Simultaneous Ipsilateral Anterior Cruciate Ligament and Proximal Hamstring Tendon Ruptures: A Case Report.

Introduction: Simultaneous anterior cruciate ligament (ACL) and ipsilateral hamstring ruptures have never been reported in the literature. The purpose of this article is to describe a treatment approach for such a case. The principles in this case can help guide treatment for any patient with concomitant ACL and hamstring pathology. Case Report: We describe the case of a 53-year-old male who presented with left ipsilateral simultaneous complete proximal hamstring tendon (HT) and ACL tears after an acute tennis injury. He was successfully treated with a staged procedure, first with a proximal HT repair and later with a delayed ACL reconstruction using a bone-patellar tendon-bone autograft. Conclusion: Ipsilateral simultaneous complete proximal HT and ACL tears can be successfully treated with acute proximal HT repair and delayed ACL reconstruction after rehabilitation from the HT repair. The synergistic relationship between the ACL and hamstring muscles in preventing anterior translation of the tibia necessitates staged reconstruction in the setting of a simultaneous injury.

The Effect of Intra-articular Corticosteroid Injections on Vaccine Efficacy: A Current Concepts Review.

Orthopedic surgeons commonly perform corticosteroid injections. These injections have systemic side effects, including suppression of the hypothalamic-pituitary adrenal axis. Due to this suppression, there is a theoretical risk of corticosteroid injections affecting the efficacy of the novel COVID-19 vaccines. This potential interaction led the American Academy of Orthopedic Surgeons to recommend, "avoiding musculoskeletal corticosteroid injections for two weeks before and one week after COVID vaccine administration." This review examines the literature underlying this recommendation. An extensive literature review was performed through PubMed, MEDLINE, and Google Scholar from database inception to May 2022. Keywords searched were COVID, coronavirus, vaccine, vaccination, steroids, and corticosteroids. Search results included articles written in the English language and encompassed reviews, case series, empirical studies, and basic science articles. There is no definitive evidence that corticosteroid injections affect COVID-19 vaccine efficacy or increase the risk of contracting COVID. The authors recommend orthopedic surgeons follow the AAOS guidelines, which recommend avoiding injections two weeks before and one week following COVID vaccine administration. Additional research is needed to better define this theoretical risk, especially since there is good evidence that injections suppress the hypothalamic-pituitary-adrenal-axis.

A rare case report of tenosynovial chondromatosis of the semimembranosus-medial collateral ligament bursa.

BACKGROUND: Synovial chondromatosis is an uncommon metaplastic process of the synovial lining that results in the formation of cartilaginous nodules within joints or their associated bursae or tendon sheaths. Radiologic evidence of mineralized bodies within these structures is typically pathognomonic for this condition. Extraarticular chondromatosis is rarer than intraarticular chondromatosis, and the knee is affected less frequently than the smaller joints of the hands and feet. To our knowledge, no reports describing this condition in the semimembranosus-medial collateral ligament (SM-MCL) bursa have been published. CASE PRESENTATION: We describe a case of tenosynovial chondromatosis in a 37-year-old woman. The case was atypical for both the location within the SM-MCL bursa and the paucity of radiodense or hypointense changes to support a clinical suspicion of chondroid metaplasia on radiographs and T2-weighted MRI, respectively. Recreational weightlifting and swimming by the patient were impaired by chronic pain, and restricted range of motion of the ipsilateral knee persisted despite extensive skilled physical therapy and injections of both corticosteroids and platelet-rich plasma. Thirteen months after a diagnostic and therapeutic knee arthroscopy, open surgical excision of the SM-MCL bursal body was performed, and knee pain and range of motion improved by the 6-week postoperative reevaluation. Pathologic evaluation of the excised tissue was consistent with tenosynovial chondromatosis. CONCLUSIONS: Synovial chondromatosis should be considered in the differential diagnosis for recalcitrant bursitis, even in the absence of classic imaging findings.

Risk Factors for Readmission following Anterior Cruciate Ligament Reconstruction.

