Acetabular retroversion does not affect outcome in primary hip arthroscopy for femoroacetabular impingement.

PURPOSE: The surgical treatment of femoral-acetabular impingement syndrome (FAIS) in patients with acetabular retroversion (AR) is arthroscopical or by a reverse periacetabular osteotomy (PAO). The purpose of the present study was to investigate the results after arthroscopic treatment of FAIS in patients with and without radiographic signs of AR in a large, prospective cohort from the Danish Hip Arthroscopy Registry (DHAR). The hypothesis was there is no difference in clinical outcome between the two groups. METHODS: Data on 4914 hip arthroscopies performed during 2012-2019 were obtained from DHAR. Patients with radiographic signs of osteoarthritis (Tönnis > 1), hip dysplasia (CEA < 25°), other hip pathologies or previous hip surgery were excluded. The clinical outcomes for patients with AR [defined by a positive posterior wall sign (PWS) in combination with a positive Ischial Spine Sign (ISS)] and patients without AR (no PWS, no ISS) were analyzed 1 and 2 years after surgery. The primary outcomes were the six domains of the Copenhagen Hip and Groin Outcome score (HAGOS), while secondary outcomes were the Hip Sports Activity Scale (HSAS), a visual analogue pain scale (VAS) and a numeric rating scale (NRS) for pain. RESULTS: A total of 3135 hip arthroscopies were included, of which 339 had AR, 1876 did not, and 920 presented one of the two signs (PWS and ISS). There were no statistically significant differences 1 and 2 years after surgery (n.s.) between patients with and without AR in HAGOS domain scores, HSAS, VAS, or NRS. Both groups showed improvement at both follow-ups. The two groups did not differ in relation to intraoperative findings and the procedures they have had. CONCLUSION: The outcome 1 and 2 years after arthroscopic treatment of FAIS is not different for patients with and without AR. LEVEL OF EVIDENCE: III.

Nonoperative, dynamic treatment of acute achilles tendon rupture: influence of early weightbearing on biomechanical properties of the plantar flexor muscle-tendon complex-a blinded, randomized, controlled trial.

Acute Achilles tendon rupture alters the biomechanical properties of the plantar flexor muscle-tendon complex that can affect functional performance and the risk of repeat injury. The purpose of the present study was to compare the biomechanical properties of the plantar flexor muscle-tendon complex in patients randomized to early weightbearing or non-weightbearing in the nonoperative treatment of Achilles tendon rupture. A total of 60 patients were randomized to full weightbearing from day 1 of treatment or non-weightbearing for 6 weeks. After 6 and 12 months, the peak passive torque at 20° dorsiflexion, the stiffness during slow stretching, and the maximal strength were measured in both limbs. The stiffness of the plantar flexor muscle-tendon complex in the terminal part of dorsiflexion was significantly increased (p = .024) in the non-weightbearing group at 12 months. The peak passive torque was significantly lower for the affected limb at 6 months (91%; p = .01), and the stiffness was significantly lower for the affected limb during the early part of dorsiflexion at 6 (67%; p < .001) and 12 (77%; p < .001) months. In conclusion, an increased stiffness of the plantar flexor muscle-tendon complex in the terminal part of dorsiflexion was found in the non-weightbearing group. The altered stiffness and strength in the affected limb could affect the coordination of gait and running.

Symptoms of nerve dysfunction after hip arthroscopy: an under-reported complication?

PURPOSE: The primary purpose of this study was to analyze the rate, pattern, and severity of symptoms of nerve dysfunction after hip arthroscopy (HA) by reviewing prospectively collected data. The secondary purpose was to study whether symptoms of nerve dysfunction were related to traction time. METHODS: From March to October 2010, 52 consecutive patients-27 male patients (mean age, 40 years; range, 21 to 63 years) and 25 female patients (mean age, 37 years; range, 15 to 60 years), underwent HA with labral repair, rim trimming, and osteoplasty. The patients received a follow-up questionnaire 1 year after HA concerning symptoms of nerve dysfunction, possible localization, and erectile dysfunction. Fifty patients participated and returned fully completed questionnaires. Patients reporting symptoms of nerve dysfunction 1 year after HA were re-examined. RESULTS: Twenty-three of 50 patients (46%) reported symptoms of nerve dysfunction during the first week after HA; this was reduced to 14 patients (28%) after 6 weeks, 11 patients (22%) after 26 weeks, and 9 patients (18%) after 1 year. One patient experienced temporary erectile dysfunction. No difference in traction time between patients with symptoms of nerve dysfunction (n = 23) and patients without (n = 27) was found (98 minutes v 100 minutes; P = .88). CONCLUSIONS: Forty-six percent of patients undergoing HA reported symptoms of nerve dysfunction within the first 6 weeks after surgery. One year postoperatively, these symptoms remained in only 18% of all patients. Traction time during surgery was not different in patients with and those without symptoms of nerve dysfunction. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Hip arthroscopy with labral repair for femoroacetabular impingement: short-term outcomes.

