Total volume of cam deformity alone predicts outcome in arthroscopy for femoroacetabular impingement.

PURPOSE: Rates for arthroscopic surgery for femoroacetabular impingement (FAI) are rising and there is growing concern related to the effectiveness and costs associated with this treatment. There is a general lack of consensus as to the criteria for surgical selection of patients. The purpose of this study was to determine whether patient outcome following arthroscopic surgery for FAI could be predicted based on the size and location of deformity. The specific questions were: (1) what is the morphology of FAI in terms of size and location of deformity in a cohort of patients selected for surgery? (2) Do morphological factors predict postoperative improvement in hip scores? (3) Do morphological factors predict preoperative hip scores? (4) Are there clusters of morphological factors which explain postsurgical improvement in hip scores? MATERIALS AND METHODS: Computer tomography (CT) surgical plans of 90 hips in 79 patients who had undergone primary hip arthroscopy for FAI were retrospectively reviewed. Four parameters for the femur and acetabulum were created: total depth of deformity, maximal depth, extent and the position of maximal deformity. This data were compared with prospectively acquired preoperative and postoperative patient outcome data using generalised linear models. RESULTS: The cohort comprised 33 males and 46 females aged 37.9 (18-61). The majority (74%) had mixed morphology, 23% isolated cam, and 3% isolated pincer. Overall, the bone depth was greatest and more extensive on the femur. Increased total additional cam deformity alone predicted poorer postoperative outcome (p = 0.045). None of the morphological factors were related to preoperative scores and there was no association between the meta-variables and postoperative outcome. CONCLUSIONS: The results of this study indicate that a greater total volume of cam deformity led to poorer postoperative patient outcome scores at 1 year. This information provides the surgeon with more accurate patient-specific data for prediction of expected outcomes. LEVEL OF EVIDENCE: Level III diagnostic.

Musculoskeletal Injury in Paddle Sport Athletes.

INTRODUCTION: Kayak racing has been an Olympic sport since 1936. The sport is evolving with the introduction of ocean skis and stand-up-paddle boards (SUP). Musculoskeletal injury incidence surveys have been conducted for ultra-marathon events, but no data have been published for other racing formats. OBJECTIVE: To identify and compare the rates and types of injuries sustained by paddling athletes as a function of discipline and training parameters in Sprint, Marathon, Ultra-Marathon, and Ocean events. METHODS: Competitors from 6 kayak and/or ocean surf-ski races in Australia were surveyed. Before each race, competitors were asked to complete a questionnaire. The questionnaire investigated paddling-related injuries over the previous 5 years, athlete morphology, flexibility, equipment and its setup, training volume, and environment. RESULTS: Five hundred eighty-three competitors were surveyed. Disciplines included 173 racing-kayak (K1), 202 touring-kayak, 146 ocean-skis, 42 SUP, and 20 other. The top 5 paddling-related injuries were shoulder (31%), low back (23.5%), wrist (16.5%), neck (13.7%), and elbow (11.0%). The highest percentage of injury was found in K1 paddlers for shoulder (40.5%), SUP for low back (33.3%), and ocean-ski for wrist (22.6%). After controlling for on-water training hours, the relative risk (RR) of wrist injury was significantly increased in ocean-ski paddlers (1.86) and in paddlers with decreased flexibility (1.53-1.83). Relative risk of shoulder and low-back injury was significantly increased in athletes with lower training volumes (1.82-2.07). Younger athletes had lower RR of wrist and shoulder injury (0.58-0.62).

Supervised or Unsupervised Rehabilitation After Total Hip Replacement Provides Similar Improvements for Patients: A Randomized Controlled Trial.

OBJECTIVE: To determine whether patients do better with unsupervised (home-based) physiotherapy or in an outpatient setting. SETTING: Acute care public hospital in the region, supporting a population of ∼540,000. DESIGN: Single-blind randomized controlled trial. PARTICIPANTS: Adult patients (N=98) after unilateral elective total hip replacement (THR) were randomly assigned to a supervised (center-based) exercise (n=56) or a unsupervised (home-based) exercise (n=42) program and followed for 6 months postsurgery. INTERVENTIONS: The supervised group attended a 4-week outpatient rehabilitation program supervised by a physiotherapist. The unsupervised group was given written and pictorial instructions to perform rehabilitation independently at home. MAIN OUTCOME MEASURES: Western Ontario and McMaster Universities Osteoarthritis Index; Short-Form 36-item Health Questionnaire (SF-36) mental and physical component summary measures; University of California, Los Angeles activity scale; and timed Up and Go test. RESULTS: There were no differences between the groups for any measure. The overall differences between the adjusted means were as follows: Western Ontario and McMaster Universities Osteoarthritis Index, 0.50 (95% confidence interval [CI], -6.8 to 5.7); SF-36 physical component summary, 0.8 (95% CI, -6.5 to 8.1); SF-36 mental component summary, 1.7 (95% CI, -4.1 to 7.4); University of California, Los Angeles activity scale, 0.3 (95% CI, 5.2 to 6.1); and timed Up and Go test, 0 seconds (95% CI, -1.4 to 1.3s). CONCLUSIONS: The results demonstrated that outcomes in response to rehabilitation after THR are clinically and statistically similar whether the program was supervised or not. The results suggest that early rehabilitation programs can be effectively delivered unsupervised in the home to low-risk patients discharged home after THR. However, the relative effect of late-stage rehabilitation was not tested.

