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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.)

Purpose: The aim of this retrospective study was to investigate, at 8 years, the clinical follow-up and failure rate (revision rate/conversion to arthroplasty) of patients with hip chondral lesions associated with femoroacetabular impingement and to compare over time the treatment by microfracture (MFx) and autologous matrix-induced chondrogenesis (AMIC)., Methods: Patients aged between 18 and 55 years, with acetabular grade III and IV chondral lesions (Outerbridge), measuring 2 to 8 cm 2 operated on at least 8 years before enrollment. Exclusion criteria were rheumatoid arthritis, dysplasia, or axial deviation of the femoral head. There were no arthritic lesions, Tonnis < 2, or joint space of at least 2 mm. MFx was performed with an awl, and the Chondro-Gide membrane used for the AMIC procedure was placed without glue. Outcomes used modified Harris hip score (mHHS) at 6 months and yearly for 8 years and patient acceptable symptomatic state., Results: Among 130 patients, 109 fulfilled inclusion criteria. Fifty were treated by MFx and 59 by AMIC. The mHHS significantly improved in both groups from 46 ± 6.0 to 78 ± 8.8 for mHHS at 6-12 months, even for lesions > 4 cm 2 . From 2 to 8 years, mHHS in the AMIC group was better than in the MFx group (P < .005). This mHHS improvement in the AMIC group was maintained through the 8-year follow-up period, whereas it deteriorated after 1 year in the MFx group (P < .005). Eleven patients (22%) in the MFx group required total hip arthroplasty (THA); none in the AMIC group did. Patient acceptable symptomatic state analysis confirmed similar short-term improvement, but a significant (P < .007) degradation after 2-8 years in MFx patients., Conclusions: MFx and AMIC techniques led to marked clinical short-term improvement in patients with chondral defects resulting from femoroacetabular impingement in the first 2 years. However, AMIC gave significantly better results as measured by mHHS, which were maintained after 8 years, the results of MFx in the hip deteriorated over time with 22% of patients undergoing conversion to THA. No patient in the AMIC group was converted to THA; the results of AMIC appeared stable over time and independent of lesion size., Level of Evidence: III, retrospective patient group study., (Copyright © 2018 The Authors. Published by Elsevier Inc. All rights reserved.)

Purpose: To determine a Patient Acceptable Symptomatic State (PASS) score for the 33-item International Hip Outcome Tool (iHOT-33) in people undergoing hip arthroscopy for primary diagnoses of femoroacetabular impingement syndrome, acetabular labral tears, and/or ligamentum teres pathology., Methods: Consecutive participants underwent hip arthroscopy by a single surgeon between August 2011 and May 2016. Participants were included if they were between ages 18 and 60 years and underwent hip arthroscopy for femoroacetabular impingement syndrome, acetabular labral tears, or ligamentum teres pathology. Participants were excluded if they did not speak sufficient English to complete the iHOT-33, had evidence of hip dysplasia, had less than 2 mm of joint space on anteroposterior radiograph, or underwent subsequent total hip replacement surgery. Participants completed the iHOT-33 preoperatively and at a minimum of 1 to a maximum of 5 years postoperatively. Participants were also asked to answer yes or no to the external anchor question of "Taking into account all the activities you do during your daily life, your level of pain and also your functional impairment, are you satisfied with your current state following your surgery?" A receiver operating characteristic (ROC) curve was used to identify the PASS score. Multiple logistic regression was performed to determine if patient factors, primary preoperative diagnosis, or intraoperative findings predicted achievement of the PASS score., Results: A total of 117 participants undergoing hip arthroscopy were included: 72 women (61.1%) and 45 men (38.5%) with mean age of 36.81 years (18-59). Forty-two (35.9%) had cam morphology, 18 (15.4%) had pincer morphology, 78 (67.2%) had labral tears, and 97 (82.9%) had ligamentum teres tears. Mean time to final follow-up was 2.25 years (range, 1-5). The PASS score at a mean of 2.25 years postoperatively was 58 as determined by the cutoff threshold on the ROC curve with the lowest difference between sensitivity and specificity (area under the ROC curve 0.88; P < .01; 95% confidence interval [CI], 0.81-0.95). No factors were predictors of achievement of the PASS score in this study (P > .05), including age (odds ratio [OR], 0.71; 95% CI, 0.32-1.56), sex (OR, 1.02; 95%, CI 0.98-1.06), preoperative iHOT-33 score (OR, 1.002; 95% CI, 0.98-1.03), primary preoperative diagnosis (OR, 0.86; 95% CI, 0.53-1.40), cam morphology (OR, 1.19; 95% CI, 0.54-2.64), Pincer morphology (OR, 0.50; 95%, CI 0.18-1.38), acetabular labral tears (OR, 1.93; 95% CI, 0.88-4.26), Outerbridge grade 3-4 chondral damage (OR, 0.97; 95% CI, 0.42-2.25), and ligamentum teres pathology (OR, 0.95; 95% CI, 0.35-2.61)., Conclusions: This study reports a PASS score of 58 for the iHOT-33 at 2 years following hip arthroscopy. The PASS score will assist in assessing response to hip arthroscopy in research and clinical settings., Level of Evidence: Level II, retrospective prognostic study., (Crown Copyright © 2018. Published by Elsevier Inc. All rights reserved.)

