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Abstract Objective To evaluate surgeons' performance in resecting CAM-type deformities using a realistic arthroscopic surgery simulator. Methods An arthroscopic simulator was created using low-cost materials with the help of a GTMax Core A1 3D printer and the programs Invesalius and Meshmixer 2017, which were used to develop femoral head parts in ABS material, with the presence of a CAM-type deformity, to mimic a femoroacetabular impact situation. After the operations were performed by 16 surgeons, the femurs were compared to a previous model with deformity and another without, using Cloudcompare, and parameters such as the volumetric difference between the operated femurs, with and without deformity, the minimum and maximum distance between them, the percentage of the deformity resected, the estimated time for total resection of the deformity, as well as a qualitative analysis based on the images and graphs provided by the program representing the areas of the parts resected, were evaluated at the end. Results The average resection speed was 34.66 mm3/min (SD = 46 mm3/min, max = 147.33; min = −2.66). The average resection rate was 26.2% (SD = 34.7%, max = 111; min = −2). Qualitative analysis showed hyporesection of deformities and sometimes hyperresection of nondeformed areas. The simulator was highly rated by the surgeons, with a tactile sensation very similar to real surgery, according to them. Conclusion Arthroscopic simulators have proved very useful in training less experienced surgeons.

Resumo Objetivo Avaliar o desempenho de cirurgiões na ressecção de deformidades tipo CAME fazendo uso de um simulador realista de cirurgia artroscópica. Métodos Um simulador artroscópico foi criado a partir de materiais de baixo custo com auxílio de uma impressora 3D GTMax Core A1 e dos programas Invesalius e Meshmixer 2017, que foram utilizados para criar peças de cabeça de fêmur em material ABS, com a presença de uma deformidade tipo CAME, a fim de mimetizar uma situação de impacto femoroacetabular. Após as operações serem realizadas por 16 cirurgiões, os fêmures foram comparados a um modelo prévio com e outro sem deformidade pelo programa Cloudcompare, sendo avaliados ao final parâmetros como diferença volumétrica entre os fêmures operados, com e sem deformidade, distância mínima e máxima entre eles, porcentagem da deformidade ressecada, tempo estimado para ressecção total da deformidade, além de uma análise qualitativa feita com base nas imagens e gráficos fornecidos pelo programa representando as áreas das peças efetivamente ressecadas. Resultados A velocidade média de resseção foi de 34,66mm3/minuto (DP = 46 mm3/min, max = 147,33 mm3/min; min = −2,66 mm3/min). A média de ressecção obtida foi de 26,2% (DP = 34,7%, max = 111%; min = −2%). A análise qualitativa demonstrou uma hiporresecção das deformidades e, por vezes, hiperresecção de áreas não deformadas. O simulador foi muito bem avaliado pelos cirurgiões, tendo uma sensação tátil bem semelhante à cirurgia real segundo os mesmos. Conclusão Simuladores artroscópicos se mostraram muito úteis no treinamento de cirurgiões menos experientes.

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INTRODUCTION: Hip instability following arthroscopy is a rare complication with a clinical spectrum ranging from gross dislocation (macro-instability) to micro-instability, characterized by pain and limitation for daily activities. Therefore, it should be considered as a potential differential diagnosis in patients experiencing persistent pain after hip arthroscopy. CASE PRESENTATION: A 41-year-old male presented with a history of anterior hip dislocation and macro-instability symptoms three years post-hip arthroscopy. Magnetic resonance imaging (MRI) revealed a disruption of the anterior hip capsule. The patient initiated physiotherapy and resumed activities, but ten months later, experienced another anterior dislocation. Pain and apprehension during external hip rotation were evident. Three-dimensional computed tomography (CT) indicated irregularities in the anterior and superior margin of the acetabulum, while MRI arthrogram showed a rupture of the anterior capsule and deficiency in the anterior hip ligaments. Open reconstruction of the anterior capsule was performed, resulting in favorable progression over the 5-year follow-up. DISCUSSION: This case highlights post-arthroscopy hip instability with a delayed presentation, possibly linked to chronic anterior capsule deficiency and inadequate acetabular coverage. Primary capsule repair after hip arthroscopy has proven effective in reducing the occurrence of instability symptoms and reoperations. CONCLUSIONS: Post-arthroscopic hip instability may manifest immediately after surgery or several years later. Open reconstruction of the anterior capsule emerges as a successful strategy for addressing this complication, demonstrating satisfactory outcomes in a 5-year follow-up.

