Progression of patellar tendinitis following treatment with platelet-rich plasma: case reports.

PURPOSE: The use of platelet-rich plasma (PRP) is becoming more attractive given its favourable side effect profile and autologous nature, leading to rapid clinical adoption in the absence of high-level evidence. We are presenting three patients who developed a progression of patellar tendinitis following treatment, which to our knowledge is the first report of worsening of patellar tendinitis following PRP therapy. METHODS: The records of three patients with symptom exacerbation of patellar tendinitis following treatment with PRP were reviewed. IRB exemption was obtained. Clinical and operative records, radiographs, and MR imaging were reviewed for all patients. RESULTS: Three patients reported to our clinic for a second opinion with symptoms of anterior knee pain consistent with patellar tendinitis. Each patient had previously been treated with PRP therapy due to prolonged symptoms. Clinical and radiological findings following treatment included patellar tendon thickening, worsening pain, discontinuation of athletic participation in all three patients, and osteolysis of the distal pole of the patella in one patient identified during surgical intervention. CONCLUSIONS: Growing interest in the use of autologous products for the management of chronic tendinopathies has led to widespread clinical implementation with minimal scientific support. It is tempting to apply a new treatment for management of a difficult clinical entity, especially when the risk/benefit ratio appears favourable. However, caution must be exercised as unexpected results may be encountered. LEVEL OF EVIDENCE: Case reports, level V.

Operative management of partial-thickness tears of the proximal hamstring muscles in athletes.

BACKGROUND: Partial tears of the hamstring muscle origin represent a challenging clinical problem to the patient and orthopaedic surgeon. Although nonoperative treatment is frequently met with limited success, there is a paucity of data on the efficacy of surgical management for partial proximal hamstring tears in the active and athletic population. PURPOSE: To evaluate the results of an anatomic repair for partial tears of the hamstring muscle origin in athletes. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: The records of 17 patients with partial tears of the proximal hamstring origin were reviewed after institutional review board approval was obtained. All patients were treated with open debridement and primary tendon repair after failure of at least 6 months of nonoperative therapy. Clinical and operative records, radiographs, and magnetic resonance images were reviewed for all patients. A patient-reported outcomes survey was completed by 14 patients that included the Lower Extremity Functional Score (LEFS), Marx activity rating scale, custom LEFS and Marx scales, and subjective patient satisfaction scores. Early and late postoperative complications were recorded. RESULTS: There were 3 male and 14 female patients; their average age was 43 years (range, 19-64 years) and average follow-up was 32 months (range, 12-51 months). There were 2 collegiate athletes (field hockey, track), 14 amateur athletes (distance running, waterskiing, tennis), and a professional bodybuilder. Postoperative LEFS was 73.3 ± 9.9 (range, 50-80) and custom LEFS was 66.7 ± 17.0 (range, 37-80) of a maximum 80 points. The most commonly reported difficulty was with prolonged sitting and explosive direction change while running. The average Marx score was 6.5 ± 5.3 (range, 0-16) of a maximum 16, correlating with a greater return to recreational running activities in this patient cohort than regular participation in pivoting or cutting sports. Marx custom scores were 20 of a maximum 20 in all patients, demonstrating no disability in the operative extremity with activities of daily living. No patient underwent a subsequent surgery. One patient was not satisfied with the result and reported persistent symptoms during competitive distance running. All patients were able to return to their preoperative level of activity after surgery. CONCLUSION: Anatomic surgical treatment of partial proximal hamstring avulsions can lead to satisfactory functional outcomes, a high rate of return to athletic activity, and low complication rate. This procedure should be reserved for patients who have failed an extended course of nonoperative treatment, and the proximity of the sciatic nerve mandates a careful assessment of the risk-benefit ratio before surgery is undertaken.

Combined ACL-posterolateral corner injury in a skeletally immature athlete.

Combined injury to the anterior cruciate ligament (ACL) and posterolateral structures of the knee is a rare yet increasingly recognized clinical entity. In children or adolescents with open growth plates, this injury pattern is considered to be even more rare than in adults. Because knee ligaments are felt to be stronger than the adjacent physeal plates, the energy of pathologic translational and rotatory stress commonly results in fracture or avulsion injuries rather than ligamentous injury. The appropriate treatment for either injury remains controversial in the skeletally immature patient, with no previously reported case of this combined injury pattern in a patient with open physes. We present a case of a 12-year-old boy who sustained an ACL-posterolateral corner injury while playing football, and subsequently underwent acute repair of the posterolateral structures with a plan to perform ACL reconstruction at a later date.

ACL graft healing and biologics.

Operative reconstruction of a torn anterior cruciate ligament (ACL) has become the most broadly accepted treatment. An important, but underreported, outcome of ACL reconstruction is graft failure, which poses a challenge for the orthopedic surgeon. An understanding of the tendon-bone healing and the intra-articular ligamentization process is crucial for orthopedic surgeons to make appropriate graft choices and to be able to initiate optimal rehabilitation protocols after surgical ACL reconstruction. This article focuses on the current understanding of the tendon-to-bone healing process for both autografts and allografts and discusses strategies to biologically augment healing.

Magnetic resonance imaging of acute patellar dislocation in children: patterns of injury and risk factors for recurrence.

