Does Injection of Hyaluronic Acid Protect Against Early Cartilage Injury Seen After Marathon Running? A Randomized Controlled Trial Utilizing High-Field Magnetic Resonance Imaging.

BACKGROUND: Previous studies have shown that runners demonstrate elevated T2 and T1ρ values on magnetic resonance imaging (MRI) after running a marathon, with the greatest changes in the patellofemoral and medial compartment, which can persist after 3 months of reduced activity. Additionally, marathon running has been shown to increase serum inflammatory markers. Hyaluronic acid (HA) purportedly improves viscoelasticity of synovial fluid, serving as a lubricant while also having chondroprotective and anti-inflammatory effects. PURPOSE/HYPOTHESIS: The purpose was to investigate whether intra-articular HA injection can protect articular cartilage from injury attributed to marathon running. The hypothesis was that the addition of intra-articular HA 1 week before running a marathon would reduce the magnitude of early cartilage breakdown measured by MRI. STUDY DESIGN: Randomized controlled trial; Level of evidence, 2. METHODS: After institutional review board approval, 20 runners were randomized into receiving an intra-articular injection of HA or normal saline (NS) 1 week before running a marathon. Exclusionary criteria included any prior knee injury or surgery and having run >3 prior marathons. Baseline 3-T knee MRI was obtained within 48 hours before the marathon (approximately 5 days after injection). Follow-up 3-T MRI scans of the same knee were obtained 48 to 72 hours and 3 months after the marathon. The T2 and T1ρ relaxation times of articular cartilage were measured in 8 locations-the medial and lateral compartments (including 2 areas of each femoral condyle) and the patellofemoral joint. The statistical analysis compared changes in T2 and T1ρ relaxation times (ms) from baseline to immediate and 3-month postmarathon scans between the HA and NS groups with repeated measures analysis of variance. RESULTS: Fifteen runners completed the study: 6 women and 2 men in the HA group (mean age, 31 years; range, 23-50 years) and 6 women and 1 man in the NS group (mean age, 27 years; range, 20-49 years). There were no gross morphologic MRI changes after running the marathon. Postmarathon studies revealed no statistically significant changes between the HA and NS groups in all articular cartilage areas of the knee on both T2 and T1ρ relaxation times. CONCLUSION: Increased T2 and T1ρ relaxation times have been observed in marathon runners, suggesting early cartilage injury. The addition of intra-articular HA did not significantly affect relaxation times in all areas of the knee when compared with an NS control.

Elbow Trauma Sequelae: Instability, Stiffness, Non-arthroplasty, and Arthroplasty Options.

Sequelae of elbow trauma are complicated to manage. Undiagnosed instability patterns are important to recognize to get the elbow into concentric alignment for further reconstructive efforts. Stiffness is also common after elbow trauma. Surgeons should be familiar with the different approaches to the elbow to safely address stiffness. Non-arthroplasty and arthroplasty salvage options are also important to understand because the indications are expanding and outcomes for these procedures are being better understood.

Hip Arthroscopy - State of the Art in 2018.

The field of hip arthroscopy has undergone considerable change in the past 25 years and continues to evolve at a rapid pace. Lessons from the early complications and challenges of hip arthroscopy have led to improved safety and refinement of instrumentation and techniques. The pathophysiology of hip injuries is better understood, and advances in surgical technique have helped expand indications, particularly as a shift from pathology resection to anatomic repair and reconstructive procedures has occurred. As the field has progressed, longitudinal outcome studies are now available to help judge efficacy. The purpose of this review is to highlight the past 30 years of hip arthroscopy, the current practice trends, and future directions of the field.

How Variable Are Achilles Allografts Used for Anterior Cruciate Ligament Reconstruction? A Biomechanical Study.