Background Symptomatic pre-arthritic deformities such as femoroacetabular impingement (FAI) or hip dysplasia often lead to localised cartilage defects and subsequently to osteoarthritis. The present review of the working group "Clinical Tissue Regeneration" of the German Society of Orthopaedics and Trauma (DGOU) and the hip committee of the AGA (German speaking Society for Arthroscopy and Joint Surgery) provides an overview of current knowledge of the diagnosis and surgical treatment of cartilage defects, in order to infer appropriate therapy recommendations for the hip. Methods Review of FAI and resultant cartilage damage in the hip as reported in published study findings in the literature and discussion of the advantages and disadvantages of different surgical procedures to preserve the joint. Results Most published studies on the surgical treatment of cartilage damage in the hip report defects caused by cam-type FAI at the acetabulum. Development of these defects can be prevented by timely elimination of the relevant deformities. At present, current full-thickness cartilage defects are mostly treated with bone marrow-stimulating techniques such as microfracture (MFx), with or without a biomaterial, and matrix-assisted autologous chondrocyte transplantation (MACT). Osteochondral autologous transplantation (OAT) is not the treatment of choice for isolated full-thickness chondral defects at the hip, because of the unfavourable risk-benefit profile. Due to the relatively short history of cartilage repair surgery on the hip, the studies available on these procedures have low levels of evidence. However, it is already becoming obvious that the experience gained with the same procedures on the knee can be applied to the hip as well. For example, limited healing and regeneration of chondral defects after MFx can also be observed at the hip joint. Conclusions The cartilage surface of the acetabulum, where FAI-related chondral lesions appear, is considerably smaller than the weight-bearing cartilage surface of the knee joint. However, as in the knee joint, MACT is the therapy of choice for full-thickness cartilage defects of more than 1.5 - 2 cm 2 . Minimally invasive types of MACT (e.g. injectable chondrocyte implants) should be preferred in the hip joint. In cases where a single-stage procedure is indicated or there are other compelling reasons for not performing a MACT, a bone marrow-stimulating technique in combination with a biomaterial covering is preferable to standard MFx. For treatment of lesions smaller than 1.5 - 2 cm 2 the indication for a single-stage procedure is wider. As with defects in the knee, it is not possible to determine a definite upper age limit for joint-preserving surgery or MACT in the hip, as the chronological age of patients does not necessarily correlate with their biological age or the condition of their joints. Advanced osteoarthritis of the hip is a contraindication for any kind of hip-preserving surgery. Long-term observations and prospective randomised studies like those carried out for other joints are necessary., Competing Interests: Interessenkonflikt: Die Autoren geben an, dass kein Interessenkonflikt besteht., (Georg Thieme Verlag KG Stuttgart · New York.)

