Signs Of Impingement Research Articles

Magnetic resonance imaging (MRI) of the knee: Identification of difficult-to-diagnose meniscal lesions.

This article characterizes common meniscal pathologies, reviews magnetic resonance imaging (MRI) diagnostic criteria for meniscal tears, and identifies difficult-to-detect tears and fragments and the best MRI sequences and practices for recognizing these lesions. These difficult-to-diagnose meniscal lesions that radiologists should consider include tears, meniscocapsular separation lesions, and displaced meniscal fragments. Meniscus tears are either vertical, which are generally associated with traumatic injury, horizontal, which are associated with degenerative injury, or combinations of both. MRI has a high sensitivity for tears but not for fragments; MRI performance is also better for medial than lateral meniscal lesions. Fragment detection can be improved by recognizing signs secondary to migration, especially signs of epiphyseal irritation and mechanical impingement. Radial and peripheral tears, as well as those close to the posterior horn insertion, have been traditionally difficult to detect, but improvements in arthroscopic knowledge, identification of common lesion patterns, and selection of the proper MRI sequence and plane for each lesion type mean that, when properly used, MRI is an invaluable tool in detecting all types of meniscal tears.

Scapular kinematics in professional wheelchair tennis players

BackgroundParticipating in wheelchair tennis increases the demands placed on the shoulder and could increase the risk of developing shoulder pain and injury that might be associated with differences in scapular kinematics. The aim of the study was to examine the presence of shoulder pain and scapular kinematics in professional wheelchair tennis players. MethodScapular kinematics were obtained in 11 professional wheelchair tennis players, 16 people with shoulder impingement and 16 people without shoulder impingement during humeral elevation and lowering. Clinical examination of the wheelchair tennis players was undertaken using the Wheelchair Users Shoulder Disability Index (WUSPI) and clinical signs of shoulder impingement. FindingsThe WUSPI questionnaire (mean = 28 SD 13.8) demonstrated wheelchair tennis participants experienced little shoulder pain and clinical examination revealed negative impingement tests. Wheelchair tennis players had greater scapular posterior tilt during humeral elevation (3.9° SE 1.71; P = 0.048) and lowering (4.3° SE 1.8; P = 0.04) on the dominant compared to non-dominant side. The dominant scapulae of wheelchair tennis players were significantly (P = 0.014) more upwardly rotated (21° SD 6.7) than the scapulae of people with shoulder impingement (14.1° SD 7.0) during scapular plane humeral elevation. InterpretationThis first study of scapular kinematics in professional wheelchair tennis athletes demonstrated bilateral asymmetries and differences to able-bodied participants with shoulder impingement. Understanding the role of sport participation on shoulder function in wheelchair users would assist in the development of preventative and treatment exercise programmes for wheelchair users at risk of shoulder injury and pain.

Evidence-Based Review of Clinical Diagnostic Tests and Predictive Clinical Tests That Evaluate Response to Conservative Rehabilitation for Posterior Glenohumeral Instability: A Systematic Review

Context:Posterior glenohumeral instability is poorly understood and can be challenging to recognize and evaluate. Using evidence-based clinical and predictive tests can assist clinicians in appropriate assessment and management.Objective:To review evidence-based clinical diagnostic tests for posterior glenohumeral instability and predictive tests that identify responders to conservative management.Data Sources:A comprehensive electronic bibliographic search was conducted using Embase, Ovid MEDLINE, PEDro, and CINAHL databases from their date of inception to February 2017.Study Selection:Studies were included for further review if they (1) reported on clinical diagnostic tests for posterior or posteroinferior instability of the glenohumeral joint, (2) assessed predictive clinical tests for posterior instability of the glenohumeral joint, and (3) were in English.Study Design:Systematic review.Level of Evidence:Level 4.Data Extraction:Data were extracted from the studies by 2 independent reviewers and included patient demographics and characteristics, index/reference test details (name and description of test), findings, and data available to calculate psychometric properties.Results:Five diagnostic and 2 predictive studies were selected for review. There was weak evidence for the use of the jerk test, Kim test, posterior impingement sign, and O’Brien test as stand-alone clinical tests for identifying posterior instability. Additionally, there was weak evidence to support the use of the painless jerk test and the hand squeeze sign as predictive tests for responders to conservative management. These findings are attributed to study design limitations, including small and/or nonrepresentative samples.Conclusion:Clustering of thorough history and physical examination findings, including the aforementioned tests, may identify those with posterior glenohumeral instability and assist in developing management strategies.

