Labral Lesions Research Articles

Review of femoroacetabular impingement syndrome

Abstract Femoroacetabular impingement syndrome (FAIS) is a common condition of the hip that can cause significant damage to the joint, leading to degeneration and osteoarthritis. FAIS constitutes an abnormal and dynamic contact between the femoral head–neck junction and the acetabular rim, resulting from altered bone morphology at one or both sites. Repetitive trauma at the site of impingement generates progressive damage to the acetabular labrum, chondrolabral junction, and articular cartilage. Proper diagnosis based on patient symptoms, specific clinical signs, and imaging findings will guide treatment and ultimately allow preservation of the native hip joint. Common symptoms in patients with FAIS include pain, clicking, catching, buckling, stiffness, giving way, and a limited range of motion of the hip. Specific clinical maneuvers can aid diagnosis, such as flexion adduction internal rotation and flexion abduction external rotation tests. Imaging diagnosis includes orthogonal hip and pelvis X-ray views, as well as magnetic resonance imaging/magnetic resonance arthrogram imaging. Initial treatment of FAIS can be conservative and include physical therapy, intra-articular injections, and activity modification. Currently, the preferred surgical management consists of hip arthroscopy, which aims to correct bony abnormalities, repair or reconstruct labral lesions and address other intra-articular and extra-articular derangements as needed.

Paper 41: Does MR Arthrography Improve Evaluation of Patients with Posterior Shoulder Instability? An Analysis from the MOON Shoulder Instability Group

Objectives: Posterior shoulder instability is an uncommon injury, accounting for 2-12% of shoulder instability patients. Magnetic resonance imaging (MRI) is often utilized to non-invasively evaluate the joint for labral, cartilage, and bony injury. MR arthrography (MRA) may improve the evaluation of these intra-articular structures, but requires additional cost, time, and an invasive procedure. Moreover, its benefits for patients with posterior shoulder instability are unclear. Accurate imaging is critical in patients undergoing surgery because certain findings may influence the surgical approach. Thus, the purpose of this study is to compare the accuracy of MRA and non-enhanced MRI in detecting labral, chondral, and osseous lesions in patients with posterior shoulder instability. Methods: There were 291 patients with unilateral posterior shoulder instability who had preoperative MRA or MRI between 2006 and 2021 in the MOON database. Images were reviewed by a fellowship-trained musculoskeletal radiologist with 10+ years of experience and an orthopaedic surgeon. Evaluators were blinded to age, gender, medical history, MR report, and arthroscopic findings, but were aware of the patient's history of posterior shoulder instability. Examinations were evaluated for presence, location, morphology, and length of glenoid labral tears. Tear length and localization were noted using a standard clock face. The presence and size of humeral/glenoid osseous and cartilage lesions was also noted.Intraoperative findings from arthroscopic evaluation were documented by the surgeon using a standard response questionnaire. Diagnostic performance of standard MRA and MRI were evaluated using sensitivity and specificity with arthroscopic evaluation as the gold-standard. Chi-squared or Fisher’s exact tests were used to compare the sensitivities and specificities of MRA and MRI. Significance was defined as P < 0.05. Results: 200 patients (69%) had MRA, while 91 patients had non-contrast MRIs of the shoulder. On imaging evaluation, 273 (94%) patients had labral tears with a mean tear size of 156º. 39 (13%) patients had humeral cartilage lesions, whereas 40 (14%) patients had glenoid cartilage lesions. 34 (12%) patients had glenoid bone loss greater than 5%. The mean glenoid bone loss was 12% (range, 5% - 26%). A reverse Hill-Sachs lesion was present in 35 (12%) patients. 16 (6%) patients had bipolar bone loss. The sensitivity for detection of labral tears was high for both MRA (0.95) and standard MRI (0.98) (Tables 1 and 2), though the specificity was low for both modalities (0.25 and 0.40, respectively). There was no difference in the sensitivities or specificities of the two imaging modalities in the detection of labral tears. MRA had a lower sensitivity than MRI in the detection of glenoid cartilage lesions (0.31 vs 0.88, p < 0.001), but no difference was observed for specificity. There was no difference in the sensitivities and specificities of MRA and MRI for humeral cartilage lesions (p = 0.354).MRA had a higher sensitivity than MRI in assessing glenoid bone loss (0.78 vs 0.50, p < 0.001), though there was no difference in specificity. There was no difference between imaging modalities in the evaluation of humeral bone loss (p = 1.000). Conclusions: In this multicenter study, MRA was the most commonly utilized preoperative advanced imaging study for patients with posterior shoulder instability. MRA had a higher sensitivity in detecting glenoid bone loss but lower sensitivity in detecting glenoid cartilage lesions compared to standard non-contrast MRI. There was no difference in diagnostic performance between MRA and MRI in the diagnosis of labral tears and humeral chondral and osseous lesions. MRA may provide an advantage over standard MRI in the evaluation of glenoid bone loss, which can influence the treatment plan for patients undergoing surgical management of posterior shoulder instability.

