injuries required surgery. Conclusion Hip/groin injuries are most common in sports that involve kicking or skating and sudden changes in direction and speed. Most hip/groin injuries in collegiate athletes are noncontact and do not result in time lost from competition, and few require surgery. This information can help guide treatment and prevention measures to limit such injuries in male and female collegiate athletes.
... F emoroacetabular impingement (FAI) is a common cause of hip pain in active adolescents and young adults, characterized by abnormal joint morphology causing aberrant contact between the proximal femur and acetabular rim. [1][2][3][4][5] Symptomatic FAI often results in significant functional limitations in activities of daily living and sports activities. 3,6 Hip arthroscopy with osteoplasty and/or acetabuloplasty is successful in reducing pain and disability in patients with FAI in whom nonoperative treatment has failed. ...
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Purpose: (1) To determine the prevalence of depression in patients undergoing hip arthroscopy for the treatment of femoroacetabular impingement (FAI) syndrome and (2) to determine whether depression has a statistically significant and clinically relevant effect on preoperative and postoperative patient-reported outcome scores. Methods: Consecutive subjects undergoing hip arthroscopy for FAI syndrome were retrospectively reviewed. The Beck Depression Inventory-II (BDI-II), Hip Outcome Score (HOS), and 33-item International Hip Outcome Tool (iHOT-33) were administered preoperatively and postoperatively. Clinically relevant differences were defined by the minimal clinically important difference, substantial clinical benefit, and patient acceptable symptom state. Comparisons between preoperative and postoperative scores were completed. The Spearman correlation coefficient (r) was used to determine the degree of correlation between the BDI-II score, HOS, and iHOT-33 score preoperatively and postoperatively. Results: We analyzed 77 patients (72.7% female patients; mean age, 35.2 ± 12.5 years). Depressive symptoms were reported as minimal (75.3%), mild (11.7%), moderate (6.5%), or severe (6.5%). Patients with minimal or mild depression had a superior HOS Activities of Daily Living (Δ17.3 preoperatively [P < .001] and Δ37.8 postoperatively [P < .001]), HOS Sport-Specific Subscore (Δ12.8 preoperatively [P = .002] and Δ52.1 postoperatively [P < .0001]), and iHOT-33 score (Δ15.4 preoperatively [P < .0001] and Δ51.3 postoperatively [P < .0001]) compared with patients with moderate or severe depression. There was a weak to moderate negative correlation between the BDI-II score and iHOT-33 score (r = -0.4614, P < .0001 preoperatively; r = -0.327, P < .0001 at 1 year), HOS Activities of Daily Living (r = -0.531, P < .0001 preoperatively), and HOS Sport-Specific Subscore (r = -0.379, P < .0017 at 1 year). Conclusions: Most patients undergoing hip arthroscopy for FAI have minimal depressive symptoms with the overall prevalence higher than the general population. Patients with minimal or mild depressive symptoms have statistically and clinically better preoperative and postoperative patient-reported outcomes, are more likely to obtain substantial clinical benefit from surgery, and are more likely to reach a patient acceptable symptom state after surgery than patients with moderate to severe depressive symptoms. Level of evidence: Level III, case-control study.
... Other hip injuries in adolescent athletes include coxa saltans in which the iliotibial band catches and snaps along the greater trochanter of the femur, apophyseal avulsion fractures at physeal plates, hip subluxation or dislocation, and athletic pubalgia consisting of osteitis pubis, adductor muscle injuries, and sports hernias (Frank, 2013). With respect to avulsion fractures, Rossi et al.,described 203 avulsion fractures documented over a twenty-two-year period and found that 54 per cent of fractures were located at the ischial tuberosity, 22 per cent at the anterior inferior iliac spine, and 19 per cent at the anterior superior iliac spine (Rossi, 2001). ...
... Labral tears are more common in patients who participate in hockey, football, gymnastics, soccer, ballet, running, yoga, and surfing. 1,2 Runners are at high risk for iliotibial band friction syndrome and iliopsoas tendinitis. Mechanical symptoms indicate labral tears and chondral lesions. ...
Article
The diagnosis and treatment of hip pain in the young adult remain a challenge. Recently, understanding of a few specific hip conditions has improved, most notably femoroacetabular impingement. The differential diagnosis of hip pain has also expanded significantly, offering new challenges and opportunities. Along with the diagnostic dilemma, optimal treatment strategies for many conditions have yet to be proven and are current areas of important inquiry. This article reviews the current research on hip pain in the young adult and presents an overview of diagnostic and management strategies.
... The prevalence of hip injuries in the young adult population is significant. In the last decades there has been significant advances in the identification and treatment of different pathologic conditions that affect the young adult hip such as labral tears, cartilage injury, capsular/ iliofemoral ligament injury, femoroacetabular impingement, hip instability and athletic pubalgia [1][2][3]. ...
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The international Hip Outcome Tool-33 (iHOT-33) is a 33-item self administered outcome measure based on a Visual Analogue Scale response format designed for young and active population with hip pathology. The aim of the present study is to translate and validate the iHOT-33 into Spanish. 97 patients undergoing hip arthroscopy were included in this prospective and multicenter study performed between January 2012 and May 2014. Crosscultural adaptation was used to translate iHOT-33 into Spanish. Patients completed the questionnaire before and after surgery. Feasibility, reliability, internal consistency, construct validity (correlation with Western Ontario and McMaster Universities Osteoarthritis Index), ceiling and floor effects and sensitivity to change were assessed for the present study. Mean age was 48 years old. Feasibility: 41.2 % patients had no blank questions, and 71.3 % of patients had fulfilled all but one or two questions. Reliability: ICC for the global questionnaire was 0.97, showing that the questionnaire is highly reproducible. Internal consistency: Cronbach's alpha was 0.98 for the global questionnaire. Construct validity: there was a high correlation with WOMAC (correlation coefficient >0.5). The Ceiling effect (taking into account the minimum detectable change) was 12.1 % and the floor effect was 21.6 %, for the global questionnaire. Large sensitivity to change was shown. the Spanish version of iHOT-33 has shown to be feasible, reliable and sensible to changes for patients undergoing hip arthroscopy. This validated translation of iHOT-33 allows for comparisons between studies involving either Spanish- or English-speaking patients. Prognostic study, Level I.
... Symptoms may include hip and groin pain and instability of the hip joint. Clinical findings include pain provoked with the hip instability tests (hyperextension-external rotation (HEER), Abductionhyperextension-external rotation (AB-HEER) and the PRONE instability test), abductor fatigue with a positive Trendelenburg sign and increased range of motion of the hip [5,[8][9][10][11]. In order to make the diagnosis of DDH complete, anteroposterior (AP) pelvic radiographs are usually obtained [12,13]. ...
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The aim of this study was to determine the additional value of the false-profile (FP) view radiograph in the diagnosis of developmental dysplasia of the hip (DDH), as compared with an anteroposterior (AP) pelvic radiograph only, and evaluate the correlation between the Wiberg-lateral center edge angle (W-LCEA) and Wiberg-anterior center edge angle (W-ACEA). We used baseline data from a nationwide prospective cohort study (Cohort Hip and Cohort Knee). DDH was quantified on AP pelvic and FP hip radiographs using semi-automatic measurements of the W-LCEA and W-ACEA. A threshold of <20° was used to determine DDH for both the W-LCEA and the W-ACEA. The proportion of DDH only present on the FP view determined the FP view additional value. The correlation between the W-LCEA and W-ACEA was determined. In total 720 participants (1391 hips) were included. DDH was present in 74 hips (5.3%), of which 32 were only present on the FP view radiograph (43.2%). The Pearson correlation coefficient between W-LCEA and W-ACEA of all included hips was 0.547 (95% confidence interval: 0.503–0.591) and 0.441 (95% confidence interval: 0.231–0.652) in hips with DDH. A mean difference of 9.4° (SD 8.09) was present between the W-LCEA and the W-ACEA in the hips with DDH. There is a strong additional value of the FP radiograph in the diagnosis of DDH. Over 4 out of 10 (43.2%) individuals’ DDH will be missed when only using the AP radiograph. In hips with DDH a moderate correlation between W-LCEA and W-ACEA was calculated indicating that joints with normal acetabular coverage on the AP view can still be undercovered on the FP view.
... The most dramatic form of postoperative instability results in complete hip dislocation, 7-10 but more commonly, capsular defects leading to microinstability may be the source of residual hip pain after surgery. [11][12][13][14] Treatment of the capsule during hip arthroscopy can come in different forms and is not standardized between surgeons. 3,14-18 Capsular management techniques can range from capsulectomy to limited capsulotomy, 15,18 interportal capsulotomy with or without repair, or T-capsulotomy with 3,16 or without repair. ...
Article
To determine the effect of different types of capsulotomies on hip rotational biomechanical characteristics. Seven fresh-frozen cadaveric hip specimens were thawed and dissected, leaving the hip capsule and labrum intact. The femur was transected and potted, and each specimen was placed in a custom loading apparatus that allowed for adjustment of flexion, extension, and axial rotation of the femur. Six reflective infrared markers were attached to the specimens to track the motion of the femoral head with respect to the acetabulum in real time, and external rotation was produced by applying a torque of 10 Nm to the hip specimens. Data analysis was performed using the 3-dimensional position of the markers in space. The specimens were tested in neutral flexion and 40° of flexion in the following capsular states: intact, interportal capsulotomy, T-capsulotomy, repaired capsulotomy, and capsulectomy. Paired t tests and analysis of variance were used with an α value of .05 set as significant. With the hip in neutral flexion, there was increased external rotation with a T-capsulotomy (91.1° ± 20.3°, P = .029) and capsulectomy (91.9° ± 19.6°, P = .015) compared with the intact hip (83.2° ± 20.5°). After complete repair of the T-capsulotomy (87.4° ± 20.6°), there was no significant difference in external rotation compared with the intact hip. No significant differences were seen between groups at 40° of hip flexion. A T-capsulotomy showed significantly increased external rotation versus the intact and interportal capsulotomy states. The repaired T-capsulotomy restored the rotational profile back to the native state. Many methods of capsular treatment during hip arthroscopy exist. Capsulotomy and capsulectomy do not restore the external rotation restraint of the hip back to its native state. Published by Elsevier Inc.
... 57 Radiographic imaging is used to evaluate for concurrent morphologic abnormalities of the hip, and MRI arthrogram is used to confirm the diagnosis of a labral tear with a sensitivity of 76% to 91%. 58 Initial treatment consists of conservative treatment, which includes rest, anti-inflammatory medication, activity modification, and physical therapy. In patient refractory to conservative treatment, arthroscopic surgery is effective with high rates of return to sport. ...
