Diagnostic Capability of Intra-Articular Injections for Femoroacetabular Impingement Syndrome: A Systematic Review.

OBJECTIVE: To review and critically appraise available literature concerning the diagnostic capability of intra-articular injections for femoroacetabular impingement (FAI) syndrome. DESIGN: Systematic review. SETTING: N/A. PARTICIPANTS: N/A. INTERVENTIONS: N/A. MAIN OUTCOME MEASURES: Studies assessing pain relief following intra-articular injections for the diagnosis of FAI syndrome, compared with arthroscopy as diagnostic reference standard, were considered eligible. Searches were performed across 8 databases, and the risk of bias was evaluated through the Quality Assessment of Diagnostic Accuracy Studies tool. RESULTS: From 489 articles identified, 4 were included for analysis. Intra-articular injections were composed of anesthetic agents (such as lidocaine, bupivacaine, and ropivacaine), combined or not with corticosteroids (triamcinolone and betamethasone). All studies were judged as "at risk of bias", and a substantial heterogeneity was found considering assessment methods and pain relief thresholds for a positive response to intra-articular injections. Overall, 2 studies reported that intra-articular injections presented a high accuracy in determining the presence of FAI syndrome. However, the remaining 2 studies indicated that intra-articular injections might present restricted diagnostic capability to discriminate FAI syndrome from healthy individuals or those with other hip pathologies. CONCLUSIONS: Based on limited evidence, the diagnostic capability of intra-articular injections for FAI syndrome cannot be supported. It remains unclear which pain relief thresholds are related to a higher diagnostic capability. The combination of anesthetics with corticosteroids should also be further explored, including multiple pain assessments for evaluation of prolonged effects.

Diagnostic Accuracy of Clinical Tests and Imaging Exams for Femoroacetabular Impingement: An Umbrella Review of Systematic Reviews.

OBJECTIVE: To synthesize available evidence about diagnostic accuracy of clinical tests and imaging examinations for femoroacetabular impingement (FAI) syndrome. DESIGN: Umbrella review. SETTING: N/A. PARTICIPANTS: N/A. INTERVENTIONS: N/A. MAIN OUTCOME MEASURES: Systematic reviews (SR) indexed in Embase, LIVIVO, PubMed, SCOPUS, the Cochrane Library, and Web of Science were searched in a 2-phase process. SR assessing diagnostic accuracy were considered eligible. RESULTS: From 1520 studies, 6 SR were included, which evaluated 24 primary studies related to FAI syndrome. Of these, 5 SR assessed clinical tests, and a substantial heterogeneity was found concerning reference standards adopted across primary studies, which included arthroscopy, clinical examination (associated or not with imaging exams), intra-articular injections, and open surgery. Most clinical tests presented higher values of sensitivity compared with specificity, although evidence was considered limited because the same primary studies were often included across SR. Nonetheless, evidence around the flexion adduction internal rotation (FADIR) test was considered stronger and its use as a screening tool was consistently supported. Only one SR assessed the accuracy of imaging examinations, which adopted open surgery as the sole reference standard. Most imaging exams presented considerably high values of sensitivity, although specificity values were notably lower. CONCLUSIONS: No robust recommendations can be provided for most clinical tests, although the FADIR test, in particular, was consistently supported as a screening tool. Moreover, although imaging examinations showed considerably high sensitivity values, evidence was considered sparse and further research is strongly recommended to validate its use as reference standards for diagnostic accuracy data.

Femoral torsion evaluation by computed tomography in a young Brazilian population with hip pain and femoroacetabular impingement.

INTRODUCTION: The aim of the study was to evaluate femoral torsion (FT) by computed tomography (CT) in young patients with hip pain and femoroacetabular impingement (FAI) in a Brazilian population. After the diagnosis of impingement, the complete analysis from the hip biomechanics and morphology has become essential. METHODS: Forty-one patients from 18 to 45 years presenting hip pain without arthrosis (Tönnis<2) were evaluated by CT scan from February 2017 to February 2018. All patients presented hip pain for at least 3 months and FAI. They have followed the same radiographic protocol and modified Harris Hip Score (mHHS) evaluation. Statistical analyses by software R version 3.4.4. with significance p < 0,05. RESULTS: After exclusion criterias, twenty-six patients (9 bilateral) were included, mostly man (73%). The average age was 35 years for both genders. BMI was 19 kg/m2 for women and 24 kg/m2 for men and the mean modified Harris Hip Score was 67 points. We have found femoral torsion changes in 11 hips with pain (31%) and high variability (60%). The mean FT was 14,5°, ranging from 0 to 39°. Patients with hip pain, CAM impingement and altered FT had no correlation when compared to controls (without pain) (p = 0.234), neither Mixed impingement (p = 0.314). Patients with Pincer impingement and painful hips had higher FT (16,63°) than controls (11,77°) (p = 0.045). Conclusion: The presence of torsional alterations in almost 1/3 of the patients with FAI and the high variability reveal the importance of measuring FT at this disease.

