Robert J. Meislin

Platelet-rich Plasma: Current Concepts and Application in Sports Medicine

Platelet-rich plasma is defined as autologous blood with a concentration of platelets above baseline values. Platelet-rich plasma has been used in maxillofacial and plastic surgery since the 1990s; its use in sports medicine is growing given its potential to enhance muscle and tendon healing. In vitro studies suggest that growth factors released by platelets recruit reparative cells and may augment soft-tissue repair. Although minimal clinical evidence is currently available, the use of platelet-rich plasma has increased, given its safety as well as the availability of new devices for outpatient preparation and delivery. Its use in surgery to augment rotator cuff and Achilles tendon repair has also been reported. As the marketing of platelet-rich plasma increases, orthopaedic surgeons must be informed regarding the available preparation devices and their differences. Many controlled clinical trials are under way, but clinical use should be approached cautiously until high-level clinical evidence supporting platelet-rich plasma efficacy is available.

Arthroscopic treatment of synovial impingement of the ankle.

Twenty-nine cases of operative arthroscopy of the an kle were done between 1985 and 1989 for synovial impingement of the ankle. The average age of the patients was 37 years. All patients (17 men, 12 women) reported an earlier history of injury, with 24 of the patients (83%) noting chronic ankle pain after an inver sion injury and 5 of the patients (17%) reporting a previous ankle fracture. Physical examination elicited anterolateral tenderness at the ankle in all cases with associated anteromedial pain in 4 patients. A demon strable click was evident in 6 of the patients (21 %) on forced dorsiflexion of the ankle. All patients failed conservative treatment including physical therapy and nonsteroidal antiinflammatory drugs. Surgery was performed at an average of 36 months postinjury. Ankle arthroscopy revealed exten sive hypertrophic synovial thickening and scar tissue anterolaterally, indicating synovial impingement in all patients. Associated chondromalacia of the distal tibia was seen in 21 % of the patients. Operative arthroscopy included partial synovectomy and debridement of the hypertrophic tissue and partial shaving chondroplasty of the tibia when indicated. Postoperatively, patients were weightbearing as tolerated. Results were as sessed subjectively and objectively. At 25-month followup 26 patients had excellent or good results and 3 had fair results; there were no poor results. There were no major complications, including infection or neurovascular compromise. The 3 patients with associated ankle instability comprised the fair result group and eventually required lateral ankle recon struction. Thus, chronic ankle pain due to synovial impingement can be safely, predictably, and effectively treated by operative ankle arthroscopy.

A Biomechanical Analysis of the Sliding Hip Screw: The Question of Plate Angle

There is general agreement that the implant of choice for intertrochanteric fractures is the sliding hip screw (SHS). However, considerable differences of opinion exist as to which plate angle—varying from 130 to 150°—is preferred. Thus far there has been no cadaver-based biomechanical analysis of this problem. To examine these questions, we determined the effect of plate angle on plate strain and proximal medial femoral strain distribution in cadaver femurs fixed with 130, 135, 140, 145, and 150° SHS after experimentally produced stable and unstable intertrochanteric fractures. Twenty-four fresh adult cadaver femurs were assigned randomly to either the 130, 135, 140, 145, or 150° SHS group. Each femur was radiographed and bone mineral density was determined by dual-photon absorptiometry. Multiple-strain gauges were affixed to the femur, with specific focus on the proximal femur and plate. Femurs were loaded at 25° adduction in increments of 70 N from 0 to 1,800 N in a servohydraulic testing machine. Femurs were tested in a progressive manner: (a) intact femur; (b) intact femur with SHS inserted; (c) a stable two-part intertrochanteric fracture reduced with SHS; (d) a four-part fracture with the posteromedial fragment (PMF) reduced anatomically by a lag screw; (e) the same fracture with the PMF rotated 180° and held in place by a lag screw to approximate a “near-anatomic” reduction; and (f) the same fracture with the PMF discarded. Screw sliding measurements were determined at regular intervals throughout each test. While the plate strain gauge demonstrated higher tensile strain in the 130° SHS group than in the other groups for all tests performed, the differences were not significant (p > 0.05). For each test, the tensile strain was lowest for the 140° SHS and highest for the 130° SHS. Less compressive strain was measured in the medial “calcar” region as the fracture became more unstable. However, the compressive strain was almost identical for all angle groups when a two-part or four-part fracture with perfect reduction was performed. Analysis of the sliding characteristics showed more screw sliding with the 150° nail than with the 130° nail (p < 0.01) or 140° nail (p < 0.05). Even though the 150° nail plate was found to achieve the greatest amount of screw sliding, it produced neither optimal compressive medial femoral loading nor a decreased plate tensile loading. The 150° SHS also “cut out” in the majority of these samples when tested to failure. The 130° nail jammed and bent for two specimens once the PMF was discarded. The matching of the plate angle to the anatomic neck-shaft angle was not found to significantly effect strain distributions (p > 0.05). The argument for using a plate angle closest to the biomechanical axis of the hip or one that is closest to the anatomic neck-shaft angle may be somewhat overstated. The goal of producing a fracture-implant combination with optimal biomechanical loading characteristics may be achievable using an SHS with a plate angle of 135 or 140°. This may limit the need for maintaining and producing large inventories of SHSs of varying plate angles.

