Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction Is Not Superior to Anatomic Single-Bundle Reconstruction at 10-Year Follow-up: A Randomized Clinical Trial.

BACKGROUND: The anatomic double-bundle (DB) technique is purported to be a superior technique due to its mimicking of the double-stranded anatomic formation of the anterior cruciate ligament (ACL). Previous studies with 2-, 5- and 10-year follow-up are conflicted as to whether this technique is superior to the previous gold standard method of ACL reconstruction, the anatomic single-bundle (SB) reconstruction. PURPOSE/HYPOTHESIS: The aim of this prospective randomized study was to compare the outcomes of the anatomic DB technique and anatomic SB technique with independent drilling at 10 years after anterior cruciate ligament (ACL) reconstruction. We hypothesized that DB ACL reconstruction would result in a better outcome in terms of the pivot-shift test. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: A total of 105 patients (33 women, 72 men; median age, 27 years [range, 18-52 years]) were randomized and underwent ACL reconstruction (DB group: n = 53; SB group: n = 52). All reconstruction procedures were performed anatomically by identifying the ACL footprint, using the anteromedial portal for femoral tunnel drilling, and utilizing interference screws for tibial and femoral fixation. One blinded observer examined the patients both preoperatively and at follow-up (median, 120 months [range, 112-134 months]). Multiple subjective and objective clinical evaluations were used to assess the outcomes. Radiographic assessments of osteoarthritis were performed using the Ahlbäck, Kellgren-Lawrence, and Fairbank classification systems early postoperatively and at the final follow-up. RESULTS: Preoperatively, no differences were found between the study groups. Overall, 70 patients (67%; DB group: n = 39; SB group: n = 31) were available for analysis at 10-year follow-up. No significant difference could be shown between the groups in terms of the pivot-shift grade, knee laxity measurements using the KT-1000 arthrometer, manual Lachman grade, single-leg hop test result, range of motion measurements, Lysholm knee score, Tegner activity score, and Knee injury and Osteoarthritis Outcome Score (KOOS) score. Correspondingly, no differences were found between the groups regarding the presence of radiographic osteoarthritis at follow-up. Both groups improved at follow-up compared with preoperatively in terms of the pivot-shift grade, knee laxity measurements using the KT-1000 arthrometer, manual Lachman grade, Lysholm knee score, and KOOS score (P < .05 [highest P value for any comparison]). CONCLUSION: The anatomic DB technique was not superior to the anatomic SB technique with independent drilling at 10-year follow-up in regard to objective and subjective measurements. As such, one could argue that there is no need for the continued use of the anatomic DB technique in an unselected population.

Patient-Reported and Quantitative Outcomes of Anatomic Anterior Cruciate Ligament Reconstruction With Hamstring Tendon Autografts.

BACKGROUND: The pivot-shift test has become more consistent and reliable and is a meaningful outcome measurement after anterior cruciate ligament reconstruction (ACLR). PURPOSE/HYPOTHESIS: The purpose of this investigation was to assess patient-reported outcomes (PROs) and the quantitative pivot shift (QPS) preoperatively, at time zero immediately after anatomic ACLR, and after 24 months as well as the relationship between PROs and the QPS. It was hypothesized that anatomic ACLR would restore rotatory stability measured by the pivot-shift test and that QPS measurements would be positively correlated with PROs. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: The ACL-injured and contralateral uninjured knees from 89 of 107 (83.2%) enrolled patients at 4 international centers were evaluated using a standardized pivot-shift test. Tibial acceleration was assessed with an inertial sensor, and lateral compartment translation was measured using an image analysis system preoperatively, at time zero immediately postoperatively, and at follow-up after 2 years. PROs were assessed at 12 and 24 months postoperatively with the International Knee Documentation Committee (IKDC) subjective knee form, Cincinnati Knee Rating System (CKRS), Marx activity rating scale, and activity of daily living score (ADLS). RESULTS: The mean patient age at surgery was 27 years (range, 15-45 years). A positive pivot shift preoperatively (side-to-side difference in tibial acceleration, 2.6 ± 4.0 m/s2; side-to-side difference in anterior tibial translation, 2.0 ± 2.0 mm) was reduced at time zero postoperatively (side-to-side difference in tibial acceleration, -0.5 ± 1.3 m/s2; side-to-side difference in anterior tibial translation, -0.1 ± 1.0 mm). All PROs improved from preoperatively to final follow-up at 24 months: from 56.5 to 85.5 points for the IKDC (P = .0001), from 28.8 to 32.4 points for the CKRS (P = .04), from 11.2 to 7.9 points for the Marx (P < .0001), and from 75.7 to 91.6 points for the ADLS (P < .0001). Neither preoperative nor time zero postoperative rotatory laxity assessed by the pivot-shift test correlated with PROs at 24-month follow-up. A graft retear was observed in 4 patients (4.5%) within 2 years of follow-up. CONCLUSION: Anatomic ACLR resulted in significantly improved and acceptable PROs at 2-year follow-up and a low failure rate. Anatomic ACLR restored QPS measurements of anterior tibial translation and tibial acceleration to those of the contralateral knee immediately after surgery while still under anesthesia, but there was no correlation between the QPS preoperatively or at time zero after ACLR and PROs at 2-year follow-up.