PURPOSE: The purpose of this study was to examine the progression of clinical outcomes 3, 6 and 12 months after hip arthroscopy with labral repair for femoroacetabular impingement (FAI). METHODS: From May 2009 to December 2011, 87 consecutive patients [55 females (median age 38, range 17-63) and 32 males (median age 38, range 15-59)] underwent hip arthroscopy and labral repair, by the same experienced surgeon. Standardised, but unstructured, post-operative rehabilitation instructions were provided. Function and pain were evaluated using modified Harris Hip Score (mHHS) and visual analogue scale (VAS) pre-operatively and post-operatively at 3, 6, and 12 months. RESULTS: A main effect of time was seen for mHHS and pain (VAS) at 3, 6, and 12 months (p < 0.001). Mean (SE) mHHS improved significantly from 59.9 (1.9) pre-operatively to 74.5 (1.9) after 3 months (p < 0.001), and again from 3 to 6 months from 74.5 (1.9) to 80.1 (1.9) (p = 0.004), with no additional changes from 6 to 12 months [80.1 (1.9)-78.7 (1.9), (n.s.)]. Also, the mean (SE) VAS improved significantly from pre-operative 57.9 (2.6) to 30.0 (2.6) after 3 months (p < 0.001), and from 30.0 (2.6) to 22.6 (2.6) (p = 0.017), after 6 months with no additional changes from 6 to 12 months [22.6 (2.6)-27.9 (2.6), (n.s.)]. CONCLUSIONS: Improvements in function (mHHS) and pain (VAS) were seen in patients after hip arthroscopy with labral repair for FAI at 3, 6, and 12 months. While significant improvements occurred from 3 to 6 months, no further improvements were seen from 6 to 12 months.

[Clinical diagnosticsand treatment of multiligament injuries of the knee].

Multiligament injuries (MLI) of the knee are rare and only ca. 150 MLI reconstructions are performed per year in Denmark. This review summarises the current guidelines for work-up and treatment. Surgical treatment of MLI is centralised to five highly specialised orthopaedic departments, while all hospitals are responsible for the initial treatment and diagnostics. Injury patterns can be complex and demand thorough analysis in collaboration with a department with highly specialised function in MLI. Although a nationwide interdisciplinary approach has been implemented, patients usually do not fully return to their pre-injury activity level and have a higher risk of developing osteoarthritis.

Arthroscopic treatment for femoroacetabular impingement syndrome (FAIS) in adolescents-5-year follow-up.

To report the minimum 5-year outcome after hip arthroscopy with labral repair in adolescents. From 2011 to 2014, 29 consecutive patients with a mean age 16.3 years (range 12.7-19.8 years) underwent hip arthroscopy treatment for femoroacetabular impingement syndrome. Patient-related outcome measures (PROMs) including modified Harris Hip Score (mHHS), Visual Analog Scale (VAS) for pain and Copenhagen Hip and Groin Outcome Score (HAGOS) were used preoperatively and at follow-up (FU). Percentage of patients achieving minimum clinically important difference (MCID) and substantial clinical benefit (SCB) for mHHS and HAGOS were determined. Mean FU was 6.7 years (range 5-9.6 years), and a 100% FU was accomplished. Significant improvements were seen for all PROMs at FU in patients not having a periacetabular osteotomy (PAO) with VAS pain score improving from mean 62 to 9, mHHS from 58 to 94 and HAGOS improved in all subgroups. For mHHS, SCB changes were achieved by 76% and MCID by 76% of the patients. Percentage of patients achieving MCID for HAGOS subgroups were 81% for pain, 67% for symptoms, 76% for physical function in daily living, 76% for physical function in sport and recreation, 81% for participation in physical activities and 81% for hip-related quality of life. Two patients had revision hip arthroscopy. PAO was later performed in three patients. The risk of further surgery with center edge (CE) bony edge (CEB) <30° was 42% and 0% with CEB ≥30°. Adolescents having hip arthroscopy with labral repair and resection of cam and pincer morphology achieve significant improvements at mean 6.7 years of FU. CEB < 30° increases the risk of further surgery.

Severe cerebral desaturation during shoulder arthroscopy in the beach-chair position.

During shoulder arthroscopy in the beach-chair position, cerebral ischemia may be a serious complication because prolonged hypotension may affect regional cerebral oxygen supply. We present the cases of 2 patients in whom a reduction in mean arterial pressure after anesthesia provoked a decrease in frontal lobe oxygenation to below the level that causes presyncopal symptoms in the awake subject. In the healthy middle-aged patient, cerebral oxygenation decreased by approximately 40%, indicating that cerebral blood flow was markedly reduced, and intravenous administration of ephedrine rapidly restored cerebral oxygenation. During surgery in the beach-chair position, hypotension must be avoided, and in all patients regional, cerebral oxygenation should be monitored and optimized.

