Labral Injury Research Articles

Hip Instability in Ballet Dancers: A Narrative Review.

Dancers possess a large degree of hip range of motion that results from a combination of innate and acquired osseous morphology and permissive soft tissues. Generalized hypermobility in dancers may predispose them to a spectrum of hip instability. The objective of this narrative review is to discuss the anatomical characteristics, pathogenesis, risk factors, clinical signs and symptoms, management, and outcomes of hip instability treatments in dancers.<br/> Methods: A retrospective search was performed beginning November 1, 2017, for English language articles regarding hip stability in the dancer. Key words used included but were not limited to: dance(r), ballet, hip, hypermobility, range of motion, instability, microinstability, and laxity. PubMed, Scopus, and MEDLINE databases were used.<br/> Results: Forty-three studies were analyzed. Groin pain was found to be the most common presenting symptom of hip instability. A variety of impingement and instability signs may be elicited during physical examination. Hypermobility is frequently observed and is thought to be a necessity for participation in elite levels of ballet. Radiographs and advanced planar imaging (magnetic resonance imaging and computed tomography) should be scrutinized to evaluate for dysplasia, cam, pincer, subspine, and rotational morphologies. Dysplasia (low volume acetabulum), cam morphology, femoral retroversion, and coxa valga are common findings in the ballet dancers' hip. Labral injuries and ligamentum teres tears are common and may potentiate instability in the hip. Management options include education, oral non-opioid medications, activity modification, exercise prescription, and surgery. Reported outcomes of these treatments in ballet are limited.<br/> Conclusion: Hip hypermobility is prevalent in the ballet population and is a clear advantage. However, it may increase the risk of instability. It is important to identify the multifactorial osseous and soft tissue etiology of hip or groin pain in dancers. Practitioners should have a high level of suspicion for hip instability in the dancer presenting with hip pain and treat accordingly. There is a significant need for increased quantity and quality of investigation into the outcomes of treatment for hip instability in the dancer.

Hypermobile Disorders and Their Effects on the Hip Joint.

Hypermobility, or joint hyperlaxity, can result from inherited connective tissue disorders or from micro- or macrotrauma to a joint. The supraphysiologic motion of the hip joint results in capsuloligamentous damage, and these patients have a propensity to develop femoroacetabular impingement syndrome (FAIS) and labral injury. In this review, the recent literature evaluating the definitions, history, incidence, genetics, and histology of hypermobile disorders is investigated. We then review the clinical evaluation, natural history, and resulting instability for patients presenting with a hypermobile hip. Lastly, treatment options and outcomes will be highlighted.

Reliability of the classification of cartilage and labral injuries during hip arthroscopy.

To determine interobserver and intraobserver reliabilities of the combination of classification systems, including the Beck and acetabular labral articular disruption (ALAD) systems for transition zone cartilage, the Outerbridge system for acetabular and femoral head cartilage, and the Beck system for labral tears. Additionally, we sought to determine interobserver and intraobserver agreements in the location of injury to labrum and cartilage. Three fellowship trained surgeons reviewed 30 standardized videos of the central compartment with one surgeon re-evaluating the videos. Labral pathology, transition zone cartilage and acetabular cartilage were classified using the Beck, Beck and ALAD systems, and Outerbridge system, respectively. The location of labral tears and transition zone cartilage injury was assessed using a clock face system, and acetabular cartilage injury using a five-zone system. Intra- and interobserver reliabilities are reported as Gwet’s agreement coefficients. Interobserver and intraobserver agreement on the location of acetabular cartilage lesions was highest in superior and anterior zones (0.814–0.914). Outerbridge interobserver and intraobserver agreement was >0.90 in most zones of the acetabular cartilage. Interobserver and intraobserver agreement on location of transition zone lesions was 0.844–0.944. The Beck and ALAD classifications showed similar interobserver and intraobserver agreement for transition zone cartilage injury. The Beck classification of labral tears was 0.745 and 0.562 for interobserver and intraobserver agreements, respectively. The Outerbridge classification had almost perfect interobserver and intraobserver agreement in classifying chondral injury of the true acetabular cartilage and femoral head. The Beck and ALAD classifications both showed moderate to substantial interobserver and intraobserver reliabilities for transition zone cartilage injury. The Beck system for classification of labral tears showed substantial agreement among observers and moderate intraobserver agreement. Interobserver agreement on location of labral tears was highest in the region where most tears occur and became lower at the anterior and posterior extents of this region. The available classification systems can be used for documentation regarding intra-articular pathology. However, continued development of a concise and highly reproducible classification system would improve communication.

