Hip Labral and Capsular Repair Are Unable to Restore Distractive Stability in a Biomechanical Model.

PURPOSE: To evaluate the change in hip distractive stability after a capsulotomy, labral tear, and simultaneous repair of both the capsule and the labrum in a biomechanical model. METHODS: Ten fresh-frozen human cadaveric hips were analyzed using a materials testing system to measure the distractive force and distance required to disrupt the hip suction seal under the following conditions: (1) native intact capsule and labrum, (2) 2- or 4-cm interportal capsulotomy (IPC), (3) labral tear, (4) T extension, (5) labral repair, (6) T extension repair, and (7) IPC repair. Each specimen was retested at 0° of flexion, 45° of flexion, and 45° of flexion with 15° of internal rotation. RESULTS: A significantly higher distractive force was required to rupture the suction seal in the intact condition compared with IPC (P = .012; 95% confidence interval [CI], 4.9-42.4); IPC and labral tear (P = .002; 95% CI, 11.3-49.4); IPC, labral tear, and T extension (P = .001; 95% CI, 13.9-51.5); IPC, labral repair, and T extension (P < .001; 95% CI, 20.8-49.7); IPC, labral repair, and T extension repair (P = .002; 95% CI, 12.5-52.4); and IPC repair, labral repair, and T extension repair (P = .01; 95% CI, 5.8-46.1). The IPC condition required a higher distractive force in isolation than when combined with a labral tear (P = .14; 95% CI, 1.2-12.0), T extension (P = .005; 95% CI, 2.8-15.3), or labral repair (P = .002; 95% CI, 4.4-18.8). CONCLUSIONS: The distractive resistance of an intact hip capsule and labrum was not restored once the soft tissues were violated, despite labral repair with a loop technique and capsular repair with interrupted figure-of-8 sutures. CLINICAL RELEVANCE: Time-zero complete capsular repair with concomitant labral repair may not be adequate to restore distractive hip stability after hip arthroscopy, reinforcing the use of postoperative precautions in the early postoperative period.

Not all patient-reported outcome measures are equivalent at two years compared to one year after anterior cruciate ligament reconstruction based on a retrospective analysis.

OBJECTIVE: This article aims to assess for clinically important differences in patient-reported outcome measures (PROMs) at one and two years post anterior cruciate ligament reconstruction (ACLR). METHODS: A retrospective comparison of prospectively collected PROMs for a single cohort who underwent a primary ACLR with or without associated meniscal surgery from 2016 to 2020 was assessed. Six externally validated PROMs were collected preoperatively and at standardized times postoperatively. Descriptive statistics and paired equivalence testing of PROMs at one and two years after surgery was completed using previously published or calculated minimal clinically important differences as upper and lower equivalence limits. A repeated measures analysis of PROMs that were not clinically equivalent at one and two years after surgery was completed to assess for a clinically significant difference. Subgroup analyses based on sex, age and associated meniscal injury were completed. RESULTS: One-hundred and forty-five participants with a mean age of 28.7 years (standard deviation: 9.9 years) were included in the final analysis. All PROMs were clinically equivalent at two years compared to one year after ACLR except the quality of life and sport and recreation domains of the Knee Injury and Osteoarthritis Outcome Score (KOOS). The quality of life (mean difference (MD):12.3, P â€‹< â€‹0.01, effect size (η2): 0.65) and sport and recreation (MD: 8.78, P â€‹< â€‹0.01, η2: 0.50) domains of the KOOS were clinically different at two years compared to one year postoperatively. No major differences were found in the subgroup analyses compared to the entire included sample. CONCLUSION: While most PROMs were equivalent at two years compared to one year after ACLR, the quality of life and sport and recreation domains of the KOOS, which reflect knee performance during higher demand activities, exhibited a clinically significant difference. LEVEL OF EVIDENCE: IV.

The Contribution of Soft Tissue and Bony Stabilizers to the Hip Suction Seal: A Systematic Review of Biomechanical Studies.

