Editorial Commentary: Periarticular and Intra-Articular Injections May Do the Right Thing for Patients' Pain but May Be the Wrong Thing for Their Articular Cartilage: Be Careful.

Periarticular and intra-articular injections are regularly used by orthopaedic surgeons both in the clinic and operative setting. These injections include the use of local anesthetics, nonsteroidal anti-inflammatories, steroidal anti-inflammatories, and other classes of pharmaceuticals. Local anesthetics can be injected alone or in conjunction with other pharmaceuticals to maximize pain control and to minimize narcotic use as part of a multimodal pain control algorithm. Use of intra-articular local anesthetics has been shown to improve postoperative pain scores and reduce intravenous and oral narcotic consumption and narcotic-related side effects, such as constipation, sedation, depression, respiratory depression, and long-term abuse potential. However, there have been reports of chondrolysis and other side effects from these injections. In general, it can be said that lidocaine is more chondrotoxic than bupivacaine and that methylprednisolone is more chondrotoxic when combined with either lidocaine or bupivacaine. Ropivacaine with steroid maybe less chondrotoxic, but this has yet to be established. It has been shown that ropivacaine with steroids may be toxic to chondrocytes as well as bovine tenocytes. In addition, it can be generalized that longer exposures, such as an indwelling, intra-articular catheter, are more chondrotoxic than shorter exposures, such as an intra-articular injection. Greater concentrations of lidocaine and bupivacaine (i.e., 1% vs 2% and 0.25% vs 0.5%, respectively) are more toxic to chondrocytes. Cellular morphine studies have resulted in conflicting reports of whether or not it is chondrotoxic. Both ketorolac and acetaminophen have been shown to decrease postoperative pain, but ketorolac also has been shown to be chondrotoxic in a human chondrocyte model. Doing the right thing for our patients' pain may be the wrong thing for their articular cartilage. Expansion of indications for these injections should be approached with caution.

Comparison of ACL Strain in the MCL-Deficient and MCL-Reconstructed Knee During Simulated Landing in a Cadaveric Model.

BACKGROUND: Noncontact anterior cruciate ligament (ACL) injury after valgus landing has been reported and studied biomechanically. However, the role of the medial collateral ligament (MCL) in dissipating these forces has not been fully elucidated. Purpose/Hypothesis: The purpose of this study was to investigate the role that the MCL plays in ACL strain during simulated landing. The hypothesis was that ACL strain would increase significantly in MCL-incompetent knees compared with the native knee and that reconstructing the MCL would return the values to those of the intact knee. STUDY DESIGN: Controlled laboratory study. METHODS: Eight fresh-frozen human cadaveric knees were used in this study. A materials testing machine applied a force of 2× body weight over 60 milliseconds to simulate landing after a jump. The knees were tested in 12 loading conditions, consisting of full extension or 15° of flexion combined with 7° of valgus or neutral alignment while the tibia was in external rotation, neutral rotation, or internal rotation. This test procedure was repeated on each specimen with the MCL transected and reconstructed. The superficial and deep MCL was transected along with the posterior oblique ligament, which was thought to simulate a worst case scenario. The MCL was reconstructed by use of semitendinosus and gracilis tendon grafts. RESULTS: During internal rotation at 0° of flexion and 0° of valgus, both the intact ( P = .005) and the reconstructed ( P = .004) MCL states placed significantly lower strain on the ACL than did the transected MCL. The reconstructed MCL state at 0° of flexion and 7° of valgus ( P = .049) along with 15° of flexion and 0° of valgus ( P = .020) also placed significantly lower strain on the ACL than did the transected MCL. For external rotation testing at 0° of flexion and 7° of valgus, the reconstructed MCL state placed significantly lower strain on the ACL than did the transected MCL ( P = .039). Finally, during neutral rotation, the ACL strain at 0° of valgus and 0° of flexion, and at 7° of valgus and 0° of flexion was significantly lower for the MCL-intact groups ( P < .028) and MCL-reconstructed groups ( P < .016) than the MCL-transected groups. CONCLUSION: The current findings demonstrate that during valgus landing, a knee with an incompetent MCL puts the ACL under increased strain. These values are highest in full extension with the tibia in internal and neutral rotation. This increased strain can be reduced to baseline levels with reconstruction. CLINICAL RELEVANCE: A knee with an incompetent MCL puts the ACL under increased strain. Once the MCL has healed in an elongated manner, MCL reconstruction should be considered.