Labral Pathology Research Articles

A pilot randomised clinical trial of physiotherapy (manual therapy, exercise, and education) for early-onset hip osteoarthritis post-hip arthroscopy

BackgroundDespite the increasing use of hip arthroscopy for hip pain, there is no level 1 evidence to support physiotherapy rehabilitation programs following this procedure. The aims of this study were to determine (i) what is the feasibility of a randomised controlled trial (RCT) investigating a targeted physiotherapy intervention for early-onset hip osteoarthritis (OA) post-hip arthroscopy? and (ii) what are the within-group treatment effects of the physiotherapy intervention and a health-education control group?MethodsThis study was a pilot single-blind RCT conducted in a private physiotherapy clinic in Hobart, Australia. Patients included 17 volunteers (nine women; age 32 ± 8 years; body mass index = 25.6 ± 5.1 kg/m2) who were recruited 4–14 months post-hip arthroscopy, with chondropathy and/or labral pathology at the time of surgery. Interventions included a physiotherapy treatment program that was semi-standardised and consisted of (i) manual therapy; (ii) hip strengthening and functional retraining; and (iii) health education. Control treatment encompassed individualised health education sessions. The primary outcome measure was feasibility, which was reported as percentage of eligible participants enrolled, adherence with the intervention, and losses to follow-up. The research process was evaluated using interviews, and an estimated sample size for a definitive study is offered. Secondary outcomes included the Hip disability and Osteoarthritis Outcome Score (HOOS) and the International Hip Outcome Tool (IHOT-33) patient-reported outcomes.ResultsSeventeen out of 48 eligible patients (35%) were randomised. Adherence to the intervention was 100%, with no losses to follow-up. The estimated sample size for a full-scale RCT was 142 patients. The within-group (95% confidence intervals) change scores for the physiotherapy group were HOOS-Symptoms 6 points (−4 to 16); HOOS-Pain 10 points (−2 to 22); HOOS-Activity of Daily Living 8 points (0 to 16); HOOS-Sport 3 points (−12 to 19); HOOS-Quality of Life 3 points (−7 to 13); and IHOT-33 7 points (−10 to 25). The within-group (95% confidence intervals) change scores for the control group were HOOS-Symptoms −4 points (−17 to 9); HOOS-Pain −2 points (−18 to 13); HOOS-Activity of Daily Living −7 points (−17 to 4); HOOS-Sport 4 points (−16 to 23); HOOS-Quality of Life −5 points (−18 to 9); and IHOT-33 −4 points (−27 to 19). Suggestions to improve study design included greater supervision of exercises and increased access to physiotherapy appointments.ConclusionsResults support the feasibility of a full-scale RCT, and recommendations for an adequately powered and improved study to determine the efficacy of this physiotherapy intervention post-hip arthroscopy to reduce pain and improve function are provided.Trial registrationAustralian Clinical Trials Registry, ACTRN12614000426684

Hip arthroscopy in patients less than 25 years of age in the treatment of labral tears: aetiology and clinical outcomes.

Hip arthroscopy has evolved into a well-established and rapidly growing field of orthopedic surgery for the management of labral tears. The purpose of this study was to review clinical outcomes of patients less than 25 years of age undergoing hip arthroscopy for treatment of a labral tear. From 2005 to 2013, 82 hips in 76 patients with mean age of 20.4 (16-25 range) underwent hip arthroscopy for treatment of labral-chondral damage. The Western Ontario McMaster Universities Osteoarthritis Index (WOMAC) and hip disability and osteoarthritis outcome score (HOOS) were recorded at latest follow-up. 36 of 86 hips (42%) had isolated labral pathology with no associated bony pathology (normal alpha and centre-edge angle; no retroversion). Beck score (intraoperative cartilage damage) of 3 or more was significantly associated with an alpha angle of more than 55 degrees (odds ratio [OR], 3.6; confidence interval [CI], 1.2-11.0) and presence of femeroacetabular impingement (OR, 4.5; CI, 1.3-15.2). HOOS pain, sports/recreation, and quality of life significantly improved from preoperative to one year after surgery (p<0.05). 8 patients had re-operations for persistent pain; 5 underwent arthroscopic labral repair; 2 underwent arthroscopy with subsequent periacetabular osteotomy (PAO); 1 had only a periacetabular osteotomy (PAO). Complications included 2 lateral femoral cutaneous nerve deficits and 1 deep vein thrombosis. Labral tears in patients less than 25 years of age occurs commonly without bony deformities, with those with normal head/neck contour demonstrating significantly less early cartilage damage than those with bony pathology. Hip arthroscopy in young patients can improve function and quality of life with minimal morbidity.

