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American Journal of Sports Medicine
Journal Prestige (SJR): 3.949
Citation Impact (citeScore): 6
Number of Followers: 183  
 
  Hybrid Journal Hybrid journal (It can contain Open Access articles)
ISSN (Print) 0363-5465 - ISSN (Online) 1552-3365
Published by Sage Publications Homepage  [1079 journals]
  • Coper Classification Early After ACL Rupture Changes With Progressive
           Neuromuscular and Strength Training and Is Associated With 2-Year Success:
           Letter to the Editor
    • Authors: Nicola Maffulli, Francesco Oliva
      Abstract: The American Journal of Sports Medicine, Volume 47, Issue 11, Page NP64-NP65, September 2019.

      Citation: The American Journal of Sports Medicine
      PubDate: 2019-09-03T06:09:25Z
      DOI: 10.1177/0363546519863310
       
  • Is Hip Arthroscopy Effective in Patients With Combined Excessive Femoral
           Anteversion and Borderline Dysplasia' Letter to the Editor
    • Authors: Sivashanmugam Raju, Karthikeyan Chinnakkannu
      Abstract: The American Journal of Sports Medicine, Volume 47, Issue 11, Page NP62-NP62, September 2019.

      Citation: The American Journal of Sports Medicine
      PubDate: 2019-09-03T06:08:40Z
      DOI: 10.1177/0363546519859831
       
  • Coper Classification Early After ACL Rupture Changes With Progressive
           Neuromuscular and Strength Training and Is Associated With 2-Year Success:
           Response
    • Authors: Louise Thoma, Hege Grindem, David Logerstedt, Michael Axe, Lars Engebretsen, May Arna Risberg, Lynn Snyder-Mackler
      Abstract: The American Journal of Sports Medicine, Volume 47, Issue 11, Page NP65-NP66, September 2019.

      Citation: The American Journal of Sports Medicine
      PubDate: 2019-09-03T06:08:08Z
      DOI: 10.1177/0363546519863309
       
  • Is Hip Arthroscopy Effective in Patients With Combined Excessive Femoral
           Anteversion and Borderline Dysplasia' Response
    • Authors: Edwin O. Chaharbakhshi, David E. Hartigan, Itay Perets, Benjamin G. Domb
      Abstract: The American Journal of Sports Medicine, Volume 47, Issue 11, Page NP62-NP63, September 2019.

      Citation: The American Journal of Sports Medicine
      PubDate: 2019-09-03T06:07:26Z
      DOI: 10.1177/0363546519859827
       
  • The Need for Minimum Reporting Standards for Studies of
           “Biologics” in Sports Medicine
    • Authors: Scott Rodeo
      Pages: 2531 - 2532
      Abstract: The American Journal of Sports Medicine, Volume 47, Issue 11, Page 2531-2532, September 2019.

      Citation: The American Journal of Sports Medicine
      PubDate: 2019-09-03T06:08:34Z
      DOI: 10.1177/0363546519872219
       
  • A Case Series of Successful Repair of Articular Cartilage Fragments in the
           Knee
    • Authors: Jessica L. Churchill, Aaron J. Krych, Mark J. Lemos, Morganne Redd, Kevin F. Bonner
      Pages: 2589 - 2595
      Abstract: The American Journal of Sports Medicine, Volume 47, Issue 11, Page 2589-2595, September 2019.
      Background:It is unclear whether chondral fragments without bone have the potential to heal after fixation. Controversy exists and opinions differ regarding the optimal treatment of chondral defects after pure chondral fracture.Purpose:To determine clinical and radiographic outcomes after internal fixation of traumatic chondral fragments repaired to bone in the knee.Study Design:Case series; Level of evidence, 4.Methods:A retrospective clinical and radiographic evaluation of 10 male patients with a mean age of 14.6 years (range, 10-25 years) at the time of surgery was performed. Eight of 10 patients were skeletally immature. Patients were selected by operating surgeons per the presence of a large displaced pure chondral fragment on magnetic resonance imaging and confirmed on intraoperative inspection. All patients had a diagnosed traumatic displaced pure chondral fracture of the knee (without bone) and underwent internal fixation with minimum 1-year follow-up. Validated patient-reported and surgeon-measured outcomes were collected pre- and postoperatively. All patients were evaluated at a mean 56 months postoperatively.Results:At surgery, the mean defect size that was primarily repaired with the displaced chondral fragment was 1.9 × 2.0 cm. With minimum 1-year follow-up, there were no clinical failures. All 8 patients who had subsequent magnetic resonance imaging follow-up had radiographic evidence of complete healing of the chondral fragment back to bone. At a mean follow-up of 56 months (range, 13-171 months; median, 36 months), patients had a mean International Knee Documentation Committee score of 94.74 (range, 87.4-100), a mean Marx Activity Scale score of 14.4 (range, 8-16), and a mean Tegner Activity Scale score of 7 (range, 5-9). At final follow-up, all patients except 1 returned to sports.Conclusion:The treatment of large traumatic chondral fragments is controversial. In this select series of 10 young patients who underwent primary repair with internal fixation, there were no failures clinically. Patients demonstrated excellent short-term clinical and radiographic results after fixation of these relatively large chondral fragments in the knee.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-09-03T06:09:24Z
      DOI: 10.1177/0363546519865497
       
  • Society News
    • Pages: 2772 - 2772
      Abstract: The American Journal of Sports Medicine, Volume 47, Issue 11, Page 2772-2772, September 2019.

