A standardised outcome measure of pain,symptoms and physical function in patients with hip and groin disability due to femoro-acetabular impingement: cross-cultural adaptation and validation of the international Hip Outcome Tool (iHOT12) in Swedish

Purpose

There is a lack of standardised outcome measures in Swedish for active, young and middle-aged patients with hip and groin disability. The purpose of this study was to adapt the English version of the international Hip Outcome Tool (iHOT12) patient-reported outcome instrument for use in Swedish patients and evaluate the adaptation according to the consensus-based standards for the selection of health status measurement instruments checklist.

Methods

Cross-cultural adaptation was performed in several steps, including translation, back-translation, expert review and pre-testing. The final version was evaluated for reliability, validity and responsiveness in a clinical study of patients [median age 37 (range 15–75)], undergoing surgery for femoro-acetabular impingement.

Results

Cronbach’s alpha was 0.89, and significant correlations were obtained with the Copenhagen Hip and Groin Outcome Score (Spearman’s r 0.10–0.70; p < 0.05) and the EuroQol, EQ-5D average score (Spearman’s r 0.27–0.56; p < 0.01). Test–retest reliability (intraclass correlation coefficient) ranged from 0.59 to 0.93 for the individual items. The smallest detectable change ranged from 17.1 to 44.9 at individual level and 3.6 to 9.4 at group level. Factor analysis revealed one factor of pain and symptoms and another factor of physical function. Effect sizes were generally medium or large.

Conclusion

The Swedish version of the iHOT12 is a valid, reliable and responsive instrument that can be used both for research and in the clinical setting.

Level of evidence

Diagnostic study, Level I.     

Can hip impingement be mistaken for tendon pain in the groin? A long-term follow-up of tenotomy for groin pain in athletes

Purpose

There are several reports on the association between pubalgia and intra-articular hip disorders. The purpose of this study was to evaluate the long-term outcome in athletes who underwent tenotomy due to long-standing groin pain. A secondary purpose was evaluating the frequency of femoro-acetabular impingement (FAI) and its impact on the long-term outcome.

Methods

Thirty-two high-level male athletes treated with adductor tenotomy, rectus abdominis tenotomy or both were included. At a median follow-up time of 6 years after the tenotomy, the subjects underwent standardised clinical examination, plain radiographs, completed web-based health-related patient-reported outcomes, including iHOT12, HAGOS (six subscales), EQ-5D (two subscales), HSAS for physical activity level and a VAS for overall hip function. Furthermore, patient satisfaction and return to sports were documented.

Results

Twenty-four of the 32 (75 %) athletes were satisfied with the outcome of the tenotomy, and 22 of the athletes (69 %) were able to return to their pre-injury sport. Before the long-term follow-up, two of these satisfied athletes had undergone repeat surgery (one hip arthroscopy due to FAI and one repeat tenotomy). Of the 24 satisfied athletes, eight (33 %) had a positive hip impingement test at the follow-up. Of the remaining eight athletes not satisfied with the outcome, only one returned to their pre-injury sport and three had undergone hip arthroscopy prior to follow-up. Five had positive hip impingement tests which was significantly more frequently than in the satisfied group (p = 0.008). The group with a positive hip impingement test reported significantly more pain and symptoms, more hip problems during sports and physical activity, as well as lower hip-related quality of life according to the HAGOS scores (p < 0.05), at follow-up.

Conclusion

Tenotomy for pubalgia yielded a satisfactory long-term outcome, with three of four athletes being able to return to their pre-injury sport. The athletes that did not return to their pre-injury sport had higher frequency of positive hip impingement test and inferior functional outcome compared with the athletes that did return to their pre-injury sport. It is therefore recommended that the hip should be carefully evaluated for hip impingement before tenotomy is considered as treatment for athletes with pubalgia.

Level of evidence

Retrospective case series, Level IV.     

