Outcomes and rate of return to play in elite athletes following arthroscopic surgery of the hip.

BACKGROUND: The tremendous physical demands of elite performance increase the risk of elite athletes sustaining various orthopaedic injuries. Hip pain is common in high-level athletes representing up to 6% of all athletic injuries. Expedient diagnosis and effective treatment are paramount for their future sporting careers and to prevent subsequent joint degeneration. PURPOSE: This systematic review aimed to evaluate the outcome and the rate of return to play (RTP) following arthroscopic procedures in the hip (osteoplasty, chondroplasty, labral repair and/or debridement, capsulotomy, capsulorrhaphy or any soft tissue procedure) in elite athletes. Elite athletes were defined as those who represented their country in international contests or were competing professionally for the purpose of this study. METHODS: A computer-based systematic search, following the PRISMA Guidelines, was performed on CENTRAL, PUBMED, EMBASE, SCOPUS, EBSCO, Google Scholar and Web of Science from inception until January 1, 2020, identifying studies that looked at return to sports post-hip arthroscopy in elite athletes. Weighted means were calculated for the RTP rate and duration and for patient-reported outcome measures (PROMs). RESULTS: After eligibility screening, 22 articles were included with a total of 999 male and seven female patients, 1146 hips and a mean age of 28.4 ± 3.2 years. The mean follow-up period was 35.8 ± 13.4 months and 15.9 ± 9.6% of athletes had undergone bilateral procedures. Overall, 93.9% (95% CI: 90.5, 96.6, P < 0.0001) of patients demonstrated RTP after 6.8 ± 2.1 months post-surgery and all PROMs improved post-operatively. During follow-up, 9.6% (95% CI: 5.2, 15.2, P = 0.025) patients needed further intervention. CONCLUSION: A high percentage of elite athletes return to the same level of competition after hip arthroscopy, with a low rate of further interventions. Hip arthroscopy appears to be an efficacious treatment for hip and/or groin pain, caused by pathologies such as FAI or labral tears, in elite athletes in the shorter term. Long term outcomes need further evaluation.

How does the cam morphology develop in athletes? A systematic review and meta-analysis.

OBJECTIVE: A higher prevalence of cam morphology has been reported in the athletic population but the development of the cam morphology is not fully understood. The purpose of this systematic review is to establish the timing of development of the cam morphology in athletes, the proximal femoral morphologies associated with its development, and other associated factors. DESIGN: Embase, MEDLINE and the Cochrane Library were searched for articles related to development of the cam morphology, and PRISMA guidelines were followed. Data was pooled using random effects meta-analysis. Study quality was assessed using the Downs and Black criteria and evidence quality using the GRADE framework. RESULTS: This search identified 16 articles involving 2,028 participants. In males, alpha angle was higher in athletes with closed physes than open physes (SMD 0.71; 95% CI 0.23, 1.19). Prevalence of cam morphology was associated with age during adolescence when measured per hip (ß 0.055; 95% CI 0.020, 0.091) and per individual (ß 0.049; 95% CI 0.034, 0.064). Lateral extension of the epiphysis was associated with an increased alpha angle (r 0.68; 95% CI 0.63, 0.73). A dose-response relationship was frequently reported between sporting frequency and cam morphology. There was a paucity of data regarding the development of cam morphology in females. CONCLUSIONS: Very low and low quality evidence suggests that in the majority of adolescent male athletes, osseous cam morphology developed during skeletal immaturity, and that prevalence increases with age. Very low quality evidence suggests that osseous cam morphology development was related to lateral extension of the proximal femoral epiphysis.

The global burden of trauma during the COVID-19 pandemic: A scoping review.