      Citation: The American Journal of Sports Medicine
      PubDate: 2019-09-03T06:07:33Z
      DOI: 10.1177/0363546519872744
       
  • Implementation of the FIFA 11+ Injury Prevention Program by High School
           Athletic Teams Did Not Reduce Lower Extremity Injuries: A Cluster
           Randomized Controlled Trial
    • Authors: James R. Slauterbeck, Rebecca Choquette, Timothy W. Tourville, Mickey Krug, Bert R. Mandelbaum, Pamela Vacek, Bruce D. Beynnon
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Lower extremity injuries are common in high school sports and are costly, and some have poor outcomes. The FIFA 11+ injury prevention program has been shown to decrease injuries in elite athletes by up to 72%.Hypothesis:High schools in which coaches implement the FIFA 11+ injury prevention program in their athletic programs will have a decreased incidence of lower extremity injuries compared with schools using their usual prepractice warm-up.Study Design:Randomized controlled trial; Level of evidence, 1.Methods:Fourteen high schools that employed an athletic trainer were randomly assigned to either the FIFA 11+ group or control group (usual warm-up routine). Exposure to sports and injuries were recorded and used to determine the incidence rates of lower extremity injuries per athlete-exposure (AE). The FIFA 11+ program was implemented by coaches and complicance with the program recorded.Results:There were 196 lower extremity injuries among 1825 athletes in the FIFA 11+ group and 172 injuries among 1786 athletes in the control group (1.59 and 1.47 injuries per 1000 AEs, respectively; P = .771). The distribution of the types of injury in the 2 groups did not differ, but the body locations where the injuries occurred differed somewhat (P = .051). The FIFA 11+ group had larger proportions of thigh and foot injuries, while the control group had higher proportions of knee and ankle injuries. Group differences in injury rates varied with sport (P = .041 for interaction), but there were no significant differences in injury rates between the FIFA 11+ and control groups by sport, level of play, and sex. In the FIFA 11+ group, 62% of the coaches reported that their teams completed the full FIFA 11+ program at least once a week, and 32% reported that they completed it at least twice a week.Conclusion:This study did not demonstrate a reduction in lower extremity injuries in schools randomized to use the FIFA 11+ program compared with schools using their usual prepractice warm-up program. Coach-reported compliance with performing the FIFA 11+ program at least twice a week was low.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-09-17T05:07:43Z
      DOI: 10.1177/0363546519873270
       
  • 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
      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
       
  • 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
      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
       
  • 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
      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
       
  • 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
      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
       
  • 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
      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
       
  • 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
      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
       
  • 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
      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
       
  • Donor Site Evaluation After Osteochondral Autograft Transplantation for
           Capitellar Osteochondritis Dissecans
    • Authors: Takeshi Matsuura, Yusuke Hashimoto, Takuya Kinoshita, Kazuya Nishino, Yohei Nishida, Junsei Takigami, Hiroshi Katsuda, Nagakazu Shimada
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Osteochondral autograft transplantation (OAT) for capitellar osteochondritis dissecans (OCD) requires harvesting of tissue from the asymptomatic knee joint. However, donor site morbidity (DSM) in such cases remains unclear.Purpose:To evaluate DSM and postoperative radiographic findings in patients undergoing OAT for advanced capitellar OCD.Study Design:Case series; Level of evidence, 4.Methods:Eighty-six juvenile athletes underwent OAT for advanced capitellar OCD. The 2000 International Knee Documentation Committee subjective score, rate of return to sports, and symptoms in the donor knee were assessed at a mean follow-up of 86 months (range, 28-185 months). Additionally, 49 of the 86 patients were assessed by radiographic and magnetic resonance imaging (MRI) findings of the knee donor site. DSM was defined according to the usual criterion (persistent symptoms for>1 year or the need for subsequent intervention) and a stricter criterion (the presence of any symptoms, such as effusion, patellofemoral complaints, crepitation, unspecified disturbance, stiffness, pain/instability during activities, and osteoarthritic change). The stricter criterion was also used to allocate patients into a DSM group and a no-DSM group.Results:Two and 11 patients were determined to have DSM according to the usual and stricter criteria, respectively. All patients returned to the competitive level of their sports. The mean International Knee Documentation Committee score was 99.0. MRI findings showed abnormal signal intensity in 17 patients (35%) and hypertrophic changes in 11 patients (22%) at the donor harvest sites. The MOCART (magnetic resonance observation of cartilage repair tissue) score was higher in the no-DSM group (mean, 68.2) than in the DSM group (mean, 52.9) (P = .027).Conclusion:OAT for juvenile athletes with advanced capitellar OCD provided good clinical outcomes. The DSM rate was relatively low (2.3%) with the usual criterion but high (12.8%) with the stricter criterion. MRI showed an abnormal signal intensity and hypertrophy in some cases.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-09-10T06:30:02Z
      DOI: 10.1177/0363546519871064
       
