Functional Results of Open Broström Ankle Ligament Repair Augmented With a Suture Tape.

BACKGROUND: The Broström procedure is the most commonly used lateral ligament repair for chronic instability, but there is concern about the strength of the repair and the risk of reinjury. Currently, the InternalBraceTM ligament augmentation repair is an accepted augmentation method for management of a Broström procedure. Our hypothesis was that augmentation of the Broström repair with an InternalBraceTM would allow accelerated rehabilitation and return to activity and would aid in stability of the repair without a tendency to stretch. METHODS: Eighty-one patients with lateral ankle instability procedures repaired with a Broström and InternalBraceTM augmentation were evaluated at a one-time postoperative visit between 6 and 24 months. Outcomes included demographics, surgical time, the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot score, Veterans Rand 12-Item Health Survey (VR-12), Foot and Ankle Ability Measure (FAAM), Visual Analog Scale (VAS), satisfaction, and objective clinical measurements. Eighty-one patients were analyzed including 30 males and 51 females. Median age was 34 years (range, 18-62 years) with a median return for follow-up of 11.5 months (range, 6-27 months). RESULTS: Average postoperative VAS and satisfaction were 0.8 ± 1.4 and 9.1 ± 1.6, respectively. Mean return to sport (n = 68) was 84.1 days. Average AOFAS Ankle-Hindfoot score was 94.3. A score of 90 or higher on the FAAM Sports subscale was seen in 79.0% of the subjects. The single-leg hop test (Limb Symmetry Index %) showed that 86.4% of patients returned to normal or near normal function. The tape measure method and ankle dorsiflexion comparisons showed a significant difference: 9.2 ± 3.3 cm (operative side) and 10.4 ± 3.7 cm (contralateral side) ( P = .034). Ankle plantar flexion comparison (goniometer) was 48.5 ± 11.5 degrees (operative side) and 49.7 ± 11.9 degrees (contralateral side), showing no difference ( P = .506). CONCLUSION: These results suggest that InternalBraceTM augmentation of a Broström procedure is a safe and efficacious procedure that produces favorable outcomes in patients in terms of preventing recurrent instability in the ankle in the short term. LEVEL OF EVIDENCE: Level IV, case series.

Predictors of Clinically Suspected Intra-articular Hip Symptoms and Prevalence of Hip Pathomorphologies Presenting to Sports Medicine and Hip Preservation Orthopaedic Surgeons.

PURPOSE: The first purpose of the study was to evaluate the prevalence of various radiographic parameters and pathomorphologies for patients presenting with the diagnosis of hip pain. The second purpose of this study was to identify those pathomorphologies and radiographic parameters that were predictive of clinically suspected intra-articular and hip joint-related symptoms. METHODS: A total of 998 hips (499 patients, 228 males, 271 females, mean age 38 years) presented to 2 orthopaedic surgeons with the diagnosis of hip pain. Patients were retrospectively identified as intra-articular and hip joint-related symptoms or extra-articular and non-hip joint-related symptoms based on history, examination, injection response, and diagnosis listed on clinical notes. A detailed morphologic evaluation of anteroposterior and 45° modified Dunn lateral radiographs of both hips was performed for all patients. RESULTS: The presence of at least 1 finding consistent with femoroacetabular impingement (FAI) was noted in 96.6% of patients (89.9% of hips) and was bilateral in 83%. The prevalence of dysplasia was 10.6% in patients (6.7% of hips) and was bilateral in 2.8%. Cam-type morphology was more common in males (P < .001). Profunda and protrusio were more common in females (P < .001). Acetabular retroversion was more common in males (P = .02). Fifty-seven percent of hips (564/998) were diagnosed clinically with intra-articular and hip joint related symptoms. Cam-type FAI, mixed-type FAI, increasing alpha angle, and increasing Tönnis grade were independent predictors of clinically suspected intra-articular and hip joint symptoms (P < .001), whereas isolated Pincer-type morphology was not. CONCLUSIONS: FAI is highly prevalent (96.6%) and frequently bilateral (83%) in patients presenting to an orthopaedic clinic with hip pain. Cam-type morphology and acetabular retroversion are more frequent in men, whereas profunda and protrusio are more frequent in women. Cam-type morphology, increasing alpha angle (larger cam morphology), and increasing Tönnis grade were highly predictive of clinically suspected intra-articular symptoms, whereas isolated pincer-type morphology was not. LEVEL OF EVIDENCE: Level III, case-control study.

Radiographic Hip Anatomy Correlates With Range of Motion and Symptoms in National Hockey League Players.