Purpose; The COVID-19 pandemic has necessitated profound adaptations in the delivery of healthcare to manage a rise in critically unwell patients. In an attempt to slow the spread of the virus nationwide lockdown restrictions were introduced. This review aims to scope the literature on the impact of the pandemic and subsequent lockdown on the presentation and management of trauma globally. Methods; A scoping review was conducted in accordance with PRISMA-ScR guidelines. A systematic search was carried out on the Medline, EMBASE and Cochrane databases to identify papers investigating presentation and management of trauma during the COVID-19 pandemic. All studies based on patients admitted with orthopaedic trauma during the COVID-19 pandemic were included. Exclusion criteria were opinion-based reports, reviews, studies that did not provide quantitative data and papers not in English. Results; 665 studies were screened, with 57 meeting the eligibility criteria. Studies reported on the footfall of trauma in the UK, Europe, Asia, USA, Australia and New Zealand. A total of 29,591 patients during the pandemic were considered. Mean age was 43.7 years (range <1-103); 54.8% were male. Reported reductions in trauma footfall ranged from 20.3% to 84.6%, with a higher proportion of trauma occurring secondary to interpersonal violence, deliberate self-harm and falls from a height. A decrease was seen in road traffic collisions, sports injuries and trauma occurring outdoors. There was no significant change in the proportion of patients managed operatively, and the number of trauma patients reported to be COVID-19 positive was low. Conclusion; Whilst the worldwide COVID-19 pandemic has caused a reduction in the number of trauma patients; the services managing trauma have continued to function despite infrastructural, personnel and pathway changes in health systems. The substantial effect of the COVID-19 pandemic on elective orthopaedics is well described, however the contents of this review evidence minimal change in the delivery of effective trauma care despite resource constraints during this global COVID-19 pandemic.

Ischiofemoral impingement: the evolutionary cost of pelvic obstetric adaptation.

The risk for ischiofemoral impingement has been mainly related to a reduced ischiofemoral distance and morphological variance of the femur. From an evolutionary perspective, however, there are strong arguments that the condition may also be related to sexual dimorphism of the pelvis. We, therefore, investigated the impact of gender-specific differences in anatomy of the ischiofemoral space on the ischiofemoral clearance, during static and dynamic conditions. A random sampling Monte-Carlo experiment was performed to investigate ischiofemoral clearance during stance and gait in a large (n = 40 000) virtual study population, while using gender-specific kinematics. Subsequently, a validated gender-specific geometric morphometric analysis of the hip was performed and correlations between overall hip morphology (statistical shape analysis) and standard discrete measures (conventional metric approach) with the ischiofemoral distance were evaluated. The available ischiofemoral space is indeed highly sexually dimorphic and related primarily to differences in the pelvic anatomy. The mean ischiofemoral distance was 22.2 ± 4.3 mm in the females and 29.1 ± 4.1 mm in the males and this difference was statistically significant (P < 0.001). Additionally, the ischiofemoral distance was observed to be a dynamic measure, and smallest during femoral extension, and this in turn explains the clinical sign of pain in extension during long stride walking. In conclusion, the presence of a reduced ischiofemroal distance and related risk to develop a clinical syndrome of ischiofemoral impingement is strongly dominated by evolutionary effects in sexual dimorphism of the pelvis. This should be considered when female patients present with posterior thigh/buttock pain, particularly if worsened by extension. Controlled laboratory study.

A discrete element model to predict anatomy of the psoas muscle and path of the tendon: Design implications for total hip arthroplasty.

BACKGROUND: The accurate estimation of a muscle's line of action is a fundamental requirement in computational modelling. We present a novel anatomical muscle wrapping technique and demonstrate its clinical use on the evaluation of the Psoas muscle mechanics in hip arthroplasty. METHODS: A volume preserving, spring model to parameterize muscle anatomy changes during motion is presented. Validation was performed by a CT scan of a cadaver model in multiple positions. The predicted psoas musculotendinous path was compared with the actual imaging findings. In a second stage, psoas kinetics were compared between a conventional versus a resurfacing hip arthroplasty during gait. FINDINGS: Anatomy prediction error was found to be 2.12 mm on average (SD 1.34 mm). When applied to psoas mechanics during walking, the muscle was found to wrap predominantly around the femoral head providing a biomechanically efficient and nearly constant moment arm for flexion during the entire gait cycle. However, this advantage was found to be lost in small diameter hip arthroplasty designs resulting in an important mechanical disadvantage. The moment arm for flexion, was on average 36% (SD 0.03%) lower in the small diameter conventional hip arthroplasty as compared to the large diameter head of the hip resurfacing and this difference was highly significant. (p < 0.001). INTERPRETATION: Despite the shortcomings of an "in silico" and cadaveric study, our findings are in accordance with previous clinical and gait studies. Furthermore, the findings are strongly in favour of large diameter implant designs, warranting their further development and optimisation.