  • Extracorporeal Shockwave Therapy Accelerates the Healing of a Meniscal
           Tear in the Avascular Region in a Rat Model
    • Authors: Shogo Hashimoto, Tsuyoshi Ichinose, Takashi Ohsawa, Noriyuki Koibuchi, Hirotaka Chikuda
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:The treatment of meniscal tears in the avascular region remains a clinical challenge. Extracorporeal shockwave therapy (ESWT) is a minimally invasive, safe, and effective therapy for various orthopaedic disorders. However, the therapeutic effect of ESWT on meniscal tears has not been reported.Purpose:To evaluate the therapeutic effect of ESWT in the treatment of meniscal tears.Study Design:Controlled laboratory study.Methods:Twelve-week-old male Wistar rats were divided into 3 groups (normal, ESWT–, and ESWT+). The authors made a full-thickness 2-mm longitudinal tear in the avascular region of the anterior horn in the latter 2 groups. At 1 week after surgery, the ESWT+ group received 800 impulses of shockwave at 0.22-mJ/mm2 energy flux density in a single session. The authors performed a histological examination to evaluate meniscal healing (n = 10 for each group) and immunohistochemistry to analyze the expression of bromodeoxyuridine (BrdU; n = 5 for each group) and CCN family member 2/connective tissue growth factor (CCN2/CTGF; n = 5 for each group) at 2, 4, and 8 weeks after ESWT. The mRNA levels of CCN2, SOX 9, VEGF-a, aggrecan, Col1a2, and Col2a1 at the site of the meniscal tear at 4 weeks after ESWT were quantitatively evaluated by a real-time polymerase chain reaction (n = 5 for each group).Results:The meniscus healing scores in the ESWT+ group were significantly higher than those in the ESWT– group at 4 weeks and 8 weeks. The ratio of BrdU-positive cells was the highest in the ESWT+ group at all observation periods. The ratio of CCN2-positive cells was highest in the ESWT+ group at 4 and 8 weeks. In the ESWT+ group, real-time polymerase chain reaction revealed that the levels of CCN2, SOX9, aggrecan, and Col2a1 were upregulated (All significant data were P < .05).Conclusion:ESWT promoted the healing of meniscal tears in the avascular area. ESWT stimulated proliferation of meniscal cells and the upregulation of cartilage-repairing factors such as CCN2, with the upregulation of cartilage-specific extracellular matrix expression.Clinical Relevance:ESWT may be an effective therapeutic option that promotes meniscal healing in the avascular region.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-09-10T06:12:01Z
      DOI: 10.1177/0363546519871059
       
  • 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
       
  • Association Between Running Shoe Characteristics and Lower Extremity
           Injuries in United States Military Academy Cadets
    • Authors: Gary L. Helton, Kenneth L. Cameron, Rebecca A. Zifchock, Erin Miller, Donald L. Goss, Jinsup Song, Michael T. Neary
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Running-related overuse injuries are very common among recreational runners, with the reported annual injury rates ranging from 39% to 85%. Relatively few large prospective cohort studies have been conducted to investigate injury risk associated with different running shoe characteristics, and the results of the existing studies are often contradictory.Purpose/Hypothesis:The purpose was to investigate the relationship between running shoe characteristics and lower extremity musculoskeletal injury. It was hypothesized that the risk of injury would be increased in individuals wearing shoes with minimal torsional stiffness and heel height compared with those wearing shoes with greater levels of torsional stiffness and heel height.Study Design:Cohort study; Level of evidence, 2.Methods:The study included 1025 incoming cadets. Shoe torsional stiffness and heel height were calculated and recorded. Demographic data were recorded and analyzed as potential covariates. Lower extremity injuries sustained over 9 weeks during cadet basic training were documented by use of the Armed Forces Health Longitudinal Technology Application and the Cadet Illness and Injury Tracking System. Kaplan-Meier survival curves were estimated, with time to incident lower extremity injury as the primary outcome by level of the independent predictor variables. Risk factors or potential covariates were carried forward into multivariable Cox proportional hazards regression models. Absolute and relative risk reduction and numbers needed to treat were calculated.Results:Approximately 18.1% of participants incurred a lower extremity injury. Cadets wearing shoes with moderate lateral torsional stiffness were 49% less likely to incur any type of lower extremity injury and 52% less likely to incur an overuse lower extremity injury than cadets wearing shoes with minimal lateral torsional stiffness, both of which were statistically significant observations. Injury risk was similar among cadets wearing shoes with minimal and extreme lateral torsional stiffness.Conclusion:Shoes with mild to moderate lateral torsional stiffness may be appropriate in reducing risk of lower extremity injury in cadets. Shoes with minimal lateral torsional stiffness should be discouraged in this population.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-09-09T05:41:33Z
      DOI: 10.1177/0363546519870534
       