Femoral acetabular impingement (FAI) has emerged as one of the more commonly recognized intraarticular hip pathologies and is often accompanied with a labral tear. The understanding of the clinical characteristics of individuals with symptomatic FAI has evolved over the past several years due to emerging research. As research progresses, there is often a gap in translating the current evidence to clinical practice. This manuscript presents the latest evidence underpinning the clinical presentation of FAI and labral tears. Evidence is presented within the context of bridging the latest research and clinical practice., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Purpose: To develop a simplified method to define a clinically relevant subregion in the course of arthroscopic treatment of femoroacetabular impingement (FAI) using T2 mapping in patients and asymptomatic volunteers. Additionally, we sought to compare the lateral and medial subregion values in asymptomatic volunteers and in patients presenting with FAI. Finally, we wanted to investigate possible associations between patients' T2 mapping values and demographic variables-i.e., alpha angle, age, sex, and body mass index (BMI)., Methods: Twenty-five asymptomatic volunteers and 23 consecutive symptomatic patients with FAI (cam or mixed type) were prospectively enrolled and evaluated with a sagittal T2 mapping sequence. The weight-bearing region of the acetabular and femoral cartilage was manually segmented and divided into medial and lateral subregions. Median T2 values were determined, and patient characteristics were assessed as potential predictors of T2 values., Results: T2 values in the lateral portion of the acetabulum were lower than in the medial portion for both asymptomatic volunteers (43 v 53 ms; P < .001) and patients with FAI (42 v 49 ms; P = .016). The medial acetabulum (MA) of asymptomatic volunteers had higher T2 values than those of the FAI group (53 v 49 ms; P = .040). The lateral-minus-medial difference was significantly larger among asymptomatic volunteers than in patients with FAI (P = .047). Patients with FAI had higher alpha angles than those of the asymptomatic volunteers, but no other associations with patient characteristics were observed., Conclusions: This study's findings suggest that there are differences in cartilage T2 mapping values between medial and lateral weight-bearing aspects of the hip and may expand the application and usefulness of biochemical magnetic resonance imaging (MRI) techniques, specifically T2 mapping, in the diagnosis of hip cartilage damage with the evaluation of clinically relevant subregions. When comparing asymptomatic volunteers and patients with FAI presenting with cam or mixed type deformity, we observed a significant contrast between the T2 mapping values of the lateral and medial portions of the weight-bearing zone of the acetabular cartilage, whereas such contrast was not observed when zone 3 was analyzed as a whole., Level of Evidence: Level III, development of diagnostic criteria on the basis of consecutive patients with a universally applied reference gold standard., (Copyright © 2015 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Although femoroacetabular impingement (FAI) syndrome is included in the etiology of lesions involving the acetabular labrum and acetabular cartilage, it is one of many possible reasons behind osteochondral lesions in the femoral head. Herein, we present clinical findings and outcomes of two cases with osteochondral defects and cam type impingement of femoral head. Both cases underwent autologous osteochondral mosaicplasty along with femoral osteochondroplasty following controlled hip dislocation. Harris hip scores improved significantly postoperatively and magnetic resonance imaging showed an adequate graft union and formation of a healthy chondral surface at the final assessment. Autologous osteochondral mosaicplasty of parafoveal region defects and femoral neck osteochondroplasty combination may be an effective treatment method for young patients with FAI syndrome. In addition, we believe that cam type impingement may also have a role in the etiology of parafoveal osteochondral lesions.

Femoroacetabular impingement is becoming an increasingly more common diagnosis in the orthopaedic community for hip pain in the younger population. Variations in the femoral head and acetabulum can lead to a sequelae of changes to the cartilage that can lead to osteoarthritis. Diagnosis is made through a combination of patient history, physical examination, and diagnostic imaging. Plain radiographs are a very useful tool for evaluating the bony anatomy, while CT scan and MRI have roles for surgical planning and more definitive diagnosis. Most patients should trial physical therapy prior to consideration for any arthroscopic or open procedures. Long-term outcome studies are being performed to determine if surgical intervention has any impact on quality of life and development of osteoarthritis.

Background: An increasing body of literature describes the clinical presentation and demographics of patients with hip labral tears. The differences in pelvic structure and joint laxity between sexes have been described; however, no study has evaluated differences in the clinical presentation of patients with symptomatic labral tears between sexes., Purpose: To describe the differences between sexes in demographics, clinical history, physical examination, and intraoperative findings in patients with symptomatic labral tears., Study Design: Cohort study; Level of evidence, 3., Methods: Data were prospectively collected between February 2008 and February 2013 on 1401 patients who had symptomatic labral tears and underwent arthroscopic surgery. Hips with previous pathologic disorders were excluded. Data on demographics and clinical history were gathered, and a physical examination was performed. Preoperative pain was estimated on the visual analog scale (VAS), and 4 hip-specific patient-reported outcomes (PROs) were administered to evaluate functional status. Intraoperative findings were recorded., Results: A total of 654 patients met our inclusion/exclusion criteria, with 320 males and 334 females. The median age for males was 38.3 years (range, 15.0-69.6 years) and for females 40.4 years (range, 13.1-66.8 years). Male patients had a higher incidence of acute injury than females (39.6% vs 27.6%, respectively; P < .05) and a higher incidence of workers' compensation status (14.1% vs 4.5%, respectively; P < .05). Females had increased range of motion compared with males, which was statistically significant for all range of motion measurements (P < .05). The anterior impingement test was positive in 94.4% of females and 92.9% of males, the flexion/abduction/external rotation test was positive in 59.5% of females and 61.5% of males, and the lateral impingement test was positive in 55.0% of females and 59.2% of males, but there was no statistically significant difference between sexes in any of the tests. Pain with palpation over the greater trochanter was positive in 22.0% of males and 36.9% of females (P < .0001). Females had lower PROs; however, VAS scores were similar., Conclusion: Male and female patients differ in their hip structure, biomechanics, and operative findings of symptomatic labral tears. However, they do not differ substantially in clinical presentation, except that males are more likely to report an acute injury and females are more likely to be evaluated with increased range of motion., (© 2014 The Author(s).)

