Spectrum of radiographic femoroacetabular impingement morphology in adolescents and young adults: an EOS-based double-cohort study.

BACKGROUND: Symptomatic femoroacetabular impingement is a known prearthritic condition. Impingement morphology is poorly defined in the adolescent population. The purpose of this study was to document the prevalence of radiographic impingement morphology in adolescents with no symptomatic hip problems. METHODS: Ninety anteroposterior images of the hip in forty-five consecutive adolescents with scoliosis met the inclusion criteria. Sex distribution was equal. The second cohort (ninety hips) was an age-matched group with no scoliosis. None had symptomatic hip problems. Images were analyzed for coxa profunda, protrusio acetabuli, Tönnis angle, anteroposterior alpha angle, center-edge angle, acetabular crossover, ischial spine sign, and neck-shaft angle. RESULTS: Of the 180 hips, 92.8% demonstrated at least one parameter suggesting impingement morphology, whereas 52.2% showed at least two signs. Evidence of coxa profunda was seen in 81.7% of the hips, while a negative Tönnis angle was seen in 31.1% and a center-edge angle indicative of acetabular overcoverage was seen in 15%. An acetabular crossover sign was detected in 27.2% of the hips, while an abnormal anteroposterior alpha angle was found in 5.6% of the hips in male patients and 6.7% of the hips in female patients. Statistical analysis revealed that abnormal alpha angles (p = 0.029), crossover signs (p = 0.029), and ischial spine signs (p = 0.026) were more common in the cohort without scoliosis, and coxa profunda was more common in females (p = 0.034). CONCLUSIONS: There was a high prevalence of radiographic impingement morphology beyond the spectrum of normal in this double-cohort study of adolescents. Femoroacetabular impingement remains a dynamic problem, and we caution against relying only on the use of hard-set static radiographic parameters when evaluating femoroacetabular impingement. This study raises the important question of what morphologic characteristics should be defined as abnormal, when at least one finding of impingement morphology is noted in such a large segment of the population. On the basis of the normative data obtained, reference values for radiographic parameters of femoroacetabular impingement morphology should be redefined. Normal values for a Tönnis angle were between -8° and 14°, the upper limit of the center-edge angle was 44°, and the normal values for femoral neck-shaft angle were between 121° and 144°. Surgical indications should be tailored to physical examination findings and not radiographic findings alone.

EOS imaging of the human pelvis: reliability, validity, and controlled comparison with radiography.

BACKGROUND: The EOS technique represents a unique imaging modality combining low radiation exposure with high image quality. As its applications for pelvic imaging may increase with time, we performed a pilot study to evaluate the validity and reliability of this technique for the assessment of gross pelvic and acetabular morphology. METHODS: Consecutive conventional and EOS radiographs of a human cadaveric pelvis were made in 5° intervals of sagittal tilt and axial rotation (range, -15° to 15° for each). Six measurements were made on each image: (1) the vertical distance between the sacrococcygeal joint and the upper border of the pubic symphysis, (2) the horizontal distance between the midpoints of these structures, (3) the distance between the anterior superior iliac spines, (4) the distance between the facets of S1, (5) the Sharp angle, and (6) the Tönnis angle. Coxa profunda and crossover signs were also evaluated. The findings of the two imaging techniques were correlated with each other and with true linear measurements made on the cadaveric pelvis. All measurements were performed by two independent observers, and one observer repeated all measurements to assess reproducibility. Both observers were blinded to the true linear measurements made on the pelvis. RESULTS: There was a strong correlation between the results of the conventional and EOS radiography (Pearson correlation coefficient, 0.644 to 0.998), and both modalities had high intraobserver and interobserver reproducibility (intraclass correlation coefficient, 0.795 to 1.000). Intraobserver and interobserver agreement on the presence of coxa profunda were both 100%. Intraobserver agreement (96.2%) and interobserver agreement (92.3%) on the presence of the crossover sign were marginally lower. Linear measurements differed significantly between the two modalities because of distortion caused by magnification effects in the conventional radiographic imaging (p < 0.05). CONCLUSIONS: The EOS imaging technique proved reliable for the assessment of gross pelvic and acetabular morphology, and it may be an alternative to current radiography for primary imaging in the pediatric population and potentially in adults as well. This study did not evaluate the ability of EOS imaging to detect subtle radiographic anatomic abnormalities.

Assessment and management of chronic pain in patients with stable total hip arthroplasty.

Total hip arthroplasty (THA) is one of the most successful operations that can restore function and relieve pain. Although a majority of the patients achieve significant pain relief after THA, there are a number of patients that develop chronic pain for unknown reasons. A literature search was performed looking for chronic pain after total hip arthroplasty and stable THA. Major causes of chronic pain include aseptic loosening or infection. However, there is a subset of patients with a stable THA that present with chronic pain which can have several aetiologies. These include soft tissue, bony, neurological, vascular and psychological causes. Essential for successful treatment is the ability to make the correct diagnosis. Thus therapy may be either non-operative or operative. In addition, diagnosis and management often may require multidisciplinary approaches to successfully alleviate chronic pain in these patients with a stable prosthesis.