Outcomes after ACL reconstruction with focus on older patients: results from The Swedish National Anterior Cruciate Ligament Register

Purpose

To investigate and analyse outcomes of patients over the age of 40 who had undergone anterior cruciate ligament (ACL) reconstruction and to compare them to their younger counterparts. We analysed patient-reported outcomes measured using the knee injury and osteoarthritis outcome score (KOOS) as well as aetiology of injury, concomitant intra-articular injuries and time from injury to surgery.

Methods

Data were extracted from the Swedish National Knee Ligament Register during the period of 2005 through 2012. The following data were extracted and analysed: patient age, gender, activity at the time of injury, time between injury and reconstruction, concomitant intra-articular injuries, graft size used for reconstruction and KOOS measured pre-operatively as well as 1, 2 and 5 years post-operatively. The cohort was stratified into age groups of 0–19, 20–29, 30–39 and ≥40 years of age.

Results

Pivoting sports were dominating as the cause of ACL injury in the younger age groups (up to 39 years). Alpine skiing and other non-specified activities were the most common causes in the older age group (≥40 years). Pre-operative KOOS was significantly lower in older age groups (p < 0.01). Post-operative KOOS regarding all subscales was significantly better in the older age group. The improvement in KOOS was significant with increasing age (p < 0.01). Older patients exhibited the greatest improvement in KOOS for all subscales at 1, 2 and 5 years post-operative follow-ups compared with pre-operative values (p < 0.01). Older patients had more cartilage injuries pre-operatively compared with younger patients. The same trend was observed in the older group for meniscus injury with and without cartilage injuries. The diameter of the graft used for ACL reconstruction was significantly larger in the older age groups and largest in the age group ≥40 years (p < 0.01). Older patients waited significantly longer for surgery after the ACL injury (p < 0.01).

Conclusion

In the older age groups, patients reported lower pre-operative KOOS compared with their younger counterparts. At follow-up, KOOS was similar in all age groups. From these results, we can therefore conclude that our hypothesis confirmed that optimal surgical results can in fact be achieved even in older patients.

Level of evidence

II.     

Translation, cultural adaptation, validity and reliability of the Turkish ASES questionnaire

Purpose

The American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) is a standard shoulder assessment form, which is comprised of objective and subjective sections and prepared by shoulder and elbow surgeons. The purpose of this study was to translate the subjective part of the ASES into Turkish and establish its cultural adaptiveness and validity.

Methods

The original version of the ASES was translated into Turkish in accordance with the stages recommended by Guillemin. Sixty-three patients (average age: 48.2 ± 13.4; range: 18–74 years) suffering from different shoulder complaints were included in the study. The ASES was completed twice at 3- to 7-day intervals for test–retest reliability. The intraclass correlation coefficient was used to calculate the test–retest reliability, and Cronbach’s alpha was used for internal consistency. Patients were asked to complete the short form 36 (SF-36) and the Shoulder Pain and Disability Index (SPADI) for correlation. Validity was evaluated by external correlation of the ASES with the SPADI and SF-S6 questionnaire, which may also be defined as ‘construct validity’. The results were analysed using Pearson’s correlation test.

Results

The test–retest reliability of the ASES pain and function subscales and total ASES score were 0.95, 0.86 and 0.94, respectively. Cronbach’s alpha coefficient for the total ASES was 0.88. The correlation between the total ASES and total SPADI score was ?0.82; the correlation coefficient between the ASES pain subscale and SPADI pain subscale was ?0.79 (p < 0.000); and the correlation between the ASES and SPADI function subscales were ?0.53 (p < 0.000). The highest correlation was between ASES and SF-36 bodily pain, as well as ASES and SF-36 mental health (r = 0.64, r = 0.56, p < 0.000), and the lowest correlations were between ASES and the SF-36 physical component score and between ASES and SF-36 social function (r = 0.28, r = 0.33 p < 0.000).

Conclusion

The Turkish version of the ASES is a valid and reliable shoulder assessment form that can be used for numerous shoulder disorders.

Level of evidence

III.     

