2026年8月 保髋进展 JCR Q3+Q4

BACKGROUND ARCO stage IIIA osteonecrosis of the femoral head (ONFH) means early collapse, but total hip replacement may be premature in relatively young patients. This retrospective study aimed to compare outcomes between hip arthroscopy combined with triangular drilling and suction decompression versus standard drilling alone. MATERIAL AND METHODS We analyzed 63 patients (76 hips) with ARCO IIIA ONFH treated from January 2018 to October 2022. The triangular group (19 patients, 19 hips, all unilateral) received arthroscopy plus triangular drilling with suction decompression. The standard group (44 patients, 57 hips, including 13 bilateral) received standard drilling alone. Outcomes included visual analog scale (VAS) score, modified Harris Hip Score (mHHS), KaplanMeier femoral head survival, operative time, and postoperative hospital stay. No patients were lost to followup. RESULTS At 3, 6, and 12 months postoperatively, the triangular group had lower VAS (P=0.009, 0.001, 0.004) and higher mHHS (P=0.006, <0.001, <0.001) than the standard group. Operative time was longer in the triangular group (142.23±22.64 vs 43.18±10.82 minutes, P<0.001), but hospital stay did not differ. During followup (1245 months), femoral head collapse occurred in 3 hips in the triangular group and 11 hips in the standard group. KaplanMeier survival was significantly better in the triangular group (logrank P=0.040). CONCLUSIONS Hip arthroscopy combined with triangular drilling and suction decompression was associated with better short to midterm pain relief, functional improvement, and femoral head survival in ARCO stage IIIA ONFH compared with standard drilling alone, although operative time was longer. These findings should be interpreted as unadjusted associations, and further prospective multicenter studies are needed.

OBJECTIVE: Developmental dysplasia of the hip (DDH) is a primary driver of secondary osteoarthritis among the young adult population. The objective of this study is to introduce and assess the "CHARKAJ Line"-a linear vector drawn tangential to the superior cortical contour of the femoral neck and extended to the acetabulum-as an adjunctive radiographic indicator to distinguish between normal and dysplastic hips.

MATERIALS AND METHODS: We performed a retrospective analysis of 132 hips (comprising 108 females and 24 males; mean age 27.6 years) that had radiographic imaging available. Using a Tönnis angle threshold of 10° to define normality, hips were classified into Normal (n = 71) or Dysplasia (n = 61) groups. On the frontal projection, the CHARKAJ Line was projected along the superior femoral neck edge extending medially toward the acetabulum. We measured the distance from the acetabulum's superolateral margin to the specific point where the CHARKAJ line transected the acetabular roof.

RESULTS: Analysis revealed that the mean intersection distance of the CHARKAJ line was significantly deeper in the normal cohort (16.97 +/- 6.76 mm) relative to the dysplastic cohort (11.59 +/- 8.29 mm). This disparity was statistically significant (p < 0.001). Interobserver reliability for the measurement was moderate (ICC = 0.75). There was statistically significant difference between LCEA and CHARKAJ line measurements between normal (LCEA between 25 and 40 degrees) and dysplasia (LCEA less than 20 degrees) cohort with p value of 0.0001.

CONCLUSION: The CHARKAJ Line reveals a statistically significant distinction in intersection depth between dysplastic and normal hips.

BACKGROUND: This study aimed to clarify the clinical and radiographic outcomes of transposition osteotomy of the acetabulum (TOA) for neurogenic hip dysplasia in skeletally mature patients.

METHODS: We retrospectively reviewed 12 patients (12 hips) with neurogenic hip dysplasia who underwent TOA between 1998 and 2019. There were three males and nine females, with a median age of 15 years. The median follow-up was 7.5 years (range, 2-21). Diagnoses included cerebral palsy, myelomeningocele, and other neurogenic conditions. Clinical outcomes were assessed using the Japanese Orthopaedic Association (JOA) hip score. Radiographic parameters, including migration percentage (MP), lateral center-edge angle (LCEA), Tönnis angle, Sharp angle, acetabular head index (AHI), anterior wall index (AWI), posterior wall index (PWI), and vertical distance (VD), were measured preoperatively, postoperatively, and at final follow-up.

RESULTS: The median JOA score improved from 49 preoperatively to 69 at latest follow-up (p < 0.001), primarily due to improvement in the pain subscale (20 vs. 40, p = 0.001). No osteoarthritis progression occurred during follow-up. MP decreased from 75% preoperatively to 13% postoperatively (p < 0.001) and was maintained at 13% at the final follow-up, with radiographic containment (MP <33%) achieved in 92% of hips. Morphological parameters (LCEA, Tönnis angle, Sharp angle, AHI, and PWI) improved after TOA (all p < 0.001), except for AWI (p = 0.068), with 33-92% of hips falling within normal ranges. The median VD decreased from 21 mm preoperatively to 5.3 mm postoperatively (p = 0.005) but increased to 12 mm at the final follow-up (p = 0.015), with superior migration in three hips (25%).

CONCLUSIONS: TOA restored acetabular coverage and provided durable radiographic containment in skeletally mature patients with neurogenic hip subluxation, with significant pain relief at mid-term follow-up. TOA represents a joint-preserving option for neurogenic hip dysplasia in skeletally mature patients.

BACKGROUND: Cam-type deformity may contribute to femoroacetabular impingement after acetabular reorientation for hip dysplasia; however, its clinical relevance after transposition osteotomy of the acetabulum (TOA) remains unclear. This study aimed to determine whether cam-type deformity affects clinical, radiographic, and patient-reported outcomes after TOA in patients with hip dysplasia.

METHODS: We retrospectively reviewed 607 patients (607 hips) who underwent TOA for symptomatic hip dysplasia between 1998 and 2019. Seventy-nine hips with cam-type deformity, defined as an alpha angle ≥55° on preoperative frog-leg lateral radiographs, were propensity score-matched 1:2 to hips without cam-type deformity using age, sex, body mass index, preoperative modified Harris Hip Score (mHHS), preoperative Tönnis grade, and preoperative lateral center-edge angle. The matched cohort comprised 76 hips with and 152 hips without cam-type deformity. Failure was defined as progression to Tönnis grade 3 osteoarthritis or conversion to total hip arthroplasty.

