Itamar B. Botser

Tears of the Ligamentum Teres Prevalence in Hip Arthroscopy Using 2 Classification Systems

Background The ligamentum teres (LT) anatomy has been known for many years. While its functionality remains debatable, it is well recognized that the LT can be a source of pain in the hip joint. In 1997, a landmark publication by Gray and Villar established a classification for LT tears and increased the awareness of LT disorders. However, the incidence of LT tears and the various tear types is unknown. Purpose The authors report the prevalence of LT tears in a population of patients who underwent hip arthroscopy, using both the Gray and Villar classification and a new descriptive classification. Study Design Case series; Level of evidence, 4. Methods Between February 2008 and January 2011, 616 hip arthroscopies were performed by the senior author. After excluding revision surgeries, a total of 558 surgeries (502 patients) were included in the study. Data were collected regarding patients’ demographics, mechanism of injury, range of motion, magnetic resonance results, and intraoperative findings. Preoperative hip-specific questionnaire scores and pain level were recorded as well. Ligamentum teres tears were classified according to Gray and Villars classification, and were also categorized using a descriptive grading system as follows: 0, no tear; 1, <50% tear; 2, >50% tear; or 3, 100% tear. Results A total of 284 (51%) of the 558 surgeries in this cohort revealed LT tears. According to the descriptive grading system, 22% were grade 1, 24% were grade 2, and 5% were grade 3. According to the Gray and Villar classification 3.7% had full rupture, 43% had a partial tear, and 4.5% had a degenerative tear. Patients with LT tears were significantly older and had worse preoperative functional scores; they did, however, have a greater range of motion. Intraoperatively, an association with larger labral tear size and acetabular chondral damage was found. Magnetic resonance arthrography was found to have low accuracy and sensitivity in detection of LT tears. No correlation to the pain level was found. Conclusion Ligamentum teres tears had a higher prevalence in this study than was published in the past, most probably attributable to a lower threshold used in defining a tear. The incidence is defined both using the Gray and Villar classification, as well as a new descriptive classification system that categorizes the LT according to amount of tearing.

Partial-Thickness Tears of the Gluteus Medius: Rationale and Technique for Trans-Tendinous Endoscopic Repair

Tears in the gluteus medius and minimus tendons, often misdiagnosed as trochanteric bursitis, have recently emerged as an important cause of recalcitrant greater trochanter pain syndrome. Advances in endoscopic surgery of the hip have created opportunities to better evaluate and treat pathology in the peritrochanteric compartment. We reviewed the literature on trochanteric pain syndrome and gluteus medius tendon injuries. Existing techniques for endoscopic and open gluteus tendon repair and potential challenges in restoration of abductor function were analyzed. Partial-thickness undersurface tears of the gluteus medius were identified as a common pathologic entity. Although these tears are otherwise analogous to partial-thickness tears of the rotator cuff, the lack of arthroscopic access to the deep side of the gluteus medius tendon represents a unique technical challenge. To address the difficulty in visualizing and thus repairing undersurface tears of the gluteus medius, a novel endoscopic trans-tendinous repair technique was developed. The purposes of this article are to review the anatomy, pathology, and existing repair techniques of gluteus medius tendon tears and to describe the rationale and surgical steps for endoscopic trans-tendinous repair.

Femoral Anteversion in the Hip: Comparison of Measurement by Computed Tomography, Magnetic Resonance Imaging, and Physical Examination

