First-line treatment for femoroacetabular impingement syndrome and hip-related quality of life: study protocol for a multicentre randomised controlled trial comparing a 6-month supervised strength exercise intervention to usual care (the Better Hip Trial).

INTRODUCTION: Femoroacetabular impingement syndrome (FAIS) is a motion-related and position-related clinical condition of the hip associated with pain, reduced physical function and hip-related quality of life (QoL). Interestingly, higher maximal muscle strength is associated with less pain, better physical function and improved QoL in people with FAIS. Furthermore, preliminary evidence suggests that a proportion of patients with FAIS respond positively to strength exercise as first-line treatment. Nonetheless, there is little evidence supporting a specific exercise intervention offered as a first-line treatment. We will conduct a randomised controlled trial investigating the clinical effectiveness and cost-effectiveness of a 6-month strength exercise intervention compared with usual care as first-line treatment in patients with FAIS. METHODS AND ANALYSIS: This is a multicentre randomised controlled trial that will be conducted at hospitals and physiotherapy clinics across Denmark and Australia. A total of 120 patients with FAIS will be randomised (1:1) to 6 months of supervised strength exercise or usual care. The primary outcome is the change in hip-related QoL measured using the International Hip and Outcome Tool 33 (iHOT-33) from baseline to the end of intervention. A health economic evaluation will be conducted from a societal and healthcare perspective based on the data collection over a 12-month period starting at baseline. The analysis will calculate incremental cost-effectiveness ratios using quality-adjusted life-years and iHOT-33 scores while estimating costs using microcosting and cost questionnaires. Secondary outcomes include objectively measured physical function at baseline and after 6 months and patient-reported outcomes measured at baseline, 3-month, 6-month and 12-month follow-up. ETHICS AND DISSEMINATION: The trial has been approved by the Committee on Health Research Ethics in the Central Denmark Region (journal no 1-10-72-45-23) and La Trobe University Human Ethics Committee (HEC24042) and is registered at the Central Denmark Region List of Research Projects (journal no 1-16-02-115-23). Informed consent will be obtained from each participant before randomisation. Results will be published in international peer-reviewed scientific journals. TRIAL REGISTRATION NUMBER: NCT05927935.

Exercise compared to a control condition or other conservative treatment options in patients with Greater Trochanteric Pain Syndrome: a systematic review and meta-analysis of randomized controlled trials.

OBJECTIVES: To estimate the effectiveness of exercise at end of treatment and long-term follow-up compared to a control condition or other conservative treatments in patients with Greater Trochanteric Pain Syndrome (GTPS). METHODS: Databases were searched September 2021 and updated September 2023. Randomized controlled trials (RCT) comparing exercise interventions for patients with GTPS, to a control condition; corticosteroid injection; shock wave therapy; or other types of exercise programs were included. Risk of bias was assessed using the ROB2 tool. Meta-analyses were performed using a random-effects model. The certainty of the evidence was rated by the GRADE approach. RESULTS: Six RCTs including a total of 733 patients with GTPS were included. Three trials compared exercise to sham exercise or wait-and-see control groups, two trials compared exercise to corticosteroid injection, two trials compared exercise to shockwave therapy, and one trial compared exercise to another type of exercise. Meta-analyses showed that in the long term, exercise slightly reduces hip pain and disease severity, while slightly improving patient-reported physical function and global rating of change compared to a control condition. No serious adverse events were reported. Compared to corticosteroid injection, exercise improves long-term global rating of change. CONCLUSION: The current evidence supports a strong recommendation for exercise as first line treatment in patients clinically diagnosed with GTPS. Compared to corticosteroid injection, exercise is superior in increasing the likelihood that a patient experiences a meaningful global improvement. These results are based on few trials and a moderate number of patients. REGISTRATION: This review was prospectively registered in the PROSPERO database of systematic reviews (ID: CRD42021261380). CONTRIBUTION OF PAPER.

Opportunity to Perform - Should Simulation-Based Surgical Training be Provided on Demand or on Supply?

