Labral Injury Research Articles

Surgical Treatment of Symptomatic Superior Labrum Anterior-Posterior Tears in Patients Older Than 40 Years

Background: Successful arthroscopic repair of symptomatic superior labral tears in young athletes has been well documented. Superior labral repair in patients older than 40 years is controversial, with concerns for residual postoperative pain, stiffness, and higher rates of revision surgery. Purpose: To analyze the published data on the surgical treatment of superior labral injuries in patients aged ≥40 years, including those with concomitant injuries to the rotator cuff. Study Design: Systematic review. Methods: A systematic review of the literature was performed using the Preferred Reporting Items of Systematic Reviews and Meta-Analysis (PRISMA) guidelines. The MEDLINE database via PubMed and the Cochrane Database of Systematic Reviews were searched for articles related to superior labrum anterior-posterior (SLAP) tears. Studies were included if they met the following criteria: the study contained at least 1 group of patients who had undergone arthroscopic repair of a type II or IV SLAP lesion with a minimum 2-year follow-up, objective and/or functional scoring systems were used to evaluate postoperative outcomes, and the mean patient age was ≥40 years for at least 1 treatment arm or subgroup analysis. Studies were excluded if the article was a review or if the article included data for SLAP type I, III, or V to X tears or Bankart lesions. Results: While several authors reported equivalent outcomes of SLAP repair in patients both older than 40 years and younger than 40 years, others demonstrated significantly higher failure rates in the older cohort. Decreased patient satisfaction and increasing complications, including postoperative stiffness and reoperations, occur at higher rates as the patient age increases. The literature demonstrates that biceps tenotomy and tenodesis are reliable alternatives to SLAP repair and that biceps tenotomy is a viable revision procedure for failed SLAP repair. With concomitant rotator cuff tears, the evidence favors debridement or biceps tenotomy over SLAP repair. Conclusion: While studies show that good outcomes can be obtained with SLAP repair in an older cohort of patients, age older than 40 years and workers’ compensation status are independent risk factors for increased surgical complications. The cumulative evidence supports labral debridement or biceps tenotomy over labral repair when an associated rotator cuff injury is present.

Superficial blood flow of the superior labrum associated with rotator cuff tear using laser Doppler flowmeter

IntroductionSuperior labrum anterior and posterior (SLAP) lesions due to overuse by repeated pitching motion and trauma are often noted and usually. However, shoulder disorders with a chronic course are often accompanied by SLAP lesions. SLAP lesions are frequently observed during arthroscopic surgery of the shoulder joint for rotator cuff tear in middle-aged and elderly individuals, suggesting the involvement of factors other than pitching motion and traumatic events in the pathogenesis. We considered that blood flow in the labrum is altered. The purpose of this study was to clarify the superficial blood flow in the superior labrum during arthroscopic surgery of the rotator cuff tear and investigate whether it is altered with labrum injury. Materials and methodsWe evaluated 33 subjects with a mean age of 55.1 years who underwent arthroscopic surgery for partial or complete rotator cuff tears. The blood flow measurement site for the superior labrum was set at the supraglenoid tubercle attachment site, and blood flow was measured twice using laser Doppler flowmeter. The mean was calculated and compared among the normal labrum and type 1 SLAP lesions. ResultsThe morphology of the labrum was normal in 16 subjects, and 17 subjects had type 1 SLAP lesions. The mean blood flow was 1.75 ml/min/100 g in subjects with a normal labrum; however, in subjects with type 1 SLAP lesions, blood flow was 1.32 ml/min/100 g, showing significant differences (P < 0.01). ConclusionSuperficial blood flow in the superior labrum of the shoulder with rotator cuff tear was measured using laser Doppler flowmetry. The blood flow in type 1 SLAP lesions was lower than that in the normal labrum.

