Person:

Martin, Scott

Many musculoskeletal disorders (MDs) are associated with irreversible bone and cartilage damage; this is particularly true for osteoarthritis (OA). Therefore, a clinical need exists for modalities which can detect OA and other MDs at early stages. Optical coherence tomography (OCT) is an infrared-based imaging, currently FDA approved in cardiology and ophthalmology, which has a resolution greater than 10 microns and acquisition rate of 120 frames/second. It has shown feasibility for imaging early OA, identifying changes prior to cartilage thinning both in vitro and in vivo in patients and in OA animal models. In addition, OCT has shown an ability to identify early rheumatoid arthritis (RA) and guide tendon repair, but has the potential for an even greater impact. Clinical trials in OA are currently underway, as well as in several other MDs.

Background: Our aim was to examine the association between an expert clinician’s impression of symptomatic meniscal tears and subsequent MRI in the context of middle-aged and older adults with knee pain. Methods: Patients older than 45 were eligible for this IRB-approved substudy if they had knee pain, had not undergone MRI and saw one of two orthopaedic surgeons experienced in the diagnosis of meniscal tear. The surgeon rated their confidence that the patient’s symptoms were due to meniscal tear. The patient subsequently had a 1.5 or 3.0 T MRI within 6 months. We examined the association between presence of meniscal tear on MRI and the surgeon’s confidence that the knee pain was due to meniscal tear using a χ2 test for trend. Results: Of 84 eligible patients, 63 % were female, with a mean age of 64 years and a mean BMI of 27. The surgeon was confident that symptoms emanated from a tear among 39 %. The prevalence of meniscal tear on MRI overall was 74 %. Among subjects whose surgeon indicated high confidence that symptoms were due to meniscal tear, the prevalence was 80 % (95 % CI 63–90 %). Similarly, the prevalence was 87 % (95 % CI 62–96 %) among those whose surgeon had medium confidence and 64 % (95 % CI 48–77 %) among those whose surgeon had low confidence (p = 0.12). Conclusion: Meniscal tears were frequently found on MRI even when an expert clinician was confident that a patient’s knee symptoms were not due to a meniscal tear, indicating that providers should use MRI sparingly and cautiously to confirm or rule out the attribution of knee pain to meniscal tear. Electronic supplementary material The online version of this article (doi:10.1186/s12891-016-1010-2) contains supplementary material, which is available to authorized users.

Objective: Lubricin is the principal boundary lubricant on articular cartilage. We aimed to describe the distribution of lubricin in the other articulating structures in the human knee and hip—menisci and labra—and to relate this distribution to the degree of tissue degeneration. Methods: Eighteen menisci and 6 labra were obtained from patients with osteoarthritis undergoing total knee and total hip replacements, respectively. Macroscopically intact specimens were fixed in formalin and processed for H&E staining and immunohistochemical evaluation with an antilubricin monoclonal antibody. Results: Lubricin was found in all tissues as a discrete layer on the tissue surface, within the extracellular matrix, and intracellularly, indicating that it plays a role in the tribology of these tissues in human subjects, and can be synthesized by cells within the tissues. While none of the samples displayed macroscopic tears, approximately 40% of the surface of the menisci and 80% of the surface of the labra displayed microscopic fibrillations and slight fraying. There was no effect of the degenerative changes on the distribution of lubricin. Conclusions: Lubricin coats nearly the entirety of the surfaces of menisci and labra, including microfibrillations and tears, with possible implications towards the tribology of the tissues and healing of tissue damage.

