Publications by authors named "Omer Mei-Dan"

107 Publications

The Everted Acetabular Labrum: Patho-anatomy, Magnetic Resonance Imaging and Arthroscopic Findings of a Native Variant.

Arthroscopy 2021 May 4. Epub 2021 May 4.

University of Colorado School of Medicine, Department of Orthopedics, Aurora, Colorado, U.S.A.. Electronic address:

Purpose: The purpose of this study was to introduce a native labral variant, the everted acetabular labrum, and to describe the patho-anatomy, magnetic resonance imaging and magnetic resonance arthrogram (MRI/MRA) characteristics and the arthroscopic findings in this condition.

Methods: All primary hip arthroscopy procedures performed by the senior author between June 2013 and January 2020 were reviewed retrospectively. An everted acetabular labrum was identified as a segment of labrum that lacked apposition to the femoral head with the hip off traction. All everted labra were treated with labral advancement and repair with or without augmentation or reconstruction. The labrum-to-femoral head distance was measured in 3T MRI/MRA at the 1-2 o'clock position. A random selection of 38 hips without an everted labrum served as controls to compare radiographic parameters.

Results: A total of 68 hips were identified as having an everted labrum during the study period (mean age, 29.1 years), and 55 hips had advanced imaging available for review. MRI/MRA scans revealed the everted labrum to have a triangular shape in 17 hips (31%) and a blunted/round shape in 38 hips (69%), which differed significantly from controls (triangular 25/38 [66%], blunted 13/38 [34%], P < 0.001). The average labrum-to-femoral head distance was 1.4 mm for everted labra versus 0.0 mm for controls (P < 0.0001) and the mean labral lengths and widths were significantly shorter than those of controls (both P < 0.01). Of the hips, 8 underwent labral reconstruction or augmentation, and 61 underwent labral advancement/repair.

Conclusion: The everted acetabular labrum is a native variant that is identifiable during hip arthroscopy by assessing the labral seal off traction. Preoperative MRI/MRA findings can be highly predictive of an everted labrum. Surgical treatment includes labral advancement and repair or reconstruction to restore contact between the labrum and the femoral head.

Level Of Evidence: III, retrospective comparative study.
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http://dx.doi.org/10.1016/j.arthro.2021.04.038DOI Listing
May 2021

A Systematic Review Shows High Variation in Terminology, Surgical Techniques, Preoperative Diagnostic Measures, and Geographic Differences in the Treatment of Athletic Pubalgia/Sports Hernia/Core Muscle Injury/Inguinal Disruption.

Arthroscopy 2021 Apr 9. Epub 2021 Apr 9.

Department of Orthopaedic Surgery, St Joseph's University Medical Center, Paterson, New Jersey, U.S.A.; New Jersey Orthopaedic Institute, Wayne, New Jersey, U.S.A.

Purpose: To perform a systematic review of reported terminologies, surgical techniques, preoperative diagnostic measures, and geographic differences in the treatment of core muscle injury (CMI)/athletic pubalgia/inguinal disruption.

Methods: A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify clinical studies or articles that described a surgical technique to treat CMI refractory to nonoperative treatment. The search phrase used was "core muscle injury" OR "sports hernia" OR "athletic pubalgia" OR "inguinal disruption." The diagnostic terminology, country of publication, preoperative diagnostic measures, surgical technique, and subspecialty of the operating surgeons described in each article were extracted and reported.

Results: Thirty-one studies met the inclusion and exclusion criteria, including 3 surgical technique articles and 28 clinical articles (2 Level I evidence, 1 Level II, 4 Level III, and 21 Level IV). A total of 1,571 patients were included. The most common terminology used to describe the diagnosis was "athletic pubalgia," followed by "sports hernia." Plain radiographs and magnetic resonance imaging of the pelvis were the most common imaging modalities used in the preoperative evaluation of CMI/athletic pubalgia/inguinal disruption. Tenderness-to-palpation testing was the most common technique performed during physical examination, although the specific locations assessed with this technique varied substantially. The operating surgeons were general surgeons (16 articles), a combination of orthopaedic and general surgeons (7 articles), or orthopaedic surgeons (5 articles). The most common procedures performed were open or laparoscopic mesh repair, adductor tenotomy, primary tissue (hernia) repair, and rectus abdominis repair. The procedures performed differed on the basis of surgeon subspecialty, geographic location, and year of publication.

Conclusions: A variety of diagnostic methods and surgical procedures have been used in the treatment of a CMI/athletic pubalgia/sports hernia/inguinal disruption. These procedures are performed by orthopaedic and/or general surgeons, with the procedures performed differing on the basis of surgeon subspecialty and geographic location.

Level Of Evidence: Level V, systematic review of Level I to V studies.
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http://dx.doi.org/10.1016/j.arthro.2021.03.049DOI Listing
April 2021

Comparing Intra-articular Injections of Leukocyte-Poor Platelet-Rich Plasma Versus Low-Molecular Weight Hyaluronic Acid for the Treatment of Symptomatic Osteoarthritis of the Hip: A Double-Blind, Randomized Pilot Study.

Orthop J Sports Med 2021 Jan 20;9(1):2325967120969210. Epub 2021 Jan 20.

Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, USA.

Background: Hyaluronic acid (HA) and leukocyte-poor platelet-rich plasma (LP-PRP) are 2 nonoperative treatment options that have been studied in patients with hip osteoarthritis (OA).

Purpose: To compare the efficacy of intra-articular injections of low-molecular weight (LMW) HA and LP-PRP in patients with hip OA.

Study Design: Randomized controlled trial; Level of evidence, 1.

Methods: A total of 34 patients (36 hips) presenting with signs of hip OA were randomized to receive 3 blinded, weekly intra-articular injections of either LP-PRP or LMW-HA. Patients were prospectively evaluated before injections and at 6 weeks and then at 3, 6, 12, and 24 months. The primary outcome, conversion to total hip arthroplasty (THA) or a hip resurfacing procedure, was analyzed along with secondary outcomes including the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score and hip range of motion.

Results: The final analysis included 33 hips (mean Kellgren-Lawrence grade, 2.73) (LMW-HA: n = 14; LP-PRP: n = 19) in 31 patients (18 male; mean age, 53.8 years). Significantly more patients converted to THA or a hip resurfacing procedure in the LMW-HA group (7/14; 50.0%) (mean, 1.3 years after first injection) than the LP-PRP group (3/19; 15.8%) (mean, 0.73 years after first injection) ( = .035). There was no significant improvement or decline in any outcome scores within the LMW-HA group from before injections to 6 weeks or 3, 6, and 12 months. For the LP-PRP group, WOMAC overall ( = .032), joint ( = .030), and function scores ( = .025) significantly improved from before injections to 6 weeks, and WOMAC joint scores significantly improved from before injections to 6 months ( = .036). When comparing the difference between groups in internal rotation at 90° of hip flexion from before injections to 6 months, the LP-PRP group demonstrated a mean 5.0° improvement, while the LMW-HA group showed a mean 1.5° decrease ( = .028).

