Defining the Percent Thresholds for Achieving the Maximum Outcome Improvement of the Modified Harris Hip Score, the Non-Arthritic Hip Score, the Hip Outcome Score-Sports Subscale, the Visual Analog Scale for Pain, and the International Hip Outcome Tool-12 in Revision Hip Arthroscopy at Minimum 2-Year Follow-Up.

PURPOSE: To determine the respective percent thresholds for achieving the maximal outcome improvement (MOI) for the modified Harris Hip Score (mHHS), the Non-Arthritic Hip Score (NAHS), the Hip Outcome Score-Sports Subscale (HOS-SSS), the visual analog scale (VAS) for pain, and the International Hip Outcome Tool-12 (iHOT-12) that were associated with satisfaction following revision hip arthroscopy, and to identify predictors for achieving the MOI. METHODS: An anchor question was provided to patients who underwent revision hip arthroscopy between April 2017 and July 2020. Patients were included for the final analysis if they answered the anchor question and had minimum 2-year follow-up. Receiver operating characteristic analysis was used to determine the thresholds for the percentage of the MOI predictive of satisfaction. A P-value of < .05 was considered significant. RESULTS: In total, 318 patients underwent revision hip arthroscopy. Of those patients, 292 (91.8%) had minimum 2-year follow-up. Of this cohort, 68 answered the anchor question, with 49 (72.1%) female and 19 (27.9%) male patients. The mean age, and body mass index time were 32.9 ± 13 years and 25.4 ± 5.1, respectively. It was determined that 42.1%, 50%, 48.1%, 50%, and 50% of MOI were the thresholds for maximal predictability of satisfaction for mHHS, NAHS, HOS-SS, VAS for pain, and the iHOT-12, respectively. The presence of unaddressed subspine impingement was a significant predictor for achieving the MOI threshold for the VAS (odds ratio 1.40; 95% confidence interval 1.00-1.95; P = 0.0273). CONCLUSIONS: Following revision hip arthroscopy, the percent thresholds for achieving the MOI at a minimum 2-year follow-up for the mHHS, NAHS, HOS-SS, VAS for pain, and iHOT-12 were 42.1%, 50%, 48.1%, 50%, and 50.9%, respectively. Addressing residual subspine impingement was identified as significant positive predictor for achieving the MOI. LEVEL OF EVIDENCE: Level IV, case-series.

Hip Pain in Adolescent Patients.

Hip pain is a common complaint in adolescents. There are several causes for hip pain in this population, with dysplasia and impingement being the most common; however, other conditions such as extra-articular impingement, torsional disorders, labral tears, and osteochondral lesions also require consideration. Many of these conditions are related to underlying anatomic abnormalities and increased activity in this age group. An understanding of the common pathologies of the adolescent hip is integral to the evaluation, diagnosis, and treatment of these patients.

Novel Method for Detecting the Stage of Arthrosis and Femoroacetabular Impingement Using a Gyroscopic Sensor and Neural Networks.

PURPOSE OF THE STUDY Femoroacetabular impingement syndrome is a complex, often post-traumatically developing impairment of the hip joint, characterized by ambiguous symptomatology, which makes early diagnosis diffi cult, especially in the early stages. Experimental retrospective study was carried out to evaluate the usability of a triaxial gyroscopic sensor in routine practice as an additional indication criterion for operative versus conservative treatment procedures. MATERIAL AND METHODS 92 patients were included in the retrospective study, and 62 completed the investigation. All patients signed informed consent. A gyroscopic sensor was placed on the right side of the pelvis above the hip joint, and the patients walked approximately 15 steps. Furthermore, an evaluation of the data during stair climbing and a complete clinical examination of the dynamics and physiological movements in the joint was carried out. Data measured with a gyroscopic sensor were processed using differential geometry methods and then evaluated using spectral analysis and neural networks. The proposed technique of diagnosing FAI using gyroscope measurement is a fast, easy-to-perform method. RESULTS Our approach in processing gyroscopic signals used to detect the stage of arthrosis and post-traumatically developing FAI could lead to more accurate early detection and capture in the early stages. CONCLUSIONS The obtained data are easily evaluated, interpretable and benefi cial in diagnosing the early stages of FAI. The results of the conducted research showed this approach to more accurate early detection of arthrosis and post-traumatically developing FAI. Key words: wearable sensors; osteoarthritis; mathematical biophysics; telemedicine.

Validation of the French version of the Non-Arthritic Hip Score (NAHS) in 113 hip arthroscopy procedures.

