Editorial Commentary: Trends in Hip Arthroscopy Require Rapid Dissemination From Higher-Volume and Academic Surgeons to the Greater Orthopaedic Community.

Trends in hip arthroscopy show that labral repair and preservation, capsular repair and preservation, and treatment of femoroacetabular impingement during hip arthroscopy are associated with superior short-term and mid- to longer-term outcomes. Hip arthroscopy, and in particular arthroscopic femoroacetabular impingement correction, is in its infancy compared with many other orthopaedic procedures. As we assimilate knowledge, data, and evidence-based research, it is critical to evaluate surgical trends and how they affect our management of these patients and pathologies. However, it is important to recognize that there is great variability with regards to surgical volume and awareness of impending evidence-based research for relatively newer procedures such as hip arthroscopy. This can lead to delays for incorporating newer evidence-based techniques. The gap is closing, but the time required to close this disparity in management trends between higher-volume/academic surgeons and the orthopaedic community as a whole could be shorter. Whether this delay for adapting evidence-based trends is consistent across the spectrum of orthopaedic surgery or specific to smaller subspecialty areas such as hip arthroscopy is unclear. Regardless, it is essential that those who are performing the larger volume of cases and research must raise our voices, turn up our loudspeakers, and publish, present, and use social media platforms to spread the word of the latest evidence-based trends quickly! It is equally critical for the greater orthopaedic community to listen for the benefit of patients. If all parties collaborate, we can get up to speed in a timelier manner and achieve the best-possible outcomes together.

Editorial Commentary: Minimizing Traction Force and Time as Well as Application of Specific Technical Pearls Might Trump the Importance of Choosing Between Post or Postless Hip Arthroscopy With Regards to Complications.

Recently, there has been a trend toward performing hip arthroscopy without a post (postless) in an effort to decrease perineal post-related complications. Previous studies have revealed a variable risk of pudendal nerve neuralgia and perineal soft-tissue injury when using a post. There is emerging evidence that arthroscopic hip procedures can be done without the use of a post, with less traction force on the perineal region, and with adequate exposure to safely accomplish a well-done femoroacetabular impingement corrective procedure. Prospective comparative studies with conclusive evidence of the superiority of either technique, however, are lacking. Complications with a post are likely associated with high traction forces, prolonged traction times, and potentially suboptimal technique and patient positioning. In addition, postless traction is in its infancy and new adverse events/outcomes are likely to emerge. There are likely specific situations and patient populations in which one technique might be superior to the other. We are the carpenters of medicine and rather than blaming our tools and throwing out a technique that has served us well for decades, we should better understand some important pearls and pitfalls that might allow either method to be safely performed.

Radiographic and Dynamic Assessment for Resection of Cam Lesions in Patients With Femoroacetabular Impingement.

Cam-type femoroacetabular impingement is characterized by a pathologic asphericity of the femoral head-neck junction, and arthroscopic femoral osteoplasty is indicated to correct the bony abnormality and restore normal hip mechanics when symptomatic. Residual femoroacetabular impingement deformity after arthroscopy is a leading cause of failure, and it is therefore critical to perform a thorough fluoroscopic and dynamic assessment when addressing cam deformities arthroscopically. The fluoroscopic assessment uses 6 anteroposterior views, including 3 in hip extension (30° internal rotation, neutral rotation, and 30° external rotation) and 3 in 50° flexion (neutral rotation, 40° external rotation, 60° of external rotation), performed before, during, and after the femoral resection. The dynamic assessment includes evaluation of impingement-free range of motion and "end feel" (a subjective description of the tactile feedback during assessment of hip motion), and should be performed before and after the femoral resection in 3 specific positions (extension/abduction, flexion/abduction, and flexion/internal rotation). Although the anterior aspect of the head-neck junction is readily accessed through standard arthroscopic portals with the hip in 30 to 50° of flexion, the posterolateral, posteromedial, and posterior extent of the femoral head-neck junction are challenging to address. The natural external rotation of the proximal femur during flexion and internal rotation during extension can be used to gain posterior lateral and medial access. Antero/posteromedial femoral access can be obtained with >50° of hip flexion with the burr in the anteromedial portal. Posterolateral femoral access is achieved with hip extension with the burr in the anterolateral portal, and further posterolateral access can be achieved with the addition of traction, allowing resection of posterolateral deformities extending beyond the lateral retinacular vessels while remaining proximal to the vessels. This comprehensive intraoperative fluoroscopic and dynamic assessment and surgical technique can lead to a predictable correction of most cam-type deformities.

