Citations

We present a case of a 17-year-old football player who had previously received multiple facet joint injections for presumed secondary osteoarthritis. 99 mTc-methylene diphosphonate single-photon emission computed tomography/computed tomography imaging of the cervical spine demonstrated focal increased radiopharmaceutical activity in the right C2 lamina, which was associated with an osteolytic lesion with a central irregular sclerotic nidus. Surgical pathology confirmed an osteoid osteoma.

Purpose To compare microfracture (MFX) and osteochondral autograft transfer (OAT) surgical techniques to determine (1) postoperative activity level, (2) subjective patient outcomes, (3) failure rates, and (4) assess if any lesion characteristics favored one technique over the other. Methods A comprehensive review of literature was performed of all studies comparing MFX and OAT. Studies included were all prospective studies that reported on activity‐based outcome measures such as Tegner activity scores and subjective outcomes such as the International Knee Documentation Committee score. Failure rates, as determined by the publishing authors, were recorded for each study. Meta‐analyses were conducted using a random‐effects model. Paired standardized mean differences (Hedges's g to account for small sample bias) were used for continuous outcome measures, and risk ratios (Mantel‐Haenszel method for small sample bias) for dichotomous outcome measures. Results Six prospective studies satisfied the eligibility criteria and included 249 patients (186 male, 120 female) with an average age of 26.4 years and follow‐up of 67.2 months. Tegner scores were superior in patients treated with OAT compared with MFX (ΔOAT‐MFX for pre‐post scores = 0.94 Tegner points, standardized mean difference [SMD] = 0.469, P = .005). Failure rates of MFX were higher than OAT (OAT = 11%, MFX = 32%, risk ratio = 2.42, P < .036). OAT was superior to MFX at 3 years in relation to subjective outcome scores (SMD = 0.404, P = .008). When assessing OAT lesions larger than 3 cm 2 , OAT was superior to MFX with respect to activity level (SMD = 0.506, P = .001). Conclusions OAT may achieve higher activity levels and lower risk of failure when compared with MFX for cartilage lesions greater than 3 cm 2 in the knee, although there was no significant difference for lesions less than 3 cm 2 at midterm. However, because of variability in patient‐specific factors such as age, preinjury activity level, lesion location and size, the superiority of OAT over MFX cannot be generalized to all patient populations and therefore requires individualized patient care. Level of Evidence Level II, meta‐analysis of Level I and II studies.

Background: The widespread use of anterior cruciate ligament (ACL) injury prevention interventions has not been effective in reducing the injury incidence among female athletes who participate in high-risk sports. Purpose/Hypothesis: The purpose of this study was to determine if biomechanical and neuromuscular factors that contribute to the knee abduction moment (KAM), a predictor of future ACL injuries, could be used to characterize athletes by a distinct factor. Specifically, we hypothesized that a priori selected biomechanical and neuromuscular factors would characterize participants into distinct at-risk profiles. Study Design: Controlled laboratory study. Methods: A total of 624 female athletes who participated in jumping, cutting, and pivoting sports underwent testing before their competitive season. During testing, athletes performed drop-jump tasks from which biomechanical measures were captured. Using data from these tasks, latent profile analysis (LPA) was conducted to identify distinct profiles based on preintervention biomechanical and neuromuscular measures. As a validation, we examined whether the profile membership was a significant predictor of the KAM. Results: LPA using 6 preintervention biomechanical measures selected a priori resulted in 3 distinct profiles, including a low (profile 1), moderate (profile 2), and high (profile 3) risk for ACL injuries. Athletes with profiles 2 and 3 had a significantly higher KAM compared with those with profile 1 ( P < .05). Conclusion: This is the first study to use LPA of biomechanical landing data to create ACL injury risk profiles. Three distinct risk groups were identified based on differences in the peak KAM. Clinical Relevance: These findings demonstrate the existence of discernable groups of athletes that may benefit from injury prevention interventions. Study Registration: ClinicalTrials.gov NCT identifier: NCT01034527.

Objectives: Medial meniscus posterior root tears (MMPRTs) present a unique challenge for both patients and surgeons as these tears have shown to be biomechanically equivalent to complete meniscectomy. However, little is known about the natural history of these lesions. Therefore, the purpose of this study is to describe the clinical course of MMPRTs with respect to subsequent operative and non-operative treatments, and associated comorbidities. Methods: Over 2600 MRIs were identified by searching radiologist reads for the terms “root” or “root tear” from 2005-2013. Presence or absence of MMPRTs and other associated boney, meniscal, or ligamentous injuries were identified and recorded. Of these MRIs, 102 MRIs from 102 patients who had unrepaired MMPRTs with minimum 2-year follow-up and no prior ligamentous surgery were followed. These MRIs were evaluated to confirm the presence of a meniscal root tear and the presence or absence of associated meniscal or ligamentous injuries, as well as meniscal extrusion, subchondral edema, or insufficiency fractures. Chart review was performed to obtain the treatment summary after diagnosis. Radiographs from before and after the diagnosis of MMPRT were reviewed and Kellgren-Lawrence scores were determined. Finally, the association between concomitant boney, ligamentous, or meniscal injuries, patient factors, and rate of arthroplasty, as well as final Kellgren-Lawrence scores were evaluated. Chi-square analysis was used for categorical variables, and Wilcoxon Rank-Sums was used for continuous variables. Kaplan-Meier analysis was used to evaluate the effect of meniscal extrusion on the time-dependant rate of arthroplasty. Results: 104 patients (43 M:61F) were diagnosed with MMPRTs at a mean age of 54±13. These patients were followed for a mean of 66±26 months. 75 (74%) patients had associated meniscal extrusion, 64 (62%) had associated subchondral edema, and 14 (13%) had associated insufficiency fractures at the time of diagnosis. After initial diagnosis, 59 (58%) underwent subsequent surgical treatment. This included 52 (51%) patients undergoing arthroscopic partial meniscectomy, and 29 (28%) patients undergoing total knee arthroplasty at a mean 38±32 (range 3-107) months after MRI. Kellgren-Lawrence grades worsened from 1.3±0.7 before diagnosis to 2.2±1.0 after (p<0.001), with a mean 44±32 months between radiographs. There was a higher rate of radiographic arthritis (K-L grade 2+) after diagnosis (73%) than before diagnosis (36%) (p<0.001). The presence of meniscal extrusion on MRI was associated with the presence of arthritis on post-diagnosis radiographs (p=0.03). Meniscal extrusion, subchondral edema, and insufficiency fractures were not associated with increased rates of surgical treatment, or time to arthroplasty. Conclusion: Little information is available to guide patients and physicians on the clinical outcomes for MMPRTs. These injuries are associated with a relatively high rate of arthroplasty and worsening arthritis, especially with concomitant meniscal extrusion. More information is needed to determine the efficacy of meniscal root repair in preventing these unfavorable outcomes.

