Background:Iatrogenic sural nerve injuries can result in significant patient morbidity and functional impairment following surgical procedures involving the distal leg, ankle, or lateral foot. This study investigates the surgical procedures implicated and the clinical presentation of patients with iatrogenic sural nerve injuries.Methods:The authors completed a retrospective review of 9 patients with iatrogenic sural neuropathy following surgical procedures between 2010 and 2022 at the University of Miami Health System. Patient demographics, surgical details, symptom onset, imaging findings, and final neuropathy diagnosis were extracted and analyzed.Results:The average age of patients was 47 years. The ankle was the common site of sural nerve injury (88.9%). Most patients experienced pain, numbness, and tingling, with tenderness and loss of sensation in the sural nerve distribution. The average time between surgery and completion of imaging evaluation for sural nerve injury was 80.5 weeks. All patients underwent ultrasound (77.8%) and/or magnetic resonance imaging (77.8%) evaluation postoperatively. The most frequent resulting pathology was neuroma formation, followed by entrapment, neuropraxia, and complete transection. Four patients had surgical management of sural nerve neuropathy, with none experiencing complete resolution of symptoms after surgery.Conclusions:This study highlights the surgical procedures that can result in iatrogenic sural nerve injuries beyond Achilles tendon repair. Increased awareness of surgical causes and continued reporting of iatrogenic sural nerve injuries can contribute to improved patient outcomes in procedures involving the distal lower extremity.

Objective Accurate preoperative assessment of radius and ulna rotation during fixation of complex forearm fractures or during the treatment of malunion/nonunion of the radius or ulna is essential for an optimal operative outcome. A CT scan is commonly used for preoperative assessment of complex fractures and certainly of malunions and nonunions of the forearm. To our knowledge, there is no standardized CT scan-based measurement of the rotation of the radius and ulna. The purpose of this study was to determine the standard rotational profile of the radius and ulna utilizing computed tomography scans in individuals without osseous deformity. Methods Computed tomography scans of 23 patients without osseous deformity or pathology of the radius or ulna were assessed. The rotation of the ulna was measured by determining the orientation of the ulnar styloid with respect to the coronoid. The rotation of the radius was measured by determining the orientation of the radial styloid relative to the bicipital tuberosity. Results The ulnar styloid was a mean of 172.0 +/- 19.3 degrees of supination relative to the coronoid process. The radial styloid was a mean of 167.8 +/- 18.3 degrees of supination relative to the bicipital tuberosity. There was no significant difference in radial or ulnar rotation regarding age, sex, race, or laterality. Conclusion Given the standard deviations present in both groups, there is a range in normal anatomy with regard to the rotational profile of the radius and ulna.

ABSTRACT:In the present case, we describe the first reported instance of a noncontact distal adductor magnus avulsion injury in a collegiate Division I football player. A 22-year-old male player initially presented with an acute posterolateral corner injury with partial thickness tears of the fibular collateral ligament (FCL), biceps femoris tendon (BFT), and popliteus tendon (PT). Appropriate management was completed. Two months later, without contact or a specific inciting event during gameplay, his condition worsened to an acute full-thickness tear of the ischiocondylar (hamstring) portion of the adductor magnus tendon, avulsed from its insertion at the adductor tubercle on the medial femoral condyle, with surrounding hemorrhage. We discuss the likely mechanism of injury, imaging findings, and management practices for avulsion injuries. Furthermore, we emphasize the importance of full recovery before returning to play to avoid reinjury. To the authors' knowledge, the pathology described in this study has not been reported previously.

