Aims. Acetabular dysplasia is frequently associated with intra-articular pathology such as labral tears, but whether labral tears should be treated at the time of periacetabular osteotomy (PAO) remains controversial. The purpose of this study was to compare the clinical outcomes and radiographic corrections of PAO for acetabular dysplasia between patients with and without labral tears pre-operatively. Patients and Methods. We retrospectively reviewed 70 hips in 67 patients with acetabular dysplasia who underwent PAO. Of 47 hips (45 patients) with labral tears pre-operatively, 27 (25 patients) underwent PAO alone, and were classified as the labral tear alone (LT) group, and 20 (20 patients) underwent combined PAO and osteochondroplasty, and were classified as the labral tear osteochondroplasty (LTO) group. The non-labral tear (NLT) group included 23 hips in 22 patients. Results. There were no significant differences between groups for post-operative Harris hip scores, degree of progression of osteoarthritis or rate of reoperation. The pre-operative alpha angle was significantly larger in the LTO group compared with the other groups (p < 0.0001). Conclusion. PAO provides equivalent short-term relief of pain and functional outcome in patients with or without labral tears. The rate of progression of osteoarthritis and reoperation was not significantly increased in patients with labral tears. Take home message: PAO provides equivalent short-term pain relief and functional outcomes in patients with acetabular dysplasia with and without labral tears. We did not find significantly increased risks of progression of osteoarthritis or re-operation in those with labral tears. Cite this article: Bone Joint J 2016;98-B:741–6

We investigated differences in the location and mode of labral tears between dysplastic hips and hips with femoroacetabular impingement (FAI). We also investigated the relationship between labral tear and adjacent cartilage damage. We retrospectively studied 72 symptomatic hips (in 68 patients: 19 men and 49 women) with radiological evidence of dysplasia or FAI on high-resolution CT arthrography. The incidence and location of labral tears and modes of tear associated with the base of the labrum (Mode 1) or body of the labrum (Mode 2) were compared among FAI, mildly dysplastic and severely dysplastic hips. The locations predominantly involved with labral tears were different in FAI and mild dysplastic hips (anterior and anterosuperior zones) and in severely dysplastic hips (anterosuperior and superior zones) around the acetabulum. Significant differences were observed in the prevalence of Mode 1 versus Mode 2 tears in FAI hips (72% (n = 13) vs 28% (n = 5)) and severe dysplastic hips (25% (n = 2) vs 75% (n = 6)). The frequency of cartilage damage adjacent to Mode 1 tears was significantly higher (42% (n = 14)) than that adjacent to Mode 2 tears (14% (n = 3)). Hip pathology is significantly related to the locations and modes of labral tears. Mode 1 tears may be a risk factor for the development of adjacent acetabular cartilage damage. Cite this article: Bone Joint J 2013;95-B:1320–5

We have reviewed the current literature to compare the results of surgery aimed to repair or debride a damaged acetabular labrum. We identified 28 studies to be included in the review containing a total of 1631 hips in 1609 patients. Of these studies 12 reported a mean rate of good results of 82% (from 67% to 100%) for labral debridement. Of the 16 studies that reported a combination of debridement and re-attachment, five reported a comparative outcome for the two methods, four reported better results with re-attachment and one study did not find any significant difference in outcomes. Due to the heterogeneity of the studies it was not possible to perform a meta-analysis or draw accurate conclusions. Confounding factors in the studies include selection bias, use of historical controls and high rates of loss of follow-up. It seems logical to repair an unstable tear in a good quality labrum with good potential to heal in order potentially to preserve its physiological function. A degenerative labrum on the other hand may be the source of discomfort and its preservation may result in persistent pain and the added risk of failure of re-attachment. The results of the present study do not support routine refixation for all labral tears. Cite this article: Bone Joint J 2014;96-B:24–30

Labral tears are commonly associated with femoroacetabular impingement. We reviewed 151 patients (156 hips) with femoroacetabular impingement and labral tears who had been treated arthroscopically. These were subdivided into those who had undergone a labral repair (group 1) and those who had undergone resection of the labrum (group 2). In order to ensure the groups were suitably matched for comparison of treatment effects, patients with advanced degenerative changes (Tönnis grade > 2, lateral sourcil height < 2 mm and Outerbridge grade 4 changes in the weight-bearing area of the femoral head) were excluded, leaving 96 patients (101 hips) in the study. At a mean follow-up of 2.44 years (2 to 4), the mean modified Harris hip score in the labral repair group (group 1, 69 hips) improved from 60.2 (24 to 85) pre-operatively to 93.6 (55 to 100), and in the labral resection group (group 2, 32 hips) from 62.8 (29 to 96) pre-operatively to 88.8 (35 to 100). The mean modified Harris hip score in the labral repair group was 7.3 points greater than in the resection group (p = 0.036, 95% confidence interval 0.51 to 14.09). Labral detachments were found more frequently in the labral repair group and labral flap tears in the resection group. No patient in our study group required a subsequent hip replacement during the period of follow-up. This study shows that patients without advanced degenerative changes in the hip can achieve significant improvement in their symptoms after arthroscopic treatment of femoroacetabular impingement. Where appropriate, labral repair provides a superior result to labral resection

This paper highlights the fact that full length labral tears are a cause of instability in posterior fracture-dislocations of the hip. From July 1994 to March 2001, 133 consecutive posterior fracture-dislocations of the hip were surgically treated. On admission, all patients were initially subjected to closed reduction, and in some cases skeletal or skin traction was applied. Pelvic radiographs were taken to confirm relocation, and CT done to look for intra-articular bone fragments. Intra-operative findings and surgical technique were recorded. Redislocation occurred in eight patients, whose surgical notes were reviewed to determine the cause. Despite 9 kg of skeletal traction, one patients’s hip redislocated the day after closed reduction. In the other seven, redislocation occurred postoperatively. The time to redislocation varied from one day to 16 weeks, and because redislocation was sometimes painless, not all patients reported it immediately. Two patients, whose radiographs showed very small fragments at the superior-posterior position, would normally have been treated conservatively. On one, surgery was performed because the fragment was lodged at the weight-bearing area of the joint. The hip of the other redislocated on skeletal traction the day after closed reduction. At surgery, it was noted that both patients had extensive soft tissue stripping and full length tears of the labrum. The other six patients had clear posterior wall fractures requiring surgical reconstruction. The fragments were often attached to the capsule but were too small to fix with screws, so buttress plating was used alone. Full-length labral tears in posterior dislocations of the hip cause instability, and failure to address this adequately at surgery may result in redislocation

We treated 133 traumatic posterior dislocations surgically between July 1994 and March 2001. In 16 patients, labral tears had occurred. Operating on posterior hip dislocations, initially we fixated the posterior wall with screws and/or buttress plate, depending on the size of the fragment, and did suture the torn labrum, relying rather on the buttress plate or intact posterior wall for stability. We began repairing the torn labrum when we realised that any small fragments still attached to the labrum simply pull out from under the buttress plate, allowing the hip to redislocate. Once the wall has been reconstructed, interrupted sutures are passed through the labrum, with the hip internally rotated to prevent shortening of the capsule when sutures are tied. A one-third tubular plate is placed over the sutures lying on the posterior wall and fixed with screws. The sutures are then tied individually over the plate. Postoperatively the patient is kept in bed for six weeks, with the hip abducted and knee extended. Seven patients in whom the labrum was not repaired experienced redislocation. We performed second operations on two of them, repositioning the plates and reconstructing the posterior wall, but redislocation again occurred. The redislocated femoral heads were damaged because they rubbed against the plate and screws. In the other nine patients, we sutured the labrum, and in a 3 month to 2.5 year follow-up, no redislocation has occurred. . Labral repair restores stability, and tying interrupted sutures over a buttress plate is an easy and effective method of repair

The technical advances in arthroscopic surgery of the hip, including the improved ability to manage the capsule and gain extensile exposure, have been paralleled by a growth in the number of conditions that can be addressed. This expanding list includes symptomatic labral tears, chondral lesions, injuries of the ligamentum teres, femoroacetabular impingement (FAI), capsular laxity and instability, and various extra-articular disorders, including snapping hip syndromes. With a careful diagnostic evaluation and technical execution of well-indicated procedures, arthroscopic surgery of the hip can achieve successful clinical outcomes, with predictable improvements in function and pre-injury levels of physical activity for many patients. This paper reviews the current position in relation to the use of arthroscopy in the treatment of disorders of the hip. Cite this article: Bone Joint J 2013;95-B:10–19

The gold standard treatment of hip dysplasia is a peri-acetabular osteotomy (PAO). Labral tears are seen in the majority of patients presenting with hip dysplasia and diagnosed using Magnetic Resonance Imaging (MRI). The goal was to (1) evaluate utility/value of MRI in patients undergoing hip arthroscopy at time of PAO, and (2) determine whether MRI findings of labral pathology can predict outcome. A prospective randomized controlled trial was conducted at tertiary institutions, comparing patients with hip dysplasia treated with isolated PAO versus PAO with adjunct hip arthroscopy. This study was a subgroup analysis on 74 patients allocated to PAO and adjunct hip arthroscopy (age 26±8 years; 89.2% females). All patients underwent radiographic and MRI assessment using a 1.5-Tesla with or 3-Tesla MRI without arthrography to detect labral or cartilage pathology. Clinical outcome was assessed using international Hip Outcome Tool-33 (iHOT). 74% of patients (55/74) were pre-operatively diagnosed with a labral tear on MRI. Among these, 41 underwent labral treatment (74%); whilst among those without a labral tear on MRI, 42% underwent labral treatment (8/19). MRI had a high sensitivity (84%), but a low specificity (56%) for labral pathology (p=0.053). There was no difference in pre-operative (31.3±16.0 vs. 37.3±14.9; p=0.123) and post-operative iHOT (77.7±22.2 vs. 75.2±23.5; p=0.676) between patients with and without labral pathology on MRI. Value of MRI in the diagnostic work-up of a patient with hip dysplasia is limited. MRI had a high sensitivity (84%), but low specificity (44%) to identify labral pathology in patients with hip dysplasia. Consequently, standard clinical MRI had little value as a predictor of outcome with no differences in PROM scores between patients with and without a labral tear on MRI. Treatment of labral pathology in patients with hip dysplasia remains controversial. The results of this subgroup analysis of a prospective, multi-centre RCT do not show improved outcome among patients with dysplasia treated with labral repair

Acetabular labral tears and associated intra-articular pathology of the hip have been recognised as a source of symptoms. However, it is now appreciated that there is a relatively high prevalence of asymptomatic labral tears. In this study, 70 young asymptomatic adult volunteers with a mean age of 26 years (19 to 41) were recruited and underwent three tesla non-arthrographic MR scans. There were 47 women (67.1%) and 23 men (32.9%). Labral tears were found in 27 volunteers (38.6%); these were an isolated finding in 16 (22.9%) and were associated with other intra-articular pathology in the remaining 11 (15.7%) volunteers. Furthermore, five (7.1%) had intra-articular pathology without an associated labral tear. Given the high prevalence of labral pathology in the asymptomatic population, it is important to confirm that a patient's symptoms are due to the demonstrated abnormalities when considering surgery. Cite this article: Bone Joint J 2015;97-B:623–7

There has been a marked increase in the number of hip arthroscopies performed over the past 16 years, primarily in the management of femoroacetabular impingement (FAI). Insights into the pathoanatomy of FAI, and high-level evidence supporting the clinical effectiveness of arthroscopy in the management of FAI, have fuelled this trend. Arthroscopic management of labral tears with repair may have superior results compared with debridement, and there is now emerging evidence to support reconstructive options where repair is not possible. In situations where an interportal capsulotomy is performed to facilitate access, data now support closure of the capsule in selective cases where there is an increased risk of postoperative instability. Preoperative planning is an integral component of bony corrective surgery in FAI, and this has evolved to include computer-planned resection. However, the benefit of this remains controversial. Hip instability is now widely accepted, and diagnostic criteria and treatment are becoming increasingly refined. Instability can also be present with FAI or develop as a result of FAI treatment. In this annotation, we outline major current controversies relating to decision-making in hip arthroscopy for FAI. Cite this article: Bone Joint J 2022;104-B(5):532–540

Objectives. The aim of this study was to investigate the structural integrity of torn and non-torn human acetabular labral tissue. Methods. A total of 47 human labral specimens were obtained from a biobank. These included 22 torn specimens and 25 control specimens from patients undergoing total hip arthroplasty with macroscopically normal labra. The specimens underwent dynamic shear analysis using a rheometer to measure storage modulus, as an indicator of structural integrity. Results. There was a significant difference in the storage modulus between torn (mean modulus = 2144.08 Pa) and non-torn (3178.1 Pa) labra (p = 0.0001). Conclusion. The acetabular labrum of young patients with a tear has significantly reduced structural integrity compared with a non-torn labrum in older patients with end-stage osteoarthritis. This study contributes to the understanding of the biomechanics of labral tears, and the observation of reduced structural integrity in torn labra may explain why some repairs fail. Our data demonstrate that labral tears probably have a relatively narrow phenotype, presenting a basis for further investigations that will provide quantifiable data to support their classification and a means to develop a standardized surgical technique for their repair. This study also demonstrates the value of novel biomechanical testing methods in investigating pathological tissues of orthopaedic interest. Cite this article: A. K. Woods, J. Broomfield, P. Monk, F. Vollrath, S. Glyn-Jones. Dynamic shear analysis: a novel method to determine mechanical integrity of normal and torn human acetabular labra: Implications for prediction of outcome of repair. Bone Joint Res 2018;7:440–446. DOI: 10.1302/2046-3758.77.BJR-2017-0282.R2

Arthroscopic hip surgery is increasingly common in Australia. Hip arthroscopy is indicated for a range of diagnostic and therapeutic purposes, including labral tears, capsular laxity and femoral-acetabular impingement (FAI). Despite this, previous cohort studies aiming to characterise hip pathology seen on arthroscopic examination are mostly limited to patients with known diagnoses of FAI. Therefore, little is known of the native articular wear patterns encountered in other disease states. Therefore, we aimed to define common osteochondral wear patterns for a cohort of patients managed via hip arthroscopy. We retrospectively analysed intraoperative data for 1127 patients managed via hip arthroscopy between 2008 and 2013, for either therapeutic or diagnostic purposes. Intraoperative data was categorized by location (A-E as defined by Fontana et al. 2016) and chondral damage (0-4 scale as defined by Beck et al. 2005) with respect to both acetabulum and femoral head. Data for 1127 patients were included. Location of acetabular chondral pathology was variable with locations C. 1. and D. 1. representing the most common regions of damage. Labral tears predominated in locations C and D. Femoral chondral pathology was evenly distributed. The degree of femoral chondral injury was predominantly grade 1, whilst acetabular wear was evenly distributed. Large proportions of wear were observed at the peripheral superior and anterior regions of the lunate surface of the acetabulum in keeping with prior works. However, we observed higher rates of central wear and lower rates of grade 4 acetabular damage extending into superior/posterior zones, in our cohort. Our work characterises common articular wear patterns encountered at the time of hip arthroscopy. Further inquiry into the natural history of osteochondral lesions is needed to better understand and manage these conditions

Labral tears are increasingly recognized as a source of hip pain. These rarely occur in normal hips, but in individuals with subtle femoral deformities. Anterior impingement of the femoral neck on the acetabulum due to loss of anterior offset results in a labral tear in active individuals. Future surgeries should be directed at this anterior offset deficiency in order to completely alleviate pain and prevent further recurrences. To determine the incidence of anterior hip impingement and femoral pathology in patients undergoing hip arthroscopy for labral tear. Anterior labral tears occur in the presence of abnormal femoral anatomy, which results in anterior hip impingement. Future treatment of labral tears should include addressing the hip impingement. Labral tears of the hip are increasingly being recognized as a source of hip pain in young, active individuals. Athroscopic labral debridement is commonly associated with poor results. As a result, it is likely that other hip pathology is present at the time of labral tear. The purpose of this study was to determine the incidence of anterior hip impingement secondary to a pistol grip deformity in patients undergoing hip arthroscopy for labral tears. The charts and radiographs of forty consecutive patients who underwent hip arthroscopy were evaluated. X-rays were evaluated for presence of acetabular or femoral pathology. Femoral pathology was then graded based on degree of slip and posterior slip angle. All patients who underwent hip arthroscopy for labral tears had abnormal femoral or acetabular anatomy. In those patients without acetabular dysplasia, a pistol grip deformity of the femoral head was present in all cases. Evidence of anterior hip impingement with osteophyte formation was present in ninety-two percent. In these patients, hip arthroscopy results in complete resolution of mechanical symptoms, but hip pain was still present. Labral tears of the hip appear to be secondary to anterior femoral impingement. This is analogous to a rotator cuff tear in the presence of shoulder impingement. Anterior impingement of the femoral neck on the acatabulum due to an anterior femoral offset deformity results in both pain and labral tears. Future surgeries should be directed at this anterior offset deficiency in order to prevent recurrent injuries or residual pain