The purpose of this study is to identify risk factors for readmission after anterior cruciate ligament (ACL) reconstruction and to determine costs associated with readmission. Using a private insurance claims' database, we identified patients who underwent ACL reconstruction from 2010 to 2015 using the International Classification of Diseases, Version 9 (ICD-9) and Current Procedural Terminology (CPT) codes. Univariate analysis was performed on demographic data, surgical characteristics, and comorbidities. Variables with p < 0.10 were added to a multivariate logistic regression model which was created to identify independent risk factors for all-cause readmission within 90 days postoperatively. Significance was considered at p < 0.05. Overall, 90,263 patients were included (average age: 29 ± 13 years, 44% female), and 1,066 (1.2%) of patients had a hospital readmission within 90 days following surgery. Risk factors for hospital readmission included cerebrovascular disease (odds ratio [OR] = 3.4, 95% confidence interval [CI]: 1.9, 6.2), diabetes mellitus (OR = 2.6, 95% CI: 1.9, 3.5), concomitant medial collateral ligament (MCL) or lateral collateral ligament (LCL) reconstruction (OR = 2.5, 95% CI: 1.9, 3.3), concomitant posterior cruciate ligament (PCL) reconstruction (OR = 2.2, 95% CI: 1.4, 3.3), age between 44 and 65 years (OR = 2.1, 95% CI: 1.6, 2.9), and depression (OR = 1.88, 95% CI: 1.49, 2.38, p < 0.001). Female sex was associated with decreased odds of 90-day hospital readmission (OR = 0.8, 95% CI: 0.7, 0.9). Each hospital readmission accounted for an estimated $17,841 (95% CI: $17,173, 18,509) in gross health care payments, and patients with readmissions had substantially higher 1-year cumulative health care costs. Readmission after ACL reconstruction was 1.2%. The strongest risk factors for 90-day readmission include cerebrovascular disease, diabetes mellitus, concomitant MCL/LCL reconstruction, concomitant PCL reconstruction, and age between 44 and 65 years. Readmission was associated with substantial health care costs.

Total Knee Arthroplasty after Anterior Cruciate Ligament Reconstruction.

The incidence of anterior cruciate ligament (ACL) reconstruction is increasing in the United States, particularly in the older athlete. Patients who undergo ACL reconstruction are at higher risk for undergoing total knee arthroplasty (TKA) later in life. TKA in patients with prior ACL reconstruction has been associated with longer operative time due in-part to difficulty with exposure and retained hardware. Outcomes after TKA in patients with prior ACL reconstruction are not well defined, with some reports showing increased rate of complications and higher risk of reoperation compared with routine primary TKA, but these results are based on small and nonrandomized cohorts. Future research is needed to determine whether graft choice or fixation technique for ACL reconstruction influences outcomes after subsequent TKA. Furthermore, whether outcomes are affected by choice of TKA implant design for patients with prior ACL reconstruction warrants further study. This review analyzes the epidemiology, operative considerations, and outcomes of TKA following ACL reconstruction.

Factors associated with RVU generation in common sports medicine procedures.

INTRODUCTION: Relative value units (RVUs) are integral to the U.S. physician compensation system used by the Centers for Medicare & Medicaid Services. The use of 'work RVUs' (herein, wRVUs) is intended to reimburse physicians according to the amount of expertise and effort needed to safely and effectively perform a procedure. Our purpose was to determine: 1) the number of wRVUs/hour generated by common sports medicine surgical procedures; and 2) how patient characteristics, surgical approach, and practice setting are associated with the number of wRVUs/hour. This analysis was performed to infer whether wRVUs are assigned appropriately according to the factors on which they are purported to be based. METHODS: We queried the American College of Surgeons' National Surgical Quality Improvement Program (NSQIP) database for common sports medicine surgical procedures performed in 2018. Data from 19,877 patients (8,258 women) with a mean age of 48 years (range, 18-90) who underwent a surgical sports medicine procedure were analyzed. Work RVUs and operative time were used to calculate work RVUs/hour for each surgical procedure. Univariate and multivariate analyses were used to assess correlations between patient characteristics and wRVUs/hour. RESULTS: Knee chondroplasty generated the most mean (± standard deviation) wRVUs/hour at 22 ± 0.5, whereas 'open tenodesis of biceps tendon, long head' generated the least at 9.6 ± 0.25 wRVUs/hour. Factors associated with a greater mean number of wRVUs/hour were younger patient age, female sex, arthroscopic approach, and outpatient setting. Arthroscopic procedures also generated more wRVUs/hour than the same procedures performed through an open approach. wRVUs were not correlated with case complexity or surgical time. CONCLUSION: wRVUs/hour in surgical sports medicine procedures vary widely depending on the procedure type, patient characteristics, surgical approach, and practice setting.