Does virtual reality simulation have a role in training trauma and orthopaedic surgeons?

Aims: The aim of this study was to assess the current evidence relating to the benefits of virtual reality (VR) simulation in orthopaedic surgical training, and to identify areas of future research. Materials and Methods: A literature search using the MEDLINE, Embase, and Google Scholar databases was performed. The results' titles, abstracts, and references were examined for relevance. Results: A total of 31 articles published between 2004 and 2016 and relating to the objective validity and efficacy of specific virtual reality orthopaedic surgical simulators were identified. We found 18 studies demonstrating the construct validity of 16 different orthopaedic virtual reality simulators by comparing expert and novice performance. Eight studies have demonstrated skill acquisition on a simulator by showing improvements in performance with repeated use. A further five studies have demonstrated measurable improvements in operating theatre performance following a period of virtual reality simulator training. Conclusion: The demonstration of 'real-world' benefits from the use of VR simulation in knee and shoulder arthroscopy is promising. However, evidence supporting its utility in other forms of orthopaedic surgery is lacking. Further studies of validity and utility should be combined with robust analyses of the cost efficiency of validated simulators to justify the financial investment required for their use in orthopaedic training. Cite this article: Bone Joint J 2018;100-B:559-65.

Complications following arthroscopic surgery of the hip: a systematic review of 36 761 cases.

AIMS: The number of patients undergoing arthroscopic surgery of the hip has increased significantly during the past decade. It has now become an established technique for the treatment of many intra- and extra-articular conditions affecting the hip. However, it has a steep learning curve and is not without the risk of complications. The purpose of this systematic review was to determine the prevalence of complications during and following this procedure. MATERIALS AND METHODS: Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used in designing this study. Two reviewers systematically searched the literature for complications related to arthroscopy of the hip. The research question and eligibility criteria were established a priori. Pertinent data were abstracted and analysed. RESULTS: We found 276 relevant studies with a total of 36 761 arthroscopies that met the inclusion criteria. The mean age of the patients was 36.7 years (1.7 to 70) and the mean body mass index was 25.7 kg/m2 (20.2 to 29.2). Femoroacetabular impingement and labral tears were the most common indications for the procedure. The total number of complications was 1222 (3.3%). Nerve injury (0.9%), mainly involving the pudendal and lateral femoral cutaneous nerves, and iatrogenic chondral and labral injury (0.7%), were the two most common complications. There were 58 major complications (0.2%), the most common being intra-abdominal extravasation of fluid, which was found in 13 cases (0.04%). There were three deaths (0.008%). CONCLUSION: Arthroscopic surgery of the hip is a procedure with a relatively low rate of complications, although some may be significant in this young cohort of patients. This study relied on the reported complications only and the results should be interpreted with caution. Cite this article: Bone Joint J 2017;99-B:1577-83.

Can hip arthroscopy in the presence of arthritis delay the need for hip arthroplasty?

Hip arthroscopy for joint preservation surgery has grown immensely over the last two decades. There is now an increasing trend to try and expand the role of hip arthroscopy to include patients of an older age or perhaps even with signs of arthritis, instead of the established patient group of young adults with mechanical symptoms or serious athletes. But how much of this growth is really justified? Once arthritis is apparent, the arthroscopic procedures needed to try and limit progression of the disease are likely to be different to those needed in young adult non-arthritic hips. Similarly, the expectation of results following an arthroscopic procedure in an older adult with arthritis must also be different. With an almost 5-fold increase in conversion rate from arthroscopy to arthroplasty in the over 50s population, arthroscopy in arthritis is a different procedure, with a different outcome, to arthroscopy in young adults with no evidence of osteoarthritis. This article takes a closer inspection at outcomes following hip arthroscopy in the older population particularly in those with evidence of early arthritis. This paper does not attempt to make recommendations in other diagnoses such as inflammatory arthritis or other secondary arthritides. It must be considered that hip arthroscopy is not a benign intervention: as well as the surgical risks, the lengthy rehabilitation period should be factored into the equation. Although the nature of surgeons is to find new techniques and push boundaries, we highlight the need for caution in undertaking arthroscopic intervention when arthritis is already apparent at presentation.

Bisphosphonates and atypical subtrochanteric fractures of the femur.

