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American Journal of Sports Medicine
Journal Prestige (SJR): 3.949
Citation Impact (citeScore): 6
Number of Followers: 188  
 
Hybrid Journal Hybrid journal   * Containing 1 Open Access Open Access article(s) in this issue *
ISSN (Print) 0363-5465 - ISSN (Online) 1552-3365
Published by Sage Publications Homepage  [1087 journals]
  • In Which Arm Position Is a Hill-Sachs Lesion Created' Letter to the
           Editor
    • Authors: Feipeng Gong, Baofu Yu, Qi Zeng, Guoming Xia
      Abstract: The American Journal of Sports Medicine, Volume 47, Issue 13, Page NP74-NP74, November 2019.

      Citation: The American Journal of Sports Medicine
      PubDate: 2019-11-01T04:13:21Z
      DOI: 10.1177/0363546519878142
       
  • In Which Arm Position Is a Hill-Sachs Lesion Created' Response
    • Authors: Jun Kawakami, Nobuyuki Yamamoto, Taku Hatta, Kiyotsugu Shinagawa, Eiji Itoi
      Abstract: The American Journal of Sports Medicine, Volume 47, Issue 13, Page NP74-NP75, November 2019.

      Citation: The American Journal of Sports Medicine
      PubDate: 2019-11-01T04:13:13Z
      DOI: 10.1177/0363546519878140
       
  • The Critical Reader—Confounding
    • Authors: James L. Carey
      Pages: 3049 - 3050
      Abstract: The American Journal of Sports Medicine, Volume 47, Issue 13, Page 3049-3050, November 2019.

      Citation: The American Journal of Sports Medicine
      PubDate: 2019-11-01T04:13:27Z
      DOI: 10.1177/0363546519884910
       
  • Society News
    • Pages: 3294 - 3295
      Abstract: The American Journal of Sports Medicine, Volume 47, Issue 13, Page 3294-3295, November 2019.

      Citation: The American Journal of Sports Medicine
      PubDate: 2019-11-01T04:12:52Z
      DOI: 10.1177/0363546519885350
       
  • Effect of Graft Choice on Revision and Contralateral Anterior Cruciate
           Ligament Reconstruction: Results From the New Zealand ACL Registry
    • Authors: Richard Rahardja, Mark Zhu, Hamish Love, Mark G. Clatworthy, Andrew Paul Monk, Simon W. Young
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:The patellar tendon is often considered the “gold standard” graft for reducing the risk of graft rupture after anterior cruciate ligament (ACL) reconstruction. However, its use may also be associated with an increased risk of injury to the contralateral ACL.Purpose:To clarify the association between graft choice and the risk of revision and contralateral ACL reconstruction.Study Design:Cohort study; Level of evidence, 2.Methods:Prospective data captured by the New Zealand ACL Registry between April 2014 and December 2018 were reviewed. All primary ACL reconstructions performed using either a hamstring tendon or patellar tendon autograft were included. Cox regression survival analysis adjusting for patient factors was performed to compare the risk of revision and contralateral ACL reconstruction between the hamstring tendon graft and the patellar tendon graft.Results:A total of 7155 primary ACL reconstructions were reviewed, of which 5563 (77.7%) were performed using a hamstring tendon graft and 1592 (22.3%) were performed using a patellar tendon graft. Patients with a hamstring tendon graft had a revision rate of 2.7% compared with 1.3% in patients with a patellar tendon graft (adjusted hazard ratio [HR], 2.51; 95% CI, 1.55-4.06; P < .001). The patellar tendon graft was associated with an increased risk of contralateral ACL reconstruction compared with the hamstring tendon graft (adjusted HR, 1.91; 95% CI, 1.15-3.16; P = .012). The number needed to treat (NNT) with a patellar tendon graft to prevent 1 revision was 73.6. However, the NNT with a hamstring tendon graft to prevent 1 contralateral reconstruction was 116.3.Conclusion:Use of a patellar tendon graft reduced the risk of graft rupture but was associated with an increased risk of injury to the contralateral ACL. Adequate rehabilitation and informed decision making on return to activity and injury prevention measures may be important in preventing subsequent injury to the healthy knee.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-11-15T06:31:01Z
      DOI: 10.1177/0363546519885148
       
  • Graft Size and Orientation Within the Femoral Notch Affect Graft Healing
           at 1 Year After Anterior Cruciate Ligament Reconstruction
    • Authors: Takeshi Oshima, Sven Putnis, Samuel Grasso, Antonio Klasan, David Anthony Parker
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:The combined influence of anatomic and operative factors affecting graft healing after anterior cruciate ligament (ACL) reconstruction within the femoral notch is not well understood.Purpose:To determine the influence of graft size and orientation in relation to femoral notch anatomy, with the signal/noise quotient (SNQ) of the graft used as a measure of graft healing after primary single-bundle ACL reconstruction.Study Design:Case series; Level of evidence, 4.Methods:A total of 98 patients with a minimum 2-year follow-up after primary single-bundle ACL reconstruction with hamstring tendon autografts were included. Graft healing was evaluated at 1 year on magnetic resonance imaging (MRI) scan as the mean SNQ measured from 3 regions situated at sites at the proximal, middle, and distal graft. Patient characteristics, chondropenia severity score, tunnel sizes, tunnel locations, graft bending angle (GBA), graft sagittal angle, posterior tibial slope (PTS), graft length, graft volume, femoral notch volume, and graft-notch volume ratio (measured using postoperative 3-T high-resolution MRI) were evaluated to determine any association with 1-year graft healing. The correlation between 1-year graft healing and clinical outcome at minimum 2 years was also assessed.Results:There was no significant difference in mean SNQ between male and female patients (P> .05). Univariate regression analysis showed that a low femoral tunnel (P = .005), lateral tibial tunnel (P = .009), large femoral tunnel (P = .011), large tibial tunnel (P < .001), steep lateral PTS (P = .010), steep medial PTS (P = .004), acute graft sagittal angle (P < .001), acute GBA (P < .001), large graft volume (P = .003), and high graft-notch volume ratio (P < .001) were all associated with higher graft SNQ values. A multivariate regression analysis showed 2 significant factors: a large graft-notch volume ratio (P = .001) and an acute GBA (P = .004). The 1-year SNQ had a weak correlation with 2-year Tegner Activity Scale score (r = 0.227; P = .026) but no other clinical findings, such as International Knee Documentation Committee subjective and Lysholm scores and anterior tibial translation side-to-side difference.Conclusion:The 1-year SNQ value had a significant positive association with graft-notch volume ratio and GBA. Both graft size and graft orientation appeared to have a significant influence on graft healing as assessed on 1-year high-resolution MRI scan.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-11-15T06:07:56Z
      DOI: 10.1177/0363546519885104
       
  • A Contemporary Look at the Evaluation and Treatment of Adult Borderline
           and Frank Hip Dysplasia
    • Authors: Matthew J. Kraeutler, Marc R. Safran, Anthony J. Scillia, Olufemi R. Ayeni, Tigran Garabekyan, Omer Mei-Dan
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Adult hip dysplasia is often diagnosed according to the lateral center-edge angle (LCEA). Patients with frank hip dysplasia (LCEA
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-11-14T06:31:21Z
      DOI: 10.1177/0363546519881411
       
  • All-Suture Anchor Settling After Arthroscopic Repair of Small and Medium
           Rotator Cuff Tears
    • Authors: Kyunghan Ro, Sung-Min Rhee, Jung Youn Kim, Myung Seo Kim, Jong Dae Kim, Hojin Lee, Yong Girl Rhee
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:All-suture anchors are increasingly being used in rotator cuff repair. However, there are debates on the micromotion of all-suture anchors.Purpose:To perform rotator cuff repair on patients with rotator cuff tears and different shoulder bone mineral densities (BMDs) and investigate (1) where the anchor is located under the cortex, (2) if there is any anchor migration settling during follow-up, and (3) if structural outcome differs according to shoulder BMD.Study Design:Cohort study; Level of evidence, 3.Methods:We retrospectively investigated 88 patients who underwent arthroscopic single-row repair for small- to medium-sized rotator cuff tears (age [mean ± SD], 58.8 ± 7.1 years) from 712 cases of rotator cuff tendon repair between November 2015 and February 2018. Inclusion criteria were as follows: use of an all-suture anchor; preoperative shoulder BMD; and magnetic resonance imaging (MRI) conducted preoperatively, 2 days after surgery, and 10 months after surgery. Patients were excluded from the study if they underwent open rotator cuff repair (n = 118), got surgery with a double-row technique (n = 178), underwent surgery with anchors other than the all-suture type (n = 273), received anchor insertion in sites other than the greater tuberosity owing to concomitant procedures such as biceps tenodesis and subscapularis repair (n = 29), did not take preoperative shoulder BMD (n = 15), had more than a large-size tear (n = 6), and were lost to follow-up (n = 5). After compression of the all-suture anchor during surgery, the strands were pulled multiple times to ensure that the anchor was fixed onto the bone with appropriate tension. BMD was measured before surgery. Depth to anchor (DA), anchor settling, and repaired rotator cuff integrity were measured with MRI. Patients were categorized into 3 groups: group A (BMD, 0.6 g/cm2; n = 25). A total of 65 patients had follow-up MRI. On the basis of rotator cuff tendon integrity, patients were categorized into either a sufficient thickness group (group S, Sugaya classification grade II or lower; n = 44) or an insufficient thickness group (group I, Sugaya classification grade III or higher; n = 21).Results:On time-zero MRI, the DA differed significantly among groups (group A, 3.62 ± 2.02 mm; group B, 5.18 ± 2.13 mm; group C, 6.30 ± 3.34 mm) (P = .001). The DA was deeper in patients with a higher BMD at time zero (r = 0.374; P = .001), but the DA did not differ at follow-up MRI (mean, 10.3 months after surgery). On follow-up MRI, anchor settling tended to increase with deeper time-zero DA (r = 0.769; P < .001). Anchor settling was significantly different among groups (group A, 1.33 ± 1.08 mm; group B, 2.78 ± 1.99 mm; group C, 3.81 ± 2.19 mm) (P = .001). The proportion of patients with sufficient thickness in each group did not show a statistical difference (group A, 70.8%; group B, 72.7%; group C, 57.9%) (P = .550).Conclusion:In conclusion, this study confirmed that the postoperative site of anchor insertion in arthroscopic single-row rotator cuff repair with all-suture anchors was located farther from the cortex in patients with higher shoulder BMD and closer to the subcortical bone in patients with lower BMD. On follow-up MRI, no further settling occurred past a certain distance from the cortex, and there was no significant difference in anchor depth or integrity of the rotator cuff tendon based on shoulder BMD. Therefore, minimal settling in the all-suture anchor did not show clinical significance.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-11-13T04:18:11Z
      DOI: 10.1177/0363546519886547
       
  • Use of the Progressive Return to Activity Guidelines May Expedite Symptom
           Resolution After Concussion for Active Duty Military
    • Authors: Jason M. Bailie, Rosemay A. Remigio-Baker, Wesley R. Cole, Karen L. McCulloch, Mark L. Ettenhofer, Therese West, Angelica Ahrens, Paul Sargent, Amy Cecchini, Saafan Malik, Lynita Mullins, Keith Stuessi, Felicia M. Qashu, Emma Gregory
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Clinical recommendations for concussion management encourage reduced cognitive and physical activities immediately after injury, with graded increases in activity as symptoms resolve. Empirical support for the effectiveness of such recommendations is needed.Purpose:To examine whether training medical providers on the Defense and Veterans Brain Injury Center’s Progressive Return to Activity Clinical Recommendation (PRA-CR) for acute concussion improves patient outcomes.Study Design:Cohort study; Level of evidence, 2.Methods:This study was conducted from 2016 to 2018 and compared patient outcomes before and after medical providers received an educational intervention (ie, provider training). Patients, recruited either before or after intervention, were assessed at ≤72 hours, 1 week, 1 month, 3 months, and 6 months after a concussion. The participant population included 38 military medical providers and 106 military servicemembers with a diagnosed concussion and treated by one of the military medical providers: 58 patient participants received care before the intervention (ie, provider training) and 48 received care after intervention. The primary outcome measure was the Neurobehavioral Symptom Inventory.Results:The patients seen before and after the intervention were predominantly male (89.7% and 93.8%, respectively) of military age (mean ± SD, 26.62 ± 6.29 years and 25.08 ± 6.85 years, respectively) and a mean ± SD of 1.92 ± 0.88 days from injury. Compared with patients receiving care before intervention, patients receiving care after intervention had smaller increases in physical activities (difference in mean change; 95% CI, 0.39 to 6.79) and vestibular/balance activities (95% CI, 0.79 to 7.5) during the first week of recovery. Although groups did not differ in symptoms at ≤72 hours of injury (d = 0.22; 95% CI, –2.21 to 8.07), the postintervention group reported fewer symptoms at 1 week (d = 0.61; 95% CI, 0.52 to 10.92). Postintervention patients who completed the 6-month study had improved recovery both at 1 month (d = 1.55; 95% CI, 5.33 to 15.39) and 3 months after injury (d = 1.10; 95% CI, 2.36 to 11.55), but not at 6 months (d = 0.35; 95% CI, 5.34 to 7.59).Conclusion:Training medical providers on the PRA-CR for management of concussion resulted in expedited recovery of patients.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-11-13T04:03:39Z
      DOI: 10.1177/0363546519883259
       
  • The Safety of Blood Flow Restriction Training as a Therapeutic
           Intervention for Patients With Musculoskeletal Disorders: A Systematic
           Review
    • Authors: Melissa C. Minniti, Andrew P. Statkevich, Ryan L. Kelly, Victoria P. Rigsby, Meghan M. Exline, Daniel I. Rhon, Derek Clewley
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:The effectiveness of blood flow restriction training (BFRT) as compared with other forms of training, such as resistance training, has been evaluated in the literature in clinical and nonclinical populations. However, the safety of this intervention has been summarized only in healthy populations and not in clinical populations with musculoskeletal disorders.Purpose:To evaluate the safety and adverse events associated with BFRT in patients with musculoskeletal disorders.Study Design:Systematic review.Methods:A literature search was conducted with 3 online databases (MEDLINE, CINAHL, and Embase). Eligibility criteria for selecting studies were as follows: (1) BFRT was used as a clinical intervention, (2) study participants had a disorder of the musculoskeletal system, (3) authors addressed adverse events, (4) studies were published in English, and (5) the intervention was performed with human participants.Results:Nineteen studies met eligibility criteria, with a pooled sample size of 322. Diagnoses included various knee-related disorders, inclusion body myositis, polymyositis or dermatomyositis, thoracic outlet syndrome, Achilles tendon rupture, and bony fractures. Nine studies reported no adverse events, while 3 reported rare adverse events, including an upper extremity deep vein thrombosis and rhabdomyolysis. Three case studies reported common adverse events, including acute muscle pain and acute muscle fatigue. In the randomized controlled trials, individuals exposed to BFRT were not more likely to have an adverse event than individuals exposed to exercise alone. Of the 19 studies, the adverse events were as follows: overall, 14 of 322; rare overall, 3 of 322; rare BFRT, 3 of 168; rare control, 0 of 154; any adverse BFRT, 10 of 168; any adverse control, 4 of 154. A majority of studies were excluded because they did not address safety.Conclusion:BFRT appears to be a safe strengthening approach for knee-related musculoskeletal disorders, but further research is needed to make definitive conclusions and to evaluate the safety in other musculoskeletal conditions. Improved definitions of adverse events related to BFRT are needed to include clear criteria for differentiating among common, uncommon, and rare adverse events. Finally, further research is needed to effectively screen who might be at risk for rare adverse events.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-11-11T05:37:34Z
      DOI: 10.1177/0363546519882652
       
  • Video Analysis of Shoulder Dislocations in Rugby: Insights Into the
           Dislocating Mechanisms
    • Authors: Connor Montgomery, David E. O’Briain, Eoghan T. Hurley, Leo Pauzenberger, Hannan Mullett, Cathal J. Moran
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Mechanisms previously described for traumatic shoulder injuries in rugby may not adequately describe all the mechanisms that result in shoulder dislocations.Purpose:To investigate the mechanism of shoulder dislocation events in professional rugby players through use of systematic video analysis.Study Design:Case series; Level of evidence, 4.Methods:In our series, 39 cases of shoulder dislocations from games played in top professional leagues and international matches across a 2-year period were available for video analysis. All cases were independently assessed by 2 analysts to identify the sequence of events occurring during shoulder dislocation. This included injury circumstance such as contact with another player or the ground, game scenario, injury timing, and the movements and force vectors involved in the dislocation mechanism.Results:We identified 4 distinct injury mechanisms. The previously described mechanisms “try scorer,”“tackler,” and “direct impact” were identified in 67% of cases. We describe a new injury mechanism occurring in the “poach position,” accounting for 18% of all shoulder dislocations studied. The remaining 15% could not be categorized. Shoulder dislocations occurred to a ball carrier in 15% of cases (n = 6) and a non–ball carrier in 85% of cases (n = 33). The injury most commonly occurred during a tackle (49%; n = 19) followed by ruck/maul (26%; n = 10). Time of injury showed that 36% (n = 14) of cases occurred in the last quarter of the game.Conclusion:Shoulder dislocations have now been shown to occur predominantly as a result of 1 of 4 distinct mechanisms, most frequently in the second half of the game. A new mechanism for shoulder dislocation has been described in this series, termed the poach position.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-11-11T05:16:27Z
      DOI: 10.1177/0363546519882412
       
  • The Influence of Psychological Factors on the Incidence and Severity of
           Sports-Related Concussions: A Systematic Review
    • Authors: Lily N. Trinh, Symone M. Brown, Mary K. Mulcahey
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:An athlete’s preexisting psychological factors may influence the incidence and/or severity of sports-related concussions (SRCs).Purpose:To determine if emotional states, personality traits, temperament, life stressors, and explanatory styles (optimism vs pessimism) influence the incidence and severity of SRCs in athletes.Study Design:Systematic review.Methods:A systematic literature search of multiple major medical reference databases was performed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Studies were included that evaluated the effect of preexisting psychological factors on the incidence and severity of SRCs in male and female athletes participating in all sports.Results:The initial search identified 1195 articles. Ten studies met our inclusion criteria and were included in our analysis. Factors such as meanness, aggression, and psychoticism were associated with an increased incidence of SRCs. Baseline traits of irritability, sadness, nervousness, and depressive symptoms were associated with worse symptomatology after SRCs. In young athletes, preexisting psychiatric illnesses, family history of psychiatric illness, and significant life stressors were associated with an increased risk of developing postconcussion syndrome after SRCs.Conclusion:This systematic review demonstrated a potential relationship between an athlete’s preexisting psychological factors and the incidence and severity of SRCs. These associations are not entirely clear owing to the heterogeneity across included studies and the low-to-moderate certainty of evidence. Future studies should attempt to evaluate men and women independently, use well-validated psychological questionnaires, and limit the usage of self-reported SRCs, when possible. Furthermore, the potential efficacy of baseline psychological factor and/or symptom reports on the prevention and management of SRCs should be explored.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-11-08T06:19:57Z
      DOI: 10.1177/0363546519882626
       
  • Do American Youth Football Players Intentionally Use Their Heads for
           High-Magnitude Impacts'
    • Authors: Jaclyn Alois, Srinidhi Bellamkonda, Eamon T. Campolettano, Ryan A. Gellner, Amaris Genemaras, Jonathan G. Beckwith, Richard M. Greenwald, Eric Smith, Steven Rowson, Stefan M. Duma, Joseph J. Crisco
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Concern for head injuries is widespread and has been reported by the media to be the number one cause of decreased participation in football among the American youth population. Identifying player mechanisms associated with intentional, or purposeful, head impacts should provide critical data for rule modifications, educational programs, and equipment design.Purpose:To investigate the frequency of intentional and unintentional head impacts and to examine the player mechanisms associated with intentional high-magnitude head impacts by comparing the impact mechanism distributions among session type, player position, and ball possession.Study Design:Cross-sectional study; Level of evidence, 3.Methods:Head impact sensors and video footage of 68 players were used to analyze and classify 1319 high-magnitude impacts recorded over 1 season of youth football.Results:In total, 80% of the high-magnitude head impacts were classified as being caused by intentional use of the head. Head-to-head impact was the primary impact mechanism (n = 868; 82.7%) within the 1050 intentional high-magnitude impacts, with classifiable mechanisms, followed by head-to-body (n = 139; 13.2%), head-to-ground (n = 34; 3.2%), and head-to-equipment (n = 9; 0.9%). Head-to-head impacts also accounted for a greater proportion of impacts during practices (n = 625; 88.9%) than games, for linemen (n = 585; 90.3%) than perimeters and backs, and for ball carriers (n = 72; 79.1%) than tacklers.Conclusion:Overall, the majority of high-magnitude head impacts were intentional and resulted from head-to-head contact. The proportion of head-to-head contact was significantly higher for practices than games, linemen than backs and perimeter players, and ball carriers than tacklers.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-11-07T06:09:58Z
      DOI: 10.1177/0363546519882034
       
