Capsular closure versus unrepaired interportal capsulotomy after hip arthroscopy in patients with femoroacetabular impingement: results of a patient-blinded randomised controlled trial.

BACKGROUND: Hip capsular management after hip arthroscopy remains a topic of debate. Most available current literature is of poor quality and are retrospective or cohort studies. As of today, no clear consensus exists on capsular management after hip arthroscopy. PURPOSE: To evaluate the effect of routine capsular closure versus unrepaired capsulotomy after interportal capsulotomy measured with NRS pain and the Copenhagen Hip and Groin Outcome Score (HAGOS). MATERIALS AND METHODS: All eligible patients with femoroacetabular impingement who opt for hip arthroscopy (n = 116) were randomly assigned to one of both treatment groups and were operated by a single surgeon. Postoperative pain was measured with the NRS score weekly the first 12 weeks after surgery. The HAGOS questionnaire was measured at 12 and 52 weeks postoperatively. RESULTS: Baseline characteristics and operation details were comparable between treatment groups. Regarding the NRS pain no significant difference was found between groups at any point the first 12 weeks after surgery (p = 0.67). Both groups significantly improved after surgery (p < 0.001). After 3 months follow-up there were no differences between groups for the HAGOS questionnaire except for the domain sport (p = 0.02) in favour of the control group. After 12 months follow-up there were no differences between both treatment groups on all HAGOS domains (p > 0.05). CONCLUSIONS: The results of this randomised controlled trial show highest possible evidence that there is no reason for routinely capsular closure after interportal capsulotomy at the end of hip arthroscopy. TRIAL REGISTRATION: This trial was registered at the CCMO Dutch Trial Register: NL55669.048.15.

Integrity of the hip capsule measured with magnetic resonance imaging after capsular repair or unrepaired capsulotomy in hip arthroscopy.

BACKGROUND: Current literature shows no clear answer on the question how to manage the capsule after hip arthroscopy. Regarding patient reported outcome measures there seems to be no difference between capsular repair or unrepaired capsulotomy. AIM: To evaluate and compare the integrity of the hip capsule measured on a magnetic resonance imaging (MRI) scan after capsular repair or unrepaired capsulotomy. METHODS: A case series study was performed; a random sample of patients included in a trial comparing capsular repair vs unrepaired capsulotomy had a postoperative MRI scan. The presence of a capsular defect and gap size were independently evaluated on MRI. RESULTS: A total of 28 patients (29 hips) were included. Patient demographics were comparable between treatment groups. There were 2 capsular defects in the capsular repair group and 7 capsular defects in the unrepaired capsulotomy group (P = 0.13). In the group of patients with a defect, median gap sizes at the acetabular side were 5.9 mm (range: 2.7-9.0) in the repaired and 8.0 mm (range: 4.5-18.0) in the unrepaired group (P = 0.462). At the muscular side gap sizes were 6.6 mm (range: 4.1-9.0) in the repaired group and 11.5 mm (range: 3.0-18.0) in the unrepaired group (P = 0.857). The calculated Odds ratio (OR) for having a capsular defect with an increasing lateral center-edge (CE) angle was 1.12 (P = 0.06). The OR for having a capsular defect is lower in the group of patients that underwent a labral repair with an OR of 0.1 (P = 0.05). CONCLUSION: There is no significant difference in capsular defects between capsular repair or unrepaired capsulotomy. Regarding clinical characteristics our case series shows that a larger CE angle increases the likelihood of a capsular defect and the presence of a labral repair decreases the likelihood of a capsular defect.

Femoroacetabular offset restoration in total hip arthroplasty; Digital templating a short stem vs a conventional stem.

