Relationship Between Hip Capsular Thickness and Instability After Previous Hip Arthroscopic Surgery: A Matched-Cohort Analysis

Background

Thinner anterior hip capsules are associated with hip laxity, but there is little known about the impact of capsular thickness on the development of instability after primary hip arthroscopic surgery.

Purpose

To investigate the relationship between hip capsular thickness as measured on preoperative magnetic resonance imaging (MRI) and the development of hip instability after hip arthroscopic surgery for femoroacetabular impingement.

Study Design

Case-control study; Level of evidence, 3.

Methods

We reviewed revision hip arthroscopic procedures performed between January 1, 2019, and May 1, 2021, at a single institution. Inclusion criteria were preoperative MRI/magnetic resonance arthrography, completion of the study traction protocol, and asymmetric distraction between the hips of ≥3 mm on examination under anesthesia. A comparison group of patients treated for femoroacetabular impingement with primary hip arthroscopic surgery who did not develop capsular instability were matched 1:1 to the patients with instability. Superolateral hip capsular thickness was measured on MRI before index surgery. Analysis was conducted using independent-samples t tests and multivariable linear regression.

Results

A total of 44 patients were included, with 22 patients each in the instability and no-instability groups. The mean capsular thickness was lower in the patients with hip instability than in those without (1.9 ± 0.6 vs 3.4 ± 1.1 mm, respectively; P < .001). Decreased capsular thickness was significantly associated with hips with instability versus no-instability (β = -1.468 [95% CI, -2.049 to -0.887]; P < .001).

Conclusion

Thinner preoperative hip capsules in the region of the iliofemoral ligament were seen in patients who subsequently underwent revision arthroscopic surgery for hip instability compared to patients who underwent primary hip arthroscopic surgery without subsequent revision. Patients at a higher risk for the development of postoperative hip instability had a superolateral hip capsular thickness of <2 mm.

Fixation Techniques for Scaphoid Nonunion

Scaphoid fractures are common injuries with high risk of nonunion. Various fixation techniques exist for managing scaphoid nonunions, including Kirschner wires, single or dual headless compression screws, combination fixation techniques, volar plating, and compressive staple fixation. The indication for each fixation technique varies depending on the patient, type of nonunion, and clinical scenario.

Previous Arthroscopic Hip Surgery Increases Axial Distractibility Compared to the Native Contralateral Hip and May Suggest Instability

PURPOSE

To compare intraoperative hip joint distractibility between hips that previously underwent arthroscopic surgery and the contralateral hip with no history of surgical manipulation.

METHODS

Patients undergoing revision hip arthroscopy between April 2019 and December 2020, who previously underwent arthroscopic hip surgery for femoroacetabular impingement syndrome, were prospectively enrolled. Exclusion criteria were any contralateral hip surgery. Before instrumentation, fluoroscopic images of both hips were obtained at 25 lbs traction intervals up to 100 lbs. Total joint space was measured at each traction interval. Distraction was calculated as the difference between the baseline joint space and the total joint space at each subsequent traction interval. Wilcoxon signed ranks tests and McNemar tests were used to compare distraction between revision and native contralateral hips.

RESULTS

Forty-seven patients were included. Mean distraction of operative hips was significantly greater than mean distraction of nonoperative hips at traction intervals of 50 lbs (2.13 vs 1.04 mm, P = .002), 75 lbs (6.39 vs 3.70 mm, P < .001), and 100 lbs (8.24 vs 5.39, P < .001). Mean total joint space of operative hips was significantly greater than mean total joint space of nonoperative hips at traction intervals of 50 lbs (6.60 vs 5.39 mm, P < .001), 75 lbs (10.86 vs 8.05 mm, P < .001), and 100 lbs (12.73 vs 9.73, P < .001). A greater percentage of operative hips achieved all distraction thresholds, in 2-mm intervals up to 10-mm, at each traction interval.

CONCLUSIONS

In the majority of patients undergoing revision hip arthroscopy, previous arthroscopic hip surgery increases axial distractibility of the hip joint compared with the native contralateral hip at axial traction forces of 50-100 lbs. Increased axial distractibility following hip arthroscopy may be suggestive of hip instability and can be assessed on a stress examination with the patient under anesthesia.