The Evaluation of Shoulder Abduction with and without Rotation on the Supraspinatus Tendon and Labrum: A Finite Element Study

Objectives:Subacromial Impingement Syndrome (SIS) is thought to be the most common cause of isolated shoulder pain. SIS is the abnormal contact of the soft tissues of the subacromial space with the inferior aspect of the anterolateral acromial arch. The actual in vivo pathophysiology of subacromial impingement is still not well-understood. Current biomechanical studies have evaluated different shoulder motions causing impingement, but they are limited to clinical subacromial impingement tests and evaluated strains at the coracoacromial ligament. In the present study, we provided an in-depth analysis of various shoulder motions on the soft tissues of the shoulder, particularly the supraspinatus tendon and labrum, through finite element analysis (FEA) utilizing a novel three-dimensional shoulder model. We hypothesize that the results will confirm previous mechanical studies on impingement and labral pathology, but bring a greater in vivo understanding of the stresses on these soft tissues.Methods:The geometry of the shoulder model was created from CT and MRI scans, and consisted of bones, ligaments, cartilage, labrum, and supraspinatus muscle and tendon (Figure 1a). Isotropic elastic material properties were used for bones and cartilage, and other soft tissues were modeled as Ogden hyperelastic material properties [1]. We then simulated 90⁰ of abduction followed by 30⁰ of internal rotation, 90⁰ abduction with 30⁰ of external rotation, 90⁰ abduction, and 90⁰ forward flexion. These movements have been theorized to result in the most contact between the supraspinatus and the acromial arch. Hwang et al previously conducted a similar study to provide initial validation [1]. The maximum von Mises stresses at the supraspinatus tendon and labrum were calculated and compared in all tested motions.Results:The stresses at the supraspinatus muscle were similar for 90⁰ abduction with 30⁰ of internal rotation, 90⁰ abduction with 30⁰ of external rotation, and 90⁰ abduction, (28 to 33 MPa) but were less for 90⁰ forward flexion (22 MPa) (Table 1). Stress values at the labrum were highest for 90⁰ abduction with 30⁰ of external rotation (22 MPa), but stresses for 90⁰ abduction, 90⁰ abduction with 30⁰ of internal rotation, and 90⁰ forward flexion were 22%, 50% and 90% less compared to abduction with external rotation (17 and 2 MPa), respectively. The stresses at the labrum were concentrated at superior and posterior labrum (Table 1, Figure 1b and 1c). Current studies suggest different causal mechanisms of SIS. It is not clear whether it is primarily due to mechanical or intrinsic degeneration Our results show higher stresses on the supraspinatus tendon at 90⁰ abduction with and without + 30⁰ of internal and external rotation. Our analyses pertain to quasi static motions but the biomechanical effects may increase under repetitive motion. Our results also show that increased superior labrum stresses take place during 90⁰ abduction, and 90⁰ abduction with 30⁰ of external rotation, which could have clinical relevance for understanding SLAP (superior labrum anterior posterior) pathology.Conclusion:This study provides insight in understanding the various shoulder motions that may lead to SIS and SLAP pathology. To date there is no such study to our knowledge that utilizes FEA to analyze such in vivo properties of the rotator cuff and labrum. This novel model will be applied to future studies assessing the effect of various acromion morphologies on SIS.Table 1:Maximum von Mises stress data at Supraspinatus muscle and labrum in response to various shoulder motionsMotionMaximum von Mises Stress Value at Supraspinatus Muscle (Mpa)Maximum von Mises Stress Value at Labrum (Mpa)Location of Maximum Stress on Labrum90° Abduction3317Superior90° Abduction with 30° Internal Rotation317Superior-Anterior90° Abduction with 30° External Rotation2822Superior-Posterior90° Forward Flexion222Superior-PosteriorInferior-Anterior

