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Pre-arthritis in the dysplastic hip is a challenging problem. Systemic drug use, such as non-steroidal anti-inflammatory drugs, and intra-articular injection, including corticosteroid and hyaluronic acid injections, are both currently the first-line treatments. Application of platelet-rich plasma and bone marrow aspirate concentrate is gathering special interests among physicians and patients; however, evidence from recent publications is limited. Translational studies using high concentrate stem cells are on-going, and have shown interactive results in the preliminary articles. Applying or regulating growth factors can be a promising frontier in the future. In this chapter, the current and possible future treatment options are introduced with review of previous clinical and translational articles.

Background\ud Femoroacetabular impingement syndrome is an important cause of hip pain in young adults. It can be treated by arthroscopic hip surgery, including reshaping the hip, or with physiotherapist-led conservative care. We aimed to compare the clinical effectiveness of hip arthroscopy with best conservative care.\ud \ud Methods\ud UK FASHIoN is a pragmatic, multicentre, assessor-blinded randomised controlled trial, done at 23 National Health Service hospitals in the UK. We enrolled patients with femoroacetabular impingement syndrome who presented at these hospitals. Eligible patients were at least 16 years old, had hip pain with radiographic features of cam or pincer morphology but no osteoarthritis, and were believed to be likely to benefit from hip arthroscopy. Patients with bilateral femoroacetabular impingement syndrome were eligible; only the most symptomatic hip was randomly assigned to treatment and followed-up. Participants were randomly allocated (1:1) to receive hip arthroscopy or personalised hip therapy (an individualised, supervised, and progressive physiotherapist-led programme of conservative care). Randomisation was stratified by impingement type and recruiting centre and was done by research staff at each hospital, using a central telephone randomisation service. Patients and treating clinicians were not masked to treatment allocation, but researchers who collected the outcome assessments and analysed the results were masked. The primary outcome was hip-related quality of life, as measured by the patient-reported International Hip Outcome Tool (iHOT-33) 12 months after randomisation, and analysed in all eligible participants who were allocated to treatment (the intention-to-treat population).\ud \ud This trial is registered as an International Standard Randomised Controlled Trial, number ISRCTN64081839, and is closed to recruitment. Findings Between July 20, 2012, and July 15, 2016, we identified 648 eligible patients and recruited 348 participants: 171 participants were allocated to receive hip arthroscopy and 177 to receive personalised hip therapy. Three further patients were excluded from the trial after randomisation because they did not meet the eligibility criteria. Follow-up at the primary outcome assessment was 92% (319 of 348 participants). At 12 months after randomisation, mean iHOT-33 scores had improved from 39·2 (SD 20·9) to 58·8 (27·2) for participants in the hip arthroscopy group, and from 35·6 (18·2) to 49·7 (25·5) in the personalised hip therapy group. In the primary analysis, the mean difference in iHOT-33 scores, adjusted for impingement type, sex, baseline iHOT-33 score, and centre, was 6·8 (95% CI 1·7–12·0) in favour of hip arthroscopy (p=0·0093). This estimate of treatment effect exceeded the minimum clinically important difference (6·1 points). There were 147 patient-reported adverse events (in 100 [72%] of 138 patients) in the hip arthroscopy group) versus 102 events (in 88 [60%] of 146 patients) in the personalised hip therapy group, with muscle soreness being the most common of these (58 [42%] vs 69 [47%]). There were seven serious adverse events reported by participating hospitals. Five (83%) of six serious adverse events in the hip arthroscopy group were related to treatment, and the one in the personalised hip therapy group was not. There were no treatment-related deaths, but one patient in the hip arthroscopy group developed a hip joint infection after surgery. Interpretation Hip arthroscopy and personalised hip therapy both improved hip-related quality of life for patients with femoroacetabular impingement syndrome. Hip arthroscopy led to a greater improvement than did personalised hip therapy, and this difference was clinically significant. Further follow-up will reveal whether the clinical benefits of hip arthroscopy are maintained and whether it is cost effective in the long term.\ud \ud Funding\ud The Health Technology Assessment Programme of the National Institute of Health Research.

Hip arthroscopy is one of the most rapidly growing areas in orthopaedic surgery because of increased awareness of nonarthritic hip pathologies, advanced imaging modalities, and advanced techniques to reproducibly manage nonarthritic hip pathologies within a deep soft-tissue envelope and a constrained joint. In addition, more academic medical centers are providing residents with education on hip arthroscopy, and many hip preservation fellowships and courses are helping increase awareness of nonarthritic hip pathologies. Nonarthritic hip pathologies currently managed via hip arthroscopy include nonrepairable labral lesions, femoroacetabular impingement, hip instability, and hip fractures. Periarticular hip pathologies currently managed via endoscopy include greater trochanteric pain syndrome, tendinopathy and tears of the gluteus medius and minimus, partial and complete hamstring avulsions, and sciatic nerve entrapment. Ischiofemoral impingement may be addressed endoscopically via the deep gluteal space. Orthopaedic surgeons should understand the role and safety of hip arthroscopy in the pediatric population, specifically in the management of slipped capital femoral epiphysis, Legg-Calvé-Perthes disease, and septic arthritis of the hip. The efficacy of hip arthroscopy is limited, and hip arthroscopy is relatively contraindicated in patients with osteoarthritis and hip dysplasia. Complications can occur and likely are underreported in patients who undergo hip arthroscopy. Orthopaedic surgeons should understand practical issues associated with incorporating hip arthroscopy into a practice, including the difficult learning curve associated with hip arthroscopy and the reluctance of some payors to reimburse procedures performed arthroscopically because hip arthroscopy is a relatively new technology.

PURPOSE OF REVIEW: Femoroacetabular impingement is a common cause of hip pain in young patients and has been shown to progress to osteoarthritis. The purpose of this review is to better understand the development of femoroacetabular impingement. RECENT FINDINGS: Recent literature shows little genetic transmission of FAI. However, molecular studies show strong similarities with the cartilage in osteoarthritis. The development of cam lesions has a strong association with sports participation, particularly at the time of physeal closure suggesting abnormal development. Lumbar, pelvis, and femoral biomechanics may also play an important role in dynamic impingement. SUMMARY: In summary, femoroacetabular impingement is a dynamic process with many influences. Further research is needed to clarify the pathophysiology of FAI development in hopes of finding preventative options to reduce symptoms and progression to osteoarthritis.

Objectives: Treatment algorithms for the arthroscopic management of femoroacetabular impingement syndrome (FAI) remain controversial due to a paucity of evidence-based guidance. Consequently, significant variability in clinical practice exists between different practitioners, necessitating expert consensus. The purpose of this study is to establish Best Practice Guidelines (BPG) using formal techniques of consensus building among a group of experienced hip arthroscopists driven by the results of a systematic review and meta-analysis. The scope of these guidelines includes preoperative recommendations, intraoperative practices, and postoperative protocols. Methods: The validated Delphi process and nominal group technique (NGT), utilized by the Centers for Disease Control and peer-reviewed orthopedic literature, were used to formally derive consensus among 15 surgeons in North America. Participants were surveyed for current practices, presented with the results of a meta-analysis and systematic literature review, and asked to vote for or against inclusion of non-leading, impartially-phrased items during three iterative rounds while preserving the anonymity of participants’ opinions. Agreement greater than 80% was considered consensus, and items near consensus (70%-80% agreement) were further queried using the NGT in a moderated group session at the American Orthopaedic Society for Sports Medicine (AOSSM) annual meeting. Results: Participants had a mean of 12.3 years of practice (range: 1-29 years) and performed an annual mean of 249 (range 100 to 500+) hip arthroscopies, with a combined total of approximately 52,580 procedures. Consensus was reached for the creation of BPG consisting of 27 preoperative recommendations, 15 intraoperative practices, and 10 postoperative protocols. The final checklist was supported by 100% of participants. Conclusion: We developed the first national consensus-based Best Practice Guidelines for the surgical and nonsurgical management of FAI. The resulting consensus items can serve as a tool to reduce the variability in pre-, intra-, and postoperative practices and guide further research for arthroscopic management of FAI.

