Sagittal Pelvic Tilt Directly Influences the Ischiofemoral Space: A Cadaveric Study.

BACKGROUND: Ischiofemoral impingement (IFI) is understood to be a pain generator in the deep gluteal space. Femoral position is known to influence the ischiofemoral space (IFS), but there has been no study examining the effect of sagittal pelvic tilt on the IFS. The purpose of this study was to determine whether changes in pelvic tilt in the sagittal plane lead to changes in the dimensions of the IFS. MATERIALS AND METHODS: Five fresh frozen cadavers (10 hips) were used for this anatomic study. The specimens were skeletonized and placed in the prone position with the pelvis fixed to a custom-built hinged table. A digital inclinometer was used to tilt the pelvis -10°, 0°, and 10° simulating posterior, neutral, and anterior pelvic tilt, respectively. Digital calipers were used to measure the dimensions of the IFS in all three positions of sagittal pelvic tilt. RESULTS: Changes in pelvic tilt resulted in significant changes in the dimensions of the IFS. Mean IFS dimensions measured 29.3±9.7 mm, 37.2±9.0 mm, and 24.3±9.2 mm in the neutral, anterior, and posterior pelvic tilt positions, respectively (P<.0001). CONCLUSION: Changes in sagittal pelvic tilt influence the dimensions of the IFS, with posterior pelvic tilt noted to significantly decrease the IFS when compared with neutral and anterior pelvic tilt. These findings suggest that further evaluation of sagittal spinopelvic balance in the etiology of symptomatic IFI may be warranted. [Orthopedics. 202x;4x(x):xx-xx.].

Iliopsoas Muscle/Tendon Proportions at Three Levels of Described Arthroscopic Tenotomy: An Anatomic Study in Fresh Cadaveric Specimens.

PURPOSE: To calculate the iliopsoas muscle/tendon ratio at 3 levels of arthroscopic iliopsoas tenotomy sites in fresh cadaveric specimens. METHODS: An anatomic study design was performed using 16 iliopsoas musculotendinous units from the level of the hip joint to their insertion on the lesser trochanter. All specimens came from 16 fresh cadaveric specimens (10 male, 6 female), with a median age of 41 years (range 31-55.25 years). Circumferential measurements of the composite musculotendinous unit and the iliopsoas tendon were then made at the lesser trochanter insertion, the site of transcapsular tenotomy, and the site of tenotomy at the level of the labrum. Anatomical variance of the iliopsoas tendon at the insertion on the lesser trochanter and muscular extension below the lesser trochanter level also were described. The difference between the median circumference of the iliopsoas musculotendinous units or the isolated tendons at the 3 levels was calculated. RESULTS: The median circumference of the iliopsoas musculotendinous unit at the level of the labrum, orbicularis zone (transcapsular tenotomy site), and the lesser trochanter was 140.9 mm (range 137.9-148.9), 136.7 mm (range 132.9-140), and 99.5 mm (range 96.5-104.8), respectively. The median circumference of the iliopsoas tendon at these same levels was 25.6 mm (range 22.7-33.7), 28.9 mm (range 25.1-32.2), and 30.9 mm (range 27.9-36.1), respectively. Accordingly, the proportions of the iliopsoas muscle/tendon at the level of the labrum, the transcapsular tenotomy site, and the lesser trochanter insertion were 18% tendon/82% muscle, 21% tendon/79% muscle, and 31% tendon/69% muscle, respectively. CONCLUSIONS: The proportions of the iliopsoas muscle/tendon at the level of the labrum, the transcapsular tenotomy site and the lesser trochanter insertion were 18% tendon/82% muscle, 21% tendon/79% muscle, and 31% tendon/69% muscle, respectively. The distal muscular projection below the tendinous insertion on the lesser trochanter may maintain the functional connection of the iliopsoas between origin and insertion even after releasing the tendon. CLINICAL RELEVANCE: This finding may have implications for a new understanding of arthroscopic tenotomy of the iliopsoas around the hip, as previously described muscle/tendon proportions were not calculated in fresh cadavers.

Editorial Commentary: Hip-Spine Syndrome: When the Hip Does Not Move, the Spine Labors Double.

When the hip does not move, the spine labors double. For example, limited hip extension results in lumbar spine hyperextension and an increase in spinal facet joint loading due to premature coupling. Patients who undergo hip surgery show significant improvement in concomitant lower back problems, and symptomatic low back pain resolves in approximately 80% of patients after total hip arthroplasty. When an impairment in hip range of motion (limitation or asymmetry) is identified, a logical relationship to lumbar pathology should be explored, and treatment options may include interventions that improve hip joint range of motion.

Carbon dioxide gas endoscopy of the deep gluteal space.