Conclusion: Intra-articular hip injections of LP-PRP in patients with hip OA resulted in an improvement in WOMAC scores and hip internal rotation at 6 months and delayed the need for THA or a hip resurfacing procedure compared with treatment with LMW-HA. A longer follow-up is necessary to further compare the effects of LP-PRP and LMW-HA injections in patients with hip OA.

Registration: NCT01920152 (ClinicalTrials.gov identifier).
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http://dx.doi.org/10.1177/2325967120969210DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7934058PMC
January 2021

Fascia Iliaca Block for Postoperative Pain Control After Hip Arthroscopy: A Systematic Review of Randomized Controlled Trials.

Am J Sports Med 2021 Mar 12:363546521996713. Epub 2021 Mar 12.

Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, USA.

Background: Various analgesic modalities have been used to improve postoperative pain in patients undergoing hip arthroscopy.

Purpose: To systematically review the literature to compare the efficacy of the fascia iliaca block (FIB) with that of other analgesic modalities after hip arthroscopy in terms of postoperative pain scores and analgesic consumption.

Study Design: Systematic review.

Methods: A systematic review was performed by searching PubMed, the Cochrane Library, and Embase up to April 2020 to identify randomized controlled trials that compared postoperative pain and analgesic consumption in patients after hip arthroscopy with FIB versus other pain control modalities. The search phrase used was "hip arthroscopy fascia iliaca randomized." Patients were evaluated based on postoperative pain scores and total postoperative analgesic consumption.

Results: Five studies (3 level 1, 2 level 2) were identified that met inclusion criteria, including 157 patients undergoing hip arthroscopy with FIB (mean age, 38.3 years; 44.6% men) and 159 patients among the following comparison groups: lumbar plexus block (LPB), intra-articular ropivacaine (IAR), local anesthetic infiltration (LAI), saline placebo, and a no-block control group (overall mean age, 36.2 years; 36.5% men). No significant differences in pain scores were reported in the postanesthesia care unit (PACU) between the FIB and LPB (3.4 vs 2.9; = .054), IAR (7.7 vs 7.9; = .72), control group (no FIB: 4.1 vs 3.8; = .76); or saline placebo (difference, -0.2 [95% CI, -1.1 to 0.7]). One study reported significantly higher pain scores at 1 hour postoperation in the FIB group compared with the LAI group (5.5 vs 3.4; = .02). Another study reported significantly greater total analgesic consumption (in morphine equivalent dosing) in the PACU among the FIB group compared with the LPB group (20.8 vs 17.0; = .02). No significant differences were observed in total PACU analgesic consumption between FIB and other analgesic modalities.

Conclusion: In patients undergoing hip arthroscopy, the FIB does not appear to demonstrate superiority to other forms of analgesics in the immediate postoperative period. Therefore, it is not recommended as a routine form of pain control for these procedures.
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http://dx.doi.org/10.1177/0363546521996713DOI Listing
March 2021

Pain Scores and Activity Tolerance in the Early Postoperative Period After Hip Arthroscopy.

Orthop J Sports Med 2020 Oct 28;8(10):2325967120960689. Epub 2020 Oct 28.

Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, USA.

Background: Despite the rapid growth in the use of hip arthroscopy, standardized data on postoperative pain scores and activity level are lacking.

Purpose: To quantify narcotic consumption and use of the stationary bicycle in the early postoperative period after hip arthroscopy.

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

Methods: In this prospective case series, patients undergoing a primary hip arthroscopy procedure by a single surgeon were asked to fill out a daily survey for 9 days postoperatively. Patients were asked to report their pain level each day on a visual analog scale from 1 to 10, along with the amount of narcotic pain pills they used during those postoperative days (PODs). Narcotic usage was converted to a morphine-equivalent dosage (MED) for each patient. Patients were also instructed to cycle daily starting on the night of surgery for a minimum of 3 minutes twice per day and were asked to rate their pain as a percentage of their preoperative pain level and the number of minutes spent cycling on a stationary bicycle per day.

Results: A total of 212 patients were enrolled in this study. Pain levels (POD1, 5.5; POD4, 3.8; POD9, 2.9; < .0001) and the percentage of preoperative pain (POD1, 51.6%; POD4, 31.8%; POD9, 29.5%; < .01) significantly decreased over the study period. The amount of narcotics used per day (reported in MED) also significantly decreased (POD1, 27.3; POD4, 22.3; POD9, 8.5; < .0001). By POD4, 41% of patients had discontinued all narcotics, and by POD9, 65% of patients were completely off narcotic medication. Patients were able to significantly increase the number of minutes spent cycling each day (POD1, 7.6 minutes; POD4, 13.8 minutes; POD9, 19.0 minutes; < .0001). Patients who received a preoperative narcotic prescription for the affected hip were significantly more likely to require an additional postoperative narcotic prescription ( < .001).

Conclusion: Patients can expect a rapid decrease in narcotic consumption along with a high degree of activity tolerance in the early postoperative period after hip arthroscopy.
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http://dx.doi.org/10.1177/2325967120960689DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7604997PMC
October 2020

Returning to Climb after Epiphyseal Finger Stress Fracture.

Curr Sports Med Rep 2020 Nov;19(11):457-462

University of Colorado School of Medicine, Department of Orthopedics, Aurora, CO.

The number of youth participating in rock climbing has increased over the years. Finger stress epiphyseal fractures are the most common injury among youth climbers. These injuries tend to occur around puberty because this is when the physis is most vulnerable to injury. Additionally, it has been found that intensive finger training (campus boarding, a previously known risk factor for epiphyseal fractures) during adolescence can lead to early-onset osteoarthritis of the hand up to a decade later. There is currently a lack of a return-to-climb protocol for youth climbers following a repetitive stress epiphyseal fracture. Because of this gap in the literature, our purpose was to create a structured return-to-play protocol specific to youth climbers who sustained an epiphyseal fracture to the finger. By establishing these guidelines, medical professionals and coaches may be able to guide their athlete to gradually and safely return to sport.
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http://dx.doi.org/10.1249/JSR.0000000000000770DOI Listing
November 2020

Editorial Commentary: Treating Hip Impingement Without a Computed Tomography Scan? You Might as Well Operate With a Blindfold.