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Soccer is the most popular sport in the world and has the fourth highest number of sports injuries. Hip and groin injuries account for 14% of soccer injuries and can be difficult to recognize and treat as they often require a high level of suspicion and advanced imaging. Groin pain can be separated into 3 categories: (1) defined clinical entities for groin pain (adductor-related, iliopsoas-related, inguinal-related [sports hernias/athletic pubalgia], and pubic-related groin pain), (2) hip-related groin pain (hip morphologic abnormalities, labral tears, and chondral injuries), and (3) other causes of groin pain. Conservative approaches are typically the first line of treatment, but operative intervention has been reported to result in higher rates of return to sport in athletes with hip-related and inguinal-related groin pain injuries. In patients with concurrent hip-related and inguinal-related groin pain, the failure to recognize the relationship and treat both conditions may result in lower rates of return to sport. Preseason screening programs can identify high-risk athletes, who may benefit from a targeted prevention program. Further study on exercise therapy, early surgical intervention, and potential biologic intervention are needed to determine the most effective methods of preventing groin injuries in athletes. https://www.amjorthopedics.com/article/hip-and-core-muscle-injuries-soccer
... High impact activities in combination with intensity of various kinds have been shown to affect the developing femur [12]. Among children, open physes and growing cartilage make them more susceptible to injury and shear forces that can result in premature physeal arrest, apophyseal avulsion fractures, and chondral injuries [13]. A higher prevalence of cam deformities (> 50%), both symptomatic and asymptomatic, has been shown in adolescent athletes that play ice hockey, basketball, and soccer when compared to controls that did not play sports [7,10,11,[14][15][16][17]. ...
Article
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Background: Femoroacetabular impingement (FAI) is an important cause of hip pain in young and active individuals and occurs as a result of size and shape mismatch between the femoral head and acetabulum. Open physes in children can make hips more susceptible to injury, and high impact forces have been suggested to affect the developing femur. The diagnosis of FAI has recently risen, especially within adolescent populations, and there is an increasing trend towards year-round participation in sports with early specialization. The PREVIEW study is an international longitudinal study designed to determine the association between sport specialization in adolescence and the development of hip impingement. Methods: This is a multicentre prospective cohort study evaluating 200 participants between the ages of 12-14 that include sport specialists at the moderate to vigorous physical activity (MVPA) level and non-sport specialists at any activity level. We will monitor physical activity levels of all participants using an activity log and a wrist-mounted activity tracker, with synced data collected every 3 months during the study period. In addition, participants will be evaluated clinically at 6, 12, and 18 months and radiographically at the time of enrolment and 24 months. The primary outcome is the incidence of FAI between groups at 2 years, determined via MRI. Secondary outcomes include hip function and health-related quality of life between subjects diagnosed with FAI versus no FAI at 2 years, as determined by the Hip Outcome Score (HOS) and Pediatric Quality of Life (PedsQL) questionnaires. Discussion: It is important to mitigate the risk of developing hip deformities at a young age. Our proposed prospective evaluation of the impact of sport activity and hip development is relevant in this era of early sport specialization in youth. Improving the understanding between sport specialization and the development of pre-arthritic hip disease such as FAI can lead to the development of training protocols that protect the millions of adolescents involved in sports annually. Trial registration: PREVIEW is registered with clinicaltrials.gov (NCT03891563).
... Several studies have demonstrated the relationship of sporting activities, such as football, hockey, rugby, and running, with the hip function of young athletes. [7][8][9][10][11][12] Loads of up to eight times the body weight on the hip joint are common in daily activities, such as jogging, and significantly greater forces than this are expected during competitive athletics. 13) However, few studies related to the onset status of hip injuries in young baseball players have been reported. ...
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Objective: The hip joint is a crucial part of the kinetic chain for throwing baseball pitches. Nevertheless, few reports have described assessments of the functional development of the hip joint in young baseball players. Methods: We examined 315 young baseball players, 7–14 years old, all of whom had completed a self-administered questionnaire including items related to the dominant side and throwing-related hip joint pain sustained during the previous year. We measured the hip ranges of motion (ROMs: external and internal rotation and flexion) and hip muscle strengths (external and internal rotation) on the dominant and non-dominant sides. The differences of hip ROMs and muscle strengths between the dominant and non-dominant sides and between age groups were investigated. Correlations were calculated between the players ages and hip ROMs and muscle strengths. Results: No baseball player reported hip pain. The hip external rotation on the dominant side was smaller than that on the non-dominant side, whereas the hip internal rotation on the dominant side was greater than that on the non-dominant side. However, no significant difference was found between the dominant and non-dominant sides in terms of the hip muscle strength. Significant positive associations were found between the player’s age and hip muscle strengths, whereas significant negative associations were found between the age and hip ROMs. Conclusions: Our data concerning the relationship between age and hip joint development could be useful for supporting strategies for the prevention and rehabilitation of throwing injuries; however, hip injuries might be rare among young baseball players.
Article
Subacute, nontraumatic hip pain is often a diagnostic challenge. Femoroacetabular impingement (FAI) is a common cause of atraumatic hip pain that is poorly understood. FAI is a result of abnormal morphologic changes in either the femoral head or the acetabulum. FAI is more prevalent in people who perform activities requiring repetitive hip flexion, but it remains common in the general population. Evaluation begins with physical examination maneuvers to rule out additional hip pathology and provocation tests to reproduce hip pain. Diagnosis is often made by radiography or magnetic resonance imaging. Initial treatment is generally more conservative, featuring activity modification and physical therapy, whereas more aggressive treatment requires operative management.
Article
Purpose: To investigate whether pelvic incidence (PI) in patients with symptomatic femoroacetabular impingement was different from that in a normal population. Methods: Retrospective analysis of 30 consecutive female and 30 consecutive male patients with computed tomography scans who underwent hip arthroscopy for FAI. PI was measured using scout lateral radiographs. The center-edge angle (CEA), acetabular version, and α angle were also measured. Each patient was subcategorized as having a cam-type deformity (α angle >55°), a deep socket deformity (CEA >39°), and/or a retroverted acetabulum (acetabular anteversion <15°). Our group and subgroups were compared with a historical control group from a previously published study of 300 volunteers. Each group was compared using a Student t test. Results: Our mean PI was 49.31° ± 12.34° (range, 28.4°-79.5°), less than the asymptomatic historical control (n = 300) with a mean PI of 55.0° ± 10.6° (range, 33°-82°) (P < .001). The subgroups for cam deformity, deep socket deformity, and acetabular retroversion have a mean PI of 48.89° ± 11.81°, 38.30° ± 7.56°, and 44.93° ± 11.32°, respectively. All had a significantly lower PI than the historical control (P < .001, P < .001, P < .001, respectively). Conclusions: We conclude that patients presenting with FAI may have a lower PI than the general population. The clinical significance of a 5.7° difference in PI remains unknown. Level of evidence: Level III, retrospective comparative study.
Article
To determine the relative influence of anteroinferior iliac spine (AIIS) or subspine decompression on proximal rectus femoris integrity and iliopsoas excursion throughout a physiological range of motion. Nineteen cadaveric hips from 10 specimens were dissected to retain the origin of the rectus femoris direct and indirect heads. The anatomic footprints of the origins were measured with calipers. Serial 5-mm resections of the AIIS were made to determine the extent of proximal tendon disruption that corresponded to each resection. Iliopsoas tendon tracking was also assessed after sequential AIIS decompression by measuring the excursion of the medial border of the iliopsoas tendon as it traveled from its native resting position to the point where it first encountered bony impingement at the AIIS. The mean proximal-distal footprint of the rectus femoris direct head was 17.95 ± 2.99 mm. The mean medial-lateral distance was 11.84 ± 2.34 mm. There was a consistent bare area along the inferior aspect of the AIIS that averaged 4.84 ± 1.42 mm. The average percentage of remaining footprint after each 5-mm resection (5 to 25 mm) was 96%, 65%, 35%, 14%, and 11%, respectively, with statistical significance noted after resections larger than 5 mm (P < .001). The native excursion distance of the iliopsoas tendon was 14.05 mm. With each 5-mm resection, the percentage of excursion before impingement on the AIIS increased by 18%, 45%, 72%, 95%, and 100%, respectively, which was statistically significance after all resections (P < .001). Our study maps the anatomic footprint of the direct head of the rectus femoris tendon and confirms a previously identified bare area along the inferior aspect of the AIIS. Female cadaveric hips had a significantly smaller rectus footprint than male cadavers in our study (P < .001). Subspine decompression greater than 10 mm significantly compromises the rectus femoris origin and should be avoided when performing arthroscopic AIIS decompression. In addition, subspine decompression significantly improves tracking of the iliopsoas tendon throughout a physiological range of motion and may be considered a surgical adjunct when treating symptomatic iliopsoas snapping. Arthroscopic subspine decompression serves as an important treatment modality for AIIS impingement. With a more thorough understanding of AIIS anatomy, subspine decompression can be used to relieve impingement symptoms and possibly improve iliopsoas tracking while safely maintaining rectus femoris footprint integrity. Published by Elsevier Inc.
Chapter
The participation of children in sporting activities provides physical, social, emotional, and psychological benefits, not without risk of injury. As we promote physical activity in this population, it is our responsibility to ensure their physical and mental health. The developmental timeline, skeletal maturity, and specific anatomic considerations must be understood and acknowledged by the physician in order to properly assess, diagnose, and treat young athletes. Acute injuries mostly occur due to contact mechanism, while overuse injuries are often related to fatigue, biomechanical alterations, and early specialization. Management must be individualized considering factors such as skeletal, metal, and chronological maturity, level of competition, and support system. The sports medicine physician serves as a diagnostician, healer, and advocate for the young athlete.
Chapter
Hip pain in an adolescent is a common complaint, with a myriad of possible diagnoses, and can range from straightforward conditions with a good prognosis to severe conditions with a poor prognosis, either for the future of the hip or the life of the patient. Many of the conditions overlap with the school-age child. This chapter will address only those not discussed in that chapter.
Article
Hip pain is a common complaint in athletes and can result in a significant amount of time lost from sport. Diagnosis of the source of hip pain can be a clinical challenge because of the deep location of the hip and the extensive surrounding soft tissue envelope. Establishing whether the source of hip pain is intra-articular or extra-articular is the first step in the process. A thorough history and a consistent and comprehensive physical examination are the foundation for the proper management of athletes with hip pain.