In-season monitoring of hip and groin strength,health and function in elite youth soccer: Implementing an early detection and management strategy over two consecutive seasons

Objectives

The primary purpose of this study was to describe an early detection and management strategy when monitoring in-season hip and groin strength, health and function in soccer. Secondly to compare pre-season to in-season test results.

Validation and reliability of the Dutch language version of the Modifiable Activity Questionnaire in healthy subjects

Background

The Modifiable Activity Questionnaire (MAQ) is a physical activity questionnaire shown to be both valid and reliable in French. After translation and adaptation to Dutch, the objective of the study was to see whether this questionnaire was valid and reliable in the Dutch language and thus could be used as a tool for the detection of exercise levels in a Dutch native-speaking population.

Methods

After translating and back translating the valid French version of the MAQ into Dutch, the final product of the Dutch version was tested twice in the same population (n = 101) interrupted by 1 week for the assessment of the test–retest reliability. To measure concurrent validity, the valid Dutch version of the IPAQ was filled in at the same time as the MAQ. To measure the construct validity of this assessment tool, a smaller sample size (n = 28) of the total population carried an accelerometer for 1 week.

Results

The intraclass correlation coefficient for the test–retest reliability was 0.78 (p < 0.01), suggesting a good test–retest reliability. Pearson’s rho correlation coefficient between the IPAQ and the MAQ was 0.41 (p < 0.01), suggesting a medium concurrent validity. Pearson correlation statistics showed a low, non-significant correlation coefficient (r = 0.243, p = 0.213) when measuring construct validity.

Conclusion

The present study shows that the Dutch language of the MAQ is reliable and has a medium concurrent validity. Although the construct validity is low, these results are in line with previous validation studies of physical activity questionnaires.     

Can TKA design affect the clinical outcome? Comparison between two guided-motion systems

Purpose

In a retrospective comparative analysis in patients undergoing primary guided-motion total knee arthroplasty (TKA), the authors have evaluated whether different TKA implant design would influence the clinical and functional outcomes.

Methods

Between 2007 and 2009, 227 computer-assisted primary TKAs were performed in 219 consecutive patients. Patients received one of the two different fixed-bearing guided-motion TKA designs assisted by navigation surgery: the Scorpio Non-Restrictive Geometry (NRG) knee system and the Journey Bi-Cruciate Stabilized (BCS) knee systems.

Results

Data were available for 180 patients (187 knees). No significant differences were observed between the two groups with respect to preoperative demographic characteristics, range of motion (ROM) and radiographic knee alignment. At a mean follow-up of 29 months, the Journey BCS group had higher mean Knee Injury and Osteoarthritis Outcome Score (KOOS) in all subscales and a greater ROM than the Scorpio NRG group. This difference was statistically significant for the KOOS subscales of pain (p = 0.007) and knee-related quality of life (p = 0.045), as well as for postoperative ROM (p = 0.018). Considering the overall complications, 1 patient of Scorpio NRG group (0.5 %) and 5 in Journey BCS (2.7 %) had stiffness. Anterior knee pain was reported in 4 cases of Scorpio NRG group (2.1 %). In the Journey BCS group were observed 2 cases (1.1 %) of frontal plane instability and 1 case (0.5 %) of synovitis pain.

Conclusions

The bearing geometry and kinematic pattern of different guided-motion prosthetic designs can affect the clinical–functional outcome and complications type in primary TKA.

Level of evidence

Clinical study, Level III.     

Complications following hip arthroscopy: a systematic review and meta-analysis

Purpose

The use of hip arthroscopy to address injuries and conditions about the hip is becoming more widespread. There are several narrative reviews regarding complications of hip arthroscopy but a systematic review is currently lacking. The primary goal of this study is to determine the complication rate associated with hip arthroscopy in the literature.

Methods

A search of the EMBASE and Ovid Medline databases was performed to identify articles published between 1 January 2000 and 25 November 2011 that reported a complication rate after hip arthroscopy. Appropriate inclusion and exclusion criteria were applied to identify articles, and a meta-analysis was performed to determine an overall complication rate. Complications were divided into major and minor.