[Younger patients with hip joint pain].

This review summarises the present knowledge of diagnosing and treating hip joint pain. The results of joint preserving surgery are good in symptomatic patients with hip dysplasia, acetabular retroversion or impingement (cam or pincer) without signs of osteoarthritis. Confirmation of intraarticular pathology as the cause of symptoms is established clinically, and the pathology can in many cases be visualised by a standing, standardised radiograph of the pelvis, which is the basis for admission to the relevant orthopaedic department. We present an algorithm for this. Dysplasia and retroversion can be treated by periacetabular osteotomy and impingement by arthroscopic procedures.

Multicentre study on capsular closure versus non-capsular closure during hip arthroscopy in Danish patients with femoroacetabular impingement (FAI): protocol for a randomised controlled trial.

INTRODUCTION: Hip arthroscopy has become a standard procedure in the treatment of hip joint pain not related to osteoarthritis or dysplasia in the young and active patient. There has been increasing focus on the contribution of the hip capsule to function and on stability following hip arthroscopy. It has been suggested that capsular closure after hip arthroscopy may prevent microinstability and macroinstability of the hip joint and reduce revision rate. However, it remains unknown whether capsular closure should be performed as a standard procedure when performing hip arthroscopies, especially in patients without additional risk factors for instability such as hypermobility or dysplasia of the hip. We hypothesised that capsular closure will lead to a superior outcome in hip arthroscopy for femoroacetabular impingement syndrome (FAIS) compared with non-capsular closure. METHODS AND ANALYSIS: In this randomised controlled, multicentre trial, 200 patients scheduled for hip arthroscopy for FAIS will be cluster randomised into one of two groups (group I: hip arthroscopy without capsular closure, group II: hip arthroscopy combined with capsular closure). Inclusion criteria are: age between 18 years and 50 years and FAIS according to the Warwick agreement. Exclusion criteria are: previous hip surgery in either hip, previous conditions of Legg-Calvé-Perthes or slipped capital femoral epiphysis, malignant disease, recent hip or pelvic fractures, arthritis, Ehlers-Danlos or Marfan disease, recent (within 6 weeks) application of intra-articular corticosteroids, language problems of any kind, and radiological signs of osteoarthritis, acetabular dysplasia or acetabular retroversion. Surgery will be performed in Denmark at four centres by four surgeons, all performing an interportal capsulotomy and closure with at least two absorbable sutures. Patients in both groups, who are blinded for the intervention, will receive the same standardised rehabilitation programme. As primary outcome scores, HAGOS (sport) will be used with HAGOS (symptoms, pain, function in daily living, participation in physical activities and hip and/or groin-related quality of life), Hip Sports Activity Scale, short validated version of the International Hip Outcome Tool, EQ-5D, Visual Analogue Scale for pain, complications and reoperation rate as secondary outcome tools. Using HAGOS (sport) as primary outcome parameter the power analysis required a minimum of 84 individuals per group. Together with a clinical examination performed by the patient's surgeon 1 year after surgery, patient reported outcome measures will be completed preoperatively, as well as at 3 months, 1 year, 2 years and 5 years postoperatively. In addition, adverse effects will be recorded. ETHICS AND DISSEMINATION: The study is approved by the Central Denmark Region Committee on Biomedical research ethics. The results of this study will be presented at national and international congresses and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT03158454; Pre-results.

The interface between periacetabular osteotomy, hip arthroscopy and total hip arthroplasty in the young adult hip.

Hip pain is highly prevalent in both the younger and the elderly population. In older patients, pain arising from osteoarthritis (OA) is most frequent, whereas in younger patients, non-degenerative diseases are more often the cause of pain. The pain may be caused by hip dysplasia and femoroacetabular impingement (FAI).Abnormal mechanics of the hip are hypothesized by some authors to cause up to 80% of OA in the hip. Therefore, correction of these abnormalities is of obvious importance when treating young patients with hip pain.Hip dysplasia can be diagnosed by measuring a CE angle < 25° on a plain standing radiograph of the pelvis.Dysplastic or retroverted acetabulum with significant symptoms should receive a periacetabular osteotomy (PAO).FAI with significant symptoms should be treated by adequate resection and, if necessary, labrum surgery.If risk factors for poor outcome of joint-preserving surgery are present (age > 45 to 50 years, presence of OA, joint space < 3 mm or reduced range of motion), the patient should be offered a total hip arthroplasty (THA) instead of PAO.THA can be performed following PAO with outcomes similar to a primary THA.Hip arthroscopy is indicated in FAI (cam and pincer) and/or for labral tears. Cite this article: EFORT Open Rev 2018;3:408-417. DOI: 10.1302/2058-5241.3.170042.