Surgical indications for treatment for femoroacetabular impingement with surgical hip dislocation

Purpose

There is a lack of detailed information about the indications of surgical treatment for femoroacetabular impingement (FAI), particularly using open surgical dislocation. The purpose of this review was to systematically review the reported indications for surgical dislocation of the hip for FAI.

Methods

Two databases (MEDLINE and EMBASE) were screened for clinical studies involving the treatment for FAI with surgical hip dislocation. We conducted a full-text review and the references for each included paper were hand-searched for other eligible studies. Papers published until September 2011 were included in this review. Two individuals reviewed all identified studies independently, and any disagreement was resolved through consensus.

Results

Fifteen studies met the eligibility criteria, which included a total of 822 patients. We identified a lack of consensus for clinical and radiographic indications for surgical hip dislocation to treat FAI. The most common clinical indications reported were clinical symptoms such as hip pain in 10 papers (67 %), a positive impingement sign in 9 papers (60 %), painful/reduced range of motion in 9 papers (60 %), activity-related groin pain in 4 papers (27 %), and non-responsive to non-operative treatment in 4 papers (27 %). The most commonly reported radiographic indicators for surgical hip dislocation were a variety of impingement findings from radiographs in all 15 included papers (100 %), a combination of radiographs and MRA in 5 papers (33 %) or radiographs and MRI in 3 papers (20 %).

Conclusions

These results showed that that there was an inconsistency between the clinical and radiographic indications for surgical hip dislocation as a treatment for femoroacetabular impingement. This review suggests that there is a need for the development of standardized clinical and radiological criteria that serve as guidelines for surgical treatment for FAI.

Level of evidence

Systematic review, Level IV.     

Pre-operative intra-articular hip injection as a predictor of short-term outcome following arthroscopic management of femoroacetabular impingement

Purpose

Diagnostic hip injections are often used to confirm intra-articular pathology prior to arthroscopic treatment for femoroacetabular impingement (FAI). However, little is known whether the type of response correlates with the post-operative functional outcomes. The purpose of this study is to document the ability of a diagnostic hip injection to predict short-term functional outcomes following arthroscopic surgical management.

Methods

A prospective cohort of 52 patients diagnosed with FAI who had an intra-articular hip injection prior to arthroscopic surgery was evaluated. A pain diary was used during the 2 weeks after hip injection to document response. In addition, the modified Harris Hip Score (mHHS) was administered preoperatively and 6 months post-operatively to assess functional outcomes. The relationship between response to an intra-articular hip injection and mHHS scores 6 months after FAI surgery was evaluated.

Results

Overall, 42 of 52 (81 %) patients diagnosed with FAI achieved pain relief from the hip injection. Outcomes according to mHHS scores improved significantly at the 6-month follow-up visit (19 points, 95 % CI 15–24, p = 0.001). The therapeutic utility of the hip injection suggested that lack of pain relief predicted a lack of functional improvement following arthroscopic surgery.

Conclusion

In this study, the data suggests that a positive response from an intra-articular hip injection is not a strong predictor of short-term functional outcomes following arthroscopic management of FAI. However, a negative response from an intra-articular hip injection may predict a higher likelihood of having a negative result from surgery.

Level of evidence

Level II.     

A painful squat test provides limited diagnostic utility in CAM-type femoroacetabular impingement

Purpose

The purpose of this study is to determine the relationship between a symptomatic maximal squat and the presence of radiographic CAM-type femoroacetabular impingement (FAI) on magnetic resonance imaging (MRI) and to determine the sensitivity and specificity of a maximal squat test for the presence of radiographic CAM-type femoral deformity in an adult population.

Methods

In this pilot study, 76 consecutive patients were recruited from an outpatient clinic at McMaster University. All patients presented with pre-arthritic hip pain and were asked to perform a maximal squat. The results of this test were compared to magnetic resonance imaging and magnetic resonance angiographic (MRI and MRA) findings evaluating and characterizing CAM-type FAI deformity.

