Gideon Mann

Platelet-Rich Plasma or Hyaluronate in the Management of Osteochondral Lesions of the Talus:

Background: Nonoperative options for osteochondral lesions (OCLs) of the talar dome are limited, and currently, there is a lack of scientific evidence to guide management. Purpose: To evaluate the short-term efficacy and safety of platelet-rich plasma (PRP) compared with hyaluronic acid (HA) in reducing pain and disability caused by OCLs of the ankle. Study Design: Randomized controlled trial; Level of evidence, 2. Methods: Thirty-two patients aged 18 to 60 years were allocated to a treatment by intra-articular injections of either HA (group 1) or PRP (plasma rich in growth factors [PRGF] technique, group 2) for OCLs of the talus. Thirty OCLs, 15 per arm, received 3 consecutive intra-articular therapeutic injections and were followed for 28 weeks. The efficacy of the injections in reducing pain and improving function was assessed at each visit using the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale (AHFS); a visual analog scale (VAS) for pain, stiffness, and function; and the subjective global function score. Results: The majority of patients were men (n = 23; 79%). The AHFS score improved from 66 and 68 to 78 and 92 in groups 1 and 2, respectively, from baseline to week 28 (P < .0001), favoring PRP (P < .05). Mean VAS scores (1 = asymptomatic, 10 = severe symptoms) decreased for pain (group 1: 5.6 to 3.1; group 2: 4.1 to 0.9), stiffness (group 1: 5.1 to 2.9; group 2: 5.0 to 0.8), and function (group 1: 5.8 to 3.5; group 2: 4.7 to 0.8) from baseline to week 28 (P < .0001), favoring PRP (P < .05 for stiffness, P < .01 for function, P > .05 for pain). Subjective global function scores, reported on a scale from 0 to 100 (with 100 representing healthy, preinjury function) improved from 56 and 58 at baseline to 73 and 91 by week 28 for groups 1 and 2, respectively (P < .01 in favor of PRP). Conclusion: Osteochondral lesions of the ankle treated with intra-articular injections of PRP and HA resulted in a decrease in pain scores and an increase in function for at least 6 months, with minimal adverse events. Platelet-rich plasma treatment led to a significantly better outcome than HA.

Secondary damage to the knee after isolated injury of the anterior cruciate ligament

Between 1978 and 1984, we examined and performed arthroscopy on 1000 consecutive patients. Ninety-eight of the 1000 had isolated ACL damage. These cases do not include patients with initial ACL injuries combined with other intraarticular damage. Diagnosis was by physical and arthroscopic examination. Examination took place an average 13.6 months after injury. Of the 98 isolated ACL injuries, 56 were complete ruptures and 42 were partial ruptures. In most cases of partial rupture, the clinical diagnosis was wrong. Meniscal damage was the usual diagnosis in these cases; the true diagnosis was made only by arthroscopic exami nation. Thirty-four of the 98 patients with isolated ACL injuries (30 men and 4 women) developed further intra articular damage. Of these 34, 20 had complete ACL rupture and 14 had partial ACL rupture. Treatment after primary injury included physiotherapy in all patients and bracing in those whose knee was unstable during daily activities. Reconstructive surgical procedures were not performed in those patients. The time lapse from the primary to the secondary injury varied from 1 month to 20 years, with an average of 28 months. The secondary damage was caused by a secondary injury that was mild (22 cases) or developed insidiously (12 cases). Five types of secondary damage were observed: partial ACL tears that became complete—11 cases; meniscal tear— 8 cases; loosening and subluxation of the anterior horn of the medial meniscus—14 cases; and fracture or damage to the articular condylar carti lage, with or without bone involvement—11 cases. It should be emphasized that the secondary damages were at times combined.

Dynamic force distribution during level walking under the feet of patients with chronic ankle instability

Objectives: To examine changes in the pattern of force transfer between the foot and the floor associated with chronically sprained ankles by measuring the peak forces and their timing under several regions of the feet during level walking. Methods: Twelve young male subjects (mean (SD) age 21 (2) years) with recurrent ankle sprains were studied. Seven of them had unilateral and bilateral chronic instability and laxity, and five had bilateral instability. Twelve healthy men (without orthopaedic or medical disease) served as a control group. Subjects walked at their own pace along a 7 m walkway, which included a Mini-EMED pressure distribution measuring system. The variables measured were relative peak force (fraction of body weight) and relative timing (fraction of stance time). These variables were measured under six regions of interest in each foot print: heel, midfoot, medial, central, and lateral forefoot, and toes. Results: (a) A significant delay to the time of peak force under the central and lateral forefoot and toes in subjects with chronic ankle instability. (b) A significant decrease in the relative forces under the heel and toes and an increase in the relative forces under the midfoot and lateral forefoot in subjects with chronic ankle instability. (c) In the patients with unilateral instability, there were no significant differences in any of the variables between the injured and non-injured foot. Conclusions: In patients with chronic ankle instability, there is a slowing down of weight transfer from heel strike to toe off, a reduced impact at the beginning and end of the stance phase, and a lateral shift of body weight.