Objectives: Acetabular labral tears are increasingly recognized as a source of hip pain in the younger, active population. Due to a significant focus on surgical intervention, there has been limited investigation on the predictive factors and natural history of non-surgical management of these injuries. Many reports recommend a trial of non-operative management with a variety of modalities including physical therapy, education, non-steroidal anti-inflammatories (NSAIDs), intra-articular injections, and activity modification. However, there is limited data supporting these claims as few studies have explored non-surgical management. Additionally, the authors were not able to find any studies on factors that portend outcomes of non-operative management. We hypothesized that patients with more significant bony FAI pathology or more severe osteoarthritis would have poorer outcomes. Methods: Eighty patients with acetabular labral tears, confirmed by MRI, receiving a minimum of one year of non-surgical management were identified. Subjects completed baseline patient reported outcome measures (PROMs: mHHS, HOS-ADL, HOS-SS, iHOT-33). Sixty five (81.25%) patients completed the same one-year follow-up functional outcomes measures in addition to a satisfaction questionnaire (37F, 28 M). Chart review was conducted to obtain demographic information and radiographic information (Tonnis grade, alpha angle, center edge angle, chondral damage, cartilage defects, cysts, and subchondral edema). Statistical significance (p<0.05) was determined t-test, anova, or Wilcoxon rank-sum. Results: Average follow up time was 24 months (R:18-30). The mean age was 41.7(R:18-57), average BMI was 26.2 (R18-39), and average Tonnis grade was 0.6 (R0-2). At follow-up, overall patients experienced a significant improvement in functional outcomes (mHHS: 66.6 vs 75.18, HOS-ADL: 75.7 vs 85.8, HOS-SS: 54 vs 69.7, iHOT-33: 47.9 vs 65.4). There was a positive correlation between baseline PROMs and follow-up PROMs as well as a negative correlation between baseline PROMs and change in PROMs over time. Tonnis grade, chondral damage, and cartilage defects portended significantly worse outcomes across all PROMs at follow-up. Presence of cysts or subchondral edema was also correlated with worse outcomes but these findings did not reach statistical significance. (Table 2). Alpha angle >55 (cam lesion) resulted in significantly worse outcomes across all PROMs although CEA>40 (pincer lesion) only reached significance for the HOS ADL and SSS. CEA< 25 (dysplasia) trended toward worse outcomes but did not reach significance. (Table1) Conclusion: Due to the limited healing potential of the labrum, the associated anatomical defects of FAI, and the potential for progression to osteoarthritis, there has been a focus on surgical intervention for FAI and labral tears. Despite a lack of evidence for its use, non-surgical management is frequently cited as the first step to treatment. As we found in a previous analysis, patients with symptomatic labral tears can experience functional improvement after minimum one year of non-surgical management. Those with signs of higher grade arthritis performed significantly worse that their less arthritic counterparts. Those with larger cam and pincer lesions also improved less than patients with less significant bony morphology. This study can help inform surgeons and their patients when they present with hip pain and inquire about non-surgical management. Change in patient reported outcome measures from baseline to follow-up for osseous morphology mHHS P Value HOS-ADL P Value HOS-SSS P Value iHOT-33 P value CEA<25 0.4814 0.0751 0.1214 0.3223 No 9.0 (14.8) 11(19) 17(30) 18(25.4) Yes 3.8(14.6) -5(13) -2(22) 11.3(12.1) CEA>40 0.0684 0.0185 0.0216 0.0838 No 10(14.7) 12(19) 19(30) 20(24) Yes 0.9(13.2) 1(12) -2(22) 3.8(25.2) Alpha>55 0.0001 0.0079 0.001 0.0001 No 12.1(14.1) 13(19) 21(29) 25.1(20.6) Yes -4.0(9.0) -1(14) -4(20) -10.4(17.2) Change in patient reported outcome measures from baseline to follow-up for cartilage status mHHS p value HOS-ADL p value HOS-SSS p value iHOT-33 p value Edema 0.0945 0.8995 0.8333 0.1312 No 10.2 (14.4) 10 (20) 16 (28) 20.4 (21.9) Yes 1.8 (14.7) 10 (14) 14 (37) 4.6 (32.5) Cartilage Degeneration 0.0001 0.0001 0.0001 0.0001 No 18.0 (9.1) 19(17) 29(27) 31.7(17.0) Yes -5.4(9.4) -3(12) -4(22) -4.0(17.9) Cartilage Defect 0.0001 0.0009 0.0089 0.0002 No 12.0(13.3) 14(18) 20(28) 22.7(22.9) Yes -6.4 (11.2) -6 (11) -5 (26) -5.9 (18.4)

The prevalence of hip arthroscopy has increased exponentially with the advent of arthroscopic labral repair techniques for femoroacetabular impingement. The goal of arthroscopic labral repair is to re-create the anatomic suction seal of the labrum against the femoral head. This important anatomic relationship has been demonstrated in several biomechanical studies. Performing the acetabular recession and evaluating the congruity of labral repairs during surgery is difficult with the application of traction distracting the femoral head from the chondrolabral junction. Additionally, prolonged traction risks nerve injury during hip arthroscopy. The purpose of this technique article is to describe a method of using traction only for central compartment work, and releasing the traction to allow the femoral head to reduce the labrum to its anatomic position for acetabular recession, anchor placement, and suture fixation. In this manner, the presented technique prevents an “out-of-round” or everted repair. This technique re-creates the native anatomy and biomechanics of the hip after acetabular recession and labral repair while decreasing traction time.