Arthroscopy 2020 07;36(7):1872-1874

University of Colorado.

Hip impingement is defined as a bony conflict between the femur and acetabulum occurring throughout normal or supraphysiological range of motion. Traditionally, the cause was attributed to reduced femoral head-neck offset and/or excessive acetabular coverage, giving rise to cam, pincer, and mixed impingement. However, recent outcome studies showing less favorable results of hip arthroscopy in patients with femoral and acetabular version abnormalities have sparked renewed interest in the pathomechanics of hip impingement. We now have a greater appreciation for the 3-dimensional scope of the problem through specialized computed tomography sequencing allowing assessment of the entire limb and pelvis. Consequently, we have learned that rotational hip range of motion is more strongly correlated with combined femoral and acetabular version than with the sphericity of the femoral head, allowing us to counsel patients accordingly. We also recognize that impingement can occur with little to no femoral asphericity if the combined femoral and acetabular version does not permit adequate clearance for unimpeded motion. This improved understanding can be applied to diagnose subtle and uncommon cases of impingement and will ultimately enable a more complete bony resection.
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http://dx.doi.org/10.1016/j.arthro.2020.04.011DOI Listing
July 2020

Longitudinal versus transverse hip arthroscopy portal cosmesis: a case-control trial of simultaneous bilateral cases.

J Hip Preserv Surg 2019 Aug 9;6(3):265-270. Epub 2019 Sep 9.

Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO, USA.

The direction and nature of incisions can impact the healing and appearance of a surgical scar. This can be attributed mainly due to skin tension and direction of force. The aim of this study was to identify differences in healing rates and scar esthetics between transverse and longitudinal portals used for hip arthroscopy. A total of 75 patients underwent bilateral hip arthroscopy for femoroacetabular impingement. All patients received a portal perpendicular to the long axis of the body on the left side (transverse portal) and parallel with the long axis of the body on the right side (longitudinal portal) for the standard anterolateral viewing portal. Postoperatively, patients were reviewed at 2 weeks, 6 weeks, 3 months and 6 months and the portal scars were assessed, photographed and measured. No patients were lost to follow-up. The transverse scars, although slightly longer, were found to be narrower at 6 weeks (3.8 mm versus 2.7 mm,  < 0.01), 3 months (4.3 mm versus 3.4 mm,  = 0.01) and 6 months postoperatively (6.1 mm versus 4.5 mm,  < 0.01). At 3 months (43 mm versus 35 mm,  = 0.029) and 6 months (49 mm versus 43 mm,  = 0.024), transverse incisions were noted to have significantly reduced total area compared with longitudinal incisions. There were no wound complications in either group. This study demonstrates that transverse portal positions for hip arthroscopy have an advantage over longitudinal portal positions in terms of total scar area and thickness up to 6 months postoperatively.
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http://dx.doi.org/10.1093/jhps/hnz036DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6874773PMC
August 2019

A Contemporary Look at the Evaluation and Treatment of Adult Borderline and Frank Hip Dysplasia.

Am J Sports Med 2020 07 14;48(9):2314-2323. Epub 2019 Nov 14.

Department of Orthopedics, School of Medicine, University of Colorado, Aurora, Colorado, USA.

Background: Adult hip dysplasia is often diagnosed according to the lateral center-edge angle (LCEA). Patients with frank hip dysplasia (LCEA <20°) traditionally require treatment with bony realignment through a periacetabular osteotomy (PAO) and/or derotational femoral osteotomy, while patients with borderline hip dysplasia (BHD) present a challenging treatment dilemma, as it remains unknown when they should be treated with hip arthroscopy and/or a PAO.

Purpose: To perform a narrative review to report the differences in hip morphology and clinical outcomes between adult patients with frank hip dysplasia and BHD.

Study Design: Narrative review.

Methods: A systematic search of the literature was conducted through the Medline, EMBASE, and Cochrane databases with the search phrase .

Results: The search identified 305 articles, of which 48 were considered relevant to this study after screening of titles and abstracts. Four articles discussed new radiographic means of evaluating adult hip dysplasia, 16 articles analyzed morphology of dysplastic hips, and 28 articles described the clinical outcomes of patients with frank hip dysplasia or BHD treated with hip arthroscopy and/or PAO. Because the level of evidence obtained from this search was not adequate for systematic review or meta-analysis, a current concepts review on the diagnosis, hip morphology, and clinical outcomes of patients with frank hip dysplasia or BHD is presented.

Conclusion: Adult hip dysplasia is most commonly diagnosed based on the LCEA; however, the LCEA is an unreliable sole marker for dysplasia, and additional radiographic parameters should be utilized. Furthermore, specific pathology identified on imaging and/or during hip arthroscopy can provide clues to a surgeon when the diagnosis is inconclusive according to history and physical examination alone. While the data support that patients with frank dysplasia are best treated with PAO, there is no such preferred treatment for patients with BHD, who have a wide spectrum of instability. Selective use of arthroscopic labral and capsular treatment alone may provide good results in carefully chosen patients with BHD, while some may end up requiring a bony realignment procedure.
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http://dx.doi.org/10.1177/0363546519881411DOI Listing
July 2020

The "Outside-In" Lesion of Hip Impingement and the "Inside-Out" Lesion of Hip Dysplasia: Two Distinct Patterns of Acetabular Chondral Injury.

Am J Sports Med 2019 10 6;47(12):2978-2984. Epub 2019 Sep 6.

University of Colorado School of Medicine, Department of Orthopedics, Aurora, Colorado, USA.

Background: Femoroacetabular impingement (FAI) and acetabular dysplasia lead to acetabular cartilage damage that commonly results in the chondral flaps seen during hip arthroscopy.

Purpose: To compare the acetabular chondral flap morphology seen during hip arthroscopy ("outside-in" vs "inside-out") with clinical and radiographic parameters underlying FAI and hip dysplasia.

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

Methods: Patients who underwent hip arthroscopy by the senior author between 2013 and 2017 with a finding of Outerbridge grade IV acetabular chondral flap were included. Each procedure was retrospectively reviewed on video and chondral flaps were categorized as inside-out or outside-in. An inside-out designation was made for flaps exhibiting an intact chondrolabral junction with a detached sleeve of chondrolabral tissue from the central acetabulum, and an outside-in designation was made for centrally anchored flaps exhibiting a break in the chondrolabral junction. Radiographic markers of hip impingement/dysplasia were noted for each patient during assignment into 1 of 2 radiographic groups: group 1, lateral center edge angle (LCEA) >20 with FAI, and group 2, LCEA ≤20 with or without cam FAI. Associations between chondral flap morphology and clinical diagnosis were tested using a chi-square test.