RESULTS: The latest mHHS was comparable between hips with and without cam-type deformity (92 vs. 96; p = 0.427) at a median follow-up of 11 and 10 years, respectively (p = 0.589). Osteoarthritis progression occurred in 8 hips (11%) and 20 hips (13%), respectively (p = 0.671), and failure occurred in 5 hips (6.6%) and 12 hips (7.9%), respectively (p = 0.796). The 10- and 20-year joint survival rates were 98% and 73% in both groups (log-rank p = 0.701). Pain, satisfaction, Forgotten Joint Score-12, and all Hip disability and Osteoarthritis Outcome Score subscales were comparable between the groups.

CONCLUSIONS: Preoperative cam-type deformity was not associated with inferior long-term outcomes after TOA for hip dysplasia. These findings suggest that an alpha angle ≥55° alone may not be sufficient to justify routine femoral osteochondroplasty during TOA; however, future studies should identify cam morphologies associated with clinically relevant residual impingement after acetabular reorientation.

BACKGROUND: Although periacetabular osteotomy (PAO) provides excellent clinical outcomes for patients with hip dysplasia, it still remains uncertain how it affects coronal and sagittal spinopelvic alignment. Therefore, this study aims to evaluate changes of coronal and sagittal spinopelvic parameters on standing AP and Lateral entire spine EOS radiographs following unilateral and bilateral PAO surgery.

METHODS: Skeletally mature patients who underwent unilateral and bilateral PAO surgery for symptomatic hip dysplasia were included in this study. Standing anteroposterior (AP) and lateral EOS spine radiographs (EOS Imaging, Paris, France) obtained preoperatively and at the last follow-up were analyzed to assess changes in coronal and sagittal plane measurements. Preoperative and postoperative radiographic outcomes were assessed using the Paired Sample t test for normally distributed variables and the Wilcoxon Signed-Rank test for non-normally distributed variables.

RESULTS: A total of 31 patients with 44 hips were included in this study following our exclusion criteria. Of those, 18 patients (58%) underwent unilateral PAO (Unilateral group) and 13 patients (42%) underwent bilateral staged PAOs (Bilateral group). The mean age of patients at first surgery was 16±3 years in the Unilateral group and 19±5 years in the Bilateral group ( P >0.05). The mean preoperative Lateral Central Edge Angle (LCEA) was 13 degrees in the Unilateral group, which improved to 28 degrees at final follow-up ( P <0.001). In the Bilateral group, the mean LCEA was 16 degrees preoperatively, which improved to 32 degrees at last follow-up ( P <0.001). While the mean Acetabular Index (AI; Tönnis Angle) improved from 17 to 5 degrees at last follow-up in the Unilateral group ( P <0.001), it improved from 9 to -1 degrees at last follow-up in the Bilateral group ( P <0.001). There were no statistically significant preoperative and postoperative Pelvic Tilt, Sacral Slope, Pelvic Incidence, Lumbar Lordosis changes in the Unilateral and Bilateral groups.

CONCLUSIONS: Spinopelvic alignment did not significantly change following either unilateral or bilateral PAOs, as assessed on standing spine radiographs. Taken together with findings from previous research, our results suggest that pelvic tilt in skeletally mature patients with acetabular dysplasia is likely a fixed morphologic characteristic rather than a compensatory or reversible mechanism.

LEVEL OF EVIDENCE: Level III.

BACKGROUND: Slipped capital femoral epiphysis (SCFE) is strongly associated with obesity, yet the underlying mechanisms remain unclear. This study evaluated whether alterations in proximal femoral morphology (PFM) associated with obesity contribute to susceptibility to SCFE, after accounting for chronological age and skeletal maturity.

METHODS: Two groups of patients were studied. The first was a group of 42 obese children (6 to 15 y) and 42 age- and sex-matched normal-weight controls. Femoral head diameter, epiphyseal cupping ratio (ECR), Alsberg angle (AA), and posterior sloping angle (PSA) were measured on pelvic radiographs. Skeletal maturity was assessed using the modified Oxford bone score (mOBS). PFM was compared under conditions of chronological age matching and skeletal maturity stratification. The second group was a retrospective cohort of patients diagnosed with SCFE at our institution between 2011 and 2025. Chronological age at onset and skeletal maturity were compared between obese and normal-weight patients.

RESULTS: At 6 to 9 years, obese children matched by chronological age showed a larger femoral head diameter, greater ECR, a smaller AA (63.6±3.7 vs. 66.1±4.1 degrees, P=0.022), and a larger PSA (4.7±3.6 vs. 2.6±4.2 degrees, P=0.049); These differences remained at 10 to 12 years but disappeared by 13 to 15 years. The mOBS was higher in the obese group at 6 to 9 and 10 to 12 years (P=0.032 and P<0.001, respectively) but was similar between groups at 13 to 15 years (P=0.522). After stratification by skeletal maturity, anatomic differences between groups were no longer significant. At equivalent mOBS levels, obese children were about a year younger than normal-weight children (P<0.05). In the SCFE group, obese patients were about a year younger than normal-weight patients, despite similar mOBS scores (19.2±1.4 vs. 19.8±2.0; P=0.199).

CONCLUSION: Obesity accelerates skeletal maturation by about 1 year and is a risk factor for SCFE. However, after adjusting for skeletal maturity, obesity does not alter PFM. Therefore, the increased risk of SCFE in obese children is likely due to high body weight or obesity-related factors, not anatomic characteristics of the proximal femur.

LEVEL OF EVIDENCE: Level III-diagnostic study.

The treatment of borderline hip dysplasia (BHD) remains controversial, with a paucity of literature on whether periacetabular osteotomy (PAO) is a viable option even in middle-aged patients over 30 years of age. This study aimed to analyse the functional outcome and activity level in relation to the patient's age after PAO for BHD. Patients over 30 years of age (G30-age 30-40; G40 age > 40) undergoing PAO for BHD were enrolled in this single-centre study with a minimum follow-up of 2 years. The patient-reported outcomes (PRO) were assessed using the numeric rating scale (NRS) for pain, the modified Harris-Hip score (mHHS), and International Hip Outcome Tool-12 (iHot-12) for joint functionality, and the University of California Los Angeles activity score (UCLA) for sports participation. Forty-eight patients (48 hips) were included. There was a significant postoperative pain relief in both groups (G30 pre-post 7.2 - 2.7, P < .001; G40 pre-post 7.3 - 2.5, P < .001). Joint functionality improved postoperatively with significant higher scores for mHHS (G30 pre-post 48.0 - 80.0, P < .001; G40 pre-post 44.9 - 84.4, P < .001) and iHot-12 (G30 pre-post 40.1 - 68.8, P < .001; G40 pre-post 41.5 - 64.9, P = .004) for patients older than 30 and 40 years. Sports participation only improved significantly after PAO in patients older than 40 years (pre-post 5.4 - 6.9, P = .019). Overall, PAO is a viable option to treat BHD in middle-aged patients, while improving pain and joint function. Even patients over 40 years of age can benefit in terms of activity and joint function.

