Treatment Of Femoroacetabular Impingement Research Articles

Hip arthroscopy for femoroacetabular impingement is associated with significant improvement in early patient reported outcomes: analysis of 4963 cases from the UK non-arthroplasty registry (NAHR) dataset

PurposeResults from recent randomised controlled trials demonstrate the superiority of surgery over physiotherapy in patients with femoroacetabular impingement (FAI) of the hip in early follow-up. However, there is paucity of evidence regarding which factors influence outcomes of FAI surgery, particularly notable is the lack of information on the effect of impingement subtype (cam or pincer or mixed) on patient reported outcomes measures (PROMs). This study aims to evaluate the early outcomes of hip arthroscopy for FAI, and their determinants.MethodsThis is a retrospective analysis of prospectively collected data from the UK Non-Arthroplasty Hip Registry (NAHR) of patients undergoing arthroscopic intervention for FAI between 2012 and 2019. The null hypothesis was that there is no difference in PROMs, based on morphological subtype of FAI treated or patient characteristics, at each follow-up timepoint. The outcome measures used for the study were the iHOT-12 score and the EQ5D Index and VAS 6- and 12-month follow-up.ResultsA cohort of 4963 patients who underwent arthroscopic treatment of FAI were identified on the NAHR database. For all FAI pathology groups, there was significant improvement from pre-operative PROMs when compared to those at 6 and 12 months. Overall, two-thirds of patients achieved the minimum clinically important difference (MCID), and almost half achieved substantial clinical benefit (SCB) for iHOT-12 by 12 months. Pre-operatively, and at 12-month follow-up, iHOT-12 scores were significantly poorer in the pincer group compared to the cam and mixed pathology groups (p < 0.01). Multivariable analysis revealed PROMS improvement in the setting of a higher-grade cartilage lesion.ConclusionThis registry study demonstrates that hip arthroscopy is an effective surgical treatment for patients with symptomatic FAI and results in a statistically significant improvement in PROMs which are maintained through 12 months follow-up.Level of evidenceIII.

Training surgical skills on hip arthroscopy by simulation: a survey on surgeon’s perspectives

PurposeThe purpose of this study is to investigate the importance of general and specific surgical skills for hip arthroscopy from the perspective of surgeons in China. Concurrently, we intend to identify the preferred type of simulation that would facilitate competency of surgical trainees in performing arthroscopy and reinforce their preparation for carrying out the actual surgical procedure.MethodsAn online survey comprising 42 questions was developed by experts in hip arthroscopy and sent to 3 online communities whose members are arthroscopic surgeons in China. The responses collected were based on a 5-point Likert scale, with an open-ended comment section. Data were analyzed using one-way AVOVA and post hoc Tukey’s test.ResultsA total of 159 valid responses from 66 junior specialist surgeons, 68 consultant surgeons, and 25 senior consultant surgeons (from 130 institutions in 27 out of 34 provincial administrative districts in China) were collected. Cognitive ability was identified as the overall most important attribute for hip arthroscopic trainees to possess, while skills relevant to the treatment of femoroacetabular impingement (FAI) were considered as the most important specific skills by the surgeons surveyed. In addition, simulation using cadaveric specimens was considered the most favorable method for surgeons to practice their surgical skills.ConclusionIn designing a training program for hip arthroscopy, it is essential to incorporate features that evaluate cognitive skills. It would be helpful for trainees to specifically practice skills that are often used in the treatment of some very common diseases of the hip joint, such as FAI. Using high-fidelity physical models for simulation to train skills of hip arthroscopy could be an ideal alternative and effective way to overcome problems arising from the lack of accessibility to cadaveric specimens.

Poster 197: Understanding the Biological Pathway of Progression of Hip OA Disease through Transcriptome Analysis

Poster 197: Understanding the Biological Pathway of Progression of Hip OA Disease through Transcriptome Analysis

