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Classic techniques in arthroscopic hip labral repair use circumferential or intrasubstance suture secured with anchors typically placed behind the labrum (capsular side). The primary goal of labral repair is to re-establish the hip suction seal and is often achieved via fixation techniques that invert viable labral tissue to restore or improve contact with the femoral head. Many repair techniques use only 1 suture limb either passed circumferentially around the labrum or passed in an intrasubstance manner, resulting in smaller purchase of labral tissue and lack of a strong inverting vector. In some cases, this may evert the labral tissue, compromising the suction seal. We describe a technique in which both suture limbs are passed in a mattress, figure-of-8 configuration, through the labral tissue, and tied on the capsular side to yield an inverting, double-limb repair. Therefore, each anchor results in a wider, more impactful repair footprint while reliably inverting the labral tissue.

To determine whether there are differences in (1) the incidence of post-related complications following hip arthroscopy between prospective and retrospective publications; and (2) between post-assisted and postless techniques.A systematic review was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to characterize post-related complications following hip arthroscopy for central or peripheral compartment hip pathology, including femoroacetabular impingement syndrome and chondrolabral injury. Inclusion criteria were prospective and retrospective Level I-IV evidence investigations that reported results of hip arthroscopy performed in the supine position. Exclusion criteria included open or extra-articular endoscopic hip surgery. Post-related complications included pudendal nerve injury (sexual dysfunction, dyspareunia, perineal pain or numbness) or perineum/external genitalia soft-tissue injury.Ninety-four studies (12,212 hips; 49% male, 51% female; 52% Level IV evidence) were analyzed. Prospective studies (3,032 hips) report a greater incidence of post-related complications compared with retrospective (8,116 hips) studies (7.1% vs 1.4%, P.001). Three studies (1,064 hips) used a postless technique and all reported a 0% incidence of pudendal neurapraxia or perineal soft tissue injury. Most pudendal nerve complications were transient, resolving by 3 months, but permanent nerve injury was reported in 4 cases. Only 19%, 22%, 7%, and 4% of studies reported a total surgery time, traction time, traction force, and bed Trendelenburg angle for their study samples, respectively.The incidence of post-related complications is 5 times greater in prospective (versus retrospective) hip arthroscopy literature. Postless distraction resulted in a 0% incidence of post-related injuries.IV, systematic review of Level I-IV evidence.

In recent years, there has been increased awareness and treatment of groin injuries in athletes. These injuries have been associated with various terminologies including sports hernia, core muscle injury (CMI), athletic pubalgia and inguinal disruption, among others. Treatment of these injuries has been performed by both orthopaedic and general surgeons and may include a variety of procedures such as rectus abdominis repair, adductor lengthening, abdominal wall repair with or without mesh, and hip arthroscopy for the treatment of concomitant femoroacetabular impingement. Despite our increased knowledge of these injuries, there is still no universal terminology, diagnostic methodology or treatment for a CMI. The purpose of this review is to present a detailed treatment algorithm for physicians treating patients with signs and symptoms of a CMI. In doing so, we aim to clarify the various pathologies involved in CMI, eliminate vague terminology, and present a clear, stepwise approach for both diagnosis and treatment of these injuries.

Background: Previous studies have demonstrated various groin-related nerve and soft tissue complications in patients undergoing hip arthroscopy with a perineal post. Purpose: To prospectively compare groin-related nerve and soft tissue complications between patients undergoing hip arthroscopy with and without the use of a perineal post. Study Design: Cohort study; Level of evidence, 2. Methods: A prospective single-surgeon cohort study was performed on all patients undergoing hip arthroscopy by the senior author between January 2020 and March 2022. A post-free hip distraction system was used at 1 center in which the senior author operates, and a system with a large padded perineal post was used at another surgical location. Patients completed a survey at the first postoperative visit (7-10 days) to determine if they had experienced any groin-related complications after surgery (groin numbness, sexual/urinary dysfunction, skin tears). Patients with a positive survey response repeated the survey at each follow-up visit (6 weeks, 3 months, 6 months) until the symptoms resolved. The rate and duration of groin-related complications were then compared between the groups. Results: A total of 87 patients were included in the study who underwent hip arthroscopy: 53 with a perineal post and 34 without. No differences were found between the post and postless groups in terms of age at surgery, sex, body mass index, or traction time. We found that 16 patients (30%) in the perineal post group experienced groin numbness versus 0 (0%) in the postless group ( P < .0001). On average, groin numbness lasted 5 ± 3 days (mean ± SD) in the perineal post group. Three patients in the perineal post group experienced sexual dysfunction for a mean 7 days, as compared with none in the postless group. Seventeen patients (32%) in the perineal post group experienced foot numbness versus 4 (12%) in the postless group ( P = .04). One patient in the perineal post group reported a superficial skin tear. Conclusion: Postless hip arthroscopy resulted in no risk of groin-related complications as compared with traditional hip arthroscopy with a perineal post.