Anterior Shoulder Instability in the Throwing Athlete

Throwers, particularly baseball players, are dependent on a delicate balance of shoulder mobility and stability to excel at their sport. Disruptions to this balance can lead to a number of different types of anterior shoulder instability: microinstability, acute atraumatic instability and traumatic instability. Pathologic microinstability can develop over time in a pitcher, as repetative throwing (ie extreme external rotation in abduction) causes stretch to the joint capsule anteriorly and impingement posteriorly. The resultant anterior or posterior shoulder pain can affect pitch velocity and control. Over time, the anterior capsule and ligaments can also become attenuated. They can tear abruptly during routine pitching, resulting in acute atraumatic instability. While microinstability and acute atraumatic instability typically occur in pitchers, position players are at a higher risk of traumatic shoulder instability. Diving for a ball or sliding into a base with an arm outstretched can cause the shoulder to sublux or frankly dislocate. These traumatic instability events often lead to injury of the anterior labrum and can result in recurrent instability. Treatment of instability in these throwing athletes includes physical therapy to restore the strength and coordination of the periscapular muscles, rotator cuff, deltoid and biceps. When nonoperative treatments fail, a number of arthroscopic and open procedures are available, with the type of procedure depending on the type of instability. While these techniques can adequately restore stability to the shoulder and many throwers do return to play, throwers do so at lower rates and often at lower levels than athletes of other sports.

Revisiting Intraarticular Corticosteroid Injections and Sports Medicine: Outcomes and Perioperative Considerations

Intraarticular corticosteroid injections are commonly administered by physicians to provide analgesia for acute athletic injuries, though there is an increasing body of literature that has illuminated substantial risks to the soft tissues. A review of Clinical Key, MEDLINE, and PubMed databases from 2012 to 2020 was performed using search terms, including corticosteroid, shoulder arthroscopy, knee arthroscopy, hip arthroscopy, intraarticular, and injections. The references of pertinent articles were reviewed for other relevant sources. Corticosteroid injections can provide reliable pain control in athletes for various pathologies affecting the shoulder, knee, and hip. The use of these medications has demonstrated efficacy in some disorders, whereas the clinical benefit for others remains questionable. Intraarticular injections to the shoulder, knee, and hip are all associated with increased risks to the soft tissues, which must be considered and weighed heavily, especially in an athlete. Perioperative corticosteroids confer an increased risk of surgical site infection after knee, shoulder, and shoulder arthroscopy. Subacromial injections confer an increased risk for revision rotator cuff repair if given within 6 months of surgery, but are safe if given at least 1 month postoperatively. Hip injections for chondral pathology perform significantly better than those for labral injuries.

Prevalence and Grading of Rotator Cuff and Labral Injuries in Shoulder Pain and Instability using MRI: ACross-sectional Study

Introduction: Shoulder joint is a highly mobile joint but is prone for rotator cuff injuries and dislocations. It is necessary to accurately diagnose rotator cuff and labral injuries so that appropriate plan of action for treatment can be taken. Magnetic Resonance Imaging (MRI) can be used to diagnose and describe the extent of rotator cuff tendon and labral injuries and any secondary rotator cuff muscle abnormalities. Aim: To study the demographic profile of patients presenting with shoulder pain and instability, identify the various rotator cuff injuries causing shoulder pain, identify the rotator cuff interval lesions causing microinstability, identify the various labral and bony pathologies in instability, describe the MRI features of the rotator cuff, rotator cuff interval, labral and bony injuries. Materials and Methods: This study was a cross-sectional study of patients with symptoms of either shoulder pain or instability who underwent MRI evaluation of the shoulder in the Department of Radiodiagnosis, Rajarajeswari Medical College and Hospital, Bengaluru, Karnataka, India, from July 2018 to December 2020. The study population consisted of 54 patients with either shoulder pain or instability who underwent MRI of shoulder. All the MRI scans of the shoulder in this study were performed using 1.5 Tesla Siemens Magnetom Avanto (Tim 76x18) MR machine using a flex coil. Results: The study population consisted of 54 patients comprising of 38 males and 16 females. The age of the patients ranged from 20-77 years. Majority of the patients were older than 50 years constituting about 33.33% of the total study population. Rotator cuff injury was the commonest cause of pain. Tendinosis was the commonest type of rotator cuff injury followed by partial-thickness and full-thickness tendon tears. The commonest grade of tendinosis was mild or grade 1. Supraspinatus tendon was the most commonly affected tendon followed by subscapularis and infraspinatus tendons. Teres minor tendon was normal in all the cases. Anterior instability was the commonest type of instability with equal prevalence of soft tissue Bankart, bony Bankart and Perthes lesions. Biceps pulley lesions resulted in long head of biceps tendon instability, microinstability and internal impingement. Conclusion: Rotator cuff injuries are the commonest cause of shoulder pain and are seen more frequently after the fifth decade. Shoulder instability is most commonly seen in young male adults. Tendinosis is the commonest type of rotator cuff injury. Supraspinatus tendon is the most commonly injured tendon. Anterior instability is the commonest type of shoulder instability. Biceps pulley lesions result in long head of biceps tendon instability, microinstability and internal impingement. MRI can diagnose interstitial or intrasubstance tendon tears which are not visualised on arthroscopy. MRI description of tendon and labral tears, tendon retraction and muscle atrophy can guide the orthopaedician during arthroscopy and in treatmentplanning.