Objectives: Distal femoral varus osteotomy is an effective treatment for unloading valgus knee malalignment; however, there is limited evidence on the ability for patients to return to athletics following this procedure. The purpose of this study is to report the functional outcomes and return to sport for athletic patients that underwent distal femoral varus osteotomy. Methods: A consecutive series of athletic patients that had undergone distal femoral varus osteotomy for symptomatic lateral compartment overload and valgus knee malalignment were prospectively reviewed. All patients had a minimum of 2-year follow-up. Radiographs were assessed to determine pre-operative and post-operative alignment. Details regarding sport of interest, ability to return to sport, and timing of return were obtained from the patients. Prospective institutional registries were utilized to collect pre-operative and post-operative Marx Activity Scale and International Knee Documentation Committee Subjective Knee Evaluation Form (IKDC) scores; these values were compared using paired t-tests with p < 0.05 as the threshold for significance. Results: A total of 13 patients with a mean age of 24 years (range: 17-35) and a mean follow-up of 43 months (range: 24-74) were included in the study. Six patients underwent medial closing wedge osteotomy, and seven patients underwent lateral opening wedge osteotomy. The mean alignment correction was 8 degrees (range: 5-13). Nine patients underwent one or more concomitant procedures at the time of the osteotomy: 6 lateral femoral condyle osteochondral allografts, 2 partial lateral meniscectomies, 1 lateral meniscus allograft transplantation, and 1 revision anterior cruciate ligament reconstruction. All patients were able to successfully return to their sport of choice (4 soccer, 2 softball, 2 running, 1 football, 1 basketball, 1 ice hockey, 1 volleyball, 1 rowing) at a mean of 11 months (range: 9-13). Furthermore, all 13 patients demonstrated an improvement in both Marx Activity Scale and IKDC scores after surgery. The mean improvement in Marx Activity Scale was 7 (mean pre-op: 4, mean post-op: 11, p < 0.01), and the mean improvement in IKDC score was 36 (mean pre-op: 53, mean post-op: 89, p < 0.01). Conclusion: Valgus knee malalignment results in overload of the lateral compartment and can severely limit one’s ability to participate in athletic activities. Correction of valgus knee malalignment through distal femoral varus osteotomy - either medial closing wedge or lateral opening wedge - can reliably result in improvement in function and return to sport, provided that concomitant chondral, meniscal, and ligamentous pathology is addressed. Therefore, distal femoral varus osteotomy should be considered in the athletic population for correction of symptomatic valgus knee malalignment.

ABSTRACT Introduction High submuscular ectopic placement of inflatable penile prosthesis (IPP) reservoirs via the inguinal canal has been popularized as an alternative to the retropubic (orthotopic) location, particularly among men with prior pelvic surgery. Published results suggest minimal complications and high patient satisfaction. However, in our practice, we identified several patients presenting for IPP revision after high submuscular placement who were found to have reservoirs within the peritoneal cavity. Aim Given the potential for complications, we performed a cadaveric study to define the anatomic location of reservoirs placed using this technique. Methods We utilized 10 fresh male cadavers without embalming. Bilateral ectopic reservoir placement (10 AMS Conceal [Boston Scientific, Marlborough, MA] and 10 Coloplast Cloverleaf [Coloplast Corp, Humlebaek, Denmark]) was performed using the high submuscular technique via a penoscrotal incision. Strict adherence to published reports detailing the technique was emphasized to assure reliability of findings. Main Outcome Measures Anatomic dissection was performed to identify reservoir location within the abdominal wall layers. Results Twenty IPP reservoirs were placed without difficulty or concern for inadvertent malpositioning. Sixteen reservoirs (80%) were found anterior to the transversalis fascia, including 7 (35%) deep to the rectus muscle and 9 (45%) deep to the external oblique fascia and lateral to the rectus muscle belly. Two reservoirs (10%) were identified in the retroperitoneal space, while 1 (5%) was preperitoneal (deep to transversalis fascia) and 1 (5%) was intraperitoneal. Conclusion Placement of IPP reservoirs using the high submuscular technique results in variable anatomic locations, including within or immediately superficial to the peritoneal cavity. Given the lack of immediate recognition and risk of delayed complications with suboptimal reservoir placement, further studies are mandated to assess the long-term safety of the technique.