Outcomes of Hip Arthroscopy in Competitive Athletes

To evaluate the minimum 2-year postoperative clinical outcomes and the rate of return to sports in athletes who underwent capsular plication for the treatment of ligamentous laxity and/or borderline dysplasia during hip arthroscopy for the treatment of femoroacetabular impingement and labral pathology. Since 2008, data were prospectively collected on patients who underwent hip arthroscopy for the treatment of femoroacetabular impingement and/or labral tears. Inclusion criteria were as follows: athlete at the high school, collegiate, or professional levels preoperatively, underwent capsular plication, and preoperatively recorded patient-reported outcome scores including modified Harris hip score (mHHS), nonarthritic athletic hip score (NAHS), hip outcome score-sports-specific subscale (HOS-SSS), and visual analog scale (VAS). Exclusion criteria were as follows: <16years old, preoperative Tönnis grade >1, and previous hip conditions. Sports activity and competitive levels were collected at a minimum of 2years postoperatively. Fifty-one hips (49 patients) met the inclusion criteria, and 41 hips (39 patients) had minimum 2-year follow-up (80.4% follow-up). Mean mHHS increased from 67.1 preoperatively to 83.5 (P < .0001). Mean NAHS increased from 66.8 to 88.8 (P < .0001). Mean HOS-SSS improved from 46.8 to 80.1 (P< .0001). Mean VAS decreased from 5.1 to 1.7 (P < .0001). Thirty-five (85.4%) hip arthroscopies allowed the patients to return to sports at follow-up. Thirty-four (82.9%) hip arthroscopies allowed the patients to maintain their competitive physical abilities at follow-up. Patient-reported outcomes and VAS in athletes significantly improved at a minimum of 2years after capsular plication as a part of hip arthroscopy addressing varying pathologies. In addition, most patients returned to sports at similar or higher competitive levels. These results suggest that capsular plication is a favorable treatment option in athletes with ligamentous laxity and/or borderline dysplasia. Level IV, therapeutic case series.

Arthroscopic Treatment of Hip Pain in Adolescent Patients With Borderline Dysplasia of the Hip: Minimum 2-Year Follow-Up

To examine arthroscopic treatment of hip pain in patients with borderline hip dysplasia (lateral center edge angle [LCEA] between 20° and 25°). From 2008 to 2013, patients below 18years of age who underwent arthroscopic hip surgery with an LCEA between 20° and 25° were retrospectively matched 1:1 to a control group without dysplasia (LCEA ≥25°) based on age, gender, femoroplasty, labral treatment, and capsular plication. Indications for surgery included failure to improve with nonoperative treatments and anti-inflammatory medications after 3months. Patient-reported outcome data were collected using modified Harris hip score, hip outcome score-activities of daily living subscale, hip outcome score-sports-specific subscale, nonarthritic athletic hip score, and visual analog scale. From 2008 to 2013, 168 patients below the age of 18 underwent arthroscopic hip surgery. Twenty-one patients met inclusion criteria and were matched 1:1 to a control group. Follow-up was achieved for 17 patients in both groups (81%). Mean follow-up time, age, and LCEA were 2.19years, 15.5years, and 22.3° for the dysplastic group and 2.16years, 16.0years, and 31.2° for the control group, respectively. Preoperative patient-reported outcomes between groups were not statistically different. At the latest follow-up, both groups showed statistically significant improvement over baseline in modified Harris hip score, hip outcome score-activities of daily living subscale, hip outcome score-sports-specific subscale, nonarthritic athletic hip score, and visual analog scale (P < .001). Latest follow-up scores were not statistically different between groups. This study shows favorable 2-year outcomes in adolescent patients with borderline dysplasia undergoing labral treatment and capsular plication. Outcomes in the borderline dysplastic patients were as good as those of a control group. Although adolescents with borderline dysplasia have traditionally been a challenging group of patients to treat, these results suggest that an arthroscopic approach that addresses both labral pathology and instability may be beneficial. Level IV, therapeutic case series.

