Paul Marchetto

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.

Cervical spine injuries in American football.

American football is a high-energy contact sport that places players at risk for cervical spine injuries with potential neurological deficits. Advances in tackling and blocking techniques, rules of the game and medical care of the athlete have been made throughout the past few decades to minimize the risk of cervical injury and improve the management of injuries that do occur. Nonetheless, cervical spine injuries remain a serious concern in the game of American football. Injuries have a wide spectrum of severity. The relatively common ‘stinger’ is a neuropraxia of a cervical nerve root(s) or brachial plexus and represents a reversible peripheral nerve injury. Less common and more serious an injury, cervical cord neuropraxia is the clinical manifestation of neuropraxia of the cervical spinal cord due to hyperextension, hyperflexion or axial loading. Recent data on American football suggest that approximately 0.2 per 100 000 participants at the high school level and 2 per 100 000 participants at the collegiate level are diagnosed with cervical cord neuropraxia. Characterized by temporary pain, paraesthesias and/or motor weakness in more than one extremity, there is a rapid and complete resolution of symptoms and a normal physical examination within 10 minutes to 48 hours after the initial injury. Stenosis of the spinal canal, whether congenital or acquired, is thought to predispose the athlete to cervical cord neuropraxia. Although quite rare, catastrophic neurological injury is a devastating entity referring to permanent neurological injury or death. The mechanism is most often a forced hyperflexion injury, as occurs when ‘spear tackling’. The mean incidence of catastrophic neurological injury over the past 30 years has been approximately 0.5 per 100 000 participants at high school level and 1.5 per 100 000 at the collegiate level. This incidence has decreased significantly when compared with the incidence in the early 1970s. This decrease in the incidence of catastrophic injury is felt to be the result of changes in the rules in the mid- 1970s that prohibited the use of the head as the initial contact point when blocking and tackling. Evaluation of patients with suspected cervical spine injury includes a complete neurological examination while on the field or the sidelines. Immobilization on a hard board may also be necessary. The decision to obtain radiographs can be made on the basis of the history and physical examination. Treatment depends on severity of diagnosed injury and can range from an individualized cervical spine rehabilitation programme for a ‘stinger’ to cervical spine decompression and fusion for more serious bony or ligamentous injury. Still under constant debate is the decision to return to play for the athlete.

Clinical, Functional, and Radiographic Assessments of the Conventional and Modified Boyd-Anderson Surgical Procedures for Repair of Distal Biceps Tendon Ruptures

The purpose of this study was to evaluate the clinical, functional, and radiographic outcomes of the conventional and modified Boyd-Anderson procedures for repair of distal biceps tendon ruptures. Thirteen of 18 men who underwent surgical repair for unilateral distal biceps tendon ruptures at one university center participated in the study. In general, follow-up outcomes were favorable with respect to return to premorbid activity levels, patient satisfaction with surgical outcome, and overall clinical results. Elbow flexion, forearm supination, and upper extremity functional concentric peak torque and range of motion results were not significantly different between the surgical and nonsurgical arms when dominance was controlled as a confounding factor. Radiographic findings revealed no clinically remarkable signs of heterotopic ossification or proximal radioulnar synostosis. Results of the study reveal that the conventional and modified Boyd-Anderson procedures are clinically, functionally, and radio-graphically efficacious for repair of distal biceps tendon ruptures.

Hyperbaric Oxygen Therapy For Acute Ankle Sprains

We conducted a randomized double-blind study of 32 subjects with acute ankle sprains to compare treatment with hyperbaric oxygen at 2 atmospheres absolute pressure (N = 16) (treatment group) with treatment with air at 1.1 atmosphere absolute pressure (N = 16) (control group) in a hyperbaric chamber. Each group received three treatments at their respective pres sures : one for 90 minutes and two for 60 minutes each. Mean age, severity grade, and time to treatment (treat ment group, 34.3 ± 6.3 hours; control group, 32.6 ± 4.6 hours) were similar in both groups. Joint function measured by a functional index improved from 0.40 ± 0.2 to 6.3 ± 0.4 with hyperbaric oxygen and from 0.8 ± 0.3 to 5.3 ± 0.6 with air. The change from initial to final evaluation was significantly greater in the treatment group. Foot and ankle volume by water displacement decreased from 1451 ± 57 ml to 1425 ± 63 ml with hyperbaric oxygen and from 1403 ± 50 ml to 1371 ± 45 ml with air (no difference was noted between hy perbaric oxygen treatment and air treatment using a two-way analysis of variance). Subjective pain index fell from 3.3 ± 0.5 to 0.8 ± 0.3 with hyperbaric oxygen and from 2.6 ± 0.3 to 0.3 ± 0.2 with air. No differences were noted in passive or active range of motion when comparing hyperbaric oxygen treatment with air treat ment. Time to recovery was the same in both groups (treatment, 16.0 ± 6.3 days; control, 15.4 ± 2.8 days). Regression analysis to determine the influence of time to treatment, initial severity of injury, hyperbaric oxy gen, and age showed no effect of hyperbaric oxygen treatment on time to recovery.