First 100 segmental labral reconstructions compared to the most recent 100: the role of surgeon experience in decreasing conversion to total hip arthroplasty.

PURPOSE: The purpose of this study was to determine if conversion to total hip arthroplasty and patient-reported outcomes were similar in the first 100 patients who underwent segmental labral reconstruction with iliotibial band autograft compared to the most recent 100 patients. METHODS: Patients who underwent hip segmental labral reconstruction with autologous iliotibial band were evaluated preoperatively and postoperatively with a minimum 2-year follow-up. The first consecutive 100 patients (Group 1) and the most recent 100 patients (Group 2) were retrospectively compared. Conversion to total hip arthroplasty, necessity of a revision hip arthroscopy, and patient-reported outcome scores were compared. RESULTS: Overall follow-up rate (> 2 years) was 94% (Group 1 vs. Group 2, 91% vs. 96%, n.s.). Mean age of Group 1 (37 ± 12) was significantly higher than that of Group 2 (34 ± 12) (p = 0.03). In Group 2, 69 surgeries out of 100 were revision hip arthroscopies, which was significantly higher rate than Group 1 (48/100) (p = 0.003). Group 1 had significantly higher rate of conversion to THA [23% (23/100) vs. 5% (5/100), p = 0.001]. Revision hip arthroscopy was performed in 11/76 (15%) in Group 1 and in 8/95 (9%) in Group 2 (n.s.). Patient-reported outcomes scores were similar between two groups (all n.s.). Higher age and joint space ≤ 2 mm were significant risk factors of total hip arthroplasty conversion. CONCLUSION: This study showed that, with experience, fewer conversions to total hip arthroplasty were seen; however, revision rate and outcomes were similar. LEVEL OF EVIDENCE: IV.

Evaluation of the Laboratorial Profile of Elderlies with Proximal Femur Fracture by Low Energy Mechanism.

Objective This study aims to evaluate the laboratory results profile of elderly patients with proximal femoral fractures and to verify the relationship between these data, fracture outcome and death. Methods Cross-sectional study of patients admitted to the orthopedic emergency service of a referral hospital between February and April 2017 with proximal femoral fracture by low energy mechanism and submitted to laboratorial and imaging tests. Patients with suspected or confirmed pathological fracture were excluded from the study. Results Sixty-six individuals were evaluated, 44 of whom were women, all over 60 years old. Transtrochanteric fractures had the highest incidence in the study (36). Alterations of parathyroid hormone and albumin levels were significant for death ( p ≤ 0.05). Length of hospital stay was not a significant factor for death. Conclusions Laboratory abnormalities were not related to the outcome of death. Albumin may be related to the risk of death. No laboratory result was pointed out as a facilitator in the generation of proximal femoral fractures. More studies are needed to better understand the laboratory influence on fractures and their consequences.

Evaluation of the Laboratorial Profile of Elderlies with Proximal Femur Fracture by Low Energy Mechanism / Avaliação do perfil laboratorial de idosos com fratura de fêmur proximal por mecanismo de baixa energia

Abstract Objective This study aims to evaluate the laboratory results profile of elderly patients with proximal femoral fractures and to verify the relationship between these data, fracture outcome and death. Methods Cross-sectional study of patients admitted to the orthopedic emergency service of a referral hospital between February and April 2017 with proximal femoral fracture by low energy mechanism and submitted to laboratorial and imaging tests. Patients with suspected or confirmed pathological fracture were excluded fromthe study. Results Sixty-six individuals were evaluated, 44 of whom were women, all over 60 years old. Transtrochanteric fractures had the highest incidence in the study (36). Alterations of parathyroid hormone and albumin levels were significant for death (p ≤ 0.05). Length of hospital stay was not a significant factor for death. Conclusions Laboratory abnormalities were not related to the outcome of death. Albumin may be related to the risk of death. No laboratory result was pointed out as a facilitator in the generation of proximal femoral fractures. More studies are needed to better understand the laboratory influence on fractures and their consequences.

