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Background: Patients presenting with lateral hip pain may pose a difficult diagnostic challenge, as pain can be due to various causes., Purpose/hypothesis: The purpose was to identify risk factors and predictors for symptomatic hip abductor tears in a cohort of patients undergoing primary hip arthroscopy for femoroacetabular impingement syndrome. We hypothesized that body mass index (BMI), female sex, age, and presence of chondral damage would be significant predictors of hip abductor pathologies., Study Design: Cohort study (diagnosis); Level of evidence, 3., Methods: Data were prospectively collected and retrospectively reviewed. Patients were included if they underwent primary hip arthroscopy between March 2009 and December 2019. Patients with Tönnis grade >1, previous hip conditions, incomplete radiographic data, or open procedures were excluded. All demographic variables, intraoperative measurements, and radiographic measurements were assessed using a bivariate analysis. A stepwise logistic regression was used to determine predictive variables., Results: In total, 255 hips with a hip abductor tear that underwent hip arthroscopy and 2106 hips without a tear that underwent hip arthroscopy were included. The stepwise logistic regression successfully created a predictive model using age, sex, BMI, lateral joint space, and alpha angle as variables. The efficiency of the predictive model was 90.7%, with an area under the curve of 0.894. The odds of having a hip abductor tear were 7.41 times higher in females (odds ratio [OR], 7.41; 95% CI, 4.61-11.9). Each additional year of age was associated with a 13.7% (OR, 1.137; 95% CI, 1.12-1.16) increase in the odds of having a tear. Similarly, with each 1-unit increase in BMI, the odds of having a tear increased by 3.4% (OR, 1.034; 95% CI, 1.01-1.06)., Conclusion: This study successfully created a predictive model that identified female sex (OR, 7.41), increasing age (OR, 1.137 for each year), and increased BMI (OR, 1.034 for each unit of BMI) as significant independent predictors of the presence of hip abductor tears in patients undergoing hip arthroscopy for femoroacetabular impingement syndrome. This model can be used in support of physical examination and imaging suggestive of hip abductor pathology to preoperatively identify the probability of a symptomatic hip abductor tear in these patients.

Background: Avulsion of the proximal hamstring origin is well documented, and surgical treatment is advocated for complete avulsions., Purpose: To compare the return to preinjury level of sport and the complexity of surgery in athletes undergoing surgical intervention for complete proximal hamstring avulsions within 6 weeks, 6 months, and after 6 months of injury., Study Design: Case series; Level of evidence, 4., Methods: This was the largest case series from a tertiary referral center reported in the literature. A total of 112 athletes were included, with complete proximal avulsion injuries confirmed on MRI scans; 63 patients (56.3%) were high-level athletes. Patients were divided into subgroups depending on the timing of surgical intervention: "early" was defined within 6 weeks, "delayed" within 6 weeks to 6 months, and "late" after 6 months. All patients were surgically explored and repaired with the aim of comparing the timing between each group and the return to preinjury sport. All patients underwent an individualized rehabilitation protocol. There was no loss to follow-up. The primary outcome measure was the return to preinjury level sports activity., Results: A total of 108 patients (96.4%) returned to sport. In the early intervention group, the average time of return to play was 16 weeks, 9 weeks faster than the delayed group and 13 weeks faster than the late group. There were 2 partial reruptures in those with delayed intervention—both athletes retired from competitive sport but were recreationally active. Two other athletes recovered well but retired from playing at all levels. Twelve athletes (2 in the early intervention group, 5 in the delayed, 5 in the late) were delayed by local nerve symptoms. Only 2 cases required further exploration., Conclusion: Early surgical intervention was associated with good clinical outcomes and a quicker return to sport; however, delaying the diagnosis can lead to prolonged morbidity and an increased likelihood of complications., (© 2014 The Author(s).)