Results

The sensitivity and specificity of the maximal squat test were 75 % (56.6–88.5 %) and 41 % (27.0–56.8 %), respectively, for CAM-type FAI deformity. The positive and negative likelihood ratios were modest at 1.3 (0.9–1.7) and 0.6 (0.3–1.2), respectively. This means that a 30 % pre-test probability is improved to 36 % following a positive squat test and reduced to 20 % with a negative squat test.

Conclusion

The maximal squat test was found to have marginal incremental diagnostic ability for CAM-type FAI. Its utility in the diagnostic evaluation of FAI remains limited. This survey elucidates areas of research for future studies relevant to the clinical diagnosis of FAI.

Level of evidence

III.     

Complications in hip arthroscopy: necessity of supervision during the learning curve

Purpose

The aim of this study was to determine whether the learning curve of arthroscopic treatment of femoroacetabular impingement (FAI) could be verified by analyzing the complication rate of this procedure. Additionally, it was investigated whether supervision by an experienced surgeon leads to a steeper learning curve (lower number of complications) when starting to perform arthroscopic FAI treatment.

Methods

The complications occurring in 317 consecutive patients treated with the sole diagnosis of FAI were analyzed. 256 patients (collective A) were treated by surgeon A between June 2005 and January 2010. Sixty-one patients (collective B) were treated by surgeon B between August 2008 and December 2009. From January to June 2008, surgeon B performed many hip arthroscopies under supervision of surgeon A. Complications were recorded in a central complication register. Statistic analysis of the complication rates was performed using Fischer’s exact T test.

Results

Subdividing collective A chronologically into thirds a significant decline of complications (p = 0.0044) was found with growing experience of the surgeon. Comparing the first 61 patients of both surgeons a significantly lower complication rate was discovered in the patients of surgeon B (p = 0.0375). In total there were 21 complications (6.6 %; CI 4.4–9.9 %). The observed complication rate was 7.0 % in collective A and 4.9 % in collective B.

Conclusion

The learning curve can be comprehended by the distribution of complications in collective A. Having spent 6 months performing under supervision of surgeon A, surgeon B has a lower complication rate than surgeon A when comparing the first 61 patients each surgeon operated on. This implies that surgeon B benefits from the experience of surgeon A. According to this analysis, beginners in arthroscopic FAI treatment should be taught at a specialized centre to reduce the number of complications.

Level of evidence

III.     

Management of knee injuries: consensus-based indications from a large community of orthopaedic surgeons

Purpose

To describe preferences and to quantify the amount of agreement among orthopaedic surgeons regarding treatment options for four clinical scenarios of knee pathologies.

Methods

A web-based survey was developed to investigate the attitudes of members of an international association of surgeons specialised in sports traumatology and knee surgery European Society of Sports Traumatology, Knee Surgery and Arthroscopy.

Results

The response rate was 40 % (412 questionnaires). An inter-rater agreement score (the Normalised Chi-square based Agreement Nomogram, NX2A) was calculated for each question. For scenario 1, 56-year-old male, degenerative medial compartment on both the femoral and tibial side, the surgical approach was preferred to the conservative approach (p < 0.001). Biological procedures were not considered appropriate, and in this respect, the respondents achieved a moderate degree of agreement (NX2A = 0.68). For scenario 2, 35-year-old male, early knee medial arthritis, the surgical treatment was preferred to conservative treatment (p < 0.001). The traditional closed-wedge tibial osteotomy was not regarded as an appropriate treatment with an excellent degree of agreement among surgeons (NX2A = 0.76). For scenario 3, 46-year-old male, ACL lesion, there was an almost disagreement, as respondents showed no preference between a surgical and conservative approach (NX2A = 0.005). Among surgical treatments, an almost perfect agreement with regard to the appropriateness of arthroscopic single-bundle ACL reconstruction with a semitendinosus/gracilis graft was reached by the surgeons (NX2A = 0.8). For scenario 4, 69-year-old male, diffuse knee arthritis (all the compartments), an almost perfect agreement in favour of a total knee prosthesis was obtained for the management of this scenario (NX2A = 0.85).

Conclusions

Web-based survey can help orthopaedic surgeons discuss and propose indications for clinical practice in the management of some of the most common joint diseases.

