Eighteen-year outcome of anterior cruciate ligament reconstruction with patellar tendon or hamstring autograft.

PURPOSE: To evaluate patient reported outcomes and radiographic arthritic changes of transtibial anterior cruciate ligament reconstruction (ACLR) with either bone-patellar tendon-bone (BPTB) or hamstrings (HS) auto-grafts at a minimum of 15-year follow-up. METHODS: Ninety-four patients (51 of the HS group, 43 of BPTB group) who were operated between the years 2000 to 2005 in two tertiary referral hospitals were contacted and invited to a retrospective evaluation. The interview included subjective outcomes using the Lysholm knee scoring questionnaire, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Tegner activity level scale, Visual Analogue Scale (VAS) for pain and patients' satisfaction scale. Knee examination included measurements of motion and stability. Knee radiographs were evaluated for osteoarthritic changes according to the Kellgren-Lawrence (KL) score. RESULTS: The average evaluation time from surgery was 18.6 years. Subjectively, there was no significant difference between groups except for a better post-operative level of activity and satisfaction in the HS group. Objectively, there was no significant difference between groups in knee stability and range of motion. Most patients had grade KL ≤ 1 radiographic osteoarthritits changes and there was no significant difference between groups. Recurrent complete tear of the reconstructed graft occurred in 3 patients of each group. In both groups 84% had no further surgery while the indications for further surgery were mostly a meniscal tear or tibial hardware removal. CONCLUSIONS: Very long-term outcomes and clinical stability of transtibial HS or BPTB graft ACL reconstruction are good with low rate of graft failure and radiographic osteoarthritis.

Pearls and pitfalls of PROMIS clinically significant outcomes in orthopaedic surgery.

INTRODUCTION: Patient-Reported Outcome Measurement Information System (PROMIS) was developed as a uniform and generalizable PROM system using item response theory and computer adaptive testing. We aimed to assess the utilization of PROMIS for clinically significant outcomes (CSOs) measurements and provide insights into its use in orthopaedic research. MATERIALS AND METHODS: We reviewed PROMIS CSO reports for orthopaedic procedures via PubMed, Cochrane Library, Embase, CINAHL, and Web of Science from inception to 2022, excluding abstracts and missing measurements. Bias was assessed using the Newcastle-Ottawa Scale (NOS) and questionnaire compliance. PROMIS domains, CSO measures, and study populations were described. A meta-analysis compared distribution and anchor-based MCIDs in low-bias (NOS ≥ 7) studies. RESULTS: Overall, 54 publications from 2016 to 2022 were reviewed. PROMIS CSO studies were observational with increasing publication rates. Evidence-level was II in 10/54, bias low in 51/54, and compliance ≥ 86% in 46/54. Most (28/54) analysed lower extremity procedures. PROMIS domains examined Pain Function (PF) in 44/54, Pain Interference (PI) in 36/54, and Depression (D) in 18/54. Minimal clinically important difference (MCID) was reported in 51/54 and calculated based on distribution in 39/51 and anchor in 29/51. Patient acceptable symptom state (PASS), substantial clinical benefit (SCB), and minimal detectable change (MDC) were reported in ≤ 10/54. MCIDs were not significantly greater than MDCs. Anchor-based MCIDs were greater than distribution based MCIDs (standardized mean difference = 0.44, p < 0.001). CONCLUSIONS: PROMIS CSOs are increasingly utilized, especially for lower extremity procedures assessing the PF, PI, and D domains using distribution-based MCID. Using more conservative anchor-based MCIDs and reporting MDCs may strengthen results. Researchers should consider unique pearls and pitfalls when assessing PROMIS CSOs.

The meniscotibial ligament role in meniscal extrusion: a systematic review and meta-analysis.

