Publications by authors named "Ehud Rath"

84 Publications

Clinical Assessment and Treatment Options for Posterior Hip Pain.

Isr Med Assoc J 2021 Aug;23(8):534-540

Department of Orthopedic Surgery, Tel Aviv Sourasky Medical Center, affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Background: Diagnosis and treatment of posterior hip pain has increased due to advancements in clinical, anatomical, biomechanical, and related pathological understandings of the hip. Due to its complexity and close anatomical relationship with many osseous, neurovascular, and musculotendinous structures, posterior hip pain must be appropriately categorized based on its origin. Therefore, it is crucial that clinicians are able to determine whether patient complaints are of extra-articular or intra-articular nature so that they can implement the optimal treatment plan. In the current review article, we discussed posterior hip pain with an emphasis on the main differential diagnoses of deep gluteal syndrome, ischiofemoral impingement, and hamstring tear/hamstring syndrome. For the appropriate diagnosis and etiology of posterior hip pain, a thorough and conclusive clinical history is imperative. Physicians should rule out the possibility of spinal involvement by physical examination and if necessary, by magnetic resonance imaging (MRI). Furthermore, because of the vicinity to other, non-orthopedic structures, an obstetric and gynecologic history, general surgery history, and urologic history should be obtained. Following the collection of patient history clinicians should adhere to an established and efficient order of evaluation starting with standing then to seated, supine, lateral, and prone testing. Imaging assessment of posterior hip pain begins with a standard anterior-posterior pelvic radiograph, in addition to frog-leg lateral. MRI is pivotal for assessing soft tissue-related extra-articular causes of hip in patients with posterior hip pain. Non-surgical treatment is preferred in most cases of deep gluteal syndrome, ischiofemoral impingement, pudendal nerve entrapment, and proximal hamstring pathologies. Surgical treatment is saved as a last resort option in cases of failed non-surgical treatment.
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August 2021

Combined endoscopic and mini-open repair of chronic complete proximal hamstring tendon avulsion: a novel approach and short-term outcomes.

J Hip Preserv Surg 2020 Dec 31;7(4):721-727. Epub 2021 May 31.

Department of Orthopedic Surgery, Affiliated with the Sackler Faculty of Medicine, Tel Aviv Medical Center, Tel Aviv University, Weizmann St 6, Tel Aviv-Yafo 6423906, Israel.

To evaluate the outcome of a novel, combined endoscopic and mini-open repair (CEMR) of a chronic complete retracted proximal hamstring tendon avulsion (PHA). A retrospective case series of a single-surgeon database for all patients, with a minimum of 1-year follow-up, who underwent CEMR between July 2015 and September 2019 was performed. Patients were evaluated for their functional outcome using the Perth Hamstring Assessment Tool (PHAT). At the latest follow-up, patients were evaluated for their muscle strength, subjective satisfaction and post-operative complications. Twelve patients who underwent endoscopic surgery for chronic PHA were identified, of which seven patients underwent CEMR. After exclusion of one patient from the study due to an open claim for health insurance, six patients (five males) with a mean age of 48 years (range 20-61 years) were evaluated. The mean time from injury to surgery was 12 months (range 2-43 months). At a mean follow-up of 28 months (range 12-55 months), the average PHAT score was 73 (range 70-80). The mean subjective activity level percentage improved from 34 (range 20-50) pre-surgery to 81 (range 75-90) post-surgery. The mean strength of the quadriceps, hamstring at 30°, and hamstring at 90° of the operated leg compared to the uninjured leg did not differ significantly. One patient underwent adhesiolysis 1 year after the index procedure for treatment of subcutaneous adhesions. CEMR is a viable and safe option for the treatment of chronic complete proximal hamstring tears, with good to excellent short-term functional outcome. Level of evidence: IV.
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http://dx.doi.org/10.1093/jhps/hnab006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8349587PMC
December 2020

Arthroscopic Repair of Humeral Avulsion of Glenohumeral Ligament Lesions: Outcomes at 2-Year Follow-up.

Orthop J Sports Med 2021 Jun 15;9(6):23259671211004968. Epub 2021 Jul 15.

Division of Orthopaedic Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Background: Humeral avulsion of the glenohumeral ligament (HAGL) is an uncommon condition but a major contributor to shoulder instability and functional decline.

Purpose: To describe the pre- and postoperative HAGL lesion presentations of instability, pain, and functionality and the return-to-sports activities in patients managed arthroscopically for anterior and posterior HAGL lesions.

Study Design: Case series; Level of evidence, 4.

Methods: Data on patients with HAGL lesions treated with arthroscopic repair between 2009 and 2018 were retrospectively retrieved from medical charts, and the patients were interviewed to assess their level of postoperative functionality. The Rowe; Constant; University of California, Los Angeles; Oxford; and pain visual analog scale (VAS) scores were obtained for both pre- and postoperative status. Return-to-sports activities and level of activities after surgery were compared with the preinjury state, and complications, reoperations, and recurrent instability were recorded and evaluated.

Results: There were 23 study patients (12 females and 11 males; mean age, 24 years). The mean follow-up duration was 24.4 months (range, 7-99 months; median, 17 months). In 7 (30.4%) of the patients, HAGL lesions were diagnosed only intraoperatively. A significant improvement was seen in all examined postoperative functional scores and VAS. At the last follow-up visit, 2 patients (8.7%) reported residual instability with no improvement in pain levels and declined any further treatment, and 3 others (13.0%) required revision surgeries for additional shoulder pathologies (reoperations were performed 18-36 months after the index procedure). The remaining 18 patients (78.3%) were free of pain and symptoms. There was a mean of 0.65 coexisting pathologies per patient, mostly superior labral anterior-posterior, Bankart, and rotator cuff lesions.

Conclusion: HAGL lesions are often missed during routine workup in patients with symptoms of instability, and a high level of suspicion is essential during history acquisition, clinical examination, magnetic resonance imaging arthrogram interpretation, and arthroscopic evaluation. Arthroscopic repair yields good pain and stability results; however, some high-level athletes may not return to their preinjury level of activity.
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http://dx.doi.org/10.1177/23259671211004968DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8287368PMC
June 2021

MRI is not reliable in classifying AIIS morphology compared to 3D CT.

Arthroscopy 2021 Jul 7. Epub 2021 Jul 7.

Division of Orthopedic Surgery, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Purpose: The purpose of this study is to determine the reliability of standard magnetic resonance imaging (MRI) evaluation of AIIS morphology compared with three-dimensional (3D) computerized tomography (CT) (reference standard).