Results

A total of 66 papers (n = 6,962 hip arthroscopies) were identified and deemed appropriate for analysis. The overall complication rate was found to be 4.0 % (95 % CI 2.9–5.2 %). Of the 287 complications identified in the literature, 20 were deemed major constituting a rate of 0.3 %.

Conclusions

Hip arthroscopy appears to be safe. The vast majority of complications are minor in nature. Prospective trials looking at the complications of hip arthroscopy would aid in identifying prognostic factors.

Level of evidence

Systematic review and meta-analysis, Level III.     

Modest mid-term outcomes after isolated arthroscopic debridement of acetabular labral tears

Purpose

Currently, 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).

Methods

The 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.

Results

Fifty-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.

Conclusions

Isolated 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 evidence

Retrospective case series, Level IV.     

The treatment of acquired patella baja with proximalize the tibial tuberosity

Purpose

Acquired patella baja may result in decreased range of motion of the knee, extensor lag, and anterior knee pain. The aim of the study was to evaluate the efficacy of tibial tubercle osteotomy with proximal displacement.

Methods

Between 1998 and 2011, a proximalization of the tibial tuberosity was performed in 15 patients (15 knees) with patella baja diagnosed using the Blackburne–Peel ratio. Clinical outcomes included the Tegner Lysholm knee scoring scales, the WOMAC questionnaire, the short form-12 (SF-12), and a visual analogue score (VAS) pain scale.

Results

Fifteen proximalizations of the tibial tuberosity were performed, with a mean follow-up period of 64 months (5–160). The mean patient age was 59 years (41–86 years). The mean preoperative Blackburne–Peel ratio of 0.4 (0.1–0.6) was improved to a mean of 1.0 (0.8–1.2) post-operatively, which was associated with significant improvements in the Lysholm knee scoring scale from 13.3 ± 13.0 to 86.7 ± 10.4 points (p < 0.0001). Quality of life, as measured using the SF-12 outcome, also improved significantly (p < 0.0001), as did all WOMAC questionnaire score subscales (p < 0.0001). The VAS preoperative status for pain improved from 8.3 ± 2.0 to 1.5 ± 1.8. No patient had delayed or non-union of the osteotomy site.

Conclusions

A series of patients with patella baja, treated with proximalization of the tibial tuberosity, achieved satisfactory outcomes in terms of pain relief and improved function, without major complication.     

Cross cultural adaptation of the Achilles tendon Total Rupture Score with reliability, validity and responsiveness evaluation

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.     

Hip arthroscopy with labral repair for femoroacetabular impingement: short-term outcomes

Purpose

The purpose of this study was to examine the progression of clinical outcomes 3, 6 and 12 months after hip arthroscopy with labral repair for femoroacetabular impingement (FAI).

Methods

From May 2009 to December 2011, 87 consecutive patients [55 females (median age 38, range 17–63) and 32 males (median age 38, range 15–59)] underwent hip arthroscopy and labral repair, by the same experienced surgeon. Standardised, but unstructured, post-operative rehabilitation instructions were provided. Function and pain were evaluated using modified Harris Hip Score (mHHS) and visual analogue scale (VAS) pre-operatively and post-operatively at 3, 6, and 12 months.

Results

A main effect of time was seen for mHHS and pain (VAS) at 3, 6, and 12 months (p < 0.001). Mean (SE) mHHS improved significantly from 59.9 (1.9) pre-operatively to 74.5 (1.9) after 3 months (p < 0.001), and again from 3 to 6 months from 74.5 (1.9) to 80.1 (1.9) (p = 0.004), with no additional changes from 6 to 12 months [80.1 (1.9)–78.7 (1.9), (n.s.)]. Also, the mean (SE) VAS improved significantly from pre-operative 57.9 (2.6) to 30.0 (2.6) after 3 months (p < 0.001), and from 30.0 (2.6) to 22.6 (2.6) (p = 0.017), after 6 months with no additional changes from 6 to 12 months [22.6 (2.6)–27.9 (2.6), (n.s.)].

