"High ankle block" for surgery at the ankle joint.

BACKGROUND: Surgery around the ankle is increasingly embedded in outpatient treatment concepts. Unfortunately, the classic "ankle block" as a concept of regional anesthesia is inappropriate for surgery around the ankle because the injection sites are too distal to block this specific region. METHODS: The "high ankle block" avoids this disadvantage by dislocating the injection points 15 cm proximal to the malleoli. Three of five peripheral nerves necessary to perform the block can be reached by a circumferential subcutaneous wall. The Posterior Tibial Nerve and the Deep Peroneal Nerve are addressed by an ultrasound guided approach. RESULTS: The efficacy of the technique is highlighted by a case series (3 cases) in which the new blockade was used as a stand-alone procedure, i.e. without additional general anesthesia. CONCLUSIONS: The "high ankle block" may serve as an ultrasound guided expansion to the classic techniques, extending the operative spectrum to the ankle region.

Anatomical and biomechanical evaluation of the lateral calcaneo-cuboid and bifurcate ligaments.

BACKGROUND: This study aims to analyze the ligaments of the dorso-lateral calcaneo-cuboid joint and to assess the biomechanical relevance of the bifurcate ligament. METHODS: 16 specimens were analyzed for their ligamentous anatomy of the dorso-lateral calcaneo-cuboid joint and side-alternating assigned to two groups with varying ligamentous dissection order. The Chopart joint was stressed in plantar, medial, and lateral direction measuring the displacement by an 3D motion tracker for every dissection step. RESULTS: 37.5% of specimens had all ligaments (lateral calcaneo-cuboid, dorsal calcaneo-cuboid, bifurcate calcaneo-cuboid, bifurcate calcaneo-navicular), 37.5% were lacking bifurcate´s calcaneo-cuboid-portion, and 25% presented without dorsal calcaneo-cuboid. Biomechanical testing revealed no significant displacement within the calcaneo-cuboid or talo-navicular joint for any stressed state except for axial compression with dissected dorsal talo-navicular joint capsule in Group 2. CONCLUSION: Broad morphological variability and missing significant displacement regardless of its integrity, make the bifurcate ligament appear of limited biomechanical relevance.

Propensity Score-Matched Analysis of Arthroscopically Assisted Ankle Facture Treatment Versus Conventional Treatment.

BACKGROUND: The aim of this study was to assess the prospective, longitudinal outcome after arthroscopically assisted open reduction and internal fixation (AORIF) and to compare the results with open reduction and internal fixation (ORIF) in complex ankle fractures. METHODS: Acute, closed, bimalleolar equivalent, bimalleolar, or trimalleolar ankle fractures were included. The AORIF cohort was enrolled prospectively. The ORIF group was identified from a retrospective database. The same inclusion and exclusion criteria were applied. The only difference was the additional arthroscopy in the AORIF cohort. The patient-reported outcome measurement (PROM) following AORIF was assessed at 1 and 4 years of follow-up using the Olerud and Molander Ankle Score (OMAS) and Tegner activity scale (TAS). The AORIF cohort was propensity score matched (nearest-neighbor matching) to the ORIF database. The OMAS and Foot and Ankle Ability Measure (FAAM) were compared between the resulting groups. Nonparametric statistics were applied; values are presented as median (interquartile range). Twenty-six AORIF patients had a prospective 4-year follow-up. RESULTS: No significant differences (1 year vs 4 years) were identified for the OMAS (90 [10] vs 90 [11]) and TAS (4 [2] vs 5 [2]). The severity of the cartilage lesions (International Cartilage Repair Society [ICRS] grade <4 vs ICRS of 4) had no significant influence on the PROMs. Twenty-five patients per cohort (AORIF vs ORIF) were matched. The OMAS (90 [13] vs 75 [40]; P = .008) and FAAM Activities of Daily Living (ADL; 96 [11] vs 88 [30]; P = .034) revealed significantly better outcomes for AORIF. More patients in the AORIF cohort returned to sport (96% vs 77%; P = .035), with a higher FAAM Sports score (88 [37] vs 56 [47]; P = .008). CONCLUSION: AORIF for complex ankle fractures led to consistently good to excellent results. The propensity score-matched analysis revealed a significantly better outcome 4 years after surgery for AORIF compared with ORIF. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

How We Manage Bone Marrow Edema-An Interdisciplinary Approach.

