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This article is a guidance how to write systematic reviews (SR's) and meta-analyses (MA) in orthopaedics and which aspects to focus on for transparency, systematicity and readability. Both SR and MA summarise and synthesise the best evidence available on a specific topic. This requires a systematic, structured and transparent process of analysis. The title should be concise, indicate type of review and ideally report the most important finding. Next, the structured abstract (no more than 350 words) should also raise key points and report the overall level of evidence. A relevant clinical question must be defined before the literature search is started. Methodological details such as databases searched, the exact search strategy (including time frame), inclusion/exclusion criteria, method of literature appraisal and statistical analysis must be described briefly. The primary and secondary outcomes should be mentioned. SR's be pre-registered before data extraction, to ensure transparency and the reduction of risk of bias. If registered, registration number should be stated in the abstract and the funding sources. A clear summary of the findings is important including the number of identified studies (depicted in a flowchart) and for meta-analyses a forest plot. The results of the literature appraisal and statistical analyses should be reported precisely. Subsequently, a general interpretation of findings and their significance and relevance to clinical practice should be provided. Clinical implications from the analysis should be drawn carefully and further research questions should be addressed. Finally, a conclusion, based solely on the results of the study is a necessity. Up to ten keywords are requested representing the main content of the article. Most applicable keywords should facilitate finding the manuscript in the databases and therefor considered carefully.

The purpose of this study is to evaluate and define what is considered an adequate radiographic correction in arthroscopic osteochondroplasty for FAI and to secondarily assess how radiographic outcomes relate to patient reported outcomes and complications. The databases EMBASE, PubMed, and MEDLINE were searched for relevant literature from database inception until January 2021. Studies were screened by two reviewers independently and in duplicate for studies reporting on post-operative radiographic outcomes in arthroscopic osteochondroplasty for FAI. Data on radiographic outcomes as well as data reporting functional outcomes and complications were recorded. A meta-analysis was used to combine the mean pre- and post-operative radiographic outcomes using a random effects model. A risk of bias assessment was performed for all included studies using the MINORS score. The most commonly reported radiographic outcome was the alpha angle with a pooled mean post-operative angle of 44° (95% CI 41°–46°), and mean pre- to post-surgical difference of − 19° (− 22 to − 16, I2 = 96%), followed by the LCEA with a pooled mean post-operative angle of 30° (95% CI 29–31) and mean difference after surgery of − 4° (− 6 to − 1, I2 = 97%,). Eleven studies reported on the correlation between radiographic and clinical outcomes with no consistent consensus correlation found amongst the included studies. Similarly, six studies correlated radiographic outcomes with conversion to THA with no consistent consensus correlation found amongst the included studies. Based on this review, the main conclusion is that there is no consensus definition on the optimal radiographic correction for FAI and there was no consistent correlation between radiographic correction and functional outcomes. However, based on the uniform improvement in functional outcomes, this review suggests a post-operative alpha angle target of 44° with a correction target of 19° and LCEA target of 30° with a correction target of 3°. IV.

Hip arthroscopy offers a minimally invasive approach for the treatment of femoroacetabular impingement (FAI). Although osteoarthritis (OA) is a known negative prognostic factor for arthroscopy, it is unclear if patients with FAI and concomitant mild to moderate OA benefit from hip preservation surgery. The goal of this study was to evaluate current practice patterns among surgeons experienced in FAI management in the treatment of patients between 40 and 60 years of age with symptomatic FAI and concomitant OA of varying severity. A 12-question cross-sectional survey was distributed using a secure electronic survey portal. The survey sought to determine surgical treatment of FAI in patients between the ages of 40 and 60 years old with concomitant OA of various degrees. Surveys were completed electronically and anonymously, with invitations distributed to members of the American Orthopaedic Society for Sports Medicine, International Society for Hip Arthroscopy, Arthroscopy Association of Canada, Canadian Orthopaedic Association, and both current and former Fowler Kennedy sports medicine fellows. A total of 76 orthopedic surgeons who treat FAI completed the survey. All respondents routinely treat FAI arthroscopically, while only 43.7% have utilized an open surgical approach. Nearly all respondents (96.0%) would consider performing hip arthroscopy in patients over 40 years of age. The respondents ranked an absence of OA (Tonnis 0 or 1) as the most important factor in deciding to move forward with surgery, while a positive response to diagnostic injection was considered the least important factor of the options given. Respondents felt that the role for hip arthroscopy in patients with symptomatic FAI decreased with increasing age and worsening degree of osteoarthritis. In patients 40–50 years old with Tonnis 1, willingness to perform surgery was 89.5%; while with Tonnis 2 this was reduced to 39.5% and with Tonnis 3 it was 5.3%. In patients 50–60 years old with Tonnis 1, 80.3% of respondents found arthroscopy to be beneficial; while with Tonnis 2 this was reduced to 22.4% and with Tonnis 3 it was 2.6%. Most respondents consider arthroscopy a viable option for patients aged 40–60 years old with mild osteoarthritis (Tonnis 1), while worsening osteoarthritis (Tonnis 3) results in greater rates of non-arthroscopic treatment. The role of arthroscopy with moderate osteoarthritis (Tonnis 2) remains unclear and should be a focus for future studies. Level V.

Importance Acute pseudoseptic arthritis is a rare complication of hyaluronic acid (HA) injections that is not well documented in the literature. Practitioners initially suspect the symptoms of this complication to represent septic arthritis, cautiously prescribing antibiotics. This review identifies that time to presentation of symptoms postinjection, negative cell cultures and lack of crystallisation could be used as differentials to suspect pseudoseptic arthritis and to prescribe anti-inflammatory drugs while closely monitoring change of symptoms. Objective The purpose of this study was to describe the presentation, diagnosis and treatment of pseudoseptic arthritis. Evidence review A systematic review of the literature was conducted for studies reporting the use of HA injections for osteoarthritis resulting in pseudoseptic arthritis using the electronic databases MEDLINE, Embase and PubMed. Pertinent data were abstracted from the search yield. A unique case of a pseudoseptic reaction is also presented. Findings A total of 11 studies (28 cases), all of level IV and V evidence were included in this review. Reported cases of pseudoseptic arthritis in the literature present with severe joint pain (100%), effusion (100%), inability to weight-bear, functional impairment, and occasionally fever (22.2%). C reactive protein and erythrocyte sedimentation rate are generally elevated (71.4% and 85.7%, respectively), and leucocytosis above 10 000 was less common (50%). All reported cases in the literature identified aseptic growth on arthrocentesis, despite four cases (15.4%) reporting synovial leucocyte counts above 50 000. The presented case is the highest reported leucocyte count at 1 74 960 cells/mm3. Conclusions and relevance Acute pseudoseptic arthritis is rare, but a number of cases have been reported in the literature. A high degree of suspicion for pseudoseptic arthritis may be maintained in patients who present under 72 hours following HA injection. Initial antibiotic treatment, along with anti-inflammatory medications until cultures are confirmed to be negative at 5 days, is a cautious approach. However, the strength of this conclusion is limited by the few reported cases. Ultimately, this review is intended to inform practitioners of the symptoms, diagnosis and treatment of this complication, such that it could be safely differentiated from septic arthritis. Level of evidence IV.

The purpose of this systematic review was to determine the return to sport rates following surgical management of ostechondritis dissecans of the elbow. The databases EMBASE, PubMed, and MEDLINE were searched for relevant literature from database inception until August 2020 and studies were screened by two reviewers independently and in duplicate for studies reporting rates of return to sport following surgical management of posterior shoulder instability. A meta-analysis of proportions was used to combine the rates of return to sport using a random effects model. A risk of bias assessment was performed for all included studies using the MINORS score. Overall, 31 studies met inclusion criteria and comprised of 548 patients (553 elbows) with a median age of 14 (range 10–18.5) and a median follow-up of 39 months (range 5–156). Of the 31 studies included, 14 studies (267 patients) had patients who underwent open stabilization, 11 studies (152 patients) had patients who underwent arthroscopic stabilization, and 6 studies (129 patients) had patients who underwent arthroscopic–assisted stabilization. The pooled rate of return to any level of sport was 97.6% (95% CI 94.8–99.5%, I2 = 32%). In addition, the pooled rate of return to the preinjury level was 79.1% (95% CI 70–87.1%, I2 = 78%). Moreover, the pooled rate of return to sport rate at the competitive level was 86.9% (95% CI 77.3–94.5%, I2 = 64.3%), and the return to sport for overhead athletes was 89.4% (95% CI 82.5–95.1%, I2 = 59%). The overall return to sport after an arthroscopic procedure was 96.4% (95% CI 91.3–99.6%, I2 = 1%) and for an open procedure was 97.8% (95% CI 93.7–99.9%, I2 = 46%). All functional outcome scores showed improvement postoperatively and the most common complication was revision surgery for loose body removal (19 patients). Surgical management of osteochondritis dissecans of the elbow resulted in a high rate of return to sport, including in competitive and overhead athletes. Similar rates of return to sport were noted across both open and arthroscopic procedures. Level IV.