Introduction: The aim of the study was to assess the surgical case volume of residents before and after simulation-based training in hip fracture surgery provided on demand versus knee and shoulder arthroscopy provided on supply. Materials and Methods: A retrospective analysis of surgical case volume in hip fracture surgery and arthroscopic shoulder and knee procedures 90 days before and after simulation-based training of either procedure. Sixty-nine orthopedic residents voluntarily participating in either simulation-based training. Hip fracture surgery simulation was provided on supply, ie, whenever 1-2 residents applied for the course, while the arthroscopic simulation course was supplied twice yearly. Results: Thirty-four residents participated in hip fracture simulation on demand and 35 residents participated in arthroscopic simulation on supply. The surgical case volume of hip fracture osteosynthesis increased from median 2.5 (range: 0-21) to median 11.5 (1-17) from 90 days before to the 90 days after the simulation-based training on demand. The median difference was 6.5 procedures (p < 0.0003). On the contrary, the surgical case volume in shoulder and knee arthroscopy was low both before and after the simulation on supply, ie, median 2 (0-22) before and median 1 (0-31) after. The median difference was 0 (p = 0.21). Conclusions: Simulation on demand was associated with increased opportunities to perform in the clinical environment after the simulation-based training compared with simulation on supply. Simulation-based training should be aligned with the clinical rotation of the residents. Simulation on demand instead of supply on fixed dates may overcome this organizational issue of aligning training with the opportunity to perform.

Combined anterior cruciate ligament revision with reconstruction of the antero-lateral ligament does not improve outcome at 2-year follow-up compared to isolated acl revision; a randomized controlled trial.

PURPOSE: It is essential to obtain rotational stability of the knee after anterior cruciate ligament reconstruction (ACL-R) and it is suggested that a supplementary reconstruction of the antero-lateral ligament (ALL-R) may supports this. Theoretically, ALL-R may be particularly advantageous to support revision of failed ACL-Rs. It was hypothesized that ACL revision combined with ALL-R will result in superior outcome compared to isolated ACL revision. METHODS: The study was designed as a randomized controlled trial. Patients eligible for first time ACL revision were randomized to either isolated ACL revision (- ALL group) or ACL revision combined with a single-stranded allograft ALL-reconstruction (+ ALL group). Patient reported outcomes and function were evaluated at two-year follow-up by KNEES-ACL, KOOS, and Tegner activity scale. Objective knee laxity was evaluated at one-year follow-up using an instrumented Rolimeter test, the pivot shift test, and a manual Lachman test. RESULTS: A total of 103 patients were enrolled with 49 patients randomized to the + ALL group and 54 patients in the - ALL group. There were no differences at baseline between groups regarding age, gender, body mass index, preoperative patient reported outcome scores and concomitant meniscus or cartilage injury. The ACL revision was performed with an allograft in 10 patients (20%) in the + ALL group and 8 patients (15%) in the -ALL group. At follow-up there was no significant difference between the groups in patient reported outcome scores and clinical knee laxity. CONCLUSION: Supplementary ALL-R does not improve subjective outcome of first time ACL revision at two-years and clinical knee stability at one-year follow-up compared to isolated ACL revision. LEVEL OF EVIDENCE: Level I.

Muscle Strength, Oxygen Saturation and Physical Activity in Patients with Chronic Exertional Compartment Syndrome Compared to Asymptomatic Controls.

Background: One of the most common causes of exercise-induced pain in the lower leg is chronic exertional compartment syndrome (CECS). Research is limited on muscle strength, oxygen saturation and physical activity in patients with CECS. Purpose: To compare muscle strength, oxygen saturation, and daily physical activity between patients with CECS and matched asymptomatic controls. A secondary purpose was to investigate the association between oxygen saturation and lower leg pain in patients with CECS. Study Design: Case-control study. Method: Maximal isometric muscle strength of the ankle plantar and dorsiflexors was tested in patients with CECS and sex- and age-matched controls using an isokinetic dynamometer and oxygen saturation (StO2) during running was tested by near infrared spectroscopy. Perceived pain and exertion were measured during the test using the Numeric Rating Scale and Borg Rating of Perceived Exertion scale and the exercise-induced leg pain questionnaire. Physical activity was assessed by accelerometry. Results: Twenty-four patients with CECS and 24 controls were included. There were no differences in maximal isometric plantar or dorsiflexion muscle strength between patients and controls. Baseline StO2 was 4.5pp (95% CI: 0.7;8.3) lower for patients with CECS than for controls, whereas no difference existed when they experienced pain or reached exhaustion. No differences were found in daily physical activities, except that on average, patients with CECS spent less time cycling daily. During the StO2 measurement, patients experienced pain or reached exhaustion while running significantly earlier than the controls (p<0.001). StO2 was not associated with leg pain. Conclusion: Patients with CECS have similar leg muscle strength, oxygen saturation and physical activity levels as asymptomatic controls. However, patients with CECS experienced significantly higher levels of lower leg pain than the controls during running, daily activities and at rest. Oxygen saturation and lower leg pain were not associated. Level of Evidence: Level 3b.