Methods: Sixty hips in 30 patients met the inclusion criteria. The images were reviewed and classified by two fellowship-trained orthopedic surgeons. A second imaging viewing session was conducted in the same manner for validation of AIIS evaluation. The agreement and accuracy indices between the two raters were calculated for each imaging modality (inter-rater agreement) as well the agreement across the imaging modality for each rater (intermethod agreement).

Results: The inter-rater agreement for the morphological evaluation of the AIIS for the first session according to 3D CT was .553 (P < .05) and by means of MRI was .0163 (P < .05). The inter-rater agreement for the second session by means of 3D CT was .449 (P < .05) and according to MRI was 0 (P < .05). The inter-method agreement for rater 1 for the first session was .04 (P < 0.05), while the agreement for rater 2 was .016 (P < .05). The intermethod agreement for rater 1 on the second session was .35 (P < 0.05), while that of rater 2 was .297(P < .05). The overall accuracy of MRI compared to 3D CT for rater 1 for the first session was .531, .490, and .959 for types I, II, III respectively and .551, .531, and .980 for the second session for types I, II, and III respectively. The overall accuracy of MRI compared to 3D CT for rater 2 for the first session was .551, .469, and .918 for types I, II, III respectively and .633, .592, and .918 for the second session for types I, II, and III, respectively.

Conclusion: MRI evaluations and subsequent classifications of AIIS morphology demonstrated a poor to slight correlation compared with that of the reference standard of 3D CT.

Level Of Evidence: II: retrospective diagnostic study.
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http://dx.doi.org/10.1016/j.arthro.2021.06.007DOI Listing
July 2021

Cryo-surgery for symptomatic extra-abdominal desmoids. A proof of concept study.

J Surg Oncol 2021 Sep 27;124(4):627-634. Epub 2021 May 27.

Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Background And Objective: Extra abdominal desmoid tumors are rare, highly aggressive, and invasive benign soft tissue tumors. Current treatment modalities show high levels of recurrence and comorbidities. Cryo-surgery as an alternative was subsequently investigated.

Methods: In this retrospective, single center study 11 patients showing symptomatic tumors were treated with individualized cryo-surgery. Treatment protocol included preoperative planning using computer rendered 3D models, intraoperative navigation and execution using cone beam guidance, and postoperative magnetic resonance imaging image analysis using a gaussian mixture model software. Subjective outcomes were reported using Short Form Health Survey (SF-36) questionnaires.

Results: Sixteen ablations were performed, each demonstrating a complete match with the determined preoperative plan and model. A total of 9/11 (82%) of patients showed improvements in symptoms and a reduction in tumor volume while 2/11 (18%) did not. Average reduction in tumor volume and viable segments were 36.7% (p = 0.0397) and 63.3% (p = 0.0477), respectively. Mild complications according to the SIR Adverse Event Classification Guidelines were experienced in 3/16 (19%) ablations. SF-36 scores showed a statistically significant improvement (p = 0.0194) in the mental health category and a nonsignificant (p = 0.8071) improvement in the physical health category.

Conclusion: Cryo-surgery using the three-phase protocol as described may improve the overall outcome of future ablation procedures.
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http://dx.doi.org/10.1002/jso.26528DOI Listing
September 2021

The Efficacy of Labral Reconstruction: A Systematic Review.

Orthop J Sports Med 2021 Feb 16;9(2):2325967120977088. Epub 2021 Feb 16.

Tel-Aviv University, Tel-Aviv, Israel.

Background: With a greater understanding of the importance of the acetabular labrum in the function of the hip, labral repair is preferred over debridement. However, in some scenarios, preservation or repair of the labrum is not possible, and labral reconstruction procedures have been growing in popularity as an alternative to labral resection.

Purpose: To provide an up-to-date analysis of the literature to determine the overall efficacy of labral reconstruction when compared with labral repair or resection.

Study Design: Systematic review; Level of evidence, 3.

Methods: PubMed, Embase, and MEDLINE databases were searched for literature regarding labral reconstruction in the hip before July 21, 2020. The results were screened and evaluated by 2 reviewers, and a third reviewer resolved any discrepancies. The final studies were evaluated using the MINORS (Methodological Index for Non-randomized Studies) score.

Results: There were 7 comparative studies that fit the inclusion criteria, with 228 hips from 197 patients. The mean follow-up was 34.6 months, and the mean age of all patients was 38.34 years. There were slightly more female patients than male patients (105 vs 92). Arthroscopic reconstruction was performed in 86% of studies (6/7); open surgical techniques, in 14% (1/7). A variety of grafts was used in the reconstructions. The indications for labral reconstruction and outcome measures varied in these publications. Nine patients were lost follow-up, and 6 patients converted to total hip replacement postlabral reconstruction. The assessment of these comparative studies illustrated statistically equivalent results between labral reconstruction and labral repair. Comparisons of labral reconstruction with labral resection also showed statistically equivalent postoperative patient-reported outcome scores; however, the rates of conversion to total hip arthroplasty were significantly higher in the population undergoing resection.

Conclusion: The review of current available comparative literature, which consists entirely of level 3 studies, suggests that labral reconstruction does improve postoperative outcomes but does not demonstrate superiority over repair. There may, however, be benefit to performing labral reconstruction over resection owing to the higher rate of conversion to total hip arthroplasty in the labral resection group.
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http://dx.doi.org/10.1177/2325967120977088DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7894601PMC
February 2021

Midterm Outcomes and Satisfaction After Hip Arthroscopy Are Associated With Postoperative Rehabilitation Factors.

Orthop J Sports Med 2021 Jan 28;9(1):2325967120981888. Epub 2021 Jan 28.

Division of Orthopedic Surgery, Tel Aviv Medical Center Affiliated to Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Background: Arthroscopic hip-preservation surgery is commonly performed to address nonarthritic sources of hip pain in young, active individuals. However, there is little evidence to support postoperative rehabilitation protocols, including the most appropriate frequency and length of individual formal physical therapy sessions. There is also a lack of information to look at patients' perceived value of their home program/self-practice in relation to outcomes.

Purpose: To investigate postoperative rehabilitation factors after hip arthroscopy related to formal physical therapy and home program/self-practice and their correlation with patient outcomes and satisfaction.

Study Design: Cohort study; Level of evidence, 3.

Methods: A total of 125 patients who underwent hip arthroscopy for femoroacetabular impingement syndrome and a labral tear (75 men) were included. The mean age was 34.6 ± 14.4 years, and the mean follow-up time was 4.9 ± 1.6 years. Hip Outcome Score-Activities of Daily Living subscale (HOS-ADL) scores, overall satisfaction scores, and factors related to supervised physical therapy and home program/self-practice were collected. Correlations between continuous variables and differences in the length of individual formal physical therapy and patients' rating of the importance of their home program/self-practice between those who would and those who would not undergo surgery again were assessed.