A case of malalignment between the scapula and trunk that induced signs of shoulder joint impingement

A case of malalignment between the scapula and trunk that induced signs of shoulder joint impingement

Incidence of femoro-acetabular impingement in adult Indian population on the basis of specific radiological findings: A prospective study

4Introduction: Femoroacetabular impingement is a major cause of early osteoarthritis of the hip, especially in young and active patients. It is characterized by an early pathologic contact during hip joint motion between acetabulum and femur that limits the physiologic hip range of motion,. Depending on clinical and radiographic findings, it can be pincer or cam type. Most patients (86%) have a combination of both forms. The role of imaging in femoroacetabular impingement is to evaluate the hip for abnormalities associated with impingement and to exclude arthritis, avascular necrosis, or other joint problems on radiographs. Materials and Methods: Between August 2010 and November 2010, 100 radiographs of pelvis with both hips and both hips lateral view of normal subjects were obtained and included in this study. All radiographic parameters of interest in the present study were assessed by three observers including one radiologist. The intraobserver and interobserver coefficients for the various parameters, assessed on a sub-set of fifty radiographs, ranged from 0.90 to 0.98 which was significant. All the 100 sets of 3 x-rays were studied in this manner. Discussion: The aim of our study was to determine the prevalence of femoroacetabular impingement in Indian population. Western countries have a proportionally higher rate of primary osteoarthritis of hip. It is increasingly coming to notice that radiographs of idiopathic osteoarthritis of hip show signs of femoroacetabular impingement. Therefore, there could be a causal association between femoroacetabular impingement and idiopathic osteoarthritis of hip. Conclusion: Femoroacetabular impingement is recognized condition causing hip pain in young active adults and is believed to be a cause of hip osteoarthritis. Further studies are still required to evaluate the nature of disease process, its natural history, actual cause and effect relationship between femoroacetabular impingement and osteoarthritis.

Association of femoroacetabular impingement and adductor enthesopathy; prevalence and outcomes

Introduction The painful groin is a challenging entity. The complexity of groin anatomy, the similarity of symptoms for different pathologies that may coexist may lead to a diagnostic dilemma and to delays in treatment. The purpose of the study is to assess the prevalence of symptoms consistent with adductor enthesopathy in patients require arthroscopic surgery for treatment of femoroacetabular impingement (FAI) and to evaluate the results of surgical treatment for both of these disorders. Methods Prospectively collected data were retrieved to identify patients with both symptomatic FAI and adductor enthesopathy at the time of presentation. Demographics, clinical examination, imaging signs of hip impingement and adductor enthesopathy were recorded. Isometric strength testing of the adductors and abductors was measured in both legs using a handheld dynamometer. Patients completed the modified Harris hip score (MHHS) pre and postoperatively and pain was evaluated on a visual analog scale. Results From our database of 1135 patients were included 38 (3.34%) patients (44 hips). There were 31 males and 7 females with a mean age 36.8 years (20–63, SD 11.6). Mean follow-up was 27.7 months (SD 19.7). Pubic cleft injections were carried out in 37 (84.09%) hips and 20 (45.4%) hips underwent selective partial adductor release. All of the patients (100%) underwent hip arthroscopic surgery for FAI. Maximum improvement in strength was observed at two months postoperatively both on the operated and non-operated side compared to preoperative strength. The MHHS improved from mean 60 (21–74, SD 16.2) preoperatively to 79 (30–100, SD 17.6) postoperatively and VAS for pain from 6.9 (SD 1.7) to 2.8 (SD 2.6). Conclusion When FAI and adductor enthesopathy are present then both pathologies should be addressed simultaneously or in a staged manner to optimize the postoperative outcomes. Pubic cleft injections and selective partial adductor release are valuable therapeutic procedures in patients treated for symptomatic FAI.

Cam Deformities and Limited Hip Range of Motion Are Associated With Early Osteoarthritic Changes in Adolescent Athletes: A Prospective Matched Cohort Study

