Objective:A workgroup of clinical experts has developed an Appropriate Use Criteria (AUC) for the use of hyaluronic acid (HA) in the treatment of osteoarthritis (OA) of the knee. The increasingly broad and varied use of HA injections, lack of published clinical guidance, and limited coverage for their use has created the imperative to establish appropriateness criteria.Methods:The experts of this workgroup represent rheumatology, orthopedic surgery, physiatry, sports medicine, and nursing clinicians with substantive knowledge of intra-articular HA therapy. This workgroup utilized the results of a systematic review of evidence, expert clinical opinion, and current evidence-based clinical practice guidelines to develop appropriateness criteria for the use of intra-articular HA for knee OA in 17 real-world clinical scenarios.Results:The workgroup scored the appropriateness of treatment of each patient scenario using a 9-point scale to designate a treatment as appropriate (7-9), uncertain (4-6), or inappropriate (1-3). Six scenarios were scored as appropriate, 10 scenarios were scored as uncertain, and 1 scenario was scored as inappropriate.Conclusion:This article can assist clinicians in shared decision-making by providing best practices in considering HA injections for knee OA treatment. Moreover, this AUC article can aid payers and policy makers in determining reimbursement and preauthorization policies and more appropriately managing health care resources. It is clear that further research is still necessary—particularly in patient populations differentiated by OA severity—that may benefit the greatest from the use of HA injections for the treatment of knee OA.

Background and objectivesMarathon runners develop transient AKI with urine sediments and injury biomarkers suggesting nephron damage.Design, setting, participants, & measurementsTo investigate the etiology, we examined volume and thermoregulatory responses as possible mechanisms in runners’ AKI using a prospective cohort of runners in the 2017 Hartford Marathon. Vitals, blood, and urine samples were collected in 23 runners 1 day premarathon and immediately and 1 day postmarathon. We measured copeptin at each time point. Continuous core body temperature, sweat sodium, and volume were assessed during the race. The primary outcome of interest was AKI, defined by AKIN criteria.ResultsRunners ranged from 22 to 63 years old; 43% were men. Runners lost a median (range) of 2.34 (0.50–7.21) g of sodium and 2.47 (0.36–6.81) L of volume via sweat. After accounting for intake, they had a net negative sodium and volume balance at the end of the race. The majority of runners had increases in core body temperature to 38.4 (35.8–41)°C during the race from their baseline. Fifty-five percent of runners developed AKI, yet 74% had positive urine microscopy for acute tubular injury. Runners with more running experience and increased participation in prior marathons developed a rise in creatinine as compared with those with lesser experience. Sweat sodium losses were higher in runners with AKI versus non-AKI (median, 3.41 [interquartile range (IQR), 1.7–4.8] versus median, 1.4 [IQR, 0.97–2.8] g; P=0.06, respectively). Sweat volume losses were higher in runners with AKI versus non-AKI (median, 3.89 [IQR, 1.49–5.09] versus median, 1.66 [IQR, 0.72–2.84] L; P=0.03, respectively). Copeptin was significantly higher in runners with AKI versus those without (median, 79.9 [IQR, 25.2–104.4] versus median, 11.3 [IQR, 6.6–43.7]; P=0.02, respectively). Estimated temperature was not significantly different.ConclusionsAll runners experienced a substantial rise in copeptin and body temperature along with salt and water loss due to sweating. Sodium and volume loss via sweat as well as plasma copeptin concentrations were associated with AKI in runners.PodcastThis article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2019_08_13_CJASNPodcast_19_09_.mp3

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Key Clinical MessageMorel‐Lavallee lesions are post‐traumatic, soft‐tissue degloving injuries commonly misdiagnosed as hematomas or ruptured bursa. The clinician needs to be aware of this injury, in order to provide appropriate patient care and treatment. If not treated early, risks include superinfection, continued expansion, overlying tissue necrosis, and suboptimal patient outcomes.

Background The obese population is more likely to develop degenerative joint disease requiring total joint arthroplasty (TJA) and also experience increased rates of adverse post-surgical outcomes. This study assessed whether a quantifiable weight loss prior to TJA had any impact on perioperative and 30-day outcomes in obese patients. Method Using the American College of Surgeons-National Surgical Quality Improvement Program database, obese patients who underwent total hip or total knee arthroplasty and lost at least 10% of their total body weight prior to surgery were identified and matched to other obese individuals undergoing the same procedures without weight loss. Perioperative outcomes, including operative time, length of stay, discharge destination, or 30-day adverse events, including complications, re-admissions, re-operations, and mortality, were then compared using conditional Logistic regression analysis. Results Analysis showed no difference between the two groups in terms of operative time, length of stay, discharge destination, or 30-day adverse events, including complications, re-admissions, re-operations, and mortality. Conclusion The results of this study suggest that weight loss alone in the preoperative period may not be sufficient to mitigate the effects of obesity on immediate post-TJA outcomes.

Ankle sprains are a common occurrence and are frequently either undertreated or overtreated. With the incidence estimated at more than 3 million a year and at a rate of 2.15/1,000 in the United States alone, this is an orthopaedic injury that providers should be acutely aware of and successfully able to evaluate and treat. This clinical feature will provide a thorough review of the mechanism of injury, the history and physical examination, and the classification and management of these injuries. Clinical red flags are discussed.

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