Barry P. Boden

Analgesic effect of intraarticular morphine, bupivacaine, and morphine/bupivacaine after arthroscopic knee surgery

In a double-blind randomized fashion, 38 patients were divided into four groups according to the intraarticular injection received after arthroscopic surgery. Patients in group I (n = 7) received saline, group II (n = 10) morphine, group III bupivacaine, and group IV (n = 11) morphine and bupivacaine. Before surgery and at 0.5, 1, 1.5, 2, 6, and 24 h postoperatively, pain levels were recorded. In addition, postoperative supplemental i.v. morphine requested by the patient was tabulated. Results showed that the mean consumption of supplemental analgesia was lowest in the morphine/bupivacaine group. Although there was a statistically significant difference in pain scores between the saline group and the other three groups during the early postoperative period, there was no significant difference in pain scores between the morphine, bupivacaine, and morphine/bupivacaine groups. We conclude that postoperative, intraarticular injection of analgesics is beneficial in reducing pain levels. The combination of morphine/bupivacaine appears to be the most beneficial analgesic due to its low supplemental analgesic requirements postoperatively.

Fatalities in High School and College Football Players

Background: Fatalities in football are rare but tragic events. Purpose: The purpose was to describe the causes of fatalities in high school and college football players and potentially provide preventive strategies. Study Design: Descriptive epidemiology study. Methods: We reviewed the 243 football fatalities reported to the National Center for Catastrophic Sports Injury Research from July 1990 through June 2010. Results: Football fatalities averaged 12.2 per year, or 1 per 100,000 participants. There were 164 indirect (systemic) fatalities (average, 8.2 annually [or 0.7 per 100,000 participants]) and 79 direct (traumatic) fatalities (average, 4.0 annually [or 0.3 per 100,000 participants]). Indirect fatalities were 2.1 times more common than direct fatalities. The risk of a fatality in college compared with high school football players was 2.8 (95% CI, 0.7-8.2) times higher for all fatalities, 3.6 (95% CI, 2.5-5.3) times higher for indirect events, 1.4 (95% CI, 0.6-3.0) times higher for direct injuries, 3.8 (95% CI, 1.8-8.3) times higher for heat illness, and 66 (95% CI, 14.4-308) times higher for sickle cell trait (SCT) fatalities. Most indirect events occurred in practice sessions; preseason practices and intense conditioning sessions were vulnerable periods for athletes to develop heat illness or SCT fatalities, respectively. In contrast, most brain fatalities occurred during games. The odds of a fatality during the second decade, compared with the first decade of the study, were 9.7 (95% CI, 1.2-75.9) for SCT, 1.5 (95% CI, 0.8-2.9) for heat illness, 1.1 (95% CI, 0.8-1.7) for cardiac fatalities, and 0.7 (95% CI, 0.4-1.2) for brain fatalities. The most common causes of fatalities were cardiac failure (n = 100, 41.2%), brain injury (n = 62, 25.5%), heat illness (n = 38, 15.6%), SCT (n = 11, 4.5%), asthma and commotio cordis (n = 7 each, 2.9% each), embolism/blood clot (n = 5, 2.1%), cervical fracture (n = 4, 1.7%), and intra-abdominal injury, infection, and lightning (n = 3, 1.2% each). Conclusion: High school and college football have approximately 12 fatalities annually with indirect systemic causes being twice as common as direct blunt trauma. The most common causes are cardiac failure, brain injury, and heat illness. The incidence of fatalities is much higher at the college level for most injuries other than brain injuries, which were only slightly more common at the college level. The risk of SCT, heat-related, and cardiac deaths increased during the second decade of the study, indicating these conditions require a greater emphasis on diagnosis, treatment, and prevention.

