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Softball is a popular sport among youth female athletes. While youth baseball has well-established, evidence-based pitching guidelines, youth softball pitching guidelines lack both evidence and enforcement. Adherence to pitch count limits in youth softball is infrequent and results in pitchers with exceedingly high pitching volumes.Pitch counts for youth fast-pitch softball teams competing for 1 consecutive year between January 2018 to December 2019 in age groups 8 and under (8U) to 14 and under (14U) were collected. Pitching volume was assessed based on individual games, single calendar days, and tournaments in which games are played on 2 or more consecutive days. Pitchers on teams were subdivided based on pitch count volumes and compared using a logarithmic transformation and geometric mean.Data was collected for 10 teams from each age division resulting in analysis of 538 pitchers on 70 teams. The average pitcher threw 813 pitches per year and appeared in 20.0% of games while the average highest volume pitcher threw 2500 pitches per year and appeared in 54.5% of games. On average, the highest volume pitcher on each team threw 40% of all team pitches, while the 3 highest volume pitchers combined threw 82% of all team pitches. The average and high-volume pitcher threw pitches in 2 or more games on the same day in 37.5% and 48.6% of possible games while pitching 2 or more consecutive days in 64.0% and 79.6% of possible games, respectively.Softball pitchers throw high volumes of pitches while also pitching multiple days consecutively. A disparity among pitchers on softball teams exists as 40% of team pitches are thrown by 1 player and over 80% of team pitches are thrown by the top 3 pitchers. These high-volume pitchers may be engaging in unsustainable pitching practices that could predispose to injury.Level IV-cross-sectional. more...

Objectives Functions of mesenchymal stem/stromal cells (MSCs) are affected by patient-dependent factors such as age and health condition. To tackle this problem, we used the cellular reprogramming technique to epigenetically alter human MSCs derived from the synovial fluid of joints with osteoarthritis (OA) to explore the potential of reprogrammed MSCs for repairing articular cartilage. Materials and Methods MSCs isolated from the synovial fluid of three patients’ OA knees (Pa-MSCs) were reprogrammed through overexpression of pluripotency factors and then induced for differentiation to establish reprogrammed MSC (Re-MSC) lines. We compared the in vitro growth characteristics, chondrogenesis for articular cartilage chondrocytes, and immunomodulatory capacity. We also evaluated the capability of Re-MSCs to repair articular cartilage damage in an animal model with spontaneous OA. Results Our results showed that Re-MSCs increased the in vitro proliferative capacity and improved chondrogenic differentiation toward articular cartilage-like chondrocyte phenotypes with increased THBS4 and SIX1 and decreased ALPL and COL10A1, compared to Pa-MSCs. In addition, Re-MSC-derived chondrocytes expressing elevated COL2A and COL2B were more mature than parental cell-derived ones. The enhancement in chondrogenesis of Re-MSC involves the upregulation of sonic hedgehog signaling. Moreover, Re-MSCs improved the repair of articular cartilage in an animal model of spontaneous OA. Conclusions Epigenetic reprogramming promotes MSCs harvested from OA patients to increase phenotypic characteristics and gain robust functions. In addition, Re-MSCs acquire an enhanced potential for articular cartilage repair. Our study here demonstrates that the reprogramming strategy provides a potential solution to the challenge of variation in MSC quality. more...

Cellular reprogramming forcing the expression of pluripotency markers can reverse aging of cells, but how molecular mechanisms through which reprogrammed cells alter aging-related cellular activities still remains largely unclear. In this study, we reprogrammed human synovial fluid-derived mesenchymal stem cells (MSCs) into induced pluripotent stem cells (iPSCs) using six reprogramming factors and reverted the iPSCs back to MSCs, as an approach to cell rejuvenation. Using the parental and reprogrammed MSCs as control nonrejuvenated and rejuvenated cells, respectively, for comparative analysis, we found that aging-related activities were greatly reduced in reprogrammed MSCs compared with those in their parental lines, indicating reversal of cell aging. Global transcriptome analysis revealed differences in activities of regulatory networks associated with inflammation and proliferation. Mechanistically, we demonstrated that, compared with control cells, the expression of GATA binding protein 6 (GATA6) in reprogrammed cells was attenuated, resulting in an increase in the activity of sonic hedgehog signaling and the expression level of downstream forkhead box P1 (FOXP1), in turn ameliorating cellular hallmarks of aging. Lower levels of GATA6 expression were also found in cells harvested from younger mice or lower passage cultures. Our findings suggest that GATA6 is a critical regulator increased in aged MSCs that controls the downstream sonic hedgehog signaling and FOXP1 pathway to modulate cellular senescence and aging-related activities. more...

