Long term improvement of knee osteoarthritis after injection of single high/very high volume of very pure PRP: A retrospective analysis of patients optimally managed in dedicated centers.

Introduction: PRP is gaining increasing interest for pain relief and improvement of joint function in patients with knee osteoarthritis (KOA) but practices and results remain heterogeneous limiting its adoption as standard of care. Current international recommendations are to collect real-life evidence of efficacy with a systematic monitoring of PRP quality and patients' outcomes. We aimed to analyze the response of patients presenting KOA and treated with standardized PRP injection in routine care. We also investigated the potential contributing factors including patient's phenotype and PRP characteristics. Methods: Patients with symptomatic KOA and that failed first-line therapy received a single injection of a qualified PRP prepared using medical devices allowing to recover a high/very high volume of very pure PRP. Visual analogue scale (VAS) and Western Ontario and McMaster Osteoarthritis Index (WOMAC) score were recorded at baseline and during 18 months follow-up. Results: 431 patients had available follow-up data at 3 months, 291 at 6 months, 137 at 12 months and 44 at 18 months. PRP induced a significant decrease of WOMAC score at all follow up endpoints (29.2 ± 19.2 at 3 months, p < 0.001 and 25.9 ± 19.7 at 12 months, p < 0.01, compared to 39.7 ± 18.9 at baseline). Similar results were observed for pain VAS (38.9 ± 23.3 at 3 months, p < 0.001 and 35.3 ± 24.1 at 12 months, p < 0.05, compared to 56.0 ± 20.7 at baseline). Changes at 12 months were correlated to baseline scores and to the level of improvement at 3 months. The proportion of OMERACT OARSI responders reached 56.2 % for the total cohort and 60.4 % for severe patients at 6 months. Treatment failure occurred for 8.4 % of patients. Age, BMI or Kellgren-Lawrence grade did not impact on efficacy. Conclusion: This real-life study evidences the clinical benefit of a standardized high or very high-volume injection of very pure PRP in patients with KOA, including those with a severe grade. It opens perspectives in the positioning of such strategy to delay arthroplasty and provide insights on factors able to anticipate long term efficacy.

Overuse injuries in high school runners: lifetime prevalence and prevention strategies.

OBJECTIVE: To evaluate lifetime prevalence and risk factors for overuse injuries in high school athletes currently participating in long-distance running and provide recommendations for injury prevention strategies. DESIGN: Retrospective study design. SETTING: Twenty-eight high schools in the San Francisco Bay Area. PARTICIPANTS: A total of 442 female and 306 male athletes, ages 13-18 years, who are on cross-country and track and field teams. METHODS: Online survey with questions that detailed previous injuries sustained and risk factors for injury. MAIN OUTCOME MEASUREMENTS: Previous overuse injuries and association of risk factors to injury (including training variables, dietary patterns, and, in girls, menstrual irregularities). RESULTS: Previous injuries were reported by 68% of female subjects and 59% of male subjects. More injury types were seen in girls (1.2 ± 1.1 versus 1.0 ± 1.0, P < .01). Both genders had similar participation in running (2.5 ± 2.2 versus 2.3 ± 2.1 years), and previous injury prevalence followed a similar pattern: tibial stress injury (girls, 41%; boys, 34%), ankle sprain (girls, 32%; boys, 28%), patellofemoral pain (girls, 21%; boys, 16%), Achilles tendonitis (girls, 9%; boys, 6%), iliotibial band syndrome (girls, 7%; boys, 5%), and plantar fasciitis (girls, 5%; boys, 3%). Higher weekly mileage was associated with previous injuries in boys, (17.1 ± 11.9 versus 14.1 ± 11.5, P < .05) but not in girls (14.4 ± 10.2 versus 12.6 ± 11.8, not significant). A strong association between higher mileage and faster performances was seen in both groups. No association between previous injury and current dietary patterns (including disordered eating and calcium intake) or menstrual irregularities was seen. CONCLUSIONS: The majority of athletes currently participating in high school cross-country and track and field have a history of sustaining an overuse injury, with girls having a higher prevalence of injury. A modest mileage reduction may represent a modifiable risk factor for injury reduction. Future research is needed to evaluate the effects of incorporating a comprehensive strength training program on the prospective development of overuse injury and performance in this population.

Chronic ankle instability and common fibular nerve injury.

The lateral collateral ligaments of the ankle are often damaged in ankle inversion injuries. Ankle inversion may also cause injury to other structures located around the ankle or further away, such as the common fibular nerve. Few descriptions exist of common fibular nerve injury associated with ankle sprains and chronic ankle instability. We describe the case of a patient who sustained common fibular nerve injury during each of two ankle sprain recurrences involving the lateral collateral ligaments. Our objectives are to illustrate the links between common fibular nerve and lateral collateral ligament injuries and to emphasize the importance of the neurological evaluation in patients seen for ankle sprains or chronic ankle instability.

Patellofemoral pain syndrome.

Patellofemoral pain (PFP) syndrome is a frequently encountered overuse disorder that involves the patellofemoral region and often presents as anterior knee pain. PFP can be difficult to diagnose. Not only do the etiology, diagnosis, and treatment remain challenging, but the terminology used to describe PFP is used inconsistently and can be confusing. Patellofemoral pain syndrome (PFPS) seems to be multifactorial, resulting from a complex interaction among intrinsic anatomic and external training factors. Although clinicians frequently make the diagnosis of PFPS, no consensus exists about its etiology or the factors most responsible for causing pain. This article discusses the pathophysiology, diagnosis, and management of PFP.

Improvement of gait in a stroke patient. A 7-year longitudinal study.

