Arthroscopic surgery for femoroacetabular impingement has limited effect in patients with Tönnis grade-2 at 4-year follow-up.

INTRODUCTION: This study evaluated intraoperative findings and outcomes in Tönnis grade-2 patients after hip arthroscopy and compared these results with patients with Tönnis grade-0 and grade-1. MATERIALS AND METHODS: Retrospective cohort study of patients undergoing hip arthroscopy between January 2013 and December 2017. Patients were divided into either Tönnis grade-2, grade-1, and grade-0 osteoarthritis groups. Labral and chondral status were evaluated. Radiographic analysis, modified Harris hip score (mHHS), a self-administered Hip Outcome Score (HOS) questionnaire, with activity of daily living (ADL) and sports subscale (SSS), and a self-administered short version of the International Hip Outcome Tool (IHOT-12) were assessed at 6, 12 months, and then yearly. Clinical meaningful outcomes were measured with the minimal clinical important difference (MCID), patient acceptable symptom state (PASS), and substantial clinical benefit (SCB) for mHHS, HOS-ADL and HOS-SSS, and IHOT-12. RESULTS: A total of 264 hip arthroscopic procedures met the inclusion criteria. There were 38 patients Tönnis grade-2, 91 patients Tönnis grade-1, and 135 patients Tönnis grade-0. Mean follow-up was 48.7 months in Tönnis grade-2 group, 48.6 months in Tönnis grade-0 group, and 48.1 months in Tönnis grade-1 group. Tönnis grade-2 patients had more extensive rim chondral damage, and a higher rate of labral debridement was performed in this group. There were no statistically significant differences in preoperative PROs among the groups. Tönnis grade-2 group had statistically significant improvement in mHHS, but not in HOS-AVD, HOS-SSS and IHOT-12. Between T1 and T2 groups there were no statistically significant differences in outcomes. Lower significant percentage values of Tönnis grade-2 patients achieved MCID, PASS, and SCB threshold. CONCLUSION: Improvements in PROs and rates of achieving clinical meaningful outcomes were limited for patients with Tönnis grade-2 after HA at 4-year follow-up. The outcomes of the Tönnis grade-2 cohort deteriorate over mid-term follow-up. Our results could be used in orthopedic practice to inform patients about the limited role of hip arthroscopy as a joint preservation procedure in these selected patients. LEVEL OF EVIDENCE: Cohort study, level 3.

Radiographic measurements have limited effect in dynamic plantar pressures in hallux valgus patients.

PURPOSE: Radiographic measurements are the gold standard in the management for preoperative surgical planning of hallux valgus deformity. Plantar pressure technology is a tool that is not commonly used to evaluate and manage hallux valgus patients, and few studies have reported the correlation of plantar pressure measurements and radiography. METHODS: A prospective cohort study was designed to analyze plantar pressure measurements and radiographic variables. The inclusion criteria were age over 18 years old, and diagnosis of hallux valgus requesting surgical correction because of discomfort, pain or difficulty with shoe wear. Plantar pressure measurements were performed using a platform. Radiographic data were obtained according to the guidelines of the AOFAS Committee on Angular Measurements. RESULTS: A total of 114 patients met the inclusion criteria. Mean age of the patients was 50 years, and 94 patients (82.5%) were women. We found significant correlations between dynamic plantar pressure measurements and HVA, DMAA, and MDA. Mean pressure under third metatarsal head was the most associated plantar pressure measurement with hallux valgus angle and metatarsal declination angle. However, this association showed signs of weakness. CONCLUSION: Hallux valgus angle and metatarsal declination angle had a minimal influence on plantar-loading parameters. Pressure values did not discriminate the magnitude of HV deformity. Others factors responsible for the observed plantar pressures pattern should be addressed.

Significant improvement after hip arthroscopy for femoroacetabular impingement in women.

