Cell-based versus corticosteroid injections for knee pain in osteoarthritis: a randomized phase 3 trial.

Various types of cellular injection have become a popular and costly treatment option for patients with knee osteoarthritis despite a paucity of literature establishing relative efficacy to each other or corticosteroid injections. Here we aimed to identify the safety and efficacy of cell injections from autologous bone marrow aspirate concentrate, autologous adipose stromal vascular fraction and allogeneic human umbilical cord tissue-derived mesenchymal stromal cells, in comparison to corticosteroid injection (CSI). The study was a phase 2/3, four-arm parallel, multicenter, single-blind, randomized, controlled clinical trial with 480 patients with a diagnosis of knee osteoarthritis (Kellgren-Lawrence II-IV). Participants were randomized to the three different arms with a 3:1 distribution. Arm 1: autologous bone marrow aspirate concentrate (n = 120), CSI (n = 40); arm 2: umbilical cord tissue-derived mesenchymal stromal cells (n = 120), CSI (n = 40); arm 3: stromal vascular fraction (n = 120), CSI (n = 40). The co-primary endpoints were the visual analog scale pain score and Knee injury and Osteoarthritis Outcome Score pain score at 12 months versus baseline. Analyses of our primary endpoints, with 440 patients, revealed that at 1 year post injection, none of the three orthobiologic injections was superior to another, or to the CSI control. In addition, none of the four groups showed a significant change in magnetic resonance imaging osteoarthritis score compared to baseline. No procedure-related serious adverse events were reported during the study period. In summary, this study shows that at 1 year post injection, there was no superior orthobiologic as compared to CSI for knee osteoarthritis. ClinicalTrials.gov Identifier: NCT03818737.

Ultrasound Evaluation of Knee Osteoarthritis.

While radiographs and magnetic resonance imaging (MRI) have long been used in the assessment of osteoarthritis (OA), ultrasound imaging has been rapidly accepted by musculoskeletal providers in both the assessment and treatment of OA. A limiting factor in the use of ultrasound is the proper training required by the user for results to be reliable and reproducible. A standardized ultrasound protocol can potentially address this limiting factor. The critical information to consider in a standardized protocol include proper patient positioning, probe alignment, probe orientation, and identification of the appropriate anatomic landmarks. The outlined protocol considers these factors with the purpose of providing a step-by-step method to assess and monitor knee OA.

Evaluation of a Standardized Cardiac Athletic Screening for National Collegiate Athletic Association (NCAA) Athletes.

INTRODUCTION: Sudden cardiac death is a rare cause of death in young athletes. Current screening techniques include history and physical exam (H and P), with or without an electrocardiogram (ECG). Adding point of care cardiac ultrasound has demonstrated benefits, but there is limited data about implementing this technology. We evaluated the feasibility of adding ultrasound to preparticipation screening for collegiate athletes. METHODS: We prospectively enrolled 42 collegiate athletes randomly selected from several sports. All athletes were screened using a 14-point H and P based on 2014 American College of Cardiology (ACC) and American Heart Association (AHA) guidelines, ECG, and cardiac ultrasound. RESULTS: We screened 11 female and 31 male athletes. On ultrasound, male athletes demonstrated significantly larger interventricular septal wall thickness (p = 0.002), posterior wall thickness (p <0.001) and aortic root breadth (p = 0.002) compared to females. Based on H and P and ECGs alone and a combination of H and P with ECG, no athletes demonstrated a positive screening for cardiac abnormalities. However, with combined H and P, ECG, and cardiac ultrasound, one athlete demonstrated positive findings. CONCLUSIONS: We believe that adding point of care ultrasound to the preparticipation exam of college athletes is feasible. This workflow may provide a model for athletic departments' screening.

Ultrasound Evaluation and Surgical Excision of a Fabella Causing Peroneal Neuropathy in a Track Athlete.