To identify patient factors associated with improved pain scores, functional hip scores, health-related quality of life, and re-operation rates after arthroscopic management of femoroacetabular impingement (FAI). Using the comprehensive dataset from the multinational Femoroacetabular Impingement Randomized Controlled Trial (FIRST), a total of 13 prognostic factors that were chosen a priori were identified that would be expected to predict post-surgical outcomes. The primary outcome was pain assessed using a Visual Analogue Scale (VAS) and secondary outcomes included hip function (Hip Outcome Score [HOS] and International Hip Outcome Tool [iHOT-12]), health-related quality of life (Short Form-12 [SF-12] and Euro-Qol 5 Dimensions [EQ-5D]), and re-operation rate. A multivariable linear regression was used to analyse the change questionnaire scores from baseline to 12 months post-surgery including all 13 prognostic factors as independent variables. A total of 27 re-operation events were analysed at 24 months using a multivariable logistic regression including only the treatment group variable. Of the 154 patients that had VAS scores completed at 12 months, a lower BMI (adjusted mean difference [aMD], 4.48 for a 5-unit decrease in BMI; 95% confidence interval [CI] 0.33–8.63; p = 0.035) was significantly associated with less pain. There was a significant negative association between increasing age and 1-year EQ-5D scores (aMD, − 0.04 for every 10-year increase in age; 95% CI − 0.07 to − 0.006; p = 0.020). The degree of impingement, severity of osteoarthritis, type of procedure, and adjudicated quality of surgery were not significantly associated with improvement across all outcomes at 12 months. Furthermore, there was no significant association between the treatment variable and the incidence of re-operation at 24 months. This study identified that lower BMI and age are predictive of improved pain and health utility scores, respectively, following arthroscopic management of FAI at 12 months post-surgery. These results may be a helpful adjunct in clinical decisions for this patient population when determining candidacy for surgical intervention. I.

To understand the early outcomes after hip arthroscopy and better define the trajectory of improvement in a prospective cohort of patients who have undergone hip arthroscopic osteochondroplasty for femoroacetabular impingement (FAI) syndrome. Data were analyzed from the Femoroacetabular Impingement RandomiSed controlled Trial (FIRST) on the 108 study patients who underwent osteochondroplasty, with or without labral repair. Study outcomes included patient-reported pain (using a 100-point Visual Analogue Scale (VAS)), hip function (using the Hip Outcome Score (HOS) and International Hip Outcome Tool (iHOT-12)), and health-related quality of life (using the EuroQol 5 Dimensions (EQ-5D)) measured at baseline, 2 weeks, 3 months, 6 months, and 12 months post-operatively. There was a decrease in mean post-operative pain VAS scores from baseline. The first 2 weeks post-operative yielded the greatest reduction in pain with a mean (SD) VAS score of 37.8 (23.4), with score stabilization between 6 months (26.9 (26.9)) and 12 months (25.3 (27.6)). Mean HOS (activities of daily living) scores improved from baseline (59.7 (16.2)) starting at 6 weeks post-operative (64.1 (19.1)). The HOS (Sports) showed no improvement from baseline (41.2 (20.4)) until 3 months (49.1 (27.9)), and continued to improve at 6 months (64.1 (28.7)) and 12 months (68.6 (30.5)). The iHOT-12 scores showed functional improvement from baseline (31.3 (18.8)), as early as 6 weeks (44.9 (22.4)) up to and including 12 months (67.1 (29.7)). EQ-5D index scores showed modest steady improvement from 6 weeks to 12 months post-operative, while the EQ-5D VAS component similarly showed modest and steady improvements from 3 months onward. Results from this study highlight that hip arthroscopic osteochondroplasty with or without labral repair for FAI leads to early pain relief. While all scores improved from baseline, functional gains appear to plateau from 6 months onwards. These data can be used to inform decision-making about timelines for rehabilitation and return to sport, a knowledge gap in the current FAI literature. II.

Background: Several techniques for hip capsular reconstruction have been described to address gross instability or microinstability due to capsular deficiency. However, objective biomechanical data to support their use are lacking. Purpose: To compare the kinematic effect of 2 capsular reconstruction techniques (iliotibial band [ITB] graft and Achilles tendon graft). Kinematic effect encompassed rotational range of motion (ROM) as well as joint translation in the coronal, sagittal, and axial planes. Study Design: Controlled laboratory study. Methods: 8 paired, fresh-frozen hemi-pelvises (16 hips) were tested on a custom-designed joint motion simulator in the intact state and after capsulectomy. Pairs were randomly allocated to either ITB or Achilles reconstruction and retested. Testing was performed at 0°, 45°, and 90° of flexion. Internal-external rotation (IR-ER) torques and abduction-adduction torques of 3 N·m were applied to the femur via a load cell at each position, and rotational ROM and joint translation in the coronal, sagittal, and axial planes were recorded. Results: At 45° and 90°, there was a significant effect of the condition of the hip on the total IR-ER ( P = .004, effect size [ES] = 0.305; and P < .001, ES = 0.497; respectively). At 45°, mean ± SD total rotation was significantly greater for the capsulectomy (59.7°± 15.9°) state compared with intact (53.3°± 13.2°; P = .007). At 90°, reconstruction significantly decreased total rotation to 49.0°± 18.9° compared with a mean total rotation of 52.8°± 18.7° after capsulectomy ( P = .02). No difference was seen in the total abduction-adduction of the hip between conditions. Comparisons of the 2 different reconstruction techniques showed no significant differences in total IR-ER or abduction-adduction ROM or joint translation in the coronal, sagittal, or axial planes. For translation, at both 0° and 45° there was a statistically significant effect of the condition on the medial-lateral translation ( P = .033; ES = 0.204). Reconstruction, independent of technique, was successful in significantly decreasing ( P = .030; P = .014) the mean medial-lateral translation at 0° and 45° of hip flexion from 5.2 ± 3.8 mm and 5.6 ± 4.0 mm to 2.8 ± 1.9 mm and 3.9 ± 3.2 mm, respectively. Conclusion: The integrity of the native hip capsule played a significant role in rotational stability, where capsulectomy significantly increased rotational ROM. Both ITB and Achilles reconstruction techniques restored normal rotational ROM of the hip at 90° of flexion as well as coronal plane stability at 0° and 45° of hip flexion. No differences were seen between ITB and Achilles reconstruction techniques. Clinical Relevance: Both capsular reconstruction techniques provide comparable joint kinematics, restoring rotation and translation to normal values with the exception of rotational ROM at 45°, which remained significantly greater than the intact state. The most significant results were the rotational stability at 90° of hip flexion and coronal plane stability at 0° and 45° of hip flexion, which were significantly improved compared with the capsulectomy state.

Greater trochanteric pain syndrome (GTPS) refers to the constellation of signs and symptoms related to pain in the trochanteric region and has recently replaced the previously ubiquitous term of ‘greater trochanteric bursitis’. GTPS is common, particularly in women 50–79 years of age, and the understanding and management of GTPS have expanded considerably in recent years to include management with arthroscopic and endoscopic techniques in recalcitrant cases. The purpose of this scoping literature review was to summarize the current evidence on arthroscopic management of GTPS including sources of evidence, key concepts, and gaps in the literature. A thorough electronic database search included studies published from 2009 to June 14, 2020. A total of 52 peer-reviewed articles were identified within the literature on arthroscopic or endoscopic management of GTPS. Of the 52 identified papers, 12 were technique descriptions, 10 papers were review articles, and 30 papers were original clinical papers. Of the 30 clinical papers, 24 (80%) were of level IV evidence, 5 (17%) were of level III evidence, and 1 (3%) was level II evidence. Among the 30 clinical studies, 988 patients were included with 761 (77%) female. Indications for surgical management included a failed trial of conservative management in all 30 studies, typically after a period of 3–6 months. Surgical management consisted of arthroscopic/endoscopic abductor tendon repair in 16 (53%) studies, arthroscopic/endoscopic bursectomy and iliotibial band release in 12 (40%) studies, and arthroscopic/endoscopic gluteal tendon contracture release in 2 (7%) studies. Overall, results following arthroscopic management of GTPS and abductor tears have been promising, including significantly improved pain scores and functional outcomes at final post-operative assessment. These studies support continued use and investigation of arthroscopic management strategies of GTPS and pave the way to conduct larger prospective studies to confirm these results in the future. IV.

Purpose Snapping hip is a common clinical condition, characterized by an audible or palpable snap of the hip joint. When the snap is perceived at the lateral side of the hip, this condition is known as external snapping hip or lateral coxa saltans, which is usually asymptomatic. Snapping hip syndrome (SHS) refers to a painful snap, which is more common in athletes who require increased hip range of motion. The aim of this article is to review the most common endoscopic techniques for the treatment of ESHS, as well as their results and limitations. Methods This is a review of the current literature of endoscopic surgical procedures and of the results of the treatment of external snapping hip syndrome. Results The pathogenesis of SHS is mechanical. The initial treatment attempt is conservative, and usually provides good results. Patients who do not respond to conservative management are candidate for surgery. The endoscopic release of the ilio-tibial band or the endoscopic release of the femoral insertion of the gluteus maximum tendon is the most popular technique. Conclusion Endoscopic techniques provide fewer complications compared to open surgery, a lower recurrence rate and good clinical outcomes. More comparative studies with a longer follow-up are required to adequate evaluate the full role of endoscopic techniques in periarticular hip surgery. Level of evidence Level V.

