Osteotomy Site Venting Enhances Femoral Bone Consolidation With Magnetic Intramedullary Lengthening Nails.

BACKGROUND: Magnetic intramedullary lengthening nailing has demonstrated benefits over external fixation devices for femoral bone lengthening. These include avoiding uncomfortable external fixation and associated pin site infections, scarring, and inhibition of muscle or joint function. Despite this, little has changed in the field of biologically enhanced bone regeneration. Venting the femoral intramedullary canal at the osteotomy site before reaming creates egress for bone marrow during reaming. The reamings that are extruded from vent holes may function as a prepositioned bone graft at the distraction gap. The relationship between venting and the consolidation of regenerating bone remains unclear. QUESTIONS/PURPOSES: (1) Do bone marrow reamings extruded through venting holes enhance the quality of bone regeneration and improve healing indices and consolidation times? (2) Is venting associated with a higher proportion of complications than nonventing? METHODS: We performed a retrospective study of femoral lengthening performed at one hospital from December 2012 to February 2022 using a magnetic intramedullary lengthening nail with or without venting at the osteotomy site before reaming. This was a generally sequential series, in which the study groups were assembled as follows: Venting was performed between July 2012 and August 2016 and again from November 2021 onward. Nonventing was used between October 2016 and October 2021 because the senior author opted to create drill holes after the reaming procedure to avoid commitment to the osteotomy level before completing the reaming procedure. Outcomes were evaluated based on bone healing time, time to achieve full weightbearing, and complications. Sixty-one femoral lengthening procedures were studied (in 33 male and 28 female patients); two patients were excluded because of implant breakage. The mean age was 17 ± 5 years. The mean amount of lengthening was 55 ± 13 mm in the venting group and 48 ± 16 mm in the nonventing group (mean difference 7 ± 21 [95% CI 2 to 12]; p = 0.07). The healing index was defined as the time (in days) required for three cortices to bridge with new bone formation divided by the length (in cm) lengthened during the clinical protocol. This index signifies the bone formation rate achieved under the specific conditions of the protocol. Full weightbearing was allowed upon bridging the regenerated gap on three sides. Consolidation time was defined as the total number of days from the completion of the lengthening phase until adequate bone union (all three cortices healed) was achieved and full weightbearing was permitted. This time frame represents the entire healing process after the lengthening is complete divided by the amount of lengthening achieved (in cm). Patient follow-up was conducted meticulously at our institution, and we adhered to a precise schedule, occurring every 2 weeks during the distraction phase and every 4 weeks during the consolidation phase. There were no instances of loss to follow-up. Every patient completed the treatment successfully, reaching the specified milestones of weightbearing and achieving three cortexes of bone bridging. RESULTS: The mean healing index time in the venting group was faster than that in the nonventing group (21 ± 6 days/cm versus 31 ± 22 days/cm, mean difference 10 ± 23 [95% CI 4 to 16]; p = 0.02). The mean consolidation time was faster in the venting group than the nonventing group (10 ± 6 days/cm versus 20 ± 22 days/cm; mean difference 10 ± 23 [95% CI 4 to 15]; p = 0.02). No medical complications such as deep vein thrombosis or fat or pulmonary embolism were seen. Two patients had lengthy delays in regenerate union, both of whom were in the nonventing group (healing indexes were 74 and 62 days/cm; consolidation time was 52 and 40 days/cm). CONCLUSION: Femoral lengthening with a magnetic intramedullary lengthening nail healed more quickly with prereaming venting than with nonventing, and it allowed earlier full weightbearing without any major associated complications. Future studies should evaluate whether there is a correlation between the number of venting holes and improvement in the healing index and consolidation time. LEVEL OF EVIDENCE: Level III, therapeutic study.

Intra-articular Knee Injection Is Less Painful Than Expected.

BACKGROUND: Intra-articular knee injections (IAKI) are commonly used for diagnostic and therapeutic purposes but may induce anxiety and fear. While existing literature has identified the variance between expected and actual pain levels in various medical procedures, this phenomenon remains unexplored in the context of IAKI. OBJECTIVES: To describe the differences between anticipated and experienced pain recorded during IAKI. METHODS: The study cohort included 50 patients who underwent IAKI by an orthopedic specialist in an outpatient clinic. Patients recruited to the study recorded the anticipated and experienced pain, anxiety index, and factors influencing injection related fear. RESULTS: The study population (n=50) demonstrated a significant difference between the pain expected before the injection (mean Visual Analogue Scale [VAS] score 6.19) and the actual experienced (mean VAS score 2.07, P-value < 0.001). Significant differences between anticipated and experienced VAS scores were demonstrated for both females and males. There was a significant difference between males and females in terms of estimated VAS score. There was no significant difference between males and females in term of the experienced VAS score. The difference (delta) between expected and experienced pain differed significantly between sexes. CONCLUSIONS: These findings emphasize the importance of educating patients about expected pain levels during IAKI. Presenting this quantified information may reassure patients that the procedure is not as painful as expected, which can potentially increase the compliance.