  • Combined Transphyseal and Lateral Extra-articular Pediatric Anterior
           Cruciate Ligament Reconstruction: A Novel Technique to Reduce ACL Reinjury
           While Allowing for Growth
    • Authors: Philip L. Wilson, Charles W. Wyatt, K. John Wagner, Nathan Boes, Meagan J. Sabatino, Henry B. Ellis
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Treatment of anterior cruciate ligament (ACL) injuries in the adolescent population continues to be complicated by an unacceptably high rate of secondary ACL injury.Purpose:To describe the failure rate and outcomes after a hybrid pediatric ACL reconstruction (ACLR) employing transphyseal hamstring (TPH) autograft combined with an extra-articular technique using an iliotibial band (ITB) autograft.Study Design:Case series; Level of evidence, 4.Methods:Consecutive patients undergoing combined TPH-ITB ACLR between January 2012 and April 2017 with a minimum 2-year follow-up were reviewed. With the goal of decreasing ACL graft injury in this high-risk group, this technique employed anteromedial portal drilling for TPH with an extraosseous femoral ITB technique and intra-articular TPH-ITB grafts fixed within the tibial bone tunnel. Demographics, bone age, standing alignment radiograph for growth and mechanical axis grade, return to sport, graft failure, and patient-reported outcome measures were analyzed.Results:A total of 61 knees in 60 adolescents underwent the combined TPH-ITB ACLR, with 57 knees (93.4%) meeting inclusion criteria with a mean follow-up of 38.5 months (range, 24-78 months). Only 3 of 57 knees (5.3%) sustained ACL reinjury. The mean age was 13.0 years (range, 11-16 years) with 36 male patients (mean bone age, 14.2 years) and 21 female patients (mean bone age, 13.3 years), and 91% of patients (52 of 57) returned to sport. Participants demonstrated a high functional level at final follow-up, with a mean score of 91.2 (range, 46.7-100) on the Pediatric International Knee Documentation Committee (Pedi-IKDC) Subjective Knee Evaluation Form and mean score of 22.4 (range, 4-30) on the Pediatric Functional Activity Brief Scale (Pedi-FABS). To critically assess growth, a cohort with ≥18 months of growth remaining at surgery was evaluated at maturity. No difference was seen in mean operative and nonoperative leg growth (49.7 mm and 49.8 mm). Although no family reported cosmetic or functional alignment or length concerns, 1 of 18 (5.5%) had a final limb length discrepancy>10 mm (12 mm) and a perioperative alignment difference (0-Grade II valgus).Conclusion:Combined TPH-ITB ACLR in adolescents resulted in high activity levels (Pedi-FABS, 22.4; median, 25) and a low (5.3%) graft failure rate at a mean 38.5 months.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-11-06T06:11:49Z
      DOI: 10.1177/0363546519881445
       
  • Incidence and Healing Rates of Meniscal Tears in Patients Undergoing
           Repair During the First Stage of 2-Stage Revision Anterior Cruciate
           Ligament Reconstruction
    • Authors: Nicholas N. DePhillipo, Travis J. Dekker, Zachary S. Aman, David Bernholt, W. Jeffrey Grantham, Robert F. LaPrade
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Meniscal tears, including tears at the root attachment, have been associated with tears of the anterior cruciate ligament (ACL) in both primary and revision settings. However, there is a paucity of literature reporting the healing rates of meniscal repair during 2-stage revision ACL reconstruction (ACLR).Purpose:To evaluate the healing rates of meniscal repairs performed during 2-stage revision ACLR in ACL-deficient knees and to report the incidence of meniscus root tears in patients undergoing primary ACLR as compared with revision ACLR.Study Design:Case series; Level of evidence, 4.Methods:Patients who underwent primary and revision ACLR by a single surgeon were retrospectively identified. Revision ACLRs were grouped according to 1- or 2-stage ACLR. Meniscal tears were grouped according to laterality (medial, lateral) and location of tears. Meniscal repair technique was recorded, including transtibial or inside-out. Meniscal repair healing was assessed via second-look arthroscopy at the time of second-stage revision ACLR.Results:There were 1168 patients identified who underwent ACLR: 851 primary and 317 revision procedures. Sixty-four patients underwent meniscal repair during first-stage bone grafting in ACL-deficient knees, with an overall healing rate of 86%. The healing rates were 82.3% for meniscus root tears via the transtibial repair technique and 92.4% for meniscal peripheral tears via the inside-out repair technique. Meniscus root tears had overall incidences of 15.5% and 26.2% in primary and revision ACLRs, respectively. The incidence of lateral meniscus posterior root tears was approximately 4 times higher than of medial meniscus posterior root tears in both primary (12.2% vs 3.2%) and revision (20.5% vs 5.6%) ACLRs.Conclusion:A high incidence of meniscus root tears was found in patients undergoing revision ACLRs as compared with primary ACLRs. Meniscal repairs have a high rate of healing and success when performed during the first stage of revision ACLR in ACL-deficient knees.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-11-06T05:33:58Z
      DOI: 10.1177/0363546519878421
       
  • Risk Factors Associated With a Noncontact Anterior Cruciate Ligament
           Injury to the Contralateral Knee After Unilateral Anterior Cruciate
           Ligament Injury in High School and College Female Athletes: A Prospective
           Study
    • Authors: Annabelle P. Davey, Pamela M. Vacek, Ryan A. Caldwell, James R. Slauterbeck, Mack G. Gardner-Morse, Timothy W. Tourville, Bruce D. Beynnon
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:The incidence of contralateral anterior cruciate ligament (CACL) injuries after recovery from a first-time anterior cruciate ligament (ACL) disruption is high in women; however, little is known about the risk factors associated with this trauma.Hypothesis:Patient characteristics, strength, anatomic alignment, and neuromuscular characteristics of the contralateral uninjured leg at the time of the first ACL trauma are associated with risk of subsequent CACL injury, and these risk factors are distinct from those for a first-time ACL injury.Study Design:Case-control study; Level of evidence, 3.Methods:Sixty-one women who suffered a first-time noncontact ACL injury while participating in high school or college sports and underwent measurement of potential risk factors on their contralateral limb soon after the initial ACL injury and before reconstruction were followed until either a CACL injury or an ACL graft injury occurred, or until the last date of contact.Results:Follow-up information was available for 55 (90.0%) of the 61 athletes and 11 (20.0%) suffered a CACL injury. Younger age, decreased participation in sport before the first ACL disruption, decreased anterior stiffness of the contralateral knee, and increased hip anteversion were associated with increases in the risk of suffering a CACL injury.Conclusion:A portion of CACL injury risk factors were modifiable (time spent participating in sport and increasing anterior knee stiffness with bracing), while others were nonmodifiable (younger age and increased hip anteversion). The relationship between younger age at the time of an initial ACL injury and increased risk of subsequent CACL trauma may be explained by younger athletes having more years available to be exposed to at-risk activities compared with older athletes. A decrease of anterior stiffness of the knee is linked to decreased material properties and width of the ACL, and this may explain why some women are predisposed to bilateral ACL trauma while others only suffer the index injury. The risk factors for CACL injury are unique to women who suffer bilateral ACL trauma compared with those who suffer unilateral ACL trauma. This information is important for the identification of athletes who may benefit from risk reduction interventions.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-11-05T05:41:22Z
      DOI: 10.1177/0363546519886260
       
  • Rate of Return to Sport and Functional Outcomes After Bilateral Hip
           Arthroscopy in High-Level Athletes
    • Authors: Philip J. Rosinsky, Cynthia Kyin, Ajay C. Lall, Jacob Shapira, David R. Maldonado, Benjamin G. Domb
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Bilateral hip symptoms are common in athletes, and athletes may require treatment with bilateral hip arthroscopy. Return-to-sport (RTS) rates in competitive athletes after unilateral procedures have been reported at 74% to 93%; however, RTS rates after bilateral hip arthroscopy are still unknown.Purpose/Hypothesis:The purpose was to determine rate of RTS in competitive athletes undergoing bilateral hip arthroscopy and report minimum 1-year patient-reported outcomes (PROs) for this cohort. We hypothesized that after bilateral hip arthroscopy, the RTS rate would be similar to the square of the probability of returning after unilateral hip arthroscopy.Study Design:Case series; Level of evidence, 4.Methods:Data were prospectively collected on patients undergoing hip arthroscopy at our institution from November 2011 to July 2018. Patients were included if they underwent bilateral hip arthroscopy and were a high school, collegiate, or professional athlete before their first surgery. A patient’s RTS was defined as return to competitive participation in one’s sport at a level the same as or higher than the preoperative level. Additionally, minimum 1-year PROs, including modified Harris Hip Score (mHHS), nonarthritic hip score, and Hip Outcome Score–Sports Specific Subscale (HOS-SSS), as well as complication rates and future surgery were compared for all patients. Rates of reaching the minimal clinically importance difference (MCID) and patient acceptable symptomatic state (PASS) for the mHHS (8 and 74, respectively) and HOS-SSS (6 and 75, respectively) were also recorded.Results:A total of 87 patients met inclusion criteria, for which follow-up was available for 82 (94.3%). At latest follow-up, 100% of professional athletes had returned to their sport, while 53.7% of the entire cohort returned to their sport, with 75.8% of male patients returning versus 38.8% of female patients (P < .001). Of patients returning, 56% did so at the same ability or higher. The most common reason for not returning was graduation or lifestyle change (47.4%). Patients returning to sport had significantly higher PROs at latest follow-up relative to those who did not return, including mHHS (93.7 vs 87.5), nonarthritic hip score (94.4 vs 88.2), and HOS-SSS (90.9 vs 78.2) (P < .05). Rates of achieving the PASS and MCID for the mHHS were not significantly different. However, for the HOS-SSS, patients who returned had significantly higher rates of achieving the MCID and PASS thresholds.Conclusion:The rate of RTS among competitive athletes after bilateral hip arthroscopy was similar to the square of published RTS rates after unilateral hip arthroscopy. Both those who returned to play and those who did not showed significant improvement in PROs after surgery. However, those who returned to sports achieved significantly higher scores in all outcome measures. Additionally, patients returning to sports showed a significantly higher rate of attaining the MCID and PASS scores for the HOS-SSS.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-11-05T05:16:03Z
      DOI: 10.1177/0363546519885354
       
  • Activity Level Maintenance at Midterm Follow-up Among Active Patients
           Undergoing Periacetabular Osteotomy
    • Authors: Ugochi C. Okoroafor, Cecilia Pascual-Garrido, Maria T. Schwabe, Jeffrey J. Nepple, Perry L. Schoenecker, John C. Clohisy
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:For active patients undergoing periacetabular osteotomy (PAO), returning to and maintaining a high level of activity postoperatively is a priority.Purpose:To evaluate the maintenance of activity levels at midterm follow-up in active patients treated with PAO for symptomatic acetabular dysplasia.Study Design:Case series; Level of evidence, 4.Methods:Patients who underwent PAO for symptomatic acetabular dysplasia between June 2006 and August 2013 were identified by a retrospective review of our prospective longitudinal institutional Hip Preservation Database. All patients with a preoperative University of California, Los Angeles (UCLA) score of ≥7 and a potential minimum 5 years of follow-up were included in the study. Functional outcome measures were the UCLA score, modified Harris Hip Score (mHHS), and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). The maintenance of high activity levels was defined as a UCLA score of ≥7 at final follow-up. Radiographic parameters were measured. Statistical significance was defined as a P value
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-11-05T05:07:12Z
      DOI: 10.1177/0363546519881421
       
  • Diagnostic Performance of Magnetic Resonance Imaging for Detecting
           Meniscal Ramp Lesions in Patients With Anterior Cruciate Ligament Tears: A
           Systematic Review and Meta-analysis
    • Authors: Boyeon Koo, Sun Hwa Lee, Seong Jong Yun, Jae Gwang Song
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:The clinical importance of meniscal ramp lesions in patients with anterior cruciate ligament (ACL) tear has emerged as a major issue. However, the diagnostic accuracy of magnetic resonance imaging (MRI) for detecting ramp lesions has a wide range.Purpose:To perform a systematic review and meta-analysis of the diagnostic performance of MRI for diagnosing ramp lesion in patients with ACL tear.Study Design:Systematic review and meta-analysis.Methods:A literature search of PubMed, EMBASE, and the Cochrane Library was performed based on the revised guidelines for the PRISMA DTA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses of Diagnostic Accuracy Studies) statement. Diagnostic performance studies using MRI as the index test and arthroscopy as the reference standard for ramp lesion were included. Bivariate and hierarchical summary receiver operating characteristic modeling was used to evaluate the diagnostic performance. Meta-regression analyses were performed to identify potential sources of heterogeneity.Results:The review and meta-analysis included 9 studies from 8 articles (883 patients with ACL tear and reconstruction). The summary sensitivity, summary specificity, and area under the hierarchical summary receiver operating characteristic for ramp lesion were 0.71 (95% CI, 0.59-0.81), 0.94 (95% CI, 0.88-0.97), and 0.90 (95% CI, 0.87-0.92), respectively. Among the potential covariates, magnet strength (P < .01), patient knee position (P = .04), and MRI interpreter (P = .04) were associated with heterogeneity in terms of sensitivity, whereas magnet strength (P = .03) was associated with heterogeneity in terms of specificity.Conclusion:MRI demonstrated moderate sensitivity and excellent specificity for diagnosing ramp lesion. Routine arthroscopic assessment is recommended for the presence of ramp lesion, regardless of whether it is suspected on MRI. Further clinicoradiological studies of diagnostic algorithms are needed for identifying ramp lesion, including high-resolution MRI with appropriate knee position.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-11-05T01:14:48Z
      DOI: 10.1177/0363546519880528
       
  • Postoperative Recurrence of Instability After Arthroscopic Bankart Repair
           for Shoulders With Primary Instability Compared With Recurrent
           Instability: Influence of Bipolar Bone Defect Size
    • Authors: Shigeto Nakagawa, Takehito Hirose, Ryohei Uchida, Makoto Tanaka, Tatsuo Mae
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:In shoulders with traumatic anterior instability, a bipolar bone defect has recently been recognized as an important indicator of the prognosis.Purpose:To investigate the influence of bipolar bone defects on postoperative recurrence after arthroscopic Bankart repair performed at primary instability.Study Design:Cohort study; Level of evidence, 3.Methods:The study group consisted of 45 patients (45 shoulders) who underwent arthroscopic Bankart repair at primary instability before recurrence and were followed for at least 2 years. The control group consisted of 95 patients (95 shoulders) with recurrent instability who underwent Bankart repair and were followed for at least 2 years. Glenoid defects and Hill-Sachs lesions were classified into 5 size categories on 3-dimensional computed tomography and were allocated scores ranging from 0 for no defect to 4 for the largest defect. The shoulders were classified according to the total score for both lesions (0-8 points). The postoperative recurrence rate was investigated for each score of bipolar bone defects and was compared between patients with primary instability and patients with recurrent instability. The same analysis was performed for the age at operation (
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-11-05T01:05:39Z
      DOI: 10.1177/0363546519880496
       
  • Native-Osteoarthritic Joint Resident Stem and Progenitor Cells for
           Cartilage Cell-Based Therapies: A Quantitative Comparison With Respect to
           Concentration and Biological Performance
    • Authors: Venkata P. Mantripragada, Wes A. Bova, Nicolas S. Piuzzi, Cynthia Boehm, Nancy A. Obuchowski, Ronald J. Midura, George F. Muschler
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Cell-based therapy for cartilage repair is a promising approach and is becoming an established technique. Yet, there is no consensus on the optimal cell source.Purpose:To provide a donor-matched quantitative comparison of the connective tissue progenitors (CTPs) derived from cartilage (Outerbridge grade 1-3 [G1-2-3]), bone marrow aspirate concentrate (BMC), infrapatellar fat pad (IPFP), synovium, and periosteum with respect to (1) cell concentration ([Cell], cells/mL), (2) CTP prevalence (PCTP, colonies per million cells), and (3) biological performance based on in vitro proliferation potential (cells per colony) colony density, and differentiation potential (expression of negatively charged extracellular matrix: glycosaminoglycan-rich extra cellular matrix [GAG-ECM]).Study Design:Descriptive laboratory study.Methods:Tissues were obtained from 10 patients undergoing total knee arthroplasty (mean age, 59 years; women, n = 6). Automated quantitative colony-forming unit analysis was used to compare [Cell], PCTP, and CTP biological performance across tissue sources.Results:[Cell] was highest in grade 3 cartilage (P = .002) and BMC (P = .001). Median PCTP was highest in IPFP (P = .001), synovium (P = .003), and G1-2 cartilage (P = .02). Proliferation was highest in synovium-derived CTPs (P < .001). Median colony density was highest in G1-2-3 (P < .001). Median GAG-ECM was highest in G1-2-3 (P < .001). Within each patient, CTPs derived from all tissues were highly heterogeneous in biological performance as determined by cells per colony, density, and GAG-ECM.Conclusion:Tissue sources differ in [Cell], PCTP, and biological attributes. The data presented in this study suggest that cartilage (G1-2-3) is the preferred tissue source for cartilage repair based on PCTP and GAG-ECM, followed by synovium, IPFP, BMC, and periosteum. However, due to the heterogeneous mixture of CTPs within each tissue source, there exists a subset of CTPs with biological performance similar to G1-2-3 cartilage, particularly in synovium and IPFP. Performance-based clonal selection and expansion of preferred CTPs and their progeny will potentially lead to improved cell population with predictive future.Clinical Relevance:Optimal tissue regeneration strategies will require informed decisions regarding which of the available tissue sources to use. Optimizing cell sourcing in any tissue may require separation of CTPs with preferred attributes from those with less desirable attributes. The heterogeneity manifest in the early stage of colony formation represents an opportunity for performance-based clone selection for clinical cell processing and manufacturing.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-10-31T10:54:29Z
      DOI: 10.1177/0363546519880905
       
  • Autologous Osteochondral Transplantation for Large Osteochondral Lesions
           of the Talus Is a Viable Option in an Athletic Population
    • Authors: Anthony Nguyen, Arul Ramasamy, Melanie Walsh, Louise McMenemy, James D.F. Calder
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Autologous osteochondral transplantation (AOT) has been shown to be a viable treatment option for large osteochondral lesions of the talus. However, there are limited data regarding the management of large lesions in an athletic population, notably with regard to return to sport. Our investigation focused on assessing both qualitative and quantitative outcomes in the high-demand athlete with large (>150 mm2) lesions.Hypothesis:AOT is a viable option in athletes with large osteochondral lesions and can allow them to return to sport at their preinjury level.Study Design:Case series; Level of evidence, 4.Methods:The study population was limited to professional and amateur athletes (Tegner score,>6) with a talar osteochondral lesion size of 150 mm2 or greater. The surgical intervention was AOT with a donor site from the lateral femoral condyle. Clinical outcomes at a minimum of 24 months included return to sport, visual analog scale (VAS) for pain score, and Foot and Ankle Outcome Score (FAOS). In addition, graft incorporation was evaluated by magnetic resonance imaging (MRI) using MOCART (magnetic resonance observation of cartilage repair tissue) scores at 12 months after surgery.Results:A total of 38 athletes, including 11 professional athletes, were assessed. The mean follow-up was 45 months. The mean lesion size was 249 mm2. Thirty-three patients returned to sport at their previous level, 4 returned at a lower level compared with preinjury, and 1 did not return to sport (mean return to play, 8.2 months). The VAS improved from 4.53 preoperatively to 0.63 postoperatively (P = .002). FAOSs improved significantly in all domains (P < .001). Two patients developed knee donor site pain, and both had 3 osteochondral plugs harvested. Univariant analysis demonstrated no association between preoperative patient or lesion characteristics and ability to return to sport. However, there was a strong correlation between MOCART scores and ability to return to sport. The area under receiver operating characteristic of the MOCART score and return to play was 0.891 (P = .005), with a MOCART score of 52.50 representing a sensitivity of 0.85 and specificity of 0.80 in determining ability to return to one’s previous level of activity.Conclusion:Our study suggests that AOT is a viable option in the management of large osteochondral talar defects in an athletic population, with favorable return to sport level, patient satisfaction, and FAOS/VAS scores. The ability to return to sport is predicated upon good graft incorporation, and further research is required to optimize this technique. Our data also suggest that patients should be aware of the increased risk of developing knee donor site pain when 3 osteochondral plugs are harvested.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-10-31T10:37:30Z
      DOI: 10.1177/0363546519881420
       
