Dilution Effect of Intra-articular Injection Administered After Knee Arthroscopy.

The hypothesis was that agents delivered intra-articularly after knee arthroscopy will be diluted by residual arthroscopic fluid. Diagnostic arthroscopy was performed on six cadaver knees. Each procedure was followed by an intra-articular injection of a dye solution. Intra-articular aspirates were gathered from three locations. With significance set at p < .05, the aspirates were compared with the initial dye concentration and with each other. No significant difference was noted among the sites, indicating that no specific knee area was exposed to a higher dye concentration. There was a significant difference in dye concentration of the aspirates when compared with the dye's initial concentration. The concentration of fluid injected intra-articularly after arthroscopy was diluted by 27%. These data indicate that agents injected into the knee postarthroscopy are significantly diluted. In vitro and in vivo experiments evaluating chondrotoxicity of various anesthetic agents may not accurately reflect the actual concentration of the drug within the knee joint unless dilution effects are taken into account.

Survey of short-term oral corticosteroid administration by orthopaedic physicians in college and high school athletes.

The use of oral corticosteroid (OCS) drugs is advocated because of their potent anti-inflammatory effects. They also possess many potential adverse effects. No study has assessed physician prescribing practices of OCS therapy in high school (HS) or college (COL) athletes. This paper reports the prescribing patterns of sports medicine physicians who used short-term OCS therapy and to describe associated complications in HS and COL athletes within a 24- month period. An internet link to a descriptive epidemiology survey was included in an e-mail to all members of the Arthroscopy Association of North America and the American Orthopaedic Society for Sports Medicine. Descriptive statistics and correlation analysis were used to examine responses. Total response rate was 32% (615/1,928). Sixty-six percent of the physicians indicated prescribing OCS to both groups of athletes, while 29% reported prescribing OCS to COL athletes and 5% to HS athletes for musculoskeletal injuries. Physicians who prescribed multiple OCS regimens to the same athlete within the same season (P = 0.01) and physicians who prescribed OCS to the skeletally immature athlete (P = 0.009) reported more complications than other physicians. Among the 412 physicians who did not prescribe OCS in the treatment of athletic induced musculoskeletal injury, 251 (61%) cited a risk of developing medical complications as the primary reason for avoiding use. The reported number of medical complications was low with no cases of avascular necrosis reported for the 2-year recall period. Orthopaedic surgeons who treated athletic induced musculoskeletal injuries with a short-term course of oral corticosteroids reported that high school and college athletes benefited with few medical complications. Key pointsThirty-four percent of orthopaedic sports medicine physicians we surveyed reported prescribing a short-term course of oral corticosteroids for the treatment of an athletic-related musculoskeletal injury within the previous 24 months of answering the survey.The orthopaedic surgeons who treated athletic induced musculoskeletal injuries with a short-term course of OCS reported the high school and college athletes benefited from OCS treatment with few medical complications.Short-term oral corticosteroid use in multiple regimens in the same athlete and in the skeletally immature athlete may pose an increased risk of medical complication.

Osteoarticular autograft and allograft transplantation of the knee: 3 year follow-up.

Between 1998 and 2001, a total of 48 patients underwent autologous or allograft osteoarticular transplantation with a minimum follow-up of 24 months. Nineteen patients underwent concomitant procedures. Average patient age was 46 years. Graft area averaged 4.8 cm2 (range, 0.2-21.6 cm(2)). Grafts implanted included 24 autografts, 12 refrigerated allografts, and 12 frozen allografts. Average follow-up was 37.1 months (range, 24-63 months). Postoperative Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, Knee Society Score (KSS), and pain scores improved significantly. Age <35 years and male gender was associated with a positive outcome. There was no significant difference in improvement between autograft and allograft groups. Nine patients, considered failures, underwent total knee arthroplasty and data analysis. No significant relationship was noted for any variable. Eighty-one percent of grafts are still functioning >3 years after transplantation.

Transfer of the latissimus dorsi as a salvage procedure for failed debridement and attempted repair of massive rotator cuff tears.

