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American Journal of Sports Medicine
Journal Prestige (SJR): 3.949
Citation Impact (citeScore): 6
Number of Followers: 215  
  Hybrid Journal Hybrid journal (It can contain Open Access articles)
ISSN (Print) 0363-5465 - ISSN (Online) 1552-3365
Published by Sage Publications Homepage  [1089 journals]
  • Corrigendum to “Defining Variations in Outcomes of Hip Arthroscopy for
           Femoroacetabular Impingement Using the 12-Item International Hip Outcome
           Tool (iHOT-12)”
    • Abstract: The American Journal of Sports Medicine, Volume 48, Issue 7, Page NP44-NP44, June 2020.

      Citation: The American Journal of Sports Medicine
      PubDate: 2020-06-05T03:56:27Z
      DOI: 10.1177/0363546520929339
      Issue No: Vol. 48, No. 7 (2020)
  • Introducing the Lateral Femoral Condyle Index as a Risk Factor for
           Anterior Cruciate Ligament Injury: Response
    • Authors: Sandro Hodel
      Abstract: The American Journal of Sports Medicine, Volume 48, Issue 7, Page NP42-NP43, June 2020.

      Citation: The American Journal of Sports Medicine
      PubDate: 2020-06-05T03:55:03Z
      DOI: 10.1177/0363546520920538
      Issue No: Vol. 48, No. 7 (2020)
  • Introducing the Lateral Femoral Condyle Index as a Risk Factor for
           Anterior Cruciate Ligament Injury: Letter to the Editor
    • Authors: Ruibo Li, Yuehong Liu, Zhi Fang, Jianjun Zhang
      Abstract: The American Journal of Sports Medicine, Volume 48, Issue 7, Page NP42-NP42, June 2020.

      Citation: The American Journal of Sports Medicine
      PubDate: 2020-06-05T03:52:49Z
      DOI: 10.1177/0363546520920546
      Issue No: Vol. 48, No. 7 (2020)
  • Mental Health in Orthopaedic Sports Medicine: Consider Your Exposure
    • Authors: David C. Landy
      Pages: 1557 - 1558
      Abstract: The American Journal of Sports Medicine, Volume 48, Issue 7, Page 1557-1558, June 2020.

      Citation: The American Journal of Sports Medicine
      PubDate: 2020-06-05T03:56:07Z
      DOI: 10.1177/0363546520920272
      Issue No: Vol. 48, No. 7 (2020)
  • Society News
    • Pages: 1786 - 1786
      Abstract: The American Journal of Sports Medicine, Volume 48, Issue 7, Page 1786-1786, June 2020.

      Citation: The American Journal of Sports Medicine
      PubDate: 2020-06-05T03:56:37Z
      DOI: 10.1177/0363546520930185
      Issue No: Vol. 48, No. 7 (2020)
  • Osteochondritis Dissecans of the Knee: An Interrater Reliability Study of
           Magnetic Resonance Imaging Characteristics
    • Authors: Peter D. Fabricant, Matthew D. Milewski, Regina O. Kostyun, Eric J. Wall, Andrew M. Zbojniewicz, Jay C. Albright, Kathryn L. Bauer, James L. Carey, Henry G. Chambers, Eric W. Edmonds, Henry B. Ellis, Theodore J. Ganley, Daniel W. Green, Nathan L. Grimm, Benton E. Heyworth, Mininder S. Kocher, Aaron J. Krych, Roger M. Lyon, Stephanie W. Mayer, Jeffrey J. Nepple, Carl W. Nissen, Andrew T. Pennock, John D. Polousky, Paul Saluan, Kevin G. Shea, Marc A. Tompkins, Jennifer Weiss, S. Clifton Willimon, Philip L. Wilson, Rick W. Wright, Gregory D. Myer
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Imaging characteristics of osteochondritis dissecans (OCD) lesions quantified by magnetic resonance imaging (MRI) are often used to inform treatment and prognosis. However, the interrater reliability of clinician-driven MRI-based assessment of OCD lesions is not well documented.Purpose:To determine the interrater reliability of several historical and novel MRI-derived characteristics of OCD of the knee in children.Study Design:Cohort study (diagnosis); Level of evidence, 3Methods:A total of 42 OCD lesions were evaluated by 10 fellowship-trained orthopaedic surgeons using 31 different MRI characteristics, characterizing lesion size and location, condylar size, cartilage status, the interface between parent and progeny bone, and features of both the parent and the progeny bone. Interrater reliability was determined via intraclass correlation coefficients (ICCs) with 2-way random modeling, Fleiss kappa, or Krippendorff alpha as appropriate for each variable.Results:Raters were reliable when the lesion was measured in the coronal plane (ICC, 0.77). Almost perfect agreement was achieved for condylar size (ICC, 0.93), substantial agreement for physeal patency (ICC, 0.79), and moderate agreement for joint effusion (ICC, 0.56) and cartilage status (ICC, 0.50). Overall, raters showed significant variability regarding interface characteristics (ICC, 0.25), progeny (ICC range, 0.03 to 0.62), and parent bone measurements and qualities (ICC range, –0.02 to 0.65), with reliability being moderate at best for these measurements.Conclusion:This multicenter study determined the interrater reliability of MRI characteristics of OCD lesions in children. Although several measurements provided acceptable reliability, many MRI features of OCD that inform treatment decisions were unreliable. Further work will be needed to refine the unreliable characteristics and to assess the ability of those reliable characteristics to predict clinical lesion instability and prognosis.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-06-25T04:40:44Z
      DOI: 10.1177/0363546520930427
  • Biceps Tenodesis for Superior Labrum Anterior-Posterior Tear in the
           Overhead Athlete: A Systematic Review
    • Authors: Travis L. Frantz, Andrew G. Shacklett, Adam S. Martin, Jonathan D. Barlow, Grant L. Jones, Andrew S. Neviaser, Gregory L. Cvetanovich
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Superior labrum anterior-posterior (SLAP) lesion is a common shoulder injury, particularly in overhead athletes. While surgical management has traditionally consisted of SLAP repair, high rates of revision and complications have led to alternative techniques, such as biceps tenodesis (BT). While BT is commonly reserved for older nonoverhead athletes, indications for its use have expanded in recent years.Purpose:To determine functional outcomes and return-to-sport rates among overhead athletes after BT for SLAP tear.Study Design:Systematic review.Methods:A systematic review was performed for any articles published before July 2019. The search phrase “labral tear” was used to capture maximum results, followed by keyword inclusion of “SLAP tear” and “biceps tenodesis.” Inclusion criteria included outcome studies of BT for isolated SLAP tear in athletes participating in any overhead sports, not limited to throwing alone. Abstracts and manuscripts were independently reviewed to determine eligibility. When clearly delineated, outcome variables from multiple studies were combined.Results:After full review, 8 articles met inclusion criteria (99 athletes; mean age, 19.8-47 years), with baseball and softball players the most common among them (n = 62). Type II SLAP tear was the most common diagnosis, and 0% to 44% of athletes had a failed previous SLAP repair before undergoing BT. Only 1 study included patients with concomitant rotator cuff repair. Open subpectoral BT was most commonly used, and complication rates ranged from 0% to 14%, with wound erythema, traumatic biceps tendon rupture, brachial plexus neurapraxia, and adhesive capsulitis being reported. Combined reported postoperative functional scores were as follows: American Shoulder and Elbow Surgeons, 81.7 to 97; 12-Item Short Form Health Survey physical, 50 to 54; visual analog scale for pain, 0.8-1.5; Kerlan Jobe Orthopaedic Clinic, 66 to 79; and satisfaction, 80% to 87%. The overall return-to-sports rate for overhead athletes was 70% (60 of 86). For studies that clearly delineated outcomes based on level of play/athlete, the combined return-to-sports rate was 69% (11 of 16) for recreational overhead athletes, 80% (4 of 5) for competitive/collegiate athletes, and 60% (18 of 30) for professionals.Conclusion:BT in the overhead athlete offers encouraging functional outcomes and return-to-sports rates, particularly in the recreational athlete. It can be successfully performed as an index operation rather than SLAP repair, as well as in a younger patient population. Careful consideration should be given to elite overhead athletes, particularly pitchers, who tend to experience poorer outcomes.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-06-24T09:51:26Z
      DOI: 10.1177/0363546520921177
  • Radiological Identification of Injury to the Kaplan Fibers of the
           Iliotibial Band in Association With Anterior Cruciate Ligament Injury
    • Authors: Lachlan M. Batty, Jerome Murgier, Julian A. Feller, Richard O’Sullivan, Kate E. Webster, Brian M. Devitt
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Recent biomechanical studies have demonstrated that the Kaplan fibers (KFs) of the iliotibial band play a role in the control of anterolateral rotation of the knee. However, controversy exists regarding whether the KFs are injured in conjunction with anterior cruciate ligament (ACL) injury.Purpose:To establish the prevalence of radiological injury to the KFs in the ACL-injured knee; to evaluate the effect of the time interval between injury and magnetic resonance imaging (MRI) on diagnosis of KF injury; and to assess for any association between KF injury and other qualitative radiological findings.Study Design:Cohort study (diagnosis); Level of evidence, 3.Methods:Preoperative MRI scans were reviewed for 161 patients with ACL injury. Specific diagnostic criteria were developed and applied to identify KF injury. Chi-square testing was performed to look for associations among KF injury, the time from injury to MRI, and associated radiological knee injuries.Results:Radiological evidence of KF injury was identified in 30 (18.6%) patients. The diagnosis of KF injury was higher in patients who had MRI scans performed within 90 days of injury as compared with ≥90 days after injury (23.7 vs 6.4%; P = .010). Patients with an MRI diagnosis of KF injury had significantly higher rates of lateral meniscal injury (40% vs 18%; P = .007), posteromedial tibial bone marrow edema (73% vs 44%; P = .003), and injury to the lateral collateral ligament (13% vs 3%; P = .019) or medial collateral ligament (23% vs 8%; P = .019).Conclusion:The prevalence of injury to the KF in patients with ACL injury as diagnosed by MRI was relatively low (18.6% of patients). However, the time interval from injury to MRI was relevant to diagnosis, with significantly higher rates of injury identification in patients with early (within 90 days) versus delayed (≥90 days) MRI. KF injury was associated with higher rates of injury to the lateral meniscal and collateral ligaments, as well as posteromedial tibial bone bruising.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-06-24T05:24:14Z
      DOI: 10.1177/0363546520931854
  • Long-term Results of the Arthroscopic Bankart Repair for Recurrent
           Anterior Shoulder Instability in Patients Older Than 40 Years: A
           Comparison With the Open Latarjet Procedure
    • Authors: Lukas Ernstbrunner, Bianca De Nard, Maurits Olthof, Silvan Beeler, Samy Bouaicha, Christian Gerber, Karl Wieser
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Long-term results of the arthroscopic Bankart repair in patients older than 40 years are unknown and may be favorable in terms of postoperative glenohumeral arthritis as opposed to the long-term results of the open Latarjet procedure in patients older than 40 years.Purpose:To analyze our long-term results of the arthroscopic Bankart repair for recurrent anterior shoulder instability in patients older than 40 years of age and to compare these results with previously published long-term results of the Latarjet procedure in a cohort of similar age.Study Design:Cohort study; Level of evidence, 3.Methods:A total of 35 consecutive patients (36 shoulders) with a mean age of 47 years (range, 40-69) at time of the arthroscopic Bankart repair were studied at a mean 13.2 years (range, 8-18) after surgery. Clinical and radiographic results were then compared with those of our previous study of 39 consecutive patients (40 shoulders) of a same age group who had been treated for the same pathology with an open Latarjet procedure.Results:Six shoulders (17%) sustained a recurrent shoulder dislocation after a mean 5.3 years; subluxation occurred in 3 shoulders (8%); and apprehension persisted in 3 shoulders (8%). Revision surgery was performed in 8 patients (22%): 2 Bankart and 6 open Latarjet. The relative preoperative Constant score and Subjective Shoulder Value were significantly improved (P < .001) at final follow-up. Arthropathy of stabilization was advanced in the shoulders of 16 patients (47%) and had progressed by at least 2 grades in 21 patients (62%). There were significantly higher rates of redislocation and subluxation when compared with the open Latarjet procedure (9 vs 3; P = .037), and the mean final Subjective Shoulder Value was significantly lower in the Bankart group (86% vs 91%; P = .011). There were no significant differences in final advanced arthropathy (16 vs 14; P = .334) and revision rates (8 vs 7; P = .409) when compared with the Latarjet procedure.Conclusion:Arthroscopic Bankart repair for recurrent anterior shoulder instability in patients older than 40 years was associated with reliable pain relief and patient satisfaction similar to that after the open Latarjet procedure. Restoration of stability was significantly less successful and development of arthropathy no better than the open Latarjet procedure in patients older than 40 years.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-06-24T05:16:52Z
      DOI: 10.1177/0363546520931090
  • A Combination Treatment of Raloxifene and Vitamin D Enhances
           Bone-to-Tendon Healing of the Rotator Cuff in a Rat Model
    • Authors: Dong Min Kim, In Kyoung Shim, Myung Jin Shin, Jae Hee Choi, Yu Na Lee, In-Ho Jeon, Hyojune Kim, Dongjun Park, Erica Kholinne, Kyoung-Hwan Koh
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Tearing and degeneration of the rotator cuff at the tendon-to-bone junction are common in adults aged ≥50 years. Few studies have reported on the relationship between estrogen and the rotator cuff enthesis. In addition to preventing bone loss, selective estrogen receptor modulators have been shown to improve tendon and muscle quality.Purpose:To evaluate the effects of raloxifene (RLX) and vitamin D on rotator cuff tendon-to-bone healing in a rat model.Study Design:Controlled laboratory study.Methods:A total of 29 female rats (58 shoulders) were assigned to 4 groups: (1) control group, (2) ovariectomy (OVX)–only group, (3) no RLX group (OVX and rotator cuff repair [RCR]), and (4) RLX group (OVX, RCR, and RLX). Rats that did not undergo rotator cuff tear (RCT) surgery were divided into the control and OVX-only groups according to OVX surgery. Rats that underwent RCT surgery and RCR were divided into the no RLX and RLX groups according to RLX and vitamin D administration. An estrogen-deficient state was induced by OVX at 12 weeks of age. Bone mineral density (BMD) and trabecular bone characteristics were measured by micro–computed tomography, and healing of the tendon-to-bone junction was evaluated by biomechanical testing, histomorphometry, and micro–magnetic resonance imaging (MRI).Results:The mean final body weight (BW; 461.6 ± 47.3 g) of the OVX-only group was significantly higher and BMD (0.25 ± 0.07 g/cm3) was significantly lower (P < .001) than the mean final BW (338.5 ± 35.1 g) and BMD (0.48 ± 0.05 g/cm3) of the control group. In contrast, the RLX group showed that the BW (369.6 ± 35.8 g) and BMD (0.41 ± 0.08 g/cm3) were not significantly different from the control group. The RLX group had a significantly higher histomorphometric total score (8.50 ± 1.05) than the no RLX group (4.83 ± 2.48). On biomechanical testing, the RLX group (29.7 ± 9.1 N) showed a significantly higher load to failure than the no RLX group (19.4 ± 8.8 N). On micro-MRI, the RLX group had a more homogeneous low signal and tendon continuity than the no RLX group.Conclusion:The combination treatment of RLX and vitamin D prevented a decrease in local BMD (greater tuberosity of the proximal humerus) and enhanced tendon-to-bone healing of the rotator cuff in a rat model.Clinical Relevance:This study induced an estrogen-deficient state similar to the human postmenopausal state and used drugs that are actually being prescribed in a clinical situation.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-06-23T06:55:32Z
      DOI: 10.1177/0363546520927015
  • The Invisible MGHL Test: Diagnostic Value and Benefits for the Repair of
           Retracted Subscapularis Tears
    • Authors: Thomas Chauvet, Emil Haritinian, Florian Baudin, Philippe Collotte, Laurent Nové-Josserand
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Some full-thickness subscapularis tendon tears and partial tears of the deep layer are difficult to characterize, leading to misdiagnosis.Purpose:To evaluate the association between displacement of the middle glenohumeral ligament (MGHL) and retracted tears of the subscapularis tendon as a possible test to improve diagnosis.Study Design:Cross-sectional study; Level of evidence, 3.Methods:Videos (N = 100) recorded during arthroscopic rotator cuff repair involving a torn subscapularis tendon were analyzed retrospectively to assess the association between the MGHL test (nonvisibility of the MGHL) and other objective anatomic criteria. The invisible MGHL test was defined as positive if the MGHL was initially nonvisible in the beach-chair position and appeared only when the subscapularis tendon was pulled back into position by using a 30° arthroscope from the standard posterior portal. The parameters considered during the initial exploration were (1) visibility of the horizontal part of the subscapularis tendon; (2) visibility of the MGHL in its usual position, crossing the superior border of the subscapularis tendon; (3) exposure of the lateral border of the subscapularis tendon (full-thickness retracted tear); and (4) complete or partial exposure of the lesser tuberosity of the humerus. Tendon retraction was evaluated in 3 stages according to the Patte classification.Results:The invisible MGHL test result was positive in 45% of cases. It was positive in 6% of cases (2 of 31) when there was no subscapularis tendon retraction and in 62% of cases (43 of 69) when there was partial or complete retraction (P < .001). The invisible MGHL test was significantly associated with the width of the tear (P < .001) and exposure of the lateral border of the subscapularis tendon (full-thickness retracted tear, P = .0002). After repair, the MGHL was visible in its anatomic position in 96% of cases.Conclusion:A positive invisible MGHL test is an alternative indication of subscapularis tendon retraction, and the relocation of the MGHL can also be used after repair to assess the proper anatomic repositioning of the subscapularis tendon.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-06-18T07:53:24Z
      DOI: 10.1177/0363546520929695
  • Combined Correction of Tibial Torsion and Tibial Tuberosity–Trochlear
           Groove Distance by Supratuberositary Torsional Osteotomy of the Tibia
    • Authors: Lukas Jud, Sarvpreet Singh, Timo Tondelli, Philipp Fürnstahl, Sandro F. Fucentese, Lazaros Vlachopoulos
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Increased external tibial torsion and tibial tuberosity–trochlear groove distance (TTTG) affect patellofemoral instability and can be corrected by tibial rotational osteotomy and tibial tuberosity transfer. Thus far, less attention has been paid to the combined correction of tibial torsion and TTTG by supratuberositary osteotomy.Purpose:To quantify the effect of a supratuberositary torsional osteotomy on TTTG.Study Design:Descriptive laboratory study.Methods:Seven patients who underwent supratuberositary osteotomy to treat patellofemoral instability and an additional 13 patients with increased TTTG were included (N = 20). With 3-dimensional (3D) surface models, supratuberositary rotational osteotomies were simulated with predefined degrees of rotation. Concomitant 3D TTTG was measured by a novel and validated measurement method. In addition, all operated patients underwent 2-dimensional (2D) radiographic evaluation with pre- and postoperative computed tomography data. Absolute differences among simulated, predicted, and achieved postoperative corrections were compared.Results:A total of 500 supratuberositary osteotomies were simulated. The linear regression estimate yielded a change of −0.68 mm (95% CI, −0.72 to −0.63; P < .0001) in 3D TTTG per degree of tibial rotation, and 2D and 3D TTTG measurements in the operated patients were comparable in pre- and postoperative measurements (preoperative, 19.8 ± 2.5 mm and 20.0 ± 2.4 mm; postoperative, 13.6 ± 3.8 mm and 14.6 ± 3.4 mm, respectively). Postoperative 2D TTTG deviated in absolute terms from predicted (regression) and simulated TTTG by 1.4 ± 1.0 mm and 1.5 ± 0.6 mm. Inter- and intrarater reliability (intraclass correlation coefficient) for radiological and simulated measurements ranged between 0.883 and 0.996 and were almost perfect.Conclusion:In supratuberositary osteotomy, TTTG changes by −0.68 mm per degree of internal tibial rotation. The absolute mean difference between postoperative predicted TTTG and 2D TTTG was only 1.4 mm. Thus, TTTG correction can be successfully predicted by the degree of tibial rotation.Clinical Relevance:TTTG correction can be successfully predicted by the degree of tibial rotation. Therefore, in selected cases, tibial torsional deformity and TTTG can be corrected by 1 osteotomy. However, isolated rotations have been performed, and unintended translational movements during tibial rotation may alter the postoperative results.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-06-18T07:34:19Z
      DOI: 10.1177/0363546520929687
  • Does Concomitant Lumbar Spine Disease Adversely Affect the Outcomes of
           Patients Undergoing Hip Arthroscopy'
    • Authors: Jonathan D. Haskel, Samuel L. Baron, Mikhail Zusmanovich, Thomas Youm
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:The practice of hip arthroscopy is increasing in popularity, which has highlighted the importance of identifying risk factors that predict hip arthroscopy outcomes. The literature suggests that lumbar spine disease is an independent risk factor for poorer outcomes following total hip arthroplasty; however, the effect of lumbar spine disease on hip arthroscopy outcomes has not been fully investigated. At present, there is a paucity of literature investigating the effect of coexisting hip and lumbar spine disease on outcomes after hip arthroscopy.Purpose:To evaluate the outcomes of hip arthroscopy in patients with concomitant lumbar spine disease compared with those without a history of lumbar spine disease.Study Design:Cohort study; Level of evidence, 3.Methods:A retrospective review of a prospectively collected, single-surgeon database was performed to identify patients who underwent hip arthroscopy with subjective and objective evidence of lumbar disease. Patients were included if they were skeletally mature; had hip disease that failed nonoperative treatment; had symptoms of low back pain, lumbar radiculopathy, or lumbar stenosis at the time of surgery; and had advanced imaging of the lumbar spine (computed tomography or magnetic resonance imaging) confirming lumbar spine disease. Patients were excluded if they had any previous hip surgery or evidence of osteoarthritis of Tönnis grade 2 or higher. The hip-spine cohort was matched by age, sex, and body mass index in a 1:3 fashion to a control cohort consisting of patients without symptoms of low back pain, lumbar radiculopathy, or lumbar stenosis at the time of surgery or a history of lumbar spine disease who underwent hip arthroscopy over the same time period. Baseline preoperative modified Harris Hip Score (mHHS) and Non-Arthritic Hip Score (NAHS) were compared with scores at 3-, 6-, 12-, and 24-month follow-up, and rates of revision arthroscopy or total hip arthroplasty were assessed. Statistical analysis was performed with the Student t test.Results:A total of 38 patients with radiographically confirmed lumbar disease were matched with 111 control patients. Preoperative mHHS and NAHS were significantly lower in the hip-spine cohort (P = .01 and P = .02, respectively); however, no significant differences were found in mHHS or NAHS between the cohorts at 3, 6, 12, and 24 months postoperatively. A 89.8% increase in mHHS was found in the hip-spine cohort, compared with a 74.4% increase in the control cohort (P = .0475). No significant differences in the rates of revision or total hip arthroplasty conversion were identified between the hip-spine and control cohorts (23.7% vs 18.0%, respectively; P = .44).Conclusion:Patients with known lumbar spine disease who underwent hip arthroscopy had a significantly greater percentage improvement at 24-month follow-up compared with those without a history of lumbar spine disease, and outcomes were ultimately not significantly different. No increased risk of reoperation was noted in patients with concomitant lumbar spine disease.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-06-18T07:28:38Z
