bluuebunny/crossref_metadata_2025 huggingface dataset:
Safety of long-acting beta agonists and inhaled corticosteroids in children and adolescents with asthma
Authors: Xia Ying , Kelton Christina M. L. , Xue Liang , Guo Jeff J. , Bian Boyang , Wigle Patricia R.
Published: September 2013

The introduction of long-acting beta agonists (LABAs) was considered a major advance in bronchodilator therapy for adult, as well as pediatric, patients with asthma. However, the use of LABAs has raised safety concerns, especially the potential for severe asthma exacerbations (SAEs) resulting in hospitalizations or even death. Meanwhile, the use of inhaled corticosteroids (ICSs), a cornerstone in the treatment of mild-to-severe persistent asthma, has been associated with growth suppression in children. The purpose of this review was to identify and discuss the major published safety studies surrounding LABA, ICS, and combined LABA/ICS usage in children. By way of a critical search for influential published clinical trials, meta-analyses, and observational studies, six studies relevant to the safety of LABA monotherapy, seven studies relevant to ICS monotherapy, and four studies on the subject of LABA/ICS combination usage were identified and reviewed. Based on the reviewed literature, the controversy surrounding these anti-asthma medications was clearly exposed. On the one hand, there is some evidence that LABA monotherapy may be associated with SAEs and asthma-related death, while ICS monotherapy may be associated with a higher risk of growth suppression. On the other hand, the concurrent use of a LABA with an ICS has been associated with positive outcomes including symptom reduction and reduced rate and severity of exacerbations. Further clinical research is warranted and has been called for by the US Food and Drug Administration.
Pregabalin: latest safety evidence and clinical implications for the management of neuropathic pain
Authors: Toth Cory
Published: September 2013

Used mainly for the management of neuropathic pain, pregabalin is a gabapentinoid or anticonvulsant that was initially developed as an antiepileptic agent. After more than a decade of experience with pregabalin, experience and studies have shown that the adverse effect profile of pregabalin is well tolerated for the management of neuropathic pain and other conditions. Its use is associated with benign central nervous system and systemic adverse effects, and there are very limited metabolic, idiosyncratic or known teratogenic adverse effects. Along with its efficacy in particular neuropathic pain conditions, pregabalin’s safety led it to be one of the first pharmacotherapies considered for the management of neuropathic pain. This review discusses the use of pregabalin as well as its potential adverse effects, including the most commonly noted features of sedation, dizziness, peripheral edema and dry mouth. Although other adverse effects may occur, these appear to be uncommon. The review also discusses the clinical implications of pregabalin’s use for the clinician.
The effects of microgravity on the urological system: a review
Authors: Drinnan Nicholas Rt , De Juniac Alexandra Begougne
Published: September 2013

Humans have evolved over thousands of years to achieve optimum performance in Earth's environment. Through our development of technology and our thirst for exploration we are subjecting ourselves to new and untested physiological challenges. In this article we examine the effect of zero gravity on the urological system in forming renal calculi in space.
Incidence of Second Anterior Cruciate Ligament (ACL) Injury 2 Years after Primary ACL Reconstruction and Return to Sport
Authors: Paterno Mark V. , Rauh Mitchell , Schmitt Laura C. , Ford Kevin R. , Hewett Timothy E.
Published: September 2013

Objectives:

The incidence of second anterior cruciate ligament (ACL) injury in the first 12 months after ACL reconstruction (ACLR) and return to sport in a young, active population has been reported to be 15 times greater than a previously uninjured cohort. It is unknown if this high relative rate of injury continues beyond the first year after return to sport following ACLR. The tested hypothesis was that the incidence rate of a subsequent ACL injury in the 2 years following ACLR and return to sports would be less than the incidence rate reported within the first 12 months after return to sport, but greater than the ACL injury incidence rate in an uninjured cohort of young athletes.

Methods:

Seventy-eight subjects who underwent ACLR and were ready to return to a pivoting/cutting sport (RTS) and 47 controls were prospectively enrolled. Each subject was followed for injury and athletic exposure (AE) data for a 24-month period after return to sport. Twenty-three subjects after ACLR and 4 control subjects suffered an ACL injury during this time. Incidence rate ratios (IRR) were calculated to compare the rates (per 1000 athletic exposures [AEs]) of ACL injury in athletes in the ACLR group and control group. For the ACLR group, similar comparisons were conducted for side of injury by sex.

Results:

The overall incidence rate of a second ACL injury within 24 months after ACLR and RTS (1.39/1000 AE) was nearly 6 times greater (IRR=5.71, 95% CI: 2.0, 22.7, p=0.0003) than healthy control subjects (0.24/1,000 AE). Female ACLR athletes demonstrated 4 times greater rate of injury within 24 months of RTS (IRR=4.51; 95% CI: 1.5-18.2, p=0.0004) than female controls. Within the ACLR group, there was a trend for female subjects to be over two (RR=2.43, 95% CI: 0.8, 8.6) times more likely to suffer a contralateral injury (1.13/1000 AEs) than an ipsilateral injury (0.47/1000 AEs). Overall, 29.5% of athletes suffered a second ACL injury within 24 months of RTS with 20.5% sustaining a contralateral injury and 9.0% incurring an ipsilateral graft re-tear injury. A higher proportion of females (23.7%) suffered a contralateral injury compared to males (10.5%). Conversely, for ipsilateral injuries, the incidence proportion between females (8.5%) and males (10.5%) were found to be similar.