BACKGROUND: Previous biomechanical studies have identified capsular closure, labral repair or reconstruction, and osteochondroplasty as important surgical interventions to improve hip stability. PURPOSE: To investigate the outcome metrics used to quantify hip stability and assess and measure the relative contributions of the labrum, capsule, and bone to hip stability through a quantitative analysis. STUDY DESIGN: Systematic review and meta-analysis; Level of evidence, 4. METHODS: PubMed and Embase databases were searched using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Included studies evaluated cadaveric hip biomechanics related to capsular, labral, and bony management during hip arthroscopy. Studies were assessed for distraction force and distance, fluid measures, and contact forces used to quantify the suction seal. Exclusion criteria included open surgery, arthroplasty, reorientation osteotomy, or traumatic dislocation. RESULTS: A total of 33 biomechanical studies comprising 322 hips that evaluated 1 or more of the following were included: distraction force or distance (24 studies), fluid measures (10 studies), and contact forces (6 studies). Compared with a capsulotomy or capsulectomy, capsular repair or reconstruction demonstrated greater resistance to distraction (standardized mean difference [SMD], 1.13; 95% CI, 0.46-1.80; P = .0009). Compared with a labral tear, a labral repair or reconstruction demonstrated less resistance to distraction (SMD, -0.67; 95% CI, -1.25 to -0.09; P = .02). Compared with a labral debridement, repair or reconstruction demonstrated greater resistance to distraction (SMD, 1.74; 95% CI, 1.23 to 2.26; P < .00001). No quantitative analysis was feasible from studies evaluating the effect of osseous resection due to the heterogeneity in methodology and outcome metrics assessed. CONCLUSION: Most biomechanical evidence supports capsulotomy repair or reconstruction to improve hip distractive stability at the end of hip arthroscopic surgery. While the repair of a torn labrum does not improve distractive resistance, it is superior to labral debridement in most biomechanical studies.

If at first you don't succeed, should you try again? The efficacy of repeated closed reductions of distal radius fractures.

INTRODUCTION: A repeated closed reduction ("re-reduction") of a displaced distal radius fracture is a common procedure performed to obtain satisfactory alignment and avoid surgery when the initial reduction is deemed unsatisfactory. However, the efficacy of re-reduction is unclear. Compared to a single closed reduction, does a re-reduction of a displaced distal radius fracture: (1) improve radiographic alignment at the time of fracture union and, (2) decrease the rate of operative intervention? MATERIALS AND METHODS: Retrospective cohort analysis of 99 adults aged 20-99 years with extra-articular or minimally displaced intra-articular, dorsally angulated, displaced distal radius fracture with or without an associated ulnar styloid fracture who underwent a re-reduction, compared against 99 adults matched for age and sex who were managed with a single reduction. Exclusion criteria were skeletal immaturity, fracture-dislocation and articular displacement greater than 2 mm. Outcome measures included radiographic alignment at fracture union and rate of surgical intervention. RESULTS: At 6-8 weeks follow-up, the single reduction group had greater radial height (p = 0.045, CI 0.04 to 3.57), and less ulnar variance (p < 0.001, CI - 3.08 to - 1.00) compared to the re-reduction group. Immediately following re-reduction, 49.5% of patients met radiographic non-operative criteria, but by 6-8 weeks follow-up, only 17.5% of patients continued to meet these criteria. Patients in the re-reduction group were treated with surgery 34.3% of the time, compared to 14.1% of the time for patients in the single reduction group (p = 0.001). In patients aged under 65 years, 49.0% of those who underwent a re-reduction were managed with surgery, compared to 21.0% of those who had a single reduction (p = 0.004). CONCLUSION: A re-reduction performed to improve radiographic alignment and avoid surgical management in this subset of distal radius fractures had minimal value. Alternative treatment options should be considered before attempting a re-reduction.

Early Investigation and Bracing in DDH Impacts Maternal Wellbeing and Breastfeeding.