Reply to the Letter to the Editor

To the editor, We thank Dr. Smoljanovic and colleagues for their comments on our study about labral injuries of the hip in rowers. Regarding ROM, we agree that underlying femoroacetabular impingement (FAI) precipitates labral tearing of the rower’s hip in flexion. The average hip flexion in this series was 101° (range: 90°–130°). The etiology of labral pathology of the hip in athletes is likely due to a combination of activity and predisposing underlying anatomy. In our study, 10 of 16 rowers returned to competitive rowing. We agree that not performing concomitant osteochondroplasty during labral surgery in some patients may have resulted in lower rates of return to rowing. This series of patients were treated from 2003 to 2010. With evolving understanding of structural abnormalities associated with intra- and extra-articular hip pathology, our current arthroscopic approach for mixed FAI typically involves labral refixation, acetabular osteochondroplasty, femoral osteochondroplasty, and capsular repair. There are many reasons why an athlete might not return to play; we did not further elucidate the reasons for not returning to rowing. On the subject of rehabilitation, the patients in our study were treated with partial weight-bearing for 3 weeks after surgery with a progressive physical therapy program. Return to rowing was allowed at 3 months after surgery if the patients met functional criteria for pain, strength, and motion. We agree with Smoljanovic and colleagues that rehabilitation should progress gradually to avoid reinjury and irritation of the hip. We treated three patients with bilateral hip pathology with unilateral hip arthroscopy. The contralateral hips in those patients had not undergone surgery at the time of last followup because they were asymptomatic or minimally symptomatic.

Results of Labral-Level Arthroscopic Iliopsoas Tenotomies for the Treatment of Labral Impingement

To document the clinical results of arthroscopic iliopsoas tenotomies performed at the level of the labrum to treat labral injuries caused by iliopsoas impingement. From a review of the database of the senior author (J.S.K.) of 300 hip arthroscopies that were performed between September 2009 and May 2011, 30 patients who had an arthroscopic release of the iliopsoas tendon at the level of the labrum and at least 2 years' follow-up were identified. In all cases the release was performed to treat a tight psoas tendon that was found at arthroscopy to be impinging on a torn or inflamed labrum. The results of hip arthroscopy in these patients were assessed with Byrd's 100-point modified Harris Hip Score system before arthroscopy and at 3, 6, 12, and 24 months after surgery. The mean age of the 30 patients was 35 years, and their preoperative scores averaged 43 points. After surgery, the patients had 6-month scores that averaged 73 points and 12-month scores that averaged 84 points (range, 40 to 100 points). Over the first postoperative year, in 3 of the 5 patients whose preoperative ultrasound imaging showed snapping of the tendon, recurrent painful snapping developed in the hip. All 3 had iliopsoas bursa injections and had immediate relief of their hip pain. In 2 patients the relief was temporary and an arthroscopic release of the tendon at the lesser trochanter was performed. The 2-year scores of the remaining 28 patients who did not have a second iliopsoas tenotomy averaged 88 points, and 23 of these patients had good or excellent results (scores ≥80 points). An arthroscopic release of the iliopsoas tendon at the level of the labrum was effective for alleviating hip pain from labral lesions caused by impingement of the tendon in 23 of 30 patients (77%). The remaining 7 patients had persistent hip pain and hip scores lower than 80 points because of recurrent snapping of the tendon (3), development of avascular necrosis (1), progression of degenerative joint disease (1), or chronic greater trochanteric bursitis (2). Level IV, therapeutic case series.

Letter to the Editor

To the Editor: Boykin et al. [2] presented a review of 18 rowers (21 hips) with MRI-confirmed labral tears in the anterior half of the acetabulum treated from 2003 to 2010. The most common presentations were groin pain (15 of 21 hips) and positive anterior femoroacetabular impingement (FAI) sign (17 of 21 hips). Fifteen of 21 hips had radiographic FAI (10 pure cam lesions and five mixed cam/pincer). Mechanism of labral injury was proposed to be repeated hip hyperflexion. It was stated that rowers’ hips go from extreme flexion to extension during the stroke. Among the hips that were treated with arthroscopic surgery (18 of 21), femoral head/neck osteochondroplasty was performed in six cases. Among these 18 patients, 10 returned to rowing, six did not, and two had missing data at a mean of 8 months (range, 3 to 25 months) after surgery. The unfavorable return to sport in this series was contrasted with an epidemiologic study showing a low percentage of rowing injuries resulted in an inability to train for more than 1 month [9]. Regarding mechanism of injury, rowers’ hips do not enter anatomical extension during rowing (approximately 20° of hip flexion remains in the finish position) [3, 8]. Hyperflexion implies joint flexion beyond normal limits [5]. Normal passive ROM at the hip joint is 135° flexion and 30° extension [4]. Kinematic analysis reveals that the ROM of the hip falls within normal ROM during rowing, and is not hyperflexed [3]. Therefore, it is likely that the high incidence of FAI in this series precipitated the tears and symptoms among majority of the rowers. Importantly, femoral alpha angle measurement of Magnetic Resonance Arthrography shows considerable variability, and clinical impingement tests remain the most reliable predictor of the presence of FAI [6]. With regards to the main goal of the paper — determining “the likelihood that a rower with labral injury, treated arthroscopically, will return to sport,” — is it possible that the low postoperative return rate was a consequence of performing femoral head/neck osteochondroplasty in only six of 15 hips with cam lesions, therefore, not directly addressing the joint impairment? Additionally, the three patients with bilateral hip pathology were only surgically treated unilaterally. How did the three untreated hips impact return to rowing? Furthermore, it is known that symptom duration longer than 3 years is associated with poor outcome after hip arthroscopy [1], however, no preoperative symptom duration was presented [2]. Finally, as return to rowing was assessed as early as 3 months postoperatively, what was the rehabilitation protocol? Return to sport after hip arthroscopy should be advanced slowly to prevent continued irritation or reinjury [7]. In the cited retrospective study regarding musculoskeletal injury present in elite-level rowers competing at the Junior World Rowing Championships, [9] the authors emphasized that study design may have resulted in under-reporting of severe rowing injury, as severely injured rowers may not have recovered to compete at the World Rowing Championships. Additionally, without presenting return to sport data in context of number of rowers who wanted to return to rowing but could not due to reoccurring symptoms, this aspect of analysis by Boykin et al. is limited in its utility [2].

