Photobiomodulation as an Adjunctive Treatment to Physiotherapy for Reduction of Anterior Knee Pain in Combat Soldiers: A Prospective, Double-Blind, Randomized, Pragmatic, Sham-Controlled Trial.

BACKGROUND AND OBJECTIVES: Anterior knee pain (AKP) is the most common knee pathology in athletes and occurs in 15% of army recruits of elite units during basic training. Of these, 50% are symptomatic 6 years later. Photobiomodulation (PBM) is a nonthermal red-to-near-infrared irradiation used for pain reduction of a variety of etiologies. This study was designed to determine whether addition of PBM to physiotherapy (PT) for AKP in combat soldiers is superior to PT alone. STUDY DESIGN/MATERIALS AND METHODS: In this prospective, double-blind, sham-controlled, randomized clinical trial (NCT02845869), 26 combat soldiers/policemen (male:female, 15:11; body mass index [BMI] = 24.2 ± 3.9, n = 46 knees), with AKP due to overuse/load, received 4 weeks of PT + sham (PT + Sham) or active PBM (wavelength = 660 and 850 nm, pulsing = 2.5 Hz, LED power = 50 mW/cm2 [local tissue/regional lymph nodes]; 810 nm continuous beam, laser cluster 6 W/cm2 [analgesia] and laser pointer 4.75 W/cm2 [trigger points]) (PT + PBM). The main outcome measures were subjective pain by visual analog scale (VAS) (0 [none]-100 [intolerable]) and functional disability by Kujala score (0 [worst]-100 [best]). Evaluations were carried out at baseline, end of treatments, and 3-month follow-up. RESULTS: All participants completed the treatment protocol without any reported adverse device effects. Post-treatment pain was significantly reduced in the PT+PBM group, compared with baseline and sham (Δpain, VAS, mean ± SD: PT + PBM = -19 ± 23, P = 0.002; PT + Sham = -6 ± 21, P = 0.16; between groups, P = 0.032). At 3-month follow-up, pain reduction was similar between groups; however, the Kujala score was significantly improved only in the PBM-treated group (ΔKujala: PT + PBM = 11 ± 10, P = 0.003; PT + Sham = 5 ± 7, P = 0.059). CONCLUSIONS: Addition of PBM to PT for AKP resulted in earlier reduction in pain and improved functionality, compared with PT alone. This noninvasive, nonpharmacologic, adjunctive therapeutic modality can be easily incorporated into team healthcare frameworks or end units and may lead to earlier return to competition or combat-level service. Lasers Surg. Med. © 2021 Wiley Periodicals LLC.

[CLINICAL AND ARTHROSCOPIC FINDINGS IN MENISCAL INJURY AND KNEE INSTABILITY: A PROSPECTIVE STUDY].

INTRODUCTION: Medical history and physical examination are expected to provide the basic knowledge allowing diagnosis of a disease and thus enabling to plan the course of treatment. OBJECTIVE: This study aimed to examine this hypothesis by comparing pre-operative diagnosis of meniscal and anterior cruciate ligament (ACL) injuries to final surgical findings. MATERIAL AND METHODS: We prospectively compared the pre-surgical diagnosis to the arthroscopic findings in 753 arthroscopic procedures. RESULTS: Clinical diagnosis of a medial meniscal (MM) tear was proven by arthroscopy in 65% of cases. Clinical diagnosis of a lateral meniscal (LM) tear was proven by arthroscopy in 54% of cases. Clinical complaints of instability correlated with partial or complete ACL rupture in 85% of cases. The accuracy of the clinical examination concerning ACL integrity ranged from 86% to 90%. Lachman and Pivot tests were slightly superior to the Drawer test. DISCUSSION: Arthroscopic surgery is the most common surgical procedure in orthopedics. The diagnosis, which is based on history and physical examination in most cases, allows proper management of the case and an appropriate treatment plan. In most scenarios, these operations are conducted based on the diagnosis and treatment performed before surgery. In this study we showed that even in experienced and skilled hands, a clinical diagnosis of meniscal tear was approved by arthroscopy in only 54% to 65% of cases. A clinical diagnosis of ACL injury was approved by arthroscopy, in 99% of cases. CONCLUSION: When planning conservative treatment or surgical intervention for a knee injury, it should be kept in mind that the clinical diagnosis of ACL rupture is highly reliable, while the clinical diagnosis of meniscal injury is only moderately reliable. Thus, especially when planning surgical intervention, the utilization of further imaging would be desirable when isolated meniscal injury is suspected.

Arthroscopy-assisted fracture fixation.

