Meniscus Root Tears: A Clinical Review.

ABSTRACT: Meniscus root tears are important to recognize early given their potentially devastating consequences on joint health. This injury results in the lost ability of the meniscus to transfer axial loads into hoop stress; therefore, it is functionally equivalent to a complete meniscectomy. This causes rapid progression of osteoarthritis and increased need to total knee arthroplasty in a previously healthy joint. Despite these consequences, root tears have only been discussed in the orthopedic literature in the last 10 to 15 years and have not been routinely integrated into nonoperative sports medicine education. It is important for all nonoperative sports medicine providers to properly diagnose and triage this injury early in its course to maximize joint preservation efforts. The goal of this manuscript is to review the anatomy, presentation, natural history, imaging, and treatment options for meniscal root tears.

Complications Following Biologic Therapeutic Injections: A Multicenter Case Series.

PURPOSE: To describe the complications that occur following biologic therapeutic injections. METHODS: We queried physician members of the Biologic Association, a multidisciplinary organization dedicated to providing a unified voice for all matters related to musculoskeletal biologics and regenerative medicine. Patients included in this study must have (1) received a biologic injection, (2) sustained an adverse reaction, and (3) had a minimum of 1-year follow-up after the injection. Patient demographic information, medical comorbidities, diagnoses, and previous treatments were recorded. The type of injection, injection setting, injection manufacturers, and specific details about the complication and outcome were collected. RESULTS: In total, 14 patients were identified across 6 institutions in the United States (mean age 63 years, range: 36-83 years). The most common injections in this series were intra-articular knee injections (50%), followed intra-articular shoulder injections (21.4%). The most common underlying diagnosis was osteoarthritis (78.5%). Types of injections included umbilical cord blood, platelet-rich plasma, bone marrow aspirate concentrate, placental tissue, and unspecified "stem cell" injections. Complications included infection (50%), suspected sterile inflammatory response (42.9%), and a combination of both (7.1%). The most common pathogen identified from infection cases was Escherichia coli (n = 4). All patients who had isolated infections underwent treatment with at least one subsequent surgical intervention (mean: 3.6, range: 1-12) and intravenous antibiotic therapy. CONCLUSIONS: This study demonstrates that serious complications can occur following treatment with biologic injections, including infections requiring multiple surgical procedures and inflammatory reactions. LEVEL OF EVIDENCE: Level IV, case series.

Botulinum Toxin for Chronic Exertional Compartment Syndrome: A Case Report With 14 Month Follow-Up.

Chronic exertional compartment syndrome (CECS) presents a unique therapeutic challenge. Fasciotomy, currently the most well accepted treatment approach, still has a significant number of treatment failures, demonstrating the need for additional options. Botulinum toxin has been introduced as a potential therapeutic agent, but long-term outcomes are unknown. We present the longest documented follow-up (14 months) of a CECS case treated with botulinum toxin injections. At 14 months follow-up, the patient reported continued pain relief and had resumed her active lifestyle without any adverse effects. Although more research is needed to optimize patient selection and treatment protocol, this case illustrates the potential for botulinum toxin as a long duration, low risk alternative treatment option for CECS.

Diaphragm depth in normal subjects.

INTRODUCTION: Needle electromyography (EMG) of the diaphragm carries the potential risk of pneumothorax. Knowing the approximate depth of the diaphragm should increase the test's safety and accuracy. METHODS: Distances from the skin to the diaphragm and from the outer surface of the rib to the diaphragm were measured using B mode ultrasound in 150 normal subjects. RESULTS: When measured at the lower intercostal spaces, diaphragm depth varied between 0.78 and 4.91 cm beneath the skin surface and between 0.25 and 1.48 cm below the outer surface of the rib. Using linear regression modeling, body mass index (BMI) could be used to predict diaphragm depth from the skin to within an average of 1.15 mm. CONCLUSIONS: Diaphragm depth from the skin can vary by more than 4 cm. When image guidance is not available to enhance accuracy and safety of diaphragm EMG, it is possible to reliably predict the depth of the diaphragm based on BMI.