The Hip Bone Is Connected to the Thigh Bone!

Over the past 10 years, we have seen a tremendous explosion in the field of hip preservation and arthroscopic hip surgery. Traditionally, the evaluation and treatment of hip pain has been limited to traumatic fractures and arthritis, with few treatment options to offer athletes with hip injuries other than rest and rehabilitation for recurrent groin pulls, hip pointers, and bursitis. Building on the pioneering work of Reinhold Ganz and colleagues, we now recognize that symptomatic hip injury is directly related to the structural morphology of the hip and the unique mechanical loads applied to the joint by various activities. This work has helped us to appreciate that the diagnoses of recurrent “groin pulls” and hip pointers of the past may in fact reflect occult structural disorders of the hip in athletes. Femoroacetabular impingement (FAI) is now recognized as one of the most common causes of early chondral and labral injury in the nondysplastic hip. Abnormalities in the sphericity of the femoral head and offset of the head-neck junction are often seen in conjunction with focal or global acetabular deformity, resulting in repetitive mechanical collisions with terminal hip range of motion during athletic activities. The recognition and correction of these abnormalities in proximal femoral and acetabular morphology have offered great promise and excitement as possible interventions to significantly improve hip range of motion, address refractory groin pain in athletes, and potentially alter the natural history and progression of osteoarthritic changes. We now recognize that the implications of FAI extend far beyond the hip itself. Patients suffering from intra-articular hip injury associated with FAI often present with associated soft tissue compensatory injuries. The restricted terminal hip range of motion secondary to FAI creates abnormal mechanics and stresses both proximal and distal in the kinetic chain. We now recognize that spondylolysis, sacroiliac joint pain, adductor and rectus abdominus injuries, athletic pubalgia/sports hernias, and proximal hamstring injuries are more frequently observed in conjunction with FAI and may reflect the impact of abnormal hip mechanics on the proximal and distal kinetic chain. Similarly, recent biomechanical and clinical studies have shown an increased risk of anterior cruciate ligament injury in the knee in the setting of restricted internal rotation of the hip. The hip bone is indeed connected to the thigh bone! The growth in our understanding of FAI has been paralleled by a rapid advancement in our surgical techniques to address labral injury and osseous deformity in a minimally invasive fashion. Improvements in instrumentation and capsular management have vastly improved the visualization and access to treat osseous deformity and soft tissue injury via an arthroscopic approach. However, the learning curve is steep, and these new techniques have been accompanied by new challenges, including an increasing incidence of revision surgery for incomplete treatment of the deformity, iatrogenic chondral injury, and poor management of the labrum and soft tissues. Merging the comprehensive and thorough nature of a surgical dislocation of the hip with the minimally invasive approach of arthroscopy remains a critically important challenge in the years to come. In this issue of Sports Health, we present a series of articles that discusses not only what we know about pre-arthritic hip injury and the treatment of FAI but also what we do not know. Defining these voids in our understanding of the etiology, natural history, and treatment of FAI is both humbling and exciting and highlights the critical need for both translational and clinical research in the field of hip preservation. The quality and outcomes of our interventions can be considerably improved by further defining the ideal population that can benefit from our interventions. Understanding the etiology of the deformity may help to implement effective prevention strategies in the skeletally immature, athletic population. Long-term outcomes and randomized studies will be critical to truly define whether our surgical interventions for FAI not only offer short-term pain relief but also truly alter the natural history and progression of the osteoarthritic changes.