  • Management of the Failed Latarjet Procedure: Outcomes of Revision Surgery
           With Fresh Distal Tibial Allograft
    • Authors: Matthew T. Provencher, Liam A. Peebles, Zachary S. Aman, Andrew S. Bernhardson, Colin P. Murphy, Anthony Sanchez, Travis J. Dekker, Robert F. LaPrade, Giovanni Di Giacomo
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Patients with recurrent anterior glenohumeral instability after a failed Latarjet procedure remain a challenge to address. Complications related to this procedure include large amounts of bone loss, bone resorption, and issues with retained hardware that necessitate the need for revision surgery.Purpose:To determine the outcomes of patients who underwent revision surgery for a recurrent shoulder instability after a failed Latarjet procedure with fresh distal tibial allograft.Study Design:Case series; Level of evidence, 4.Methods:All consecutive patients who underwent revision of a failed Latarjet procedure with distal tibial allograft were prospectively enrolled. Patients were included if they had physical examination findings consistent with recurrent anterior shoulder instability. Patients were excluded if they had prior neurologic injury, a seizure disorder, bone graft requirements to the humeral head, or findings of multidirectional or posterior instability. History of shoulder instability was documented, including initial dislocation history, duration of instability, number of prior surgeries, examination findings, plain radiographic and computed tomography (CT) data, and arthritis graded with Samilson and Prieto (SP) classification. All patients were treated with hardware removal, capsular release with subsequent repair, and fresh distal tibial allograft to the glenoid. Outcomes before and after revision were assessed according to the American Shoulder and Elbow Score (ASES), Single Assessment Numerical Evaluation (SANE), and Western Ontario Shoulder Index (WOSI) and statistically compared. All patients underwent a CT scan of the distal tibial allograft at a minimum 4 months after surgery.Results:There were 31 patients enrolled (all males), with a mean age of 25.5 years (range, 19-38 years) and a mean follow-up time of 47 months (range, 36-60 months) after revision with distal tibial allograft. Before distal tibial allograft augmentation, the mean percentage glenoid bone loss was 30.3% (range, 25%-49%). All patients after their Latarjet stabilization had recurrent shoulder dislocation (11/31, 35.5%) or subluxation (20/31, 64.5%), and all patients had symptoms consistent with recurrent shoulder instability upon physical examination. Radiographs demonstrated 2 fixation screws in all cases, mean SP grade was 0.5 (range, 0-3), and CT scans revealed that a mean 78% of the Latarjet coracoid graft had resorbed (range, 37%-100%). Patient-reported outcome scores improved significantly pre- to postoperatively for ASES (40 to 92, P = .001), SANE (44 to 91, P = .001), and WOSI (1300 to 310, P = .001). There were no cases of recurrence, and a final CT scan of the distal tibial revision demonstrated a complete union at the glenoid–distal tibial allograft interface in 92% of patients.Conclusion:The majority of the failed Latarjet procedures included in this study had near-complete resorption of the coracoid graft and hardware complications. At a minimum follow-up time of 36 months, patients who underwent revision treatment for a failed Latarjet procedure with a fresh distal tibial allograft demonstrated excellent clinical outcomes and near-complete osseous union at the glenoid-allograft interface. Although patients evaluated with recurrent anterior shoulder instability after a failed Latarjet procedure remain a challenge to address, fresh distal tibial allograft augmentation is a viable and highly effective revision procedure to treat this patient population.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-09-09T05:24:29Z
      DOI: 10.1177/0363546519871896
       
  • Relationship Between Glenohumeral Internal Rotation Deficit and Medial
           Elbow Torque in High School Baseball Pitchers
    • Authors: D. Grace Smith, Alexander J. Swantek, Caleb M. Gulledge, Vincent A. Lizzio, Angel Bermudez, Brian M. Schulz, Eric C. Makhni
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Alterations in throwing mechanics have been identified as a risk factor for overuse injuries in baseball players. Glenohumeral internal rotation deficit (GIRD) has been found to adversely affect throwing mechanics, but the effect of GIRD on medial elbow torque is unclear.Purpose:To investigate the relationship between GIRD and medial elbow torque in high school–aged baseball pitchers.Study Design:Descriptive laboratory study.Methods:High school baseball pitchers (14-18 years old) were recruited for participation in this study. Players’ height, weight, body mass index, and arm measurements were recorded as well as shoulder and elbow range of motion measurements. GIRD was calculated from the difference between dominant and nondominant shoulder internal rotation. Participants then pitched 5 fastballs at maximum effort while wearing a wireless sensor that recorded elbow torque, arm slot, arm speed, shoulder rotation, and ball velocity. Principal component analysis was performed to determine which variables were associated with elbow torque or ball velocity.Results:Twenty-three high school pitchers participated in this study; 35% (n = 8) of participants exhibited GIRD of at least 20°. The mean GIRD was 15.3°± 11.2° and was not a predictor of medial elbow torque (P = .205) or ball velocity (P = .333). Ball velocity, age, and height were predictors of medial elbow torque (P = .012, P = .003, and P = .024, respectively).Conclusion:In high school baseball pitchers, GIRD was not associated with medial elbow torque during the pitching motion. Instead, ball velocity, player age, and player height carried greater significance.Clinical Relevance:This study suggests that high school pitchers with GIRD do not have an inherently greater risk for increased medial elbow torque during the throwing motion. It is recommended that pitchers instead assess their ball velocity to evaluate for relative differences in medial elbow torque.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-09-09T05:13:07Z
      DOI: 10.1177/0363546519868939
       
  • Prevalence of and Risk Factors for Total Hip and Knee Replacement in
           Retired National Football League Athletes
    • Authors: Madeleine A.M. Davies, Zachary Y. Kerr, J.D. DeFreese, Nigel K. Arden, Stephen W. Marshall, Kevin M. Guskiewicz, Darin A. Padua, Brian Pietrosimone
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Osteoarthritis is a substantial cause of disability. Joint replacement prevalence relates to the burden of severe osteoarthritis, and identifying risk factors for end-stage disease may indicate intervention opportunities. American football has high youth and elite participation, and determining risk factors for severe osteoarthritis may support future morbidity prevention.Purpose:To (1) determine the prevalence of hip and knee replacement in retired National Football League (NFL) athletes, (2) examine risk factors for replacement, and (3) identify the association between knee injuries and knee replacement.Study Design:Case-control study; Level of evidence, 3.Methods:Retired NFL athletes who participated in a general health survey were included. This historical cohort included those playing between 1929 and 2001. The association between self-reported playing or injury history, and replacement after retirement, was assessed with prevalence ratios (PRs). Models were adjusted for potential confounders of age and weight.Results:Data for 2432 retired male NFL players (69.3% response rate) who had participated in football for a mean 15.2 years were included, in which 277 players reported replacement after retirement (11.4%). More participants reported knee replacement (7.7%) than hip replacement (4.6%). The majority of participants reported previous severe knee injury (53%), and the most prevalent was meniscal tear (32.2%). In multivariable models, age (10-year increase, PR, 2.23; 95% CI, 1.99-2.51), current weight (PR, 1.10; 95% CI, 1.06-1.14), and reporting 1 (PR, 1.78; 95% CI, 1.14-2.77), 2 (PR, 1.91; 95% CI, 1.16-3.15), or ≥3 knee injuries (PR, 3.44; 95% CI, 2.33-5.09) were associated with knee replacement. Age (10-year increase, PR, 1.86; 95% CI, 1.59-2.18), linemen (PR, 1.62; 95% CI, 1.03-2.55), and reporting 1 (PR, 1.72; 95% CI, 1.05-2.80), 2 (PR, 2.77 95% CI, 1.58-4.84), or ≥3 (PR, 2.44; 95% CI, 1.52-3.91) hip injuries were associated with hip replacement. Each reported knee injury type was cross-sectionally associated with replacement after retirement (P < .05).Conclusion:Knee replacement was more prevalent than hip replacement. Risk factors differed between the hip and the knee, with age and severe joint injury associated with hip and knee replacement, weight with knee replacement, and playing position associated with hip replacement. Joint injury and weight management may be prevention opportunities to reduce morbidity and end-stage osteoarthritis in this population.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-09-09T05:01:05Z
      DOI: 10.1177/0363546519870804
       