Objectives: Application of growth factors for cartilage injury has been considered in recent studies; however, the effect of blocking detrimental growth factors for cartilage injury has not been well described. It is known that transforming growth factor beta 1 (TGF-β1) is overproduced in osteoarthritic joints. It has been reported that angiotensin II-induced activation of TGF-β1-pSmad2/3 signaling, which can result in fibrosis, can be inhibited by losartan (an FDA-approved hypertension drug). Although bone marrow stimulation (BMS) is often the first choice for clinical treatment of cartilage injuries, fibrocartilage, not pure hyaline cartilage, has been reported after BMS surgery. Our lab has shown that blocking TGF-β1 with losartan can decrease fibrosis in muscle injury models. We hypothesized that blocking TGF-β1 would improve cartilage healing in a rabbit osteochondral defect injury model via decreasing the amount of fibrocartilage formation, and increase hyaline-like cartilage formation, thus enhancing BMS-mediated cartilage repair. Methods: An osteochondral defect (diameter: 5 mm, depth: 2 mm) was made in the patellar groove of 48 New Zealand White rabbits. The rabbits were divided into 3 groups (N=8/group/time point) randomly: a control group (defect only), a BMS group (osteochondral defect + BMS), and a losartan-treated group (osteochondral defect + BMS + losartan). For the rabbits in the losartan-treated group, 10mg/kg/day dose of losartan was administrated orally from the day after surgery through the day of euthanasia. Rabbits were sacrificed 6 weeks and 12 weeks post-operatively, respectively. Macroscopic appearance, microcomputed tomography (microCT), histological assessment, and gene expression were evaluated. Results: The losartan-treated group scored highest in the International Cartilage Repair Society (ICRS) macroscopic assessment. MicroCT showed healing of the bony defect in the losartan-treated group, in comparison to no healing in the control group and partial healing in the BMS group. Histologically, results obtained using the Modified O’Driscoll ICRS grading system yielded significantly superior scores in the losartan-treated group compared to both the control group and the BMS group (12 weeks, mean [SD], control: 30.1 [3.6], BMS: 35.0 [3.7], losartan-treated: 41.4 [4.7]; p< 0.001 compared to control group, p= 0.012 compared to BMS group, respectively). TGF-β1 signaling and TGF-β activated kinase-1 were suppressed in the fat pad tissues. Conclusion: Biologically regulated BMS by blocking TGF-β1 (oral intake of losartan) provided superior cartilage repair via decreasing fibrocartilage formation and resulting in hyaline-like cartilage, compared to outcomes from BMS only. FDA-approved blocking growth factor drugs will be a new frontier of biologically regulated BMS, which will be easily translatable into clinical settings as an off-label use. [Figure: see text]

Objectives: The possibility of preserving platelet-rich plasma (PRP) from young, healthy individuals for future use is a compelling approach to reduce or delay degenerative processes, presuming that the retention of the biological properties are maintained. The purpose of this study was to measure and compare matrix metalloproteinases (MMP) isoform concentrations between whole blood (WB), leukocyte-rich PRP (LR-PRP) inactivated (LR-I) and activated (LR-A), leukocyte-poor PRP (LP-PRP) inactivated (LP-I) and activated (LP-A). Methods: Following institutional review board approval (2017-36), 24 donors that were physically and mentally healthy were prospectively enrolled in the study. Approximately 60 mL of WB was drawn from each donor to produce inactivated and activated LP-PRP and LR-PRP using manual processing methodology, as previously described. A complete blood count for WB and inactivated PRP products was obtained to verify that concentration of platelets was achieved. WB, LP-I, and LR-I samples were set aside for immunoassay and analysis. The LP-I and LR-I products were activated with 10% calcium chloride and recombinant thrombin in a red-top 10 mL vacutainer tube. Blood fractions were either immediately assayed and analyzed (fresh) or stored at -80℃ for 24 hours, 72 hours, and 160 hours. Commercial kits (EMD Millipore) were used according to manufacturer’s instructions for protein content: MMP-1, MMP-3, MMP-9, MMP-10, and MMP-12. A standard methodology for the Luminex 200® system was used as previously published. A pairwise Wilcoxin rank test was performed for statistical calculation. Results: Twenty-two healthy donors (n = 12 females, n = 10 males) with a mean age of 37.7 (range: 21 to 60), and average BMI of 23.7 kg/m2, were used in the final analysis. MMP-1 significantly increased between fresh and 160 hours in WB (pConclusion: In this study, we evaluated the influence of short-term freezing (-80℃) on MMP concentrations in WB, inactivated PRP, and activated PRP formulations. Our results suggest that certain MMP isoforms, can either increase or decrease in response to freezing in WB, inactivated PRP, and activated PRP formulations. The development of PRP preservation approaches through minimal manipulation, without attenuating its biological properties, represents an important step in PRP mediated tissue regeneration and repair. [Figure: see text][Figure: see text][Figure: see text][Figure: see text]

The artistic nature of dance in combi- nation with the technical perfection required during performance makes it a highly demanding discipline. Starting at a young age, serious ballet students undergo long hours of training. Professional ballet dancers continue to train intensively in order to maintain their technical proficiency. Hip pathology in ballet dancers has been frequently reported in the literature, including femoroacetabular impingement syndrome, hip instability, muscle injuries, and early osteoarthritis. Screening programs to identify these hip joint pathologies (at- risk hips) in ballet dancers when they are still asymptomatic or their injury does not affect their performance are useful to aid in the development of prevention and treatment strategies. The purpose of this cross-sectional study was to identify hips at risk in the members of a professional ballet company using ultrasound-assisted physical examination. A high prevalence of cam lesions was detected in this cohort. Dancers with cam lesions were more likely to have an acetabular labral tear. In addition, there was a positive correlation between cam lesions and positive dial test, which is an indication of hip microinstability. Work of this kind can help to improve understanding of hip pathology in dancers and facilitate activity modification programs to prevent progression of their hip injuries.

Hip arthroscopy is an innovative surgical tool that is minimally invasive; however, the working space is very limited because of small surgical wounds. Recent literature has shown that capsular repair after capsulotomy during hip arthroscopy facilitates the restoration of hip joint stability. Previous Technical Notes have introduced the shoelace capsule closing technique using a single Ultratape. However, even with the shoelace capsule closing technique, we periodically have encountered difficult cases with extensive capsular laxity. In this Technical Note, we introduce an improved hip capsule plication technique using 2 pieces of Ultratape for treating borderline hip dysplasia with capsular laxity. This double shoelace capsule plication technique theoretically reduces tearing risks during closure of delicate and fragile capsules. Level of evidence: 1 (hip); 2 (other).

Objectives: Arthroscopic hip labral preservation techniques have evolved over the last decade. Arthroscopic hip labral augmentation with iliotibial band (ITB) autograft placed into a labral defect with viable circumferential fibers is a novel treatment option to restore the hip suction seal and improve functionality. The purpose of this study is to determine midterm (3-5 year follow up) outcomes of arthroscopic hip labral augmentation procedure. Methods: Patients who underwent arthroscopic hip labral augmentation from August 2011 to March 2017 were prospectively evaluated. Pre- and post-operative patient reported outcome scores were compared and included SF12 PCS, SF12 MCS, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Modified Harris Hip Score (mHHS), Hip Outcome Score (HOS) (Activities of Daily Living (ADL) and Sport). Post-operative Tegner Activity Scale and patient satisfaction (1 – 10) were also evaluated. Results: One hundred and six patients underwent arthroscopic hip labral augmentation with minimum 3-year follow-up. Mean follow-up was 5-year follow-up (range, 3 to 9.2 years). All patient reported outcomes improved after labral augmentation (SF12 PCS 39±8 vs. 50±10, p>0.01; mHHS 59±15 vs. 79±21, pConclusions: Arthroscopic hip labral augmentation is a successful treatment option for patients that have viable circumferential fibers present at the time of arthroscopy. This technique continues to show improved patient reported outcomes and is another hip labral preservation technique that may help reestablish the intra-articular fluid suction seal.

Arthroscopic procedures for treatment of hip pathology are growing exponentially as a result of continued improvements in the understanding of intra- and extra-articular hip anatomy and technological advancements in instrumentation. Nevertheless, it has been reported that the main cause of revision hip arthroscopy is related to a suboptimal intrasurgical management of the abnormal morphology in femoroacetabular impingement (FAI). Under-resection, over-resection, and in some cases combined under-resection and over-resection at different locations of the cam lesion at the femoral head-neck junction may lead to poor outcomes as a result of residual impingement or the iatrogenic creation of structural instability. Thus, an intraoperative assessment technique capable of revealing in real time the effect of the resection is vital for a successful procedure. Therefore, we present a technical note describing our preferred method to dynamically assess overall hip range of motion, motion at risk, and evaluation of the osteoplasty after surgical correction of FAI.