Anatomic Variance of the Iliopsoas Tendon

Background: The iliopsoas tendon has been implicated as a generator of hip pain and a cause of labral injury due to impingement. Arthroscopic release of the iliopsoas tendon has become a preferred treatment for internal snapping hips. Traditionally, the iliopsoas tendon has been considered the conjoint tendon of the psoas major and iliacus muscles, although anatomic variance has been reported. Hypothesis: The iliopsoas tendon consists of 2 discrete tendons in the majority of cases, arising from both the psoas major and iliacus muscles. Study Design: Descriptive laboratory study. Methods: Fifty-three nonmatched, fresh-frozen, cadaveric hemipelvis specimens (average age, 62 years; range, 47-70 years; 29 male and 24 female) were used in this study. The iliopsoas muscle was exposed via a Smith-Petersen approach. A transverse incision across the entire iliopsoas musculotendinous unit was made at the level of the hip joint. Each distinctly identifiable tendon was recorded, and the distance from the lesser trochanter was recorded. Results: The prevalence of a single-, double-, and triple-banded iliopsoas tendon was 28.3%, 64.2%, and 7.5%, respectively. The psoas major tendon was consistently the most medial tendinous structure, and the primary iliacus tendon was found immediately lateral to the psoas major tendon within the belly of the iliacus muscle. When present, an accessory iliacus tendon was located adjacent to the primary iliacus tendon, lateral to the primary iliacus tendon. Conclusion: Once considered a rare anatomic variant, the finding of ≥2 distinct tendinous components to the iliacus and psoas major muscle groups is an important discovery. It is essential to be cognizant of the possibility that more than 1 tendon may exist to ensure complete release during endoscopy. Clinical Significance: Arthroscopic release of the iliopsoas tendon is a well-accepted surgical treatment for iliopsoas impingement. The most widely used site for tendon release is at the level of the anterior hip joint. The findings of this novel cadaveric anatomy study suggest that surgeons should be mindful that more than 1 tendon may be present and require release for curative treatment.

The state of the art in arthroscopic hip surgery

Hip arthroscopy is among the most rapidly evolving arthroscopic techniques in the last decade and offers the benefits of being both a minimally invasive procedure and an excellent diagnostic tool. Improvements in instrumentation and surgical skills have advanced our ability to accurately diagnose and treat various conditions of the hip joint, and hip arthroscopy has elucidated several pathologies that cause disabling symptoms. Many of these conditions were previously unrecognized and left untreated. The indications for hip arthroscopy include the management of early osteoarthritis, synovial disorders (e. g., synovial osteochondromatosis), labral tears, chondral lesions, and femoroacetabular impingement (FAI), which is increasingly recognized as a disorder that can lead to the development of early cartilage and labral injury. A better understanding of hip arthroscopy, including the anatomy, improved surgical techniques, indications, and complications of the procedure, is essential for its success. This review article discusses the state of the art of arthroscopic hip surgery.

Glenohumeral instability in patients over 40 years-old: injuries, treatment and complications

IntroductionRecurrent shoulder dislocation is infrequent after forty years and presents different injuries than younger patients. ObjectiveTo compare injuries and complications after surgery between one group older than forty years of age and another younger group. Material and methodsA review was made on all patients who had undergone arthroscopic surgery due to glenohumeral instability from 1999 until 2011. The mean follow-up was 64 months.The case group consisted of all patients older than 40 years at the time of the surgery (n=21), which was compared with a similar sized control group of randomly selected younger patients (n=27). ResultsThe mean age in the older group was 54 years (SD 11.86), while it was 26 years (SD 5.80) in the younger group.No differences were founded between both groups in labrum injury, Hill–Sachs injury, and bone Bankart lesion (P>.05). Rotator cuff tears were 7.3 times (95% CI; 2.5–21.6) more frequent in the older group (81%) compared to the younger group (P<.05). However, neurological injuries after dislocation were not more frequent in this group.There was no significant difference between the complications after surgery and the age according to the design (P>.05). ConclusionsAnterior recurrent dislocation after forty years of age is usually associated with rotator cuff tears. Arthroscopic treatment of instability was effective with no more postoperative complications.