Article
Background: The incidence of hip arthroscopic surgery is increasing in the young athlete. This has also led to increased numbers of revision hip arthroscopic surgery. Hypothesis/purpose: The purpose of this study was to describe the outcomes after revision hip arthroscopic surgery in patients ≤18 years of age in comparison to a matched cohort of patients undergoing primary hip arthroscopic surgery. Our hypothesis was that patients undergoing revision hip arthroscopic surgery would demonstrate similar outcomes to those patients undergoing primary hip arthroscopic surgery. Study design: Cohort study; Level of evidence, 3. Methods: Patients were included in the study if they underwent revision hip arthroscopic surgery by a single surgeon and did not undergo prior open hip surgery. Each patient in the revision hip arthroscopic surgery cohort was matched with 2 patients undergoing primary hip arthroscopic surgery from the same institution. Cohorts were matched by age, sex, and year of surgery. Preoperatively and at a minimum follow-up of 2 years, outcome scores were collected. The primary outcome measure was the Hip Outcome Score for activities of daily living scale (HOS-ADL), a self-reported validated outcome instrument, in addition to the HOS for sports scale (HOS-Sport), modified Harris Hip Score (mHHS), and 12-Item Short Form Health Survey Physical Component Summary (SF-12 PCS). Results: Forty-two patients were included in the revision group and were matched with 84 patients in the primary group. The mean age in both groups was 16 years (range, 14-18 years). All female patients in the study were ≥14 years of age, and all male patients were ≥16 years of age. In patients undergoing revision, 13 underwent 1 prior surgical procedure, 22 underwent 2 prior surgical procedures, and 7 underwent ≥3 prior surgical procedures. The mean time from last surgery to revision was 18.7 months (range, 4.7-74 months). Eleven patients (26%) had prior femoroacetabular impingement treated, which required osteoplasty or rim trimming at revision. Subsequent hip arthroscopic surgery was reported in 3 of 84 (4%) patients in the primary group and 6 of 42 (14%) patients in the revision group (P = .162). The mean follow-up in the revision group was 43 ± 17 months, and scores significantly improved (HOS-ADL: 59.6 to 77.6; HOS-Sport: 37.6 to 64.8; mHHS: 55.3 to 74.3; SF-12 PCS: 41.0 to 50.4; P < .05). The mean follow-up in the primary group was 45 ± 18 months, and all scores significantly improved (HOS-ADL: 65.8 to 87.4; HOS-Sport: 46.3 to 79.9; mHHS: 57.5 to 84.2; SF-12 PCS: 39.0 to 51.8; P < .05). At follow-up, there were no significant differences between the primary and revision groups for the HOS-ADL values (P = .051) and SF-12 PCS values (P = .846). Patients in the primary group had significantly higher HOS-Sport values (P = .008), mHHS values (P = .008), and patient satisfaction (P = .008). Patients who underwent 1 prior hip arthroscopic procedure had a higher mean postoperative mHHS value (79.5 vs 72, respectively), HOS-ADL value (91.2 vs 73.4, respectively), and HOS-Sport value (76 vs 60, respectively) (P < .05) compared with those who underwent more than 1 prior procedure. Median patient satisfaction was 9.0 (range, 2-10) in the primary group and 8.0 (range, 2-10) in the revision group. Conclusion: In conclusion, young patients who required revision hip arthroscopic surgery showed significant improvement in patient-reported outcome scores; however, final outcome scores in the revision group for sport activity, general health, and satisfaction were lower than those in the primary group. Patients who underwent 1 revision surgical procedure had higher outcome scores than patients who underwent more than 1 revision surgical procedure.
Article
This article provides concise and up-to-date information on the most common hip pathologies that affect adolescent athletes. We cover the evaluation and treatment of avulsion injuries, stress fractures, slipped capital femoral epiphysis (SCFE), femoroacetabular impingement, developmental dysplasia of the hip, Legg-Calve-Perthes disease, and coxa saltans focusing on minimizing advanced imaging and using conservative therapy when applicable. Although this is not an all-encompassing list of disorders, it is key to understand these hip pathologies because these injuries occur commonly and can also have detrimental complications if not diagnosed and addressed early, especially SCFE and femoral neck stress fractures.
Chapter
The diagnosis of hip and pelvic pathology can be difficult, and a complete understanding of anatomy and pathology combined with a thorough history and physical examination is essential. Differentiation between primary hip and pelvic pathology and secondary compensatory dysfunction is crucial to designing an appropriate treatment strategy. The treating clinician should be aware of all available imaging modalities, including radiographs, MRI, and CT, which are essential to formulating an accurate diagnosis. There is a high rate of asymptomatic hip and pelvic pathology in athletic individuals. Imaging findings should be correlated with clinical symptoms and examination findings. Most hip and pelvic pathologies respond favorably to an initial trial of non-operative treatment. Femoral neck fractures, joint sepsis, and traumatic hip dislocations in an athlete require emergent treatment. Surgical treatment options for injuries that do not respond to conservative measures are evolving. The increased utilization of hip arthroscopy has expanded the surgical indications for hip and pelvic pathology with promising results. Femoroacetabular impingement is an increasingly recognized pathology that can contribute to symptomatic impingement, instability, and other painful conditions.
Chapter
The injuries sustained by dance students are mainly the result of overuse (excessive quantity) or abuse (incorrect technique); thus, they could be prevented. The outcome of a dance injury can either affect participation in dance for a given time or bring the student’s potential development as a dancer to an end. In order to predict who is prone to what injuries the medical profession has developed screening processes by which one can draw conclusions for individual dance students regarding their risk factors for certain injuries, and also accumulate data regarding this specific population and establish “norms” and objective parameters to compare between individuals. This chapter will address the differences between specific age groups and describe the correlation between body structure, dance technique, and some pathologies. It should provide tools to empower students and teachers, and enhance medical professionals’ knowledge of the specific issues relevant to dance students.
Chapter
Hip problems are common in young dancers and often preventable. The extreme ranges of motion demanded of the dancer’s hip without the necessary strength and flexibility to accommodate them create the potential for injury. Additionally, some dancers may have an anatomic makeup that predisposes them to injury, and those with developing musculoskeletal systems may be particularly vulnerable. Pathology about the hip ranges from intra-articular to extra-articular, as well as referred pain from adjacent structures. Diagnosis begins with a history and physical examination to formulate a differential diagnosis, and imaging can be used as an adjunct. Treatment of injuries relies on an understanding of the mechanics of dance, especially as they apply to the dance discipline in question, the associated hip anatomy, and the specific etiology of the injury. When rehabilitation and physical therapy fail, additional interventions such as targeted steroid injections or surgery may be beneficial.
Article
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The purpose of this study was to determine the (1) return-to-sport rate for National Football League (NFL) players following femoroacetabular impingement surgery, (2) postoperative career length and games per season, (3) pre- and postoperative performance, and (4) postoperative performance compared with control players matched by position, age, years of experience, and performance. National Football League athletes who underwent hip arthroscopy for femoroacetabular impingement and matched controls were identified. A Bonferroni correction was used to control for multiple comparisons, with statistical significance set at P≤.007. Fifty-five players (63 surgeries) were analyzed (mean age, 27.5±3.4 years; mean years in NFL at time of surgery, 4.7±2.9). Forty-seven (53 surgeries, 84.1%) NFL players returned to sport at a mean of 6.7±3.8 months following surgery. There was no difference (P>.007) in the mean career length of players in the control group (3.7±2.2 years) vs players who underwent hip arthroscopy (3.5±2.1 years). There was no difference (P>.007) in mean games played per season of players in the control group (12.5±3.1) vs those who underwent hip arthroscopy (12.1±4.0). Quarterbacks had significantly better postoperative performance scores when compared with post-index matched controls (P=.007). The return-to-sport rate is high for NFL athletes after hip arthroscopy for femoroacetabular impingement. There were similar games per season and career lengths postoperatively compared with preoperatively and matched controls. Quarterbacks had significantly better postoperative performance when compared with matched controls. All other positions had similar postoperative performance compared with preoperatively and matched controls
Article
This study sought to determine outcomes of a graduated management protocol from therapy to arthroscopy for adolescents presenting with hip pain and an associated acetabular tear. Thirty-seven hips with an MRI confirmed labral tear were prospectively enrolled in a graduated management protocol created for adolescents. The protocol began with activity modification and focused physical therapy. Patients with persistent symptoms were offered an intraarticular corticosteroid injection. Those with continued symptoms were treated with arthroscopic surgery. The modified Harris hip score (mHHS) and nonarthritic hip score (NAHS) were recorded at the initial visit. Patients were contacted by telephone at 1, 2, and 5 years from enrollment for repeat assessment with mHHS and NAHS. At presentation, the mean mHHS and NAHS for the entire cohort was 66.4 ± 11.4 and 70.2 ± 12.6, and these values improved significantly to 89.3 ± 10.6 and 87.0 ± 11.4 at a mean follow-up of 35.7 ± 18.3 months (range 11.7-64.4 months). Forty-two percent of hips were managed with physical therapy and activity modifications alone, 28% of hips progressed to a steroid injection but did not require surgery, and 31% required arthroscopic intervention. Seventy-three percent of hips treated with activity modification alone, 80% treated with an injection, and 82% of hips treated with arthroscopic repair met the minimal clinically significant difference (MCID) (P = 0.859). At an average of 36 months follow-up, the majority (78%) of adolescent patients with an acetabular labral tear will achieve the MCID utilizing a graduated management protocol.
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Abstract Objective: The aim of this study was to translate and cross-culturally adapt the Nonarthritic Hip Score (NAHS) into Turkish and determine the validity and reliability of the translated version in physically active patients with hip pain. Methods: Sixty young to middle-aged and physically active patients (34 women and 26 men; mean age=35 years; age range: 18-40 years) with hip pain were included in the study. The original version of the NAHS was first translated into Turkish and back-translated into English by two bilingual translators each. The back-translated version was compared with the initial English version by a committee of the four translators. The Turkish version was then tested with 15 patients with hip pain and 15 healthy individuals. The participants were asked whether they had difficulties in understanding the questions. Subsequently, the questionnaire was accepted for use in the study population. Test-retest reliability and internal consistency were assessed using Intraclass Correlation Coefficient (ICC) and Cronbach's alpha, respectively. The construct validity was determined via the Pearson correlation coefficient between the NAHS and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), modified Harris Hip Score (mHHS), and Short Form-12 (SF-12). Floor and ceiling effects were analyzed. Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were performed to test construct validity. Results: An ICC of 0.994 and Cronbach's alpha value of 0.908 were obtained; thus, the Turkish version of the NAHS was reliable. Neither floor nor ceiling effects (15%) were found in the sub-parameters (8.3-1.7%) and the total score (1.7%) of the NAHS. The EFA test showed that this questionnaire had four factors. Model fit indices in CFA were χ2/df=2.23, Tucker-Lewis index=0.90, comparative fit index=0.91, goodness of fit index=0.63, root mean square error of approximation=0.14 (90% CI: 0.12-0.16). The NAHS total score showed an excellent correlation with WOMAC (r=-0.909), mHHS (r=0.850), and SF-12 (r=0.811) scores. Conclusion: The Turkish version of the NAHS is a valid and reliable questionnaire for young and physically active patients with hip pain. Level of evidence: Level II, Diagnostic study.