The treatment of hip and pelvic pain associated with abnormalities of the deep gluteal space has evolved and increasingly involves endoscopic techniques with a saline expansion medium. This investigation presents a surgical technique utilizing carbon dioxide as the insufflation medium for deep gluteal space endoscopy in 17 cadaveric hips. This technique was successful in 94% (16/17) of the hips, allowing for visualization of the sciatic nerve, posterior femoral cutaneous nerve, pudendal nerve, branch of the inferior gluteal artery crossing the sciatic nerve, piriformis muscle, hamstring tendon origin, and lesser trochanter. Our experience suggests that gas expansion presents several advantages over fluid expansion.

Cognitive behavioral therapy reduces illness perceptions and anxiety symptoms in patients with unruptured intracranial aneurysm.

The main purpose of this study was to assess the relation between cognitive behavioral therapy and possible changes in illness perceptions and anxiety in patients diagnosed with unruptured intracranial aneurysm. An observational study of an intervention with 67 patients with an unruptured intracranial aneurysm from two medical centers in a Colombian city (n = 35 on the intervention group) was carried out. To assess changes, measurements were taken at baseline and at one-year follow-up with the Beck Anxiety Inventory and the Illness Perception Questionnaire, brief version, taking into account the importance of perceptions in the process of adjusting to illness and acquiring healthy life habits. Hypotheses were tested by a structural model. The results obtained from this study showed that illness perceptions were related to anxiety levels at both time points; however, the relations were stronger before cognitive behavioral therapy (ßt0 = 0.61, p < 0.01; ßt1 = 0.37, p < 0.01). Cognitive behavioral therapy was found to be a moderator of changes in both illness perceptions and anxiety at the time of follow-up (ß = -0.31, p < 0.01; ß = -0.26, p < 0.01). The structural model suggests that cognitive behavioral therapy is associated with less anxiety (ß = -0.17, p < 0.05) and better illness perceptions (ß = -0.35, p < 0.01) in patients diagnosed with unruptured intracranial aneurysms.

Personality and anxiety are related to health-related quality of life in unruptured intracranial aneurysm patients selected for non-intervention: A cross sectional study.

BACKGROUND: Personality traits and mental health problems have been previously reported in unruptured intracranial aneurysm (UIA) patients; however, few studies have clarified the relations between these variables and health-related quality of life (HRQoL). This study was designed to characterize the personality traits, HRQoL and mental health of patients with UIA and to evaluate whether personality has an influence on HRQoL and whether this is mediated by the patients' emotional symptoms. METHODS: Sixty-three patients with UIAs (mean age 62.6 years, 83.9% women) answered questionnaires for depression, anxiety, HRQoL and personality traits between June 2016 and May 2019. RESULTS: Eight percent of the sample had depression, and 27.4% had anxiety. Participants showed high levels of responsibility, kindness and neuroticism and low levels of extraversion and openness. HRQoL scores were normal compared with the Colombian population. Structural equation analysis showed that patients' HRQoL was negatively affected by anxiety levels and that the latter are associated with the patient's personality, where neuroticism is directly associated with symptomatology and inversely associated with extraversion. CONCLUSIONS: The results of this study showed the importance of personality and emotional symptoms in the HRQoL of UIA patients. These results are important for developing strategies for psychological counseling in patients with UIAs.

Reliability of the Arthroscopic Classifications of Hip Chondral Lesions.

Objective To evaluate the inter- and intraobserver reliability of the Outerbridge, Beck, and Haddad classifications for acetabular joint cartilage lesions through the arthroscopic procedure. Methods A total of 60 hip arthroscopy videos were evaluated twice by 4 surgeons at 2 different times to assess the inter- and intraobserver reproducibility of the classifications, and the data was analyzed by means of the weighted Cohen Kappa index. Results The mean weighted Kappa values in the interobserver assessment of the Outerbridge, Beck, and Haddad classifications were, respectively, 0.72, 0.78, and 0.68. The three classifications were considered as presenting good interobserver agreement. Regarding the intraobserver assessment of the Outerbridge, Beck, and Haddad classifications, the weighted Kappa values were, respectively, 0.9, 0.9, and 0.93. The three classifications were considered as presenting excellent intraobserver agreement. Conclusion In the present series, the Outerbridge, Beck, and Haddad classifications presented good interobserver reproducibility and excellent intraobserver reproducibility when evaluating acetabular chondral lesions by the arthroscopic approach.

Evaluación de resultados en una serie de pacientes con reparación de aneurimas aórticos mediante endoprótesis fenestradas / Evaluation of results in a series of patients with repair of aortic aneurims by fenestrated graft stent