This study aimed to analyse the incidence, the operative findings and outcomes of hip arthroscopy after periacetabular osteotomy (PAO). We conducted a retrospective study of prospective collected data to report the operative findings and outcomes of hip arthroscopy for recurrent pain following PAO for acetabular dysplasia. Demographic data, radiographic and arthroscopic findings were analysed. Pre- and post-operative patient reported outcome measures (PROMs) were collected. Of 184 PAO patients, 15 hips in 15 patients (8.2%) underwent post-PAO hip arthroscopy with 2 males and 13 females at a mean time of 3.9 ±2.9(0.3–10) years. Hip arthroscopy findings included labral tears (15 hips, 100%), chondral damage (11 hips, 73%) with one Beck 1, two Beck 2, four Beck 4, and four Beck 5 damage. There were 8 (53%) isolated labral debridement, 7 (47%) labral repair, and 2 (13%) adhesiolysis. A femoral osteochondroplasty was performed in 4 (27%) hips. Four hips (27%) were finally converted to total hip replacement at a mean delay of 2.3 ±1.4 (0.7–3.2) years post hip arthroscopy and these 4 patients were significantly older than those who were not (p=0.02). There were no significant differences in PROMs pre and post hip scope. 8.2% of patients undergoing a PAO required a hip scope for persistent hip pain. Common post-PAO hip arthroscopy findings included labral tears, chondral changes and femoroacetabular impingement. 27% of patients finally underwent conversion to total hip replacement at a mean follow-up of 4.5 years post hip scope

Background: Acetabular labral tears are increasingly recognised as a cause of hip pain in young adults and middle aged patients. Degenerative acetabular conditions and sporting activities can cause labral injury. Recent interest has focussed on anterior femoroacetabular impingement as a cause of labral injury, progressive articular cartilage damage and secondary osteoarthritis. Labral tears are difficult to diagnose clinically or with conventional radiographic techniques. Aim: The purpose of this study was to assess the accuracy of MR arthrography in locating labral tears and articular cartilage defects compared with hip arthroscopy. Materials and Methods: 200 consecutive patients with a diagnosis of acetabular labral tear underwent hip arthroscopy. All of them had a preoperative Magnetic Resonance Arthrogram done by a single musculoskeletal radiologist using a standard protocol. The labrum was assessed for abnormalities of morphology and signal intensity. Acetabular articular cartilage defects were expressed as a reduction in joint space. All hip arthroscopies were done by a single surgeon after a trial period of conservative therapy consisting of activity modification, physiotherapy and non-steroidal anti-inflammatory medications. All procedures were recorded digitally and documented in an operative report. Labral tears and acetabular cartilage abnormalities were described by location and appearance. Results: Comparison of MRA and hip arthroscopy findings demonstrate MRA to have a sensitivity of 100%, positive predictive value of 99%, negative predictive value of 100% and accuracy of 99% in predicting labral tears. MRA correctly identified the location of labral tears in 90% of cases. Acetabular cartilage abnormalities were under recognised by MRA (43 hips on MRA vs 54 hips on arthroscopy). MRA was not sensitive enough to pick up early delamination of cartilage adjacent to labral tear in 6 hips. Conclusion: Hip MRA with radial reformatting has high accuracy rates in diagnosing and localising hip labral lesions

Purpose: A prospective investigation to define the syndrome associated with symptomatic labral tears definitively diagnosed at hip arthroscopy. Methods: 66 consecutive patients that had an arthroscopically documented labral tear were evaluated. Demographics, symptomatology, examination, previous treatments, functional limitations, were assessed prospectively. Onset/duration of symptoms to diagnosis of tears, other diagnoses offered by healthcare providers, and non-labral procedures that patients had undergone for the symptoms were analyzed. Radiographic abnormalities and MR arthrography findings were recorded. Results: There were 47 female and 19 male patients with a mean age of 38 years. Initial presentation: insidious in 61%, acute injury in 30%, and trauma in 9% hips. Moderate to severe pain occurred in 86% of patients, with groin pain predominating (92%). Fifty three percent had true mechanical symptoms - catching/locking. Walking, pivoting, impact activity aggravated patient symptoms (p< 0.05). Pain was characterized as a combination of dull aching pain with intermittent episodes of sharp pain in 70%(p=0.001). Pain was frequently activity related (p< 0.05) and night pain occurred in 71% of patients (p=0.0006). The majority of patients (98%) with a labral tear reported being active/athletic. On examination 39% patients had a limp, 38% a positive Trendelenburg sign, and 95% a positive impingement sign. The mean time to diagnosis of labral tear from the onset of symptoms was 21 months. A mean of 3.3 healthcare providers were seen prior to a definitive diagnosis. Surgery on another anatomic site was recommended in 11 patients and 4 of these underwent an unsuccessful surgery prior to diagnosis of the labral tear. Radiographic data indicated that 38% of hips had an underlying structural abnormality consistent with mild development dysplasia or anterior femoroacetabular impingement. Preoperative MRA detected 73% of the labral tears. Conclusions: The clinical presentation of a labral tear may vary, with duration of symptoms often greater than 12 months prior to diagnosis. In young, active patients with a predominant complaint of groin pain with or without a history of trauma, the diagnosis of a labral tear should be suspected, and investigated, as radiographs and history may be nonspecific for this diagnosis

Introduction: Hip pain in young adults can be associated with radiographic finding of acetabular labral tears in magnetic resonance arthrography. Acetabular labral tears can occur in dysplastic hips and in arthrotic hips as well, but often no comobidity is found. Up to now there is no prospective study published following patients with magnetic resonance arthrography verified acetabular labral tears over time and re-evaluating them with MR years later. There is also no stage related therapy published according to labral damage. The aim of this study was to follow 100 MRI verified acetabular labral tears for four years. Material and methods: Study design was prospective, observers were blinded. At primary investigation 36 clinical and 30 radiological parameters were recorded. At follow up these factors were recorded again and additionally SF36 and Harris Hip score were recorded. Results: 100 patients with average age 42 were included. 91% of all patients could be followed for over 48 months. 55 operations were performed in 50 patients . 20 patients showed concomitant developmental dysplasia of the hip, 16 patients arthrosis, 40 patients both and 15 patients had a labral lesion alone. The last group of patients never required any operation. 28 patients had a labral lesion grade I, 29 grade II, 34 grade III. Patients with grade III lesions had a significantly lower HHS at the first examination. At follow up between all groups of patients no difference regarding any clinical parameter was found. Operations were only necessary if comorbidity (dysplasia or arthrosis) was found. No single radiologic or clinical parameter could predict operation. Nine of thirteen labral surgeries were revised (triple osteotomies or THR). No correlation between severity of labral lesion at first MRI and any parameter at follow up could be found. Conclusion: If no comorbidity was found an acetabular labral tear alone never needed operative treatment. Although there exist a series of different operative treatment opportunities in meniscal/glenoid labrum surgery , we could not find the need for surgical intervention if the acetabular labral tear occurs alone. We therefore recommend physiotherapy and non – operative treatment for these patients

Purpose: Acetabular labral tears are most commonly associated with minor or atraumatic events. As a result, it is likely that these tears occur in the presence of an abnormal hip joint. The purpose of this investigation was to establish whether anterior hip impingement, secondary to an anterior femoral offset deficiency from a pistol grip deformity, was a common and poorly recognized cause of acetabular labral tears. Methods: Sixty-five consecutive patients who underwent a hip arthroscopy and were found to have a labral tear were evaluated. Preoperative hip radiographs were evaluated for abnormalities of the femur and /or acetabulum. The patient’s outcome with respect to resolution to pain and mechanical symptoms was assessed. Results: All labral tears identified at the time of hip arthroscopy were found to be located anteriorly. A pistol grip deformity of the proximal femur was identified on the preoperative radiographs in 92% of the patients. Labral excision resulted in complete resolution of hip pain in only 8 (28%). With the remaining 72% experiencing mild or moderate pain. Conclusions: Acetabular labral tears are the result of repetitive femoral-acetabular impingement, from a pistol grip deformity, with eventual tearing of the labrum from a relatively minor trauma. This is analogous to a rotator cuff repair in the shoulder that is secondary to repetitive impingement by the acromium. Decompression or correction of the anterior hip impingement should routinely be considered at the time of labral surgery to provide complete relief of symptoms and diminish the risk of future joint degeneration

Background. Magnetic resonance arthrography is the current method of choice for investigating patients with a clinical diagnosis of femoroacetabular impingement prior to performing hip arthroscopy. The aim of our study was to assess the efficacy of this investigation by comparing the findings of MR arthrogram with those found at arthroscopy, with reference to labral tears and chondral damage. Methods. A prospective trial to investigate the sensitivity, specificity, accuracy and predictive value of MRA for diagnosis of labral tears and chondral defects. Over a 25-month period 69 hips undergoing hip arthroscopy were investigated with MRA prior to the definitive operative procedure. MRA findings were compared to the intraoperative findings. Results. In the assessment of labral tears, MRA demonstrated a sensitivity of 81% with a specificity of 51% and an accuracy of 58%. Positive predictive value of MRA was 33% and negative predictive value 90%. For chondral defects MRA demonstrated a sensitivity of 17%, a specificity of 100% and accuracy of 55%. Positive predictive value of MRA was 100% and negative predictive value was 51%. Conclusions. In what the authors believe to be the first UK study to explore both chondral injury and labral tears in a prospective manner and looking specifically at accuracy, it can be seen that the MRA has poor accuracy for both pathologies. Therefore we suggest a moved away from MRA, which is an invasive procedure with associated risks

Background: Cam-type femoroacetabular impingement (FAI) is becoming more recognized. Cartilage lesions of the acetabulum and labral tears are frequently encountered. The goal of this study was to accurately describe and communicate these injuries and thus providing a standard for reporting injury, management, and outcome. Methods: We evaluated acetabular cartilage lesions and labral tears found during hip arthroscopy in 52 patients with radiological signs of cam-type FAI. They were graded according to the morphology and extent of the lesion. The labral tears were described according to the classification by Lage. Results: Eleven patients (21.2%) had normal cartilage, 14 (26.9%) had a grade 1, 17 (32.7%) a grade 2, 6 (11.5%) a grade 3, and 4 (7.7%) a grade 4 lesion. Labral tears were found in 31 patients (59.6%). There was a high correlation between age and the presence and extent of acetabular cartilage and labral lesions (r=0.70; p< 0.0001 and r=0.45; p< 0.001 respectively). There was also a high correlation between the extent of the acetabular cartilage lesion and the presence of labral lesions (r=0.62; p< 0.0001). Conclusion: In our study there was a high prevalence of associated injuries (86.5%) in cam-type FAI. Despite the recognized consequences of associated lesions on treatment and outcome, no classification system includes this aspect of FAI. Based on our findings, we developed a system to grade acetabular cartilage lesions according to their morphology and extent. This should provide the surgeon with a standardized tool to better describe the full extent of the injury and treat it accordingly

Aims. Research on hip biomechanics has analyzed femoroacetabular contact pressures and forces in distinct hip conditions, with different procedures, and used diverse loading and testing conditions. The aim of this scoping review was to identify and summarize the available evidence in the literature for hip contact pressures and force in cadaver and in vivo studies, and how joint loading, labral status, and femoral and acetabular morphology can affect these biomechanical parameters. Methods. We used the PRISMA extension for scoping reviews for this literature search in three databases. After screening, 16 studies were included for the final analysis. Results. The studies assessed different hip conditions like labrum status, the biomechanical effect of the cam, femoral version, acetabular coverage, and the effect of rim trimming. The testing and loading conditions were also quite diverse, and this disparity limits direct comparisons between the different researches. With normal anatomy the mean contact pressures ranged from 1.54 to 4.4 MPa, and the average peak contact pressures ranged from 2 to 9.3 MPa. Labral tear or resection showed an increase in contact pressures that diminished after repair or reconstruction of the labrum. Complete cam resection also decreased the contact pressure, and acetabular rim resection of 6 mm increased the contact pressure at the acetabular base. Conclusion. To date there is no standardized methodology to access hip contact biomechanics in hip arthroscopy, or with the preservation of the periarticular soft-tissues. A tendency towards improved biomechanics (lower contact pressures) was seen with labral repair and reconstruction techniques as well as with cam correction. Cite this article: Bone Joint Res 2023;12(12):712–721

Introduction. Femoroacetabular impingement(FAI) is a relatively common cause causes of hip pain and dysfunction in active young adults. The concept of FAI was popularized by Ganz et al in early 2000s. Surgical treatment for FAI has been widely employed over the last two decades. The long term outcome of femoroacetabular osteoplasty (FAO) and risk factors for long-term failure of FAO is less studied. The goal of this single surgeon series is to identify the long term outcome of FAO (minimum 10-year follow-up) and risk factors for surgical treatment failure in these patients. Methods. The prospective database on hip joint preservation identified 1,120 patients who have undergone FAO between January 2005-June 2019. Of these 164 patients (178 hips) have a minimum 10-year follow-up (range, 10–14). The database collects detailed information on patient demographics, clinical history, radiographic and cross sectional imaging findings, intraoperative findings (site and size of chondral lesion, labral tear, subchondral cyst, size of cam lesion, etc), and patient outcome using the modified HHS, SF-36, and UCLA activity score. Patients are contacted on an annual basis and the functional outcome instruments administered. Of 1,120 patients, 122 patients have been lost to follow-up. Results. The mean age of patients in the cohort is 34.3±10.4 years and 39.6% of patients are female. FAO resulted in an improvement in mean mHHS (58.2±3.9 to 86.4±3.2) and SF-36(60.4±4 to 85±4.1) in 89% of patients. At the latest follow up 8.1% of patients have undergone THA. The study found that older age, longer preoperative symptomatic period, higher preoperative alpha angle, presence of hip dysplasia and acetabular retroversion, inability to repair acetabular labrum, and full thickness acetabular chondral lesion were associated with higher risk of failure of treatment. Conclusion. Patients with symptomatic FAI who undergo surgery experience pain relief and functional improvement that appears to endure over a decade in the majority. This study on a large cohort with long term follow-up has also identified patients who are at higher risk of failure. The study has also shed light on some interesting findings such as labral tear being very common in patients without hip symptoms and others that will be presented. For any tables or figures, please contact the authors directly

Our understanding of pre-arthritic hip disease has evolved tremendously but challenges remain in categorizing diagnosis, which ultimately impacts choice of treatments and clinical outcomes. This study aims to report patient reported outcome measures (PROMs) comparing four different condition groups within hip preservation surgery by a group of fellowship-trained surgeons. From 2018 to 2021, 380 patients underwent hip preservation surgery at our center and were classified into five condition groups: dysplasia: 82 (21.6%), femoro-acetabular impingement (FAI): 173 (45.4%), isolated labral tear: 103 (27.1%), failed hip preservation: 20 (5.3%) and history of childhood disease/other: 2 (0.5%). International hip outcomes Tool 12 (IHOT-12), numeric pain score and patient-reported outcomes measurement information system (PROMIS) were collected pre-operatively and at 3 months and 1 year post-operatively, with 94% and 82% follow-up rate respectively. Arthroscopy (75.5%) was the most common procedure followed by peri-acetabular osteotomy (PAO) (22.4%) and surgical dislocation (2.1%). Re-operation rate were respectively 18.3% (15), 5.8% (10), 4.9% (5), 30% (6) and 0%. There were 36 re-operations in the cohort, 14 (39%) for unintended consequences of initial surgery, 10 (28%) for mal-correction leading to a repeat operation, 8 (22%) progression of arthritis, and 4 (11%) for incorrect initial diagnosis/intervention. Most common re-operations were hardware removal 31% (7 PAO, 3 surgical hip dislocation and 1 femoral de-rotational osteotomy), arthroscopy 31% (11) and arthroplasty 28% (10). All groups had significant improvements in their IHOT-12 as well as PROMIS physical and numerical pain scales, except those with failed hip preservation. Dysplasia group showed a slower recovery. Overall, this study demonstrated a clear relation between the condition groups, their respective intervention and the significant improvements in PROMs with isolated labral pathology being a valid diagnosis. Establishing tertiary referral centers for hip preservation and longer follow-up is needed to monitor the overall survivorship of these various procedures

Over half of postpartum women experience pelvic ring or hip pain, with multiple anatomic locations involved. The sacroiliac joints, pubic symphysis, lumbar spine and pelvic girdle are all well documented pain generators. However, despite the prevalence of postpartum hip pain, there is a paucity of literature regarding underlying soft tissue intra-articular etiologies. The purpose of this systematic review is to document and assess the available evidence regarding underlying intra-articular soft tissue etiologies of peri- and postpartum hip pain. Three online databases (Embase, PubMed and Ovid [MEDLINE]) were searched from database inception until April 11, 2021. The inclusion criteria were English language studies, human studies, and those regarding symptomatic labral pathology in the peri- or postpartum period. Exclusion criteria were animal studies, commentaries, book chapters, review articles and technical studies. All titles, relevant abstracts and full-text articles were screened by two reviewers independently. Descriptive characteristics including the study design, sample size, sex ratio, mean age, clinical and radiographic findings, pathology, subsequent management and outcomes were documented. The methodological quality of the included studies was assessed using the Methodological Index for Non-Randomized Studies (MINORS) instrument. The initial search identified 2472 studies. A systemic screening and assessment of eligibility identified 5 articles that satisfied the inclusion criteria. Twenty-two females were included. Twenty patients presented with labral pathology that necessitated hip arthroscopy with labral debridement or repair with or without acetabuloplasty and/or femoroplasty. One patient presented with an incidental labral tear in the context of osteitis condensans illi. One patient presented with post-traumatic osteoarthritis necessitating a hip replacement. The mean MINORS score of these 5 non-comparative studies was 2.8 (range 0-7) demonstrating a very low quality of evidence. The contribution of intra-articular soft tissue injury is a documented, albeit sparse, etiology contributing to peri- and postpartum hip pain. Further research to better delineate the prevalence, mechanism of injury, natural history and management options for women suffering from these pathologies at an already challenging time is necessary to advance the care of these patients