Utilization of Orthobiologics by Sports Medicine Physicians: A Survey-based Study.

Introduction:Investigations are rapidly increasing into products referred to as orthobiologics and their utility in the nonsurgical and surgical treatment of diverse orthopaedic pathology.Methods:Members (599) of the American Orthopaedic Society for Sports Medicine were sent a survey that assessed their usage, motivation for use, and perceived efficacy of the following orthobiologics: leukocyte-rich platelet-rich plasma, leukocyte-poor platelet-rich plasma (PRP-LP), bone marrow aspirate concentrate, amniotic membrane products, adipose-derived mesenchymal stromal cells, and umbilical cord–derived cells. Application of these orthobiologics for the following pathologies was assessed: osteoarthritis, muscle injuries, tendon injuries, ligament injuries, labral injuries, and focal articular cartilage tears.Results:The survey was completed by 165 respondents (27.5%), of which 66.1% reported using at least one orthobiologic in their practice. Orthobiologic users reported the following: 71.6% are increasing their use, and 23.9% advertise their use. PRP-LP is the most commonly used orthobiologic for 76.1%, with 30% of PRP-LP users reporting use due to competitor utilization. The pathology most commonly treated with orthobiologics is osteoarthritis, for 71.6% of users, who primarily use PRP-LP in the knee joint. Leukocyte-rich platelet-rich plasma is the most popular orthobiologic in muscle, ligament, tendon, and labral injuries, whereas bone marrow aspirate concentrate is most popular for focal articular cartilage injuries. Primary orthobiologic-eligible groups were adults and recreational noncompetitive athletes. More than half (>50%) of orthobiologic users perceived all but umbilical cord–derived cells to be efficacious.Conclusion:Orthobiologics are used by a significant number of sports medicine physicians and are likely increasing in popularity. Among orthobiologics, platelet-rich plasmas are the most popular, and osteoarthritis is the pathology most likely to be treated. Orthobiologics are sometimes used for reasons other than clinical efficacy, especially competitor utilization, and physicians are disparate in their application of these products.

Periacetabular osteotomy with concomitant hip arthroscopy: A case series with 24 months minimum follow-up.

To describe patient-reported outcomes, radiological results, and revision to total hip replacement in patients with hip dysplasia that underwent periacetabular osteotomy as isolated treatment or concomitant with hip arthroscopy. Case series study. Between 2014 and 2017, patients were included if they complained of hip pain and had a lateral center-edge angle ≤ of 20°. Exclusion criteria included an in-maturate skeleton, age of 40 or older, previous hip surgery, concomitant connective tissue related disease, and Tönnis osteoarthritis grade ≥ 1. All patients were studied before surgery with an anteroposterior pelvis radiograph, false-profile radiograph, and magnetic resonance imaging. Magnetic resonance imaging was used to assess intraarticular lesions, and if a labral or chondral injury was found, concomitant hip arthroscopy was performed. The non-parametric median test for paired data was used to compare radiological measures (anterior and lateral center-edge angle, Tönnis angle, and extrusion index) after and before surgery. Survival analysis was performed using revision to total hip arthroplasty as a failure. Kaplan Meier curve was estimated. The data were processed using Stata. A total of 15 consecutive patients were included; 14 (93%) were female patients. The median follow-up was 3.5 years (range, 2 to 8 years). The median age was 20 (range 13 to 32). Lateral center-edge angle, Tönnis angle, and extrusion index correction achieved statistical significance. Seven patients (47%) underwent concomitant hip arthroscopy; three of them (47%) were bilateral (10 hips). The labrum was repaired in six cases (60%). Three patients (15%) required revision with hip arthroplasty, and no hip arthroscopy-related complications are reported in this series. To perform a hip arthroscopy concomitant with periacetabular osteotomy did not affect the acetabular correction. Nowadays, due to a lack of conclusive evidence, a case by case decision seems more appropriate to design a comprehensive treatment.

Research progress in arthroscopic treatment of acetabular labrum injury

To review the surgical methods of arthroscopy in the treatment of acetabular labrum injury, and to provide reference for clinical treatment. The literature about the surgical methods and clinical results of hip arthroscopy in the treatment of acetabular labrum injury was reviewed and analyzed. In the early stages of hip arthroscopy, the removal of the torn labrum is the primary treatment option. The current principles of treatment are based on the specific circumstances of a torn labrum, including acetabular labrum debridement, acetabular labrum repair, acetabular labrum reconstruction, and acetabular labrum augmentation. Hip arthroscopy has become the preferred technique for the treatment of acetabular labrum injury. Labral repair is still the first choice, and labral reconstruction is used when acetabular labrum injury cannot be repaired.