Level of evidence

Cross-sectional survey, Level V.     

Radiographic prevalence of CAM-type femoroacetabular impingement after open reduction and internal fixation of femoral neck fractures

Purpose

The purpose of this study was to estimate the radiographic prevalence of CAM-type femoroacetabular impingement (FAI) in elderly patients (≥50 years) who have undergone internal fixation for femoral neck fracture.

Methods

A total of 187 frog-leg lateral radiographs of elderly patients who underwent internal fixation for a femoral neck fracture were reviewed by two independent reviewers. The alpha angle, beta angle, and femoral head–neck offset ratio were calculated. The presence of two abnormal radiographic parameters was deemed to be diagnostic of radiographic CAM-type impingement.

Results

Radiographic CAM-type FAI was identified in 157 out of 187 (84 %) patients who underwent internal fixation for fractures of the femoral neck. Moderate-to-good inter-observer reliability was achieved in the measurement of radiographic parameters. With reference to fracture subtypes and prevalence of radiographic features of CAM-type morphology, 97 (72 %) out of 134 patients were positive for CAM in Garden subtypes I and II, whereas 49 (85.9 %) out of 57 patients had radiographic CAM in Garden III and IV subtypes.

Conclusion

There was a high prevalence of CAM-type FAI in patients that underwent surgical fixation of femoral neck fractures. This is significantly higher than the reported prevalence in non-fracture patient populations. The high prevalence of CAM morphology could be related to several factors, including age, fracture morphology, quality of reduction, type of fixation, and fracture healing.

Level of evidence

IV.     

Femoroacetabular impingement: normal values of the quantitative morphometric parameters in asymptomatic hips

Objective

To determine the means and the reference intervals of the quantitative morphometric parameters of femoroacetabular impingement (FAI) in normal hips with high-resolution computed tomography (CT).

Methods

We prospectively included 94 adult individuals who underwent CT for thoracic, abdominal or urologic pathologies. Patients with a clinical history of hip pathology and/or with osteoarthritis on CT were excluded. We calculated means and 95 % reference intervals for imaging signs of cam-type (alpha angle at 90° and 45° and femoral head–neck offset) and pincer-type impingement (acetabular version angle, lateral centre-edge angle and acetabular index).

Results

The 95 % reference interval limits were all far beyond the abnormal thresholds found in the literature for cam-type and to a lesser extent for pincer-type FAI. The upper limits of the reference intervals for the alpha angles (at 90°/45°) were 68°/83° (men) and 69°/84° (women), compared to thresholds from the literature (50°, 55° or 60°). Reference intervals were similar between genders for cam-type parameters, and slightly differed for pincer-type.

Conclusion

The 95 % reference intervals of morphometric measurements of FAI in asymptomatic hips were beyond the abnormal thresholds, which was especially true for cam-type FAI. Our results suggest the need for redefining the current morphometric parameters used in the diagnosis of FAI.

Key Points

? 95 % reference intervals limits of FAI morphotype were beyond currently defined thresholds. ? Reference intervals of pincer-type morphotype measurements were close to current definitions. ? Reference intervals of cam-type morphotype measurements were far beyond the current definitions. ? Current morphometric definitions of cam-type morphotype should be used with care.     

Incidence of greater trochanteric pain syndrome in patients suspected for femoroacetabular impingement evaluated using magnetic resonance arthrography of the hip

Objectives:

We evaluated the incidence of greater trochanter pain syndrome (GTPS) in patients who underwent magnetic resonance arthrography (MRA) of the hip for a suspected femoroacetabular impingement (FAI) syndrome.

Methods:

Hip MRA performed at our institution (3/2012–1/2014) were reviewed. The absence/presence of FAI (cam, pincer, and mixed) was noted. GTPS diagnosis was based on gluteus medius/minimus tendinopathy/tears, trochanteric bursitis, fascia lata thickening, and trochanter bone oedema/erosion. Subgroup analysis for age (under/over 40 years) and FAI type (cam, pincer, and mixed) was also performed.