Introduction: The popularity of hip arthroscopy has lagged behind that of other joints. However surgeons are increasingly using hip arthroscopy to investigate and treat disorders such as early osteoarthritis, inflammatory arthritis, labral tears, loose bodies and paediatric hip disease. We present the indications, intra operative findings and outcomes of patients undergoing hip arthroscopy. Methods: Prospective study of 43 patients from 2000 to 2005 undergone hip arthroscopy performed by the senior author. Pre & post operative visual analogue scores and oxford hip scores were recorded. CT or MRI was performed were clinically indicated. Mean follow up 4 months, range(2– 10). Results: 45 hips. 20 right. 21 left. 2 bilateral. 22 females. 21 males. Mean age 39.6yrs, Range 20–65yrs. Symptoms: Pain, Clicking, Giving way. History: Idiopathic pain 30, DDH 5, Perthes 3, Trauma acetabulum fracture 2, RT A Dislocation 1, SUFE 1, Non union 1. 6 patients had pre-op CT scans and 22 had MRI. MRI Findings: 3 loose bodies, 14 labral tears, 2 large filling defects, 3 normal MRI. 42 Arthroscopic debridement and wash outs, 3 failed scopes. Intra operative findings: 5 loose bodies, 4 degenerate labrum’s, 10 labral tears, 14 Grade 3–4 Osteoarthritic changes, 7 Torn ligament Teres,1 normal joint. 3 normal MRI findings had labral tears and articular cartilage defects. Mean Pre-op VAS- 7.9 Range(5– 10). Mean Post-op VAS- 4.7 Range(1– 10). Mean Pre-op Oxford Hip score – 39.4 Range(27–53). Mean Post-op Oxford Hip Score – 25.2 Range(12–51). Patient Satisfaction score – 7.3 Range(1–10). 1 Superficial wound infection, settled with antibiotics. Discussion: Hip arthroscopy is of value in assessing and treating patients with hip pain of uncertain cause. Our results indicated good patient satisfaction and outcomes with improved pain and Oxford hip scores. However patient selection and diagnostic expertise are critical to successful outcomes

Since its creation, labral repair has become the preferred method among surgeons for the arthroscopic treatment of acetabular labral tears resulting in pain and dysfunction for patients. Labral reconstruction is performed mainly in revision hip arthroscopy but can be used in the primary setting when the labrum cannot be repaired or is calcified. The purpose of this study was to compare the survival between primary labral repair and labral reconstruction with survival defined as no further surgery (revision or total hip replacement). Patients who underwent labral repair or reconstruction between January 2005 and December 2018 in the primary setting were included in the study. Patients were included if they had primary hip arthroscopy with the senior author for femoroacetabular impingement (FAI), involving either labral reconstruction or labral repair, and were within the ages of 18 and 65 at the time of surgery. Exclusion criteria included confounding injuries (Leggs Calves Perthes, avascular necrosis, femoral head fracture, etc.), history of unilateral or bilateral hip surgeries, or Tönnis grades of 2 or 3 at the time of surgery. Labral repairs were performed when adequate tissue was available for repair and labral reconstruction was performed when tissue was absent, ossified or torn beyond repair. A total of 501 labral repairs and 114 labral reconstructions performed in the primary setting were included in the study. Labral reconstruction patients were older (37±10) compared to labral repair (34±11).(p=0.021). Second surgeries were required in 19/114 (17%) of labral reconstruction and 40/501(8%) [odds ratio: 2.3; 95% CI 1.3 to 4.2] (p=0.008). Revision hip arthroscopy were required in 6/114(5%) labral reconstructions and 33/501(6.5%) labral repair (p=0.496). Total hip replacement was required in 13/114 labral reconstructions and 7/501 labral repairs [odds ratio:9.1 95%CI 3.5 to 23] (p=< 0.01). The mean survival for the labral repair group was 10.2 years (95%CI:10 to 10.5) and 11.9 years (98%CI:10.9 to 12.8) in the labral reconstruction group. Conversion to total hip was required more often following primary labral reconstruction. Revision hip arthroscopy rates were similar between groups as was the mean survival, with both over 10 years. Similar survival was seen in labral repair and reconstruction when strict patient selection criteria are followed

We have reviewed a consecutive series of six professional footballers who presented with intractable hip pain which was attributed at arthroscopy, to an anterior acetabular labral tear with adjacent chondral damage. The location and type of labral tear were identical for each patient. There was no evidence of acetabular dysplasia. A variable area of chondral damage was associated with the labral tear. All unstable tissue was resected. Five returned to professional football at the highest level. Acetabular labral pathology should be included in the differential diagnosis of footballers with hip or groin pain. Arthroscopy of the hip is an appropriate method of diagnosis and treatment and minimises the length of rehabilitation required

The December 2013 Hip & Pelvis Roundup. 360 . looks at: Enhanced recovery works; Acetabular placement; Exercise better than rest in osteoarthritis patients; if Birmingham hip resurfacing is immune from pseudotumour; HIV and arthroplasty; Labral tears revisited; Prophylactic surgery for FAI; and Ceramics and impaction grafting

Purpose. Rectus femoris avulsion (RFA) injuries in paediatric patients are currently managed conservatively. However, the proximal attachment of the rectus femoris muscle lies in a critical zone in the hip joint with attachments to the anterior hip capsule and anterior inferior iliac spine. Violent avulsions therefore could cause damage to the adjacent acetabular labrum and articular cartilage initiating a process leading to early degenerative changes in the hip. To date, the association between rectus avulsions and labral tears has not been studied. Method. The complete medical records of patients who were presented to McMaster University Medical Center with rectus femoris avulsions between 1983 and 2008 who were between the ages of 2 and 18 were identified. Patients were included if they had documented plain radiographs and magnetic resonance arthrography images of their hip. MRIs were reviewed by an independent musculoskeletal radiologist blinded from the history of the patients. Results. 16 patients were identified in the database with rectus femoris avulsions diagnosed on plain radiograph and 7 were included in the study with documented MRIs. The average age of patients was 13 (Range 7–16). All injuries occurred during sports activity with 43% occurred during running, 29% with kicking during soccer and during skating acceleration while playing hockey. One patient had a concurrent sartorius avulsion. All patients with rectus femoris avulsions had labral tears identified on MRI in the zone adjacent to rectus insertion. All patients were treated conservatively. Clinical records suggested 72% of patients were still limping and 86% were experiencing residual pain at last follow-up. Conclusion. Patients with rectus femoris avulsions may be at risk for concurrent traumatic labral tears. These patients should be assessed for labral pathology including a clinical examination and MRI arthrography. Level of Evidence: Level IV

Arthroscopic labral debridement has become and accepted mode of treatment for acetabular labral tears (ALTs) and yet results in literature are few and conflicting especially with regards presence of cartilage damage and its influence on outcome. Aim of our prospective cohort study was to look at outcome of ALTs post arthroscopic limbectomy using validated questionnaires at average of 2 years. We also looked at the sensitivity of MR arthrography in detecting ALTs and cartilage damage. Consecutive cohort of 82 patients who were suspected of having ALTs by senior author had MR arthrography followed by hip arthroscopy. All patients filled out a WOMAC, NAHS scores before and after the operation. All patients who were followed up also filled an especially designed five-point functional questionnaire. At time of arthroscopy the presence of labral tear, its position in the acetabulum and degree of cartilage damage (based on Outerbridge classification) were recorded and correlated with Mra and patient outcome. Seventy six patients were found to have a labral tear, with majority of these lesions in the anterior or antero-superior quadrant. 59% of patients were shown to have an associated degree of cartilage damage. Although overall all patients showed significant improvement in their functional scores, those with high grade cartilage damage had poorer results in comparison. We also found that patients with older age are at higher risk of requiring a THJR in the first 2 years following arthroscopy. MRa proved to a sensitive tool at detecting labral pathology but not so at identifying presence of cartilage damage. Arthroscopic debridement of ALTs in patients presenting with mechanical hip symptoms provides good functional outcome, however it should be used with caution in those with high grade articular cartilage damage and older age group where there is higher likelihood of failure

Purpose: The treatment and prognosis of labral tears secondary to femoroacetabular impingement depends on the severity of the labral injury and whether or not there is concomitant injury and delamination of the adjacent articular cartilage. At present, there is no simple and reproducible technique to determine if there is delamination of the adjacent articular cartilage. We undertook a study to determine if the preoperative presence of a previously undescribed radiographic finding, a “delamination cyst”, correlated with delamination of the articular cartilage at the time of hip arthroscopy. Method: The preoperative radiographs of 125 consecutive hip arthroscopies in which a labral tear was identified intraoperatively were retrospectively reviewed.. In each case an anteroposterior (AP) pelvis and AP, lateral and frog lateral hip radiographs were evaluated for the presence of delamination cysts, perilabral cysts, abnormalities of the femur and acetabulum, as well as arthritic changes. A “delamination cyst” was defined as a subchondral cyst either directly adjacent to a perilabral cyst, or in relation to a subchondral crack in the anterolateral portion of the acetabulum. These findings were then compared and correlated to the intraoperative arthroscopic findings. Results: We identified 16 patients with delamination cysts on radiographs and 15 patients with delamination of the acetabulum on arthroscopy. A strong correlation was found between the preoperative radiographic presence of a delamination cyst and acetabular delamination at the time of arthroscopy – sensitivity of 93.3%, specificity of 98.8%, positive predictive value of 93% and a negative predictive value of 99% (p=0.034). No other radiographic findings were associated with the status of the articular cartilage. Conclusion: A “delamination cyst” is a previously undescribed and novel radiographic sign that can accurately predict preoperatively which patients with labral tears have associated acetabular cartilage delamination or chondral damage. Delamination cysts can be easily identified on plain radiographs without performing any special imaging or invasive infiltrations. Identifying these cysts preoperatively can aid the surgeon in selecting the appropriate surgical procedure and help predict the patient’s prognosis following the planned surgical procedure

Femoroacetabular impingement is recognised as being a cause of labral tears and chondral damage. We report a series of five patients who presented with persistent pain in the hip after arthroscopy for isolated labral debridement. All five had a bony abnormality consistent with cam-type femoroacetabular impingement. They had a further operation to correct the abnormality by chondro-osteoplasty of the femoral head-neck junction. At a mean follow-up of 16.3 months (12 to 24) all had symptomatic improvement

Aim: To evaluate the results of arthroscopic repair of anterior and superior glenoid labral tears in the shoulder with metallic knotless suture anchors with an average follow up of 31 months. Material and methods: Between 2000 and 2002, 55 patients with labral tears underwent arthroscopic repair with metallic knotless suture anchors (Mitek, Ethicon Ltd). Their average age was 36 years (range 16 to 67). Thirty-seven patients presented with anterior instability. Twenty-one patients presented with painful shoulder without instability. In the instability group there were eight acute dislocations and twenty-nine recurrent dislocations. All patients underwent examination under anaesthesia, arthroscopic repair of labral tears using the metallic knotless suture anchors, thermal capsulorraphy and closure of the rotator interval. Subacromial decompression was performed when indicated. Rehabilitation consisted of sling immobilisation for four weeks followed by gradual strengthening program over three months with the physiotherapist. Contact sports were allowed at 1 year. Evaluation: Patients were evaluated preoperatively and at the time of final follow-up using Constant score and Modified Rowe – Zarin score system. Results: Three out of the thirty-seven patients in the instability group had recurrent dislocation. A fourth patient had pain with a positive anterior apprehension test thus making the overall recurrence rate of 11%. In the painful shoulder group, good and excellent results were recorded in twenty out of twenty-one patients (95%). Of the fifty five patients who had labral repair, five had poor functional outcome secondary to pain in their shoulder (9%). One patient had a fall and required further surgery to replace one dislodged anchor. Conclusions: We found the metallic knotless suture anchor easy to use and stabilised the torn labrum well. The success rate for instability compares well with the published literature. However, we have some concern of our observation of early degenerative changes in some of our patients treated for recurrent dislocation

The epidemiological data and intra-operative findings from 260 consecutive arthroscopically-diagnosed acetabular labral tears seen over a ten-year period were analysed. Radiographs of 128 of these patients were assessed for dysplasia using established radiological parameters. Patients with acetabular dysplasia were then compared against those without in order to identify any differences in gender, age, the side of the tear, the pattern of the tear, the number of quadrants involved, the quadrant preference and the prevalence of intra-articular comorbidity. Dysplasia was found in 46% (59 of 128) of the hips. No significant differences existed between the dysplastic and non-dysplastic subgroups as regards gender distribution, the side of the lesion, the number of quadrants involved or the distribution of tears among the quadrants. However, tears associated with dysplasia were diagnosed in an older age group, had a different pattern and were associated with a much higher prevalence of osteoarthritis

We present to you a match-controlled study assessing co-existing arthroscopic findings during hip arthroscopy in patients with an intraoperative diagnosis of a central acetabular osteophyte (CAO). We feel that this manuscript is both pertinent and timely. Recent literature has described the entity of central acetabular impingement, in which an osteophyte of the cotyloid fossa impinges against the superomedial femoral head and fovea. The technique for central acetabular decompression has also been described to treat this entity. The primary purpose of this study was to report the prevalence of femoral head articular damage in a matched cohort of patients with and without central acetabular osteophyte (CAO) that was identified during hip arthroscopy. A secondary purpose was to identify the rates of co-existing intraarticular pathology in both patient groups. Intraoperative data was collected prospectively on all patients undergoing hip arthroscopy at our institution between February 2008 to March 2015,. The inclusion criteria for this study were the presence of a CAO identified during hip arthroscopy for a labral tear and/or femoroacetabular impingement (FAI). Exclusion criteria were revision surgeries, Tönnis grade 1 and higher, and previous hip conditions such as Legg-Calves-Perthes disease, avascular necrosis, and prior surgical intervention. The matched cohort control group was selected based on gender, age within 5 years, body mass index (BMI), and workers' compensation claim, on a 1:3 ratio to patients who underwent hip arthroscopy for a labral tear and/or FAI and did not have a CAO. The CAO group consisted of 126 patients, which were matched to 378 patients in the control group. The grades of femoral and acetabular chondral damage were significantly different between the two groups (p<0.01). This study showed that patients with CAO had a significantly higher prevalence of femoral and acetabular chondral damage, size of articular defects on both surfaces and the prevalence of LT tears compared to matched controls

Aims. The number of patients undergoing arthroscopic surgery of the hip has increased significantly during the past decade. It has now become an established technique for the treatment of many intra- and extra-articular conditions affecting the hip. However, it has a steep learning curve and is not without the risk of complications. The purpose of this systematic review was to determine the prevalence of complications during and following this procedure. Materials and Methods. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used in designing this study. Two reviewers systematically searched the literature for complications related to arthroscopy of the hip. The research question and eligibility criteria were established a priori. Pertinent data were abstracted and analysed. Results. We found 276 relevant studies with a total of 36 761 arthroscopies that met the inclusion criteria. The mean age of the patients was 36.7 years (1.7 to 70) and the mean body mass index was 25.7 kg/m. 2. (20.2 to 29.2). Femoroacetabular impingement and labral tears were the most common indications for the procedure. The total number of complications was 1222 (3.3%). Nerve injury (0.9%), mainly involving the pudendal and lateral femoral cutaneous nerves, and iatrogenic chondral and labral injury (0.7%), were the two most common complications. There were 58 major complications (0.2%), the most common being intra-abdominal extravasation of fluid, which was found in 13 cases (0.04%). There were three deaths (0.008%). Conclusion. Arthroscopic surgery of the hip is a procedure with a relatively low rate of complications, although some may be significant in this young cohort of patients. This study relied on the reported complications only and the results should be interpreted with caution. Cite this article: Bone Joint J 2017;99-B:1577–83

Reconstructive acetabular osteotomy is a well established and effective procedure in the treatment of acetabular dysplasia. However, the dysplasia is frequently accompanied by intra-articular pathology such as labral tears. We intended to determine whether a concomitant hip arthroscopy with peri-acetabular rotational osteotomy could identify and treat intra-articular pathology associated with dysplasia and thereby produce a favourable outcome. We prospectively evaluated 43 consecutive hips treated by combined arthroscopy and acetabular osteotomy. Intra-operative arthroscopic examination revealed labral lesions in 38 hips. At a mean follow-up of 74 months (60 to 97) the mean Harris hip score improved from 72.4 to 94.0 (p < 0.001), as did all the radiological parameters (p < 0.001). Complications included penetration of the joint by the osteotome in one patient, a fracture of the posterior column in another and deep-vein thrombosis in one further patient. This combined surgical treatment gave good results in the medium term. We suggest that arthroscopy of the hip can be performed in conjunction with peri-acetabular osteotomy to provide good results in patients with symptomatic dysplasia of the hip, and the arthroscopic treatment of intra-articular pathology may alter the progression of osteoarthritis

We document intra-articular pathology in collision athletes with shoulder instability and describe the ‘collision shoulder’ – a direct impact without dislocation, with unusual labral injury, significant intra-articular pathology and neurology. 183 collision athletes were treated for labral injuries in 3 centres. Details of injury mechanism and intra-articular pathology at surgery were recorded. Premier league and International (Elite) comprised 72 players. A tackle was implicated in 52% of injuries and 65% had a dislocation. The mechanism of injury was ABduction External Rotation (ABER) in 45%, direct impact 36%, abduction only 8% and axial load 6%. Dislocation occurred in 51% of shoulders with ABER mechanism. A Bankart lesion was found in 79% of these shoulders; Hill-Sachs in 58% and Bony Bankart in 26%. Inferoposterior labral tears were present in only 11%, Superior Labral Antero-Posterior (SLAP) lesions in 32% and partial injury to the rotator cuff in 32%. In those sustaining a direct impact to the shoulder, 61% did not document dislocation, had a high incidence of inferoposterior labral involvement (50%), neurological symptoms (32%), but a low incidence of Bankart (33%), Hill-Sachs (22%) and Bony Bankart (11%) lesions. The mechanism did not affect incidence of superior labral/SLAP tears (18%), or capsular tears (including Humeral Avulsion of Glenohumeral Ligaments – HAGL) – 15%. Elite athletes had less dislocations (43% vs 74%) irrespective of mechanism, but were 40% more likely to have neurology, posteroinferior labral, cartilaginous or capsular injuries. They had twice the incidence of Bony Bankart and rotator cuff lesions and 5 times more SLAP/superior labral tears. Collision athletes with shoulder instability have a wide spectrum of pathoanatomy of the labrum and frequent associated intra-articular lesions. Significant injury often occurs in the Elite athlete and those sustaining a direct hit without dislocation (the ‘Collision Shoulder’)

