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Femoroacetabular impingement (FAI) is a condition that predominantly affects young people between the ages of 20 and 40. It is characterized by hip pain associated with reduced range of movement of the hip joint. If left untreated, FAI leads to osteoarthritis. When first described in the scientific literature in 2003, the concept of FAI was based on two different anatomic features: cam-type deformity and pincer-type deformity. Since that initial description clinical experience and scientific investigation have identified a third pillar of FAI: abnormal femoral torsion. This first article reviews the concept and diagnosis of FAI., Competing Interests: Les auteurs n’ont déclaré aucun conflit d’intérêts en relation avec cet article.

Purpose: To determine the respective percent thresholds for achieving the maximal outcome improvement (MOI) for the modified Harris Hip Score (mHHS), the Non-Arthritic Hip Score (NAHS), the Hip Outcome Score-Sports Subscale (HOS-SSS), the visual analog scale (VAS) for pain, and the International Hip Outcome Tool-12 (iHOT-12) that were associated with satisfaction following revision hip arthroscopy, and to identify predictors for achieving the MOI., Methods: An anchor question was provided to patients who underwent revision hip arthroscopy between April 2017 and July 2020. Patients were included for the final analysis if they answered the anchor question and had minimum 2-year follow-up. Receiver operating characteristic analysis was used to determine the thresholds for the percentage of the MOI predictive of satisfaction. A P-value of < .05 was considered significant., Results: In total, 318 patients underwent revision hip arthroscopy. Of those patients, 292 (91.8%) had minimum 2-year follow-up. Of this cohort, 68 answered the anchor question, with 49 (72.1%) female and 19 (27.9%) male patients. The mean age, and body mass index time were 32.9 ± 13 years and 25.4 ± 5.1, respectively. It was determined that 42.1%, 50%, 48.1%, 50%, and 50% of MOI were the thresholds for maximal predictability of satisfaction for mHHS, NAHS, HOS-SS, VAS for pain, and the iHOT-12, respectively. The presence of unaddressed subspine impingement was a significant predictor for achieving the MOI threshold for the VAS (odds ratio 1.40; 95% confidence interval 1.00-1.95; P = 0.0273)., Conclusions: Following revision hip arthroscopy, the percent thresholds for achieving the MOI at a minimum 2-year follow-up for the mHHS, NAHS, HOS-SS, VAS for pain, and iHOT-12 were 42.1%, 50%, 48.1%, 50%, and 50.9%, respectively. Addressing residual subspine impingement was identified as significant positive predictor for achieving the MOI., Level of Evidence: Level IV, case-series., (Copyright © 2023 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Femoroacetabular impingement (FAI) syndrome is a common cause of hip and groin pain in young individuals. FAI syndrome is a triad of signs, symptoms, and imaging findings. Necessary but not sufficient for the diagnosis of FAI syndrome is the presence of cam and/or pincer morphology of the hip. However, pathological thresholds for cam and pincer morphologies are not well-established. Management of FAI syndrome is typically through either physiotherapist-led therapy or surgical intervention. Physiotherapist-led management involves exercises aimed to optimise movement patterns of the hip and pelvis to prevent impingement from occurring, activity modification and analgesia, whereas surgical management involves arthroscopic resection of the cam/pincer morphology and treatment of concomitant soft tissue pathologies such as labral tears, cartilage lesions or ligamentum teres tears. Careful consideration of intervention is required given that FAI syndrome may predispose those affected to developing future osteoarthritis of the hip. In most clinical trials, hip arthroscopy has been found to provide greater improvement in patient-reported outcomes in the short-term compared to physiotherapy, however it is unknown whether this is sustained in the long-term or affects the future development of hip osteoarthritis., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: DJH is employed by the University of Sydney and Royal North Shore Hospital. His salary support for the University of Sydney is supported by Arthritis Australia and an NHMRC Investigator Grant Leadership 2 (#1194737). DJH is the co-director of the Sydney Musculoskeletal Health Flagship. In addition, DJH is the editor of the osteoarthritis section for UpToDate, co-Editor in Chief of Osteoarthritis and Cartilage and board member of Osteoarthritis Research Society International. DJH provides consulting advice on scientific advisory boards for Pfizer, Lilly, TLCBio, Novartis, Tissuegene, and Biobone. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Hip pain is a common complaint in adolescents. There are several causes for hip pain in this population, with dysplasia and impingement being the most common; however, other conditions such as extra-articular impingement, torsional disorders, labral tears, and osteochondral lesions also require consideration. Many of these conditions are related to underlying anatomic abnormalities and increased activity in this age group. An understanding of the common pathologies of the adolescent hip is integral to the evaluation, diagnosis, and treatment of these patients.

Background: The Non-Arthritic Hip Score (NAHS) used to evaluate the hip in younger patients is a self-administered questionnaire with 20 items in four sections: pain, symptoms, function, and activities. Although used in France, no transcultural version had been validated. The objective of this study was to translate the NAHS into French then assess the validity, reliability, and sensitivity to change of the French-language version (NAHS-Fr) in younger patients with hip conditions other than osteoarthritis., Hypothesis: The NAHS-Fr demonstrates good validity and reliability when used in younger French-speaking patients with hip pain., Material and Methods: We conducted a prospective observational study in 105 patients (62 males and 43 females) scheduled for surgery on one or both hips (113 hips in total) to treat cam-type femoro-acetabular impingement or labral lesions. Before and 6 months after surgery, each patient completed the NAHS-Fr and Western Ontario and McMaster Osteoarthritis Index (WOMAC). Statistical tests were done to evaluate validity, reliability, and sensitivity to change, as recommended by the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN)., Results: The response rate was 100%, confirming that the NAHS-Fr was easy to use. The NAHS-Fr was both valid and reliable. No ceiling or floor effect was detected for the total NAHS-Fr score. All items had Cronbach alpha coefficients greater than 0.8, indicating good internal consistency. External consistency between the NAHS-Fr and WOMAC was negative (-0.676) due to inversely proportional score indexing. Before surgery, the NAHS-Fr and WOMAC scores were strongly and significantly correlated (p<0.0001). The effect size was greater than 0.8, indicating good sensitivity to the change induced by surgery., Discussion: These results confirm the study hypothesis: the NAHS-Fr has the same good psychometric characteristics as does the original version and versions in other languages. The NAHS-Fr is useful for evaluating younger patients with non-osteoarthritic hip pain and can be used by French-speaking surgeons in everyday clinical practice., Level of Evidence: IV, prospective observational non-comparative cohort study., (Copyright © 2023 Elsevier Masson SAS. All rights reserved.)

Purpose: Though an increasing number of adults older than 50 years are undergoing hip arthroscopy for treatment of Femoroacetabular Impingement Syndrome (FAIS), it is unclear how their timeline for functional outcome improvement compares to that of younger patients. The purpose of this study was to assess the impact of age on time to achieving the Minimum Clinically Important Difference (MCID), Substantial Clinical Benefit (SCB), and Patient Acceptable Symptom State (PASS) following primary hip arthroscopy for FAIS., Methods: A retrospective comparative single-surgeon cohort study of primary hip arthroscopy patients with minimum 2-year follow-up was conducted. Age categories were 20-34 years, 35-49 years, and 50-75 years. All subjects completed the modified Harris Hip Score (mHHS) prior to surgery and at 6-month, 1-year, and 2-year follow-up. MCID and SCB cutoffs were defined as pre-to-postoperative increases in mHHS by ≥ 8.2 and ≥ 19.8, respectively. PASS cutoff was set at postoperative mHHS ≥ 74. Time to achievement of each milestone was compared using interval-censored survival analysis. The effect of age was adjusted for Body Mass Index (BMI), sex, and labral repair technique using an interval-censored proportional hazards model., Results: Two hundred eighty-five patients were included in the analysis with 115 (40.4%) aged 20-34 years, 92 (32.3%) aged 35-49 years, and 78 (27.4%) aged 50-75 years. There were no significant differences between groups in time to achievement for the MCID (n.s.) or SCB (n.s.). However, patients in the oldest group had significantly longer time to PASS than those in the youngest group, both in the unadjusted analysis (p = 0.02) and after adjusting for BMI, sex, and labral repair technique (HR 0.68, 95% CI 0.48-0.96, p = 0.03)., Conclusion: Achievement of the PASS, but not the MCID or SCB, is delayed among FAIS patients aged 50-75 years who undergo primary hip arthroscopy compared to those aged 20-34 years. Older FAIS patients should be counseled appropriately about their longer timeline to achieving hip function comparable to their younger counterparts., Level of Evidence: III., (© 2023. The Author(s) under exclusive licence to European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA).)