Periacetabular osteotomy (PAO) is a widely used surgical technique for symptomatic developmental dysplasia of the hip (DDH). However, the incidence of posterior column fractures after PAO and the risk factors are not adequately investigated. Identification rates have been improved by using oblique radiographs, but few reports have examined the incidence of posterior column fractures using early postoperative computed tomography (CT) scans. This study aimed to investigate the incidence and risk factors for postoperative posterior column fracture following PAO using early postoperative CT scans. This study included 80 hips from patients who underwent PAO for symptomatic DDH. Radiographic parameters such as lateral center-edge angle (LCEA), anterior center-edge angle (ACEA), acetabular roof obliquity (ARO), and the thickness of the posterior column before and after surgery were evaluated using preoperative and early postoperative (within 1 month) CT images. Statistical analyses were conducted to identify risk factors associated with postoperative posterior column fracture. Postoperative CT scans revealed that postoperative posterior column fracture occurred in 42% of cases. A preserved posterior column thickness of <13 mm was identified as a significant risk factor for postoperative posterior column fracture. In conclusion, Posterior column fractures are a relatively common complication following PAO, with a higher incidence than previously reported. A preserved posterior column thickness of <13 mm is a critical risk factor for postoperative posterior column fracture. These results suggest that early weight-bearing should be approached with caution and that accurate osteotomy techniques using computer-assisted surgery are needed.

This retrospective analysis investigated relationships between pain levels, the extent of hip dysplasia, and behavioral health diagnoses in adolescent and adult patients diagnosed with developmental dysplasia of the hip (DDH). 105 patients (119 hips, age: 22.5 ± 0.7 yrs, body mass index (BMI): 24.8 ± 0.53) with DDH were included, focusing on demographic information, pain assessments (VAS), lateral center-edge angle (LCEA) measurements, and behavioral health data. Patients were white (92%), female (90%), and privately insured (77%). The average VAS score was moderate, 4.2 ± 2.7. No significant difference was found in pain or LCEA based on age, although higher pain was correlated with milder dysplasia (r = .254). Patients reporting severe pain had the most mild degree of dysplasia (LCEA 18.1° ± 4.9°). When analyzing those who underwent surgery, 18 patients (20/96 surgical hips) had mild pain, with an average LCEA of 13.7° ± 8.4 and 20 patients (21/96 surgical hips) had severe pain with an average LCEA of 17.8° ± 5.2°. In the nonsurgical group (n = 24 hips), 38% reported moderate/severe pain with mild hip dysplasia (LCEA = 17.6° ± 4.0). 74 patients received MRI imaging; labral tears were identified in 53 hips. Higher pain scores were associated with a labral tear (P < .05). 30% (n = 32) of patients had at least one behavioral health (BH) diagnosis. A trend was observed for longer duration of symptoms in patients with BH diagnosis: 26.5 ± 26.9 months versus 19.2 ± 16.0 months, P = .090. This study emphasizes the intricate relationships between anatomical, psychological, and socio-demographic factors in the perception of pain related to DDH, highlighting the necessity for multidisciplinary strategies in treatment planning and surgical decision making.

A periacetabular osteotomy (PAO) seeks to improve native hip function in patients with pre-arthritic dysplasia. Fulfilment of expectations has been shown to influence post-operative satisfaction in spine surgery and knee arthroplasty, but has not been investigated for PAOs. This study analyses relationships between preoperative patient expectations, patient-reported outcomes, and patient satisfaction in young adults undergoing PAO. Patients undergoing PAO in 2012-2014 at a tertiary care centre were asked to complete a preoperative survey indicating their expectations on a Likert scale (not improved-greatly improved) in six domains: pain, stability, stiffness, walking, locking/catching, and athletics. At 7-9 years after PAO, patients reported outcomes on the same Likert scales. Patients were also asked about satisfaction (very dissatisfied-very satisfied) in each domain and overall helpfulness of the PAO (extremely unhelpful-extremely helpful). Change between preoperative expectation and long-term outcome was assessed using the Wilcoxon signed rank test for paired ordinal data. The association between expectations/outcomes alignment with satisfaction and perceived helpfulness of PAO was assessed with Spearman rank correlation. Alignment between patient expectations and long-term outcomes correlated with long-term satisfaction for all domains, with the strongest correlation in the pain domain. Alignment between patient expectations and long-term outcomes also correlated with perceived helpfulness of the PAO for all domains except for walking ability and stiffness. Regardless of preoperative expectation level, patients whose expectations align with their outcomes are generally more satisfied and perceive their procedure as more helpful compared with those with misaligned expectations and outcomes.

Labral tears in hip dysplasia arise from structural instability and excessive shear forces. Yoon's classification system, based on arthroscopic findings, was developed to reflect the natural course of labral tears in hip dysplasia and guide surgical decision-making. However, its reliability when applied to MRI-based grading remains unclear. We retrospectively included 105 hips from 88 patients with hip dysplasia, including borderline hip dysplasia, who underwent arthroscopic labral repair between 2022 and 2024. Labral tears were classified arthroscopically using Yoon's classification. MRI grading was independently performed by two observers. The reliability between MRI and arthroscopic grading was assessed using Cohen's weighted kappa and Gwet's Agreement Coefficient 1 (AC1); correlation was evaluated with Kendall's tau-b. Inter- and intra-observer reliabilities were also analysed. Most labral tears were arthroscopically graded as Grade 3 (81.0%) and primarily located in Zones 2-3 (79.0%). The reliability between MRI and arthroscopic grading was moderate (κ = 0.49 for observer 1, κ = 0.54 for observer 2). Inter-observer reliability was moderate (κ = 0.60), and intra-observer reliability was good (κ = 0.69) (P < .001). The observed percent agreement was 81.0% and Gwet's AC1 showed good reliability (0.782, P < .001). The reliability between MRI-based and arthroscopic grading was moderate according to Yoon's classification. Discrepancies, particularly in assessing CLR integrity, highlight the need to interpret MRI findings alongside clinical evaluation when planning treatment for labral tears in hip dysplasia.