BACKGROUND: Acute patellar dislocation is a common traumatic condition of the knee seen in the active adolescent. The patterns of injury to the ligamentous and chondral surfaces following dislocation have not been well defined in the pediatric population. The purpose of this study was to characterize the patterns of medial patellofemoral ligament (MPFL), vastus medialis obliqus (VMO), and osteochondral injury on magnetic resonance imaging (MRI) following first-time acute lateral patellar dislocation in pediatric patients. METHODS: Following approval by the Institutional Review Board, a radiology query was performed to identify all patients between the ages of 11 and 18 years who underwent MRI following an acute first-time patellar dislocation over a 10-year period. The presence and location of injury to the MPFL, VMO, and chondral surfaces were evaluated on MRI images. A retrospective review of the patient's chart was conducted to confirm that clinical history was consistent with an acute patellar dislocation. Demographic data, including age at the time of injury, sex, knee affected, mechanism of injury, and recurrence of dislocation, were retrieved from the chart. The data were analyzed as a single cohort. RESULTS: One hundred and eleven patients, including 56 males and 46 females with a mean age of 14.9 years (range, 11 to 18 y), were included. MRI demonstrated MPFL injury in 87 patients (78.4%). MPFL injury was present at an isolated patellar insertion in 34 patients (31%) and an isolated femoral insertion in 16 patients (14%). MPFL injury at more than one location was present in 37 patients (33%). VMO edema was present in 62 patients (56%), consistent with sprain or tear. Osteochondral fracture was identified in 38 knees (34%), with 25 from the medial patellar facet, 5 from the lateral femoral condyle, and 8 from both locations. CONCLUSIONS: Acute patellar dislocations remain a common injury in pediatric patients. The pattern of injury to the MPFL and VMO on MRI has not been described in a pediatric population. The triad of injury to the MPFL, VMO, and chondral surfaces should be recognized and understood, particularly when surgical reconstruction is necessary. LEVEL OF EVIDENCE: Level III.

Use of thermography and fluorescein angiography in the management of a Chilean flamingo with avascular necrosis of the wing.

A Chilean flamingo (Phoenicopterus chilensis) was presented to the veterinary clinic at the North Carolina Zoological Park for evaluation of acute weakness of the right wing. Results of a physical examination revealed a lack of a palpable pulse in the radial artery, which suggested occlusion or obstruction of the vessel. Radiography, thermography, and fluorescein angiography confirmed right wing injury and vascular compromise. Based on the poor prognosis for return to function associated with irreversible vascular damage, the wing was amputated. After a period of observation and treatment, the bird was returned to public exhibit.

Anatomy and biomechanics of the posterior cruciate ligament, medial and lateral sides of the knee.

The evaluation and management of posterior cruciate ligament (PCL) injuries presents a clinical challenge to even the most experienced orthopedic surgeons. Increasing emphasis has also been placed on the diagnosis of associated ligamentous and cartilaginous injuries that may contribute to patterns of instability not solely attributed to the PCL deficiency. Although a uniformly accepted surgical technique to restore the anatomy and biomechanics of the multiligament injured knee does not exist, careful identification and management of additional ligamentous injuries are critical in achieving optimum results and avoid further insult or degradation of the knee joint owing to continued instability. Knowledge of the PCL anatomy and associated structures, combined with a clinical understanding of the biomechanics of the native tissues assist the orthopedic surgeon in treating these difficult injuries.

A clinically relevant review of hip biomechanics.

The hip is a complex anatomic structure composed of osseous, ligamentous, and muscular structures responsible for transferring the weight of the body from the axial skeleton into the lower extremities. This must be accomplished while allowing for dynamic loading during activities such as gait and balance. The evaluation of hip pain and periarticular pathology can be challenging because of the complex local anatomy and broad differential diagnosis. Recent advancements in the evaluation and surgical treatment of hip pathology have led to a renewed interest in the management of these disorders. An understanding of the basic biomechanical and kinematic function of the hip and the consequences of associated pathology can greatly assist the orthopaedic surgeon in appropriately diagnosing and treating these problems. In this review we discuss the basic biomechanical concepts of the native hip and surrounding structures and the changes experienced as a result of various pathologies including dysplasia, femoroacetabular impingement, labral injury, capsular laxity, hip instability, and articular cartilage injury. We will also discuss the clinical implications and surgical management of these pathologies and their role in restoring or preserving the native function of the hip joint.

Nandrolone decanoate and load increase remodeling and strength in human supraspinatus bioartificial tendons.

BACKGROUND: To date, no studies document the effect of anabolic steroids on rotator cuff tendons. STUDY DESIGN: Controlled laboratory study. HYPOTHESIS: Anabolic steroids enhance remodeling and improve the biomechanical properties of bioartificially engineered human supraspinatus tendons. METHODS: Bioartificial tendons were treated with either nandrolone decanoate (nonload, steroid, n = 18), loading (load, nonsteroid, n = 18), or both (load, steroid, n = 18). A control group received no treatment (nonload, nonsteroid [NLNS], n = 18). Bioartificial tendons' remodeling was assessed by daily scanning, cytoskeletal organization by staining, matrix metalloproteinase-3 levels by ELISA assay, and biomechanical properties by load-to-failure testing. RESULTS: The load, steroid group showed the greatest remodeling and the best organized actin cytoskeleton. Matrix metallo-proteinase-3 levels in the load, steroid group were greater than those of the nonload, nonsteroid group (P <.05). Ultimate stress and ultimate strain in the load, steroid group were greater than those of the nonload, nonsteroid and nonload, steroid groups (P <.05). The strain energy density in the load, steroid group was greater when compared to other groups (P <.05). CONCLUSIONS: Nandrolone decanoate and load acted synergistically to increase matrix remodeling and biomechanical properties of bioartificial tendons. CLINICAL RELEVANCE: Data suggest anabolic steroids may enhance production of bioartificial tendons and rotator cuff tendon healing in vitro. More research is necessary before such clinical use is recommended.