Results:

N = 189 patients were included (n = 125 males; age 39 ± 12 years). FAI was diagnosed in n = 133 (70, 4%): cam type, n = 85 (63, 9%); pincer type, n = 22 (16, 6%); and mixed type, n = 26 (19, 5%). N = 72 patients (38.1%) had tendinopathy, n = 14 (7.4%) had trochanter erosion, n = 31 (16.4%) had bursitis, n = 4 had bone oedema (2.1%), and n = 3 (1.6%) had fascia lata thickening, resulting in GTPS diagnosis in n = 74 patients (39.2%). The association of normal hip morphology/GTPS was significantly higher (P = 0.023) than that of FAI/GTPS. Under 40 years, GTPS incidence was higher in patients with normal hip and pincer-type FAI (P = 0.028). Over 40 years, no difference between patients with/without FAI (P = 0.119) was seen.

Conclusions:

GTPS was more frequently observed in patients with normal hip morphology than in patients with FAI, particularly in patients under 40.

     

Radiographic findings of femoroacetabular impingement in capoeira players

Purpose

Capoeira is a Brazilian martial art that requires extreme movements of the hip to perform jumps and kicks. This study evaluated a group of capoeira players to assess the prevalence of femoroacetabular impingement (FAI) in athletes practicing this martial art.

Methods

Twenty-four experienced capoeira players (14 men, 10 women) underwent a diagnostic assessment, including clinical examination and standard radiographs of the pelvis and hips. The α-angle, head–neck offset, crossover sign, acetabular index, lateral centre-edge angle, and the Tönnis grade were assessed using the radiographs. Clinical relationships for any radiographic abnormalities indicating FAI were also evaluated.

Results

Four subjects (17 %) reported pain in their hips. Forty-four hips (91.7 %) had at least one radiographic sign of CAM impingement, and 22 (45.8 %) had an α-angle of more than 60°. Eighteen hips (37.5 %) had at least one sign of pincer impingement and 16 (33.3 %) a positive crossover sign. Sixteen hips (33.3 %) had mixed impingement. There was a significant positive association between having an α-angle of more than 60° and the presence of groin pain (P = 0.002). A reduced femoral head–neck offset (P < 0.001) and an increased α-angle on the anteroposterior radiograph (P = 0.008) were independently associated with a higher Tönnis grade.

Conclusion

High prevalence of radiographic CAM-type FAI among these skilled capoeira players was found. In these subjects, a negative clinical correlation for an increased α-angle was also detected. Additional caution should be exercised whenever subjects with past or present hip pain engage in capoeira.

Level of evidence

Diagnostic, Level III.     

Patient-specific instruments: industry’s innovation with a surgeon’s interest

Purpose

The aim of this study was (1) to survey the orthopaedic companies about the volume of patient-specific instruments (PSI) used in Europe and worldwide; (2) to survey a group of knee arthroplasty surgeons on their acceptance of PSI and finally; (3) to survey a medico-legal expert on PSI-related issues.

Methods

Seven orthopaedic implant manufacturers were contacted to obtain their sales figures (in volume) of PSI in Europe and worldwide for the 2011 and 2012 period. During the Open Meeting of the Belgian Knee Society, a survey by a direct voting system was submitted to a selection of knee surgeons. Finally, a number of medico-legal ‘PSI-related’ questions were submitted to an adult reconstruction surgeon/legal expert.

Results

The total volume, for all contacted companies, of PSI in Europe for 2012 was 17,515 total knee arthroplasty (TKA) and 82,556 TKA worldwide. Biomet (Warsaw, USA) was the number one in volume, both in Europe as worldwide with their Signature system. Biomet represented 27 % of the market share in PSI worldwide. Stryker preferred not to reply to the survey because of the FDA class 1 recall on ShapeMatch cutting guides. Eighty per cent of the Belgian knee surgeons expressed a great interest in PSI and especially, for 58 % of them, if it would increase their surgical accuracy. They valued it even more in unicompartmental arthroplasty, and 55 % was ready to use single-use instruments. Surprisingly, 47 % of surgeons thought it was the company’s responsibility if something goes wrong with a PSI-assisted case. The medico-legal expert concluded that PSI is a complex process that exposes surgeons to new risks in case of failure and stated that companies should not produce surgical guides without validation of the planning by the surgeon.