Increasing incidence of primary reverse and anatomic total shoulder arthroplasty in the United States.

BACKGROUND: The purpose of this study was to determine the incidence of primary reverse total shoulder arthroplasty (RTSA) and anatomic total shoulder arthroplasty (TSA) in the United States and examine changes in age- and sex-based procedure rates. A secondary goal was to determine the incidence of hemiarthroplasty. METHODS: Using nationally representative data along with US Census data, we identified >508,000 cases of primary RTSA, anatomic TSA, and shoulder hemiarthroplasty from 2012 to 2017. Trends in the incidence of each procedure were analyzed, and sex- and age-adjusted procedure rates were calculated. RESULTS: From 2012 to 2017, the population-adjusted incidence of primary RTSA increased from 7.3 cases per 100,000 persons (22,835 procedures) to 19.3 cases per 100,000 (62,705 procedures); anatomic TSA increased from 9.5 cases per 100,000 (29,685 procedures) to 12.5 cases per 100,000 (40,665 procedures); and hemiarthroplasty decreased from 3.7 cases per 100,000 (11,695 procedures) to 1.5 cases per 100,000 (4930 procedures). These trends were observed among male and female patients, as well as all age groups. The greatest increase in incidence was seen in male patients as well as patients aged 50-64 years undergoing RTSA. CONCLUSION: The incidence of primary RTSA and incidence of anatomic TSA have increased substantially in the United States from 2012 to 2017 whereas the incidence of hemiarthroplasty has decreased.

Anterior Cruciate Ligament Injuries in the Older Athlete.

CONTEXT: Older adults are remaining active longer and continuing during later stages of life to participate in sports and activities that involve pivoting on 1 foot. The rate of anterior cruciate ligament (ACL) tears is increasing in people older than 40 years of age, which has caused a concomitant increase in the rate of surgical reconstruction. EVIDENCE ACQUISITION: We searched the PubMed database for articles published in English between January 1980 and January 2018 using the terms anterior cruciate ligament injury, ACL injury, ACL tear, anterior cruciate ligament reconstruction, ACLR, older, older athlete, and elderly. STUDY DESIGN: Clinical review. LEVEL OF EVIDENCE: Level 4. RESULTS: Nonoperative treatment with activity modification and physical therapy may be an appropriate option for nonathletes older than 40 years of age with physically low-demand lifestyles. For patients with injuries that are unresponsive to nonoperative treatment or athletes participating in physically demanding activities, ACL reconstruction can improve function and facilitate return to sports. When evaluating whether a patient is a candidate for surgery, numerous variables should be considered, such as timing, graft choice, and postoperative rehabilitation. CONCLUSION: Outcomes of ACL reconstruction in older athletes are similar to those of younger patients. To date, published evidence is inadequate to determine the long-term effects of nonoperative and operative treatment as well as the role of ACL reconstruction in the development of osteoarthritis in the older athlete.

Associations between preoperative depression and opioid use after anterior cruciate ligament reconstruction and concomitant procedures.