Superficial Vein Thrombosis After Intra-articular Particulate Steroid Injection for Knee Osteoarthritis.

ABSTRACT: Intra-articular steroid injections for knee osteoarthritis are a routine procedure in musculoskeletal clinics. While their role in osteoarthritis care is debatable, they serve as an important therapeutic option to relieve osteoarthritis-associated pain. Potential risks are self-limited (increased pain flare, local skin irritation, flushing, insomnia) or severe (septic arthritis, intravascular medication placement, and the deleterious effect on cartilage and bone). In our experience, more serious adverse events are rare. In this case, we present a complication secondary to intra-articular steroid administration that has not previously been reported in the literature: superficial vein thrombosis. This will raise awareness among clinicians, improve the informed consent process, and provide an approach for the management of subsequent injections.

The quality and accuracy of direct-to-consumer biologic marketing for shoulder pathology are poor.

Background: The growing role of biologic therapies as adjunct or standalone procedures in orthopedic practice has led to greater levels of direct-to-consumer biologic marketing. The present study aims to assess the quality, accuracy, and readability of online educational resources available to patients regarding biologic therapies for shoulder pathology. Methods: Eight search terms relevant to shoulder biologic therapies (shoulder + BMAC, Bone Marrow Aspirate Concentrate, PRP, Platelet Rich Plasma, Lipogems, Adipose Tissue, Biologic therapy, and Stem cell therapy) were searched across three separate search engines. The first 25 websites of each search were recorded. Duplicate websites and those not specific to shoulder pathology were excluded. Three evaluators independently assessed quality using an author-derived scoring rubric for a total of 25 possible points and accuracy for a total of 12 possible points. The Flesch-Kincaid readability test was used to quantify reading levels. Websites were further characterized by authorship and the presence of commercial bias. Results: Of the 600 results from the initial search, 59 met inclusion criteria. The mean quality of the websites was poor, with 7.97 ± 2.3 of 25 points (32%). The mean accuracy was low, with 8.47 ± 1.52 of 12 points (71%). The average reading level was 11.2 ± 1.93, with 32% of websites' reading at greater than 12th grade reading level. The search terms of "shoulder PRP" and "shoulder Platelet Rich Plasma" yielded the highest quality results (mean = 8.14 ± 2.63). "shoulder Lipogems" and "shoulder Adipose tissue" yielded the most accurate results (mean = 9.25 ± 0.96). "shoulder BMAC" and "shoulder bone marrow aspirate concentrate" were most difficult to read (mean = 12.54 ± 3.73). Sixty-four percent of websites were authored by physicians, hospitals, or medical groups. The accuracy of websites authored by health care professionals was significantly higher than the accuracy of those authored by other industry sources (P = .01). Fifteen percent of websites demonstrated commercial bias. Discussion: The online resources available to patients seeking information about biologic therapies for the treatment of shoulder pathologies are of very poor quality, moderately poor accuracy, and advanced readability. Providers should caution patients about the reliability of direct-to-consumer biologic marketing for shoulder pathology. Conclusion: The information available to patients online regarding the diagnosis, evaluation, and treatment of shoulder pathology with biologic therapies is of poor quality and accuracy and difficult readability.

Adipose-Derived Stem Cells, Obesity, and Inflammation: A Systematic Review and Implications for Osteoarthritis Treatment.

ABSTRACT: Adipose is a known source of mesenchymal stem cells that can be used to treat musculoskeletal disorders, such as osteoarthritis. Because obesity often coexists with osteoarthritis, excess adiposity may be a useful source of mesenchymal stem cells. However, obesity is associated with systemic inflammation, which may influence the quality of adipose-derived stem cells. We performed a systematic review of the literature examining adipose-derived stem cell behavior, cytokine, and growth factor profiles from obese and nonobese patients. Two independent reviewers applied the inclusion/exclusion criteria and independently extracted data including mesenchymal stem cell count/viability/behavior, growth factor, and/or cytokine expression. Twenty-two articles met criteria for inclusion. Samples from obese patients had increased mesenchymal stem cell content (n = 6), but decreased proliferative ability (n = 3), and increased expression of interleukin 1 (n = 3), interleukin 6 (n = 3), and tumor necrosis factor α (n = 6). There was also greater macrophage content (n = 4). Weight loss normalized cellular function. In vitro behavior and quality of adipose-derived stem cell are significantly different between obese and nonobese patients. Samples from obese patients had greater adipose-derived stem cell content, lower proliferative ability, increased senescence, and increased proinflammatory cytokine expression. Differences in cellular function should be considered when using adipose to treat musculoskeletal pathology in obese and nonobese patients.

