Labral Pathology Research Articles

Arthroscopic Decompression and Subsequent Bone-Grafting of Spinoglenoid Cyst

Spinoglenoid cysts are associated with labral tears; however, little is known about their associated bony pathology. This Technical Note describes an arthroscopic technique to decompress and subsequently graft a spinoglenoid cyst and associated bony defect. Appropriate preoperative imaging is key to understanding the location of the bony defect and therefore crucial to the success of the bone graft. Adequate release of the labrum should be performed to fully visualized the bony lesion. A subchondroplasty cannulated drill is then placed in the bony defect under direct visualization and said defect is then filled with calcium phosphate cement. Care is taken to ensure no cement is allowed to extrude into the shoulder joint. After the cement has cured, labral pathology is repaired and the usual postoperative physiotherapy protocol is initiated.

Is hip arthroscopy useful in the treatment of borderline dysplasia?: a case-control study

IntroductionSince arthroscopy remains a controversial treatment of hip dysplasia, our objective was to analyse its clinical and radiological results in a cohort of patients with dysplasia and compare them to controls with femoroacetabular impingement (FAI). Material and methodsWe retrospectively analysed a series of patients who underwent hip arthroscopy for the treatment of labral pathology; 29 of them with borderline hip dysplasia and 197 with FAI, comparing reoperations and joint survival. The diagnosis of borderline dysplasia was made with a lateral centre-edge angle greater than 18° but less than 25°. The average follow-up was 43 months. We performed a multivariate regression analysis to evaluate the association of reoperations with different demographic, radiological and intraoperative variables. ResultsSeven complications were registered in the FAI group (1 medically treated superficial wound infection, 3 pudendal nerve paraesthesias, 1 deep vein thrombosis and 2 heterotopic ossifications) and none in the dysplasia group. While 5 patients from the FAI group required a new surgery, none of the dysplasia group was re-operated (p=.38). After adjusting for confounders, reoperation showed a very strong association with the finding of osteochondral lesions during index surgery, with a coefficient of .12 (p<.001, 95%CI=.06-.17). ConclusionHip arthroscopy was useful in the treatment of borderline dysplasia, without non-inferior survival compared to the FAI group. We suggest indicating it carefully in dysplasia cases, whenever the symptoms of femoroacetabular friction prevail over those of instability.

¿Es útil la artroscopia de cadera para el tratamiento de la displasia limítrofe?: análisis de casos y controles

IntroductionSince arthroscopy remains a controversial treatment of hip dysplasia, our objective was to analyse its clinical and radiological results in a cohort of patients with dysplasia and compare them to controls with femoroacetabular impingement (FAI). Material and methodsWe retrospectively analysed a series of patients who underwent hip arthroscopy for the treatment of labral pathology; 29 of them with borderline hip dysplasia and 197 with FAI, comparing reoperations and joint survival. The diagnosis of borderline dysplasia was made with a lateral centre-edge angle greater than 18° but less than 25°. The average follow-up was 43 months. We performed a multivariate regression analysis to evaluate the association of reoperations with different demographic, radiological and intraoperative variables. ResultsSeven complications were registered in the FAI group (1 medically treated superficial wound infection, 3 pudendal nerve paraesthesias, 1 deep vein thrombosis and 2 heterotopic ossifications) and none in the dysplasia group. While 5 patients from the FAI group required a new surgery, none of the dysplasia group was re-operated (p=.38). After adjusting for confounders, reoperation showed a very strong association with the finding of osteochondral lesions during index surgery, with a coefficient of .12 (p<.001, 95%CI=.06-.17). ConclusionHip arthroscopy was useful in the treatment of borderline dysplasia, without non-inferior survival compared to the FAI group. We suggest indicating it carefully in dysplasia cases, whenever the symptoms of femoroacetabular friction prevail over those of instability.

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.

High Prevalence of Superior Labral Anterior-Posterior Tears Associated With Acute Acromioclavicular Joint Separation of All Injury Grades.