The evolution of femoroacetabular impingement surgical management as a model for introducing new surgical techniques.

Introducing new surgical techniques and concepts can be difficult. There are many hurdles to overcome initially, such as the learning curve, equipment and technique development, before a standard of care can be established. In the past, new surgical techniques have been developed, and even widely accepted, before any scientific evaluation has been made. At that stage, it may be too late properly to evaluate the effectiveness of treatments, as the objectiveness and/or randomisation process may be obstructed. Since the introduction of evidence-based medicine (EBM), there have been high standards of scientific rigour to prove the efficacy of treatments. Based on the nature of evidence-based acceptance, innovations cannot be subjected to this final process before their evolution process is complete and, as a result, there is a need for the staged scientific development of new surgical techniques that should be adopted. This paper presents a model for this kind of stepwise introduction based on the actual evolution of FAI syndrome surgery. By following a scientific algorithmic methodology, new surgical techniques and concepts can be introduced in a stepwise manner to ensure the evidence-based progression of knowledge.

Good 5-year outcomes after arthroscopic treatment for femoroacetabular impingement syndrome.

PURPOSE: The purpose of the present study was to evaluate the outcome of arthroscopic treatment for femoroacetabular impingement (FAI) syndrome 5 years post-surgery using patient-reported outcome scores (PROMs) validated for a young and active population with hip complaints. METHODS: Patients were prospectively included in the study. A total of 184 patients [males = 110 (59.8%), females = 74 (40.2%)], with mean age 38.0, underwent arthroscopic treatment for FAI syndrome and were analysed. Preoperatively and at the 5-year follow-up, patients completed a set of self-administered web-based PROMs consisting of the International Hip Outcome Tool (iHOT-12), the Copenhagen Hip and Groin Outcome Score (HAGOS), the Hip Sports Activity Scale (HSAS), the EuroQoL-5 Dimension Questionnaire (EQ-5D), the EQ-Visual Analogue Scale (VAS) and the VAS for overall hip function and overall satisfaction. The Wilcoxon signed rank test was used to compare preoperative PROM values with those obtained at the 5-year follow-up. RESULTS: A comparison of preoperative PROM scores and those obtained at the 5-year follow-up revealed statistically significant improvements for all outcome scores (p < 0.05), except for the HSAS score, which were unchanged; iHOT-12 (42.9 vs 67.2), HAGOS different subscales (50.2 vs 69.6, 55.7 vs 76.1, 59.2 vs 72.3, 41.1 vs 66.4, 30.8 vs 60.2, 31.6 vs 60.4), EQ-5D (0.570 vs 0.742), EQ-VAS (66.6 vs 74.4), HSAS (3.13 vs 3.17) and VAS for overall hip function (47.9 vs 69.2). At the 5-year follow-up, 154 patients reported that they were satisfied with surgery (84.6%). Survivorship at the 5-year follow-up was 86.4%. CONCLUSION: Arthroscopic treatment for FAI syndrome yields good patient-reported outcome at the 5-year follow-up. LEVEL OF EVIDENCE: II.

