Marcin Kowalczuk

Does Femoroacetabular Impingement Contribute to the Development of Hip Osteoarthritis? A Systematic Review.

Femoroacetabular impingement (FAI) has been linked to specific patterns of cartilage damage. The goal of this systematic review is to answer the following questions: (1) Does FAI contribute to the development and progression of hip osteoarthritis (OA)? (2) If FAI does contribute to the development and progression of hip OA, does CAM-type or pincer-type impingement play a greater role? A search of the electronic databases, MEDLINE and EMBASE, was performed to identify relevant studies performed between January 1, 2000 and January 1, 2015 that link the pathophysiology of OA to FAI. Methodological quality of included studies was assessed by 2 reviewers using the Methodological Index for Non-Randomized Studies criteria. An intraclass correlation coefficient with 95% confidence intervals was used to determine agreement between reviewers on quality scores. Overall 35 studies were identified that met inclusion criteria. Certain morphologic features of CAM-type FAI, particularly elevated alpha angle, do seem to predispose select patients to radiographic progression of hip OA. In comparison with pincer-type impingement, the association between CAM-type impingement and hip OA is better understood. Long-term surgical outcome studies will further delineate the role of FAI in the development and progression of hip OA.

Hip arthroscopy in the setting of hip dysplasia: A systematic review

Objective Hip arthroscopy in the setting of hip dysplasia is controversial in the orthopaedic community, as the outcome literature has been variable and inconclusive. We hypothesise that outcomes of hip arthroscopy may be diminished in the setting of hip dysplasia, but outcomes may be acceptable in milder or borderline cases of hip dysplasia. Methods A systematic search was performed in duplicate for studies investigating the outcome of hip arthroscopy in the setting of hip dysplasia up to July 2015. Study parameters including sample size, definition of dysplasia, outcomes measures, and re-operation rates were obtained. Furthermore, the levels of evidence of studies were collected and quality assessment was performed. Results The systematic review identified 18 studies investigating hip arthroscopy in the setting of hip dysplasia, with 889 included patients. Criteria used by the studies to diagnose hip dysplasia and borderline hip dysplasia included centre edge angle in 72% of studies but the range of angles were quite variable. Although 89% of studies reported improved post-operative outcome scores in the setting of hip dysplasia, revision rates were considerable (14.1%), with 9.6% requiring conversion to total hip arthroplasty. Conclusion The available orthopaedic literature suggests that although improved outcomes are seen in hip arthroscopy in the setting of hip dysplasia, there is a high rate of re-operation and conversion to total hip arthroplasty. Furthermore, the criteria used to define hip dysplasia vary considerably among published studies. Cite this article: M. Yeung, M. Kowalczuk, N. Simunovic, O. R. Ayeni. Hip arthroscopy in the setting of hip dysplasia: A systematic review. Bone Joint Res 2016;5:225–231. DOI: 10.1302/2046-3758.56.2000533.

Trends in reporting of mechanisms and incidence of hip injuries in males playing minor ice hockey in Canada: a cross-sectional study.

Background There has been a noted increase in the diagnosis and reporting of sporting hip injuries and conditions in the medical literature but reporting at the minor hockey level is unknown. The purpose of this study is to investigate the trend of reporting hip injuries in amateur ice hockey players in Canada with a focus on injury type and mechanism. Methods A retrospective review of the Hockey Canada insurance database was performed and data on ice hockey hip injuries reported between January 2005 and June 2011 were collected. The study population included all male hockey players from Peewee (aged 11–12 years) to Senior (aged 20+ years) participating in amateur level competition sanctioned by Hockey Canada. Reported cases of ice hockey hip injuries were analyzed according to age, mechanism of injury, and injury subtype. Annual injury reporting rates were determined and using a linear regression analysis trended to determine the change in ice hockey hip injury reporting rate over time. Results One hundred and six cases of ice hockey-related hip injuries were reported in total. The majority of injuries (75.5%) occurred in players aged 15–20 years playing at the Junior level. Most injuries were caused by a noncontact mechanism (40.6%) and strains were the most common subtype (50.0%). From 2005 to 2010, the number of reported hip injuries increased by 5.31 cases per year and the rate of reported hip injury per 1,000 registered players increased by 0.02 cases annually. Conclusion Reporting of hip injuries in amateur ice hockey players is increasing. A more accurate injury reporting system is critical for future epidemiologic studies to accurately document the rate and mechanism of hip injury in amateur ice hockey players.

