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.     

Pre-operative intra-articular hip injection as a predictor of short-term outcome following arthroscopic management of femoroacetabular impingement

Purpose

Diagnostic hip injections are often used to confirm intra-articular pathology prior to arthroscopic treatment for femoroacetabular impingement (FAI). However, little is known whether the type of response correlates with the post-operative functional outcomes. The purpose of this study is to document the ability of a diagnostic hip injection to predict short-term functional outcomes following arthroscopic surgical management.

Methods

A prospective cohort of 52 patients diagnosed with FAI who had an intra-articular hip injection prior to arthroscopic surgery was evaluated. A pain diary was used during the 2 weeks after hip injection to document response. In addition, the modified Harris Hip Score (mHHS) was administered preoperatively and 6 months post-operatively to assess functional outcomes. The relationship between response to an intra-articular hip injection and mHHS scores 6 months after FAI surgery was evaluated.

Results

Overall, 42 of 52 (81 %) patients diagnosed with FAI achieved pain relief from the hip injection. Outcomes according to mHHS scores improved significantly at the 6-month follow-up visit (19 points, 95 % CI 15–24, p = 0.001). The therapeutic utility of the hip injection suggested that lack of pain relief predicted a lack of functional improvement following arthroscopic surgery.

Conclusion

In this study, the data suggests that a positive response from an intra-articular hip injection is not a strong predictor of short-term functional outcomes following arthroscopic management of FAI. However, a negative response from an intra-articular hip injection may predict a higher likelihood of having a negative result from surgery.

Level of evidence

Level II.     

Arthroscopic treatment for acute septic arthritis of the hip joint in adults

Purpose

The purpose of our study was to evaluate the efficacy and safety of the arthroscopic management of septic arthritis of the hip joint.

Methods

From October 2009 to October 2010, nine patients with septic arthritis of the hip were treated with arthroscopic debridement and drainage and systemic antibiotics according to bacterial sensitivity or with empiric antibiotics if no bacteria was isolated from the cultures. All patients were placed in the supine position on a fracture table, and two or three arthroscopic portals were used. The medical records were retrospectively reviewed to determine the efficacy and safety of hip arthroscopy for septic arthritis.

Results

There were 4 men and 5 women, with a mean age of 49.8 years (SD 12.1). No major complication related to arthroscopy of the hip was encountered. Staphylococcus aureus was identified in 4 patients. Average follow-up was 19.4 months (SD 4.1). Septic arthritis relapsed in one patient, but the other 8 patients experienced no recurrence during the follow-up period.

Conclusions

Arthroscopic lavage and debridement is a safe and effective procedure for septic arthritis of the hip joint.

Level of evidence

IV.     

MR imaging of meniscal tears: comparison of intermediate-weighted FRFSE imaging with intermediate-weighted FSE imaging

Purpose

We compared intermediate-weighted fast spin-echo (IW-FSE) images with intermediate-weighted fast-recovery FSE (IW-FRFSE) images in the diagnosis of meniscal tears.

Materials and methods

First, 64 patients were recruited, and the arthroscopic findings (n?=?40) and image analysis (n?=?19) identified 59 torn menisci with 36 patients. Both the diagnostic performance and image quality in assessing meniscal tears was evaluated for IW-FSE and IW-FRFSE images using a four-point scale. Signal-to-noise ratio (SNR) calculation was performed for both sets of images.

Results

IW-FRFSE image specificity (100?%) for diagnosing the posterior horn of the medial meniscus (MM) tear with reader 1 was significantly higher than that of IW-FSE images (90?%). Mean ratings of the contrast between the lesion and normal signal intensity within the meniscus were significantly higher for the IW-FRFSE image ratings than the IW-FSE images in most meniscal tears. Mean SNRs were significantly higher for IW-FSE images than for IW-FRFSE images (P?<?0.05).

Conclusions

IW-FRFSE imaging can be used as an alternative to the IW-FSE imaging to evaluate meniscal tears.     

