M. Russell Giveans

Arthroscopic Debridement Versus Refixation of the Acetabular Labrum Associated With Femoroacetabular Impingement

PURPOSE The purpose of this study was to compare the outcomes of arthroscopic labral debridement with those of labral refixation. METHODS We reviewed patients who underwent labral debridement during a period before the development of labral repair techniques. Patients with labral tears deemed repairable with our current arthroscopic technique were compared with patients who underwent labral refixation with a minimum 1 of year of follow-up. To better match the 2 groups, only patients with labral pathology caused by pincer-type or combined pincer- and cam-type femoroacetabular impingement were included. In the first 36 hips the labrum was debrided (group 1); in the next 39 hips the labrum underwent refixation (group 2). Outcomes were measured preoperatively and postoperatively with the modified Harris Hip Score (HHS), Short Form 12, and visual analog scale for pain. Preoperative and postoperative radiographs were obtained to evaluate bony resection (alpha angle) and osteoarthritis (Tönnis grade). RESULTS The mean age was 31 years in group 1, with a mean follow-up of 21.4 months, and 27 years in group 2, with a mean follow-up of 16.5 months. Preoperative subjective outcomes scores were not significantly different between groups. At the 1-year follow-up visit, subjective outcomes were significantly improved (P < .01) in both groups. HHSs were significantly better for the refixation group (94.3) compared with the debridement group (88.9) at 1 year (P = .029). At most recent follow-up, good to excellent results were noted in 66.7% of hips in the debridement group compared with 89.7% of hips in the refixation group (P < .01). CONCLUSIONS Although other variables could have influenced these outcomes, these preliminary results indicate that labral refixation resulted in better HHS outcomes and a greater percentage of good to excellent results compared with the results of labral debridement in an earlier cohort. LEVEL OF EVIDENCE Level III, retrospective comparative study.

Arthroscopic Debridement Versus Refixation of the Acetabular Labrum Associated With Femoroacetabular Impingement Mean 3.5-Year Follow-up

Background: The acetabular labrum provides a sealing function and a degree of hip joint stability. Limited, short-term follow-up studies suggest that labral refixation/preservation leads to superior outcomes compared with labral debridement/excision. Purpose: To compare the results of labral refixation versus focal labral excision/debridement in a cohort of patients who underwent arthroscopic correction of femoroacetabular impingement (FAI). Study Design: Cohort study; Level of evidence, 3. Methods: We reported on patients who underwent labral debridement/focal labral excision during a period before the development of labral repair techniques. Patients with labral tears thought to be repairable with our current arthroscopic technique were compared with a cohort of patients who underwent labral refixation. To better match the 2 groups, only patients with labral pincer- or combined-type FAI were included. In the first 44 hips, the labrum was focally excised/debrided (group 1); in the next 50 hips, the labrum was refixed (group 2). Outcomes were measured with the modified Harris Hip Score (HHS), Short Form 12 (SF-12), and a visual analog scale (VAS) for pain preoperatively and postoperatively. Preoperative and postoperative radiographs were obtained to evaluate bony resection. Results: The mean age was 32 years in group 1 and 28 years in group 2 with a mean follow-up of 42 months (range, 24-72 months). Preoperative mean subjective outcome scores were not significantly different between groups. At a mean 3.5 years’ follow-up, subjective outcomes were significantly improved (P < .01) for both groups compared with preoperative scores. The HHS (P = .001), SF-12 (P = .041), and VAS pain scores (P = .004) were all significantly better for the refixation group compared with the debridement group at the most recent follow-up. At a mean 3.5 years’ follow-up, good to excellent results were noted in 68% of the focal excision/debridement group and 92% of the refixation group (P = .004). Conclusion: Although other factors may have influenced these results, labral refixation compared with an earlier cohort of focal labral excision/debridement resulted in better HHS, SF-12, and VAS pain outcomes and a greater percentage of good to excellent results at a mean 3.5-year follow-up.