Meniscus tears of the knee are among the most common orthopedic knee injury. Specifically, tears of the posterior root can result in abnormal meniscal extrusion leading to decreased function and progressive osteoarthritis. Despite contemporary surgical treatments of posterior meniscus root tears, there is a low rate of healing and an incidence of residual meniscus extrusion approaching 30%, illustrating an inability to recapitulate native meniscus function. Here, we characterized the differential functional behavior of the medial and lateral meniscus during axial compression load and dynamic knee motion using a cadaveric model. We hypothesized essential differences in extrusion between the medial and lateral meniscus in response to axial compression and knee range of motion. We found no differences in the amount of meniscus extrusion between the medial and lateral meniscus with a competent posterior root (0.338mm vs. 0.235mm; p-value = 0.181). However, posterior root detachment resulted in a consistently increased meniscus extrusion for the medial meniscus compared to the lateral meniscus (2.233mm vs. 0.4705mm; p-value < 0.0001). Moreover, detachment of the posterior root of the medial meniscus resulted in an increase in extrusion at all angles of knee flexion and was most pronounced (4.00mm ± 1.26mm) at 30-degrees of knee flexion. In contrast, the maximum mean extrusion of the lateral meniscus was 1.65mm ± 0.97mm, occurring in full extension. Furthermore, only the medial meniscus extruded during dynamic knee flexion after posterior root detachment. Given the differential functional behaviors between the medial and lateral meniscus, these findings suggest that posterior root repair requires reducing overall meniscus extrusion and recapitulating the native functional responses specific to each meniscus. more...

Objectives: This study’s objective was to determine whether multimodal analgesia plus an injection of the hamstring sheath immediately following the harvest of the semitendinosus and gracilis tendons during hamstring autograft anterior cruciate ligament reconstruction (ACLR) reduces postoperative pain. We hypothesized that multimodal analgesia plus a hamstring sheath injection of the harvest site for autograft hamstring ACLR reduces postoperative pain. Methods: The Institutional Review Board approved this study registered with ClinicalTrials.gov and identified by NCT01868425. This study was a single-center, surgeon stratified double-blind, placebo-controlled, randomized study from April 2013 to December 2017. Patients were randomly assigned to one of two groups, in a 1:1 ratio per surgeon, to receive either standard of care analgesia plus intra-operative hamstring sheath saline injection (Placebo group) or standard of care analgesia plus multimodal analgesia plus intraoperative hamstring sheath anesthetic injection (MA group) for patients undergoing ACLR with hamstring autograft. Eligible participants were adults aged 18 years to 55 years old consented for ACLR using hamstring tendon autograft. Contraindication to a femoral nerve block, allergy to protocol medications, nervous system disease, renal or hepatic impairment, history of opioid dependence or current narcotic use, significant psychiatric disease, pregnancy or lactating, a seizure disorder, history of postoperative nausea and vomiting, latex allergy, and clinically significant cardiac or pulmonary disease excluded patients for participation in this study. The primary endpoint was total postoperative opioid administration. Secondary endpoints included the patient’s subjective pain score for the posterior, anterior, and lateral side of the knee, postoperative nausea, sedation, and pruritus scores. Based on our preliminary data, we estimated the mean opioid for standard care will be 6.6 morphine equivalents with a standard deviation of 6.2 morphine equivalents. Testing the ability of multimodal analgesia to reduce opioid usage by at least 50%, a minimal sample size of 45 subjects per group was needed to achieve 80% power based on a one-tailed t-test and a significance level < 0.05. Student’s t-test compared outcomes between groups. Additionally, a linear regression model for was also used for the primary outcome with total opioid administration as the dependent variable in order to control for body mass index (BMI) and sex, providing an adjusted estimate of the difference between groups. Results: A total of 112 patients (Figure 1) met inclusion criteria and were randomized into the placebo group (n = 57) and MA group (n = 55). Demographic data demonstrated no significant differences between groups (Table 1). The primary analysis was postoperative opioid administration and included all patients randomly assigned to either group for opioid administration in the postoperative anesthetic care unit (PACU), however opioid administration in 24 hours after discharge was not recorded for five patients in the MA group, leaving 50 patients remaining for the per-protocol analyses. Secondary outcome data was not recorded for one patient in the placebo group leaving 56 patients remaining for the per-protocol analyses. The mean postoperative opioid needs (Table 2) for patients in the MA group (18.7 ± 13.14) was less than those in the placebo group (22.6 ± 11.15), although this was not statistically significant (p-value = 0.140). Secondary outcomes (Figure 2A) demonstrated a significant reduction in posterior knee pain postoperatively in the MA group (2.84 ± 2.25) compared to Placebo (3.56 ± 1.97; p-value = 0.0362). There were no significant differences in postoperative pain in the front or sides of the knee. Similarly, there were no significant differences in pruritis (MA: 0.26 ± 0.99 vs. Placebo: 0.696 ± 1.73; p-value = 0.2163), sedation (MA: 5.02 ± 2.29 vs. Placebo: 4.61 ± 2.16; p-value = 0.656), and nausea (MA: 1.16 ± 2.28 vs Placebo: 0.714 ± 1.72; p-value = 0.243) scores (Figure 2B). Conclusions: Multimodal analgesia plus hamstring sheath injection reduces postoperative patient reported posterior knee pain compared to placebo for patients undergoing ACLR using hamstring tendon autograft. However, multimodal analgesia plus a hamstring sheath injection does not reduce postoperative opioid requirements. more...