      DOI: 10.1177/0363546520929344
  • Maximum Bridging Suture Tension Provides Better Clinical Outcomes in
           Transosseous-Equivalent Rotator Cuff Repair: A Clinical, Prospective
           Randomized Comparative Study
    • Authors: Joo Han Oh, Ji Soon Park, Sung-Min Rhee, Joo Hyun Park
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Some studies reporting clinical outcomes after transosseous-equivalent (TOE) repair have attributed type II rotator cuff failure to excessive bridging suture tension, as it can cause overloading on the medial row. In a previous biomechanical cadaveric study, increasing bridging suture tension over 90 N did not improve the contact area and ultimate failure load of the TOE construct, despite increasing the contact force and contact pressure.Purpose:To compare the clinical outcomes of different bridging suture tensions after TOE rotator cuff repair based on the results of a previous biomechanical study.Study Design:Randomized controlled trial; Level of evidence, 2.Methods:A total of 78 patients who underwent arthroscopic rotator cuff repair for medium- to large-sized tears were prospectively enrolled and randomly divided into 2 groups according to the applied bridging suture tension: optimum tension group (96.3 ± 4.9 N) and maximum tension group (199.0 ± 20.3 N). Bridging suture tension was measured with a customized tensiometer, as used in the previous biomechanical study. The functional outcome was measured at the final follow-up (27.4 ± 5.9 months [range, 24-45 months]) using the visual analog scale for pain, American Shoulder and Elbow Surgeons score, Simple Shoulder Test, and Constant score, and the anatomic outcome was evaluated using magnetic resonance imaging or ultrasonography at least 12 months after surgery.Results:Overall, 64 patients (32 in each group) were analyzed. The functional outcomes improved significantly compared with preoperative values (all P < .05) but did not show significant differences between the 2 groups (all P> .05). Regarding the anatomic outcomes, the maximum tension group (n = 1; 3.1%) had a significantly lower healing failure rate than the optimum tension group (n = 9; 28.1%) (P = .013). One patient in the maximum tension group had a type II failure.Conclusion:Maximum bridging suture tension in TOE repair for medium- to large-sized rotator cuff tears provided better anatomic healing with less risk of medial rotator cuff failure, which differs from the results of a previous time-zero biomechanical study.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-06-18T07:21:58Z
      DOI: 10.1177/0363546520930425
  • Comparison of Patellofemoral Kinematics and Stability After Medial
           Patellofemoral Ligament and Medial Quadriceps Tendon–Femoral Ligament
    • Authors: Robert Spang, Jonathan Egan, Philip Hanna, Aron Lechtig, Daniel Haber, Joseph P. DeAngelis, Ara Nazarian, Arun J. Ramappa
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:There is a lack of evidence regarding the optimum extensor-sided fixation method for medial patellofemoral ligament (MPFL) reconstruction. There is increased interest in avoiding patellar drilling via soft tissue–only fixation to the distal quadriceps, thus reconstructing the medial quadriceps tendon–femoral ligament (MQTFL). The biomechanical implications of differing extensor-sided fixation constructs remain unknown.Hypothesis:The null hypothesis was there would be no differences between traditional MPFL reconstruction and MQTFL reconstruction with respect to resistance to lateral translation, patellar position, or patellofemoral contact pressures.Study Design:Controlled laboratory study.Methods:Nine adult knee specimens were mounted on a jig that applied static, physiologic loads to the quadriceps tendons. Patellar position and orientation, knee flexion angle, and patellofemoral pressure were recorded at 8 different flexion angles between 0° and 110°. Additionally, a lateral patellar excursion test was conducted wherein a load was applied directly to the patella in the lateral direction with the knee at 30° of flexion and subjected to 2-N quadriceps loads. Testing was conducted under 4 conditions: intact, transected MPFL, MQTFL reconstruction, and MPFL reconstruction. For MQTFL reconstruction, the surgical technique established by Fulkerson was employed. For MPFL reconstruction, a traditional technique was utilized.Results:The patellar excursion test showed no significant difference between the MQTFL and intact states with respect to lateral translation. MPFL reconstruction led to significantly less lateral translation (P < .05) than all other states. There were no significant differences between MPFL and MQTFL reconstructions with respect to peak patellofemoral contact pressure. MPFL and MQTFL reconstructions both resulted in increased internal rotation of the patella with the knee in full extension.Conclusion:Soft tissue-only extensor-sided fixation to the distal quadriceps (MQTFL) during patella stabilization appears to re-create native stability in this time 0 cadaver model. Fixation to the patella (MPFL) was associated with increased resistance to lateral translation.Clinical Relevance:Evolving anatomic knowledge and concern for patellar fracture has led to increased interest in MQTFL reconstruction. Both MQTFL and MPFL reconstructions restored patellofemoral stability to lateral translation without increasing contact pressures under appropriate graft tensioning, with MQTFL more closely restoring native resistance to lateral translation at the time of surgery.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-06-18T07:09:58Z
      DOI: 10.1177/0363546520930703
  • Exosomes Isolated From Platelet-Rich Plasma and Mesenchymal Stem Cells
           Promote Recovery of Function After Muscle Injury
    • Authors: Shama R. Iyer, Amanda L. Scheiber, Paul Yarowsky, R. Frank Henn, Satoru Otsuru, Richard M. Lovering
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Clinical use of platelet-rich plasma (PRP) and mesenchymal stem cells (MSCs) has gained momentum as treatment for muscle injuries. Exosomes, or small cell–derived vesicles, could be helpful if they could deliver the same or better physiological effect without cell transplantation into the muscle.Hypothesis:Local delivery of exosomes derived from PRP (PRP-exos) or MSCs (MSC-exos) to injured muscles hastens recovery of contractile function.Study Design:Controlled laboratory study.Methods:In a rat model, platelets were isolated from blood, and MSCs were isolated from bone marrow and expanded in culture; exosomes from both were isolated through ultracentrifugation. The tibialis anterior muscles were injured in vivo using maximal lengthening contractions. Muscles were injected with PRP-exos or MSC-exos (immediately after injury and 5 and 10 days after injury); controls received an equal volume of saline. Histological and biochemical analysis was performed on tissues for all groups.Results:Injury resulted in a significant loss of maximal isometric torque (66% ± 3%) that gradually recovered over 2 weeks. Both PRP-exos and MSC-exos accelerated recovery, with similar faster recovery of contractile function over the saline-treated group at 5, 10, and 15 days after injury (P < .001). A significant increase in centrally nucleated fibers was seen with both types of exosome groups by day 15 (P < .01). Genes involved in skeletal muscle regeneration were modulated by different exosomes. Muscles treated with PRP-exos had increased expression of Myogenin gene (P < .05), whereas muscles treated with MSC-exos had reduced expression of TGF-β (P < .05) at 10 days after muscle injury.Conclusion:Exosomes derived from PRP or MSCs can facilitate recovery after a muscle strain injury in a small-animal model likely because of factors that can modulate inflammation, fibrosis, and myogenesis.Clinical Relevance:Given their small size, low immunogenicity, and ease with which they can be obtained, exosomes could represent a novel therapy for many orthopaedic ailments.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-06-16T06:31:38Z
      DOI: 10.1177/0363546520926462
  • Zoledronic Acid Substantially Improves Bone Microarchitecture and
           Biomechanical Properties After Rotator Cuff Repair in a Rodent Chronic
           Defect Model
    • Authors: Jakob E. Schanda, Claudia Keibl, Patrick Heimel, Xavier Monforte, Stefan Tangl, Xaver Feichtinger, Andreas H. Teuschl, Andreas Baierl, Christian Muschitz, Heinz Redl, Christian Fialka, Rainer Mittermayr
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Bone mineral density at the humeral head is reduced in patients with chronic rotator cuff tears. Bone loss in the humeral head is associated with repair failure after rotator cuff reconstruction. Bisphosphonates (eg, zoledronic acid) increase bone mineral density.Hypothesis:Zoledronic acid improves bone mineral density of the humeral head and biomechanical properties of the enthesis after reconstruction of chronic rotator cuff tears in rats.Study Design:Controlled laboratory study.Methods:A total of 32 male Sprague-Dawley rats underwent unilateral (left) supraspinatus tenotomy with delayed transosseous rotator cuff reconstruction after 3 weeks. All rats were sacrificed 8 weeks after rotator cuff repair. Animals were randomly assigned to 1 of 2 groups. At 1 day after rotator cuff reconstruction, the intervention group was treated with a single subcutaneous dose of zoledronic acid at 100 µg/kg bodyweight, and the control group received 1 mL of subcutaneous saline solution. In 12 animals of each group, micro–computed tomography scans of both shoulders were performed as well as biomechanical testing of the supraspinatus enthesis of both sides. In 4 animals of each group, histological analyses were conducted.Results:In the intervention group, bone volume fraction (bone volume/total volume [BV/TV]) of the operated side was higher at the lateral humeral head (P = .005) and the medial humeral head (P = .010) compared with the control group. Trabecular number on the operated side was higher at the lateral humeral head (P = .004) and the medial humeral head (P = .001) in the intervention group. Maximum load to failure rates on the operated side were higher in the intervention group (P < .001). Cortical thickness positively correlated with higher maximum load to failure rates in the intervention group (r = 0.69; P = .026). Histological assessment revealed increased bone formation in the intervention group.Conclusion:Single-dose therapy of zoledronic acid provided an improvement of bone microarchitecture at the humeral head as well as an increase of maximum load to failure rates after transosseous reconstruction of chronic rotator cuff lesions in rats.Clinical Relevance:Zoledronic acid improves bone microarchitecture as well as biomechanical properties after reconstruction of chronic rotator cuff tears in rodents. These results need to be verified in clinical investigations.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-06-16T05:01:06Z
      DOI: 10.1177/0363546520926471
  • Scapular Morphologic Characteristics and Rotator Cuff Tear Pattern Are
           Independently Associated With Chronic Pseudoparalyis: A Matched-Pair
           Analysis of Patients With Massive Rotator Cuff Tears
    • Authors: Lukas Ernstbrunner, Rany El Nashar, Samy Bouaicha, Karl Wieser, Christian Gerber
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:It is unclear which structural parameters determine the development or the absence of chronic pseudoparalysis (PP) in patients with massive rotator cuff tears (mRCTs).Purpose:To determine whether scapular morphologic characteristics and extent of rotator cuff tearing are independent factors associated with chronic PP.Study Design:Case-control study; Level of evidence, 3.Methods:In this retrospective case-control study, 50 patients with chronic mRCT (≥2 fully detached tendons) and active scapular plane abduction less than 90° (PP group) were age- and sex-matched with a cohort of 50 patients with chronic mRCT and an active scapular plane abduction greater than 90° (non-PP; NPP group). Analysis of standardized, plain radiographs included measurement of the critical shoulder angle (CSA) and the acromiohumeral distance (ACHD) on anteroposterior views and measurement of posterior acromial tilt, anterior and posterior acromial coverage, and posterior acromial height on standardized outlet views. Measurements on magnetic resonance imaging included fatty muscle infiltration, anterior (subscapularis) and posterior (infraspinatus/teres minor) tear extension, and global tear extension (anterior + posterior tear extension) in the parasagittal plane.Results:Overall, no significant difference was found in patients’ demographic characteristics (P> .05). Univariate analyses confirmed significant differences between the PP and NPP groups in active scapular plane abduction (51°± 22° vs 135°± 29°; P < .001). Multivariate analyses revealed independent factors associated with PP compared with the NPP group: CSA (38.2°± 4.6° vs 35.2°± 3.7°; P = .001); ACHD (4.7 ± 2.2 vs 7.3 ± 2.6 mm; P < .001); posterior acromial height (22 ± 10 vs 17 ± 7 mm; P = .005); and anterior (–9°± 21° vs 25°± 12°; P < .001) and posterior (–18°± 14° vs 2°± 14°; P < .001) tear extension. The NPP group had significantly less involvement and fatty infiltration of the subscapularis (1.4 ± 0.6) compared with the PP group (2.2 ± 0.9) (P < .001).Conclusion:This study confirms that global RCT extension and the quality of the inferior half of the subscapularis are significantly associated with chronic pseudoparalysis. The study further shows that acromial morphologic characteristics are relevant in the development of pseudoparalysis. Patients with pseudoparalysis have a larger CSA, less ACHD, and a higher positioned acromion in the sagittal plane.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-06-16T04:49:43Z
      DOI: 10.1177/0363546520929353
  • Are the Classic and the Congruent Arc Latarjet Procedures Equally
           Effective for the Treatment of Recurrent Shoulder Instability in
    • Authors: Luciano A. Rossi, Ignacio Tanoira, Tomás Gorodischer, Ignacio Pasqualini, Domingo Luis Muscolo, Maximiliano Ranalletta
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:There is a lack of evidence in the literature comparing outcomes between the classic and the congruent arc Latarjet procedures in athletes.Purpose:To compare return to sports, functional outcomes, and complications between the classic and the congruent arc Latarjet procedures in athletes with recurrent glenohumeral instability.Study Design:Cohort study; Level of evidence, 3.Methods:Between June 2009 and June 2017, 145 athletes with recurrent anterior glenohumeral instability underwent surgery with the Latarjet as a primary procedure in our institution. The classic procedure was used in 66 patients, and the congruent arc method was used in 79 patients. Return to sports, range of motion (ROM), the Rowe score, a visual analog scale (VAS) for pain in sports activity, and the Athletic Shoulder Outcome Scoring System (ASOSS) were used to assess functional outcomes. Recurrences were also evaluated. The postoperative bone block position and consolidation were assessed with computed tomography.Results:In the total population, the mean follow-up was 41.3 months (range, 24-90 months) and the mean age was 25.3 years (range, 18-45 years). In total, 90% of patients were able to return to sports; of these, 91% returned at their preinjury level of play. No significant difference in shoulder ROM was found between preoperative and postoperative results. The Rowe, VAS, and ASOSS scores showed statistical improvement after operation (P < .001). The Rowe score increased from a preoperative mean of 42.8 points to a postoperative mean of 95.2 points (P < .01). Subjective pain during sports improved from 3.2 points preoperatively to 0.7 points at last follow-up (P < .01). The ASOSS score improved significantly from a preoperative mean of 46.4 points to a postoperative mean of 88.4 points (P < .01). No significant differences in shoulder ROM and functional scores were found between patients who received the classic vs congruent arc procedures. There were 5 recurrences (3.5%): 3 dislocations (2%) and 2 subluxations (1%). No significant difference in the recurrence rate was noted between groups. The bone block healed in 134 cases (92%).Conclusion:In athletes with recurrent anterior glenohumeral instability, the Latarjet procedure produced excellent functional outcomes. Most athletes returned to sports at their preinjury level, and the rate of recurrence was very low, regardless of whether the patients received surgery with the classic or congruent arc technique.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-06-16T04:44:05Z
      DOI: 10.1177/0363546520928343
  • Long-Term Follow-up of Skeletally Immature Patients With Physeal-Sparing
           Combined Extra-/Intra-articular Iliotibial Band Anterior Cruciate Ligament
           Reconstruction: A 3-Dimensional Motion Analysis
    • Authors: Dai Sugimoto, Amy J. Whited, Jeff J. Brodeur, Elizabeth S. Liotta, Kathryn A. Williams, Mininder S. Kocher, Lyle J. Micheli, Benton E. Heyworth
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:The physeal-sparing iliotibial band (ITB) anterior cruciate ligament (ACL) reconstruction (ACLR) is a well-established technique for treating skeletally immature patients with ACL rupture. However, the long-term implications of the procedure on the intricacies of kinetic and kinematic function of the knee have not been comprehensively investigated.Purpose:To assess the short-, mid-, and long-term effects of ITB ACLR on kinetic and kinematic parameters of knee functions.Study Design:Case series; Level of evidence, 4.Methods:A total of 38 patients who had undergone an ITB ACLR as a skeletally immature child were recruited to participate in a 3-dimensional (3D) motion analysis testing protocol at an institutional injury prevention center between 1 and 20 years after reconstruction. Exclusion criteria were congenital ACL deficiency and any other major knee injury (defined as an injury requiring surgery or rehabilitation>3 months) on either knee. 3D and force plate parameters included in the analysis were knee moment, ground-reaction force, and vertical jump height measured during drop vertical jump and vertical single-limb hop. Paired t tests and equivalency analyses were used to compare the parameters between cases (ITB ACLR limb) and controls (contralateral/nonsurgical limbs).Results:Paired t tests showed no statistically significant differences between limbs, and equivalency analyses confirmed equivalency between limbs for all tested outcome variables.Conclusion:The ITB ACLR appears to restore normal, symmetric, physiologic kinetic and kinematic function in the growing knee by 1 year after reconstruction, with maintenance of normal parameters for up to 20 years.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-06-10T12:29:40Z
      DOI: 10.1177/0363546520927399
  • Lateral Center-Edge Angle Is Not Predictive of Acetabular Articular
           Cartilage Surface Area: Anatomic Variation of the Lunate Fossa
    • Authors: Thai Q. Trinh, Michael Leunig, Christopher M. Larson, John Clohisy, Jeff Nepple, Ira Zaltz, Bryan T. Kelly, Micah B. Naimark, Asheesh Bedi
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Surgical treatment of symptomatic femoroacetabular impingement (FAI) and dysplasia requires careful characterization of acetabular morphology. The lateral center-edge angle (LCEA) is often used to assess lateral acetabular anatomy. Previous work has questioned the LCEA as a surrogate for acetabular contact/articular cartilage surface area because of the variable morphology of the lunate fossa.Hypothesis:We hypothesized that weightbearing articular cartilage of the acetabulum would poorly correlate with LCEA secondary to significant variation in the size of the lunate fossa.Study Design:Cohort study (Diagnosis); Level of evidence, 3.Methods:Patients with 3D CT imaging undergoing either hip arthroscopy or periacetabular osteotomy for FAI or symptomatic hip instability were retrospectively identified. The LCEA and femoral head diameter were measured on an anteroposterior pelvis radiograph. Patients were grouped according to their lateral acetabular coverage as undercoverage (LCEA, 40°). Patients were randomly identified until each group contained 20 patients. The articular surface area was measured from preoperative 3D CT data. Linear regression analysis was performed to examine the relationship between articular surface area and LCEA. Continuous and categorical data were analyzed utilizing analysis of variance and chi-square analysis. Statistical significance was set at P < .05.Results:No difference in age (P = .52), body mass index (BMI) (P = .75), or femoral head diameter (P = .66) was noted between groups. A significant difference in articular surface area was observed between patients with undercoverage and those with overcoverage (20.4 cm2 vs 24.5 cm2; P = .01). No significant difference was identified between the undercoverage and normal groups (20.4 cm2 vs 23.3 cm2; P = .09) or the normal and overcoverage groups (23.3 cm2 vs 24.5 cm2; P = .63). A moderate positive correlation was observed between LCEA and articular surface area across all patients (r = 0.38; P = .002) but not when patients with undercoverage were excluded (r = 0.02; P = .88). Significant variation in surface area was observed within each group such that no patient in any group was outside of 2 SDs of the means of the other groups. When patients were categorized into quartiles established by the articular surface area for the entire population, 40% of patients with overcoverage were observed in the first or second quartile (lower area).Conclusion:Lateral acetabular undercoverage based on the LCEA (25°), however, is not predictive of increased, normal, or decreased acetabular surface area.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-06-10T05:31:10Z
      DOI: 10.1177/0363546520924038
  • Better Clinicoradiological Results of BST-CarGel Treatment in Cartilage
           Repair Compared With Microfracture in Acetabular Chondral Defects at 2
    • Authors: Rakesh John, Jie Ma, Ivan Wong
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:BST-CarGel (CarGel) is an injectable chitosan scaffold that is mixed with fresh, autologous blood and injected into the site of microfracture (MF) to physically stabilize clots and enhance cartilage repair.Purpose:To evaluate short-term clinicoradiological outcomes of patients treated arthroscopically for acetabular chondral defects with CarGel in conjunction with MF compared with those treated with MF alone.Study Design:Cohort study; Level of evidence, 3.Methods:All patients who underwent hip arthroscopy and received MF with or without CarGel for acetabular chondral defects between 2014 and 2018 with a minimum 2-year clinicoradiological follow-up were included. Intraoperative details, postoperative complications, and clinical outcome scores, including the international Hip Outcome Tool–33 (iHOT-33), Hip Outcome Score (HOS)–Activities of Daily Living (HOS-ADL), and Hip Outcome Score–Sports Profile, were analyzed. Serial plain radiographs were assessed independently by 2 blinded observers. A survival analysis was performed to identify the number of cases converted to total hip arthroplasty (THA) in both groups, which was correlated with the cartilage defect size at the time of surgery.Results:Eighty patients (54 CarGel and 26 MF) were evaluated, including 56 men (70%) and 48 right hips (60%). Three patients were lost to follow-up. There were no major adverse events in either group. The average defect size was 3.63 and 4.97 cm2 in MF and CarGel, respectively (P = .002). There was a statistically significant improvement in iHOT-33 (from 43.24 to 60.17 in MF and from 41.13 to 58.39 in CarGel) and HOS-ADL (from 62.25 to 76.75 in MF and from 44.69 to 79.16 in CarGel) scores. There was no difference between the 2 groups in the outcome scores after adjusting for covariates. Survival analysis showed 34.6% of MF cases and 5.9% of CarGel cases were converted to THA (P = .001). The mean defect size of the failure group was higher in CarGel than in MF (8.83 and 3.72 cm2, respectively). Mean joint space reduction was 1.41 mm in MF and 0.19 mm in CarGel (P < .001).Conclusion:Two-year clinicoradiological results were promising in these lesions that are difficult to treat. Arthroscopic treatment of chondral acetabular defects with CarGel demonstrated a significant decrease in progressive loss of joint space and conversion to THA compared with MF as an isolated procedure.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-06-10T04:57:34Z
      DOI: 10.1177/0363546520924841
  • In Memoriam: Hua Feng, MD
    • Abstract: The American Journal of Sports Medicine, Ahead of Print.