LEVEL OF EVIDENCE

III, case-control study.

Meshed Acellular Dermal Matrix for Two-Staged Prepectoral Breast Reconstruction: An Institutional Experience

The introduction of acellular dermal matrix (ADM) to breast reconstruction has allowed surgeons to reexplore the prepectoral implant placement technique in postmastectomy breast reconstruction. Our institution adopted a novel approach using meshed ADM to lessen the financial burden of increased ADM utilization with the prepectoral breast reconstruction. This is a retrospective, single-center review of two-stage prepectoral breast reconstruction using meshed human-derived ADM for anterior prosthesis coverage. Patient demographics, oncologic data, perioperative characteristics, and complications were examined and reported as means with standard deviations. Cost-saving with the meshed technique was evaluated. Forty-eight patients (72 breasts) with a mean age of 48.5 ± 15.0 years (range 26–70 years) were included in the study. The mean follow-up time was 13.2 ± 4.4 months (range 4.1–25.8 months). Nineteen breasts (24.6%) experienced complications, with seromas being the most common complication (12.5%, n  = 9). Expander removal and reoperation occurred at a rate of 8.3 and 9.7%, respectively. The average time to drain removal was 18.8 ± 6.6 days (range 8–32 days). Meshed ADM provided an average cost savings of $6,601 for unilateral and $13,202 for bilateral reconstructions. Our study found that human-derived meshed ADM can be safely used in two-staged prepectoral tissue expander-based breast reconstruction and can result in significant cost savings.

Capsular Repair During Hip Arthroscopy Demonstrates Restoration of Axial Distraction Resistance in an in Vivo Intraoperative Testing Model

BACKGROUND

Cadaveric models demonstrate that failure of hip capsular repair is dependent on the robustness of the repair construct. In vivo data on capsular repair construct efficacy are limited. We investigated the effect of a figure-of-8 capsular repair on hip distraction resistance relative to native and post-capsulotomy states. We hypothesized that an unrepaired capsulotomy would demonstrate increased axial distraction compared with the native state and that capsular repair would restore distraction resistance to native levels.

METHODS

Patients undergoing primary hip arthroscopy by a single surgeon were prospectively enrolled between March 2020 and June 2020. Prior to any instrumentation, fluoroscopic images of the operative hip were obtained at 12.5-lbs (5.7-kg) traction intervals, up to 100 lbs (45.4 kg). Anterolateral, modified anterior, and distal anterolateral portals were established. Following interportal capsulotomy, labral repair, and osteochondroplasty, fluoroscopic images were reobtained at each traction interval. Capsular repair was performed with use of a figure-of-8 suture configuration. Traction was reapplied and fluoroscopic images were again obtained. Joint distraction distance was measured at each traction interval for all 3 capsular states. Anteroposterior pelvic radiographs were utilized to scale fluoroscopic images to obtain joint space measurements in millimeters.

RESULTS

A total of 31 hips in 31 patients were included. Capsulotomy resulted in significant increases in distraction distance from 25 (11.3 kg) to 100 lbs of traction compared with both native and capsular repair states (all comparisons, p ≤ 0.017). Capsular repair yielded a significantly greater distraction distance compared with the native state at 37.5 lbs (17.0 kg; 5.49 versus 4.98 mm, respectively; p = 0.012) and 50 lbs (22.7 kg; 6.08 versus 5.35 mm; p < 0.001). The mean difference in distraction distance between native and capsular repair states from 25 to 100 lbs of traction was 0.01 mm.

CONCLUSIONS

This in vivo model demonstrates that an unrepaired interportal capsulotomy significantly increases axial distraction distance compared with the native, intact hip capsule. Performing a complete capsular closure reconstitutes resistance to axial distraction intraoperatively. Future research should evaluate the in vivo effects and associated clinical outcomes of other published capsular repair techniques and assess the durability of capsular repairs over time.