Resumen Introducción: el aneurisma de aorta tiene una prevalencia de 5,7%; sin tratamiento su desenlace final es la ruptura y en ocasiones la muerte. En la actualidad, existe el reparo endovascular mediante prótesis fenestradas para pacientes en quienes es inviable el procedimiento quirúrgico. Están diseñadas para adaptarse a la anatomía única de cada paciente y dan cabida al flujo de uno o más vasos viscerales logrando resultados satisfactorios. Objetivo: reportar una serie de casos de pacientes con aneurismas de aorta tratados mediante endoprótesis fenestradas en un centro de referencia cardiovascular de Medellín, Colombia, entre 2013 y 2017. Método: estudio descriptivo, restrospectivo, de una serie de casos, cuya información se obtuvo por medio de una fuente secundaria. Resultados: los resultados se presentaron como porcentajes y frecuencias. Se utilizó el programa SPSS versión 20.0. La mayoría de los pacientes fueron hombres, con promedio de edad de 69,5 ±7,9 años. La mediana del diámetro aneurismático fue de 6,0 cm (RIQ 5,0-8,25). La mayoría de las complicaciones fueron vasculares. El 80,0% de los pacientes tuvieron algún seguimiento radiológico al mes, 6 meses o a los 12 meses después de la intervención; el 100,0% requirió revascularización del o los vasos intervenidos. Conclusiones: se considera que el balance adecuado entre riesgos y beneficios que otorga la técnica hace que, para el grupo específico de pacientes cuyas características clínicas y anatómicas hacen poco factible la cirugía, el uso de las prótesis fenestradas sea seguro y tenga resultados clínicos y de supervivencia similares al compararse con la literatura.

Abstract Introduction: Aortic aneurysm has a prevalence of 5.7%. Its final outcome without is a rupture, and occasionally death. Endovascular repair can currently be carried out using a fenestrated stent graft in patients in whom a surgical procedure is not feasible. These grafts are designed to adapt to the unique anatomy of each patient, and makes room for one or more visceral vessels to flow, achieving satisfactory results. Objective: To report a case series of patients with aortic aneurysms treated with a fenestrated stent graft between 2013 and 2017 in a cardiovascular reference centre in Medellín, Colombia. Method: A descriptive, retrospective study was conducted on a case series, in which the information was obtained for a secondary source. The results are presented as percentages and frequencies. The statistics program SPSS version 20.00 was used. Results: The majority of patients were male, and the mean age was 69.5 ±7.9 years. The median aneurysm diameter was 6.0 cm (IQR 5.0-8.25). The majority of complications were vascular. Some type of radiological follow-up was carried out on 80% of the patients at one month, 6 months, and 12 months after the intervention. All of them (100%) required revascularisation of the vessels intervened. Conclusions: The risk-benefit ratio is considered adequate for this technique. It means that, for the specific group of patients that have clinical and anatomical characteristics that make surgery highly unlikely, the use of fenestrated stent grafts are safe, and have similar clinical and survival results when compared with the literature.

Reliability of the Arthroscopic Classifications of Hip Chondral Lesions* / Confiabilidade das classificações artroscópicas das lesões condrais do quadril*

Abstract Objective To evaluate the inter- and intraobserver reliability of the Outerbridge, Beck, and Haddad classifications for acetabular joint cartilage lesions through the arthroscopic procedure. Methods A total of 60 hip arthroscopy videos were evaluated twice by 4 surgeons at 2 different times to assess the inter- and intraobserver reproducibility of the classifications, and the data was analyzed by means of the weighted Cohen Kappa index. Results The mean weighted Kappa values in the interobserver assessment of the Outerbridge, Beck, and Haddad classifications were, respectively, 0.72, 0.78, and 0.68. The three classifications were considered as presenting good interobserver agreement. Regarding the intraobserver assessment of the Outerbridge, Beck, and Haddad classifications, the weighted Kappa values were, respectively, 0.9, 0.9, and 0.93. The three classifications were considered as presenting excellent intraobserver agreement. Conclusion In the present series, the Outerbridge, Beck, and Haddad classifications presented good interobserver reproducibility and excellent intraobserver reproducibility when evaluating acetabular chondral lesions by the arthroscopic approach.

Resumo Objetivo Avaliar a confiabilidade inter- e intraobservador das classificações de Outerbridge, Beck e Haddad para lesões da cartilagem articular acetabular com o uso da via artroscópica. Métodos Foram avaliados 60 vídeos de artroscopias do quadril por 4 cirurgiões em 2 momentos para avaliar a reprodutibilidade inter- e intraobservador das classificações. Os dados foram analisados a partir do cálculo do índice Kappa de Cohen ponderado. Resultados Os valores do Kappa ponderado médio na avaliação interobservador das classificações de Outerbridge, Beck e Haddad foram, respectivamente, 0,72, 0,78 e 0,68. As três classificações foram consideradas como de boa concordância interobservador. Comrelação à avaliação intraobservador das classificações de Outerbridge, Beck e Haddad, os valores Kappa foram, respectivamente, 0,9, 0,9 e 0,93. As três classificações foram consideradas excelentes na comparação intraobservador. Conclusão Na presente série, as classificações de Outerbridge, Beck e Haddad apresentaram boa reprodutibilidade interobservador e excelente reprodutibilidade intraobservador ao avaliar lesões condrais acetabulares por via artroscópica.

Current Concepts Review: Evaluation and Management of Posterior Hip Pain.