Paper 22: PREDICTORS OF RE-OPERATION IN ADOLESENTS UNDERGOING HIP PRESERVATION SURGERY FOR FEMOROACETABULAR IMPINGEMENT

Objectives:Femoroacetabular Impingement(FAI) is a condition caused by repetitive motion of abnormal hip osseous anatomy that contributes to labral and chondral injury. An understanding of radiographic parameters associated with successful primary surgery has not been well established. The primary objective was to determine pre-operative radiographic parameters that predict reoperation for FAI and, secondarily, correlate radiographic measures and outcomes in these patients.Methods:A prospectively-collected institutional registry of adolescent patients (age <19 y.o.) who underwent surgery for FAI (arthroscopic/open) was reviewed. Standing AP pelvis X-rays were analyzed for alpha, lateral center edge(LCEA), Tönnis, and Sharp’s angles, and femoro-epiphyseal acetabular(FEAR) index. Patient-reported outcomes(PROs) [modified Harris Hip Score (mHHS), Hip Disability and Osteoarthritis Outcome Score(HOOS)] were analyzed. Mann-Whitney-U test was used to compare the radiographic measures of re-operation to non-reoperation patients and those who achieved MCID to those who did not. Radiographic indication of risk for re-operation was evaluated with receiver operating characteristic(ROC) analysis. Spearman’s correlation was calculated between radiographic measurements and PROs at 2-years post-op.Results:Eighty-seven patients underwent primary surgery (56 surgical dislocations vs 31 scopes) for FAI. The average age at time of primary operation was 16.27 years(73.6%Female). 10 underwent re-operation (11.5%) at an average of 20.6 months from primary surgery. No differences were found in demographics, activity, surgery type, labral disease, or alpha angle for re-operation vs. non-reoperation. The LCEA, FEAR Index, Sharps, and Tönnis angle were significantly different (p<0.05) (Table 1).ROC analysis indicated that LCEA<21 and FEAR index>-8.8 were predictors for increased risk of reoperation. Patients with LCEA<21°, 46% underwent a reoperation compared to those with LCEA>21° (6%). Patients with FEAR index<-8.8, 32% underwent a reoperation compared to patients>-8.8 (5%). Patients who achieved MCID (61.9%) had lower BMI, worse pre-operative PROs, and better post-operative PROs at 2-years. Alpha, Tönnis, and Sharp’s angles were positively correlated with 2+ year PROs, while LCEA was negatively correlated(p<0.05).Conclusions:In patients undergoing treatment for FAI, a reoperation was associated with radiographic signs of hip dysplasia, indicating that patients with a shallower acetabulum are at risk for a repeat operation. Surgeons can utilize these parameters to help in surgical decision making, better predict outcomes and to counsel patients the need for potential subsequent surgery.UPLOAD-https://planion-client-files.s3.amazonaws.com/AOSSM/blobs/10177e80-b6a8-458e-b216-840ad950f2a6/1/Tables.docx

Poster 192: Femoroacetabular Impingement in Elite Skiers and Snowboarders: Return to Sport and Outcomes after Hip Arthroscopy

Objectives:Hip arthroscopy has been shown to be an effective treatment for femoroacetabular impingement (FAI) in high level athletes; however, limited outcomes and return to play data exists for hip arthroscopy in skiers and snowboarders. The purpose of this study is to determine the return to sport rate of elite skiers and snowboarders who have undergone hip arthroscopic surgery for FAI and to assess hip-related outcomes at a minimum 2-years follow up.Methods:Elite skiers and snowboarders who underwent hip arthroscopy for the treatment of FAI between 2005 and 2018 were identified through a retrospective review of prospectively collected data. Data was obtained from www.fis-ski.org, www.usskiandsnowboard.org, www.xgames.com, and www.wikipedia.org, including information on each players’ career length, participation on a national team, and time between surgery and first competition post-surgery. Patient reported outcome measures (PROs) were prospectively collected pre-operatively and at minimum 2 years post-operatively.Results:Twenty-six elite skiers and snowboarders (34 hips) were included. The mean age at surgery was 24.5 ± 6.7 years (range 18.7-46.8). A total of 85% returned to elite level competition at 8.9 months (range 2.9-23.7) with an average career length of 3.6 ± 2.7 years. Four athletes required revision arthroscopy with adhesions being the most frequent indication. At mean follow-up of 7.7 ± 3.2 years, significant improvement in PROs was demonstrated for HOS-ADL (76 ± 20 to 95 ±6), HOS-SSS (63 ± 28 to 92 ± 14), mHHS (70 ± 19 to 89 ± 12), and SF12-PCS (45 ± 11 to 54 ± 8). Patient acceptable symptom state (PASS) was achieved in 88% for HOS-ADL, 88% for HOS-SSS, and 83% for mHHS. Median patient satisfaction was 10.Conclusions:The return to competition rate in elite skiers and snowboarders after hip arthroscopy for FAI is 85% at an average of 8.9 months with a career length of 3.6 years after surgery. Significant improvement in PROs was demonstrated for HOS-ADL, HOS-SSS, mHHS, and SF12-PCS with median patient satisfaction score of 10. These findings support hip arthroscopy as an effective procedure for the treatment of FAI in elite skiers and snowboards with symptomatic activity limiting hip pain allowing them to return to their previously level of competition at a high rate.

Paper 44: Does femoral osteoplasty enhance clinical outcomes and survivorship of FAI surgery at long-term follow-up beyond fifteen years?