      Citation: The American Journal of Sports Medicine
      PubDate: 2020-06-10T04:45:47Z
      DOI: 10.1177/0363546520935088
  • Graft-Preserving Arthroscopic Debridement With Hardware Removal Is
           Effective for Septic Arthritis After Anterior Cruciate Ligament
           Reconstruction: A Clinical, Arthrometric, and Magnetic Resonance Imaging
    • Authors: Mirco Lo Presti, Giuseppe Gianluca Costa, Alberto Grassi, Sergio Cialdella, Giuseppe Agrò, Maurizio Busacca, Maria Pia Neri, Giuseppe Filardo, Stefano Zaffagnini
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Arthroscopic debridement with graft preservation has been advocated as the treatment of choice for septic arthritis after anterior cruciate ligament (ACL) reconstruction, but no previous studies have investigated if hardware removal, while retaining the graft in situ, improves the success rate. Moreover, it is unclear whether the premature removal of fixation devices may affect graft integration and knee stability.Purpose/Hypothesis:The purpose was to assess the clinical and functional outcomes of patients with septic arthritis after ACL reconstruction who underwent arthroscopic debridement, while retaining the graft in situ but removing fixation devices, and to determine if premature hardware removal affects graft integrity and function. The hypothesis was that arthroscopic debridement with hardware removal would be effective in eradicating infections while not compromising graft integration and function.Study Design:Case series; Level of evidence, 4.Methods:From a cohort of 2384 cases of arthroscopic ACL reconstruction, 24 patients with postoperative septic arthritis were included for the analysis; 18 patients were available for a clinical evaluation using the International Knee Documentation Committee (IKDC) form, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Lysholm score, and Tegner score at a minimum 12-month follow-up. Knee laxity was assessed clinically with standardized manual laxity tests and instrumentally using an arthrometer and a triaxial accelerometer. Additionally, 3-T magnetic resonance imaging (MRI) at final follow-up was performed, focusing on the graft signal, the cartilage status, and the occurrence of arthrofibrosis.Results:Eradication of the infection was achieved in all cases, and only 1 graft removal was performed because of insufficient tension. Among the remaining 23 patients, a single arthroscopic debridement procedure with hardware removal while preserving the graft was effective in 21 cases (91%) at a mean of 30 ± 37 days from ACL reconstruction to debridement. At last follow-up, 2 patients required a further ACL revision procedure. The mean IKDC, WOMAC, Lysholm, and Tegner scores of the patients available for the clinical evaluation were 75 ± 19, 90 ± 8, 79 ± 21, and 6 ± 2, respectively. No abnormal laxity was reported on manual testing, and arthrometric and accelerometer tests also demonstrated good knee stability (mean KT-1000 arthrometer side-to-side difference was 1.6 ± 1.2 mm at manual maximum force). On MRI, a good graft signal was found in 50% of cases, while concomitant signs of arthrofibrosis were detected in 81% of patients. Severe cartilage defects (International Cartilage Repair Society grade ≥3) were reported in 63% of cases.Conclusion:Arthroscopic debridement with hardware removal was effective in the eradication of infections after ACL reconstruction with extra-articular fixation while preserving graft integrity without compromising knee stability. Patients and surgeons should be aware of complications that might affect the outcome, particularly arthrofibrosis and chondrolysis.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-06-10T04:42:52Z
      DOI: 10.1177/0363546520924823
  • Intra-articular Injection of Pure Platelet-Rich Plasma Is the Most
           Effective Treatment for Joint Pain by Modulating Synovial Inflammation and
           Calcitonin Gene-Related Peptide Expression in a Rat Arthritis Model
    • Authors: Naoko Araya, Kazumasa Miyatake, Kunikazu Tsuji, Hiroki Katagiri, Yusuke Nakagawa, Takashi Hoshino, Hiroaki Onuma, Saisei An, Hirofumi Nishio, Yoshitomo Saita, Ichiro Sekiya, Hideyuki Koga
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Platelet-rich plasma (PRP) has emerged as a treatment for osteoarthritis (OA). However, the effect that leukocyte concentrations in PRP have on OA remains unclear.Purpose:To clarify the optimal PRP formulation for OA treatment by comparing pure PRP, leukocyte-poor PRP (LP-PRP), and leukocyte-rich PRP (LR-PRP) in a rat arthritis model.Study Design:Controlled laboratory study.Methods:Knee arthritis was induced bilaterally in male Wistar rats with intra-articular injections of monosodium iodoacetate (MIA) on day 0. Rats were randomly assigned to 1 of 3 treatment groups (pure PRP, LP-PRP, and LR-PRP). On day 1, allogenic PRP was injected into the right knee of rats and phosphate-buffered saline was injected into the left knee as a control. Weight distribution on the hindlimbs was measured for 14 days to assess pain behavior. Rats were euthanized at day 5 or 14 for histological assessment of synovial tissue and cartilage. Immunohistochemical staining of calcitonin gene-related peptide (CGRP) and α-smooth muscle actin was performed to determine the mechanism of pain relief induced by the PRP preparations.Results:In all groups, PRP increased the load-sharing ratio on PRP-injected knees, with pure PRP eliciting the largest effect among the 3 kinds of PRP (P < .05). Structural changes in the synovial tissue were significantly inhibited in the pure-PRP group compared with the control group after both 5 and 14 days (P < .001 and P = .025, respectively), whereas no significant difference was found between the control, LP-PRP, and LR-PRP groups. An inhibitory effect on cartilage degeneration was observed only in the pure-PRP group on day 14. Pure PRP also significantly inhibited expression of CGRP-positive nerve fibers in the infrapatellar fat pad compared with the other groups (P < .05).Conclusion:In an MIA-induced arthritis model, pure PRP injection was the most effective treatment for reduction of pain-related behavior and inhibition of synovial inflammation and pain sensitization.Clinical Relevance:PRP formulations should be optimized for each specific disease. This study shows the superiority of pure PRP for treatment of arthritis and joint pain.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-06-10T03:55:32Z
      DOI: 10.1177/0363546520924011
  • Comparing the Responsiveness of the Global Rating Scale With Legacy Knee
           Outcome Scores: A Delaware-Oslo Cohort Study
    • Authors: Jessica L. Johnson, James J. Irrgang, May Arna Risberg, Lynn Snyder-Mackler
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:The selection of patient-reported outcome measures (PROMs) is essential for obtaining meaningful information to treat a patient, determine a plan of care, and make clinical decisions; however, the process of selecting PROMs for clinical care is difficult, with the need to balance these multiple factors. Variation makes it difficult to compare data across providers and studies.Hypothesis/Purpose:The purpose was to determine the responsiveness of 4 PROMs via effect size and the presence of a ceiling effect in the 5 years after anterior cruciate ligament reconstruction (ACLR). We hypothesized that the single-item Global Rating Scale (GRS) would have an effect size and ceiling effect similar to the commonly used legacy PROMs.Study Design:Cohort study (diagnosis); Level of evidence, 2.Methods:Of the 300 participants, 218 had ACLR, completed postoperative progressive criterion-based rehabilitation early after surgery, and were followed for 5 years. We collected data based on the GRS, the Knee Outcome Survey–Activities of Daily Living Scale (KOS-ADLS), the International Knee Documentation Committee–Subjective Knee Form (IKDC-SKF), and the KOOS (Knee injury and Osteoarthritis Outcome Score) before and after training and at 6, 12, 24, and 60 months after ACLR.Results:The IKDC-SKF had the largest effect sizes and lowest ceiling effects. The GRS had a similar size and change in both effect size and ceiling effect when compared with the longer PROMs. The GRS and IKDC-SKF had a correlation of 0.72, and the GRS had a minimal detectable change of 2.9 or 4.8, depending on methodology.Conclusion:The GRS responded similarly to the IKDC-SKF, KOS-ADLS, and KOOS and was responsive to patient change. The ease of use and patient-specific nature of the question means that it may be appropriate to use the GRS in clinical care as a consistent measure throughout the course of rehabilitation.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-06-09T06:21:04Z
      DOI: 10.1177/0363546520924817
  • Influence of Glenoid Labral Bumper Height and Capsular Volume on Clinical
           Outcomes After Arthroscopic Bankart Repair as Assessed With Serial CT
           Arthrogram: Can Anterior-Inferior Volume Fraction Be a Prognostic
    • Authors: Seung-Jun Lee, Jung-Han Kim, Heui-Chul Gwak, Chang-Wan Kim, Chang-Rack Lee, Soo-Hwan Jung, Chung-Il Kwon
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Arthroscopic labral repair combined with capsular plication decreases joint volume and restores glenoid labral bumper height; thus, the procedure helps decrease capsular redundancy. However, the decreased volume and restored glenoid labral bumper height could change over time, which could influence the outcome of the operation.Purpose:To (1) measure glenoid labral bumper height and capsular volume quantitatively in serial computed tomography arthrography (CTA) and evaluate the relationship between bumper height and joint volume and (2) compare the difference in bumper height and joint volume between groups with and without apprehension after arthroscopic Bankart repair.Study Design:Case-control study; Level of evidence, 3.Methods:Patients who had undergone arthroscopic Bankart repair between January 2012 and June 2016, and were assessed by CTA 3 to 6 months and 12 to 18 months after the operation were included. An image reconstruction program (3-dimensional slicer) was used to calculate inferior, anterior-inferior, and posterior-inferior joint volumes; the ratio of the anterior-inferior volume to the inferior volume was defined as the anterior-inferior volume fraction (VFAI). We also measured glenoid labral bumper height at the 5-, 4-, and 3-o’clock positions.Results:A total of 50 patients were enrolled as study participants (mean age, 25.2 ± 9.29 years). Of these, 10 patients had either redislocation or apprehension, and 40 patients had neither. A significant correlation was observed between 5-o’clock glenoid labral bumper height and VFAI on early CTA (3-6 months) and late CTA (12-18 months) (early CTA: Pearson coefficient, –0.335, P = .040; late CTA: Pearson coefficient, –0.468, P = .003). VFAI at the early CTA was 42.20 ± 10.15 in the group with apprehension and 33.49 ± 9.66 in the group without apprehension; a significant difference was observed. VFAI at the late CTA was 45.84 ± 11.97 in the group with apprehension and 37.65 ± 9.70 in the group without apprehension and thus showed a significant difference between the 2 groups. However, the 3-, 4-, and 5-o’clock glenoid labral bumper heights on early and late CTAs did not show a statistically significant difference between the 2 groups.Conclusion:Early postoperative VFAI is related to postoperative apprehension and redislocation and might be reduced by increasing the 5-o’clock glenoid labral bumper height.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-06-09T06:08:10Z
      DOI: 10.1177/0363546520924809
  • Reconsidering Reciprocal Length Patterns of the Anteromedial and
           Posterolateral Bundles of the Anterior Cruciate Ligament During In Vivo
    • Authors: Zoë A. Englander, Jocelyn R. Wittstein, Adam P. Goode, William E. Garrett, Louis E. DeFrate
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Some cadaveric studies have indicated that the anterior cruciate ligament (ACL) consists of anteromedial and posterolateral bundles that display reciprocal function with regard to knee flexion. However, several in vivo imaging studies have suggested that these bundles elongate in parallel with regard to flexion. Furthermore, the most appropriate description of the functional anatomy of the ACL is still debated, with the ACL being described as consisting of 2 or 3 bundles or as a continuum of fibers.Hypothesis:As long as their origination and termination locations are defined within the ACL attachment site footprints, ACL bundles elongate in parallel with knee extension during gait.Study Design:Descriptive laboratory study.Methods:High-speed biplanar radiographs of the right knee joint were obtained during gait in 6 healthy male participants (mean ± SD: body mass index, 25.5 ± 1.2 kg/m2; age, 29.2 ± 3.8 years) with no history of lower extremity injury or surgery. Three-dimensional models of the right femur, tibia, and ACL attachment sites were created from magnetic resonance images. The bone models were registered to the biplanar radiographs, thereby reproducing the in vivo positions of the knee joint. For each knee position, the distances between the centroids of the ACL attachment sites were used to represent ACL length. The lengths of 1000 virtual bundles were measured for each participant by randomly sampling locations on the attachment site surfaces and measuring the distances between each pair of locations. Spearman rho rank correlations were performed between the virtual bundle lengths and ACL length.Results:The virtual bundle lengths were highly correlated with the length of the ACL, defined as the distance between the centroids of the attachment sites (rho = 0.91 ± 0.1, across participants; P < 5 × 10-5). The lengths of the bundles that originated and terminated in the anterior and medial aspects of the ACL were positively correlated (rho = 0.81 ± 0.1; P < 5 × 10-5) with the lengths of the bundles that originated and terminated in the posterior and lateral aspects of the ACL.Conclusion:As long as their origination and termination points are specified within the footprint of the attachment sites, ACL bundles elongate in parallel as the knee is extended.Clinical Relevance:These data elucidate ACL functional anatomy and may help guide ACL reconstruction techniques.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-06-09T04:46:35Z
      DOI: 10.1177/0363546520924168
  • Large Drill Holes Are Still Present in the Long Term After Arthroscopic
           Bankart Repair With Absorbable Tacks: An 18-Year Randomized Prospective
    • Authors: Christina Chrysanthou Constantinou, Ninni Sernert, Lars Rostgård-Christensen, Jüri Kartus
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Studies have demonstrated the development of an osseous reaction at the drill sites of anchors after arthroscopic shoulder surgery.Purpose:To investigate the drill-hole size at 18 years after arthroscopic Bankart repair using either fast polygluconate acid (PGA) or slow polylevolactic acid (PLLA) absorbable tacks and to compare the functional outcomes and development of osteoarthritis.Study design:Randomized controlled trial; Level of evidence, 2.Methods:40 patients with unidirectional anterior shoulder instability, treated with arthroscopic Bankart repair, were randomized into the PGA group (n = 20) or the PLLA group (n = 20). Plain radiographs of both shoulders, as well as computed tomography (CT) images of the operated shoulder, were used to evaluate the drill-hole size, volume, and degenerative changes. Functional outcomes were assessed by use of the Rowe score, Constant score, and Western Ontario Shoulder Instability (WOSI) index.Results:Of the 40 patients, 32 patients returned for the follow-up (15 PGA and 17 PLLA). No significant differences were found in the population characteristics between the study groups. The mean follow-up time was 18 years for both groups. No significant differences were seen in range of motion, strength in abduction, or Constant, Rowe, and WOSI scores between the groups. Recurrence rate was 33% in the PGA group and 6% in the PLLA group during the follow-up period (P = .07). The drill-hole appearance on plain radiographs (invisible/hardly visible/visible/cystic) was 11/2/2/0 and 6/5/5/1 for the PGA and PLLA groups, respectively (P = .036). The mean ± SD drill-hole volume as estimated on CT images was 89 ± 94 and 184 ± 158 mm3 in the PGA and PLLA groups, respectively (P = .051). Degenerative changes (normal/minor/moderate/severe) on plain radiographs were 7/4/4/0 and 3/8/5/1 for the PGA and PLLA groups, respectively (P = .21), and on CT images were 5/7/3/0 and 2/6/6/3 for the PGA and PLLA groups, respectively (P = .030).Conclusion:This long-term follow-up study demonstrated that the PLLA group had significantly more visible drill holes than the PGA group on plain radiographs. However, this difference was not evident on CT imaging, with both groups having several visible cystic drill holes and a substantial drill-hole volume defect. No significant differences were found between the study groups in terms of clinical outcomes.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-06-08T08:49:59Z
      DOI: 10.1177/0363546520922191
  • Diagnostic Accuracy of Physical Examination Tests in Core Muscle Injury
    • Authors: Jennifer Kurowicki, Matthew J. Kraeutler, Iciar M. Dávila Castrodad, Alexander K. Hahn, Erica S. Simone, Michael A. Kelly, Toghrul Talishinskiy, Anthony J. Scillia
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Core muscle injury (CMI), often referred to as a sports hernia, is a common cause of groin pain in athletes characterized by concomitant injury to the insertion of the adductor longus and the rectus abdominis muscles. Currently, the literature on CMI is sparse with no standardized physical examination tests used in the diagnosis of this type of injury.Purpose:To determine the diagnostic accuracy of various physical examination tests in the diagnosis of CMI.Study Design:Cohort study (Diagnosis); Level of evidence, 3.Methods:A consecutive series of patients evaluated by the senior author with symptoms consistent with CMI were included. Four physical examination tests were routinely performed in these patients by the senior author and were noted in each patient’s chart as positive or negative: (1) pain with resisted cross-body sit-up in figure-of-4 position, (2) pain with straight-leg sit-up, (3) pain with resisted hip flexion in external rotation (external rotation Stinchfield test), and (4) the presence of an adductor contracture. CMI was independently diagnosed by a reference standard (magnetic resonance imaging [MRI]). All MRI scans were read by a musculoskeletal fellowship-trained radiologist. The sensitivity and specificity of each physical examination test alone and in combination were calculated based on this reference standard.Results:A total of 81 patients were included in this study. MRI was positive for a CMI in 39 patients (48%) overall. Both the cross-body sit-up test and the presence of an adductor contracture were found to have a sensitivity of 100% (specificity, 3% for both). The external rotation Stinchfield test was found to have the highest specificity of 60% (sensitivity, 15%). The sensitivity of all 4 physical examination tests in combination was found to be 100% (specificity, 0%).Conclusion:Certain physical examination maneuvers can be used to assist in the diagnosis of a CMI. The cross-body sit-up test and the presence of an adductor contracture are highly sensitive but nonspecific tests for CMI and therefore should be used in conjunction with diagnostic imaging before deciding on an appropriate treatment course.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-06-08T07:56:29Z
      DOI: 10.1177/0363546520926029
  • Arthroscopic Treatment of Osteochondral Lesions of the Talus in a
           Pediatric Population: A Minimum 2-Year Follow-up
    • Authors: Michael J. Carlson, Tomasz T. Antkowiak, Nicholas J. Larsen, Gregory R. Applegate, Richard D. Ferkel
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Treatment of osteochondral lesions of the talus (OLTs) in children presents a difficult clinical challenge, with few large series reported.Purpose:To evaluate functional and radiographic outcomes for children and adolescents undergoing arthroscopic treatment of symptomatic OLT with a minimum follow-up of 2 years.Study Design:Case series; Level of evidence, 4.Methods:Patients were identified who had symptomatic OLT treated arthroscopically with marrow stimulation techniques. Inclusion criteria were age ≤18 years, symptomatic chronic OLT as the surgical indication, failure of nonoperative treatment, and minimum follow-up of 24 months. Outcome measures included Foot Function Index, American Orthopaedic Foot and Ankle Society Hindfoot Score, Tegner Activity Scale, 36-Item Short Form Health Survey (Short Form-36, v 2), visual analog scale, ankle range of motion, and patient satisfaction survey. Weightbearing radiographs were compared with preoperative radiographs via an ankle arthritis classification system. Magnetic resonance imaging (MRI) was used to evaluate postoperative lesion characteristics per the MOCART scale (magnetic resonance observation of cartilage repair tissue). The size, location, lesion stability, traumatic etiology, skeletal maturity, and length of follow-up were recorded and analyzed through univariate logistic regression.Results:The study group consisted of 22 patients (11 male, 11 female) with a mean age of 14.4 years (range, 8-18 years) and a mean follow-up of 8.3 years (range, 2-27 years). Of 22 patients, 20 were satisfied with the results from surgery and would recommend it to others. Mean follow-up visual analog scale for pain was reported as 2.2 on a 10-point scale, and mean American Orthopaedic Foot and Ankle Society score at follow-up was 86.6. Mean postoperative Foot Function Index scores for the study group were as follows: pain, 17.1; disability, 16.5; activity, 4.7; and overall, 38.7. Mean Short Form-36 physical component score was 50.7. Postoperative radiographs indicated a van Dijk osteoarthritis grade of 0 in 56%, I in 38%, II in 6%, and III in 0%. Postoperative MRI MOCART scores showed complete filling of the cartilage in 27% of cases, complete graft integration in 22%, and intact repair surface in 22%, with a mean MOCART score of 48.0. No correlation was found between radiographic and MRI findings and clinical outcomes. None of the prognostic factors were significantly associated with patient satisfaction, progression of arthritis, or MOCART scores.Conclusion:Arthroscopic treatment of symptomatic OLT in adolescent patients (≤18 years) demonstrated high functional outcomes, high clinical satisfaction rates, and minimal radiographic osteoarthritic progression despite low MOCART scores.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-06-08T07:47:29Z
      DOI: 10.1177/0363546520924800
  • Incidence of Lower Extremity Injury in the National Football League: 2015
           to 2018
    • Authors: Christina D. Mack, Richard W. Kent, Michael J. Coughlin, Kristin Y. Shiue, Leigh J. Weiss, James R. Jastifer, Edward M. Wojtys, Robert B. Anderson
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Lower extremity injuries are the most common injuries in professional sports and carry a high burden to players and teams in the National Football League (NFL). Injury prevention strategies can be refined by a foundational understanding of the occurrence and effect of these injuries on NFL players.Purpose:To determine the incidence of specific lower extremity injuries sustained by NFL players across 4 NFL seasons.Study Design:Descriptive epidemiology study.Methods:This retrospective, observational study included all time-loss lower extremity injuries that occurred during football-related activities during the 2015 through 2018 seasons. Injury data were collected prospectively through a leaguewide electronic health record (EHR) system and linked with NFL game statistics and player participation to calculate injury incidence per season and per 10,000 player-plays for lower extremity injuries overall and for specific injuries. Days lost due to injury were estimated through 2018 for injuries occurring in the 2015 to 2017 seasons.Results:An average of 2006 time-loss lower extremity injuries were reported each season over this 4-year study, representing a 1-season risk of 41% for an NFL player. Incidence was stable from 2015 to 2018, with an estimated total missed time burden each NFL season of approximately 56,700 player-days lost. Most (58.7%) of these injuries occurred during games, with an overall higher rate of injuries observed in preseason compared with regular season (11.5 vs 9.4 injuries per 10,000 player-plays in games). The knee was the most commonly injured lower extremity region (29.3% of lower body injuries), followed by the ankle (22.4%), thigh (17.2%), and foot (9.1%). Hamstring strains were the most common lower extremity injury, followed by lateral ankle sprains, adductor strains, high ankle sprains, and medial collateral ligament tears.Conclusion:Lower extremity injuries affect a high number of NFL players, and the incidence did not decrease over the 4 seasons studied. Prevention and rehabilitation protocols for these injuries should continue to be prioritized.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-06-02T09:35:47Z
      DOI: 10.1177/0363546520922547
  • Effect of Platelet-Rich Plasma on Nonsurgically Treated Acute Achilles
           Tendon Ruptures: A Randomized, Double-Blinded Prospective Study
    • Authors: Anders Ploug Boesen, Morten Ilum Boesen, Rudi Hansen, Kristoffer Weisskirchner Barfod, Anders Lenskjold, Peter Malliaras, Henning Langberg
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:An acute Achilles tendon rupture (ATR) is a long-lasting and devastating injury. Possible biological augmentation to promote and strengthen tendon healing after an ATR would be desirable.Purpose:To determine whether the application of a platelet-rich plasma (PRP) injection in nonsurgically treated ATRs may promote healing and thereby improve functional outcomes.Study Design:Randomized controlled trial; Level of evidence, 2.Methods:A total of 40 men (aged 18-60 years) with an ATR incurred within 72 hours were included, and 38 were followed for 12 months. All patients were treated with an orthosis with 3 wedges for 8 weeks; full weightbearing from day 1 was allowed, combined with either 4 PRP or 4 placebo injections (a few drops of saline,
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-06-02T09:27:04Z
      DOI: 10.1177/0363546520922541
  • Clinical Value of Ultrasonographic Assessment in Lateral Epicondylitis
           Versus Asymptomatic Healthy Controls
    • Authors: Thøger P. Krogh, Ulrich Fredberg, Christian Ammitzbøll, Torkell Ellingsen