  • The “Outside-In” Lesion of Hip Impingement and the “Inside-Out”
           Lesion of Hip Dysplasia: Two Distinct Patterns of Acetabular Chondral
           Injury
    • Authors: Matthew J. Kraeutler, Jesse A. Goodrich, Matthew J. Fioravanti, Tigran Garabekyan, Omer Mei-Dan
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Femoroacetabular impingement (FAI) and acetabular dysplasia lead to acetabular cartilage damage that commonly results in the chondral flaps seen during hip arthroscopy.Purpose:To compare the acetabular chondral flap morphology seen during hip arthroscopy (“outside-in” vs “inside-out”) with clinical and radiographic parameters underlying FAI and hip dysplasia.Study Design:Cohort study; Level of evidence, 3.Methods:Patients who underwent hip arthroscopy by the senior author between 2013 and 2017 with a finding of Outerbridge grade IV acetabular chondral flap were included. Each procedure was retrospectively reviewed on video and chondral flaps were categorized as inside-out or outside-in. An inside-out designation was made for flaps exhibiting an intact chondrolabral junction with a detached sleeve of chondrolabral tissue from the central acetabulum, and an outside-in designation was made for centrally anchored flaps exhibiting a break in the chondrolabral junction. Radiographic markers of hip impingement/dysplasia were noted for each patient during assignment into 1 of 2 radiographic groups: group 1, lateral center edge angle (LCEA)>20 with FAI, and group 2, LCEA ≤20 with or without cam FAI. Associations between chondral flap morphology and clinical diagnosis were tested using a chi-square test.Results:Overall, 95 patients (103 hips) were included (group 1, 78 hips; group 2, 25 hips). Among hips in group 2, 24 had concurrent cam FAI. There was a significant relationship between chondral flap type and radiographic diagnosis (P < .001). Among group 1 hips, 78% exhibited outside-in type chondral flaps, 12% exhibited combined outside-in and inside-out flaps, and 10% exhibited inside-out flaps. Group 2 hips showed 72% inside-out type chondral flaps, 16% combined, and 12% outside-in. Hips exhibiting outside-in type flaps were significantly more likely to be in group 1 (positive predictive value [PPV], 91%; negative predictive value [NPV], 69%). Similarly, hips exhibiting inside-out type flaps were significantly more likely to be in group 2 (PPV, 56%; NPV, 95%). Altogether, 90% of group 1 hips exhibited an outside-in lesion and 88% of group 2 hips exhibited an inside-out lesion.Conclusion:Acetabular chondral flap type visualized during hip arthroscopy correlates with radiographic markers of hip impingement and hip instability. Outside-in flaps are highly predictive of FAI, whereas inside-out flaps are highly predictive of acetabular dysplasia.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-09-06T04:50:34Z
      DOI: 10.1177/0363546519871065
       