OBJECTIVE:Ethnicity is associated with varying reporting of pain, coping mechanisms, and disease severity in patients with knee osteoarthritis (KOA). However, few studies have evaluated its importance in ethnicity, particularly the Hispanic population. This study compares pain intensity (VAS), function (WOMAC), and pain catastrophizing (PCS) between Hispanic (HP) and non-Hispanic White patients (NHWP) stratified by socio-economic status (SES) and osteoarthritis radiographic K-L grade. METHODS:A cross-sectional study of patients from a tertiary care clinic between July 2021 and December 2022 was performed. Patients with knee pain, radiographs, and doctor-diagnosis of KOA completed questionnaires in English or Spanish. Descriptive statistics characterized demographic differences between NHWP and HP in VAS, WOMAC, and PCS. Two one-way analyses of variance evaluated the effect of both ethnicity and sex, with subgroup analyses stratifying by K-L grade. Multivariate general linear models assessed primary outcomes while controlling for confounders. RESULTS:A total of 195 subjects (HP = 145, NHWP = 50) were included. HP exhibited higher VAS, PCS, and WOMAC scores compared to NHWP. PCS was higher in HP (p = 0.004, mean = 8.89) than NHWP (mean = 4.58), as was VAS (p < 0.001, mean = 4.28 vs. 2.74) and WOMAC (p = 0.029, mean = 27.86 vs. 21.58). These differences remained when controlled for NSES and K-L grade. Stratifying by sex and comparing primary outcomes between HP and NHWP, male HP had greater VAS (p = .021, mean = 3.83 vs. 2.42) and PCS (p = .008, mean = 8.83 vs. 3.35), while female HP had greater VAS (p = .019, mean = 4.62 vs. 3.08) and nonsignificantly greater PCS (p = .164, mean = 8.94 vs. 5.92). CONCLUSION:HP with KOA reported greater pain severity, functional limitation, and PCS. compared with NHWP, even after adjusting for NSES and K-L grade. Our findings expand on previous reports by including a larger number of HP and analyzing the role of sex, impact of socioeconomic status, and influence of radiographic severity on patient symptoms.

Background:Combined injuries observed with first-time lateral patellar dislocation (LPD) of the knee, particularly significant soft tissue injury, can inform surgical intervention criteria. Purpose:The purpose of this study was to compare MRI findings in LPD to surgical correlation concerning meniscal pathology as a guide for surgical management. Study design:Retrospective case series, Level of evidence, 4. Methods:A retrospective review was conducted of 355 cases of patients with lateral patellar dislocation from 2012 to 2022. Imaging was reviewed by musculoskeletal radiologists blinded to surgical results for evidence of soft tissue injury, and associated arthroscopic data and operative reports were reviewed. Results:Out of 44 cases of LPD in 42 patients who underwent MPFL reconstructive surgery, 27 (61%) cases had grade 2a or higher signal changes in the anterior horn of the lateral meniscus, of which 10 (23%) had grade 3 signal changes. There were zero cases of meniscal tear in these cases upon review of operative reports and arthroscopic images. Conclusion:MRI findings of signal alterations in the lateral meniscus post-LPD may not indicate an actual tear. This could aid in surgical decision-making in primary LPD management.

Osteoarthritis (OA) represents a significant global health burden without a known disease modifying agent thereby necessitating pursuit of innovative therapeutic approaches. The infrapatellar fat pad (IFP) serves as a reservoir of mesenchymal stem/stromal cells (MSC), and with adjacent synovium plays key roles in joint disease affecting local inflammatory responses. Therapeutically, IFP-MSC have garnered attention for their potential in OA treatment due to their immunomodulatory and regenerative properties. However, optimizing their therapeutic efficacy necessitates a comprehensive understanding of how growth medium and inflammatory/hormonal priming influence their behavior. In this study, we isolated and expanded IFP-MSC in three different growth media: DMEM + 10% fetal bovine serum (FBS), DMEM + 10% human platelet lysate (HPL), and xeno-/serum-free synthetic (XFSF) medium. Subsequently, cells were induced with an inflammatory/fibrotic cocktail (TIC) with or without oxytocin (OXT). We evaluated various parameters including growth kinetics, phenotype, immunomodulatory capacity, gene expression, and macrophage polarization capacity. Our results revealed significant differences in the behavior of MSC cultured in different media. IFP-MSC cultured in HPL and XFSF exhibited superior growth kinetics and colony-forming abilities compared to those cultured in FBS. Furthermore, both HPL and XFSF media enhanced the expression of MSC markers (> 90%) and potentiated their immunomodulatory properties. Notably, XFSF-conditioned IFP-MSC demonstrated the highest attenuation of peripheral blood mononuclear cell (PBMC) proliferation, indicating their robust immunosuppressive capacity. Additionally, TIC priming further augmented the immunomodulatory functionality of MSC, with IFP-MSC exhibiting enhanced suppression of PBMC proliferation upon TIC priming. Of particular interest, gene expression analysis revealed distinct patterns in TIC + OXT induced MSC compared to TIC only induced, with upregulation of genes associated with immunomodulatory and regenerative functions. Furthermore, TIC + OXT priming promoted M2 polarization in macrophages, suggesting a potential therapeutic strategy for immune-mediated inflammatory joint conditions including OA. Our findings highlight the critical influence of growth medium and inflammatory/hormonal priming on MSC behavior and therapeutic potential. XFSF and HPL media offer promising alternatives to FBS, enhancing MSC growth and immunomodulatory properties. Moreover, TIC + OXT priming represents a novel approach to augment MSC immunomodulation and promote M2 polarization, providing insights into potential therapeutic strategies for OA and other immune-mediated inflammatory conditions.

