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Background: Hip instability has classically been associated with developmental dysplasia of the hip (DDH) in newborns and children. However, numerous factors may contribute to hip instability in children, adolescents, and adults., Purpose: This review aims to concisely present the literature on hip instability in patients of all ages in order to guide health care professionals in the appropriate diagnosis and treatment of the various disorders which may contribute to an unstable hip., Methods: We reviewed the literature on the diagnosis and surgical management of hip dysplasia and other causes of hip instability., Conclusions: Multiple intra- and extra-articular variables may contribute to hip instability, including acetabular bony coverage, femoral torsion, femoroacetabular impingement, and soft tissue laxity. Physical examination and advanced imaging studies are essential to accurately diagnose the pathology contributing to a patient's unstable hip. Conservative management, including activity modification and physical therapy, may be used as a first-line treatment in patients with intra-articular hip pathology. Patients who continue to experience symptoms of pain or instability should proceed with arthroscopic or open surgical treatment aimed at correcting the underlying pathology., Level of Evidence: V.

This is the first report of the psychobiology of stress in BASE jumpers, one of the most dangerous forms of extreme sport. We tested the hypotheses that indicators of emotional style (temperament) predict salivary cortisol reactivity, whereas indicators of intentional goal-setting (persistence and character) predict salivary alpha-amylase reactivity during BASE jumping. Ninety-eight subjects completed the Temperament and Character Inventory (TCI) the day before the jump, and 77 also gave salivary samples at baseline, pre-jump on the bridge over the New River Gorge, and post-jump upon landing. Overall BASE jumpers are highly resilient individuals who are highly self-directed, persistent, and risk-taking, but they are heterogeneous in their motives and stress reactivity in the Hypothalamic-Pituitary-Adrenal (HPA) stress system (cortisol reactivity) and the sympathetic arousal system (alpha-amylase reactivity). Three classes of jumpers were identified using latent class analysis based on their personality profiles, prior jumping experience, and levels of cortisol and alpha-amylase at all three time points. "Masterful" jumpers (class 1) had a strong sense of self-directedness and mastery, extensive prior experience, and had little alpha-amylase reactivity and average cortisol reactivity. "Trustful" jumpers (class 2) were highly cooperative and trustful individuals who had little cortisol reactivity coincident with the social support they experienced prior to jumping. "Courageous" jumpers (class 3) were determined despite anxiety and inexperience, and they had high sympathetic reactivity but average cortisol activation. We conclude that trusting social attachment (Reward Dependence) and not jumping experience predicted low cortisol reactivity, whereas persistence (determination) and not jumping experience predicted high alpha-amylase reactivity., (Copyright © 2016 The Authors. Published by Elsevier Inc. All rights reserved.)

To investigate the correlation between femoroacetabular cartilage thickness and lateral acetabular coverage in patients undergoing hip arthroscopy for a variety of indications. Articular cartilage at the hip is hypothesized to undergo adaptive change secondary to unique patterns of pathomechanical loading which results in a direct relationship between acetabular coverage and femoroacetabular cartilage thickness. A cohort of 252 patients presenting to our dedicated hip preservation service between June 2013 and June 2015 were retrospectively analysed. Preoperative radiographs and MRI studies were obtained for all symptomatic hips and classified according to radiographic lateral center edge angle (LCEA) as follows: normal acetabular coverage (25-40°), acetabular overcoverage (≥40°), borderline dysplasia (20-24.9°) and frank dysplasia (<20°). Femoroacetabular cartilage thickness was measured on a preoperative MRI-scan at the fovea, middle sourcil, and lateral sourcil. In all groups, cartilage thickness was maximized at the lateral sourcil relative to the middle sourcil or fovea ( P < 0.001). Furthermore, articular cartilage thickness was significantly increased when comparing one group to successive groups with diminished lateral acetabular coverage. Indeed, multivariate analyses confirmed LCEA to be the strongest determinant of femoroacetabular cartilage thickness compared with age, gender, body-mass index or presence of cam/pincer lesions. Patients with borderline and frank dysplasia exhibit increased values of femoroacetabular cartilage thickness in the weight-bearing zone, potentially indicating a compensatory reaction to the lack of bony coverage. Articular cartilage thickness may serve as an instability marker and inform clinical decision-making for patients with borderline dysplasia.

The purpose of this study was to investigate the effect of general anesthesia on preoperative passive hip range of motion (ROM) in patients undergoing hip arthroscopy for various indications. A total of 260 consecutive patients undergoing hip arthroscopy were included in this study. Passive hip ROM was evaluated bilaterally in the clinic and subsequently under general anesthesia immediately preoperatively. Demographic variables, including age, height, weight, and clinical diagnosis, were recorded for all patients. Hips with pincer-type femoroacetabular impingement (FAI) and hips with acetabular dysplasia showed a mean increase of 4° and 6°, respectively, in hip external rotation at 90° of hip flexion (ER-90) with induction of anesthesia (P=.018 and P=.021, respectively). In contrast, a statistically significant reduction in hip abduction (2°) and hip flexion (4°) was observed following induction of anesthesia in healthy contralateral hips of patients presenting with unilateral hip pathology (P=.01 and P<.001, respectively). Hip ROM does not change to a clinically significant extent with induction of general anesthesia. Small increases in external rotation in patients with FAI or acetabular dysplasia are within the standard error for ROM measurements. [Orthopedics. 2016; 39(6):e1165-e1169.]., (Copyright 2016, SLACK Incorporated.)

Acetabular rim fractures, or os acetabuli, are hypothesized to occur as a result of an unfused ossification center or a stress fracture from repetitive impingement of an abnormally shaped femoral neck against the acetabular rim. When treated surgically, these fragments are typically excised as part of the correction for femoroacetabular impingement. However, in some patients, removal of these fragments can create symptoms of gross instability or microinstability of the hip. In these cases, internal fixation of the fragment is necessary. The purpose of this technical note is to describe indications, the arthroscopic technique, and postoperative care for fixation of acetabular rim fractures.

Osteoarthritis of the hip remains a prevalent disease condition that influences ever-changing treatment options. Procedures performed to correct anatomic variations, and, in turn, prevent or slow the progression of osteoarthritis, are aptly referred to as types of hip preservation surgery (HPS). Conditions that predispose individuals to femoroacetabular impingement (FAI), including pincer- and cam-type morphology, and hip dysplasia are specifically targeted in HPS. Common surgical interventions include acetabuloplasty, osteochondroplasty, periacetabular osteotomy (PAO), and derotational femoral osteotomy (DFO). The radiologist's understanding of the surgical approach, pre- and postoperative imaging findings, and common complications of HPS are paramount to providing value to the patient and surgeon. Acetabuloplasty and osteochondroplasty are performed to address pincer- and cam-type morphology in patients with FAI. With both of these HPS techniques, the goal is to restore the normal morphology by resecting excess bone in the acetabulum or femoral head or neck. As a result, a frequently encountered complication is incomplete or excessive resection. Excessive resection can predispose the patient to dislocation in the case of acetabuloplasty and fracture in the case of osteochondroplasty. Iatrogenic injury to adjacent structures such as the ischiofemoral ligament and acetabular cartilage also may occur. Although rare, especially when an arthroscopic approach is used, avascular necrosis remains a risk. Femoral head undercoverage in hip dysplasia is corrected by using PAO, which may be performed as the sole procedure or in conjunction with DFO. Incomplete or excessive rotation during surgery can result in postprocedural complications. As with any orthopedic procedure involving osteotomy, nonhealing is a risk. Iatrogenic injury in the form of fracture or hardware failure also may be seen. © RSNA, 2016.