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Ultrasonography (US) is often used in the assessment of lateral epicondylitis (LE). The strength of evidence supporting its role is, however, not well-documented.Purpose:To describe and compare the US tendinopathic changes observed in patients with LE and the general population, including any correlation between patient characteristics and US outcomes.Study Design:Cross-sectional study; Level of evidence, 3.Methods:Tendon thickness, color Doppler activity, and bone spur were assessed by US in 264 participants with healthy elbows and 60 patients with chronic LE. In addition to patient characteristics, Patient-Rated Tennis Elbow Evaluation (PRTEE) score, pain, and disability were recorded.Results:Depending on the measurement technique used, mean LE tendon thickness increased by 0.53 mm (10.2%) or 0.70 mm (14.5%) as compared with the contralateral arm and 0.40 mm (7.9%) or 0.41 mm (8.5%) as compared with the general population. Mean color Doppler activity (scale, 0-4) was 3.47 in the LE arm versus 0.13 in the contralateral asymptomatic arm and 0.26 in the general population. Bone spur was observed in 78% of the LE arms as opposed to 45% in the contralateral arms and 50% in the general population. In the LE group and the general population, the prevalence of bone spur increases with age. No correlations were observed with pain, disability, PRTEE, and disease duration.Conclusion:Increased common extensor tendon thickness is part of the tendinopathic changes observed in LE. However, given the marked variation in natural tendon thickness and small increases in tendon thickness in patients with LE, this technique cannot be used as a stand-alone diagnostic tool but rather as a supplement to the overall assessment. The contralateral elbow (if asymptomatic) is a better tendon thickness comparator than a general population mean value. Color Doppler activity is an indicator of ongoing tendinopathy and supports the LE diagnosis, but it is not pathognomonic for the condition. Absence of Doppler activity in a patient with suspected LE should raise suspicion of other diagnoses. Identification of a bone spur is of very limited clinical value given the high prevalence in the general population. The important outcomes of pain, disability, PRTEE, and disease duration did not correlate with any of the investigated US techniques.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-06-02T08:36:56Z
      DOI: 10.1177/0363546520921949
  • Return to Sport Following High Tibial Osteotomy With Concomitant
           Osteochondral Allograft Transplantation
    • Authors: Joseph N. Liu, Avinesh Agarwalla, David R. Christian, Grant H. Garcia, Michael L. Redondo, Adam B. Yanke, Brian J. Cole
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Young patients with symptomatic chondral defects in the medial compartment with varus malalignment may undergo opening wedge high tibial osteotomy (HTO) with concomitant osteochondral allograft transplantation (OCA) (HTO + OCA). Although patients have demonstrated favorable outcomes after HTO + OCA, limited information is available regarding return to sporting activities after this procedure.Purpose:To evaluate (1) the timeline to return to sports (RTS), (2) patient satisfaction, and (3) reasons for discontinuing sporting activity after HTO + OCA, and to identify predictive factors of RTS.Study Design:Case series; level of evidence, 4.Methods:Consecutive patients who underwent HTO + OCA for varus deformity and medial femoral condyle focal chondral defects with a minimum 2-year follow-up were retrospectively reviewed. Patients completed a subjective sports questionnaire, satisfaction questionnaire, visual analog scale for pain, and Single Assessment Numerical Evaluation.Results:Twenty-eight patients with a mean age of 36.97 ± 7.52 years were included at mean follow-up of 6.63 ± 4.06 years. Fourteen patients (50.0%) required reoperation during the follow-up period, with 3 (10.7%) undergoing knee arthroplasty. Twenty-four patients participated in sports within 3 years before surgery, with 19 patients (79.2%) able to return to at least 1 sport at a mean 11.41 ± 6.42 months postoperatively. However, only 41.7% (n = 10) were able to return to their preoperative level. The most common reasons for sports discontinuation (n = 20; 83.3%) were a desire to prevent further damage to the knee (70.0%), persistent pain (55.0%), persistent swelling (30.0%), and fear (25.0%).Conclusion:In young, active patients with varus deformity and focal medial femoral condyle chondral defects, HTO + OCA enabled 79.2% of patients to RTS by 11.41 ± 6.42 months postoperatively. However, only 41.7% of patients were able to return to their preinjury level or better. It is imperative that patients be appropriately educated to manage postoperative expectations regarding sports participation after HTO + OCA.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-05-27T08:22:11Z
      DOI: 10.1177/0363546520920626
  • The Use of Recombinant Human Growth Hormone to Protect Against Muscle
           Weakness in Patients Undergoing Anterior Cruciate Ligament Reconstruction:
           A Pilot, Randomized Placebo-Controlled Trial
    • Authors: Christopher L. Mendias, Elizabeth R. Sibilsky Enselman, Adam M. Olszewski, Jonathan P. Gumucio, Daniel L. Edon, Maxwell A. Konnaris, James E. Carpenter, Tariq M. Awan, Jon A. Jacobson, Joel J. Gagnier, Ariel L. Barkan, Asheesh Bedi
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Anterior cruciate ligament (ACL) tears are common knee injuries. Despite undergoing extensive rehabilitation after ACL reconstruction (ACLR), many patients have persistent quadriceps muscle weakness that limits their successful return to play and are also at an increased risk of developing knee osteoarthritis (OA). Human growth hormone (HGH) has been shown to prevent muscle atrophy and weakness in various models of disuse and disease but has not been evaluated in patients undergoing ACLR.Hypothesis:Compared with placebo treatment, a 6-week perioperative treatment course of HGH would protect against muscle atrophy and weakness in patients undergoing ACLR.Study Design:Randomized controlled trial; Level of evidence, 2.Methods:A total of 19 male patients (aged 18-35 years) scheduled to undergo ACLR were randomly assigned to the placebo (n = 9) or HGH (n = 10) group. Patients began placebo or HGH treatment twice daily 1 week before surgery and continued through 5 weeks after surgery. Knee muscle strength and volume, patient-reported outcome scores, and circulating biomarkers were measured at several time points through 6 months after surgery. Mixed-effects models were used to evaluate differences between treatment groups and time points, and as this was a pilot study, significance was set at P < .10. The Cohen d was calculated to determine the effect size.Results:HGH was well-tolerated, and no differences in adverse events between the groups were observed. The HGH group had a 2.1-fold increase in circulating insulin-like growth factor 1 over the course of the treatment period (P < .05; d = 2.93). The primary outcome measure was knee extension strength, and HGH treatment increased normalized peak isokinetic knee extension torque by 29% compared with the placebo group (P = .05; d = 0.80). Matrix metalloproteinase–3 (MMP3), which was used as an indirect biomarker of cartilage degradation, was 36% lower in the HGH group (P = .05; d = –1.34). HGH did not appear to be associated with changes in muscle volume or patient-reported outcome scores.Conclusion:HGH improved quadriceps strength and reduced MMP3 levels in patients undergoing ACLR. On the basis of this pilot study, further trials to more comprehensively evaluate the ability of HGH to improve muscle function and potentially protect against OA in patients undergoing ACLR are warranted.Registration:NCT02420353 ( identifier)
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-05-26T12:00:03Z
      DOI: 10.1177/0363546520920591
  • A Synthetic Graft With Multilayered Co-Electrospinning Nanoscaffolds for
           Bridging Massive Rotator Cuff Tear in a Rat Model
    • Authors: Shuang Cong, Yaying Sun, Jinrong Lin, Shaohua Liu, Jiwu Chen
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Graft bridging is used in massive rotator cuff tear (MRCT); however, the integration of graft-tendon and graft-bone is still a challenge.Hypothesis:A co-electrospinning nanoscaffold of polycaprolactone (PCL) with an “enthesis-mimicking” (EM) structure could bridge MRCT, facilitate tendon regeneration, and improve graft-bone healing.Study Design:Controlled laboratory study.Methods:First, we analyzed the cytocompatibility of the electrospinning nanoscaffolds, including aligned PCL (aPCL), nonaligned PCL (nPCL), aPCL–collagen I, nPCL–collagen II, and nPCL-nanohydroxyapatite (nHA). Second, for the EM condition, nPCL–collagen II and nPCL-nHA were electrospun layer by layer at one end of the aPCL–collagen I; for the control condition, the nPCL was electrospun on the aPCL. In 40 mature male rats, resection of both the supraspinatus and infraspinatus tendons was performed to create MRCT, and the animals were divided randomly into EM and control groups. In both groups, one end of the layered structure was fixed on the footprint of the rotator cuff, whereas the other end of the layered structure was sutured with the tendon stump. The animals were euthanized for harvesting of tissues for histologic and biomechanical analysis at 4 weeks or 8 weeks postoperatively.Results:All scaffolds showed good cytocompatibility in vitro. The graft-tendon tissue in the EM group had more regularly arranged cells, denser tissue, a significantly higher tendon maturing score, and more birefringence compared with the control group at 8 weeks after operation. Newly formed fibrocartilage could be observed at the graft-bone interface in both groups by 8 weeks, but the EM group had a higher graft-bone healing score and significantly more newly formed fibrocartilage than the control group. An enthesis-like structure with transitional layers was observed in the EM group at 8 weeks. Biomechanically, the values for maximum failure load and stiffness of the tendon-graft-bone complex were significantly higher in the EM group than in the control group at 8 weeks.Conclusion:The co-electrospinning nanoscaffold of aPCL–collagen I could be used as a bridging graft to improve early graft-tendon healing for MRCT in a rat model and enhance early enthesis reconstruction in combination with a multilayered structure of nPCL–collagen II and nPCL-nHA.Clinical Relevance:We constructed a graft to bridge MRCT, enhance graft-tendon healing and graft-bone healing, and reconstruct the enthesis structure.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-05-26T04:50:14Z
      DOI: 10.1177/0363546520917684
  • Biomechanical Functional Elbow Restoration of Acute Ulnar Collateral
           Ligament Tears: The Role of Internal Bracing on Gap Formation and Repair
    • Authors: Samuel Bachmaier, Coen A. Wijdicks, Nikhil N. Verma, Laurence D. Higgins, Stefan Greiner
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Biomechanical studies have compared augmented primary repair with internal bracing versus reconstruction techniques of the anterior ulnar collateral ligament (aUCL) in the elbow. However, aUCL repair alone has not been compared with augmented repair or reconstruction techniques.Hypothesis:Internal bracing of aUCL repair provides improved time-zero stabilization in terms of gap formation, torsional stiffness, and residual torque compared with both repair alone and the modified docking technique, with enhanced valgus stability restoration to that of the native ligament.Study Design:Controlled laboratory study.Methods:We randomized 8 matched pairs of cadaveric elbows to undergo either augmented aUCL repair or a modified docking technique through use of the palmaris longus tendon. Valgus laxity testing was consecutively performed at 90° of flexion on the intact, torn, and repaired conditions as well as the previously assigned techniques. First, intact elbows were loaded up to 10 N·m valgus torque to evaluate time-zero ligament rotations at valgus moments of 2.5, 5.0, 7.5, and 10 N·m. Rotation controlled cycling was performed (total 1000 cycles) for each surgical condition. Gap formation, stiffness, and residual torque were analyzed. Finally, these elbows and 8 additional intact elbows underwent torque to failure testing (30 deg/min).Results:Repair alone revealed low torsional resistance and gapping, similar to the torn state. The augmented repair technique showed significantly higher torsional stiffness (P < .001) and residual torque (P < .001) compared with all other conditions and restored native function. Although reconstruction revealed similar initial stiffness and residual torque compared with an intact ligament, a steady decrease of torsional resistance led to a completely loose state at higher valgus rotations. Analysis of covariance between all groups showed significantly less gap formation for augmented repair (P < .001). The native failure load and stiffness were significantly higher and were similar to those of augmented repair (P = .766).Conclusion:Internal bracing of aUCL repair restored valgus stability to the native state with statistically improved torsional resistance, loading capability, and gap formation compared with reconstruction, especially at the upper load range of native aUCL function in the elbow.Clinical Relevance:We found that aUCL repair with an internal brace effectively improves time-zero mechanical characteristics and may provide stabilized healing with accelerated and reliable recovery without the need for a tendon graft.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-05-26T04:34:03Z
      DOI: 10.1177/0363546520921174
  • Quantitative and Qualitative Analyses of the Glenohumeral Ligaments: An
           Anatomic Study
    • Authors: Travis J. Dekker, Zachary S. Aman, Liam A. Peebles, Hunter W. Storaci, Jorge Chahla, Peter J. Millett, Matthew T. Provencher
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:While several studies have qualitatively described the anatomy of the glenohumeral ligaments, there remains a lack of consensus regarding their quantitative humeral and glenoid attachment sites.Purpose:To quantitatively and qualitatively describe the anatomic humeral and glenoid attachment sites of the glenohumeral ligaments and their relationship to well-established anatomic landmarks.Study Design:Descriptive laboratory study.Methods:A total of 10 nonpaired, fresh-frozen human cadaveric shoulders were included in this study. A 3-dimensional coordinate measuring device was used to quantify the location of pertinent bony landmarks and soft tissue attachment areas. All subcutaneous tissues and musculature were removed, with the exception of the rotator cuff (respective muscle bellies cut at their musculotendinous junctions) and the long head of the biceps tendon. The superior glenohumeral ligament (SGHL), middle glenohumeral ligament (MGHL), anteroinferior glenohumeral ligament (AIGHL), posteroinferior glenohumeral ligament (PIGHL), and coracohumeral ligament (CHL) were then transected. Coordinates of points along the perimeters of attachment sites were used to calculate areas, while coordinates of center points were used to determine distances between surgically relevant attachment sites and pertinent bony landmarks.Results:The mean length of the SGHL humeral attachment along the intra-articular cartilage margin was 9.5 ± 3.2 mm, spanning from 12:55 to 1:40, while the SGHL glenoid attachment to the labrum was 1.9 ± 1.2 mm medial to the most lateral extent of the labral rim, spanning from 12:30 to 12:45. The mean length of the MGHL attachment along the intra-articular cartilage margin was 16.4 ± 3.0 mm, equating to 2:10 to 3:35 on the humeral head clockface, and the glenoid attachment was confluent with the labrum, attaching 1.5 ± 1.0 mm medial to the most lateral extent of the labral rim and thus extending from 1:50 to 2:35 on the glenoid clockface. The mean length of the AIGHL attachment along the intra-articular cartilage margin was 12.0 ± 3.0 mm, spanning from 4:05 to 5:10 on the humeral head clockface. The AIGHL bony footprint on the glenoid neck was 48.4 ± 24.5 mm2. The confluent attachment of the AIGHL to the labrum was 1.2 ± 0.9 mm medial to the most lateral extent of the labral rim, corresponding to 3:30 to 4:05 on the glenoid clockface. The mean length of the PIGHL attachment along the intra-articular cartilage margin was 12.0 ± 1.4 mm, spanning from 7:40 to 8:50 on the humeral head clockface. The PIGHL attachment to the labrum was 1.2 ± 0.5 mm medial to the most lateral extent of the labral rim. This attachment to the labrum was calculated to span from 7:35 to 8:50 on the glenoid clockface. The mean length of the CHL origin from the coracoid was 12.9 mm, with its most anterior point located a mean of 14.1 mm from the tip of the coracoid. The mean length of the CHL attachment along the intra-articular cartilage margin was 10.0 ± 4.0 mm, spanning from 11:55 to 12:40 on the humeral head clockface.Conclusion:Glenohumeral ligaments were consistently identified in all specimens with minor anatomic variability for the SGHL, MGHL, AIGHL, and PIGHL. Important landmarks including the cartilage surface of the humerus, the bicipital groove, and the clockface can be utilized intraoperatively when attempting anatomic repair of these structures.Clinical Relevance:There are multiple open and arthroscopic shoulder procedures that rely on anatomic restoration of these static stabilizers to provide optimal shoulder function and prevent recurrent instability. The qualitative descriptions are comparable with current literature; however, this study is the first to quantify the glenohumeral capsular and ligamentous attachments. The data provided allow for reliable landmarks to be established from known bony and soft tissue structures.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-05-22T05:51:56Z
      DOI: 10.1177/0363546520917665
  • Root Repair Versus Partial Meniscectomy for Medial Meniscus Posterior Root
           Tears: Comparison of Long-term Survivorship and Clinical Outcomes at
           Minimum 10-Year Follow-up
    • Authors: Kyu Sung Chung, Jeong Ku Ha, Ho Jong Ra, Woo Jin Yu, Jin Goo Kim
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:The importance of repair in medial meniscus posterior root tears (MMPRTs) has been increasingly recognized because it restores hoop tension. However, no study has compared the long-term outcomes between meniscectomy and repair.Hypothesis:Survivorship and clinical outcomes of repair would be better than those of meniscectomy after long-term follow-up.Study Design:Cohort study; Level of evidence, 3.Methods:Between 2005 and 2009, patients with MMPRTs who had been followed up for at least 10 years after partial meniscectomy (n = 18) or pullout repair (n = 37) were recruited. Clinical assessments, including the Lysholm score and International Knee Documentation Committee (IKDC) subjective score, were evaluated preoperatively and at the final follow-up. The final results in each group were compared with the preoperative results, and the final results of the groups were compared. Clinical failure was defined as conversion to total knee arthroplasty (TKA), and the final clinical scores were assessed just before TKA. Kaplan-Meier survival analysis was used to investigate the survival rates of surgical procedures.Results:Mean ± SD follow-up period was 101.4 ± 45.9 and 125.9 ± 21.2 months in the meniscectomy and repair groups, respectively (P = .140). The mean Lysholm and IKDC scores, respectively, in the meniscectomy group were 50.8 ± 7.7 and 37.6 ± 7.0 preoperatively and 58.2 ± 22.1 and 44.4 ± 19.0 postoperatively (P = .124; P = .240). In the repair group, the mean Lysholm score and IKDC score, respectively, significantly increased from 52.3 ± 10.9 and 41.0 ± 9.6 preoperatively to 77.1 ± 24.0 and 63.7 ± 20.6 postoperatively (P < .001; P < .001). The final Lysholm and IKDC scores in the repair group were significantly better than those in the meniscectomy group (P = .004; P = .003). In cases of clinical failure, 10 patients (56%) in the meniscectomy group and 8 patients (22%) in the repair group converted to TKA in the follow-up period (P = .016). According to Kaplan-Meier analysis, the 10-year survival rates for the meniscectomy and repair groups were 44.4% and 79.6%, respectively (P = .004).Conclusion:In MMPRTs, root repair was superior to partial meniscectomy in terms of clinical results for at least 10 years of follow-up. From a long-term perspective, repair with restoration of hoop tension is more effective management than meniscectomy.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-05-21T08:26:40Z
      DOI: 10.1177/0363546520920561
  • The Biomechanical Effect of Bone Grafting and Bone Graft Remodeling in
           Patients With Anterior Shoulder Instability
    • Authors: Bastian Sigrist, Stephen Ferguson, Elisabeth Boehm, Christian Jung, Markus Scheibel, Philipp Moroder
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Individual constitutional differences in glenoid shape and bone remodeling require a patient-specific and longitudinal approach to evaluate the biomechanical effects of glenoid bone grafting in patients with anterior shoulder instability.Purpose:To quantify the longitudinal, in vivo, biomechanical effects of bone grafting, bone graft remodeling, and glenoid shape in patients with anterior shoulder instability by means of patient-specific finite element models.Study Design:Descriptive laboratory study.Methods:In total, 25 shoulders of 24 patients with anterior shoulder instability and anterior glenoid bone loss underwent an arthroscopic iliac crest bone graft transfer (ICBGT) procedure with either autologous or allogenic bone. Patient-specific finite element simulations based on preoperative, postoperative, and follow-up computed tomography scans were used to quantify the bone-mediated stability ratio (SR) and the distance to dislocation. Additionally, the relationship between glenoid morphological parameters and the SR was assessed.Results:The ICBGT procedure significantly increased the SR and distance to dislocation in the 2-, 3-, and 4-o’clock directions immediately after the surgical intervention (P < .01) in both the autograft and the allograft groups. Although the SR and distance to dislocation decreased subsequently, autografts showed long-term effects on SR and dislocation distance in the 3-o’clock direction (P < .01) and on SR in the 4-o’clock direction (P < .01). Allografts showed no significant effect on SR and dislocation distance in long-term follow-up (P> .05). Overall, glenoid retroversion as well as cavity depth predicted stability in all 4 dislocation directions, with glenoid cavity depth showing the highest correlation coefficients (R = 0.71, 0.8, 0.73, and 0.7 for 2-, 3-, 4-, and 5-o’clock, respectively).Conclusion:The autologous ICBGT procedure biomechanically improved anterior shoulder stability in long-term follow-up, whereas the use of allografts did not show any bone-mediated biomechanical effect at follow-up due to resorption. Furthermore, in addition to measurements of defect extent, the glenoid depth and version seem to be useful parameters to determine the biomechanical effect and need for glenoid bone grafting in patients with shoulder instability.Clinical Relevance:This study proposes the use of autologous bone grafts for a successful long-term stabilization effect. Additionally, this study proposes additional glenoid morphological measures to predict shoulder stability.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-05-21T08:14:11Z
      DOI: 10.1177/0363546520919958
  • CD10/Neprilysin Enrichment in Infrapatellar Fat Pad–Derived Mesenchymal
           Stem Cells Under Regulatory-Compliant Conditions: Implications for
           Efficient Synovitis and Fat Pad Fibrosis Reversal
    • Authors: Dimitrios Kouroupis, Annie C. Bowles, Thomas M. Best, Lee D. Kaplan, Diego Correa
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Synovitis and infrapatellar fat pad (IFP) fibrosis participate in various conditions of the knee. Substance P (SP), a neurotransmitter secreted within those structures and historically associated with nociception, also modulates local neurogenic inflammatory and fibrotic responses. Exposure of IFP mesenchymal stem cells (IFP-MSCs) to a proinflammatory/profibrotic environment (ex vivo priming with TNFα, IFNγ, and CTGF) induces their expression of CD10/neprilysin, effectively degrading SP in vitro and in vivo.Purpose/Hypothesis:The purpose was to test the therapeutic effects of IFP-MSCs processed under regulatory-compliant protocols, comparing them side-by-side with standard fetal bovine serum (FBS)–grown cells. The hypothesis was that when processed under such protocols, IFP-MSCs do not require ex vivo priming to acquire a CD10-rich phenotype efficiently degrading SP and reversing synovitis and IFP fibrosis.Study Design:Controlled laboratory study.Methods:Human IFP-MSCs were processed in FBS or either of 2 alternative conditions—regulatory-compliant pooled human platelet lysate (hPL) and chemically reinforced medium (Ch-R)—and then subjected to proinflammatory/profibrotic priming with TNFα, IFNγ, and CTGF. Cells were assessed for in vitro proliferation, stemness, immunophenotype, differentiation potential, transcriptional and secretory profiles, and SP degradation. Based on a rat model of acute synovitis and IFP fibrosis, the in vivo efficacy of cells degrading SP plus reversing structural signs of inflammation and fibrosis was assessed.Results:When compared with FBS, IFP-MSCs processed with either hPL or Ch-R exhibited a CD10High phenotype and showed enhanced proliferation, differentiation, and immunomodulatory transcriptional and secretory profiles (amplified by priming). Both methods recapitulated and augmented the secretion of growth factors seen with FBS plus priming, with some differences between them. Functionally, in vitro SP degradation was more efficient in hPL and Ch-R, confirmed upon intra-articular injection in vivo where CD10-rich IFP-MSCs also dramatically reversed signs of synovitis and IFP fibrosis even without priming or at significantly lower cell doses.Conclusion:hPL and Ch-R formulations can effectively replace FBS plus priming to induce specific therapeutic attributes in IFP-MSCs. The resulting fine-tuned, regulatory-compliant, cell-based product has potential future utilization as a novel minimally invasive cell therapy for the treatment of synovitis and IFP fibrosis.Clinical Relevance:The therapeutic enhancement of IFP-MSCs manufactured under regulatory-compliant conditions suggests that such a strategy could accelerate the time from preclinical to clinical phases. The therapeutic efficacy obtained at lower MSC numbers than currently needed and the avoidance of cell priming for efficient results could have a significant effect on the design of clinical protocols to potentially treat conditions involving synovitis and IFP fibrosis.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-05-19T04:56:50Z
