[Show abstract][Hide abstract] ABSTRACT: Purpose: To provide a comprehensive review and summary of the research published in Arthroscopy: The Journal of Arthroscopic and Related Surgery and The American Journal of Sports Medicine (AJSM) related to hip arthroscopy for femoroacetabular impingement (FAI). Methods: A comprehensive review was conducted in duplicate of Arthroscopy and AJSM from February 2012 to February 2015 for all articles related to FAI, and a quality assessment was completed for all included studies. Clinical outcomes were dichotomized into short-term (<6 months) and midterm (<24 months) outcomes, and values were pooled when possible. Results: We identified 60 studies in Arthroscopy and 44 studies in AJSM, primarily from North America (78.8%), that predominantly assessed clinical outcomes after arthroscopic hip surgery (46.1%). Seventy-one percent of Arthroscopy studies and 20.5% of AJSM studies were Level IV evidence. The modified Harris Hip Score (mHHS) was used by 81.5% of included studies. Pooled weighted mean mHHS values after arthroscopic surgery for FAI showed improvements at the midterm from 60.5 points (range, 56.6 to 83.6 points) to 80.5 points (range, 72.1 to 98.0 points) out of a possible 100 points. Pooled weighted outcomes for labral repair showed mean mHHS improvements from 63.8 points (range, 62.5 to 69.0 points) preoperatively to 86.9 points (range, 85.5 to 89.9 points) up to 24 months postoperatively. Conclusions: This comprehensive review of research published in Arthroscopy and AJSM over the past 3 years identified a number of key findings. Arthroscopic intervention results in improvements in functional outcomes at both the short-term and midterm for patients with symptomatic FAI in the absence of significant existing degenerative changes. Labral repair may result in improvements over labral debridement. The most commonly used outcome score was the mHHS for objective assessment of surgical success. There is a need for continued focus on improvement of methodologic quality and reporting of research pertaining to FAI.
Full-text · Article · Jan 2016 · Arthroscopy The Journal of Arthroscopic and Related Surgery
[Show abstract][Hide abstract] ABSTRACT: Core muscle injury/sports hernia/athletic pubalgia is an increasingly recognized source of pain, disability, and time lost from athletics. Groin pain among athletes, however, may be secondary to various etiologies. A thorough history and comprehensive physical examination, coupled with appropriate diagnostic imaging, may improve the diagnostic accuracy for patients who present with core muscular injuries. Outcomes of nonoperative management have not been well delineated, and multiple operative procedures have been discussed with varying return-to-athletic activity rates. In this review, we outline the clinical entity and treatment of core muscle injury and athletic pubalgia. In addition, we describe the relationship between athletic pubalgia and femoroacetabular impingement along with recent studies that have investigated the treatment of these related disorders.
No preview · Article · Nov 2015 · Sports medicine and arthroscopy review
[Show abstract][Hide abstract] ABSTRACT: Purpose
The purpose of this study was to describe the occurrence of ischiofemoral impingement (IFI) and hamstring dysfunction following malunion or non-union of ischial tuberosity apophyseal avulsion fractures and report the short-term outcomes of surgical treatment with regard to alleviating symptomatic extra-articular impingement.
All patients who underwent surgery for recalcitrant hip and buttock pain in the setting of prior ischial tuberosity avulsion fracture at three tertiary-level hip preservation centres were included for this review. A total of ten patients met our inclusion criteria and underwent sciatic neurolysis, resection of the ischial tuberosity fragment and hamstring reattachment. Clinical outcomes scores were collected post-operatively including the Modified Harris Hip Score (mHHS) and the Hip Outcomes Score (HOS).
Ten patients with a mean age of 18 years (range 14–28) underwent surgery for symptomatic ischiofemoral impingement after ischial tuberosity avulsion fracture. At a mean of 2.2-year follow-up (range 1.7–3.5), the median post-operative mHHS was 89.7 (65.7–96.8) and HOS ADL and Sport subscales were 90 % or greater in all cases. Five patients (50 %) rated their hip as normal, and five patients (50 %) rated their hip as near normal.
Malunion or non-union following ischial tuberosity apophyseal fracture can lead to IFI and hamstring dysfunction. Clinically, the resultant pain and dysfunction is often chronic, and can be debilitating. In select cases, a reliable surgical technique is presented to improve hamstring function and correct ischiofemoral impingement in this setting with good-to-excellent outcomes in the majority of cases at short-term follow-up.