Conclusion

Patient-specific instruments is of great interest if it can proof to increase the surgical accuracy in knee arthroplasty to the level surgeons are expecting and if in the same time it would make the surgical process more efficient.

Level of evidence

V.     

Radiographic signs associated with femoroacetabular impingement occur with high prevalence at all ages in a hospital population

Objectives

Femoroacetabular impingement (FAI) is increasingly diagnosed clinically. Controversy exists about the significance of radiographic findings. Our goal is to determine the prevalence of radiographic FAI types and parameters in a hospital population clinically not suspected of having FAI. In addition we assessed whether pain, age and gender are associated with higher prevalences.

Methods

Three hundred ten patients were included in this retrospective study. After applying the exclusion criteria, 262 patients (522 hips) remained. Two observers scored for radiographic parameters. A generalised estimation equation, Pearson’s χ² test and logistic regression model were used.

Results

Radiographic signs of FAI were absent in only 58 hips (11.1 %). In the 40 hips (7.7 %) with cam impingement, males were more affected (P?<?0.001). In the 330 hips (63.2 %) with pincer impingement, females were more often affected (P?<?0.001). In the 82 hips (15.7 %) with signs of mixed type impingement, male hips were significantly (P?<?0.001) more often affected. Age had some effect on the prevalence of coxa vara, acetabular index and acetabular retroversion. No correlation with pain was found.

Conclusions

In this hospital population, signs occurred at a high rate. Radiographic parameters attributed to FAI are non-specific. Especially radiographic signs attributed to pincer type impingement have a high prevalence.

Key Points

? Femoroacetabular impingement is associated with an abnormal configuration of the hip joint. ? The prevalence of femoroacetabular impingement parameters was high in our study population. ? The diagnosis of femoroacetabular impingement should be made clinically.     

Early magnetic resonance imaging in acute knee injury: a cost analysis

Purpose

Acute knee injury is common, and MRI is often only used when non-operative management fails because of limited availability. We investigated whether early MRI in acute knee injury is more clinically and cost-effective compared to conventional physiotherapy and reassessment.

Methods

All patients with acute indirect soft tissue knee injury referred to fracture clinic were approached. Recruited patients were randomised to either the MRI group: early MRI within 2 weeks or the control group: conventional management with physiotherapy. Patients were assessed in clinic initially, at 2 weeks and 3 months post-injury. Management costs were calculated for all patients until surgical treatment or discharge.

Results

Forty-six patients were recruited: 23 in the MRI and 23 in the control group. Male sex and mean age were similar in the two groups. The total management cost of the MRI group was £16,127 and control group was £16,170, with a similar mean cost per patient (NS). The MRI group had less mean physiotherapy (2.5 ± 1.9 vs. 5.1 ± 3.5, p < 0.01) and outpatient appointments (NS). Median time to surgery and time off work was less in the MRI group (NS). The MRI group had less pain (p < 0.05), less activity limitation (p = 0.04) and better satisfaction (p = 0.04).

Conclusions

Early MRI in acute knee injury facilitates faster diagnosis and management of internal derangement at a cost comparable to conventional treatment. Moreover, patients had significantly less time off work with improved pain, activity limitation and satisfaction scores.

Level of evidence

II.     

Modest mid-term outcomes after isolated arthroscopic debridement of acetabular labral tears

Purpose

Currently, there is a paucity of literature regarding outcomes after isolated labral debridement. The purpose of this study was to (1) report the reoperation rate following isolated labral debridement, (2) report clinical and functional outcomes after labral debridement with a minimum 2-year follow-up and (3) identify risk factors for worse clinical and functional outcomes. It was hypothesized that inferior outcomes are associated with an increasing Tönnis grade and those with untreated femoral acetabular impingement (FAI).

