John O’Donnell

Arthroscopic femoral osteochondroplasty for cam lesions with isolated acetabular chondral damage

This study evaluates the outcome of arthroscopic femoral osteochondroplasty for cam lesions of the hip in the absence of additional pathology other than acetabular chondral lesions. We retrospectively reviewed 166 patients (170 hips) who were categorised according to three different grades of chondral damage. The outcome was assessed in each grade using the modified Harris Hip Score (MHHS) and the Non-Arthritic Hip Score (NAHS). Overall, at the last follow-up (mean 22 months, 12 to 72), the mean MHHS had improved by 15.3 points (95% confidence interval (CI), 8.9 to 21.7) and the mean NAHS by 15 points (95% CI, 9.4 to 20.5). Significantly better results were observed in hips with less severe chondral damage. Microfracture in limited chondral lesions showed superior results. Arthroscopic femoral osteochondroplasty for cam impingement with microfracture in selected cases is beneficial. The outcome correlates with the severity of acetabular chondral damage.

Arthroscopic treatment for acetabular labral tears of the hip without bony dysmorphism.

Background Surgical treatment for labral tears of the hip has shown good results in patients with bony impingement lesions; however, results are also affected by the correction of bony abnormalities. This study evaluates the outcome of arthroscopic treatment for acetabular labral tears without associated dysplasia or bony impingement lesions. Hypothesis Based on the structural importance of the acetabular labrum, labral tear debridement or repair can relieve pain and improve function. Study Design Case series; Level of evidence, 4. Methods The study included 81 patients who were categorized according to 4 morphologic labral tear types. The tear type, degree of synovitis, and chondral damage were analyzed with the use of multivariate regression analysis and correlated to the clinical outcome. The outcome was assessed utilizing the modified Harris hip score (MHHS) and the nonarthritic hip score (NAHS). Results There were 81 patients (81 hips), including 20 men and 61 women, with 41 right and 40 left hips. Their mean age was 44 years. Overall, at an average follow-up of 3 years the mean MHHS had improved by 18 points (95% confidence interval [CI], 13-23) and the mean NAHS by 17 points (95% CI, 12-22). An improvement after arthroscopic treatment was noticed in all types of labral tears of the hip. The level of synovitis and of chondral lesions was found to have a significant negative effect on the clinical outcome. Conclusion Arthroscopic treatment for acetabular labral tears of the hip without dysplasia or bony impingement lesions has good short- to midterm results. The best outcome is expected in the absence of synovitis and chondral lesions.

The Ligamentum Teres Test A Novel and Effective Test in Diagnosing Tears of the Ligamentum Teres

Background: A ligamentum teres (LT) injury is a common finding at the time of hip arthroscopic surgery in patients with chronic groin and hip pain; however, LT tears have been difficult to identify before surgery. There have been no unique features identified on history assessment, physical examination, or imaging that reliably identify injuries of the LT preoperatively. Purpose: To report a new clinical examination to assess the presence of an LT tear: the LT test. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: The study consisted of 75 patients undergoing hip arthroscopic surgery for multiple lesions. Each patient was evaluated by 2 independent examiners using the LT test, leading to a total of 150 tests being performed. The LT test is conducted with the hip flexed at 70° and 30° short of full abduction; the hip is then internally and externally rotated to its limits of motion. Pain on either internal or external rotation is consistent with a positive LT test result. Hip arthroscopic surgery was then performed and all intra-articular abnormalities noted. Arthroscopic images were taken of each LT and examined by a third independent examiner who determined the presence or absence of a tear. Clinical examination findings were compared with the arthroscopic findings to determine the sensitivity, specificity, and positive and negative predictive values. In addition, the presence of intra-articular pathological lesions was compared with the test results to determine if there was a correlation between the presence of an intra-articular pathological abnormality and a positive LT test result. Results: Of the 150 examinations performed, the test result was positive 55% of the time (77 examinations). The sensitivity and specificity of the test were 90% and 85%, respectively. The positive predictive value was 84%, and the negative predictive value was 91%. The presence of an LT tear, pincer lesion, and labral tear that required repair was associated with a positive LT test result. The κ coefficient for interobserver reliability was .80. Conclusion: The LT test is an effective way of assessing the presence of LT tears with moderate to high interobserver reliability. In addition to an LT tear, the presence of a pincer lesion or labral tear requiring repair are also associated with a positive LT test result.

Successful treatment of isolated, partial thickness ligamentum teres (LT) tears with debridement and capsulorrhaphy.