The opioid epidemic has prompted an emphasis on investigating opioid-sparing alternatives for pain management following knee arthroscopy. This review evaluated the effects of perioperative nonopioid adjunct analgesia on postoperative opioid consumption and pain control in patients undergoing knee arthroscopy. A systematic review and meta-analysis was performed using the following databases: PubMed, Embase, Web of Science, MEDLINE, and SCOPUS. Prospective comparative studies assessing the efficacy of various perioperative nonopioid analgesic strategies in patients undergoing knee arthroscopy were included. Twenty-five studies (n = 2408) were included. Pre-emptive nonopioid pain medications demonstrated a reduction in cumulative postoperative oral morphine equivalent (OME) consumption by 11.8 mg (95% CI − 18.3, − 5.4, p ≤ 0.0001) and VAS pain scores by 1.5 (95% CI − 2.3, − 0.7, p

The femoroacetabular impingement randomised controlled trial (FIRST) is a multi-center randomized controlled trial (RCT), comparing arthroscopic osteochondroplasty with arthroscopic lavage in adults aged 18–50 years diagnosed with non-arthritic femoroacetabular impingement (FAI) syndrome. The purpose of the present study is to report the prevalence, distribution and severity of adverse events during and within 24-month follow-up period. Of the 220 patients included, 6 were adjudicated as ineligible, for a total of 214 patients included in the final analysis. An independent Adjudication Committee evaluated operatively treated and non-operatively treated adverse events that were related to the hip. Adverse events were also reported directly by each participating clinical site. Continuous variables were reported as mean and standard deviation, categorical variables were reported as counts and percentages. There were a total of 52 (24.2%, 52/214) adverse events in 46 (21.5%) patients (mean age 34.2 ± 7.9 years, 58.7% male) during the 24-month follow-up. There were 12.6% (27/214) operatively treated adverse events for: hip pain, re-injury of labrum and heterotopic ossification. There were 11.7% (25/214) non-operatively treated adverse events for predominantly: hip pain, hip tendinopathy and hip popping/snapping. Approximately, 87% of adverse events resolved within the 24-month follow-up time. Given the inherent challenges with conducting RCTs, the results of this adverse event study from the FIRST trial demonstrate that it is safe to perform an RCT addressing FAI syndrome. Level III.

Press-fit fixation is a hardware-free technique in anterior cruciate ligament reconstruction (ACLR). The purpose of this review was to quantitatively assess the risk profile and outcomes of press-fit fixation and provide an update on its effectiveness compared to more standard fixation techniques of ACLR. The electronic databases PUBMED, MEDLINE, and EMBASE were searched on March 26, 2020 for therapeutic randomized controlled trials (RCT) addressing press-fit fixation for primary ACLR. The Grading of Recommendations Assessment, Development and Evaluation tool was used to assess the quality for randomized studies. A meta-analysis with a random-effects model was used to pool applicable outcomes data. A total of six eligible RCTs were included in this review. There were 292 patients (72.9% male) with a mean age of 28.8 ± 3.8 years and a mean follow-up of 81.3 ± 88.3 months that underwent press-fit ACLR on the femoral, tibial or both tunnels. Femoral fixation techniques included press-fit fixation (96.6%) and cross-pin fixation (3.4%). Tibial fixation techniques included press-fit (37.0%), staples (28.1%), interference screws (21.2%) and abarticular post-screws (13.7%). Graft options included bone–patellar tend–-bone autografts (73.6%) and semitendinosus and gracilis tendon autograft (26.4%). Significant improvements (p

This systematic review aims to assess the diagnosis, indications and treatment of femoroacetabular impingement (FAI) prior to the year 2000 and to determine if historical concepts remain applicable today. PUBMED, MEDLINE and EMBASE were searched for literature evaluating the diagnosis/treatment of FAI prior to 2000. Cadaver/non-human, non-English and review studies were excluded. Quality assessment was performed using the Methodological Index for Non-Randomized Studies. Nine studies comprising 307 patients [315 hips; mean age of 32.6 ± 2.4 years (range, 12–58)] were included. Patients reported groin pain. Magnetic resonance arthrography (MRA; n = 76) and the anterior impingement test (AIT) (n = 88) were used to diagnose impingement. Surgical dislocation with a trochanteric flip osteotomy (n = 237) and Bernese periacetabular osteotomy (n = 40) were common treatments. Pain and range of motion improved for patients. Overall complication rate was 35% (n = 99), with heterotopic ossification (n = 79) most commonly reported. Prior to 2000, there was low quantity and quality of research on the diagnosis/management of FAI. Diagnostic evaluation was primarily through clinical examination (i.e. groin pain and AIT). MRA was occasionally used to detect labral degeneration; however, utilization of computed tomography (CT) and diagnostic injections were not reported. Surgical dislocation and osteotomies of the acetabulum yielded desirable short-term clinical outcomes with a moderate complication rate. No study reported using arthroscopy for FAI management prior to 2000. Clinicians today can learn from historical principles (i.e. clinical diagnosis of FAI, management with surgical correction of femoral head–neck offset) while applying novel techniques (i.e. CT, injections, arthroscopic surgical techniques and rehabilitation) to improve patient outcomes.Level of EvidenceIV (systematic review of III and IV evidence).

Hip arthroscopy (HA) has increased exponentially over the last decade. A recent systematic review found that the risk of venous thromboembolism (VTE) is 2%. This was higher than previous reports which may have underestimated the true incidence of VTE in HA. Thus, protocols to mediate VTE may be more necessary than previously thought. The aim of this article is to present a VTE prevention protocol and evaluate its subsequent efficacy. This is a prospective study of 880 consecutive HA cases. All patients were treated according to a predetermined VTE protocol which classified patients as high (≥1 risk factors) or low (no risk factors) risk for post-operative VTE. In high-risk patients, the protocol followed that of low-risk patients but additionally included rivaroxaban for 2 weeks post-operatively. The incidence of VTE was recorded and analysed in this study. A total of 880 HA cases at an average age of 35.4 years were evaluated, with 76.6% (n = 674) undergoing labral repair and concomitant cam and/or pincer resection, 17.2% (n = 151) of cases for isolated labral tear repaired, and 6.1% (n = 55) classified as other. The overall incidence of VTE was 0.45%. The incidence of VTE was 1.2% and 0.16% in high- and low-risk groups, respectively. Oral VTE prophylaxis was not associated with post-operative complications. This study demonstrated a lower rate of VTE in both risk groups. It highlights the value of a predetermined risk-adjusted protocol to VTE prophylaxis. Rivaroxaban prophylaxis is safe and efficacious in HA with a low associated morbidity.

This study aims to present a systematic review and synthesized evidence on the epidemiological factors, diagnostic methods and treatment options available for this phenomenon. A multi-database search (OVID Medline, EMBASE and PubMed) was performed according to PRISMA guidelines on 18 June 2019. All studies of any study design discussing on the epidemiological factors, diagnostic methods, classification systems and treatment options of the wave sign were included. The Newcastle–Ottawa quality assessment tool was used to appraise articles. No quantitative analysis could be performed due to heterogeneous data reported; 11 studies with a total of 501 patients with the wave sign were included. Three studies examined risk factors for wave sign and concluded that cam lesions were most common. Other risk factors include alpha angle >65° (OR=4.00, 95% CI: 1.26–12.71, P=0.02), male gender (OR 2.24, 95% CI: 1.09–4.62, P=0.03) and older age (OR=1.04, 95% CI: 1.01–1.07, P=0.03). Increased acetabular coverage in setting of concurrent cam lesions may be a protective factor. Wave signs most commonly occur at the anterior, superior and anterosuperior acetabulum. In terms of staging accuracy, the Haddad classification had the highest coefficients in intraclass correlation (k=0.81, 95% CI: 0.23–0.95, P=0.011), inter-observer reliability (k=0.88, 95% CI: 0.72–0.97, P

The purpose of this study was to systematically review the methodology, response rate and quality of survey studies related to femoroacetabular impingement (FAI) syndrome. A search was conducted on three databases (PubMed, EMBASE, MEDLINE) for relevant studies from database inception to 27 January 2020. Data extracted included study and survey characteristics, as well as response rates. The quality of the included studies was also assessed using a previously published quality assessment tool. Data were analysed with means, ranges, standard deviations, 95% confidence intervals and bivariate analysis. Eleven studies (13 surveys) were included in this review out of a total of 1608 initial titles found. Surveys were most often administered via the Internet (72%) to orthopaedic surgeons (54%). The mean response rate was 70.4%. The mean quality score was moderate 13.3/24 (SD ±4.3). The criterion that most often scored high was ‘clearly defined purpose and objectives’ (11/11). The most common survey topic investigated surgeons’ knowledge regarding FAI diagnosis and management (n = 7). In addition, bivariate analysis between quality score and response rate showed no significant correlation (Spearman’s rho = −0.090, P = 0.85). Overall, survey studies related to FAI syndrome most often use Internet-based methods to administer surveys. The most common target audience is orthopaedic surgeons. The topics of the surveys most often revolve around orthopaedic surgeons’ knowledge and opinions relating to the diagnosis and management of FAI syndrome. The response rate is high in patient surveys and lower in larger surgeon surveys. Overall, the studies are of moderate quality.

The cement-in-cement technique for revision hip arthroplasty has many potential advantages and has recently gained widespread interest but still lacks evidence to support it. Our aim was to examine the surgical and patient-reported outcomes after cement-in-cement revision hip arthroplasty. A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed and EMBASE databases were searched up to February 2019 for original studies reporting the outcomes of revision hip arthroplasty surgeries using the cement-in-cement technique. The methodological quality was assessed using the methodological index for non-randomized studies scale. Sixteen non-comparative studies met the eligibility criteria, comprising 1899 hips in 1856 patients (72.2 mean age, 37% male), with a mean follow-up of 7.2 years. Most studies reported only primary revisions and focused on the stem component. Intraoperative complications such as femoral or acetabular fractures (5.3%) were low and easily manageable with no relevant sequelae, as were dislocation rates (2.8% of uncomplicated events and 1.6% of cases requiring re-revision). Failure (considered if there was aseptic loosening of the cement-in-cement revised component, 2%), re-revision (9.3%), implant survival and late complication rates were favourable. Functional patient-reported outcomes showed an overall improvement above the minimal clinically important difference at final follow-up. The cement-in-cement technique is a viable option for hip arthroplasty revision surgery with low intraoperative and late complication rates, dislocations and immediate post-operative morbidity, resulting in good functional patient-reported outcomes and favourable medium-term implant survival.