The aim of this study was to compare the efficacy and safety profiles of acemetacin and indomethacin for prophylaxis of heterotopic ossification (HO) following hip arthroscopy. While indomethacin is a well-established agent, evidence on acemetacin remains limited. This retrospective study included 114 hips of 110 patients who underwent hip arthroscopy for femoroacetabular impingement between September 2022 and September 2024. Patients received indomethacin or acemetacin for 3 weeks postoperatively. HO development was assessed radiologically using the Brooker classification. Functional outcomes and non-steroidal anti-inflammatory drug-related adverse events were recorded and compared. HO developed in 6 hips (5.3%): 4 in the indomethacin group (8%) and 2 in the acemetacin group (3.1%) (P = .402). All HO cases were Brooker grade 1 or 2. Gastrointestinal adverse events occurred more frequently in the indomethacin group (16%) compared to the acemetacin group (4.7%) (P = .042). No significant differences were found between groups regarding demographic data, functional scores, or laboratory parameters. Among the variables analysed, a higher number of suture anchors used during labral repair was the only factor significantly associated with HO development (P = .023). No significant differences in functional scores were observed between HO and non-HO patients, though scores tended to be higher in the non-HO group. Both acemetacin and indomethacin are effective for HO prophylaxis after hip arthroscopy. However, acemetacin was associated with fewer gastrointestinal adverse events, suggesting it may be a more tolerable alternative. Given the retrospective design and low event rate, larger prospective trials are required to validate these findings.

The fragility index (FI) assesses the robustness or fragility of statistically significant results in randomized controlled trials (RCTs), but is limited to dichotomous outcomes. The continuous FI (CFI) extends this concept to continuous outcomes. This is particularly relevant when comparing hip arthroscopy (HA) and conservative management or physical therapy (PT) for the treatment of femoroacetabular impingement syndrome (FAIS), which commonly demonstrates significantly higher improvement in patient-reported outcomes among surgical intervention arms in comparison to conservative management. The study aimed to identify RCTs comparing outcomes after HA or conservative management for FAIS and characterize the fragility of statistically significant results. PubMed, Embase, Cochrane, and ClinicalTrials.gov were utilized for RCT search. The Cochrane risk-of-bias tool for randomized trials was used to assess the risk of bias. RCTs were included if (1) they contained a HA and conservative management or PT arm, and (2) reported ≥ one statistically significant outcome. CFI and FI were calculated for significant continuous and categorical outcomes, respectively. Five RCTs met inclusion criteria. Risk of bias was 'low' in 2 RCTs and 'some concerns' in 3 RCTs. The mean CFI was 15.84 (range, 8.8-28.4). The mean dichotomous FI was 3.5 (range, 1-6). Loss to follow-up exceeded calculated CFI or FI in 2 of the 5 RCTs. These findings may provide surgeons with greater confidence that HA can have superior clinical outcomes compared to PT, particularly when considering HA as a treatment option following unsuccessful conservative management. Meta-Analysis; Level of Evidence, 2.

Radiographs do not entirely capture the complexity of acetabular morphology. The purpose of this study was to establish normative three-dimensional (3D) acetabular morphology in young adults without hip disease and identify sex-specific differences in acetabular coverage. We analysed 3505 hips from 1856 asymptomatic subjects aged 18-25; 48% were female (n = 890), who had undergone pelvic computed tomography (CT) scans for abdominal pain. We used a custom software to automatically segment the CT data and create 3D models. The centre-edge angle (CEA) and acetabular rim lateral extension (ARLE) were assessed at various clock-face positions around the acetabulum and sex-related differences were calculated. Females had greater acetabular coverage posteriorly, with higher mean CEA values at 9 o'clock (12° versus 9°; P < .001) and 10 o'clock (23° versus 20°; P < .001) and higher ARLE at 9 o'clock (0.54 versus 0.51; P < .001), 10 o'clock (0.63 versus 0.60; P < .001), and 11 o'clock (0.71 versus 0.70; P < .001). Males exhibited greater superior and anterior coverage, with higher CEA values at 12 o'clock (36° versus 34°; P < .001), 1 o'clock (28° versus 26°; P < .001), and 2 o'clock (4° versus 2°; P < .001) and higher ARLE at 12 o'clock (0.74 versus 0.73; P < .001), 1 o'clock (0.67 versus 0.66; P < .001), and 3 o'clock (0.25 versus 0.24; P = .01). Using automatic computational 3D modelling we found greater posterior acetabular coverage in females, whereas males exhibited more extensive superior and anterior coverage. Detailed 3D mapping of acetabular morphology may enable the development of standardized, sex-specific models to improve diagnosis and guide surgical planning of acetabular dysplasia and pincer femoroacetabular impingement.

The 2024 International Society for Hip Preservation physiotherapy agreement presents expert-driven rehabilitation guidelines for use following hip arthroscopy (HA) for femoroacetabular impingement syndrome (FAIS). The expert-panel consisted of 11 physiotherapists and eight surgeons representing five countries specializing hip preservation. Despite the favorable outcomes of HA for FAIS demonstrated in the current literature, there is a paucity of research supporting a specific physiotherapy protocol. These guidelines were created utilizing a modified-Delphi technique where panelists utilized the Grading of Recommendations, Assessment, Development, and Evaluation scale to determine inclusion of treatment interventions within each phase. The panelists recommend six phases of rehabilitation with a time and milestone-based approach beginning in the immediate post-operative period and continuing the through the return to sport phase. These expert-driven guidelines will help reduce practice variation and standardize post-operative timelines.

The Journal of Hip Preservation Surgery (JHPS) is not the only place where work in the field of hip preservation can be published. Although our aim is to offer the best of the best, we are continually fascinated by work, which finds its way into journals other than our own. There is much to learn from it, and so JHPS has selected six recent and topical subjects for those who seek a summary of what is taking place in our ever-fascinating world of hip preservation. What you see here are the mildly edited abstracts of the original articles, to give them what JHPS hopes is a more readable feel. If you are pushed for time, what follows should take you no more than 10 min to read. So here goes ….