Quality Assessment of Prospective Cohort Studies Evaluating Arthroscopic Treatment for Femoroacetabular Impingement Syndrome: A Systematic Review.

BACKGROUND: Femoroacetabular impingement (FAI) syndrome is a cause of pain and reduced range of motion in the hip joint. Given the limited number of randomized controlled trials, prospective cohort studies constitute the dominant part of the available prospective evidence evaluating relevant clinical outcomes after arthroscopic hip surgery for FAI. PURPOSE: To assess the methodological quality of prospective cohort studies evaluating arthroscopic surgery for FAI and to determine whether there has been an improvement in methodological quality over time. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: A systematic literature search was performed in PubMed, Embase (OvidSP), and the Cochrane Library. Included studies were clinical prospective cohort studies of primary arthroscopic surgery for cam and/or pincer morphology FAI. Methodological quality was assessed with the Methodological Index for Non-randomized Studies (MINORS). The mean MINORS score for studies published during the first 5 years of the period was compared with those published during the last 5 years to evaluate methodological improvement over time. The methodological quality of randomized controlled trials was also assessed with the Coleman Methodology Score. RESULTS: The search yielded 53 studies. There were 34 noncomparative studies, 15 nonrandomized comparative studies, and 4 randomized controlled trials. The included studies were published between 2008 and 2017. The mean ± SD MINORS score for noncomparative and comparative studies was 10.4 ± 1.4 of 16 possible and 18.7 ± 2.0 of 24 possible, respectively. The mean Coleman Methodology Score for randomized controlled trials was 79.0 ± 7.0 of 100 possible. CONCLUSION: The methodological quality of prospective cohort studies evaluating arthroscopic surgery for FAI is moderate for comparative and noncomparative studies. Common areas for improvement include unbiased assessment of study endpoints and prospective sample-size calculations. Despite an increase in the number of published studies, an improvement in methodological quality over time was not observed.

Anatomic Anterior Cruciate Ligament Reconstruction Using Hamstring Tendons Restores Quantitative Pivot Shift.

BACKGROUND: It is still uncertain how surgical reconstruction of the anterior cruciate ligament (ACL) is able to restore rotatory laxity of the involved joint. The desired amount of restraint applied by the ACL graft, as compared with the healthy knee, has not been fully clarified. PURPOSE: To quantify the ability of single-bundle anatomic ACL reconstruction using hamstring tendons in reducing the pivot-shift phenomenon immediately after surgery under anesthesia. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: An inertial sensor and image analysis were used at 4 international centers to measure tibial acceleration and lateral compartment translation of the knee, respectively. The standardized pivot-shift test was quantified in terms of the side-to-side difference in laxity both preoperatively and postoperatively with the patient under anesthesia. The reduction in both tibial acceleration and lateral compartment translation after surgery and the side-to-side difference were evaluated using the Wilcoxon signed-rank test. Alpha was set at P < .05. RESULTS: A total of 107 patients were recruited for the study, and data were available for 89 patients. There was a statistically significant reduction in quantitative rotatory knee laxity between preoperatively (inertial sensor, 2.55 ± 4.00 m/s2; image analysis, 2.04 ± 2.02 mm) and postoperatively (inertial sensor, -0.54 ± 1.25 m/s2; image analysis, -0.10 ± 1.04 mm) between the involved and healthy joints, as measured by the 2 devices (P < .001 for both). Postoperatively, both devices detected a lower rotatory laxity value in the involved joint compared with the healthy joint (inertial sensor, 2.45 ± 0.89 vs 2.99 ± 1.10 m/s2, respectively [P < .001]; image analysis, 0.99 ± 0.83 vs 1.09 ± 0.92 mm, respectively [P = .38]). CONCLUSION: The data from this study indicated a significant reduction in the pivot shift when compared side to side. Both the inertial sensor and image analysis used for the quantitative assessment of the pivot-shift test could successfully detect restoration of the pivot shift after anatomic single-bundle ACL reconstruction. Future research will examine how pivot-shift control is maintained over time and correlation of the pivot shift with return to full activity in patients with an ACL injury.