Background:Despite the relatively high number of cases of acromioclavicular joint (AC) separation in the athletic population, optimal clinical outcomes are not achieved in every case. Limited data exist regarding the prevalence of intra-articular glenohumeral pathologies (IAPs) associated with acute AC separation of all injury grades.Purpose:To determine the prevalence of IAPs associated with AC separation, regardless of severity.Study Design:Case series; Level of evidence, 4.Methods:A total of 62 patients (mean age, 37.6 years) with acute AC separation were included in this study; 41 were nonoverhead recreational athletes. All patients underwent magnetic resonance arthrography (MRA) to evaluate for IAPs. Arthroscopic data from patients undergoing surgical treatment were correlated with MRA results.Results:Patients sustained acute AC separation of Rockwood grade 1 (16.1%), grade 2 (46.8%), grade 3 (25.8%), and grade 4 (11.3%). A concomitant IAP was present in 48 of 62 (77.4%) patients and included superior labral anterior-posterior tears (72.6%), anterior labral tears (24.2%), posterior labral tears (4.8%), supraspinatus tears (3.2%), and inferior glenohumeral ligament ruptures (1.6%). There were 18 (29.0%) patients who had a concomitant pathology in >1 intra-articular structure (combined IAPs). Additionally, 71.8% of patients with grade 1 and 2 AC separation had associated IAPs, and 23.1% had combined IAPs. Furthermore, in patients younger than 40 years, 64.0% of those with grade 1 to 3 AC separation demonstrated associated labral pathologies. There was no difference when comparing age or severity of AC separation and the prevalence of concomitant labral tears (P = .36 and .22, respectively).Conclusion:There was a high prevalence of IAPs among patients undergoing MRA after AC separation. While an IAP has been described in association with high-grade AC separation previously, the high prevalence of IAPs in low-grade separation in our study was unexpected and suggests that a thorough evaluation and clinical follow-up for patients with all grades of AC separation may be beneficial.

Predictors of Large Labral Tears: A Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability Cohort Study

Objectives:Labral tears are often described by either their location (superior, anterior, or posterior) or their size, commonly defined as degrees of labral involvement from 0° to 360°. Large tears are thought to include 270° or more of the labrum, which has been reported to include 3.3% to 6.5% of those undergoing shoulder instability surgery for labral pathology. Demographic or injury characteristics of those with large labral tears (>270°) has not been defined in the literature. The purpose of this study was to identify factors predictive of a large labral tear at the time of shoulder instability surgery.Methods:As part of the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability cohort, patients undergoing open or arthroscopic shoulder instability surgery for a labral tear were evaluated. Those with an isolated SLAP (superior labrum anterior to posterior) tear or a concomitant rotator cuff tear requiring repair were excluded. Demographic data, injury history, preoperative patient-reported outcome scores (PROs), imaging and intraoperative findings, and surgical procedures performed were recorded. The treating surgeon reported the size and location of labral pathology visualized at the time of surgery. Patients with greater than a 270° tear were defined as having a large labral tear. For categorical demographic variables, a chi-square test or Fisher’s Exact test was used, as appropriate based on cell counts. For continuous demographic variables, a two-sample t-test was performed. In order to build a predictive logistic regression model for large tears, the Feasible Solutions Algorithm (Lambert et al. 2018) was used to add significant interaction effects iteratively until no more significant two-way interactions could be added to the model.Results:After applying exclusion criteria, 1235 patients were available for analysis. There were 222 females (18.0%) and 1013 males (82.0%) in the cohort with an average age of 24.7 years old (12 – 66 years old). The incidence of large tears was 4.6% with the average tear size being 141.9°, or 39.4%. Males accounted for significantly more of the large tears seen in the cohort (94.7%, p = 0.01). Racquet sports (p = 0.002), swimming (p = 0.02), softball (p = 0.05), skiing (p = 0.04), and golf (p = 0.04) were all found to be predictive of large labral tears as was a higher Western Ontario Shoulder Instability (WOSI) score (p = 0.01) (Table 1). Patients with a larger body mass index (BMI) who played contact sports were also more likely to have large tears (p = 0.007). Age, race, history of dislocation, injury during sport, or previous shoulder surgery were not associated with having a larger tear.Conclusion:Patients with large labral tears are a small, but not insignificant, subset of patients undergoing shoulder instability surgery. Multiple factors were identified as being associated with large labral tears at the time of surgery including male sex, pre-operative WOSI score, and participation in certain sports including racquet sports, softball, skiing, swimming, and golf. Surgeons treating patients with these risk factors should be prepared to encounter a large labral tear at the time of surgery. Further studies will evaluate the outcomes of this patient population.Table 1.Comparison of patient demographics and sport history between shoulder instability patients with large labral tears (>270°).Small Tears (<270°)Large Tears(>270°)PN1178 (95.4%)57 (4.6%)-Sex (F, M (%F))219,959 (81.4% M)3, 54 (94.7% M)0.01Age24.69.0265.9.70.13Injury During Sport836 (71.0%)42 (73.7%)0.74Racquet Sport46 (3.9%)7 (12.3%)0.002Swimming205 (17.4%)17 (29.8%)0.02Softball114 (9.7%)10 (17.5%)0.05Skiing206 (17.5%)16 (28.1%)0.04Golf225 (19.0%)17 (19.8%)0.04