  • The Anterolateral Structure of the Knee Does Not Affect Anterior and
           Dynamic Rotatory Stability in Anterior Cruciate Ligament Injury:
           Quantitative Evaluation With the Electromagnetic Measurement System
    • Authors: Daisuke Araki, Takehiko Matsushita, Yuichi Hoshino, Kanto Nagai, Kyohei Nishida, Hideyuki Koga, Tomomasa Nakamura, Mai Katakura, Takeshi Muneta, Ryosuke Kuroda
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:The biomechanical function of the anterolateral structure (ALS), which includes the anterolateral joint capsule and anterolateral ligament (ALL), remains a topic of debate.Hypothesis:The ALS contributes to knee joint stability during the Lachman test and the pivot-shift test in anterior cruciate ligament (ACL)–deficient knees.Study Design:Controlled laboratory study.Methods:Fourteen fresh-frozen hemipelvis lower limbs were used. For 7 specimens, the anterior one-third of the ALS and the residual ALS were cut intra-articularly with a radiofrequency device. Subsequently, the ACL was cut arthroscopically. For the other 7 specimens, the ACL was cut first, followed by the anterior one-third of the ALS and the residual ALS intra-articularly. During the procedures, the iliotibial band (ITB) was kept intact. At each condition, the anterior tibial translation (ATT) during the manual Lachman test and the acceleration of posterior tibial translation (APT) and the posterior tibial translation (PTT) during the manual pivot-shift test were measured quantitatively with an electromagnetic measurement system. The mean values of those parameters were compared among 6 groups (ACL intact, one-third ALS cut, all ALS cut, ACL cut, ACL/one-third ALS cut, and ACL/all ALS cut).Results:The mean ATTs during the Lachman test and the mean APTs and PTTs in the ACL-cut conditions (ACL cut, ACL/one-third ALS cut, and ACL/all ALS cut) were significantly larger than those under the ACL-intact conditions (ACL intact, one-third ALS cut, all ALS cut) (P < .01). However, no statistically significant differences were observed among the intact, one-third ALS–cut, and all ALS–cut conditions, within the ACL-intact or ACL-cut conditions.Conclusion:Intra-articular dissection of the ALS did not increase the ATT during the Lachman test or the APT and PTT during the pivot-shift test under the intact condition of the ITB, regardless of the integrity of the ACL. When the ITB is intact, the ALS does not have a significant role in either anterior or dynamic rotatory knee stability, while the ACL does.Clinical Relevance:Recent growing interest about ALL reconstruction or ALS augmentation may not have a large role in controlling either anterior or dynamic rotatory knee instability in isolated ACL-deficient knees.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-10-28T08:57:22Z
      DOI: 10.1177/0363546519879692
       
  • A 10% Increase in Step Rate Improves Running Kinematics and Clinical
           Outcomes in Runners With Patellofemoral Pain at 4 Weeks and 3 Months

         This is an Open Access Article Open Access Article

    • Authors: Christopher Bramah, Stephen J. Preece, Niamh Gill, Lee Herrington
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Aberrant frontal-plane hip and pelvis kinematics have been frequently observed in runners with patellofemoral pain (PFP). Gait retaining interventions have been shown to improve running kinematics and may therefore be beneficial in runners with PFP.Purpose:To investigate whether a 10% increase in the running step rate influences frontal-plane kinematics of the hip and pelvis as well as clinical outcomes in runners with PFP.Study Design:Case series; Level of evidence, 4.Methods:Runners with PFP underwent a 3-dimensional gait analysis to confirm the presence of aberrant frontal-plane hip and/or pelvis kinematics at baseline. A total of 12 participants with frontal-plane hip and/or pelvis kinematics 1 standard deviation above a reference database were invited to undergo the gait retraining intervention. Running kinematics along with clinical outcomes of pain and functional outcomes were recorded at baseline, 4 weeks after retraining, and 3 months. Gait retraining consisted of a single session where step rate was increased by 10% using an audible metronome. Participants were asked to continue their normal running while self-monitoring their step rate using a global positioning system smartwatch and audible metronome.Results:After gait retraining, significant improvements in running kinematics and clinical outcomes were observed at 4-week and 3-month follow-up. Repeated-measures analysis of variance with post hoc Bonferroni correction (P < .016) showed significant reductions in peak contralateral pelvic drop (mean difference [MD], 3.12° [95% CI, 1.88°-4.37°]), hip adduction (MD, 3.99° [95% CI, 2.01°-5.96°]), and knee flexion (MD, 4.09° [95% CI, 0.04°-8.15°]) as well as significant increases in self-reported weekly running volume (MD, 13.78 km [95% CI, 4.62-22.93 km]) and longest run pain-free (MD, 6.84 km [95% CI, 3.05-10.62 km]). Friedman test with a post hoc Wilcoxon signed-rank test showed significant improvements on a numerical rating scale for worst pain in the past week and the Lower Extremity Functional Scale.Conclusion:A single session of gait retraining using a 10% increase in step rate resulted in significant improvements in running kinematics, pain, and function in runners with PFP. These improvements were maintained at 3-month follow-up. It is important to assess for aberrant running kinematics at baseline to ensure that gait interventions are targeted appropriately.Registration:NCT03067545 (ClinicalTrials.gov identifier)
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-10-28T05:35:22Z
      DOI: 10.1177/0363546519879693
       
  • Biomechanical Effects of Additional Anterolateral Structure Reconstruction
           With Different Femoral Attachment Sites on Anterior Cruciate Ligament
           Reconstruction
    • Authors: Mai Katakura, Hideyuki Koga, Tomomasa Nakamura, Daisuke Araki, Kanto Nagai, Kyohei Nishida, Ryosuke Kuroda, Takeshi Muneta
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Recently reported anterolateral structure reconstructions (ALSRs) to augment intra-articular anterior cruciate ligament reconstruction (ACLR) use various femoral attachment sites, and their biomechanical effects are still unknown.Hypothesis:ALSR concomitant with ACLR would control anterolateral rotational instability better than ACLR alone, and if ALSR had different femoral attachment sites, there would be different effects on its control of anterolateral rotational instability.Study Design:Controlled laboratory study.Methods:Twelve fresh-frozen hemipelvis lower limbs were included. Anterior tibial translation during the Lachman test and tibial acceleration during the pivot-shift test were measured with a 3-dimensional electromagnetic measurement system in situations with the (1) ACL and ALS intact, (2) ACL and ALS cut, (3) ALSR without ACLR (ALSR alone), (4) ACLR without ALSR (ACLR alone), and (5) ALSR with ACLR. Three femoral attachment sites were used for ALSR: F1, 2 mm anterior and 2 mm distal to the lateral epicondyle; F2, 4 mm posterior and 8 mm proximal to the lateral epicondyle; and F3, over-the-top position for the lateral extra-articular tenodesis. The Steel test and Wilcoxon signed rank test were used for statistical analysis.Results:Anterior tibial translation during the Lachman test in the ACL and ALS–cut state was significantly larger than it was in the ACL and ALS–intact state, while its difference disappeared after ACLR. As for the pivot-shift test, additional ALSR with F2 to ACLR significantly decreased the acceleration (P = .046), although additional ALSR with F1 and F3 showed no significant effect.Conclusion:ALSR with the femoral attachment site 4 mm posterior and 8 mm proximal to the lateral epicondyle in addition to ACLR played a role in reducing anterolateral rotational instability the most effectively among the measured attachment sites.Clinical Relevance:The present data will contribute to determine the appropriate femoral attachment site for ALSR to better control anterolateral rotational instability after ACL reconstruction.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-10-28T05:10:34Z
      DOI: 10.1177/0363546519880192
       
  • Anatomic and Biomechanical Evaluation of Ulnar Tunnel Position in Medial
           Ulnar Collateral Ligament Reconstruction
    • Authors: Pascual H. Dutton, Michael B. Banffy, Trevor J. Nelson, Melodie F. Metzger
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Although numerous techniques of reconstruction of the medial ulnar collateral ligament (mUCL) have been described, limited evidence exists on the biomechanical implication of changing the ulnar tunnel position despite the fact that more recent literature has clarified that the ulnar footprint extends more distally than was appreciated in the past.Purpose:To evaluate the size and location of the native ulnar footprint and assess valgus stability of the medial elbow after UCL reconstruction at 3 ulnar tunnel locations.Study Design:Controlled laboratory study.Methods:Eighteen fresh-frozen cadaveric elbows were dissected to expose the mUCL. The anatomic footprint of the ulnar attachment of the mUCL was measured with a digitizing probe. The area of the ulnar footprint and midpoint relative to the joint line were determined. Medial elbow stability was tested with the mUCL in an intact, deficient, and reconstructed state after the docking technique, with ulnar tunnels placed at 5, 10, or 15 mm from the ulnotrochlear joint line. A 3-N·m valgus torque was applied to the elbow, and valgus rotation of the ulna was recorded via motion-tracking cameras as the elbow was cycled through a full range of motion. After kinematic testing, specimens were loaded to failure at 70° of elbow flexion.Results:The mean ± SD length of the mUCL ulnar footprint was 27.4 ± 3.3 mm. The midpoint of the anatomic footprint was located between the 10- and 15-mm tunnels across all specimens at a mean 13.6 mm from the joint line. Sectioning of the mUCL increased elbow valgus rotation throughout all flexion angles and was statistically significant from 30° to 100° of flexion as compared with the intact elbow (P < .05). mUCL reconstruction at all 3 tunnel locations restored stability to near intact levels with no significant differences among the 3 ulnar tunnel locations at any flexion angle.Conclusion:Positioning the ulnar graft fixation site up to 15 mm from the ulnotrochlear joint line does not significantly increase valgus rotation in the elbow.Clinical Relevance:A more distal ulnar tunnel may be a viable option to accommodate individual variation in morphology of the proximal ulna or in a revision setting.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-10-24T09:18:34Z
      DOI: 10.1177/0363546519880182
       
  • The Effect of Sport-Related Concussion Injuries on Concussion Symptoms and
           Health-Related Quality of Life in Male and Female Adolescent Athletes: A
           Prospective Study
    • Authors: Timothy A. McGuine, Adam Pfaller, Stephanie Kliethermes, Allison Schwarz, Scott Hetzel, Erin Hammer, Steven Broglio
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Sport-related concussions (SRCs) are associated with short-term disablement, characterized as increased concussion symptoms and lower health-related quality of life (HRQoL). However, there are limited longitudinal data detailing how an SRC affects disablement beyond short-term injury recovery.Purpose:To longitudinally assess the effect of SRCs on symptoms and HRQoL in high school athletes through the 12 months after injury.Study Design:Cohort study; Level of evidence, 2.Methods:The 125 participants included high school athletes who sustained an SRC (female patients, 36%; mean ± SD age, 15.9 ± 1.1 years). The Post-concussion Symptom Scale (PCSS) from the Sport Concussion Assessment Tool–3 and the Pediatric Quality of Life Inventory 4.0 (PedsQL) were completed at enrollment and repeated at 24 to 72 hours (onset) and at 7 days (D7) after the SRC; on the date of return to play (RTP); and at 3, 6, and 12 months (M12) after the SRC. Scores at each time point were compared with the athletes’ own baseline via linear mixed models for repeated measures, controlling for age, sex, and history of previous SRC and with patient as a random effect.Results:Relative to baseline, female patients reported higher PCSS symptom and severity scores at onset (P < .001) and D7 (P < .001), while scores were not higher (P> .05) for RTP through M12. As compared with baseline, male patients reported higher PCSS scores at onset (P < .001) and D7 (P = .003) and severity scores at onset (P < .001) and D7 (P = .016), while the symptom and severity scores were not higher (P> .05) at RTP through M12. Female participants reported lower PedsQL physical scores at onset (P = .006), while scores were not lower (P> .05) from D7 through M12. Female psychosocial scores were not lower (P> .05) at any time after the SRC, while the total PedsQL score was lower at onset (P = .05) but not from D7 through M12. Male physical scores were lower at onset (P < .001) and D7 (P = .001) but not lower (P> .05) from RTP through M12. Male psychosocial and PedsQL scores were unchanged (P> .05) from baseline at onset through M12.Conclusion:After an SRC, high school athletes reported initial disablement (increased symptoms and lower HRQoL) through their RTP. However, after RTP, no similar disablement was detected through 12 months after injury.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-10-24T09:10:54Z
      DOI: 10.1177/0363546519880175
       
  • Outcomes After Latarjet Procedure: Patients With First-Time Versus
           Recurrent Dislocations
    • Authors: Alexandre Hardy, Vincent Sabatier, Pierre Laboudie, Bradley Schoch, Marie Vigan, Jean David Werthel, Geoffroy Nourissat, Philippe Valenti, Jean Kany, Julien Deranlot, Nicolas Solignac, Philippe Hardy
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:The preoperative number of dislocations has been previously proved to be a major factor influencing the results after Bankart repair with more preoperative dislocations correlated with higher recurrence rates and more reoperations. This could possibly be because of the lower quality of the tissue repaired during the procedure after multiple dislocations. On the other hand, the Latarjet procedure does not “repair” but rather reconstructs and augments the anterior glenoid.Purpose/Hypothesis:The main objective was to report the clinical outcomes of patients undergoing a Latarjet procedure after 1 dislocation versus multiple (≥2) dislocations. The hypothesis was that the preoperative number of dislocations would not influence clinical results.Study Design:Cohort study; Level of evidence, 3.Methods:Patients older than 18 years who had undergone a primary Latarjet procedure for shoulder instability with at least 2 years of follow-up were included. Three different techniques were used: a mini-open technique using 2 screws, an arthroscopic technique using 2 screws, and an arthroscopic technique using 2 cortical buttons. Patients were evaluated and answered a questionnaire to assess the number of episodes of dislocation before surgery, the time between the first dislocation and surgery, recurrence of the dislocation, revision surgery, the Walch-Duplay score, the Simple Shoulder Test score, and the visual analog scale (VAS) score for pain.Results:A total of 308 patients were included for analysis with a mean follow-up of 3.4 ± 0.8 years. Of that, 83 patients were included in the first-time dislocation group and 225 in the recurrent dislocation group. At last follow-up, the rates of recurrence and reoperation were not significantly different between groups: 4.8% in the first-time dislocation group versus 3.65% in the recurrent dislocation group and 6.1% versus 4.0%, respectively. The overall Walch-Duplay scores at last follow-up were also comparable between the 2 groups, 67.3 ± 24.85 and 71.8 ± 25.1, even though the first-time dislocation group showed a lower pain subscore (15.0 ± 8.6 vs 18.0 ± 7.5; P = .003). The VAS for pain was also significantly higher in the first-time dislocation group compared with the recurrent dislocation group (1.8 ± 2.3 vs 1.2 ± 1.7; P = .03).Conclusion:The number of episodes of dislocation before surgery does not affect postoperative instability rates and reoperation rates after the Latarjet procedure. However, patients with first-time dislocations had more postoperative pain compared with patients with recurrent dislocations before surgery.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-10-24T08:59:34Z
      DOI: 10.1177/0363546519879929
       
  • The Femoral Footprint Position of the Anterior Cruciate Ligament Might Be
           a Predisposing Factor to a Noncontact Anterior Cruciate Ligament Rupture
    • Authors: Dimitris Dimitriou, Zhongzheng Wang, Diyang Zou, Tsung-Yuan Tsai, Naeder Helmy
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Although the femoral tunnel position is crucial to anatomic single-bundle anterior cruciate ligament (ACL) reconstruction, the recommendations for the ideal femoral footprint position are mostly based on cadaveric studies with small sample sizes, elderly patients with unknown ACL status, and 2-dimensional techniques. Furthermore, a potential difference in the femoral ACL footprint position and ACL orientation between ACL-ruptured and ACL-intact knees has not been reported in the literature.Hypothesis:The femoral ACL footprint position and ACL orientation vary significantly between ACL-ruptured and matched control ACL-intact knees.Study Design:Cross-sectional study; Level of evidence, 3.Methods:Magnetic resonance images of the knees of 90 patients with an ACL rupture and 90 matched control participants who had a noncontact knee injury without an ACL rupture were used to create 3-dimensional models of the femur and tibia. The ACL footprints were outlined on each model, and their positions (normalized to the lateral condyle width) as well as ACL orientations were measured with an anatomic coordinate system.Results:The femoral ACL footprint in patients with an ACL rupture was located at 36.6% posterior and 11.2% distal to the flexion-extension axis (FEA). The ACL orientation was 46.9° in the sagittal plane, 70.3° in the coronal plane, and 20.8° in the transverse plane. The ACL-ruptured group demonstrated a femoral ACL footprint position that was 11.0% more posterior and 7.7% more proximal than that of the control group (all P < .01). The same patients also exhibited 5.7° lower sagittal elevation, 3.1° higher coronal plane elevation, and 7.9° lower transverse plane deviation (all P < .01). The optimal cutoff value of the femoral ACL footprint position to prevent an ACL rupture was at 30% posterior and 12% distal to the FEA.Conclusion:The ACL femoral footprint position might be a predisposing factor to an ACL rupture. Patients with a>30% posterior and
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-10-24T08:39:34Z
      DOI: 10.1177/0363546519878706
       
  • Point-of-Care Procedure for Enhancement of Meniscal Healing in a Goat
           Model Utilizing Infrapatellar Fat Pad–Derived Stromal Vascular Fraction
           Cells Seeded in Photocrosslinkable Hydrogel
    • Authors: Benjamin B. Rothrauff, Hiroshi Sasaki, Shinsuke Kihara, Kalon J. Overholt, Riccardo Gottardi, Hang Lin, Freddie H. Fu, Rocky S. Tuan, Peter G. Alexander
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Large radial tears of the meniscus involving the avascular region can compromise meniscal function and result in poor healing and subsequent osteochondral degeneration. Augmentation of surgical repairs with adipose-derived stromal vascular fraction (SVF), which contains mesenchymal stromal cells, may improve meniscal healing and preserve function (ie, chondroprotection).Purposes:(1) To develop a goat model of a radial meniscal tear with resulting osteoarthritis and (2) to explore the efficacy of a 1-step procedure utilizing infrapatellar fat pad–derived SVF cells seeded in a photocrosslinkable hydrogel to enhance meniscal healing and mitigate osteochondral degeneration.Study Design:Controlled laboratory study.Methods:A full-thickness radial tear spanning 90% of the medial meniscal width was made at the junction of the anterior and middle bodies of the goat stifle joint. Tears received 1 of 3 interventions (n = 4 per group): untreated, repair, or repair augmented with photocrosslinkable methacrylated gelatin hydrogel containing 2.0 × 106 SVF cells/mL and 2.0 µg/mL of transforming growth factor β3. The contralateral (left) joint served as a healthy control. At 6 months, meniscal healing and joint health were evaluated by magnetic resonance imaging (MRI) and assessed by histological and macroscopic scoring. The Whole-Organ Magnetic Resonance Imaging Score and the presence of a residual tear, as evaluated with T2 MRI sequences, were determined by a single blinded orthopaedic surgeon.Results:When compared with tears left untreated or repaired with suture alone, augmented repairs demonstrated increased tissue formation in the meniscal tear site, as seen on MRI and macroscopically. Likewise, the neotissue of augmented repairs possessed a histological appearance more similar, although still inferior, to healthy meniscus. Osteochondral degeneration in the medial compartment, as evaluated by the Whole-Organ Magnetic Resonance Imaging Score and Inoue (macroscopic) scale, revealed increased degeneration in the untreated and repair groups, which was mitigated in the augmented repair group. Histological evaluation with a modified Mankin score showed a similar trend. In all measures of osteochondral degeneration, the augmented repair group did not differ significantly from the uninjured control.Conclusion:A radial tear spanning 90% of the medial meniscal width in a goat stifle joint showed poor healing potential and resulted in osteochondral degeneration by 6 months, even if suture repair was performed. Augmentation of the repair with a photocrosslinkable hydrogel containing transforming growth factor β3 and SVF cells, isolated intraoperatively by rapid enzymatic digestion, improved meniscal healing and mitigated osteoarthritic changes.Clinical Relevance:Repair augmentation with an SVF cell–seeded hydrogel may support successful repair of meniscal tears previously considered irreparable.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-10-23T07:55:56Z
      DOI: 10.1177/0363546519880468
       
