Pall Jonasson

Total dislocation of the hip joint after arthroscopy and ileopsoas tenotomy

AbstractThe hip is a highly stable joint. Non-traumatic dislocation of the hip is extremely uncommon. In this article, we report two cases of non-traumatic hip dislocations following hip arthroscopy. In both cases, capsulotomy and ileopsoas tenotomy had been performed. These cases raise questions about the importance of the natural stabilisers of the hip. Level of evidence V.

Good Results After Hip Arthroscopy for Femoroacetabular Impingement in Top-Level Athletes

Background: Femoroacetabular impingement (FAI) is a common cause of hip pain and dysfunction among athletes. Although arthroscopic surgery is an established treatment option for FAI, there are few studies reporting detailed outcomes using validated outcome measurements specifically designed for young and active athletes. Purpose: To report outcomes 1 year after arthroscopic treatment of FAI in top-level athletes using validated outcome measurements adapted for a young and active population. Study Design: Case series; Level of evidence, 4. Methods: A total of 85 top-level athletes (68 males, 17 females) with a mean (±SD) age of 25 ± 5 years underwent arthroscopic surgery for FAI. All athletes who reported Hip Sports Activity Scale (HSAS) levels 7 or 8 (range, 0-8) prior to symptom onset were included. The cohort was prospectively evaluated using online web-based validated health-related patient-reported outcomes measures (HR-PROMs), including the short version of the International Hip Outcome Tool (iHOT-12), the Copenhagen Hip and Groin Outcome Score (HAGOS; 6 subscales), the EuroQOL 5 dimensions questionnaire (EQ-5D; 2 subscales), the Hip Sports Activity Scale (HSAS) for physical activity level, and a visual analog scale (VAS) for overall hip function. Furthermore, patients reported their overall satisfaction with treatment. Results: The mean follow-up time was 12.3 ± 0.6 months. Preoperative scores compared with those obtained at the 12-month follow-up revealed statistically and clinically significant improvements (P < .0001) for all measured outcomes: iHOT-12 (42 vs 73), VAS for global hip function (52 vs 77), HSAS (4.3 vs 5.7), EQ-5D index (0.60 vs 0.83), EQ-VAS (68 vs 82), and HAGOS subscales (60 vs 83, 50 vs 73, 66 vs 86, 39 vs 75, 27 vs 70, and 34 vs 67). At the 12-month follow-up, 79 athletes (93%) reported that they were satisfied with the outcome of surgery. At follow-up, 62 athletes (73%) had returned to competitive sports (HSAS levels 5-8) and 44 (52%) to their previous HSAS level of activity (HSAS level 7 or 8). Twenty-three athletes (27%) did not return to competitive sports (HSAS level ≤4). Significantly lower levels of return to sports were seen with longer symptom duration (P < .05). Conclusion: Twelve months after surgery, arthroscopic treatment for FAI in top-level athletes resulted in statistically and clinically significant improvements at the group level in all outcome parameters for pain, symptoms, function, physical activity level, quality of life, and general health. One year after surgery, approximately 3 of 4 top-level athletes had returned to sports.

A Swedish hip arthroscopy registry: demographics and development

AbstractPurpose Hip arthroscopy is a rapidly expanding field in orthopaedics. Indications and surgical procedures are increasing. Although several studies report favourable clinical outcomes, further scientific evidence is needed for every aspect of this area. Accordingly, a registry for hip arthroscopy was developed. The purpose of this study is to describe the development of the registry and present its baseline data.MethodsA Scandinavian expert group agreed to use a set of functional outcome scores for the evaluation of hip arthroscopy patients. They were the international hip outcome tool-12, hip and groin outcome score, EQ-5D, hip-specific activity level scale and visual analogue scale for overall hip function. These scores were validated and culturally adapted to Swedish. A database was created for web-based, self-administered questionnaires. Perioperative data were also collected.ResultsThe process leading to the registry is reported. Baseline data from the first 606 patients collected during a 14-month period are presented. The preferred surgical technique is presented. The mean operation time was 69 (SD 14) minutes. In 333 procedures, mixed cam and pincer pathology were addressed, compared with 223 procedures with the treatment of isolated cam pathology. Outpatient surgery was performed in all patients.ConclusionThe baseline data in this study can be used as reference values for future scientific work from this registry. Knowledge of the process leading to the development of the registry could be useful to other researchers planning similar work.Level of evidenceIV.