BACKGROUND: Hip disorders in athletes have been increasingly recognized. PURPOSE: To characterize radiographic hip anatomy for National Hockey League (NHL) players and correlate it with hip range of motion and hip symptoms and/or surgery. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Fifty-nine professional hockey players (118 hips) with 1 NHL organization (mean age, 24.2 years; range, 18-36) prospectively underwent history and physician examination by 2 independent orthopaedic surgeons. Current or previous groin and/or hip pain or surgery was noted. Anteroposterior (AP) pelvis and bilateral Dunn lateral radiographs were obtained for all players with assessment of hip morphology by 2 blinded independent orthopaedic surgeons. RESULTS: Good to very good reliability of radiographic assessments was noted (intraclass correlation coefficients = 0.749-0.958). Sixty-four percent of athletes had a positive crossover sign, while 86% and 60% had a positive posterior wall sign and a prominent ischial spine sign, respectively. Twenty-one percent of hips demonstrated dysplastic acetabular features (lateral center edge angle <25°). Eighty-five percent and 89% of hips demonstrated cam-type morphology based on alpha angle (>50° Dunn lateral) and head-neck offset, respectively. Good to very good reliability was noted for ROM assessments (intraclass correlation coefficient >0.69). Mean hip flexion was 107.4º ± 6.7º, and mean hip internal rotation was 26.1º ± 6.6º. Thirty-one percent of hips had a history of hip-related pain and/or surgery. Higher AP, Dunn lateral, and maximal alpha angles correlated with decreased hip internal rotation ( P = .004). Greater AP alpha angle correlated with decreased hip extension/abduction ( P = .025), and greater Dunn lateral and maximal alpha angle correlated with decreased hip flexion/abduction ( P = .001). A positive posterior wall sign correlated with increased straight hip abduction, while other radiographic acetabular parameters were not predictive of range of motion. Only decreased hip external rotation and total arc of motion correlated with an increased risk for current or prior hip symptoms or surgery ( P < .001). CONCLUSION: Hip anatomy in NHL players is characterized by highly prevalent cam-type morphology (>85%) and acetabular retroversion (>60%). In addition, acetabular dysplasia (21%) was relatively common. Greater cam-type morphology correlated with decreased hip range of motion, and a positive crossover sign correlated with increased hip abduction. Decreased hip external rotation and total arc of motion were predictive of hip-related pain and/or surgery.

Comparison of Three Total Ankle Replacement Systems Done at a Single Facility.

BACKGROUND: Ankle replacement surgery is an established and accepted way to treat end stage ankle arthritis. Though there are multiple publications looking at results with various ankle replacement systems, most of them are single implant longitudinal studies from a single institution. There are, however, no prospective randomized studies evaluating the outcomes of different total ankle arthroplasty (TAA) systems; in fact, there are no comparative studies at all. METHODS: The comparative results of 3 different total ankle systems (INBONE, STAR, and Salto Talaris) were evaluated. All the TAA system implants were performed at a single institution from 2007 to 2011. The data were evaluated by authors completely independent from the study institution. The goal was to look at the results in an objective, noninstitution perspective. RESULTS: At minimum 2-year follow-up there is no statistical difference in outcomes scores or functional tests between the INBONE, STAR, or Salto Talaris, with all 3 TAA systems resulting in statistically significant improvement of all parameters since baseline. CONCLUSIONS: This is the first study that compares the results of 3 different total ankle replacement systems done at a single institution over the same period of time. Even though it is not a randomized study, it gives a valuable perspective of the short-term results. LEVELS OF EVIDENCE: Therapeutic, Level IV: Case series.

Intraoperative and Early Postoperative Complications After Hip Arthroscopic Surgery: A Prospective Multicenter Trial Utilizing a Validated Grading Scheme.

BACKGROUND: There is limited literature looking at comprehensive complication rates after arthroscopic hip procedures. PURPOSE: To prospectively report complication rates for a consecutive series of hips undergoing arthroscopic procedures. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Over a 29-month period, 1615 consecutive hips in patients with a mean age of 30.5 years underwent arthroscopic hip procedures at 4 institutions. The diagnosis, demographic information, and procedures were recorded, and a validated grading classification for complications of hip joint surgery was utilized prospectively. The cohort with complications was observed postoperatively for a mean of 36.7 months (range, 24-54 months). RESULTS: There were 1487 primary hip arthroscopic procedures and 128 revision hip arthroscopic procedures. Arthroscopic femoroacetabular impingement correction was performed in 1505 hips (93.2%), and 1273 hips (78.8%) underwent a labral repair procedure. The most common event was postoperative lateral femoral cutaneous (LFC) nerve disturbance (16.5%), which persisted beyond 6 months in only 1.6%. The incidence of iatrogenic chondral injuries was 1.2%, iatrogenic labral punctures was 0.9%, superficial portal infections was 1.1%, sensory deficits about the foot was 0.8%, deep venous thrombosis was 0.1%, pulmonary embolism was 0.1%, perineal numbness (pudendal nerve) was 1.4%, heterotopic ossification was 0.8%, and femoral neck stress fractures was 0.1%. There was no iatrogenic instability, avascular necrosis, or extra-abdominal fluid extravasation identified in this cohort. The overall complication rate, not including temporary LFC periportal and thigh numbness (sequela), was 8.3% (134 hips). Overall, a grade 1 complication was seen in 7.2% (117 hips), grade 2 in 0.6% (10 hips), grade 3 in 0.4% (6 hips), and grade 4 in 0.1% (1 hip). There was a significantly higher rate of complications for longer surgical time and traction time (P < .01) and for female patients as compared with male patients (P = .017). Most notably, traction time longer than 60 minutes was associated with a significantly increased complication rate (P < .001). Hips with pudendal nerve neurapraxia had longer traction times than those without (61.5 vs 43.8 minutes, respectively; P < .001). No differences were found between primary versus revision cases (P = .123) or between labral repair versus debridement (P = .209), and body mass index had no effect on the complication rate (P = .103). CONCLUSION: The overall complication rate after hip arthroscopic surgery at tertiary hip centers was 8.3%, with higher rates reported for longer traction times (>60 minutes) and for female patients. Compared with surgical hip dislocation using the same classification system, the overall rate of complications was similar, but the rate of higher grade complications was lower for arthroscopic hip procedures.