PURPOSE: This study was designed to evaluate outcomes in women after hip arthroscopy (HA) for femoroacetabular impingement syndrome (FAIS) and compare these results with men. METHODS: Retrospective study of a prospective database of patients undergoing hip arthroscopy between 2015 and 2018. Inclusion criteria were patients between 18 and 50 years of age, diagnosis of FAIS, complete clinical patient-reported outcomes (PROs), radiographic measurements, and underwent at least a 2-year HA follow-up. For each woman, two men underwent HA were matched in a 1:2 ratio based on age within 5 years, and date of surgery within 6 months. Diagnostic arthroscopy was performed to evaluate labral and chondral status. Radiographic evaluation, a self-administered Hip Outcome Score (HOS) questionnaire, with activity of daily living (ADL) and sports subscale (SSS), and a self-administered short version of the International Hip Outcome Tool (iHOT-12) were assessed at 6 months, 12 months, and then yearly. Clinical relevance was measured with the minimal clinical important difference (MCID), patient acceptable symptom state (PASS), and substantial clinical benefit (SCB) for HOS-ADL, HOS-SSS, and iHOT-12. RESULTS: One hundred and eighty-five patients met the inclusion criteria. Fifty-two women were matched with 104 men. Significant differences in terms of demographics, radiographic results, intraoperative findings and arthroscopic procedures were found between women and men. Mean follow-up was 48.4 months in women and 50.2 months in men. Both groups showed significant improvement from preoperative PROs to the latest follow-up. There were no significant differences between groups in preoperative PROs, latest follow-up PROs and PROs improvements. The difference in frequency of patients achieving MCID, PASS, and SCB was only significant greater for iHOT-12 PASS in women compared with men. CONCLUSION: Significant improvements in PROs in women after HA for FAIS at 4-year follow-up were found. Differences between women and men in PROs and rates of achieving MCID, SCB and PASS were only significant for iHOT-12 PASS. LEVEL OF EVIDENCE: IV.

Hallux valgus with and without metatarsalgia in women: a matched-cohort study of plantar pressure measurements.

BACKGROUND: Few previous studies focused on plantar loading patterns in HV patients with metatarsalgia. Are there any differences in plantar pressure measurements in women with HV with and without metatarsalgia? METHODS: A prospective matched-cohort study was designed to analyze plantar pressure measurements in women with HV with and without metatarsalgia from January 2017 to December 2019. The inclusion criteria were age over 18 years old, women, diagnosis of HV with metatarsalgia. Control group had the same inclusion criteria, except metatarsalgia. Patient-reported outcomes scores included American Orthopedic Foot and Ankle Society Score (AOFAS), and Visual Analog Scale (VAS). Radiographic data were obtained according to the guidelines of the AOFAS Committee on Angular Measurements. Plantar pressure measurements were performed using a platform. RESULTS: Forty-seven patients met the inclusion criteria. An age-, BMI-, and hallux valgus angle-matched cohort of 47 patients were also selected. There were no statistically significant differences in demographic data and radiographic assessment. HV with metatarsalgia group showed greater values in peak and mean force, peak and mean pressure, and pressure-time integral under toes and metatarsal heads. These differences reached statistically significant in mean force (p = 0.009) and peak force (p = 0.003) under T1; mean pressure (p = 0.01) and peak pressure (p = 0.04) under T1; and mean force (p = 0.003) under MH1. The binary logistic regression analysis showed mean force under T1 as the most associated plantar pressure measurement with the presence of metatarsalgia. C-statistic was 0.66. Mean force > 35 N had a 70% of sensitivity and a 57% of specificity as a cut-off value for the presence of metatarsalgia. CONCLUSION: HV patients with metatarsalgia had greater values in plantar pressure measurements. Mean force under T1 could be used as a plantar pressure measurement to predict metatarsalgia.

Arthroscopic management with labral preservation, femoral osteoplasty, and capsular plication in patients with borderline hip dysplasia. Results of a matched-cohort study at minimum two year follow-up.

PURPOSE: The purpose of this study was to assess intra-operative findings, surgical procedures, and outcomes in a cohort of patients with borderline hip dysplasia treated with arthroscopic labral repair, femoral osteoplasty, and capsular plication, and compare these outcomes with those of a rigorously matched control group without dysplasia. METHODS: Data were prospectively collected and retrospectively reviewed for patients with a lateral center-edge angle between 20 and 24° who underwent hip arthroscopy surgery between 2014 and 2018. Labral, chondral status, psoas impingement, ligamentum teres, and cam morphology were evaluated. Patient-reported outcomes (PROs) scores included modified Harris Hip Score (mHHS), Hip Outcome Score Activities of Daily Living Subscale (HOS-AVD) and Hip Outcome Score Sport-Specific Subscale (HOS-SSS), and International Hip Outcome Tool-12 (IHOT-12). Clinical relevance was measured with the minimal clinical important difference (MCID), patient acceptable symptom state (PASS), and substantial clinical benefit (SCB). RESULTS: Twenty patients met the inclusion criteria. An age- and sex-matched control group of 40 patients was also selected. Arthroscopic intra-operative findings were similar between cohorts. At a mean follow-up of 50 months in the borderline hip dysplasia cohort, and 52 months in the control cohort, there was a significant improvement in PROs in both cohorts, and no significant differences could be detected at the latest follow-up. The difference in frequency of patients achieving the MCID, PASS, and SCB was not statistically significant between cohorts. CONCLUSION: With strict patient selection criteria, hip arthroscopy may be a beneficial approach in patients with borderline hip dysplasia.

