Knotless Anchors in Acetabular Labral Repair: A Biomechanical Comparison.

PURPOSE: To analyze the failure mechanism, stiffness, and pullout strength of acetabular knotless suture anchors. METHODS: Seven suture anchors were tested in high-density (0.48 g/cc) synthetic blocks. The anchors were implanted perpendicular to the bone block. The anchor's suture(s) were tied around a loop of 8 high-strength nonabsorbable sutures and pulled in line with the anchor at a rate of 1 mm/s until failure. The following knotless anchors were tested: Stryker Knotilus 3.5, Arthrex Pushlock 2.9, Linvatec PopLok 2.8, Linvatec PopLok 3.3, ArthroCare SpeedLock HIP (3.4-mm), and Smith & Nephew Bioraptor Knotless 2.9. The standard knot tying Smith & Nephew Bioraptor 2.9 mm served as a baseline for comparison. RESULTS: Stiffness was highest in the Pushlock, the SpeedLock HIP, and Knotilus. At 1 mm displacement, the SpeedLock HIP exhibited significantly higher load than all other anchors, excluding the Pushlock and PopLok 3.3 (P ≤ .012 for all comparisons). Excluding the SpeedLock HIP and Knotilus, the Pushlock displayed significantly higher load than all other anchors at 2-mm displacement (P ≤ .015 for all comparisons). Maximum load was the highest for the Knotilus and Bioraptor knotted anchor (P < .001 compared with all other anchors). CONCLUSIONS: All knotless suture anchors used in hip arthroscopy, except for the Knotilus 3.5, failed by suture pullout from the anchor. The 2 anchors with the highest maximum load, the Knotilus 3.5 and knotted Bioraptor 2.9, failed by suture failure; however, these anchors displayed the lowest stiffness and load at 1 mm displacement among all anchors tested. Stiffness and loads at clinically relevant displacements, not maximum load alone, may be most important in predicting anchor clinical performance during the early phases of labral healing. CLINICAL RELEVANCE: Knotless suture anchors tend to fail by suture pullout from the anchor, yet the stiffness of these constructs suggests that minimal displacement of the repair will occur under physiologic loads.

Incidence and Epidemiology of Foot and Ankle Injuries in Elite Collegiate Athletes.

BACKGROUND: Foot and ankle injuries are increasing in competitive professional and collegiate athletics. Many of these injuries result in considerable missed time from sports and often require surgical intervention. To develop and implement effective practice participation strategies, return-to-play protocols, and injury prevention programs, an understanding of injury trends and epidemiology is vital. PURPOSE: This study aimed to evaluate the incidence of foot and ankle injuries in elite athletes participating in 37 sports at a single National Collegiate Athletics Association (NCAA) Division 1 institution. STUDY DESIGN: Descriptive epidemiological study. METHODS: We evaluated the injury records of all varsity sports at a single NCAA Division 1 athletics program, including 1076 athletes participating in 37 sports. Detailed injury data were prospectively collected in a secure electronic database over a 2-year period. We reviewed the database for all foot/ankle injuries. Inclusion criteria were any foot/ankle injury that was sustained during an NCAA-sanctioned event and subsequently received medical treatment. Independent variables included athlete and injury demographics, missed days, physician visits, imaging results, and whether the injury required surgery. Injury incidence, relative frequency distributions, and sample proportions were dependent metrics for this investigation. RESULTS: During the study period, a total of 3861 total musculoskeletal injuries were recorded. There were 1035 foot/ankle injuries (27%). Of all foot/ankle injuries, 21% (218 of 1035) caused the athlete to miss at least 1 day of participation, with an average of 12.3 days of time loss from sport. Furthermore, 27% of athletes with foot/ankle injuries were referred for office evaluation by a physician, and 84% of these required radiologic imaging. The overall injury incidence rate was 3.80 per 1000 athlete-exposures (AEs). The 4 sports with the highest incidence rate (>75th percentile) were women's gymnastics, women's cross-country, women's soccer, and men's cross country. The most frequently occurring foot/ankle injuries were ankle ligament injuries, tendinopathies or fasciopathies, and bone stress injuries. CONCLUSION: The prevalence of foot/ankle injury in a large NCAA Division 1 athletics program was 27% of total musculoskeletal injuries over a 2-year period, with 21% of these injuries resulting in missed time. There were significantly higher foot and ankle injury incidence rates and more missed time in female athletes and women's sports.