PURPOSE: To report on the gait improvement obtained in a stroke patient after applying three treatments for spastic equinus varus foot: botulinum toxin injection (BTI), tibial nerve neurotomy (TNN), and orthopaedic surgery (triple arthrodesis), during a 7-year longitudinal follow-up period. METHOD: A quantified analysis of a stroke patient's gait was performed on a Gaitrite walking mat before and after applying BTI 3 years, TNN 4 years and orthopaedic surgery 7 years after the stroke. RESULTS: After the three treatments, the spasticity disappeared, the range of ankle motion improved and voluntary command of the tibialis anterior became possible. Upon comparing the gait parameters before treatment and after the three treatments, it was observed that the comfortable gait velocity had increased (from 0.42 m/s to 0.70 m/s), the step length had become more symmetrical (from left 19 cm, right 57 cm to left 50 cm, right 51 cm), the step width had decreased (from 23 cm to 12 cm). In terms of participation, walking barefoot had become possible without a cane, as well as going up and down stairs and walking outdoors on uneven ground without any help. CONCLUSIONS: Stroke patients during the chronic phase with a spastic equinovarus deformity can benefit from various commonly used therapeutic interventions. BTI and TNN were found to be efficient but only for a short time. Orthopaedic surgery gave the most long-lasting results. Further studies should be performed on a larger number of patients to determine the most suitable options for treating stroke patients with an equinus varus foot.

Orthotic fitting improves gait in a patient with generalized secondary dystonia.

OBJECTIVE: To determine whether an orthotic fitting improved gait in an adult patient presenting with generalized secondary dystonia. PATIENT: The patient had stance and gait disturbances associated with pain, ankle instability and fatigability. Clinical examination showed the presence of dystonia in the foot and ankle, along with equinovarus foot, mainly on the left side. The patient was fitted with a patellar tendon-bearing orthosis on the left side, orthopaedic shoes and plantar orthoses. METHODS: The outcome of the treatment after 12 months was assessed on the basis of a physical examination and an instrumental gait assessment, using the GAITRite(R) system to analyse spatiotemporal parameters and force-plates to measure body weight distribution. RESULTS: The fitting resulted in a significant improvement in gait, reduced pain and ankle instability, decreased cadence, increased step length and single foot support time, and reduced asymmetry of the temporo-spatial patterns and body weight distribution. CONCLUSION: Patellar tendon-bearing orthoses and orthopaedic shoes could provide a good therapeutic approach for improving gait in patients with generalized secondary dystonia.

Changes in postural control in hemiplegic patients after stroke performing a dual task.

OBJECTIVE: To determine the effects of an attentional task on hemiplegic patients' postural control performances. DESIGN: Retrospective study. SETTING: Department of physical and rehabilitation medicine at a university hospital. PARTICIPANTS: Twenty-three hemiplegic patients and 23 healthy age- and sex-matched control subjects. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Sway area and sway path of the center of pressure were measured during 30 seconds in standing subjects and patients under 3 conditions: eyes open (EO), EO while performing a simple arithmetic task (EO-AT), and eyes closed (EC). RESULTS: In the hemiplegic patients, the body sway area increased significantly with EC (P<.001) and during the EO-AT task (P<.017) in comparison with EO. Sway area with EO-AT remained, however, significantly smaller than with EC (P<.014). In the healthy subjects, the body sway did not differ significantly between the EO-AT and EO tasks (P<.42). The increase observed in the sway area and path in the hemiplegic population during the EO-AT task correlated significantly with age. CONCLUSIONS: The postural performances of hemiplegic patients decreased during both the arithmetic task and the EC task. The cognitive task had no effect on healthy subjects' postural performances. This study is the first to show the combined effects of age and dual task on the postural performances of hemiplegic subjects.

Gait recovery in a distal spinal muscular atrophy patient wearing a patellar tendon-bearing orthosis and orthopaedic shoes.

OBJECTIVE: To illustrate that a patient with distal spinal muscular atrophy can recover gait with a combination of orthoses and orthopaedic shoes. SUBJECT: A 28-year-old man with distal spinal muscular atrophy affecting only the distal muscles of the lower limbs. Clinical examination showed a bilateral pes cavus with a varus and a 90 degrees equinus of the ankle joint. METHODS: The patient was fitted with orthopaedic shoes and a patellar tendon-bearing orthosis. In order to assess the clinical effects of this fitting, a complete physical examination was performed and the patient's temporo-spatial gait parameters were assessed quantitatively using gait analysis tools (Gaitrite) both prior to treatment and after one month. RESULTS: Before the fitting, the patient was not able to walk alone or to maintain an upright position and he suffered from foot pain. One month after the fitting was applied, the patient was able to walk alone and to maintain an upright position for 1 hour. His pain disappeared. Quantified study of the patient's gait parameters shows that the temporo-spatial parameters are close to normal with fitting. CONCLUSION: Clinical and quantitative data both confirm the subjective improvements reported by the patient.

Does fascicular neurotomy have long-lasting effects?

OBJECTIVE: To determine whether fascicular neurotomy has long-lasting effects on spasticity. DESIGN: We present 4 clinical cases and a critical analysis of the literature. PATIENTS: This is a retrospective study on 4 patients referred to our department for spastic equinovarus foot deformity. For all 4, neurotomy was successful not long after surgery, but spasticity reappeared after a few months. METHODS: We compared our results with those in the PubMed database. RESULTS: Most publications acknowledge the immediate effectiveness of this surgery, but do not study the long-term effects of neurotomy. No publication proved long-lasting effects of neurotomy for spastic equinovarus foot deformity. The only long-term follow-up with a sufficient population is the one of Berard et al. who reported 61% recurrence. CONCLUSION: There is no study showing that tibial nerve neurotomy has long-lasting effects. The 4 cases reported are an illustration that recurrence of spasticity may occur after neurotomy. These findings have to be taken into account for treatment decision-making and for provision of information to patients.