Conclusion:

These data support the hypothesis that in the 24 months following ACLR and RTS, patients are at greater risk (nearly 6 times) to suffer a subsequent ACL injury compared to young athletes without a history of ACL injury. Additionally, the contralateral limb of female patients appears to be at greatest risk. These 24 month outcome data, analyzed in conjunction with recent 12 month outcome data which noted a 15 times greater risk of ACL injury compared to healthy control subject, indicate that the greatest risk of second ACL injury after ACLR occurs during the initial 12 months after ACLR and RTS than the second year after RTS.
Ultra-Low Velocity Knee Dislocations: A Challenging Population of Multiligament Knee Injuries
Authors: Werner Brian C. , Gwathmey Frank W. , Gilmore Carl J. , Miller Mark D.
Published: September 2013

Objectives:

Multiligament knee injuries (MLI) are usually associated with high energy mechanisms such as motor vehicle accidents or sports injuries. However, obese patients are at risk of MLI from simple falls. Termed “ultra-low velocity” (ULV) dislocations, these may be associated with higher associated risks and complications due to the patient’s inherent size. The objectives of this study are to characterize the epidemiology, risk factors, associated neurovascular injuries, and perioperative complications of ULV dislocations to allow surgeons to make informed decisions regarding their care.

Methods:

Study Design: Retrospective cohort study. 215 consecutive patients with MLI were identified over a 12 year period. Their charts were reviewed to identify a cohort of patients with mechanisms consistent with ULV dislocation (n=23). This cohort was compared to all MLI. Additionally, ULV patients with neurovascular injury were compared to those without neurovascular injury. Analysis: Means and ranges were calculated for continuous variables (age, BMI) and compared between cohorts using Student’s t test. Frequencies for categorical variables were compared using chi square tests.

Results:

Compared to all patients with MLI, the ULV cohort had significantly higher BMI, greater prevalence of female gender, and higher rates of both peroneal nerve and popliteal artery injury (Table I). Within the ULV cohort, patients with neurovascular injury demonstrated significantly greater post-operative complications (Table II). There was a trend for higher BMI to be predictive of neurovascular injury in ULV dislocations, but patient numbers limited any additional statistical analysis.

Conclusion:

ULV knee injuries occur in patients with greater BMI, more frequently in females, and with higher rates of concomitant neurovascular injury compared to other MLI. Additionally, a greater incidence of post-operative complications can be expected after ligament reconstruction in this population.
Identifying Cam Lesions on the False Profile View
Authors: Hellman Michael D. , Fillingham Yale A. , Gupta Anil K. , Frank Rachel , Haughom Bryan D. , Nho Shane Jay
Published: September 2013

Objectives:

Recently the AP, Dunn and Frog Leg Lateral radiographic views have been verified to accurately reflect the findings of three dimensional imaging while assessing for cam lesions. The false profile radiographic view is traditionally used to measure acetabular coverage in the setting of femoroacetabular impingement. We believe it should also be used to assess the femoral head neck junction. Our objective is to verify the accuracy of this view with respect to 3D CT scan findings.

Methods:

We retrospectively reviewed 37 consecutive surgical patients between May 2012 and September 2012 with preoperative radial oblique reformatted CT scans and plain radiographs. Alpha angles were measured on plain radiographs (AP, Dunn, False Profile) and CT reformats. Abnormal alpha angles were considered greater than 55 degrees and the CT scans were considered gold standard. Post-operative radiographs were also measured. Two physicians independently measured the images and the results were compared.

Results:

The false profile view was 70.6% sensitive and 95.0% specific for diagnosing a cam lesion. It was noted that the false profile view was 1.31 times better than other views at visualizing the anterior head-neck junction at a 3 o’clock position (See image 1). The false profile view pre-operative mean alpha angle was 53.4° versus its post-operative mean alpha angle was 41.9°, Δ = 11.5° (t = 0.001). The interclass correlation coefficient (ICC) was found to be 0.81.

Conclusion:

This is the first study to suggest using the false profile view to assess the femoral head neck junction. For diagnostic and treatment purposes, the false profile view effectively characterizes cam lesions, particularly anterior 3 o’clock lesions. Further, it shows promising results as a peri-operative assessment tool to verify adequate osteoplasty. Measuring the alpha angle on this view also appears to be a reproducible with a significant ICC. We believe this view should be used for both acetabular coverage measurements as well as for femoral head neck junction measurements.
Risk Factors for Anterior Glenohumeral Instability
Authors: Owens Brett D. , Campbell Scot , Cameron Kenneth L.
Published: September 2013

Objectives:

While anterior glenohumeral instability has been shown to be common in young athletes, the risk factors for injury are poorly understood. The elucidation of risk factors is critical to help develop prevention strategies. We hypothesized that specific modifiable and non-modifiable factors at baseline would be associated with the subsequent risk of injury in a cohort of young athletes.