Radiographic Diagnosis of Pincer-Type Femoroacetabular Impingement: A Systematic Review.

Background:Femoroacetabular impingement (FAI) is a well-recognized condition that causes hip pain and can lead to early osteoarthritis if not managed properly. With the increasing awareness and efficacy of operative treatments for pincer-type FAI, there is a need for consensus on the standardized radiographic diagnosis.Purpose:To perform a systematic review of the evidence regarding imaging modalities and radiographic signs for diagnosing pincer-type FAI.Study Design:Systematic review; Level of evidence, 4.Methods:A literature review was performed in 2016 using the Cochrane, PubMed, and Embase search engines. All articles focusing on a radiographic diagnosis of pincer-type FAI were reviewed. Each of the included 44 articles was assigned the appropriate level of evidence, and the particular radiographic marker and/or type of imaging were also summarized.Results:There were 44 studies included in the final review. Most of the articles were level 4 evidence (26 articles), and there were 12 level 3 and 6 level 2 articles. The crossover sign was the most commonly used radiographic sign (27/44) followed by the lateral center-edge angle (22/44). Anteroposterior (AP) pelvis plain radiographs were the most commonly used imaging modality (33 studies). Poor-quality evidence exists in support of most currently used radiographic markers, including the crossover sign, lateral center-edge angle, posterior wall sign, ischial spine sign, coxa profunda, acetabular protrusion, and acetabular index. There is poor-quality conflicting evidence regarding the use of the herniation pit to diagnose pincer-type FAI. Some novel measurements, such as β-angle, acetabular roof ratio, and acetabular retroversion index, have been proposed, but they also lack support from the literature.Conclusion:No strong evidence exists to support a single best set of current radiographic markers for the diagnosis of pincer-type FAI, largely due to the lack of better quality trials (levels 1 and 2) that compare conventional radiographic findings with the gold standard, which is the intraoperative findings. More sophisticated imaging modalities such as computed tomography and magnetic resonance arthrography are often needed to diagnose pincer-type FAI, and these investigations are relatively accurate in assessing labral pathology or cartilage damage.

95% PREVALENCE OF ABNORMALITY ON HIP MRI IN ELITE ACADEMY LEVEL RUGBY UNION; A CLINICAL AND IMAGING STUDY OF HIP DISORDERS

BackgroundHip disorders are common in field based athletes. To date there have been no studies profiling hips in elite level rugby.ObjectiveIdentify the prevalence of hip disorders (clinical and imaging) in...

Outcomes in patients with glenoid labral lesions: a cohort study

Background/aimFor patients presenting with glenoid labral pathologies, there is little information on how operative interventions affect long-term outcomes and health-related quality of life (HRQoL). This study evaluated outcomes in operative...

Modelling the Functional Comorbidity Index as a predictor of health-related quality of life in patients with glenoid labrum disorders

Background/aimHealth-related quality of life (HRQoL) is increasingly assessed within orthopaedic research. For those patients presenting with glenoid labral pathologies, there is little information on how baseline comorbidities affect long-term outcomes...

Superior labrum almost always tears following subscapularis injuries

Purpose and Hypothesis:The subscapularis tendon is the major medial support of the long head of biceps tendon (LHBT). Thus, tears of subscapularis may cause biceps tendon subluxation or dislocation. A subluxated biceps tendon may cause a superior labrum injury because of the changed direction of the biceps tendon pulling vector. The purpose of this study is to express the frequency of superior labrum anterior posterior (SLAP) lesions accompanying subscapularis tears.Methods:The digital files of 2010 patients who underwent shoulder arthroscopy were reviewed retrospectively. 141 videos of 141 patients with subscapularis tear were examined in terms of superior labrum and biceps tendon injuries by one of the authors in this study. The results were compared with those of all the 2010 patients who underwent shoulder arthroscopy for any reason. The statistical analysis was made with a statistics programme by the Independent Samples T-Test.Results:There were 113 videos on which the superior labrum and LHBT could be examined precisely. Mean age was 57.8 and 66% of the patients were female. 96.4% of the 113 patients were having a SLAP lesion. 10.6% of those were SLAP I and 89.4% were SLAP II lesion. Out of 2010 patients, the SLAP lesion ratio was 32.2% of which 4.9% were SLAP I. That difference between the patients with and without subscapularis tear was statistically significant.Conclusions:Following the loss of medial support, the LHBT and its pulling vector subluxate anteriorly resulting in a tear of the superior labrum from anterior to posterior. In this study, SLAP lesions were strongly correlated with subscapularis tears as well. Furthermore, the synovial hypertrophy initiated after a superior labrum pathology at superior aspect of the glenoid spreads over the LHBT. An inflamed LHBT firstly degenerates, and then ruptures. According to this study, tears of subscapularis should be repaired when encountered in order to prevent the upcoming secondary intra-articular disorders.Figure 1Figure shows the concurrent subscapularis tear and SLAP lesion in a patient who underwent shoulder arthroscopy.