Objectives:Cam-type femoroacetabular impingement (FAI) is now well-established as a risk factor for intra-articular damage (labrum and articular cartilage) and secondary osteoarthritis. Long-term studies of FAI surgery are critical in understanding clinical outcomes, refining surgical treatments and predicting osteoarthritis progression. Nevertheless, studies beyond 15 years are uncommon. Although femoral osteoplasty is now common practice in treating cam FAI, long-term data supportive of this procedure and its ability to alter the natural history of FAI are not available. The purpose of this study was to analyze the long-term clinical outcomes and survivorship of symptomatic FAI treatment by arthroscopic correction of labral pathology alone or in combination with femoral osteoplasty (structural FAI correction).Methods:A retrospective comparative study was performed on two consecutive, longitudinal cohorts of patients with isolated cam-type FAI that underwent surgical treatment of labral pathology either with femoral osteoplasty (HSLO group, 23 hips) or without femoral osteoplasty (HS group, 17 hips). These cohorts were captured immediately prior to and after implementation of femoral osteoplasty into our practice and have been previously reported on at mean 2-year followup. The current study investigated clinical outcomes and survivorship at minimum 15-year followup. Patients with pincer or combined cam-pincer morphologies were excluded. Clinical outcomes were measured with the modified Harris hip score (mHHS). Kaplan-Meier survival was assessed for THA-free and reoperation-free survivorship.Results:The HSLO group included 23 hips followed for a mean of 16.0 ±0.6 years, and the HS group 17 hips followed for 19.7 ±1.2. The HSLO group had a significantly higher final mHHS (82.7 vs. 64.7, p=0.002) and mHHS improvement (18.4 vs. 6.1, p=0.02) compared to the HS group. The rate of THA conversion (22% vs. 59%, P=0.02) and overall reoperation (22% vs. 70%, P=0.003) were significantly lower in the HSLO group. THA conversion occurred at a mean of 5.8 ±2.5 years postoperatively in the HSLO group, and 7.1 ±4.0 years in the HS group. The HSLO group had significantly greater 15-year THA-free survivorship (78% vs 41%, p=0.02) and reoperation-free survivorship (78% vs. 29%, p=0.003) by Kaplan-Meier analysis.Conclusions:This study demonstrates better long-term clinical outcomes and survivorship with combined arthroscopy and femoral osteoplasty compared to arthroscopy alone. These long-term data strongly support the current practice of femoral osteoplasty in patients with cam FAI morphologies and suggest that this treatment alters the natural history of FAI.Figure 1.Comparative Survival

Two-Tiered Resection of Cam Lesions in Hip Femoroacetabular Impingement: Optimizing Femoral Head Sphericity

Hip arthroscopy is one of the most rapidly growing fields in orthopaedic surgery. One of the most frequent pathologies treated with hip arthroscopy remains femoroacetabular impingement, which is addressed by labral repair and femoral osteoplasty. The most commonly cited reason for failure of arthroscopic treatment of femoroacetabular impingement is under-resection of the cam lesion. Surgeons frequently use evaluations of preoperative images, intraoperative fluoroscopy, and dynamic range of motion to ensure adequate resection. In this article, we describe a reproducible and standardized technique to assist in appropriate resection. This is achieved by a 2-tiered resection technique: Tier 1 aims to set the depth of resection and restore the head-neck offset. Tier 2 then matches the depth of the resection set by tier 1 and allows for retention of appropriate transition of the proximal convexity to the distal concavity seen in more ideally shaped femoral heads. With this technique, we offer a tool to avoid under-resection in the area of maximal conflict while simultaneously minimizing the risk of proximal over-resection and thus compromising the fluid seal dynamics of the joint in deeper flexion angles.

Acetabular Cartilage Lesions Predict Inferior Mid-Term Outcomes for Arthroscopic Labral Repair and Treatment of Femoroacetabular Impingement Syndrome

To analyze the effect of acetabular chondrosis at a minimum of 2 years following hip arthroscopy in patients undergoing labral repair and treatment of femoroacetabular impingement. From 2014 to 2017, patients undergoing arthroscopic labral repair were prospectively enrolled in a multicenter hip arthroscopy registry. The registry was retrospectively queried for primary labral repair patients with complete 2-year outcomes and a Tonnis grade of less than 2. Patients were grouped according to severity of articular cartilage damage noted intraoperatively using the Beck classification system: none, low-grade (Grade 1 or 2), or high-grade (Grade 3 or 4) damage. A Kruskal-Wallis test and post hoc Dunn's test with Holm correction compared 2-year postoperative outcome scores of the iHOT-12 scale between groups. The proportion of patients in each cohort who achieved the clinically significant thresholds of the minimum clinically important difference (MCID), patient-acceptable symptom scale, and substantial clinical benefit (SCB) were analyzed. Multivariate logistic regression models identified predictors of achieving clinical thresholds while controlling for demographic variation. 422 patients met inclusion criteria, from which 347 completed 2-year outcomes. All groups experienced improvement in iHOT-12 scores from baseline to follow-up (P < .001). iHOT-12 scores at follow-up were inferior for Low-Grade Damage and High-Grade Damage Groups relative to the No Damage Group (P= .04; P= .03). When accounting for age, body mass index, gender, and preoperative iHOT-12 scores in logistic regression models, the presence of high-grade lesions was a negative predictor for achieving SCB (OR [95% CI], 0.54 [0.29-0.96]) and low-grade lesions a negative predictor for achieving MCID (0.50 [0.27-0.92]. Among patients with high-grade lesions, there was no significant difference in 2-year iHOT-12 scores between those undergoing chondroplasty (n= 50) and those undergoing microfracture (n= 14) (P= .14). Acetabular cartilage damage portends inferior patient-reported outcomes 2 years after primary labral repair and treatment of femoroacetabular impingement. The presence of cartilage lesions was a negative predictor of individual achievement of several clinical thresholds. III, Retrospective comparative cohort.

