Systematic Review

Extra-Articular Hip Impingement: A Systematic Review Examining Operative Treatment of Psoas, Subspine, Ischiofemoral, and Greater Trochanteric/Pelvic Impingement Darren de SA, M.D., Hussain Alradwan, M.B.B.S., F.R.C.S.(C), Stephanie Cargnelli, M.D. Cand., Zoyah Thawer, M.D. Cand., Nicole Simunovic, M.Sc., Edwin Cadet, M.D., Nicolas Bonin, M.D., Christopher Larson, M.D., and Olufemi R. Ayeni, M.D., M.Sc., F.R.C.S.(C)

Purpose: Extra-articular hip impingement can be the result of psoas impingement (PI), subspine impingement (SSI), ischiofemoral impingement (IFI), and greater trochanteric/pelvic impingement (GTPI). Symptoms may be due to bony abutment or soft-tissue irritation, and often, it is a challenge to differentiate among symptoms preoperatively. Currently, the clinical picture and diagnostic criteria are still being refined for these conditions. This systematic review was conducted to examine each condition and elucidate the indications for, treatment options for, and clinical outcomes of surgical management. Methods: We searched online databases (Medline, Embase, and PubMed) for English-language clinical studies published from database inception through December 31, 2013, addressing the surgical treatment of PI, SSI, IFI, and GTPI. For each condition, 2 independent assessors reviewed eligible studies. Descriptive statistics are presented. Results: Overall, 9,521 studies were initially retrieved; ultimately, 14 studies were included examining 333 hips. For PI, arthroscopic surgery resulted in 88% of patients achieving good to excellent results, as well as significant improvements in the Harris Hip Score (P ¼ .008), Hip Outcome ScoreeActivities of Daily Living (P ¼ .02), and Hip Outcome ScoreeSport (P ¼ .04). For SSI, arthroscopic decompression, with no major complications, resulted in a mean 18.5 improvement in flexion range of motion, as well as improvements in pain (mean visual analog scale score of 5.9 points preoperatively and 1.2 points postoperatively) and the modified Harris Hip Score (mean of 64.97 points preoperatively and 91.3 points postoperatively). For both IFI and GTPI, open procedures anecdotally improved patient symptoms, with no formal objective outcomes data reported. Conclusions: This review suggests that there is some evidence to support that surgical treatment, by arthroscopy for PI and SSI and by open surgery for IFI and GTPI, results in improved patient outcomes. Level of Evidence: Systematic review of Level IV and V (case report) studies.

From the Division of Orthopaedic Surgery, Department of Surgery, McMaster University Medical Centre (D.d.S., H.A., O.R.A.), the Michael G. DeGroote School of Medicine (S.C., Z.T.), and Department of Clinical Epidemiology and Biostatistics (N.S.), McMaster University, Hamilton, Ontario, Canada; the Ministry of Higher Education (H.A.), Riyadh, Saudi Arabia; the Lyon-Ortho-Clinic (N.B.), Lyon, France; Raleigh Orthopaedic Clinic (E.C.), Raleigh, North Carolina, and Minnesota Orthopedic Sports Medicine Institute at Twin Cities Orthopedics (C.L.), Edina, Minnesota, U.S.A. The authors report the following potential conflict of interest or source of funding: E.C. receives support from Smith & Nephew. N.B. receives support from Dedienne Sante and Smith & Nephew. C.L. receives support from Smith & Nephew and A3 Surgical, consultancy and stock options. Received February 7, 2014; accepted February 26, 2014. Address correspondence to Olufemi R. Ayeni, M.D., M.Sc., F.R.C.S.(C), McMaster University Medical Center, 1200 Main St W, Room 4E17, Hamilton, ON L8N 3Z5, Canada. E-mail: [email protected] Ó 2014 by the Arthroscopy Association of North America 0749-8063/14105/$36.00 http://dx.doi.org/10.1016/j.arthro.2014.02.042

