Utility of Intra-articular Hip Injections for Femoroacetabular Impingement: A Systematic Review.

BACKGROUND: Femoroacetabular impingement (FAI) is a condition that is becoming increasingly recognized as a common etiology of hip pain in athletes, adolescents, and adults. However, history and clinical examination are often inconclusive in reaching a diagnosis, while imaging often detects asymptomatic abnormalities. Treatment has traditionally been limited to surgery, with the role of conservative management remaining unclear. PURPOSE: To evaluate the utility of the intra-articular hip injection in the diagnosis and management of FAI. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: MEDLINE, EMBASE, and PubMed databases were screened in duplicate for studies published between January 1946 and January 2014. Search terms included femoroacetabular impingement, hip impingement, and intra-articular injection. Quality assessment using the Methodological Index for Non-Randomized Studies (MINORS) scale was completed for all included studies. Data evaluated included study design, study objectives, number of hips, injected product, duration of pain relief, and outcomes measured. RESULTS: Our search yielded 8 studies involving 281 hips. Studies were categorized into diagnostic (4 studies), therapeutic (3 studies), and prognostic (1 study) applications. Patients with FAI and its degenerative sequelae obtained greater relief from diagnostic intra-articular hip injection than those without (P < .05). The diagnostic intra-articular injection performed under ultrasound guidance was better tolerated than injections performed under fluoroscopic guidance (pain rating, 5.6 vs 3.0; P < .1). Intra-articular injection of hyaluronic acid was the most effective at providing pain relief (in 23 patients), with significant improvements of functional outcome measures (Harris Hip Score, visual analog scale) present at 12 months. Pooled results with corticosteroid injection resulted in improvement in only 15% (9/60) of patients at 6 weeks. A negative response to intra-articular hip injection was a strong predictor for poor surgical outcomes. CONCLUSION: The results of this review suggest that (1) pain relief obtained from an intra-articular hip injection supports a diagnosis of FAI, (2) therapeutic relief at 12 months may be achieved, particularly with hyaluronic acid, and (3) a negative response to preoperative injections may predict poor short-term surgical outcomes. Additional large studies are required to build on the small number of studies included in this review, and further delineate the role of intra-articular hip injection in the management of FAI.

Gait and lower extremity kinematic analysis as an outcome measure after femoroacetabular impingement surgery.

PURPOSE: Lower extremity and pelvis kinematics have been shown to be abnormal in patients with femoroacetabular impingement (FAI). We conducted this systematic review to evaluate the current status of gait and lower extremity kinematics as an outcome measure in patients treated surgically for FAI. METHODS: We searched the Embase, Medline, and PubMed databases for all reports of studies published through February 22, 2014, evaluating kinematic assessment of patients undergoing FAI surgery. A review of eligible studies was conducted, and the references were searched. Methodologic quality was evaluated for all studies that met the inclusion and exclusion criteria, and data were extracted regarding methods of kinematic assessment and clinical and kinematic outcomes. RESULTS: We identified 633 reports, of which 5 met our eligibility criteria. These studies included a total of 58 patients with symptomatic FAI (age range, 18 to 50 years). All included studies were of moderate methodologic quality. Kinematic assessments were completed preoperatively and postoperatively with variable methodology and follow-up (range, 3 to 32 months). Most studies used high-speed motion-capture camera systems with reflective tracking markers to evaluate in vivo kinematic function. Of the 5 included studies, 3 documented kinematic improvements postoperatively particularly regarding sagittal hip range of motion primarily with flexion (weighted mean, 35.1° ± 5.4° preoperatively and 37.8° ± 6.3° postoperatively). CONCLUSIONS: Gait and lower extremity kinematics can be used as an outcome measure after FAI surgery. However, the lack of uniformity in the methodology used and underpowered case series limit the ability to identify clear and predictable differences after corrective surgery for FAI. Though statistically significant, functional outcome improvements were often conflicting and not necessarily of clinical significance. A uniform outcome measure and technique to reliably assess in vivo hip motion are required for future comparative studies. LEVEL OF EVIDENCE: Level IV, systematic review of Level IV studies.

Extra-articular hip impingement: a systematic review examining operative treatment of psoas, subspine, ischiofemoral, and greater trochanteric/pelvic impingement.

PURPOSE: Extra-articular hip impingement can be the result of psoas impingement (PI), subspine impingement (SSI), ischiofemoral impingement (IFI), and greater trochanteric/pelvic impingement (GTPI). Symptoms may be due to bony abutment or soft-tissue irritation, and often, it is a challenge to differentiate among symptoms preoperatively. Currently, the clinical picture and diagnostic criteria are still being refined for these conditions. This systematic review was conducted to examine each condition and elucidate the indications for, treatment options for, and clinical outcomes of surgical management. METHODS: We searched online databases (Medline, Embase, and PubMed) for English-language clinical studies published from database inception through December 31, 2013, addressing the surgical treatment of PI, SSI, IFI, and GTPI. For each condition, 2 independent assessors reviewed eligible studies. Descriptive statistics are presented. RESULTS: Overall, 9,521 studies were initially retrieved; ultimately, 14 studies were included examining 333 hips. For PI, arthroscopic surgery resulted in 88% of patients achieving good to excellent results, as well as significant improvements in the Harris Hip Score (P = .008), Hip Outcome Score-Activities of Daily Living (P = .02), and Hip Outcome Score-Sport (P = .04). For SSI, arthroscopic decompression, with no major complications, resulted in a mean 18.5° improvement in flexion range of motion, as well as improvements in pain (mean visual analog scale score of 5.9 points preoperatively and 1.2 points postoperatively) and the modified Harris Hip Score (mean of 64.97 points preoperatively and 91.3 points postoperatively). For both IFI and GTPI, open procedures anecdotally improved patient symptoms, with no formal objective outcomes data reported. CONCLUSIONS: This review suggests that there is some evidence to support that surgical treatment, by arthroscopy for PI and SSI and by open surgery for IFI and GTPI, results in improved patient outcomes. LEVEL OF EVIDENCE: Systematic review of Level IV and V (case report) studies.

