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Background: A previous publication demonstrated that the oral intake of losartan promoted microfracture-mediated hyaline-like cartilage repair in osteochondral defects of a rabbit knee model. However, an intra-articular (IA) injection of losartan may have direct beneficial effects on cartilage repair and has not been studied., Purpose: To determine the dosage and beneficial effects of an IA injection of losartan on microfracture-mediated cartilage repair and normal cartilage homeostasis., Study Design: Controlled laboratory study., Methods: Rabbits were divided into 5 groups (n = 6 each): a microfracture group (MFX group) and 4 different losartan treatment groups that received varying doses of IA losartan (0.1, 1, 10, and 100 mg per knee). An osteochondral defect (5 mm) was created in the trochlear groove cartilage of 1 limb in each rabbit, and 5 microfracture perforations were made in the osteochondral defect. Both the injured and the contralateral knee joints were injected with IA losartan immediately after microfracture and at 2 and 4 weeks after surgery. Rabbits were sacrificed at 6 weeks after surgery for analysis including gross observation, micro-computed tomography, histology, and reverse transcription quantitative polymerase chain reaction., Results: Micro-computed tomography and gross observation demonstrated comparable subchondral bone healing and hyaline-like cartilage morphology in the 0.1-, 1-, and 10-mg losartan groups relative to the MFX group. Conversely, the 100-mg losartan group showed neither bony defect healing nor cartilage repair. Histology revealed higher O'Driscoll scores and hyaline-like cartilage regeneration in the 1-mg losartan group compared with the MFX group. In contrast, the 100-mg losartan group showed the lowest histology score and no cartilage repair. An IA injection of losartan at the doses of 0.1, 1, and 10 mg did not cause adverse effects on uninjured cartilage, while the 100-mg dose induced cartilage damage. Quantitative polymerase chain reaction results showed downregulation of the transforming growth factor β (TGF-β) signaling pathway after IA losartan injection., Conclusion: An IA injection of losartan at the dose of 1 mg was most effective for the enhancement of microfracture-mediated cartilage repair without adversely affecting uninjured cartilage. Conversely, a high dose (100 mg) IA injection of losartan inhibited cartilage repair in the osteochondral defect and was chondrotoxic to normal articular cartilage., Clinical Relevance: An IA injection of losartan at an optimal dosage represents a novel microfracture enhancement therapy and warrants a clinical trial for future clinical applications.

Background: Bone marrow stimulation (BMS) via microfracture historically has been a first-line treatment for articular cartilage lesions. However, BMS has become less favorable because of resulting fibrocartilage formation. Previous studies have shown that angiogenesis blockade promotes cartilage repair. Bevacizumab is a Food and Drug Administration-approved medication used clinically to prevent angiogenesis., Hypothesis: The intra-articular injection of bevacizumab would prevent angiogenesis after BMS and lead to improved cartilage repair with more hyaline-like cartilage., Study Design: Controlled laboratory study., Methods: The dose of bevacizumab was first optimized in a rabbit osteochondral defect model with BMS. Then, 48 rabbits (n = 8/group/time point) were divided into 3 groups: osteochondral defect (defect), osteochondral defect + BMS (BMS group), and osteochondral defect + BMS + bevacizumab intra-articular injection (bevacizumab group). Rabbits were sacrificed at either 6 or 12 weeks after surgery. Three-dimensional (3D) micro-computed tomography (microCT), macroscope score, modified O'Driscoll histology scores, collagen type 2, Herovici staining, and hematoxylin and eosin staining were performed. Angiogenesis markers were also evaluated., Results: The intra-articular dose of 12.5 mg/0.5 mL bevacizumab was found to be effective without deleteriously affecting the subchondral bone. Intra-articular injection of bevacizumab resulted in significantly improved cartilage repair for the bevacizumab group compared with the BMS or the defect group based on 3D microCT, the macroscope score (both P < .05), the modified O'Driscoll histology score ( P = .0034 and P = .019 vs defect and BMS groups, respectively), collagen type 2, Herovici staining, and hematoxylin and eosin staining at 6 weeks. Cartilage in the bevacizumab group had significantly more hyaline cartilage than did that in other groups. At 12 weeks, the cartilage layer regenerated in all groups; however, the bevacizumab group showed more hyaline-like morphology, as demonstrated by microCT, histology scores ( P < .001 and .0225 vs defect and BMS groups, respectively), histology, and immunohistochemistry. The bevacizumab injection did not significantly change mRNA expressions of smooth muscle actin, vascular endothelial growth factor, or hypoxia-inducible factor-1 alpha., Conclusion: Intra-articular injection of bevacizumab significantly enhanced the quality and quantity of hyaline-like cartilage after BMS in a rabbit model. Future large-animal and human studies are necessary to evaluate the clinical effect of this therapy, which may lead to improved BMS outcomes and thus the durability of the regenerated cartilage., Clinical Relevance: The use of bevacizumab may be an important clinical adjunct to improve BMS-mediated cartilage repair.