      DOI: 10.1177/0363546520917699
  • Platelet-Rich Plasma Injection for the Treatment of Hamstring Injuries: A
           Systematic Review and Meta-analysis With Best-Worst Case Analysis
    • Authors: Dexter Seow, Yoshiharu Shimozono, Tengku Nazim B. Tengku Yusof, Youichi Yasui, Andrew Massey, John G. Kennedy
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Hamstring injuries are common and account for considerable time lost to play in athletes. Platelet-rich plasma has potential as a means to accelerate healing of these injuries.Purpose:(1) To present the evidence of platelet-rich plasma injection in the treatment of hamstring injuries, (2) evaluate the “best-case scenario” in dichotomous outcomes, and (3) evaluate the “worst-case scenario” in dichotomous outcomes.Study Design:Systematic review and meta-analysis.Methods:Two authors systematically reviewed the PubMed, Embase, and Cochrane Library databases according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, with any discrepancies resolved by mutual consensus. The level of evidence was assessed per the criteria of the Oxford Centre for Evidence-Based Medicine and the quality of evidence by the Coleman Methodology Score. Meta-analysis by fixed effects models was used if heterogeneity was low (I2 < 25%) and random effects models if heterogeneity was moderate to high (I2≥ 25%). P values
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-05-19T04:43:49Z
      DOI: 10.1177/0363546520916729
  • The Effect of Thursday Night Games on In-Game Injury Rates in the National
           Football League
    • Authors: Jose R. Perez, Jonathan Burke, Abdul K. Zalikha, Dhanur Damodar, Joseph S. Geller, Andrew N.L. Buskard, Lee D. Kaplan, Michael G. Baraga
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Although claims of increased injury rates with Thursday night National Football League (NFL) games exist, a paucity of data exist substantiating these claims.Purpose:To evaluate the effect of rest between games on in-game injury rates as it pertains to overall injury incidence, location, and player position.Study Design:Descriptive epidemiologic study.Methods:Data were obtained from official NFL game books for regular season games from all 32 teams for the 2013-2016 seasons. All in-game injuries recorded in official game books were included. Rest periods between games were classified as short (4 days), regular (6-8 days), or long (≥10 days). Overall observed injury rates per team-game were analyzed in relation to different rest periods using negative binomial regression. For results with significant overall findings, pairwise comparisons were tested using the Wald chi-square test. Exploratory secondary analyses were performed in a similar fashion to assess differences in injury rates for the different rest periods when stratified by anatomic location and player position.Results:A total of 2846 injuries were identified throughout the 4 seasons. There was an overall significant difference in injuries per team-game between short, regular, and long rest (P = .01). With short rest, an observed mean of 1.26 injuries per game (95% CI, 1.06-1.49) was significantly different from the 1.53 observed injuries per game with regular rest (95% CI, 1.46-1.60; P = .03), but not compared with the 1.34 observed injuries per game with long rest (P = .56). For player position, only the tight end, linebacker, and fullback group demonstrated significant differences between the injury rates for different rest categories. Quarterback was the only position with more injuries during games played on Thursday compared with both regular and long rest. This specific analysis was underpowered and the difference was not significant (P = .08). No differences were found regarding injury rates in correlation with differences in rest periods with different injury locations.Conclusion:A short rest period between games is not associated with increased rates of observed injuries reported in NFL game books; rather, our data suggest there are significantly fewer injuries for Thursday night games compared with games played on regular rest. Future research correlating rest and quarterback injury rates is warranted.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-05-15T05:50:14Z
      DOI: 10.1177/0363546520919989
  • Association Between the Postoperative Condition of the Subscapularis
           Tendon and Clinical Outcomes After Superior Capsular Reconstruction Using
           Autologous Tensor Fascia Lata in Patients With Pseudoparalytic Shoulder
    • Authors: Kazumasa Takayama, Shunsuke Yamada, Yuu Kobori, Hayao Shiode
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Superior capsular reconstruction (SCR) has been performed for irreparable rotator cuff tear and pseudoparalytic shoulder (PPS); however, poor clinical outcomes have occasionally been reported. Previous studies have shown that the cause of poor clinical results was mainly graft rupture; however, poor clinical outcomes have also been observed in some cases even though the graft was not ruptured.Hypothesis/Purpose:We hypothesized that the subscapularis (SSC) tendon would be an important factor affecting clinical outcomes after SCR. The purpose was to clarify the correlation between the condition of the SSC tendon and clinical outcomes after SCR in patients with PPS.Study Design:Cohort study; Level of evidence, 3.Methods:This retrospective cohort study included 27 patients who had undergone SCR for PPS performed by 1 surgeon between June 2014 and July 2017. The 27 patients were divided into 3 groups for evaluation: group A (n = 12), irreparable supraspinatus (SSP) and infraspinatus (ISP) tears but intact SSC tendon; group B (n = 11), irreparable SSP and ISP tears and repairable SSC tear; and group C (n = 4), irreparable SSP, ISP, and SSC tears. We evaluated the preoperative and postoperative ranges of motion (ROMs; active flexion, abduction, external rotation, and internal rotation), the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form score, and graft condition on magnetic resonance imaging at 12 months postoperatively. All data were analyzed using the Mann-Whitney U, Wilcoxon signed-rank test, and Fisher exact tests, and P < .05 was considered significant.Results:Postoperative flexion, abduction, and internal rotation ROMs were significantly lower in group C than in groups A and B (flexion: 70.0° ± 17.8° vs 153.3° ± 14.3° and 154.5° ± 14.3°, P = .003 and P = .003, respectively; abduction: 67.5° ± 15° vs 148.3° ± 22.5° and 140° ± 29.3°, P = .003 and P = .004, respectively; internal rotation: L4 vs Th10 and Th11, P = .005 and P = .008, respectively). All 23 patients in groups A and B were able to recover from PPS; however, no patient recovered from PPS in group C.Conclusion:The present study suggests that the SSC tendon is the important factor for achieving good clinical outcomes after SCR in patients with PPS. When the SSC tendon was irreparable, SCR was not an effective treatment for patients with PPS.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-05-15T05:21:10Z
      DOI: 10.1177/0363546520919956
  • Visualization of Proximal and Distal Kaplan Fibers Using 3-Dimensional
           Magnetic Resonance Imaging and Anatomic Dissection
    • Authors: Daniel P. Berthold, Lukas Willinger, Lukas N. Muench, Philipp Forkel, Andreas Schmitt, Klaus Woertler, Andreas B. Imhoff, Elmar Herbst
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:In current magnetic resonance imaging (MRI) of the knee, injuries to the anterolateral ligament complex (ALC) and the Kaplan fibers (KFs) are not routinely assessed. As ruptures of the KFs contribute to anterolateral rotatory instability in the anterior cruciate ligament–deficient knee, detecting these injuries on MRI may help surgeons to individualize treatment.Purpose:To visualize the KFs on 3-T MRI and to conduct a layer-by-layer dissection of the ALC.Study Design:Descriptive laboratory study.Methods:Ten fresh-frozen human cadaveric knees (mean ± SD age, 72 ± 8.5 years) without history of ligament injury were used in this study. Before layer-by-layer dissection of the ALC, MRI was performed to define the radiologic anatomy of the KFs. A coronal T1-weighted 3-dimensional turbo spin echo sequence and a transverse T2-weighted turbo spin echo sequence were obtained. Three-dimensional data sets were used for multiplanar reconstructions.Results:KFs were identified in 100% of cases on MRI and in anatomic dissection. The mean length of the proximal and distal KFs was 17.9 ± 3.6 mm and 12.4 ± 6.5 mm, respectively. On MRI, the distance from the lateral femoral epicondyle to the proximal KFs was 35.9 ± 6.9 mm and to the distal KFs, 16.6 ± 4.1 mm; in anatomic dissection, the distances were 41.4 ± 8.1 mm for proximal KFs and 28.2 ± 8.1 mm for distal KFs. The distance from the lateral joint line to the proximal KFs was 63.5 ± 7.6 mm and to the distal KFs, 45.3 ± 3.7 mm. Interobserver reliability for image analysis was excellent for all measurements.Conclusion:KFs can be consistently identified on MRI with use of 3-dimensional sequences. Subsequent anatomic dissection confirmed their close topography to the superior lateral genicular artery. For clinical implications, the integrity of the KFs should be routinely reviewed on MRI scansClinical Relevance:As ruptures of the KFs contribute to anterolateral rotatory instability, accurate visualization of the KFs on MRI may facilitate surgical decision making for additional anterolateral procedures in the anterior cruciate ligament–deficient knee.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-05-14T06:02:54Z
      DOI: 10.1177/0363546520919986
  • Platelet-Rich Plasma Versus Hyaluronic Acid for Knee Osteoarthritis: A
           Systematic Review and Meta-analysis of Randomized Controlled Trials
    • Authors: John W. Belk, Matthew J. Kraeutler, Darby A. Houck, Jesse A. Goodrich, Jason L. Dragoo, Eric C. McCarty
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Platelet-rich plasma (PRP) and hyaluronic acid (HA) are 2 nonoperative treatment options for knee osteoarthritis (OA) that are supposed to provide symptomatic relief and help delay surgical intervention.Purpose:To systematically review the literature to compare the efficacy and safety of PRP and HA injections for the treatment of knee OA.Study Design:Meta-analysis of level 1 studies.Methods:A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify level 1 studies that compared the clinical efficacy of PRP and HA injections for knee OA. The search phrase used was platelet-rich plasma hyaluronic acid knee osteoarthritis randomized. Patients were assessed via the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), visual analog scale (VAS) for pain, and Subjective International Knee Documentation Committee (IKDC) scale. A subanalysis was also performed to isolate results from patients who received leukocyte-poor and leukocyte-rich PRP.Results:A total of 18 studies (all level 1) met inclusion criteria, including 811 patients undergoing intra-articular injection with PRP (mean age, 57.6 years) and 797 patients with HA (mean age, 59.3 years). The mean follow-up was 11.1 months for both groups. Mean improvement was significantly higher in the PRP group (44.7%) than the HA group (12.6%) for WOMAC total scores (P < .01). Of 11 studies based on the VAS, 6 reported PRP patients to have significantly less pain at latest follow-up when compared with HA patients (P < .05). Of 6 studies based on the Subjective IKDC outcome score, 3 reported PRP patients to have significantly better scores at latest follow-up when compared with HA patients (P < .05). Finally, leukocyte-poor PRP was associated with significantly better Subjective IKDC scores versus leukocyte-rich PRP (P < .05).Conclusion:Patients undergoing treatment for knee OA with PRP can be expected to experience improved clinical outcomes when compared with HA. Additionally, leukocyte-poor PRP may be a superior line of treatment for knee OA over leukocyte-rich PRP, although further studies are needed that directly compare leukocyte content in PRP injections for treatment of knee OA.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-04-17T04:21:30Z
      DOI: 10.1177/0363546520909397
  • Regional Interdependence and the Role of the Lower Body in Elbow Injury in
           Baseball Players: A Systematic Review
    • Authors: Matthew Jordan Deal, Bradley P. Richey, Cyrus Anthony Pumilia, Ibrahim Mamdouh Zeini, Charles Wolf, Todd Furman, Daryl Christopher Osbahr
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Elbow injuries are exceedingly common in baseball players. Previous studies have identified that upper extremity strength and range of motion deficits pose a risk for these injuries, but few studies have examined the effect of lower extremity deficits. Given the role of the lower extremity in the kinetic chain of the baseball throwing motion, lower body deficits may affect the kinematics of the upper extremity and play a role in the elbow injury of baseball players.Purpose:To systematically review the current literature investigating the association of trunk and lower extremity deficits with elbow pain or injury in baseball players.Study Design:Systematic review.Methods:A systematic review of the literature was performed according to the PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) guidelines to identify and analyze all previous studies focused on the association of elbow pain and/or injury with functional deficits of the trunk and lower extremities.Results:A total of 14 studies met inclusion criteria, examining a range of baseball players extending from youth to professional athletes. One of the 14 studies examined other types of overhead throwing athletes alongside baseball players. Lower extremity–related risk factors for elbow pain and injury in these athletes were found and stratified per level of play. Factors included specific hip range of motion, lower extremity injury or pain, balance, and foot arch posture. Associations were also found with lower extremity injury and noncompliance with primary prevention programs.Conclusion:Specific lower extremity deficits were found to be independent risk factors for elbow pain and injury in throwing athletes at certain levels of play. Additionally, prevention programs designed to correct deficits in identified risk factors were effective in reducing the incidence of elbow injury in youth athletes. These results highlight the potential of screening and subsequent intervention to reduce the incidence of elbow injury in certain subsets of baseball players.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-04-16T07:35:31Z
      DOI: 10.1177/0363546520910138
  • Tear Completion Versus In Situ Repair for 50% Partial-Thickness
           Bursal-Side Rotator Cuff Tears: A Biomechanical and Histological Study in
           an Animal Model
    • Authors: Anil Pulatkan, Wasim Anwar, Omer Ayık, Ergun Bozdag, Ayse Nur Yildirim, Mehmet Kapicioglu, Ibrahim Tuncay, Kerem Bilsel
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Tear completion followed by repair (TCR) and in situ repair (ISR) have been widely used for bursal-side partial-thickness rotator cuff tears (PTRCTs). Both techniques have shown favorable results; however, controversy continues in terms of the best management.Purpose:To compare the histological and biomechanical outcomes of these 2 techniques for 50% partial-thickness bursal-side rotator cuff tear repair in a rabbit model.Study Design:Controlled laboratory study.Methods:A total of 27 rabbits were used in this experimental study. Seven rabbits were sacrificed at the beginning of the study to form an intact tendon control group. A chronic 50% partial-thickness bursal-side tear model was created in 20 rabbits, and 5 rabbits were sacrificed for biomechanical testing of chronic partial-thickness tears (control group) without repair. In 15 rabbits, partial-thickness tears were repaired after 8 weeks. Partial-thickness tears in the right shoulders were completed to full thickness and repaired; in contrast, left shoulders were repaired in situ. All rabbits were euthanized 8 weeks after the repair. The tendons were tested biomechanically for ultimate failure, linear stiffness, and displacement. Histological evaluations of tendon-to-bone healing were performed via the modified Watkins score.Results:Macroscopically, all repaired tendons were attached to the greater tuberosity. The TCR group had a higher failure load than the ISR group, with mean values of 140.4 ± 13.8 N and 108.1 ± 16.6 N, respectively (P = .001). The modified Watkins score was significantly higher in the TCR group (23.5; range, 22-27) than in the ISR group (19.5; range, 16-22) (P = .009).Conclusion:Both repair techniques are effective for 50% partial-thickness bursal-side rotator cuff tears; however, TCR yields significantly superior biomechanical and histological characteristics compared with ISR.Clinical Relevance:Tear completion and repair technique may increase tendon-to-bone healing and thereby reduce re-rupture rate in the partial thickness bursal side rotator cuff tears.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-04-16T05:07:39Z
      DOI: 10.1177/0363546520909854
  • All-Inside Repair of Bucket-Handle Meniscal Tears: Clinical Outcomes and
           Prognostic Factors
    • Authors: Carolyn A. Ardizzone, Darby A. Houck, Derek W. McCartney, Armando F. Vidal, Rachel M. Frank
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:There is no consensus on technique of choice for repair of bucket-handle meniscal tears (BHMTs).Purpose:To determine factors that affect patient outcomes and failure rates in patients undergoing all-inside repairs of BHMTs.Study Design:Systematic review.Methods:A systematic review of 3 databases using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was performed. All English-language literature from 1993 to 2019 describing clinical outcomes for patients undergoing all-inside BHMT repair with ≥12-month follow-up was reviewed by 2 independent reviewers. Patient characteristics (patient sex, age), intraoperative factors (laterality, concomitant procedures, surgical technique, implants utilized), and postoperative outcomes (failure rates) were analyzed. Study quality was evaluated with the Modified Coleman Methodology Score (MCMS).Results:Fifteen studies (1 level 1, 4 level 3, 10 level 4) with 763 total patients (64% male; average age, 26.4 years [range, 9-58 years]; average follow-up, 39.8 months [range, 12-120 months]) including 396 all-inside BHMT repairs were included. Six devices were used for repair including the Meniscal Repair System, FasT-Fix, Meniscus Arrow, Biofix Arrow, RapidLoc device, and PDS II suture, with failure rates of 13.5%, 22.4%, 27.1%, 42.9%, 45.2%, and 0%, respectively. The overall repair failure rate was 29.3% at an average of 13.0 months (range, 5.0-32.4 months), but 19.0% for devices still in use. The RapidLoc and Biofix Arrow had higher failure rates than other devices (P = .0003). Women (31%) were less likely to experience a failure than were men (69%) (P = .03). Longer follow-up duration resulted in higher failure rates (>30 months, 34.4%; .05 for all). The overall average MCMS was 54.4 ± 12.Conclusion:The overall failure rate after all-inside repair of BHMTs is 29.3% at an average of 13.0 months, with no difference in failure rates between medial and lateral meniscal repairs. The variables shown to negatively affect the failure rates were the RapidLoc and Biofix Arrow, male sex, and longer follow-up duration.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-03-20T03:33:29Z
      DOI: 10.1177/0363546520906141
  • Superior Capsule Reconstruction for Irreparable Massive Rotator Cuff
           Tears: Does It Make Sense' A Systematic Review of Early Clinical
    • Authors: Burak Altintas, Michael Scheidt, Victor Kremser, Robert Boykin, Sanjeev Bhatia, Kaveh R. Sajadi, Scott Mair, Peter J. Millett
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Treatment of irreparable massive rotator cuff tears (MRCTs) in patients without advanced glenohumeral osteoarthritis remains a challenge. Arthroscopic superior capsule reconstruction (SCR) represents a newer method for treatment with increasing popularity and acceptance.Purpose:To analyze the clinical evidence surrounding SCR and determine the current clinical outcomes postoperatively.Study Design:Systematic review.Methods:A systematic review of the literature was performed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Electronic databases of PubMed, MEDLINE, Cochrane, and Google Scholar were used for the literature search. The study quality was evaluated according to the Modified Coleman Methodology Score. Studies in English evaluating SCR outcomes were included.Results:Seven studies were reviewed, including 352 patients (358 shoulders) treated with arthroscopic SCR with the mean duration of follow-up ranging from 15 to 48 months (range, 12-88 months). Fourteen patients were lost to follow-up, leaving 338 patients (344 shoulders) with clinical outcome data. Graft types included dermal allografts (n = 3 studies), fascia lata autografts (n = 3), or both (n = 1). Most commonly, a double-row technique was utilized for humeral graft fixation. The most common complication included graft tears in 13% of patients, resulting in 15 SCR revisions and 7 reverse shoulder arthroplasties. Postoperatively, improvements in visual analog scale (2.5 to 5.9), American Shoulder and Elbow Surgeons (20 to 56), Japanese Orthopaedic Association (38.0), Subjective Shoulder Value (37.0 to 41.3), and Constant (11.6 to 47.4) scores were observed. Three studies reported respective satisfaction rates of 72.9%, 85.7% and 90%. Increases in external rotation, internal rotation, and abduction with improved strength in external rotation were observed postoperatively. Improvement of pseudoparalysis was also observed in 3 studies. One study reported return to sports in 100% of patients (2 competitively, 24 recreationally) with no adverse outcomes.Conclusion:SCR showed good to excellent short-term clinical outcomes with adequate pain relief and functional improvement. The current evidence suggests that the procedure is an alternative for symptomatic patients with irreparable MRCT; however, the included studies were fair to poor in quality, and there were some notable complications. Long-term follow-up will determine the longevity and ultimate role of this new method in the treatment of irreparable MRCT.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-03-19T05:45:00Z
      DOI: 10.1177/0363546520904378
  • Adjunct Analgesia Reduces Pain and Opioid Consumption After Hip
           Arthroscopy: A Systematic Review of Randomized Controlled Trials
    • Authors: Kyle N. Kunze, Evan M. Polce, Daniel T. Lilly, Flavio L. Garcia, Matthew R. Cohn, Shane J. Nho, Jorge Chahla
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Patients who undergo hip arthroscopy inevitably experience pain postoperatively; however, the efficacy and safety of adjunct analgesia to prevent or reduce pain are not well-understood.Purpose:To perform a comprehensive qualitative synthesis of available randomized controlled trials evaluating the effect of adjunct analgesia on postoperative (1) pain, (2) opioid use, and (3) length of stay (LOS) in patients undergoing hip arthroscopy.Study Design:Systematic review.Methods:PubMed, OVID/MEDLINE, and Cochrane Controlled Register of Trials were queried for studies pertaining to analgesia interventions for patients undergoing hip arthroscopy. Two authors independently assessed article bias and eligibility. Data pertaining to changes in pain scores, additional analgesia requirements, length of hospital stay, and complications were extracted and qualitatively reported. Network meta-analyses were constructed to depict mean pain, opioid use, and LOS among the 3 analgesia categories (blocks, local infiltration analgesia, and celecoxib).Results:Fourteen level 1 studies were included; 12 (85.7%) reported pain reductions in the immediate and perioperative period after hip arthroscopy. Of the 7 studies that assessed an intervention (2 celecoxib, 1 fascia iliaca block, 1 lumbar plexus block, 1 femoral nerve block, 1 intra-articular bupivacaine, 1 extracapsular bupivacaine) versus placebo, more than half reported that patients who received an intervention consumed significantly fewer opioids postoperatively than patients who received placebo (lowest P value = .0006). Of the same 7 studies, 2 reported significantly shortened LOS with interventions, while 4 reported no statistically significant difference in LOS and 1 did not report LOS as an outcome.Conclusion:The majority of studies concerning adjunct analgesia for patients undergoing hip arthroscopy suggest benefits in pain reduction early in the postoperative period. There is mild evidence that adjunct analgesia reduces postoperative opioid use and currently inconclusive evidence that it reduces length of hospital stay. Furthermore, it appears that local infiltration analgesia may provide the greatest benefits in reductions in pain and opioid consumption. We recommend the use of adjunct analgesia in appropriately selected patients undergoing hip arthroscopy without contraindication who are at a high risk of severe postoperative pain.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-03-02T09:28:09Z
      DOI: 10.1177/0363546520905884
  • Relationship of the Medial Patellofemoral Ligament Origin on the Distal
           Femur to the Distal Femoral Physis: A Systematic Review
    • Authors: Kyle R. Sochacki, Kevin G. Shea, Kunal Varshneya, Marc R. Safran, Geoffrey D. Abrams, Joseph Donahue, Seth L. Sherman