Results: The frequency and length of individual formal physical therapy sessions were significantly correlated with postoperative HOS-ADL scores ( = 0.22, = .014; and = 0.24, = .007, respectively) and level of satisfaction ( = 0.24, = .007; and = 0.21, = .02, respectively). The length of individual formal physical therapy sessions was significantly greater in those who noted they would undergo surgery again (35.3 vs 26.3; = .033). A significant correlation was identified between the rating of the importance of their home program/self-practice and postoperative HOS-ADL scores ( = 0.29; = .001) and their level of satisfaction ( = 0.23; = .009). There was a significant difference in the rating of the importance of their home program/self-practice between those who would undergo surgery again and those who would not (8.9 vs 7.8; = .007).

Conclusion: Surgeons and physical therapists should emphasize the value of home program/self-practice when it comes to outcomes and may want to encourage their patients to participate in more frequent, longer, formal physical therapy sessions.
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http://dx.doi.org/10.1177/2325967120981888DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7869163PMC
January 2021

Sonographic evaluation of anterior inferior iliac spine morphology demonstrates excellent accuracy when compared to false profile view.

Knee Surg Sports Traumatol Arthrosc 2021 May 8;29(5):1413-1419. Epub 2020 Oct 8.

Division of Orthopedic Surgery, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, 6 Weizman Street, 64239, Tel Aviv, Israel.

Purpose: To compare ultrasound examination to false profile radiographs in identification and classification of AIIS morphology. The study hypothesis stated that sonographic imaging of the AIIS correlates well to AIIS morphology seen on false profile radiographs.

Methods: Fifty-three hips in 30 consecutive patients met the inclusion criteria. A single, fellowship trained, orthopedic surgeon performed an ultrasound on all of the patients to evaluate the AIIS morphology. The patients underwent standing false profile radiographs. The US and radiographic images were independently reviewed and classified according to Hetsroni classification of AIIS morphology by two senior, fellowship trained, orthopedic surgeons. Agreement between the two raters was calculated for each imaging modality (inter-rater agreement) as well as the agreement between the rating in each modality by the same rater ("inter-method" agreement).

Results:  The agreement between the raters (inter-rater agreement) for morphologic evaluation of the AIIS by means of FP view was 88.8% (p < 0.001) and that by means of US was 81.5%(p < 0.001). The overall accuracy of the US compared to the FP view was 92.3% (48/52) for both rater 1 and 2.

Conclusion:  This study showed near-perfect agreement in analyzing the morphology of the AIIS in a group of patients with hip pathology. Office sonographic evaluation of the AIIS is reliable and, therefore, may be routinely utilized in the clinic setting avoiding unnecessary radiation exposure to the patient.

Level Of Evidence: Level II.
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http://dx.doi.org/10.1007/s00167-020-06304-xDOI Listing
May 2021

Preemptive analgesia in hip arthroscopy: intra-articular bupivacaine does not improve pain control after preoperative peri-acetabular blockade.

Hip Int 2020 Aug 31:1120700020950247. Epub 2020 Aug 31.

Department of Orthopaedic Surgery, Tel Aviv Sourasky Medical Center, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Introduction: Literature addressing postoperative pain management after hip arthroscopy is relatively scarce. This study aimed to assess if there was added analgesic benefit associated with postoperative intra-articular bupivacaine blockade for patients who received preoperative peri-acetabular blockade for hip arthroscopy procedures.

Methods: 52 patients were included in this comparative cohort study. Group 1 consisted of 20 patients who received preoperative peri-acetabular blockade and postoperative intra-articular blockade. The control group (Group 2), consisted of 32 patients who received only preoperative peri-acetabular blockade. Postoperative pain was recorded via visual analogue scale (VAS) pain scores, analgesic consumption, and pain diaries for 2 weeks postoperatively.

Results: Postoperative VAS pain scores were significantly lower in the experimental group at the 30-minute recovery room assessment (VAS scores Group 1: 1.1; Group 2: 3.00, = 0.034). Other than the 30-minute recovery room assessment, VAS pain scores, narcotic medication consumption, and non-narcotic analgesic consumption did not differ between the 2 groups at any time point in the study period.

Conclusions: This study did not demonstrate significant clinical benefit for patients who receive postoperative intra-articular blockade in addition to preoperative peri-acetabular blockade with bupivacaine 0.5%. We recommend the use of preoperative peri-acetabular bupivacaine blockade without intra-articular blockade postoperatively for pain control in the setting of hip arthroscopy surgery.
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http://dx.doi.org/10.1177/1120700020950247DOI Listing
August 2020

Editorial Commentary: Intra-abdominal Fluid Extravasation During Hip Arthroscopy-Although Rare, Don't Be Complacent.

Authors:
Eyal Amar Ehud Rath

Arthroscopy 2020 04;36(4):1061-1062

Tel Aviv University (E.R.).

Hip arthroscopy has become the gold standard for the treatment of femoroacetabular impingement syndrome. Intra-abdominal fluid extravasation is the most commonly reported major complication, with variable rates depending on the measurement method. Little is known about the evolution of the fluid extravasation throughout the surgical procedure, and the risk factors for this complication are in need of validation. We recommend performing mitigating actions including keeping the surgical time to a minimum, monitoring core body temperature, performing psoas release (if planned) last, and keeping inflow fluid pressure as low as possible.
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http://dx.doi.org/10.1016/j.arthro.2020.01.009DOI Listing
April 2020

Postoperative Weightbearing Protocols After Arthroscopic Surgery for Femoroacetabular Impingement Does Not Affect Patient Outcome: A Comparative Study With Minimum 2-Year Follow-up.

Arthroscopy 2020 01;36(1):159-164

Orthopedic Division, Souraski Medical Center, Tel-Aviv, Israel.

Purpose: To evaluate the effects of immediate postoperative weightbearing protocols after hip arthroscopy for femoroacetabular impingement (FAI) with minimum 2-year follow-up, as measured by patient-reported outcome measures and satisfaction rates.

Methods: Between January 2011 and June 2016, patients undergoing hip arthroscopy for FAI and labral tears were reviewed. Exclusion criteria was previous hip pathology or arthroscopy, active Workers' Compensation claims, and concomitant pathologies impeding weightbearing. Patients who were operated on before September 2013 were treated with 3 weeks of postoperative non-weightbearing (NWB), with weightbearing as tolerated (WBAT) thereafter. From October 2013, patients were allowed immediate postoperative WBAT.

