Surgical Reattachment of Rare Proximal Adductor Avulsion Injury in a Female Athlete: A Case Report.

CASE: A 54-year-old female professional equestrian sustained a traumatic right groin injury with disabling groin pain. Magnetic resonance images indicated a proximal adductor avulsion injury with a 3.2-cm tendon retraction. Surgical reattachment of the fibrocartilage avulsion with suture anchor repair was subsequently performed. CONCLUSION: Adductor avulsion injuries have been rarely reported in female athletes. Patient-reported outcomes demonstrate a successful return to preinjury levels of daily function and sports performance after surgery for a female athlete. Surgical reattachment should be considered for the management of proximal adductor avulsion injuries in elite female athletes.

Acetabular Rim Disorders: Epidemiology, Etiology, Management, and Outcomes.

¼ Anatomic disorders of the acetabular rim are a common, correctable source of hip pain in younger patients.¼ Some common conditions of involving abnormal acetabular rim morphology include developmental dysplasia of the hip, pincer-type femoroacetabular impingement, acetabular protrusion, and acetabular retroversion.¼ Treatment option for these conditions were historically limited to open osteotomy and osteoplasty procedures; however, there is increasing use of arthroscopic intervention for these patients.¼ Arthroscopic intervention has demonstrated short-term success in a variety of focal acetabular rim disorders; however, further research is needed to determine the long-term outcomes of these procedures and their utility in more global pathology.

Surgical Outcomes of Inguinal-, Pubic-, and Adductor-Related Chronic Pain in Athletes: A Systematic Review Based on Surgical Technique.

BACKGROUND: Controversies remain regarding the surgical treatment of inguinal-, pubic-, and adductor-related chronic groin pain (CGP) in athletes. PURPOSE: To investigate the outcomes of surgery for CGP in athletes based on surgical technique and anatomic area addressed. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: The PubMed and Embase databases were searched for articles reporting surgical treatment of inguinal-, pubic-, or adductor-related CGP in athletes. Inclusion criteria were level 1 to 4 evidence, mean patient age >15 years, and results presented as return-to-sport, pain, or functional outcomes. Quality assessment was performed with the CONSORT (Consolidated Standards of Reporting Trials) statement or MINORS (Methodological Index for Non-randomized Studies) criteria. Techniques were grouped as inguinal, adductor origin, pubic symphysis, combined inguinal and adductor, combined pubic symphysis and adductor, or mixed. RESULTS: Overall, 47 studies published between 1991 and 2020 were included. There were 2737 patients (94% male) with a mean age at surgery of 27.8 years (range, 12-65 years). The mean duration of symptoms was 13.1 months (range, 0.3-144 months). The most frequent sport involved was soccer (71%), followed by rugby (7%), Australian football (5%), and ice hockey (4%). Of the 47 articles reviewed, 44 were classified as level 4 evidence, 1 study was classified as level 3, and 2 randomized controlled trials were classified as level 1b. The quality of the observational studies improved modestly with time, with a mean MINORS score of 6 for articles published between 1991 and 2000, 6.53 for articles published from 2001 to 2010, and 6.9 for articles published from 2011 to 2020. Return to play at preinjury or higher level was observed in 92% (95% CI, 88%-95%) of the athletes after surgery to the inguinal area, 75% (95% CI, 57%-89%) after surgery to the adductor origin, 84% (95% CI, 47%-100%) after surgery to the pubic symphysis, and 89% (95% CI, 70%-99%) after combined surgery in the inguinal and adductor origin. CONCLUSION: Return to play at preinjury or higher level was more likely after surgery for inguinal-related CGP (92%) versus adductor-related CGP (75%). However, the majority of studies reviewed were methodologically of low quality owing to the lack of comparison groups.

Arthroscopic Management of Subspinous Impingement in Borderline Hip Dysplasia and Outcomes Compared With a Matched Cohort With Nondysplastic Femoroacetabular Impingement.