Outcome after hip arthroscopy for femoroacetabular impingement in 289 patients with minimum 2‐year follow‐up

Femoroacetabular impingement (FAI) is a common cause of hip pain and dysfunction. The purpose of this study was to report outcome 2 years after the arthroscopic treatment of FAI using validated outcome measurements. Two hundred and eighty‐nine patients (males = 190, females = 99) with a mean age of 37 years underwent arthroscopic surgery for FAI. Patients were included consecutively in a hip arthroscopy registry. The cohort was evaluated using online web‐based validated health‐related patient‐reported outcomes measurements, including the iHOT‐12, HAGOS, EQ‐5D, HSAS for physical activity level, VAS for overall hip function and overall satisfaction. The mean follow‐up time was 25.4 months. Pre‐operative scores compared with those obtained at follow‐up revealed statistically and clinically significant improvements (P < 0.05) for all measured outcomes; iHOT‐12 (43 vs 66), VAS for global hip function (50 vs 71), HSAS (2.9 vs 3.6), EQ‐5D index (0.58 vs 0.75), EQ‐VAS (67 vs 75) and HAGOS different subscales (56 vs 76, 51 vs 69, 60 vs 78, 40 vs 65, 29 vs 57, 33 vs 58). At the 2‐year follow‐up, 236 patients (82%) reported they were satisfied with the outcome of surgery. We conclude that arthroscopic treatment for FAI resulted in statistically and clinically significant improvements in outcome parameters.

Outcome of hip arthroscopy in patients with mild to moderate osteoarthritis—A prospective study

Osteoarthritis (OA) of the hip is a common cause of hip pain. The arthroscopic management of patients with femoro-acetabular impingement (FAI) has been reported to yield good outcomes. The purpose of this study was to report on outcome following the arthroscopic treatment of patients with FAI in the presence of mild to moderate OA. Seventy-five patients undergoing arthroscopic surgery for FAI, all with preoperative radiological signs of mild to moderate OA were prospectively included in this study. A 2-year follow-up, using web-based patient-reported outcome measures, including the International Hip Outcome Tool (iHOT-12), Copenhagen Hip and Groin Outcome (HAGOS), EQ-5D, Hip Sports Activity Scale (HSAS) for physical activity level and a visual analogue scale (VAS) for overall hip function, was performed, complemented by a radiographic evaluation. At follow-up (mean 26 months, SD 5), five patients (7%) had undergone total hip arthroplasty, leaving 70 patients for the analysis. Preoperative scores compared with those obtained at the 2-year follow-up revealed significant improvements (P < 0.0001) for all measured outcomes; the iHOT-12 (42 versus 65), VAS for global hip function (48 versus 68), HSAS (2.5 versus 3), EQ5D index (0.62 versus 0.76), EQ VAS (69 versus 75) and different HAGOS subscales (54 versus 72, 47 versus 67, 56 versus 75, 40 versus 61, 33 versus 56, 31 versus 55). At follow-up, 56 (82%) patients reported that they was satisfied with the outcome of surgery. Arthroscopic treatment for patients with FAI in the presence of mild to moderate OA resulted in statistically significant and clinically relevant improvements in outcome measures related to pain, symptoms, function, physical activity level and quality of life in the majority of patients.

Range of Hip Joint Motion Is Correlated With MRI-Verified Cam Deformity in Adolescent Elite Skiers:

