Thursday, 28 February 2008

Adductor-related groin pain in competitive athletes. Role of adductor enthesis, magnetic resonance imaging, and entheseal pubic cleft injections.

J Bone Joint Surg Am. 2007 Oct;89(10):2173-8.

Department of Orthopaedics, Bradford Royal Infirmary, Duckworth Lane, Bradford BD9 6RJ, England. e.schilders@btopenworld.com.

BACKGROUND: Adductor dysfunction is a condition that can cause groin pain in competitive athletes, but the source of the pain has not been established and no specific interventions have been evaluated. We previously defined a magnetic resonance imaging protocol to visualize adductor enthesopathy. The aim of this study was to elucidate, in the context of adductor-related groin pain in the competitive athlete, the role of the adductor enthesis (origin), the relevance of adductor enthesopathy diagnosed with magnetic resonance imaging, and the efficacy of entheseal pubic cleft injections of local anesthetic and steroids. METHODS: We reviewed the findings in a consecutive series of twenty-four competitive athletes who had presented to our sports medicine clinic with groin pain secondary to adductor longus dysfunction. Magnetic resonance imaging was performed to assess the adductor longus origin for the presence or absence of enthesopathy. Seven patients (Group 1) had no evidence of enthesopathy on magnetic resonance imaging, and seventeen patients (Group 2) had enthesopathy confirmed on magnetic resonance imaging. All patients were treated with a single pubic cleft injection of local anesthetic and steroid into the adductor enthesis. At one year after this treatment, the patients were assessed for recurrence of symptoms. RESULTS: On clinical reassessment five minutes after the injection, all twenty-four athletes reported resolution of the groin pain. At one year, none of the seven patients in Group 1 had experienced a recurrence. Sixteen of the seventeen patients in Group 2 had a recurrence of the symptoms (p <>

Arthroscopic surgery of the hip: current concepts and recent advances.

J Bone Joint Surg Br. 2006 Dec;88(12):1557-66.

Khanduja V, Villar RN.

The Wellington Hospital, St John's Wood, London, UK. vikaskhanduja@aol.com

This review describes the development of arthroscopy of the hip over the past 15 years with reference to patient assessment and selection, the technique, the conditions for which it is likely to prove useful, the contraindications and complications related to the procedure and, finally, to discuss possible developments in the future.

Groin pain in the soccer athlete: fact, fiction, and treatment

Clin Sports Med. 1998 Oct;17(4):787-93, vii.

Gilmore J.

Groin and Hernia Clinic, London, England, United Kingdom.Groin pain in the soccer athlete is a common problem accounting for 5% of soccer injuries. Groin distribution has proved to be the most common cause of groin pain. Other causes are direct trauma, ostetis pubis, muscle injuries, fractures, bursitis, hip problems, and hernia and referred pain. Soccer players with groin pain present a complex management problem that is discussed.

Long-standing groin pain in sportspeople falls into three primary patterns, a "clinical entity" approach: a prospective study of 207 patients.

Br J Sports Med. 2007 Apr;41(4):247-52; discussion 252. Epub 2007 Jan 29.

Hölmich P.

Department of Orthopaedic Surgery, Amager University Hospital, Copenhagen DK-2300 S, Denmark.

per.holmich@ah.hosp.dk

BACKGROUND: Groin pain remains a major challenge in sports medicine. AIM: To examine 207 consecutive athletes (196 men, 11 women) with groin pain using a standardised and reliable clinical examination programme that focused on signs that suggest pathology in (1) the adductors, (2) the ilopsoas and (3) the rectus abdominis. PATIENTS AND METHODS: Most patients were football players (66%) and runners (18%). In this cohort, the clinical pattern consistent with adductor-related dysfunction, was the primary clinical entity in 58% of the patients and in 69% of the football players. Iliopsoas-related dysfunction was the primary clinical entity in 36% of the patients. Rectus abdominis-related dysfunction was found in 20 (10%) patients but it was associated with adductor-related pain in 18 of these patients. Multiple clinical entities were found in 69 (33%) patients; of these, 16 patients had three clinical entities.
CONCLUSIONS: These descriptive data extend previous findings that physical examination for groin pain can be reliable. While underscoring the prevalence of adductor-related physical examination abnormality in football players, the data highlight the prevalence of examination findings localising to the iliopsoas among this cohort. Also, the fact that combinations of clinical entities were present has important implications for treatment. The finding of multiple abnormal clinical entities also raises the possibility that earlier presentation may be prudent; it is tempting to speculate that one clinical entity likely precedes other developing entities. These data argue for the need for a trial where clinical entities are correlated with systematic investigation including MRI and ultrasonography.

