Successful Hip Arthroscopy Using Postless Distraction in a Professional Basketball Player: A Case Report.

CASE: A 36-year-old 7'0' male professional basketball player presented with hip pain and radiographic imaging consistent with femoroacetabular impingement syndrome and a labral tear. Hip arthroscopy was performed with the patient positioned supine on a postless distraction table to negate the risk of pudendal nerve and perineal skin complications. Hip distraction was achieved with only 40 lbs (18.14 kg) of distraction force. Labral repair and cam osteochondroplasty were safely performed without complication. CONCLUSIONS: This case is the first to demonstrate that postless distraction may be considered for patients at end ranges of height that exceed the limitations of common hip arthroscopy tables.

The effect of joint space on midterm outcomes after arthroscopic hip surgery for femoroacetabular impingement.

BACKGROUND: Excellent short-term results have been reported after hip arthroscopic surgery to address femoroacetabular impingement (FAI). Purpose/ HYPOTHESIS: The purpose of this study was to determine if patients with narrow joint spaces had inferior outcomes at a postoperative minimum of 5 years and if they had a higher conversion rate to total hip arthroplasty (THA). The hypothesis was that patients with ≤2-mm joint spaces would report inferior outcomes and that patients with >2-mm joint spaces would have improved survivorship (no conversion to THA). STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Between March 2005 and January 2008, prospectively collected data were analyzed for patients older than 18 years of age undergoing hip arthroscopic surgery for FAI. Radiographic measurements of joint space were collected, and hips were grouped as having preserved (>2 mm) or limited (≤2 mm) joint space. Outcome measures included the Western Ontario and McMaster Universities Arthritis Index (WOMAC), modified Harris Hip Score (MHHS), Hip Outcome Score (HOS) for activities of daily living and sports, and Short Form-12 (SF-12). RESULTS: There were 559 patients included, 466 (83%) of whom were contacted. Fifty-four patients with limited joint spaces (86%) converted to THA, while only 63 patients with preserved joint spaces (16%) converted to THA. The mean survival time for patients with preserved joint spaces was 88 months (95% CI, 85-91 months), and the mean survival time for patients with limited joint spaces was 40.0 months (95% CI, 33.7-46.3 months) (P = .0001). Complete follow-up outcome data were available on 323 patients, none of whom had THA, with a mean follow-up of 73 months. The mean postoperative HOS for activities of daily living and sports were significantly better in patients with preserved joint spaces (82 vs. 62 [P = .012] and 77 vs. 47 [P = .003], respectively) compared with those with limited joint spaces at a mean of 73 months postoperatively (range, 60-97 months). CONCLUSION: Hip arthroscopic surgery for FAI resulted in significantly better outcomes and activity levels at minimum 5-year follow-up in patients with preserved joint spaces. Hips with limited joint spaces converted to THA earlier than did those with preserved joint spaces.

Management of labral tears of the hip in young patients.

Our understanding of labral tears in young patients has evolved significantly in recent years. Successful outcome depends on addressing all bony impingement to improve the intra-articular environment, and prevent further damage to the labrum and articular cartilage. Improved clinical outcomes are associated with labral repair; in cases of a deficient labrum, arthroscopic reconstruction techniques have been developed, with promising clinical outcomes. This article reviews the anatomy of the acetabular labrum, and discusses the pathogenesis of labral tears as well as various treatment options, including arthroscopic labral repair and reconstruction.

The approach to the evaluation and surgical treatment of mechanical hip pain in the young patient: AAOS exhibit selection.

The mechanical causes of hip pain in a young athlete often reflect a complex combination of static and dynamic factors. A comprehensive diagnostic approach is paramount to the development of a rational treatment strategy that will address all underlying pathologic factors. The goals of this paper are to highlight the pertinent biomechanical factors of the hip joint in femoroacetabular impingement and to discuss the clinical history, physical examination, and radiographic findings that are essential to formulating a proper diagnosis and an effective treatment plan. In addition, the current literature and reported outcomes of femoroacetabular impingement surgery in athletic patients are reviewed.

Diagnosis and management of superior labral anterior posterior tears in throwing athletes.

Injury to the superior glenoid labrum is increasingly recognized as a significant source of shoulder pain and dysfunction in the throwing athlete. Several theories have been proposed to explain the pathogenesis of superior labral anterior posterior (SLAP) tears. The clinical examination of the superior labrum-biceps tendon complex remains challenging because of a high association of other shoulder injuries in overhead athletes. Many physical examination findings have high sensitivity and low specificity. Advances in soft tissue imaging such as magnetic resonance arthrography allow for improved detection of labrum and biceps tendon lesions, although correlation with history and physical examination is critical to identify symptomatic lesions. Proper treatment of throwers with SLAP tears requires a thorough understanding of the altered biomechanics and the indications for nonoperative management and arthroscopic treatment of these lesions.

Diagnosis and management of the multiligament-injured knee.

Knee injuries involving multiple ligaments, which are often associated with tibiofemoral joint dislocations, are complex injuries that are challenging to evaluate and treat. The clinician must have a thorough understanding of knee anatomy and be capable of a detailed physical examination to determine the extent and pattern of injury. Accurate interpretation of imaging studies is crucial but cannot replace the physical examination. The magnitude of deforming forces and amount of translation and rotation of the tibia in relation to the femur determine the risk for neurovascular injury. Most patients with multiligament knee injuries undergo surgical management; however, some patients may be best served by a nonoperative approach. Successful rehabilitation consists of achieving good range of motion and strength, as well as normal gait mechanics, while respecting the stages of healing.