Methods:

We conducted a prospective cohort study in which 714 young athletes were followed from June 2006 through May 2010. Baseline assessments included a subjective history of instability, physical examination by a sports-trained orthopaedic surgeon, range-of-motion, strength with a hand-held dynamometer, and bilateral noncontrast shoulder MRI. A musculoskeletal radiologist measured glenoid version, glenoid height, glenoid width, glenoid index (height-to-width ratio), glenoid depth, rotator interval (RI) height, RI width, RI area, RI index, and the coracohumeral interval. Subjects were followed to document all acute anterior shoulder instability events during the 4 year follow-up period. The time to shoulder instability event during the follow-up period was the primary outcome of interest. Univariate and multivariable Cox proportional hazards regression models were used to analyze the data.

Results:

We obtained complete data on 714 subjects. During our 4 year surveillance period, there were 38 anterior instability events documented. While controlling for covariates, significant risk factors of physical exam were: apprehension sign HR=2.96 (1.48, 5.90, p=0.002) and relocation sign HR=4.83 (1.75, 13.33, p=0.002). Baseline range-of-motion and strength measures were not associated with subsequent injury. Significant anatomic risk factors on MRI measurement were glenoid index HR=8.12 (1.07, 61.72) p=0.043 and the coracohumeral interval HR=1.20 (1.08, 1.34, p=0.001).

Conclusion:

This prospective cohort study revealed significant risk factors for shoulder instability in this high-risk population. While modifiable risk factors such as strength and range-of-motion were not associated with subsequent instability, some non-modifiable risk factors were. That the exam findings of apprehension and relocation were significant while controlling for prior history of injury suggests that patients may be unaware of prior instability episodes. The anatomic variables of significance are also not surprising - tall and thin glenoids were at higher risk compared to short and wide glenoids; and the risk of instability increased by 20% for every 1mm increase in coracohumeral distance.
The Elite Football Players with a Fifth Metatarsal Fracture
Authors: Ross James R. , Brophy Robert H. , Wright Rick W.
Published: September 2013

Objectives:

Fractures of the proximal fifth metatarsal can be a difficult clinical problem, especially in the athlete who wishes to return to competition. Clinical and radiographic evaluation cannot always be relied upon to assess complete healing. Refracture, after operative and nonoperative treatment, of a fifth metatarsal is a known phenomenon. The purpose of the study was to characterize and describe the prevalence of fifth metatarsal fractures in athletes at the NFL Scouting Combine and test the hypothesis that radiographic healing and symptom free return to play in college predict length of career and risk of re-injury.

Methods:

A retrospective review was performed of the database of players presenting to the annual NFL National Invitational Camp from 2005 to 2010 to identify athletes in whom fifth metatarsal fractures occurred. Each of these players underwent anteroposterior (AP), oblique, and lateral foot radiographs that were analyzed for indicators of hindfoot malalignment in addition to the presence or absence of a residual fracture gap. The date of the injury, the date of surgery (if applicable), and the number of games missed after the injury were also obtained from history. An internet search and NFL.com was used to determine the effect of their prior fifth metatarsal injury on the player’s career (games played, career length, and re-injury).

Results:

87 feet (81 players; 4.4% of all players) were identified. 52.9% of these injuries occurred in the left foot. Among all NFL Scouting Combine participants, fifth metatarsal fractures most commonly occurred in offensive linemen (20.7%), wide out receivers (20.7%), defensive linemen (17.2%), and defensive backs (11.5%). 78.2% of players were treated with an intramedullary screw. A persistent fracture gap was noted in 18.4% of players. 17.2% of players had a re-injury during their career. No radiographic measurements differed between players that had a residual fracture gap or re-injury. Players that played at least one full collegiate season after injury were less likely to have re-injury during professional play (5.6% vs. 46.7%; p < 0.001) or a residual fracture gap (9.7% vs. 60%; p < 0.001). Players without a residual gap were also less likely to have a re-injury (7% vs. 37.5%; p < 0.001). Players treated with surgery were less likely to have re-injury (10.3% vs. 21.1%) but more likely to have gap formation (20.6% vs. 10.5%).

Conclusion:

Players who are able to complete at least one full year of collegiate football after a fifth metatarsal fracture are less likely to have re-injury or a residual fracture gap. No radiographic measurements are predictive of re-injury or residual fracture gap.
Corticosteroid Injections Hasten Return to Play of National Football League Players Following Stable Ankle Syndesmosis Sprains
Authors: Mansour Alfred A. , Porter David A. , Young Jason Paul , Hammer Dave , Boublik Martin , Schlegel Theodore F.
Published: September 2013

Objectives:

Injuries to the ankle syndesmosis are common in contact athletes and may result in significant time lost from sport. Syndesmosis sprains require more treatment and time off for recovery as compared to lateral ankle sprains. A previous study of collegiate football players described an average of 31 days lost from these injuries treated with standard conservative measures and rehabilitation protocols. Treatment methods for stable syndesmosis sprains are not well documented in the literature. The purpose of this study was to compare our series of stable ankle syndesmosis sprains treated with or without corticosteroid injections.