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Transforming the orthopedic landscape, hip arthroscopy pioneers a minimally invasive surgical approach for diagnosing and addressing hip pathologies. With its origins dating back to Burman's 1931 cadaveric study, this groundbreaking technique gained clinical relevance in 1939 through Takagi's report. However, the 1980s marked the actual emergence of hip arthroscopy for treating a wide range of hip disorders. Now, a staple in modern orthopedics, hip arthroscopy empowers patients with previously undiagnosed and untreated hip conditions, enabling them to obtain relief and reclaim their lives. By employing a compact camera and specialized tools, surgeons expertly navigate the hip joint, performing procedures from excising loose bodies and mending labral tears to addressing femoroacetabular impingement and tackling other intricate issues. This innovative approach has dramatically elevated patients' quality of life, allowing them to embrace targeted treatments and resume daily activities without resorting to lifestyle alterations.

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BACKGROUND: No consensus is available regarding which radiographic measurement most accurately correlates with anterior coverage of the femoral head. PURPOSE: (1) To determine the correlation between 2 measurements of anterior wall coverage: total anterior coverage (TAC) calculated from radiographs and equatorial anterior acetabular sector angle (eAASA) calculated from computed tomography (CT) scans; (2) to define the correlation between anterior center-edge angle (ACEA) and anterior wall index (AWI) with TAC and eAASA; and (3) to investigate what other radiographic metrics may help predict anterior coverage. STUDY DESIGN: Cohort study (Diagnosis); Level of evidence, 3. METHODS: The authors retrospectively reviewed 77 hips (48 patients) for which radiographs and CT scans were obtained for reasons other than hip-related pain. Mean age of the population was 62 ± 22 years; 48 (62%) hips were from female patients. Two observers measured lateral center-edge angle (LCEA), AWI, Tönnis angle, ACEA, CT-based pelvic tilt, and CT-based acetabular version, with all Bland-Altman plots within 95% agreement. Correlation between intermethod measurements was estimated with a Pearson coefficient. Linear regression was used to test the ability of baseline radiographic measurements to predict both TAC and eAASA. RESULTS: Pearson coefficients were r = 0.164 (ACEA vs TAC; P = .155), r = 0.170 (ACEA vs eAASA; P = .140), r = 0.58 (AWI vs TAC; P = .0001), and r = 0.693 (AWI vs eAASA; P < .0001). Multiple linear regression model 1 showed that AWI (ß = 17.8; 95% CI, 5.7 to 29.9; P = .004), CT acetabular version (ß = -0.45; 95% CI, -0.71 to -0.22; P = .001), and LCEA (ß = 0.33; 95% CI, 0.19 to 0.47; P = .001) were useful to predict TAC. Multiple linear regression model 2 revealed that AWI (ß = 25; 95% CI, 15.67 to 34.4; P = .001), CT acetabular version (ß = -0.48; 95% CI, -0.67 to -0.29; P = .001), CT pelvic tilt (ß = 0.26; 95% CI, 0.12 to 0.4; P = .001), and LCEA (ß = 0.21; 95% CI, 0.1 to 0.3; P = .001) accurately predicted eAASA. Model-based estimates and 95% CIs using 2000 bootstrap samples from the original data were 6.16 to 28.6 for AWI in model 1 and 15.1 to 34.26 for AWI in model 2. CONCLUSION: There was a moderate to strong correlation between AWI and both TAC and eAASA, whereas ACEA correlated weakly with the former measurements, thus not being useful to quantify anterior acetabular coverage. Other variables such as LCEA, acetabular version, and pelvic tilt may also help predict anterior coverage in asymptomatic hips.