PURPOSE: the purpose of this article was to systematically analyze the results of published studies in the literature which evaluated the use of arthroscopically assisted techniques in intra-articular fracture fixation. METHODS: published investigations to date were analyzed by classifying them according to joints that were involved with intra-articular fractures including: knee, ankle, hip, shoulder, elbow, and wrist joints. The results were studied to assess the feasibility, efficiency, and outcomes of arthroscopy-assisted fracture fixation. RESULTS: arthroscopy-assisted techniques have been used successfully for the treatment of fractures of the tibial plateau, tibial eminence, malleoli, pilon, calcaneus, femoral head, glenoid, greater tuberosity, distal clavicle, radial head, coronoid, distal radius, and scaphoid. The major advantages of arthroscopic fracture fixation over open methods are direct visualization of the intra-articular space, decreased invasiveness, and the possibility for multitask interventions through which fixation of the fracture, and repair of the soft tissues and the cartilage can be performed simultaneously. The time-consuming and technically demanding nature of the procedures with a prolonged learning curve and limited fixation alternatives are the main disadvantages of this technique. CONCLUSION: arthroscopic fixation is increasingly utilized for certain intra-articular fracture types due to the minimally invasive nature of the procedures and high accuracy. Randomized controlled trials are needed to justify wider use of arthroscopy-assisted techniques for treatment of intra-articular fractures.

Migrating shrapnel: a rare cause of knee synovitis.

UNLABELLED: Shrapnel injuries in soft tissues often do not require surgical excision. Metals that remain embedded in the surrounding tissue are not thought to cause significant damage and the patients are generally asymptomatic. This case presentation describes a patient who sustained a penetrating shrapnel injury to his thigh, where the metal fragment was not removed. However, more than 20 years later, the patient developed knee synovitis. On X-ray the shrapnel was seen in the suprapatellar pouch. An arthroscopy was preformed and the shrapnel was removed with full healing of the patient. CONCLUSION: although nonsurgical treatment of shrapnel in soft tissues is the treatment of choice in many cases, late migration is possible, causing distal symptoms and may require surgical excision.

Symptomatic bipartite patella: treatment alternatives.

Bipartite patella is usually an asymptomatic, incidental finding. However, in adolescents, it may be a cause of anterior knee pain following trauma or a result of overuse or strenuous sports activity. Most patients improve with nonsurgical treatment. Surgery is considered when nonsurgical treatment fails. Excision of the fragment is the most popular surgical option, with good results. However, when the fragment is large and has an articular surface, excision may lead to patellofemoral incongruity. Lateral retinacular release and detachment of the vastus lateralis muscle insertion are other surgical options and are reported to produce good pain relief and union in some patients. These procedures reduce the traction force of the vastus lateralis on the loose fragment. Internal fixation of the separated fragment has limited support in the literature. Understanding the possible consequences of different treatment approaches to painful bipartite patella is necessary to preserve quadriceps muscle strength and patellofemoral joint function.

Reduced Anterior Cruciate Ligament Vascularization Is Associated With Chondral Knee Lesions.

This study tested the association between periligamentous vascularization of the anterior cruciate ligament (ACL) and the presence of chondral knee lesions via retrospective analysis of prospectively collected data from 702 consecutive knee arthroscopic procedures. In each case, the ACL periligamentous envelope was documented as follows: (1) vascular, where the ACL was covered with blood vessels along its entire length; (2) centrally avascular, where the central third of the ACL was not covered but peripheral vascularized coverage was present; and (3) avascular, where there was no blood vessel coverage of the ACL. Inclusion criteria for the study were as follows: (1) age older than 18 years and (2) normal knee ligament laxity. Univariate analysis and multiple logistic regression were used to test the association between chondral lesions and each of the variables: sex, age, meniscus tear, decreased ACL vascularity, and concomitant chondral lesion in another knee compartment. The cohort included 516 knees. In the univariate analysis, all variables were associated with a chondral lesion, but only older age and decreased ACL vascularity were associated with chondral lesions in each knee compartment. In the regression model, only decreased ACL vascularity was associated with chondral lesions in each knee compartment. For avascular knees, the odds ratio was 2.84 for medial femoral condyle lesions (95% confidence interval, 1.73-4.68; P=.000), 2.44 for lateral femoral condyle lesions (95% confidence interval, 1.19-5.03; P=.015), and 2.48 for patellofemoral lesions (95% confidence interval, 1.55-3.97; P=.000). The findings showed that decreased ACL periligamentous vascularization is associated with chondral lesions of the femoral condyles in knees with preserved ACL laxity. [Orthopedics. 2016; 39(4):e737-e743.].