Outcomes of Surgical Treatment for Anterior Tibial Stress Fractures in Athletes: A Systematic Review.

BACKGROUND: Although most anterior tibial stress fractures heal with nonoperative treatment, some may require surgical management. To our knowledge, no systematic review has been conducted regarding surgical treatment strategies for the management of chronic anterior tibial stress fractures from which general conclusions can be drawn regarding optimal treatment in high-performance athletes. PURPOSE: This systematic review was conducted to evaluate the surgical outcomes of anterior tibial stress fractures in high-performance athletes. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: In February 2017, a systematic review of the PubMed, MEDLINE, Cochrane, SPORTDiscus, and CINAHL databases was performed to identify studies that reported surgical outcomes for anterior tibial stress fractures. Articles meeting the inclusion criteria were screened, and reported outcome measures were documented. RESULTS: A total of 12 studies, published between 1984 and 2015, reporting outcomes for the surgical treatment of anterior tibial stress fractures were included in this review. All studies were retrospective case series. Collectively, surgical outcomes for 115 patients (74 males; 41 females) with 123 fractures were evaluated in this review. The overall mean follow-up was 23.3 months. The most common surgical treatment method reported in the literature was compression plating (n = 52) followed by drilling (n = 33). Symptom resolution was achieved in 108 of 123 surgically treated fractures (87.8%). There were 32 reports of complications, resulting in an overall complication rate of 27.8%. Subsequent tibial fractures were reported in 8 patients (7.0%). Moreover, a total of 17 patients (14.8%) underwent a subsequent procedure after their initial surgery. Following surgical treatment for anterior tibial stress fracture, 94.7% of patients were able to return to sports. CONCLUSION: The available literature indicates that surgical treatment of anterior tibial stress fractures is associated with a high rate of symptom resolution and return to play in athletes, although the high complication rate and potential need for subsequent procedures are important considerations for surgeons and patients.

Chondroprotection and the prevention of osteoarthritis progression of the knee: a systematic review of treatment agents.

BACKGROUND: Structure-modifying medications or nutraceuticals may be an effective treatment for osteoarthritis. This study identified 12 treatments that may possess chondroprotective properties: oral glucosamine; chondroitin; nonsteroidal anti-inflammatory drugs (NSAIDs); polyunsaturated fatty acids; S-adenosylmethionine; avocado and soybean unsaponifiable fractions; methylsulfonylmethane; vitamins C, D, and E; intra-articular injections of hyaluronic acid; and platelet-rich plasma (PRP). PURPOSE: To perform a systematic review of randomized controlled trials for the effectiveness of each agent in preserving articular cartilage of the knee and delaying the progression of osteoarthritis. STUDY DESIGN: Systematic review; Level of evidence, 2. METHODS: A literature search was performed using PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials. Searches were performed using "treatment," "osteoarthritis," and "knee" as keywords. Selection criteria included randomized controlled trials of ≥12 months, with a placebo control, measuring radiographic changes in joint space width, cartilage volume, or radiographic progression of osteoarthritis. The primary outcome was changes in joint integrity measures. RESULTS: A total of 3514 studies were identified from the initial search, 13 of which met inclusion criteria. Treatment with chondroitin sulfate showed a significant reduction in cartilage loss in 3 of 4 studies identified compared with placebo. Two of 3 trials identified for glucosamine also reported significant structural effects relative to placebo. Intra-articular hyaluronic acid was effective in lowering the rate of cartilage loss in only 1 of 3 studies identified versus placebo. Of the 6 studies identified for NSAIDs, vitamin E, and vitamin D, none showed any structural effect compared with placebo. No studies were found that met the inclusion criteria for polyunsaturated fatty acids, S-adenosylmethionine, avocado and soybean unsaponifiable fractions, methylsulfonylmethane, vitamin C, or PRP. CONCLUSION: For patients with or at risk for osteoarthritis, the use of glucosamine and chondroitin sulfate may serve as a nonoperative means to protect joint cartilage and delay osteoarthritis progression. Hyaluronic acid injections showed variable efficacy, while NSAIDs and vitamins E and D showed no effect on osteoarthritis progression. The other agents evaluated had no evidence in the literature to support or refute their use for chondroprotection.

Neurologic thoracic outlet syndrome: summarizing a complex history and evolution.

Thoracic outlet syndrome (TOS) is a blanket term encapsulating many different clinical entities. Neurologic or neurogenic TOS (NTOS) is its main contributor, but it remains a complicated and sometimes controversial entity. NTOS incorporates numerous types, etiologies, clinical presentations, diagnostic findings, and therapeutic modalities. This article reviews the spectrum of disease within the thoracic outlet that affects the brachial plexus, with a special emphasis on the commonly afflicted sports medicine patient.

Exertional leg pain: teasing out arterial entrapments.