Results: Overall, 95 patients (103 hips) were included (group 1, 78 hips; group 2, 25 hips). Among hips in group 2, 24 had concurrent cam FAI. There was a significant relationship between chondral flap type and radiographic diagnosis ( < .001). Among group 1 hips, 78% exhibited outside-in type chondral flaps, 12% exhibited combined outside-in and inside-out flaps, and 10% exhibited inside-out flaps. Group 2 hips showed 72% inside-out type chondral flaps, 16% combined, and 12% outside-in. Hips exhibiting outside-in type flaps were significantly more likely to be in group 1 (positive predictive value [PPV], 91%; negative predictive value [NPV], 69%). Similarly, hips exhibiting inside-out type flaps were significantly more likely to be in group 2 (PPV, 56%; NPV, 95%). Altogether, 90% of group 1 hips exhibited an outside-in lesion and 88% of group 2 hips exhibited an inside-out lesion.

Conclusion: Acetabular chondral flap type visualized during hip arthroscopy correlates with radiographic markers of hip impingement and hip instability. Outside-in flaps are highly predictive of FAI, whereas inside-out flaps are highly predictive of acetabular dysplasia.
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http://dx.doi.org/10.1177/0363546519871065DOI Listing
October 2019

The CU PAO: A Minimally Invasive, 2-Incision, Interlocking Periacetabular Osteotomy: Technique and Early Results.

J Bone Joint Surg Am 2019 Aug;101(16):1495-1504

Southern California Hip Institute, North Hollywood, California.

Background: The aims of this study were to describe a novel minimally invasive, interlocking periacetabular osteotomy (PAO) for the treatment of hip dysplasia that was developed at our institution and to report on its safety, complications, and early clinical outcomes.

Methods: This was a prospective longitudinal study of the first 200 consecutive hips that underwent the CU (University of Colorado) PAO, an interlocking osteotomy combining the benefits of the Birmingham interlocking pelvic osteotomy (BIPO) and the Ganz PAO. The technique provides direct visualization of the sciatic nerve during the ischial osteotomy and allows for immediate weight-bearing postoperatively. Demographic characteristics, intraoperative and perioperative parameters, and functional outcomes were documented. All patients underwent hip arthroscopy 3 to 10 days prior to the PAO to address concomitant intra-articular pathology. Mechanical deep venous thrombosis (DVT) prophylaxis was used for 2 weeks postoperatively. Results were stratified to compare the first 100 and the second 100 cases.

Results: A total of 161 patients (200 hips) underwent primary PAO; mean follow-up was 20 months (range, 3 to 33 months). The mean patient age at the time of surgery was 29.4 years (range, 13 to 55 years). Females accounted for 89% of the patients included in this study. The average length of stay was 4 days. A concomitant proximal femoral derotational osteotomy was performed in 19 hips. The lateral center-edge angle (LCEA) improved from a mean of 18.8° preoperatively to 31.5° postoperatively (p < 0.001). The mean Non-Arthritic Hip Score (NAHS) improved from 56.0 preoperatively to 89.4 at the 24-month follow-up (p < 0.0001). Paresthesias in the distribution of the lateral femoral cutaneous nerve were common (65% at 2 weeks postoperatively) but resolved in 85% of the patients within the first 6 months. There were no sciatic nerve-related complications, deep infections, or DVTs.

Conclusions: The CU PAO enables corrective realignment of symptomatic acetabular dysplasia with direct visualization of the sciatic nerve, early weight-bearing, cosmetic incisions, and good short-term outcomes.

Level Of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.2106/JBJS.19.00005DOI Listing
August 2019

Distal Adductor Longus Avulsion: A Technique for Successful Repair.

Arthrosc Tech 2019 Jun 23;8(6):e617-e622. Epub 2019 May 23.

Department of Orthopedic Surgery and Radiology, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, U.S.A.

Strains of the adductor muscle are common among athletes, but avulsion at its insertion is rare. Likewise, the diagnosis and management of distal ruptures of the adductors are infrequently reported in the literature. Presented here are the common presenting clinical findings of chronic distal adductor longus tendon ruptures and a description of how these can be successfully treated with a previously undescribed surgical technique. Preoperative and postoperative magnetic resonance imaging can be compared for verification of successful surgical repair. Also reviewed are common sports and mechanisms that elicit this injury pattern, adductor longus muscle function, relevant surgical anatomy, and treatment strategies.
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http://dx.doi.org/10.1016/j.eats.2019.02.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6624124PMC
June 2019

Return to Sport After Proximal Hamstring Tendon Repair: A Systematic Review.

Orthop J Sports Med 2019 Jun 24;7(6):2325967119853218. Epub 2019 Jun 24.

Department of Orthopaedics, Tulane University School of Medicine, New Orleans, Louisiana, USA.

Background: Previous studies have evaluated functional outcomes and return-to-sport rates after proximal hamstring tendon (HT) repair.

Purpose: To systematically review the literature in an effort to evaluate return-to-sport rates after proximal HT repair.

Study Design: Systematic review; Level of evidence, 4.

Methods: A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify studies that evaluated postoperative lower extremity function and return-to-sport rates in patients after proximal HT repair. Search terms used were "hamstring," "repair," "return to sport," and "return to play." Patients were assessed based on return to sport, return to preinjury activity level, type of HT tear (complete or partial), and interval from injury to surgery. Patients were also divided into subgroups depending on timing of the surgical intervention: early, <1 month; delayed, 1 to 6 months; and late, >6 months from the time of injury.

Results: Sixteen studies (one level 2, five level 3, ten level 4) met the inclusion criteria, including 374 patients with a complete proximal HT tear (CT group) and 93 patients with a partial proximal HT tear (PT group), with a mean follow-up of 2.9 years. Overall, 93.8% of patients (438/467) returned to sport, including 93.0% (348/374) in the CT group and 96.8% (90/93) in the PT group ( = .18). The mean time to return to sport was 5.7 months, and 83.5% of patients (330/395) returned to their preinjury activity level. The early group demonstrated the greatest rate of return to sport at 94.4% (186/197) as well as the quickest time to return at a mean of 4.8 months, although this was not found to be statistically significant.

Conclusion: Over 90% of patients undergoing repair of a complete or partial proximal HT tear can be expected to return to sport regardless of the tear type. Early surgical interventions of these injuries may be associated with a quicker return to sport, although the rate of return to sport does not differ based on timing of the surgical intervention.
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http://dx.doi.org/10.1177/2325967119853218DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6591667PMC
June 2019

Effects of Hip Arthroscopy Without a Perineal Post on Venous Blood Flow, Muscle Damage, Peripheral Nerve Conduction, and Perineal Injury: A Prospective Study.

