Pincer Impingement Research Articles

FEMOROACETABULAR IMPINGEMENT INSURANCE COVERAGE TRENDS IN RECENT YEARS: A COHORT BASED ANALYSIS

Background: The diagnostic criteria for surgical indication of femoroacetabular impingement (FAI) remain controversial. With a growing body of literature investigating the quality of these criteria, little is known about the direction that these have had on changes of third-party policies. The purpose of this study was to measure how these changes in policy would affect the exclusion of a cohort of previously identified FAI patients who were treated operatively. Methods: Four insurance companies’ coverage policies with specific criteria for the surgical treatment of FAI were applied to this population at two time points, 2012 and 2018, to determine whether these third-party payer criteria for FAI surgery were met. The insurance criteria were assessed in a prospective multicenter cohort of 712 patients undergoing primary FAI surgery. The policies listed various combinations of age, symptom duration, positive impingement test, radiographic osteoarthritis, radiographic sign of CAM and/or pincer impingement, and physical exam findings. Results: The cohort of 712 hips included 324 men [45.5%] and 388 females [54.5] with a mean age of 28.7 years. Overall, insurance criteria were not met in: Insurance #1 old 30.1%, new 25.7%; Insurance #2 old and new 17.8%, Insurance #3 old 21.9%, new 21.1%; and Insurance #4 old 17.8%, new 14.9%-20.6%. In 2012, the average percent exclusion of the four companies was 21.9%, this number decreased slightly to 20.6% overall in 2018. The most likely reason to be excluded was found to be failure to meet imaging criteria. The second most likely failed characteristic was a negative impingement test (65 patients excluded). Several insurance companies continue to utilize Outerbridge criteria for cartilage lesions which cannot be assessed preoperatively. Discussion and Conclusion: The diagnosis of FAI and its surgical indications have no definitive set criteria. Our study shows that with a six-year span of growing literature and updated policies, nearly 1 in 5 patients deemed to need surgical intervention by experienced hip preservation surgeons would still be denied coverage. There is a need for continued improvement of consensus regarding the diagnosis of FAI and appropriate indications for surgical intervention based on the available literature.

Bernese periacetabular osteotomy through adouble approach : Simplification of asurgical technique.

Reorientation of the acetabulum to normalize load transfer or avert femoroacetabular pincer impingement to prevent osteoarthritis of the hip. Persisting acetabular dysplasia after closure of growth plates or acetabular malrotation. High dislocation of hip, secondary acetabulum, increased misalignment on functional X‑ray, high-grade mobility restriction. Relative: degenerative changes, advanced age. Bernese periacetabular osteotomy through two incisions; all bone cuts are carried out under direct vision. The osteotomies are equivalent to the classic Ganz method. In a slightly tilted forward lateral decubitus position, aposterior incision is applied for the ischium osteotomy and the caudal portion of the retroacetabular osteotomy. The pubis and ilium osteotomies are performed in a supine position through an anterior approach with subsequent reorientation and screw fixation. The rectus femoris is not dissected unless joint exposure is required. Partial weight bearing with 20 kg for the first 6weeks postoperatively, followed by stepwise transition to full loads after radiological control. In total, 34patients (37hips) were followed up for 20.4 ± 10.3 months. Tönnis osteoarthritis scale levels remained constant. The center-edge angle of Wiberg increased from 13.2 ± 7.5° to 26.5 ± 6.7°, the Tönnis angle (acetabular index) changed from 13.8 ± 6.5° to 3.4 ± 4.4°. At follow-up, the Merle d'Aubigné and Postel score was 16.5 ± 1.4; the modified Harris hip score 87.6 ± 13.9 and the International hip outcome tool (iHOT)-12 78.2 ± 20.3 points. The mean surgical time was 213 ± 29 min. Severe complications were not observed.