Background: The natural history of femoroacetabular impingement (FAI) remains incompletely understood. In particular, there is limited documentation of joint damage in adolescent patients with limited range of motion (LROM) of the hip, which is commonly associated with FAI. Purpose: To evaluate changes in magnetic resonance imaging (MRI), radiographs, and clinical examinations over 5 years in a group of athletes from a wide variety of sports with asymptomatic LROM of the hip compared with matched controls. Study Design: Cohort study (prognosis); Level of evidence, 2. Methods: The authors screened 226 male and female athletes aged 12 to 18 years presenting for preparticipation sports physical examinations. Using a goniometer, we identified 13 participants with at least one hip having internal rotation <10° with the hip flexed to 90°. Overall, 21 of 26 hips (81%) had internal rotation <10°. These participants were age- and sex-matched to 13 controls with internal rotation >10°. At the time of enrollment, all participants were asymptomatic and underwent a complete hip examination and radiographic imaging with radiographs (anteroposterior [AP] and von Rosen views) and non-arthrogram MRI. Participants returned at 5-year follow-up and underwent repeat hip examinations, imaging (AP and lateral radiographs and non-arthrogram MRI), and hip function questionnaires. MRI scans were classified as “normal” versus “abnormal” based on the presence of any of 13 scored chondral, labral, or osseous abnormalities. Comparisons between the LROM group and control group were performed using generalized linear models (either linear, logistic, or log-binomial regression as appropriate for the outcome) with generalized estimating equations to account for the within-participant correlation due to patients having both hips included. Relative risk (RR) estimates are reported with 95% CIs. Results: At the time of study enrollment, 16 of 26 hips (62%) in the LROM group had abnormal MRI findings within the acetabular labrum or cartilage compared with 8 of 26 hips (31%) in the control group (RR, 2.0; 95% CI, 0.95-4.2; P = .067). The mean alpha angle measured from radial MRI sequences was 58° in the LROM group versus 44° in the control group (P < .0001). In the LROM group, 13 of 26 hips (50%) had a positive anterior impingement sign, whereas 0 of 26 hips (0%) had a positive anterior impingement sign in the control group. At 5-year follow-up, 18 of 19 hips (95%) in the LROM group had abnormal MRI findings compared with 14 of 26 hips (54%) in the control group (RR, 1.7; 95% CI, 1.1-2.7; P = .014). New or progressive findings were documented on MRI in 15 of 20 hips in the LROM group compared with 8 of 26 hips in the control group (RR, 2.4; 95% CI, 1.2-4.8; P = .011). Six of 22 hips (27%) in the LROM group progressed from Tönnis grade 0 to Tönnis grade 1 in degenerative changes, whereas all 26 hips in the control group remained at Tönnis grade 0 on hip radiographs. In the LROM group, 11 of 22 hips (50%) had a positive anterior impingement sign, whereas 1 of 26 hips (4%) had a positive anterior impingement sign in the control group. A cam deformity (alpha angle >55° on lateral radiographs) was present in 20 of 22 hips (91%) in the LROM group and 12 of 26 hips (46%) in the control group (P = .0165). The following variables at baseline were associated with an increased risk of degenerative changes at 5-year follow-up for the entire cohort: decreased hip internal rotation, positive anterior impingement sign, decreased hip flexion, increased alpha angle, and presence of a cam lesion. Conclusion: At 5 years, young athletes with LROM of the hip showed increased progressive degenerative changes on MRI and radiographs compared with matched controls. Although the majority of these participants remained asymptomatic, those with features of FAI had radiographic findings consistent with early osteoarthritis. These outcomes suggest that more aggressive screening and counseling of young active patients may be helpful to prevent hip osteoarthritis in those with FAI.

Minimum 2-Year Outcomes of Hip Arthroscopic Surgery in Patients With Acetabular Overcoverage and Profunda Acetabulae Compared With Matched Controls With Normal Acetabular Coverage

Background: Advancements in instrumentation and techniques have extended the scope of hip arthroscopic surgery to treat complex osseous deformities that were previously best addressed with an open approach. Global pincer-type femoroacetabular impingement is an example of an abnormality requiring osseous correction with a technically challenging access point. Purpose: To report on the patterns of clinical presentation and intra-articular derangements, radiological associations, and minimum 2-year outcomes after hip arthroscopic surgery in patients with a lateral center edge angle (LCEA) >40° and profunda acetabulae in comparison with matched controls with normal acetabular coverage. Study Design: Cohort study; Level of evidence, 3. Methods: Data were collected on all patients undergoing hip arthroscopic surgery during the study period from April 2008 to April 2013. All patients who had undergone hip arthroscopic surgery for symptomatic labral tears not responsive to a minimum of 3 months of physical therapy with both an LCEA >40° and profunda acetabulae, as defined by the ilioischial line lateral to the medial border of the teardrop, and without a history of hip surgery or hip conditions were included. This group was matched in a 1-to-1 ratio with a control group that had also undergone the arthroscopic management of symptomatic labral tears refractory to a minimum of 3 months of physical therapy with an LCEA between 25° and 40° according to age within 3 years, sex, body mass index category, Tönnis grade, labral treatment, and capsular treatment. Range of motion, impingement signs, and radiographic indices of coverage and version were recorded for each group. Four patient-reported outcome (PRO) scores, the visual analog scale (VAS) for pain, patient satisfaction, revision hip arthroscopic surgery, and conversion to total hip arthroplasty (THA) were also recorded. Results: Thirty-nine patients met the inclusion criteria for the study (overcoverage) group, of which 36 (92.3%) patients had a minimum 2-year follow-up; 215 patients satisfied the inclusion criteria for the control (normal coverage) group, of which 183 (85.1%) had a minimum 2-year follow-up. Thirty-six patients were matched in each group using the above criteria. There was no difference with respect to range of motion and impingement signs between the groups. The study group had significantly higher radiological markers of overcoverage but not retroversion compared with the control group. The study group had a significantly higher incidence of Seldes type 2 tears compared with the control group: 50.0% versus 19.4%, respectively (P = .013). Both groups demonstrated significant improvements in the mean scores of all PROs, but the study group had a lower magnitude of improvement for all the PROs compared with the control group, with the modified Harris Hip Score (mHHS) achieving statistical significance: 13.5 versus 21.7 points, respectively (P = .032). The study group had a significantly lower mean patient satisfaction score compared with the control group: 6.61 versus 7.91, respectively (P = .019). The study group also had a significantly higher incidence of conversion to THA compared with the control group: 4 versus 0, respectively (P = .040). Conclusion: Hip arthroscopic surgery for the management of symptomatic labral tears in patients with combined overcoverage and coxa profunda is associated with improvements in patient outcomes and pain at a minimum 2-year follow-up. However, the degree of improvement is of lower magnitude compared with a matched cohort with normal coverage undergoing the arthroscopic management of symptomatic labral tears. While hips with lateral overcoverage combined with coxa profunda may have a smaller potential for improvement compared with hips with normal coverage, this type of osseous morphology is still repairable with arthroscopic treatment.