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xtra-articular hip impingement refers to a variety of increasingly recognized hip disorders causing pain and limited function in young, nonarthritic patients. Specific disorders include psoas impingement (PI), subspine impingement (SSI), ischiofemoral impingement (IFI), and greater trochanteric/pelvic impingement (GTPI). These etiologies are individually unique and are fundamentally different from the traditional hip impingement attributed to the abnormal femoral neck and acetabular rim abutment characteristic of femoroacetabular impingement (FAI). PI, first described in 2007 by Heyworth et al.,1 represents a distinct etiology for acetabular labral tears at the atypical anterior location (3-o’clock position for a right hip or 9-o’clock position for a left hip) (Fig 1). The International Society for Hip Arthroscopy defines this area as between zones 1 and 2.2 Examining 7 of 24 patients undergoing revision hip arthroscopy,

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D. DE SA ET AL. Fig 1. (A) Arthroscopic image of iliopsoas notch and iliopsoas impingement (arrows). Inset shows the osseous hemipelvis, with the acetabulum centered, and the location of the iliopsoas notch (arrow). (B) Arthroscopic image of a patient in whom psoas release was performed, showing synovitis adjacent to creasing of the 3-o’clock position with labral chondral separation (arrow). The patient was positioned supine, and an anterolateral viewing portal was used. (Figure 1A courtesy of Dr. N. Bonin. Figure 1B courtesy of Dr. E. Cadet.)

Heyworth et al. observed how partial psoas tendon release at the level of a torn anterior labrum resulted in arthroscopically visualized impingement-free motion. In FAI and other conditions (trauma, dysplasia, degeneration, and hypermobility), labral tears occur in the typical International Society for Hip Arthroscopy zone 2 and zone 3 anterosuperior locations (1- through 2-o’clock position for a right hip or 10- through 11o’clock position for a left hip).3-5 SSI (Fig 2) causes pain with straight hip flexion and is attributed to abnormal contact stresses between the distal femoral neck and a prominent anterior inferior iliac spine (AIIS).6,7 Figure 3 presents radiographic, 3-dimensional computed tomography, and intraoperative arthroscopic images of SSI and its pathology. IFI results from a narrowing of the ischiofemoral spacedan area bordered laterally by the ischial tuberosity and medially by the femoral lesser trochanter.8 GTPI, traditionally a sequela of Perthes disease, refers to a painful, abnormal contact between a prominent greater trochanter and ilium when the hip is abducted in full extension.9 Macnicol and Makris,9 in 1991, described the clinical “gear-stick” sign used to diagnose GTPI. The etiology, clinical presentation, diagnostic criteria, and treatment options for these forms of extra-articular hip impingement are sparsely reported. We therefore

conducted a systematic review for each conditiondPI, SSI, IFI, and GTPIdto answer 3 fundamental questions relating to each condition: (1) What are the indications and contraindications for surgical management of the condition? (2) What surgical options exist for definitive treatment of the condition? (3) What are the outcomes after surgical intervention? This review was undertaken to collate the latest evidence to guide surgeon practices, optimize patient care, and further highlight areas requiring additional study.

Methods Search Strategy Two reviewers independently searched the online databases Medline, Embase, and PubMed for articles addressing the surgical management of PI, SSI, IFI, and GTPI. The databases were searched for studies from 1974 through December 31, 2013. To ensure thoroughness, the search terms “acetabulum,” “psoas muscles,” “psoas,” “arthroscopy,” “tenotomy,” “tenosynovitis,” “femoroacetabular impingement,” and “tendon entrapment” were used for PI. For SSI, the terms “subspine impingement,” “extra-articular hip impingement,” “femoroacetabular impingement,” “AIIS avulsion,” and “AIIS impingement” were used. For IFI, the search terms

Fig 2. (A) Plain anteroposterior radiograph showing characteristic prominent AIIS of SSI (arrow). (B) Arthroscopic image of a supine patient, viewed through the anterolateral portal, showing a site of ossification of SSI, as well as its relation to the hip acetabulum, labrum, and femoral neck (arrows). (Figures courtesy of Dr. N. Bonin.)

