Increased extrusion and ICRS grades at 2-year follow-up following transtibial medial meniscal root repair evaluated by MRI.

PURPOSE: The purpose of the current study was to evaluate the short-term results of meniscal root repair surgery, assessing clinical and radiographic outcomes, utilizing MRI to assess root healing and extent of post-operative extrusion. METHODS: This was a single-center, retrospective study evaluating patients who had undergone a medial meniscus posterior root repair using a transtibial pullout technique with two locking cinch sutures. Demographic data were collected from patient charts. Clinical outcomes were assessed with pre- and post-operative IKDC and Lysholm scores. Pre-op scores were taken at the patients' initial clinical visit, mean 1.55 months prior to surgery (± 1.8 months, min 0.3, max 7.3). Radiographic outcomes were assessed with MRI evaluation of root healing, meniscal extrusion, and cartilage degeneration using ICRS criteria. Tunnel placement was evaluated and compared to the anatomic footprint. RESULTS: Eighteen patients (47.2 years ± 11.9) were evaluated at mean follow-up of 24.9 months (± 7.2, min 18.4, max 35.6). The IKDC score significantly increased from 45.9 (± 12.6) pre-operatively to 76.8 (± 14.7) post-operatively (p < 0.001). Lysholm scores also increased from 50.9 (± 7.11) to 87.1 (± 9.8) (p < 0.001). Mean tunnel placement was 5.3 mm (± 3.5, range 0-11.8) away from the anatomic footprint. Mean extrusion increased from 4.74 mm (± 1.7) pre-operatively to 5.98 (± 2.8) post-operatively (p < 0.02). No patients with > 3 mm of extrusion on pre-operative MRI had < 3 mm of extrusion on post-operative MRI. Both medial femoral condyle and medial tibial plateau ICRS grades worsened significantly (p < 0.02 and p < 0.01, respectively). On MRI, one root appeared completely healed, 16 partially healed, and one not healed. CONCLUSION: Patients treated with the transtibial suture pull-out technique with two locking cinch sutures had improved clinical outcomes, but only partial healing in the majority of cases, increased extrusion, and progression of medial compartment cartilage defect grade on follow-up MRI. Patients should be counseled that although clinical outcomes in the short term may be optimistic, long-term outcomes regarding progression to degenerative arthritis may not be as predictable. CLINICAL LEVEL OF EVIDENCE: III.

Maximum load to failure and tensile displacement of an all-suture glenoid anchor compared with a screw-in glenoid anchor.

PURPOSE: The purpose of this study was to evaluate the biomechanical behavior of an all-suture glenoid anchor in comparison with a more conventional screw-in glenoid anchor, with regard to maximum load to failure and tensile displacement. METHODS: All mechanical testing was performed using an Instron ElectroPuls E1000 mechanical machine, with a 10 N pre-load and displacement rate of 10 mm/min. Force-displacement curves were generated, with calculation of maximum load, maximum displacement, displacement at 50 N and stiffness. Pretesting of handset Y-Knots in bone analog models revealed low force displacement below 60 N of force. Subsequently, three groups of anchors were tested for pull out strength in bovine bone and cadaver glenoid bone: a bioabsorbable screw-in anchor (Bio Mini-Revo, ConMed Linvatec), a handset all-suture anchor (Y-Knot, ConMed Linvatec) and a 60 N pre-tensioned all-suture anchor (Y-Knot). A total of 8 anchors from each group was tested in proximal tibia of bovine bone and human glenoids (age range 50-90). RESULTS: In bovine bone, the Bio Mini-Revo displayed greater maximum load to failure (206 ± 77 N) than both the handset (140 ± 51 N; P = 0.01) and the pre-tensioned Y-Knot (135 ± 46 N; P = 0.001); no significant difference was seen between the three anchor groups in glenoid bone. Compared to the screw-in anchors, the handset all-suture anchor displayed inferior fixation, early displacement and greater laxity in the bovine bone and cadaveric bone (P < 0.05). Pre-tensioning the all-suture anchor to 60 N eliminated this behavior in all bone models. CONCLUSIONS: Handset Y-Knots display low force anchor displacement, which is likely due to slippage in the pilot hole. Pre-tensioning the Y-Knot to 60 N eliminates this behavior. LEVEL OF EVIDENCE: I.

