Radiographic Parameters of Adult Hip Dysplasia.

As knowledge about the origin and morphologic characteristics of hip pain in the young adult has evolved, so too has the clinician's ability to assess for various pathologies of the hip on radiographs, magnetic resonance imaging (MRI)/magnetic resonance arthrography (MRA), and computed tomography (CT). Because there is no algorithm at this time directly indicating what to do in more subtle hip morphologies, such as microinstability and borderline hip dysplasia (BHD), a skilled hip preservation specialist must use multiple imaging sources and know how to interpret them correctly. Imaging parameters used in the workup for hip dysplasia and BHD include the lateral center-edge angle, Tönnis angle, iliofemoral line, and presence of an upsloping lateral sourcil or everted labrum, among many others. The purpose of this narrative review was to detail various established criteria and parameters on anteroposterior pelvis plain radiographs, MRI/MRA, and CT that assist in defining the nature and severity of instability present in a dysplastic hip, thereby aiding in the development of patient-specific surgical treatment plans.

Pain Scores and Activity Tolerance in the Early Postoperative Period After Hip Arthroscopy.

BACKGROUND: Despite the rapid growth in the use of hip arthroscopy, standardized data on postoperative pain scores and activity level are lacking. PURPOSE: To quantify narcotic consumption and use of the stationary bicycle in the early postoperative period after hip arthroscopy. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: In this prospective case series, patients undergoing a primary hip arthroscopy procedure by a single surgeon were asked to fill out a daily survey for 9 days postoperatively. Patients were asked to report their pain level each day on a visual analog scale from 1 to 10, along with the amount of narcotic pain pills they used during those postoperative days (PODs). Narcotic usage was converted to a morphine-equivalent dosage (MED) for each patient. Patients were also instructed to cycle daily starting on the night of surgery for a minimum of 3 minutes twice per day and were asked to rate their pain as a percentage of their preoperative pain level and the number of minutes spent cycling on a stationary bicycle per day. RESULTS: A total of 212 patients were enrolled in this study. Pain levels (POD1, 5.5; POD4, 3.8; POD9, 2.9; P < .0001) and the percentage of preoperative pain (POD1, 51.6%; POD4, 31.8%; POD9, 29.5%; P < .01) significantly decreased over the study period. The amount of narcotics used per day (reported in MED) also significantly decreased (POD1, 27.3; POD4, 22.3; POD9, 8.5; P < .0001). By POD4, 41% of patients had discontinued all narcotics, and by POD9, 65% of patients were completely off narcotic medication. Patients were able to significantly increase the number of minutes spent cycling each day (POD1, 7.6 minutes; POD4, 13.8 minutes; POD9, 19.0 minutes; P < .0001). Patients who received a preoperative narcotic prescription for the affected hip were significantly more likely to require an additional postoperative narcotic prescription (P < .001). CONCLUSION: Patients can expect a rapid decrease in narcotic consumption along with a high degree of activity tolerance in the early postoperative period after hip arthroscopy.

Longitudinal versus transverse hip arthroscopy portal cosmesis: a case-control trial of simultaneous bilateral cases.

The direction and nature of incisions can impact the healing and appearance of a surgical scar. This can be attributed mainly due to skin tension and direction of force. The aim of this study was to identify differences in healing rates and scar esthetics between transverse and longitudinal portals used for hip arthroscopy. A total of 75 patients underwent bilateral hip arthroscopy for femoroacetabular impingement. All patients received a portal perpendicular to the long axis of the body on the left side (transverse portal) and parallel with the long axis of the body on the right side (longitudinal portal) for the standard anterolateral viewing portal. Postoperatively, patients were reviewed at 2 weeks, 6 weeks, 3 months and 6 months and the portal scars were assessed, photographed and measured. No patients were lost to follow-up. The transverse scars, although slightly longer, were found to be narrower at 6 weeks (3.8 mm versus 2.7 mm, P < 0.01), 3 months (4.3 mm versus 3.4 mm, P = 0.01) and 6 months postoperatively (6.1 mm versus 4.5 mm, P < 0.01). At 3 months (43 mm2 versus 35 mm2, P = 0.029) and 6 months (49 mm2 versus 43 mm2, P = 0.024), transverse incisions were noted to have significantly reduced total area compared with longitudinal incisions. There were no wound complications in either group. This study demonstrates that transverse portal positions for hip arthroscopy have an advantage over longitudinal portal positions in terms of total scar area and thickness up to 6 months postoperatively.