Treating Knee Osteoarthritis With Platelet-Rich Plasma and Hyaluronic Acid Combination Therapy: A Systematic Review.

BACKGROUND: Platelet-rich plasma (PRP) and hyaluronic acid (HA) are injectable treatments for knee osteoarthritis. The focus of previous studies has compared their efficacy against each other as monotherapy. However, a new trend of combining these 2 injections has emerged in an attempt to have a synergistic effect. PURPOSE: To systematically review the clinical literature examining the combined use of PRP + HA. DESIGN: Systematic review. METHODS: A systematic review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using PubMed and Embase. The following search terms were used: knee osteoarthritis AND platelet rich plasma AND hyaluronic acid. The review was performed by 2 independent reviewers who applied the inclusion/exclusion criteria and independently extracted data, including methodologic scoring, PRP preparation technique, HA composition, and patient-reported outcomes (PROs). RESULTS: A total of 431 articles were screened, 12 reviewed in full, and 8 included in the final analysis: 2 case series, 3 comparative, and 3 randomized studies. Average follow-up was 9 months. The modified Coleman Methodology Score was 38.13 ± 13.1 (mean ± SD). Combination therapy resulted in improved PROs in all studies. Of the comparative and randomized studies, 2 demonstrated that combination therapy was superior to HA alone. However, when PRP alone was used as the control arm (4 studies), combination therapy was not superior to PRP alone. CONCLUSION: Combination therapy with PRP + HA improves PROs and is superior to HA alone but is not superior to PRP alone.

Utility of Percutaneous Ultrasonic Tenotomy for Tendinopathies: A Systematic Review.

CONTEXT: Chronic tendinopathy is a challenging problem that can lead to significant disability and limitation in not only athletics but also activities of daily living. While there are many treatment techniques described for this overuse injury, no single modality has been proven superior to all others. With recent advances in medical technology, percutaneous ultrasonic tenotomy (PUT) for tendinosis has gained traction with promising results. OBJECTIVE: To examine the data published on PUT for treatment of tendinopathy, analyze the outcomes of the procedure, including duration of pain relief and patient-reported outcomes, and assess the rate of complications associated with the procedure. DATA SOURCES: PubMed, MEDLINE, EMBASE, and Google Scholar. STUDY SELECTION: The following combination of keywords was entered into the electronic search engines: ultrasonic tenotomy, ultrasound tenotomy, Tenex, and ultrasonic percutaneous tenotomy. The search results were screened for studies relevant to the topic. Only English-language studies were considered for inclusion. Studies consisting of level 4 evidence or higher and those involving human participants were included for more detailed evaluation. LEVEL OF EVIDENCE: Level 4. DATA EXTRACTION: Articles meeting the inclusion criteria were sorted and reviewed. Type of tendinopathy studied, outcome measures, and complications were recorded. Both quantitative and qualitative analyses were performed on the data collected. RESULTS: There were a total of 7 studies that met the inclusion criteria and quality measures-5 studies involving the treatment of elbow tendinopathy and 1 study each involving the management of Achilles tendinopathy and plantar fasciitis. PUT resulted in decreased pain/disability scores and improved functional outcome scores for chronic elbow tendinopathy and plantar fasciitis. Results for Achilles tendinopathy showed modest improvement in the short term, but long-term data are lacking. CONCLUSION: PUT is a minimally invasive treatment technique that can be considered in patients with tendinopathy refractory to conservative treatment measures. Further higher quality studies are necessary to accurately assess the comparative effectiveness of this treatment modality.