Methods:

A retrospective review of ankle syndesmosis sprains from two National Football League (NFL) teams over an eight-year period (2003-2011) was performed. All players were evaluated with standard radiographs as well as magnetic resonance imaging (MRI) to confirm their diagnosis. All players were subsequently treated with (Group 1) or without (Group 2) a corticosteroid injection into the syndesmosis within 72 hours of injury and progressed through a nonoperative rehabilitation program based on the treatment practices of the team. Time lost was calculated as total days from date of onset before returning to unrestricted activity including practice and games.

Results:

A total of 31 stable ankle syndesmosis sprains were identified. All injuries confirmed with MRI were reviewed. Thirteen players received a corticosteroid injection (Group 1) within the syndesmosis and had an average return of 15 days (5-26). Eighteen players did not receive a corticosteroid injection (Group 2) within the syndesmosis and had an average return of 25 days (1-43). This difference in return was statistically significant (p=0.0097). All players in both groups returned to play. There was one recurrence in Group 1 and two recurrences in Group 2.

Conclusion:

Ankle syndesmosis sprains are debilitating injuries for NFL players and result in significant time lost from sport. Compared to our control group, the use of corticosteroid injection coupled with standard rehabilitation for acute stable ankle syndesmosis sprains hastened return to play by an average of 40% (10 days). In a highly competitive athlete, this may represent a significant clinical difference.
Does Sex Matter? Analysis Of Results At 5 Years After Matrix-assisted Autologous Chondrocyte Transplantation In A Large Cohort Of Patients
Authors: Kon Elizaveta , Patella Silvio , Filardo Giuseppe , Martino Alessandro Di , Perdisa Francesco , Matteo Berardo Di , Merli Maria Letizia , Marcacci Maurilio
Published: September 2013

Objectives:

The main purpose was to document and analyze the influence of sex on the clinical outcome in a large cohort of patients treated with a cartilage regenerative procedure for knee chondral lesions and prospectively followed at medium-term follow-up.

Methods:

250 knees have been treated with matrix-assisted autologous chondrocyte transplantation (MACT) and prospectively evaluated at 1, 2, and minimum 5-year follow-up. The patients were 182 men and 68 women affected by focal International Cartilage Repair Society (ICRS) grade III-IV chondral knee defects involving femoral condyles, trochleae and patellae. Two homogeneous groups of 56 patients each have been selected by a blinded independent statistician for a case-control comparative analysis. The clinical outcome was analysed using the Cartilage standard Evaluation Form as proposed by ICRS and the Tegner score.

Results:

After the treatment, a statistically significant improvement in all the scores was observed in both groups. The IKDC subjective score showed better results for men at all follow-ups in the general population: 79.5±18.6 vs 64.3±20.2 for men and women respectively (p<0.0005) at 5 years; the same trend was confirmed by EQ-VAS and Tegner scores. The case control analysis with scores standardized according to the specific patient category didn’t confirm the sex related difference and did not show any statistically significant difference at all follow-ups between men and women. Etiology, lesion site and pre-injury activity level differ in women and men affected by cartilage lesions and are responsible for the difference in the final outcome of the general population.

Conclusion:

Women have a different chondral lesion pattern; more frequently they present unfavorable conditions related to etiology, site and activity level; they also reach lower not normalized scores. However, a case-control analysis with normalized data for the specific patient's categories showed that on equal terms women have the same success possibilities than men after a surgical treatment for knee cartilage regeneration.
Comparable Maintenance of Tibial Slope in Two High Tibial Osteotomy Techniques
Authors: Hamilton Stephen Christopher , Bennett Grant Whitby , Bush Curtis Anderson , Wyland Douglas J.
Published: September 2013

Objectives:

High tibial osteotomies (HTO) are commonly performed to correct coronal malalignment in young, active patients who have concomitant cartilage lesions and/or cruciate ligament insufficiency. An unintended change of native tibial slope can negatively affect both the strain on reconstructed cruciate ligaments and the contact forces on cartilage. Therefore, one of the goals when performing an HTO is to minimize any change in posterior tibial slope. This study was designed to determine if there is a time zero difference in the maintenance of native tibial slope when performing valgus producing opening wedge HTOs using two distinct surgical techniques and fixation devices.

Methods:

Controlled Laboratory Study. Experienced surgeons performed valgus producing opening wedge HTOs in 24 matched paired cadaveric specimens using free hand (FH, n=12) and biplanar cutting jig (Jig, n=12) techniques. Digital fluoroscopy was used to capture anteroposterior and lateral images in all specimens, and the angle of posterior tibial slope (TS) was measured using digital software (NIH image; Bethesda, MD) in a manner blinded for technique and fixation.

