Outcomes of intra-articular corticosteroid injections for adolescents with hip pain.

Intra-articular injection of corticosteroid and anesthetic (CSI) is a useful diagnostic tool for hip pain secondary to labral tears or femoroacetabular impingement (FAI). However, the effectiveness of CSI as a stand-alone treatment for hip pain in adolescents is unknown. The purpose of this study is to evaluate the use of CSI for the treatment of hip pain and determine factors that may affect outcomes after injection. Retrospective analysis of 18 patients and 19 hips that underwent fluoroscopic guided hip injection for the treatment of pain at a single institution from 2012 to 2015 was carried out in this study. Mean age at the time of injection was 15.1 years (range 13-17) with mean follow-up of 29.4 months. Fifty-two percent (10/19 hips) went on to surgery after the injection. Average time to surgical conversion was 12.8 months after CSI. Cam or pincer morphologies were present in 90% (9/10 hips) of the operative group. Patients with FAI were more likely to need surgery than patients without bony abnormalities (RR= 10, 95% CI 1.6-64.2, P = 0.0001). There was no difference in the presence of labral tears in the operative and non-operative groups (100% versus 89%, P = 0.47). For adolescents without bony abnormalities, 90% improved with CSI alone and did not require further treatment within 2.4 years. Fluoroscopic guided corticosteroid hip injection may have limited efficacy for the treatment of hip pain secondary to FAI in adolescents. However, for patients without osseous deformity, CSI may offer prolonged improvement of symptoms even in the presence of labral tears

Periportal Capsulotomy: A Technique for Limited Violation of the Hip Capsule During Arthroscopy for Femoroacetabular Impingement.

Hip arthroscopy has become the standard treatment for symptomatic femoroacetabular impingement as patients have shown good outcomes and high satisfaction with this intervention. However, capsular management to gain access for intra-articular procedures remains greatly debated. Capsular closure is advocated particularly in the setting of interportal or T-capsulotomy to avoid complications of instability or nonhealing capsule. We introduce a technique for capsular management through a limited periportal capsulotomy during arthroscopic treatment of femoroacetabular impingement. In using dilation of the anterolateral and mid-anterior portals without completion of a full interportal capsulotomy, the stabilizing iliofemoral ligament is preserved. We have found that periportal capsulotomy provides safe and sufficient access to the hip joint without necessitating capsular closure

DeepVoting: A Robust and Explainable Deep Network for Semantic Part Detection under Partial Occlusion

In this paper, we study the task of detecting semantic parts of an object, e.g., a wheel of a car, under partial occlusion. We propose that all models should be trained without seeing occlusions while being able to transfer the learned knowledge to deal with occlusions. This setting alleviates the difficulty in collecting an exponentially large dataset to cover occlusion patterns and is more essential. In this scenario, the proposal-based deep networks, like RCNN-series, often produce unsatisfactory results, because both the proposal extraction and classification stages may be confused by the irrelevant occluders. To address this, [25] proposed a voting mechanism that combines multiple local visual cues to detect semantic parts. The semantic parts can still be detected even though some visual cues are missing due to occlusions. However, this method is manually-designed, thus is hard to be optimized in an end-to-end manner. In this paper, we present DeepVoting, which incorporates the robustness shown by [25] into a deep network, so that the whole pipeline can be jointly optimized. Specifically, it adds two layers after the intermediate features of a deep network, e.g., the pool-4 layer of VGGNet. The first layer extracts the evidence of local visual cues, and the second layer performs a voting mechanism by utilizing the spatial relationship between visual cues and semantic parts. We also propose an improved version DeepVoting+ by learning visual cues from context outside objects. In experiments, DeepVoting achieves significantly better performance than several baseline methods, including Faster-RCNN, for semantic part detection under occlusion. In addition, DeepVoting enjoys explainability as the detection results can be diagnosed via looking up the voting cues

Hip Arthroscopic Surgery for Femoroacetabular Impingement: A Prospective Analysis of the Relationship Between Surgeon Experience and Patient Outcomes.