Cartilage lesions in the hip are of high prevalence. Most of these lesions are treated with microfracture. Microfracture has relatively good subjective outcomes for smaller lesions; however, it is limited by the ability to reproduce hyaline cartilage, especially in older patients. For larger chondral defects, we present a technique using juvenile allograft cartilage implantation implanted arthroscopically to treat cartilage lesions in the hip. The purpose of this technical note is to describe the arthroscopic technique for treating chondral lesions in the hip with allograft juvenile cartilage.

Introduction: Achilles tendon ruptures cause considerable morbidity and functionality reduction. There is lack of consensus regarding the best option for treatment following acute Achilles tendon rupture. Recent studies have failed to show substantial difference in outcome following conservative or operative treatment using an early active rehabilitation program. Meta-analyses have shown that conservative management has increased the risk of re-rupture, whereas operative intervention carries risks of complications related to the wound and iatrogenic nerve injury. This article reviews the updated literature-based guidelines for the treatment of Achilles tendon tears.

Treatment of hip cartilage disease is challenging, and there is no clear algorithm to address this entity. Biomarkers are arising as promising diagnostic tools because they could play a role in the early assessment of the prearthritic joint and as a prognostic factor before and after treatment. The potential effect of biomarkers may be used to categorize individuals at risk of evolving to severe osteoarthritis, to develop new measures for clinical progression of the disease, and to develop new treatment options for the prevention of osteoarthritis progression. A trend toward a less invasive biological treatment will usher in a new treatment era. With the growth of surgical skills in hip arthroscopy, cartilage restoration techniques are evolving in a fast and exponential manner. Biological and surgical treatments have been proposed to treat these pathologies. Biological treatments include platelet-rich plasma, stem cells or bone marrow aspirate concentration, hyaluronic acid, losartan, and fish oil. Surgical treatments include microfracture alone or augmented, direct repair, autologous chondrocyte implantation, matrix-induced chondrocyte implantation, autologous matrix-induced chondrogenesis, mosaicplasty, osteochondral allograft transplantation, and stem cells implanted in matrix (stem cells in membranes/expanded stem cells). This article reviews new evidence available on treatment options for chondral lesions and early osteoarthritis of the hip. [Orthopedics. 2016; 39(4):e715-e723.]., (Copyright 2016, SLACK Incorporated.)

Background: Bony morphological abnormalities of the hip joint are often accompanied by adaptive soft tissue changes. These adaptive changes, if better understood and characterized, may serve to inform clinical decision making., Purpose: To investigate the correlation between the size of the hip labrum and lateral acetabular coverage in patients at our hip preservation clinic., Study Design: Cross-sectional study; Level of evidence, 3., Methods: A cohort of 236 patients seen at a dedicated hip preservation service between June 2013 and June 2015 were retrospectively analyzed. Patients were grouped according to the degree of acetabular coverage, as measured by the lateral center-edge angle (LCEA): normal acetabular coverage (25°-39.9°), acetabular overcoverage (≥40°), borderline dysplasia (20°-24.9°), and frank dysplasia (<20°). Preoperative magnetic resonance imaging was utilized to measure the length of the labrum at 3 locations: laterally, anteriorly, and anteroinferiorly., Results: Frankly dysplastic and borderline dysplastic hips exhibited larger values of labral length at all locations when compared with hips with normal acetabular coverage (P < .001) or acetabular overcoverage (P < .001). Interestingly, mean labral length values in frank dysplasia were statistically similar to corresponding measurements in borderline dysplasia. In hips with frank dysplasia, borderline dysplasia, or normal acetabular coverage, labral length was consistently greatest at the lateral labrum and correspondingly lowest at the anteroinferior labrum (P < .001). In hips with acetabular overcoverage, labral length did not vary significantly between the lateral, anterior, and anteroinferior locations. Multivariate analyses confirmed LCEA to be the strongest predictor of labral length, irrespective of measurement location., Conclusion: Patients with borderline dysplasia and frank dysplasia exhibited increased values of labral length in the weightbearing zone, potentially indicating a compensatory reaction to the lack of bony coverage. Labral length may serve as an instability marker and inform clinical decision making for patients with borderline dysplasia., (© 2016 The Author(s).)

Purpose: To determine the safety and efficacy of hip arthroscopy performed in the peripheral compartment as a diagnostic and therapeutic treatment option for patients with hip pain after hip resurfacing surgery., Methods: Indications for hip arthroscopy after hip resurfacing included patients with a symptomatic hip-resurfaced arthroplasties who did not respond to nonoperative treatment. Patients who underwent a hip arthroscopy after a painful hip resurfacing were included with a minimum of 1 year follow-up. Subgroup analysis was performed according to whether an established diagnosis was made before arthroscopic intervention or not. Subjective measures were based on Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores, and results were calculated and analyzed., Results: We included 68 patients (26 male [38%] and 42 female [62%]) who underwent subsequent hip arthroscopy from a population of 978 consecutive hip-resurfaced arthroplasties performed between 1999 and 2010. The average age was 58 (range, 37 to 78 years). The mean follow-up after hip arthroscopy was 3.4 years (range, 12 months to 5.8 years). Patients who had an established diagnosis (n = 41) before hip arthroscopy showed statistical improvement in their WOMAC scores (7 to 2, P < .001). Only 3 (7%) of these 41 patients failed and were converted to a total hip replacement (THR); however, patients who did not have an established diagnosis (n = 27) before undergoing hip arthroscopy showed statistical worsening of the WOMAC (15 to 21, P = .002). Ten (37%) of these 27 patients without a diagnosis failed and needed to be converted to a THR. A significant correlation was found between the collections found on ultrasound (psoas bursa and/or in the hip joint) and the need for synovectomy (P = .01). The overall revision rate to THR after hip resurfacing in our group of patients was 1.3% (n = 13). Female patients were more likely to require postresurfacing hip arthroscopy with 42 (60%) female to only 26 (40%) male patients undergoing this procedure. In our study population, 70% (14/21, P < .05) of patients with hip pain caused by severe metal synovial reaction or metal-on-metal reaction were women. A total of 5 (7%) patients had minor-to-mild complications after hip arthroscopy., Conclusions: Hip arthroscopy is a safe surgical treatment option for those patients with a painful hip resurfacing arthroplasty. Having an accurate diagnosis before hip arthroscopy improves the likelihood a good outcome., Level of Evidence: Level IV - therapeutic case series., (Copyright © 2016 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Piriformis syndrome is the compression or the irritation of the sciatic nerve by the adjacent piriformis muscle in the buttock leading to symptoms that include buttock pain, leg pain, and altered neurology in the sciatic nerve distribution. Epidemiological figures of the prevalence are unknown, but are estimated to be about 12.2% to 27%. There is no consensus on the diagnostic criteria. Advancement in magnetic resonance imaging allows us to observe unilateral hyperintensity and bowing of the sciatic nerve. The pathophysiology of the disease includes single blunt trauma, overuse causing piriformis hypertrophy, and long-term microtrauma causing scarring. Treatments include physiotherapy, steroid injections, and surgery. Minimally invasive techniques are emerging with the hope that with less postoperative scar tissue formation, there will be less recurrence of the disease. In this chapter, senior author describes his technique for endoscopic sciatic neurolysis.