Early Patient Satisfaction Results on a Modern Generation Fixed-Bearing Total Ankle Arthroplasty.

BACKGROUND: This study presents patient-reported outcomes and patient satisfaction data for the largest series of US patients undergoing modern fixed-bearing total ankle arthroplasty (TAA). METHODS: We retrospectively reviewed the records of 300 consecutive patients who underwent 321 modern, fixed-bearing TAAs at a single institution. Veterans Rand 12-Item Health Survey (VR-12), Ankle Osteoarthritis Scale (AOS), and the American Orthopaedic Foot & Ankle Society (AOFAS) Hindfoot score were collected preoperatively and at subsequent follow-up appointments. A patient satisfaction survey was also distributed to each patient postoperatively. Of the 321 TAAs, 245 (232 patients) had a minimum of 2-year follow-up and a complete data set. Furthermore, 192 patients underwent concomitant procedures. The average follow-up was 38.9 months (24-84.5). Eight patients have been lost to follow-up (7 deceased and 1 refused further follow-up). RESULTS: The mean AOFAS score preoperatively was 41.1 and at latest follow-up was 84.6 (P < .01). The mean VR-12 score was 29.7 (Physical) and 54.1 (Mental) preoperatively and 42.7 (Physical) and 55.7 (Mental) at latest follow-up (P < .01 and P > .05, respectively). AOS pain and disability scores improved significantly after TAA (P < .01). The patient satisfaction survey indicated that 84% experienced very good to excellent pain relief, 78% reported improved ability to perform daily tasks, and 54% indicated improvement in their ability to perform heavy work or recreational activities. In addition, 94% would probably or definitely have the procedure on the contralateral ankle. Two patients underwent revision TAA at a minimum of 36 months; 8 patients failed the primary TAA and were converted to ankle fusions at a mean of 20.1 months (6.1-46.1). CONCLUSION: Early results of a large series of a modern TAA system demonstrate improvement in patient satisfaction, quality of life, activity, and pain for patients with end-stage ankle arthritis. Early revision was due to infection or loosening of the tibial component. LEVEL OF EVIDENCE: Level IV, case series.

Allograft and Autograft Transphyseal Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients: Outcomes and Complications.

PURPOSE: The purpose of the study was to evaluate outcomes, graft failure rates, and complications after transphyseal soft-tissue allograft and autograft anterior cruciate ligament (ACL) reconstruction (ACLR) in patients with open growth plates. METHODS: Twenty-nine skeletally immature athletes (30 knees) with a mean age of 13.9 years (range, 9 to 16 years) underwent transphyseal ACLR (22 with quadrupled hamstring autograft and 8 with tibialis anterior allograft). Of the patients, 5 were Tanner stage I, 17 were Tanner stage II, and 7 were Tanner stage III. Outcomes included KT-1000 (MEDmetric, San Diego, CA) measurements and International Knee Documentation Committee (IKDC), Cincinnati, and Lysholm scoring. Radiographs were evaluated for asymmetrical physeal closure, growth arrest lines, and knee alignment. RESULTS: The mean outcomes scores, excluding the 5 graft failures, were 91.8 points for the IKDC score, 93.0 points for the Cincinnati score, and 91.5 points for the Lysholm score at a mean of 4 years' follow-up (range, 24 to 84 months). The 95% confidence intervals for the differences were -27.7 to -18.0 for the IKDC score, -26.4 to -12.1 for the Cincinnati score, and -20.1 to -6.4 for the Lysholm score. One hundred percent of patients ultimately returned to their prior level of sports, but only 76% maintained that level at most recent follow-up. The mean KT-1000 side-to-side difference at most recent follow-up was 0.4 mm (SD, 1.3 mm; range, -2 to 3 mm) (n = 25). Evaluation at a minimum of 2 years postoperatively showed 4 patients with Harris growth arrest lines and 1 genu valgum deformity that spontaneously corrected at latest follow-up. For the remaining 29 knees, there was a mean side-to-side difference of 1.3° (range, 0° to 4°) in the radiographic tibiofemoral angle and 0.2 cm (range, 0 to 1 cm) for clinical leg-length measurements. Sports-related graft failure occurred at a mean of 24 months after ACLR in 16.7% of patients (37.5% with allografts [3 of 8] v 9% with autografts [2 of 22], P = .10). In 5 patients (16.7%), a contralateral ACL injury was sustained. CONCLUSIONS: Transphyseal ACLR in patients with open growth plates resulted in a high rate of return to sports with a low rate of growth arrest and deformity at a mean of 4 years' follow-up. Harris growth arrest lines and a case of genu valgum deformity that spontaneously corrected, however, were observed. Graft failure rates and contralateral ACL tears were not insignificant in this young patient population. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Hip Arthroscopy for Removal of an Acetabular Rim-Based Osteoid Osteoma and Concomitant Femoroacetabular Impingement Correction.