Healing of joint capsule after hip arthroscopy using interportal capsulotomy and capsular closure influences clinical outcomes

BackgroundHip arthroscopy for treatment of femoroacetabular impingement (FAI) has developed rapidly and has been shown to significantly decrease pain and improve hip function. However, the relationship between hip capsule characteristics and healing after arthroscopic surgery and changes in patient-reported outcomes scores (PROs) for postoperative pain, function, and symptoms is still uncertain.MethodsWe retrospectively evaluated consecutive patients who were diagnosed with FAI and underwent hip arthroscopy for treatment in our hospital between May 2018 and November 2020. All patients had preoperative MRI and postoperative MRI at least 6 months after arthroscopy. Hip capsular thickness was measured at the proximal, middle, and distal site of the capsule. PROs and PROs at final follow-up were obtained, including visual analog scale (VAS) for pain and modified Harris Hip Score (mHHS).ResultsA total of 194 patients were included in this study. The mean MRI follow-up time was 14.3 (range, 6–37) months, and the mean clinical follow-up time was 26.1 (range, 12–43) months. Postoperative capsular thickness or net change were not correlated with postoperative PROs and VAS (P > .05). Capsular defect was observed in 17 (8.8%) patients. Patients with capsular defect had a relatively higher BMI (P < .05). Patients with capsular defect had a significant lower mHHS and higher VAS compared with patients with continuous capsule (P < .05). Ninety-one percentage of patients with continuous capsule surpassed minimal clinically important difference (MCID) and 80.8% achieved PASS, but only 58.8% of patients with capsular defect surpassed MCID and 47.1% achieved patient acceptable symptom state (PASS).ConclusionsPostoperative capsular thickness may not have influence on the clinical outcomes of hip arthroscopy for treatment of FAI. Some capsule of patients who underwent arthroscopic interportal capsulotomy and repair could not heal. Postoperative capsular continuity had a great impact on the clinical outcomes of hip arthroscopy for FAI. Patients with higher BMI may be more likely to have capsule failure to heal.

Predictive radiological parameters of failure following surgical management of femoroacetabular impingement associated with borderline acetabular dysplasia

IntroductionThe role of arthroscopic treatment of femoroacetabular impingement (FAI) in mild or borderline hip dysplasia (lateral center edge angle=18–25) is controversial. It is recommended to combine capsular plication with femoral neck osteoplasty and suture repair of the labrum. Few studies have investigated which radiological parameters are associated with failure of this procedure. HypothesisA larger number of radiological signs of mild or borderline hip dysplasia than radiological signs of FAI negatively influence the outcomes of arthroscopic treatment. MethodsThis was a retrospective study done with data collected prospectively after a minimum of 2 years’ follow-up in patients who underwent arthroscopic treatment of FAI due to cam impingement combined with mild to moderate hip dysplasia. Patients with hip osteoarthritis graded as ≥ Tönnis 2 were excluded. Functional outcome scores (mHHS and NAHS) were determined along with the need for reoperation. Three groups were defined based on the outcomes: success (mHHS ≥ Patient Acceptable Symptomatic State [PASS]); moderate improvement (improvement in mHHS + mHHS<PASS) and failure (worsening of the mHHS). Demographic data, radiographic parameters (LCEA, Tönnis angle, alpha angle, offset, FEAR index, Shenton's line, Cliff sign, anterior wall index [AWI], posterior wall index [PWI]) and intraoperative findings were compared between these three groups. The area under the curve (AUC) for the most relevant data identified during the univariate analysis were then modeled to define which factors were the best at predicting failed arthroscopic treatment a posteriori. ResultsThe study analyzed 39 patients. The mean mHHS was 76±15 [40–92]. The “success” group consisted of 21 patients (56%, 21/39), the “moderate improvement” group of 12 patients (31%, 12/39) and the failure group of 6 patients (13%, 6/39) (2 subsequently underwent total hip replacement, 4 underwent shelf acetabuloplasty). The FEAR index was significantly higher and the AWI and VCE were significantly lower in the “failure” group. The FEAR index was the best predictive factor; an index ≥ 4° detected 100% of failures with 96% specificity. The patients in the “moderate improvement” group were significantly older (37 years±8 [18–45]<p= 0.04) with a significantly higher offset (2mm±3 [−5–5]<p=0.004); an offset ≥ 2mm could detect 73% of them with a specificity of 72%. ConclusionA FEAR index ≥ 4° and offset ≥ 2mm is best able to detect patients at risk of failure and unsatisfactory results, respectively, in the mild clinical cam-type impingement in a population of FAI patients. Level of evidenceIV, retrospective series.

Patient-Perceived Outcomes Improve Faster Than Hip Strength in Recovery After Surgical Correction for Symptomatic Femoroacetabular Impingement.

