Symptom Chronicity and Tobacco Use: Differences in Athletic and Nonathletic Candidates for Cartilage Surgery

OBJECTIVE

To determine whether there are differences in symptomatic knee cartilage defects and rates of tobacco use among age-matched athletes versus nonathletes undergoing initial arthroscopic knee surgery who meet demographic and radiographic criteria for cartilage restoration surgery.

DESIGN

Age-matched athletes (n = 186) and nonathletes (n = 159) age 40 or less with a body mass index (BMI) of 35 kg/m² or less (mean 26.8 SD 4.1) and <50% joint space narrowing on weight-bearing radiographs were included. All patients had a symptomatic Outerbridge grade 2 or higher cartilage defect visualized during knee arthroscopy. Relationship between athletic status and chronicity of knee symptoms prior to surgery and tobacco use status, cartilage defect Outerbridge grade, size, and location at time of surgery were characterized.

RESULTS

Nonathletes were more likely to smoke (P < 0.001) and had higher BMI (P = 0.005). Duration of symptoms prior to surgery was shorter among athletes (P < 0.001). Grade 4 defects were equally prevalent (P = 0.96) as were multicompartment grade 3-4 lesions (P = 0.12). Mean grade 3-4 defect size was similar in lateral (P = 0.96) and medial compartments (P = 0.82). There was a trend toward larger anterior compartment defects in nonathletes (P = 0.07).

CONCLUSIONS

Among age-matched athletes and nonathletes with symptomatic cartilage defects who meet demographic criteria for cartilage restoration, nonathletes were more likely to smoke and have a longer duration of symptoms prior to treatment. Athletes tended to present earlier but with similar size defects compared to nonathletes, supporting accelerated treatment of defects in athletes and caution toward allowing continued athletic participation in patients with known cartilage defects.

Tuberculosis of the extra-axial skeleton in paediatric patients

ABSTRACT BACKGROUND: Musculoskeletal tuberculosis (MSK TB) is a disease entity that often mimics other orthopaedic conditions in its radiographic and clinical presentation, which can delay diagnosis and treatment. The purpose of this study is to examine the clinical and radiographic presentation as well as the accuracy of various diagnostic tests, treatment, complications and outcome in paediatric patients diagnosed with MSK TB. We aim to provide insight into typical presenting features in order to expedite diagnosis in this perplexing disease. METHODS: We retrospectively reviewed 77 consecutive patients with extra-axial MSK TB treated at our institution over a ten-year period from 2008 to 2018. We collected data on initial clinical presentation, laboratory values, radiographic findings, diagnostic testing, treatment and outcomes. We performed quantitative and qualitative analysis to look for patterns in presentation that can help with diagnosis and factors affecting the clinical outcomes. RESULTS: The most common clinical presentation was pain of the affected limb. Constitutional symptoms were uncommon. Our patients presented with thrombocytosis and anaemia, but normal white cell counts. Inflammatory markers were mildly elevated. Of diagnostic tests employed, the Mantoux skin test yielded the most positive results (70%) followed by tissue PCR (53%). The hip was most frequently involved, followed by the knee and elbow. Most patients presented with normal appearing X-rays. We had a medical compliance rate of 94% with all patients followed up to completion of treatment having resolution of active disease. Thirty-nine per cent of our patients had residual joint stiffness or deformity following completion of treatment, ranging from ankylosis to mildly decreased joint range. CONCLUSION: Patients with MSK TB usually present with non-specific symptoms and signs, and a high index of suspicion should be maintained in endemic areas. Typical haematological findings are an elevated ESR and CRP accompanied by anaemia and thrombocytosis. Radiographs at presentation are non-specific in more than 50% of patients. A combination of diagnostic modalities should be employed as no single test is 100% sensitive or specific. Compliance with medical treatment reliably leads to resolution of the disease. Residual joint pathology is common and needs to be addressed secondarily. Level of evidence: Level 4 Keywords: musculoskeletal tuberculosis, paediatric tuberculosis, joints, anti-tuberculosis treatment, deformity, GeneXpert

Utility of Percutaneous Ultrasonic Tenotomy for Tendinopathies: A Systematic Review

CONTEXT

Chronic tendinopathy is a challenging problem that can lead to significant disability and limitation in not only athletics but also activities of daily living. While there are many treatment techniques described for this overuse injury, no single modality has been proven superior to all others. With recent advances in medical technology, percutaneous ultrasonic tenotomy (PUT) for tendinosis has gained traction with promising results.