Accuracy of Magnetic Resonance Arthrography in the Detection and Classification of Chronic Anteroinferior Labrum Lesions

INTRODUCTION: Bankart, and Bankart variant labrum lesions such as Perthes lesion and anterior labrum periosteal sleeve avulsion are different types of surgically treatable anterioinferior labral lesions contributing to shoulder instability. Successful outcome following arthroscopic surgery requires accurate lesion diagnosis, pre operative planning and deployment of accordant surgical technique. The purpose of our study was to retrospectively evaluate the accuracy of Magnetic Resonance Arthrography not only in the detection but also the classification of chronic antero-inferior labrum injuries by using arthroscopy as the reference standard. STUDY DESIGN & METHODS: This study included 80 consecutive patients, 12 female with mean age of 28 year (range 17-46) presenting with recurrent shoulder instability who underwent Magnetic Resonance Arthrography in neutral and abduction external rotation positions prior to arthroscopic stabilisation. The findings of a single dedicated musculoskeletal radiologist were compared with the arthroscopic findings of a single experienced shoulder surgeon. RESULTS: Arthroscopic findings revealed 40 Bankart, 18 anterior labrum periosteal sleeve avulsion and 15 Perthes anteroinferior labrum lesions. Magnetic Resonance Arthrography detected 95.8% of overall labrum lesions with a sensitivity of 94% (0.86 to 0.98 ) and specificity 85.7% (0.46 to 0.99 ) and correctly classified 90% of labrum lesions with an accuracy of 93.8% (0.86-0.97) for Bankart lesions, 95% (0.88-0.98) for anterior labrum periosteal sleeve avulsion lesions and 95.5% (0.91-0.99) for Perthes lesions. CONCLUSION: Our study demonstrates that Magnetic Resonance Arthrography in neutral and abduction and external rotation position can achieve high levels of accuracy in detecting and correctly classifying chronic anteroinferior labrum lesions. It emphasises its value in alerting the surgeon to the presence and the type of labrum lesion. This allows forward-planning the surgical technique to be employed for intra-operative detection, correct dissection and optimal fixation.

Scapular Dyskinesis and the Kinetic Chain: Recognizing Dysfunction and Treating Injury in the Tennis Athlete.

This article aims to provide a comprehensive understanding of the evaluation, diagnosis, and management of scapular dyskinesis and its impact on the kinetic chain in tennis athletes. Optimal glenohumeral biomechanics are intimately associated with proper scapular motion and function. The tennis serve requires the scapula to act as a force transducer in the kinetic chain to convert potential energy generated in the lower extremities to kinetic energy in the upper extremity. Any aberration within this complex kinetic chain will result in force uncoupling and increases the potential for injury through compensatory mechanisms. Specifically, scapular dyskinesis has been associated with an increased risk of shoulder pain of up to 43% in overhead athletes. These pathologies include rotator cuff disease, subacromial and posterior impingement, labral injuries, and SLAP tears. Although the direct causality of these injuries remains controversial, multiple kinematic studies have demonstrated altered scapular positioning increasing the predilection for soft tissue pathology. The diagnosis of scapular dyskinesis is predicated upon a thorough history, physical examination, and observational analysis of key nodes in the kinetic chain during tennis activity. Conservative management remains the mainstay of treatment and consists of a graduated physical therapy regimen. Although shoulder pain in the overhead athletes is often multifactorial, early recognition and treatment of scapular dyskinesis generally carry a favorable prognosis and result in improved patient outcomes.

Arthroscopic classification of intra-articular hip pathology demonstrates at best moderate interrater reliability.

The purpose of this study was to report several novel classification systems for intra-articular lesions observed during hip arthroscopy, and to quantify the interrater reliability of both these novel systems and existing classifications of intra-articular lesions when tested by a group of high-volume hip arthroscopists. Five hip arthroscopists deliberated over shortcomings in current classification systems and developed several novel grading systems with particular effort made to capture factors important to the treatment and outcomes of hip arthroscopy for labral injury. A video learning module describing the classifications was then developed from the video archive of surgeries performed by the senior author and reviewed by study participants. Following review of the module, a pilot study was completed using five randomly selected videos, after which participating surgeons met once more to discuss points of disagreement and to seek clarification. The final video collection for testing reliability was composed of 29 videos selected with the intent of capturing all sublevels of each classification scheme. Study participants recorded their assessments using each classification scheme, and interrater reliability was calculated by a study participant not involved in grading. The average kappa coefficients for the classification schemes ranged from 0.38 to 0.54, with the interrater reliability of all classification schemes except labral degeneration qualifying as moderate. The percent of cases with absolute agreement ranged from 17.2% to 51.7% across the classification systems. Even among a group of high-volume hip arthroscopists who engaged in several discussions about the proposed classification schemes, grades were found to have at best moderate interrater reliability. Moderate interrater reliability is demonstrated for novel grading systems for describing labral tear complexity, labral bruising, labral size, and extent of synovitis, and fair reliability is demonstrated for labral degeneration. Further development and refinement of multifactorial grading systems for describing labral injury are indicated. Evaluating the multifactorial nature of intra-articular lesions in the hip is an important part of intraoperative decision-making and defining reliable classifications for intra-articular lesions is a critical first step towards developing generalizable criteria for guiding treatment type. Level III.