Predictive value of robotic-assisted total hip arthroplasty.

Acetabular cup positioning, leg-length discrepancy, and global offset are important parameters associated with outcomes following total hip arthroplasty (THA). Deviation from an accepted range of values can lead to significant complications, including dislocation, leg-length discrepancy, impingement, accelerated bearing surface wear, and revisions. The purpose of this study was to assess whether robotic-assisted THA was reliable in predicting radiographic measurements of cup inclination and anteversion, leg-length change, and global offset change. All 61 robotic-assisted THAs that met the inclusion and exclusion criteria were performed by a single surgeon through a mini-posterior approach. Data provided by the robot were collected prospectively, and radiographic data were collected retrospectively by 2 blinded independent reviewers. The cohort in this study consisted of 27 male and 34 female patients, with an average age of 60.5 years. A strong inter- and intraobserver correlation was found for the radiographic measurements of cup inclination, cup anteversion, leg-length discrepancy, and global offset (r>0.8 with P<.001 for all). Ninety-six point seven percent of robotic-measured inclination angles and 98.4% of robotic-measured anteversion angles were within 10° of radiographic measurements. One hundred percent of robotic-measured leg-length change and 91.8% of robotic-measured global offset change were within 10 mm of radiographic measurements. Robotic-assisted THA showed good predictive value for cup inclination and anteversion angles and measurements of leg-length change and global offset change done postoperatively on plain radiographs. Further refinement of the robotic system would make it more accurate in predicting the postoperative parameters mentioned.

Outcomes of hip arthroscopy in patients aged 50 years or older compared with a matched-pair control of patients aged 30 years or younger.

PURPOSE: Age has been suggested as a negative prognostic factor for hip arthroscopy. The purpose of this study was to compare patient characteristics and outcomes after hip arthroscopy in patients aged 50 years or older with a matched control group of patients aged 30 years or younger at a minimum postoperative follow-up of 2 years. METHODS: Between September 2008 and March 2010, data were prospectively collected on all patients aged 50 years or older undergoing primary hip arthroscopy. Fifty-two patients met our inclusion and matching criteria, of whom all 52 (100%) were available for follow-up at a minimum of 2 years. This cohort was compared with a matched-pair control group of patients aged 30 years or younger who underwent similar procedures. RESULTS: The mean age of the study group was 54.8 years (range, 50 to 69 years), and that of the control group was 20.3 years (range, 13 to 30 years). The groups were matched at a 1:1 ratio, including 18 male patients (34.6%) and 34 female patients (65.4%) in each group, with a mean follow-up period of 32 months (range, 24 to 54 months). In the younger control group, the score improvement from preoperatively to 2 years' follow-up was 62.9 to 84.2 for the modified Harris Hip Score, 60.5 to 84.2 for the Non-Arthritic Hip Score, 63.1 to 86.5 for the Hip Outcome Score-Activities of Daily Living, and 42.2 to 72.7 for the Hip Outcome Score-Sport-Specific Subscale. In the older study group, the score improvement from preoperatively to 2 years' follow-up was 61.2 to 82.2 for the modified Harris Hip Score, 59.9 to 80.4 for the Non-Arthritic Hip Score, 63.9 to 83 for the Hip Outcome Score-Activities of Daily Living, and 41.2 to 64.6 for the Hip Outcome Score-Sport-Specific Subscale. All improvements in both groups were statistically significant at the 2-year postoperative follow-up (P < .001). There was no significant difference for all patient-reported outcome (PRO) scores at final follow-up between both groups. When we compared the change in PRO scores (Δ) from preoperatively to 2 years postoperatively, there was no significant difference between both groups. The overall survivorship rate was 98.1% for the younger control group and 82.7% for the older study group. CONCLUSIONS: Survivors aged 50 years or older show similar improvement to patients aged 30 years or younger in PRO and patient satisfaction scores. The 2-year survivorship rate was 98.1% for the younger control group and 82.7% for the older study group. Therefore we believe that hip arthroscopy should be considered a valid treatment option when treating hip pain in patients aged 50 years or older with a Tönnis arthritic grade of 0 or 1. Older patients should be counseled on the possibility of later conversion to total hip arthroplasty. Future work may include development of a decision-making tool to assess for prognosis to better delineate the indications for hip arthroscopy in the older population. LEVEL OF EVIDENCE: Level III, therapeutic case-control study.