The sizing of hamstring grafts for anterior cruciate reconstruction: intra- and inter-observer reliability.

PURPOSE: The objective of this study was to establish the intra- and inter-observer reliability of hamstring graft measurement using cylindrical sizing tubes. METHODS: Hamstring tendons (gracilis and semitendinosus) were harvested from ten cadavers by a single surgeon and whip stitched together to create ten 4-strand hamstring grafts. Ten sports medicine surgeons and fellows sized each graft independently using either hollow cylindrical sizers or block sizers in 0.5-mm increments­the sizing technique used was applied consistently to each graft. Surgeons moved sequentially from graft to graft and measured each hamstring graft twice. Surgeons were asked to state the measured proximal (femoral) and distal (tibial) diameter of each graft, as well as the diameter of the tibial and femoral tunnels that they would drill if performing an anterior cruciate ligament (ACL) reconstruction using that graft. Reliability was established using intra-class correlation coefficients. RESULTS: Overall, both the inter-observer and intra-observer agreement were >0.9, demonstrating excellent reliability. The inter-observer reliability for drill sizes was also excellent (>0.9). Excellent correlation was seen between cylindrical sizing, and drill sizes (>0.9). CONCLUSIONS: Sizing of hamstring grafts by multiple surgeons demonstrated excellent intra-observer and intra-observer reliability, potentially validating clinical studies exploring ACL reconstruction outcomes by hamstring graft diameter when standard techniques are used. LEVEL OF EVIDENCE: III.

Risk factors for the development of heterotopic ossification after knee dislocation.

BACKGROUND: Results of treatment for acute knee dislocations and multiligament knee injuries may be influenced by a multitude of patient- and injury-related factors, including neurologic function, vascular status, ipsilateral fractures, and joint stability. The development of heterotopic ossification (HO) may nullify any benefits of reconstruction, because it can cause stiffness and discomfort. Identifying factors associated with HO after knee dislocation may help identify patients who might benefit from prophylaxis. QUESTIONS/PURPOSES: The purposes of this study were (1) to identify specific risk factors for the development of HO in patients with knee dislocation; and (2) to elucidate the relationship between the presence of absence of HO and postoperative range of motion. METHODS: Between 2005 and 2010, we performed 101 multiligament reconstructions for patients with knee dislocations, of which 91 (90%) in 91 patients were available for followup at a minimum of 6 months (mean, 18 months; range, 6-44 months), and were reviewed here. AP and lateral radiographs were reviewed for all patients and HO was classified according to the Mills and Tejwani classification system. This knee dislocation cohort was separated into two groups based on the presence or absence of HO for comparison. Using a significance level of p < 0.05 for factors in the univariate analyses, we identified potential variables for a multivariate logistic regression model to identify risk factors predicting development of HO in patients with multiligament knee injuries; multivariate analysis then was performed to mitigate the influence of potentially confounding variables. Thirty patients (34%) developed HO after multiligament knee injury in our series. RESULTS: Posterior cruciate ligament reconstruction was the only independent predictor of HO that we identified (odds ratio, 6.3; 95% confidence interval, 1.2-34.6). Patients who developed HO were more likely to develop stiff knees and undergo surgery (50%; 15 of 30 patients) versus those without HO (12%; seven of 58 patients) to attempt to restore functional range of motion (p < 0.001). CONCLUSIONS: HO is a common complication after knee dislocation and can diminish range of motion and cause patients to undergo further surgery. Posterior cruciate ligament reconstruction is an independent risk factor for the development of HO. Strategies to identify risk factors for, and safe prevention of, HO after multiple ligament injury and surgery should be investigated going forward. LEVEL OF EVIDENCE: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Platelet-rich plasma in the management of articular cartilage pathology: a systematic review.