Treatment strategies for ACL injuries continue to evolve. Evidence supporting best practice guidelines to manage ACL injury is largely based on studies with low-level evidence. An international consensus group of experts was convened determine consensus regarding best available evidence on operative versus non-operative treatment for ACL injury. The purpose of this study is to report the consensus statements on operative versus non-operative treatment of ACL injuries developed at the ACL Consensus Meeting Panther Symposium 2019. Sixty-six international experts on the management of ACL injuries, representing 18 countries, convened and participated in a process based on the Delphi method of achieving consensus. Proposed consensus statements were drafted by the Scientific Organising Committee and Session Chairs. Panel participants reviewed preliminary statements prior to the meeting and provided initial agreement and comments on the statement via online survey. During the meeting, discussion and debate occurred for each statement, after which a final vote was then held. Eighty per cent agreement was defined a priori as consensus. A total of 11 of 13 statements on operative versus non-operative treatment of ACL injury reached consensus during the Symposium. Nine statements achieved unanimous support, two reached strong consensus, one did not achieve consensus, and one was removed due to redundancy in the information provided. In highly active patients engaged in jumping, cutting and pivoting sports, early anatomical ACL reconstruction is recommended due to the high risk of secondary meniscus and cartilage injuries with delayed surgery, although a period of progressive rehabilitation to resolve impairments and improve neuromuscular function is recommended. For patients who seek to return to straight plane activities, non-operative treatment with structured, progressive rehabilitation is an acceptable treatment option. However, with persistent functional instability, or when episodes of giving way occur, anatomical ACL reconstruction is indicated. The consensus statements derived from international leaders in the field may assist clinicians in deciding between operative and non-operative treatment with patients after an ACL injury. Level of evidence: Level V

Loss to follow-up in registry studies is a problem due to potential selection bias. There is no consensus on the effect of response rate. The aim of this study was to compare patient-reported outcome measures (PROMs) between responders and initial non-responders (INR) in a hip arthroscopy registry and to examine whether demographics affect the response rate. Data from hip arthroscopies performed at two centres in Gothenburg were collected and the patients were followed up with PROMs. The follow-up was a minimum of 2 years after surgery. All 536 patients who underwent primary hip arthroscopies during 2015 and 2016 and had recorded pre-operative PROMs were included. A total of 396 patients completed the follow-up and were labelled ‘Responders’ (R) and 107 patients responded after reminders were sent and labelled ‘Initial non-responders’ (INR). The mean time of follow-up was 24.7 ± 2.9 and 42.5 ± 7.0 months for the R- and INR-group, respectively. There were no differences between the two groups at the follow-up for the Copenhagen Hip and Groin Outcome Score, European Quality of life 5 dimensions questionnaire, EQ-VAS, International Hip Outcome Tool or a visual analogue scale for hip function. A larger proportion of R was satisfied after hip arthroscopy compared with INR (86% versus 70%, P = 0.0003). INR were younger than responders (31.5 ± 12.5 versus 35.6 ± 12.7 years of age). The conclusion of the study was that there were no differences between R and INR at the follow-up across the PROMs except patient satisfaction, where responders were more satisfied.

Background Femoroacetabular impingement (FAI) is an important cause of hip pain in young and active individuals and occurs as a result of size and shape mismatch between the femoral head and acetabulum. Open physes in children can make hips more susceptible to injury, and high impact forces have been suggested to affect the developing femur. The diagnosis of FAI has recently risen, especially within adolescent populations, and there is an increasing trend towards year-round participation in sports with early specialization. The PREVIEW study is an international longitudinal study designed to determine the association between sport specialization in adolescence and the development of hip impingement. Methods This is a multicentre prospective cohort study evaluating 200 participants between the ages of 12–14 that include sport specialists at the moderate to vigorous physical activity (MVPA) level and non-sport specialists at any activity level. We will monitor physical activity levels of all participants using an activity log and a wrist-mounted activity tracker, with synced data collected every 3 months during the study period. In addition, participants will be evaluated clinically at 6, 12, and 18 months and radiographically at the time of enrolment and 24 months. The primary outcome is the incidence of FAI between groups at 2 years, determined via MRI. Secondary outcomes include hip function and health-related quality of life between subjects diagnosed with FAI versus no FAI at 2 years, as determined by the Hip Outcome Score (HOS) and Pediatric Quality of Life (PedsQL) questionnaires. Discussion It is important to mitigate the risk of developing hip deformities at a young age. Our proposed prospective evaluation of the impact of sport activity and hip development is relevant in this era of early sport specialization in youth. Improving the understanding between sport specialization and the development of pre-arthritic hip disease such as FAI can lead to the development of training protocols that protect the millions of adolescents involved in sports annually. Trial registration PREVIEW is registered with clinicaltrials.gov (NCT03891563).

Background: Femoroacetabular impingement syndrome (FAIS) is a common cause of hip pain and disability in athletes. Arthroscopic treatment for FAIS is well-established; however, the long-term results in elite athletes are limited. Purpose: To evaluate outcomes 5 years after arthroscopic treatment for FAIS in elite athletes. Study Design: Case series; Level of evidence, 4. Methods: Elite athletes undergoing arthroscopic treatment for FAIS with a minimum 5-year follow-up were included. They were prospectively followed up with patient-reported outcome measures. An elite athlete was defined as having a Hip Sports Activity Scale (HSAS) level of 7 or 8 before the onset of symptoms. Preoperatively and 5 years after surgery, all athletes completed a web-based questionnaire, including the Copenhagen Hip and Groin Outcome Score (comprising 6 subscales), the EQ-5D and EQ-VAS (European Quality of Life–5 Dimensions Questionnaire and European Quality of Life–Visual Analog Scale), iHOT-12 (International Hip Outcome Tool), a visual analog scale for hip function, and the HSAS. Moreover, patients reported their overall satisfaction with their hip function. Preoperative measurements were compared with the 5-year follow-up. Results: A total of 64 elite athletes (52 men, 12 women) with a mean ± SD age of 24 ± 6 years were included. On average, patients reported a statistically significant and clinically relevant improvement from preoperative patient-reported outcome measures to the 5-year follow-up ( P < .0003), Copenhagen Hip and Groin Outcome Score subscales (symptoms, 51.7 vs 71.9; pain, 61.0 vs 81.1; function of daily living, 67.1 vs 83.6; function in sports and recreation, 40.0 vs 71.5; participation in physical activity, 25.0 vs 67.4; hip and groin–related quality of life, 34.4 vs 68.0), EQ-5D (0.60 vs 0.83), EQ-VAS (66.1 vs 76.7), and iHOT-12 (40.0 vs 68.8). At the 5-year follow-up, 90.5% reported satisfaction with their overall hip function. In total, 54% still participated in competitive sports (HSAS, 5-8) at follow-up, while 77% had decreased their level. Older patients and patients with longer duration of symptoms reported a significantly lower level of sports activity (HSAS, 0-4; P < .009). Conclusion: Arthroscopic treatment for FAIS in elite athletes results in a statistically significant and clinically relevant improvement regarding symptoms, hip function, quality of life, and pain 5 years after surgery. Approximately half of the cohort was still in competitive sports at follow-up, yet 77% had decreased their level of sports. Nine of 10 patients were satisfied with their surgery.

The purpose of this systematic review was to assess the surgical techniques, indications outcomes and complications for pediatric patients (≤ 19 years old) undergoing shoulder stabilization procedures for anterior shoulder instability. The electronic databases MEDLINE, EMBASE, CINAHL, and Web of Science were searched from data inception to March 14, 2019 for articles addressing surgery for pediatric patients with anterior shoulder instability. The Methodological Index for Non-randomized Studies (MINORS) tool was used to assess the quality of included studies. Overall 24 studies, with a total of 688 patients (696 shoulders) and a mean age of 16.6 ± 2.5 years met inclusion criteria. Mean follow-up was 49 ± 26 months. The majority (59%) of studies only offered shoulder stabilization procedures to patients with more than one shoulder dislocation, however, three studies reported operating on pediatric patients after first time dislocations. Of the included patients 525 had arthroscopic Bankart repair (78%), 75 had open Bankart repair (11%), 34 had modified Bristow (5%), and 26 had Latarjet (4%) procedures. The overall complication rate was 26%. Patients undergoing arthroscopic Bankart repair experienced the highest recurrence rate of 24%. There were no significant differences in recurrent instability (n.s.) or loss of external rotation (n.s.) in pediatric patients treated with arthroscopic Bankart repair compared to open Latarjet. Patients had a 95% rate of return to sport at any level (i.e. preinjury level or any level of play) postoperatively (95%). Pediatric patients are at high risk of recurrent instability after surgical stabilization. The majority of pediatric patients with anterior shoulder instability were treated with arthroscopic Bankart repair. Most studies recommend surgical stabilization only after more than one dislocation. However, given the high rates of recurrence with non-operative management, it may be reasonable to perform surgery at a first-time dislocation, particularly in those with other risk factors for recurrence. With the current evidence and limited sample sizes, it is difficult to directly compare the surgical interventions and their post-operative efficacy (i.e. re-dislocation rates or range of motion). There was an overall high rate of return to sport after surgical stabilization at final follow-up. IV.