Platelet-Rich Plasma Content of Active Spinal Cord Injured Patients: A Controlled Laboratory Study.

OBJECTIVE: Platelet-rich plasma has potential uses for patients with spinal cord injuries. However, no study has quantified the cellular and growth factor content of platelet-rich plasma in this population. This study aimed to analyze (1) platelet-rich plasma content of spinal cord injury subjects and (2) the effect of high-intensity interval exercise on their platelet-rich plasma. DESIGN: Ten spinal cord injury patients and 10 controls were enrolled. At rest, platelet-rich plasma was created from both groups. The spinal cord injury group then performed high-intensity interval exercise and underwent a second blood draw to create post-high-intensity interval exercise platelet-rich plasma. Complete blood counts and growth factor analysis (via enzyme-linked immunosorbent assay) was performed on all platelet-rich plasma. RESULTS: The spinal cord injury group had lower platelets (305,700 ± 85,697/µl vs 380,800 ± 57,301/µl, P = 0.015) and transforming growth factor ß (12.84 ± 1.58 vs 14.33 ± 0.63 ng/ml, P = 0.023). Four minutes of high-intensity interval exercise increased the platelets (305,700 ± 85,697/µl to 399,200 ± 96,251/µl, P = 0.004), leukocytes (906 ± 930 vs 2504 ± 3765/µl, P = 0.002) and transforming growth factor ß (12.84 ± 1.58 to 14.28 ± 1.21 ng/ml, P = 0.020). CONCLUSIONS: Spinal cord injury patients have fewer platelets and transforming growth factor ß in their platelet-rich plasma at baseline compared with controls. Exercise increased platelet, leukocyte, and transforming growth factor ß yield, compensating for the baseline deficits.

Induction of HLA-B27-Associated Reactive Arthritis After a Wharton's Jelly "Stem Cell" Injection.

Orthobiologic injections are an emerging treatment option for musculoskeletal conditions. Allogenic gestational tissue-derived products, including umbilical cord-derived Wharton's jelly, are among the available options. These tissues are currently being harvested and sold by companies as an off-the-shelf "stem cell" injection for conditions such as back pain and osteoarthritis. Despite documented infections from similar umbilical cord derivatives, "stem cell clinics" continue to use them. Here, we report the first documented case of HLA-B27-associated reactive arthritis induced by a Wharton's jelly stem cell injection. A 36-yr-old man was injected with Wharton's jelly for low back pain and within 24 hours developed fevers, chills, polyarthritis, and enthesitis. Infectious disease work-up was negative. Inflammatory markers were elevated and his HLA-B27 antigen was positive. Initial treatment included methylprednisolone and sulfasalazine. This case highlights the unknown dangers of these allogenic injections and physicians should remain cautious about their use until further study and regulation can ensure patient safety.

Percutaneous ultrasonic tenotomy effectively debrides tendons of the extensor mechanism of the knee: A technical note.

BACKGROUND: Percutaneous ultrasonic tenotomy (PUT) is a minimally-invasive method of treating patellar tendinosis, but its immediate effect on tendon structure has never been studied. Given the crucial nature of the extensor mechanism of the knee, it is important to understand the procedure's effect on tendon structure prior to clinical implementation. The aim of this study was to analyze the tendon structure of the extensor mechanism of the knee after PUT in a cadaveric model. METHODS: Four fresh-frozen cadaveric specimens (two patellar and two quadriceps tendons) underwent PUT. The tendons were then sectioned and stained with hematoxilin & eosin (H&E). The sections were analyzed for a clear area of debridement. The area of debridement was calculated as an average of three measurements. RESULTS: All four tendons demonstrated a clear area of debridement limited to the treatment area without damaging any surrounding tissue. The area of debridement for the patellar and quadriceps tendons treated was 2.89 mm2, 1.5 mm2, 2.98 mm2 and 7.29 mm2, respectively. CONCLUSIONS: Percutaneous ultrasonic tenotomy effectively debrided the treatment area in all tendons without damaging surrounding tissue. Further work is needed to report clinical outcomes, assess the risk of post-procedure tendon rupture and define return-to-sport progression.