Objective: This study aimed at identifying the optimal threshold value to detect cartilage lesions with Standardized delayed Gadolinium-Enhanced MRI of Cartilage (dGEMRIC) at 3 T and evaluate intra- and inter-observer repeatability., Design: We retrospectively reviewed 20 hips in 20 patients. dGEMRIC maps were acquired at 3 T along radial imaging planes of the hip and standardized to remove the effects of patient's age, sex and diffusion of gadolinium contrast. Two observers separately evaluated 84 Standardized dGEMRIC maps, both by visual inspection and using an average index for a region of interest (ROI) in the acetabular cartilage. A radiologist evaluated the acetabular cartilage on morphologic MR images at exactly the same locations. Using intra-operative findings as reference, the optimal threshold to detect cartilage lesions with Standardized dGEMRIC was assessed and results were compared with the diagnostic performance of morphologic magnetic resonance imaging (MRI)., Results: Using z < -2 as threshold and visual inspection of the color-adjusted maps, sensitivity, specificity and accuracy for Observer 1 and Observer 2, were 83%, 60% and 75%, and 69%, 70% and 69%, respectively. Overall performance was 52%, 67% and 58%, when using an average z for the acetabular cartilage, compared to 37%, 90% and 56% for morphologic assessment. The kappa coefficient was 0.76 and 0.68 for intra- and inter-observer repeatability, respectively, indicating substantial agreement., Conclusions: Standardized dGEMRIC at 3 T is accurate in detecting cartilage damage and could improve preoperative assessment in femoroacetabular impingement (FAI). As cartilage lesions in FAI are localized, visual inspection of the Standardized dGEMRIC maps is more accurate than an average z for the acetabular cartilage., (Copyright © 2014 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved.)

Objective: The objective of our study was to prospectively compare the diagnostic performance of MR arthrography and conventional MRI with surgical correlation in the same patient for detecting labrum and articular cartilage defects., Subjects and Methods: Twenty-eight patients (mean age, 31.8 years) underwent MR arthrography, conventional MRI, and subsequent hip surgery, which served as the reference standard. Labrum and cartilage defects were evaluated at MRI by two independent readers. A McNemar test and kappa statistics were used for statistical analysis., Results: At surgery, 31 labral tears were identified. MR arthrography had an advantage over conventional MRI for detecting labral tears at the anterosuperior quadrant (sensitivity of MR arthrography, 81% and 69% for readers 1 and 2, respectively; sensitivity of conventional MRI, 50% for both readers); this difference in performance between MR arthrography and conventional MRI was statistically significant for reader 1 (p = 0.02) but not for reader 2 (p = 0.2). Interobserver agreement for labral tears was higher for MR arthrography (κ = 0.81) than for conventional MRI (κ = 0.63). Surgery showed 31 acetabular cartilage defects and nine femoral cartilage defects. MR arthrography had an advantage over conventional MRI for detecting acetabular cartilage defects (sensitivity of MR arthrography, 71% and 92% for readers 1 and 2, respectively; sensitivity of conventional MRI, 58% and 83%), whereas there was no advantage to using MR arthrography for detecting femoral cartilage defects with statistically significant difference for the acetabular cartilage or femoral cartilage. Interobserver agreement was slightly higher for MR arthrography (κ = 0.50) than for conventional MRI (κ = 0.40) for assessing the acetabular cartilage and was almost identical for the femoral cartilage (κ = 0.62 and 0.63, respectively)., Conclusion: MR arthrography was superior to conventional MRI for detecting labral tears and acetabular cartilage defects and showed a higher interobserver agreement. For femoral cartilage lesions, both modalities yielded comparable results.