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Fig 3. (A) Plain anteroposterior radiograph of SSI, showing prior apophyseal avulsion. (B) Three-dimensional computed tomography image of SSI. (C, D) Arthroscopic images of supine patients, viewed through the anterolateral portal, showing bruising in the region of the AIIS (C) and burring of the prominent AIIS (D). (Figures courtesy of Dr. C. Larson.)

“ischiofemoral impingement” and “extra-articular hip impingement” were used. For GTPI, the terms “greater trochanter,” “trochanteric impingement,” “pelvic impingement,” and “Perthes” were used as search terms. In addition, the references of included studies were searched for studies that may have been missed in the initial searches. The specific search strategies per database for each condition are outlined in Appendix Tables 1A, 1B, 1C, and 1D, with Fig 4 outlining the systematic application of our inclusion/exclusion criteria for each condition. Eligibility Criteria For each condition, the research question and inclusion/exclusion criteria were determined a priori and included English-language studies of all levels of evidence on humans. Specific criteria for PI included the following: studies on native hips of patients aged at least 12 years who were followed up for a minimum of 6 months and who underwent surgical treatment (open and/or arthroscopic) for PI or iliopsoas impingement. For SSI, IFI, and GTPI, the criteria were quite broad and included studies on native human hips that underwent surgical treatment (open and/or

arthroscopic) for diagnosed SSI, IFI, or GTPI with outcomes data reported. For the latter 3 conditions, there were no specific age or follow-up criteria. We excluded studies not reporting surgical outcomes data, such as radiographic studies, review articles, and instructional course lectures; studies examining other conditions such as PI after total hip arthroplasty; or studies of patients with FAI, internal snapping hip syndrome, non-Perthes conditions (for GTPI), and so on. Article Screening For each condition, the titles, abstracts, and full texts were screened in duplicate with application of the aforementioned criteria; disagreements were addressed by discussion between the 2 reviewers, and unresolved conflicts were addressed by a third reviewer. From the eligible studies for each condition, the references were also searched to capture any additional articles that may have escaped the initial search strategy. Relevant demographic, surgical, and clinical outcomes data were abstracted in duplicate, recorded in Microsoft Excel 2007 spreadsheets (Microsoft, Redmond, WA), and are presented in Tables 1 (PI), 2 (SSI), 3 (IFI), and 4 (GTPI).

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Fig 4. (A) Systematic screening processes for PI literature review, (B) SSI literature review, (C) IFI literature review, and (D) GTPI literature review.

Assessment of Agreement A weighted k and 95% confidence intervals (CIs) for the full-text stage of article screening was calculated to assess inter-rater agreement, with k of 0.61 or greater, k of 0.21 to 0.60, and k of 0.20 or less indicating substantial, moderate, and slight agreement, respectively.10 At the title and abstract screening stages, if at least 1 reviewer believed a study should proceed to the next stage of screening, it was included to avoid missing any potentially eligible articles. Data Analyses Descriptive statistics of the eligible studies for all 4 conditions were performed. A meta-analysis was not feasible because there were no intra-study comparison data. The studies from each strategy, though similar in study design and surgical technique, showed variability in patient-reported outcome measures. Formal quality scoring of included studies was not performed because of the quality of evidence (i.e., case series and reports) produced by the search strategies.

Results Psoas Impingement Search Strategy. After the exclusion of 622 duplicate studies from the initial 1,627 retrieved, 2 studies ultimately satisfied our inclusion/exclusion criteria for this review.3,5 Figure 4A outlines the screening process. The reviewers had a k value of 0.75 (95% CI, 0.71 to 0.78) at the title screen and k of 0.66 (95% CI, 0.41 to 0.82) at the abstract screening stages, indicating high and moderate agreement, respectively. There was full agreement at the full-text stage. Study Characteristics. The systematic search retrieved no randomized controlled trials. Both studies included were retrospective case series, conducted in the United States, on 22 patients and 25 patients treated with arthroscopic surgery. Both studies compared predominantly female competitive athletes, with similar demographic characteristics and pathology, and over a similar period to facilitate descriptive comparisons between them. Table 1 provides a summary of individual study demographic data.

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Fig 4. (Continued).

