Hip arthroscopy with initial access to the peripheral compartment for femoroacetabular impingement: midterm results from a large-scale patient cohort.

BACKGROUND: Hip arthroscopy with initial access to the peripheral compartment could reduce the risk of iatrogenic injury to the labrum and cartilage; furthermore, it avoids the need for large capsulotomies with separate portals for peripheral and central (intra-articular) arthroscopy. Clinical results of the peripheral-compartment-first technique remain sparse, in contrast to those of conventional hip arthroscopy starting in the intra-articular central compartment. The purpose of this study was to assess outcome of hip arthroscopy with the peripheral-compartment-first technique, including complication rates, revision rates and patient-reported outcome scores. MATERIALS AND METHODS: This outcome study included 704 hips with femoroacetabular impingement. All arthroscopies were performed using the peripheral-compartment-first technique. A joint replacement registry and the institutional database were used to assess the revision and complication rates, while patient-reported outcome measures were used to assess functional outcomes and patient satisfaction. RESULTS: In total, 704 hips (615 patients) were followed up for a mean of 6.2 years (range 1 to 9 years). The mean age of the patients was 32.1 ± 9.2 years. During the follow-up period, 26 of 704 (3.7%) hips underwent total hip arthroplasty (THA) after a mean of 1.8 ± 1.2 years, and 18 of the 704 (2.6%) hips required revision hip arthroscopy after a mean of 1.2 ± 2.1 years. 9.8% of the hips had an unsatisfactory patient-reported outcome at final follow-up. CONCLUSIONS: The results for the peripheral-compartment-first technique were promising. We recommend a well-conducted randomized controlled clinical trial to guide future therapeutic recommendations regarding the most favorable hip arthroscopy technique. LEVEL OF EVIDENCE: Level IV, therapeutic study. TRIAL REGISTRATION: This study was registered at ClinicalTrials.gov (U.S. National Library of Medicine; ID: NCT05310240).

Are degenerative findings detected on traction MR arthrography of the hip associated with failure of arthroscopic femoroacetabular impingement surgery?

OBJECTIVES: To identify preoperative degenerative features on traction MR arthrography associated with failure after arthroscopic femoroacetabular impingement (FAI) surgery. METHODS: Retrospective study including 102 patients (107 hips) undergoing traction magnetic resonance arthrography (MRA) of the hip at 1.5 T and subsequent hip arthroscopic FAI surgery performed (01/2016 to 02/2020) with complete follow-up. Clinical outcomes were assessed using the International Hip Outcome Tool (iHOT-12) score. Clinical endpoint for failure was defined as an iHOT-12 of < 60 points or conversion to total hip arthroplasty. MR images were assessed by two radiologists for presence of 9 degenerative lesions including osseous, chondrolabral/ligamentum teres lesions. Uni- and multivariate Cox regression analysis was performed to assess the association between MRI findings and failure of FAI surgery. RESULTS: Of the 107 hips, 27 hips (25%) met at least one endpoint at a mean 3.7 ± 0.9 years follow-up. Osteophytic changes of femur or acetabulum (hazard ratio [HR] 2.5-5.0), acetabular cysts (HR 3.4) and extensive cartilage (HR 5.1) and labral damage (HR 5.5) > 2 h on the clockface were univariate risk factors (all p < 0.05) for failure. Three risk factors for failure were identified in multivariate analysis: Acetabular cartilage damage > 2 h on the clockface (HR 3.2, p = 0.01), central femoral osteophyte (HR 3.1, p = 0.02), and femoral cartilage damage with ligamentum teres damage (HR 3.0, p = 0.04). CONCLUSION: Joint damage detected by preoperative traction MRA is associated with failure 4 years following arthroscopic FAI surgery and yields promise in preoperative risk stratification. CLINICAL RELEVANCE STATEMENT: Evaluation of negative predictors on preoperative traction MR arthrography holds the potential to improve risk stratification based on the already present joint degeneration ahead of FAI surgery. KEY POINTS: • Osteophytes, acetabular cysts, and extensive chondrolabral damage are risk factors for failure of FAI surgery. • Extensive acetabular cartilage damage, central femoral osteophytes, and combined femoral cartilage and ligamentum teres damage represent independent negative predictors. • Survival rates following hip arthroscopy progressively decrease with increasing prevalence of these three degenerative findings.

