Understanding the Remplissage: History, Biomechanics, Outcomes, and Current Indications

PURPOSE OF REVIEW

Arthroscopic remplissage has continued to gain popularity as an adjunct to Bankart repair for patients with anterior shoulder instability. Although the original remplissage technique was described over 15 years ago, our understanding of when and how to use this procedure continues to evolve. This article provides a review of how remplissage affects shoulder biomechanics, compares clinical outcomes between remplissage and other procedures for shoulder instability, and discusses current indications for remplissage.

RECENT FINDINGS

Current research focuses on the use of remplissage across a wide range of glenoid bone loss. Remplissage appears effective at preventing recurrent instability in patients with glenoid bone loss up to 15% of the glenoid width. However, once glenoid bone exceeds 15%, outcomes tend to favor bony reconstruction procedures such as Latarjet. Results of biomechanical studies examining shoulder range of motion (ROM) after remplissage are mixed, though clinical studies tend to report no significant limitations in ROM when remplissage is added to a Bankart repair. Adding a remplissage to conventional Bankart repair may improve clinical outcomes and lower rates of recurrent instability without significantly altering shoulder ROM. However, surgeons should recognize its limitations in treating patients with large amounts of glenoid bone loss and should be prepared to discuss alternative procedures on a case-by-case basis. Absolute indications and contraindications for remplissage are not well defined currently and require further scientific research.

Acromioclavicular joint dislocation and concomitant labral lesions: a systematic review

Acromioclavicular (AC) joint dislocations frequently co-occur with intra-articular glenohumeral pathologies. Few comprehensive studies have focused on labral tears specifically associated with AC joint trauma. This systematic review will address this gap. A comprehensive electronic search was conducted across PubMed, Cochrane Library, and Google Scholar (pages 1-20) spanning from 1976 to May 19, 2023. Seven studies met the inclusion criteria for this systematic review, consisting of three retrospective studies and four case series. These studies collectively involved 1,044 patients, of whom 282 had concomitant labral lesions. The pooled prevalence of intra-articular labral injuries associated with acute AC joint dislocation was 27%. The prevalence of these labral lesions varied significantly between studies, ranging from 13.9% to 84.0% of patients, depending on the study and the grade of AC joint dislocation. Various types of labral tears were reported, with superior labrum anterior to posterior (SLAP) lesions being the most common. The prevalence of SLAP lesions ranged from 7.2% to 77.4%, with higher grades of AC joint dislocations often associated with a higher prevalence of SLAP tears. Moreover, grade V dislocations exhibited a complete correlation with SLAP tears. The studies yielded contradictory findings regarding older age and higher grades of AC joint dislocation as risk factors for concurrent labral lesions. This review underscores the frequent association between labral lesions and AC joint dislocations, particularly in cases of lower-grade injuries. Notably, SLAP lesions emerged as the predominant type of labral tear.

Patients aged 50-75 years take longer to achieve the patient acceptable symptom state than patients aged 20-34 years following primary hip arthroscopy for femoroacetabular impingement syndrome

PURPOSE

Though an increasing number of adults older than 50 years are undergoing hip arthroscopy for treatment of Femoroacetabular Impingement Syndrome (FAIS), it is unclear how their timeline for functional outcome improvement compares to that of younger patients. The purpose of this study was to assess the impact of age on time to achieving the Minimum Clinically Important Difference (MCID), Substantial Clinical Benefit (SCB), and Patient Acceptable Symptom State (PASS) following primary hip arthroscopy for FAIS.

METHODS

A retrospective comparative single-surgeon cohort study of primary hip arthroscopy patients with minimum 2-year follow-up was conducted. Age categories were 20-34 years, 35-49 years, and 50-75 years. All subjects completed the modified Harris Hip Score (mHHS) prior to surgery and at 6-month, 1-year, and 2-year follow-up. MCID and SCB cutoffs were defined as pre-to-postoperative increases in mHHS by ≥ 8.2 and ≥ 19.8, respectively. PASS cutoff was set at postoperative mHHS ≥ 74. Time to achievement of each milestone was compared using interval-censored survival analysis. The effect of age was adjusted for Body Mass Index (BMI), sex, and labral repair technique using an interval-censored proportional hazards model.

RESULTS

Two hundred eighty-five patients were included in the analysis with 115 (40.4%) aged 20-34 years, 92 (32.3%) aged 35-49 years, and 78 (27.4%) aged 50-75 years. There were no significant differences between groups in time to achievement for the MCID (n.s.) or SCB (n.s.). However, patients in the oldest group had significantly longer time to PASS than those in the youngest group, both in the unadjusted analysis (p = 0.02) and after adjusting for BMI, sex, and labral repair technique (HR 0.68, 95% CI 0.48-0.96, p = 0.03).

CONCLUSION

Achievement of the PASS, but not the MCID or SCB, is delayed among FAIS patients aged 50-75 years who undergo primary hip arthroscopy compared to those aged 20-34 years. Older FAIS patients should be counseled appropriately about their longer timeline to achieving hip function comparable to their younger counterparts.

LEVEL OF EVIDENCE

III.

Functional outcome and athletic level after arthroscopic repair followed by triple pelvic osteotomy in patients with labral tears resulting from acetabular dysplasia

BACKGROUND

Patients with acetabular dysplasia are at a higher risk of developing symptomatic labral tears. Isolated treatments that address these pathologies are well established. Combined treatment with hip reorientation osteotomy using Bernese periacetabular osteotomy in addition to arthroscopic labral repair show good results. Studies that report the outcome in patients who received both arthroscopic labral repair and a triple pelvic osteotomy (TPO) are lacking. The aim of this study is to investigate the short to midterm functional outcome and activity level in these patients.

METHODS

This case series retrospectively included 8 patients (2 male, 6 female) with acetabular dysplasia (lateral center-edge angle [LCEA] ≤ 25°) and a labral tear on magnetic resonance arthrography (MRA). All patients underwent arthroscopic labral repair followed by TPO after an average period of 3 months (range 2-6). Average age at the time of surgery was 25 years (range 15-37). Patients were followed up and the following main parameters were assessed: LCEA, modified Harris hip score (mHSS), Tegner score, UCLA score, patient satisfaction on a scale of 1-4.

RESULTS

The mean follow-up was 19 months (range 15-25). The mean LCEA increased from 18° to 37° (p < 0.0001). The mHSS improved from a mean of 79 to 94 on final follow-up (p = 0.00123). The Tegner and UCLA scores had a median of 4 and 5, respectively. The mean LCEA increased from 18° to 37° (p < 0.0001). The mean patient satisfaction was 3.6.

CONCLUSION

Patients with evidence of a labral tear resulting from acetabular dysplasia benefit from arthroscopic repair followed by a TPO. The literature still lacks evidence that labral repair and reorientation osteotomy produce superior outcome compared to osteotomy alone. Treatment should consider clinical presentation in addition to radiological findings with emphasis on MRA.