Background: Radiologically verified cam-type femoroacetabular impingement (FAI) has been shown to correlate with reduced internal rotation, reduced passive hip flexion, and a positive anterior impingement test. Purpose: To validate how a clinical examination of the hip joint correlates with magnetic resonance imaging (MRI)–verified cam deformity in adolescents. Study Design: Cross-sectional study; Level of evidence, 3. Methods: The sample group consisted of 102 adolescents with the mean age 17.7 ± 1.4 years. The hip joints were examined using MRI for measurements of the presence of cam (α-angle ≥55°) and clinically for range of motion (ROM) in both supine and sitting positions. The participants were divided into a cam and a noncam group based on the results of the MRI examination. Passive hip flexion, internal rotation, anterior impingement, and the FABER (flexion, abduction, and external rotation) test were used to test both hips in the supine position. With the participant sitting, the internal/external rotation of the hip joint was measured in 3 different positions of the pelvis (neutral, maximum anteversion, and retroversion) and lumbar spine (neutral, maximum extension, and flexion). Results: Differences were found between the cam and noncam groups in terms of the anterior impingement test (right, P = .010; left, P = .006), passive supine hip flexion (right: mean, 5°; cam, 117°; noncam, 122° [P = .05]; and left: mean, 8.5°; cam, 116°; noncam, 124.5° [P = .001]), supine internal rotation (right: mean, 4.9°; cam, 24°; noncam, 29° [P = .022]; and left: mean, 4.8°; cam, 26°; noncam, 31° [P = .028]), sitting internal rotation with the pelvis and lumbar spine in neutral (right: mean, 7.95°; cam, 29°; noncam, 37° [P = .001]; and left: mean, 6.5°; cam, 31.5°; noncam, 38° [P = .006]), maximum anteversion of the pelvis and extension of the lumbar spine (right: mean, 5.2°; cam, 20°; noncam, 25° [P = .004]; and left: mean, 5.85°; cam, 20.5; noncam, 26.4° [P = .004]), and maximum retroversion of the pelvis and flexion of the spine (right: mean, 8.4°; cam, 32.5°; noncam, 41° [P = .001]; and left: mean, 6.2°; cam, 36°; noncam, 42.3° [P = .012]). The cam group had reduced ROM compared with the noncam group in all clinical ROM measures. Conclusion: The presence of cam deformity on MRI correlates with reduced internal rotation in the supine and sitting positions, passive supine hip flexion, and the impingement test in adolescents.

The morphologic characteristics and range of motion in the hips of athletes and non-athletes

The cam deformity may cause impingement and probably leads to osteoarthritis of the hip. The aetiology of the cam deformity is incompletely understood. Vigorous training during skeletal growth can lead to the development of cam and symptoms of femoro-acetabular impingement and subsequent osteoarthritis of the hip. The purpose of this study was to compare the radiographic characteristics and range of motion between a group of athletes and a non-athletic control group. Thirty-two male athletes (17 soccer players and 15 ice-hockey players) and thirty non-athletes, used as a control group, were examined clinically and radiographically. Hip range of motion was measured and the FADIR and FABER tests were performed. Standard radiographs of both hips were taken. The centre-edge angle, alpha angle, caput-collum-diaphysis angle, head-neck offset and Tönnis grade were registered. The athletes had a higher Tönnis grade (right P =  0.009, left P =  0.004), more pain on the FADIR test (right P =  0.006, left P =  0.001) and lower ROM in internal (right P =  0.003, left P =  0.025) and external rotation (P < 0.001). A superiorly placed cam deformity (seen on an AP pelvis view) was correlated with reduced external rotation (right P =  0.001, left P =  0.004) and mild osteoarthritis (Tönnis grade 1), (P =  0.015, left P =  0.020), while a more anteriorly placed cam deformity (seen on a modified Lauenstein view) was correlated with reduced internal rotation (right P =  0.029, left P =  0.013). A lower range of motion, more osteoarthritic changes and more pain were found in the athletes than the controls. The control group had more cam deformities than previously reported.

Pelvic Retroversion is Associated with Flat Back and Cam Type Femoro-Acetabular Impingement in Young Elite Skiers