Prevalence of Radiographic Morphology of Femoroacetabular Impingement in Indian Population: A Multicenter Study

BackgroundFemoroacetabular impingement (FAI) is an overlooked entity in India, as primary osteoarthritis of hip is uncommon in Indian population. The purpose of this study is to find out the prevalence of radiographic morphology of FAI in young asymptomatic population in India. MethodsThis is a multicenter, cross-sectional study. Radiographs of 500 young asymptomatic volunteers were taken from 10 centers across India. Suboptimal imaging lead to exclusion of 48 radiographs. Crossover sign, ischial spine sign, and posterior wall sign were included in “acetabular rotation abnormalities (R),” lateral center-edge angle and acetabular index were included in “acetabular overcoverage abnormalities (O)” while pistol grip deformity and alpha angle in “femoral abnormalities (F).” Furthermore, all the hips were divided into 4 types: normal hips (N); type I hip with single abnormality (R/O/F); type II with combination of any 2 (RO/RF/OF), and type III with all 3 abnormalities. ResultsSixty-eight percent of 904 hips had at least 1 type of abnormality with 47.5% hips having signs of pincer impingement, 7.9% with signs of cam impingement, and 10.8% with mixed signs. Type I.R hips (32%) were the most common hips followed by type I.O hips (18%) and type I.F (8%). Males had higher percentage of abnormalities (1.5 times) compared to females. Interobserver reliability was 0.55 to 0.81 for all the parameters. Power of study was 0.98. ConclusionRadiographic morphology of FAI exists with high prevalence in young asymptomatic Indian population similar to other ethnicities except for low prevalence of cam morphology. Long-term follow-up of this cohort will reveal the natural history of these morphologies.

Impingement-free Hip Range of Motion in Asymptomatic Young Adult Females

Background: Femoroacetabular impingement is a recognized cause of early hip osteoarthritis. This is attributed to either a cam impingement caused by a non-spherical head or a pincer impingement caused by excessive acetabular coverage. Although many surgical techniques aim to improve hip range of motion, little normative data exist on dynamic impingement-free hip range of motion (ROM) in asymptomatic individuals. Hip ultrasound can effectively …

Radiographic and Clinical Outcomes of Adolescents With Acetabular Retroversion Treated Arthroscopically.

Retroversion of the acetabulum is a cause of pincer impingement. Symptomatic retroversion has traditionally been treated with anteverting periacetabular osteotomy (PAO). However, arthroscopic rim trimming can also treat pincer impingement associated with acetabular retroversion. The purpose of this study was to report the outcomes and radiographic findings in a series of adolescent patients with symptomatic acetabular retroversion treated arthroscopically. Data were prospectively gathered at a single institution using an established hip preservation registry. Patients below 18 years with a retroverted acetabulum that underwent primary hip arthroscopy with 2-year follow-up were included. Acetabular retroversion was defined by 3 radiographic criteria: the presence of crossover, ischial spine sign, and posterior wall sign. Radiographic measurements of the lateral center-edge angle, anterior center-edge angle, alpha angle, and crossover percentage were reported preoperatively and postoperatively. Patient-reported outcome (PROs) measures included the modified Harris Hip Score, the non-Arthritic Hip Score, Hip Outcome Score Sports Subscale, visual analog scale, and patient satisfaction, recorded at 3 months, 1 year, and 2 years, postoperatively. In addition, International Hip Outcome Tool scores were gathered at 2 years. Between April 2008 and July 2014, there were 43 patients (48 hips) treated with hip arthroscopy who met the inclusion criteria. The average age was 16.1 years (range, 13.9 to 17.9 y) and there were 38 females and 10 males. The average follow-up was 50.4 months, with a minimum of 2 years. Statistically significant improvements in all PROs were found at 2 years postoperatively. There were 9 hips with lateral center-edge angle ≤25 degrees; the PROs of this group was not different than patients with normal coverage. Three patients underwent arthroscopic revision. No patient subsequently underwent anteverting PAO during the study period. There were no reported complications. Femoroacetabular impingement caused by acetabular retroversion treated with hip arthroscopy demonstrates good outcomes at 2 years with a low complication rate. Symptomatic adolescents may be safely and successfully treated arthroscopically, potentially avoiding anteverting PAO. Level of evidence 4-case series.

Acetabular labral tear description and measures of pincer and cam-type femoroacetabular impingement and interobserver variability on 3 T MR arthrograms

PurposeTo evaluate the inter-rater agreement for description of labral tears and measures of femoroacetabular impingement (FAI) on 3 T hip MR arthrography. Materials and methods53 hip MR arthrograms were reviewed by three musculoskeletal radiologists. Labral tears were described (Czerny classification) with extents recorded. Cam- and pincer-type FAI measures were performed. Intraclass correlation (ICC) and kappa statistic (κ) assessed inter-observer agreement. ResultsThere was fair agreement for labral tear description (κ = 0.25–0.39) and for alpha angles (ICC = 0.54), and fair to excellent agreement for other measures of FAI (ICC = 0.51–0.90). ConclusionThere is moderate inter-observer variability reporting labral tears and measures of FAI.