3-T MRI assessment of osteophyte formation in patients with unilateral anterior cruciate ligament injury and reconstruction

Objective

To define the number and distribution of osteophytes (OPs) in bilateral knee MRI (magnetic resonance imaging) of patients with unilateral anterior cruciate ligament (ACL) rupture.

Materials and methods

Bilateral knee MRIs of 20 patients with unilateral ACL rupture and reconstruction were retrospectively analyzed for OPs. OPs were graded following the KOSS (knee OA scoring system) classification and their compartmental distribution was assessed following the WORMS (Whole-Organ Magnetic Resonance Imaging Score) classification.

Results

All examined knees revealed OPs. Knees with ACL rupture showed significant (p?<?0.001) higher total numbers of OPs (mean 11.6; SD?±?4.4) than knees with intact ACL (mean 5.1; SD?±?2.3). Knees with ACL rupture showed increased OP formation in all knee compartments with predominance of marginal OPs in the lateral femorotibial compartment especially on the tibia.

Conclusions

Our results show that after knee injury with ACL rupture and reconstruction, all knee compartments were involved in post-traumatic increase of OP formation. The most affected compartment was the lateral femorotibial compartment on the tibial side.     

Critical three-dimensional factors affecting outcome in osteochondral lesion of the talus

Purpose

This study aimed to investigate the relationship between clinical outcomes, patient demographics and the 3D-geometric profiles of the osteochondral lesion of the talus (OLT) following arthroscopic debridement and bone marrow stimulation.

Methods

Between 2005 and 2011, arthroscopic debridement and bone marrow stimulation were performed on 50 ankles with OLT mean age of 36.0 (19.1) years and mean follow-up time of 35.5 (20.2) months. Clinical data were assessed using validated Japanese Society of Surgery of the Foot scoring. An outcome was deemed unsatisfactory if the JSSF score was less than 80. Magnetic resonance imaging and X-rays were used to assess the 3D-geometric profiles of the OLT.

Results

The mean preoperative and postoperative scores were 73.4 (13.6) and 89.6 (11.5), respectively (p < 0.001). Unsatisfactory outcomes were identified in 12 % of patients. Linear regression analyses showed that lesion depth and patient age were significantly negatively correlated with postoperative scores (p < 0.001). High prognostic significances were attributed to defect depth and age of patient, and cut-off values of 7.8 mm and 80 years, respectively, were recommended to avoid a postoperative score less than 80. No significant correlations between poor clinical outcome and the other lesion profiles or demographic factors were identified.

Conclusion

Using 3D-geometric and demographic profiles, defect depth and age of patient are essential prognostic factors in OLT and may act as a basis for preoperative surgical decisions. A lesion depth ≥7.8 mm and age ≥80 years predict an unsatisfactory outcome following arthroscopic debridement and bone marrow stimulation.

Level of evidence

Retrospective comparative study, Level III.     

Learning curve of office-based ultrasonography for rotator cuff tendons tears

Purpose

To compare the accuracy of ultrasonography and MR arthrography (MRA) imaging in detecting of rotator cuff tears with arthroscopic finding used as the reference standard.

Methods

The ultrasonography and MRA findings of 51 shoulders that underwent the arthroscopic surgery were prospectively analysed. Two orthopaedic doctors independently performed ultrasonography and interpreted the findings at the office. The tear size measured at ultrasonography and MRA was compared with the size measured at surgery using Pearson correlation coefficients (r). The sensitivity, specificity, accuracy, positive predictive value, negative predictive value and false-positive rate were calculated for a diagnosis of partial-and full-thickness rotator cuff tears. The kappa coefficient was calculated to verify the inter-observer agreement.

Results

The sensitivity of ultrasonography and MRA for detecting partial-thickness tears was 45.5 and 72.7 %, and that for full-thickness tears was 80.0 and 100 %, respectively. The accuracy of ultrasonograpy and MRA for detecting partial-thickness tears was 45.1 and 88.2 %, and that for full-thickness tears was 82.4 and 98 %, respectively. Tear size measured based on ultrasonography examination showed a poor correlation with the size measured at arthroscopic surgery (r = 0.21; p < 0.05). However, tear size estimated by MRA showed a strong correlation (r = 0.75; p < 0.05). The kappa coefficient was 0.47 between the two independent examiners.