Results:

There was good to excellent intra- and inter-observer reliability with the measurement technique using a Model 3, k, intra-class correlation coefficient (ICC). Both observers’ measurements passed tests for homogeneity (p=0.07, and p=0.12). There was no significant change in the maintenance of tibial slope between JIG and FH groups for observer 1 [JIG = 2.40° (SD = 1.3°) FH= 2.95° (SD=2.89°), p = 0.55] or observer 2 [JIG = 2.32° (SD = 2.5°) FH = 3.14° (SD=3.3°), p = 0.49].

Conclusion:

When performing a valgus producing opening wedge HTO, neither the cutting jig nor the free hand technique maintained native posterior tibial slope. Both techniques increased posterior tibial slope by an average of 2-3° with no significant difference between the groups. This change in posterior tibial slope is consistent with previously reported values in the literature.
Intra- And Inter- Observer Agreement In The Classification And Treatment Of Midshaft Clavicle Fractures
Authors: Jones Grant L. , Bishop Julie , Lewis Brian , Pedroza Angela , MOON Shoulder Group
Published: September 2013

Objectives:

The purpose of this study was to determine the intraobserver and interobserver reliability in the classification of midshaft clavicle fractures via standard plain radiographs and to determine the intraobserver and interobserver agreement in the treatment of these fractures.

Methods:

Charts of patients seen by the two senior authors from 2006 to 2011 were reviewed to identify patients treated for clavicle fractures (CPT 23500 and 23515). AP and 30 degree cephalad radiographs were selected, representing midshaft clavicle fractures treated both operatively and non-operatively. Thirty pairs of radiographs were included in the investigation. The radiographs were standardized for size to allow accurate measurements within a non-PACS program. A PDF file was created with all representative radiographs. Clinical scenarios were created for each set of radiographs, and the evaluators were asked to perform the following tasks: 1) measure the degree of shortening in millimeters; 2) determine the percent displacement; 3) determine whether the fracture was comminuted; and 4) state whether they would treat the fracture operatively or non-operatively. The radiographs and clinical scenario handout, along with instructions on how to use the measuring tool with Adobe Reader, were distributed to 16 shoulder/sports medicine fellowship-trained orthopaedic surgeons who completed the evaluations. The radiographs and scenarios were then reordered and redistributed approximately three months later.

Results:

Intra and interobserver results are summarized in table 1. The following variables statistically predicted whether surgery was recommended (p< 0.001): 1) odds of surgery are 2.26 if comminution was noted holding displacement and the interaction between displacement and shortening constant, and 2) the odds of surgery are 3.37 if there is displacement > 100% compared to displacement 0-49% holding comminution and shortening constant.

Conclusion:

Our study demonstrated that there was moderate to strong interobserver and intraobserver agreement for both displacement and comminution when utilizing standard plain radiographs. However, there was only weak to no interobserver agreement and minimal intraobserver agreement on the amount of shortening. Also, there was minimal interobserver and only moderate intraobserver agreement on whether operative treatment should be selected, most likely due to the poor reliability of plain radiographs in determining the degree of shortening. Therefore, other modalities including comparison radiographs of the contralateral clavicle should be considered to more reliably measure the degree of shortening and help determine the need for surgery.
Does One Size Fit All: Variation In Tibial Tubercle Trochlear Groove (TTTG) Measurements As A Function Of Age, Size, And Patellar Instability
Authors: Pennock Andrew T. , Alam Milad , Bastrom Tracey P.
Published: September 2013

Objectives:

The tibial tubercle trochlear groove (TTTG) measurement was developed to quantify rotational abnormalities about the knee associated with patella instability and to help guide surgical decision making. The purpose of this study was to assess variations in TTTG as a function of patient age and size in a population of patients with patella instability compared to those with no instability.

Methods:

This IRB approved retrospective study assessed all patients under the age of 21 undergoing a surgical procedure for patella instability from 2010 to 2012. A cohort of 180 patients with no history of patella instability or patellofemoral complaints was used as a control group. TTTG was measured in all patients on MR axial images using the centers of the tibial tubercle and the trochlear groove. Data was then normalized based on patient height, weight, BMI, and femur width. Statistical analysis was performed with an alpha set at p<0.05 to declare significance.

Results:

The average age of the 45 patella instability patients was 15.4 years (range 10 - 18), their mean TTTG was 16.3 mm (range 6.5 - 26), and 51% were male. By comparison, the mean age of the control was 16 years (range 10-19), the mean TTTG was 11.7 mm (range 3 - 22), and 58% were male. The TTTG and the normalized TTTG for height, weight, BMI, and femur width were all greater in the patella instability group compared to the control group (p≤0.001). 31% of patients had a TTTG greater than 20 mm in the instability group compared to 2.7% in the control group (p<0.05, Specificity 97%, Sensitivity 31%). TTTG was found to increase as a function of height in both groups (r =0.14, p=0.04) and decreased with age only in the instability group (r = -0.3, p=0.04). There was no correlation between TTTG and age in the non-instability group (r= -0.04, p=0.5). TTTG was not associated with patient gender, weight, or BMI (p>0.05).