Risk Factors for Recurrent Shoulder Instability after Arthroscopic Revision Anterior Stabilization

Objectives: Individuals that fail arthroscopic anterior stabilization of the shoulder represent a unique and challenging patient population. To date, there have been few large studies that have investigated failure rates following arthroscopic revision anterior stabilization (ARAS) for failed primary arthroscopic stabilization. This study aims to determine the risk factors for recurrence of shoulder instability following ARAS. We hypothesized that male gender, younger age, participation in contact sports, significant glenoid and/or humeral bone loss, ligamentous laxity, and worker’s compensation would increase the risk of revision failure. Methods: Patients who underwent ARAS after a failed arthroscopic primary Bankart repair and had a minimum of 2-year follow-up were included in this study. Glenoid and humeral bone loss were quantitatively assessed using pre-operative T1-weighted magnetic resonance arthrograms to determine if the lesions were on- or off-track. Failure was defined as a recurrent dislocation or subluxation. Chi-square test and t-test were used to compare demographical and surgical parameters between failure and non-failure groups. The significance level was set to 0.05. Results: Sixty-five patients [age at revision = 26 years (range, 15 - 57), 44 (68%) male] met the inclusion criteria. The mean follow-up time was 4.7 years (range, 2 - 10.8). Twenty-seven patients (42%) had a failed revision at a mean time of 2.3 years (range, 0.2 - 6.1). Age less than 22 years old, ligamentous laxity, the presence of an off-track lesion, and a concomitant superior labral anterior to posterior were significantly associated with revision failure (p < 0.05) (Table 1). No difference was observed in the size of glenoid defect between failure and non-failure groups (14.1% ± 4.4% vs. 13.7% ± 3.9%, p = 0.762). The width and depth of the Hill-Sachs lesions were not significantly different between groups (width: 15.3 ± 5.1 mm vs. 14.2 ± 4.8 mm, p = 0.432; depth: 4.2 ± 2.3 mm vs. 3.5 ± 1.8 mm, p = 0.244). On multivariate analysis, only the presence of an off-track lesion, age less than 22 years, and ligamentous laxity were independent predictors for recurrent instability (OR = 8.9, p = 0.022; OR = 5.4, p = 0.028; OR = 7.8, p = 0.031, respectively). Conclusion: The failure rate of arthroscopic revision anterior stabilization was 42% with off-track lesions, age less than 22 years, and ligamentous laxity independent risk factors for recurrent instability. While ARAS may be a viable treatment option in the appropriate setting, our study suggests that considerable thought should be exercised before utilizing this approach given the significant number of patients who suffered recurrent instability at greater than 2-years follow-up. For young patients with off-track lesions and/or evidence of ligamentous laxity on physical exam, strong consideration should be given to either an open Bankart repair, a bony augmentation procedure such as a Bristow-Latarjet procedure, or an arthroscopic revision approach with additional augmentation such as a remplissage. Table 1. Parameters Tested Against Arthroscopic Revision Anterior Stabilization Failurea Parameter Revision Failure No Revision Failure OR p-value Age at revision <22y 16/27 (59%) 13/38 (34%) 2.80 0.045 Ligamentous Laxity 10/27 (37%) 5/38(13%) 3.88 0.024 Off-Track Lesion 10/22 (45%) 4/36(11%) 6.67 0.003 SLAP Tear 11/27 (41%) 6/38 (16%) 3.67 0.024 Male Gender 17/27 (63%) 27/38 (71%) 0.69 0.492 BMI> 30 kg/m2 3/24 (13%) 3/27 (11%) 1.14 1.000 Dominant Side Instability 20/27 (74%) 23/38 (61%) 1.86 0.255 Bilateral Anterior Instability 3/27(11%) 7/38 (18%) 0.55 0.503 Workers’ Compensation 3/27 (11%) 9/38 (24%) 0.40 0.331 Athletes 12/27 (44%) 17/38 (45%) 0.99 0.981 Contact sports 9/12 (75%) 12/17(71%) 1.25 1.000 Competitive Level 3/12 (25%) 3/17 (18%) 1.56 0.699 Open Primary Bankart Repair 2/23 (9%) 4/35(11%) 0.74 1.000 Traumatic Repair Failure 7/18 (39%) 16/35(46%) 0.76 0.635 Time from Failure to Revision < 1 y 21/27 (78%) 31/38(82%) 0.79 0.706 Total Number of Anchors ≤ 3 6/20 (30%) 10/30(33%) 0.86 0.804 Number of Anteroinfaior Anchors ≤ 3 14/20(70%) 19/30(63%) 1.35 0.626 Label Tear > 120° 13/20(65%) 20/30(67%) 0.93 0.903 aData expressed as count/number of available cases (%). Competitive level is defined as collegiate or higher. Bold denotes significance. SLAP, superior labrum anterior and posterior; BMI, body mass index; OR, odds ratio.