The effect and interplay of pathomorphology and joint kinematics is increasingly recognized as important in the study of femoroacetabular impingement (FAI). Hip joint kinematics consists of motion analysis at the macroscopic hip joint level. Although overall joint morphology and subject-specific kinematics are important, the cellular mechanobiology of cartilage and the biologic response to cartilage injury are poorly understood and require further study if surgeons are to understand how tissue damage actually occurs. A clearer understanding of these factors may provide the foundation for new treatments that could alter the joint injury associated with FAI. The purpose of this study group was to discuss the current evidence regarding the interaction of hip joint motion, cartilage mechanics, and cartilage biology with FAI and determine future priorities for research in these areas to expand the surgeon's ability to understand and manage this increasingly recognized clinical entity. Specific research needs were identified in four areas: motion analysis (how do muscle contributions to joint loading influence the disease process?), arthrokinematics (what happens at the joint level in vivo?), cartilage mechanics (how do cartilage cells respond to different mechanical stimuli?), and cartilage biology (need to identify biomarkers for cartilage degradation).

Objective: To validate a new method to analyze delayed gadolinium-enhanced magnetic resonance imaging of cartilage (dGEMRIC) measurements in the hip for early assessment of cartilage defects in femoroacetabular impingement (FAI)., Methods: We performed a retrospective review of 10 hips in 10 FAI patients, who underwent hip arthroscopy. T1-weighted images and dGEMRIC T(1) maps were acquired at 1.5 T on coronal planes, including the anterior-superior, superior, posterior-superior hip cartilage. For all slices, a region of interest (ROI) was defined over the central portion of the femoral cartilage, assumed to be healthy, and T1 values (x) were transformed to standard scores (z) using z = (x -μ)/σ, where μ and σ are the average and standard deviation of T1 in the femoral ROI. Diagnostic performance of the resulting standardized dGEMRIC maps was evaluated against intraoperative findings and compared with that of a previously proposed dGEMRIC analysis as well as morphologic assessment., Results: Assuming z = -2 or z = -3 as the threshold between normal and degenerated cartilage, sensitivity, specificity and accuracy were 88%, 51% and 62%, and 71%, 63% and 65%, respectively. By using T1 = 500 ms as single threshold for all dGEMRIC T1 maps, these values became 47%, 58% and 55%, whereas they were 47%, 79% and 70% for morphologic evaluation., Conclusions: Standardized dGEMRIC can increase the sensitivity in detecting abnormal cartilage in FAI and has the potential to improve the clinical interpretation of dGEMRIC measurements in FAI, by removing the effect of inter- and intra-patient T1 variability., (Copyright © 2012 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved.)

Background: The results of surgical treatment for femoroacetabular impingement have been increasingly reported, and more advanced intra-articular disease has been identified as an important predictive factor of outcome. Yet, the reliability of arthroscopic hip disease classification has not been well defined. Purpose/, Hypothesis: To determine the intraobserver and interobserver reliability of the Beck classification of labral and articular cartilage disease (anterior-superior acetabular rim) encountered in hip arthroscopy. Secondly, we identified the sources of poor reliability that may be improved with future disease classification schemes. Our hypothesis was that the Beck classification of labral and chondral lesions would demonstrate substantial reliability, while the differentiation of early forms of disease would be a common source of disagreement., Study Design: Cohort study; Level of evidence, 3., Methods: Four experienced hip arthroscopists reviewed standardized arthroscopic videos of 40 cases. Arthroscopic findings at the anterior-superior acetabular rim were classified using the Beck classification of labral and articular cartilage disease. Repeat classification of videos was performed at least 2 weeks later. The reliability of arthroscopic classification was defined using the average weighted Cohen κ values and agreement rates., Results: Arthroscopic classification of labral disease using the Beck classification demonstrated moderate to substantial interobserver reliability (average κ = .62; range, .48-.78) and an overall agreement rate of 81.7%. Intraobserver reliability showed a similar level of reliability (average κ = .65; agreement rate, 80.6%). The differentiation between labral degeneration and labral detachment was a common source of disagreement. Similarly, the Beck classification of articular cartilage disease had moderate to substantial interobserver reliability (average κ = .65; range, .49-.78) and overall agreement rate of 57.5%. Intraobserver reliability showed a slightly better level of reliability (average κ = .80; agreement rate, 77.5%). The differentiation between articular cartilage malacia and debonding was a common source of disagreement., Conclusion: The arthroscopic classification of acetabular rim disease with the Beck classification has substantial interobserver reliability. This level of reliability is similar to previously reported arthroscopic disease classifications in the knee and shoulder and seems appropriate for future outcome reporting. Future classifications that eliminate common sources of disagreement may further improve the reliability.