Background: The acetabular labrum contains free nerve endings, and an unstable labrum can result in increased femoral head movement during hip motion. This can be caused by chondrolabral junction (CLJ) separation, especially in association with pincer-type femoroacetabular impingement, and may contribute to hip pain., Hypothesis: Rim resection alone has no effect on suction seal biomechanics. Further, separation of the CLJ changes hip suction seal biomechanics when compared with those of the native state, whereas repair and refixation with suture anchors restore these biomechanical parameters., Study Design: Controlled laboratory study., Methods: A total of 12 fresh-frozen human cadaveric hips were used in this study. Hips were mounted in a saline bath on a dynamic tensile testing machine and were distracted at a rate of 0.5 mm/s from neutral position. A total of 3 parameters (force, displacement, and intra-articular pressure) were measured throughout testing. Before testing, hips were randomly allocated to 1 of 2 groups: 1 that included the CLJ separation (CLJ Cut group) and 1 that did not (CLJ Intact group). Hips were tested in the following states: (1) native, (2) rim trimming, (3) separated CLJ (CLJ Cut group only), and (4) labral repair/refixation. For each group a linear mixed-effects model was used to compare biomechanical parameters between states., Results: Rim trimming did not affect any suction seal parameters relative to those of the native state. In the CLJ Cut group, no significant difference in distance to break the suction seal was observed for any states compared with that of the native state. In the CLJ Intact group, the distance to break the suction seal was significantly shorter in the labral refixation state (1.8 mm) than the native state (5.6 mm; P = .002). The maximum distraction force (62.1 ± 54.1 N) and the peak negative pressure (-36.6 ± 24.2 kPa) of the labral repair/refixation state were significantly lower than those of the native state in both groups (93.4 ± 41.7 N, P = .01; -60.7 ± 20.4 kPa, P = .02)., Conclusion: Rim trimming did not change the biomechanical properties of the labral suction seal. Labral refixation resulted in a shorter distance to break the labral suction seal. This indicates that labral mobility is reduced by the labral refixation procedure, which could be beneficial in postoperative pain relief and labral healing., Clinical Relevance: The labral refixation reduced labral mobility, which could be beneficial for both pain relief and labral healing to the acetabulum after pincer-type femoroacetabular impingement resection.

Background: The acetabular labrum has been found to provide a significant contribution to the distractive stability of the hip. However, the influence of labral height on hip suction seal biomechanics is not known., Hypothesis: The smaller height of acetabular labrum is associated with decreased distractive stability., Study Design: Descriptive laboratory study., Methods: A total of 23 fresh-frozen cadaveric hemipelvises were used in this study. Hips with acetabular dysplasia or femoroacetabular impingement-related bony morphologic features, intra-articular pathology, or no measurable suction seal were excluded. Before testing, each specimen's hip capsule was removed, a pressure sensor was placed intra-articularly, and the hip was fixed in a heated saline bath. Labral size was measured by use of a digital caliper. Maximum distraction force, distance to suction seal rupture, and peak negative pressure were recorded while the hip underwent distraction at a rate of 0.5 mm/s. Correlations between factors were analyzed using the Spearman rho, and differences between groups were detected using Mann-Whitney U test., Results: Of 23 hips, 12 satisfied inclusion criteria. The maximum distraction force and peak negative pressure were significantly correlated ( R = -0.83; P = .001). Labral height was largely correlated with all suction seal parameters (maximum distraction force, R = 0.69, P = .013; distance to suction seal rupture, R = 0.55, P = .063; peak negative pressure, R = -0.62, P = .031). Labral height less than 6 mm was observed in 5 hips, with a mean height of 6.48 mm (SD, 2.65 mm; range, 2.62-11.90 mm; 95% CI, 4.80-8.17 mm). Compared with the 7 hips with larger labra (>6 mm), the hips with smaller labra had significantly shorter distance to suction seal rupture (median, 2.3 vs 7.2 mm; P = .010) and significantly decreased peak negative pressure (median, -59.3 vs -66.9 kPa; P = .048)., Conclusion: Smaller height (<6 mm) of the acetabular labrum was significantly associated with decreased distance to suction seal rupture and decreased peak negative pressure. A new strategy to increase the size of the labrum, such as labral augmentation, could be justified for patients with smaller labra in order to optimize the hip suction seal., Clinical Relevance: The height of the acetabular labrum is correlated with hip suction seal biomechanics. Further studies are required to identify the clinical effects of labral height on hip stability.