Background: Patients with symptomatic femoroacetabular impingement (FAI) have hip strength deficits, instability, and increased risk for concomitant injury. While surgical intervention is an effective method of treatment for FAI, more information is needed about the recovery process. Purposes: We sought to understand how patients with FAI recover from surgical correction in the short term. Do patients' perceptions of improvement correspond with measured improvements in hip strength? Methods: We conducted a prospective cohort study of 17 patients (11 male, age range: 16-38 years) who were diagnosed with symptomatic FAI at a single surgeon's practice. Hip strength (flexion, extension, and abduction) was measured preoperatively and at 14, 26, and 52 weeks postoperatively. Patient-reported outcomes using the modified Harris Hip Score (mHHS) and Hip Outcome Osteoarthritis Score (HOOS) subscales were measured at the same time points and at 2 weeks postoperatively. Results: Compared with preoperative values, there was a significant increase in postoperative values at 26 and 52 weeks in normalized isokinetic hip extension (29% and 38%, respectively) and normalized hip abduction (48% and 55%, respectively). No differences in strength were observed at 14 weeks. Modified Harris Hip Score and all HOOS subscales were decreased by 2 weeks postoperatively, and by 14 weeks mHHS improved by 21%, and HOOS subscales improved as well (activities of daily living by 18%, pain by 34%, quality of life by 69%, sport and recreation by 36%, and symptoms by 28%). Conclusion: We observed that patient-reported outcomes including symptoms, function, and satisfaction improved at 14 weeks, while objective measures of hip strength improved at 26 weeks following surgical correction of FAI. More rigorous study is indicated.

Sagittal Plane Mobility in Adolsents with Femoroacetabular Impingment

Background:Femoroacetabular impingement (FAI) is a dynamic degradative condition of the hip joint characterized by classic physical exam findings in combination with abnormal radiographs and/or MRI. Although this abnormal morphologic relationship contributes to FAI, the role of physical therapy to mitigate symptoms by improving strength and mobility of the hip remains the first line treatment. Despite this common treatment algorithm, limited knowledge exists on the effects of sagittal balance, lumbopelvic mobility, and its role in the development of treatment for symptomatic FAI.Hypothesis/Purpose:To review lumbopelvic mobility from standing to sitting position in adolescent athletes who present with clinical signs of FAI.Methods:Pelvic radiographic measurements in the sagittal plane were performed on a retrospective series of consecutive patients who presented with clinical diagnosis of FAI at a pediatric sports medicine institution from April 2019-March 2021. Standardized EOS dynamic lateral pelvic images were performed in standing and sitting positions to evaluate the differences in sacral slope, pelvic tilt, and pelvic incidence. Data from bi-positional radiographs were combined with standard measurements for FAI obtained on AP pelvis (lateral center edge angle, acetabular inclination) and 45 degree Dunn views (alpha angle), and patient reported outcomes (PROs) (mHHS, HOOS, UCLA). Differences in sacral slope from pre-treatment radiographs were used to determine comparison groups: those with a change vs. those with limited change between a sitting and standing position.Results:76 adolescent patients (mean age 15.7 years [12-24]; 71.5% females) with sitting/standing lateral pelvis radiographs and a clinical diagnosis of FAI were identified. Between sitting and standing positions, there was no change in pelvic incidence, while significant differences were noted in sacral slopes and pelvic tilt (Table 1). Variability in sacral slope differences between sitting and standing were identified with 10 (13.9%) patients having minimal (<10o) change, while 8 (11.1%) demonstrated changes > 40o (Figure 1). Adolescent patients with FAI who demonstrated more mobility from sitting to standing position had a higher sacral slope in the standing position. No correlations were noted between pelvic incidence or sacral slope and radiographic measures associated with FAI, PROs or differences in those with variable changes in sacral slope from sitting to standing position.Conclusion:Lateral pelvic imaging may be an important tool for understanding dynamic hip impingement. In adolescent patients signs and symptoms with clinical FAI, significant variability exists in lumbopelvic mechanics, regardless of the severity of radiographic values.Table 1.Radiographic measurements performed on a sitting and standing lateral pelvic radiographs using EOS. Values listed are mean (standard deviation; range).Figure 1.Sitting and Standing lateral pelvic images from 2 patients. Top row: Standing lateral pelvis (A) and sitting lateral pelvis (B) with a significant change in sacral angle and pelvic tilt with no changes in pelvic incidence. Not the change in lumbar lordosis in this patient. Bottom row: Standing lateral pelvic (A) and sitting lateral pelvic (B) without significant change in lumbosacral position.