Iliopsoas pathology, treatment, and outcomes in patients undergoing hip arthroscopy for femoroacetabular impingement: Findings from the [redacted] study group

Paste abstract here and remove the remaining text. *For structured abstracts, begin each section under a separate, bolded subheading. Suggested subheadings are belowObjectives:The iliopsoas is a major hip flexor that provides anterior hip stability. Recent studies report significant compromise to these important functions with iliopsoas tenotomy. The purpose of this study is to report the prevalence, associated findings, rendered procedures, and outcomes of hips with iliopsoas involvement undergoing hip arthroscopy for FAI and/or chondrolabral pathology. The hypothesis is that there is a decrease in the incidence of tenotomy compared with historic controls and that tenotomy compromises patient-reported outcomes.Methods:Level of evidence 3 controlled study with prospectively-collected multicenter database from 7 centers. Enrolled patients that underwent isolated hip arthroscopy that reached 2-year minimum follow-up with iHOT-12 were assigned to Iliopsoas group defined as pre-operative diagnosis of iliopsoas tendonitis, internal snapping symptoms, intra-operative anteroinferior labral pathology (below 3 O’clock location) and/or preoperative psoas injection or the control group. The prevalence of iliopsoas pathology, radiographic and intra-operative findings, and rendered procedures between groups were compared using Chi square analysis. Minimum 2-year outcomes of Iliopsoas group versus control group were compared using analysis of variance (a priori alpha set at 0.05). Subanalysis within the Iliopsoas group was performed of patients with versus without tenotomy.Results:There were 97 study group subjects and 1053 control group subjects. There was no statistical difference in demographics between the groups (p>0.05) nor was there a difference in length of preoperative symptom duration (p=0.51). There were no significant differences in the incidence of cam impingement, pincer impingement or dysplasia between cohorts, nor were there significant differences between radiographic measures. There was a similar incidence of femoroplasty, acetabuloplasty, chondroplasty, microfracture, and synovectomy (p>0.05) regardless of iliopsoas involvement. There was not a significant effect on the surgical treatment of the labrum based on psoas involvement (p>0.16). Labral repair was performed in 55% of patients with iliopsoas involvement and 62% of patients without iliopsoas involvement. Although there was not a significant difference in capsular closure between cohorts (96% vs 93%, p=0.121), the overwhelming majority of patients with psoas involvement received capsular repair (87%) or plication (9%). Pre-operative iHOT-12 scores were similar 34 (SD: 18) for the iliopsoas group and 35 (SD 18) for the control group groups (p=0.51). Post-operative iHOT-12 scores improved to 72 for both the groups. The iliopsoas group achieved MCID, SCB, and PASS scores established for the iHOT-12 of 83%, 62%, and 58% which were similar to the control group. Ten subjects (10%) in the iliopsoas group received iliopsoas tenotomy. Subjects with tenotomy had lower 2-year post-op iHOT-12 scores compared to the non-tenotomy subgroup (55 vs 72, respectively; p=0.03) . This corresponded with lower achievement of MCID scores (60% vs 86%; p=0.03) and SCB scores (30% vs 70%, p=0.01) of patients with tenotomy compared to those without tenotomy.Conclusion:Iliopsoas tenotomy is rarely performed relative to its prevalence in patients undergoing hip arthroscopy by high volume surgeons for FAI and/or chondrolabral pathology. Surgical outcomes are not worsened with iliopsoas involvement but are worsened with tenotomy.

Editorial Commentary for In Throwers with Posterior Instability, Rotator Cuff Tears are Common but Do Not Affect Surgical Outcomes

Superior labral pathology is an exceedingly common entity among throwers, and in recent years, a number of reports have elucidated the prevalence of posterior glenohumeral instability among overhead athletes (baseball, softball, volleyball.) However, within this unique patient population, these conditions should not be viewed as separate clinical entities, but, rather as findings that exist on a single pathomechanic spectrum. In 2020, we now know that the complexity of the symptomatic thrower’s shoulder is a consequence of the complex anatomic relationships between the biceps tendon, capsulolabral tissues, posterosuperior rotator cuff, and the glenoid. In 2003, Burkhart et al. noted that diminished glenohumeral range of motion (i.e. glenohumeral internal rotation deficit “GIRD”) was common among throwers with painful shoulders. These authors further described a posterior-inferior capsular contracture as the “essential lesion” in the development of diminished range of motion in conjunction with impingement of the supraspinatus tendon between the greater tuberosity and the posterior-superior labrum (“pathologic internal impingement”) [1,2]. It is this internal impingement that so often manifests as partial thickness, articular sided supraspinatus tears in the throwing athlete. But these findings are now perhaps better understood as sequelae of a number of anatomic factors, including humeral retrotorsion, contractures of the coracohumeral ligament, pectoralis, and anterior deltoid, as well as dynamic muscle stiffness that can occur in response to the repetitive strains involved in overhead throwing.