Less invasive direct anterior approach (DAA) and dual mobility cup (DMC) are increasingly adopted in practice over the last decade. Their use aims to reduce, as much as possible, soft tissue dissection and dislocation rate. This study aims to present a novel surgical technique to reduce a DMC prosthesis during a DAA easily. A mildly modified version of the direct anterior approach is proposed. When leg lengths, stability, impingement, and tension have been checked, the trial stem is disassembled in situ, dislocated, and removed, leaving the space to exchange the trial double mobility head with the definitive one. When the definitive stem is inserted, the surgeon guides and helps the assistant to match the trunnion in the double mobility head. As soon as the components are matched, the traction is released, and the unit is impacted by an alternation of axial traction and release. Of 164 patients who underwent primary total hip arthroplasty (December 2016–May 2017) by a single surgeon, a double mobility cup through DAA and the “head-first” technique was performed in 26 patients (15.8%). The mean operative time was 130 min (85–220 min; SD 34.28). No significant complications occurred during the mean follow-up of 23.6 months. Specific difficulties can be anticipated when pairing dual mobility cup and direct anterior approach. The “head-first” technique is a useful technique in reducing the possible difficulties related to the reduction of double mobility cup through a less invasive direct anterior approach.

Background: Little League shoulder (LLS) is an overuse injury characterized by throwing-related pain that commonly presents in adolescent male athletes. Investigations into the optimal duration of rest from throwing and protocols for graduated return to sports (RTS) are lacking. Purpose: To summarize the current literature with respect to the diagnosis, management, RTS, and return to throwing for LLS. Design: Systematic review; Level of evidence, 4. Methods: The databases EMBASE, MEDLINE, and PubMed were searched between inception and April 22, 2020. References of retrieved records were reviewed for potentially eligible studies. English-language studies that reported the diagnosis and/or management of LLS in children or adolescents were included. Studies of animals or cadavers, review articles, and non—peer reviewed records were excluded. Data were summarized narratively using descriptive statistics. Results: Overall, 23 studies (21 level 4 studies, 2 level 3 studies) met the criteria for a total of 266 participants with a weighted mean age of 12.8 years (range, 7.4-17 years). Treatment recommendations evolved from prolonged rest and complete cessation of throwing to shorter periods of rest and graduated RTS. Less than half (11/23) of studies reported specific criteria to RTS; 1 case report discussed a coaching strategy to resume throwing, and 1 case report discussed a regimented throwing program. The proportion of participants returning to any sport participation was 94.0% (n = 157/167). The proportion returning to their preinjury level of sport was 92.5% (n = 123/133). Upon RTS, 18.7% (n = 35/187) of participants experienced a recurrence of symptoms. Premature closure of the epiphysis was reported in 1 participant. Conclusion: Young athletes with LLS may return to play after a period of rest, and a high proportion return to their preinjury level of sport. Further prospective studies are warranted to develop evidence-based, graduated RTS protocols and to better capture any long-term sequelae of the condition.

PURPOSE OF REVIEW: The purpose of this systematic review was to assess the outcomes and complications of described cartilage restoration techniques for cartilage defects (grades I to IV) in the adolescent knee. RECENT FINDINGS: Eleven studies satisfied the inclusion criteria comprising 307 patients with a mean follow-up of 4.6 years (range 1–18.9 years). Study patients were treated with autologous chondrocyte implantation (ACI) (n = 98, mean age 16.0), microfracture (MFx) (n = 36, mean age 15.4), internal fixation (n = 71, mean age 13.1), osteochondral allograft (OCA) transplantation (n = 78, mean age 16.4), and cartillage and excision (n = 24; mean age 14.2). ACI, MFx, OCA transplantation, and internal fixation showed significant improvement in knee functionality scores. The overall complication rate was 10.6% (n = 31). OCA transplantation had the highest complication rate (26.9%; n = 21/78). SUMMARY: In summary, our review shows that ACI was the most commonly used technique. Furthermore, ACI, MFx, OCA transplantation, and internal fixation show the most promise in treating the adolescent population due to positive postoperative functional outcomes and low complication rates. However, future studies with large sample sizes, standardized outcome documentation, and long-term follow-up are required to confirm these preliminary results.

Fluoroscopy is used in hip arthroscopy (HA) for portal placement, instrument localisation, and guidance in bony resection. The recent increase in arthroscopic hip procedures may place patients and surgeons at risk for increased radiation exposure and radiation-induced complications. The purpose of the current systematic review was to assess intraoperative radiation exposure in HA. The systematic review was conducted according to PRISMA guidelines; inclusion criteria were studies assessing radiation exposure in HA. 9 studies including 994 patients were included. Mean age was 38.6 years and 48% (436 of 906) were female. Mean time of fluoroscopy exposure was 0.58 minutes. Dose area product was 129.5 cGycm2. Mean intraoperative absorbed radiation dose studies was 12.6 mGy. Mean intraoperative effective dose was 0.48 mSv. The mean occupational exposure to the surgeon per case was 0.0031 mSv. Higher patient body mass index (BMI) correlated to greater patient effective and cumulative dose ( p Radiation dose and effective dose were well under the thresholds for deterministic effects (2 Gy) and annual radiation exposure for occupational workers (20 mSv). Intraoperative radiation exposure to patients and surgeons is within acceptable annual radiation limits. Ensuring careful selection of perioperative imaging modalities, proper protective shielding, specifically the use of leaded eyeglasses, and optimal C-arm positioning are key strategies to reduce radiation exposure to patients and surgeons alike.

Background Total knee arthroplasty using patient-specific instrumentation (TKA-PSI), which are disposable cutting block guides generated to fit each patient’s 3-dimensional knee anatomy, has been developed to treat patients with end-stage osteoarthritis of the knee. Surrogate markers such as radiographic malalignment have been well investigated, however, patient-important outcomes are not well examined to elucidate the efficacy of TKA-PSI. The aim of this review is to determine if TKA-PSI improves patient-reported outcome measures (PROM), surgery time, blood loss, transfusion and complications (e.g. surgical site infection, deep venous thrombosis, and revision TKA). Methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and ongoing clinical trials. For PROMs, surgery time, blood loss, and transfusion rate, we included randomized controlled trials (RCT) comparing TKA-PSI and standard TKA to treat osteoarthritis of the knee. For complications, we also included non-randomized comparative studies (non-RCT). Results This review includes 38 studies, 24 of which were RCT and 14 of which were non-RCT. These included a total of 3487 patients. The predominant population in the included studies highly reflected the general population, with 62% being female, aged over 60 and having end-stage osteoarthritis of the knee. TKA-PSI did not improve PROMs as compared to standard TKA for less than 1-year (mean difference 0.48, 95% confidence interval (CI) -1.92–0.97 in the Oxford knee score, mean 3-month follow-up) and for 1-year or more (mean difference 0.25, 95%CI − 4.39–4.89 in the WOMAC score, mean 29-month follow-up). TKA-PSI did not reduce surgery time (mean difference − 3.09 min, 95%CI -6.73–0.55). TKA-PSI decreased blood loss with a small effect size corresponding to a 0.4 g/dl hemoglobin decrease (95%CI 0.18–0.88), but did not decrease transfusion rate (risk difference − 0.04, 95%CI -0.09–0.01). TKA-PSI did not reduce complication rates (risk difference 0.00, 95%CI − 0.01–0.01 in the composite outcome). Conclusions TKA-PSI does not improve patient-reported outcome measures, surgery time, and complication rates as compared to standard TKA. TKA-PSI decreases blood loss with a small effect, which is not enough to reduce transfusion rate.

This is a technique guide for open anterior capsule reconstruction in unstable native hips due to Ehlers–Danlos syndrome. Ehlers–Danlos syndrome is a connective tissue disease that predisposes an individual to hypermobility of their soft tissues and recurrent subluxations and dislocations of their joints. This may lead to constant instability, guarding of the hip, and subsequent arthritic changes and poor quality of life. We demonstrate anterior capsule reconstruction of the hip using an Achilles tendon allograft performed through a direct anterior approach to the hip (Heuter's approach). This technique guide outlines in detail the surgical steps required to accomplish this reconstructive procedure. Furthermore, a narrated surgical video is provided that clearly depicts the anticipated result of the increased constrained provided to the hip from the anterior capsule reconstruction using an Achilles tendon allograft.

Revision anterior cruciate ligament (ACL) procedures are increasing in incidence and possess markedly inferior clinical outcomes (76% satisfaction) and return-to-sports (57%) rates than their primary counterparts. Given their complexity, a universal language is required to identify and communicate the technical challenges faced with revision procedures and guide treatment strategies. The proposed REVision using Imaging to guide Staging and Evaluation (REVISE) ACL (anterior cruciate ligament) Classification can serve as a foundation for this universal language that is feasible and practical with acceptable inter-rater agreement. A focus group of sports medicine fellowship-trained orthopaedic surgeons was assembled to develop a classification to assess femoral/tibial tunnel “usability” (placement, widening, overlap) and guide the revision reconstruction strategy (one-stage vs. two-stage) post–failed ACL reconstruction. Twelve board-certified sports medicine orthopaedic surgeons independently applied the classification to the de-identified computed tomographic (CT) scan data of 10 patients, randomly selected, who failed ACL reconstruction. An interclass correlation coefficient (ICC) was calculated (with 95% confidence intervals) to assess agreement among reviewers concerning the three major classifications of the proposed system. Across surgeons, and on an individual patient basis, there was high internal validity and observed agreement on treatment strategy (one-stage vs. two-stage revision). Reliability testing of the classification using CT scan data demonstrated an ICC (95% confidence interval) of 0.92 (0.80–0.98) suggesting “substantial” agreement between the surgeons across all patients for all elements of the classification. The proposed REVISE ACL Classification, which employs CT scan analysis to both identify technical issues and guide revision ACL treatment strategy (one- or two-stage), constitutes a feasible and practical system with high internal validity, high observed agreement, and substantial inter-rater agreement. Adoption of this classification, both clinically and in research, will help provide a universal language for orthopaedic surgeons to discuss these complex clinical presentations and help standardize an approach to diagnosis and treatment to improve patient outcomes. The Level of Evidence for this study is 3.