Reliability of Conventional Hip MRI in Detecting Labral Tear and Labrocartilagenous Lesions in cases of Femoroacetabular Impingement, A Comparative Study with Hip Arthroscopy

BACKGROUND

Imaging studies play a crucial role in diagnosing femoroacetabular impingement (FAI), including plain radiography and Magnetic Resonance Imaging (MRI). FAI is a combined pathology of bony abnormality, labral and labrocartilagenous erosions. Surgical treatment for such cases has become more established and preoperative imaging is the roadmap that includes the assessment of labrum and articular cartilage.

METHODS

During a period of 2 years, thirty-seven patients with a clinical diagnosis of FAI were retrospectively enrolled in this study, including 17 men and 20 women, aged 27-62 years. There were 22 right hips and 15 left hips. MRI was done for all patients to identify bony details, labral and chondral abnormalities and to exclude coexisting disorders. The imaging findings were compared with the arthroscopic data.

RESULTS

15 patients had Pincer FAI, 11 patients had CAM, and 11 patients had combined Cam/Pincer FAI. Labral tear was detected in 100 % of patients, 97 % had an anterosuperior labral tear. 82 % of patients had partial thickness cartilage lesions and 8 % had full thickness cartilage lesions. MRI had a sensitivity of 100 % compared to hip arthroscopy in detecting labral tear, 60 % in detecting cartilage erosion.

CONCLUSION

Conventional hip MRI detects bony changes in FAI, type of impingement and associated labral tear and cartilage erosions in comparison to the hip arthroscopy.

Midterm results after arthroscopic femoral neck osteoplasty combined with labral debridement for cam type femoroacetabular impingement in active adults

INTRODUCTION

Arthroscopic labral procedures are frequently undertaken in patients with femoroacetabular impingement (FAI). The role of arthroscopic femoral neck osteoplasty is well established, but less is known about labral procedures. This study evaluates the midterm efficacy and feasibility of arthroscopic osteoplasty with concomitant labral debridement for cam impingement in active adults.

METHODS

The present study was conducted according to the STROBE Statement. All 108 patients who underwent primary hip arthroscopy for cam type FAI combined with labral debridement were considered. Axial and anteroposterior plain radiographs of the pelvis were obtained preoperatively to identify the cam deformity and assess the presence of osteoarthritis, the lateral centre-edge angle, and the alpha angle. The ROM (flexion, extension, abduction, adduction, and intra/extra rotation) was evaluated. The following PROMs were administered: visual analogic scale (VAS), Tegner Activity Scale, non-arthritic hip score (NAHS), the international Hip Outcome Tool (iHOT-33) overall score, and related subscales: symptoms and functional limitations, sports and recreational activities, job-related concerns, and social, emotional, and lifestyle concerns.

RESULTS

At a mean of 2.0 ± 1.1 months, all 108 patients returned to their daily activities with no limitation. At a mean of 2.6 ± 1.4 months, all 108 patients were able to return to sport with no limitation. At 11.9 ± 2.1-month follow-up, no differences were reported in the range of motion compared to baseline: flexion (P = 0.3), extension (P = 0.09), abduction (P = 0.1), adduction (P = 0.3), internal rotation (P = 0.4), and external rotation (P = 0.6). At 72.8 ± 21.7-month follow-up, the mean VAS score was 1.7 ± 3.0, Tegner Activity Scale 3.5 ± 1.4, NAHS 92.1 ± 21.5, iHOT33 83.3 ± 27.2. At a mean of 21.7 ± 15.5 months following the index procedure, 14 of 108 patients had undergone total hip arthroplasty. No further revisions or complications were reported.

CONCLUSION

Arthroscopic femoral neck osteoplasty with concomitant labral debridement for cam type of FAI in active adults yields the reliable results, with a rate of progression to total hip arthroplasty of 13% (14 of 108) at 3-year follow-up. All patients returned to their daily activities with no limitation 2 months postoperatively. Within 3 months, all patients returned to sport with no limitations. No complication related to the index procedure was reported, and no further arthroscopic procedures were necessary.

Hip Labral Reconstruction: Techniques and Outcomes

PURPOSE OF REVIEW

With increased understanding of the biomechanical function of the acetabular labrum, more attention has been directed towards surgical techniques that preserve or restore normal joint anatomy. While labral repair has been shown to produce superior outcomes to labral debridement, repair is not always possible in the setting of severe labral intrasubstance tearing or deficiency. These patients were previously left without suitable arthroscopic treatment options.

RECENT FINDINGS

Labral reconstruction is an emerging procedure that has been shown to offer promising outcomes for traditionally difficult-to-treat hip pathology. Short- and mid-term follow-up studies have consistently demonstrated significant improvement in patient-reported outcomes, function, and patient satisfaction postoperatively, often despite less favorable preoperative characteristics. Labral reconstruction is a viable arthroscopic treatment option that has been shown to reliably produce clinically meaningful results in patients with severe labral pathology that is not amenable to repair/refixation or augmentation.

The correlation between the labrum size and the labral tear in asymptomatic volunteers and symptomatic patients

BACKGROUND

Some studies have proved that labrum size is associated with symptoms in patients with hip labral tear. The correlation between the labrum size and the labral tear in asymptomatic volunteers and symptomatic patients is still uncertain.

METHODS

The volunteers with no history of pain, injury, or surgery were recruited from the community. Patients who were diagnosed with labral tear and underwent hip arthroscopic surgery in this period in our hospital were also included. The length and height of the acetabular hip labrum were measured at three separate anatomic sites through magnetic resonance imaging (MRI) along the acetabular rim: lateral, anterior, and anteroinferior.

RESULTS

A total of 70 volunteers (125 hips) and 70 patients (70 hips) were included in this study. Sixty-six (52.8%) hips had labral tears in all 125 hips of volunteers. The lateral labral length of volunteers with labral tears was significantly larger than those without labral tears (P < .05). In 14 volunteers with unilateral labral tears, length of lateral, anterior, and anteroinferior labrum in the side with tear were significantly larger than normal on the other side. The anterior labral height of volunteers was significantly larger than that of patients (P < .05).

CONCLUSIONS

In conclusion, asymptomatic volunteers with larger length of lateral, anterior, and anteroinferior labrum are more prone to present with labral tears. Symptomatic patients with labral tears exhibited thinner anterior labrum. Further studies are warranted to explore the mechanisms of labral tears in asymptomatic people and validate the use of labral size as a guide to differential diagnosis and treatment.

Femoroacetabular Impingement and Labral Tear: From the Most Highly Cited Articles to Research Interests

Objective

To highlight the characteristics of the most highly cited articles and propose the research interests over the past decades in the field of femoroacetabular impingement (FAI) and labral tear.