Results: A total of 351 hip arthroscopic surgeries were performed; 133 of these patients met the inclusion criteria. Of the 133 included patients, 69 were in the NWB group and 64 were in the WBAT group. No differences were found in terms of sex (P = .603) or age (P = .241). No differences were found in postoperative scores (the Modified Harris Hip Score was 84.5 [range 79-89] for NWB vs 86.7 [78-89] for WBAT [P = .0.523], and the Hip Outcome Score was 83.1 [78-88] vs 88.4 [80-90], respectively; P = .130). Subjective rates of improvement, satisfaction score and the will to undergo surgery again did not differ between the groups (P = .674, P = .882, P = .730). The rate of subjects who met or exceeded the MCID in the NWB and WBAT groups was 82.6% and 81.2% for the Modified Harris Hip Score (P = .838) and 79.7% and 82.8% for the Hip Outcome Score (P = .647). There were no reported complications. Limitations include the possibility of the study being underpowered.

Conclusions: After a 2-year minimum follow-up, patient-reported outcome measures and satisfactory rates with immediate weightbearing after hip arthroscopy for isolated FAI syndrome and labral tears do not differ significantly from results after strict NWB rehabilitation protocols. Revising weightbearing restrictions may allow for a more comfortable rehabilitation process after arthroscopic hip surgery for FAI and labral repair.

Level Of Evidence: Level 3 - case-control study.
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http://dx.doi.org/10.1016/j.arthro.2019.08.012DOI Listing
January 2020

A combined endoscopic and open surgical approach for chronic retracted proximal hamstring avulsion.

J Hip Preserv Surg 2019 Aug 11;6(3):284-288. Epub 2019 Oct 11.

Department of Orthopaedic Surgery, Tel Aviv Medical Center, Sackler Faculty of Medicine and Tel Aviv University, Weizmann St 6, Tel Aviv 6423906 Israel.

Proximal hamstring avulsion is an uncommon injury which usually requires surgical intervention. When possible, primary surgical fixation is recommended. In chronic hamstring avulsion with significant retraction of the tendon, hamstring reconstructions using an autograft or allograft are required in order to bridge the gap. This is mainly performed using an open surgical technique. We describe a combined endoscopic and open surgical approach to hamstring reconstruction surgery.
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http://dx.doi.org/10.1093/jhps/hnz037DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6874769PMC
August 2019

Does capsular closure influence patient-reported outcomes in hip arthroscopy for femoroacetabular impingement and labral tear?

J Hip Preserv Surg 2019 Aug 4;6(3):199-206. Epub 2019 Jul 4.

Department of Orthopaedic Surgery, Tel Aviv Medical Center, Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Weizmann St 6, Tel Aviv-Yafo, Israel.

Capsulotomy is necessary to facilitate instrument manoeuvrability within the joint capsule in many arthroscopic hip surgical procedures. In cases where a clear indication for capsular closure does not exist, surgeon's preference and experience often determines capsular management. The purpose of this study was to assess the influence of capsular closure on clinical outcome scores and satisfaction in patients who underwent hip arthroscopy surgery for femoroacetabular impingement (FAI) and labral tear. Data were prospectively collected and retrospectively analysed for hip arthroscopy surgeries with a minimum 2 years follow-up. Patients with developmental dysplasia of the hip, previous back or hip surgeries, and degenerative changes to this hip and secondary gains were excluded. Demographic data, intraoperative findings and patient-reported outcome scores were recorded, including the Modified Harris Hip Score (MHHS) and Hip Outcome Score (HOS). A total of 29 and 35 patients were included in the non-closure and closure groups, respectively. The mean follow-up time was over 3 years for both groups. The mean pre-operative and post-operative HOS scores and MHHS scores did not significantly differ between groups (pre-operative HOS: 65.6 and 66.3, = 0.898; post-operative HOS: 85.4 and 87.2, = 0.718; pre-operative MHHS: 63.2 and 58.4, = 0.223; post-operative MHHS: 85.7 and 88.7, = 0.510). Overall patient satisfaction did not differ significantly between groups (non-closure 86.3%, closure group 88.6%; = 0.672). Capsular closure did not significantly influence satisfaction or clinical outcome scores in patients who underwent arthroscopic hip surgery for FAI or labral tear.
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http://dx.doi.org/10.1093/jhps/hnz025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6874774PMC
August 2019

The anatomical properties of the indirect head of the rectus femoris tendon: a cadaveric study with clinical significance for labral reconstruction surgery.

Arch Orthop Trauma Surg 2020 Jan 16;140(1):85-92. Epub 2019 Nov 16.

Tel Aviv Medical Center, Department of Orthopaedic Surgery, Affiliated With the Sackler Faculty of Medicine and Tel Aviv University, Weizmann St 6, 6423906, Tel Aviv-Yafo, Israel.

Background: Acetabular labral tear is a common pathology. In some clinical situations, primary labral repair may not be possible and labral reconstruction is indicated.

Purpose And Clinical Relevance: Describe the anatomy of the indirect head of the rectus femoris (IHRF) tendon with clinical application in arthroscopic labral reconstruction surgery.

Methods: Twenty-six cadaver hips were dissected. Thirteen measurements, each with clinical relevance to arthroscopic labral reconstruction using an IHRF tendon graft were taken on each hip. All measurements were taken in triplicate. Mean values, standard deviations and intra-observer reliability were calculated.

Results: The mean footprint of the direct head of the rectus femoris tendon was 10.6 mm × 19.6 mm. The width and thickness at the confluence of both heads were 10.9 mm and 6.9 mm, respectively. The mean total length of the footprint and "free portion" of the IHRF was 55.3 mm, the mean cranial to caudal footprint measured at the 12 o'clock, 1 o'clock, and 2 o'clock positions were 22.3 mm. The mean length of the Indirect Head footprint alone was 38.1 mm. The mean length of IHRF tendon suitable for grafting was 46.1 mm and the mean number of clock face sectors covered by this graft was 3.3 clock face sectors. Intra-observer reliability was ≥ 0.90 for all recorded measurements. The origin of the IHRF on the acetabulum fans out posteriorly, becoming thinner and wider as the origin travels posteriorly. The tendon footprint is firmly attached on the lateral wall of the ilium and becomes a free tendon overlying the acetabular bone as it travels anteriorly and distally towards its muscular attachment.

Conclusion: The IHRF tendon is in an ideal location for harvesting and contains the appropriate thickness, length and triangular architecture to serve as a safe and local graft source for acetabular labral reconstruction surgery.
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http://dx.doi.org/10.1007/s00402-019-03293-6DOI Listing
January 2020

Does hip morphology correlate with proximal femoral fracture type?

Hip Int 2020 Sep 11;30(5):629-634. Epub 2019 Jul 11.

Department of Orthopaedic Surgery, Tel Aviv Sourasky Medical Centre, Israel.

Purpose: To determine if boney morphology influences the anatomic location of hip fractures in elderly patients.