BACKGROUND: Allograft tendon used in anterior cruciate ligament reconstruction (ACLR) requires sterilization before implantation. Low-dose gamma irradiation is a means of sterilization that may minimize tissue damage. PURPOSE: To quantify the variability in mechanical properties between low-dose irradiated Achilles tendon allografts used for ACLR. STUDY DESIGN: Descriptive laboratory study. METHODS: A total of 15 intact outer-third Achilles tendon allograft specimens were collected from the remains of full Achilles allografts used for intraoperative ACLR at a single hospital. All grafts were obtained from a single tissue bank and underwent proprietary disinfection and low-dose gamma irradiation (1.5-2.5 Mrad). Biomechanical testing was carried out to measure tendon elongation, failure location during tensile testing, maximum stress, maximum strain, and modulus of elasticity. The mean and standard deviation were calculated for each outcome measure, and the variability between specimens was calculated by the coefficient of variation (CV). The effect of donor age on graft material properties was examined by use of linear regression. One-way analysis of variance was performed to compare differences in the mechanical properties across failure locations. RESULTS: During cyclic testing, tendon elongation averaged 1.4% ± 1.6% with a CV of 118%. During failure testing, the maximum stress averaged 12.2 ± 4.1 MPa, maximum strain averaged 21.0% ± 6.3%, and modulus of elasticity averaged 95.5 ± 30.8 MPa. The CVs for maximum stress, maximum strain, and modulus of elasticity were 34%, 30%, and 32%, respectively. Ten tendons failed in the midsubstance and 5 failed at the tendon-bone enthesis. No differences were noted in mechanical properties between grafts that failed in the midsubstance versus those that failed at the enthesis. Donor age did not correlate with allograft elongation during cyclic load or any of the material property measures during failure testing. CONCLUSION: The variabilities in the material properties and graft elongation during cyclic loading of Achilles tendon allografts used in ACLR fall within the range of properties reported in the literature for other ACLR allografts. Material properties do not differ by donor age or graft failure location observed during failure testing. CLINICAL RELEVANCE: Surgeons should be aware that there exists considerable variation in the mechanical properties of Achilles allograft tendons used for ACLR. This variability is difficult to detect by tissue bank screening or the treating surgeon's inspection and may contribute to the heterogeneity in outcomes of allograft ACLR.

Partial and Full-Thickness RCT: Modern Repair Techniques.

PURPOSE OF REVIEW: The purpose of this article is to review the recent literature concerning modern repair techniques related to partial- and full-thickness rotator cuff tears. RECENT FINDINGS: The understanding of rotator cuff pathology and healing continues to evolve, beginning with emerging descriptions of the anatomic footprint and natural history of rotator cuff tears. Significant controversy remains in treatment indications for partial-thickness rotator cuff lesions as well as optimal surgical repair techniques for both partial- and full-thickness tears. Techniques such as margin convergence and reduction of the so-called "comma" tissue have improved the ability to anatomically reduce large and retracted tears. Repair strength and contact pressures are improved with double-row repairs and transosseus-equivalent techniques compared to traditional single-row repairs. Future work is directed towards obtaining reliable radiographic healing and demonstrating clinical superiority and cost-effectiveness of a single technique. Much recent work regarding rotator cuff anatomy and pathology has been reported. Newer techniques improve repair strength. Despite these advances, significant questions remain concerning surgical indications and clinical outcomes.

Is There an Association Between the "Critical Shoulder Angle" and Clinical Outcome After Rotator Cuff Repair?