BACKGROUND: Failure in restoring individual anatomy could be a reason for persistent functional limitations post total hip arthroplasty. Femoroacetabular offset (FAO) plays an important role in anatomic restoration, as loss of offset ≥ 5 mm is associated with altered gait and decreased functional outcome. Preoperative assessment by use of digital templating has shown to be a reliable method for sizing the components in total hip arthroplasty, and can show if anatomic restoration is achieved. In recent years, short stems are growing in popularity as it could allow better restoration due to more variety in placement. AIM: To assess whether restoration of the FAO differs between a short or a conventional stem by use of digital templating. Additionally, association of the preoperative offset and caput-colllum-diaphyseal angle (CCD-angle) within restoration of both stems was investigated, and the reliability of measurements was assessed. METHODS: A total of 100 standardized hip radiographs were used for digital templating. Restoration of FAO was classified into "restored" or "not restored", when a < 5 mm or ≥ 5 mm difference from baseline value presented, respectively. Differences between the two stems concerning proportions of correct restoration of the FAO were analyzed by use of McNemar tests. To assess association between CCD-angle and preoperative FAO with absolute FAO restoration, multi-level analysis was performed by use of a linear mixed model to account for paired measurements. Through determination of the optimal point under the curve in operating curve-analysis, bootstrapping of thousand sets was performed to determine the optimal cutoff point of the preoperative FAO for restoration within the limits of 5 mm. Three observers participated for inter-observer reliability, with two observers measuring the radiographs twice for intra-observer reliability. RESULTS: The mean preoperative FAO was 79.7 mm (range 62.5-113 mm), with a mean CCD-angle of 128.6° (range 114.5°-145°). The conventional stem could only restore the FAO in 72 of the cases, whereas the short stem restored the FAO in all cases. CCD-angle was not a predictor, but the preoperative FAO was. A cut-off point of 81.25 mm (95% confidence interval of 80.75-84.75 mm) in preoperative FAO was found where the conventional stem was unable to restore the FAO. Reliability of measurements was excellent, with an intra-observer reliability of 0.99 and inter-observer reliability in baseline measurements higher than 0.9 between the three observers. CONCLUSION: In preoperative planning of FAO restoration in total hip arthroplasty, digital templating shows that short stems with a curve following the medial calcar are potentially better at restoring the FAO compared to conventional stems if the preoperative offset is ≥ 80.0 mm.

Failed medial buttress plating of a femoral neck fracture salvaged with a Pauwels osteotomy: Case report and review of literature.

Two young patients with a Pauwels type 3 femoral neck fracture were treated with cannulated screws and the addition of an anteromedial buttress plate on the femoral neck. Both developed a non-union necessitating a salvage procedure. A Pauwels' osteotomy led to uneventful and complete healing in both patients. The purpose of this report is to describe the current literature on anteromedial buttress plating in femoral neck fractures and discusses a reproducible hip preserving salvage option when a non-union develops.

The influence of pain catastrophizing and central sensitization on the reported pain after hip arthroscopy.

PURPOSE: This study was conducted to investigate whether the pain catastrophizing scale (PCS) and the central sensitization inventory (CSI) are predictive factors for the reported pain after hip arthroscopy. METHODS: A total of 37 patients undergoing hip arthroscopy for femoroacetabular impingement syndrome and labral tears were prospectively enrolled. All patients completed the PCS and CSI before hip arthroscopy. Postoperative pain was measured with the numeric rating scale (NRS) weekly the first 12 weeks after surgery by electronic diary. RESULTS: At baseline, univariate analyses showed that both the CSI and PCS were significantly associated with the NRS outcome (p < 0.01). During 12 weeks follow-up, a significant decrease on the NRS was observed (p < 0.01). Univariate analyses showed that both the CSI and PCS were significantly associated with the NRS during follow-up. Multivariate mixed model analysis showed that only the PCS remained significantly associated with the NRS outcome with a ß of 0.07 (95% CI 0.03-0.11, p < 0.01). CONCLUSION: Results indicate that both the PCS and CSI are associated with the reported postoperative pain after hip arthroscopy. The PCS and CSI may be useful in daily practice to identify patients that possibly benefit from pain catastrophizing reduction therapy (e.g. counseling) prior to surgery. LEVEL OF EVIDENCE: IV.

