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Meniscal tears are the most common knee injury, and partial meniscectomies are the most common orthopaedic surgical procedure. The injured meniscus has an impaired ability to distribute load and resist tibial translation. Partial or complete loss of the meniscus promotes early development of chondromalacia and osteoarthritis. The primary goal of treatment for meniscus-deficient knees is to provide symptomatic relief, ideally to delay advanced joint space narrowing, and ultimately, joint replacement. Surgical treatments, including meniscal allograft transplantation (MAT), high tibial osteotomy (HTO), and distal femoral osteotomy (DFO), are options that attempt to decrease the loads on the articular cartilage of the meniscus-deficient compartment by replacing meniscal tissue or altering joint alignment. Clinical and biomechanical studies have reported promising outcomes for MAT, HTO, and DFO in the postmeniscectomized knee. These procedures can be performed alone or in conjunction with ligament reconstruction or chondral procedures (reparative, restorative, or reconstructive) to optimize stability and longevity of the knee. Complications can include fracture, nonunion, patella baja, compartment syndrome, infection, and deep venous thrombosis. MAT, HTO, and DFO are effective options for young patients suffering from pain and functional limitations secondary to meniscal deficiency.

Purpose To conduct a systematic review of overlapping meta-analyses comparing treatment of knee osteoarthritis (OA) with intra-articular viscosupplementation (intra-articular hyaluronic acid [IA-HA]) versus oral nonsteroidal anti-inflammatory drugs (NSAIDs), intra-articular corticosteroids (IA-corticosteroids), intra-articular platelet-rich plasma (IA-PRP), or intra-articular placebo (IA-placebo) to determine which meta-analyses provide the best current evidence and identify potential causes of discordance. Methods Literature searches were performed for meta-analyses examining use of IA-HA versus NSAIDs, IA-corticosteroids, IA-PRP, or IA-placebo. Clinical data were extracted, and meta-analysis quality was assessed. The Jadad algorithm was applied to determine which meta-analyses provided the highest level of evidence. Results Fourteen meta-analyses met the eligibility criteria and ranged in quality from Level I to IV evidence. In studies reporting patient numbers, there were a total of 20,049 patients: 13,698 receiving IA-HA, 355 receiving NSAIDs, 294 receiving IA-corticosteroids, and 5,702 receiving IA-placebo. Ten studies examined the effects of IA-HA versus IA-placebo; of these, 5 found that IA-HA improved pain and 4 found that IA-HA improved function. No clinically relevant differences in the efficacy of IA-HA versus NSAIDs regarding pain and function were found. Regarding IA-HA versus IA-PRP, IA-HA improved knee function at 2 and 6 months after injection but the effects were less robust than those of IA-PRP. Regarding IA-HA versus IA-corticosteroids, the positive effects of IA-HA were greater at 5 to 13 weeks and persisted for up to 26 weeks. After application of the Jadad algorithm, 2 concordant high-quality meta-analyses were selected and both showed that IA-HA provided clinically relevant improvements in pain and function compared with IA-placebo. Conclusions This systematic review of overlapping meta-analyses comparing IA-HA with other nonoperative treatment modalities for knee OA shows that the current highest level of evidence suggests that IA-HA is a viable option for knee OA. Its use results in improvements in knee pain and function that can persist for up to 26 weeks. IA-HA has a good safety profile, and its use should be considered in patients with early knee OA. Level of Evidence Level IV, systematic review of Level I to IV studies.