Editorial Commentary: Restoration of Hip Capsular Tension Is More Important Than Repair Construct Configuration.

The debate regarding optimal capsular management during hip arthroscopy has been evolving for over 20 years. Femoroacetabular impingement emerged in the arthroscopic world in the early 2000s. However, the ability to address osseous deformities and decompress and/or reshape them was limited by the hip capsular structures and small capsulotomies. Some surgeons attempted to arthroscopically manage these deformities with limited capsulotomies, with not surprisingly limited success. Others made larger capsular windows (capsulectomies) to more accurately manage these deformities but potentially left some patients with varying degrees of iatrogenic microinstability or macroinstability. Over time, an increasing awareness of post-arthroscopy instability in the form of case reports, case series, and backroom chatter among the hip arthroscopy thought leaders brought the idea of routine capsular closure to the forefront. Biomechanical studies defined the role of the hip capsular ligaments, the deficits created with various capsulotomies during surgery, and the ability to restore stability after capsular repair. Clinical studies revealed better outcomes and lower revision rates after capsular repair for subtle osseous and soft-tissue instability, revision cases, and athletes compared with unrepaired capsulotomies. Various capsular repair constructs (side-to-side repairs, capsular shifts, and various suture configurations and suture materials) have been proposed, without evidence to support a superior technique or suture material. In the end, capsular management is an evolving art that takes into account various patient-specific factors (i.e., individual activity requirements, soft-tissue and osseous parameters, and intraoperative impressions) with the end goal of achieving a stable, impingement-free joint. There might be various capsular management roads to travel, but the destination remains the same.

Editorial Commentary: Routine Preoperative Magnetic Resonance Imaging for Hip Arthroscopy Is Wasting Health Care Dollars and Delaying Surgical Intervention: Decision Making Should Be at the Discretion of the Health Care Provider Not Mandated by Health Care Insurers.

Making an accurate preoperative diagnosis is critical to optimizing outcomes after hip arthroscopy. A detailed history, thorough physical examination, imaging studies, and diagnostic injections must all be considered in the decision-making process. In today's health care climate, it is imperative to obtain essential and indicated preoperative information while being mindful of health care dollars. Magnetic resonance imaging (MRI) of the hip has been shown to be a highly sensitive modality for hip and pelvis disorders. However, it is critical to recognize that acetabular labral tears and other hip pathology are highly prevalent in an asymptomatic young adult population. There are certainly situations when an MRI should be obtained (suspected arthritic symptoms, avascular necrosis, synovial disorders, uncommon osseous tumors); however, these patients generally present with atypical symptoms. In addition, obtaining an MRI can delay surgical intervention, which has been shown to lead to inferior outcomes in prior studies. MRI is not imperative when patients present with typical intermittent, deep anterior, lateral, groin pain with prolonged sitting, twisting and pivoting, and transitioning from sitting to standing. The typical physical examination includes positive hip impingement testing (FADIR / anterior impingement test) that recreates the patients presenting complaints. Appropriate imaging includes plain radiographs revealing adequate acetabular coverage (not significantly dysplastic) or acetabular overcoverage (pincer-type femoracetabular impingement), cam-type femoracetabular impingement, and well-maintained joint space on all views, including a false profile radiograph to further evaluate the anterior joint space. Finally, a diagnostic injection can be invaluable to further confirm the hip joint proper as the source of pain. If all of the above criteria are met, I strongly believe an MRI is unlikely to alter the surgical decision-making process. In the end, the treating clinician should determine when an MRI is necessary based on the presenting symptoms and examination, rather than insurers applying a blanket requirement for preauthorization. This physician autonomy would ultimately lead to more efficient and cost-effective patient care. Medicine is an art, and unjustified handcuffing of the artist without evidence could result in inferior results.

Editorial Commentary: Ultrasound-Guided Injection With Dynamic Assessment Could Improve Outcomes in Atypical and Revision Hip Arthroscopy Patients: But Today, Few Are Trained to Hear at Such High Frequencies.