Methods: All patients with hip fractures between 2008 and 2012 who had hip radiographs taken prior to the fracture were reviewed. Fractures were classified as intracapsular or extracapsular and hip morphology was measured on the pre-fracture x-rays. Hip morphology was determined by alpha angle, lateral central edge angle, acetabular index, neck-shaft angle, hip axis length, femoral neck diameter, Tönnis classification for hip osteoarthritis (OA) and the presence of a crossover sign.

Results: 148 subjects (78.4% female, age 83.5 years) with proximal femur fractures were included. 44 patients (29.7%) had intracapsular fractures and 104 (70.3%) had extracapsular fractures. 48% of patients had previous hip fractures on the contralateral side and 74.6% had the same type of fracture bilaterally. The rates of bilateral intracapsular and extracapsular fractures were similar (33.7% vs. 40.9% respectively, 0.39). Extracapsular fractures had a statically significant higher neck-shaft angle, a shorter hip axis length, a narrower femoral neck diameter and a higher grade of Tönnis classification of OA ( 0.04, 0.046, 0.03, 0.02 respectively). Acetabular coverage and the proximal femoral head-neck junction, which were evaluated by lateral centre-edge angle (LCEA), acetabular index and the presence of a crossover sign, did not correlate with fracture type. The alpha angle > 40° had a statistically significant higher likelihood for extracapsular fractures ( 0.013).

Conclusions: Acetabular coverage and proximal femoral head-neck junction morphology, were found to partially correlate with the location of hip fractures and do not fully elucidate fracture type susceptibility.
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http://dx.doi.org/10.1177/1120700019859275DOI Listing
September 2020

Chondral lesions in the hip: a review of relevant anatomy, imaging and treatment modalities.

J Hip Preserv Surg 2019 Jan 16;6(1):3-15. Epub 2019 Apr 16.

Division of Orthopaedic Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

The diagnosis and treatment of chondral lesions in the hip is an ongoing challenge in orthopedics. Chondral lesions are common and several classification systems exist to classify them based on severity, location, radiographic parameters, and potential treatment options. When working up a patient with a potential hip chondral lesion, a complete history, thorough physical exam, and ancillary imaging are necessary. The physical exam is performed with the patient in standing, supine, prone, and lateral positions. Plain film radiographs are indicated as the first line of imaging; however, magnetic resonance arthrogram is currently the gold standard modality for the diagnosis of chondral lesions outside of diagnostic arthroscopy. Multiple treatment modalities to address chondral lesions in the hip exist and new treatment modalities continue to be developed. Currently, chondroplasty, microfracture, cartilage transplants (osteochondral autograft transfer, mosaicplasty, Osteochondral allograft transplantation) and incorporation of orthobiologics (Autologous chondrocyte implantation, Autologous matrix-induced chondrogenesis, Mononuclear concentrate in platelet-rich plasma) are some techniques that have been successfully applied to address chondral pathology in the hip. Further refinement of these modalities and research in novel techniques continues to advance a surgeon's ability to address chondral lesions in the hip joint.
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http://dx.doi.org/10.1093/jhps/hnz002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6501440PMC
January 2019

Which patients are less likely to improve after arthroscopic rotator cuff repair?

Acta Orthop Traumatol Turc 2019 Sep 8;53(5):356-359. Epub 2019 Mar 8.

Orthopedic Department, Sackler Faculty of Medicine, Tel-Aviv University, Israel; Orthopedic Department, Hasharon Hospital, Rabin Medical Center, Petach-Tikva, Israel.

Objective: The aim of this study was to evaluate which specific factors influence the improvement in function and to estimate the time to obtain pain relief following arthroscopic rotator cuff repair.

Methods: A total of 97 patients (57 men and 40 women; mean age: 55.5 ± 9.3 years) who had arthroscopic rotator cuff repair between 2013 and 2016 were included into the study. Multivariable stepwise analysis included preoperative variables (age, gender, body mass index, comorbidities, occupation and participation in sports, Oxford shoulder score at baseline, preceding injury and duration of preoperative symptoms) and arthroscopic findings (size of rotator cuff tear, pathology of the long head of the biceps and cartilage lesions). The change in the Oxford shoulder score at the last follow-up was modeled as a function of the above predictor variables. The time to regain a visual analogue scale (VAS) under two points following surgery was considered the time to regain substantial pain relief.

Results: The mean follow-up time was 33.2 ± 14.4 months. Twenty three patients had partial thickness and seventy four had full thickness supraspinatus tears. In third of the patients the tears were defined as large full thickness. At the last follow-up the mean Oxford shoulder score improved from 13.8 ± 4.8 to 42.1 ± 7.2 points (P < 0.001). The mean VAS improved from a preoperative score of 6.7 ± 1.3 points to 1.5 ± 0.6 points postoperatively (P < 0.001) and 80 (83%) patients declared they were satisfied to have had the operation. The mean time interval for substantial pain relief was 4.9 ± 3.6 months. Patients with higher preoperative Oxford shoulder score and larger tear size were correlated with lesser improvement in Oxford shoulder score (R = 0.5, P = 0.001).

Conclusion: Arthroscopic rotator cuff repair improved pain and function at an average follow-up of three years. A substantial pain relief was regained within five months from surgery. Larger rotator cuff tear size and more favorable preoperative function were predictors of worse postoperative function.

Level Of Evidence: Level IV, Therapeutic study.
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http://dx.doi.org/10.1016/j.aott.2019.02.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6819785PMC
September 2019

Simultaneous pigmented villonodular synovitis and synovial chondromatosis of the hip: case report.

J Hip Preserv Surg 2018 Dec 31;5(4):443-447. Epub 2018 Oct 31.

Minimal Invasive Orthopedics Unit, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel.

This report presents a case of a 37-year-old female with a history of hip pain. Magnetic resonance arthrography revealed loose bodies within the joint and synovial hypertrophy indicative of synovial chondromatosis (SC). Hip arthroscopy revealed free chondral bodies and focal villonodular synovial proliferation. The focal synovial proliferation was excised, a total synovectomy performed, and all cartilaginous free bodies removed. A post-operative histological examination of the removed nodular mass and synovium yielded evidence of both SC and pigmented villonodular synovitis (PVNS). A 1-year post-operative clinical examination showed marked clinical improvement and no signs of recurrence on MR images. Despite the clinical similarities, PVNS and SC are two distinct conditions that, to our knowledge, have never been reported as simultaneously occurring in a hip joint. The simultaneous presence of both pathologies may suggest a common origin of synovial metaplasia.
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http://dx.doi.org/10.1093/jhps/hny034DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6328742PMC
December 2018

Graft choices for acetabular labral reconstruction.