Although good to excellent short-term results of arthroscopic partial limbectomy of the hip have been reported, there is little information on the long-term outcome of the procedure. We report a case with a 16-year follow-up. A 34-year old woman presented with a three-month history of severe pain and limitation of movement of the hip. Plain radiographs and arthrography showed no abnormality. MRI showed an effusion and a deformity of the anterosuperior part of the labrum. This was confirmed as an inverted labral tear that was debrided arthroscopically. At 16 years post-operatively, she remained symptom-free. Plain radiographs showed no abnormality and MRI suggested that the sealing effect of the scar tissue prevented articular damage and degeneration

We treated eight dysplastic acetabula in six skeletally mature patients with Down’s syndrome by a modified Bernese periacetabular osteotomy. The mean age at the time of surgery was 16.5 years (12.8 to 28.5). Mean length of follow-up was five years (2 to 10.4). Pre-operatively the mean (Tönnis) acetabular angle was 28°, the centre-edge angle was −9°, and the extrusion index was 60%; post-operatively they were 3°, 37°, and 17%, respectively. Two patients with post-operative (Tönnis) acetabular angles > 10° developed subluxation post-operatively and required secondary varus derotation femoral osteotomies. Another patient developed a late labral tear which was treated arthroscopically. All eight hips remain clinically stable, and are either asymptomatic or symptomatically improved. These results suggest that the modified Bernese periacetabular osteotomy can be used successfully in the treatment of acetabular dysplasia in patients with Down’s syndrome

The management of shoulder instability has changed a great deal in the last five years due to a better understanding of the biomechanics of the shoulder and the use of arthroscopic surgery. It is essential to understand the anatomy of the labrum and bony structures of the shoulder joint, as well as the contribution of these structures as well as the Rotator Cuff to stability in the different positions of the arm. The history and examination still remains the most important diagnostic tool and a thorough history and examination cannot be over-emphasised. MR Arthrography is the investigation of choice in confirming the diagnosis of instability while a CT scan may be required if there is significant bony damage. The most controversial topic is that of the first time dislocator. If there is a significant labral tear then the options of an arthroscopic labral repair or external rotation brace need to be considered. In the absence of a labral tear then physiotherapy is the treatment of choice. For recurrent dislocators, the results of arthroscopic labral repairs with capsular plication techniques are approaching those of the gold standard open stabilisation. If, however, there is significant bony damage to the glenoid or humeral head then a bone block procedure may be the treatment of choice. Rotator Cuff tears need to be excluded in older patients with instability and often in such cases an arthroscopic procedure to deal with the Rotator Cuff and Labrum can be done simultaneously

In previously published work, MR arthrogram (MRA) has sensitivities and specificities of 88–100% and 89–93% respectively in detection of glenoid labrum tears. Our practice suggested higher frequency of falsely negative reports. We aimed to assess accuracy of this costly modality in practice. We retrospectively reviewed MRA reports of 90 consecutive patients with clinical shoulder instability who had undergone arthroscopy. All had history of traumatic anterior dislocation and had positive anterior apprehension tests. All underwent stabilisation during the same procedure. We compared the findings, using arthoscopy as gold standard in identification of glenoid labral tears. 83/90 patients had glenoid labrum tears at arthroscopy. Only 54 were correctly identified at MRA. All normal labra were identified. This gave sensitivity of 65% and specificity of 100% in identification of all types of glenoid labrum tear. The majority had anterior glenoid labral tears, which were detected at an even lower rate of sensitivity (58%). Sensitivity of MRA in this series is significantly lower than previously published. This study highlights the importance of an accurate history and clinical examination by specialist shoulder surgeons in the management of glenohumeral instability. The need for this costly investigation may not be as high as is currently the case

In a longitudinal case-control study, we followed 81 subjects with dysplasia of the hip and 136 control subjects without dysplasia for ten years assessing radiological evidence of degeneration of the hip at admission and follow-up. There were no cases of subluxation in the group with dysplasia. Neither subjects with dysplasia nor controls had radiological signs of ongoing degenerative disease at admission. The primary radiological discriminator of degeneration of the hip was a change in the minimum joint space width over time. There were no significant differences between these with dysplasia and controls in regard to age, body mass index or occupational exposure to daily repeated lifting at admission. We found no significant differences in the reduction of the joint space width at follow-up between subjects with dysplasia and the control subjects nor in self-reported pain in the hip. The association of subluxation and/or associated acetabular labral tears with dysplasia of the hip may be a conditional factor for the development of premature osteoarthritis in mildly to moderately dysplastic hips

Abstract. OBJECTIVES. Cam femoroacetabular impingement (FAI – femoral head-neck deformity) and developmental dysplasia of the hip (DDH – insufficient acetabular coverage) constitute a large portion of adverse hip loading and early degeneration. Spinopelvic anatomy may play a role in hip stability thus we examined which anatomical relationships can best predict range of motion (ROM). METHODS. Twenty-four cadaveric hips with cam FAI or DDH (12:12) were CT imaged and measured for multiple femoral (alpha angles, head-neck offset, neck angles, version), acetabular (centre-edge angle, inclination, version), and spinopelvic features (pelvic incidence). The hips were denuded to the capsule and mounted onto a robotic tester. The robot positioned each hip in multiple flexion angles (Extension, Neutral 0°, Flexion 30°, Flexion 60°, Flexion 90°); and performed internal-external rotations to 5 Nm in each position. Independent t-tests compared the anatomical parameters and ROM between FAI and DDH (CI = 95%). Multiple linear regressions determined which anatomical parameters could predict ROM. RESULTS. The FAI group demonstrated restricted ROM in deep hip flexion, with DDH showing higher ROM in Flexion 30° (+20%, p = 0.03), 60° (+31%, p = 0.001), and 90° (+36%, p = 0.001). In Neutral 0° and Flexion 30°, femoral neck and version angles together predicted ROM (R. 2. = 60%, 58% respectively); whereas in Flexion 60°, pelvic incidence and femoral neck angle predicted ROM (R. 2. = 77%). In Flexion 90°, pelvic incidence and radial alpha angle together predicted ROM (R. 2. = 81%), where pelvic incidence alone accounted for 63% of this variance. CONCLUSIONS. Pelvic incidence is essential to predict hip ROM. Although a cam deformity or acetabular undercoverage can elevate risks of labral tears and progressive joint degeneration, they may not be primary indicators of restrictive hip impingement or dysplastic instability. Better delineating additional spinopelvic characteristics can formulate early diagnostic tools and improve opportunities for nonsurgical management. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Keywords. Shoulder; dislocation; instability; skeletal immaturity; arthroscopic Bankart repair; outcomes. Introduction. Non-operative management of traumatic shoulder instability in children has a recurrence rate of up to 100%. Short-term outcomes of surgery in adults results has a quoted recurrence rates of around 10%. The aim of this study was to examine the surgical outcomes of adolescent patients (aged 13 to 18 years) undergoing arthroscopic stabilisation for shoulder instability. Methods. All patients had a labral tear sustained whilst participating in contact sports (84% rugby). Atraumatic, primary joint hyperlaxity and dyskinetic causes were excluded. All patients had a primary arthroscopic stabilisation. Patients were reviewed in clinic or contacted by post with a standardised outcome proforma. Sixty one shoulders in 57 patients met the inclusion criteria and were included. Mean follow up was 22 months, mean age was 16.8 (range 13 to 18), and 98% were male. All were Stanmore type 1 pathology. 16% had a concomitant SLAP repair, and 16% had a posterior labral tear. Results. 31% (19) reported recurrent dislocation, and 11 patients required further surgery. This is significantly higher than published series for adults, despite the senior author being a tertiary specialist. Despite the high recurrence rate, the median improvement in shoulder function was 90% and the median VAS for pain was 0. The majority of patients (61%) had a full return to pre-injury sporting activities, while 23% returned to decreased sporting activity and 16% stopped. The mean post-operative Oxford instability score was 26.8 (SD 12.9 range 12 to 48). 90% of recurrent dislocations occurred whilst playing rugby, but other than this, we could not identify any significant risk factors for the 19 shoulders that had recurrent dislocations (gender, type of sport, hyper laxity, type of tear). Conclusions. This study demonstrates that adolescent patients have a high risk of recurrent dislocation following arthroscopic stabilisation. Patients should be appropriately counselled and alternative procedures such as the coracoid transfer should be considered. Level of evidence: IV

Aim. The aim of this study was to assess the role of hip arthroscopy in the management of hip pain in elite athletes. Patients and methods. It is a retrospective study of prospectively collected data. 31 hip arthroscopies were performed on 27 elite athletes. All the patients were assessed pre-operatively with a thorough clinical examination, radiographs and MRI scans. The modified HHS was also recorded for all the patients' pre and post-operatively. All operations were performed by the senior author, and the patients were assessed at 6 weeks, 3 months, 6 months and a year following the operation. Results. The M:F ratio was 25:2 with an average age of 38 years (Range: 18-58) in the study group. 65% of the patients were professional football players followed by cricket and tennis. The patients were referred at an average of 506 days. Two of the 27 patients demonstrated minimal acetabular dysplasia on their pre-operative radiographs. Of the 31 arthroscopies, a primary diagnosis of a labral tear was made in 20, a chondral flap and delamination in 5, early osteoarthritis in 4 and a ligamentum teres tear in 2. Along with the primary diagnosis of a labral tear, twelve of the 20 patients had a secondary diagnosis of chondral injury and or Femeroacetabular Impingement as well. There were no complications reported. Conclusions. Hip Injuries in athletes are reported late and Chondral Flaps and Ligamentum teres tears are under-diagnosed. Most athletes have a good chance to return back to the original level of sport within 4 months following hip arthroscopy. However, about 40% do continue to have some form of pain. Hip arthroscopy is a safe and effective method for diagnosis and treatment of intra-articular disorders in elite athletes

The purpose of this study is to audit the early clinical outcomes of a consecutive series of hip arthroscopies performed by one surgeon. Pre-operative WOMAC and Non Arthritic Hip scores were performed on the patients. All patients had MRI arthrograms. These were correlated with the clinical findings at the time of surgery. Postoperatively all complications were recorded and at one year post surgery the pre-operative scores were repeated. There are 37 consecutive cases. 15 males and 22 females. Average age 39 years. 76% of cases were accident related. The average length of symptoms pre-operatively was 21 months. There were 2 false negative MRI arthrograms and one false positive. The surgical treatment included debridement of 18 labral tears and 10 labral tears associated with an articular cartilage defect. The average traction time was 39 minutes. The complications were minor and all have resolved. There are many indications for hip arthroscopy however the outcomes of labral debridement are not clearly defined. This paper attempts to measure the success of arthroscopic labral debridement in a consecutive series of patients. The clinical symptoms and MRI arthrograms seem to have a good correlation with the arthroscopic findings. The short term results of this treatment are encouraging as is the low morbidity associated with the surgery itself

The October 2012 Shoulder & Elbow Roundup. 360. looks at: fast-absorbing suture anchors for use in shoulder labral tears; double-row rotator cuff repair; degenerate massive rotator cuff tears addressed with partial repair; open and arthroscopic stabilisation of Bankart lesions; predicting the risk of revision humeral head replacement; arthroscopic treatment for frozen shoulder; and long-term follow-up of the Bristow-Latarjet procedure

Labral tears can lead to disabling hip pain however underlying structural (femoroacetabular impingement) and developmental abnormalities predisposing to labral pathology may be left untreated if the peripheral compartment is ignored during hip arthroscopy. Femoroace-tabular impingement (FAI) can be secondary to abnormal morphologic features involving either the proximal femur and/or the acetabulum. Both acetabular labral tears and FAI lead to premature osteoarthritis of the hip. Early diagnosis and treatment of these hip pathologic abnormalities is important, not only to provide pain relief but also to prevent the development of osteoarthritis. Purpose: To describe the technique for arthroscopy of the peripheral compartment of the hip joint without traction. Methods: We performed 9 hip arthroscopies without traction from a lateral and and anterolateral portals in the supine position. After a traditional central arthroscopy with traction, 60 degrees of flexion at the hip joint without traction allowed relaxation of the anterior capsule and increased the intra-articular volume of the peripheral compartment. Results: Inspection of the peripheral compartment was obtained from the anterolateral portal. The anterior neck area, medial neck area, medial head area, anterior head area, lateral head area and lateral neck area were viewed. In 3 patients, loose bodies were removed. In 1 patient with PVNS synovial biopsy was taken and synovectomy was performed. Osteochondroplasty was performed in 5 patients for femoroacetabular impingement. No complications were observed. Conclusions: Hip arthroscopy without traction is mandatory to complete assessment and adequate treatment of the painful hip

The spectrum of pathoanatomy in collision athletes with shoulder instability is wide, with a high incidence of extended labral lesions and associated intra-articular injuries. The ‘collision shoulder’ describes an injury sustained by direct impact to the shoulder without dislocation, but with extensive labral damage and a high incidence of other intra-articular pathology and neurological symptoms. One hundred and eighty-three collision athletes (rugby and rugby league) were treated for labral injuries related to their sport in three different centres. Details of the mechanism of injury and findings at surgery were recorded. Only 60% of athletes in the series presented following a documented dislocation or subluxation episode of the shoulder. An additional pattern of injury was recognised in the remaining athletes involving a direct impact injury to the shoulder. In these athletes the clinical symptoms and signs were less specific but there was a high incidence of ‘dead arm’ at the time of injury (72%). The spectrum of pathology in this series was wide with a high incidence of associated intra-articular lesions. In those athletes with an impact type of injury without dislocation there was more extensive labral pathology with a high incidence of posterior labral tears (50%). The incidence of associated chondral lesions was similarly very high but significant bony pathology was less common than in the dislocation group (11 % versus 26%). Elite athletes had less frank dislocations but were more likely to sustain neurological injury, posterior labral tears, SLAP lesions and cartilaginous and capsular injuries. The incidence of all lesions in this series of collision athletes is higher than those previously published. These lesions often occurred in the absence of a frank dislocation (the ‘collision shoulder). It is important to anticipate additional pathology when planning definitive management in these patients, with surgery tailored to the specific lesions found. The athlete with an impact type of injury without dislocation can do well following surgery, with a high rate of return to contact sport, either at the same or a higher level

Femoroacetabular impingement is defined as abnormal abutment between the femoral head, or the femoral head-neck junction, and the acetabulum. It is now established that FAI is a major etiological factor in the development of osteoarthritis (OA) of the hip. FAI is increasingly recognized as a cause of hip pain in young active individuals. Clinical features of FAI include pain in the groin but this may also be felt in the gluteal region, trochanteric region, or in the thigh. Symptoms most commonly begin as an intermittent discomfort, often during or following periods of repetitive hip motion e.g. running, walking, progressing to more constant and intense pain. Stiffness is common, with reductions in the range of hip flexion, and internal rotation in particular. Patients may also complain of clicking, popping, or snapping sensations in the affected hip. Operative treatment of FAI is principally aimed at removing cam lesions and increasing femoral head-neck offset (osteochondroplasty), and treating associated soft tissue lesions such as labral tears. Acetabular recession with labral reattachment is increasingly used for pincers lesions but great care is needed to ensure that the overall coverage of the hip is not reduced. As proficiency with arthroscopic techniques has improved, arthroscopic osteochondroplasty and labral debridement/repair has become increasingly popular for the treatment for FAI, with promising functional results in a range of studies. 150 consecutive patients who underwent hip arthroscopy for CAM type FAI with minimum 1 year follow up were prospectively studied. Patient satisfaction, non-arthritic hip score, re-operations and conversion to arthroplasty were analysed. There were a total of 90 males and 60 females. The average age group was 32 years (27 to 46 years). All patients underwent osteoplasty of the CAM lesion and stabilisation/ repair of the labral tears. A comparison of pre procedure non arthritic hip scores with the scores at latest follow up (minimum 1 year, maximum 3 years) showed a significant improvement (56 vs 86; p <0.01). There were 2 re operations for unresolved symptoms and 1 conversion to arthroplasty for continued pain associated with significant loss of articular cartilage. Perineal numbness was noted in 9 patients all of which resolved. No other major complications were noted in this series. Hip impingement symptoms resolved in all cases and a good (20 %) to excellent (75%) outcome was reported. Arthroscopic management of CAM type FAI is associated with subjective and objective improvement in hip function at early follow up. Longer follow-up is necessary to analyse the ability of this procedure to arrest progression of degenerative hip disease