OBJECTIVE

To examine the data published on PUT for treatment of tendinopathy, analyze the outcomes of the procedure, including duration of pain relief and patient-reported outcomes, and assess the rate of complications associated with the procedure.

DATA SOURCES

PubMed, MEDLINE, EMBASE, and Google Scholar.

STUDY SELECTION

The following combination of keywords was entered into the electronic search engines: ultrasonic tenotomy, ultrasound tenotomy, Tenex, and ultrasonic percutaneous tenotomy. The search results were screened for studies relevant to the topic. Only English-language studies were considered for inclusion. Studies consisting of level 4 evidence or higher and those involving human participants were included for more detailed evaluation.

LEVEL OF EVIDENCE

Level 4.

DATA EXTRACTION

Articles meeting the inclusion criteria were sorted and reviewed. Type of tendinopathy studied, outcome measures, and complications were recorded. Both quantitative and qualitative analyses were performed on the data collected.

RESULTS

There were a total of 7 studies that met the inclusion criteria and quality measures-5 studies involving the treatment of elbow tendinopathy and 1 study each involving the management of Achilles tendinopathy and plantar fasciitis. PUT resulted in decreased pain/disability scores and improved functional outcome scores for chronic elbow tendinopathy and plantar fasciitis. Results for Achilles tendinopathy showed modest improvement in the short term, but long-term data are lacking.

CONCLUSION

PUT is a minimally invasive treatment technique that can be considered in patients with tendinopathy refractory to conservative treatment measures. Further higher quality studies are necessary to accurately assess the comparative effectiveness of this treatment modality.

No differences in short-term outcomes between patients with anaerobic and aerobic culture positive prosthetic joint infection

BACKGROUND

Prosthetic joint infection (PJI) is a devastation complication of total joint arthroplasty that can result in poor patient outcomes. Anaerobic organisms make up a small proportion of PJI cases and are much less studied. Studies comparing patient outcomes in anaerobic PJI to outcomes in aerobic PJI are sparse. The purpose of this study was to compare the clinical presentation, duration of antibiotics, type of treatment provided, and final outcome between PJI patients with anaerobic infection and those with aerobic infection.

METHODS

This was a retrospective study of 26 patients who underwent treatment for PJI at a tertiary referral center. Eight patients with anaerobic PJI were compared to 18 patients with aerobic PJI in terms of clinical presentation, laboratory values, treatment duration, and functional outcome. Statistical analysis was performed on continuous variables of interest.

RESULTS

The results of our study showed that there are no differences in short term clinical outcomes between PJI patients with cultures positive for anaerobic vs aerobic organisms (38.9% vs 50% successfully treated). Inflammatory markers were higher in the aerobic group and patients in the anaerobic group tended to have fewer medical comorbidities.

CONCLUSION

PJI caused by anaerobic organisms results in poor patient outcomes similar to infection caused by aerobic organisms. There are some differences in clinical presentation between the two groups that can be explained by the fact that anaerobic organisms are of low virulence and result in indolent infections causing longstanding symptoms.

Sacral Stress Fractures: A Rare but Curable Cause of Back Pain in Athletes

BACKGROUND

Stress fractures of the sacrum are an uncommon cause of low back and buttock pain in athletes. They have been described in a few case reports, with the injury occurring most often in female distance runners. Given the rarity of this condition, there is a general lack of awareness of this injury, which may lead to a missed or delayed diagnosis.

STUDY DESIGN

Case series.

LEVEL OF EVIDENCE

Level 5.

METHODS

The 5 cases were identified by performing a medical records search within the practices of the senior authors over a 3-year period from January 2016 to December 2018.