Patient Expectations of Pain Versus Experienced Expectations of Pain Following Shoulder Injection.

PURPOSE: Corticosteroids, platelet-rich plasma, and hyaluronic acid injections to either the subacromial space (SAS) or the glenohumeral joint (GHJ) of the shoulder are commonly used for diagnostic and therapeutic purposes in outpatient settings. The first aim of this study was to determine whether the anticipated pain level differed significantly from the actual pain level experienced by patients who underwent shoulder injections. The second aim was to determine whether there was a significant difference in these pain levels between SAS and GHJ injections. The secondary goal was to investigate the correlation between patients' demographic data, anxiety characteristics, and pain scores. DESIGN: Prospective clinical study. METHODS: This study involved patients who completed a three-part questionnaire prior as well as following an injections to the GHJ\SAS. FINDINGS: Sixty-three patients (28 males; 35 females), mean age of 54.28 years (standard deviation 13.95, range 25 to 84) met the inclusion criteria. There was a significant difference between the anticipated and the experienced pain (visual analog score 6.03 vs 3.17, P < .001). Experienced pain of the GHJ injections (n = 34) was rated as being greater than that of the SAS injections (n = 29) with borderline significance (visual analog scale 3.79 vs 2.36; P = .05). Forty-five patients (71.42%) reported a decrease in at least one pain category between anticipated and experienced pain compared to an increase reported by two patients (3.17%). CONCLUSIONS: Injections to the GHJ and SAS were shown to be significantly less painful than anticipated by the patients. GHJ injections were perceived as more painful than SAS injections. Communicating this evidence-based reassuring information with patients prior to an injection may alleviate fear of the procedure, reduce the perception of pain, and ultimately improve compliance with the procedure.

Violation of expectations is correlated with satisfaction following hip arthroscopy.

PURPOSE: The mechanism by which preoperative expectations may be associated with patient satisfaction and procedural outcomes following hip preservation surgery (HPS) is far from simple or linear. The purpose of this study is to better understand patient expectations regarding HPS and their relationship with patient-reported outcomes (PROs) and satisfaction using machine learning (ML) algorithms. METHODS: Patients scheduled for hip arthroscopy completed the Hip Preservation Surgery Expectations Survey (HPSES) and the pre- and a minimum 2 year postoperative International Hip Outcome Tool (iHOT-33). Patient demographics, including age, gender, occupation, and body mass index (BMI), were also collected. At the latest follow-up, patients were evaluated for subjective satisfaction and postoperative complications. ML algorithms and standard statistics were used. RESULTS: A total of 69 patients were included in this study (mean age 33.7 ± 13.1 years, 62.3% males). The mean follow-up period was 27 months. The mean HPSES score, patient satisfaction, preoperative, and postoperative iHOT-33 were 83.8 ± 16.5, 75.9 ± 26.9, 31.6 ± 15.8, and 73 ± 25.9, respectively. Fifty-nine patients (86%) reported that they would undergo the surgery again, with no significant difference with regards to expectations. A significant difference was found with regards to expectation violation (p < 0.001). Expectation violation scores were also found to be significantly correlated with satisfaction. CONCLUSION: ML algorithms utilized in this study demonstrate that violation of expectations plays an important predictive role in postoperative outcomes and patient satisfaction and is associated with patients' willingness to undergo surgery again. LEVEL OF EVIDENCE: IV.

Inter and intra-observer agreement of the 3-dimensional CT based anterior inferior iliac spine classification system shows fair-to-moderate agreement among high volume hip surgeons.