BACKGROUND: The Non-Arthritic Hip Score (NAHS) used to evaluate the hip in younger patients is a self-administered questionnaire with 20 items in four sections: pain, symptoms, function, and activities. Although used in France, no transcultural version had been validated. The objective of this study was to translate the NAHS into French then assess the validity, reliability, and sensitivity to change of the French-language version (NAHS-Fr) in younger patients with hip conditions other than osteoarthritis. HYPOTHESIS: The NAHS-Fr demonstrates good validity and reliability when used in younger French-speaking patients with hip pain. MATERIAL AND METHODS: We conducted a prospective observational study in 105 patients (62 males and 43 females) scheduled for surgery on one or both hips (113 hips in total) to treat cam-type femoro-acetabular impingement or labral lesions. Before and 6 months after surgery, each patient completed the NAHS-Fr and Western Ontario and McMaster Osteoarthritis Index (WOMAC). Statistical tests were done to evaluate validity, reliability, and sensitivity to change, as recommended by the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN). RESULTS: The response rate was 100%, confirming that the NAHS-Fr was easy to use. The NAHS-Fr was both valid and reliable. No ceiling or floor effect was detected for the total NAHS-Fr score. All items had Cronbach alpha coefficients greater than 0.8, indicating good internal consistency. External consistency between the NAHS-Fr and WOMAC was negative (-0.676) due to inversely proportional score indexing. Before surgery, the NAHS-Fr and WOMAC scores were strongly and significantly correlated (p<0.0001). The effect size was greater than 0.8, indicating good sensitivity to the change induced by surgery. DISCUSSION: These results confirm the study hypothesis: the NAHS-Fr has the same good psychometric characteristics as does the original version and versions in other languages. The NAHS-Fr is useful for evaluating younger patients with non-osteoarthritic hip pain and can be used by French-speaking surgeons in everyday clinical practice. LEVEL OF EVIDENCE: IV, prospective observational non-comparative cohort study.

A scoping review: sexual activity and functioning before and after surgery for femoroacetabular impingement (FAI), labral tears, and hip dysplasia.

INTRODUCTION: There is limited information on sexual activity and functioning for patients with hip abnormalities, specifically femoroacetabular impingement (FAI), labral tears, and hip dysplasia, before and after surgical interventions. OBJECTIVES: The aim of this review was to synthesize the existing literature on sexual activity and functioning for patients with FAI, labral tears, and/or hip dysplasia before and after their respective surgeries. METHODS: We performed a rigorous, comprehensive search on multiple databases including PubMed, EMBASE, CINAHL, and Web of Science. Subject headings and a search string of key terms including Medical Subject Headings were used systematically to search these databases. The reference list was reviewed with an additional reviewer to reduce bias. RESULTS: A total of 726 articles were found during the search, which were narrowed down to 22 articles that included at least 1 hip abnormality in relation to sexual functioning, sexual pain, or sexual activity. FAI, labral tears, and hip dysplasia can affect sexual activity, functioning, and positioning, and corrective surgery generally improves these metrics. Surgery improved vulvodynia, clitorodynia, and scrotal pain symptoms for some patients, though arthroscopy resulted in some instances of temporary pudendal nerve dysfunction. CONCLUSION: This review may serve as an important resource for surgeons, healthcare providers, researchers, physical therapists, and patients to understand the relationship between the hips and sexual functioning, and to bridge the gaps among the disciplines of orthopedics, pelvic floor physiology, and sexual health. Hip anatomy impacts sexual activity, functioning, and positioning as well as vulvodynia and scrotal pain symptoms for some patients, and a comprehensive hip evaluation by a qualified hip specialist should be considered for patients with such complaints.

Smartphone Technology to Remotely Measure Postural Sway during Double- and Single-Leg Squats in Adults with Femoroacetabular Impingement and Those with No Hip Pain.

