Orthopedics

Gomez-Hoyos, J., R. L. Martin and H. D. Martin (2018). “Current Concepts Review: Evaluation and Management of Posterior Hip Pain.” J Am Acad Orthop Surg 26(17): 597-609.

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Understanding the etiology of and evolving research on intra- and extra-articular hip complaints requires comprehensive diagnosis and management of the spectrum of posterior hip diseases. Interest in posterior hip disorders has increased in recent years as new studies and theories have emerged regarding the disease process. Although most of the differential diagnoses around the posterior hip have traditionally been considered uncommon, recent reports suggest that these complaints have instead been commonly overlooked. Failure to identify the cause of posterior hip pain in a timely manner can increase pain perception, deteriorate the patient’s hope, and consequently affect quality of life. Posterior hip pain could be differentiated as intrapelvic and extrapelvic, and differential diagnosis is made based on a comprehensive history, physical examination, and imaging studies. Plain radiography, CT, MRI, 3T MRI, and imaging-guided injection tests are usually necessary for accurate diagnosis. Surgical intervention, whether endoscopic or open, is required for patients with long-standing symptoms for whom nonsurgical treatment has been unsuccessful and who have experienced temporary relief of their symptoms after injection. Orthopedic surgeons are uniquely trained in understanding the anatomy, biomechanics, clinical evaluation and treatment of all five layers of the hip.

Gomez-Hoyos, J., R. L. Martin and H. D. Martin (2018). “Current Concepts Review: Evaluation and Management of Posterior Hip Pain.” J Am Acad Orthop Surg Aug 3. [Epub ahead of print].

Full text of this article.

Understanding the etiology of and evolving research on intra- and extra-articular hip complaints requires comprehensive diagnosis and management of the spectrum of posterior hip diseases. Interest in posterior hip disorders has increased in recent years as new studies and theories have emerged regarding the disease process. Although most of the differential diagnoses around the posterior hip have traditionally been considered uncommon, recent reports suggest that these complaints have instead been commonly overlooked. Failure to identify the cause of posterior hip pain in a timely manner can increase pain perception, deteriorate the patient’s hope, and consequently affect quality of life. Posterior hip pain could be differentiated as intrapelvic and extrapelvic, and differential diagnosis is made based on a comprehensive history, physical examination, and imaging studies. Plain radiography, CT, MRI, 3T MRI, and imaging-guided injection tests are usually necessary for accurate diagnosis. Surgical intervention, whether endoscopic or open, is required for patients with long-standing symptoms for whom nonsurgical treatment has been unsuccessful and who have experienced temporary relief of their symptoms after injection. Orthopedic surgeons are uniquely trained in understanding the anatomy, biomechanics, clinical evaluation and treatment of all five layers of the hip.

Kearns, N. T., J. K. Peterson, L. Smurr Walters, W. T. Jackson, J. M. Miguelez and T. Ryan (2018). “Development and Psychometric Validation of Capacity Assessment of Prosthetic Performance for the Upper Limb (CAPPFUL).” Arch Phys Med Rehabil. May 16. [Epub ahead of print].

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OBJECTIVES: (1) Develop a performance-based measure for adult upper limb (UL) prosthetic functioning through broad (i.e. overall performance) and functional domain-specific (e.g., control skills) assessment of commonplace activities; (2) conduct initial psychometric evaluation of the Capacity Assessment of Prosthetic Performance for the Upper Limb (CAPPFUL). DESIGN: Internal consistency of CAPPFUL and interrater reliability for task, functional domain, and full scale (sub)scores among three independent raters were estimated. Known-group validity was examined comparing scores by amputation level. Convergent validity was assessed between CAPPFUL and two hand dexterity/function tests; discriminant validity against self-reported disability. SETTING: Six prosthetic rehabilitation centers across the United States. PARTICIPANTS: Subjects (n = 60) with UL amputation utilizing a prosthesis. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Not applicable. RESULTS: Interrater reliability was excellent for scoring on the task, domain, and full scale scores (ICCs = .88-.99). Internal consistency was good (alpha = .79-.82). Generally, subjects with higher amputation levels scored lower (worse) than subjects with lower amputation levels. CAPPFUL demonstrated strong correlations with measures of hand dexterity/functioning (rs = -.58-.72); moderate correlation to self-reported disability (r = -.35). CONCLUSIONS: CAPPFUL was designed as a versatile, low burden measure of prosthesis performance for any UL functional prosthetic device type and any UL amputation level. CAPPFUL assesses overall performance, as well as five functional performance domains, during completion of 11 tasks that require movement in all planes while manipulating everyday objects requiring multiple grasp patterns. Psychometric evaluation indicates good interrater reliability, internal consistency, known-group validity, and convergent and discriminant validity.RE