Understanding the etiology of and evolving research on intra- and extra-articular hip complaints requires comprehensive diagnosis and management of the spectrum of posterior hip diseases. Interest in posterior hip disorders has increased in recent years as new studies and theories have emerged regarding the disease process. Although most of the differential diagnoses around the posterior hip have traditionally been considered uncommon, recent reports suggest that these complaints have instead been commonly overlooked. Failure to identify the cause of posterior hip pain in a timely manner can increase pain perception, deteriorate the patient's hope, and consequently affect quality of life. Posterior hip pain could be differentiated as intrapelvic and extrapelvic, and differential diagnosis is made based on a comprehensive history, physical examination, and imaging studies. Plain radiography, CT, MRI, 3T MRI, and imaging-guided injection tests are usually necessary for accurate diagnosis. Surgical intervention, whether endoscopic or open, is required for patients with long-standing symptoms for whom nonsurgical treatment has been unsuccessful and who have experienced temporary relief of their symptoms after injection. Orthopedic surgeons are uniquely trained in understanding the anatomy, biomechanics, clinical evaluation and treatment of all five layers of the hip.

Accuracy of 3 Clinical Tests to Diagnose Proximal Hamstrings Tears With and Without Sciatic Nerve Involvement in Patients With Posterior Hip Pain.

PURPOSE: To determine the diagnostic accuracy of the active hamstring test at 30° (A-30) and 90° (A-90) of knee flexion, the long stride heel strike (LSHS) test, and combination of the 3 tests for individuals with hamstring tendon tears, with and without sciatic nerve involvement. METHODS: A retrospective review of 564 consecutive clinical records identified 42 subjects with a mean age of 50.31 ± 15 years who underwent a standard physical examination prior to magnetic resonance imaging (MRI) evaluation and diagnostic injection for posterior hip. The physical examination included the A-30, A-90, and LSHS tests. Sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio were calculated to determine the diagnostic accuracy of these 3 tests. RESULTS: Forty-two subjects (female = 32 and male = 10) with a mean age of 50.31 years (range 15-77, ± SD 14.52) met the inclusion criteria and were included in the review. Based on MRI and/or injection, 64.28% (27/42) of subjects were diagnosed with hamstring tear. Fourteen (51.85%) presented with sciatic nerve involvement. The sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio for each test were as follows: A-30 knee flexion: 0.73, 0.97, 23.43, 0.28, and 84.73; A-90 knee flexion: 0.62, 0.97, 20.00, 0.39, and 51.67; LSHS: 0.55, 0.73, 2.08, 0.61, and 3.44. The most accurate findings were obtained when the results of the A-30 and A-90 were combined, with sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio of 0.84, 0.97, 26.86, 0.17, and 161.89, respectively. CONCLUSION: The combination of the active hamstring A-30 and A-90 tests proved to be a highly accurate and valuable tool to diagnose proximal hamstring tendons tears with or without sciatic nerve involvement in subjects presenting with posterior hip pain. LEVEL OF EVIDENCE: Level III, diagnostic study.

The effects of hip abduction on sciatic nerve biomechanics during terminal hip flexion.

Terminal hip flexion contributes to increased strain in peripheral nerves at the level of the hip joint. The effects of hip abduction and femoral version on sciatic nerve biomechanics are not well understood. A decrease in sciatic nerve strain will be observed during terminal hip flexion and hip abduction, independent of femoral version. Six un-embalmed human cadavers were utilized. Three Differential Variable Reluctance Transducers (DVRTs) sensors were placed on the sciatic nerve while the leg was flexed to 70° with a combination of - 10°, 0°, 20° and 40° adduction/abduction. DVRT placement included: (i) under piriformis, (ii) immediately distal to the gemelli/obturator, (iii) four centimeters distal to sensor two. A de-rotational osteotomy to decrease femoral version 10° was performed, and sciatic nerve strain was measured by the same procedure. Data were analyzed with three-way analysis of variance and Bonferroni post-hoc analysis to identify differences in the mean values of sciatic nerve strain between native and decreased version state, hip abduction angle and DVRT sensor location. Significant main effects were observed for femoral version (P = 0.04) and DVRT sensor location (P = 0.01). Sciatic nerve strain decreased during terminal hip flexion and abduction in the decreased version state. An 84.23% decrease in sciatic nerve strain was observed during hip abduction from neutral to 40° in the presence of decreased version at terminal hip flexion. The results obtained from this study confirm the role of decreased femoral version and hip abduction at terminal hip flexion to decrease the strain in the sciatic nerve.

