Patrick C. McCulloch

Efficacy of Intra-articular Platelet-Rich Plasma Injections in Knee Osteoarthritis: A Systematic Review.

PURPOSEnTo determine (1) whether platelet-rich plasma (PRP) injection significantly improves validated patient-reported outcomes in patients with symptomatic knee osteoarthritis (OA) at 6 and 12 months postinjection, (2) differences in outcomes between PRP and corticosteroid injections or viscosupplementation or placebo injections at 6 and 12 months postinjection, and (3) similarities and differences in outcomes based on the PRP formulations used in the analyzed studies.nnnMETHODSnPubMed, Cochrane Central Register of Controlled Trials, SCOPUS, and Sport Discus were searched for English-language, level I evidence, human inxa0vivo studies on the treatment of symptomatic knee OA with intra-articular PRP compared with other options, with a minimum of 6 months of follow-up. A quality assessment of all articles was performed using the Modified Coleman Methodology Score (average, 83.3/100), and outcomes were analyzed using 2-proportion z-tests.nnnRESULTSnSix articles (739 patients, 817 knees, 39% males, mean age of 59.9 years, with 38 weeks average follow-up) were analyzed. All studies met minimal clinical important difference criteria and showed significant improvements in statistical and clinical outcomes, including pain, physical function, and stiffness, with PRP. All but one study showed significant differences in clinical outcomes between PRP and hyaluronic acid (HA) or PRP and placebo in pain and function. Average pretreatment Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores were 52.36 and 52.05 for the PRP and HA groups, respectively (Pxa0= .420). Mean post-treatment WOMAC scores for PRP were significantly better than for HA at 3 to 6 months (28.5 and 43.4, respectively; Pxa0= .0008) and at 6 to 12 months (22.8 and 38.1, respectively; Pxa0= .0062). None of the included studies used corticosteroids.nnnCONCLUSIONSnIn patients with symptomatic knee OA, PRP injection results in significant clinical improvements up to 12 months postinjection. Clinical outcomes and WOMAC scores are significantly better after PRP versus HA at 3 to 12 months postinjection. There is limited evidence for comparing leukocyte-rich versus leukocyte-poor PRP or PRP versus steroids in this study.nnnLEVEL OF EVIDENCEnLevel I, systematic review of Level I studies.

Chondral Defect Repair After the Microfracture Procedure A Nonhuman Primate Model

Background The extent and time course of chondral defect healing after microfracture in humans are not well described. Although most physicians recommend a period of activity and weightbearing restriction to protect the healing cartilage, there are limited data on which to base decisions regarding the duration of such restrictions. Hypothesis Evaluation of the status of chondral defect repair at different time points after microfracture in a primate model may provide a rationale for postoperative activity recommendations. Study Design Descriptive laboratory study. Methods Full-thickness chondral defects created on the femoral condyles and trochlea of 12 cynomolgus macaques were treated with microfracture and evaluated by gross and histologic examination at 6 and 12 weeks. Results At 6 weeks, there was limited chondral repair and ongoing resorption of subchondral bone. By 12 weeks, the defects were completely filled and showed more mature cartilage and bone repair. Conclusion In the primate animal model, significant improvements in the extent and quality of cartilage repair were observed from the 6- to 12-week time points after microfracture. Clinical Relevance The poor status of the defect repair at 6 weeks and the ongoing healing observed from the 6- to 12-week time points may indicate that the repair is vulnerable during this initial postoperative period. Assuming the goal of postoperative weightbearing and activity restriction in patients after microfracture is to protect immature repair tissue, this study lends support to extending such recommendations longer than 6 weeks.

Return to Play After Treatment of Superior Labral Tears in Professional Baseball Players