Predictors of outcome at 2-year follow-up after arthroscopic treatment of femoro-acetabular impingement.

Femoro-acetabular impingement (FAI) is a common cause of hip pain and dysfunction in the young and active population. Despite reports of good short-term outcomes following treatment for FAI, less is known about the possible preoperative predictors of treatment outcome. The purpose of this study was to identify predictors of treatment outcome, using a patient-reported outcome measurement score (PROM) validated for use in a young and active population undergoing arthroscopic surgery for FAI. Patients were prospectively enrolled and analysed using the PROM International Hip Outcome Tool (iHOT-12) preoperatively and at a 2-year follow-up. Predictors of treatment outcome chosen for analysis were age, gender, duration of symptoms until surgery, level of cartilage damage, preoperative score and FAI type. A total of 198 patients, 122 males and 76 females (M: 61.6%, F: 38.4%), with a mean age of 41 ± 12.1 years, were analysed. The preoperative iHOT-12 score correlated with the postoperative iHOT-12 score at the 2-year follow-up. For one iHOT-12 point positive difference preoperatively, an additional 0.65 points were gained postoperatively at the 2-year follow-up (P ≤ 0.001). Age, gender, symptom duration until surgery, level of cartilage damage and FAI type did not have a statistically significant correlation to the postoperative score. Preoperative hip function as measured by the iHOT-12 is a potential predictor of outcome following FAI surgery relative to other factors.

Comparison of outcome after anatomic double-bundle and antero-medial portal non-anatomic single-bundle reconstruction in ACL-injured patients.

PURPOSE: The aim of this study was to compare anatomic double-bundle anterior cruciate ligament reconstruction with non-anatomic single-bundle reconstruction. METHODS: In a prospective consecutive series, 94 unselected patients [45 anatomic double-bundle (ADB) and 49 non-anatomic single-bundle (SB)] underwent ACL reconstruction involving hamstring tendon autograft, interference screw fixation on both the femoral and tibial side and drilling the femoral tunnel(s) through the antero-medial portal in both groups. In the ADB group, the remnants of the ACL were identified and the grafts were placed anatomically. In the SB group, traditional placement of the graft was performed in a less anatomic manner. Pre-operatively, the groups were comparable in terms of age, gender, time between injury and operation and associated injuries. One independent physiotherapist performed all the pre-operative and post-operative assessments. RESULTS: The follow-up period was 26 (22-34) and 24 (23-30) months in the ADB and SB groups, respectively (p = 0.005). At follow-up, 78 % in the ADB group and 74 % in the SB group had a negative pivot-shift test (n.s.). The KT-1000 134N measurements were 2 (-5 to 10.5) and 2 (-4 to 7) mm in the ADB and SB groups, respectively (n.s.). At follow-up, the extension deficit was significantly larger in the ADB group than in the SB group (p = 0.001). The Tegner activity scale was significantly higher in the ADB group both pre-operatively and at follow-up (p = 0.03 and p = 0.004). In overall terms, both groups had improved significantly at the two-year follow-up. CONCLUSION: In an unselected group of ACL-injured patients, anatomic double-bundle reconstruction did not result in better rotational or antero-posterior stability measurements than antero-medial portal non-anatomic single-bundle reconstruction at the two-year follow-up. LEVEL OF EVIDENCE: III.

Outcome of hip arthroscopy in patients with mild to moderate osteoarthritis-A prospective study.