Clinical outcomes following arthroscopic treatment of femoro-acetabular impingement using a minimal traction approach and an initial capsulotomy. Minimum two year follow-up.

Although the arthroscopic management of femoroacetabular impingement (FAI) is increasing, severe complications have been reported due to traction. We developed an arthroscopic technique based on an initial capsulotomy and a minimal traction approach. The main purpose of this study was to analyze the clinical outcomes of FAI treatment using this technique after at least two years of follow-up. Forty-seven consecutive patients underwent surgery for FAI. There were two initial portals: a proximal anterolateral portal and a distal anterior instrumental portal. An anterior working space was created and a T-shaped incision was made in the anterior capsule to relieve joint distraction. Short traction (less than 20 mn) made it possible to approach the central compartment. Acetabuloplasty was performed in the presence of pincer impingement. Traction was then released. A head-neck femoral osteochondroplasty was performed in case of bump impingement. All patients underwent a mean 3.3 ± one years of follow-up based on two self-administered questionnaires: the Harris hip score and the QOL Oxford score. None of the patients were lost to follow-up. There were three complications: two ossifications and one case of injury to the femoral cutaneous nerve with good clinical outcomes at the final follow-up. Five patients (10%) underwent surgical revision after a mean 1.4years of follow-up: three total hip arthroplasties, one peri-acetabular osteotomy, and one repeat arthroscopic hip debridement. The Harris score increased significantly from 60 ± 10 to 86 ± 15 (p < 0.0001) and the Oxford score improved from 34 ± 15 to 50 ± 11. Only 25% of patients had a "forgotten hip" at the final follow-up. Our clinical results were comparable to previously reported outcomes with other surgical techniques for the management of FAI. However, it should also be noted that despite these good clinical outcomes, the percentage of patients with a "forgotten hip" is low, and patients should be informed of this.

Labral cuff refixation in the hip: rationale and operative technique for preserving the chondrolabral interface for labral repair: a case series.

ABSTRACTArthroscopic labral ‘takedown’ and refixation is utilized to permit adequate visualization and resection of the acetabular rim deformity, in patients with pincer or mixed femoroacetabular impingement. Deficiencies exist in present techniques, which include disruption of vital anatomical support and vascular structures to the labrum and chondrolabral junction, drill or anchor articular penetration risk, bunching, elevation and instability of the labrum. A new operative technique is described which preserves the important chondrolabral interface, accurately restoring the ‘flap seal’ of the acetabular labrum while minimizing vascular disruption and reducing the risk of drill and anchor penetration. A prospective series of 123 consecutive cases of pincer or mixed femoroacetabular impingement, treated with arthroscopic labral cuff refixation and preservation of the chondrolabral interface, is reported; operative technique and 2-year outcomes are presented.

Association Between Labral Ossification and Sacroiliac Joint Disease: A Link to an Autoimmune Etiology