ABSTRACT Context Osteoporosis is a chronic bone metabolic disease characterized by decreased bone mass, leading to increased frailty and a subsequent fracture risk. Peak bone mineral density (BMD) is achieved in early adulthood and may be the most important factor leading to the development of osteoporosis in older adults. Objective This study aimed to analyze the effects of plyometrics on BMD in young men and premenopausal women. Design This study used randomized controlled trials found in MEDLINE, Embase, and CINAHL published between January 1, 1990, and November 1, 2022. Keywords included plyometrics, jumping, jump training, bone health, and bone mineral density. Articles were assessed for methodological quality using the Consolidated Standards of Reporting Trials 2010 checklist. Eligibility Criteria Randomized controlled trials investigating BMD in healthy premenopausal women and men between the ages of 18 and 60 yr that compared plyometrics with control were included. Study Selection Two reviewers independently screened 553 abstracts. Main Outcome Measures Mean baseline and follow-up dual-energy x-ray absorptiometry scores and standard deviations were extracted to calculate the standard mean difference. After extraction, the magnitude of difference between control and treatment groups were analyzed using the Hedges and Olkin method for effect size. Results The 12 included studies had high methodological quality. Of the 12 studies, 10 reported statistically significant increase in BMD at ≥1 site when compared with control. Two studies showed equal improvement when compared with resistance-only training. After analysis, a large positive effect size with strongly positive correlation was seen between plyometrics and lumbar spine BMD. Conclusion Plyometric training is a safe and time-efficient method to improve BMD in premenopausal people 18–65 yr old. Large effect sizes were associated with increased training intensity and lasted months after the intervention was complete. Plyometrics seems to be a comparable alternative to resistance training with respect to bone health.

Abstract Objective: Race is associated with reporting of pain, coping mechanisms, and disease severity in patients with knee osteoarthritis (KOA). However, few studies have evaluated its importance in ethnicity, particularly the Hispanic population. We compare pain perception (VAS), function (WOMAC), and pain catastrophizing (PCS) between Hispanic (HP) and non-Hispanic (NHWP) patients stratified by socio-economic status (SES) and K-L grade. Methods: A cross-sectional study of patients from a tertiary care clinic between July 2021 and December 2022 was performed. Patients with knee pain, radiographs, and doctor-diagnosis of KOA completed questionnaires in English or Spanish. Descriptive statistics characterized demographic differences between NHWP and HP in VAS, PCS, and WOMAC. Two one-way analyses of variance evaluated the effect of both ethnicity and sex, with subgroup analyses stratifying by K-L grade. Multivariate general linear models assessed primary outcomes while controlling for confounders. Results: HP exhibited higher VAS, PCS, and WOMAC scores compared to NHWP. PCS was higher in HP (p = 0.004, mean = 8.89) than NHWP (mean = 4.58), as was VAS (p < 0.001, mean = 4.28 vs. 2.74) and WOMAC (p = 0.029, mean = 27.86 vs. 21.58). These differences remained when controlled for SES and K-L grade. Stratifying by sex and comparing primary outcomes between HP and NHWP, male HP had greater VAS (p = .021, mean = 3.83 vs. 2.42) and PCS (p = .008, mean = 8.83 vs. 3.35), while female HP had greater VAS (p = .019, mean = 4.62 vs. 3.08) and nonsignificantly greater PCS (p = .164, mean = 8.94 vs. 5.92). Conclusion: HP with KOA reported greater pain intensity, functional limitation, and PCS compared with NHWP, even after adjusting for SES and K-L grade.