BACKGROUND: The COVID-19 pandemic has accelerated the demand for utilising telehealth as a major mode of healthcare delivery, with increasing interest in the use of tele-platforms for remote patient assessment. In this context, the use of smartphone technology to measure squat performance in people with and without femoroacetabular impingement (FAI) syndrome has not been reported yet. We developed a novel smartphone application, the TelePhysio app, which allows the clinician to remotely connect to the patient's device and measure their squat performance in real time using the smartphone inertial sensors. The aim of this study was to investigate the association and test-retest reliability of the TelePhysio app in measuring postural sway performance during a double-leg (DLS) and single-leg (SLS) squat task. In addition, the study investigated the ability of TelePhysio to detect differences in DLS and SLS performance between people with FAI and without hip pain. METHODS: A total of 30 healthy (nfemales = 12) young adults and 10 adults (nfemales = 2) with diagnosed FAI syndrome participated in the study. Healthy participants performed DLS and SLS on force plates in our laboratory, and remotely in their homes using the TelePhysio smartphone application. Sway measurements were compared using the centre of pressure (CoP) and smartphone inertial sensor data. A total of 10 participants with FAI (nfemales = 2) performed the squat assessments remotely. Four sway measurements in each axis (x, y, and z) were computed from the TelePhysio inertial sensors: (1) average acceleration magnitude from the mean (aam), (2) root-mean-square acceleration (rms), (3) range acceleration (r), and (4) approximate entropy (apen), with lower values indicating that the movement is more regular, repetitive, and predictable. Differences in TelePhysio squat sway data were compared between DLS and SLS, and between healthy and FAI adults, using analysis of variance with significance set at 0.05. RESULTS: The TelePhysio aam measurements on the x- and y-axes had significant large correlations with the CoP measurements (r = 0.56 and r = 0.71, respectively). The TelePhysio aam measurements demonstrated moderate to substantial between-session reliability values of 0.73 (95% CI 0.62-0.81), 0.85 (95% CI 0.79-0.91), and 0.73 (95% CI 0.62-0.82) for aamx, aamy, and aamz, respectively. The DLS of the FAI participants showed significantly lower aam and apen values in the medio-lateral direction compared to the healthy DLS, healthy SLS, and FAI SLS groups (aam = 0.13, 0.19, 0.29, and 0.29, respectively; and apen = 0.33, 0.45, 0.52, and 0.48, respectively). In the anterior-posterior direction, healthy DLS showed significantly greater aam values compared to the healthy SLS, FAI DLS, and FAI SLS groups (1.26, 0.61, 0.68, and 0.35, respectively). CONCLUSIONS: The TelePhysio app is a valid and reliable method of measuring postural control during DLS and SLS tasks. The application is capable of distinguishing performance levels between DLS and SLS tasks, and between healthy and FAI young adults. The DLS task is sufficient to distinguish the level of performance between healthy and FAI adults. This study validates the use of smartphone technology as a tele-assessment clinical tool for remote squat assessment.

Patients aged 50-75 years take longer to achieve the patient acceptable symptom state than patients aged 20-34 years following primary hip arthroscopy for femoroacetabular impingement syndrome.

PURPOSE: Though an increasing number of adults older than 50 years are undergoing hip arthroscopy for treatment of Femoroacetabular Impingement Syndrome (FAIS), it is unclear how their timeline for functional outcome improvement compares to that of younger patients. The purpose of this study was to assess the impact of age on time to achieving the Minimum Clinically Important Difference (MCID), Substantial Clinical Benefit (SCB), and Patient Acceptable Symptom State (PASS) following primary hip arthroscopy for FAIS. METHODS: A retrospective comparative single-surgeon cohort study of primary hip arthroscopy patients with minimum 2-year follow-up was conducted. Age categories were 20-34 years, 35-49 years, and 50-75 years. All subjects completed the modified Harris Hip Score (mHHS) prior to surgery and at 6-month, 1-year, and 2-year follow-up. MCID and SCB cutoffs were defined as pre-to-postoperative increases in mHHS by ≥ 8.2 and ≥ 19.8, respectively. PASS cutoff was set at postoperative mHHS ≥ 74. Time to achievement of each milestone was compared using interval-censored survival analysis. The effect of age was adjusted for Body Mass Index (BMI), sex, and labral repair technique using an interval-censored proportional hazards model. RESULTS: Two hundred eighty-five patients were included in the analysis with 115 (40.4%) aged 20-34 years, 92 (32.3%) aged 35-49 years, and 78 (27.4%) aged 50-75 years. There were no significant differences between groups in time to achievement for the MCID (n.s.) or SCB (n.s.). However, patients in the oldest group had significantly longer time to PASS than those in the youngest group, both in the unadjusted analysis (p = 0.02) and after adjusting for BMI, sex, and labral repair technique (HR 0.68, 95% CI 0.48-0.96, p = 0.03). CONCLUSION: Achievement of the PASS, but not the MCID or SCB, is delayed among FAIS patients aged 50-75 years who undergo primary hip arthroscopy compared to those aged 20-34 years. Older FAIS patients should be counseled appropriately about their longer timeline to achieving hip function comparable to their younger counterparts. LEVEL OF EVIDENCE: III.

Ten-Year Survivorship, Outcomes, and Sports Participation in Athletes After Primary Hip Arthroscopy for Femoroacetabular Impingement Syndrome.

