Anil S. Ranawat

Anterior dislocation of the hip after arthroscopy in a patient with capsular laxity of the hip. A case report.

Capsular laxity is a poorly understood but increasingly recognized cause of hip pain1,2. As with shoulder instability, hip instability represents a wide spectrum of pathologic entities, ranging from acute traumatic dislocation to chronic capsular laxity. Primary capsular laxity is often associated with underlying collagen abnormalities, such as those seen with Ehlers-Danlos or Marfan syndrome. Secondary capsular laxity is seen more commonly in athletes and is secondary to overuse or repetitive activities2. Although the mainstay of treatment for these conditions has been nonoperative, surgical intervention may be indicated because of either recurrent instability or lack of pain relief with nonoperative measures. Surgical treatment may require access to both the hip capsule and the labrum through either an open3-5 or an arthroscopic6-12 approach. Although the latter techniques are relatively new, two studies have demonstrated that arthroscopic surgery can provide stability to the hip joint10,11. However, while arthroscopic techniques are generally less invasive than open surgical techniques, hip arthroscopy is not without complications13. This case study documents the first report, to our knowledge, of a hip dislocation following an arthroscopic procedure of the hip. The patient was informed that data concerning the case would be submitted for publication, and she consented. A fifty-two-year-old Caucasian woman presented to our clinic in the fall of 2005 with a two-year history of pain in the right groin and anterior part of the thigh and a sensation of “popping” in the right hip. She had undergone bilateral shoulder capsulorrhaphy for multidirectional instability (the right shoulder in 2002, and the left in 2000) as well as bilateral knee meniscal repairs (both in 1999). On physical examination, both the affected right hip and the asymptomatic left hip had flexion to 120° …

Fresh stored allografts for the treatment of osteochondral defects of the knee.

BACKGROUND Osteochondral allograft reconstruction of articular cartilage defects is a well-established cartilage repair strategy. Currently, fresh osteochondral allograft tissue is commercially available to clinicians approximately thirty days following graft harvest. Little clinical information is available on the outcome of patients who have been treated with fresh allografts stored for several weeks or more. The purpose of this study was to prospectively analyze the clinical outcome and graft morphology of patients who received fresh, hypothermically stored, allograft tissue for the treatment of symptomatic chondral and osteochondral defects of the knee. METHODS Nineteen patients with symptomatic chondral and osteochondral lesions of the knee who were treated with fresh osteochondral allografts between 1999 and 2002 were prospectively followed. The mean age at the time of surgery was thirty-four years. Validated outcomes instruments (the Activities of Daily Living Scale and the Short Form-36) were used; all patients must have had a baseline functional score prior to surgery and a minimum two-year follow-up evaluation. All grafts were obtained from commercial vendors; the mean preimplantation storage time of the graft was thirty days (range, seventeen to forty-two days). The mean lesion size was 602 mm(2). Magnetic resonance imaging was used to evaluate the morphologic characteristics of the implanted grafts. RESULTS The mean duration of clinical follow-up was forty-eight months (range, twenty-one to sixty-eight months). The mean score (and standard deviation) on the Activities of Daily Living Scale increased from a baseline of 56 +/- 24 to 70 +/- 22 at the time of the final follow-up (p < 0.05). The mean Short Form-36 score increased from a baseline of 51 +/- 23 to 66 +/- 24 at the time of final follow-up (p < 0.005). With the numbers studied, we could not correlate graft storage time, body mass index, lesion size, lesion location, or patient age with the functional outcome scores. At a mean follow-up interval of twenty-five months, cartilage-sensitive magnetic resonance imaging demonstrated that the normal articular cartilage thickness was preserved in eighteen implanted grafts, and allograft cartilage signal properties were isointense relative to normal articular cartilage in eight of the eighteen grafts. Osseous trabecular incorporation of the allograft was complete or partial in fourteen patients and poor in four patients. Complete or partial trabecular incorporation positively correlated with Short Form-36 scores at the time of follow-up (r = 0.487, p < 0.05). CONCLUSIONS Fresh osteochondral allografts that were hypothermically stored between seventeen and forty-two days were effective in the short term both structurally and functionally in reconstructing symptomatic chondral and osteochondral lesions of the knee. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Meniscal Root Tears: Diagnosis and Treatment