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Purpose: The aim of this study was to determine correlation between the spinopelvic parameters in sitting and standing positions (sacral slope [SS], lumbar lordosis [LL], spinopelvic tilt [SPT], pelvic incidence [PI], and pelvic femoral angle [PFA]), with hip function assessed using the modified Harris hip scores (mHHs) in patients with symptomatic femoroacetabular impingement (FAI) at diagnosis. Materials and Methods: A retrospective study of 52 patients diagnosed with symptomatic FAI was conducted. Evaluation of the spinopelvic complex in terms of SS, LL, SPT, PI and PFA was performed using lateral radiographs of the pelvis and lumbosacral spine in standing and sitting positions. Assessment of hip function at diagnosis was performed using the mHHs. Calculation of spinopelvic mobility was based on the difference (Δ) between measurements performed in standing and sitting position. Results: The median time of pain evolution was 11 months (interquartile range [IQR], 5-24 months) with a median mHHs of 66.0 points (IQR, 46.0-73.0) at diagnosis. The mean change of LL, SS, SPT, and PFA was 20.9±11.2°, 14.2±8.6°, 15.5±9.0°, and 70.7±9.5°, respectively. No statistically significant correlation was observed between spinopelvic parameters and the mHHs (P>0.05). Conclusion: Radiological parameters of the spinopelvic complex did not show correlation with hip function at the time of diagnosis in patients with symptomatic FAI. Conduct of further studies will be required in the effort to understand the effect of the spinopelvic complex and its compensatory mechanics, primarily between the hip and spine, in patients with FAI before and after hip arthroscopy.

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

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Abstract Objective To analyze the relationship between pubalgia and femoroacetabular impingement (FAI) in professional athletes of a soccer club, defining the prevalence of these conditions in the sample studied. Methods It is an epidemiological, cross-sectional, and analytical study including 90 professional soccer players active from 2019 to 2021. We accessed the medical records of the subjects to retrieve information from the modified Pre-Competition Medical Assessment (PCMA) protocol, orthopedic physical examination, and anteroposterior pelvic radiographs to assess pubalgia and FAI, respectively. Inclusion criteria were athletes playing in the professional soccer club in the 2019 to 2021 season, who underwent a modified PCMA upon admission, and who signed an informed consent form. Results FAI was highly prevalent (85.6%) in the sample. This prevalence may occur because, in Brazil, people start playing sports early, not always in suitable fields, or with no proper equipment and supervision. In addition, the CAM-type impingement was the most frequent (62.2%). These injuries are related to high-intensity movements, including those associated with soccer. Furthermore, there is no dependency correlation between pubalgia and FAI. FAI was present in only 20% of athletes with pubalgia complaints. Conclusion There was a high prevalence of FAI in professional soccer players in the studied population (85.6%) but with no relationship between FAI and pubalgia.

Resumo Objetivo Analisar a relação entre a pubalgia e o impacto femoroacetabular (IFA) em atletas profissionais de um clube de futebol, definindo a prevalência de pubalgia e de impacto femoroacetabular na casuística estudada. Métodos É um estudo epidemiológico, transversal e analítico. Foram selecionados 90 atletas profissionais de futebol atuantes no período de 2019-2021. Foram acessados os prontuários para obtenção do protocolo PCMA modificado, além de exame físico ortopédico e de radiografias da bacia com incidência anteroposterior para avaliação de pubalgia e IFA, respectivamente. Critérios de Inclusão: Atletas que atuaram no clube de futebol de campo profissional na temporada de 2019 a 2021, que foram submetidos a aplicação do PCMA modificado na admissão e que assinaram o TCLE. Resultados O IFA apresentou elevada prevalência na amostra (85.6%), o que pode ocorrer pois, no Brasil, os jovens iniciam a prática esportiva em idade muito precoce, além do fato de os jogadores nem sempre praticarem o esporte em campos adequados ou com equipamentos e supervisão adequada. Ademais, o impacto tipo CAM foi o mais frequente (62.2%). O surgimento dessas lesões é relacionado a movimentos de alta intensidade, como os vistos no futebol. Outrossim, observou-se que não há correlação de dependência entre a pubalgia e o IFA. Foi visto que o IFA estava presente em apenas 20% dos atletas queixosos de pubalgia. Conclusão Há elevada prevalência de IFA em atletas de futebol profissional na população estudada (85.6%) e não houve relação entre o IFA e a presença de pubalgia.