Serious shoulder injuries in professional soccer: return to participation after surgery

An evidence base for the management and prevention of shoulder injuries in soccer is lacking. The aim of this study was to demonstrate the type, mechanism and recovery time after surgery associated with serious shoulder injuries sustained in professional soccer to build an evidence base foundation. Fifty-two professional soccer players underwent shoulder surgery for injuries sustained during match play. Of these, 25 fulfilled the inclusion criteria. Data were collected for injury mechanism and type; clinical, radiological and surgical findings and procedures; and return to full participation. Subjects were all managed by the same surgeon. Labral injuries represented the most common injury type affecting 21 (84 %) subjects; two rotator cuff (8 %) and two combined labral/rotator cuff (8 %) injuries were less common. Fourteen (56 %) subjects sustained a high-energy trauma injury in a combined abduction and external rotation position. Six (24 %) subjects sustained a low-energy trauma mechanism in variable positions, while five (20 %) had a gradual onset of symptoms. Twenty-two (88 %) subjects reported a dislocation as a feature of their presentation. All of the subjects with high- and low-energy trauma mechanisms reported a dislocation occurring at the time of injury. Eight (32 %) subjects had sustained a previous significant shoulder injury to the ipsilateral side. Goalkeepers did not sustain low-energy trauma injuries. Outfield players returned to full participation in a mean time of 11.6 weeks, while goalkeepers did so in 11.1 weeks post-surgery. Return to participation time ranged from 7 to 24 weeks with a median of 11 weeks. Professional soccer players can expect a return to participation within 12 weeks post-surgery. The majority of serious shoulder injuries in soccer occur at a positional extreme of external rotation and abduction in high-energy situations, while a significant number occur in low-energy situations away from this position. Most serious shoulder injuries in professional soccer are dislocations. Previous shoulder injury is considered a risk factor. IV.

Inestabilidad glenohumeral en pacientes mayores de 40 años: lesiones, tratamiento y complicaciones

IntroductionRecurrent shoulder dislocation is infrequent after forty years and presents different injuries than younger patients. ObjectiveTo compare injuries and complications after surgery between one group older than forty years of age and another younger group. Material and methodsA review was made o all patients who had undergone arthroscopic surgery due to glenohumeral instability from 1999 until 2011. The mean follow-up was 64 months.The case group consisted of all patients older than 40 years at the time of the surgery (n=21), which was compared with a similar sized control group of randomly selected younger patients (n=27). ResultsThe mean age in the older group was 54 years (SD 11.86), while it was 26 years (SD 5.80) in the younger group.No differences were founded between both groups in labrum injury, Hill-Sachs injury, and bone Bankart lesion (P>.05). Rotator cuff tears were 7.3 times (95% CI; 2.5-21.6) more frequent in the older group (81%) compared to the younger group (P<.05). However, neurological injuries after dislocation were not more frequent in this group.There was no significant difference between the complications after surgery and the age according to the design (P>.05). ConclusionsAnterior recurrent dislocation after forty years of age is usually associated with rotator cuff tears. Arthroscopic treatment of instability was effective with no more postoperative complications.

Accuracy of internet images of glenoid labral injuries

The internet is a convenient source of health information used widely by patients and doctors. Previous studies have found that the written information provided was often inaccurate. There is no literature regarding the accuracy of medical images on the internet. The aim of this study was to assess the accuracy of internet images of injuries to the glenoid labrum following shoulder dislocation. The Google and Bing search engines were used to find images of Bankart, Perthes and anterior labroligamentous periosteal sleeve avulsion (ALPSA) lesions. Three independent reviewers assessed the accuracy of image labelling. Of images labelled 'Bankart lesion', 30% (9/30) were incorrect while 'Perthes lesion' images were incorrect in 15% of cases (9/60) and 4% of 'ALPSA lesion' images were incorrect (2/46). There was good interobserver reliability (kappa = 0.81). Labelling accuracy was better on educational sites than on commercial sites (6% vs 25% inaccurate, p=0.0013). Caution is recommended when interpreting non-peer reviewed images on the internet.