Level of evidence
No preview · Article · Oct 2015 · Knee Surgery Sports Traumatology Arthroscopy
[Show abstract][Hide abstract] ABSTRACT: Purpose: To define surgeon willingness to participate in large, multicenter randomized controlled trials (RCTs) to address common treatment decisions for the management of femoroacetabular impingement (FAI) and to define the feasibility of executing these RCTs. Methods: Thirty case vignettes of consecutive, symptomatic FAI patients who underwent FAI corrective surgery by a single surgeon were provided to members of the Academic Network of Conservational Hip Outcomes Research (ANCHOR). Each surgeon (n = 10) completed a questionnaire in a blinded fashion to determine willingness to participate and enroll the patient in 6 different potential RCTs. The proportion of yes/no ratings were blindly assessed for all 6 RCTs. Differences were tested with chi(2)-tests, and odds ratios were calculated. Results: Seventy-seven percent and 42% of surgeons were willing to enroll patients in a surgical versus nonoperative FAI RCT with 6-month and 12-month crossover arms, respectively. Only 25% and 53% of surgeons were willing to consider randomization of operative versus nonoperative treatment for femoral and acetabular sided osseous deformities, respectively. Regarding the capsulolabral complex, 63% and 78% were amenable to randomization of labral refixation versus debridement and capsular closure versus no closure, respectively. Statistically, surgeon ratings differed significantly (Pearson chi(2) = 246.302; P < .001). Conclusions: Surgeons are willing to participate in surgical versus nonsurgical trials with a 6-month crossover endpoint, yet surgeons are reluctant to offer surgical treatment of FAI without correction of osseous deformity, particularly for cam-type pathomorphology. RCTs to address management of the capsulolabral structures may be more feasible and generalizable based on the willingness of hip preservation surgeons to enroll patients.
No preview · Article · Sep 2015 · Arthroscopy The Journal of Arthroscopic and Related Surgery
[Show abstract][Hide abstract] ABSTRACT: Femoroacetabular impingement is typically described as occurring between the femoral head-neck junction and the acetabular rim and secondary to pathomorphologic osseous changes in these areas. Extra-articular sources of femoroacetabular impingement have been increasingly recognized and treated. One of the more commonly described sources has been subspine impingement, the mechanical conflict between the anterior inferior iliac spine (AIIS) and the distal femoral neck. The etiologies of AIIS pathomorphology include apophyseal avulsions of the AIIS, rectus femoris avulusions with ossification, overcorrection after periacetabular osteotomy, and developmental. Patients often present with groin pain with deep hip flexion. Cadaveric studies have noted a reproducible bare area on the inferior aspect of the AIIS, and a corresponding footprint of the direct head of the rectus femoris measuring 2.2 × 1.6 cm on average. Arthroscopic decompression of the AIIS has been performed with good short-term outcomes and significant improvement in end terminal range of motion.
No preview · Article · Jul 2015 · Operative Techniques in Sports Medicine
[Show abstract][Hide abstract] ABSTRACT: Femoroacetabular impingement (FAI) is a common, debilitating cause of hip pain for many individuals. Recent literature suggests that for a significant proportion of these patients, FAI is a precursor for early degenerative disease of the hip. Advances in our understanding of the disease, imaging technology and surgical techniques has enabled surgeons to address this structural disease. Hip preservation surgery has continued to grow in popularity over the past decade. In fact, there has been an 18-fold increase in the number of hip arthroscopy procedures performed by American Board of Orthopaedic Surgery candidates from 2003 to 2009. More importantly, many studies have reported good to excellent short- and mid-term outcomes. Furthermore, hip arthroscopy has been shown to be a cost-effective mode of treatment among patients with FAI without arthritis. Arthroscopy is a preferred approach to amenable pathological deformities and can be associated with fewer complications than other operative techniques.
No preview · Article · Apr 2015 · The Journal of arthroplasty
[Show abstract][Hide abstract] ABSTRACT: Objectives: Previous reports regarding arthroscopic management of dysplastic hip morphologies have conflicting results. Arthroscopy alone in the setting of dysplastic morphologies is controversial.
[Show abstract][Hide abstract] ABSTRACT: Complications and failures after hip arthroscopy are reported to be relatively uncommon. Because there are no recent comprehensive, prospective studies observing complications and failures after hip arthroscopy, the current rates are unclear. As the number of surgeons performing hip arthroscopy and the number of procedures performed continue to increase, there is the need for an increased awareness of potential adverse events.
No preview · Article · Mar 2015 · Instructional course lectures
[Show abstract][Hide abstract] ABSTRACT: Background
Often, anteroposterior (AP) pelvic radiographs are performed with the patient positioned supine. However, this may not represent the functional position of the pelvis and the acetabulum, and so when assessing patients for conditions like femoroacetabular impingement (FAI), it is possible that standing radiographs better incorporate the dynamic influences of periarticular musculature and sagittal balance. However, this thesis remains largely untested.