Article
Introduction. The number of acute and stressful injuries has been increasing in recent years. Injuries of the musculoskeletal system in children seeking emergency care account for 41%, while children aged from 5 to 17 years with chronic sports injuries account for 53% who need medical attention. The lower extremity is the most frequently affected part of patients aged from 5 to 18 years, which is about 60% of all injuries. Aim of the study. To show the possibilities of magnetic resonance imaging in the diagnosis of sports injuries of lower extremities in children. Materials and methods. MRI was performed on a scanner with a magnetic field strength of 3 T to obtain multi-planar STIR, T1-, T2- and PD-weighted images (WI) SE and GE in axial, oblique frontal and sagittal projections with a slice thickness of 4 mm, as well as 2D and 3D isotropic images that were used to obtain images with contrast gain. Specialized coils were used for MRI. MRI was performed in case of damage to the hip (n = 19), knee (n = 329), and ankle joints (n = 32). Results. Studies of the hip were limited to sports muscle injury - muscle strain due to forced contractile load (75.8%) and muscle bruises (24.2%). According to the MRI results, 320 children with knee injury were diagnosed with ACL ruptures, in 67% - complete (n = 214), 33% (n = 106) - partial. Eight (3.7%) of 214 athletes had isolated full breaks in ACL; the remaining 206 were associated with damage to other structures of the knee joint. ACL ruptures were accompanied in all 320 cases of hemarthrosis. Of 30 patients with an ankle injury, 17 had an anterior talofibular ligament (56.7%), in 8 cases with an avulsion of bone fragments from the lateral ankle. Partial deltoid ligament injuries were detected in 9 patients (30.0%); complete ruptures were rare and were observed in only two patients (6.7%). Conclusion. Among imaging methods, MRI plays a decisive role in the diagnosis of sports injuries in children.
Article
Objective We aim to determine if pelvic incidence (PI) differed between a symptomatic femoroacetabular impingement (FAI) population and a control. Methods We retrospectively identified a cohort of symptomatic FAI patients and compared measured PI to a control group. Results The PI was significantly lower in the FAI group compared to the control (51.32±1.07 vs. 55.63±1.04; P < 0.01). Conclusion The mean PI was significantly decreased in the FAI population compared to a control.
Article
Purpose: To describe the injury rates, mechanisms, time loss, and rates of surgery for hip/groin injuries in National Collegiate Athletic Association (NCAA) athletes across 25 collegiate sports during the 2009/10 to 2013/14 academic years. Methods: Data from the 2009/10 to 2013/14 academic years were obtained from the NCAA Injury Surveillance Program (ISP). Rates of hip/groin injuries, mechanism of injury, time lost from competition, and surgical treatment were calculated. Differences between sex-comparable sports were quantified using rate ratios and injury proportion ratios. A sport-specific biomechanical classification system, which included cutting, impingement, overhead/asymmetric, endurance, and flexibility sports, was applied for subgroup analysis. Results: In total, 1,984 hip injuries were reported in 25 NCAA sports, including 9 male and female sports, 3 male-only sports, and 4 female-only sports between the years 2009/10 and 2013/14, resulting in an overall hip injury rate of 53.1/100,000 athletic exposures (AEs). In sex-comparable sports, (basketball, cross-country, lacrosse, ice hockey, indoor track, outdoor track, soccer, swimming, and tennis), men were more commonly affected than women (59.53 vs 42.27 per 100,000 AEs respectively; rate ratio, 1.41; 95% confidence interval, 1.28-1.55). Subgroup analysis demonstrated that the highest rate of hip injuries per 100,000 AEs occurred in impingement sports (96.9). Endurance sports had the highest proportion of injured athletes with time lost >14 days (9.5%). For impingement-type sports, the most common mechanism of injury was no apparent contact (48.2%). The rate of athletes undergoing surgery per 100,000 AEs was highest in impingement-type sports (2.0). Conclusions: We have identified that impingement-type sports are most frequently associated with hip injuries. Additionally, this study demonstrates that hip injuries sustained in athletes who played impingement-type sports had a significantly higher rate of surgical intervention than other sport classifications. Level of evidence: Level III, prognostic study.
Chapter
Pediatric pelvic, hip, and thigh injuries are becoming increasingly more common. Careful clinical diagnosis with considerations of broad differentials and appropriate treatment in this age group is crucial. This chapter will review basic hip anatomy. Much more attention will be applied to clinical history and physical evaluation. It will also include in-depth discussion of some of the most common acute and chronic injuries seen in the pediatric hip, as well as provide some basic steps for management. Brief discussion is provided regarding prevention of sports injuries as well as timing for return to play. At its conclusion, the reader should feel more confident in differentiating, diagnosing, and managing a wide spectrum of pediatric sports injuries.
Article
Developmental dysplasia of the hip (DDH) in adolescents and young adults can cause notable pain and dysfunction and is a leading cause of progressive hip osteoarthritis in affected patients. Recognition of the clinical symptoms and radiographic presentation of DDH in adolescents and young adults are paramount for early management. Plain radiographs are critical for making proper diagnosis, whereas three-dimensional imaging including MRI and/or CT detects intra-articular pathology and better characterizes hip morphology. Management of early, symptomatic DDH includes nonsurgical modalities and open joint preservation techniques. Arthroscopic management can be used as an adjunct for symptomatic treatment and for addressing intra-articular pathology, but it alone does not correct the underlying osseous dysplasia and associated instability. The periacetabular osteotomy has become the mainstay of efforts to redirect the acetabulum and preserve the articular integrity of the hip; however, the proximal femur is also a potential source of pathology that should be considered. Open hip procedures are technically demanding yet provide the opportunity for pain relief, improved function, and preservation of the hip joint.
Article
Purpose The purpose of this systematic review is to synthesize the existing literature surrounding hip arthroscopy in the adolescent athlete population to determine patient reported outcomes, return to sport rates, complications, and reoperations associated with this intervention. Methods A systematic literature review was performed using PubMed (MEDLINE), Cochrane Library, and Embase according to PRISMA guidelines. Studies were included if they were published in English with greater than 2 participants, contained patients aged 10-19 years old or classified as “high school athletes” or “middle school athletes,” and reported post-operative patient reported outcomes and return to sport. Patient reported outcomes (PROs), and their associated p-values were recorded. Finally, return to sport outcomes and sports played were also extracted from the included studies. Weighted kappa was used to assess inter-reviewer agreement. Results 11 studies included in the final analysis, resulting in 344 patients and 408 hips analyzed by this review. Patient reported outcomes (PROs) were reported in all studies. The Modified Harris Hip Score (mHHS) was utilized in all but one study. Six of the eleven studies reported a 100% return to sport rate, for a total of 98/98 athletes returning to sport. Fabricant et al did note that a majority of athletes who returned to sport were able to do so at a subjective “nearly normal” level. Only 4 of the studies reported complications, with the majority being transient neuropraxias. Conclusions Adolescent athletes who undergo hip arthroscopy demonstrate favorable post-operative patient reported outcome scores, high rates of return to sport, and an overall low complication rate. The heterogeneity in both surgical methodology and outcome measures used for evaluation and treatment leads to continued ambiguity with regards to the optimal method for managing adolescent athletes with hip pathology. Level of evidence Level V, systematic review of Level II-V studies
Article
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MULTIPLE SURGICAL PROCEDURES EXIST FOR THE TREATMENT OF OSTEITIS PUBIS: curettage of the symphysis joint, wedge resection, complete resection of the joint, placement of extraperitoneal retropubic synthetic mesh, and arthrodesis of the joint. However, a paucity of literature has reported long-term successful outcomes with the aforementioned approaches. Patients treated operatively have reported recalcitrant pain resulting from iatrogenic instability. The article presents the results of a conservative operative technique that avoids disruption of adjacent ligaments. Preserving the adjacent ligamentous structures will allow competitive athletes to return to competition and activities of daily living free of iatrogenic pelvic instability and pain. Case series. Four competitive athletes (2 professional and 2 collegiate football players) diagnosed with osteitis pubis were treated conservatively for a minimum of 6 months. Patients underwent surgical intervention upon failure to respond to nonoperative management. The degenerative tissue was resected, allowing only bleeding cancellous bone to remain while preserving the adjacent ligaments. An arthroscope was used to assist in curettage, allowing the debridement to be performed through a small incision in the anterior capsule. The symptoms of all 4 patients resolved, and they returned to competitive athletics. This ligament-sparing technique provided a solid, stable repair and pain relief. This surgical technique preserves the adjacent ligamentous structures and allows competitive athletes to return to competition and activities of daily living free of pain and void of pelvic instability. This technique is a surgical treatment option for athletes with osteitis pubis who fail conservative treatment.
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Purpose: To describe an arthroscopic technique for decompression of a prominent anterior inferior iliac spine (AIIS) leading to extra-articular hip impingement and to provide short-term outcome after this procedure. Methods: We retrospectively reviewed office charts, imaging studies, operative reports, arthroscopic images, preoperative and postoperative hip flexion range of motion, and preoperative and postoperative modified Harris Hip Scores in a consecutive series of 10 male patients who had arthroscopic decompression of symptomatic AIIS deformities leading to extra-articular hip impingement. The procedure was performed through standard anterolateral and mid-anterior hip arthroscopy portals that were also used to explore the joint and address concomitant intra-articular pathologies. Results: The mean age was 24.9 years, with 8 of 10 patients aged younger than 30 years. In 9 patients, an anterior cam lesion was identified and decompressed before the AIIS decompression. The mean follow-up time was 14.7 months (range, 6 to 26 months). Hip flexion range of motion improved from 99° ± 7° before surgery to 117° ± 8° after surgery (P < .001). The modified Harris Hip Score improved from 64 ± 18 before surgery to 98 ± 2 at latest follow-up after surgery (P < .001). Conclusions: Arthroscopic decompression of a symptomatic AIIS deformity is a reproducible procedure that can provide excellent outcomes at short-term follow-up. As opposed to using an open approach for decompressing a prominent AIIS, an arthroscopic approach may be of particular value in patients with mixed intra- and extra-articular sources of hip dysfunction, because it enables the surgeon to address all pathologies with a single arthroscopic procedure. Level of evidence: Level IV, therapeutic case series.
