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1.  Is Posterior Hip Instability Associated with Cam and Pincer Deformity? 
Posterior hip instability is an increasingly recognized injury in athletes; however, the function of patients after these injuries and an understanding of the pathoanatomy and underlying mechanism are currently unclear.
We determined (1) the function of patients after these hip injuries using validated, self-reported outcome instruments and (2) the specific pathoanatomy sustained in these events to better understand the mechanism of posterior hip instability.
We reviewed the records of all 22 athletes presenting to our clinics with a posterior acetabular rim fracture confirming a posterior hip instability episode. Radiograph, CT, and MRI findings were documented in all patients. Intraoperative findings were recorded in patients undergoing surgery. There were 19 males and three females with an average age of 22 years (range, 13–31 years). Minimum followup was 2 years (average, 4 years; range, 2–16 years).
The mean modified Harris hip score was 94, Hip Outcome Scores for Activities of Daily Living and Sport were 99 and 87, respectively, and 20 of 22 athletes returned to sport. The most common constellation of pathoanatomy was a posterior labral tear with rim fracture, anterior labral tear, capsular tear, ligamentum teres avulsion, and chondral injury of the femoral head with loose bodies. Sixteen of the 18 patients with femoroacetabular impingement (FAI) had a twisting or noncontact mechanism of injury.
When posterior hip subluxation is recognized and avascular necrosis avoided, these athletes generally have high functional outcome scores and high rates of return to sport. There is an apparent association between the occurrence of posterior hip instability and the presence of structural abnormalities often associated with FAI, which may contribute to a mechanism of FAI-induced posterior subluxation.
Level of Evidence
Level IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence
PMCID: PMC3492598  PMID: 22879091
2.  An Algorithmic Approach to Mechanical Hip Pain 
HSS Journal  2012;8(3):213-224.
As our understanding of hip pathology evolves, the focus is shifting toward earlier identification of hip pathology. Therefore, it is vitally important to elucidate intra-articular versus extra-articular pathology of hip pain in every step of the patient encounter: history, physical examination, and imaging.
The objective was to address the following research questions: (1) Can an algorithmic approach to physical examination of a painful non-arthritic hip provide a more accurate diagnosis and improved treatment plan? (2) Does an anatomical layered concept of clinical diagnosis improve diagnostic accuracy? (3) What are the diagnostic tools necessary for the accurate application of a four-layer (osteochondral, inert, contractile, and neuromechanical) diagnosis?
An unrestricted computerized search of MEDLINE was conducted. Different terms were used in various combinations.
An algorithmic approach to physical examination of a painful nonarthritic hip, including history, physical examination (specific tests), and advanced imaging allow for better interpretation of debilitating intra- and extra-articular disorders and their effect on core performance. Additionally, it improves our understanding as to how underlying abnormal joint mechanics may predispose the hip joint and the associated hemipelvis to asymmetric loads. These abnormal joint kinematics (layer I) can lead to cartilage and labral injury (layer II), as well as resultant injury to the musculotendinous (layer III) and neural structures (layer IV) about the hip joint and the hemipelvis. The layer concept is a systematic means of determining which structures about the hip are the source of hip pathology and how to best implement treatment.
A clear understanding of the differential diagnosis of hip pain through a detailed and systematic physical examination, diagnostic imaging assessment, and the interpretation of how mechanical factors can result in such a wide range of compensatory injury patterns about the hip can facilitate the diagnosis and treatment recommendations.
PMCID: PMC3470663  PMID: 24082863
hip pain; mechanical hip pain; intra-articular hip pathology; extra-articular hip pathology; physical examination of the hip joint
3.  Preoperative Three-dimensional CT Predicts Intraoperative Findings in Hip Arthroscopy 
Currently, plain radiographs and MRI are the standard imaging modalities used for diagnosing femoroacetabular impingement (FAI) and preoperative planning for arthroscopic treatment of FAI. The value of three-dimensional (3D) CT for these purposes is unclear.
We therefore determined the reliability of CT assessment of FAI and whether CT findings of hip disease predict arthroscopic findings.
