Evaluation of Achilles Tendon Stiffness as Measured by Shear Wave Elastography in Female College Athletes Compared With Nonathletes.

BACKGROUND: We sought to utilize a noninvasive technology to assess the effects of activity on Achilles tendon stiffness and define baseline Achilles tendon stiffness in female college athletes compared with nonathletes using tendon shear wave velocity as a marker for tendon stiffness. HYPOTHESIS: Training status and exercise may affect Achilles tendon stiffness. LEVEL OF EVIDENCE: Level 4. METHODS: A total of 32 college-age female athletes were prospectively enrolled (n = 17 varsity athletes and n = 15 nonathletes). Demographic characteristics, activity level, and previous injuries were recorded. Sonographic shear wave elastography (SWE) was used to assess Achilles tendon shear wave velocity bilaterally for all subjects, both at baseline and after 2 minutes of exercise. Student t tests were used to compare the mean elastography measurements between participants stratified by athlete status and pre/postexercise stimulus. Analysis of variance (ANOVA) was used to compare the mean proximal, middle, and distal Achilles tendon elastography measurements. RESULTS: As seen by a greater mean shear wave velocity (8.60 ± 1.58 m/s vs 8.25 ± 1.89 m/s; P = 0.02), athletes had stiffer tendons than nonathletes. Exercise stimulus decreased average tendon shear wave velocity (8.57 ± 1.74 m/s vs 8.28 ± 1.72 m/s; P = 0.05). Tendon shear wave velocity was greatest proximally and least distally with significant differences between each region (P < 0.001). In addition, there was a significant 2-way interaction between weekly training status and foot dominance (P = 0.01). Post hoc analysis showed that this result was due to differences in tendon shear wave velocity between the dominant and nondominant lower extremity in nonathletes (7.73 ± 2.00 m/s vs 8.76 ± 1.62 m/s; P < 0.001). CONCLUSION: Female varsity collegiate athletes have higher baseline Achilles tendon stiffness as measured by SWE compared with nonathletes. Mean tendon stiffness varies based on Achilles measurement location. SWE is a quick, cost-effective, and noninvasive imaging modality that can be used to evaluate tendon stiffness and elasticity. CLINICAL RELEVANCE: SWE is an efficient and noninvasive imaging modality that can evaluate dynamic tendon stiffness and elasticity. SWE may be helpful to assess injuries in female college athletes and may play a role in risk stratification or clinical follow-up. In theory, SWE could be used to identify athletes with increased elasticity as a marker for potential risk for rupture in this population.

Pericapsular nerve group (PENG) block for hip arthroscopy: a randomized, double-blinded, placebo-controlled trial.

INTRODUCTION: Arthroscopic hip surgery is associated with significant postoperative pain. Femoral nerve blocks have been shown to improve postoperative analgesia at the expense of quadriceps weakness. The pericapsular nerve group (PENG) block could be an alternative that may improve postoperative analgesia while preserving quadriceps strength. Our hypothesis was that a PENG block would provide superior postoperative analgesia compared with a sham block following arthroscopic hip surgery. METHODS: Subjects presenting for arthroscopic hip surgery were randomized in a 1:1 ratio to either an ultrasound-guided unilateral, single-injection PENG block (PENG group) with 20 mL of 0.5% ropivacaine or a sham injection with 5 mL of 0.9% normal saline (Sham group) prior to receiving general anesthesia. The primary outcome of this study was worst pain score within 30 min of emergence from anesthesia. Secondary outcomes included opioid consumption, patient satisfaction with analgesia, opioid-related adverse events, and persistent opioid use at 1 week. RESULTS: Sixty-eight subjects, 34 from the PENG group and 34 from the Sham group, completed the study per protocol. Analysis of the primary outcome demonstrated a mean difference in pain scores of -0.79 (95% CI -1.96 to 0.37; p=0.17) between the PENG and Sham groups immediately following surgery. No secondary outcomes showed statistically significant differences between groups. DISCUSSION: This study demonstrates that a preoperative PENG block does not improve analgesia following arthroscopic hip surgery. TRIAL REIGSTRATION NUMBER: NCT04508504.

Surgical Release of the Adductor Longus With or Without Sports Hernia Repair Is a Useful Treatment for Recalcitrant Groin Strains in the Elite Athlete.