Seven patients who had a previously failed attempt at debridement and repair of a massive rotator cuff tear were managed with latissimus dorsi transfer. Patient age averaged 63 years and average follow-up was 31 months. All patients were evaluated with shoulder radiographs, Constant and Murley Scores, UCLA Shoulder Score, visual analog pain score, range of motion, and the Short Shoulder Form. Modest improvement was noted in forward flexion and abduction. Significant improvement was noted in shoulder function. Transfer of the latissimus dorsi as salvage for a previously failed repair of a massive rotator cuff tear is effective in providing pain relief and improving shoulder function.

The effect of posterior cruciate ligament injury and reconstruction on meniscal strain.

BACKGROUND: The relationship between posterior cruciate ligament insufficiency and meniscal injury is unclear. HYPOTHESIS: Posterior cruciate ligament insufficiency results in increased medial and lateral meniscal strain. STUDY DESIGN: Descriptive anatomic study. METHODS: Eight cadaveric specimens were evaluated with a 6-axis load cell and differential variable reluctance transducer strain gauges placed in both menisci. Data were recorded in the posterior cruciate ligament-intact state after posterior cruciate ligament transection and after posterior cruciate ligament reconstruction. RESULTS: The effect of posterior cruciate ligament state on meniscal strain was more pronounced at higher flexion angles. At 60 degrees and 90 degrees of flexion, there was a significant effect of posterior cruciate ligament sectioning and reconstruction on meniscal strain (P < .026). Average meniscal strain for both medial and lateral menisci increased between the intact and the posterior cruciate ligament-cut states. Posterior cruciate ligament reconstruction decreased strain values to that of the intact knee. CONCLUSIONS: Meniscal strain increases with complete posterior cruciate ligament injury and is returned to posterior cruciate ligament-intact levels after posterior cruciate ligament reconstruction. CLINICAL RELEVANCE: Posterior cruciate ligament reconstruction may play an important role in reducing meniscal strain and subsequent degeneration within the posterior cruciate ligament-injured knee.

Chondrocyte viability in refrigerated osteochondral allografts used for transplantation within the knee.

PURPOSE: To evaluate cell viability and matrix characteristics of refrigerated osteochondral allografts implanted up to 44 days after harvest. METHODS: Sixteen refrigerated allografts underwent histologic and ultrastructural examination and fluorescence excitation analysis prior to implantation. The average size of the graft implanted was 6.2 cm(2) (+/-3.4 cm(2)). Refrigerated allografts averaged 30 days (range, 17 to 44 days) from donor expiration to implantation. Nine specimens underwent cell viability testing. The percent viability of refrigerated allografts prior to implantation averaged 67%. RESULTS: No significant correlations were noted between histologic score, electron microscopy score, matrix staining percent (MSP) score, and viability. When time to implantation was assessed, an inverse correlation was noted with MSP score (r =.539) (P < 0.05), indicating less matrix staining in grafts refrigerated longer after harvest. CONCLUSION: The current data indicate that refrigerated osteochondral allografts can be maintained for up to 44 days with average chondrocyte viability of 67%.

Intramedullary plate fixation of a distal humerus fracture: a case report.

A case of a complex distal humeral fracture is presented. The patient lacked sufficient bony architecture to allow for conventional reconstruction. A technique is described using an intramedullary plate to obtain bony stabilization and permit early range of motion exercises.

A biomechanical comparison of three lower extremity tendons for ligamentous reconstruction about the knee.