The hip antero-superior labral tear with avulsion of rectus femoris (HALTAR) lesion: does the SLAP equivalent in the hip exist?

BACKGROUND: The purpose of this report is to describe a new lesion, the "Hip Antero-superior Labral Tear with Avulsion of Rectus femoris (HALTAR)". This injury may be seen in both adolescent and skeletally mature athletes and shares several characteristics with the "Superior Labral tear from Anterior to Posterior (SLAP)" lesion in the shoulder. METHODS: We present a case example, as well as a detailed anatomic description of the pathological condition. RESULTS: As the rectus femoris crosses two joints it is exposed to substantial forces during muscle contraction. Considering the peri-articular origin of the reflected head at the superior aspect of the acetabular rim, a powerful eccentric contraction of the rectus femoris muscle or traction related to sudden knee flexion may cause an avulsion injury of the rectus femoris as well as a concomitant labral tear. CONCLUSIONS: A strain injury of the rectus femoris muscle, which is common in young athletic patients, may cause a concomitant tear of the acetabular labrum. Therefore, we recommend further diagnostic work-up in cases with prolonged hip pain and impaired hip function following an AIIS injury in order to identify any associated peri- and intra-articular damage. In our experience these patients seldom need aggressive surgical management.

Impact of surgical intervention and postoperative pain on electrical skin resistance at acupuncture points: an exploratory study.

OBJECTIVES: One theory about acupuncture suggests that pathological processes can cause measurable changes in electrical skin resistance (ESR) at acupuncture points (APs). Although the theory has yet to be proven, ESR measurements (ESRMs) form a frequently used part of contemporary acupuncture. The aim of this study was to test the so-called 'electrical responsiveness' of APs in the setting of a defined operative trauma. METHODS: ESRMs (n=424) were performed at the APs and surrounding skin of GB34 and ST38 in 163 participants using an impedance meter array developed for the purpose of ESRMs. For each group the percentage of measurements with a significantly different ESR between the APs and the surrounding skin was calculated and compared with each other. Measurements of four groups were compared: healthy control subjects (n=30) and patients after ophthalmic (n=29), hip (n=42) and shoulder (n=30) surgery. The influence of postoperative pain intensity was also assessed. RESULTS: Group comparison showed no significant differences for ST38. The ESRMs at GB34 had a significantly higher percentage of measurements with an increased ESR after ophthalmic (23.2%) and hip (22.2%) surgery, but not after shoulder surgery (7.5%). Subgroup analysis showed that an increase in pain intensity tended to lead to a decrease in the number of APs with ESR changes. CONCLUSION: These results suggest that reactive changes in ESR at APs might exist. Pain and alertness seem to have an impact on ESR at APs. However, the current data do not allow for conclusions to be drawn concerning the clinical use of ESRMs.

Hip arthrodesis in the pediatric population: where do we stand?

Reconstructive and salvage procedures have continued to evolve in orthopedic surgery with changing functional demands of the population as well as advances in implants and surgical techniques. What used to be popular or traditional care at some point may eventually become a thing of the past, and this is true as far as many orthopedic surgical procedures are concerned. Understanding the etiology, pathogenesis, and managing and postponing the destructive pathway of osteoarthritis (OA) has been the goal of orthopedists since the specialty began in the early part of 18(th) century. Options of treating the severe sequelae of an arthritic joint have varied in different treatment eras. Management options have changed from a spectrum of non-treatment and slow suffering to muscle and soft-tissue releases, interposition arthroplasty and eventual extreme options like joint fusion or arthrodesis. The concept and advent of joint replacement surgery started a new era in the management of OA and was a dream come true in many ways. Mobility and stability are achieved together during the arthroplasty (joint replacement) that allowes the patient to maintain a good level of function. Arthroplasty certainly has its pros and cons as we have discovered in the past six decades. Pushing the envelope to younger population has its limitation in terms of longevity of the prosthesis, early loosening, need for repeated revisions that at some point may not be technically possible and risk of infection and disastrous consequences like PE and death associated with the gravity of the procedure. As infrequent as it is in today's clinical practice, arthrodesis of the hip joint has a role and remains a solid option for a well selected case.The purpose of this review is to discuss the current indications in the pediatric population and outline surgical techniques for hip arthrodesis while pointing out limitations and shortcomings.

Discrepancy between prevalence and perceived effectiveness of treatment methods in myofascial pain syndrome: results of a cross-sectional, nationwide survey.