J Hip Preserv Surg 2018 Dec 27;5(4):329-338. Epub 2018 Sep 27.

Department of Orthopaedic Surgery, Tel Aviv Medical Center, Sackler Faculty of Medicine and Tel Aviv University, Weizmann St 6, Tel Aviv-Yafo, Israel.

The acetabular labrum plays a key role in maintaining hip function and minimizing hip degeneration. Once thought to be a rare pathology, advances in imaging have led to an increase in the number of diagnosed labral tears. While still a relatively new field, labral reconstruction surgery is an option for tears that are irreparable or require revision after primary repair. Various autograft and allograft options exist when considering labral reconstruction. The first labral reconstruction surgery was described using the ligamentum teres capitis, and has since evolved, incorporating more graft sources and reconstructive techniques. The purpose of this review is to assess and describe the different graft sources and technique currently implemented by hip surgeons. Moreover, this review attempts to determine whether a single labral reconstructive graft type is superior to the others. Techniques using the Ligamentum teres capitis autograft, ITB autograft, gracilis autograft, quadriceps tendon autograft, capsular autograft, semitendinosus allograft, indirect head of the rectus femoris autograft, peroneus brevis tendon allograft and Tensor fascia lata allograft were found. Scoring was available on 5 out of the 9 graft types. The advantages and disadvantages of each graft source is described as a comparative tool. No single graft type has shown increased benefit in acetabular labral reconstruction. The lack of uniform outcome measurements hinders comparison of reported outcomes. Surgeons should make an informed decision based on their experience as well as the patient's history and needs when choosing which graft type would be best suited for their patients.
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http://dx.doi.org/10.1093/jhps/hny033DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6328747PMC
December 2018

CORR Insights®: When Do Patients Return to Previous Daily Activity After Arthroscopic Rotator Cuff Repair?

Authors:
Ehud Rath

Clin Orthop Relat Res 2019 02;477(2):414-415

E. Rath, Orthopedic Division, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.

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http://dx.doi.org/10.1097/CORR.0000000000000588DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6370088PMC
February 2019

The detached stump of the torn anterior cruciate ligament adheres to the femoral notch wall and then to the posterior cruciate ligament within 6 months from injury.

Knee Surg Sports Traumatol Arthrosc 2019 Aug 14;27(8):2653-2658. Epub 2018 Nov 14.

Orthopedic Department, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.

Purpose: To evaluate the progressive changes in the morphology of traumatic ruptures of the anterior cruciate ligament (ACL) over time. A secondary objective was evaluating their correlation with meniscal tears or chondral lesions.

Methods: The study included one hundred and one patients who underwent ACL reconstruction surgery of the knee after a definite date of injury. The torn ACL remnant morphological pattern was assessed and classified during arthroscopy. A correlation analysis was performed between the pathological features of the remnant and the time length from injury. In addition, correlation between ACL remnant subtypes and meniscal tears or chondral lesions was evaluated.

Results: At surgery there were four distinct ACL tear morphological patterns that were correlated to the time span from injury (r = 0.61, p < 0.001) and ended with scarring of the femoral remnant to the posterior cruciate ligament. The early pattern was noticed within median time of 2.6 months from injury and appeared as a separate stump with no scar tissue. The following two patterns appeared within 6 months from injury and were characterized by adhesion of scar tissue to different locations in the femoral notch. The last morphological pattern appeared as adherence of the ACL stump to the posterior cruciate ligament. This pattern was seen in some patients within 6 months from injury but was the dominant pattern later on and was also correlated with meniscal tears.

Conclusions: During the first 3 months from injury the gross morphological features of the torn ACL remnant showed no scar. This phase was followed by scarring of the femoral remnant at first to the femoral notch, and eventually to the posterior cruciate ligament within 6 months from injury and later on. Therefore, further research on the healing potential of the human ACL stump and its biological environment should be focused on the first 3 months from injury.

Study Design: Case series; Level of evidence, 4.
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http://dx.doi.org/10.1007/s00167-018-5293-8DOI Listing
August 2019

Hip arthroscopy as a treatment for obturator neuropathy secondary to intra-pelvic ganglion: a case report.

J Hip Preserv Surg 2018 Aug 31;5(3):319-322. Epub 2018 Aug 31.

Sackler School of Medicine.

The most common types of cystic lesions around the hip joint are synovial or ganglion cysts. In rare cases, the cysts can compress adjacent structures and cause symptoms to arise. Obturator neuropathy secondary to a hip ganglion cyst is a rare phenomenon, with scarce reports on suggested treatment options. Hip arthroscopy is a potential minimally invasive treatment that has yet to be described in such cases. We present a 52-year-old male suffering from obturator neuropathy caused by an intra-pelvic ganglion cyst arising from the hip joint. Hip arthroscopy was performed for decompression of the cyst and dilation of the stalk opening. Six-month post-operative follow-up showed resolution of symptoms and complete elimination of the cyst on magnetic resonance imaging.
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http://dx.doi.org/10.1093/jhps/hny023DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6206690PMC
August 2018

Relatively High Complication and Revision Rates of the Mayo Metaphysical Conservative Femoral Stem in Young Patients.

Orthopedics 2018 Jul 9;41(4):e516-e522. Epub 2018 May 9.

The Mayo metaphysical conservative femoral stem (Zimmer, Warsaw, Indiana) is a wedge-shaped implant designed to transfer loads proximally, reduce femoral destruction, and enable the preservation of bone stock in the proximal femur. Thus, it is a potentially preferred prosthesis for active, non-elderly patients who may require additional future surgeries. This retrospective case study analyzed the outcomes of consecutive patients who underwent total hip replacements with this stem between May 2001 and February 2013. All patients underwent clinical assessment, radiological evaluation for the presence and development of radiolucent lines, and functional assessment (numerical analog scale, Harris hip score, and Short Form-12 questionnaire). Ninety-five hips (79 patients) were available for analysis. The patients' mean age was 43 years (range, 18-64 years), and the mean follow-up was 97 months (range, 26.9-166 months). The postoperative clinical assessments and functional assessments revealed significant improvements. Sixteen patients (20.3%) had 18 orthopedic complications, the most common of which were an intraoperative femoral fracture and implant dislocation requiring revision surgeries in 10 hips (10.5%). Radiological analysis revealed evidence of femoral remodeling in 64 (67.4%) implants, spot welds (neocortex) in 35 (36.8%), and osteolysis in 3 (3.2%). These results suggest that the conservative hip femoral implant has an unacceptable complication rate for non-elderly patients. [Orthopedics. 2018; 41(4):e516-e522.].
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http://dx.doi.org/10.3928/01477447-20180503-01DOI Listing
July 2018

Subspinal impingement: clinical outcomes of arthroscopic decompression with one year minimum follow up.