Recreational Sports and Intra-articular Hip Injuries in Patients Undergoing Hip Arthroscopy for Femoroacetabular Impingement.

PURPOSE: We aimed to determine the relationship between recreational sports and intra-articular hip injuries in an active population that had undergone hip arthroscopy for femoroacetabular impingement syndrome. METHODS: A retrospective review was performed of prospectively collected data from patients undergoing hip arthroscopy between January 2015 and December 2016. Inclusion criteria included patients between 18 and 50 years of age who had participated in recreational sports prior to surgery and had a minimum of a 2-year follow-up. Labral injury was evaluated using the Multicenter Arthroscopic Hip Outcome Research Network classification, and rim chondral injuries were evaluated using the Acetabular Labral Articular Disruptions system. Ligamentum teres tear and psoas impingement were also recorded. Sports were classified as rotational running (soccer, basketball, handball), flexibility (martial arts, dance), asymmetric-overhead (racquet), or endurance (running, swimming, cycling). Primary univariate analysis of sports' independent associations, demographic characteristics, intra-articular hip injuries, and outcomes was performed. RESULTS: Patients included 185 people with a mean age of 36.7 years. Patients participating in rotational running sports and flexibility sports had a significantly greater proportion of rim chondral injuries than those participating in endurance sports or asymmetric overhead sports (P = 0.02). Ligamentum teres tears were significantly associated with flexibility sports (P < 0.001). A total of 84.7%, 67.7%, 67.2%, and 71.2% of patients met minimal clinically important difference levels for the modified Harris Hip Score (mHHS), the Hip Outcome Score (HOS)10 questionnaire with activities of daily living (HOS-ADL), the sports subscale (HOS-SSS), and the International Hip Outcome Tool (iHOT-12), respectively; 94.9%, 66.2% and 62.7% met the patient acceptable symptom state for mHHS, HOS-ADL, and HOS-SSS, respectively; 86.7%, 48.5%, 47.8%, and 32.4% found substantial clinical benefit for mHHS, HOS-ADL, HOS-SSS, and iHOT-12, respectively. CONCLUSIONS: Rotational running sports were significantly associated with rim chondral injuries. Flexibility sports were significantly associated with rim chondral injuries and ligamentum teres tears. Athletes participating in these sports are more likely to have intra-articular hip injuries than those in the other sports categories. LEVEL OF EVIDENCE: Level IV, prognostic case series.

Topical tranexamic acid in cemented primary total knee arthroplasty without tourniquet: a prospective randomized study.

PURPOSE: Tranexamic acid (TXA) has been shown to be effective in reducing blood loss after total knee replacement. The purpose of this study was to prospectively assess the effectiveness of topical TXA use, to reduce blood loss after primary total knee replacement without tourniquet, and to compare these outcomes with a control group that did not receive tranexamic acid. METHODS: This is a prospective, randomized study to assess the effect of a 2-g topical tranexamic acid in 50 mL physiological saline solution in total knee replacement without tourniquet and drain. Primary outcomes were total blood loss. Secondary outcomes were hemoglobin and hematocrit level, hemoglobin and hematocrit drop, transfusion rates, length of hospital stay, deep vein thrombosis, and pulmonary embolism events. RESULTS: Preoperative and intraoperative data were similar between the two groups. The mean total blood loss was 620 mL in the topical tranexamic acid group and 1094 mL in the control group with significant differences (p = 0.001), which meant 43% reduction in total blood loss. The hemoglobin and hematocrit postoperative value was significantly higher in the topical tranexamic acid group than in the control group (p = 0.002). Transfusion rates were 0% in the topical tranexamic group and 4.3% in the control group. The length of stay was significantly lower in the topical tranexamic acid group (p = 0.01). There were no DVT or PE in any group. CONCLUSION: A single dose of 2-g TXA in 50 mL topical administration significantly reduces blood loss and improves postoperative blood chemistries in patients undergoing unilateral primary cemented TKA without tourniquet and drain compared to a control group, without increasing the risk of thromboembolic complications.