Patients with developmental dysplasia of the hip often have compensatory labral hypertrophy, which presumably lends stability to an unstable joint. Conversely, patients with acetabular overcoverage may have small or ossified labra. The purpose of this study is to explore the interaction of labral length with the degree of acetabular hip coverage. A retrospective cohort of patients with hip pain presenting to a hip preservation center, who had undergone hip magnetic resonance imaging and AP pelvis radiographs were studied. General linear multivariate models were used to assess the association between three measures of labral length (lateral, anterior and anterior inferior locations along the acetabular rim) and the X-ray derived lateral center edge angle (LCEA) of Wiberg. Of the three acetabular labral locations measured, only the lateral labrum was associated with LCEA Wiberg (P = 0.0008). Lateral labral length increases as LCEA of Wiberg decreases. The anterior and anterior inferior labral locations did not show a predictable increase in labral length as LCEA Wiberg decreased.

Ligamentum teres (LT) tears are increasingly being recognized as a source of pain and dysfunction in the hip. Although debridement for partial tears of the LT has long been established as the standard of care with good pain relief, reconstruction has been successfully performed in select patients to address concerns of persistent symptomatic instability. The current technique for femoral tunnel preparation carries the added morbidity of open dissection in the peritrochanteric space, an unnecessarily long tunnel with excessive bone removal, and a need for a very long graft due to distal fixation at the lateral femoral cortex. To address these shortcomings, we present a technique for arthroscopic femoral tunnel drilling at the level of the head-neck junction, allowing for an all-arthroscopic LT reconstruction.

Acetabular intraosseous cysts are frequently encountered in patients with dysplasia or femoroacetabular impingement. Small cysts are typically addressed by removing the cyst lining and stimulating healing via microfracture or abrasion chondroplasty. In contrast, larger cysts involving 1-3 cm(3) frequently require additional fortification with bone graft material to facilitate osseous ingrowth and cyst healing. Previous arthroscopic reports have described the use of rim trimming to access the extra-articular side of the cyst, with subsequent use of straight metal cannulas for delivery of bone graft material. The downsides of this technique include the requirement for rim trimming, which may be ill advised in patients with normal coverage or dysplasia, as well as the creation of a second breach in the cyst wall, precluding pressurization of the bone graft material. We describe an arthroscopic technique using a curved delivery device allowing for deeper penetration into the cyst cavity through the articular side and greater delivery of bone graft material.

Excessive acetabular anteversion is an important treatment consideration in hip preservation surgery. There is currently no reliable quantitative method for determining acetabular anteversion utilizing radiographs alone. The three main purposes of this study were to: (i) define and validate the neck axis distance (NAD) as a new visual and reproducible semi-quantitative radiographic parameter used to measure acetabular anteversion; (ii) determine the degree of correlation between NAD and computed tomography (CT)-measured acetabular anteversion; (iii) establish a sensitive and specific threshold value for NAD to identify excessive acetabular anteversion. This retrospective cohort study included all patients presenting to a single institution over a 14-month period who had undergone a dedicated musculoskeletal CT pelvis along with a standardized anteroposterior (AP) pelvis radiograph. Trained observers measured the NAD on the AP pelvis radiograph and equatorial acetabular anteversion on CT for all hips. Mixed model analysis was used to find prediction equations, and ROC analysis was used to evaluate the diagnostic accuracy of NAD. NAD is a valid semi-quantitative predictor of acetabular anteversion and strongly correlates with CT-measured equatorial acetabular anteversion (P  <  0.0001). A NAD measurement of greater than 14 mm predicts excessive acetabular anteversion with 76% sensitivity and 78% specificity. NAD is an accurate radiographic predictor of acetabular anteversion, which may be readily used as an effective screening tool during the evaluation of patients with hip pain.

Background: Orientation abnormalities of the acetabulum and femur have been implicated in early-onset coxarthrosis. The purpose of this study was to identify clinical examination findings predictive of such hip morphologies., Methods: A consecutive cohort of 221 patients (442 hips) undergoing hip arthroscopy was included. Demographic characteristics including age, diagnosis, sex, height, weight, body mass index (BMI), and physical activity level were recorded. Passive range of motion was measured for all hips. Preoperative computed tomography scans were utilized to measure femoral torsion and central acetabular version, and a combined femoral torsion-acetabular version (COTAV) index was defined as their sum., Results: The study cohort comprised 221 patients (sixty-four males, 157 females) with a mean age of 32.5 years and mean BMI of 24.2 kg/m(2). Overall, hips with femoral antetorsion and acetabular anteversion exhibited the greatest internal rotation range of motion at a neutral hip position (mean, 44.2°), whereas hips with femoral retrotorsion and acetabular retroversion demonstrated the lowest corresponding value (20.1°; p < 0.001). Femoral torsion was significantly associated with female sex (p < 0.001), BMI (p < 0.001), and presence of pathology corresponding to cam-type femoroacetabular impingement (FAI) (p = 0.044). Central acetabular version was significantly associated with age (p = 0.021), female sex (p < 0.001), and absence of mixed-type FAI pathology (p = 0.025). Increasing age and internal rotation range of motion at a neutral hip position were the most significant predictors of an increased COTAV index., Conclusions: This study confirmed that passive hip range of motion significantly predicts combined femoral torsion and central acetabular version. Accurate clinical assessment of the COTAV index may inform surgical decision-making in hip preservation surgery., (Copyright © 2016 by The Journal of Bone and Joint Surgery, Incorporated.)

Symptomatic anterior instability of the hip is typically iatrogenic in nature and poses a challenging problem for the orthopaedist. With early recognition, capsular repair and plication are often effective in restoring stability. Cases involving multiple instability episodes or those with delayed presentation, however, may have patulous and deficient capsular tissue precluding successful capsulorrhaphy. Capsular reconstruction may play an important role in restoring stability in these difficult cases. We present an arthroscopic technique for iliofemoral ligament reconstruction, with Achilles tendon allograft, to address instability of the hip due to anterior capsular deficiency.

Biomechanical stability is the primary function of the acetabular labrum. It provides a hip suction seal and optimal joint function. Labral tears are a common reason for hip arthroscopy, to improve patient function and to prevent long-term degenerative arthropathy. Arthroscopic labral repair has shown significantly better outcomes in return to premorbid activity levels when compared with labral debridement. Injury to the acetabular labrum is a challenge and can lead to long-term complications. In this scenario, arthroscopic labral reconstruction has shown good results regarding patient subjective and objective outcomes. We describe a technique for complete arthroscopic labral reconstruction using tensor fascia lata allograft.