Am J Sports Med 2019 07 24;47(8):1931-1938. Epub 2019 May 24.

University of Colorado School of Medicine, Department of Orthopedics, Aurora, Colorado, USA.

Background: Prior reports of hip arthroscopy using a perineal post have established the risks of groin soft tissue injury, sexual dysfunction, and altered lower extremity neurovascular function. These parameters have not been investigated for hip arthroscopy without the use of a perineal post.

Purpose: To evaluate the effects of postless hip arthroscopy on lower extremity venous blood flow, nerve conduction, muscle tissue damage, and perineal injury.

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

Methods: Patients between the ages of 18 and 50 years undergoing an elective unilateral or simultaneous bilateral hip arthroscopy were enrolled. Creatine phosphokinase (CPK)-MM levels and D-dimer levels were obtained preoperatively, immediately postoperatively, and 7 to 12 days postoperatively. Bilateral Doppler ultrasonography of the common femoral vein (CFV) and popliteal vein were conducted intraoperatively. Somatosensory evoked potentials (SSEPs) and transcranial motor evoked potentials (TcMEPs) were measured intraoperatively for the lower limbs. Perineal injury was assessed at 7 to 12 days postoperatively.

Results: 35 patients underwent a total of 40 hip arthroscopies. No significant differences were found in venous blood flow between the operative and nonoperative legs for either the CFV or popliteal vein. SSEP monitoring of the peroneal nerve showed no significant reduction when traction was applied to the operative leg, 90.8%, compared with final measurement just before it was removed, 72.4% ( = .09). For TcMEPs measured in the muscles outside of the traction boots, no significant changes were seen in the percentage of cases with abnormal measurements throughout the procedure. CPK-MM levels preoperatively, immediately postoperatively, and 7 to 12 days after surgery were on average 112, 190, and 102 IU/L, respectively (normal, <156 IU/L). No significant relationship was found between abnormal venous flow and altered D-dimer levels. No clinical evidence of nerve or vascular injury was encountered, and no groin soft tissue complications were observed during the study period.

Conclusion: Postless hip arthroscopy is safe, without a notable reduction of venous blood flow or alteration of nerve function in the operative leg. Muscle tissue damage is subclinical, transient, and reduced compared with distraction with a post. No cases of perineal injury were observed during the study period.
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http://dx.doi.org/10.1177/0363546519849663DOI Listing
July 2019

Hamstring Injuries: Risk Factors, Treatment, and Rehabilitation.

J Bone Joint Surg Am 2019 May;101(9):843-853

Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, Louisiana.

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http://dx.doi.org/10.2106/JBJS.18.00261DOI Listing
May 2019

Increased Prevalence of Femoroacetabular Impingement in Patients With Proximal Hamstring Tendon Injuries.

Arthroscopy 2019 05 12;35(5):1396-1402. Epub 2019 Apr 12.

Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, U.S.A.. Electronic address:

Purpose: To determine the prevalence of clinically diagnosed femoroacetabular impingement (FAI) in a consecutive series of patients presenting with proximal hamstring tendon injury and to correlate this with pelvic anatomic factors.

Methods: The prevalence of clinically symptomatic cam-, pincer-, and mixed-type and overall FAI was calculated among a consecutive series of patients presenting to a hip preservation clinic with a confirmed clinical and radiographic diagnosis of proximal hamstring tendon injury between 2012 and 2017. The presence of a cam lesion was determined by an alpha angle > 50° on radiographs and computed tomography radial sequences of the head-neck junction and a femoral head-neck offset ratio < 0.18. Clinical diagnoses of osseous impingement were determined according to accepted pathomorphologic signs and measurements. A diagnosis of FAI was confirmed by imaging findings of acetabular overcoverage for pincer-type FAI and the presence of an anterior or lateral cam lesion for cam-type FAI.

Results: Overall, 120 hips in 97 patients (mean age, 45 years) were included in this study. A clinical diagnosis of FAI was noted in 70.8% of hips (pincer-type 9.2%, cam-type 40.8%, mixed-type 20.8%), an approximate 2- to 7-fold increased prevalence in comparison with the general population from prior studies.

Conclusions: The prevalence of FAI is high in patients with symptomatic proximal hamstring tendon pathology. Because FAI results in restriction of hip range of motion and altered pelvic tilt, future studies are warranted to investigate whether the presence of FAI acts as a predisposing factor for injury to the hamstring muscle complex.

Level Of Evidence: Level IV, case series.
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http://dx.doi.org/10.1016/j.arthro.2018.11.037DOI Listing
May 2019

Open Repair of Acute Proximal Adductor Magnus Avulsion.

Arthrosc Tech 2019 Jan 24;8(1):e75-e80. Epub 2018 Dec 24.

Steadman Hawkins Clinic-Denver, Greenwood Village, Colorado, U.S.A.

Hip adduction is accomplished through coordinated effort of the adductor magnus, brevis, and longus and the obturator externus and pectineus muscles. Each of these muscles may be injured at its proximal or distal insertion or in its midsubstance. The incidence of injuries to the adductor complex is difficult to determine in sport because of players' underreporting and playing through minor strains. The most commonly injured adductor muscle is the adductor longus muscle. The injury most frequently occurs at the proximal or distal musculotendinous junction, but several case reports of origin and insertional ruptures of the adductor longus exist in the literature. Successful outcomes have been obtained with both operative and nonoperative approaches in these cases. Reports of isolated proximal avulsion of the adductor magnus are less common. This article describes our surgical technique for management of a rare acute proximal adductor magnus avulsion.
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http://dx.doi.org/10.1016/j.eats.2018.09.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6408720PMC
January 2019

Simultaneous Bilateral Hip Arthroscopy in Adolescent Athletes With Symptomatic Femoroacetabular Impingement.

J Pediatr Orthop 2019 Apr;39(4):193-197

Department of Orthopedics, University of Colorado School of Medicine.

Background: Femoroacetabular impingement represents a common cause of hip pain in adolescents. The purpose of the present study was to evaluate the safety and efficacy of simultaneous bilateral hip arthroscopy for bilateral symptomatic femoroacetabular impingement in adolescent athletes.

Methods: Clinical data were collected in a prospective database on patients who underwent unilateral or simultaneous bilateral hip arthroscopy and included complications, reoperation rate, and return to play time. Differences in International Hip Outcome Tool (iHOT)-12 scores according to hip side and postoperative follow-up time (preoperative, 1.5, 3, 6, 12, and 24 mo) were evaluated using a 2×6 repeated-measures analysis of variance with post hoc repeated-measures 1-way analysis of variance and Bonferroni-corrected paired t tests.