Minimally invasive percutaneous radiofrequency ablation (RFA) techniques are the standard of care for treating simple osteoid osteomas (OOs). Historically, OOs were treated with open en bloc resection or curettage of the nidus. RFA procedures have been linked to soft-tissue complications of varying severity. In addition, RFA may be a poor choice for periarticular OOs because of the potential for procedure-related articular cartilage damage. Hip arthroscopy is a widely accepted approach for the treatment of femoroacetabular impingement. We describe arthroscopic resection of an acetabular rim-based OO as part of a rim resection and labral repair. Early clinical follow-up suggests that arthroscopic resection of an OO in this unusual location is precise and predictable, allows for an additional evaluation of associated symptomatic pathology (i.e., femoroacetabular impingement), and results in prompt symptom resolution.

Arthroscopic Management of Dysplastic Hip Deformities: Predictors of Success and Failures With Comparison to an Arthroscopic FAI Cohort.

BACKGROUND: Reports regarding arthroscopy for mild hip dysplasia have conflicting results. HYPOTHESIS: Arthroscopy for borderline/mild hip dysplasia would lead to improved outcomes but be inferior to arthroscopy for femoroacetabular impingement (FAI). STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A total of 88 hips (77 patients, 71% female; mean age, 33.9 years) with dysplastic radiographic findings were retrospectively reviewed at a mean follow-up of 26.0 months after hip arthroscopy. Specific procedures included labral repair (76%), labral debridement (23%), capsular repair/plication (82%), and femoral osteochondroplasty (72%). Radiographic parameters included lateral center-edge angle, neck-shaft angle, Tönnis angle, extrusion index, femoral head lateralization, and break in the Shenton line. Pre- and postoperative function were evaluated prospectively with the modified Harris Hip Score (mHHS), 12-Item Short Form Health Survey, and visual analog scale for pain. The results of the dysplastic cohort were compared with an age-matched cohort of 231 hips without radiographic dysplasia that underwent arthroscopic FAI correction during the study period (mean follow-up, 22.7 months). RESULTS: The mean lateral center-edge angle was 20.8° (range, 8.7°-24.5°), and the mean Tönnis angle was 11.0° (range, 0°-22.2°). At the time of final follow-up, the dysplastic cohort demonstrated a mean mHHS of 81.3 with a mean 15.6-point improvement in mHHS, compared with 88.4 and 24.4 points, respectively, in the FAI cohort (P = .00044). The dysplastic cohort had 60.9% good/excellent results and 32.2% failures, compared with 81.2% good/excellent results and 10.5% failures for the FAI cohort (P < .01). Failure was defined as an mHHS ≤70 or eventual pelvic/femoral osteotomy or total hip arthroplasty. Dysplastic hips that underwent capsular plication and labral repair had greater good/excellent results (73%) and mean latest mHHS (85), as well as lower failure rates (18%) compared with the remainder of the dysplastic cohort (P < .05). Grade 4 chondral defects were predictive of lower scores (P = .02). There were no other statistically significant differences for outcomes regarding sex, age, or radiographic parameters (P > .05). There were no iatrogenic subluxations/dislocations. CONCLUSION: Arthroscopic management of mild to moderate acetabular dysplasia had inferior good/excellent results and higher failure rates when compared with an FAI cohort; therefore, isolated arthroscopic procedures in this population should be cautiously considered. These results were independent of patient sex. Labral repair and capsular plication resulted in better clinical outcomes in this mildly dysplastic cohort.

Core Muscle Injury/Sports Hernia/Athletic Pubalgia, and Femoroacetabular Impingement.

Core muscle injury/sports hernia/athletic pubalgia is an increasingly recognized source of pain, disability, and time lost from athletics. Groin pain among athletes, however, may be secondary to various etiologies. A thorough history and comprehensive physical examination, coupled with appropriate diagnostic imaging, may improve the diagnostic accuracy for patients who present with core muscular injuries. Outcomes of nonoperative management have not been well delineated, and multiple operative procedures have been discussed with varying return-to-athletic activity rates. In this review, we outline the clinical entity and treatment of core muscle injury and athletic pubalgia. In addition, we describe the relationship between athletic pubalgia and femoroacetabular impingement along with recent studies that have investigated the treatment of these related disorders.