Purpose To determine whether the hip arthroscopy literature to date has shown outcomes consistent with published patient acceptable symptomatic state (PASS) and minimal clinically important difference (MCID) estimates. Methods All clinical investigations of hip arthroscopy using modified Harris Hip Score (mHHS) and/or Hip Outcome Score (HOS) outcomes with at least 1 year of follow-up were reviewed. Ninety-one studies (9,746 hips) were included for review. Eighty-one studies (9,317 hips) contained only primary hip arthroscopies and were the primary focus of this review. The remaining studies (429 hips) did not exclude patients with prior surgical history and were thus considered separately. Mean mHHS, HOS-ADL (Activities of Daily Living) and HOS-SS (Sports-Specific) scores were compared with previously published PASS and MCID values. Results After 31 ± 20 months, 5.8% of study populations required revision arthroscopy and 5.5% total hip arthroplasty. A total of 88%, 25%, and 30% of study populations met PASS for mHHS, HOS-ADL, and HOS-SS, respectively, and 97%, 90%, and 93% met MCID. On bivariate analysis, increasing age was associated with significantly worse postoperative mHHS ( P R 2 = 0.14), HOS-SS ( P = .05, R 2 = 0.12), and rates of reoperation ( P = .02, R 2 = 0.08). Increasing body mass index was associated with significantly worse HOS-ADL ( P = .02, R 2 = 0.35) and HOS-SS ( P = .03, R 2 = 0.30). Conclusions In this meta-analysis of 81 studies of primary hip arthroscopy, we have found that more than 90% of study populations meet MCID standards for the most commonly used patient-reported outcomes measures in hip arthroscopy literature, mHHS and HOS. Eighty-eight percent meet PASS standards for the mHHS, but PASS standards are far more difficult to achieve for HOS-ADL (25%) and HOS-SS (30%) subscales. Differences in psychometric properties of the mHHS and HOS likely account for the discrepancies in PASS. Level of Evidence Level IV, systematic review of Level I to IV studies.

Anterior hip pain can be difficult to diagnose due to the many pathologies and overlapping pain patterns that exist in the hip region. Clinical findings of pain at the anterior inferior iliac spine with passive hip flexion, proximal quadriceps pain and weakness, and painful impingement tests of the hip may be indicative of subspine hip impingement. This report describes the diagnosis and treatment of anterior hip pain, including subspine impingement and femoroacetabular impingement in an elite weightlifter. This case also describes how with the correct diagnosis and treatment, the athlete returned to play to her previous level of sport 11 months after a complex hip injury.

Background: The incidence of hip arthroscopic surgery is increasing in the young athlete. This has also led to increased numbers of revision hip arthroscopic surgery. Hypothesis/Purpose: The purpose of this study was to describe the outcomes after revision hip arthroscopic surgery in patients ≤18 years of age in comparison to a matched cohort of patients undergoing primary hip arthroscopic surgery. Our hypothesis was that patients undergoing revision hip arthroscopic surgery would demonstrate similar outcomes to those patients undergoing primary hip arthroscopic surgery. Study Design: Cohort study; Level of evidence, 3. Methods: Patients were included in the study if they underwent revision hip arthroscopic surgery by a single surgeon and did not undergo prior open hip surgery. Each patient in the revision hip arthroscopic surgery cohort was matched with 2 patients undergoing primary hip arthroscopic surgery from the same institution. Cohorts were matched by age, sex, and year of surgery. Preoperatively and at a minimum follow-up of 2 years, outcome scores were collected. The primary outcome measure was the Hip Outcome Score for activities of daily living scale (HOS-ADL), a self-reported validated outcome instrument, in addition to the HOS for sports scale (HOS-Sport), modified Harris Hip Score (mHHS), and 12-Item Short Form Health Survey Physical Component Summary (SF-12 PCS). Results: Forty-two patients were included in the revision group and were matched with 84 patients in the primary group. The mean age in both groups was 16 years (range, 14-18 years). All female patients in the study were ≥14 years of age, and all male patients were ≥16 years of age. In patients undergoing revision, 13 underwent 1 prior surgical procedure, 22 underwent 2 prior surgical procedures, and 7 underwent ≥3 prior surgical procedures. The mean time from last surgery to revision was 18.7 months (range, 4.7-74 months). Eleven patients (26%) had prior femoroacetabular impingement treated, which required osteoplasty or rim trimming at revision. Subsequent hip arthroscopic surgery was reported in 3 of 84 (4%) patients in the primary group and 6 of 42 (14%) patients in the revision group ( P = .162). The mean follow-up in the revision group was 43 ± 17 months, and scores significantly improved (HOS-ADL: 59.6 to 77.6; HOS-Sport: 37.6 to 64.8; mHHS: 55.3 to 74.3; SF-12 PCS: 41.0 to 50.4; P < .05). The mean follow-up in the primary group was 45 ± 18 months, and all scores significantly improved (HOS-ADL: 65.8 to 87.4; HOS-Sport: 46.3 to 79.9; mHHS: 57.5 to 84.2; SF-12 PCS: 39.0 to 51.8; P < .05). At follow-up, there were no significant differences between the primary and revision groups for the HOS-ADL values ( P = .051) and SF-12 PCS values ( P = .846). Patients in the primary group had significantly higher HOS-Sport values ( P = .008), mHHS values ( P = .008), and patient satisfaction ( P = .008). Patients who underwent 1 prior hip arthroscopic procedure had a higher mean postoperative mHHS value (79.5 vs 72, respectively), HOS-ADL value (91.2 vs 73.4, respectively), and HOS-Sport value (76 vs 60, respectively) ( P < .05) compared with those who underwent more than 1 prior procedure. Median patient satisfaction was 9.0 (range, 2-10) in the primary group and 8.0 (range, 2-10) in the revision group. Conclusion: In conclusion, young patients who required revision hip arthroscopic surgery showed significant improvement in patient-reported outcome scores; however, final outcome scores in the revision group for sport activity, general health, and satisfaction were lower than those in the primary group. Patients who underwent 1 revision surgical procedure had higher outcome scores than patients who underwent more than 1 revision surgical procedure.

Purpose To describe T2 mapping values in arthroscopically determined International Cartilage Repair Society (ICRS) grades in damaged and healthy-appearing articular cartilage waste specimens from arthroscopic femoroacetabular impingement (FAI) treatment. Furthermore, we sought to compare ICRS grades of the specimens with biochemical, immunohistochemistry and histologic endpoints and assess correlations with T2 mapping. Methods Twenty-four patients were prospectively enrolled, consecutively, between December 2011 and August 2012. Patients were included if they were aged 18 years or older and met criteria that followed the clinical indications for arthroscopy to treat FAI. Patients with prior hip trauma including fracture or dislocation or who have undergone prior hip surgery were excluded. All patients received a preoperative sagittal T2 mapping scan of the hip joint. Cartilage was graded intraoperatively using the ICRS grading system, and graded specimens were collected as cartilage waste for histologic, biochemical, and immunohistochemistry analysis. Results Forty-four cartilage specimens (22 healthy-appearing, 22 damaged) were analyzed. Median T2 values were significantly higher among damaged specimens (55.7 ± 14.9 ms) than healthy-appearing specimens (49.3 ± 12.3 ms; P = .043), which was most exaggerated among mild (grade 1 or 2) defects where the damaged specimens (58.1 ± 16.4 ms) were significantly higher than their paired healthy-appearing specimens (48.7 ± 15.4 ms; P = .026). Severely damaged specimens (grade 3 or 4) had significantly lower cumulative H&E than their paired healthy-appearing counterparts ( P = .02) but was not statistically significant among damaged specimens with mild (grade 1 or 2) defects ( P = .198). Among healthy-appearing specimens, median T2 and the percentage of collagen fibers oriented parallel were significantly correlated (rho = 0.425, P = .048). Conclusions This study outlines the potential for T2 mapping to identify early cartilage degeneration in patients undergoing arthroscopy to treat FAI. Findings in ICRS grade 1 and 2 degeneration corresponded to an increase in T2 values. Further biochemical evaluation revealed a significant difference between healthy-appearing cartilage and late degeneration in cumulative H&E as well as significantly lower percentage of collagen fibers oriented parallel and a higher percentage of collagen fibers oriented randomly when considering all grades of cartilage damage. Level of Evidence Level II, prospective comparative study.

Background: Previous studies have shown that professional hockey players return to sport at a high rate after hip arthroscopy, although it is unknown how long players continue to compete at a professional level after surgery. Purpose: To determine the prevalence of athletes who continued playing in the National Hockey League (NHL) for a minimum of 5 years after hip arthroscopy for treatment of symptomatic femoroacetabular impingement (FAI) and to determine predictors associated with length of career. Study Design: Case series; Level of evidence, 4. Methods: A total of 60 professional hockey players (69 hips) underwent hip arthroscopy for FAI by a single surgeon between 2005 and 2010. Data were retrieved from NHL.com and Hockey-reference.com regarding information on each player’s professional career. Position played, age, surgical procedure, and intraoperative findings were also used in data analysis. Results: There were 12 centers, 15 defensemen, 16 goalies, and 17 wings studied. Of the 60 athletes, 40 (67%) continued to play professionally a minimum of 5 years after hip arthroscopy. As of the 2015 season, the mean length of a player’s NHL career was 13.7 years (range, 2-27 years), with an average of 5.9 years played after hip arthroscopy. There was no difference in length of career or years played when goalies were compared with other positions ( P = .760). Length of career and years played after arthroscopy correlated with age at surgery ( r = 0.799 and −0.408, respectively). Players who played ≥5 years after arthroscopy were significantly younger than those who did not (25 vs 30 years; P = .001). Athletes who played Conclusion: Professional NHL players who underwent hip arthroscopy for FAI were able to continue playing for an average of 5.9 years after surgery, with 67% playing a minimum of 5 years postoperatively. Younger age and shorter duration of symptoms at time of surgery correlated with greater length of career and years played after hip arthroscopy. Players who did not play a minimum of 5 years postoperatively had significantly longer duration of symptoms before surgery. The study data support early arthroscopic treatment of professional hockey players with symptomatic FAI.