Osteoarthritis (OA) of the hip is a common cause of hip pain. The arthroscopic management of patients with femoro-acetabular impingement (FAI) has been reported to yield good outcomes. The purpose of this study was to report on outcome following the arthroscopic treatment of patients with FAI in the presence of mild to moderate OA. Seventy-five patients undergoing arthroscopic surgery for FAI, all with preoperative radiological signs of mild to moderate OA were prospectively included in this study. A 2-year follow-up, using web-based patient-reported outcome measures, including the International Hip Outcome Tool (iHOT-12), Copenhagen Hip and Groin Outcome (HAGOS), EQ-5D, Hip Sports Activity Scale (HSAS) for physical activity level and a visual analogue scale (VAS) for overall hip function, was performed, complemented by a radiographic evaluation. At follow-up (mean 26 months, SD 5), five patients (7%) had undergone total hip arthroplasty, leaving 70 patients for the analysis. Preoperative scores compared with those obtained at the 2-year follow-up revealed significant improvements (P < 0.0001) for all measured outcomes; the iHOT-12 (42 versus 65), VAS for global hip function (48 versus 68), HSAS (2.5 versus 3), EQ5D index (0.62 versus 0.76), EQ VAS (69 versus 75) and different HAGOS subscales (54 versus 72, 47 versus 67, 56 versus 75, 40 versus 61, 33 versus 56, 31 versus 55). At follow-up, 56 (82%) patients reported that they was satisfied with the outcome of surgery. Arthroscopic treatment for patients with FAI in the presence of mild to moderate OA resulted in statistically significant and clinically relevant improvements in outcome measures related to pain, symptoms, function, physical activity level and quality of life in the majority of patients.

Good Results After Hip Arthroscopy for Femoroacetabular Impingement in Top-Level Athletes.

BACKGROUND: Femoroacetabular impingement (FAI) is a common cause of hip pain and dysfunction among athletes. Although arthroscopic surgery is an established treatment option for FAI, there are few studies reporting detailed outcomes using validated outcome measurements specifically designed for young and active athletes. PURPOSE: To report outcomes 1 year after arthroscopic treatment of FAI in top-level athletes using validated outcome measurements adapted for a young and active population. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A total of 85 top-level athletes (68 males, 17 females) with a mean (±SD) age of 25 ± 5 years underwent arthroscopic surgery for FAI. All athletes who reported Hip Sports Activity Scale (HSAS) levels 7 or 8 (range, 0-8) prior to symptom onset were included. The cohort was prospectively evaluated using online web-based validated health-related patient-reported outcomes measures (HR-PROMs), including the short version of the International Hip Outcome Tool (iHOT-12), the Copenhagen Hip and Groin Outcome Score (HAGOS; 6 subscales), the EuroQOL 5 dimensions questionnaire (EQ-5D; 2 subscales), the Hip Sports Activity Scale (HSAS) for physical activity level, and a visual analog scale (VAS) for overall hip function. Furthermore, patients reported their overall satisfaction with treatment. RESULTS: The mean follow-up time was 12.3 ± 0.6 months. Preoperative scores compared with those obtained at the 12-month follow-up revealed statistically and clinically significant improvements (P < .0001) for all measured outcomes: iHOT-12 (42 vs 73), VAS for global hip function (52 vs 77), HSAS (4.3 vs 5.7), EQ-5D index (0.60 vs 0.83), EQ-VAS (68 vs 82), and HAGOS subscales (60 vs 83, 50 vs 73, 66 vs 86, 39 vs 75, 27 vs 70, and 34 vs 67). At the 12-month follow-up, 79 athletes (93%) reported that they were satisfied with the outcome of surgery. At follow-up, 62 athletes (73%) had returned to competitive sports (HSAS levels 5-8) and 44 (52%) to their previous HSAS level of activity (HSAS level 7 or 8). Twenty-three athletes (27%) did not return to competitive sports (HSAS level ≤4). Significantly lower levels of return to sports were seen with longer symptom duration (P < .05). CONCLUSION: Twelve months after surgery, arthroscopic treatment for FAI in top-level athletes resulted in statistically and clinically significant improvements at the group level in all outcome parameters for pain, symptoms, function, physical activity level, quality of life, and general health. One year after surgery, approximately 3 of 4 top-level athletes had returned to sports.

A Swedish hip arthroscopy registry: demographics and development.