Article
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Labral tears typically occur anterosuperiorly in association with femoroacetabular impingement or dysplasia. Less commonly, labral pathology may occur in an atypical direct anterior location adjacent to the iliopsoas tendon in the absence of bony abnormalities. We hypothesize that this pattern of injury is related to compression or traction on the anterior capsulo-labral complex by the iliopsoas tendon where it crosses the acetabular rim. In a retrospective review of prospectively collected data, we identified 25 patients that underwent isolated, primary, unilateral iliopsoas release and presented for at least 1 year follow-up (mean 21 months). Pre-operative demographics, clinical presentation, intra-operative findings, and outcome questionnaires were analyzed. The injury was treated with a tenotomy of the iliopsoas tendon at the level of the joint line and either labral debridement or repair. Mean post-operative outcome scores were 87.17, 92.46, and 78.8 for the modified Harris Hip Score, activities of daily living Hip Outcome Score, and sports-related score, respectively. The atypical labral injury identified in this study appears to represent a distinct pathological entity, psoas impingement, with an etiology which has not been previously described.
Article
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Femoroacetabular impingement (FAI) is increasingly diagnosed in young and middle-aged patients. Although arthroscopic procedures are becoming frequently used in the treatment of FAI, there are little data regarding rates of complications or the ability of hip arthroscopy to improve hip function specifically in the adolescent athlete population. Because arthroscopic treatment is being used in the treatment of FAI, it is vital to know what, if any, improvements in hip function can be expected and the potential complications. We asked (1) whether validated measures of hip function improve after arthroscopic treatment of FAI in adolescent athletes, and (2) what complications might be expected during and after arthroscopic treatment of FAI in these patients. We retrospectively reviewed the records of 27 hips in 21 patients 19 years of age or younger who underwent arthroscopic treatment for FAI between 2007 and 2008. From the records we extracted demographic data, operative details, complications, and preoperative and postoperative modified Harris hip scores (HHS) and the Hip Outcome Score (HOS). The minimum followup was 1 year (average, 1.5 years; range, 1-2.5 years). Modified HHS improved by an average of 21 points, the activities of daily living subset of the HOS improved by an average of 16 points, and the sports outcome subset of the HOS improved by an average of 32 points. All patients' self-reported ability to engage in their preoperative level of athletic competition improved. In 24 hips that underwent cam decompression, the mean alpha-angle improved from 64° ± 16° to 40° ± 5.3° postoperatively. We found short-term improvements in HOS and HHS with no complications for arthroscopic treatment of FAI in our cohort of adolescent athletes. We believe arthroscopic treatment of FAI by an experienced hip arthroscopist should be considered in selected patients when treating athletically active adolescents for whom nonoperative management fails.
Article
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Athletic injuries in or around the hip in the adolescent athlete encompass possible causes such as a single, traumatic event to those of repetitive microtrauma. The injuries may involve the bone or the soft tissues, with former involving the epiphysis, apophysis, metaphysis, or diaphysis, whereas the latter includes muscles and tendons. With the improvements in surgical technique and instrumentation for hip arthroscopy and the development of magnetic resonance arthrography, clinicians have been able to diagnose and treat labral tears, hip instability, snapping hip, loose bodies, chondral injuries, and femoroacetabular impingement. The clinician needs to consider acquired conditions that may have coincidentally become apparent as a result of the adolescent's participation in an organized sports program. These include slipped capital femoral epiphysis, Legg-Calvé-Perthes disease, and pathologic lesions and fractures. This study reviews the more common acute and chronic overuse injuries in or around the hip in the adolescent athlete and discusses hip injury prevention in this active patient population.
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Midterm outcome studies show that symptomatic femoroacetabular impingement (FAI) can be successfully treated by addressing the underlying pathomorphology with open or arthroscopic surgery. Although athletes may be vulnerable to hip injury from impingement, limited information is available regarding the results of open surgery in this group. High-level athletes with FAI can resume their sports after surgical hip dislocation and continue professional careers for a significant period. Case series; Level of evidence, 4. Twenty-two professional male athletes (19.7 ± 2.2 years) were evaluated by postal survey at a mean of 45.1 months (range, 12 to 79) after treatment by surgical hip dislocation (30 hips, cam- or mixed-type FAI; mean α angle, 69.3°; 14 ice hockey players). Evaluation included types and level of sports, subjective ratings, and CLINICAL OUTCOMES: Hip Outcome Score, SF-12, UCLA (University of California, Los Angeles) activity scale, Hip Sports Activity Scale, visual analog scale for pain. The primary outcome variable was return to professional sports; the clinical result was the secondary outcome variable. At follow-up, 21 of 22 patients (96%) were still competing professionally: 19 at their previous level and 2 in minor leagues. Eighteen (82%) were satisfied with their hip surgery and 19 (86%) with their sports ability. Mean activity levels were 9.8 per the UCLA scale and 7.6 per the Hip Sports Activity Scale. Mean scores of the Hip Outcome Score-Activities of Daily Living and Sport subscales were 94.5 and 89.1. Mean scores of the SF-12 physical and mental component summaries were 51.1 and 54.3. Pain levels during sports were 1.8 per the visual analog scale. Surgical hip dislocation for the treatment of FAI allows athletes to resume sports and continue professional careers at the same level for several years. Clinical outcomes in terms of subjective ratings and scores were favorable.
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The iliocapsularis muscle is a little known muscle overlying the anterior hip capsule postulated to function as a stabilizer of dysplastic hips. Theoretically, this muscle would be hypertrophied in dysplastic hips and, conversely, atrophied in stable and well-constrained hips. However, these observations have not been confirmed and the true function of this muscle remains unknown. We quantified the anatomic dimensions and degree of fatty infiltration of the iliocapsularis muscle and compared the results for 45 hips with deficient acetabular coverage (Group I) with 40 hips with excessive acetabular coverage (Group II). We used MR arthrography to evaluate anatomic dimensions (thickness, width, circumference, cross-sectional area [CSA], and partial volume) and the amount of fatty infiltration. We observed increased thickness, width, circumference, CSA, and partial volume of the iliocapsularis muscle in Group I when compared with Group II. Additionally, hips in Group I had a lower prevalence of fatty infiltration compared with those in Group II. The iliocapsularis muscle typically was hypertrophied, and there was less fatty infiltration in dysplastic hips compared with hips with excessive acetabular coverage. These observations suggest the iliocapsularis muscle is important for stabilizing the femoral head in a deficient acetabulum. This muscle serves as an anatomic landmark when performing a periacetabular osteotomy. Additionally, preoperative evaluation of morphologic features of the muscle can be used as an adjunct for decision making when treating patients with borderline hip dysplasia or femoroacetabular impingement.
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Our purpose was to describe the appearance of the acetabular capsular-labral complex on MR arthrography and to correlate this appearance with surgical findings in adult patients and with gross anatomic findings in cadavers. MR arthrography of the hip joint was performed in 40 patients and six cadavers. All patients underwent subsequent arthrotomy of the hip. MR arthrography consisted of a T1-weighted three-dimensional gradient-echo sequence in both the coronal oblique and sagittal oblique planes after intraarticular injection of a 2 mmol/l solution of gadopentetate dimeglumine. The normal and pathologic appearance of the capsular-labral complex was assessed, and the labra were evaluated on the basis of morphology, signal intensity, presence of a tear, and attachment to the acetabulum. MR arthrography findings were correlated with the surgical results in all patients and with the anatomic sections of the cadaveric hip joint specimens. MR arthrography images of the T-weighted three-dimensional gradient-echo sequences allowed visualization of the anatomic structures. The normal labrum was triangular, without any sublabral sulcus, and of homogeneous low signal intensity. A recess between the labrum and the joint capsule could be identified in instances in which no thickened labrum was present. Labral lesions included labral degeneration, a tear, or a detached labrum either with or without thickening of the labrum. The sensitivity for detection and correct staging of labral lesions with MR arthrography in the patient study was 91%; the specificity, 71%; and the accuracy, 88%. MR arthrography with T1-weighted three-dimensional gradient-echo sequences allows excellent assessment of the normal and pathologic acetabular capsular-labral complex.
Article
Purpose To report the complications associated with surgical correction of internal snapping hip. Study Design Retrospective review. Methods A review of 92 cases of internal coxa saltans (12 bilateral) from 1982 to 2002 was performed to identify complications following primary surgical correction. An inguinal approach was used for iliopsoas tendon fractional lengthening. The average follow-up time per patient was 5.4 years. Results A total of 40 complications occurred in 32 patients. Complications included persistent hip pain (n = 6), sensory deficit (n = 8), and hip flexor weakness persisting longer than 1 month (n = 3). Additionally, painful bursa formation (n = 1), hematoma requiring reexploration (n = 1), and superficial infection (n = 1) were noted. Some patients developed recurrent snapping after a 3-month snapping-free interval (n = 9), and some patients never had complete resolution of snapping and were considered failures (n = 11). Of these failures/recurrences, 8 patients had a second tenotomy with 4 failures. Two had a third tenotomy, with 1 failure. Conclusions In this series, primary iliopsoas tendon lengthening in patients with internal coxa saltans was without any complication in only 60% of patients; however, overall patient satisfaction was 89%.
Article
Femoroacetabular impingement (FAI) is a common cause of intra-articular hip pathology and secondary osteoarthritis. It affects athletes at a young age as they push their bodies beyond the diminished physiologic limits imposed by the altered joint morphology. Understanding the cause of this condition and its assessment in athletes is important. The scientific literature was reviewed to reflect the current understanding of hip joint pathology among athletic individuals. Focus is given to the literature since 2003, when FAI was first reported as a cause of joint damage in the native hip. There are 3 types of FAI: pincer, cam, and combined. The pathomechanics and pattern of secondary intra-articular pathology are different among the types. History and examination usually reflect findings of joint damage among athletes, and radiographs can reveal the presence of underlying FAI. Other imaging studies may variably aid in detecting the pathology. FAI is a common cause of hip problems in athletes. Early recognition is an important first step in order to avoid the severe secondary damage that can occur.
Article
PURPOSE: The purpose of this study was to survey experts in the field of hip arthroscopy from the Multicenter Arthroscopy of the Hip Outcomes Research Network (MAHORN) group to determine the frequency of symptomatic intra-abdominal fluid extravasation (IAFE) after arthroscopic hip procedures, identify potential risk factors, and develop preventative measures and treatment strategies in the event of symptomatic IAFE. METHODS: A survey was sent to all members of the MAHORN group. Surveys collected data on general hip arthroscopy settings, including pump pressure and frequency of different hip arthroscopies performed, as well as details on cases of symptomatic IAFE. Responses to the survey were documented and analyzed. RESULTS: Fifteen hip arthroscopists from the MAHORN group were surveyed. A total of 25,648 hip arthroscopies between 1984 and 2010 were reviewed. Arthroscopic procedures included capsulotomies, labral reattachment after acetabuloplasty, peripheral compartment arthroscopy, and osteoplasty of the femoral head-neck junction. Of the arthroscopists, 7 (47%) had 1 or more cases of IAFE (40 cases reported). The prevalence of IAFE in this study was 0.16% (40 of 25,650). Significant risk factors associated with IAFE were higher arthroscopic fluid pump pressure (P = .004) and concomitant iliopsoas tenotomy (P < .001). In all 40 cases, the condition was successfully treated without long-term sequelae. Treatment options included observation, intravenous furosemide, and Foley catheter placement, as well as 1 case of laparotomy. CONCLUSIONS: Symptomatic IAFE after hip arthroscopy is a rare occurrence, with an approximate prevalence of 0.16%. Prevention of IAFE should include close intraoperative and postoperative monitoring of abdominal distention, core body temperature, and hemodynamic stability. Concomitant iliopsoas tenotomy and high pump pressures may be risk factors leading to symptomatic IAFE. LEVEL OF EVIDENCE: Level IV, therapeutic case series.