Imaging modalities for hip disorders all have their strengths and weaknesses. Magnetic resonance imaging is superior for evaluating soft tissue pathology, computerized tomography best characterizes osseous morphology, and plain radiographs can accurately depict 2-dimensional anatomy and are familiar to most clinicians. Ultrasound-guided injections have become commonplace in the musculoskeletal arena. Ultrasound evaluation of musculoskeletal anatomy has received increased attention, has the ability to image soft tissue and osseous structures, and more importantly, has the ability to dynamically evaluate these structures in real time. A noninvasive dynamic assessment of the hip region could be an absolute game changer for the hip preservation/sports medicine community in the diagnosis of atypical hip pain, femoroacetabular impingement, and labral tears. Widespread ability and expertise to perform these dynamic ultrasound assessments, however, is not in place at this time. We need more training and studies to best harness the potential benefits of these sound waves.

Editorial Commentary: Psoas Tenotomy in the Setting of a Borderline Dysplastic Hip Risks Iatrogenic Instability: Be Extremely Cautious and Particularly in Athletes.

Successful outcomes after psoas tenotomies have been reported and proposed in the setting of recalcitrant internal snapping and psoas impingement. However, case reports citing hip flexion weakness and iatrogenic instability created concern regarding the role for psoas tenotomies. Despite these concerns, some recent studies reporting improved outcomes after endoscopic psoas tenotomies breathe further life into this controversial topic. Psoas tenotomy in the setting of a borderline dysplastic hip likely carries an even greater risk for iatrogenic instability. It might be critical to evaluate for clinical signs and symptoms of instability in addition to radiographic parameters to avoid this potentially devastating complication. In addition, the traditional definition of borderline dysplasia is based on lateral acetabular coverage that might be less important than anterior acetabular coverage and femoral version when contemplating psoas tenotomies on the basis of the dynamic anterior stabilizing effect of the iliopsoas myotendinous unit. Surgeons should also be extremely cautious when considering psoas tenotomy in an athletic population with the potential for persistent weakness and limited data hinting at inferior sports specific outcomes. In the end, it is not clear whether the psoas tenotomy "drives" the improvements seen in some studies, or whether many of these patients ultimately battle their way into a minimally clinically important difference "despite" the psoas tenotomy.

Posterior Tibial Slope: Understand Bony Morphology to Protect Knee Cruciate Ligament Grafts.

Improved understanding of the biomechanical significance and clinical repercussions of tibial slope on cruciate ligament function has sparked a newfound clinical interest in this morphological feature. Using either magnetic resonance imaging or lateral tibia radiographs, the anterior-posterior angulation of the tibial plateau relative to the tibial shaft can be measured. Clinical and biomechanical studies have reported that increased posterior tibial slope (PTS) places significantly increased tension on the native and reconstructed anterior cruciate ligament (ACL), leading to an increased risk of failure. It has also been suggested that increased PTS of the lateral tibial plateau has a greater impact on ACL forces and anterior tibial translation than PTS of the medial tibial plateau. Conversely, a decreased PTS has been shown to be a risk factor for recurvatum deformity, posterior cruciate ligament (PCL) injury, and posterior tibial translation and has been linked to single bundle PCL reconstruction failure. In the setting of ACL insufficiency with a PTS greater than 12°, anterior closing wedge osteotomy has been shown to be protective for ACL reconstructions. Alternatively, some surgeons have advocated for the addition of lateral extraarticular stabilization procedures in the setting of increased PTS. Further, in the setting of PCL insufficiency with an anteriorly directed, or flat, PTS, anterior opening wedge osteotomy has shown encouraging results. In addition, double bundle PCL reconstructions should be strongly considered in the setting of anteriorly directed, or flat, tibial slope.

Posterior Tibial Slope Measurements Using the Anatomic Axis Are Significantly Increased Compared With Those That Use the Mechanical Axis.