Femoroacetabular impingement is a common cause of labral damage and hip pain in athletes. In severe labral tears with inadequate healthy labrum for repair, labral reconstruction has shown positive clinical outcomes in the general population. This study aimed to conduct a systematic review and meta-analysis on athletes undergoing arthroscopic hip labral reconstruction, focusing on postoperative patient-reported outcomes (PROs) and return to play (RTP). A systematic review of the literature was performed to include studies reporting PROs of labral reconstruction in athletes across multiple databases. Of the initial 430 identified records, four satisfied inclusion criteria of reporting PROs at 1-year minimum follow-up and RTP. Athletes included recreational through professional levels. Three studies analyzed return to same level of play (RTSP). Meta-analysis was conducted by pooling data, creating forest plots, and reporting odds ratios (OR). The four studies included 126 hips with average age at surgery of 32.2 years. All PROs in each study showed significant improvements with postoperative pooled weighted improvements in modified Harris Hip Score by 18.9 (Cohen's d = 1.10), Non-arthritic Hip Score by 19.6 (Cohen's d = 1.10), Hip Outcome Score-Sport by 25.6 (Cohen's d = 1.15), and Visual Analogue Scale-Pain by -3.0 (Cohen's d = -1.81). RTP averaged 81.4%, ranging from 73.3% to 90.0%. RTSP ranged from 40.6% to 81.0% with an overall OR of 83 (I²= 0.00). This meta-analysis found excellent patient-reported clinical outcomes at 1-year minimum follow-up after labral reconstruction in athletes, and a return-to-play rate of 81.4%. These data can help counsel athletes who undergo arthroscopic hip labral reconstruction.

The Guardian table is widely utilized for combined hip arthroscopy and periacetabular osteotomy (PAO) due to its postless traction design and the ability to perform both procedures without the need for redraping. This retrospective cohort study reports one surgeon's use of the Guardian table extension during combined hip arthroscopy and PAO and the occurrence of intraoperative posterior column fractures. Seventy-two consecutive PAO procedures performed at a single institution between February 2023 and January 2025 were analysed. Procedures involving concomitant hip arthroscopy (n = 26) utilized the Guardian table, whereas those without arthroscopy (n = 46) used a conventional radiolucent table. Patient demographics, clinical data, and complications were reviewed. Additionally, mechanical testing quantified table stability by measuring peak absolute acceleration ('table bounce') using accelerometry during simulated malleting. The incidence of intraoperative posterior column fractures was significantly higher with the Guardian table (4/26, 15.4%) compared to the conventional table (0/46, 0%; P = .0062). Mechanical testing demonstrated significantly greater table bounce for the Guardian table (69.1 ± 3.4 m/s2 versus 28.2 ± 4.4 m/s2, P < .001). Patient characteristics and surgical complexity did not differ significantly between fracture and non-fracture cases. These findings suggested that the Guardian table extension system was associated with increased risk of posterior column fractures, likely due to lack of distal support and stability. Surgeons should consider alternative table setups or intraoperative support modifications to mitigate this risk during PAO procedures.

Hip arthroscopy requires a capsulotomy to achieve adequate visualization and access; however, an excessive incision can increase the risk of postoperative instability. This technical note describes a less-invasive capsulotomy technique guided by the "gluteus minimus sign," a fibrous membrane connecting the main tendon of the gluteus minimus to the joint capsule. Cadaveric analysis confirmed that this fibrous membrane corresponds to the anterosuperior region of the femoral neck. Most gluteus minimus functions can be preserved by limiting the anterior extension of the capsulotomy to within this sign. When additional anterior exposure is necessary, superficial tendon fibers can be incised using an arthroscopic knife. This technique offers a safe, anatomically informed, and strategically targeted capsulotomy that balances preservation of joint stability with adequate surgical access.

Femoroacetabular impingement with cam morphology that fails nonoperative management can be addressed with hip arthroscopy and cam resection. There exists a wide variation of cam morphology due to various etiologies that can make some cam lesions more challenging to address. A thorough preoperative evaluation and the utilization of a variety of intraoperative techniques can allow for adequate arthroscopic resection of these otherwise challenging cam lesions. In this technique video, we describe a systematic approach for the preoperative assessment of femoroacetabular impingement due to a cam lesion and consideration of different approaches for arthroscopic resection based on cam-specific morphology.

As an increasingly recognized technique, the longitudinal outside-in capsulotomy (LOIC) has the advantages of reducing damage to the iliofemoral ligament and decreasing the impact on hip joint stability. However, it has limitations in exposing and addressing acetabular-sided lesions, particularly in femoroacetabular impingement syndrome cases with posterior pathologies. In this report, we describe a modified capsulotomy technique based on LOIC to obtain a balance between reducing damage to the iliofemoral ligament and achieving adequate visualization of acetabular-sided pathologies. Furthermore, the LOIC usually requires transecting the zona orbicularis to expose and address femoral-sided lesions, but standard repair techniques may be insufficient to adequately restore its anatomic continuity and mechanical strength. In this report, we describe an anatomic suture technique specifically designed for the anatomic repair of the zona orbicularis during LOIC.

Hip arthroscopy is a widely accepted, minimally invasive technique for treating various hip joint disorders. The traditional approach typically involves the supine position with traction and an anterolateral entry point. However, this approach presents challenges, including insufficient exposure of posterior hip lesions and an increased risk of nerve injury. In this technical note, we describe a posterolateral portal in the lateral decubitus position, eliminating the need for traction and fluoroscopy. This technique provides direct access to posterior hip lesions and facilitates effective resection with minimal muscle damage. Additionally, it avoids interference with anterior structures and circumvents potential complications associated with traction and fluoroscopy. This approach offers a promising alternative for arthroscopic management of posterior hip pathologies.

ABSTRACT: Femoroacetabular impingement syndrome is a significant morphology-driven hip disorder in which abnormal osseous geometry and dynamic hip motion lead to intra- and/or extra-articular mechanical conflict. Repetitive impingement induces chondrolabral injuries, promoting early joint degeneration and representing a major pathway to osteoarthritis. Although cam and pincer morphologies and femoral torsion abnormalities are commonly observed on imaging, these features alone are not sufficient for diagnosis, requiring integration with clinical evaluation.

ABSTRACT: Imaging plays a pivotal role in assessing femoroacetabular impingement syndrome, from diagnosis to preoperative planning and postoperative follow-up. Conventional radiography remains indispensable for the primary assessment of hip morphology. Computed tomography provides high-resolution three-dimensional characterization of osseous structures and torsional alignment. Magnetic resonance imaging, including direct magnetic resonance arthrography and traction or position-specific protocols, allows detailed evaluation of chondrolabral lesions, cartilage integrity, and periarticular soft tissues. Quantitative cartilage imaging and three-dimensional modeling further enhance detection of early degeneration, motion-dependent impingement, and dynamic instability.