Background: Microfracture or bone marrow stimulation (BMS) is often the first choice for clinical treatment of cartilage injuries; however, fibrocartilage, not pure hyaline cartilage, has been reported because of the development of fibrosis in the repair tissue. Transforming growth factor β1 (TGF-β1), which can promote fibrosis, can be inhibited by losartan and potentially be used to reduce fibrocartilage., Hypothesis: Blocking TGF-β1 would improve cartilage healing in a rabbit knee BMS model via decreasing the amount of fibrocartilage and increasing hyaline-like cartilage formation., Study Design: Controlled laboratory study., Methods: An osteochondral defect was made in the patellar groove of 48 New Zealand White rabbits. The rabbits were divided into 3 groups: a defect group (defect only), a BMS group (osteochondral defect + BMS), and a BMS + losartan group (osteochondral defect + BMS + losartan). For the rabbits in the BMS + losartan group, losartan was administrated orally from the day after surgery through the day of euthanasia. Rabbits were sacrificed 6 or 12 weeks postoperatively. Macroscopic appearance, microcomputed tomography, histological assessment, and TGF-β1 signaling pathway were evaluated at 6 and 12 weeks postoperatively., Results: The macroscopic assessment of the repair revealed that the BMS + losartan group was superior to the other groups tested. Microcomputed tomography showed superior healing of the bony defect in the BMS + losartan group in comparison with the other groups. Histologically, fibrosis in the repair tissue of the BMS + losartan group was significantly reduced when compared with the other groups. Results obtained with the modified O'Driscoll International Cartilage Repair Society grading system yielded significantly superior scores in the BMS + losartan group as compared with both the defect group and the BMS group ( F value: 15.8, P < .001, P = .012, respectively). TGF-β1 signaling and TGF-β-activated kinase 1 of the BMS + losartan group were significantly suppressed in the synovial tissues., Conclusion: By blocking TGF-β1 with losartan, the repair cartilage tissue after BMS was superior to the other groups and consisted primarily of hyaline cartilage. These results should be easily translated to the clinic because losartan is a Food and Drug Administration-approved drug and it can be combined with the BMS technique for optimal repair of chondral defects., Clinical Relevance: Biologically regulated marrow stimulation by blocking TGF-β1 (oral intake of losartan) provides superior repair via decreasing fibrocartilage formation and resulting in hyaline-like cartilage as compared with outcomes from BMS only.

Background: The acetabular labrum plays important roles in proprioception, nociception, synovial fluid seal effect, and static and dynamic joint stability and as a shock absorber. Clinical and radiographic risk factors for unsalvageable labral tear in femoroacetabular impingement (FAI) are not well established., Purpose: To identify predictors of unsalvageable labral tear during initial hip arthroscopic management of FAI., Study Design: Case-control study; Level of evidence, 3., Methods: Patients were included who underwent primary hip arthroscopic treatment for FAI between March 2009 and March 2014. Patients were excluded who had <2-year follow-up, underwent bilateral surgery, or had a history of surgery, osteoarthritis (Tönnis grade 2 or 3), and other diagnoses, including lateral center-edge angle <25° diagnosed as developmental hip dysplasia. Patients were divided into 2 groups according to their labral condition: reconstruction and refixation. Unsalvageable labral tear was defined as any irreparable labral tear, including severe degenerative tear, frayed labrum, labral ossification, flattened labrum, and failed prior repair during surgery. Univariate and multivariate analyses identified risk factors for segmental labral reconstruction. Patient-reported outcome scores and postoperative revision rates were also assessed., Results: Twenty-five hips (18 male, 7 female) and 126 hips (65 male, 61 female) were included in the reconstruction and refixation groups, respectively. The mean ± SD ages were 52.6 ± 15.0 and 36.5 ± 16.1 years in the reconstruction and refixation groups, respectively. In the reconstruction group, the mean modified Harris Hip Score significantly improved from 67.3 ± 14.9 preoperatively to 95.0 ± 8.1 at final follow-up ( P < .001), and the mean Nonarthritic Hip Score improved from 63.0 ± 18.3 preoperatively to 89.5 ± 10.1 at final follow-up ( P < .001). In the refixation group, the mean modified Harris Hip Score significantly improved from 69.2 ± 18.6 preoperatively to 93.0 ± 11.2 at final follow-up ( P < .001), and the mean Nonarthritic Hip Score improved from 60.7 ± 18.8 preoperatively to 88.6 ± 15.0 at final follow-up ( P < .001). No significant difference was noted in patient-reported outcome scores and revision hip arthroscopy rates. The rate of conversion of total hip arthroplasty was higher in the reconstruction group than in the refixation group. Risk factors for unsalvageable labral tear were age ≥45 years (odds ratio [OR], 8.83; P < .007), body mass index ≥23.1 kg/m 2 (OR, 13.05; P < .001), and vertical center anterior angle ≥36° (OR, 19.03; P < .001). Furthermore, in this study, unsalvageable labral tears were present in cases with at least 2 of the 3 risk factors., Conclusion: Age ≥45 years, body mass index ≥23.1 kg/m 2 , and vertical center anterior angle ≥36° are risk factors for unsalvageable labral tear at initial hip arthroscopic surgery for patients with FAI.

