Lior Laver

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.

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

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.

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

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.

PRP for Degenerative Cartilage Disease A Systematic Review of Clinical Studies

Objective: To explore the utilization of platelet-rich plasma (PRP) for degenerative cartilage processes and evaluate whether there is sufficient evidence to better define its potential effects. Design: Systematic literature reviews were conducted in PubMed/MEDLINE and Cochrane electronic databases till May 2015, using the keywords “platelet-rich plasma OR PRP OR autologous conditioned plasma OR ACP AND cartilage OR chondrocyte OR chondrogenesis OR osteoarthritis (OA) OR arthritis.” Results: The final result yielded 29 articles. Twenty-six studies examined PRP administration for knee OA and 3 involved PRP administration for hip OA. The results included 9 prospective randomized controlled trials (RCTs) (8 knee and 1 hip), 4 prospective comparative studies, 14 case series, and 2 retrospective comparative studies. Hyaluronic acid (HA) was used as a control in 11 studies (7 RCTs, 2 prospective comparative studies, and 2 retrospective cohort). Overall, all RCTs reported on improved symptoms compared to baseline scores. Only 2 RCTs—one for knee and one for hip—did not report significant superiority of PRP compared to the control group (HA). Nine out of 11 HA controlled studies showed significant better results in the PRP groups. A trend toward better results for PRP injections in patients with early knee OA and young age was observed; however, lack of uniformity was evident in terms of indications, inclusion criteria, and pathology definitions in the different studies. Conclusion: Current clinical evidence supports the benefit in PRP treatment for knee and hip OA, proven to temporarily relieve pain and improve function of the involved joint with superior results compared with several alternative treatments. Further research to establish the optimal preparation protocol and characteristics of PRP injections for OA is needed.

Chronic tibialis anterior tendon tear treated with an Achilles tendon allograft technique.

Tibialis anterior tendon tear is an uncommon injury. Nontraumatic or degenerative tears are usually seen in the avascular zone of the tendon. Treatment can be conservative or surgical. Conservative treatment is adequate for low-demand older patients. For active patients, surgical treatment can be challenging for the surgeon because after debridement of degenerative tissue, a gap may be formed that can make side-to-side suture impossible. The authors present allograft Achilles tendon insertion for reconstruction of chronic degenerative tears. Using Achilles tendon allograft has the advantage of bone-to-bone fixation, allowing rapid incorporation and earlier full weight bearing.

Neuromuscular and inflammatory responses to handball small-sided games: the effects of physical contact

The aim of this study was to investigate the influence of physical contact on neuromuscular impairments and inflammatory response during handball small‐sided games. Using a counterbalanced design, 12 elite male junior handball players were divided into two groups: contact (C‐SSG) and no‐contact (NC‐SSG), performing both contact and no‐contact small‐sided games, in reverse order on two training sessions separated by 5 days. The methodology and rules were identical for the two SSG regimens, with the only difference being the inclusion or prohibition of upper body use for physical contacts. Upper and lower body neuromuscular performances and blood concentrations of inflammatory cytokine IL‐6 were assessed before and immediately after the games. During small‐sided games, video analysis was used to establish the physical contact counts. Significant differences were found in most upper and lower limbs muscles kinetic variables and in the physical contact events (all P < 0.001) following the two training regimens. There was an increase in IL‐6 after C‐SSG and no changes following NC‐SSG (P < 0.05 and P = 0.12, respectively). Moreover, a strong correlation was found between the number of physical contacts and IL‐6 responses (r = 0.971, P < 0.001) in C‐SSG. This study indicates that an inflammatory response and large upper and lower body neuromuscular impairments result from physical contact in elite handball players. These outcomes outline the specific physiological profile of C‐SSG that, in turn, might be used by practitioners and coaches as a practical approach to strategically select exercises in athletes overall training program.

Anatomy of the sural nerve and its relation to the achilles tendon by ultrasound examination.

Sural nerve injury is a relatively common complication after surgery on the Achilles tendon. Studies to determine the course of the sural nerve have been performed on cadaveric specimens. The purpose of this cross-sectional study was to use ultrasound to determine the relations of the sural nerve in a healthy population. The authors performed ultrasound examination of the posterior triangle of the ankle and Achilles tendon to determine the course of the sural nerve relative to the Achilles tendon in healthy participants. The mean distance between the nerve and the tendon was 21.48, 11.47, 5.8, and 0.81 mm lateral to the Achilles tendon as measured at the insertion and 4, 8, and 11 cm proximally, respectively. Male participants tended to have a nerve that was initially more lateral to the Achilles insertion compared with women. The distance between the sural nerve and the Achilles tendon was found to be lower in older participants, with the nerve passing significantly closer to the tendon at all levels (P<.01). Three anatomical variants were reported, with the nerve crossing the lateral border of the Achilles low or high or with multiple branches yet to converge. The course of the sural nerve can be visualized and plotted relative to the Achilles tendon using ultrasound examination in healthy participants. Older patients may be at an increased risk of iatrogenic nerve injury because the nerve courses closer to the Achilles tendon than that in young patients. Intraoperative ultrasound examination may be a useful modality to prevent sural nerve injury during Achilles tendon surgery.

Successful treatment of groin pain syndrome in a pole-vault athlete with core stability exercise

The purpose of this case report was to present a case of groin pain in a pole vault athlete describing the biomechanical features of the injury`s mechanism, acute medical management, and its successful rehabilitation. A 22-year-old professional pole-vaulter sustained an injury during a regular training session. The athlete reported significant left lower abdominal and left proximal adductor discomfort in all activities, including basic trunk motion when moving in bed, sit to stand, and walking, and was unable to return to the regular training. Clinical evaluation and imaging studies addressed the injury to a case of adductor-related groin pain associated with pubic symphysis degeneration. Treatment consisted of an exercise-based therapeutic protocol based on trunk and core muscle strengthening and stability program, with progressive motor and functional demands. Significant improvements in the overall clinical findings and functional outcomes were reported after 52 days of intervention when the athletes returned to his full athletic activity. These results suggest that an appropriate rehabilitation program, focused on trunk and core musculature stability exercise addressing to sport-related specific demands, should be considered as an optimal conservative method in the multidisciplinary approach for treatment of groin pain and prior to any surgical intervention.

Pedal coral injury: A case report

Corals are marine animals that live in compact colonies. They secret calcium carbonate to form a skeletal structure. Coral sting or abrasions usually cause erythema and localized pain with a mild local toxic reaction. We describe a large bony injury in the hallux due to retained coral fragments in a young patient who sustained a mild injury during water sports in the Red Sea. The coral fragment was not removed during the first visit to ER, causing chronic local inflammation and ultimately a large bony injury. Vigorous localized debridement must be performed in all marine injuries to remove all possible fragments that can lead to irreversible local bony injury.