BACKGROUND: Hip arthroscopy is an effective treatment tool for athletes with femoroacetabular impingement (FAI) syndrome. However, long-term data are scarce. PURPOSE: To assess survivorship, minimum 10-year patient-reported outcome measures (PROMs), and sports participation after primary hip arthroscopy for FAI syndrome in athletes and to perform a propensity-matched comparison between patients undergoing labral debridement and labral repair. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Athletes who underwent hip arthroscopy for FAI syndrome between February 2008 and December 2010 were eligible. Exclusion criteria were other ipsilateral hip condition, Tönnis grade ≥2, or no baseline PROMs. Survivorship was defined as no conversion to total hip arthroplasty. The Patient Acceptable Symptom State (PASS), minimal clinically important difference (MCID), maximum outcome improvement (MOI) satisfaction threshold, and sports participation were reported. A propensity-matched comparison between labral debridement and labral repair was performed. Two additional propensity-matched subanalyses were performed for capsular management and cartilage damage. RESULTS: In total, 189 hips (177 patients) were included. The mean ± SD follow-up was 127.2 ± 6.0 months. Survivorship was 85.7%. Significant improvement in all PROMs was reported (P < .001). A total of 46 athletes with labral repair were propensity matched to 46 athletes with labral debridement. This subanalysis demonstrated significant and comparable improvement in all PROMs at minimum 10-year follow-up (P < .001). For the labral repair group, the PASS achievement rates were 88.9% for the modified Harris Hip Score (mHHS) and 80% for the Hip Outcome Score-Sport Specific Subscale (HOS-SSS); the MCID achievement rates were 80.6% for the mHHS and 84% for HOS-SSS; and for the MOI satisfaction threshold, rates were 77.8%, 80.6%, and 55.6% for the mHHS, Nonarthritic Hip Score, and visual analog scale, respectively. For the labral debridement group, the PASS achievement rates were 85.3% for the mHHS and 70.4% for the HOS-SSS; the MCID achievement rates were 81.8% for the mHHS and 74.1% for HOS-SSS; and for the MOI satisfaction threshold, rates were 72.7%, 81.8%, and 66.7% for the mHHS, Nonarthritic Hip Score, and visual analog scale. Total hip arthroplasty conversions occurred significantly sooner with labral debridement than labral repair (P = .048). Age was identified as a significant predictor of achieving the PASS. CONCLUSION: Primary hip arthroscopy for FAI syndrome in athletes results in 85.7% survivorship and sustained PROM improvement at a minimum 10-year follow-up. A significant time delay to total hip arthroplasty conversion at 10-year follow-up was reported with labral repair over debridement, although this should be interpreted with caution, as the total number of conversions was small.

Single-Leg Squat Test in the Clinical Setting Does Not Discriminate Patients With Femoroacetabular Impingement Syndrome From Asymptomatic Individuals.

CONTEXT: Laboratorial 3-dimensional kinematic analyses have shown changes in the single-leg squat's (SLS) pattern of patients with femoroacetabular impingement syndrome (FAIS). However, it is unknown whether clinicians are able to detect these changes using 2-dimensional kinematics. OBJECTIVE: To compare the frontal plane 2-dimensional kinematics of patients with FAIS and asymptomatic individuals in the SLS test performed in a clinical setting. DESIGN: Case-control study. SETTING: Physical therapy clinic. PARTICIPANTS: Twenty men with bilateral FAIS and 20 asymptomatic men. MAIN OUTCOME MEASURES: Two-dimensional kinematic analysis was collected in the frontal plane during the execution of the SLS test. The outcomes were squat depth, pelvic drop (pelvis angle relative to the horizontal plane), hip adduction (femur angle relative to the pelvis), and knee valgus (femur angle relative to the tibia). RESULTS: Most and least painful limbs of patients with FAIS had squat depth (9.8% [2.9%] and 9.5% [3.1%] of height), pelvic drop (4.2° [3.9°] and 3.7° [4.2°]), hip adduction (74.9° [5.8°] and 75.9° [5.7°]), and knee valgus (4.0° [11.0°] and 5.0° [9.9°]) similar to asymptomatic individuals (9.0% [2.3%], 4.8° [2.6°], 73.7° [4.9°], and -1.7° [8.5°]; P > .05 for all). CONCLUSION: The frontal plane 2-dimensional kinematic analysis of the SLS test in the clinical setting is not able to distinguish patients with FAIS from asymptomatic individuals.

Moderators, Mediators, and Prognostic Indicators of Treatment With Hip Arthroscopy or Physical Therapy for Femoroacetabular Impingement Syndrome: Secondary Analyses From the Australian FASHIoN Trial.