Advanced MRI cartilage imaging such as T(1)-rho (T1ρ) for the diagnosis of early cartilage degradation prior to morpholgic radiological changes may provide prognostic information in the management of joint disease. This study aimed first to determine the normal T1ρ profile of cartilage within the hip, and secondly to identify any differences in T1ρ profile between the normal and symptomatic femoroacetabular impingement (FAI) hip. Ten patients with cam-type FAI (seven male and three female, mean age 35.9 years (28 to 48)) and ten control patients (four male and six female, mean age 30.6 years (22 to 35)) underwent 1.5T T1ρ MRI of a single hip. Mean T1ρ relaxation times for full thickness and each of the three equal cartilage thickness layers were calculated and compared between the groups. The mean T1ρ relaxation times for full cartilage thickness of control and FAI hips were similar (37.17 ms (SD 9.95) and 36.71 ms (SD 6.72), respectively). The control group demonstrated a T1ρ value trend, increasing from deep to superficial cartilage layers, with the middle third having significantly greater T1ρ relaxation values than the deepest third (p = 0.008). The FAI group demonstrated loss of this trend. The deepest third in the FAI group demonstrated greater T1ρ relaxation values than controls (p = 0.028). These results suggest that 1.5T T1ρ MRI can detect acetabular hyaline cartilage changes in patients with FAI.

Objective: To compare the diagnostic ability of MR arthrography (MRa) and MDCT arthrography (CTa) in depicting surgically proven hip labral tears and articular cartilage degradation., Materials and Methods: Labral pathology and articular cartilage were prospectively evaluated with MRa and CTa in 14 hips of 10 patients. The findings were evaluated by two independent observers (a musculoskeletal fellow and one senior musculoskeletal radiologist). Sensitivity, specificity, accuracy, and positive predictive value were determined using arthroscopic and open surgery findings as the standard of reference. Interobserver agreement was recorded. All images were assessed for the presence of a labral tear (according to Czerny classification) and for cartilage erosion using a 3 point scale for both methods: 1 = complete visualization-sharp edges, 2 = blurred edges fissuring-partial defects, 3 = exposed bone. The same classification was applied surgically., Results: Disagreement between the senior observer and the fellow observer was recorded in three cases of labral tearing with MRa and six with CTa. Disagreement was also found in four cases of cartilage erosion with both MRa and CTa. The percent sensitivity, specificity, accuracy, and positive predictive value for correctly assessing the labral tear were as follows for MRa/CTa, respectively: 100/15, 50/13, 90/14, and 90/13 (P < 0.05). The same values for cartilage assessment were 63/66, 33/40, 50/57 and 55/66 (P > 0.05)., Conclusion: Interobserver reproducibility with MRa is very good for labral tearing assessment. MRa is better for assessing labral tears. CTa shows better, but not statistically significant, demonstration of the articular cartilage.

Background: Tears of the acetabular labrum can lead to pain, disability, and osteoarthritis. Several pathomechanisms have been proposed, including femoroacetabular impingement (FAI). Labral tears have been reported to occur in the presence of even subtle deformities of the acetabulum and femoral head-neck junction., Questions/purposes: We analyzed the association of the extent of bony deformity and presence and extent of labral lesions in hips with FAI., Patients and Methods: Radiographs of 123 hips in 116 patients receiving surgical treatment for FAI were analyzed and correlated to the presence and extent of labral lesions. Radiographic parameters of the acetabulum included acetabular index of the weightbearing zone, center-edge angle, inclination of the acetabulum, lateral head extrusion index, and retroversion. On the femoral side, neck-shaft angle, asphericity of the femoral head, superior and anterior alpha angle, offset, and offset ratio were measured. Osteoarthritis was graded according to Tönnis and Kellgren and Lawrence. Labral lesions were graded according to the modified Beck classification. A correlation between labral lesions and age, gender, affected side, type of impingement, and presence and extent of chondromalacia also was tested., Results: No correlation was found between presence or extent of labral lesions and any radiographic parameter tested, except osteoarthritis classification. The severity of labral lesions correlated to the severity of acetabular chondromalacia as well as patient age (Beck Grade 0 versus Grade 1, Beck Grade 0 versus Grades 1 and 2)., Conclusions: In the presence of impingement-inducing deformity, the extent of deformation is not associated with the incidence of labral lesions. Labral lesions are associated with early degenerative hip disease in FAI., Level of Evidence: Level I, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.