Patterns of bone and soft-tissue injury at the symphysis pubis in soccer players: observations at MRI.

AJR Am J Roentgenol. 2007 Mar;188(3):W291-6.

Cunningham PM, Brennan D, O'Connell M, MacMahon P, O'Neill P, Eustace S.

Department of Radiology, Cappagh National Orthopaedic Hospital, Finglas, Dublin 11, Ireland.

OBJECTIVE: The objectives of our study were, first, to use MRI to determine the prevalence of osteitis pubis and of adductor dysfunction at the symphysis pubis in soccer players presenting with pubalgia and, second, to determine whether the two entities are mechanically related and whether one of the entities precedes or predisposes the development of the other. MATERIALS AND METHODS: One hundred consecutive soccer players with debilitating groin pain were referred for MRI. One hundred asymptomatic age- and sex-matched elite athletes were included as control subjects. The "secondary cleft" sign was used to indicate an adductor microtear at the symphyseal enthesis. Osteitis pubis was recorded if paraarticular bone edema was identified along the symphyseal margins but was remote from the adductor attachment. Images were reviewed independently by two radiologists who were blinded to the side of symptoms. Statistical analysis was performed using the chi-square test. RESULTS: Of 100 patients, groin pain was directly attributed to inflammation at the symphysis pubis or its muscular attachments in 97 (isolated adductor microtears, n = 47; isolated osteitis pubis, n = 9; both, n = 41). An "accessory cleft," reflecting an adductor enthetic microtear, was identified in 88 of these patients (p <>

CONCLUSION: In soccer players with pubalgia, adductor dysfunction is a more frequent MRI finding than osteitis pubis. The findings of this study suggest that both entities are mechanically related and that osteitis pubis and adductor dysfunction frequently coexist but, because adductor dysfunction is commonly identified in the absence of osteitis, that adductor dysfunction most likely precedes the development of osteitis pubis in soccer players. The presence of edema on fat-suppressed images of the symphysis is a strong predictor of abnormality at this site in soccer players when compared with age- and sex-matched control subjects.

Clinical presentation of femoroacetabular impingement.

Knee Surg Sports Traumatol Arthrosc. 2007 Aug;15(8):1041-7. Epub 2007 May 12.

Philippon MJ, Maxwell RB, Johnston TL, Schenker M, Briggs KK.

Steadman Hawkins Research Foundation, Attn: Clinical Research, 181 W. Meadow Dr. Ste 1000, Vail, CO 81657, USA.

The purpose of this study was to identify subjective complaints and objective findings in patients treated for femoroacetabular impingement (FAI). Three hundred and one arthroscopic hip surgeries were performed to treat FAI. The most frequent presenting complaint was pain, with 85% of patients reporting moderate or marked pain. The most common location of pain was the groin (81%). The average modified Harris Hip score was 58.5 (range 14-100). The average sports hip outcome score was 44.0 (range 0-100). The anterior impingement test was positive in 99% of the patients. Range of motion was reduced in the injured hip. Patients who had degenerative changes in the hip had a greater reduction in range of motion. The most common symptom reported in patients with FAI was groin pain. Patient showed decreased ability to perform activities of daily living and sports. Significant decreases in hip motion were observed in operative hips compared to non-operative hips.

Sports hernias

Adv Surg. 2007;41:177-87.

Diesen DL, Pappas TN.Department of Surgery, Duke University, DUMC 3479, Durham, NC 27710, USA.

diese001@mc.duke.edu

Sportsman's hernia is an increasingly recognized cause of chronic groin pain in athletes. Although the definition is controversial, it is a condition of chronic inguinal/pubic exertional pain caused by rectus abdominal wall weakness or injury without a palpable hernia, usually affecting high-performance male athletes. Diagnosis is made after careful history and physical examination. Some radiographic studies such as ultrasound or MRI may be helpful in evaluating these patients and ruling out other pathology, although no radiographic study can rule out sportsman's hernias. Because sports hernias are not true hernias but an injury in the rectus insertion, unilateral or bilateral rectus reattachment is the most appropriate surgical treatment. This reattachment may be done in combination with adductor release in the setting of adductor pain or weakness on physical examination. Other surgical repairs (eg, Lichtenstein, Shouldice, Kugel, laparoscopic) do not stabilize the pelvis and tend not to be as successful. In the motivated patient, after surgical repair and physical rehabilitation, 95% are free of pain and able to return to competitive sports.

