Hudgens, Joshua L.

AbstractPurposeCurrently, there is a paucity of literature regarding outcomes after isolated labral debridement. The purpose of this study was to (1) report the reoperation rate following isolated labral debridement, (2) report clinical and functional outcomes after labral debridement with a minimum 2‐year follow‐up and (3) identify risk factors for worse clinical and functional outcomes. It was hypothesized that inferior outcomes are associated with an increasing Tönnis grade and those with untreated femoral acetabular impingement (FAI).MethodsThe records of patients undergoing hip arthroscopy between 1998 and 2005 were reviewed. Patients with labral tears who underwent isolated arthroscopic labral debridement were identified. Kaplan–Meier estimate of failure (defined as subsequent surgery) was performed for all patients. Patients with minimum 2‐year follow‐up were assessed with Modified Harris Hip Score (MHHS) and Hip Outcome Score (HOS). Univariate analysis was then performed to assess which factors were associated with worse clinical and functional outcomes.ResultsFifty‐nine hips in 57 patients met our inclusion criteria (39 females, 18 males) with a mean age of 46 ± 14 years and mean follow‐up of 5 (range 2–14) years. Overall, 45 % of the hips failed for repeat surgery (20 %) or rating for hip function as abnormal or severely abnormal (25 %). Twelve hips (20 %) required subsequent surgical intervention at a mean 23 (range 6–60) months (7 total hip arthroplasties, 2 open revisions, 3 arthroscopic revisions). Of the remaining hips, mean MHHS was 83.4 ± 19.7, mean HOS ADL score was 83.8 ± 21.3 and mean HOS sport score was 70.6 ± 32.9, with 33 of 41 (75 %) reporting normal or nearly normal current level of function. Univariate analysis revealed that hips with untreated bony impingement (p = 0.01) or requiring concomitant chondroplasty (p = 0.03) had inferior clinical outcome scores.ConclusionsIsolated arthroscopic labral debridement for hip labral tears had 45 % combined poor results when strictly defining failure as repeat surgery or abnormal hip rating. Untreated FAI and concomitant chondroplasty were risk factors for inferior outcome. We recommend concomitant treatment for bony impingement lesions and preservation of the labrum whenever possible.Level of evidenceRetrospective case series, Level IV.

Abstract Purpose Intra‐articular (IA) hip cortisone injection is commonly performed as a therapeutic modality in patients with femoral acetabular impingement (FAI). To our knowledge, there is no published data evaluating the clinical benefit of these injections. The purpose of this study was to assess the efficacy of therapeutic IA cortisone injection in these patients. Methods At our institution, patients with FAI and labral tear prospectively recorded their numerical rating scale (NRS) pain scores pre‐injection, during post‐injection anaesthetic phase, and at 14 days post‐injection. From this cohort, all patients treated with guided IA cortisone injection, no radiographic evidence of arthritis (Tönnis grade 0 or 1) and pain relief during the anaesthetic phase of the IA injection were included. An absolute change of two points on the NRS score was considered the minimal amount of clinically significant pain relief. Pain scores were compared between the different types of steroid injected. Results Fifty‐four patients (35 females, 19 males) with a mean age of 32 ± 12 years were included. Average median pre‐injection NRS score was 7.0 (range 2.5–10.0), post‐injection anaesthetic phase was 1.0 (range 0.0–5.0), and 14 day post‐injection was 5.0 (range 0.0–10.0). As a group, NRS scores significantly diminished from post‐injection anaesthetic phase to 14 days post‐injection ( p < 0.001). At 14 days post‐injection, only 20 patients (37 %) and at 6 weeks, only 3 patients (6 %) reported a clinically significant decrease in pain. Average duration of pain relief was 9.8 days. There was no difference in pain reduction between steroid preparations. Conclusion In patients with symptomatic FAI and labral tear, intra‐articular cortisone injection has limited clinical benefit as a therapeutic modality. However, anaesthetic‐only IA injections for patients who may be candidates for hip arthroscopy can be a useful diagnostic tool. Level of evidence Therapeutic case series, Level IV.