  • Functional Results and Outcomes After Repair of Partial Proximal Hamstring
           Avulsions at Midterm Follow-up
    • Authors: Justin W. Arner, Halle Freiman, Craig S. Mauro, James P. Bradley
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Partial avulsions of the proximal hamstring origin remain a challenging problem with nonoperative treatments frequently providing limited success. The literature is limited regarding the outcomes of operative management in the active and athletic population.Hypothesis:Surgical fixation of proximal hamstring ruptures will have favorable outcomes at midterm follow-up.Study design:Case series; Level of evidence, 4.Methods:A total of 64 patients with partial avulsions of the proximal hamstring origin treated with surgical fixation by a single surgeon were reviewed at a 2-year minimum follow-up. All patients had initially undergone failed nonoperative treatment. Patient-reported outcome scores on the Lower Extremity Functional Score (LEFS), Marx Activity Rating Scale, custom LEFS and Marx scales, and total proximal hamstring score were evaluated. Data on patient-perceived strength, return to sport, and satisfaction were also collected.Results:The cohort included 27 male and 37 female (N = 64) patients with a mean age of 47.3 years (range, 16-65 years), and all were reviewed at a mean 6.5-year (range, 2-12.5 years) follow-up. The average postoperative LEFS was 96% (range, 68%-100%), with the custom LEFS being 90% (range, 39%-100%). The mean Marx score was 12.4 (range, 4-16). The Marx custom score demonstrated no disability with activities of daily living. The mean total proximal hamstring score was 94% (range, 69%-100%). No differences in any outcome measures were seen when comparing acute versus chronic repairs. Three patients underwent further hamstring surgery. No patients reported symptoms of numbness in the operative extremity at rest, while 3 patients had a superficial stitch abscess treated with antibiotics alone. The most commonly reported difficulty was with prolonged sitting. Ninety-seven percent were satisfied with surgery, 92% reported they could participate in strenuous activity, and 97% estimated their strength to be>75%, while 64% estimated it to be 100% of their contralateral side. Patients returned to sport at an average of 11.1 months, and all that returned were satisfied with their performance.Conclusion:Both early and delayed anatomic surgical repair of partial proximal hamstring avulsions leads to successful functional outcomes, a high rate of return to athletic activity, and low complication rates at the 6.5-year follow-up. Nonoperative treatments should first be attempted.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-10-21T10:09:23Z
      DOI: 10.1177/0363546519879117
       
  • The Association Between Tibial Slope and Revision Anterior Cruciate
           Ligament Reconstruction in Patients ≤21 Years Old: A Matched
           Case-Control Study Including 317 Revisions
    • Authors: Joseph D. Cooper, Wei Wang, Heather A. Prentice, Tadashi T. Funahashi, Gregory B. Maletis
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:There is evidence that tibial slope may play a role in revision risk after anterior cruciate ligament reconstruction (ACLR); however, prior studies are inconsistent.Purpose:To determine (1) whether there is a difference in lateral tibial posterior slope (LTPS) or medial tibial posterior slope (MTPS) between patients undergoing revised ACLR and those not requiring revision and (2) whether the medial-to-lateral slope difference is different between these 2 groups.Study Design:Case-control study; Level of evidence, 3.Methods:We conducted a matched case-control study (2006-2015). Cases were patients aged ≤21 years who underwent revision surgery after primary unilateral ACLR; controls were patients aged ≤21 years without revision who were identified from the same source population. Controls were matched to cases by age, sex, body mass index, race, graft type, femoral fixation device, and post-ACLR follow-up time. Tibial slope measurements were made by a single blinded reviewer using magnetic resonance imaging. The Wilcoxon signed rank test and McNemar test were used for continuous and categorical variables, respectively.Results:No difference was observed between revised and nonrevised ACLR groups for LTPS (median: 6° vs 6°, P = .973) or MTPS (median: 4° vs 5°, P = .281). Furthermore, no difference was found for medial-to-lateral slope difference (median: −1 vs −1, P = .289). A greater proportion of patients with revised ACLR had an LTPS ≥12° (7.6% vs 3.8%) and ≥13° (4.7% vs 1.3%); however, this was not statistically significant after accounting for multiple testing.Conclusion:We failed to observe an association between revision ACLR surgery and LTPS, MTPS, or medial-to-lateral slope difference. However, there was a greater proportion of patients in the revision ACLR group with an LTPS ≥12°, suggesting that a minority of patients who have more extreme values of LTPS have a higher revision risk after primary ACLR. A future cohort study evaluating the angle that best differentiates patients at highest risk for revision is needed.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-10-21T08:19:51Z
      DOI: 10.1177/0363546519878436
       
  • Evaluation of Osseous Morphology of the Hip Using Zero Echo Time Magnetic
           Resonance Imaging
    • Authors: Ryan E. Breighner, Eric A. Bogner, Susan C. Lee, Matthew F. Koff, Hollis G. Potter
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Femoroacetabular impingement syndrome (FAIS) is a common disorder of the hip resulting in groin pain and ultimately osteoarthritis. Radiologic assessment of FAI morphologies, which may present with overlapping radiologic features of hip dysplasia, often requires the use of computed tomography (CT) for evaluation of osseous abnormality, owing to the difficulty of direct visualization of cortical and subchondral bone with conventional magnetic resonance imaging (MRI). The use of a zero echo time (ZTE) MRI pulse sequence may obviate the need for CT by rendering bone directly from MRI.Purpose/Hypothesis:The purpose was to explore the application of ZTE MRI to the assessment of osseous FAI and dysplasia morphologies of the hip. It was hypothesized that angular measurements from ZTE images would show significant agreement with measurements obtained from CT images.Study Design:Cohort study (diagnosis); Level of evidence, 2.Methods:Thirty-eight hips from 23 patients were imaged with ZTE MRI and CT. Clinically relevant angular measurements of hip morphology were made in both modalities and compared to assess agreement. Measurements included coronal and sagittal center-edge angles, femoral neck-shaft angle, acetabular version (at 1-, 2-, and 3-o’clock positions), Tönnis angle, alpha angle, and modified-beta angle. Interrater agreement was assessed for a subset of 10 hips by 2 raters. Intermodal agreement was assessed on the complete cohort and a single rater.Results:Interrater agreement was demonstrated in both CT and ZTE, with intraclass correlation coefficient values ranging from 0.636 to 0.990 for ZTE and 0.747 to 0.983 for CT, indicating “good” to “excellent” agreement. Intermodal agreement was also shown to be significant, with intraclass correlation coefficients ranging from 0.618 to 0.904.Conclusion:Significant agreement of angular measurements for hip morphology exists between ZTE MRI and CT imaging. ZTE MRI may be an effective method to quantitatively evaluate osseous hip morphology.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-10-21T07:59:01Z
      DOI: 10.1177/0363546519878170
       
  • Return to Play and Long-term Participation in Pivoting Sports After
           Anterior Cruciate Ligament Reconstruction
    • Authors: Line Lindanger, Torbjørn Strand, Anders Odd Mølster, Eirik Solheim, Eivind Inderhaug
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Rupture of the anterior cruciate ligament (ACL) is a common and feared injury among athletes because of its potential effect on further sports participation. Reported rates of return to pivoting sports after ACL reconstruction (ACLR) vary in the literature, and the long-term consequences of returning have rarely been studied.Purpose:To examine the rate and level of return to pivoting sports after ACLR, the duration of sports participation, and long-term consequences of returning to pivoting sports.Study Design:Cohort study; Level of evidence, 2.Methods:All primary ACLRs with a bone–patellar tendon–bone autograft between 1987 and 1994 (N = 234) in athletes participating in team handball, basketball, or soccer before injury were selected from a single-center quality database. A long-term evaluation (median, 25 years; range, 22-30 years) was performed using a questionnaire focusing on return to pivoting sports, the duration of sports activity after surgery, later contralateral ACL injuries, revision surgery, and knee replacement surgery. Participants were stratified into 2 groups depending on the time between injury and surgery (early, .05), but males had longer sports careers (median, 10 years; range, 1-23 years) than females (median, 4 years; range, 1-25 years; P < .001). The incidence of contralateral ACL injuries was 28% among athletes who returned to sports versus 4% among athletes who did not return (P = .017) after early ACLR. The pooled reinjury rate after return to preinjury level of sports was 41% (30%, contralateral injuries; 11%, revision surgery). The incidence of contralateral ACL injuries was 32% among females versus 23% among males (P> .05) and, for revision surgery, was 12% among females versus 7% among males (P> .05) after returning to sports. Having a late ACLR was associated with an increased risk of knee replacement surgery (9% vs 3%; P = .049) when compared with having an early ACLR.Conclusion:ACLR does not necessarily enable a return to preinjury sports participation. By returning to pivoting sports after ACLR, athletes are also facing a high risk of contralateral ACL injuries. Long-term evaluations in risk assessments after ACLR are important, as a significant number of subsequent ACL injuries occur later than the routine follow-up.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-10-21T07:41:13Z
      DOI: 10.1177/0363546519878159
       
  • Does Injection of Hyaluronic Acid Protect Against Early Cartilage Injury
           Seen After Marathon Running' A Randomized Controlled Trial Utilizing
           High-Field Magnetic Resonance Imaging
    • Authors: Amit Nathani, Garry E. Gold, Uchechukwuka Monu, Brian Hargreaves, Andrea K. Finlay, Elka B. Rubin, Marc R. Safran
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Previous studies have shown that runners demonstrate elevated T2 and T1ρ values on magnetic resonance imaging (MRI) after running a marathon, with the greatest changes in the patellofemoral and medial compartment, which can persist after 3 months of reduced activity. Additionally, marathon running has been shown to increase serum inflammatory markers. Hyaluronic acid (HA) purportedly improves viscoelasticity of synovial fluid, serving as a lubricant while also having chondroprotective and anti-inflammatory effects.Purpose/Hypothesis:The purpose was to investigate whether intra-articular HA injection can protect articular cartilage from injury attributed to marathon running. The hypothesis was that the addition of intra-articular HA 1 week before running a marathon would reduce the magnitude of early cartilage breakdown measured by MRI.Study Design:Randomized controlled trial; Level of evidence, 2.Methods:After institutional review board approval, 20 runners were randomized into receiving an intra-articular injection of HA or normal saline (NS) 1 week before running a marathon. Exclusionary criteria included any prior knee injury or surgery and having run>3 prior marathons. Baseline 3-T knee MRI was obtained within 48 hours before the marathon (approximately 5 days after injection). Follow-up 3-T MRI scans of the same knee were obtained 48 to 72 hours and 3 months after the marathon. The T2 and T1ρ relaxation times of articular cartilage were measured in 8 locations—the medial and lateral compartments (including 2 areas of each femoral condyle) and the patellofemoral joint. The statistical analysis compared changes in T2 and T1ρ relaxation times (ms) from baseline to immediate and 3-month postmarathon scans between the HA and NS groups with repeated measures analysis of variance.Results:Fifteen runners completed the study: 6 women and 2 men in the HA group (mean age, 31 years; range, 23-50 years) and 6 women and 1 man in the NS group (mean age, 27 years; range, 20-49 years). There were no gross morphologic MRI changes after running the marathon. Postmarathon studies revealed no statistically significant changes between the HA and NS groups in all articular cartilage areas of the knee on both T2 and T1ρ relaxation times.Conclusion:Increased T2 and T1ρ relaxation times have been observed in marathon runners, suggesting early cartilage injury. The addition of intra-articular HA did not significantly affect relaxation times in all areas of the knee when compared with an NS control.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-10-21T06:31:28Z
      DOI: 10.1177/0363546519879138
       
  • Single-Leg Squat Performance and Its Relationship to Extensor Mechanism
           Strength After Anterior Cruciate Ligament Reconstruction
    • Authors: Lachlan M. Batty, Julian A. Feller, Taylor Hartwig, Brian M. Devitt, Kate E. Webster
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Performance in strength and functional testing is important when considering return to sport after anterior cruciate ligament (ACL) reconstruction. Both knee extensor strength and the single-leg squat (SLS) have been used in this context.Purpose:To evaluate the relationship between knee extensor strength and SLS performance after primary ACL reconstruction.Study Design:Cohort study (Diagnosis); Level of evidence, 3.Methods:A prospective cohort of 100 patients was assessed 6 and 12 months after primary ACL reconstruction with a hamstring tendon autograft. Knee extensor peak torque was measured. Three sequential SLSs were performed, and the maximum flexion angle identified from frame-by-frame video analysis was used as the measure of squat performance. A limb symmetry index (LSI) was calculated and satisfactory performance defined as ≥90%.Results:Extensor mechanism strength deficits were seen in 75% of patients at 6 months and 57% at 12 months postoperatively. Mean extensor mechanism strength showed a large improvement between 6 and 12 months (123.6 vs 147.8 N·m, respectively; P < .001; Cohen d = 1.10), and while there was also a statistically significant improvement in the mean maximum flexion angle, the change was small (66.1° vs 68.1°, respectively; P = .011; Cohen d = 0.26). There was a weak positive correlation between knee extensor strength and the SLS maximum flexion angle at 6 months (r = 0.342; P < .001) and 12 months (r = 0.245; P = .014). An SLS LSI
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-10-21T06:28:48Z
      DOI: 10.1177/0363546519878432
       
  • Outcomes After Arthroscopic Hip Labral Reconstruction: A Systematic Review
           and Meta-analysis
    • Authors: Michael D. Rahl, Collin LaPorte, Gabrielle K. Steinl, Michaela O’Connor, T. Sean Lynch, Travis J. Menge
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:The acetabular labrum is critical to maintenance of hip stability and has been found to play a key role in preservation of the hip fluid seal. For irreparable labral damage, arthroscopic labral reconstruction is an evolving technique that has been shown to decrease hip pain and restore function.Purpose:To provide a comprehensive review of current literature for arthroscopic hip labral reconstruction, with a focus on determining if outcomes differ between autograft or allograft tissue.Study Design:Systematic review and meta-analysis.Methods:PubMed and Scopus online databases were searched with the key terms “hip,”“labrum,”“reconstruction,” and “graft” in varying combinations. Procedures performed, complications, failures, and functional outcome measures were included in this analysis. The inverse variance method was used to calculate pooled estimates and 95% CIs.Results:Eight studies with 537 hips were included. Mean age was 37.4 years (95% CI, 34.5-40.4 years), and mean follow-up time was 29 months (95% CI, 26-33 months). Survivorship after autograft reconstruction ranged from 75.7% to 100%, as compared with 86.3% to 90.0% in the allograft cohort. In the autograft cohort, failures included 0% to 13.2% conversion to total hip arthroplasty and 0% to 11.0% revision hip arthroscopy. Failures in the allograft cohort included 0% to 12.9% total hip arthroplasty conversion, 0% to 10.0% revision arthroscopy, and 0% to 0.8% open revision surgery. Based on 6 studies, the modified Harris Hip Score improved by a mean 29.0 points after labral reconstruction (P < .0001).Conclusion:Arthroscopic hip labral reconstruction results in clinically significant improvements in patient-reported outcomes. Our analysis indicates that there are no significant differences in outcomes based on graft type alone. A number of factors may determine graft choice, including patient preference, surgeon experience, operative time, morbidity, and cost. Proper patient selection based on age and severity of degenerative joint disease will also optimize outcomes after labral reconstruction.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-10-21T06:24:25Z
      DOI: 10.1177/0363546519878147
       
  • Partial-Thickness Rotator Cuff Tear by Itself Does Not Cause Shoulder Pain
           or Muscle Weakness in Baseball Players
    • Authors: Teruhisa Mihata, Rei Morikura, Akihiko Hasegawa, Kunimoto Fukunishi, Takeshi Kawakami, Yukitaka Fujisawa, Mutsumi Ohue, Masashi Neo
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Partial-thickness rotator cuff tears are common shoulder injuries in baseball players. For some tears, the symptoms can be relieved through physical therapy or debridement without rotator cuff repair.Purpose:To assess whether partial-thickness rotator cuff tear by itself causes shoulder pain and muscle weakness in baseball players.Study Design:Cross-sectional study; Level of evidence, 3.Methods:We studied 87 university baseball players (age, 19.5 ± 0.8 years; baseball career, 11.5 ± 1.6 years). All data were obtained during a full-participation annual medical check in 1 team. Rotator cuff tendons were examined ultrasonographically and allocated to 4 groups: (1) no tear, (2) supraspinatus tendon tear, (3) infraspinatus tendon tear, and (4) both supraspinatus and infraspinatus tendon tears. Current shoulder pain and shoulder muscle strength (dominant/nondominant) in abduction, external rotation, and internal rotation were compared by using chi-square and t tests. All players could play baseball with or without shoulder pain in this study.Results:Of the 87 players, 41 (47%) had articular-sided partial-thickness rotator cuff tears diagnosed on ultrasonography; the remaining 46 athletes were tear-free. Of the 41 affected patients, 19 had tears in the supraspinatus, 13 in the infraspinatus, and 9 in both the supraspinatus and infraspinatus tendons. Tear depth (mean ± SD) was 4.6 ± 2.3 mm in the supraspinatus and 6.2 ± 3.6 mm in the infraspinatus. Neither the rate of shoulder pain nor muscle strength differed significantly among the 4 groups (P = .96 and P = .15-.70, respectively).Conclusion:Articular-sided partial-thickness rotator cuff tear—by itself—did not cause shoulder pain and muscle weakness in university baseball players. Most so-called articular-sided partial-thickness rotator cuff tears may not be pathologic tendon tears.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-10-14T05:21:01Z
      DOI: 10.1177/0363546519878141
       
  • Are Implant Choice and Surgical Approach Associated With Biceps Tenodesis
           Construct Strength' A Systematic Review and Meta-regression
    • Authors: Hiroshi F. Aida, Brendan Y. Shi, Eric G. Huish, Edward G. McFarland, Uma Srikumaran
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Despite the increasing use of biceps tenodesis, there is a lack of consensus regarding optimal implant choice (suture anchor vs interference screw) and implant placement (suprapectoral vs subpectoral).Purpose/Hypothesis:The purpose was to determine the associations of procedural parameters with the biomechanical performance of biceps tenodesis constructs. The authors hypothesized that ultimate failure load (UFL) would not differ between sub- and suprapectoral repairs or between interference screw and suture anchor constructs and that the number of implants and number of sutures would be positively associated with construct strength.Study Design:Meta-analysis.Methods:The authors conducted a systematic literature search for studies that measured the biomechanical performance of biceps tenodesis repairs in human cadaveric specimens. Two independent reviewers extracted data from studies that met the inclusion criteria. Meta-regression was then performed on the pooled data set. Outcome variables were UFL and mode of failure. Procedural parameters (fixation type, fixation site, implant diameter, and numbers of implants and sutures used) were included as covariates. Twenty-five biomechanical studies, representing 494 cadaveric specimens, met the inclusion criteria.Results:The use of interference screws (vs suture anchors) was associated with a mean 86 N–greater UFL (95% CI, 34-138 N; P = .002). Each additional suture used to attach the tendon to the implant was associated with a mean 53 N–greater UFL (95% CI, 24-81 N; P = .001). Multivariate analysis found no significant association between fixation site and UFL. Finally, the use of suture anchors and fewer number of sutures were both independently associated with lower odds of native tissue failure as opposed to implant pullout.Conclusion:These findings suggest that fixation with interference screws, rather than suture anchors, and the use of more sutures are associated with greater biceps tenodesis strength, as well as higher odds of native tissue failure versus implant pullout. Although constructs with suture anchors show inferior UFL compared with those with interference screws, incorporation of additional sutures may increase the strength of suture anchor constructs. Supra- and subpectoral repairs provide equivalent biomechanical strength when controlling for potential confounders.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-10-04T10:34:52Z
      DOI: 10.1177/0363546519876107
       
  • Outcomes of Hip Arthroscopic Surgery in Adolescents With a Subanalysis on
           Return to Sport: A Systematic Review
    • Authors: Sarah L. Chen, David R. Maldonado, Cammille C. Go, Cynthia Kyin, Ajay C. Lall, Benjamin G. Domb
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:There is a plethora of literature on outcomes after hip arthroscopic surgery in the adult population; however, outcomes in the adolescent population have not been as widely reported. Additionally, as adolescents represent a very active population, it is imperative to understand their athletic activity and return to sport after hip arthroscopic surgery.Purpose:To analyze patient-reported outcomes (PROs) after hip arthroscopic surgery in adolescents (aged 10-19 years) and present a return-to-sport analysis in the athletic adolescent subgroup.Study Design:Systematic review; Level of evidence, 4.Methods:The PubMed, Embase, and Cochrane databases were searched according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to identify articles that reported PROs after hip arthroscopic surgery in adolescents. The standardized mean difference was calculated to compare the effect size of hip arthroscopic surgery on various PROs. For the athletic subgroup, a return-to-sport summary was also provided.Results:Ten studies, with 618 adolescent hips and a collective study period of December 2004 to February 2015, were included in this systematic review. Across all studies, the mean age was 15.8 years (range, 11.0-19.9 years), and female patients composed approximately 56.7% of the entire cohort. The mean follow-up was 34.5 months (range, 12-120 months). The modified Harris Hip Score (mHHS) was reported in 9 studies, and at latest follow-up, scores were excellent in 4 studies (range, 90-95) and good in the remaining 5 studies (range, 82.1-89.6). All adolescents also showed significant improvement on the Non-Arthritic Hip Score (NAHS), the Hip Outcome Score–Activities of Daily Living (HOS-ADL), the HOS–Sport-Specific Subscale (HOS-SSS), the physical component of the 12-Item Short Form Health Survey (SF-12P), a visual analog scale for pain (VAS), and both versions of the International Hip Outcome Tool (iHOT-12 and iHOT-33) at latest follow-up (P < .05). Further, mean improvements reported in all studies surpassed reported values of the minimal clinically important difference and patient acceptable symptomatic state for the mHHS, HOS-ADL, HOS-SSS, and iHOT-33. Finally, the collective return-to-sport rate among athletic adolescents was 84.9%.Conclusion:In the setting of labral tears and femoroacetabular impingement, hip arthroscopic surgery can safely be performed in adolescents and leads to significant functional improvement. Furthermore, athletic adolescents return to sport at high levels after hip arthroscopic surgery.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-09-20T08:38:22Z
      DOI: 10.1177/0363546519875131
       