Sutureless tension-free hernia repair with human fibrin glue (tissucol) in soccer players with chronic inguinal pain: initial experience.

Int J Sports Med. 2007 Oct;28(10):873-6. Epub 2007 May 11.

Department of General Surgery, Second University of Naples, School of Medicine, Naples, Italy.

silvestro.canonico@unina2.it

Chronic groin pain is a common symptom experienced by soccer players, resulting in many athletes undergoing prolonged periods of conservative treatment. In a high proportion of these cases, however, the cause of groin pain is due to impalpable hernias, thus nullifying the usefulness of a conservative approach. Of the current surgical procedures for inguinal hernia repair, the Lichtenstein technique is widely used. The present study aims to evaluate the efficacy of mesh fixation with human fibrin glue (Tissucol) in open, tension-free inguinal repair, in the treatment of soccer players with groin hernia. A sutureless Lichtenstein technique was employed in 16 consecutive soccer players with primary groin hernia. Inguinal nerves were prepared and preserved. Human fibrin glue was used for mesh fixation, in place of conventional sutures. Results were rated as excellent in all cases, with no reported intra- or postoperative complications. All patients were discharged 4 - 5 h after the operation, and all returned to full pre-injury level sporting-activity, on average, 31 days (range 24 - 42 days) post surgery. This study confirms the efficacy of sutureless tension-free hernia repair with human fibrin glue for the treatment of soccer players suffering from chronic groin pain due to impalpable groin hernia.

Hip joint pain referral patterns: a descriptive study.

Pain Med. 2008 Jan;9(1):22-5.

Lesher JM, Dreyfuss P, Hager N, Kaplan M, Furman M.

Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA.

Objective. To determine hip joint pain referral patterns. Design. Retrospective analysis. Setting. Multicenter. Patients. Fifty-one consecutive patients meeting clinical criteria of a symptomatic hip joint. Interventions. Fluoroscopically guided intra-articular hip joint injection. Outcome Measures. Anatomic pain map before hip injection and visual analog scale both before and after hip injection. Results. The hip joint was shown to cause pain in traditionally accepted referral areas to the groin and thigh in 55% and 57% of patients, respectfully. However, pain referral was also seen in the buttock and lower extremity distal to the knee in 71% and 22%, respectively. Foot and knee pain were seen in only 6% and 2% of patients, respectively, while lower lumbar spine referral did not occur. Fourteen pain referral patterns were observed. Conclusions. Buttock pain is the most common pain referral area from a symptomatic hip joint. Traditionally accepted groin and thigh referral areas were less common. Hip joint pain can occasionally refer distally to the foot. Lower lumbar spine referral did not occur.

Inguinal hernia vs. arthritis of the hip in sporting adolescents--case report and review of the literature.

Eur J Med Res. 2007 Jul 26;12(7):314-9.

Holzheimer RG, Gresser U.


Department of Surgery and Rheumatology, Praxisklinik Sauerlach, Sauerlach, Germany. gresser.holzheimer@web.de

Chronic pain in the hip, groin or thigh can be caused by a wide spectrum of diseases posing extended diagnostic problems. We describe the case of a 10-years old child with chronic pain in the groin with gait restriction for more than six months without successful classification and treatment. The girl suffered from heavy pain in the groin after a sporting contest which forced her to walk with walking sticks and to avoid climbing stairs. Within six months she was examined by pediatric, orthopedic, pediatric surgery, pediatric orthopedic, radiology, pediatric rheumatology specialists. Working diagnoses were transient synovitis (coxitis fugax), arthritis, streptococcal arthritis, Morbus Perthes, rheumatic fever, rheumatoid arthritis. She was treated with antibiotics and ibuprofen in high dosage. Repeated laboratory tests and imaging studies (ultrasound, x-rays, magnetic resonance imaging) of the hip and pelvis did not support any of these diagnoses. Six months after beginning of the complaints the girl was presented by her mother to our institution. The physical examination showed a sharp localized pain in the groin, just in the region of the inguinal ligament with otherwise free hip movement. There was no visible inguinal hernia. The family history for hernia was positive. After infiltration of the ilioinguinal nerve the girl had a complete long-lasting disappearance of pain and gait disturbance. This led to the diagnosis of inguinal hernia with nerve entrapment. After hernia repair and neurolysis/neurectomy there was a continuous state of disappearance of pain and gait disturbances.