The hip labrum reconstruction: indications and outcomes--a systematic review.

PURPOSE: With further understanding of the function and the importance of the hip labrum, greater attention has been paid to preserve and repair the damaged labrum. Hip labrum reconstruction has been described to optimize hip preservation when the labrum is deficient. This systematic review aimed to explore and identify the reported indications and outcomes in patients who undergo labral reconstruction of the hip joint. METHODS: The electronic databases EMBASE, MEDLINE, and PubMed were searched for all available dates up to July 2013. Further hand search of the reference sections of the included studies was done. Two reviewers searched, screened, and evaluated the included studies for data quality using the Methodological Index for Non-Randomized Studies (MINORS) Scale. Data were also abstracted in duplicate, and agreement and descriptive statistics are presented. RESULTS: There were 5 eligible studies (3 case series, 1 prospective cohort, and 1 retrospective chart review) with a total of 128 patients, and an average 11/16 quality on the MINORS score included in this review. All patients were diagnosed with femoroacetabular impingement and underwent labral reconstruction. Ninety-four patients were assessed at follow-up (73.4 % survivorship) between a reported mean range of 10 and 49 months. There was variability between the studies with regard to the graft types utilized (ilio-tibial band, Gracilis tendon, Ligamentum teres), surgical approaches [open (18.7 %) vs. arthroscopic (81.3 %)], and the reported outcome measures. Overall, improvement was observed in the patient-reported outcomes and functional scores (mHHS, HOS, UCLA, NASH, and SF-12). The failure rate or conversion to THA rate in all available patients was 20 %. The most common indication for labrum reconstruction was a young, active patient with minimal arthritis and non-salvageable or deficient labrum. Other indications included instability, pain, and hypotrophic dysfunctional labrum. CONCLUSION: Based on the current available evidence, hip labrum reconstruction is a new technique that shows short-term improvement in patient-reported outcomes and functional scores post-operatively. The main indication for reconstruction was a deficient labrum due to previous surgical excision or irreparable tears in young patients with no significant arthritis. Long-term follow-up results with higher quality studies are still lacking based on this review.

A Systematic Review and Meta-Analysis of En-Bloc vs Intralesional Resection for Giant Cell Tumor of Bone of the Distal Radius.

INTRODUCTION: Surgical management of Giant Cell Tumor of Bone of the distal radius (GCTDR) remains controversial due to risk of local recurrence (LR) offset by functional limitations which result from en-bloc resection. This study aims to determine the oncologic and functional outcomes of wide excision (WE) vs intralesional curettage (IC) of GCTDR. METHODS: A complete search of the applicable literature was done. Included studies reported on patients from the same cohort who were surgically treated for GCTDR with WE or IC. Two reviewers independently assessed all papers. The primary outcome measure was LR. RESULTS: One-hundred-forty-one patients from six studies were included: 60 treated with WE, and 81 with IC. Five WE patients (8%) suffered LR whereas 25 IC patients (31%) did. The odds of LR were three times less in the WE group vs the IC group. MSTS1993 scores, where available, were on average 'good' with WE and 'excellent' with IC. CONCLUSIONS: Within statistical limitations the data support an attempt, where feasible, at wrist joint preservation and superior function with IC. Intralesional curettage is reasonable when the functional benefit outweighs the risk of recurrence as is the case in many cases of GCT of the distal radius.

Return to preinjury activity levels after surgical management of femoroacetabular impingement in athletes.

PURPOSE: A systematic review was conducted to identify, assess, and summarize the available evidence pertaining to surgical intervention for femoroacetabular impingement (FAI) in athletes. Summary estimates of treatment effect (proportion with 95% confidence interval [CI]) were calculated specifically for the rate of return to sport. METHODS: Electronic databases (Medline, Embase, and Cochrane Library) were searched from inception to November 2011. The references of included articles were reviewed for eligible studies. The inclusion criteria were clinical studies, studies involving humans, minimum 6 months' follow-up, exclusive FAI treatment, and focus on athletes. Exclusion criteria were review articles, basic science investigations, radiologic studies, arthroplasty, and nonathlete clinical studies. A quality assessment of the included articles was conducted by 2 reviewers using a quality assessment tool developed by Yang et al. We used a random-effects model (DerSimonian-Laird method) to calculate weighted proportions. Percentages with 95% CIs are reported. RESULTS: Nine articles met the inclusion and exclusion criteria in this review. There was 72% agreement (95% CI, 0% to 94%) between the 2 independent reviewers for inclusion and quality assessment of the studies. A total of 418 athletes were surgically treated for FAI and were available for assessment. The rate of return to sport was 92% (95% CI, 87% to 96%), and the rate of return to the previous level of competition was 88% (95% CI, 80% to 94%). CONCLUSIONS: Despite the limitations of our systematic review, the findings suggest that surgical treatment for FAI resulted in a high return to preinjury activity levels of sports. LEVEL OF EVIDENCE: Level IV, systematic review of Level IV studies (case series).