Knee Surg Sports Traumatol Arthrosc 2020 Sep 2;28(9):2756-2762. Epub 2018 Apr 2.

Sourasky Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.

Purpose: This study was designed to (1) evaluate the clinical outcomes after arthroscopic subspinal decompression in patients with hip impingement symptoms and low AIIS, and to (2) assess the presence of low anterior inferior iliac spine on the pre-operative radiographs of patients with established subspinal impingement diagnosed intra-operatively.

Methods: Retrospective analysis of patients who underwent arthroscopic subspinal decompression has been performed. The indications for surgery were femoroacetabular impingement (FAI), or subspinal impingement. Pre-operative radiographs were assessed for anterior inferior iliac spine type. Intra-operative diagnosis of low anterior inferior iliac spine was based on the level of anterior inferior iliac spine extension relative to the acetabulum and the presence of reciprocal labral and chondral lesions. In patients where low anterior inferior iliac spine was not diagnosed on pre-operative radiographs, the pre-operative radiographs were re-read retrospectively to assess missed signs of low anterior inferior iliac spine.

Results: Thirty-four patients underwent arthroscopic subspinal decompression between 2012 and 2015. The patients were followed for a median of 25 months (13-37 months). Intra-operatively, grade 2 anterior inferior iliac spine was found in 27 patients and grade 3 anterior inferior iliac spine was found in 7 patients. MHHS, HOS, and HOSS scores increased from median (range) pre-operative scores of 55 (11-90), 48 (20-91) and 20 (0-80) to 95 (27-100), 94 (30-100) and 91 (5-100), respectively (p < 0.0001, p = 0.001, p < 0.0001, respectively). Pre-operative diagnosis of low AIIS was made in 6/34 patients via AP radiographs. On retrospective analysis of pre-operative radiographs, signs of low AIIS were still not observed in 21/34 (61.8%) patients.

Conclusions: Arthroscopic subspinal decompression of low AIIS yielded significantly improved outcome measures and high patient satisfaction at a minimum of 13 months follow-up. Low AIIS is often under-diagnosed on AP pelvis and lateral frog radiographs and if left untreated, may result in unresolved symptoms and failed procedure.

Level Of Evidence: IV.
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http://dx.doi.org/10.1007/s00167-018-4923-5DOI Listing
September 2020

Recurrent rotator cuff tear: is ultrasound imaging reliable?

J Shoulder Elbow Surg 2018 Jul 3;27(7):1263-1267. Epub 2018 Feb 3.

Reading Shoulder Unit, Royal Berkshire Hospital, Reading, UK.

Background And Hypothesis: The diagnostic workup of the painful shoulder after rotator cuff repair (RCR) can be quite challenging. The aim of this study was to assess the reliability of ultrasonography (US) for the detection of recurrent rotator cuff tears in patients with shoulder pain after RCR. We hypothesized that US for the diagnosis of recurrent rotator cuff tear after RCR would not prove to be reliable when compared with surgical arthroscopic confirmation (gold standard).

Methods: In this cohort study (diagnosis), we retrospectively analyzed the data of 39 patients with shoulder pain after arthroscopic RCR who had subsequently undergone US, followed by revision arthroscopy. The rotator cuff was evaluated first using US for the presence of retears. Thereafter, revision arthroscopy was performed, and the diagnosis was either established or disproved. The sensitivity and specificity of US were assessed in reference to revision arthroscopy (gold standard).

Results: A rotator cuff retear was indicated by US in 21 patients (54%) and by revision arthroscopy in 26 patients (67%). US showed a sensitivity of 80.8% and specificity of 100% in the diagnosis of rotator cuff retears. Omission of partial rotator cuff retears resulted in a spike in sensitivity to 94.7%, with 100% specificity remaining.

Conclusion: US imaging is a highly sensitive and specific test for the detection of recurrent rotator cuff tears, as confirmed by revision arthroscopy, in patients with a painful shoulder after primary RCR.
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http://dx.doi.org/10.1016/j.jse.2017.12.017DOI Listing
July 2018

Past Methylphenidate Exposure and Stress Fractures in Combat Soldiers: A Case-Control Study.

Am J Sports Med 2018 03 13;46(3):728-733. Epub 2017 Dec 13.

Unit of Military Physiology, Heller Institute of Medical Research, Sheba Medical Center at Tel HaShomer, Tel Aviv University, Ramat Gan, Israel.

Background: Previous research has revealed decreased bone mineral density (BMD) among children and adolescents who receive methylphenidate (MP) treatment for attention deficit hyperactivity disorder (ADHD). These findings have major clinical implications given that the prevalence of medication-treated ADHD is on the rise worldwide. We decided to investigate the clinical effect of MP exposure on the incidence of stress fractures, for which a low BMD is a risk factor.

Hypothesis: Exposure to MP is a risk factor for stress fractures.

Study Design: Case-control study; Level of evidence, 3.

Methods: This is a case-control study of combat soldiers who served in the military for 3 years between 2005 and 2015. The case group included 2400 soldiers with at least 1 stress fracture diagnosed by a bone scan. The control group comprised 6187 combat soldiers without a diagnosis of a stress fracture. The use of MP was determined by an automated text search of medical records and manual sorting of the results. Other study variables included age; sex; weight; height; body mass index (BMI); place of birth; and characterization of fractures by location, side, and grade. Odds ratios of stress fractures, the attributable proportion among the exposed, and the population attributable fraction were calculated using standard contingency tables. Logistic regression was fitted after adjusting for covariates.

Results: The previous use of MP was associated with a higher risk of stress fractures (odds ratio, 1.15 [95% CI, 1.07-1.24]). The attributable proportion was 13.2%, and the population attributable fraction was 0.3%. Logistic regression demonstrated an increased risk of stress fractures associated with past MP use, preserved after adjusting for BMI, sex, and place of birth ( P = .005). Female sex, BMI ≤20 kg/m, and 20 < BMI ≤25 kg/m were independent positive predictors of a stress fracture, while African origin was a negative predictor. Most participants who used MP had only 1 fracture (77.8%), while the majority of participants who did not use MP in the past had ≥2 coincident fractures (53.5%) ( P = .003).

Conclusion: This study supports the hypothesis that an MP-associated reduction in BMD has a clinical effect in the form of an increased incidence of stress fractures. The high percentage of fractures attributed to MP use may serve as a basis for risk stratification, that is, the referral of patients with a history of MP use to BMD measurements.
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http://dx.doi.org/10.1177/0363546517741705DOI Listing
March 2018

A novel non-invasive hip traction technique for hip arthroscopy in the below-knee amputation (BKA) patient.