BACKGROUND: There are multiple causes of posterior knee pain and radicular symptoms. A symptomatic fabella is a rare cause but should be considered in the differential diagnosis. PURPOSE: Physicians should consider a symptomatic fabella as a diagnosis when common treatments for posterior knee pain have not alleviated the symptoms. STUDY DESIGN: Case report. METHODS: Review of clinical documentations of an orthopedist, physiatrist, physical therapist, 2 primary care sports medicine physicians, and the surgical report of an orthopedist. RESULTS: It took time and resources including several referrals and imaging modalities to make a final diagnosis. CONCLUSION: Symptomatic fabellae are an uncommon finding but should be considered in the differential diagnosis with an athlete with posterior knee pain. CLINICAL RELEVANCE: Considerable time and resources were used to ultimately diagnose and treat a NCAA Division 1 athlete. Surgical excision was required of a sesamoid bone that is present in 30% of individuals.

Interposition Dermal Matrix Xenografts: A Successful Alternative to Traditional Treatment of Massive Rotator Cuff Tears.

BACKGROUND: Management of massive rotator cuff tears in shoulders without glenohumeral arthritis remains problematic for surgeons. Repairs of massive rotator cuff tears have failure rates of 20% to 94% at 1 to 2 years postoperatively as demonstrated with arthrography, ultrasound, and magnetic resonance imaging. Additionally, inconsistent outcomes have been reported with debridement alone of massive rotator cuff tears, and limitations have been seen with other current methods of operative intervention, including arthroplasty and tendon transfers. HYPOTHESIS: The use of interposition porcine acellular dermal matrix xenograft in patients with massive rotator cuff tears will result in improved subjective outcomes, postoperative pain, function, range of motion, and strength. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Sixty patients (61 shoulders) were prospectively observed for a mean of 50.3 months (range, 24-63 months) after repair of massive rotator cuff tears with porcine acellular dermal matrix xenograft as an interposition graft. Subjective outcome data were obtained with visual analog scale for pain score (0-10, 0 = no pain) and Modified American Shoulder and Elbow Surgeons (MASES) score. Active range of motion in flexion, external rotation, and internal rotation were recorded. Strength in the supraspinatus and infraspinatus muscles was assessed manually on a 10-point scale and by handheld dynamometer. Ultrasound was used to assess the integrity of the repair during latest follow-up. RESULTS: Mean visual analog scale pain score decreased from 4.0 preoperatively to 1.0 postoperatively ( P < .001). Mean active forward flexion improved from 140.7° to 160.4° ( P < .001), external rotation at 0° of abduction from 55.6° to 70.1° ( P = .001), and internal rotation at 90° of abduction from 52.0° to 76.2° ( P < .001). Supraspinatus manual strength increased from 7.7 to 8.8 ( P < .001) and infraspinatus manual strength from 7.7 to 9.3 ( P < .001). Mean dynamometric strength in forward flexion was 77.7 N in nonoperative shoulders (shoulder that did not undergo surgery) and 67.8 N ( P < .001) in operative shoulders (shoulder that underwent rotator cuff repair with interposition porcine dermal matrix xenograft). Mean dynamometric strength in external rotation was 54.5 N in nonoperative shoulders and 50.1 N in operative shoulders ( P = .04). Average postoperative MASES score was 87.8. Musculoskeletal ultrasound showed that 91.8% (56 of 61) of repairs were fully intact; 3.3% (2 of 61), partially intact; and 4.9% (3 of 61), not intact. CONCLUSION: Patients who underwent repair of massive rotator cuff tears with interposition porcine acellular dermal matrix graft have good subjective function as assessed by the MASES score. Patients have significant improvement in pain, range of motion, and manual muscle strength. Postoperative ultrasound demonstrated that the repair was completely intact in 91.8% of patients, a vast improvement compared with results previously reported for primary repairs of massive rotator cuff tears.

Medicolegal aspects of sports medicine.

Legal issues in sports medicine are rapidly developing and establishing an important body of jurisprudence that defines the legal rights and duties of all those involved with protecting the health and safety of athletes. The law makes important distinctions between the relevant duty of care owed to high-school, college, and professional athletes because of the differing legal relationships that arise out of athletic participation at different levels of competition.