CONCLUSION: To avoid such a diagnostic dilemma one should always discuss all possible causes. Non-visible inguinal hernia may be more common in females than previously thought. Nerve entrapment as a cause of groin pain has been well described. The relationship of the start of complaints with sporting activity, a positive family history for inguinal hernia, a lack of signs of inflammation and bone involvement in the laboratory and imaging studies together with a localized pain in the groin, almost immediate long-lasting disappearance of pain after infiltration of the ilioinguinal nerve allowing free motion leads to the diagnosis of inguinal hernia with nerve entrapment. Hernia repair and neurolysis are the adequate treatment avoiding unnecessary radiation.

Air Bubble Saline Arthrosonography in Imaging Rotator Cuff Tears

Air Bubble Saline Arthrosonography in Imaging Rotator Cuff Tears

By David Martin, MBBS, BMed Sc(Hons), FRACS, FAOrthA; Parminder J. S. Jeer, MBBS, FRCS, FRCS(Tr&Orth); Yegappan Kalairajah, MA, MPhil, MBBChir, FRCS; Mark Falworth, MBBS, FRCS(Eng), FRCS (Tr&Orth); Steven Zadow, MBBS(Hons), FRANZCR; Neil Simmons, MBBS, FRACR
ORTHOPEDICS 2008; 31:140

February 2008

Air bubble saline arthrosonography decreases user dependency and increases accuracy in the identification and characterization of rotator cuff tears.

The accurate identification and characterization of rotator cuff tears is important when planning surgical intervention and determining the prognosis in patients with rotator cuff pathology.1,2 Imaging modalities used to investigate a suspected rotator cuff tear include plain radiography, magnetic resonance imaging (MRI), and ultrasonography scanning, all of which can be combined with arthrography.

Magnetic resonance imaging and ultrasonography scanning have been reported to be highly accurate in detecting rotator cuff tears.3-10 Reports comparing ultrasonography scanning and MRI findings with arthrography and surgical findings suggest similar specificity but lower sensitivity of ultrasonography scanning in the detection of full and partial thickness tears.11,12 These studies demonstrated the possibility of limited accuracy of ultrasonography scanning diagnosis when lower frequency transducers were used, along with high operator dependency.11,12 However, compared with MRI, ultrasonography scanning is more readily available, more economical, and less time-consuming. Despite these advantages, ultrasonography scanning has not been widely accepted in the orthopedic community, particularly as an office tool in the investigation of rotator cuff pathology.13,14

This article describes a new method of combining ultrasonography scanning with an air bubble and saline arthrogram to improve the ease of identification and characterization of rotator cuff tears.

Technique

Air bubble arthrosonogram improves the investigator’s ability to recognize and characterize rotator cuff tears. The technique involves shaking 15 mL of saline with 3 to 5 mL of air in a 20-mL syringe to generate numerous air bubbles. The ultrasonography scanning probe is positioned posteriorly over the infraspinatus tendon with the patient facing the monitor. The mixture is then injected into the glenohumeral joint using a 22-gauge, 50-mm–long needle, which is inserted beneath the probe using a standard posterior approach to the shoulder. After retracting the needle, the patient is encouraged to exercise the shoulder for 30 seconds to aid the distribution of the air bubbles and saline. If pain is a limiting factor when performing shoulder movements, the saline can be substituted with a local anesthetic. Standard ultrasonography scanning of the shoulder is then performed.

Improved visualization of the rotator cuff tear is possible due to the air bubble–tissue interface. In rotator cuff tears, the bubbles are seen escaping from the glenohumeral joint. The bubbles that adhere to the tear edge help to characterize the nature and extent of the tear. Partial tears are more easily identified, as the defect is more clearly visualized.