  • Patient-Specific 3-D Magnetic Resonance Imaging–Based Dynamic Simulation
           of Hip Impingement and Range of Motion Can Replace 3-D Computed
           Tomography–Based Simulation for Patients With Femoroacetabular
           Impingement: Implications for Planning Open Hip Preservation Surgery and
           Hip Arthroscopy
    • Authors: Till D. Lerch, Celia Degonda, Florian Schmaranzer, Inga Todorski, Jennifer Cullmann-Bastian, Guoyan Zheng, Klaus A. Siebenrock, Moritz Tannast
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Femoroacetabular impingement (FAI) is a complex 3-dimensional (3D) hip abnormality that can cause hip pain and osteoarthritis in young and active patients of childbearing age. Imaging is static and based on 2-dimensional radiographs or computed tomography (CT) scans. Recently, CT-based 3D impingement simulation was introduced for patient-specific assessments of hip deformities, whereas magnetic resonance imaging (MRI) offers a radiation-free alternative for surgical planning before hip arthroscopic surgery.Purpose:To (1) investigate the difference between 3D models of the hip, (2) correlate the location of hip impingement and range of motion (ROM), and (3) correlate diagnostic parameters while comparing CT- and MRI-based osseous 3D models of the hip in symptomatic patients with FAI.Study Design:Cohort study (Diagnosis); Level of evidence, 2.Methods:The authors performed an institutional review board–approved comparative and retrospective study of 31 hips in 26 symptomatic patients with FAI. We compared CT- and MRI-based osseous 3D models of the hip in the same patients. 3D CT scans (slice thickness, 1 mm) of the entire pelvis and the distal femoral condyles were obtained. Preoperative MRI of the hip was performed including an axial-oblique T1 VIBE sequence (slice thickness, 1 mm) and 2 axial anisotropic (1.2 × 1.2 × 1 mm) T1 VIBE Dixon sequences of the entire pelvis and the distal femoral condyles. Threshold-based semiautomatic reconstruction of 3D models was performed using commercial software. CT- and MRI-based 3D models were compared with specifically developed software.Results:(1) The difference between MRI- and CT-based 3D models was less than 1 mm for the proximal femur and the acetabulum (median surface distance, 0.4 ± 0.1 mm and 0.4 ± 0.2 mm, respectively). (2) The correlation for ROM values was excellent (r = 0.99, P < .001) between CT and MRI. The mean absolute difference for flexion and extension was 1.9°± 1.5° and 2.6°± 1.9°, respectively. The location of impingement did not differ between CT- and MRI-based 3D ROM analysis in all 12 of 12 acetabular and 11 of 12 femoral clock-face positions. (3) The correlation for 6 diagnostic parameters was excellent (r = 0.98, P < .001) between CT and MRI. The mean absolute difference for inclination and anteversion was 2.0°± 1.8° and 1.0°± 0.8°, respectively.Conclusion:Patient-specific and radiation-free MRI-based dynamic 3D simulation of hip impingement and ROM can replace CT-based 3D simulation for patients with FAI of childbearing age. On the basis of these excellent results, we intend to change our clinical practice, and we will use MRI-based 3D models for future clinical practice instead of CT-based 3D models. This allows radiation-free and patient-specific preoperative 3D impingement simulation for surgical planning and simulation of open hip preservation surgery and hip arthroscopic surgery.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-09-05T03:36:32Z
      DOI: 10.1177/0363546519869681
       
  • Optimal Outcomes for Acute Avulsion Fracture of the Achilles Tendon
           Treated With the Insertional Reattachment Technique: A Case Series of 31
           Cases With Over 2 Years of Follow-up
    • Authors: Yanbin Pi, Yuelin Hu, Chen Jiao, Yingfang Ao, Qinwei Guo
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Avulsion fracture of the Achilles tendon is a less common but debilitating disorder. There is a paucity of literature on this problem.Purpose:To present a retrospective case series assessing the clinical outcomes of avulsion fracture of the Achilles tendon after a reattachment procedure and to identify potential factors predicting postoperative outcomes.Study Design:Case series; Level of evidence, 4.Methods:A consecutive case series of 35 patients with acute insertional rupture of the Achilles tendon who received a reattachment procedure between 2011 and 2017 were reviewed. All patients were measured and classified by magnetic resonance imaging (MRI) and surgical findings. Patient-reported outcomes were evaluated using the visual analog scale (VAS) for pain, American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot Scale, Foot Function Index (FFI), Tegner score, and Ankle Activity Score (AAS). The range of motion and single-legged heel raise test were also conducted for both ankles.Results:Thirty-one out of 35 (88.57%) patients were followed up for an average of 43.65 months. The VAS pain score and AOFAS Ankle-Hindfoot score improved from 4.87 ± 1.61 preoperatively to 2.07 ± 1.57 postoperatively and from 58.32 ± 18.66 preoperatively to 87.32 ± 7.53 postoperatively, respectively (both P < .001). The mean FFI, AAS, and Tegner scores after the operation were 11.84 ± 1.62, 5.71 ± 2.18, and 4.61 ± 1.31, respectively. Compared with the intact ankle, the mean deficit in dorsiflexion in the involved ankle was 9.54°± 6.25° (range, 0.59°-23.70°; P < .001) and the mean deficit in plantarflexion in the involved ankle was 6.31°± 4.02° (range, 0.24°-14.92°; P < .001). Thirty patients could perform the single-legged heel raise on the operative leg. A larger body mass index was associated with worse postoperative AOFAS and FFI outcomes. Longer follow-up predicted statistically significantly better FFI scores. Better postoperative dorsiflexion was associated with better postoperative FFI, AAS, and Tegner scores, and a statistically significant interaction was found between the VAS score and plantarflexion deficit. Age, preoperative insertional tenderness, Haglund deformity, and MRI classification showed little association with postoperative outcomes.Conclusion:This study demonstrated that the reattachment procedure for acute avulsion fracture of the Achilles tendon can achieve firm fixation and promising outcomes.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-09-04T12:41:16Z
      DOI: 10.1177/0363546519869952
       
  • Exposure to American Football and Neuropsychiatric Health in Former
           National Football League Players: Findings From the Football Players
           Health Study
    • Authors: Andrea L. Roberts, Alvaro Pascual-Leone, Frank E. Speizer, Ross D. Zafonte, Aaron L. Baggish, Herman Taylor, Lee M. Nadler, Ann Connor, Rachel Grashow, Alexandra M. Stillman, Dean A. Marengi, Marc G. Weisskopf, Theodore K. Courtney
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Former American football players have a higher prevalence of cognitive impairment than that of the US general population. It remains unknown what aspects of playing football are associated with neuropsychiatric outcomes.Hypothesis:It was hypothesized that seasons of professional football, playing position, and experience of concussions were associated with cognition-related quality of life (QOL) and indicators of depression and anxiety.Study Design:Descriptive epidemiology study.Methods:The authors examined whether seasons of professional football, playing position, and experience of concussions, as measured by self-report of 10 symptoms, were associated with cognition-related QOL and indicators of depression and anxiety in a cross-sectional survey conducted 2015 to 2017. Cognition-related QOL was measured by the short form of the Quality of Life in Neurological Disorders: Applied Cognition–General Concerns. The Patient Health Questionnaire–4 measured depression and anxiety symptoms. Of 13,720 eligible men with apparently valid contact information, 3506 players returned a questionnaire at the time of this analysis (response rate = 25.6%).Results:Seasons of professional play (risk ratio [RR] per 5 seasons = 1.19, 95% CI = 1.06-1.34) and playing position were associated with cognition-related QOL. Each 5 seasons of play was associated with 9% increased risk of indicators of depression at borderline statistical significance (P = .05). When compared with former kickers, punters, and quarterbacks, men who played any other position had a higher risk of poor cognition-related QOL, depression, and anxiety. Concussion symptoms were strongly associated with poor cognition-related QOL (highest concussion quartile, RR = 22.3, P < .001), depression (highest quartile, RR = 6.0, P < .0001), and anxiety (highest quartile, RR = 6.4, P < .0001), even 20 years after last professional play.Conclusion:The data suggest that seasons of play and playing position in the NFL are associated with lasting neuropsychiatric health deficits. Additionally, poor cognition-related QOL, depression, and anxiety appear to be associated with concussion in the long term.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-08-30T12:00:01Z
      DOI: 10.1177/0363546519868989
       