Background:Hip arthroscopic surgery is a rapidly growing procedure, but it may be associated with a steep learning curve. Few studies have used patient-reported outcome (PRO) surveys to investigate the relationship between surgeon experience and patient outcomes after the arthroscopic treatment of femoroacetabular impingement (FAI). Hypothesis:Patients undergoing hip arthroscopic surgery for the treatment of FAI in the early stages of a surgeon's career will have significantly worse outcomes and longer procedure times compared with patients treated after the surgeon has gained experience. Study Design:Cohort study; Level of evidence, 2. Methods:Patients undergoing hip arthroscopic surgery for FAI and labral injuries were prospectively enrolled during a sports medicine fellowship-trained surgeon's first 15 months of practice. Patients were stratified into an early group, consisting of the first 30 consecutive cases performed by the surgeon, and a late group, consisting of the second 30 consecutive cases. Radiographic and physical examinations were performed preoperatively and postoperatively. PRO surveys, including the 12-item Short Form Health Survey (SF-12), the modified Harris Hip Score (mHHS), and the Hip disability and Osteoarthritis Outcome Score (HOOS), were administered preoperatively and at a minimum of 1 year postoperatively. Results:There was no difference between the early and late groups for patient age (37.2 ± 11.5 vs 35.3 ± 10.8 years, respectively; P = .489), body mass index (25.6 ± 4.0 vs 25.1 ± 4.5 kg/m2, respectively; P = .615), or sex (P = .465). There was a significantly increased procedure time (119.3 ± 21.0 vs 99.0 ± 28.6 minutes, respectively; P = .002) and traction time (72.7 ± 21.4 vs 59.0 ± 16.7 minutes, respectively; P = .007) in the early group compared with the late group. Mean postoperative PRO scores significantly improved in both groups compared with preoperative values for all surveys except for the SF-12 mental component summary. No differences were found in PRO score improvements or complication rates between the early and late groups. Conclusion:The total procedure time and traction time decrease after a surgeon's first 30 hip arthroscopic surgery cases for FAI and labral tears, but patient outcomes can similarly improve regardless of surgeon experience in the early part of his or her career

Return to Play Following Shoulder Stabilization: A Systematic Review and Meta-analysis.

BackgroundAnterior shoulder instability can be a disabling condition for the young athlete; however, the best surgical treatment remains controversial. Traditionally, anterior shoulder instability was treated with open stabilization. More recently, arthroscopic repair of the Bankart injury with suture anchor fixation has become an accepted technique.HypothesisNo systematic reviews have compared the rate of return to play following arthroscopic Bankart repair with suture anchor fixation with the Bristow-Latarjet procedure and open stabilization. We hypothesized that the rate of return to play will be similar regardless of surgical technique.Study designSystematic review; Level of evidence, 4.MethodsWe performed a systematic review and meta-analysis focused on return to play following shoulder stabilization. Inclusion criteria included studies in English that reported on rate of return to play and clinical outcomes following primary arthroscopic Bankart repair with suture anchors, the Latarjet procedure, or open stabilization. Statistical analyses included Student t tests and analyses of variance.ResultsSixteen papers reporting on 1036 patients were included. A total of 545 patients underwent arthroscopic Bankart repair with suture anchors, 353 with the Latarjet procedure, and 138 with open repair. No significant difference was found in patient demographic data among the studies. Patients returned to sport at the same level of play (preinjury level) more consistently following arthroscopic Bankart repair (71%) or the Latarjet procedure (73%) than open stabilization (66%) (P < .05). Return to play at any level and postoperative Rowe scores were not significantly different among studies. Recurrent dislocation was significantly less following the Latarjet procedure (3.5%) than after arthroscopic Bankart repair (6.6%) or open stabilization (6.7%) (P < .05).ConclusionThis systematic review demonstrates a greater rate of return to play at the preinjury level following arthroscopic Bankart repair and the Latarjet procedure than open stabilization. Despite this difference, >65% of all treated athletes returned to sport at their preinjury levels, with other outcome measures being similar among the treatment groups. Therefore, arthroscopic Bankart repair, the Latarjet procedure, and open stabilization remain good surgical options in the treatment of the athlete with anterior shoulder instability

Equivalent Mid-Term Results of Open vs Endoscopic Gluteal Tendon Tear Repair Using Suture Anchors in Forty-Five Patients.