Bone marrow edema (BME) is a descriptive term for a common finding in magnetic resonance imaging (MRI). Although pain is the major symptom, BME differs in terms of its causal mechanisms, underlying disease, as well as treatment and prognosis. This complexity together with the lack of evidence-based guidelines, frequently makes the identification of underlying conditions and its management a major challenge. Unnecessary multiple consultations and delays in diagnosis as well as therapy indicate a need for interdisciplinary clinical recommendations. Therefore, an interdisciplinary task force was set up within our large osteology center consisting of specialists from internal medicine, endocrinology/diabetology, hematology/oncology, orthopedics, pediatrics, physical medicine, radiology, rheumatology, and trauma surgery to develop a consenus paper. After review of literature, review of practical experiences (expert opinion), and determination of consensus findings, an overview and an algorithm were developed with concise summaries of relevant aspects of the respective underlying disease including diagnostic measures, clinical features, differential diagnosis and treatment of BME. Together, our single-center consensus review on the management of BME may help improve the quality of care for these patients.

Arthroscopically Assisted Treatment of Complex Ankle Fractures: Intra-articular Findings and 1-Year Follow-Up.

Especially after complex ankle fractures, patients regularly suffer from residual symptoms, presumably due to occult intra-articular injuries. The aim of this study was to evaluate the intra-articular lesions, identify fractures specifically at risk for these, and assess the results after arthroscopically assisted open reduction and internal fixation of complex ankle fractures after 1 year. The primary outcome was the American Orthopedic Foot and Ankle Society (AOFAS) hindfoot score. Secondary outcome parameters were the Olerud and Molander Ankle Score (OMAS), Tegner activity scale, arthroscopic findings, functional assessment, and complications. Thirty-two patients (56% female) were enrolled. Chondral lesions were detected in 91%. Full-thickness lesions treated by microfracturing were observed in 0% of unimalleolar, 43% of bimalleolar, and 40% of trimalleolar fractures. After 1 year, the median (interquartile range) AOFAS was 94 (9) and OMAS was 90 (10) for all patients. When analyzing factors possibly influencing the outcome, age, sex, smoking, grading for surgical procedures according to the American Society of Anesthesiologists, fracture type (uni-, bi-, or trimalleolar), severity of chondral lesions graded according to the International Cartilage Repair Society (grade <4 versus grade 4), and syndesmotic instability had no significant influence on the outcome. The only variable significantly influencing the AOFAS (p = .004) and OMAS (p < .001) was body mass index (BMI; rs = -0.522 and -0.606, respectively), with a higher BMI resulting in inferior outcome scores. Complications were observed in 3 patients, 2 with superficial skin necrosis at the posterolateral incision and 1 nonunion of the medial malleolus. Taken together, these data show that intra-articular injuries were common in ankle fractures. Bi- and trimalleolar fractures were particularly at risk for full-thickness lesions. A higher BMI tended to result in inferior outcome scores. Arthroscopically assisted open reduction and internal fixation led to good to excellent results in all but 1 patient.

Significant increase of pathogen detection rate by dry arthroscopic biopsies at suspected low-grade infection following total knee arthroplasty: a prospective observational study.

INTRODUCTION: The differentiation between stiff-knee and low-grade periprosthetic joint infection (PJI) is the current diagnostic challenge in total knee (TKA) revision arthroplasty. The aim of this study was to investigate the additional value of dry biopsies, compared to wet biopsies, in patients presenting with knee stiffness following primary TKA. MATERIALS AND METHODS: Single center, prospective observational study. Consecutive patients with joint stiffness of unknown origin following primary TKA were enrolled. Patient assessment followed the diagnostic standard algorithm. During diagnostic arthroscopy, synovial fluid (synovial WBC, PMN%) and five dry biopsies (dry) were collected. Then fluid was infused and another five microbiology (wet) and five histological biopsies gathered, all from identical locations. The primary outcome parameter was the difference between the pathogens in wet and dry biopsies. RESULTS: 71 patients (61% females, 67 ± 10 years) were eligible. Preoperative blood serology mean CRP (0.7 ± 1.5 mg/dl; p = 0.852), WBC (6.6 ± 1.7 G/l; p = 0.056), and synovial fluid mean WBC (1639 ± 2111; p = 0.602), PMN% (38 ± 28; p = 0.738) did not differ between patients with negative, positive wet or dry biopsies. The histology was in 11% positive (p = 0.058). In 32% at least one pathogen was detected, 48% from wet, 44% from dry biopsies. An inhomogeneous distribution was found. Cutibacterium acnes (100%) was solely found in wet, Micrococcus luteus (75%), Staphylococcus capitis (67%), and Micrococcus lylae (100%) were predominantly found in dry biopsies. Additional dry biopsies increased the pathogen detection rate by 49%. CONCLUSION: The addition of dry biopsies to the current standard diagnostic algorithm for PJI increased the pathogen detection rate by 49%.