Return to Play After Complex Knee Injuries: Return to Play After Medial Collateral Ligament Injuries

The medial collateral ligament is the most commonly injured knee ligament in professional footballers. Injuries are the result of a valgus force being imparted onto the knee joint usually after contact with another player or object. Given its extra-articular location, the medial collateral ligament has a high propensity to heal with non-operative treatment, but surgical treatment is warranted in select situations. A high index of suspicion for concurrent injuries to other knee structures is paramount as this significantly impacts treatment decisions. Irrespective of non-operative or operative treatment, structured rehabilitation protocols are critical to the successful management of these injuries. This chapter will provide a comprehensive guide to the diagnosis and management of medial collateral ligament injuries with a focus on safe return to play in football.

Is Lateral Femoral Notch Depth Associated with Rotatory Instability in ACL Deficient Knees: A Quantitative Pivot Shift Analysis

Objectives: Persistent rotatory knee instability after anterior cruciate ligament (ACL) reconstruction is relatively common. While the causes of this persistent instability are multifactorial, bony morphologic characteristics have been proposed to play a role. Therefore, the purpose of this study was to evaluate the relationship between the well-described lateral femoral notch (LFN) depth and quantitative measures of rotatory knee stability. We hypothesized that greater LFN depth would be associated with increased rotatory knee instability. Methods: A consecutive series of patients undergoing primary ACL reconstruction at our university medical center from June 2014 to April 2016 were analyzed. Inclusion criteria included primary ACL tear, no concurrent ligamentous or bony injury requiring operative treatment, no history of previous knee injury or surgery to the ACL-injured extremity, and no history of injury or surgery to the contralateral knee. A standardized pivot shift test was performed by the senior surgeon preoperatively under anesthesia in both knees and quantified using tablet image analysis software and accelerometer sensors as previously described and validated. Lateral knee radiographs and sagittal magnetic resonance images (MRI) of the injured knee were evaluated for depth of the LFN as previously described. A line tangent to the lateral femoral condyle articular surface was drawn across the notch. Notch depth was measured perpendicular from this line to the deepest point of the LFN. Pearson correlation coefficient was used to analyze correlations between continuous variables. Chi-square test was used to analyze relationships between notch depth and presence/absence of medial or lateral meniscus tears. Analyses were performed with SPSS 22.0 and significance was set at a p<0.05. Results: Fifty patients met inclusion criteria and were included in this study (mean age 24 years, range 13-45; 28 females, 22 males). Mean LFN depth as measured via x-ray was 0.8 mm (SD=0.63, n=50) and via MRI was 1.0 mm (SD=0.73, n=47). Twenty-two (44%) patients had a medial meniscus tear and 27 (54%) had a lateral meniscus tear. LFN on x-ray had moderate but significant positive correlations with ipsilateral lateral compartment acceleration (r=0.402, p=0.004) and acceleration side-to-side differences (r=0.407, p=0.003). LFN depth on MRI had moderate but significant positive correlations with ipsilateral lateral compartment acceleration (r=0.334, p=0.022) and acceleration side-to-side differences (r=0.363, p=0.012). LFN depth on x-ray was significantly associated with the presence of a lateral meniscus tear (p=0.014). There were no significant associations between LFN depth (x-ray or MRI) on ipsilateral or contralateral lateral compartment translation, contralateral lateral compartment acceleration, or the presence of medial meniscus tears. Conclusion: The results from this study demonstrated that a well described bony morphologic feature - LFN depth - was correlated with higher lateral compartment acceleration as measured by quantitative pivot shift analysis. Furthermore, greater LFN depth was associated with an increased incidence of lateral meniscus tears, which supports findings from previous studies. Assessment of LFN depth may help clinicians identify patients with greater rotatory instability prior to ACL reconstruction and potentially direct surgical treatment to account for additional rotatory knee instability. Table 1: Mean Quantitative Pivot Shift Values of the Injured and Uninjured Knee Injured Uninjured Side-to-Side Difference Compartment Acceleration (m/s2) 5.14 (SD=0.73) 3.45 (SD=0.95) 1.68 (SD=2.09) Lateral Compartment Translation (mm) 3.67 (SD=2.30) 1.22 (SD=0.75) 2.46 (SD=2.24)