Radiologic Presentation in Subspine Impingement and Correlation with Intraarticular Impingement in the Hip

Background Besides the known intraarticular femoroacetabular impingement (FAI), recently forms of extra-articular impingement of the hip have been increasingly recognized. Recent studies have described an extra-articular impingement between a distal extension of the anterior inferior iliac spine (AIIS) and the femoral neck (AIIS or subspine impingement). Evidently, an association between this subspine impingement and an intraarticular FAI seems to exist. Little is known about the incidence of this impingement type and the value of its radiological diagnostics. The aim of this study was therefore to evaluate the correlation of a subspine impingement with intraarticular femoroacetabular impingement and radiological criteria of subspine impingement. Material and Methods In 2013 arthroscopic correction of intra-articular femoroacetabular impingement was performed in 80 cases. This collective was evaluated for simultaneous intraoperative findings of subspine impingement. In addition, the patients were evaluated for radiological signs of subspine impingement in conventional X-ray. A projection of the AIIS either below the acetabular sourcil or the anterior acetabular rim in an AP pelvis X-ray was considered as a radiological sign of low AIIS formation. These radiological findings were compared with the presence of intraoperative signs for subspine impingement, which are defined as a combination of focal capsule synovitis, labral ecchymosis close to the AIIS and a decreased offset between the acetabular rim and the AIIS. The specificity and sensitivity of the pre-operative radiological signs were calculated. Results A subspine impingement was found in 17 cases (21 %, 3 female, 14 male, mean age 28 years). A projection of the AIIS caudal to the acetabular sourcil in the AP pelvis X-ray was represented in 15 of the 17 cases detected (sensitivity 0.90, specificity 0.88). A projection below the anterior glenoid rim was detectable in 2 cases with symptomatic AIIS impingement (sensitivity 0.12, specificity 1). Conclusion A relevant proportion of patients with intraarticular FAI showed intraoperative signs for an additive extraarticular AIIS impingement. Preoperative pelvic X-rays are helpful with a sensitivity of 90 % in detecting the presence of a distal extension of the AIIS in FAI patients. Evaluation of the preoperative AP pelvis x-ray should include the projection of the AIIS. We recommend evaluation for subspine impingement during routine arthroscopy.

KALK study: ultrasound guided needling and lavage (barbotage) with steroid injection versus sham barbotage with and without steroid injection - protocol for a randomized, double-blinded, controlled, multicenter study

BackgroundFor the treatment of calcific tendinitis of the shoulder a variety of treatment regimes exist. Commonly used treatment measures include medication with oral analgesics, corticosteroid injections, extracorporeal shockwave therapy, ultrasound guided needling and lavage, and surgical treatment. Earlier cohort studies suggest that patients may benefit from these treatments, but there are few randomized studies and conflicting evidence about the effectiveness of the various treatments. In the present study we aim to compare the effectiveness of ultrasound guided needling and lavage (barbotage) together with a steroid injection to sham barbotage with and without an additional steroid injection.MethodsThe study will be performed in six secondary-care institutions in Norway and Sweden. It is designed as a pragmatic, randomized, three-arm, parallel group, double-blinded, sham-controlled clinical trial with a 2-year follow-up. It will be performed on 210 patients, aged 30 years or older, presenting with painful arc, positive impingement sign and a calcium deposit > 5 mm. Randomization to one of the three treatment options will be performed by using an online central randomization system. The three treatment groups are barbotage together with a subacromial steroid injection (the barbotage group), sham barbotage together with a subacromial steroid injection (the steroid group) or sham barbotage without a subacromial steroid injection (the placebo group). In the placebo group the steroid injection will be replaced by a short-acting local anaesthetic. Standardized home-based post-treatment physiotherapy will be performed by all patients for 8 weeks. Follow-ups are at 2 and 6 weeks, 4, 8, 12 and 24 months after treatment was given and will be performed with the patients and the outcome assessors blinded for group assignment. Primary outcome will be the Oxford shoulder score at 4 month follow-up. Secondary outcome measures are the QuickDASH upper extremity score, the EQ-5D-5L general health score and visual analogue scales for pain at rest, during activity, and at night.DiscussionThe scientific evidence from this placebo-controlled trial will be of importance for future treatment recommendations in patients with calcific tendinitis.Trial registrationClinicalTrials.gov: NCT02419040, registered 10 April 2015EudraCT: 2015-002343-34, registered 23 September 2015 (retrospectively registered)