Background: The published return-to-play (RTP) rates for athletes who have undergone surgical repair of superior labrum anterior-posterior (SLAP) tears vary widely and are generally accepted to be lower in the subset of competitive throwers. The efficacy of nonsurgical treatment for this group is unknown. Hypothesis: Nonsurgical treatment of SLAP tears in professional baseball players leads to RTP before consideration of surgical treatment. Incorporating performance statistics and level of competition will result in lower calculated RTP rates than have been previously reported. Study Design: Case series; Level of evidence, 4. Methods: A retrospective review of 119 consecutive patients in a single professional baseball organization with persistent shoulder pain that limited the ability to compete was performed. Sixty-eight patients had magnetic resonance imaging–documented SLAP lesions. All patients had failed 1 attempt at rehabilitation but had continued with supervised physical therapy. Treatment was according to an algorithm focusing on the correction of scapular dyskinesia and posterior capsular contracture with glenohumeral internal rotation deficit (GIRD), followed by pain-free return to throwing. Those who failed 2 cycles of nonsurgical treatment were treated surgically. Success was defined by 2 different standards: (1) RTP, in accordance with previous studies; and (2) a more stringent standard of return to the same level/quality of professional competition (A, AA, AAA, etc) with the incorporation of a return to preinjury individual performance statistics (earned run average, walks plus hits per inning pitched), termed “return to prior performance” (RPP). Results: Sixty-eight athletes were identified with SLAP lesions. Twenty-one pitchers successfully completed the nonsurgical algorithm and attempted a return. Their RTP rate was 40%, and their RPP rate was 22%. The RTP rate for 27 pitchers who underwent 30 procedures was 48%, and the RPP rate was 7%. For 10 position players treated nonsurgically, the RTP rate was 39%, and the RPP rate was 26%. The RTP rate for 13 position players who underwent 15 procedures was 85%, with an RPP rate of 54%. Conclusion: Nonsurgical treatment correcting scapular dyskinesia and GIRD had a reasonable success rate in professional baseball players with painful shoulders and documented SLAP lesions. The rate of return after surgical treatment of SLAP lesions was low for pitchers. The RTP and RPP rates were higher for position players than for pitchers. Nonsurgical treatment should be considered for professional baseball players with documented SLAP lesions, as it can lead to acceptable RTP and RPP rates.

Hip Dislocation or Subluxation After Hip Arthroscopy: A Systematic Review

PURPOSEnTo determine patient- and surgery-specific characteristics of patients sustaining postarthroscopic hip dislocation or subluxation.nnnMETHODSnA systematic review of multiple medical databases was registered with PROSPERO and performed using Preferred Reporting Items for Systemic Reviews and Meta-Analysis guidelines. Level I to IV clinical outcome studies reporting the presence of hip dislocation or subluxation after hip arthroscopy were eligible. Length of follow-up was not an exclusion criterion. All patient- and surgery-specific variables were extracted from each, specifically evaluating osseous morphology and resection details; labral, iliopsoas, ligamentum teres, and capsular management; generalized ligamentous laxity; instability direction and mechanism; management; and outcome. Study authors were individually contacted to assess most recent outcome.nnnRESULTSnTen articles with 11 patients were analyzed (mean patient age: 36.6 ± 12.3xa0years). There were 9 hip dislocations and 2 subluxations. Mean time between surgery and dislocation was 3.2 ± 4.0xa0months (range: recovery room to 14xa0months). Anterior was the most frequent dislocation direction (8 cases). Acetabular undercoverage (preoperative dysplasia or iatrogenic rim over-resection) was observed in 5 cases. Labral debridement was performed in 5 cases, iliopsoas tenotomy in 3 cases, and ligamentum teres debridement in 1 case. A T capsulotomy was created in 1 case (isolated interportal in other 10 cases). Capsular closure was performed in 2 cases (both interportal). Generalized ligamentous laxity was diagnosed in 1 case. Axa0combination of external rotation and extension was observed in 5 of the 6 cases reporting the mechanism of anterior dislocation. Four cases were successfully treated with closed reduction; 4 required total hip arthroplasty; and 3 required revision capsulorrhaphy.nnnCONCLUSIONSnPostarthroscopic hip instability was observed in patients with acetabular undercoverage (including iatrogenic resection), labral debridement, capsular insufficiency, or iliopsoas tenotomy. Most dislocations were anterior, occurring with hip extension and external rotation.nnnLEVEL OF EVIDENCEnLevel IV, systematic review of Level IV studies.