OBJECTIVE: Using systematic review methodology, we endeavored to answer the following questions concerning the treatment of osteochondral pathology: (1) what pathologies have been treated in vivo with the use of platelet-rich plasma (PRP); (2) what methods of PRP preparation and delivery have been reported; (3) what assessment tools and comparison group have been used to assess its effectiveness; and (4) what are the clinical outcomes of its use. DATA SOURCES: A systematic literature search was performed of the OVID, EMBASE, and Evidence Based Medicine Reviews databases to identify all studies published up to October 2012 that assessed clinical outcomes of the use of PRP for the treatment of chondral and osteochondral pathology, excluding those including concomitant management of acute fractures or ligament reconstruction. DATA EXTRACTION: The included studies were reviewed and the following data were extracted and tabulated: study authors' year and journal, study design and level of evidence, pathology treated, methods of PRP preparation and delivery, and clinical outcome scores. DATA SYNTHESIS: Ten studies were included in the final analysis. The majority of studies assessed the use of PRP in the treatment of degenerative osteoarthritis of the knee or hip (representing 570 of a total of 662 joints). The majority of patients were treated with intra-articular injections, whereas 2 studies used PRP as an adjunct to surgical treatment. Significant improvements in joint-specific clinical scores (7 of 8 studies), general health scores (4 of 4 studies), and pain scores (4 of 6 studies) compared with baseline were reported up to 6-month follow-up, but few studies provided longer-term data. No studies reported worse scores compared with baseline at final follow-up. Three of 4 comparative studies reported significantly better clinical and/or pain scores when compared with hyaluronic acid injections at similar follow-up times. CONCLUSIONS: Currently, there is a paucity of data supporting the use of PRP for the management of focal traumatic osteochondral defects. There is limited evidence suggesting short-term clinical benefits with the use of PRP for symptomatic osteoarthritis of the knee, but the studies published to date are of poor quality and at high risk for bias. Further high-quality comparative studies with longer follow-up are needed to ascertain whether PRP is beneficial, either alone or as an adjunct to surgical procedures, in the management of articular cartilage pathology.

Musculoskeletal Injuries in Yoga.

While yoga has been widely studied for its benefits to many health conditions, little research has been performed on the nature of musculoskeletal injuries occurring during yoga practice. Yoga is considered to be generally safe, however, injury can occur in nearly any part of the body-especially the neck, shoulders, lumbar spine, hamstrings, and knees. As broad interest in yoga grows, so will the number of patients presenting with yoga-related injuries. In this literature review, the prevalence, types of injuries, forms of yoga related with injury, specific poses (asanas) associated with injury, and preventive measures are discussed in order to familiarize practitioners with yoga-related injuries.

Osteomyelitis After Calcium Phosphate Subchondroplasty A Case Report.

Subchondroplasty is a relatively new procedure developed to treat bone marrow lesions by injecting a calcium phosphate bone substitute into the pathologic, subchondral area of bone under fluoroscopic guidance. The procedure is described as a minimally invasive strategy that provides reliable relief of pain while preserving the native joint with minimal risk of significant complications. No prospective, randomized clinical trials have reported the efficacy of the procedure. Here, we present the case of a 64-year-old healthy male who developed Staphylococcus aureus osteomyelitis following subchondroplasty requiring further surgical intervention and intravenous antibiotic therapy.

The Posteromedial Corner of the Knee: Anatomy, Pathology, and Management Strategies.

The posteromedial corner of the knee encompasses five medial structures posterior to the medial collateral ligament. With modern MRI systems, these structures are readily identified and can be appreciated in the context of multiligamentous knee injuries. It is recognized that anteromedial rotatory instability results from an injury that involves both the medial collateral ligament and the posterior oblique ligament. Like posterolateral corner injuries, untreated or concurrent posteromedial corner injuries resulting in rotatory instability place additional strain on anterior and posterior cruciate ligament reconstructions, which can ultimately contribute to graft failure and poor clinical outcomes. Various options exist for posteromedial corner reconstruction, with early results indicating that anatomic reconstruction can restore valgus stability and improve patient function. A thorough understanding of the anatomy, physical examination findings, and imaging characteristics will aid the physician in the management of these injuries.

Endoscopic Gluteus Medius Repair Augmented With Bioinductive Implant.