PURPOSE: The purpose of this multicenter, multinational study is to evaluate the agreement level of the Hetsroni's classification system across high-volume hip surgeons who specialize in hip preservation surgeries. METHODS: Four surgeons from three countries reviewed a digital survey that included 93 3D CT images of the hip from 53 patients. The population was composed of individuals who had undergone a pelvis CT scan in a tertiary hospital between 2000 and 2016. Each rater reviewed the images and classified each image according to AIIS subtype I, II, or III. After a minimum of two months, the raters repeated the survey. The inter-rater and intra-rater agreement was then assessed. The kappa values were calculated to determine variability. RESULTS: Inter-rater agreement levels yielded fair agreement for both sessions (Kappa = 0.4, p value < 0.001 in the first and Kappa = 0.27, p value < 0.001 in the second). Inter-rater agreement levels separating non-pathological Type I from pathological Types II and III yielded moderate to fair inter-rater agreement levels (K = 0.47, p value < 0.001 in the first session and k = 0.32, p value < 0.001 in the second). Intra-rater reliability displayed moderate agreement (average K = 0.53). CONCLUSION: The current 3D CT-based AIIS classification system shows fair-to-moderate inter- and intra-rater agreement among high-volume hip surgeons. According to this study, the agreement of the Hetsroni classification system is not able to be sufficiently reproduced. Since accurate classification of the AIIS morphology is imperative in establishing proper treatment for SSI, this classification system there is therefore limited in its clinical value. LEVEL OF EVIDENCE: III.

The "Selfie Test": A Novel Test for the Diagnosis of Lateral Epicondylitis.

Background: Lateral epicondylitis (LE) is one of the most diagnosed elbow pathologies. The purpose of this study was to determine the diagnostic test accuracy of a new test (selfie test) for the diagnosis of LE. Methods: Medical data were collected from adult patients who presented with LE symptoms and ultrasound findings that supported the diagnosis. Patients underwent a physical examination, including provocative tests for diagnosis as well as the selfie test, and were asked to fill out the Patient-Rated Tennis Elbow Evaluation (PRTEE) questionnaire and subjectively rate the activity of their affected elbow. Results: Thirty patients were included in this study (seventeen females, 57%). The mean age was 50.1 years old (range of 35 to 68 years). The average duration of symptoms was 7 ± 3.1 months (range of 2 to 14 months). The mean PRTEE score was 61.5 ± 16.1 (range of 35 to 98), and the mean subjective elbow score was 63 ± 14.2 (range of 30 to 80). Mill's, Maudsley's, Cozen's, and the selfie tests had sensitivities of 0.867, 0.833, 0.967, and 0.933, respectively, with corresponding positive predictive values of 0.867, 0.833, 0.967, and 0.933. Conclusions: The selfie test's active nature, which allows patients to perform the assessment themselves, could be a valuable addition to the diagnostic process, potentially improving the accuracy of the diagnosis of LE (levels of evidence: IV).

Magnetic Resonance Imaging Is Not Reliable in Classifying Anterior Inferior Iliac Spine Morphology Compared to 3-Dimensional Computerized Tomography.

PURPOSE: The purpose of this study is to determine the reliability of standard magnetic resonance imaging (MRI) evaluation of AIIS morphology compared with three-dimensional (3D) computerized tomography (CT) (reference standard). METHODS: Sixty hips in 30 patients met the inclusion criteria. The images were reviewed and classified by two fellowship-trained orthopedic surgeons. A second imaging viewing session was conducted in the same manner for validation of AIIS evaluation. The agreement and accuracy indices between the two raters were calculated for each imaging modality (inter-rater agreement) as well the agreement across the imaging modality for each rater (intermethod agreement). RESULTS: The inter-rater agreement for the morphological evaluation of the AIIS for the first session according to 3D CT was .553 (P < .05) and by means of MRI was .0163 (P < .05). The inter-rater agreement for the second session by means of 3D CT was .449 (P < .05) and according to MRI was 0 (P < .05). The inter-method agreement for rater 1 for the first session was .04 (P < 0.05), while the agreement for rater 2 was .016 (P < .05). The intermethod agreement for rater 1 on the second session was .35 (P < 0.05), while that of rater 2 was .297(P < .05). The overall accuracy of MRI compared to 3D CT for rater 1 for the first session was .531, .490, and .959 for types I, II, III respectively and .551, .531, and .980 for the second session for types I, II, and III respectively. The overall accuracy of MRI compared to 3D CT for rater 2 for the first session was .551, .469, and .918 for types I, II, III respectively and .633, .592, and .918 for the second session for types I, II, and III, respectively. CONCLUSION: MRI evaluations and subsequent classifications of AIIS morphology demonstrated a poor to slight correlation compared with that of the reference standard of 3D CT. LEVEL OF EVIDENCE: Level II, retrospective diagnostic study.

Preoperative Expectations Do Not Correlate With Postoperative iHOT-33 Scores and Patient Satisfaction Following Hip Arthroscopy for the Treatment of Femoroacetabular Impingement Syndrome.