Background: Diagnostic imaging represents the fastest growing segment of costs in the US health system. This study investigated the cost-effectiveness of alternative diagnostic approaches to meniscus tears of the knee, a highly prevalent disease that traditionally relies on MRI as part of the diagnostic strategy., Purpose: To identify the most efficient strategy for the diagnosis of meniscus tears., Study Design: Economic and decision analysis; Level of evidence, 1., Methods: A simple-decision model run as a cost-utility analysis was constructed to assess the value added by MRI in various combinations with patient history and physical examination (H&P). The model examined traumatic and degenerative tears in 2 distinct settings: primary care and orthopaedic sports medicine clinic. Strategies were compared using the incremental cost-effectiveness ratio (ICER)., Results: In both practice settings, H&P alone was widely preferred for degenerative meniscus tears. Performing MRI to confirm a positive H&P was preferred for traumatic tears in both practice settings, with a willingness to pay of less than US$50,000 per quality-adjusted life-year. Performing an MRI for all patients was not preferred in any reasonable clinical scenario. The prevalence of a meniscus tear in a clinician's patient population was influential. For traumatic tears, MRI to confirm a positive H&P was preferred when prevalence was less than 46.7%, with H&P preferred above that. For degenerative tears, H&P was preferred until the prevalence reaches 74.2%, and then MRI to confirm a negative was the preferred strategy. In both settings, MRI to confirm positive physical examination led to more than a 10-fold lower rate of unnecessary surgeries than did any other strategy, while MRI to confirm negative physical examination led to a 2.08 and 2.26 higher rate than H&P alone in primary care and orthopaedic clinics, respectively., Conclusion: For all practitioners, H&P is the preferred strategy for the suspected degenerative meniscus tear. An MRI to confirm a positive H&P is preferred for traumatic tears for all practitioners. Consideration should be given to implementing alternative diagnostic strategies as well as enhancing provider education in physical examination skills to improve the reliability of H&P as a diagnostic test., Clinical Relevance: Alternative diagnostic strategies that do not include the use of MRI may result in decreased health care costs without harm to the patient and could possibly reduce unnecessary procedures., (© 2014 The Author(s).)

Background: A ligamentum teres (LT) injury is a common finding at the time of hip arthroscopic surgery in patients with chronic groin and hip pain; however, LT tears have been difficult to identify before surgery. There have been no unique features identified on history assessment, physical examination, or imaging that reliably identify injuries of the LT preoperatively., Purpose: To report a new clinical examination to assess the presence of an LT tear: the LT test., Study Design: Cohort study (diagnosis); Level of evidence, 2., Methods: The study consisted of 75 patients undergoing hip arthroscopic surgery for multiple lesions. Each patient was evaluated by 2 independent examiners using the LT test, leading to a total of 150 tests being performed. The LT test is conducted with the hip flexed at 70° and 30° short of full abduction; the hip is then internally and externally rotated to its limits of motion. Pain on either internal or external rotation is consistent with a positive LT test result. Hip arthroscopic surgery was then performed and all intra-articular abnormalities noted. Arthroscopic images were taken of each LT and examined by a third independent examiner who determined the presence or absence of a tear. Clinical examination findings were compared with the arthroscopic findings to determine the sensitivity, specificity, and positive and negative predictive values. In addition, the presence of intra-articular pathological lesions was compared with the test results to determine if there was a correlation between the presence of an intra-articular pathological abnormality and a positive LT test result., Results: Of the 150 examinations performed, the test result was positive 55% of the time (77 examinations). The sensitivity and specificity of the test were 90% and 85%, respectively. The positive predictive value was 84%, and the negative predictive value was 91%. The presence of an LT tear, pincer lesion, and labral tear that required repair was associated with a positive LT test result. The κ coefficient for interobserver reliability was .80., Conclusion: The LT test is an effective way of assessing the presence of LT tears with moderate to high interobserver reliability. In addition to an LT tear, the presence of a pincer lesion or labral tear requiring repair are also associated with a positive LT test result.

Background: Lesions of the biceps pulley and instability of the long head of the biceps tendon are common diagnoses in patients with anterior shoulder pain., Purpose: To analyze the pathoanatomy of the biceps reflection pulley ("pulley") in consecutive patients undergoing shoulder arthroscopy., Study Design: Cohort study (prevalence); Level of evidence, 2., Methods: Prospective data were collected on 229 shoulders in consecutive patients (155 male,74 female) who underwent shoulder arthroscopy (121 rotator cuff pathology, 50 instability, 43 osteoarthritis, 15 miscellaneous). The average age was 48.5 years (range, 18-76 years). Sixty-eight shoulders had underwent a previous surgery., Results: The long head of the biceps tendon was absent in 21 shoulders (9.2%); 1 was excluded for incomplete data. In 207 shoulders, the mean width of the long head of the biceps tendon was 6.0 mm (range, 3-10 mm), and the pulley complex, 7.2 mm (range, 4-15 mm). Sixty-seven patients (32.4%) had a pulley tear: 48 shoulders had anteromedial pulley tears, 32 posterolateral, with 13 combined anteromedial-posterolateral lesions. Patients with pulley tears were significantly older than those without (57 vs 44 years, P < .001). For anteromedial pulley tears, the mean width of the long head of the biceps tendon was significantly larger in the torn group (6.4 vs 5.8 mm, P = .012). The anteromedial or posterolateral pulley tears were significantly associated with subluxation or dislocation of the long head of the biceps tendon (P = .001), with a pulley torn in all 27 cases of biceps dislocation. In 173 shoulders with a centered long head of the biceps tendon, the pulley was torn in 36 (23 anteromedial, 18 posterolateral [with 5 being combined]). Pulley tears and rotator cuff injury showed a significant association (P < .001). Superior labral anterior posterior lesions were significantly associated with anteromedial (P < .008) and posterolateral pulley tears (P < .021)., Conclusion: Pulley lesions are fairly common in patients undergoing arthroscopic surgery and were found in 32.4% of this prospective cohort (67 of 207). Current consensus indicates that pulley lesions are often associated with rotator cuff tears. This series also showed correlations with superior labral anterior posterior tears, biceps instability, and long head of the biceps tendon tears.