Conclusions

The accuracy of office-based ultrasonography for beginner orthopaedic surgeons to detect full-thickness rotator cuff tears was comparable to that of MRA but was less accurate for detecting partial-thickness tears and torn size measurement. Inter-observer agreement on the interpretation was fair. These results highlight the importance of the correct technique and experience in operation of ultrasonography in shoulder joint.

Level of evidence

Diagnostic study, Level II.     

Arthroscopic inside-out repair of complete radial tears of the meniscus with a fibrin clot

Purpose

To report on the results of 12 complete radial tears of the meniscus treated using arthroscopic inside-out repair with fibrin clots, the results showed good meniscal healing and excellent clinical outcomes.

Methods

From 2007 to 2009, 12 patients with complete radial tears of the meniscus were treated by arthroscopic inside-out repair with fibrin clots. In all patients, the International Knee Documentation Committee (IKDC) subjective knee form and Lysholm score were determined pre- and post-operatively. We performed magnetic resonance imaging (MRI) and if indicated, we performed a second-look arthroscopic examination.

Results

At a mean of 30 ± 4 postoperative months, the Lysholm score and IKDC subjective knee score had improved from 65 ± 6 and 57 ± 7 to 94 ± 3 and 92 ± 3, respectively. Eleven of 12 cases showed complete healing on follow-up MRI. Six of 7 patients undergoing a second-look arthroscopic examination had healed completely.

Conclusion

This study shows successful meniscal repairs using fibrin clots in complete radial tears. This surgical procedure appears to be a good treatment method for complete radial tear of the meniscus.

Level of evidence

Case series, Level IV.     

Digital X-ray radiogrammetry of hand or wrist radiographs can predict hip fracture risk—a study in 5,420 women and 2,837 men

Objectives

To assess whether digital X-ray radiogrammetry (DXR) analysis of standard clinical hand or wrist radiographs obtained at emergency hospitals can predict hip fracture risk.

Methods

A total of 45,538 radiographs depicting the left hand were gathered from three emergency hospitals in Stockholm, Sweden. Radiographs with insufficiently included metacarpal bone, fractures in measurement regions, foreign material or unacceptable positioning were manually excluded. A total of 18,824 radiographs from 15,072 patients were analysed with DXR, yielding a calculated BMD equivalent (DXR-BMD). Patients were matched with the national death and inpatient registers. Inclusion criteria were age ≥ 40 years, no prior hip fracture and observation time > 7 days. Hip fractures were identified via ICD-10 codes. Age-adjusted hazard ratio per standard deviation (HR/SD) was calculated using Cox regression.

Results

8,257 patients (65.6 % female, 34.4 % male) met the inclusion criteria. One hundred twenty-two patients suffered a hip fracture after their radiograph. The fracture group had a significantly lower DXR-BMD than the non-fracture group when adjusted for age. The HR/SD for hip fracture was 2.52 and 2.08 in women and men respectively. The area under the curve was 0.89 in women and 0.84 in men.

Conclusions

DXR analysis of wrist and hand radiographs obtained at emergency hospitals predicts hip fracture risk in women and men.

Key Points

? Digital X-ray radiogrammetry of emergency hand/wrist radiographs predicts hip fracture risk. ? Digital X-ray radiogrammetry (DXR) predicts hip fracture risk in both women and men. ? Osteoporosis can potentially be identified in patients with suspected wrist fractures. ? DXR can potentially be used for selective osteoporosis screening.     

Ligamentum teres: a functional description and potential clinical relevance

Purpose

The primary purpose of this study was to investigate the role the ligamentum teres has in providing hip stability using a biomechanical model. The second purpose was to review arthroscopic findings in those with a complete ligamentum teres rupture and question them regarding instability to determine how clinical findings related to the biomechanical model.