PURPOSE: To examine the correlation between preoperative patient expectation and International Hip Outcome Tool (iHOT-33) score and postoperative satisfaction of patients undergoing hip arthroscopy for the treatment of femoroacetabular impingement syndrome. METHODS: Patients scheduled for surgery completed the Hip Preservation Surgery Expectations Survey (HPSES), as well as the preoperative and a minimum 2-year postoperative iHOT-33. Patient demographics that were collected included gender, age, occupation, and body mass index (BMI). At the latest follow-up, patients were evaluated for their subjective satisfaction and postoperative complications. An in-depth analysis was performed to assess the correlation between HPSES, iHOT-33, and patient satisfaction. RESULTS: Sixty-nine patients (62.3% males; mean age: 33.7 ± 13.1 years; BMI: 23.9 ± 3.5 kg/m2) were included in this study. The mean HPSES score was 83.8 ± 16.5. The mean iHOT-33 improved from 31.6 ± 15.8 preoperatively to 73 ± 25.9 postoperatively (95% CI = 35.2,47.8; P < .01), and the mean patient satisfaction was 75.9 ± 26.9. There were no statistically significant differences in mean HPSES score between males and females (95% CI = 79.9,87.8; P = .35) nor between different occupational groups (95% CI = 79.4,87.6, P = .095). No correlation was found between age and HPSES score (r = .036; P =.76). There was a negligible correlation between HPSES score and postoperative iHOT-33 score (r = -.117; P = .34) and patient satisfaction (r = -.042; P = .73). Postoperative iHOT-33 score had a significant high correlation with patient satisfaction (r = .8; P < .001). CONCLUSION: Preoperative expectations do not correlate with postoperative iHOT-33 scores and patient satisfaction with surgery at 2 years after surgery. Gender and occupation did not differ significantly with regard to preoperative expectations, and there was no correlation between age and HPSES score. LEVEL OF EVIDENCE: IV, retrospective case series.

Sonographic evaluation of anterior inferior iliac spine morphology demonstrates excellent accuracy when compared to false profile view.

PURPOSE: To compare ultrasound examination to false profile radiographs in identification and classification of AIIS morphology. The study hypothesis stated that sonographic imaging of the AIIS correlates well to AIIS morphology seen on false profile radiographs. METHODS: Fifty-three hips in 30 consecutive patients met the inclusion criteria. A single, fellowship trained, orthopedic surgeon performed an ultrasound on all of the patients to evaluate the AIIS morphology. The patients underwent standing false profile radiographs. The US and radiographic images were independently reviewed and classified according to Hetsroni classification of AIIS morphology by two senior, fellowship trained, orthopedic surgeons. Agreement between the two raters was calculated for each imaging modality (inter-rater agreement) as well as the agreement between the rating in each modality by the same rater ("inter-method" agreement). RESULTS:  The agreement between the raters (inter-rater agreement) for morphologic evaluation of the AIIS by means of FP view was 88.8% (p < 0.001) and that by means of US was 81.5%(p < 0.001). The overall accuracy of the US compared to the FP view was 92.3% (48/52) for both rater 1 and 2. CONCLUSION:  This study showed near-perfect agreement in analyzing the morphology of the AIIS in a group of patients with hip pathology. Office sonographic evaluation of the AIIS is reliable and, therefore, may be routinely utilized in the clinic setting avoiding unnecessary radiation exposure to the patient. LEVEL OF EVIDENCE: Level II.

Accelerated rehabilitation following reverse total shoulder arthroplasty.