Labral tears are a significant cause of hip pain and are currently the most common indication for hip arthroscopy. Compared with labral debridement, labral repair has significantly better outcomes in terms of both daily activities and athletic pursuits in the setting of femoral acetabular impingement. The classic techniques described in the literature for labral repair all use loop or pass-through intrasubstance labral sutures to achieve a functional hip seal. This hip seal is important for hip stability and optimal joint biomechanics, as well as in the prevention of long-term osteoarthritis. We describe a novel eversion-inversion intrasubstance suturing technique for labral repair and reconstruction that can assist in restoration of the native labrum position by re-creating an optimal seal around the femoral head.

Objectives: This study has three aims: (1) validate a new radiographic measure of acetabular version, the transverse axis distance (TAD) by showing equivalent TAD accuracy in predicting CT equatorial acetabular version when compared to a previously validated, but more cumbersome, radiographic measure, the p/a ratio; (2) establish predictive equations of CT acetabular version from TAD; (3) calculate a sensitive and specific cut point for predicting excessive CT acetabular anteversion using TAD., Materials and Methods: A 14-month retrospective review was performed of patients who had undergone a dedicated MSK CT pelvis study and who also had a technically adequate AP pelvis radiograph. Two trained observers measured the radiographic p/a ratio, TAD, and CT acetabular equatorial version for 110 hips on a PACS workstation. Mixed model analysis was used to find prediction equations, and ROC analysis was used to evaluate the diagnostic accuracy of p/a ratio and TAD., Results: CT equatorial acetabular version can accurately be predicted from either p/a ratio (p < 0.001) or TAD (p < 0.001). The diagnostic accuracies of p/a ratio and TAD are comparable (p =0.46). Patients whose TAD is higher than 17 mm may have excessive acetabular anteversion. For that cutpoint, the sensitivity of TAD is 0.73, with specificity of 0.82., Conclusion: TAD is an accurate radiographic predictor of CT acetabular anteversion and provides an easy-to-use and intuitive point-of-care assessment of acetabular version in patients with hip pain.

Purpose: Syndesmotic sprains are uncommon injuries that require prolonged recovery. The influence of ultrasound-guided injections of platelet-rich plasma (PRP) into the injured antero-inferior tibio-fibular ligaments (AITFL) in athletes on return to play (RTP) and dynamic stability was studied., Methods: Sixteen elite athletes with AITFL tears were randomized to a treatment group receiving injections of PRP or to a control group. All patients followed an identical rehabilitation protocol and RTP criteria. Patients were prospectively evaluated for clinical ability to return to full activity and residual pain. Dynamic ultrasound examinations were performed at initial examination and at 6 weeks post-injury to demonstrate re-stabilization of the syndesmosis joint and correlation with subjective outcome., Results: All patients presented with a tear to the AITFL with dynamic syndesmosis instability in dorsiflexion-external rotation, and larger neutral tibia-fibula distance on ultrasound. Early diagnosis and treatment lead to shorter RTP, with 40.8 (±8.9) and 59.6 (±12.0) days for the PRP and control groups, respectively (p = 0.006). Significantly less residual pain upon return to activity was found in the PRP group; five patients (62.5 %) in the control group returned to play with minor discomfort versus one patient in the treatment group (12.5 %). One patient in the control group had continuous pain and disability and subsequently underwent syndesmosis reconstruction., Conclusions: Athletes suffering from high ankle sprains benefit from ultrasound-guided PRP injections with a shorter RTP, re-stabilization of the syndesmosis joint and less long-term residual pain., Level of Evidence: II.

Unlabelled: We prospectively evaluated the degree of absolute agreement between measurements of lateral center-edge angle (LCEA) on plain radiography (XR) and computed tomography (CT) in a consecutive cohort of 205 patients (410 hips) undergoing hip arthroscopy. Preoperative measurements of the LCEA were performed bilaterally utilizing standardized anteroposterior radiographs and coronal reformatted CT scans. Demographic variables including age, gender, height, weight, BMI and clinical diagnosis were recorded for all patients. Overall, measured values of the LCEA were 2.1° larger on CT compared with XR (32.9° versus 30.8°, P < 0.001). Subgroup analysis revealed the highest mean difference in hips with acetabular dysplasia and concomitant cam-type femoroacetabular impingement (FAI) [mean difference (CT-XR) 5.5°, 95% confidence interval (CI) 3.7°-7.3°, P = 0.011], followed by hips with isolated acetabular dysplasia (mean difference [CT-XR] 4.9°, 95% CI 2.7°-7.0°, P < 0.001). In contrast, 119 (29.0%) of the hips demonstrated larger measurements of the LCEA on 25 XR relative to CT. Of these hips, 20 (16.8%) had pincer-FAI and 25 had cam-FAI (21.0%), representing a significantly higher proportion compared with all other clinical subgroups (P = 0.045 and 0.036, respectively). Our study demonstrates measured values of the LCEA are consistently inflated on CT relative to XR for a wide variety of hip pathologies, highlighting the need for standardization and validation of CT-based measurements to improve the quality of clinical decision making., Level of Evidence: Diagnostic Level II.

Background: chronic proximal hamstring tendinopathies is a disabling activity related condition. Currently, there is no well-accepted or extensively documented non-operative treatment option that provides consistently successful results., Purpose: to evaluate the efficacy of ultrasound guided platelet-rich plasma injections in treating chronic proximal hamstring tendinopathies., Methods: a total of 18 consecutive patients were retrospectively analyzed. All patients received a single injection of platelet rich plasma via ultra-sound guidance by a single radiologist. Outcome measures included a questionnaire evaluating previous treatments, visual analog scale (VAS) for pain, subjective improvement, history of injury, and return to activity., Results: the patient population included 12 females and 6 males. The average age at the time of the injection was 42.6 years (19-60). Provocative activities included running, biking, swimming. The average body mass index of patients was 22.9 (17.2-30.2). The average time of chronic pain prior to receiving the first injection was 32.6 months (6-120). All patients had attempted other forms of non-surgical treatment prior to entering the study. The average VAS pre-injection was 4.6 (0-8). Six months after the injection, 10/18 patients had 80% or greater improvement in their VAS. Overall, the average improvement was 63% (5-100). The only documented side effect was post-injection discomfort that resolved within seventy-two hours., Conclusion: chronic hamstring tendinopathy is a debilitating condition secondary to the pain, which limits an athlete's ability to perform. For refractory cases of chronic insertional proximal hamstring injuries, platelet-rich plasma injections are safe and show benefit in the majority of patients in our study, allowing return to pre-injury activities., Study Design: Case series; Level of evidence, 4.

Background: suturing techniques employed to close subcuticular surgical incisions are varied., Purpose: we present the "bow-tie" stitch, which is removed by pulling one side of the stitch with no need for sharp object stitch cutting. The stitch results in good approximation and scarring while enabling proper oozing., Methods: we have used this suture repeatedly for wound closure after hip and knee arthroscopy; its application to other superficial skin closures is easily appreciated., Results: this method of skin closure allows for ease of tying for the surgeon, aesthetically pleasing results for the patient, pain-free suture removal, no risk of suture knots becoming embedded in healing tissue, and decreased risk of infection and damage to skin, as instruments are not required for suture removal.