Background:Previous studies have demonstrated the risks of pudendal nerve and/or soft tissue complications due to the use of a perineal post during hip arthroscopy. Recently, various postless hip arthroscopy techniques have been described in the literature.Purpose:To assess the current international trends in the use of postless hip arthroscopy among hip preservation specialists.Study Design:Cross-sectional study.Methods:An anonymous 11-item survey was sent by email to all members of the International Society for Hip Arthroscopy (ISHA) in January 2022. Surgeons were asked various questions regarding their current use of post-assisted or postless hip arthroscopy, if they had changed their setup technique during their career and the reason for that change, and their perceived rate of pudendal nerve and/or perineal soft tissue injuries using their current technique. Descriptive statistics were used to report the results of each question. The Student t test was used to compare the number of years in practice between post-assisted and postless users. Fisher exact tests were performed to compare categorical rates of pudendal nerve and soft tissue complications between post-assisted and postless users.Results:A total of 126 surveys were completed from 431 ISHA members (29.2%). Sixty-one percent of the surgeons currently use a perineal post, while 33% use a postless technique. Seventy-five percent of the perineal post users and 98% of the postless users self-reported a rate of pudendal nerve and/or soft tissue injury of Conclusion:Although use of a perineal post is still a more common setup technique among hip arthroscopists, approximately one-third of surgeons use a postless technique. Surgeons who have switched to a postless technique often did so because of perineal complications, with the majority noticing a subjective decrease in these complications with the use of postless hip arthroscopy.

Background: Various analgesic modalities have been used to improve postoperative pain in patients undergoing hip arthroscopy. Purpose: To systematically review the literature to compare the efficacy of the fascia iliaca block (FIB) with that of other analgesic modalities after hip arthroscopy in terms of postoperative pain scores and analgesic consumption. Study Design: Systematic review. Methods: A systematic review was performed by searching PubMed, the Cochrane Library, and Embase up to April 2020 to identify randomized controlled trials that compared postoperative pain and analgesic consumption in patients after hip arthroscopy with FIB versus other pain control modalities. The search phrase used was “hip arthroscopy fascia iliaca randomized.” Patients were evaluated based on postoperative pain scores and total postoperative analgesic consumption. Results: Five studies (3 level 1, 2 level 2) were identified that met inclusion criteria, including 157 patients undergoing hip arthroscopy with FIB (mean age, 38.3 years; 44.6% men) and 159 patients among the following comparison groups: lumbar plexus block (LPB), intra-articular ropivacaine (IAR), local anesthetic infiltration (LAI), saline placebo, and a no-block control group (overall mean age, 36.2 years; 36.5% men). No significant differences in pain scores were reported in the postanesthesia care unit (PACU) between the FIB and LPB (3.4 vs 2.9; P = .054), IAR (7.7 vs 7.9; P = .72), control group (no FIB: 4.1 vs 3.8; P = .76); or saline placebo (difference, –0.2 [95% CI, –1.1 to 0.7]). One study reported significantly higher pain scores at 1 hour postoperation in the FIB group compared with the LAI group (5.5 vs 3.4; P = .02). Another study reported significantly greater total analgesic consumption (in morphine equivalent dosing) in the PACU among the FIB group compared with the LPB group (20.8 vs 17.0; P = .02). No significant differences were observed in total PACU analgesic consumption between FIB and other analgesic modalities. Conclusion: In patients undergoing hip arthroscopy, the FIB does not appear to demonstrate superiority to other forms of analgesics in the immediate postoperative period. Therefore, it is not recommended as a routine form of pain control for these procedures.