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Objective: To compare the clinical outcomes between patients with moderate and severe slipped capital femoral epiphysis (SCFE) treated with osteotomy at the base of neck and osteoplasty and with healthy individuals. Methods: Comparative cohort with 12 patients (14 hips) with moderate and severe SCFE who underwent osteotomy at the base of neck and osteoplasty between 2007 and 2014. The mean age at surgery was 13.3 ± 2.5 years and the mean follow-up was 3.8 ± 2.2 years. We assessed the level of hip pain by the visual analog scale (VAS) and anterior impingement test (AIT); the level of function using the Harris Hip Score (HHS) and 12-Item Short Form Health Survey (SF-12), the range of motion (ROM) by goniometry and Drehmann sign, and the hip muscular strength by isokinetic and Trendelenburg sign. Results: The level of pain was slightly higher in the SCFE cohort compared with healthy hips (VAS, 0.8 ± 1.4 vs 0 ± 0, 0.007; AIT, 14% vs 0%, p = 0.06; respectively). No differences were observed between the SCFE and control cohort for the functional scores (HHS, 94 ± 7 vs 100 ± 1, p = 0.135); except for ROM, with increased internal rotation (37.3º ± 9.4º vs 28.7º ± 8.2º, p < 0.001), and strength, with decreased abduction torque (75.5 ± 36.9 Nm/Kg vs 88.5 ± 27.6 Nm/Kg, p = 0.045) in the SCFE cohort. Conclusion: The osteotomy at the base of neck and the osteoplasty restored the hip motion and muscle strength, except for the abductor strength, to near normal levels, representing a viable option for the treatment of moderate and severe SCFE. Level of Evidence III, Ambidirectional Cohort Study.

Objetivo: Comparar resultados clínicos de pacientes com escorregamento epifisário proximal do fêmur (EEPF) moderado e grave tratados com osteotomia basocervical e cervicoplastia com indivíduos saudáveis. Métodos: Coorte comparativa com 12 voluntários saudáveis e 12 pacientes (14 quadris) com EEPF moderado e grave submetidos à osteotomia basocervical e cervicoplastia entre 2007 e 2014. A média de idade na cirurgia foi de 13,3 ± 2,5 anos e o seguimento médio de 3,8 ± 2,2 anos. Avaliou-se nível de dor no quadril utilizando a escala visual analógica (EVA) e o teste de impacto anterior (TIA); nível de função usando o Harris Hip Score (HHS) e o 12-Item Short Form Health Survey (SF-12); amplitude de movimento (ADM) com goniometria e sinal de Drehmann; e força muscular do quadril com dinamômetro isocinético e sinal de Trendelenburg. Resultados: O nível de dor foi ligeiramente maior na coorte de EEPF comparado a quadris saudáveis (EVA, 0,8 ± 1,4 vs 0 ± 0, 0,007; TIA, 14% vs 0%, p = 0,06; respectivamente). Não foram observadas diferenças entre os grupos EEPF e controle para os escores funcionais (HHS, 94 ± 7 vs 100 ± 1, p = 0,135), exceto para ADM, com aumento da rotação interna (37,3º ± 9,4º vs 28,7º ± 8,2º, p < 0,001), e força, com diminuição do torque de abdução (75,5 ± 36,9 Nm/Kg vs 88,5 ± 27,6 Nm/Kg, p = 0,045), para o grupo EEPF. Conclusão: A osteotomia basocervical e a cervicoplastia restauraram o movimento do quadril e a força muscular, com exceção da força abdutora, a níveis próximos do normal, representando uma opção viável para o tratamento de EEPF moderado e grave. Nível de Evidência III, Estudo de Coorte Ambidirecional.

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

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

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

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