BACKGROUND: Arthroscopic management of femoroacetabular impingement (FAI) in the setting of borderline hip dysplasia is controversial. Recently, there has been increased awareness of a prominent anterior inferior iliac spine (AIIS) resulting in subspinous impingement. PURPOSE/HYPOTHESIS: The purpose was to report outcomes of arthroscopic subspinous decompression in patients with symptomatic hip impingement and borderline hip dysplasia compared with a matched cohort with nondysplastic FAI. Addressing a prominent subspinous region and cam/pincer lesion in the borderline dysplastic hip may lead to favorable outcomes comparable with those of patients undergoing arthroscopic management of nondysplastic FAI. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Patients with symptomatic hip impingement, borderline dysplasia (lateral center-edge angle [LCEA], 18°-24°), and prominent AIIS (BDSI group) whose nonoperative management failed and who subsequently underwent arthroscopic subspinous decompression were retrospectively identified. Three-dimensional computed tomography imaging was used to categorize AIIS morphology into type 1, 2, or 3 (Hetsroni classification). Patient-reported outcome (PRO) scores consisting of the modified Harris Hip Score (mHHS), Hip Outcome Score-Activities of Daily Living (HOS-ADL), and Hip Outcome Score-Sport-Specific Subscale (HOS-SSS) were obtained preoperatively and at an average of 44 months postoperatively (range, 23-61 months). Exclusion criteria were Tönnis osteoarthritis grade >1 and a history of previous hip procedures. An age-, sex-, and body mass index-matched cohort of patients without dysplasia (LCEA, >25°) who underwent arthroscopic FAI surgery with a minimum 2-year follow-up were selected to serve as the control group. RESULTS: Eighteen patients, 19 hips (14 women and 4 men; average age, 28 years) were included. Of the 19 hips in the BDSI group, the average LCEA and alpha angle were 21.8° and 66.2°, respectively; 14 hips were Hestroni type 2, and 5 hips were type 1. There were no postoperative complications or additional procedures performed since the last follow-up. Repeated-measures analysis of variance revealed a significant improvement in all PRO scores from preoperatively to the last follow-up: mHHS, 64.7 to 87.7 (P < .001); HOS-ADL, 62.1 to 92.1 (P < .001); HOS-SSS, 26.5 to 87.1 (P < .001). An analysis of covariance revealed that patients with type 2 AIIS had a significantly higher postoperative mHHS than those with a type 1 morphology (88.3 and 95.6, respectively; P < .01) The BDSI group had a significantly lower preoperative HOS-SSS (26.5; P < .001) in comparison with the control group. However, there was no significant difference in postoperative outcome scores between groups. The BDSI group underwent significantly more microfracture, capsular plication, and ligamentum teres debridement (15.8%; P = .04). CONCLUSION: Arthroscopic AIIS decompression in patients with coexisting borderline dysplasia and subspinous impingement is a safe and effective method of treatment that produces outcomes comparable with those of a cohort with nondysplastic FAI.

Best Practice Guidelines for Hip Arthroscopy in Femoroacetabular Impingement: Results of a Delphi Process.

BACKGROUND: Treatment algorithms for the arthroscopic management of femoroacetabular impingement (FAI) syndrome remain controversial because of a paucity of evidence-based guidance. Consequently, notable variability in clinical practice exists between different practitioners, necessitating expert consensus. The purpose of this study is to establish best practice guidelines (BPG) using formal techniques of consensus building among a group of experienced hip arthroscopists driven by the results of a systematic review and meta-analysis. The scope of these guidelines includes preoperative recommendations, intraoperative practices, and postoperative protocols. METHODS: The validated Delphi process and the nominal group technique (NGT), used by the Centers for Disease Control and Prevention and the peer-reviewed orthopaedic literature, were used to formally derive consensus among 15 surgeons in North America. Participants were surveyed for current practices, presented with the results of a meta-analysis and systematic literature review, and asked to vote for or against the inclusion of nonleading, impartially phrased items during three iterative rounds while preserving the anonymity of participants' opinions. Agreement greater than 80% was considered consensus, and items near consensus (70% to 80% agreement) were further queried using the NGT in a moderated group session at the American Orthopaedic Society for Sports Medicine annual meeting. RESULTS: Participants had a mean of 12.3 years of practice (range: 1 to 29 years) and performed an annual mean of 249 (range 100 to 500+) hip arthroscopies, with a combined total of approximately 52,580 procedures. Consensus was reached for the creation of BPG consisting of 27 preoperative recommendations, 15 intraoperative practices, and 10 postoperative protocols. The final checklist was supported by 100% of participants. CONCLUSION: We developed the first national consensus-based BPG for the surgical and nonsurgical management of FAI. The resulting consensus items can serve as a tool to reduce the variability in preoperative, intraoperative, and postoperative practices and guide further research for the arthroscopic management of FAI.