INTRODUCTION: The meniscotibial ligament (MTL) limits extrusion of the medial meniscus (MM). While meniscal extrusion may be detrimental to knee joint biomechanics, the role of the MTL in meniscal extrusion is debatable. We sought to perform a systematic review and meta-analysis to evaluate the role of the MTL and surgical techniques for MTL repair. MATERIALS AND METHODS: Following Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines we searched PubMed, Cochrane Library, and Embase for: (("Meniscotibial") OR ("Coronary") OR ("Ramp")) AND ("Extrusion"). After screening and applying eligibility criteria, data were extracted for MTL pathology types ("traumatic" ruptures or "induced" injuries) and meniscal extrusion. A meta-analysis evaluated the mean difference of extrusion between "intact" MTLs (native or repaired) and "injured" MTLs (induced or traumatic). We further performed a subgroup analysis between traumatic and induced MTL lesions. RESULTS: This systematic review included six studies, which all evaluated MM extrusion. There were 74 knees with induced MTL injuries and 19 knees with traumatic MTL ruptures. Study designs were heterogenic and utilized three types of MTL repair procedures. The meta-analysis included 18 human knees and revealed that sectioning the MTL created a 2.92 mm [- 0.18 to 6.03] MM extrusion, while MTL repair decreased MM extrusion by - 2.11 mm [- 3.03 to - 1.21]. CONCLUSIONS: MTL injury may result in approximately 3 mm of MM extrusion, while repair of the MTL can decrease extrusion by 2 mm. Several novel surgical techniques exist to repair the MTL. However, studies reporting clinical outcomes of these various procedures are scarce.

[SEPTIC KNEE - DIAGNOSIS AND TREATMENT].

INTRODUCTION: Acute septic arthritis of the knee joint is an orthopedic emergency, potentially devastating, which can lead to high morbidity and may even be life-threatening. While any synovial joint can be infected, the knee is the most often affected joint and is involved in about 50 % of the cases. The infection is usually caused by a gram-positive bacteria. The diagnosis is made by synovial fluid aspiration, microbiological analysis and hematological investigations of inflammatory measures. Treatment requires emergency irrigation and debridement of the joint, and intravenous antibiotics. Surgical debridement can be performed either arthroscopically or via open arthrotomy. In recent years, arthroscopic treatment demonstrated more favorable outcomes with better functional outcomes, shorter operative time and hospital stays.

Individualized tibial tubercle-trochlear groove distance-to-patellar length ratio (TT-TG/PL) is a more reliable measurement than TT-TG alone for evaluating patellar instability.

PURPOSE: To evaluate the intra/inter-rater and diagnostic reliability of the sagittal plane adjusted patellar instability ratios (PIRs) compared to tibial tubercle-trochlear groove (TT-TG) distance alone while employing a matched case-control analysis for age and sex to minimize a potential confounding effect. METHODS: A retrospective case-control study was performed of all knee MRI studies of patients diagnosed with patellar instability, between 2005 and 2020 at a regional tertiary medical centre. Using a 1:1 case-control matching of sex and age at the time of the diagnosis, one control subject was assigned to each case of patellar instability. Measurements of TT-TG distance, sagittal patellar length (PL), sagittal patellar tendon length (PTL), TT-TG/PL ratio, and TT-TG/PTL ratio were conducted. Two orthopaedic surgery residents and a senior musculoskeletal radiologist were assigned to assess the intra- and inter-rater reliability. Inter-class coefficients were calculated (ICC). The receiver operating characteristic (ROC) curve and area under curve (AUC) for each parameter were compared to evaluate for diagnostic reliability. Odds ratios (OR) and their 95% confidence intervals (CI) were calculated and a multivariable logistic regression model was performed to control for possible confounders. RESULTS: The study included 324 individuals (162 case-control matched pairs). In terms of intra- and inter-rater reliability, TT-TG/PL and TT-TG/PTL ratios showed an excellent correlation within and between readers (TT-TG/PL; intra-rater ICC 0.94 and inter-rater ICC 0.92, TT-TG/PTL; intra-rater ICC 0.91 and inter-rater ICC 0.88). The ROC curve showed a slightly greater AUC of the TT-TG/PL ratio compared to TT-TG distance alone (0.75 vs 0.73, p < 0.001). When applying the pathologic cutoff of TT-TG ≥ 20 mm and TT-TG/PL ≥ 0.5; the calculated odds ratios for the above cutoff were as follows; TT-TG distance alone had an OR of 14 (95% CI 1.8-106.5, p = 0.011) and OR for TT-TG/PL ratio was 23 (95% CI 3.1-170.3, p = 0.002). In the multivariable analysis, while controlling for height and weight, only the association between TT-TG/PL ratio and patellar dislocation remained statistically significant with an adjusted OR of 2.7 (CI 1.3-5.4, p = 0.006), compared to TTTG distance alone (OR = 1.9, n.s.). CONCLUSIONS: Patellar instability ratios are significantly more reliable compared to TT-TG distance alone for the evaluation of patellar instability. Patellar instability ratios present superior diagnostic reliability, sensitivity and specificity, and intra\inter rater reliability. Thus, patellar instability ratios could function as a valuable diagnostic tool for the evaluation of patellar instability. LEVEL OF EVIDENCE: III.