The main indication for surgical management was hip pain due to arthroscopically confirmed acetabular labral lesions at the anterior (2- to 3-o’clock) position (Table 5). Clinical history and physical examination indications for surgery included anterior hip pain, pain with active hip flexion, a positive impingement test, focal tenderness over the iliopsoas at the level of the anterior joint line, and pain or apprehension with resisted straight-leg raise (Table 5). Contraindications for surgery included radiographic evidence of other pathologies, labral tears not located at the anterior (2to 3-o’clock) position, and an audible or palpable snapping of the psoas tendon (Table 5). All patients were treated arthroscopically with psoas tendon tenotomy, and labral lesions were addressed by either debridement or reattachment (Table 6). Arthroscopic images outlining the procedure are shown in Figs 5 and 6. Surgical treatment of PI and its associated labral lesions resulted in improvements in both subjective and objective clinical outcomes, with no major or moderate complications reported (Table 7). Only 1 patient required revision arthroscopic surgery for a previously unaddressed labral lesion (Table 7).

Subspine Impingement Search Strategy. After the elimination of duplicate studies, 844 titles from an initial 2,080 retrieved were screened, yielding 677 studies and 15 studies for the abstract and full-text screens, respectively. Of these, 7 studies met the inclusion criteria,6,7,11-15 with Fig 4B outlining the screening process. The reviewers had excellent agreement at the title screen (k ¼ 0.99) and full agreement at the abstract and full-text screening stages (k ¼ 1.0). Study Characteristics. Of the 7 included studies, 2 were case series and 5 were case reports, totaling 167 patients (180 hips). Although the majority were conducted in the United States, 2 studies were completed in the United Kingdom and one in China. Patients were generally aged younger than 30 years and were predominantly male, and the majority were treated by an arthroscopic approach. Table 2 outlines additional individual study demographic information. The major reported indications for surgical treatment (options listed in Table 8) of SSI included persistent pain after intra-articular anesthetic injection with (deep) hip

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Table 1. Participant Demographic Data for Studies Evaluating Surgical Treatment of Iliopsoas Impingement

Study Domb et al.3 (2011)

Cascio et al.5 (2013)

Study FollowDesign, Level Sample Size Up Previous of Evidence (Hips/Patients) Age (yr) % F Follow-Up (yr) (%) Intervention Quality Assessment Retrospective 25/25 25.1 (range, 92 1.75 69.4 20 patients with 11 of 36 patients were lost to case series, 15-37) (minimum, 1) intra-articular follow-updno reasons Level IV injection provided; subjective patient preoperatively; description of improvement 4 patients with in physical ability psoas injection preoperatively Retrospective 26/22 19 (range, 95 Minimum, 0.5 72.7 NR 6 of 22 patients were lost to case series, 12-25) follow-updno reasons Level IV provided; low interobserver agreement for FAI (65%), capsular laxity (58%), and non-arthroplasty PI (NR)

F, female; NR, not reported.

flexion and either pain with palpation of the AIIS and/ or imaging showing a prominent AIIS (Fig 2C). Hetsroni et al.6 described a method to radiographically classify the degree of SSI, with each type referring to the presence or absence and extent of bony prominences between the caudad level of the AIIS and acetabular rim. For example, type 1 has no bony prominences, whereas the presence of bony prominences extending to the acetabular rim and distally to the anterior-superior acetabular rim characterizes types 2 and 3, respectively.6 There were no reported contraindications for surgery. By use of the case series on 163

hips by Hapa et al.,7 by far the most recent and largest sample, there was an approximate 22.2-point increase in the postoperative modified Harris Hip Score and 3.0point reduction in the pain score on a visual analog scale. This was consistent among the other 2 studies as well, with Hetsroni et al. showing improvement from 64.2  17.9 points (poor) preoperatively to 98.4  2.1 points (excellent) postoperatively on the modified Harris Hip Score. In 1 study that used the Non-Arthritic Hip Score, improvements from 22 points to 98 points (preoperative to postoperative) resulted from decompression of the AIIS.12 Range of motion (mainly hip

Table 2. Participant Demographic Data for Studies Evaluating Surgical Treatment of SSI

Study Hapa et al.7 (2013)