Sports Hernia/Athletic Pubalgia Among Women.

BACKGROUND: "Athletic pubalgia," a term that has gained acceptance over "sports hernia," is more common in men than women; however, it represents a significant source of morbidity for patients of both sexes. Inconsistent terminology surrounding this entity poses a diagnostic challenge and makes studying the populations at risk difficult. PURPOSE: To review a case series of women with athletic pubalgia by analyzing their presentations, concomitant pathologies, and surgical outcomes. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Between 2013 and 2016, 197 patients were seen and evaluated for the diagnosis of athletic pubalgia. Eighteen patients seen during this time were women. All patients received "pubalgia protocol" magnetic resonance imaging and subsequent surgical intervention for their pathologies. Outcomes among 17 women were assessed with a patient questionnaire >1 year after surgery. RESULTS: Of the 17 women, 9 had rectus aponeurotic plate injury only, or pure athletic pubalgia; the remaining 8 had athletic pubalgia in combination with ≥1 inguinal, obturator, and femoral hernias. Regarding female patients in both groups, 88.2% reported that the surgery was a success at follow-up. CONCLUSION: Surgical repair of athletic pubalgia among women is successful in dramatically reducing pain levels in this important subset of patients.

The pyramidalis-anterior pubic ligament-adductor longus complex (PLAC) and its role with adductor injuries: a new anatomical concept.

PURPOSE: Adductor longus injuries are complex. The conflict between views in the recent literature and various nineteenth-century anatomy books regarding symphyseal and perisymphyseal anatomy can lead to difficulties in MRI interpretation and treatment decisions. The aim of the study is to systematically investigate the pyramidalis muscle and its anatomical connections with adductor longus and rectus abdominis, to elucidate injury patterns occurring with adductor avulsions. METHODS: A layered dissection of the soft tissues of the anterior symphyseal area was performed on seven fresh-frozen male cadavers. The dimensions of the pyramidalis muscle were measured and anatomical connections with adductor longus, rectus abdominis and aponeuroses examined. RESULTS: The pyramidalis is the only abdominal muscle anterior to the pubic bone and was found bilaterally in all specimens. It arises from the pubic crest and anterior pubic ligament and attaches to the linea alba on the medial border. The proximal adductor longus attaches to the pubic crest and anterior pubic ligament. The anterior pubic ligament is also a fascial anchor point connecting the lower anterior abdominal aponeurosis and fascia lata. The rectus abdominis, however, is not attached to the adductor longus; its lateral tendon attaches to the cranial border of the pubis; and its slender internal tendon attaches inferiorly to the symphysis with fascia lata and gracilis. CONCLUSION: The study demonstrates a strong direct connection between the pyramidalis muscle and adductor longus tendon via the anterior pubic ligament, and it introduces the new anatomical concept of the pyramidalis-anterior pubic ligament-adductor longus complex (PLAC). Knowledge of these anatomical relationships should be employed to aid in image interpretation and treatment planning with proximal adductor avulsions. In particular, MRI imaging should be employed for all proximal adductor longus avulsions to assess the integrity of the PLAC.

Anchor-induced chondral damage in the hip.

The purpose of this study is to investigate the outcomes from anchor-induced chondral damage of the hip, both with and without frank chondral penetration. A multicenter retrospective case series was performed of patients with chondral deformation or penetration during initial hip arthroscopic surgery. Intra-operative findings, post-surgical clinical courses, hip outcome scores and descriptions of arthroscopic treatment in cases requiring revision surgery and anchor removal are reported. Five patients (three females) of mean age 32 years (range, 16-41 years) had documented anchor-induced chondral damage with mean 3.5 years (range, 1.5-6.0 years) follow-up. The 1 o'clock position (four cases) and anterior and mid-anterior portals (two cases each) were most commonly implicated. Two cases of anchor-induced acetabular chondral deformation without frank penetration had successful clinical and radiographic outcomes, while one case progressed from deformation to chondral penetration with clinical worsening. Of the cases that underwent revision hip arthroscopy, all three had confirmed exposed hard anchors which were removed. Two patients have had clinical improvement and one patient underwent early total hip arthroplasty. Anchor-induced chondral deformation without frank chondral penetration may be treated with close clinical and radiographic monitoring with a low threshold for revision surgery and anchor removal. Chondral penetration should be treated with immediate removal of offending hard anchor implants. Preventative measures include distal-based portals, small diameter and short anchors, removable hard anchors, soft suture-based anchors, curved drill and anchor insertion instrumentation and attention to safe trajectories while visualizing the acetabular articular surface.