SI joint abnormalities are more prevalent in patients with FAI associated with labral ossification (LO) than in a matched control group without LO; suggesting there may be an autoimmune link to LO. Labral ossification has been identified as an adult acquired form of pincer impingement. The etiology of this process is unknown. There is a predilection for middle-age females, although it is likely that various subgroups exist with different etiologies. An autoimmune process is one possibility, and sacroiliac joint disease is associated with autoimmune disorders, most specifically ankylosing spondylitis. Therefore, a search was made to evaluate whether there was a correlation between labral ossification and SI joint disease. A group of 52 patients (56 hips) with labral ossification has been previously reported. In order to determine whether there was a correlation between SI joint disease and labral ossification, the CT scans of this group with labral ossification were reviewed assessing the SI joint, and compared to an age, gender, and FAI type-matched control cohort. The SI joints were graded according to the modified NY criteria. The evaluator was blinded as to whether the scan was from a patient in the study or control group to eliminate potential bias in interpreting the status of the SI joint. The influence of independent variables of gender and age (those over and under the average age) was evaluated. 28 patients (29 hips) previously identified as having labral ossification had a CT scan available for evaluation of the ipsilateral SI joint and were included as the labral ossification cohort (LO). There were 17 females and 12 males, with average 45 years, six Pincer type FAI and 23 combined Cam and Pincer FAI. The control group (n=29) was comprised of 17 females and 12 males with average 45 years, and FAI subtype 5 Pincer and 24 combined. Grade 3 SI joint abnormalities were significantly more prevalent in the LO cohort (28%) compared to the controls (7%) (p=.037), and grade 0-1 changes (relatively normal SI joints) were significantly less common in patients with labral ossification (38%) than controls (72%) (p=.008). Sub-analysis of the patients based on age demonstrated that 35% of the LO cohort<45yrs had ipsilateral Grade 3 SI joint abnormalities, while none of the control patients <45yrs had grade 3 changes (p=.041). Analysis based on gender revealed that 42% of the males with labral ossification had Grade 3 changes, compared to 8% of the male controls (p=.155). Eighteen percent of the LO cohort females had Grade 3 changes compared to 6% of the female controls (p=.601). Patients with acquired FAI due to labral ossification are more likely to have SI joint pathology than patients with FAI not involving labral ossification. These differences were greatest among males and also among patients less than 45 years of age. The etiology of labral ossification has been unknown. SI joint disease is associated with autoimmune disorders such as ankylosing spondylitis; and the increased prevalence of SI disease in these patients with labral ossification suggests a connection with an autoimmune etiology. The variable prevalence among different subgroups also suggests that these patients with labral ossification may represent a heterogeneous population with differing etiologies among the subgroups. This study is an important step in better discerning the cause of labral ossification; which will prove to be essential in determining how best to treat patients with this disorder. The surface is just being scratched.

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.

CORR Insights®: Complete Circumferential Osseous Extension in the Acetabular Rim Occurs Regardless of Acetabular Coverage.

CORR Insights®: Complete Circumferential Osseous Extension in the Acetabular Rim Occurs Regardless of Acetabular Coverage.

Femoroacetabular impingement causes osteoarthritis of the hip by migration and micro-instability of the femoral head

Femoroacetabular impingement is the condition whereby parts of the proximal femur mechanically collide with the acetabular rim leading to adjacent and contrecoup acetabular damage. Evidence is growing that at least for cam impingement, and perhaps less so for pincer impingement, there is a relation to the development of osteoarthritis.It has been demonstrated that surgery for impingement can improve function and decrease pain. Intuitively, it would then make sense that surgical intervention would prevent further degeneration. However, available literature to date cannot assure that it does. Therefore, the impingement itself seems not a sufficient cause to consistently cause osteoarthritis.For many years we have observed a phenomenon whereby the femoral head ‘migrates’ anteriorly and superiorly in the acetabulum in patients with cam impingement. The same, but less constant, can be observed in pincer impingement, where the head may migrate posteriorly and medially. Migration of the femoral head is known in the literature and seen as caused by, or as part of, osteoarthritis of the hip. We suggest that the migration is caused by the impingement, and that the femoral head wanders into the impingement-related area with cartilage damage. In cam impingement this may be anterolateral, in pincer impingement posteromedial. The effect must be a huge increase in compression forces, especially in cam impingement. The migration may even lead to, or be a sign of, micro-instability of the femoral head in the acetabulum, which may produce an increase in shear forces. We therefore hypothesise that impingement may lead to osteoarthritis by means of migration and the possible existence of micro-instability of the femoral head. Detecting and quantifying these phenomena seem of uttermost importance and may add a new dimension to conservative hip surgery.