Femoroacetabular impingement is a well-described pre-arthritic condition with two main types; cam and pincer. Studies using the open treatment for impingement have described patterns of articular cartilage wear specific to cam and pincer impingement. Assessing articular damage in the hip joint is an important component of treatment. Intravenous gadolidium allows radiologists to perform an indirect assessment of articular cartilage glycosaminoglycan (GAG) content by using a technique called dGEMRIC. Using this indirect assessment of articular cartilage, we compared the dGEMRIC indices in a group of six cam and seven pincer patients to a control group (n = 12) of asymptomatic controls that had no plain MRI findings of osteoarthritis. The superior portion of the hip joint was divided into seven regions from 9 to 3 o'clock. These regions were then subdivided into peripheral and central regions. The cam and pincer groups both had statistically lower dGEMRIC values compared to the control group. The cam group demonstrated not only peripheral but also central involvement of the joint and this was concentrated in the anterior portion of the joint. The pincer group exhibited more global hip involvement with all areas of the hip averaging a dGEMRIC index 28% less than controls. With the use of dGEMRIC more specific patterns of cartilage wear can be elicited in patients with impingement, which may improve patient selection and help better understand the progression of osteoarthithis throughout the hip joint., (Copyright © 2011 Orthopaedic Research Society.)

Purpose: The purpose of this study was to compare the percent relief from injection among subjects with arthroscopic findings of femoroacetabular impingement (FAI) and labral and chondral pathologies while controlling for coexisting extra-articular pathology., Methods: We retrospectively reviewed 72 consecutive subjects (54 female and 18 male subjects), aged 29.9 ± 10.4 years (range, 16 to 55 years), who underwent hip arthroscopy. Three separate analyses of covariance compared the percent relief after injection between groups based on surgically confirmed type of impingement (none, cam, pincer, or combined), labral pathology (none, mild, or torn), and chondral pathology (none, mild acetabular abnormality, acetabular delamination, or femoral lesion) while controlling for the presence of extra-articular pathology (iliotibial band, iliopsoas tendinopathy, or bursitis)., Results: The results of analysis 1 (F₃,₆₇ = 1.96, P = .128, partial η² = .081) and analysis 2 (F₂,₆₈ = 0.008, P = .992, partial η² = .000) indicated no significant main effect for FAI and labral pathology, respectively, on percent relief from injection. The results for analysis 3 indicated a significant main effect for chondral pathology of the hip on the percent relief from injection (F₃,₆₇ = 3.03, P < .05, partial η² = .128). Post hoc analysis showed that those with mild chondral pathology of the acetabulum and those with acetabular delamination had significantly greater percent relief compared with those without chondral pathology. Extra-articular pathology did not influence the percent relief from injection in any of the analyses., Conclusions: Subjects with chondral damage had greater relief from injection than those without, regardless of severity. The presence and severity of FAI and labral pathology did not influence the percent relief from injection. Concurrent extra-articular pathology did not alter the interpretation of the percent relief from injection. Therefore the interpretation and diagnostic value of an anesthetic injection in those with primary intra-articular pathology does not need to be altered by the presence of coexisting extra-articular hip pathology., Level of Evidence: Level IV, therapeutic case series., (Copyright © 2011 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

There have been considerable recent advances in the understanding and management of femoroacetabular impingement and associated labral and chondral pathology. We have developed a classification system for acetabular chondral lesions. In our system, we use the six acetabular zones previously described by Ilizaliturri et al. The cartilage is then graded on a scale of 0 to 4 as follows: grade 0, normal articular cartilage lesions; grade 1, softening or wave sign; grade 2, cleavage lesion; grade 3, delamination; and grade 4, exposed bone. The site of the lesion is further classed as A, B or C based on whether the lesion is less than one-third of the distance from the acetabular rim to the cotyloid fossa, one-third to two-thirds of the same distance and greater than two-thirds of the distance, respectively. In order to validate the classification system, six surgeons graded ten video recordings of hip arthroscopy. Our findings showed a high intra-observer reliability of the classification system with an intraclass correlation coefficient of 0.81 and a high interobserver reliability with an intraclass correlation coefficient of 0.88. We have developed a simple reproducible classification system for lesions of the acetabular cartilage, which it is hoped will allow standardised documentation to be made of damage to the articular cartilage, particularly that associated with femoroacetabular impingement.