Background: The suture-bridging technique is a new arthroscopic technique to repair rotator cuff tears. Biomechanical advantages compared with double-row fixations have been described., Hypothesis: The authors hypothesized that arthroscopic suture-bridging repair of the supraspinatus tendon would result in a superior clinical outcome and lower retear rates compared with previously published results after double-row fixation., Study Design: Case series; Level of evidence, 4., Methods: Fifty-one consecutive patients, with a median age of 62 years (range, 37-76 years), who had undergone an arthroscopic suture-bridging repair of an isolated supraspinatus tendon tear were evaluated in this prospective study 4, 12, and a median of 24 months postoperatively. Subjective and functional outcome was assessed using the simple shoulder test and Constant score. With magnetic resonance imaging 12 months postoperatively, the tendon integrity and potential predictors of failures were evaluated., Results: The simple shoulder test scores improved significantly from 9 points (range, 1-12 points) at 4 months, to 12 points (range, 1-12 points) at 12 months, and 12 points (range, 5-12 points) at 24 months postoperatively. The Constant score increased significantly from preoperative 64% (range, 37%-92%) to 82% (range, 36%-100%) at 4 months, 96% (range, 49%-100%) at 12 months, and 96% (range, 64%-100%) at 24 months postoperatively. Magnetic resonance imaging 12 months after surgery showed retears in 28.9%. Two different types of retears could be observed: insufficiently healed and medially retorn supraspinatus tendons. The Constant score did not differ significantly between the groups with retears and intact repairs. A patient age of more than 60 years was found to influence tendon healing significantly., Conclusion: The hypothesis, that arthroscopic suture-bridging repair of the supraspinatus tendon would result in a superior clinical outcome and lower retear rates compared with previously published results after double-row fixation, could not be confirmed. The functional outcome after the new suture-bridging technique was good and comparable with the reported results after double-row repair from the literature. A structural failure of tendon repair was not identical to clinical failure.

Background: No consensus has been reached with regard to the ideal timing of anterior cruciate ligament reconstruction in terms of reducing secondary meniscal tears in anterior cruciate ligament-deficient knees., Hypothesis: Delay in anterior cruciate ligament reconstruction increases the incidence and severity of medial meniscal tears., Study Design: Case series; Level of evidence, 4., Methods: Thirty-one patients were evaluated with arthroscopic all-inside suturing of medial meniscal tears with concurrent anterior cruciate ligament reconstruction who had at least 2 preoperative magnetic resonance imaging studies. Patients were evaluated during the acute phase of injury, but anterior cruciate ligament reconstruction surgery was delayed at least 6 months. Mean interval between first and second imaging studies was 36.8 months. Subsequent medial meniscal tears were identified as longitudinal or bucket-handle types. Relationships between medial meniscal lesions and patient age, time interval between the date of initial injury and surgery, repetitive injury, and patient activity level were evaluated., Results: During the first preoperative magnetic resonance imaging studies, 14 knees had no medial meniscal tear, 15 a longitudinal tear, and 2 a bucket-handle-type tear; during the second preoperative imaging studies, 5 knees had no medial meniscal tear, 19 a longitudinal tear, and 7 a bucket-handle-type tear. The incidence of medial meniscal tears increased from 55% in first studies to 84% in second studies for chronic anterior cruciate ligament-insufficient knees (P = .0054). Eight knees without a tear during first studies had a longitudinal tear during second studies, 1 knee without a tear and 4 with a longitudinal tear in first studies had a bucket-handle-type tear in second studies. Thirteen knees (42%) had a worse meniscal status during the second studies., Conclusion: Delayed anterior cruciate ligament reconstruction increases the likelihood of a medial meniscal tear, suggesting that early anterior cruciate ligament reconstruction should reduce or prevent additional medial meniscal injury. The findings show that further medial meniscal damage is common if surgery is delayed by 6 months or more.

