Editorial Commentary: There Are Limited Changes In Gait Biomechanics After Femoroacetabular Impingement Surgery: A Call for More Comprehensive Functional Testing.

Background: Spinopelvic parameters, including pelvic tilt (PT), sacral slope (SS), and pelvic incidence, have been developed to characterize the relationship between lumbar spine and hip motion, but a paucity of literature is available characterizing differences in spinopelvic parameters among patients with femoroacetabular impingement syndrome (FAIS) versus patients without FAIS, as well as the effect of these parameters on outcomes of arthroscopic treatment of FAIS. Purpose: To (1) identify differences in spinopelvic parameters between patients with FAIS versus controls without FAIS; (2) identify associations between spinopelvic parameters and preoperative patient-reported outcomes (PROs); and (3) identify differences in PROs between patients with stiff spines (standing-sitting ΔSS ≤10°) versus those without. Study Design: Cohort study; Level of evidence, 2. Methods: The study enrolled patients ≥18 years of age who underwent primary hip arthroscopy for treatment of FAIS with cam, pincer, or mixed (cam and pincer) morphology. Participants underwent preoperative standing-sitting imaging with a low-dose 3-dimensional radiography system and were matched on age and body mass index (BMI) to controls without FAIS who also underwent EOS imaging. Spinopelvic parameters measured on EOS films were compared between the FAIS and control groups. Patients with FAIS completed the modified Harris Hip Score (mHHS) and Non-Arthritic Hip Score (NAHS) before surgery and at 1-year follow-up. Outcome scores were compared between patients with stiff spines versus those without. Associations between spinopelvic parameters and baseline outcome scores were assessed with Pearson correlations. Continuous variables were compared with Student t test and/or Mann-Whitney U test, and categorical variables were compared with Fisher exact test. Results: A total of 50 patients with FAIS (26 men; 24 women; mean age, 36.1 ± 10.7 years; mean BMI, 25.6 ± 4.2) were matched to 30 controls without FAIS (13 men; 17 women; mean age, 36.6 ± 9.5 years; mean BMI, 26.7 ± 3.6). Age, sex, and BMI were not significantly different between the FAIS and control groups (P > .05). Standing PT was not significantly different between stiff and non-stiff cohorts (P = .73), but sitting PT in the FAIS group was more than double that of the control group (36.5° vs 15.0°; P < .001). Incidence of stiff spine was significantly higher in the FAIS group (62.0% vs 3.3%; P < .001). Among FAIS patients, those with stiff spines had a significantly higher prevalence of cam impingement, whereas those with non–stiff spines had a higher prevalence of mixed impingement (P = .04). No significant differences were seen in preoperative mHHS or NAHS scores or pre- to postoperative improvement in scores between FAIS patients with stiff spines versus those without (P > .05), but a greater sitting SS was found to be positively correlated with a higher baseline mHHS (r = 0.36; P = .02). Conclusion: Patients with FAIS were more likely to have a stiff spine (standing-sitting ΔSS ≤10°) compared with control participants without FAIS. FAIS patients with stiff spines were more likely to have isolated cam morphology than patient without stiff spines. Although sitting SS was positively correlated with baseline mHHS, no significant differences were seen in 1-year postoperative outcomes between FAIS patients with versus without stiff spine.

