Arthroscopic treatment of medial shelf syndrome.

Medial shelf or "plica" syndrome is a pathological condition of the knee that often follows knee injury in young athletes, the symptoms of which often mimic other internal derangements of the knee. Its anatomy, pathomechanics, and clinical presentation along with treatments suggested in the orthopedic literature are reviewed here. Two-year follow-up studies on the treatment of this syndrome by arthroscopic resection in 51 knees in 42 patients are presented as well.

Factors associated with decreased muscle strength after anterior cruciate ligament reconstruction with hamstring tendon grafts.

PURPOSE: To identify factors associated with decreased muscle strength and activity after anterior cruciate ligament (ACL) reconstruction with semitendinosus-gracilis tendon (ST-G) grafts. TYPE OF STUDY: Retrospective review. METHODS: Eighty-five patients who underwent ACL reconstruction with ST-G grafts were evaluated at a mean of 44.4 months after surgery. Patients underwent isokinetic testing, physical examination, radiographs, instrumented laxity testing, and Lysholm, Cincinnati, and International Knee Documentation Committee (IKDC) ratings. Cartilage and meniscal pathology at surgery was reviewed. Strength group 1 (n = 30) showed greater than 20% deficits in strength; strength group 2 (n = 55) had less than 20% strength deficits. Activity group 1 (n = 60) maintained their IKDC activity level at final follow-up relative to preinjury level; activity group 2 (n = 25) decreased activity by 1 or more levels. RESULTS: With all patients combined, there was less than a 4% difference in mean hamstring and quadriceps strength between the reconstructed and contralateral legs at follow-up. Knee flexion deficits were associated with decreased hamstring strength. Subjective giving way and squatting/kneeling discomfort were associated with decreased quadriceps strength. Patients in strength group 1 were more likely to have squatting/kneeling discomfort and lower Cincinnati Function scores. Activity group 2 had a longer interval from injury to surgery and more chondromalacia at surgery. At follow-up, activity group 2 had lower subjective scores and was more likely to have pain, swelling, giving way, and flexion deficits. Activity group 2 also had greater deficits in quadriceps strength. CONCLUSIONS: Articular cartilage injury and meniscal pathology were not associated with decreased muscle strength. ACL reconstruction with ST-G grafts has a 38% incidence of squatting/kneeling pain that occurs secondary to patellofemoral crepitus, harvest site symptoms, and tibial hardware sensitivity. LEVEL OF EVIDENCE: Level IV, therapeutic, case series, no control group.

A comparison of the effects of radiofrequency treatment and mechanical shaving for meniscectomy.

PURPOSE: The goal of this ex vivo pilot study was to compare radiofrequency treatment with cutting and shaving treatment of meniscal tears by use of a mechanical testing procedure and electron microscopy to establish the mechanical characteristics and qualitative appearance of meniscal tissue after the use of each of these procedures. METHODS: In this study 136 menisci were explanted and divided into 4 groups: a damaged, untreated control group; a group damaged in the same way as the control group and treated by mechanical shaving of the meniscal tear; a group damaged in a similar way and then treated by radiofrequency by use of a radiofrequency wand; and a fourth group in which plunge-cutting by use of the radiofrequency wand was used to resect the tissue, beginning at the superior surface of the meniscus in a place that corresponded to the location of the meniscal tears. The menisci were then tested for strength by applying radial tension to the tear. Electron microscopy at low and high magnification was used to evaluate the appearance of the surface of the menisci after shaving or radiofrequency treatment. RESULTS: Static mechanical testing to failure showed no significant difference between the control group and the 3 test groups. However, there was a statistically significant difference between the radiofrequency-treated groups and the mechanically shaved group at the .033 level. On fatigue testing, there was no statistically significant difference in the failure cycles, but the coefficient of variation was 8 times greater for the mechanically shaved menisci versus the radiofrequency-treated menisci. Scanning electron microscopy showed that the mechanically treated menisci had flat surfaces with clefts or fissures. The radiofrequency-treated menisci had a homogeneous appearance without clefts. CONCLUSIONS: This study showed that radiofrequency-treated damaged tissue leaves a qualitatively different surface from the mechanically treated menisci, which failed at a significantly higher load on static testing. On fatigue testing, there was greater variation in the number of cycles to failure of mechanically treated specimens versus the radiofrequency-treated menisci. CLINICAL RELEVANCE: Although recurrent meniscal tears are uncommon, they may be of value in evaluating different methods of meniscectomy. This study points out mechanical and qualitative differences between shaved and radiofrequency-treated meniscectomy.