BACKGROUND: Although randomized controlled trials comparing hip arthroscopy with physical therapy for the treatment of femoroacetabular impingement (FAI) syndrome have emerged, no studies have investigated potential moderators or mediators of change in hip-related quality of life. PURPOSE: To explore potential moderators, mediators, and prognostic indicators of the effect of hip arthroscopy and physical therapy on change in 33-item international Hip Outcome Tool (iHOT-33) score for FAI syndrome. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Overall, 99 participants were recruited from the clinics of orthopaedic surgeons and randomly allocated to treatment with hip arthroscopy or physical therapy. Change in iHOT-33 score from baseline to 12 months was the dependent outcome for analyses of moderators, mediators, and prognostic indicators. Variables investigated as potential moderators/prognostic indicators were demographic variables, symptom duration, alpha angle, lateral center-edge angle (LCEA), Hip Osteoarthritis MRI Scoring System (HOAMS) for selected magnetic resonance imaging (MRI) features, and delayed gadolinium-enhanced MRI of cartilage (dGEMRIC) score. Potential mediators investigated were change in chosen bony morphology measures, HOAMS, and dGEMRIC score from baseline to 12 months. For hip arthroscopy, intraoperative procedures performed (femoral ostectomy ± acetabular ostectomy ± labral repair ± ligamentum teres debridement) and quality of surgery graded by a blinded surgical review panel were investigated for potential association with iHOT-33 change. For physical therapy, fidelity to the physical therapy program was investigated for potential association with iHOT-33 change. RESULTS: A total of 81 participants were included in the final moderator/prognostic indicator analysis and 85 participants in the final mediator analysis after exclusion of those with missing data. No significant moderators or mediators of change in iHOT-33 score from baseline to 12 months were identified. Patients with smaller baseline LCEA (ß = -0.82; P = .034), access to private health care (ß = 12.91; P = .013), and worse baseline iHOT-33 score (ß = -0.48; P < .001) had greater iHOT-33 improvement from baseline to 12 months, irrespective of treatment allocation, and thus were prognostic indicators of treatment response. Unsatisfactory treatment fidelity was associated with worse treatment response (ß = -24.27; P = .013) for physical therapy. The quality of surgery and procedures performed were not associated with iHOT-33 change for hip arthroscopy (P = .460-.665 and P = .096-.824, respectively). CONCLUSION: No moderators or mediators of change in hip-related quality of life were identified for treatment of FAI syndrome with hip arthroscopy or physical therapy in these exploratory analyses. Patients who accessed the Australian private health care system, had smaller LCEAs, and had worse baseline iHOT-33 scores, experienced greater iHOT-33 improvement, irrespective of treatment allocation.

Groin pain of neurological origin as a differential diagnosis of femoroacetabular impingement.

BACKGROUND: To describe the experience in the diagnostic process and treatment of patients with groin pain (GP) of neurological origin due to entrapment of the iliohypogastric (IH), ilioinguinal (IL) and genitofemoral (GF) nerves in a hip preservation clinic. METHODS: Retrospective study of patients with GP of neurological origin confirmed with ultrasound-guided nerve block. Clinical outcomes were reported in 21 cases (age, 53.3 ± 15.9 years) treated with conservative treatment from January to December 2019, and in 9 patients (age 43.7 ± 14.6 years) who underwent neurectomy from January 2015 to December 2019. Pain intensity was assessed with a numerical rating scale (NRS) before starting the diagnostic process (Day 0) and at the end of follow-up. RESULTS: All cases reported pain on groin palpation. Half of these cases also reported a positive FADIR test (flexion, adduction, internal rotation) (15/30). On day 0, the intensity of pain in cases treated with conservative treatment was severe in 19 patients (NRS 7-10) and moderate in 2 (NRS 4-6), with a median improvement of 7 points (interquartile range [IQR] 5.5-8.0) at the end of follow-up (p < 0.001). In neurectomy group, a similar improvement in pain severity was (Day 0: 9 points [IQR 8.0-9.0]; end of follow-up: 0 points [IQR: 0-2.0]; p = 0.002). At the end of the study, 17/21 patients with conservative treatment and 7/9 with neurectomy were pain free or with mild pain (NRS < 3). CONCLUSIONS: In cases with PG of neurological origin, there is a high frequency of false positives in the FADIR test. Our findings suggest that neurectomy is a treatment option for patients in whom conservative treatment fails, providing significant pain relief.

The diagnosis of hip microinstability is correlated with ease of intra-operative hip distraction.