Tendinopathies encompass a highly prevalent, multi-faceted spectrum of disorders, characterized by activity-related pain, compromised function, and propensity for an extended absence from sport and the workplace. The pathophysiology of tendinopathy continues to evolve. For decades, it has been related primarily to repetitive overload trauma but more recently, the onset of tendinopathy has been attributed to the tissue’s failed attempt to heal after subclinical inflammatory and immune challenges (failed healing model). Conventional tendinopathy management produces only short-term symptomatic relief and often results in incomplete repair or healing leading to compromised tendon function. For this reason, there has been increased effort to develop therapeutics to overcome the tissue’s failed healing response by targeting the cellular metaplasia and pro-inflammatory extra-cellular environment. On this basis, stem cell-based therapies have been proposed as an alternative therapeutic approach designed to modify the course of the various tendon pathologies. Mesenchymal stem/stromal cells (MSCs) are multipotent stem cells often referred to as “medicinal signaling cells” due to their immunomodulatory and anti-inflammatory properties that can produce a pro-regenerative microenvironment in pathological tendons. However, the adoption of MSCs into clinical practice has been limited by FDA regulations and perceived risk of adverse events upon infusion in vivo. The introduction of cell-free approaches, such as the extracellular vesicles of MSCs, has encouraged new perspectives for the treatment of tendinopathies, showing promising short-term results. In this article, we review the most recent advances in MSC-based and MSC-derived therapies for tendinopathies. Preclinical and clinical studies are included with comment on future directions of this rapidly developing therapeutic modality, including the importance of understanding tissue loading and its relationship to any treatment regimen.

Knee osteoarthritis (KOA) is a chronic disease accompanied by debilitating symptoms including pain, stiffness, and limited physical functionality, which have been shown to be associated with pain catastrophizing. Previous studies have revealed racial discrepancies in pain catastrophizing, notably between Hispanics and non-Hispanics while pointing to potential health disparities. Using a conceptual model, this study aimed to investigate racial differences in associations between KOA symptoms with specific pain catastrophizing domains (rumination, magnification, and helplessness). Patients with KOA (n = 253; 147 Hispanics, 106 non-Hispanic Whites) completed a survey that included measures of knee symptoms, pain catastrophizing, and demographic variables. Structural equation modeling revealed that among Hispanics, each pain catastrophizing domain (rumination, magnification, and helplessness) was associated with at least two symptomatic experiences, including pain severity and difficulty in physical function. Specifically, pain severity was associated with (a) rumination: β = 0.48, p < 0.001, (b) magnification: β = 0.31, p = 0.003; and (c) helplessness: β = 0.39, p < 0.001). Additionally, a lower score in physical function was associated with higher magnification (β = 0.26, p = 0.01), and helplessness (β = 0.25, p = 0.01). Among non-Hispanic White patients, pain severity was further associated with two domains of pain catastrophizing, including rumination (β = 0.39, p < 0.001) and helplessness (β = 0.35, p = 0.01). In addition, association pathways for demographic variables revealed that older Hispanics experienced greater challenges with higher pain severity (β = 0.26, p = 0.01) and greater difficulty with physical function (β = 0.31, p < 0.001) while Hispanics females experienced higher pain (β = 0.19, p = 0.03). These findings highlight the importance of designing tailored interventions that consider key demographic factors such as age, and gender, to improve physical function that might alleviate pain catastrophizing among Hispanics with KOA.

[This corrects the article DOI: 10.1016/j.radcr.2022.05.035.].