The discovery of induced pluripotent stem cells (iPSCs) has revolutionized biomedicine. Although the potential of iPSCs for tissue regeneration, disease modeling and drug screening has been largely recognized, findings of iPSC research to date are mostly focused on neurology, cardiology and haematology. For orthopaedics, growing interest in the unique cell type has prompted more researchers to get involved in iPSC research. In this article, we introduce the brief history of cellular reprogramming and different reprogramming methods that have been developed, discuss the biology of iPSCs and review previously reported findings of iPSC studies in orthopaedics. The Translational potential of this article: Stem cell therapies hold great promise for treating orthopaedic diseases, manifested in recent study findings and results of clinical trials. iPSCs are a unique stem cell type derived from a patient’s own cells while still possessing the embryonic stem cell-featured pluripotency for generation of all tissues in the body. The distinctive properties make iPSCs much desirable to fulfill the promise of regenerative medicine for clinical orthopaedics. Keywords: Cellular reprogramming, Disease modelling, Drug screening, Induced pluripotent stem cell, Musculoskeletal regeneration more...

Background Anterior cruciate ligament (ACL) rupture in humans is a common condition associated with knee pain, joint instability, and secondary osteoarthritis (OA). Surgical treatment with an intraarticular graft provides reasonable outcomes at mid and long-term follow-up. Non-modifiable and modifiable factors influence risk of ACL rupture. The etiology, mechanobiology, causal biomechanics, and causal molecular pathways are not fully understood. The dog model has shared features of ACL rupture that make it a valuable spontaneous preclinical animal model. In this article, we review shared and contrasting features of ACL rupture in the two species and present information supporting spontaneous canine ACL rupture as a potentially useful preclinical model of human ACL rupture with a very large subject population. Results ACL rupture is more common in dogs than in humans and is diagnosed and treated using similar approaches to that of human patients. Development of OA occurs in both species, but progression is more rapid in the dog, and is often present at diagnosis. Use of client-owned dogs for ACL research could reveal impactful molecular pathways, underlying causal genetic variants, biomechanical effects of specific treatments, and opportunities to discover new treatment and prevention targets. Knowledge of the genetic contribution to ACL rupture is more advanced in dogs than in humans. In dogs, ACL rupture has a polygenetic architecture with moderate heritability. Heritability of human ACL rupture has not been estimated. Conclusion This article highlights areas of One Health research that are particularly relevant to future studies using the spontaneous canine ACL rupture model that could fill gaps in current knowledge. more...