Arthroscopic Posterior Labral Repair and Capsular Shift With a Lateralized Posterior Portal

Arthroscopic techniques for posterior shoulder subluxation with labral injuries in athletes have shown good results. The difficulty with the procedure is gaining appropriate access to the posteroinferior quadrant of the glenoid at a steep enough angle that allows for safe anchor placement. Various portals have been described that can be used as accessory portals for anchor placement. Although the use of additional portals to create appropriate access to the joint is always encouraged, preoperative planning can minimize the need for their use. The video shows a simple technique for posterior labral repair with capsular plications through a lateralized posterior portal in the lateral decubitus position. This technique allows the surgeon to address posterior labral tears and capsular laxity without the need for accessory portals.

Arthroscopic findings in the recurrent anterior instability of the shoulder

A recurrent anterior shoulder dislocation consists of a variety of lesion types. To evaluate the pathological classification of recurrent anterior dislocation of the shoulder joint under arthroscopy. Thirty-one patients with recurrent anterior shoulder dislocation were inspected by arthroscopy, including 23 males and 8 females, with a mean age of 35.1 (18-46) years. The patients were divided into two groups: 17 with shoulder dislocation and hyper-laxity (the hyper-laxity group) and 14 with only traumatic shoulder dislocation (the trauma group). All the patients were assessed by arthroscopy for pathological changes, and the differences in the pathological changes were compared between the two groups. All these 31 patients suffered from anteroinferior labrum injury. Twenty-five had Hill-Sachs injury; 27, bone or cartilage injury of anteroinferior glenoid; 16, SLAP injury; and 5, rotator cuff injury. Bankart injury occurred more in the trauma group, and anterior labroligamentous periosteal sleeve avulsion injury and glenolabral articular disruption injury were more in the hyper-laxity group. Bone or cartilage injury of anteroinferior glenoid was more noticed in the trauma group. Significant differences are found under arthroscopy in the pathological changes of recurrent anterior shoulder dislocation between the purely traumatic group and the hyper-laxity group. The pathological changes in the trauma group were more severe than in the hyper-laxity group.

Labral Injuries of the Hip in Rowers

Injuries of the hip in the adolescent and young adult athlete are receiving more attention with advances in the understanding of femoroacetabular impingement (FAI), labral pathology, and hip arthroscopy. Labral tears have not been well characterized in rowers. The purposes of this study were (1) to describe the clinical presentation of labral pathology in rowers; (2) to describe the MRI and radiographic findings of labral pathology in rowers; and (3) to determine the likelihood that a rower with labral injury, treated arthroscopically, will return to sport. We conducted a review from August 2003 to August 2010 to identify all rowers with MRI-confirmed intraarticular pathology of the hip presenting to our institution. Baseline demographics, symptoms and physical findings, and location of the labral tear with associated pathology, management, and early followup were recorded. The review yielded a total of 21 hips (18 rowers, three with bilateral labral pathology) with a mean patient age of 18.5 years (range, 14-23 years). Most of the rowers (85%) were female and the series included prep school (44%) and collegiate rowers (56%). Eighteen of the 21 hips (85%) eventually underwent arthroscopic surgery at our institution. A large majority of patients had isolated groin pain (71%) and physical findings consistent with impingement (81%). There was no single, dominant location for the labral tears on MRI. Among the 18 patients who had surgery, 10 (56%) returned to rowing, six (33%) never returned, and return data were not available for two (11%) at a mean of 8 months (range, 3-25 months) after surgery. The repetitive motions of the hip required for rowing may be a factor leading to intraarticular labral injuries in the athletes. Underlying anatomic abnormalities of the hip such as FAI may predispose certain patients to these injuries. However, many patients treated arthroscopically did not return to sport at a mean of 8 months after surgery.