Objectives: To determine rates of perioperative opioid use and characterize associations between preoperative depression and chronic and cumulative opioid consumption after ACL reconstruction.Methods: Using insurance claims data, we identified 48,657 adults who underwent ACL reconstruction from 2010 to 2015, had prescription drug insurance, and had ≥1 year of continuous insurance enrollment postoperatively. Chronic opioid use was defined as filling ≥120 days' supply from 3 to 12 months postoperatively. Logistic and linear regression, controlled for age, sex, and Charlson Comorbidity Index value, were used to determine associations of preoperative depression with binary and continuous outcomes, respectively.Results: Preoperatively, 2,237 patients (4.6%) had depression and 2,387 (4.9%) were taking opioids; patients with depression had 6.5 times the odds (95% confidence interval [CI]: 5.8, 7.3) of taking opioids than patients without depression. Postoperatively, 25% of the patients filled ≥1 opioid prescription; mean duration of use was 13 ± 11 days, and 362 patients (0.7%) had chronic use. Patients with preoperative depression were less likely than patients without depression to fill an opioid prescription postoperatively (OR 0.2, 95% CI: 0.2, 0.2). Of patients who filled opioid prescriptions postoperatively, those with preoperative depression were more likely to refill that prescription at least once (OR 2.0, 95% CI: 1.9, 2.2) but did not have greater odds of chronic use (OR 0.9, 95% CI: 0.5, 1.5). Preoperative depression was not associated with greater cumulative opioid consumption from 3 to 12 months postoperatively (ß = -40, 95% CI: -226, 146).Conclusion: Although patients with preoperative depression were more likely to take opioids preoperatively and to obtain ≥1 opioid refill postoperatively, they did not have greater odds of chronic postoperative opioid use or greater cumulative opioid consumption after ACL reconstruction.

Opioid Prescribing Trends and Geographic Variation After Anterior Cruciate Ligament Reconstruction.

INTRODUCTION: Opioid prescribing patterns play an important role in the opioid epidemic in the United States. The purpose of this study is to examine the trends and geographic variation in opioid prescribing patterns after anterior cruciate ligament (ACL) reconstruction. HYPOTHESIS: Regional differences in opioid prescribing patterns after ACL reconstruction are present. STUDY DESIGN: Descriptive epidemiology study. LEVEL OF EVIDENCE: Level 4. METHODS: The Truven Health MarketScan Commercial Claims database was used to analyze all patients with perioperative private insurance coverage who underwent ACL reconstruction from January 1, 2010, to November 31, 2017. Total number and morphine milligram equivalents per day (MMED) of opioid prescriptions were examined, and regional and statewide variation was assessed. RESULTS: A total of 90,068 ACL reconstruction patients who underwent surgery between 2010 and 2017 were included in the study. Overall, 67% received an opioid prescription within 30 days of surgery and 17% received an opioid prescription ≥90 MMED. The West (20%) had the highest proportion of patients with an opioid prescription ≥90 MMED and the Northeast had the lowest (12%), P < 0.001. The number of opioid prescriptions as well as proportion of opioid prescriptions ≥90 MMED varied significantly by state, P < 0.001. There was a significant increase in number of opioid prescriptions from 2010 to 2017 (62% in 2010 and 83% in 2017; P < 0.001). A significant change in the proportion of patients being prescribed ≥90 MMED was also present (P = 0.04; 15% in 2010, 17% in 2011, 17% 2012, 17% in 2013, 15% in 2014, 20% in 2015, 18% in 2016, and 15% in 2017). CONCLUSION: This study shows a trend of increasing opioid prescriptions and geographic variations in the amount and MMED of opioid prescriptions for patients undergoing ACL reconstruction. These data highlight several areas of improvement that state officials and national entities can use to help curb the opioid epidemic and underscore the importance of national guidelines for opioid prescribing. CLINICAL RELEVANCE: Knowledge of prescribing patterns after specific procedures may help provide more direct insight and guidance to surgeons and patients regarding postoperative pain management.

Image-Guided Chondrocyte Harvesting for Autologous Chondrocyte Implantation: Initial Feasibility Study with Human Cadaver and Pilot Clinical Experience.