BackgroundLittle is known about the relative efficacy of open (OGR) vs endoscopic (EGR) gluteal tendon repair of gluteal tendon tears in minimizing pain and restoring function. Our aim is to compare these 2 surgical techniques and quantify their impact on clinical outcomes.MethodsAll patients undergoing gluteal tendon tear repair at our institution between 2015 and 2018 were retrospectively reviewed. Pain scores, limp, hip abduction strength, and the use of analgesics were recorded preoperatively and at last follow-up. The Hip disability and Osteoarthritis Outcome Score Junior and Harris Hip Score Section1 were obtained at last follow-up. Fatty degeneration was quantified using the Goutallier-Fuchs Classification (GFC). Statistical analysis was conducted using one-way analysis of variance and t-tests.ResultsForty-five patients (mean age 66, 87% females) met inclusion criteria. Average follow-up was 20.3 months. None of the 10 patients (22%) undergoing EGR had prior surgery. Of 35 patients (78%) undergoing OGR, 12 (27%) had prior hip replacement (75% via lateral approach). The OGRs had more patients with GFC ≥2 (50% vs 11%, P = .02) and used more anchors (P = .03). Both groups showed statistical improvement (P ≤ .01) for all outcomes measured. GFC >2 was independently associated with a worst limp and Harris Hip Score Section 1 score (P = .05). EGR had a statistically higher opioid use reduction (P < .05) than OGR. Other comparisons between EGR and OGR did not reach statistical significance.ConclusionIn this series, open vs endoscopic operative approach did not impact clinical outcomes. More complex tears were treated open and with more anchors. Fatty degeneration adversely impacted outcomes. Although further evaluation of the efficacy of EGR in complex tears is indicated, both approaches can be used successfully

Clinical measurements versus patient-reported outcomes: analysis of the American Shoulder and Elbow Surgeons physician assessment in patients undergoing reverse total shoulder arthroplasty.

BackgroundThe American Shoulder and Elbow Surgeons (ASES) score is composed of a patient-reported portion and a physician assessment. Although the patient-reported score is frequently used to assess postoperative outcomes after shoulder arthroplasty, no previous studies have used the physician-assessment component. This study evaluated the relationship of the ASES physician-assessment measurements with patient-reported shoulder and general health outcomes.MethodsA retrospective review of a prospectively collected multicenter database was used to analyze patients who underwent primary reverse total shoulder arthroplasty (RTSA) from 2012 to 2015 with a minimum 2-year follow-up. ASES physician-assessment and patient-reported components and 12-Item Short Form Health Survey (SF-12) general health questionnaires were obtained preoperatively and 2 years postoperatively. The relationship between ASES physician measurements with ASES patient-reported outcome (PRO) scores and SF-12 Physical and Mental domain scores was assessed with Pearson correlation coefficients.ResultsIncluded were 74 patients (32 men; mean age, 69.2 years; body mass index, 29.4 kg/m2). Preoperative physician measurements and PRO scores were not significantly correlated. Postoperatively, only the ASES physician-measured active (R = 0.54, P < .01) and passive forward flexion (R = 0.53, P < .01) demonstrated moderate correlation with ASES patient scores. The remaining clinical measurements had no significant correlations with ASES patient or SF-12 scores. During the 2-year period, only improvements in active forward flexion correlated with improvements in ASES patient scores (R = 0.36, P < .01).ConclusionsLittle correlation exists between clinical measurements from the ASES physician component and PROs, including the ASES patient-reported and SF-12 general health surveys, in RTSA patients. Improvement in active forward flexion is the only clinical measurement correlated with PRO improvement at 2 years

Do Outcomes of Arthroscopic Subscapularis Tendon Repairs Depend on Rotator Cuff Fatty Infiltration?