We retrospectively assessed the preoperative CT scans of 118 patients who underwent primary hip arthroscopy. Intraoperative findings, including size of the cam lesion, presence of an acetabular labral articular disruption lesion, and one of four types of labral tear were recorded and compared with the retrospectively read CT findings.
Agreement analysis between CT and intraoperative detection of FAI yielded kappa values of 0.48 for cam lesions and 0.16 for pincer lesions. Increasing values for the CT-based alpha angle correlated with increasing severity of arthroscopically assessed acetabular labral articular disruption grade. Each pattern of FAI predicted a specific labral tear type.
Our data suggest CT has moderate value in predicting mechanically based labral tear patterns, although better parameters for assessment of pincer lesions are needed. Diagnostic assessment of patients with suspected FAI may be improved with use of 3D CT.
Level of Evidence
Level III, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.
PMCID: PMC3369089  PMID: 22528376
4.  Hip Injuries in the Overhead Athlete 
The overhead athlete is at risk for shoulder and elbow injuries. However, the mechanics associated with overhead sports also place athletes at risk for hip injuries. Advancements in hip arthroscopy have identified femoroacetabular impingement (FAI) and instability as potential contributors to labral and chondral pathology in this athletic population.
We therefore determined whether hip function improves after arthroscopic treatment of FAI in overhead athletes and the rate at which overhead athletes returned to preinjury level of play.
We retrospectively identified high-level baseball and lacrosse players (varsity high school, collegiate, and professional) who underwent arthroscopic treatment for FAI. Thirty-four athletes with an average age of 21.4 years met study criteria. There were 16 baseball players and 18 lacrosse players. All patients completed modified Harris hip scores and were assessed for ability to return to preinjury level of play. The minimum followup was 12 months (average, 25 months; range 12–41 months).
Mean modified Harris hip scores improved from 70 to 92. Thirty-three of 34 patients were able to return to preinjury level of sports participation.
Arthroscopic management of hip injuries in the high-level overhead throwing athlete can result in a high rate of return to play. Mechanical overload of the hip from impingement and secondary instability can have a substantial effect on hip function and may be the cause of deterioration in athletic performance in some cases.
Level of Evidence
Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
PMCID: PMC3348320  PMID: 22415726
5.  Hip Arthroscopy Improves Symptoms Associated with FAI in Selected Adolescent Athletes 
Femoroacetabular impingement (FAI) is increasingly diagnosed in young and middle-aged patients. Although arthroscopic procedures are becoming frequently used in the treatment of FAI, there are little data regarding rates of complications or the ability of hip arthroscopy to improve hip function specifically in the adolescent athlete population. Because arthroscopic treatment is being used in the treatment of FAI, it is vital to know what, if any, improvements in hip function can be expected and the potential complications.
We asked (1) whether validated measures of hip function improve after arthroscopic treatment of FAI in adolescent athletes, and (2) what complications might be expected during and after arthroscopic treatment of FAI in these patients.
We retrospectively reviewed the records of 27 hips in 21 patients 19 years of age or younger who underwent arthroscopic treatment for FAI between 2007 and 2008. From the records we extracted demographic data, operative details, complications, and preoperative and postoperative modified Harris hip scores (HHS) and the Hip Outcome Score (HOS). The minimum followup was 1 year (average, 1.5 years; range, 1–2.5 years).
Modified HHS improved by an average of 21 points, the activities of daily living subset of the HOS improved by an average of 16 points, and the sports outcome subset of the HOS improved by an average of 32 points. All patients’ self-reported ability to engage in their preoperative level of athletic competition improved. In 24 hips that underwent cam decompression, the mean alpha-angle improved from 64° ± 16° to 40° ± 5.3° postoperatively.
We found short-term improvements in HOS and HHS with no complications for arthroscopic treatment of FAI in our cohort of adolescent athletes. We believe arthroscopic treatment of FAI by an experienced hip arthroscopist should be considered in selected patients when treating athletically active adolescents for whom nonoperative management fails.
Level of Evidence
Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
PMCID: PMC3238006  PMID: 21833657
6.  Defining the Origins of the Iliofemoral, Ischiofemoral, and Pubofemoral Ligaments of the Hip Capsuloligamentous Complex Utilizing Computer Navigation 
HSS Journal  2011;7(3):239-243.