Methods

The ISI Web of Science database (Clarivate Analytics, New York, the United States) was utilized for the identification of articles on 15 December 2020. FAI and labral tear‐related articles (1138 articles) were retrieved, of which the 100 most‐cited articles (top 100) were identified. Subsequent analysis included citation density (citations/article age), authorship, institution, journal, geographic distribution, level of evidence, and theme.

Results

The number of citations per article ranged from 66 to 1189 with a mean of 163.31. The majority of articles were published in the United States (all articles/top 100 = 655/57) and Switzerland (85/22). University of Bern (n = 10) was the most prolific institution. The journal with the most of articles was Arthroscopy: The Journal of Arthroscopic and Related Surgery. The most prolific coauthor (all articles) or first authors (top 100) was Domb (n = 109) and Philippon (n = 6), respectively. The evidence with the most articles is level IV (n = 41). The top three most popular topics of research article were outcomes of surgery (n = 23), imaging diagnosis (n = 18), and comparison of surgery (n = 8). The top four most prevalent themes of review were labral tears (n = 3), FAI (n = 3), comparison of surgery imaging diagnosis, and outcomes of surgery (both n = 2). Six keywords with the newest average publication year, including FAI syndrome (average publication year = 2019.50), patient‐reported outcomes (2019.43), femoroplasty (2018.60), clinical outcomes (2018.17), borderline dysplasia (2018.00), and capsule (2018.00). Five keywords with the highest average citations, including outcome (average citations = 88.50), alpha angle (58.00), complications (55.86), revision hip arthroscopy (49.00), and systematic review (46.14).

Conclusions

Outcomes research is the most popular research interest and patient‐reported outcome instruments might be further and widely used in the emerging articles in the near future. The field of FAI and labral tear has shown an obvious trend of development and is steadily evolving. It could be predicted that there will be an increasing number of publications in the following years, with the United States and Switzerland maintaining leadership in this field.

Arthroscopic classification of intra-articular hip pathology demonstrates at best moderate interrater reliability

PURPOSE

The purpose of this study was to report several novel classification systems for intra-articular lesions observed during hip arthroscopy, and to quantify the interrater reliability of both these novel systems and existing classifications of intra-articular lesions when tested by a group of high-volume hip arthroscopists.

METHODS

Five hip arthroscopists deliberated over shortcomings in current classification systems and developed several novel grading systems with particular effort made to capture factors important to the treatment and outcomes of hip arthroscopy for labral injury. A video learning module describing the classifications was then developed from the video archive of surgeries performed by the senior author and reviewed by study participants. Following review of the module, a pilot study was completed using five randomly selected videos, after which participating surgeons met once more to discuss points of disagreement and to seek clarification. The final video collection for testing reliability was composed of 29 videos selected with the intent of capturing all sublevels of each classification scheme. Study participants recorded their assessments using each classification scheme, and interrater reliability was calculated by a study participant not involved in grading.

RESULTS

The average kappa coefficients for the classification schemes ranged from 0.38 to 0.54, with the interrater reliability of all classification schemes except labral degeneration qualifying as moderate. The percent of cases with absolute agreement ranged from 17.2% to 51.7% across the classification systems.

CONCLUSIONS

Even among a group of high-volume hip arthroscopists who engaged in several discussions about the proposed classification schemes, grades were found to have at best moderate interrater reliability. Moderate interrater reliability is demonstrated for novel grading systems for describing labral tear complexity, labral bruising, labral size, and extent of synovitis, and fair reliability is demonstrated for labral degeneration. Further development and refinement of multifactorial grading systems for describing labral injury are indicated. Evaluating the multifactorial nature of intra-articular lesions in the hip is an important part of intraoperative decision-making and defining reliable classifications for intra-articular lesions is a critical first step towards developing generalizable criteria for guiding treatment type.

LEVEL OF EVIDENCE

Level III.

Evaluation of Athletes with Hip Pain

Hip pain is a common complaint in athletes and can result in a significant amount of time lost from sport. Diagnosis of the source of hip pain can be a clinical challenge because of the deep location of the hip and the extensive surrounding soft tissue envelope. Establishing whether the source of hip pain is intra-articular or extra-articular is the first step in the process. A thorough history and a consistent and comprehensive physical examination are the foundation for the proper management of athletes with hip pain.

Comparison of 2D, 3D, and radially reformatted MR images in the detection of labral tears and acetabular cartilage injury in young patients

OBJECTIVE

The purpose of this study was to compare the utility of two-dimensional high-resolution (2D), 3-dimensional with multiplanar reconstruction (3D MPR), and radially reformatted (RR) MRIs when evaluating the complexities of the hip joint in patients with femoroacetabular impingement (FAI). We hypothesized RR would be superior in detecting labral pathology and 2D would be superior in detecting transition zone and acetabular cartilage injury.

MATERIALS AND METHODS

2D, 3D MPR, and RR MRIs of 33 patients, who later underwent surgical treatment for FAI, were evaluated for sensitivity, specificity, and accuracy. Bland-Altman methods were used to estimate agreement between each method and the gold-standard, arthroscopic visualization of the hip joint, regarding the percentage of the hip joint affected by each injury type.

RESULTS

3D MPR and RR groupings were associated with the highest sensitivity and accuracy for labral injury. 3D MPR demonstrated the smallest bias in assessing the percentage of joint affected by labral injury and was the most accurate in identifying acetabular cartilage injury, whereas RR had the smallest mean difference in assessing the percentage of joint affected by acetabular cartilage injury. 2D was the most accurate in identifying transition zone injuries, while RR was superior in assessing the percentage of the joint affected by transition zone injury.

CONCLUSIONS

Our results suggest that including both 3D MPR and RR MRI groupings is favorable for accurate joint visualization and well-informed treatment planning, especially given that labral injury is a main source of pain and dysfunction for FAI patients.

Assessment of the duration and effectiveness of intra-articular lidocaine injections for groin pain in patients with labral tears involving early osteoarthritis

Introduction: Intra-articular lidocaine injections have been used to confirm the hip pathology and may predict the efficacy of arthroscopic surgery. We have routinely performed the injections as a surgical indicator. The aim of this study was to assess the duration and effectiveness of these diagnostic intra-articular lidocaine injections on groin pain in patients with labral tears involving early osteoarthritis. Methods: A total of 113 patients were included in this study. All patients received one injection of 10 ml of 1% lidocaine into the hip joint under fluoroscopy. The duration and effectiveness of the injection were assessed 2 weeks after the injection and at a minimum of 1 year of follow-up. The effect of the injection was graded as 0: unchanged or worse; 1: an effect only on the day of injection; 2: the effect lasted a few days; 3: the effect lasted about a week; and 4: symptom remission. In addition, we recorded whether hip arthroscopic surgery was eventually performed. Results: The effect was rated as 0 in 19 patients (16.8%), as 1 in 30 patients (26.5%), as 2 in 38 patients (33.6%), as 3 in 13 patients (11.5%), and as 4 in 13 patients (11.5%). Seventy-two patients (63.7%) underwent hip arthroscopic surgery. No relationship with patients’ characteristics was found. Conclusion: In total, 83% of patients experienced some effect of the lidocaine injection. Furthermore, 11.5% of patients experienced complete remission of their symptoms.