Treatment of Athletes With Symptomatic Intra-Articular Hip Pathology and Athletic Pubalgia/Sports Hernia: A Case Series

PURPOSE The purpose of the study was to evaluate the results of surgical treatment in athletes with associated intra-articular hip pathology and extra-articular sports pubalgia. METHODS Between December 2003 and September 2009, 37 hips (mean patient age, 25 years) were diagnosed with both symptomatic athletic pubalgia and symptomatic intra-articular hip joint pathology. There were 8 professional athletes, 15 collegiate athletes, 5 elite high school athletes, and 9 competitive club athletes. Outcomes included an evaluation regarding return to sports and modified Harris Hip Score, Short Form 12 score, and visual analog scale score. RESULTS We evaluated 37 hips at a mean of 29 months (range, 12 to 78 months) after the index surgery. Thirty-one hips underwent thirty-five athletic pubalgia surgeries. Hip arthroscopy was performed in 32 hips (30 cases of femoroacetabular impingement treatment, 1 traumatic labral tear, and 1 borderline dysplasia). Of 16 hips that had athletic pubalgia surgery as the index procedure, 4 (25%) returned to sports without limitations, and 11 (69%) subsequently had hip arthroscopy at a mean of 20 months after pubalgia surgery. Of 8 hips managed initially with hip arthroscopy alone, 4 (50%) returned to sports without limitations, and 3 (43%) had subsequent pubalgia surgery at a mean of 6 months after hip arthroscopy. Thirteen hips had athletic pubalgia surgery and hip arthroscopy at one setting. Concurrent or eventual surgical treatment of both disorders led to improved postoperative outcomes scores (P < .05) and an unrestricted return to sporting activity in 89% of hips (24 of 27). CONCLUSIONS When surgery only addressed either the athletic pubalgia or intra-articular hip pathology in this patient population, outcomes were suboptimal. Surgical management of both disorders concurrently or in a staged manner led to improved postoperative outcomes scoring and an unrestricted return to sporting activity in 89% of hips. LEVEL OF EVIDENCE Level IV, therapeutic case series.

Arthroscopic Hip Revision Surgery for Residual Femoroacetabular Impingement (FAI) Surgical Outcomes Compared With a Matched Cohort After Primary Arthroscopic FAI Correction

Background: There are limited data reporting outcomes after revision arthroscopic surgery for residual femoroacetabular impingement (FAI). Hypothesis: (1) Revision arthroscopic FAI correction results in improved outcomes, but they are inferior to those of primary arthroscopic FAI correction. (2) Improved postrevision radiographic parameters are predictive of better outcomes. Study Design: Cohort study; Level of evidence, 3. Methods: Patients who underwent arthroscopic hip revision for residual FAI were reviewed. Pathomorphological findings, intraoperative findings, and preoperative and postoperative modified Harris Hip Score (MHHS), Short Form–12 (SF-12), and pain on a visual analog scale (VAS) values were evaluated. Outcomes after revision arthroscopic FAI correction were compared with outcomes of a matched cohort who underwent primary arthroscopic FAI correction. Results: A total of 79 patients (85 hips) with a mean age of 29.5 years underwent arthroscopic revision FAI correction (mean follow-up, 26 months). The labrum was debrided (27 hips), repaired (49 hips), or reconstructed (7 hips). Two labrums were stable and required no treatment. The results of revision arthroscopic FAI correction were compared with those of 220 age- and sex-matched patients (237 hips) who underwent primary arthroscopic FAI correction (mean follow-up, 23 months). The mean improvement in outcome scores after revision FAI correction was 17.8 (MHHS), 12.5 (SF-12), and 1.4 (VAS) points compared with 23.4 (MHHS), 19.7 (SF-12), and 4.6 (VAS) points after primary arthroscopic FAI correction. The mean improvement was significantly better in the primary cohort compared with the revision cohort (P < .01 for MHHS, SF-12, and VAS values). Good/excellent results were achieved in 81.7% of the primary cohort and 62.7% of the revision cohort (P < .01). Greater postoperative head-neck offset (P = .024), subspine/anterior inferior iliac spine (AIIS) decompression (P = .014), labral repair/reconstruction (P = .009), and capsular plication (P = .032) were significant predictors for better outcomes after revision surgery. Conclusion: Arthroscopic hip revision surgery for residual FAI yielded significantly improved outcome measures, but these were inferior to those after primary arthroscopic FAI corrective surgery. Improved femoral head-neck offset after cam decompression, identification and treatment of subspine/AIIS impingement, labral preservation/reconstruction, and capsular preservation/plication may be paramount to achieve satisfactory outcomes.