Predictors of Re-Operation in Adolesents Undergoing Hip Preservation Surgery for Femoroacetabular Impingement

Background:Femoroacetabular Impingement(FAI) is a condition caused by repetitive motion of abnormal hip osseous anatomy that contributes to labral and chondral injury. An understanding of radiographic parameters associated with successful primary surgery has not been well established.Hypothesis/Purpose:The primary objective was to determine pre-operative radiographic parameters that predict reoperation for FAI and, secondarily, correlate radiographic measures and outcomes in these patients.Methods:A prospectively-collected institutional registry of adolescent patients (age <19 y.o.) who underwent surgery for FAI (arthroscopic/open) was reviewed. Standing AP pelvis X-rays were analyzed for alpha, lateral center edge(LCEA), Tönnis, and Sharp’s angles, and femoro-epiphyseal acetabular(FEAR) index. Patient-reported outcomes(PROs) [modified Harris Hip Score (mHHS), Hip Disability and Osteoarthritis Outcome Score(HOOS)] were analyzed. Mann-Whitney-U test was used to compare the radiographic measures of re-operation to non-reoperation patients and those who achieved MCID to those who did not. Radiographic indication of risk for re-operation was evaluated with receiver operating characteristic(ROC) analysis. Spearman’s correlation was calculated between radiographic measurements and PROs at 2-years post-op.Results:Eighty-seven patients underwent primary surgery (56 surgical dislocations vs 31 scopes) for FAI. The average age at time of primary operation was 16.27 years(73.6%Female). 10 underwent re-operation (11.5%) at an average of 20.6 months from primary surgery. No differences were found in demographics, activity, surgery type, labral disease, or alpha angle for re-operation vs. non-reoperation. The LCEA, FEAR Index, Sharps, and Tönnis angle were significantly different (p<0.05) (Table 1).ROC analysis indicated that LCEA<21 and FEAR index>-8.8 were predictors for increased risk of reoperation. Patients with LCEA<21°, 46% underwent a reoperation compared to those with LCEA>21° (6%). Patients with FEAR index<-8.8, 32% underwent a reoperation compared to patients>-8.8 (5%).Patients who achieved MCID (61.9%) had lower BMI, worse pre-operative PROs, and better post-operative PROs at 2-years. Alpha, Tönnis, and Sharp’s angles were positively correlated with 2+ year PROs, while LCEA was negatively correlated(p<0.05).Conclusion:In patients undergoing treatment for FAI, a reoperation was associated with radiographic signs of hip dysplasia, indicating that patients with a shallower acetabulum are at risk for a repeat operation. Surgeons can utilize these parameters to help in surgical decision making, better predict outcomes and to counsel patients the need for potential subsequent surgery.Table 1.Radiographic measurements of preoperative AP pelvis X-rays and their association with reoperation

Paper 23: Long Term Outcomes After Arthroscopic Treatment of Femoroacetabular Impingement for Patients with Borderline Dysplasia

Objectives:Outcomes following isolated hip arthroscopy for patients with dysplasia have been unfavorable, results have included iatrogenic instability and conversion to total hip arthroplasty (THA) at a young age. However, patients with borderline dysplasia have portended more favorable results at short and medium term follow-up. The purpose of this study was to assess long term outcomes after hip arthroscopy for femoroacetabular impingement (FAI) in borderline dysplasia (BD) patients (LCEA, 18°-25°) compared to a control cohort of nondysplastic patients (LCEA, 25°-40°).Methods:Between March 2009 and July 2012, a BD group of 33 patients (38 hips) was identified. An age- and sex-matched control group of 83 patients (96 hips) was also identified. Patient-reported outcome scores, including the modified Harris Hip Score (mHHS), the Hip Outcome Score–Activities of Daily Living (HOS-ADL) and Sport-Specific Subscale (HOS-SSS), and the International Hip Outcome Tool (iHOT-33), were collected preoperatively and subsequently at an average of 9.6 years post-operatively.Results:The mean LCEA and Tönnis angle was 22.4° ± 2.02° and 6.2° ± 3.23° in the BD group and 31.7° ± 3.52° and 2.42° ± 3.02° in the control group, respectively (P <0.001). A labral repair was performed in 78.9% and 76% of the BD and control groups, respectively, all patients underwent capsular closure as part of routine hip arthroscopy. A cam decompression was performed in 97.4% of the BD patients and 99.0% of the control patients. At mean follow-up of 9.6 years (range, 8.2-11.6 years) on average there was significant improvement in all patient-reported outcomes scores in both groups (P<0.001). There were no significant differences between pre and post-operative scores between BD and control groups. Two hips (5.2%) underwent revision surgery in the BD group and 10 hips (10.4%) in the control group, of these one patient in the BD group underwent THA and one patient who underwent bilateral hip arthroscopies in the control group underwent bilateral hip resurfacing.Conclusions:Durable outcomes (>9 years) with low revision rates can be expected after isolated hip arthroscopy that includes cam resection, labral refixation and capsular closure in BD patients with equivalent outcomes to a nondysplastic cohort.

Pre- and intraoperative decision-making challenges in hip arthroscopy for femoroacetabular impingement.