Background: As the number of hip arthroscopic surgeries being performed increases, so too does the prevalence of revision hip arthroscopic surgery. Hypothesis/Purpose: The purpose of this study was to compare outcomes in patients requiring revision hip arthroscopic surgery to patients undergoing primary hip arthroscopic surgery. The hypothesis was that patients undergoing revisions would demonstrate similar outcomes to those undergoing primary hip arthroscopic surgery. Study Design: Cohort study; Level of evidence, 2. Methods: Included in the study were patients undergoing revision hip arthroscopic surgery who did not have a history of prior open hip surgery. Each patient in the revision cohort was matched with 2 patients undergoing primary hip arthroscopic surgery. Preoperatively and at a minimum follow-up of 2 years, outcome scores were collected, including the Hip Outcome Score–Activities of Daily Living subscale (HOS-ADL), which was the primary outcome variable; modified Harris hip score (mHHS); Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC); Hip Outcome Score–Sports subscale (HOS-Sports); and the 12-Item Short Form Health Survey (SF12). At follow-up, scores from the Tegner activity scale and patient self-reported satisfaction with surgical outcome were also collected. Results: A total of 246 patients in the revision cohort were matched with 492 patients in the primary cohort. In the revision cohort, 183 patients had 1 prior surgery, 45 had 2 surgeries, and 18 had ≥3 prior surgeries. Subsequent hip arthroscopic surgery was reported in 39 of 492 (8%) patients in the primary cohort and 5 of 246 (2%) patients in the revision cohort ( P = .001). Subsequent surgery was reported in 50 of 492 (10%) patients in the primary cohort and 15 of 246 (6%) patients in the revision cohort ( P = .07). Both groups saw significant improvement in outcome scores from preoperation to follow-up. The HOS-ADL was lower in the revision cohort preoperatively (65 vs 70) and postoperatively (79 vs 87) ( P = .001). This was also seen in the HOS-Sports, WOMAC, and SF12 physical component scores. Patients who had 1 prior hip arthroscopic procedure had higher postoperative mHHS (81 vs 75) compared with patients with >1 hip arthroscopic procedure; however, there was no difference in postoperative mHHS between the single-revision cohort and the primary cohort. In the revision group, patients whose HOS-ADL improved ≥10 points had greater joint space. Patients with greater improvement were more likely to have had a previous labral tear that was not repaired and to require capsular plication at revision. Conclusion: Patients who underwent revision hip arthroscopic surgery had significant improvement in outcome scores but did have lower scores compared with patients with primary hip arthroscopies. Patients with ≥2 revisions had lower outcomes. Improvement in the revision cohort was seen in patients with increased joint space, no prior labral repair, and capsular plication at revision.

IntroductionAthletic groin pain requiring surgery remains a diagnostic and therapeutic challenge. This systematic review aims to identify the most common causes of groin pain in athletes requiring surgery. Additionally, it aims to further characterise their susceptible athlete profiles, common physical examination and imaging techniques, and surgical procedures performed. This will enable the orthopaedic sports medicine clinician/surgeon to best treat these patients.Materials and methodsThe electronic databases MEDLINE, PubMed and EMBASE were searched from database inception to 13 August 2014 for studies in the English language that addressed athletic groin pain necessitating surgery. The search was updated on 4 August 2015 to find any articles published after the original search. The studies were systematically screened and data were abstracted in duplicate, with descriptive data presented.ResultsA total of 73 articles were included within our study, with data from 4655 patients abstracted. Overall, intra-articular and extra-articular causes of groin pain in athletes requiring surgery were equal. The top five causes for pain were: femoroacetabular impingement (FAI) (32%), athletic pubalgia (24%), adductor-related pathology (12%), inguinal pathology (10%) and labral pathology (5%), with 35% of this labral pathology specifically attributed to FAI.ConclusionsGiven the complex anatomy, equal intra-articular and extra-articular contribution, and potential for overlap of clinical entities causing groin pain leading to surgery in athletes, further studies are required to ascertain the finer details regarding specific exam manoeuvres, imaging views and surgical outcomes to best treat this patient population.

Purpose To determine factors associated with grade IV cartilage defects in the hip in patients undergoing hip arthroscopy with joint pain. Methods Data from consecutive patients who underwent hip arthroscopy performed by a single surgeon over a period of 4 years were included in this study. The study group included 1,097 patients (491 women and 606 men; mean age, 37 years) who underwent hip arthroscopy for pain, had no prior hip surgery, and were aged 18 years or older. Preoperative radiographs, patient demographic characteristics, and operative details were used to identify risk factors for cartilage defects. Results Grade IV chondral defects were present in 308 of 1,097 hips (28%). Isolated chondral lesions were more frequently observed on the acetabulum (76%) than on the femoral head (24%). Defects of the acetabulum were more commonly anterosuperior (94.7%) and less commonly posterolateral (5.3%). Patients with less than 2 mm of joint space on preoperative radiographs were 8 times more likely to have a grade IV lesion than those with more than 2 mm. Men were more likely than women to have grade IV lesions (35% v 19%, P = .0001); patients with grade IV lesions were older than those without (42 years v 34 years, P = .0001). Hips with grade IV lesions had significantly higher alpha angles than those without (74° v 70°, P = .0001). Patients with grade IV defects reported a longer duration of symptoms than those without (37 months v 27 months, P = .007). Independent risk factors for the presence of grade IV chondral defects were less than 2 mm of joint space, male gender, increasing age, larger alpha angle, and longer duration of symptoms. Conclusions Grade IV chondral defects in patients undergoing hip arthroscopy were associated with decreased joint space, increased time from symptom onset to arthroscopy, male gender, and larger alpha angles associated with femoroacetabular impingement. Level of Evidence Level IV, prognostic case series.

Background:The rate of return to sport after surgical treatment of femoroacetabular impingement (FAI) syndrome (FAIS) has been studied in high-level athletes. However, few studies examining this rate have focused exclusively on National Collegiate Athletic Association (NCAA) Division I athletes.Purpose:To evaluate the return-to-sport rate after hip arthroscopy for FAIS and to examine the influence of sport type on the clinical presentation of FAIS in collegiate athletes.Study Design:Case series; Level of evidence, 4.Methods:Included in this study were NCAA Division I student-athletes who underwent hip arthroscopy for FAIS at our institution between 2010 and 2017. Exclusion criteria were history of previous hip pathology, pediatric hip disease, radiographic evidence of osteoarthritis (Tönnis grade >0), prior lower extremity procedure, history of chronic pain, osteoporosis, or history of systemic inflammatory disease. Athletes were categorized into 6 subgroups based on the type of sport (cutting, contact, endurance, impingement, asymmetric/overhead, and flexibility) by using a previously reported classification system. Patient characteristics and preoperative, intraoperative, and return-to-sport variables were compared among sport types.Results:A total of 49 hip arthroscopies for FAIS were performed in 39 collegiate athletes (10 females, 29 males; mean age, 19.5 ± 1.3 years). A total of 1 (2.6%) cutting athlete, 15 (38.5%) contact athletes, 8 (20.5%) impingement athletes, 6 (15.4%) asymmetric/overhead athletes, and 9 (23.1%) endurance athletes were included in the study. There were no differences among sports groups with respect to the FAI type. Endurance athletes had lower rates of femoral osteochondroplasty (45.5%) and labral debridement (0.0%) ( P < .0001). Contact sport athletes had higher rates of labral debridement (50.0%; P < .0001). Patients were evaluated for return to sport at an average of 1.96 ± 0.94 years. Overall, the return-to-sport rate was 89.7%. There were no differences in return-to-sport rates based on the sport type except for endurance athletes, who returned at a lower rate (66.6%; P < .001). No differences in return-to-sport rate ( P = .411), duration after return ( P = .265), or highest attempted level of sport resumed ( P = .625) were found between patients who underwent labral repair versus debridement.Conclusion:Collegiate-level athletes who underwent hip arthroscopy for FAIS returned to sport at high and predictable rates, with endurance athletes possibly returning to sport at lower rates than all other sport types. Surgical procedures may be influenced by sport type, but the rate of return to sport between athletes who underwent labral debridement versus labral repair was similar.