Arthroscopic Single-Row Versus Double-Row Rotator Cuff Repair: A Meta-analysis of the Randomized Clinical Trials

PURPOSE The purpose of this meta-analysis was to critically assess whether there are differences in clinical outcomes between single-row and double-row rotator cuff repair in prospective randomized Level I studies. METHODS Using Medline, Scopus, Scirus, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and the Cochrane Library, as well as a hand search, we searched for randomized prospective trials comparing single-row and double-row rotator cuff repair. The functional outcome scores included the American Shoulder and Elbow Surgeons shoulder scale, the Constant shoulder score, and the University of California, Los Angeles shoulder rating scale. A test of heterogeneity was performed to determine whether there was a difference across the included studies. RESULTS Five studies met our inclusion criteria. A test of heterogeneity showed no difference across these studies. The functional American Shoulder and Elbow Surgeons; Constant; and University of California, Los Angeles outcomes scores showed no difference between single- and double-row rotator cuff repair. CONCLUSIONS We found no significant differences in clinical outcomes between single-row and double-row rotator cuff repair in a meta-analysis of Level I studies. LEVEL OF EVIDENCE Level I, meta-analysis of Level I randomized controlled studies.

Arthrodesis versus ORIF for Lisfranc fractures.

The Lisfranc joints make up the bony structural support of the transverse arch in the midfoot and account for approximately 0.2% of all fractures. Early recognition and treatment of this injury are paramount to preserving normal foot biomechanics and function. Controversy exists regarding the optimal treatment of patients with Lisfranc injuries, particularly when the instability is entirely ligamentous.The authors performed a qualitative, systematic review of the literature to compare the 2 most common procedures for Lisfranc fractures: primary arthrodesis and open reduction and internal fixation (ORIF). Six articles with a total of 193 patients met the inclusion criteria. At 1-year follow-up, the mean American Orthopaedic Foot and Ankle Society score of ORIF patients was 72.5 and of arthrodesis patients was 88.0. Fishers exact test revealed no significant effect of treatment group on the percentage on patients who had an anatomic reduction (P=.319).This study highlights that both procedures yield satisfactory and equivalent results. A slight advantage may exist in performing a primary arthrodesis for Lisfranc joint injuries in terms of clinical outcomes.

Complications Observed Following Labral or Rotator Cuff Repair with Use of Poly-L-Lactic Acid Implants

BACKGROUND A variety of complications associated with the use of poly-L-lactic acid (PLLA) implants, including anchor failure, osteolysis, glenohumeral synovitis, and chondrolysis, have been reported in patients in whom these implants were utilized for labral applications. We report on a large series of patients with complications observed following utilization of PLLA implants to treat either labral or rotator cuff pathology. METHODS Patients who had undergone arthroscopic debridement to address pain and loss of shoulder motion following index labral or rotator cuff repair with PLLA implants were identified retrospectively with use of our research database. A total of forty-four patients in whom macroscopic anchor debris had been observed and/or biopsy samples had been obtained during the debridement were included in the study. Synovial biopsy samples taken at the time of the arthroscopic debridement were available for thirty-eight of the forty-four patients and were analyzed by a board-certified pathologist. Magnetic resonance imaging (MRI) scans acquired after the index procedure and data from the arthroscopic debridement were available for all patients. RESULTS Macroscopic intra-articular anchor debris was observed in >50% of the cases. Giant cell reaction was observed in 84%; the presence of polarizing crystalline material, in 100%; papillary synovitis, in 79%; and arthroscopically documented Outerbridge grade-III or IV chondral damage, in 70%. A significant correlation (rho = 0.36, p = 0.018) was observed between the time elapsed since the index procedure and the degree of chondral damage. A recurrent rotator cuff tear that was larger than the tear documented at the index procedure was observed in all patients whose index procedure included a rotator cuff repair. CONCLUSIONS Clinically important gross, histologic, and MRI-visualized pathology was observed in a large cohort of patients in whom PLLA implants had been utilized to repair lesions of the labrum or rotator cuff.