Background To determine if the addition of anterior capsular tightening to the treatment of partial ligamentum teres (LT) tears by debridement will diminish the recurrence rate of symptoms due to LT retears. Method A prospective case series, including all patients treated for an isolated LT tear from June 2009 to August 2011. Arthroscopically the tear was debrided using radiofrequency (RF) and the joint capsule was tightened using either RF or suture plication. All the patients were prospectively assessed with the Modified Harris Hip Score (MHHS) and the Non Arthritic Hip Score (NAHS). A total of 1574 hip arthroscopies were performed from June 2009 to November 2011. Isolated partial LT tears, were found in 27 hips (26 patients). The average age was 24.4 years (range 12-45). There were 24 females and two males. Results Over an average follow-up period of 32 months (range 23-49), MHHS and NAHS preoperative outcome scores improved significantly. No revision surgery was required for a recurrent tear. conclusion Debridement of partial thickness LT tears, with additional anterior capsule tightening, has been shown to lead to improvents in MHHS and NAHS, with no recurrence of symptoms due to LT retear in the short to medium term.

The Effectiveness of Platelet-Rich Plasma Injections in Gluteal Tendinopathy: A Randomized, Double-Blind Controlled Trial Comparing a Single Platelet-Rich Plasma Injection With a Single Corticosteroid Injection:

Background: Gluteus medius/minimus tendinopathy is a common cause of lateral hip pain or greater trochanteric pain syndrome. Hypothesis: There would be no difference in the modified Harris Hip Score (mHHS) between a single platelet-rich plasma (PRP) injection compared with a corticosteroid injection in the treatment of gluteal tendinopathy. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: There were 228 consecutive patients referred with gluteal tendinopathy who were screened to enroll 80 participants; 148 were excluded (refusal: n = 42; previous surgery or sciatica: n = 50; osteoarthritis, n = 17; full-thickness tendon tear, n = 17; other: n = 22). Participants were randomized (1:1) to receive either a blinded glucocorticoid or PRP injection intratendinously under ultrasound guidance. A pain and functional assessment was performed using the mHHS questionnaire at 0, 2, 6, and 12 weeks and the patient acceptable symptom state (PASS) and minimal clinically important difference (MCID) at 12 weeks. Results: Participants had a mean age of 60 years, a ratio of female to male of 9:1, and mean duration of symptoms of >14 months. Pain and function measured by the mean mHHS showed no difference at 2 weeks (corticosteroid: 66.95 ± 15.14 vs PRP: 65.23 ± 11.60) or 6 weeks (corticosteroid: 69.51 ± 14.78 vs PRP: 68.79 ± 13.33). The mean mHHS was significantly improved at 12 weeks in the PRP group (74.05 ± 13.92) compared with the corticosteroid group (67.13 ± 16.04) (P = .048). The proportion of participants who achieved an outcome score of ≥74 at 12 weeks was 17 of 37 (45.9%) in the corticosteroid group and 25 of 39 (64.1%) in the PRP group. The proportion of participants who achieved the MCID of more than 8 points at 12 weeks was 21 of 37 (56.7%) in the corticosteroid group and 32 of 39 (82%) in the PRP group (P = .016). Conclusion: Patients with chronic gluteal tendinopathy >4 months, diagnosed with both clinical and radiological examinations, achieved greater clinical improvement at 12 weeks when treated with a single PRP injection than those treated with a single corticosteroid injection. Registration: ACTRN12613000677707 (Australian New Zealand Clinical Trials Registry).

The reliability of commonly used arthroscopic classifications of ligamentum teres pathology

Abstract The importance of the ligamentum teres (LT) in the hip is increasingly being recognized. However, the incidence of LT tears in the literature is extremely variable. Although classification systems exist their reliability in classifying LT pathology arthroscopically has not been well defined. To determine the inter- and intra-observer reliability of two existing classifications systems for the diagnosis of LT pathology at hip arthroscopy. Second, to identify key pathological findings currently not included. Four experienced hip-arthroscopists reviewed 40 standardized arthroscopic videos. Arthroscopic findings of the LT were classified using the Gray and Villar (G&V) and descriptive classification (DC). Reviewers were asked to record other relevant pathology encountered. Inter- and intra-observer reliability was defined using Fleiss-Kappa and Cohen-Kappa statistics. Both classifications demonstrated fair inter-observer reliability. The intra-observer reliability for G&V was moderate-to-substantial and for DC was slight-to-moderate. An absolute agreement rate of 10% (G&V) and 37.5% (DC) was found. Differentiation between normal, and partial or low-grade tears was a common source of disagreement. The prevalence of LT pathology was 90%. Synovitis was the most common diagnostic finding that was not included in either classification system used in this study. Arthroscopic classification of LT pathology using the G&V and the DC demonstrated only fair inter-observer reliability. The major discrepancy in interpretation was between normal, and partial or low-grade tears. The presence of synovitis was not in either classification but was considered an important arthroscopic finding. Thorough arthroscopic scrutiny reveals the prevalence of LT pathology is higher than previously reported.