Development of an accelerated functional rehabilitation protocol following minimal invasive Achilles tendon repair.

PURPOSE: Surgical repair after acute Achilles tendon rupture leads to lower re-rupture rates than non-surgical treatment. After open repair, early functional rehabilitation improves outcome, but there are risks of infection and poor wound healing. Minimal invasive surgery reduces these risks; however, there are concerns about its stability. Consequently, physicians may have reservations about adopting functional rehabilitation. There is still no consensus about the post-operative treatment after minimal invasive repair. The aim of this study was to define the most effective and safe post-operative rehabilitation protocol following minimal invasive repair. METHODS: A systematic literature search in Embase, MEDLINE and Cochrane Library for prospective trials reporting on early functional rehabilitation after minimal invasive repair was performed. Seven studies were included. RESULTS: One randomized controlled trail, one prospective comparative and five prospective non-comparative studies were identified. Four studies performed full weight bearing, all demonstrating good functional results, an early return to work/sports and high satisfaction. One study allowed early mobilization leading to excellent subjective and objective results. The only randomized controlled trial performed the most accelerated protocol demonstrating a superior functional outcome and fewer complications after immediate full weight bearing combined with free ankle mobilization. The non-comparative study reported high satisfaction, good functional results and an early return to work/sports following combined treatment. CONCLUSION: Immediate weight bearing in a functional brace, together with early mobilization, is safe and has superior outcome following minimally invasive repair of Achilles tendon rupture. Our recommended treatment protocol provides quality assurance for the patient and reliability for the attending physician. LEVEL OF EVIDENCE: II.

Ankle dorsiflexion: what is normal? Development of a decision pathway for diagnosing impaired ankle dorsiflexion and M. gastrocnemius tightness.

INTRODUCTION: Impaired ankle dorsiflexion (ADF) is known to increase forefoot pressure, which is associated to various pathologies affecting the foot and ankle. M. gastrocnemius tightness (MGT) is its most common cause. Up to date we are missing a standardized examination procedure, norm values, and a valid decision pathway to diagnose impaired ADF and MGT. The aim of this study was to define norm values for ADF using a standardized examination procedure. These were used to define a decision pathway to diagnose impaired ADF and MGT. MATERIALS AND METHODS: 64 young, asymptomatic subjects were examined. Based on a standardized examination procedure, bilateral ADF, both with the knee extended and flexed, non-weight bearing and weight bearing, was assessed by three investigators. Inter-rater test reliability and norm values for ADF were calculated. Side differences were analyzed. ADF differences between the knee extended and flexed were calculated. RESULTS: The standardized examination procedure revealed high ICC values (0.876-0.915). ADF values with the knee extended for the left/right limb were 22.7° ± 5.9° [95 % CI 21.2°-24.3°]/23.4° ± 6.5° [95 % CI 21.7°-25.1°] non-weight bearing and 33.3° ± 5.5° [95 % CI 31.9°-34.7°]/33.6° ± 5.6° [95 % CI 32.1°-35.0°] weight bearing. Physiological side differences with the knee extended were <6° (95 % CI). Knee flexion resulted in an approximate ADF increase of 10°. CONCLUSIONS: Based on an extensive systematic approach, physiological values for ADF were assessed in a large asymptomatic population. This allowed the definition of a decision pathway to diagnose impaired ADF and MGT. Patients presenting with pathologies associated with impaired ADF should be examined according to the herein presented examination protocol. This systematic approach provides a consistent definition of impaired ADF and MGT, which is the prerequisite to study the effectiveness of treatment strategies for MGT.

The value of arthroscopy in the treatment of complex ankle fractures - a protocol of a randomised controlled trial.