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:The relationship between the medial patellofemoral ligament (MPFL) and the distal femoral physis has been reported in multiple studies.Purpose:To determine the distance from the MPFL central origin on the distal femur to the medial distal femoral physis in skeletally immature participants.Study Design:Systematic review.Methods:A systematic review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Multiple databases were searched for studies investigating the anatomic origin of the MPFL on the distal femur and its relationship to the medial distal femoral physis in skeletally immature participants. Study methodological quality was analyzed with the Anatomical Quality Assessment tool, with studies categorized as low risk, high risk, or unclear risk of bias. Continuous variable data were reported as mean ± SD. Categorical variable data were reported as frequency with percentage.Results:Seven articles were analyzed (298 femurs, 53.7% male patients; mean age, 11.7 ± 3.4 years). There was low risk of bias based on the Anatomical Quality Assessment tool. The distance from the MPFL origin to the distal femoral physis ranged from 3.7 mm proximal to the physis to 10.0 mm distal to the physis in individual studies. Six of 7 studies reported that the MPFL origin on the distal femur lies distal to the medial distal femoral physis in the majority of specimens. The MPFL originated distal to the medial distal femoral physis in 92.8% of participants at a mean distance of 6.9 ± 2.4 mm.Conclusion:The medial patellofemoral ligament originates distal to the medial distal femoral physis in the majority of cases at a mean proximal-to-distal distance of 7 mm distal to the physis. However, this is variable in the literature owing to study design and patient age and sex.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-02-28T07:05:53Z
      DOI: 10.1177/0363546520904685
  • Treatment of Pectoralis Major Tendon Tears: A Systematic Review and
           Meta-analysis of Repair Timing and Fixation Methods
    • Authors: Blake M. Bodendorfer, David X. Wang, Brian P. McCormick, Austin M. Looney, Christine M. Conroy, Caroline M. Fryar, Joshua A. Kotler, William J. Ferris, William F. Postma, Edward S. Chang
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Repair of torn pectoralis major tendons is generally considered superior to nonoperative management, but there is a paucity of comparative data to demonstrate ideal repair timing and fixation methods.Purpose/Hypothesis:The purpose was to compare the outcomes between acute and chronic repair and among the various methods of fixation (transosseous tunnels, cortical buttons, suture anchors, screws with washers, and direct repair). It was hypothesized that acute repair would have superior outcomes and there would be similar outcomes among the various methods of fixation.Study Design:Meta-analysis.Methods:In accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a systematic review of the literature was completed through MEDLINE, SPORTDiscus, CINAHL, Cochrane, Embase, and Web of Science databases. English-language studies were included with a minimum of 6 months’ mean follow-up and 5 cases per study. MINORS (Methodological Index for Nonrandomized Studies) was utilized to assess the quality of the existing literature. Analysis of mechanisms of injury and meta-analysis of pooled outcomes were completed. Pooled effect sizes were calculated from random effects models. Continuous variables were assessed via mixed model analysis, with the individual study designated as a random effect and the desired treatment for comparison as a fixed effect. Bivariate frequency data were transformed through Freeman-Tukey log-linear transformation for variance stabilization and then assessed through a mixed model with a study-level random effect and subsequently back-transformed. Significance was set at P < .05.Results:Twenty articles with 384 injuries met the inclusion criteria for comparison. All patients were male, with 61.9% of injuries occurring during weight training, at a mean age of 31.53 years, and with a mean follow-up of 30.12 months. Included studies scored a mean (SD) 15.53 ± 4.26 (range, 7.0-23.3) by MINORS criteria. Acute repair was significantly superior to chronic repair, with a relative improvement of functional outcome by 0.85 (P = .004) and satisfaction with cosmesis by 20.50% (P = .003). There was a trend toward acute repair having a higher proportion of patients who were pain-free (34.47%, P = .064). There were no significant differences among the methods of fixation for repair.Conclusion:Acute repair of pectoralis major tendon tears resulted in significantly superior functional outcomes and cosmesis satisfaction with a trend toward a higher proportion of patients who were pain-free. There were no significant differences among the methods of fixation for repair.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-02-28T05:16:21Z
      DOI: 10.1177/0363546520904402
  • Efficacy of Nonaugmented, Static Augmented, and Dynamic Augmented Suture
           Repair of the Ruptured Anterior Cruciate Ligament: A Systematic Review of
           the Literature
    • Authors: Roy A.G. Hoogeslag, Reinoud W. Brouwer, Astrid J. de Vries, Barbara C. Boer, Rianne Huis in ‘t Veld
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Anterior cruciate ligament suture repair (ACLSR) was abandoned late last century in favor of anterior cruciate ligament (ACL) reconstruction (ACLR) because of overall disappointing results. However, in recent years there has been renewed and increasing interest in ACLSR for treatment of ACL ruptures. Several contemporary ACLSR techniques are being used, but any difference in effectiveness is unclear.Hypothesis:Contemporary nonaugmented (NA), static augmented (SA), and dynamic augmented (DA) ACLSR leads to (1) comparable outcomes overall and (2) comparable outcomes between proximal third, middle third, and combined ACL rupture locations (a) within and (b) between ACLSR technique categories.Study Design:Systematic review.Methods:An electronic search was performed in the MEDLINE and Embase databases for the period between January 1, 2010, and August 7, 2019. All articles describing clinical and patient-reported outcomes for ACLSR were identified and included, and outcomes for NA, SA, and DA ACLSR categories were compared.Results:A total of 31 articles and 2422 patients were included. The majority of articles (65%) and patients (89%) reported outcomes of DA ACLSR. Overall, there was high heterogeneity in study characteristics and level as well as quality of evidence (19 level 4; 7 level 3; 3 level 2; and 2 level 1). Most studies indicated excellent patient-reported outcomes. Overall, the variability in (and the maximum of) the reported failure rate was high within all ACLSR categories. The variability in (and the maximum of) the reported rate of all other complications was highest for DA ACLSR. Regarding ACL rupture location, the failure rate was highest in proximal ACL ruptures within the SA and DA ACLSR categories; rates of all other reported complications were highest in combined ACL ruptures within the DA ACLSR category. However, no studies in the NA category and only 1 study in the SA ACLSR category evaluated combined ACL ruptures. The majority of studies comparing ACLSR and ACLR found no differences in outcomes.Conclusion:The amount of high-quality evidence for contemporary ACLSR is poor. This makes it difficult to interpret differences among ACLSR categories and among ACL rupture locations and, though promising, to establish the role of ACLSR in the treatment of ACL ruptures. More high-quality large randomized clinical trials with longer follow-up comparing ACLSR and ACLR are needed.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-02-26T10:09:24Z
      DOI: 10.1177/0363546520904690
  • Complications After Distal Biceps Tendon Repair: A Systematic Review
    • Authors: Melanie Amarasooriya, Gregory Ian Bain, Tom Roper, Kimberley Bryant, Karim Iqbal, Joideep Phadnis
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Distal biceps tendon injuries typically occur in the dominant arm of men in their fourth decade of life. Surgical repair restores flexion and supination strength, resulting in good functional outcome. The complication profile of each surgical approach and fixation technique has not been widely studied in the literature.Purpose:To report the rate of complications after repair of complete distal biceps ruptures, to classify them according to surgical approach and fixation technique, and to analyze risk factors and outcomes of the individual complications.Study Design:Systematic review.Methods:Studies published in English on primary repair of the distal biceps between January 1998 and January 2019 were identified. Data on complications were extracted and classified as major and minor for analysis. A quantitative synthesis of data was done to compare the complication rates between (1) limited anterior incision, extensile anterior incision, and double incision and (2) 4 fixation methods.Results:Seventy-two articles including 3091 primary distal biceps repairs were identified. The overall complication rate was 25% (n = 774). The major complication rate was 4.6% (n = 144) and included a 1.6% (n = 51) rate of posterior interosseous nerve injury; 0.3% (n = 10), median nerve injury; 1.4% (n = 43), rerupture; and a 0.1% (n = 4), synostosis. Brachial artery injury, ulnar nerve injury, compartment syndrome, proximal radius fracture, and chronic regional pain syndrome occurred at a rate of
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-02-24T07:33:25Z
      DOI: 10.1177/0363546519899933
  • Ischemic Therapy in Musculoskeletal Medicine
    • Authors: Austin J. Ramme, Brennan J. Rourke, Christopher M. Larson, Asheesh Bedi
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:The competitive environment of athletics has promoted the exploration of any technology application that may offer an edge with performance and recovery from injury. Ischemic therapy is one such technology that has rapidly been incorporated into training rooms and physical therapy clinics worldwide. This therapy modality is reported to increase an athlete’s ability to improve muscle mass, strength, and endurance.Purpose:To provide the sports medicine physician with an understanding of the current state of ischemic therapy technology, including treatment specifications, known physiological effects, hypothesized mechanisms, biochemical effects, athletic applications, medical applications, animal models, and future research recommendations.Study Design:Literature review.Methods:A computer-based search of the PubMed database was used to perform a comprehensive literature review on musculoskeletal ischemic therapy.Results:The current research on ischemic therapy is largely composed of case series with varying equipment, methods, and therapy specifications. The publication of case series has value in identifying this technology for future research, but the results of these studies should not be justification for application to athletes without validation of safety and effectiveness.Conclusion:To date, ischemic therapy remains unvalidated, and the mechanism by which it improves muscle performance is not clear.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-02-11T07:38:32Z
      DOI: 10.1177/0363546520901539
  • Effect of Normal Saline Injections on Lateral Epicondylitis Symptoms: A
           Systematic Review and Meta-analysis of Randomized Clinical Trials
    • Authors: Carlos Alberto Acosta-Olivo, Juan Manuel Millán-Alanís, Luis Ernesto Simental-Mendía, Neri Álvarez-Villalobos, Félix Vilchez-Cavazos, Víctor Manuel Peña-Martínez, Mario Simental-Mendía
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Lateral epicondylitis, or tennis elbow, is a painful degenerative disorder that commonly occurs in adults between 40 and 60 years of age. Normal saline (NS) injections have been used as placebo through a large number of randomized controlled trials (RCTs) focused on the treatment of lateral epicondylitis.Purpose:This meta-analysis of RCTs aimed to assess the therapeutic effect of NS injections on lateral epicondylitis symptoms and compare results with established minimal clinically important difference criteria.Study Design:Systematic review and meta-analysis.Methods:MEDLINE, Embase, Web of Science, and Scopus databases were searched for clinical trials reporting pain and joint function with the visual analog scale, Patient-Rated Tennis Elbow Evaluation, and Disabilities of the Arm, Shoulder and Hand in patients with lateral epicondylitis. The meta-analysis was conducted with a random effects model and generic inverse variance method. Heterogeneity was tested with the I2 statistic index.Results:A total of 15 RCTs included in this meta-analysis revealed a significant improvement in pain (mean difference, 3.61 cm [95% CI, 2.29-4.92 cm]; P < .00001; I2 = 88%; visual analog scale) and function (mean difference, 25.65 [95% CI, 13.30-37.99]; P < .0001; I2 = 82%; Patient-Rated Tennis Elbow Evaluation / Disabilities of the Arm, Shoulder and Hand) after NS injection (≥6 months).Conclusion:NS injections yielded a statistically significant and clinically meaningful improvement in pain and functional outcomes in patients with lateral epicondylitis. New research should focus on better methods to diminish the potential confounders that could lead to this effect because NS injections could mask the real effect of an active therapeutic intervention in RCT.Registration:CRD42019127547 (PROSPERO).
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-02-11T07:23:50Z
      DOI: 10.1177/0363546519899644
  • The Concept of Sport Sampling Versus Sport Specialization: Preventing
           Youth Athlete Injury: A Systematic Review and Meta-analysis
    • Authors: Seth L. Carder, Nicolas E. Giusti, Lisa M. Vopat, Armin Tarakemeh, Jordan Baker, Bryan G. Vopat, Mary K. Mulcahey
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:The prevalence of youth athletes specializing in 1 sport has been increasing over the past decade. Subsequently, the rate of youth athlete injury has also been increasing. It is possible that an association exists between youth specialization and sports injury rate.Purpose:To determine if sport sampling is associated with a lower sports injury rate in youths compared with youths who specialize in 1 sport.Study Design:Systematic review and meta-analysis.Methods:A systematic review was conducted following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using PubMed, Embase, and the Cochrane library. Inclusion criteria included studies written in the English language, studies with athletes between 7 and 18 years of age, studies that report injury rates, and studies that specify if athletes were sport samplers or specialized in a sport. Data relevant to this study, including injuries and patient characteristics, were extracted and statistically analyzed.Results:The initial search identified 324 studies, 6 of which met inclusion criteria. From these 6 studies, the total participant number was 5736. Of those, 2451 (42.7%) were “sport samplers,” 1628 (28.4%) were “sport specializers,” and 1657 (28.9%) were considered “others” (ie, could not be classified as true samplers or true specializers). The average age of all the athletes was 14.6 years (range, 7-18 years). Sport specializers had a significantly higher injury risk than the sport samplers (RR, 1.37; 95% CI, 1.19-1.57; P < .0001). There was a higher risk of injury in the “others” group when compared with the “sport sampler” group (RR, 1.21; 95% CI, 1.14-1.29; P < .0001). There was a higher risk of injury in the “sport specializer” group over the “others” group (RR, 1.09; 95% CI, 1.04-1.14; P < .005).Conclusion:Sport sampling is associated with a decreased risk of sports injury in youth athletes when compared with those who specialize in 1 sport. Injury rates increase as a youth athlete becomes increasingly specialized. Youth athletes would benefit substantially from participating in sport sampling.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-01-21T06:33:22Z
      DOI: 10.1177/0363546519899380
  • Predictive Modeling to Determine Functional Outcomes After Arthroscopic
           Rotator Cuff Repair
    • Authors: Salvatore Frangiamore, Grant J. Dornan, Marilee P. Horan, Sandeep Mannava, Erik M. Fritz, Zaamin B. Hussain, Gilbert Moatshe, Jonathan A. Godin, Jonas Pogorzelski, Peter J. Millett
      First page: 1559
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Arthroscopic rotator cuff repair (ARCR) is one of the most commonly performed orthopaedic surgical procedures; however, patient-reported outcomes have varied greatly in the literature.Purpose:To identify preoperative factors that affect outcomes and to develop prognostic tools for predicting functional outcomes in future ARCR cases.Study Design:Cohort study; Level of evidence, 3.Methods:Patients were included who underwent ARCR for repairable full-thickness rotator cuff tears with at least 2 years of follow-up. Twelve predictors were entered as candidate predictors in each model: age, sex, workers’ compensation (WC) status, previous cuff repair, tear size, tear shape, multiple-tendon involvement, tendon stump length, Goutallier classification, critical shoulder angle, length of follow-up, and baseline subjective outcomes score. Postoperative American Shoulder and Elbow Surgeons (ASES), 12-Item Short Form Health Survey Physical Component Summary (SF-12 PCS), QuickDASH (short version of Disabilities of the Arm, Shoulder and Hand), and patient satisfaction were each modeled through proportional odds ordinal logistic regression. Model results were presented with marginal covariate effect plots and predictive nomograms.Results:Overall, 552 shoulders fit inclusion criteria. The mean age at surgery was 60.2 years (range, 23-81 years). Twenty-five (4.5%) shoulders underwent revision cuff repair or reverse arthroplasty at a mean 1.9 years (range, 0.1-7.9 years) postoperatively. Overall, 509 shoulders were eligible for follow-up, and minimum 2-year postoperative patient-reported outcomes were obtained for 449 (88.2%) at a mean 4.8 years (range, 2-11 years). The ASES score demonstrated significant improvement from pre- to postoperative median (interquartile range): 58 (44.9-71.6) to 98.3 (89.9-100; P < .001). Women demonstrated significantly higher 2-year reoperation rates than men (5.8% vs 1.6%; odds ratio, 2.8 [95% CI, 0.73-9.6]; P = .023). Independently significant predictors for lower postoperative ASES scores included previous ARCR (P < .001), female sex (P < .001), and a WC claim (P < .001). Significant predictors for worse QuickDASH scores included WC claim (P < .001), female sex (P < .001), previous ARCR (P = .007), and ≥7 years of follow-up time. Significant predictors for lower SF-12 PCS scores included WC claim (P < .001), female sex (P = .001), and lower baseline SF-12 PCS. Last, significant independent predictors of patient satisfaction included previous ARCR (P = .004), WC claim (P = .011), female sex (P = .041), and age (P = .041).Conclusion:Excellent clinical outcomes and low failure rates were obtained after ARCR by using careful patient selection and modern surgical techniques for ARCR. Female sex, WC claim, and previous ARCR were significant predictors of poorer outcomes in at least 3 patient-reported outcome models. Prognostic nomograms were developed to aid in future patient selection, clinical decision making, and patient education.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-05-14T03:55:07Z
      DOI: 10.1177/0363546520914632
  • Long-term Results of Arthroscopic Rotator Cuff Repair: A Follow-up Study
           Comparing Single-Row Versus Double-Row Fixation Techniques
    • Authors: Fabian Plachel, Paul Siegert, Katja Rüttershoff, Kathi Thiele, Doruk Akgün, Philipp Moroder, Markus Scheibel, Christian Gerhardt
      First page: 1568
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Arthroscopic rotator cuff repair (RCR) with suture anchor–based fixation techniques has replaced former open and mini-open approaches. Nevertheless, long-term studies are scarce, and lack of knowledge exists about whether single-row (SR) or double-row (DR) methods are superior in clinical and anatomic results.Purpose:To analyze long-term results after arthroscopic RCR in patients with symptomatic rotator cuff tears and to compare functional and radiographic outcomes between SR and DR repair techniques at least 10 years after surgery.Study Design:Cohort study; Level of evidence, 3.Methods:Between 2005 and 2006, 40 patients with a symptomatic full-thickness rotator cuff tear (supraspinatus tendon tear with or without a tear of the infraspinatus tendon) underwent arthroscopic RCR with either an SR repair with a modified Mason-Allen suture–grasping technique (n = 20) or a DR repair with a suture bridge fixation technique (n = 20). All patients were enrolled in a long-term clinical evaluation, with the Constant score (CS) as the primary outcome measure. Furthermore, an ultrasound examination was performed to assess tendon integrity and conventional radiographs to evaluate secondary glenohumeral osteoarthritis.Results:A total of 27 patients, of whom 16 were treated with an SR repair and 11 with a DR repair, were followed up after a mean ± SD period of 12 ± 1 years (range, 11-14 years). Five patients underwent revision surgery on the affected shoulder during follow-up period, which led to 22 patients being included. The overall CS remained stable at final follow-up when compared with short-term follow-up (81 ± 8 vs 83 ± 19 points; P = .600). An increasing number of full-thickness retears were found: 6 of 22 (27%) at 2 years and 9 of 20 (45%) at 12 years after surgery. While repair failure negatively affected clinical results as shown by the CS (P < .05), no significant difference was found between the fixation techniques (P = .456). In general, progressive osteoarthritic changes were observed, with tendon integrity as a key determinant.Conclusion:Arthroscopic RCR with either an SR or a DR fixation technique provided good clinical long-term results. Repair failure was high, with negative effects on clinical results and the progression of secondary glenohumeral osteoarthritis. While DR repair slightly enhanced tendon integrity at long-term follow-up, no clinical superiority to SR repair was found.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-05-11T03:48:06Z
      DOI: 10.1177/0363546520919120
  • Does the Dog-Ear or Bird-Beak Deformity Remodel After Rotator Cuff
    • Authors: Yong Bok Park, Jung Ho Park, Seung Won Lee, Tae Wan Jung, Kyoung Hwan Koh, Jae Chul Yoo
      First page: 1575
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Dog-ear and bird-beak deformities are common after transosseous-equivalent repair (suture bridge technique). The natural course of deformities after rotator cuff (RC) repair using the suture bridge technique is unclear. The remodeling potential of these deformities has not been investigated.Purpose:To evaluate remodeling and retear rates associated with deformities after RC repair.Study Design:Cohort study; Level of evidence, 3.Methods:Between November 2011 and February 2012, we studied 99 consecutive shoulders. All patients underwent arthroscopic RC repair via the suture bridge technique with or without additional sutures. Two groups were formed: no deformity (n= 46) and deformity (n = 53). Deformity was defined as marginal detachment and protrusion of the RC after repair, involving inappropriate compression of the suture limbs from the anchors. Tendon height was measured from the highest point of the most protruding portion of the cuff to the cortex on semi-coronal magnetic resonance imaging (MRI) scan. Change in tendon height was evaluated on MRI scan at 1 week and 6 months postoperatively. Clinical assessment at every patient visit included the American Shoulder and Elbow Surgeons (ASES) score, Constant shoulder score, and visual analog scale for pain (pVAS) score.Results:No significant differences were found in age, sex, symptom duration, tear size, and preoperative ASES, Constant, and pVAS scores (P> .05) between the 2 groups. The initial tendon height was 7.4 ± 1.5 mm in the no-deformity group and 9.3 ± 2.0 mm in the deformity group. Follow-up height was 6.3 ± 2.1 mm in the no-deformity group and 6.4 ± 1.6 mm in the deformity group. Mean postoperative tendon heights were 90.1% ± 23.8% of the initial height in the no-deformity group and 73.2% ± 15.1% in the deformity group. Clinical scores (ASES, Constant, and pVAS) were not significantly different between the groups at 6 months. There were 4 shoulders in each group that experienced retearing (types 4 and 5 according to the Sugaya classification) at 6 months postoperatively. There was no difference in retear rate (P> .999).Conclusion:Most deformities after RC repair were remodeled with no effect on retears. Clinical outcomes were not affected by deformities.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-05-05T03:49:28Z
      DOI: 10.1177/0363546520915199
  • Superior Labral Anterior Posterior Repair and Biceps Tenodesis Surgery:
           Trends of the American Board of Orthopaedic Surgery Database
    • Authors: Gregory L. Cvetanovich, Anirudh K. Gowd, Travis L. Frantz, Brandon J. Erickson, Anthony A. Romeo
      First page: 1583
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Recent evidence has specified indications for performing superior labral anterior posterior (SLAP) repair and biceps tenodesis (BT) for the treatment of bicipital-labral lesions in the shoulder. Trends in performance of these procedures are expected to reflect the growing body of research regarding this topic.Purpose:To report practice trends for the surgical treatment of SLAP lesions utilizing the American Board of Orthopaedic Surgery (ABOS) database, particularly in older patients.Study Design:Cohort study; Level of evidence, 3.Methods:The ABOS database was retrospectively queried between 2012 and 2017 by Current Procedural Terminology (CPT) codes for SLAP repair (29807), open BT (23430), and arthroscopic BT (29828). The patient population was excluded if any concomitant open shoulder procedure was performed. Trends over time were evaluated with respect to case volume, patient age, surgeon subspecialty, and whether a concomitant arthroscopic rotator cuff repair (RCR) was performed (CPT 29827).Results:A total of 9908 cases met inclusion/exclusion criteria: 4632 performed with RCR and 5276 performed without. The mean age of patients without RCR was 40.8 ± 13.8 years, while for those receiving RCR it was 55.0 ± 9.9 years (P < .001). In patients without RCR, there was a significant decline in rate of SLAP repairs performed over this period (P < .001). A significantly greater proportion of patients receiving open and arthroscopic BT were older than 35 years of age, compared with those receiving SLAP repair (P < .001). Within the RCR cohort, there was also a significant decline in concomitant SLAP repairs performed (P < .001) over the study period. With respect to BT, open BT was performed more frequently in the cohort without RCR (74.5%) than in the cohort with RCR (52.1%) (P < .001). Similarly, arthroscopic BT was performed more commonly in the cohort with RCR (47.9%) than in the cohort without RCR (25.5%) (P < .001).Conclusion:The ABOS database revealed significantly reduced rates of SLAP repairs performed in recent times. Trends with age remained consistent over time, in that SLAP repairs were predominantly performed in younger patients. Open BT was performed more frequently overall, but with an increased proportion of arthroscopic BT occurring with RCR. Arthroscopic BT was performed much more frequently with RCR than without.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-04-16T07:43:52Z