Elevated levels of TNF-α, IL-1β and IL-6 in the synovial tissue of patients with labral tear: a comparative study with hip osteoarthritis

BACKGROUND

Labral tear can be the initiating factor in the onset of hip osteoarthritis (HOA). However, the physiopathology of labral tear is not fully understood. Our aim was to compare synovial tissue inflammatory cytokine levels between patients with labral tear and late-stage HOA.

METHODS

Synovial tissue from sites showing the greatest inflammation was harvested from 106 hips from 100 subjects during hip surgery. RNA was extracted, and levels of TNFA, IL1B, IL6 and COX2 mRNA were compared among all patients using real-time PCR. Additionally, we examined whether femoroacetabular impingement (FAI) was associated with elevated levels of inflammatory cytokines in patients with labral tear. To analyze the effects of TNF-α on inflammatory mediators in hip synovial tissue, synovial fibroblasts were extracted from hip synovial tissue of patients with labral tear and late-stage HOA (n = 5 each). Mononuclear cells were extracted from synovial tissue, cultured for 7 days, and stimulated with control or 10 ng/mL human recombinant TNF-α for 1 day. mRNA was extracted from stimulated cells and IL1B, IL6, and COX2 levels were determined using real-time PCR.

RESULTS

TNFA, IL1B, and COX2 expression in synovial tissue were significantly higher in patients with labral tear than late-stage HOA (TNFA, p <  0.001; IL1B, p <  0.001; COX2, p = 0.001). There were no differences in expression between patients with labral tear with and without FAI (TNFA, p = 0.546; IL1B, p = 0.559; IL6, p = 0.599; COX2, p = 0.124). Compared to vehicle control, TNF-α stimulation significantly elevated IL1B, IL6, and COX2 expression in synovial fibroblasts collected from patients with labral tear and late-stage HOA (IL1B, p = 0.043 and p = 0.043; IL6, p = 0.043 and 0.043; COX2, p = 0.043 and p = 0.080, respectively).

CONCLUSIONS

TNFA, IL1B, and COX2 expression were elevated in the synovial tissue of patients with labral tear. Further investigations are needed to reveal the relationship between inflammatory cytokine levels and various aspects of labral tear pathology, including pain and the onset and progression of OA.

Patient-specific factors are associated with severity of chondrolabral injury in patients with femoroacetabular impingement

PURPOSE

The purpose of this study was to evaluate the relationship between patient-specific factors, preoperative radiographic findings, and the presence and severity of chondrolabral damage identified during hip arthroscopy for femoroacetabular impingement.

METHODS

Between 2014 and 2017, patients who underwent hip arthroscopy for FAI and labral tear were retrospectively reviewed. Patient-specific variables including age, gender, BMI, LCEA, and alpha angle were collected. Surgical reports were reviewed for labral tear position and size, as well as severity of acetabular and femoral chondromalacia.

RESULTS

There were 205 patients who met inclusion criteria with a mean age of 33 years (range 15-66), BMI 26.5 (range 15.9-44.5), LCEA 32.2° (range 21.0°-56.0°) and alpha angle 59.1° (range 33.0°-86.0°). Greater age (p = 0.023), alpha angle (p = 0.011) and male gender (p < 0.001) significantly correlated with high-grade acetabular chondral damage. Increased LCEA (p < 0.001), increased alpha angle (p = 0.012), and greater age (p = 0.002) were significantly associated with increased labral tear size.

CONCLUSIONS

Greater age, male gender, increased BMI and increased alpha angle were associated with more advanced acetabular chondromalacia. Additionally, greater age, increased LCEA, and increased alpha angle was associated with larger labral tear size.

LEVEL OF EVIDENCE

IV.

Intra-articular pathology affects outcomes after joint preserving surgery for osteonecrosis of the femoral head

PURPOSE

Currently, knowledge regarding the intra-articular pathology and its relationship to outcomes after joint-preserving surgery in patients with osteonecrosis of the femoral head (ONFH) is lacking. The purposes were to evaluate the intra-articular pathology and its relationship with outcomes of joint-preserving surgery in ONFH.

METHODS

We reviewed 41 hips with ONFH in 41 patients (27 women; mean age, 34.9 years old) who underwent intertrochanteric curved varus osteotomy. Radiographic evaluations were based on pre-operative imaging studies, including radiographs, computed tomography (CT), and magnetic resonance imaging (MRI). Intra-articular pathology was evaluated by arthroscopic inspection of the femoral head, labrum, and acetabular cartilage during surgery. In addition, we performed radiographic measurements of the hip, including the collapse of the femoral head and minimal joint space width at three  years post-operatively and at final follow-up.

RESULTS

Arthroscopy revealed damage to the acetabular cartilage and labrum in 22 (54%) and 13 patients (32%), respectively. However, these lesions could be detected on imaging in only 13 (32%) and ten patients (24%), respectively. The change in joint space width after surgery was significantly higher in patients with cartilage degeneration and labral injury (P = 0.02, P = 0.02). Logistic regression analysis for subsequent progression of osteoarthritis showed an association with degenerative changes of articular cartilage and the labral tear as independent predictors (P = 0.001, P = 0.03).

CONCLUSIONS

Our data demonstrate the presence of labral and acetabular cartilage lesions in ONFH patients, while images do not reveal the full extent of the tissue damage. These intra-articular pathologies can be associated with the outcomes after joint-preserving surgery.

Radiographic analysis of subclinical appearances of the hip joint among patients with labral tears

Objective

Labral tears can be complicated by hip diseases, including osteoarthritis or femoral acetabular impingement. To accurately plan hip arthroscopy or subsequent conversion to total hip arthroplasty, the presence of bony abnormalities in the hip joint must be evaluated. This study aimed to elucidate the utility of multiplanar reconstruction computed tomography (mCT) for the detection of subclinical coincidence of osteoarthritis or femoral acetabular impingement with a labrum tear.

Materials and methods

We retrospectively analysed 34 patients (36 hips) with labrum tears without apparent osteoarthritis or hip dysplasia from 2012 to 2015. The joint spaces were calculated using radiographs or mCT, and the detection rates of degenerative cyst and herniation pit were compared.