  • Outcomes More Than 2 Years After Meniscal Repair for Radial/Flap Tears of
           the Posterior Lateral Meniscus Combined With Anterior Cruciate Ligament
           Reconstruction
    • Authors: Akira Tsujii, Yasukazu Yonetani, Kazutaka Kinugasa, Tomohiko Matsuo, Kenji Yoneda, Tomoki Ohori, Masayuki Hamada
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Meniscal function after repair of radial/flap tears of the posterior horn of the lateral meniscus (LM) with anterior cruciate ligament reconstruction (ACLR) has not been comprehensively investigated.Purpose:To evaluate not only the clinical and radiographic outcomes of patients with repair of radial/flap tears of the posterior LM with ACLR but also the healing status of the repaired meniscus and changes of chondral status with second-look arthroscopy.Study Design:Case series; Level of evidence, 4.Methods:From January 2008 to April 2016, 41 patients of a consecutive series of 505 primary anatomic ACLR cases had a concomitant radial/flap tear of the posterior horn of the LM and underwent side-to-side repair with an inside-out or all-inside technique. All patients were followed for>2 years, evaluated clinically and radiologically (radiograph and magnetic resonance imaging [MRI]), and compared with a control group without any concomitant injuries that underwent ACLR. Of the 41 patients, 30 were assessed by second-look arthroscopy 2 years postoperatively.Results:The mean follow-up times of the study and control groups were 3.4 and 3.9 years, respectively. The study group showed no significant differences in clinical findings, lateral joint space narrowing on radiograph, and coronal extrusion on MRI as compared with the control group, whereas sagittal extrusion on MRI progressed significantly in the study group (1.2 ± 1.5 mm vs 0.32 ± 1.0 mm, P < .001). Eighteen patients (60%) obtained complete healing; 9 (30%) showed partial healing; and 3 (10%) failed to heal on second-look arthroscopy. Changes of chondral status in the femoral condyle showed no significant difference between the groups (P = .29). However, chondral status of the lateral tibial plateau worsened significantly in the study group (P = .0011).Conclusion:The clinical and radiographic outcomes after repair of radial/flap tears of the posterior horn of the LM as combined with anatomic ACLR were successful and comparable with those after isolated ACLR without any other injuries at a mean postoperative follow-up of 3.4 years, except for sagittal extrusion on MRI. Chondral lesions of the lateral tibial plateau deteriorated regardless of meniscal healing at 2 years postoperatively. Surgeons should keep in mind that chondral injuries might progress over the midterm.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-08-30T08:32:24Z
      DOI: 10.1177/0363546519869955
       
  • 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
       
  • The Ideal Location of the Lateral Hinge in Medial Closing Wedge Osteotomy
           of the Distal Femur: Analysis of Soft Tissue Coverage and Bone Density
    • Authors: Tae Woo Kim, Myung Chul Lee, Jae Ho Cho, Jong Seop Kim, Yong Seuk Lee
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Although an appropriate hinge position to prevent unstable lateral hinge fractures is well established in medial opening wedge high tibial osteotomy, the position during medial closing wedge distal femoral osteotomy has not been elucidated.Purpose/Hypothesis:The purpose was to evaluate the ideal hinge position that would prevent an unstable lateral hinge fracture during biplanar medial closing wedge distal femoral osteotomy based on soft tissue coverage and bone density around the hinge area. The hypothesis was that the ideal hinge position could be clarified by analyzing soft tissue coverage and bone density around the lateral hinge area.Study Design:Controlled laboratory study.Methods:In 20 cadaveric knees (mean age, 70.3 ± 19.2 years), the femoral attachment of the gastrocnemius lateral head was quantitatively analyzed as a soft tissue stabilizer using digital photography and fluoroscopy. Then, medial closing wedge distal femoral osteotomy was performed, locating the lateral hinge either inside (group 1) or outside (group 2) the femoral attachment of the gastrocnemius lateral head, and the incidence of unstable lateral hinge fractures was compared between the 2 groups. Cortical bone density around the lateral hinge was measured using Hounsfield units on 30 computed tomography scans and reconstructed as a 3-dimensional mapping model. The transitional zone with low bone density was regarded as the safe hinge position with an increased capacity for bone deformation.Results:The upper and lower margins of the femoral attachment of the gastrocnemius lateral head were 9.1 ± 0.9 mm above and 8.0 ± 1.4 mm below the upper border of the lateral femoral condyle, respectively, and the femoral attachment of the gastrocnemius lateral head was widest in the anteroposterior dimension 0.4 ± 1.7 mm above the upper border of the lateral femoral condyle. The incidence of unstable lateral hinge fractures during osteotomy was significantly decreased in group 1 compared with group 2 (group 1: 0/10; group 2: 5/10; P = .01). An isolated transitional zone with low bone density was observed in all 30 knees and located 1.3 ± 0.8 mm above the upper border of the lateral femoral condyle. Bone density of the transitional zone with low bone density was significantly lower than surrounding femoral cortices (P < .001).Conclusion:Only the upper border of the lateral femoral condyle can be recommended as an ideal hinge position to prevent unstable lateral hinge fractures during biplanar medial closing wedge distal femoral osteotomy based on soft tissue coverage and bone density.Clinical Relevance:When the hinge is positioned at the upper border of the lateral femoral condyle during biplanar medial closing wedge distal femoral osteotomy, the risk of unstable hinge fractures can be minimized.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-08-29T04:51:29Z
      DOI: 10.1177/0363546519869325
       