Complete Circumferential Osseous Extension in the Acetabular Rim Occurs Regardless of Acetabular Coverage

Complete circumferential osseous extension in the acetabular rim has been reported to occur in the deep hip with pincer impingement. However, this phenomenon occasionally is observed in dysplastic hips without pincer impingement, and the degree to which this finding might or might not be associated with hip pain, and how often it occurs bilaterally among patients, are not well characterized. (1) To determine the proportion of patients with complete circumferential osseous extension in the acetabular rim using three-dimensional (3-D) CT in patients with and without hip pain who had CT scans obtained for various reasons. (2) To elucidate how often this complete circumferential osseous extension occurred bilaterally among those patients. (3) To investigate the relationship between the proportions of patients with complete circumferential osseous extension observed on CT scans among three different acetabular coverage groups: dysplasia, normal, and overcoverage. (4) To determine how often the finding of hip pain was associated with complete circumferential osseous extension. Between September 2011 to July 2016, we evaluated 3788 patients with pelvic complaints such as hip, groin, thigh, buttock, or sacroiliac joint pain. We obtained consent from 26% (992 of 3788) of them, and obtained 3-D CT scans as part of that evaluation. For the current retrospective study, we excluded patients younger than 20 years or 80 years or older (181 patients), patients who had previous hip surgery (185 patients), patients with severe osteoarthritis with Tönnis Grades 2 or 3 (301 patients), and patients who could not have an accurate lateral center-edge (LCE) angle measured owing to poor-quality radiographs (24 patients), leaving 301 patients (602 hips) for this analysis. In this study population, patients reported pain in 131 hips (22%), defined as all types of hip pain except for trauma, including activity pain, pain with sports, pain on motion, and impingement pain; the others did not report hip pain. The mean age of the patients was 56 ± 16 years, and the mean LCE angle was 26° ± 8° (range, -9° to 47°). We first determined the proportion of patients with complete circumferential osseous extension in the acetabular rim using 3-D CT for those with and without hip pain who had CT obtained for various reasons. We next elucidated how often this complete circumferential osseous extension occurred bilaterally among the patients, and finally we investigated the relationship between the proportion of patients with complete circumferential osseous extension observed on CT scans among the three groups: dysplasia (defined as LCE angles of 22° or smaller), normal, and overcoverage (defined as LCE angles of 34° or larger) groups. We finally determined how often the finding was associated with hip pain attributable to complete circumferential osseous extension. The proportion of patients with complete circumferential osseous extension was 6% (18 of 301 patients). Eighty-nine percent (16 of 18) of the patients had bilateral complete circumferential osseous extension. There were no differences in the proportions of patients with complete circumferential osseous extension among the three groups: 5.3% (odds ratio [OR], 1.02; 95% CI, 0.45-2.31; p = 0.97), 5.3%, and 7.4% (OR, 0.70; 95% CI, 0.28-1.73; p = 0.44) in the dysplasia, normal, and overcoverage groups, respectively, with the numbers available. Eighteen percent (six of 34) of the hips with complete circumferential osseous extension had pain. Complete circumferential osseous extension in the acetabular rim is relatively uncommon. When it occurs, it usually is bilateral, it occurs regardless of acetabular coverage, and it is associated with pain in a minority of patients. Level III, prognostic study.

Arthroscopic Hip Surgery in the Elite Athlete: Comparison of Female and Male Competitive Athletes

Background: Few studies have published the results of hip arthroscopic surgery in elite athletes and none studying a significant number of elite female athletes. Purpose: (1) To compare sex-based differences in the ability to return to prior competitive sports activity after arthroscopic hip surgery. (2) To compare sex-based differences in the type of sports activity, diagnosis, and treatment in athletes requiring hip arthroscopic surgery. Study Design: Cohort study; Level of evidence, 3. Methods: Data on all elite athletes who underwent primary hip arthroscopic surgery between 2007 and 2014 were included. Athletes with a Hip Sports Activity Scale (HSAS) score of over 6 were identified. The preoperative evaluation included a medical history, history of sports activity, and hip-specific outcome scores (Modified Harris Hip Score [MHHS] and International Hip Outcome Tool–33 [iHOT-33]). Surgical findings and time to return to competitive sports were documented. Results: Of 547 hips in 484 consecutive patients, 98 elite athletes (49 female) with a mean follow-up of 18.9 ± 12.8 months were identified. Eighty patients desired to return to their original competitive activity: 38 were female (42 hips; mean age, 21.5 ± 3.9 years), and 42 were male (54 hips; mean age, 20.5 ± 1.9 years). Moreover, 84.2% of female athletes and 83.3% of male athletes were able to return to the same level of competition at a mean of 8.3 ± 3.0 and 8.8 ± 2.9 months, respectively. Significant improvements between preoperative and postoperative outcome scores were seen in both groups (all P < .0001). Female athletes had more pincer femoroacetabular impingement (FAI) (P = .0004) and instability (P < .0001). Conversely, male athletes were diagnosed more commonly with combined FAI (P < .0001), demonstrated greater acetabular cartilage damage (P = .0004), and required microfracture more often (P = .0014). Female athletes competed more frequently in flexibility (4/38, 11%; P = .047) and endurance (9/38, 24%) sports, while male athletes participated in cutting (14/42, 33%), contact (6/42, 14%), and asymmetric (13/42, 31%) sports more often. Patients who returned to their baseline level of competition had a shorter duration of symptoms preoperatively (P = .001). Microfracture status did not affect the ability to return to sports. Conclusion: Female and male elite athletes were able to return to competitive sports activity at the same or higher level after hip arthroscopic surgery at a similar rate, although their performance in sports was not measured. Distinct differences in the diagnosis, treatment, and type of sports activity between sexes were seen. The duration of symptoms negatively correlated with outcomes. Microfracture did not affect the return to sports.