Resumo Objetivo Avaliar o perfil laboratorial de idosos com fratura de fêmur proximal e verificar a relação dos dados com o desfecho da própria fratura e como desfecho óbito. Métodos Estudo transversal de pacientes admitidos na emergência ortopédica de um hospital referência, entre os meses de fevereiro e abril de 2017, com fratura de fêmur proximal, por mecanismo de baixa energia, sendo coletados exames laboratoriais e de imagem. Foram excluídos do estudo pacientes comsuspeita ou confirmação de fratura patológica. Resultados Foram avaliados 66 indivíduos, sendo 44 mulheres, todos com idade superior a 60 anos. A fratura transtrocantérica apresentou maior incidência no estudo (36). Alterações do hormônio da paratireoide (PTH) e da albumina foram significativos para óbito (p ≤ 0,05). O tempo de internação não foi fator significativo para óbito. Conclusões Alterações laboratoriais não estavam relacionadas ao desfecho de óbito. A albumina pode estar relacionada ao risco de óbito. Nenhum resultado laboratorial foi apontado como facilitador na geração de fraturas de fêmur proximal. Mais estudos são necessários para poder entender melhor a influência do quadro laboratorial do paciente na ocorrência de fraturas e suas consequências.

Predicting Severe Cartilage Damage in the Hip: A Model Using Patient-Specific Data From 2,396 Hip Arthroscopies.

PURPOSE: To determine patient-specific factors that can be used to predict the presence of severe articular cartilage damage in the hip in patients without osteoarthritis. METHODS: The prevalence of severe (Outerbridge grade III or IV) cartilage damage to the acetabulum and femoral head was prospectively recorded at hip arthroscopy. Patients who underwent primary hip arthroscopic surgery between 2006 and 2016 performed by a single surgeon were included. Patients were excluded if they underwent previous hip surgery, had poor-quality radiographs, were younger than 16 years at the time of surgery, or had a minimal joint space of 2 mm or less. The relation between severe cartilage damage and preoperative patient characteristics was examined using multivariable logistic regression analysis with restricted cubic splines. RESULTS: Of the 2,396 hips presenting for hip arthroscopy, 995 (41%) had severe cartilage damage to the acetabulum and 257 (11%) had severe cartilage damage to the femoral head. Older age was a significant risk factor for severe cartilage damage both to the acetabulum (χ2 = 69.5, P < .001) and to the femoral head (χ2 = 53.9, P < .001). An age of 45 years was associated with a 1.96 (95% confidence interval, 1.54-2.49) increase in the odds of severe acetabular cartilage damage and a 3.94 (95% confidence interval, 2.61-5.94) increase in the odds of severe femoral head cartilage damage relative to an age of 20 years. Male sex was associated with severe cartilage damage to the acetabulum (χ2 = 66.7, P < .001), and a lower center-edge angle was a significant risk factor for severe cartilage damage to the femoral head (χ2 = 78.5, P < .001). Predictive nomograms were established for severe cartilage lesions. CONCLUSIONS: The primary risk factors for severe hip cartilage damage were older age for both the femoral head and acetabulum; a lower center-edge angle and larger Tönnis angle for the femoral head; and male sex, body mass index, alpha angle, and joint space for the acetabulum. The likelihood of cartilage damage to the hip can be estimated clinically using a prediction nomogram. LEVEL OF EVIDENCE: Level III, cross-sectional study.

Labral Preservation: Outcomes Following Labrum Augmentation Versus Labrum Reconstruction.