Results: In total, 24 patients (36 hips) were studied, of whom 12 underwent simultaneous bilateral hip arthroscopy (24 hips) and a case-matched control group of 12 patients underwent unilateral hip arthroscopy. There were 5 males in each group (41.7%). Average age was 15.7 and 16.5 years in the bilateral and unilateral groups, respectively. No patients were lost to follow-up. In the bilateral group, a significant increase in mean iHOT-12 score was observed between 1.5- and 3-month follow-up (61.8 vs. 82.8, respectively; P=0.003), and 6-, 12-, and 24-month follow-up (91.4, 95.1, and 96.6, respectively, P=0.004). At all follow-up times, there were no significant differences in mean iHOT-12 scores or other outcome measures between bilateral and unilateral cohorts. Time to return to preinjury level of activity was similar between the bilateral and unilateral groups (4.7 vs. 4.9 mo, respectively; P=0.40). One transient lateral femoral cutaneous nerve palsy occurred in each group, though no other complications were documented. No patients required revision surgery by latest follow-up.

Conclusions: Bilateral simultaneous hip arthroscopy is safe and reproducible in adolescent athletes, achieving equivalent outcomes, and similar rehabilitation time when compared with unilateral surgery.

Level Of Evidence: Level II-therapeutic study.
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http://dx.doi.org/10.1097/BPO.0000000000000987DOI Listing
April 2019

Editorial Commentary: Which Allograft Is Superior for Hip Capsular Reconstruction? Let's Choose the Right Patient Before We Choose the Right Graft.

Arthroscopy 2019 03;35(3):787-788

University of Colorado School of Medicine.

The hip is an inherently stable joint. Acetabular depth and version, femoral torsion, and congruency of articulation form the pillars of hip stability, with the labrum and capsule serving as secondary stabilizers. The increasing prevalence of capsular deficiency in the setting of revision hip arthroscopy has led to the development of capsular reconstruction techniques. The first step in hip capsular reconstruction, however, is selecting the right patient for the procedure.
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http://dx.doi.org/10.1016/j.arthro.2018.11.068DOI Listing
March 2019

Combined Lateral Osseolabral Coverage Is Normal in Hips With Acetabular Dysplasia.

Arthroscopy 2019 03 4;35(3):800-806. Epub 2019 Feb 4.

Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, U.S.A.

Purpose: To compare the lateral osseolabral coverage between groups of patients with different degrees of acetabular bony coverage using a magnetic resonance imaging parameter known as the combined lateral center-edge angle (cLCEA).

Methods: The cLCEA was measured among a consecutive series of patients presenting to a dedicated hip preservation surgeon with a magnetic resonance imaging scan. The cLCEA was measured using a coronal T1 or proton density image and was defined as the angle subtended by (1) a line through the center of the femoral head and orthogonal to the transverse line passing through the teardrops of both hips and (2) an oblique line drawn from the center of the femoral head to the free edge of the lateral acetabular labrum. The average difference between the lateral center-edge angle (LCEA) and the cLCEA was calculated and compared between groups based on acetabular bony coverage: dysplasia (LCEA <20°), borderline dysplasia (LCEA 20°-24.9°), normal coverage (LCEA 25°-39.9°), and overcoverage (LCEA ≥40°).

Results: In total, 341 patients (386 hips) were included. There were no significant differences in cLCEA between hips with normal acetabular coverage and dysplasia (P = .10) or borderline dysplasia (P = .46). Despite the large difference in mean LCEA between dysplasia (14.8° ± 3.9°) and acetabular overcoverage (43.1° ± 2.8°), the mean cLCEA values exhibited only a modest difference (44.7° ± 4.9° vs 52.7° ± 4.5°, respectively). Concordantly, hips with dysplasia exhibited the largest difference between mean LCEA and cLCEA (delta = 29.9° ± 4.7°) and hips with acetabular overcoverage had the smallest difference between measures (9.6° ± 5.2°).

Conclusions: With decreasing acetabular bony coverage, there is increasing labral size such that the total osseolabral coverage, measured by the combined LCEA, remains equivalent between hips with normal acetabular coverage versus dysplasia.

Level Of Evidence: Level III, retrospective comparative study.
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http://dx.doi.org/10.1016/j.arthro.2018.10.133DOI Listing
March 2019

Upsloping lateral sourcil: a radiographic finding of hip instability.

J Hip Preserv Surg 2018 Dec 1;5(4):435-442. Epub 2018 Dec 1.

Department of Orthopaedics, University of Colorado School of Medicine, Aurora, CO, USA.

While radiographic findings of frank hip dysplasia are well defined, there is a lack of diagnostic criteria for patients with radiographically 'normal' hips who have borderline morphologic deficits and clinical instability. In this study, we aim to define and validate a new radiographic finding associated with hip instability known as the upsloping lateral sourcil (ULS). Patients (316) were reviewed for lateral center edge angles, generalized joint laxity assessed with the Beighton Hypermobility Score and the presence of the ULS. The ULS was defined as a caudal-to-cranial inclination of the middle-to-far lateral aspect of the acetabular sourcil with loss of the normal lateral acetabular concavity. The prevalence of the ULS correspondingly increased with the degree of under-coverage as defined by LCEA. Within the normal coverage group, hips with a ULS had smaller LCEAs than those without ULS (29° versus 32°,  < 0.001). Among hips with a ULS, 59.00% had generalized joint laxity. The association between the ULS finding and generalized joint laxity was statistically significant ( < 0.01). The ULS is seen with higher prevalence in patients with clinical hip laxity and radiographically decreasing LCEA and may serve as an adjunctive finding in patients presenting with hip pain and instability. The ULS may help to characterize patients with borderline hip dysplasia and laxity that fall outside conventional imaging criteria for dysplasia.
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http://dx.doi.org/10.1093/jhps/hny042DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6328756PMC
December 2018

A multicenter, double-blind, randomized controlled trial comparing magnetic resonance imaging evaluation of repaired versus unrepaired interportal capsulotomy in patients undergoing hip arthroscopy for femoroacetabular impingement.

J Hip Preserv Surg 2018 Dec 26;5(4):349-356. Epub 2018 Nov 26.

Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO, USA.