Are we failing in hip protrusio treatment?

In a recent article published in Clinical Orthopaedics and Related Research, Hanke and colleagues (1) reported the longest follow up trial available in the literature about the survivorship of hips with protrusio acetabuli treated with circumferential acetabular trimming through surgical hip dislocation. This group of patients was compared with a group of pincer type femoroacetabular impingement (FAI) without severe overcoverage. Severe pincer impingement (protrusio acetabuli) is an established cause of hip pain and osteoarthritis (OA): the acetabular roof is negatively tilted and typically deep with relative global overcoverage of the femoral head that overlaps the ilioischial line medially and protrudes in the true pelvis; therefore the size of the lunate surface is increased and leads to a pincer type FAI. Safe surgical hip dislocation described by Ganz et al .(2) with circumferential rim trimming and labral refixation or reconstruction is the current gold standard treatment for this acetabular morphology. Unfortunately this study underlines a poor expectation of survival in half of the hips with protrusio acetabuli compared with the control group according to Kaplan and Meier method’s endpoints (1): conversion to total hip arthroplasty (THA), radiographic progression of osteoarthritis, and Merle d’Aubigne-Postel score less than 15 points.

Endoscopic repair of hip abductor tears: outcomes with two-year follow-up.

Abductor lesions are increasingly recognized as a source of recalcitrant laterally based hip pain and dysfunction. There is a growing body of evidence that many of these may be amenable to endoscopic repair. To report the demographic data and outcomes of endoscopic hip abductor repair. Twelve patients underwent endoscopic abductor repair with 2-year follow-up. These patients were prospectively assessed with modified Harris hip and iHOT scores. The indications for surgery were clinical and MRI findings of symptomatic abductor tears that had failed conservative treatment. All patients underwent concomitant or prior arthroscopy of the joint. Repair was performed with suture anchors using an iliotibial band-sparing endoscopic technique; followed by a 4-month structured rehabilitation protocol. Follow-up was obtained on all patients at 24 months. The average age was 56 years (range 39–77 years). These were all females. All demonstrated improved modified Harris hip scores, averaging 43 points (preop 42; postop 85). Eleven of 12 (92%) demonstrated improved iHOT scores, averaging 52 points (preop 21; postop 73). Ten patients had accompanying intra-articular pathology including 10 labral tears, 7 chondral lesions, 6 synovitis and 1 pincer impingement. There were no complications, and none underwent further surgery. Abductor tears of the hip can be clinically relevant and respond well to endoscopic repair. This tends to be a disorder of older females who present with severe disability, reflected by low preoperative modified Harris hip scores, and demonstrate significant, although incomplete, improvement.

CORR Insights®: What MRI Findings Predict Failure 10 Years After Surgery for Femoroacetabular Impingement?

CORR Insights®: What MRI Findings Predict Failure 10 Years After Surgery for Femoroacetabular Impingement?

Surgical hip dislocation for treatment of cam femoroacetabular impingement.