BACKGROUND: Myofascial pain is a common dysfunction with a lifetime prevalence affecting up to 85% of the general population. Current guidelines for the management of myofascial pain are not available. In this study we investigated how physicians on the basis of prescription behaviour evaluate the effectiveness of treatment options in their management of myofascial pain. METHODS: We conducted a cross-sectional, nationwide survey with a standardized questionnaire among 332 physicians (79.8% male, 25.6% female, 47.5 +/- 9.6 years) experienced in treating patients with myofascial pain. Recruitment of physicians took place at three German meetings of pain therapists, rheumatologists and orthopaedists, respectively. Physicians estimated the prevalence of myofascial pain amongst patients in their practices, stated what treatments they used routinely and then rated the perceived treatment effectiveness on a six-point scale (with 1 being excellent). Data are expressed as mean +/- standard deviation. RESULTS: The estimated overall prevalence of active myofascial trigger points is 46.1 +/- 27.4%. Frequently prescribed treatments are analgesics, mainly metamizol/paracetamol (91.6%), non-steroidal anti-inflammatory drugs/coxibs (87.0%) or weak opioids (81.8%), and physical therapies, mainly manual therapy (81.1%), TENS (72.9%) or acupuncture (60.2%). Overall effectiveness ratings for analgesics (2.9 +/- 0.7) and physical therapies were moderate (2.5 +/- 0.8). Effectiveness ratings of the various treatment options between specialities were widely variant. 54.3% of all physicians characterized the available treatment options as insufficient. CONCLUSIONS: Myofascial pain was estimated a prevalent condition. Despite a variety of commonly prescribed treatments, the moderate effectiveness ratings and the frequent characterizations of the available treatments as insufficient suggest an urgent need for clinical research to establish evidence-based guidelines for the treatment of myofascial pain syndrome.

Surgical and nonsurgical treatment of total rupture of the pectoralis major muscle in athletes: update and critical appraisal.

The complete rupture of the pectoralis major tendon is an uncommon injury but has become increasingly common among athletes in recent years. This may be due to a higher number of individuals taking part in high-impact sports and weightlifting as well as the use of anabolic substances, which can make muscles and tendons vulnerable to injury. In recent literature, there are only few recommendations to rely on conservative treatment alone, but there are a number of reports and case series recommending early surgical intervention. Comparing the results of the two treatment regimens, there is clear evidence for a superior outcome after surgical repair with better cosmesis, better functional results, regaining of muscle power, and return to sports compared with the conservative treatment. In summary, anatomic surgical repair is the treatment of choice for complete acute ruptures of the pectoralis major tendon or muscle in athletes.

Characteristics of electrical skin resistance at acupuncture points in healthy humans.

OBJECTIVES: The aim of this study was to evaluate the phenomenon of electrical skin resistance (ESR) changes at different acupuncture points (APs). SETTING: This single-blinded study was performed at the hospital of the University of Munich. DESIGN: Six common APs were measured (TE5, PC6, LU6, ST36, SP6, GB39) in 53 subjects. Subgroups were formed with varying time intervals for follow-ups (1 minute, 1 hour, 1 week) and a varying grade of reduction of the stratum corneum. METHODS: Electrical skin resistance measurements (ESRMs) were taken from a skin area of 6 x 6 cm using an array consisting of 64 (8 x 8) electrodes. The electrodes corresponding to the AP were located and the ESRM results were compared to those of the surrounding electrodes. The methodological setting made it possible to minimize major influence factors on electrical skin impedance measurements. RESULTS: A total of 631 ESRMs was evaluated: In 62.8% of the measured APs, no significant ESR difference was found. In 234 (37.2%) of the ESRMs, the ESR at the AP was significantly different from the surrounding skin area, with 163 (25.9%) points showing a lower and 71 (11.3%) points showing a higher ESR. Reproducibility was extremely high after 1 minute but was low after 1 hour and 1 week. CONCLUSIONS: This study shows that electrical skin resistance at APs can either be lower or higher compared to the surrounding area. The phenomenon is characterized by high short-term and low long-term reproducibility. Therefore, we conclude that APs might possess specific transient electrical properties. However, as the majority of the measured APs did not show a changed ESR, it cannot be concluded from our data that electrical skin resistance measurements can be used for acupuncture point localization or diagnostic/therapeutic purposes.

Changes in electrical skin resistance at gallbladder 34 (GB34).

OBJECTIVE: Electrodermal screening is widely used in the acupuncture community for point location, diagnosis and therapy. However the underlying theory that electrical skin resistance (ESR) of an area corresponding to an acupuncture point (AP) is lower than ESR of the surrounding areas is yet to be proven. The objective of this study was to evaluate and quantify the phenomenon of ESR changes at the Gallbladder 34 (GB34) Acupuncture Point (AP). MATERIALS AND METHODS: In this single-blinded study GB34 was measured bilaterally in 43 healthy volunteers. Electrical skin resistance measurements (ESRMs) were performed with a specially designed array consisting of 64 (8 x 8) electrodes on an area of 6 x 6 cm. Then the electrodes corresponding to the AP were identified and compared with those of the surrounding electrodes with Wilcoxon rank sum test. Values for p of less than 0.05 were considered statistically significant. RESULTS: Eighty-one ESRMs were evaluated. ESR was significantly different from the surrounding skin area in 27 (33.3%) cases with 15 (18.5%) points showing a lower and 12 (14.1%) points showing a higher ESR. CONCLUSION: This shows that ESR changes at APs exist in one third of the measured points, a very low rate for a postulation that forms the basis of various diagnosis and therapy systems.