Using a simplified version of a common surgical grading scale for acetabular labral tears improves the utility of preoperative hip MRI for femoroacetabular impingement.

To evaluate whether a commonly used surgical grading scale, when applied to acetabular labral findings on MRI, could improve preoperative planning and counseling for patients undergoing hip arthroscopy. We evaluated 76 clinical MRIs performed on patients with femoroacetabular impingement. Three musculoskeletal radiologists and one musculoskeletal fellow reviewed each scan in a blinded fashion, classifying the acetabular labrum from 12:00 to 4:00 using the Beck scale, a common surgical grading scale. Clinical correlation was provided via surgical examination and classification. Reliability was determined between readers and between reader and surgical data using Cohen's kappa and Krippendorff's alpha at each clock position and for the worst grading for each scan. In addition, a simplified version of the scale comprised of only two grades, potentially reparable and not potentially reparable, was evaluated. When the scale was simplified into categories of potentially reparable and not potentially reparable, the sensitivity was excellent, ranging from 85.5 to 96%. Observer agreement when using individual Beck grades was found to range from poor to fair; Kappa ranged from 0.03 to 0.19, and Alpha ranged from - 0.27 to 0.22. The simplified version of the Beck labral scale when applied to MRI is a highly sensitive predictor of potentially reparable labral pathology while excluding normal and grossly degenerative tissue. Use of this scale provides clinically relevant information that can drive preoperative planning and improve patient counseling. It does so in a standardized fashion that can be applied across practice sites and without additional cost.

Outcomes of Preoperative Opioid Usage in Hip Arthroscopy: A Comparison With Opioid-Naïve Patients

To compare postoperative outcomes between opioid-naïve patients and patients with a history of preoperative opioid usage undergoing hip arthroscopy. The secondary purpose is to determine whether preoperative opioid users consumed more oral morphine milligram equivalents than opioid-naïve patients following surgery. This is a single-center, retrospective analysis comparing outcomes and postoperative opioid usage between patients with and without a history of preoperative opioid use. Inclusion criteria included patients ≥18 years, Tönnis grade 0 or 1, imaging consistent with FAI or labral pathology, and a diagnosis of symptomatic FAI requiring hip arthroscopy. Patient outcomes were compared throughout a 2-year follow-up using the modified Harris Hip Score, Nonarthritic Hip Score, and visual analog scale (VAS). In total, 17 patients were evaluated in each cohort. The mean age of the study cohort and control cohort were 52.0 ± 9.4 years and 51.2 ± 12.2 years, respectively. Female patients were 58.8% (n= 10) of both cohorts. Non-naïve patients had a lower preoperative Nonarthritic Hip Score (P= .05) and a greater VAS at their 6-month and 1-year (P < .001) postoperative visits. Naïve patients reported greater modified Harris Hip Scores 2 years postoperatively (P < .001). The study cohort was prescribed greater levels of oral morphine equivalents at the postoperative 1-year visit (P= .05). Opioid-naïve patients were more likely to reach minimally clinically important difference and patient acceptable symptom state of VAS at a faster rate. At the 2-year follow-up, 11.8% of opioid-naïve patients continued to take opioids compared with 58.8% from the non-naïve group for persistent hip pain (P < .001). We determined that preoperative opioid usage in patients undergoing hip arthroscopy is associated with inferior outcomes compared with opioid-naïve patients. In addition, preoperative opioid users are likely to continue the use of opioid medications postoperatively and at greater doses than opioid-naïve patients. 3, retrospective comparative study.

Approach to a Failed Hip Arthroscopy.

Hip arthroscopy has seen increasing utilization over the last decade. This is largely related to increased recognition and improved techniques for treating femoroacetabilar impingement (FAI). Though hip arthroscopy generally yields favorable outcomes, there are a subset of patients who have residual or recurrent symptoms that require reoperation. The current review discusses an algorithmic approach to evaluating patients following a failed hip arthroscopy including a framework for clinical and radiographic assessment, available treatment options, and associated outcomes in revision surgery. Residual FAI has been demonstrated to be the most common indication for revision arthroscopy. Other indications include residual or recurrent labral pathology, gross instability, microinstability, or adhesions. Appropriate history and imaging are important to determine the cause for residual symptoms. Novel techniques including labral and capsular reconstruction, and modified remplissage procedures have been developed to deal with complex revision cases. Though studies have shown improved outcomes after revision surgery, they have been shown to result in inferior outcomes compared to a matched cohort following primary hip arthroscopy. Management of a failed hip arthroscopy remains a complex problem. Focused history, cross-sectional imaging, and revision hip arthroscopy with novel techniques can improve outcomes, albeit to a lesser extent than patients undergoing successful primary hip arthroscopy. The information provided here can help guide treatment and set appropriate patient expectations for revision surgery.