Radiographic Prevalence of Dysplasia, Cam, and Pincer Deformities in Elite Ballet

Background: The demands of hip strength and motion in ballet are high. Hip disorders, such as cam and pincer deformities or dysplasia, may affect dance performance. However, the prevalence of these radiographic findings is unknown. Purpose: To determine the prevalence of radiographic cam and pincer deformities, borderline dysplasia, and dysplasia in a professional ballet company. Study Design: Cross-sectional study; Level of evidence, 3. Methods: An institutional review board–approved cross-sectional investigation of a professional ballet company was undertaken. Male and female adult dancers were eligible for inclusion. Four plain radiographs were obtained (standing anteroposterior pelvis, bilateral false profile, and supine Dunn 45°) and verified for adequacy. Cam and pincer deformities, dysplasia, borderline dysplasia, and osteoarthritis were defined. All plain radiographic parameters were measured and analyzed on available radiographs. Student t test, chi-square test (and Fisher exact test), and Spearman correlation analyses were performed to compare sexes, groups, and the effect of select radiographic criteria. Results: A total of 47 dancers were analyzed (21 males, 26 females; mean age (±SD), 23.8 ± 5.4 years). Cam deformity was identified in 25.5% (24/94) of hips and 31.9% (15/47) of subjects, with a significantly greater prevalence in male dancers than females (48% hips and 57% subjects vs 8% hips and 12% subjects; P < .001 and P = .001, respectively). Seventy-four percent of subjects had at least 2 of 6 radiographic signs of pincer deformity. Male dancers had a significantly greater prevalence of both prominent ischial spine and posterior wall signs (P = .001 and P < .001, respectively), while female dancers had a significantly greater prevalence of coxa profunda (85% female hips vs 26% male hips; P < .001). Eighty-nine percent of subjects had dysplasia or borderline dysplasia in at least 1 hip (37% dysplastic), with a significantly greater prevalence of dysplasia or borderline dysplasia in female versus male dancers (92% female hips vs 74% male hips; P < .022). Further, in those with dysplasia or borderline dysplasia, 92% of female and 82% of male dancers had bilateral findings. Conclusion: In this professional ballet company, a high prevalence of radiographic abnormalities was found, including cam and pincer deformity and dysplasia. The results also revealed several sex-related differences of these abnormalities in this unique population. The long-term implications of these findings in this group of elite athletes remain unknown, and this issue warrants future investigation.

The utility of the KJOC score in professional baseball in the United States

Background: The Kerlan-Jobe Orthopaedic Clinic (KJOC) Shoulder and Elbow questionnaire has been shown by previous studies to be more sensitive than other validated subjective measurement tools in the detection of upper extremity dysfunction in overhead-throwing athletes. Purpose: The primary objective was to establish normative data for KJOC scores in professional baseball players in the United States. The secondary objectives were to evaluate the effect of player age, playing position, professional competition level, history of injury, history of surgery, and time point of administration on the KJOC score. Study Design: Cross-sectional study; Level of evidence, 3. Methods: From 2011 to 2012, a total of 203 major league and minor league baseball players within the Houston Astros professional baseball organization completed the KJOC questionnaire. The questionnaire was administered at 3 time points: spring training 2011, end of season 2011, and spring training 2012. The KJOC scores were analyzed for significant differences based on player age, injury history, surgery history, fielding position, competition level, self-reported playing status, and time point of KJOC administration. Results: The average KJOC score among healthy players with no history of injury was 97.1 for major league players and 96.8 for minor league players. The time point of administration did not significantly affect the final KJOC score (P = .224), and KJOC outcomes did not vary with player age (r = −0.012; P = .867). Significantly lower average KJOC scores were reported by players with a history of upper extremity injury (86.7; P < .001) and upper extremity surgery (75.4; P < .0001). The KJOC results did vary with playing position (P = .0313), with the lowest average scores being reported by pitchers (90.9) and infielders (91.3). Conclusion: This study establishes a quantitative baseline for the future evaluation of professional baseball players with the KJOC score. Age and time of administration had no significant effect on the outcome of the KJOC score. Missed practices or games within the previous year because of injury were the most significant demographic predictors of lower KJOC scores. The KJOC score was shown to be a sensitive measurement tool for detecting subtle changes in the upper extremity performance of the professional baseball population studied.