The impact of body mass index on the accuracy of the physical examination of the knee.

PURPOSE: Obesity is a worldwide pandemic; however, no adaptations were made to the physical examination of obese patient's knees. The accuracy of the physical examination is critical for correct assessment and selection of treatment. We aimed to assess whether body mass index (BMI) affects the sensitivity and specificity of common provocative knee tests. METHODS: We studied 210 patients who underwent knee arthroscopy to treat anterior cruciate ligament (ACL) and meniscal pathologies. BMI and the knee's physical examination were documented pre-operatively. Sensitivity, specificity, and accuracy of ACL and meniscal provocative tests in relation to BMI were evaluated using arthroscopy as a gold standard. RESULTS: The Anterior Drawer, Lachman, and Pivot-Shift tests for ACL tears were significantly less accurate and sensitive, yet more specific, in obese patients when compared to normal and overweight patients. The McMurray, Apley Grind, and Thessaly tests for medial meniscus tears showed greater sensitivity, but lower specificity, in patients with increased BMI. Above normal BMIs, independently of age and gender, were significantly associated with higher odds for positive ACL tests. CONCLUSION: Tests for ACL tears are less sensitive in obese patients and alternatives to the classic tests should be considered. Medial meniscus tests tend to be more sensitive and less specific in patients with greater BMIs. Their results should be carefully interpreted due to possible false positives. The physician should take into consideration the impact of patient BMI on the accuracy of their physical examination of the knee to optimize treatment decision-making.

T2 Mapping Values in Postmeniscectomy Knee Articular Cartilage after Running: Early Signs of Osteoarthritis?

Loading on the joints during running may have a deleterious effect on post-partial meniscectomy knee cartilage, leading to osteoarthritis. Utilizing T2-mapping measurements before and after running may enable the observation of changes in the articular cartilage of the postmeniscectomy knees compared with healthy knees. After medial partial meniscectomy, 12 volunteers underwent magnetic resonance imaging (MRI) of the both knees, before and immediately after 30 minutes of running. Quantitative assessment of articular cartilage was performed using a T2-mapping technique. In the medial compartment of the operated knees, significantly lower T2 values were found in anterior tibial plateau (pre- vs. postrun: 33.85 vs. 30.45 ms; p = 0.003) and central tibial plateau (33.33 vs. 30.63 ms; p = 0.007). Similar differences were found in lateral regions of central femur (post- vs. prerun: 35.86 vs. 40.35 ms; p = 0.015), posterior femur (34.89 vs. 37.73 ms; p = 0.001), and anterior tibia (24.66 vs. 28.70 ms, p = 0.0004). In lateral compartment, postrun values were significantly lower in operated compared with healthy knees, in central femur (34.89 vs. 37.59 ms; p = 0.043), posterior femoral (36.88 vs. 39.36 ms; p = 0.017), anterior tibia (24.66 vs. 30.20 ms; p = 0.009), and posterior tibia (28.84 vs. 33.17 ms; p = 0.006). No statistical difference was found while comparing postrun to prerun healthy knees. Lower T2 values were found in operated knees after 30 minutes of running. These changes were seen in medial and lateral compartments. We suspect that running may subject the articular cartilage to excessive loads in the post-partial meniscectomy knee, loads that in healthy knee do not cause any changes.

Height Gain Prediction in Adolescent Idiopathic Scoliosis Based on Preoperative Parameters.