Introduction: There is limited information on sexual activity and functioning for patients with hip abnormalities, specifically femoroacetabular impingement (FAI), labral tears, and hip dysplasia, before and after surgical interventions., Objectives: The aim of this review was to synthesize the existing literature on sexual activity and functioning for patients with FAI, labral tears, and/or hip dysplasia before and after their respective surgeries., Methods: We performed a rigorous, comprehensive search on multiple databases including PubMed, EMBASE, CINAHL, and Web of Science. Subject headings and a search string of key terms including Medical Subject Headings were used systematically to search these databases. The reference list was reviewed with an additional reviewer to reduce bias., Results: A total of 726 articles were found during the search, which were narrowed down to 22 articles that included at least 1 hip abnormality in relation to sexual functioning, sexual pain, or sexual activity. FAI, labral tears, and hip dysplasia can affect sexual activity, functioning, and positioning, and corrective surgery generally improves these metrics. Surgery improved vulvodynia, clitorodynia, and scrotal pain symptoms for some patients, though arthroscopy resulted in some instances of temporary pudendal nerve dysfunction., Conclusion: This review may serve as an important resource for surgeons, healthcare providers, researchers, physical therapists, and patients to understand the relationship between the hips and sexual functioning, and to bridge the gaps among the disciplines of orthopedics, pelvic floor physiology, and sexual health. Hip anatomy impacts sexual activity, functioning, and positioning as well as vulvodynia and scrotal pain symptoms for some patients, and a comprehensive hip evaluation by a qualified hip specialist should be considered for patients with such complaints., (© The Author(s) 2023. Published by Oxford University Press on behalf of The International Society of Sexual Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: To describe the experience in the diagnostic process and treatment of patients with groin pain (GP) of neurological origin due to entrapment of the iliohypogastric (IH), ilioinguinal (IL) and genitofemoral (GF) nerves in a hip preservation clinic., Methods: Retrospective study of patients with GP of neurological origin confirmed with ultrasound-guided nerve block. Clinical outcomes were reported in 21 cases (age, 53.3 ± 15.9 years) treated with conservative treatment from January to December 2019, and in 9 patients (age 43.7 ± 14.6 years) who underwent neurectomy from January 2015 to December 2019. Pain intensity was assessed with a numerical rating scale (NRS) before starting the diagnostic process (Day 0) and at the end of follow-up., Results: All cases reported pain on groin palpation. Half of these cases also reported a positive FADIR test (flexion, adduction, internal rotation) (15/30). On day 0, the intensity of pain in cases treated with conservative treatment was severe in 19 patients (NRS 7-10) and moderate in 2 (NRS 4-6), with a median improvement of 7 points (interquartile range [IQR] 5.5-8.0) at the end of follow-up ( p   <  0.001). In neurectomy group, a similar improvement in pain severity was (Day 0: 9 points [IQR 8.0-9.0]; end of follow-up: 0 points [IQR: 0-2.0]; p   =  0.002). At the end of the study, 17/21 patients with conservative treatment and 7/9 with neurectomy were pain free or with mild pain (NRS < 3)., Conclusions: In cases with PG of neurological origin, there is a high frequency of false positives in the FADIR test. Our findings suggest that neurectomy is a treatment option for patients in whom conservative treatment fails, providing significant pain relief.

Background: Hip arthroscopy is an effective treatment tool for athletes with femoroacetabular impingement (FAI) syndrome. However, long-term data are scarce., Purpose: To assess survivorship, minimum 10-year patient-reported outcome measures (PROMs), and sports participation after primary hip arthroscopy for FAI syndrome in athletes and to perform a propensity-matched comparison between patients undergoing labral debridement and labral repair., Study Design: Cohort study; Level of evidence, 3., Methods: Athletes who underwent hip arthroscopy for FAI syndrome between February 2008 and December 2010 were eligible. Exclusion criteria were other ipsilateral hip condition, Tönnis grade ≥2, or no baseline PROMs. Survivorship was defined as no conversion to total hip arthroplasty. The Patient Acceptable Symptom State (PASS), minimal clinically important difference (MCID), maximum outcome improvement (MOI) satisfaction threshold, and sports participation were reported. A propensity-matched comparison between labral debridement and labral repair was performed. Two additional propensity-matched subanalyses were performed for capsular management and cartilage damage., Results: In total, 189 hips (177 patients) were included. The mean ± SD follow-up was 127.2 ± 6.0 months. Survivorship was 85.7%. Significant improvement in all PROMs was reported ( P < .001). A total of 46 athletes with labral repair were propensity matched to 46 athletes with labral debridement. This subanalysis demonstrated significant and comparable improvement in all PROMs at minimum 10-year follow-up ( P < .001). For the labral repair group, the PASS achievement rates were 88.9% for the modified Harris Hip Score (mHHS) and 80% for the Hip Outcome Score-Sport Specific Subscale (HOS-SSS); the MCID achievement rates were 80.6% for the mHHS and 84% for HOS-SSS; and for the MOI satisfaction threshold, rates were 77.8%, 80.6%, and 55.6% for the mHHS, Nonarthritic Hip Score, and visual analog scale, respectively. For the labral debridement group, the PASS achievement rates were 85.3% for the mHHS and 70.4% for the HOS-SSS; the MCID achievement rates were 81.8% for the mHHS and 74.1% for HOS-SSS; and for the MOI satisfaction threshold, rates were 72.7%, 81.8%, and 66.7% for the mHHS, Nonarthritic Hip Score, and visual analog scale. Total hip arthroplasty conversions occurred significantly sooner with labral debridement than labral repair ( P = .048). Age was identified as a significant predictor of achieving the PASS., Conclusion: Primary hip arthroscopy for FAI syndrome in athletes results in 85.7% survivorship and sustained PROM improvement at a minimum 10-year follow-up. A significant time delay to total hip arthroplasty conversion at 10-year follow-up was reported with labral repair over debridement, although this should be interpreted with caution, as the total number of conversions was small.

Background: The COVID-19 pandemic has accelerated the demand for utilising telehealth as a major mode of healthcare delivery, with increasing interest in the use of tele-platforms for remote patient assessment. In this context, the use of smartphone technology to measure squat performance in people with and without femoroacetabular impingement (FAI) syndrome has not been reported yet. We developed a novel smartphone application, the TelePhysio app, which allows the clinician to remotely connect to the patient's device and measure their squat performance in real time using the smartphone inertial sensors. The aim of this study was to investigate the association and test-retest reliability of the TelePhysio app in measuring postural sway performance during a double-leg (DLS) and single-leg (SLS) squat task. In addition, the study investigated the ability of TelePhysio to detect differences in DLS and SLS performance between people with FAI and without hip pain., Methods: A total of 30 healthy (nfemales = 12) young adults and 10 adults (nfemales = 2) with diagnosed FAI syndrome participated in the study. Healthy participants performed DLS and SLS on force plates in our laboratory, and remotely in their homes using the TelePhysio smartphone application. Sway measurements were compared using the centre of pressure (CoP) and smartphone inertial sensor data. A total of 10 participants with FAI (nfemales = 2) performed the squat assessments remotely. Four sway measurements in each axis (x, y, and z) were computed from the TelePhysio inertial sensors: (1) average acceleration magnitude from the mean (aam), (2) root-mean-square acceleration (rms), (3) range acceleration (r), and (4) approximate entropy (apen), with lower values indicating that the movement is more regular, repetitive, and predictable. Differences in TelePhysio squat sway data were compared between DLS and SLS, and between healthy and FAI adults, using analysis of variance with significance set at 0.05., Results: The TelePhysio aam measurements on the x- and y-axes had significant large correlations with the CoP measurements (r = 0.56 and r = 0.71, respectively). The TelePhysio aam measurements demonstrated moderate to substantial between-session reliability values of 0.73 (95% CI 0.62-0.81), 0.85 (95% CI 0.79-0.91), and 0.73 (95% CI 0.62-0.82) for aamx, aamy, and aamz, respectively. The DLS of the FAI participants showed significantly lower aam and apen values in the medio-lateral direction compared to the healthy DLS, healthy SLS, and FAI SLS groups (aam = 0.13, 0.19, 0.29, and 0.29, respectively; and apen = 0.33, 0.45, 0.52, and 0.48, respectively). In the anterior-posterior direction, healthy DLS showed significantly greater aam values compared to the healthy SLS, FAI DLS, and FAI SLS groups (1.26, 0.61, 0.68, and 0.35, respectively)., Conclusions: The TelePhysio app is a valid and reliable method of measuring postural control during DLS and SLS tasks. The application is capable of distinguishing performance levels between DLS and SLS tasks, and between healthy and FAI young adults. The DLS task is sufficient to distinguish the level of performance between healthy and FAI adults. This study validates the use of smartphone technology as a tele-assessment clinical tool for remote squat assessment.

Context: Laboratorial 3-dimensional kinematic analyses have shown changes in the single-leg squat's (SLS) pattern of patients with femoroacetabular impingement syndrome (FAIS). However, it is unknown whether clinicians are able to detect these changes using 2-dimensional kinematics., Objective: To compare the frontal plane 2-dimensional kinematics of patients with FAIS and asymptomatic individuals in the SLS test performed in a clinical setting., Design: Case-control study., Setting: Physical therapy clinic., Participants: Twenty men with bilateral FAIS and 20 asymptomatic men., Main Outcome Measures: Two-dimensional kinematic analysis was collected in the frontal plane during the execution of the SLS test. The outcomes were squat depth, pelvic drop (pelvis angle relative to the horizontal plane), hip adduction (femur angle relative to the pelvis), and knee valgus (femur angle relative to the tibia)., Results: Most and least painful limbs of patients with FAIS had squat depth (9.8% [2.9%] and 9.5% [3.1%] of height), pelvic drop (4.2° [3.9°] and 3.7° [4.2°]), hip adduction (74.9° [5.8°] and 75.9° [5.7°]), and knee valgus (4.0° [11.0°] and 5.0° [9.9°]) similar to asymptomatic individuals (9.0% [2.3%], 4.8° [2.6°], 73.7° [4.9°], and -1.7° [8.5°]; P > .05 for all)., Conclusion: The frontal plane 2-dimensional kinematic analysis of the SLS test in the clinical setting is not able to distinguish patients with FAIS from asymptomatic individuals.