Study Design, Level of Evidence Case series, Level IV

Hetsroni et al.6 (2012)

Case series, Level IV

10 patients

Mean, 24.9 (range, 15-24)

100

Mean  SD, 14.1  7.2 mo (range, 6-26 mo)

Yes in all patients

Larson et al.11 (2011)

Case report, Level V

3 patients

Mean, 23 (range, 17-31)

33

Matsuda and Calipusan12 (2012) Pan et al.13 (2008) Rajasekhar et al.14 (2001) Irving15 (1964)

Case report, Level V

1 patient

13

100

Mean  SD, 16  3.5 mo (range, 12-18 mo) 18 mo

Yes in 2 patients, NR in 1 patient Yes

Case report, Level V Case report, Level V

1 patient

30

100

5 wk

Yes

1 patient

25

100

30 mo

NR

Surgical Intervention Arthroscopic decompression of AIIS with/without cam resection/rim trim/labral repair with/without other procedures Arthroscopic decompression of AIIS plus cam resection with/without rim trim plus labral repair or debridement Arthroscopic decompression of AIIS with/without osteoplasty and labral repair Arthroscopic “spinoplasty” plus cam resection plus rim trim plus labral refixation Open decompression of AIIS plus arthroscopy Open resection of exuberant callus

Case report, Level V

1 patient

14

100

NR

NR

Open resection of exostosis

NR, not reported; M, male.

Sample Size 163 hips

Age (yr) Mean, 27.8 (range, 14-52)

%M 50

Follow-Up Mean  SD, 11.1  4.1 mo (range, 6-24 mo)

FAI Symptoms Present Yes

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Table 3. Study Demographic Data for IFI Literature Review

Study Ali et al.8 (2011)

Study Design, Level of Evidence Case report, Level V

Age (yr) 17

Gender F

Follow-Up 10 wk

Surgical Intervention Open surgical resection of lesser trochanter

Ganz et al.17 (2013)

Case series, Level IV

Range of 11-63 for 14 patients (8 hips)

10 F and 4M

3.5 yr (range, 2-12 yr)

All had residual Perthes or Perthes-like disease Excision of oversized lesser trochanter was preferred method Distal advancement of lesser trochanter

Viala et al.16 (2012)

Case report, Level V

37

F

6 mo

Open resection of exostosis (PMHx of hereditary multiple exostoses)

Outcomes No pain No snapping of quadratus femoris No impingement intraoperatively in neutral position of hip in extension Substantial increase in ROM Normal strength of active hip flexion Recurrent hip subluxation disappeared No complications All patients healed; no residual exostosis Pain relief

F, female; M, male; NR, not reported; PMHx, past medical history; ROM, range of motion.

flexion) was the primary outcome reported, with 1 study showing improvement from a mean of 98.5  6.7 preoperatively to 117  7.5 postoperatively.6 All patients reported improved pain, and no major complications were reported. Asymptomatic heterotrophic ossification was described in 2 patients (Table 9). Ischiofemoral Impingement Search Strategy. Figure 4C outlines the systematic screening process, which resulted in 3 eligible studies from 1,407 initially searched after duplicate studies were discarded.8,16,17 Nearly perfect agreement (k ¼

0.99) was achieved in the title screening process, with both reviewers disagreeing on only 4 studies. Full agreement in the abstract and full-text phases was achieved. Study Characteristics. The search discovered 2 case reports and 1 case series from outside of North America, predominantly on female patients treated by open procedures. Table 3 provides a summary of the individual study data. Because only anecdotal outcomes data were reported and no intra-study comparison data were available, qualitative findings are presented.

Table 4. Study Demographic Data for GTPI Literature Review

Study Leunig and Ganz18 (2011)

Macnicol and Makris9 (1991)

Study Design, Level of Evidence Case series, Level IV

Case series, Level IV

F, female; NR, not reported.