BACKGROUND: Autologous chondrocyte implantation (ACI), a promising modality for repairing full-thickness cartilage defects, requires 2 consecutive arthroscopic procedures for chondrocyte harvesting and implantation. In the present study, we assessed the feasibility and efficacy of image-guided chondrocyte harvesting as an alternative to arthroscopic biopsy. METHODS: We induced full-thickness cartilage defects in 10 human cadaveric knees. Computed tomographic arthrography (CTA) was performed following the intra-articular administration of Omnipaque 350 to measure the diameters of the induced cartilage defects. Subsequently, 2 independent operators conducted CTA-guided chondrocyte harvesting (from the medial and lateral trochlear ridges) in each knee. The time for chondrocyte harvesting, accuracy (distance between the predefined target on CTA and the final insertion site of the needle), and number of needle readjustments were recorded. In the institutional review board-approved clinical study, informed consent was obtained and chondrocyte harvesting was performed both with use of a conventional arthroscopic biopsy method and with use of a needle through an arthroscopy access site in 10 subjects for whom ACI was indicated. The samples were processed and cultured blindly, and the quantity and quality of the samples were determined. RESULTS: CTA measurements of full-thickness cartilage defects showed high to perfect absolute agreement and consistency when compared with direct measurements (overall interclass correlation coefficient, 0.933 to 0.983; p < 0.05). For both operators, image-guided chondrocyte harvesting from the lateral ridge was more accurate (p = 0.007 and 0.040) and faster (p = 0.056 and 0.014) in comparison with harvesting from the medial ridge. In the clinical study, no significant difference was observed for the growth index of samples between the needle-harvest and conventional methods (p = 0.897). CONCLUSIONS: CTA can be used for precise measurement of full-thickness cartilage defects. Image-guided chondrocyte harvesting is a viable alternative to traditional arthroscopic biopsy for ACI. CLINICAL RELEVANCE: We recognize the current pivotal role of arthroscopic biopsy, as a part of ACI, for chondrocyte harvesting as well as for delineating the nature of the lesion. However, on the basis of our results, image-guided chondrocyte retrieval may obviate the need for arthroscopic biopsy in some patients in the future.

Factors Affecting Perceptions of Open, Mini-Open, and Arthroscopic Rotator Cuff Repair Techniques Among Medical Professionals.

Although no long-term difference between arthroscopic and mini-open rotator cuff repairs has been documented, use of arthroscopic repair has exploded. We conducted a study to determine which repair technique medical professionals preferred for their own surgery and to analyze the perceptions shaping those opinions. A survey was emailed to selected professionals at our institution: attendings, residents, and allied health professionals; 84 (41, 20, and 23, respectively) responded. Irrespective of specialty or career length, almost half (39, 46%) preferred deferring the repair choice to their surgeon; the other 45 preferred arthroscopic (22, 26%), mini-open (19, 23%), open (2, 2%), or no (2, 2%) repair. Most agreed repairs were safe and fast but had no opinion about cost-effectiveness or which technique provided the best outcome. Significantly (P < .05) more respondents thought arthroscopic and mini-open repairs promoted quick healing, good cosmetic results, and patient satisfaction compared with open repair, but these repairs were also perceived as significantly (P < .05) harder to learn and more challenging than open repair. It is important for medical professionals to recognize these biases, especially given that many defer to the judgment of their medical peers.

Epidemiology of Injuries in Major League Baseball Catchers.

BACKGROUND: In part because of the perception that many injuries occur during collisions with the catcher at home plate, Major League Baseball (MLB) officials recently implemented rule changes to prevent these injuries. There is little research on the rate, type, and severity of injuries in MLB catchers. PURPOSE: To (1) determine the types and severity of injuries to catchers, (2) determine catchers' athlete exposure (AE) rate of injuries, and (3) assess the perception that catchers are at risk for career-ending injuries caused by home plate collisions. STUDY DESIGN: Descriptive epidemiology study. METHODS: The MLB Electronic Baseball Information System was queried for injuries in catchers during the 2001-2010 seasons categorized by cause (collision vs noncollision), diagnosis, and severity. All collision injuries were confirmed by reviewing publicly accessible records and news media. The injury exposure rate per 1000 AEs was calculated, and the rate of injury, associated days on the disabled list (DL), and injury severity were determined on the basis of cause and location of injury. Poisson regression was used to compare rates among seasons, and significance was set at P < .05. RESULTS: During the study period, 134 injuries were sustained, resulting in 6801 days lost. The mean time on the DL was 50.8 days (range, 15-236). The average injury rate was 2.75 injuries per 1000 AEs (range, 0.82-5.14). Of those 134 injuries, 20 were collision injuries. Collision injuries resulted in a mean of 39 days (range, 15-93) of DL time, compared with 53 days for noncollision injuries (range, 15-236), which was not a significant difference. No collision injury was career ending. Noncollision injuries more commonly resulted in >100 days on the DL compared with collision injuries (P = .049). CONCLUSION: Study findings indicated that (1) the most common type of injury to catchers was noncollision injury, (2) the rate of injuries to catchers is lower than previously reported rates for other player positions, and (3) this study did not support the perception that collision injuries are a frequent cause of career-ending injury to catchers.