The CU PAO: A Minimally Invasive, 2-Incision, Interlocking Periacetabular Osteotomy: Technique and Early Results.

BACKGROUND: The aims of this study were to describe a novel minimally invasive, interlocking periacetabular osteotomy (PAO) for the treatment of hip dysplasia that was developed at our institution and to report on its safety, complications, and early clinical outcomes. METHODS: This was a prospective longitudinal study of the first 200 consecutive hips that underwent the CU (University of Colorado) PAO, an interlocking osteotomy combining the benefits of the Birmingham interlocking pelvic osteotomy (BIPO) and the Ganz PAO. The technique provides direct visualization of the sciatic nerve during the ischial osteotomy and allows for immediate weight-bearing postoperatively. Demographic characteristics, intraoperative and perioperative parameters, and functional outcomes were documented. All patients underwent hip arthroscopy 3 to 10 days prior to the PAO to address concomitant intra-articular pathology. Mechanical deep venous thrombosis (DVT) prophylaxis was used for 2 weeks postoperatively. Results were stratified to compare the first 100 and the second 100 cases. RESULTS: A total of 161 patients (200 hips) underwent primary PAO; mean follow-up was 20 months (range, 3 to 33 months). The mean patient age at the time of surgery was 29.4 years (range, 13 to 55 years). Females accounted for 89% of the patients included in this study. The average length of stay was 4 days. A concomitant proximal femoral derotational osteotomy was performed in 19 hips. The lateral center-edge angle (LCEA) improved from a mean of 18.8° preoperatively to 31.5° postoperatively (p < 0.001). The mean Non-Arthritic Hip Score (NAHS) improved from 56.0 preoperatively to 89.4 at the 24-month follow-up (p < 0.0001). Paresthesias in the distribution of the lateral femoral cutaneous nerve were common (65% at 2 weeks postoperatively) but resolved in 85% of the patients within the first 6 months. There were no sciatic nerve-related complications, deep infections, or DVTs. CONCLUSIONS: The CU PAO enables corrective realignment of symptomatic acetabular dysplasia with direct visualization of the sciatic nerve, early weight-bearing, cosmetic incisions, and good short-term outcomes. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Distal Adductor Longus Avulsion: A Technique for Successful Repair.

Strains of the adductor muscle are common among athletes, but avulsion at its insertion is rare. Likewise, the diagnosis and management of distal ruptures of the adductors are infrequently reported in the literature. Presented here are the common presenting clinical findings of chronic distal adductor longus tendon ruptures and a description of how these can be successfully treated with a previously undescribed surgical technique. Preoperative and postoperative magnetic resonance imaging can be compared for verification of successful surgical repair. Also reviewed are common sports and mechanisms that elicit this injury pattern, adductor longus muscle function, relevant surgical anatomy, and treatment strategies.

Effects of Hip Arthroscopy Without a Perineal Post on Venous Blood Flow, Muscle Damage, Peripheral Nerve Conduction, and Perineal Injury: A Prospective Study.