Anterior internal impingement of the shoulder in rugby players and other overhead athletes

Background/ObjectiveImpingement syndromes are a common cause of shoulder pain in overhead athletes. Anterior internal impingement is a recently suggested mechanism for activity-related pain of the shoulder. Impingement syndromes were initially described to occur due to repetitive or excessive contact between the rotator cuff and other structures in the shoulder. MethodsThis is a retrospective, clinical case study reporting 54 consecutive cases of anterior internal impingement in overhead athletes, of which 28 (51.2%) cases were of rugby players. All had undergone physiotherapy without relief of the symptoms. Of 54, there were 45 male and 9 female patients with an average age of 27 years (range, 17–51). The mean duration from injury to surgery was 40.7 weeks (range, 5–364). Of the 54 patients, 29 (53.7%) were full-time professional and 25 (46.3%) were semiprofessional or recreational athletes. The players associated the onset of pain occurred following an injury in 29/54 cases (53.4%), whereas in the remaining 25 cases (46.2%), a gradual onset of symptoms was described. All 54 patients could demonstrate a “functional impingement sign” in positioning their arm and provoke pain. ResultOn examination, the examiner could reproduce the same pain in 38/54 (70.3%) patients only. Of the 54 patients, “SLAP tests” including O’Brien’s test, Palm up test, and compression rotation test were positive in shoulders of 39 (72.2 %) patients, Jobe’s test in 27 (50%), Gerber’s lift off test in 6 (11%), and Hawkin’s test in 6 (11%) patients. During arthroscopic assessment, impinging flap tears were found in 44 (81.4%) patients from the SLAP, whereas undersurface rotator cuff flap tears were found in 24 (44.4%), flap tears from the anterior or inferior labrum were found in 16 (29.6%), and distal subscapularis flap tears were found in 10 (18.5%) patients. Only in 12/54 patients (22.2%) was an isolated pathology found, in all cases SLAP tears. Treatment included vaporisation and excision of the impinging flaps. In 15/54 (27.7%) patients, repair of an unstable SLAP tear was undertaken using absorbable suture anchors and fibre wires. All athletes returned to their previous activity level within 17.2 weeks (range, 6–36) from surgery and were discharged when they claimed that they were symptom free. ConclusionThis series of anterior internal impingement, which we believe is the largest in the literature to date, demonstrates the value of an to assess and successfully treat overhead athletes with anterior impingement syndrome.

The Prevalence and Characteristics of Thoracic Outlet Syndrome in High School Baseball Players

Thoracic outlet syndrome (TOS) is one of the common neurovascular disorders of the upper extremities, and the compression or traction of the brachial plexus is the main pathology. We hypothesized that baseball players are more likely to be affected by TOS compared with other overhead-throwing athletes because of strenuous use of their throwing arm. The purpose of this study was to investigate the prevalence and clinical characteristics of TOS in high school baseball players. One thousand two hundred eighty-eight high school baseball players were included in this study. The prevalence of symptomatic TOS and its association to disorders of the upper extremities were investigated. The prevalence of symptomatic TOS was 32.8%. Age- and position-adjusted logistic regression analysis revealed that subjects with symptomatic TOS were at significantly higher risk of shoulder and/or elbow pain (odds ratio [OR]: 1.96, 95% confidence interval [CI]: 1.50 - 2.58) and a higher recurrence rate of shoulder and/or elbow pain during the previous season (OR: 2.38, 95% CI: 1.87 - 3.04). As for physical findings, subjects with symptomatic TOS were also at significantly higher risk of MUCL tenderness (OR: 2.53, 95% CI: 1.83 - 3.50), positive milking maneuver, (OR: 2.63, 95% CI: 1.78 - 3.91), positive subacromial impingement sign (OR: 1.92, 95% CI: 1.20 - 3.07), and positive posterior impingement sign (OR: 2.34, 95% CI: 1.67 - 3.28) compared to the subjects without symptomatic TOS. It is necessary to recognize that TOS is not a rare pathology in overhead-throwing athletes, especially baseball players, and that players with symptomatic TOS are at significantly higher risk of shoulder/elbow pain.