Plantar pressure improvement in moderate hallux valgus with modified chevron osteotomy: Clinical and radiographic outcomes.

BACKGROUND: Hallux valgus (HV) is widely treated by Chevron osteotomy (CO); however, a modified CO may improve patient outcomes and recovery. METHODS: A prospective study was designed to analyze plantar pressure measurements and clinical and radiographic outcomes of a modified CO for HV. Recruitment was between February 2016 and February 2017. INCLUSION CRITERIA: diagnosis of moderate HV; an indication for surgical correction due to discomfort, pain or difficulty with shoe wear; and age over 18 years. Clinical and radiographic outcomes were evaluated using the American Orthopedic Foot and Ankle Society (AOFAS) guidelines and a visual analog scale (VAS). RESULTS: Forty-four patients met inclusion criteria. After surgery, the highest percentage in mean pressure was in the first and fifth metatarsal heads. At 12 months' follow-up, the AOFAS score improved, but differences in VAS scale were only significant at baseline. CONCLUSIONS: Modified CO is a good option for people with HV, improving foot activity compared to preoperative levels while limiting the time needed for recovery.

Progressive Akin Osteotomy.

The most common complication associated to Akin osteotomy is the intraoperative fracture of the lateral cortex of the proximal phalanx. We present a progressive Akin osteotomy that preserves the lateral cortex of the proximal phalanx and allows to remove the exact wedge size to achieve the preoperative planned correction.

Femoroacetabular impingement: prospective study of rate and factors related for nerve injury after hip arthroscopy.

Prospective, longitudinal, descriptive study was conducted from January 2016 to January 2018 to detect nerve dysfunction after hip arthroscopy. A total of 110 patients were included. Twenty-four hours after surgery, 62.7% reported symptoms of abnormal sensation at least in one area. The most common was the perineal area. Three weeks after hip arthroscopy, 42.6% still experienced abnormal sensation. Six months after hip arthroscopy, only one patient remained with symptoms. Nerve dysfunction after HA was more common than has been reported in the literature within large populations. Traction time was a significant factor for the development of perineal nerve dysfunction.

Indirect Scapholunate Ligament Repair: All Arthroscopic.

The arthroscopic technique most frequently used in acute scapholunate instability is reduction and fixation with Kirschner wires. To repair the injured ligament, open surgery and dorsal capsular plication are recommended, but this procedure has the risk of damaging secondary dorsal stabilizers, the dorsal blood supply, and the proprioceptive innervation of the posterior interosseous nerve. In this report, we present an all-arthroscopic technique of a dorsal reconstruction of the scapholunate interosseous ligament for scapholunate instability using a tape by tethering the scaphoid to the lunate.

Matched cohort study of topical tranexamic acid in cementless primary total hip replacement.

PURPOSE: Tranexamic acid has been shown to be effective in reducing blood loss after total hip replacement. The purpose of this study was to prospectively assess the effectiveness of topical TXA use to reduce blood loss after primary total hip replacement and to compare these outcomes with those of a matched control group from a similar cohort that did not have received tranexamic acid. METHODS: This is a prospective matched control study to assess the effect of a 2 g topical tranexamic acid in 50 mL physiological saline solution in total hip replacement. Primary outcomes were hemoglobin and hematocrit drop, and total blood loss. Secondary outcomes were transfusion rates, length of hospital stay, deep vein thrombosis, and pulmonary embolism events. RESULTS: We could match 100 patients to a control group. There were no statistical significantly differences between the two groups. The hemoglobin and hematocrit postoperative values were significantly higher in topical tranexamic acid group than in control group (P < 0.001). The mean total blood loss was 769 in topical tranexamic acid group and 1163 in control group with significant differences (P = 0.001), which meant 34% reduction in total blood loss. Length of stay was lower in topical tranexamic acid group. The risk of deep vein thrombosis and pulmonary events did not increase. CONCLUSIONS: A single dose of 2 g tranexamic acid in 50 mL physiological saline solution topical administration was effective and safe in reducing bleeding in patients undergoing unilateral primary non-cemented total hip replacement compared to a matched control group.

Arthroscopic Treatment of a Malunion of a Posteromedial Tubercle Fracture of the Talus.

Posteromedial ankle impingement is rare and uncommonly associated with a fracture. Bone resection of the fragment is the recommended treatment. In this report, we describe the step-by-step surgical technique of arthroscopic resection of a malunion of a posteromedial talus fracture to correct the impingement.