Massive or 2-tendon rotator cuff tears in active patients with minimal glenohumeral arthritis: clinical and radiographic outcomes of reconstruction using dermal tissue matrix xenograft.

BACKGROUND: The management of irreparable massive or full-thickness 2-tendon rotator cuff tears in active patients with minimal glenohumeral arthritis remains a difficult challenge for the treating surgeon. Many different treatment options, with varied success, have been proposed. HYPOTHESES: (1) Patients undergoing reconstruction of irreparable massive or full-thickness 2-tendon rotator cuff tears by dermal tissue matrix xenograft would demonstrate improvements in pain, range of motion, strength, and subjective functional outcomes. (2) Postoperative ultrasonography would demonstrate intact repairs at a minimum 2-year follow-up. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Twenty-six patients (27 shoulders) underwent reconstruction of irreparable massive or full-thickness 2-tendon rotator cuff tears by dermal tissue matrix xenograft. Pain level (scale 0-10, 10 = severe pain), active range of motion, and supraspinatus and external rotation strength were assessed. Subjective outcome measures included American Shoulder and Elbow Score (ASES) and Short Form-12 (SF-12) score. Clinical and radiographic analyses were performed at an average 32-month follow-up period (minimum 2-year follow-up). Ultrasound imaging (static and dynamic) of the operative shoulder was performed at final follow-up to assess the integrity of the construct. RESULTS: Mean patient age was 60 years. Mean pain level decreased from 5.1 to 0.4 (P = .002). Mean active forward flexion and abduction improved from 138.8° to 167.3° (P = .024) and 117.9° to 149.3° (P = .001), respectively. Supraspinatus and external rotation strength improved from 7.2 to 9.4 (P = .001) and 7.4 to 9.5 (P = .001), respectively. Mean ASES improved from 62.7 to 91.8 (P = .0007), and mean SF-12 scores improved from 48.4 to 56.6 (P = .044). Twenty-one patients (22 shoulders) returned for a dynamic and static ultrasound of the operative shoulder at a minimum 2-year follow-up. Sixteen patients (73%) demonstrated a fully intact tendon-graft reconstruction, 5 patients (22%) had a partially intact reconstruction, and 1(5%) had a complete tear at the graft-bone interface caused by suture anchor pullout as a result of a fall. There were no cases of infection or tissue rejection. CONCLUSION: Active patients with massive or 2-tendon rotator cuff tears with minimal glenohumeral arthritis continue to be a subset of the population for whom there is no current standard of care. Results suggest that the use of porcine xenograft may be an effective means by which to treat these patients.

Anteromedial subtalar dislocation.

Subtalar dislocation is the simultaneous dislocation of the talocalcaneal and talonavicular joints of the foot, typically caused by falls from heights, twisting leg injuries and motor vehicle accidents. The dislocation can occur medially, lateral, anterior or posterior, but most commonly occurs from inversion injury producing a medial dislocation. These dislocations may be accompanied by fractures. Careful physical examination must be performed to assess for neurovascular compromise. Most subtalar dislocations can be treated with closed reduction under sedation. However, if the dislocation is associated with an open fracture it may require reduction in the operating room. Treatment should include postreduction plain x-ray and CT scan to evaluate for proper alignment and for fractures. This article presents a case of medial subtalar dislocation in a 23-year-old football player.

Dermal tissue allograft for the repair of massive irreparable rotator cuff tears.