PURPOSE: To compare posterior tibial slope (PTS) measurements from standard lateral knee radiographs with measurements from full-length lateral tibia radiographs. METHODS: We performed a multicenter, prospective study. Lateral knee and full-length lateral tibia radiographs were obtained for each patient, and PTS was measured. Slope measurements were obtained by measuring the angle between an average of the medial and lateral tibial plateaus and a representative tibial diaphysis line. The proximal anatomic axis was measured on lateral knee radiographs, and both the mechanical axis and anatomic axis were measured on full-length lateral tibia radiographs. The mechanical axis was defined as the center of the plateau to the center of the plafond, and the anatomic axis was defined as the center of the tibial diaphysis. The minimal clinically significant difference was defined a priori as 2° of PTS or greater. RESULTS: A total of 140 patients met the inclusion criteria. The average PTS using the proximal anatomic axis was 11.6° ± 3.2° on lateral knee radiographs; the PTS measured on full-length lateral tibia radiographs was 9.5° ± 3.4° using the mechanical axis and 11.8° ± 3.1° using the anatomic axis. There was a significant difference between the measurements with the mechanical axis and both anatomic axis measurements (P < .01) but no significant difference between the 2 anatomic axis measurement techniques (P = .574). In total, 55% of patients (n = 77) had a 2° or greater difference between the proximal anatomic axis and mechanical axis PTS measurement techniques. CONCLUSIONS: There was no significant difference between PTS measurements that used the proximal anatomic axis from lateral knee radiographs and those that used the anatomic axis from full-length lateral tibia radiographs. Thus, lateral knee radiographs are adequate to accurately obtain tibial slope measurements. However, there was a significant difference between PTS measurements that used the anatomic axis and those that used the mechanical axis of the tibia. CLINICAL RELEVANCE: It is recommended that future studies report tibial slope based upon measurements that utilize the anatomic axis in order to ensure that subsequent conclusions are comparable, independent of the radiographic view.

A Systematic Review Shows High Variation in Terminology, Surgical Techniques, Preoperative Diagnostic Measures, and Geographic Differences in the Treatment of Athletic Pubalgia/Sports Hernia/Core Muscle Injury/Inguinal Disruption.

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.

Is Arthroscopic Hip Labral Repair/Reconstruction Surgery Effective for Treating Femoroacetabular Impingement in the Presence of Osteoarthritis?

OBJECTIVE: To investigate clinical outcomes after arthroscopic labral preservation surgery for femoroacetabular impingement (FAI) in the presence of osteoarthritis (OA) compared with FAI without significant OA. DESIGN: Retrospective case-control study. SETTING: Department of Orthopaedic Surgery and Sports Medicine, Hospital of Academic Institute. PATIENTS: Femoroacetabular impingement patients (n = 97; ≥35 years) undergoing arthroscopic FAI correction with labral preservation surgery from March 2009 to April 2014 were enrolled in this study. INTERVENTIONS: Patients were divided into 2 groups: FAI group (79 patients), with Tonnis grade 0 or 1, and FAI + OA group (18 patients), with Tonnis grade 2 or 3. MAIN OUTCOME MEASURES: We examined the clinical outcomes using the Modified Harris Hip Score (MHHS), Nonarthritic Hip Score (NAHS), and the conversion rate to total hip arthroplasty (THA). RESULTS: No significant differences existed between the 2 groups with respect to age, sex, follow-up period, or preoperative MHHS or NAHS. The mean MHHS and NAHS at the final follow-up were significantly lower in the FAI + OA group than in the FAI group. There was a significant difference in the rate of conversion to THA and failure between the 2 groups (THA 5% vs 50%) (failure 15% vs 67%). CONCLUSION: Patients with FAI in the presence of OA did not improve after arthroscopic labral preservation surgery and had a high conversion rate to THA. LEVEL OF EVIDENCE: Level III.

Editorial Commentary: "The Earth is Not Flat": Progressing From Plain Radiographs to Three-Dimensional Imaging When Evaluating Hip Disorders.

Dysplastic hip morphologies have received increasing attention in the hip preservation community. Defining and characterizing "transitional acetabular coverage" or "borderline" dysplasia has been extraordinarily challenging, and these hips have been lumped together based on focal radiographic measurements such as the lateral center edge and Tonnis angles. Some of these hips are treated with arthroscopy and some with corrective osteotomies without definitive patient-related outcome measure winners in our literature. Three-dimensional imaging evaluation of these hips with regard to acetabular and femoral-sided anatomy will be required to more clearly define any consistent anatomic variants and their respective optimal surgical approaches.

Editorial Commentary: Comparing Medial and Lateral Meniscal Root Tears Is Like Comparing Apples and Oranges.

The importance of treating meniscal root tears has been increasingly recognized, and surgeons have to make conscious decisions routinely regarding repair for select patients. The clinical and patient demographic differences between medial and lateral meniscal root tears are important and ultimately leave us wondering whether outcome differences are due to unique anatomic factors or the patient population sustaining these injuries.