The purpose of this study was to determine the effect of supine and standing pelvic orientation on (1) measurements of acetabular version and common radiographic signs of FAI as assessed on two- and three-dimensional (3-D) imaging; and (2) on terminal hip range of motion (ROM).
Preoperative pelvic CT scans of 50 patients (50 hips) who underwent arthroscopic surgery for the treatment of FAI between July 2013 and October 2014 were analyzed. The mean age of the study population was 29 ± 10 years (range, 15–50 years) and 70% were male. All patients had a standing AP pelvis radiograph, a reconstructed supine radiograph from the CT data, and a 3-D model created to allow manipulation of pelvic tilt and simulate ROM to osseous contact. Acetabular version was measured and the presence of the crossover sign, prominent ischial spine sign, and posterior wall sign were recorded on simulated plain radiographs. Measurements of ROM to bony impingement were made during (1) simulated hip flexion; (2) simulated internal rotation in 90° of flexion (IRF); and (3) simulated internal rotation in 90° of flexion and 15° adduction (FADIR), and the location of bony contact between the proximal femur and acetabular rim was defined. These measurements were calculated for supine and standing pelvic orientations. A paired Student’s t-test was used for comparison of continuous variables, whereas chi square testing was used for categorical variables. A p value of
Full-text · Article · Jan 2015 · Clinical Orthopaedics and Related Research
[Show abstract][Hide abstract] ABSTRACT: Hip pathology and nonarthritic hip conditions have only recently been recognized as a cause of hip pain. In 2003, Ganz, Leunig and colleagues described the concept of femoroacetabular impingement (FAI) as a cause of hip pain and a mechanism for end-stage hip osteoarthritis. Ganz et al. also postulated that 70-90% of hip osteoarthritis is likely due to abnormal hip mechanics related to FAI, dysplasia, or other hip deformities. Over the past ten years, the treatment of these non-arthritic hip pathologies has grown dramatically, and has been estimated to grow by 15% each year. It is the largest segment of grown in sports medicine and orthopedics as a whole. However, no definitive reference yet exists on hip arthroscopy and hip joint preservation surgery. While books have been published on hip arthroscopy, these texts are limited to the technical aspects of the procedure and do not explore content related to hip joint preservation surgery. The scope of this book covers the basic science of hip pathology, anatomy, biomechanics, pathology, and treatment. It has put together up-to-date research and has invited opinion leaders in the field to contribute to the text. The book is focused on disease pathology and provides comprehensive information on each disease topic, which is followed by technique-driven chapters to provide surgeons a reference for any procedure related to non-arthritic conditions of the hip.
[Show abstract][Hide abstract] ABSTRACT: Proximal hamstring avulsion injuries are more commonly being recognized and can cause significant disability for the active patient. Patients frequently experience a loss of leg control and difficulties decelerating the leg, making athletic activities difficult. Unfortunately, patients may present late due to either misdiagnosis or failed attempts at conservative treatment. Retraction and scarring of the hamstring tendons can limit the surgeon’s ability to repair the tendon to the ischial tuberosity without excessive tension. Use of an Achilles tendon allograft, can obviate the need for distal fractional lengthening or tenodesis and provides improved outcomes for activities of daily living and sports-related activities.
This chapter provides key history and exam findings to aid in diagnosis and describes the surgical procedure for allograft reconstruction for irreparable ruptures. Tendon fixation is described through use of either suture anchors or bone plug and interference screw depending on patient characteristics and intraoperative visualization. Postoperative protocols including hinged knee bracing are outlined. Most patients return to sport by 6 months although will improve for a year following the surgery. Posterior thigh numbness and superficial skin infection are the most common adverse events. Return to sports is inferior to acute repair, but return to activities of daily living is comparable to acute repairs with universally high satisfaction rates after allograft reconstruction.
[Show abstract][Hide abstract] ABSTRACT: The use of hip arthroscopy has rapidly increased over the past 30 years and investigations into its use have seen an exponential increase over the past decade. Advancements in techniques and instrumentation have allowed an increasing number of orthopedists to perform this operation to address a rapidly expanding number of disorders of the hip and adjacent anatomy. Hip arthroscopy is most commonly performed for intra-articular conditions such as FAI, labral and chondral lesions, disorders of the synovium and capsule, loose bodies, ligamentum teres injuries, and septic arthritis and as a diagnostic aid in conjunction with other procedures. Periarticular conditions such as greater trochanteric pain syndrome, snapping hip, extra-articular FAI, and pathology in the posterior gluteal space are also increasingly addressed with the aid of hip arthroscopy. Contraindications to the procedure, as its strengths and limitations are better defined through increased study and use, have also evolved. These include the presence of advance stages of osteoarthritis, inflammatory arthritis, various forms of hip dysplasia, chronic muscle pathology, preexisting neurologic injury, and greater trochanter impingement, among others. This chapter will expand upon these indications and contraindications, reviewing evidence to help guide both beginner and advanced hip arthroscopists. As the use of hip arthroscopy continues to expand, the utility and limitations of its use will continue to evolve.