Conclusion:

Much like adult patients, an elevated TTTG is associated with patella instability both in pediatric and adolescent patients. However, this measurement varies as a function of patient age and height. Normalization of TTTG to patient height may control for size variations and should be undertaken in the work-up and management of patients with patella instability. Given the dependence of TTTG on patient age and height, care should be taken when using absolute values or a singular critical cutoff in the adolescent or pediatric population in the surgical decision process.
Arthroscopic Hip Revision Surgery for Residual FAI: Surgical Outcomes
Authors: Larson Christopher M. , Giveans Russell , Bedi Asheesh , Samuelson Kathryn M. , Stone Rebecca M.
Published: September 2013

Objectives:

There is a steep surgical learning curve when managing femoroacetabular impingement (FAI) and residual FAI can lead to continued pain and disability. There is very limited data reporting outcomes after revision arthroscopy for residual FAI.

Methods:

The records of patients that underwent arthroscopic hip revision surgery for residual FAI based on plain radiographs and 3D CT scans were reviewed. Pre and post-operative structural pathomorphology, intra-operative findings, and pre and post-operative outcomes measures using Modified Harris Hip Scoring (MHHS), SF-12 scoring, and pain on a visual analogue scale (VAS) were evaluated. Outcomes after revision arthroscopic FAI correction were compared to a cohort that underwent primary arthroscopic FAI correction.

Results:

48 patients (53 hips) underwent arthroscopic revision FAI correction (mean 20.0 months follow-up). There were 62 previous arthroscopic surgeries and 4 previous surgical dislocations. There were 23 males and 25 females with a mean age of 29.9 years (range 18 - 59). 48 hips had residual cam-type FAI, and 40 hips had residual pincer-type FAI and underwent femoral and rim resections, respectively. The labrum was debrided in 27 hips, repaired in 24 hips and reconstructed with allograft in 2 hips. Adhesions were excised for 35 hips. The results of revision arthroscopic FAI correction were compared to 154 patients (169 hips) that underwent primary arthroscopic FAI correction (mean 25.2 months follow-up). The mean improvement for outcomes scores after revision FAI correction was 13.7 points (MHHS, p<.01), 8.6 points (SF-12, p<.01), and 2.6 points (VAS, p<.01) compared to 23.7 points (MHHS, p<.01), 22.3 points (SF-12, p<.01), and 4.6 points (VAS, p<.01) after primary arthroscopic FAI correction. Most recent outcomes scores and mean improvement in outcome scores were significantly better after primary (81% good/ excellent results) compared to revision (63.3% good/excellent results) FAI correction (MHS (p=.012), SF-12 (p<.01), VAS (p<.01).

Conclusion:

With appropriate indications and expectations, arthroscopic hip revision surgery for residual FAI led to significantly improved outcome measures. Outcomes, however, were inferior to those after primary arthroscopic FAI corrective surgery.
Radiographic Evaluation of Pincer-type FAI
Authors: Skendzel Jack G. , Goljan Peter , Briggs Karen K. , Philippon Marc J.
Published: September 2013

Objectives:

Radiographic analysis is utilized by surgeons to evaluate for the presence of both cam- and pincer-type femoroacetabular impingement (FAI). Coxa profunda, in which the acetabular fossa crosses or touches the ilioischial line medially, as well as the acetabular crossover sign, in which the anterior acetabular wall is more lateral than the posterior wall, are two of the methods historically employed in making a diagnosis of pincer-type FAI. It has also been proposed that lateral center edge (LCE) angles > 40 degrees are indicative of acetabular overcoverage.

Methods:

Between March 2005 and September 2006, 677 consecutive patients presented to the clinic for surgical treatment of hip pain due to FAI and associated chondrolabral dysfunction. All patients underwent radiographic imaging consisting of an AP pelvis as part of a standard clinical evaluation. From these radiographs, the presence of coxa profunda, the crossover sign, and the lateral center edge angle were prospectively recorded for each patient. Patients were included in the study if they had a properly performed AP radiograph of the pelvis. Exclusion criteria included a history of avascular necrosis, previous hip fracture, systemic inflammatory disease affecting the hip, or any prior hip surgery. The incidence of coxa profunda and the acetabular crossover sign was determined. We hypothesized that coxa profunda and the crossover sign are not associated with increased lateral center edge angles.

Results:

There were 207 patients that met the inclusion criteria and were included in the study. The average age of the patients was 42 (range, 18 to 77). The prevalence of coxa profunda and the acetabular crossover sign was 127/207 (61.3%) and 79/207 (38.1%), respectively. The average LCE angle was 34 degrees (range, 20 to 52). There was no significant difference between LCE angles and gender (p = 0.809) and the presence of an acetabular crossover sign and gender were not associated (p = 0.468). Coxa profunda was more commonly associated with female gender (p = 0.0001). Coxa profunda was not associated with the presence of a crossover sign (p = 0.890), nor was it associated with a LCE angle greater than 40 degrees (p = 0.732). Twenty-eight hips had LCE over 40(13%). There was no significant difference in the LCE angle in patients with a positive crossover sign(34.3 vs 34.0;p = 0.657) or coxa profunda (34.6 vs 33.3;p = 0.119).