OBJECTIVES: Bisphosphonates are widely used as first-line treatment for primary and secondary prevention of fragility fractures. Whilst they have proved effective in this role, there is growing concern over their long-term use, with much evidence linking bisphosphonate-related suppression of bone remodelling to an increased risk of atypical subtrochanteric fractures of the femur (AFFs). The objective of this article is to review this evidence, while presenting the current available strategies for the management of AFFs. METHODS: We present an evaluation of current literature relating to the pathogenesis and treatment of AFFs in the context of bisphosphonate use. RESULTS: Six broad themes relating to the pathogenesis and management of bisphosphonate-related AFFs are presented. The key themes in fracture pathogenesis are: bone microdamage accumulation; altered bone mineralisation and altered collagen formation. The key themes in fracture management are: medical therapy and surgical therapy. In addition, primary prevention strategies for AFFs are discussed. CONCLUSIONS: This article presents current knowledge about the relationship between bisphosphonates and the development of AFFs, and highlights key areas for future research. In particular, studies aimed at identifying at-risk subpopulations and organising surveillance for those on long-term therapy will be crucial in both increasing our understanding of the condition, and improving population outcomes.Cite this article: N. Kharwadkar, B. Mayne, J. E. Lawrence, V. Khanduja. Bisphosphonates and atypical subtrochanteric fractures of the femur. Bone Joint Res 2017;6:144-153. DOI: 10.1302/2046-3758.63.BJR-2016-0125.R1.

Measuring hip muscle strength in patients with femoroacetabular impingement and other hip pathologies: A systematic review.

OBJECTIVES: The aim of this study was to systematically review the literature on measurement of muscle strength in patients with femoroacetabular impingement (FAI) and other pathologies and to suggest guidelines to standardise protocols for future research in the field. METHODS: The Cochrane and PubMed libraries were searched for any publications using the terms 'hip', 'muscle', 'strength', and 'measurement' in the 'Title, Abstract, Keywords' field. A further search was performed using the terms 'femoroacetabular' or 'impingement'. The search was limited to recent literature only. RESULTS: A total of 29 articles were reviewed to obtain information on a number of variables. These comprised the type of device used for measurement, rater standardisation, the type of movements tested, body positioning and comparative studies of muscle strength in FAI versus normal controls. The studies found that hip muscle strength is lower in patients with FAI; this is also true for the asymptomatic hip in patients with FAI. CONCLUSIONS: Current literature on this subject is limited and examines multiple variables. Our recommendations for achieving reproducible results include stabilising the patient, measuring isometric movements and maximising standardisation by using a single tester and familiarising the participants with the protocol. Further work must be done to demonstrate the reliability of any new testing method.Cite this article: E. Mayne, A. Memarzadeh, P. Raut, A. Arora, V. Khanduja. Measuring hip muscle strength in patients with femoroacetabular impingement and other hip pathologies: A systematic review. Bone Joint Res 2017;6:66-72. DOI: 10.1302/2046-3758.61.BJR-2016-0081.

The normal ischiofemoral distance and its variations.

The aim of this study is to measure the ischiofemoral distance (IFD) in the normal hip with healthy surrounding soft tissues and describe its variations caused by gender, age and proximal femoral anatomy so that this could serve as a reference for future studies on this subject. This is a retrospective study in which we reviewed the CT scans of 149 patients (298 hips) who had a CT of their pelvis for non-orthopaedic (abdomino-pelvic) pathology. The images were reviewed by two independent observers and the IFD (the smallest distance between the lateral cortex of the ischial tuberosity and the posteromedial cortex of the lesser trochanter), offset (the perpendicular distance from the centre of the femoral head to a line running down the middle of the shaft of the femur) and the neck-shaft angle (the angle between the lines in the middle of the neck to the line forming the axis of the femoral shaft) were measured. The CT scans belonged to 71 males and 78 females (M: 48%, F: 52%), with an average age of 51 ± 19 years (range 18-92). The mean IFD was 18.6 ± 8 mm in the females and 23 ± 7 mm in the males and this difference was statistically significant (P < 0.001). The IFD increased by 1.06 mm for each 1 mm of offset and dropped by 0.09 mm with each year of age. However, the neck-shaft angle did not show any significant correlation with the IFD.

Iatrogenic vascular injuries during arthroplasty of the hip.