The Dancer's Hip: The Hyperflexible Athlete: Anatomy and Mean 3-Year Arthroscopic Clinical Outcomes.

PURPOSE: To report preoperative anatomy, patient-related outcomes measures, and return to dance rates in a cohort of competitive dancers undergoing an arthroscopic hip procedure. METHODS: Competitive dancers who underwent an arthroscopic hip procedure between 2008 and 2016 were included. Specific types of dance performed, morphology, and radiographic parameters were documented. Outcomes were evaluated with Modified Harris Hip Score (mHHS), the 12-Item Short Form Health Survey, visual analog scale, and Hip Disability and Osteoarthritis Outcome Scores (HOOS). RESULTS: There were 63 competitive dancers (77 hips) with a mean age 21.2 years in the current study. Specific types of dance performed included 57 studio dance and 41 high-kick dance, and 28 dancers (44%) were professional-level. Morphology included cam-type femoroacetabular impingement (95%), pincer-type femoroacetabular impingement (40%), anterior inferior iliac spine impingement (subspine) (83%), and mild (borderline) dysplasia (11%). Procedures performed included 95% labral repairs, 5% labral debridements, 99% femoral resections, 49% rim resections, 88% subspine decompressions, and 66% capsular plications. At mean 36 months' follow-up post-arthroscopy, the mean outcome improvements were 25.6 points (mHHS), 18.9 points (HOOS-activities of daily living), 29.9 points (HOOS-Sports), 8.7 points (12-Item Short Form Health Survey), and 3.7 points (visual analog scale) (P < .01 for each). Scores were significantly improved from preoperatively to most recent follow-up for mHHS (60.0 vs 85.6 points), HOOS-activities of daily living (72.5 vs 91.5 points), and HOOS-Sports (49.7 vs 79.6) (P < .01). Sixty-three percent of dancers returned to their previous level of competitive dance, 21% returned to limited or modified dance, and 16% were unable to return to dance, including 1 retirement. CONCLUSIONS: A careful arthroscopic approach to address cam-type pathomorphology, highly prevalent subspine impingement, and capsular laxity in competitive dancers can achieve a modest rate of return to sport and good-to-excellent patient-reported outcomes at short- to mid-term (3-year) follow-up. Eighty-four percent of dancers ultimately returned to competitive dance, although only 63% returned to their preinjury competitive level. LEVEL OF EVIDENCE: IV, case series.

Arthroscopic anterior inferior iliac spine decompression does not alter postoperative muscle strength.

PURPOSE: The purpose of this study was to assess the additional effect of anterior inferior iliac spine (AIIS) decompression on knee extensor and hip flexor strength and compare functional outcomes after arthroscopic FAI correction with and without AIIS decompression. METHODS: Sixty patients who underwent arthroscopic FAI correction surgery were divided into two groups matched for AIIS morphology: 31 patients who underwent arthroscopic FAI surgery only (without AIIS decompression) (FAI group) (AIIS Type I; n = 5, Type II; n = 26, Type III; n = 0) and 29 patients who underwent arthroscopic FAI surgery with AIIS decompression (AIIS group) (AIIS Type I; n = 5, Type II; n = 24, Type III; n = 0). Knee extensor and hip flexor strength were evaluated preoperatively and at 6 months after surgery. Patient-reported outcome (PRO) scores using the modified Harris hip score (MHHS), the nonarthritic hip score (NAHS) and iHOT-12 were obtained preoperatively and at 6 months after surgery. RESULTS: In the AIIS group, there was no significant difference between knee extensor strength pre- and postoperatively (n.s.). In the AIIS group, hip flexor strength was significantly improved postoperatively compared to preoperative measures (p < 0.05). In the FAI group, there were no significant improvements regarding muscle strength (n.s.). While there were no significant differences of preoperative and postoperative MHHS and NAHS between both groups (MHHS; n.s., NAHS; n.s.), the mean postoperative iHOT-12 in the FAI group was inferior to that in the AIIS group. (p < 0.01). The revision surgery rate for the AIIS group was significantly lower compared with that in the FAI group (p < 0.05). CONCLUSION: Anterior inferior iliac spine decompression, as a part of an arthroscopic FAI corrective procedure, had a lower revision surgery rate and did not compromise knee extensor and hip flexor strength, and it improved clinical outcomes comparable to FAI correction without AIIS decompression. AIIS decompression for FAI correction improved postoperative PRO scores without altering the muscle strength of hip flexor and knee extensor. LEVEL OF EVIDENCE: III.