Conclusion:

Coxa profunda and the presence of a crossover sign are not associated with significant lateral acetabular overcoverage (LCE angles > 40 degrees). The presence of an elevated LCE angle does not always indicate acetabular overcoverage.
Hip Labral Tears among Asymptomatic Professional Hockey Players Identified on MRI
Authors: Gallo Robert A. , Silvis Matthew , Smetana Brandon , Mosher Timothy , Stuck Dan , Lynch Scott A. , Black Kevin P.
Published: September 2013

Objectives:

We have previously reported on the prevalence of pathologic hip findings on the MRIs of asymptomatic professional hockey players. The significance of these findings, found in the asymptomatic player, is unknown. The purpose of this study is to report clinical follow-up of this cohort at four years.

Methods:

21 professional hockey players with no previous hip/groin pain underwent hip/pelvis MRI. Self-reported symptoms were measured using a modified Oswestry Disability Questionnaires at one and two years following MRI. Games played for each player were followed over a four-year period. Variance of games played greater than five per year compared to baseline (games played year prior to MRI) were explored for specific injury.

Results:

16/21 and 14/21 minor league hockey players were available at one- and two-year follow-up, respectively. 19/21 players remained active within four years. Fourteen remained at same level, four advanced to higher level of play, and one was demoted to a lower level at the end of four years. At one-year follow-up, two players (both with labral tear) admitted to groin pain; one, who also had bilateral adductor tendinosis, eventually missed games due to lateral hip pain in the third season after the MRI. At two-year follow-up, one other player (bilateral labral tears) admitted to hip tightness for a week but did not miss any games. Of the15 players that had an asymptomatic labral tear, two players advanced to NHL, ten remained at same level, one demoted, and two retired within four-year follow-up period. Among 9 players with labral tears on original MRI and available for questioning at two years, seven had no hip or groin symptoms and only one of 3 “symptomatic” players missed any games or sought treatment. Only four players had no abnormalities on MRI. None developed symptoms within two years. 3/4 remained at same level while the other advanced to the NHL.

Conclusion:

Although common on MRI among asymptomatic professional hockey players, hip labral tears produce symptoms in 20% within two years, but only 6.7% result in missed games within four years due to hip-related pain.
Pre-operative Femoral Nerve Block in Hip Arthroscopy—A Retrospective Review of 108 Consecutive Cases
Authors: Dold Andrew P. , Murnaghan Michael Lucas , Brull Richard , Whelan Daniel B.
Published: September 2013

Objectives:

To evaluate the safety and efficacy of pre-operative femoral nerve block for post-operative pain control in patients undergoing hip arthroscopy.

Methods:

A retrospective chart review of 108 consecutive hip arthroscopy cases (in 103 patients) was carried out. All patients underwent hip arthroscopy at a single academic centre by two orthpaedic surgeons with advanced fellowship training in hip arthroscopy. All patients underwent arthroscopy under general anaesthetic with our without pre-operative femoral nerve block. Patients were separated into two groups based on the presence or absence of a pre-operative femoral nerve block prior to induction of general anesthesia. Groups were compared with respect to patient gender, age, body mass index (BMI), ASA Physical Status classification, procedure performed, operative time, total intra-operative morphine-equivalent dose, post-anesthesia care unit (PACU) pain scores (0 to 10) recorded at 0, 15, 30, 45, and 60 minutes post-operatively, total PACU morphine-equivalent dose, presence of nausea or vomiting in the PACU, time to discharge from PACU, oxycodone consumption in the surgical day care unit (SDCU), and highest pain score (0 to 10) in the SDCU prior to discharge.

Results:

Twelve cases were excluded from analysis for a total of 96 cases (in 92 patients). Forty patients had general anesthesia alone (Group A) and 56 patients had a pre-operative femoral nerve block prior to the induction of general anesthesia (Group B). There was no significant difference between the groups with regard to gender, age, weight, height, BMI, ASA classification, or type of procedure performed. Patients who received a femoral nerve block had a significantly shorter operative time and received a significantly lower total intra-operative morphine-equivalent dose than those patients who did not receive a block. Post-operative pain scores were lower at all time points for the femoral nerve block group, however statistical significance was seen only at the 60 minute post-operative time point (p < 0.05). Patients who did not receive a block had significantly higher morphine-equivalent doses in the PACU. There was no difference in rates of nausea and vomiting and time to discharge from the PACU between the two groups. Oxycodone consumption in the surgical day care unit (SDCU) was similar between groups, but the femoral nerve block patients had significantly lower pain scores prior to discharge from the SDCU. Two patients in Group A group were admitted to hospital post-operatively due to inadequate post-operative pain control. No complications were noted in any patient with regard to the femoral nerve block.

