Therapeutic ultrasound related pain threshold in elite track & field athletes with tibial bone stress injuries.

OBJECTIVE: Tibial stress injuries are challenging in terms of early diagnosis, management strategy, and safe return-to-play. In the present study, pain production associated with the application of therapeutic ultrasound (TUS) was used as a primary diagnostic tool to assess tibial bone stress injuries, and the sensitivity of this procedure was compared with Magnetic Resonance Imaging (MRI). SUBJECT AND METHODS: The study was designed as a retrospective analysis of prospectively collected data on tibial bone stress injuries in elite Track and field athletes attending the National Track and Field Athletics Centre in Thessaloniki, Greece, in the period 1995-2007. All patients underwent evaluation by TUS, and the sensitivity of the procedure was compared with MRI. RESULTS: Four of 29 athletes showed a positive TUS examination for stress injury while MRI showed normal findings. Additionally, 5 athletes evidenced MRI findings typical of a tibial bone stress injury, while TUS evaluation was negative. Using MRI as the standard, TUS displayed a sensitivity of 79.2%. CONCLUSION: Therapeutic ultrasound is a reproducible modality with satisfactory reliability and sensitivity related to MRI, and could represent a useful tool for clinicians to primarily assess suspected tibial bone stress injuries in high qualification Track and Field athletes.

Assessing the accuracy of arthroscopic and open measurements of the size of rotator cuff tears: A simulation-based study.

BACKGROUND: Arthroscopic procedures are commonly performed for rotator cuff pathology. Repair of rotator cuff tears is a commonly performed procedure. The intraoperative evaluation of the tear size and pattern contributes to the choice and completion of the technique and the prognosis of the repair. AIM: To compare the arthroscopic and open measurements with the real dimensions of three different patterns of simulated rotator cuff tears of known size using a plastic shoulder model. METHODS: We created three sizes and patterns of simulated supraspinatus tears on a plastic shoulder model (small and large U-shaped, oval-shaped). Six orthopaedic surgeons with three levels of experience measured the dimensions of the tears arthroscopically, using a 5 mm probe, repeating the procedure three times, and then using a ruler (open technique). Arthroscopic, open and computerized measurements were compared. RESULTS: A constant underestimation of specific dimensions of the tears was found when measured with an arthroscope, compared to both the open and computerized measurements (mean differences up to -7.5 ± 5.8 mm, P < 0.001). No differences were observed between the open and computerized measurements (mean difference -0.4 ± 1.6 mm). The accuracy of arthroscopic and open measurements was 90.5% and 98.5%, respectively. When comparing between levels of experience, senior residents reported smaller tear dimensions when compared both to staff surgeons and fellows. CONCLUSION: This study suggests that arthroscopic measurements of full-thickness rotator cuff tears constantly underestimate the dimensions of the tears. Development of more precise arthroscopic techniques or tools for the evaluation of the size and type of rotator cuff tears are necessary.

Individualised radial extracorporeal shock wave therapy (rESWT) for symptomatic calcific shoulder tendinopathy: a retrospective clinical study.

BACKGROUND: A retrospective single centre cohort analysis was performed to evaluate an individualised radial extracorporeal shock wave therapy (rESWT) protocol for treatment of symptomatic calcific shoulder tendinopathy. METHODS: 67 patients (79 Shoulders) were identified with 76 shoulders included for analysis. rESWT treatment protocol was adapted according to individual response to treatment. Variables included number of sessions, shockwave impulses, pressure and frequency. Success rate was estimated as the percentage of patients having ≥60% visual analogue score (VAS) pain decrease at follow-up. Recurrence at 1 year was recorded. RESULTS: Using this individualised symptom guided protocol, patients underwent a mean of 7 ± 1.5 rESWT sessions, with mean pressure of 1.7 ± 0.2 bar, mean frequency of 5 ± 0.3 Hz and 2175 ± 266 impulses. The mean pre-treatment VAS score of 6.7 ± 1.1 was significantly decreased to 3.2 ± 0.8 immediately post-treatment, 2.6 ± 0.9 at 1 month, 1.7 ± 1.0 at 3 months and 0.8 ± 1.0 at 1 year follow up (α = 0.05). One-year success rate was estimated at 92% and 1-year recurrence rate was 7%. CONCLUSIONS: We conclude that in this retrospective study an individualised rESWT protocol resulted in a high success rate with low number of recurrences. Randomised controlled trials to support these findings are recommended.

Para-articular extraskeletal chondroma mimicking first metatarsophalangeal synovitis.

Extraskeletal chondroma is a rare benign tumor with symptoms that could mimic other common musculoskeletal pathological entities. We present a rare case of an extraskeletal para-articular chondroma of the first metatarsophalangeal joint which was initially misinterpreted as joint synovitis, based on magnetic resonance imaging findings. Histology revealed benign chondroma of the foot, which was finally treated with radical surgical excision. More than 2 years postoperatively, no recurrence of the tumor has been encountered.

Therapeutic Ultrasound in Navicular Stress Injuries in Elite Track and Field Athletes.