PURPOSE: Hip microinstability has emerged as a contributor to young adult, non-arthritic hip pain. There is a paucity of objective clinical data to identify patients with hip microinstability and guide surgical treatment. The purpose of this study was to identify the degree of distractibility in patients with and without microinstability undergoing hip arthroscopy. METHODS: A single-surgeon series of hip arthroscopies were retrospectively reviewed from 2014-2020. All procedures were performed with paralysis on a fracture table with a perineal post where 1 turn of fine traction equates to 4 mm of axial traction. Diagnosis was recorded as isolated instability, instability plus femoroacetabular impingement (FAI), and isolated FAI. Operative reports were reviewed to collect patient demographic data, number of turns of traction required for adequate distraction of the femoral head relative to the acetabulum (10 mm), and the presence of residual subluxation after initial traction was released. RESULTS: A total of 464 patients were identified, 26 (5.6%) with isolated microinstability, 183 (39.4%) with microinstability with FAI anatomy, and 255 (55.0%) with FAI. The concurrent diagnosis of microinstability was associated with decreased turns required to adequately distract the hip. Isolated microinstability patients required 6.9 turns (IQR 4.6-8.8) while those with instability plus FAI required 8.8 turns (IQR 6.5-11) and isolated FAI required 19.1 turns (IQR 15-22). Residual subluxation after removal of negative intra-articular pressure but before performing the hip arthroscopy was more commonly associated with instability, occurring in 84.6% of isolated instability and 86.9% of instability plus FAI as compared with 29.8% in the isolated FAI cohort. CONCLUSION: A diagnosis of hip microinstability, with or without features of FAI, is associated with decreased axial traction required to distract the hip. These data support the use of intra-operative ease of distraction as a method of identifying patients with hip microinstability. LEVEL OF EVIDENCE: Level III.

A scoping review of postoperative return to sport criteria and protocols for patients with femoroacetabular impingement syndrome.

PURPOSE: To identify the objective criteria and guidelines utilized to determine if patients diagnosed with FAIS can safely return to sport following hip arthroscopy. METHODS: The electronic databases MEDLINE Ovid, EMBASE Ovid, and CINAHL were searched to identify eligible studies. Details of study design, sample size, primary diagnosis, and return to sport protocol, duration, and rate were collected by two reviewers, independently. RESULTS: Sixty-two studies were selected for full text review of which 14 were included in the final analysis. Of these, nine were clinical commentaries and five were retrospective cohort studies. Three types of rehabilitation guidelines are currently utilized postoperatively: 4-phase, 5-phase, and 6-phase protocols. Although all 14 studies recommend using various types of outcome measures to evaluate a patient's ability to return to sport, only eleven outlined the specific outcome criteria they must achieve to do so. The most utilized outcome measures are the hip outcome score, active and passive range of motion tests, gait analysis, single- and double-leg squat tests, and the Vail hip sports test. Criteria across all three types of protocols was variable, but they all evaluated the same international classification of disability and function constructs described by the World Health Organization: body function, body structure limitations, and activity capacity limitations. CONCLUSIONS: There is no consensus on the optimal methods of evaluating a patient's readiness to return to sport after undergoing hip arthroscopy, with most criteria focused on expert opinion. Performance-based return to sport outcome criteria is not clearly defined, and validated outcome measures are not being used for FAIS patients post hip arthroscopy. Lastly, well-conducted prospective cohort studies using validated outcome measures and objective definitions of return to sport are needed to consistently identify signs that are prognostic of safe return to sport.

Editorial Commentary: The Pelvis is the Lowest Vertebral Level: Diagnostic Approach to Hip-Spine Syndrome.

The human pelvis represents a wonderful example of apparent idealistic simplicity overwhelmed by realistic complexity. Traditionally, the pelvis has been termed a "ring" linking the lower extremity to the spine via the sacroiliac joint. In essence, the pelvis is the lowest vertebral level-"the hip bone's connected to the spine bone." Thus, the law of parsimony seemingly applies in the diagnosis and management of both arthritic and nonarthritic hip and spine disorders in isolation or combination. However, an inverse Occam's razor is much more likely. The layered theory of hip disorders illustrates how a base osteochondral layer (femoroacetabular impingement syndrome, ischiofemoral impingement from either the lesser trochanter or greater trochanter, arthritis), a static inert soft-tissue layer (labrum, capsule, ligament), a dynamic soft-tissue layer (muscle, tendon), and a neurokinetic chain layer all interact and can lead to hundreds, if not thousands, of different combinations of primary and secondary symptom sources. Although correlation does not equal causation, intuitively and overly simplistically, a stiff painful hip can transfer stress across the pelvic ring to the spine, causing back pain. Alternatively, 2 separate symptom sources could be present at the same time. Biomechanical stress transfer can occur from flexion-based (e.g., femoroacetabular impingement syndrome) or extension-based (e.g., ischiofemoral impingement) problems. The diagnosis of hip-spine syndrome in patients becomes really complicated usually really fast, encompassing the hip joint, peritrochanteric space, deep gluteal space, pelvis and pelvic floor, sacroiliac joint, and lumbosacral spine-and don't forget mental health and the mind controls the musculotendinous system in these challenging, often frustrated, patients. Static imaging findings necessitate dynamic symptom correlation, especially via pertinent values including pelvic incidence; pelvic tilt; sacral slope; lumbar lordosis; femoral and acetabular version; cam, pincer, and dysplastic morphologies; and leg length. Judicious diagnostic injections can greatly assist in clinical symptom interpretation. Successful treatment requires consideration and management of the primary etiology and pertinent secondary downstream effects. When a patient's hip hurts, one should always look at the patient's back; when a patient's back hurts, one should always look at the patient's hip.