Recalcitrant Septic Nonunion of the Ulna.

An infected diaphyseal forearm nonunion can be a challenge. After several failed salvage procedures, the patient can be left with residual pain, shortening, bone loss, and poor soft tissue envelope. Keystones for infected nonunion treatment are debridement, cultures, antibiotics, stability, and restore alignment. This report describes the current literature on the treatment of forearm nonunion, and we present a case of a recalcitrant infected ulna nonunion that ultimately healed after 12 surgeries.

A Missense Mutation in RAB28 in a Family with Cone-Rod Dystrophy and Postaxial Polydactyly Prevents Localization of RAB28 to the Primary Cilium.

Purpose: Cone-rod dystrophy (CRD) is a rare hereditary eye disorder that causes progressive degeneration of cone and rod photoreceptors. More than 30 genes, including RAB28, have been associated with CRD; however, only a few RAB28 variants have been reported to be associated with CRD. In this study, we describe two brothers with CRD and a homozygous missense variant, c.55G>A (p.Gly19Arg), in RAB28. Methods: The missense variant was identified as part of a study investigating underlying genetic defects in a large patient cohort (n = 667) using targeted next-generation sequencing of 125 genes associated with retinal dystrophy. Cellular localization of RAB28 and ciliogenesis in patient fibroblasts were investigated by immunofluorescence microscopy. The effect of the missense variant on RAB28 expression level was investigated by quantitative real-time PCR. Results: Two brothers of a consanguineous couple presented with CRD, postaxial polydactyly (PAP), and myopia. Both brothers had a homozygous missense RAB28 variant located in the G1 box of the guanosine triphosphate/guanosine diphosphate binding domain of RAB28. This missense variant caused a considerable reduction of RAB28 localized to the cilia, whereas ciliogenesis seemed unaffected. Conclusions: The missense variant in RAB28 is classified as likely pathogenic with functional effect on protein localization. The combination of retinal dystrophy and PAP are well known from ciliopathies; however, more data are needed to finally conclude that the RAB28 variant described here is the cause of PAP in these brothers.

Plethora of Traumatic Lesions of Bilateral Knee Extensor Mechanism in Osteogenesis Imperfecta.

Introduction: Injuries to the quadriceps extensor mechanism are rare in patients with Osteogenesis Imperfecta (OI). To the best of our knowledge, non-union of the patella in OI, either as an isolated problem or in combination with an acute fracture, has not been previously reported. Case report: We describe how we surgically approached both the fracture and the non-union simultaneously. The surgical technique and steps are described in detail. Post-operative course was uneventful and the outcome was favorable, with full return of function for the patient. Conclusion: A review of various knee extensor mechanism injuries in OI is described as illustrated in a single patient. The unusual simultaneous surgical treatment of a non-union and an acute fracture in the same patella shows that despite the severely compromised bone in this rare bone disease the bone still has a capacity to heal with a functional outcome.

Molecular genetic analysis using targeted NGS analysis of 677 individuals with retinal dystrophy.

Inherited retinal diseases (IRDs) are a common cause of visual impairment. IRD covers a set of genetically highly heterogeneous disorders with more than 150 genes associated with one or more clinical forms of IRD. Molecular genetic diagnosis has become increasingly important especially due to expanding number of gene therapy strategies under development. Next generation sequencing (NGS) of gene panels has proven a valuable diagnostic tool in IRD. We present the molecular findings of 677 individuals, residing in Denmark, with IRD and report 806 variants of which 187 are novel. We found that deletions and duplications spanning one or more exons can explain 3% of the cases, and thus copy number variation (CNV) analysis is important in molecular genetic diagnostics of IRD. Seven percent of the individuals have variants classified as pathogenic or likely-pathogenic in more than one gene. Possible Danish founder variants in EYS and RP1 are reported. A significant number of variants were classified as variants with unknown significance; reporting of these will hopefully contribute to the elucidation of the actual clinical consequence making the classification less troublesome in the future. In conclusion, this study underlines the relevance of performing targeted sequencing of IRD including CNV analysis as well as the importance of interaction with clinical diagnoses.