This study aimed to determine whether the addition of platelet-rich plasma (PRP) during hip arthroscopy improves functional outcomes in femoroacetabular impingement (FAI) surgery. This was a prospective randomized single-blinded trial of arthroscopic hip patients aged between 16 and 50 years with a diagnosis of FAI conducted at a single centre. Patients with any previous hip surgery and significant osteoarthritic changes (Tonnis grade > 2) were excluded. Before surgery, patients were randomly assigned to receive either a PRP injection or a saline placebo. Efficacy was evaluated at 6 months, 1 year and 2 years post-surgery using patient-reported outcomes. The short version International Hip Outcome Tool (iHOT12) was the primary outcome. Recruited patients (n = 113) were aged 36.0 ± 10.5 (mean ± standard deviation) years and 56% male. At baseline, iHOT12 scores of the PRP (mean 43.8 ± 22.4) and placebo groups (mean 45.2 ± 21.5) were similar. At a minimum follow-up of 2 years, both groups had improved iHOT12 scores (PRP: mean 83.6 ± 13.4, control: mean 77.1 ± 23.3), with no significant difference in change between the two groups (P = 0.19). There were no significant group differences for the change in Non-Arthritic Hip and Hip Disability and Osteoarthritis Outcome Score—Shortform scores between the two groups (P = 0.22 and 0.46, respectively). The present study does not support the peri-operative use of PRP in arthroscopic surgery for FAI for mid-term improvement. There were no significant differences in outcome between PRP and placebo groups at 2-year minimum follow-up after surgery.

The number of youth participating in rock climbing has increased over the years. Finger stress epiphyseal fractures are the most common injury among youth climbers. These injuries tend to occur around puberty because this is when the physis is most vulnerable to injury. Additionally, it has been found that intensive finger training (campus boarding, a previously known risk factor for epiphyseal fractures) during adolescence can lead to early-onset osteoarthritis of the hand up to a decade later. There is currently a lack of a return-to-climb protocol for youth climbers following a repetitive stress epiphyseal fracture. Because of this gap in the literature, our purpose was to create a structured return-to-play protocol specific to youth climbers who sustained an epiphyseal fracture to the finger. By establishing these guidelines, medical professionals and coaches may be able to guide their athlete to gradually and safely return to sport.

The purpose of this study was to establish an international expert consensus on operating room findings that aid in the diagnosis of hip instability.An expert panel was convened to build an international consensus on the operating room diagnosis/confirmation of hip instability. Seventeen surgeons who have published or lectured nationally or internationally on the topic of hip instability were invited to participate. Fifteen panel members completed a pre-meeting questionnaire and agreed to participate in a 1-day consensus meeting on May 15, 2021. A review of the literature was performed to identify published intraoperative reference criteria used in the diagnosis of hip instability. Studies were included for discussion if they reported and intraoperative findings associated with hip instability. The evidence for and against each criteria was discussed, followed by an anonymous voting process. For consensus, defined a priori, items were included in the final criteria set if at least 80% of experts agreed.A review of the published literature identified 11 operating room criteria that have been used to facilitate the diagnosis of hip instability. Six additional criteria were proposed by panel members as part of the pre-meeting questionnaire. Consensus agreement was achieved for 8 criteria, namely ease of hip distraction under anesthesia (100.0% agreement), inside-out pattern of chondral damage (100.0% agreement), location of chondral damage on the acetabulum (93.3% agreement), pattern of labral damage (93.3% agreement), anteroinferior labrum chondral damage (86.7% agreement), perifoveal cartilage damage (97.6% agreement), a capsular defect (86.7% agreement), and capsular status (80.0% agreement). Consensus was not achieved for 9 items, namely ligamentum teres tear (66.7% agreement), arthroscopic stability tests (46.7% agreement), persistent distraction after removal of traction (46.7% agreement), findings of examination under anesthesia (46.7% agreement), the femoral head divot sign (40.0% agreement), inferomedial synovitis (26.7% agreement), drive-through sign (26.7% agreement), iliopsoas irritation (26.7% agreement) and ligamentum teres-labral kissing lesion (13.3% agreement). All experts agreed on the final list of 8 criteria items reaching consensus.This expert panel identified 8 criteria that can be used in the operating room to help confirm the diagnosis of hip instability.Level V expert opinion.