ABSTRACT: Accurate differentiation between impingement and instability is critical. Imaging findings guide planning, patient selection, and prognostication, supporting surgical interventions while minimizing risks. This review provides a structured overview of femoroacetabular impingement syndrome pathomechanics and imaging, highlighting conventional and advanced modalities, established and emerging diagnostic parameters, and their implications for patient-specific management.

BACKGROUND: Hip arthroscopy outcomes for femoroacetabular impingement remain heterogeneous. The Hip Outcome Score (HOS) comprises 2 distinct subscales measuring activities of daily living and sports performance, yet their dissociation after surgery remains poorly characterised.

PURPOSE: To identify distinct recovery phenotypes after hip arthroscopy using unsupervised machine learning and determine preoperative predictors of phenotype membership.

METHODS: We analysed 326 consecutive patients with complete 1-year HOS-ADL and HOS-Sports data. K-means clustering was performed on 5 outcome variables with Gaussian Mixture Model validation. Multinomial logistic regression identified preoperative predictors.

RESULTS: 4 phenotypes emerged: Complete Responders (41.7%), ADL-Dominant Responders (27.3%), Slow Progressors (19.0%), and Non-Responders (12.0%). ADL-Dominant phenotype was predicted by age >40 years (OR 3.42, p < 0.001), Tegner <5 (OR 2.87, p = 0.001), and Outerbridge III-IV (OR 2.41, p = 0.005).

CONCLUSIONS: 4 robust recovery phenotypes exist, with 27% demonstrating ADL-sports dissociation predicted by older age, lower activity, and greater chondral damage. Recognition enables personalised preoperative counselling.

BACKGROUND: Charcot-Marie-Tooth (CMT) disease is a common inherited progressive sensorimotor neuropathy which can complicate intraoperative monitoring (IOM). Transcranial motor-evoked potentials (TcMEPs) have been found to be effective in obtaining IOM in CMT patients undergoing spine surgery. The aim of this study was to examine the effectiveness of TcMEPs and somatosensory-evoked potentials (SSEPs) in IOM in CMT patients undergoing periacetabular osteotomies (PAOs) for hip dysplasia.

METHODS: A retrospective case series was conducted in all CMT patients aged <19 years at a single institution who underwent PAO for hip dysplasia from 2020 to 2025. Demographics, diagnosis, IOM data, and perioperative results were recorded.

RESULTS: In total, 102 CMT patients from our institution's specialty clinic were reviewed. Fifteen (15%) had hip dysplasia. Of these, 7 had PAO surgery, with 6 having PAO with IOM. Five of 6 of study patients had the CMT1A subtype. All patients had absent or greatly reduced SSEPs. Five of the 6 (83%) had obtainable TcMEPs that could be used for IOM but required increased sweep lengths and/or signal intensities. No notable complications related to IOM were noted.

CONCLUSIONS: TcMEPs are preferred to SSEPs when monitoring interoperatively during PAO in CMT patients with hip dysplasia. Increased sweep lengths and/or signal intensities were required. Preoperative CMT diagnosis allows anticipation of IOM difficulties by the technician to make appropriate changes to allow monitoring.

KEY CONCEPTS: (1)Charcot-Marie-Tooth (CMT) is a common inherited progressive sensorimotor neuropathy which can complicate intraoperative monitoring (IOM).(2)Fifteen percent of CMT patients have hip dysplasia that may require surgical intervention. Surgeons should be aware of potential technical issues with IOM if this is requested for the procedure.(3)Somatosensory-evoked potentials (SSEPs) are greatly reduced or absent in CMT patients undergoing periacetabular osteotomy (PAO) for hip dysplasia. Use of transcranial motor-evoked potentials (TcMEPs) improves the ability to obtain baseline IOM with increased sweep lengths and increased signal intensities(4)TcMEPs are preferred to SSEPs when obtaining IOM during PAO surgery in CMT patients with hip dysplasia.

LEVEL OF EVIDENCE: IV, Retrospective case series.

BACKGROUND: Spinopelvic assessment is critical for surgical planning. It is unknown if age, sex, and body mass index (BMI) influence pelvic orientation during development. This study aimed to (1) describe normative pelvic orientation and (2) investigate how patient-specific factors influence pelvic orientation throughout development from childhood to early adulthood.

METHODS: Computed tomography pelvis scans of supine asymptomatic patients were obtained at a single institution from 2004 to 2022. Three-dimensional measurements of pelvic incidence (PI), sacral slope (SS), and pelvic tilt (PT) were measured utilizing a custom-developed software (VirtualHip, Boston Children's Hospital). Pelvic orientations were modeled as a function of age, sex, and BMI with univariate and multivariable generalized additive models.

RESULTS: A total of 9,721 patients (14.2 ± 4.2 years) were included with 49% females (n = 4,800), 35.1% skeletally immature (n = 3,413) as defined by triradiate cartilage closure, and 18.5% obese patients (n = 1,311) as defined by BMI > 95th percentile. Spinopelvic parameters were not static over the course of development. After skeletal maturity, females had slightly higher PI and PT compared to males (<3°, P < .001). PI trends were not static across age and physeal status. Pubertal patients with an open physis had higher PI by 3-4° as compared to patients with closed physes (P = .03). Sex- and obesity-related differences were small prior to skeletal maturity (<2°, P < .001). Multivariable analyses revealed that skeletally mature females had differences in SS, whereas skeletally mature males had differences in PT by about 2° when obese.

CONCLUSIONS: Unlike adults, there are no significant variations in spinopelvic balance during development from ages 7 to 25. Based on a large sample size of 9,721 patients, this work establishes normative values for supine spinopelvic balance during skeletal development stratified by sex, age, BMI, and skeletal maturity. Future investigations on the clinical impact of minor variations between groups based on these subgroups may uncover phenotypic predispositions to spine-pelvis pathology.