Vascular causes of exertional lower extremity pain are relatively rare, but may be the answer in athletes refractory to treatment for the more common overuse syndromes of the lower extremities. It is important to differentiate these vascular causes from chronic exertional compartment syndrome (CECS), medial tibial stress syndrome (MTSS), and stress fractures in order to develop appropriate treatment plans, avoid complications, and return athletes to play expeditiously. Important vascular etiologies to be considered are popliteal artery entrapment syndrome (PAES), endofibrotic disease, popliteal artery aneurysm, cystic adventitial disease, and peripheral arterial dissections. The diagnostic workup involves angiography or noninvasive vascular studies such as Doppler ultrasound or magnetic resonance angiography in both the neutral and provocative positions. Treatment of these vascular abnormalities typically involves surgical correction of the vascular anomaly.

Sonographically guided percutaneous needle tenotomy for treatment of common extensor tendinosis in the elbow.

OBJECTIVE: Chronic tendinosis of the common extensor tendon of the lateral elbow can be a difficult problem to treat. We report our experience with sonographically guided percutaneous needle tenotomy to relieve pain and improve function in patients with this condition. METHODS: We performed sonographically guided percutaneous needle tenotomy on 58 consecutive patients who had persistent pain and disability resulting from common extensor tendinosis. Under a local anesthetic and sonographic guidance, a needle was advanced into the common extensor tendon, and the tip of the needle was used to repeatedly fenestrate the tendinotic tissue. Calcifications, if present, were mechanically fragmented, and the adjacent bony surface of the apex and face of the epicondyle were abraded. Finally, the fenestrated tendon was infiltrated with a solution containing corticosteroid mixed with bupivacaine. After the procedure, patients were instructed to perform passive stretches and to undergo physical therapy. During a subsequent telephone interview, patients answered questions about their experience, their functioning level, and their perceptions of procedure outcome. RESULTS: Fifty-five (95%) of 58 patients were contacted by telephone and agreed to participate in the study. Thirty-five (63.6%) of 55 respondents reported excellent outcomes, 16.4% good, 7.3% fair, and 12.7% poor. The average follow-up time from the date of the procedure to the date of the interview was 28 months (range, 17-44 months). No adverse events were reported; 85.5% stated that they would refer a friend or close relative for the procedure. CONCLUSIONS: Sonographically guided percutaneous needle tenotomy for lateral elbow tendinosis is a safe, effective, and viable alternative for patients in whom all other nonsurgical treatments failed.

Superior labrum, anterior-posterior lesions and biceps injuries: diagnostic and treatment considerations.

Proximal biceps tendon rupture, biceps tendinitis, and medical biceps subluxation are injuries that occur alone and in association with other pathologic conditions of the shoulder. The literature describes various strategies for imaging and treating these biceps tendon complex injuries but offers no clear consensus on a gold-standard approach. The keys to successful treatment are an accurate diagnosis, identification of associated pathologic conditions, and assessment of functional limitations of the injury.

Dynamic US of the anterior band of the ulnar collateral ligament of the elbow in asymptomatic major league baseball pitchers.

PURPOSE: To determine whether dynamic ultrasonography (US) can reveal abnormalities of the anterior band of the ulnar collateral ligament (UCL) of the elbow in asymptomatic major league professional baseball players. MATERIALS AND METHODS: US was performed in 26 asymptomatic major league professional baseball pitchers before spring training. Images were obtained in both pitching and nonpitching arms with a multifrequency 13-MHz linear-array transducer. The thickness of the anterior band of the UCL and the width of the joint it spans (the ulnohumeral joint) were measured with the elbow at 30 degrees of flexion, both at rest and with valgus stress. The thickness of the anterior band of the UCL and the width of the joint space were compared for pitching and nonpitching arms by using the Student t test. The prevalence of hypoechoic areas and calcifications within the anterior band of the UCL in pitching and nonpitching arms was compared by using the McNemar test. The average time of the US examinations was recorded. RESULTS: At rest, the mean thickness (+/- 1 SD) of the anterior band of the UCL was 6.3 mm +/- 1.1 in pitching arms and 5.3 mm +/- 1.0 in nonpitching arms. This difference was statistically significant (P <.01). With stress, the anterior band thickness was 6.3 mm +/- 1.4 in the pitching arms and 4.8 mm +/- 0.9 in the nonpitching arms (P <.001). The joint space width at rest was 2.8 mm +/- 1.0 in the pitching arms and 2.5 mm +/- 0.7 in the nonpitching arms (not statistically significant). When stress was applied, however, the joint space width was significantly greater in the pitching arms than in the nonpitching arms (4.2 mm +/- 1.5 vs 3 mm +/- 1.0, respectively; P <.01). Hypoechoic foci within the anterior band of the UCL were seen in 18 of 26 (69%) pitching arms and three of 26 (12%) nonpitching arms (P <.001). Calcifications were detected in nine of 26 (35%) pitching arms but in none of the nonpitching arms (P <.001). The average time for bilateral US was 10.4 minutes. CONCLUSION: Dynamic US provides a rapid means for evaluating the anterior band of the UCL in professional baseball pitchers. In pitching arms, this band is thicker, is more likely to have hypoechoic foci and/or calcifications, and demonstrates more laxity with valgus stress.