Trombectomía mecánica en pacientes con ataque cerebrovascular isquémico: serie de casos en un centro de referencia colombiano / Mechanical Thrombectomy in patients with isquemic stroke: Case series in a Colombian reference center

RESUMEN OBJETIVO: Este artículo describe las características clínicas, indicaciones y desenlaces de mortalidad, eventos adversos e independencia funcional en pacientes con ataque cerebrovascular isquémico, ACVi, sometidos a trombectomía mecánica con stent Solitaire, TMSS. MATERIALES Y MÉTODOS: Estudio descriptivo, retrospectivo, de corte trasversal llevado a cabo entre abril de 2013 y abril de 2016. RESULTADOS: Durante el periodo de tiempo evaluado, se sometieron un total de 10 pacientes a TMSS. La edad media de los pacientes fue 62 años. Todos los pacientes tenían una buena clase funcional previa al ACVi, definida como una escala modificada de Rankin de 0 a 2. Al momento de la consulta, la escala de Rankin modificada fue 4. Los pacientes se sometieron a estrategia reperfusión combinada que consta de trombolisis intravenosa más trombectomía mecánica. Sin embargo, un 40 % de los pacientes tenía contraindicación para trombolisis. La mortalidad fue de 20 %, al igual que el sangrado cerebral que se presentó en 20 % de los pacientes y el Rankin modificado mejoró a lo largo del seguimiento en el 70 % de los pacientes, con un total de 50 % de pacientes que lograron independencia funcional significativa. CONCLUSIÓN: Parece haber impacto importante en la independencia funcional de pacientes sometidos a estrategia combinada de reperfusión cerebral con el uso de stents recuperadores, sin diferencia en la seguridad y mortalidad comparado con la estrategia estándar.

SUMMARY OBJECTIVE: This paper describes the clinical features, treatment indications, mortality and severity of global disability in the follow up outcomes in isquemic cerebrovascular stroke patients submitted to mechanical thrombectomy. MATERIALS AND METHODS: Retrospective, descriptive, cross-sectional study conducted from April 2013 to April 2016. RESULTS: During the study period, ten patients underwent mechanical thrombectomy. Mean age was 62, median modified Rankin Scale Score at acceptance was 4. Initially, all patients had a combined reperfusion approach, unless there were contraindications. Intravenous thrombolysis was contraindicated in 40% of patients. Mortality Trombectomía mecánica en pacientes con ataque cerebrovascular isquémico: serie de casos en un centro de referencia colombiano rate was 20% as well as intraparenchimal hemorrhage. Modified Rankin Scale improved during follow up in 70% of patients. Of these, functional independence was achieved by 50% of patients. CONCLUSION: it seems to be a functional independence impact on patients submitted to mechanical thrombectomy. There is not difference in safety and mortality outcomes.

Influence of Aging on Microvascular Supply of the Gluteus Medius Tendon: A Cadaveric and Histologic Study.

PURPOSE: The purpose of this cadaveric study was to assess the relation between age and microvascular supply of 3 areas of the gluteus medius tendon using a previously validated CD31 immunohistochemistry staining technique. METHODS: Twenty-four fresh-frozen gluteus medius specimens were obtained through a posterolateral approach to the hip. Specimens aged 18 years or older, of either sex, and of any race were considered for this study. The average age of donors was 47.3 years (range, 18-68 years). Each sample was divided into 3 portions: musculotendinous, tendinous, and tendon-bone junction. H&E staining was used for qualitative structural analysis, and then all samples underwent staining with CD31 immunohistochemistry for quantitative assessment of vessels per square millimeter. A comparison of the microvessel density between zones according to age was performed by an analysis of variance. To evaluate the relation between microvessel supply and age, a regression model with curvilinear estimation was used. The data were fitted to a quadratic model. RESULTS: Vascular supply in transversal and longitudinal cuts regardless of the zone was, on average, 53.9 ± 32.1 vessels/mm2 and 51.1 ± 19.3 vessels/mm2, respectively. All the areas of the tendon showed a strength of relation (R) ranging from 0.41 to 0.76 between age and vascular supply. In addition, the proportion of vascular supply change explained by age (R2) was significant in most cases (ranging from 0.17 to 0.56, with P < .05). CONCLUSIONS: There is a chronological relation between aging and microvascular supply of the gluteus medius tendon, in which an initial increase occurs from 18 years of age to 30 to 40 years of age, with a progressive decrease after 50 years of age. CLINICAL RELEVANCE: The findings of our study may have implications for increased vulnerability of the gluteus medius tendon and decreased healing potential.

The Hip-Spine Effect: A Biomechanical Study of Ischiofemoral Impingement Effect on Lumbar Facet Joints.

PURPOSE: To assess the relation between ischiofemoral impingement (IFI) and lumbar facet joint load during hip extension in cadavers. METHODS: Twelve hips in 6 fresh T1-to-toes cadaveric specimens were tested. A complete pretesting imaging evaluation was performed using computed tomography scan. Cadavers were positioned in lateral decubitus and fixed to a dissection table. Both legs were placed on a frame in a simulated walking position. Through a posterior lumbar spine approach L3-4 and L4-5 facet joints were dissected bilaterally. In addition, through a posterolateral approach to the hip, the space between the ischium and the lesser trochanter was dissected and measured. Ultrasensitive, and previously validated, piezoresistive force sensors were placed in lumbar facet joints of L3-4 and L4-5. Lumbar facet loads during hip extension were measured in native hip conditions and after simulating IFI by performing lesser trochanter osteotomy and lengthening. Four paired t-tests were performed comparing normal and simulated IFI on the L3-L4 and L4-L5 facet joint loads. RESULTS: After simulating IFI, mean absolute differences of facet joint load were 10.8 N (standard error of the mean [SEM] ±4.53, P = .036) for L3-4 at 10° of hip extension, 13.71 N (SEM ±4.53, P = .012) for L3-4 at 20° of hip extension, 11.49 N (SEM ±4.33, P = .024) for L4-5 at 10° of hip extension, and 6.67 N (SEM ±5.43, P = .245) for L4-5 at 20° of hip extension. A statistically significant increase in L3-4 and L4-5 lumbar facet joint loads of 30.81% was found in the IFI state as compared with the native state during terminal hip extension. CONCLUSIONS: Limited terminal hip extension due to simulated IFI significantly increases L3-4 and L4-5 lumbar facet joint load when compared with non-IFI native hips. CLINICAL RELEVANCE: This biomechanical study directly links IFI to increased lumbar facet loads and supports the clinical findings of IFI causing lumbar pathology. Assessing and treating (open or endoscopic) hip disorders that limit extension could have benefit in patients with concomitant lower back symptoms.