Purpose: To identify the objective criteria and guidelines utilized to determine if patients diagnosed with FAIS can safely return to sport following hip arthroscopy., Methods: The electronic databases MEDLINE Ovid, EMBASE Ovid, and CINAHL were searched to identify eligible studies. Details of study design, sample size, primary diagnosis, and return to sport protocol, duration, and rate were collected by two reviewers, independently., Results: Sixty-two studies were selected for full text review of which 14 were included in the final analysis. Of these, nine were clinical commentaries and five were retrospective cohort studies. Three types of rehabilitation guidelines are currently utilized postoperatively: 4-phase, 5-phase, and 6-phase protocols. Although all 14 studies recommend using various types of outcome measures to evaluate a patient's ability to return to sport, only eleven outlined the specific outcome criteria they must achieve to do so. The most utilized outcome measures are the hip outcome score, active and passive range of motion tests, gait analysis, single- and double-leg squat tests, and the Vail hip sports test. Criteria across all three types of protocols was variable, but they all evaluated the same international classification of disability and function constructs described by the World Health Organization: body function, body structure limitations, and activity capacity limitations., Conclusions: There is no consensus on the optimal methods of evaluating a patient's readiness to return to sport after undergoing hip arthroscopy, with most criteria focused on expert opinion. Performance-based return to sport outcome criteria is not clearly defined, and validated outcome measures are not being used for FAIS patients post hip arthroscopy. Lastly, well-conducted prospective cohort studies using validated outcome measures and objective definitions of return to sport are needed to consistently identify signs that are prognostic of safe return to sport.

Purpose: Hip microinstability has emerged as a contributor to young adult, non-arthritic hip pain. There is a paucity of objective clinical data to identify patients with hip microinstability and guide surgical treatment. The purpose of this study was to identify the degree of distractibility in patients with and without microinstability undergoing hip arthroscopy., Methods: A single-surgeon series of hip arthroscopies were retrospectively reviewed from 2014-2020. All procedures were performed with paralysis on a fracture table with a perineal post where 1 turn of fine traction equates to 4 mm of axial traction. Diagnosis was recorded as isolated instability, instability plus femoroacetabular impingement (FAI), and isolated FAI. Operative reports were reviewed to collect patient demographic data, number of turns of traction required for adequate distraction of the femoral head relative to the acetabulum (10 mm), and the presence of residual subluxation after initial traction was released., Results: A total of 464 patients were identified, 26 (5.6%) with isolated microinstability, 183 (39.4%) with microinstability with FAI anatomy, and 255 (55.0%) with FAI. The concurrent diagnosis of microinstability was associated with decreased turns required to adequately distract the hip. Isolated microinstability patients required 6.9 turns (IQR 4.6-8.8) while those with instability plus FAI required 8.8 turns (IQR 6.5-11) and isolated FAI required 19.1 turns (IQR 15-22). Residual subluxation after removal of negative intra-articular pressure but before performing the hip arthroscopy was more commonly associated with instability, occurring in 84.6% of isolated instability and 86.9% of instability plus FAI as compared with 29.8% in the isolated FAI cohort., Conclusion: A diagnosis of hip microinstability, with or without features of FAI, is associated with decreased axial traction required to distract the hip. These data support the use of intra-operative ease of distraction as a method of identifying patients with hip microinstability., Level of Evidence: Level III., (© 2022. The Author(s) under exclusive licence to European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA).)

PURPOSE OF THE STUDY Femoroacetabular impingement syndrome is a complex, often post-traumatically developing impairment of the hip joint, characterized by ambiguous symptomatology, which makes early diagnosis diffi cult, especially in the early stages. Experimental retrospective study was carried out to evaluate the usability of a triaxial gyroscopic sensor in routine practice as an additional indication criterion for operative versus conservative treatment procedures. MATERIAL AND METHODS 92 patients were included in the retrospective study, and 62 completed the investigation. All patients signed informed consent. A gyroscopic sensor was placed on the right side of the pelvis above the hip joint, and the patients walked approximately 15 steps. Furthermore, an evaluation of the data during stair climbing and a complete clinical examination of the dynamics and physiological movements in the joint was carried out. Data measured with a gyroscopic sensor were processed using differential geometry methods and then evaluated using spectral analysis and neural networks. The proposed technique of diagnosing FAI using gyroscope measurement is a fast, easy-to-perform method. RESULTS Our approach in processing gyroscopic signals used to detect the stage of arthrosis and post-traumatically developing FAI could lead to more accurate early detection and capture in the early stages. CONCLUSIONS The obtained data are easily evaluated, interpretable and benefi cial in diagnosing the early stages of FAI. The results of the conducted research showed this approach to more accurate early detection of arthrosis and post-traumatically developing FAI. Key words: wearable sensors; osteoarthritis; mathematical biophysics; telemedicine.

Background: Although randomized controlled trials comparing hip arthroscopy with physical therapy for the treatment of femoroacetabular impingement (FAI) syndrome have emerged, no studies have investigated potential moderators or mediators of change in hip-related quality of life., Purpose: To explore potential moderators, mediators, and prognostic indicators of the effect of hip arthroscopy and physical therapy on change in 33-item international Hip Outcome Tool (iHOT-33) score for FAI syndrome., Study Design: Cohort study; Level of evidence, 2., Methods: Overall, 99 participants were recruited from the clinics of orthopaedic surgeons and randomly allocated to treatment with hip arthroscopy or physical therapy. Change in iHOT-33 score from baseline to 12 months was the dependent outcome for analyses of moderators, mediators, and prognostic indicators. Variables investigated as potential moderators/prognostic indicators were demographic variables, symptom duration, alpha angle, lateral center-edge angle (LCEA), Hip Osteoarthritis MRI Scoring System (HOAMS) for selected magnetic resonance imaging (MRI) features, and delayed gadolinium-enhanced MRI of cartilage (dGEMRIC) score. Potential mediators investigated were change in chosen bony morphology measures, HOAMS, and dGEMRIC score from baseline to 12 months. For hip arthroscopy, intraoperative procedures performed (femoral ostectomy ± acetabular ostectomy ± labral repair ± ligamentum teres debridement) and quality of surgery graded by a blinded surgical review panel were investigated for potential association with iHOT-33 change. For physical therapy, fidelity to the physical therapy program was investigated for potential association with iHOT-33 change., Results: A total of 81 participants were included in the final moderator/prognostic indicator analysis and 85 participants in the final mediator analysis after exclusion of those with missing data. No significant moderators or mediators of change in iHOT-33 score from baseline to 12 months were identified. Patients with smaller baseline LCEA (β = -0.82; P = .034), access to private health care (β = 12.91; P = .013), and worse baseline iHOT-33 score (β = -0.48; P < .001) had greater iHOT-33 improvement from baseline to 12 months, irrespective of treatment allocation, and thus were prognostic indicators of treatment response. Unsatisfactory treatment fidelity was associated with worse treatment response (β = -24.27; P = .013) for physical therapy. The quality of surgery and procedures performed were not associated with iHOT-33 change for hip arthroscopy ( P = .460-.665 and P = .096-.824, respectively)., Conclusion: No moderators or mediators of change in hip-related quality of life were identified for treatment of FAI syndrome with hip arthroscopy or physical therapy in these exploratory analyses. Patients who accessed the Australian private health care system, had smaller LCEAs, and had worse baseline iHOT-33 scores, experienced greater iHOT-33 improvement, irrespective of treatment allocation.