Glenohumeral Findings on Magnetic Resonance Imaging Correlate With Innings Pitched in Asymptomatic Pitchers

Background: In recent years, there has been a documented increase in the number of professional baseball players on the disabled list and the total number of days on the disabled list. Pitchers account for the largest number of disabled list reports. Purpose: To examine the relationship between magnetic resonance imaging (MRI) findings in asymptomatic professional pitchers and subsequent time on the disabled list (DL). Study Design: Cohort study (Prognosis); Level of evidence, 2. Methods: A total of 21 asymptomatic professional pitchers from a single Major League Baseball (MLB) organization underwent preseason MRIs of their dominant shoulder from 2001 to 2010. Asymptomatic was defined as no related DL stays in the 2 seasons before the MRI. These studies were reevaluated by a fellowship-trained musculoskeletal radiologist who was blinded to patient name, injury history, and baseball history. A second investigator who was blinded to the MRI results collected demographic data, total career number of innings pitched, and any subsequent DL reports for each subject. Results: The mean age at the time of MRI was 29.04 years (range, 20-39 years). Eleven of 21 pitchers had a rotator cuff tear (RCT): 9 had an articular surface tear (AST), and 2 had a full-thickness rotator cuff tear (FTT). Ten had superior labral anterior posterior (SLAP) tears, and 13 had either anterior or posterior labral tears. There was a statistically significant relationship between the number of innings pitched and presence of an RCT (AST + FTT). The mean number of career innings pitched by those with an RCT was 1014 compared with a mean of 729 innings pitched in pitchers without an RCT (P < .01). In addition, the number of career innings pitched was moderately correlated with presence of RCT (r = 0.46) and presence of superior and anterior/posterior labral tears (r = 0.43). There were no statistically significant findings between any single preseason MRI finding and subsequent time on the DL. Conclusion: The MRI findings in asymptomatic MLB pitchers do not appear to be related to near future placement on the DL. However, there was a significant difference in numbers of innings pitched between pitchers who had an RCT and those who did not and a moderate correlation between innings pitched and the presence of RCT as well as the presence of labral lesions. This finding supports the notion that RCT and labral injury in pitchers may result from repetitive overhead motion with subsequent strain on the rotator cuff tendons and glenoid labrum. Asymptomatic shoulder lesions in professional baseball pitchers appear to be more frequent than previously thought.

Circumferential Reconstruction of Severe Acetabular Labral Damage Using Hamstring Allograft: Surgical Technique and Case Series

With excessive acetabular coverage, such as coxa profunda or protrusio, contact between the femoral neck and acetabular rim cause direct damage to the labrochondral junction, and indirect edge loading from a levering effect which may result in hip arthrosis. Arthrosis may be delayed or avoided by addressing the overcoverage and restoring mechanical function of the labrum. We describe four cases of adjunctive complete acetabular labral replacement for circumferential, irreparable labral injury using fresh frozen semitendinous allografts through surgical hip dislocation. Over a two-year period four patients (age range: 20 to 47 years) underwent surgical hip dislocation to address femoroacetabular impingement with rim trimming, femoral osteochondroplasty, and labral reconstruction. Pre- and postoperative patient reported outcomes were assessed by Oxford Hip Score (OHS), Hip Outcome Score (HOS), and Global Treatment Outcome (GTO) score. Disease progression was graded using AP pelvic radiographs and arthroMR. The average LCE correction was 18º (range 7-25º), achieving an average LCE of 33º (range 32-35) postoperatively. Using protected weight bearing all trochanteric osteotomies healed within six weeks after surgery. OA did not progress in any hips. Mean OHS and HOS scores improved 6.3 and 19.8 at one-year follow up. All four patients reported good results according to the GTO. There were two adverse events that resolved and did not affect outcome. Despite complex deformities and preexisting cartilage and labrum wear in this young cohort, three of four patients reported significant functional improvement after treatment of this rare condition. Preliminary experience with circumferential labral reconstruction using hamstring allografts is promising, although long-term data needs to be established.

Treatment of femoroacetabular impingement: a systematic review.

The purpose of this review is to determine if there is a difference in outcomes after: (1) nonsurgical vs surgical treatment of FAI; (2a) surgical dislocation with greater trochanteric osteotomy, (2b) anterior mini-open, (2c) arthroscopic plus mini-open, and (2d) arthroscopic surgery for FAI; (3) difference in complication and re-operation rates; and (4a) labral refixation and (4b) labral debridement for labral injuries. A systematic review of multiple databases was performed after PROSPERO registration and using PRISMA guidelines. Level I-IV evidence clinical studies with minimum 2-year follow-up were included. Data were compared using 2-sample and 2-proportion Z-test calculators. Study methodological quality was analyzed using Modified Coleman Methodology Score (MCMS). Recommendations were made using SORT (Strength Of Recommendation Taxonomy). Twenty-nine studies were included (2369 subjects; 2507 hips). MCMS was poor. Mean subject age was 34.4+/-8.4years and mean follow-up was 3.1+/-0.9years. Statistically significant differences were observed following both nonsurgical and surgical treatment, with greater (P < 0.05) improvements following surgery (SORT B), without consistent significant differences observed between different surgical techniques (SORT C). There was a greater (P < 0.05) reoperation and complication rate following surgical dislocation vs mini-open and arthroscopic techniques (SORT A). Clinical outcomes were significantly better (P < 0.05) following labral refixation vs debridement (SORT B). Outcomes of operative treatment of femoroacetabular impingement are significantly better than nonsurgical management. Surgical treatment significantly improves outcomes, with no consistent significant differences exhibited between open and arthroscopic techniques. Open surgical dislocation has significantly greater reoperation and complication rates vs mini-open and arthroscopic techniques. Outcomes of labral refixation are significantly better than debridement in patients with labral injuries.