RESULTS

Three of 5 patients (1 male, 2 females) returned to regular activity after diagnosis and treatment. Two (1 male, 1 female) have yet to return to regular activity. Magnetic resonance imaging was the key modality in all diagnoses. All 3 female patients had components of the female athlete triad-menstrual irregularity, disordered eating, and decreased bone mineral density.

CONCLUSION

A high index of suspicion is required to make the correct diagnosis and initiate treatment for this rare condition given its association with low body mass index, vitamin D insufficiency, disordered eating, and malabsorption disorders. Appropriate treatment includes rest from the causative activity, nutritional support, and biomechanical optimization. In severe, chronic, or recurrent cases, referral for nutritional counseling, hormonal replacement therapies, and mental health support may be necessary.

CLINICAL RELEVANCE

Sacral stress fractures, though uncommon, should be included prominently in the differential diagnosis for runners with low back pain, especially if the athlete has a history of prior stress fracture or the female athlete triad.

Rapid return to function and stability with dual mobility components cemented into an acetabular reconstructive cage for large osseous defects in the setting of periacetabular metastatic disease

BACKGROUND AND OBJECTIVES

Large acetabular defects secondary to metastatic disease frequently require extensive acetabular reconstruction. Techniques of acetabular reconstruction have been described, but no consensus for the management of these defects has been reached so far. We present our technique and patient outcomes for acetabular reconstruction by cementing a dual mobility cup into an acetabular cage.

METHODS

We reviewed 152 total hip arthroplasties and identified 19 patients with periacetabular metastatic disease and large defects who required acetabular reconstruction utilizing a dual mobility cup cemented into an acetabular reconstructive cage. The following outcomes were evaluated: pain relief, functional improvement, postoperative complications.

RESULTS

Mean follow-up was 3 years, with 13 of the 19 patients eligible for 2-year follow-up. Patients reported a significant improvement in both pain and functional outcomes. There were no dislocations or signs of loosening. Two patients developed postoperative infections. One patient required hemipelvectomy 16 months postop due to recurrence of metastatic disease.

CONCLUSIONS

Cementing a dual mobility cup into an acetabular cage provides a highly stable and durable option for patients with periacetabular metastatic disease and large defects. Patients are able to return to immediate full weight bearing with significant improvement in both function and pain at 2 years.

Evaluation, diagnosis, and treatment of chronic exertional compartment syndrome: a review of current literature

Chronic exertional compartment syndrome (CECS) is a rare condition that usually affects distance runners and other running athletes. It is characterized by pain and pressure in one or multiple muscle compartments with repetitive physical activity. Reduction in pain typically occurs with cessation of activity. Evaluation of CECS consists of a thorough history of patient symptoms and ruling out of other causes of symptoms. Post-exercise pressure measurements can help confirm the diagnosis when symptoms are consistent and imaging evaluation negative for other causes. Non-operative treatment is a viable option for hindfoot runners and patients with anterior compartment syndrome of the leg. Limited-incision fasciotomy has been shown to be the most effective treatment and remains the gold standard for treatment. Minimal-incision open fasciotomy and endoscopic fasciotomy have surgical outcomes similar to wide-open fasciotomy. Military patients treated with fasciotomy have higher failure rates compared to civilians. Pediatric patients have similar outcomes compared to adults.

The Impact of Imaging Modality on the Measurement of Coronal Plane Alignment After Total Knee Arthroplasty

BACKGROUND

The optimal coronal alignment after total knee arthroplasty (TKA) has become an area of increased debate. Sources of variability among investigations include the radiographic technique used for both preoperative surgical planning and postoperative alignment assessments. This study's purpose was to assess the impact of the imaging modality used on the measurement of coronal plane alignment after TKA.

METHODS

A consecutive series of patients undergoing TKA using the same cruciate-retaining prosthesis were included for analysis. Postoperatively, all patients received both a rotationally controlled, scout computed tomography scan and a hip-knee-ankle (HKA) image using the EOS Imaging system (EOS Inc., Paris, France). Two, independent observers measured the HKA angle, and femoral and tibial component alignment from each image.