Background: The Pitch Smart guidelines aim to limit youth baseball pitching behaviors associated with overuse injuries. Despite many youth baseball leagues being compliant with the guidelines, during tournaments, pitch count restrictions or guidelines are often not followed. Purpose: To perform a quantitative analysis of pitch counts in youth baseball players and evaluate compliance with regard to the Pitch Smart guidelines in the tournament setting. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Included in the analysis were 100 youth baseball teams that competed in the 8-and-under to 14-and-under age divisions during the 2019 tournament season. Pitching data were compared with the Pitch Smart guidelines. Violations were identified as (1) exceeding maximum daily pitch count, (2) inadequate rest between pitching events, and (3) pitching more than 1 event on the same day. Pitcher and game factors were analyzed for possible relationships to guideline violations using mixed-effects negative binomial regression models, with comparisons of violations using rate ratios (RRs). Results: Analysis included 1046 pitchers and 2439 games. There were 1866 total Pitch Smart guideline violations, with 48.6% of pitchers having at least 1 violation. Inadequate rest was the most common reason for violation, with noncompliance occurring in 43.3% of pitchers. The highest rate of any violation (0.32 per appearance) occurred in the 8-and-under age division. High-volume pitchers had increased violation rates in each category compared with low-volume pitchers ( P < .001). Violation rates were increased more than twice the rate when pitchers participated in ≥5 consecutive games without a rest day when compared with a single game (RR, 2.48; P < .001). Conclusion: Noncompliance with Pitch Smart guidelines in tournament settings occurred in more than 90% of teams and almost half of all pitchers. Factors associated with noncompliance included younger pitcher age, high-volume pitching, and pitching in multiple consecutive games. Education of tournament directors, coaches, parents, and athletes regarding pitching guidelines is warranted in order to limit the risk of injury. more...

Background: Athletic pubalgia (AP) is an increasingly recognized injury among young athletes. This study aimed to evaluate the characteristics associated with AP in college football players. Hypothesis: Repetitive explosive movements that require aggressive core muscle activation results in AP in collegiate football players. Study Design: Retrospective cohort design. Level of Evidence: Level 3. Methods: Football student-athletes at a single Division I collegiate institution from January 2010 to December 2019 were included in the study. The primary outcome measure was surgery for AP. The odds of AP were determined using logistic regression, with the dependent variable being whether or not the student-athlete received AP surgery. Independent variables included Olympic weightlifting (OWL) exposure, primary playing position (skill position vs nonskill position), and body mass index (BMI). Results: A total of 1154 total student-athlete exposures met the inclusion criteria. Of the 576 student-athletes exposed to OWL (OWL occurred throughout entire calendar year), 20 developed AP, whereas 7 student-athletes not exposed to OWL (OWL was not performed at any point during calendar year) developed AP. Student-athletes exposed to OWL had a 2.86 (95% CI, 1.25-7.35; P = 0.02) times higher odds of AP than players not exposed after controlling for primary playing position and BMI. Skill position players had a 9.32 (95% CI, 1.71-63.96; P = 0.01) times higher odds of AP than nonskill position players when controlling for BMI and OWL training. Conclusion: Modifiable factors that increase exposure to repetitive explosive activities, such as OWL and playing a skill position, may be important considerations in developing AP. Clinical Relevance: The cause of AP is multifactorial and poorly understood. Identifying factors associated with AP informs athletes, athletic trainers, physicians, and coaches. more...

Inspired by how cartilage is developed, stem cell derivatives forming facial and articular cartilage are studied for joint repair., Generating phenotypic chondrocytes from pluripotent stem cells is of great interest in the field of cartilage regeneration. In this study, we differentiated human induced pluripotent stem cells into the mesodermal and ectomesodermal lineages to prepare isogenic mesodermal cell–derived chondrocytes (MC-Chs) and neural crest cell–derived chondrocytes (NCC-Chs), respectively, for comparative evaluation. Our results showed that both MC-Chs and NCC-Chs expressed hyaline cartilage–associated markers and were capable of generating hyaline cartilage–like tissue ectopically and at joint defects. Moreover, NCC-Chs revealed closer morphological and transcriptional similarities to native articular chondrocytes than MC-Chs. NCC-Ch implants induced by our growth factor mixture demonstrated increased matrix production and stiffness compared to MC-Ch implants. Our findings address how chondrocytes derived from pluripotent stem cells through mesodermal and ectomesodermal differentiation are different in activities and functions, providing the crucial information that helps make appropriate cell choices for effective regeneration of articular cartilage. more...