Background: Delayed gadolinium-enhanced magnetic resonance imaging of cartilage (dGEMRIC) is an advanced imaging technique that is purported to quantify cartilage damage in acute and chronic joint disease and predict periacetabular osteotomy (PAO) outcomes. There is a paucity of literature relating dGEMRIC values to arthroscopic findings before PAO and postoperative outcomes after PAO. Purpose: To assess the utility and validity of dGEMRIC as a preoperative and prognostic assessment tool of cartilage status and integrity as it relates to intraoperative findings and midterm postoperative outcomes after PAO. Study Design: Case series; Level of evidence, 4. Methods: We analyzed a cohort of 58 patients (70 hips) with a median age of 30.1 years (range, 15-50) with hip dysplasia who underwent hip arthroscopy, followed by a PAO with preoperative dGEMRIC. The primary outcome measures were intraoperative assessment and correlation with cartilage damage (presence of cartilage flap, Outerbridge grade of the acetabulum and femoral head). Secondary outcome measures were postoperative patient-reported outcome (PRO) scores, including the International Hip Outcome Tool and Non-arthritic Hip Score. Correlation analyses were performed to determine the relationship between dGEMRIC values and (1) PROs and (2) intraoperative assessment of cartilage damage. Results: There were significant negative linear relationships between dGEMRIC values and the primary outcome measures: presence of a cartilage flap (coronal, P = .004; sagittal, P < .001), Outerbridge grade of acetabular articular cartilage lesion (coronal, P = .002; sagittal, P = .003), and Outerbridge grade of femoral head articular cartilage lesion (coronal, P = .001; sagittal, P < .001). Despite significant overall improvement in all patients, there was no significant correlation between preoperative dGEMRIC values and improvement in PROs from presurgery to latest postoperative follow-up (median, 2.2 years; range, 1.0-5.0 years). Conclusion: Although dGEMRIC values (sagittal and coronal) were significant predictors of the intraoperative presence of cartilage flaps and overall cartilage integrity, they were not associated with midterm outcomes after PAO.

Background: Prior reports of hip arthroscopy using a perineal post have established the risks of groin soft tissue injury, sexual dysfunction, and altered lower extremity neurovascular function. These parameters have not been investigated for hip arthroscopy without the use of a perineal post. Purpose: To evaluate the effects of postless hip arthroscopy on lower extremity venous blood flow, nerve conduction, muscle tissue damage, and perineal injury. Study Design: Case series; Level of evidence, 4. Methods: Patients between the ages of 18 and 50 years undergoing an elective unilateral or simultaneous bilateral hip arthroscopy were enrolled. Creatine phosphokinase (CPK)–MM levels and D-dimer levels were obtained preoperatively, immediately postoperatively, and 7 to 12 days postoperatively. Bilateral Doppler ultrasonography of the common femoral vein (CFV) and popliteal vein were conducted intraoperatively. Somatosensory evoked potentials (SSEPs) and transcranial motor evoked potentials (TcMEPs) were measured intraoperatively for the lower limbs. Perineal injury was assessed at 7 to 12 days postoperatively. Results: 35 patients underwent a total of 40 hip arthroscopies. No significant differences were found in venous blood flow between the operative and nonoperative legs for either the CFV or popliteal vein. SSEP monitoring of the peroneal nerve showed no significant reduction when traction was applied to the operative leg, 90.8%, compared with final measurement just before it was removed, 72.4% ( P = .09). For TcMEPs measured in the muscles outside of the traction boots, no significant changes were seen in the percentage of cases with abnormal measurements throughout the procedure. CPK-MM levels preoperatively, immediately postoperatively, and 7 to 12 days after surgery were on average 112, 190, and 102 IU/L, respectively (normal, Conclusion: Postless hip arthroscopy is safe, without a notable reduction of venous blood flow or alteration of nerve function in the operative leg. Muscle tissue damage is subclinical, transient, and reduced compared with distraction with a post. No cases of perineal injury were observed during the study period.

The most predictive factor for hamstring injury is a previous hamstring injury.Magnetic resonance imaging is the most useful study for determining the extent of the hamstring injury and whether surgical intervention is warranted.Conservative treatment is indicated for acute hamstring strains, partia

To determine the prevalence of clinically diagnosed femoroacetabular impingement (FAI) in a consecutive series of patients presenting with proximal hamstring tendon injury and to correlate this with pelvic anatomic factors.The prevalence of clinically symptomatic cam-, pincer-, and mixed-type and overall FAI was calculated among a consecutive series of patients presenting to a hip preservation clinic with a confirmed clinical and radiographic diagnosis of proximal hamstring tendon injury between 2012 and 2017. The presence of a cam lesion was determined by an alpha angle50° on radiographs and computed tomography radial sequences of the head-neck junction and a femoral head-neck offset ratio0.18. Clinical diagnoses of osseous impingement were determined according to accepted pathomorphologic signs and measurements. A diagnosis of FAI was confirmed by imaging findings of acetabular overcoverage for pincer-type FAI and the presence of an anterior or lateral cam lesion for cam-type FAI.Overall, 120 hips in 97 patients (mean age, 45 years) were included in this study. A clinical diagnosis of FAI was noted in 70.8% of hips (pincer-type 9.2%, cam-type 40.8%, mixed-type 20.8%), an approximate 2- to 7-fold increased prevalence in comparison with the general population from prior studies.The prevalence of FAI is high in patients with symptomatic proximal hamstring tendon pathology. Because FAI results in restriction of hip range of motion and altered pelvic tilt, future studies are warranted to investigate whether the presence of FAI acts as a predisposing factor for injury to the hamstring muscle complex.Level IV, case series.