Ehlers-Danlos Syndrome: Arthroscopic Management for Extreme Soft-Tissue Hip Instability.

PURPOSE: To present outcomes in a series of patients with Ehlers-Danlos syndrome (EDS)-hypermobility type who underwent hip arthroscopy for associated hip pain and extreme capsular laxity. METHODS: A retrospective chart review identified 16 hips with confirmed EDS--hypermobility type that underwent hip arthroscopy for continued pain and capsular laxity. All patients had complaints of "giving way" and pain, an easily distractible hip with manual traction under fluoroscopy, and a patulous capsule at the time of surgery. No patient had osseous evidence of acetabular hip dysplasia or prior confirmed hip dislocation. Outcomes were evaluated preoperatively and postoperatively with the modified Harris Hip Score (mHHS), the 12-Item Short Form Health Survey (SF-12), and a visual analog scale (VAS) for pain. RESULTS: Evidence of symptomatic femoroacetabular impingement (FAI) was found in 15 hips (93.8%). The 16th hip had subjective giving way with a positive anterior impingement test and was easily distractible, had a labral tear, and had a patulous capsule at the time of surgery. The mean follow-up period was 44.61 months (range, 12 to 99 months). The mean preoperative lateral center-edge angle was 31.8° (range, 25° to 44°), and the mean Tönnis angle was 3.6° (range, -2° to 8°). Mean femoral version measured on computed tomography (CT) scans was 19.2° (range, -4.0° to 31.0°). Of the hips, 13 underwent primary arthroscopy and 3 underwent revision. All hips underwent hip arthroscopy with an interportal capsular cut only and arthroscopic capsular plication. There were 13 labral repairs, 2 labral debridements, 8 rim resections, 15 femoral resections, 2 psoas tenotomies, and 1 microfracture. Improved stability with an inability to distract the hip with manual traction under fluoroscopy was noted in all hips after plication. The mean alpha angle preoperatively was 58.7° on anteroposterior radiographs and 63.6° on lateral radiographs compared with 47.4° and 46.1°, respectively, postoperatively. There were significant improvements for all outcomes (mHHS, P = .002; SF-12 score, P = .027; and VAS score, P = .0004). The mean mHHS, SF-12 score, and VAS score were 45.6 points, 62.4 points, and 6.5 points, respectively, preoperatively compared with 88.5 points, 79.3 points, and 1.6 points, respectively, at a mean follow-up of 45 months. No EDS patients were lost to follow-up or excluded from analysis. The mean improvement in mHHS from preoperatively to postoperatively was 42.9 points, and there were no iatrogenic dislocations. One patient underwent further revision arthroscopy for recurrent pain, subjective giving way, and capsular laxity. CONCLUSIONS: FAI and extreme capsular laxity can be seen in the setting of EDS. Although increased femoral version was common, acetabular dysplasia was not common in our study. Meticulous capsular plication, arthroscopic correction of FAI when present, and labral preservation led to dramatic improvements in outcomes and subjective stability without any iatrogenic dislocations in this potentially challenging patient population. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Characterization of symptomatic hip impingement in butterfly ice hockey goalies.

PURPOSE: This study aimed to characterize the radiographic deformity observed in a consecutive series of butterfly goalies with symptomatic mechanical hip pain and to use computer-based software analysis to identify the location of impingement and terminal range of motion. We also compared these analyses to a matched group of positional hockey players with symptomatic femoroacetabular impingement (FAI). METHODS: A consecutive series of 68 hips in 44 butterfly-style hockey goalies and a matched group of 34 hips in 26 positional hockey players who underwent arthroscopic correction for symptomatic FAI were retrospectively analyzed. Each patient underwent preoperative anteroposterior (AP) and modified Dunn lateral radiographs and computed tomography (CT) of the affected hips. Common FAI measurements were assessed on plain radiographs. Patient-specific, CT-based 3-dimensional (3D) models of the hip joint were developed, and the femoral version, alpha angles at each radial clock face position, and femoral head coverage were calculated. Maximum hip flexion, abduction, internal rotation in 90° flexion (IRF), flexion/adduction/internal rotation (FADIR), and butterfly position were determined, and the areas of bony collision were defined. RESULTS: Butterfly goalies had an elevated mean alpha angle on both AP (61.3°) and lateral radiographs (63.4°) and a diminished beta angle (26.0°). The mean lateral center-edge angle (LCEA) measured 27.3° and acetabular inclination was 6.1°. A crossover sign was present in 59% of the hips. The maximum alpha angle on the radial reformatted computed tomographic scan was significantly higher among the butterfly goalies (80.9° v 68.6°; P < .0001) and was located in a more lateral position (1:00 o'clock v. 1:45 o'clock; P < .0001) compared with positional players. CONCLUSIONS: Symptomatic butterfly hockey goalies have a high prevalence of FAI, characterized by a unique femoral cam-type deformity and noted by an elevated alpha angle and loss of offset, which is greater in magnitude and more lateral when compared with that in positional hockey players. Associated acetabular dysplasia is also common among hockey goalies. LEVEL OF EVIDENCE: Level IV, prognostic case series.