Acute compartment syndrome of the lower extremity secondary to noncontact injury

We retrospectively reviewed the cases of three patients with injuries similar to the mechanism of an ankle sprain which resulted in compartment syndrome of the lower extremity. All three patients presented with sharp, proximal, anterolateral pain in the leg after an indirect, twisting injury. None of the injuries involved direct contact. Two of the three athletes initially presented to local hospitals, where the injury was misdiagnosed as an ankle sprain. The mechanism appears to be a muscle strain or tear with resultant hemorrhage in the compartment. All three patients returned to high-level athletics after prolonged recovery periods.

Patellofemoral Kinematics and Tibial Tuberosity-Trochlear Groove Distances in Female Adolescents With Patellofemoral Pain.

Background: Patellofemoral pain (PFP) is a prevalent disorder among female adolescents. Overuse is frequently cited as the cause of pain for this population. What is currently unclear, however, is if the patella demonstrates abnormal tracking patterns relative to the femoral trochlear groove in female adolescents with PFP. Purpose: The aim of this case-control study was to determine if abnormal patellar tracking patterns are present in female adolescents with PFP. The secondary aim was to identify if an increased tibial tuberosity–trochlear groove (TT-TG) distance is associated with the observed kinematic patterns. Study Design: Controlled laboratory study. Methods: Twenty female adolescent knees from 12 patients with PFP and 20 age-matched female knees from 13 healthy controls were recruited for this study. Patellofemoral kinematics (eg, lateral patellar displacement) during a repetitive knee extension-flexion maneuver was quantified by dynamic cine phase-contrast magnetic resonance imaging (MRI). Static MRI scans were used to determine the TT-TG distance. Results: Relative to the control cohort, female adolescents with PFP demonstrated significantly greater lateral displacement at 10° (3.2 mm; P < .001), 20° (2.3 mm; P < .001), and 30° (1.7 mm; P = .014) of knee flexion. A subgroup within this cohort (7 knees from 5 patients) demonstrated extreme lateral maltracking >2 SDs of the mean of the control cohort. This subgroup also demonstrated a greater TT-TG distance relative to the controls (Δ = 4.2 mm; P = .001). Conclusion: This study demonstrates abnormal lateral patellar displacement in the absence of patellar tilt in female adolescents with PFP. Because all adolescents from both cohorts participated in impact sports, it appears that rigorous athletic training alone is inadequate to produce symptoms in this population. Rather, PFP may derive from a combination of physical activity in the context of pathological kinematics. Clinical Relevance: Abnormal patellar tracking patterns and abnormal static alignment have been shown to contribute to the etiology of patellofemoral pain in adults. This study demonstrates that pathologic patellar tracking patterns are present in adolescent females with patellofemoral pain.

The Tibial Tubercle–Trochlear Groove Distance Is Greater in Patients With Patellofemoral Pain: Implications for the Origin of Pain and Clinical Interventions

Background: The distance between the tibial tubercle (TT) and trochlear groove (TT-TG distance) is known to be greater in patients with patellar instability. However, the potential role and prevalence of pathological TT-TG distances in a large cohort of skeletally mature patients with isolated patellofemoral pain (PFP) are not clear. Purpose: To determine if the mean TT-TG distance is greater in patients with PFP, who lack a history of patellar dislocations, knee trauma, or osteoarthritis, relative to healthy controls. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A total of 50 knees (38 patients) with PFP and 60 knees (56 controls) without PFP formed the basis of this study. Magnetic resonance imaging was used to determine the TT-TG distance from 3-dimensional static scans. Results: The cohort with PFP demonstrated a significantly greater mean TT-TG distance relative to asymptomatic controls (13.0 vs 10.8 mm, respectively; P = .001). Among the cohort with PFP, 15 knees (30%) demonstrated TT-TG distances ≥15 mm, and 3 knees (6%) demonstrated TT-TG distances ≥20 mm. Conclusion: Most adult patients with isolated PFP have elevated TT-TG distances compared with controls, which likely contributes to the force imbalance surrounding the knee.