BACKGROUND: Chronic strain and/or tendinopathy of the adductor longus tendon can be a cause of long-standing groin pain in the elite athlete, resulting in significant time lost from competition. Accurate diagnosis and treatment can expedite return to play. PURPOSE/HYPOTHESIS: To evaluate return to sport and performance in National Collegiate Athletic Association (NCAA) Division I football players and National Football League (NFL) players following adductor longus release with or without sports hernia repair. We hypothesized that adductor release will be an effective method of treatment for recalcitrant groin/adductor pain in these athletes. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A cohort study was performed of all NFL players and NCAA Division I college athletes who had undergone an adductor longus tendon release with or without sports hernia repair by 1 of 2 fellowship-trained orthopaedic surgeons between May 1999 and January 2013. All patients reported groin pain below the inguinal ligament and localized to their adductor longus. Symptoms lasted longer than 10 weeks and limited their ability to effectively perform during sport, as assessed by their coach and self-assessment. Questionnaires were given to all 26 patients to assess long-term surgical outcomes. A subgroup analysis was performed for NFL players, in which "performance scores" were calculated according to individual player statistics while playing. Scores obtained before the diagnosis of chronic adductor longus tendinopathy or strain were compared with those after surgery. Patients with prior abdominal or pelvic surgery, radiographic evidence of degenerative joint disease of the hip, labral tears or femoral acetabular impingement, prostatic or urinary tract disease, or nerve entrapment of the ilioinguinal, genitofemoral, or lateral femoral cutaneous nerves were excluded from the study. RESULTS: A total of 32 athletes underwent an adductor longus tenotomy during the study period. Of these patients, 28 were college- or professional-level athletes who underwent an adductor longus tenotomy, with a mean ± SD follow-up time of 6.2 ± 4.2 years (range, 12-178 months). Of the 32 patients, 20 had a concomitant sports hernia repair in addition to an adductor longus tenotomy. Thirty-one patients (97%) were able to return to their previous sport, and 30 (94%) were able to return at their previous level of play. Thirty patients (94%) reported that they were satisfied with their decision to have surgery. No player complained of weakness or a decrease in running speed or power. Mean return to play was 12 weeks from date of surgery. In the subgroup analysis of 16 NFL players, there were no statistically significant differences for the pre- versus postoperative comparisons of the athlete performance scores (P = .74) and the percentage of the games started versus played (P = .46). After separation of players who had a concomitant hernia repair from players who did not, there was no statistically significant difference in performance scores or percentages of games started. CONCLUSION: In this study of elite athletes, adductor longus tenotomy with or without a concomitant sports hernia repair provided overall acceptable and excellent results. Athletes were able to return to their previous level of athletic competition and performance with consistent relief of groin pain. Return to play in an NFL game averaged 12 weeks following surgery.

Magnetic Resonance Imaging (MRI) and Hip Arthroscopy Correlations.

The hip is a complex joint which commonly generates referrals to orthoaedic surgeons. Hip arthroscopy continues to expand its indications for addressing hip pathology. Before operative intervention, the appropriate information must be obtained with magnetic resonance imaging playing a significant role in the workup given its outstanding characterization of soft tissue anatomy. We attempt to highlight multiple hip findings to correlate intraoperative arthroscopic findings with specific magnetic resonance imaging images and sequences.

The Transseptal Arthroscopic Knee Portal Is in Close Proximity to the Popliteal Artery: A Cadaveric Study.

The purpose of this study was to use fluoroscopy to measure the distance between the transseptal portal and the popliteal artery under arthroscopic conditions with an intact posterior knee capsule, and to determine the difference between 90 degrees of knee flexion and full extension. The popliteal artery of eight fresh-frozen cadaveric knees was dissected and cannulated proximal to the knee joint. The posterolateral, posteromedial, and transseptal portals were then established at 90 degrees of flexion. A 4-mm switching stick was placed through the transseptal portal, and barium contrast was injected into the popliteal artery. A lateral fluoroscopic image was taken with the knee in 90 degrees of flexion and full extension, and the distance between the popliteal artery and the switching stick was measured and compared using a paired t-test. In knee flexion, the average distance between the transseptal portal and the anterior aspect of the popliteal artery for the eight cadaveric specimens was 12.0 mm ± 3.3 mm; in extension, this decreased to 9.0 mm ± 2.7 mm. The distance between the transseptal portal and popliteal artery was significantly higher at 90 degrees of knee flexion as compared with extension (p = 0.0005). The transseptal posterior knee arthroscopic portal must be carefully created due to the close proximity to the popliteal artery, and may be closer to the artery than previously reported in specimens with an intact posterior knee capsule. Creating the portal with the knee in flexion significantly displaces the popliteal artery away from the portal reducing the risk of arterial injury.