Background: In the symptomatic discoid lateral meniscus, the effectiveness of preoperative magnetic resonance imaging (MRI) is not well documented., Hypothesis: Magnetic resonance imaging classification will provide more information to the surgeon in choosing the appropriate treatment methods with the help of arthroscopic findings., Study Design: Cohort study (diagnosis); Level of evidence, 2., Methods: Sixty-seven patients (82 knees) were reviewed. The preoperative MRI was checked in 76 of 82 knees. The Lysholm and Ikeuchi grading scales were evaluated. Images were analyzed from MRI, and findings were classified into 4 categories: no shift, anterocentral shift, posterocentral shift, and central shift. Tear pattern classifications were based on arthroscopic findings: horizontal tear, peripheral tear, horizontal and peripheral tear, posterolateral corner loss, and others. The correlations between MRI classification tear patterns and surgical methods were analyzed using the chi-square test or the Fisher exact test. The sensitivity, specificity, and accuracy of shift in preoperative MRI-according to the existence of peripheral tear when corroborated with arthroscopy-were also analyzed with the chi-square test. Inter- and intraobserver reliability was statistically analyzed by producing the inter- and intraclass correlation coefficient., Results: The mean preoperative Lysholm score was 77.3 (range, 43-97), and the last follow-up Lysholm score had increased to 96.8 (range, 84-100; P < .001). At last follow-up (100% follow-up), the Ikeuchi grading scale scored 48 knees as excellent, 30 as good, and 4 as fair. According to the MRI classification, 43 knees were no shift; 6, anterocentral shift; 15, posterocentral shift; and 12, central shift. Shift-type knees had a significantly larger number of peripheral tears, and repairs were performed in the shift-type knees (55%) more frequently than in the no-shift-type knees (28%). Among 82 knees, 31 were repaired simultaneously after a central partial meniscectomy., Conclusion: Magnetic resonance imaging classification provides more information to surgeons in choosing the appropriate treatment methods, although the final decision regarding procedure is made during arthroscopy after thorough analysis of the tear.

Background: Different patterns of bone bruising are seen on magnetic resonance imaging in acute anterior cruciate ligament ruptures. These patterns may relate to the mechanism of injury., Hypothesis: There is a correlation between the mechanism of anterior cruciate ligament injury and bone bruise patterns on magnetic resonance imaging., Study Design: Cohort study; Level of evidence, 2., Methods: Data regarding the mechanism of anterior cruciate ligament rupture were collected prospectively on patients who had anterior cruciate ligament reconstructions. Inclusion criteria included a clear history of mechanism, magnetic resonance imaging within 6 weeks of injury, and no previous knee injury. Patients were divided into noncontact and contact mechanism groups. Bone bruise frequency, location, depth, and intensity were analyzed using magnetic resonance imaging and correlated with the mechanism of injury., Results: Two hundred fifty-six patients were identified; 100 met the inclusion criteria, 86 were in the noncontact mechanism group, and 14 were in the contact mechanism group. The proportion of bone bruises in the lateral compartment in both groups was higher (P < .001) than in the medial compartment. Bone bruising was more frequent, deeper, and more intense in the noncontact group, with frequency (P = .019) and intensity (P < .001) scores reaching significance at the lateral tibial plateau. Medial compartment bone bruising was seen more frequently than previously reported, particularly in the noncontact group., Conclusion: The noncontact mechanism appears to cause more severe bone bruising in both the medial and lateral compartments.