PURPOSE: The purpose of this study was to compare the clinical outcomes and patient satisfaction between patients with previous surgeries who underwent hip labral augmentation versus labral reconstruction surgery. METHODS: From 2006 to 2014, all patients with previous labral procedures who underwent subsequent labral augmentation by the senior surgeon were included. Patients with joint space ≤2 mm and lateral center edge angle <20° and who refused to participate in follow-up were excluded. Patients who underwent labral augmentation, preserving macroscopically healthy native labral tissue and adding iliotibial band graft to increase labral volume, were compared with a matching group (1:2) of patients who underwent labral reconstruction where damaged or absent native labral tissue was replaced by the graft. Hip Outcome Score-Activity of Daily Living (HOS-ADL) was the primary outcome measure. Secondary outcomes included the modified Harris Hip Score (mHHS), HOS for Sports (HOS-Sport), Short Form-12, Western Ontario and McMaster Universities Osteoarthritis Index, and patient satisfaction with outcome. Nonparametric statistics were used to compare groups. RESULTS: Thirty-three patients (12 males, 21 females) who underwent labral augmentation (LA group) were compared with 66 (24 males, 42 females) labral reconstruction patients (LR group). The average age was 29 ± 10 years in both groups. Six patients (18%) required revision arthroscopy in the LA group, and 9 patients (14%) in the LR group (P = .563). One patient (3%) in the LA group required a total hip arthroplasty, and 3 patients in the LR group (4.5%) had a total hip arthroplasty (P = .99). Of the remaining 26 patients in the LA group and 53 patients in the LR group, minimum 2-year follow-up was available for 21 (81%) and 51 (96%), respectively. Postoperatively the HOS-ADL, HOS-Sport, mHHS, and Western Ontario and McMaster Universities Osteoarthritis Index were significantly higher in the LA group (P < .05). The percentage of patients who reached minimum clinically important difference was significantly higher in the LA group for HOS-ADL (P = .002) and HOS-Sport (P = .008); however, there was no difference for the mHHS (P = .795). Patient satisfaction was 10 and 8 in the LA group and LR group, respectively (P = .585). CONCLUSIONS: In patients with previous procedures, the labral augmentation technique with preservation of macroscopically healthy native labral fibers resulted in significantly better outcomes compared with the segmental labral reconstruction procedure where damaged or previously removed labrum was replaced by a graft. LEVEL OF EVIDENCE: Level III, comparative case series.

Prevalence of High-Grade Cartilage Defects in Patients With Borderline Dysplasia With Femoroacetabular Impingement: A Comparative Cohort Study.

PURPOSE: To compare the prevalence, size, and location of Outerbridge grade III and IV cartilage defects on the femoral head and acetabulum between patients with borderline acetabular dysplasia and patients with non-borderline dysplasia who underwent hip arthroscopy for femoroacetabular impingement (FAI). METHODS: Patients aged 18 years or older who underwent primary hip arthroscopy for correction of FAI and labral repair from November 2005 to April 2016 were included. We excluded patients with previous hip surgery, a radiographic hip joint space of 2 mm or less, and/or a lateral center-edge angle (LCEA) of less than 20° or greater than 40°. The study patients were divided into 2 groups based on the LCEA on the anteroposterior pelvic radiograph: Patients with an LCEA between 20° and 25° were included in the borderline group, and patients with an LCEA between 25° and 40° were included in the non-borderline group. The prevalence, size, and location of Outerbridge grade III and IV chondral lesions on the femoral head and acetabulum were recorded intraoperatively. Comparisons between groups were performed with the Mann-Whitney U test for nonparametric testing and the t test for data that were normally distributed. Data were analyzed to calculate odds ratios associated with the various factors. RESULTS: In total, 2,429 patients (1,114 women and 1,315 men) met the inclusion criteria. The borderline group consisted of 305 patients (150 men and 155 women), whereas the non-borderline dysplasia group comprised 2,124 patients (1,165 men and 959 women). Outerbridge grade III and IV chondral lesions were found on the femoral head in 118 patients with borderline dysplasia (39%) and 127 patients with non-borderline dysplasia (6%) and on the acetabulum in 132 patients with borderline dysplasia (43%) and 874 patients with non-borderline dysplasia (41%). Patients with borderline dysplasia were 10 times more likely (95% confidence interval, 7.3-13.4; P < .001) to have a grade III or IV cartilage defect on the weight-bearing surface of the femoral head (P < .001) than patients with non-borderline dysplasia. On the acetabular side, no difference in the prevalence of severe cartilage damage was detected between the 2 groups (P = .588). The size of chondral damage was significantly greater in patients with borderline dysplasia on the acetabulum (P = .039) compared with the non-borderline dysplasia group. CONCLUSIONS: Patients with FAI and borderline dysplasia are at higher risk of having Outerbridge grade III and IV chondral damage on the femoral head than patients with non-borderline dysplastic hips. Borderline dysplastic hips also presented with significantly larger chondral defects on the acetabular surface. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Current concepts in revision hip arthroscopy.