Introduction Patients with intra-articular hip pathology see an average of three clinicians prior to diagnosis. A 2015 study by Rankin et al. suggested femoroacetabular impingement (FAI) syndrome was described in 40% of hip joint pathology. FAI syndrome occurs when irregularities in femoral and acetabular anatomy create abnormal contact forces across the joint, leading to labral and chondral damage. These anatomical irregularities are categorised into three morphologies: cam (an aspherical femur head resulting in superior acetabulum impingement), pincer (over-coverage of the femoral head by the acetabulum) and mixed. This case highlights this tricky diagnosis in a young and active patient. Case description A 28-year-old fit and active man presented with a three-year history of gradually worsening atraumatic right hip pain. He described a constant ache in the anterior aspect of the right hip, occasionally referring to the groin and right knee. He experienced significant morning stiffness of the right hip, lasting approximately 30 minutes. His symptoms were aggravated by prolonged walking and running. He denied lower limb paraesthesia, numbness, incontinence, rashes and was otherwise systemically well. He reported no past medical history, family history and was on no regular medications. He practises yoga a few times a week but has had to stop his recreational running due to his pain. Examination revealed no deformity of the lumbar or sacral spine. There was no swelling, redness, or tenderness on palpation. Range of motion of the right hip was significantly limited, with flexion to 90 degrees, abduction to 30 degrees, external rotation to 25 degrees and internal rotation to 0 degrees (in flexion). Trendelenburg's test was negative. Functional assessment revealed poor pelvic control on right side during single-leg squat and lunge. The modified Thomas test showed tense hip flexors bilaterally, worse on right. FADIR test was strongly positive on the right but all other special tests for the hip, including Laslett’s cluster of sacroiliac provocation tests, were negative. After significant discussion regarding radiation exposure, he was referred for an X-ray pelvis and right hip. This revealed significant widening of both femoral heads and necks, with joint space narrowing with articular sclerosis. This was worse on the right side with femoral osteophyte formation. Appearances were in keeping with bilateral cam morphology, with associated changes in the right hip joint indicative of femoral acetabular impingement. He has since been referred to physiotherapy and orthopaedics to explore management options, whilst encouraged to continue his yoga practise. Discussion A 2014 cross-sectional study by Clohisy et al. reported the average age of FAI syndrome to be 28 years and the Frank et al. 2015 systematic review revealed cam morphology was more prevalent in men and three times more likely in athletes than the general population. This patient exemplifies these demographics. His history and examination contained features typical of FAI syndrome: his description of pain on movement, positive FADIR test, restricted internal rotation restriction, and poor single leg balance. However, classical symptoms of clicking, catching, and locking were not reported. This corroborates with the 2016 Warwick Consensus statement that FAI syndrome diagnosis does not rely on a single symptom or clinical sign. The statement confirms that X-Ray is the initial imaging modality of choice, which includes AP, lateral and Dunn views as was requested in this case. Treatment options to allow our patient to return to running include conservative management with patient education, anti-inflammatory agents, and physiotherapy. The Hoit et al. 2019 systematic review showed that physiotherapy, targeting core stability, proprioception, and correction of hip destabilising imbalances, provided significant improvements in functional outcomes compared to controls without. This supports a trial of physiotherapy before further interventions and commends the patient’s participation in yoga. Evidence for intra-articular injections of corticosteroids, hyaluronic acid or platelet-rich plasma is currently limited and are unlikely to be considered for this patient. Surgery aims to arthroscopically correct anatomical abnormalities. Two RCTs, UK FASHIoN and FAIT, compared surgery and physiotherapy interventions in FAI syndrome patients and showed statistically significant improvement in symptoms and functional outcomes with surgery, particularly in those with cam morphology like our patient. Orthopaedics may offer this option to our patient due to his lack of negative prognostic indicators related to surgery with the exception of his extended duration of symptoms. Key learning points Hip and pelvic pain with morning stiffness in a young adult male is not always inflammatory in nature, and femoroacetabular impingement (FAI) syndrome should be considered in these patients. FAI is associated with pain on movement, positive FADIR test, restricted internal rotation, and poor single leg balance, but clicking/locking is not always described. In primary care where access to MR imaging may be limited, AP, lateral and Dunn view X-rays of the pelvis and femoral neck can help clinch the diagnosis if there is uncertainty Cam morphology of the hip, revealed by X-ray, is more prevalent in men and athletes and has better treatment outcomes with surgery compared to physiotherapy. Referral to a specialist musculoskeletal service is recommended to discuss management options of physiotherapy, intra-articular injections and surgery alongside patient education and anti-inflammatory medication. Discussing the clinical experience of peers evaluating, diagnosing, treating, and monitoring long-term outcomes of similar patients will contribute to the understanding of the rapidly evolving evidence base.

Global Acetabular Retroversion Is Not Associated With Differences in Outcomes After Primary Hip Arthroscopy Among Patients With Femoroacetabular Impingement Syndrome: A Matched Cohort Study With Minimum 5-Year Follow-Up

Regarding “Operative Versus Nonoperative Treatment of Femoroacetabular Impingement Syndrome: A Meta-analysis of Short-Term Outcomes”

Prevalence and Consistency in Surgical Outcome Reporting for Femoroacetabular Impingement Syndrome: A Scoping Review

Author Reply to “Regarding ‘Routine Interportal Capsular Repair Does Not Lead to Superior Clinical Outcome Following Arthroscopic Femoroacetabular Impingement Correction With Labral Repair’”