PURPOSE The purpose of this study was to evaluate the correlation between computed tomography (CT) and magnetic resonance imaging (MRI) measurements of femoral anteversion, as well as the relation of anteversion with physical examination and radiographic findings. METHODS Preoperative CT and MRI measurements of anteversion along with clinical examination were performed on 129 consecutive hips before hip arthroscopy for nonarthritic hip injuries. All anteversion measurements were performed by 2 musculoskeletal radiologists. The radiographic findings and physical examination findings were analyzed for statistically significant correlations. For statistical analysis purposes, the patients were divided into 3 groups according to the mean CT anteversion measurement: group I (low), less than 10°; group II (medium), 10° to 22°; and group III (high), greater than 22°. RESULTS High interobserver correlation was found for femoral anteversion measurement by CT and MRI (r = 0.95 and r = 0.86, respectively; P < .0001 for both). CT and MRI measurements showed high correlation with each other (r = 0.80, P < .0001). However, in 96% of the cases, the CT measurement was larger, with a mean difference of 8.9° (range, -37° to 1.5°). A significant correlation coefficient was found between internal rotation and anteversion angles as measured by CT (r = 0.36, P < .0001). However, no correlation was found with other hip movement measurements. Abnormal femoral acetabular bony architecture of the hip was found in 64% of the patients; isolated cam impingement was more prevalent in group I, whereas isolated pincer impingement was more prevalent in group III (P = .01). CONCLUSIONS Although high correlation was found between anteversion angle measurements by CT and MRI, significant discrepancies in the absolute anteversion number between the 2 techniques suggest that they may not be interchangeable. Furthermore, CT was found to have higher interobserver reliability than MRI. There was a significant correlation between CT and examination of internal rotation of the hip. Clinically, the findings of the study show that the diagnosis of excessive femoral anteversion or retroversion should have different thresholds according to MRI and CT measurements; moreover, the diagnosis should not rely exclusively on either examination or radiologic criteria. LEVEL OF EVIDENCE Level III, retrospective comparative study.

Outcomes of Endoscopic Gluteus Medius Repair With Minimum 2-Year Follow-up

Background: Gluteus medius tears may be present in as many as 25% of late middle-aged women and 10% of middle-aged men, and they are often misdiagnosed. Outcomes of endoscopic repair of gluteus medius tears have seldom been reported. Purpose: To report the early outcomes of endoscopic repair of partial- and full-thickness gluteus medius tears. Study Design: Case series; Level of evidence, 4. Methods: Between April 2009 and January 2010, data were prospectively collected for all patients undergoing endoscopic gluteus medius repair by one of the authors. Inclusion criteria for the study were patients undergoing repair for either high-grade, partial-, or full-thickness tears. Only patients with endoscopic evidence of a gluteus medius tear were treated surgically. In the case of an articular-side tear, a transtendinous repair technique was used, whereas in the presence of a full-thickness tear, the tendon was refixated to the bone directly. Results: A total of 15 patients met the inclusion criteria. The cohort included 14 women and 1 man, with an average age of 58 years (range, 44-74 years). Endoscopically, 6 cases were found to be partial-thickness tears. Nine were either full-thickness tears or near-full-thickness tears, which were completed for the repair. Follow-up was obtained on all patients at an average of 27.9 months postoperatively (range, 24-37 months). Fourteen of the 15 patients showed postoperative improvement in all 4 hip-specific scores used to assess outcome, with an average improvement of more than 30 points for all scores. Satisfaction with the surgery results was reported to be from good to excellent (scores of 7-10 out of 10) in 14 of 15 patients. Conclusion: This study demonstrates that endoscopic surgical repair, whether performed through a transtendinous or full-thickness technique, can be an effective treatment of gluteus medius tears at a minimum follow-up of 2 years. Longer term follow-up studies are necessary to determine whether these therapeutic and functional gains are maintained.

Risk Factors for Ligamentum Teres Tears

PURPOSE The purpose of this study was to examine the relationship between nontraumatic ligamentum teres (LT) tears and acetabular radiographic architecture. METHODS The inclusion criteria for this study were all patients who had anteroposterior pelvis radiographic views and had undergone arthroscopic examination of the LT. The exclusion criteria were Tonnis arthritic grade 3 and traumatic high-energy mechanisms of injury. Radiographic data were measured preoperatively on an anteroposterior pelvis view, including acetabular inclination (AI), lateral center edge (CE) angle, magnitude of cross-over sign, and ischial spine prominence. A Lateral Coverage Index (LCI) was defined as the center edge angle minus acetabular inclination. Hips were divided into 3 groups according to the LCI: (1) high: 34° and above; (2) medium: 19° to 33°; and (3) low: below 19°. RESULTS Of the 463 hips (430 patients) included in the study, 226 (49%) had a partial- or full-thickness LT tear. Patients with tears were significantly older than patients without tears (P < .0001), with average ages of 38 and 33 years, respectively. Radiographically, patients with tears had less acetabular retroversion, as reflected by lower ischial spine prominence values and lesser cross-over signs (P = .01 and .0005, respectively). Using the LCI, 115 hips (25%) were classified as high, 236 (50%) as medium, and 114 (25%) as low. Hips with low LCI were 1.74 times more likely to have LT tears than high LCI hips. CONCLUSIONS This study found that the presence of LT tears was associated with acetabular bony morphology and age. LT tears were less frequent with high LCI and acetabular retroversion and less frequent in patients younger than 30 years. Further study is needed to establish whether there is a causal relationship between acetabular undercoverage and LT tears and whether LT tears may be a sign of microinstability of the hip. LEVEL OF EVIDENCE Level IV, therapeutic case series.