Hip MRI in flexion abduction external rotation for assessment of the ischiofemoral interval in patients with hip pain-a feasibility study.

OBJECTIVES: To assess the feasibility of flexion-abduction-external rotation (FABER) magnetic resonance imaging (MRI) of the hip to visualize changes in the ischiofemoral interval and ability to provoke foveal excursion over the acetabular rim. METHODS: IRB-approved retrospective single-center study. Patients underwent non-contrast 1.5-T hip MRI in the neutral and FABER position. Two readers measured the ischiofemoral interval at three levels: proximal/distal intertrochanteric distance and ischiofemoral space. Subgroup analysis was performed for hips with/without high femoral torsion, or quadratus femoris muscle edema (QFME), respectively. A receiver operating curve with calculation of the area under the curve (AUC) for the prediction of QFME was calculated. The presence of foveal excursion in both positions was assessed. RESULTS: One hundred ten patients (121 hips, mean age 34 ± 11 years, 67 females) were evaluated. FABER-MRI led to narrowing (both p < .001) of the ischiofemoral interval which decreased more at the proximal (mean decrease by 26 ± 7 mm) than at the distal (6 ± 7 mm) intertrochanteric ridge. With high femoral torsion/ QFME, the ischiofemoral interval was significantly narrower at all three measurement locations compared to normal torsion/no QFME (p < .05). Accuracy for predicting QFME was high with an AUC of .89 (95% CI .82-.94) using a threshold of ≤ 7 mm for the proximal intertrochanteric distance. With FABER-MRI foveal excursion was more frequent in hips with QFME (63% vs 25%; p = .021). CONCLUSION: Hip MRI in the FABER position is feasible, visualizes narrowing of the ischiofemoral interval, and can provoke foveal excursion. CRITICAL RELEVANCE STATEMENT: FABER MRI may be helpful in diagnosing ischiofemoral impingement and detecting concomitant hip instability by overcoming shortcomings of static MR protocols that do not allow visualization of dynamic changes in the ischiofemoral interval and thus may improve surgical decision making. KEY POINTS: • FABER MRI enables visualization of narrowing of the ischiofemoral interval proximal to the lesser trochanter. • Proximal intertrochanteric distance of ≤ 7 mm accurately predicts quadratus femoris muscle edema. • Foveal excursion was more frequent in hips with quadratus femoris muscle edema.

Can gadolinium contrast agents be replaced with saline for direct MR arthrography of the hip? A pilot study with arthroscopic comparison.

OBJECTIVE: To compare image quality and diagnostic performance of preoperative direct hip magnetic resonance arthrography (MRA) performed with gadolinium contrast agent and saline solution. METHODS: IRB-approved retrospective study of 140 age and sex-matched symptomatic patients with femoroacetabular impingement, who either underwent intra-articular injection of 15-20 mL gadopentetate dimeglumine (GBCA), 2.0 mmol/L ("GBCA-MRA" group, n = 70), or 0.9% saline solution ("Saline-MRA" group, n = 70) for preoperative hip MRA and subsequent hip arthroscopy. 1.5 T hip MRA was performed including leg traction. Two readers assessed image quality using a 5-point Likert scale (1-5, excellent-poor), labrum and femoroacetabular cartilage lesions. Arthroscopic diagnosis was used to calculate diagnostic accuracy which was compared between groups with Fisher's exact tests. Image quality was compared with the Mann-Whitney U tests. RESULTS: Mean age was 33 years ± 9, 21% female patients. Image quality was excellent (GBCA-MRA mean range, 1.1-1.3 vs 1.1-1.2 points for Saline-MRA) and not different between groups (all p > 0.05) except for image contrast which was lower for Saline-MRA group (GBCA-MRA 1.1 ± 0.4 vs Saline-MRA 1.8 ± 0.5; p < 0.001). Accuracy was high for both groups for reader 1/reader 2 for labrum (GBCA-MRA 94%/ 96% versus Saline-MRA 96%/93%; p > 0.999/p = 0.904) and acetabular (GBCA-MRA 86%/ 83% versus Saline-MRA 89%/87%; p = 0.902/p = 0.901) and femoral cartilage lesions (GBCA-MRA 97%/ 99% versus Saline-MRA 97%/97%; both p > 0.999). CONCLUSION: Diagnostic accuracy and image quality of Saline-MRA and GBCA-MRA is high in assessing chondrolabral lesions underlining the potential role of non-gadolinium-based hip MRA. KEY POINTS: • Image quality of Saline-MRA and GBCA-MRA was excellent for labrum, acetabular and femoral cartilage, ligamentum teres, and the capsule (all p > 0.18). • The overall image contrast was lower for Saline-MRA (Saline-MRA 1.8 ± 0.5 vs. GBCA-MRA 1.1 ± 0.4; p < 0.001). • Diagnostic accuracy was high for Saline-MRA and GBCA-MRA for labrum (96% vs. 94%; p > 0.999), acetabular cartilage damage (89% vs. 86%; p = 0.902), femoral cartilage damage (97% vs. 97%; p > 0.999), and extensive cartilage damage (97% vs. 93%; p = 0.904).