Femoroacetabular impingement (FAI) has been frequently identified in the active adolescent. This has commonly been associated with sports that require extreme hip range of motion. It has also been suggested that repeated stress to the physis can contribute to the development of cam impingement. Several areas are critical to address in the adolescent athlete, including the status of the physis and hormonal changes. During hip arthroscopy, care should be taken to avoid damage to the physis. Common injuries addressed at arthroscopy include labral tears, cartilage injuries, ligamentum teres tears, capsular damage in addition to bony abnormalities associated with FAI. In primary hip arthroscopy in the adolescent, labral repair is the most common treatment for labral tears. If the labrum is very small and does not maintain the seal with the femoral head, a labral augmentation can be performed. Labral augmentations are more common in revision hip arthroscopy cases. Revision hip arthroscopy can be necessary in adolescents who may develop postoperative adhesions. Outcomes in patients who undergo one revision are similar to those that undergo a primary hip arthroscopy, but with more than one revision, outcomes are inferior. With appropriate treatment excellent outcomes may be achieved in adolescent patients.

Hip impingement can be caused by both intra- and extra-articular pathologies and may lead to significant pain and disability. Femoroacetabular impingement may present in 3 forms of intra-articular impingement: cam, pincer, or mixed. Extra-articular impingement is also common yet less recognized, but may also lead to significant functional limitations. In 1 form, the anterior-inferior iliac spine or subspine region may impinge on the femoral neck during motion. Symptoms include limited and painful hip flexion. Physical examination as well as diagnostic injections in the region can help distinguish the cause of pain. Hip arthroscopy has been reported to produce excellent results with correction of the bony deformity in the subspine region and acetabular rim. Here, we outline subspine impingment and describe our preferred surgical technique.

Background: The capsular ligaments and the labral suction seal cooperatively manage distractive stability of the hip. Capsular reconstruction using an iliotibial band (ITB) allograft aims to address capsular insufficiency and iatrogenic instability. However, the extent to which this procedure may restore hip distractive stability after a capsular defect is unknown. Purpose: To evaluate the biomechanical effects of capsular reconstruction on distractive stability of the hip joint. Study Design: Controlled laboratory study. Methods: Eight fresh-frozen cadaveric hip specimens were dissected to the level of the capsule and axially distracted in 3 testing states: intact capsule, partial capsular defect, and capsular reconstruction with an ITB allograft. Each femur was compressed with 500 N of force and then distracted 6 mm relative to the neutral position at 0.5 mm/s. Distractive force was continuously recorded, and the first peak delineating 2 phases of hip distractive stability in the force-displacement curve was analyzed. Results: The median force at maximum distraction in the capsular reconstruction state (156 N) was significantly greater than that in the capsular defect state (89 N; P = .036) but not significantly different from that in the intact state (218 N; P = .054). Median values for distractive force at first peak (60 N, 72 N, and 61 N, respectively; P = .607), distraction at first peak (2.3 mm, 2.3 mm, and 2.5 mm, respectively; P = .846), and percentage decrease in distractive force (35%, 78%, and 63%, respectively; P = .072) after the first peak were not significantly different between the intact, defect, and reconstruction states. Conclusion: Capsular reconstruction with an ITB allograft significantly increased the force required to distract the hip compared with a capsular defect in a cadaveric model. To our knowledge, this is the first study to report an initial peak distractive force and to propose 2 distinct phases of hip distractive stability. Clinical Relevance: The consequences of a capsular defect on distractive stability of the hip may be underappreciated among the orthopaedic community; with that said, capsular reconstruction using an ITB allograft provided significantly increased distractive stability and should be considered an effective treatment option for patients with symptomatic capsular deficiency.

Background:Previous studies have demonstrated that hip arthroscopy is an effective treatment for symptomatic femoroacetabular impingement (FAI) in professional athletes across a variety of sports. However, the return-to-play rates and postoperative performance of elite basketball players after hip arthroscopy are currently unknown.Purpose:To determine return-to-play rates and postoperative performance among professional basketball athletes after hip arthroscopy.Study Design:Case series; Level of evidence, 3.Methods:Eighteen professional basketball players underwent hip arthroscopy (24 hips) for symptomatic FAI between 2001 and 2016 by a single surgeon. Return to play was defined as competing in a single professional game of equal level after surgery. Data were retrospectively obtained for each player from basketball-reference.com , ESPN.com , eurobasket.com, and individual team websites. Matched controls were selected from the websites to compare performances.Results:The mean age at the time of surgery was 25.6 years, and the mean body mass index was 24.4 kg/m2. All players returned to their previous levels of competition, with a mean number of 4 seasons played after surgery (median, 3; range, 1-12). The mean ± SD time between the date of surgery and return to a professional game was 7.1 ± 4.4 months. There was no change in player efficiency rating when pre- and postinjury performance were compared. When compared with controls, players undergoing surgery also had no significant decline in player efficiency rating.Conclusion:Elite basketball athletes who undergo hip arthroscopy for the treatment of FAI return to their presurgical levels of competition at a high rate. These athletes demonstrate no significant overall decrease in performance upon their return to play.

Purpose To determine patient-specific factors that can be used to predict the presence of severe articular cartilage damage in the hip in patients without osteoarthritis. Methods The prevalence of severe (Outerbridge grade III or IV) cartilage damage to the acetabulum and femoral head was prospectively recorded at hip arthroscopy. Patients who underwent primary hip arthroscopic surgery between 2006 and 2016 performed by a single surgeon were included. Patients were excluded if they underwent previous hip surgery, had poor-quality radiographs, were younger than 16 years at the time of surgery, or had a minimal joint space of 2 mm or less. The relation between severe cartilage damage and preoperative patient characteristics was examined using multivariable logistic regression analysis with restricted cubic splines. Results Of the 2,396 hips presenting for hip arthroscopy, 995 (41%) had severe cartilage damage to the acetabulum and 257 (11%) had severe cartilage damage to the femoral head. Older age was a significant risk factor for severe cartilage damage both to the acetabulum (χ2 = 69.5, P Conclusions The primary risk factors for severe hip cartilage damage were older age for both the femoral head and acetabulum; a lower center-edge angle and larger Tonnis angle for the femoral head; and male sex, body mass index, alpha angle, and joint space for the acetabulum. The likelihood of cartilage damage to the hip can be estimated clinically using a prediction nomogram. Level of Evidence Level III, cross-sectional study.

Intra-articular femoroacetabular impingement (FAI) is an abnormal contact of the acetabular rim and the femoral head-neck junction and can occur from either anterior or posterior conflicts. This condition causes labral and cartilage damage, leads to painful range of motion, and may cause osteoarthritis over time. In addition to the known intra-articular causes, recent advances in physical examination of the hip, as well as hip arthroscopy, have identified extra-articular causes of posterior femoroacetabular impingement. The purpose of this chapter is to discuss, in detail, the etiology, pathology, examination, and treatment of posterior femoroacetabular impingement. The goal is to describe the unique approach to this challenging diagnosis and offer the orthopedic surgeon new tools with which to return patients and athletes to their daily lives and to their respective sports.

The purpose of this study was to compare the midterm outcomes and conversion to total hip arthroplasty (THA) rate in patients who had repair of the capsulotomy versus nonrepair following arthroscopic hip labral repair and correction of femoroacetabular impingement (FAI).All patients undergoing primary arthroscopic hip labral repair and correction of FAI between 2005 and 2012 were eligible for this study. Exclusion criteria were age18 years, lateral center-edge angle25°, previous hip procedures, femoral avascular necrosis, radiographic joint space ≤ 2 mm, or microfracture at arthroscopy. Patients who did not have the capsulotomy repaired were matched 1:2 with patients who had the capsulotomy repaired. Patients were matched by age, gender, and intraoperative procedures. The primary outcome score was the Hip Outcome Score Daily Living (HOS-ADL).Forty-two patients (18 female patients, 24 male patients) without repair of the capsulotomy were matched with 84 patients with repaired capsulotomy. The average age for both groups was 38 ± 15 years. Patients in the nonrepair group were 6.8 (95% confidence interval, 1.2-52) times more likely to undergo THA compared with the repair group. There was no difference in revision rate between the 2 groups. The mean follow-up time was 7.3 ± 2.7 years and 6.4 ± 2.3 years for the nonrepair and repair group, respectively (P = .107). Patients in the repair group had significantly higher HOS-ADL (P = .01) and modified Harris hip score (mHHS; P = .007). The percentage of patients who reached minimum clinically important difference was significantly higher in the repair group for HOS-ADL (P = .002) and HOS-Sport (P = .036) compared with the nonrepair group. However, there was no difference in the percentage of patients who reached minimal important change for the mHHS (P = .060). Following hip arthroscopy, the average alpha angle was 41.6° ± 6° in the nonrepair group and 40.8° ± 3° in the repair group.Patients who undergo arthroscopic FAI correction and hip labral repair with repair of the capsulotomy had higher HOS-ADL and mHHS scores at midterm follow-up compared with patients with nonrepair, and the percentage of patients who reached the minimum clinically important difference was significantly higher in the repair group for HOS-ADL and HOS-Sport compared with the nonrepair group. In addition, a lower rate of conversion to THA was seen in the repair group.Level III, retrospective comparative study.