Background:Insertion force has been shown to significantly reduce chondrocyte viability during osteochondral allograft transplantation. How graft size influences the required insertion force and chondrocyte viability has yet to be determined.Hypothesis/Purpose:The purpose was to characterize how graft size influences insertion force requirements and chondrocyte viability during osteochondral transplantation. The hypothesis was that larger grafts would require greater force and reduce chondrocyte viability.Study Design:Controlled laboratory study.Methods:Four graft sizes—15 × 5 mm, 15 × 10 mm, 25 × 5 mm, and 25 × 10 mm (diameter × depth)—were harvested from 13 thawed fresh-frozen human cadaveric distal femurs. Average, maximum, and cumulative force and number of impacts were recorded for 44 grafts by a surgical mallet embedded with a calibrated force sensor. In a separate experiment, fresh osteochondral tissues were subjected to mechanical loading. To capture a range of clinically important forces, categories were selected to correspond to impaction force data. Chondrocyte viability was assessed with confocal laser microscopy and live/dead staining.Results:Total force for all grafts averaged 4576 N. Median number of impacts for all grafts was 20 (range, 7-116). The mean number of impacts for 5-mm-deep grafts was 14.2 (95% CI, 10.8-18.6), as compared with 26.3 (95% CI, 19.9-34.4) for 10-mm-deep grafts ( P < .001). The mean cumulative force for 5-mm-deep grafts was 2128 N (95% CI, 1467-3087), as opposed to 4689 N (95% CI, 3232-6803) for 10-mm-deep grafts ( P = .001). For every 1 mm in graft depth, an average of 13.1% (95% CI, 6.2%-20.3%) more impacts are required when controlling for diameter and density ( P < .001). For every 1 mm in graft depth, the force required increases on average by 17.1% (95% CI, 7.7%-27.4%) when controlling for diameter and density ( P = .001). There was a significant reduction in chondrocyte viability for the forces required for graft thickness values >10 mm. Only forces associated with graft thickness 70%.Conclusion:Insertion force increases significantly with increasing graft depth. Controlling for diameter and bone density, a 1-mm increase in graft depth is associated with 13.1% more impacts and 17.1% more force. Chondrocyte viability was significantly reduced to Clinical Relevance:Based on the current data, graft depth is an important consideration for surgeons when sizing osteochondral allograft transplant for chondral lesions of the knee. more...

Importance Anterior cruciate ligament (ACL) injury can be a devastating injury that without surgery may lead to chronic instability. Although surgical reconstruction recreates the stabilising constraint of the native ACL, postoperative pain and subsequent arthrosis may follow. Objectives The primary objective of this systematic review is to determine whether the presence of a bone bruise following ACL rupture adversely affects the clinical outcomes following surgical reconstruction. Evidence review A standardised research protocol was used as outlined by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Studies included were those with level of evidence (I, II, III, IV) and had MRI data on the presence of bone bruise and clinical outcome measures in patients who underwent surgical reconstruction of the ACL after traumatic rupture. Articles were searched using PubMed/Medline, Cochrane Library, CINAHL and EMBASE databases using a keyword search. Article references and conference proceedings were subsequently reviewed on identification of articles found via the keyword search. Non-English literature, animal and basic science studies, studies focused on the skeletally immature and level of evidence (V) were excluded. A quantitative analysis of the data retrieved was summarised. Findings Five studies met the inclusion criteria. Follow-up ranged from the time of surgical reconstruction to 165 months. Although a variety of clinical outcome measures were used across studies, bone bruise cohorts did not demonstrate clinically inferior outcome scores. Conclusions and relevance Although osteochondral injury is frequently identified following ACL injury, the presence of a bone bruise alone does not appear to significantly adversely affect the clinical outcome of surgically reconstructed ACLs. However, factors such as articular cartilage injury and alteration in joint loading may be important variables for further research. Level of evidence IV. more...

