The 2016 Warwick Agreement on femoroacetabular impingement (FAI) syndrome was convened to build an international, multidisciplinary consensus on the diagnosis and management of patients with FAI syndrome. 22 panel members and 1 patient from 9 countries and 5 different specialties participated in a 1-day consensus meeting on 29 June 2016. Prior to the meeting, 6 questions were agreed on, and recent relevant systematic reviews and seminal literature were circulated. Panel members gave presentations on the topics of the agreed questions at Sports Hip 2016 , an open meeting held in the UK on 27–29 June. Presentations were followed by open discussion. At the 1-day consensus meeting, panel members developed statements in response to each question through open discussion; members then scored their level of agreement with each response on a scale of 0–10. Substantial agreement (range 9.5–10) was reached for each of the 6 consensus questions, and the associated terminology was agreed on. The term ‘femoroacetabular impingement syndrome’ was introduced to reflect the central role of patients' symptoms in the disorder. To reach a diagnosis, patients should have appropriate symptoms, positive clinical signs and imaging findings. Suitable treatments are conservative care, rehabilitation, and arthroscopic or open surgery. Current understanding of prognosis and topics for future research were discussed. The 2016 Warwick Agreement on FAI syndrome is an international multidisciplinary agreement on the diagnosis, treatment principles and key terminology relating to FAI syndrome.

The Warwick Agreement on femoroacetabular impingement syndrome has been endorsed by the following 25 clinical societies: American Medical Society for Sports Medicine (AMSSM), Association of Chartered Physiotherapists in Sports and Exercise Medicine (ACPSEM), Australasian College of Sports and Exercise Physicians (ACSEP), Austian Sports Physiotherapists, British Association of Sports and Exercise Medicine (BASEM), British Association of Sport Rehabilitators and Trainers (BASRaT), Canadian Academy of Sport and Exercise Medicine (CASEM), Danish Society of Sports Physical Therapy (DSSF), European College of Sports and Exercise Physicians (ECOSEP), European Society of Sports Traumatology, Knee Surgery and Arthroscopy (ESSKA), Finnish Sports Physiotherapist Association (SUFT), German-Austrian-Swiss Society for Orthopaedic Traumatologic Sports Medicine (GOTS), International Federation of Sports Physical Therapy (IFSPT), International Society for Hip Arthroscopy (ISHA), Groupo di Interesse Specialistico dell’A.I.F.I., Norwegian Association of Sports Medicine and Physical Activity (NIMF), Norwegian Sports Physiotherapy Association (FFI), Society of Sports Therapists (SST), South African Sports Medicine Association (SASMA), Sports Medicine Australia (SMA), Sports Doctors Australia (SDrA), Sports Physiotherapy New Zealand (SPNZ), Swedish Society of Exercise and Sports Medicine (SFAIM), Swiss Society of Sports Medicine (SGMS/SGSM), Swiss Sports Physiotherapy Association (SSPA).

https://bjsm.bmj.com/content/bjsports/50/19/1169.full.pdf

The Warwick Agreement on femoroacetabular impingement syndrome (FAI syndrome): an international consensus statement

Purpose: The aim of this study was to determine the prevalence of radiographic findings suggestive of femoroacetabular impingement (FAI) in asymptomatic individuals. Methods: A systematic review was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies reporting radiographic, computed tomographic, or magnetic resonance imaging (MRI) findings that were suggestive of FAI in asymptomatic volunteers were included. Cam, pincer, and combined pathologic conditions were investigated. Results: We identified 26 studies for inclusion, comprising 2,114 asymptomatic hips (57.2% men; 42.8% women). The mean participant age was 25.3 � 1.5 years. The mean alpha angle in asymptomatic hips was 54.1 � � 5.1 � . The prevalence of an asymptomatic cam deformity was 37% (range, 7% to 100% between studies)d54.8% in athletes versus 23.1% in the general population. Of the 17 studies that measured alpha angles, 9 used MRI and 9 used radiography (1 study used both). The mean lateral and anterior center edge angles (CEAs) were 31.2 � and 30 � , respectively. The prevalence of asymptomatic hips with pincer deformity was 67% (range 61% to 76% between studies). Pincer deformity was poorly defined (4 studies [15%]; focal anterior overcoverage, acetabular retroversion, abnormal CEA or acetabular index, coxa profunda, acetabular protrusio, ischial spine sign, crossover sign, and posterior wall sign). Only 7 studies reported on labral injury, which was found on MRI without intra-articular contrast in 68.1% of hips. Conclusions: FAI morphologic features and labral injuries are common in asymptomatic patients. Clinical decision making should carefully analyze the association of patient history and physical examination with radiographic imaging. Level of Evidence: Level IV, systematic review if Level II-IV studies.

Prevalence of Femoroacetabular Impingement Imaging Findings in Asymptomatic Volunteers: A Systematic Review

Background
The prevalence of a cam-type deformity in athletes and its association with vigorous sports activities during and after the growth period is unknown.