BACKGROUND: Glenohumeral internal rotation deficit (GIRD) can negatively impact shoulder function particularly in the throwing athlete. QUESTIONS/PURPOSE: This study aimed to systematically evaluate recent trends in clinical outcomes and quality of published evidence pertaining to GIRD. METHODS: A systematic review was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, MEDLINE, PubMed Central, and Embase were searched from January 1, 2011, through April 23, 2017, for all articles evaluating GIRD. Two reviewers independently screened articles for eligibility and extracted data for analysis. RESULTS: Eighty-two articles were included in the final review. In general, the overall number of articles published increased over time. Two-thirds of all studies were conducted in the USA. Seventy-eight percent (N = 64) of included studies were level-III to level-V evidence, with no level-I study performed during the study period. Eighty-five percent of studies were either epidemiologic, review, or imaging articles, and only 12% were clinical studies. Significant variability in the clinical definition of GIRD was identified. All studies evaluating non-operative management of GIRD demonstrated significant improvements in internal rotation of the affected extremity. CONCLUSION: Current trends in GIRD-related literature demonstrate limited focus on clinical, therapeutic, or patient-reported outcomes and mostly consist of low-level evidence. There is a lack of consensus in the literature on what clinically constitutes GIRD. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11420-019-09691-1) contains supplementary material, which is available to authorized users.

Femoroacetabular impingement (FAI) is increasingly recognized as a risk factor for early hip degeneration in young active patients. The diagnosis depends on clinical examination and proper imaging that should be able to identify abnormal and sometimes subtle morphological changes. Labral tears and cartilage lesions rarely occur without underlying bone abnormalities. Surgical approaches to treat FAI are increasing significantly worldwide, even without a clearly defined consensus of what should be accepted as the standard imaging diagnosis for FAI morphology.Hip abnormalities encompass many variations related to the shape, size, and spatial orientation of both sides of the joint and can be difficult to characterize if adequate imaging is not available.This article presents a comprehensive review about the information orthopaedic surgeons need to know from radiologists to plan the most rational approach to a painful hip resulting from a mechanical abnormality.

Background: The decreased hip range of motion seen in femoroacetabular impingement syndrome (FAIS) may lead to compensatory increased motion at the symphysis pubis (SP) with resultant increased stress on the joint, which can subsequently lead to osteitis pubis. Purpose: To quantify the prevalence of SP abnormalities in patients with FAIS through the use of imaging modalities and to compare outcomes based on the presence of SP abnormalities. Study Design: Cohort study; Level of evidence, 3. Methods: Radiographs and magnetic resonance imaging (MRI) scans of 1009 consecutive patients who underwent primary hip arthroscopy for FAIS from January 2012 to January 2016 were identified. Exclusion criteria were patients undergoing revision or bilateral surgery, patients with dysplasia, and patients with less than 2-year follow-up. On radiographs, SP joints were reviewed for joint surface erosions, subchondral sclerosis and cysts, and ankylosis. MRI scans were reviewed for marrow edema in the subarticular pubic bone, subchondral sclerosis and cysts, joint surface erosions, and ankylosis. Patients with SP abnormalities were matched 1:2 to patients without SP abnormalities by age and body mass index. Outcomes included the Hip Outcome Score–Activities of Daily Living (HOS-ADL), HOS–Sports Subscale (HOS-SS), modified Harris Hip Score (mHHS), International Hip Outcome Tool–12 (iHOT-12), and visual analog scales (VAS) for pain and satisfaction. Results: 830 patients were included; 23 (2.8%) demonstrated SP abnormalities. Of the 726 (72%) MRI scans reviewed, 15 (1.8%) showed bone marrow edema, subchondral sclerosis, erosions, or ankylosis. After matching, patients without SP abnormalities had significantly greater HOS-ADL (95.7 vs 83.0; P = .008), HOS-SS (91.6 vs 61.9; P = .003), iHOT-12 (89.5 vs 74.6; P = .046), and VAS satisfaction (91.3 vs 58.8; P = .004) scores, in addition to less postoperative pain (6.3 vs 23.5; P < .001). No significant differences were found in the mHHS (92.5 vs 82.2; P = .08). Patients without SP abnormalities had higher odds of achieving the minimal clinically important difference for the HOS-ADL (odds ratio [OR], 4.5; 95% CI, 1.3-14.1; P = .010), the HOS-SS (OR, 7.2; 95% CI, 1.8-18.5; P = .006), and the mHHS (OR, 14.5; 95% CI, 1.8-24.7; P = .013). Conclusion: A low prevalence (1.8%-2.6%) of SP joint abnormality is seen on imaging in patients with FAIS. These patients may demonstrate significantly inferior clinical outcomes and persistent postoperative pain after FAIS treatment.

Purpose The purpose of the present study was to evaluate the outcome of arthroscopic treatment for femoroacetabular impingement (FAI) syndrome 5 years post-surgery using patient-reported outcome scores (PROMs) validated for a young and active population with hip complaints. Methods Patients were prospectively included in the study. A total of 184 patients [males = 110 (59.8%), females = 74 (40.2%)], with mean age 38.0, underwent arthroscopic treatment for FAI syndrome and were analysed. Preoperatively and at the 5-year follow-up, patients completed a set of self-administered web-based PROMs consisting of the International Hip Outcome Tool (iHOT-12), the Copenhagen Hip and Groin Outcome Score (HAGOS), the Hip Sports Activity Scale (HSAS), the EuroQoL-5 Dimension Questionnaire (EQ-5D), the EQ-Visual Analogue Scale (VAS) and the VAS for overall hip function and overall satisfaction. The Wilcoxon signed rank test was used to compare preoperative PROM values with those obtained at the 5-year follow-up. Results A comparison of preoperative PROM scores and those obtained at the 5-year follow-up revealed statistically significant improvements for all outcome scores (p

Importance The critical shoulder angle (CSA) is a relatively new radiographic parameter correlated with pathologies such as rotator cuff tears and osteoarthritis. Objective The purpose of this systematic review was to: (1) determine the degree of correlation between the CSA and shoulder pathologies, (2) determine the reliability of measuring CSA between (inter-rater reliability) and within (intrarater reliability) clinicians, (3) assess the accuracy of different imaging modalities used for measuring the CSA and (4) determine the association of CSA with patient outcomes after surgery. Evidence review The electronic databases MEDLINE, EMBASE and PubMed were searched in March 2018 for relevant studies. The results are presented in a narrative summary. Findings A total of 26 studies and 4563 patients satisfied the inclusion criteria. The majority of CSAs were measured using radiographs (98.2%) in neutral rotation (72.9%). Significant associations (p 35°) with primary rotator cuff tears and the risk of re-tear following a repair. The CSA has excellent intrarater (intraclass correlation coefficient (ICC) 0.903 to 0.996) and inter-rater reliability (ICC 0.869 to 0.980) when measured with radiographs. High variability in measurements was found when using MRI. The CSA, however, is not a clear, significant independent predictor (p>0.05) of outcomes after the surgical management of shoulder pathologies. Conclusions and relevance The CSA is an effective radiographic parameter that is associated with rotator cuff tears and osteoarthritis. Lower CSAs ( 35°) are associated with primary rotator cuff tears and re-tear after arthroscopic repair. Currently, there is a limited predictive value of the CSA in patient-reported outcomes after rotator cuff repair. The CSA is measured with high intrarater and inter-rater reliability for both radiographs and CT scans. Measuring the CSA using radiographs with the arm in the neutral rotation is currently recommended. Future studies are required to further investigate how best use the CSA to guide patient management and its predictive value. Level of evidence IV.

Importance Ulnar collateral ligament (UCL) injuries commonly occur in baseball players. Strategies for injury prevention have long been accepted without clinical data informing which risk factors lead to serious injury. Objective The objective of this study was to systematically review the impact of various pitching-related risk factors for UCL injury in baseball players from all levels of play. Evidence review The electronic databases MEDLINE, EMBASE and PubMed were systematically searched until 4 March 2018, and pertinent data were abstracted by two independent reviewers. Search terms included ‘ulnar collateral ligament’, ‘medial ulnar collateral ligament’, ‘Tommy John’, ‘risk’ and ‘association’. Inclusion criteria were English-language studies, level of evidence I–IV and studies reporting risk factors for UCL injury of the elbow in baseball players. Study quality was assessed using the methodological index for non-randomised studies (MINORS) criteria. The results are presented in a narrative summary. Findings Pitching practices (workload and pitch characteristics) were reported in 9/15 studies. Specifically, three of four studies (n=1810) reported increased pitch workload as a risk factor for native UCL injury (p Conclusions and relevance Pitching practices, reflected by increased pitch workload and velocity, were most commonly associated with UCL injury; however, the definition of workload (number of pitches per game, inning or season) was inconsistently reported. Biomechanical risk factors were less commonly reported and lack sufficient evidence to recommend preventative strategies. More quality data is needed to refine the current recommendations for injury prevention in baseball players. Level of evidence III.

Achilles tendon ruptures are devastating injuries for National Basketball Association (NBA) players: prior studies have demonstrated decreased performance following return-to-play, but none have ev...