Purpose: To analyze and compare the mid-term outcomes of hip arthroscopy for patients with and without labral degeneration from multiple orthopaedic centers. The purpose of this research is to develop an understanding of the impacts of labral degeneration on patient outcomes following arthroscopic treatment of labral tears., Methods: A prospective multicenter hip arthroscopy registry was queried for primary surgeries from January 2014 to October 2017 with completed 2-year International Hip Outcome Tool-12 (iHOT-12) reports. Patients were placed into cohorts based on the presence or absence of labral degeneration noted intraoperatively during hip arthroscopy. Degeneration was defined as yellowing, ossification, or calcification present in at least 50% of the labrum. Differences in baseline variation between groups were assessed with a Wilcoxon rank-sum test or χ 2 test. Two-year outcomes were assessed with iHOT-12. Multivariate logistic regression models were fitted while controlling for age, body mass index, sex, and preoperative iHOT-12 scores to identify significant predictors of achieving the clinically significant thresholds of minimal clinically important difference, substantial clinical benefit, and patient-acceptable symptom scale., Results: In total, 735 patients met inclusion criteria, of whom 613 had complete outcomes information. Relative to the control group, the labral degeneration group was significantly older (mean age 44 ± 11 years vs 33 ± 12 years; P < .01). Both groups experienced statistically significant improvement in iHOT-12 scores from baseline to final follow-up (P < .001); however, patients with labral degeneration reported inferior 2-year iHOT-12 scores when compared with patients without degeneration (P < .001). In the logistic regression models, labral degeneration was a significant negative predictor of achieving iHOT-12 minimal clinically important difference (odds ratio [OR] 0.47; 95% confidence interval [95% CI] 0.28-0.79), patient acceptable symptom state (OR 0.50; 95 CI 0.32-0.77), and substantial clinical benefit (OR 0.58; 95% CI 0.37-0.89)., Conclusions: The results of our study conclude that patients with nondegenerative labral tissue at the time of repair have superior patient-reported outcomes at mid-term follow-up. The presence of labral degeneration was a negative predictor of achieving clinically significant thresholds after controlling for patient age, body mass index, sex, and baseline iHOT-12 scores., Level of Evidence: III, retrospective comparative prognostic trial., (Copyright © 2022 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: The Hip Sports Activity Scale (HSAS) is a hip-specific instrument for assessing the present levels of physical activity among patients with femoroacetabular impingement (FAI) syndrome. When evaluating treatment outcomes in patients with FAI syndrome, it is necessary to use joint-specific instruments and ones that can evaluate the levels of physical activity in these patients, such as the HSAS-Brazil., Objective: To validate the HSAS-Brazil among a group of physically active patients after arthroscopic treatment of FAI syndrome., Design and Setting: Cross-sectional research of quantitative and qualitative types using data obtained from July 2018 to October 2019., Methods: A total of 58 patients of both genders diagnosed with FAI syndrome and who had undergone hip arthroscopy participated in this research. To establish reliability and validity, patients first answered the Brazilian versions of the 12-Item Short-Form Health Survey (SF-12), Nonarthritic Hip Score (NAHS), and HSAS; after a 48-hour interval, they answered the HSAS-Brazil again., Results: For test-retest reliability, the interclass correlation was 0.908 (P < 0.001). The HSAS-Brazil correlated to the NAHS-Brazil (r = 0.63, P < 0.001), as well as the SF-12 (Physical Health) (r = 0.42, P = 0.001)., Conclusion: The HSAS-Brazil was validated and proved to be a reliable and valid scale to assess sports activity levels in physically active patients with FAI syndrome after arthroscopic treatment.

Purpose: The purpose of this study was to determine and establish the MCID for the NAHS at 2 years in patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS)., Methods: Patients that underwent primary hip arthroscopy for FAIS between 2010 and 2016 were analyzed for eligibility. Data were collected from a single surgeon's hip arthroscopy database. MCID was calculated for the NAHS utilizing a distribution-based method., Results: The study included 298 patients (184 females) with an average age of 40.4 ± 13.0 years and average body mass index (BMI) of 25.7 ± 4.2 kg/m 2 . At baseline, the cohort's average NAHS score was 48.7 ± 13.6 and demonstrated an improvement of 36.5 ± 17.0 for NAHS at follow-up. This resulted in MCID values of + 8.5 for NAHS., Conclusion: This is the first study to report the MCID (+ 8.5) for NAHS following primary hip arthroscopy, and as such, is a valuable contribution to future hip arthroscopy research., Level of Evidence: IV., (© 2021. The Author(s), under exclusive licence to The Author(s) under exclusive licence to European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA).)

Background: Over the past several years there has been a marked increase in the number of Israel Defense Forces (IDF) soldiers having hip arthroscopy based on magnetic resonance arthrography diagnosis of hip labral tears and/or impingement., Objectives: To detail characteristics of soldiers who underwent hip arthroscopy and assess outcomes and rate of return to duty., Methods: A retrospective chart review was conducted of all soldiers who underwent hip arthroscopy 2018 to 2020, and soldiers referred for hip arthroscopy during 2021. Demographic, medical, and military service data were collected from the computerized patient record., Results: Our study comprised 117 soldiers (29% combatants, 24% females) who underwent hip arthroscopy, mean age 22 ± 3 years, range 18-42; 45% had physiotherapy before surgery; 31% were diagnosed during or within 3 months of having back pain and 20% had been referred for psychological assistance (not related to the hip pain); 15.4% had serious adverse events. The mean time to return to any duty (including clerical work) was 8.0 ± 0.6 months; 56% of the soldiers never returned to service and were discharged from the military. During the one-year follow-up, only 6% returned to their full pre-symptom activity., Conclusions: The short-term results of IDF soldiers who underwent hip arthroscopy during the study period were much inferior to those reported among athletes. The lack of specificity of the diagnostic tools (history, examination, and imaging) used to determine whether surgery for hip pain is likely to be beneficial in this population may be contributing to over-diagnosis and over-treatment.

Background: Femoroacetabular impingement syndrome (FAIS) has gained vast importance in the last two decades. Multiple studies have shown that if untreated, early osteoarthritis of the hip joint may result. Hip arthroscopy is one of the fastest growing procedures in the orthopedic cosmos, having already replaced the majority of (mini) open techniques in FAIS surgery. However, with the recent remarkable increase in the volume of hip arthroscopies performed worldwide, the number of patients with persistent or recurrent symptoms after FAIS surgery is also growing., Pathology: Potential underlying pathologies are misresection of the bony deformity, insufficiency fracture of the femoral head neck junction or the femoral subchondral head itself (SIFFH), adhesions, failed chondrolabral or capsular treatment, septic arthritis, heterotopic ossification or a wrong indication in the case of osteoarthritis that is already too advanced. Most of these occur more often during the extensive learning curve for hip arthroscopy., Diagnostics: High-quality imaging plays a key role in determining the need for revision surgery vs. further conservative treatment. Therapeutical avenues are shown with the common goal of proper detection and correction of the underlying pathology to address unsatisfactory FAIS treatment outcomes and ensure long-term survival of the native hip joint., (© 2022. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Background: The purpose of this study was to search for changes in functional outcomes of patients undergoing hip arthroscopy for femoroacetabular impingement (FAI) between short and medium-term follow-up. Secondary aims included reporting rates of revision surgery and total hip arthroplasty (THA) at medium-term follow-up., Hypothesis: We hypothesised that patients' functional outcomes would improve between short and medium-term follow-up., Patients and Methods: Consecutive patients undergoing hip arthroscopy with a diagnosis of femoroacetabular impingement with labral tears between February 2013 and June 2015 were included. Twelve item international hip outcome tool (iHOT-12) and EuroQol 5D-5L (EQ-5D) scores were collected preoperatively, at short-term and medium-term follow-up. Short-term scores were recorded at a minimum of one year postoperatively and medium-term scores at a minimum of five years postoperatively. Survivorship was assessed with Kaplan-Meier analysis., Results: Short-term outcome data (at median follow-up 1.6 year, Interquartile range [IQR] 1-2.5) was available for 70 of 87 patients (80.5%) and medium-term outcome data (at median follow-up of 6.5 years, IQR 6-7.1) was available for 68 patients (78.2%). Median age at the time of surgery was 31 years (IQR 25-37). The median iHOT-12 scores at short and medium-term follow-up were 72 (IQR 48.75-91.25) and 85.8 (IQR 66.7-96.7) respectively (p<0.001). Medium-term survivorship was 91.2%. Survivorship following labral repair was 94.2%, and 81.3% following labral debridement (p=0.09)., Discussion: Patients undergoing hip arthroscopy for FAI reported continued improvement in iHOT-12 scores between short and medium-term follow-up. Medium-term survivorship following FAI surgery may be greater when the labrum is repaired, although comparisons are limited by their differing indications. Conversion to THA was low with just 4 patients (4.6%) undergoing or being listed for THA at final follow-up., Level of Evidence: IV, Case series., (Copyright © 2021 Elsevier Masson SAS. All rights reserved.)

Background: Extensive literature has described surgical outcomes for pre-arthritic hip pain, but the proportion of patients who progress to surgery remains unknown., Objective: To determine the proportion of patients who present to a tertiary referral center for pre-arthritic hip pain and progress to surgery at minimum 1-year follow-up., Design: Retrospective cohort study., Setting: Single tertiary care academic medical center., Patients: Patients ages 13 to 40 years who presented for initial evaluation to a conservative or surgical orthopedic specialist and were diagnosed with pre-arthritic hip pain (n = 713 patients, 830 hips)., Intervention: Not applicable., Main Outcome Measures: The primary outcome was the rate of progression to surgery at minimum 1-year follow-up for the entire cohort. Predictors of progression to surgery were determined for the entire cohort and for radiographically defined subgroups using multiple logistic regression. Candidate predictors included baseline demographic, radiographic, clinical diagnosis, and patient-reported outcome measures., Results: In a cohort with a mean age of 25.4 (SD 8.1) years, 72.7% female, and mean follow-up of 2.6 (range 1.0-4.8) years, 429 of 830 hips (51.7%, 95% confidence interval [CI] 48.2% to 55.1%) progressed to surgery. Predictors of surgical progression in the entire cohort included younger age (OR 0.95/year, 95% CI 0.93 to 0.98), pain duration longer than 6 months (ORs 1.87-2.03, p ≤ .027), worse physical function (OR 0.96/Patient-Reported Outcomes Measurement Information System [PROMIS] point, 0.92 to 0.99), and a clinical diagnosis of femoroacetabular impingement (FAI) (OR 3.47, 2.05 to 5.89), acetabular dysplasia (OR 2.75, 1.73 to 4.35), and/or labral tear (OR 10.71, 6.98 to 16.47). Radiographic dysplasia (lateral center edge angle <20 degrees) increased the likelihood of surgery in all subgroups (ORs 2.05-8.47, p ≤ .008). Increasing maximum α angle increased the likelihood of surgery in patients with severe cam FAI (α > 63 degrees) (OR 1.03/degree, 1.00 to 1.06)., Conclusion: Almost half of patients with pre-arthritic hip pain did not progress to surgery at a minimum 1-year follow-up. A trial of conservative management is likely worthwhile in most patients., (© 2021 American Academy of Physical Medicine and Rehabilitation.)