Outcomes of primary arthroscopic shoulder stabilization in active patients over 40—results at a mean follow-up of 7 years

PurposeThe purpose of this study is to report clinical outcomes, return to activity, redislocation rate, and rate of conversion to arthroplasty for active patients over age 40 undergoing primary arthroscopic shoulder stabilization. MethodsPatients over 40 years of age who underwent arthroscopic capsulolabral repair for shoulder instability between December 2005 and January 2018 with a minimum of 2-year postoperative follow-up were enrolled in this retrospective, monocentric study. Clinical outcome scores including the 12-Item Short Form Survey (SF-12), American Shoulder and Elbow Surgeons (ASES), Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH), Single Assessment Numeric Evaluation (SANE), and VAS pain were collected. Additionally, it was determined which patients reached the minimal clinically important difference (MCID) and the patient acceptable symptom state (PASS) for the ASES score. Bivariate analysis was utilized to determine if there was any association between baseline demographic and clinical factors with the outcome scores. ResultsOf a total of 814 patients assessed for eligibility, a total of 40 patients were included and 33 patients (8 females) were available for follow-up. Average age was 49.4 ± 7.6 years. At an average follow-up of 7.0 ± 3.6 years, all the outcome scores significantly improved compared to baseline. These include ASES (69.9 ± 19 to 95.8 ± 7.6, p<.001), QuickDASH (29.7 ± 17.7 to 3.9 ± 5.4, p<.002); SANE (53.5 ± 29.3 to 91.6 ± 14.3, p<.003), SF-12 (45.6± 8.8 to 55.2 ± 5.7, p<.001) and VAS (2.1 ± 2.1 to 0.3 ± 1, p<.002). MCID was reached by 72.7% of the patients and 81.8% reached the PASS threshold for the ASES score. Postoperative shoulder stability improved substantially and significantly. Median postoperative satisfaction was 10/10 (range 1-10). 95.6% of the patients returned to sport, with 91.0% of the patients able to return to pre-injury level. One patient (3%) underwent revision surgery for osteoarthritis, in the form of comprehensive arthroscopic management procedure. The presence of cartilage defects cartilage defects Outerbridge grade >2 (p=0.020) and posterior labral lesions (p=0.03) at index surgery were significantly associated with inferior outcomes in the ASES score. ConclusionActive patients aged 40 years and older undergoing arthroscopic shoulder stabilization experienced favorable functional outcomes at a mean follow-up of 7 years, with low rates of revision surgery or of progression to clinically relevant osteoarthritis. However, the presence of high-grade cartilage lesions and the presence of a posterior labral tear were associated with inferior clinical outcomes.

Glenoid Concavity Affects Anterior Shoulder Stability in an Active-Assisted Biomechanical Model.

The treatment of bony glenoid defects after anteroinferior shoulder dislocation currently depends on the amount of glenoid bone loss (GBL). Recent studies have described the glenoid concavity as an essential factor for glenohumeral stability. The role of glenoid concavity in the presence of soft tissue and muscle forces is still unknown. Glenoid concavity would have a major impact on glenohumeral stability in an active-assisted biomechanical model including soft tissue and the rotator cuff's compression forces. Controlled laboratory study. In 8 human shoulder specimens, individual coordinate systems were calculated based on anatomic landmarks. The glenoid concavity was measured biomechanically and based on computed tomography. Static load was applied to the rotator cuff tendons and the deltoid muscle. In a robotic test setup, anteriorly directed force was applied to the humeral head until translation of 5 mm (Nant) was achieved. Nant was used as a parameter indicating shoulder stability. This was performed in the following testing stages: (1) intact joint, (2) labral lesion, (3) 10% GBL, and (4) 20% GBL. The 8 specimens were divided equally into 2 subgroups (low concavity [LC] versus high concavity [HC]), with 4 specimens each, according to the previously measured concavity. Anterior glenohumeral stability was highly correlated with the native glenoid concavity (R 2 = 0.8). In the testing stages 1 to 3, we found a significantly higher mean stability in the HC subgroup compared with the LC subgroup (P≤ .0142). The HC subgroup still showed higher absolute Nant values with 20% GBL; however, there was no significant difference from the LC subgroup. The loss of stability in 20% GBL was correlated with the initial concavity (R 2 = 0.86). Thus, a higher loss of Nant in the HC subgroup was observed (P = .0049). In an active-assisted model with intact soft tissue surrounding and muscular compression forces, the glenoid concavity correlates with shoulder stability. In bony defects, loss of concavity is an essential factor causing instability. Due to their significantly higher native stability, glenoids with HC can tolerate a higher amount of GBL. Glenoid concavity should be considered in an individualized treatment of bony glenoid defects. Further studies are required to establish reference values and develop therapeutic algorithms.

Comparison of 3T MR arthrography and 3T MRI in intra-articular hip pathology: a cost-analysis.