PURPOSE: Hip arthroscopy is a rapidly expanding field in orthopaedics. Indications and surgical procedures are increasing. Although several studies report favourable clinical outcomes, further scientific evidence is needed for every aspect of this area. Accordingly, a registry for hip arthroscopy was developed. The purpose of this study is to describe the development of the registry and present its baseline data. METHODS: A Scandinavian expert group agreed to use a set of functional outcome scores for the evaluation of hip arthroscopy patients. They were the international hip outcome tool-12, hip and groin outcome score, EQ-5D, hip-specific activity level scale and visual analogue scale for overall hip function. These scores were validated and culturally adapted to Swedish. A database was created for web-based, self-administered questionnaires. Perioperative data were also collected. RESULTS: The process leading to the registry is reported. Baseline data from the first 606 patients collected during a 14-month period are presented. The preferred surgical technique is presented. The mean operation time was 69 (SD 14) minutes. In 333 procedures, mixed cam and pincer pathology were addressed, compared with 223 procedures with the treatment of isolated cam pathology. Outpatient surgery was performed in all patients. CONCLUSION: The baseline data in this study can be used as reference values for future scientific work from this registry. Knowledge of the process leading to the development of the registry could be useful to other researchers planning similar work.

A standardised outcome measure of pain, symptoms and physical function in patients with hip and groin disability due to femoro-acetabular impingement: cross-cultural adaptation and validation of the international Hip Outcome Tool (iHOT12) in Swedish.

PURPOSE: There is a lack of standardised outcome measures in Swedish for active, young and middle-aged patients with hip and groin disability. The purpose of this study was to adapt the English version of the international Hip Outcome Tool (iHOT12) patient-reported outcome instrument for use in Swedish patients and evaluate the adaptation according to the consensus-based standards for the selection of health status measurement instruments checklist. METHODS: Cross-cultural adaptation was performed in several steps, including translation, back-translation, expert review and pre-testing. The final version was evaluated for reliability, validity and responsiveness in a clinical study of patients [median age 37 (range 15-75)], undergoing surgery for femoro-acetabular impingement. RESULTS: Cronbach's alpha was 0.89, and significant correlations were obtained with the Copenhagen Hip and Groin Outcome Score (Spearman's r 0.10-0.70; p < 0.05) and the EuroQol, EQ-5D average score (Spearman's r 0.27-0.56; p < 0.01). Test-retest reliability (intraclass correlation coefficient) ranged from 0.59 to 0.93 for the individual items. The smallest detectable change ranged from 17.1 to 44.9 at individual level and 3.6 to 9.4 at group level. Factor analysis revealed one factor of pain and symptoms and another factor of physical function. Effect sizes were generally medium or large. CONCLUSION: The Swedish version of the iHOT12 is a valid, reliable and responsive instrument that can be used both for research and in the clinical setting.

Can hip impingement be mistaken for tendon pain in the groin? A long-term follow-up of tenotomy for groin pain in athletes.

PURPOSE: There are several reports on the association between pubalgia and intra-articular hip disorders. The purpose of this study was to evaluate the long-term outcome in athletes who underwent tenotomy due to long-standing groin pain. A secondary purpose was evaluating the frequency of femoro-acetabular impingement (FAI) and its impact on the long-term outcome. METHODS: Thirty-two high-level male athletes treated with adductor tenotomy, rectus abdominis tenotomy or both were included. At a median follow-up time of 6 years after the tenotomy, the subjects underwent standardised clinical examination, plain radiographs, completed web-based health-related patient-reported outcomes, including iHOT12, HAGOS (six subscales), EQ-5D (two subscales), HSAS for physical activity level and a VAS for overall hip function. Furthermore, patient satisfaction and return to sports were documented. RESULTS: Twenty-four of the 32 (75 %) athletes were satisfied with the outcome of the tenotomy, and 22 of the athletes (69 %) were able to return to their pre-injury sport. Before the long-term follow-up, two of these satisfied athletes had undergone repeat surgery (one hip arthroscopy due to FAI and one repeat tenotomy). Of the 24 satisfied athletes, eight (33 %) had a positive hip impingement test at the follow-up. Of the remaining eight athletes not satisfied with the outcome, only one returned to their pre-injury sport and three had undergone hip arthroscopy prior to follow-up. Five had positive hip impingement tests which was significantly more frequently than in the satisfied group (p = 0.008). The group with a positive hip impingement test reported significantly more pain and symptoms, more hip problems during sports and physical activity, as well as lower hip-related quality of life according to the HAGOS scores (p < 0.05), at follow-up. CONCLUSION: Tenotomy for pubalgia yielded a satisfactory long-term outcome, with three of four athletes being able to return to their pre-injury sport. The athletes that did not return to their pre-injury sport had higher frequency of positive hip impingement test and inferior functional outcome compared with the athletes that did return to their pre-injury sport. It is therefore recommended that the hip should be carefully evaluated for hip impingement before tenotomy is considered as treatment for athletes with pubalgia.