Hip arthroscopy is an evolving procedure and its indications have expanded. The number of patients undergoing this procedure has increased significantly as well as the number of surgeons being trained. This has resulted in a notable increase in post-operative complication rates creating the need to develop advanced hip arthroscopic techniques. Revision hip arthroscopy is often complex and many factors should be considered to achieve a satisfactory clinical outcome. Careful pre-operative planning and agreement of expectations between the physician and patient regarding the procedure are important. This review describes several advanced treatment options that are used mainly in revision or complex primary hip arthroscopy cases. Labral reconstruction or augmentation technique is used in cases of severely deficient acetabular labral tissue to restore the fluid seal mechanism. In cases of symptomatic (often post-operative) adhesion formation, a spacer between the labrum and the joint capsule is useful for pain relief and prevention of future adhesions. Large defects of the capsule due to previous unrepaired capsulotomy or any other cause can be addressed with the capsular reconstruction technique. Ligamentum teres reconstruction using an anterior tibialis allograft is indicated in patients with hip instability and persistent pain after previous debridement or with complete tears of this structure. The senior author's treatment of choice in cases of previous over-resection of CAM impingement is the remplissage technique to restore the bony defect of the femoral head-neck junction and preserve the joint seal.

Revision Hip Arthroscopy After Labral Reconstruction Using Iliotibial Band Autograft: Surgical Findings and Comparison of Outcomes With Labral Reconstructions Not Requiring Revision.

PURPOSE: To determine the causes of revision hip arthroscopy in patients who underwent labral reconstruction and to compare outcomes of these patients with patients who did not require a revision following reconstruction. METHODS: Patients who underwent revision hip arthroscopy after previous labral reconstruction from 2006 to 2014 were included. Patients with less than 2-year follow-up, preoperative joint space of ≤2 mm, or who underwent other reconstructive procedures at the time of labral reconstruction were excluded. Each patient was matched by year of surgery, age, gender, and the number of previous surgeries with 2 patients that underwent labral reconstruction but did not require a revision following the reconstruction. Preoperatively and at a minimum 2-year follow-up, outcome scores were collected including the Hip Outcome Score-Activities of Daily Living (HOS-ADL) and HOS-Sports Scale, modified Harris Hip Score, Western Ontario and McMaster Universities Index (WOMAC), the 12-Item Short Form Health Survey (SF-12) Physical Component Summary, and the patient satisfaction outcome were collected. Differences between the preoperative and the postoperative outcomes score of each patient in the 2 groups was assessed using the paired t test. The Mann-Whitney U test was used to compare the 2 groups. RESULTS: From 347 patients who underwent iliotibial band autograft labrum reconstruction from 2006 to 2014, 28 hips (8%) in 26 patients (18 females and 8 males) had revision arthroscopy after labral reconstruction. The mean age was 32 years (range: 16-64). The mean number of hip surgeries prior to the labral reconstruction was 1.9 ± 1.2. The average time from the last labral reconstruction procedure to revision labral reconstruction was 27 months (range: 5-59). Procedures performed at revision included lysis of adhesions (100%), additional femoroacetabular impingement (FAI) correction (50%), ligamentum teres debridement (50%), psoas release (29%), labral augmentation or reconstruction (14%), and others. Following revision surgery after previous labral reconstruction, 4 patients (14%) underwent total hip arthroplasty and 2 (7%) patients required a subsequent revision arthroscopy (age 67 and 23) at 15 months and 16 months. The average follow-up time was 3.6 years ± 1 year after revision following labral reconstruction and after labral reconstruction in the nonrevision group. No significant difference was detected in the outcome scores and postoperative satisfaction between the 2 groups. The HOS-ADL improved 16 points in the nonrevision group and 19 points in the revision group. CONCLUSIONS: Patients who underwent revision surgery after labral reconstruction were mostly female, with 2 or more surgeries prior to reconstruction, and 14% required THA and 7% had recurrent scarring. In those who did not fail, outcomes significantly improved and were similar with patients who did not need revision. Adhesions and residual FAI were the most common findings during revision labral reconstruction. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Outcomes following arthroscopic hip segmental labral reconstruction using autologous capsule tissue or indirect head of the rectus tendon.