J Hip Preserv Surg 2017 Aug 15;4(3):258-259. Epub 2017 Jun 15.

Tel Aviv Sourasky Medical Center, Affiliated with the Sackler Faculty of Medicine and Tel Aviv University, 6 Wiseman Street, Tel Aviv, Israel.

Prolonged sitting and mobilizing from a seated position are known to exacerbate the symptoms in patients with hip pathology. For patients who lack mobility and require extended periods of time in seated positions, such as amputees, the symptoms of femeroacetabular impingement can be debilitating and limit their ability to operate a wheelchair, use a prosthetic limb or complete activities of daily living. Hip arthroscopy surgery offers a minimally invasive technique to treat hip pathology but requires hip distraction to facilitate instrument maneuverability. Invasive methods of hip distraction have been previously described for use in amputees for hip arthroscopy. We herein describe a non-invasive surgical technique for hip distraction in the below-knee amputation patient.
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http://dx.doi.org/10.1093/jhps/hnx019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5604086PMC
August 2017

Intraobserver and interobserver reliability of the Copeland-Levy classification for arthroscopic evaluation of subacromial impingement.

J Shoulder Elbow Surg 2017 Dec 14;26(12):2167-2172. Epub 2017 Sep 14.

Reading Shoulder Unit, Royal Berkshire Hospital, Reading, UK.

Background: Defining a simple and reliable classification for acromial and bursal impingement lesions is necessary to standardize terminology, to improve communication, and to allow better evaluation of the proper treatment of impingement lesions and rotator cuff tears. The purpose of this study was to assess orthopedic surgeons' intraobserver and interobserver reliability of the Copeland-Levy classification.

Methods: Six fellowship-trained orthopedic surgeons reviewed shoulder arthroscopy videos of 69 consecutive patients who underwent shoulder arthroscopy for rotator cuff tear repair or subacromial decompression. The surgeons were asked to classify impingement lesions according to the Copeland-Levy classification. One month afterward, the surgeons were requested to repeat the evaluation of the same impingement lesions. Intraobserver reliability was calculated using Cohen's weighted κ. Interobserver reliability was calculated using Kendall's W.

Results: Overall intraobserver reliability for acromial and bursal lesions was κ = 0.86 (95% confidence interval, 0.82-0.9) and κ = 0.97 (95% confidence interval, 0.95-0.98), respectively. Interobserver reliability for acromial and bursal lesions was W = 0.87 and W = 0.92, respectively.

Conclusion: Intraobserver and interobserver reliability of the Copeland-Levy classification among senior orthopedic surgeons is excellent. Hence, we suggest the Copeland-Levy classification be used to standardize terminology of the subacromial impingement lesion.
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http://dx.doi.org/10.1016/j.jse.2017.07.018DOI Listing
December 2017

Acetabular labral reconstruction using the indirect head of the rectus femoris tendon significantly improves patient reported outcomes.

Knee Surg Sports Traumatol Arthrosc 2018 Aug 17;26(8):2512-2518. Epub 2017 Jul 17.

Department of Orthopedic Surgery, Tel Aviv Medical Center, Affiliated with the Sackler Faculty of Medicine and Tel Aviv University, Tel Aviv, Israel.

Purpose And Hypothesis: The aim of this study was to evaluate outcomes after acetabular labral reconstruction using the indirect head of the rectus femoris tendon. The study hypothesis stated that arthroscopic acetabular labral reconstruction may improve patient reported outcomes in patients with labral tears that were not amenable to repair.

Methods: Between 2009 and 2015, the senior author performed 31 acetabular labral reconstructions using the indirect head of the rectus femoris tendon. The graft is harvested through the same arthroscopic portals established for the procedure. The graft was gradually secured to the acetabular rim starting at its origin to the myotendinous junction, reestablishing the suction seal of the joint. Medical records and surgical reports were reviewed for demographic data, and outcome measures were assessed with pre- and postoperative modified Harris Hip Scores (mHHS).

Results: Twenty-two patients with follow-up of more than 2 years were evaluated. Fourteen procedures were revision hip arthroscopy and 8 were primary labral reconstruction in 13 males and 9 females. The median age was 43 (range 22-68 years old). The median follow-up time was 36.2 months with a range from 24 to 72 months. The median preoperative mHHS was 67.1. Postoperatively, patients improved to a median mHHS of 97.8 (range 73.7-100) (p < 0.0001).

Conclusion: Acetabular labral reconstruction using the indirect head of the rectus femoris tendon is a minimally invasive surgical procedure. The technique was applicable in all patients in this study with good outcomes. This procedure is clinically relevant for patients with large labral tears not amendable to labral repair as it offers good results using a local allograft. The local allograft is clinically advantageous as there is no additional donor-site morbidity and no risk of disease transmission.

Level Of Evidence: IV.
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http://dx.doi.org/10.1007/s00167-017-4641-4DOI Listing
August 2018

Manipulation under anaesthetic for frozen shoulder using Codman's paradox: a safe and early return of function.

Int Orthop 2018 02 11;42(2):339-344. Epub 2017 Jul 11.

Reading Shoulder Unit, Royal Berkshire Hospital, Reading, UK.

Purpose: Although previously frozen shoulder was thought to resolve by two to three years, recent studies demonstrated the symptoms can remain for much longer. Manipulation under anaesthetic (MUA) has been shown to be successful in relieving pain and restoring function. Yet, concerns have been raised regarding its safety and the risks of complications. We utilise Codman's paradox to manipulate the shoulder, avoiding rotational torque on the humerus. The aim of our study was to asses shoulder function in the early post MUA period.

Methods: Two hundred twelve consecutive patients (224 shoulders) (mean age 52.4 years) underwent MUA using Codman's paradox for frozen shoulder as sole procedure between 2005 and 2013. All were evaluated clinically, preoperatively and postoperatively, at three weeks and three months, for Constant score (CS), pain, range of motion (ROM), patient satisfaction and subjective shoulder value (SSV).

Results: At three weeks and three months, a significant improvement was found in CS from 30.7 to 66 and 70 respectively. Forward elevation improved from 91° to 154° and 160 °, abduction from 69° to 150° and 156 °, internal rotation from 12° to 62° and 66 °, and external rotation from 10° to 46° and 50 °. Pain score improved from 4.4/15 to 9.6/15 and 10.4/15, SSV improved from 1.5/10 to 6.5/10 and 6.7/10. (p<0.001).

Conclusion: Use of Codman's paradox provides a safe and efficient way to perform MUA for frozen shoulder. It results in dramatic early improvement in ROM, functional outcomes and high satisfaction, as early as three weeks post-operatively.
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http://dx.doi.org/10.1007/s00264-017-3558-3DOI Listing
February 2018
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