PEDIATRIC AND ADOLESCENT SHOULDER INSTABILITY: DOES INSURANCE STATUS PREDICT THE DEVELOPMENT OF BONY BANKART AND ENGAGING HILL-SACHS LESIONS?

Background:Pediatric and adolescent patients who undergo shoulder stabilization surgery have higher rates of failure than their adult counterparts. The impact of insurance status on intra-operative findings and outcomes is largely unknown.Hypothesis/Purpose:We hypothesized that patients with public insurance who undergo shoulder stabilization surgery would have greater degrees of bony pathology; leading to poor outcomes after stabilization.Methods:This was a retrospective cohort study of pediatric and adolescent patients with public and private insurance who were treated for recurrent shoulder instability from 2011-2017. Patients were treated at a tertiary care children’s hospital by a single orthopaedic surgeon. Patients 10 to 18 years of age were included in the study if they presented with recurrent shoulder instability and underwent surgical intervention for their injury. Time from injury to clinical consultation, imaging, and surgical intervention; incidences of labral pathology and secondary bony injury; and rates of repeat dislocation and repeat surgery were compared between the public and private insurance cohortsResults:Thirty-seven patients had public insurance while 18 patients had private insurance. Privately insured patients were evaluated by clinicians nearly five times faster than were publicly insured patients (p < 0.001), and they obtained MRIs over four times faster than did public insurance patients (p < 0.001). Publicly insured patients were twice as likely to have secondary bony injuries (p=0.043). Postoperatively, a significantly greater number (24.3%) of publicly insured patients experienced re-dislocation versus the complete absence of re-dislocation in the privately insured patients (p=0.022).Conclusion:Public insurance status impacts access to care and correlates with both the development of secondary bony injury and an increased rate of clinical failure manifested as repeat post-operative dislocations.Table 1.Data SummaryAll (n=55)Public Insurance (n=37)Private Insurance (n=18)Days from Injury to Clinic298.71402.3885.61Days from Injury to MRI323.04431.9799.11Days from Injury to Surgery451.76561.38226.44*Days from Clinic to MRI24.3329.5913.50*Days from MRI to Surgery128.73129.41127.33Number of prior dislocationsNone = 3Single = 2Multiple = 32None = 6Single = 0Multiple = 12Incidence of anterior only vs. complex labral pathologyAnterior only = 81.8% (45/55)Complex = 18.2% (10/55)Anterior only = 83.8% (31/37)Complex = 16.2% (6/37)Anterior only = 77.8% (14/18)Complex = 22.2% (4/18)Incidence of bony involvement (Y/N)56.4% (31/55)67.6% (25/37)33% (6/18)Incidence of repeat dislocations16.4% (9/55)24.3% (9/37)0.00% (0/18)*Incidence of repeat surgery5.5% (3/55)8% (3/37)0.00% (0/18) Table 1 shows the summary of results for public and private insurance cohorts for days from injury to clinic, injury to MRI, injury to surgery, clinic to MRI, MRI to surgery as well as number of prior dislocations, incidence of anterior only vs. complex labral pathology, incidence of bony involvement, incidence of repeat dislocations, and incidence of repeat surgery. * denotes that the difference between the two insurance cohorts was not statistically significant.

ADOLESCENT POSTERIOR-SUPERIOR GLENOID LABRAL PATHOLOGY: DOES INVOLVEMENT OF THE BICEPS ANCHOR MAKE A DIFFERENCE?