Functional Outcomes and Return to Sports After Acute Repair, Chronic Repair, and Allograft Reconstruction for Proximal Hamstring Ruptures:

Background: There are limited data regarding outcomes and return to sports after surgery for acute versus chronic proximal hamstring ruptures. Hypothesis: Surgery for chronic proximal hamstring ruptures leads to improved outcomes and return to sports but at a lower level than with acute repair. Proximal hamstring reconstruction with an Achilles allograft for chronic ruptures is successful when direct repair is not possible. Study Design: Cohort study; Level of evidence, 3. Methods: Between 2002 and 2012, a total of 72 patients with a traumatic proximal hamstring rupture (51 acute, 21 chronic) underwent either direct tendon repair with suture anchors (n = 58) or Achilles allograft tendon reconstruction (n = 14). Results from the Single Assessment Numeric Evaluation (SANE) for activities of daily living (ADL) and sports-related activities, Short Form–12 (SF-12), visual analog scale (VAS), and a patient satisfaction questionnaire were obtained. Results: The mean time to surgery in the chronic group was 441.4 days versus 17.8 days in the acute group. At a mean follow-up of 45 months, patients with chronic tears had inferior sports activity scores (70.2% vs 80.3%, respectively; P = .026) and a trend for decreased ADL scores (86.5% vs 93.3%, respectively; P = .085) compared with those with acute tears. Patients with chronic tears, however, reported significant improvements postoperatively for both sports activity scores (30.3% to 70.2%; P < .01) and ADL scores (56.1% to 86.5%; P < .01). Greater than 5 to 6 cm of retraction in the chronic group was predictive of the need for allograft reconstruction (P = .015) and resulted in ADL and sports activity scores equal to those of chronic repair (P = .507 and P = .904, respectively). There were no significant differences between groups in SF-12, VAS, or patient satisfaction outcomes (mean, 85.2% satisfaction overall). Conclusion: Acute repair was superior to chronic surgery with regard to return to sports. Acute and chronic proximal hamstring repair and allograft reconstruction had favorable results for ADL. For low-demand patients or those with medical comorbidities, delayed repair or reconstruction might be considered with an expected 87% return to normal ADL. For patients who desire to return to sports, acute repair is recommended.

Magnetic Resonance Imaging After Arthroscopic Microfracture of Capitellar Osteochondritis Dissecans