The purpose of this study was to determine the outcomes following segmental labral reconstruction (labral defects measuring <1 cm) using a segment of capsular tissue or a segment of the indirect head of rectus femoris tendon. Eleven patients (five females and six males) underwent segmental labral reconstruction using a segment of capsule (eight patients) or indirect head of rectus tendon (three patients) by a single surgeon from March 2005 to October 2012. The average age of the patients was 35 years old (range, 20-51 years). Data collected included the pre- and post-operative Hip Outcome Score (HOS-ADL and HOS-SS), the modified Harris Hip Score and patient satisfaction rate (1 = unsatisfied, 10 = very satisfied), complications, necessity of revision hip arthroscopy and conversion to total hip arthroplasty. Average follow-up time was at 62 months (range, 9-120 months). No patient required revision hip arthroscopy or converted to total hip arthroplasty. The HOS-ADL significantly improved from 73 to 89 (P < 0.05). The HOS-SS showed significant improvement from 52 to 79 and the modified Harris Hip Score significantly improved from 66 to 89. Median patient satisfaction rate was 9 out of 10 (range, 3-10). In a small sample, the arthroscopic hip segmental labral reconstruction showed significant improvement in patient-reported outcomes. This treatment provides an option in cases of small labrum defects (<1 cm) or deficits in patients while providing improved function and high patient satisfaction.

Arthroscopic Reconstruction of the Ligamentum Teres: A Guide to Safe Tunnel Placement.

PURPOSE: To provide a quantitative guide to tunnel placement concurrently through the femur and acetabulum during a ligamentum teres reconstruction, minimizing the risk of injury to the obturator neurovascular bundle. METHODS: Nine human cadaveric pelvises, complete with femurs (mean age, 59.6 years; age range, 47-65 years), were studied. Before dissection, a 3-dimensional coordinate-measuring device was used to record the neutral orientation of the femur in the acetabulum. The specimens were then dissected free of all extra-articular soft tissue, except for the ligamentum teres and the obturator neurovascular bundle, and digitized. An anatomic femoral reconstruction tunnel through the femoral neck was simulated and extended along its axis into the acetabulum. The femur was digitally rotated internally from 0° to 30° and externally from 0° to 40°, as well as abducted from 0° to 30° and adducted from 0° to 20°, in increments of 1°. At each position, the location of the simulated acetabular reconstruction tunnel was measured with respect to the obturator bundle and the edge of the acetabular fossa. RESULTS: The anatomic reconstruction tunnel entered the lateral side of the femur at a mean distance of 7.0 mm distal and 5.8 mm anterior to the center of the vastus ridge. By angling the femur at 15° of internal rotation and 15° of abduction, the obturator neurovascular bundle was avoided in 100% of specimens. CONCLUSIONS: The most important finding of this study was that a ligamentum teres reconstruction tunnel could be reamed through the femoral neck and safely positioned in the acetabulum by angling the femur at 15° of internal rotation and 15° of abduction. CLINICAL RELEVANCE: These quantitative descriptions of the ligamentum teres reconstruction tunnels can be used to guide arthroscopic surgical interventions designed to address ligamentum teres pathology.

Twenty-Year Systematic Review of the Hip Pathology, Risk Factors, Treatment, and Clinical Outcomes in Artistic Athletes-Dancers, Figure Skaters, and Gymnasts.

OBJECTIVE: To identify (1) the predominant level of evidence of the clinical studies regarding the hip pathology, risk factors, treatment, and clinical outcomes in artistic athletes (dancers, figure skaters, and gymnasts) (2) the most commonly reported hip pathology, risk factors, treatments, and clinical outcomes in dancers, figure skaters, and gymnasts. METHODS: To conduct this systematic review PubMed, EMBASE, and Scopus databases were searched for relevant studies and pertinent data were collected from the eligible articles. Included were studies which reported hip injuries in artistic athletes, the risk factors, treatment, and/or the clinical outcomes. We excluded case reports or irrelevant studies. No meta-analysis was performed because of study heterogeneity. The methodical index for nonrandomized studies (MINORS) criteria were used for quality control. MAIN RESULTS: Thirty-eight studies were included in the analysis. The mean MINORS score was 13.6 ± 4.6 points indicating fair quality of evidence of the included articles. The predominant level of evidence was level IV. Chondrolabral pathology and muscle injuries were the most commonly reported pathologies. We found only 2 risk factor analysis studies; however, many studies reported risk correlation between artistic sports or imaging findings and hip pathology. Treatment strategies were reported in only 7 studies, clinical outcomes are significantly underreported. CONCLUSION: Chondrolabral pathology was the most commonly reported hip pathology in artistic athletes, however, prospective cohort studies are necessary to really understand these injuries and their associated risk factors. The lack of clinical outcomes is significant and future data collection is required to assess the effectiveness of the various treatments.