Arthroscopic Hip Revision Surgery for Residual Femoroacetabular Impingement (FAI): Surgical Outcomes Compared With a Matched Cohort After Primary Arthroscopic FAI Correction.

BACKGROUND: There are limited data reporting outcomes after revision arthroscopic surgery for residual femoroacetabular impingement (FAI). HYPOTHESIS: (1) Revision arthroscopic FAI correction results in improved outcomes, but they are inferior to those of primary arthroscopic FAI correction. (2) Improved postrevision radiographic parameters are predictive of better outcomes. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Patients who underwent arthroscopic hip revision for residual FAI were reviewed. Pathomorphological findings, intraoperative findings, and preoperative and postoperative modified Harris Hip Score (MHHS), Short Form-12 (SF-12), and pain on a visual analog scale (VAS) values were evaluated. Outcomes after revision arthroscopic FAI correction were compared with outcomes of a matched cohort who underwent primary arthroscopic FAI correction. RESULTS: A total of 79 patients (85 hips) with a mean age of 29.5 years underwent arthroscopic revision FAI correction (mean follow-up, 26 months). The labrum was debrided (27 hips), repaired (49 hips), or reconstructed (7 hips). Two labrums were stable and required no treatment. The results of revision arthroscopic FAI correction were compared with those of 220 age- and sex-matched patients (237 hips) who underwent primary arthroscopic FAI correction (mean follow-up, 23 months). The mean improvement in outcome scores after revision FAI correction was 17.8 (MHHS), 12.5 (SF-12), and 1.4 (VAS) points compared with 23.4 (MHHS), 19.7 (SF-12), and 4.6 (VAS) points after primary arthroscopic FAI correction. The mean improvement was significantly better in the primary cohort compared with the revision cohort (P < .01 for MHHS, SF-12, and VAS values). Good/excellent results were achieved in 81.7% of the primary cohort and 62.7% of the revision cohort (P < .01). Greater postoperative head-neck offset (P = .024), subspine/anterior inferior iliac spine (AIIS) decompression (P = .014), labral repair/reconstruction (P = .009), and capsular plication (P = .032) were significant predictors for better outcomes after revision surgery. CONCLUSION: Arthroscopic hip revision surgery for residual FAI yielded significantly improved outcome measures, but these were inferior to those after primary arthroscopic FAI corrective surgery. Improved femoral head-neck offset after cam decompression, identification and treatment of subspine/AIIS impingement, labral preservation/reconstruction, and capsular preservation/plication may be paramount to achieve satisfactory outcomes.

Functional Outcomes and Return to Sports After Acute Repair, Chronic Repair, and Allograft Reconstruction for Proximal Hamstring Ruptures.

BACKGROUND: There are limited data regarding outcomes and return to sports after surgery for acute versus chronic proximal hamstring ruptures. HYPOTHESIS: Surgery for chronic proximal hamstring ruptures leads to improved outcomes and return to sports but at a lower level than with acute repair. Proximal hamstring reconstruction with an Achilles allograft for chronic ruptures is successful when direct repair is not possible. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Between 2002 and 2012, a total of 72 patients with a traumatic proximal hamstring rupture (51 acute, 21 chronic) underwent either direct tendon repair with suture anchors (n = 58) or Achilles allograft tendon reconstruction (n = 14). Results from the Single Assessment Numeric Evaluation (SANE) for activities of daily living (ADL) and sports-related activities, Short Form-12 (SF-12), visual analog scale (VAS), and a patient satisfaction questionnaire were obtained. RESULTS: The mean time to surgery in the chronic group was 441.4 days versus 17.8 days in the acute group. At a mean follow-up of 45 months, patients with chronic tears had inferior sports activity scores (70.2% vs 80.3%, respectively; P = .026) and a trend for decreased ADL scores (86.5% vs 93.3%, respectively; P = .085) compared with those with acute tears. Patients with chronic tears, however, reported significant improvements postoperatively for both sports activity scores (30.3% to 70.2%; P < .01) and ADL scores (56.1% to 86.5%; P < .01). Greater than 5 to 6 cm of retraction in the chronic group was predictive of the need for allograft reconstruction (P = .015) and resulted in ADL and sports activity scores equal to those of chronic repair (P = .507 and P = .904, respectively). There were no significant differences between groups in SF-12, VAS, or patient satisfaction outcomes (mean, 85.2% satisfaction overall). CONCLUSION: Acute repair was superior to chronic surgery with regard to return to sports. Acute and chronic proximal hamstring repair and allograft reconstruction had favorable results for ADL. For low-demand patients or those with medical comorbidities, delayed repair or reconstruction might be considered with an expected 87% return to normal ADL. For patients who desire to return to sports, acute repair is recommended.