Standing or supine x-rays after total hip replacement - when is the safe zone not safe?

An acetabular prosthesis orientated outside the 'safe zone' is one of the key contributing factors in increasing complications after total hip replacement (THR). Although acetabular orientation is routinely assessed using supine x-rays, standing x-rays have been proposed because a change in body position alters pelvic tilt and therefore acetabular orientation. This study aimed to assess whether acetabular components orientated within the 'safe zone' in supine can also be outside the 'safe zone' in standing. Thirty patients (12M, 18F) had lateral and antero-posterior pelvic x-rays taken in standing and supine positions six weeks post THR. Pelvic tilt and acetabular orientation (anteversion and inclination) were measured and compared with respect to the limits of the 'safe zone'. In standing, the pelvis was relatively posteriorly tilted and both acetabular anteversion and inclination increased (p<0.0001). In 16 patients the acetabulum was orientated within the 'safe zone' in supine but outside the 'safe zone' in standing. Patients were significantly more likely to be outside the 'safe zone' in standing than when supine (p<0.0001).

Physiotherapist-directed rehabilitation exercises in the outpatient or home setting improve strength, gait speed and cadence after elective total hip replacement: a systematic review.

QUESTION: In people who have been discharged from hospital after a total hip replacement, do rehabilitation exercises directed by a physiotherapist improve strength, gait, function and quality of life? Are these exercises as effective in an unsupervised home-based setting as they are in a supervised outpatient setting? DESIGN: Systematic review with meta-analysis of randomised trials. PARTICIPANTS: Adult patients after elective total hip replacement. INTERVENTION: Physiotherapist-directed rehabilitation exercises after discharge from hospital following total hip replacement. OUTCOME MEASURES: Hip and knee strength, gait parameters, functional measures, and quality of life. RESULTS: Five studies comprising 234 participants were included in the review. Sufficient data for meta-analysis were only obtained for hip and knee strength, gait speed and cadence. Physiotherapy rehabilitation improved hip abductor strength by a mean of 16Nm (95% CI 10 to 22), gait speed by 6 m/min (95% CI 1 to 11) and cadence by 20 steps/min (95% CI 8 to 32). Favourable but non-significant improvements in strength were noted for other muscle groups at the hip and knee. Function and quality of life could not be meta-analysed due to insufficient data and heterogeneity of measures, but functional measures tended to favour the physiotherapy rehabilitation group. Most outcomes were similar between outpatient and home-based exercise programs. CONCLUSION: Physiotherapy rehabilitation improves hip abductor strength, gait speed and cadence in people who have been discharged from hospital after total hip replacement. Physiotherapist-directed rehabilitation exercises appear to be similarly effective whether they are performed unsupervised at home or supervised by a physiotherapist in an outpatient setting.

Ultrasound assessment of the anatomical validity of T3 and L4 as sEMG recording sites.

The accuracy of surface EMG measurement is dependent upon minimizing potential crosstalk from other muscles. Although they are deeply situated, in places the erector spinae are covered with electrically silent aponeuroses rather than active muscle tissue. Theoretically these aponeuroses can serve as windows for sEMG recordings. A recent anatomical study concluded that T3 and L4 are ideal sites for recording the ES because the superficial muscle aponeuroses are wide at these sites. The aim of this prospective study was to investigate these sites in vivo using real time ultrasound. Ultrasound images from 20 subjects (10<30 years and 10>70 years; equal numbers of males and females in each group) were acquired during rest and in prone extension with the arms in three different positions. The most superficial aponeurosis widths were measured. The mean T3 aponeurosis width reduced significantly in extension from 4.4±4.7mm at rest to 1.8±2.6mm in extension (p<0.0001). Males had significantly smaller T3 aponeurosis widths than females (p=0.049). The mean L4 aponeurosis width also significantly decreased in extension from 35.5±7.0mm at rest to 29.9±7.2mm in extension (p<0.0001) due to 'doming' of the aponeurosis. Our results demonstrate that T3 is not a reliable site over which to record the ES because the aponeurosis width is too narrow. L4 is a good site if the electrodes are placed no more than 20mm from the midline.