Meniscus Repair and Replacement.

The importance of preserving the function of the meniscus is seen with renewed interest. There has been an evolution of arthroscopic meniscus repair from inside-out, outside-in, meniscal fixators, to all-inside suturing techniques. Tear patterns once ignored or thought to be irreparable, such as root tears and horizontal cleavage tears, have recently been undergoing repair with promising results. Newer techniques have also recently allowed surgeons to address postmeniscectomy knee pain. Replacing lost tissue with scaffolds or replacing the meniscus with an allograft helps restore function and reduce degenerative changes.

Return to Play in Athletes Receiving Cervical Surgery: A Systematic Review.

Study Design Systematic review. Clinical Questions Among athletes who undergo surgery of the cervical spine, (1) What proportion return to play (RTP) after their cervical surgery? (2) Does the proportion of those cleared for RTP depend on the type of surgical procedure (artificial disk replacement, fusion, nonfusion foraminotomies/laminoplasties), number of levels (1, 2, or more levels), or type of sport? (3) Among those who return to their presurgery sport, how long do they continue to play? (4) Among those who return to their presurgery sport, how does their postoperative performance compare with their preoperative performance? Objectives To evaluate the extent and quality of published literature on the topic of return to competitive athletic completion after cervical spinal surgery. Methods Electronic databases and reference lists of key articles published up to August 19, 2015, were searched to identify studies reporting the proportion of athletes who RTP after cervical spine surgery. Results Nine observational, retrospective series consisting of 175 patients were included. Seven reported on professional athletes and two on recreational athletes. Seventy-five percent (76/102) of professional athletes returned to their respective sport following surgery for mostly cervical herniated disks. Seventy-six percent of recreational athletes (51/67) age 10 to 42 years RTP in a variety of sports following surgery for mostly herniated disks. No snowboarder returned to snowboarding (0/6) following surgery for cervical fractures. Most professional football players and baseball pitchers returned to their respective sport at their presurgery performance level. Conclusions RTP decisions after cervical spine surgery remain controversial, and there is a paucity of existing literature on this topic. Successful return to competitive sports is well described after single-level anterior cervical diskectomy and fusion surgery for herniated disk. RTP outcomes involving other cervical spine diagnoses and surgical procedures remain unclear. Additional quality research is needed on this topic.

Injury Rate and Patterns Among CrossFit Athletes.

BACKGROUND: CrossFit is a type of competitive exercise program that has gained widespread recognition. To date, there have been no studies that have formally examined injury rates among CrossFit participants or factors that may contribute to injury rates. PURPOSE: To establish an injury rate among CrossFit participants and to identify trends and associations between injury rates and demographic categories, gym characteristics, and athletic abilities among CrossFit participants. STUDY DESIGN: Descriptive epidemiology study. METHODS: A survey was conducted, based on validated epidemiologic injury surveillance methods, to identify patterns of injury among CrossFit participants. It was sent to CrossFit gyms in Rochester, New York; New York City, New York; and Philadelphia, Pennsylvania, and made available via a posting on the main CrossFit website. Participants were encouraged to distribute it further, and as such, there were responses from a wide geographical location. Inclusion criteria included participating in CrossFit training at a CrossFit gym in the United States. Data were collected from October 2012 to February 2013. Data analysis was performed using Fisher exact tests and chi-square tests. RESULTS: A total of 486 CrossFit participants completed the survey, and 386 met the inclusion criteria. The overall injury rate was determined to be 19.4% (75/386). Males (53/231) were injured more frequently than females (21/150; P = .03). Across all exercises, injury rates were significantly different (P < .001), with shoulder (21/84), low back (12/84), and knee (11/84) being the most commonly injured overall. The shoulder was most commonly injured in gymnastic movements, and the low back was most commonly injured in power lifting movements. Most participants did not report prior injury (72/89; P < .001) or discomfort in the area (58/88; P < .001). Last, the injury rate was significantly decreased with trainer involvement (P = .028). CONCLUSION: The injury rate in CrossFit was approximately 20%. Males were more likely to sustain an injury than females. The involvement of trainers in coaching participants on their form and guiding them through the workout correlates with a decreased injury rate. The shoulder and lower back were the most commonly injured in gymnastic and power lifting movements, respectively. Participants reported primarily acute and fairly mild injuries.

Acute traumatic tear of gluteus medius and minimus tendons in a patient without antecedant peritrochanteric hip pain.