Hip joint motion does not change one year after arthroscopic osteochondroplasty in patients with femoroacetabular impingement evaluated with dynamic radiostereometry.

PURPOSE: Dynamic radiostereometric analysis (dRSA) enables precise non-invasive three-dimensional motion-tracking of bones for assessment of joint kinematics. Hereby, the biomechanical effects of arthroscopic osteochondroplasty of the hip (ACH) can be evaluated in patients with femoroacetabular impingement (FAI). The aim was to investigate the pre- and postoperative range of motion (ROM) and the CT bone volume removed (BV) after ACH. We hypothesize increase in ROM 1 year after surgery. METHODS: Thirteen patients (6 female) with symptomatic FAI were included prospectively. The patient's hips were CT-scanned and CT-bone models were created. Preoperative dRSA recordings were acquired during passive flexion to 90°, adduction, and internal rotation (FADIR). ACH was performed, CT and dRSA were repeated 3 months and 1 year postoperatively. Hip joint kinematics before, and 3 months and 1 year after ACH were compared pairwise. The bone volume removal was quantified and compared to change in ROM. RESULTS: Mean hip internal rotation, adduction and flexion were all unchanged after ACH at 1-year follow-up (p > 0.84). HAGOS scores revealed improvement of quality of life (QOL) from 32 to 60 (p = 0.02). The BV was between 406 and 1783 mm3 and did not correlate to post-operative ROM. CONCLUSIONS: ACH surgery in FAI patients had no impact of ROM at 1-year follow-up. QOL improved significantly. This indicates that the positive clinical effects reported after ACH might be a result of reduced labral stress and cartilage pressure during end-range motion rather than increased ROM. LEVEL OF EVIDENCE: Therapeutic prospective cohort study, level II.

Clinical outcomes after revision hip arthroscopy in patients with femoroacetabular impingement syndrome (FAIS) are inferior compared to primary procedures. Results from the Danish Hip Arthroscopy Registry (DHAR).

PURPOSE: As many as 10% of primary hip arthroscopies end up with a revision arthroscopy procedure when treating patients suffering from femoroacetabular impingement syndrome (FAIS). In general, revision procedures are indicated because of residual impingement, but only a few studies present outcome data from revision hip arthroscopy after failed FAIS surgical treatment. The purpose of this study was to evaluate clinical outcomes after revision hip arthroscopy in a FAIS cohort and compare outcomes with a primary FAIS hip arthroscopy cohort and describe potential causes of failure after the primary hip arthroscopy. It was hypothesized that subjective outcomes improve after revision hip arthroscopy although outcomes were expected to be inferior to primary hip arthroscopic outcomes. METHODS: Three-hundred and thirty-one arthroscopic revision hip FAIS patients were included from the Danish Hip Arthroscopy Registry (DHAR). Patient-related outcome measures (PROM's), Copenhagen Hip and Groin Outcome Scores (HAGOS), Hip Sports Activity Scale (HSAS), EQ-5D and Numeric Rating Scale (NRS) pain, were assessed in the study cohort prior to the primary procedure and at revision and at follow-up one year after the revision procedure. These data were compared with 4154 primary hip arthroscopic FAIS patients. RESULTS: One-year after revision surgery, mean follow-up (in months ± SD): 12.3 ± 1.6, significant improvements (p < 0.05) in all PROMs was demonstrated, but FAIS patients in the primary hip arthroscopic cohort demonstrated significantly higher outcomes, in all PROMs, when compared at one-year follow-up. Scar tissue, residual osseous impingement and insufficient healing of the labral repair were reported as the main reasons for revision surgery. The conversion to total hip arthroplasty was low (6.4%). CONCLUSION: Revision hip arthroscopy in FAIS patients improves subjective outcomes significantly, although they are poorer than after primary FAIS hip arthroscopy. Main reasons for revision arthroscopy was scar tissue, residual femoroacetabular impingement and insufficient healing of labral repair. LEVEL OF EVIDENCE: Level III.

[Joint-preserving surgery in hip and knee and development of secondary osteoarthritis].

The purpose of this review was to elucidate if surgery can prevent secondary osteoarthritis (OA) in hip dysplasia, femoroacetabular impingement syndrome, varus malalignment of the knee, patella instability, anterior cruciate ligament injury and intra-articular fracture of the knee or hip. In conclusion, there is evidence that surgery for intra articular fracture of the knee or hip reduces the risk of secondary OA. There is a lack of prospective comparative studies for the remaining investigated conditions and as such no convincing evidence that surgery reduces the risk of secondary OA.