Clinical presentation and imaging results of patients with symptomatic gluteus medius tears.

Greater trochanteric pain syndrome (GTPS) is a common complaint. Recently, it has become well recognized that tendinopathy and tears of the gluteus medius (GM) are a cause of recalcitrant GTPS. Nevertheless, the clinical syndrome associated with GM tears is not fully characterized. We characterize the clinical history, findings on physical examination, imaging and intraoperative findings associated with symptomatic GM tears. Forty-five patients (47 hips) who underwent GM repair for the diagnosis of tear were evaluated. Pain was estimated on the visual analog scale (VAS) and hip-specific scores were administered to assess functional status. The imaging modalities were reviewed and intra operative findings were recorded. The average patient age was 54 years (17-76), 93% were females. Symptom onset was commonly insidious (75%) and the average time to diagnosis was 28 months (2-240). The most common pain location was the lateral hip (75%). The average pre-surgery VAS and modified Harris Hip Score were 6.65 (0-10) and 55.5 (12-90), respectively. All patients had pathological findings on magnetic resonance angiogram (MRA) ranging from tendinosis to complete tears of the GM tendon. There was a discrepancy between MRA interpretation by a radiologist and findings during surgery. Hip abductor tears are an under-recognized cause of hip pain and hip symptomatology. In this study, we further characterize the clinical presentation of this entity. The data we present here may facilitate early diagnosis, early orthopedic care and avoid unnecessary prolonged patient sufferings.

Open surgical dislocation versus arthroscopic treatment of femoroacetabular impingement.

It is unclear if open surgical dislocation or arthroscopy of the hip is superior for the treatment of femoroacetabular impingement (FAI). We prospectively compared the clinical results of these 2 surgical methods performed by a single surgeon. Five patients met the inclusion criteria for the open surgical dislocation group and 18 for the arthroscopic group. Patient-reported scores, including the modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score-Sport-Specific Subscale (HOS-SSS) and Hip Outcome Score-Activities of Daily Living (HOS-ADL) were used preoperatively, and at 3 months, 6 months, and 1 year postoperatively to compare the 2 groups. Average follow-up was 14.7 months (range, 12 to 25 months); both groups showed significant improvement in their postoperative scores compared with preoperative scores (P < .01). The arthroscopic group had better, earlier improvement at 3- and 6-month follow-up, with NAHS significantly better at 3 months (P < .0002). However, improvements were comparable between the 2 groups at 1 year. Open surgical dislocation and arthroscopy are viable options for the treatment of FAI. The arthroscopic group demonstrated a trend toward faster recovery and quicker return to sports, but larger and longer-term studies are needed.

Arthroscopic Iliopsoas Fractional Lengthening for Internal Snapping of the Hip: Clinical Outcomes With a Minimum 2-Year Follow-up.