A Dynamic Ultrasound Examination for the Diagnosis of Ankle Syndesmotic Injury in Professional Athletes A Preliminary Study

Background Syndesmotic ankle injuries are not easy to recognize when an associated fracture or frank diastasis is not present. There is a need for a simple, fast, inexpensive, and easily reproducible diagnostic tool to assess the integrity of the distal tibiofibular synedesmosis. Hypothesis Dynamic ultrasound (US) examination can accurately diagnose anteroinferior tibiofibular ligament (AITFL) rupture. Study Design Cohort study (diagnosis); Level of evidence, 2. Methods We evaluated 3 groups: 9 consecutive professional athletes with recent AITFL rupture, a control group of 18 subjects without a history of ankle injury, and 20 patients with lateral ankle sprain. The dynamic US examination was performed in neutral (N), forced internal rotation (IR), and external rotation (ER) of the foot for measuring the tibiofibular clear space on the anterior aspect of the ankle, at the level of the AITFL, 1 cm proximal to the joint line. Results The mean age of the study group was 27 years (range, 16-32). Magnetic resonance imaging (MRI) confirmed the diagnosis of AITFL rupture in all cases. Differences between the injured and control group were statistically significant for the N, IR, and ER positions (P < .001) and for the measured Δ between the AITFL in the ER and N positions (P < .01). The difference in the tibiofibular clear space between the 2 ankles of the injured athletes was significantly different compared with the control athletes for all 3 positions (P < .001). The measured difference between the ER and N positions for both sides of the study group showed a specificity and sensitivity of 100% (P < .001; cutoff point of 0.9 mm and 0.7 mm, respectively). The Δ (Δ = ER — N) of the injured side showed a specificity and sensitivity of only 89% (P < .001; cutoff point of 0.4 mm). Additionally, the third group with the history of lateral ankle sprain showed, as expected, that this type of injury does not correlate with AITFL injury on dynamic US examination. Conclusion We conclude that dynamic US examination can be used to accurately diagnose an AITFL rupture. This preliminary study has found the described method to be a simple, inexpensive, and easily reproducible examination.

Platelet-rich plasma: any substance into it?

Autologous platelet-rich plasma (PRP) is perceived to accelerate healing in muscu loskeletal injuries. PRP is increasingly used in situations that require rapid return-to play, which, in the professional sports arena, translates to fame and money. It is astonishing but understandable that the most influential stimulus for PRP therapy in the USA, years after the method had been popularised in Europe, was a February 2009 article in the lay press.1nnHuman blood platelet counts are approx imately 200 000/ml. PRP is an autologous concentration of human platelets above this in a small volume of plasma.2 Reports vary regarding the platelet concentration and different growth factors present in the PRP concentrate. Also, there are many preparation protocols, kits, centrifuges and methods to trigger platelet activation before use. The same is true for application methods, including using injectable activated PRP liquid concentrate versus implanting a fibrin scaffold, optimal timing of injection and the specific volume to use. Almost every major manufacturer in the orthopaedic and sports medicine world markets a different commercial kit. Some claim to produce a better quantity and quality of PRP than their competitors from the same amount of blood from the same patient. Costs vary tremendously: a commercial kit yields a PRP concentrate at the cost of several hundred dollars, but inhouse non-automatised techniques produce a PRP concentrate for approximately US

The Medial Longitudinal Arch as a Possible Risk Factor for Ankle Sprains: A Prospective Study in 83 Female Infantry Recruits

10. Each method to concentrate platelets leads to a different product with different biology and potential uses,3 with a high variation (3 to 27-fold) in growth factor concentration and in the kinetics of release.3,–,5 Most techniques yield a PRP concentrate of approximately 10% of the blood volume taken (eg, 20 ml of whole blood would result in approximately 2 ml of PRP). These differences might be of relevance to clinical management, …

The Role of the Knee Brace in the Prevention of Anterior Knee Pain Syndrome

Background: Ankle sprains are frequent, especially in athletes, soldiers, or others who perform high levels of physical activity. Although prevention is a primary goal, little is known about the risk factors. We evaluated the association of the structure of the medial arch of the foot to the occurrence of acute and recurrent ankle sprains in 83 female infantry recruits. We found no previous studies on ankle sprains in women in the English literature. Methods: Arch height was quantified using the Chippaux-Smirak index, and each arch was classified as high, normal, or low. Retrospective data were obtained from questionnaires in which the soldiers noted whether or not they had had ankle sprains in the past, the grade of the sprain, and recurrence. Prospective data were accumulated in the 4 months of basic training, during which time every ankle sprain was documented and classified according to its grade and cause. Results: The retrospective data showed more frequent ankle sprains in the low arch group than in the normal arch group, mainly in the right foot (RR of 2.9, p < 0.05). Recurrent sprains studied retrospectively also showed that more sprains occurred in the low arch group than in the normal arch and high arch groups (RR of 10.3, p < 0.05). The prospective data suggested a pattern toward the same outcome (50% in the low arch as opposed to 36% in the normal arch group, RR, 1.3), but with no statistical significance. Conclusions: We concluded that a low arch of the foot might be a risk factor for ankle sprains. However, our study consisted of a relatively small population, and further studies are needed.