High-volume image-guided injection in the chronic recalcitrant non-insertional patellar tendinopathy: a retrospective case series.

PURPOSE: To evaluate if High-volume Image-guided Injection (HVIGI)-treatment for chronic Patellar tendinopathy (PT) improve function and reduce pain at 16-months follow-up. METHODS: Patients with resistant PT who failed to improve after a three-month eccentric loading program were included in the study. Maximal tendon thickness was assessed with ultrasound. All patients were injected with 10 mL of 0.5% Marcaine, 0.5 mL Triamcinolonacetonid (40 mg/mL) and 40 mL of 0.9% NaCl saline solution under real-time ultrasound-guidance and high pressure. All outcome measures were recorded at baseline and at 16 months. A standardised Heavy Slow Resistance rehabilitation protocol was prescribed after HVIGI-treatment. Clinical outcome was assessed with the Victorian Institute of Sports Assessment-Patella tendon questionnaire (VISA-P) and statistically analyses were performed. RESULTS: The study included 28 single treatment HVIGI procedures in PT in 23 patients (19 men, 4 women) with a mean age of 30.3 (range 19-52). The mean duration of symptoms before HVIGI was 33 months. The baseline VISA-P score of 43 ± 17 (range 15-76) improved to 76 ± 16 (range 42-95) after 16 months (p < 0.01). Of the 28 HVIGI procedures 12 patients (15 PT) were not satisfied after the initial HVIGI procedure. Of these, 5 patients (5 PT) had additional HVIGI, 2 patients (2 PT) had corticoid injection and 6 patients (8 PT) needed surgery. Of the remaining 11 patients (13 PT), 9 patients had more than a 13-point improvement in the VISA-P score after 16 months. CONCLUSIONS: In this retrospective case-study, only 9 patients (32%) did benefit of a single HVIGI treatment at 16-months and a 33-point significant improvement was seen on the VISA-P score.

Bone ingrowth into open architecture PEEK interference screw after ACL reconstruction.

PURPOSE: Open or fenestrated interference screw design that allow bone ingrowth is a concept for improved bone healing to softtissue graft and bone filling in bone tunnels after anterior cruciate ligament reconstruction (ACLR) The aim of the current study was to assess CT scanning evaluated bone ingrowth into an open architecture interference screws in the tibial tunnel of patients undergoing ACL with soft tissue grafts. It was hypothesized that open architecture interference screws would stimulate bone ingrowth into the screw cavities. METHODS: Twelve patients requiring ACLR were included. They underwent arthroscopic ACLR with semitendinosus-/gracilis tendon graft and an open architecture polyetheretherketone (PEEK) interference screw. The patients were scanned with a multi-slice CT scanner two weeks, six and twelve months postoperatively. On CT reconstruction slices bone ingrowth into the screw was measured. Subjective and objective clinical outcome international knee documentation committee score and instrumented knee laxity determination were collected. RESULTS: At six months no implants demonstrated more than 10% bone ingrowth. At twelve months 42% (5/12) implants had more than 10% bone ingrowth (p = 0.009). The average bone filling into the screws was 7.7%. There was no tunnel widening or cyst formation seen in relation to any of the implants. Subjective IKDC score improved significantly from 50.6 baseline to 80.1 at 24 month follow-up. Preoperative side-to-side knee laxity improved from 3.7 (2.1) to 1.4 (1.2) mm at twelve months. There were no serious adverse events in relation to the new open architecture thread PEEK interference screw during or after hamstring ACL reconstruction. CONCLUSION: The present study demonstrated that open architecture thread PEEK interference screw can stimulate bone ingrowth into the screws after soft tissue ACL reconstruction with at 12 months with an average bone filling into screws was 7.7%. Knee stability, functional, subjective and objective outcomes were similar to large volume ACL outcome studies. TRIAL REGISTRATION: The study was registered at ClinicalTrials # NCT02382341 . 12-09-2014. LEVEL OF EVIDENCE: IV.

The effect of high-volume image-guided injection in the chronic non-insertional Achilles tendinopathy: a retrospective case series.