Intraoperative Fluoroscopic Imaging to Treat Cam Deformities: Correlation With 3-Dimensional Computed Tomography.

BACKGROUND: In the diagnosis and surgical treatment of cam-type femoroacetabular impingement (FAI), 3-dimensional (3D) imaging is the gold standard for detecting femoral head-neck junction malformations preoperatively. Intraoperative fluoroscopy is used by many surgeons to evaluate and verify adequate correction of the deformity. PURPOSE: (1) To compare radial reformatted computed tomography (CT) scans with 6 defined intraoperative fluoroscopic views before surgical correction to determine whether fluoroscopy could adequately depict cam deformity, and (2) to define the influence of femoral version on the clock-face location of the maximum cam deformity on these views. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: A consecutive series of 50 hips (48 patients) that underwent arthroscopic treatment for symptomatic FAI by a single surgeon were analyzed. Each patient underwent a CT scan and 6 consistent intraoperative fluoroscopy views: 3 views in hip extension and 3 views in hip flexion of 50°. The alpha angles of each of the fluoroscopic images were compared with the radial reformatted CT using a 3D software program. Femoral version was also defined on CT studies. Statistical analysis was performed using the Student t test, with P < .05 defined as significant. RESULTS: Fifty-two percent of patients were male, average age 28 years (range, 15-56 years). The maximum mean alpha angle on fluoroscopy was 65° (range, 37°-93°) and was located on the anteroposterior (AP) 30° external rotation (ER) fluoroscopy view. In comparison, the mean CT-derived maximum alpha angle was 67° and was located at 1:15 (P = .57). The mean clock-face positions of each of the fluoroscopy views (standardized to the right hip) were AP 30° internal rotation, 11:45; AP 0° (neutral) rotation, 12:30; AP 30° ER, 1:00; flexion/0° (neutral) rotation, 1:45; flexion/40° ER, 2:15; and flexion/60° ER, 2:45. Increased femoral anteversion (>20°) was associated with a significant change in the location of the maximum alpha angle (1:45 vs 1:15; P = .002). CONCLUSION: The described 6 fluoroscopic views are very helpful in localization and visualization of the typical cam deformity from 11:45 to 2:45 and can be used to reliably confirm a complete intraoperative resection of cam-type deformity in most patients. These views correlate with preoperative 3D imaging and may be of even greater importance in the absence of preoperative 3D imaging.

Current concepts and trends for operative treatment of FAI: hip arthroscopy.

There has been an increasing body of literature regarding arthroscopic management of femoroacetabular impingement (FAI). Refinement of arthroscopic techniques has allowed for more complete management of FAI, and meta-analysis and systematic reviews have shown comparable outcomes to surgical hip dislocation with appropriate indications. There are still, however, pathomorphologies that are not accessible or much more challenging to address arthroscopically, and open corrective procedures should be considered in these situations. Extra-articular FAI is receiving increased attention and can be secondary to anterior inferior iliac spine/subspine impingement, trochanteric-pelvic impingement, and ischio-femoral impingement. Femoral and acetabular version and their impact on hip stability as well as the concept of impingement induced instability are being increasingly recognized. Acetabular labral and capsular management and repair techniques have also received increased attention. Finally, 3-dimensional imaging and dynamic software analysis are beginning to emerge as potential tools to better evaluate hip pathomorphology.

Treatment of osteochondral lesions of the talus with particulated juvenile cartilage.

BACKGROUND: Numerous modalities are used today to treat symptomatic osteochondral lesions in the ankle. However, there are ongoing challenges with the treatment of certain lesions, and concerns exist regarding long-term effectiveness. METHODS: The purpose of the study was to collect clinical outcomes of pain and function in retrospectively and prospectively enrolled patients treated with particulated juvenile cartilage for symptomatic osteochondral lesions in the ankle. This study collected outcomes and incidence of reoperations in standard clinic patients. The analysis presented here includes final follow-up to date for 12 males and 11 females representing 24 ankles. Subjects had an average age at surgery of 35.0 years and an average body mass index of 28 ± 5.8. Fourteen ankles had failed at least 1 prior bone marrow stimulation procedure. The average lesion size was 125 ± 75 mm(2), and the average depth was 7 ± 5 mm. In conjunction with the treatment, 9 (38%) ankles had 1 concomitant procedure and 9 (38%) had more than 1 concomitant procedure. Clinical evaluations were performed with an average follow-up of 16.2 months. RESULTS: Average outcome scores at final follow-up were American Orthopaedic Foot & Ankle Society Ankle-Hindfoot Scale 85 ± 18 with 18 (78%) ankles demonstrating good to excellent scores, Short-Form 12 Health Survey (SF12) physical composite score 46 ± 10, SF12 mental health composite score 55 ± 7.1, Foot and Ankle Ability Measure (FAAM) activities of daily living 82 ± 14, FAAM Sports 63 ± 27, and 100-mm visual analog scale for pain 24 ± 25. Outcomes data divided by lesion size demonstrated 92% (12/13) good to excellent results in lesions 10 mm or larger and those smaller than 15 mm. To date, 1 partial graft delamination has been reported at 16 months. CONCLUSIONS: Preliminary data from a challenging clinical population with large, symptomatic osteochondral lesions in the ankle suggest that treatment with particulated juvenile cartilage could improve function and decrease pain. Longer follow-up and additional subjects are needed to evaluate improvement level and ideal patient indications. LEVEL OF EVIDENCE: Level IV, case series.