Prevalence of Scapular Dyskinesis in Overhead and Nonoverhead Athletes: A Systematic Review

Background: Scapular dyskinesis, or abnormal dynamic scapular control, is a condition that is commonly associated with shoulder pathology but is also present in asymptomatic individuals. Literature varies on whether it represents a cause or symptom of shoulder pathology, but it is believed to be a risk factor for further injury. Clinical identification focuses on visual observation and examination maneuvers. Treatment of altered scapular motion has been shown to improve shoulder symptoms. It is thought to be more common in overhead athletes due to their reliance on unilateral upper extremity function but the incidence within nonoverhead athletes is unknown. Hypothesis: Overhead athletes will have a greater prevalence of scapular dyskinesis when compared with nonoverhead athletes. Study Design: Systematic review; Level of evidence, 3. Methods: After PROSPERO registration, a systematic review was performed using PRISMA guidelines through the PubMed database looking for studies published before October 2014. All studies containing the search terms scapular, scapulothoracic, dyskinesis, dyskinesia, shoulder athlete, or overhead athlete were included. Studies that did not include prevalence data for scapular dyskinesis were excluded. Study methodological quality was evaluated using the modified Coleman methodology score. Descriptive statistics and 2-proportion 2-tailed z-tests were used to compare the reported prevalence of scapular dyskinesis between overhead and nonoverhead athletes. Results: Twelve studies were analyzed including 1401 athletes (1257 overhead and 144 nonoverhead; mean age, 24.4 ± 7.1 years; 78% men). All the studies were evidence level 2 (33%) or level 3 (67%). The reported prevalence of scapular dyskinesis was significantly (P < .0001) higher in overhead athletes (61%) compared with nonoverhead athletes (33%). Conclusion: Scapular dyskinesis was found to have a greater reported prevalence (61%) in overhead athletes compared with nonoverhead athletes (33%). Clinical Relevance: Prevalence data for scapular dyskinesis are scarce within the literature. Information on the reported prevalence, laterality, and association with the dominant extremity will allow for better allocation of diagnostic and therapeutic interventions. Recognition and treatment will help athletes to optimize functional performance and decrease the risk of further shoulder injury.

Radiographic Evidence of Hip Microinstability in Elite Ballet

PURPOSEnTo determine prevalence, magnitude, and predisposing radiographic features of hip subluxation in elite ballet dancers.nnnMETHODSnA cross-sectional investigation of professional male and female ballet dancers was performed using 5 plain radiographs. A splits anteroposterior (AP) radiograph was performed with legs abducted parallel to the trunk in the coronal plane (splits position; grand écart facial). Hip center position (HCP) was measured on standing AP pelvis and AP pelvis splits views and the difference calculated (subluxation distance) to determine prevalence and magnitude of femoral head subluxation. Student t test compared HCP on AP pelvis and splits radiographs. Pearson correlations were used to correlate splits HCP with radiographic measures of femoroacetabular impingement and dysplasia.nnnRESULTSnAnalyzing 47 dancers (21 men, 26 women; 23.8 ± 5.4xa0years), mean HCP on standing AP pelvis was 9.39 ± 3.33xa0mm versus 10.8 ± 2.92xa0mm on splits radiograph, with mean subluxation distance of 1.41xa0mmxa0(Pxa0= .035). Forty-two dancers femoral heads translated laterally with splits positioning, and 17 dancers (36%) exhibited a vacuum sign (bilateral in 71% of subjects with at least 1 hip vacuum sign). There was strong positive correlation (rxa0= 0.461, Pxa0= .001) with splits HCP and alpha angle (Dunn 45°), and moderate negative correlation (rxa0=xa0-0.332, Pxa0= .022) with subluxation distance and neck-shaft angle. In men, splits HCP increased as lateral center edge angle (CEA) decreased (rxa0=xa0-0.437, Pxa0= .047), as anterior CEA decreased (rxa0=xa0-0.482, Pxa0= .027), as Tönnis angle increased (rxa0= 0.656, Pxa0= .001), and as femoral head extrusion index increased (rxa0= 0.511, Pxa0= .018). In women, there was moderate negative correlation (rxa0=xa0-0.389, Pxa0= .049) with subluxation distance and neck-shaft angle.nnnCONCLUSIONSnHip subluxation occurs during splits in most professional ballet dancers, with a significantly greater magnitude of subluxation in women than men. Subluxation magnitude increases with increasing alpha angle and decreasing neck-shaft angle. In men, the magnitude increases with severity of dysplasia. Women had subluxation regardless of acetabular morphology but increased subluxation with decreased neck-shaft angle. This provides radiographic support for hip microinstability in elite ballet.nnnLEVEL OF EVIDENCEnLevel IV, diagnostic.