Comparison of 2D, 3D, and radially reformatted MR images in the detection of labral tears and acetabular cartilage injury in young patients.

The purpose of this study was to compare the utility of two-dimensional high-resolution (2D), 3-dimensional with multiplanar reconstruction (3D MPR), and radially reformatted (RR) MRIs when evaluating the complexities of the hip joint in patients with femoroacetabular impingement (FAI). We hypothesized RR would be superior in detecting labral pathology and 2D would be superior in detecting transition zone and acetabular cartilage injury. 2D, 3D MPR, and RR MRIs of 33 patients, who later underwent surgical treatment for FAI, were evaluated for sensitivity, specificity, and accuracy. Bland-Altman methods were used to estimate agreement between each method and the gold-standard, arthroscopic visualization of the hip joint, regarding the percentage of the hip joint affected by each injury type. 3D MPR and RR groupings were associated with the highest sensitivity and accuracy for labral injury. 3D MPR demonstrated the smallest bias in assessing the percentage of joint affected by labral injury and was the most accurate in identifying acetabular cartilage injury, whereas RR had the smallest mean difference in assessing the percentage of joint affected by acetabular cartilage injury. 2D was the most accurate in identifying transition zone injuries, while RR was superior in assessing the percentage of the joint affected by transition zone injury. Our results suggest that including both 3D MPR and RR MRI groupings is favorable for accurate joint visualization and well-informed treatment planning, especially given that labral injury is a main source of pain and dysfunction for FAI patients.

Posterior Labral Injury and Glenohumeral Instability in Overhead Athletes: Current Concepts for Diagnosis and Management.

Posterior glenohumeral instability in overhead athletes presents a unique set of challenges for both diagnosis and treatment. Although a great deal of attention has been focused on the management of injuries to the biceps-labrum complex and rotator cuff in throwers, comparatively less has been written about posterior glenohumeral instability within this unique cohort. Historically, posterior instability has been observed secondary to either acute trauma or repetitive microtrauma, usually among collision athletes, weight lifters, and rowers. However, posterior glenohumeral instability resulting from pathology of the posterior capsulolabral tissues in throwers is a different entity, and the clinical assessment begins with an accurate differentiation between adaptive capsular laxity and labral injury with pathologic instability. Some posterior capsule labrum tears confirmed on arthroscopy will require nothing more than débridement. However, for more extensive lesions, surgical treatment must balance the necessity to repair torn capsulolabral tissues with the tendency to over constrain the shoulder. The literature provides mixed results regarding the likelihood of overhead athletes with posterior glenohumeral instability and labral injury treated surgically returning to their preinjury level of sport performance.

Recreational Sports and Intra-articular Hip Injuries in Patients Undergoing Hip Arthroscopy for Femoroacetabular Impingement

PurposeWe aimed to determine the relationship between recreational sports and intra-articular hip injuries in an active population that had undergone hip arthroscopy for femoroacetabular impingement syndrome.MethodsA retrospective review was performed of prospectively collected data from patients undergoing hip arthroscopy between January 2015 and December 2016. Inclusion criteria included patients between 18 and 50 years of age who had participated in recreational sports prior to surgery and had a minimum of a 2-year follow-up. Labral injury was evaluated using the Multicenter Arthroscopic Hip Outcome Research Network classification, and rim chondral injuries were evaluated using the Acetabular Labral Articular Disruptions system. Ligamentum teres tear and psoas impingement were also recorded. Sports were classified as rotational running (soccer, basketball, handball), flexibility (martial arts, dance), asymmetric-overhead (racquet), or endurance (running, swimming, cycling). Primary univariate analysis of sports’ independent associations, demographic characteristics, intra-articular hip injuries, and outcomes was performed.ResultsPatients included 185 people with a mean age of 36.7 years. Patients participating in rotational running sports and flexibility sports had a significantly greater proportion of rim chondral injuries than those participating in endurance sports or asymmetric overhead sports (P = 0.02). Ligamentum teres tears were significantly associated with flexibility sports (P < 0.001). A total of 84.7%, 67.7%, 67.2%, and 71.2% of patients met minimal clinically important difference levels for the modified Harris Hip Score (mHHS), the Hip Outcome Score (HOS)10 questionnaire with activities of daily living (HOS-ADL), the sports subscale (HOS-SSS), and the International Hip Outcome Tool (iHOT-12), respectively; 94.9%, 66.2% and 62.7% met the patient acceptable symptom state for mHHS, HOS-ADL, and HOS-SSS, respectively; 86.7%, 48.5%, 47.8%, and 32.4% found substantial clinical benefit for mHHS, HOS-ADL, HOS-SSS, and iHOT-12, respectively.ConclusionsRotational running sports were significantly associated with rim chondral injuries. Flexibility sports were significantly associated with rim chondral injuries and ligamentum teres tears. Athletes participating in these sports are more likely to have intra-articular hip injuries than those in the other sports categories.Level of EvidenceLevel IV, prognostic case series.