Context: To determine optimal treatment strategies for shoulder impingement syndrome (SIS). Objective: To compare subacromial nonsteroidal anti-inflammatory injections (SNIs) and subacromial corticosteroid injections (SCIs) on pain relief and functional improvement in individuals with SIS. Second, to perform a cost analysis of the 2 injections. Data Sources: MEDLINE, SPORTDiscus, CINAHL, Embase, Web of Science, and SCOPUS databases were searched for randomized controlled trials using several keywords. Study Selection: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were utilized, and 10 studies comparing changes in pain or function in humans with SIS receiving SNIs or SCIs were included. Quality and risk of bias were assessed using the Consolidated Standards of Reporting Trials (CONSORT) 2010 scale and the Cochrane Collaboration tool. Study Design: Systematic review and meta-analysis. Level of Evidence: Level 1. Data Extraction: Baseline and follow-up scores of the visual analog, Constant-Murley, and University of California Los Angeles shoulder scales were extracted to calculate effect sizes (ESs), represented as Cohen d. Metaregression and publication bias analyses were performed. Procedural and medication costs were extracted from Medicare guidelines. Results: A total of 7 high and 3 good quality studies were included, with a mean score of 21.1. Only 1 study had a high risk of bias. The meta-analyses produced pooled ESs of 0.05 ( P = 0.83), 0.12 ( P = 0.71), and 0.07 ( P = 0.79) for each scale, respectively, with CIs crossing 0. Procedural costs were equal between groups, whereas ketorolac was the least costly medication ($0.47). There was no significant difference in side effects between the 2 injections. Conclusion: SNIs are as effective as SCIs for short-term pain relief and improving function in patients with subacromial impingement syndrome. In addition, they are less expensive and cause no major difference in complications, providing a viable, cost-effective alternative for injection therapy in patients with SIS.

This letter focuses on a recently published article that provided an exceptional description of the effect of epigenetic modifications on gene expression patterns related to skeletal system remodeling. Specifically, it discusses a novel modality of epigenetic regulation, the long noncoding RNAs (lncRNAs), and provides evidence of their involvement in mesenchymal stromal/stem cells osteo-/adipo-genic differentiation balance. Despite focus on lncRNAs, there is an emerging cross talk between lncRNAs and miRNAs interaction as a novel mechanism in the regulation of the function of the musculoskeletal system, by controlling bone homeostasis and bone regeneration, as well as the osteogenic differentiation of stem cells. Thus, we touched on some examples to demonstrate this interaction. In addition, we believe there is still much to discover from the effects of lncRNAs on progenitor and non-progenitor cell differentiation. We incorporated data from other published articles to review lncRNAs in normal progenitor cell osteogenic differentiation, determined lncRNAs involved in osteoarthritis pathogenesis in progenitor cells, and provided a review of lncRNAs in non-progenitor cells that are differentially regulated in osteoarthritis. In conclusion, we really enjoyed reading this article and with this information we hope to further our under standing of lncRNAs and mesenchymal stromal/stem cells regulation.

Quintero, Daniel BS; Allegra, Paul R. MD; Cardoso, Fabiano N. MD; McNamara, Colin A. MD; Martin, Anthony R. MD; Ezuddin, Nisreen MD; Carvajal, Jaime MD; Jose, Jean DO Author Information

BACKGROUND: Osteoarthritis (OA) of the knee afflicts over 54 million Americans including 3.1 million Hispanics. Several studies provide treatment guidelines for OA in a stepwise fashion, beginning with physical therapy and only intensifying treatment after 6 months of therapy or identification of radiographic severity (K-L grade of 2 or greater). This approach correlates well with worsening patient symptoms in the non-Hispanic Caucasian individual (NHWP)4. To date, no association between pain, function, and K-L grade has been established in the Hispanic population. Additionally, no comparative analysis of pain catastrophizing for knee OA in Hispanic persons and NHWP has been reported. PURPOSE: Characterize Hispanic patients with knee OA on basis of pain (VAS), function (WOMAC), and radiographic severity (K-L grade) and compare findings to those of NHWP. METHODS: With IRB approval, we conducted a convenient sampling of 90 patients. Patients were considered if they presented with knee pain and were given a primary diagnosis of OA. Patients who met our inclusion criteria were administered PCS, WOMAC, VAS and demographic questionnaires. K-L grade was determined using WBAPE radiographs. RESULTS: 75 patients were analyzed. 54 Hispanic (30% M: F), 25 NHWP (36% M: F). On average, Hispanic patients report greater pain scores than non-Hispanics (p < 0.05). Additionally, Hispanic patients reported greater functional impairment (p < 0.05). There was minimal difference in pain catastrophizing scores between Hispanic (10.9 +/- 10.7 and Caucasian patients (6.5 +/- 5.6). The differences in average K-L grade were insignificant 1.97 and 2.06, respectively. The correlation between VAS and K-L as well as WOMAC and K-L in Hispanics was weak (R < 0.7). CONCLUSION: Hispanics demonstrated greater pain scores with greater functional impairment without demonstrating significantly different scores in pain catastrophizing. These same patients demonstrated a weak correlation between pain, function, and radiographic score, questioning the utility of K-L grade in management of these patients.