To compare the lateral osseolabral coverage between groups of patients with different degrees of acetabular bony coverage using a magnetic resonance imaging parameter known as the combined lateral center-edge angle (cLCEA).The cLCEA was measured among a consecutive series of patients presenting to a dedicated hip preservation surgeon with a magnetic resonance imaging scan. The cLCEA was measured using a coronal T1 or proton density image and was defined as the angle subtended by (1) a line through the center of the femoral head and orthogonal to the transverse line passing through the teardrops of both hips and (2) an oblique line drawn from the center of the femoral head to the free edge of the lateral acetabular labrum. The average difference between the lateral center-edge angle (LCEA) and the cLCEA was calculated and compared between groups based on acetabular bony coverage: dysplasia (LCEA20°), borderline dysplasia (LCEA 20°-24.9°), normal coverage (LCEA 25°-39.9°), and overcoverage (LCEA ≥40°).In total, 341 patients (386 hips) were included. There were no significant differences in cLCEA between hips with normal acetabular coverage and dysplasia (P = .10) or borderline dysplasia (P = .46). Despite the large difference in mean LCEA between dysplasia (14.8° ± 3.9°) and acetabular overcoverage (43.1° ± 2.8°), the mean cLCEA values exhibited only a modest difference (44.7° ± 4.9° vs 52.7° ± 4.5°, respectively). Concordantly, hips with dysplasia exhibited the largest difference between mean LCEA and cLCEA (delta = 29.9° ± 4.7°) and hips with acetabular overcoverage had the smallest difference between measures (9.6° ± 5.2°).With decreasing acetabular bony coverage, there is increasing labral size such that the total osseolabral coverage, measured by the combined LCEA, remains equivalent between hips with normal acetabular coverage versus dysplasia.Level III, retrospective comparative study.

Hip adduction is accomplished through coordinated effort of the adductor magnus, brevis, and longus and the obturator externus and pectineus muscles. Each of these muscles may be injured at its proximal or distal insertion or in its midsubstance. The incidence of injuries to the adductor complex is difficult to determine in sport because of players' underreporting and playing through minor strains. The most commonly injured adductor muscle is the adductor longus muscle. The injury most frequently occurs at the proximal or distal musculotendinous junction, but several case reports of origin and insertional ruptures of the adductor longus exist in the literature. Successful outcomes have been obtained with both operative and nonoperative approaches in these cases. Reports of isolated proximal avulsion of the adductor magnus are less common. This article describes our surgical technique for management of a rare acute proximal adductor magnus avulsion.

While radiographic findings of frank hip dysplasia are well defined, there is a lack of diagnostic criteria for patients with radiographically ‘normal’ hips who have borderline morphologic deficits and clinical instability. In this study, we aim to define and validate a new radiographic finding associated with hip instability known as the upsloping lateral sourcil (ULS). Patients (316) were reviewed for lateral center edge angles, generalized joint laxity assessed with the Beighton Hypermobility Score and the presence of the ULS. The ULS was defined as a caudal-to-cranial inclination of the middle-to-far lateral aspect of the acetabular sourcil with loss of the normal lateral acetabular concavity. The prevalence of the ULS correspondingly increased with the degree of under-coverage as defined by LCEA. Within the normal coverage group, hips with a ULS had smaller LCEAs than those without ULS (29° versus 32°, P