BACKGROUND: Internal snapping of the hip is caused by the iliopsoas (IP) tendon sliding over the iliopectineal eminence or the femoral head. In many cases that require hip arthroscopic surgery, there is coexistent painful internal snapping. In such cases, fractional lengthening of the IP tendon has been suggested as an adjunctive procedure. PURPOSE: To examine the outcomes and effectiveness of arthroscopic IP tendon fractional lengthening as a solution to coexistent internal hip snapping in patients undergoing hip arthroscopic surgery for a labral tear and/or femoroacetabular impingement. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Between June 2010 and June 2011, data were prospectively collected for all patients with internal snapping of the hip who underwent primary arthroscopic IP tendon fractional lengthening, with a minimum 2-year follow-up. All patients were interviewed by telephone with specific questions regarding the resolution or persistence of snapping. Patients were assessed preoperatively and postoperatively using the following patient-reported outcome (PRO) measures: Non-Arthritic Hip Score (NAHS), Hip Outcome Score-Activity of Daily Living (HOS-ADL) and Sport-Specific Subscale (HOS-SSS), and modified Harris Hip Score (mHHS). Pain was recorded on a visual analog scale (VAS), and satisfaction was measured on a scale from 0 to 10. RESULTS: A total of 55 patients were included, with all PROs showing statistically significant improvement postoperatively (NAHS: 57.6 ± 20.6 preoperatively vs. 80.2 ± 19.2 at 2 years; HOS-ADL: 60.9 ± 21.4 preoperatively vs. 81.8 ± 20.6 at 2 years; HOS-SSS: 43.4 ± 24.6 preoperatively vs. 70.0 ± 26.7 at 2 years; and mHHS: 62.3 ± 16.4 preoperatively vs. 80.5 ± 18.3 at 2 years) (P < .001 for all). Forty-five patients (81.8%) reported good/excellent satisfaction (≥7). Overall, 45 patients (81.8%) reported resolution of painful snapping. Patients who had resolution of snapping had statistically significant superior outcomes compared with those with persistent snapping using the change in the NAHS value (25.8 ± 16.1 vs. 8.0 ± 22.5, respectively; P = .005), change in the HOS-ADL value (23.6 ± 18.0 vs. 8.5 ± 15.2, respectively; P = .017), change in the HOS-SSS value (30.7 ± 26.9 vs. 8.7 ± 23.6, respectively; P = .021), and change in the mHHS value (23.3 ± 20.1 vs. 4.4 ± 9.9, respectively; P = .005). CONCLUSION: A majority of patients reported resolution of painful snapping and improvement in symptoms. Nonetheless, the rate of persistence of internal snapping at a minimum 2 years postoperatively was higher than that reported in previous studies.

Comparison of robotic-assisted and conventional acetabular cup placement in THA: a matched-pair controlled study.

BACKGROUND: Improper acetabular component orientation in THA has been associated with increased dislocation rates, component impingement, bearing surface wear, and a greater likelihood of revision. Therefore, any reasonable steps to improve acetabular component orientation should be considered and explored. QUESTIONS/PURPOSES: We therefore sought to compare THA with a robotic-assisted posterior approach with manual alignment techniques through a posterior approach, using a matched-pair controlled study design, to assess whether the use of the robot made it more likely for the acetabular cup to be positioned in the safe zones described by Lewinnek et al. and Callanan et al. METHODS: Between September 2008 and September 2012, 160 THAs were performed by the senior surgeon. Sixty-two patients (38.8%) underwent THA using a conventional posterior approach, 69 (43.1%) underwent robotic-assisted THA using the posterior approach, and 29 (18.1%) underwent radiographic-guided anterior-approach THAs. From September 2008 to June 2011, all patients were offered anterior or posterior approaches regardless of BMI and anatomy. Since introduction of the robot in June 2011, all THAs were performed using the robotic technique through the posterior approach, unless a patient specifically requested otherwise. The radiographic cup positioning of the robotic-assisted THAs was compared with a matched-pair control group of conventional THAs performed by the same surgeon through the same posterior approach. The safe zone (inclination, 30°-50°; anteversion, 5°-25°) described by Lewinnek et al. and the modified safe zone (inclination, 30°-45°; anteversion, 5°-25°) of Callanan et al. were used for cup placement assessment. Matching criteria were gender, age ± 5 years, and (BMI) ± 7 units. After exclusions, a total of 50 THAs were included in each group. Strong interobserver and intraobserver correlations were found for all radiographic measurements (r > 0.82; p < 0.001). RESULTS: One hundred percent (50/50) of the robotic-assisted THAs were within the safe zone described by Lewinnek et al. compared with 80% (40/50) of the conventional THAs (p = 0.001). Ninety-two percent (46/50) of robotic-assisted THAs were within the modified safe zone described by Callanan et al. compared with 62% (31/50) of conventional THAs p (p = 0.001). The odds ratios for an implanted cup out of the safe zones of Lewinnek et al. and Callanan et al. were zero and 0.142, respectively (95% CI, 0.044, 0.457). CONCLUSIONS: Use of the robot allowed for improvement in placement of the cup in both safe zones, an important parameter that plays a significant role in long-term success of THA. However, whether the radiographic improvements we observed will translate into clinical benefits for patients-such as reductions in component impingement, acetabular wear, and prosthetic dislocations, or in terms of improved longevity-remains unproven.