Are there Sex differences in Return to Play Rates in High Level Athletes Following Hip Arthroscopy?

Objectives:Return to sport is a common co ncern in those undergoing arthroscopic surgery for the treatment of femoroacetabular impingement. These are commonly young active individuals with high-level athletic aspirations. Setting expectations in terms of appropriate time frame and success rates are an integral piece of pre-operative education and planning. The goals of this study were to examine return to play (RTP) rates and time frames in professional and collegiate athletes following hip arthroscopy, evaluate sex differences in return to play (morphology and rates), and evaluate differences in return to play for the most common sports.Methods:A retrospective review of a continuous cohort of patients undergoing hip arthroscopy for the treatment of femoroacetabular impingement and labral injury was conducted between January 2014 and December 2018. Athletes whom were participating in collegiate or professional sports prior to surgery were included. Chart review was conducted to gather sport specific information, morphologic data, clearance dates, successful return, and subsequent surgery. Successful return to sport was determined by being able to return to participation following clearance in at least one season. Descriptive statistics were utilized to summarize the data set and chi-square and t-tests were utilized to examine differences between groups.Results:265 patients undergoing 332 hip arthroscopies participating in collegiate or professional sports prior to surgery were identified (75.4% male and 24.6% female), with 237 collegiate athletes and 95 professional athletes. There was a significant difference in mean alpha angles between males and females, 70.2 ± 10.5 males and 60.7± 10.0 in females, (p<0.001), but no significant differences in coronal center edge angles or femoral version. 87% of the athletes participated in hockey, football, lacrosse, soccer, baseball, soccer, or basketball. Given that a significant portion of the athletes were in college, there was a portion that graduated and thus no longer participated in collegiate athletics (27 hips), and 3 athletes (all with bilateral hip arthroscopies) were unable to return to sport due to other conditions. 91.9% of athletes were able to return to sport. 19 athletes (22 hips) were unable to return to sport. The group that was unable to return was predominantly female (73%), and this difference was significant (p<0.001). There was a significant difference between the returning group and the group that failed to return to sport in alpha angle (RTP 68.6 ± 10.8 vs No RTP 60.7± 10.6), but there were no differences in coronal center edge angle or femoral version. The difference in alpha angle is due to the predominance of females (whom had significantly lower alphas) in the unable to return group. 10 athletes (11 hips, 3.3%) required subsequent surgery (revision arthroscopy, conversion to periacetabular osteotomy, or hip resurfacing). Times for return to play were available to 205 of the athletes, averaging 6.8 months± 2.8. There was no significant difference between the males and females for return to play. There was trend towards shorter length of return for hockey athletes. There was a significant difference in the return to sport rates between the sport groups, but there were some groups with smaller sample sizes that should be taken into account. The groups with more athletes unable to return were soccer and lacrosse; these sports also had a high number of female athletes. There were no hockey athletes that were unable to return, and only 1 football athlete was unable to return.Conclusions:Hip arthroscopy for the treatment of femoroacetabular impingement and labral injury allows patients to return to sport at a high level within an average of 6.8 months. However, female athletes are less likely to have a successful return and should potentially be counseled as such. This may also inform pre-operative rehabilitation programs and intra-operative planning for female athletes. Further research should examine causes for decreased rate of return for females, and potential ways to maximize recovery and return to sport following hip arthroscopy.Athletes’ Ability to Return to Play by Sport Able Unable % RTP Football52198.20%Hockey710100.00%Soccer21580.80%Basketball24292.30%Baseball32294.10%Lacrosse43589.60%

Venting the Central Compartment of the Hip Prior to Distraction Minimizes Overall Hip Distraction Forces