Article
The acetabular labrum provides a sealing function and a degree of hip joint stability. Limited, short-term follow-up studies suggest that labral refixation/preservation leads to superior outcomes compared with labral debridement/excision. To compare the results of labral refixation versus focal labral excision/debridement in a cohort of patients who underwent arthroscopic correction of femoroacetabular impingement (FAI). Cohort study; Level of evidence, 3. We reported on patients who underwent labral debridement/focal labral excision during a period before the development of labral repair techniques. Patients with labral tears thought to be repairable with our current arthroscopic technique were compared with a cohort of patients who underwent labral refixation. To better match the 2 groups, only patients with labral pincer- or combined-type FAI were included. In the first 44 hips, the labrum was focally excised/debrided (group 1); in the next 50 hips, the labrum was refixed (group 2). Outcomes were measured with the modified Harris Hip Score (HHS), Short Form 12 (SF-12), and a visual analog scale (VAS) for pain preoperatively and postoperatively. Preoperative and postoperative radiographs were obtained to evaluate bony resection. The mean age was 32 years in group 1 and 28 years in group 2 with a mean follow-up of 42 months (range, 24-72 months). Preoperative mean subjective outcome scores were not significantly different between groups. At a mean 3.5 years' follow-up, subjective outcomes were significantly improved (P < .01) for both groups compared with preoperative scores. The HHS (P = .001), SF-12 (P = .041), and VAS pain scores (P = .004) were all significantly better for the refixation group compared with the debridement group at the most recent follow-up. At a mean 3.5 years' follow-up, good to excellent results were noted in 68% of the focal excision/debridement group and 92% of the refixation group (P = .004). Although other factors may have influenced these results, labral refixation compared with an earlier cohort of focal labral excision/debridement resulted in better HHS, SF-12, and VAS pain outcomes and a greater percentage of good to excellent results at a mean 3.5-year follow-up.
Article
The purpose of this study was to examine the association between femoral anteversion and clinical outcomes after arthroscopic lengthening of a symptomatic, snapping psoas tendon in young patients. Sixty-seven consecutive patients with symptomatic coxa saltans underwent arthroscopic psoas tendon lengthening through a transcapsular approach during a 3-year period by a single arthroscopic hip surgeon. Demographic and clinical variables were collected. Patients were divided into low/normal femoral version and high femoral version groups and analyzed for association of femoral version with clinical outcomes as measured by the modified Harris Hip Score (mHHS) and Hip Outcome Score (HOS) preoperatively and postoperatively with a minimum of 6 months' follow-up (range, 6 to 24 months). Two-sample t tests were used for data analysis, with P < .05 defined as significant. Preoperative evaluation showed excessive anteversion (>25°) associated with worse HOS sports subscale scores (26.6 v 50.0 for excessive v low/normal anteversion, P = .013) and no difference in mHHS and HOS activities-of-daily living subscale scores. Postoperative mHHS scores were significantly different (76.9 v 86.1 for excessive v low/normal anteversion, P = .031). No association was noted between clinical outcome measures and any other clinical or demographic variable (P > .05). Patients with increased femoral anteversion may be at greater risk for inferior clinical outcomes after arthroscopic lengthening of a symptomatic, snapping psoas tendon. The psoas tendon may be an important passive and dynamic stabilizer of the hip in these patients, and release may result in a greater alteration of kinematics with high-demand activities, particularly terminal extension and external rotation when the tendon is typically at its highest tension. These results may help surgeons identify which patients may be at risk for inferior clinical outcome after psoas lengthening.
Article
The clinical syndrome of athletic pubalgia has prematurely ended many promising athletic careers, has made many active, fitness conscious adults more sedentary, and has served as a diagnostic and therapeutic conundrum for innumerable trainers and physicians worldwide for decades. This diagnosis actually arises from one or more lesions within a spectrum of musculoskeletal and visceral injuries. In recent years, MRI has helped define many of these syndromes, and has proven to be both sensitive and specific for numerous potential causes of athletic pubalgia. This text will provide a comprehensive, up to date review of expected and sometimes unexpected MRI findings in the setting of athletic pubalgia, and will delineate an imaging algorithm and MRI protocol to help guide radiologists and other clinicians dealing with refractory, activity related groin pain in an otherwise young, healthy patient. There is still more to be learned about prevention and treatment plans for athletic pubalgia lesions, but accurate diagnosis should be much less nebulous and difficult with the use of MRI as a primary imaging modality.
Article
Surgical hip dislocation enables complete exposure of the hip joint for treatment of various hip disorders.There is limited information regarding the complications associated with this procedure. Our purpose is to report the incidence of complications associated with surgical dislocation of the hip in a large, multicenter patient cohort. A retrospective, multicenter analysis of patients who had undergone surgical hip dislocation was performed.Patients who had undergone a simultaneous osteotomy were excluded. Complications were recorded, with specific assessment for osteonecrosis, trochanteric nonunion, femoral neck fracture, nerve injury, heterotopic ossification, and thromboembolic disease. We graded complications with a validated classification scheme that includes five grades based on the treatment required to manage the complication and any long-term morbidity. With this classification, a Grade-I complication is one that requires no change in the routine postoperative course, Grade II requires a change in outpatient management, Grade III requires invasive surgical or radiologic management, Grade IV is associated with long-term morbidity or is life-threatening,and Grade V results in death. The study included 334 hips in 302 patients seen at eight different North American centers. There were eighteen complications (5.4%) that were classified as Grade I (not clinically relevant and required no deviation from routine postoperative care). There were six complications (1.8%) classified as Grade II (treated on an outpatient basis or with close observation and resolved). There were nine complications (2.7%) classified as Grade III (treatable and resolved with surgery or inpatient management). There was one complication (0.3%) classified as Grade IV (resulting in a long-term deficit). A total of thirty hips had one or more complications, for an overall incidence of 9%. Excluding heterotopic ossification, the complication rate was sixteen (4.8%) of 334. Surgical hip dislocation is a safe procedure with a low complication rate. Many of the complications were clinically unimportant heterotopic ossification. There were no cases of femoral head osteonecrosis or femoral neck fracture, and, with the exception of one sciatic neurapraxia that partially resolved, no other complication resulted in long-term morbidity.
Article
Chronic mechanical overload of the acetabular rim may lead to acetabular labral disease in patients with hip dysplasia. Although arthroscopic debridement of the labrum may provide symptomatic relief, the underlying mechanical abnormality remains. There is little information regarding how the results of periacetabular osteotomy are affected by a prior primary treatment for labral disease in the presence of acetabular dysplasia. In a retrospective matched-cohort study, seventeen patients who had arthroscopic labral debridement prior to periacetabular osteotomy (the arthroscopy group) were compared with a control group of thirty-four patients who did not undergo arthroscopic labral debridement prior to periacetabular osteotomy (the non-arthroscopy group). Two control patients were randomly matched to each experimental patient from a pool of controls. Functional outcomes were assessed with use of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Failure of periacetabular osteotomy was defined as conversion to a total hip replacement. Changes in the preoperative and postoperative WOMAC scores of arthroscopy and non-arthroscopy patients were comparable, and the differences between the two treatment groups were not significant. We were unable to show a significant difference between the seventeen arthroscopy and thirty-four non-arthroscopy patients with regard to the risk of having to undergo a total hip replacement. When arthroscopic labral debridement fails to improve symptoms in patients with labral disease secondary to acetabular dysplasia, periacetabular osteotomy may still be considered as a joint-preserving procedure that can achieve good functional results.
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
Surgical management of the problematic hip in adolescent and young adult patients can be challenging. In many of these patients, hip arthrosis and pain occur secondary to hip dysplasia associated with chronic instability, whether the result of prior treatment or chronic unmanaged acetabular dysplasia. Surgical techniques such as the Bernese periacetabular osteotomy are performed to correct acetabular deficiency, restore hip joint stability, and eliminate pain. Patients with previous Legg-Calvé-Perthes disease or slipped capital femoral epiphysis frequently note onset of symptomatic hip arthrosis and pain in adolescence or young adulthood. Pain occurs secondary to pathologic impingement of the deformed proximal femur against the anterolateral acetabulum (ie, femoroacetabular impingement). The recent successful innovation of the transtrochanteric surgical hip dislocation approach provides complete access to the hip and offers the potential for comprehensive correction of both the often severe proximal femoral deformity and associated labral chondral disease secondary to Legg-Calvé-Perthes disease and slipped capital femoral epiphysis. Restoration of more normal proximal femoral morphology results in marked improvement in functional outcome. Effective orthopaedic management requires an understanding of the mechanisms of hip disease as well as surgical expertise.
A periacetabular osteotomy,indicated for adults or adolescents requiring correction of congruency and containment of the femoral head, is a common surgical procedure to address developmental dysplasia of the hip. To describe developmental hip dysplasia, a surgical procedure performed to address the condition, as well as therapeutic exercise and functional progression principles utilized to return a patient to tennis following periacetabular osteotomy. The patient was a 14 year-old female who underwent a Ganz periacetabular osteotomy of the right pelvis due to developmental dysplasia of the hip. Post-operative outpatient physical therapy consisted of strengthening of the hip, thigh, and core musculature, as well as activities to increase muscular and cardiovascular endurance, anaerobic conditioning, lower extremity proprioception, and soft tissue length. A functional progression program to return to tennis was also provided. The patient was seen in outpatient physical therapy for a total of 34 visits over the course of 42 weeks. Results of a Lower Extremity Functional Scale (LEFS) indicated that heavy activities of daily living, as well as recreational and sporting activities, were improved following the post-operative rehabilitation program. The role of the physical therapist is vital in prescribing and progressing activity levels to facilitate return of function following this periacetabular osteotomy. Surgery that is technically well performed followed by a comprehensive rehabilitation program can allow for resumption of pre-morbid activities, enhancement of the quality of life, and return to sports activities.
