Clinical Management of Patellar Tendinopathy.

Patellar tendinopathy is a common yet misunderstood condition that afflicts a variety of patient populations. This lack of understanding affects the ability of clinicians to provide effective treatment interventions. Patients with tendinopathy often report long-term and low to moderate levels of pain, diminished flexibility, and reduced strength, as well as decreased physical function. Load-management strategies combined with exercise regimens focused on progressive tendon loading are the most effective treatment options for patients with patellar tendinopathy. This review will provide an evidence-based approach to patellar tendinopathy, including its pathoetiology, evaluation, and treatment strategies.

Platelet-Rich Plasma versus Corticosteroid Injection for the Treatment of Lateral Epicondylitis: A Systematic Review of Systematic Reviews.

BACKGROUND: Lateral epicondylitis (LE) is one of the most commonly reported musculoskeletal disorders in the upper extremity. The mechanism of LE is repetitive motion that causes a strain of the extensor tendons. This consequently causes pain and tendinosis at the tendinous attachment site on the lateral epicondyle. Most cases of LE are treated nonoperatively with a variety of interventions, such as injections. PURPOSE: The aim of this systematic review (SR) is to synthesize the current evidence on the efficacy of platelet rich plasma (PRP) injections versus corticosteroid (CS) injections as treatment interventions for LE. STUDY DESIGN: Systematic Review. METHODS: Online databases were searched from database inception to February 24th, 2020 for relevant SR's evaluating PRP vs. CS injections as treatment methods for LE. Two independent researchers searched and screened for articles that were systematic reviews that directly compared PRP to CS injections for LE. RESULTS: A total of five SR's were included in this review that were published between 2016 and 2020. CS injections were more efficacious for short-term pain relief, and PRP injections were more efficacious for long-term pain relief and improved function. CONCLUSION: PRP injections appear to be a more effective long-term treatment option than CS injections for those with LE who did not respond to conservative management. LEVEL OF EVIDENCE: 1.

Early Ambulation After Hip Fracture Surgery Is Associated With Decreased 30-Day Mortality.

INTRODUCTION: Hip fractures frequently present in complicated patients and are fraught with high morbidity and mortality rates. Postoperatively, delayed ambulation has been identified as a factor associated with increased mortality, although its magnitude has yet to be quantified. Therefore, this article aims to evaluate mortality after hip fracture surgery because it relates to early postoperative ambulation, taking into account preexisting comorbidity burden. METHODS: This is a retrospective review of patients older than age 65 years who underwent surgical fixation for hip fractures because of a low-energy mechanism. Ambulation during the first 3 postoperative days was recorded along with age and preexisting comorbidity burden (Modified 5-Factor Frailty Index), and 30-day and 1-year mortality statuses were examined. Multivariable logistic regression was used to analyze the association between postoperative ambulation and mortality. RESULTS: Of 485 patients initially identified, 218 met the inclusion criteria. Overall mortality rates were 6.4% at 30 days and 18.8% at 1 year. Two-thirds of patients ambulated in the first 3 postoperative days versus one-third who did not. Patients who did not ambulate had both significantly increased 30-day mortality (odds ratio [OR] 4.42, P = 0.010, 95% confidence intervals [CIs] 1.42 to 13.75) and 1-year mortality (OR 2.26, P = 0.022, 95% CI 1.12 to 4.53). After multivariable logistic regression accounting for age and comorbidity status, ambulation remained strongly associated with 30-day (OR 3.87, P = 0.024, 95% CI 1.20 to 12.50) but not 1-year mortality (OR 1.66, P = 0.176, 95% CI 0.80 to 3.48). Although neither were significant at 30 days, both increasing age (OR 1.05, P = 0.020, 95% CI 1.01 to 1.10) and Modified 5-Factor Frailty Index (OR 1.62, P = 0.005, 95% CI 1.16 to 2.26) correlated with increased mortality at 1 year. CONCLUSION: Early ambulation after hip fracture surgery bears a notable, almost four-fold, association with early postoperative mortality independent of age and medical comorbidities. Our results support a growing body of evidence that ambulation is a powerful tool that should continue to be emphasized to optimize mortality in hip fracture patients.

Open Treatment for Unstable Osteochondritis Dissecans of the Knee: Autologous Bone Grafting and Bioabsorbable Fixation.

Osteochondritis dissecans is a common osteochondral abnormality affecting the knee. In unstable lesions, the underlying bone can be significantly abnormal and necessitate treatment. Although many techniques exist, we favor an open surgical approach to ensure that the bone is properly managed. Autologous bone graft can easily be obtained locally and used to restore the bony architecture. The subsequent use of bioabsorbable implants provides a robust means of fixation that allows for single-stage surgery. This Technical Note describes a straightforward but reliable approach to a challenging pathology.