BACKGROUND: An anatomical reconstruction of the ankle congruity is the important prerequisite in the operative treatment of acute ankle fractures. Despite anatomic restoration patients regularly suffer from residual symptoms after these fractures. There is growing evidence, that a poor outcome is related to the concomitant traumatic intra-articular pathology. By supplementary ankle arthroscopy anatomic reduction can be confirmed and associated intra-articular injuries can be treated. Nevertheless, the vast majority of complex ankle fractures are managed by open reduction and internal fixation (ORIF) only. Up to now, the effectiveness of arthroscopically assisted fracture treatment (AORIF) has not been conclusively determined. Therefore, a prospective randomised study is needed to sufficiently evaluate the effect of AORIF compared to ORIF in complex ankle fractures. METHODS/DESIGN: We perform a randomised controlled trial at Munich University Clinic enrolling patients (18-65 years) with an acute ankle fracture (AO 44 A2, A3, B2, B3, C1 - C3 according to AO classification system). Patients meeting the inclusion criteria are randomised to either intervention group (AORIF, n = 37) or comparison group (ORIF, n = 37). Exclusion criteria are fractures classified as AO type 44 A1 or B1, pilon or plafond-variant injury or open fractures. Primary outcome is the AOFAS Score (American Orthopaedic Foot and Ankle Society). Secondary outcome parameter are JSSF Score (Japanese Society of Surgery of the Foot), Olerud and Molander Score, Karlsson Score, Tegner Activity Scale, SF-12, radiographic analysis, arthroscopic findings of intra-articular lesions, functional assessments, time to return to work/sports and complications. This study protocol is accordant to the SPIRIT 2013 recommendation. Statistical analysis will be performed using SPSS 22.0 (IBM). DISCUSSION: The subjective and functional outcome of complex ankle fractures is regularly unsatisfying. As these injuries are very common it is essential to improve the postoperative results. Potentially, arthroscopically assisted fracture treatment can significantly improve the outcome by addressing the intra-articular pathologies. Given the absolute lack of studies comparing AORIF to ORIF in complex ankle fractures, this randomised controlled trail is urgently needed to evaluate the effectiveness of additional arthroscopy. TRIAL REGISTRATION: ClinicalTrials.gov reference: NCT02449096 (Trial registration date: April 7th, 2015).

The influence of distal screw length on the primary stability of volar plate osteosynthesis--a biomechanical study.

BACKGROUND: Extensor tendon irritation is one of the most common complications following volar locking plate osteosynthesis (VLPO) for distal radius fractures. It is most likely caused by distal screws protruding the dorsal cortex. Shorter distal screws could avoid this, yet the influence of distal screw length on the primary stability in VLPO is unknown. The aim of this study was to compare 75 to 100% distal screw lengths in VLPO. METHODS: A biomechanical study was conducted on 11 paired fresh-frozen radii. HRpQCT scans were performed to assess bone mineral density (BMD) and bone mineral content (BMC). The specimens were randomized pair-wise into two groups: 100% (group A) and 75% (group B) unicortical distal screw lengths. A validated fracture model for extra-articular distal radius fractures (AO-23 A3) was used. Polyaxial volar locking plates were mounted, and distal screws was inserted using a drill guide block. For group A, the distal screw tips were intended to be flush or just short of the dorsal cortex. In group B, a target screw length of 75% was calculated. The specimens were tested to failure using a displacement-controlled axial compression test. Primary biomechanical stability was assessed by stiffness, elastic limit, and maximum force as well as with residual tilt, which quantified plastic deformation. RESULTS: Nine specimens were tested successfully. BMD and BMC did not differ between the two groups. The mean distal screw length of group A was 21.7 ± 2.6 mm (range: 16 to 26 mm), for group B 16.9 ± 1.9 mm (range: 12 to 20 mm). Distal screws in group B were on average 5.6 ± 0.9 mm (range: 3 to 7 mm) shorter than measured. No significant differences were found for stiffness (706 ± 103 N/mm vs. 660 ± 124 N/mm), elastic limit (177 ± 25 N vs. 167 ± 36 N), maximum force (493 ± 139 N vs. 471 ± 149 N), or residual tilt (7.3° ± 0.7° vs. 7.1° ± 1.3°). CONCLUSION: The 75% distal screw length in VLPO provides similar primary stability to 100% unicortical screw length. This study, for the first time, provides the biomechanical basis to choose distal screws significantly shorter then measured.