Correlation between Intensity of Pain and Disability Due to Intra-articular Lesions in Patients with Femoroacetabular Impingement Syndrome / Correlação entre intensidade da dor e incapacidade com as lesões intra-articulares em pacientes com síndrome do impacto femoroacetabular

Abstract Objective To correlate radiographic alterations and lesions in intra-articular structures of the acetabulum with the intensity of pain and disability of patients diagnosed with femoroacetabular impingement syndrome. Methods A retrospective analysis of the preoperative data of 182 patients (190 hips) was performed. Clinical variables such as age, gender, the practice of physical activity, and radiographic variables, such as the Wiberg and alpha angles, were evaluated. Through an intraoperative video, the extent of the chondral and labial lesions was evaluated considering the clock-face method, the degree of joint involvement by the Outerbridge classification, and the presence of wave lesions. The variables were analyzed by linear regression, with the intensity of the pain assessed by the Visual Analog Scale (VAS), and functional disability measured by the Modified Harris Hip Score (mHHS). Results The mean age of the patients was of 38.5 ± 9.6 years, the mean intensity of the pain was of 7.8 ± 1.6, and the mean mHHS score was of 56.3 ± 12.7. In total, 61% of the sample were classified as Outerbridge III or IV, and 12.6% had wave lesions. There was a correlation between the male gender (r = 0.497) and lower intensity of the pain, and a correlation of age (r = -0.27), the male gender (r = 8.419) and physical activity with higher functional scores on the mHHS (r = 4.729). Conclusion There was no correlation of the radiographic and arthroscopic parameters of the present study and the intensity of pain and the disability of the patients. The male gender is related to lower intensity of pain, and higher functional ability is related to the male gender, lower age, and the practice of physical activity. Level of Evidence IV.

Resumo Objetivo Correlacionar alterações radiográficas e lesões de estruturas intra-articulares do acetábulo com a intensidade da dor e a incapacidade de pacientes com diagnóstico de síndrome do impacto femoroacetabular. Métodos Realiou-se uma análise retrospectiva de dados pré-operatórios de 182 pacientes (190 quadris). Foram avaliadas variáveis clínicas como idade, sexo e prática de atividade física, e variáveis radiográficas, como ângulo de Wiberg e o ângulo alfa. Por meio do vídeo intraoperatório, foi avaliada a extensão das lesões condrais e labiais considerando-se o método clock-face, o grau de comprometimento articular pela classificação de Outerbridge, e a presença de lesão em onda. As variáveis foram analisadas por meio de regressão linear, tendo como variáveis dependentes a intensidade da dor, avaliada pela Escala Visual Analógica (EVA), e a incapacidade funcional, mensurada pelo Harris Hip Score modificado (HHSm). Resultados A média de idade dos pacientes foi de 38,5 ± 9,6 anos, a da intensidade da dor, 7,8 ± 1,6, e a do HHSm, 56,3 ± 12,7. No total, 61% da amostra apresentava Outerbridge III ou IV, e 12,6% apresentava lesão em onda. Observou-se correlação do sexo masculino (r = 0,497) com menor intensidade da dor, e correlação da idade (r = −0,27), do sexo masculino (r = 8,419) e da realização de atividade física com maior escore funcional no HHSm (r = 4,729). Conclusão Não houve correlação dos parâmetros radiográficos e artroscópicos deste estudo com a intensidade da dor e a incapacidade dos pacientes. O sexo masculino está relacionado com menor intensidade da dor, e maior capacidade funcional está relacionada com o sexo masculino, menor idade, e a prática de atividade física. Nível de Evidência IV.

Editorial Commentary: Successful Revision Hip Arthroscopy Requires Accurate Diagnosis of the Cause of Failure: "One-Size-Fits-All Surgery Is Not Appropriate".

As hip arthroscopy increases in scope and quantity, treatment options for patients who did not respond to primary surgery expand as well. As our techniques improve and become more nuanced, it is crucial that our understanding of individual patients' root cause pathology keeps pace to ensure that the right patients get the right surgery.