Background: Posterior shoulder instability accounts for a small proportion of all shoulder instability, although it can affect athletes of all types, from contact to overhead athletes. Surgical treatment is quite successful in these patients; however, the literature reports a wide range of rates of return to sport. Purpose/Hypothesis: The purpose was to determine the return-to-sport rates after surgical stabilization for posterior shoulder instability. It was hypothesized that patients would experience a high rate of return to sport. Study Design: Systematic review and meta-analysis; Level of evidence, 4. Methods: Embase, PubMed, and MEDLINE were searched for relevant literature from database inception until April 2020, and studies were screened by 2 reviewers independently and in duplicate for studies reporting rates of return to sport after surgical management of posterior shoulder instability. Demographic data as well as data on return to sport and functional outcomes were recorded. A meta-analysis of proportions was used to combine the rates of return to sport using a random effects model. A risk of bias was assessed for all included studies. Results: Overall, 32 studies met inclusion criteria and comprised 1100 patients (1153 shoulders) with a mean age of 22.8 years (range, 11-65) and a mean follow-up of 43.2 months (range, 10-228). The pooled rate of return to any level of sport was 88% (95% CI, 84%-92%; I2 = 68.7%). In addition, the pooled rate of return to the preinjury level was 68% (95% CI, 60%-76%; I2 = 79%). Moreover, the pooled return-to-sport rate for contact athletes was 94% (95% CI, 90%-97%; I2 = 0%), while for throwing athletes it was 88% (95% CI, 83%-92%; I2 = 0%). Conclusion: Surgical management of posterior shoulder instability resulted in a high rate of return to sport, as well as significant pain reduction and functional improvement in most patients. However, only two-thirds of athletes can return to their preinjury levels of sport.

Background Opioids continue to be the analgesic of choice for postoperative pain control following arthroscopic knee and shoulder surgery. Despite their widespread use, there are limited evidence-based clinical practice guidelines for postoperative opioid prescribing. The Non-Opioid Prescriptions after Arthroscopic Surgery in Canada (NO PAin) Trial is a randomized controlled trial (RCT) designed to determine whether a non-opioid analgesia approach to postoperative pain, compared to usual care, reduces oral morphine equivalents (OME) consumed in patients undergoing outpatient knee and shoulder arthroscopy. Methods This is a multi-centre, RCT with a target sample size of 200 patients. Adult (18+ years of age) patients undergoing outpatient knee and shoulder arthroscopy will be randomized to a non-opioid postoperative protocol (intervention) or the current standard of care (control). The intervention will consist of a standardized non-opioid analgesic prescription, a limited rescue opioid prescription, and a patient education infographic. The control is defined as the treating surgeons’ pre-trial postoperative analgesic regimen. Exclusion criteria include chronic opioid use, concomitant open surgery, contraindications to the prescribed analgesics or ongoing workers compensation/litigation. The primary outcome is OMEs consumed at 6 weeks postoperatively. Secondary outcomes will include patient-reported pain and satisfaction, quantity of OMEs prescribed, number of opioid refills, and any adverse events up to 6 weeks postoperatively. Utilizing the intention to treat principle for all analyses, independent samples t-test and presented with a p-value as well as a mean difference (MD) with 95% confidence intervals (CIs) will be performed for primary and secondary outcomes. Discussion The ongoing opioid epidemic and overprescribing of opioids in orthopaedics serve as the rationale for this trial. There is a lack of evidence upon which to develop post-operative pain management guidelines for patients undergoing arthroscopic surgery. A prospective evaluation of this relatively inexpensive intervention will demonstrate whether an explicit effort to reduce the number of opioids prescribed results in a reduction in the amount of opioids consumed and help to inform future studies and guidelines. Trial registration The NO PAin trial has been prospectively registered with clinicaltrials.gov (NCT04566250).

Femoroacetabular impingement (FAI) is a hip disorder which can often present bilaterally. The purpose of this systematic review was to explore the current practices for bilateral hip arthroscopy in treating FAI as they relate to outcomes and complications.This review has been conducted according to the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA). The electronic databases PubMed, MEDLINE, EMBASE, and CENTRAL (Cochrane Central Register of Controlled Trials) were searched from data inception to October 18th, 2020. The Methodological Index for Non-randomized Studies (MINORS) was used to assess study quality. Data are presented descriptively.Overall, 19 studies were identified, comprising 957 patients (48.6% male) with a mean age of 27.9 ± 7.1 years and a mean follow-up of 31.7 ± 20.8 months. The majority of patients were treated with a staged bilateral hip arthroscopy (78.5%) with a mean duration between surgeries of 7.1 ± 4.0 months. Significant preoperative-to-postoperative improvements for clinical outcomes such as pain, hip function, and health-related daily living as well as radiographic outcomes were reported in six studies for staged procedures (p 0.05) and three studies for simultaneous procedures (p 0.02). Significant improvements in patient-reported outcomes (e.g., HOS-ADL, Pain, HOS-SS, mHHS, and NAHS) were found in favor of those undergoing a shorter delay between surgeries in three studies (i.e., 3, 10 or 17 months) (p 0.05) compared to those who had delayed surgeries (i.e., 3, 10, or 17 months). The overall complication rate was 10.1% (97/957).Bilateral surgery for FAI yields improved outcomes postoperatively and complication rates similar to unilateral surgery. The overall complication rate was 10.1% with the most common complication being revision surgery. Staged bilateral surgery is more commonly performed than simultaneous surgery. Clinicians should consider preoperative imaging, clinical history, and patient values when deciding between staged and simultaneous procedures for bilateral FAI surgery. Future studies are required to determine the optimal indications for simultaneous versus staged procedures, as well as the ideal timing between surgeries for the latter.Level IV.

Purpose To determine whether arthroscopic osteochondroplasty demonstrated effectiveness in a pragmatic femoroacetabular impingement patient population embedded within FIRST (the Femoroacetabular Impingement RandomiSed controlled Trial). Methods All cohort patients were not randomized and were followed prospectively with a follow-up assessment protocol identical to that in FIRST. The primary outcome was hip pain using a 100-point visual analog scale. Secondary outcomes included hip function (Hip Outcome Score, International Hip Outcome Tool-12), health utility (EuroQol 5 Dimensions), and health-related quality of life (Short Form-12) at 12 months, as well as operatively and nonoperatively treated hip complications at 24 months. We performed multivariable regressions to compare these outcomes between 3 groups of patients: (1) those randomized to lavage in FIRST, (2) those randomized to osteochondroplasty in FIRST, and (3) those who received osteochondroplasty as part of the cohort study. Results All groups had improvements across all questionnaire outcomes from baseline to 12 months, with no significant differences. There were significantly more reoperations in the lavage trial group compared with those in the embedded cohort (adjusted odds ratio [aOR] 3.08; 95% confidence interval [CI] 1.23-7.73; P = .016). There were significantly more nonoperatively treated hip complications in the lavage trial group and in the osteochondroplasty trial group when compared with those in the embedded cohort (aOR 3.81; 95% CI 1.19-12.17; P = .024 and aOR 4.55; 95% CI 1.43-14.42; P = .010, respectively). Conclusions Hip arthroscopic osteochondroplasty and lavage led to improvement in hip pain, function, and health-related quality of life at 12 months across both randomized controlled trial (RCT) and cohort patients. The pragmatic cohort receiving osteochondroplasty had (1) significantly fewer complications than RCT patients, (2) significantly less reoperations than RCT patients randomized to arthroscopic lavage, and (3) fewer, although nonsignificant, reoperations than RCT osteochondroplasty patients. Level of Evidence II, therapeutic.

Imaging assessment for the clinical management of femoroacetabular impingement (FAI) is controversial because of a paucity of evidence-based guidance and notable variability among practitioners. Hence, expert consensus is needed because standardised imaging assessment is critical for clinical practice and research. We aimed to establish expert-based statements on FAI imaging by using formal methods of consensus building. The Delphi method was used to formally derive consensus among 30 panel members from 13 countries. Forty-four questions were agreed upon, and relevant seminal literature was circulated and classified in major topics to produce answering statements. The level of evidence was noted for all statements, and panel members were asked to score their level of agreement (0–10). This is the second part of a three-part consensus series and focuses on ‘General issues’ and ‘Parameters and reporting’. Forty-seven statements were generated and group consensus was reached for 45. Twenty-five statements pertaining to ‘General issues’ (9 addressing diagnosis, differential diagnosis, and postoperative imaging) and ‘Parameters and reporting’ (16 addressing femoral/acetabular parameters) were produced. The available evidence was reviewed critically, recommended criteria for diagnostic imaging highlighted, and the roles/values of different imaging parameters assessed. Radiographic evaluation (AP pelvis and a Dunn 45° view) is the cornerstone of hip-imaging assessment and the minimum imaging study that should be performed when evaluating adult patients for FAI. In most cases, cross-sectional imaging is warranted because MRI is the ‘gold standard’ imaging modality for the comprehensive evaluation, differential diagnosis assessment, and FAI surgical planning. • Diagnostic imaging for FAI is not standardised due to scarce evidence-based guidance on which imaging modalities and diagnostic criteria/parameters should be used. • Radiographic evaluation is the cornerstone of hip assessment and the minimum study that should be performed when assessing suspected FAI. Cross-sectional imaging is justified in most cases because MRI is the ‘gold standard’ modality for comprehensive FAI evaluation. • For acetabular morphology, coverage (Wiberg’s angle and acetabular index) and version (crossover, posterior wall, and ischial spine signs) should be assessed routinely. On the femoral side, the head–neck junction morphology (α° and offset), neck morphology (NSA), and torsion should be assessed.

The original version of this article, published on 14 May 2020, unfortunately contained a mistake.