High prevalence of hip lesions secondary to arthroscopic over- or undercorrection of femoroacetabular impingement in patients with postoperative pain.

OBJECTIVES: To compare the prevalence of pre- and postoperative osseous deformities and intra-articular lesions in patients with persistent pain following arthroscopic femoroacetabular impingement (FAI) correction and to identify imaging findings associated with progressive cartilage damage. METHODS: Retrospective study evaluating patients with hip pain following arthroscopic FAI correction between 2010 and 2018. Pre- and postoperative imaging studies were analyzed independently by two blinded readers for osseous deformities (cam-deformity, hip dysplasia, acetabular overcoverage, femoral torsion) and intra-articular lesions (chondro-labral damage, capsular lesions). Prevalence of osseous deformities and intra-articular lesions was compared with paired t-tests/McNemar tests for continuous/dichotomous data. Association between imaging findings and progressive cartilage damage was assessed with logistic regression. RESULTS: Forty-six patients (mean age 29 ± 10 years; 30 female) were included. Postoperatively, 74% (34/46) of patients had any osseous deformity including 48% (22/46) acetabular and femoral deformities. Ninety-six percent (44/46) had an intra-articular lesion ranging from 20% (9/46) for femoral to 65% (30/46) for acetabular cartilage lesions. Prevalence of hip dysplasia increased (2 to 20%, p = 0.01) from pre- to postoperatively while prevalence of cam-deformity decreased (83 to 28%, p < 0.001). Progressive cartilage damage was detected in 37% (17/46) of patients and was associated with extensive preoperative cartilage damage > 2 h, i.e., > 60° (OR 7.72; p = 0.02) and an incremental increase in postoperative alpha angles (OR 1.18; p = 0.04). CONCLUSION: Prevalence of osseous deformities secondary to over- or undercorrrection was high. Extensive preoperative cartilage damage and higher postoperative alpha angles increase the risk for progressive degeneration. KEY POINTS: • The majority of patients presented with osseous deformities of the acetabulum or femur (74%) and with intra-articular lesions (96%) on postoperative imaging. • Prevalence of hip dysplasia increased (2 to 20%, p = 0.01) from pre- to postoperatively while prevalence of a cam deformity decreased (83 to 28%, p < 0.001). • Progressive cartilage damage was present in 37% of patients and was associated with extensive preoperative cartilage damage > 2 h (OR 7.72; p = 0.02) and with an incremental increase in postoperative alpha angles (OR 1.18; p = 0.04).

The Lisbon Agreement on femoroacetabular impingement imaging-part 2: general issues, parameters, and reporting.