BACKGROUND: Massive irreparable rotator cuff tears in patients without advanced glenohumeral arthritis can pose a challenge to surgeons. Numerous management strategies have been utilized, and studies have shown varied results with regard to shoulder pain, range of motion, strength, and overall function. HYPOTHESIS: Patients undergoing repair of massive irreparable rotator cuff tears through a mini-open approach with the use of human dermal tissue matrix allograft would demonstrate an improvement in pain, range of motion, strength, and subjective functional outcomes. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: We performed a prospective observational study of 24 patients who underwent interposition repair of massive rotator cuff tears using human dermal allograft. All patients were evaluated preoperatively and postoperatively by the treating surgeon. Data were collected preoperatively and postoperatively for an average 3-year follow-up period (range, 29-40 months). Active range of motion as well as supraspinatus and infraspinatus strength was assessed. Subjective outcome measures included pain level (visual analog scale of 0-10, with 10 = severe pain), American Shoulder and Elbow Score (ASES), and Short-Form 12 (SF-12) score. Imaging evaluation to assess for repair integrity was performed using static and dynamic ultrasonography at final follow-up. RESULTS: Mean pain level decreased from 5.4 to 0.9 (P = .0002). Mean active forward flexion and external rotation motion improved from 111.7° to 157.3° (P = .0002) and from 46.2° to 65.1° (P = .001), respectively. Mean shoulder abduction improved from 105.0° to 151.7° (P = .0001). Supraspinatus and infraspinatus strength improved from 7.2 to 9.4 (P = .0003) and from 7.8 to 9.3 (P = .002), respectively. Mean ASES improved from 66.6 to 88.7 (P = .0003). Mean SF-12 scores improved from 48.8 to 56.8 (P = .03). One partial graft retear occurred because of patient noncompliance during postoperative rehabilitation. However, this patient still demonstrated improvement in pain, motion, and subjective outcomes at final follow-up. Ultrasonography demonstrated "fully intact" repairs in 76% of patients. All remaining patients had "partially intact" repairs. There were no complete tears. CONCLUSION: In our series of carefully selected candidates, all patients demonstrated a significant improvement in pain, range of motion, and strength. Subjective outcome measures, including mean ASES and SF-12 scores, also demonstrated significant improvement at an average 3-year follow-up.

Dorsal wrist mass: the carpal boss.

The carpal boss is an osseous overgrowth that is occasionally mistaken for a ganglion cyst. This report highlights the case a 36-year-old patient who was originally diagnosed by his primary care physician with a ganglion cyst and was sent to an orthopaedist for aspiration. Upon further evaluation with a plain radiograph, the dorsal wrist mass was found to be a carpal boss. The patient was treated with rest and a wrist brace, and was informed that a corticosteroid injection or surgical excision would be necessary if conservative treatment failed. The patient was asymptomatic on follow-up and invasive procedures were not necessary.

Carpal contusions in an elite platform diver.

Wrist and hand injuries are common in elite divers, as all correctly performed dives end with a head first entry into the water with the hands extended above the head. This case presentation was an Olympic level diver with 3 months of persistent dorsal wrist pain. MRI findings showed contiguous contusions to the lunate, capitate, hamate and distal radius and also a peripheral tear of the ulnar attachment of the triangular fibrocartilage complex (TFCC). The repeated dorsiflexion stress of entry into the water likely caused these injuries. Although the authors had suspected a TFCC injury and did find an isolated ulnar-sided peripheral tear, the complicating carpal contusions led us to choose a conservative treatment plan, which was the only intervention the patient ultimately required.

Gastrointestinal infections in the traveling athlete.

Because athletes travel to competitions all over the world, sports medicine providers need to be able to diagnose and treat gastrointestinal infections. Traveler's diarrhea (TD) is by far the most common gastrointestinal illness. TD is a self-limited condition caused by bacteria, viruses, or parasites, and it can easily be treated. Nevertheless, there are preventative measures that should be taken to limit the exposure to TD in the first place.

Medicolegal issues in sports medicine.

This article reviews medicolegal issues in sports medicine. Nonmusculoskeletal medical conditions discussed include cardiac abnormalities, heat illness, and concussion in the athlete. Musculoskeletal injuries with the greatest potential for litigation, knee dislocation, and cervical spine trauma, are also reviewed. We provide legal case examples and discuss evaluation and treatment strategies to assist the medical team in the care of athletes.