Purpose The purpose of this study was to systematically review the literature in order to compare the efficacy of platelet-rich plasma (PRP) and hyaluronic acid (HA) injections for the treatment of hip osteoarthritis (OA). Methods A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify randomized controlled trials that compared the clinical efficacy of PRP and HA injections for hip OA. The search phrase used was hip osteoarthritis platelet-rich plasma hyaluronic acid randomized. Patients were assessed based on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the Visual Analog Scale (VAS) for pain, and the Harris Hip Score (HHS). Sub-analyses were performed for any outcome score in which at least three studies reported results. Results Six studies (5 Level I, 1 Level II) met inclusion criteria, including 211 patients undergoing intra-articular injection(s) with PRP (mean age 60.0 years, mean follow-up 12.2 months) and 197 patients with HA (mean age 62.3 years, mean follow-up 11.9 months). No significant differences were found in the weighted improvement of any outcome score (WOMAC, VAS, HHS) from pre-injection to post-injection between groups. When excluding a study with the highest risk of bias to eliminate heterogeneity, pooled sub-analysis demonstrated no significant differences in WOMAC subscores between PRP and HA groups. Similarly, in a pooled sub-analysis that isolated patients treated with leukocyte-poor PRP, no significant differences in WOMAC subscores were found between PRP and HA groups. Conclusion Patients undergoing treatment for hip OA with either PRP or HA injections can expect to experience similarly beneficial short-term clinical outcomes.

Background:Hyaluronic acid (HA) and leukocyte-poor platelet-rich plasma (LP-PRP) are 2 nonoperative treatment options that have been studied in patients with hip osteoarthritis (OA).Purpose:To compare the efficacy of intra-articular injections of low–molecular weight (LMW) HA and LP-PRP in patients with hip OA.Study Design:Randomized controlled trial; Level of evidence, 1.Methods:A total of 34 patients (36 hips) presenting with signs of hip OA were randomized to receive 3 blinded, weekly intra-articular injections of either LP-PRP or LMW-HA. Patients were prospectively evaluated before injections and at 6 weeks and then at 3, 6, 12, and 24 months. The primary outcome, conversion to total hip arthroplasty (THA) or a hip resurfacing procedure, was analyzed along with secondary outcomes including the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score and hip range of motion.Results:The final analysis included 33 hips (mean Kellgren-Lawrence grade, 2.73) (LMW-HA: n = 14; LP-PRP: n = 19) in 31 patients (18 male; mean age, 53.8 years). Significantly more patients converted to THA or a hip resurfacing procedure in the LMW-HA group (7/14; 50.0%) (mean, 1.3 years after first injection) than the LP-PRP group (3/19; 15.8%) (mean, 0.73 years after first injection) ( P = .035). There was no significant improvement or decline in any outcome scores within the LMW-HA group from before injections to 6 weeks or 3, 6, and 12 months. For the LP-PRP group, WOMAC overall ( P = .032), joint ( P = .030), and function scores ( P = .025) significantly improved from before injections to 6 weeks, and WOMAC joint scores significantly improved from before injections to 6 months ( P = .036). When comparing the difference between groups in internal rotation at 90° of hip flexion from before injections to 6 months, the LP-PRP group demonstrated a mean 5.0° improvement, while the LMW-HA group showed a mean 1.5° decrease ( P = .028).Conclusion:Intra-articular hip injections of LP-PRP in patients with hip OA resulted in an improvement in WOMAC scores and hip internal rotation at 6 months and delayed the need for THA or a hip resurfacing procedure compared with treatment with LMW-HA. A longer follow-up is necessary to further compare the effects of LP-PRP and LMW-HA injections in patients with hip OA.Registration:NCT01920152 ( ClinicalTrials.gov identifier).

PURPOSE The purpose of this study was to introduce a native labral variant, the everted acetabular labrum, and to describe the patho-anatomy, magnetic resonance imaging and magnetic resonance arthrogram (MRI/MRA) characteristics and the arthroscopic findings in this condition. METHODS All primary hip arthroscopy procedures performed by the senior author between June 2013 and January 2020 were reviewed retrospectively. An everted acetabular labrum was identified as a segment of labrum that lacked apposition to the femoral head with the hip off traction. All everted labra were treated with labral advancement and repair with or without augmentation or reconstruction. The labrum-to-femoral head distance was measured in 3T MRI/MRA at the 1-2 o'clock position. A random selection of 38 hips without an everted labrum served as controls to compare radiographic parameters. RESULTS A total of 68 hips were identified as having an everted labrum during the study period (mean age, 29.1 years), and 55 hips had advanced imaging available for review. MRI/MRA scans revealed the everted labrum to have a triangular shape in 17 hips (31%) and a blunted/round shape in 38 hips (69%), which differed significantly from controls (triangular 25/38 [66%], blunted 13/38 [34%], P < 0.001). The average labrum-to-femoral head distance was 1.4 mm for everted labra versus 0.0 mm for controls (P < 0.0001) and the mean labral lengths and widths were significantly shorter than those of controls (both P < 0.01). Of the hips, 8 underwent labral reconstruction or augmentation, and 61 underwent labral advancement/repair. CONCLUSION The everted acetabular labrum is a native variant that is identifiable during hip arthroscopy by assessing the labral seal off traction. Preoperative MRI/MRA findings can be highly predictive of an everted labrum. Surgical treatment includes labral advancement and repair or reconstruction to restore contact between the labrum and the femoral head. LEVEL OF EVIDENCE III, retrospective comparative study.