Context: Energy drinks are the fastest growing product in the beverage industry. However, there is concern regarding potential for adverse effects with use. Objective: To evaluate the reported adverse effects of energy drink consumption. Data Sources: The electronic databases MEDLINE, EMBASE, and PubMed were searched for relevant studies from inception to November 2019, and pertinent data were abstracted. Study Selection: Only clinical studies reporting adverse events after energy drink consumption were included. Study Design: Systematic review. Level of Evidence: Level 4. Data Extraction: Data regarding sample size characteristics, energy drink characteristics, comparators, and all adverse events were extracted in duplicate and recorded. Results: A total of 32 studies and 96,549 individuals were included. Frequently reported adverse events in the pediatric population were insomnia (35.4%), stress (35.4%), and depressive mood (23.1%). Frequently reported adverse events in the adult population were insomnia (24.7%), jitteriness/restlessness/shaking hands (29.8%), and gastrointestinal upset (21.6%). Alcohol mixed with energy drinks significantly reduced the likelihood of sedation effects but increased the likelihood of stimulatory effects. Energy drink consumption significantly increased the odds of insomnia (OR, 5.02; 95% CI, 1.72-14.63) and jitteriness/activeness (OR, 3.52; 95% CI, 1.28-9.67) compared with the control group. Conclusion: The authors recommend that individuals avoid frequent energy drink consumption (5-7 energy drinks/week) and avoid co-consumption with alcohol; increased regulatory standards should be placed in the sale of energy drinks, particularly with regard to the pediatric population.

The purpose of this systematic review is to assess outcomes and complications of patients undergoing Salter’s innominate osteotomies (SIOs) for the correction of hip dysplasia along with patient and technical factors that can be optimized to improve outcomes after SIO. MEDLINE and EMBASE were searched from data inception to 9 October 2018. Data were presented descriptively. Twenty-seven studies were identified including 1818 hips (87.1%) treated with SIO (mean age of 2.1 ± 2.5 years and mean follow-up of 3.5 ± 5.0 years). Patients undergoing SIO had a post-operative center-edge angle (CEA) of 31.3° ± 5.3° and an acetabular index (AI) angle of 16.1° ± 5.2°. Patients undergoing SIO with pre-operative traction had significantly lower (P = 0.049) post-operative McKay criteria scores compared to patients without pre-operative traction. Patients undergoing SIO between the ages of 1.5–2 years had significantly better (P

Background:Femoroacetabular impingement (FAI) is a condition known to cause hip pain in young adults.Purpose:To evaluate the efficacy of the surgical correction of FAI via arthroscopic osteochondroplasty with or without labral repair compared with arthroscopic lavage of the hip joint with or without labral repair.Study Design:Randomized controlled trial; Level of evidence, 1.Methods:A total of 220 male and female participants aged 18 to 50 years with nonarthritic FAI suitable for surgical treatment were recruited for the trial at 10 clinical centers in Canada, Finland, and Denmark between October 2012 and November 2017, of whom 214 were included in the final analysis. In the osteochondroplasty group, cam- and/or pincer-type lesions were resected using fluoroscopic guidance. In the lavage group, the joint was washed out with 3 L of normal saline. Surgeons were instructed to repair the labrum in both groups if it was mechanically unstable once probed, showing visible displacement or chondrolabral separation. The primary outcome was patient-reported pain (using the 100-point visual analog scale [VAS]) at 12 months. Secondary outcomes included hip function (Hip Outcome Score [HOS] and International Hip Outcome Tool), physical and mental health (12-Item Short Form Health Survey), and health utility (EuroQol–5 Dimensions) at 12 months as well as any reoperations and other hip-related adverse events at 24 months.Results:At 12 months, there was no difference in pain (VAS) between the groups (mean difference [MD], 0.11 [95% CI, –7.22 to 7.45]; P = .98). Also, 88.3% (189/214) of participants had a labral tear, of which 60.3% were repaired. For the secondary outcomes, there were no significant differences between treatment groups, with the exception of the HOS activities of daily living domain in which lavage showed significant improvement compared with osteochondroplasty (MD, –5.03 [95% CI, −10.40 to −0.03]; P = .049). By 24 months, there were significantly fewer reoperations reported in the osteochondroplasty group (8/105) than the lavage group (19/104) (odds ratio, 0.37 [95% CI, 0.15-0.89]; P = .026). The primary reasons for a reoperation included hip pain (15/27; 55.6%) and a reinjury of the labrum (11/27; 40.7%).Conclusion:Both the osteochondroplasty and the lavage groups with or without labral repair for FAI had significantly improved pain or function significantly at 1 year. By 2 years, the reoperation rate was significantly lower in the osteochondroplasty group.Registration:NCT01623843 ( ClinicalTrials.gov identifier)

The purpose of this study was to examine the existing literature to determine the dimensions of the acetabular labrum, with a focus on hypotrophic labra, including the modalities and accuracy of measurement, factors associated with smaller labra, and any impacts on surgical management. Four databases (PubMed, Ovid [MEDLINE], Cochrane Database, and EMBASE) were searched from database inception to January 2020. Two reviewers screened the literature independently and in duplicate. Methodological quality of included papers was assessed using the Methodological Index for Non-Randomized Studies (MINORS) criteria. Where possible, data on labral size were combined using a random effects model. Twenty-one studies (5 level II, 9 level III, 7 level IV) were identified. This resulted in 6,159 patients (6,436 hips) with a mean age of 34.3 years (range 8.4–85). The patients were 67.3% female with an average follow-up of 57.3 months. There was no consistent definition of labral size quoted throughout the literature. The mean width on MRI/MRA was 7.3 mm (95% CI 6.9–7.8 mm), on computed tomography arthrography was 8.7 mm (95% CI 8.0–9.3), and during arthroscopy was 5.0 mm (95% CI 4.9–5.2). Inter-observer reliability was good to excellent in all modalities. Labral hypotrophy may be associated with increased acetabular coverage. Hypertrophic labra were highly associated with acetabular dysplasia (r = − 0.706, − 0.596, − 0.504, respectively; P

The learning curve of hip arthroscopy has been described as steep. A wide range, between 30 and 520 cases, has been gathered as the learning curve before complications are minimized. While the precise number of cases required for proficiency has remained elusive, the heterogeneity in surgeon profile and baseline training can serve as an explanation. Moreover, as caseload increases, case complexity, revision surgeries, and outside referrals may begin to consume the greater-volume surgeon. While the learning curve remains hard to define, innovations in surgical training hold the promise of improving proficiency. Regardless of career stage, hip arthroscopists can still expect improved patient outcomes with appropriate indications and a properly executed procedure.

Background: Arthroscopic iliopsoas tendon release is a surgical treatment option for painful snapping hips, although it has been associated with controversy surrounding potential complications including decreased hip flexion strength, iatrogenic hip instability, and iliopsoas atrophy. Purpose: To systematically assess the efficacy and safety of arthroscopic iliopsoas tenotomy during hip arthroscopic surgery as an intervention for painful snapping hips. Study Design: Systematic review; Level of evidence, 4. Methods: A total of 3 online databases (Embase, PubMed, and MEDLINE) were searched from database inception until September 2019 for studies investigating iliopsoas tenotomy during hip arthroscopic surgery. Studies were screened by 2 reviewers independently and in duplicate, and studies investigating arthroscopic iliopsoas tendon release were included. Demographic data as well as data on treatment success, functional outcome scores, and radiological outcomes were recorded. A risk of bias assessment was performed for all included studies. Results: Overall, 21 studies were identified with a total of 824 patients (875 hips). These patients were 82.5% female (680/824), with a mean age of 28.1 years (range, 12-62 years) and mean follow-up of 32.1 months (range, 3-73 months). Arthroscopic iliopsoas tenotomy was performed at the level of the labrum in 811 hips (92.7%) or the lesser trochanter in 64 hips (7.3%). The overall reported success rate of the procedure in resolving snapping hips was 93.0% (266/286), and all studies reported an improvement in functional outcome scores. Only 6 studies (93 hips) discussed postoperative hip flexion strength, with complete recovery of strength reported in 4 studies (47 hips) and mild decreases reported in the other 2 studies (46 hips). Iliopsoas atrophy was evaluated radiologically (3 studies; 66 hips) and was found postoperatively in 92.4% (61/66) of hips. No major complications were reported. Conclusion: Arthroscopic release of the iliopsoas tendon was effective in alleviating pain and persistent clicking associated with a snapping hip. Although patients demonstrated some early postoperative weakness and iliopsoas atrophy on radiological imaging, the results from studies to date showed satisfactory clinical function and return to sports/activities. High-quality comparative studies are needed to further assess arthroscopic iliopsoas tendon release to determine the optimal technique and location of tendon release.

Objective To explore a novel ultrasound-guided injection technique of releasing extra-articular anterior hip adhesions in arthroscopically treated femoroacetabular impingement patients. Materials and methods IRB-approved pilot study included 24 consecutive patients referred for ultrasound-guided injection (Jan 1, 2017–Mar 31, 2018) with anterior hip pain and/or limited hip flexion following arthroscopic treatment for femoroacetabular impingement. They underwent ultrasound-guided pressure injection, releasing post-operative extra-articular adhesions between the joint capsule and flexor tendons along the arthroscopic portal followed by steroid instillation. A visual analogue pain score of 0–10 and standard Hip Outcome Score was used to record treatment response pre-injection, at 6 weeks and at 6 months following injection. Results Nine out of 11 patients (complete data group) who answered all questionnaires showed response to injection with improvement in Hip Outcome Scores at 6 weeks and 6 months. Three out of 10 patients (incomplete data group) showed significant response to injection from clinical follow-up records. No records were available in 3 patients. In total, 12 (57.14%) out of 21 patients showed response to injection. No post-procedure complications. Conclusion Ultrasound-guided pressure injection is a novel, safe, and effective procedure providing pain relief and improved hip movement as evaluated in our small sample study. The limitations of this pilot project include small sample size, lack of control group, short 6-month follow-up, and single institution study. This minimally invasive technique could be a cost-effective alternative to surgical adhesiolysis and can potentially be extended for extra-articular adhesions at other peripheral joints, amenable to ultrasound.