      DOI: 10.1177/0363546520913538
  • Intramuscular Brown Fat Activation Decreases Muscle Atrophy and Fatty
           Infiltration and Improves Gait After Delayed Rotator Cuff Repair in Mice
    • Authors: Zili Wang, Xuhui Liu, Kunqi Jiang, Hubert Kim, Shingo Kajimura, Brian T. Feeley
      First page: 1590
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Successful repair of large and massive rotator cuff (RC) tears remains a challenge at least partially because of secondary muscle atrophy and fatty infiltration. β3 Adrenergic agonists are a group of drugs that promote fat resorption through “white fat browning” of intramuscular stem cells.Purpose:To test the role of a β3 adrenergic receptor agonist, amibegron, in improving muscle quality and forelimb function in a delayed RC repair model via promoting brown/beige adipose tissue activation.Study Design:Controlled laboratory study.Methods:Three-month-old PDGFRα-GFP reporter mice, wild type C57BL/6J mice, and uncoupling protein 1 (UCP-1) knockout mice underwent unilateral supraspinatus tendon transection with a 6-week delayed tendon repair. Animals with sham surgery served as controls. Amibegron was given either immediately after tendon transection or after repair. Gait analysis was conducted to measure forelimb function at 6 weeks after tendon repair. Animals were sacrificed at 6 weeks after repair. Supraspinatus muscles were harvested and analyzed histologically. Reverse transcription polymerase chain reaction was performed to quantify gene expression related to atrophy, fibrosis, and fatty infiltration.Results:Histology of PDGFRα reporter mice showed significantly increased UCP-1 expression, suggesting white fat browning in muscle after RC repair. As administered either immediately after tendon transection or after tendon repair, amibegron significantly reduced muscle atrophy and fatty infiltration and resumed normal upper extremity gait in wild type mice. However, the effect of amibegron was not present in UCP-1 knockout mice, suggesting that the effect of amibegron in treating RC muscle atrophy and fatty infiltration is through a UCP 1–dependent mechanism.Conclusion:Amibegron reduced muscle atrophy and fatty infiltration and improved forelimb function after delayed RC repair through a UCP 1–dependent mechanism. This may be an effective clinical treatment strategy for patients to improve muscle quality after RC repair.Clinical Relevance:β3 Adrenergic agonists may serve as a new pharmacologic modality to treat RC muscle atrophy and fatty infiltration to improve clinical outcome of RC repair.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-04-13T04:24:00Z
      DOI: 10.1177/0363546520910421
  • The Influence of Pitch Velocity on Medial Elbow Pain and Medial Epicondyle
           Abnormality Among Youth Baseball Players
    • Authors: Daisuke Kurokawa, Takayuki Muraki, Hiroaki Ishikawa, Kiyotsugu Shinagawa, Hideaki Nagamoto, Hiroyuki Takahashi, Nobuyuki Yamamoto, Minoru Tanaka, Eiji Itoi
      First page: 1601
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Pitch velocity is associated with elbow injuries among skillful baseball players. However, the relationship between pitch velocity and throwing elbow injuries among youth players has not yet been clarified.Purpose:To investigate the influence of pitch velocity on medial elbow pain and medial epicondyle abnormality among youth baseball players.Study Design:Cohort study; Level of evidence, 3.Methods:The participants consisted of 256 elementary school players (mean age, 11 ± 1 years; range, 9-12 years). The medial aspect of the elbow was evaluated using ultrasound imaging. A questionnaire was used to investigate past or present pain in the elbow, background of the players (age, height, body mass index, and years of baseball experience), and playing environment (number of days of practice in a week, experience as a pitcher, and cryotherapy of the shoulder and elbow after practice). Positioning of the scapula, range of motion in shoulder internal/external rotations and hip internal rotation, angle of the straight-leg raise, and heel-to-buttock distance were measured. The pitch velocity was recorded using a pitch velocity radar gun. The relationship between these variables and the presence of medial epicondyle abnormality, as well as past or present elbow pain, were statistically analyzed.Results:A medial epicondyle abnormality was observed in 130 players (51%), elbow pain in the past in 65 players (25%), and elbow pain during the examination in 14 players (5%). Sixty-nine players (27%) experienced elbow pain either in the past or during examination. Abnormality of the medial epicondyle had a relationship with the pitch velocity (odds ratio [OR], 1.1 for increase of 1 km/h; 95% CI, 1.1-1.2; P < .0001) and the number of practice days in a week (OR, 1.8 for increase of the practice days; 95% CI, 1.4-2.5; P < .0001). Pitch velocity was also significantly related with past pain, present pain, and past and/or present pain of the elbow (OR [km/h], 1.1, 1.1, 1.1; 95% CI, 1.0-1.1, 1.0-1.2, 1.1-1.2; P < .0001, P = .002, P < .0001, respectively).Conclusion:Pitch velocity was significantly associated with abnormality of the medial epicondyle and elbow pain. A 10-km/h increase in pitch velocity would increase the risk of medial epicondyle abnormality and medial elbow pain by 3 times.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-05-04T05:24:57Z
      DOI: 10.1177/0363546520914911
  • A Multicenter Study of Radiographic Measures Predicting Failure of
           Arthroscopy in Borderline Hip Dysplasia: Beware of the Tönnis Angle
    • Authors: Kade S. McQuivey, Erwin Secretov, Benjamin G. Domb, Bruce A. Levy, Aaron J. Krych, Matthew Neville, David E. Hartigan
      First page: 1608
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Hip arthroscopy has been previously demonstrated to be an effective treatment for adult mild hip dysplasia. There are many radiographic parameters used to classify hip dysplasia, but to date few studies have demonstrated which parameters are of most importance for predicting surgical outcomes.Purpose:To identify preoperative radiographic parameters that are associated with poor outcomes in the arthroscopic treatment of adult mild hip dysplasia.Study Design:Case-control study; Level of evidence, 3.Methods:Radiographic analysis was performed in patients with mild hip dysplasia who underwent arthroscopic surgery between 2009 and 2015. Preoperative radiographic measurements included lateral center edge angle, Tönnis angle, neck shaft angle, anterior center edge angle, alpha angle, femoral head extrusion index, and acetabular depth-to-width ratio. Failure was defined as failure to achieve the minimal clinically important difference (MCID) utilizing the modified Harris Hip Score or as the need for secondary operation. The equal variance t test was used to analyze radiographic parameters. Statistical significance was determined using a P value of .05.Results:A total of 373 hips underwent analysis with an average follow-up of 41 months (range, 24-102 months). Of these, 46 hips (12%) required secondary operation, and 95 (25%) failed to meet the MCID. The overall failure rate was 32.4%. There was no single measurement or combination thereof associated with failure to reach the MCID. Higher preoperative Tönnis angles were associated with secondary operation, with a mean of 6.7° (95% CI, 5.3°-8.1°) in the secondary operation group versus 4.8° (95% CI, 4.4°-5.3°) in the nonsecondary operation group (P = .006). The odds ratio was 1.12 (95% CI, 1.0-1.2; P = .05) per degree increase in Tönnis angle for secondary operation. In patients with a Tönnis angle>10°, 84% required secondary operation.Conclusion:Higher Tönnis angles portend a higher risk for revision surgery. The probability of secondary operation was increased by a magnitude of 1.12 with each degree increase in the Tönnis angle. In patients with a Tönnis angle>10°, 84% required a secondary operation.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-04-28T04:56:46Z
      DOI: 10.1177/0363546520914942
  • Patients With Borderline Hip Dysplasia Achieve Clinically Significant
           Improvement After Arthroscopic Femoroacetabular Impingement Surgery: A
           Case-Control Study With a Minimum 5-Year Follow-up
    • Authors: Edward C. Beck, Justin Drager, Benedict U. Nwachukwu, Jonathan Rasio, Kyleen Jan, Jorge Chahla, Shane J. Nho
      First page: 1616
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Hip arthroscopy for the treatment of femoroacetabular impingement syndrome (FAIS) in patients with borderline hip dysplasia (BHD) is becoming a more common practice. However, the literature on achieving meaningful outcomes at midterm follow-up, as well as predictors of these outcomes, is limited.Purpose:To (1) compare the rates of achieving meaningful clinical outcomes between patients with and without BHD and (2) identify the predictors for achieving clinical success among patients with BHD 5 years after undergoing hip arthroscopic surgery for FAIS.Study Design:Cohort study; Level of evidence, 3.Methods:Data from consecutive patients who underwent primary hip arthroscopic surgery with routine capsular closure for the treatment of FAIS between January 2012 and August 2014 were collected and retrospectively analyzed. Patients with BHD (lateral center-edge angle [LCEA] 20°-25°) were matched 1:2 by age (±1 year) and body mass index (BMI; ±5 kg/m2) to control patients with normal acetabular coverage (LCEA 25°-40°). Data collected included baseline and 5-year postoperative patient-reported outcomes. The minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) were calculated for each patient-reported outcome measure and compared between the 2 groups. A binary logistic regression analysis was used to identify significant predictors of achieving the MCID and PASS in the BHD group.Results:The MCID in the BHD group was defined as 9.6, 14.1, and 9.5 for the Hip Outcome Score–Activities of Daily Living, Hip Outcome Score–Sports Subscale, and modified Harris Hip Score, respectively. Threshold scores for achieving the PASS in both groups were 90.9, 76.6, and 81.9, respectively. A total of 88 patients were identified with having BHD and were matched to 176 controls. No statistical differences were identified for age, BMI, or sex. Both the BHD and the non-BHD groups had statistically significant increases in patient-reported outcome scores over the 5-year period, but the difference in both groups was not statistically significant (P> .05 for all). There was no statistical difference in the frequency of patients in the BHD and non-BHD groups achieving the MCID (86.6% vs 85.2%, respectively; P = .804) or PASS (76.0% vs 73.7%, respectively; P = .675) on at least 1 outcome measure. The logistic regression model demonstrated that being physically active (odds ratio [OR], 27.59; P = .005) and being female (OR, 14.64; P = .025) were independent predictors of achieving the MCID, while running (OR, 11.1; P = .002), being female (OR, 7.6; P = .011), and a larger preoperative LCEA (OR, 2.3; P = .001) were independent preoperative predictors of achieving the PASS.Conclusion:The rates of achieving clinical success 5 years after undergoing arthroscopic treatment with capsular closure for FAIS were not significantly different between patients with BHD and those with normal acetabular coverage. Being physically active, running for exercise, female sex, and a larger LCEA were preoperative predictors of achieving clinical success at 5 years in patients with BHD.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-05-14T05:46:33Z
      DOI: 10.1177/0363546520916473
  • Achieving Successful Outcomes of Hip Arthroscopy in the Setting of
           Generalized Ligamentous Laxity With Labral Preservation and Appropriate
           Capsular Management: A Propensity Matched Controlled Study
    • Authors: David R. Maldonado, Jeffery W. Chen, Mitchell J. Yelton, Philip J. Rosinksy, Jacob Shapira, Ciaran Brayboy, Ajay C. Lall, Benjamin G. Domb
      First page: 1625
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Association among generalized ligamentous laxity (GLL), hip microinstability, and patient-reported outcomes (PROs) after hip arthroscopy has yet to be completely established.Purposes:(1) To report minimum 2-year PROs in patients with GLL who underwent hip arthroscopy in the setting of symptomatic labral tears and femoroacetabular impingement syndrome and (2) to compare clinical results with a matched-pair control group without GLL.Study Design:Cohort study; Level of evidence, 3.Methods:Data from a prospectively collected database were retrospectively reviewed between August 2014 and December 2016. Patients were considered eligible if they received primary arthroscopic treatment for symptomatic labral tears and femoroacetabular impingement. Inclusion criteria included preoperative and minimum 2-year follow-up scores for the following PROs: modified Harris Hip Score (mHHS), Non-arthritic Hip Score (NAHS), and visual analog scale for pain (VAS). From the sample population, 2 groups were created: the GLL group (Beighton score ≥4) and the control group (Beighton score .05). Preoperative radiographic measurements demonstrated no difference between groups. Intraoperative findings and procedures between groups were similar except for capsular treatment, with the GLL group receiving a greater percentage of capsular plications (P = .04). At minimum 2-year follow-up, both groups showed significant improvement in PROs and VAS (P < .001). Furthermore, the postoperative PROs at minimum 2-year follow-up and the magnitude of improvement (delta value) were similar between groups for mHHS, NAHS, HOS-SSS, and VAS (P> .05). Moreover, groups reached comparable rates of MCID and PASS for mHHS, HOS-SSS, and iHOT-12.Conclusion:Patients with GLL after hip arthroscopy for symptomatic femoroacetabular impingement and labral tears may expect favorable outcomes with appropriate labral and capsular management at minimum 2-year follow-up. When compared with a pair-matched control group without GLL, results were comparable for mHHS, NAHS, HOS-SSS, and VAS and reached PASS and/or MCID for mHHS, HOS-SSS, and iHOT-12.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-05-06T06:34:32Z
      DOI: 10.1177/0363546520914604
  • Hips With Acetabular Retroversion Can Be Safely Treated With Advanced
           Arthroscopic Techniques Without Anteverting Periacetabular Osteotomy:
           Midterm Outcomes With Propensity-Matched Control Group
    • Authors: David R. Maldonado, Jeffery W. Chen, Cynthia Kyin, Philip J. Rosinksy, Jacob Shapira, Jarod M. Karom, Ajay C. Lall, Benjamin G. Domb
      First page: 1636
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Different options, from reverse (anteverting) periacetabular osteotomy to hip arthroscopy, have been proposed for surgical treatment of femoroacetabular impingement syndrome (FAIS) in the setting of acetabular retroversion.Purpose:(1) To report and analyze midterm patient-reported outcome scores (PROs) in patients with FAIS and labral tears in the setting of acetabular retroversion after isolated hip arthroscopy and (2) to compare these PROs with those of a propensity-matched control group without acetabular retroversion.Study Design:Cohort study; Level of evidence, 3.Methods:Prospectively collected data were retrospectively reviewed for patients who underwent hip arthroscopy for FAIS and labral tear treatment between June 2008 and March 2014. Inclusion criteria were as follows: acetabular retroversion, pre- and postoperative PROs for modified Harris Hip Score (mHHS), Non-arthritic Hip Score, Hip Outcome Score–Sports Specific Scale (HOS-SSS), and visual analog scale (VAS). Propensity score matching was utilized to identify a control group without acetabular retroversion matched 1:1 with similar age, sex, body mass index, acetabular and femoral head Outerbridge grade, preoperative lateral center-edge angle, and labral treatment. Patient acceptable symptomatic state (PASS) and/or minimal clinically important difference (MCID) for the mHHS, HOS-SSS, International Hip Outcome Tool–12, and VAS was calculated.Results:A total of 205 hips with acetabular retroversion were matched to a control group. The groups showed no difference in demographic variables. The retroversion group was composed of 139 female and 66 male hips, with a mean ± SD age of 23.81 ± 7.28 years and follow-up time of 65.24 ± 20.31 months. Intraoperative diagnostic data and procedures performed were similar between groups, except more femoroplasties were performed in the retroversion group. Significant improvements for the mHHS, Non-arthritic Hip Score, HOS-SSS, and VAS were seen for both groups at a mean 5-year follow-up. The proportion of patients who reached the PASS and MCID were similar.Conclusion:In the setting of FAIS and labral tears, patients with acetabular retroversion can be safely treated with advanced hip arthroscopic techniques without reverse (anteverting) periacetabular osteotomy in a high-volume surgeon’s hands. Patients with acetabular retroversion demonstrated favorable PROs at midterm follow-up. Furthermore, the proportion of patients reaching the MCID and PASS for several PROs were comparable with those of a propensity-matched control group without acetabular retroversion.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-05-14T05:27:08Z
      DOI: 10.1177/0363546520916737
  • Inflammatory Response of Articular Cartilage to Femoroacetabular
           Impingement in the Hip
    • Authors: Masahiko Haneda, Muhammad Farooq Rai, Regis J. O’Keefe, Robert H. Brophy, John C. Clohisy, Cecilia Pascual-Garrido
      First page: 1647
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Femoroacetabular impingement (FAI) has been proposed as an etiologic factor in up to 50% of hips with osteoarthritis (OA). Inflammation is thought to be one of the main initiators of OA, yet little is known about the origin of intra-articular inflammation in FAI hips.Hypothesis:Articular cartilage from the impingement zone of patients with FAI has high levels of inflammation, reflecting initial inflammatory process in the hip.Study Design:Controlled laboratory study.Methods:Head-neck cartilage samples were obtained from patients with cam FAI (cam FAI, early FAI; n = 15), advanced OA secondary to cam FAI (FAI OA, late FAI; n = 15), and advanced OA secondary to developmental dysplasia of the hip (DDH OA, no impingement; n = 15). Cartilage procured from young adult donors (n = 7) served as control. Safranin O–stained sections were assessed for cartilage abnormality. Tissue viability was detected by TUNEL assay. Immunostaining of interleukin 1β (IL-1β), catabolic markers (matrix metalloproteinase 13 [MMP-13], a disintegrin and metalloproteinase with thrombospondin motif 4 [ADAMTS-4], aggrecan antibody to C-terminal neoepitope [NITEGE]), and an anabolic marker (type II collagen [COL2]) was performed to evaluate molecular inflammation and metabolic activity. The average percentage of immunopositive cells from the total cell count was calculated. Kruskal-Wallis test followed by Steel-Dwass post hoc test was used for multiple comparisons.Results:Microscopic osteoarthritic changes were more prevalent in cartilage of cam FAI and FAI OA groups compared with DDH OA and control groups. Cartilage in cam FAI and FAI OA groups, versus the DDH group, had higher expression of inflammatory molecules IL-1β (69.7% ± 18.1% and 72.5% ± 13.2% vs 32.7% ± 14.4%, respectively), MMP-13 (79.6% ± 12.6% and 71.4% ± 18.8% vs 38. 5% ± 13.3%), ADAMTS-4 (83.9% ± 12.2% and 82.6% ± 12.5% vs 45.7% ± 15.5%), and COL2 (93.6% ± 3.9% and 92.5% ± 5.8% vs 53.3% ± 21.0%) (P < .001). Expression of NITEGE was similar among groups (cam FAI, 89.7% ± 7.7%; FAI OA, 95.7% ± 4.7%; DDH OA, 93.9% ± 5.2%; P = .0742). The control group had minimal expression of inflammatory markers. Inflammatory markers were expressed in all cartilage zones of early and late FAI but only in the superficial zone of the no impingement group.Conclusion:Cartilage from the impingement zone in FAI is associated with a high expression of inflammatory markers, extending throughout all cartilage zones.Clinical Relevance:Inflammation associated with FAI likely has a deleterious effect on joint homeostasis. Further clinical and translational studies are warranted to assess whether and how surgical treatment of FAI reduces molecular inflammation.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-05-08T04:25:05Z
      DOI: 10.1177/0363546520918804
  • The Role of Patient Characteristics in the Success of Nonoperative
           Treatment of Anterior Cruciate Ligament Injuries
    • Authors: Jelle P. van der List, Frans J.A. Hagemans, Dirk Jan Hofstee, Freerk J. Jonkers
      First page: 1657
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Anterior cruciate ligament (ACL) tears can either be treated nonoperatively with physical therapy and then treated operatively if persistent instability is present, or be directly treated operatively. Advantages of early ACL reconstruction surgery include shorter time from injury to surgery and potentially fewer meniscal injuries, but performing early ACL reconstruction in all patients results in surgery in patients who might not need ACL reconstruction. It is important to assess in which patients nonoperative treatment is successful and which patients will require ACL reconstruction and thus might be better treated surgically in an earlier phase.Purpose:To identify patient characteristics that predict the success of nonoperative treatment.Study Design:Cohort study (Prognosis); Level of evidence, 2.Methods:All patients with complete ACL injuries who were evaluated between 2014 and 2017 at our clinic were included. The minimum follow-up was 2 years. The initial treatment and ultimate ACL reconstruction were reviewed. Univariate analysis was performed using Mann-Whitney U tests and chi-square tests and multivariate analysis using binary logistic regression.Results:A total of 448 patients were included with a median age of 26 years and median Tegner level of 7 and mean Tegner level of 6.4. At initial consultation, 210 patients (47%) were treated nonoperatively with physical therapy and 126 of these patients (60%) ultimately required ACL reconstruction. Nonoperative treatment failed in 88.9% of patients 40 years (P < .001); and 41.9% of patients with Tegner level 3 to 6, and 82.8% of patients with Tegner level 7 to 10. Age
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-05-13T04:51:34Z
      DOI: 10.1177/0363546520917386
  • A Randomized Controlled Trial of Bone–Patellar Tendon–Bone Anterior
           Cruciate Ligament Reconstruction With and Without Lateral Extra-articular
           Tenodesis: 19-Year Clinical and Radiological Follow-up
    • Authors: Marie Castoldi, Robert A. Magnussen, Stanislas Gunst, Cécile Batailler, Philippe Neyret, Sébastien Lustig, Elvire Servien
      First page: 1665
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Arthroscopic anterior cruciate ligament (ACL) reconstruction (ACLR) with a bone–patellar tendon–bone graft (BTB) is a reliable surgical option for the control of anterior knee laxity after ACL injury. The addition of a lateral extra-articular tenodesis (LET) may improve control of rotation knee laxity and improve short-term graft survival in high-risk patients.Purpose:The aims of this study were to compare long-term patient-reported outcomes, graft survival, and risk of osteoarthritis between ACLR with and without LET.Study Design:Randomized controlled trial; Level of evidence, 2.Methods:This study included 121 consecutive knees (120 patients) presenting to a single center with an ACL rupture between 1998 and 1999. In total, 61 knees were randomized to an isolated BTB ACLR, and 60 knees were randomized to a BTB ACLR with an extra-articular lateral tenodesis with gracilis tendon (modified Lemaire).Results:Eighty knees in 79 patients (66%) were available for follow-up at a postoperative mean of 19.4 years (range, 19-20.2). Of those patients, 43 had a clinical examination and completed patient-reported outcome questionnaires, and the other 37 patients were evaluated through the questionnaires alone. Standard radiographs were available for 45 patients and laximetry (TELOS) for 42 patients. Mean subjective International Knee Documentation Committee score at last follow-up was 81.8, and no differences were noted between the BTB and BTB-LET groups (P = .7). Two-thirds of patients were still participating in pivoting sports. A total of 17 knees (21%) experienced a graft failure, 5 of which (6%) underwent revision ACLR. There was no significant difference in graft failure risk between the BTB group (29%) and the BTB-LET group (13%; P = .1). Lateral tibiofemoral osteoarthritis was significantly more frequent in the BTB-LET group (59%) as compared with the BTB group (22%; P = .02). Lateral compartment osteoarthritis was correlated with partial lateral meniscectomy.Conclusion:There were no significant differences in long-term patient-reported outcomes after ACLR with or without an LET. LET may increase the risk of lateral compartment osteoarthritis at long-term follow-up. There was a trend toward decreased graft failure risk with the addition of LET but this study was underpowered to assess this outcome.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-05-05T03:57:09Z
      DOI: 10.1177/0363546520914936
  • Analysis of Risk Factors for Ramp Lesions Associated With Anterior
           Cruciate Ligament Injury
    • Authors: Seong Hwan Kim, Hyun Je Seo, Dong Won Seo, Kang-Il Kim, Sang Hak Lee
      First page: 1673
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:The incidence of meniscocapsular junction tears of the medial meniscus posterior horn, known as ramp lesions, is reported to be 9.3% to 23.9%. However, these lesions are not consistently diagnosed with routine arthroscopic exploration and magnetic resonance imaging (MRI).Purpose:To determine risk factors associated with ramp lesions in anterior cruciate ligament–injured knees.Study Design:Cross-sectional study; Level of evidence, 3.Methods:A total of 275 patients undergoing anterior cruciate ligament reconstruction between June 2011 and March 2019 were included in this study. Exclusion criteria were revisions, fracture histories, and multiple-ligament injuries other than medial collateral ligament injury. Patients were divided into 2 groups, those with and without ramp lesions according to arthroscopic diagnosis. Binary logistic regression was used to analyze risk factors: age, sex, body mass index, time from injury to surgery (3° (OR, 2.339; 95% CI, 1.048-5.217; P = .038), steeper medial tibial slope (OR, 1.289; 95% CI, 1.002-1.66; P = .049) and meniscal slope (OR, 1.464; 95% CI, 1.137-1.884; P = .003), and gradual lateral tibial slope (OR, 0.775; 95% CI, 0.657-0.914; P = .002). The area under the curve for the prediction model developed by logistic regression was 0.779 (sensitivity, 75.8%; specificity, 71.7%; P < .001) for ramp lesions.Conclusion:Care should be taken with patients who have significant risk factors for ramp lesions, including bone contusion at the posterior medial tibial plateau, chronic injury, steeper medial tibial and meniscal slope, gradual lateral tibial slope, and varus knee>3°.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-05-08T05:25:52Z