Introduction: The spino-pelvic complex in humans helps to maintain an upright posture, by balancing the spinal sagittal alignment with the hip joints and pelvic girdle. The extent of how the hip joint may influence the spino-pelvic alignment is not fully understood. Hip joint cam femoro-acetabular impingement is a common source of hip and groin disability in young athletes and has been linked to abnormal joint morphology from repetitive loading of the proximal femoral head abutting against the acetabulum. The aim of this study was to compare the radiological parameters of spino-pelvic sagittal alignment and spinal types according to Roussouly’s classification in relation to hip joint cam femoro-acetabular impingement. Methods: The sample group (n=102), mean age (17.7 ± 1.4) years, consisted of elite skiers (n=75) and nonathletes (n=27). Hip joints were examined for increased morphological cam deformity, (alpha angle greater than 55o) with Magnetic Resonance Imaging and standing lateral plain radiographs were taken for measurements of the spinopelvic sagittal alignment. Results: A significant difference was shown in a mixed population (skiers and non-athletes) for an increased Pelvic Tilt angle (13°, SD 10.2) in the presence of morphological hip joint cam deformity compared with participants without cam deformity (8.5°, SD 7.1, P=0.036). Type II Roussouly spines occurred more frequently in skiers in the presence of increased cam (67%) compared with no cam (33%), however, this was not significant (P=0.19). Secondary findings highlighted significant differences shown for the prevalence of cam in a mixed-population for gender; males 60% (n=26) shown to have significantly more cam deformity compared with females 22% (n=10, P=0.001). Similar for height, with taller participants being shown to have significantly more cam deformity >177cm (SD 7.6) compared with no cam deformity <170 cm (SD 7.5, P=0.001). Conclusion: A significant difference was shown with an increased Pelvic Tilt angle for an age-matched mixedgroup of elite skiers and non-athletes in the presence of increased morphological hip joint cam type femoro-acetabular impingement. Moreover, Elite skiers were shown to have an increased distribution of spinal Type II classification according to Roussouly in the presence of an increased frequency of cam femoro-acetabular impingement.

The effect of repetitive flexion and extension fatigue loading on the young porcine lumbar spine, a feasibility study of MRI and histological analyses

BackgroundThe biomechanical mechanisms of failure of FSUs have been studied but the correlation of repetitive flexion and extension loadings to the initial phase of fatigue in young FSUs are still not known. The purpose of the study was to examine the fatigue results of low magnitude repetitive flexion and extension loading on porcine lumbar Functional Spinal Units (FSUs) with Magnetic Resonance Imaging (MRI) and histology.MethodsEight FSUs were subject to repetitive pivot flexion and eight to extension loading by a protocol of 20 000 cycles at 1 Hz with a load of 700 N. All loaded FSUs (N = 16) were examined with MRI and histology post loading. Three FSUs were examined with MRI as controls. Further three FSUs were non loaded histology controls.ResultsFifteen (94%) of the loaded FSUs have decreased MRI signal in the growth zone of the superior vertebra and 12 (75%) in the inferior vertebrae. Fourteen (88%) FSUs have increased signal in the superior vertebral body. Fourteen (88%) FSUs have a reduced signal in all or any endplate. The histology morphometry displayed that the unstained parts of the epiphyseal growth zone were larger among the loaded FSUs (mean 29% vs 4%) and that the chondrocytes in the endplate and growth zones had abnormal structure and deformed extracellular matrix.ConclusionRepetitive loading of young porcine FSUs in both extension and flexion causes concurrent MRI and histological changes in the growth zones and endplates, which could be a first sign of fatigue and an explanation for the disc, apophyseal and growth zone injuries seen among adolescent athletes.

The effect of pelvic tilt and cam on hip range of motion in young elite skiers and nonathletes

Background Current knowledge of the effect of changes in posture and the way cam morphology of the hip joint may affect hip range of motion (ROM) is limited. Purpose To determine the effect of changes in pelvic tilt (PT) on hip ROM and with/without the presence of cam. Study design This was a cross-sectional study. Materials and methods The hip ROM of 87 subjects (n=61 young elite skiers, n=26 nonathletes) was examined using a goniometer, in three different seated postures (flexed, neutral, and extended). The hips of the subjects were further subgrouped into cam and no-cam morphology, based on the magnetic resonance imaging findings in the hips. Results There was a significant correlation between the hip ROM and the seated posture in both extended and flexed postures compared with the neutral posture. There was a significant decrease in internal hip rotation when the subjects sat with an extended posture with maximum anterior PT (p<0.0001). There was a significant increase in internal hip rotation when the subjects sat with a flexed posture with maximum posterior PT (p<0.001). External rotation was significantly decreased in an extended posture with maximum anterior PT (p<0.0001), but there was no difference in flexed posture with maximum posterior PT. The hips with cam morphology had reduced internal hip rotation in all three positions, but they responded to the changes in position in a similar manner to hips without cam morphology. Conclusion Dynamic changes in PT significantly influence hip ROM in young people, independent of cam or no-cam morphology.