The purpose of this study was to evaluate the magnetic resonance imaging (MRI) appearance of the hip capsule in patients with femoroacetabular impingement (FAI) undergoing hip arthroscopy with capsular repair versus non-repair. A multicenter clinical trial was performed with 31 patients (49 hips) undergoing hip arthroscopy for treatment of FAI. A small- to moderate-sized interportal capsulotomy was performed. Each hip was randomized to capsular repair versus non-repair of the interportal capsulotomy. MRI was performed at 6 and 24 weeks postoperatively and was analyzed by two musculoskeletal radiologists. Patients and the radiologists were blinded to the treatment applied. Capsular defect size and capsule thickness were recorded on each scan. Mean patient age was 31.4 years. Capsular repair was performed in 23 (46.9%) hips. Mean capsulotomy length was 35 mm at Center X and 23 mm at Center Y. At 6 weeks postoperatively, a healed hip capsule (with no apparent capsulotomy defect) was observed in 10 (43.4%) hips that underwent capsular repair and 4 (15.4%) hips that did not undergo capsular repair ( = 0.13). At 24 weeks postoperatively, 25/30 hips (83.3%) achieved complete closure of the capsulotomy defect, with no significant difference between treatment groups. Repair of an interportal capsulotomy following hip arthroscopy for FAI results in a non-significantly higher percentage of healed hip capsules at 6 weeks postoperatively compared with leaving the capsule unrepaired, though the difference normalizes by 24-week follow-up. Repair of a small- to moderate-sized interportal capsulotomy does not provide a radiographic advantage following hip arthroscopy for FAI.
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http://dx.doi.org/10.1093/jhps/hny045DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6328748PMC
December 2018

Children and extreme sports: a parent's perspective.

Authors:
Omer Mei-Dan

Res Sports Med 2018 ;26(sup1):1-4

a Department of Orthopedics , University of Colorado School of Medicine , Aurora , CO , USA.

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http://dx.doi.org/10.1080/15438627.2018.1432195DOI Listing
January 2019

Efficacy of a non-image-guided diagnostic hip injection in patients with clinical and radiographic evidence of intra-articular hip pathology.

J Hip Preserv Surg 2018 Aug 3;5(3):220-225. Epub 2018 May 3.

Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO, USA.

The purpose of this study was to determine the likelihood of pain relief, as a measure of accurate diagnosis of intra-articular hip pathology and correct needle placement, with a non-image-guided intra-articular hip injection performed bedside in the clinic. A retrospective study of prospectively collected data was performed in a consecutive cohort of patients diagnosed with symptomatic intra-articular hip pathology who underwent a non-image-guided intra-articular injection in the clinic. All patients had clinical and radiographic evidence of hip impingement, hip instability, chondrolabral pathology, or other causes of intra-articular hip pain. A previously described technique for a non-image-guided hip injection was performed using 7-10 ml of 1% lidocaine for diagnostic evaluation with some patients receiving 2 ml of Kenalog-40 if clinically indicated. Ten minutes following each injection, the patient was asked to report the percent improvement in pain (from 0 to 100%) while physical examination and provocative tests were repeated. The final study cohort comprised 142 patients (161 injections). In three cases, patients were either unable to assess or quantify any change in pain level 10 min following the injection. In the remaining 158 hip injections, pain relief was noted in 156 cases (156/158, 98.7%), with at least 70% improvement in pain level noted in 152 cases (152/158, 96.2%). Average pain relief among all 158 injections was 89 ± 16%. A non-image-guided diagnostic intra-articular hip injection yields reliable short-term pain relief, simultaneously endorsing accurate diagnosis of hip pathology and intra-articular needle placement.
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http://dx.doi.org/10.1093/jhps/hny013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6206695PMC
August 2018

Comparison of the Personality Traits of Male and Female BASE Jumpers.

Front Psychol 2018 18;9:1665. Epub 2018 Sep 18.

Department of Psychiatry, Washington University in St. Louis, St. Louis, MO, United States.

BASE jumping is an extreme adventure sport which consists of jumping from a fixed object with specially adapted parachutes. A few studies of the personality of BASE jumpers have been conducted, but little is known about how the women in this sport compare to the men. The purpose of this study is to compare the personality traits among a sample of men and women who are experienced BASE jumpers, as this provides an interesting and important opportunity to better understand the motivation for extreme sports. Eighty-three participants completed the Temperament and Character Inventory the day before the jump at the New River Gorge Bridge Day BASE Jumping event, West Virginia, United States. The sample included 64 men and 19 women. Results show that men and women BASE jumpers shared similar personality traits both in terms of temperament and character, except for the character trait of cooperativeness on which women scored higher than men. This suggests that the basic drive for participation in extreme sports is self-regulation of personal emotional drives and needs for self-actualization, rather than to oppose social pressure or cultural bias against female participation. These findings are discussed in relation with other studies conducted among extreme athletes and in terms of congruence between personality and activity.
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http://dx.doi.org/10.3389/fpsyg.2018.01665DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6160869PMC
September 2018

Incidence of deep venous thrombosis following periacetabular and derotational femoral osteotomy: a case for mechanical prophylaxis.

J Hip Preserv Surg 2018 Jul 5;5(2):119-124. Epub 2018 Mar 5.

Department of Orthopedics, University of Colorado School of Medicine, 12631 East 17 Avenue, Mail Stop B202, Room L15-4505, Aurora, CO 80045, USA.

There are currently no established guidelines for appropriate antithrombotic prophylaxis following periacetabular osteotomy (PAO) or derotational femoral osteotomy (DFO). The purpose of this study was to determine the incidence of clinical deep venous thrombosis (DVT) following PAO and/or DFO wherein a portable, mechanical device and low-dose aspirin were used postoperatively for DVT prophylaxis. Patients who had undergone staged hip arthroscopy and primary PAO and/or DFO were prospectively reviewed. Following PAO/DFO, patients were prophylactically treated for thromboembolic disease with a portable, mechanical compression device for 3 weeks and low-dose aspirin for 4 weeks. Patients were followed in clinic until 24 months postoperatively. During the study period, 145 hips (124 patients) underwent surgery (PAO: 109, DFO: 24, PAO + DFO: 12). Overall, the incidence of clinically apparent DVT was 0% in the study cohort. Average estimated blood loss during surgery was 601 mL and five cases required blood transfusions of 1 or 2 units. Ten patients were seen in the emergency room 10-20 days after surgery presenting with calf tenderness and DVT was ruled out in all cases with ultrasound. There were no postoperative bleeding or wound complications. A portable, mechanical compression device and low-dose aspirin effectively lessens the risk of DVT following staged hip arthroscopy and PAO/DFO without an increased risk of bleeding complications.
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http://dx.doi.org/10.1093/jhps/hny008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5961113PMC
July 2018

Standardizing the Prearthritic Hip Joint Space Width: An Analysis of 994 Hips.

Arthroscopy 2018 07 2;34(7):2114-2120. Epub 2018 May 2.