BACKGROUND: Postoperative rehabilitation is considered essential and indeed routine practice following rTSA. However, the optimal approach to postoperative rehabilitation is unknown, based on protocols for anatomic TSA, and published literature is sparse, as is the quantity and quality of research evidence. The aim of this study is to outline the accelerated rehabilitation protocol (with immediate activity and no immobilization at all) following reverse total shoulder arthroplasty (rTSA) and assess its safety and effectiveness compared to the more conservative rehabilitation protocols of immobilization in a sling for 6 weeks and for 3 weeks. MATERIALS AND METHODS: Between July 2005 and October 2017, a total of 357 consecutive rTSA in 320 patients underwent a primary rTSA and were included in the study. Patients were divided into 3 groups depending on rehabilitation protocol (6 and 3 weeks' postoperative immobilization, respectively, for groups 1 and 2, and no immobilization for group 3). Patients were assessed preoperatively and reviewed at 3 weeks, 3, 6, and 12 months, and yearly thereafter postoperatively. Constant score (CS), Subjective Shoulder Value (SSV), patient satisfaction, and pain scores were used at each appointment and patients assessed both clinically and radiographically. RESULTS: Mean age at surgery was 76 years (range 40-93). At 1-year follow-up, the CS improved from 16.6 (adjusted 23.9) to 63.2 (adjusted 91.5) in group 1 (n = 114), from 21.5 (adjusted 30.7) to 67.7 (adjusted 98.4) in group 2 (n = 125), and from 22.6 (adjusted 31.3) to 66.6 (adjusted 94.9) in group 3 (n = 118). Pain score improved from 3.1/15 preoperatively to 12.5/15 postoperatively in group 1, from 3.5/15 to 13/15 in group 2, and from 3.7/15 to 12.5/15 in group 3. SSV improved to 8.5/10, 8.6/10, and 8.1/10 for groups 1, 2, and 3, respectively. Mean range of motion (ROM) improved to 142° elevation and 131° abduction in group 1, 153° elevation and 144° abduction in group 2, and 149° elevation and 146° abduction in group 3. No statistically significance differences were observed in CS, SSV, patient satisfaction, pain, and ROM between the 3 groups. Less postoperative complications were observed in group 3 (No immobilization). CONCLUSION: Accelerated rehabilitation regime post rTSA without immobilization is safe and lead to reliable good clinical results and quick return to function. This study confirms noninferiority of the accelerated rehabilitation regime with fewer postoperative complications related to falls. Accelerated rehabilitation regime post rTSA have further psychological and emotional advantage to the patient, with earlier return to normal function and regaining independence. We recommend the accelerated rehabilitation regime without immobilization following rTSA.

Clinical Assessment and Treatment Options for Posterior Hip Pain.

BACKGROUND: Diagnosis and treatment of posterior hip pain has increased due to advancements in clinical, anatomical, biomechanical, and related pathological understandings of the hip. Due to its complexity and close anatomical relationship with many osseous, neurovascular, and musculotendinous structures, posterior hip pain must be appropriately categorized based on its origin. Therefore, it is crucial that clinicians are able to determine whether patient complaints are of extra-articular or intra-articular nature so that they can implement the optimal treatment plan. In the current review article, we discussed posterior hip pain with an emphasis on the main differential diagnoses of deep gluteal syndrome, ischiofemoral impingement, and hamstring tear/hamstring syndrome. For the appropriate diagnosis and etiology of posterior hip pain, a thorough and conclusive clinical history is imperative. Physicians should rule out the possibility of spinal involvement by physical examination and if necessary, by magnetic resonance imaging (MRI). Furthermore, because of the vicinity to other, non-orthopedic structures, an obstetric and gynecologic history, general surgery history, and urologic history should be obtained. Following the collection of patient history clinicians should adhere to an established and efficient order of evaluation starting with standing then to seated, supine, lateral, and prone testing. Imaging assessment of posterior hip pain begins with a standard anterior-posterior pelvic radiograph, in addition to frog-leg lateral. MRI is pivotal for assessing soft tissue-related extra-articular causes of hip in patients with posterior hip pain. Non-surgical treatment is preferred in most cases of deep gluteal syndrome, ischiofemoral impingement, pudendal nerve entrapment, and proximal hamstring pathologies. Surgical treatment is saved as a last resort option in cases of failed non-surgical treatment.

Editorial Commentary: Intra-abdominal Fluid Extravasation During Hip Arthroscopy-Although Rare, Don't Be Complacent.

Hip arthroscopy has become the gold standard for the treatment of femoroacetabular impingement syndrome. Intra-abdominal fluid extravasation is the most commonly reported major complication, with variable rates depending on the measurement method. Little is known about the evolution of the fluid extravasation throughout the surgical procedure, and the risk factors for this complication are in need of validation. We recommend performing mitigating actions including keeping the surgical time to a minimum, monitoring core body temperature, performing psoas release (if planned) last, and keeping inflow fluid pressure as low as possible.

Postoperative Weightbearing Protocols After Arthroscopic Surgery for Femoroacetabular Impingement Does Not Affect Patient Outcome: A Comparative Study With Minimum 2-Year Follow-up.