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.

Short-/Intermediate-Term Outcomes after Medial Patellofemoral Ligament Reconstruction in the Treatment of Chronic Lateral Patellofemoral Instability

Abstract Purpose: Disruption of the medial patellofemoral ligament (MPFL) is now considered the essential lesion of recurrent lateral patellar dislocation in patients with normal lower extremity alignment. Reconstruction of the MPFL is a technique gaining significant success in the treatment of patients with this disabling condition. Hypothesis: Reconstruction of the MPFL in patients with chronic patellar instability and normal lower extremity alignment will improve knee function and symptoms, with a high percentage of patients achieving good to excellent results at early follow-up. Study Design: Case series; Level of evidence; 4. Methods: A consecutive series of patients with lateral patellofemoral instability who underwent MPFL reconstruction were reviewed. Reconstruction was performed with either soft tissue allograft (23 patients) or hamstring tendon autograft (12 patients). Outcomes were determined by patient scores from the Kujala Anterior Knee Pain Scale, recurrence of patellar instability, and patient function at a minimum of 12 months of postoperative follow-up. Results: Thirty-five patients were followed for a mean of 21.0 months (range, 12-45 months) after surgery. The Kujala subjective knee score improved significantly from 49.0 preoperatively to 89.5 postoperatively (P < 0.001). No statistical significance was found between postoperative Kujala scores and graft type, or time from initial injury to surgical reconstruction. A firm endpoint to lateral translation of the patella, and no feelings of apprehension were noted in all patients at most recent follow-up. The majority of patients noted that they were more active than before reconstructive surgery, with 86% participating in “strenuous” to “very strenuous” activities at the time of follow-up. No recurrent dislocations were reported. Conclusion: Reconstruction of the MPFL provides excellent stability and functional outcomes for patients with recurrent patellar instability.

Mean subaxial space available for the cord index as a novel method of measuring cervical spine geometry to predict the chronic stinger syndrome in American football players.

OBJECT The chronic stinger syndrome is a distinct entity from acute stingers and has been shown to have its own pathophysiology that, unlike acute stingers, may reflect long-standing geometrical changes of the subaxial spinal canal and chronic irritation/degeneration of the exiting nerve root complex. There is no method available, however, to accurately predict these symptoms in athletes. The mean subaxial cervical space available for the cord (MSCSAC) is a novel alternative to the Torg ratio for predicting neurological symptoms caused by cervical spondylosis in elite athletes. It is the goal of this study to determine critical values for this measurement index and to retrospectively correlate those values to neurological symptoms. METHODS Magnetic resonance images obtained in 103 male athletes participating in the 2005 and 2006 National Football League Scouting Combine and a control group of 42 age-matched male nonathletes were retrospectively reviewed. The Torg ratio and SAC values were calculated in triplicate at each cervical level from C3-6 by using lateral radiographs and midsagittal T2-weighted MR images of the cervical spine, respectively. These values were then averaged for each individual to produce mean subaxial cervical Torg ratio (MSCTR) and MSCSAC values. Receiver operating characteristic curves were constructed for each measurement technique and were compared based on their respective area under the curves (AUCs). RESULTS The MSCSAC difference between athletes with and without chronic stingers was statistically significant (p < 0.01). The difference between athletes with and without chronic stingers compared with controls was also statistically significant (p < 0.001 and p < 0.001, respectively). The AUC for the MSCSAC was 0.813, which was significantly greater than the AUC for both the MSCTR (p = 0.0475) and the individual Torg ratio (p = 0.0277). The MSCTR had the second largest AUC (0.676) and the conventional method of measuring individual Torg ratio values produced the lowest AUC (0.661). It was found that using the MSCSAC with a critical value of 5.0 mm produced a sensitivity of 80% and a negative likelihood ratio of 0.23 for predicting chronic stingers. Lowering the cutoff value to 4.3 mm for the MSCSAC resulted in a possible confirmatory test with a specificity of 96% and a positive likelihood ratio of 13.25. CONCLUSIONS A critical value of 5.0 mm for the MSCSAC provides the clinician with a screening test for chronic stingers and anything < 4.3 mm adds additional confidence as a confirmatory test. These results are approximately 20% more accurate than the classic Torg ratio based on our AUC analysis. It was found that measuring the spinal geometry throughout the length of the subaxial cervical spine produced a more reliable method by which to predict neurological symptoms than the traditional approach of measuring individual levels. This shows that the underlying pathogenesis of the chronic stinger syndrome is best characterized as a process that involves the entire subaxial region uniformly.