High Intensity Interval Exercise Increases Platelet and Transforming Growth Factor-ß Yield in Platelet-Rich Plasma.

BACKGROUND: Platelet-rich plasma (PRP) is an emerging orthobiologic treatment for musculoskeletal conditions like osteoarthritis. Two studies have demonstrated the influence of longer duration exercise on PRP composition, but no study has ever explored the impact of high intensity interval exercise (HIIE) on PRP content. OBJECTIVE: To quantify cellular and growth factor content changes in PRP after 4 minutes of HIIE. DESIGN: Controlled laboratory pilot study. SETTING: Academic sports medicine center. PARTICIPANTS: Ten healthy volunteers (5 male, 5 female). INTERVENTION: Volunteers had PRP prepared from 15 mL of whole blood using a single spin, plasma-based system (autologous conditioned plasma [ACP]) immediately before and after 4 minutes of HIIE on a stationary exercise bike (Tabata protocol). MAIN OUTCOME MEASURE: The PRP was sent for complete blood counts and enzyme-linked immunosorbent assay (ELISA) to quantify transforming growth factor (TGF)-ß, platelet-derived growth factor (PDGF), insulin-like growth factor (IGF)-1, and vascular endothelial growth factor (VEGF). RESULTS: Mean platelet count in PRP increased from 367.4 ± 57.5 k/µL to 497.7 ± 93.3 k/µL after 4 minutes of HIIE (P < .001). TGF-ß also increased from 8237.2 ± 7676.5 pg/mL to 21 535.7 ± 4062.6 pg/mL postexercise (P = .004). The other cellular components (leukocytes, red blood cells, and mean platelet volume) and growth factors (PDGF, IGF-1, and VEGF) were not significantly changed. CONCLUSIONS: A short 4-minute bout of HIIE significantly increased the total platelet count and TGF-ß concentration in PRP.

Sonographically Guided Knee Meniscus Injections: Feasibility, Techniques, and Validation.

BACKGROUND: There is a growing interest in the use of biologic agents such as platelet-rich plasma and mesenchymal stem/stromal cells to treat musculoskeletal injuries, including meniscal tears. Although previous research has documented the role of diagnostic ultrasound to evaluate meniscal tears, sonographically guided (SG) techniques to specifically deliver therapeutic agents into the meniscus have not been described. OBJECTIVE: To describe and validate SG injection techniques for the body and posterior horn of the medial and lateral meniscus. DESIGN: Prospective, cadaveric laboratory investigation. SETTING: Academic institution procedural skills laboratory. SUBJECTS: Five unenbalmed cadaveric knee-ankle-foot specimens from 5 donors (3 female and 2 male) ages 33-92 years (mean age 74 years) with body mass indices of 21.1-32.4 kg/m2 (mean 24.1 kg/m2). METHODS: A single, experienced operator completed SG injections into the bodies and posterior horns of the medial and lateral menisci of 5 unenbalmed cadaveric knees using colored latex and a 22-gauge, 38-mm needle. After injection, coinvestigators dissected each specimen to assess latex distribution within the menisci and identify injury to intra-articular and periarticular structures. MAIN OUTCOME MEASURES: Latex location within the target region of meniscus (accurate/inaccurate), and iatrogenic injury to "at risk" intra- and periarticular structures (present/absent). RESULTS: Seventeen of 20 injections were accurate. Two of 3 inaccurate injections infiltrated the posterior horn of the medial meniscus instead of the targeted meniscal body. One inaccurate lateral meniscus injection did not contain latex despite sonographically accurate needle placement. No specimen exhibited injury to regional neurovascular structures or intra-articular hyaline cartilage. CONCLUSIONS: SG meniscus injections are feasible and can accurately and safely deliver injectates such as regenerative agents into bodies and posterior horns of the medial and lateral menisci. The role of SG intrameniscal injections in the treatment of patients with degenerative and traumatic meniscal disorders warrants further exploration. LEVEL OF EVIDENCE: Not applicable.