Editorial Commentary: Total Hip Arthroplasty After Hip Arthroscopy-Solution for the Failed Arthroscopy or a Matter of Pushing the Envelope and Questionable Indications.

With the inevitable explosion of arthroscopic hip procedures being performed, the less frequent indications and failures are becoming prevalent enough to analyze. As with any procedure, failures occur and solutions are sought after. "Total hip arthroplasty after prior hip arthroscopy" is a statement that brings to mind several questions and comments. Yes, it is important to evaluate the impact of a prior arthroscopy on eventual total hip arthroplasty outcomes and complication rates. The bigger question when the arthroplasty is performed less than 2 years after hip arthroscopy, however, is "How did we get here?" The pivotal issue at hand might be one of pushing surgical indications a bit too forcefully on multiple fronts. It might be time to return to "Indications 101" to minimize an exponential increase regarding this particular topic with this particular failure timeline.

Editorial Commentary: Subspine Hip Abnormalities: Exploring the Difference Between "Morphology" and "Impingement".

Subspine impingement has been increasingly recognized as a source of hip pain over the past 5 to 10 years. Some surgeons routinely perform subspine/anterior inferior iliac spine (AIIS) decompressions, whereas others rarely perform these procedures as part of an arthroscopic hip procedure. Subspine impingement has been implicated with high range-of-motion activities, various AIIS morphologies and deformities, and in the setting of persistent anterior hip pain after intra-articular anesthetic injections. Dynamic computed tomographic imaging has recently shown subspine impingement even with relatively normal AIIS morphology and in the setting of decreased femoral anteversion. These findings further emphasize the importance of understanding and defining relationships between morphology and impingement. Ultimately, subspine decompressions might be critical to achieve the best possible outcome after arthroscopic hip procedures in a subset of patients, but making the diagnosis remains challenging for clinicians.

Arthroscopic Surgery for Femoroacetabular Impingement in Skeletally Immature Athletes: Radiographic and Clinical Analysis.

PURPOSE: To evaluate radiographic and clinical outcomes after arthroscopic femoroacetabular impingement (FAI) correction in symptomatic adolescent athletes with open physes. METHODS: We retrospectively reviewed radiographic and clinical outcomes in patients treated with a non-physeal-sparing arthroscopic approach for symptomatic FAI with open physes and a minimum 1-year follow-up. Specific plain radiographic and computed tomography parameters were determined, and preoperative and postoperative outcomes were prospectively evaluated with modified Harris Hip Score (mHHS), 12-Item Veterans-Rand, and pain on a visual analog scale. RESULTS: Thirty-seven hips (28 patients; 75% male) with a mean age of 15.9 years (range, 12.8-18.3 years) had imaging studies consistent with open femoral neck and iliac crest physes. The ischial tuberosity and greater trochanteric physes were open in 95% and 54% of the hips, respectively. All patients participated in organized athletics, and 50% were in multiple sports year-round. Mean follow-up was 39.8 months post-arthroscopic FAI correction. There was a mean 27.7-point improvement in the mHHS (P < .001), a 4.8-point decrease in the visual analog scale for pain (P < .001), and a 15.2-point improvement in the 12-Item Veterans-Rand physical component (P < .001). Ninety-three percent of patients returned to their preinjury level of sports participation without limitations. Thirty (81.1%) patients demonstrated improvements in mHHS greater than the minimally clinically important difference (of mHHS 8 points). Two patients could not reach minimally clinically important difference because of a preoperative mHHS of > 92. There were no postoperative physeal growth arrests, growth disturbances, physeal instability, or avascular necrosis. CONCLUSIONS: A non-physeal-sparing arthroscopic approach for FAI in adolescents with open physes is safe and effective with no evidence of clinically relevant complication of growth arrest-related deformity or physeal instability in patients with a minimum of 1 year (mean, 39.8 months) of follow-up after surgery. Young, highly athletic adolescent patients with larger FAI deformities demonstrated greater outcomes improvement after arthroscopy. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Low-Dose Computed Tomography Reduces Radiation Exposure by 90% Compared With Traditional Computed Tomography Among Patients Undergoing Hip-Preservation Surgery.