PURPOSE: To evaluate the effects of immediate postoperative weightbearing protocols after hip arthroscopy for femoroacetabular impingement (FAI) with minimum 2-year follow-up, as measured by patient-reported outcome measures and satisfaction rates. METHODS: Between January 2011 and June 2016, patients undergoing hip arthroscopy for FAI and labral tears were reviewed. Exclusion criteria was previous hip pathology or arthroscopy, active Workers' Compensation claims, and concomitant pathologies impeding weightbearing. Patients who were operated on before September 2013 were treated with 3 weeks of postoperative non-weightbearing (NWB), with weightbearing as tolerated (WBAT) thereafter. From October 2013, patients were allowed immediate postoperative WBAT. RESULTS: A total of 351 hip arthroscopic surgeries were performed; 133 of these patients met the inclusion criteria. Of the 133 included patients, 69 were in the NWB group and 64 were in the WBAT group. No differences were found in terms of sex (P = .603) or age (P = .241). No differences were found in postoperative scores (the Modified Harris Hip Score was 84.5 [range 79-89] for NWB vs 86.7 [78-89] for WBAT [P = .0.523], and the Hip Outcome Score was 83.1 [78-88] vs 88.4 [80-90], respectively; P = .130). Subjective rates of improvement, satisfaction score and the will to undergo surgery again did not differ between the groups (P = .674, P = .882, P = .730). The rate of subjects who met or exceeded the MCID in the NWB and WBAT groups was 82.6% and 81.2% for the Modified Harris Hip Score (P = .838) and 79.7% and 82.8% for the Hip Outcome Score (P = .647). There were no reported complications. Limitations include the possibility of the study being underpowered. CONCLUSIONS: After a 2-year minimum follow-up, patient-reported outcome measures and satisfactory rates with immediate weightbearing after hip arthroscopy for isolated FAI syndrome and labral tears do not differ significantly from results after strict NWB rehabilitation protocols. Revising weightbearing restrictions may allow for a more comfortable rehabilitation process after arthroscopic hip surgery for FAI and labral repair. LEVEL OF EVIDENCE: Level 3 - case-control study.

Subspinal impingement: clinical outcomes of arthroscopic decompression with one year minimum follow up.

PURPOSE: This study was designed to (1) evaluate the clinical outcomes after arthroscopic subspinal decompression in patients with hip impingement symptoms and low AIIS, and to (2) assess the presence of low anterior inferior iliac spine on the pre-operative radiographs of patients with established subspinal impingement diagnosed intra-operatively. METHODS: Retrospective analysis of patients who underwent arthroscopic subspinal decompression has been performed. The indications for surgery were femoroacetabular impingement (FAI), or subspinal impingement. Pre-operative radiographs were assessed for anterior inferior iliac spine type. Intra-operative diagnosis of low anterior inferior iliac spine was based on the level of anterior inferior iliac spine extension relative to the acetabulum and the presence of reciprocal labral and chondral lesions. In patients where low anterior inferior iliac spine was not diagnosed on pre-operative radiographs, the pre-operative radiographs were re-read retrospectively to assess missed signs of low anterior inferior iliac spine. RESULTS: Thirty-four patients underwent arthroscopic subspinal decompression between 2012 and 2015. The patients were followed for a median of 25 months (13-37 months). Intra-operatively, grade 2 anterior inferior iliac spine was found in 27 patients and grade 3 anterior inferior iliac spine was found in 7 patients. MHHS, HOS, and HOSS scores increased from median (range) pre-operative scores of 55 (11-90), 48 (20-91) and 20 (0-80) to 95 (27-100), 94 (30-100) and 91 (5-100), respectively (p < 0.0001, p = 0.001, p < 0.0001, respectively). Pre-operative diagnosis of low AIIS was made in 6/34 patients via AP radiographs. On retrospective analysis of pre-operative radiographs, signs of low AIIS were still not observed in 21/34 (61.8%) patients. CONCLUSIONS: Arthroscopic subspinal decompression of low AIIS yielded significantly improved outcome measures and high patient satisfaction at a minimum of 13 months follow-up. Low AIIS is often under-diagnosed on AP pelvis and lateral frog radiographs and if left untreated, may result in unresolved symptoms and failed procedure. LEVEL OF EVIDENCE: IV.

The anatomical properties of the indirect head of the rectus femoris tendon: a cadaveric study with clinical significance for labral reconstruction surgery.

BACKGROUND: Acetabular labral tear is a common pathology. In some clinical situations, primary labral repair may not be possible and labral reconstruction is indicated. PURPOSE AND CLINICAL RELEVANCE: Describe the anatomy of the indirect head of the rectus femoris (IHRF) tendon with clinical application in arthroscopic labral reconstruction surgery. METHODS: Twenty-six cadaver hips were dissected. Thirteen measurements, each with clinical relevance to arthroscopic labral reconstruction using an IHRF tendon graft were taken on each hip. All measurements were taken in triplicate. Mean values, standard deviations and intra-observer reliability were calculated. RESULTS: The mean footprint of the direct head of the rectus femoris tendon was 10.6 mm × 19.6 mm. The width and thickness at the confluence of both heads were 10.9 mm and 6.9 mm, respectively. The mean total length of the footprint and "free portion" of the IHRF was 55.3 mm, the mean cranial to caudal footprint measured at the 12 o'clock, 1 o'clock, and 2 o'clock positions were 22.3 mm. The mean length of the Indirect Head footprint alone was 38.1 mm. The mean length of IHRF tendon suitable for grafting was 46.1 mm and the mean number of clock face sectors covered by this graft was 3.3 clock face sectors. Intra-observer reliability was ≥ 0.90 for all recorded measurements. The origin of the IHRF on the acetabulum fans out posteriorly, becoming thinner and wider as the origin travels posteriorly. The tendon footprint is firmly attached on the lateral wall of the ilium and becomes a free tendon overlying the acetabular bone as it travels anteriorly and distally towards its muscular attachment. CONCLUSION: The IHRF tendon is in an ideal location for harvesting and contains the appropriate thickness, length and triangular architecture to serve as a safe and local graft source for acetabular labral reconstruction surgery.