Methods

The records of patients undergoing hip arthroscopy between 1998 and 2005 were reviewed. Patients with labral tears who underwent isolated arthroscopic labral debridement were identified. Kaplan–Meier estimate of failure (defined as subsequent surgery) was performed for all patients. Patients with minimum 2-year follow-up were assessed with Modified Harris Hip Score (MHHS) and Hip Outcome Score (HOS). Univariate analysis was then performed to assess which factors were associated with worse clinical and functional outcomes.

Results

Fifty-nine hips in 57 patients met our inclusion criteria (39 females, 18 males) with a mean age of 46 ± 14 years and mean follow-up of 5 (range 2–14) years. Overall, 45 % of the hips failed for repeat surgery (20 %) or rating for hip function as abnormal or severely abnormal (25 %). Twelve hips (20 %) required subsequent surgical intervention at a mean 23 (range 6–60) months (7 total hip arthroplasties, 2 open revisions, 3 arthroscopic revisions). Of the remaining hips, mean MHHS was 83.4 ± 19.7, mean HOS ADL score was 83.8 ± 21.3 and mean HOS sport score was 70.6 ± 32.9, with 33 of 41 (75 %) reporting normal or nearly normal current level of function. Univariate analysis revealed that hips with untreated bony impingement (p = 0.01) or requiring concomitant chondroplasty (p = 0.03) had inferior clinical outcome scores.

Conclusions

Isolated arthroscopic labral debridement for hip labral tears had 45 % combined poor results when strictly defining failure as repeat surgery or abnormal hip rating. Untreated FAI and concomitant chondroplasty were risk factors for inferior outcome. We recommend concomitant treatment for bony impingement lesions and preservation of the labrum whenever possible.

Level of evidence

Retrospective case series, Level IV.     

Combined arthroscopic management of concurrent posterior and anterior ankle pathologies

Purpose

To determine the technical feasibility and preliminary clinical efficacy of performing simultaneous arthroscopic management in cases with combined posterior and anterior ankle pathologies utilizing previously described standard arthroscopic procedures within a single surgical sitting.

Methods

Nineteen consecutive patients with combined anterior and posterior ankle pathologies were included in the current study, after at least 6 months of failed conservative managements. Combined standard posterior and anterior ankle arthroscopy was performed in all patients within the same surgical session; first with the patient in the prone position, then with the patient turned onto the supine position to perform the anterior procedure.

Results

All patients were available for the follow-up; the median follow-up period was 33 months (range 22–61 months). No persistent neurological deficits or infections were recorded. The American Orthopedic Foot and Ankle Society Ankle and Hind foot Scale score significantly improved from 70.2 ± 15.2 points preoperatively to reach 93.0 ± 5.4 points at 1 year post-operatively (p < 0.001). Sixteen patients (84.2 %) returned to their previous activity levels.

Conclusions

Combined arthroscopic management of concurrent posterior and anterior ankle pathologies within the same surgical session is initially clinically encouraging; it allows for an earlier return to activities of daily living without a significantly added morbidity.

Level of evidence

Case series, Level IV.     

Limited therapeutic benefits of intra-articular cortisone injection for patients with femoro-acetabular impingement and labral tear

Purpose

Intra-articular (IA) hip cortisone injection is commonly performed as a therapeutic modality in patients with femoral acetabular impingement (FAI). To our knowledge, there is no published data evaluating the clinical benefit of these injections. The purpose of this study was to assess the efficacy of therapeutic IA cortisone injection in these patients.

Methods

At our institution, patients with FAI and labral tear prospectively recorded their numerical rating scale (NRS) pain scores pre-injection, during post-injection anaesthetic phase, and at 14 days post-injection. From this cohort, all patients treated with guided IA cortisone injection, no radiographic evidence of arthritis (Tönnis grade 0 or 1) and pain relief during the anaesthetic phase of the IA injection were included. An absolute change of two points on the NRS score was considered the minimal amount of clinically significant pain relief. Pain scores were compared between the different types of steroid injected.