Meniscal tears within the body of the meniscus or at the meniscocapsular junction represent a well-understood and manageable condition encountered in clinical practice. In comparison, however, meniscal root tears (MRTs) often go unnoticed and represent a unique injury pattern with unique biomechanical consequences. Though first described decades ago, improvements in magnetic resonance imaging and arthroscopy have only recently enhanced our diagnostic and treatment capabilities with regard to MRTs. This review contains an anatomic description of the roots including their significance in meniscal function as well as the consequences of their loss. In addition, how to properly identify MRTs and when it is appropriate to surgically repair them are described. Finally, we review the surgical techniques available in the existing literature and present an illustrative case.

Total Hip Arthroplasty for Posttraumatic Arthritis after Acetabular Fracture

Total hip arthroplasty (THA) outcomes for posttraumatic arthritis after acetabular fracture have yielded inferior results compared to primary nontraumatic THA. Recently, improved results have been demonstrated using cementless acetabular reconstruction. Thirty-two patients underwent THA for posttraumatic arthritis after acetabular fracture; 24 were treated with open reduction internal fixation, and 8 were managed conservatively. Time from fracture to THA was 36 months (6-227 months). Average follow-up was 4.7 years (2.0-9.7 years). Harris Hip score increased from 28 (0-56) to 82 points (20-100). Six patients required revision. Five-year survival with revision, loosening, dislocation, or infection as an end point was 79%. Survival for aseptic acetabular loosening was 97%. Revision surgery correlated with nonanatomic restoration of the hip center and a history of infection (P < .05). Despite obvious challenges, advances in fracture management and cementless acetabular fixation in THA demonstrate improved results for posttraumatic arthritis following acetabular fracture.

Posterolateral Corner Injury of the Knee: Evaluation and Management

Abstract Posterolateral corner injury, an increasingly recognized entity, is commonly associated with concomitant ligament disruptions. Prompt recognition is critical for several reasons. Missed posterolateral corner injuries increase the failure rates for both anterior and posterior cruciate ligament reconstructions. Also, untreated posterolateral corner injuries lead to chronic disability. Acute (ie, immediate) surgical intervention results in superior outcomes compared with chronic (ie, late) reconstruction. Although no universal classification system has been adopted, attention to both varus and rotational stability is critical. Multiple options exist for posterolateral corner reconstruction, although recent trends have shifted toward anatomic reconstruction techniques.

Radiographic Predictors of Hip Pain in Femoroacetabular Impingement

The primary diagnosis of femoroacetabular impingement is based on clinical symptoms, physical exam findings, and radiographic abnormalities. The study objective was to determine the radiographic findings that correlate with and are predictive of hip pain in femoroacetabular impingement (FAI). One hundred prospective patients with unilateral FAI symptoms based on clinical and radiographic findings were included in this study. All patients filled out a WOMAC pain questionnaire. Two independent-blinded surgeons assessed antero-posterior and lateral radiographs for 33 radiographic parameters of FAI. Correlations between pain scores and radiographic findings were calculated. A matched radiographic analysis was performed comparing symptomatic versus asymptomatic hips. Radiograph findings were also compared between males and females. Weak positive correlations were identified between increasing pain scores with radiographic findings of posterior wall dysplasia, presence of a shallow socket, and a more lateral acetabular fossa relative to the Ilioischial line. A symptomatic hip had a lower neck shaft angle, greater distance from Ilioischial line to acetabular fossa and larger distance from cross-over sign to superolateral point of the acetabulum when compared to the asymptomatic hip in the same patient. Symptomatic hips in males had more joint space narrowing, femoral osteophytes, higher alpha angles and larger, more incongruent femoral heads compared to females. Females had more medial acetabular fossa relative to the Ilioischial line and smaller femoral head extrusion index. Similar to other musculoskeletal conditions, radiographic findings of FAI are poor predictors of hip pain.

