The Influence of Perioperative Nerve Block on Strength and Functional Return to Sports After Anterior Cruciate Ligament Reconstruction.

BACKGROUND: Patients often have quadriceps or hamstring weakness after anterior cruciate ligament reconstruction (ACLR), despite postoperative physical therapy regimens; however, little evidence exists connecting nerve blocks and ACLR outcomes. PURPOSE: To compare muscle strength at return to play in patients who received a nerve block with ACLR and determine whether a specific block type affected subjective knee function. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Patients were recruited 5 to 7 months after primary, isolated ACLR and completed bilateral isokinetic strength tests of the knee extensor/flexor groups as a single-session return-to-sport test. Subjective outcomes were assessed with the International Knee Documentation Committee (IKDC) score. Strength was expressed as torque normalized to mass (N·m/kg) and limb symmetry index as involved/uninvolved torque. Chart review was used to determine the type of nerve block and graft used. Nerve block types were classified as knee extensor motor (femoral nerve), knee flexor motor (sciatic nerve), or isolated sensory (adductor canal block/saphenous nerve). A 1-way analysis of covariance controlling for graft type was used. RESULTS: A total of 169 patients were included. Graft type distribution consisted of 102 (60.4%) ipsilateral bone-patellar tendon-bone (BTB) and 67 (39.6%) ipsilateral hamstring tendon. Nerve block type distribution consisted of 38 (22.5%) femoral, 25 (14.8%) saphenous, 45 (26.6%) femoral and sciatic, and 61 (36.1%) saphenous and sciatic. No significant difference was found in knee extensor strength (P = .113) or symmetry (P = .860) between patients with knee extensor motor blocks (1.57 ± 0.45 N·m/kg; 70.1% ± 15.3%) and those without (1.47 ± 0.47 N·m/kg; 69.6% ± 18.8%). A significant difference was found between patients with knee flexor motor blocks (0.83 ± 0.26 N·m/kg) and those without (0.92 ± 0.27 N·m/kg) for normalized knee flexor strength (P = .21) but not knee flexor symmetry (P = .592). Controlling for graft type, there were no differences in subjective knee function (IKDC score) between all nerve block groups (P = .57). CONCLUSION: Our data showed that use of a sciatic nerve block with ACLR in patients with hamstring and BTB grafts influences persistent knee flexor strength deficits at time of return to sports. Although the cause of postoperative muscular weakness is multifactorial, this study adds to the growing body of evidence suggesting that perioperative nerve blocks affect muscle strength and functional rehabilitation after ACLR.

The Timing of Corticosteroid Injections Following Simple Knee Arthroscopy Is Associated With Infection Risk.

PURPOSE: To examine any association between the timing of ipsilateral postoperative corticosteroid injection following simple knee arthroscopy and infection. METHODS: Private payer (PP) and Medicare (MC) national insurance databases were queried for patients who underwent simple arthroscopic knee procedures. Patients undergoing concomitant open or more complex procedures with grafts were excluded. Patients who underwent ipsilateral corticosteroid injections within 2, 4, 6, and 8 weeks postoperatively were then identified. Postoperative infection within 90 days after the injection was assessed using International Classification of Diseases, 9th Revision, and Current Procedural Terminology coding and compared using a multivariate binomial logistic regression analysis. RESULTS: A total of 5,533 patients were identified, including 725 that received an injection within 2 weeks; 1,236 patients within 4 weeks; 1,716 patients within 6 weeks; and 1,856 patients that received an injection within 8 weeks postoperatively. In both the PP and MC datasets, the rate of infection was significantly higher in the 2-week group compared with the 6- (PP: odds ratio [OR] 3.81, P = .012; MC: OR 9.36, P = .001) and 8-week (PP: OR 8.59, P = .003; MC: OR 7.80, P = .001) groups. The rate of infection was also higher in the 4-week group compared with the 6- (PP: OR 2.54, P = .024; MC: OR 8.91, P = .001) and 8-week (PP: OR 5.64, P = .009; MC: OR 7.80, P = .001) groups. There was no difference in infection rates between the 2- and 4-week groups in either dataset (PP: P = .278; MC: P = .861). CONCLUSIONS: There is a significant association between intra-articular knee corticosteroid injections within 4 weeks of surgery and an increased incidence of postoperative infection in both MC and PP patients after knee arthroscopy compared with patients with steroid injections more than 4 weeks postoperatively and matched controls who did not receive injections. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Avoiding Complications with MPFL Reconstruction.

PURPOSE OF REVIEW: To discuss the potentially significant complications associated with medial patellofemoral ligament (MPFL) reconstruction. Additionally, to review the most current and relevant literature with an emphasis on avoiding these potential complications. RECENT FINDINGS: Multiple cadaveric studies have characterized the anatomy of the MPFL and the related morphologic abnormalities that contribute to recurrent lateral patellar instability. Such abnormalities include patella alta, excessive tibial tubercle to trochlear grove (TT-TG) distance, trochlear dysplasia, and malalignment. Recent studies have evaluated the clinical outcomes associated with the treatment of concomitant pathology in combination with MPFL reconstruction, which is critical in avoiding recurrent instability and complications. Although there remains a lack of consensus regarding various critical aspects of MPFL reconstruction, certain concepts remain imperative. Our preferred methods and rationales for surgical techniques are described. These include appropriate work up, a combination of procedures to address abnormal morphology, anatomical femoral insertion, safe and secure patellar fixation, appropriate graft length fixation, and thoughtful knee flexion during fixation.