The chondral print sign: what does it really mean?

The chondral print (CP) sign is a chondral change on the humeral head underneath the long head of the biceps (LHB) tendon. Several suggested causative links have been described, but the pathologic mechanism remains unclear. We designed this prospective cohort association study of 102 consecutive shoulder arthroscopies to investigate proposed associations of CP with LHB, rotator cuff, labral pathology, and other chondral lesions. Data collection was by a specifically designed pro forma, and statistical analysis was performed. We identified 24 patients (23.5%) with the CP sign. Patients were a mean age of 58 years. Shoulders with positive CP sign had associated pathologies: 16 superior labral anteroposterior (SLAP) tears, 4 LHB instabilities, and 11 other LHB lesions. We also recorded other chondral lesions, 10 humeral head and 12 on the glenoid surface. The overall arthroscopic appearance of CP signs could be classified into 3 different types. Statistical analysis revealed that the CP sign is not statistically associated with LHB instability, any other LHB pathologies, rotator cuff tears, or instability. The CP sign was statistically positively associated with SLAP lesions (but only if type 1 were included). There was a weak association of CP sign with age and a positive association of SLAP lesions with other (non-CP) humeral chondral lesions. Our prospective association study cannot determine the cause of the CP sign. It does not seem to be a reliable sign of LHB instability or of other LHB pathology. There is an association with age and degenerative SLAP lesions.

Operative findings and complications associated with adjunctive hip arthroscopy in 95 hips undergoing periacetabular osteotomy.

to report our initial experience with adjunctive hip arthroscopy and periacetabular osteotomy (PAO). Retrospective review of patients who underwent PAO and ipsilateral hip arthroscopy between 2003 and 2013. Indications for arthroscopy were mechanical symptoms and/or positive magnetic resonance imaging to suggest intra-articular pathology including chondrolabral lesions, ligamentum teres tears and hypertrophy, and synovitis. Preoperative Tönnis arthritis grades, age, sex, operative findings and treatment, complications, and, if available, hip survival were recorded. Of 78 patients (95 hips) included, 64 (82%) were female and 14 (18%) male, average age was 30.6 (14-63) years. Tönnis grades were 0 in 40 hips (42%), 1 in 45 hips (47%), and 2 in 10 hips (11%). No Tönnis 3 hips were included. 84% of hips demonstrated labral pathology. 92% had chondromalacia, which was severe enough in 4 patients to warrant cancellation of PAO; all 4 have subsequently required total hip replacement at short-term follow-up. Labral debridement was performed in 73 hips and refixation in 7. 5 postoperative complications occurred - none major, including 1 fluid extravasation, 1 case of heterotopic ossification, and 3 transient neuropraxias. Intraarticular pathology is highly prevalent in patients undergoing PAO with mechanical symptoms, and can be safely managed by adjunctive arthroscopy. Complications were minimal in our series and are comparable to reports of PAO without arthroscopy. Arthroscopy can treat pathology that is inaccessible during standalone PAO and permits avoidance of routine arthrotomy, surgical dislocation, rectus release, and futile PAO in cases with severe articular damage.

Arthroscopic autologous chondrocyte implantation in the hip for the treatment of full-thickness cartilage defects - A case series of 29 patients and review of the literature.