  • Outcomes of Revision Hip Arthroscopic Surgery: A Systematic Review and
           Meta-analysis
    • Authors: Michaela O’Connor, Gabrielle K. Steinl, Ajay S. Padaki, Kyle R. Duchman, Robert W. Westermann, T. Sean Lynch
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:While the indications for primary hip arthroscopic surgery in treating femoroacetabular abnormalities continue to be defined, the indications and outcomes for revision hip arthroscopic surgery remain ambiguous. However, revision hip arthroscopic surgery is performed in 5% to 14% of patients after their index procedure. While patient-reported outcomes (PROs) generally improve after revision procedures, the extent of their improvement is not well defined.Purpose:To determine the outcomes and efficacy of revision hip arthroscopic surgery in patients who remain symptomatic after their index procedure.Study Design:Meta-analysis and systematic review.Methods:The terms “hip arthroscopy,”“revisions,”“outcomes,” and “femoroacetabular impingement” were searched in PubMed, Web of Science, Scopus, Cochrane Library, and Google Scholar. After screening, 15 studies were included for review. In addition to hip-specific metrics, functional outcome measures were included. Pooled estimates and 95% CIs were calculated using inverse variance methods.Results:A total of 4765 hips in 4316 patients were identified. The most common indication for revision surgery was inadequate bony resection during the index procedure. Meta-analysis showed that all PROs improved significantly from baseline to final follow-up after revision hip arthroscopic surgery. Notably, the modified Harris Hip Score (mHHS) increased a mean of 17.20 points after revision hip arthroscopic surgery, the Hip Outcome Score–Activities of Daily Living (HOS-ADL) improved by 13.98, and the visual analog scale (VAS) for pain decreased by 3.16. However, when compared with primary hip arthroscopic surgery, the mean PRO scores after revision hip arthroscopic surgery were lower. After revision hip arthroscopic surgery, the rates of conversion to total hip arthroplasty ranged from 0% to 14.3%, and the rates of further arthroscopic revision ranged from 2% to 14%.Conclusion:Inadequate bony resection represents the most common indication for revision hip arthroscopic surgery. PROs improve significantly after revision hip arthroscopic surgery but remain lower than those of patients undergoing primary hip arthroscopic surgery.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-09-10T05:57:33Z
      DOI: 10.1177/0363546519869671
       
  • A Majority of Anterior Cruciate Ligament Injuries Can Be Prevented by
           Injury Prevention Programs: A Systematic Review of Randomized Controlled
           Trials and Cluster–Randomized Controlled Trials With Meta-analysis
    • Authors: Yu-Lun Huang, Jaehun Jung, Colin M.S. Mulligan, Jaekeun Oh, Marc F. Norcross
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Anterior cruciate ligament (ACL) injury prevention programs (IPPs) are generally accepted as being valuable for reducing injury risk. However, significant methodological limitations of previous meta-analyses raise questions about the efficacy of these programs and the extent to which meeting current best-practice ACL IPP recommendations influences the protective effect of these programs.Purpose:To (1) estimate the protective effect of ACL IPPs while controlling for common methodological limitations of previous meta-analyses and (2) systematically categorize IPP components and factors related to IPP delivery to assess the validity of current best-practice IPP recommendations.Study Design:Systematic review with meta-analysis.Methods:A systematic search of 5 electronic scientific databases was conducted to identify studies testing the efficacy of ACL IPPs. Studies were included if (1) the intervention aimed to prevent ACL injury, (2) the incidence rate (IR) or other outcome data that made it possible to calculate the IR for both the intervention and control groups were reported, and (3) the study design was a prospective randomized controlled trial (RCT) or cluster-RCT.Results:Of the 2219 studies screened, 8 studies were included in the quantitative synthesis, and their analysis revealed a significant reduction in ACL IR when athletes received IPPs (IR ratio = 0.47; 95% CI, 0.30-0.73; P < .001). The majority of included IPPs tended to meet minimum best-practice recommendations and incorporated plyometric, strengthening, and agility exercises along with feedback on proper landing technique. However, the specific exercises included in each IPP and key factors related to IPP delivery were highly variable.Conclusion:Despite limiting the analysis to only high-quality studies and controlling for time at risk and potential clustering effects, the study showed that ACL IPPs had a significant protective effect and reduced injury rates by 53%. However, significant variability in the specific exercises and the manner of program delivery suggests that ACL IPPs may be able to be designed within an overarching best-practice framework. This may allow practitioners the flexibility to develop IPPs that meet the specific characteristics of the target population and potentially increase the likelihood that these programs will be widely adopted and implemented.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-08-30T08:31:54Z
      DOI: 10.1177/0363546519870175
       
  • Anterior Cruciate Ligament Reconstruction Within 3 Weeks Does Not Increase
           Stiffness and Complications Compared With Delayed Reconstruction: A
           Meta-analysis of Randomized Controlled Trials
    • Authors: Luca Deabate, Davide Previtali, Alberto Grassi, Giuseppe Filardo, Christian Candrian, Marco Delcogliano
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Injury-to-surgery time has been identified as a key point in anterior cruciate ligament (ACL) reconstruction, with early versus delayed treatment remaining a debated and controversial topic in the management of ACL tears.Purpose/Hypothesis:The aim was to quantitatively synthesize the best literature evidence by including only randomized controlled trials (RCTs) comparing early versus delayed ACL reconstruction, with a clear and univocal definition of cutoffs of early or delayed surgery. The hypothesis was that early treatment would lead to similar final clinical results compared with the delayed approach while providing a faster recovery without an increase in complications after ACL reconstruction.Study Design:Meta-analysis.Methods:A systematic literature search was performed on February 12, 2019, using PubMed, Web of Science, Cochrane Library, and gray literature databases. According to previous literature, 2 analyses with different cutoffs for injury-to-surgery time (3 weeks and 10 weeks) were performed to distinguish early and delayed reconstruction. The influence of timing was analyzed through meta-analyses in terms of patient-reported outcome measures (PROMs), risk of complications, range of motion (ROM) limitation, risk of retears, and residual laxity. Risk of bias and quality of evidence were assessed following the Cochrane guidelines.Results:Eight studies (5 in 3-week cutoff analysis and 3 in 10-week cutoff analysis) were included. No differences were found in terms of PROMs, risk of complications, ROM limitation, risk of retears, and residual laxity either in the 3-week cutoff analysis or in the 10-week cutoff analysis (P> .05). The level of evidence was moderate to low for the outcomes of the 3-week cutoff analysis and low to very low for the outcomes of the 10-week cutoff analysis.Conclusion:This meta-analysis did not confirm the previously advocated benefits of delaying ACL surgery to avoid the acute posttraumatic phase. In fact, RCTs demonstrated that timing of surgery after ACL tears has no influence on the final functional outcome, risk of retears, or residual instability. While no data were available about the recovery time, literature results showed that early ACL reconstruction could be performed without increasing the risk of complications.Study Registration:CRD42019119319 (PROSPERO).
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-08-05T06:48:53Z
      DOI: 10.1177/0363546519862294
       
  • Suture Button Versus Hook Plate for Acute Unstable Acromioclavicular Joint
           Dislocation: A Meta-analysis
    • Authors: Cong Wang, Jia-Hong Meng, Yi-Wen Zhang, Ming-Min Shi
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Surgical treatment is indicated for unstable acromioclavicular (AC) joint dislocation. The hook plate (HP) technique is a commonly used treatment method, but the use of the suture button (SB) technique is increasing.Purpose:To conduct a meta-analysis of clinical studies evaluating patient outcomes between the SB and HP techniques for acute unstable AC joint dislocation.Study Design:Meta-analysis.Methods:A literature search of the Embase, PubMed, and Cochrane Library databases was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Cohort studies and case-control studies comparing the SB and HP procedures for acute unstable AC joint dislocation were included. Statistical analysis was performed with RevMan (v 5.3.5).Results:Eight clinical studies that met the inclusion criteria were identified and included a total of 204 patients treated with the SB technique and 195 patients with the HP technique. Patients treated with the SB technique had a higher Constant score (mean difference [MD], 3.95; 95% CI, 1.20-6.70; P = .005) and a lower visual analog scale pain score (MD, –0.75; 95% CI, –1.12 to 0.37; P < .0001) when compared with the HP technique. No significant differences in operation time (MD, –0.38; 95% CI, –7.14 to 6.37; P = .91), coracoclavicular distance (MD, –0.07; 95% CI, –0.49 to 0.35; P = .75), complications (odds ratio, 0.59; 95% CI, 0.22-1.54; P = .28), and loss of reduction (odds ratio, 2.55; 95% CI, 0.66-9.83; P = .17) were found between the SB and HP techniques. The subgroup analysis showed that the arthroscopic SB technique resulted in a higher Constant score (MD, 6.75; 95% CI, 4.21-9.29; P < .00001) as compared with the HP technique, but no differences were observed between the open SB and HP techniques (MD, 0.69; 95% CI, –0.82 to 2.20; P = .37).Conclusion:This meta-analysis demonstrated that the SB technique resulted in better functional outcomes and a reduced visual analog scale pain score when compared with the HP technique. However, for operation time, coracoclavicular distance, complications, and loss of reduction, there were no statistically significant differences between the techniques. Compared with the open procedure, arthroscopic SB may be superior for better functional outcomes.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-07-17T11:30:36Z
      DOI: 10.1177/0363546519858745
       
  • Dynamic Stabilization of Syndesmosis Injuries Reduces Complications and
           Reoperations as Compared With Screw Fixation: A Meta-analysis of
           Randomized Controlled Trials
    • Authors: Alberto Grassi, Kristian Samuelsson, Pieter D’Hooghe, Matteo Romagnoli, Massimiliano Mosca, Stefano Zaffagnini, Annunziato Amendola
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Several devices for obtaining dynamic fixation of the syndesmosis have been introduced in recent years, but their efficacy has been tested in only a few randomized controlled trials (RCTs), without demonstrating any clear benefit over the traditional static fixation with screws.Purpose:To perform a level 1 meta-analysis of RCTs to investigate the complications, subjective outcomes, and functional results after dynamic or static fixation of acute syndesmotic injuries.Study Design:Meta-analysis of RCTs.Methods:A systematic literature search was performed of the Medline/PubMed, Cochrane Central Register of Controlled Trials, and Embase electronic databases, as well as ClinicalTrials.gov for unpublished studies. Eligible studies were RCTs comparing dynamic fixation and static fixation of acute syndesmosis injuries. A meta-analysis was performed, while bias and quality of evidence were rated according to the Cochrane Database questionnaire and the Grading of Recommendations Assessment, Development and Evaluation guidelines.Results:Dynamic fixation had a significantly reduced relative risk (RR = 0.55, P = .003) of complications—in particular, the presence of inadequate reduction at the final follow-up (RR = 0.36, P = .0008) and the clinical diagnosis of recurrent diastasis or instability (RR = 0.10, P = .03). The effect was more evident when compared with permanent screws (RR = 0.10, P = .0001). The reoperation rate was similar between the groups (RR = 0.64, P = .07); however, the overall risk was reduced after dynamic fixation as compared with static fixation with permanent screws (RR = 0.24, P = .007). The American Orthopaedic Foot & Ankle Society score was significantly higher among patients treated with dynamic fixation—6.06 points higher (P = .005) at 3 months, 5.21 points (P = .03) at 12 months, and 8.60 points (P < .00001) at 24 months—while the Olerud-Molander score was similar. The visual analog scale for pain score was reduced at 6 months (–0.73 points, P = .003) and 12 months (–0.52 points, P = .005), and ankle range of motion increased by 4.36° (P = .03) with dynamic fixation. The overall quality of evidence ranged from “moderate” to “very low,” owing to a substantial risk of bias, heterogeneity, indirectness of outcome reporting, and evaluation of a limited number of patients.Conclusion:The dynamic fixation of syndesmotic injuries was able to reduce the number of complications and improve clinical outcomes as compared with static screw fixation—especially malreduction and clinical instability or diastasis—at a follow-up of 2 years. A lower risk of reoperation was found with dynamic fixation as compared with static fixation with permanent screws. However, the lack of patients or personnel blinding, treatment heterogeneity, small samples, and short follow-up limit the overall quality of this evidence.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-06-12T06:24:38Z
      DOI: 10.1177/0363546519849909
       
  • Hamstring Autograft Versus Hybrid Graft for Anterior Cruciate Ligament
           Reconstruction: A Systematic Review
    • Authors: Hong-De Wang, Shi-Jun Gao, Ying-Ze Zhang
      Abstract: The American Journal of Sports Medicine, Ahead of Print.

      Citation: The American Journal of Sports Medicine
      PubDate: 2019-06-05T03:56:55Z
      DOI: 10.1177/0363546519849483
       
  • Two-Stage Revision Anterior Cruciate Ligament Reconstruction: A Systematic
           Review of Bone Graft Options for Tunnel Augmentation
    • Authors: Hytham S. Salem, Derek P. Axibal, Michelle L. Wolcott, Armando F. Vidal, Eric C. McCarty, Jonathan T. Bravman, Rachel M. Frank
      Abstract: The American Journal of Sports Medicine, Ahead of Print.

      Citation: The American Journal of Sports Medicine
      PubDate: 2019-05-22T10:38:16Z
      DOI: 10.1177/0363546519841583
       
  • Properties and Function of the Medial Patellofemoral Ligament: A
           Systematic Review
    • Authors: Christian Huber, Qiang Zhang, William R. Taylor, Andrew A. Amis, Colin Smith, Seyyed Hamed Hosseini Nasab
      Abstract: The American Journal of Sports Medicine, Ahead of Print.

      Citation: The American Journal of Sports Medicine
      PubDate: 2019-05-15T06:32:39Z
      DOI: 10.1177/0363546519841304
       
  • Hop Testing Lacks Strong Association With Key Outcome Variables After
           Primary Anterior Cruciate Ligament Reconstruction: A Systematic Review
    • Authors: Justin M. Losciale, Garrett Bullock, Christina Cromwell, Leila Ledbetter, Laura Pietrosimone, Timothy C. Sell
      Abstract: The American Journal of Sports Medicine, Ahead of Print.

      Citation: The American Journal of Sports Medicine
      PubDate: 2019-05-07T08:11:18Z
      DOI: 10.1177/0363546519838794
       
  • A Practical Guide for the Current Use of Biologic Therapies in Sports
           Medicine
    • Authors: Joseph D. Lamplot, Scott A. Rodeo, Robert H. Brophy
      Abstract: The American Journal of Sports Medicine, Ahead of Print.

      Citation: The American Journal of Sports Medicine
      PubDate: 2019-04-30T08:11:02Z
      DOI: 10.1177/0363546519836090
       
  • Repair of Rotator Cuff Tears in the Elderly: Does It Make Sense' A
           Systematic Review
    • Authors: Burak Altintas, Nicole L. Anderson, Rafael Pitta, Patrick S. Buckley, Sanjeev Bhatia, Matthew T. Provencher, Peter J. Millett
      Abstract: The American Journal of Sports Medicine, Ahead of Print.

      Citation: The American Journal of Sports Medicine
      PubDate: 2019-04-30T08:03:02Z
      DOI: 10.1177/0363546519834574
       
  • Cost-efficacy of Knee Cartilage Defect Treatments in the United States
    • Authors: Joshua S. Everhart, Andrew B. Campbell, Moneer M. Abouljoud, J. Caid Kirven, David C. Flanigan
      Abstract: The American Journal of Sports Medicine, Ahead of Print.

      Citation: The American Journal of Sports Medicine
      PubDate: 2019-04-30T04:43:00Z
      DOI: 10.1177/0363546519834557
       
  • Horizontal Instability of the Acromioclavicular Joint: A Systematic Review
    • Authors: Gianna M. Aliberti, Matthew J. Kraeutler, Jeffrey D. Trojan, Mary K. Mulcahey
      Abstract: The American Journal of Sports Medicine, Ahead of Print.

      Citation: The American Journal of Sports Medicine
      PubDate: 2019-04-23T07:59:30Z
      DOI: 10.1177/0363546519831013
       
  • Current Workload Recommendations in Baseball Pitchers: A Systematic Review
    • Authors: Neil K. Bakshi, Paul M. Inclan, Jacob M. Kirsch, Asheesh Bedi, Cristine Agresta, Michael T. Freehill
      Abstract: The American Journal of Sports Medicine, Ahead of Print.

      Citation: The American Journal of Sports Medicine
      PubDate: 2019-04-23T07:50:47Z
      DOI: 10.1177/0363546519831010
       
  • Return to Sport After Arthroscopic Rotator Cuff Repair: Is There a
           Difference Between the Recreational and the Competitive Athlete'
    • Authors: Burak Altintas, Nicole Anderson, Grant J. Dornan, Robert E. Boykin, Catherine Logan, Peter J. Millett
      Abstract: The American Journal of Sports Medicine, Ahead of Print.

      Citation: The American Journal of Sports Medicine
      PubDate: 2019-03-11T04:42:43Z
      DOI: 10.1177/0363546519825624
       
  • Midshaft Clavicle Fractures: Surgery Provides Better Results as Compared
           With Nonoperative Treatment: A Meta-analysis
    • Authors: Enrico Guerra, Davide Previtali, Simone Tamborini, Giuseppe Filardo, Stefano Zaffagnini, Christian Candrian
      Abstract: The American Journal of Sports Medicine, Ahead of Print.

      Citation: The American Journal of Sports Medicine
      PubDate: 2019-03-05T04:38:45Z
      DOI: 10.1177/0363546519826961
       
  • Anterior Cruciate Ligament Reconstruction: A Systematic Review and
           Meta-analysis of Outcomes for Quadriceps Tendon Autograft Versus
           Bone–Patellar Tendon–Bone and Hamstring-Tendon Autografts
    • Authors: Dany Mouarbes, Jacques Menetrey, Vincent Marot, Louis Courtot, Emilie Berard, Etienne Cavaignac
      Abstract: The American Journal of Sports Medicine, Ahead of Print.

      Citation: The American Journal of Sports Medicine
      PubDate: 2019-02-21T10:12:11Z
      DOI: 10.1177/0363546518825340
       
  • Efficacy of Pharmacological Therapies for Adhesive Capsulitis of the
           Shoulder: A Systematic Review and Network Meta-analysis
    • Authors: Dimitrios Kitridis, Konstantinos Tsikopoulos, Ilias Bisbinas, Paraskevi Papaioannidou, Panagiotis Givissis
      Abstract: The American Journal of Sports Medicine, Ahead of Print.