Post-operative guidelines following hip arthroscopy.

Rehabilitation following hip arthroscopy can vary significantly. Existing programs have been developed as a collaborative effort between physicians and rehabilitation specialists. The evolution of protocol advancement has relied upon feedback from patients, therapists and observable outcomes. Although reports of the first femoroacetabular impingement (FAI) surgeries were reported in the 1930’s, it was not until recently that more structured, physiologically based guidelines have been developed and executed. Four phases have been developed in this guideline based on functional and healing milestones achieved which allow the patient to progress to the next level of activity. The goal of Phase I, the protective phase, is to progressively regain 75% of full range of motion (ROM) and normalize gait while respecting the healing process. The primary goal of Phase II is for the patient to gain function and independence in daily activities without discomfort. Rehabilitation goals include uncompensated step up/down on an 8 inch box, as well as, adequate pelvic control during low demand exercises. Phase III goals strive to accomplish pain free, non-compensated recreational activities and higher demand work functions. Manual muscle testing (MMT) grading of 5/5 should be achieved for all hip girdle musculature and an ability to dynamically control body weight in space. Phase IV requires the patient be independent with home and gym programs and be asymptomatic and pain free following workouts. Return to running may be commenced at the 12 week mark, but the proceeding requirements must be achieved. Athletes undergoing the procedure may have an accelerated timetable, based on the underlying pathology. Recognizing the patient’s pre-operative health status and post-operative physical demands will direct both the program design and the program timetable.

Causes and Risk Factors for Revision Hip Preservation Surgery

Background: Identifying causes and risk factors for failure of hip preservation surgery is critical to properly address residual pathological abnormalities in the revision setting and improve outcomes in this subset of patients. Purpose: To identify the structural causes of failure in both open and arthroscopic hip preservation procedures and to identify demographic and radiographic risk factors that correlate with the need for revision surgery. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A single-center hip preservation registry was reviewed (N = 1898 procedures in 1600 patients) to identify 147 patients (n = 152 procedures) who had undergone previous pelvic surgery. Exclusion criteria included residual deformity from pediatric hip disease (n = 5 patients). Preoperative demographics, intraoperative findings, radiographic data, and clinical outcome scores were compared between cohorts with and without revision surgery in the registry. Postoperative, short-term patient-reported outcome scores for the revision cohort were described. Results: The most common reason for revision was residual intra-articular femoroacetabular impingement (74.8%), followed by extra-articular impingement (9.5%). The majority of revision cases (78.9%) could be addressed with arthroscopic surgery, with the exception of extra-articular impingement or residual acetabular dysplasia, which necessitated open approaches. Patients who underwent revision were more likely to be female, were younger in age, and had worse preoperative outcome scores than did those in the primary cohort. Abnormal femoral version and the presence of acetabular dysplasia were not significantly different between the revision and primary cohorts. Short-term improvements in patient-reported outcome scores were found in the revision cohort at a mean of 15.0 months from the last revision surgery. Conclusion: Residual intra- and extra-articular impingement were the most common reasons for revision in this cohort. Patients who underwent revision tended to be younger in age, were female, and had worse preoperative hip functional outcomes than did those in the primary cohort. Abnormal femoral version or acetabular coverage was not increased in our revision cohort.