PURPOSE: The purpose of this investigation was to evaluate 3 previously unreported allograft tendons for use in knee surgery. These are the doubled tibialis anterior (TA), doubled tibialis posterior (TP), and doubled peroneus longus (PL) tendons. TYPE OF STUDY: A biomechanical evaluation of the properties of the TA, TP, and PL. METHODS: Sixteen fresh-frozen cadaveric lower limbs were used for testing. All specimens had the TA, TP, and PL tendons harvested. All specimens were tested in a custom-designed hydraulic testing machine using dry ice clamps. Each tendon was elongated at a rate of 1 mm/s. Load and displacement were recorded with an analog to digital interface board. Stiffness, modulus of elasticity, and stress and strain at failure were calculated. RESULTS: The average tested lengths of the TA, TP, and PL were 37 cm (range, 13-68 cm), 33 cm (range, 7-74 cm), and 42 cm (range, 17-69 cm), respectively. The average cross-sectional areas of the doubled TA, TP, and PL were 38 mm2, 48 mm2, and 37 mm2, respectively. The average failure loads for the doubled TA, TP, and PL tendons were 3,412 N, 3,391 N, and 2,483 N, respectively. The maximum stresses of the 3 tendons did not differ significantly (85-108 Mpa). The TA had the greatest stiffness (344 N/mm), followed by the TP (302 N/mm) and the PL (244 N/mm). Previous authors have documented the biomechanical strength of grafts for ACL reconstruction between 1,700 and 2,900 Newtons. The ultimate tensile strength and stiffness reported for the TA and TP grafts exceeded that for all previously reported grafts, including the doubled semitendinosus-gracilis. CONCLUSIONS: The TA, TP, and PL tendons showed excellent biomechanical properties when compared with historical data evaluating other graft sources. The biomechanical properties observed for the TA, TP, and PL were noted in specimens despite an average age of 78.3 years.

Return to Play After Open Bankart Repair: A Systematic Review.

BACKGROUND: Results of open Bankart repair have been well reported. However, less information is available outlining the timetable for return to play (RTP) in athletes after this procedure. PURPOSE: To review the current literature regarding (1) the timetable recommended for athletes to RTP after an open Bankart repair and (2) the objective criteria on which the decision to allow an athlete to RTP is based. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: A comprehensive literature search was conducted of all relevant English-language articles using the electronic databases OVID and PubMed between the years 1947 and 2012 to identify open Bankart repair. Two reviewers screened articles for eligibility based on the following criteria: (1) an open Bankart repair, (2) a minimum follow-up of at least 8 months, (3) any report that described the procedure in athletes, and (4) any report that described the time for an athlete to RTP. All relevant data were collected and analyzed with regard to number of patients; mean follow-up; Rowe, Constant, and American Shoulder and Elbow (ASES) scores; redislocation rate; and return-to-sport timing. RESULTS: In all, 559 relevant citations were identified, of which 29 articles met the inclusion criteria. The mean follow-up was 51.7 months (range, 8-162 months), and the mean age was 25.9 years (range, 21-31 years). The average Rowe score for all studies was 86.9 (range, 63-90). The average redislocation rate was 5.3%. Twenty-six of 29 studies cited a specific timetable for unrestricted RTP, with an average of 23.2 weeks (range, 12-36 weeks). Only 38% of authors reported sport-specific criteria for return to competition, with the majority allowing return to noncontact sports at 12 to 16 weeks, and the resumption of throwing/contact sports by 24 weeks. Three reports described specific functional parameters for RTP. CONCLUSION: The current review summarized return-to-play guidelines for athletic competition after open Bankart repair. These data may provide general guidelines to aid surgeons when determining the appropriate timetable to allow an athlete to return to unrestricted competition.

Joint stability characteristics of the ankle complex in female athletes with histories of lateral ankle sprain, part II: clinical experience using arthrometric measurement.