Assessment of musculoskeletal knowledge in primary care residents.

We assessed musculoskeletal training in primary care residency programs at the University of Arizona to determine whether formal orthopedic instruction increased musculoskeletal knowledge. The University of Pennsylvania Basic Competency Examination in Musculoskeletal Medicine was administered to 38 of 52 primary care resident volunteers. The established "passing" score to demonstrate basic competency on this test is 73.1%. The overall score of the residents tested was 56.3% (range, 21%-88%). Eight of 38 residents had a score of 73.1% or higher. The mean scores were 61.5% with orthopedic rotation and 47.3% without orthopedic rotation. The difference was statistically significant (P=.05). Pediatric residents had the least exposure to musculoskeletal training, and none of them "passed" the competency examination. Primary care providers have a larger role in managing musculoskeletal problems with current managed health care systems in the United States. Many primary care residency programs do not provide adequate training in musculoskeletal medicine. The majority of exiting primary care residents do not have basic competency in managing musculoskeletal problems. Our study results show that residents who take an orthopedic rotation have a larger knowledge base. It seems reasonable to increase primary care residents' formal education regarding musculoskeletal problems.

Patellofemoral pain and functional outcome after anterior cruciate ligament reconstruction: an analysis of the literature.

We reviewed the literature for reports on anterior knee pain and function after endoscopic single-incision anterior cruciate ligament reconstruction. The risk for developing a range-of-motion extension deficit of more than 3 degrees 2 years after surgery was 62% higher for patients who underwent a patellar tendon procedure than for patients who underwent a hamstring graft procedure, and the risk for having an abnormal International Knee Documentation Committee score was 9% higher. There were no statistically significant functional differences between the 2 groups. We also concluded that studies done from "high-quality randomized trials" are insufficient alone; clinicians should evaluate results from meta-analyses to determine whether data from individual studies were properly combined.

Subchondral fracture of the hip caused by axial loading: a case report and review of the literature.

In this article, we report on a rare case of an isolated subchondral fracture of the hip of an athlete-the patient was a 20-year-old football player--and review the English-language literature on this type of injury.

Long-term outcomes of allograft reconstruction of the anterior cruciate ligament.

Recent studies have found higher rates of failed reconstruction of the anterior cruciate ligament (ACL) with use of allograft when compared with autograft reconstruction. To evaluate the long-term outcomes of allograft ACL reconstruction, we retrospectively reviewed the cases of all patients who underwent allograft (n=99) or autograft (n=24) ACL reconstruction by 2 senior surgeons at a single institution over an 8-year period. Seventeen (17%) of the 99 allograft reconstructions required additional surgery. Reoperation and revision ACL reconstruction rates (30.8% and 20.5%, respectively) were much higher for patients 25 years of age or younger than for patients older than 25 years. In our cohort of NCAA (National Collegiate Athletic Association) Division I athletes, the revision ACL reconstruction rate was 62% for allograft ACL reconstruction and 0% for autograft reconstruction. Our study found that reoperation and revision rates for irradiated soft-tissue allograft ACL reconstruction were higher than generally quoted for autograft reconstruction. Given the extremely high graft failure rates in patients younger than 25 years, we recommend against routine use of irradiated soft-tissue allograft for ACL reconstruction in younger patients.

Co-culture of adipose derived stem cells and chondrocytes with surface modifying proteins induces enhanced cartilage tissue formation.