Background: There is a dearth of knowledge regarding the correlation between femoroacetabular impingement (FAI) and osteitis pubis (OP) among symptomatic soccer players., Purpose: To elucidate whether arthroscopic FAI correction is effective for young competitive soccer players with FAI combined with OP or perisymphyseal pubic bone marrow edema (BME)., Study Design: Case series; Level of evidence, 4., Methods: A total of 577 consecutive patients who underwent arthroscopic FAI correction were retrospectively reviewed with a minimum 2-year follow-up. Competitive soccer players who were professional, college, and high school athletes were included. The authors assessed the modified Harris Hip Score and Nonarthritic Hip Score preoperatively and at 6 months, 1 year, and 2 years after surgery. In addition, players were divided into groups according to radiographic evidence of OP and BME (2 groups each). Clinical outcomes, return to play, and radiographic assessments were compared between groups., Results: Twenty-eight hips met the inclusion criteria. The median modified Harris Hip Score significantly improved after hip arthroscopy (81.4, preoperatively; 95.7 at 6 months, P = .0065; 100 at 1 year, P = .0098; 100 at 2 years, P = .013). The median Nonarthritic Hip Score also significantly improved (75.0, preoperatively; 96.3 at 6 months, P = .015; 98.8 at 1 year, P = .0029; 100 at 2 years, P = .015). Furthermore, 92.0% of players returned to play soccer at the same or higher level of competition at a median 5.5 months (range, 4-15 months); 67.8% had radiological confirmation of OP; and 35.7% had pubic BME. The alpha angle was significantly higher in pubic BME group than the no-pubic BME group (64.8° vs 59.2°, P = .027), although there was no significant difference between the OP and no-OP groups. The prevalence of tenderness of the pubic symphysis significantly decreased preoperatively (32.1%) to postoperatively (3.6%). Magnetic resonance imaging findings confirmed that pubic BME disappeared in all players at a median 11 months (range, 6-36) after initial surgery., Conclusions: Arthroscopic management for FAI provides favorable clinical outcomes, a high rate of return to sports, and, when present, resolution of pubic BME among competitive soccer players.

Background: The capsular ligaments and the labral suction seal cooperatively manage distractive stability of the hip. Capsular reconstruction using an iliotibial band (ITB) allograft aims to address capsular insufficiency and iatrogenic instability. However, the extent to which this procedure may restore hip distractive stability after a capsular defect is unknown., Purpose: To evaluate the biomechanical effects of capsular reconstruction on distractive stability of the hip joint., Study Design: Controlled laboratory study., Methods: Eight fresh-frozen cadaveric hip specimens were dissected to the level of the capsule and axially distracted in 3 testing states: intact capsule, partial capsular defect, and capsular reconstruction with an ITB allograft. Each femur was compressed with 500 N of force and then distracted 6 mm relative to the neutral position at 0.5 mm/s. Distractive force was continuously recorded, and the first peak delineating 2 phases of hip distractive stability in the force-displacement curve was analyzed., Results: The median force at maximum distraction in the capsular reconstruction state (156 N) was significantly greater than that in the capsular defect state (89 N; P = .036) but not significantly different from that in the intact state (218 N; P = .054). Median values for distractive force at first peak (60 N, 72 N, and 61 N, respectively; P = .607), distraction at first peak (2.3 mm, 2.3 mm, and 2.5 mm, respectively; P = .846), and percentage decrease in distractive force (35%, 78%, and 63%, respectively; P = .072) after the first peak were not significantly different between the intact, defect, and reconstruction states., Conclusion: Capsular reconstruction with an ITB allograft significantly increased the force required to distract the hip compared with a capsular defect in a cadaveric model. To our knowledge, this is the first study to report an initial peak distractive force and to propose 2 distinct phases of hip distractive stability., Clinical Relevance: The consequences of a capsular defect on distractive stability of the hip may be underappreciated among the orthopaedic community; with that said, capsular reconstruction using an ITB allograft provided significantly increased distractive stability and should be considered an effective treatment option for patients with symptomatic capsular deficiency.