There has been a marked increase in the number of hip arthroscopies performed over the past 16 years, primarily in the management of femoroacetabular impingement (FAI). Insights into the pathoanatomy of FAI, and high-level evidence supporting the clinical effectiveness of arthroscopy in the management of FAI, have fuelled this trend. Arthroscopic management of labral tears with repair may have superior results compared with debridement, and there is now emerging evidence to support reconstructive options where repair is not possible. In situations where an interportal capsulotomy is performed to facilitate access, data now support closure of the capsule in selective cases where there is an increased risk of postoperative instability. Preoperative planning is an integral component of bony corrective surgery in FAI, and this has evolved to include computer-planned resection. However, the benefit of this remains controversial. Hip instability is now widely accepted, and diagnostic criteria and treatment are becoming increasingly refined. Instability can also be present with FAI or develop as a result of FAI treatment. In this annotation, we outline major current controversies relating to decision-making in hip arthroscopy for FAI. Cite this article: Bone Joint J2022;104-B(5):532-540.

Femoroacetabular Impingement in Elite Skiers and Snowboarders: Return to Sports and Outcomes After Hip Arthroscopy

Background: Hip arthroscopy has been shown to be an effective treatment for femoroacetabular impingement (FAI) in high–level athletes; however, limited outcome and return–to–play data exist for hip arthroscopy in skiers and snowboarders. Purposes: To determine the return–to–sports rate of elite skiers and snowboarders who have undergone hip arthroscopic surgery for FAI and to assess hip–related outcomes at a minimum 2–year follow–up. Study Design: Case series; Level of evidence, 4. Methods: Elite skiers and snowboarders who underwent hip arthroscopy for the treatment of FAI between 2005 and 2018 were identified via a retrospective review of prospectively collected data. Data were obtained from fis-ski.org, usskiandsnowboard.org, xgames.com, and wikipedia.org, including information on each player's career length, participation on a national team, and time between surgery and first competition after surgery. Patient-reported outcomes (PROs) were prospectively collected preoperatively and at minimum 2 years postoperatively. Results: In total, 26 elite skiers and snowboarders (34 hips) were included. The mean ± standard deviation age at surgery was 24.5 ± 6.7 years (range, 18.7-46.8 years). A total of 85% (22/26) returned to elite–level competition at 8.9 months (range, 2.9-23.7 months) with an average career length of 3.6 ± 2.7 years after surgery. Four athletes (5 hips) required revision arthroscopy, with adhesions being the most frequent indication. At a mean follow–up of 7.7 ± 3.2 years, significant improvement in PROs (P < .05) was demonstrated for the Hip Outcome Score (HOS)–Activities of Daily Living (from 76 ± 20 to 95 ± 6), HOS–Sport Specific Subscale (from 63 ± 28 to 92 ± 14), modified Harris Hip Score (from 70 ± 19 to 89 ± 12), and 12-Item Short Form Health Survey Physical Component Summary (from 45 ± 11 to 54 ± 8). Patient satisfaction had a mean of 8 ± 2 (range, 1-10) and median of 10. Conclusion: The return–to–competition rate in elite skiers and snowboarders after hip arthroscopy for FAI was 85% at an average of 8.9 months and with a career length of 3.6 years after surgery. Significant improvement in PROs was demonstrated for the HOS–Activities of Daily Living, HOS–Sport Specific Subscale, modified Harris Hip Score, and 12-Item Short Form Health Survey Physical Component Summary, with a median patient satisfaction score of 10. These findings support hip arthroscopy as an effective procedure for the treatment of FAI in elite skiers and snowboarders with symptomatic activity–limiting hip pain, allowing them to return to their previous levels of competition at a high rate.

Hip Arthroscopy for Femoroacetabular Impingement-Associated Labral Tears: Current Status and Future Prospects.

Femoroacetabular impingement (FAI) has emerged as a common cause of hip pain, especially in young patients. While the exact cause of FAI is unknown, it is thought to result from repetitive microtrauma to the proximal femoral epiphysis leading to abnormal biomechanics. Patients typically present with groin pain that is exacerbated by hip flexion and internal rotation. Diagnosis of FAI is made through careful consideration of patient presentation as well as physical exam and diagnostic imaging. Use of radiographs can help diagnose both cam and pincer lesions, while the use of MRI can diagnose labral tears and cartilage damage associated with FAI. Both non-operative and surgical options have their role in the treatment of FAI and its associated labral tears; however, hip arthroscopy has had successful outcomes when compared with physical therapy alone. Unfortunately, chondral lesions associated with FAI have had poorer outcomes with a higher conversion rate to arthroplasty. Capsular closure following hip arthroscopy has shown superior clinical outcomes and therefore should be performed if possible. More recently, primary labral reconstruction has emerged in the literature as a good option for irreparable labral tears. While non-operative management may have its role in treating patients with FAI, hip arthroscopy has developed a successful track record in being able to treat cam and pincer lesions, chondral damage, and labral injuries.

Allograft Labral Reconstruction of the Hip: Expanding Evidence Supporting Greater Utilization in Hip Arthroscopy.