KEY CONCEPTS: (1)Spinopelvic parameters are not static over the course of pediatric development.(2)Sex- and weight-related differences in spinopelvic parameters prior to skeletal maturity are minimal (<2°, P < .001)(3)After skeletal maturity, females had a trend toward minimally higher PI and PT than in males (<3°, P < .001), while obese patients trended toward up to 2° higher SS with no difference in PI or PT (P < .001).(4)Patients 12-14 years of age with an open triradiate cartilage demonstrated a 3-4° increase in pelvic incidence than those with closed physes (P < .05).

LEVEL OF EVIDENCE: III.

BACKGROUND: The sphericity deviation score (SDS) is a continuous parameter to describe femoral head shape in patients with Perthes disease. The aims of this study were to evaluate the reproducibility of SDS and its association with the 3-group Stulberg classification.

METHODS: Anteroposterior and frog-leg lateral radiographs of 41 healed Perthes hips were assessed. Six observers with varying levels of experience, independently performed SDS measurements on two occasions, 2 weeks apart. Associations between SDS and the modified 3-group Stulberg classification were tested using ANOVA or Kruskal-Wallis tests and Spearman's rank correlation coefficient (rho). Intra- and interobserver agreement was assessed with Bland-Altman 95% limits of agreement (LoA), and reliability was analyzed by intraclass correlation coefficients (ICC).

RESULTS: The median SDS values in hips with a round femoral head were significantly higher when measured by inexperienced observers than those measured by experienced observers (30 vs 17; P < 0.001). The SDS values did not significantly correlate with the Stulberg classification among inexperienced observers. Among experienced observers, a strong correlation was found (Spearman's rho 0.670; P < 0.001); however, only 2 of 3 observers were able to distinguish between round and oval hips. Interobserver agreement for SDS was unacceptable (LoA >40) for inexperienced observers and marginal (LoA 20-40) for experienced observers. Interobserver reliability was poor for inexperienced observers (ICC 0.15; P = .02) and moderate for experienced observers (ICC 0.69; P < .001).

CONCLUSIONS: SDS is a complex parameter that did not consistently differentiate between femoral head shapes when used by inexperienced observers. Even among experienced pediatric orthopaedic researchers, SDS showed marginal interobserver agreement. The method should be used only by experienced observers in scientific studies.

KEY CONCEPTS: (1)The Sphericity Deviation Score (SDS) correlates significantly with the Stulberg classification only when measured by experienced pediatric orthopaedic researchers.(2)SDS is a complex and time-consuming parameter that often failed to distinguish clearly between adjacent Stulberg categories (e.g., round vs. ovoid hips).(3)Among inexperienced observers, the limits of agreement (LoA) of SDS measurements were unacceptable and the reliability (ICC) was poor.(4)SDS should be used only by experienced observers in scientific studies. Even among experienced researchers, interobserver LoA was marginal, indicating that further methodological refinements are desirable.

LEVEL OF EVIDENCE: III, retrospective cohort study.

UNLABELLED: Neuromuscular hip dysplasia often results in posterior and lateral acetabular insufficiency. Many pelvic osteotomies have been used for its treatment. The San Diego acetabuloplasty is a clearly described procedure that results in predictable improvements in posterior and lateral acetabular coverage. Good clinical and radiographic results are reported when combined with single-stage hip reconstruction for patients with cerebral palsy. Herein, the technical details of the procedure are highlighted with a representative case and accompanying technique video.

KEY CONCEPTS: (1)The San Diego acetabuloplasty aims to increase posterior and lateral acetabular coverage of the femoral head by maintaining an intact anterior-medial hinge point at the horizontal limb of the triradiate cartilage.(2)Outer-table dissection of the ilium is all that is required to perform the osteotomy in isolation, with limited bicortical violation only at the interspinous (between anterior superior and anterior inferior iliac spines) and sciatic notch regions.(3)Positive results have been reported with single-stage combination with femoral osteotomy for neuromuscular hip reconstruction in nonambulant patients.(4)An accompanying surgical technique video outlines the main technical considerations.

BACKGROUND: Legg-Calvé-Perthes disease (LCPD) classically affects children aged 2-14 years. However, there is considerable variability in reported incidence, and larger-scale nationally representative age data in the United States are lacking. Some investigators have also suggested that the age at presentation may be trending younger in recent years. Therefore, the purpose of this study was to explore temporal trends in the epidemiology and demographic characteristics of LCPD and determine whether the age of children presenting with LCPD is changing.

METHODS: A retrospective review of all patients under 15 years of age diagnosed with LCPD between January 1, 2015, and December 31, 2024, was conducted at a single large tertiary care center and using the TriNetX US Research network. Geographic and demographic information, including age, sex, race, and ethnicity, was collected. Incident cases were calculated per 100,000 children within the specified period.

RESULTS: A total of 3,495 children (330 regional and 3,162 nationwide) were diagnosed with LCPD in our 10-year period (average age: 7.7 ± 3.2 years [regional], 7.4 ± 3.4 years [nationwide]). Between both cohorts, males (78.3%, 82.9%) represented a significantly larger proportion than females (20.6%, 17.1%). The average incidence rate (IR) was 7.82 per 100,000 children at our center and 6.75 per 100,000 nationwide. Children aged 5-9 years represented the most common group of new diagnoses for all but 1 year across both cohorts. The overall disease incidence significantly decreased over time both regionally and nationally (P < .05). Nationally, disease incidence significantly decreased in children aged 10-14 years (P < .05) and appeared to trend downward regionally; the average age at diagnosis did not significantly decrease over time across both cohorts.

CONCLUSIONS: In this large US study on the epidemiology of LCPD, we demonstrate both regional and nationwide IRs within a narrower range than previously described (∼7/100,000). The LCPD IR has significantly decreased over time, with the most prominent decrease seen in older children. We did not observe a significant change in the age of presentation over the last decade.

KEY CONCEPTS: (1)The incidence of Legg-Calvé-Perthes disease (LCPD) in the United States has decreased over time, with a contemporary nationwide incidence rate of approximately 7 cases per 100,000 children.(2)Children aged 5-9 years remain the most commonly affected group, while new diagnoses among older children (10-14 years) have decreased and appear to be contributing to the overall declining disease incidence.(3)Despite these epidemiological shifts, average age at LCPD diagnosis has remained stable.

LEVEL OF EVIDENCE: III, Retrospective cohort study.