Purpose: The purpose of this study was to determine whether hip arthroscopy can be performed using conventional knee-length arthroscopy instrumentation., Methods: We included 116 consecutive hip arthroscopies (104 patients) in this study. Age, side of surgery, height (in inches), weight (in pounds), body mass index (BMI), and a subjective assessment of body type (1, muscular; 2, somewhat overweight; 3, overweight; 4, thin; and 5, normal weight) were recorded. The depth from the skin at 2 portal sites to 3 commonly accessed positions (12 o'clock, 3 o'clock, and acetabular fossa) was assessed using a guide with marked notches (in millimeters). Subgroup analysis was performed according to BMI and subjective biotype for each patient., Results: We included 104 patients with a mean age of 35 years (range, 14 to 55 years). As categorized by BMI, 60% of patients were normal weight, 22% were overweight, 16% were obese, and 2% were underweight. All but 8 procedures were performed with conventional knee-length arthroscopic shavers and burrs. The 8 procedures that needed additional hip instrumentation were performed in patients who required ligamentum teres debridement or those with iliopsoas tenotomy. Overall, the distance from skin to socket was less than 11 cm at the 12-o'clock and 3-o'clock positions from both the anterolateral and anterior portals. Obese and overweight patients had statistically longer distances from skin to socket at all 3 measurement points compared with underweight and normal-weight patients. Considering biotype, the distances from skin to socket in underweight, normal-weight, and muscular patients were all equal to or less than 10 cm., Conclusions: The distance from skin to socket at the 12- and 3-o'clock positions is less than 11 cm, suggesting that hip arthroscopy can be performed with conventional knee-length instrumentation devices. In obese and overweight patients and patients requiring ligamentum teres debridement or iliopsoas tendon release, specific hip arthroscopic tools should be available., Level of Evidence: Level IV, therapeutic case series., (Copyright © 2014 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Objective: Mountaineering and mountain-related sports are growing in popularity and are associated with significant risk of injury. There is a perception that mountaineers possess unique personality characteristics that attract them to the sport. We aim to determine whether there are any identifiable differences between the personality characteristics of experienced mountaineers and a normal control population and to determine whether there is an association between specific personality traits and risk of injury., Methods: Questionnaires were utilized to obtain data on demographics, accidents, and personality characteristics from a population of experienced mountaineers. The Temperament and Character Inventory (TCI) was used, and the results were compared with normative data from age-matched controls., Results: Forty-seven mountaineers from 8 different countries enrolled in the study. The mean age was 33 years, and 44 (90%) had been mountaineering for more than 5 years. Twenty-three climbers (49%) had been involved in a total of 33 accidents. Mountaineers scored higher on novelty seeking (P < .05) and self-directedness (P < .05) and lower on harm avoidance (P < .001) and self-transcendence (P < .001). There was a significant association between the character measure of cooperativeness and the total number (-.33, P < .05) and severity (-.475, P < .05) of accidents., Conclusions: Mountaineering is associated with significant risk of injury. Wide variation in the scores of personality traits suggests that there is not a tightly defined personality profile among mountaineers. Scores on cooperativeness may assist in determining risk of injury in mountaineers., (Copyright © 2014 Wilderness Medical Society. All rights reserved.)

Femoral derotational osteotomy is an acceptable treatment for excessive femoral torsion. The described procedure is a minimally invasive single-incision technique based on an intramedullary saw that enables an inside-out osteotomy, preserving the periosteum and biological activity in the local bone and soft tissue. After the osteotomy is complete and correction is achieved, an expandable intramedullary nail is used to achieve immediate stability, without the need for locking screws. Indications, tips, and pitfalls related to this novel osteotomy technique are discussed., (Copyright 2014, SLACK Incorporated.)

Labral tears are a significant cause of hip pain and are currently the most common indication for hip arthroscopy. Compared with labral debridement, labral repair has significantly better outcomes in terms of both daily activities and athletic pursuits in the setting of femoral acetabular impingement. The techniques described in the literature all use anchor placement on the capsular aspect of the acetabular rim, which can be difficult especially anteriorly, where the rim is very thin, and has the potential for significant complications. Anchor breakage, anchor slippage into the surrounding (capsular side) soft tissue, and penetration of the cartilage surface are among the most common complications. We describe an intra-articular anchor placement technique for labral repair from inside out. This technique, because of the location of the anchor and direction of suture pull, can assist in labral advancement in cases in which the native labrum fails to create a seal because of its location away from the femoral head.

The function of the ligamentum teres remains poorly understood, but tears have been recognized as a source of hip pain. In some patients with complete ligamentum teres tears, symptoms of instability are described. Microinstability and excess motion are hypothesized to be a source of pain and mechanical symptoms. Efforts in recent years to improve symptoms have led to the development of techniques used to reconstruct the ligamentum teres, with some early evidence that reconstruction can improve symptoms in appropriately selected patients. We describe our technique for ligamentum teres allograft reconstruction using anchors made only of suture seated in the acetabular floor.

Sural nerve injury is a relatively common complication after surgery on the Achilles tendon. Studies to determine the course of the sural nerve have been performed on cadaveric specimens. The purpose of this cross-sectional study was to use ultrasound to determine the relations of the sural nerve in a healthy population. The authors performed ultrasound examination of the posterior triangle of the ankle and Achilles tendon to determine the course of the sural nerve relative to the Achilles tendon in healthy participants. The mean distance between the nerve and the tendon was 21.48, 11.47, 5.8, and 0.81 mm lateral to the Achilles tendon as measured at the insertion and 4, 8, and 11 cm proximally, respectively. Male participants tended to have a nerve that was initially more lateral to the Achilles insertion compared with women. The distance between the sural nerve and the Achilles tendon was found to be lower in older participants, with the nerve passing significantly closer to the tendon at all levels (P<.01). Three anatomical variants were reported, with the nerve crossing the lateral border of the Achilles low or high or with multiple branches yet to converge. The course of the sural nerve can be visualized and plotted relative to the Achilles tendon using ultrasound examination in healthy participants. Older patients may be at an increased risk of iatrogenic nerve injury because the nerve courses closer to the Achilles tendon than that in young patients. Intraoperative ultrasound examination may be a useful modality to prevent sural nerve injury during Achilles tendon surgery., (Copyright 2014, SLACK Incorporated.)