Purpose of ReviewThe current review investigates outcomes and failure rates associated with arthroscopic circumferential allograft labral reconstruction of the hip, both as a revision and primary procedure in treating femoroacetabular hip impingement and labral-related pathology.Recent FindingsNumerous studies within the last decade have demonstrated excellent patient-reported outcomes, high rates of return-to-play in athletes, and low failure rates in patients having undergone arthroscopic circumferential allograft labral reconstruction of the hip. Removal of chronically diseased and injured labral tissue can eliminate a significant pain-generator from the hip joint. Additionally, circumferential reconstruction of the labrum restores the hoop fiber strength and fluid seal akin to what would be seen with native, healthy labral tissue. Recent research has shown that arthroscopic circumferential allograft labral reconstruction may be used not only in the revision setting, but as a primary procedure. Circumferential labral reconstruction should be considered when a surgeon feels that the labrum is irreparable or has failed previous repair.SummaryArthroscopic circumferential allograft labral reconstruction of the hip can be utilized as treatment option not only in revision settings, but also in primary treatment for femoroacetabular impingement and labral pathology

Cleft Sign and Bone Marrow Edema of the Pubic Symphysis Are Associated With Sports and Bony Morphology in Patients With Femoroacetabular Impingement and Labral Tears.

Background:The cleft sign (CS) and bone marrow edema (BME) are considered magnetic resonance imaging (MRI) findings signifying a pubic pathology, which is associated with groin pain; however, their relationship with bony morphology related to femoroacetabular impingement (FAI) has not been established.Purpose:To investigate the prevalence of CS and BME in symptomatic patients with acetabular labral tears and assess their possible association with bone morphology and sport-specific activities.Study Design:Cross-sectional study; Level of evidence, 3.Methods:This study enrolled 418 patients (469 hips) undergoing hip arthroscopic surgery for labral tears. Also included were patients with labral tears in the setting of either hip dysplasia or borderline hip dysplasia who were undergoing endoscopic shelf acetabuloplasty combined with hip arthroscopic labral repair, cam osteoplasty, and capsular plication. All patients were screened for superior CS (SCS), inferior CS (ICS), and BME of the ipsilateral side of the pubis using 3-T MRI. We measured the following angles: lateral center edge (LCE), Sharp, Tönnis, vertical-central-anterior, and alpha. Then, we evaluated the relationship between patient characteristics and abnormal findings on MRI scans (preoperatively vs 1 year postoperatively).Results:An overall 397 hips were included: 200 in men and 197 in women (mean ± SD age, 35.3 ± 16.0 years). There were hips in 214 athletes (53.9%) and hips in 183 nonathletes (46.1%). MRI findings revealed SCS, ICS, and BME in 18 (4.5%), 13 (3.3%), and 34 hips (8.6%), respectively. Abnormal MRI findings at the pubis were seen more often in athletes than nonathletes (23.8% vs 3.3%), and contact sports athletes had the most frequent abnormalities. There was no SCS in patients with an LCE angle <22°. SCS was more frequently seen in those who had an alpha angle ≥71°. More than 60% of abnormal findings at the pubis diminished after arthroscopic surgery that included FAI correction and labral repair.Conclusion:In patients with labral tears, CS and BME were seen more frequently in athletes versus nonathletes, especially contact athletes with FAI-related bony abnormalities. More than 60% of abnormal MRI pubis findings resolved after arthroscopic treatment of FAI.

Sexual and urinary function post-surgical treatment of femoroacetabular impingement: experience from the FIRST trial and embedded cohort study.

ABSTRACTThe goal of this study was to investigate the sexual and urinary function and any related complications in patients post-hip arthroscopy for the treatment of femoroacetabular impingement (FAI). Data from 214 patients enrolled in the FIRST trial and 110 patients enrolled in the trial’s embedded prospective cohort study (EPIC) were analyzed. EPIC patients either refused to participate in the trial or did not meet the FIRST eligibility criteria. Outcomes included the International Consultation on Continence Questionnaire (ICIQ) for males (ICIQ-MLUTS) and females (ICIQ-FLUTS) and the Female Sexual Function Index (FSFI) and International Index of Erectile Function (IIEF) administered before surgery and at 6 weeks and 12 months. Urinary and sexual function adverse events were recorded up to 24 months. Linear regression analyses were conducted to compare the osteochondroplasty and lavage groups in the FIRST trial and to evaluate age and traction time as prognostic factors among all patients. Longer traction time was associated with a small but statistically significant improvement in urinary voiding function in males at 6 weeks and 12 months (MD (95% CI) = 0.25 (0.12, 0.39), P < 0.001 and 0.21 (0.07, 0.35), P = 0.004), respectively. Mean traction time was 43.7 (± 23.2) min for FIRST trial and 52.8 (± 15.2) min for EPIC cohort patients. Increasing age in male patients was associated with a decrease in urinary continence at 6 weeks (MD (95% CI) = 0.25 (−0.42, −0.09), P = 0.003). FIRST male patients who received osteochondroplasty improved significantly in sexual function at 12 months compared to males in the EPIC cohort (MD (95% CI) = 2.02 (0.31, 3.72), P = 0.020). There was an overall complication rate of 1.2% at 24 months [one urinary infection, two instances of erectile dysfunction (one transient and one ongoing at 24 months) and one reported transient numbness of tip of the penis]. Hip arthroscopy for the treatment of FAI has a low rate of sexual and urinary dysfunction and adverse events.