Contribution of the Pubofemoral Ligament to Hip Stability: A Biomechanical Study.

PURPOSE: To determine the isolated function of the pubofemoral ligament of the hip capsule and its contribution to hip stability in external/internal rotational motion during flexion greater than 30° and abduction. METHODS: Thirteen hips from 7 fresh-frozen pelvis-to-toe cadavers were skeletonized from the lumbar spine to the distal femur with the capsular ligaments intact. Computed tomographic imaging was performed to ensure no occult pathological state existed, and assess bony anatomy. Specimens were placed on a surgical table in supine position with lower extremities resting on a custom-designed polyvinylchloride frame. Hip internal and external rotation was measured with the hip placed into a combination of the following motions: 30°, 60°, 110° hip flexion and 0°, 20°, 40° abduction. Testing positions were randomized. The pubofemoral ligament was released and measurements were repeated, followed by releasing the ligamentum teres. RESULTS: Analysis of the 2,106 measurements recorded demonstrates the pubofemoral ligament as a main controller of hip internal rotation during hip flexion beyond 30° and abduction. Hip internal rotation was increased up to 438.9% (P < .001) when the pubofemoral ligament was released and 412.9% (P < .001) when both the pubofemoral and teres ligament were released, compared with the native state. CONCLUSIONS: The hypothesis of the pubofemoral ligament as one of the contributing factors of anterior inferior hip stability by controlling external rotation of the hip in flexion beyond 30° and abduction was disproved. The pubofemoral ligament maintains a key function in limiting internal rotation in the position of increasing hip flexion beyond 30° and abduction. This cadaveric study concludes previous attempts at understanding the anatomical and biomechanical function of the capsular ligaments and their role in hip stability. CLINICAL RELEVANCE: The present study contributes to the understanding of hip stability and biomechanical function of the pubofemoral ligament.

Accuracy of 2 Clinical Tests for Ischiofemoral Impingement in Patients With Posterior Hip Pain and Endoscopically Confirmed Diagnosis.

PURPOSE: To establish the accuracy of the long-stride walking (LSW) and ischiofemoral impingement (IFI) tests for diagnosing IFI in patients whose primary symptom is posterior hip pain. METHODS: Confirmed IFI cases and cases in which IFI had been ruled out were identified considering imaging, injections, and endoscopic assessment, combined with pain relief and negative IFI-specific tests after treatment. Demographic data, duration of symptoms, pain location, ischiofemoral space, quadratus femoris space, quadratus femoris edema, surgical findings, and visual analog scale score for pain before and after treatment were computed for all patients included in this study. Sensitivity, specificity, predictive values, likelihood ratios, and diagnostic odds ratios were computed individually for the LSW test and IFI test. RESULTS: Cases from 1,166 consecutive hip operations and charts from 564 consecutive outpatients were retrospectively reviewed to identify patients who underwent injection and/or endoscopic surgery because of posterior hip pain. Thirty individuals (21 women and 9 men) with a mean age of 49.8 years (range, 20 to 76 years; standard deviation, 13.0 years) were included for analysis. Of the 30 patients, 17 (56.6%) were confirmed as positive for IFI and 13 (43.4%) were confirmed as negative for IFI. The IFI test had a sensitivity of 0.82, specificity of 0.85, positive predictive value of 0.88, negative predictive value of 0.79, positive likelihood ratio of 5.35, negative likelihood ratio of 0.21, and diagnostic odds ratio of 25.6. The LSW test had a sensitivity of 0.94, specificity of 0.85, positive predictive value of 0.89, negative predictive value of 0.92, positive likelihood ratio of 6.12, negative likelihood ratio of 0.07, and diagnostic odds ratio of 88.8. CONCLUSIONS: In patients with complaints of posterior hip pain and negative evaluation findings for lumbosacral spine involvement or static/dynamic mechanical axis malalignment, the IFI and LSW tests are highly accurate to help identify those with or without IFI. LEVEL OF EVIDENCE: Level III, diagnostic study.