Background: Previous studies have demonstrated that hip arthroscopy is an effective treatment for symptomatic femoroacetabular impingement (FAI) in professional athletes across a variety of sports. However, the return-to-play rates and postoperative performance of elite basketball players after hip arthroscopy are currently unknown., Purpose: To determine return-to-play rates and postoperative performance among professional basketball athletes after hip arthroscopy., Study Design: Case series; Level of evidence, 3., Methods: Eighteen professional basketball players underwent hip arthroscopy (24 hips) for symptomatic FAI between 2001 and 2016 by a single surgeon. Return to play was defined as competing in a single professional game of equal level after surgery. Data were retrospectively obtained for each player from basketball-reference.com , ESPN.com , eurobasket.com, and individual team websites. Matched controls were selected from the websites to compare performances., Results: The mean age at the time of surgery was 25.6 years, and the mean body mass index was 24.4 kg/m 2 . All players returned to their previous levels of competition, with a mean number of 4 seasons played after surgery (median, 3; range, 1-12). The mean ± SD time between the date of surgery and return to a professional game was 7.1 ± 4.4 months. There was no change in player efficiency rating when pre- and postinjury performance were compared. When compared with controls, players undergoing surgery also had no significant decline in player efficiency rating., Conclusion: Elite basketball athletes who undergo hip arthroscopy for the treatment of FAI return to their presurgical levels of competition at a high rate. These athletes demonstrate no significant overall decrease in performance upon their return to play.

Background: Several studies have shown the relationship between poorer clinical outcomes of arthroscopic femoroacetabular impingement syndrome surgery and focal chondral defects or global chondromalacia/osteoarthritis. Although recent studies described good outcomes after the conjunctive application of synovial mesenchymal stem cells (MSCs), none demonstrated the application of synovial MSCs for cartilaginous hip injuries., Purpose: To compare the characteristics of MSCs derived from the paralabral synovium and the cotyloid fossa synovium and determine which is the better source., Study Design: Controlled laboratory study., Methods: Synovium was harvested from 2 locations of the hip-paralabral and cotyloid fossa-from 18 donors. The number of cells, colony-forming units, viability, and differentiation capacities of adipose, bone, and cartilage were collected and compared between groups. In addition, real-time polymerase chain reaction was used to assess the differentiation capacity of adipose, bone, and cartilage tissue from both samples., Results: The number of colonies and yield obtained at passage 0 of synovium from the cotyloid fossa was significantly higher than that of the paralabral synovium ( P < .01). In adipogenesis experiments, the frequency of detecting oil red O-positive colonies was significantly higher in the cotyloid fossa than in the paralabral synovium ( P < .05). In osteogenesis experiments, the frequency of von Kossa and alkaline phosphatase positive colonies was higher in the cotyloid fossa synovium than in the paralabral synovium ( P < .05). In chondrogenic experiments, the chondrogenic pellet culture and the gene expressions of COL2a1 and SOX9 were higher in the cotyloid fossa synovium than in the paralabral synovium ( P < .05)., Conclusion: MSCs from the cotyloid fossa synovium have higher proliferation and differentiation potential than do those from the paralabral synovium and are therefore a better source., Clinical Relevance: Synovial cells from the cotyloid fossa synovium of patients with femoroacetabular impingement syndrome are more robust in vitro, suggesting that MSCs from this source may be strongly considered for stem cell therapy.

Background: Arthroscopic hip surgery has been shown to be effective in returning professional athletes back to play at a high level of performance in different sports. Limited information exists regarding professional soccer players and their return to play., Purpose: To determine the rate and time to return to sport for professional soccer players after hip arthroscopic surgery for the treatment of femoroacetabular impingement (FAI) and to identify possible risk factors associated with a delay in returning to play., Study Design: Case series; Level of evidence, 4., Methods: Professional soccer players who underwent hip arthroscopic surgery for FAI by a single surgeon between 2005 and 2015 were evaluated. Data retrieved from www.mlssoccer.com , www.fifa.com , www.transfermarkt.co.uk , and www.wikipedia.org included information on each player's professional career, participation on the national team, length of professional career before surgery, number of appearances (games) before surgery, time between surgery and first appearance in a professional game, and number of appearances after surgery. Other data were obtained from the patient's medical records., Results: Twenty-four professional soccer players (26 hips) were included. The mean age at surgery was 25.0 ± 4.0 years (range, 19-32 years). A total of 96% of patients were able to return to play at the professional level. The mean time between surgery and the first professional game played was 9.2 months (range, 1.9-24.0 months). On average, players played in 70 games after surgery (range, 0-224). National team players were able to return to play significantly earlier than the rest of the players (median, 5.7 months vs 11.6 months, respectively; P = .018). Severe chondral damage and microfracture did not interfere with return to play., Conclusion: The arthroscopic management of FAI in symptomatic professional soccer players allowed 96% of them to return to play. Players with national team experience were able to return to play earlier than those without it. Severe chondral damage and microfracture did not interfere with return to play.