BACKGROUND: The purpose of the study was to identify preoperative parameters which are associated with height gain after corrective surgery for adolescent idiopathic scoliosis (AIS) and their use to preoperatively quantify the potential for height gain after AIS correction. METHODS: Our study included 87 consecutive patients with AIS who underwent posterior fusion. Patients' height was measured the day before surgery and before their discharge. Demographic and radiologic variables were analyzed for predictability of height gain. RESULTS: The mean height gain was 3.85 cm. We have found a statistically significant correlation between height gain and the following measures: preoperative thoracic curve, preoperative thoracolumbar curve, preoperative thoracic kyphosis, flexibility of the main thoracic and thoracolumbar curves, and number of fused levels (all P<0.05). Patients with Lenke type 1 and 2 had statistically less height gain compared with patients with Lenke type 3, 4, 6. CONCLUSION: Most of the scoliosis patients with Lenke type 1 and 2 will gain up to 3 cm after surgery while most of the patients with Lenke type 3, 4, 6 will gain more than 3 cm. Most patients with Lenke type 3, 4, 6 with a major curve of less than 60 degrees will gain up to 4 cm, while most of those with a major curve of more than 60 degrees will gain more than 4 cm. Patient with a positive thoracic sagittal modifier tend to have more height gain after surgery.

Arthroscopic management of greater trochanter pain syndrome and abductor tears has demonstrated promising results in terms of improvement in pain scores and functional outcomes: a scoping review.

PURPOSE: Greater trochanteric pain syndrome (GTPS) refers to the constellation of signs and symptoms related to pain in the trochanteric region and has recently replaced the previously ubiquitous term of 'greater trochanteric bursitis'. GTPS is common, particularly in women 50-79 years of age, and the understanding and management of GTPS have expanded considerably in recent years to include management with arthroscopic and endoscopic techniques in recalcitrant cases. The purpose of this scoping literature review was to summarize the current evidence on arthroscopic management of GTPS including sources of evidence, key concepts, and gaps in the literature. METHODS: A thorough electronic database search included studies published from 2009 to June 14, 2020. A total of 52 peer-reviewed articles were identified within the literature on arthroscopic or endoscopic management of GTPS. RESULTS: Of the 52 identified papers, 12 were technique descriptions, 10 papers were review articles, and 30 papers were original clinical papers. Of the 30 clinical papers, 24 (80%) were of level IV evidence, 5 (17%) were of level III evidence, and 1 (3%) was level II evidence. Among the 30 clinical studies, 988 patients were included with 761 (77%) female. Indications for surgical management included a failed trial of conservative management in all 30 studies, typically after a period of 3-6 months. Surgical management consisted of arthroscopic/endoscopic abductor tendon repair in 16 (53%) studies, arthroscopic/endoscopic bursectomy and iliotibial band release in 12 (40%) studies, and arthroscopic/endoscopic gluteal tendon contracture release in 2 (7%) studies. CONCLUSION: Overall, results following arthroscopic management of GTPS and abductor tears have been promising, including significantly improved pain scores and functional outcomes at final post-operative assessment. These studies support continued use and investigation of arthroscopic management strategies of GTPS and pave the way to conduct larger prospective studies to confirm these results in the future. LEVEL OF EVIDENCE: IV.

Avoiding Injury to the Popliteal Neurovascular Bundle in All-Inside Suturing of the Posterior Horn of the Lateral Meniscus: A Magnetic Resonance Imaging Assessment of Portal Selection and Safety.