Transcriptomic analysis of synovial extracellular RNA following knee trauma: A pilot study.

Traumatic knee injuries often result in damage to articular cartilage and other joint structures. Such trauma is a strong risk factor for the future development and progression of osteoarthritis (OA). The molecular mechanisms and signaling pathways modulating response to knee joint trauma remain unclear. Moreover, investigations of biomarkers influencing responses have been targeted rather than broad, unbiased discovery studies. Herein, we characterize the complete complement of extracellular RNA (exRNA) in the synovial fluid of 14 subjects following knee injury. Fluid was collected during surgery from the injured knees, and from the contralateral knee in a subset, undergoing surgical repair of the ACL and/or meniscal repair/debridement. Arthroscopic grading of chondral damage in four knee compartments was performed using the Outerbridge classification. exRNA was extracted and subjected to massively parallel total RNA sequencing. Differential abundance of RNA was calculated between the subject cohorts of injured and non-injured knee, average Outerbridge score ≥0.5 and less, and chronic and acute injury duration defined as ≤4 months till surgery or longer. Overall, expression of several thousand genes was identified in the synovial fluid. Furthermore, differential expression analysis suggests a role of exRNA fragments of matrix metalloproteinases and skeletal muscle fiber genes in the response to traumatic injury. Together, these data suggest that high-throughput approaches can indicate exRNA molecular signatures following knee trauma. Future studies are required to more fully characterize the biological roles of these exRNA and the cadence of their respective release that may lead to translational treatment options for post-traumatic OA. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:1659-1665, 2018.

Treatment of Popliteal (Baker) Cysts With Ultrasound-Guided Aspiration, Fenestration, and Injection: Long-term Follow-up.

BACKGROUND: The purpose of this study was to determine the efficacy of ultrasound-guided aspiration, fenestration, and injection as a treatment in patients with symptomatic popliteal cysts. HYPOTHESIS: Ultrasound-guided aspiration, fenestration, and injection (UGAFI) is an effective and safe treatment option for symptomatic popliteal cysts. STUDY DESIGN: Retrospective cohort study. LEVEL OF EVIDENCE: Level 3. METHODS: Patients who received a UGAFI of popliteal cysts from 2008 to 2011 were identified. Preaspiration (PA) and follow-up Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores, cyst recurrence, complications, cyst complexity, and size were obtained and compared for statistical significance. UGAFI involved aspiration of fluid through a spinal needle, fenestration of the cyst walls and septations, and injection of 1 mL (40 mg) triamcinolone (Kenalog) and 2 mL 0.5% bupivacaine (Sensorcaine) into the decompressed remnant. RESULTS: The mean PA WOMAC score (48.55) improved significantly at final follow-up (FFU) to 17.15 (P < 0.0001) for 47 patients. Within the WOMAC subcategories, there was also a significant difference in pain (PA, 10.68; FFU, 3.94; P < 0.0001), stiffness (PA, 4.51; FFU, 1.77; P < 0.0001), and physical function (PA, 31.34; FFU, 12.17; P < 0.0001). There were 6 reaspirations for recurrence (12.7%), and 1 patient underwent unicompartmental knee arthroplasty. There were no infections or other complications. CONCLUSION: Significant clinical improvement in patients with symptomatic popliteal cysts can be achieved via UGAFI as the sole treatment. CLINICAL RELEVANCE: UGAFI is a safe and effective option as the sole treatment modality for symptomatic popliteal cysts.

Subchondral insufficiency fractures of the knee: review of imaging findings.

Subchondral insufficiency fracture of the knee (SIFK) is a potentially devastating disorder that may progress rapidly to osteoarthritis with articular surface collapse. It should be suspected in the appropriate clinical setting, as in early stages it is usually indistinct on initial plain radiographs and magnetic resonance imaging is required for a definitive diagnosis. Outcome of SIFK depends on several factors, including the initial subchondral fracture size, patient BMI, degree of osteopenia, as well as early diagnosis and initial treatment. The purpose of this paper is to review the clinical presentation, pathophysiology, image findings, complications and outcome of SIFK.

Ultrasound-guided needle localization of the saphenous nerve for removal of neuroma in the infrapatellar branches: technical report.

BACKGROUND: Neuromata formation in the infrapatellar branch of the saphenous nerve (IPBSN) has been well described as a potential complication of arthroscopic knee surgery and knee trauma. Resection has been proven to provide improvement of pain and increased range of motion. Currently, physical examination and surgical exploration based on anatomic landmarks are the standard for intraoperative localization of IPBSN neuromas. OBJECTIVE: To demonstrate the anatomy of the IPSBN and the use of preoperative ultrasound and needle placement for localization of the nerve before sectioning. METHODS: Using both anatomic dissections and the combination of preoperative ultrasound and curved-needle placement, we demonstrate the technical nuances to localize the IPBSN before operative section. RESULTS: Cadaveric dissection is used to illustrate the main trunk of the IPSBN and its branches. In 2 cases, ultrasound guidance was effectively used to localize the saphenous nerve and its branches and facilitate the operative treatment of patients with symptomatic IPBSN neuromas. CONCLUSION: Ultrasound is a widely accepted and commonly utilized imaging modality; however, in this report, ultrasound-guided needle localization was used to aid in the resection of neuromas of small, painful sensory nerves.