Is intraarticular pathology common in patients with hip dysplasia undergoing periacetabular osteotomy?

BACKGROUND: Periacetabular osteotomy (PAO) enables correction of bony acetabular deficiency in the setting of hip dysplasia. Patients with insufficient acetabular coverage often have intraarticular pathology, but the degree of this pathology has been incompletely characterized. We have used arthroscopy as an adjunct to PAO to further delineate intraarticular pathology in patients with hip dysplasia with mechanical symptoms. QUESTIONS/PURPOSES: We documented the arthroscopic incidence of (1) femoral and acetabular chondral pathology, (2) femoral neck cam lesions, and (3) internal snapping or ligamentum teres pathology among patients having arthroscopy before PAO. METHODS: We reviewed all 16 patients (17 hips; mean age at surgery, 21 years; range, 12-33 years) with hip dysplasia who underwent PAOs and concomitant hip arthroscopy at our institutions from October 2010 to March 2012. During this period, 80 patients underwent PAOs, making the arthroscopic cohort 21% of the total cohort. Indications for concomitant hip arthroscopy were mechanical symptoms consistent with labral pathology identified on MRI. We documented pathology involving the labrum, chondral surface, ligamentum teres, cam deformity, and psoas tendon. RESULTS: Arthroscopy revealed significant intraarticular pathology in all patients. Fourteen hips had anterosuperior labral tears, and three hips had preoperative findings of internal snapping hip. Eleven hips had femoral cam-type lesions in addition to dysplasia, and 16 hips had articular chondral injury. Two hips had full-thickness ligamentum tears, and 13 hips had partial-thickness tears. CONCLUSIONS: Intraarticular pathology at the time of PAO is common. Future studies are needed to rigorously address the use of arthroscopic intervention during PAO and the impact on clinical outcome compared to PAO alone.

Surgical dislocation of the hip versus arthroscopic treatment of femoroacetabular impingement: a prospective matched-pair study with average 2-year follow-up.

PURPOSE: The purpose of this study was to prospectively compare outcomes of patients receiving surgical hip dislocation and those undergoing arthroscopic treatment for femoroacetabular impingement (FAI), using a matched-pair analysis. METHODS: Between January 2008 and August 2011, patients aged 30 years or younger with a diagnosis of FAI treated with surgical dislocation or arthroscopy were included. Patients were excluded with Tönnis grade 2 or greater, dysplasia, Legg-Calve-Perthes disease, and previous hip surgery. Patients treated with surgical dislocation were pair-matched to patients treated arthroscopically in a 1:2 ratio. Patient-reported outcomes were prospectively obtained in all patients preoperatively and postoperatively at 3 months, at 1 year, at 2 years, and at latest follow-up. Alpha angles were measured preoperatively and postoperatively for both groups. Revision surgery and complications were recorded for each group. RESULTS: Ten patients were included in the surgical dislocation group, and 20 pair-matched patients were included in the arthroscopic group. We obtained 100% follow-up at a mean of 24.8 months in the open group and 25.5 months in the arthroscopic group. Preoperative scores were similar between the 2 groups; significant improvements were made postoperatively for both groups. When we compared the 2 groups, the change in Hip Outcome Score-Sport-Specific Subscale (42.8 v 23.5, P = .047) and 2-year Non-Arthritic Hip Score (94.2 v 85.7, P = .01) were significantly higher in the arthroscopic group. Both groups showed a significant decrease in the alpha angle postoperatively (P = .775). CONCLUSIONS: Favorable results were shown with both approaches, with significant improvement in all patient-reported outcome measures and high patient satisfaction ratings. However, arthroscopic treatment of FAI showed greater improvement in the Hip Outcome Score-Sport-Specific Subscale and a higher absolute Non-Arthritic Hip Score at an average 2-year follow-up. LEVEL OF EVIDENCE: Level II, prospective matched-pair comparative study.