OBJECTIVE: To ascertain whether therapeutic ultrasound (TUS) can be used to assess the progression of conservative management in navicular stress injuries. DESIGN: This is a prospective, clinical case series. Level of evidence IV. SETTING: All participants were examined and followed up in a private Sports Injury Clinic. PARTICIPANTS: Ten elite track and field athletes with severe dorsal midfoot pain over the navicular bone participated in this study. INTERVENTIONS: All patients underwent both TUS and magnetic resonance imaging (MRI) evaluation. The painful threshold of TUS on initial evaluation was a mean of 0.707 ± 149 W/cm, and MRI detected a navicular stress injury in all patients. The athletes received conservative treatment and underwent sequential TUS evaluations at 4, 8, 12 and 16 weeks. MAIN OUTCOME MEASURES: Therapeutic ultrasound pain threshold values were recorded, and the patients were additionally asked to grade local tenderness on a Visual Analogue Scale. Time to return to play was also recorded. RESULTS: The level of pain produced by the application of TUS on a navicular stress fracture seemed to correlate well with Visual Analogue Scale scores and the grade of fracture demonstrated on MRI. The initial low TUS painful mean value increased to a normal mean value of 1.97 ± 0.067 W/cm by 16 weeks. When clinical and TUS findings had returned to normal, the patients were allowed to return to sports activities, with no recurrences experienced during the study period. CONCLUSIONS: The production of pain associated with the application of TUS on a navicular stress fracture is a safe and reproducible method of monitoring the resolution of these fractures. We have used it successfully in making return-to-play decisions for elite level track and field athletes.

Arthroscopic treatment of chronic patellar tendinopathy in high-level athletes.

To present the results of arthroscopic treatment of patellar tendinopathy in high-level competition athletes. Eleven high-level athletes presented chronic patellar tendinopathy which did not respond to long term conservative treatment. Average age of the patients was 24.8 ±3.4 years old. All patients received an arthroscopic procedure with osteoplasty of the distal patellar pole, debridement of the underlying Hoffa fat pad and of the degenerated areas of the proximal posterior patella tendon and cauterization of the visible neo-vessels. Mean duration of follow-up was 17.4±4 months. Patients showed a major improvement in the Lysholm score from 49.9±5.2 to 92.5±7 and in the VISA P score from 41.2±5.2 to 86.8±14.9 on tenth post-operative week. All patients had returned to sports activities by the twelfth postoperative week. Arthroscopic treatment of chronic patellar tendinopathy found to be a minimal invasive and safe technique which produced satisfactory results.

Residual malformations and leg length discrepancy after treatment of fibular hemimelia.

BACKGROUND: Fibular hemimelia has been reported as the most common congenital longitudinal deficiency of the long bones. Previous studies have focused on the best treatment options for this congenital condition. There is very little to our knowledge in the literature focused on residual persisting malformations and leg length discrepancy after treatment. METHODS: Seven patients presenting fibular hemimelia in eight fibulae received treatment between years 1988 and 2001. Pre-treatment average leg length discrepancy was 5.3 cm. All patients presented associated congenital deformities of the ipsilateral leg. Six patients received surgical treatment. Average post-treatment follow up was 9.7 years. Residual malformations and leg length discrepancy were recorded for all patients. It is a retrospective case series study at one institution by two of the presenting authors as senior surgeons. RESULTS: Average leg length gained after successful bone lengthening in six patients was 5.06 cm. Although there was a significant functional improvement, a number of residual malformations and leg length inequality was recorded. Residual average leg length discrepancy of 3.1 cm was observed in five patients who completed surgical treatment. Five patients presented a limp. Residual anterior-medial bowing of the tibia was observed in four patients. Calf atrophy was present in all seven patients. Valgus deformity of the ankle was remained in two patients. CONCLUSIONS: Treatment of fibular hemimelia, even in cases graded as successful, showed to be accompanied by a number of persisting residual deformities and recurrent leg length inequality. Although the number of patients is limited, the high rate of this phenomenon is indicative of the significance of the report. The family and the patients themselves should have the right expectations and will be more co-operative when well informed about this instance. A report of common post-treatment residual deformities should be valuable in best possible treatment planning of fibular hemimelia.

Acromial morphology: effects of suboptimal radiographs.

Acromial morphology is one of the important factors related to rotator cuff pathology, especially if there is acromial encroachment onto the supraspinatus tendon. This is the rationale for many surgeons performing an acromioplasty, based on preoperative radiographs, in their treatment of rotator cuff disease. However, geometric measurements of the acromion are dependent on the radiographic view, and suboptimal radiographs of the scapula might bias the acromial morphology on the radiographs. Our objective was to study the effect of suboptimal lateral-view radiographs of the scapula on 6 acromial angles, which have been correlated with rotator cuff pathology, by use of a computational method. Anatomic landmarks were digitized on 12 cadaveric scapulae via a spatial linkage system. A coordinate system based on the scapula was then created that allowed projection of the anatomic landmarks on the sagittal plane and simulated the optimal lateral-view radiograph of the scapula. By rotating the coordinate system in the coronal plane (cranial and caudal projections) and axial plane (anterior and posterior projections) with 5 degrees, 10 degrees, 15 degrees, and 20 degrees increments, 16 suboptimal lateral-view radiographs of the scapula were simulated. Significant differences in the 6 acromial angles (P < .01) between the optimal and suboptimal lateral-view radiographs of the scapula were found in almost every cranial and caudal projection. Rotating the projection in the axial plane did not significantly affect the acromial angles (P > .05) up to 20 degrees of rotation in the anterior and posterior direction. Of the 6 different acromial angles, the acromial slope was least affected when the projection was varied. In contrast, the anterior slope of the acromion was highly affected by errors in the projection.