Article
Hip arthroscopy has become an established procedure for certain hip disorders. Complications of hip arthroscopy have been characterized in adult populations, but complications in children and adolescents have not been well described. The purpose of this study was to characterize complications of hip arthroscopy in children and adolescents. The study design was a retrospective review of 218 hip arthroscopies in 175 patients aged 18 years old and younger over a 9-year period by a single surgeon at a tertiary-care children's hospital. Patient demographics, indications for surgery, and complications after surgery were recorded. Indications for surgery included: isolated labral tear (n=131), labral tear with concomitant hip disorder (n=37), Perthes disease (n=10), hip dysplasia (n=5), juvenile rheumatoid arthritis (n=3), loose bodies (n=3), osteochondral fracture (n=3), synovitis (n=2), avascular necrosis (n=1), chondral lesion (n=1), iliopsoas tendinitis (n=1), and slipped capital femoral epiphysis (n=1). The overall complication rate in the study population was 1.8%. Complications of arthroscopy included: transient pudendal nerve palsy (n=2), instrument breakage (n=1), and suture abscess (n=1). No cases of proximal femoral physeal separation, osteonecrosis, or growth disturbance were noted. Hip arthroscopy in children and adolescents seems to be a safe procedure with a low complication rate similar to adults. IV (case series).
Article
The acetabular labrum plays an important role in hip joint stability and protection of the articular cartilage of the hip. Despite this, few investigators have evaluated its microscopic vasculature and, to our knowledge, none has assessed its macroscopic blood supply. The purposes of this study were to identify the origin and course of the vascular supply to the acetabular labrum to determine if this blood supply is affected by a labral tear. Colored silicone was injected into the vascular tree proximal to thirty-five hips in twenty-eight fresh cadavers. Twenty-four hours after injection, anatomic dissection was performed and the vessels supplying the labrum were followed from their origin to their final distribution. Additionally, labral segments of fifteen randomly selected hips were resected to assess the acetabular rim's vascular contribution, and fifteen hips were dislocated for complete intra-articular inspection of the labrum. Radial branches of a previously described periacetabular periosteal vascular ring were identified as the source of labral blood supply in all thirty-five hips. These branches coursed toward the hip joint on the periosteal surface, penetrated the joint capsule near its innominate insertion, and continued within a loose connective-tissue layer on the capsular surface of the labrum. No contribution from the hip capsule, synovial lining, or osseous acetabular rim could be demonstrated. An intact vascular supply was identified in all seven hips with a labral tear. The acetabular labrum receives its blood supply from radial branches of a periacetabular periosteal vascular ring that traverses the osseolabral junction on its capsular side and continues toward the labrum's free edge. The hip capsule, the synovial lining, and the osseous acetabular rim do not appear to provide substantial contributions to the labral blood supply.
Article
Indications for endoscopic surgery of the hip have expanded recently. The technique has found a clear indication in the management of snapping hip syndromes, both external snapping hip and internal snapping hip. Even though the snapping hips (external and internal) share a common name, they are very different in origin. The external snapping hip is produced by the iliotibial band snapping over the prominence of the greater trochanter during flexion and extension. Indication for surgical treatment is painful snapping with failure of conservative treatment. The endoscopic technique is designed to release the iliotibial band producing a diamond shape defect on the iliotibial band lateral to the greater trochanter. The defect allows the greater trochanter to move freely without snapping. The greater trochanteric bursa is resected through the defect and the abductor tendons inspected. This procedure is performed without traction and usually only the peritrochanteric space is accessed. If necessary, hip arthroscopy can also be performed. There is limited literature regarding the results of endoscopic treatment for the external snapping hip syndrome, but early reports are encouraging. The internal snapping hip syndrome is produced by the iliopsoas tendon snapping over the iliopectineal eminence or the femoral head. The snapping phenomenon usually occurs with extension of the hip from a flexed position of more than 90 degree. Two different endoscopic techniques have been described to treat this condition. Iliopsoas tendon release at the level of the hip joint, with this technique the iliopsoas bursa is accessed through an anterior hip capsulotomy and is frequently referred to as a transcapsular release. The second technique is a release at the insertion of the iliopsoas tendon on the lesser trochanter, with this technique the iliospaos bursa is accessed directly. In every report the iliopsoas tendon release has been combined with arthroscopy of the hip joint. It has been documented that more than half of the patients with internal snapping hip syndrome have intra-articular hip pathology. The results of endoscopic release of the iliopsoas tendon in the treatment of internal snapping hip syndrome are encouraging and seem to be better than those reported for open procedures.
Article
Hip instability is becoming a more commonly recognized source of pain and disability in patients. Traumatic causes of hip instability are often clear. Appropriate treatment includes immediate reduction, early surgery for acetabular rim fractures greater than 25% or incarcerated fragments in the joint, and close follow-up to monitor for avascular necrosis. Late surgical intervention may be necessary for residual symptomatic hip instability. Atraumatic causes of hip instability include repetitive external rotation with axial loading, generalized ligamentous laxity, and collagen disorders like Ehlers-Danlos. Symptoms caused by atraumatic hip instability often have an insidious onset. Patients may have a wide array of hip symptoms while demonstrating only subtle findings suggestive of capsular laxity. Traction views of the affected hip can be helpful in diagnosing hip instability. Open and arthroscopic techniques can be used to treat capsular laxity. We describe an arthroscopic anterior hip capsular plication using a suture technique.
Article
Patients with developmental dysplasia of the hip may present with acetabular rim overloading, labral hypertrophy, and tear. Our hypothesis was that isolated arthroscopic treatment of labral tear is likely to fail in most patients. We investigated 34 patients who underwent at least one arthroscopy of the hip for labral tear. Developmental hip dysplasia or other morphologic abnormalities of the hip were confirmed in all patients. Arthroscopy failed to relieve pain in 24 patients. We observed accelerated arthritis in 14 patients and migration of the femoral head in 13 patients. Sixteen patients underwent further surgery (further surgeries included periacetabular osteotomy [6 patients], femoroacetabular osteoplasty [7 patients], and total hip arthroplasty [3 patients]). At the latest follow-up, all patients but one were pain-free. Patients with evidence of abnormal hip morphologies may not benefit from hip arthroscopy and isolated treatment of the labrum; in fact, the latter may accelerate the process of arthritis in some patients.
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
Posttraumatic recurrent posterior hip dislocations were observed in two adult patients. In neither case was there evidence of acetabular dysplasia, paralysis, or infection. In both cases the only significant abnormality discovered was a marked posterior capsular redundancy. In the second case this was clearly shown by a computed tomography (CT) arthrogram. In both instances plication of the posterior capsule prevented further dislocations; however, the second patient developed massive heterotopic ossification around the involved joint and osteonecrosis of the femoral head. Investigation with CT arthrography of patients sustaining one or more dislocations in response to minimal trauma aids in evaluation of capsular abnormalities that may be surgically correctable.
Article
Eighteen patients with 20 symptomatic hips underwent lengthening of the iliopsoas tendon for persistent painful snapping of this "internal" variety of snapping hip. We referred to the pathologic, painful snapping of the ilio psoas in the deep anterior groin as the "internal" snap ping hip. This is in contrast to the more common and better-known "external" snapping that involves the greater trochanter and its overlying soft tissues. The results of our iliopsoas lengthening procedure are pre sented here. Lengthening of the iliopsoas tendon was accom plished by step cutting of the tendinous portion of the iliopsoas. The pathoanatomy of this poorly understood symptom complex was described in a 1984 paper from this institution and is reviewed here. Iliopsoas bursography demonstrated a sudden jerk ing movement of the iliopsoas tendon between the anterior inferior iliac spine and iliopectineal eminence, synchronous with the patient's pain and often accom panied by an audible snap. The average preoperative duration of symptoms was 2.9 years, and the average length of postoperative followup was 25 months. All patients, except one, had a marked reduction in the frequency of snapping after tendon lengthening, and 14 of 20 hips had no snapping postoperatively. Of the six patients who had recurrence of snapping, all but one stated that this occurred much less frequently and was much less painful compared to the preoperative state. Two hips required reoperation. Postoperatively, only three patients complained of subjective weakness, and most patients were unlimited in physical activity with return to activities such as competitive football, pole vaulting, and long-distance running. A frequent complication has been transient or per manent sensory loss of the anterolateral thigh, yet no motor deficits have occurred. An operative approach through a cosmetic transverse inguinal incision, differ ent from our previous approach, is described. Nearly all patients felt that they were much better because of the procedure, and only one patient stated that she would not repeat the procedure for the same problem. We feel that judicious lengthening of the painful snap ping iliopsoas tendon near the brim of the pelvis can be of great benefit to symptomatic patients.
Article
Avulsion fractures of the pelvic apophyses are seen infrequently but they show a consistent pattern in mechanism, patient's age, symptoms, physical findings, and roentgenographic appearance. Some disagreement exists in the literature concerning the treatment of these fractures. This study indicates that early diagnosis and a carefully directed nonoperative treatment program will produce positive results for avulsion fractures of the pelvis. Twenty-seven cases of acute avulsion fracture of the pelvis were successfully treated in a directed nonoperative program.
Article
Athletic injuries to the hip and pelvis in pediatric and adolescent athletes, although uncommon, may encompass a wide spectrum of entities. A familiarity with this spectrum and a high index of suspicion in the proper clinical setting will ensure timely diagnosis and help to facilitate implementation of a proper treatment plan thereby assuring safe return to play.
Article
To assess the impact of traumatic hip dislocations in the skeletally immature patient, 42 children younger than 16 years of age (average age, 9 years 10 months) who were treated at the authors' institution were studied. Data were collected from charts and radiographs and by completion of questionnaires. The average followup after injury was 10 years 1 month. The majority of dislocations (64%) were attributable to low energy injuries. Ipsilateral fractures about the hip occurred in 17% of patients. Avascular necrosis of the femoral head developed in 12% of patients, with the amount of time spent dislocated being the only statistically proven risk factor. Patients whose reduction was delayed greater than 6 hours had a 20 times higher risk of having avascular necrosis develop compared with patients whose hips were reduced in 6 hours or less. The use of computed tomography for joint asymmetry of 3 mm or greater and omission of bone scan screening were supported by this study. Functional outcomes were very good in this series with 95% of patients suffering mild (usually weather related) or no pain and 95% of patients suffering mild pain (intermittently noticeable) or no limp. A large percentage of the patients (78%) continued to participate in high demand activities such as football, soccer, and basketball.