Introduction. Posterior superior glenoid impingement as a cause of partial rotator cuff lesions and posterior superior labral tears in overhead athletes was first described in the early 90’s by Walch and Jobe. Material and methods. From January 1994 to January 2002, 71 patients were treated (48 men and 23 women). The majority were overhead athletes: handball (39), ketcher sports (12), volleyball (8), others (12). Indications for surgery were shoulder pain with athletic activity and a failed trial of conservative treatment. Mean age was 26 (range, 17–41) years. Mean duration of symptoms was 31 (range, 7–120) months. Following diagnostic arthroscopy–excluding anterior inferior ligament lesions and other significant intaarticular pathology–the partial rotator cuff lesions and posterior superior labral tears were debrided arthroscopically. During postoperative rehabilitation emphasis was placed on strengthening rotator cuff muscles, restoring normal scapulohumeral rhythm and avoiding stretching of the anterior static glenohumeral stabilizers. Results. In 97% of cases a partial rotator cuff were found, and 90% had significant posterior–superior labral lesions. There were also 6 SLAP type II lesions that were repaired. Sixty four out of 71 patients were available for a follow up of minimum 2 years: 61% were able to return to preinjury activity level without any shoulder symptoms and 22% were not able to return to their desired sport. Overall satisfaction rate was 84%. The average time for return to sports participation was 9 (range, 4–12) months. Thirty six out of 46 patients had a telephone interview in a second minimum 5 years follow up. Fifty two percent (52%) were still active overhead athletes and 48% had stopped athletic activity (half of them because of shoulder problems). Six patients had secondary operations: 4 a capsular shift procedure and 2 a subacromial decompression. Conclusion. In patients with symptomatic posterior superior impingement arthroscopic debridement followed by careful rehabilitation is an acceptable treatment. There is some tendency for the symptoms to recur over time

Introduction: Hip arthroplasty is growing in importance and relevance in the detection and treatment of various pathologies affecting the hip joint. A growing number of indications exist including the diagnosis and treatment of synovial-based disease, extraction of loose bodies within the joint, and treating chondral flaps and labral tears. Hip arthroplasty represents a minimally invasive, joint preserving, effective and reproducible tool to achieve these. The literature cites few complications arising from the procedure. Study: Retrospective study of the outcomes of 20 patients who underwent hip arthroplasty between March 1999 and October 2002. Methods: All the patients were first clinically assessed and then underwent Magnetic Resonance Imaging of their hips prior to undergoing arthroplasty. The indications for the MR arthrography included hip or groin pain, joint stiffness with associated impaired exercise tolerance. Arthroscopy was performed as a day case under general anaesthetic. The patients were placed supine on a fracture table and traction applied, under image control 30 and 70 degree arthoscopes were placed through an anterior and peritrochanteric portals. The patients followed up for an average of 20 months (6–44 months) and assessed for pain, mechanical symptoms, activity level, work status, sports ability and performance of activities of daily living. Data collected was retrospectively reviewed. Results: The correlation between MR imaging and arthroscopy was approximately 80%. MR imaging detected all the labral tears present in 10 patients. This sensitivity was however reduced for the detection of small osteophytes (105), synovitis (5%), and minor labral radial fibrillation (5%). Four patients had loose bodies, which were successfully extracted. The patients whose symptoms were the result of mechanical pathology achieved complete resolution of their symptoms post operatively. No complications were seen. Conclusion: Hip arthroplasty can be performed for a variety of conditions with reasonable expectations of success and minimal complication rate

Introduction and Aims: There is a relationship between the anatomy of the hip joint and the development of arthritis. A common cause of hip pain in the young adult that can lead to arthritis is acetabular dysplasia. More recently, femoroacetabular impingement has been described as another cause of hip pain. The purpose of our study was to evaluate the applicability of pelvic computed tomography (CT) with three-dimensional surface rendering to evaluate femoro-acetabular impingement. Method Thirty-six hips (30 patients; 17 males; 13 females) with persistent hip pain, mean age 41 (37–52), underwent three-dimensional CT of the pelvis, as well as MRI arthrography with gadolinium enhancement. On 3D CT, the concavity of the femoral head-neck junction (offset), alpha angle as described by Notzli was calculated to depict the anterior femoral neck contour. The concavity of the posterior aspect of the head neck junction was measured as the beta angle. The same measurements were made in 20 hips, consisting of randomly selected patients with no prior history of hip pathology or pain (mean age 37; 13 males; eight females). Results The mean alpha angle for the symptomatic group was 66.4 (39–94) and 43.8 (39.3–48.3) for the control group (p=0.001). All symptomatic hips had abnormal findings on MRA: labral tears in all; cartilage delamination/ulceration in 14 hips; herniation pits in six hips. The majority of labral tears and delamination were located in the antero-superior quadrant. In the surgical treated group, all MRA findings were confirmed. The mean beta angle was significantly smaller (increase concavity) in the symptomatic versus the controls: 40.2 versus 43.8 (p=0.011). Interestingly in the symptomatic group the beta angle was significantly lower than the alpha angle (p< 0.02), but not in the controls. Conclusion: 3D CT with surface rendering and multiplanar reformation is useful to determine degree of bone buttressing of the anterior femoral head-neck junction quantitatively assessed by alpha angle measurement, which is elevated in patients with femoro-acetabular impingement. With a greater posterior concavity i.e. small beta angle in the symptomatic group versus the control, subclinical slipped femoral epiphysis remains a plausible cause of this deformity

Background. The acetabular labrum provides sealing function and a degree of hip joint stability. Previous early(16 month) and mid-term(mean 3.5 years) follow-up of this cohort reported better patient related outcome measures in the refixation group. Methods. We reported patients who underwent labral debridement/focal labral excision during a period before the development of labral repair techniques. Patients with labral tears thought to be repairable with our current arthroscopic technique were compared with patients who underwent labral refixation. In 46 hips, the labrum was focally excised/debrided (group 1); in 54 hips, the labrum was refixed (group 2). Outcomes were measured with modified-Harris-Hip-Score (mHHS), Short Form-12 (SF-12), and a visual-analog-scale(VAS) for pain preoperatively and postoperatively. Results. Mean age was 33 years in group 1 and 28 years in group 2 with mean follow-up of 7 years (range, 2–13.6 years). At mean follow-up, subjective outcomes were significantly improved (P<.01) for both groups compared with preoperative scores. The mHHS (P=.005), SF-12 (P=.025), and VAS pain scores (P<.001) were all significantly better for refixation group compared with debridement group. Although most recent outcomes for both groups fell at mean 7 years' follow-up in comparison to 16 month and 3.5 year follow-up, the disparity between groups was greater in favor of labral refixation. Good-to-excellent results were 47.7% in debridement and 86.3% in refixation (p<.001), and failure rates were 29.6% (debridement) and 13.7% (refixation group) (p =.059). There were 4 revisions in the debridement group and 2 revisions in the refixation group. Conclusion. Longer term follow-up comparing focal labral debridement/excision to refixation revealed a decrease in patient related outcome scoring and good/excellent results in both groups. Ultimately, there was a greater drop in outcome measures and good/excellent results in the debridement group and better maintenance of results in the refixation group at mean 7 years follow-up. For any tables or figures, please contact the authors directly

In the young and highly active population of military patients, femoroacetabular impingement can be a source of serious disability as well as a threat to their career. This morbidity can be treated with hip arthroscopy with debridement of cam lesion, and excision or repair of a corresponding labral tear. We report on the long term outcomes (>1 year) of 26 military cases who underwent hip arthroscopy for femoroacetabular impingement, in a single surgeon's series. Twenty two patients (four bilateral cases) underwent hip arthroscopy as a day case procedure during the period February 2013 to October 2014. Non-Arthritic Hip Scores (NAHS) were obtained from patients pre-operatively, at two months, four months and at least one year post-operatively. There was a significant improvement in NAHS at two months (75.6)(p<0.05), four months (85.1)(p<0.001) and one year (84.8)(p<0.001), compared to pre-operative NAHS (65.8). There was no significant change in NAHS beyond four months. Only three out of the 22 patients were medically discharged secondary to persistent hip symptoms. Hip arthroscopy for femoroacetabular impingement is an effective, viable procedure for military patients. Mobility, pain and function is significantly improved after surgery. This improvement is sustained in the long term up to and beyond one year

Objective. To define the common pathology of the hips with irreducible posterior dislocation combined with femoral head fracture and the outcome of surgical treatment using surgical hip dislocation technique. Design: retrospective observational clinical study. Setting: Level III referral trauma center. Patients/Participants: from January 2011till February 2014 five patients with irreducible posterior hip dislocation and femoral head fracture who underwent operation were included and they followed for at least 18 months. Intervention. Open reduction and internal fixation of fractured femoral head and labral repair by suture anchors using surgical hip dislocation through trochanteric flip osteotomy approach. Main Outcome Measures: Clinical and radiographical findings of the irreducible posterior hip dislocation, intraoperative findings, clinical outcomes using Merle d'Aubigné & Postel and Thompson & Epstein scores, and radiological outcome. Results. All patients presented clinically with a shortened lower limb in neutral or external rotation of the hip (not in Internal rotation). All were Pipkin type II fracture of femoral head with the intact part of the head buttonholed on the posterior wall of the acetabulum through a capsule-labral flap. Postoperative computed tomography revealed perfect reduction except one case with severe comminution with good reduction. Only one patient with delayed operative management developed avascular necrosis and underwent total hip arthroplasty. Conclusion. Irreducible femoral head fracture-dislocation is rare injury with different clinical presentation that shows neutral or externally rotated limb and optimal surgical management is not clear. Surgical hip dislocation gives full access to the femoral head for reconstruction and opportunity to direct repair of the labral tears

There are a number of progressive conditions that afflict the hip and result in degenerative arthritis. Along the path of progression of the disease and prior to the development of arthritis, some of these conditions may be treatable by joint preservation procedures. Periacetabular osteotomy for developmental dysplasia of the hip (DDH), femoroacetabular osteoplasty for femoroacetabular impingement (FAI), and a variety of surgical procedures for management of early osteonecrosis of the femoral head are some examples of joint preservation of the hip. DDH is characterised by abnormal development of the acetabulum and the proximal femur that leads to suboptimal contact of the articular surfaces and the resultant increase in joint reaction forces. FAI is a condition characterised by an abnormal contact between the femoral neck and the acetabular rim. FAI is believed to exist when a triad of signs (abnormal alpha angle, labral tear, and chondral lesion) can be identified. The question that remains is whether joint preservation procedures are able to avert the need for arthroplasty or just an intervention along the natural path of progression of the hip disease. There is an interesting study that followed 628 infants born in a Navajo reservation, including 8 infants with severe dysplasia, for 35 years. None of the children with DDH had surgical treatment and all had developed severe arthritis in the interim. The latter study and a few other natural history studies have shown that the lack of administration of surgical treatment to patients with symptomatic DDH results in accelerated arthritis. The situation is not so clear with FAI. Some believe that FAI is a pre-arthritic condition and surgical treatment is only effective in addressing the symptoms and does not delay or defer an arthroplasty. While others believe that restoration of the normal mechanical environment to the hip of FAI patients, by removing the abnormal contact and repair of the labrum, is likely to change the natural history of the disease and at minimum delay the need for an arthroplasty. There is a need for natural history studies or case series to settle the latter controversy

Background. Acetabular labral tears can cause pain and microinstability and are the most common indication for hip arthroscopy. Hip labral repair demonstrates better clinical outcome scores at a mean of 3.5 years post surgery than labral excision and tends to be performed in a younger age group. While different labral stitch configurations are possible, the most frequently used are a mattress stitch passed though the hip labrum at its widest part, or a simple loop surrounding the labrum. To determine the strength of variousrepair techniques and the impact suture passer sizesonhip labrum failure after cyclic loading. Methods. 35 unattached fresh-frozen bovine hip labrums were assigned to 5 repair techniques (7 specimens each): Group 1: horizontal mattress using a penetrating grasper; Group 2: vertical mattress using a penetrating grasper; Group 3: vertical mattress using asuture lasso; Group 4: Oblique repair using a penetrating grasper; Group 5: vertical mattress using a penetrating grasper and monopolar radio frequency device. Using a materials testing machine and after a 10N preload, each contruct was subjected to 20 cycles at 5N–80N. Cyclic elongation, peak-to-peak displacement, ultimate failure load, stiffness, and failure mode were recorded. Results. Group 1 (249N) had lower ultimate load than groups 2 (277N), 3 (289N), 4 (281N), and 5 (278N) (p<0.05) and higher peak to peak displacement, cyclic elongation (14mm) than group 3 (12mm) (p<0.05). Group 2 (15mm) had higher peak to peak displacement than group 3 (p<0.05). Group 3 had lower cyclic elongation and peak to peak displacements than group 4 (p<0.05). Conclusion. A horizontal mattress hip labrum repair demonstrates lower ultimate failure load than a vertical mattress or an oblique suture repair. A smaller diameter suture passing device demonstrated less cyclic displacement but no difference in ultimate failure load than a large diameter device. Radiofrequency treatment did not have any effect on the strength of the suture repair configuration. Level of evidence. Level 5

Introduction. Hypoplasia of the glenoid is a rare condition caused by incomplete ossification of the postero-inferior aspect of the developing glenoid. It may be isolated or associated with a more generalised condition. The clinical symptomatology is variable depending on the age at time of presentation. Materials and Methods. We performed a retrospective chart review of patients who presented with shoulder complaints, and in whom a radiographic diagnosis of glenoid hypoplasia had been made. From January 2002 to December 2012, 8 patients (9 shoulders) with radiological signs of glenoid hypoplasia were identified. The mean age at presentation was 39 years (range 23 to 77) and the mean symptom duration was 12.5 months (range 1 to 48). Results. The diagnoses encountered included: impingement with rotator cuff tendonitis (2 shoulders), rotator cuff dysfunction with biceps tendonitis (1 shoulder), a SLAP lesion (2 shoulders), calcific tendonitis (1 shoulder), a posterior labral tear (1shoulder), multidirectional instability (1 shoulder), and adhesive capsulitis (1 shoulder). Of these nine, six shoulders were managed non-operatively and three were managed surgically, all with satisfactory results. The mean follow-up period was 30 months (range 5 to 60) and the mean Oxford shoulder score was 46.7 (range 42 to 48). Conclusion. We present a series of patients, who have been managed for a variety of shoulder pathologies, and in whom underlying glenoid hypoplasia has been diagnosed. NO DISCLOSURES

Femoroacetabular impingement (FAI) is commonly associated with early hip arthritis. We reviewed our series of 1300 hip resurfacing procedures. More than 90% of our male patients, with an average age of 53 years, had cam impingement lesions. In this condition, there are anterior femoral neck osteophytes, and a retroverted femoral head on a normally anteverted neck. It is postulated that FAI results in collision of the anterior neck of the femur against the rim of the acetabulum, causing damage to the acetabular labrum and articular cartilage, resulting in osteoarthritis. Early treatment of FAI involves arthroscopic or open removal of bone from the anterior femoral neck, as well as repair or removal of labral tears. However, once osteoarthritis has developed, hip replacement or hip resurfacing is indicated. Hip resurfacing can re-orient the head and re-shape the neck. This helps to restore normal biomechanics to the hip, eliminate FAI, and improve range of motion. Since many younger men with hip arthritis have FAI, and are also considered the best candidates for hip resurfacing, it is evident that resurfacing has a role in these patients

Aims

Periacetabular osteotomy (PAO) is the preferred treatment for symptomatic acetabular dysplasia in adolescents and young adults. There remains a lack of consensus regarding whether intra-articular procedures such as labral repair or improvement of femoral offset should be performed at the time of PAO or addressed subsequent to PAO if symptoms warrant. The purpose was to determine the rate of subsequent hip arthroscopy (HA) in a contemporary cohort of patients, who underwent PAO in isolation without any intra-articular procedures.