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The Cam-type Deformity of the Proximal Femur Arises in Childhood in Response to Vigorous Sporting Activity

Introduction and Aims: There is a relationship between the anatomy of the hip joint and the development of arthritis. A common cause of hip pain in the young adult that can lead to arthritis is acetabular dysplasia. More recently, femoroacetabular impingement has been described as another cause of hip pain. The purpose of our study was to evaluate the applicability of pelvic computed tomography (CT) with three-dimensional surface rendering to evaluate femoro-acetabular impingement. Method Thirty-six hips (30 patients; 17 males; 13 females) with persistent hip pain, mean age 41 (37–52), underwent three-dimensional CT of the pelvis, as well as MRI arthrography with gadolinium enhancement. On 3D CT, the concavity of the femoral head-neck junction (offset), alpha angle as described by Notzli was calculated to depict the anterior femoral neck contour. The concavity of the posterior aspect of the head neck junction was measured as the beta angle. The same measurements were made in 20 hips, consisting of randomly selected patients with no prior history of hip pathology or pain (mean age 37; 13 males; eight females). Results The mean alpha angle for the symptomatic group was 66.4 (39–94) and 43.8 (39.3–48.3) for the control group (p=0.001). All symptomatic hips had abnormal findings on MRA: labral tears in all; cartilage delamination/ulceration in 14 hips; herniation pits in six hips. The majority of labral tears and delamination were located in the antero-superior quadrant. In the surgical treated group, all MRA findings were confirmed. The mean beta angle was significantly smaller (increase concavity) in the symptomatic versus the controls: 40.2 versus 43.8 (p=0.011). Interestingly in the symptomatic group the beta angle was significantly lower than the alpha angle (p Conclusion: 3D CT with surface rendering and multiplanar reformation is useful to determine degree of bone buttressing of the anterior femoral head-neck junction quantitatively assessed by alpha angle measurement, which is elevated in patients with femoro-acetabular impingement. With a greater posterior concavity i.e. small beta angle in the symptomatic group versus the control, subclinical slipped femoral epiphysis remains a plausible cause of this deformity.

Three-dimensional computed tomography of the hip in the assessment of femoroacetabular impingement

Background:Studies have demonstrated hip arthroscopy to be an effective treatment for femoroacetabular impingement (FAI) with associated labral tears. The purposes of this study were to report 10-year outcomes and hip survival following hip arthroscopy for FAI and to compare labral debridement with

Survivorship and Outcomes 10 Years Following Hip Arthroscopy for Femoroacetabular Impingement: Labral Debridement Compared with Labral Repair.

Background: Femoroacetabular impingement is a cause of hip pain in adults and is a possible precursor of osteoarthritis, with the cam type of impingement being the most common. The purpose of this study was to determine the prevalence of cam-type morphology of the hip in asymptomatic patients.

Methods: Two hundred asymptomatic volunteers with no prior hip surgery or childhood hip problems underwent magnetic resonance imaging targeted to both hips. The subjects were examined at the time of magnetic resonance imaging for internal rotation of the hips at 90° of hip flexion and for a positive impingement sign. The contour of the femoral head-neck junction was quantified with use of the alpha angle. A value of >50.5° was considered positive for cam morphology. Measurements were performed independently by two musculoskeletal radiologists.

Results: The mean age of the individuals was 29.4 years (range, 21.4 to 50.6 years); 79% were white, and 55.5% were women. The mean alpha angle anteriorly at the three o’clock position was 40.9° ± 7.0° on the right and 40.6° ± 7.1° on the left, whereas the mean alpha angle anterosuperiorly at the 1:30 position was 50.2° ± 8.0° on the right and 50.1° ± 8.3° on the left. Fourteen percent of the volunteers had at least one hip with cam morphology: 10.5% had an elevated alpha angle on either the right or the left side, and 3.5% had the deformity in both hips. Seventy-nine percent (twenty-two) of twenty-eight individuals who had an elevated alpha angle were men, and 21% (six) were women. Individuals with an elevated alpha angle on at least one side tended to be male (p < 0.001), with 24.7% (twenty-two) of eighty-nine men having cam morphology compared with only 5.4% (six) of 111 women.

Conclusions: The prevalence of cam-type femoroacetabular impingement deformity is higher in men as well as in individuals with decreased internal rotation. Defining what represents a normal head-neck contour is important for establishing treatment strategies in patients presenting with prearthritic hip pain.