CONTEXT: This is part II of a 2-part series discussing stability characteristics of the ankle complex. In part I, we used a cadaver model to examine the effects of sectioning the lateral ankle ligaments on anterior and inversion motion and stiffness of the ankle complex. In part II, we wanted to build on and apply these findings to the clinical assessment of ankle-complex motion and stiffness in a group of athletes with a history of unilateral ankle sprain. OBJECTIVE: To examine ankle-complex motion and stiffness in a group of athletes with reported history of lateral ankle sprain. DESIGN: Cross-sectional study. SETTING: University research laboratory. PATIENTS OR OTHER PARTICIPANTS: Twenty-five female college athletes (age = 19.4 ± 1.4 years, height = 170.2 ± 7.4 cm, mass = 67.3 ± 10.0 kg) with histories of unilateral ankle sprain. INTERVENTION(S): All ankles underwent loading with an ankle arthrometer. Ankles were tested bilaterally. MAIN OUTCOME MEASURE(S): The dependent variables were anterior displacement, anterior end-range stiffness, inversion rotation, and inversion end-range stiffness. RESULTS: Anterior displacement of the ankle complex did not differ between the uninjured and sprained ankles (P = .37), whereas ankle-complex rotation was greater for the sprained ankles (P = .03). The sprained ankles had less anterior and inversion end-range stiffness than the uninjured ankles (P < .01). CONCLUSIONS: Changes in ankle-complex laxity and end-range stiffness were detected in ankles with histories of sprain. These results indicate the presence of altered mechanical characteristics in the soft tissues of the sprained ankles.

Joint stability characteristics of the ankle complex after lateral ligamentous injury, part I: a laboratory comparison using arthrometric measurement.

CONTEXT: The mechanical property of stiffness may be important to investigating how lateral ankle ligament injury affects the behavior of the viscoelastic properties of the ankle complex. A better understanding of injury effects on tissue elastic characteristics in relation to joint laxity could be obtained from cadaveric study. OBJECTIVE: To biomechanically determine the laxity and stiffness characteristics of the cadaver ankle complex before and after simulated injury to the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) during anterior drawer and inversion loading. DESIGN: Cross-sectional study. SETTING: University research laboratory. PATIENTS OR OTHER PARTICIPANTS: Seven fresh-frozen cadaver ankle specimens. INTERVENTION(S): All ankles underwent loading before and after simulated lateral ankle injury using an ankle arthrometer. MAIN OUTCOME MEASURE(S): The dependent variables were anterior displacement, anterior end-range stiffness, inversion rotation, and inversion end-range stiffness. RESULTS: Isolated ATFL and combined ATFL and CFL sectioning resulted in increased anterior displacement but not end-range stiffness when compared with the intact ankle. With inversion loading, combined ATFL and CFL sectioning resulted in increased range of motion and decreased end-range stiffness when compared with the intact and ATFL-sectioned ankles. CONCLUSIONS: The absence of change in anterior end-range stiffness between the intact and ligament-deficient ankles indicated bony and other soft tissues functioned to maintain stiffness after pathologic joint displacement, whereas inversion loading of the CFL-deficient ankle after pathologic joint displacement indicated the ankle complex was less stiff when supported only by the secondary joint structures.

Modified technique for unipolar allograft ankle replacement: midterm follow-up. A case report.

The management of tibiotalar arthritis remains a clinical challenge. Conventional treatment relies primarily upon arthrodesis or prosthetic arthroplasty. Fresh osteochondral total ankle allograft transplantation has been reported in limited cases. We report the case of a 42-year-old male who underwent a tibial refrigerated osteochondral allograft and a talar refrigerated osteochondral mosiacplasty. At 66-month follow-up, the patient demonstrated no limp with walking and was able to participate in tennis and snow skiing with no pain. His Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index, total WOMAC score, and American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale score were 0, 94, and 98, respectively. The final radiograph showed complete integration of the allograft with mild joint space narrowing. Osteochondral allografting for ankle arthritis may be considered an option in select patients.

Apoptosis and mitochondrial dysfunction in human chondrocytes following exposure to lidocaine, bupivacaine, and ropivacaine.