Plate failure following plate osteosynthesis in periprosthetic femoral fractures.

BACKGROUND: Increasing numbers of total knee and hip arthroplasties result in a growing number of periprosthetic femoral fractures (PPFF). PPFF with a stable stem component are treated commonly with plate osteosynthesis. Therefore plate failure is seen as a major complication. The aim of this retrospective study was to investigate the patients' outcome after plate failure. METHODS: The database of a Level 1 trauma center was searched for all patients treated for a PPFF with plate osteosynthesis. Patients with plate failure were investigated specifically. Standard demographic data, details on initial arthroplasty, trauma, and treatment were recorded for all patients. All fractures were classified and their outcome reviewed. RESULTS: Seven (8.8%) out of 80 patients treated with plate osteosynthesis following PPFF met our inclusion criterion being plate failure. All these patients were female, with an average age at primary surgery of 74 ± 13 years and a mean follow-up of 885 days (range, 264-2549). Four patients suffered a PPFF after total hip arthroplasty (THA) (2 Vancouver Type B1 and 2 Type C) and three after total knee arthroplasty (TKA) (Lewis-Rorabeck Type II). Following plate failure, four patients healed uneventfully and three patients experienced complications such as pseudarthrosis, screw loosening, and further plate failure. CONCLUSION: In patients with poor bone quality, bone graft, bone cement, and bone biologics have to be considered in revision surgery. Furthermore, long-stem revision and tumor prosthesis are an additional solution.

Laparoscopic adrenalectomy--10-year experience at a teaching hospital.

BACKGROUND: Minimally invasive adrenalectomy has been adopted as the treatment of choice for benign adrenal tumors. This study aimed to investigate the outcome of laparoscopic adrenalectomies performed over a 10-year period at a teaching hospital. METHODS: All laparoscopic adrenalectomies carried out between 1 April 2000 and 31 March 2010 were evaluated with respect to perioperative management, complications, conversion rate, learning curve, tumor size, and surgically relevant characteristics of different adrenal pathologies. RESULTS: Over a period of 10 years, 215 laparoscopic lateral transabdominal adrenalectomies were carried out for Conn's syndrome (n = 90), Cushing's syndrome (n = 72), pheochromocytoma (n = 30), metastatic disease (n = 8), incidentalomas (n = 10), and other rare adrenal pathologies (n = 5). Morbidity, mortality, and conversion rate were 7.0, 0.9, and 4.2 %, respectively. Patients with Cushing's disease and bilateral adrenalectomy showed a higher complication rate. In retrospect, the indication for a laparoscopic approach was at least questionable in five cases. During these 10 years, four surgeons unfamiliar with the technique received intensive training to a defined plan. CONCLUSIONS: Laparoscopic adrenalectomy represents a safe operating technique associated with few complications and a low conversion rate. Patients with severe Cushing's disease are prone to complications and require intensive monitoring postoperatively. Laparoscopic adrenalectomy is associated with a learning curve, and particular emphasis should be given to surgical training.

Accelerated rehabilitation following Achilles tendon repair after acute rupture - Development of an evidence-based treatment protocol.

The acute rupture of the Achilles tendon is a protracted injury. Surgery is only the beginning of a long rehabilitation period. Therefore, the rehabilitation protocol is an integral aspect to restore the pre-injury activity level. Despite several trials available comparing different treatment regimes, there is still no consensus regarding the optimal protocol. Consequently, the aim of our study was to systematically search the evidence available and define a precise rehabilitation programme after operative repair of acute Achilles tendon rupture based on the trials with the highest level of evidence. We performed a systematic literature search in Medline, Embase and Cochrane library. We identified twelve randomized controlled trials comparing different treatment regimes after operative repair of the Achilles tendon. Five trials compared full to non weight bearing, all applying immobilization in equinus. Immediate full weight bearing led to significant higher patient satisfaction, earlier ambulation and return to pre-injury activity. Four trials compared early ankle mobilization to immobilization. All trials found mobilization to be superior as it shortens time to return to work and sports significantly. Three trials compared the combination of full weight bearing and early ankle mobilization to immobilization. This combination was most beneficial. Patients showed significantly higher satisfaction, less use of rehabilitation resources, earlier return to pre-injury activities and further demonstrated significantly increased calf muscle strength, reduced atrophy and tendon elongation. No study found an increased rerupture rate for the more progressive treatment. In conclusion, the rehabilitation protocol after Achilles tendon repair should allow immediate full weight bearing. After the second postoperative week controlled ankle mobilization by free plantar flexion and limited dorsiflexion at 0° should be applied.