Purpose: Current literature indicates that the appropriate treatment of articular cartilage defects has significant influence on the postoperative outcome after hip arthroscopy. In the hip, arthroscopic treatment of cartilage defects is technically challenging, especially the autologous chondrocyte implantation/matrix-associated autologous chondrocyte implantation (ACI/MACI) procedures. The purpose of this prospective study was to introduce two injectable MACI products with self-adherent properties. Furthermore, we report short-term outcome and review the current literature. Methods: Full-thickness cartilage defects of 29 patients caused by the femoroacetabular impingement (FAI) were treated arthroscopically with an injectable MACI product in a two-step surgical procedure. The patient-related outcome was assessed with International Hip Outcome Tool (iHOT33), Euro-Quol group score (EQ-5D) and Non-Arthritic-Hip-Score (NAHS) at baseline, six weeks, six, 12 and 24 months. Results: Twenty-nine out of 46 patients (27 male/two female) with a mean age of 30.3 years (range 18–45 years) and an average defect size of 2.21 cm2 were available for follow-up after a mean of 19 months (range 6–24 months). All defects were located on the acetabulum International Cartilage Repair Society (ICRS) grade 3A–3D (nine 3A; eleven 3B; six 3C; three 3D). Twenty-six patients had associated labral pathology (23 repair 1–5 anchors; three partial trimming). Twenty-seven defects were caused by the FAI (20 CAM, six combined, one Pincer), two cases were of traumatic cause. An overall statistically significant improvement was observed for all assessment scores at an average follow-up of 19 months. Conclusion: In this study, we present short-term data of new arthroscopic injectable matrix-associated, autologous chondrocyte implants as a treatment option for full-thickness cartilage defects of the hip. All patient-administered assessment scores demonstrated an increase in activity level, quality of life and reduction of pain after a 19-month follow-up. Further randomized controlled trails (RCTs) with comparison of natural history, bone marrow stimulation techniques and MACI of the hip have to approve the results in long-term follow-up.

CORR Insights®: Periacetabular Osteotomy Provides Higher Survivorship Than Rim Trimming for Acetabular Retroversion.

CORR Insights®: Periacetabular Osteotomy Provides Higher Survivorship Than Rim Trimming for Acetabular Retroversion.

Outcomes Following Arthroscopic Repair of Posterior Labral Tears in Patients Older Than 35 Years.

Although the results of arthroscopic management of posterior labral pathology in young athletes have been reported extensively in the literature, the clinical outcomes in older patients are unknown. This retrospective review included patients older than 35 years who underwent arthroscopic posterior labral repair. Functional outcome scores were collected, and subgroup analyses were performed to evaluate the impact of patient-specific factors. Forty-three patients met the inclusion criteria; average follow-up was 36.9 months (range, 24-54 months). Mean patient age at the time of surgery was 40.9 years (range, 35-57 years). Average outcome scores at final follow-up were Quick Disabilities of the Arm, Shoulder and Hand Scale (QuickDASH), 19±22; Simple Shoulder Test (SST), 9.9±3; Western Ontario Shoulder Instability Index (WOSI), 601±546; and Single Assessment Numeric Evaluation (SANE), 79.6%±23.4%. No significant differences in outcomes were observed in patients with preoperative symptomatic instability, active workers' compensation claims, or traumatic injury (P>.05). The presence of intraoperatively definable chondral damage (Outerbridge grade III or higher) was associated with significantly worse final functional outcomes (QuickDASH: 29 vs 11.9, P=.03; SST: 8.5 vs 10.9, P=.02; WOSI: 875 vs 407, P=.01; and SANE: 70.6% vs 86%, P=.05). One patient (2%) experienced a minor postoperative complication, and 3 patients (7%) required subsequent procedures: 2 total shoulder arthroplasties and 1 revision labral repair. The results of arthroscopic posterior labral repair in patients older than 35 years were variable and worse than those previously reported in younger patients. The presence of chondral damage at the time of the index procedure was a negative predictive factor. [Orthopedics. 2017; 40(2):e305-e311.].