Objectives: Osteoarthritis (OA) is a debilitating disease that, in some form, affects up to 47 million Americans each year and is estimated to affect 67 million by 2030. Hyaluronic acid (HA) is currently utilized as an intra-articular injection for treatment of patients with knee OA. A movement in biochemical research has emerged that focuses on analysis of catabolic and anabolic growth factors of the joint. It is proposed that platelet-rich plasma (PRP) is a biologic alternative to HA that may alter the intra-articular biologic milieu to mitigate the symptoms of OA. The purpose of this double-blind prospective randomized clinical trial is to compare the effects of PRP to HA for the treatment of OA in the knee using validated clinical outcome measures and biologic correlates associated with OA. Methods: Patients with a minimum of 3 months of symptomatic unilateral knee OA and Kellgren-Lawrence Grade 1-3 OA were randomized into two cohorts. One cohort received three weekly ultrasound-guided injections of HA and the other received three weekly injections of PRP. Patients in both cohorts were seen again at 6-, 12-, and 24-weeks following their index treatment. At each visit, including the treatment and index visits, patients completed a survey that included Lysholm, IKDC, WOMAC, and VAS pain, and underwent a clinical examination. Patients also underwent an ultrasound-guided aspiration of the knee for synovial fluid analysis during each of the treatment visits and at 3-month and 6-month follow up. Synovial fluid was grouped and analyzed via ELISA assay. Results: 111 patients (mean age 56.2 +/- 10.2 years; 53 male, 58 female) met inclusion criteria and were randomized into either the HA or PRP cohort. Eleven (9.9 %) patients were lost to follow-up or unwilling to complete the study. In all of the scales measured, outcomes improved significantly from the index visit at 6 months post treatment (pConclusion: The findings of this study support a significant improvement of pain and function at 6 months with the use of intra-articular PRP as well as HA for the treatment of OA. Findings further suggest that PRP may be a superior treatment for the active patient with OA.

Objectives: Background: Multiple meta-analyses have been published to in efforts to determine whether operative or non-operative treatment of Achilles tendon ruptures affords superior outcomes. The results, however, remain varied and inconsistent. Purpose: To perform a systematic review of overlapping meta-analyses comparing operative and non-operative treatment of Achilles tendon ruptures in order to determine which meta-analyses provide the highest level of evidence for treatment recommendations. Methods: Methods: A systematic review of the literature was performed to identify meta-analyses that fit our inclusion criteria. Data was extracted from these meta-analyses regarding patient outcomes and re-ruptures. Meta-analysis quality was assessed using the Oxman-Guyatt and Quality of Reporting of Meta-analyses (QUOROM) systems. The Jadad algorithm was applied to determine the meta-analyses with the highest level of evidence. Results: Results: Nine meta-analyses met the eligibility criteria, with all but one study including level I evidence. A total of 5,842 patients were included. Seven studies found a higher rate of rerupture in the non-operative group but a higher rate of complications in the operative group. One study found no differences in rerupture or complication rates, and one study found surgery decreased rerupture rates only when compared to non-operative treatment without a functional brace. Three studies also identified an earlier return to work in the operative group. Almost all (8 out of 9) of the meta-analyses had Oxman-Guyatt scores (>3) indicating no major flaws. Conclusion: Conclusions: Operative treatment of Achilles tendon ruptures decreases rerupture rates but increases the risk for minor complications when compared to non-operative treatment. Additionally, surgical treatment may allow earlier return to work.

The valgus forces generated by throwing athletes can cause injuries and permanently damage the medial elbow structures. Clinicians must have a clear understanding of the ulnar collateral ligament complex and the associated medial elbow structures at risk in these athletes. Taking a detailed history, conducting a physical examination, and obtaining imaging studies will aid in making the correct diagnosis and giving these injuries the appropriate treatment. Pain around the medial elbow is of concern to throwing athletes, coaches, and medical staff. Valgus forces generated by the throwing motion add considerable stress to the medial elbow structures and thus potentially cause injury. Baseball players, particularly pitchers, are most often affected, but athletes participating in sports such as football, volleyball, water polo, tennis, and javelin throwing can also be affected.