MR arthrography (MRA) has previously been the radiological gold standard for investigating labral and chondral lesions of the hip joint. In recent years, 3T MRI has demonstrated comparable accuracy, being adopted as the first-line imaging investigation in many institutions. We compare the associated increased cost and radiation dose of the fluoroscopic component of the MRA compared to MRI. In this retrospective review over 2years, 120 patients (mean age 27.3years ± 13.2, range 8-67) underwent 3T MRA or non-contrast 3T MRI. Three musculoskeletal radiologists reported the data independently. Primary objectives included cost-comparison between each and radiation dose of the fluoroscopic component of the MRA. Secondary objectives included comparing detection of pathology involving the acetabular labrum, femoral cartilage, and acetabular cartilage. Then, 58 (48%) underwent 3T MRA and 62 (52%) patients underwent 3T MRI. The added cost of the fluoroscopic injection prior to MRA was €116.31/patient, equating to €7211.22 savings/year. MRA was associated with a small radiation dose of 0.003mSv. Transitioning from 3T MRA to 3T MRI in the investigation of intra-articular hip pathology increases cost savings and reduces radiation dose.

Extended Interportal Capsulotomy for Hip Arthroscopy, a Single-Center Clinical Experience.

Background and Objectives: The number of hip arthroscopy procedures is on the rise worldwide, and awareness regarding proper management of the hip capsule has increased. No capsulotomy shape is agreed upon as a standard approach, with literature supporting both isolated interportal and T-shaped capsulotomies. The aim of this retrospective cohort study is to report the clinical results of a standardized extended interportal capsulotomy (EIPC) during hip arthroscopy. Materials and Methods: Patients operated on between 2017 and 2020 with a hip arthroscopy were eligible. The inclusion criteria were ages 18-60 years, failed non-operative treatment, and at least a 2-year follow-up. Exclusion criteria were bilateral femoroacetabular impingement syndrome (FAS) cases or labral lesions, ipsilateral knee injury, history of ipsilateral hip surgery, and significant spine lesions. Data regarding demographic characteristics such as age, gender, operation date, BMI, but also Beighton score, presence of postoperative pudendal nerve damage, and revision for any reason were gathered from patients' records. All patients were evaluated preoperatively with a visual analog scale (VAS), the Hip Disability and Osteoarthritis Outcome Score (HOOS), and the modified Harris Hip Score (mHHS). Results: Of the 97 patients operated on with a hip arthroscopy between the defined dates, only 90 patients were included. The mean age was 37.9 ± 9.8, and 58.9% of patients were male. The most frequent surgical indication was an isolated FAS lesion (73.3%), followed by FAS associated with a labral tear (12.2%), an isolated labrum tear (10.0%), synovitis (3.3%), and a loose body (1.1%). The mean follow-up for the study cohort was 39.3 months. The majority of the patients had uneventful surgeries (76.7%), while there were three cases of sciatic nerve neuropraxia and 12 cases of pudendal nerve neuropraxia. Two patients underwent revision surgery during the study period. Comparison between preoperative and postoperative clinical scores showed a significant improvement with a final mHHS mean value of 67.7 ± 18.2, an HOOS value of 74.1 ± 13.2, and a low VAS score of 1.3 ± 1.2. Conclusions: A hip arthroscopy procedure with a standardized and unrepaired, extended interportal capsulotomy is a safe procedure with satisfactory mid-term results and high overall patient satisfaction. At a minimum of 2 years and a mean of 39.2 months, patients showed improved clinical scores and a low revision rate.

THE ROLE OF THE LOW FIELD MAGNETIC RESONANCE IMAGING IN THE DIAGNOSIS OF THE COMMON SHOULDER JOINT LESIONS

This article reviews the role of the low field magnetic resonance imaging (MRI) with magnetic field strengths of 0.4 Tesla in the evaluation of the main pathologic conditions of the shoulder joint commonly encountered in clinical practice. Shoulder pain is a common clinical complaint that may be caused by abnormalities of the rotator cuff tendon, labrum and a variety of other pathological conditions. The differential diagnosis is extensive and includes tendinosis and rotator cuff pathology, instability, labral lesions, biceps disorders, radiculopathy, and thoracic outlet syndrome. In older patients, arthritis may even be a factor. The goal of this study was to evaluate the feasibility and diagnostic confidence of an open low field MRI in patients with shoulder joint pain. Our data was obtained from 40 patients: 24 Male (60%) and 16-Female (40%). Their ages ranged between 17 and 70 years. All patients were investigated by conventional X-rays and MRI in the medical diagnostic center of Aden Resonance in Al-Mansoura district in Aden city. MRI was performed at an open 0. 4 Tesla MR-unit (Hitachi - Japan-Aperto Lucent). The study protocol comprised axial, sagittal &amp; coronal STIR-T2 and T1 weighted images of 3-4 mm thickness. 55 patients (52.4%) were investigated by high field MRI 1. 5 T (Neusoft) as a reference method.