Transesophagography Identifies Guide Wire Impingement on the Tricuspid Valve Chordae Duringtranscatheter Closure of the Perimembranous Ventricular Septal Defect

Percutaneous transcatheter device closure of the perimembranous ventricular septal defect (VSD) in proper case is now an alternative to surgical VSD repair. However, some complications during the transcatheter closure procedure might happen, which includean impingement of the arteriovenous rail (AVr) in the chordae of tricuspid valve (TV) and result in chordae rupture withsevere tricuspid regurgitation. Conventionally, we used fluoroscopic images to help judginga ‘safe, straightAVr’ from a ‘wrong, curvedAVr’.Determined to observe the right from wrong AVr course with transesophagography (TEE) directly, we performed this study. This retrospective study enrolled 17 patients of perimembranous VSD that received transcatheter VSD closing procedure in Children's Hospital of China Medical University, Taichung, Taiwan in last 4 years. Philips iE33 Echocardiography with omniplane TEE probes were used. TEE study kept going on throughout the whole procedure. The spatial relationships between guiding wire, AVr, delivery long sheath and the AO valve, VSD, aneurysm tissue and TV were particularly noticed of. TV leaflets restriction or deformity by the guide wire or AVr, with or without tricuspid regurgitation, were considered as signs of chordae impingement and the AVr must be removed and re-attempted. Guide wire impingement on TV chordae occurred in one patient and AVr impingement occurred in 4 patients. Compared to the conventional fluoroscopic guideline of ‘wrong, curved AVr line’, only 2 of the 4 AVr impingement cases displayed this fluoroscopic curved line. Instead, TEE observed quite a few significant image abnormalities of TV restriction, including ‘dome-shape deformity of the septal leaflet at systole’, ‘ring-shape deformity at diastole’, ‘seagull deformity of TV at systole’, ‘hanging bed-deformity of TV at diastole’, and ‘redundant tissue tag’ etc., in addition to the appearance of TV regurgitation. For ascertain a safe AVr course that was passing rightly through the membranous VSD and the TV commissure, the fluoroscopic imageaddress only roughly ‘a straight’ from ‘a curved’ AVr line. TEE appeared to be a superior and useful modality for a detail description of TV impingement by AVr or guide wire.

Prevalence of Cam and Pincer Deformities in the X-Rays of Asymptomatic Individuals.

Objective The presence of radiological signs of femoroacetabular impingement (FAI) is not necessarily associated with symptoms. Hence, the prevalence of cam and pincer deformities in the overall population may be underestimated. The purpose of this study was to screen an unselected cohort of people without hip symptoms for native radiological signs of cam and pincer deformities to determine their actual prevalence. Materials and Methods 110 asymptomatic patients had AP pelvis X-rays and cross-table hip X-rays performed. We evaluated the images for the presence of cross-over signs and measured lateral center edge (LCE) angles, alpha angles (α-angles), and femoral offset ratios. Results Positive cross-over signs were seen in 34%; LCE angles > 40° in 13%; and femoral offset ratios < 0.18 in 43%. In 41% of the patients, α-angles were >50°. Male patients showed significantly higher α-angles, lower offset ratios, and a higher prevalence of cross-over signs. In contrast, female patients had significantly higher LCE angles. Conclusion According to our data, radiological signs of cam and pincer deformities are common in asymptomatic people. In clinical practice, patients presenting with hip pain and radiological signs of FAI should undergo further diagnostic evaluation. However, in asymptomatic patients, no further evaluation is recommended.

Outcome after arthroscopic labral surgery in patients previously treated with periacetabular osteotomy: a follow-up study of 43 patients.

To identify factors predicting failure after hip arthroscopy in patients with previous periacetabular osteotomy (PAO) defined as a conversion to total hip replacement (THR) and to evaluate the patient reported outcome scores. Of 55 hips treated with hip arthroscopy after PAO from Aug 2008 to 2012 at Aarhus University Hospital, 43 hips were included (median age: 36.1 yrs, range 16.3–56.9 yrs). Indications were unacceptable pain, a positive FABER and impingement test and signs of labral damage on MR-arthrography. Outcomes were evaluated with mHHS and HOS. Failure was defined as conversion to a THR. Nine hips were converted to a THR. Kaplan-Meier survival rate was 52.8% (95% CI, 10%–83.8%) at 6.5 years follow-up. Statistically significant predictors of failure: joint space width after PAO <3.0 mm and Tönnis grade of 2. Fourteen hips needed revision hip arthroscopy. Labral damage was present in 84% of the hips. In 42% of the hips cartilage lesions of Becks grade >3 were found. Mean mHHS and HOS were 65.7 and 68.8 respectively at follow-up. A NRS pain score of >3 in rest and during activity were present in respectively, 43% and 62% of the patients. Hip arthroscopy after PAO demonstrated limited clinical benefit with no decrease in pain levels and 21% of patients needing reoperation to THR. Radiographic signs of joint degeneration after PAO are predictors of faiElure. Further studies are needed to clarify what role hip arthroscopy should play in this patient group.