Patellar Maltracking Persists in Adolescent Females With Patellofemoral Pain: A Longitudinal Study

Background: Patellofemoral pain is one of the most common conditions seen in sports medicine practices, particularly among adolescent females. However, the natural history of the underlying pathology in patellofemoral pain during puberty remains poorly understood. Purpose: The purpose of this longitudinal study is to assess changes in patellar maltracking patterns in subjects with patellofemoral pain as they mature from mid- to late adolescence. Study Design: Cohort study; Level of evidence, 3. Methods: Three-dimensional patellofemoral kinematic data were acquired during active knee extension-flexion using dynamic magnetic resonance imaging in 6 girls (10 knees; mean age, 14.0 years) with clinically diagnosed patellofemoral pain. The subjects then returned as late adolescents (mean age, 18.5 years) for follow-up scanning. Three-dimensional patellofemoral kinematic parameters were evaluated across the range of motion, but comparison between time points was restricted to 10° of flexion. Participation in impact and nonimpact physical activities, pain score based on the visual analog scale, and the anterior knee pain score were also compared across initial and follow-up visits. Results: All subjects reported improved patellofemoral pain symptoms at follow-up, and one subject reported complete resolution. However, relative to the initial visit, no differences were found in patellar maltracking. There was a decrease in hours engaged in impact physical activities for all subjects at follow-up. Conclusion: This study provides insight into the natural history of patellofemoral pain in adolescent females. The relatively unchanged patellofemoral maltracking across subjects suggests that potential anatomic and kinematic abnormalities contributing to patellofemoral pain during mid-adolescence persist during skeletal maturation. Symptom improvement for these subjects did not result from a change in patellofemoral tracking, but rather from other causes.

The Relationship of Static Tibial Tubercle–Trochlear Groove Measurement and Dynamic Patellar Tracking:

Background: The tibial tubercle to trochlear groove (TT-TG) distance is used for screening patients with a variety of patellofemoral joint disorders to determine who may benefit from patellar medialization using a tibial tubercle osteotomy. Clinically, the TT-TG distance is predominately based on static imaging with the knee in full extension; however, the predictive ability of this measure for dynamic patellar tracking patterns is unknown. Purpose: To determine whether the static TT-TG distance can predict dynamic lateral displacement of the patella. Study Design: Cohort study (Diagnosis); Level of evidence, 2. Methods: The static TT-TG distance was measured at full extension for 70 skeletally mature subjects with (n = 32) and without (n = 38) patellofemoral pain. The dynamic patellar tracking patterns were assessed from approximately 45° to 0° of knee flexion by use of dynamic cine-phase contrast magnetic resonance imaging. For each subject, the value of dynamic lateral tracking corresponding to the exact knee angle measured in the static images for that subject was identified. Linear regression analysis determined the predictive ability of static TT-TG distance for dynamic patellar lateral displacement for each cohort. Results: The static TT-TG distance measured with the knee in full extension cannot accurately predict dynamic lateral displacement of the patella. There was weak predictive ability among subjects with patellofemoral pain (r2 = 0.18, P = .02) and no predictive capability among controls. Among subjects with patellofemoral pain and static TT-TG distances 15 mm or more, 8 of 13 subjects (62%) demonstrated neutral or medial patellar tracking patterns. Conclusion: The static TT-TG distance cannot accurately predict dynamic lateral displacement of the patella. A large percentage of patients with patellofemoral pain and pathologically large TT-TG distances may have neutral to medial maltracking patterns.

Adolescents and Adults with Patellofemoral Pain Have Different Pathological Knee Kinematics