Intraoperative conversion of a four-strand hamstring autograft to a five-strand configuration during an anterior cruciate ligament (ACL) reconstruction has been reported. However, the expected change in graft size and the dependence on patient characteristics are currently not well described. The purpose of this study was to determine the effective change in hamstring graft diameter and reliance on patient characteristics when intraoperatively converting a four-strand hamstring autograft into a five-strand configuration during an ACL reconstruction. A prospective, paired cohort study design was used to measure individual hamstring autograft diameter intraoperatively using traditional four-strand configuration followed by a five-strand configuration. All hamstring tendons included were long enough to consider a five-strand configuration. Five-strand hamstring autograft increased graft diameter in all patients. Hamstring tendon graft diameter increased by an average of 0.99 mm (95% confidence interval [CI]: 0.84–1.11) in the five-strand configuration compared with the traditional four-strand configuration (mean: 7.8 mm). There was no significant difference in the average increase in graft diameter between males (1.04 mm) and females (0.92 mm) (p = 0.323). Eighty-three percent (95% CI: 57.8–95.6) of average graft diameters ≤ 8 mm in the four-strand configuration achieved an average graft diameter of >8 mm in the five-strand configuration, and 70% (95% CI: 35.4– 91.9) of four-strand configuration average diameters 8.0 mm in the five-strand configuration. Five-strand hamstring autograft reliably increased intraoperative hamstring tendon autograft diameter, with an average of 1 mm, compared with traditional four-strand configuration. This increase in diameter is independent of sex and remained significant when controlling for age, laterality, body mass index, and semitendinosus length. more...

Background: Over the past decade, the use of psychotropic medications (PTMs) in the United States has doubled, and currently 20% of adults are taking 1 or more of these antidepressant, antianxiety, antipsychotic, or mood-altering medications. To date, however, the incidence of PTM use in patients undergoing hip arthroscopy and the results of hip arthroscopy in these patients have not been reported. Purpose: To determine the prevalence of PTM use in patients undergoing hip arthroscopy and to compare the outcomes of patients taking PTMs versus those of patients not taking PTMs. Study Design: Cohort study; Level of evidence, 3. Methods: Medical records of 880 consecutive patients who underwent hip arthroscopy performed by the senior author were reviewed and data were collected, including the number and types of PTMs that these patients were taking at the time of their hip arthroscopy. All hips were assessed with the Byrd modified Harris Hip Score (mHHS) preoperatively; 709 patients (81%) had scores obtained at 12 months and 669 patients (76%) at 24 months after surgery. Demographic data and mHHS of patients taking psychotropic medications (PTM group) were compared with those of patients not taking PTMs (NPTM group). Results: Four hundred twenty-two (48%) of the 880 patients studied were taking PTMs at the time of their hip arthroscopy; significant differences between the PTM and NPTM groups were average age (48 vs 35 years, respectively), and the high percentage of females (53%) and low percentage of males (38%) in the PTM group. Preoperative scores for the PTM and NPTM groups were similar (41 vs 42 points, respectively), but postoperative scores of the PTM group were significantly lower at 6 months (72 vs 89 points), 12 months (77 vs 91 points), and 24 months (79 vs 88 points) after surgery ( P = .01). In contrast, the scores of the subgroups of PTM and NPTM adolescents obtained at 3 months (92.5 vs 88.9 points), 6 months (92.1 vs 90.3 points), 12 months (89.5 vs 92.1 points), and 24 months (90.3 vs 90.1 points) after surgery did not significantly differ. Conclusion: The incidence of PTM use in this series of patients with hip arthroscopy was triple that reported for US adults (48% vs 17%, respectively) and adolescents (23% vs 6.3%), and the PTM group had significantly lower 12- and 24-month mHHS results than the NPTM group. These results suggest that (1) patients undergoing hip arthroscopy who are taking PTMs are at significantly higher risk for poor outcomes and (2) their use of PTMs should be identified and addressed before proceeding with hip arthroscopy. more...