PURPOSE: To evaluate if High-volume Image-guided Injection (HVIGI)-treatment for chronic mid-portion Achilles tendinopathy (AT) improve function and reduce pain at 12-months follow-up. METHODS: Patients with resistant mid-portion AT who failed to improve after a three-month eccentric loading program were included in the study. Maximal tendon thickness was assessed with ultrasound. All patients were injected with 10 mL of 0.5% Marcaine, 0.5 mL Triamcinolonacetonid (40 mg/mL) and 40 mL of 0.9% NaCl saline solution under real-time ultrasound-guidance and high pressure. All outcome measures were recorded at baseline and 12 months. A standardized eccentric rehabilitation protocol was prescribed after HVIGI-treatment. Clinical outcome was assessed with the Victorian Institute of Sports Assessment-Achilles tendon questionnaire (VISA-A) and statistically analyses were performed. RESULTS: The study included 30 single treatment HVIGI procedures in AT in 28 patients (23 men, 5 women) with a mean age of 45.1 (range 16-63). The mean duration of symptoms before HVIGI was 37 months. The baseline VISA-A score of 50 ± 15 (range 14-74) improved to 61 ± 21 (range 31-94) after 1 year (p = 0.04). Of the 30 AT procedures 10 patients (11 AT) were not satisfied after the initial HVIGI procedure. Of these, 8 patients (9 AT) needed additional HVIGI and two patients needed surgery. Of the remaining 18 patients (19 AT), 10 patients had more than a 10-point improvement in the VISA-A score after 1 year. CONCLUSIONS: In this retrospective case-study, only 10 patients (33%) did benefit of a single HVIGI treatment at 12-months and an 11-point significant improvement was seen at on the VISA-A score.

An Updated Description of More Than 5,000 Procedures from the Danish Hip Arthroscopy Registry.

BACKGROUND: The Danish Hip Arthroscopy Registry (DHAR) started as a web-based prospective registry in 2012. The aim of this study was to evaluate and report epidemiologic and perioperative data from 5,333 procedures and to describe the development of the DHAR. METHODS: The DHAR collects data from patients prospectively at the time of inclusion (preoperative evaluation) and at 1, 2, 5, and 10 years after arthroscopic hip surgery. The surgeon reports surgical data at the time of surgery. The DHAR uses a number of validated patient-related outcome measures (PROMs): the Copenhagen Hip and Groin Outcome Score (HAGOS), Hip Sports Activity Scale (HSAS), EuroQol 5 Dimensions (EQ-5D), and a numeric rating scale for pain (NRS pain). RESULTS: Of the 5,333 procedures, 58% were done in female patients. The mean age was 37.7 years. The mean duration of surgery was 78 minutes, and the mean duration of traction was 45 minutes. Combined cam and pincer resections were performed in 64% of the patients, and labral repair was done in 82%. The most common type of acetabular chondral damage found was Beck grade-2 lesions (43%). Grade-3 and 4 changes were seen in 29% and 11% of the patients, respectively. The 1-year HAGOS PROM values increased to a median of 69.1 (interquartile range [IQR], 68.2 to 70.0) for pain, 64.9 (IQR, 64.0 to 65.7) for symptoms, 71.3 (IQR, 70.3 to 72.3) for activities of daily living, 56.2 (IQR, 55.1 to 57.4) for sports, 42.2 (IQR, 40.8 to 43.5) for physical activity, and 50.7 (IQR, 49.7 to 51.8) for quality of life, and the 1-year EQ-5D increased to a median of 0.75 (IQR, 0.74 to 0.76). Five-year outcomes for 383 patients showed a significant increase in all PROMs (p < 0.05). CONCLUSIONS: Patients referred for hip arthroscopy reported pain, functional disabilities, and a decreased activity level and quality of life prior to surgery but demonstrated improvements after 1 and 5 years. The problems with developing and maintaining a large clinical registry are described. The development of a national clinical registry for hip arthroscopy was considered successful. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

A simple rehabilitation regime improves functional outcome in patients with patellafemoral pain after 12 month.

PURPOSE: The purpose of the present study was to investigate the effects of a 3-month multimodal intervention including patient education, a simple hip exercise program, footwear adjustment, and foot orthoses to reduce symptoms in patients with patellafemoral pain (PFP). METHODS: Patients were diagnosed based on a physical examination, patient symptoms and ruled out intra-articular knee pathologies by MRI. Patients were educated on PFP and participated in a 3-month exercise program; shoes with solid heel-caps were recommended, and custom made orthoses with arch support were recommended to patients with foot pronation. The Anterior Knee Pain Scale (AKPS) and the pain numeric rating scale (NRS) were used to evaluate the outcomes of the intervention and collected at baseline, 3 and 12-months follow-ups. RESULTS: Sixty-five patients (age 18 years (9-32)) were included in a consecutive prospective cohort. The AKPS score improved from 71 ± 24 to 89 ± 9 (p < 0.01) at 12 months follow up. The NRS-rest and NRS-activity improved from 3 to 0 (p < 0.01) and 7 to 3 (p < 0.01) respectively. 78% of the patients clinically improved (i.e., demonstrated a > 10-point improvement (minimal clinically important difference (MCID))) considering the AKPS; and 76% and 73% clinically improved (i.e., demonstrated (MCID) a ≥ 2-point improvement) in their NRS-rest and NRS-activity, respectively. No patients experienced a decrease in their AKPS score or an increase in their NRS-rest and NRS-activity scores at 12-months. CONCLUSION: A 3-month PFP multimodal treatment strategy focusing on patient education, footwear adjustment, orthoses, and simple hip muscle exercises significantly improved functional outcomes and reduced pain at a 12 month follow-up.