Objectives:Arthroscopic hip surgery requires application of ipsilateral lower extremity traction to achieve adequate joint distraction and hip central compartment access. Higher traction forces applied to the lower extremity allow greater hip joint distraction, improving the working space, in order minimize iatrogenic chondral and labral injury. However, greater traction forces have demonstrated a higher potential for iatrogenic traction related injuries. Controversy exists about the clinical relevance of procedural modifications, such as venting the hip, as a means of reducing the amount of traction force required to safely distract the hip joint. This study was designed to evaluate the difference between no venting versus venting the hip prior to application of traction on the overall amount of traction needed to distract the hip joint during hip arthroscopy.Methods:A total of 55 hips in 54 consecutive patients undergoing primary arthroscopic hip surgery were retrospectively reviewed. Prior to any instrumentation, interval fluoroscopic images of the operative hip joint were taken at 0, 25, 50, 75, and 100 pound-force (lb-f) (0, 11.3, 22.7, 34.0, and 45.4 kilogram-force (kg-f)) of applied traction. The hip was then taken off traction and the joint was vented using a standard hip access 14-gauge spinal needle and injected with 20 milliliters of air. Before any additional intervention, traction was again applied to the operative extremity and fluoroscopic images were obtained at the same traction force intervals. Joint displacement was measured at each traction force interval both before and after venting. Fluoroscopic images were scaled based on AP pelvis radiographs in order to obtain millimeteric joint space measurements.Results:The mean difference in hip joint displacement without venting and with venting was 0.29, 2.24, 4.06, 4.13, and 3.80mm at 25, 50, 75, and 100 lbs-f of traction, respectively. Paired samples t-testing demonstrated statistically significant increases in distraction distance (p<0.01) at all levels of traction (Table 1). Prior to venting, 0%, 7.3%, 27.8%, 44.0% of hips distracted at least 10 mm at 25, 50, 75, and 100 lbs-f of traction, respectively. After venting, 14.6%, 45.0%, 74.0%, 86% of hips distracted at least 10 mm at 25, 50, 75, and 100 lbs-f of traction, respectively (Figure 1).Conclusion:This study demonstrates that venting the hip prior to the application of traction significantly increases the amount of distraction distance achieved for a given traction force at multiple levels of traction. With venting of the hip, the percentage of hips achieving at least 10mm of distraction for 100lbsf almost doubled. These findings suggest venting the hip prior to application of traction could serve to reduce the maximal amount of traction required to safely instrument the hip arthroscopically.Table 1.Pre and post-venting distraction distances by amount of traction force Amount of Traction Pre-venting Mean Distraction Distance (mm)Post-venting Mean Distraction Distance (mm)Mean Pre- versus Post-venting Difference (mm)p-value0 lb-f (0 kg-f)4.614.900.290.00325 lb-f (11.3 kg-f)4.877.112.24<0.00150 lb-f (22.7 kg-f)5.829.884.06<0.00175 lb-f (34.0 kg-f)7.6611.784.13<0.001100 lb-f (45.4 kg-f)9.2213.023.80<0.001Figure 1.

Superior Labral Injuries in Elite Gymnasts: Symptoms, Pathology, and Outcomes After Surgical Repair.

Background:Superior labral anterior-posterior (SLAP) lesions are common among elite gymnasts and throwing athletes. Although SLAP lesions in throwers are well-described in the literature, no study has described the characteristics of SLAP lesions in gymnasts. We aimed to reveal the characteristics of SLAP lesions in gymnasts by comparing the location and extension of these lesions between gymnasts and throwers.Hypothesis:The location and arc of SLAP lesions in gymnasts will be different from those in throwing athletes.Study Design:Case series; Level of evidence, 4.Methods:This study included 27 shoulders in 20 males and 3 females with a mean ± SD age of 20 ± 2.5 years (range, 16-25 years). We performed debridement alone for shoulders with a stable lesion. Anterior and/or posterior labral repair was added for unstable SLAP lesions depending on the extension and stability of the lesions. We investigated symptoms, onset, return to sport (based on patient records), and subjective shoulder values. SLAP lesions were evaluated through use of the Snyder classification. The location and arc of SLAP lesions were determined from surgical records and videos and described by use of the right shoulder clockface method. During the same period, 65 baseball players (65 shoulders; all males; mean age, 23 ± 7.0 years; range, 16-44 years) underwent arthroscopic SLAP surgery. We compared the location and arc of SLAP lesions between gymnasts and baseball players.Results:Symptoms during gymnastics included pain (100%), apprehension (48%), or catching (11%). We found that 20 shoulders had symptom onset during gymnastics, most commonly during rings events. Type II SLAP lesions were found in 17 shoulders, type III in 2 shoulders, and type IV in 8 shoulders. The mean center of SLAP lesions was at the 11:40 clockface position in 27 gymnasts and 10:40 clockface position in 65 baseball players, and the difference was statistically significant (P < .001). The mean arc of SLAP lesions was 125° in gymnasts and 140° in baseball players, and the difference was not significant. We performed debridement in 2 shoulders (7%) and labral repair in 25 shoulders (93%). After surgery, all patients returned to gymnastics. The mean subjective shoulder value was 35 (range, 10-90) preoperatively and 76 (range, 40-100) postoperatively.Conclusion:SLAP lesions in gymnasts were significantly located anteriorly compared with those in baseball players. All patients returned to gymnastics after arthroscopic surgery. Secure repair of SLAP lesions may be important for good surgical outcomes, because 50% of patients experienced preoperative shoulder apprehension.