BRAZILIAN ORTHOPEDISTS' OPINIONS AND PERCEPTIONS ON FEMOROACETABULAR IMPINGEMENT.

ABSTRACTObjective: To assess the opinion of Brazilian orthopedists surgeons on the diagnosis and treatment of femoroacetabular impingement (FAI).Methods: A questionnaire was sent to several orthopedic societies around the world, including the Sociedade Brasileira de Ortopedia e Traumatologia (SBOT). This questionnaire was sent electronically and included questions on many topics related to FAI.Results: 253 Brazilian orthopedists responded the questionnaire. Sixty-eight point nine percent worked in private practice and 23.1% in academic institutions. Pain during hip rotation was the most important finding in the clinical history according to 81.8% of the respondents and the anterior impingement sign was the most important finding in the physical examination according to 88.2%. Initial treatment was physiotherapy according to 86.2%. Surgical treatment was hip arthroscopy according to 38.8%, and via surgical hip dislocation for 14.7%.Conclusion: Brazilian orthopedists' opinions on FAI are similar to their international colleagues. There is considerable discrepancy in the answers provided, demonstrating a need for future investigation on FAI, in order to institute proper treatment and diagnosis protocols. Level of Evidence V. Expert Opinion.

Neuropathic pain in patients with rotator cuff tears.

BackgroundRecent studies have confirmed the existence of neuropathic pain (NeP) components in patients with musculoskeletal disorders. However, the presence of NeP in patients with rotator cuff tears has not been investigated thus far. Therefore, we studied the prevalence of NeP and the prognostic factors for NeP in patients with rotator cuff tears.MethodsData were collected from 110 patients with rotator cuff tears, diagnosed by physical examination and magnetic resonance imaging, who attended an outpatient clinic between August 2013 and August 2014. The measured parameters included visual analog scale (VAS) pain scores, painDETECT questionnaire (PDQ) responses, a physical examination, and magnetic resonance imaging. To evaluate the factors associated with NeP, we performed a two-stage analysis. For univariate analysis, we used the Mann-Whitney U test. For multivariate analysis, forward stepwise regression was performed using factors that demonstrated statistical significance in the univariate analysis.ResultsPatients were classified into three groups according to their PDQ score: an NeP group (n = 12; 10.9 %), possible NeP group (n = 33; 30.0 %), and a nociceptive pain (NoP) group (n = 65; 59.1 %). In the univariate analysis between the NeP group and NoP group, NeP was affected by sex (p = 0.034), VAS score (average pain during the past 4 weeks; p = 0.013), and positive Neer and Hawkins impingement signs (p = 0.039). In the multivariate analysis, VAS score (p = 0.031) was an independent prognostic factor for NeP.ConclusionsUsing the PDQ, we found that 10.9 % of patients with rotator cuff tears may have NeP. The VAS score (average pain during the past 4 weeks) was a prognostic factor for NeP. Clinicians should remain vigilant for heterogeneous etiologies of pain in patients with rotator cuff tears.

Retrospective Analysis of Idiopathic Hip Osteoarthritis Based on Anteroposterior Pelvic Radiograph; Hip Osteoarthritis Caused by Femoroacetabular Impingement

Background: Femoroacetabular Impingement (FAI) means pathological impact between the femoral head-neck junction and the acetabular rim. Objectives: The aim of this retrospective study was to analyze Femoroacetabular Impingement (FAI) signs, which can lead to idiopathic hip osteoarthritis, from preoperative radiographs of patients indicated for total hip replacement as compared to radiographs of patients without this indication. Methods: We examined the preoperative anteroposterior (AP) pelvic radiograph, the pincer and cam FAI signs of patients between 45 and 60 years, who had undergone total hip replacement. We examined in the same group, the operated side and the non-operated hips with osteoarthritis (patients group). In the control group we examined the pelvic radiograph of patients without symptoms between 45 and 60 years old (control, group). Results: In the patient group (215 patients, 313 hips) we noted the signs of FAI in 88% while in the control group (112 patients 224 hips) these signs were found in 8.8% of cases. Conclusions: In 88% of primary osteoarthritis cases we found FAI morphology on the AP pelvic radiograph, similarly to those found in the bibliography, and we considered naming primary osteoarthritis, secondary osteoarthritis caused by FAI. In the majority of cases, early diagnosis with simple, cheap and easily accessible AP pelvic radiograph with low dose of radiationmay also be warranted

What Are the Results of Surgical Treatment of Hip Dysplasia With Concomitant Cam Deformity?