Symptomatic snapping hip: targeted treatment for maximum pain relief.

A painful condition known as snapping hip may prevent athletes from attaining peak performance, and it presents diagnostic and treatment challenges to the sports medicine physician as well. Three types of snapping hip (external, internal, and intra-articular) are known, and each has a distinct pathomechanic cause, specific symptoms, and classic clinical presentation. History and physical exam are coupled with a variety of imaging modalities to help distinguish the three types. Nonoperative approaches are the mainstay of treatment, but, if unsuccessful, operative treatments also achieve good results. Patients may resume their activities when pain subsides.

Use of 3D MR reconstructions in the evaluation of glenoid bone loss: a clinical study

ObjectiveTo assess the ability of 3Dxa0MR shoulder reconstructions to accurately quantify glenoid bone loss in the clinical setting using findings at the time of arthroscopy as the gold standard.Materials and methodsRetrospective review of patients with MR shoulder studies that included 3Dxa0MR reconstructions (3Dxa0MR) produced using an axial Dixon 3D-T1W-FLASH sequence at our institution was conducted with the following inclusion criteria: history of anterior shoulder dislocation, arthroscopy (OR) performed within 6xa0months of the MRI, and an estimate of glenoid bone loss made in the OR using the bare-spot method. Two musculoskeletal radiologists produced estimates of bone loss along the glenoid width, measured in mm and %, on 3Dxa0MR using the best-fit circle method, which were then compared to the OR measurements.ResultsThere were a total of 15 patients (13xa0men, two women; mean age, 28, range, 19–51xa0years). There was no significant difference, on average, between the MRI (mean 3.4xa0mm/12.6xa0%; range, 0–30xa0%) and OR (mean, 12.7xa0%; range, 0–30xa0%) measurements of glenoid bone loss (pu2009=u20090.767). A 95xa0% confidence interval for the mean absolute error extended from 0.45–2.21xa0%, implying that, when averaged over all patients, the true mean absolute error of the MRI measurements relative to the OR measurements is expected to be less than 2.21xa0%. Inter-reader agreement between the two readers had an IC of 0.92 and CC of 0.90 in terms of percentage of bone loss.Conclusions3Dxa0MR reconstructions of the shoulder can be used to accurately measure glenoid bone loss.

Detection of cartilage damage in femoroacetabular impingement with standardized dGEMRIC at 3 T

OBJECTIVEnThis study aimed at identifying the optimal threshold value to detect cartilage lesions with Standardized delayed Gadolinium-Enhanced MRI of Cartilage (dGEMRIC) at 3 T and evaluate intra- and inter-observer repeatability.nnnDESIGNnWe retrospectively reviewed 20 hips in 20 patients. dGEMRIC maps were acquired at 3 T along radial imaging planes of the hip and standardized to remove the effects of patients age, sex and diffusion of gadolinium contrast. Two observers separately evaluated 84 Standardized dGEMRIC maps, both by visual inspection and using an average index for a region of interest (ROI) in the acetabular cartilage. A radiologist evaluated the acetabular cartilage on morphologic MR images at exactly the same locations. Using intra-operative findings as reference, the optimal threshold to detect cartilage lesions with Standardized dGEMRIC was assessed and results were compared with the diagnostic performance of morphologic magnetic resonance imaging (MRI).nnnRESULTSnUsing z < -2 as threshold and visual inspection of the color-adjusted maps, sensitivity, specificity and accuracy for Observer 1 and Observer 2, were 83%, 60% and 75%, and 69%, 70% and 69%, respectively. Overall performance was 52%, 67% and 58%, when using an average z for the acetabular cartilage, compared to 37%, 90% and 56% for morphologic assessment. The kappa coefficient was 0.76 and 0.68 for intra- and inter-observer repeatability, respectively, indicating substantial agreement.nnnCONCLUSIONSnStandardized dGEMRIC at 3 T is accurate in detecting cartilage damage and could improve preoperative assessment in femoroacetabular impingement (FAI). As cartilage lesions in FAI are localized, visual inspection of the Standardized dGEMRIC maps is more accurate than an average z for the acetabular cartilage.