Background: Borderline developmental dysplasia of the hip (BDDH) is frequently diagnosed concurrently with cam impingement. While hip arthroscopy has advanced the treatment of hip joint pathology, including femoroacetabular impingement (FAI), arthroscopic treatment for FAI in the setting of BDDH remains a challenge amid a subset of patients. The risk factors of poor clinical results after hip arthroscopic labral preservation and FAI corrections in the setting of BDDH patients have not been well established., Hypothesis: Pre- and intraoperative findings can predict the poor clinical outcomes after hip arthroscopic surgery for FAI in the setting of BDDH., Study Design: Case control study; Level of evidence, 3., Methods: Of patients with BDDH (defined as lateral center edge [LCE] angle between 20° and 25°) who underwent arthroscopic procedures for FAI between 2009 and 2014, 45 met inclusion criteria (45 hips: 15 males and 30 females). Their mean age was 31.4 years (range, 12-65 years), and the mean LCE angle was 23.2°. Clinical and radiographic follow-up evaluations up to a minimum of 2 years after surgery were performed for all patients. Failure of the procedure was defined as conversion to subsequent surgery or having a Tönnis osteoarthritis grade of 2, and success was defined as patients who did not need subsequent surgery. Univariate analysis and Cox hazard proportional analysis were performed for both cohorts., Results: Of 45 patients, 11 (24%) had revision surgery (endoscopic shelf acetabuloplasty for 5 patients, total hip arthroplasty for 2, and revision hip arthroscopy for 2) or advanced to Tönnis grade ≥2 osteoarthritis and thus constituted the failure group. In the success group, modified Harris Hip Score (median, pre- vs postoperative: 72.1 vs 100, P< .001, Wilcoxon signed-rank test) and nonarthritic hip score (58.8 vs 98.8, P< .001) were significantly improved at the minimum 2-year follow-up. The median age of the failure group was significantly higher than that of the success group (47.0 vs 20.0, P< .001, Mann-Whitney Utest). Risk factors of poor clinical outcomes were identified as follows: age ≥42 years (hazard ratio [HR], 11.6; 95% CI, 2.5-53.9; P= .002, Cox hazard model), broken Shenton line (HR, 6.4; 95% CI, 1.9-22.3; P= .003), Tönnis angle ≥15° (HR, 3.9; 95% CI, 1.2-12.9; P= .03), vertical center anterior (VCA) angle ≤17° (HR, 5.0; 95% CI, 1.5-17.1; P= .01), Tönnis grade 1 at preoperative radiograph (HR, 3.6; 95% CI, 1.1-11.7; P= .04), severe cartilage delamination at acetabulum (HR, 11.8; 95% CI, 3.0-46.1; P< .001), and mild cartilage damage at femoral head (HR, 8.1; 95% CI, 2.1-30.8; P= .002)., Conclusion: Preoperative predictors of poorer outcomes from hip arthroscopic labral preservation, capsular plication, and cam osteoplasty in the setting of BDDH are age ≥42 years old, broken Shenton line, osteoarthritis, Tönnis angle ≥15°, and VCA angle ≤17° on preoperative radiographs. Intraoperative predictors of poorer outcomes are severe acetabular chondral damage and even mild femoral chondral damage. Although the patients in the setting of BDDH may have good outcomes from isolated hip arthroscopy, caution is suggested for those with the aforementioned risk factors.