Glenohumeral findings on magnetic resonance imaging correlate with innings pitched in asymptomatic pitchers.

BACKGROUND: In recent years, there has been a documented increase in the number of professional baseball players on the disabled list and the total number of days on the disabled list. Pitchers account for the largest number of disabled list reports. PURPOSE: To examine the relationship between magnetic resonance imaging (MRI) findings in asymptomatic professional pitchers and subsequent time on the disabled list (DL). STUDY DESIGN: Cohort study (Prognosis); Level of evidence, 2. METHODS: A total of 21 asymptomatic professional pitchers from a single Major League Baseball (MLB) organization underwent preseason MRIs of their dominant shoulder from 2001 to 2010. Asymptomatic was defined as no related DL stays in the 2 seasons before the MRI. These studies were reevaluated by a fellowship-trained musculoskeletal radiologist who was blinded to patient name, injury history, and baseball history. A second investigator who was blinded to the MRI results collected demographic data, total career number of innings pitched, and any subsequent DL reports for each subject. RESULTS: The mean age at the time of MRI was 29.04 years (range, 20-39 years). Eleven of 21 pitchers had a rotator cuff tear (RCT): 9 had an articular surface tear (AST), and 2 had a full-thickness rotator cuff tear (FTT). Ten had superior labral anterior posterior (SLAP) tears, and 13 had either anterior or posterior labral tears. There was a statistically significant relationship between the number of innings pitched and presence of an RCT (AST + FTT). The mean number of career innings pitched by those with an RCT was 1014 compared with a mean of 729 innings pitched in pitchers without an RCT (P < .01). In addition, the number of career innings pitched was moderately correlated with presence of RCT (r = 0.46) and presence of superior and anterior/posterior labral tears (r = 0.43). There were no statistically significant findings between any single preseason MRI finding and subsequent time on the DL. CONCLUSION: The MRI findings in asymptomatic MLB pitchers do not appear to be related to near future placement on the DL. However, there was a significant difference in numbers of innings pitched between pitchers who had an RCT and those who did not and a moderate correlation between innings pitched and the presence of RCT as well as the presence of labral lesions. This finding supports the notion that RCT and labral injury in pitchers may result from repetitive overhead motion with subsequent strain on the rotator cuff tendons and glenoid labrum. Asymptomatic shoulder lesions in professional baseball pitchers appear to be more frequent than previously thought.

Stress injuries of the ischiopubic synchondrosis.

A 12-year-old competitive runner with enlarged symptomatic right-sided ischiopubic synchondrosis (IPS) is presented, highlighting the pertinent clinical and radiographic findings as well as the basic principles of conservative management and appropriate follow-up surveillance. Magnetic resonance imaging (MRI) studies revealed remarkable asymmetric enlargement of the right inferior pubic ramus with axial fat-suppressed proton density MRI demonstrating an irregular low signal intensity intramedullary line within the right ischiopubic junction. In symptomatic patients, a thorough review of radiologic imaging is warranted in order to confirm the diagnosis of IPS and investigate potential associated injuries. The pertinent radiographic findings vital to making an accurate diagnosis and treatment plan are reviewed.

Anterior cruciate ligament injury and access to care in South Florida: does insurance status play a role?

BACKGROUND: Health insurance status and access to care are recurring topics of discussion and concern. The purpose of this investigation was to examine access to care on the basis of insurance status for patients with anterior cruciate ligament (ACL) injuries in South Florida. METHODS: From March 2010 to March 2011, eighty patients with ACL injuries were identified at a county hospital sports medicine clinic and a university-based sports medicine practice. Demographic and injury-specific data were obtained with attention to the date of injury, the date of diagnosis, and the number of medical visits. Hazard ratios and 95% confidence intervals were calculated from multivariable Cox proportional-hazards regression models to determine the effect of insurance type on the time to diagnosis of an ACL tear. RESULTS: Patients with private insurance were diagnosed at a median fourteen days after the injury, whereas those receiving Medicaid and those without insurance were diagnosed a median of fifty-six and 121 days after the injury, respectively (p < 0.001). Patients without insurance and those receiving Medicaid had more medical visits prior to diagnosis (median, four; range two to six) than those with private insurance (median, three; range, one to five) (p = 0.006). Differences for patient delays due to not seeking care were not significant among the three groups (p = 0.484). CONCLUSIONS: When grouped according to insurance status, subjects receiving Medicaid in South Florida faced greater system-related delays in obtaining care than did subjects with private insurance. System-related factors such as lack of access to specialized care result in an increased number of medical encounters. These regional findings are consistent with those of other regional studies on access to orthopaedic care.