BACKGROUND: The outcomes of Pavlik Harness (PH) management for Developmental Dysplasia of the Hip (DDH) are equivalent regardless of the initiation timing, if it is within the first 6 weeks of life. A PH may be a physical barrier to breastfeeding, which is important for nutrition, immunity, and normal child development. The diagnosis of DDH and early management with a PH may also negatively affect the maternal psychosocial wellbeing and the infant-maternal relationship. The purpose of this study is to investigate the impact of the diagnosis of DDH and the management with a PH has on maternal wellbeing and maintenance of breastfeeding, compared with being screened for but not diagnosed with DDH. METHODS: A retrospective cohort of the mothers of infants who were diagnosed with DDH and treated with a PH brace was compared with the mothers of infants who were screened for DDH only. The Hip Worries Inventory and Edinburgh Postnatal Depression Scale were completed by the mothers in both groups. The PH group also completed an in-house questionnaire specific to PH and breastfeeding. RESULTS: Eighty completed surveys were included, 50 from the treatment group. The mean age of the PH initiation was 6.2 weeks. The modified Hip Worries Inventory score was higher in the treatment group, with a mean difference (MD) of 9.7 out of 50 (95% confidence interval, CI, 6.8, 12.5). The MD of the Edinburgh Postnatal Depression Scale was 2.0 out of 30 (CI -0.5, 4.5). Although there was no difference in the breastfeeding ease before and after the PH initiation (MD-0.2, CI-0.7, 0.2), 83% of mothers found breastfeeding more difficult with a PH and 11% of mothers stopped breastfeeding earlier than planned because of the PH. CONCLUSIONS: Mothers of infants with DDH worry more about their child's hips and the PH. Screening alone may contribute to maternal psychological dejection and negative thoughts. The presence of a PH makes breastfeeding more difficult. LEVEL OF EVIDENCE: Retrospective comparative study, level III.

Intra-articular Soft Tissue Pathology of the Postpartum Hip: A Systematic Review.

PURPOSE OF REVIEW: Pregnancy-related lumbopelvic and hip pain affects over half of postpartum females and has multiple aetiologies. The relative contribution of intra-articular soft tissue pathology to pregnancy-related hip pain is unknown. The current review investigates the available evidence regarding underlying intra-articular soft tissue aetiologies of hip pain in females during pregnancy and in the acute postpartum period. RECENT FINDINGS: Three online databases (Embase, PubMed and Ovid [MEDLINE]) were searched from database inception until 11 April 2021. All titles, relevant abstracts and full-text articles were screened by two reviewers independently. The methodological quality of the included studies was assessed using the Methodological Index for Non-Randomized Studies (MINORS) instrument. Descriptive study characteristics are presented in a narrative summary. Five level IV evidence articles were eligible for inclusion. Twenty-two females were included. Twenty patients presented with labral pathology, 15 of which necessitated hip arthroscopy with labral debridement or repair with or without acetabuloplasty and/or femoroplasty. One patient presented with an incidental labral tear in the context of osteitis condensans illi. One patient presented with posttraumatic osteoarthritis necessitating a hip arthroplasty. The contribution of intra-articular soft tissue injury is a documented, albeit sparse, aetiology contributing to pregnancy-related hip pain. Further research to better delineate the prevalence, natural history and optimal management options for females who sustained these injuries at a life-altering juncture is necessary to advance the care of these patients.

Near-peer question writing and teaching programme.

BACKGROUND: Near-peer assisted learning (NPAL) is an increasingly important tool in medical education; however, although numerous published papers discuss its merits, the evidence on the effectiveness and student perception of NPAL is limited. We describe a novel near-peer question writing and teaching programme to assess whether it improves the confidence of first-year medical students for their first In-Course Assessment (ICA) in medical school. The evidence on the effectiveness and student perception of NPAL is limited METHODS: A team of medical students designed a question development procedure and a structured teaching programme. A total of 280 first-year medical students were invited to appraise the questions. A questionnaire assessing confidence and student perception was sent to participants at different time points leading up to and after their first ICA at the medical school. Statistical analysis was performed using spss 20. RESULTS: One hundred and seventy one students attempted the questions. Students felt more confident with short-answer questions (SAQs; 95% CI 1.5-2.0, p < 0.05) and multiple-choice questions (MCQs; 95% CI 1.0-1.5, p < 0.05), as assessed using the Wilcoxon signed-rank test. Overall, students were satisfied with the NPAL questions and teaching programme following their university examinations (p > 0.01). CONCLUSION: The NPAL project highlighted a trend towards improving students' confidence. Furthermore, the question writing and teaching programme can be used as a guide to confidently hold teaching sessions in the future. The NPAL project further reinforces existing published papers that have shown NPAL to be a powerful adjunct to existing undergraduate medical education.