BACKGROUND: Prior reports of hip arthroscopy using a perineal post have established the risks of groin soft tissue injury, sexual dysfunction, and altered lower extremity neurovascular function. These parameters have not been investigated for hip arthroscopy without the use of a perineal post. PURPOSE: To evaluate the effects of postless hip arthroscopy on lower extremity venous blood flow, nerve conduction, muscle tissue damage, and perineal injury. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Patients between the ages of 18 and 50 years undergoing an elective unilateral or simultaneous bilateral hip arthroscopy were enrolled. Creatine phosphokinase (CPK)-MM levels and D-dimer levels were obtained preoperatively, immediately postoperatively, and 7 to 12 days postoperatively. Bilateral Doppler ultrasonography of the common femoral vein (CFV) and popliteal vein were conducted intraoperatively. Somatosensory evoked potentials (SSEPs) and transcranial motor evoked potentials (TcMEPs) were measured intraoperatively for the lower limbs. Perineal injury was assessed at 7 to 12 days postoperatively. RESULTS: 35 patients underwent a total of 40 hip arthroscopies. No significant differences were found in venous blood flow between the operative and nonoperative legs for either the CFV or popliteal vein. SSEP monitoring of the peroneal nerve showed no significant reduction when traction was applied to the operative leg, 90.8%, compared with final measurement just before it was removed, 72.4% (P = .09). For TcMEPs measured in the muscles outside of the traction boots, no significant changes were seen in the percentage of cases with abnormal measurements throughout the procedure. CPK-MM levels preoperatively, immediately postoperatively, and 7 to 12 days after surgery were on average 112, 190, and 102 IU/L, respectively (normal, <156 IU/L). No significant relationship was found between abnormal venous flow and altered D-dimer levels. No clinical evidence of nerve or vascular injury was encountered, and no groin soft tissue complications were observed during the study period. CONCLUSION: Postless hip arthroscopy is safe, without a notable reduction of venous blood flow or alteration of nerve function in the operative leg. Muscle tissue damage is subclinical, transient, and reduced compared with distraction with a post. No cases of perineal injury were observed during the study period.

Injury Recurrence Among High School Athletes in the United States: A Decade of Patterns and Trends, 2005-2006 Through 2015-2016.

BACKGROUND: As participation in high school athletics increases, so does the number of adolescents experiencing sports-related injury. Understanding injury patterns is an important component to developing and evaluating prevention and rehabilitation programs. PURPOSE: To analyze recurrent injury rates and patterns among high school athletes, to compare recurrent injuries with new injuries, and to evaluate injury trends over time. STUDY DESIGN: Descriptive epidemiology study. METHODS: High school sports injury data on 24 sports were collected from 2005-2006 through 2015-2016 via the High School RIO (Reporting Information Online) surveillance system. Injury rates were calculated as number of injuries per 10,000 athletic exposures (AEs). Injury rate ratios and injury proportion ratios (IPRs) were calculated to compare differences among subgroups. RESULTS: Overall, 78,005 injuries were sustained during 40,195,806 AEs, for an injury rate of 19.41 per 10,000 AEs. Of these, 69,821 (89.5%) were new injuries, and 8184 (10.5%) were recurrent. The ankle was the most commonly injured body part among recurrent injuries, while the head/face was the most common body part that sustained new injuries. Ligament sprains were more often recurrent, while concussions were more commonly diagnosed as new, although concussions represented 16.7% of recurrent injuries. Trends for recurrent injuries over time were relatively stable. The proportion of athletes who had >3 weeks of time loss or medical disqualification (15.8% vs 13.3%; IPR, 1.19; 95% CI, 1.13-1.26) or who voluntarily withdrew from sport (2.5% vs 1.1%; IPR, 2.33; 95% CI, 2.00-2.73) was significantly greater for recurrent injuries than new injuries. Furthermore, a greater proportion of recurrent injuries resulted in surgery (8.1% vs 6.0%; IPR, 1.34; 95% CI, 1.24-1.46). CONCLUSION: Although only 10.5% of all injuries were recurrent, they more frequently resulted in missing >3 weeks of playing time and were more often managed surgically when compared with new injuries. The rate of recurrent injuries has not increased over the past decade.

Current Concepts of the Anterolateral Ligament of the Knee: Anatomy, Biomechanics, and Reconstruction.