Arthroscopic excision of synovial hemangioma of the knee

A synovial hemangioma in the knee joint of a 33-year old woman was diagnosed and removed arthroscopically. Preoperatively, this rare benign soft tissue lesion had caused recurrent swelling of the knee along with persistent pain and occasional buckling. Two years after surgery, the patient has a painless range of motion with no evidence of recurrence.

Clinical Outcomes After Chronic Distal Biceps Reconstruction With Allografts

Background: Chronic ruptures of the distal biceps are often complicated by tendon retraction and fibrosis, precluding primary repair. Reconstruction with allograft augmentation has been proposed as an alternative for cases not amenable to primary repair. Purpose: To investigate the clinical outcomes of late distal biceps reconstruction using allograft tissue. Study Design: Case series; Level of evidence, 4. Methods: A total of 20 patients who underwent distal biceps reconstruction with allograft tissue between May 2007 and May 2012 were identified. Charts were retrospectively reviewed for postoperative complications, gross flexion and supination strength, and range of motion. Subjective functional outcomes were assessed prospectively with the Mayo Elbow Performance Score (MEPS) and Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. Results: Eighteen patients with adequate follow-up were included in the study. All had undergone late distal biceps reconstruction with allografts (Achilles [n = 15], semitendinosus [n = 1], gracilis [n = 1], or anterior tibialis [n = 1]) for symptomatic chronic ruptures of the distal biceps. At a mean office follow-up of 9.3 months (range, 4-14 months), all patients had full range of motion and mean gross strength of 4.7 of 5 (range, 4-5) in flexion and supination. After a mean out-of-office follow-up at 21 months (range, 7-68.8 months), the mean DASH score was 7.5 ± 17.9, and the mean MEPS increased from 43.1 preoperatively to 94.2 postoperatively (P < .001). The only complication observed was transient posterior interosseous nerve palsy in 2 patients. Additionally, all but 1 patient reported a cosmetic deformity. However, all patients found it acceptable. Conclusion: Late reconstruction for chronic ruptures of the distal biceps using allograft tissue is a safe and effective solution for symptomatic patients with functional demands in forearm supination and elbow flexion. While there are several graft options, the literature supports good results with Achilles tendon allografts. Further studies are needed to evaluate the clinical outcomes of other allograft options.

Type III acromioclavicular joint separation associated with late brachial-plexus neurapraxia

We report the case of a 28-year-old woman who developed signs and symptoms of brachial-plexus neurapraxia eight years after a type III acromioclavicular (AC) joint separation. Stabilization of the AC joint resulted in resolution of the symptoms.

The Effect of Repair of the Lacertus Fibrosus on Distal Biceps Tendon Repairs: A Biomechanical, Functional, and Anatomic Study

Background To date, repair of the lacertus in distal biceps tendon ruptures, recommended by some, has not been evaluated. The goal of these biomechanical experiments was to evaluate the degree to which its repair increases the strength of a distal biceps tendon repair. Hypothesis An intact or repaired lacertus fibrosus will increase the strength of a distal biceps tendon repair. Study Design Controlled laboratory study. Methods Four matched pairs of fresh-frozen human cadaveric upper extremities were prepared by isolating the lacertus fibrosus and the distal biceps tendon. The extremity was placed in a custom-built rig with the distal biceps brachii clamped and affixed to a stepper motor assembly. The distal biceps tendon was sharply removed directly from the radial tuberosity and repaired through a bony tunnel in all specimens. One side of each pair was randomized to also receive repair of the lacertus. The specimens were pulled at a constant rate until failure. Results The mean failure strength, defined as maximal strength to 15 mm of displacement, was higher in specimens with a repaired lacertus (250.2 N vs 158.2 N; P = .012), as was mean maximum strength (256.8 N v. 164.5 N; P = .0058). Mean stiffness was not significantly different (16.36 N/mm vs 13.8 N/mm; P = .58). All specimens failed due to fracture at the bony bridge. Conclusion Repair of the lacertus strengthened distal biceps tendon repair in a controlled laboratory setting. Clinical Relevance Repair of the lacertus fibrosus as an adjunct to distal biceps tendon repair strengthens the repair in the laboratory setting. Clinical testing is needed to verify that this increased strength improves clinical results. Surgeons should be cautioned to protect the underlying neurovascular structures during repair of the lacertus fibrosus and to avoid an overly tight repair.