Arthroscopic Psoas Management: Techniques for Psoas Preservation and Psoas Tenotomy

The iliopsoas tendon is an important dynamic stabilizer of the hip joint, and it should be carefully identified and preserved during routine hip arthroscopy. However, it may also be a source of hip pain manifesting as iliopsoas tendinitis or a snapping hip or contributing to the development of labral pathology caused by psoas impingement. In the appropriately indicated, refractory cases of iliopsoas-related hip pain, surgical intervention in the form of an iliopsoas tenotomy at the level of the labrum can result in reliable pain relief. We describe a method to identify and protect the iliopsoas tendon during routine hip arthroscopy when preservation is desired. In addition, we detail how to deepen the psoas tunnel if psoas impingement is present but psoas tenotomy is contraindicated. We also describe a reproducible technique of arthroscopic iliopsoas tenotomy using standard portals and minimal equipment when indicated.

Evaluation of Shoulder-Stabilizing Braces: Can We Prevent Shoulder Labrum Injury in Collegiate Offensive Linemen?

Background:Shoulder injuries remain one of the most common injuries among collegiate football athletes. Offensive linemen in particular are prone to posterior labral pathology.Purpose:To evaluate the efficacy of shoulder bracing in collegiate offensive linemen with respect to injury prevention, severity, and lost playing time.Study Design:Cohort study; Level of evidence, 3.Methods:Offensive linemen at a single collegiate institution wore bilateral shoulder-stabilizing braces for every contact practice and game beginning in the spring of 2013. Between spring of 2007 and fall of 2012, offensive linemen did not wear any shoulder braces. Player injury data were collected for all contact practices and games throughout these time periods to highlight differences with brace use.Results:Forty-five offensive linemen (90 shoulders) participated in spring and fall college football seasons between 2007 and 2015. There were 145 complete offensive linemen seasons over the course of the study. Offensive linemen not wearing shoulder braces completed 87 seasons; offensive linemen wearing shoulder braces completed 58 seasons. Posterior labral tear injury rates were calculated for players who wore the shoulder braces (0.71 per 1000 athlete-exposures) compared with shoulders of players who did not wear the braces (1.90 per 1000 athlete-exposures). The risk ratio was 0.46 (95% CI, 0.16-1.30; P = .14). Mean time (contact practices and games) missed due to injury was significant, favoring less time missed by players who used braces (8.7 vs 36.60 contact practices and games missed due to injury; P = .0019). No significant difference in shoulder labral tears requiring surgery was found for brace use compared with no brace use.Conclusion:Shoulder-stabilizing braces were shown not to prevent posterior labral tears among collegiate offensive lineman, although they were associated with less time lost to injury. The results of this study have clinical significance, indicating that wearing a shoulder brace provides a protective factor for offensive linemen.

Hip instability treated with arthroscopic capsular plication

Atraumatic microinstability of the hip is felt to be a cause of intra-articular pathology, particularly tears of the anterior labrum. The purpose of this study is to evaluate a consecutive series of patients with atraumatic hip microinstability that resulted in anterior labral and cartilage pathology, treated with hip arthroscopy and capsular plication without any associated bony procedures. Thirty-two patients underwent hip arthroscopy and suture capsular plication for the treatment of hip instability without concomitant bony resections of the acetabulum or proximal femur between November 2009 and November 2012 and were followed for a minimum of 12months. Patients were clinically evaluated preoperatively and again at 3, 6, 12, 24, and 36months postoperatively with the modified Harris hip score (mHHS) and iHOT score in some patients (as this was introduced late in the study). Comparison was made evaluating centre-edge angle, Tönnis angle, physical examination findings, and demographics on outcome. There was significant improvement in the mean mHHS from 67 (SD=8.7) to 97 (SD=4.7) and iHOT score from 41 (SD=18.3) to 85 (SD=10.1) at final follow-up. When comparing patients with mild hip dysplasia to patients without hip dysplasia, there was no significant difference in clinical outcome at any point in follow-up. There was no significant association between patient age, duration of preoperative symptoms, previous ipsilateral hip arthroscopy, nature of onset of symptoms, centre-edge angle, Tönnis angle, or preoperative physical examination findings with clinical outcome at final follow-up. Isolated arthroscopic suture capsular plication performed for the treatment of hip instability resulted in improved patient pain and function at a minimum of 1-year follow-up.

Management of Acute Work-Related Shoulder Injuries by an Early Shoulder Assessment Program: Efficiency of Imaging Investigations.