Cross-cultural adaptation to Swedish and validation of the Copenhagen Hip and Groin Outcome Score (HAGOS) for pain, symptoms and physical function in patients with hip and groin disability due to femoro-acetabular impingement.

PURPOSE: There is a lack of standardised outcome measures in Swedish for active, young and middle-aged patients with hip and groin disability. The purpose of this study was to adapt the Danish version of the Copenhagen Hip and Groin Outcome Score (HAGOS) patient-reported outcome instrument for use in Swedish patients and evaluate the adaptation according to the Consensus-Based Standards for the Selection of Health Status Measurement Instruments checklist. METHODS: Cross-cultural adaptation was performed in several steps, including translation, back-translation, expert review and pretesting. The final version was evaluated for reliability, validity and responsiveness. Five hundred and two patients (337 men and 167 women, mean age 37, range 15-75) were included in the study. RESULTS: Cronbach's alpha for the six HAGOS-S subscales ranged from 0.77 to 0.89. Significant correlations were obtained with the international Hip Outcome Tool average score (r s = 0.37-0.68; p < 0.01) and a standardised instrument, the EuroQol, EQ-5D total score (r s = 0.40-0.60, p = 0.01), for use as a measurement of health outcome. Test-retest reliability (intraclass correlation coefficient) ranged from 0.81 to 0.87 for the six HAGOS-S subscales. The smallest detectable change ranged from 7.8 to 16.1 at individual level and 1.6-3.2 at group level. Factor analysis revealed that the six HAGOS-S subscales had one strong factor per subscale. Effect sizes were generally medium or large. CONCLUSION: The Swedish version of the HAGOS is a valid, reliable and responsive instrument that can be used both for research and in the clinical setting at individual and group level.

Strength of the porcine proximal femoral epiphyseal plate: the effect of different loading directions and the role of the perichondrial fibrocartilaginous complex and epiphyseal tubercle - an experimental biomechanical study.

BACKGROUND: The high loads on adolescent athletes' musculoskeletal system are known to cause morphological and degenerative changes in bone, intervertebral discs and joints. It has been suggested that the cam deformity of the proximal femoral head originates from a subclinical slipped capital femoral epiphysis (SCFE) as a result of non-physiological loading. The perichondrial fibrocartilaginous complex (PFC) and the epiphyseal tubercle are believed to stabilise the proximal femoral epiphysis, but their role is still unclear. The aim of the present study was to develop an experimental, biomechanical model to evaluate the strength of the porcine proximal femoral epiphysis in different loading directions and, furthermore, to investigate the stabilising role of the PFC and the epiphyseal tubercle. METHODS: A descriptive laboratory study. An in-vitro model was developed and nine young (5 months) porcine proximal femoral epiphyses were loaded to failure; three in the anterior-posterior direction, three in the lateral-medial direction and three in the vertical direction. The injured proximal femoral epiphyses were then examined both macroscopically and histologically. RESULTS: Anterior and lateral loading of the proximal femoral epiphysis resulted in failure of the epiphyseal plate, while vertical loading resulted in a fracture epiphyseolysis. The epiphysis was weakest when exposed to a lateral load and strongest when exposed to a vertical load. Despite histological epiphyseolysis, the PFC was intact in 15 of 27 (56%) slices. In histological examinations, the epiphyseal tubercle appears to halt the slide of the epiphysis. CONCLUSIONS: We have developed an experimental, biomechanical model to measure the strength of the proximal femoral epiphyseal plate in different loading directions. The strength of the proximal femur was weakest through the epiphyseal plate. The epiphysis was weakest when exposed to a lateral load and strongest when exposed to a vertical load. The epiphyseal tubercle and the PFC stabilise the epiphysis when the epiphyseal plate is damaged. The findings in the present study indicate that overloading the hips in growing individuals can disrupt the epiphyseal plate. These findings may have implications when it comes to understanding the pathogenesis of cam deformity of the hip.