Return to Play After Hip Arthroscopic Surgery for Femoroacetabular Impingement in Professional Soccer Players.

BACKGROUND: Arthroscopic hip surgery has been shown to be effective in returning professional athletes back to play at a high level of performance in different sports. Limited information exists regarding professional soccer players and their return to play. PURPOSE: To determine the rate and time to return to sport for professional soccer players after hip arthroscopic surgery for the treatment of femoroacetabular impingement (FAI) and to identify possible risk factors associated with a delay in returning to play. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Professional soccer players who underwent hip arthroscopic surgery for FAI by a single surgeon between 2005 and 2015 were evaluated. Data retrieved from www.mlssoccer.com , www.fifa.com , www.transfermarkt.co.uk , and www.wikipedia.org included information on each player's professional career, participation on the national team, length of professional career before surgery, number of appearances (games) before surgery, time between surgery and first appearance in a professional game, and number of appearances after surgery. Other data were obtained from the patient's medical records. RESULTS: Twenty-four professional soccer players (26 hips) were included. The mean age at surgery was 25.0 ± 4.0 years (range, 19-32 years). A total of 96% of patients were able to return to play at the professional level. The mean time between surgery and the first professional game played was 9.2 months (range, 1.9-24.0 months). On average, players played in 70 games after surgery (range, 0-224). National team players were able to return to play significantly earlier than the rest of the players (median, 5.7 months vs 11.6 months, respectively; P = .018). Severe chondral damage and microfracture did not interfere with return to play. CONCLUSION: The arthroscopic management of FAI in symptomatic professional soccer players allowed 96% of them to return to play. Players with national team experience were able to return to play earlier than those without it. Severe chondral damage and microfracture did not interfere with return to play.

Arthroscopic Focal Subspinal Decompression and Management of Pincer-Type Femoroacetabular Impingement.

Femoroacetabular impingement syndrome is a common hip pathology significantly affecting not only the intra- and extra-articular structures but also the biomechanical function of the joint. Cam and pincer bony lesions have been extensively studied. However, during recent years, other types of extra-articular impingement between the pelvic and femoral bone have been investigated. When a prominent or morphologically abnormal anterior-inferior iliac spine (AIIS) impinges repetitively on the femoral side during motion, the subspinal acetabular region becomes prominent and extends toward the intra-articular part of the joint. This results in restriction of the range of motion of the hip and pain, especially with flexion. Therefore, during hip arthroscopy, it is necessary to evaluate the subspinal region (triangular area located at 1:30 to 2:30 o'clock using the acetabular clock face system). For the correction of the acetabular bone pathology to be complete, the surgeon should focus both on the pincer and subspinal impingement lesions. This article describes our preferred technique to successfully address subspinal and pincer acetabular impingement during hip arthroscopy. The pearls and pitfalls of this technique are discussed.

Arthroscopic Hip Labral Augmentation Technique With Iliotibial Band Graft.

The importance of the acetabular labrum has been well documented for the function and overall health of the hip joint. Several biomechanical studies have shown the sealing effect of the acetabular labrum. In the past decade, labral repair procedures have gained increased attention, with the literature suggesting that the outcomes after hip arthroscopy are directly related to labral preservation. However, a primary labral repair can be challenging in cases of hypoplastic, ossified, or complex and irreparable labral tears in which there is insufficient tissue to perform a primary repair. For these cases, labral reconstruction becomes a viable option with good outcomes at short-term and midterm follow-up. A subset of these patients may show viable remnants of the labral circumferential fibers but, because of the low tissue volume, these remnant fibers are unable to maintain the suction seal. In this situation, a labral augmentation may be a viable alternative to labral reconstruction while preserving as much native labral tissue as possible. The purpose of this Technical Note is to describe an arthroscopic hip labral augmentation technique using iliotibial band autograft or allograft.

Quantitative Anatomic Analysis of the Native Ligamentum Teres.