Anterior cruciate ligament injury alters preinjury lower extremity biomechanics in the injured and uninjured leg: the JUMP-ACL study.

BACKGROUND: Information as to how anterior cruciate ligament (ACL) injury and reconstructive surgery (ACLR) alter lower extremity biomechanics may improve rehabilitation and return to play guidelines, reducing the risk for repeat ACL injury. AIM: To compare lower extremity biomechanics before ACL injury and after subsequent ACLR for the injured and uninjured leg. METHODS: Baseline unilateral lower extremity biomechanics were collected on the dominant leg of participants without ACL injury when they entered the Joint Undertaking to Monitor and Prevent ACL (JUMP-ACL) study. Thirty-one participants with subsequent ACL injury, reconstructive surgery and full return to physical activity completed repeat, follow-up biomechanical testing, as did 39 uninjured, matched controls. Not all injured participants suffered injury to the dominant leg, requiring separation of those with ACL injury into two groups: ACLR-injured leg group (n=12) and ACLR-uninjured leg group (n=19). We compared the landing biomechanics of these three groups (ACLR-injured leg, ACLR-uninjured leg, control) before ACL injury (baseline) with biomechanics after ACL injury, surgery and return to physical activity (follow-up). RESULTS: ACL injury and ACLR altered lower extremity biomechanics, as both ACLR groups demonstrated increases in frontal plane movement (increased hip adduction and knee valgus). The ACLR-injured leg group also exhibited decreased sagittal plane loading (decreased anterior tibial shear force, knee extension moment and hip flexion moment). No high-risk biomechanical changes were observed in control group participants. CONCLUSIONS: ACL injury and ACLR caused movement pattern alterations of the injured and uninjured leg that have previously shown to increase the risk for future non-contact ACL injury.

Upper-extremity peripheral nerve blocks in the perioperative pain management of orthopaedic patients: AAOS exhibit selection.

BACKGROUND: Over the past twenty-five years, peripheral nerve blocks have become increasingly common for the management of perioperative pain of the upper extremity. Several factors have led to increasing acceptance and use of these peripheral nerve blocks, including a greater awareness and measurement of patient pain and a greater emphasis on decreasing the duration of hospital stays and associated costs. METHODS: We present a review of peripheral nerve blocks for procedures involving the upper extremity, including indications, contraindications, anatomy and technique, expected clinical outcomes and the associated levels of evidence, cost-effectiveness, and complications. We reviewed the scientific literature for studies on the effectiveness of peripheral nerve blocks for orthopaedic procedures involving the upper extremity. Particular attention was directed at the most commonly used nerve blocks, the levels of evidence supporting their use, and emerging technologies such as ultrasonographic guidance. RESULTS: Peripheral nerve blocks for upper-extremity procedures improve postoperative pain control and patient satisfaction, can be administered safely, and have a low complication rate. They are also associated with enhanced participation in postoperative rehabilitation, decreased hospital stays, and decreased costs. There are increasingly higher levels of evidence in the literature to support the use of peripheral nerve blocks in a wide variety of orthopaedic procedures ranging from the shoulder to the hand. CONCLUSIONS: The use of peripheral nerve blocks in upper-extremity surgery is common. To actively participate with the patient and anesthesiologist to ensure the best possible outcomes, the orthopaedic surgeon must be well informed regarding the benefits and limitations of this modality.