Concomitant Glenohumeral Pathologies in Patients with Acromioclavicular Joint Dislocations: How Do Acute and Chronic Instabilities Differ?

Background: Concomitant glenohumeral pathologies may be present in patients with acromioclavicular joint (ACJ) dislocations. This study aims to record and compare the prevalence and treatment of CGP in cases with acute and chronic ACJ dislocations. Methods: This retrospective cross-sectional binational, bicentric study included patients that underwent arthroscopically assisted stabilization for acute (group A) and chronic (group C) ACJ dislocations. Intraoperatively, CGPs and eventual treatments (debridement and reconstructive measures) were recorded. Results: The study included 540 patients (87% men; mean age 39.4 years), with 410 (75.9%) patients in group A and 130 (24.1%) in group C. Patients in group C were older (p < 0.001). The CGP prevalence was 30.7%, without a difference between groups A and C (p = 0.19). Supraspinatus tendon (SSP) and labral lesions were most common. Within group C, CGPs were more prevalent in surgery-naïve patients (p = 0.002). Among 49 patients with previous surgical treatment, CGPs tended to be more common in patients with prior open surgery than arthroscopically assisted surgery (p = 0.392). Increased CGP prevalence was associated with higher age (r = 0.97; p = 0.004) (up to 63% in the oldest age group, but also 17% for youngest age group) and higher in cases with Rockwood type-IIIB injuries compared to type-V injuries (p = 0.028), but type-IIIB injuries included more group C cases (p < 0.001). The most frequently found CGPs were treated by debridement rather than reconstructive interventions (SSP and labrum: p < 0.001, respectively). Conclusions: This study shows that one in three patients with ACJ instabilities has a CGP, especially elderly patients. Most of the CGPs were treated by debridement rather than constructive interventions.

Shoulder pathologies in CrossFit: a magnetic resonance imaging study of 51 cases.

Recent scientific work shows that the most common injuries in CrossFit© occur in the shoulder joint. This paper aims to provide a review of shoulder pathologies in a young CrossFit© cohort via MRI and clinical examination. A survey was conducted in 13 CrossFit "boxes" in Germany, in which athletes with recurrent shoulder pain could report for a clinical examination and MRI diagnostic. Fifty-one CrossFit athletes with chronic shoulder pain agreed to participate in the study and were then examined physically and by MRI. Fifty-one active CrossFit athletes aged 21-45 years (mean 33.7 years, 35 male and 16 female) were recruited. The most frequently detected pathologies were partial lesions of the supraspinatus tendon (N.=25; 49%) and labral lesions (N.=11; 21.6%). The findings also identified partial lesions of the subscapularis tendon (N.=9; 17.6%), pulley lesions (N.=9; 17.6%), and partial lesions of the infraspinatus muscle (N.=2; 3.9%). These data demonstrate the need for a specific focus on particular shoulder injuries in CrossFit. Knowledge about the type of shoulder pathologies caused by CrossFit training allows for training-specific adaptations with regard to prevention, as well as a more targeted, sport-specific therapy. This study is the first in the literature to present on structural changes in the shoulders of active CrossFit athletes.

Acromioclavicular joint dislocation and concomitant labral lesions: a systematic review.

Acromioclavicular (AC) joint dislocations frequently co-occur with intra-articular glenohumeral pathologies. Few comprehensive studies have focused on labral tears specifically associated with AC joint trauma. This systematic review will address this gap. A comprehensive electronic search was conducted across PubMed, Cochrane Library, and Google Scholar (pages 1-20) spanning from 1976 to May 19, 2023. Seven studies met the inclusion criteria for this systematic review, consisting of three retrospective studies and four case series. These studies collectively involved 1,044 patients, of whom 282 had concomitant labral lesions. The pooled prevalence of intra-articular labral injuries associated with acute AC joint dislocation was 27%. The prevalence of these labral lesions varied significantly between studies, ranging from 13.9% to 84.0% of patients, depending on the study and the grade of AC joint dislocation. Various types of labral tears were reported, with superior labrum anterior to posterior (SLAP) lesions being the most common. The prevalence of SLAP lesions ranged from 7.2% to 77.4%, with higher grades of AC joint dislocations often associated with a higher prevalence of SLAP tears. Moreover, grade V dislocations exhibited a complete correlation with SLAP tears. The studies yielded contradictory findings regarding older age and higher grades of AC joint dislocation as risk factors for concurrent labral lesions. This review underscores the frequent association between labral lesions and AC joint dislocations, particularly in cases of lower-grade injuries. Notably, SLAP lesions emerged as the predominant type of labral tear.

Posterior Compression Test: a Provocative Test for Detecting Posterior Labral Tears.