Conclusions

Improvements in function (mHHS) and pain (VAS) were seen in patients after hip arthroscopy with labral repair for FAI at 3, 6, and 12 months. While significant improvements occurred from 3 to 6 months, no further improvements were seen from 6 to 12 months.

Level of evidence

Prospective case series, Level IV.     

Attentional focus and mental skills in senior and junior professional rugby union players

Objective

The aim of the present study was to examine possible differences in attentional focus and mental skills depending on athlete’s experience.

Method

Forty-seven junior sub-elite, between ages of 15 and 18 years (M = 15.77, SD = 0.84) and 43 senior elite rugby union players, between ages of 20 and 37 years (M = 26.40, SD = 4.88), participated in this study. We measured attentional focus and mental skills using a short version of the Test of Attentional and Interpersonal Styles and the Sport Performance Psychological Inventory.

Results

The results showed statistically significant differences between the groups for one of the mental skills examined and for all the attentional focus dimensions, evidencing consistently more functional psychological profiles for the more experienced groups.

Conclusions

Data suggest that attentional focus skills increase with experience. Future research directions and practical implications are discussed.     

Intra-articular adhesions following hip arthroscopy: a risk factor analysis

Purpose

The purpose of this study was to evaluate possible risk factors for symptomatic adhesions after hip arthroscopy.

Methods

Data were analysed from hip arthroscopies performed between 2005 and 2009. Only primary hip arthroscopies were included. Data collected included demographics, primary treatment, rehabilitation, revision surgery, and presence of adhesions at revision.

Results

One thousand two hundred and sixty-four hips in patients 18 years or older underwent primary hip arthroscopy during the defined period. Eight underwent revision hip arthroscopy by a different surgeon. Patients under 30 years of age were 5.9 times more likely to be in the adhesion group [95 % CI 3.1–11.5]. Patients who underwent microfracture were 3.1 times less likely to have adhesions compared to patients who did not [95 % CI 1.1–8.2]. Patients who did not receive circumduction therapy were 4.1 times more likely to have adhesions compared to those who performed circumduction exercises [95 % CI 1.25–11.0].

Conclusion

Risk factors for adhesions following hip arthroscopy identified were age under 30, modified Harris Hip score under 50, no microfracture performed, and rehabilitation without circumduction.

Level of evidence

IV.     

Dual-energy subtraction radiography improves laryngeal delineation in patients with moderate to severe cervical spondylosis

Purpose

To investigate the feasibility of dual-energy subtraction (DES) in patients with moderate-severe cervical spondylosis for improving delineation of the larynx on flat panel detector (FPD) radiography.

Materials and methods

For 118 patients, we graded conventional/DES anterior–posterior views for delineation of the vocal cords, subglottis, and pyriform sinus using a 5-point scale and lateral views from conventional laryngeal FPD radiography to determine cervical spondylosis severity on a scale from 0 (none) to 3 (severe). We compared the delineation of each anatomical structure in both groups of grades 0–1 and grades 2–3 of spondylosis severity between conventional and DES methods and the improved delineation rate for each anatomical structure by DES compared to the conventional method between both groups.

Results

With DES, the delineation of each anatomical structure was significantly better than with conventional radiography for both groups (P < 0.0001). The improved delineation rate of the vocal cord and subglottis using DES was significantly higher in grades 2–3 than in grades 0–1 (P < 0.05), although there was no significant difference in the delineation rate of the pyriform sinus between the groups (P = 0.847).

Conclusion

DES provides better delineation of the laryngeal anatomy than conventional FPD radiography predominantly in patients with moderate-severe cervical spondylosis.     

Transcatheter Arterial Embolization With Spherical Embolic Agent for Pulmonary Metastases From Renal Cell Carcinoma

Purpose

This retrospective study aimed to evaluate the safety and local efficacy of transcatheter arterial embolization (TAE) with superabsorbent polymer microspheres (SAP-MS) in patients with pulmonary metastases from renal cell carcinoma (RCC).