Hip arthroscopy results in improved patient reported outcomes compared to non-operative management of waitlisted patients

Abstract Hip arthroscopy (HA) is an established treatment option to address intra-articular pathology of the hip. However, some clinicians encourage non-operative management (NOM). Non-operative management may include active measures such as physiotherapy and intra-articular steroid injections, or NOM may involve so called watchful waiting with no active intervention. These approaches, along with surgery have been detailed recently in the Warwick Agreement, a Consensus Statement regarding diagnosis and treatment of Femoroacetabular Impingement Syndrome The aim of this study is to compare the change in clinical outcome scores of waitlisted patients with intra-articular hip pathology who receive no active treatment with matched controls that have undergone HA. Patients less than 60 years of age were identified from a HA waiting list in a single hospital in the Australian public hospital system. Patient reported outcomes (PRO) were collected whilst patients waited for surgery. During this waiting period no specific treatment was offered. A separate group of patients who had previously undergone HA were matched based on age, sex, body mass index and baseline non-arthritic hip scores (NAHS). The groups were compared using the NAHS as the primary outcome measures. Modified Harris Hip Scores were also collected and compared. Thirty-six patients were included in each group, with a mean follow up of 19 months (12–36). There were no significant differences in age, sex, BMI and NAHS between groups at baseline. At final follow up, mean NAHS scores after HA were significantly higher than scores after NOM, 82.1 (36.4–100.0) versus 48.9 (11.3–78.8), respectively (P < 0.001) with a large effect size for mean change in scores between groups (d = 1.77, 95% CI 1.21–2.30). Mean mHHS after HA were significantly higher than scores after NOM, 84.3 (15.4–100.0) versus 48.1 (21.0–66.0) respectively (P < 0.001), with a large effect size for mean change in scores between groups (d = 1.92, 95% CI 1.34–2.46). HA may lead to significant improvements in PRO when compared to non-operative management of waitlisted patients with intra-articular pathology of the hip at 18 months follow-up.

The role of the ligamentum teres in the adult hip: redundant or relevant? A review

ABSTRACT The ligamentum teres (LT) has traditionally been described as a redundant structure with no contribution to hip biomechanics or function. There has been renewed interest in the LT as a source of hip pathology due to the high prevalence of LT pathology observed at the time of hip arthroscopy. The LT acts a secondary stabilizer to supplement the work of the capsular ligaments and works in a sling-like manner to prevent subluxation of the hip at the extremes of motion. The presence of free nerve endings within the LT indicates a definite role in pain generation, with the LT undergoing various mechanical and histological adaptations to hip pathology.

A novel and simple classification for ligamentum teres pathology based on joint hypermobility

Abstract Ligamentum teres (LT) pathology (including synovitis, partial and complete tears) is common at the time of hip arthroscopy with a reported prevalence of 51–90%. Currently, there are four published classifications of LT injuries and tears. The majority focuses on differentiating partial from full thickness tears, whereas a more recently published classification also incorporates the presumed underlying mechanism of pathology. A recent review of the current classification systems found that all are deficient for lack of inclusion of what constitutes a normal ligament, lack of inclusion of synovitis as a source of pathology and lack of inclusion of hypermobility as part of the treatment algorithm. Also, the two most commonly used classification systems have only fair inter-observer reliability. Recent work has found that underlying joint hypermobility plays an important role in LT pathology and that the addition of capsular plication/suture at the time of surgery for LT pathology improves outcomes and reduces re-tear rates. In order to address these problems which have been identified with the currently available classification systems, we propose a novel and simple classification for LT pathology based on underlying joint hypermobility [as assessed by the Beighton test score (BTS)]. LT pathology is used to divide all patients into four types: 0 normal (which includes minor fraying), 1 synovitis (which would also include minor fraying), 2 partial tear and 3 complete tear. Further, all types are subdivided into two groups: Group A patients have no clinical evidence of joint hypermobility (BTS < 3), whereas Group B patients do have clinical evidence of joint hypermobility (BTS ≥ 4). On the basis of this classification system and the available literature, we have also developed a treatment algorithm for LT pathology.

The Effectiveness of Platelet-Rich Plasma Injections in Gluteal Tendinopathy: Response:

Dear Editor: I read with interest this report of a randomized controlled trial and noticed irregularities within the study, for which I would appreciate further elucidation. In brief, these relate to the sample characteristics (diagnosis), the assertion that this study supports platelet-rich plasma (PRP) as a biological treatment, persistent pain at inclusion as a control for natural history, and the notion of staging-based treatment.