Purpose: The purpose of this study was to investigate whether, in patients with bilateral symptomatic femoroacetabular impingement, bilateral surgery under 1 anesthetic is safe and efficacious and allows a rapid return of function compared with staged procedures., Methods: Three groups were evaluated: in group 1 both hips were treated simultaneously, in group 2 both hips were treated in a staged fashion, and in group 3 a single hip was addressed. The outcome measures were anesthesia and surgical times; time in the hospital; visual analog scale score for pain on postoperative days 1, 3, 7, and 30; analgesic use; and time until the patient could bike, drive, perform office work, perform gym activities, run, and return to play. Midterm evaluation was performed with the Non-Arthritic Hip Score and Western Ontario and McMaster Universities Osteoarthritis Index score at 6 and 12 months postoperatively., Results: We enrolled 76 patients (122 hips) in this study. There were 42 male and 34 female patients. The mean age was 33 years (range, 14 to 50 years), and the mean body mass index was 24 (range, 18 to 35). Group 1 comprised 26 patients (52 hips, 16 male and 10 female patients). Group 2 comprised 20 patients (40 hips, 13 male and 7 female patients), with a mean time between surgeries of 14.56 weeks. Group 3 comprised 33 patients (30 hips, 13 male and 17 female patients). No preoperative differences were found between the groups. The surgical and anesthesia times in group 1 were significantly longer than those in groups 2 and 3. We found no significant differences in postoperative visual analog scale scores, analgesic use, or length of hospital stay. Group 1 required more time before patients were able to ride a stationary bicycle (14.7 days in group 1, 7.8 days in group 2, and 8.5 days in group 3; P < .05). We found no differences between the groups regarding when patients returned to driving, performing office work, or reporting a normal gait. Each group had significant improvements in the Western Ontario and McMaster Universities Osteoarthritis Index and Non-Arthritic Hip Score at 6 and 12 months compared with preoperatively (P < .05). No significant differences in outcome scores were found in the 3 groups before surgery and at 6 or 12 months after surgery., Conclusions: Simultaneous femoroacetabular impingement surgery does not lead to higher rates of complications, postoperative pain, analgesic use, or side effects. The return to daily activities is similar to a single-hip procedure with the advantage of a single rehabilitation., Level of Evidence: Level III, retrospective comparative study., (Copyright © 2014 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Objective: To analyze fatality data associated with wingsuit use in an international case series of fixed-object sport parachuting (BASE jumping) to identify incident and injury mechanisms and to form a basis for potential prevention measures and future safety recommendations., Methods: A descriptive epidemiological study was performed of fatal injury events occurring in wingsuit BASE jumping. Fatalities (n = 180) were sequentially analyzed assessing human, equipment, and environmental factors from 1981 to 2011. Main outcome measures included descriptions of typical fatal incident and injury mechanisms., Results: Of the 180 fatal events, 39 (22%) were related to use of wingsuits; 38 (97%) launched from cliffs and 1 (3%) from a building. Of the 39 fatalities, 19 (49%) were caused from cliff strikes, 18 (46%) from ground impact, and 1 (3%) from a building strike. Thirty-eight (97%) of the fatalities were male. During 2002 to 2007 there was a total of 61 BASE jumping deaths, 10 (16%) of which were related to the use of wingsuits, whereas during 2008 to 2011 there was a total 59 fatal events, of which 29 (49%) were related to the use of wingsuits. Seventeen fatalities (39%) were attributed to wingsuit path miscalculation. In the first 8 months of 2013, 17 of 19 (90%) fatalities were wingsuit related. Most fatalities occurred between April and October, reflecting a seasonal increase in activity in the northern hemisphere summer., Conclusions: Wingsuit-related BASE jump fatalities appear to be increasing as wingsuit BASE jumping increases in popularity. Most fatalities are attributed to cliff or ground impact, and are mostly the result of flying path miscalculation., (Copyright © 2013 Wilderness Medical Society. Published by Elsevier Inc. All rights reserved.)

Chronic, exercise-related groin pain is a debilitating condition. Nonoperative treatment has limited efficacy, but surgical intervention on the adductor-abdomino complex may be used to alleviate symptoms and allow return to play (RTP). The purpose of this study was to report the outcome of adductor tenotomy and hernioplasty for professional soccer players with groin pain. Between 2000 and 2006, a total of 155 professional and recreational soccer players with recalcitrant groin pain (with or without lower abdominal pain) and resistance to conservative treatment were included in this retrospective analysis. Ninety-six patients were treated with adductor tenotomy and 59 patients were treated with combined adductor tenotomy and hernioplasty. No difference in pre- or postoperative parameters was detected between groups, apart from abdominal wall muscle defects revealed during ultrasound for patients in the combined group. The RTP time and subjective and objective outcome measures were compared. A combined score was developed to evaluate outcomes that consisted of overall satisfaction (50%), RTP time (15%), and Tegner scores (35%). Mean RTP was 11 weeks (range, 4-36 weeks). Postoperative Tegner score remained 8.2 (same as the preinjury Tegner score). Subjective outcome was rated 4.3 of 5. The combined score indicated 80% of good or excellent results for both groups. Surgical intervention allows RTP at the same level in professional soccer players following failure of nonoperative treatments. Athletes with adductor syndrome and accompanying sportsman's hernia may benefit from adductor tenotomy alone., (Copyright 2013, SLACK Incorporated.)

A comprehensive knowledge of normal hip anatomy and imaging techniques is essential in the evaluation and assessment of the patient with hip pain. This article reviews the osseous, soft tissue, and vascular components of the hip and the normal anatomical variants encountered in routine hip imaging. Basic and advanced hip imaging is discussed with particular emphasis on radiographic and computed tomography measurements and their utility in evaluating patients with developmental hip dysplasia and femoroacetabular impingement syndrome., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Background: Randomized studies have so far failed to show a difference in outcome between operative and nonoperative management of Achilles tendon rupture, provided that no rerupture occurs. Percutaneous Achilles repair has been suggested to result in superior patient satisfaction compared with open repair in patients with an acute Achilles tendon rupture, but there are no outcome data available with validated methods describing the progression of recovery during the first year., Purpose: To evaluate the outcome of patients with a ruptured Achilles tendon, managed by percutaneous repair, during the first year following repair with a valid, reliable, and responsive outcome measure. Furthermore, the effects of time between injury and surgery, age, and complications on outcome were also evaluated., Study Design: Case series., Methods: A total of 73 patients (60 males and 13 females) with a mean age of 45.5 years were included. Patient age, length of time between injury and surgery, and complications were documented. Patients were evaluated using the Achilles tendon Total Rupture Score (ATRS) at 3, 6, 9, and 12 months following repair., Results: The median ATRS results at 3, 6, 9, and 12 months were 42.5, 73, 83, and 89, respectively. The number of patients who reported excellent or good scores (ATRS >84) at 3, 6, 9, and 12 months were 3%, 36%, 57%, and 69%, respectively. There were no significant differences in outcome at each time point for those patients undergoing early (≤48 hours) compared with late surgery or between those <65 and those >65 years of age. The complication rate was 13.5%. Patients who had a complication had a lower ATRS result at 3 months following surgery, but there were no differences after that time point., Conclusion: The patients in the present study reported marked improvement in function between 3 and 6 months following surgery, with continuing but less steep improvement up to 1 year following surgery. The presence of a complication other than rerupture did not affect the end-stage outcome but did affect that at 3 months following surgery., Clinical Relevance: This study demonstrates improving scores with time over the first year following surgery, against which other treatment methods can be compared.

Purpose: The Achilles tendon Total Rupture Score (ATRS) was developed because of the need for a reliable, valid and sensitive instrument to evaluate symptoms and their effects on physical activity in patients following either conservative or surgical management of an Achilles tendon rupture. Prior to using the score in larger randomized trial in an English-speaking population, we decided to perform reliability, validity and responsiveness evaluations of the English version of the ATRS. Even though the score was published in English, the actual English version has not be validated and compared to the results of the Swedish version., Methods: From 2009 to 2010, all patients who received treatment for Achilles tendon rupture were followed up using the English version of the ATRS. Patients were asked to complete the score at 3, 6 and 12 months following treatment for Achilles tendon rupture. The ATRS was completed on arrival in the outpatient clinic and again following consultation., Results: The outcomes of 49 (13 female and 36 male) patients were assessed. The mean (SD) age was 49 (12) years, and 27 patients had treatment for a left-sided rupture, 22 the right. All patients received treatment for ruptured Achilles tendons: 38 acute percutaneous repair, 1 open repair, 5 an Achilles tendon reconstruction using a Peroneus Brevis tendon transfer for delayed presentation, 1 gracilis augmented repair for re-rupture and 4 non-operative treatment for mid-portion rupture. The English version of ATRS was shown to have overall excellent reliability (ICC = 0.986). There was no significant difference between the results with the English version and the Swedish version when compared at the 6-month- or 12-month (n.s.) follow-up appointments. The effect size was 0.93. The minimal detectable change was 6.75 points., Conclusions: The ATRS was culturally adapted to English and shown to be a reliable, valid and responsive method of testing functional outcome following an Achilles tendon rupture.

