Benjamin R. Kivlan

Response to Diagnostic Injection in Patients With Femoroacetabular Impingement, Labral Tears, Chondral Lesions, and Extra-Articular Pathology

PURPOSE The purpose of this study was to compare the percent relief from injection among subjects with arthroscopic findings of femoroacetabular impingement (FAI) and labral and chondral pathologies while controlling for coexisting extra-articular pathology. METHODS We retrospectively reviewed 72 consecutive subjects (54 female and 18 male subjects), aged 29.9 ± 10.4 years (range, 16 to 55 years), who underwent hip arthroscopy. Three separate analyses of covariance compared the percent relief after injection between groups based on surgically confirmed type of impingement (none, cam, pincer, or combined), labral pathology (none, mild, or torn), and chondral pathology (none, mild acetabular abnormality, acetabular delamination, or femoral lesion) while controlling for the presence of extra-articular pathology (iliotibial band, iliopsoas tendinopathy, or bursitis). RESULTS The results of analysis 1 (F₃,₆₇ = 1.96, P = .128, partial η² = .081) and analysis 2 (F₂,₆₈ = 0.008, P = .992, partial η² = .000) indicated no significant main effect for FAI and labral pathology, respectively, on percent relief from injection. The results for analysis 3 indicated a significant main effect for chondral pathology of the hip on the percent relief from injection (F₃,₆₇ = 3.03, P < .05, partial η² = .128). Post hoc analysis showed that those with mild chondral pathology of the acetabulum and those with acetabular delamination had significantly greater percent relief compared with those without chondral pathology. Extra-articular pathology did not influence the percent relief from injection in any of the analyses. CONCLUSIONS Subjects with chondral damage had greater relief from injection than those without, regardless of severity. The presence and severity of FAI and labral pathology did not influence the percent relief from injection. Concurrent extra-articular pathology did not alter the interpretation of the percent relief from injection. Therefore the interpretation and diagnostic value of an anesthetic injection in those with primary intra-articular pathology does not need to be altered by the presence of coexisting extra-articular hip pathology. LEVEL OF EVIDENCE Level IV, therapeutic case series.

A cadaveric model for ligamentum teres function: a pilot study

PurposeDespite the prevalence and clinical consequences of ligamentum teres pathology, its function is poorly understood. The purpose of this study was to help define the role the ligamentum teres may have in hip joint stabilization and determine whether a ball and string model could be used to describe the function of the ligamentum teres.MethodsEight embalmed cadavers were dissected to remove all soft tissue from around the hip, leaving only the ligamentum teres intact. Available hip abduction, adduction, medial rotation, and lateral rotation range of motion were measured for three repeated trials. The position of the ligamentum teres in relation to the femoral head was recorded at the endpoint position of these movements.ResultsAn endpoint position as limited by the ligamentum teres for abduction, medial rotation, and lateral rotation was identified at a mean of 73°(SD 11°), 64°(SD 11°), and 58°(SD 10°), respectively. Hip adduction was limited by bony contact and therefore was not measured. The ligamentum teres wrapped around the femoral head to prevent inferior, posterior, and anterior subluxation with abduction, medial rotation, and lateral rotation, respectively. Repeated measures ANOVA indicated no significant difference in endpoint position based on trial number for the three movements (n.s.).ConclusionThe ligamentum teres consistently tightened to limit hip abduction, medial rotation, and lateral rotation. These results support a ball and string model for the femoral head and ligamentum teres. This information could be important for those with hip instability and ligamentum teres pathology.

Function of the Ligamentum Teres in Limiting Hip Rotation: A Cadaveric Study

PURPOSE The purpose of this cadaveric study was to evaluate the function of the ligamentum teres (LT) in limiting hip rotation in 18 distinct hip positions while preserving the capsular ligaments. METHODS Twelve hips in 6 fresh-frozen pelvis-to-toes cadaveric specimens were skeletonized from the lumbar spine to the distal femur, preserving only the hip ligaments. Hip joints were arthroscopically accessed through a portal located between the pubofemoral and iliofemoral ligaments to confirm the integrity of the LT. Three independent measurements of hip internal and external rotation range of motion (ROM) were performed in 18 defined hip positions of combined extension-flexion and abduction-adduction. The LT was then arthroscopically sectioned and rotation ROM reassessed in the same positions. A paired sample t test was used to compare the average internal and external hip rotation ROM values in the intact LT versus resected conditions in each of the 18 positions. P < .0014 was considered significant. RESULTS A statistically significant influence of the LT on internal or external rotation was found in 8 of the 18 hip positions tested (P < .0014). The major increases in internal and external rotation ROM occurred when the hip was in 90° or 120° of flexion. CONCLUSIONS The major function of the LT is controlling hip rotation. The LT functions as an end-range stabilizer to hip rotation dominantly at 90° or greater of hip flexion, confirming its contribution to hip stability. CLINICAL RELEVANCE Ruptures of the LT contribute to hip instability dominantly in flexed hip positions.