Femero acetabular impingement is a common casue of hip and groin pain. Its presence can be expected from clinical examination and confirmed with appropriate imaging. Treatment of the CAM lesion has been well described by Ganz et al and the open treatment of this condition has been shown to be effective. However, there is significant morbidity associoated with this surgery. Arthroscopic treatment of the CAM lesion and also pincer impingement can be safely performed and the techniques will be shown. We will detail our experience in performing over 500 arthroscopies for femero acetabular impingement. This will be a visual demonstration of the techniques we use on a day to day basis. We will demonstrate different degrees of rim lesions, labral tears, labral repairs, acetabular rim excision, femero osteochondroplasty, checking impingement and intra-operative techniques for confirming position of resection. In the future this technique will be widley used to treat FAI by a greater number of surgeons

We have compared the findings of MRI with those of hip arthroscopy in 23 hips in young adults with hip pain. Large deep cartilage deficiencies on the acetabulum or femoral head, the percentage of femoral head cover, and the presence of marginal osteophytes seen on MRI correlated well with those seen at arthroscopy, but chondral softening, fibrillation, or partial-thickness defects less than 1 cm in diameter were less consistently detected by MRI. Osteochondral loose bodies and labral tears were not well demonstrated by MRI, but were readily identified and treated at arthroscopy. Arthroscopy of the hip is a useful investigation for hip pain in young adults especially when standard non-invasive MRI fails to provide a clear diagnosis

Superior labral tears of the shoulder involve the biceps tendon and labrum complex which may be detached, displaced inferiorly, and interposed between the glenoid and the humeral head. We have treated ten young athletes with painful shoulders due to this lesion by arthroscopic stapling. Arthroscopy at the time of staple removal, after three to six months, showed that all the lesions had been stabilised. Clinical review at over 24 months showed an excellent or good result in 80%. The two relative failures were due in one to residual subacromial bursitis, and the other to multidirectional shoulder instability. Arthroscopic stapling can restore the shoulder anatomy, and it is recommended for active adolescent athletes with this lesion

Aim. This pilot study aimed to identify the important symptomatic, functional and psychosocial aspects of hip disorders from the perspective of adolescent patients and their families in order to begin developing a patient-focused instrument (Bridging Adolescent Self-Reported Hip – BASH - score). Methods. This was a qualitative patient-centred study at a tertiary paediatric orthopaedic centre involving 50 adolescents aged 13–17 years, composed of five groups of 10 adolescents with slipped capital femoral epiphysis (SCFE), hip dysplasia (DDH), labral tears undergoing arthroscopic treatment, lower limb trauma and a miscellaneous group with conditions including Perthes' disease. A control group of 100 adolescents were also interviewed from a local school. Adolescent and separate concurrent parent groups underwent an ‘open’ phase face-to-face or telephone interview (theme development). This involved agreeing or disagreeing with statements, and open exploration of ideas related to the ‘day in the life’ of an adolescent with hip problems in order to generate and specify themes. This was followed by ranking and finally, scoring and testing. Results. All focus groups consistently and successfully generated themes related to hip problems and the majority of adolescents and parents were able to easily localise their issues to the hip. The ranking activity enabled the final definition of three key themes: a) physical symptoms, b) limitations and restrictions on life activities and situations and c) emotional experiences and self-consciousness which formed the basis of scoring and testing and the test version of the BASH score for adolescents. Scaling was developed with a total of 20 items rated on a five-point scale based on the frequency of effect from 0 (always) to 5 (never) providing a maximum score of 100. Conclusion. The BASH score is the first patient-reported outcome score for adolescent hip disorders developed with adolescents for adolescents

Introduction. Femoroacetabular impingement (FAI) is a relatively recent recognised condition and a potential cause of anterior hip pain in the young military adult population. Both Cam and Pincer type FAI may lead to inflammation, labral tears, and or damage to the smooth articular cartilage of the acetabulum leading potentially to early osteoarthritis of the hip. Open Surgical hip dislocation using the Ganz Trochanteric Flip approach is an accepted technique allowing osteoplasty of the femoral neck and acetabular rim combined with labral repair if required. We present our results of this technique used in military personnel. Methods. All Military personnel who underwent FAI surgery in our unit since August 2006 were included in the study. Functional outcome was measured using the Oxford hip and McCarthy non-arthritic hip scores pre and post-operatively. Results: 13 hips in 11 patients with an average age of 36 years (21–45) underwent surgical hip dislocation for treatment of FAI. Average time of downgrading prior to surgery was 9.3(3-18) months. 6 out of the 11 patients have been upgraded to P2. Average time to upgrading was 6.8(3-17) months. There were no infections, dislocations, or neurovascular complications. Mean Oxford Hip Score improved from 22.8(range 8–38) to 39.5(11–48) and mean McCarthy hip score from 49.6(33.75–80) to 79.2(36.25–100) with an average follow up of 19.4 months (range 4– 42 months). Discussion. The early results of surgical hip dislocation in military personnel are encouraging. Long-term follow-up is required to see if this technique prevents the natural progression to osteoarthritis

The purpose of this study was to investigate whether patients who had had excision of the Ligamentum Teres as part of a surgical hip dislocation for femoro-acetabular impingement exhibited symptoms of acute Ligamentum Teres rupture post-operatively. Recent reports in the literature suggest that injury to the Ligamentum Teres can cause instability, severe pain and inability to walk. We present the results of a postal questionnaire to 217 patients who had undergone open surgical hip dislocation for femoro-acetabular impingement where the LT was excised. This included seven patients who had undergone bilateral surgery. The questionnaire was designed to enquire about specific symptoms attributed to LT injuries in the literature; gross instability, incomplete reduction, inability to bear weight and mechanical symptoms. 161 patients responded (75%), with a total of 168 (75%) questionnaires regarding 224 hips completed. There were 104 females and 64 males. Median age was 34 and median follow-up was 52 months. All patients were found to have cam deformities, 72% (n=121) had associated labral tears. All patients were able to fully weight bear after surgery. 77% experienced no groin pain and 61% experienced no pain on exercise. 35% of patients experienced popping and locking in their operated hip and 24% had subjective feeling of their hip giving way. Oxford Hip scores and Nonarthritic Hip scores improved by 12 and 28 points respectively (n=47). Our results show that the symptoms of pain and instability described with LT pathology can be present but are by no means universal. This leads us to conclude that their symptoms may be attributed to labral pathology which is frequently noted to coexist

Purpose: Femoroacetabular impingement (FAI) is recognized as an etiological risk factor for hip arthritis. The potential for joint preserving surgical techniques that may delay the progression to early arthritis and retard the possibility of arthroplasty at a young age is promising. This study presents the outcome of surgical treatment of FAI through a less invasive technique performed through a modified Smith-Peterson approach without hip dislocation, or arthroscopy. Method: Using an institutional database, a total of 72 patients (80 hips) with radiographic and clinical diagnosis of FAI who underwent direct anterior femoroacetabular osteoplasty (FAO) were identified. Preoperative and postoperative functional evaluation was performed on these patients. The operative findings were recorded in detail and evaluated with regard to outcome. Results: Intraoperative diagnosis of labral tear and osteochondral lesions in the anterosuperior acetabulum was confirmed in all cases. The surgical approach provided adequate access to allow labral repair and osteoplasty of the femoral neck and the acetabulum, whenever needed. There were no intraoperative complications. All patients experienced a significant improvement in function as measured by modified Harris hip and SUSHI scores. Majority (85%) of the patients were satisfied with the outcome of the surgery. In addition, Health Survey SF-36 showed most patients felt their health had improved significantly. The predictors of poor outcome were previous hip scope, lack of labrum for repair, large chondral lesions, and workman’s compensation status. Conclusion: This study presents the early results of a less invasive surgical treatment for femoroacetabular impingement. This ongoing study shows that the described technique seems to be a viable approach for treatment of this painful condition in the young

Aims

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.

Since 2003 we have adopted an aggressive approach to the management of slipped upper femoral epiphysis (SUFE) deformity, an important cause of femoro-acetabular impingement and associated with the development of early adult hip arthritis. Sixteen patients aged 16.7 years (range 11–20), 13 male, have undergone surgery to manage their SUFE deformity. Nine underwent primary surgery using a Ganz approach (7) or in-situ pinning with femoral neck resection via a Smith-Peterson approach (2). Seven had previously undergone in-situ pinning 26 months earlier (range 4–44 months) of whom two had acetabular chondral flap tears with eburnated bone and six had significant labral degenerative changes associated with calcification or tears. Only one of the nine patients who underwent primary aggressive management of their SUFE, had a labral tear. Four patients underwent mobilisation of the femoral head on its vascular pedicle, followed by anatomical realignment. At an average follow-up of 22.3 months (range 1–41 months) 15 remained well with excellent function. Leg lengths remained equal in 12, with average shortening of 2 cm in the remaining four. Segmental AVN occurred in the first patient after damage to the vascular pedicle during drilling of the neck; the technique has been modified to prevent this. Despite having performed over 400 surgical hip dislocations, the authors continue to find the management of this condition challenging; nevertheless, having seen the consequences of femoro-acetabular impingement in these young patients, we believe that aggressive management to correct anatomical alignment is essential for the future well being of the hip

We present our data on a cohort of 25 patients who had an arthroscopy of their hip between the ages of 12 and 17 out of over 1100 hip arthroscopies performed. All patients presented with pain and marked restriction of activities. Either a CT (before MRI was available) or MRI scan was done pre-operatively. 10 patients presented with a history of either Perthes disease, DDH or a defined injury causing their symptoms. In the remaining the onset of symptoms was spontaneous. The intra-operative diagnosis varied: normal (6), labral tear (6), loose bodies (2), debris and/or chondromalacia (8), synovitis (2) and damaged ligamentum teres (1). None of the patients developed a complication. The pre-operative Harris Hip Score ranged from 0 to 40 (mean 21) for pain and 0 to 47 (mean 35) for function. The follow-up ranged from 6 weeks to 9years (mean 3 years). Harris Hip Score at latest follow-up ranged from 10 to 44 (mean 33) for pain and from 31 to 47 (mean 43) for function. Conclusion: Hip arthroscopy is a very useful tool as part of the investigation and treatment of hip problems in carefully selected children and adolescents

Introduction. Symptomatic neglected and displaced three- and four-part proximal humeral fractures are often difficult to reconstruct. Replacement has been reported to give poor functional outcome and hence is not the ideal treatment option. We report our results of secondary reconstruction of these difficult fractures with a locking plate system. Material and methods. Between 2003 and 2005, 15 healthy active patients with displaced three- to four-part fractures underwent revision/secondary open reduction and internal fixation with a locking plate system (Philos, Stratec UK Ltd). Ten patients had delayed presentation. Three patients had failed previous internal fixation. One patient had non-union and one had malunited fracture. Their average age was 63 years. Objective assessment was measured by the Constant score, subjective assessment by the Oxford questionnaire. The mean follow-up was 14 months. Surgical technique. In revision cases, the fracture was approached through the same incision. All metal work was removed. Careful attention was given to restore the normal anatomy of the humeral head with correct placement of the tuberosities. Reduction was held with Ticron sutures through the rotator cuff followed by fixation with the locking plate. Two patients required arthroscopic repair of their labral tears. The shoulder was immobilised in a sling for four weeks followed by a gradual mobilisation programme. Results. All fractures united. No failure of fixation was observed. The mean Constant score was 73. The pain component improved from 3 pre-operatively to 14 at follow-up. The average range of flexion was 1100, abduction of 950 and external rotation of 350. All patients had good to excellent subjective outcome. We encountered poor rotator cuff function in one patient. Conclusion. Successful reconstruction of three- and four-part proximal humeral fractrures is possible. Anatomical restoration of humeral head and tuberosities prior to plate fixation is essential for good outcome

Introduction. Femoroacetabular impingement (FAI) causes anterior hip pain, labral tears and damage to the articular cartilage leading to early osteoarthritis of the hip. Surgical hip dislocation and osteoplasty of the femoral neck and acetabular rim is a technique pioneered by the Bernese group for the treatment of FAI. We present and discuss our results of this technique. Methods. Functional outcome was measured in hips with over 12 month follow-up using the Oxford hip and McCarthy non-arthritic hip scores pre- and post-operatively. Results. From March 2003 to December 2005, 79 hips underwent surgical hip dislocation for treatment of FAI. Ten were skeletally immature and excluded. In 16 hips, grade 4 osteoarthritis was present in greater than 10 × 10mm regions after reshaping of the abnormal anatomy. In these cases, hip resurfacing was performed. Of the 53 hips preserved (average age 37(17-65)), 35 had the labrum detached, debrided and reattached using bone anchors, 32 underwent recession of the acetabular rim at the site of impingement, 21 had chondral ‘carpet’ flaps debrided, 5 had removal of medial osteophytes, 7 had labral and/or bony cysts excised and grafted and 1 underwent an osteochondral graft. In 5 hips osteoarthritis progressed requiring hip resurfacing at an average of 8 months. Oxford Hip Score improved from an average 32 (range 13-59) to 23 (12-45) and McCarthy hip score from 50 (19-76) to 63 (28-79) in the preserved hips at an average 20 months following surgery (range 12-38 months). Conclusion. The early results of surgical hip dislocation are encouraging. The open procedure has distinct advantages compared to arthroscopy enabling a wider range of lesions to be treated. Careful patient selection is important in order to exclude patients with hip osteoarthritis. Long-term follow-up is required to see if this technique prevents the natural progression to osteoarthritis

Introduction: Femoroacetabular impingement (FAI) causes anterior hip pain, labral tears and damage to the articular cartilage leading to early osteoarthritis of the hip. Surgical hip dislocation and osteoplasty of the femoral neck and acetabular rim is a technique pioneered by the Bernese group for the treatment of FAI. We present and discuss our results of this technique. Methods: Functional outcome was measured using the Oxford hip and McCarthy non-arthritic hip scores pre and post-operatively. Results: Since January 2003, 36 hips in 34 patients (average age of 43 years (14–65)) underwent surgical hip dislocation for treatment of FAI. In 9 hips, grade 4 osteoarthritis was present in greater than 10 x 10mm regions after reshaping of the abnormal anatomy. In these cases, hip resurfacing was performed. Of the 27 hips preserved, 14 had chondral ‘carpet’ flaps debrided, 17 underwent recession of the acetabular rim at the site of impingement, 6 had removal of medial osteophytes, 6 had labral and/or bony cysts excised and grafted and 1 underwent an osteochondral graft. Oxford Hip Score improved from an average 36 (range 17–59) to 23 (12–45) and McCarthy hip score from 43 (9–74) to 62 (36–72) in the preserved hips at an average 15 months following surgery (range 6–33 months). Discussion: The early results of surgical hip dislocation are encouraging. Careful patient selection is important in order to exclude patients with hip osteoarthritis. Long-term follow-up is required to see if this technique prevents the natural progression to osteoarthritis

Introduction: Chondral lesions are the second most common pathology encountered during hip arthroscopy. Microfracture is a simple and effective technique to treat chondral lesions with proven long term results in the knee. However, there is little evidence to confirm the ability of microfracture to produce repair tissue in hip joint. Methods: Patients with acetabular chondral defect treated with microfracture during primary arthroscopy and who had a subsequent hip arthroscopy enabling visualisation of the treated chondral defect were included in the study. Over a three year period 185 patients had microfracture for treatment of full thickness chondral defect. 11 patients (8 males and 3 females) with a mean age of 35 years (range 17–54 years) who had revision hip arthroscopy form the study population. The size of chondral defect was measured at the time of primary arthroscopy. Microfracture was performed using arthroscopic awls with a standard technique. Postoperatively a strict rehabilitation protocol was followed. The extent and quality of repair tissue was assessed by visual inspection at second look arthroscopy. Results: All patients had chondral lesions confined to the antero-superior aspect of the acetabulum with an associated labral tear. None had diffuse osteoarthritis. The average defect measured 180 mm2 (range 50–300). The mean time interval between primary and revision arthroscopy was 12 months. Excluding one failure the overall percent fill of the defects was 95% (range 75 – 100) with good quality cartilage. Discussion: Only one other series has reported on the macroscopic results of microfracture in the hip. Our series agrees with the results of those authors. These similar results from 2 centres confirm that arthroscopic microfracture is an effective treatment for acetabular chondral lesions in carefully selected patients

Aims

This study uses prospective registry data to compare early patient outcomes following arthroscopic repair or debridement of the acetabular labrum.

Background. Labral tears are now recognised as a common pathology especially in young adults. With advancement of arthroscopic techniques, most recent published literature is focused on short- or mid-term results of labral repair or re-fixation. There is limited data regarding long-term results of labral debridement and effect of co-existing pathology on outcomes. We investigated long-term results after arthroscopic labral debridement, the predictors of outcomes and correlation with any co-existing hip pathology. Materials and Methods. Between 1996 and 2003, 50 patients who underwent hip arthroscopy and labral debridement with mean follow-up of 8.4±1.7 years (range 7-13.6 years) were included in our study. Patients' pre-operative Harris Hip Score and co-existing pathologies such as FAI, dysplasia or arthritis were recorded as variables. Further, patients' post-operative HHS and satisfaction at the time of follow-up were recorded as outcomes. Spearman's rho correlation coefficient and regression analysis were calculated between these variables and outcomes. Results. Good or excellent results were noted in 80% of patients. The mean pre-operative HHS was 79.3±8.2 (range 58-86) which was improved to 92.2±12.1 (range 46-100) post-operatively. Patients without co-existing pathology had significantly higher satisfaction and HSS. Arthritis had a significantly negative correlation with post-op HHS (rho= -0.27, P<0.05) and satisfaction (rho= -0.32, P<0.05). Eighty-four percent of patients were satisfied and 16% were dissatisfied. All dissatisfied patients (eight cases) had arthritis; two patients also had FAI that did not have decompression of the lesion since it was not recognised at the time. In regression analysis, arthritis was the strongest independent predictors of post-op HHS and satisfaction. Conclusion. Arthroscopic labral debridement of symptomatic tears without co-existing pathology can result in favorable long-term results. Arthritis is the strongest independent predictors of outcomes

The cause of unremitting hip joint pain often remains undiagnosed. In the knee, MRI often accurately detects soft tissue pathology, but there is a less than 5% chance that MRI will show an abnormality such as a labral tear. Because conventional surgery can lead to such complications as avascular necrosis, muscle weakness, trochanteric nonunion, heterotopic bone formation, neurovascular injuries and DVT, diagnostic open arthrotomy is seldom performed. Further, prolonged hospitalisation is costly and commits the patient to an extended rehabilitation program. Arthroscopic hip surgery, a relatively new but well-established procedure, permits the identification of previously unrecognised disorders and in some pathologies offers definitive treatment. In young selected patients with OA it serves as a temporary palliative procedure. This presentation is based on the first 50 hip arthroscopies performed by the author. Indications for operation were chronic hip pain without radiologically-discernible cause, the presence of loose bodies following trauma, chondrocalcinosis, labral lesions, chondral injuries, ruptured ligamentum teres, avascular necrosis, early OA, biopsy for suspected RA, and non-specific synovial disease. All patients were in hospital for only a day. Mobilisation was encouraged from day one. Dramatic improvement in previous symptoms was noted postoperatively. In three patients with degenerative changes, pain returned after a mean of 6 months and THR was subsequently performed. Hip arthroscopy is a minimally invasive diagnostic and treatment technique, especially in young patients presenting with hip pain