Department of Orthopedics, University of Colorado School of Medicine, University of Colorado, Aurora, Colorado, U.S.A.. Electronic address:

Purpose: The purposes of this study were (1) to define a normal prearthritic hip joint space width (JSW) in symptomatic and asymptomatic patients with various degrees of acetabular coverage based on the lateral center edge angle (LCEA) and (2) to determine predictors of JSW using patient-specific variables.

Methods: In a consecutive series of patients presenting to a hip preservation clinic between July 2012 and April 2016, a standard weight-bearing anteroposterior pelvic view was obtained. JSW was defined as the distance between the bony contour of the acetabular rim and femoral head in 2 locations (lateral and medial weight-bearing zone). Hips with severe anatomic deformity, a Tönnis grade >0, or a lateral or medial JSW <2.5 mm were excluded. A linear mixed model analysis was performed in order to determine which variables (age, sex, side, height, weight, symptomatic/asymptomatic, LCEA, and clinical diagnosis) were significantly related to JSW.

Results: A total of 994 hips were included. LCEA was found to be a significant predictor of both the lateral and medial JSW, with a decreased JSW associated with increasing degrees of acetabular bony coverage (P < .02). A mean 0.9 mm (20%) difference in medial JSW was found between patients with frank dysplasia (LCEA <20°) compared with those with pincer-type FAI (LCEA ≥40°). There was no difference between symptomatic and asymptomatic hips, either for lateral (asymptomatic: 4.51 ± 0.83 mm; symptomatic: 4.52 ± 0.85 mm; P = .58) or medial JSW (asymptomatic: 4.02 ± 0.96 mm; symptomatic: 3.97 ± 0.84 mm; P = .49).

Conclusions: The LCEA is a significant predictor of hip JSW, with the mean JSW decreasing with increasing degrees of acetabular bony coverage. Joint space is not a major factor in symptomatology in adults with prearthritic hip pain.

Level Of Evidence: Level III, retrospective comparative study.
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http://dx.doi.org/10.1016/j.arthro.2018.02.036DOI Listing
July 2018

Femoral Version Abnormalities Significantly Outweigh Effect of Cam Impingement on Hip Internal Rotation.

J Bone Joint Surg Am 2018 Feb;100(3):205-210

Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado.

Background: The purpose of this study was to investigate the effects of femoral version, cam-type femoroacetabular impingement (FAI), and the combination of the 2 on the passive hip range of motion (ROM).

Methods: We prospectively analyzed a consecutive cohort of 220 patients (440 hips) who presented with unilateral or bilateral hip pain. The passive hip ROM was measured bilaterally with the patient in prone, supine, and lateral positions. Femoral version was measured and the presence of cam-type deformity was determined on preoperative computed tomography (CT) scans. Diagnostic findings of cam-type FAI included an alpha angle of >50° on CT radial sequences of the head-neck junction and a femoral head-neck offset ratio of <0.18 on both radiographs and CT.

Results: Multivariate linear regression analysis confirmed that femoral version, as compared with the presence of a cam lesion, was a stronger independent predictor of internal rotation ROM. Conversely, the presence of a cam lesion resulted in a significant decrease in the passive hip flexion ROM (p < 0.001) with no additional effects due to the degree of femoral version. The passive hip internal rotation ROM in neutral flexion/extension and with the hip in 90° of flexion were maximized in patients with femoral anteversion and decreased significantly with each incremental decrease in femoral version (p < 0.001).

Conclusions: Abnormalities in femoral version significantly outweigh the effect of cam-type impingement on the passive hip internal rotation ROM. In contrast, the presence of a cam lesion significantly decreases the hip flexion ROM, irrespective of the degree of femoral version. These findings help to inform surgical decision-making for patients with cam-type FAI or femoral version abnormalities.

Clinical Relevance: It is common clinical practice to ascribe loss of hip internal rotation to the presence of a cam lesion and to assume that arthroscopic femoral osteoplasty will substantially improve internal rotation postoperatively. Our study shows that the cam lesion is more intimately tied to hip flexion than to hip internal rotation. This result directly impacts the clinical assessment of a patient presenting with radiographic findings of FAI.
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http://dx.doi.org/10.2106/JBJS.17.00376DOI Listing
February 2018

MRI Evaluation of Repaired Versus Unrepaired Interportal Capsulotomy in Simultaneous Bilateral Hip Arthroscopy: A Double-Blind, Randomized Controlled Trial.

J Bone Joint Surg Am 2018 Jan;100(2):91-98

Departments of Radiology (C.D.S.) and Orthopaedics (O.M.-D.), University of Colorado School of Medicine, Aurora, Colorado.

Background: Techniques used in hip arthroscopy continue to evolve, and controversy surrounds the need for capsular repair following this surgical intervention. The purpose of this study was to evaluate the magnetic resonance imaging (MRI) appearance of the hip capsule in patients with femoroacetabular impingement (FAI) who underwent simultaneous bilateral hip arthroscopy through an interportal capsulotomy with each hip randomized to undergo capsular repair or not undergo such a repair.

Methods: This double-blind, randomized controlled trial included 15 patients (30 hips), with a mean age of 29.2 years, who underwent simultaneous bilateral hip arthroscopy utilizing a small (<3-cm) interportal capsulotomy for the treatment of FAI. The first hip treated in each patient was intraoperatively randomized to undergo capsular repair or no capsular repair. The contralateral hip then received the opposite treatment. MRI was performed at 6 and 24 weeks postoperatively, and the scans were analyzed by 2 musculoskeletal radiologists. The patients and the radiologists were blinded to the treatment performed on each hip. Capsular dimensions were measured at the level of the healing capsulotomy site and, for hips with a persistent defect, at locations both proximal and distal to the defect. These values were then analyzed at both time points to assess the rate and extent of capsular healing.

Results: At 6 weeks postoperatively, a continuous hip capsule (with no apparent capsulotomy defect) was observed in 8 hips treated with capsular repair and 3 hips without such a repair. Of the 19 hips with a discontinuous capsule at 6 weeks, 17 were available for follow-up at 24 weeks postoperatively; all 17 demonstrated progression to healing, with a contiguous appearance without defects and no difference in capsular dimensions between treatment cohorts.

Conclusions: Arthroscopic repair of a small interportal hip capsulotomy site yields an insignificant increase in the percentage of continuous hip capsules seen on MRI at 6 weeks postoperatively compared with no repair. Repaired and unrepaired capsulotomy sites progressed to healing with a contiguous appearance on MRI by 24 weeks postoperatively.

Level Of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.2106/JBJS.17.00365DOI Listing
January 2018