The purpose is to assess the diagnostic accuracy of a provocative test coined as the 'posterior compression test' (PCT) in those with the suspected posterior labral tear or lesion. A total of 515 'arthroscopic labral repairs' were identified between April 2013 and September 2020. Excluding those with concomitant shoulder pathologies, and only including those with pre-operative documentation of the PCT and/or the Jerk test, 191 patients were included. For the purposes of the analyses, the patients were divided into 'non-posterior' labral tear group which included the anterior labral tears and/or the superior labral anterior-to-posterior (SLAP) tears, versus 'any posterior' labral tear group which included the isolated posterior labral tears, the SLAP tears with posterior extension and the pan-labral tears. When the PCT was performed for the isolated posterior labral tears, the sensitivity was 92.6% with the specificity of 86.5%. The positive predictive value and negative predictive value were 71.4-97%, respectively. The Jerk test's sensitivity was 77.8% but when the two tests were combined, the sensitivity increased up to 96.3%. The combined sensitivity with the Jerk test was still up to 94.6% with the AUC (area under curve) /ROC (receiver operator characteristic) at 0.855. Low 'false-positive' rate with the PCT was observed when the test was performed for the 'non-posterior' labral group, with the sensitivity of 13.5%. The posterior compression test correlated well with the arthroscopic diagnoses in a subset of patients with suspected posterior labral pathology, possibly by means of direct stimulation. III; Diagnostic Study.

Concomitant Biceps Tenodesis Does Not Portend Inferior Outcomes After Anterior Glenohumeral Stabilization

Background: Military patients are known to suffer disproportionately high rates of glenohumeral instability as well as superior labrum anterior to posterior (SLAP) tears. Additionally, a concomitant SLAP tear is frequently observed in patients with anterior shoulder instability. Even though biceps tenodesis has been demonstrated to produce superior outcomes to SLAP repair in military patients with isolated SLAP lesions, no existing studies have reported on outcomes after simultaneous tenodesis and anterior labral repair in patients with co-existing abnormalities. Purpose: To evaluate outcomes after simultaneous arthroscopic-assisted subpectoral biceps tenodesis and anterior labral repair in military patients younger than 40 years. We also sought to compare these outcomes with those after repair of an isolated anterior labral tear. Study Design: Cohort study; Level of evidence, 3. Methods: This study is a retrospective analysis of all military patients younger than 40 years from a single base who underwent arthroscopic anterior glenohumeral stabilization with or without concomitant biceps tenodesis between January 2010 and December 2019. Patients with glenoid bone loss of >13.5% were not eligible for inclusion. Outcome measures including the visual analog scale (VAS) for pain, the Single Assessment Numeric Evaluation (SANE), the American Shoulder and Elbow Surgeons (ASES) shoulder score, the Rowe instability score, and range of motion were administered preoperatively and postoperatively, and scores were compared between groups. Results: A total of 82 patients met inclusion criteria for the study. All patients were active-duty service members at the time of surgery. The mean follow-up was 87.75 ± 27.05 months in the repair + tenodesis group and 94.07 ± 28.72 months in the isolated repair group (P = .3085). Patients who underwent repair + tenodesis had significantly worse preoperative VAS pain (6.85 ± 1.86 vs 5.02 ± 2.07, respectively; P < .001), ASES (51.78 ± 11.89 vs 62.43 ± 12.35, respectively; P = .0002), and Rowe (26.75 ± 7.81 vs 37.26 ± 14.91, respectively; P = .0002) scores than patients who underwent isolated repair. Both groups experienced significant improvements in outcome scores postoperatively (P < .0001 for all), and there were no statistically significant differences in postoperative outcome scores or range of motion between groups. There were no differences in the percentage of patients who achieved the minimal clinically important difference, substantial clinical benefit, and patient acceptable symptom state for the VAS pain, SANE, ASES, and Rowe scores between groups. Overall, 37 of the 40 (92.50%) patients in the repair + tenodesis group and 40 of the 42 (95.24%) patients in the isolated repair group returned to unrestricted active-duty military service (P = .6045). In addition, 38 (95.00%) patients in the repair + tenodesis group and 40 (95.24%) patients in the isolated repair group returned to preinjury levels of sporting activity (P = .9600). There were no significant differences in the number of failures, revision surgical procedures, or patients discharged from the military between groups (P = .9421, P = .9400, and P = .6045, respectively). Conclusion: The findings of this study indicate that simultaneous biceps tenodesis and labral repair was a viable treatment option for the management of concomitant SLAP and anterior labral lesions in young, active military patients younger than 40 years.

Association of Chondrolabral Lesions with Ultrasound-Guided Detection of Pathological Head-Neck Contour.