Methods

Sixteen patients with unresectable pulmonary metastases from RCC refractory to standard therapy were enrolled to undergo TAE with the purpose of mass reduction and/or palliation. The prepared SAP-MS swell to approximately two times larger than their dry-state size (100–150 μm [n = 14], 50–100 μm [n = 2]). Forty-nine pulmonary nodules (lung n = 22, mediastinal lymph node n = 17, and hilar lymph node n = 10) were selected as target lesions for evaluation. Local tumor response was evaluated 3 months after TAE according to Response Evaluation Criteria in Solid Tumors (RECIST; version 1.1). The relationship between tumor enhancement ratio by CT during selective angiography and local tumor response was evaluated.

Results

The number of TAE sessions per patient ranged from 1 to 5 (median 2.9). Embolized arteries at initial TAE were bronchial arteries in 14 patients (87.5 %) and nonbronchial systemic arteries in 11 patients (68.8 %). Nodule-based evaluation showed that 5 (10.2 %) nodules had complete response, 17 (34.7 %) had partial response, 15 (30.6 %) had stable disease, and 12 (24.5 %) had progressive disease. The response rate was significantly greater in 22 lesions that had a high tumor enhancement ratio than in 27 lesions that had a slight or moderate ratio (90.9 vs. 7.4 %, p = 0.01). Severe TAE-related adverse events did not occur.

Conclusion

TAE with SAP-MS might be a well-tolerated and locally efficacious palliative option for patients with pulmonary metastases from RCC.     

Learning curve of basic hip arthroscopy technique: CUSUM analysis

Purpose

Hip arthroscopy is known to have a steep learning curve by measuring operation times or complication rates. However, these measures are arbitrary and are based on the number of procedures performed rather than clinical outcomes. Recently, Cumulative sum (CUSUM) analysis has been used to monitor the performance of a single surgeon by evaluating clinical outcomes. Our purpose was to determine the learning curve for basic hip arthroscopy technique using CUSUM technique.

Methods

Forty consecutive patients who underwent hip arthroscopy were evaluated. Modified Harris Hip Score less than 80 at 6 months postoperatively was considered as treatment failure. Patients were chronologically stratified in two groups (the early group—cases 1–20, and the late group—cases 21–40), and age, gender, body mass index, and operation time were compared in both group. CUSUM analysis was then used to plot the learning curve.

Results

Eight patients (20 %) experienced treatment failure. Although there was no significant difference of treatment failure rate between the early and late groups (30 vs. 10 %, n.s.), the operation time was shorter in the late group (p = 0.014). In addition, CUSUM analysis showed that failure rates diminished rapidly after 21 cases and reached an acceptable rate after 30 cases.

Conclusions

Surgeon’s experience is an important predictor of failure after hip arthroscopy, and CUSUM analysis revealed that a learning period is required to become proficient at this procedure, and that experience of approximately 20 cases is required to achieve satisfactory outcomes in terms of clinical outcomes. Surgeon can use the present learning curve for self-monitoring and continuous quality improvement in hip arthroscopy.

Level of evidence

Retrospective case series, Level IV.     

Hepatic cysts treated with percutaneous ethanol sclerotherapy: time to extend the indications to haemorrhagic cysts and polycystic liver disease

Objectives

To describe the long-term clinical and morphological outcome of symptomatic hepatic cysts treated with percutaneous ethanol sclerotherapy (PES).

Methods

From December 2003 to September 2011, all patients with hepatic cysts undergoing PES with a follow-up after 12 months were included. Evolution of the volume of the cysts and clinical and biological data were recorded. Features of the cyst were evaluated in each patient: simple, haemorrhagic or developed on underlying polycystic liver disease (PCLD).