Kraeutler, M. J., K. V. Patel, A. Hosseini, G. Li, T. J. Gill and J. T. Bravman (2018). “Variability in the Clock Face View Description of Femoral Tunnel Placement in ACL Reconstruction Using MRI-Based Bony Models.” J Knee Surg. Feb 8. [Epub ahead of print].

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Though controversial, the “clock face view” of the intercondylar notch remains a way some surgeons communicate regarding placement of the femoral tunnel in anterior cruciate ligament reconstruction. The purpose of this study was to quantify the differences in angle measurement between several previous descriptions of the clock face view by using a new reference standard. Three-Tesla magnetic resonance imaging (MRI) was used to scan 10 human knees to create three-dimensional MRI-based bony models which were used for measurements. A standardized clock face view was developed with the knee flexed to 90 degrees using the junction of the cartilage and cortex of the medial and lateral surfaces of medial and lateral femoral condyles as the 3 o’clock and 9 o’clock, respectively, with the 12 o’clock established as the midpoint of the roof of the intercondylar notch. With the knee viewed at 90 degrees of flexion, an “idealized” femoral tunnel position was plotted on the medial wall of the lateral femoral condyle at 30 degrees (corresponding to the 10 o’clock or 2 o’clock position). The clock faces as described by Edwards et al, Heming et al, and Mochizuki et al were each then overlaid on this same model and the difference in measurement calculated. The average angles measured when the previously described clock faces were projected onto the idealized clock face view comparing a mark made at 30 degrees were 47.7 degrees , 7.2 degrees , and 49.8 degrees for the methods described by Edwards et al, Heming et al, and Mochizuki et al, respectively (all p < 0.001). Significant variation exists between angle measurements in simulated femoral tunnel placement based on the varying descriptions of the intercondylar clock face.

Martin, R. L., R. G. Schroder, J. Gomez-Hoyos, A. N. Khoury, I. J. Palmer, R. P. McGovern and H. D. Martin (2018). “Accuracy of 3 Clinical Tests to Diagnose Proximal Hamstrings Tears With and Without Sciatic Nerve Involvement in Patients With Posterior Hip Pain.” Arthroscopy 34(1): 114-121.

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PURPOSE: To determine the diagnostic accuracy of the active hamstring test at 30 degrees (A-30) and 90 degrees (A-90) of knee flexion, the long stride heel strike (LSHS) test, and combination of the 3 tests for individuals with hamstring tendon tears, with and without sciatic nerve involvement. METHODS: A retrospective review of 564 consecutive clinical records identified 42 subjects with a mean age of 50.31 +/- 15 years who underwent a standard physical examination prior to magnetic resonance imaging (MRI) evaluation and diagnostic injection for posterior hip. The physical examination included the A-30, A-90, and LSHS tests. Sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio were calculated to determine the diagnostic accuracy of these 3 tests. RESULTS: Forty-two subjects (female = 32 and male = 10) with a mean age of 50.31 years (range 15-77, +/- SD 14.52) met the inclusion criteria and were included in the review. Based on MRI and/or injection, 64.28% (27/42) of subjects were diagnosed with hamstring tear. Fourteen (51.85%) presented with sciatic nerve involvement. The sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio for each test were as follows: A-30 knee flexion: 0.73, 0.97, 23.43, 0.28, and 84.73; A-90 knee flexion: 0.62, 0.97, 20.00, 0.39, and 51.67; LSHS: 0.55, 0.73, 2.08, 0.61, and 3.44. The most accurate findings were obtained when the results of the A-30 and A-90 were combined, with sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio of 0.84, 0.97, 26.86, 0.17, and 161.89, respectively. CONCLUSION: The combination of the active hamstring A-30 and A-90 tests proved to be a highly accurate and valuable tool to diagnose proximal hamstring tendons tears with or without sciatic nerve involvement in subjects presenting with posterior hip pain. LEVEL OF EVIDENCE: Level III, diagnostic study.