Background:Adolescent athletes are at risk to sustain an injury to the posterior and superior labrum of the glenoid. Limited information is available regarding the outcomes of surgical intervention in this specific age cohort.Purpose:To compare those patients with pure posterior pathology and those with involvement of the biceps anchor (superior labrum anterior-posterior tears - SLAP) to determine risks for failure in the surgical management.Methods:A retrospective review was performed on all patients under the age of 19 years over an eight year period to identify those treated for superior and posterior labral pathology, followed by chart review, radiographic review and arthroscopic findings. Demographics and other variables were recorded, including: etiology (traumatic versus atraumatic), activity/sports (overhead versus non-overhead), involvement of the biceps anchor – crossing the 12 o’clock position (Posterior vs SLAP), associated pathologies, outcome scores (SANE – Self Assessment Numerical Evaluation versus PASS – Pediatric Adolescent Shoulder Score), and complications.Results:48 patients (30 males, 18 females) with a mean age at surgery of 16.5 years (range 13.5 to 19) were identified that met criteria with a mean follow-up of 4.1 years (range 1.3 to 6.9). Nineteen subjects had SLAP tears, and 29 subjects had posterior tears. All but 2 regularly participated in sports at the time of their injury; of the athletes, 26 (56.5%) played an overhead sport and 20 (43.5%) played a non-overhead sport. The etiology of the injury was traumatic in 25 cases (52.1%), and atraumatic in 23 cases (47.9%). Outcome scores were not significantly different between etiology or type of sports played; but, the mean PASS score in the SLAP group was 88.7, compared to 76.2 in the posterior group (p=0.005) at final assessment. Only 1 SLAP patient failed management (5.3%) compared to 5 patients in the posterior only cohort (17.2%).Conclusion:SLAP tears have better outcomes and lower failure rates than posterior only tears in the adolescent population. Posterior-superior labral tears can occur in all sport types with multiple etiologies, but the only factor that appears to play a role in ultimate outcome is whether or not the tear crosses under the biceps anchor to the anterior side.

Accuracy of MRI in diagnosing rotator cuff and labral tears of shoulder

Introduction: The most common cause of shoulder pain is rotator cuff pathology and most common finding in shoulder instability is labral tears, hence these two are the most common abnormalities detected in MRI shoulder and the common indication of arthroscopic intervention. MRI has decisive role in planning the treatment for patients. Hence analysing the accuracy and pitfalls of MRI in diagnosing rotator cuff and labral tears in comparison with arthroscopy, which is the gold standard tool is necessary. Aim: To compare the MRI shoulder accuracy with arthroscopy, as the gold standard in detecting rotator cuff and labral pathologies of shoulder. Materials and Methods: Prospective study of forty consecutive patients with chronic shoulder pain and instability presented to out patient clinic of orthopaedics department of our hospital with clinical signs of rotator cuff tear, impingement and instability, who had undergone MRI of the shoulder joint followed by arthroscopic intervention. The MRI results were compared with arthroscopy findings for evaluation of diagnostic accuracy. Results: Out of 40 patients, supraspinatus tendon tear was the commonest pathology detected and next common was the Bankart’s labral tear. MRI showed 100% sensitivity in the diagnosis of complete thickness supraspinarus and subscapularis tears and bankart’s lesion but had poor sensitivity of 60% to detect SLAP tear. The accuracy of MRI in detecting rotator cuff tear and labral tears were comparable. Conclusion: MRI is highly sensitive in diagnosing rotator cuff tears and Bankart’s tear but was not sensitive in diagnosing SLAP tears. Radiologist needs to understand the pitfalls of MRI while evaluating the MRI shoulder for higher accuracy.

Variations In Glenoid Bony Morphology May Predict Recurrent Instability After Arthroscopic Bankart Repair

Objectives: Variations in bony anatomy may be a significant risk factor for failure of stabilization surgery and could help explain the etiology of recurrent dislocations. Identifying these variations may help guide surgical decision making. The aim of this study was to develop a method to quantify bony morphology and measure glenoid and humeral head volume on MRI to identify risk factors for failure after Bankart repair. We hypothesized that the ratio of humeral head to glenoid volume and a shallower glenoid socket or greater radius of curvature would be significant risk factors in patients who failed stabilization surgery. Methods: This was a retrospective case-control study of 289 patients from 2005-2015. Inclusion criteria were primary anterior arthroscopic shoulder stabilization, no prior shoulder surgery, and traumatic etiology. Exclusion criteria were posterior labral pathology, multidirectional instability, connective tissue disorder, or concomitant rotator cuff pathology. Surgical failure was defined as a redislocation event and these cases were compared 1:2 to an age- and sex-matched control without recurrent instability. Demographic data was obtained by chart review. Pre-operative MR arthrograms were analyzed by two trained reviewers. Vitrea software (Vital Images, Minnetonka, MN) was utilized to measure the volume and radius of curvature of both the humeral head (Figure 1) and glenoid on T1 sequences. A larger radius of curvature corresponded to an overall shallower glenoid socket. Fisher exact and the student t test were used for statistical analysis with significant defined as p &lt; 0.05. Results: Ninety-five patients met the inclusion criteria, 36 of whom were in the case group, with an average follow-up of 30.3 months. There was no difference between groups with regard to baseline demographic and radiographic parameters (Table 1). The average number of preoperative dislocations was significantly higher in the failure group (3.13 vs. 1.91, p &lt; 0.05). The humeral head (67.8 ml vs 62.3 ml, p =0.13) and glenoid volume (13.7 ml vs 13.0 ml, p=0.42) were similar between the two groups, as was the ratio of the two (5.1 vs 4.9, p=0.30). The radius of curvature of the glenoid was slightly larger, or shallower, in the case group compared to the control group (23.8 mm vs 22.6 mm, p=0.02). The ratio of the radius of curvature of the humeral head to the glenoid was similar between the two groups (1.1 vs 1.1, p=0.11). Further analysis demonstrated that a greater portion of patients with a glenoid radius of curvature greater than 24.5 experienced a postoperative dislocation compared to those who had a smaller radius of curvature (63.6% vs 26.0%, p &lt; 0.01) (Table 1). There was no significant difference between the number of preoperative dislocations between patients with larger or smaller glenoid radius of curvature (2.7 vs 2.3, p = 0.57). Conclusion: Using a novel method of quantifying the bony morphology, our results demonstrate that a larger radius of curvature, particularly greater than 24.5 mm, which is indicative of a shallower glenoid, may predispose patients to failure following a primary arthroscopic Bankart. These findings suggest that the overall bony concavity of the glenoid may play an inherent role regarding stability. [Table: see text]