Background: Osteochondritis dissecans (OCD) of the capitellum affects young athletes involved in elbow load-bearing activities. Unstable lesions are best managed surgically, although debate remains regarding the optimal method. Arthroscopic treatment allows rapid recovery, but the effect on the articular surface is undetermined. Hypothesis: The clinical outcome after arthroscopic microfracture of stage III/IV capitellum OCD would be successful in terms of return to sport and restoration of function, and there would be some evidence of articular restoration or repair. Study Design: Case series; Level of evidence, 4. Methods: We reviewed records of 10 consecutive adolescent patients (age ≤18 years) with stage III or IV OCD lesions of the capitellum managed with arthroscopic microfracture. The mean age at the time of surgery was 13.9 years (range, 10.8-18.5 years); 7 patients were skeletally immature and 3 were skeletally mature. Pre- and postoperative functional assessment included active range of motion, Mayo Elbow Performance Score (MEPS), and Timmerman/Andrews elbow score. All patients underwent plain radiographic and magnetic resonance imaging (MRI) evaluation at a minimum of 12 months (mean, 27 months; range, 12-49 months) and clinical evaluation at a minimum of 24 months (mean, 42 months; range, 27-54 months) after surgery. Results: The mean range of motion improved in both flexion (135.8°→140.7°, P = .112) and extension (20.4°→–2.2°, P = .005). The mean MEPS (70.5→97, P = .007) and Timmerman/Andrews elbow scores (116.4→193.0, P = .008) improved significantly. magnetic resonance imaging (MRI) evaluation demonstrated an improvement in overall joint congruence and the formation of a reparative articular surface in 8 of 10 (80%) patients. No reoperations or major complications were encountered. Six of 8 patients involved in competitive athletics returned to the same level of participation at an average of 5.1 months. Conclusion: Arthroscopic OCD fragment excision and capitellar microfracture demonstrates good to excellent functional results in short-term follow-up. Follow-up MRI suggests potential for a reparative fibrocartilaginous articular surface. Longer term follow-up is necessary to determine durability of the technique.

Intraoperative and Early Postoperative Complications After Hip Arthroscopic Surgery A Prospective Multicenter Trial Utilizing a Validated Grading Scheme

Background: There is limited literature looking at comprehensive complication rates after arthroscopic hip procedures. Purpose: To prospectively report complication rates for a consecutive series of hips undergoing arthroscopic procedures. Study Design: Case series; Level of evidence, 4. Methods: Over a 29-month period, 1615 consecutive hips in patients with a mean age of 30.5 years underwent arthroscopic hip procedures at 4 institutions. The diagnosis, demographic information, and procedures were recorded, and a validated grading classification for complications of hip joint surgery was utilized prospectively. The cohort with complications was observed postoperatively for a mean of 36.7 months (range, 24-54 months). Results: There were 1487 primary hip arthroscopic procedures and 128 revision hip arthroscopic procedures. Arthroscopic femoroacetabular impingement correction was performed in 1505 hips (93.2%), and 1273 hips (78.8%) underwent a labral repair procedure. The most common event was postoperative lateral femoral cutaneous (LFC) nerve disturbance (16.5%), which persisted beyond 6 months in only 1.6%. The incidence of iatrogenic chondral injuries was 1.2%, iatrogenic labral punctures was 0.9%, superficial portal infections was 1.1%, sensory deficits about the foot was 0.8%, deep venous thrombosis was 0.1%, pulmonary embolism was 0.1%, perineal numbness (pudendal nerve) was 1.4%, heterotopic ossification was 0.8%, and femoral neck stress fractures was 0.1%. There was no iatrogenic instability, avascular necrosis, or extra-abdominal fluid extravasation identified in this cohort. The overall complication rate, not including temporary LFC periportal and thigh numbness (sequela), was 8.3% (134 hips). Overall, a grade 1 complication was seen in 7.2% (117 hips), grade 2 in 0.6% (10 hips), grade 3 in 0.4% (6 hips), and grade 4 in 0.1% (1 hip). There was a significantly higher rate of complications for longer surgical time and traction time (P < .01) and for female patients as compared with male patients (P = .017). Most notably, traction time longer than 60 minutes was associated with a significantly increased complication rate (P < .001). Hips with pudendal nerve neurapraxia had longer traction times than those without (61.5 vs 43.8 minutes, respectively; P < .001). No differences were found between primary versus revision cases (P = .123) or between labral repair versus debridement (P = .209), and body mass index had no effect on the complication rate (P = .103). Conclusion: The overall complication rate after hip arthroscopic surgery at tertiary hip centers was 8.3%, with higher rates reported for longer traction times (>60 minutes) and for female patients. Compared with surgical hip dislocation using the same classification system, the overall rate of complications was similar, but the rate of higher grade complications was lower for arthroscopic hip procedures.