Purpose To perform a systematic review of reported terminologies, surgical techniques, preoperative diagnostic measures, and geographic differences in the treatment of core muscle injury (CMI)/athletic pubalgia/inguinal disruption. Methods A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify clinical studies or articles that described a surgical technique to treat CMI refractory to nonoperative treatment. The search phrase used was “core muscle injury” OR “sports hernia” OR “athletic pubalgia” OR “inguinal disruption.” The diagnostic terminology, country of publication, preoperative diagnostic measures, surgical technique, and subspecialty of the operating surgeons described in each article were extracted and reported. Results Thirty-one studies met the inclusion and exclusion criteria, including 3 surgical technique articles and 28 clinical articles (2 Level I evidence, 1 Level II, 4 Level III, and 21 Level IV). A total of 1,571 patients were included. The most common terminology used to describe the diagnosis was “athletic pubalgia,” followed by “sports hernia.” Plain radiographs and magnetic resonance imaging of the pelvis were the most common imaging modalities used in the preoperative evaluation of CMI/athletic pubalgia/inguinal disruption. Tenderness-to-palpation testing was the most common technique performed during physical examination, although the specific locations assessed with this technique varied substantially. The operating surgeons were general surgeons (16 articles), a combination of orthopaedic and general surgeons (7 articles), or orthopaedic surgeons (5 articles). The most common procedures performed were open or laparoscopic mesh repair, adductor tenotomy, primary tissue (hernia) repair, and rectus abdominis repair. The procedures performed differed on the basis of surgeon subspecialty, geographic location, and year of publication. Conclusions A variety of diagnostic methods and surgical procedures have been used in the treatment of a CMI/athletic pubalgia/sports hernia/inguinal disruption. These procedures are performed by orthopaedic and/or general surgeons, with the procedures performed differing on the basis of surgeon subspecialty and geographic location. Level of Evidence Level V, systematic review of Level I to V studies.

Hip impingement is defined as a bony conflict between the femur and acetabulum occurring throughout normal or supraphysiological range of motion. Traditionally, the cause was attributed to reduced femoral head-neck offset and/or excessive acetabular coverage, giving rise to cam, pincer, and mixed impingement. However, recent outcome studies showing less favorable results of hip arthroscopy in patients with femoral and acetabular version abnormalities have sparked renewed interest in the pathomechanics of hip impingement. We now have a greater appreciation for the 3-dimensional scope of the problem through specialized computed tomography sequencing allowing assessment of the entire limb and pelvis. Consequently, we have learned that rotational hip range of motion is more strongly correlated with combined femoral and acetabular version than with the sphericity of the femoral head, allowing us to counsel patients accordingly. We also recognize that impingement can occur with little to no femoral asphericity if the combined femoral and acetabular version does not permit adequate clearance for unimpeded motion. This improved understanding can be applied to diagnose subtle and uncommon cases of impingement and will ultimately enable a more complete bony resection.

Basketball is a physically demanding, high-speed pivoting sport in which injury risk, especially to the lower limbs, is high, including injuries to and around the hip [1–5]. Basketball players perform repetitive activities that require wide ranges of motion of the hip such as jumping, pivoting, sprinting, and direction changes. These repetitive activities over time may contribute to the development of various injuries in and around the hip. While the last two decades have introduced a better understanding of intra-articular hip pathology, the majority of injuries to the hip in basketball are still extra-articular. However, as the understanding and diagnosis of femoro-acetabular impingement syndrome (FAIS) has increased in recent years, it is likely that a number of athletes might have been misdiagnosed as having a “strain” over the years when pain etiology was actually FAIS. This chapter addresses the spectrum of the common hip and groin injuries in basketball, diagnosis and management, from soft tissue injuries to extra- and intra-articular impingement, with a focus on FAIS.