Age (yr) Range, 9-21

Mean, 14 (range, 14-41)

Sample Size (Hips) 14 (13 with Perthes or Perthes-like deformities)

26 (80% F)

Follow-Up Minimum, 36 mo

Mean, 8 yr (range, 2-22 yr)

Indications Intervention Deformed epiphysis Reduction osteotomy Short femoral neck Colonna procedure in 1 hip Greater trochanter with tip Pelvic acetabular osteotomy with higher than center of reduction osteotomy in 8 hips femoral head on (3 at a later date) radiographs Congenital dislocation, Mean of 2.1 previous operations: 22 hips 11 derotation femoral osteotomies Perthes disease, 2 hips 9 open reductions Septic arthritis, 2 hips 15 varus or valgus femoral Post-traumatic vascular osteotomies necrosis, 1 hip 15 Salter innominate osteotomies 4 Chiari pelvic osteotomies 1 Wainwright shelf operation 1 greater trochanteric transfer combined with valgus femoral osteotomy 1 greater trochanteric transfer combined with Chiari osteotomy

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Table 5. Reported Indications and Contraindications for Surgical Management of PI Study Domb et al.3

Clinical History Anterior hip pain Pain with active hip flexion No history of trauma or instability

Cascio et al.5

Hip pain (medial labrum) despite rest and physical therapy

Physical Examination Findings Positive impingement test (pain with passive flexioneadductione internal rotation) Focal tenderness over iliopsoas at level of anterior joint line Pain or apprehension with resisted straight-leg raise NR

Radiographic Findings Any labral abnormality (frank tears, mucoid degeneration, inflammation) on MRI at direct anterior site

Diagnostic Injection Any relief from pain after intra-articular injection or after psoas injection

NR

Any relief from intraarticular injection of Marcaine, lidocaine, and steroid

Arthroscopy Labral injury (frank tears, mucoid degeneration, inflammation) directly adjacent to tendinous portion of iliopsoas muscle at 3-o’clock position

Contraindications Any radiographic evidence of damage to articular cartilage, dysplasia, acetabular retroversion, profunda acetabuli, cam lesions, or labral tear in any part of labrum other than direct anterior site

Audible or palpable snapping of psoas tendon Labral tears from 10- to 2-o’clock position on MR arthrogram Radiographic evidence of pincer abnormality or any significant hip laxity

D. DE SA ET AL.

MR, magnetic resonance; MRI, magnetic resonance imaging; NR, not reported.

Table 6. Surgical Treatment Options for Management of Iliopsoas Impingement Study Domb et al.3 (2011)

Surgical Approach Arthroscopicdinitially inserted through anterolateral portal in all cases with anterior, posterolateral, and distal lateral accessory portals used as necessary

Psoas Procedure Tenotomy in 100%

Labral Procedure Debridement in 92%, reattachment to acetabular rim in 8%

Complications No revisions No complications

Cascio et al.5 (2013)

Arthroscopicd2 portals: anterolateral (viewing) and mid-anterior portal (working)

Tenotomy in 100%

Reattachment to acetabular rim in 100%

1 revision at 18 mo for unaddressed labral lesion No major or moderate complications 2 minor complications: ankle and/ or knee pain and lateral femoral cutaneous nerve paresthesias

Postoperative Rehabilitation Restriction of flexion beyond 70 -90 for 3 wk Internal rotation pillow and boots for 1-3 wk at night Continuous passive motion machine for 4-8 h/d for 7-14 d Crutches and partial weight bearing used for at least 2 wk Physical therapy 2-3 times per week for 8-12 wk Compression stockings on both legs and feet in internal rotation boots Peroneal post pillow between both feet

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Fig 5. Arthroscopic images of a supine patient with PI, (A) viewed through the anterolateral portal, showing the probed psoas tendon, (B) psoas tendon fraying, (C) psoas tendon inflammation and partial tearing, and (D) psoas tenotomy (E) with labral repair. (Figures courtesy of Dr. N. Bonin.)

Explicit indications and/or contraindications for surgical management were not reported, although both patients underwent surgery for persistent hip/ groin pain and had some imaging characteristics to suggest that the ischiofemoral space was narrowed or its structures (namely the quadratus femoris) were irritated (Fig 7). Open decompression by removal of the lesser trochanter to increase the ischiofemoral space relieved painful symptoms, improved range of motion, and showed no complications (Table 3 and Fig 8).