Periacetabular osteotomy (PAO) is a reliable procedure to correct the deficient acetabular coverage in hips with developmental dysplasia. It is unclear how the presence of additional femoral cam-type deformity might influence the clinical and radiographic treatment results of PAO. (1) Are there differences in clinical scores (WOMAC, EQ-5D) and examination findings (impingement sign) or radiographic measures of acetabular orientation and head sphericity after PAO for isolated acetabular dysplasia when compared with the combined pathology of dysplasia and additional femoral cam deformity? (2) Are these clinical and radiographic findings after combined surgical therapy for additional cam deformity influenced by different pathology-adjusted surgical techniques? From July 2005 to December 2010, 86 patients (106 hips) underwent PAO for hip dysplasia. Surgical and outcome data were prospectively collected and retrospectively reviewed in a comparative observational study. Indications for surgery were a lateral center-edge angle less than 25° and hip pain for at least 6 months. The contraindications for surgery were advanced radiographic osteoarthritis (Kellgren-Lawrence Grade 3), incongruency of joint space, and patient age > 50 years. Depending on preoperative hip ROM, impingement test, and presence of a radiographically visible cam deformity, treatment allocation was performed: Group I: isolated PAO in patients without symptomatic asphericity, Group IIa: PAO with subsequent osteochondroplasty through arthrotomy for patients with symptomatic cam deformity and no labrochondral pathology, and Group IIb: arthroscopically assisted osteochondroplasty and additional labrochondral repair with subsequent PAO when patients had labrochondral lesions in addition to a symptomatic cam deformity. Clinical outcome (impingement test, EQ-5D, WOMAC) as well as radiographic parameters (lateral center-edge angle, crossover sign, alpha angle, osteoarthritis grade) were obtained after a mean followup of 63 ± 18 months (range, 31-102 months) and compared with the baseline data. Eleven patients (13%) were lost to followup. With the numbers available, our study had 80% power to detect a difference between Groups I and II of 10 points on the WOMAC scores. There was no difference in the increase of WOMAC scores in patients with PAO alone (Group I; preoperative score 74 ± 17 versus postoperative 91 ± 15, p = 0.033) when compared with PAO and concurrent osteochondroplasty (Groups II A and B preoperative 73 ± 19 versus postoperative 90 ± 13 p < 0.001). The mean postoperative alpha angles in Group II (38° ± 6°) improved when compared with preoperative values (56° ± 15°; p < 0.001) and were even lower than native offset alpha angles in Group I (47° ± 11°). Clinical scores as well as postoperative radiographic parameters were not different between patients with conventional osteochondroplasty alone (Group IIA) and patients with arthroscopically assisted cam resection and intraarticular labrochondral repair (Group IIB). With the numbers available, we detected no differences in outcome scores and radiographic results between patients who had been treated with PAO alone and patients who underwent combined PAO and offset correction for cam deformity. Although arthroscopically assisted treatment of advanced labrochondral lesions together with osteochondroplasty is possible during PAO and the results were not different in this small study when compared with patients with PAO and osteochondroplasty alone, the type and extent of damage that would indicate additional cartilage surgery over cam resection alone remain unclear. Level III, therapeutic study.

Hip resurfacing for osteonecrosis: two- to 18-year results of the Conserve Plus design and technique.

Hip resurfacing arthroplasty (HRA) is an alternative to conventional total hip arthroplasty for patients with osteonecrosis (ON) of the femoral head. Our aim was to report the long-term outcome of HRA, which is not currently known. Long-term survivorship, clinical scores and radiographic results for 82 patients (99 hips) treated with HRA for ON over a period of 18 years were reviewed retrospectively. The mean age of the 67 men and 15 women at the time of surgery was 40.8 years (14 to 64). Patients were resurfaced regardless of the size of the osteonecrotic lesion. The mean clinical follow-up was 10.8 years (2 to 18). The mean University of California, Los Angeles hip scores at the last follow-up were 9.3, 9.4, 9.2 and 6.8 for pain, walking, function and activity, respectively. A total of six hips underwent revision surgery, four for loosening of the femoral component and two for loosening of the acetabular component. Using any revision as an end point, the 15-year Kaplan-Meier survivorship was 90.3%. There were no wear-related failures. There were no femoral failures among the hips reconstructed with a cemented metaphyseal stem. A total of five hips showed narrowing of the femoral neck; all stabilised and remain asymptomatic, 21 showed signs of femoral neck impingement. To our knowledge, this is the first report of a series of HRA performed for ON with 15-year survivorship. Our data confirm that patients with advanced stages of ON of the femoral head are excellent candidates for HRA. Cite this article: Bone Joint J 2016;98-B:901-9.