Diagnosis and management of humeral head bone loss in shoulder instability.

Humeral head bone defects (Hill-Sachs lesions) are caused by anterior shoulder dislocation with impaction of the posterosuperior humeral head onto the anterior glenoid rim. Frequently, these bony lesions are associated with glenohumeral instability, and large lesions may contribute to recurrent instability after failure of a soft tissue repair. To improve outcomes and minimize the risk of persistent instability, a thorough understanding of the biomechanics of humeral bone loss is required. Detection and quantification of clinically relevant humeral head bone loss are performed through an accurate history, physical examination, and interpretation of imaging studies. The diagnosis and treatment options for reverse Hill-Sachs lesions are discussed, and the various treatment options for Hill-Sachs lesions are reviewed, including operative techniques to limit engagement of the deformity by soft tissue transfer, rotational osteotomy, bone grafting, or osteochondral transplantation.

Long head of biceps brachii tendon evaluation: accuracy of preoperative ultrasound.

OBJECTIVE: The purpose of this study was to investigate the ability of ultrasound to accurately identify long head of biceps brachii (LHB) tendon abnormalities. MATERIALS AND METHODS: The surgical findings for 66 consecutive patients who underwent arthroscopic shoulder surgery were retrospectively compared with the findings of preoperative ultrasound examination. Patients were excluded if more than 200 days elapsed between ultrasound and surgery. Ultrasound images were obtained using high-frequency transducers and were compared with findings at arthroscopy for the presence of LHB tendon abnormalities, including full-thickness tears, partial-thickness tears, or nontear abnormalities, including tendinosis and tenosynovitis. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were calculated for full- and partial-thickness tears. RESULTS: Ultrasound correctly identified 90% (35/39) of normal LHB tendons, 88% (7/8) of full-thickness tears, 27% (3/11) of partial-thickness tears, and 22% (2/9) of tendons with nontear abnormality in those patients who underwent surgery. In the ultrasound diagnosis of full-thickness tear versus other findings, sensitivity was 0.88, specificity was 0.98, PPV was 0.88, NPV was 0.98, and accuracy was 0.97; in the ultrasound diagnosis of partial-thickness tear versus other findings, sensitivity was 0.27, specificity was 1.00, PPV was 1.00, NPV was 0.88, and accuracy was 0.88, in those patients who underwent surgery. CONCLUSION: Shoulder ultrasound is an accurate method to confirm a normal biceps tendon or full-thickness tear, but is less accurate in the diagnosis of partial-thickness tear and nontear abnormalities.

Total hip arthroplasty modular neck failure.

The use of modular components in total hip arthroplasty has increased in popularity. The advantages of modularity in hip arthroplasty include improved visualization during acetabular revision and restoration of proper hip biomechanics. Disadvantages include disassociation of components, failure at modular junctions, corrosion, and the generation of metal ions and debris. We present 2 cases that demonstrate the potential for modular neck fracture, requiring subsequent revision of well-fixed components.

Arthroscopic glenoid osteochondral allograft reconstruction without subscapularis takedown: technique and literature review.

Failure to address glenoid deficiency/osteochondral defects can lead to persistent shoulder instability despite a surgical stabilization procedure. In patients with significant glenoid bone loss, osteoarticular allograft transplantation has the potential benefit of restoring normal glenohumeral anatomy. It may also reduce the risk of recurrent instability and permit near-normal postoperative range of motion while avoiding the complications of nonanatomic reconstruction techniques. Numerous open methods of anatomic glenoid reconstruction have been described, including the use of iliac crest autograft, distal tibia allograft, and glenoid allograft. Our purpose is to review the literature regarding the surgical treatment of glenoid bone deficiency. We also describe a novel technique of arthroscopic anteroinferior glenoid reconstruction using glenoid osteochondral allograft without subscapularis takedown. The potential risks and benefits of our technique are also discussed.

Activation of the shoulder musculature during pendulum exercises and light activities.

STUDY DESIGN: Prospective, single-group, repeated-measures design. OBJECTIVES: To evaluate electromyographic (EMG) signal amplitude in the supraspinatus, infraspinatus, and deltoid muscles during pendulum exercises and light activities in a group of healthy subjects. BACKGROUND: There are numerous rehabilitation protocols used after rotator cuff repair. One of the most commonly used exercises in these protocols is the pendulum. Patients can easily perform these exercises incorrectly, and may also perform light activities of daily living without knowing that they may be putting excessive stress on the repair. The effect of improperly performed pendulum exercises and light activities after rotator cuff repair is unknown. METHODS: Muscle activity was recorded in 13 subjects performing pendulum exercises incorrectly and correctly in both large (51-cm) and small (20-cm) diameters, and while typing, drinking, and brushing their teeth. RESULTS: Incorrect and correct large pendulums and drinking elicited more than 15% maximum voluntary isometric contraction in the supraspinatus and infraspinatus. The supraspinatus EMG signal amplitude was greater during large, incorrectly performed pendulums than during those performed correctly. Both correct and incorrect large pendulums resulted in statistically higher muscle activity in the supraspinatus than the small pendulums. CONCLUSION: Larger pendulums may require more force than is desirable early in rehabilitation after rotator cuff repair.