[Younger patients with hip joint pain].

This review summarises the present knowledge of diagnosing and treating hip joint pain. The results of joint preserving surgery are good in symptomatic patients with hip dysplasia, acetabular retroversion or impingement (cam or pincer) without signs of osteoarthritis. Confirmation of intraarticular pathology as the cause of symptoms is established clinically, and the pathology can in many cases be visualised by a standing, standardised radiograph of the pelvis, which is the basis for admission to the relevant orthopaedic department. We present an algorithm for this. Dysplasia and retroversion can be treated by periacetabular osteotomy and impingement by arthroscopic procedures.

Quadriceps tendon grafts does not cause patients to have inferior subjective outcome after anterior cruciate ligament (ACL) reconstruction than do hamstring grafts: a 2-year prospective randomised controlled trial.

OBJECTIVE: We performed a randomised controlled trial (RCT) in patients undergoing ACL reconstruction (ACLR) using either quadriceps tendon graft (QT) or semitendinosus/gracilis hamstring (STG) graft. We compared subjective outcome (primary outcome) and knee stability, donor site morbidity and function (secondary outcomes). METHODS: From 2013 to 2015, we included 99 adults with isolated ACL injuries in the RCT. Fifty patients were randomised to QT grafts and 49 to STG grafts and followed for 2 years. Patient evaluated outcomes were performed by subjective International Knee Documentation Committee, Knee Injury and Osteoarthritis Outcome Score, Kujala and Tegner activity scores. Knee laxity was measured with a KT-1000 arthrometer. Donor site morbidity was evaluated by the 'donor site-related functional problems following ACLR score'. One-leg hop test tested limp strength symmetry. RESULTS: At 2-year follow-up, there was no difference between the two graft groups regarding subjective patient outcome, knee stability and reoperations. Also, at 2 years, donor site symptoms were present in 27% of patients in the QT group and 50% of patients in the STG group. The donor site morbidity score was 14 and 22 for the QT and STG, respectively. Hop test demonstrated lower limp symmetry for QT graft than STG graft of 91% and 97% respectively. CONCLUSION: QT graft for ACLR did not result in inferior subjective outcome compared with STG graft. However, QT graft was associated with lower donor site morbidity than STG grafts but resulted in more quadriceps muscle strength deficiency than hamstring grafts. Both graft types had similar knee stability outcome. TRIAL REGISTRATION NUMBER: NCT02173483.

Demographic and Radiographic Factors Associated With Intra-articular Hip Cartilage Injury: A Cross-sectional Study of 1511 Hip Arthroscopy Procedures.

BACKGROUND: Moderate to severe (grade 3-4) hip joint cartilage injury seems to impair function in patients with femoroacetabular impingement syndrome. PURPOSE: To investigate whether demographic and radiographic factors were associated with moderate to severe hip joint cartilage injury. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Patients were identified in the Danish Hip Arthroscopy Registry. The outcome variables were acetabular cartilage injury (modified Beck grade 0-2 vs 3-4) and femoral head cartilage injury (International Cartilage Repair Society grade 0-2 vs 3-4). Logistic regressions assessed the association with the following: age (<30 vs 30-50 years); sex; sport activity level (Hip Sports Activity Scale); alpha angle (AA) assessed as normal (AA <55°), cam (55°≤ AA <78°), or severe cam (AA ≥78°); lateral center-edge angle (LCEA) assessed as normal (25°≤ LCEA ≤ 39°), pincer (LCEA >39°), or borderline dysplasia (LCEA <25°); joint space width (JSW) assessed as normal (JSW >4.0 mm), mild reduction (3.1 mm ≤ JSW ≤ 4.0 mm), or severe reduction (2.1 mm ≤ JSW ≤ 3.0 mm). RESULTS: A total of 1511 patients were included (mean ± SD age: 34.9 ± 9.8 years). Male sex (odds ratio [OR], 4.42), higher age (OR, 1.70), increased AA (cam: OR, 2.23; severe cam: OR, 4.82), and reduced JSW (mild: OR, 2.04; severe: OR, 3.19) were associated (P < .05) with Beck grade 3-4. Higher age (OR, 1.92), increased Hip Sports Activity Scale (OR, 1.13), borderline dysplasia (OR, 3.08), and reduced JSW (mild: OR, 2.63; severe: OR, 3.04) were associated (P < .05) with International Cartilage Repair Society grade 3-4. CONCLUSION: Several demographic and radiographic factors were associated with moderate to severe hip joint cartilage injury. Most notably, increased cam severity and borderline dysplasia substantially increased the risk of grade 3-4 acetabular and femoral head cartilage injury, respectively, indicating that specific deformity may drive specific cartilage injury patterns in the hip joint.