Outcomes of endoscopic gluteus medius repair with minimum 2-year follow-up.

BACKGROUND: Gluteus medius tears may be present in as many as 25% of late middle-aged women and 10% of middle-aged men, and they are often misdiagnosed. Outcomes of endoscopic repair of gluteus medius tears have seldom been reported. PURPOSE: To report the early outcomes of endoscopic repair of partial- and full-thickness gluteus medius tears. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Between April 2009 and January 2010, data were prospectively collected for all patients undergoing endoscopic gluteus medius repair by one of the authors. Inclusion criteria for the study were patients undergoing repair for either high-grade, partial-, or full-thickness tears. Only patients with endoscopic evidence of a gluteus medius tear were treated surgically. In the case of an articular-side tear, a transtendinous repair technique was used, whereas in the presence of a full-thickness tear, the tendon was refixated to the bone directly. RESULTS: A total of 15 patients met the inclusion criteria. The cohort included 14 women and 1 man, with an average age of 58 years (range, 44-74 years). Endoscopically, 6 cases were found to be partial-thickness tears. Nine were either full-thickness tears or near-full-thickness tears, which were completed for the repair. Follow-up was obtained on all patients at an average of 27.9 months postoperatively (range, 24-37 months). Fourteen of the 15 patients showed postoperative improvement in all 4 hip-specific scores used to assess outcome, with an average improvement of more than 30 points for all scores. Satisfaction with the surgery results was reported to be from good to excellent (scores of 7-10 out of 10) in 14 of 15 patients. CONCLUSION: This study demonstrates that endoscopic surgical repair, whether performed through a transtendinous or full-thickness technique, can be an effective treatment of gluteus medius tears at a minimum follow-up of 2 years. Longer term follow-up studies are necessary to determine whether these therapeutic and functional gains are maintained.

Risk factors for ligamentum teres tears.

PURPOSE: The purpose of this study was to examine the relationship between nontraumatic ligamentum teres (LT) tears and acetabular radiographic architecture. METHODS: The inclusion criteria for this study were all patients who had anteroposterior pelvis radiographic views and had undergone arthroscopic examination of the LT. The exclusion criteria were Tonnis arthritic grade 3 and traumatic high-energy mechanisms of injury. Radiographic data were measured preoperatively on an anteroposterior pelvis view, including acetabular inclination (AI), lateral center edge (CE) angle, magnitude of cross-over sign, and ischial spine prominence. A Lateral Coverage Index (LCI) was defined as the center edge angle minus acetabular inclination. Hips were divided into 3 groups according to the LCI: (1) high: 34° and above; (2) medium: 19° to 33°; and (3) low: below 19°. RESULTS: Of the 463 hips (430 patients) included in the study, 226 (49%) had a partial- or full-thickness LT tear. Patients with tears were significantly older than patients without tears (P < .0001), with average ages of 38 and 33 years, respectively. Radiographically, patients with tears had less acetabular retroversion, as reflected by lower ischial spine prominence values and lesser cross-over signs (P = .01 and .0005, respectively). Using the LCI, 115 hips (25%) were classified as high, 236 (50%) as medium, and 114 (25%) as low. Hips with low LCI were 1.74 times more likely to have LT tears than high LCI hips. CONCLUSIONS: This study found that the presence of LT tears was associated with acetabular bony morphology and age. LT tears were less frequent with high LCI and acetabular retroversion and less frequent in patients younger than 30 years. Further study is needed to establish whether there is a causal relationship between acetabular undercoverage and LT tears and whether LT tears may be a sign of microinstability of the hip. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

MR imaging of the hip: pathologies and morphologies of the hip joint, what the surgeon wants to know.

MR imaging of the hip is frequently used in symptomatic patients before hip preservation surgery; it is used as a decision-making tool and as a planning tool. The MRI can confirm the preliminary working diagnosis, identify other possible sources of pain, and highlight anatomic areas that are not routinely viewed during surgery. In addition, MR imaging is capable of illustrating normal and abnormal bony morphology of the femur and pelvis; and in the case that arthrography is used, diagnostic injection can be administrated concurrently. This article highlights a surgeon's perspective on the use of MR imaging in the patient with nonarthritic hip pain.