Fig 6. Arthroscopic image of a supine patient, viewed from the central compartment, showing the probed psoas tendon and repaired acetabular labrum. (Figure courtesy of Dr. E. Cadet.)

Greater Trochanteric/Pelvic Impingement Search Strategy. Ultimately, 2 studies from an initial retrieval of 1,713 studies satisfied the aforementioned inclusion criteria.9,18 Nearly perfect agreement (k ¼ 0.99) was achieved at the title and abstract screening stages, with the reviewers differing on only 5 studies,

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Table 7. Clinical Outcomes After Surgical Treatment of PI

Study Domb et al.3 (2011)

No. Reporting Subjective Clinically Good or Excellent Outcome 88%

Cascio et al.5 (2013)

NR

Mean Net Improvement in Outcome Score (Average Change) HHS, 24.42 (range, NR); P ¼ .008* HOS-ADL, 14.27 (range, NR); P ¼ .02* HOS-Sport, 20.38 (range, NR); P ¼ .04* HHS, 24 (range, NR)

HHS, Harris Hip Score; HOS-ADL, Hip Outcome ScoreeActivities of Daily Living; HOS-Sport, Hip Outcome ScoreeSport; NR, not reported. *Significant finding.

of impingement (Fig 9) improved hip motion (approximately 15 of hip abduction in extension), as well as abduction power, gait, and overall pain levels, and lessened fatigue from prolonged standing or walking. Residual acute to subacute pain observed postoperatively was attributed to inadequate advancement (i.e., the tip of the greater trochanter was still higher than the center of the femoral head on radiographs), whereas chronic pain was due to progression of degenerative intra-articular changes (Table 10).

Discussion

and complete agreement was achieved at the full-text phase. Figure 4D outlines the systematic process.

The critical role of the acetabular labrum with regard to hip stability, decreasing cartilage wear, and maintaining the joint fluideseal effect has been well documented.19 Therefore preserving or repairing a pathologic labrum is intuitive; likewise, identifying causative factors can help prevent a recurrence.

Study Characteristics. Both included studies were case series, one from the United States18 and the other from Scotland,9 and used open procedures performed on a total of 40 hips. Table 4 provides individual study demographic data. Specific, uniform indications and contraindications for surgery were not reported, although Table 4 lists individual patient indications. One radiographic parameter used for overall surgical planning of significance was the relation of the greater trochanteric tip to the center of the femoral head on radiographs, with a higher tip being more suggestive of impingement. No uniform correctional procedure was identified. Options included distal (and lateral) transfer of the greater trochanter and various reduction osteotomy procedures outlined in Table 4. Although no objective outcomes data were reported, technically, correction was safe, with osteotomy sites healing within 6 to 8 weeks; no osteonecrosis evident at 3 years postoperatively; and sparse, minor complications reported (i.e., 1 superficial infection treated successfully with antibiotics). Subjectively, addressing a prominent greater trochanter as a source

Key Findings Regarding PI, our review suggests that in individuals with hip pain attributable to acetabular labral lesions at the anterior (2- to 3-o’clock) position, due to a tight iliopsoas tendon, arthroscopic iliopsoas tenotomy with associated labral debridement or reattachment is a viable treatment (Figs 5 and 6). Although aggressive release clinically may lead to hip flexion weakness, this has not been substantiated in the literature. Caution is warranted because Fabricant et al.20 showed that psoas tendon lengthening may lead to inferior outcomes in the setting of increased anteversion, and caution should be exercised in the setting of hip dysplasia to avoid exacerbating anterior instability. For SSI, our review further suggests that short-term outcomes of surgical decompression of a prominence of the AIIS are favorable for patients with characteristic anterior hip pain worsened with straight hip flexion. For both IFI and GTPI, we found limited, low-quality evidence to suggest that surgical intervention to widen the ischiofemoral space by lesser trochanteric excision or ischial tuberosity decompression for IFI or to reduce the

Table 8. Reported Diagnostic Criteria and Surgical Indications for Treatment of SSI Study Hapa et al.7 (2013) Hetsroni et al.6 (2012)