Results

Fifty-four patients (35 females, 19 males) with a mean age of 32 ± 12 years were included. Average median pre-injection NRS score was 7.0 (range 2.5–10.0), post-injection anaesthetic phase was 1.0 (range 0.0–5.0), and 14 day post-injection was 5.0 (range 0.0–10.0). As a group, NRS scores significantly diminished from post-injection anaesthetic phase to 14 days post-injection (p < 0.001). At 14 days post-injection, only 20 patients (37 %) and at 6 weeks, only 3 patients (6 %) reported a clinically significant decrease in pain. Average duration of pain relief was 9.8 days. There was no difference in pain reduction between steroid preparations.

Conclusion

In patients with symptomatic FAI and labral tear, intra-articular cortisone injection has limited clinical benefit as a therapeutic modality. However, anaesthetic-only IA injections for patients who may be candidates for hip arthroscopy can be a useful diagnostic tool.

Level of evidence

Therapeutic case series, Level IV.     

Sources and quality of literature addressing femoroacetabular impingement

Purpose

In the last 5 years, there has been an increasing interest in the concepts, pathoanatomy, and management of femoroacetabular impingement (FAI). The aim of this study was to determine the trends in FAI literature with specific emphasis on the quality and source of publications in the literature.

Methods

A systematic review of two electronic databases (MEDLINE, EMBASE) was conducted to identify FAI-related publications from 2005 to 2010. Studies were included if they were published in peer-review journals and were written in English. Abstracted data included year of publication, study design, type of study, level of evidence, number of patients and hips, gender, weighted mean age of patients, and type of journal.

Results

There were 298 relevant studies. Between 2005 and 2010, there was an approximate fivefold increase in the number of FAI-related publications. Most of these studies came from the orthopaedic literature (197 articles or 66 %), while the remainder arose from other medical specialties. The majority of publications consisted of level 4 and 5 studies (248 articles). There were no level 1 studies identified.

Conclusion

Between 2005 and 2010, there has been a dramatic increase in FAI-related publications, but high-quality studies are still lacking.

Level of evidence

IV.     

Can hip impingement be mistaken for tendon pain in the groin? A long-term follow-up of tenotomy for groin pain in athletes

Purpose

There are several reports on the association between pubalgia and intra-articular hip disorders. The purpose of this study was to evaluate the long-term outcome in athletes who underwent tenotomy due to long-standing groin pain. A secondary purpose was evaluating the frequency of femoro-acetabular impingement (FAI) and its impact on the long-term outcome.

Methods

Thirty-two high-level male athletes treated with adductor tenotomy, rectus abdominis tenotomy or both were included. At a median follow-up time of 6 years after the tenotomy, the subjects underwent standardised clinical examination, plain radiographs, completed web-based health-related patient-reported outcomes, including iHOT12, HAGOS (six subscales), EQ-5D (two subscales), HSAS for physical activity level and a VAS for overall hip function. Furthermore, patient satisfaction and return to sports were documented.

Results

Twenty-four of the 32 (75 %) athletes were satisfied with the outcome of the tenotomy, and 22 of the athletes (69 %) were able to return to their pre-injury sport. Before the long-term follow-up, two of these satisfied athletes had undergone repeat surgery (one hip arthroscopy due to FAI and one repeat tenotomy). Of the 24 satisfied athletes, eight (33 %) had a positive hip impingement test at the follow-up. Of the remaining eight athletes not satisfied with the outcome, only one returned to their pre-injury sport and three had undergone hip arthroscopy prior to follow-up. Five had positive hip impingement tests which was significantly more frequently than in the satisfied group (p = 0.008). The group with a positive hip impingement test reported significantly more pain and symptoms, more hip problems during sports and physical activity, as well as lower hip-related quality of life according to the HAGOS scores (p < 0.05), at follow-up.

Conclusion

Tenotomy for pubalgia yielded a satisfactory long-term outcome, with three of four athletes being able to return to their pre-injury sport. The athletes that did not return to their pre-injury sport had higher frequency of positive hip impingement test and inferior functional outcome compared with the athletes that did return to their pre-injury sport. It is therefore recommended that the hip should be carefully evaluated for hip impingement before tenotomy is considered as treatment for athletes with pubalgia.

Level of evidence

Retrospective case series, Level IV.