Labral Penetration Rate in a Consecutive Series of 300 Hip Arthroscopies

Background: Intraoperative labral injury during the establishment of the first portal in hip arthroscopy has been reported to be as high as 20%. Purpose: The purpose of the study was to prospectively identify the incidence of acetabular labral injuries that occurred while using a current technique for the establishment of portals during hip arthroscopy. Study Design: Case series; Level of evidence, 4. Methods: Between the years 2008 and 2010, data were prospectively collected for all patients undergoing hip arthroscopic surgery. Patients with previous labral resection or Tonnis grade greater than 1 were excluded. Patients were positioned supine, traction was applied, and portals were established. The anterolateral portal was created first by venting the joint with a spinal needle and then re-entering the joint with the same needle with the bevel side facing the labrum. Next, the midanterior portal was created under vision. A thorough examination of the acetabular labrum was conducted arthroscopically through multiple viewing portals, and labral injuries related to the establishment of portals were identified and noted. Results: A total of 300 patients were included in the study; only 2 patients (0.67%) suffered intraoperative labral injuries at the study period. One injury occurred during revision arthroscopy, while the second involved a hyperplastic labrum in a dysplastic hip. No patient with normal hip morphological characteristics undergoing a hip arthroscopy suffered a labral tear as a result of portal placement. Conclusion: The incidence of iatrogenic labral injury during hip arthroscopy can be as low as 0.67% when using the described technique.

Is intraarticular pathology common in patients with hip dysplasia undergoing periacetabular osteotomy

BackgroundPeriacetabular osteotomy (PAO) enables correction of bony acetabular deficiency in the setting of hip dysplasia. Patients with insufficient acetabular coverage often have intraarticular pathology, but the degree of this pathology has been incompletely characterized. We have used arthroscopy as an adjunct to PAO to further delineate intraarticular pathology in patients with hip dysplasia with mechanical symptoms.Questions/purposesWe documented the arthroscopic incidence of (1) femoral and acetabular chondral pathology, (2) femoral neck cam lesions, and (3) internal snapping or ligamentum teres pathology among patients having arthroscopy before PAO.MethodsWe reviewed all 16 patients (17 hips; mean age at surgery, 21 years; range, 12–33 years) with hip dysplasia who underwent PAOs and concomitant hip arthroscopy at our institutions from October 2010 to March 2012. During this period, 80 patients underwent PAOs, making the arthroscopic cohort 21% of the total cohort. Indications for concomitant hip arthroscopy were mechanical symptoms consistent with labral pathology identified on MRI. We documented pathology involving the labrum, chondral surface, ligamentum teres, cam deformity, and psoas tendon.ResultsArthroscopy revealed significant intraarticular pathology in all patients. Fourteen hips had anterosuperior labral tears, and three hips had preoperative findings of internal snapping hip. Eleven hips had femoral cam-type lesions in addition to dysplasia, and 16 hips had articular chondral injury. Two hips had full-thickness ligamentum tears, and 13 hips had partial-thickness tears.ConclusionsIntraarticular pathology at the time of PAO is common. Future studies are needed to rigorously address the use of arthroscopic intervention during PAO and the impact on clinical outcome compared to PAO alone.Level of EvidenceLevel IV, diagnostic study. See Instructions for Authors for a complete description of levels of evidence.

Arthroscopic Iliopsoas Fractional Lengthening for Internal Snapping of the Hip Clinical Outcomes With a Minimum 2-Year Follow-up