Figure 1: Left shoulder sta

Figure 1A: The bursa, humeral head, and trough from previous repair are seen

Figure 1B: The humeral head and trough from previous repair are seen


Figure 1C: The metal artifact, humeral head, and corocoid process are seen

Standard ultrasonography scan along the long axis of the supraspinatus tendon.
It is not clear from this image as to whether the previous cuff repair is intact.
The bursa, humeral head, and trough from previous repair are seen (A).
Left shoulder air bubble saline arthrogram demonstrating no significant
differences compared with standard ultrasonography.
With no fluid or bubbles in the bursa, the integrity of the
previous supraspinatus tendon repair is confirmed.
The humeral head and trough from previous repair are seen (B).
Postgadolinium T1 fat saturated magnetic resonance image of the left
shoulder demonstrating a thin and irregular supraspinatus tendon in
the presence of a previous repair. No contrast has entered the bursa
confirming an intact cuff repair, although there are irregularities on
the articular surface of the supraspinatus. The metal artifact, humeral head,
and corocoid process are seen (C). Abbreviations: A=metal artifact, B=bursa,
CP=corocoid process, HH=humeral head, SS=supraspinatus tendon, and T=trough.

The resulting images of this technique, performed on the left and right shoulders of a 45-year-old man with previous cuff repairs, are presented in Figures 1 and 2. Four years after the cuff repairs, the patient reported discomfort and weakness in both shoulders. Standard ultrasonography scanning was performed (Figures 1A, 2A). Due to the difficulty in a definitive diagnosis, an air bubble saline arthrogram was performed in each case (Figures 1B, 2B). Magnetic resonance imaging was performed to confirm the ultrasonography findings (Figures 1C, 2C, 2D). An Acuson sequoia ultrasound machine with a 15- to 8-MHz–wide linear array (Acuson, Mountain View, California) was used to create these images.

Discussion

A diagnostic test is judged by its accuracy, sensitivity, and specificity. This modified technique improves upon conventional ultrasonography scanning in fulfilling these criteria.

This technique has been helpful in the diagnosis of rotator cuff pathology while also being simple, safe, and without complications. It has the advantages of arthrography without the possible complications linked to contrast media.15 Furthermore, it is quicker, more economical, and more accessible than MRI and sensitive enough to aid in the diagnosis of rotator cuff pathology. The ability to characterize tear size, thickness, and edge morphology is also improved on. It is particularly useful as an adjunct to ultrasonography scanning if there is a thickened subacromial bursa, which can make the diagnosis of a rotator cuff tear more difficult. The echogenic shadowing produced around the cuff tear is also helpful if a clear ultrasound image is not produced due to prior surgery, or if the anatomy is too distorted to confidently diagnose using standard ultrasound techniques. Air bubble saline arthrosonography can be used in these cases rather than MRI, which is more expensive and may not be as readily accessible.

Figure 2A: The humeral head, cartilage, and trough from previous repair are seenFigure 2B: The humeral head, cartilage, and trough from previous repair are seen
Figure 2C: Contrast in the bursal space suggests a torn cuff repair. The humeral head is seenFigure 2D: The long head biceps, humeral head, and corocoid process are seen

Figure 2: Right shoulder standard ultrasonography scan along the long

axis of the supraspinatus tendon at its anterior aspect. It is difficult to
define the difference between the tendon and bursa, and the integrity
of the previous cuff repair is not conclusive. The humeral head, cartilage,
and trough from previous repair are seen (A). Right shoulder air bubble
saline arthrogram demonstrating distension of the bursa and a more
defined edge to the torn supraspinatus tendon. This confirms a full
thickness tear of the previous repair. The humeral head, cartilage,
and trough from previous repair are seen (B). Postgadolinium T1 fat
saturated magnetic resonance image of the right shoulder demonstrating
a more posterior aspect of the supraspinatus tendon which is irregular on
its articular surface. Contrast in the bursal space suggests a torn cuff repair.
The humeral head is seen (C). Postgadolinium T1 fat saturated magnetic
resonance image of the right shoulder demonstrating contrast in the bursal space,
confirming a full thickness tear of the supraspinatus tendon. The long head biceps,
humeral head, and corocoid process are seen (D). Abbreviations: B=bursa, C=cartilage,
CP=corocoid process, FTT=full thickness tear, HH=humeral head, LHB=long head biceps,
SS=supraspinatus tendon, and T=trough.