Prepatellar and olecranon bursitis: literature review and development of a treatment algorithm.

PURPOSE: Olecranon bursitis and prepatellar bursitis are common entities, with a minimum annual incidence of 10/100,000, predominantly affecting male patients (80 %) aged 40-60 years. Approximately 1/3 of cases are septic (SB) and 2/3 of cases are non-septic (NSB), with substantial variations in treatment regimens internationally. The aim of the study was the development of a literature review-based treatment algorithm for prepatellar and olecranon bursitis. METHODS: Following a systematic review of Pubmed, the Cochrane Library, textbooks of emergency medicine and surgery, and a manual reference search, 52 relevant papers were identified. RESULTS: The initial differentiation between SB and NSB was based on clinical presentation, bursal aspirate, and blood sampling analysis. Physical findings suggesting SB were fever >37.8 °C, prebursal temperature difference greater 2.2 °C, and skin lesions. Relevant findings for bursal aspirate were purulent aspirate, fluid-to-serum glucose ratio <50 %, white cell count >3,000 cells/µl, polymorphonuclear cells >50 %, positive Gram staining, and positive culture. General treatment measures for SB and NSB consist of bursal aspiration, NSAIDs, and PRICE. For patients with confirmed NSB and high athletic or occupational demands, intrabursal steroid injection may be performed. In the case of SB, antibiotic therapy should be initiated. Surgical treatment, i.e., incision, drainage, or bursectomy, should be restricted to severe, refractory, or chronic/recurrent cases. CONCLUSIONS: The available evidence did not support the central European concept of immediate bursectomy in cases of SB. A conservative treatment regimen should be pursued, following bursal aspirate-based differentiation between SB and NSB.

A treatment strategy for complex cases of osteomyelitis in children and its applicability on three exemplary cases.

The aim of this study was to carry out a two-step surgical approach for complex cases of pediatric osteomyelitis. The surgical technique used here involved initial bone debridement and stabilization by a customized spacer (intramedullary Kirschner wires mantled with refobacin-palacosa cement). After infection eradication, the spacer was removed and distraction osteogenesis performed. This study included one boy and two girls (aged 7-10 years) with severe osteomyelitis (tibia: two, femur: one). At least 50% of the bone was initially resected, and either a bifocal physeal distraction (tibia) or callus distraction (subtrochanteric osteotomy) was performed. At discharge they were able to walk without assistance. Complete infection eradication and load restraining reconstruction was achieved in all three children.

Radiographic predictors of hip pain in femoroacetabular impingement.

The primary diagnosis of femoroacetabular impingement is based on clinical symptoms, physical exam findings, and radiographic abnormalities. The study objective was to determine the radiographic findings that correlate with and are predictive of hip pain in femoroacetabular impingement (FAI). One hundred prospective patients with unilateral FAI symptoms based on clinical and radiographic findings were included in this study. All patients filled out a WOMAC pain questionnaire. Two independent-blinded surgeons assessed antero-posterior and lateral radiographs for 33 radiographic parameters of FAI. Correlations between pain scores and radiographic findings were calculated. A matched radiographic analysis was performed comparing symptomatic versus asymptomatic hips. Radiograph findings were also compared between males and females. Weak positive correlations were identified between increasing pain scores with radiographic findings of posterior wall dysplasia, presence of a shallow socket, and a more lateral acetabular fossa relative to the Ilioischial line. A symptomatic hip had a lower neck shaft angle, greater distance from Ilioischial line to acetabular fossa and larger distance from cross-over sign to superolateral point of the acetabulum when compared to the asymptomatic hip in the same patient. Symptomatic hips in males had more joint space narrowing, femoral osteophytes, higher alpha angles and larger, more incongruent femoral heads compared to females. Females had more medial acetabular fossa relative to the Ilioischial line and smaller femoral head extrusion index. Similar to other musculoskeletal conditions, radiographic findings of FAI are poor predictors of hip pain.