Relationship between the Patient-Reported Outcomes Measurement Information System (PROMIS) computer adaptive testing and legacy instruments in patients undergoing isolated biceps tenodesis

The purpose of this study was to correlate the Patient-Reported Outcomes Measurement Information System (PROMIS) computer adaptive testing (CAT) domains with commonly used legacy patient-reported outcome measures (PROMs) preoperatively in a population of patients presenting to a tertiary care orthopedic center for biceps and labral pathology. Prospective data were collected on 175 patients scheduled to undergo isolated biceps tenodesis at a tertiary center. Enrollees completed legacy scores (Veterans RAND 12-Item Health Survey, Short Form 12, American Shoulder and Elbow Surgeons [ASES] Assessment Form, Single Assessment Numeric Evaluation, and Constant-Murley score) and PROMIS CAT questionnaires (Upper Extremity [UE], Pain Interference [PIF], and Depression). In addition, patients were asked to provide an assessment of the strength, function, and pain of the affected shoulder using a custom visual analog scale (VAS) questionnaire. Spearman rank correlations of the PROMIS CAT with legacy measures and the custom VAS were calculated. Floor and ceiling effects were assessed. The UE CAT yielded moderate correlations with the ASES score (r = 0.57) and the custom VAS strength score (r = 0.50-0.57). The PIF CAT demonstrated moderate correlations with the VAS pain score (r = 0.45) and high-moderate correlations with the ASES score, VR6D score, and UE CAT (r = 0.61-0.66). The Depression CAT demonstrated high-moderate correlations with the mental health legacy measures (r = -0.64 to -0.61). There was a significant relative floor effect for the Depression CAT at a score of 34.2 (19%). The PIF CAT was comparable to the ASES score, the current gold standard. Compared with legacy measures, both the UE CAT and PIF CAT are less burdensome and have few floor or ceiling effects. The PIF CAT may be a viable alternative to describe the physical and psychosocial impact of pain in biceps tenodesis patients.

The incidence and pattern of iliopsoas tendinitis following hip arthroscopy.