OBJECTIVES: Imaging assessment for the clinical management of femoroacetabular impingement (FAI) is controversial because of a paucity of evidence-based guidance and notable variability among practitioners. Hence, expert consensus is needed because standardised imaging assessment is critical for clinical practice and research. We aimed to establish expert-based statements on FAI imaging by using formal methods of consensus building. METHODS: The Delphi method was used to formally derive consensus among 30 panel members from 13 countries. Forty-four questions were agreed upon, and relevant seminal literature was circulated and classified in major topics to produce answering statements. The level of evidence was noted for all statements, and panel members were asked to score their level of agreement (0-10). This is the second part of a three-part consensus series and focuses on 'General issues' and 'Parameters and reporting'. RESULTS: Forty-seven statements were generated and group consensus was reached for 45. Twenty-five statements pertaining to 'General issues' (9 addressing diagnosis, differential diagnosis, and postoperative imaging) and 'Parameters and reporting' (16 addressing femoral/acetabular parameters) were produced. CONCLUSIONS: The available evidence was reviewed critically, recommended criteria for diagnostic imaging highlighted, and the roles/values of different imaging parameters assessed. Radiographic evaluation (AP pelvis and a Dunn 45° view) is the cornerstone of hip-imaging assessment and the minimum imaging study that should be performed when evaluating adult patients for FAI. In most cases, cross-sectional imaging is warranted because MRI is the 'gold standard' imaging modality for the comprehensive evaluation, differential diagnosis assessment, and FAI surgical planning. KEY POINTS: • Diagnostic imaging for FAI is not standardised due to scarce evidence-based guidance on which imaging modalities and diagnostic criteria/parameters should be used. • Radiographic evaluation is the cornerstone of hip assessment and the minimum study that should be performed when assessing suspected FAI. Cross-sectional imaging is justified in most cases because MRI is the 'gold standard' modality for comprehensive FAI evaluation. • For acetabular morphology, coverage (Wiberg's angle and acetabular index) and version (crossover, posterior wall, and ischial spine signs) should be assessed routinely. On the femoral side, the head-neck junction morphology (α° and offset), neck morphology (NSA), and torsion should be assessed.

The Lisbon Agreement on Femoroacetabular Impingement Imaging-part 3: imaging techniques.

OBJECTIVES: Imaging diagnosis of femoroacetabular impingement (FAI) remains controversial due to a lack of high-level evidence, leading to significant variability in patient management. Optimizing protocols and technical details is essential in FAI imaging, although challenging in clinical practice. The purpose of this agreement is to establish expert-based statements on FAI imaging, using formal consensus techniques driven by relevant literature review. Recommendations on the selection and use of imaging techniques for FAI assessment, as well as guidance on relevant radiographic and MRI classifications, are provided. METHODS: The Delphi method was used to assess agreement and derive consensus among 30 panel members (musculoskeletal radiologists and orthopedic surgeons). Forty-four questions were agreed on and classified into five major topics and recent relevant literature was circulated, in order to produce answering statements. The level of evidence was assessed for all statements and panel members scored their level of agreement with each statement during 4 Delphi rounds. Either "group consensus," "group agreement," or "no agreement" was achieved. RESULTS: Forty-seven statements were generated and group consensus was reached for 45. Twenty-two statements pertaining to "Imaging techniques" were generated. Eight statements on "Radiographic assessment" and 12 statements on "MRI evaluation" gained consensus. No agreement was reached for the 2 "Ultrasound" related statements. CONCLUSION: The first international consensus on FAI imaging was developed. Researchers and clinicians working with FAI and hip-related pain may use these recommendations to guide, develop, and implement comprehensive, evidence-based imaging protocols and classifications. KEY POINTS: • Radiographic evaluation is recommended for the initial assessment of FAI, while MRI with a dedicated protocol is the gold standard imaging technique for the comprehensive evaluation of this condition. • The MRI protocol for FAI evaluation should include unilateral small FOV with radial imaging, femoral torsion assessment, and a fluid sensitive sequence covering the whole pelvis. • The definite role of other imaging methods in FAI, such as ultrasound or CT, is still not well defined.

Correction to: The Lisbon Agreement on Femoroacetabular Impingement Imaging-part 1: overview.

The original version of this article, published on 14 May 2020, unfortunately contained a mistake.

The Lisbon Agreement on Femoroacetabular Impingement Imaging-part 1: overview.

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

MR arthrography of the hip with and without leg traction: Assessing the diagnostic performance in detection of ligamentum teres lesions with arthroscopic correlation.