BACKGROUND: Several mechanisms have been proposed to explain toxicity of local anesthetics to chondrocytes, including the blockade of potassium channels and mitochondrial injury. The purposes of this investigation were to study the effects of lidocaine, bupivacaine, and ropivacaine on human chondrocyte viability and mitochondrial function in vitro and to characterize the type of cell death elicited following exposure. METHODS: Primary chondrocyte cultures from patients with osteoarthritis undergoing knee replacement were treated with saline solution and the following concentrations of local anesthetics: 2%, 1%, and 0.5% lidocaine, 0.5% and 0.25% bupivacaine, and 0.5% and 0.2% ropivacaine for one hour. Cell viability and apoptosis were measured by flow cytometry at twenty-four hours and 120 hours after treatment. Nuclear staining and caspase 3 and 9 cleavage assays (Western blot) were used to further establish the induction of apoptosis. Mitochondrial dysfunction was evaluated by the accumulation of mitochondrial DNA damage (quantitative Southern blot), changes in adenosine triphosphate production (bioluminescence kit), and mitochondrial protein levels (Western blot analysis). RESULTS: Exposure of primary human chondrocytes to a 2% concentration of lidocaine caused massive necrosis of chondrocytes after twenty-four hours, 1% lidocaine and 0.5% bupivacaine caused a detectable, but not significant, decrease in viability after twenty-four hours, while 0.5% lidocaine, 0.25% bupivacaine, and both concentrations of ropivacaine (0.5% and 0.2%) did not affect chondrocyte viability. Flow cytometry analysis of chondrocytes 120 hours after drug treatment revealed a significant decrease in viability (p < 0.05) with a concomitant increase in the number of apoptotic cells at all concentrations of lidocaine, bupivacaine, and ropivacaine analyzed, except 0.2% ropivacaine. Apoptosis was verified by observation of condensed and fragmented nuclei and a decrease in procaspase 3 and 9 levels. Local anesthetics induced mitochondrial DNA damage and a decrease in adenosine triphosphate and mitochondrial protein levels. CONCLUSIONS: Lidocaine, bupivacaine, and ropivacaine cause delayed mitochondrial dysfunction and apoptosis in cultured human chondrocytes.

Effects of hyaluronic acid on mitochondrial function and mitochondria-driven apoptosis following oxidative stress in human chondrocytes.

Hyaluronic acid is widely used in the treatment of osteoarthritis and exerts significant chondroprotective effects. The exact mechanisms of its chondroprotective action are not yet fully elucidated. Human articular chondrocytes actively produce reactive oxygen and nitrogen species capable of causing cellular dysfunction and death. A growing body of evidence indicates that mitochondrial dysfunction and mitochondrial DNA damage play a causal role in disorders linked to excessive generation of oxygen free radicals. We hypothesized that the chondroprotective effects of hyaluronic acid on oxidatively stressed chondrocytes are due to preservation of mitochondrial function and amelioration of mitochondria-driven apoptosis. When primary human chondrocyte cultures were exposed to reactive oxygen or nitrogen species generators, mitochondrial DNA damage along with mitochondrial dysfunction and mitochondria-driven apoptosis accumulated as a consequence. In addition, cytokine-treated primary human chondrocytes showed increased levels of mitochondrial DNA damage. Pretreatment of chondrocytes with hyaluronic acid caused a decrease of mitochondrial DNA damage, enhanced mitochondrial DNA repair capacity and cell viability, preservation of ATP levels, and amelioration of apoptosis. The results of these studies demonstrate that enhanced chondrocyte survival and improved mitochondrial function under conditions of oxidative injury are probably important therapeutic mechanisms for the actions of hyaluronic acid in osteoarthritis.

Knee and ankle position, anterior drawer laxity, and stiffness of the ankle complex.