Prevalence of Cam-Type Femoroacetabular Impingement Morphology in Asymptomatic Volunteers

To evaluate whether biopsy with vacuum-assisted biopsy (VAB) devices improves histologic underestimation rates of benign papillomas when compared to smaller bore core needle biopsy (CNB) devices Patients with biopsy-proven benign papillomas with surgical resection or minimum 12 months follow-up were selected Two breast pathologists reviewed all pathology slides of percutaneous and excisional biopsy specimens Histologic underestimation rates for lesions biopsied with 10-12 Gauge (G) VAB were compared to those with 14G CNB A total of 107 benign papillomas in 107 patients from two centers were included There were 60 patients (mean age 57 years, SD 103 years) diagnosed with VAB and 47 patients (mean age 576 years, SD 113 years) with 14G CNB who underwent surgical excision or imaging follow-up The upgrade rate to ductal carcinoma in situ or invasive carcinoma was 16% (1/60) with VAB and 85% (4/47) with 14G Upgrade to atypia was 33% (2/60) after VAB and 106% (5/47) with CNB The total underestimation rates were 5% (3/60) with VAB and 191% (9/47) with CNB The odds of an upgrade to malignancy was 55 times higher with a 14G needle than VAB (95% CI: 0592-50853, p = 017) We observed a lower but not statistically significant upgrade rate to malignancy and atypia with the use of the 10-12 G VAB as compared with 14G CNB When a papilloma without atypia is diagnosed with vacuum biopsy there is a high likelihood that it is benign; however, if surgical excision is not performed, long-term follow-up is still required

Benign Papillomas of the Breast Diagnosed on Large-Gauge Vacuum Biopsy compared with 14 Gauge Core Needle Biopsy – Do they require surgical excision?

In our study, no tumors were missed as a result of ureteral nonopacification; secondary signs were present in all cases in which tumor existed in a ureteral segment that was nonopacified at CT urography.

Targeted Delayed Scanning at CT Urography: A Worthwhile Use of Radiation?

Background The Ovarian-Adnexal Reporting and Data System (O-RADS) US risk stratification and management system (O-RADS US) was designed to improve risk assessment and management of ovarian and adnexal lesions. Validation studies including both surgical and nonsurgical treatment as the reference standard remain lacking. Purpose To externally validate O-RADS US in women who underwent either surgical or nonsurgical treatment and to determine if incorporating acoustic shadowing as a benign finding improves diagnostic performance. Materials and Methods This retrospective study included consecutive women who underwent pelvic US between August 2015 and April 2017 at a tertiary referral oncology center. Two independent readers blinded to clinical and histologic outcome assigned an O-RADS risk category and an International Ovarian Tumor Analysis (IOTA) Assessment of Different NEoplasias in the adneXa (ADNEX) model risk of malignancy score to assessable lesions. Reference standards were surgical histopathology or 2-year imaging follow-up. Receiver operating characteristic (ROC) curve analysis was used to evaluate performance of the O-RADS US, ADNEX, and modified O-RADS models incorporating acoustic shadowing. Results In total, 227 women (mean age, 52 years ± 16 [SD]) with 262 ovarian or adnexal lesions were evaluated. Of these lesions, 187 (71%) were benign and 75 (29%) were malignant. The proportion of malignancy was 0% (0 of 100) for O-RADS 2, 3% (one of 32) for O-RADS 3, 35% (22 of 63) for O-RADS 4, and 78% (52 of 67) for O-RADS 5. The area under the ROC curve (AUC) for O-RADS and ADNEX was 0.91 (95% CI: 0.88, 0.94) and 0.95 (95% CI: 0.92, 0.97; P = .01), respectively. The addition of acoustic shadowing as a benign finding improved O-RADS AUC to 0.94 (95% CI: 0.91, 0.96; P = .01). Use of O-RADS 4 as a threshold yielded a sensitivity of 99% (74 of 75; 95% CI: 96, 100) and a specificity of 70% (131 of 187; 95% CI: 64, 77). Conclusion In a tertiary referral oncology center, the Ovarian-Adnexal Reporting and Data System US risk stratification and management system enabled accurate distinction of benign from malignant ovarian and adnexal lesions. Adding acoustic shadowing as a benign finding improved its diagnostic performance. © RSNA, 2022 See also the editorial by Levine in this issue.

External Validation of O-RADS US Risk Stratification and Management System.

Background:It has been shown that cam deformities are located at a more anterosuperior location than was previously described.Purpose:To establish, in a large group of asymptomatic participants, the normative range of the alpha angle in the anterosuperior location in both the oblique axial and radial views of magnetic resonance imaging (MRI).Study Design:Cross-sectional study; Level of evidence, 3.Methods:In 197 asymptomatic participants (394 asymptomatic hips) with a mean age of 29.4 years (range, 21.4-50.6 years), T1-weighted MRI scans were studied. The anterosuperior alpha angle measurement was performed by 2 observers using a previously described methodology and also using the radial view. The intraclass correlation coefficient (ICC) was determined for interobserver and intraobserver reliability. Descriptive statistics, the Student t test, correlation studies, and the Bland-Altman technique were used for data analysis.Results:The ICC for interobserver and intraobserver reproducibility was 0.74 (good a...

Kalesha Hack

Papers

Prevalence of Cam-Type Femoroacetabular Impingement Morphology in Asymptomatic Volunteers

Benign Papillomas of the Breast Diagnosed on Large-Gauge Vacuum Biopsy compared with 14 Gauge Core Needle Biopsy – Do they require surgical excision?

Targeted Delayed Scanning at CT Urography: A Worthwhile Use of Radiation?

External Validation of O-RADS US Risk Stratification and Management System.

Alpha Angle Measurements in Healthy Adult Volunteers Vary Depending on the MRI Plane Acquisition Used.