No Difference in Outcome Between Femoral Soft-Tissue and Screw Graft Fixation for Reconstruction of the Medial Patellofemoral Ligament: A Randomized Controlled Trial.

PURPOSE: The aim of the present randomized controlled trial was to compare 2 different medial patellofemoral ligament reconstruction (MPFL-R) techniques that utilize different femoral fixation principles, which could affect subjective clinical outcomes and surgical morbidity. METHODS: Sixty patients were randomly assigned to 2 MPFL-R techniques: bone or soft-tissue fixation of the graft at the femoral condyle. Patients had operations performed between 2010 and 2015 at a single center. Indication for surgery was 2 or more patellar dislocations. When the bone fixation technique was used, the gracilis tendon was fixed with the use of an interference screw. When the soft-tissue fixation technique was used, the gracilis tendon was looped around the adductor magnus tendon. Both techniques used patella-graft fixation with drill holes in the medial patellar edge. Clinical outcomes were evaluated by means of Kujala, knee injury and osteoarthritis outcome, and pain scores before the operation and at 1- and 2-year follow-up examinations. Surgical morbidity was evaluated by pain on palpation along the reconstruction site. RESULTS: Kujala scores were 88 and 89 for bone and soft-tissue fixation groups, respectively, with no difference between groups (P = .73). No significant differences in knee injury osteoarthritis outcome or pain scores were found. Analysis of surgical morbidity, defined as femoral-based tenderness overlying the fixation site, demonstrated that 13% and 12% of patients had significant tenderness at the reconstruction site after bone and soft-tissue MPFL-R, respectively. No patellar re-dislocations were observed in either group. CONCLUSIONS: MPFL-R with soft-tissue graft fixation at the femoral condyles resulted in findings for subjective clinical outcome, patellar stability, and pain level similar to those associated with MPFL-R with bone fixation. Surgical morbidity was also similar between patients who had soft-tissue and those who had bone fixation MPFL-R. Soft-tissue femoral graft fixation does not result in inferior clinical outcomes compared with screw fixation, and it can be used safely for MPFL-R.

Danish Hip Arthroscopy Registry: predictors of outcome in patients with femoroacetabular impingement (FAI).

PURPOSE: Predictors of outcome after femoroacetabular impingement (FAI) surgery are not well-documented. This study presents data from the Danish Hip Arthroscopy Registry (DHAR) for such analyses. The purpose of this study was to identify predictors of poor outcome after FAI surgery in a Danish FAI population. The primary hypothesis was that older patients, patients with severe cartilage damage and female patients might have inferior outcome results compared with younger patients, patients with minor cartilage damage and male patients. METHODS: Radiological and surgical data as well as patient-reported outcome measures (PROM) from FAI patients in DHAR between January 2012 and May 2015 were collected. PROMs consisting of Copenhagen Hip and Groin Outcome Score (HAGOS), quality of life (EQ-5D), Hip Sports Activity Scale (HSAS) and Numeric Rating Scale (NRS) pain scores were assessed. The patients were divided into three age groups (< 25, 25-39 and ≥ 40 years). Cartilage injuries were classified according to International Cartilage Repair Society (ICRS) (femoral side) and modified Becks (acetabular side) classifications. A non-parametric statistic method was used to analyze the differences between the preoperative and postoperative PROM values. RESULTS: Data from 2054 FAI procedures in DHAR was collected. 53% of the procedures were done in female patients. All HAGOS sub-scales, EQ-5D, HSAS and NRS pain (rest and walk) demonstrated significant improvements in all age groups at follow-up. Comparison between age groups demonstrated poorer outcomes in both older age groups when compared with the < 25 years age group at 1- and 2-year follow-ups. Higher degrees of femoral and acetabular cartilage injury did have a negative influence on outcome at follow-up. Comparison between genders demonstrated lower preoperative outcomes in females and lower outcome score (HSAS) 1 and 2 years after FAI surgery. CONCLUSIONS: Age above 25 and major cartilage injury might negatively affect the outcome of surgery, however, gender could not be identified as a negative predictor of clinical outcome after FAI surgery, but might negatively affect sports participation in females. LEVEL OF EVIDENCE: III, prospective cohort study.