Results

Narrow joint spaces (< 2 mm) were more clearly detected in mCT (p < 0.05, chi-square analysis) than in radiographs. The detection rate of cysts in the acetabulum was 8.3% using radiographs and 36.1% using mCT (p < 0.001, chi-square analysis). Additionally, the detection of herniation pit was 8.3% and 25.0% using radiographs and mCT, respectively (p = 0.053, chi-square analysis).

Conclusion

We performed the radiographic analysis of patients with labral tears using radiographs and mCT. The mCT allowed for fine detection of narrow joint spaces and subtle subclinical appearances. The results of this study may provide surgeons with more appropriate strategies for the treatment of labral tears.

ACR Appropriateness Criteria® Shoulder Pain-Traumatic

Traumatic shoulder pain is pain directly attributed to a traumatic event, either acute or chronic. This pain may be the result of either fracture (the clavicle, scapula, or proximal humerus) or soft-tissue injury (most commonly of the rotator cuff, acromioclavicular ligaments, or labroligamentous complex). Imaging assessment of traumatic shoulder pain begins with conventional radiography and, depending on physical examination findings, will require MRI or MR arthrography for assessment of soft-tissue injuries and CT for delineation of fracture planes. Ultrasound excels in assessment of rotator cuff injuries but has limited usefulness for assessment of the deep soft-tissues. CT angiography and conventional arteriography are helpful for assessment of vascular injury, and bone scintigraphy can be used in assessment of complex regional pain syndrome after traumatic shoulder injury. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Arthroscopic Repair of Acetabular Labral Tears Associated with Femoroacetabular Impingement: 7-10 Years of Long-Term Follow-up Results

Background

The purpose of this study is to report the long-term follow-up results of arthroscopic repair of acetabular labral tears with femoroacetabular impingement (FAI).

Methods

Of 45 patients who underwent arthroscopic labral repair under the diagnosis of acetabular labral tears with FAI from January 2008 to December 2010 and met our inclusion criteria, 41 patients who were available for a long-term follow-up were included in the analysis. We compared the long-term follow-up results with the previously reported short-term follow-up results of the same patients. The mean follow-up period was 92.4 months (range, 85 to 117 months). There were 21 males and 20 females, and their mean age at surgery was 34.6 years (range, 16 to 54 years). A modified Harris hip score (mHHS), visual analog scale (VAS), hip outcome score-activity of daily living (HOS-ADL), hip outcome score-activity-sport-specific subscale (HOS-SSS), and patient satisfaction were used for evaluation of the clinical results and Tönnis grade for detection of early osteoarthritis (OA).

Results

The mean VAS score decreased from 6.4 points to 1.8 points (p < 0.001), the mean mHHS increased from 59.5 points to 86.8 points (p < 0.001), and the mean HOS-ADL and HOS-SSS increased from 58.3 and 51.2, respectively, to 85.2 and 82.4, respectively (p < 0.001), between the preoperative and last follow-up assessment. The mean patient satisfaction score was 7.6 of 10. The average Tönnis grade at the last follow-up (0.67; range, 0 to 3) was not significantly different from the preoperative average (0.51; range, 0 to 1). Only one case was converted to total hip arthroplasty because of progression of OA at 8 years after surgery. Five cases of secondary arthroscopic surgery were performed before maximum 5 years postoperatively because of labro-synovial adhesion (three cases), pullout of the suture anchor (one case) or symptomatic heterotrophic ossification (one case).

Conclusions

The clinical and radiological long-term follow-up revealed that improvement after arthroscopic labral repair and osteoplasty for FAI were maintained in most cases without significant progression of arthritis. Anatomical recovery of the acetabular labrum was associated with the improvement of clinical symptoms.

Relationship between spinal sagittal alignment and acetabular coverage: a patient-matched control study

INTRODUCTION

The significance of the relationship between the spine and hip joints has been frequently discussed. However, the relationship between acetabular coverage and spinal sagittal alignment has not been fully elucidated as previous studies did not adequately control for factors that might affect the spinopelvic alignment. The aim of this study was to elucidate the impact of acetabular coverage on spinal sagittal alignment by comparing patient groups matched on sex, age, and the presence of hip and anterior impingement pain.

MATERIALS AND METHODS

We prospectively enrolled 30 women undergoing periacetabular osteotomy (PAO) for developmental dysplasia of the hip (DDH) and 30 women undergoing hip arthroscopic surgery (HAS) for labral tears. The lateral centre edge angle was measured on hip radiographs. In addition, the sagittal vertical axis, pelvic tilt, pelvic incidence, sacral slope (SS), and lumbar lordosis (LL) were measured on preoperative plain radiographs of the whole spine to assess the sagittal spinal alignment. Clinical and radiologic data were compared between the two groups (PAO vs. HAS).

RESULTS

The patient groups did not differ in age and body mass index. The mean SS was significantly greater in the PAO group (41.6° ± 1.6°) than in the HAS group (35.3° ± 1.5°; P = 0.0039). Additionally, the mean LL was significantly greater in the PAO group (54.5° ± 2.0°) than in the HAS group (45.1° ± 1.9°; P = 0.0015).

CONCLUSIONS

The SS and LL were greater in patients with DDH than in patients with hip pain, but without DDH. Patients with DDH might show lumbar hyperlordosis to rotate the pelvis anteriorly, increasing the anterosuperior acetabular coverage.

Arthroscopic acetabular labral reconstruction with rectus femoris tendon autograft: Our experiences and early results

Background

The native labrum has been shown to play a critical role in the maintenance of overall health of the cartilage of the hip. Disruption of the labral seal could be detrimental to the overall nutrition of the cartilage, leading to its premature degeneration.

Purpose

This study sought to investigate patients undergoing labral reconstruction with indirect head of rectus femoris autograft, to determine the subjective improvement in pain they experienced, the complications and reoperation rates including conversion to Total hip replacement(THR).

Method

We retrospectively reviewed all 7 patients who underwent labral reconstruction using indirect head of the rectus femoris tendon autograft between January 2013 to October 2015. We assessed improvement in pain and function, complications, and subsequent surgery. The minimum follow-up was 12 months (average, 15 months; range, 12-18 months).

Results

All patients reported subjective improvement in preoperative pain and function. The mean modified Harris Hip Score (mHHS) improved significantly from 56 (54-60) preoperatively to 93 (90-97)) at mean latest follow-up. The mean change of mHHS was 36 (30-43) and mean postoperative patient satisfaction score was 9.1. We observed no radiological progression of arthritis as well as no patient had revision procedure including total hip replacement.

Conclusion

Acetabular labrum reconstruction for irreparable labral tears in young patients with no significant arthritis, using indirect head of the rectus femoris tendon autograft is a new technique that shows improvement in pain and function post-operatively. Long-term follow-up results with higher quality studies will be necessary to further define the role of labral reconstruction in hip preservation surgery.