PURPOSE: We assessed the risk of injury to the popliteal neurovascular bundle (PNVB) while suturing the posterior horn of the lateral meniscus (PHLM). METHODS: We simulated all-inside suturing of the PHLM using magnetic resonance imaging of 60 knees. Lines were drawn from the medial and the lateral edges of the patellar tendon to the PHLM at increasing distances from the posterior cruciate ligament (PCL) to simulate suturing device trajectory. Distance from each line to the PNVB was measured (d). A similar analysis was performed using lines drawn from 1 cm medial and 1 cm lateral to the patellar tendon. We compared the average "d" at increasing distances from the PCL, between the different simulated portal entry points. We have also analyzed the association between different demographic characteristics and the shortest distance from the PVNB to the PHLM. RESULTS: Of 1200 measurements performed, the simulated suturing trajectory transected the PNVB 343 times (28.6%). At 0 mm from the PCL, the safest portal was the 1-cm lateral portal (P < .001), with an average "d" of 2.7 mm. At 3 mm, 6 mm, 9 mm, and 12 mm from the PCL, the safest portal was the 1-cm medial portal (P < .001), with average "d" of 3.8 mm, 6.9 mm, 10.1 mm, and 13.5 mm, respectively. Average distance between the PHLM and the PNVB was 7.8 mm. Shorter distance between the PHLM and the PNVB was associated with younger age and female sex (P = .014 and .001, respectively). CONCLUSIONS: All-inside suturing of the PHLM at 0 mm from the PCL is safer with a more lateral portal. Beyond 3 mm from the PCL, a more medial portal carries a lower risk to the PNVB. Young and female patients have a shorter distance between the PHLM and the PNVB, suggesting a greater risk for injury to the PNVB. Careful preoperative magnetic resonance imaging assessment may assist in safer portal selection when planning repair of the PHLM. CLINICAL RELEVANCE: This study describes a magnetic resonance imaging-based risk assessment for injury of the PVNB while suturing the PHLM. It allows the orthopaedic surgeon a better understanding of the anatomic relationship between the popliteal neurovascular bundle and the lateral meniscus and can assist in portal selection and safety.

Preoperative Delayed Gadolinium-Enhanced Magnetic Resonance Imaging of Cartilage (dGEMRIC) for Patients Undergoing Hip Arthroscopy: Indices Are Predictive of Magnitude of Improvement in Two-Year Patient-Reported Outcomes.

BACKGROUND: Delayed gadolinium-enhanced magnetic resonance imaging of cartilage (dGEMRIC) has been used in the detection of chondropathy. Our study aimed to determine whether dGEMRIC indices are predictive of two-year patient-reported outcomes and pain scores following hip arthroscopy. METHODS: Between August 2008 and April 2012, sixty-five patients (seventy-four hips) underwent primary hip arthroscopy with preoperative dGEMRIC and a minimum of two years of follow-up. Exclusion criteria were previous hip surgery, slipped capital femoral epiphysis, inflammatory arthropathy, Legg-Calvé-Perthes disease, and arthritis of >1 Tönnis grade. Patients were classified in two groups on the basis of a dGEMRIC cutoff of 323 msec, which was one standard deviation (SD) below the study cohort mean dGEMRIC index of 426 msec. Patient-reported outcome tools used included the modified Harris hip score (mHHS), the Nonarthritic Hip Score (NAHS), the Hip Outcome Score Activities of Daily Living (HOS-ADL), and the Hip Outcome Score Sport-Specific Subscale (HOS-SSS) as well as a visual analog scale (VAS) for pain and a patient satisfaction score. RESULTS: There were sixty-four hips that met the inclusion criteria; fifty-two (81.3%) had a minimum of two years of follow-up. Twelve of the sixty-four hips had a dGEMRIC index of <323 msec (Group 1), and fifty-two hips had a dGEMRIC index of ≥323 msec (Group 2). There was no significant difference between the groups with respect to age, sex, and body mass index. There was no significant difference between the groups in mean preoperative patient-reported outcome scores and the VAS for pain. At the two-year follow-up, Group 1 had significant improvement in the mHHS, whereas Group 2 demonstrated significant improvement in all patient-reported outcome scores and the VAS. The improvement in all patient-reported outcome scores was significantly larger for Group 2 compared with Group 1. There was no significant difference in patient satisfaction between groups and no significant correlation between dGEMRIC indices and the patient-reported outcome measures. CONCLUSIONS: Patients with a dGEMRIC index of ≥323 msec (less than one SD below the cohort mean) demonstrated significantly greater improvement in patient-reported outcome scores and the VAS for pain after hip arthroscopy.

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.

Does obesity affect outcomes after hip arthroscopy? A cohort analysis.