      Citation: The American Journal of Sports Medicine
      PubDate: 2019-02-08T09:19:25Z
      DOI: 10.1177/0363546518823337
       
  • Location of the Glenoid Defect in Shoulders With Recurrent Posterior
           Glenohumeral Instability
    • Authors: Travis J. Dekker, Liam A. Peebles, Brandon T. Goldenberg, Peter J. Millett, James P. Bradley, Matthew T. Provencher
      First page: 3051
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Posterior glenoid bone deficiency is an increasingly recognized entity in the setting of recurrent posterior shoulder instability; however, little is known about the subject. Due to the paucity of literature on posterior bone loss, historical comparisons with anterior bone loss may not be fully accurate.Purpose:To systematically describe the morphology of posterior bone defects in the setting of recurrent posterior shoulder instability based on several quantitative parameters, including the mean location, orientation, and extent of bone loss on a clockface model, as well as the angle of the defect relative to the long axis of the glenoid.Study Design:Cross-sectional study; Level of evidence, 4.Methods:Three-dimensional reconstructed computed tomography scans of serially collected patients with a history of recurrent posterior shoulder instability were evaluated by 3 separate reviewers. The posterior glenoid bone defect was characterized using the following measures: (1) the mean lesion location and orientation based on a clockface model with 6 o’clock denoted as inferior and 9 o’clock as directly posterior for all patients; (2) the total extent of the posterior bone defect based on the clockface; and (3) the average angle of the bone loss relative to the long axis of the glenoid.Results:A total of 70 male patients and 1 female patient with a mean age of 29.3 years (range, 24.4-35.1 years) were included in the analysis. The mean clockface location of the posterior glenoid defect originated at 6:44 (range, 4:16-8:12) and extended to a mean of 9:28 (range, 7:02-10:38). The mean extent of the posterior glenoid defect was 2:43 (range, 1:08-4:50), which corresponds to a mean total bone loss arc of 81.5° (range, 34.2°-144.9°), nearly 1 quadrant of the glenoid. Posterior bone loss occurred in a posteroinferior direction at a mean angle of 30.7° (range, 8.0°-80.0°) relative to the long axis of the glenoid.Conclusion:Posterior bone defects in the setting of posterior shoulder instability most commonly occur in the posteroinferior quadrant of the glenoid and extend on average from 6:44 to 9:28 (81.5° total degrees of arc) on a clockface model. Posterior bone loss occurs at a mean of 30° off the long axis of the glenoid in a posteroinferior direction, which is historically different from anterior bone loss, which occurs parallel to the long axis of the glenoid. This study serves to highlight the location and orientation of bone loss that one can expect in a patient with recurrent posterior shoulder instability, although additional work is needed to assess why this develops.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-10-16T05:34:23Z
      DOI: 10.1177/0363546519876282
       
  • Long-term Results of the Open Latarjet Procedure for Recurrent Anterior
           Shoulder Instability in Patients Older Than 40 Years
    • Authors: Lukas Ernstbrunner, Lara Wartmann, Stefan M. Zimmermann, Pascal Schenk, Christian Gerber, Karl Wieser
      First page: 3057
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Subgroup analyses of the Latarjet procedure have suggested that age over 40 years is a risk factor for dislocation arthropathy.Purpose:To analyze long-term results of the open Latarjet procedure for recurrent anterior shoulder dislocation in patients at least 40 years of age.Study Design:Case series; Level of evidence, 4.Methods:39 consecutive patients (40 shoulders) with a mean age of 48 years (range, 40-66 years) at surgery were evaluated at a mean follow-up of 11.0 years (range, 8-16 years). Of these, 15 patients (38%) had undergone previous soft tissue stabilization surgery. Long-term results were assessed clinically and radiographically, including computed tomography scanning at final follow-up.Results:No recurrence of dislocation was noted. Subluxation had occurred in 3 patients (8%), and apprehension persisted in 5 patients (13%). The total Walch-Duplay score averaged 89 points at the final follow-up, and the mean Subjective Shoulder Value (60%-91%) had improved significantly (P < .001). In total, 36 patients rated their result as excellent, 3 as good. Further, 6 patients (15%) underwent joint-preserving reoperation, and 1 patient (3%) had reverse total shoulder arthroplasty for severe dislocation arthropathy. Dislocation arthropathy was severe in 14 patients (37%) and had progressed by at least 2 grades in 17 patients (45%). Patients with severe dislocation arthropathy had already shown degenerative changes preoperatively as opposed to those who ultimately had no or moderate dislocation arthropathy (n = 24) (P < .001). Progression of dislocation arthropathy was associated with lateral (>1 mm) graft positioning (P < .001) and older age at surgery (r = 0.58; P < .001).Conclusion:The open Latarjet procedure for recurrent anterior shoulder instability in patients older than 40 years reliably restores stability and leads to high patient satisfaction. This procedure is, however, associated with a substantial rate of advanced but clinically mild symptomatic dislocation arthropathy, which is associated with the degree of preoperative joint degeneration, older age at surgery, and lateral graft placement.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-09-12T07:50:02Z
      DOI: 10.1177/0363546519872501
       
  • Comparative Effectiveness of Operative Versus Nonoperative Treatment for
           Rotator Cuff Tears: A Propensity Score Analysis From the ROW Cohort
    • Authors: Nitin B. Jain, Gregory D. Ayers, Run Fan, John E. Kuhn, Jon J.P. Warner, Keith M. Baumgarten, Elizabeth Matzkin, Laurence D. Higgins
      First page: 3065
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:The evidence to support operative versus nonoperative treatment for rotator cuff tears is sparse and inconclusive.Purpose:To assess pain and functional outcomes in patients undergoing operative and nonoperative treatments for rotator cuff tears.Study Design:Cohort study; Level of evidence, 3.Methods:From March 2011 to February 2015, a multicenter cohort of patients with rotator cuff tears undergoing operative and nonoperative treatments was recruited. Patients completed a detailed history questionnaire, the Shoulder Pain and Disability Index (SPADI), and the American Shoulder and Elbow Surgeons (ASES) standardized form and underwent magnetic resonance imaging. In addition to baseline assessments, patients received follow-up questionnaires at 3, 6, 12, and 18 months. Propensity score weighting was used to balance differences in characteristics of the operative and nonoperative groups.Results:Adjusted for propensity scores, the operative (n = 50) and nonoperative (n = 77) groups had similar characteristics, as evidenced by the small standardized mean differences between the groups. Adjusted mean differences in the SPADI and ASES scores between the operative and nonoperative groups were –22.0 points (95% CI, –32.1 to –11.8) and –22.2 points (95% CI, –32.8 to –11.6) at 18 months, respectively. The operative group had a significantly higher proportion of patients who showed ≥30% (P = .002) and ≥50% (P < .0001) improvement in SPADI and ASES scores as compared with the nonoperative group.Conclusion:In this prospective cohort study, patients undergoing operative treatment had significantly better pain and functional outcomes as compared with patients undergoing nonoperative treatment for rotator cuff tears. Differences between the 2 groups in SPADI and ASES scores at the 6- to 18-month time points met the minimal clinically important difference (depending on the threshold used). A large randomized controlled trial is needed to answer this question more definitively.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-09-13T05:00:55Z
      DOI: 10.1177/0363546519873840
       
  • The Effect of Preexisting and Shoulder-Specific Depression and Anxiety on
           Patient-Reported Outcomes After Arthroscopic Rotator Cuff Repair
    • Authors: Brian C. Lau, Melissa Scribani, Jocelyn Wittstein
      First page: 3073
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Few studies have considered the potential effect of depression or anxiety on outcomes after rotator cuff repair.Purpose:To evaluate the effect of a preexisting diagnosis of depression or anxiety, as well as the feeling of depression and anxiety directly related to the shoulder, on the American Shoulder and Elbow Surgeons (ASES) score.Study Design:Cohort study; Level of evidence, 3.Methods:This study is a retrospective review of prospectively collected data on patients who underwent arthroscopic rotator cuff repair and were evaluated by the ASES score preoperatively and at a minimum 12 months postoperatively as part of the senior author’s shoulder registry. Preexisting diagnoses of depression and/or anxiety were recorded, and questions from the Western Ontario Rotator Cuff Index directed at feelings of depression or anxiety related to the shoulder were also evaluated. The Wilcoxon rank sum test was used to compare ASES scores between patients with and without anxiety and/or depression. Spearman correlation was used to correlate questions on depression and anxiety with ASES scores.Results:A total of 187 patients (63 females, 124 males; mean age, 58.6 years, SD, 8.7 years) undergoing arthroscopic rotator cuff repair were evaluated with a mean follow-up of 47.5 months (SD, 17.4 months; range, 12-77 months). Fifty-three patients (mean age, 60 years; SD, 8.6 years) had preexisting diagnoses of depression and/or anxiety and 134 patients (mean age, 58.1 years; SD, 8.7 years) did not. Patients with depression and/or anxiety had significantly lower preoperative and postoperative ASES scores (60.7 vs 67.8, P = .014; and 74.6 vs 87.1, P = .008, respectively). The change in ASES scores from preoperative to postoperative, however, was not significantly different (18.0 vs 14.9). A higher score of depression or anxiety related to the shoulder had a negative correlation with the preoperative (r = −0.76, P < .0001; and r = −0.732, P < .0001, respectively) and postoperative (r = −0.31, P = .0001; and r = −0.31, P = .0003, respectively) ASES scores, but a positive correlation (r = 0.50, P < .0001; and r = 0.43, P < .0001, respectively) with the change in ASES scores.Conclusion:Patients with a history of depression and/or anxiety have lower outcome scores preoperatively and postoperatively; however, they should expect the same amount of relief from arthroscopic rotator cuff repair as those without a history of depression or anxiety. Stronger feelings of depression or anxiety directly related to the shoulder correlated with lower preoperative and postoperative outcome scores, but a greater amount of improvement from surgery. The results from this study suggest that a preexisting diagnosis of depression or anxiety, as well as feelings of depression or anxiety directly related to the shoulder, should be considered during the management of patients with rotator cuff tears.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-10-04T10:52:23Z
      DOI: 10.1177/0363546519876914
       
  • Changes of Supraspinatus Muscle Volume and Fat Fraction After Successful
           or Failed Arthroscopic Rotator Cuff Repair
    • Authors: Karl Wieser, Jethin Joshy, Lukas Filli, Philipp Kriechling, Reto Sutter, Philipp Fürnstahl, Paola Valdivieso, Sabine Wyss, Dominik C. Meyer, Martin Flück, Christian Gerber
      First page: 3080
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Muscle atrophy and fatty infiltration are limiting factors for successful rotator cuff (RC) repair. Quantitative data regarding these hallmarks of degenerative muscle changes after RC repair in humans are scarce. By utilizing a new application of the 6-point Dixon magnetic resonance imaging technology, 3-dimensional volume and fat fraction analysis of the whole RC muscle have become possible.Purpose:Quantitative analysis of atrophy and fatty infiltration of the supraspinatus muscle after healed and failed RC tendon-to-bone repair.Study Design:Cohort study; Level of evidence, 3.Methods:Muscle volume and fat fraction were measured preoperatively and at 3 and 12 months postoperatively in 19 failed and 21 healed arthroscopic supraspinatus tendon repairs, with full muscle volume segmentation and magnetic resonance Dixon sequences.Results:In both groups, the muscle volume initially decreased 3 months after RC repair by –3% in intact (P = .140) and –10% in failed repair (P = .004) but recovered between 3 and 12 months to 103% (P = .274) in intact and 92% (P = .040) in failed repairs when compared with the preoperative volume (difference of change between groups, preoperative to 12 month: P = .013). The supraspinatus muscle’s fat fraction did not significantly change after successful repair (6.5% preoperative, 6.6% after 3 months, and 6.7% after 12 months; all nonsignificant). There was, however, a significant increase from 7.8% to 10.8% at 3 months (P = .014) and 11.4% at 12 months (P = .020) after failed repair (difference between groups at 3- and 12-month follow-up: P = .018 and P = .001, respectively).Conclusion:After successful arthroscopic repair, RC tendon tear–induced fatty infiltration can be almost stopped, and muscle atrophy can even be slightly reversed. In case of a failed repair, however, these changes are further pronounced during the first 3 postoperative months but seem to stabilize thereafter.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-09-19T06:27:22Z
      DOI: 10.1177/0363546519876289
       
  • Effect of Fatty Acid–Binding Protein 4 Inhibition on Rotator Cuff Muscle
           Quality: Histological, Biomechanical, and Biomolecular Analysis
    • Authors: Yong-Soo Lee, Ja-Yeon Kim, Kwang Il Kim, Se-Young Ki, Seok Won Chung
      First page: 3089
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:A rotator cuff tear (RCT) induces fatty acid–binding protein 4 (FABP4) expression, resulting in ectopic fat accumulation in the rotator cuff muscle.Purpose:To evaluate whether FABP4 inhibition reduces fatty infiltration and improves muscle physiology after RCT in a rat model.Study Design:Controlled laboratory study.Methods:Human supraspinatus muscle and deltoid muscle tissues were acquired from patients with RCTs during arthroscopic surgery, and FABP4 expression in the supraspinatus muscle was evaluated as compared with the intact deltoid muscle. A rat RCT model was established by detaching the supraspinatus tendon, after which a specific FABP4 inhibitor was locally injected into the supraspinatus muscle 4 times at 3-day intervals starting 2 weeks after the surgery. Body weight and blood glucose levels were measured at 2 and 4 weeks after the RCT, and the mRNA and protein expressions of various target molecules (including FABP4), histological changes, and biomechanical tensile strength were assessed in the supraspinatus muscles at 4 weeks after the RCT.Results:The expression of human FABP4 was significantly increased in the torn rotator cuff muscle as compared with the intact deltoid muscle. In the rat model, the mRNA and protein expressions of FABP4 and HIF1α were significantly increased by the RCT as compared with the control. The FABP4 inhibitor treatment significantly decreased FABP4 expression when compared with the vehicle treatment; however, HIF1α expression was not significantly decreased versus the vehicle treatment. Histologically, RCT induced noticeable muscle fatty infiltration, which was remarkably reduced by the local injection of the FABP4 inhibitor. Biomechanically, the tensile strength of the rotator cuff muscle after the RCT was significantly improved by the FABP4 inhibitor in terms of load to failure and total energy to failure.Conclusion:RCT induces FABP4 expression in human and rat rotator cuff muscles. The FABP4 inhibitor drastically decreased the histological fatty infiltration caused by RCT and improved the tensile strength of the rotator cuff muscle.Clinical Relevance:FABP4 inhibitor may have a beneficial effect on the muscle quality after RCT.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-09-13T05:22:36Z
      DOI: 10.1177/0363546519873856
       
  • Humeral Retroversion and Injury Risk After Proximal Humeral Epiphysiolysis
           (Little Leaguer’s Shoulder)
    • Authors: Atsushi Ito, Teruhisa Mihata, Yuji Hosokawa, Akihiko Hasegawa, Masashi Neo, Munekazu Doi
      First page: 3100
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:The increased humeral retroversion on the dominant side of throwing athletes is thought to result from repetitive throwing motion. Little Leaguer’s shoulder—a rotational stress fracture of the proximal humeral epiphyseal plate—may influence the risk of humeral retroversion and injury of the shoulder or elbow joint.Purpose:To investigate the effect of Little Leaguer’s shoulder on humeral retroversion and the rates of shoulder and elbow injuries.Study Design:Cohort study; Level of evidence, 3.Methods:10 high school baseball players (average age, 16.6 years; range, 16-18 years) who had experienced Little Leaguer’s shoulder during elementary or junior high school (average age, 12.6 years; range, 11-15 years) were enrolled in the study. As a control group, 22 high school baseball players (average age, 16.9 years; range, 16-18 years) who had never had any shoulder or elbow injury during elementary and junior high school were included. Humeral retroversion on ultrasonographic measurement, shoulder range of motion, and rates of shoulder and elbow injuries were evaluated.Results:Humeral retroversion was significantly greater on the dominant side than on the nondominant side in both players with Little Leaguer’s shoulder (dominant, 104°± 8°; nondominant, 84°± 12°; P < .001) and controls (dominant, 91°± 13°; nondominant, 81°± 10°; P < .001). In the dominant shoulder, humeral retroversion was greater in the Little Leaguer’s shoulder group than in the control group (P = .008). When the effects of humeral retroversion were excluded, maximal external rotation was significantly less in the dominant shoulder than in the nondominant shoulder in the Little Leaguer’s shoulder group (by 11°± 12°, P = .02), whereas no significant difference was found between dominant (110°± 11°) and nondominant (111°± 13°) shoulders in the control group (P = .64). The rates of shoulder and elbow pain were significantly higher in the Little Leaguer’s shoulder group (shoulder pain 80%, elbow pain 70%) than in the control group (shoulder pain 9%, P < .001; elbow pain 32%, P = .04).Conclusion:Humeral retroversion was increased in baseball players without any history of shoulder or elbow injury during elementary and junior high school and was further increased in players who had had Little Leaguer’s shoulder. Increased humeral retroversion after Little Leaguer’s shoulder may be a risk factor for future shoulder or elbow injury.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-10-04T10:26:07Z
      DOI: 10.1177/0363546519876060
       
  • Nonoperative Treatment of Elbow Ulnar Collateral Ligament Injuries With
           and Without Platelet-Rich Plasma in Professional Baseball Players: A
           Comparative and Matched Cohort Analysis
    • Authors: Aakash Chauhan, Peter McQueen, Peter N. Chalmers, Michael G. Ciccotti, Christopher L. Camp, John D’Angelo, Hollis G. Potter, Stephen A. Fealy, Brandon J. Erickson, Heinz R. Hoenecke, Daniel Keefe, Julie McCauley, Jan Fronek
      First page: 3107
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Recent studies evaluating nonoperative treatment of elbow ulnar collateral ligament (UCL) injuries augmented with platelet-rich plasma (PRP) have shown promising results. To date, no comparative studies have been performed on professional baseball players who have undergone nonoperative treatment with or without PRP injections for UCL injuries.Hypothesis:Players who received PRP injections would have better outcomes than those who did not receive PRP.Study Design:Cohort study; Level of evidence, 3.Methods:The Major League Baseball (MLB) Health and Injury Tracking System identified 544 professional baseball players who were treated nonoperatively for elbow UCL injuries between 2011 and 2015. Of these, 133 received PRP injections (PRP group) before starting their nonoperative treatment program, and 411 did not (no-PRP group). Player outcomes and a Kaplan-Meier survival analysis were compared between groups. In addition, to reduce selection bias, a 1:1 matched comparison of the PRP group versus the no-PRP group was performed. Players were matched by age, position, throwing side, and league status: major (MLB) and minor (Minor League Baseball [MiLB]). A single radiologist with extensive experience in magnetic resonance imaging (MRI) interpretation of elbow injuries in elite athletes analyzed 243 MRI scans for which images were accessible for tear location and grade interpretation.Results:Nonoperative treatment of UCL injuries resulted in an overall 54% rate of return to play (RTP). Players who received PRP had a significantly longer delay in return to throwing (P < .001) and RTP (P = .012). The matched cohort analysis showed that MLB and MiLB pitchers in the no-PRP group had a significantly faster return to throwing (P < .05) and the MiLB pitchers in the no-PRP group had a significantly faster RTP (P = .045). The survival analysis did not reveal significant differences between groups over time. The use of PRP, MRI grade, and tear location were not statistically significant predictors for RTP or progression to surgery.Conclusion:In this retrospective matched comparison of MLB and MiLB pitchers and position players treated nonoperatively for a UCL tear, PRP did not improve RTP outcomes or ligament survivorship, although there was variability with respect to PRP preparations, injection protocols, time from injury to injection, and rehabilitation programs. MRI grade and tear location also did not significantly affect RTP outcomes or progression to surgery.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-10-07T06:03:43Z
      DOI: 10.1177/0363546519876305
       
  • Femoroacetabular Impingement Patients With Decreased Femoral Version Have
           Different Impingement Locations and Intra- and Extraarticular Anterior
           Subspine FAI on 3D-CT–Based Impingement Simulation: Implications for Hip
           Arthroscopy
    • Authors: Till D. Lerch, Adam Boschung, Inga A.S. Todorski, Simon D. Steppacher, Florian Schmaranzer, Guoyan Zheng, Michael K. Ryan, Klaus A. Siebenrock, Moritz Tannast
      First page: 3120
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:It remains unclear whether decreased femoral version (FV) causes anterior intra- or extra-articular femoroacetabular impingement (FAI). Therefore, we evaluated symptomatic hips with decreased FV, with and without cam and pincer FAI, by using computed tomography (CT)–based virtual 3-dimensional (3D) impingement simulation and compared this group with patients with normal FV and with asymptomatic hips.Purpose:To investigate (1) the osseous range of motion, (2) the osseous femoral and acetabular impingement zones, and (3) whether hip impingement is extra- or intra-articular in symptomatic hips with FAI.Study Design:Cross-sectional study; Level of evidence, 3.Methods:An institutional review board–approved, retrospective comparative analysis was performed on a total of 84 hips in 68 participants. Of these, 37 hips in 24 symptomatic patients with FAI had decreased FV. These hips were compared with 21 hips of 18 symptomatic patients with anterior FAI with normal FV (10°-25°) and 26 asymptomatic hips with no FAI and normal FV. All patients with FAI were symptomatic and had anterior hip pain and a positive anterior impingement test. They underwent pelvic CT scans to measure FV. Decreased FV was defined as FV less than 5°. The 37 hips with decreased FV presented both with and without cam and pincer FAI. All 84 hips were evaluated by use of CT-based 3D models and a validated 3D range of motion and impingement simulation. Asymptomatic hips were contralateral normal hips imaged in patients undergoing total hip arthroplasty.Results:Hips with FAI combined with decreased FV had a significantly (P < .001) lower mean flexion (114°± 8° vs 125°± 13°) and internal rotation (IR) at 90° of flexion (18°± 6° vs 32°± 9°, P < .001) compared with the asymptomatic control group. Symptomatic patients with FAI and normal FV had flexion of 120°± 16° and IR at 90° of flexion of 23°± 15°. In a subgroup analysis, we found a significantly (P < .001) lower IR in 90° of flexion in hips with FV less than 5° combined with mixed-type FAI compared with hips with FV less than 5° without a cam- or pincer-type deformity. The maximal acetabular impingement zone for hips with decreased FV was located at the 2-o’clock position and ranged from 1 to 3 o’clock. In hips with decreased FV, most of the impingement locations were intra-articular but 32% of hips had combined intra- and extra-articular FAI in internal rotation in 90° of flexion. During the flexion-adduction-IR test performed in 10° and 20° of adduction, extra-articular subspine FAI had significantly (P < .001) higher prevalence (68% and 84%) in hips with decreased FV compared with normal hips.Conclusion:Hips with FAI and decreased FV had less flexion and internal rotation in 90° of flexion compared with the asymptomatic control group. The majority of hip impingement due to low FV was intra-articular, but one-third of samples had combined intra- and extra-articular subspine FAI. Anterior extra- and intra-articular hip impingement can be present in patients who have FAI with decreased FV. This could be important for patients undergoing hip arthroscopy.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-09-20T08:35:42Z
      DOI: 10.1177/0363546519873666
       