In 1879, Paul Segond described an avulsion fracture (now known as a Segond fracture) at the anterolateral proximal tibia with the presence of a fibrous band at the location of this fracture. Although references to this ligament were occasionally made in the anatomy literature after Segond's discovery, it was not until 2012 that Vincent et al named this ligament what we know it as today, the anterolateral ligament (ALL) of the knee. The ALL originates near the lateral epicondyle of the distal femur and inserts on the proximal tibia near Gerdy's tubercle. The ALL exists as a ligamentous structure that comes under tension during internal rotation at 30°. In the majority of specimens, the ALL can be visualized as a ligamentous structure, whereas in some cases it may only be palpated as bundles of more tense capsular tissue when internal rotation is applied. Biomechanical studies have shown that the ALL functions as a secondary stabilizer to the anterior cruciate ligament (ACL) in resisting anterior tibial translation and internal tibial rotation. These biomechanical studies indicate that concurrent reconstruction of the ACL and ALL results in significantly reduced internal rotation and axial plane tibial translation compared with isolated ACL reconstruction (ACLR) in the presence of ALL deficiency. Clinically, a variety of techniques are available for ALL reconstruction (ALLR). Current graft options include the iliotibial (IT) band, gracilis tendon autograft or allograft, and semitendinosus tendon autograft or allograft. Fixation angle also varies between studies from full knee extension to 60° to 90° of flexion. To date, only 1 modern study has described the clinical outcomes of concomitant ALLR and ACLR: a case series of 92 patients with a minimum 2-year follow-up. Further studies are necessary to define the ideal graft type, location of fixation, and fixation angle for ALLR. Future studies also must be designed in a prospective comparative manner to compare the clinical outcomes of patients undergoing ACLR with ALL reconstruction versus without ALL reconstruction. By discovering the true effect of the ALL, investigators can elucidate the importance of ALLR in the setting of an ACL tear.

Current pain prescribing habits for common shoulder operations: a survey of the American Shoulder and Elbow Surgeons membership.

BACKGROUND: Orthopedic surgeons are among the highest prescribers of narcotic pills, and no guidelines currently exist for appropriate management of postoperative pain within this field. The purpose of this study was to gain understanding of the current pain management strategies used perioperatively and postoperatively among orthopedic shoulder surgeons. METHODS: Members of the American Shoulder and Elbow Surgeons were e-mailed an online survey regarding methods for managing pain in the perioperative and postoperative setting for total shoulder arthroplasty, labral and capsular stabilization procedures, and rotator cuff repair. Postoperative narcotic prescribing amounts were converted into oral morphine equivalents. RESULTS: The survey response rate was 25.8% (170/658), with >90% of surgeons reporting use of a standard pain management regimen in the perioperative and postoperative periods. A regional nerve block was used on the operative day by >80% of surgeons for all 3 procedures. Short-acting narcotics are prescribed for postoperative pain control by >85% of surgeons, with long-acting narcotics provided by <14%. More than 400 oral morphine equivalents of short-acting narcotic are prescribed by shoulder surgeons. Referral to a pain specialist or primary care physician is made after 12 weeks by 92.3% of surgeons if patients continue to require narcotic painkillers. CONCLUSION: The majority of shoulder surgeons use a standard pain management protocol in perioperative and postoperative settings. Regimens frequently include a regional nerve block, nonsteroidal anti-inflammatory drugs, and short-acting oral narcotics. Findings from this study provide guidelines on standard pain management strategies for common shoulder operations based on expert opinion.

Epidemiology of Injuries Sustained as a Result of Intentional Player Contact in High School Football, Ice Hockey, and Lacrosse: 2005-2006 Through 2015-2016.