CONTEXT: Anterior drawer testing of the ankle is commonly used to diagnose lateral ligamentous instability. Our hypothesis was that changing knee and ankle positions would change the stability of the ankle complex during anterior drawer testing. OBJECTIVES: To assess the effects of knee and ankle position on anterior drawer laxity and stiffness of the ankle complex. DESIGN: A repeated-measures design with knee and ankle position as independent variables. SETTING: University research laboratory. PATIENTS OR OTHER PARTICIPANTS: Bilateral ankles of 10 female (age = 19.8 +/- 1.1 years) and 10 male (age = 20.8 +/- 1.2 years) collegiate athletes were tested. INTERVENTION(S): Each ankle complex underwent loading using an ankle arthrometer under 4 test conditions consisting of 2 knee positions (90 degrees and 0 degrees of flexion) and 2 ankle positions (0 degrees and 10 degrees of plantar flexion [PF]). MAIN OUTCOME MEASURE(S): Recorded anterior laxity (mm) and stiffness (N/mm). RESULTS: Anterior laxity of the ankle complex was maximal with the knee positioned at 90 degrees of flexion and the ankle at 10 degrees of PF when compared with the knee positioned at 0 degrees of flexion and the ankle at 10 degrees or 0 degrees of PF (P < .001), whereas ankle complex stiffness was greatest with the knee positioned at 0 degrees of flexion and the ankle at 0 degrees of PF (P < .009). CONCLUSIONS: Anterior drawer testing of the ankle complex with the knee positioned at 90 degrees of flexion and the ankle at 10 degrees of PF produced the most laxity and the least stiffness. These findings indicate that anterior drawer testing with the knee at 90 degrees of flexion and the ankle at 10 degrees of PF may permit better isolation of the ankle capsuloligamentous structures.

The results of arthroscopic versus mini-open repair for rotator cuff tears at mid-term follow-up.

BACKGROUND: To prospectively evaluate patients who underwent a "mini-open" repair versus a completely arthroscopic technique for small to large size rotator cuff tears. METHODS: Fifty-two patients underwent "mini-open" or all arthroscopic repair of a full thickness tear of the rotator cuff. Patients who complained of shoulder pain and/or weakness and who had failed a minimum of 6 weeks of physical therapy and had at least one sub-acromial injection were surgical candidates. Pre and post-operative clinical evaluations included the following: 1) demographics; 2) Simple Shoulder Test (SST); 3) University of California, Los Angeles (UCLA) rating scale; 4) visual analog pain assessment (VAS); and 5) pre-op SF12 assessment. Descriptive analysis was performed for patient demographics and for all variables. Pre and post outcome scores, range of motion and pain scale were compared using paired t-tests. Analysis of variance (ANOVA) was used to evaluate any effect between dependent and independent variables. Significance was set at p is less than or equal to 0.05. RESULTS: There were 31 females and 21 males. The average follow-up was 50.6 months (27 - 84 months). The average age was similar between the two groups [arthroscopic x = 55 years/mini-open x = 58 years, p = 0.7]. Twenty-seven patients underwent arthroscopic repair and 25 underwent repair with a mini-open incision. The average rotator cuff tear size was 3.1 cm (range: 1-5 centimeters). There was no significant difference in tear size between the two groups (arthroscopic group = 2.9 cm/mini-open group = 3.2 cm, p = 0.3). Overall, there was a significant improvement from pre-operative status in shoulder pain, shoulder function as measured on the Simple Shoulder test and UCLA Shoulder Form. Visual analog pain improved, on average, 4.4 points and the most recent Short Shoulder Form and UCLA scores were 8 and 26 respectively. Both active and passive glenohumeral joint range of motion improved significantly from pre-operatively. CONCLUSION: Based upon the number available, we found no statistical difference in outcome between the two groups, indicating that either procedure is efficacious in the treatment of small and medium size rotator cuff tears. LEVEL OF EVIDENCE: Type III.

A salvage procedure for refractory shoulder instability.

We present the case of a patient with symptomatic refractory multidirectional shoulder instability who was treated with staged bilateral anterior and posterior glenoid bone augmentation after previous failed arthroscopic and open procedures. The patient was pain free postoperatively and has not had symptoms of instability in either shoulder. At her most recent followup, 24 months after surgery, she had nearly full symmetric shoulder range of motion without anterior or posterior apprehension signs. Her Constant-Murley scores were 77 and 79 on the right and left, respectively, with UCLA scores of 29 on the right and the left shoulders. Her Short Form-36 overall score was 105, indicating overall satisfaction. Currently, the patient states that she can do all daily activities without restrictions. In carefully selected patients, the use of anterior and posterior glenoid bone augmentation may be effective as a salvage procedure in rare cases of refractory multidirectional shoulder instability.