The Association Between Avulsions of the Reflected Head of the Rectus Femoris and Labral Tears

The aim of this study was to investigate if an association existed between the reflected head of rectus femoris avulsion injuries and labral tears in pediatric patients referred for magnetic resonance arthrography (MRA) or magnetic resonance imaging (MRI) evaluation. Electronic medical records of the patients between the ages of 12 and 18 who were treated at the hospitals affiliated by McMaster University between June 2000 and November 2010 with a diagnosis of rectus femoris avulsion injuries were retrospectively identified and analyzed. Patients were included if they had magnetic resonance imaging or MRA images of their hip. Nine patients with avulsion injuries of the rectus femoris muscle were identified. The patient population consisted of 4 females and 5 males (range, 8 to 17 y, mean age 14 y). All injuries occurred during sports activity, which included running and kicking during soccer, skating in hockey, and a squatting exercise. MRA examination of 7 of these patients demonstrated associated labral tears. All patients were initially treated conservatively. Five patients continued to sustain from residual pain in the 9 months after the initial injury. Two of these patients with significant refractory pain were subsequently treated with hip arthroscopy. Intraoperatively, 1 small labral tear and 1 labral avulsion were identified and treated. This study suggests that there may be an association between avulsion of the reflected head of rectus femoris and labral injuries and that there may be an underlying spectrum of traction injuries. Patients with rectus femoris avulsion injuries with persistent symptoms may be at risk for concurrent traumatic labral tears. Level 4, retrospective case series.

The Effect of Capsulectomy On Hip Joint Biomechanics

Objectives:Hip arthroscopy is performed in young adult patients with hip pain. During arthroscopy, capsulectomy is performed to improve intraoperative visualization. The stability of the hip joint after capsulectomy is relatively unknown. Our study evaluated anterior hip stability in capsular sectioned states with labral injury. We theorized the load required for anterior translation would decrease with greater capsular injury.Methods:Ten human cadaveric pelvises (20 hips, mean 54.25 years) without radiographic evidence of degeneration or dysplasia were harvested. The hips were prepared and mounted onto a custom built testing fixture. Two pelvises were excluded due to fixation issues for one or both hips. The 16 hips were tested in five states (table 1). Each hip was tested in neutral position with a 20N compressive force. The capsular incision was made in-line with the femoral neck. The labrectomy was made at 2:30 position. The sutured capsule was created using #2 Ethibond suture 1cm apart along the incision. The partial capsulectomy was made by resecting the iliofemoral ligament, leaving the pubofemoral and ischiofemoral ligaments intact. Total capsulectomy state was created by removing the remaining capsule. The load at 12mm of anterior translation was recorded for each state after two preconditioning trials.Results:A repeated measures ANOVA with a Bonferroni adjustment showed no difference between all-intact vs. sutured-intact. It also demonstrated no significant difference between the sutured-intact and the sutured labrectomy states. A repeated measures ANOVA with a Bonferroni adjustment was run to compare the capsular states with a 1cm partial labrectomy (table 2). There was a significant difference between the sutured-labrectomy and the partial capsulectomy (p=0.0146) and between the sutured-labrectomy and the total capsulectomy (p=0.0005). There was also a significant difference when comparing the partial capsulectomy and the total capsulectomy (p=0.0377).Conclusion:The findings demonstrate that both the capsule and labrum play a role in providing anterior hip stability. These results indicate that the iliofemoral ligament is crucial for preventing anterior translation in labral injured states. Intraoperative capsulectomy should be avoided in patients with large irreparable labral tears to prevent postoperative anterior hip instability