Background Single-incision anterior cruciate ligament reconstruction with a bone–patellar tendon–bone construct is commonly performed with 180° rotation of the graft. It has been hypothesized that further rotation of the graft to 540° can effectively shorten the graft to address graft length–tunnel mismatch. Initial biomechanical failure characteristics of rotated constructs have been reported, but cyclic loading of tendons has not been performed. Hypothesis Graft rotation affects the biomechanical properties of the construct. Study Design Controlled laboratory study. Methods Thirty-five bone–patellar tendon–bone composite porcine right knee specimens were randomized into 3 groups and were externally rotated to 0°, 180°, or 540°. Each group was then cyclically loaded in an artificial synovial fluid medium between 50 and 250 N for 5000 cycles, loaded between 50 and 500 N for an additional 5000 cycles, and finally subjected to load-to-failure testing. Results Graft rotation shortened constructs by 1.7 ± 0.8 mm at 180° of rotation and 7.6 ± 2.0 mm at 540° of rotation (P < .01). There was a statistically significant increase in strain during cyclic loading at 540°. No significant differences in maximum load, yield stress, yield strain, or modulus of elasticity were detected in single-cycle load-to-failure testing after cyclic loading. Conclusion Rotation of bone–patellar tendon–bone constructs to 540° predictably shortens the effective graft length at the expense of increased strain with cyclic loading at stresses equivalent to walking and running. Clinical Relevance Although rotation to 540° potentially addresses graft length–tunnel mismatch, further clinical evaluation is required to evaluate the impact of increased strain on knee laxity and to determine the effects of physiologic loading of rotated bone–patellar tendon–bone constructs in vivo.

Purpose: Postoperative pain pumps are increasingly used to deliver a continuous infusion of local anesthetic into the surgical wound or the joint. Recently, there have been concerns that the use of such devices may be associated with chondrotoxicity and even cases of chondrolysis in the shoulder. An experimental model is presented that investigates potential chondrotoxic effects of a continuous intra-articular infusion of bupivacaine in the rabbit shoulder. Methods: We divided 30 rabbits into 3 groups that received continuous infusions of either saline solution, bupivacaine, or bupivacaine with epinephrine into the glenohumeral joint over a period of 48 hours. Animals were killed after 1 week, and osteochondral and synovial samples from the glenohumeral joint underwent analyses with confocal microscopy for live/dead cell assay, metabolic sulfate uptake assessment, and conventional histologic analysis. Results: Infusion of bupivacaine with epinephrine and without epinephrine decreased sulfate uptake by 56% ( P = .009) and 50% ( P = .02), respectively, when compared with saline solution; cell viability decreased by 20% ( P = .08) and 32% ( P = .02), respectively. Histologic analysis yielded significantly worse scores for bupivacaine infusion with epinephrine ( P = .004) and without epinephrine ( P = .02). The results for bupivacaine with or without epinephrine were not significantly different. Conclusions: Continuous intra-articular infusion of bupivacaine with and without epinephrine led to significant histopathologic and metabolic changes in articular cartilage. Clinical Relevance: Bupivacaine showed profound chondrotoxic effects in an experimental model that closely followed the current clinical application of postoperative pain pumps. The results caution against the use of such devices in applications for smaller joints with minimal clearance or dilution as a result of hematoma, where continuous exposure of cartilage to bupivacaine is expected.

The rationale for meniscal repair is based on the importance of the meniscus in overall knee function and stability as well as the inferior results seen with meniscectomy. The high success rate usually seen with arthroscopic meniscal repair has made it the treatment of choice for peripheral meniscal tears. This study reviewed the records of patients who have failed meniscal repair surgery to gain greater understanding of the factors that may predispose a patient to a failed outcome. From 1987 to 2002, three hundred meniscal repairs were performed (203 medial and 97 lateral). Thirty-seven patients had failed meniscal repairs. Records were available for 33 (89%) patients. The mean patient age was 25 years (range: 13-48 years) at the time of meniscal injury. The average initial tear size was 2.7 cm with a mean rim width of 2.3 mm. Eighty-eight percent occurred in ACL tears. The average time interval from initial repair to the recurrence of symptoms was 34 months. Patients who were older at the time of meniscal repair failed significantly later than those patients who were younger at the time of repair. With age stratification, those patients who were aged > or =29 years at time of meniscal repair failed at an average of 23 months. In contrast, patients who were aged > or =30 years at the time of repair failed at an average of 53 months. Larger initial tears failed significantly sooner than smaller tears. Initial tears with larger rim widths demonstrated a trend toward shorter time to failure. Patients who underwent combined ligament reconstruction with meniscal repair failed at an average of 37 months. Deficient ACLs that were treated with isolated meniscal repairs (ACL intact) failed at an average of 16 months.