BACKGROUND: Lacrosse and ice hockey are quickly growing in popularity, while football remains the most popular sport among high school student-athletes. Injuries remain a concern, given the physical nature of these contact sports. PURPOSE: To describe the rates and patterns of injuries sustained as a result of intentional player contact in United States high school boys' football, ice hockey, and lacrosse. STUDY DESIGN: Descriptive epidemiology study. METHODS: We conducted a secondary analysis of High School RIO (Reporting Information Online) data, including exposure and injury data collected from a large sample of high schools in the United States from 2005-2006 through 2015-2016. Data were analyzed to calculate rates, assess patterns, and evaluate potential risk factors for player-to-player contact injuries. RESULTS: A total of 34,532 injuries in boys' football, ice hockey, and lacrosse occurred during 9,078,902 athlete-exposures (AEs), for a rate of 3.80 injuries per 1000 AEs in the 3 contact sports of interest. The risk of injuries was found to be greater in competition compared with practice for all 3 sports, with the largest difference in ice hockey (rate ratio, 8.28) and the smallest difference in lacrosse (rate ratio, 3.72). In all 3 contact sports, the most commonly injured body site in competition and practice caused by both tackling/checking and being tackled/checked was the head/face. However, a significantly greater proportion of concussions sustained in football were the result of tackling compared with being tackled (28.2% vs 24.1%, respectively). In addition, a significantly greater proportion of concussions were sustained in competition compared with practice for all 3 sports. CONCLUSION: This study is the first to collectively compare injury rates and injury patterns sustained from intentional player-to-player contact in boys' high school football, ice hockey, and lacrosse. Notably, there was a relatively high risk of injuries and concussions during football practices.

MRI to Arthroscopy Correlations in SLAP Lesions and Long Head Biceps Pathology.

Superior labral anterior and posterior lesions and long head biceps injury are 2 common sources of shoulder pain. The presenting complaints and physical examination findings for these etiologies are often nonspecific, making diagnosis challenging. Further complicating their diagnoses, these 2 pathologies often cooccur together or with other shoulder pathologies such as subacromial bursitis, rotator cuff tear, and shoulder instability. However, with advancement in magnetic resonance imaging and shoulder arthroscopy techniques the ability to diagnose and treat these pathologies has vastly improved over the past 30 years. This review provides a case-based description of the correlation between magnetic resonance imaging and arthroscopic findings in common superior labral anterior and posterior and long head biceps injury, accompanied with current management strategies.

The Iliofemoral Line: A Radiographic Sign of Acetabular Dysplasia in the Adult Hip.

BACKGROUND: Several radiographic parameters utilized for the diagnosis of acetabular dysplasia in adults suffer from poor reproducibility and reliability. PURPOSE: To define and validate a novel radiographic parameter (the iliofemoral line [IFL]) for the detection of frank and borderline hip dysplasia and to compare the sensitivity and specificity of this radiographic marker to those of previously validated qualitative parameters. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: A consecutive cohort of 222 adult patients (436 hips) undergoing hip preservation surgery was included. The IFL, which extends from the lateral femoral neck through the inner cortical lip of the iliac crest, intersects the femoral head in cases of dysplasia. Percent medialization of the IFL was defined as the horizontal distance of the exposed femoral head lateral to the IFL, relative to the horizontal femoral head width at the center of the femoral head. RESULTS: Percent medialization of the IFL was strongly correlated to the lateral center edge angle ( P < .0001). Values of percent medialization ranging from 15% to 22% predicted the presence of borderline hip dysplasia with a sensitivity of 62% and specificity of 89%, while values exceeding 22% predicted the presence of frank acetabular dysplasia with a sensitivity of 77% and specificity of 94%. By comparison, abnormality of the Shenton line demonstrated a sensitivity of 3.7% and specificity of 97% for the detection of borderline dysplasia and a sensitivity of 16% and specificity of 99% for the detection of frank acetabular dysplasia. Compared with the Shenton line, percent medialization of the IFL was significantly more sensitive for the detection of both borderline and frank acetabular dysplasia (both P < .0001). The intraobserver and interobserver reproducibility of the horizontal difference outside the IFL were 0.99 and 0.96, respectively. CONCLUSION: Percent medialization of the IFL is a reliable and accurate radiographic marker of frank acetabular dysplasia and, to a lesser extent, borderline dysplasia. The use of this radiographic parameter as an additional tool may enable the earlier detection of borderline and frank hip dysplasia in young adults presenting with hip pain.

Proportion of Obese Patients Presenting to Orthopedic Total Joint Arthroplasty Clinics.