Vascular injuries during total hip arthroplasty (THA) are rare but when they occur, have serious consequences. These have traditionally been managed with open exploration and repair, but more recently there has been a trend towards percutaneous endovascular management. We performed a systematic review of the literature to assess if this change in trend has led to an improvement in the overall reported rates of morbidity and mortality during the last 22 years in comparison with the reviews of the literature published previously. We found a total of 61 articles describing 138 vascular injuries in 124 patients. Injuries because of a laceration were the most prevalent (n = 51, 44%) and the most common presenting feature, when recorded, was bleeding (n = 41, 53.3%). Delay in diagnosis was associated with the type of vascular lesion (p < 0.001) and the clinical presentation (p = 0.002). Open exploration and repair was the most common form of management, however percutaneous endovascular intervention was used in one third of the injuries and more constantly during the last 13 years. The main overall reported complications included death (n = 9, 7.3%), amputation (n = 2, 1.6%), and persistent ischaemia (n = 9, 7.3%). When compared with previous reviews there was a similar rate of mortality but lower rates of amputation and permanent disability, especially in patients managed by endovascular strategies.

Negative pressure wound therapy for managementof the surgical incision in orthopaedic surgery: A review of evidence and mechanisms for an emerging indication.

OBJECTIVES: The period of post-operative treatment before surgical wounds are completely closed remains a key window, during which one can apply new technologies that can minimise complications. One such technology is the use of negative pressure wound therapy to manage and accelerate healing of the closed incisional wound (incisional NPWT). METHODS: We undertook a literature review of this emerging indication to identify evidence within orthopaedic surgery and other surgical disciplines. Literature that supports our current understanding of the mechanisms of action was also reviewed in detail. RESULTS: A total of 33 publications were identified, including nine clinical study reports from orthopaedic surgery; four from cardiothoracic surgery and 12 from studies in abdominal, plastic and vascular disciplines. Most papers (26 of 33) had been published within the past three years. Thus far two randomised controlled trials - one in orthopaedic and one in cardiothoracic surgery - show evidence of reduced incidence of wound healing complications after between three and five days of post-operative NPWT of two- and four-fold, respectively. Investigations show that reduction in haematoma and seroma, accelerated wound healing and increased clearance of oedema are significant mechanisms of action. CONCLUSIONS: There is a rapidly emerging literature on the effect of NPWT on the closed incision. Initiated and confirmed first with a randomised controlled trial in orthopaedic trauma surgery, studies in abdominal, plastic and vascular surgery with high rates of complications have been reported recently. The evidence from single-use NPWT devices is accumulating. There are no large randomised studies yet in reconstructive joint replacement. Cite this article: Bone Joint Res 2013;2:276-84.

Exam corner--November 2013.

The FRCS (Tr & Orth) examination has three components: MCQs, Vivas and Clinical Examination. The Vivas are further divided into five sections comprising Basic Science, Adult Pathology, Hands, Children's Orthopaedics and Trauma. The Clinical Examination section is divided into upper- and lower-limb cases. The aim of this section in the Journal is to focus specifically on the trainees preparing for the exam and to cater to all the sections of the exam every month. The vision is to complete the cycle of all relevant exam topics (as per the syllabus) in four years.

Exam corner--August 2013.

The FRCS (Tr & Orth) examination has three components: MCQs, Vivas and Clinical Examination. The Vivas are further divided into four sections comprising Basic Science, Adult Pathology, Hands and Children's Orthopaedics and Trauma. The Clinical Examination section is divided into Upper and Lower limb cases. The aim of this section in the Journal is to focus specifically on the trainees preparing for the exam and to cater to all the sections of the exam. The vision is to complete the cycle of all relevant exam topics (as per the syllabus) in four years.

Exam corner--June 2013.

The FRCS (Tr & Orth) examination has three components: MCQs, Vivas and Clinical Examination. The Vivas are further divided into four sections comprising Basic Science, Adult Pathology, Hands and Children's Orthopaedics and Trauma. The Clinical Examination section is divided into Upper and Lower limb cases. The aim of this section in the Journal is to focus specifically on the trainees preparing for the exam and to cater to all the sections of the exam. The vision is to complete the cycle of all relevant exam topics (as per the syllabus) in four years.