Femoral Neck Anteversion and Lesser Trochanteric Retroversion in Patients With Ischiofemoral Impingement: A Case-Control Magnetic Resonance Imaging Study.

PURPOSE: To assess the relationship between the femoral neck version (FNV) and lesser trochanteric version (LTV) in symptomatic patients with ischiofemoral impingement (IFI) as compared with asymptomatic hips. METHODS: The FNV and LTV of patients with symptomatic IFI who underwent magnetic resonance imaging assessment including a standardized femoral version study protocol were compared with those of patients with asymptomatic hips in this retrospective, observational study. Patients with isolated intra-articular pathology, prior hip fracture, and lesser trochanter deformity were excluded. The FNV, LTV, ischiofemoral space, and quadratus femoris space were evaluated on axial magnetic resonance imaging, as well as the angle between the LTV and the FNV. Independent t-tests were used to determine differences between groups. RESULTS: Data from 11 out 15 symptomatic patients and 250 out of 320 asymptomatic patients were analyzed. The mean ischiofemoral space (11.9 v 22.9 mm; P < .001; 95% confidence interval [CI], 6.9 to 15.2) and mean quadratus femoris space (7.2 mm v 14.9 mm; P < .001; 95% CI, 5.4 to 8.6) were significantly smaller in symptomatic patients versus asymptomatic patients. There was no difference in mean LTV between groups (-23.6° v -24.2°; P = .8; 95% CI, -7.5 to 6.4), however, the mean FNV (21.7° v 14.1°; P = .02; 95% CI, -14.2 to -1.1) and the angle between the FNV and LTV on average (45.4° v 38.3°; P = .01; 95% CI, -12.9 to -1.3) were higher in symptomatic than in asymptomatic patients, with statistical significance. CONCLUSIONS: The femoral mean neck anteversion and the mean angle between the FNV and LTV are significantly higher in patients with symptomatic IFI. The mean LTV is not increased in patients with symptomatic ischiofemoral impingement as compared with those patients with asymptomatic hips. LEVEL OF EVIDENCE: Level III, diagnostic study.

Dolor posoperatorio en pacientes sometidos a artroscopia de cadera con la técnica dentro-fuera en comparación con la técnica fuera-dentro / Douleur postopératoire chez les patients traités par la technique arthroscopique de dehors en dedans en comparaison avec la technique de dedans en dehors au niveau de la hanche / Postoperative pain in patients undergoing hip arthroscopy with inside-out technique compared with the outside-in technique

Objetivo: comparar el dolor posoperatorio en pacientes sometidos a artroscopia de cadera con la técnica dentro-fuera en comparación con la técnica fuera-dentro. Métodos: se realizó un estudio prospectivo en el que se comparó el dolor posoperatorio en un grupo de pacientes (n = 31) a los que se les realizó artroscopia de cadera mediante la técnica fuera-dentro, con los pacientes (n = 31) a los que se les realizó con la técnica dentro-fuera; ambos grupos de pacientes recibieron la misma analgesia multimodal. Los parámetros principales medidos fueron: la escala visual análoga en diferentes momentos hasta 24 horas después de la operación y la necesidad de opiáceos. Para las variables categóricas se realizó la comparación mediante Chi cuadrado, y para las variables cuantitativas mediante t Student o Mann-Whitney. Se calcularon el OR y el IC 95 por ciento. Para el análisis de los datos se utilizó el programa SPSS versión 21.0 y se consideró un error alfa de 5 por ciento. Resultados: la escala visual análoga posoperatoria fue menor en pacientes con la técnica de fuera-dentro después de 1 hora (diferencia media 1,9 IC 95 por ciento: 0,5 a 3,2, p = 0,01), después de 2 horas (diferencia media 1,29 IC 95 por ciento: 0,3 a 2,2, p = 0,01), y en el momento del alta (diferencia media 0,77 IC 95 por ciento: 0,16 a 1,18; p = 0,01). Sin embargo, 24 horas después del procedimiento, la diferencia no fue significativa (diferencia media 0,4 IC 95 por ciento: 0,02 a 0,84; p = 0,08). Las necesidades de opioides en el posoperatorio fueron significativamente menores en los pacientes con la técnica fuera-dentro ─6,5 por ciento vs. 41,9 por ciento─ (OR crudo 0,09 IC 95 porciento: 0,02 a 0,47; p = 0,004), incluso después de ajustar por edad, sexo y el IMC (OR ajustado 0,09 IC 95 por ciento: 0,016 hasta 0,51, p = 0,006). Conclusiones: los pacientes a los que se les realiza artroscopia de cadera con la técnica fuera-dentro tienen menos dolor posoperatorio y requerimientos de opioides que aquellos a los que se les realiza la técnica dentro-fuera(AU)