People of all backgrounds are susceptible to bone and cartilage damage, and these injuries can be debilitating. Current treatments for bone and cartilage injuries are less than optimal, and we are interested in developing new approaches to treat these diseases, specifically using human muscle-derived stem cells (hMDSCs). Our lab previously demonstrated that sex differences exist between male and female murine MDSCs; thus, this paper sought to investigate whether sex differences also exist in hMDSCs. In the present study, we characterized the chondrogenic and osteogenic sex differences of hMDSCs in vitro and in vivo. We performed in vitro osteogenic and chondrogenic differentiation using hMDSC pellet cultures. As demonstrated by microCT, histology, and immunohistochemistry, male hMDSCs were more chondrogenic and osteogenic than their female counterparts in vitro. No differences were observed based on the sex of hMDSCs in osteogenic and chondrogenic gene expression and cell surface markers. For our in vivo study, we transduced hMDSCs with lenti-BMP2/GFP and transplanted these cells into critical-sized calvarial defects in mice. MicroCT results revealed that male hMDSCs regenerated more bone at 2 weeks and demonstrated higher bone density at 4 and 6 weeks than female hMDSCs. Histology demonstrated that both male and female hMDSCs regenerated functional bone. Clinical relevance: These studies reinforce that stem cells isolated from male and female patients differ in function, and we should disclose the sex of cells used in future studies. Considering sex differences of hMDSCs may help to improve cell-based therapies for autologous cell treatment of bone and cartilage damage. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:1339-1349, 2019.

Hip arthroscopy is an evolving procedure and its indications have expanded. The number of patients undergoing this procedure has increased significantly as well as the number of surgeons being trained. This has resulted in a notable increase in post-operative complication rates creating the need to develop advanced hip arthroscopic techniques. Revision hip arthroscopy is often complex and many factors should be considered to achieve a satisfactory clinical outcome. Careful pre-operative planning and agreement of expectations between the physician and patient regarding the procedure are important. This review describes several advanced treatment options that are used mainly in revision or complex primary hip arthroscopy cases. Labral reconstruction or augmentation technique is used in cases of severely deficient acetabular labral tissue to restore the fluid seal mechanism. In cases of symptomatic (often post-operative) adhesion formation, a spacer between the labrum and the joint capsule is useful for pain relief and prevention of future adhesions. Large defects of the capsule due to previous unrepaired capsulotomy or any other cause can be addressed with the capsular reconstruction technique. Ligamentum teres reconstruction using an anterior tibialis allograft is indicated in patients with hip instability and persistent pain after previous debridement or with complete tears of this structure. The senior author’s treatment of choice in cases of previous over-resection of CAM impingement is the remplissage technique to restore the bony defect of the femoral head-neck junction and preserve the joint seal.

Background: The diagnosis and treatment of femoroacetabular impingement (FAI) have increased steadily within the past decade, and research indicates clinically significant improvements after treatment of FAI with hip arthroscopy. Purpose: This study examined the societal and economic impact of hip arthroscopy by high-volume surgeons for patients with FAI syndrome aged Study Design: Economic and decision analysis; Level of evidence, 2. Methods: The cost-effectiveness of hip arthroscopy versus nonoperative treatment was evaluated by calculating direct and indirect treatment costs. Direct cost was calculated with Current Procedural Terminology medical codes associated with FAI treatment. Indirect cost was measured with the patient-reported data of 102 patients who underwent arthroscopy and from the reimbursement records of 32,143 individuals between the ages of 16 and 79 years who had information in a private insurance claims data set contained within the PearlDiver Patient Records Database. The indirect economic benefits of hip arthroscopy were inferred through regression analysis to estimate the statistical relationship between functional status and productivity. A simulation-based approach was then used to estimate the change in productivity associated with the change in functional status observed in the treatment cohort between baseline and follow-up. To analyze cost-effectiveness, 1-, 2-, and 3-way sensitivity analyses were performed on all variables in the model, and Monte Carlo analysis evaluated the impact of uncertainty in the model assumptions. Results: Analysis of indirect costs identified a statistically significant increase of mean aggregate productivity of $8968 after surgery. Cost-effectiveness analysis showed a mean cumulative total 10-year societal savings of $67,418 per patient from hip arthroscopy versus nonoperative treatment. Hip arthroscopy also conferred a gain of 2.03 quality-adjusted life years over this period. The mean cost for hip arthroscopy was estimated at $23,120 ± $10,279, and the mean cost of nonoperative treatment was estimated at $91,602 ± $14,675. In 99% of trials, hip arthroscopy was recognized as the preferred cost-effective strategy. Conclusion: FAI syndrome produces a substantial economic burden on society that may be reduced through the indirect cost savings and economic benefits from hip arthroscopy.

Cartilage damage is frequently seen during hip arthroscopy for femoroacetabular impingement or trauma. Currently, microfracture is the most common procedure for treating severe chondral defects. Studies have suggested that the presence of acetabular cartilage lesions can cause poor outcomes. Defects of the femoral head are seen less frequently, and less research exists on how these lesions contribute to outcomes. Although the presence of cartilage damage may be a predictor of poorer outcomes, one must also consider the treatment and postoperative rehabilitation as the main factors in outcomes.

The 2016 Warwick Agreement on femoroacetabular impingement (FAI) syndrome was convened to build an international, multidisciplinary consensus on the diagnosis and management of patients with FAI syndrome. 22 panel members and 1 patient from 9 countries and 5 different specialties participated in a 1-day consensus meeting on 29 June 2016. Prior to the meeting, 6 questions were agreed on, and recent relevant systematic reviews and seminal literature were circulated. Panel members gave presentations on the topics of the agreed questions atSports Hip 2016, an open meeting held in the UK on 27–29 June. Presentations were followed by open discussion. At the 1-day consensus meeting, panel members developed statements in response to each question through open discussion; members then scored their level of agreement with each response on a scale of 0–10. Substantial agreement (range 9.5–10) was reached for each of the 6 consensus questions, and the associated terminology was agreed on. The term ‘femoroacetabular impingement syndrome’ was introduced to reflect the central role of patients' symptoms in the disorder. To reach a diagnosis, patients should have appropriate symptoms, positive clinical signs and imaging findings. Suitable treatments are conservative care, rehabilitation, and arthroscopic or open surgery. Current understanding of prognosis and topics for future research were discussed. The 2016 Warwick Agreement on FAI syndrome is an international multidisciplinary agreement on the diagnosis, treatment principles and key terminology relating to FAI syndrome.The Warwick Agreement on femoroacetabular impingement syndrome has been endorsed by the following 25 clinical societies: American Medical Society for Sports Medicine (AMSSM), Association of Chartered Physiotherapists in Sports and Exercise Medicine (ACPSEM), Australasian College of Sports and Exercise Physicians (ACSEP), Austian Sports Physiotherapists, British Association of Sports and Exercise Medicine (BASEM), British Association of Sport Rehabilitators and Trainers (BASRaT), Canadian Academy of Sport and Exercise Medicine (CASEM), Danish Society of Sports Physical Therapy (DSSF), European College of Sports and Exercise Physicians (ECOSEP), European Society of Sports Traumatology, Knee Surgery and Arthroscopy (ESSKA), Finnish Sports Physiotherapist Association (SUFT), German-Austrian-Swiss Society for Orthopaedic Traumatologic Sports Medicine (GOTS), International Federation of Sports Physical Therapy (IFSPT), International Society for Hip Arthroscopy (ISHA), Groupo di Interesse Specialistico dell’A.I.F.I., Norwegian Association of Sports Medicine and Physical Activity (NIMF), Norwegian Sports Physiotherapy Association (FFI), Society of Sports Therapists (SST), South African Sports Medicine Association (SASMA), Sports Medicine Australia (SMA), Sports Doctors Australia (SDrA), Sports Physiotherapy New Zealand (SPNZ), Swedish Society of Exercise and Sports Medicine (SFAIM), Swiss Society of Sports Medicine (SGMS/SGSM), Swiss Sports Physiotherapy Association (SSPA).