Triceps Tendon Ruptures Requiring Surgical Repair in National Football League Players.

Background: Complete triceps tendon ruptures are relatively rare in the general population but slightly more prevalent in professional football. One prior study found 11 complete ruptures over a 6-season period. Hypothesis: Triceps ruptures occur more commonly in football linemen due to forced elbow flexion during an eccentric contraction and may occur more commonly with the increasing size and speed of professional players. Surgical repair allows full return to sports, but with a lengthy recovery time. Study Design: Case series; Level of evidence, 4. Methods: A search of the National Football League Injury Surveillance System (NFLISS) found a total of 37 triceps tendon ruptures requiring surgical repair from the years 2000 to 2009. Data were obtained for setting of injury, player position, activity causing injury, play type, time of game when injury occurred, height, weight, body mass index (BMI), and number of days lost from football. Results: There were 37 players requiring surgical repair for triceps tendon ruptures over the 10-season period. The average height, weight, and BMI of the players were 75 inches, 292 pounds, and 36.5 kg/m2, respectively. The majority of players were linemen (86%): 16 defensive, 15 offensive, and 1 tight end. The injury took place while blocking or being blocked in 29 players (78%) and while tackling or being tackled in 5 players (14%). Players missed an average of 165 days (range, 49-318 days) from football as a result of their injury and surgery. Conclusion: Triceps tendon tears requiring surgical repair are more common in professional football players than in the general population and are occurring more commonly than previously reported. Surgical repair allows return to play. Clinical Relevance: Our study identifies the rate of triceps tendon tears requiring repair in the NFL according to position, identifying which players may be most at risk for this injury.

Assessment of the endoscopic semitendinosus/ gracilis autograft procedure with interference screw fixation for reconstruction of the anterior cruciate ligament

The semitendinosus/gracilis autograft procedure with interference screw fixation was evaluated for clinical effectiveness of anterior cruciate ligament (ACL) reconstruction. Thirty patients underwent the procedure and were evaluated an average of 15 months postoperatively. Results revealed 22 (73%) patients had a standard knee evaluation form score of normal or nearly normal, and 24 (80%) patients returned to strenuous or moderate activity levels. Average Lysholm outcome score was 89, and bilateral KT-2000 differences were <3 mm at follow-up. Functional knee test symmetry index percentage outcome for the one-legged hop test was 92.6% for distance and 98% for time. Length of time (i.e., < or =90 days or > or =91 days) between injury and surgery was independent of outcome. These findings indicate the semitendinosus/gracilis autograft is a viable procedure for reconstruction of the ACL-deficient knee.

A Composite Athletic Tape With Hyperelastic Material Properties Improves and Maintains Ankle Support During Exercise

STUDY DESIGN Controlled laboratory testing using a single-group, prospective, repeated-measures design. OBJECTIVES To compare the material properties of a hyperelastic athletic tape to a conventional tape and to compare the passive ankle support of these tapes before and after exercise. BACKGROUND The near-linear material properties of conventional athletic tape may interfere with ankle motion, resulting in reduced athletic performance. Conventional athletic tape is also known to lose much of its initial support during exercise. It was assumed that a tape constructed of Kevlar fibers embedded in a silicon matrix would possess hyperelastic material properties that would improve ankle support. METHODS A tensile testing machine was used to determine the tensile material properties of 11 samples of conventional and hyperelastic tape. The ankles of 11 young, healthy athletes were taped, one ankle with conventional tape and the other ankle with hyperelastic tape. The passive ankle support of each tape was measured with an instrumented linkage (the ankle flexibility tester) before and after 30 minutes of exercise. RESULTS The composite tape had a significantly higher load to failure than the conventional tape. It had significantly lower initial stiffness and higher late stiffness than conventional tape, thus demonstrating highly hyperelastic behavior. The hyperelastic tape maintained a significantly higher portion of its support during the 30 minutes of exercise than the conventional tape. CONCLUSIONS Composite athletic tape with highly hyperelastic properties can be constructed and maintains a larger portion of its support during short-duration exercises (less than 30 minutes) than conventional athletic tape.