Hip Arthroscopy: Common Problems and Solutions

The use of hip arthroscopy continues to expand. Understanding potential pitfalls and complications associated with hip arthroscopy is paramount to optimizing clinical outcomes and minimizing unfavorable results. Potential pitfalls and complications are associated with preoperative factors such as patient selection, intraoperative factors such as iatrogenic damage, traction-related complications, inadequate correction of deformity, and nerve injury, or postoperative factors such as poor rehabilitation. This article outlines common factors that contribute to less-than-favorable outcomes.

Impingement-type bony morphology was related to cartilage defects, but not pain in professional ballet dancers' hips

OBJECTIVES

Professional ballet dancers may have hip bony morphology that predisposes them to cartilage or labral injury. However, the relationship between bony morphology and pathology has not been investigated in ballet. This study investigates associations between bony morphology, chondrolabral defects and hip pain in ballet dancers.

DESIGN

Cross-sectional study.

METHODS

33 male and female professional ballet dancers, (mean age 27 years (range 19-39)), completed questionnaires with hip pain measured on a visual analogue scale; and underwent 3.0-T magnetic resonance imaging (3T MRI) to measure lateral centre edge angles (LCEA), alpha angles in the anterior and superior position, femoral neck-shaft angles (NSA) and acetabular version angles; and to detect acetabular labral tear and articular cartilage defects.

RESULTS

Seventeen dancers (51.5%) had impingement-type (alpha angle>50.5° or acetabular version <10° or >20°) and 19 (58%) had instability-type (LCEA<25° or NSA>135°) bony morphology. Cartilage defect prevalence was higher in dancers with impingement-type bony morphology (n=14) compared to those without impingement-type morphology (n=4, p=0.001). There was no relationship between instability-type bony morphology and cartilage defects (p>0.05). There was no relationship between labral tears and bony morphology (p>0.05). Neither chondrolabral pathology nor any morphological feature were associated with hip pain (p>0.05 for all).

CONCLUSIONS

Impingement-type bony morphology was related to cartilage defects, but not labral tear. Hip pain was not associated with pathology or bony morphology. Longitudinal studies are warranted to determine if bony features, such as cam morphology, acetabular retroversion or anteversion, are precursors to symptomatic hip joint injury or osteoarthritis.

Arthroscopic Acetabular Labral Reconstruction with Fascia Lata Allograft: Clinical Outcomes at Minimum One-Year Follow-Up

BACKGROUND

The integrity of the acetabular labrum is crucial to normal biomechanics of the hip joint. Disruption of the labral seal could be detrimental to the overall nutrition of the cartilage, leading to its premature degeneration.

PURPOSE

The aim of this study is to determine the clinical effectiveness of arthroscopic hip labral reconstruction using fascia lata allograft. The hypothesis is that labral reconstruction would provide good clinical outcomes.

METHODS

We retrospectively reviewed all 10 patients who underwent labral reconstruction with fascia lata allograft from January 2013 to October 2015. We assessed improvement in pain and function, complications, and subsequent surgery. The minimum follow-up was 12 months (average, 22.9 months; range, 16-36 months).

RESULTS

All patients reported subjective improvement in preoperative pain and function. The mean modified Harris hip score improved significantly from 58 (55-60) to 95 (91-98). The mean change of modified Harris hip score was 36 (31-41) and mean post-operative patient satisfaction score was 9.5(8-10). We observed no radiological progression of arthritis as well as no patient had revision procedure including total hip replacement.

CONCLUSION

Arthroscopic labral reconstruction using a fascia lata tendon allograft is an effective and safe procedure that not only provides excellent clinical outcomes in short term but also potentially prevent continued cartilage degeneration by restoring acetabular labral seal in patients with deficient or resected labrums.

Glenohumeral position during CT arthrography with arthroscopic correlation: optimization of diagnostic yield

OBJECTIVE

To evaluate the diagnostic yield of two acquisitions of single-contrast CT arthrography (CTA) of the shoulder in internal, neutral, or external glenohumeral rotation with arthroscopic correlation.

MATERIALS AND METHODS

The CT study was obtained using two acquisitions (first the humerus positioned in maximum tolerated external rotation with the arm along the body and the second with the humerus in internal rotation with the palm placed flat on the table). Two independent readers blinded to the arthroscopic results evaluated the CTA images for labral tears, glenoid bone loss/fractures, and cartilage loss. For each CTA acquisition, sensitivity and specificity for detection of the aforementioned pathology were assessed. Inter-reader agreement was quantified by weighted ĸ statistics.

RESULTS

Sensitivity and specificity for detecting anteroinferior or posterior labral tears was highest with neutral rotation (sensitivity 91-100%, specificity 61-100%). For glenoid fracture, sensitivity (67%) was highest with external rotation and specificity (100%) was highest with internal rotation. For cartilage loss, sensitivity (64%) and specificity (89%) was highest with external rotation and neutral rotation, respectively. Neutral rotation showed high sensitivity and specificity for glenoid fractures and cartilage loss. Inter-reader agreement ranged from fair to very good.

CONCLUSIONS

Neutral glenohumeral position in shoulder CT arthrography was adequately sensitive and specific for the detection of intra-articular pathology, avoiding the use of more than one acquisition.

The cytokine expression in synovial membrane and the relationship with pain and pathological findings at hip arthroscopy

Background

Synovial membrane inflammation is the most common finding presenting during hip arthroscopy, and may play a role in hip pain. We sought to determine the relationships between synovial cytokine levels, hip pain, and arthroscopic findings of the hip joint.

Methods

We prospectively included 33 patients who underwent arthroscopic hip surgery (34 hips). For all patients, radiographs and severity of pain were evaluated preoperatively. During arthroscopy, we classified the chondral injury and synovitis, noted the incidence of labral tear and its instability, and a sample of the synovial membrane was harvested for quantitative PCR to determine levels of TNFα, IL1β, IL6, ADAMTS4, MMP1, and MMP3. The relationships between the levels of these cytokines, severity of hip pain, and the pathological findings during arthroscopy were examined.

Results

Pain intensity and cytokine levels were not significantly different between patients with labral tear or instability and those without. By contrast, the expression of TNFα, IL1β, IL6, and MMP1 mRNA was significantly higher in patients with diffuse synovitis than in patients with focal synovitis. VAS score during rest showed significant positive correlation with IL6 (r = 0.45, p < 0.01), while VAS score on walking showed a positive correlation with TNFα (r = 0.47, p < 0.01), and ADAMTS4 (r = 0.51, p < 0.01). The modified Harris Hip pain score showed a negative correlation with TNFα (r = −0.38, p = 0.04) and IL6 (r = −0.58, p < 0.01).

Conclusions

The severity of synovitis and chondral injury are considered to be more important in the pathology of hip pain than labral tear or instability. Inflammatory cytokines, especially TNFα and IL6 might play an important role in the pathogenesis of pain in patients indicated for hip arthroscopy, possibly depending on the severity of synovitis.