The purpose of this study was to evaluate the magnetic resonance imaging (MRI) appearance of the hip capsule in patients with femoroacetabular impingement (FAI) undergoing hip arthroscopy with capsular repair versus non-repair. A multicenter clinical trial was performed with 31 patients (49 hips) undergoing hip arthroscopy for treatment of FAI. A small- to moderate-sized interportal capsulotomy was performed. Each hip was randomized to capsular repair versus non-repair of the interportal capsulotomy. MRI was performed at 6 and 24 weeks postoperatively and was analyzed by two musculoskeletal radiologists. Patients and the radiologists were blinded to the treatment applied. Capsular defect size and capsule thickness were recorded on each scan. Mean patient age was 31.4 years. Capsular repair was performed in 23 (46.9%) hips. Mean capsulotomy length was 35 mm at Center X and 23 mm at Center Y. At 6 weeks postoperatively, a healed hip capsule (with no apparent capsulotomy defect) was observed in 10 (43.4%) hips that underwent capsular repair and 4 (15.4%) hips that did not undergo capsular repair (P = 0.13). At 24 weeks postoperatively, 25/30 hips (83.3%) achieved complete closure of the capsulotomy defect, with no significant difference between treatment groups. Repair of an interportal capsulotomy following hip arthroscopy for FAI results in a non-significantly higher percentage of healed hip capsules at 6 weeks postoperatively compared with leaving the capsule unrepaired, though the difference normalizes by 24-week follow-up. Repair of a small- to moderate-sized interportal capsulotomy does not provide a radiographic advantage following hip arthroscopy for FAI.

The purpose of this study was to determine the likelihood of pain relief, as a measure of accurate diagnosis of intra-articular hip pathology and correct needle placement, with a non-image-guided intra-articular hip injection performed bedside in the clinic. A retrospective study of prospectively collected data was performed in a consecutive cohort of patients diagnosed with symptomatic intra-articular hip pathology who underwent a non-image-guided intra-articular injection in the clinic. All patients had clinical and radiographic evidence of hip impingement, hip instability, chondrolabral pathology, or other causes of intra-articular hip pain. A previously described technique for a non-image-guided hip injection was performed using 7–10 ml of 1% lidocaine for diagnostic evaluation with some patients receiving 2 ml of Kenalog®-40 if clinically indicated. Ten minutes following each injection, the patient was asked to report the percent improvement in pain (from 0 to 100%) while physical examination and provocative tests were repeated. The final study cohort comprised 142 patients (161 injections). In three cases, patients were either unable to assess or quantify any change in pain level 10 min following the injection. In the remaining 158 hip injections, pain relief was noted in 156 cases (156/158, 98.7%), with at least 70% improvement in pain level noted in 152 cases (152/158, 96.2%). Average pain relief among all 158 injections was 89 ± 16%. A non-image-guided diagnostic intra-articular hip injection yields reliable short-term pain relief, simultaneously endorsing accurate diagnosis of hip pathology and intra-articular needle placement.

Adventure and extreme sports (AES) have gained enormous popularity over the past two decades and are now performed not only by adventurous elite athletes, including youth, but are very common among...

There are currently no established guidelines for appropriate antithrombotic prophylaxis following periacetabular osteotomy (PAO) or derotational femoral osteotomy (DFO). The purpose of this study was to determine the incidence of clinical deep venous thrombosis (DVT) following PAO and/or DFO wherein a portable, mechanical device and low-dose aspirin were used postoperatively for DVT prophylaxis. Patients who had undergone staged hip arthroscopy and primary PAO and/or DFO were prospectively reviewed. Following PAO/DFO, patients were prophylactically treated for thromboembolic disease with a portable, mechanical compression device for 3 weeks and low-dose aspirin for 4 weeks. Patients were followed in clinic until 24 months postoperatively. During the study period, 145 hips (124 patients) underwent surgery (PAO: 109, DFO: 24, PAO + DFO: 12). Overall, the incidence of clinically apparent DVT was 0% in the study cohort. Average estimated blood loss during surgery was 601 mL and five cases required blood transfusions of 1 or 2 units. Ten patients were seen in the emergency room 10–20 days after surgery presenting with calf tenderness and DVT was ruled out in all cases with ultrasound. There were no postoperative bleeding or wound complications. A portable, mechanical compression device and low-dose aspirin effectively lessens the risk of DVT following staged hip arthroscopy and PAO/DFO without an increased risk of bleeding complications.