BACKGROUND: Obesity presents a challenging problem in surgical treatment and has led to poorer postoperative outcomes. The purpose of this study was to evaluate whether hip arthroscopy in the obese patient influences postoperative clinical and patient-reported outcome scores. METHODS: From February 2008 to February 2012, data were collected prospectively on all patients undergoing primary hip arthroscopy. A total of 680 patients were included. All patients were assessed preoperatively and postoperatively with four patient-reported outcome measures. Pain was estimated on the visual analog scale. The patient satisfaction score was measured. Three groups were stratified by body mass index. The non-obese group, those with a body mass index of <30 kg/m(2) (mean, 23.61 kg/m(2)), included 562 patients with a mean age of 34.78 years. The class-I obese group, those with a body mass index of ≥30 to 34.9 kg/m(2) (mean, 33.85 kg/m(2)), included ninety-four patients with a mean age of 44.02 years. The class-II obese group, those with a body mass index of ≥35 to 39.9 kg/m(2) (mean, 39.11 kg/m(2)), included twenty-four patients with a mean age of 39.33 years. RESULTS: In the non-obese group, the score improvement from the preoperative assessment to the two-year follow-up visit was 63.41 to 83.81 points for the modified Harris hip score, 60.86 to 83.62 points for the Non-Arthritic Hip Score, 66.24 to 86.24 points for the Hip Outcome Score Activities of Daily Living, and 44.01 to 73.26 points for the Hip Outcome Score Sport-Specific Subscale. In the class-I obese group, the score improvement from the preoperative assessment to the two-year follow-up visit was 54.81 to 75.95 points for the modified Harris hip score, 48.98 to 72.51 points for the Non-Arthritic Hip Score, 53.22 to 72.99 points for the Hip Outcome Score Activities of Daily Living, and 30.56 to 60.75 points for the Hip Outcome Score Sport-Specific Subscale. In the class-II obese group, the score improvement from the preoperative assessment to the two-year follow-up visit was 50.81 to 80.01 points for the modified Harris hip score, 42.36 to 72.50 points for the Non-Arthritic Hip Score, 48.11 to 74.73 points for the Hip Outcome Score Activities of Daily Living, and 28.25 to 62.56 points for the Hip Outcome Score Sport-Specific Subscale. Traction time did not vary significantly between groups (p < 0.05). CONCLUSIONS: Our study demonstrated that obese patients started with lower absolute scores preoperatively and ended with lower overall absolute postoperative scores. However, obese patients showed substantial benefit from hip arthroscopy and demonstrated a degree of improvement that was similar to that of the control non-obese group.

Effect of femoral anteversion on clinical outcomes after hip arthroscopy.

PURPOSE: To compare the clinical outcomes after hip arthroscopy of patients with femoral retroversion, normal femoral version, and excessive femoral anteversion. METHODS: Patients who underwent primary hip arthroscopy from August 2008 to April 2011 and underwent femoral anteversion measurement by magnetic resonance imaging/magnetic resonance arthrogram were included. The patients were divided into 3 groups: retroversion, normal version, and excessive anteversion. The normal-version group was considered to have a value within 1 SD of the mean femoral version value. Four patient-reported outcome scores and the visual analog pain score were prospectively collected with analysis performed retrospectively. RESULTS: Two hundred seventy-eight patients met the inclusion criteria. Among these patients, mean anteversion was 8.2° ± 9.3°, creating a retroversion group defined as -2° or less and an anteversion group defined as 18° or greater. There were 25 patients in the retroversion group, 219 in the normal-version group, and 34 in the excessive-anteversion group. Most labral tears were noted in the 12- to 2-o'clock range, with the main difference at the anterior 3-o'clock position, where the excessive-anteversion group showed a lower incidence of tearing (30%) than the retroversion group (73%) and normal-anteversion group (78%). Postoperatively, there was a statistically significant improvement from preoperative scores in all 3 groups and for all scores (P < .001). When the postoperative scores were compared for the 3 groups, although all scores were higher in the retroversion group than in the other 2 groups, this was not statistically significant and there were no significant differences in scores among the 3 groups (modified Harris Hip Score, P = .104; Non-Arthritic Hip Score, P = .177; Hip Outcome Score-Activities of Daily Living, P = .152; Hip Outcome Score-Sport-Specific Subscale, P = .276; visual analog scale score, P = .508). CONCLUSIONS: On the basis of patient-reported outcome scores without accounting for diagnoses and treatments, the amount of femoral anteversion does not appear to affect the clinical outcomes after hip arthroscopy. LEVEL OF EVIDENCE: Level III, retrospective comparative 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.