Morphologic similarities between the abductor mechanisms of the hip and shoulder have given rise to the term rotator cuff tear of the hip. Although the true incidence of gluteus medius and minimus tears in the general population is unknown, the association between these tears and recalcitrant lateral hip pain has been described as greater trochanteric pain syndrome. Historically, tears of the gluteus medius and minimus have been thought to be attritional, and associated with chronic peritrochanteric pain, found incidentally during fracture fixation or hip arthroplasty, or with failure of abductor repair following arthroplasty utilizing the anterolateral approach. The literature supports favorable clinical outcomes with operative repair utilizing either endoscopic or open techniques. To our knowledge, there has never been a reported case of an acute traumatic tear of the gluteus medius and minimus that occurred without antecedant peritrochanteric hip pain. In this case, the patient was treated with acute open repair of the gluteus medius and minimus tendons within 3 weeks of injury and excellent clinical results were obtained at 6-month follow-up. Of note, the patient was notified and gave consent for his case to be used in publication.

Acute femoral "peel-off" tears of the posterior cruciate ligament: technique for arthroscopic anatomical repair.

Management of posterior cruciate ligament injuries remains a topic of discussion among treating physicians. Injury severity, anatomical location, and presence of concomitant associated knee injuries are important factors that may be used to guide treatment strategies. Various subtypes of posterior cruciate ligament injury have been identified. Each has unique properties that affect treatment design. Among these subtypes is the acute femoral "peel-off" tear, which represents a distinct pattern of injury that consistently has demonstrated a favorable capacity for healing with repair rather than reconstruction. In this article, we present an arthroscopic anatomical repair technique that has been used with success at our institution. It is important to properly identify such injuries in a timely manner so that appropriate treatment is initiated and the patient may be spared a lengthier and more technically complex reconstruction procedure.

Comparison of the collagen meniscus implant with partial meniscectomy. A prospective randomized trial.

BACKGROUND: Loss of meniscal tissue leads to increased pain and decreased clinical function and activity levels. We hypothesized that patients receiving a collagen meniscus implant would have better clinical outcomes than patients treated with partial medial meniscectomy alone. METHODS: Three hundred and eleven patients with an irreparable injury of the medial meniscus or a previous partial medial meniscectomy, treated by a total of twenty-six surgeon-investigators at sixteen sites, were enrolled in the study. There were two study arms, one consisting of 157 patients who had had no prior surgery on the involved meniscus (the "acute" arm of the study) and one consisting of 154 patients who had had one, two, or three prior meniscal surgical procedures (the "chronic" arm). Patients were randomized either to receive the collagen meniscus implant or to serve as a control subject treated with a partial meniscectomy only. Patients underwent frequent clinical follow-up examinations over two years and completed validated outcomes questionnaires over seven years. The patients who had received a collagen meniscus implant were required by protocol to have second-look arthroscopy at one year to determine the amount of new tissue growth and to perform a biopsy to assess tissue quality. Reoperation and survival rates were determined. RESULTS: In the acute group, seventy-five patients received a collagen meniscus implant and eighty-two were controls. In the chronic group, eighty-five patients received the implant and sixty-nine were controls. The mean duration of follow-up was fifty-nine months (range, sixteen to ninety-two months). The 141 repeat arthroscopies done at one year showed that the collagen meniscus implants had resulted in significantly (p = 0.001) increased meniscal tissue compared with that seen after the original index partial meniscectomy. The implant supported meniscus-like matrix production and integration as it was assimilated and resorbed. In the chronic group, the patients who had received an implant regained significantly more of their lost activity than did the controls (p = 0.02) and they underwent significantly fewer non-protocol reoperations (p = 0.04). No differences were detected between the two treatment groups in the acute arm of the study. CONCLUSIONS: New biomechanically competent meniscus-like tissue forms after placement of a collagen meniscus implant, and use of the implant appears safe. The collagen meniscus implant supports new tissue ingrowth that appears to be adequate to enhance meniscal function as evidenced by improved clinical outcomes in patients with a chronic meniscal injury. The collagen meniscus implant has the utility to be used to replace irreparable or lost meniscal tissue in patients with a chronic meniscal injury. The implant was not found to have any benefit for patients with an acute injury.

Arthroscopic evaluation of radiofrequency chondroplasty of the knee.