OBJECTIVES: To retrospectively assess the diagnostic performance of hip MR arthrography with and without traction in detecting ligamentum teres (LT) lesions with arthroscopic correlation and to evaluate the effect of traction on the imaging appearance of the LT. METHODS: 73 MR arthrograms (73 consecutive patients, mean age, 34.5 years; range, 14-55 years) obtained without and with leg traction (application of 15-23 kg, use of a supporting plate for the contralateral leg) were included. Two blinded readers independently evaluated LT lesions on MR arthrograms on separate occasions: coronal images without traction; coronal images with traction; a multiplanar traction protocol. MR findings were correlated with arthroscopic records. Sensitivity/specificity of traction and non-traction imaging was compared on coronal images with the exact McNemar test. Imaging appearance of the LT with and without traction was assessed in consensus and compared on coronal images using McNemar and McNemar-Bowker tests. (p<0.05, * corrected for type I error). RESULTS: With arthroscopy 29 (40%) LT lesions were identified in 73 patients. Sensitivity was 72%/90% (without traction/with traction; p=0.25*), specificity was 89%/77% (p=0.25*) for reader 1 in assessing coronal images and for reader 2 sensitivity was 59%/86% (p=0.044*) and specificity was 93%/82% (p=0.25*). Alterations in fiber orientation, signal intensity, surface, dimension, fiber continuity after application of traction were observed in 33/73 (45%, p=0.002*), 6/73 (8%, p=0.223), 9/73 (12%, p=0.36*), 6/73 (8%, p=0.031) respectively 9/73 (12%, p=0.003) cases. Traction-related alterations in at least one criterion were observed in 41/73 (56%) cases. CONCLUSION: Application of traction can considerably alter the imaging appearance of the LT and resulted in higher rates of true-positive and false-positive findings compared to conventional MR arthrography.

Diagnostic performance of direct traction MR arthrography of the hip: detection of chondral and labral lesions with arthroscopic comparison.

OBJECTIVES: To assess diagnostic performance of traction MR arthrography of the hip in detection and grading of chondral and labral lesions with arthroscopic comparison. METHODS: Seventy-five MR arthrograms obtained ± traction of 73 consecutive patients (mean age, 34.5 years; range, 14-54 years) who underwent arthroscopy were included. Traction technique included weight-adapted traction (15-23 kg), a supporting plate for the contralateral leg, and intra-articular injection of 18-27 ml (local anaesthetic and contrast agent). Patients reported on neuropraxia and on pain. Two blinded readers independently assessed femoroacetabular cartilage and labrum lesions which were correlated with arthroscopy. Interobserver agreement was calculated using κ values. Joint distraction ± traction was evaluated in consensus. RESULTS: No procedure had to be stopped. There were no cases of neuropraxia. Accuracy for detection of labral lesions was 92 %/93 %, 91 %/83 % for acetabular lesions, and 92 %/88 % for femoral cartilage lesions for reader 1/reader 2, respectively. Interobserver agreement was moderate (κ = 0.58) for grading of labrum lesions and substantial (κ = 0.7, κ = 0.68) for grading of acetabular and femoral cartilage lesions. Joint distraction was achieved in 72/75 and 14/75 hips with/without traction, respectively. CONCLUSION: Traction MR arthrography safely enabled accurate detection and grading of labral and chondral lesions. KEY POINTS: • The used traction technique was well tolerated by most patients. • The used traction technique almost consistently achieved separation of cartilage layers. • Traction MR arthrography enabled accurate detection of chondral and labral lesions.

Improving visualization of the central compartment of the hip with direct MR arthrography under axial leg traction: a feasibility study.

RATIONALE AND OBJECTIVES: To evaluate the feasibility of a modified approach for direct magnetic resonance (MR) arthrography of the hip under leg traction in achieving a sufficient femoroacetabular interface and improving the visualization of the ligamentum teres. MATERIALS AND METHODS: Forty-six MR arthrograms of 44 patients who underwent MR arthrography with and without leg traction were included into the study. Traction approach included injection of 18-27 mL of fluid (local anesthetic, contrast agent), application of weight-adapted traction load (15-23 kg), and the use of a supporting plate. Patients were instructed to report on pain and complications with an integer pain scale. Joint distraction was measured on coronal images obtained with and without traction, and two radiologists independently evaluated whether femoroacetabular cartilage layers and the ligamentum teres could be seen as distinct entities. McNemar test was used and interobserver agreement was assessed. RESULTS: No patient asked for termination of the examination. There were no cases of neuropraxia. Mean difference in distraction was 3.7 mm/3.6 mm (reader 1/reader 2). Cartilage layers could be seen as distinct entities in 43/43 (93.5%/93.5%) and 6/8 (13%/17.4%) of the joints with/without traction (P < .001/P < .001), respectively. The ligamentum teres could be differentiated in 33/30 (71.7%/65.2%) cases with traction, in 33/30 (71.7%/65.2%) cases without traction (P < .999/P < .999), and in 40/37 (87%/80.4%) cases with both the techniques combined. CONCLUSIONS: Traction MR arthrography is safe and technically feasible. It enabled the differentiation between femoroacetabular cartilage layers in most cases. Visualization of the ligamentum teres was optimal by combining imaging with both modalities.