Shoulder Injuries in the Overhead Throwing Athlete

The overhead pitching motion is a coordinated sequence of movements that subjects the shoulder to extreme forces. The ultimate goal of this complex, dynamic activity is to generate high ball velocity and accuracy. In doing so, repetitive throwing can cause adaptive and pathologic changes in the thrower's shoulder. This article reviews the relevant shoulder anatomy, the kinetic chain, and throwing mechanics, as well as common shoulder injuries and surgical options for the treating orthopedic surgeon.

The mechanics of focal chondral defects in the hip

There is a mean incidence of osteoarthritis (OA) of the hip in 8% of the overall population. In the presence of focal chondral defects, defined as localized damage to the articular cartilage, there is an increased risk of symptomatic progression toward OA. This relationship between chondral defects and subsequent development of OA has led to substantial efforts to develop effective procedures for surgical cartilage repair. This study examined the effects of chondral defects and labral delamination on cartilage mechanics in the dysplastic hip during the gait cycle using subject-specific finite element analysis. Models were generated from volumetric CT data and analyzed with simulated chondral defects at the chondrolabral junction on the posterior acetabulum during five distinct points in the gait cycle. Focal chondral defects increased maximum shear stress on the osteochondral surface of the acetabular cartilage, when compared to the intact case. This effect was amplified with labral delamination. Additionally, chondral defects increased the first principal Lagrange strain on the articular surface of the acetabular cartilage and labrum. Labral delamination relieved some of this tensile strain. As defect size was increased, contact stress increased in the medial zone of the acetabulum, while it decreased anteriorly. The results suggest that in the presence of chondral defects and labral delamination the cartilage experiences elevated tensile strains and shear and contact stress, which could lead to further damage of the cartilage, and subsequent arthritic progression. The framework presented here will serve as the procedure for future finite element studies on cartilage mechanics in hips with varying disease states with simulated chondral defects and labral tears.

Clinical outcomes after arthroscopic acetabular labral repair using knot-tying or knotless suture technique

BACKGROUND

The purpose of the study was to compare the clinical results of arthroscopic labral repair using knot-tying and knotless suture anchor techniques for patients with labral tears.

METHODS

From September 2012 to May 2013, we performed a randomized, prospective analysis of 40 hips with labral tears treated with arthroscopic labral repair via knot-tying (group A) or knotless suture anchors (group B). A total of 33 patients were treated for labral tears, and 7 of them received bilateral labral repair. Outcomes and intraoperative parameters were prospectively measured with the UCLA score, the modified Harris Hip Score (MHHS), the Hip disability and Osteoarthritis Outcome Score (HOOS), and the Hip Outcome Score (HOS).

RESULTS

Three patients (3 hips) were lost to follow up. A total of 37 hips (30 patients) were finally analyzed: 19 hips in group A and 18 in group B. The mean traction time for group A and group B was 72.2 versus 68.7 min, respectively (p = 0.314). Although the clinical outcome scores in both groups improved between the initial and final visits, there was no difference in measurements parameters between the two groups. Survival rate, using reoperation or progression of osteoarthritis as the primary end points, was 100 %. 83 % of cases had excellent and good MHHS scores after 2 years of follow-up. During arthroscopic surgery, the drill penetrated the closing subchondral area or the joint in three hips. There was no progression of arthritic change at the latest follow-up.

CONCLUSIONS

Labral repair with either knot-tying or knotless suture anchor resulted in significant postoperative improvements and no difference between the two groups after 2 years of follow-up.

Hip Arthroscopy for Incarcerated Acetabular Labrum following Reduction of Traumatic Hip Dislocation: Three Case Reports

Traumatic hip fracture-dislocations are associated with chondral and labral pathology as well as loose bodies that can be incarcerated in the hip joint. Incarceration, such as interposed labrum between acetabulum and femoral head that is not readily visualized preoperatively, is a rare but important cause of pain and can potentially be a source for early degeneration and progression to osteoarthritis. We present three cases, arthroscopic surgery of incarcerated acetabular osseo-labral fragment following reduction of traumatic hip fracture-dislocation.

Magnetic resonance arthrography and the prevalence of acetabular labral tears in patients 50 years of age and older

OBJECTIVE

Arthroscopy for acetabular labral tears has minimal impact on pain and function in older patients, especially in the setting of concomitant osteoarthritis. Still, many physicians seek this diagnosis with MR arthrography. Our purpose is to assess the frequency of acetabular labral tears in older patients with hip pain and correlate likelihood of labral pathology with severity of osteoarthritis as visualized on conventional radiograph.

MATERIALS AND METHODS

From 2004 to 2013, 208 hip MRI arthrograms and corresponding radiographs on patients aged 50 years and older were identified. Age, gender, grade and location of labral tear, alpha angle, Tönnis grade, and joint space width were documented. Labral tears and alpha angle were identified and measured on MR arthrogram. Tönnis grade and joint space width were measured on radiographs.

RESULTS AND CONCLUSIONS

On MR arthrography, true labral tearing was identified in 73 % of patients. There was some degree of labral pathology in 93.3 % of patients, and this increased to 100 % in patients with moderate to severe osteoarthritis, as defined by Tönnis grade 2-3 or joint space width ≤ 2 mm. There were no statistically significant correlations between labral tear grade and Tönnis grade or joint space width. Given the high frequency of labral pathology and the questionable efficacy of arthroscopic surgical intervention in older patients, MR arthrography should be primarily for those with minimal arthritis on radiograph and potential to benefit from surgery. If further imaging beyond radiographs is necessary in these patients, standard MRI may be a more appropriate imaging tool.

Return to Play Following Hip Arthroscopy

Femoroacetabular impingement may be particularly disabling to the high-demand athlete, especially those with significant cutting and pivoting requirements. If nonoperative treatment fails to adequately alleviate symptoms or sufficiently restore function in the athlete, hip arthroscopy can lead to improved pain, improved range of motion, and high rates of return to play with proper postoperative rehabilitation. The rate of return to previous level of competition is also high with accurate diagnosis and well-executed correction of deformity. A clear understanding of the etiology, diagnosis, management, and outcomes is essential for clinicians to optimally help patients to return to play.

Do labral tears influence poor outcomes after periacetabular osteotomy for acetabular dysplasia?

AIMS

Acetabular dysplasia is frequently associated with intra-articular pathology such as labral tears, but whether labral tears should be treated at the time of periacetabular osteotomy (PAO) remains controversial. The purpose of this study was to compare the clinical outcomes and radiographic corrections of PAO for acetabular dysplasia between patients with and without labral tears pre-operatively.