ObjectiveTo determine the effectiveness of hip arthroscopy combined with endoscopic iliotibial band (ITB) release in patients with both femoroacetabular impingement (FAI) syndrome and external snapping hip (ESH).MethodsRetrospectively review the preoperative and minimum of 2‐year follow‐up data of patients with both FAI syndrome and ESH who underwent endoscopic ITB release during hip arthroscopy (FAI + ESH group) from January 2014 to December 2018. The same number of age‐ and gender‐matched FAI syndrome patients without ESH undergoing hip arthroscopy were enrolled in the control group (FAI group). Patient‐reported outcomes (PROs) including international Hip Outcome Tool (iHOT‐33), modified Harris Hip Score (mHHS), visual analog scale for pain (VAS‐pain), and abductive force of affected hip at 3 month and 2 years postoperatively were comparatively analyzed. The VAS‐satisfaction score of two groups at 2 years postoperatively were also analyzed.ResultsThe prevalence of ESH in FAI syndrome patients undergoing hip arthroscopy in our institution was 5.5% (39 of 715 hips), including nine males (10 hips) and 29 females (29 hips). The mean age at the time of surgery was 32.1 ± 6.9 years (range, 22–48 years). According to inclusion and exclusion criteria, 23 patients were enrolled in FAI + ITB group. Twenty‐three age‐ and sex‐matched FAI syndrome patients were enrolled in FAI group. At 24 months postoperatively, no patient still suffered ESH symptoms and painful palpation at lateral region in FAI + ITB group. The iHOT‐33, mHHS, and VAS‐pain score of patients in FAI + ESH group were significantly severer than patients in FAI group preoperatively (41.6 ± 7.5 vs 48.8 ± 7.2, 54.8 ± 7.2 vs 59.2 ± 6.9, 5.5 ± 0.9 vs 4.7 ± 1.0; P < 0.05), while there was no significant difference in these scores between the patients in FAI + ESH group and FAI group at 3‐month and 24‐month follow‐up (73.6 ± 8.5 vs 76.1 ± 6.9, 85.3 ± 7.8 vs 84.2 ± 6.6, 0.8 ± 0.9 vs 0.6 ± 0.9; P > 0.05). At 3 months after surgery, the abductive force of operated hip was significantly smaller than that in FAI group (82.4 ± 12.4 N vs 91.9 ± 16.1 N, P < 0.05), whereas there was no significant difference at 24 months after surgery (101.6 ± 14.9 N vs 106.5 ± 13.7 N, P > 0.05). The VAS‐satisfaction scores of patients in the two groups were at a similarly high level (90.5 ± 6.8 vs 88.8 ± 7.3, P > 0.05). There was no complication and no arthroscopic revision in either group until 2‐year follow‐up.ConclusionAlthough abductive force recovery of the hip was delayed, hip arthroscopy combined with endoscopic ITB release addressed hip snapping in patients with both FAI syndrome and ESH, and could get similar functional improvement, pain relief, recovery speed, as well as patient satisfaction compared with the pure hip arthroscopy in FAI syndrome patients without ESH.

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. 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. 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%). 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 III.

Dynamic Assessment of Femoroacetabular Impingement Syndrome Hips

ObjectiveHip preservation surgery has expanded to include treatment of hip pathology in elderly patients. Most data on efficacy of arthroscopy treatment in patients with femoroacetabular impingement syndrome (FAIS) has been generated from Western populations, while studies in the older Asian FAIS population are lacking. Here, we report efficacy of hip arthroscopy for treatment of Asian patients aged 50 years and above.MethodsWe retrospectively reviewed data from 775 hips that were treated arthroscopically for FAIS between 2016 and 2019. Patients with a history of hip surgery, contralateral surgery during the follow‐up period, lateral center‐edge angle (LCEA) <25°, Tӧnnis grade ≥2, and incomplete records were excluded. Patient‐reported outcomes (PROs), such as modified Harris Hip Score (mHHS), Hip Outcome Score‐Activities of Daily Living (HOS‐ADL), International Hip Outcome Tool 12‐component form (iHOT‐12), and Visual Analog Scale (VAS) were compared pre‐ and post‐operation. We also recorded radiographic measures, intraoperative findings, procedures, complications, and subsequent surgical revisions. Finally, we correlated demographics with PRO improvement among the study group.ResultsA total of 57 hips met the inclusion and exclusion requirements and were therefore included in the final analysis. After the follow‐up period (3.3 years), most patients exhibited significantly higher PROs than preoperative values, HOS‐ADL (65.0–81.7), iHOT‐12 (44.3–69.1), mHHS (58.9–81.7), and VAS (5.8–2.2; all p < 0.001). Shorter symptom duration was significantly correlated with improved HOS‐ADL (p = 0.015), and mHHS score (p = 0.022). The overall rate of complications and rate of revisions were 5.3% and 7.0%, respectively, and none of the patients required total hip arthroplasty (THA).ConclusionsArthroscopic surgery confers significant clinical outcomes in most FAIS patients in the Asian population who are aged 50 years and above. These benefits are accompanied by either a low revision rate or conversion to THA, while shorter symptom duration is positively correlated with improved HOS‐ADL and mHHS scores.