[Show abstract][Hide abstract] ABSTRACT: Recognition of femoroacetabular impingement as a potential precursor to hip osteoarthritis has led to the development of both open and arthroscopic hip preservation surgery. Successful short- and midterm clinical outcomes have been reported following hip preservation surgery. Improvements in technique and instrumentation have led to a dramatic increase in the number of surgeons performing hip arthroscopy and the number of cases performed internationally.However, there is a significant learning curve associated with hip arthroscopy. Although the rate of minor complications is low (7.5 %), it is largely related to the learning curve. The two most common minor complications are iatrogenic chondrolabral injury and temporary neuropraxia. Open surgical hip dislocation permits a 360 A view of the femoral head and acetabulum but requires a larger incision, greater soft tissue dissection, and a trochanteric osteotomy. Although the rate of minor complications is reportedly higher following open surgical hip dislocation due to the occasional development of painful hardware requiring removal, the rate of major complications is less than 1 % in both open and arthroscopic hip preservation surgery. Thus, both open and arthroscopic hip preservation surgeries appear to be safe. Lack of clarity in reporting complications within orthopedic surgery has spurred academic hip surgeons to adapt and test a general surgery-validated complication reporting system for use in hip preservation.
[Show abstract][Hide abstract] ABSTRACT: Previous studies have reported residual deformity to be the most common reason for revision hip arthroscopy. An awareness of the most frequent locations of the residual deformities may be critical to minimize these failures.
The purposes of this study were to (1) define the three-dimensional (3-D) morphology of hips with residual symptoms before revision femoroacetabular impingement (FAI) surgery; (2) determine the limitation in range of motion (ROM) in these patients using dynamic, computer-assisted, 3-D analysis; and (3) compare these measures with a cohort of patients who underwent successful arthroscopic surgery for FAI by a high-volume hip arthroscopist.
Between 2008 and 2013, one senior surgeon (BTK) performed revision arthroscopic FAI procedures on patients with residual FAI deformity and symptoms after prior unsuccessful arthroscopic surgery; all of these 47 patients (50 hips) had preoperative CT scans. Mean patient age was 29 ± 9 years (range, 16-52 years). Three-dimensional models of the hips were created to allow measurements of femoral and acetabular morphology and ROM to bony impingement using a validated, computer-based dynamic imaging software. During the same time period, 65 patients with successful primary arthroscopic treatment of FAI by the same surgeon underwent preoperative CT scans for the symptomatic contralateral hip; this group of 65 patients thus fortuitously provided postoperative evaluation of the originally operated hip and served as a control group. A comparison of the virtual correction with the actual correction in the primary successful FAI treatment cohort was performed. Correspondingly, a comparison of the recommended virtual correction with the correction evident at the time of presentation after failed primary surgery in the revision cohort was performed. Analysis was performed by two independent observers (JRR, OA) and a paired t-test was used for comparison of continuous variables, whereas chi-square testing was used for categorical variables with p < 0.05 defined as significant.
Ninety percent (45 of 50) of patients undergoing revision surgery for symptomatic FAI had residual deformities; the mean maximal alpha angle in revision hips was 68° ± 16° and was most often located at 1:15, considering the acetabulum as a clockface and 1 to 5 o'clock as anterior independent of side. Twenty-six percent (13 of 50) of hips had signs of overcoverage with a lateral center-edge angle greater than or equal to 40°. Dynamic analysis revealed mean direct hip flexion of 114° ± 11° to osseous impingement. Internal rotation in 90° of hip flexion and flexion, adduction, internal rotation to osseous contact were 28° ± 12° and 20° ± 10°, respectively, which were less than those in hips that had underwent hip arthroscopy by a high-volume hip arthroscopist (all p < 0.001).
We found marked radiographic evidence of incomplete correction of deformity in patients with residual symptoms compared with patients with successful results with residual deformity present in the large majority of patients (45 of 50 [90%]) undergoing residual FAI surgery. We recommend careful attention to full 3-D resection of impinging structures.
Level III, retrospective study, case series.
Preview · Article · Dec 2014 · Clinical Orthopaedics and Related Research