To use computer navigation software to investigate the specific origins of the hip capsuloligamentous complex.
Six fresh frozen cadaver hips were anatomically landmarked utilizing a three-dimensional computer navigation system. The acetabular origins of the iliofemoral, pubofemoral, and ischiofemoral ligaments were statically digitized. Computer software was used to create a 180° (6:00) meridian line positioned over the midpoint of the acetabular notch, and to present the results in a clocklike manner in hours and minutes (00:00) and also degrees relative to the 12 o’clock position.
The iliofemoral ligament origin starts at 17° (±31°) from the 12 o’clock position, or 12:35 (±1:02) in hours and minutes, and ends at 69° (±13°) or 2:18 (±0:25), spanning a mean distance of 52° (±19°). The ischiofemoral ligament has the broadest origin, starting at 262° (±12°) or 8:44 (±0:24), and ending at 353° (±17°) or 11:45 (±0:14), spanning a mean distance of 90° (±6°). The pubofemoral ligament origin is the smallest, starting at 121° (±5°) or 4:02 (±0:11), and ending at 163° (±9°) or 5:27 (±0:18), spanning a mean distance of 42° (±5°). The iliofemoral ligament origin demonstrates the greatest anatomic variability with regards to its location and its size (p = 0.002).
This study demonstrates that there is significant variability in the size and location of the iliofemoral ligament origin versus the pubofemoral and ischiofemoral ligaments.
Level of Evidence
Level IV anatomic cadaveric study. See the guidelines online for a complete description of level of evidence.
PMCID: PMC3192898  PMID: 23024620
hip ligaments; computer navigation; hip capsule; hip arthroscopy
7.  Iliopsoas Impingement: A Newly Identified Cause of Labral Pathology in the Hip 
HSS Journal  2011;7(2):145-150.
Labral tears typically occur anterosuperiorly in association with femoroacetabular impingement or dysplasia. Less commonly, labral pathology may occur in an atypical direct anterior location adjacent to the iliopsoas tendon in the absence of bony abnormalities. We hypothesize that this pattern of injury is related to compression or traction on the anterior capsulo-labral complex by the iliopsoas tendon where it crosses the acetabular rim. In a retrospective review of prospectively collected data, we identified 25 patients that underwent isolated, primary, unilateral iliopsoas release and presented for at least 1 year follow-up (mean 21 months). Pre-operative demographics, clinical presentation, intra-operative findings, and outcome questionnaires were analyzed. The injury was treated with a tenotomy of the iliopsoas tendon at the level of the joint line and either labral debridement or repair. Mean post-operative outcome scores were 87.17, 92.46, and 78.8 for the modified Harris Hip Score, activities of daily living Hip Outcome Score, and sports-related score, respectively. The atypical labral injury identified in this study appears to represent a distinct pathological entity, psoas impingement, with an etiology which has not been previously described.
PMCID: PMC3145856  PMID: 22754415
psoas impingement; hip arthroscopy; labral tears
8.  Improved Arthroscopic Visualization of Peripheral Compartment 
Arthroscopy Techniques  2012;1(1):e57-e62.
Femoroacetabular impingement is a recognized cause of hip pain and motion restrictions. Advancements in hip arthroscopy have allowed surgeons the ability to treat this condition more effectively. However, the learning curve is steep for osteochondroplasty of the femoral head-neck junction in the peripheral compartment. Therefore we present a reproducible technique that allows improved visualization of the peripheral compartment and treatment of the cam lesion with hip arthroscopy. Our technique uses the anterior portal as a viewing portal, a distal anterolateral accessory portal as a working portal, and the anterolateral portal for soft-tissue retraction.
PMCID: PMC3678621  PMID: 23766977
9.  CT Reveals a High Incidence of Osseous Abnormalities in Hips with Labral Tears 
Acetabular labral tears are being diagnosed with increasing frequency and there is a growing consensus that these tears rarely occur in the absence of osseous abnormalities.
We therefore determined the presence of structural abnormalities in patients with acetabular labral tears using a standardized CT protocol.