Objectives: To examine whether a hip brace can improve hip health quality-of-life (QoL) and is well-tolerated in people with femoroacetabular impingement syndrome (FAIS) or symptomatic labral tears after 6 weeks of wear., Design: Parallel, two-arm, exploratory randomized trial., Setting: Hospital and private clinics of orthopaedic surgeons., Participants: Individuals >18 years with FAIS or labral tears., Interventions: Usual conservative care versus usual conservative care plus a hip brace., Main Outcomes: Patient-reported outcomes were assessed with the International Hip Outcome Tool (iHOT-33), and Copenhagen Hip and Groin Outcome Scores (HAGOS). Brace acceptability was measured using the Quebec User Evaluation of Satisfaction with Assistive Technology survey. Independent t-tests assessed between-group differences., Results: Thirty-eight participants were recruited, 19 each group, 60% women, mean age 39.3 ± 11.8 years, body mass index 25.3 ± 4.4 kg/m2, iHOT-33 36.6 ± 24.8. Three participants dropped out (one usual care, 2 braced). The mean between-group difference for iHOT-33 was 19.4 (95% confidence interval [CI] 1.68-37.06, P = 0.03) favoring the brace. There were improvements in most HAGOS subscale scores favoring the brace. Issues with brace tolerability for some participants were perceived comfort and effectiveness. Three brace-related adverse events were reported., Conclusion: Between-group differences favored the braced group for hip health QoL, pain, symptoms, and function. Although these were promising results, the CIs for the estimates were wide, the small sample size likely a contributing factor. Our results suggest that further investigation of the brace is warranted, we calculated sample sizes and made recommendations for the design of a future trial., Competing Interests: The research design, conduct and reporting were independent of any conflict of interest from the company, Ossur HF, Iceland who provided partial funding and supplied the hip braces for the study. D.J. Hunter has consultancies of <$10,000 / year with the following: Merck Serono, Pfizer, Lilly, TLCBio. The reamaining authors report no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Femoroacetabular impingement syndrome (FAIS) is a relevant cause of groin pain in adolescents. Athletes are particularly affected., Objectives: The article shall provide an evidence-based background for FAIS counseling and therapy in adolescents., Material and Methods: On the basis of the current literature, an overview of the prevalence and pathogenesis, evaluation and diagnostics, as well as the therapeutic recommendations for FAIS in adolescents was compiled., Results and Discussion: FAIS in adolescents primarily affects physically active patients. Certain sports favor the development of FAIS. Cam impingement, pincer impingement, and combined FAIS are the most common entities in this age group. Cam morphology occurs shortly before closure of the proximal femoral growth plate. In cam impingement, the slipped capital femoral epiphysis (SCFE) must be distinguished from the primary cam morphology. SCFE requires rapid surgical treatment with stabilization of the epiphysis, while primary cam impingement can be analyzed electively, and conservative treatment is first recommended. Damage to the labrum and cartilage is regularly observed. A systematic radiological evaluation using X‑rays and MRI is mandatory in order to develop an adequate treatment plan. In adolescent patients with FAIS, a conservative attempt at therapy should always be made; if this is unsuccessful, surgical repair with hip arthroscopy is indicated. The postoperative results are very good in adolescents, with a rapid improvement in symptoms, few complications, and a high return-to-sport rate., (© 2022. The Author(s).)

Introduction: Hip arthroscopy is not always successful, leading to high rates of total hip arthroplasty (THA) after arthroscopy. The aim of this study was to identify risk factors for THA, revision arthroscopy and low patient satisfaction and to compare outcomes of the different procedures of primary hip arthroscopy., Methods: A total of 91 primary hip arthroscopy procedures in 90 patients (66% female) were analysed. Data were gathered from patient files and a questionnaire was sent to patients including the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), modified Harris Hip Score (mHHS), the EuroQol 5-dimension and questions about return to sports, satisfaction and pain before and after surgery. Using regression analyses, predictive factors for the outcomes were identified., Results: After a mean of 1.6 years, 4 patients (4%) underwent revision arthroscopy and 10 (11%) a THA. Of the responders (62%), 66% of the patients was satisfied to very satisfied about the surgery. Mean mHHS score was 75.3 (SE 1.9) and the mean WOMAC score was 81.0 (SE 2.8). Return to sports rate was 58%. A higher age was a significant predictor for lower satisfaction ( p  = 0.008) and a longer duration of symptoms was a significant predictor for worse mHHS outcome scores ( p  = 0.005)., Conclusion: A higher age is a predictor for a lower satisfaction and a longer duration of symptoms before surgery has a negative influence on functional outcome. No risk factors for THA or revision arthroscopy were found and there were no significant differences in outcome measurements between the performed surgeries.

This statement summarises and appraises the evidence on diagnostic tests and clinical information, and non-operative treatment of femoroacetabular impingement (FAI) syndrome and labral injuries. We included studies based on the highest available level of evidence as judged by study design. We evaluated the certainty of evidence using the Grading of Recommendations Assessment Development and Evaluation framework. We found 29 studies reporting 23 clinical tests and 14 different forms of clinical information, respectively. Restricted internal hip rotation in 0° hip flexion with or without pain was best to rule in FAI syndrome (low diagnostic effectiveness; low quality of evidence; interpretation of evidence: may increase post-test probability slightly), whereas no pain in Flexion Adduction Internal Rotation test or no restricted range of motion in Flexion Abduction External Rotation test compared with the unaffected side were best to rule out (very low to high diagnostic effectiveness; very low to moderate quality of evidence; interpretation of evidence: very uncertain, but may reduce post-test probability slightly). No forms of clinical information were found useful for diagnosis. For treatment of FAI syndrome, 14 randomised controlled trials were found. Prescribed physiotherapy, consisting of hip strengthening, hip joint manual therapy techniques, functional activity-specific retraining and education showed a small to medium effect size compared with a combination of passive modalities, stretching and advice (very low to low quality of evidence; interpretation of evidence: very uncertain, but may slightly improve outcomes). Prescribed physiotherapy was, however, inferior to hip arthroscopy (small effect size; moderate quality of evidence; interpretation of evidence: hip arthroscopy probably increases outcome slightly). For both domains, the overall quality of evidence ranged from very low to moderate indicating that future research on diagnosis and treatment may alter the conclusions from this review., Competing Interests: Competing interests: KT is Deputy Editor in BJSM, and have received grants from the Danish Society of Sports Physical Therapy., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The tremendous physical demands of elite performance increase the risk of elite athletes sustaining various orthopaedic injuries. Hip pain is common in high-level athletes representing up to 6% of all athletic injuries. Expedient diagnosis and effective treatment are paramount for their future sporting careers and to prevent subsequent joint degeneration., Purpose: This systematic review aimed to evaluate the outcome and the rate of return to play (RTP) following arthroscopic procedures in the hip (osteoplasty, chondroplasty, labral repair and/or debridement, capsulotomy, capsulorrhaphy or any soft tissue procedure) in elite athletes. Elite athletes were defined as those who represented their country in international contests or were competing professionally for the purpose of this study., Methods: A computer-based systematic search, following the PRISMA Guidelines, was performed on CENTRAL, PUBMED, EMBASE, SCOPUS, EBSCO, Google Scholar and Web of Science from inception until January 1, 2020, identifying studies that looked at return to sports post-hip arthroscopy in elite athletes. Weighted means were calculated for the RTP rate and duration and for patient-reported outcome measures (PROMs)., Results: After eligibility screening, 22 articles were included with a total of 999 male and seven female patients, 1146 hips and a mean age of 28.4 ± 3.2 years. The mean follow-up period was 35.8 ± 13.4 months and 15.9 ± 9.6% of athletes had undergone bilateral procedures. Overall, 93.9% (95% CI: 90.5, 96.6, P < 0.0001) of patients demonstrated RTP after 6.8 ± 2.1 months post-surgery and all PROMs improved post-operatively. During follow-up, 9.6% (95% CI: 5.2, 15.2, P = 0.025) patients needed further intervention., Conclusion: A high percentage of elite athletes return to the same level of competition after hip arthroscopy, with a low rate of further interventions. Hip arthroscopy appears to be an efficacious treatment for hip and/or groin pain, caused by pathologies such as FAI or labral tears, in elite athletes in the shorter term. Long term outcomes need further evaluation., (© 2021. The Author(s).)