Background: Patients with developmental dysplasia of the hip (DDH) have a greater risk of acetabular labral tearing and joint instability, which predispose them to developing osteoarthritis. The arthroscopic management of DDH, however, remains controversial., Hypothesis: Specific clinical characteristics and radiographic parameters correlate with and predict a worsened clinical outcome after hip arthroscopic surgery for DDH., Study Design: Case control study; Level of evidence, 3., Methods: Of patients with DDH who underwent an arthroscopic procedure between March 2009 and June 2011, there were 28 hips in 28 patients (6 male and 22 female) that met the inclusion criteria. The mean patient age was 28.4 years. Clinical and radiographic follow-up evaluations up to a minimum of 2 years after surgery were performed for all patients. Failure of the procedure was defined as conversion to subsequent surgery or having a Tönnis osteoarthritis grade of 2 and modified Harris Hip Score (mHHS) that remained <85, and success was defined as patients who did not need subsequent surgery and had an mHHS >85. Univariate analysis and Cox hazard proportional analysis were performed on the 2 subpopulations., Results: There were 9 patients in the failure group (including 3 hips with T nnis grade 2) and 19 patients in the success group. In 22 of 28 patients, the mean mHHS significantly improved from 61.6 ± 18.8 (range, 12.0-85.0) preoperatively to 94.3 ± 7.0 (range, 73.7-100.0) at final follow-up, and the mean Non-Arthritic Hip Score (NAHS) improved from 56.2 ± 13.9 (range, 35.0-81.3) preoperatively to 92.7 ± 9.5 (range, 65.0-100.0) at final follow-up (P < .001, Wilcoxon signed-rank test). Univariate analysis showed that a broken Shenton line was significantly more prevalent in the failure group compared with the success group (8/9 [89%] vs 3/19 [16%] patients, respectively; P < .001). High-grade cartilage delamination (Multicenter Arthroscopy of the Hip Outcomes Research Network [MAHORN] grades 3-5) was significantly higher in the failure group than in the success group (8/9 [89%] vs 3/19 [16%] patients, respectively; P < .001). The median femoral neck-shaft (FNS) angle in the failure group was significantly higher than that in the success group (139° vs 134°, respectively; P = .01). Further, Cox hazard proportional analysis of the failure group showed that the predictors for a poor clinical outcome were the presence of a broken Shenton line, FNS angle >140°, center-edge (CE) angle <19°, body mass index (BMI) >23 kg/m(2), acetabular cartilage damage (MAHORN grades 3-5), and cartilage damage of the femoral head (International Cartilage Repair Society grades 2-4). The most important predictors for a poor clinical outcome at the time of surgery were a broken Shenton line and an FNS angle >140°., Conclusion: Patients with a broken Shenton line, FNS angle >140°, CE angle <19°, or BMI >23 kg/m(2) at the time of surgery are not good candidates for the arthroscopic management of DDH., (© 2015 The Author(s).)

Background: Various procedures, such as arthroscopic debridement, osteochondral transplantation, and bone plug fixation, have been described for the treatment of osteochondritis dissecans (OCD) of the humeral capitellum. However, the use of hydroxyapatite/poly-L-lactate acid (HA/PLLA) thread pins to fix the osteochondral fragment in an OCD lesion is a recent development., Hypothesis: Adolescent throwing athletes would return to preinjury levels of function after arthroscopic osteochondral fragment fixation using HA/PLLA thread pins., Study Design: Case series; Level of evidence, 4., Methods: Enrolled in this prospective cohort study were 18 adolescent baseball players (mean age, 14.2 years; range 12-16, years) with elbow OCD who underwent arthroscopic fragment fixation with HA/PLLA thread pins between 2006 and 2009. All patients were affected on their dominant side. Plain radiographs taken before surgery showed an open physis in 13 patients (72%) and a closed physis in 5 patients (28%). During surgery, the condition of the OCD lesion was evaluated by use of the International Cartilage Research Society (ICRS) classification system; there were 5 grade II, 11 grade III, and 2 grade IV cases. Outcomes were assessed after 3 years (mean, 39 months; range, 36-50 months). Elbow function was measured using the Timmerman and Andrews score and the Mayo Elbow Performance Index. Return to sports activity was assessed as higher than preinjury, same level, lower level, or no return to sports., Results: The mean Timmerman and Andrews score improved significantly from 126.6±6.5 to 197.5±1.5, and the mean Mayo Elbow Performance Index improved significantly from 68.0±2.1 to 98.06±0.9 (P=.0001 for both). Mean elbow extension improved significantly from -10°±10.4° to -0.8°±5.2° (P=.006), and mean flexion improved significantly from 123.1°±17.9° to 138.6°±6.1° (P=.001). Three patients had a loss of extension greater than 5°. Five patients returned to a higher level of sports activity, 10 patients returned to the same level, and 2 patients returned to a lower level. A remaining patient did not return to baseball. In one patient, the lesion did not heal, resulting in fragmentation at 1 year after surgery. This patient consequently underwent revision arthroscopy to remove the lesion, and he eventually returned to sports at the same level of activity., Conclusion: Arthroscopic fragment fixation using HA/PLLA thread pins provides a beneficial clinical outcome to adolescent baseball players with humeral capitellar OCD., (© 2015 The Author(s).)