BACKGROUND: Considerable debate exists over the use of radiofrequency-based chondroplasty to treat partial-thickness chondral defects of the knee. This study used second-look arthroscopy to evaluate cartilage defects previously treated with bipolar radiofrequency-based chondroplasty. HYPOTHESIS: Partial-thickness articular cartilage lesions treated with bipolar radiofrequency-based chondroplasty will show no progressive deterioration. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: One hundred ninety-three consecutive patients underwent bipolar radiofrequency-based chondroplasty over 38 months; 15 (25 defects treated with bipolar radiofrequency-based chondroplasty) underwent repeat arthroscopy for recurrent or new injuries. Time from the initial to repeat arthroscopy ranged from 0.7 to 32.7 months. At both procedures, the location, size, grade, and stability of lesions were evaluated, recorded, and photographed arthroscopically. RESULTS: At the initial procedure, 25 lesions treated using bipolar radiofrequency-based chondroplasty ranged from 9 to 625 mm2 (mean, 170.2 +/- 131.2 mm2; median, 120 mm2); at second look, lesion size was 9 to 300 mm2 (mean, 107.7 +/- 106.7 mm2; median, 100 mm2). At second look, 3 (12%) demonstrated unstable borders with damage in the surrounding cartilage that appeared to be progressive. Eight (32%) lesions were unchanged in size. Eight (32%) demonstrated partial filling with stable repair tissue, and 6 (24%) demonstrated complete filling with stable repair tissue. Lesions in the tibiofemoral compartments showed better response to radiofrequency chondroplasty than did those within the patellofemoral joint (P < .05). CONCLUSION: Only 3 of 25 lesions demonstrated progression. More than 50% showed partial or complete filling of the defect. Bipolar radiofrequency chondroplasty is an effective way to treat partial-thickness cartilage lesions; however, long-term effects of this treatment on cartilage remain unknown.

Second-look arthroscopic observations after radiofrequency treatment of partial thickness articular cartilage defects in human knees: report of four cases.

Partial thickness articular cartilage defects in the knee are commonly encountered clinical problems. Recently, use of radiofrequency-based devices for performing arthroscopic chondroplasty has gained popularity. However, published experimental studies using different methods for evaluating the histologic effects of radiofrequency-chondroplasty on surrounding cartilage offer contradictory results. To date, few clinical findings after radiofrequency-based chondroplasty have been reported. We present four patients where follow-up arthroscopy documented partial thickness articular defects treated previously with radiofrequency-based chondroplasty to be completely filled with stable repair tissue. No attempt was made to stimulate cartilage regeneration (ie, abrasion or microfracture) in any of these cases.

Results of repeat meniscal repair.

BACKGROUND: The efficacy of repeat repair of retorn menisci has not been demonstrated. PURPOSE: To document clinical and radiographic results of repeat repair of retorn menisci that had previously undergone primary repair. STUDY DESIGN: Uncontrolled retrospective review. METHODS: Eighteen consecutive repeat meniscal repairs were performed over an 11-year period. RESULTS: Fourteen of 18 patients (13 repeat meniscal repairs and 1 second repeat meniscal repair) had clinically intact menisci and were available for a mean follow-up of 7.33 years (range, 3.25 to 13.75). The average durability of the initial repair was 3.46 years (range, 0.17 to 14.67). Five patients sustained a tear at the site of rerepair; one underwent second repeat repair of the meniscus and the other four patients underwent partial meniscectomy. The mean Lysholm score for the remaining 14 patients was 82.1 (range, 38 to 100), and the mean Tegner score was 5.6 (range, 2 to 8). On the International Knee Documentation Committee rating scale, five knees received an overall rating of normal; six, nearly normal; and three, abnormal. Radiographs revealed grade 0 changes (normal) in five of the involved knee compartments and grade I changes (sclerosis or mild narrowing measuring 1 to 2 mm) in the remaining five. CONCLUSIONS: Repeat repair of retorn menisci had a 72% survival rate with relief of symptoms and return to high levels of function.

Arthrofibrosis of the knee following ligament surgery.

Arthrofibrosis of the knee is one of the most serious complications that can result from ligament surgery. Reported incidence of arthrofibrosis following anterior cruciate ligament reconstruction ranges from 4% to 35%. The loss of motion caused by arthrofibrosis can be even more disabling than the instability for which the reconstruction was performed, often requiring extensive physical therapy and/or surgical lysis of adhesions. With aggressive rehabilitation and modifications in the bracing of knees undergoing ligament reconstruction, the incidence of this complication has decreased significantly. Additionally, delaying anterior cruciate ligament reconstruction until the acute inflammatory period has resolved has also been shown to be a significant factor in the reduction of postoperative knee stiffness.

Meniscus repair: considerations in treatment and update of clinical results.

The meniscus plays an important role in the function of the knee. Preservation of the meniscus is preferred if possible when considering treatment of a meniscus tear. A thorough understanding of the anatomy of the meniscus, the structure, the mechanics, and other factors of meniscal healing are critical when evaluating the torn meniscus for a reparative procedure. Many options for meniscus repair exist for the orthopaedist. Options such as open repair or arthroscopically-assisted inside-out techniques have long-term favorable results. The all-inside techniques are attractive because of the decrease in operative time and ease of the technique. Short-term results are positive for the all-inside technique; however, good long-term data on these techniques are lacking. Few well-designed prospective studies exist on any of the meniscus repair techniques. Future directions include the potential use of growth factors and gene therapy to augment meniscus repair.