Purpose: There has been a significant increase in the number of costly investigations of the shoulder joint over the past decade. The purposes of this study were to (1) describe the diagnostic imaging investigations ordered for injured workers seen at an Early Shoulder Physician Assessment (ESPA) program, (2) evaluate the impact of these investigations on final diagnosis and management, and (3) examine how efficient the program was by determining the appropriateness of referrals and whether costly imaging was justified. Methods: This was a retrospective review of the electronic files of injured workers who had been referred to an early assessment program because they had not progressed in their recovery or return-to-work plan within 16 weeks of the injury or reoccurrence. Results: The data of 750 consecutive patients-337 women (45%) and 413 men (55%), mean age 49 (SD 11) years-were reviewed. A total of 183 patients (24%) had been referred for further investigation. Of these, 90 (49%) were considered candidates for surgery (group 1), 58 (32%) had a change in diagnosis or management (group 2), and 17 (9%) had no change in diagnosis or management (group 3); 18 (10%) patients were lost to follow-up. We noticed a pattern in the type of diagnosis and the groups: full-thickness rotator cuff (RC) tear was the predominant diagnosis (Fisher's exact test [FET]=0.001, p<0.0001) for group 1. No statistically significant differences were found among the groups in the prevalence of labral pathology (FET=0.010, p=0.078), impingement syndrome (FET=0.012, p=0.570), partial-thickness RC tear (FET=0.004, p=0.089), or biceps pathology (FET=0.070, p=0.149). Ultrasound investigations were more prevalent in group 2 (FET=0.004, p=0.047). No pattern was found for use of magnetic resonance imaging and group allocation. However, all magnetic resonance arthrogram investigations (FET=0.007, p=0.027) had been ordered for patients who required labral or instability-related surgery. Conclusions: Of the injured workers we studied, 24% had further investigation, and the type and severity of pathology had affected the type of investigation. For the 165 patients who were included in groups 1-3, the ESPA was 90% efficient, with only 10% of patients not having had a change in diagnosis or management.

Sex and gender disparity in pathology, disability, referral pattern, and wait time for surgery in workers with shoulder injury.

BackgroundThe role of sex as an important biological determinant of vulnerability to sustaining injury and gender as a social determinate of access to resources, referral for medical care and perceived disability remains conflicted in injured workers. The purpose of this study was to examine sex and gender disparity following a compensable work-related shoulder injury.MethodsThis study involved cross-sectional analyses of data of two independent samples of workers with shoulder injury. Measures of disability and pain were the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) and Numerical Pain Rating Scale (NPRS) for patients seen at an Early Shoulder Physician Assessment (ESPA) program and the American Shoulder and Elbow Surgeons (ASES) assessment form and Visual Analogue Scale (VAS) for the sample who underwent surgery.ResultsThe files of 1000 (443 females, 557 men) consecutive patients seen at an ESPA program and 150 (44 females, and 106 men) consecutive patients who underwent rotator cuff surgery (repair or decompression) were reviewed. Significant gender disparity was observed in the referral pattern of injured workers seen at the ESPA program who were referred for surgical consultation (22 vs. 78 % for females and males respectively, p < 0.0001). The independent rotator cuff surgical group had a similar gender discrepancy (29 % vs. 71 %, p < 0.0001). The timeframe from injury to surgery was longer in women in the surgical group (p = 0.01). As well, women waited longer from the date of consent to date of surgery (p = 0.04). Women had higher incidence of repetitive injuries (p = 0.01) with men reporting higher incidence of falls (p = 0.01). Women seen at the ESPA program were more disabled than men (p = 0.02). Women in both samples had a higher rate of medication consumption than men (p = 0.01 to <0.0001). Men seen at the ESPA program had a higher prevalence of full thickness rotator cuff tears (p < 0.0001) and labral pathology (p = 0.01). However, these pathologies did not explain gender disparity in the subsample of ESPA who were referred for surgical consultation or those who had surgery.ConclusionsSex and gender disparity exists in workers with shoulder injuries and is evident in the mechanism of injury, perceived disability, medication consumption, referral pattern, and wait time for surgery.