Purpose: The purpose of this study was to investigate and validate the accuracy and safety of a technique using an anterior approach for non-image-guided intra-articular injection of the hip by use of anatomic landmarks., Methods: We enrolled 55 patients. Injections were performed before supine hip arthroscopy after landmarking and before application of traction. After the needle insertion, success was confirmed with an air arthrogram and by direct visualization after arthroscope insertion. Accuracy and difficulty achieving correct needle placement were correlated with age, weight, height, body mass index, body type, gender, and surgical indication, as well as femoral and pelvic morphology. Forty-five patients who underwent injection in the office were followed up separately to document injection side effects. Needle placement accuracy was correlated to patients' demographics. All statistical tests with P values were 2 sided, with the level of significance set at P < .05., Results: There were 51 correct needle placements and 4 misses, yielding a 93% success rate. The most common location for needle placement was the upper medial head-neck junction. Female gender was correlated with a more difficult needle placement and misses in relation to group size (P = .06). The reasons for misplacements of the needle were a high-riding trochanter, increased femoral version, thick adipose tissue over the landmarks, and variant of ilium morphology. Of 45 patients in the side effect study arm, 3 reported sensory changes of the lateral femoral cutaneous nerve that resolved within 24 hours., Conclusions: Hip injections by use of the direct anterior approach, from the intersection of the lines drawn from the anterior superior iliac spine and 1 cm distal to the tip of the greater trochanter, are safe and reproducible. Patient characteristics, such as increased subcutaneous adipose tissue or osseous anatomic variants, can lead to difficulty in placing the needle successfully. These characteristics can be predicted with the aid of physical examination and careful study of the pelvic radiographs., Level of Evidence: Level IV, therapeutic case series., (Copyright © 2013 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: Dynamic US examination is a convenient, accurate, inexpensive and reproducible diagnostic tool for assessing the integrity of the distal tibiofibular syndesmosis in ankle injuries. However normal values for physiological functional widening of the anterior tibiofibular clear space in healthy subjects has yet to be determined. The purpose of this study was to determine normal values for the syndesmosis clear space on ultrasound examination., Methods: We evaluated 110 healthy subjects. A dynamic U.S examination was performed in neutral (N), forced internal rotation (IR) and external rotation (ER) of the ankle. In each position the anterior tibiofibular clear space was measured at the level of the anterior inferior tibio-fibular ligament (AITFL). Height and calf length were also recorded. Results were analyzed in relation to age, activity, dominant leg and gender., Results: Mean age was 32 years (range 16-60). There were 59 males and 51 females. 60% were professional athletes. Mean height was 173 cm (range 149-192). Functional Mean position measurements for clear space opening were: N=3.7mm, IR=3.6mm and ER=4.0mm. In younger men and women the clear space was significantly wider in neutral (Men: Y=3.8, O=3.4 \ Women: Y=3.8, O=3.4) and with rotational force application (Men ER: Y=4.1, O=3.6 \ Women ER: Y=4.1, O=3.8) compared to older subjects (p<0.05). There was no correlation with activity, height or the leg length.Females had a higher syndesmosis widening ratio (ER/N) under stress than males (p<0.01) this tended to occur more commonly in active subjects., Conclusions: Normal values for the syndesmosis clear space on ultrasound examination were determined as 3.78mm in neutral, 3.64mm in internal rotation and 4.08mm in external rotation. The clear space was shown to decrease with age both as an absolute measure and when rotational stresses are applied. Females tend to have a larger clear space and a greater functional widening.These findings provide a useful reference for radiologists and sports physicians when performing ultrasound assessment of ankle syndesmotic injuries and we encourage use of this modality.

We evaluated the efficacy of intra-articular viscosupplementation with sodium hyaluronate in the management of osteoarthritis of the subtalar joint. A total of 22 patients, aged 22 to 72 years (mean 53), with symptomatic subtalar joint osteoarthritis of 1 to 20 years' duration (mean 4.2) and a severity of Kellgren-Lawrence grade II to IV and Paley and Hall grade 1 to 3, were entered into the present study. Intra-articular injections of 10 mg sodium hyaluronate (Euflexxa) were administered weekly to the subtalar joint for 3 weeks. Clinical evaluations and objective scoring using the American Orthopaedic Foot and Ankle Society Ankle Hindfoot score, visual analog scale, maximum walking distance, pain frequency, and subjective global function were performed at baseline and 4, 12, and 28 weeks after treatment. Significant improvement occurred in the American Orthopaedic Foot and Ankle Society Ankle Hindfoot scores (baseline score 54.5, week 28 score 73.7; p < .01) and visual analog scale assessment (baseline pain, stiffness, and function score 5.4, 5.8, and 6.9; week 28 pain, stiffness, and function score 2.8, 3.1, and 3.8, respectively; p < .01). Global assessment showed improvement in 18 of 20 patients completing the study (p < .01). The tolerated walking distance significantly improved from 770 ± 886 m to 2,075 ± 1,500 m (p < .001). Improvement lasted for more than 6 months. Intra-articular injection of sodium hyaluronate should be considered in the conservative management of subtalar osteoarthritis., (Copyright © 2013 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Surgeons use hip arthroscopy to address intra-articular pathology of the hip. To access the central compartment, traction must be applied to the leg. Various types of equipment and techniques have been used, but many have limitations. Improved ability to assess the offending pathology is achieved with improved ability to move the hip joint in space during surgery. Dynamic assessment of femoroacetabular impingement allows the surgeon to gauge the adequacy of resection. We describe the use of an articulated traction device that allows complete surgeon control over the leg position, as well as the freedom to place the leg in virtually any position with ease, unencumbered by the mechanics of a standard traction table. This device provides the surgeon with an improved ability to dynamically assess the hip and removes some of the responsibility of the operating room staff for intraoperative leg positioning.

Hip arthroscopy is being used with increasing frequency as the understanding of arthroscopic management of groin pain improves. To access the hip joint arthroscopically, traction must be placed on the leg. In most cases, countertraction is provided with a padded post in the groin. Complications of traction are often attributed to the post and include perineal or pudendal neuropraxias and skin complications. The purpose of this study was to investigate the safety of a traction technique that avoids a perineal post. A supine position is used with the foot in a standard traction boot. The patient is moved down the table such that his or her perineum is located 7 to 10 cm proximal to the traction post. The post is also located 5 to 10 cm lateral to midline. The operative table is placed in 15° to 20° of Trendelenburg. With this position, enough friction is generated between the patient's upper body and bed to allow successful hip distraction without the post contacting with the perineum. One hundred seventy patients (111 men and 59 women) were followed prospectively and evaluated for possible side effects of this traction technique immediately postoperatively and 1 and 14 days and 3 and 6 months postoperatively. Patients were examined at each visit. No significant complications related to traction occurred during follow-up. The described technique has been used in more than 2000 hip arthroscopies without a documented groin or perineal complication. It allows easy positioning and access to the central compartment., (Copyright 2013, SLACK Incorporated.)