Outcomes After Arthroscopic Treatment of Femoroacetabular Impingement for Patients With Borderline Hip Dysplasia

Background: The outcomes of hip arthroscopy in the treatment of dysplasia are variable. Historically, arthroscopic treatment of severe dysplasia (lateral center-edge angle [LCEA] <18°) resulted in poor outcomes and iatrogenic instability. However, in milder forms of dysplasia, favorable outcomes have been reported. Purpose: To compare outcomes after hip arthroscopy for femoroacetabular impingement (FAI) in borderline dysplastic (BD) patients compared with a control group of nondysplastic patients. Study Design: Cohort study; Level of evidence, 3 Methods: Between March 2009 and July 2012, a BD group (LCEA, 18°-25°) of 46 patients (55 hips) was identified. An age- and sex-matched control group of 131 patients (152 hips) was also identified (LCEA, 25°-40°). Patient-reported outcome scores, including the modified Harris Hip Score (mHHS), the Hip Outcome Score–Activities of Daily Living (HOS-ADL) and Sport-Specific Subscale (HOS-SSS), and the International Hip Outcome Tool (iHOT-33), were collected preoperatively and at 1 and 2 years postoperatively. Results: The mean LCEA was 22.4° ± 2.0° (range, 18.4°-24.9°) in the BD group and 31.0° ± 3.1° (range, 25.4°-38.7°) in the control group (P < .001). The mean preoperative alpha angle was 66.3° ± 9.9° in the BD group and 61.7° ± 13.0° in the control group (P = .151). Cam decompression was performed in 98.2% and 99.3% of cases in the BD and control groups, respectively; labral repair was performed in 69.1% and 75.3% of the BD and control groups, respectively, with 100% of patients having a complete capsular closure performed in both groups. At a mean follow-up of 31.3 ± 7.6 months (range, 23.1-67.3 months) in unrevised patients and 21.6 ± 13.3 months (range, 4.7-40.6 months) in revised patients, there was significant improvement (P < .001) in all patient-reported outcome scores in both groups. Multiple regression analysis did not identify any significant differences between groups. Importantly, female sex did not appear to be a predictor for inferior outcomes. Two patients (4.3%) in the BD group and 6 patients (4.6%) in the control group required revision arthroscopy during the study period. Conclusion: Favorable outcomes can be expected after the treatment of impingement in patients with borderline dysplasia when labral refixation and capsular closure are performed, with comparable outcomes to nondysplastic patients. Further follow-up in larger cohorts is necessary to prove the durability and safety of hip arthroscopy in this challenging group and to further explore potential sex-related differences in outcome.

A Biomechanical Analysis of the Native Coracoclavicular Ligaments and Their Influence on a New Reconstruction Using a Coracoid Tunnel and Free Tendon Graft

PURPOSE To understand and characterize the kinematic properties of the 2 coracoclavicular ligaments and to evaluate the biomechanical performance of a new 3-tunnel reconstruction of the coracoclavicular ligaments by use of a free tendon graft. METHODS Ten fresh-frozen cadaveric shoulders were tested. The kinematics and in situ forces of the coracoclavicular ligaments were tested with a robotic testing system. Kinematics of the shoulder in the intact state, in the sectioned state, and finally, after a coracoclavicular reconstruction and a coracoclavicular sling reconstruction were evaluated. RESULTS The conoid had higher in situ forces during anterior and superior loading of the clavicle when compared with the trapezoid ligament, whereas the trapezoid ligament had higher in situ forces during posterior loading. Sectioning the trapezoid ligament significantly increased translation of the clavicle in the posterior direction, whereas sectioning the conoid ligament significantly increased superior translation. When we compared the 2 reconstruction techniques, the coracoid tunnel reconstruction was superior in controlling anterior translation whereas the coracoclavicular sling reconstruction was inferior because of anterior displacement of the graft. There was no significant difference in posterior or superior translation between either reconstruction technique. CONCLUSIONS The trapezoid and conoid ligaments have unique functions in normal shoulder kinematics because of their anatomic attachments. By more faithfully restoring these insertion sites on the clavicle and controlling motion of the graft on the coracoid, the 3-tunnel reconstruction technique more closely restores native shoulder kinematics than the coracoclavicular sling technique. CLINICAL RELEVANCE Understanding the unique roles of the conoid and trapezoid bundles of the coracoclavicular ligament may improve surgical techniques in the management of acromioclavicular joint injuries. The reconstructive technique presented more faithfully restores normal kinematics and forces across the acromioclavicular joint than the coracoclavicular sling technique.