This study aimed to investigate whether the asphericity of the neck-head junction of the femur confirmed via ultrasound is associated with further pathology due to femoro-acetabular impingement (FAI). After a clinical examination with positive FAI tests, an ultrasound examination of the hip was performed. In the case of asphericity, a quantitative ultrasound-assisted assessment of the hip was performed, followed by contrast-enhanced arthro-MRI with the question of cartilage or labral damage. We included 51 patients with a mean age of 35.25. According to the examination algorithm, asphericity was present in all patients via ultrasonography. The average anterior alpha angle (AAA) determined in ultrasonography was 43.49°. The average AAA on the arthro-MRI was 44.19°. The mean anterior head neck offset (AHNO) in ultrasound was 5.27 mm, and in arthro-MRI, it was 5.36 mm. Arthro-MRI confirmed a bump in 47 patients and a talization disorder in 4 patients. In 49 patients, a labral lesion was found, with one being a re-rupture. Furthermore, in one patient, labral degeneration was identified. Cartilage damage to the hip joint was found in 25 patients. Two patients had neither labral nor cartilage damage in the arthro-MRI. In our study, sonographically confirmed asphericity of the head-neck junction was found in 49 cases, which was associated with further pathology and, according to the current doctrine, was attributable to the FAI and required surgical intervention. This study shows that the detection of a pathologic head and neck contour via ultrasound in combination with positive clinical signs, as present in FAI, is associated with chondrolabral lesions detected via arthro-MRI in 96.1% of cases.

Isolated Arthroscopic Debridement of Acetabular Labral Tears: High Rates of Failure and Conversion to Total Hip Arthroplasty at 13-Year Minimum Follow-up

Background: Historically, symptomatic hip labral lesions were treated with arthroscopic debridement. Hip labral repair has become the standard treatment for labral pathology; however, to date, there are limited long-term studies regarding the outcomes of isolated labral debridement. Purpose: To (1) evaluate the long-term patient-reported outcomes of isolated labral debridement, (2) report reoperation and arthroplasty rates, and (3) identify risk factors contributing to reoperation or poor clinical outcomes. Study Design: Case series; Level of evidence, 4 Methods: A retrospective review of a prospectively generated cohort of 59 hips in 57 patients from 1996 to 2010 who underwent hip arthroscopy with labral debridement was performed. Only patients with Tönnis grade <3 were included. Additionally, given the time period analyzed, resection of cam morphology was not performed, and the interportal capsulotomy was not repaired. The pre- and postoperative modified Harris Hip Score; Hip Outcome Score (HOS)-Activities of Daily Living and -Sports scores; and reoperation, conversion to total hip arthroplasty, and risk factors were analyzed. Results: In total, 48 hips in 47 patients (14 men, 33 women; mean age, 48.0 ± 12.9 years) met inclusion criteria and were followed for a mean of 17 ± 3 years (range, 13-27 years). The mean preoperative Tönnis grade was 1.3 ± 0.6 (range, 0-2), the mean chondral acetabular International Cartilage Regeneration & Joint Preservation Society (ICRS) grade was 1.7 ± 1.6 (range, 0-4), the mean chondral femoral ICRS grade was 0.9 ± 1.4, and the mean acetabular labral articular cartilage grade was 2.5 ± 1.2 (range, 0-4). At the final follow-up, mean the modified Harris Hip Score, HOS-Activities of Daily Living score, and HOS-Sports score were 82.2 ± 16.6, 81.9 ± 20.5, and 82.2 ± 20.5, respectively. Nineteen hips underwent subsequent reoperation at a mean of 5.5 ± 6.2 years (range, 0.5-21.2 years) postoperatively, including 16 hips (33% overall) being converted to total hip arthroplasty. Higher acetabular ICRS chondral grades at the time of surgery were observed in patients who went on to subsequent surgery compared with those who did not (2.3 ± 1.6 vs 1.1 ± 1.5; P = .02). In reoperation-free hips, Tönnis grade demonstrated a trend of increasing over time (1.4 preoperatively vs 1.7 at radiographic follow-up; P = .08). At the final follow-up, 19 hips (40%) had undergone reoperation, and 5 additional hips (10%) were rated as “abnormal” or “severely abnormal” in function, resulting in an overall clinical failure rate of 50%. Conclusion: Isolated labral debridement was found to result in high rates of failure and reoperation, with a third of patients being converted to arthroplasty and half of patients meeting criteria for reoperation or clinical failure. Of note, for patients remaining reoperation-free, satisfactory outcome scores were observed.

MRI Findings of Periarticular Lesions with Isolated Greater Tubercle Fractures and Dislocation.

To identify MRI findings for injuries to periarticular soft tissue structures that were related to isolated greater tubercle fracture. 16 patients (mean age: 53.8, range 30-71 yrs) were enrolled and diagnosed with isolated greater tubercle (GT) fracture with CT and MRI and underwent shoulder arthroscopy from September 2009 to April 2019. Two musculoskeletal radiologists were blinded to the patient history and arthroscopic surgical findings and reviewed patient's CT and MRI. Fracture displacement, fracture center, and presence of bony Bankart lesion with Hill sachs lesion were checked on shoulder CT. Soft tissue injuries, including rotator cuff injury, deltoid muscle injury, long head of biceps tendon injury, capsular injury, glenoid injury, and injury location of the subscapularis and infraspinatus were checked on shoulder MRI. MRI showed supraspinatus injury (56.3%), subscapularis injury (56.3%), deltoid muscle injury (25%), infraspinatus injury (25%), teres minor muscle injury (37.5%), injury of the long head of the biceps tendon (43.8%), inferior glenohumeral ligament tear (87.5%), superior labral anterior-toposterior lesion (25%), Bankart lesion (18.8%), and Hill-Sachs lesion (6.3%). 88.9% of subscapularis injuries and 75% of infraspinatus injuries showed caudal predominance. All of the patients with infraspinatus injuries showed concomitant teres minor muscle injuries. In order of frequency, the fracture centers were anterior (25%), posterior (31.3%), and all (43.8%). For patients with Bankart and Hill- Sachs lesions, the fracture center included the posterior portion in all cases. MRI and active arthroscopic examinations may be valuable when an isolated GT avulsion fracture is identified on X-ray examination.