This prospective study on symptomatic adult patients with femoroacetabular impingement (FAI) who underwent open surgical intervention for management was designed to identify any obvious histological differences in the damaged acetabular cartilage within different subgroups of FAI. 20 patients underwent surgical intervention following safe surgical dislocation of the hip. There were 6 cases of cam impingement, 5 cases of pincer impingement and 9 of the mixed type. Pincer impingement cases demonstrated a characteristic focal, well-circumscribed and localized area of severe damage. On the other hand, cases with cam impingement showed a diffuse area of involvement affecting a larger surface of the acetabular cartilage, with degenerative changes, superficial erosions and some discontinuities. A small biopsy specimen of the acetabular rim including bone, cartilage and labrum from the affected zone was obtained in all cases. Histological evaluation was performed under normal and polarized light microscopy. Histological findings helped corroborate the pre-operative diagnosis and also define the unique nature of impingement and specific damage according to the type of impingement.

Acetabular labral tears have been the focus of much attention in recent years. With the increased use of hip arthroscopy and magnetic resonance arthrography, the infrequent labral tear has proved to be more prevalent than previously thought. The majority of labral tears occur due to an underlying anatomic abnormality. Anatomic abnormalities that can lead to labral tears include femoracetabular impingement, acetabular retroversion, abnormal femoral head, Legg Calvé Perthes, slipped capital epiphysis, capsular laxity, and dysplasia of the hip. Tears in the labrum may lead to the advancement of osteoarthritis. Optimal management of a labral tear may involve addressing underlying anatomic abnormalities in addition to the labral tear itself.

Objective: The purpose of this study was to investigate whether T1-mapping of hip joint with intra-articular delayed gadolinium-enhanced magnetic resonance imaging (MRI) of cartilage (ia-dGEMRIC) is comparable to the already established intravenous (iv)-technique for assessing different grades of cartilage degeneration., Materials and Methods: The study cohort consisted of 53 patients with symptomatic femoroacetabular impingement (FAI) that were randomly recruited for either iv-dGEMRIC or ia-dGEMRIC studies. RI was performed in supine position at a 1.5 Tesla (T) system (Magnetom Avanto, Siemens, Erlangen, Germany) using a body matrix-phased array coil. Twenty-six patients (18 males, 8 females; mean age +/- standard deviation [SD]: 32.1 +/- 8.8 years, range: 17-49 years) underwent iv-dGEMRIC whereas 27 patients (17 males, 10 females; mean age 34.0 +/- 10.8 years, range: 13.0-57 years) underwent ia-dGEMRIC mapping. On average patients suffered from FAI for 23.9 +/- 20.9 months in the iv-dGEMRIC group (range: 5-108 months) whereas FAI was symptomatic for 20.9 +/- 25.2 months in the ia-dGEMRIC group (range: 3-120 months). Patient demographics and symptomatology in both groups were not statistically different., Results: Mapping with both techniques (iv and ia) demonstrated appropriately similar differences between various grades of cartilage degeneration. Overall, there was no significant difference between iv-dGEMRIC and ia-dGEMRIC T1 mean values in all grades of cartilage findings (P: 0.394, 0.400, and 0.173). Of note, the T1 values after iv-dGEMRIC were higher (544.3 +/- 104.2 milliseconds) in regions with cartilage damage extent <0.75 cm than in regions where no damage was noted (535.7 +/- 112.4 milliseconds). After ia-dGEMRIC the T1 values were similar (521.2 +/- 125.1 milliseconds vs. 521.1 +/- 94.3 milliseconds)., Conclusions: Intravenous contrast remains the standard method of contrast administration in the current scenario when dGEMRIC imaging is performed. Our results demonstrate that the information and mapping values obtained by the ia-technique are similar to those of the iv-technique. The intravenous route can have its own problems in certain patients with impaired renal function tests or when parenteral access is an issue in many patients. Intra-articular technique could be a good alternative in such cases whereas maintaining the quality of imaging and obtained information. Thus, in well-selected cases ia-dGEMRIC mapping may be a potential alternative to iv-dGEMRIC for hip joint cartilage analysis., Level of Evidence: Prospective case series, Diagnostic study comparing different modalities of assessing status of hip joint cartilage: Level II evidence.