BACKGROUND: Variations in scapular morphology have been associated with the development of atraumatic rotator cuff tears (RCTs). The critical shoulder angle (CSA) accounts for both glenoid inclination and lateral extension of the acromion. The impact of the CSA on outcomes after rotator cuff repair (RCR) has not been investigated previously. HYPOTHESIS: Our hypothesis was that individuals with smaller CSAs will have better patient-reported outcome scores over time compared with those with larger CSAs. Theoretically, a smaller CSA minimizes the biomechanical forces favoring superior translation of the humeral head, which may be advantageous after RCR. This is the first study to examine the relationship between the CSA and clinical outcomes after RCR. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Fifty-three patients (mean age, 61 years) with atraumatic full-thickness RCTs who underwent arthroscopic RCR were prospectively evaluated. Demographic data as well as the Western Ontario Rotator Cuff Index (WORC) score, American Shoulder and Elbow Surgeons (ASES) score, and a visual analog scale (VAS) for pain were prospectively collected at various time points up to 24 months postoperatively. Statistical analysis included longitudinal multilevel regression modeling to investigate the association between the CSA and the WORC, ASES, and VAS scores. RESULTS: The overall clinical outcome, as measured by the WORC, ASES, and VAS, improved significantly (P < .0001). Controlling for demographic and clinical characteristics, a multilevel regression analysis demonstrated that the CSA was not a significant independent predictor for change in WORC (P = .581), ASES (P = .458), or VAS (P = .859) scores at 24 months after arthroscopic RCR. Interobserver and intraobserver reliability for CSA measurements resulted in interclass correlation coefficients of 0.986 and 0.982, respectively (P < .001), indicating excellent agreement. CONCLUSION: The CSA did not appear to be a significant predictor of patient-reported outcomes after arthroscopic repair of atraumatic full-thickness RCTs.

An Algorithmic Approach to the Management of Recurrent Lateral Patellar Dislocation.

High-level evidence supports nonoperative treatment for first-time lateral acute patellar dislocations. Surgical intervention is often indicated for recurrent dislocations. Recurrent instability is often multifactorial and can be the result of a combination of coronal limb malalignment, patella alta, malrotation secondary to internal femoral or external tibial torsion, a dysplastic trochlea, or disrupted and weakened medial soft tissue, including the medial patellofemoral ligament (MPFL) and the vastus medialis obliquus. MPFL reconstruction requires precise graft placement for restoration of anatomy and minimal graft tension. MPFL reconstruction is safe to perform in skeletally immature patients and in revision surgical settings. Distal realignment procedures should be implemented in recurrent instability associated with patella alta, increased tibial tubercle-trochlear groove distances, and lateral and distal patellar chondrosis. Groove-deepening trochleoplasty for Dejour type-B and type-D dysplasia or a lateral elevation or proximal recession trochleoplasty for Dejour type-C dysplasia may be a component of the treatment algorithm; however, clinical outcome data are lacking. In addition, trochleoplasty is technically challenging and has a risk of substantial complications.

Multiple Adjacent Isolated Thoracic Spinous Process Fractures in High-Energy Trauma.

Isolated thoracic spinous process fractures involving multiple adjacent vertebral segments are a rare occurrence in the setting of high-energy trauma. These findings should prompt further investigation to exclude other concomitant osseous or ligamentous injuries. Evaluation by computed tomography is often most useful to detect these fractures. Proper treatment of extensive multilevel injury is poorly defined in the literature. In our experience, conservative management consisting of initial bracing with graduated lifting restrictions has produced excellent functional results.

Delayed presentation of pharyngeal erosion after anterior cervical discectomy and fusion.

Dysphagia after anterior cervical discectomy and fusion (ACDF) is common, with a prevalence ranging between 28% and 57% of cases. However, nearly all cases resolve spontaneously within 2 years, thus identifying patients who require more detailed or invasive work-up is a challenging task for clinicians. A review of literature reveals a paucity of case reports detailing work-up and successful management options. The authors performed a clinical and radiographic review of a case of a 47-year-old female who presented with persistent dysphagia 3 years following anterior cervical spine surgery and was found to have an erosive pharyngeal defect with exposed spinal hardware. The diagnosis was made with direct laryngoscopy and treatment consisted of plate removal and pharyngeal repair, followed by revision fusion with deformity correction. This case and the accompanying pertinent review of the literature highlight the importance of a thorough evaluation of dysphagia, especially in the mid- and late-term postoperative period following ACDF, when most cases of dysphagia should have been resolved. Correctly identifying the underlying etiology of dysphagia may lead to improved revision of ACDF outcomes. Unresolved dysphagia should be a red flag for surgeons as it may be the presentation of erosive esophageal/pharyngeal damage, a rare but serious complication following ACDF.