This study reports the initial clinical results of 540 degrees of graft rotation or free tibial bone block to address graft tunnel mismatch in endoscopic anterior cruciate ligament (ACL) reconstruction. The operative reports of patients who underwent endoscopic ACL reconstruction between 1999 and 2001 were reviewed. Nine of 11 patients treated with a free tibial bone block and 14 of 17 patients treated with 540 degrees of graft rotation were evaluated. Mean follow-up was 20 months (range: 13-40 months) for the bone block group and 34 months (range: 18-48 months) for the 540 degrees group. There were statistically significant improvements in physical examination test results postoperatively, and only one patient in the 540 degrees group had a grade one positive pivot shift test. KT-1000 arthrometer testing demonstrated a statistically significant decrease in manual maximum and side-to-side differences at final follow-up. Mean Lysholm and Noyes sports function scores were excellent or good for all patients. One patient required reoperation for flexion contracture, one patient required an arthroscopic irrigation and debridement for a minor infection, and one patient required arthroscopic subtotal medial meniscectomy for failed meniscal repair. No difference was noted between these results and previous results of patients undergoing conventional endoscopic ACL reconstruction. These results demonstrate graft rotation and free bone block techniques are effective in addressing graft tunnel mismatch in endoscopic ACL reconstruction.

Drs Creighton and Bach and Mr Kinder are from the Division of Sports Medicine, Rush University Medical Center, Chicago, Ill. Reprint requests: Bernard R. Bach, Jr, MD, 1725 W Harrison St, Ste 1063, Chicago, IL 60612. Compartment syndrome is an elevation of the interstitial pressure in a closed osseofascial compartment that results in microvascular compromise. The condition may be further classifi ed as either acute or chronic. Common causes of acute compartment syndrome include fractures, severe blunt soft tissue trauma, arterial injury, limb compression, and burns. Chronic compartment syndrome is caused by increased muscle volume most commonly occurring during exercise. The diagnosis of an acute compartment syndrome is made by clinical signs and can be further confi rmed by compartment pressure measurements.1-6 Measurements of compartment pressure are used for the evaluation of a compartment in which the diagnosis of compartment syndrome cannot be made or ruled out with certainty, as in a patient with altered mental status or in chronic exertional compartment syndrome.3 Signs and symptoms of acute compartment syndrome include pain out of proportion, increased use of analgesics, pain with passive muscle stretching, paresis, paresthesia, and diminished pulses. Pulses usually remain intact due to arterial pulses remaining higher than the pressure of the compartment compressing the artery. The following case report describes the clinical presentation and treatment of compartment syndrome following an inversion injury of the ankle.

This prospective randomized clinical trial evaluated whether the use of radiofrequency energy (RFE) devices for soft-tissue ablation and coagulation cause thermal injury to bone. Fifty patients underwent one of three treatment modalities: electrocautery, monopolar RFE, or bipolar RFE. Preoperative and postoperative magnetic resonance imaging was compared to evaluate for evidence of osteonecrosis. Postoperative MRI of all patients did not reveal any osteonecrosis or subchondral edema. These findings indicate electrocautery, monopolar RFE, and bipolar RFE devices can be used safely for soft-tissue ablation and hemostasis.

The purpose of this study is to evaluate ultrasonic suture welding of monofilament suture in an animal model of rotator cuff repair with biomechanical and histologic analyses. We randomly assigned 46 shoulders in 23 rabbits to 1 of 3 treatment groups: sham-operated (n = 15), knotted (n = 15), and welded (n = 16). Supraspinatus defects were surgically created and acutely repaired with suture anchors loaded with either No. 2-0 Ethibond for knotted group or No. 2-0 nylon for welded shoulders. Eighteen weeks postoperatively, all animals were killed, and the shoulders underwent either biomechanical testing or histologic analysis. The maximum stress of the sham-operated group (20.6 N/mm2) was significantly greater than that of both the knotted (10.2 N/mm2) and welded (8.3 N/mm2) groups (P.05), but no differences were observed between the knotted and welded groups. Although some histologic changes were noted, none was considered to be significant to distinguish either group.