Background: Anatomic landmarks located on the proximal femur have only recently been defined, and there is a lack of radiographic guidelines for their locations presented in the literature. With the confident identification of these landmarks, radiographs could provide more assistance in preoperative evaluations, intraoperative guidance, and postoperative assessments. Purpose: To quantify the radiographic locations of endoscopic landmarks of the proximal femur. Study Design: Descriptive laboratory study. Methods: Ten cadaveric specimens were dissected, and radio-opaque hardware was placed for each landmark of interest. Radiographs were obtained and measurements recorded in anteroposterior (AP) and Dunn 45° views. Results: In the AP view, the gluteus medius insertion was located a mean 12.9 ± 2.4 mm and 34.7 ± 5.1 mm from the piriformis fossa and vastus tubercle, respectively. The piriformis fossa was a mean 14.8 ± 5.9 mm and 4.9 ± 1.9 mm from the anterior and posterior tips of the greater trochanter, respectively. The anterior and posterior tips of the greater trochanter were a mean 14.8 ± 5.1 mm from each other. In the Dunn 45° view, the piriformis fossa was a mean 13.3 ± 2.0 mm, and the vastus tubercle was a mean 21.5 ± 6.0 mm, from the gluteus medius insertion. Moreover, the vastus tubercle was a mean 33.5 ± 6.4 mm from the anterior tip of the greater trochanter and 31.6 ± 8.5 mm from the posterior tip of the greater trochanter. Conclusion: In spite of the variation in cadaveric sizes, quantitative descriptions of endoscopic landmarks were reproducible in clinical views. Clinical Relevance: A detailed understanding of how the described landmarks present radiographically is relevant to preoperative planning, intraoperative evaluations, and postoperative assessments.

The acetabular labrum is a complex fibrocartilaginous structure with unique anatomy. Its unique anatomy imparts biomechanical functions important in hip stability, synovial fluid dynamics, contact pressure dissipation, proprioception, and nociception. Although the importance of labral preservation through surgical repair techniques has been increasingly recognized, situations do occur where the labrum is either absent, deficient, or simply irreparable. In these situations, both open and arthroscopic reconstructive techniques have been described to help restore the function of the native labral tissue. Efforts should be made to maintain or reestablish the native structure and function of the labrum in young patients with at least 2 mm of joint space based on the available biomechanical and clinical evidence. Return to sport, significant improvements in pain and function, high levels of satisfaction, and avoidance of hip arthroplasty have been shown in patients undergoing labral reconstruction. Although short-term results of labral reconstruction are promising, long-term follow-up and comparative studies will be necessary to further define its indications and contraindications.

Currently, there exists a need for a more thorough understanding of native hip joint kinematics to improve the understanding of pathological conditions, injury mechanisms, and surgical interventions. A biomechanical testing system able to accomplish multiple degree-of-freedom (DOF) movements is required to study the complex articulation of the hip joint. Therefore, the purpose of this study was to assess the repeatability and comparative accuracy of a 6 DOF robotic system as a testing platform for range of motion in vitro hip biomechanical analysis. Intact human cadaveric pelvises, complete with full femurs, were prepared, and a coordinate measuring machine collected measurements of pertinent femoral and pelvic bony landmarks used to define the anatomic hip axes. Passive flexion/extension path and simulated clinical exam kinematics were recorded using a 6 DOF robotic system. The results of this study demonstrate that the 6 DOF robotic system was able to identify hip passive paths in a highly repeatable manner (median RMS error of

Purpose To identify the indications and outcomes in patients undergoing revision hip arthroscopy. Methods The electronic databases Embase, Medline, HealthStar, and PubMed were searched from 1946 to July 19, 2014. Two blinded reviewers searched, screened, and evaluated the data quality of the studies using the Methodological Index for Non-Randomized Studies scale. Data were abstracted in duplicate. Agreement and descriptive statistics are presented. Results Six studies were included (3 prospective case series and 3 retrospective chart reviews), with a total of 448 hips examined. The most common indications for revision hip arthroscopy included residual femoroacetabular impingement (FAI), labral tears, and chondral lesions. The mean interval between revision arthroscopy and the index procedure was 25.6 months. Overall, the modified Harris Hip Score improved by a mean of 33.6% (19.3 points) from the baseline score at 1-year follow-up. In 14.6% of patients, further surgical procedures were required, including re-revision hip arthroscopy (8.0%), total hip replacement (5.6%), and hip resurfacing (1.0%). Female patients more commonly underwent revision hip arthroscopy (59.7%). Conclusions The current evidence examined in this review supports revision hip arthroscopy as a successful intervention to improve functional outcomes (modified Harris Hip Score) and relieve pain in patients with residual symptoms after primary FAI surgery, although the outcomes are inferior when compared with a matched cohort of patients undergoing primary hip arthroscopy for FAI. The main indication for revision is a candidate who has symptoms due to residual cam- or pincer-type deformity that was either unaddressed or under-resected during the index operation. However, it is important to consider that the studies included in this review are of low-quality evidence. Surgeons should consider incorporating a minimum 2-year follow-up for individuals after index hip-preservation surgery because revisions tended to occur within this time frame. Level of Evidence Level IV, systematic review of Level III and IV studies.

To better understand how radiograph imaging is currently used throughout perioperative care for femoroacetabular impingement (FAI) and to define surgeon knowledge and perspective on radiation safety when treating FAI. An online questionnaire was designed to be completed by hip arthroscopists on the imaging modalities and projections they use during evaluation and treatment of FAI and the associated radiation exposures and safety. A sample of practicing attending orthopaedic surgeons was surveyed via an anonymous survey link emailed to corresponding authors on publications related to FAI. The anonymous survey link was also provided to orthopaedic surgeons at the 2014 Vail Hip Symposium. Ninety-one surgeons completed the survey. Of these participants, 72 surgeons (79.1 %) indicated they use pre-operative radiographs and intra-operative spot fluoroscopic images during FAI treatment. Thirty-three surgeons (36.3 %) use pre-operative computed tomography (CT). Twenty-three surgeons (25.3 %) use real-time moving fluoroscopy. A majority of surgeons incorrectly answered multiple-choice questions about which C-arm positions and settings result in the lowest doses of radiation to the surgeon or patient. Eighty-three surgeons (91.2 %) indicated they believe most orthopaedic surgeons need to be more informed about radiation safety. This study gives a quantitative representation of the imaging modalities and projections utilized during perioperative treatment for FAI. This study also identified a lack of knowledge of radiation safety among orthopaedic surgeons treating patients with FAI and demonstrates the need for greater education. IV.

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 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.

Background: With an improved understanding of the importance of the labrum, labral repair is replacing labral debridement as a component of hip arthroscopy for femoroacetabular impingement. Labral repair can be performed by passing suture limbs either around (looped) or through (pierced) the labral tissue. Purpose: To determine whether there is any clinical difference between these different labral repair techniques. Study Design: Cohort study; Level of evidence, 3. Methods: A prospective data registry was queried for patients who underwent primary hip arthroscopy with labral repair from 2009 to 2011. Patients older than 18 years who had undergone labral repair were included in the study. Exclusion criteria included previous hip surgery, avascular necrosis, joint space less than 2 mm, and labral reconstruction or augmentation. Patients were grouped based upon the 3 labral repair techniques: looped, pierced, or combined. Statistical equivalence testing was performed to evaluate the primary outcome measure, the Hip Outcome Score–activities of daily living subscale (HOS-ADL). Other measures included the HOS–sport subscale (HOS-Sport), modified Harris hip score (mHHS), Short Form–12 (SF-12), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and patient satisfaction with outcome (1-10 scale; 10 = very satisfied). Results: Preoperative scores improved in the looped group (HOS-ADL, from 68 to 91; mHHS, from 64 to 83; HOS-Sport, from 51 to 81; and WOMAC, from 23 to 9), the pierced group (HOS-ADL, from 64 to 89; mHHS, from 62 to 83; HOS-Sport, from 46 to 77; and WOMAC, from 34 to 12), and the combined group (HOS-ADL, from 64 to 89; mHHS, from 63 to 83; HOS-Sport, from 52 to 79; and WOMAC, from 26 to 12). Median patient satisfaction in all groups was 9.0. The 3 labral repair groups were shown to be statistically and clinically equivalent ( P < .05) with respect to the validated HOS-ADL to within a clinically irrelevant threshold at mean 36-month follow-up. In addition, there were no differences in secondary outcome measures or in the revision rate (looped, 7% [14/209], pierced, 8% [5/65], and combined, 6% [5/83]). Conclusion: This study showed equivalent HOS-ADL outcomes between looped, pierced, and combined labral repairs. Secondary outcome measures, including failure and revision rates, were not significantly different among the groups. Thus, suture type did not influence outcomes.