The Effect on External Rotation of an Anchor Placed Anterior to the Biceps in Type 2 SLAP Repairs in a Cadaveric Throwing Model

PURPOSEnThis study examined whether there is a difference in external rotation (ER) between type 2 SLAP repairs consisting of anchors placed only posterior to the biceps insertion compared with repairs with an additional anchor placed anterior to the biceps.nnnMETHODSnSeven cadaveric shoulders from donors with a mean age of 39.4 years were tested. Type 2 SLAP lesions were created, followed by a 3-anchor repair: a standard repair with 2 anchors posterior to the biceps plus an additional anchor anterior to the biceps. The specimens were placed on a material testing system machine and rotation was measured under a constant torque. The sutures were then removed sequentially from anterior to posterior during testing.nnnRESULTSnThe average ER of the intact shoulder was 115.7° ± 2.6°. After SLAP tear creation and cyclic loading, the ER was 118.5° ± 2.6°, which decreased to 116.5° ± 2.6° after repair. This corresponds to a reduction of 2.0° of ER (P < .0001) with the repair. After release of the anterior anchor, the ER increased to 117.9° ± 2.6°, which corresponds to an increase in shoulder motion of 1.4° of ER (P = .0011). Additional release of the middle anchor, leaving only the posterior anchor intact, resulted in 118.0° ± 2.7° of ER, which corresponds to an increase of only 0.1° of ER (P = .7667).nnnCONCLUSIONSnFollowing type 2 SLAP repair in the cadaveric shoulder, removing the effect of the anchor anterior to the biceps resulted in a small but statistically significant increase in ER. The anterior anchor had the greatest effect on ER. The presence of 1 or 2 anchors posterior to the biceps did not have a significant effect on rotation.nnnCLINICAL RELEVANCEnWhen performing SLAP repairs on those in whom even a small loss of ER would be detrimental, such as baseball pitchers, avoidance of the use of an anchor anterior to the biceps should be considered.

Does high knee flexion cause separation of meniscal repairs

Background: Previous clinical studies comparing nonrestrictive and restrictive protocols after meniscal repair have shown no difference in outcomes; however, some surgeons still limit range of motion out of concern that it will place undue stress on the repair. Hypothesis: Large acute medial meniscal tears will gap during simulated open chain exercises at high flexion angles, and a repaired construct with vertical mattress sutures will not gap. Study Design: Controlled laboratory study. Methods: Tantalum beads were implanted in the medial menisci of 6 fresh-frozen cadaveric knees via an open posteromedial approach. Each knee underwent 10 simulated open chain flexion cycles with loading of the quadriceps and hamstrings. Testing was performed on 3 different states of the meniscus: intact, torn, and repaired. Biplanar radiographs were taken of the loaded knee in 90°, 110°, and 135° of flexion for each state. A 2.5-cm tear was created in the posteromedial meniscus and repaired with inside-out vertical mattress sutures. Displacement of pairs of beads spanning the tear was measured in all planes by use of radiostereometric analysis (RSA) with an accuracy of better than 80 μm. Results: With a longitudinal tear, compression rather than gapping occurred in all 3 regions of the posterior horn of the meniscus (mean ± standard deviation for medial collateral ligament [MCL], –321 ± 320 μm; midposterior, –487 ± 256 μm; root, –318 ± 150 μm) with knee flexion. After repair, meniscal displacement returned part way to intact values in both the MCL (+55 ± 250 μm) and root region (–170 ± 123 μm) but not the midposterior region, where further compression was seen (–661 ± 278 μm). Conclusions: Acute posteromedial meniscal tears and repairs with vertical mattress sutures do not gap, but rather compress in the transverse plane at higher flexion angles when subjected to physiologic loads consistent with active, open kinetic chain range of motion rehabilitation exercises. The kinematics of the repaired meniscus more closely resemble that of the intact meniscus than that of the torn meniscus in regions adjacent to the MCL and the root but not in the midposterior region, where meniscal repair led to increased compression across the tear plane. Clinical Relevance: This study supports the idea that nonrestrictive unresisted open chain range of motion protocols do not place undue stress on meniscal repairs.