Capsulotomy, which is commonly performed in hip arthroscopy, assists visualization and instrument navigation. Despite the necessity, the optimal technique, amount of resection, and indications for capsulotomy remain unknown. Capsular repair is increasingly considered because of concerns raised about the long-term effects of extensive capsulotomies and reports of devastating postoperative side effects. It was recently recommended that any patient undergoing hip arthroscopy with a large capsular defect or ligamentous laxity should be considered for capsular repair and/or plication. We present a novel technique for capsular repair using the SpeedStitch device (ArthroCare, Austin, TX), originally designed for shoulder rotator cuff repair. This capsular repair technique has proven to be easy, fast, and reproducible. If performed in the correct manner, this technique has the potential to preserve the anatomy and integrity of the iliofemoral ligament and reduce the rates of postoperative instability and pain.

Objective: To report the demographic characteristics, injury rate, severity, and morbidity in BASE jumping., Design: Cross-sectional survey., Setting: BASE jumping group meetings from 2006 to 2010., Participants: Heterogenic group of 102 International BASE jumpers., Assessment of Risk Factors: Injuries reported as function of jumps made, jumping days, age, experience, and sex., Main Outcome Measures: Incidence, severity, and type of injuries., Results: Responses from 68 subjects were available for analysis. The median number of jumps was estimated at 286 per respondent. The median time respondents had participated in BASE jumping was 5.8 years. There were 39 reported severe injuries sustained by 29 different jumpers. Nineteen thousand four hundred ninety-seven jumps were reported, resulting in 2 severe injuries per 1000 jumps (0.2% severe injury rate) or 2.6 severe injuries per 1000 jumping days. Forty-nine respondents (72%) had witnessed the death or serious injury of other participants in the sport. Twenty-four accidents (61%) involved the lower limbs, 8 (20%) the back/spine, 7 (18%) the chest wall, and 5 (13%) were a head injury. The mean Abbreviated Injury Score was 3.2 (range, 2-5). Fifteen (52%) of the 29 injured jumpers required 20 acute surgical interventions, which were mostly orthopedic related. There was a significant correlation between number of jumps made and injuries sustained (P < 0.05)., Conclusions: BASE jumpers have an average of 1 severe injury for every 500 jumps. Most active BASE jumpers have witnessed death or severe injury of a participant and have experienced a "close call" incident.

Background: Nonoperative options for osteochondral lesions (OCLs) of the talar dome are limited, and currently, there is a lack of scientific evidence to guide management., Purpose: To evaluate the short-term efficacy and safety of platelet-rich plasma (PRP) compared with hyaluronic acid (HA) in reducing pain and disability caused by OCLs of the ankle., Study Design: Randomized controlled trial; Level of evidence, 2., Methods: Thirty-two patients aged 18 to 60 years were allocated to a treatment by intra-articular injections of either HA (group 1) or PRP (plasma rich in growth factors [PRGF] technique, group 2) for OCLs of the talus. Thirty OCLs, 15 per arm, received 3 consecutive intra-articular therapeutic injections and were followed for 28 weeks. The efficacy of the injections in reducing pain and improving function was assessed at each visit using the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale (AHFS); a visual analog scale (VAS) for pain, stiffness, and function; and the subjective global function score., Results: The majority of patients were men (n = 23; 79%). The AHFS score improved from 66 and 68 to 78 and 92 in groups 1 and 2, respectively, from baseline to week 28 (P < .0001), favoring PRP (P < .05). Mean VAS scores (1 = asymptomatic, 10 = severe symptoms) decreased for pain (group 1: 5.6 to 3.1; group 2: 4.1 to 0.9), stiffness (group 1: 5.1 to 2.9; group 2: 5.0 to 0.8), and function (group 1: 5.8 to 3.5; group 2: 4.7 to 0.8) from baseline to week 28 (P < .0001), favoring PRP (P < .05 for stiffness, P < .01 for function, P > .05 for pain). Subjective global function scores, reported on a scale from 0 to 100 (with 100 representing healthy, preinjury function) improved from 56 and 58 at baseline to 73 and 91 by week 28 for groups 1 and 2, respectively (P < .01 in favor of PRP)., Conclusion: Osteochondral lesions of the ankle treated with intra-articular injections of PRP and HA resulted in a decrease in pain scores and an increase in function for at least 6 months, with minimal adverse events. Platelet-rich plasma treatment led to a significantly better outcome than HA.

We review the management of rotator cuff tears, the mechanism of action of autologous blood products, principally platelet-rich plasma, and the current evidence for effective use of platelet-rich plasma, particularly in relation to the shoulder and chronic rotator cuff tears, for biological augmentation of rotator cuff repair., (Copyright © 2012 S. Karger AG, Basel.)

The shoulder is a common source of disability resulting from traumatic and degenerate tears of the rotator cuff, subacromial impingement, and osteoarthritis. Nonoperative management has focused on treatment of the predisposing factors, the use of analgesics and anti-inflammatory medication usually in association with local anesthetic and steroid injections. Surgical intervention allows debridement of the degenerate cuff and partial thickness cuff tears, subacromial bursitis, impinging bone spurs and osteophytes together with rotator cuff repairs. Repairs of degenerate and torn tissue are often prone to failure due to many intrinsic and extrinsic factors. It is assumed that some biological therapies might improve clinical, mechanical, and histologic outcomes. Injections of platelet-rich plasma (PRP) have led to reduced pain and improved recovery in other degenerate pathologies areas together with the restoration of function. This study reviews the current literature on PRP and in particular discusses its relevance in the treatment of rotator cuff tears.

Autologous platelet-rich plasma (PRP) is a relatively new biotechnology backed by over two decades of research in diverse areas. With its growing use for the treatment of musculoskeletal injuries, Orthopaedic Sports Medicine may be the discipline in which translational use of PRP has progressed most rapidly. PRP therapy involves the injection of a small volume of plasma or the application of PRP gel foam directly to the site of injury. It is composed of numerous growth factors (GF) secreted from large numbers of 'activated' platelets, directed at facilitating and enhancing physiological wound healing and rapid tissue regeneration. With wide variations in preparation protocols, kits, activation methods, platelet concentrations and growth factors, many questions are still unanswered. Similarly, application methods, timing of treatment and volume of injection are inconsistent, emphasizing the need for appropriately powered level 1 and 2 studies with adequate and relevant outcome measures and clinically appropriate follow-up in order to assess the efficacy and effectiveness of all elements of PRP therapy. Clinical interventions in sports and musculoskeletal medicine aim to achieve predictable, rapid tissue repair and enhance wound heating and to restore the high mechanical performance and functional levels of non-injured tissue in the shortest possible time. PRP may be a remarkable step forward in this quest. This review will evaluate the evolution and most recent contributions of PRP treatment.