BACKGROUND: Breech presentation is a strong risk factor for developmental dysplasia of the hip (DDH), a condition that, when diagnosed late, can lead to poor outcomes. Accordingly, it is recommended that breech-born infants undergo hip ultrasound (US) screening at 6 weeks or receive an anteriorpostierior (AP) pelvic radiograph at 6 months of age to enable early detection and timely intervention. Research evaluating guideline adherence and the factors influencing screening outcomes remain limited. In this study, we investigate sociodemographic factors that influence delayed or missed US screening among breech-born infants.

METHODS: An institutional review board-approved, retrospective cohort study of breech-born infants between 2008 and 2023 at a single institution was conducted. Sociodemographic variables as well as presence and/or timing of US screening were extracted from electronic health records. Screening outcomes were categorized by US timing: (1) screened between 4 and 8 weeks (defined as adherent), (2) screened outside this window, or (3) not screened. Comparisons were performed across groups.

RESULTS: Two hundred fifty-four infants were born breech and met eligibility criteria. Fifty-one percent underwent "timely" screening, 28% were screened outside the recommended window, and 21% had no screening at all. Univariate analysis demonstrated that infant ethnicity, maternal marital status, insurance type, and Area Deprivation Index (ADI) were significantly associated with screening timeliness. In multivariate analyses, infant ethnicity, as well as maternal insurance type, marital status, and ADI were associated with reduced likelihood of adherent screening.

CONCLUSIONS: Despite the recommended US screening at 6 weeks of age for infants with select risk factors for DDH, half of infants were screened in a timely fashion, while 1 in 5 infants were not screened at all. Several maternal sociodemographic characteristics were associated with untimely or lack of screening. Addressing these factors through targeted interventions is critical to reduce disparities in early identification, timely treatment, and DDH outcomes overall.

KEY CONCEPTS: (1)Fifty-one percent of breech-born infants received a screening ultrasound that was adherent to guidelines.(2)Twenty-one percent of the population for whom screening was recommended did not receive screening at all.(3)Screening completion and timeliness is impacted by maternal marital status, insurance type, and area deprivation index, as well as infant ethnicity.(4)More equitable screening outcomes for developmental dysplasia of the hip will require system-level changes, driven by the collaboration of specialists and primary care providers, which address the social determinants of health.

LEVEL OF EVIDENCE: Level III, Retrospective Cohort.

BACKGROUND: Acetabular dysplasia (AD) is a prominent cause of hip pain and dysfunction among adolescents and young adults (AYAs). The gold standard treatment is periacetabular osteotomy (PAO), but there is limited research regarding the perspectives of those considering this procedure. We explored the decision-making and needs of people with AD related to PAO to inform future decision aid development.

METHODS: We conducted semi-structured interviews with people with AD age ≥13 years who underwent PAO >6 months ago. Questions explored experiences with AD diagnosis, PAO decision-making, and thoughts and preferences regarding a PAO decision aid. We inductively and deductively coded interviews to identify key themes.

RESULTS: 17 participants (12 female, 5 male) completed the interview (age at first PAO = 19.6 ± 5.0 years, range 13-29 years; time from surgery to interview = 934.5 ± 405.7 days; range 312-1510 days). Key themes included: 1) Participants experienced two distinct pathways for AD diagnosis with the majority seeing multiple providers from symptom onset to AD diagnosis while others were diagnosed after imaging due to an acute musculoskeletal injury; 2) Participants overwhelmingly felt relief upon being diagnosed with AD; 3) Female and male participants disclosed PAO concerns that differed by sex; 4) Participants appreciated engaging in shared decision-making around PAO with their surgeon and healthcare team and valued open, transparent conversations about the surgery and recovery; 5) Participants desired tailored peer connections; 6) Participants would value a PAO decision aid that was online, interactive, and comprehensive.

CONCLUSIONS: AYAs with AD experience different pathways to diagnosis and the decision to undergo a PAO. They value open, honest communication with their surgical team and peer connections, and favor the development of a comprehensive interactive online decision aid. This work can serve as a model for similar formative research for AYAs considering a variety of elective orthopaedic procedures.

KEY CONCEPTS: (1)Most people with acetabular dysplasia (AD) see multiple providers from symptom onset to diagnosis, and experience relief upon being diagnosed.(2)Females and males with AD considering periacetabular osteotomy (PAO) hold concerns that differ by sex.(3)People with AD considering PAO appreciate transparent and open communication with their surgeon and also desire tailored peer connections.(4)People with AD considering PAO would value a comprehensive decision aid that is online and interactive to facilitate the decision-making process.

LEVEL OF EVIDENCE: Level V.

OBJECTIVE: The purpose of this study was to evaluate the difference in patient-reported outcome measures (PROMs) after hip arthroscopy (HA) among patients with commercial insurance as compared with those with government-provided insurance, such as Medicare, Medicaid, and TRICARE or Veterans Affairs (VA).

METHODS: This retrospective cohort study queried an institutional database for patients 18 years or older who underwent HA in the prior 10 years. Patients were excluded if they did not have at least 1-year postoperative PROMs, were self-pay, had Workers' Compensation insurance, were uninsured, or had a hip arthroplasty after their arthroscopy. Patients were divided into four groups: commercial insurance, Medicare, Medicaid, and VA or TRICARE. Demographic information and PROMs were collected at a minimum of 1-year follow-up, including the modified Harris Hip Score, Hip Outcome Score (HOS)-Activities of Daily Living, HOS-Sports, and Non-Arthritic Hip Score.

RESULTS: This study included 84 patients, 31 of whom had government-provided insurance, 53 had commercial insurance; 11 had Medicaid, six had Medicare, and 14 had VA or TRICARE coverage. Medicare patients were significantly older than those with commercial insurance (P=0.002). Patients with Medicaid (n=6) had significantly lower PROMs than those with commercial insurance (n=53). Significant differences were found in the modified Harris Hip Score (Medicare 50.8±15.1, commercial 69.1±15.8; P=0.015), HOS-Activities of Daily Living (Medicare 59.5±15.3, commercial 77.8±18.2; P=0.021), HOS-Sports (Medicare 31.9±16.1, commercial 69.7±28.0; P=0.005), and Non-Arthritic Hip Score (Medicare 55.8±18.0, commercial 77.6±19.5; P=0.020). No difference in PROMs were noted between those with commercial insurance and those with Medicaid or VA/TRICARE coverage.

CONCLUSIONS: This study demonstrated that those with Medicare insurance had significantly lower PROMs than those with commercial insurance. It is unclear, however, to what extent this finding reflects underlying demographic differences such as age. Further research is needed to clarify this relationship.