Aim: To determine whether isolated lesions of the glenoid labrum or capsulolabral lesios influence anterior and inferior shoulder stability in a cadaver model that leaves all other glenohumeral structures, including the capsule, intact. Methods: Sequential arthroscopic resection of the labrum was performed with a motorized shaver in seventeen fresh cadaver shoulders. A capsulolabral dehiscence was created arthroscopically in another eleven fresh cadaver shoulders. The capsulolabral complex was divided into five zones: from superior to posterior. Inferior and anterior stability were tested before and after each cutting step. Results: The hyper-abduction test showed progressive increase in abduction with each step, with a maximum of 120° reached after removal of the labrum in all four zones or after detachment of all zones. Resection of the superior to inferior labrum maximally resulted in subluxation, but not in dislocation of the shoulder. Capsulolabral dehiscence of all but the posterior zones resulted in a locked (6/11) or a metastable (4/11) dislocation. In the other specimens the posterior zone needed to be detached as well for a metastable dislocation. Conclusion: Purely labral lesions and limited capsulolabral detachments do not seem to be sufficient to allow the humeral head to dislocate. Labral tears can therefore be debrided without consequences for shoulder stability. In the present study, a capsulolabral detachment in the antero-inferior zone (the typical Bankart lesion) does not allow the humeral head to dislocate. This leads us to suggest that associated lesions must exist in chronic instability

Purpose: Hip arthroscopy has been used at an increasing frequency over the last few years. Majority of patients undergoing hip arthroscopy are young and active individuals who seek definitive therapy for a painful hip condition and wish to avoid undergoing a hip replacement. Although relatively successful, complications following hip arthroscopy occur. This multi-institutional study presents a worrisome and previously unrecognized complication of hip arthroscopy, namely chondrolysis that lead to accelerated development of end-stage arthritis. Method: Using the computerized database in each institution, patients undergoing total hip arthroplasty between 1999–2008 who had received hip arthroscopy prior to arthroplasty were identified. 39 patients were identified to have undergone at least one hip arthroscopy on the affected hip prior to arthroplasty. There were 21 female and 18 male patients. The mean age of patients at the time of hip arthroscopy was 45.9 years. Data regarding demographics, comorbidities, preoperative diagnosis, number of previous procedures, and the details of the surgical procedure were compiled. Radiographs were evaluated. Results: The median time from arthroscopy to arthroplasty was 14.8 months (range 2.2 months to 7 years). Fourteen patients (35%) underwent THA within 12 months of a previous hip arthroscopy and in nine of these patients the indication for hip arthroscopy was labral tear debridement. These patients despite having none to minimal arthritis at the time of arthroscopy developed accelerated arthritis within a year that necessitated hip replacement. Conclusion: Hip arthroscopy can cause accelerated degenerative arthritis of the hip in some patients. We believe the subset of our patients who developed arthritis so early after hip arthroscopy may have suffered chondrolysis and/or chondral injury during the arthroscopy that resulted in progressive and aggressive arthritis of the hip within 12 months. Hip arthroscopy should be reserved for a select group of patients. All measures to minimize the possibility of chondrolysis and/or chondral injury should be exercised

We would like to present our experience with hip arthroscopy done in a dorsal decubitus traction table with three standart portals. In a period of 24 months we operated 60 hips (55 patients) with a multitude of patologies. There were 30 men and 25 women with a mean age of 33,4 years old. The mean follow-up was 6 months. Labral tears were found in 20 scopes, associated with arthrosis in 4 cases and ligamentus teres tear in 2 cases. We did hip scopes in 10 total joint replacements to evaluate infection ( 5 cases), to treat acute infection ( 2 cases) and to evaluate pain with no apparent etiology (3 cases). Eigth cases were done after a hip dislocation, to evaluate and compare the arthroscopy with CT scans and MRI. In three of these cases we extracted bone fragments from within the joint. We had two cases of gunshot projectiles that were extractes successfully. Three cases were done in acute hip pyoartrosis. We had a 16% complication rate, mainly in the 25 first cases (pudendal nerve apraxia in 4 cases, condral flap tears in 4 cases, broken instrumental in 3 cases, worsening of syntoms in 2 cases, genital aedema in 2 cases, and others in 4 cases). The preliminary results showed an improving in Harris hip score in 57% of the patients. The results are encouraging and we must stress that there is a learning curve that is long, but hip arthroscopy is going to be an important and standart procedure in the very near future for hip surgeons

Introduction: Femoro-acetabular impingement (FAI) causes anterior hip pain, labral tears and damage to the articular cartilage leading to early osteoarthritis of the hip. Surgical hip dislocation and osteoplasty of the femoral neck and acetabular rim is a technique pioneered by the Bernese group for the treatment of FAI. We present and discuss our results of this technique. Methods: functional outcome was measured using the oxford hip and McCarthy non-arthritic hip scores pre and post-operatively. Results: Since January 2003, 36 hips in 34 patients (average age of 43 years (14–65)) underwent surgical hip dislocation for treatment of FAI. In 9 hips, grade 4 osteoarthritis was present in greater than 10 x 10mm regions after reshaping of the abnormal anatomy. In these cases, hip resurfacing was performed. Of the 27 hips preserved, 14 had chondral ‘carpet’ flaps debrided, 17 underwent recession of the acetabular rim at the site of impingement, 6 had removal of medial osteophytes, 6 had labral and/or bony cysts excised and grafted and 1 underwent an osteochondral graft. In 3 hips (12%) osteoarthritis progressed requiring hip resurfacing within the first year. Oxford Hip Score improved from an average 36 (range 17–59) to 23 (12–45) and McCarthy hip score from 43 (9–74) to 62 (36–72) in the preserved hips at an average 15 months following surgery (range 6–33 months). Discussion: The early results of surgical hip dislocation are encouraging. The open procedure has distinct advantages compared to arthroscopy enabling a wider range of lesions to be treated. Careful patient selection is important in order to exclude patients with hip osteoarthritis. Long-term follow-up is required to see if this technique prevents the natural progression to osteoarthritis

Background. The acetabular labrum is an essential stabilizer of the hip joint, imparting its greatest effect in extreme joint positions where the femoral head is disposed to subluxation and dislocation. However, its stabilizing value has proved difficult to quantify. The objective of the present study was to assess the contribution of the entire acetabular labrum to mechanical joint stability. We introduce a novel “dislocation potential test” that utilizes a dynamic, cadaveric, robotic model that functions in real-time under load-control parameters to map the joint space for low-displacement determination of stability, and quantify using the “stability index”. Methods. Five fresh-frozen human cadaveric hips without labral tears were mounted to a six-degree-of-freedom robotic manipulator and studied in 2 distinct joint positions provocative for either anterior or posterior dislocation. Dislocation potential tests were run in 15° intervals, or sweep planes, about the face of the acetabulum. For each interval, a 100 N force vector was applied medially and swept laterally until dislocation occurred. Three-dimensional kinematic data from conditions with and without labrum were quantified using the stability index, which is the percentage of all directions a constant force can be applied within a given sweep plane while maintaining a stable joint. Results. Global stability indices, considering all sweep planes, were significantly greater with labrum intact than after total labrectomy for both anterior (Figure 1A) (p = 0.02) and posterior (Figure 1B) (p<0.001) provocative positions. Regional stability indices, based upon the expected range of dislocation for each provocative position, were also significantly greater and of slightly larger magnitude for the intact condition than after total labrectomy (p<0.001). Conclusions. This is the first known application of a six-degree-of-freedom robot to recreate mechanical hip impingement and dislocation to elucidate the role of the labrum in hip stability. Our results suggest that at least in extreme positions, the labrum imparts significant overall mechanical resistance to hip dislocation compared to the condition without the labrum. Regional contributions of the labrum are greatest in the direction of dislocation as foretold by joint position as indicated by region-based stability indices. Future studies involving more clinically relevant injury patterns with greater soft tissue preservation in a younger cadaveric population would better reflect the in vivo effects of labral injury so that treatment strategies can be developed accordingly

Since 2003 we have adopted an aggressive approach to the management of the SUFE deformity, an important cause of anterior femoro-acetabular impingement, associated with the development of early adult hip arthritis. 16 patients aged 16.7 years (range 11–20, 3 female, 13 male, 8 right, 8 left hips) underwent surgery to manage their SUFE deformity. 7 patients had secondary correction of deformity after previous in-situ pinning and 9 underwent primary surgical management using a Ganz approach (7) or primary in-situ pinning with femoral neck resection via a Smith-Peterson approach (2). Of the 7 patients who had primary in-situ pinning 26 months (range 4–44 months) earlier, 2 had acetabular chondral flap tears with eburnated bone and 6 had significant labral degenerative changes associated with calcification or tears. Only one of the nine patients who underwent primary aggressive management of their SUFE, had a labral tear. 4 patients underwent mobilisation of the femoral head on its vascular pedicle followed by anatomical realignment. At an average follow-up of 22.3 months (range 1–41 months) 15 remained well with excellent function. Leg lengths remained equal in 12, with an average shortening of 2cm in the remaining 4 patients. Segmental AVN occurred in the first patient after damage to the vascular pedicle during drilling of the neck; the technique has been modified to prevent further occurrences. Removal of the trochanteric osteotomy screws has been performed in 4 cases. Despite having performed over 400 surgical hip dislocation, the authors continue to find the management of this condition challenging; nevertheless, having seen the direct consequences of femoro-acetabular impingement at an early stage in these young patients, we believe that aggressive management to correct anatomical alignment is essential for the future well being of the hip

Introduction: Symptomatic neglected and displaced three and four-part proximal humeral fractures are often difficult to reconstruct. Replacements has been reported to give poor functional outcome and hence not the ideal treatment option. We report our results of secondary reconstruction of these difficult fractures with a locking plate system. Material and Methods: Between 2003 and 2005, 15 healthy active patients with displaced three to four-part fractures underwent revision/secondary open reduction and internal fixation with a locking plate system (Philos, Stratec UK Ltd). Ten patients had delayed presentation. Three patients had failed previous internal fixation. One patient had non-union and one had malunited fracture. Their average age was 63 years. Objective assessment was measured by the Constant score, subjective assessment by the Oxford questionnaire. The mean follow-up was 14 months. Surgical technique: In revision cases, the fracture was approached through the same incision. All metal work was removed. Careful attention was given to restore the normal anatomy of humeral head with correct placement of the tuberosities. Reduction was held with Ticron sutures through the rotator cuff followed by fixation with the locking plate. Two patients required arthroscopic repair of their labral tears. The shoulder was immobilised in a sling for four weeks followed by gradual mobilisation program. Results: All fractures united. No failure of fixation was observed. The mean Constant score was 73. The pain component improved from 3 preoperatively to 14 at follow up. The average range of flexion was 1100, abduction of 950 and external rotation of 350. All patients had good to excellent subjective outcome. We encountered poor rotator cuff function in one patient. Conclusion: Successful reconstruction of three and four part proximal humeral fractrures is possible. Anatomical restoration of humeral head and tuberosities prior to plate fixation is essential for good outcome

Purpose: There is a paucity of literature describing clinical outcomes following hip arthroscopy. Variables associated with short or prolonged recovery are undefined. This presents a challenge to surgeons in preoperatively communicating with patients about expectations after surgery. The goals of this study are to identify predictors of recovery and to develop models which will facilitate the proper counseling of patients prior to hip arthroscopy. In this study, we define a normal recovery after hip arthroscopy, determine the predictive values of preoperative and intraoperative variables for recovery and for progression to total hip arthroplasty (THA) after hip arthroscopy. Method: A retrospective review of 216 individuals treated with hip arthroscopy at a tertiary medical center was conducted by a single reviewer. Univariate analysis was used to identify independent variables that correlated with prolonged or short recovery following hip arthroscopy and also on variables correlated with progression to THA. Binary logistic regression analysis was used to develop and test multivariate models for predicting prolonged recovery and progression to THA. Results: Univariate analyses revealed multiple variables (spanning demographics, past medical history, radiographic findings, physical examination findings, and intraoperative findings) which were significantly (p≤0.05) correlated with prolonged recovery (13 significant predictors) and also with progression to THA (14 significant predictors). A multivariate predictive algorithm was generated using 5 significant predictors of prolonged recovery, which included Workman’s compensation involvement, female gender, use of pain medications, presence of a limp, and presence of a lateral labral tear. This algorithm was tested successfully using an independent sample of 25 individuals. Three multivariate predictors of progression to THA after hip arthroscopy were identified, including radiographic presence of arthritis, female gender and the presence of grade 4 chondral lesions, and a predictive algorithm was generated. Conclusion: We generated and initially validated a multivariate algorithm to predict prolonged recovery following hip arthroscopy. If validated in larger sample, this model may allow a surgeon to appropriately counsel patients regarding expectations for recovery after hip arthroscopy

The Rotator Cuff Registry is a unique initiative of the New Zealand Shoulder & Elbow Society. The aim of the study was to enrol nationwide all patients undergoing rotator cuff repair over a 22 month period to provide best practice guidelines for management of rotator cuff tears. To qualify for the Registry patients have to undergo surgical repair of either a partial or full thickness rotator cuff tear. Prior to surgery patients fill out a registration document as well as a pain score and Flex-SF function score. The Surgeon completes an operating day questionnaire detailing operative findings and repair methods. Follow-up is by pain and Flex-SF function scores returned at six, twelve and twenty-four months from surgery. By the 31st December 2010 3000 patients had been recruited. Analysis of the first 2684 patients for the purpose of this abstract showed 70% Male and 30% female. The dominant arm was involved in 65%. 19% of patients were in high demand occupations, 27% in medium demand and 33% low demand occupations. 16% of patients were treated with all arthroscopic repair, 40% were mini-open and 44% open. Comparing pre-op and one year post-op activity scores by surgical approach the Flex-SF improved by 12.97 points in the arthroscopic group, 13.3 in the mini-open and 12.72 in the open (NSS). Pre-op, 6 mth and 12mth pain scores were arthroscopic 4.60, 1.81 and 1.57, mini-open 4.34, 2.15 and 1.52 and open 4.82, 2.27 and 1.86. Preoperatively, the open approach had statistically more pain than the mini-open. At 6 months the arthroscopic group had statistically less pain than the open and at twelve months the mini-open had statistically less pain than the open group. For all tear sizes significant improvements in Fex-SF were seen both from preoperative levels to 6 month follow-up and from 6–12 month follow-up. A labral tear was present in 12% and repaired in 25% of these. No difference was seen in outcome between these groups Biceps tenolysis was undertaken in 27% and tenodesis in 23%. A single row repair was selected in 44% and a double row in 56%. Double row repair resulted in better Flex-SF scores in the large tears. Six, twelve and some twenty-four month data will be presented. Outcome was unaffected by the surgical approach with arthroscopic, mini-open and open results essentially identical

Background. Femoroacetabular impingement (FAI) may be a predisposing factor in progression of osteoarthritis. The use of hip arthroscopy is in its infancy with very few studies currently reported. Early reports show favourable results for treatment of young patients with FAI. This prospective study over a larger age spectrum represents a significant addition to this expanding field of minimally invasive surgery. Methods. Over a twenty-two month period all patients undergoing interventional hip arthroscopy were recorded on a prospective database. Patient demographics, diagnosis, operative intervention and complications were noted. Patients were scored pre-operatively and postoperatively at 6 months and 1 year using the McCarthy score. Results. 94 patients met the criteria for inclusion in this study. Median age was 39 (15–66) years with 57.4% female, 16 patients were over the age of 50 years. At operation, 50 patients had a labral tear, 70 had cam impingement and 62 had chondral damage, with 21 of these deemed severe (grade 3 or 4). For all patients a mean increase in the McCarthy score of 14.6 (p=<0.0001) was seen at 6 months and 19.1 (p=0.0002) at 1 year postoperatively. For those over 50 years, at 6 months an increase of 11.9 (p=0.08) was seen, improving to 33.8 (p=<0.0001) at 1 year. Eight patients underwent THR, of these, 2 were over 50 years of age. All of this group of patients had chondral damage (50% judged as severe at arthroscopy). At 6 months postoperatively these patients had severe pain and their mean score worsened by −16.3 (p=0.2). Few complications were seen, 7 patients had tight access (5 males), 3 of which received chondral scuffing and 1 had the procedure abandoned, 1 patient had groin labral bruising and 2 patients had transient parasthesia. Conclusions. Patients see a gradual and significant improvement post hip arthroscopy, with symptoms continuing to improve until 1 year. This is a well-tolerated procedure with a low complication rate and the opportunity for treatment of a range of hip pathology. Patients over the age of 50 gain a significant improvement from this procedure. Two groups of patients who gain no improvement are those with inflammatory arthropathy and those with dysplastic acetabulae

The New Zealand Nationwide Rotator Cuff Registry is a first worldwide. An initiative of The NZ Shoulder and Elbow Society, work commenced on the project in July, 2005, and the Pilot Study involving four surgeons and 200 patients commenced in September 2007 and finished in February, 2009. The Nationwide Registry commenced in March, 2009, and by 30th June 520 patients had been recruited. This presentation will focus on the data for the first six months of the study. Analysis of data for the first four months showed that 71% of patients were male and 29% female. 62% involved the right shoulder. 88% of patients considered their shoulder problem accident-related. The rotator cuff repair was undertaken all-arthroscopic in 71 (13.8%), mini-open in 256 (49.6%), and open in 189 (36.6%). 95% were primary operations and acromioplasty was undertaken in 90%. Using Cofield’s classification, tear size was small (< 1cm in AP length) in 10%, 1–3cm in 62% and large in 28%. Average pain score did not correlate with AP tear size but the Flex-SF activity score deteriorated with tear size. The supraspinatus was normal in 6% and had a full thickness tear of all of the tendon in 39%, part of the tendon in 38% and had a partial thickness tear in 17%. The subscapularis was involved in 33% and infraspinatus in 28%. A labral tear was present in 8.4% and was repaired in 2.1%. Distal clavicle excision was undertaken in 9% of which 62% were open and 38% arthroscopic. The long head of biceps was normally located in 82%, subluxed in 11% and dislocated in 7%. In 47% of cases it was normal, in 42% damaged and in 11% ruptured. Tenodesis was undertaken in 24%, tenotomy in 19% and in 57% the tendon was left in situ. Double row repair was utilised in 60% and single row in 40%. Suture anchors were used in 78% of repairs, bone tunnels in 7% and a combination in 15%. The tendon quality was rated very well in 26%, good in 54% thin in 13% and poor in 7%. Postoperatively 42% were immobilised for 6 weeks, 24% for 4 weeks and 11% were not immobilised. A polysling was used in 56% and abduction pillow in 21%, and an ultrasling in 10%. Smoking and NSAID use will be compared in patient-derived outcome data at 6 months, one year and two years from surgery