Background:Rotator cuff fatty infiltration has been correlated with poorer radiographic and clinical outcomes in supraspinatus and infraspinatus tendon repairs, but this has not been well-studied in subscapularis tendon repairs. Purpose:To evaluate the influence of preoperative rotator cuff fatty infiltration on postoperative outcomes for patients undergoing arthroscopic subscapularis tendon repair. Study Design:Cohort study; Level of evidence, 3. Methods:Patients who underwent arthroscopic subscapularis repair between 2010 and 2016 were retrospectively identified, and demographic data and surgical findings were recorded. The extent of fatty infiltration was determined on preoperative magnetic resonance imaging by the Fuchs modification of the Goutallier classification. At the most recent follow-up, patients completed the Patient-Reported Outcomes Measurement Information System for Upper Extremity (PROMIS-UE) computer adaptive test and a postoperative visual analog scale for pain. The distribution of fatty infiltration was compared between patients undergoing subscapularis tendon repair versus subscapularis tendon repair combined with a posterior cuff repair. Outcomes were compared for patients using Goutallier grade 0-1 versus grade ≥2 changes in each rotator cuff muscle. Multivariate linear regression analysis was performed to evaluate the influence of muscle quality, as well as demographic factors, on PROMIS-UE scores. Significance was defined as P < .05. Results:There were 140 shoulders included (mean age, 61.8 years; 42.1% female; mean follow-up, 51.7 months). The prevalence of Goutallier grade 2 changes or higher was significantly greater in patients with multitendon repair relative to isolated subscapularis tendon repair. For the overall group of all patients undergoing subscapularis tendon repair, whether in isolation or as part of a multitendon repair, PROMIS-UE scores were significantly lower for patients with infraspinatus muscle grade 2 or higher Goutallier changes relative to grade 0 or 1. After adjustment for age, body mass index, patient sex, and fatty infiltration in other rotator cuff muscles, poor infraspinatus muscle quality remained the only significant predictor for lower PROMIS-UE scores. Conclusion:Patients undergoing arthroscopic subscapularis tendon repair with poor infraspinatus muscle quality had worse patient-reported outcomes. This was true whether subscapularis tendon repair was isolated or was performed in conjunction with supraspinatus and infraspinatus tendon repairs

Use of Air Arthrograms to Aid in Joint Distraction During Hip Arthroscopic Surgery Decreases Postoperative Pain and Opioid Requirements.

BackgroundPositive-pressure air arthrography and venting of the hip capsule are techniques used to decrease the traction forces needed for joint distraction during hip arthroscopic surgery. Little is known about the effects that these techniques have on postoperative pain.HypothesisPositive-pressure air arthrography and venting during hip arthroscopic surgery will decrease patient-reported pain and narcotic requirements in the acute postoperative setting.Study designCohort study; Level of evidence, 3.MethodsA retrospective cohort analysis was conducted to analyze 35 patients who underwent positive-pressure air arthrography and venting to aid joint distraction during hip arthroscopic surgery versus a group with similar demographics, pathologies, and treatments who did not undergo air arthrography. Numeric pain rating scale (NPRS) scores and medication administration including narcotic and nonnarcotic analgesia in the postanesthesia care unit (PACU) were tracked and compared.ResultsThe maximum (7.17 vs 4.97, respectively), minimum (2.43 vs 1.09, respectively), and mean (5.15 vs 3.11, respectively) NPRS scores were all higher in the control group compared with the air arthrogram group (P < .001, P = .007, and P < .001, respectively). The administration of oral morphine equivalents (OMEs) during the PACU stay was significantly lower in the air arthrogram group, with a mean of 36.75 ± 11.37 OMEs, compared with 44.53 ± 16.06 OMEs in the control group (P = .023). There was no difference in postoperative nonopioid medications, such as ketorolac or acetaminophen, given between groups.ConclusionPatients undergoing hip arthroscopic surgery with air arthrography and venting used to aid distraction had significantly less postoperative pain and required a lower total dosage of opioids during their PACU stay when compared with patients who underwent hip arthroscopic surgery without air arthrography