Diagnostic Criteria and Indications for AIIS Decompression Terminal hip flexion pain and limitations, tenderness to palpation of AIIS, imaging showing type 2 or 3 AIIS, intraoperative focal bruising and synovitis in region of AIIS Anterior hip pain, tenderness over AIIS, limited and painful terminal flexion, pain not resolved with intra-articular injection, prominent AIIS on imaging Painful limited flexion, limited response to intra-articular injection, prominent AIIS on imaging Positive impingement sign/FABER, malunited prominent AIIS

Larson et al.11 (2011) Matsuda and Calipusan12 (2012) Pan et al.13 (2008) Painful flexion with rotation, prominent AIIS on imaging Rajasekhar et al.14 (2001) Limited painful deep flexion, tenderness anterior hip, malunited prominent AIIS on imaging Pain with rotation and abduction, palpable lump over AIIS, exostosis seen on imaging Irving15 (1964) FABER, flexioneabductioneexternal rotation.

Table 9. Clinical Outcomes and Complications From Surgical Management of SSI Flexion ( ) Study Hapa et al.7 (2013)

Larson et al.11 (2011)

Matsuda and Calipusan12 (2012) Pan et al.13 (2008) Rajasekhar et al.14 (2001) Irving15 (1964)

VAS

2 3 4 5 6 7 8 9 10 1 2 3 1

100 100 110 100 100 90 90 105 100 105 100 110 NR

110 115 110 110 120 125 110 130 125 125 130 125 NR

1 1

90

120

1

59 41 68 73 43 81 62 74 45 74 74 79 NAHS, 22

100 100 100 100 96 96 96 96 100 85 100 96 NAHS, 98

5.7 4.85 8 NR

Postoperative 1.9 (0-7.8) NR

Previous Event/AIIS Morphology Type 2 in 131 hips, type 3 in 32 hips All patients had AIIS deformity with assumption of previous AIIS at younger age

Complications NR None

1.65 0 1.75 NR

d Pelvic osteotomy AIIS avulsion AIIS avulsion

None

1 asymptomatic HO

Improved pain

AIIS traction spur AIIS avulsion

None None

Improved pain

AIIS avulsion

1 asymptomatic exostosis recurrence

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Hetsroni et al.6 (2012)

MHHS

Preoperative Postoperative Preoperative Postoperative Preoperative Case No. 163 hips No deficit 63.1 (21-90) 85.3 (37-100) 4.9 (0.1-8.6) (150 patients) 1 90 115 96 100 NR

HO, heterotrophic ossification; MHHS, modified Harris Hip Score; NAHS, Non-Arthritic Hip Score; NR, not reported; VAS, visual analog scale.

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Fig 7. (A) Axial, (B) coronal, and (C) sagittal magnetic resonance images of a left hip showing edema within the quadratus femoris and narrowing in the ischiofemoral space (stars). (Figures courtesy of Dr. O. R. Ayeni.)

prominence of the greater trochanter (by osteotomy, advancement [distally and/or laterally], and so on) for GTPI may prove of clinical benefit, with minimal risk. However, given the current state of available evidence, these results must be interpreted with caution, understanding that all nonoperative and operative interventions need further investigation with higherquality studies.

Strengths and Limitations This is the first systematic review addressing the surgical treatment of pain and dysfunction due to PI, SSI, IFI, and GTPI. From a methodologic standpoint, the strengths of our review include the independent, systematic search strategy, blinding of assessors, and high inter-rater agreement, thus minimizing selection and source bias. The use of predetermined broad parameters

for our inclusion/exclusion criteria, as well as multiple search strategies, helped to limit publication bias. The limitations of this review stem largely from the quality of the included studies and include, but are not limited to, the following: retrospective nature; small sample size; lack of control groups, limiting statistical comparison; unique patient population (i.e., a majority of female athletes); unexplained and inadequate follow-up (i.e.,

pelvic impingement.

Extra-articular hip impingement can be the result of psoas impingement (PI), subspine impingement (SSI), ischiofemoral impingement (IFI), and greater ...
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