Introduction. Acetabular labral pathology is now recognized as a more common injury than previously thought. With cost constraints of MRI and invasiveness of MRI arthrogram, physical examination remains essential for diagnosis. Most tests for labral pathology are currently done in the supine position. We have developed the “twist test,” which is done with the patient standing and can evaluate the patient in functional, weight bearing position. The purpose of this study is to describe the twist test and compare its reliability to MRI arthrogram. Material and methods. Between June 2009 and August 2010, the twist test was performed on all patients presenting to our clinic with complaint of hip pain. 371 patients had the twist test performed. Of these, 247 had an MRI arthrogram (MRA) of the affected hip. The twist test results were compared with MRA findings. A labral tear, degeneration, fraying and paralabral cyst were considered as a positive MRA. The twist test is done with the patient facing the examiner, toes pointing forward. The patient bends their knees to 30 degrees and performs a windshield wiper like action with maximal excursion to the left and right. If the patient tolerates this, then the patient first gets on the unaffected leg, again with the knee bent at 30 degrees, and “does the twist” one-legged, with the examiner holding their hands gently for balance. The test is then repeated on the affected hip. A positive test is groin pain on the affected hip, apprehension with performing the test on the affected hip, or gross range of motion deficits on the affected hip compared with the unaffected side. Results. Among 160 patients with positive twist test, 154 patients had positive MRA and 6 had negative MRA. Among 87 patients with negative twist test, 72 had positive MRA and 15 had negative MRA. In comparison with MRA, the sensitivity and specificity of twist test for labral injury were 68.14% and 71.5% respectively. Positive predictive value (precision) of twist test for diagnosis of labral lesion was 96.25% and the accuracy was 68.4%. Conclusions. Physical examination tests for hip pathology are an important screening tool. Current tests include the McCarthy test and the impingement test. We introduce a new test for hip labral pathology, which is done standing. In our study, the twist test had a high positive predictive value (96.25%), so this test can be beneficial for ruling out labral pathology. An added benefit is that this test is quick to perform, so it could be incorporated into a general sports physical screening examination

Aims

The outcomes following nonoperative management of minimally displaced greater tuberosity (GT) fractures, and the factors which influence patient experience, remain poorly defined. We assessed the early patient-derived outcomes following these injuries and examined the effect of a range of demographic- and injury-related variables on these outcomes.

Lesions of the acetabular rim have been implicated as a cause of hip pain in various pathologic conditions and are considered to predispose the hip to development of accelerated degenerative disease. In developmental dysplasia of the hip (DDH) and anterior femoroacetabular impingement (FAI), intrinsically normal intraarticular soft tissue structures are exposed to joint loading forces that physically exceed their tolerance level posing these pathomorphologies as precursors of osteoarthritis. In DDH, the deficient acetabular coverage of the femoral head has been related to osteoarthrosis, while the orientation of the femoral head is considered to play a less important role. The resulting instability and anterolateral migration tendency of the femoral head leads to chronic shear stresses at the acetabular margin. In FAI, repetitive peak contact pressures occur when the femoral head-neck junction abuts against the acetabular rim during joint flexion. Predisposing morphologies are femoral abnormalities such as an insufficient femoral head-neck offset seen in head tilt or pistol grip deformities, slipped capital femoral epiphysis, or malunited femoral neck fractures with the orientation and shape of the acetabulum contributing to this pathology. In classical DDH and FAI, diagnosis is primarily based on clinical signs and symptoms and conventional radiography. However, in cases of clinical and radiographic borderline disease establishment of the correct diagnosis is sometimes difficult. This presentation reports how the MRarthrographic appearance of acetabular rim pathologies can be used to differentiate both conditions. In DDH and FAI, labral pathologies localize identically with a predilection to the anterosuperior quadrant of the acetabulum. Labral tears are found in 64% in both groups. The volume of the labrum is increased in 86% DDH hips but in none of the FAI hips. Ganglion formation in the periacetabular area is seen in 71% DDH and 21% FAI hips. These findings provide evidence that the anterosuperior acetabular rim represents the initial fatiguing site of the hip under both DDH and FAI. The capability of MR-arthrography to depict differences in labral pathologies suggests this method as a helpful diagnostic tool to define the most appropriate treatment strategy specifically in borderline cases

Introduction: Acromioclavicular (AC) joint injuries are common in both the sporting and working populations. Most injuries are grade I in severity and settle with an appropriate non-operative treatment program. Arthroscopic soft tissue debridement of the AC Joint without excising the distal clavicle, is a bone sparing procedure that, to our knowledge, has never been reported in the literature. This paper is a retrospective review of patients with chronic recalcitrant AC joint injuries, who underwent arthroscopic soft tissue debridement of the AC joint. Materials and Methods: Fourteen patients underwent arthroscopic AC joint soft tissue debridement. All patients had failed a non-operative treatment program including physiotherapy, anti-inflammatory tablets and corticosteroid injections. All patients had been symptomatic for a minimum of four months prior to surgery. The surgery involves a glenohumeral joint arthroscopy, subacromial bursoscopy and AC joint arthroscopy. Excision of the torn AC joint meniscus, AC joint synovectomy and soft tissue clearance were performed in all cases. Surgery was performed as a day-only procedure. Results: Ten out of fourteen patients obtained good pain relief and a corresponding increase in function. One patient was lost to follow-up. One patient subsequently underwent an open AC joint reconstruction for chronic instability. Five patients had previously undiagnosed SLAP tears. Conclusion. Arthroscopic soft tissue debridement for recalcitrant AC joint injuries gave good results in 77% of cases. Arthroscopy of the glenohumeral joint in patients with presumed isolated AC joint disease is important as there is a significant proportion of patients who have associated significant superior labral tears. Soft tissue arthroscopic AC joint debridement allows quick post-operative rehabilitation, an early return to sport and work and avoids having to excise bone from the distal clavicle. Arthroscopic AC joint debridement is contraindicated in patients who have grade II or grade III AC joint instability

This study attempted to ascertain if patients with high superior pubic ramus fractures (HSPR) have worse clinical functional outcomes than patients with low superior pubic ramus fractures (LSPR). A retrospective cohort of patients was examined. A statistically significant difference was found with respect to Harris Hip Score, MFA score, Bother Index, and Functional Index. Patients with LSPR fractures consistently scored better on mobility and activity of daily living functional testing. Patients with HSPR fractures were limited in physical abilities and lifestyle adjustment. This study illustrates a need to re-examine our treatment of high pubic ramus fractures. The purpose of this study was to ascertain if patients with high superior pubic ramus fractures have worse clinical functional outcomes than patients with low superior pubic ramus fractures. Patients with Low Superior Pubic Ramus (LSPR) fractures consistently scored better on mobility and activity of daily living functional testing. Patients with High Superior Pubic Ramus (HSPR) fractures were more limited in physical abilities and lifestyle adjustment. No distinction of level of this common fracture is routinely distinguished with treatment usually independent of level. This study illustrates a need to re-examine our treatment of high pubic ramus fractures. A statistically significant difference was found when the HSPR fracture group was compared to the LSPR fracture group with respect to Harris Hip Score (P=0.0024), MFA score (P=0.0304), Bother Index (P=0.0338), and Functional Index (P=0.0385), and had hip pain which was a limiting factor (P=0.011). This is a retrospective cohort study of patients sustaining a superior pubic ramus fracture. The criterion for grouping was fracture proximity to the acetabulum. MFA (Short Form) and Harris Hip Score were performed. A physical exam was performed on all patients. The two groups were compared using the Wilcoxon test for continuous variables and the Chi-square test for contingency tables. These fractures are commonly felt to be of minimal significance. Common treatment regimes consist of pain control and early mobilization. The etiology of the increased pain and functional disability in patients with HSPR fractures is unclear. Our hypotheses include labral tear and missed true acetabular fractures

Introduction: Chondral lesions are the second most common pathology encountered during hip arthroscopy and can cause substantial morbidity and functional limitation. Microfracture is a simple and effective technique to treat chondral lesions. Studies have shown good long term results in the knee. However there is little evidence to confirm the ability of microfracture to produce repair tissue in hip joint. Methods: Patients aged 18 years or older who had a full thickness acetabular chondral defect treated with microfracture during primary arthroscopy and who had a subsequent hip arthroscopy enabling visualisation of the treated chondral defect were included in the study. Over a three year period 185 patients had microfracture for treatment of full thickness chondral defect. 11 patients (8 males and 3 females) with a mean age of 35 years (range 17–54 years) who had revision hip arthroscopy for various reasons form the study population. The size of chondral defect was measured at the time of primary arthroscopy. Microfracture was performed using arthroscopic awls with a standard technique. Postoperatively a strict rehabilitation protocol was followed with no weight bearing allowed for six weeks. The extent and quality of repair tissue was assessed by visual inspection at second look arthroscopy. Results: All acetabular chondral lesions were identified in the antero-superior quadrant at primary arthroscopy. The average defect after debridement measured 180 mm2 (range 50–300 mm2). 10 patients had chondral lesions confined to the acetabulum. 1 patient had a large femoral head defect in addition, due to Avascular Necrosis. None of the patients had diffuse osteoarthritis. All patients had an associated labral tear. The mean time interval between the primary and revision arthroscopy was 12 months. Excluding 1 failure the overall percent fill of the defects was 95% (range 75 – 100%) with good quality (Grade 1) cartilage. There was one failure with only a 25% fill. In that particular patient a large flap of delaminated cartilage was not resected at primary arthroscopy. Instead microfracture was done under the flap in the hope of encouraging the cartilage to stick to the underlying bone. Unfortunately the cartilage continued to remain delaminated and also hindered the formation of new repair tissue. Conclusion: Only one other series of second look arthroscopy after microfracture has been reported. Our series agrees with the results of those authors. These similar results from 2 centres confirm that arthroscopic microfracture is an effective treatment for acetabular chondral lesions in carefully selected patients

Introduction: Periacetabular rotational osteotomy is a joint preserving reconstructive surgery indicated in hip dysplasia. However hip dysplasia is frequently accompanied by intraarticular pathology like labral tears. This study was undertaken to ascertain whether:. concomitant hip arthroscopy during osteotomy could identify intra-articular pathology associated with hip dysplasia;. hip arthroscopy combined with our technique of acetabular osteotomy was effective in treatment of intraarticular pathology;. this technique was associated with a favorable outcome over a mid term followup period. Materials: Between July 2001 and February 2005, 43 dysplastic hips with 40 patients consecutive of periac-etabular rotational osteotomy using modified Ollier’s approach and concomitant hip arthroscopy could be followed up at average 52 months (range, 42–67 months). On arthroscopic examination labral lesion and cartilage condition was evaluated and torn labrum was treated. Two patients underwent simultaneous femoral procedures. Mean age at the time of surgery was 40 years (range, 20–67 years). Pre and postoperative hip function was compared using Harris hip score. Radiographic evaluation consisted of pre and postoperative measurement of CE angle, Sharp angle, acetabular head index, head lateralization index and medialization of femoral head. The degree of osteoarthritis was evaluated and compared by radiographic appearance using Tönnis classification. Results: Intraoperative arthroscopic examination revealed labral lesion in 38 hips. Twenty-eight (65%) out of 43 cases showed cartilage degeneration on arthros-copy. Mean HHS changed from 72.4 preoperatively to 94 postoperatively. On radiographic evaluation CE angle changed from 6.3o to 32.3o, Sharp angle changed from 47o to 39o, acetabular head index changed from 57% to 92% thus indicating the increase in contact area. Head lateralization index changed from 61.2 to 54.9. At the latest review, the severity of osteoarthritis improved in 12 (28%), remained unchanged in 29 (67.4%), and worsened in 2 cases (4.7%). Complications include intraarticular osteotomy, disruption of posterior column and deep vein thrombosis in 1 case each. No other complications like non-union, nerve injury, avascular necrosis, or infection were seen. No patients underwent a conversion THA indicating a 100% survival for the minimum followup period of 42 months and beyond. Conclusion: Periacetabular rotational osteotomy showed good results in midterm and in 88% of cases we observed and treated labral lesion through a concomitant hip arthroscopy. Thus we recommend that evaluation and treatment of labral lesion should be considered when the joint-preserving acetabular osteotomy is performing due to dysplastic hip

Thirty-seven hips in thirty-four patients, mean age forty-one, underwent surgical dislocation of the hip with chondro-osteoplasty for the treatment of femoroacetabular impingement. At a mean follow-up of 2.1 years (2.0–4.0), the pre & post-operative outcome scores were for the: WOMAC 59.2 to 81.0 (p< 0.001), UCLA Hip Scores for pain 4.2 to 7.6;walking 7.3 to 8.6;function 6.2 to 8.1;activity level 4.3 to 6.9 (p< 0.05); and SF-12 physical 37.4 to 48.0 (p< 0.003) & mental 46.0 to 51.6 (p< 0.01). No hips have undergone further reconstructive surgery. Complications: one failure of fixation of the trochanteric osteotomy and one excision of bilateral ectopic ossification. No cases of osteonecrosis. The purpose of our study was to evaluate the early clinical results and quality of life outcome after chondro-osteoplasty of the femoral head/neck junction for the treatment of femoroacetabular impingement. An offset correction by surgical dislocation of the hip joint is a safe and an effective procedure in the treatment of femoroacetabular impingement commonly associated with labral tears. Femoro acetabular impingement is a due to an absence of concavity at the anterolateral head neck junction associated with labral pathology. At short-term followup correction of the bony abnormality has improved functional outcome both from a disease-specific and health-related standpoint. Thirty-seven hips (eighteen males; sixteen females) with persistent hip pain mean age forty-one (twenty-four to fifty-two) underwent 3-Dimensional CT of the pelvis and MR Arthrography prior to undergoing surgical dislocation with chondro-osteoplasty of the femoral head/neck junction. Preoperatively, the mean alpha angle of Notzli was 65.6(range, 42.0–95). At a mean follow-up of 2.1 years (2.0–4.0), the pre & post-operative outcome scores were for the: WOMAC 59.2 to 81.0 (p< 0.001), UCLA Hip Scores for pain 4.2 to 7.6;walking 7.3 to 8.6;function 6.2 to 8.1;activity level 4.3 to 6.9 (p< 0.05); and SF-12 physical 37.4 to 48.0 (p< 0.003) & mental 46.0 to 51.6 (p< 0.01). No hips have undergone further reconstructive surgery. Complications: one failure of fixation of the trochanteric osteotomy and one excision of bilateral ectopic ossification. No cases of osteonecrosis. Nine hips had removal of painful internal fixation

Introduction: Hip Surgical Dislocation (SHD) according the technique described by Ganz et al. is a safe and powerful tool to access intra-articular hip pathology in adults. Some indications may also arise in younger patients to correct slipped capital femoral epiphysis or femoral neck deformities. Materials and Methods: From 2004 to 2008 we have selected 45 patients on whom the procedure was done to treat femoroacetabular impingement (FAI). The average follow up time is 3 years, and patient mean age 26 years. The indications for SHD were:. mixed FAI in 26 cases,. pure cam FAI in 6 cases and. pure pincer FAI in 13 cases. 42 hips where graded as Tönnis 0 and 2 as Tönnis 1. All patients where evaluated according to the non arthritic hip score (NAHS – McCarthy et all) before and after the surgery at 3, 6, 12, 24 and 36 months. Osyrix. ®. software was used to measure radiographic parameters. The numeric variables where treated using SPSS for windows (paired t student test). Surgical Technique: In all 45 cases we did SHD, acetabular and/or femoral head neck junction trimming and labrum refixation. In half cases an anterior step trochanteric osteotomy was done and in 7 cases additional relative neck lengthening was performed. Results: The average alfa angle measured in the standard crosstable view x ray was 72° before surgery and 36° after surgery (p=0,0001). The NAHS before surgery was 40,8 average: 9,71 – pain; 6,9 – symptoms; 9 – function and 6,9 – activities and after surgery 76,38 average (p= 0,0001) 17,5 – pain (p= 0,0001); 12,9 – symptoms (p= 0,0001); 16 - function (p= 0,0001) and 14,9 - activities (p= 0,0001). All patients improved motion, specially flexion, internal rotation (p= 0,0001). The results did not differ significantly in the patients who had a trochanteric anterior step osteotomy. One patient had a total hip replacement for ongoing osteoartrithis. We had no avascular necrosis so far and no neurovascular damage. Trochanteric screw removal was done in 3 cases for local irritation. We had 2 capsule adhesions, released shortly after using arthroscopy. Conclusions: SHD is a demanding technique with full access to femoral head and acetabular deformities as well as cartilage or labral tears. It can be done safely with a low complication rate. The best results are achieved in young patients without degenerative cartilage and significant labrum changes. Hip degenerative changes contraindicates this procedure. Modification of trochanteric osteotomy does not seem to influence results