Cutaneous infections in wrestlers.

CONTEXT: Cutaneous infections are common in wrestlers. Although many are simply a nuisance in the everyday population, they can be problematic to wrestlers because such infections may result in disqualification from practice or competition. Prompt diagnosis and treatment are therefore important. EVIDENCE ACQUISITION: Medline and PubMed databases, the Cochrane Database of Systematic Reviews, and UpToDate were searched through 2012 with the following keywords in various combinations: skin infections, cutaneous infections, wrestlers, athletes, methicillin-resistant Staphylococcus aureus, skin and soft tissue infections, tinea corporis, tinea capitis, herpes simplex, varicella zoster, molluscum contagiosum, verruca vulgaris, warts, scabies, and pediculosis. Relevant articles found in the primary search, and selected references from those articles were reviewed for pertinent clinical information. RESULTS: The most commonly reported cutaneous infections in wrestlers are herpes simplex virus infections (herpes gladiatorum), bacterial skin and soft tissue infections, and dermatophyte infections (tinea gladiatorum). The clinical appearance of these infections can be different in wrestlers than in the community at large. CONCLUSION: For most cutaneous infections, diagnosis and management options in wrestlers are similar to those in the community at large. With atypical presentations, testing methods are recommended to confirm the diagnosis of herpes gladiatorum and tinea gladiatorum. There is evidence to support the use of prophylactic medications to prevent recurrence of herpes simplex virus and reduce the incidence of dermatophyte infections in wrestlers.

Lower-extremity peripheral nerve blocks in the perioperative pain management of orthopaedic patients: AAOS exhibit selection.

BACKGROUND: The utilization of peripheral nerve blocks in orthopaedic surgery has paralleled the rise in the number of ambulatory surgical procedures performed. Optimization of pain control in the perioperative orthopaedic patient contributes to improved patient satisfaction, early mobilization, decreased length of hospitalization, and decreased associated hospital and patient costs. Our purpose was to provide a concise, pertinent review of the use of peripheral nerve blocks in various orthopaedic procedures of the lower extremity, with specific focus on procedural anatomy, indications, patient outcome measures, and complications. METHODS: We reviewed the literature and reference textbooks on commonly performed lower-extremity peripheral nerve block procedures in orthopaedic surgery, focusing on those most commonly used. RESULTS: The use of lower-extremity peripheral nerve blocks is a safe and effective approach to perioperative pain management. Different techniques and timing can have an important impact on patient satisfaction, and each technique has specific indications and complications. For major hip surgery, one of the most commonly used is the lumbar plexus block, which can result in early mobilization, reduced postoperative pain, and decreased opioid-associated adverse events. Associated complications include epidural spread of anesthesia, retroperitoneal hematoma formation, and postoperative falls. For arthroscopic and open knee procedures, the femoral nerve block is frequently used adjunctively. It provides improved early postoperative pain control, early mobilization with therapy, and increased patient satisfaction compared with intra-articular or intravenous opioids alone; it also provides cost savings. However, some studies have shown no significant difference in outcome measures compared with intra-articular opioids alone for arthroscopic anterior cruciate ligament reconstruction. Associated complications include nerve injury, intravascular injection, and postoperative falls. CONCLUSIONS: The use of peripheral nerve blocks in lower-extremity surgery is becoming a mainstay of perioperative pain management strategy.

An unusual mechanism for injury of the anterior cruciate ligament in figure skating.

A 20-year-old competitive figure skater presented with an acute disabling knee injury that occurred in the overhead, non-weight-bearing knee during the performance of a Biellmann spin. Examination and magnetic resonance imaging confirmed the diagnosis of a complete anterior cruciate ligament (ACL) tear. To our knowledge, no previous cases of acute injury of the ACL sustained during the execution of a Biellmann spin have been reported. The ACL injury we report is unique because it occurred without the blade contacting the ice. The mechanism of injury has some features that are similar to those of other noncontact ACL injuries, with the addition of centrifugal force as a potential contributor to the injury.