Results

Fifty-eight cysts (median volume 666 mL) were treated in 57 patients (52 women, mean age 58 years (18–80)). Twenty-two patients (39 %) had simple hepatic cysts, 19 (33 %) had dominant cysts on PCLD and 20 had haemorrhagic cysts (34.5 %), including 4 with PCLD. After a mean 27.3 months of follow-up, the final median cystic volume was 13.5 mL (p?<?0.0001), and the median reduction in cyst volume was 94 % (58–100 %). Treatment was satisfactory in 95 % of the patients (54/57) (symptoms disappeared in 45/57 (79 %), decreased in 9/57 (16 %)). There was no clinical or morphological difference between patients with PCLD, haemorrhagic cysts or simple cysts.

Conclusion

The clinical and morphological efficacy of a single session of PES is very high, regardless of the presence of intracystic haemorrhage or underlying PCLD.

Key Points

? The clinical efficacy of percutaneous ethanol sclerotherapy is very high. ? Haemorrhagic content should not be a contraindication for percutaneous sclerotherapy. ? Dominant cysts on polycystic liver disease should be treated with PES. ? Imaging follow-up should not be performed shortly after the procedure.     

Dutch translation of the Kujala Anterior Knee Pain Scale and validation in patients after knee arthroplasty

Purpose

To translate and validate the Kujala Anterior Knee Pain Scale (AKPS) in patients who have undergone total knee arthroplasty (TKA) or unicompartmental knee arthroplasty (UKA) and evaluate the internal consistency, construct validity and ceiling or floor effect.

Methods

After standard forward and backward translation was performed, 302 patients who have received a TKA or UKA filled out the AKPS together with Hospital for Special Surgery (HSS) patella score, visual analogue score (VAS) for pain, the Oxford 12-item questionnaire and the SF-36 at follow-up. The internal consistency was tested using Cronbach’s α coefficient. The construct validity was assessed using Spearman’s rank correlation (R) to test for correlations between the AKPS and VAS HSS, HSS patella score, VAS month, Oxford 12-item questionnaire and SF-36 subscales. Ceiling or floor effects are given in percentage of patients giving a maximum or minimum score.

Results

The internal reliability of the AKPS is acceptable with a Cronbach’s α of 0.81 in patients after TKA or UKA. A high correlation was found between the AKPS and the Oxford 12-item questionnaire (R = 0.81). Moderate correlations were found with the VAS month (R = 0.63), HSS patella score (R = 0.51) and SF-36 subscales physical functioning (R = 0.59), role-physical (R = 0.59), bodily pain (R = 0.57). Other correlations were poor, therefore indicating a good convergent and divergent validity. Ceiling effects were observed for the HSS patella score (31 %), VAS HSS (51 %), VAS pain (19 %), SF36-RP (46 %), SF36-RE (80 %) and SF36-BP (24 %). No ceiling or floor effect was found for the AKPS, Oxford 12-item and the other SF36 domains.

Conclusions

The AKPS appears to be reliable and valid in patients after knee arthroplasty, with no ceiling and floor effects, and can be used to assess anterior knee pain in patient who underwent joint replacement surgery.

Level of evidence

Diagnostic study, Level I.     

Prediction of therapeutic effectiveness according to CT findings after therapeutic lymphangiography for lymphatic leakage

Purpose

To evaluate the correlation between computed tomography (CT) findings after therapeutic lymphangiography for lymphatic leakage and the clinical course of lymphatic leakage.

Materials and methods

Therapeutic lymphangiography for lymphatic leakage was performed in 14 patients. In all patients, CT was performed 0.5–26 h (mean 6.9 h) after lymphangiography and results were retrospectively evaluated.

Results

In 8 of the 14 patients (57 %), lymphatic leakage stopped after lymphangiography. Lymphatic leakage was detected on CT in 9 of the 14 patients (64 %) and had either a nodular (n = 4) or beaded appearance (n = 5). The amount of drainage had decreased the day after lymphangiography, and leakage finally stopped in all 4 patients in whom the leakage had a nodular appearance. However, leakage did not stop in 3 of the 5 patients having leakage with a beaded appearance.

Conclusion

A nodular appearance of leakage might predict success of therapeutic lymphangiography.