BACKGROUND: While recent studies have addressed the biomechanical function of the ligamentum teres and provided descriptions of ligamentum teres reconstruction techniques, its detailed quantitative anatomy remains relatively undocumented. Moreover, there is a lack of consensus in the literature regarding the number and morphology of the acetabular attachments of the ligamentum teres. PURPOSE: To provide a clinically relevant quantitative anatomic description of the native human ligamentum teres. STUDY DESIGN: Descriptive laboratory study. METHODS: Ten human cadaveric hemipelvises, complete with femurs (mean age, 59.6 years; range, 47-65 years), were dissected free of all extra-articular soft tissues to isolate the ligamentum teres and its attachments. A coordinate measuring device was used to quantify the attachment areas and their relationships to pertinent open and arthroscopic landmarks on both the acetabulum and the femur. The clock face reference system was utilized to describe acetabular anatomy, and all anatomic relationships were described using the mean and 95% confidence intervals. RESULTS: There were 6 distinct attachments to the acetabulum and 1 to the femur. The areas of the acetabular and femoral attachment footprints of the ligamentum teres were 434 mm2 (95% CI, 320-549 mm2) and 84 mm2 (95% CI, 65-104 mm2), respectively. The 6 acetabular clock face locations were as follows: anterior attachment, 4:53 o'clock (95% CI, 4:45-5:02); posterior attachment, 6:33 o'clock (95% CI, 6:23-6:43); ischial attachment, 8:07 o'clock (95% CI, 7:47-8:26); iliac attachment, 1:49 o'clock (95% CI, 1:04-2:34); and a smaller pubic attachment that was located at 3:50 o'clock (95% CI, 3:41-4:00). The ischial attachment possessed the largest cross-sectional attachment area (127.3 mm2; 95% CI, 103.0-151.7 mm2) of all the acetabular attachments of the ligamentum teres. CONCLUSION: The most important finding of this study was that the human ligamentum teres had 6 distinct points of attachment on the acetabulum (transverse, anterior, and posterior margins of the acetabular notch and cotyloid fossa attachments: ilium, ischium, and pubis) and 1 on the femur. On the acetabulum, the anterior attachment was substantially larger than the posterior attachment and was located at a mean clock face position of 4:53 o'clock. CLINICAL RELEVANCE: These quantitative descriptions of the ligamentum teres can be used by clinicians to arthroscopically identify the attachments of the ligamentum teres, guiding arthroscopic surgical interventions designed to address ligamentum teres pathology.

Treatment of Femoroacetabular Impingement: Labrum, Cartilage, Osseous Deformity, and Capsule.

Femoroacetabular impingement (FAI) surgery aims to restore the native anatomical relationships between bones and the soft tissues comprising the hip joint. The goal of this approach is to mimic the natural biomechanical function of the hip joint and translate it into a perfect clinical outcome. In this article, we describe the indications and contraindications for our preferred hip arthroscopic techniques for correcting FAI in both primary and revision cases and discuss the role of postoperative rehabilitation and use of biologics in further improving patient outcomes.

An Anatomic Analysis of Mid-anterior and Anterolateral Approaches for Hip Arthrocentesis: A Male Cadaveric Study.

PURPOSE: To determine the accuracy and safety of non-image-guided modified mid-anterior and anterolateral approaches to the hip joint for arthrocentesis. METHODS: Six pairs (n = 12) of human cadaveric hemipelvises underwent methylene blue hip injections through either a mid-anterior or an anterolateral approach. The distance from the mid-anterior approach to the lateral femoral cutaneous nerve (LFCN) was measured. Needle orientation was defined by a combination of 2 angles, calculated by the computer software analysis of digitized points. Distal Angle was defined as the angle between the lateral axis and an intermediate needle position, in the coronal plane, toward the distal axis. Anterior Angle was defined as the angle between the intermediate needle position of Distal Angle and the final position, toward the anterior axis. RESULTS: Methylene blue was successfully injected into the joint capsule in all specimens. The mean distances from the needle to the LFCN for both the mid-anterior and anterolateral approaches were 19.3 ± 7.9 and 80.3 ± 28.3 mm, respectively. For the mid-anterior approach, Distal AngleM was a mean of 53.9° ± 14.9° and Anterior AngleM was a mean of 33.4° ± 15.6°. For the anterolateral approach, Distal AngleL was a mean of 14.5° ± 14.2° and Anterior AngleL was a mean of 4.5° ± 13.6°. CONCLUSIONS: This study showed that mid-anterior and anterolateral approaches for non-image-guided hip injections or arthrocentesis can avoid the LFCN and be effectively performed in males, despite the exhibited variability in the quantitative descriptions of these techniques. The landmarks and measurements presented can be used as general guidelines for clinical studies regarding hip arthrocentesis and injections. CLINICAL RELEVANCE: The high variability of the needle placement and trajectory of the mid-anterior and anterolateral approaches performed in this study showed that these techniques were not easily quantitatively defined. However, both of these approaches appeared to be safe and effective.