RESULTS

After classifying overall and component alignment as neutral, varus, or valgus, 40.6% (65 of 160) of knees had a discordant alignment classification for HKA, 28.1% (45 of 160) for femoral component alignment, and 26.9% (43 of 160) for tibial component alignment between their computed tomography and EOS images. Overall, 24.4% (39 of 160) of patients had a HKA difference of ≥3° between the 2 images, whereas 18.8% (30 of 160) and 20.0% (32 of 160) of patients had a femoral and tibial component alignment difference of ≥2°, respectively.

CONCLUSION

Significant differences are present when comparing 2 measurement techniques of mechanical alignment after TKA. The impact of imaging modality on postoperative assessments must be accounted for and be consistent when comparing the results of different investigations.

Does Use of a Variable Distal Femur Resection Angle Improve Radiographic Alignment in Primary Total Knee Arthroplasty?

BACKGROUND

The distal femur resection in total knee arthroplasty (TKA) is commonly made using a fixed angle relative to an intramedullary rod. This study's purpose was to assess if a variable distal femur resection angle technique improves femoral component alignment in TKA.

METHODS

This was a review of primary TKAs performed by 2 surgeons. One surgeon used a fixed resection angle of 5° for varus and 3° for valgus knees ("fixed" cohort). The second used hip-knee-ankle (HKA) radiographs to measure the angle between the femoral anatomic axis and a line perpendicular to the femoral mechanical axis, which was used as the resection angle for each patient ("variable" cohort). Femoral component and HKA alignment were measured from standing HKA radiographs by 2, independent, blinded observers. Two hundred ninety patients were needed for power to detect a 15% difference in femoral component "outliers" (target of 0° ± 2°; significance = P < .05).

RESULTS

Three hundred twenty consecutive patients were included with no differences in age, body mass index, or preoperative deformity (P = .3-.8). A 5° resection angle was used in 46.3% of the variable and 80.0% of the fixed cohort patients. A total of 80.2% of femoral components in the variable and 63.1% in the fixed cohort were within 0° ± 2° (P = .002; 84.6% of variable and 56.3% of fixed for valgus knees, P < .001). The mean HKA alignment was improved in the variable cohort (-1.4° ± 3.3° vs -2.6° ± 3.3°, P = .001).

CONCLUSION

Use of a variable distal femur resection angle improves femoral component alignment after TKA.

Utility of Screening for Cerebral Vasospasm Using Digital Subtraction Angiography

BACKGROUND AND PURPOSE

Cerebral arterial vasospasm (CVS) is a common complication of aneurysmal subarachnoid hemorrhage strongly associated with neurological deterioration and delayed cerebral ischemia (DCI). The utility of screening for CVS as a surrogate for early detection of DCI, especially in patients without clinical signs of DCI, remains uncertain.

METHODS

We performed a retrospective analysis of 116 aneurysmal subarachnoid hemorrhage patients who underwent screening digital subtraction angiography to determine the association of significant CVS and subsequent development of DCI. Patients were stratified into 3 groups: (1) no symptoms of DCI before screening, (2) ≥1 episodes of suspected DCI symptoms before screening, and (3) unable to detect symptoms because of poor examination.

RESULTS

Patients asymptomatic before screening had significantly lower rates of CVS (18%) compared with those with transient symptoms of DCI (60%; P<0.0001). None of the 79 asymptomatic patients developed DCI after screening, regardless of digital subtraction angiography findings, compared with 56% of those with symptoms (P<0.0001). Presence of CVS was significantly associated with DCI in those with transient symptoms and in those whose examinations did not permit clear assessment (odds ratio 16.0, 95% confidence interval 2.2-118.3, P=0.003).

CONCLUSIONS

Patients asymptomatic before screening have low rates of CVS and seem to be at negligible risk of developing DCI. Routine screening of asymptomatic patients seems to have little utility. Screening may still be considered in patients with possible symptoms of DCI or those with examinations too poor to clinically detect symptoms because finding CVS may be useful for risk stratification and guiding management.