Standardization of the functional syndesmosis widening by dynamic U.S examination

Our prospective study evaluates the use of a knee brace with a silicon patellar support ring as a method of preventing anterior knee pain from developing in young persons undergoing strenuous physical exercise. We studied 60 young athletes, who qualified for a strenu ous physical training course and who had not suffered from anterior knee pain previously. Twenty-seven sub jects were in the brace group and 33 were in the nonbrace control group. The incidence of anterior knee pain syndrome increased with the intensity of exertion as the study progressed; i.e., subjects ran 6 km in the 1 st week, gradually increasing each week up to 42 km/week at the 8th week. Yet, there was a significant reduction in the incidence of the syndrome at the end of the study in male athletes who had applied the braces before exercise sessions and in the brace group as a whole, compared with the control group. Prophylactic use of the brace, as described, did not reduce the ability of the athletes who wore braces to improve their physical fitness parameters in response to exercise. These data indicate that the use of a brace may be an effective way to prevent the development of anterior knee pain syndromes in persons participating in strenuous and intensive physical exercise.

Intra-articular Injections of Hyaluronic Acid in Osteoarthritis of the Subtalar Joint: A Pilot Study

BackgroundDynamic US examination is a convenient, accurate, inexpensive and reproducible diagnostic tool for assessing the integrity of the distal tibiofibular syndesmosis in ankle injuries. However normal values for physiological functional widening of the anterior tibiofibular clear space in healthy subjects has yet to be determined. The purpose of this study was to determine normal values for the syndesmosis clear space on ultrasound examination.MethodsWe evaluated 110 healthy subjects. A dynamic U.S examination was performed in neutral (N), forced internal rotation (IR) and external rotation (ER) of the ankle. In each position the anterior tibiofibular clear space was measured at the level of the anterior inferior tibio-fibular ligament (AITFL). Height and calf length were also recorded. Results were analyzed in relation to age, activity, dominant leg and gender.ResultsMean age was 32 years (range 16–60). There were 59 males and 51 females. 60% were professional athletes. Mean height was 173 cm (range 149–192). Functional Mean position measurements for clear space opening were: N=3.7mm, IR=3.6mm and ER=4.0mm. In younger men and women the clear space was significantly wider in neutral (Men: Y=3.8, O=3.4 Women: Y=3.8, O=3.4) and with rotational force application (Men ER: Y=4.1, O=3.6 Women ER: Y=4.1, O=3.8) compared to older subjects (p<0.05). There was no correlation with activity, height or the leg length.Females had a higher syndesmosis widening ratio (ER/N) under stress than males (p<0.01) this tended to occur more commonly in active subjects.ConclusionsNormal values for the syndesmosis clear space on ultrasound examination were determined as 3.78mm in neutral, 3.64mm in internal rotation and 4.08mm in external rotation. The clear space was shown to decrease with age both as an absolute measure and when rotational stresses are applied. Females tend to have a larger clear space and a greater functional widening.These findings provide a useful reference for radiologists and sports physicians when performing ultrasound assessment of ankle syndesmotic injuries and we encourage use of this modality.

Prevention of avascular necrosis in displaced talar neck fractures by hyperbaric oxygenation therapy: a dual case report.

We evaluated the efficacy of intra-articular viscosupplementation with sodium hyaluronate in the management of osteoarthritis of the subtalar joint. A total of 22 patients, aged 22 to 72 years (mean 53), with symptomatic subtalar joint osteoarthritis of 1 to 20 years duration (mean 4.2) and a severity of Kellgren-Lawrence grade II to IV and Paley and Hall grade 1 to 3, were entered into the present study. Intra-articular injections of 10 mg sodium hyaluronate (Euflexxa) were administered weekly to the subtalar joint for 3 weeks. Clinical evaluations and objective scoring using the American Orthopaedic Foot and Ankle Society Ankle Hindfoot score, visual analog scale, maximum walking distance, pain frequency, and subjective global function were performed at baseline and 4, 12, and 28 weeks after treatment. Significant improvement occurred in the American Orthopaedic Foot and Ankle Society Ankle Hindfoot scores (baseline score 54.5, week 28 score 73.7; p < .01) and visual analog scale assessment (baseline pain, stiffness, and function score 5.4, 5.8, and 6.9; week 28 pain, stiffness, and function score 2.8, 3.1, and 3.8, respectively; p < .01). Global assessment showed improvement in 18 of 20 patients completing the study (p < .01). The tolerated walking distance significantly improved from 770 ± 886 m to 2,075xa0± 1,500 m (p < .001). Improvement lasted for more than 6 months. Intra-articular injection of sodium hyaluronate should be considered in the conservative management of subtalar osteoarthritis.