Iliopsoas tendinitis is a known source of extra-articular hip pain and it has been shown to be a common cause of continued hip pain following total hip arthroplasty. While iliopsoas tendinitis after hip arthroscopy is a well-known phenomenon amongst hip arthroscopists, its presentation, course, and treatment has yet to be elucidated. An IRB-approved chart review was performed of patients undergoing hip arthroscopy for femoroacetabular impingement (FAI) between March 2015 and July 2017. No cases of dysplasia were included. All patients had combined cam/pincer impingement as well as labral pathology. Tendinitis patients were identified. Patient demographics, surgical data, time to onset/diagnosis of iliopsoas tendinitis, treatment (oral anti-inflammatories, corticosteroid injection, physical therapy), and resolution of symptoms were recorded. These cases were age- and sex-matched to a control group that did not develop postoperative iliopsoas tendinitis for comparison. Patient outcomes were measured with the modified Harris Hip Score (mHHS) and Nonarthritic Hip Score (NAHS) recorded from the preoperative and 1-year postoperative visits. Of 258 hip arthroscopy cases, 18 cases (7.0%) of postoperative iliopsoas tendinitis were diagnosed under high resolution ultrasound. On average, iliopsoas tendinitis was diagnosed 2.8 ± 1.8 months after surgery. There were no significant differences in age, sex, and BMI between patients that developed IP tendinitis compared to those that did not. No specific procedures were found to be significantly associated with incidence of postoperative IP tendinitis, including capsular closure.18 patients were treated with corticosteroid injection, which provided mild to moderate improvement for 5 (27.8%) patients and completely resolved symptoms for 13 patients (72.2%). Of all 18 patients with postoperative iliopsoas tendinitis confirmed by response to a diagnostic injection, 10 (55.6%) had symptoms improve within 3 months of diagnosis, 2 (11.1%) between 3 and 6 months, 4 (22.2%) between 6 and 12 months, and 2 (11.1%) after 1 year. No patients went on to have surgery for this problem. Patients with iliopsoas tendinitis had lower MHHS (p = 0.04) and NAHS (p = 0.09) scores at their 1-year postoperative visits. Iliopsoas tendinitis is a common source of pain following arthroscopic hip surgery and can be effectively diagnosed and treated with ultrasound-guided injection. Therefore, surgeons performing arthroscopic procedures of the hip must remain aware of and include it in their differential when encountering patients with hip flexion pain after surgery. Research should be continued to further evaluate the long-term outcomes and return to sport rates of these patients.

Adolescent Posterior-Superior Glenoid Labral Pathology: Does Involvement of the Biceps Anchor Make a Difference?

Background: Adolescent athletes are at risk of sustaining an injury to the posterior and superior labrum of the glenoid. Limited information is available regarding the outcomes of surgical intervention in this specific age cohort. Purpose: To compare those patients with pure posterior pathology and those with posterior labral tears that involve the biceps anchor (superior labrum anterior-posterior [SLAP] tears) to determine risks for failure in the surgical management. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective review was performed on all patients under the age of 19 years over an 8-year period to identify those treated for superior and posterior labral pathology, followed by chart review, radiographic review, and arthroscopic findings. Patient characteristics and other variables were recorded, including cause (traumatic vs atraumatic), activity/sports (overhead vs nonoverhead), involvement of the biceps anchor—crossing the 12-o’clock position (posterior vs SLAP), associated pathologies, outcome scores (Single Assessment Numerical Evaluation [SANE] and Pediatric/Adolescent Shoulder Survey [PASS] scores), and complications. Results: Forty-eight patients (30 boys, 18 girls) with a mean age at surgery of 16.5 years (range, 13.5-19 years) were identified who met criteria, with a mean follow-up of 4.1 years (range, 1.3-6.9 years). Nineteen patients had SLAP tears and 29 patients had posterior tears. All but 2 regularly participated in sports at the time of their injury; of the athletes, 26 (56.5%) played an overhead sport and 20 (43.5%) played a nonoverhead sport. The cause of the injury was traumatic in 25 cases (52.1%) and atraumatic in 23 cases (47.9%). Outcome scores were not significantly different between cause or type of sports played; SANE scores were not significantly different by tear type (mean SLAP score, 88.4 compared with mean posterior score, 80.9; P = .124); but the mean PASS score in the SLAP group was 88.7, compared with 76.2 in the posterior group (P = .005) at final assessment. Only 1 SLAP patient had failed management (5.3%) compared with 5 patients in the posterior-only cohort (17.2%). Conclusion: Posterior SLAP tears have better outcomes and lower failure rates than posterior-only tears in the adolescent population. Posterior-superior labral tears can occur in all sports types with multiple causes, but the only factor that appears to play a role in ultimate outcome is whether the tear crosses under the biceps anchor to the anterior side.

Ultrasound of glenoid labrum with MR arthrographic correlation.

Ultrasound (US) is a reliable non-invasive method to image the rotator cuff tendons. Even though glenoid labral pathology is common, it is not routinely looked at as part of the shoulder ultrasound protocol. Currently, the gold standard for labral imaging remains MR arthrography. However, given the rather long waiting list and cost implications, US may be used as a modality to quickly screen the shoulder for gross labral pathology. Whilst there is relative paucity of the literature outlining labral pathology on US, there is none correlating sonographic and corresponding MRI appearances. We present a pictorial review highlighting scanning positioning, US and corresponding MRI appearances of a normal labrum and various labral pathologies. We discuss useful scanning tips and characteristic US signs which can help the radiologist.

Consensus recommendations on the classification, definition and diagnostic criteria of hip-related pain in young and middle-aged active adults from the International Hip-related Pain Research Network, Zurich 2018

There is no agreement on how to classify, define or diagnose hip-related pain—a common cause of hip and groin pain in young and middle-aged active adults. This complicates the work...