Article
We have evaluated the utility of ultrasonographic guidance for intervention in the musculoskeletal system. All interventional musculoskeletal procedures using ultrasonographic guidance performed at our institution from July 1998 through November 1999 were reviewed. Examinations were performed using either a linear or curved phased array transducer, based on depth and local geometry. The choice of needle was likewise optimized for specific anatomic conditions. One hundred ninety-five procedures were performed on 167 patients from July 1998 through November 1999. Thirty-one procedures had magnetic resonance correlation within 6 months beforehand. Excluding large-joint aspirations and injections, we found that 180 of the procedures were more readily performed using ultrasonography than any other imaging modality. These included therapeutic injections into tendon sheaths (biceps, flexor digitorum longus, posterior tibial, and iliopsoas), Morton's neuromas, plantar fascia, wrist ganglia, and tarsal tunnel cysts; peritendinous hamstring injections; and synovial cyst and muscle biopsies. In all cases, the target of interest was identified easily with ultrasonography, and needle position was documented readily. Also in all cases, aspiration or medication delivery to the site of interest was observed during real time and was documented on postprocedure images of the area. No significant complications (e.g., bleeding, infection, and neurovascular compromise) were encountered during or immediately after any procedure. Ultrasonography is a readily available imaging modality useful for guiding interventional procedures in the musculoskeletal system. The ability to document exact needle placement in real time confirms accurate placement of therapeutic injections, fluid aspiration, and soft tissue biopsies.
Article
To describe the prevalence, location and sports distribution of pelvic avulsion fractures in adolescent competitive athletes. One thousand two hundred and thirty-eight radiographs of the pelvis taken for focal traumatic symptoms in athletes with an age range of 11-35 years over a period of 22 years were reviewed. One hundred and ninety-eight adolescent athletes were affected by 203 avulsion fractures of the pelvic apophyses (five cases presented multiple locations). The localisation was the ischial tuberosity (IT) in 109 cases, anterior inferior iliac spine (AIIS) in 45 cases, anterior superior iliac spine (ASIS) in 39 cases, superior corner of pubic symphysis (SCPS) in 7 cases and iliac crest (IC) in 3 cases. Soccer (74 cases) and gymnastics (55 cases) were the sports with the highest number of avulsion fractures documented. Apophyseal avulsion fractures of the pelvis in adolescent competitive athletes are most common in soccer and gymnastics. The lesions are usually the consequence of sudden and forceful muscle-tendon contractions during sport activities. Plain radiographs, are determinant for the diagnosis.
Article
Many children today participate in highly organized sports programs that involve regimented year-round repetitive training. This type of training has led to an increased incidence of overuse musculoskeletal injuries. Sports physicians have dealt with sports injuries in children for many years and, on the basis of their clinical experience, have developed guidelines to treat and to try and prevent these injuries. The purpose of this article is to provide a biomechanical perspective of sports injuries in young athletes and blend ideas from this perspective with more traditional clinical perspectives that dominate the literature relative to this topic. Basic tissue and gross movement mechanics principles are used to identify growth, morphological, and movement factors that may predispose a child to an overuse injury. Several biomechanical analyses of simple movement tasks are presented to quantify the forces developed in various tissues and to illustrate the effects that growth can have on these forces. Guidelines are given for developing injury prediction models that may be used in the future to establish safe and effective training guidelines for children.
Article
Instability in the hip joint is much less common than in the shoulder, but can be a source of great disability. The hip joint relies much less on its adjacent soft tissue for stability because of its intrinsic osseous stability in the hip. It is apparent that any deviation from "normal" bony anatomy will lead to more dependence on capsular tissue and labrum for stability. The author began to recognize and treat hip instability arthroscopically in 1998. Early results are promising and the purpose of this article is to enlighten the reader on the role of arthroscopic thermal capsular shrinkage in the hip and its specific indications.
Article
There have been very few reports regarding symptomatic snapping of the iliopsoas tendon, and none of those reports have dealt exclusively with an adolescent population. We report our experience with the surgical treatment of this entity in a group of patients who had an average age of fifteen years. Nine adolescent patients (eleven hips) underwent fractional lengthening of the iliopsoas tendon at the musculotendinous junction because of persistent painful snapping of the hip. A modified iliofemoral approach to the iliopsoas tendon was used. The diagnosis in all cases was made on the basis of the history and a physical examination. Plain radiographs were made for all patients to rule out an osseous intra-articular loose body. Follow-up consisted of personal interviews and physical examinations performed at least two years postoperatively. Preoperatively, all patients had audible snapping with pain localized to the anterior part of the groin. The average duration of symptoms was 2.3 years. Prior to the onset of symptoms, all but one of the patients had been involved in competitive athletic activities. Postoperatively, all patients were able to return to the preoperative level of activity without subjective weakness. The average duration of postoperative follow-up was four years. Hip-flexion strength was noted to be nearly equal to that on the contralateral side. All patients reported that they would have the operation again under similar circumstances. One patient had recurrent snapping but stated that it was less frequent and less painful than the preoperative snapping. Two patients had transient sensory loss in the anterolateral aspect of the thigh. We conclude that fractional lengthening of the iliopsoas tendon at the musculotendinous junction is an effective and safe approach for adolescent patients with persistent symptomatic snapping of the iliopsoas tendon that is unresponsive to conservative measures.
Article
We have undertaken a prospective evaluation of health-related quality-of-life outcomes in 26 consecutive patients undergoing periacetabular osteotomy with a minimum follow-up of 24 months (24 to 42). The Western Ontario-Macmaster (WOMAC) and Short Form 36 (SF-36) outcome measures were evaluated preoperatively and at follow-up. Secondary outcome measures included retrospective assessment of sports activity and satisfaction with the procedure. Follow-up data were available for 22 patients (85%). A significant improvement in the pain (p < 0.0001) and function (p < 0.0001) scales of the WOMAC and the SF-36 physical score (p < 0.0001) was seen. The mean sports activity score improved from 1.9 to 4.4, with a very high mean satisfaction rating of 89.7/100. A significant improvement in both global and disease-specific health outcomes can be expected after this operation, with a high rate of satisfaction and improvement in sporting activities.
Article
A multitude of factors including biochemical, genetic, and acquired abnormalities may contribute to osteoarthritis of the hip. Although the pathomechanism of degenerative process affecting the dysplastic hip is well understood, the exact pathogenesis for idiopathic osteoarthritis has not been established. Based on clinical experience, with more than 600 surgical dislocations of the hip, allowing in situ inspection of the damage pattern and the dynamic proof of its origin, we propose femoroacetabular impingement as a mechanism for the development of early osteoarthritis for most nondysplastic hips. The concept focuses more on motion than on axial loading of the hip. Distinct clinical, radiographic, and intraoperative parameters can be used to confirm the diagnosis of this entity with timely delivery of treatment. Surgical treatment of femoroacetabular impingement focuses on improving the clearance for hip motion and alleviation of femoral abutment against the acetabular rim. It is proposed that early surgical intervention for treatment of femoroacetabular impingement, besides providing relief of symptoms, may decelerate the progression of the degenerative process for this group of young patients.
Article
Intra-articular pathology of the hip is often associated with dysplasia. The presence of dysplasia is often believed to be a harbinger of poor results for arthroscopy. The purpose of this study was to report the results of operative hip arthroscopy in conjunction with dysplastic disease of the hip. Prospective clinical case series. All patients undergoing hip arthroscopy are prospectively assessed with a modified Harris hip score performed preoperatively and postoperatively at 3, 12, 24, and 60 months. A minimum of 1-year follow-up has currently accumulated for 184 consecutive cases. The center edge (CE) angle of Wiberg is measured on the anteroposterior pelvis film and categorized as normal (> 25 degrees ), dysplastic (< 20 degrees ), or borderline dysplasia (20 degrees -25 degrees ). In this study, 48 patients were identified with either dysplasia (16) or borderline dysplasia (32). At an average of 27 months, 100% follow-up was noted. For the dysplastic group, the average preoperative score was 57 and postoperative score was 83. For borderline dysplasia, the average preoperative score was 50 and postoperative score was 77. Statistically, no difference was found between the 2 groups. Collectively, the average improvement was 27 points, with 79% (38 patients) of patients showing at least a 10-point improvement. The results of arthroscopy in the presence of dysplasia compare favorably with the general population previously reported. The response to treatment is probably dictated more by the nature of the intra-articular pathology rather than simply the presence or absence of radiographic evidence of dysplasia.
Article
External snapping hip is an entity that describes a snap that is felt on the lateral aspect of the hip. Several surgical interventions are described. The external snapping hip can be corrected with a simple procedure that is minimally invasive and less demanding than other techniques. This is a retrospective review from June 1994 until January 2002 looking at released external snapping hips. There were 16 patients with 17 hips; follow-up was in 15 patients with 16 snapping hips. Twelve patients with 13 hips were contacted by telephone interview, and 3 were followed up by their most recent chart note. All underwent the same procedure performed by the senior author. The questionnaire was conducted at an average of 32.5 months after surgery (range, 9-74 months). For 3 patients, chart-only follow-up was at 6 weeks, 3 months, and 6 months, respectively. Fourteen of 16 hips remained asymptomatic after final surgical release (2 hips needed a second release). All patients contacted by telephone would undergo the same procedure again if faced with the same symptoms. This technique is simpler than most of those previously described with the benefit of no formal postoperative regimen and comparable results.
Article
We evaluated the percentage of patients with acetabular labral tears who have a structural hip abnormality detectable by conventional radiography. Records from our institution from 1996 through 2002 were reviewed to identify all patients with labral tears. Patients were excluded who had classic hip dysplasia, advanced osteoarthritis, or a history of pelvic or femoral osteotomy. The hip radiographs were evaluated for abnormalities of Tönnis angle, center-edge angle of Wiberg, acetabular version, femoral neck-shaft angle, congruency between the femoral head and acetabulum, anterior femoral head-neck offset, and presence of femoral head osteophytes. Twenty-seven of the 31 patients (87%) had at least one abnormal finding and 35% had more than one abnormality. Ten patients had a retroverted acetabulum, 16 had coxa valga, 11 had an abnormal femoral head-neck offset, and 14 had osteophytes on the femoral head. Four of 31 patients (13%) had no identifiable structural abnormalities. To our knowledge, this is the first study to document that the majority of patients with labral tears have a structural hip abnormality detectable with conventional radiographs. Familiarity with these structural abnormalities is important for early detection and accurate diagnosis, and may impact optimal treatment planning and prognosis.
Article
Hip arthroscopy has defined elusive causes of hip pain. HYPOTHESIS/PURPOSE: It is postulated that the reliability of various investigative methods is inconsistent. The purpose of this study is to evaluate the diagnostic accuracy of these methods. Retrospective review of prospectively collected data. Five parameters were assessed in 40 patients: clinical assessment, high-resolution magnetic resonance imaging, magnetic resonance imaging with gadolinium arthrography, intra-articular bupivacaine injection, and arthroscopy. Using arthroscopy as the definitive diagnosis, the other parameters were evaluated for reliability. Hip abnormality was clinically suspected in all cases with 98% accuracy (1 false positive). However, the nature of the abnormality was identified in only 13 cases with 92% accuracy. Magnetic resonance imaging variously demonstrated direct or indirect evidence of abnormality but overall demonstrated a 42% false-nega