Background: Recent studies report a relatively high failure rate for tendon-bone healing after rotator cuff repair. Several studies have investigated biologically augmented rotator cuff repair; however, none has shown the application of synovial mesenchymal stem cells for such repair., Purpose: To demonstrate whether cells derived from shoulder tissues have mesenchymal stem cell properties and to identify which tissue is the best source of the mesenchymal stem cells., Study Design: Controlled laboratory study., Methods: Forty-two patients with a diagnosed rotator cuff tear preoperatively were enrolled in this study. Human mesenchymal tissues were obtained during arthroscopic surgery for rotator cuff tears from 19 donors who met the inclusion criteria and had investigable amounts of tissue. Colony-forming units, yield obtained, expandability, differentiation potential, epitope profile, and gene expression were compared among the cells from 4 shoulder tissues: synovium of the glenohumeral joint, subacromial bursa, margin of the ruptured supraspinatus tendon, and residual tendon stump on the greater tuberosity (enthesis)., Results: The number of live passage 0 cells from whole tissue was significantly higher in cells derived from the subacromial bursa (P < .05). Subacromial bursa-derived cells retained their expandability even at passage 10. In adipogenesis experiments, the frequency of Oil Red O-positive colonies was significantly higher for synovium- and subacromial bursa-derived cells than for tendon- and enthesis-derived cells (P < .0001). In studies of osteogenesis, the rate of von Kossa- and alkaline phosphatase-positive colonies was highest in subacromial bursa-derived cells (P < .0001). The chondrogenic potential was highest in cells derived from the enthesis. For epitope profiling, 11 surface antigens were measured, and most had similar epitope profiles, irrespective of cell source., Conclusion: The findings indicate that the subacromial bursa is a good candidate for the source of mesenchymal stem cells in rotator cuff tears., Clinical Relevance: Synovial cells from the subacromial bursa in patients with rotator cuff tears are a superior cell source in vitro, suggesting that mesenchymal stem cells from this tissue could be good candidates for biological augmentation of rotator cuff repair.

This study focused on the intracellular signal transduction system and microtubule-associated proteins (MAPs), such as MAP-2 and Tau protein. The modulation of these proteins and their correlation with ultrastructural changes were investigated in rat pituitary prolactin (PRL) cells. Adult female Wistar rats were treated with estrogen and bromocriptine and their pituitary glands were removed for analysis of the expression of tubulin, MAP-2, Tau protein, protein kinase C (PKC), and calcium calmodulin (CaM) kinase. Western blot analysis showed that estrogen increased and bromocriptine decreased the expression of PKC alpha, beta 1, beta 2, CaM kinase alpha, beta, MAP-2, and Tau protein. MAP-2 and Tau protein, which are cytosolic proteins, being translated on free ribosomes, were associated with the membrane of whirling rough endoplasmic reticulum (RER) in estrogen-treated cells and dissociated with vesiculated RER induced by bromocriptine. These results suggested that the modulation of MAP-2 and Tau protein may reflect changes of PKC and CaM kinase, and that the quantitative changes and intracellular modulation of MAPs induced by estrogen and bromocriptine, i.e., estrogen-induced association and bromocriptine-induced dissociation of MAP-2 and Tau protein with membrane of RER, may reflect the dynamics of microtubules and are associated with structural changes in the RER and changes in the synthesis and intracellular transport of PRL.

A seventeen-year-old man with hemophilia A developed nausea, vomiting, and unsteady gait after mild head trauma. Magnetic resonance imaging clearly demonstrated localized bleeding in cerebellar vermis. Quick administration of factor VIII concentrates prevented further extension of the bleeding and the patient completely recovered without neurologic impairment. In hemophiliac patients, careful evaluation of intracranial lesions is desired after head trauma even if they show only nonspecific symptoms.

A fifty-four-year-old woman died from multiple brain infarction and hemorrhage in the bilateral cerebrum, cerebellum, and brainstem, with renal infarction. She developed hematuria and transient blindness sixteen days before admission. Low-grade fever, heart murmur, and aortic valve vegetation on ultrasonic cardiography suggested infectious endocarditis. Autopsy study revealed occult adenocarcinoma in the lung and nonbacterial thrombotic endocarditis, but infective endocarditis was not histologically confirmed. The patient was considered to be a rare case of nonbacterial thrombotic endocarditis who developed multiple small infarctions mainly in the brainstem and cerebellum. Nonbacterial thrombotic endocarditis seems to be still an important disease as the embolic source, even if cryptic, of systemic thromboembolism.