Patients with gluteus minimus and medius tears that fail nonoperative management may be indicated for surgical repair; however, structural failure after gluteal tendon repair remains unacceptably high. This is likely related to the limited healing potential of tendinous tissue, which is poorly vascular and heals by formation of fibrocartilaginous scar tissue rather than histologically normal tendon. An emerging option to augment tendon healing is the use of a bioinductive implant that is designed to amplify the host healing response and induce the formation of healthy tendon tissue. Though it is rapidly being adopted for partial- and full-thickness rotator cuff tears, this implant has not yet been used in the hip. A detailed technical description and a discussion of the advantages and disadvantages of the technique are provided.

Osteochondral Proximal Tibial and Lateral Meniscal Allograft Transplant.

Knee pain in young, active patients with meniscus-deficient knees and articular cartilage damage can present a challenge to treatment. Meniscal allograft transplantation (MAT) has shown good clinical results as treatment for meniscus deficiency; however, worse outcomes have been observed in patients with significant chondral damage. The development of chondral restorative techniques such as osteochondral allograft transplantation (OCA) has expanded the population of patients who may benefit from MAT. We present a case of proximal tibial osteochondral and lateral meniscal allograft transplant. This review includes a sample of patient examinations and imaging, followed by a detailed technical description of the case. The technique article concludes with a discussion on the niche combined MAT-OCA procedures occupy in the patient treatment realm.

Preoperative Femoral Nerve Block for Hip Arthroscopy: A Randomized, Triple-Masked Controlled Trial.

BACKGROUND: Arthroscopy has become a standard method of treatment for a variety of intra-articular hip disorders. While most arthroscopic hip procedures are performed as outpatient surgeries, patients can still experience significant postoperative pain and opioid-associated side effects. PURPOSE: The potential benefits of a preoperative femoral nerve block (FNB) in hip arthroscopy were explored in a previous retrospective review. The study objective was to confirm these findings in a prospective randomized study. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: Fifty patients undergoing hip arthroscopy were included in this prospective, single-center, randomized controlled trial that was patient-, operator-, and assessor-blinded. Patients received either a preoperative ultrasound-guided FNB with 20 mL of 0.5% bupivacaine (FNB group) or normal saline (control group). Nerve blockade was confirmed via standardized sensory testing before the induction of general anesthesia. The primary endpoint was cumulative consumption of oral morphine equivalent at 24 hours after discharge. Secondary endpoints included opioid use at various time points, pain scores, Quality of Recovery (QoR-27) score, incidence of nausea and vomiting, time to discharge, block-related complications, falls at 24 hours, and patient satisfaction. RESULTS: Fifty patients completed the study, including 27 in the FNB group and 23 in the control group. Most patient characteristics were statistically similar between groups except for operative time, which was longer in the control group. Cumulative oral morphine consumption was lower in the FNB group at 48 hours; there was no difference at 24 hours or 7 days postoperatively. Pain scores were significantly lower up to 6 hours postoperatively in the FNB group compared with control; however, rebound pain was observed at 24 hours after discharge in patients who received FNB. There was no difference in most secondary outcomes. Importantly, a total of 6 patients in the FNB group reported falls (without injury) within the first 24 hours postoperatively compared with none in the control group. Patient satisfaction with pain control was high in both groups at all time points. CONCLUSION: Preoperative FNB may improve early pain control after hip arthroscopy. However, given the observed risk of falls, the routine use of FNB for outpatient hip arthroscopy cannot be recommended.

Preoperative femoral nerve block in hip arthroscopic surgery: a retrospective review of 108 consecutive cases.