Labral penetration rate in a consecutive series of 300 hip arthroscopies.

BACKGROUND: Intraoperative labral injury during the establishment of the first portal in hip arthroscopy has been reported to be as high as 20%. PURPOSE: The purpose of the study was to prospectively identify the incidence of acetabular labral injuries that occurred while using a current technique for the establishment of portals during hip arthroscopy. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Between the years 2008 and 2010, data were prospectively collected for all patients undergoing hip arthroscopic surgery. Patients with previous labral resection or Tonnis grade greater than 1 were excluded. Patients were positioned supine, traction was applied, and portals were established. The anterolateral portal was created first by venting the joint with a spinal needle and then re-entering the joint with the same needle with the bevel side facing the labrum. Next, the midanterior portal was created under vision. A thorough examination of the acetabular labrum was conducted arthroscopically through multiple viewing portals, and labral injuries related to the establishment of portals were identified and noted. RESULTS: A total of 300 patients were included in the study; only 2 patients (0.67%) suffered intraoperative labral injuries at the study period. One injury occurred during revision arthroscopy, while the second involved a hyperplastic labrum in a dysplastic hip. No patient with normal hip morphological characteristics undergoing a hip arthroscopy suffered a labral tear as a result of portal placement. CONCLUSION: The incidence of iatrogenic labral injury during hip arthroscopy can be as low as 0.67% when using the described technique.

Femoral anteversion in the hip: comparison of measurement by computed tomography, magnetic resonance imaging, and physical examination.

PURPOSE: The purpose of this study was to evaluate the correlation between computed tomography (CT) and magnetic resonance imaging (MRI) measurements of femoral anteversion, as well as the relation of anteversion with physical examination and radiographic findings. METHODS: Preoperative CT and MRI measurements of anteversion along with clinical examination were performed on 129 consecutive hips before hip arthroscopy for nonarthritic hip injuries. All anteversion measurements were performed by 2 musculoskeletal radiologists. The radiographic findings and physical examination findings were analyzed for statistically significant correlations. For statistical analysis purposes, the patients were divided into 3 groups according to the mean CT anteversion measurement: group I (low), less than 10°; group II (medium), 10° to 22°; and group III (high), greater than 22°. RESULTS: High interobserver correlation was found for femoral anteversion measurement by CT and MRI (r = 0.95 and r = 0.86, respectively; P < .0001 for both). CT and MRI measurements showed high correlation with each other (r = 0.80, P < .0001). However, in 96% of the cases, the CT measurement was larger, with a mean difference of 8.9° (range, -37° to 1.5°). A significant correlation coefficient was found between internal rotation and anteversion angles as measured by CT (r = 0.36, P < .0001). However, no correlation was found with other hip movement measurements. Abnormal femoral acetabular bony architecture of the hip was found in 64% of the patients; isolated cam impingement was more prevalent in group I, whereas isolated pincer impingement was more prevalent in group III (P = .01). CONCLUSIONS: Although high correlation was found between anteversion angle measurements by CT and MRI, significant discrepancies in the absolute anteversion number between the 2 techniques suggest that they may not be interchangeable. Furthermore, CT was found to have higher interobserver reliability than MRI. There was a significant correlation between CT and examination of internal rotation of the hip. Clinically, the findings of the study show that the diagnosis of excessive femoral anteversion or retroversion should have different thresholds according to MRI and CT measurements; moreover, the diagnosis should not rely exclusively on either examination or radiologic criteria. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

[Significance of plain radiography in shoulder pain diagnosis].

Shoulder pain is a common complaint--almost 20% of the population will suffer shoulder pain during their life time. Despite the availability of newer imaging techniques for evaluation of the shoulder, the first imaging study should be radiography. Recently, ultrasonography of the shoulder has become one of the first studies performed. Sometimes, ultrasonography is conducted before radiography; moreover, many patients are being referred to a shoulder specialist without performing an X-ray. There is a plethora of pathologies that can cause shoulder pain--rotator cuff tears, impingement syndrome, calcified tendinitis, osteoarthritis, rheumatoid arthritis, neoplasms and more. This review aims to show the significance of plain radiography in the diagnosis of shoulder pathologies, in order to encourage the use of this modality. In this paper we shall review the different causes of shoulder pain and their radiographic characteristics.