Purpose The purpose of this study was to determine whether outcomes after hip arthroscopy were different based on femoral version. Methods The inclusion criteria were diagnosis of femoroacetabular impingement (FAI) based on clinical examination and/or imaging findings and preoperative measurement of femoral version by magnetic resonance imaging. For this study, the definition of FAI was a positive impingement sign, a positive flexion–abduction–external rotation examination finding, or radiographic signs of impingement. A query of a prospective data registry identified 180 patients who matched the inclusion and exclusion criteria. Group 1 had version of less than 5° (n = 48), group 2 had version of 5° to 15° (n = 84), and group 3 had version greater than 15° (n = 48). The mean age of the patients was 35 years (range, 18 to 61 years). Results On radiographic examination, the mean alpha angle for all patients' injured hips was 63° (range, 42° to 88°). The mean center-edge angle was 30° (range, 20° to 43°), and mean femoral version was 9.9° (range, −16° to 29°). There was no significant difference in age, alpha angle, or center-edge angle among the 3 version groups. A significant difference in psoas release procedures (psoas impingement) was seen with increasing femoral version. The mean follow-up period was 30 months (range, 18 to 47 months). Patient-reported functional outcomes were not statistically different among the groups. Conclusions Patient-reported functional outcomes after hip arthroscopy for labral tears and FAI were not different based on femoral version in this population. Although some differences were observed regarding intraoperative findings, these also did not result in differences in patient outcomes reported at a mean follow-up of 2 years. Level of Evidence Level IV, therapeutic case series.

Background: In cases where the acetabular labrum is severely damaged and irreparable, labral reconstructions are becoming an increasingly preferred means of preserving the fluid seal effect of the labrum. However, the graft that most closely replicates the biomechanical properties of the native labrum remains undetermined. Purpose: To characterize the tensile properties and geometry of the labrum, as well as iliotibial band, semitendinosus, gracilis, and anterior tibialis grafts. Study Design: Controlled laboratory study. Methods: Five graft groups—(1) acetabular labrum, (2) iliotibial band, (3) semitendinosus, (4) gracilis, and (5) anterior tibialis—with 8 specimens per group were tested. Grafts were tested using a materials testing system in response to a stepwise sinusoidal cyclic loading protocol. Uniaxial tensile loads were initially applied from 20 to 50 N for 100 cycles at 0.5 Hz, followed by incremental increases of 50 N in the upper force every 100 cycles until failure or successful completion of 100 cycles at 300 N. This protocol was designed to be representative of progressive loading experienced during rehabilitation. Cyclic displacement was recorded after 100 (50 N), 200 (100 N), 300 (150 N), 400 (200 N), 500 (250 N), and 600 (300 N) cycles. Results: The mean elongation (95% CI) after 100 cycles from 20 to 50 N was similar for all groups: acetabular labrum, 0.68 mm (0.57-0.78 mm); iliotibial band, 0.68 mm (0.47-0.89 mm); semitendinosus, 0.68 mm (0.51-0.84 mm); gracilis, 0.62 mm (0.46-0.79 mm); and anterior tibialis, 0.66 mm (0.58-0.73 mm). After 100 cycles from 20 to 300 N (600 cycles total), the mean elongation of the labrum was 4.53 mm (3.71-5.35 mm), and the mean elongations of the iliotibial band, semitendinosus, gracilis, and anterior tibialis were 4.65 mm (3.23-6.07 mm), 4.41 mm (3.45-5.36 mm), 5.12 mm (3.09-7.16 mm), and 5.33 mm (4.40-6.25 mm), respectively. Conclusion: All tested grafts and the acetabular labrum exhibited similar cyclic elongation behavior in response to simulated physiologic forces. In addition, differences in variability in both elongation and geometry existed for all graft types. Clinical Relevance: All tested grafts can be considered viable acetabular labrum reconstruction graft options.

Femoroacetabular impingement (FAI) is a major cause of hip morbidity. However, bony abnormalities within the hip, can have a major role on ipsilateral joints such as the knee and the ankle. It has been reported that a diminished range of motion of the hip could increase the risk of ACL injury. Screening for FAI has shown that individuals develop bony abnormalities at a young age, especially those involved in sports. More research is needed to determine if programs that address loss of hip motion may alter risk of ACL injury. In addition, the risk of intra-articular hip damage must also be managed with prvention programs of programs which allow individuals to adapt their activities to deal with the bony abnormalities of FAI. The purpose of this chapter was to describe the most important aspects of the evaluation, pathophysiology and prevention of FAI and increased risk of ACL injuries.

Purpose This study was carried out to assess the quality of information available on YouTube regarding femoroacetabular impingement (FAI). Methods YouTube was searched on September 7, 2013 using the search terms FAI , femoroacetabular impingement , and hip impingement . Analysis was restricted to the first 3 pages of results for each search term. English language was a prerequisite for inclusion. Videos were evaluated by 2 independent reviewers (M.G.M., D.J.H.) using novel scoring checklists for diagnosis and treatment of FAI. Interobserver reliability analysis was evaluated using the intraclass correlation coefficient (ICC). Videos were grouped according to quality assessment score, and the group means were analyzed for differences in video characteristics using the analysis of variance (ANOVA) model. Videos were characterized by the source of content. Results After filtering 1,288,324 potential videos, 52 videos were identified and included for analysis. The mean video quality assessment scores were 3.1 for diagnosis and 2.9 for treatment (maximum score = 16). No videos were scored as excellent (quality assessment score > 12). Effective resources included 3 videos on diagnosis and one video on treatment. No statistically significant differences were found between high- and low-scoring videos for duration, days online, views per day, likes, likes per day, likes per view, dislikes, or likes-dislikes difference for either diagnosis or treatment ( P > .05 for all). The source of most of the videos was educational (67%), and most of these included physicians (66%). Conclusions Patients searching YouTube for videos pertaining to FAI will be presented with a sizeable repository of content of overall low quality. As such, physicians need to recognize the potential influence of YouTube videos on patients' preconceptions of their conditions and the effect on the physician-patient consultation. This review highlights the need for evidence-based, comprehensive educational videos addressing FAI diagnosis and treatment. Level of Evidence Level V, systematic review of non–peer-reviewed resources.

The most commonly used parameter for defining cam-type femoroacetabular impingement(FAI) has been the alpha angle. The purpose of this study was to determine if patient-reported outcomes 5 years following hip arthroscopy for FAI were associated with postoperative alpha angle. We hypothesized that patient-reported outcomes would not be influenced by postoperative alpha angle in patients with FAI. 230 patients had primary hip arthroscopy for FAI and chondrolabral dysfunction. The median age was 40 years (range 18–69). All patients had preoperative and 1 day postoperative alpha angles recorded. At minimum 5 years following arthroscopy, all patients completed an online questionnaire that included the modified Harris Hip score(MHHS), WOMAC, HOS ADL, HOS Sport, SF12 and patient satisfaction. This study was IRB approved. Patients were grouped into two, based on their postoperative alpha angle

A thorough evaluation of the hip must include a comprehensive medical and surgical history focused on the hip joint, surrounding soft tissues, and the associated structures of the spine, pelvis, and lower extremities. These details can guide the physical examination and provide insight into the cause of the patient's chief complaints. A proper examination includes physical examination while the patient is in the upright, supine, prone, and lateral position, as well as an evaluation of gait. Guided by a thorough history, the physical examination enables the surgeon to distinguish between intra-articular and extra-articular contributors to hip pain, selection of appropriate imaging modalities, and ultimately supports medical decision making.

Objectives: The objective of this study was to compare the risk of Outerbridge grade 3 or 4 defects in hips with different labrum thickness in patients undergoing primary hip arthroscopy for FAI. Methods: Between 2005 and 2014, patients who underwent hip arthroscopy by a single surgeon and met the inclusion criteria were included in this study. The labrum was measured with an arthroscopic ruler at 3 points that corresponded with 9 o’clock, 12 o’clock and 3 o’clock during hip arthroscopy from the chondrolabral junction to the edge of the labrum. Four specific measurements were stablished as a parameter for the labral thickness (4, 5, 6 and 7 cm). The lower labral thickness measurement of the three performed was used as a guide for the groups classification. Patients were compared based on the labrum thickness regarding the prevalence of Outerbridge grade III and IV on the femoral head (FH) and acetabulum. Patients were excluded if they had previous arthroscopic or open hip surgery, had inmeasurement of the labrum or had insurgical data. Results: Eight hundred forty-three patients were included on this study, the average age was 31.7 years old, regarding gender, 468 females and 367 males. There was no difference in the sample characterization variables. Hips with small labrums were more likely to have a grade 3 or 4 chondral defect on the femoral head. First, comparing patients with 7 and 6 mm of labral thickness, patients measuring 6mm had an 1.7 relative risk for severe chondral damage on the FH [1.04 to 2.7] p=0.033. Second, when patients with 7 and 5 mm are compared, patients with 5mm of labral thickness have a 4.3 relative risk[2.2 to 4.3]p