Responsiveness of the foot and ankle ability measure (FAAM) in individuals with diabetes

BACKGROUND The impact of diabetes on physical function pose a challenge in assessing clinical outcomes. OBJECTIVE The purpose of this study was to provide evidence of responsiveness for the foot and ankle ability measures (FAAM) in individuals with diabetes mellitus. METHODS The two most recent FAAM scores of 155 diabetic patients treated for foot/ankle pathology were analyzed. Based on physical component summary (PCS) scores of the SF-36, subjects were categorized as improved (>7-point positive change), worsened (>7-point negative change), or unchanged (<7-point change). Analyses of the worsened and improved groups were compared to the unchanged group using two-way repeated measures ANOVAs and ROC curve analyses. RESULTS The ANOVAs demonstrated a significant difference between groups (P = 0.001). ROC curves analysis for detecting an improvement or decline in status were 0.73 (95% CI 0.62-0.84) and 0.70 (95% CI 0.59-0.81), respectively. An increase in FAAM score of 9 points represented the minimal clinically important difference (MCID) with 0.64 sensitivity and 0.78 specificity. A decrease in FAAM score of 2 points represented a MCID with 0.65 sensitivity and 0.61 specificity. CONCLUSIONS The FAAM demonstrated responsiveness to change in individuals with orthopedic foot and ankle dysfunction complicated by diabetes and can be used to measure patient outcomes over a 6-month period.

Defining the greater trochanter-ischial space: a potential source of extra-articular impingement in the posterior hip region

The purpose of this study was to describe greater trochanteric-ischial impingement and the relative position of the hip joint where impingement occurs. Twenty-three hips from 13 embalmed cadavers (seven males and six females) with a lifespan ranging between 46 and 91 years were used for this study. The pelvic region of each cadaver was skeletonized leaving only the hip capsule and the sciatic nerve. From 90° of flexion, the hip was extended while maintaining a position of 30° abduction and 60° external rotation. The position of hip flexion was recorded when there was contact between the greater trochanter and the ischium. The procedure was repeated in 0° abduction. A Flexion-Abduction-External Rotation (FABER) test was then performed on all specimens with a positive finding defined as contact between the greater trochanter and the ischium. In 30° abduction, contact of the ischium and the greater trochanter occurred in 87% (20/23) of the hips at an average of 47° of flexion (SD 10; range 20–60°). In 0° abduction, a positive finding was noted in 39% (9/23) of hips at an average of 59° flexion (SD 6; range 52–70°). A positive finding in the FABER test position was noted in 96% (22/23) of hips. The greater trochanter can impinge on the ischium when the hip is extended from 90° flexion in a 60° externally rotated position. This impingement occurred more commonly when the hip was in 30° abduction compared with neutral abduction. The FABER test position consistently created greater trochanteric–ischial impingement.

Hip Dysplasia: Prevalence, Associated Findings, and Procedures From Large Multicenter Arthroscopy Study Group

PURPOSE To report observational findings of patients with acetabular dysplasia undergoing hip arthroscopy. METHODS We performed a comparative case series of multicenter registry patients from January 2014 to April 2016 meeting the inclusion criteria of isolated hip arthroscopy, a documented lateral center-edge angle (LCEA), and completion of preoperative patient-reported outcome measures. A retrospective analysis compared range of motion, intra-articular pathology, and procedures of patients with dysplasia (LCEA ≤25°) and patients without dysplasia (LCEA >25°). RESULTS Of 1,053 patients meeting the inclusion criteria, 133 (13%) had dysplasia with a mean LCEA of 22.8° (standard deviation, 2.4°) versus 34.6° (standard deviation, 6.3°) for non-dysplasia patients. There were no statistically significant differences in preoperative modified Harris Hip Score, International Hip Outcome Tool-12 score, or visual analog scale score (pain). Cam deformity occurred in 80% of dysplasia patients. There was a significant difference in internal rotation between the dysplasia (21°) and non-dysplasia groups (16°, P < .001). Mean internal rotation (33.5°; standard deviation, 15.6°) of the dysplastic subjects without cam morphology was greater than that of the dysplastic patients with cam morphology (18.5°; standard deviation, 11.6°; P < .001). Hypertrophic labra were found more commonly in dysplastic (33%) than non-dysplastic hips (11%, P < .001). Labral tears in patients with dysplasia were treated by repair (76%), reconstruction (13%), and selective debridement (11%); labral treatments were not significantly different between cohorts. The most common nonlabral procedures included femoroplasty (76%) and synovectomy (73%). There was no significant difference between the dysplasia and non-dysplasia groups regarding capsulotomy types and capsular closure rates (96% and 92%, respectively). CONCLUSIONS Dysplasia, typically of borderline to mild severity, comprises a significant incidence of surgical cases (13%) by surgeons performing high-volume hip arthroscopy. Despite having similar preoperative pain and functional profiles to patients without dysplasia, dysplasia patients may have increased flexed-hip internal rotation. Commonly associated cam morphology significantly decreases internal rotation. Arthroscopic labral repair, femoroplasty, and closure of interportal capsulotomy are the most commonly performed procedures. LEVEL OF EVIDENCE Level III, therapeutic comparative case series.

Physical Therapy and Rehabilitation in Posterior Hip Pathology

A standard comprehensive physical examination should be performed for those with posterior hip pain to determine a diagnosis, classify individuals into treatment categories, and identify impairments that need to be addressed with physical therapy intervention. A physical therapy- based evaluation algorithm and classification-based treatment categories include considerations for the lumbosacral spine and intra-articular and extra-articular sources of hip posterior pain. Posterior impingement, musculotendinous pathologies, nerve entrapments, and boney impingement are sources of posterior hip pain that can be addressed with intervention directed at strength, range of motion, flexibility, neuromuscular control, and biomechanical deficits.

Rehabilitation After Hip Arthroscopy

Protocols for hip arthroscopy have traditionally been based on time established criteria for tissue healing. However, there are several factors to consider beyond the surgical procedure that influence the progression of a rehabilitation program. Progression should be based on not only time frame but also objective criteria-based indicators. This chapter describes potential strategies to improve communication between the therapist and surgical team, outlines general postoperative rehabilitation guidelines related to common arthroscopic surgical procedures, defines criteria to progress a patient along various phases of a protocol, and highlights pearls and perils along the rehabilitation process.