Objective: The purpose of this study was to propose and validate a novel physical examination test for ischiofemoral impingement with magnetic resonance imaging (MRI) correlation., Methods: We prospectively studied 24 women with buttock (deep gluteal) pain and 27 asymptomatic women. Each group underwent a 2-stage physical examination test that featured hip adduction-external rotation-extension and knee flexion. Visual analog scale pain scores were noted just before and during test stages on both sides. The MRI findings of the ischiofemoral impingement were evaluated quantitatively and qualitatively., Results: Mean ages were 56.0 and 55.2 years (P = 0.797), and mean body mass indexes were 29.1 and 28.8 kg/m2 (P = 0.817) in symptomatic and asymptomatic groups, respectively. Ischiofemoral spaces were significantly narrower (P < 0.001), ischial angles were wider (P < 0.001, right; P = 0.002, left), and soft tissue edema at the ischiofemoral space was more common (P < 0.001) in the symptomatic group, which also had higher pretest visual analog scale scores (P < 0.001) that increased significantly during both upright standing (P = 0.003, right; P < 0.001, left) and recumbent (P < 0.001 for both sides) stages of the physical examination test., Conclusions: A novel physical examination test significantly increases symptoms of ischiofemoral impingement with positive MRI correlation., Competing Interests: The authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To investigate the effectiveness of ultrasound (US) guided intra-hip joint injection to estimate the outcome of hip arthroscopy in patients with femoroacetabular impingement (FAI) syndrome., Methods: Patients with FAI syndrome (n = 60) were prospectively enrolled in our study. Before hip arthroscopy, a mix of 4 mL 2% lidocaine and 4 mL 1% ropivacaine were injected into the hip joint under the guidance of US. The clinical efficacy of the intra-articular injection was evaluated by comparing the visual analog scale (VAS) and international hip outcome tool 12 (iHOT-12) results before and after the injection. The outcome of hip arthroscopy was evaluated by iHOT-12, the modified Harris hip score (MHHS), and the patient's satisfaction 12 months after the operation. The outcome of intra-articular injection and hip arthroscopy were compared. Factors related to the outcomes of hip arthroscopy were evaluated. The correlation between the efficacy of intra-hip joint injection and arthroscopy was evaluated., Results: The VAS of patients decreased from 11.3 ± 7.7 to 3.3 ± 4.5, and the iHOT-12 increased from 52.1 ± 23.2 to 84.1 ± 18.1 after intra-articular injection (all P < 0.001). The iHOT-12 score increased from 52.1 ± 23.2 to 78.9 ± 19.2, and the MHHS increased from 66.5 ± 6.8 to 81.6 ± 8.1 after hip arthroscopy (all P < 0.001). The satisfaction rate of arthroscopy, including very satisfied and effective patients, was 93.3%. Multi-variable logistic regression showed that only iHOT-12 improved value after injection was included in the regression formula of satisfaction, with the β of -0.154, standard error of 0.071, Wald value of 4.720, and OR of 0.857 (95%CI 0.746-0.985) (P = 0.03). Significant correlation was detected between iHOT-12 scores after intra-articular anesthesia and at 12 months after arthroscopy (r = 0.784, P < 0.001). So was the iHOT-12 improved value (r = 0.781, P < 0.001) and the iHOT-12 improved ratio (r = 0.848, P < 0.001). If we had performed arthroscopy only on patients with post-injection iHOT-12 score improvement ≥10, the satisfaction rate of arthroscopy would have increased to 96.6%., Conclusions: US-guided intra-hip joint injection may provide a feasible way to estimate the outcome of hip arthroscopy in patients with FAI syndrome, and could be used as a method for indication selection of hip arthroscopy., (© 2021 The Authors. Orthopaedic Surgery published by Chinese Orthopaedic Association and John Wiley & Sons Australia, Ltd.)

This article provides concise and up-to-date information on the most common hip pathologies that affect adolescent athletes. We cover the evaluation and treatment of avulsion injuries, stress fractures, slipped capital femoral epiphysis (SCFE), femoroacetabular impingement, developmental dysplasia of the hip, Legg-Calve-Perthes disease, and coxa saltans focusing on minimizing advanced imaging and using conservative therapy when applicable. Although this is not an all-encompassing list of disorders, it is key to understand these hip pathologies because these injuries occur commonly and can also have detrimental complications if not diagnosed and addressed early, especially SCFE and femoral neck stress fractures., Competing Interests: Disclosure The authors have nothing to disclose., (Published by Elsevier Inc.)

The hip and pelvis have a complex anatomy and are a common source of pain and injury in the athletic population. The clinical examination of the hip requires a systematic approach to differentially diagnose hip problems with overlapping pain referral patterns. Because of the complex anatomy of the hip, the physical examination is a comprehensive evaluation of the 4 main pain generators of the hip from deep to superficial: the osteochondral, capsulolabral, musculotendinous, and neurovascular elements of the hip. The hip examination begins with the standing examination and gait analysis followed by a seated, supine, lateral, and prone examination. A targeted physical examination used in conjunction with a layered understanding of the hip and pelvis can help guide diagnostic testing, distinguish hip-specific diagnoses from similar presenting pathologies, and inform treatment.

Objective: Evaluate interobserver and intraobserver reliability of hip arthroscopic classifications for labral tears., Design: Retrospective diagnostic study of nonconsecutive patients., Setting: Institutional study., Patients: From a database of 278 hip arthroscopy videos for treatment of femoroacetabular impingement, 70 videos were chosen by simple random sampling. Exclusion criteria included presence of radiological arthrosis (Tonnis > 2), previous hip surgery, inadequate lesion palpation, poor image quality, and refusal to participate in the study. The final sample included 60 videos., Interventions: Four hip surgeons evaluated the videos twice at 1-month intervals and classified the lesions according to Lage, Seldes, and Beck classifications for hip labral tears., Main Outcome Measures: Interobserver and intraobserver reliability with the percent of agreement and weighted Cohen kappa values., Results: Patients had a mean age of 33 years (SD, 7; range, 18-47 years), and 32 (53%) were men. Femoroacetabular impingement types included combined (CAM and pincer) in 31 (52%), CAM in 27 (45%), and pincer in 2 (3%). For interobserver reliability, the average weighted kappa values were 0.68, 0.65, and 0.78 for the Lage, Seldes, and Beck classifications, respectively. For intraobserver reliability, the mean weighted kappa values were 0.87, 0.64, and 0.93 for the Lage, Seldes, and Beck classifications, respectively., Conclusions: Beck classification had the highest average values for interobserver and intraobserver agreements. Lage, Seldes, and Beck scores for acetabular labrum tears showed substantial interobserver agreement. In the intraobserver evaluation, the Seldes system presented substantial agreement, whereas Lage and Beck classifications were considered excellent agreement., Competing Interests: The authors report no conflicts of interest., (Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.)