Previous concerns with ultrasonography scanning were based on its operator and equipment dependency. This dependence should be reduced by the greater ease of interpretation of the ultrasonography images using the air bubble saline arthrosonogram technique. Furthermore, this technique should allow orthopedic surgeons performing office-based ultrasonography scanning greater diagnostic accuracy, thereby aiding in the management of rotator cuff disease.

We acknowledge that validation of the technique with a prospective study correlating ultrasonography scanning appearance with operative findings at surgery and MRI are needed.

References

  1. Yamaguchi K, Levine WN, Marra G, Galatz LM, Klepps S, Flatow EL. Transitioning to arthroscopic rotator cuff repair: the pros and cons. Instr Course Lect. 2003; 52:81-92.
  2. Warner JJ, Goltz RJ, Irrgang JJ, Groff YJ. Arthroscopic-assisted rotator cuff repair: patient selection and treatment outcome. J Shoulder Elbow Surg. 1997; 6(5):463-472.
  3. Teefey SA, Hasan SA, Middleton WD, Patel M, Wright RW, Yamaguchi K. Ultrasonography of the rotator cuff. A comparison of ultrasonographic and arthroscopic findings in one hundred consecutive cases. J Bone Joint Surg Am. 2000; 82(4):498-504.
  4. Brenneke SL, Morgan CJ. Evaluation of ultrsonography as a diagnostic technique in the assessment of rotator cuff tendon tears. Am J Sports Med. 1992; 20(3):287-289.
  5. van Holsbeeck MT, Kolowich PA, Eyler WR, et al. US depiction of partial-thickness tear of the rotator cuff tear. Radiology. 1995; 197(2):443-446.
  6. Wiener SN, Seitz WH Jr. Sonography of the shoulder in patients with tears of the rotator cuff: accuracy and value for selecting surgical options. AJR Am J Roentgenol. 1993; 160(1):103-110.
  7. Hodler J, Fretz CJ, Terrier F, Gerber C. Rotator cuff tears: a correlation of sonographic and surgical findings. Radiology. 1988; 169(3):791-794.
  8. Ziatkin MB, Iannotti JP, Roberts MC, et al. Rotator cuff tears: diagnostic performance of MR imaging. Radiology. 1989; 172(1):223-229.
  9. Robertson PL, Schweltzer ME, Mitchell DG, et al. Rotator cuff disorders: interobserver and intraobserver variation in diagnosis with MR imaging. Radiology. 1995; 194(3):831-835.
  10. Wnorowski DC, Levinsohn M, Chamberlain BC, McAndrew DL. Magnetic resonance imaging assessment of the rotator cuff: is it really accurate? Arthroscopy. 1997; 13(6):710-719.
  11. Martin-Hervas C, Romero J, Navas-Acien A, Reboiras JJ, Munuera L. Ultrasonographic and magnetic resonance images of rotator cuff lesions compared with arthroscopy or open surgery findings. J Shoulder Elbow Surg. 2001; 10(5):410-415.
  12. Nelson MC, Leather GP, Nirschl RP, Pettrone FA, Freedman MT. Evaluation of the painful shoulder. A prospective comparison of magnetic resonance imaging, computerized tomographic arthrography, ultrasonography, and operative findings. J Bone Joint Surg Am. 1991; 73(5):707-716.
  13. Hollister MS, Mack LA, Patten RM, Winter TC 3rd, Matsen FA 3rd, Veith RR. Association of sonographically detected subacromial/subdeltoid bursal effusion and intraarticular fluid with rotator cuff tear. AJR Am J Roentgenol. 1995; 165(3):605-608.
  14. Milgram C, Shaffer M, Gilbert S, van Holsbeeck M. Rotator-cuff changes in asymptomatic adults. The effect of age, hand dominance and gender. J Bone Joint Surg Br. 1995; 77(2):296-298.
  15. Newberg AH, Munn CS, Robbins AH. Complications of arthrography. Radiology. 1985; 155(3):605-606.

Authors

Drs Martin, Jeer, Kalairajah, and Falworth are from SPORTSMED SA; and Drs Zadow and Simmons are from Jones and Partners, Adelaide, Australia.

Drs Martin, Jeer, Kalairajah, Falworth, Zadow, and Simmons have no relevant financial relationships to disclose.

Correspondence should be addressed to: Mark Falworth, MBBS, FRCS(Eng), FRCS (Tr&Orth), SPORTSMED SA, 32 Payneham Rd, Stepney Adelaide, SA 5069, Australia.

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