An Unusual Case Of Shoulder Pain In A High School Football Player

HISTORY: A 15 year-old right hand dominant male presented to sports medicine clinic due to left shoulder pain. The mechanism of injury was while playing football the day prior where he jumped to catch a pass, and landed directly on grass onto his left shoulder with arm by his side. Heard a “pop” when he landed, and was experiencing intermittent, generalized shoulder pain since the event. Denied prior injury of affected extremity as well as denied numbness or tingling. There was no swelling, discoloration, or bruising per the patient or the mother of the patient. There was no obvious reported deformity of the shoulder as well. The patient denied any neck or elbow pain. Symptoms were improved at rest and with arm at his side. PHYSICAL EXAM: Left Shoulder: Pain with passive abduction, flexion on range of motion (ROM) testing. Active ROM is full in all directions. Tender to palpation (TTP) at the AC joint and scapular angle; no TTP at scapular body. Strength: 2/5 supraspinatus, 3/5 external rotation, 4/5 internal rotation, abduction, and biceps. Positive empty can and drop arm. No erythema, normal sensation throughout left upper extremity, and radial and ulnar pulses 2+ and regular. DIFFERENTIAL DIAGNOSIS: 1. Acromioclavicular sprain 2. Rotator Cuff injury 3. Glenoid labrum injury 4. Distal clavicle contusion 5. Glenohumeral dislocation TEST AND RESULTS: 1. XR Left Shoulder: no acute fracture, dislocation, or soft tissue abnormality2. XR Left Scapula: No acute displaced fracture. 3. MRI (no IV contrast) Left Shoulder: Feathery edema in the rotator cuff musculature centered about the scapula. Low grade muscular strain vs underlying non-displaced scapular body fracture. 4. CT Shoulder Trauma w/ Joint (no IV contrast): Non-displaced hairline fracture in the mid scapular body perpendicular to the long axis. AC and GH joints are intact. FINAL WORKING DIAGNOSIS: Non-displaced extra-articular fracture in the mid scapular body TREATMENT AND OUTCOMES: 1. Immobilization with sling for initial 4 weeks with pendulum swings twice daily 2. At week 4, no pain at rest with asymptomatic full strength. Physical Therapy initiated. 3. Cleared for non-contact and non-collision activities at week 8. 4. Returned to all activities without restriction at week 12.

Superior Labrum Injuries in Elite Gymnasts: Symptom, Pathology, and Outcome after Surgical Repair

Objectives:Superior labral anterior-posterior (SLAP) lesions are common among gymnasts and throwing athletes. Although SLAP lesions in throwers are well described in the literature, no study has described the characteristics of SLAP lesions in gymnasts. We aimed to reveal the characteristics of SLAP lesions in gymnasts by comparing the location and extension of these lesions between gymnasts and throwers.Methods:This study included 27 shoulders in 20 male and 3 female patients with a mean age of 20 years (range, 16-25 years). We performed debridement alone for shoulders with a stable lesion. Anterior and/or posterior labrum repair was added for unstable SLAP lesions, depending on the extension and stability of the lesions. We investigated symptoms, onset, sports return based on patient records, and subjective shoulder values (SSVs). SLAP lesions were evaluated using the Snyder classification. The location and extension of SLAP lesions were determined from surgical records and videos, and described using the right shoulder clock-face method. During the same period, 65 baseball players (65 shoulders) underwent arthroscopic SLAP surgery. They were all men with a mean age of 23 years (range, 16-44 years). We also investigated the location and extension of SLAP lesions in baseball players for comparison. Statistical analysis was performed using the Mann-Whitney U-test for comparing the center and arc of SLAP lesions between gymnasts and baseball players. The Mann-Whitney U-test was also used to compare the preoperative and postoperative SSVs. The level of significance was set at P<0.05.Results:Symptoms during gymnastics included pain (100%), apprehension (48%), or catching (11%). Twenty shoulders had symptom onset during gymnastics, most commonly during rings events. Type II SLAP lesions were found in 17 shoulders, type III in 2 shoulders, and type IV in 8 shoulders. The mean center of SLAP lesions was located at 11:40 in 27 gymnasts and at 10:40 in 65 baseball players, and the difference was statistically significant (P<0.001). The mean arc of SLAP lesions was 125° in gymnasts and 140° in baseball players, and the difference was not significant (P=0,09) (Figure 1). We performed debridement (Figure 2) in 2 shoulders (7%) and labrum repair (Figure 3,4) in 25 shoulders (93%). After surgery, all patients returned to gymnastics. The mean SSV was 35 (range, 10-90) preoperatively and 76 (range, 40-100) postoperatively.Conclusion:SLAP lesions in gymnasts were significantly located anteriorly than those in baseball players. Most SLAP lesions in the shoulders of gymnasts had symptom onset during suspension events such as rings or bars, and half of the gymnasts complained of shoulder apprehension in addition to pain. Fixation of both the anterior and posterior labrum was performed in 63% of the patients, and all patients returned to gymnastics after arthroscopic surgery. Secure repair of SLAP lesions may be important for good surgical outcomes because gymnasts require a stable glenohumeral joint.Figure 1.Figure 2.