An 18-year-old right-hand dominant woman presented with an enlarging right medial elbow mass which was associated with worsening paresthesias during the past 2 months, primarily affecting her ring and small fingers. She denied any weakness or loss of function. There was no family history of soft tissue tumors, neurocutaneous disorders, or neuropathy. Physical examination revealed an elongated soft tissue mass along the posteromedial aspect of her right elbow. The mass was fairly firm, did not transilluminate, and was mobile in the mediolateral plane. Although the mass was not tender to palpation, percussion of the mass reproduced her paresthesias (a positive Tinel’s sign). Moreover, light touch sensation was intact. Further evaluationof her right upper extremity revealed normal ROM, vascular status, and no atrophy of the upperextremity muscles. Small finger abduction strength was 4/5 with remaining strength testing revealing no other weakness. There was no associated lymphadenopathy. Laboratory tests, including a complete blood count with differential, a comprehensive metabolic panel, sedimentation rate, C-reactive protein, and lactate dehydrogenase levels, were normal. Imaging studies included AP and lateral radiographs of the humerus (Fig. 1) and MRI (Fig. 2). Based on the history, physical examination, laboratory studies, and imaging studies, what is the differential diagnosis at this point? more...

Sarcomas are a rare, heterogeneous group of malignant tumors of the bone or soft tissue. Although historically intended for the pharmaceutical treatment of microbes, today chemotherapy is used in orthopaedic oncology and is arguably the primary reason for improved survivorship. Agents such as anthracyclines (eg, doxorubicin), alkylating agents (eg, cyclophosphamide, ifosfamide), antimetabolites (eg, methotrexate), topoisomerase inhibitors (eg, etoposide [VP-16]), vinca alkaloids (eg, vincristine), and cytotoxic antibiotics (eg, actinomycin D) are used in various combinations to manage different types of tumors. Side effects are common and range from mild to severe. The effectiveness of the chemotherapy regimen correlates with the extent of tumor necrosis. more...

Extra-abdominal desmoid tumors continue to present unique challenges. Although the majority of patients can achieve durable local control, recalcitrant disease can prove frustrating for patients, their families, and providers. This is especially true when morbid local treatment modalities are undertaken in hopes of controlling a benign disease. There is little universal agreement regarding the optimal management of this potentially locally aggressive neoplasm; however, the overall goal of treatment is durable local control. Because of the unpredictable nature of desmoid tumors, treatment must be individualized on a case-by-case basis, utilizing a multimodal approach, and optimized in a multidisciplinary setting. Primary desmoid tumors that are symptomatic or progressing and can be excised with function-sparing surgery are treated operatively; surgical excision with negative margins (R0 resection) is generally the preferred method of treatment. Radiation therapy is used in combination with surgical resection for microscopically positive margins (R1 resection) when future recurrence may jeopardize limb preservation or function. For symptomatic or enlarging desmoids where surgery will incur significant functional deficits in order to obtain at best an R1 resection, definitive radiation or percutaneous ablation is utilized. Desmoid tumors that are asymptomatic, not enlarging, and located in areas that are remote from vital structures may be carefully observed. Systemic therapy is commonly utilized as an adjunct or primary treatment for symptomatic or enlarging tumors. The mainstay of treatment of recurrent desmoids tumor is surgery with a goal of an R0 resection often combined with radiation therapy. The evolving role of alternative methods of local control (such as cryoablation) is currently being investigated. As the cellular understanding of desmoid tumor improves, the ability to better predict the biological behavior will hopefully improve treatment selection. more...

Background: Soft tissue sarcomas (STS) of the hand are exceedingly rare. The aim of this study was to review our institution’s experience with STS of the hand to identify factors affecting outcomes and survivorship. Methods: We retrospectively reviewed the records of 46 hand STS treated with definitive surgery at our institution between 1992 and 2013. Pertinent demographics as well as information regarding the surgical procedure, and disease status at latest follow-up were reviewed. Mean age at diagnosis was 38 years with a mean follow-up of 5 years. Results: The most common tumor subtypes were epithelioid (n = 10) and synovial sarcoma (n = 8). Sixty-one percent were superficial in location. Thirty-three patients had had a nononcologic resection prior to definitive surgical treatment at our institution. Ultimately, negative margins were obtained in all cases. Local recurrence was observed in 5 patients and distant metastases in 14 patients. Tumor sizes ≥2 cm, American Joint Committee on Cancer (AJCC) grade, and depth of the tumor were found to adversely affect the outcome in terms of disease-free and overall survival. Reexcision of an inadvertently excised tumor at an outside institution did not adversely affect the outcome. The 10-year overall and disease-free survival was 72% and 63%. Conclusions: Local recurrence after a wide excision was observed infrequently; however, distant disease was relatively common. Tumors with a size ≥2 cm were associated with a worse disease-free and overall survival, highlighting the aggressive nature of these tumors. more...