Background: Even though there are several physical tests available for superior labrum anterior posterior lesions, there have been very few reports on their accuracy, and none can be regarded as completely predictive for the presence of a superior labrum anterior posterior lesion in the shoulder joint., Hypothesis: This new clinical test is a useful and accurate technique for detecting superior labral tears in the shoulder joint., Study Design: Cohort study (diagnosis); Level of evidence, 2., Methods: This test was conducted independently by 2 physicians before any other diagnostic evaluation. In all cases, the glenohumeral joint was investigated first, and the appropriate treatments were performed on the lesion. A protocol was established to evaluate the sensitivity, specificity, and positive and negative predictive values of this new clinical test. The reproducibility of this test was evaluated with a kappa coefficient., Results: Sixty-one patients (61 shoulders) were examined with the passive compression test, and all underwent arthroscopic surgery. In 31 patients with a positive passive compression test result, 27 had a superior labrum anterior posterior lesion, and in 30 patients with a negative passive compression test result, 6 had a superior labrum anterior posterior lesion. The sensitivity of the test was 81.8%, and the specificity was 85.7%. The positive predictive value was 87.1%, and the negative predictive value was 80.0%. The kappa coefficient was 0.771 between the 2 independent examiners (P< .01)., Conclusion: The passive compression test is a useful and accurate technique for predicting superior labral tears of the shoulder joint.

Background: Complete proximal hamstring tendon rupture is a rare injury associated with significant functional loss. Nonoperative treatment has proven inadequate in returning patients to their previous activity level., Purpose: We wanted to describe the outcome of primary surgical repair of the proximal hamstring tendon avulsion., Study Design: Retrospective cohort study., Methods: Between 1994 and 1999, 11 patients (4 women and 7 men) with an average age of 41.5 years (range, 21 to 51) had a diagnosis of complete proximal hamstring tendon rupture based on mechanism of injury, physical examination, and radiographic assessment. All underwent a single operation followed by standard postoperative physical therapy. At the latest follow-up (average, 34 months), patients completed a questionnaire regarding such outcome parameters as pain, function, leg control, stiffness, return to activity, and overall satisfaction., Results: Isokinetic muscle testing revealed an overall average of 91%return of hamstring muscle strength. Ten of 11 patients were satisfied with the result, and 7 of 9 athletically active patients were able to return to sport an average of 6 months (range, 3 to 10) after surgery. No difference between early and late repairs was identified in regard to functional outcome or return to sport., Conclusions: Satisfactory results can be achieved with both early and late hamstring tendon repairs in a majority of cases with surgical repair., (Copyright 2002 American Orthopaedic Society for Sports Medicine)

A study to determine the sensitivity, specificity, and positive and negative predictive values of several clinical diagnostic tests of subcutaneous Achilles tendon rupture was performed during a 13-year period. There were 174 patients with clinical diagnosis of unilateral complete subcutaneous Achilles tendon tear and 28 patients with unilateral suspected but no actual Achilles tendon tear. The following tests were used: palpation, calf squeeze, Matles, Copeland, and O'Brien. Palpation of the gap was the least sensitive clinical test with the patient awake (0.73), increasing to 0.81 when the test was performed under anesthesia; the Copeland and O'Brien tests showed a sensitivity of 0.8. Both the calf squeeze and Matles tests were significantly more sensitive than the other tests (0.96 and 0.88, respectively; 0.022 < P < 0.05). All tests showed a high positive predictive value, with no statistically significant difference between the various tests. In the 28 patients with no evidence of a subcutaneous Achilles tendon tear on imaging, the tests showed a high capability to detect that the Achilles tendon was intact (gap palpation specificity, 0.89; calf squeeze test specificity, 0.93; Matles test specificity, 0.85). Whichever tests were performed, at least two of them were positive for a subcutaneous tear of the Achilles tendon in all patients in this study.

To establish the value of magnetic resonance imaging in determining which patients with ankle sprains will benefit from surgical treatment, 1 uninjured volunteer and 15 patients with acute, subacute, and chronic injuries of the lateral ankle ligaments were imaged at 1.0 tesla using a fast imaging with steady-state precision three-dimensional technique and 1.5-mm slice thickness. A dedicated knee coil was used to hold the foot in a neutral or plantar-flexed position. In cases of acute, low-grade injuries, fraying of the anterior talofibular ligaments with intact calcaneofibular ligaments was observed in the presence of edema and hemorrhagic fluid. In cases of acute, high-grade sprains, the calcaneofibular ligament appeared wavy or was visualized only partially or not at all. Subacute injuries showed ligament disruption; chronic lesions, on occasion, showed atrophy of the calcaneofibular ligament but no edema or hemorrhagic fluid. These findings showed a good qualitative correlation with the results of graded stress radiography. Magnetic resonance imaging can definitely determine the ligaments involved in lateral ankle sprains and provide useful anatomic information in cases in which acute or reconstructive surgery is contemplated. However, the magnetic resonance imaging findings do not directly correlate with degree of instability and do not replace those of physical examination or routine radiographic studies.