The incidence of venous thromboembolism (VTE)--after hip arthroscopy.

PURPOSE: The purpose of this study was to determine the incidence of venous thromboembolism (VTE) after hip arthroscopy. METHODS: Over the course of 13 months, four surgeons that routinely perform hip arthroscopy participated in a protocol to screen all patients postoperatively for deep venous thrombosis (DVT) using bilateral venous duplex ultrasound at or about the 2 week postoperative time point. All patients were assessed and stratified for VTE risk prior to surgery. Mechanical intraoperative and postoperative chemoprophylaxis were not administered. Perioperative factors, such as weightbearing status after surgery, traction time, and anesthesia type, were recorded. RESULTS: We identified 139 eligible patients (average age 37.7, SD = 12.0) that underwent hip arthroscopy. The incidence of symptomatic VTE was 1.4 percent (2/139). Of the entire patient pool, 81 obtained a follow-up ultrasound. There were no cases of asymptomatic deep vein thrombosis (DVT). There were two symptomatic venous thromboembolic events noted; one DVT and one pulmonary embolus. One patient had no risk factors; the other was overweight and routinely took oral contraceptives. Amongst the patient cohort, the mean BMI was 25.9 (SD = 4.8). The mean traction time was 58.9 minutes (SD = 23.1). Most patients (71%) were partial weightbearing after the procedure. CONCLUSION AND CLINICAL RELEVANCE: In patients undergoing hip arthroscopy, the rate of postoperative VTE was low, despite the use of prolonged axial traction and surgical proximity to the pelvic veins. Although patients should be counseled preoperatively regarding the risk of VTE, we believe that routine use of pharmacologic prophylaxis is not indicated following hip arthroscopy if patients are properly risk stratified prior to surgery and found to be at low risk for VTE.

Labral tears, extra-articular injuries, and hip arthroscopy in the athlete.

Labral tears in athletes can lead to disabling hip pain and affect their athletic performance. Other intra-articular lesions, including chondral injuries, capsular abnormalities, and ligamentum teres tears, commonly coexist with acetabular labral tears. Isolated athletic injury or repetitive traumatic activity can lead to labral tears; however, underlying structural (femoroacetabular impingement) and developmental abnormalities predisposing athletes to labral pathology must be addressed. Recent studies have demonstrated lesions associated with acetabular labral tears, and that labral tears rarely occur as isolated injuries. Return to sport is favorable in athletes who have labral tears if they are properly treated with arthroscopic intervention.

Endoscopic treatment of calcific tendinitis of gluteus medius and minimus.

Calcific tendinitis results from deposition of calcium hydroxyapatite crystals in periarticular muscle attachments. Although involvement of tendons around the hip is not uncommon, gluteus medius and minimus tendons are rarely affected. We present endoscopic treatment of calcific tendonitis of gluteus medius and minimus and associated trochanteric bursitis in a patient with 2-year history of lateral hip pain. This is the first reported case treated using an endoscopic approach, which is effective and minimally invasive.

Knee fractures in the athlete.

Sports-related fractures of the knee, although uncommon, do occur during athletic participation. The assessment and management of each fracture type have been emphasized in this article to provide a guideline for treating these acute knee injuries to a successful return to sports-specific competition. Anatomic fracture reduction is necessary to have optimal joint function in the knee as well as stability of fracture for early joint motion, promote bone healing, and avoid traumatic arthritis. This is especially crucial to the injured athlete, as residual deficits of the knee can greatly affect performance. Selection of low-profile implants at the time of surgery to prevent soft tissue irritation and possible implant removal must also be considered with the return to athletic activity.