We evaluated 135 consecutive patients with labral tears diagnosed by MRI with CT scans of the symptomatic hip. The CT scans were evaluated in a standardized fashion to determine acetabular and femoral pathomorphologic features. Acetabular evaluation included version measurements and anterior and lateral center-edge angles. Femoral parameters evaluated included version, alpha angle, and neck-shaft angle.
One hundred twenty-two (90%) of the 135 hips had structural abnormalities. One hundred two (76%) had an alpha angle greater than 50°, 18 (13%) had femoral version less than 5°, 22 (16%) had femoral version greater than 25º, and five (4%) had coxa valga. Fifty-eight (43%) patients had acetabular retroversion and five (4%) had a lateral center-edge angle less than 20º. Of the 58 patients with acetabular retroversion, 23 had isolated cranial retroversion, 12 had isolated central retroversion, and 23 had combined cranial and central retroversion. Sixty-seven of the 121 hips (55%) with bony abnormalities had a combination of abnormalities.
Ninety percent of patients with labral tears had structural abnormalities seen on CT scans. These structural abnormalities frequently occur in combination, and understanding these underlying morphologic features of the hip can help guide treatment.
Level of Evidence
Level IV, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.
PMCID: PMC3032877  PMID: 20886325
10.  The layer concept: utilization in determining the pain generators, pathology and how structure determines treatment 
The level of understanding of pain in the non-arthritic hip has made significant strides in the last couple of decades beginning with the discoveries of Reinhold Ganz, MD. However, even with the detection of subtle bony abnormalities, including femoroacetabular impingement, a clinician’s ability to differentiate pain generators in the hip has been ambiguous. Deciphering the etiology of the pathology versus the pain generator is essential in prescribing the proper treatment. The Layer Concept developed by Dr. Bryan Kelly, is a systematic means of determining which structures about the hip are the source of the pathology, which are the pain generators and how to then best implement treatment. Four layers will be discussed in this article. Layer I, the osseous layer, Layer II, the inert tissue layer, Layer III, the contractile layer and Layer IV, the neuromechanical layer.
PMCID: PMC3535125  PMID: 22371303
Femoroacetabular impingement; Hip arthroscopy; Bony pathology; Capsular laxity; Neuromuscular control
11.  Traumatic Osteochondral Injury of the Femoral Head Treated by Mosaicplasty: A Report of Two Cases 
HSS Journal  2010;6(2):228-234.
The increased risk of symptomatic progression towards osteoarthritis after chondral damage has led to the development of multiple treatment options for cartilage repair. These procedures have evolved from arthroscopic lavage and debridement, to marrow stimulation techniques, and more recently, to osteochondral autograft and allograft transplants, and autogenous chondrocyte implantation. The success of mosaicplasty procedures in the knee has led to its application to other surfaces, including the talus, tibial plateau, patella, and humeral capitellum. In this report, we present two cases of a chondral defect to the femoral head after a traumatic hip dislocation, treated with an osteochondral autograft (OATS) from the ipsilateral knee, and the inferior femoral head, respectively, combined with a surgical dislocation of the hip. At greater than 1 year and greater than 5 years of follow-up, MRI studies have demonstrated good autograft incorporation with maintenance of articular surface conformity, and both patients clinically continue to have no pain and full active range of motion of their respective hips. In our opinion, treatment of osteochondral defects in the femoral head surface using a surgical dislocation combined with an OATS procedure is a promising approach, as full exposure of the femoral head can be obtained while preserving its vasculature, thus enabling adequate restoration of the articular cartilage surface.
PMCID: PMC2926357  PMID: 21886541
hip dislocation; osteochondral autograft transplant; femoral head; osteochondral defect; osteochondral injury; mosaicplasty
12.  Arthroscopic Anterior and Posterior Labral Repair After Traumatic Hip Dislocation: Case Report and Review of the Literature 
HSS Journal  2010;6(2):223-227.
With the improvements in flexible instrumentation, hip arthroscopy is being increasingly used to treat a variety of hip pathology, including labral tears. However, up to this point, there has not been a case report of an anterior and a posterior labral tear successfully repaired arthroscopically. We present a case report of a 27-year-old male firefighter who presented to our institution with an anterior and posterior labral tear, as well as a cam lesion and loose body, following a traumatic hip dislocation. The purpose of this case report is to illustrate that both anterior and posterior labral tears can be repaired using hip arthroscopy. Anterior and posterior labral tears can be caused by a traumatic hip dislocation, and both can be successfully repaired using arthroscopic techniques.