Tears of the ligamentum teres: prevalence in hip arthroscopy using 2 classification systems.

BACKGROUND: The ligamentum teres (LT) anatomy has been known for many years. While its functionality remains debatable, it is well recognized that the LT can be a source of pain in the hip joint. In 1997, a landmark publication by Gray and Villar established a classification for LT tears and increased the awareness of LT disorders. However, the incidence of LT tears and the various tear types is unknown. PURPOSE: The authors report the prevalence of LT tears in a population of patients who underwent hip arthroscopy, using both the Gray and Villar classification and a new descriptive classification. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Between February 2008 and January 2011, 616 hip arthroscopies were performed by the senior author. After excluding revision surgeries, a total of 558 surgeries (502 patients) were included in the study. Data were collected regarding patients' demographics, mechanism of injury, range of motion, magnetic resonance results, and intraoperative findings. Preoperative hip-specific questionnaire scores and pain level were recorded as well. Ligamentum teres tears were classified according to Gray and Villar's classification, and were also categorized using a descriptive grading system as follows: 0, no tear; 1, <50% tear; 2, >50% tear; or 3, 100% tear. RESULTS: A total of 284 (51%) of the 558 surgeries in this cohort revealed LT tears. According to the descriptive grading system, 22% were grade 1, 24% were grade 2, and 5% were grade 3. According to the Gray and Villar classification 3.7% had full rupture, 43% had a partial tear, and 4.5% had a degenerative tear. Patients with LT tears were significantly older and had worse preoperative functional scores; they did, however, have a greater range of motion. Intraoperatively, an association with larger labral tear size and acetabular chondral damage was found. Magnetic resonance arthrography was found to have low accuracy and sensitivity in detection of LT tears. No correlation to the pain level was found. CONCLUSION: Ligamentum teres tears had a higher prevalence in this study than was published in the past, most probably attributable to a lower threshold used in defining a tear. The incidence is defined both using the Gray and Villar classification, as well as a new descriptive classification system that categorizes the LT according to amount of tearing.

Open surgical dislocation versus arthroscopy for femoroacetabular impingement: a comparison of clinical outcomes.

PURPOSE: Over the last decade, the surgical treatment of femoroacetabular impingement (FAI) has evolved as surgical techniques through arthroscopy, open surgical dislocation, and combined approaches have been developed. The purpose of this systematic review was to evaluate and compare the clinical results of available surgical approaches for FAI. METHODS: A review of the literature was performed through the PubMed database and related articles' reference lists. Inclusion criteria were (1) all patients treated for FAI, (2) Level I, II, III, or IV study design, and (3) written in the English language. Case reports and studies involving patients with acetabular dysplasia were excluded. RESULTS: Overall, 1,299 articles fit our keyword search criteria. Of these, 26 articles reported clinical outcomes, using 3 surgical modalities: open surgical dislocation, arthroscopic, and combined approaches. In compiling the data in these articles, we analyzed the outcomes of a total 1,462 hips in 1,409 patients. The most published surgical method was arthroscopy, which included 62% of the patients. Labral repair was performed more frequently in open surgical dislocation (45%) and combined approach (41%) procedures than in arthroscopies (23%). Mean improvement in the modified Harris hip score after surgery was 26.4 for arthroscopy, 20.5 for open surgical dislocation, and 12.3 for the combined approach. A higher rate of return to sport was reported for arthroscopy in professional athletes than for open surgical dislocation. Overall complication rates were 1.7% for the arthroscopic group, 9.2% for the open surgical dislocation group, and 16% in the combined approach group. CONCLUSIONS: All 3 surgical approaches led to consistent improvements in patient outcomes. Because a wide variety of subjective hip questionnaires were used, direct comparisons could not be made in many cases, and none of the approaches could be clearly shown to be superior to the others. However, it seems that, overall, the arthroscopic method had the lowest complication and fastest rehabilitation rate.