Disclosures: Liza Grosman-Rimon: I Have No Relevant Financial Relationships To Disclose Objective: The aims of the present study were to compare levels of circulating inflammatory biomarkers and growth factors between patients with myofascial pain syndrome (MPS) and control participants, and to assess the relationship among inflammatory markers and growth factors in the two groups. Design: Case-control. Setting: Patients recruited from the hospital Emergency Department and non-MPS controls (n1⁄421), recruited via advertisements in the hospital and community. Participants: Patients (n1⁄437) with myofascial pain and non-MPS controls (n1⁄421), recruited via advertisements in the hospital and community. Interventions: Venous blood draw for biomarker assessment. Main Outcome Measures: Serum inflammatory and growth factor. Results: Blood levels of the cytokines IL-6, TNF and IL-12 and the chemokines MCP-1, MDC, eotaxin, GM-CSF, IL-8, MIP-1b were significantly higher in patients with MPS than controls. The results of the growth factor analyses revealed significantly higher levels of FGF-2, PDGF, and VEGF in MPS patients versus controls. The pattern of correlation coefficients between cytokines and growth factors differed considerably for MPS patients and controls with far fewer significant coefficients observed in the controls. Serum inflammatory and growth factor biomarkers were elevated in MPS patients. Conclusions: Inflammatory biomarkers and growth factor levels may play an important role in the onset and maintenance of MPS and therefore may be useful in the diagnosis and treatment of MPS. Understanding the mechanisms of inflammation in MPS necessitates future research. Level of Evidence: Level III

Poster 119 Pathological Patellofemoral Kinematics Contribute to Idiopathic Patellofemoral Pain in Adolescence and Persist at Four Year Follow-up.

Disclosures: Claire Gross: I Have No Relevant Financial Relationships To Disclose Objective: To evaluate the impact of hip related injuries on the quality of life in professional ballet dancers. Design: Retrospective cross-sectional study. Setting: Large urban professional ballet company. Participants: Thirty-seven professional ballet dancers, ages 18-33, who completed a post-hire health screening prior to the start of the company’s season. Interventions: Not applicable. Main Outcome Measures: Participants completed the Hip Disability and Osteoarthritis Outcome Score (HOOS), which assesses level of disability due to a hip problem, and contains five subscales: pain, other symptoms, activities of daily living (ADLs), function in sports, and quality of life (QoL). Subjects were also asked to self-report current or prior history of hip problems/injuries. Unpaired t tests were used to compare the HOOS scores of the dancers with a history of a hip problem to those without such a history. A Bonferroni correction was used to account for multiple comparisons, with P<.010 meeting statistical significance. Results: Dancers with a self-reported history of a hip problem (8 of 37) reported statistically lower HOOS subscores for pain (P1⁄4.006) and QoL (P1⁄4.0001). The remaining subscores were not significantly different between groups: symptoms (P1⁄4.047), ADLs (P1⁄4.047), sports (P1⁄4.016). Conclusions: Hip problems and injuries have a significant impact on quality of life in professional ballet dancers as assessed by the HOOS. This impact persists despite a lack of significant effect of hip problems on ability to perform ADLs or sports-related tasks. The presence of a hip problem should be viewed as a risk factor for worsened quality of life in this population. Level of Evidence: Level III

Video Analysis of Anterior Cruciate Ligament (ACL) Injuries: A Systematic Review.

Background:As the most viable method for investigating in vivo anterior cruciate ligament (ACL) rupture, video analysis is critical for understanding ACL injury mechanisms and advancing preventative training programs. Despite the limited number of published studies involving video analysis, much has been gained through evaluating actual injury scenarios. Methods:Studies meeting criteria for this systematic review were collected by performing a broad search of the ACL literature with use of variations and combinations of video recordings and ACL injuries. Both descriptive and analytical studies were included. Results:Descriptive studies have identified specific conditions that increase the likelihood of an ACL injury. These conditions include close proximity to opposing players or other perturbations, high shoe-surface friction, and landing on the heel or the flat portion of the foot. Analytical studies have identified high-risk joint angles on landing, such as a combination of decreased ankle plantar flexion, decreased knee flexion, and increased hip flexion. Conclusions:The high-risk landing position appears to influence the likelihood of ACL injury to a much greater extent than inherent risk factors. As such, on the basis of the results of video analysis, preventative training should be applied broadly. Kinematic data from video analysis have provided insights into the dominant forces that are responsible for the injury (i.e., axial compression with potential contributions from quadriceps contraction and valgus loading). With the advances in video technology currently underway, video analysis will likely lead to enhanced understanding of non-contact ACL injury.