The purpose of this study is to demonstrate that the percentage of obese individuals initially presenting to total joint arthroplasty clinics in a public, tertiary hospital is greater than the proportion of obese individuals in the general population. In a retrospective, comparative study of patients seen in total joint replacement clinics at a public, tertiary hospital with an ICD-9 diagnosis of hip or knee osteoarthritis and documented body mass index, the proportion of obese individuals was compared with recent obesity data for the general population from the Centers for Disease Control and Prevention. Patients who had previously undergone hip or knee replacement surgery were excluded. Comorbid conditions, functional comorbidity index (FCI) scores, and Charlson comorbidity index scores were compared between obese and nonobese cohorts. The study included 499 patients aged 20 to 92 years (mean, 64.3 years), 58.9% of whom were female. Fifty-five percent of patients were obese, a significantly greater percentage than in the national (34.9%; P<.0005; odds ratio [OR]=2.23), regional (29.5%; P<.0005; OR=2.85), and state (31.1%; P<.0005; OR=2.64) populations. Obese patients had significantly more comorbid conditions (P<.002) and higher functional comorbidity index scores (P<.0009). The number of comorbidities and having Medicare/Medicaid insurance were predictive of obesity. This study highlights that the majority of patients presenting to orthopedic total joint arthroplasty clinics are obese and that they come with significantly more comorbidities. The total joint surgeon has a unique opportunity to facilitate weight loss in the obese osteoarthritic patient prior to joint replacement.

Patient impressions of reimbursement for orthopedic spine surgeons.

The study aim was to understand patient impressions of reimbursement to orthopedic spine surgeons. Our findings revealed that the majority of patients significantly overestimate the amount surgeons are reimbursed per procedure. Despite this, most feel that surgeons are appropriately compensated. Additionally, many patients are unaware of the global billing period.

A-type nuclear lamins act as transcriptional repressors when targeted to promoters.

Regions of heterochromatin are often found at the periphery of the mammalian nucleus, juxtaposed to the nuclear lamina. Genes in these regions are likely maintained in a transcriptionally silent state, although other locations at the nuclear periphery associated with nuclear pores are sites of active transcription. As primary components of the nuclear lamina, A- and B-type nuclear lamins are intermediate filament proteins that interact with DNA, histones and known transcriptional repressors, leading to speculation that they may promote establishment of repressive domains. However, no direct evidence of a role for nuclear lamins in transcriptional repression has been reported. Here we find that human lamin A, when expressed in yeast and cultured human cells as a fusion protein to the Gal4 DNA-binding domain (DBD), can mediate robust transcriptional repression of promoters with Gal4 binding sites. Full repression by lamin A requires both the coiled-coil rod domain and the C-terminal tail domain. In human cells, other intermediate filament proteins such as lamin B and vimentin are unable to confer robust repression as Gal4-DBD fusions, indicating that this property is specific to A-type nuclear lamins. These findings indicate that A-type lamins can promote transcriptional repression when in proximity of a promoter.

Age- and calorie-independent life span extension from dietary restriction by bacterial deprivation in Caenorhabditis elegans.

BACKGROUND: Dietary restriction (DR) increases life span and delays age-associated disease in many organisms. The mechanism by which DR enhances longevity is not well understood. RESULTS: Using bacterial food deprivation as a means of DR in C. elegans, we show that transient DR confers long-term benefits including stress resistance and increased longevity. Consistent with studies in the fruit fly and in mice, we demonstrate that DR also enhances survival when initiated late in life. DR by bacterial food deprivation significantly increases life span in worms when initiated as late as 24 days of adulthood, an age at which greater than 50% of the cohort have died. These survival benefits are, at least partially, independent of food consumption, as control fed animals are no longer consuming bacterial food at this advanced age. Animals separated from the bacterial lawn by a barrier of solid agar have a life span intermediate between control fed and food restricted animals. Thus, we find that life span extension from bacterial deprivation can be partially suppressed by a diffusible component of the bacterial food source, suggesting a calorie-independent mechanism for life span extension by dietary restriction. CONCLUSION: Based on these findings, we propose that dietary restriction by bacterial deprivation increases longevity in C. elegans by a combination of reduced food consumption and decreased food sensing.