An unusual case of leg pain in a competitive cyclist: a case report and review of the literature.

Cycling has become a popular recreational and competitive sport. The number of people participating in the sport is gradually increasing. Despite being a noncontact, low-impact sport, as many as 85% of athletes engaged in the sport will suffer from an overuse injury, with the lower limbs comprising the majority of these injuries. Up to 20% of all lower extremity overuse injuries in competitive cyclists are of a vascular source. A 39-year-old competitive cyclist had a 5-year history of thigh pain during cycling, preventing him from competing. The patient was eventually diagnosed with external iliac artery endofibrosis. After conservative treatment failed, the patient underwent corrective vascular surgery with complete resolution of his symptoms and return to competitive cycling by 1 year. Since its first description in 1985, there have been more than 60 articles addressing external iliac artery endofibrosis pathology.

Arthroscopic hip surgery with a microfracture procedure of the hip: clinical outcomes with two-year follow-up.

BACKGROUND: Outcome studies assessing a cohort of patients receiving microfracture in the hip have focused on second look arthroscopy and return to sport, which have shown favourable results in the absence of osteoarthritis. Few studies exist focusing on clinical outcomes after microfracture in the hip using patient reported outcome (PRO) scores. The purpose of this study is to evaluate two-year clinical outcomes of a series of patients treated with microfracture during arthroscopic hip surgery using PRO scores. METHODS: During the study period, all workers' compensation (WC) and non-WC patients treated with microfracture during arthroscopic hip surgery were included. Four PRO scores, pain scores and satisfaction were used to assess clinical outcomes. Any revision surgeries or conversions to total hip arthroplasty (THA) were noted. Location of microfracture procedure, lesion size and additional variables assessed survivorship. RESULTS: Thirty-seven cases met the inclusion/exclusion criteria, of which 30 patients (30/37, 81%) were available for minimum two-year follow-up. Twenty-six patients were classified as survivors. Preoperative scores for patients with WC status were lower than non-WC patients and statistically significant (p<0.5) for three of the PROs. However, changes in all four PRO measurements demonstrated statistically significant improvements from preoperative to two-year follow-up for both compensation groups (p<0.05). The amount of change in PRO scores for both compensation groups was similar and not statistically significant. Two patients required THA and two patients required revision arthroscopy. CONCLUSION: Our study demonstrates statistically significant clinical improvement in PRO's after receiving microfracture during arthroscopic hip surgery at minimum two-year follow-up.

Sex-Based Differences in the Clinical Presentation of Patients With Symptomatic Hip Labral Tears.

BACKGROUND: An increasing body of literature describes the clinical presentation and demographics of patients with hip labral tears. The differences in pelvic structure and joint laxity between sexes have been described; however, no study has evaluated differences in the clinical presentation of patients with symptomatic labral tears between sexes. PURPOSE: To describe the differences between sexes in demographics, clinical history, physical examination, and intraoperative findings in patients with symptomatic labral tears. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Data were prospectively collected between February 2008 and February 2013 on 1401 patients who had symptomatic labral tears and underwent arthroscopic surgery. Hips with previous pathologic disorders were excluded. Data on demographics and clinical history were gathered, and a physical examination was performed. Preoperative pain was estimated on the visual analog scale (VAS), and 4 hip-specific patient-reported outcomes (PROs) were administered to evaluate functional status. Intraoperative findings were recorded. RESULTS: A total of 654 patients met our inclusion/exclusion criteria, with 320 males and 334 females. The median age for males was 38.3 years (range, 15.0-69.6 years) and for females 40.4 years (range, 13.1-66.8 years). Male patients had a higher incidence of acute injury than females (39.6% vs 27.6%, respectively; P < .05) and a higher incidence of workers' compensation status (14.1% vs 4.5%, respectively; P < .05). Females had increased range of motion compared with males, which was statistically significant for all range of motion measurements (P < .05). The anterior impingement test was positive in 94.4% of females and 92.9% of males, the flexion/abduction/external rotation test was positive in 59.5% of females and 61.5% of males, and the lateral impingement test was positive in 55.0% of females and 59.2% of males, but there was no statistically significant difference between sexes in any of the tests. Pain with palpation over the greater trochanter was positive in 22.0% of males and 36.9% of females (P < .0001). Females had lower PROs; however, VAS scores were similar. CONCLUSION: Male and female patients differ in their hip structure, biomechanics, and operative findings of symptomatic labral tears. However, they do not differ substantially in clinical presentation, except that males are more likely to report an acute injury and females are more likely to be evaluated with increased range of motion.