The Relationship Between the Location of Uptake on Positron Emission Tomography/Computed Tomography and the Impingement Point by Computer Simulation in Femoroacetabular Impingement Syndrome With Cam Morphology

Recent advancements in surgical technology and techniques have improved functional results for operative treatment of femoroacetabular impingement syndrome (FAIS). Few studies have comprehensively evaluated the literature regarding return to sport criteria, timing, level, and rates. The purpose of this study was to review recent studies regarding return to play after surgical correction of FAIS. We will specifically evaluate the level of return to play and look to compare pre- and postoperative competition levels when available. We will also analyze timing of return to play from injury to surgery. Additionally, we will elucidate any sport-specific criteria that may determine readiness for return. Athletes with FAIS treated non-operatively have a low rate of return to sport and are often functionally limited in their level of performance. Surgical management of FAIS includes hip arthroscopy as well as open techniques. Current literature suggests a high rate of return to sport after contemporary surgery for FAIS at 87-93% overall. Rate of return to the same level of competition following surgery for FAIS is 55-83% in pooled studies. Limited evidence is available comparing postoperative rehabilitation protocols and timing of return among different sports. Operative treatment of FAIS results in high rates of return to sport and functional performance. The results of this study may help educate patients preoperatively in regard to the likelihood of functional return to sport and sport-specific considerations. Further research evaluating rehabilitation protocols and return criteria may better elucidate timing intervals for patients to maximize function while limiting complications.

Surgical dislocation of the hip is rarely undertaken. The potential danger to the vascularity of the femoral head has been emphasised, but there is little information as to how this danger can be avoided. We describe a technique for operative dislocation of the hip, based on detailed anatomical studies of the blood supply. It combines aspects of approaches which have been reported previously and consists of an anterior dislocation through a posterior approach with a 'trochanteric flip' osteotomy. The external rotator muscles are not divided and the medial femoral circumflex artery is protected by the intact obturator externus. We report our experience using this approach in 213 hips over a period of seven years and include 19 patients who underwent simultaneous intertrochanteric osteotomy. The perfusion of the femoral head was verified intraoperatively and, to date, none has subsequently developed avascular necrosis. There is little morbidity associated with the technique and it allows the treatment of a variety of conditions, which may not respond well to other methods including arthroscopy. Surgical dislocation gives new insight into the pathogenesis of some hip disorders and the possibility of preserving the hip with techniques such as transplantation of cartilage.

The purpose of this study was to (i) assess whether squat and gait biomechanical measures improve in patients with femoroacetabular impingement syndrome (FAIS) 6 months after surgery compared to pre-operative measures and (ii) compare biomechanical properties to controls without FAIS. In this prospective study, biomechanical data during a double leg squat task and gait for 15 FAIS patients and 9 controls were collected using three-dimensional motion analysis. Data were collected in the FAIS group at two-time points, pre-operatively and 6-month post-operatively following arthroscopic hip surgery, and at a single time point for the healthy controls. Independent sample’s t-test were used to compare the FAIS group to the controls, and paired samples t-test were used to determine within-group differences before and after hip arthroscopy in the FAIS group. The results indicated that there were significant within-group increases for sagittal plane moment rate during the double leg squat task (P = 0.009) between the pre-operative and post-operative time points for the FAIS group. Between-group differences showed that FAIS patients pre-operatively exhibit slower squat velocities during the descent (P = 0.005) and ascent phase (P = 0.012) of a double leg squat when compared healthy controls. Reduced hip external rotation moments during gait (P = 0.02) were also found between FAIS patients pre-operatively and controls. In conclusion, alterations in hip biomechanics are present before surgery for FAIS when compared to healthy controls, and joint mechanics change 6 months after surgery. However, the biomechanical differences during a double leg squat and gait were minimal.

Background Femoroacetabular impingement (FAI) syndrome may affect gait kinematics differently between males and females. Objectives To investigate whether individuals with FAI syndrome have different hip and pelvic motion during gait, at their preferred speed and a prescribed speed, compared to individuals of the same sex without pain. Methods Twenty-one participants (11 males and 10 females) with FAI syndrome and 41 participants (19 males and 22 females) without hip pain were included in this case-control laboratory study. There were no differences between the 2 groups in age, body mass index, and activity score. Kinematic data for all participants were collected while walking at a preferred speed and at 1.25 m/s. For sex and walking speed, linear regression analyses were used to examine the effect of group and the interaction of group by limb. Results At both speeds, males with FAI syndrome walked with more than 6° less peak hip extension (P≤.018), 5° greater anterior pelvic tilt (P≤.020), and 5° less posterior pelvic tilt (P≤.018) compared to males without hip pain. Females with FAI syndrome walked with 2° less hip extension (P≤.012) and at least 3° more hip adduction (P<.001) in the more painful hip than in the less painful hip at both speeds. Conclusion Males and females with FAI syndrome have different gait alterations when compared to a same-sex comparison group. In males, differences were between groups. In females with FAI syndrome, differences were between the more painful and the less painful limb. J Orthop Sports Phys Ther 2018;48(8):649-658. Epub 22 May 2018. doi:10.2519/jospt.2018.7913.