Methods

A string model was created to examine ligamentum teres excursion during various hip positions. A retrospective review of 350 consecutive surgical patients identified 20 subjects with a complete ligamentum teres rupture that was not repaired at the time of surgery.

Results

The model found the ligamentum teres to have the greatest excursion when the hip was externally rotated in flexion (ER/FLEX) and internally rotated in extension (IR/EXT). During operative assessment, it was noted that all 20 subjects had laxity during dynamic impingement testing when their hip was in a position of ER/FLEX. Nine (45%) of the 20 subjects with ligamentum teres rupture were available for follow-up (mean 31 months post-op). Five out of these 9 subjects noted instability: 5 of 9 with squatting (ER/FLEX) and 4 of 9 with crossing one leg behind of the other (IR/EXT). These 5 subjects had osseous risk factors that compromised hip stability including inferior acetabular insufficiency.

Conclusions

The ligamentum teres may contribute to hip stability when the hip is in ER/FLEX and IR/EXT. Individuals with osseous risk factors for instability, including inferior acetabular insufficiency, may have instability with squatting (ER/FLEX) and crossing one leg behind of the other (IR/EXT).

Level of evidence

IV.     

Transarticular drilling for stable juvenile osteochondritis dissecans of the medial femoral condyle

Purpose

Drilling is the most common operative treatment for stable juvenile osteochondritis dissecans (OCD) of the knee. However, prognostic factors remain unclear because of lack of precise radiographic and histopathologic investigations. The purpose of this study was to evaluate the clinical results and prognostic factor of the arthroscopic drilling for juvenile OCD lesions at the medial femoral condyle (MFC), using computed tomography (CT) images.

Methods

Eighteen skeletally immature patients (boys, n?=?16; girls, n?=?2, mean age, 12?years) underwent arthroscopic antegrade transarticular drilling for a total of 19 OCD lesions of MFC. Functional outcomes were evaluated with the Lysholm score at follow-up (mean, 30?months). Preoperative osteochondral condition and postoperative healing were evaluated by CT images.

Results

All 18 patients returned to their previous level of sports activity and showed excellent functional outcomes (mean Lysholm score, 77.2?±?9.4 preoperative vs. 99.5?±?1.6 postoperative). There were 10 osteochondral lesions and 9 subchondral bone defect lesions under preoperative CT examination. Postoperatively, 15 of 19 lesions healed completely at a mean of 6?months; however, the remaining four lesions (all osteochondral types) did not achieve complete radiographic healing after 2?years.

Conclusion

Transarticular drilling for stable juvenile OCD produced excellent functional outcomes. However, the osteochondral type may influence radiographic outcome.

Level of evidence

Case series, Level IV.     

Femoroacetabular impingement: is hyaluronic acid effective?

Purpose

Femoroacetabular impingement may predispose to the development of hip osteoarthritis. Conservative treatments are effective in the short term, but surgery is often required. Aim of this paper was to report the short-term results on hip pain and function after ultrasound-guided injections of hyaluronic acid.

Methods

In this open prospective trial, twenty patients suffering from mild femoroacetabular impingement were enrolled. Each patient received a 2-ml intra-articular ultrasound-guided injection of hyaluronic acid at baseline and after 40 days; the same dosing schedule was repeated after 6 months. The clinical evaluation was performed at baseline and after 6 and 12 months of follow-up. Pain score, Lequesne Index, Harris Hip Score and anti-inflammatory medication consumption were measured. Adverse events were also registered.

Results

Twenty-three hips (3 bilateral cases) were treated. Pain decreased from 6.7 ± 1.3 to 3.7 ± 1.8 and to 1.7 ± 1.8 after 6 and 12 months, respectively; Lequesne Index was reduced and the mean Harris Hip Score improved from 83.3 ± 6 before treatment to 88.2 ± 4.7 at 12 months. Consumption of anti-inflammatory drugs was also reduced, from 14 to 4 subjects and from 3.6 ± 2.2 to 1.3 ± 1.3 tablets/week. Local side effects after injection were observed only in 2 cases.