Radial Planes in Hip Magnetic Resonance Imaging: Techniques, Applications, and Perspectives.

The hip cartilage and labrum, as the main targets of femoroacetabular impingement, sports-related or traumatic damage, as well as congenital and developmental abnormalities, have attracted increasing attention with the development of magnetic resonance imaging (MRI) and hip arthroscopy. MRI is a commonly used imaging modality to noninvasively visualize the hip cartilage and labral lesions. However, conventional orthogonal MRI planes encounter unique challenges given the ball-and-socket configuration of the hip joint, its anatomically abducted and anteverted orientation, and the thin, closely apposed cartilage enveloping the femoral head and acetabulum. Advancements in hip MRI's radial plane, which is acquired through the center of the hip joint, offer a solution. This technology provides true cross-sectional images of the cartilage and labrum perpendicular to the curvature of the joint, thereby mitigating the partial-volume-averaging effects. The integration of 3.0-Tesla high field strength and three-dimensional (3D) acquisition techniques further enhances the capabilities of the radial plane. This combination yields a high signal-to-noise ratio, high spatial resolution, high contrast between intraarticular structures, while minimizing partial-volume-averaging effects. Such improvements potentially facilitate the comprehensive detection of even minor chondral and labral lesions. The capability for multiplanar reconstruction from a single 3D volumetric acquisition further strengthens the usefulness of the radial plane by aiding in precise localization of hip cartilage and labral lesions, in line with hip arthroscopy findings. These advancements have the potential to standardize MRI evaluations and radiographic reporting systems for hip cartilage and labrum, offering precise guidance for hip arthroscopy. This article presents a comprehensive review of radial plane technology applied to the hip MRI, and discusses the morphological assessment and localization of hip cartilage and labral lesions utilizing this advanced imaging technique. EVIDENCE LEVEL: 5 TECHNICAL EFFICACY: Stage 2.

Validation of the French version of the Non-Arthritic Hip Score (NAHS) in 113 hip arthroscopy procedures

BackgroundThe Non-Arthritic Hip Score (NAHS) used to evaluate the hip in younger patients is a self-administered questionnaire with 20 items in four sections: pain, symptoms, function, and activities. Although used in France, no transcultural version had been validated. The objective of this study was to translate the NAHS into French then assess the validity, reliability, and sensitivity to change of the French-language version (NAHS-Fr) in younger patients with hip conditions other than osteoarthritis. HypothesisThe NAHS-Fr demonstrates good validity and reliability when used in younger French-speaking patients with hip pain. Material and methodsWe conducted a prospective observational study in 105 patients (62 males and 43 females) scheduled for surgery on one or both hips (113 hips in total) to treat cam-type femoro-acetabular impingement or labral lesions. Before and 6 months after surgery, each patient completed the NAHS-Fr and Western Ontario and McMaster Osteoarthritis Index (WOMAC). Statistical tests were done to evaluate validity, reliability, and sensitivity to change, as recommended by the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN). ResultsThe response rate was 100%, confirming that the NAHS-Fr was easy to use. The NAHS-Fr was both valid and reliable. No ceiling or floor effect was detected for the total NAHS-Fr score. All items had Cronbach alpha coefficients greater than 0.8, indicating good internal consistency. External consistency between the NAHS-Fr and WOMAC was negative (–0.676) due to inversely proportional score indexing. Before surgery, the NAHS-Fr and WOMAC scores were strongly and significantly correlated (p<0.0001). The effect size was greater than 0.8, indicating good sensitivity to the change induced by surgery. DiscussionThese results confirm the study hypothesis: the NAHS-Fr has the same good psychometric characteristics as does the original version and versions in other languages. The NAHS-Fr is useful for evaluating younger patients with non-osteoarthritic hip pain and can be used by French-speaking surgeons in everyday clinical practice. Level of evidenceIV, prospective observational non-comparative cohort study.

Incidence ofShoulder Labral Pathology inUnited States Military Members.