Surgical approach for open reduction and internal fixation of clavicle fractures: a comparison of vertical and horizontal incisions.

PURPOSE: This study was designed to compare the results of clavicle fracture open reduction internal fixation (ORIF) with standard horizontal incision versus vertical incision. METHODS: ORIF surgery performed between October 2012 and August 2016 was included. The surgical approach was chosen according to surgeon preference as vertical or horizontal. Functional outcomes, fracture union, complications, scar appearance, skin irritation, and denervation around the scar were assessed at a minimum follow-up of three months. RESULTS: Thirty-eight patients, age 39 ± 12 years, were operated upon, 22 through vertical incisions and 16 through horizontal incisions. There were no significant group differences in functional scores, fracture union, or complications. Two patients in the vertical incision group had a post-operative haematoma. The scar length was significantly shorter when a vertical incision was used (6.75 ± 1.25 cm vs 8.9 ± 2.3 cm, P = 0.001). The typical distribution of hypoesthetic skin area distal and lateral to the scar represented iatrogenic damage to the supraclavicular nerves and was found in 66% of patients. The mean hypoesthetic surface area was smaller in the vertical incision group (38 ± 29 cm2 vs 48 ± 28 cm2, P = non-significant). CONCLUSION: Vertical incision results in shorter scars but may be associated with increased incidence of haematomas. Meticulous closure of the subcutaneous tissue is recommended.

Acetabular labral reconstruction using the indirect head of the rectus femoris tendon significantly improves patient reported outcomes.

PURPOSE AND HYPOTHESIS: The aim of this study was to evaluate outcomes after acetabular labral reconstruction using the indirect head of the rectus femoris tendon. The study hypothesis stated that arthroscopic acetabular labral reconstruction may improve patient reported outcomes in patients with labral tears that were not amenable to repair. METHODS: Between 2009 and 2015, the senior author performed 31 acetabular labral reconstructions using the indirect head of the rectus femoris tendon. The graft is harvested through the same arthroscopic portals established for the procedure. The graft was gradually secured to the acetabular rim starting at its origin to the myotendinous junction, reestablishing the suction seal of the joint. Medical records and surgical reports were reviewed for demographic data, and outcome measures were assessed with pre- and postoperative modified Harris Hip Scores (mHHS). RESULTS: Twenty-two patients with follow-up of more than 2 years were evaluated. Fourteen procedures were revision hip arthroscopy and 8 were primary labral reconstruction in 13 males and 9 females. The median age was 43 (range 22-68 years old). The median follow-up time was 36.2 months with a range from 24 to 72 months. The median preoperative mHHS was 67.1. Postoperatively, patients improved to a median mHHS of 97.8 (range 73.7-100) (p < 0.0001). CONCLUSION: Acetabular labral reconstruction using the indirect head of the rectus femoris tendon is a minimally invasive surgical procedure. The technique was applicable in all patients in this study with good outcomes. This procedure is clinically relevant for patients with large labral tears not amendable to labral repair as it offers good results using a local allograft. The local allograft is clinically advantageous as there is no additional donor-site morbidity and no risk of disease transmission. LEVEL OF EVIDENCE: IV.

Preemptive Analgesia in Hip Arthroscopy: A Randomized Controlled Trial of Preemptive Periacetabular or Intra-articular Bupivacaine in Addition to Postoperative Intra-articular Bupivacaine.