PURPOSE: To compare the delivered radiation dose between a low-dose hip computed tomography (CT) scan protocol and traditional hip CT scan protocols (i.e., "traditional CT"). METHODS: This was a retrospective comparative cohort study. Patients who underwent hip-preservation surgery (including arthroscopy, surgical hip dislocation, or periacetabular osteotomy procedures) at our institution between 2016 and 2017 were identified. Patients were excluded if they had a body mass index (BMI) greater than 35, they underwent previous surgery, or a radiation dose report was absent. The low-dose group included patients who underwent hip CT at our institution using a standardized protocol of 100 kV (peak), 100 milliampere-seconds (mAs), and a limited scanning field. The traditional CT group included patients who had hip CT scans performed at outside institutions. The total effective dose (Ehip), effective dose per millimeter of body length scanned, patients' age, and patients' BMI were compared by univariate analysis. The correlation of Ehip to BMI was assessed. RESULTS: The study included 41 consecutive patients in the low-dose group and 18 consecutive patients in the traditional CT group. Low-dose CT resulted in a 90% reduction in radiation exposure compared with traditional CT (Ehip, 0.97 ± 0.28 mSv vs 9.68 ± 6.67 mSv; P < .0001). Age (28 ± 11 years vs 26 ± 10 years, P = .42), sex (83% female patients vs 76% female patients, P = .74), and BMI (24 ± 3 vs 24 ± 3, P = .75) were not different between the 2 groups. Ehip had a poor but significant correlation to BMI in the low-dose CT group (R2 = 0.14, slope = 0.03, P = .02) and did not correlate to BMI in the traditional CT group (R2 = 0.13, P = .14). CONCLUSIONS: A low-dose hip CT protocol for the purpose of hip-preservation surgical planning resulted in a 90% reduction in radiation exposure compared with traditional CT. LEVEL OF EVIDENCE: Level II, diagnostic study.

Predictors of Clinically Suspected Intra-articular Hip Symptoms and Prevalence of Hip Pathomorphologies Presenting to Sports Medicine and Hip Preservation Orthopaedic Surgeons.

PURPOSE: The first purpose of the study was to evaluate the prevalence of various radiographic parameters and pathomorphologies for patients presenting with the diagnosis of hip pain. The second purpose of this study was to identify those pathomorphologies and radiographic parameters that were predictive of clinically suspected intra-articular and hip joint-related symptoms. METHODS: A total of 998 hips (499 patients, 228 males, 271 females, mean age 38 years) presented to 2 orthopaedic surgeons with the diagnosis of hip pain. Patients were retrospectively identified as intra-articular and hip joint-related symptoms or extra-articular and non-hip joint-related symptoms based on history, examination, injection response, and diagnosis listed on clinical notes. A detailed morphologic evaluation of anteroposterior and 45° modified Dunn lateral radiographs of both hips was performed for all patients. RESULTS: The presence of at least 1 finding consistent with femoroacetabular impingement (FAI) was noted in 96.6% of patients (89.9% of hips) and was bilateral in 83%. The prevalence of dysplasia was 10.6% in patients (6.7% of hips) and was bilateral in 2.8%. Cam-type morphology was more common in males (P < .001). Profunda and protrusio were more common in females (P < .001). Acetabular retroversion was more common in males (P = .02). Fifty-seven percent of hips (564/998) were diagnosed clinically with intra-articular and hip joint related symptoms. Cam-type FAI, mixed-type FAI, increasing alpha angle, and increasing Tönnis grade were independent predictors of clinically suspected intra-articular and hip joint symptoms (P < .001), whereas isolated Pincer-type morphology was not. CONCLUSIONS: FAI is highly prevalent (96.6%) and frequently bilateral (83%) in patients presenting to an orthopaedic clinic with hip pain. Cam-type morphology and acetabular retroversion are more frequent in men, whereas profunda and protrusio are more frequent in women. Cam-type morphology, increasing alpha angle (larger cam morphology), and increasing Tönnis grade were highly predictive of clinically suspected intra-articular symptoms, whereas isolated pincer-type morphology was not. LEVEL OF EVIDENCE: Level III, case-control study.