Treatment Options for Patellar Tendinopathy: A Systematic Review.

PURPOSE: To compare the efficacy of common invasive and noninvasive patellar tendinopathy (PT) treatment strategies. METHODS: A systematic search was performed in PubMed, Google Scholar, CINAHL, UptoDate, Cochrane Reviews, and SPORTDiscus. Fifteen studies met the following inclusion criteria: (1) therapeutic outcome trial for PT, and (2) Victorian Institute of Sports Assessment was used to assess symptom severity at follow-up. Methodological quality and reporting bias were evaluated with a modified Coleman score and Begg's and Egger's tests of bias, respectively. RESULTS: A total of 15 studies were included. Reporting quality was high (mean Coleman score 86.0, standard deviation 9.7), and there was no systematic evidence of reporting bias. Increased duration of symptoms resulted in poorer outcomes regardless of treatment (0.9% decrease in improvement per additional month of symptoms; P = .004). Eccentric training with or without core stabilization or stretching improved symptoms (61% improvement in the Victorian Institute of Sports Assessment score, 95% confidence interval [CI] 53% to 69%). Surgery in patients refractory to nonoperative treatment also improved symptoms (57%, 95% CI 52% to 62%) with similar outcomes among arthroscopic and open approaches. Results from shockwave (54%, 95% CI 22% to 87%) and platelet-rich plasma (PRP) studies (55%, 95% CI 5% to 105%) varied widely though PRP may accelerate early recovery. Finally, steroid injection provided no benefit (20%, 95% CI -20% to 60%). CONCLUSIONS: Initial treatment of PT can consist of eccentric squat-based therapy, shockwave, or PRP as monotherapy or an adjunct to accelerate recovery. Surgery or shockwave can be considered for patients who fail to improve after 6 months of conservative treatment. Corticosteroid therapy should not be used in the treatment of PT. LEVEL OF EVIDENCE: Level IV, systematic review of Level II-IV studies.

Perioperative Allogeneic Red Blood-Cell Transfusion Associated with Surgical Site Infection After Total Hip and Knee Arthroplasty.

BACKGROUND: Perioperative allogeneic red blood-cell transfusion is a suspected risk factor for surgical site infection (SSI) after total joint arthroplasty (TJA), but the interrelationships among SSI risk, transfusion dose, preoperative anemia, and the presence of coagulopathies have not been well described. METHODS: Data on SSI within 1 year after surgery as well as on transfusion with blood products within 30 days after surgery were obtained for 6,788 patients who had undergone primary or revision total hip or knee arthroplasty from 2000 to 2011 in a single hospital system. Multivariate logistic regression modeling was used to determine the independent association between allogeneic red blood-cell transfusion and SSI. RESULTS: There was a dose-dependent association between allogeneic red blood-cell transfusion and SSI, with the infection rate increasing as the transfusion dose increased from 1 unit (odds ratio [OR] = 1.97; 95% confidence interval [CI] = 1.38, 2.79; p < 0.001), to 2 units (OR = 2.20; CI = 1.37, 3.44; p = 0.002), to 3 units (OR = 3.66; CI = 1.72, 7.16; p = 0.001), and to >3 units (OR = 7.40; CI = 4.91, 11.03; p < 0.001) after controlling for medical comorbidities, planned procedure, preoperative anemia, and preexisting coagulopathies. A preexisting bleeding disorder (OR = 2.09; CI = 1.57, 2.80; p < 0.001) and clotting disorder (OR = 1.37; CI = 1.14, 1.64; p = 0.001) and preoperative anemia (OR = 3.90; CI = 3.31, 4.61; p < 0.001) were all independent risk factors for transfusion after adjusting for the planned procedure. CONCLUSIONS: We found a dose-dependent relationship between allogeneic red blood-cell transfusion and SSI risk after total hip or knee arthroplasty. Additionally, preoperative anemia or a known bleeding or clotting disorder were risk factors for the need for allogeneic red blood-cell transfusion. Our findings underscore the need for preoperative risk assessment, methods to limit surgical tissue injury, and optimized blood conservation strategies. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Variation in tibial tuberosity lateralization and distance from the tibiofemoral joint line: An anatomic study.

BACKGROUND: To describe variation in tibial tuberosity position in a normal adult population and inter-rater reliability of measurements of tibial tuberosity position. METHODS: Surface models of 161 proximal tibia specimens (83 female, 78 male; 80 black, 81 white; age 28.7years, SD 7.5) were created with a three-dimensional laser scanner. Percent lateralization, tuberosity-eminence angle, and distance from joint surface were measured for each specimen. Variation in tuberosity position by sex, race, age, height, and BMI was calculated. Multivariate regression was used to assess for demographic factors independently associated with tuberosity positioning. RESULTS: Mean percent lateralization was 57.9% (SD 2.4, range 52.4-64.9%). Tuberosity-eminence angle mean was 11.03° (SD 2.8, range 0-18.7°). Percent lateralization and tuberosity-eminence angle were not influenced by sex, race, age, height or, BMI (p>0.05). Mean tuberosity distance from joint surface was 29.2mm (SD 3.5, range 16.6-38.6mm) and larger in males than females (30.7mm (SD 2.9), 27.6mm (SD 3.3); p<0.001). Tuberosity distance from joint surface increased 0.18mm on average per 1.0cm increase in height (p<0.001). Inter-rater reliability was high for distance from joint surface (Cronbach alpha=0.99) and percent lateralization. CONCLUSIONS: Tibial tuberosity percent lateralization falls in a narrow range for individuals, whereas tuberosity-eminence angle and distance from joint line are more variable. Inter-rater reliability is high for percent lateralization and distance for the joint surface. Distance of tibial tuberosity from joint surface is associated with sex and height.

The ACL injury response: A collagen-based analysis.

BACKGROUND: Anterior cruciate ligament (ACL) injuries do not effectively heal. Tendon graft tissue after reconstruction shows rapid tissue turnover and 'ligamentization.' It is unknown whether native torn ACL tissue undergoes significant collagen turnover after injury or is arrested by the intraarticular environment. It is also unknown whether injury mechanism or chronicity affect torn ligament tissue turnover. METHODS: Thirty-three mid-substance ACL biopsies were obtained during primary arthroscopic ACL reconstruction (n=31; nine contact injuries, 22 non-contact injuries, 22 males, 11 females; mean age 28.5 years; median injury to surgery time 12 weeks), or from cadavers as uninjured ACL (n=2). As a marker for collagen turnover, immature collagen cross-link content was determined by ninhydrin reagent assays. The immature cross-link content was assessed against injury mechanism, patient age, and injury to surgery time. Histochemical analysis was conducted on two uninjured ACL cadaveric controls, a four-week-old ACL tear, and a four-year-old ACL tear. RESULTS: Contact and non-contact groups were not demographically different with respect to sex, patient age, injury to surgery time, and activity involvement prior to injury, which ranged from basketball to logging. Collagen crosslink content was very low across all samples, suggesting high tissue turnover between injury and surgery regardless of injury mechanism (non-contact: 1.68ng/mol, CI 0.48-2.89; contact: 1.50ng/mol, CI 0.14-2.86; p=0.842). CONCLUSION: Collagen turnover occurs rapidly after ACL injury regardless of contact or non-contact mechanism. Robust tissue turnover starts within the first several weeks after injury and persists to some extent throughout the life of the torn ACL.