The Extended Flexor Carpi Radialis Approach for Concurrent Carpal Tunnel Release and Volar Plate Osteosynthesis for Distal Radius Fracture.

PURPOSE: To determine the relative benefits of an extended flexor carpi radialis (FCR) (eFCR) approach with prophylactic carpal tunnel release at the time of volar plate osteosynthesis for distal radius fracture via a single incision into the traditional volar Henry (VH) approach. METHODS: This was a prospective cohort comparison of preoperative and postoperative median nerve function of 27 patients (15 eFCR and 12 VH) with unilateral, isolated distal radius fractures requiring open reduction internal fixation without preoperative acute carpal tunnel syndrome. Patients were operated on via either the eFCR or VH approach. The validated Levine-Katz Carpal Tunnel Questionnaire (symptom and functional severity scores) was administered and Semmes-Weinstein monofilament and 2-point discrimination testing were conducted preoperatively and at 6 weeks and 3 months postoperatively. Grip and pinch strength were measured at 6 weeks and 3 months. The groups were comparable in terms of age, sex, and fracture type and displacement. RESULTS: Comparing across groups, there were no statistically significant differences in any outcome measured preoperatively or postoperatively. The eFCR and VH groups demonstrated significant improvement in functional severity scores, symptom severity, and grip strength. The symptom severity score improved to statistical significance at 6 weeks in the eFCR group and at 3 months in the VH group. CONCLUSIONS: In this small comparative study, the eFCR approach was found to be safe and efficacious. There was no increased surgical morbidity, which suggests that this technique can be used safely for all patients undergoing volar plating and not just in cases of concurrent carpal tunnel syndrome. It allows easier retraction of carpal tunnel contents; therefore, it is our preferred approach.

Treatment trends in adolescent clavicle fractures.

BACKGROUND: Controversy continues with regard to decision making for operative treatment of adolescent clavicle fractures, while the literature continues to support operative treatment for select middle third fractures in adults. The purpose of our study was to evaluate the recent trends in nonoperative and operative management of adolescent clavicle fractures in the United States. METHODS: Data were derived from a publicly available database of patients, PearlDiver Patient Records Database. The database was queried for ICD-9 810.02 (closed fracture of shaft of clavicle), with the age restriction of either 10 to 14 or 15 to 19 years old, along with CPT-23500 (closed treatment of clavicular fracture) and CPT-23515 (open treatment of clavicular fracture) from 2007 to 2011. The χ analysis was used to determine statistical significance with regard to procedural volumes, sex, and region. The Student t test was used to compare average charges between groups. RESULTS: A significant increase in the number of adolescent clavicle fractures managed operatively (CPT-23510, ages 10 to 19 y) from 309 in 2007 to 530 in 2011 was observed (P<0.0001). There was a significantly greater increase in operative management of clavicle fractures in the age 15 to 19 subgroup compared with the age 10 to 14 subgroup (P<0.0001). In the operative group, there was a trend toward a higher number of males being managed with operative intervention. The overall average monetary charge for both nonoperatively and operatively managed adolescent clavicle fractures increased significantly in the study period. A statistically significant increase in normalized incidence of operatively managed adolescent clavicle fractures was noted in the midwest, south, and west regions with the greatest increase in west region where the incidence increased over 2-fold (P<0.0001). CONCLUSIONS: Adolescent clavicle fractures seem to be being treated increasingly with open reduction and internal fixation recently, especially in the 15 to 19 age group. Nevertheless, there remains of lack of high-level studies comparing outcomes of operative and conservative treatment specifically for the adolescent population to justify this recent trend. LEVEL OF EVIDENCE: Level IV-retrospective database analysis.