Radiographic, histologic, and arthroscopic findings in amorphous calcifications of the hip labrum.

PURPOSE: The purpose of this study was to evaluate the clinical, radiographic, histologic, and intraoperative findings of an amorphous calcification involving the acetabular labrum. METHODS: From October 2008 to April 2013, all patients who underwent arthroscopic hip surgery for symptomatic intra-articular hip disorders and were found to have the characteristic calcific deposit involving the acetabular labrum were included. These patients were reviewed retrospectively on prospectively collected data. Radiographs were retrospectively evaluated for morphologic features of impingement and characteristics of labral calcification. RESULTS: Sixteen patients were identified as having amorphous calcification at the time of arthroscopy. There were 15 women and 1 man. Mean age was 37.3 years (range, 30 to 50 years). Symptoms were present for a mean of 9.3 months (range, 3 to 48 months). All patients reported anterior groin pain. Fifteen (94%) patients had positive anterior impingement and 9 (56%) had positive results for lateral impingement. Calcifications measured on average 3.2 mm (range, 1.9 mm to 5.6 mm), and 14 had a clear separation from the rim with increased opacity compared with neighboring trabecular bone. Intraoperatively, the characteristic amorphous calcium deposit was located in the anterosuperior labrum, with the deposit found to be accessible from the capsule-labral recess in all cases. All patients had labral tears and all patients had at least one component of femoroacetabular impingement (FAI). CONCLUSIONS: Calcification in the anterosuperior acetabular labrum presents with a consistent patient demographic and distinct radiographic and arthroscopic presentation that is different from os acetabuli. As with os acetabuli, one should have a high suspicion for FAI when this lesion is encountered. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Revision hip preservation surgery with hip arthroscopy: clinical outcomes.

PURPOSE: To analyze and report the clinical outcomes of a cohort of patients who underwent revision hip preservation with arthroscopy and determine predictors of positive and negative outcomes. METHODS: During the study period from April 2008 to December 2010, all patients who underwent revision hip preservation with arthroscopy were included. This included patients who had previous open surgery and underwent revision with arthroscopy. Patient-reported outcome (PRO) scores were obtained preoperatively and at 3-month, 1-year, 2-year, and 3-year follow-up time points. Any revision surgeries and conversions to total hip arthroplasty were noted. A multiple regression analysis was performed to look for positive and negative predictive factors for improvement in PROs after revision hip arthroscopy. RESULTS: Forty-seven hips in 43 patients had completed 2 years' follow-up or needed total hip arthroplasty. The mean length of follow-up was 29 months (range, 24 to 47 months). Of the hips, 31 (66%) had either unaddressed or incompletely treated femoroacetabular impingement. There was a significant improvement in all PRO scores at a mean of 29 months after revision (P < .0001). The visual analog scale score improved from 7.3 ± 1.5 to 3.9 ± 2.5 (P < .0001). Improvements in the Non-Arthritic Hip Score of at least 10 points and 20 points were found in 28 hips (65%) and 19 hips (44%), respectively. Four hips in 3 patients required conversion to total hip arthroplasty. Positive predictive factors for PRO improvement were previous open surgery, pincer impingement, cam impingement, symptomatic heterotopic ossification, and segmental labral defects treated with labral reconstruction. CONCLUSIONS: On the basis of multiple PROs, revision hip preservation with hip arthroscopy can achieve moderately successful outcomes and remains a viable treatment strategy after failed primary hip preservation surgery. Preoperative predictors of success after revision hip arthroscopy include segmental labral defects, unaddressed or incompletely addressed femoroacetabular impingement, heterotopic ossification, and previous open surgery. LEVEL OF EVIDENCE: Level IV, therapeutic case series.