Shoulder injuries account for approximately 8% to 24% of all musculoskeletal injuries in the military. Recently, a change was made to service-specific physical fitness tests. Knowledge of relative shoulder labral injury rates before and after this change would help guide future directions and preventive strategies. However, we found no previous literature evaluating the rates of labral injury among United States Military branch personnel by enlistment status (enlisted versus officer), gender, age, or race. In this retrospective epidemiological study, we queried the Defense Medical Epidemiology Database for International Classification of Disease, Tenth Revision (ICD-10) code S43.43 (superior glenoid labrum lesion) to determine the total number of patients with a shoulder labral injury from 2016 to 2019. Results were assessed for demographic associations of shoulder labral injury with branch, service occupation, rank, gender, race, and age. Queries were limited to first-time occurrences and ambulatory data only. Overall, our study found the incidence of shoulder labral injuries to be largely conserved each year from 2016 to 2019 (3.22-3.35/1000/year). Incidence of labral injury was highest in males, White service members, the junior enlisted, the Army service branch, ages 20 to 29, and enlisted non-combat personnel. With knowledge of injury patterns in specific military populations, initiatives may be taken to identify at-risk service members with the goal of informing future preventive strategies.

Factors influencing patient-reported outcomes following periacetabular osteotomy and open osteochondroplasty in the setting of borderline hip dysplasia.

This study reports mid-term outcomes after periacetabular osteotomy (PAO) exclusively in a borderline hip dysplasia (BHD) population to provide a contrast to published outcomes for arthroscopic surgery of the hip in BHD. We identified 42 hips in 40 patients treated between January 2009 and January 2016 with BHD defined as a lateral centre-edge angle (LCEA) of ≥ 18° but < 25°. A minimum five-year follow-up was available. Patient-reported outcomes (PROMs) including Tegner score, subjective hip value (SHV), modified Harris Hip Score (mHHS), and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) were assessed. The following morphological parameters were evaluated: LCEA, acetabular index (AI), α angle, Tönnis staging, acetabular retroversion, femoral version, femoroepiphyseal acetabular roof index (FEAR), iliocapsularis to rectus femoris ratio (IC/RF), and labral and ligamentum teres (LT) pathology. The mean follow-up was 96 months (67 to 139). The SHV, mHHS, WOMAC, and Tegner scores significantly improved (p < 0.001) at last follow-up. According to SHV and mHHS, there were three hips (7%) with poor results (SHV < 70), three (7%) with a fair score (70 to 79), eight (19%) with good results (80 to 89), and 28 (67%) who scored excellent (> 90) at the last follow-up. There were 11 subsequent operations: nine implant removals due to local irritation, one resection of postoperative heterotopic ossification, and one hip arthroscopy for intra-articular adhesions. No hips were converted to total hip arthroplasty at last follow-up. The presence of preoperative labral lesions or LT lesions did not influence any PROMs at last follow-up. From the three hips that had poor PROMs, two have developed severe osteoarthritis (> Tönnis II), presumably due to surgical overcorrection (postoperative AI < -10°). PAO is reliable in treating BHD with favourable mid-term outcomes. Concomitant LT and labral lesions did not negatively influence outcomes in our cohort. Technical accuracy with avoidance of overcorrection is essential in achieving successful outcomes.

Poster 175: ALPSA Lesions Associated with High Rate of Early Repair Failure

Objectives: Anterior labroligamentous periosteal sleeve avulsion (ALPSA) lesions occur in patients with recurrent shoulder instability and are associated with higher rates of failure after capsulolabral repair surgery compared to typical Bankart lesions. Despite recognition that these lesions can portend poor outcomes, there is relatively limited data to understand the associated injuries and postoperative course in a young, active population. The purpose of this study is to evaluate ALPSA lesions for associated pathology and outcomes. Methods: Methods: We reviewed the records of 312 patients who underwent arthroscopic shoulder stabilization by one of two fellowship trained sports surgeons at a single facility between 1 January 2010 and 31 December 2015. Inclusion criteria were a minimum follow-up of five years after index surgical repair and presence of an ALPSA lesion as identified on arthroscopic exam, leaving 46 patients available for review. Our primary outcome measures were failure and operative revision surgery. We considered failure as any recurrent shoulder instability events including subjective subluxation and dislocation, recurrence of pain consistent with instability, or functionally limiting apprehension. We performed survival analysis and a multivariate logistic regression analysis to identify factors associated with failure. Results: Results: In total, 46 patients with average age 21.2 years met inclusion and underwent surgery a median of 7.1 months after initial recalled injury event. 11/46 had concomitant posterior pathology in addition to anterior labral lesion. Six patients were found to have SLAP lesions. All patients experienced subjective instability, and 44/46 endorsed pain prior to surgery. 38/46 reported having experienced complete dislocation. The median number of dislocations before surgery was 3. Repairs were performed with average 3.7 anchors. Eight patients failed surgery at median 15.1 months post-index procedure, with 75% of failures occurring before two years with the remaining 25% occurring later in follow-up. Three of these failed revision repair. Conclusions: Conclusions: ALPSA lesions frequently occur in the presence of other intra-articular shoulder lesions and portend a high rate of recurrent shoulder instability despite repair. Notably, while failure occurs at a high rate, most repair failure for these lesions tends to occur early.