A prospective randomized study comparing double- and single-bundle techniques for anterior cruciate ligament reconstruction.

BACKGROUND: The aim of the study was to compare the results after arthroscopic anterior cruciate ligament (ACL) reconstruction using either the double-bundle or single-bundle technique with hamstring tendon autografts in an unselected group of patients. HYPOTHESIS: Double-bundle ACL reconstruction will render a better outcome on the pivot-shift test. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: A randomized series of 103 patients (33 women, 70 men; median age, 27 years; range, 18-52 years) with a unilateral ACL rupture underwent anatomic ACL reconstruction. The double-bundle technique was used in 53 patients, and the single-bundle technique was used in 50 patients. The ACL footprint was visualized, and the femoral tunnel was drilled through the anteromedial portal; interference screw fixation was used at both ends. The patients were examined preoperatively and at a median of 26 months (range, 22-42 months) after the reconstruction by a blinded observer. The primary variable was the pivot-shift test. RESULTS: At 2-year follow-up, 98 patients (93%) were examined. Clinical assessments at follow-up revealed no significant differences between the double-bundle and single-bundle groups in terms of the pivot-shift test, KT-1000 arthrometer laxity measurements, manual Lachman test, range of motion, Lysholm knee scoring scale, Tegner activity scale, Knee Injury and Osteoarthritis and Outcome Score (KOOS), 1-legged hop test, and square hop test. A significant improvement was seen in both groups compared with the preoperative values in terms of most clinical assessments. CONCLUSION: In this prospective randomized study, the primary variable, the pivot-shift test, and other subjective and objective outcome variables revealed no significant differences between the double-bundle and single-bundle techniques at 2 years after ACL reconstruction in an unselected group of patients.

Quantitative evaluation of the pivot shift by image analysis using the iPad.

PURPOSE: To enable comparison of test results, a widely available measurement system for the pivot shift test is needed. Simple image analysis of lateral knee joint translation is one such system that can be installed on a prevalent computer tablet (e.g. iPad). The purpose of this study was to test a novel iPad application to detect the pivot shift. It was hypothesized that the abnormal lateral translation in ACL deficient knees would be detected by the iPad application. METHODS: Thirty-four consecutive ACL deficient patients were tested. Three skin markers were attached on the following bony landmarks: (1) Gerdy's tubercle, (2) fibular head and (3) lateral epicondyle. A standardized pivot shift test was performed under anaesthesia, while the lateral side of the knee joint was monitored. The recorded movie was processed by the iPad application to measure the lateral translation of the knee joint. Lateral translation was compared between knees with different pivot shift grades. RESULTS: Valid data sets were obtained in 20 (59 %) ACL deficient knees. The remaining 14 data sets were invalid because of failure to detect translation or detection of excessive translation. ACL deficient knees had larger lateral translation than the contra-lateral knees (p < 0.01). In the 20 valid data sets, which were graded as either grade 1 (n = 10) or grade 2 (n = 10), lateral translation was significantly larger in the grade 2 pivot shift (3.6 ± 1.2 mm) than the grade 1 pivot shift (2.7 ± 0.6 mm, p < 0.05). CONCLUSION: Although some technical corrections, such as testing manoeuvre and recording procedure, are needed to improve the image data sampling using the iPad application, the potential of the iPad application to classify the pivot shift was demonstrated.

Total dislocation of the hip joint after arthroscopy and ileopsoas tenotomy.

The hip is a highly stable joint. Non-traumatic dislocation of the hip is extremely uncommon. In this article, we report two cases of non-traumatic hip dislocations following hip arthroscopy. In both cases, capsulotomy and ileopsoas tenotomy had been performed. These cases raise questions about the importance of the natural stabilisers of the hip. Level of evidence V.