Objective: compare postoperative pain in patients undergoing hip arthroscopy with the inside-out technique compared to outside-in technique. Methods: a prospective study was conducted on postoperative pain in a group of patients (n = 31) who underwent hip arthroscopy by outside-in technique, which were compared with patients (n = 31) who received the inside-out technique. Both groups of patients received the same multimodal analgesia. The main parameters were measured: visual analogue scale at different times up to 24 hours after surgery and opioid need. Categorical variables were compared using Chi-square, and quantitative variables using Student t or Mann-Whitney. OR and CI 95 percent were calculated. SPSS version 21.0 was used for data analysis program and an alpha error of 5 percent was considered. Results: postoperative visual analogue scale was lower in patients with outside-in technique after 1 hour (mean difference 1.9, 95 percent CI 0.5 to 3.2, p = 0.01) after 2 hours (mean difference 1.29, 95 percent CI 0.3 to 2.2, p = 0.01) and at discharge (mean difference 0.77, 95 percent CI 0.16 to 1.18; p = 0.01). However, 24 hours after the procedure, the difference was not significant (mean difference 0.4, 95 percent CI 0.02 to 0.84; p = 0.08). Opioid requirements postoperatively were significantly lower in patients with the outside-in technique ─6,5 percent vs. 41.9 percent─ (crude OR 0.09 95 percnt CI 0.02 to 0.47; p = 0.004), even after adjusting age, sex and BMI (adjusted OR 0.09, 95 percent CI: 0.016 to 0.51, p = 0.006). Conclusions: Patients who underwent hip arthroscopy with outside-in technique have less postoperative pain and opioid requirements that those who undergo the inside-out technique(AU)

Objectif: le but de ce travail est de comparer la douleur postopératoire chez des patients opérés par la technique arthroscopique de dedans en dehors avec la technique de dehors en dedans au niveau de la hanche. Méthodes: une étude prospective a été réalisée afin de comparer la douleur postopératoire dans un groupe de patients traités par la technique arthroscopique de dehors en dedans (n = 31) et dans un groupe de patients traités par la technique arthroscopique de dedans en dehors (n = 31) au niveau de la hanche. Tous les deux groupes ont reçu une analgésie multimodale. On a fondamentalement évalué des paramètres tels que l'échelle visuelle analogique (EVA) en différents moments, même 24 heures après l'opération, et le besoin d'opiacés. Pour les variables catégoriques, on a utilisé le test de Chi carré, et pour les variables quantitatives le test du t de Student ou de Mann-Whitney. On a également calculé l'OR et l'IC 95 pourcent. Pour l'analyse des données, on a utilisé le logiciel SPSS v21.0, et une erreur alpha de 5 pourcent a été considérée. Résultats: la valeur EVA en postopératoire a été inférieure chez les patients opérés par la technique de dehors en dedans après 1 h (différence moyenne 1.9 IC 95 pourcent : 0.5 à 3.2, p = 0.01), après 2 h (différence moyenne 1.29 IC 95 pourcent : 0.3 à 2.2, p = 0.01), et à la sortie de l'hôpital (différence moyenne 0,77 IC 95 pourcent : 0.16 à 1.18 ; p = 0.01). Par contre, la différence n'a pas été significative (différence moyenne 0.4 IC 95 pourcent : 0.02 à 0.84 ; p = 0.08) 24 h après le geste opératoire. Le besoin d'opiacés en postopératoire a été significativement inférieur chez les patients traités par la technique de dehors en dedans ─6.5 pourcent vs. 41.9 pourcent─ (OR cru 0.09 IC 95 pourcent : 0.02 à 0.47 ; p = 0.004), même après l'ajustement par âge, sexe et IMC (OR ajusté 0.09 IC 95 pourcent : 0.016 jusqu'à 0.51, p = 0.006). Conclusions: on conclut que les patients traités par la technique arthroscopique de dehors en dedans souffrent moins de douleur postopératoire et n'ont pas besoin d'opiacés que ceux qui ont été traités par la technique arthroscopique de dedans en dehors. Mots clés: arthroscopie de hanche, technique arthroscopique de dehors en dedans, technique arthroscopique de dedans en dehors, blocage fémoral, blocage ilio-facial, analgésie multimodale, douleur postopératoire(AU)

Dry Endoscopic-Assisted Mini-Open Approach With Neuromonitoring for Chronic Hamstring Avulsions and Ischial Tunnel Syndrome.

Chronic hamstring origin avulsions and ischial tunnel syndrome are common causes of posterior hip pain. Although physical therapy has shown benefits in some cases, recent evidence has reported better outcomes with surgical treatment in appropriately selected patients. The full-open approach has been the classic procedure to address this problem. However, the complications related to extensive tissue exposure and the proximity of the incision to the perianal zone have led to the description of full-endoscopic techniques. Achieving an accurate hamstring repair could be technically demanding with a full-endoscopic procedure. Accurate reattachment is crucial in hamstring repair because of the functional demand of the muscles crossing of 2 major joints (hip and knee). This surgical note describes a mixed technique including a mini-open approach, neuromonitoring, and dry endoscopic-assisted repair of the hamstring origin as an alternative for treating patients with chronic hamstring avulsions and ischial tunnel syndrome that remain symptomatic despite nonoperative treatment.