The interface between periacetabular osteotomy, hip arthroscopy and total hip arthroplasty in the young adult hip.

Hip pain is highly prevalent in both the younger and the elderly population. In older patients, pain arising from osteoarthritis (OA) is most frequent, whereas in younger patients, non-degenerative diseases are more often the cause of pain. The pain may be caused by hip dysplasia and femoroacetabular impingement (FAI).Abnormal mechanics of the hip are hypothesized by some authors to cause up to 80% of OA in the hip. Therefore, correction of these abnormalities is of obvious importance when treating young patients with hip pain.Hip dysplasia can be diagnosed by measuring a CE angle < 25° on a plain standing radiograph of the pelvis.Dysplastic or retroverted acetabulum with significant symptoms should receive a periacetabular osteotomy (PAO).FAI with significant symptoms should be treated by adequate resection and, if necessary, labrum surgery.If risk factors for poor outcome of joint-preserving surgery are present (age > 45 to 50 years, presence of OA, joint space < 3 mm or reduced range of motion), the patient should be offered a total hip arthroplasty (THA) instead of PAO.THA can be performed following PAO with outcomes similar to a primary THA.Hip arthroscopy is indicated in FAI (cam and pincer) and/or for labral tears. Cite this article: EFORT Open Rev 2018;3:408-417. DOI: 10.1302/2058-5241.3.170042.

Multicentre study on capsular closure versus non-capsular closure during hip arthroscopy in Danish patients with femoroacetabular impingement (FAI): protocol for a randomised controlled trial.

INTRODUCTION: Hip arthroscopy has become a standard procedure in the treatment of hip joint pain not related to osteoarthritis or dysplasia in the young and active patient. There has been increasing focus on the contribution of the hip capsule to function and on stability following hip arthroscopy. It has been suggested that capsular closure after hip arthroscopy may prevent microinstability and macroinstability of the hip joint and reduce revision rate. However, it remains unknown whether capsular closure should be performed as a standard procedure when performing hip arthroscopies, especially in patients without additional risk factors for instability such as hypermobility or dysplasia of the hip. We hypothesised that capsular closure will lead to a superior outcome in hip arthroscopy for femoroacetabular impingement syndrome (FAIS) compared with non-capsular closure. METHODS AND ANALYSIS: In this randomised controlled, multicentre trial, 200 patients scheduled for hip arthroscopy for FAIS will be cluster randomised into one of two groups (group I: hip arthroscopy without capsular closure, group II: hip arthroscopy combined with capsular closure). Inclusion criteria are: age between 18 years and 50 years and FAIS according to the Warwick agreement. Exclusion criteria are: previous hip surgery in either hip, previous conditions of Legg-Calvé-Perthes or slipped capital femoral epiphysis, malignant disease, recent hip or pelvic fractures, arthritis, Ehlers-Danlos or Marfan disease, recent (within 6 weeks) application of intra-articular corticosteroids, language problems of any kind, and radiological signs of osteoarthritis, acetabular dysplasia or acetabular retroversion. Surgery will be performed in Denmark at four centres by four surgeons, all performing an interportal capsulotomy and closure with at least two absorbable sutures. Patients in both groups, who are blinded for the intervention, will receive the same standardised rehabilitation programme. As primary outcome scores, HAGOS (sport) will be used with HAGOS (symptoms, pain, function in daily living, participation in physical activities and hip and/or groin-related quality of life), Hip Sports Activity Scale, short validated version of the International Hip Outcome Tool, EQ-5D, Visual Analogue Scale for pain, complications and reoperation rate as secondary outcome tools. Using HAGOS (sport) as primary outcome parameter the power analysis required a minimum of 84 individuals per group. Together with a clinical examination performed by the patient's surgeon 1 year after surgery, patient reported outcome measures will be completed preoperatively, as well as at 3 months, 1 year, 2 years and 5 years postoperatively. In addition, adverse effects will be recorded. ETHICS AND DISSEMINATION: The study is approved by the Central Denmark Region Committee on Biomedical research ethics. The results of this study will be presented at national and international congresses and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT03158454; Pre-results.