PATIENTS AND METHODS

We retrospectively reviewed 70 hips in 67 patients with acetabular dysplasia who underwent PAO. Of 47 hips (45 patients) with labral tears pre-operatively, 27 (25 patients) underwent PAO alone, and were classified as the labral tear alone (LT) group, and 20 (20 patients) underwent combined PAO and osteochondroplasty, and were classified as the labral tear osteochondroplasty (LTO) group. The non-labral tear (NLT) group included 23 hips in 22 patients.

RESULTS

There were no significant differences between groups for post-operative Harris hip scores, degree of progression of osteoarthritis or rate of reoperation. The pre-operative alpha angle was significantly larger in the LTO group compared with the other groups (p < 0.0001).

CONCLUSION

PAO provides equivalent short-term relief of pain and functional outcome in patients with or without labral tears. The rate of progression of osteoarthritis and reoperation was not significantly increased in patients with labral tears.

TAKE HOME MESSAGE

PAO provides equivalent short-term pain relief and functional outcomes in patients with acetabular dysplasia with and without labral tears. We did not find significantly increased risks of progression of osteoarthritis or re-operation in those with labral tears. Cite this article: Bone Joint J 2016;98-B:741-6.

SLAP repair with arthroscopic decompression of spinoglenoid cyst

Introduction: A spinoglenoid cyst with suprascapular nerve disorders is highly associated with superior labrum anterior posterior (SLAP) lesion. Conservative or surgical treatment is applied to relieve pain and neurological symptoms. The purpose of this study was to evaluate clinical outcomes of patients treated by arthroscopic surgery for SLAP lesion with a spinoglenoid cyst.

Methods: The subjects of this study were six patients with SLAP lesion with a spinoglenoid cyst who underwent arthroscopic surgery. There was one female and five males with a mean age of 48.5 years. SLAP lesion was found in all the patients at arthroscopy. A small tear of the rotator cuff was found in the two patients. The SLAP lesion was repaired using suture anchors, and the rotator cuff tears were repaired by suture-bridge fixation. The spinoglenoid cyst was decompressed through the torn labrum in three patients, and through the released superior to posterior portion of the capsule in the other three patients.

Results: All patients showed excellent improvement in pain and muscle strength at the final follow-up examination. The mean Constant score was improved from 60.5 points preoperatively to 97.2 points postoperatively. The mean visual analog scale (VAS) score decreased from 4.5 on the day of the surgery to 2.5 within one week postoperatively. Postoperative MRI showed disappearance or reduction of the spinoglenoid cyst in four and two patients, respectively. There were no complications from the surgical intervention and in the postoperative period.

Discussion: The patients treated by decompression through the released capsule obtained pain relief at an early period after the surgery. Arthroscopic treatment for a spinoglenoid cyst can provide a satisfactory clinical outcome. Arthroscopic decompression of a spinoglenoid cyst through the released capsule is recommended for a safe and reliable procedure for patients with suprascapular nerve disorders.

Postural correction reduces hip pain in adult with acetabular dysplasia: A case report

Developmental dysplasia of the hip is often diagnosed in infancy, but less severe cases of acetabular dysplasia are being detected in young active adults. The purpose of this case report is to present a non-surgical intervention for a 31-year-old female with mild acetabular dysplasia and an anterior acetabular labral tear. The patient presented with right anterior hip and groin pain, and she stood with the trunk swayed posterior to the pelvis (swayback posture). The hip pain was reproduced with the anterior impingement test. During gait, the patient maintained the swayback posture and reported 6/10 hip pain. Following correction of the patient's posture, the patient's pain rating was reduced to a 2/10 while walking. The patient was instructed to maintain the improved posture. At the 1 year follow-up, she demonstrated significantly improved posture in standing and walking. She had returned to recreational running and was generally pain-free. The patient demonstrated improvement on self-reported questionnaires for pain, function, and activity. These findings suggest that alteration of posture can have an immediate and lasting effect on hip pain in persons with structural abnormality and labral pathology.

Practical approach to hip pain

Hip pain is a common complaint among patients presenting to outpatient clinics. Stratifying patients based on age, acuity, and location of pain (extra-articular vs intra-articular) can help to aid in appropriate imaging and timely referral to an orthopedic surgeon. A thorough history and an organized physical examination combined with radiographs are usually sufficient to diagnose most hip complaints. If the diagnosis remains uncertain, magnetic resonance imaging, usually with intra-articular gadolinium, is the imaging modality of choice in diagnosing both intra-articular and extra-articular pathologies.

Arthroscopic classification of posterior labrum glenoid insertion

PURPOSE

We performed a prospective arthroscopic study to explore the variability of the posterior labrum glenoid insertion. We aimed to classify the insertions and to explore whether these insertions can be identified by pre-operative arthro-CT scan.

PATIENTS AND METHODS

From January to December 2011, 86 patients were prospectively included in the current study. During arthroscopy, anterior labrum was evaluated and posterior labrum was assessed in 3 different locations: superior, medial, and inferior. For each segment, the labrum was considered normally inserted (directly to the glenoid cartilage), medialized (inserted at the posterior part of the glenoid bone, without direct contact with the cartilage), torn (macroscopic degenerative changes, tears, fragments) or absent (agenesis). Imaging was analyzed segment by segment by an experienced osteoarticular radiologist, using the same classification.

RESULTS

Four types of posterior labrum insertions were identified. Type 1, 60% of the cases, corresponded to a posterior labrum totally inserted in the glenoid, with direct contact with the cartilage. Type 2, 20% of the cases, represented medialized insertion of the superior segment. Type 3, 15% of the cases, represented an associated medialization of the superior and medial segment of the posterior labrum. Type 4 is a medialized insertion of the all-posterior labrum. Fifty-six shoulders were used for arthro-CT and arthroscopy correlation: for the superior segment (n=22/56), the sensitivity of arthro-CT to identify an abnormal insertion when the labrum is medialized was 68.18%, specificity 70.59%, positive predictive value (PPV) 60%, and negative predictive value (NPV) 77.42%. For the medial segment (n=16/56), the sensitivity of arthro-CT to identify an abnormal insertion when the labrum is medialized was 81.25%, specificity 57.50%, PPV 43.33% and NPV 88.46%. For the inferior segment (n=5/56), the sensitivity was 100%, specificity 47.60%, PPV 15.63% and NPV 100%.

CONCLUSION

The current study points out the high variability of shoulder posterior labrum glenoid insertion, and thus the risk of misdiagnosis with posterior labral tears, especially in posterior instability and also the risk of considering as labral lesions some non-pathological aspects.

LEVEL OF EVIDENCE

Level III. Anatomic prospective study.

Arthroscopy of the hip: factors affecting outcome

Hip arthroscopy is a rapidly progressing field that has advanced in function and survivorship over the past decade. As increasing literature is published on outcomes of hip arthroscopy, a retrospective review has allowed for the identification of factors that affect survivorship. Within this review, the authors present the factors identified to date that affect survivorship after hip arthroscopy while raising questions about the future direction of the field.

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.