Background: Internal snapping of the hip is caused by the iliopsoas (IP) tendon sliding over the iliopectineal eminence or the femoral head. In many cases that require hip arthroscopic surgery, there is coexistent painful internal snapping. In such cases, fractional lengthening of the IP tendon has been suggested as an adjunctive procedure. Purpose: To examine the outcomes and effectiveness of arthroscopic IP tendon fractional lengthening as a solution to coexistent internal hip snapping in patients undergoing hip arthroscopic surgery for a labral tear and/or femoroacetabular impingement. Study Design: Case series; Level of evidence, 4. Methods: Between June 2010 and June 2011, data were prospectively collected for all patients with internal snapping of the hip who underwent primary arthroscopic IP tendon fractional lengthening, with a minimum 2-year follow-up. All patients were interviewed by telephone with specific questions regarding the resolution or persistence of snapping. Patients were assessed preoperatively and postoperatively using the following patient-reported outcome (PRO) measures: Non-Arthritic Hip Score (NAHS), Hip Outcome Score–Activity of Daily Living (HOS-ADL) and Sport-Specific Subscale (HOS-SSS), and modified Harris Hip Score (mHHS). Pain was recorded on a visual analog scale (VAS), and satisfaction was measured on a scale from 0 to 10. Results: A total of 55 patients were included, with all PROs showing statistically significant improvement postoperatively (NAHS: 57.6 ± 20.6 preoperatively vs 80.2 ± 19.2 at 2 years; HOS-ADL: 60.9 ± 21.4 preoperatively vs 81.8 ± 20.6 at 2 years; HOS-SSS: 43.4 ± 24.6 preoperatively vs 70.0 ± 26.7 at 2 years; and mHHS: 62.3 ± 16.4 preoperatively vs 80.5 ± 18.3 at 2 years) (P < .001 for all). Forty-five patients (81.8%) reported good/excellent satisfaction (≥7). Overall, 45 patients (81.8%) reported resolution of painful snapping. Patients who had resolution of snapping had statistically significant superior outcomes compared with those with persistent snapping using the change in the NAHS value (25.8 ± 16.1 vs 8.0 ± 22.5, respectively; P = .005), change in the HOS-ADL value (23.6 ± 18.0 vs 8.5 ± 15.2, respectively; P = .017), change in the HOS-SSS value (30.7 ± 26.9 vs 8.7 ± 23.6, respectively; P = .021), and change in the mHHS value (23.3 ± 20.1 vs 4.4 ± 9.9, respectively; P = .005). Conclusion: A majority of patients reported resolution of painful snapping and improvement in symptoms. Nonetheless, the rate of persistence of internal snapping at a minimum 2 years postoperatively was higher than that reported in previous studies.

Predictive Value of Robotic-Assisted Total Hip Arthroplasty

Acetabular cup positioning, leg-length discrepancy, and global offset are important parameters associated with outcomes following total hip arthroplasty (THA). Deviation from an accepted range of values can lead to significant complications, including dislocation, leg-length discrepancy, impingement, accelerated bearing surface wear, and revisions. The purpose of this study was to assess whether robotic-assisted THA was reliable in predicting radiographic measurements of cup inclination and anteversion, leg-length change, and global offset change. All 61 robotic-assisted THAs that met the inclusion and exclusion criteria were performed by a single surgeon through a mini-posterior approach. Data provided by the robot were collected prospectively, and radiographic data were collected retrospectively by 2 blinded independent reviewers. The cohort in this study consisted of 27 male and 34 female patients, with an average age of 60.5 years. A strong inter- and intraobserver correlation was found for the radiographic measurements of cup inclination, cup anteversion, leg-length discrepancy, and global offset (r>0.8 with P<.001 for all). Ninety-six point seven percent of robotic-measured inclination angles and 98.4% of robotic-measured anteversion angles were within 10° of radiographic measurements. One hundred percent of robotic-measured leg-length change and 91.8% of robotic-measured global offset change were within 10 mm of radiographic measurements. Robotic-assisted THA showed good predictive value for cup inclination and anteversion angles and measurements of leg-length change and global offset change done postoperatively on plain radiographs. Further refinement of the robotic system would make it more accurate in predicting the postoperative parameters mentioned.

MR Imaging of the Hip: Pathologies and Morphologies of the Hip Joint, What the Surgeon Wants to Know

MR imaging of the hip is frequently used in symptomatic patients before hip preservation surgery; it is used as a decision-making tool and as a planning tool. The MRI can confirm the preliminary working diagnosis, identify other possible sources of pain, and highlight anatomic areas that are not routinely viewed during surgery. In addition, MR imaging is capable of illustrating normal and abnormal bony morphology of the femur and pelvis; and in the case that arthrography is used, diagnostic injection can be administrated concurrently. This article highlights a surgeons perspective on the use of MR imaging in the patient with nonarthritic hip pain.