Athletic hip injuries account for a substantial portion of missed time from sports in high-level athletes. For both femoroacetabular impingement (FAI) and core muscles injuries, a thorough history and physical examination are paramount to guide the treatment. While advanced imaging including computed tomography and magnetic resonance imaging are frequently obtained, a wealth of information can be ascertained from standard radiographs alone. For patients with isolated or combined FAI and core muscle injuries (CMIs), the initial treatment is often nonoperative and consists of rest, activity modification, and physical therapy of the hips, core, and trunk. Injections may then aid in both confirming diagnosis and temporary symptom abatement. Arthroscopic procedures for refractory FAI in experienced hands have been shown to be both safe and efficacious. While surgical repair options for CMIs are significantly more variable, long-term studies have demonstrated the rapid resolution of symptoms and high return to play rates. More recently, anatomic and clinical correlations between FAI and CMIs have been identified. Special attention must be paid to elite athletes as the incidence of concurrent FAI with CMI is extremely high yet with significant symptom variability. Predictable return to play in athletes with coexisting symptomatic intra-articular and extra-articular symptomatology is incumbent upon the treatment of both pathologies., Competing Interests: Disclosure: T.S.L. is a paid consultant to Conmed Linvatec and Smith & Nephew. C.M.L. is a paid consultant to Smith & Nephew. J.W.T.B. is a paid consultant and receives royalties from Smith & Nephew and receives royalties from Springer. A.S.P. declares no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To evaluate the diagnostic value of ultrasound and ultrasound-guided hip injection in the diagnosis of femoroacetabular impingement (FAI) with atypical symptoms., Methods: We evaluated consecutive patients diagnosed with FAI and with atypical symptoms who underwent ultrasound-guided hip injection between January 2017 and February 2019. All patients underwent systematic physical examination, ultrasound examination, magnetic resonance imaging (MRI) examination, and ultrasound-guided injection before surgery. Patients with positive response to ultrasound-guided hip injection were recommended to undergo arthroscopic surgery to treat intra-articular pathology. Sensitivity, specificity, accuracy, and positive predictive value (PPV) of ultrasound and MRI were calculated by using arthroscopic surgery as the gold standard. The accuracy of ultrasound-guided hip injection was recorded. Preoperative and postoperative patient-reported outcomes included visual analog scale for pain and modified Harris Hip Score., Results: A total of 78 patients with atypical symptoms were diagnosed with FAI. Among these 78 patients, 50 patients had positive responses to injection and 28 patients had negative responses to injection. A total of 36 patients finally underwent arthroscopic surgery. Response to the ultrasound-guided intra-articular injection was 91.7% accurate for detecting the presence of intra-articular abnormality. There were no complications of injection in any of the patients. The sensitivity, PPV, and accuracy by ultrasound diagnosis of cam impingement were 82.9%, 96.7%, and 80.6%, respectively. The sensitivity and accuracy by ultrasound diagnosis of anterosuperior labral tear were both 72.2%. For MRI diagnosis of cam impingement, the sensitivity, PPV and accuracy were 72.2%, 96.3%, and 74.3%, respectively. For MRI diagnosis of labral tear, the sensitivity and accuracy were both 88.9%. Thirty-four patients (94.4%) surpassed the minimal clinically important difference, and 33 patients (91.7%) achieved the patient acceptable symptomatic state., Conclusions: Ultrasound and ultrasound-guided hip injection have high accuracy in the diagnosis of femoroacetabular impingement with atypical symptoms., Level of Evidence: IV, case series., (Copyright © 2020 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: Outcomes for operative and nonoperative management of femoroacetabular impingement syndrome (FAIS) are variable. Understanding factors that inform patients' treatment decisions may optimize their outcomes., Objective: To identify factors that predict which patients with FAIS proceed to surgery within 90 days of their initial evaluation by an orthopedic surgeon. The study explored potential predictors of surgical intervention, including demographic factors, activity level, symptom duration, previous treatment, hip function, pain, presence of labral tear, and patient interest in surgical and physical therapy (PT) treatment., Design: Prospective cohort., Setting: Single-site academic medical center., Patients: Seventy-seven individuals with FAIS., Intervention: After evaluation in a hip preservation clinic, participants reported activity level, symptom duration, treatment history, hip function [Hip Outcome Score Activities of Daily Living(HOS-ADL)], pain severity and location, and treatment interests. These variables were evaluated based on univariate analysis for entry into a multiple binomial logistic regression to identify predictors of surgery within 90 days. Adjusted marginal prevalence ratios and 95% confidence interval estimates (PR [95% CI]) were reported (P ≤ .05)., Main Outcome Measure(s): Ninety-day treatment (surgery or not)., Results: Participants indicated initial interest in surgery (n = 27), PT (n = 22), both (n = 18), or neither (n = 10). Those only interested in PT had lower prevalence of diagnosed labral tear (P < .001) and previous PT for the hip (P < .001). Prevalence of previous injection was higher for those only interested in surgery than for those with any interest in PT (P < .001). Thirty-six of 77 participants (46%) underwent surgery within 90 days. Surgical interest (3.56 [1.57, 5.46]), previous hip injection (3.06 [1.73, 3.89]), younger age (0.95 [0.92, 0.98]), and worse hip function (0.97 [0.95, 0.99]) were significant (P ≤ .02) predictors of surgery., Conclusions: Treatment interest and history, patient function, and age were significantly related to participants' decision to pursue surgical intervention within 90 days. Patient engagement in the decision-making process should include considerations of patient knowledge of, and experience with, the various treatment options., (© 2020 American Academy of Physical Medicine and Rehabilitation.)

Often referred to as a "sports hernia" or "core muscle injury," athletic pubalgia is a common yet poorly defined athletic injury. It is characterized by abdominal and groin pain likely from weakening or tearing of the abdominal wall without evidence of a true hernia. Symptoms can appear acutely or insidiously, primarily as groin and lower abdominal pain that can radiate toward the perineum and proximal adductors. Pain is exacerbated by athletic activity such as kicking, cutting, and sprinting. The pubis acts as a pivot point between the abdominal musculature and lower-extremity adductors, and therefore, pain with palpation over the symphysis or its surrounding structures is typical in athletic pubalgia. Symptoms can be reproduced during a resisted sit-up or with a forced cough or sneeze. Clinical examination should include an evaluation of articular hip pathology to identify underlying femoroacetabular impingement syndrome. Magnetic resonance imaging can aid in ruling out other pathologies and identify specific findings including tears or strains of the ipsilateral rectus abdominis or adductor tendons. Lidocaine injections can be used to localize the source of the pain. First-line treatment consists of a period of rest and anti-inflammatories, followed by a course of focused physical therapy. If conservative therapy fails to allow an athlete to return to activity, a variety of open or laparoscopic surgical techniques can be used. The surgical principles include reattachment of the rectus abdominis and repair or reinforcement of the abdominal musculature in layers to re-create the inguinal ligament anatomy. At times, variations of pelvic floor repair are performed or the addition of an adductor tenotomy or repair is used concomitantly. Numerous studies report a high rate of return to play after surgical management. Diagnosis and appropriate treatment of coexisting femoroacetabular impingement syndrome are crucial to a successful return to athletic activity., (Copyright © 2020 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Purpose: As the prevalence of femoro-acetabular impingement syndrome (FAIS) in symptomatic patients who lack evidence of hip osteoarthritis (OA) remains to be described, the purpose of this study was to calculate the prevalence of FAIS in this patient population., Methods: Libraries of PubMed, Embase, and Ovid were systematically reviewed for all studies between 2009 and 2019, investigating femoro-acetabular impingement and hip pain. Level I-IV studies delineating patients with hip pain who do not have OA (Tonnis or Outerbridge grades < three) were included. Demographics, outcomes, radiographic parameters, and criteria were entered into a meta-analysis to calculate the incidence of FAIS in non-arthritic symptomatic hips., Results: In total, 2264 patients (2758 hips) were included in the pooled analysis. Weighted mean age was 31 years. The incidence of FAIS in patients with no evidence of osteoarthritis but who complain of hip pain is 61% (47.3-74.4%). In total, 1483 hips were diagnosed with FAIS. Of the studies that described the rates of all three of the various subtypes of FAIS in their reports, 37% had a combined-type, 38% had a cam-type, and 25% had a pincer-type FAIS., Conclusion: Femoroacetabular impingement should be suspected in 47 to 74% of patients with hip pain and without arthritis. Physicians must maintain a high index of suspicion for FAIS in young patients presenting with hip pain, as FAIS is a common and treatable condition that, if left alone, may lead to hip degeneration.

Background: Ultrasound-assisted measurement of hip flexion has demonstrated that hip flexion has been historically overestimated in men. To our knowledge, assessment of hip flexion in women using similar methods has not been reported. Establishing normative values for hip flexion is vital to aid diagnosis, management, and future research. Therefore, we asked 2 questions: (1) At what range of midsagittal hip flexion do soft-tissue impingement and femoroacetabular abutment occur in asymptomatic young adult women? (2) Do radiographic findings on a supine anteroposterior pelvic radiograph correlate with ultrasound-assisted measurements of hip flexion?, Methods: Fifty-five asymptomatic adult women volunteers (107 hips) underwent ultrasound-assisted assessment of hip flexion. Hip flexion was recorded at the initiation of labral contact and at bone-on-bone contact. Recorded motion was correlated with common radiographic measurements of hip morphology as observed on a supine anteroposterior pelvic radiograph., Results: The mean age of the subjects was 26 ± 3 years (range, 21 to 35 years), and the mean body mass index was 23 ± 3 kg/m (range, 17 to 31.6 kg/m). Mean impingement-free and maximum midsagittal passive flexion were 72° ± 8° (95% confidence interval [CI], 70° to 74°) and 101° ± 11° (95% CI, 99° to 103°), respectively. There were no significant correlations between radiographic measurements of hip morphology and ultrasound-measured hip range of motion., Conclusions: Observed hip flexion in the asymptomatic hips of young women is substantially less than has been historically reported. Morphologic features that are measurable on anteroposterior pelvic radiographs do not correlate with ultrasound-measured hip flexion. Diagnosis of hip disorders and treatments that are designed to alter hip range of motion should be based on normative data. Future studies regarding surgical restoration and/or preservation of hip flexion should be based on an understanding of normal hip range of motion., Clinical Relevance: Ultrasound-assisted hip flexion measurement established normative values to guide surgical restoration and/or preservation of hip flexion.

Introduction: Acetabular retroversion syndrome is associated with pincer-type femoroacetabular impingement (FAI) and results, theoretically, from an externally rotated hemipelvis. The purpose of this study was to examine our surgical experience and the clinical results of functional acetabular retroversion syndrome treated with minimally-invasive periacetabular osteotomy (PAO)., Methods: We performed a retrospective cohort study of prospectively collected data in consecutive patients who had an anteverting PAO from 01 November 2010 to 31 December 2015. All patients were followed up clinically and radiologically.Functional scores were ascertained using pre- and postoperative iHOT-12 and EQ-5D. The effect of hypermobility, smoking status and body mass index (BMI) on outcome measures was evaluated., Results: 31 anteverting PAOs were performed on 27 consecutive patients. All patients were female. The mean age was 26.7 years (SD 6.7). The mean BMI was 25.8 kg/m 2 (SD 5.1). 5 patients were smokers (16.1%) and 11 exhibited signs of generalised joint laxity. 23 hips had undergone prior hip arthroscopy and 1 patient had previous open FAI surgery. The minimum clinical follow-up was 2 years (mean 3.4 years; range 2-7 years). A crossover sign was present in all cases. The mean iHOT-12 score improved from 19.5 to 51 at 6 months, 64.5 at 1 year and 48 at 2 years following surgery ( p < 0.05) EQ-5D improved from 0.42 preoperatively to 0.76 at 6 months and 0.69 at 1 year following surgery ( p < 0.05)., Conclusions: We have characterised functional acetabular retroversion syndrome (FARS) as a condition affecting young, active females which severe symptoms out of proportion to demonstrable radiographic pathology.