  • How Can We Define Clinically Important Improvement in Pain Scores After
           Hip Arthroscopy for Femoroacetabular Impingement Syndrome' Minimum
           2-Year Follow-up Study
    • Authors: Edward C. Beck, Benedict U. Nwachukwu, Kyle N. Kunze, Jorge Chahla, Shane J. Nho
      First page: 3133
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Patient postoperative pain is being increasingly reported in the field of hip preservation surgery. The visual analog scale (VAS) for pain is one of the most commonly utilized measures for perioperative pain assessment. Currently, there is limited understanding of clinically significant improvement in VAS pain.Purpose:(1) To define the substantial clinical benefit (SCB), patient acceptable symptomatic state (PASS), and minimal clinically important difference (MCID) for the VAS pain score in patients undergoing hip arthroscopy for femoroacetabular impingement syndrome after 2 years from surgery and (2) to identify preoperative predictors of achieving each outcome endpoint.Study Design:Case series; Level of evidence, 4.Methods:Data from consecutive patients who underwent primary hip arthroscopy between November 2014 and March 2017 were collected and analyzed. Baseline data and postoperative patient-reported outcome scores were recorded at 2 years postoperatively. To quantify clinical significance of outcome achievement for the VAS pain score, the MCID, PASS, and SCB were calculated.Results:A total of 976 patients were included in the final analysis. The VAS pain score threshold for achieving the MCID was defined as a decrease of 14.8; the PASS was defined as achieving a 2-year postoperative score of 21.6 points; and the SCB was defined as a decrease of 25.5 or a score of 15.4 points at 2 years. The rates of achieving the MCID, PASS, and SCB were 97.6%, 66.4%, and 71.2%, respectively. Regression analysis demonstrated that sports involvement, low body mass index, smaller preoperative alpha angle, and absence of articular damage and chondromalacia were predictive of achieving the PASS (all P < .05). Preoperative predictors for achieving the SCB included being male, no smoking history, smaller alpha angle, higher modified Harris Hip Score, and lower VAS pain score (all P < .05).Conclusion:This study identified scores for VAS pain that can be used to define clinically significant outcome after arthroscopic treatment of femoroacetabular impingement syndrome. Specifically, a decrease in pain score of 14.8 was a clinically important improvement in VAS pain, while an absolute score
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-10-11T07:52:41Z
      DOI: 10.1177/0363546519877861
       
  • Defining Minimal Clinically Important Difference and Patient Acceptable
           Symptom State After Isolated Endoscopic Gluteus Medius Repair
    • Authors: Kelechi R. Okoroha, Edward C. Beck, Benedict U. Nwachukwu, Kyle N. Kunze, Shane J. Nho
      First page: 3141
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Endoscopic surgical repair has become a common procedure for treating patients with gluteus medius tears. However, meaningful clinical outcomes after the procedure have not been defined.Purpose:To (1) define the minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS) in patients undergoing endoscopic gluteus medius repair and (2) determine correlations between preoperative patient characteristics and achievement of MCID/PASS.Study Design:Case series; Level of evidence, 4.Methods:A retrospective review was performed of prospectively collected data from all patients undergoing primary endoscopic repair of gluteus medius tears between January 2012 and February 2017 with a minimum 2-year follow-up. Patient data collected included patient characteristics, radiographic parameters, preoperative clinical function scores, and postoperative patient-reported outcomes (PROs). Paired t tests were used to compare the differences in 2-year PROs. The MCID and PASS for each PRO were calculated and Spearman coefficient analysis was used to identify correlations between MCID, PASS, and preoperative variables.Results:A total of 60 patients were included in the study. A majority of patients were female (91.7%), with an average age and body mass index of 57.9 ± 9.91 years and 27.6 ± 6.1, respectively. The MCIDs of the Activities of Daily Living (ADL) and Sport-Specific (SS) subscales of the Hip Outcome Score (HOS) and the modified Harris Hip Score (mHHS) were calculated to be 15.02, 14.53, and 14.13, respectively. The PASS scores of HOS-ADL, HOS-SS, and mHHS were calculated to be 81.32, 67.71, and 77.5, respectively. In addition, 76.7% of patients achieved either MCID or PASS postoperatively, with 77.8% and 69.0% reaching at least 1 threshold score for achieving MCID and PASS, respectively, and 48.3% achieving both MCID and PASS. Smoking had a negative and weak association with achieving PASS (r = −0.271; P = .039). No other patient characteristic variables were found to correlate with achieving MCID or PASS.Conclusion:In patients undergoing endoscopic gluteus medius repair, our study defined MCID and PASS for HOS-ADL, HOS-SS, and mHHS outcome scores. A large percentage of patients (76.7%) achieved meaningful clinical outcomes at 2 years after surgery.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-10-16T04:45:19Z
      DOI: 10.1177/0363546519877179
       
  • Association of Preoperative Gluteal Muscle Fatty Infiltration With Patient
           Outcomes in Women After Hip Abductor Tendon Repair Augmented With LARS
    • Authors: Jay R. Ebert, Anne Smith, William Breidahl, Michael Fallon, Gregory C. Janes
      First page: 3148
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Hip abductor tendon repair has demonstrated encouraging outcomes. The influence of fatty infiltration (FI) on outcome has not been explored.Purpose:To investigate the association between preoperative hip abductor FI and clinical outcome after hip abductor tendon repair.Study Design:Case series; Level of evidence, 4.Methods:A total of 84 women underwent hip abductor tendon repair. The mean age was 64.6 years (range, 43-84 years); body mass index, 27.7 (range, 20.0-40.2); and duration of symptoms, 3.4 years (range, 6 months–20 years). The 6-minute walk test, isometric hip abduction strength assessment, and patient-reported outcome measures, including the Harris Hip Score and Oxford Hip Score, were completed presurgery and 2 years after surgery. Patient satisfaction and perceived improvement were assessed 2 years after surgery. All patients underwent preoperative magnetic resonance imaging on the affected hip, and the Goutallier system was used to grade the degree of FI in the anterior, middle, and posterior thirds of the gluteus medius and minimus on a 0-4 ordinal scale. A single FI score for the gluteus medius and minimus was calculated, as was a combined FI score.Results:All clinical scores significantly improved over time (P < .001). Preoperatively, FI was more severe in the gluteus minimus, with the most severe FI (grades 2-4) demonstrated in the middle (n = 56, 66.7%) and anterior (n = 17, 20.2%) portions of the gluteus minimus and the middle (n = 27, 32.1%) and anterior (n = 12, 14.3%) portions of the gluteus medius. Older age was associated with greater FI (combined FI score: r = 0.529, P < .001), although duration of symptoms (r = 0.035, P = .753) and body mass index (r = 0.089, P = .464) were not. Greater FI was associated with less improvement in hip strength of the unaffected leg (coefficient, –1.6, 95% CI: −2.8 to −0.4), although no other significant associations were observed between FI and pre- or postoperative clinical scores.Conclusion:Preoperative FI was not associated with pertinent parameters of patient outcome after hip abductor tendon repair, including pain, symptoms, functional capacity, perceived improvement, and satisfaction. Based on these outcomes, surgical repair may be considered in the presence of more severe FI.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-09-12T08:25:50Z
      DOI: 10.1177/0363546519873672
       
  • Can the FEAR Index Be Used to Predict Microinstability in Patients
           Undergoing Hip Arthroscopic Surgery'
    • Authors: Jeremy N. Truntzer, Daniel J. Hoppe, Lauren M. Shapiro, Marc R. Safran
      First page: 3158
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Atraumatic hip instability, or microinstability, is a challenging diagnosis for clinicians to make. Several radiographic parameters have been proposed to help identify patients with instability as a means to direct treatment. The Femoro-epiphyseal Acetabular Roof (FEAR) index was recently offered as a parameter to predict instability in a borderline dysplastic population.Purpose:To evaluate the FEAR index in a series of predominantly nondysplastic patients undergoing hip arthroscopic surgery to determine if it can accurately predict patients with diagnosed microinstability at the time of surgery.Study Design:Cohort study (diagnosis); Level of evidence, 2.Methods:A consecutive series of 200 patients undergoing hip arthroscopic surgery were evaluated for microinstability intraoperatively. Microinstability was diagnosed based on previously published criteria. Retrospectively, radiographic parameters were measured including the lateral center edge angle of Wiberg (LCEA), Tönnis angle, physeal scar angle, and FEAR index. Patients were excluded if they previously had any type of bony procedures performed, underwent prior open hip surgery or total hip arthroplasty of the ipsilateral hip, had osteoarthritis (Tönnis grade>1), or had any radiographic features of moderate-to-severe acetabular dysplasia including an LCEA
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-10-11T06:51:14Z
      DOI: 10.1177/0363546519876105
       
  • In Vivo Anterior Cruciate Ligament Deformation During a Single-Legged Jump
           Measured by Magnetic Resonance Imaging and High-Speed Biplanar Radiography
           
    • Authors: Zoë A. Englander, Edward L. Baldwin, Wyatt A.R. Smith, William E. Garrett, Charles E. Spritzer, Louis E. DeFrate
      First page: 3166
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:The in vivo mechanics of the anterior cruciate ligament (ACL) and its bundles during dynamic activities are not completely understood. An improved understanding of how the ACL stabilizes the knee is likely to aid in the identification and prevention of injurious maneuvers.Purpose/Hypothesis:The purpose was to measure in vivo ACL strain during a single-legged jump through use of magnetic resonance imaging (MRI) and high-speed biplanar radiography. We hypothesized that ACL strain would increase with the knee near extension, and a peak in ACL strain would occur just before landing from the jump, potentially due to quadriceps contraction in anticipation of landing.Study Design:Descriptive laboratory study.Methods:Models of the femur, tibia, and ACL attachment sites of 8 male participants were generated from MRI scans through use of solid modeling. High-speed biplanar radiographs were obtained from these participants as they performed a single-legged jump. The bone models were registered to the biplanar radiographs, thereby reproducing the in vivo positions of the joint throughout the jump. ACL and bundle elongations were defined as the centroid to centroid distances between attachment sites for each knee position. ACL strain was defined as ACL length normalized to its length measured in the position of the knee at the time of MRI.Results:Peaks in ACL strain were observed before toe-off and 55 ± 35 milliseconds before initial ground contact. These peaks were associated with the knee positioned at low flexion angles. Mean ACL strain was inversely related to mean flexion angle (rho = −0.73, P < .001), such that ACL strain generally increased with knee extension throughout the jumping motion. ACL bundle lengths were significantly (rho> 0.85, P < .001) correlated with overall ACL length.Conclusion:These findings provide insight into how landing in extension can increase the risk of ACL injury. Specifically, this study shows that peak ACL strain can occur just before landing from a single-legged jump. Thus, when an individual lands on an extended knee, the ACL is relatively taut, which may make it particularly vulnerable to injury, especially in the presence of a movement perturbation or unanticipated change in landing strategy.Clinical Relevance:This study provides a novel measurement of dynamic ACL strain during an athletic maneuver and lends insight into how landing in extension can increase the likelihood of ACL failure.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-10-08T04:17:03Z
      DOI: 10.1177/0363546519876074
       
  • Risk Factors for Loss to Follow-up in 3202 Patients at 2 Years After
           Anterior Cruciate Ligament Reconstruction: Implications for Identifying
           Health Disparities in the MOON Prospective Cohort Study
    • Authors: Prem N. Ramkumar, Muhammad B. Tariq, Annunziato Amendola, Jack T. Andrish, Robert H. Brophy, Warren R. Dunn, David C. Flanigan, Laura J. Huston, Morgan H. Jones, Christopher C. Kaeding, Michael W. Kattan, Robert G. Marx, Matthew J. Matava, Eric C. McCarty, Richard D. Parker, Armando F. Vidal, Michelle L. Wolcott, Brian R. Wolf, Rick W. Wright, Kurt P. Spindler
      First page: 3173
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Understanding the risk factors for loss to follow-up in prospective clinical studies may allow for a targeted approach to minimizing follow-up bias and improving the generalizability of conclusions in anterior cruciate ligament reconstruction (ACLR) and other sports-related interventions.Purpose:To identify independent risk factors associated with failure to complete (ie, loss to follow-up) patient-reported outcome measures (PROMs) at 2 years after ACLR within a well-funded prospective longitudinal cohort.Study Design:Cohort study (prognosis); Level of evidence, 2.Methods:All patients undergoing primary or revision ACLR enrolled in the prospectively collected database of the multicenter consortium between 2002 and 2008 were included. Multivariate regression analyses were conducted to determine which baseline risk factors were significantly associated with loss to follow-up at a minimum of 2 years after surgery. Predictors assessed for loss to follow-up were as follows: consortium site, sex, race, marital status, smoking status, phone number provided (home or cell), email address provided (primary or secondary), years of school completed, average hours worked per week, working status (full-time, part-time, homemaker, retired, student, or disabled), number of people living at home, and preoperative PROMs (Knee injury and Osteoarthritis Outcome Score, Marx Activity Rating Scale, and International Knee Documentation Committee).Results:A total of 3202 patients who underwent ACLR were enrolled. The 2-year PROM follow-up rate for this cohort was 88% (2821 of 3202). Multivariate analyses showed that patient sex (male: odds ratio [OR], 1.80) and race (black: OR, 3.64; other nonwhite: OR, 1.81) were independent predictors of 2-year loss to follow-up of PROMs. Education level was a nonconfounder.Conclusion:While education level did not predict loss to follow-up, patients who are male and nonwhite are at increased risk of loss to follow-up of PROM at 2 years. Capturing patient outcomes with minimal loss depends on equitable, not equal, opportunity to maximize generalizability and mitigate potential population-level health disparities.Registration:NCT00478894 (ClinicalTrials.gov identifier).
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-10-07T06:29:07Z
      DOI: 10.1177/0363546519876925
       
  • Bone Bruise and Anterior Cruciate Ligament Tears: Presence, Distribution
           Pattern, and Associated Lesions in the Pediatric Population
    • Authors: Vittorio Bordoni, Giorgio di Laura Frattura, Davide Previtali, Simone Tamborini, Christian Candrian, Marirosa Cristallo Lacalamita, Filippo Del Grande, Giuseppe Filardo
      First page: 3181
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Bone bruise characteristics after anterior cruciate ligament (ACL) injury have been correlated with the level of joint derangement in adults. However, the literature lacks information about younger patients, whose higher ligamentous laxity may lead to different lesion patterns.Purpose:To investigate the prevalence, size, location, and role of bone bruise associated with ACL rupture in the pediatric population.Study Design:Cross-sectional study; Level of evidence, 3.Methods:Knee magnetic resonance imaging scans (MRIs) of patients aged 8 to 16 years with ACL tears from 2010 to 2018 were selected from the institution database. Inclusion criteria were open or partially open physes, less than 90 days between trauma and MRI, and no history of injury or surgery. Presence, localization, and size of bone bruise were analyzed by 2 blinded researchers and scored with the Whole-Organ Magnetic Resonance Imaging Score (WORMS) bone bruise subscale. Ligamentous, cartilaginous, meniscal, and other lesions were documented.Results:Of the 78 pediatric patients selected from the database, 54 (69%) had bone bruise. The mean area of bone bruise was larger in males than in females (femur, 3.8 ± 2.8 vs 2.2 ± 1.4 cm2, respectively, P = .006; tibia, 2.6 ± 1.6 vs 1.5 ± 0.8 cm2, respectively, P = .007). The subregions most affected by bone bruise were the lateral posterior tibia and the lateral central femur (in 83% and 80% of the knees affected, respectively). A low correlation was found between age and bone bruise area (biggest areas r = 0.30, P = .03, and sum of areas r = 0.27, P = .04), but no correlation was found between age and WORMS (femur, r = −0.03, P = .85; tibia, r = −0.04, P = .76). The injuries most associated with bone bruise were 23 meniscal lesions (43%), 10 lesions of other ligaments (19.0%), 2 cartilage lesions (3.7%), and 2 patellar fractures (3.7%).Conclusion:The prevalence of bone bruises in pediatric patients with ACL tears is high, although it seems slightly lower than the prevalence documented in adults but with similar localization. The area and the distribution pattern of bone bruises are similar among different ages. The pediatric patients had a lower presence of cartilage and meniscal lesions compared with that reported in adults, which suggests a different effect of this trauma on the knee of pediatric patients.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-09-12T08:03:48Z
      DOI: 10.1177/0363546519872975
       
  • Evaluating the Accuracy of Tibial Tunnel Placement After Anatomic
           Single-Bundle Anterior Cruciate Ligament Reconstruction
    • Authors: Christopher Pedneault, Carl Laverdière, Adam Hart, Mathieu Boily, Mark Burman, Paul A. Martineau
      First page: 3187
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Anatomic anterior cruciate ligament (ACL) reconstruction improves knee kinematics and joint stability in symptomatic patients who have ACL deficiency. Despite a concerted effort to place the graft within the ACL’s native attachment sites, the accuracy of tunnel placement using contemporary techniques is not well established.Purpose:The present study uses 3-dimensional magnetic resonance imaging (3D MRI) to prospectively evaluate the accuracy of tibial tunnel placement after anatomic ACL reconstruction.Study Design:Case series; Level of evidence, 4.Methods:40 patients with symptomatic, ACL-deficient knees were prospectively enrolled in the study and underwent 3D MRI of both their injured and uninjured knees before and after surgery through use of a validated imaging protocol. The root ligament of the anterior horn of the lateral meniscus was used as a radiographic reference, and the center of the reconstructed graft was compared with that of the contralateral normal knee. The tunnel angles and intra-articular graft angles were also measured, as was the percentage overlap between the native tibial footprint and tibial tunnel.Results:The reconstructed tibial footprint was placed at a mean ± SD of 2.14 ± 2.45 mm (P < .001) medial and 5.11 ± 3.57 mm (P < .001) posterior to the native ACL footprint. The mean distance between the center of the native and reconstructed ACL at the tibial attachment site was 6.24 mm. Of the 40 patients, 18 patients had a tibial tunnel that overlapped more than 50% of the native footprint, and 10 patients had maximal (100%) overlap. Further, 22 of the 40 patients had less than 50% overlap with the native footprint, and in 12 patients the footprint was missing completely.Conclusion:Despite the use of contemporary surgical techniques to perform anatomic ACL reconstruction, a significant positioning error in tibial tunnel placement remains.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-09-12T08:11:32Z
      DOI: 10.1177/0363546519873633
       
  • Effect of Meniscal Ramp Lesion Repair on Knee Kinematics, Bony Contact
           Forces, and In Situ Forces in the Anterior Cruciate Ligament
    • Authors: Jan-Hendrik Naendrup, Thomas R. Pfeiffer, Calvin Chan, Kanto Nagai, João V. Novaretti, Andrew J. Sheean, Sven T. Shafizadeh, Richard E. Debski, Volker Musahl
      First page: 3195
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Meniscal ramp lesions are possible concomitant injuries in cases of anterior cruciate ligament (ACL) deficiency. Although recent studies have investigated the influence of ramp lesions on knee kinematics, the effect on the ACL reconstruction graft remains unknown.Purpose/Hypothesis:The purpose was to determine the effects of ramp lesion and ramp lesion repair on knee kinematics, the in situ forces in the ACL, and bony contact forces. It was hypothesized that ramp lesions will significantly increase in situ forces in the native ACL and bony contact forces and that ramp lesion repair will restore these conditions comparably with those forces of the intact knee.Study Design:Controlled laboratory study.Methods:Investigators tested 9 human cadaveric knee specimens using a 6 degrees of freedom robotic testing system. The knee was continuously flexed from full extension to 90° while the following loads were applied: (1) 90-N anterior load, (2) 5 N·m of external-rotation torque, (3) 134-N anterior load + 200-N compression load, (4) 4 N·m of external-rotation torque + 200-N compression load, and (5) 4 N·m of internal-rotation torque + 200-N compression load. Loading conditions were applied to the intact knee, a knee with an arthroscopically induced 25-mm ramp lesion, and a knee with an all-inside repaired ramp lesion. In situ forces in the ACL, bony contact forces in the medial compartment, and bony contact forces in the lateral compartment were quantified.Results:In response to all loading conditions, no differences were found with respect to kinematics, in situ forces in the ACL, and bony contact forces between intact knees and knees with a ramp lesion. However, compared with intact knees, knees with a ramp lesion repair had significantly reduced anterior translation at flexion angles from full extension to 40° in response to a 90-N anterior load (P < .05). In addition, a significant decrease in the in situ forces in the ACL after ramp repair was detected only for higher flexion angles when 4 N·m of external-rotation torque combined with a 200-N compression load (P < .05) and 4 N·m of internal-rotation torque combined with a 200-N compression load were applied (P < .05).Conclusion:In this biomechanical study, ramp lesions did not significantly affect knee biomechanics at the time of surgery.Clinical Relevance:From a biomechanical time-zero perspective, the indications for ramp lesion repair may be limited.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-09-27T08:47:09Z
      DOI: 10.1177/0363546519872964
       