Conclusion:

A pre-operative femoral nerve block is a safe procedure that may decrease the requirement for intra-operative morphine while providing effective post-operative pain control in patients undergoing hip arthroscopy.
Functional Outcomes Following Surgical Repair of Acute and Chronic Ruptures of the Proximal Hamstring Tendons
Authors: Larson Christopher M. , Rust David , Samuelson Kathryn M. , Giveans Russell , Stone Rebecca M.
Published: September 2013

Objectives:

Surgical repair of complete ruptures of the proximal hamstring tendons have shown improved function compared with non-operative treatment, however, results have been less favorable in the setting of a chronic tendon rupture. We previously described our surgical technique using an allograft Achilles tendon reconstruction and now report on functional outcomes of a larger patient cohort with longer follow-up and compare these with patients that underwent acute primary repair.

Methods:

Between 2002 and 2011, 23 patients with chronic ruptures who had undergone reconstruction using an Achilles tendon allograft and 57 patients with acute ruptures who had undergone primary repair were contacted and asked to rate their current function from 0-100% for both activities of daily living and sports-related activities. Additionally, those with chronic ruptures were asked to rate their level of function after their injury and prior to surgery. Patients were also asked to complete the SF-12 and a Patient Satisfaction Questionnaire.

Results:

Patients who had an Achilles reconstruction for chronic tears reported significant improvement in their function from pre-surgery to post-surgery for both activities of daily living (51% vs. 90%, p < 0.01) and sports-related activities (20% vs. 68%, p < 0.01) at an average follow-up of 46.8 months. Compared with the acute repair group (average follow-up 42.3 months) those in the chronic reconstruction group reported similar function for activities of daily living (90% vs. 92%, p = 0.484), but decreased function in sports-related activities, which approached statistical significance (68% vs. 79%, p = 0.125). A higher percentage in the acute repair group reported that their hamstring felt “normal” (83% vs. 67%, p=.013). All other quality of life and satisfaction scores were similar between groups.

Conclusion:

Both acute repair and chronic reconstruction of complete proximal hamstring tears yield favorable results for activities of daily living. With respect to sports-related activities, acute repair yields improved function. For low-demand patients or those with medical comorbidities that preclude acute surgical treatment, initial non-operative management with the option for Achilles allograft reconstruction at a later time can be expected to give approx 90% return of function for everyday activities. For patients that desire to return to sports or higher demand activities, acute repair is recommended.
Risk factors for Recurrent Anterior Cruciate Ligament Reconstruction: A Population Study in Ontario, Canada with 5-year Follow-up
Authors: FRCSC David Wasserstein , Khoshbin Amir , Dwyer Tim , Chahal Jaskarndip , Gandhi Rajiv , Mahomed Nizar , Ogilvie-Harris Darrell
Published: September 2013

Objectives:

Anterior cruciate ligament reconstruction (ACLR) is routinely performed to treat symptomatic instability. Despite being a common procedure, significant variation persists in technique and graft choice. How patient, provider and surgical factors influence the risk of revision or contralateral primary ACLR has not been investigated using administrative data. The goal of our study was to define the rate and risk factors for ACL re-operation in Ontario.

Methods:

All primary elective ACLR performed in Ontario, Canada from July 2003 to March 2008 in patients aged 15 to 60 years were identified via billing, diagnosis and procedural databases. The main outcomes were revision and contralateral ACLR, sought until January 2012. Patient factors (age, gender, co-morbidity, income quintile, and length of index hospital admission), provider factors (surgeon volume, academic hospital status) and surgical factors (allograft vs. autograft; fixation: screw, button, staple; concomitant operative procedures) were used as covariates in a Cox Proportional Hazards survivorship model to generate Hazard Ratios (HR) with confidence intervals (alpha 0.05). Kaplan-Meier survivorship curves to revision were generated.

Results:

A total of 12,967 ACLR with a mean follow-up of 5.2 years were identified. The revision rate was 2.6% [after a median 2.72 years (interquartile range 1.38, 4.11)]. The rate of primary contralateral ACLR was 4.6% [after a median 2.71 years (interquartile range 1.49, 4.22)]. In the Cox model, younger age [15-19 years; HR=2.1 (95% CI: 1.5-2.9), p<0.001], ACLR performed at an academic hospital [HR=1.6 (95% CI: 1.2-2.1), p<0.001] and the use of allograft [HR=1.7 (95% CI: 1.1-2.6), p=0.02] significantly increased the risk of revision ACLR. The K-M curves to revision ACLR for allograft and autograft demonstrated equivalent survivorship for approximately 3 years, after which allograft ACLR were more commonly revised (Figure 1). Only younger age [15-19 years; HR=2.1, (95% CI: 1.6-2.7), p<0.001] was associated with an increased risk of contralateral ACLR.

Conclusion:

Contralateral ACLR was more frequent than revision ACLR in this population, while both re-operations were significantly more common in patients <20 years old. Academic hospital status but not surgeon volume, and the use of allograft also increased the risk of revision ACLR. Late failure of allograft ACLR is a novel finding.