Background:Cam femoroacetabular impingement is caused by a misshapen femoral head with a reduced head neck offset, commonly in the anterolateral quadrant. Friction in flexion, adduction and internal rotation causes limitation of the hip movements and pain progressively leading to labral and chondral damage and osteoarthritis. Surgical hip dislocation described by Ganz permits full exposure of the hip without damaging its blood supply. An osteochondroplasty removes the bump at the femoral head neck junction to recreate the offset for impingement free movement.Materials and Methods:Sixteen patients underwent surgery with surgical hip dislocation for the treatment of cam femoroacetabular impingement by open osteochondroplasty over last 6 years. Eight patients suffered from sequelae of avascular necrosis (AVN). Three had a painful dysplastic hip. Two had sequelae of Perthes disease. Three had combined cam and pincer impingement caused by retroversion of acetabulum. All patients were operated by the trochanteric flip osteotomy with attachments of gluteus medius and vastus lateralis, dissection was between the piriformis and gluteus minimus preserving the external rotators. Z-shaped capsular incision and dislocation of the hip was done in external rotation. Three cases also had subtrochanteric osteotomy. Two cases of AVN also had an intraarticular femoral head reshaping osteotomy.Results:Goals of treatment were achieved in all patients. No AVN was detected after a 6 month followup. There were no trochanteric nonunions. Hip range of motion improved in all and Harris hip score improved significantly in 15 of 16 cases. Mean alpha angle reduced from 86.13° (range 66°–108°) to 46.35° (range 39°–58°).Conclusion:Cam femoroacetabular Impingement causing pain and limitation of hip movements was treated by open osteochondroplasty after surgical hip dislocation. This reduced pain, improved hip motion and gave good to excellent results in the short term.

Arthroscopic treatment of femoroacetabular pincer impingement.

Arthroscopic resection of the bony overhang of the acetabular rim with concurrent treatment of associated chondrolabral injury in order to improve femoroacetabular clearance, provide symptomatic relief and in theory, delay the onset or progression of osteoarthritis of the hip. Clinical and radiographic evidence of femoroacetabular pincer or combined impingement, with minimal to moderate degenerative change in the hip joint. Advanced osteoarthritis of the hip joint. Femoroacetabular pincer impingement arising from generalised overcoverage, e.g. coxa profunda. Acetabular retroversion in a dysplastic hip. Arthroscopy of the peripheral compartment, using a proximal anterolateral viewing portal and anterior and anterolateral working portals. Labral assessment, release from its capsular reflection, limited bony resection of the acetabular rim or labral ossification. Central compartment arthroscopy under traction, using the anterolateral and anterior portals alternately as viewing and working portals, and a distal anterolateral accessory portal. The labrum is detached to expose the bony overhang in the acetabular rim, which is resected with a burr. The labrum is refixed if it is of sufficient quality and debrided or resected otherwise. Labral resection: partial weight bearing, with pain-controlled progression to full weight bearing over 1-2 weeks. Labral refixation: Protected (20 kg) weight bearing for the first 4 weeks. Continuous passive motion therapy and the use of a stationary bicycle for 4 weeks, and early proprioceptive training are part of the rehabilitation regimen. Arthroscopic treatment of femoroacetabular impingement has been shown to provide symptomatic relief, improve hip outcome scores and is postulated to delay progression of osteoarthritis. Better clinical outcomes can be obtained with labral refixation if the labrum is of sufficient quality.

Description and mid-term results of the 'over the top' technique for the treatment of the pincer deformity in femoroacetabular impingement.

Pincer impingement is often treated by surgical labral separation from the acetabular rim and rim reduction. A more recent technique the so-called ‘over the top’ involves reduction of the bony acetabular rim without separation of the labrum. Our purpose is to report mid-term results of the ‘over the top’ technique. Between January 2006 and January 2013 a consecutive series of patients with femoroacetabular impingement (FAI) diagnosis, treated with the ‘over the top’ technique were included, using the lateral approach. The Western Ontario and MacMaster (WOMAC) scores were evaluated. Fifty patients (20 males and 30 females) from the Hip and Knee Joint Reconstructive and hip arthroscopy division were included. The average age was 30.5 years old and the average follow-up was 48 months (range 70–90). Preoperative WOMAC average was 42. Post-operative WOMAC was 81.3 (P = 0.01). One patient required an arthroscopic revision due to adherences, but had a full recovery after the revision surgery. The ‘over the top’ technique is an excellent choice for the treatment of the pincer deformity in the FAI avoiding the injury of the chondrolabral union.