[Persistent or recurrent symptoms after surgery for femoroacetabular impingement syndrome (FAIS) : Pathology, diagnostics and therapy]. / Persistierende oder wiederkehrende Beschwerden nach femoroazetabulärer Impingement-Chirurgie : Ursachen, Diagnostik und Therapie.

BACKGROUND: Femoroacetabular impingement syndrome (FAIS) has gained vast importance in the last two decades. Multiple studies have shown that if untreated, early osteoarthritis of the hip joint may result. Hip arthroscopy is one of the fastest growing procedures in the orthopedic cosmos, having already replaced the majority of (mini) open techniques in FAIS surgery. However, with the recent remarkable increase in the volume of hip arthroscopies performed worldwide, the number of patients with persistent or recurrent symptoms after FAIS surgery is also growing. PATHOLOGY: Potential underlying pathologies are misresection of the bony deformity, insufficiency fracture of the femoral head neck junction or the femoral subchondral head itself (SIFFH), adhesions, failed chondrolabral or capsular treatment, septic arthritis, heterotopic ossification or a wrong indication in the case of osteoarthritis that is already too advanced. Most of these occur more often during the extensive learning curve for hip arthroscopy. DIAGNOSTICS: High-quality imaging plays a key role in determining the need for revision surgery vs. further conservative treatment. Therapeutical avenues are shown with the common goal of proper detection and correction of the underlying pathology to address unsatisfactory FAIS treatment outcomes and ensure long-term survival of the native hip joint.

Validation of the Brazilian version of the Hip Sports Activity Scale (HSAS) for patients with femoroacetabular impingement: a cross-sectional study.

BACKGROUND: The Hip Sports Activity Scale (HSAS) is a hip-specific instrument for assessing the present levels of physical activity among patients with femoroacetabular impingement (FAI) syndrome. When evaluating treatment outcomes in patients with FAI syndrome, it is necessary to use joint-specific instruments and ones that can evaluate the levels of physical activity in these patients, such as the HSAS-Brazil. OBJECTIVE: To validate the HSAS-Brazil among a group of physically active patients after arthroscopic treatment of FAI syndrome. DESIGN AND SETTING: Cross-sectional research of quantitative and qualitative types using data obtained from July 2018 to October 2019. METHODS: A total of 58 patients of both genders diagnosed with FAI syndrome and who had undergone hip arthroscopy participated in this research. To establish reliability and validity, patients first answered the Brazilian versions of the 12-Item Short-Form Health Survey (SF-12), Nonarthritic Hip Score (NAHS), and HSAS; after a 48-hour interval, they answered the HSAS-Brazil again. RESULTS: For test-retest reliability, the interclass correlation was 0.908 (P < 0.001). The HSAS-Brazil correlated to the NAHS-Brazil (r = 0.63, P < 0.001), as well as the SF-12 (Physical Health) (r = 0.42, P = 0.001). CONCLUSION: The HSAS-Brazil was validated and proved to be a reliable and valid scale to assess sports activity levels in physically active patients with FAI syndrome after arthroscopic treatment.

Short-term Results and Return to Duty Following Hip Arthroscopy in Soldiers.

BACKGROUND: Over the past several years there has been a marked increase in the number of Israel Defense Forces (IDF) soldiers having hip arthroscopy based on magnetic resonance arthrography diagnosis of hip labral tears and/or impingement. OBJECTIVES: To detail characteristics of soldiers who underwent hip arthroscopy and assess outcomes and rate of return to duty. METHODS: A retrospective chart review was conducted of all soldiers who underwent hip arthroscopy 2018 to 2020, and soldiers referred for hip arthroscopy during 2021. Demographic, medical, and military service data were collected from the computerized patient record. RESULTS: Our study comprised 117 soldiers (29% combatants, 24% females) who underwent hip arthroscopy, mean age 22 ± 3 years, range 18-42; 45% had physiotherapy before surgery; 31% were diagnosed during or within 3 months of having back pain and 20% had been referred for psychological assistance (not related to the hip pain); 15.4% had serious adverse events. The mean time to return to any duty (including clerical work) was 8.0 ± 0.6 months; 56% of the soldiers never returned to service and were discharged from the military. During the one-year follow-up, only 6% returned to their full pre-symptom activity. CONCLUSIONS: The short-term results of IDF soldiers who underwent hip arthroscopy during the study period were much inferior to those reported among athletes. The lack of specificity of the diagnostic tools (history, examination, and imaging) used to determine whether surgery for hip pain is likely to be beneficial in this population may be contributing to over-diagnosis and over-treatment.