Healing and normal fibroblasts exhibit differential proliferation, collagen production, alpha-SMA expression, and contraction.

This study determines the differences in proliferation, collagen production, alpha-smooth muscle actin (alpha-SMA) expression, and contraction between healing and normal fibroblasts. Transected and sham-operated rat medial collateral ligaments (MCL) were used to obtain healing and normal fibroblasts, respectively. It was found that healing fibroblasts in monolayer culture proliferated 1.4-fold faster at 48 h and had 1.7-fold greater protein expression of alpha-SMA than normal fibroblasts. In addition, it was noted that the proliferation of healing fibroblasts in collagen gels was not significantly different from that of normal fibroblasts at 24 h, but it was at 48 h. Furthermore, in collagen gels, healing fibroblasts produced more type I collagen than normal fibroblasts and generated 1.6- and 1.7-fold larger contractile forces at 15 and 20 h, respectively, than their normal counterparts. Taken together, the results of this study show that healing fibroblasts possess a differential proliferation, alpha-SMA protein expression, and contraction than normal fibroblasts.

Decreasing inflammatory response of injured patellar tendons results in increased collagen fibril diameters.

Tissue inflammation is essential in the healing process, but its effect on the quality of the healing tissue is not clear. This study determines the effect of decreasing early inflammation during wound healing in genetic deficient mice on collagen fibril diameter. Two strains of mice were used: three C3H/HeJ mice and three C3H/HeN mice for each of two time points (7 and 14 days postinjury). C3H/HeJ mice have a genetic deficiency in the production of tumor necrosis factor by macrophages and other cytokines in response to endotoxin, and C3H/HeN mice have no genetic deficiency. The right patellar tendon of both mouse strains was transversely transected, whereas the left patellar tendon was left intact for control. After 7 and 14 days, both right and left patellar tendons were harvested, and tendon samples were examined with transmission electron microscopy. We found that at 7 days, transected tendons of C3H/HeJ mice exhibited on average 1.6 times larger collagen fibril diameters than transected C3H/HeN tendons, whereas at 14 days, collagen fibril diameters of the C3H/HeJ mice were 1.3 times that of C3H/HeN mice. Also, at both 7 days and 14 days, collagen fibrils in C3H/HeJ mice appeared more organized than C3H/HeN mice. In addition, control tendons in both mouse strains showed no significant differences in collagen fibril diameter and organization. Therefore, these results suggest that decreasing the inflammatory response in the early stages of tendon wound healing enhances the quality of the healing tendon through increased collagen fiber diameter and better organization.

The effectiveness of reconstruction of the anterior cruciate ligament using the novel knot/press-fit technique: a cadaveric study.

BACKGROUND: A variety of fixation devices are used for anterior cruciate ligament reconstruction with hamstring tendon grafts. These devices increase costs and can present artifacts in magnetic resonance imaging as well as complications in revision surgery. Therefore, a novel knot/press-fit technique that requires no implantable devices has been introduced. NULL HYPOTHESIS: The knot/press-fit technique restores knee kinematics as well as the more commonly used EndoButton CL fixation and has similar biomechanical properties as other devices published in the literature. STUDY DESIGN: Controlled laboratory study. METHODS: Eight fresh-frozen cadaveric knees (52 +/- 7 years) were tested using a robotic/universal force-moment sensor testing system. The knee kinematics of the intact, anterior cruciate ligament-deficient, EndoButton-reconstructed, and knot/press-fit-reconstructed knee in response to both a 134-N anterior tibial load and a combined rotatory load at multiple knee flexion angles was determined. Differences between the 4 knee states were evaluated with a 2-factor repeated-measures analysis of variance (P < .05). To determine the stiffness and strength of the knot/press-fit fixation, the femur-graft-tibia complex was tested in uniaxial tension. RESULTS: In response to an anterior tibial load, the anterior tibial translation for the knot/press-fit reconstruction was found to be not significantly different from that of the intact anterior cruciate ligament as well as that of the EndoButton reconstruction (P > .05). In response to a combined rotatory load, neither reconstruction procedure could effectively reduce the coupled anterior tibial translation to that of the intact knee, and no significant difference between the 2 reconstructions could be detected (P > .05). The stiffness of the knot/press-fit complex was found to be 37.8 +/- 9.6 N/mm, and the load at failure was 540 +/- 97.7 N, which is equal to other devices published in the literature. CLINICAL RELEVANCE: The experiment suggests that the knot/press-fit technique may be a reliable alternative for the femoral fixation of hamstring tendon grafts.