PURPOSE: To evaluate and compare the efficacy of intra-articular and periacetabular blocks for postoperative pain control after hip arthroscopy. METHODS: Forty-two consecutive patients scheduled for hip arthroscopy were randomized into 2 postoperative pain control groups. One group received preemptive intra-articular 20 mL of bupivacaine 0.5% injection, and the second group received preemptive periacetabular 20 mL of bupivacaine 0.5% injection. Before closure all patients received an additional dose of 20 mL of bupivacaine 0.5% intra-articularly. Data were compared with respect to postoperative pain with visual analog scale (VAS) and analgesic consumption, documented in a pain diary for 2 weeks after surgery. RESULTS: Twenty-one patients were treated with intra-articular injection, and 21 patients with peri-acetabular injection. There were no significant differences with regards to patient demographics or surgical procedures. VAS scores recorded during the first 30 minutes postoperatively and 18 hours after surgery were significantly lower in the periacetabular group compared with in the intra-articular group (0.667 ± 1.49 vs 2.11 ± 2.29; P < .045 and 2.62 ± 2.2 vs 4.79 ± 2.6; P < .009). There were no differences between the groups with regard to analgesic consumption. CONCLUSIONS: Periacetabular injection of bupivacaine 0.5% was superior to intra-articular injection in pain reduction after hip arthroscopy at 30 minutes and 18 hours postoperatively. However, total analgesic consumption over the first 2 postoperative weeks and VAS pain measurements were not significantly affected. LEVEL OF EVIDENCE: Level I, randomized controlled trial.

Hip Arthroscopy for Femoral-Acetabular Impingement: Do Active Claims Affect Outcomes?

PURPOSE: To compare outcomes of 3 patient groups undergoing hip arthroscopy. METHODS: This study included 138 consecutive hip arthroscopies (106 analyzed) for femoral-acetabular impingement (FAI) with or without labral tear in patients with a minimum 1-year follow-up. Inclusion criteria included patients older than 18 with clinical or radiologic manifestation of FAI with or without labral tear. Exclusion criteria included previous hip surgery and various hip pathologies. Patients were classified into 3 study groups. Group 1 included work-related injuries with active claims ACs (n = 33); mean age, 32 (range, 19 to 63); group 2 included sports injuries with no ACs (n = 35); mean age, 32 (range, 18 to 69); and group 3 included non-sports-related injuries without pending ACs (NAS; n = 38); mean age, 45 (range, 20 to 68). Outcomes were assessed using modified Harris hip scores (mHHS) and hip outcome scores (HOS) preoperatively and during the final evaluation. RESULTS: Baseline score for all groups did not significantly differ (P = .210 for mHHS, P = .176 for HOS). All groups significantly improved from preoperative to final evaluation (group 1: mHHS P = .42, HOS P = .001; group 2: mHHS P < .001, HOS P < .001; group 3 NAS: mHHS P = .001, HOS P = .007). AC patients had the lowest final evaluation scores, while the sports group had the highest. The NAS group did not differ from either group at final evaluation. Preoperative and final evaluation scores inversely correlated with age (r range, -24 to -28; P < .05). CONCLUSIONS: This study has shown that patients may benefit from arthroscopic repair of FAI and labral tears regardless of ACs. The level of improvement, however, is not constant across patients with different characteristics. Moreover, it appears that age may impact perceived improvement after hip arthroscopy. Hip arthroscopy as an intervention in patients with ACs provided positive outcomes, corroborating that an AC is not a contraindication for this procedure. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Bicycle-Related Shoulder Injuries: Etiology and the Need for Protective Gear.

BACKGROUND: The popularity of bicycle riding for recreation, exercise and transportation has grown enormously in recent years, which has led to an increased incidence of bicycle-related injuries. While these injuries involve mainly the musculoskeletal system, data on shoulder-specific injuries incurred while bike riding are lacking. Classifying these shoulder injuries may provide insight and assistance in the creation and implementation of effective protective gear and measures. OBJECTIVES: To investigate the types and mechanisms of shoulder injuries among cyclists. METHODS: This study retrospectively examined all cyclists who incurred shoulder injuries while riding and were admitted to the emergency department and shoulder clinic between January 2008 and November 2013. The study included 157 subjects with various bicycle-related shoulder injuries treated with either conservative or surgical measures. RESULTS: Eighty-four percent of injuries were caused by a direct blow to the shoulder, 7% by falling on an outstretched hand, 6% were traction injuries, and 3% were due to hyperabduction. Nine different clinical types of injury were observed; the most common injuries were clavicle fractures (32%), followed by acromioclavicular joint dislocations (22%), rotator cuff tears (22%), and humeral fractures (8%). Fifty-one percent of subjects were managed with conservative care and the remaining patients required surgical interventions. CONCLUSIONS: Shoulder injuries incurred while riding a bicycle span the entire spectrum of shoulder injuries and often result in debilitating conditions. Although the use of helmets is increasing, there is currently no effective protective gear or measures to prevent riders from suffering shoulder injuries.