Conclusions

Hyaluronic acid is safe and effective in the treatment of mild femoroacetabular impingement, with significant pain reduction and function improvement.

Level of evidence

IV.     

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.     

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.     

Does varus alignment increase after medial meniscectomy?

Purpose

In patients who underwent arthroscopic meniscectomy for medial meniscus tears, the authors wished to ascertain (1) whether varus alignment in the lower extremity would increase after an operation and (2) if so, what the related factors would be.

Methods

Among 181 patients from 20 to 60 years of age who underwent arthroscopic medial meniscectomy for medial meniscus tears between 2002 and 2005, 56 patients followed for a minimum period of 5 years were enroled for this study. Alignment in the lower extremity was measured preoperatively and again at the last follow-up. Change in varus alignment (the difference between preoperative alignment and alignment at the last follow-up) was analyzed in relation to sex, age, body mass index (BMI), resection amount (partial vs. total), preoperative alignment, and follow-up duration, using multiple linear regression analysis.

Results

Varus deformity increased by 1.7° ± 1.5° from a preoperative mean of 2.4° ± 2.4° to a mean of 4.1° ± 3.0° at the last follow-up, which was statistically significant (p = 0.000). From multiple linear regression analysis, only the resection amount (partial meniscectomy or total meniscectomy) was found to be significantly related to the change in varus alignment (p = 0.002). Other factors including sex, age, BMI, preoperative alignment, presence of cartilage injury and follow-up duration were not significantly related to the change in varus alignment after the operation.

Conclusions

Arthroscopic meniscectomy performed in patients with medial meniscus tears aggravated varus alignment in the lower extremity at the last follow-up. In addition, the increase in varus deformity was significantly higher among patients with total meniscectomy than among those with partial meniscectomy.

Level of evidence

Retrospective comparative study, Level III.     

Improved outcomes with arthroscopic repair of partial-thickness rotator cuff tears: a systematic review

Purpose

The optimum treatment strategy for the surgical management of partial-thickness rotator cuff tears (PTRCT) is evolving. In this study, two research questions were sought to be answered: “Does the repair technique for PTRCTs involving >50% of the tendon thickness have an effect on structural and functional outcomes of arthroscopic repair?” and “Is there a difference in outcomes of arthroscopically treated articular- and bursal-sided PTRCTs?”.

Methods

A systematic review according to the PRISMA statement was conducted to identify all literature published reporting on outcomes of arthroscopic treatment of PTRCTs classified with the Ellman classification with minimum 2-year follow-up. Prospective randomized trials were eligible for quantitative synthesis. A total of 19 studies, published between 1999 and 2015, met the inclusion criteria of this systematic review. Two studies reporting outcomes of articular-sided PTRCTs with prospective randomized study design were included in quantitative synthesis calculations.

Results

Arthroscopic repair of PTRCTs >50% thickness results in significant pain relief and good to excellent functional outcomes. When in situ repair was compared with repair of the tendon after completion to full-thickness RCT, there were no significant differences in functional or structural outcomes or complication rates. The best treatment method for low-grade PTRCTs remains unclear.

Conclusions

The repair technique (in situ repair versus repair of the tendon after completion to full-thickness RCT) did not significantly affect the outcomes for arthroscopic repair of PTRCTs >50% thickness. The current literature contains evidence for inferior outcomes and higher failure rates after arthroscopic debridement of bursal-sided compared to articular-sided PTRCTs, and some evidence suggests that repair of lower-grade bursal-sided tears may be beneficial over debridement.

Level of evidence

IV.

     

Cross-cultural adaptation to Swedish and validation of the Copenhagen Hip and Groin Outcome Score (HAGOS) for pain,symptoms and physical function in patients with hip and groin disability due to femoro-acetabular impingement

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 Danish version of the Copenhagen Hip and Groin Outcome Score (HAGOS) 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 pretesting. The final version was evaluated for reliability, validity and responsiveness. Five hundred and two patients (337 men and 167 women, mean age 37, range 15–75) were included in the study.