OBJECTIVES: Current treatments for focal cartilage defects include osteochondral allograft transplants-a common treatment for large defects and revisions of previously autografted joints. Allografts with weak osseous regions are usable, since bone remodeling replaces inferior quality bone. However, poor quality chondral surfaces on grafts preclude their use, leading to grafting material shortages. Endogenous adult stem cells can make hyaline-like cartilage tissue on scaffolds. To increase the number of usable allografts, tissue culture methods using adipose derived stem cells (ASCs) were developed to grow cartilage on grafts. METHODS: Co-cultures utilized living chondrocytes in host cartilage, modeling in vivo conditions, and ASCs seeded on the allografts. Sterilized allografts were treated with Poly-L-Lysine and ProNectin. Tissue growth was analyzed and quantified with histological techniques. RESULTS AND CONCLUSIONS: Monoculture experiments produced tenuous cartilage formation when proteins were utilized and allograft surfaces were perforated. Extensive tissue formation was observed with co-culture and the presence of type II collagen was confirmed with immunohistochemistry. Results demonstrate that co-culture techniques offer a better means of growing tissue on allograft cartilage surfaces. Additionally, the use of proteins to facilitate surface attachment produced more tissue formation demonstrating that cell attachment is crucial when growing cartilage on allografts. Development of new culture techniques to evaluate treatment strategies will accelerate the rate at which cartilage procedures using endogenous cells are possible. This will increase the number of usable grafts and allow critical selection of grafts to fit specific surfaces increasing surgical success by returning the joint to its native structure.

Coding practices affect the cost of distal radius fracture care.

The purpose of this study was to determine the impact of an Emergency Medicine Department's billing practices on the total cost of care for distal radius fractures. This study identified patients by International Classification of Diseases, Ninth Revision (ICD-9) billing codes treated by the Department of Orthopaedic Surgery (DOS) and Department of Emergency Medicine (DEM) at the University of Arizona. In every case, the surgical modifier 54 was used. The billing records in each case for the DEM and the DOS were reviewed. When the fracture was manipulated and the DEM was the attending of record for the initial visit, the total cost of fracture care was increased by $500. When the fracture was not manipulated, the total cost of fracture care was increased by $270. Although more than one-third of patients had surgery by the DOS, the DEM used a global billing code that indicates "restorative" treatment. This is an example of the manipulation of Current Procedural Terminology coding to enhance revenue generation with increased cost to the healthcare system, and no added value to outcome.

Accuracy of magnetic resonance imaging of the knee in the community setting.

BACKGROUND: Magnetic resonance imaging (MRI) is routinely used in the diagnosis of sports-related knee injuries. PURPOSE: To determine the accuracy, sensitivity, and specificity of MRI compared with clinical evaluation in the diagnosis of meniscal pathology when the MRI facility and the radiologist are not preselected. METHODS: A total of 288 knee arthroscopies were retrospectively compared. Patients were divided into 3 groups: those who had MRI performed and interpreted at a single institution, MRI performed and interpreted at community facilities, or a clinical evaluation by a senior orthopaedic surgeon. RESULTS: The sensitivity, specificity, and accuracy of the diagnosis of medial meniscal pathology at a single institution were 90%, 59%, 76%; in community facilities, 73%, 68%, 70%; and by a clinical evaluation, 93%, 55%, 73%, respectively. For lateral meniscal pathology, the results were as follows: single institution, 75%, 76%, 81%; community facilities, 60%, 88%, 79%; and clinical evaluation, 45%, 90%, 79%, respectively. Sensitivity for medial meniscus was greater than for lateral meniscus, but specificity of diagnosis was better for lateral meniscus by MRI and clinical evaluation. While not statistically significant, there was increased sensitivity in the diagnosis of medial meniscus and lateral meniscus at SIs, but they have less specificity than at community facilities. The number of false-positive diagnoses (ie, no intra-articular pathology) that resulted in surgery was 4 of 288 (1.39%). The overall accuracy for medial meniscus by MRI was 73% vs 73% for clinical evaluation. The overall accuracy for MRI for lateral meniscus was 78% vs 79% for clinical evaluation. CONCLUSION: Routine MRI may not be more beneficial than clinical evaluation when there is no preselection of MRI facility and interpreting radiologist. CLINICAL RELEVANCE: The use of MRI for diagnosing meniscal pathology should be reserved for those cases where the orthopaedic clinical examination is ambiguous.