Objectives: Peroneal nerve injuries are not uncommon with multiligament (ML) knee dislocations. However, there remains little information on outcome of these injuries. Therefore, the purpose of this study was to (1) report the clinical and functional outcomes after ML knee injury with concomitant peroneal nerve palsy, (2) compare recovery and outcome with partial versus complete peroneal nerve injury, (3) compare outcomes to a matched cohort of ML knee injuries without concomitant peroneal nerve palsy. Methods: Patients that underwent surgical reconstruction of a ML knee injury from 1993 to 2010 were reviewed and concomitant nerve injuries were identified, forming the peroneal nerve injury group (PI). Patient demographics, injury mechanism, modified Schenck classification, and peroneal nerve function, treatment, and recovery were documented. Patients were divided into two sub-groups: complete peroneal nerve palsy (CNP) and partial peroneal nerve palsy (PNP). A second group of patients with ML knee injury without peroneal nerve injury were identified, forming the no nerve injury group (NI). The PI and NI groups were matched based on Modified Schenck Classification, age, and gender. Peroneal nerve motor grade was assessed at last clinical follow-up and outcome scores were obtained using the International Knee Documentation Committee (IKDC) and Lysholm forms at a minimum of 2 years post-op. Data was analyzed using univariate and multivariate models to assess for predictive factors between the groups. Results: 27 patients (24 males, 3 females) met inclusion criteria for the PI group (9 CNP and 18 PNP). Treatment for CNP included an AFO for all patients, non-operative (1), neurolysis (2), tendon transfer (3), nerve transfer (1), and combined nerve/tendon transfer (1). One patient in the CNP group required additional surgery, undergoing below knee amputation. Treatment for PNP included non-op (12), neurolysis (4), nerve transfer (1), and combined nerve/tendon transfer (1). 2 patients with incomplete nerve palsy required additional surgery, undergoing an arthrodesis and a total knee arthroplasty. 3 CNP (37.5%) and 15 PNP (83.3%) regained 3/5 or greater tibialis anterior (TA) strength. PNP was associated with increased recovery of 3/5 extensor hallucis longus (EHL) strength (p=0.0093). Outcome scores were obtained for 17 of the remaining patients at a mean 6.6 (range 2-18) years. Univariate analysis revealed no difference between the CNP and PNP groups. Final motor grade of 3/5 did not predict improved outcomes. Not undergoing a tendon transfer procedure predicted better outcomes on the IKDC score (70.5 vs 45.0; p=0.027). All other peroneal nerve interventions were not associated with improved motor or functional outcome. 20 patients formed the NI group. The PI and NI groups were matched on gender (18 M, 2 F), age (mean 30.8 vs 29.5 years), and Modified Schenck Classification (2 KD-I, 10 KD-IIIL, 5 KD-IV, 3 KD-V vs 2, 7, 8, and 3 respectively). In univariate analysis, the PI group had inferior outcomes on both the IKDC (64.5 vs 77.3; p=0.036) and Lysholm (67.1 vs 83.0; p=0.023) scores. Conclusion: Patients with partial peroneal nerve palsy are more likely to regain antigravity EHL strength, but not antigravity TA strength. There is no significant difference in outcomes between partial and complete peroneal nerve palsy. In ML knee injuries, patients with peroneal nerve injury have significantly worse outcomes than similar patients without peroneal nerve injury.

The incidence of ACL tears is rising in the pediatric and adolescent populations as these individuals succumb to traumatic and nontraumatic athletic injuries. Management of this condition in the skeletally immature patient poses a challenge and is controversial. Operative reconstruction carries the concern for damage to the physis with resultant limb length inequality and angular joint deformity but provides stability to the knee and allows return of function in most patients. On the other hand, nonoperative treatment has been shown to carry an increased risk of meniscal and articular cartilage damage and is difficult from a compliance standpoint in this demographic. For the majority of skeletally immature patients, operative treatment is recommended as it has shown good clinical and functional results with minimal risk of growth disturbance. This paper aims to address the natural course of ACL injuries in the skeletally immature patient, treatment options with associated complications, and current preventative strategies.