Magnetic resonance imaging after arthroscopic microfracture of capitellar osteochondritis dissecans.

BACKGROUND: Osteochondritis dissecans (OCD) of the capitellum affects young athletes involved in elbow load-bearing activities. Unstable lesions are best managed surgically, although debate remains regarding the optimal method. Arthroscopic treatment allows rapid recovery, but the effect on the articular surface is undetermined. HYPOTHESIS: The clinical outcome after arthroscopic microfracture of stage III/IV capitellum OCD would be successful in terms of return to sport and restoration of function, and there would be some evidence of articular restoration or repair. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: We reviewed records of 10 consecutive adolescent patients (age ≤18 years) with stage III or IV OCD lesions of the capitellum managed with arthroscopic microfracture. The mean age at the time of surgery was 13.9 years (range, 10.8-18.5 years); 7 patients were skeletally immature and 3 were skeletally mature. Pre- and postoperative functional assessment included active range of motion, Mayo Elbow Performance Score (MEPS), and Timmerman/Andrews elbow score. All patients underwent plain radiographic and magnetic resonance imaging (MRI) evaluation at a minimum of 12 months (mean, 27 months; range, 12-49 months) and clinical evaluation at a minimum of 24 months (mean, 42 months; range, 27-54 months) after surgery. RESULTS: The mean range of motion improved in both flexion (135.8°â†’140.7°, P = .112) and extension (20.4°â†’-2.2°, P = .005). The mean MEPS (70.5→97, P = .007) and Timmerman/Andrews elbow scores (116.4→193.0, P = .008) improved significantly. magnetic resonance imaging (MRI) evaluation demonstrated an improvement in overall joint congruence and the formation of a reparative articular surface in 8 of 10 (80%) patients. No reoperations or major complications were encountered. Six of 8 patients involved in competitive athletics returned to the same level of participation at an average of 5.1 months. CONCLUSION: Arthroscopic OCD fragment excision and capitellar microfracture demonstrates good to excellent functional results in short-term follow-up. Follow-up MRI suggests potential for a reparative fibrocartilaginous articular surface. Longer term follow-up is necessary to determine durability of the technique.

Arthroscopic debridement versus refixation of the acetabular labrum associated with femoroacetabular impingement: mean 3.5-year follow-up.

BACKGROUND: The acetabular labrum provides a sealing function and a degree of hip joint stability. Limited, short-term follow-up studies suggest that labral refixation/preservation leads to superior outcomes compared with labral debridement/excision. PURPOSE: To compare the results of labral refixation versus focal labral excision/debridement in a cohort of patients who underwent arthroscopic correction of femoroacetabular impingement (FAI). STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: We reported on patients who underwent labral debridement/focal labral excision during a period before the development of labral repair techniques. Patients with labral tears thought to be repairable with our current arthroscopic technique were compared with a cohort of patients who underwent labral refixation. To better match the 2 groups, only patients with labral pincer- or combined-type FAI were included. In the first 44 hips, the labrum was focally excised/debrided (group 1); in the next 50 hips, the labrum was refixed (group 2). Outcomes were measured with the modified Harris Hip Score (HHS), Short Form 12 (SF-12), and a visual analog scale (VAS) for pain preoperatively and postoperatively. Preoperative and postoperative radiographs were obtained to evaluate bony resection. RESULTS: The mean age was 32 years in group 1 and 28 years in group 2 with a mean follow-up of 42 months (range, 24-72 months). Preoperative mean subjective outcome scores were not significantly different between groups. At a mean 3.5 years' follow-up, subjective outcomes were significantly improved (P < .01) for both groups compared with preoperative scores. The HHS (P = .001), SF-12 (P = .041), and VAS pain scores (P = .004) were all significantly better for the refixation group compared with the debridement group at the most recent follow-up. At a mean 3.5 years' follow-up, good to excellent results were noted in 68% of the focal excision/debridement group and 92% of the refixation group (P = .004). CONCLUSION: Although other factors may have influenced these results, labral refixation compared with an earlier cohort of focal labral excision/debridement resulted in better HHS, SF-12, and VAS pain outcomes and a greater percentage of good to excellent results at a mean 3.5-year follow-up.