  • The Contribution of Partial Meniscectomy to Preoperative Laxity and Laxity
           After Anatomic Single-Bundle Anterior Cruciate Ligament Reconstruction: In
           Vivo Kinematics With Navigation
    • Authors: Alberto Grassi, Stefano Di Paolo, Gian Andrea Lucidi, Luca Macchiarola, Federico Raggi, Stefano Zaffagnini
      First page: 3203
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Limited in vivo kinematic information exists on the effect of clinical-based partial medial and lateral meniscectomy in the context of anterior cruciate ligament (ACL) reconstruction.Hypothesis:In patients with ACL deficiency, partial medial meniscus removal increases the anteroposterior (AP) laxity with compared with those with intact menisci, while partial lateral meniscus removal increases dynamic laxity. In addition, greater postoperative laxity would be identified in patients with partial medial meniscectomy.Study design:Cross-sectional study; Level of evidence, 3.Methods:A total of 164 patients with ACL tears were included in the present study and divided into 4 groups according to the meniscus treatment they underwent: patients with partial lateral meniscectomy (LM group), patients with partial medial meniscectomy (MM group), patients with partial medial and lateral meniscectomy (MLM group), and patients with intact menisci who did not undergo any meniscus treatment (IM group). A further division in 2 new homogeneous groups was made based on the surgical technique: 46 had an isolated single-bundle anatomic ACL reconstruction (ACL group), while 13 underwent a combined single-bundle anatomic ACL reconstruction and partial medial meniscectomy (MM-ACL group). Standard clinical laxities (AP translation at 30° of knee flexion, AP translation at 90° of knee flexion) and pivot-shift (PS) tests were quantified before and after surgery by means of a surgical navigation system dedicated to kinematic assessment. The PS test was quantified through 3 different parameters: the anterior displacement of the lateral tibial compartment (lateral AP); the posterior acceleration of the lateral AP during tibial reduction (posterior acceleration); and finally, the area included by the lateral AP translation with respect to the flexion/extension angle (area).Results:In the ACL-deficient status, the MM group showed a significantly greater tibial translation compared with the IM group (P < .0001 for AP displacement at 30° [AP30] and 90° [AP90] of flexion) and the LM group (P = .002 for AP30 and P < .0001 for AP90). In the PS test, the area of LM group was significantly larger (57%; P = .0175) than the one of the IM group. After ACL reconstruction, AP translation at 30° was restored, while the AP90 remained significantly greater at 1.3 mm (P = .0262) in the MM-ACL group compared with those with intact menisci.Conclusion:Before ACL reconstruction, partial medial meniscectomy increased AP laxity at 30° and 90° and lateral meniscectomy increased dynamic PS laxity with respect to intact menisci. Anatomic single-bundle ACL reconstruction decreased laxities, but a residual anterior translation of 1.3 mm at 90° remained in patients with partial medial meniscectomy, with respect to those with intact menisci.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-10-15T04:29:22Z
      DOI: 10.1177/0363546519876648
       
  • Survival Analysis of Revision Autologous Chondrocyte Implantation for
           Failed ACI
    • Authors: Takahiro Ogura, Tim Bryant, Gergo Merkely, Brian A. Mosier, Tom Minas
      First page: 3212
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Autologous chondrocyte implantation (ACI) provides a successful outcome for treating articular cartilage lesions. However, there have been very few reports on the clinical outcomes of revision ACI for failed ACI.Purpose:To evaluate clinical outcomes in patients who underwent revision ACI of the knee for failure of an initial ACI and to determine the factors affecting the survival rate.Study Design:Case series; Level of evidence, 4.Methods:A review of a prospectively collected data set was performed from patients who underwent revision ACI of the knee for failure of an initial ACI between 1995 and 2014 by a single surgeon. The authors evaluated 53 patients (53 knees; mean age, 38 years) over a mean 11.2-year follow-up (range, 2-20). A total of 62 cartilage lesions were treated for failed graft lesions after an initial ACI, and 31 new cartilage lesions were treated at revision ACI, as there was progression of disease. Overall, 93 cartilage lesions (mean, 1.8 lesions per knee) with a total surface area of 7.4 cm2 (range, 2.5-18 cm2) per knee were treated at revision ACI. Survival analysis was performed with the Kaplan-Meier method, with ACI graft failure or conversion to a prosthetic arthroplasty as the endpoint. The modified Cincinnati Knee Rating Scale, Western Ontario and McMaster Universities Osteoarthritis Index, visual analog scale, and 36-Item Short Form Health Survey were used to evaluate clinical outcomes. Patients also self-reported knee function and satisfaction. Standard radiographs were evaluated with Kellgren-Lawrence grades.Results:Survival rates were 71% and 53% at 5 and 10 years, respectively. Survival subanalysis revealed a trend that patients without previous cartilage repair procedures before an initial ACI had better survival rates than those with such procedures (81% vs 62% at 5 years, 64% vs 42% at 10 years, P = .0958). Patients with retained grafts showed significant improvement in pain and function, with a high level of satisfaction. At a mean 5.1 years postoperatively, 18 of 27 successful knees were radiographically assessed with no significant osteoarthritis progression. Outcomes for 26 patients were considered failures (mean, 4.9 years postoperatively), in which 15 patients had prosthetic arthroplasty (mean, 4.6 years) and the other 11 patients had revision cartilage repair (mean, 5.4 years) and thus could maintain their native knees.Conclusion:Results of revision ACI for patients who failed ACI showed acceptable clinical outcomes. Revision ACI may be an option for young patients after failed initial ACI, particularly patients without previous cartilage repair procedures and those who desire to maintain their native knees.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-10-07T06:17:45Z
      DOI: 10.1177/0363546519876630
       
  • Collagenous Ultrastructure of the Torn Medial Meniscus Posterior Root: A
           Transmission Electron Microscopy Study
    • Authors: Young-Jin Seo, Sung-Jae Kim, Dawoon Jung, Jeehyoung Kim, Young-Soo Shin, Seungbi Choi, Eun Shin, Si Young Song
      First page: 3221
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:The collagen ultrastructure of torn medial meniscus posterior roots (MMPRs) has not been precisely defined.Purpose:To investigate the ultrastructure of torn MMPRs, focusing on their collagen fibers, and to compare the collagen net architecture between intact and torn MMPRs using the Collagen Meniscal Architecture (CMA) scoring system.Study Design:Descriptive laboratory study.Methods:Forty-three human meniscal specimens were obtained from 32 patients with osteoarthritis during total knee arthroplasty between January 2018 and November 2018. There were 23 specimens taken from patients with an MMPR tear and 20 taken from patients without an MMPR tear served as a control group. The presence of an MMPR tear was defined as a complete radial tear within 9 mm of the posterior root attachment. The collagen ultrastructure of the meniscal specimens was assessed with transmission electron microscopy using the CMA scoring system. Patient demographics included sex, age, and body mass index, and radiographic assessments included the Kellgren-Lawrence (K-L) grading system and the mechanical axis angle.Results:The median CMA score was significantly higher in torn MMPRs (5.5 [interquartile range, 3.5-6.0]) than in intact MMPRs (2.0 [interquartile range, 1.5-3.8]) (P < .001). When the CMA scores were converted to CMA grading, 23 torn MMPRs had 1 grade I, 9 grade II, and 13 grade III menisci. In 20 intact MMPRs, there were 12 grade I, 7 grade II, and 1 grade III menisci. No significant differences in sex, age, body mass index, K-L grade, or mechanical axis angle were found between groups.Conclusion:This study showed that torn MMPRs had decreased numbers and disorganized courses of collagen fibers. The structural problem of torn MMPRs can negatively affect meniscal healing, function, and long-term survival after root repair.Clinical Relevance:These results might provide a histopathological reason for the low healing rate after MMPR repair.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-10-11T06:56:08Z
      DOI: 10.1177/0363546519876110
       
  • Symptomatic Venous Thromboembolism After Achilles Tendon Rupture: A
           Nationwide Danish Cohort Study of 28,546 Patients With Achilles Tendon
           Rupture
    • Authors: Melissa Hornbæk Pedersen, Liv Riisager Wahlsten, Henrik Grønborg, Gunnar Hilmar Gislason, Michael Mørk Petersen, Anders Nissen Bonde
      First page: 3229
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Venous thromboembolism (VTE) is a well-known complication of Achilles tendon rupture (ATR) and carries a high risk of morbidity and mortality. Although routine thromboprophylaxis for patients with ATR is not recommended, sparse knowledge is available regarding risk factors associated with VTE in patients with ATR.Purpose:To use Danish nationwide registers to identify incidence rates for symptomatic VTE and risk factors associated with increased risk of developing VTE in patients with ATR.Study Design:Cohort study; Level of evidence, 3.Methods:By crosslinking nationwide registers, we identified all patients with diagnosed ATR in Denmark from 1997 to 2015. We stratified patients into 4 groups by age and treatment modality (ie, operative vs nonoperative treatment). The main outcome was VTE within 180 days. We calculated crude incidence rates and considered age, sex, year, comorbidities, and medications as risk factors for VTE in Poisson regression models.Results:We identified 28,546 patients with ATR, of whom 389 (1.36%) were hospitalized with VTE during the follow-up period: 278 due to deep vein thromboses and 138 due to pulmonary embolism. Incidence rates were highest during the first month and ranged from 4.6 to 14.6 events per 100 person-years. VTEs were most frequent among nonoperatively treated patients aged ≥50 years. In Poisson regression analyses, having had VTE beforehand was associated with an increased risk of VTE, as was male sex in the nonoperative treatment group aged ≥50 years; among women
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-10-01T10:36:16Z
      DOI: 10.1177/0363546519876054
       
  • Positive Effect of Platelet-Rich Plasma on Pain in Plantar Fasciitis: A
           Double-Blind Multicenter Randomized Controlled Trial
    • Authors: Joost C. Peerbooms, Paul Lodder, Brenda L. den Oudsten, Kamiel Doorgeest, Hans M. Schuller, Taco Gosens
      First page: 3238
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:When nonoperative treatment for chronic plantar fasciitis fails, often a corticosteroid injection is given. Corticosteroid injection gives temporary pain reduction but no healing. Platelet-rich plasma (PRP) has proven to be a safe therapeutic option in the treatment of tendon, muscle, bone, and cartilage injuries.Purpose:To determine the effectiveness of PRP as compared with corticosteroid injections for chronic plantar fasciitis.Study Design:Randomized controlled trial; Level of evidence, 1.Methods:Patients with chronic plantar fasciitis were allocated to have steroid injection or PRP. The primary outcome measure was the Foot Function Index (FFI) Pain score. Secondary outcome measures were function, as scored by the FFI Activity, FFI Disability, and American Orthopaedic Foot & Ankle Society, and quality of life, as scored with the short version of the World Health Organization Quality of Life (WHOQOL-BREF). All outcomes were measured at baseline and at 4, 12, and 26 weeks and 1 year after the procedure.Results:Of the 115 patients, 63 were allocated to the PRP group, of which 46 (73%) completed the study, and 52 were allocated to the control group (corticosteroid injection), of which 36 (69%) completed the study. In the control group, FFI Pain scores decreased quickly and then remained stable during follow-up. In the PRP group, FFI Pain reduction was more modest but reached a lower point after 12 months than the control group. After adjusting for baseline differences, the PRP group showed significantly lower pain scores at the 1-year follow-up than the control group (mean difference, 14.4; 95% CI, 3.2-25.6). The number of patients with at least 25% improvement (FFI Pain score) between baseline and 12-month follow-up differed significantly between the groups. Of the 46 patients in the PRP group, 39 (84.4%) improved at least 25%, while only 20 (55.6%) of the 36 in the control group showed such an improvement (P = .003). The PRP group showed significantly lower FFI Disability scores than the control group (mean difference, 12.0; 95% CI, 2.3-21.6).Conclusion:Treatment of patients with chronic plantar fasciitis with PRP seems to reduce pain and increase function more as compared with the effect of corticosteroid injection.Registration:NCT00758641 (ClinicalTrials.gov identifier).
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-10-11T07:17:07Z
      DOI: 10.1177/0363546519877181
       
  • Exosomes Isolated From Adipose-Derived Stem Cells: A New Cell-Free
           Approach to Prevent the Muscle Degeneration Associated With Torn Rotator
           Cuffs
    • Authors: Chongyang Wang, Wei Song, Bi Chen, Xudong Liu, Yaohua He
      First page: 3247
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Fatty infiltration, inflammation, and apoptosis are common degenerative changes in patients with chronic rotator cuff tears that can lead to muscle atrophy and can even result in massive irreparable rotator cuff tears. Some data have demonstrated the proregenerative, anti-inflammatory, and anti-apoptotic properties of stem cell–derived exosomes in some orthopaedic disorders, but their effect on torn rotator cuff muscles has never been investigated.Purpose:To study the effect of exosomes isolated from human adipose-derived stem cells (ASCs-Exos) on muscle degeneration, regeneration, and biomechanical properties in a rat model of a massive rotator cuff tear (MRCT).Study Design:Controlled laboratory study.Methods:A bilateral supraspinatus and infraspinatus tenotomy was performed on rats to create an MRCT model. Forty-two rats were randomly assigned to 3 groups: the sham surgery group, the saline group (lesions treated with a saline injection), and the ASCs-Exos group (lesions treated with an ASCs-Exos injection). Wet muscle weight, fatty infiltration, inflammation, vascularization, regeneration, and biomechanical properties were evaluated at 8 and 16 weeks after surgery.Results:The results revealed that the ASCs-Exos treatment could prevent the atrophy, fatty infiltration, inflammation, and vascularization of muscles in the MRCT model (P < .001). Additionally, the myofiber regeneration and biomechanical properties of ASCs-Exos-treated rotator cuffs were significantly elevated compared with those in the saline-treated group (P < .001).Conclusion:This study demonstrates that ASCs-Exos can effectively decrease atrophy and degeneration and improve muscle regeneration and biomechanical properties in torn rotator cuff muscles.Clinical Relevance:ASCs-Exos can be used as a new cell-free approach to prevent the muscle degeneration associated with torn rotator cuffs and may be helpful to repair torn rotator cuffs. Nevertheless, further work needs to be done in a large animal model owing to the inherent regenerative potential possessed by rodents.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-09-27T09:03:49Z
      DOI: 10.1177/0363546519876323
       
  • Multiple Concussions Increase Odds and Rate of Lower Extremity Injury in
           National Collegiate Athletic Association Athletes After Return to Play
    • Authors: Garrett K. Harada, Caitlin M. Rugg, Armin Arshi, Jeremy Vail, Sharon L. Hame
      First page: 3256
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Concussion in collegiate athletics is one of the most prevalent sport-related injuries in the United States, with recent studies suggesting persistent deficits in neuromuscular control after a concussion and an associated increase in risk of lower extremity injury.Purpose:To expand on the relationship between concussion and lower extremity injury by examining the effect of multiple concussions (MC) on rate and odds of future lower extremity injury in collegiate athletes after return to play (RTP) compared with matched controls.Study Design:Cohort study; Level of evidence, 3.Methods:From 2001 to 2016, 48 National Collegiate Athletic Association Division I athletes sustaining multiple concussions at a single institution were identified. Athletes with multiple concussions (MC) were matched directly to athletes with a single concussion (SC) and to athletes with no concussion history (NC) by sex, sport, position, and games played. Incidence of, time to, and location of lower extremity injury were recorded for each group after RTP from their first reported concussion until completion of their collegiate career. Logistic regression was used to analyze odds ratios (ORs) for sustaining lower extremity injury, whereas time to injury was summarized by use of Kaplan-Meier curves and log rank test analysis.Results:The incidence of lower extremity injury after RTP was significantly greater (P = .049) in the MC cohort (36/48, 75%) than in SC athletes (25/48 = 52%) and NC athletes (27/48 = 56%). Similarly, odds of lower extremity injury were significantly greater in the MC cohort than in SC athletes (OR, 3.00; 95% CI, 1.26-7.12; P = .01) and NC athletes (OR, 1.66; 95% CI, 1.07-2.56; P = .02). Time to lower extremity injury was significantly shorter in the MC group compared with matched controls (P = .01). No difference was found in odds of lower extremity injury or time to lower extremity injury between SC and NC athletes.Conclusion:Collegiate athletes with MC were more likely to sustain a lower extremity injury after RTP in a shorter time frame than were the matched SC and NC athletes. This may suggest the presence of a cohort more susceptible to neuromuscular deficits after concussion or more injury prone due to player behavior, and it may imply the need for more stringent RTP protocols for athletes experiencing MC.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-09-12T07:55:45Z
      DOI: 10.1177/0363546519872502
       
  • Influence of Test Environment, Age, Sex, and Sport on Baseline
           Computerized Neurocognitive Test Performance
    • Authors: Jonathan French, Patrick Huber, Joseph McShane, Cyndi L. Holland, Robert J. Elbin, Anthony P. Kontos
      First page: 3263
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Baseline computerized testing is a common component of concussion assessments, and the testing environment has been suggested to influence test performance and validity.Purpose:To compare concussion baseline computerized neurocognitive test performance and validity among adolescent athletes based on testing environment (group, individual), age group (10-12, 13-15, 16-18 years), sex (male, female), and sport type (collision/combat, contact, noncontact).Study Design:Cohort study; Level of evidence, 3.Methods:Through a concussion community outreach program, participants completed baseline computerized neurocognitive testing using Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT). A total of 2845 athletes aged 10 to 18 years completed the baseline assessment. A total of 2241 (79%) athletes completed baseline testing in a group environment, and 604 (21%) completed testing in an individual environment. A random subsample of 500 athletes from each group was selected for statistical comparison.Results:No significant differences were supported in baseline computerized neurocognitive test performance between the group and individual administration environments. Test validity was statistically similar across testing environment, age group, and sex. However, patients of older age (16-18 years), female sex, and collision/combat and contact sports performed better on ImPACT. There were differences in total symptom severity scores (t = 2.19, df = 998, P = .03), with participants in the group testing environment reporting lower total symptom severity scores than those in the individual testing environment. The rates of invalid tests were low across all age groups, averaging from 4.0% in the 10- to 12-year age group to 4.8% in the 13- to 15-year age group.Conclusion:The findings indicated that concussion baseline neurocognitive test performance is similar when administered in group and individual testing environments. However, differences based on age group, sex, and sport type should be considered when interpreting baseline computerized neurocognitive test scores. The finding of higher symptom scores in older adolescents in the individual testing environment suggests that they may be less forthcoming about symptoms in a group setting.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-10-14T04:58:40Z
      DOI: 10.1177/0363546519875137
       
  • Age-Appropriate Pediatric Sports Patient-Reported Outcome Measures and
           Their Psychometric Properties: A Systematic Review
    • Authors: Joash R. Suryavanshi, Rie Goto, Bridget Jivanelli, Peter D. Fabricant, Jamila Aberdeen, Timothy Duer, Kenneth C. Lam, Corinna C. Franklin, James MacDonald, Kevin G. Shea
      First page: 3270
      Abstract: The American Journal of Sports Medicine, Ahead of Print.

      Citation: The American Journal of Sports Medicine
      PubDate: 2019-01-16T07:44:56Z
      DOI: 10.1177/0363546518818822
       
  • Comparative Effectiveness of Cartilage Repair With Respect to the Minimal
           Clinically Important Difference
    • Authors: Kristofer J. Jones, Benjamin V. Kelley, Armin Arshi, David R. McAllister, Peter D. Fabricant
      First page: 3284
      Abstract: The American Journal of Sports Medicine, Ahead of Print.

      Citation: The American Journal of Sports Medicine
      PubDate: 2019-05-13T11:15:41Z
      DOI: 10.1177/0363546518824552
       
 
 
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