      DOI: 10.1177/0363546520918207
  • Return to Play and Career Length After Anterior Cruciate Ligament
           Reconstruction Among Canadian Professional Football Players
    • Authors: Robert Longstaffe, Jeff Leiter, Tanner Gurney-Dunlop, Robert McCormack, Peter MacDonald
      First page: 1682
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:For many athletes, a tear of the anterior cruciate ligament (ACL) represents a significant injury that requires a prolonged period away from the sport with substantial rehabilitation.Hypothesis:There will be no difference in return to play (RTP) and career length after hamstring tendon (HT) ACL reconstruction in a group of Canadian Football League professional players as compared with what has been already been reported in the literature among professional football players.Study Design:Case-control study; Level of evidence, 3.Methods:Data on athletes who sustained an ACL injury were collected by team physicians and head athletic trainers from 2002 to 2017 from 2 Canadian Football League teams. Patient details included age at the time of injury, initial injury date, position, practice versus game injury, and primary versus rerupture with injury-specific data, such as affected limb, concomitant injuries, graft choice, and procedure performed. RTP rates and career length data were collected through publically available internet sources. Comparisons between the non-RTP and RTP groups were made with independent-sample t tests. Binomial logistic regression was performed to determine variables (ie, games preinjury, graft type, meniscal injury, collateral ligament injury) that contributed to players not being able to RTP.Results:A total of 44 ACL reconstructions were performed over the study period (HT, n = 32 [72.7%]; bone–patellar tendon–bone [BPTB], n = 8 [18.2%]; allograft, n = 4 [9.1%]). Overall, 69.8% (n = 30) were able to RTP in at least 1 game, while 30.2% (n = 13) did not return. Mean time to return was 316.1 days (range, 220-427 days), or 10.4 months. For those players who did RTP, mean career length after ACL reconstruction was 2.8 seasons, or 34.4 games. The majority (56.8%) of injuries occurred early in the season. Breakdown by graft type demonstrated RTP rates among HT, BPTB, and allograft of 64.5% (n = 20), 87.5% (n = 7), and 75% (n = 3), respectively. Career length among HT, BPTB, and allograft was 2.9, 2.4, and 3 seasons. Logistic regression analysis found only concomitant medial collateral ligament (MCL) injuries to be a negative predictor for RTP. Meniscal injuries were associated with a decreased RTP rate and career length, but this was not statistically significant.Conclusion:The RTP rates after ACL reconstruction in this study are similar to those reported in National Football League players. A concomitant injury to the MCL injury was a negative predictor of RTP. Meniscal injuries demonstrated a trend for decreased RTP rate and career length, but this was not a significant predictor. A large portion of injuries occur early in the season, and further study should be done to examine potential preventative strategies to reduce ACL injuries.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-05-07T09:40:34Z
      DOI: 10.1177/0363546520918224
  • The Influence of Perioperative Nerve Block on Strength and Functional
           Return to Sports After Anterior Cruciate Ligament Reconstruction
    • Authors: Michelle E. Kew, Stephan G. Bodkin, David R. Diduch, Marvin K. Smith, Anthony Wiggins, Stephen F. Brockmeier, Brian C. Werner, F. Winston Gwathmey, Mark D. Miller, Joseph M. Hart
      First page: 1689
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Patients often have quadriceps or hamstring weakness after anterior cruciate ligament reconstruction (ACLR), despite postoperative physical therapy regimens; however, little evidence exists connecting nerve blocks and ACLR outcomes.Purpose:To compare muscle strength at return to play in patients who received a nerve block with ACLR and determine whether a specific block type affected subjective knee function.Study Design:Cohort study; Level of evidence, 3.Methods:Patients were recruited 5 to 7 months after primary, isolated ACLR and completed bilateral isokinetic strength tests of the knee extensor/flexor groups as a single-session return-to-sport test. Subjective outcomes were assessed with the International Knee Documentation Committee (IKDC) score. Strength was expressed as torque normalized to mass (N·m/kg) and limb symmetry index as involved/uninvolved torque. Chart review was used to determine the type of nerve block and graft used. Nerve block types were classified as knee extensor motor (femoral nerve), knee flexor motor (sciatic nerve), or isolated sensory (adductor canal block/saphenous nerve). A 1-way analysis of covariance controlling for graft type was used.Results:A total of 169 patients were included. Graft type distribution consisted of 102 (60.4%) ipsilateral bone–patellar tendon–bone (BTB) and 67 (39.6%) ipsilateral hamstring tendon. Nerve block type distribution consisted of 38 (22.5%) femoral, 25 (14.8%) saphenous, 45 (26.6%) femoral and sciatic, and 61 (36.1%) saphenous and sciatic. No significant difference was found in knee extensor strength (P = .113) or symmetry (P = .860) between patients with knee extensor motor blocks (1.57 ± 0.45 N·m/kg; 70.1% ± 15.3%) and those without (1.47 ± 0.47 N·m/kg; 69.6% ± 18.8%). A significant difference was found between patients with knee flexor motor blocks (0.83 ± 0.26 N·m/kg) and those without (0.92 ± 0.27 N·m/kg) for normalized knee flexor strength (P = .21) but not knee flexor symmetry (P = .592). Controlling for graft type, there were no differences in subjective knee function (IKDC score) between all nerve block groups (P = .57).Conclusion:Our data showed that use of a sciatic nerve block with ACLR in patients with hamstring and BTB grafts influences persistent knee flexor strength deficits at time of return to sports. Although the cause of postoperative muscular weakness is multifactorial, this study adds to the growing body of evidence suggesting that perioperative nerve blocks affect muscle strength and functional rehabilitation after ACLR.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-04-28T04:19:02Z
      DOI: 10.1177/0363546520914615
  • Does Age Itself Have an Adverse Effect on Survivorship of Meniscal
           Allograft Transplantation' A Cartilage Status and Time From Previous
           Meniscectomy–Matched Cohort Study
    • Authors: Ju-Ho Song, Seong-Il Bin, Jong-Min Kim, Bum-Sik Lee, Dong-Wook Son
      First page: 1696
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:The aging process is accompanied by several conditions that could affect the outcome of meniscal allograft transplantation (MAT). These conditions have made it difficult for clinicians to determine the effect of chronologic age on survivorship after MAT.Hypothesis:Advanced age does not have an adverse effect on survivorship of MAT when controlling for age-related factors, such as cartilage status and time from previous meniscectomy.Study Design:Cohort study; Level of evidence, 3.Methods:The records of 264 consecutive patients who underwent primary medial or lateral MAT were reviewed. To check whether there was a difference in MAT survivorship according to age, a cutoff value was calculated from a time-dependent receiver operating characteristic curve. Survival rates, as well as clinical improvement as determined using the Lysholm score, were compared between groups divided by the cutoff value. Patients were matched for cartilage status and elapsed time from previous meniscectomy. Differences in survivorship and clinical outcomes were assessed between the matched groups.Results:A time-dependent receiver operating characteristic curve showed that the difference in MAT survivorship was maximized with a cutoff age of 43 years. Kaplan-Meier analysis showed a significant difference in MAT survivorship between the older and younger groups (log-rank test, P = .01). However, after matching for cartilage status and time from previous meniscectomy, which left 56 patients per group, there was no significant difference in MAT survivorship (log-rank test, P = .10) between the groups. Regarding clinical outcomes, the mean Lysholm scores were not significantly different between the older and younger groups (P = .19, before matching; P = .39, after matching).Conclusion:MAT survivorship was more affected by age-related prognostic factors, such as cartilage status and time from previous meniscectomy, than age itself. Clinical outcomes did not show differences according to age, either.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-05-12T04:09:38Z
      DOI: 10.1177/0363546520916727
  • Medial Meniscal Posterior Horn Tears Are Associated With Increased
           Posterior Tibial Slope: A Case-Control Study
    • Authors: Hyun-Soo Moon, Chong-Hyuk Choi, Min Jung, Dae-Young Lee, Kwang-Sik Eum, Sung-Hwan Kim
      First page: 1702
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:While the medial meniscal posterior horn (MMPH) is reported to bear a considerable portion of overall load on the knee joint, including compressive and shear forces, no study has yet investigated the relationship between the MMPH and posterior tibial slope (PTS), which is a geometric factor associated with the shear force component in the presence of a compressive load in the knee joint.Hypothesis/Purpose:The purpose was to investigate the relationship between the PTS and MMPH tears in patients without ligamentous injury. It was hypothesized that the PTS is greater in patients with MMPH tears as compared with those without.Study Design:Cohort study; Level of evidence, 3.Methods:From March 2015 to December 2018, 159 patients with isolated MMPH tears and 60 patients without any pathologic findings on magnetic resonance imaging (control group) were included in this study. The PTS in the affected and contralateral knees was compared between the groups, which were statistically matched according to baseline characteristics (ie, age, sex, body mass index, radiographic osteoarthritis grade according to the Kellgren-Lawrence scale, and hip-knee-ankle angle) via the inverse probability of treatment weighting method. Furthermore, the MMPH tear group was subdivided according to meniscal tear patterns; these subgroups were then compared with the control group.Results:The mean PTS was significantly greater in the MMPH tear group than in the control group (affected knee: MMPH tear group, 7.0°± 3.4° [mean ± SD]; control group, 5.2°± 2.1°, P < .001; contralateral knee: MMPH tear group, 6.7°± 3.3°; control group, 4.7°± 2.2°, P < .001). The mean PTS in each subgroup also tended to be greater than that in the control group. In the receiver operating characteristic curve analysis, the cutoff point of the PTS discriminating between the MMPH tear and control groups was 6.6° for the affected knee (sensitivity, 55.3%; specificity, 75.0%) and 5.5° for the contralateral knee (sensitivity, 61.0%; specificity, 76.7%).Conclusion:An increased PTS is strongly associated with an increased incidence of MMPH tears and less affected by the meniscal tear patterns.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-05-14T05:43:30Z
      DOI: 10.1177/0363546520917420
  • Between-Limb Differences in Patellofemoral Joint Forces During Running at
           12 to 24 Months After Unilateral Anterior Cruciate Ligament Reconstruction
    • Authors: Prasanna Sritharan, Anthony G. Schache, Adam G. Culvenor, Luke G. Perraton, Adam L. Bryant, Kay M. Crossley
      First page: 1711
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Patellofemoral joint (PFJ) osteoarthritis may occur after anterior cruciate ligament reconstruction (ACLR). The mechanisms underpinning the development of PFJ osteoarthritis are not known but may relate to altered PFJ loading. Few studies have assessed PFJ loads during high-impact tasks, such as running, beyond the acute rehabilitation phase (ie,>12 months) after ACLR.Purpose/Hypothesis:The purpose was to compare between-limb joint angles, joint moments, and PFJ contact force during running in individuals at 12 to 24 months after unilateral ACLR. We hypothesized that peak knee flexion angle, knee extension moment, and PFJ contact force during stance would be lower in the ACLR limb compared with the uninjured limb.Study Design:Controlled laboratory study.Methods:55 participants (mean ± SD age, 28 ± 7 years), 12 to 24 months after ACLR, ran at a self-selected speed (2.9 ± 0.3 m/s). Measured kinematics and ground-reaction forces were input into musculoskeletal models to calculate joint moments and muscle forces. These values were subsequently input into a PFJ model to calculate contact force peak and impulse. Outcome measures were compared between the ACLR and uninjured limbs.Results:In the ACLR limb, compared with the uninjured limb, the PFJ contact force displayed a lower peak (ACLR, 6.1 ± 1.3 body weight [BW]; uninjured, 6.7 ± 1.4 BW; P < .001) and impulse (ACLR, 0.72 ± 0.17 BW*seconds [BWs]; uninjured, 0.81 ± 0.17 BWs; P < .001). At the time of the peak PFJ contact force, the knee extension moment was lower in the ACLR limb (ACLR, 14.0 ± 2.4 %BW*height [%BW*HT]; uninjured, 15.5 ± 2.5 %BW*HT; P < .001). The opposite was true for the ankle plantarflexion moment (ACLR, 12.1 ± 2.6 %BW*HT; uninjured, 11.5 ± 2.7 %BW*HT; P = .019) and the hip extension moment (ACLR, 2.3 ± 2.5 %BW*HT; uninjured, 1.6 ± 2.3 %BW*HT; P = .013). The foot-ground center of pressure was located more anteriorly with respect to the ankle joint center (ACLR, 5.8 ± 0.9 %height [%HT]; uninjured, 5.4 ± 1.0 %HT; P = .001). No differences were found for the sagittal plane hip, knee, and ankle angles.Conclusion:The ACLR limb experienced lower peak PFJ loads during running, explained by a small anterior shift in the foot-ground center of pressure during stance that offloaded the torque demand away from the ACLR knee.Clinical Relevance:Lower net PFJ loading during running in the ACLR limb more than 12 months after ACLR suggests that underloading might play a role in the onset of PFJ osteoarthritis after ACLR.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-05-06T06:16:02Z
      DOI: 10.1177/0363546520914628
  • Comparison of Tendon Lengthening With Traditional Versus Accelerated
           Rehabilitation After Achilles Tendon Repair: A Prospective Randomized
           Controlled Trial
    • Authors: Kelechi R. Okoroha, Najib Ussef, Toufic R. Jildeh, Lafi S. Khalil, Laith Hasan, Carter Bench, Ferras Zeni, Erik Eller, Vasilios Moutzouros
      First page: 1720
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Early weightbearing protocols after Achilles tendon repair promote mobilization, yet little is known about their effect on tendon lengthening.Purpose:To evaluate tendon lengthening after Achilles tendon repair with accelerated rehabilitation.Study Design:Randomized controlled trial; Level of evidence, 1.Methods:Patients undergoing primary repair for acute Achilles tendon ruptures consented to have tantalum beads placed within the tendon. Patients were randomized into either a traditional (weightbearing at 6 weeks) or accelerated (graduated weightbearing at 2 weeks) rehabilitation group. The primary outcome of the study was postoperative tendon elongation as measured by radiostereometric beads. Secondary outcomes included Achilles Tendon Total Rupture Score (ATRS) and Patient-Reported Outcomes Measurement Information System Pain Interference Short Form (PROMIS PI-SF) score.Results:All 18 patients included in the final analysis were found to have significant tendon lengthening after surgery, with a mean lengthening of 15.9 mm. No significant differences were found in overall lengthening between the traditional and accelerated rehabilitation groups (15.3 ± 4.5 vs 16.4 ± 4.7 mm, respectively; P = .33) at final follow-up. The repair site in each group was found to lengthen more than the intratendinous site (traditional group, 13.2 vs 2.1 mm; accelerated group, 16.8 vs −0.4 mm); however, no difference in lengthening was seen between groups (P = .82 and P = .31, respectively). The greatest amount of lengthening occurred between 2 and 6 weeks, and the least amount of lengthening occurred between 6 and 12 weeks, with no difference between the traditional and accelerated groups at these time points (P = .84 and P = .38, respectively). No differences were noted in ankle range of motion (dorsiflexion, P = .16; plantarflexion, P = .08) or outcome scores (ATRS, P = .56; PROMIS PI-SF, P = .54).Conclusion:This study’s findings demonstrate that all patients undergoing operative repair of Achilles tendon ruptures had lengthening after surgery. No difference was found in tendon lengthening (repair site or intratendinous) at any time point between patients undergoing traditional versus accelerated rehabilitation postoperatively. The greatest amount of lengthening was found to occur between 2 and 6 weeks postoperatively, and tendon lengthening decreased significantly after 6 weeks.Registration:NCT04050748 ( identifier).
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-03-23T09:51:15Z
      DOI: 10.1177/0363546520909389
  • Dose-Dependent Effects of Platelet-Rich Plasma Powder on Chondrocytes In
    • Authors: Olga Hahn, Matthias Kieb, Anika Jonitz-Heincke, Rainer Bader, Kirsten Peters, Thomas Tischer
      First page: 1727
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Platelet-rich plasma (PRP) is widely used in sports medicine. However, neither preparation nor parameters for clinical application, such as concentration, timing, and number of applications, are standardized, making research and clinical utilization challenging.Purpose:To investigate the effect of varying doses of PRP powder in terms of different concentrations, timing, and number of applications on human chondrocytes in a reproducible cell culture model.Study Design:Controlled laboratory study.Methods:A standardized lyophilized platelet growth factor preparation (PRP powder) was used to stimulate human chondrocytes. Chondrocytes were cultivated for 2 weeks with different stimulation frequencies (2×, 3×, 6×) and different concentrations of PRP powders (0.5%, 1%, 5%). Cell proliferation and metabolic cell activity were analyzed on days 7 and 14. Phenotypic changes were visualized through live-dead staining. Chondrogenic differentiation was quantified with enzyme-linked immunosorbent assay to assess the synthesis of procollagen types 1 and 2. Furthermore, sulfated proteoglycans and glycosaminoglycans were analyzed.Results:Human chondrocytes exhibited a significant dose- and time-dependent increase after 14 days in cell number (1% and 5% PRP powder vs unstimulated control: 7.95- and 15.45-fold increase, respectively; 2× vs 6× stimulation with 5% PRP powder: 4.00-fold increase) and metabolic cell activity (1% and 5% PRP powder vs unstimulated control: 3.27-fold and 3.58-fold change, respectively). Furthermore, cells revealed a significant increase in the amount of bone-specific procollagen type 1 (14 days, 1.94-fold) and sulfated glycosaminoglycans (14 days, 2.69-fold); however, no significant change was observed in the amount of cartilage-specific collagen type 2.Conclusion:We showed that chondrocytes exhibit a significant dose- and time-dependent increase in cell number and metabolic cell activity. The standardized use of growth factor concentrates in cell culture models can contribute to clinical knowledge in terms of dosage and timing of PRP applications.Clinical Relevance:Problems with PRP, such as the absence of standardization, lack of consistency among studies, and unknown dosage, could be solved by using characterized PRP powder made by pooling and lyophilizing multiple platelet concentrates. The innovative PRP powder generates new possibilities for PRP research, as well as for the treatment of patients.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-04-13T04:33:00Z
      DOI: 10.1177/0363546520911035
  • Repair of Osteochondral Defects With Predifferentiated Mesenchymal Stem
           Cells of Distinct Phenotypic Character Derived From a Nanotopographic
    • Authors: Yingnan Wu, Zheng Yang, Vinitha Denslin, XiaFei Ren, Chang Sheng Lee, Fung Ling Yap, Eng Hin Lee
      First page: 1735
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Articular cartilage has a zonal architecture and biphasic mechanical properties. The recapitulation of surface lubrication properties with high compressibility of the deeper layers of articular cartilage during regeneration is essential in achieving long-term cartilage integrity. Current clinical approaches for cartilage repair, especially with the use of mesenchymal stem cells (MSCs), have yet to restore the hierarchically organized architecture of articular cartilage.Hypothesis:MSCs predifferentiated on surfaces with specific nanotopographic patterns can provide phenotypically stable and defined chondrogenic cells and, when delivered as a bilayered stratified construct at the cartilage defect site, will facilitate the formation of functionally superior cartilage tissue in vivo.Study Design:Controlled laboratory study.Methods:MSCs were subjected to chondrogenic differentiation on specific nanopatterned surfaces. The phenotype of the differentiated cells was assessed by the expression of cartilage markers. The ability of the 2-dimensional nanopattern-generated chondrogenic cells to retain their phenotypic characteristics after removal from the patterned surface was tested by subjecting the enzymatically harvested cells to 3-dimensional fibrin hydrogel culture. The in vivo efficacy in cartilage repair was demonstrated in an osteochondral rabbit defect model. Repair by bilayered construct with specific nanopattern predifferentiated cells was compared with implantation with cell-free fibrin hydrogel, undifferentiated MSCs, and mixed-phenotype nanopattern predifferentiated MSCs. Cartilage repair was evaluated at 12 weeks after implantation.Results:Three weeks of predifferentiation on 2-dimensional nanotopographic patterns was able to generate phenotypically stable chondrogenic cells. Implantation of nanopatterned differentiated MSCs as stratified bilayered hydrogel constructs improved the repair quality of cartilage defects, as indicated by histological scoring, mechanical properties, and polarized microscopy analysis.Conclusion:Our results indicate that with an appropriate period of differentiation, 2-dimensional nanotopographic patterns can be employed to generate phenotypically stable chondrogenic cells, which, when implanted as stratified bilayered hydrogel constructs, were able to form functionally superior cartilage tissue.Clinical Relevance:Our approach provides a relatively straightforward method of obtaining large quantities of zone-specific chondrocytes from MSCs to engineer a stratified cartilage construct that could recapitulate the zonal architecture of hyaline cartilage, and it represents a significant improvement in current MSC-based cartilage regeneration.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-03-19T05:56:42Z
      DOI: 10.1177/0363546520907137
  • Patellofemoral Cartilage Restoration: A Systematic Review and
           Meta-analysis of Clinical Outcomes
    • Authors: Betina B. Hinckel, Eli L. Pratte, Charles A. Baumann, Anirudh K. Gowd, Jack Farr, Joseph N. Liu, Adam B. Yanke, Jorge Chahla, Seth L. Sherman
      First page: 1756
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Many surgical options for treating patellofemoral (PF) cartilage lesions are available but with limited evidence comparing their results.Purpose:To determine and compare outcomes of PF cartilage restoration techniques.Study Design:Systematic review and meta-analysis.Methods:PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) guidelines were followed by utilizing the PubMed, EMBASE, and Cochrane Library databases. Inclusion criteria were clinical studies in the English language, patient-reported outcomes after PF cartilage restoration surgery, and>12 months’ follow-up. Quality assessment was performed with the Coleman Methodology Score. Techniques were grouped as osteochondral allograft transplantation (OCA), osteochondral autograft transfer (OAT), chondrocyte cell–based therapy, bone marrow–based therapy, and scaffolds.Results:A total of 59 articles were included. The mean Coleman Methodology Score was 71.8. There were 1937 lesions (1077 patellar, 390 trochlear, and 172 bipolar; 298 unspecified). The frequency of the procedures was as follows, in descending order: chondrocyte cell–based therapy (65.7%), bone marrow–based therapy (17.2%), OAT (8%), OCA (6.6%), and scaffolds (2.2%). When compared with the overall pooled lesion size (3.9 cm2; 95% CI, 3.5-4.3 cm2), scaffold (2.2 cm2; 95% CI, 1.8-2.5 cm2) and OAT (1.5 cm2; 95% CI, 1.1-1.9 cm2) lesions were smaller (P < .001), while chondrocyte cell–based therapy lesions were larger (4.7 cm2; 95% CI, 4.1-5.3 cm2; P = .039). Overall, the instability pool was 11.9%, and the anatomic risk factors pool was 32.1%. Statistically significant improvement was observed on at least 1 patient-reported outcome in chondrocyte cell–based therapy (83%), OAT (78%), OCA (71%), bone marrow–based therapy (64%), and scaffolds (50%). There were no significant differences between any group and the overall pooled change in International Knee Documentation Committee score (30.2; 95% CI, 27.4-32.9) and Lysholm score (25.2; 95% CI, 16.9-33.5). There were no significant differences between any group and the overall pooled rate in minor complication rate (7.6%; 95% CI, 4.7%-11.9%) and major complication rate (8.3%; 95% CI, 5.7%-12.0%); however, OCA had a significantly greater failure rate (22.7%; 95% CI, 14.6%-33.4%) as compared with the overall rate (6.8%; 95% CI, 4.7%-9.5%).Conclusion:PF cartilage restoration leads to improved clinical outcomes, with low rates of minor and major complications. There was no difference among techniques; however, failures were higher with OCA.
      Citation: The American Journal of Sports Medicine
      PubDate: 2020-01-04T12:18:26Z
      DOI: 10.1177/0363546519886853
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