Results

Cronbach’s alpha for the six HAGOS-S subscales ranged from 0.77 to 0.89. Significant correlations were obtained with the international Hip Outcome Tool average score (r _s = 0.37–0.68; p < 0.01) and a standardised instrument, the EuroQol, EQ-5D total score (r _s = 0.40–0.60, p = 0.01), for use as a measurement of health outcome. Test–retest reliability (intraclass correlation coefficient) ranged from 0.81 to 0.87 for the six HAGOS-S subscales. The smallest detectable change ranged from 7.8 to 16.1 at individual level and 1.6–3.2 at group level. Factor analysis revealed that the six HAGOS-S subscales had one strong factor per subscale. Effect sizes were generally medium or large.

Conclusion

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

Level of evidence

Diagnostic study, Level I.     

Treatment of chronic syndesmotic injury: a systematic review and meta-analysis

Purpose

The purpose of this study is to systematically review and meta-analyse the available literature on the treatment of chronic syndesmotic injuries of the ankle.

Methods

A systematic review of the PubMed/MEDLINE and EMBASE databases was conducted in August 2012 utilizing the keywords (treatment OR intervention) AND (injury OR sprain OR rupture) AND (syndesmosis OR syndesmotic OR “high ankle” OR “anterior inferior tibiofibular ligament” OR AITFL OR “posterior inferior tibiofibular ligament” OR PITFL OR tibiofibular diastasis). Studies that reported the outcomes of the surgical treatment of chronic syndesmotic injury were included in our review. Chronic was defined as symptoms longer than 6 months. Meta-analysis based on random-effects models was performed to pool the rates of success for different treatment methods.

Results

The search yielded 416 publications from PubMed/MEDLINE and 473 publications from EMBASE. After abstract and full-text review, 15 articles were included in this review. Treatment methods were placed into three broad surgical treatment categories: screw fixation, arthrodesis and arthroscopic debridement. The most common treatment strategy employed was screw fixation. The pooled rates of success for screw fixation, arthrodesis and arthroscopic debridement were 87.9, 79.4 and 78.7 %, respectively.

Conclusion

The current evidence on the treatment of chronic syndesmosis injuries in the ankle is limited to prospective and retrospective case series. The pooled success rates for screw fixation, arthrodesis and arthroscopic debridement each exceeded 78 %. Future high-level studies are required to discern the most appropriate treatment strategy(ies) for chronic syndesmotic injuries of the ankle.     

Supraspinatus tendon tears: comparison of 3D US and MR arthrography with surgical correlation

Objective

The objective of the study was to compare the diagnostic reliability of 3D US with MR arthrography in diagnosing supraspinatus tendon tears, with arthroscopic findings used as the standard.

Materials and methods

In a prospective study 50 patients who later underwent arthroscopic surgery of the rotator cuff were examined pre-operatively by 3D US with MR arthrography. The presence or absence of a full- or partial-thickness supraspinatus tendon tear and the tear size as demonstrated by each imaging and arthroscopy was recorded. The tear size was divided into three grades: small (<1 cm), medium (1-3 cm), and large (>3 cm).

Results

The arthroscopic diagnosis was a full-thickness tear in 40 patients, partial-thickness tears in 5, and intact supraspinatus tendon in 5. 3D US correctly diagnosed 35 out of 40 full-thickness tears and MR arthrography 39 out of 40 full-thickness tears. Regarding partial-thickness tears, 3D US underestimated 2 cases as no tear and overestimated 1 case as a full-thickness tear. MR arthrography underestimated 1 case as a partial-thickness tear and overestimated 2 cases as full-thickness and partial-thickness tears respectively. 3D US and MR arthrography yield a sensitivity for full-thickness tears of 87.5% and 97.5% with specificity of 90.0% and 90.0%. Based on the grading system, 3D US measurements correctly predicted the tear size of 23 (65.7%) of the 35 full-thickness tears and MR arthrography 30 (75.0%) of the 39 full-thickness tears.

Conclusion

Three-dimensional ultrasound seems to be a promising imaging modality comparable to MR arthrography for the assessment of the supraspinatus tendon tears.