Juxtacortical lesions appear as neoplastic formations on the outer cortical surface of bone. They can arise from nonneoplastic and neoplastic origin, the latter of which might be malignant. Juxtacortical lesions of neoplastic origin can be categorized into bone-forming lesions, cartilaginous lesions, fibrous lesions, lesions of local vascular or neurogenic origin, or metastatic lesions. Forming a differential diagnosis can be challenging for any physician assistant. We selected a series of cases from our tertiary care clinic that have been subject to discussion for their similarity but vastly different prognosis. Our aim is to provide a rubric to compare juxtacortical lesions with guide orthopaedic and sport medicine providers in determining the immediacy of referral and follow-up.

Several studies have previously documented the development of complications stemming from injection with one of the various COVID-19 vaccines. No study, however, has discussed the spontaneous development of a soft tissue mass shortly after a COVID-19 vaccine injection. We report on 66-year-old female with concerns of a growing shoulder mass, 2 weeks after receiving a COVID-19 vaccine booster. Initial work-up with X-ray and MRI was concerning for a soft tissue neoplasm, specifically a soft tissue sarcoma. Subsequent ultrasound guided biopsy demonstrated a benign granulomatous lesion. No further management was required as the lesion spontaneously resolved during a 3-month follow-up period.

Objective: Identify factors predictive of therapeutic success following ultrasound-guided sheath injection of the long head of the biceps tendon. Materials and Methods: A total of 162 cases were divided into three groups based on clinical responses: complete, partial, or no relief. The presence or absence of clinical symptoms, glenohumeral joint structural pathology, and treatment method was compared. Results: Of the 115 injections with follow-up, 19.1% reported no clinical response while 53.0% had a complete response. Patients with fibromyalgia or chronic spine pain were strongly associated with a poor outcome (odds ratio [OR] = 5.7, P < .001). Conclusion: Ultrasound-guided intra-sheath injection is an effective method of non-surgical management for biceps tendinopathy.

The vascular supply of the shoulder and forearm are principal derivates of the ipsilateral subclavian artery. The trajectory of this arterial supply predisposes it to concomitant injuries in the shoulder and clavicular fractures proximally and elbow dislocation distally. Distal bicep tendon tears often occur most commonly in middle-aged men due to trauma to the elbow, typically in weight-bearing situations [1]. To our knowledge, this is the first case of distal biceps tendon tear repair resulting in distal brachial artery injury from displaced hardware due to postoperative re-injury. We present a case of a 41-year-old male who developed a vaso-occluding hematoma at the distal biceps secondary to a displaced fixation screw. The patient required emergency vascular surgery with embolectomy and arterial bypass. Although this patient fully recovered, the clinical course the patient experienced could have been minimized with appropriate postoperative care. This report aims to alert clinicians to the relevant local anatomy and relate it to the proposed mechanism of injury, thereby bringing attention to the importance of postoperative limb protection in at-risk patients. The timing of the injury, and the protracted rate of thrombus formation suggest that the brachial artery's thrombosis was associated with the screw pullout during reinjury of the area. Screw pullout in orthopedics is a rare phenomenon that can lead to significant complications. The risk of reinjury, screw pullout, and other complications such as thrombosis is evidence to support the careful treatment of the area postoperatively.