Acromioclavicular joint injuries in overhead athletes: a concise review of injury mechanisms, treatment options, and outcomes.

PURPOSE OF THE REVIEW: To review the relevant literature surrounding acromioclavicular (AC) joint injuries particularly pertaining to overhead athletes. RECENT FINDINGS: The AC joint is a unique anatomic and biomechanical portion of the shoulder that can be problematic for athletes, particularly throwers, when injured. Treatment of these injuries remains a topic in evolution. Low-grade injuries (Rockwood types I & II) are typically treated non-operatively while high-grade injuries (types IV, V, and VI) are considered unstable and often require operative intervention. Type III AC separations remain the most controversial and challenging as no clear treatment algorithm has been established. A wide variety of surgical techniques exist. Unfortunately, relatively little literature exists with regard to overhead athletes specifically. Treatment of AC joint injuries remains challenging, at times, particularly for overhead athletes. Operative indications and techniques are still evolving, and more research is needed specifically surrounding overhead athletes.

Trifurcate Origin of Long Head of Biceps Brachii: A Case Report and Literature Review.

INTRODUCTION: Variant anatomy of the intra-articular portion of the long head of the biceps tendon (LHBT) is rare, and its clinical significance is poorly understood. However, these variants are encountered with increasing frequency due to increasing use of shoulder arthroscopy. CASE REPORT: We report a case of a trifurcate intra-articular LHBT, a variation which, to our knowledge, has not been previously described. The patient was an adult male presenting with chronic atraumatic shoulder pain that worsened with overhead activity. On arthroscopy, the LHBT was found to have three origins from the (1) supraspinatus tendon, (2) superior labrum, and (3) rotator interval that joined together distally within the biceps tunnel. We believe the split tendon may have caused impingement the biceps tunnel; therefore, the patient was treated with subpectoral tenodesis. He also underwent subacromial decompression and rotator cuff debridement. CONCLUSION: This case highlights the importance of surgeon and radiologist awareness of split LHBT variant anatomy, such that misdiagnosis and unnecessary treatment may be avoided.

Management of the Stiff Shoulder With Arthroscopic Circumferential Capsulotomy and Axillary Nerve Release.

Management of the stiff shoulder is a common and frequently daunting clinical scenario. Arthroscopic capsular release is usually an option for management of severe, chronic glenohumeral joint contractures when conservative treatment fails. Technical hurdles including a thickened capsule, reduction in joint volume, and difficulty with positioning the shoulder intraoperatively can make this procedure challenging. In addition, incomplete release and recalcitrant stiffness are frequent issues. We believe a complete release of the capsule entails special attention to the axillary pouch and requires identification and protection of the axillary nerve. We present a technique for a complete arthroscopic circumferential capsulotomy and detail our approach to safely dissect and protect the axillary nerve under arthroscopic visualization.

Biceps Tenodesis: Anatomic Tensioning.

Biceps tenodesis is a commonly employed surgical intervention for refractory symptoms related to the biceps-labral complex, those intra-articular and those within the extra-articular bicipital tunnel. While a litany of surgical techniques exists, the optimal method for ensuring an anatomic length-tension relationship during tenodesis remains elusive. Appropriate tensioning may limit undesirable outcomes such as cramping or cosmetic deformity. We describe herein our technique as a simple and efficient means to establish patient-specific, anatomic tensioning of the long head of the biceps during tenodesis.

Arthroscopic-Assisted Fixation of Ideberg Type III Glenoid Fractures.

Operative treatment of scapular fractures with extension into the glenoid can be a challenging clinical scenario. Though traditionally addressed in an open fashion, the morbidity of this approach, complemented by advancements in arthroscopic technique and instrumentation, has led to increasing use of arthroscopic-assisted fixation. We describe our technique, including pearls and pitfalls, for minimally invasive fixation of Ideberg type III glenoid fractures. This approach minimizes morbidity, allows optimal visualization and reduction, and provides good functional results.

Playing hurt: hand and wrist injuries and protected return to sport.

When treating hand and wrist injuries, there is often an opportunity to allow an athlete to return to play before complete healing of the injury and/or surgery. Protective devices can make this possible. The risks of returning to play in this manner depend on many factors including the injury itself, position played, hand dominance, etc. Communication between treating health care professional, athlete, trainer, and coaches is critical in this decision process. Protective options include taping, custom-made splints, commercially available braces, soft casts, and hard casts. Ability to use these devices during competition is governed by the rules of each individual sport and often dependent on final approval by referee or game official.