Devon Klein

SPECT/CT in the Management of Osteochondral Lesions of the Talus:

Background: The treatment of osteochondral lesion of the talus (OLT) is mainly based upon the stage of the disease so accurate imaging is crucial. SPECT/CT combines bone scan with high-resolution CT and can provide functional-anatomical images in a single stage. The purpose of this study was to assess the value of SPECT/CT in the management of OLT. Materials and Methods: From 2004 to 2009, 22 patients with OLT were identified that had both SPECT/CT and MRI of the foot and ankle. All charts were reviewed to ascertain the reason for ordering the SPECT/CT and the additional information obtained. AOFAS outcome scores were calculated at the time of followup. Results: Twelve patients underwent ankle arthroscopy for debridement or drilling of the osteochondral lesion. The mean AOFAS score in these 12 patients was 83.6. SPECT/CT helped preoperative planning by identifying the exact location of the active lesion, especially in multifocal disease or revision surgeries while showing the depth of the active lesion. Ten patients had conservative management due to minimal or no activity over the lesion on SPECT/CT images. The mean AOFAS score in these ten patients was 78.8 which was comparable to the operative group. Conclusion: We believe SPECT/CT was able to provide additional diagnostic value by demonstrating a co-existing pathology as a potential cause of pain and in preoperative planning by showing the depth of activity and the precise location of the active segment in multiple lesions. Level of Evidence: III, Retrospective Case Control Study

Accuracy of Diagnostic Injection in Differentiating Source of Atypical Hip Pain

It is not uncommon to encounter patients with atypical hip or lower extremity pain, ill-defined clinicoradiological features, and concomitant hip and lumbar spine arthritis. The purpose of this study is to present our experience using the response resulting from a combined anesthetic-steroid hip injection for treatment selection in these patients. A retrospective analysis of 204 consecutive diagnostic hip injections was undertaken. Patient charts were scrutinized for outcomes of injection and treatment. Our findings suggest that the relief of symptoms following injection of local anesthetic and steroid into the hip joint has a sensitivity of 91.5%, specificity and positive predictive value of 100%, and negative predictive value of 84.6% for response to total hip arthroplasty. We thereby believe that this is a reliable test with low morbidity and can predict the potential benefit of total hip arthroplasty in this diagnostically challenging group of patients.

Comparison of Mini-Open Versus Arthroscopic Harvesting of Osteochondral Autografts in the Knee: A Cadaveric Study

PURPOSE To prove that the assessment of osteochondral graft perpendicularity with magnetic resonance imaging (MRI) will allow for a precise measurement of graft perpendicularity and for an improved comparison of arthroscopic versus mini-open harvest techniques. METHODS Ten fresh cadaveric knees (mean age, 39.4 years) underwent harvest of 6-mm osteochondral plugs using the Osteochondral Autograft Transfer System (OATS; Arthrex, Naples, FL). A total of 8 plugs were harvested per knee from 3 donor sites: the lateral supracondylar ridge, the medial supracondylar ridge, and the lateral intercondylar notch. Two surgeons performed the graft harvest, alternating between mini-open (5 specimens) and arthroscopic (5 specimens) techniques to minimize bias. The osteochondral plugs were labeled and plated by a novel agar plating technique and then underwent MRI for measurement of graft perpendicularity. The data were analyzed to look for a significant difference in perpendicularity between the 2 harvest techniques, as well as overall graft acceptability. RESULTS One specimen in the open harvest technique group was unable to undergo optimal MRI because of difficulties encountered with the novel agar plating system resulting in graft movement during imaging. When we compared the mini-open and arthroscopic harvest techniques, the mean angle of perpendicularity at the lateral intercondylar notch harvest site was 84.1° and 84.2°, respectively (P = .958). At the medial supracondylar ridge harvest site, the mean angle of perpendicularity for the mini-open and arthroscopic techniques was 88.4° and 81.0°, respectively, with a mean difference of 7.4° (P = .006). At the lateral supracondylar ridge harvest site, the mean angle of perpendicularity for the mini-open and arthroscopic techniques was 85.7° and 87.1°, respectively (P = .237). CONCLUSIONS A significant difference in osteochondral autograft perpendicularity was noted at the medial supracondylar ridge when we compared the mini-open and arthroscopic harvesting techniques. This suggests that when one is harvesting autologous osteochondral grafts from the medial supracondylar ridge, the mini-open technique may be preferred. CLINICAL RELEVANCE When harvesting autologous osteochondral grafts from the medial supracondylar ridge of the knee, the mini-open technique will potentially allow for a more perpendicular graft for implantation.

Effect of Intraoperative Platelet-Rich Plasma Treatment on Postoperative Donor Site Knee Pain in Patellar Tendon Autograft Anterior Cruciate Ligament Reconstruction: A Double-Blind Randomized Controlled Trial:

Background: Donor site morbidity in the form of anterior knee pain is a frequent complication after bone–patellar tendon–bone (BPTB) autograft anterior cruciate ligament (ACL) reconstruction. Hypothesis/Purpose: The purpose was to examine the effect of the intraoperative administration of platelet-rich plasma (PRP) on postoperative kneeling pain. It was hypothesized that PRP treatment would reduce knee pain. Study Design: Randomized controlled trial; Level of evidence, 2. Methods: Fifty patients (mean ± SD age, 30 ± 12 years) undergoing BPTB ACL autograft reconstruction were randomized to the PRP (n = 27) or sham (n = 23) treatment. In either case, 10 mL of venous blood was drawn before the induction of anesthesia and either discarded (sham) or processed (PRP) for preparation of a PRP gel to be later mixed with donor site bone chips and inserted into the patellar defect. At 12 weeks, 6 months, 1 year, and 2 years after surgery, patients completed International Knee Documentation Committee (IKDC) forms and visual analog scale pain scores for activities of daily living and kneeling. Healing indices at the donor site were assessed by routine noncontrast magnetic resonance imaging (MRI) at 6 months. Mixed-model analysis of variance was used to assess the effect of PRP on patient symptoms and MRI indices of donor site healing, as measured by the width of the donor site defect. Results: Kneeling pain, pain with activities of daily living, and IKDC scores were not different between treatment groups at any of the time intervals (P = .08-.83). Kneeling pain improved from 12 weeks to 6 months and from 1 to 2 years (P < .05). IKDC scores improved substantially from 12 weeks to 6 months (P < .001) and continued to improve to 2 years (PRP, 86 ± 19; sham, 89 ± 10). MRI indices of donor site healing were not different between treatment groups (P = .53-.90). Conclusion: Whether randomized to receive PRP in their patellar defect or not, patients continued to have similar levels of kneeling pain and patellar defect sizes after autograft BPTB ACL reconstruction. Registration: NCT01765712 (ClinicalTrials.gov identifier).

Sports Hernia/Athletic Pubalgia Among Women

Background: “Athletic pubalgia,” a term that has gained acceptance over “sports hernia,” is more common in men than women; however, it represents a significant source of morbidity for patients of both sexes. Inconsistent terminology surrounding this entity poses a diagnostic challenge and makes studying the populations at risk difficult. Purpose: To review a case series of women with athletic pubalgia by analyzing their presentations, concomitant pathologies, and surgical outcomes. Study Design: Case series; Level of evidence, 4. Methods: Between 2013 and 2016, 197 patients were seen and evaluated for the diagnosis of athletic pubalgia. Eighteen patients seen during this time were women. All patients received “pubalgia protocol” magnetic resonance imaging and subsequent surgical intervention for their pathologies. Outcomes among 17 women were assessed with a patient questionnaire >1 year after surgery. Results: Of the 17 women, 9 had rectus aponeurotic plate injury only, or pure athletic pubalgia; the remaining 8 had athletic pubalgia in combination with ≥1 inguinal, obturator, and femoral hernias. Regarding female patients in both groups, 88.2% reported that the surgery was a success at follow-up. Conclusion: Surgical repair of athletic pubalgia among women is successful in dramatically reducing pain levels in this important subset of patients.

Effect of Intraoperative Platelet-Rich-Plasma Treatment on Post Operative Donor Site Knee Pain in Patellar Tendon Autograft ACL Reconstruction A Double-Blind Randomized Controlled Trial

Objectives: Donor site morbidity in the form of anterior knee pain is a frequent complication after bone-patellar tendon-bone (BPTB) autograft ACL reconstruction. The purpose of this Level I study was to examine the effect of the intraoperative administration of platelet-rich plasma on post operative knee pain and patellar defect healing. Methods: Fifty-nine patients (29±12 y/o) undergoing BPTB ACL reconstruction and eligible to enter the study, were randomized to the treatment (PRP; n=31) or non treatment (sham n=28) arms of the study just prior to surgery. In either case, 10 cc of venous blood was drawn prior to the induction of anesthesia and either discarded (sham) or processed (PRP) for preparation of a PRP gel to be later mixed with donor site bone chips and inserted into the patellar defect. At 12 weeks and 6 months after surgery, patients completed IKDC forms and VAS pain scores for ADLs and kneeling (0-10 scale). Healing indices at the donor site were assessed by MRI at 6 months and included the following measurements taken from axial sequences: AP tendon dimensions at the level of the superior tibial cortex, roof of the intercondylar notch and width at the largest patella graft deficit. Mixed model ANOVA was used to assess the effect of PRP on patient symptoms and MRI indices of donor site healing. The primary dependent variable was VAS kneeling pain. It was estimated that with 25 patients per group there would be 80% power to detect a 1.5-point difference in kneeling pain between treatments at P<0.05. A between group difference of 1.5-points in VAS for kneeling pain was deemed to represent a clinically relevant difference. Results: VAS Kneeling Pain at 12 weeks tended to be lower in the PRP versus placebo group (4.5±3.6 vs. 6.2±2.4, P=0.051) but no difference was apparent at 6 months (3.7±3.2 vs. 4.4±2.9, P=0.41). Kneeling pain decreased from 12 weeks to 6 months (P<0.001) with a trend for a greater decrease in the placebo group (Time by Treatment P=0.097). VAS Pain with ADLs was not different between treatment groups at 12 weeks (PRP 2.0±2.3 vs. Placebo 2.8±1.8, P=0.16) or 6 months (1.5±1.9 vs. 1.7±2.1, P=0.60). Pain with ADLs decreased from 12 weeks to 6 months (P<0.05) with no difference between treatment groups (Time by Treatment P=0.52). IKDC scores improved from 12 weeks to 6 months (P<0.001), with no difference between treatment groups (Time by Treatment P=0.73). IKDC scores were not different between treatment groups at 12 weeks (64±16 vs. 64±12, P=0.83) or 6 months (75±18 vs. 73±11, P=0.66). MRI indices of donor site healing were not different between treatment groups (P=0.60 to 0.97). Conclusion: Whether randomized to receive PRP in their patellar defect or not, patients continued to have similar levels of kneeling pain and patellar defect sizes 6 months after BPTB ACL autograft reconstruction. The intraoperative administration of PRP into the patellar donor site following ACL reconstruction with BPTB autograft has no significant effect on the parameters of post operative knee pain or donor site healing.