Femoroacetabular impingement results from a mismatch of congruency between the femoral head and the acetabulum. This condition is most common among young, active patients and may lead to pain, decreased quality of life, and inability to participate in athletics. Hip preservation surgery is widely performed is used as a definitive treatment option in athletes at all levels of competition. Athletes have reported high rates of return to play and satisfaction and expect rehabilitation to require approximately 4 to 6 months. This article provides an overview of femoroacetabular impingement, including diagnosis and treatment, with focus on athletes and return to play., Competing Interests: Disclosure This research was funded by The Rothman Institute and Thomas Jefferson University., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Purpose: Clinical examination is an important part in the diagnosis of femoroacetabular impingement (FAI) syndrome. However, knowledge on reliability and validity of clinical diagnostic tests is scarce. The aims were to evaluate the inter-rater agreement and diagnostic accuracy of clinical tests to detect patients with FAI syndrome., Methods: Eighty-one patients (49% women) were recruited. Two experienced raters performed impingement and range of motion (ROM) tests. Three criteria had to be fulfilled for the diagnosis of FAI syndrome: (1) symptoms; (2) CAM and/or Pincer morphology; and (3) being responder to intra-articular block injection. For inter-rater agreement, the Cohen's kappa statistics were used (0.41-0.60 = moderate, 0.61-0.80 = substantial agreement). For diagnostic accuracy, sensitivity, specificity, positive and negative predictive values were calculated., Results: Anterior impingement test (AIMT), FADIR test and FABER test showed kappa values above 0.6. All passive hip ROM, except extension, had kappa values above 0.4. AIMT and FADIR showed the highest sensitivity, i.e., 80%, with a specificity of 26% and 25%, respectively. Passive hip ROM in internal rotation with neutral hip position had a sensitivity of 29% and a specificity of 94%., Conclusion: The AIMT, FADIR and FABER tests were reliable between two experienced raters, while results from different raters for hip ROM should be interpreted with caution. The AIMT and FADIR test can only be used to rule out patients with FAI syndrome, while evaluation of ROM in internal rotation with neutral position may be more suitable to rule in patients with FAI syndrome., Level of Evidence: II.

Objectives: Imaging assessment for the clinical management of femoroacetabular impingement (FAI) syndrome remains controversial because of a paucity of evidence-based guidance and notable variability in clinical practice, ultimately requiring expert consensus. The purpose of this agreement is to establish expert-based statements on FAI imaging, using formal techniques of consensus building., Methods: A validated Delphi method and peer-reviewed literature were used to formally derive consensus among 30 panel members (21 musculoskeletal radiologists and 9 orthopaedic surgeons) from 13 countries. Forty-four questions were agreed on, and recent relevant seminal literature was circulated and classified in five major topics ('General issues', 'Parameters and reporting', 'Radiographic assessment', 'MRI' and 'Ultrasound') in order to produce answering statements. The level of evidence was noted for all statements, and panel members were asked to score their level of agreement with each statement (0 to 10) during iterative rounds. Either 'consensus', 'agreement' or 'no agreement' was achieved., Results: Forty-seven statements were generated, and group consensus was reached for 45 (95.7%). Seventeen of these statements were selected as most important for dissemination in advance. There was no agreement for the two statements pertaining to 'Ultrasound'., Conclusion: Radiographic evaluation is the cornerstone of hip evaluation. An anteroposterior pelvis radiograph and a Dunn 45° view are recommended for the initial assessment of FAI although MRI with a dedicated protocol is the gold standard imaging technique in this setting. The resulting consensus can serve as a tool to reduce variability in clinical practices and guide further research for the clinical management of FAI., Key Points: • FAI imaging literature is extensive although often of low level of evidence. • Radiographic evaluation with a reproducible technique is the cornerstone of hip imaging assessment. • MRI with a dedicated protocol is the gold standard imaging technique for FAI assessment.

Background: Peripheral cupping of the capital femoral epiphysis over the metaphysis has been reported as a precursor of cam morphology, but may also confer stability of the epiphysis protecting it from slipped capital femoral epiphysis (SCFE). The purpose of this study was to investigate the relationship between a novel morphologic parameter of inherent physeal stability, epiphyseal cupping, and the development of SCFE in a dual-center matched-control cohort study., Methods: We performed a dual-center age-matched and sex-matched cohort study comparing 279 subjects with unilateral SCFE and 279 radiographically normal controls from 2 tertiary children's hospitals. All SCFE patients had at least 18 months of radiographic follow-up for contralateral slip surveillance. Anteroposterior and frog lateral pelvis radiographs were utilized to measure the epiphyseal cupping ratio and the current standard measure of inherent physeal stability, the epiphyseal extension ratio., Results: Control hips were found to have greater epiphyseal cupping than the contralateral uninvolved hip of SCFE subjects both superiorly (0.28±0.08 vs. 0.24±0.06; P<0.001) and anteriorly (0.22±0.07 vs. 0.19±0.06; P<0.001). The 58/279 (21%) subjects who went on to develop contralateral slip had decreased epiphyseal cupping superiorly (0.25±0.07 vs. 0.23±0.05; P=0.03) and anteriorly (0.20±0.06 vs. 0.17±0.04; P<0.001). When we compared controls with hips that did not progress to contralateral slip and hips that further developed a contralateral SCFE, 1-way ANOVA demonstrated a stepwise decrease in epiphyseal cupping and epiphyseal extension ratio in the anterior and superior planes from control hips to contralateral hips without subsequent slip to contralateral hips that developed a SCFE (P<0.01 for each)., Conclusions: This study provides further evidence that epiphyseal cupping around the metaphysis is associated with decreased likelihood of SCFE and may reflect increased inherent physeal stability. Epiphyseal cupping may represent an adaptive mechanism to stabilize the epiphysis during adolescence at the long-term cost of the eventual development of associated cam-femoroacetabular impingement deformity., Levels of Evidence: Level III-prognostic Study.

Dislocation after total hip arthroplasty (THA) remains a major issue and an important post-surgical complication. Impingement and subsequent dislocation are influenced by the design (head size) and position (anteversion and abduction angles) of the acetabulum and different movements of the patient, with external extension and internal flexion the most critical movements. The aim of this study is to develop a computational tool based on a three-dimensional (3D) parametric finite element (FE) model and an artificial neural network (ANN) to assist clinicians in identifying the optimal prosthesis design and position of the acetabular cup to reduce the probability of impingement and dislocation. A 3D parametric model of a THA was used. The model parameters were the femoral head size and the acetabulum abduction and anteversion angles. Simulations run with this parametric model were used to train an ANN, which predicts the range of movement (ROM) before impingement and dislocation. This study recreates different configurations and obtains absolute errors lower than 5.5° between the ROM obtained from the FE simulations and the ANN predictions. The ROM is also predicted for patients who had already suffered dislocation after THA, and the computational predictions confirm the patient's dislocations. Summarising, the combination of a 3D parametric FE model of a THA and an ANN is a useful computational tool to predict the ROM allowed for different designs of prosthesis heads.

Objectives: The purpose of this study was to determine if the CT texture profile of acetabular subchondral bone differs between normal, asymptomatic cam-positive, and symptomatic cam-FAI hips. In addition, the utility of texture analysis to discriminate between the three hip statuses was explored using a machine learning approach., Methods: IRB-approved, case-control study analyzing CT images in subjects with and without cam morphology from August 2010 to December 2013. Sixty-eight subjects were included: 19 normal controls, 26 asymptomatic cam, and 23 symptomatic cam-FAI. Acetabular subchondral bone was contoured on the sagittal oblique CT images using ImageJ ®. 3D histogram texture features (mean, variance, skewness, kurtosis, and percentiles) were evaluated using MaZda software. Groupwise differences were investigated using Kruskal-Wallis tests and Mann-Whitney U tests. Gradient-boosted decision trees were created and trained to discriminate between control and cam-positive hips., Results: Both asymptomatic and symptomatic cam-FAI hips demonstrated significantly higher values of texture variance (p = 0.0007, p < 0.0001), 90th percentile (p = 0.007, p = 0.006), and 99th percentile (p = 0.009, p = 0.009), but significantly lower values of skewness (p = 0.0001, p = 0.0013) and kurtosis (p = 0.0001, p = 0.0001) compared to normal controls. There were no differences in texture profile between asymptomatic cam and symptomatic cam-FAI hips. Machine learning models demonstrated high classification accuracy for discriminating control hips from asymptomatic cam-positive (82%) and symptomatic cam-FAI (86%) hips., Conclusions: Texture analysis can discriminate between normal and cam-positive hips using conventional descriptive statistics, regression modeling, and machine learning algorithms. It has the potential to become an important tool in compositional analysis of hip subchondral trabecular bone in the context of FAI, and possibly serve as a biomarker of joint degeneration., Key Points: • The CT texture profile of acetabular subchondral bone is significantly different between normal and cam-positive hips. • Texture analysis can detect changes in subchondral bone in asymptomatic cam-positive hips that are equal to that of symptomatic cam-FAI hips. • Texture analysis has the potential to become an important tool in compositional analysis of hip subchondral bone in the context of FAI and may serve as a biomarker in the study of joint physiology and biomechanics.