The purpose of this study was to evaluate the knees of asymptomatic National Basketball Association (NBA) players via magnetic resonance imaging (MRI) and confirm or dispute findings reported in the previous literature. It is thought that a variety of significant abnormalities affecting the knee exist in asymptomatic patients and that these findings can be accurately identified on MRI. Two months prior to the 2005 season, bilateral knee MRI examinations of 14 asymptomatic NBA players (28 knees) were evaluated for abnormalities of the articular cartilage, menisci, and patellar and quadriceps tendons. The presence of joint effusion, subchondral edema, and cystic lesions and the integrity of the collateral and cruciate ligaments were also assessed. more...

Background: Iliopsoas (IP) muscle atrophy is a known consequence of open IP tenotomy, but the severity of IP muscle atrophy that occurs after arthroscopic labral-level IP tenotomies has not been documented. Purpose: To document the severity of muscle atrophy that occurs in the iliacus, psoas, and adjacent hip musculature after arthroscopic labral-level IP tenotomy. Study Design: Case series; Level of evidence, 4. Methods: Twenty-eight patients who had magnetic resonance arthrograms (MRAs) obtained prior to and 3 months to 5 years after arthroscopic labral-level IP tenotomies are the basis of this report. The pre- and postoperative MRAs of each patient were examined in consensus by 2 musculoskeletal radiologists who graded the postoperative muscle atrophy from 0 (no fatty infiltration) to 4 (>75% fatty infiltration) and noted any compensatory muscle hypertrophy or abnormal IP tendon morphology. Patients also were assessed with the Byrd 100-point modified Harris Hip Scoring system (MHHS) preoperatively and at the time of their postoperative MRA. Results: Postoperative MRAs were obtained on average 1.7 years (range, 3 months to 5 years) after hip arthroscopy. None of the patients had muscle atrophy on their preoperative MRAs. In contrast, 89% of patients had iliacus and psoas muscle atrophy on their postoperative MRAs, but only 2 (7%) developed grade 4 atrophy, and the majority (64%) had either grade 1 (n = 15) or no atrophy (n = 3). In addition, there were no significant differences in the MHHS of the patients with mild (grades 0-1), moderate (grades 2-3), or severe (grade 4) postoperative atrophy. Postoperative MRAs also demonstrated low-grade atrophy (grades 1-2) in the quadratus femoris (n = 5) and rectus femoris (n = 1) muscles, and 16 patients (57%) had distortion of the tendon, but none had a gap in their tendon. Conclusion: A majority of patients (89%) developed IP muscle atrophy after arthroscopic labral-level IP tenotomies, and although this percentage was similar (89% vs 90%) to that reported with lesser trochanteric IP tenotomies, the patients did not (1) develop atrophy of the gluteus maximus and vastus lateralis muscles, (2) have chronic IP tendon disruption, or (3) develop the severity of IP atrophy (55% grade 4 vs 7% grade 4) that has been reported after arthroscopic lesser trochanteric IP tenotomies. more...

Myositis ossificans is a self-limiting, benign ossifying lesion that can affect any type of soft tissue, including subcutaneous fat, tendons, and nerves. It is most commonly found in muscle as a solitary lesion. Ossifying soft-tissue lesions historically have been inconsistently classified. Fundamentally, myositis ossificans can be categorized into nonhereditary and hereditary types, with the latter being a distinct entity with a separate pathophysiology and treatment approach. The etiology of myositis ossificans is variable; however, clinical presentation generally is characterized by an ossifying soft-tissue mass. Advanced cross-sectional imaging alone can be nonspecific and may appear to be similar to more sinister etiologies. Therefore, the evaluation of a suspicious soft-tissue mass often necessitates multiple imaging modalities for accurate diagnosis. When imaging is indeterminate, biopsy may be required for a histologic diagnosis. However, histopathology varies based on stage of evolution. The treatment of myositis ossificans is complex and is often made in a multidisciplinary fashion because accurate diagnosis is fundamental to a successful outcome. more...