Characterization of the linked ovine insulin and insulin-like growth factor-II genes

The ovine insulin-like growth factor-II (oIGF-II) gene is comprised of 9 exons that span approximately 25 kb. Approximately 750 nucleotides upstream of oIGF-II exon 1 are the three exons of the ovine insulin gene that are transcribed in the same direction as oIGF-II. The genomic organization and expression of the oIGF-II gene is similar to that of the human IGF-II gene. Four putative promoters direct the transcription of six 5' noncoding exons (1, 3, 4, 5, 6, and 7), which are alternatively spliced to the shared exons 8, 9, and 10. An ovine exon comparable to human exon 2 has not been identified. Multiple transcription initiation sites were identified for exons 1 and 6 by primer extension analysis. Using a reverse transcriptase polymerase chain reaction (RT-PCR) assay, exon 1 and 3 transcripts were shown to be expressed in adult but not fetal liver. In addition, a novel transcript, which contained exon 1 spliced directly to exon 8, was detected in adult liver. Exon 4 transcripts were not detected in either fetal or adult liver, whereas exon 6 and 7 transcripts were detected in both fetal and adult liver. Exon 5 transcripts were also expressed in both fetal and adult liver, which is in contrast to the tumor cell-specific expression of human exon 5. Like the human and rodent genes, the regulation of expression of the oIGF-II gene is under complex control.

Characterization of multiple transcription initiation sites of the ovine insulin-like growth factor-I gene and expression profiles of three alternatively spliced transcripts

Alternative splicing of ovine insulin-like growth factor-I (IGF-I) transcripts generates three different mRNAs. Class 1 and class 2 transcripts contain exons 1 and 2 spliced to exon 3, respectively. A novel IGF-I mRNA containing exon W is spliced to exon 3 and has been located upstream of exon 1. No in-frame methionine codon was present in exon W and therefore translation is proposed to initiate at the methionine codon present in exon 3. Using primer extension, transcription initiation sites were found 179, 336, and 368 nucleotides upstream of exon 1 and 86, 96, 131, and approximately 850 nucleotides upstream of exon 2. The locations of these transcription initiation sites are well conserved among mammalian and avian IGF-I genes. Expression of exon 1-, 2-, and W-specific transcripts was examined in brain, heart, kidney, liver, lung, skeletal muscle, and spleen from adult ewes or 75-day fetal lambs using a reverse transcriptase-polymerase chain reaction assay. Exon 1 transcripts were the most abundant and found in all fetal and adult tissues. Exon 2 transcripts were found in all tissues and were generally expressed the highest in adult liver. Exon W transcripts were also found to be expressed in all tissues examined. Thus, the three alternatively spliced ovine IGF-I transcripts were expressed in a variety of fetal and adult tissues.

Cloning of ovine insulin-like growth factor-I cDNAs: heterogeneity in the mRNA population

We have isolated and characterized lamb liver cDNAs encoding ovine insulin-like growth factor-I (oIGF-I) precursor polypeptide to study IGF-I gene expression in ruminants. Four cDNA clones were sequenced revealing two different exon 1 sequences (designated 1A and 1B) and four different putative poly(A) adenylation sites. cDNAs containing exon 1A or exon 1B encode precursor polypeptides of 138 or 154 amino acids, respectively. A 130-amino-acid peptide is encoded by all cDNAs examined. These precursors include a hydrophobic leader peptide of varying lengths, the 70-amino-acid oIGF-I, and a 35-amino-acid carboxyl terminal extension peptide. The predicted amino acid sequence of the oIGF-I peptide differs from the human, bovine, and porcine IGF-Is at a single amino acid (at position 66, alanine is substituted for proline) and differs from rat and mouse IGF-Is at 4 and 5 positions, respectively. Both the amino- and carboxy-terminal extension peptides showed regions of extensive sequence homology. Ovine IGF-I amino-terminal peptides are 1 amino acid longer than other mammalian IGFs due to the presence of an extra amino acid (glutamine) present at the proposed boundary of exon 1 and exon 2. Northern blot analysis revealed multiple oIGF-I transcripts in a broad band at 800-1,100 nucleotides and other transcripts of higher molecular weight in liver. There was no detectable expression in either spleen or brain.