BACKGROUND: The utility of a femoral nerve block as an adjunct for pain management has been recognized for various surgical techniques but has yet to be examined in the preoperative setting as an adjunct to general anesthesia for improved postoperative pain control in hip arthroscopic surgery. PURPOSE: To evaluate the safety and efficacy of a preoperative femoral nerve block for postoperative pain control in patients undergoing hip arthroscopic surgery. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A retrospective chart review of 108 consecutive hip arthroscopic surgery cases (in 103 patients) was carried out. All patients underwent arthroscopic surgery under a general anesthetic with or without a preoperative femoral nerve block. Groups were compared with respect to patient sex, age, and body mass index (BMI); physical status classification according to the American Society of Anesthesiologists (ASA); procedure performed; operative time; total intraoperative morphine-equivalent dose; pain scores (0-10 scale) recorded at 0, 15, 30, 45, and 60 minutes postoperatively in the post-anesthesia care unit (PACU); total morphine-equivalent dose in the PACU; presence of nausea or vomiting in the PACU; time to discharge from the PACU; oxycodone consumption in the surgical day care unit (SDCU); and maximal patient-reported pain score in the SDCU. RESULTS: Twelve cases were excluded from the analysis for a total of 96 cases (in 92 patients). Forty patients had general anesthesia alone (group A), and 56 patients had a preoperative femoral nerve block before the induction of general anesthesia (group B). There was no significant difference between the groups with regard to sex, age, weight, height, BMI, ASA classification, or type of procedure performed. Patients who received a femoral nerve block also received a significantly lower total intraoperative morphine-equivalent dose than did those patients who did not receive a block. Postoperative patient-reported pain scores were lower at all time points for the femoral nerve block group; however, a statistical significance was seen only at the 60-minute postoperative time point. Patients who did not receive a block had significantly higher morphine-equivalent doses in the PACU. There was no difference in the rates of nausea and vomiting and time to discharge from the PACU between the 2 groups. Oxycodone consumption in the SDCU was similar between the groups, but the femoral nerve block group had significantly lower maximal patient-reported pain scores in the SDCU. Two patients in the general anesthesia group were admitted to the hospital postoperatively because of inadequate postoperative pain control. No complications were noted in any patient with regard to the femoral nerve block. CONCLUSION: A preoperative femoral nerve block is a relatively safe procedure that may decrease the requirement for intraoperative morphine while providing effective postoperative pain control in patients undergoing hip arthroscopic surgery.

Upper instrumented vertebral fractures in long lumbar fusions: what are the associated risk factors?

STUDY DESIGN: A retrospective comparative study. OBJECTIVE: To investigate the risk factors associated with upper instrumented vertebral (UIV) fractures in adult lumbar deformity. SUMMARY OF BACKGROUND DATA: Long segment lumbar fusions may lead to junctional failures. The purpose of this study was to determine factors associated with junctional failures. METHODS: Twenty-seven consecutive patients from 2001 to 2008 with minimum 4 levels fused, lower instrumented vertebra (LIV) of L5 or S1, upper instrumented vertebra of T10 or distal, and no previous surgery proximal to the instrumentation were retrospectively reviewed. We describe the UIV angle, the sagittal angle of the upper instrumented vertebra with the horizontal. Patients were divided into 3 groups: group 1, 7 patients with UIV fractures; group 2, 6 patients with other proximal failures; and group 3, 14 patients with no proximal complications. RESULTS: The mean number of levels fused was 5.7 (4-7), 5.2 (4-8), and 6.2 (4-8); mean age was 64.1, 61.8, and 64.1, and mean body mass index was 33.5, 30.0, and 31.6 for groups 1, 2, and 3, respectively (P > 0.05). Osteotomies were performed in 5 of 7 in group 1, 1 of 6 in group 2, and 5 of 14 in group 3. Mean follow-up was 26.3 months. The average intraoperative UIV angle (UIV0) and immediate postoperative UIV angle (UIV1) were 18.6°/15.4° for group 1, 5.7°/5.3° for group 2, and 10.3°/7.1° for group 3 (P < 0.05). Surgical revision rates were higher in group 1 (71%) compared with groups 2 (50%) and 3 (43%). Eight of 11 (73%) patients with upper instrumented vertebra of L1 or L2 had either UIV fracture or other proximal failure compared with 5 of 16 (31%) in patients with upper instrumented vertebra of T10, T11, or T12. CONCLUSION: Our series of long lumbar fusions had a high long-term complication and revision rate. A high UIV angle on intraoperative lateral radiograph was strongly associated with UIV fractures. UIVs of L1 or L2 had a higher rate of adjacent segment or UIV failure.