Impingement around the hip: beyond cam and pincer.

In this review, we bring to the attention of the reader three relatively unknown types of hip impingement. We explain the concept of low anterior inferior iliac spine (AIIS) impingement, also known as sub-spine impingement, ischio-femoral impingement (IFI) and pelvi-trochanteric impingement. For each type of impingement, we performed a search of relevant literature.We searched the PubMed, Medline (Ovid) and Embase databases from 1960 to March 2016. For each different type of impingement, a different search strategy was conducted.In total, 19 studies were included and described. No data analysis was performed since there was not much comparable data between studies.An overview of symptoms, clinical tests and possible surgical treatment options for the three different types of extra-articular impingement is provided.Several disorders around the hip can cause similar complaints. Therefore, we plead for a standardized classification. In young and athletic patients, in particular, there is much to gain if hip impingement is diagnosed early. Cite this article: EFORT Open Rev 2018;3:30-38. DOI: 10.1302/2058-5241.3.160068.

Posterior Ankle Impingement in Two Athletic Twin Brothers, Could Genetics Play a Role?

Pain posteriorly in the ankle can be caused by bony impingement of the posterolateral process of the talus. This process impinges between the tibia and calcaneus during deep forced plantar flexion. If this occurs it is called posterior ankle impingement syndrome. We report the case of 2 athletic monozygotic twin brothers with bony impingement posteriorly in the left ankle. Treatment consisted of ankle arthroscopy in both patients during which the symptomatic process was easily removed. At 3 months after surgery, both patients were completely free of pain, and 1 of the brothers had already returned to sports. The posterior ankle impingement syndrome is not a rare syndrome, but it has not been described in siblings thus far. That these 2 patients are monozygotic twin brothers suggests that genetics could play a role in the development of skeletal deformities that can result in posterior ankle impingement syndrome.

Clinical and genetic characterization of a Danish family with North Carolina macular dystrophy.

PURPOSE: To describe the phenotype of a family with an autosomal dominant macular dystrophy and identify the chromosomal location of the gene that causes this phenotype. METHODS: Twelve members of a three-generation family underwent routine clinical examination, including fundus photography. Four of the patients underwent extended examination with Goldmann perimetry, full-field electroretinogram, dark adaptation, and color vision testing, and two patients underwent optical coherence tomography and fundus autofluorescence examination. DNA samples were obtained from 12 family members and 3 spouses and genotyped at the known North Carolina Macular Dystrophy (NCMD) locus on chromosome 6q (MCDR1: OMIM 136550) using short tandem repeat polymorphisms. DNA samples were subsequently examined with a genome-wide scan of single nucleotide polymorphisms and the genotypes that were produced were studied with linkage and haplotype analyses. RESULTS: The 10 affected family members had clinical findings of macular lesions that are typical for NCMD. The small drusen-like yellowish lesions of mild NCMD were hyperautofluorescent. Hyperpigmented foveal lesions were surrounded by a zone of confluent hyperautofluorescence. Linkage analysis of short tandem repeat polymorphism genetic markers excluded the NCMD locus on chromosome 6. However, analysis of single nucleotide polymorphism genotypes from a genome-wide scan showed that NCMD in our pedigree is linked to a region on chromosome 5p that overlaps the previously mapped macular dystrophy (MCDR3) locus with a maximum log of the odds (LOD) score of 2.69 at a recombination fraction of 0.00 (markers D5S406, D5S1987, and D5S2505). DISCUSSION: We report the first pedigree with NCMD from Scandinavia, and the first confirmation that a gene for this condition is located on chromosome 5p13-p15. The bright elements or lesions typical of NCMD differed from drusen in that no sign of accumulation of material between the retinal pigment epithelium and Bruch's membrane was seen. While the present study has found indications that the elements are located in the outermost layers of the retina, their precise location remains to be identified directly.