PMCID: PMC2926365  PMID: 21886540
anterior; posterior; hip; labral tear; traumatic dislocation; arthroscopy repair
14.  Subacromial Injection Improves Deltoid Firing in Subjects with Large Rotator Cuff Tears 
HSS Journal  2009;6(1):30-36.
Previous studies demonstrate that scapulohumeral mechanics improve after subacromial injection. However, it is unclear how injection affects muscle firing. Forty-one subjects with two-tendon rotator cuff tears and 23 volunteer subjects with normal rotator cuffs documented by ultrasonography were examined. Electromyographic activity from 12 muscles was collected during ten functional tasks. Nine symptomatic subjects with rotator cuff tears underwent subacromial injection of anesthetic and underwent repeat electromyographic examination. Subjects with rotator cuff tears demonstrate global electromyographic differences when compared to normal controls. Asymptomatic subjects with rotator cuff tears had significantly increased anterior deltoid firing when compared to symptomatic counterparts during forward shoulder elevation. After subacromial injection, symptomatic subjects demonstrate increased anterior deltoid firing. Previous in vitro and in vivo studies have suggested that pain leads to deltoid inhibition and that subacromial injection leads to improved deltoid firing and, subsequently, improved shoulder function. This study provides direct evidence that subacromial injection improves deltoid firing in symptomatic subjects with rotator cuff tears. These findings reinforce the concept that deltoid inhibition resulting from pain is an important component of the motor disability associated with rotator cuff tears.
PMCID: PMC2821485  PMID: 19763696
rotator cuff injuries; intra-articular injection; local anesthetics; electromyography; biomechanics; shoulder joint; muscle; tendon injuries; pain; adult; human
16.  Arthroscopic management of an intraarticular osteochondroma of the hip 
Orthopedic Reviews  2009;1(1):e2.
The role of hip arthroscopy in the management of femoroacetabular impingement (FAI) has been advancing rapidly. In this case report, we describe the use of hip arthroscopy to successfully treat a femoral neck osteochondroma that caused a symptomatic labral tear in a 37 year old woman. Hip arthroscopy offers several advantages to surgical dislocation of the hip in the management of intraarticular pathology and FAI. Hip arthroscopy is minimally invasive without the significant trauma to hip musculature, is useful in treatment of labral tears generated by FAI, and can be used to resect small lesions on the femoral head.
PMCID: PMC3143959  PMID: 21808666
hip arthroscopy; osteochondroma; femoroacetabular impingement; labral tear.
17.  Hip Arthroscopy Update 
HSS Journal  2005;1(1):40-48.
The management of hip injuries in the athlete has evolved significantly in the past few years with theadvancement of arthroscopic techniques. The application of minimally invasive surgical techniques has facilitated relatively rapid returns to sporting activity in recreational and elite athletes alike. Recent advancements in both hip arthroscopy and magnetic resonance imaging have elucidated several sources of intraarticular pathology that result in chronic and disabling hip symptoms. Many of these conditions were previously unrecognized and thus, left untreated. Current indications for hip arthroscopy include management of labral tears, osteoplasty for femoroacetabular impingement, thermal capsulorrhaphy and capsular plication for subtle rotational instability and capsular laxity, lateral impact injury and chondral lesions, osteochondritis dissecans, ligamentum teres injuries, internal and external snapping hip, removal of loose bodies, synovial biopsy, subtotal synovectomy, synovial chondromatosis, infection, and certain cases of mild to moderate osteoarthritis with associated mechanical symptoms. In addition, patients with long-standing, unresolved hip joint pain and positive physical findings may benefit from arthroscopic evaluation. Patients with reproducible symptoms and physical findings that reveal limited functioning, and who have failed an adequate trial of conservative treatment will have the greatest likelihood of success after surgical intervention. Strict attention to thorough diagnostic examination, detailed imaging, and adherence to safe and reproducible surgical techniques, as described in this review, are essential for the success of this procedure.
PMCID: PMC2504137  PMID: 18751808

Results 1-17 (17)