  • The Effectiveness of a Hinged Elbow Orthosis in Medial Collateral Ligament
           Injuries: An In Vitro Biomechanical Study
    • Authors: Ranita H.K. Manocha, James A. Johnson, Graham J.W. King
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Medial collateral ligament (MCL) injuries are common after elbow trauma and in overhead throwing athletes. A hinged elbow orthosis (HEO) is often used to protect the elbow from valgus stress early after injury and during early return to play. However, there is minimal evidence regarding the efficacy of these orthoses in controlling instability and their influence on long-term clinical outcomes.Purpose:(1) To quantify the effect of an HEO on elbow stability after simulated MCL injury. (2) To determine whether arm position, forearm rotation, and muscle activation influence the effectiveness of an HEO.Study Design:Controlled laboratory study.Methods:Seven cadaveric upper extremity specimens were tested in a custom simulator that enabled elbow motion via computer-controlled actuators and motors attached to relevant tendons. Specimens were examined in 2 arm positions (dependent, valgus) and 2 forearm positions (pronation, supination) during passive and simulated active elbow flexion while unbraced and then while braced with an HEO. Testing was performed in intact elbows and repeated after simulated MCL injury. An electromagnetic tracking device measured valgus angulation as an indicator of elbow stability.Results:When the arm was dependent, the HEO increased valgus angle with the forearm in pronation (+1.0°± 0.2°, P = .003) and supination (+1.5°± 0.0°, P = .006) during active motion. It had no significant effect on elbow stability during passive motion. In the valgus position, the HEO had no effect on elbow stability during passive or active motion in pronation and supination. With the arm in the valgus position with the HEO, muscle activation reduced instability during pronation (–10.3°± 2.5°, P = .006) but not supination (P = .61).Conclusion:In this in vitro study, this HEO did not enhance mechanical stability when the arm was in the valgus and dependent positions after MCL injury.Clinical Relevance:After MCL injury, an HEO likely does not provide mechanical elbow stability during rehabilitative exercises or when the elbow is subjected to valgus stress such as occurs during throwing.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-08-28T05:07:11Z
      DOI: 10.1177/0363546519870517
       
  • Professional Athletes Are at Higher Risk of Septic Arthritis After
           Anterior Cruciate Ligament Reconstruction: An Analysis of 4421 Consecutive
           Patients Including 265 Elite Athletes From the SANTI Study Group
    • Authors: Bertrand Sonnery-Cottet, Adnan Saithna, Felipe Galvão Abreu, Florent Franck, Guilherme Venturi de Abreu, Thais D. Vieira, Matthew Daggett, Charles Pioger
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Professional athletes are reported to be at greater risk of septic arthritis (SA) after anterior cruciate ligament reconstruction (ACLR) than the nonprofessional population. However, this finding has been controversial, and confusion has arisen in the literature owing to the underpowering of previous studies.Purpose/Hypothesis:The purpose was to report the differences in the rate of SA after ACLR in a large series of patients and to perform pooled data analysis including previously published studies. The hypothesis was that professional athletes have a significantly higher risk of SA than nonprofessional athletes.Study Design:Case-control study; Level of evidence, 3.Methods:A retrospective analysis of prospectively collected data was performed. Patients who underwent ACLR between January 2009 and July 2017 (with a minimum follow-up of 12 months) were considered for study eligibility. The rate of SA was determined, and multivariate analysis was used to evaluate potentially important risk factors, including participation in professional sport. Furthermore, a literature search was performed, and data were extracted from all identified relevant studies. A pooled data analysis was performed to determine differences in the risk of SA between professional and nonprofessional populations.Results:The current series comprised 4421 anterior cruciate ligament surgical procedures with 265 professional athletes. There were 15 cases of SA diagnosed over the study period (0.34%; 95% CI, 0.19%-0.56%). Ten cases occurred in professional athletes (3.8%; 95% CI, 1.82%-6.83%). The percentage of SA was 0.12% (95% CI, 0.04%-0.28%) in the nonprofessional population. Being a professional athlete was associated with a significantly increased risk of SA after ACLR (odds ratio, 21.038; 95% CI, 6.585-75.789; P < .0001). This finding was confirmed in the pooled data analysis comprising 11,416 patients including 1118 professional athletes (odds ratio, 5.03; 95% CI, 1.17-21.61).Conclusion:Professional athletes are at greater risk of SA after ACLR than nonprofessional athletes. The results of previous studies may have been conflicting owing to underpowering. The current study confirms the elevated risk by using a large clinical series and pooled data analysis to avoid the limitations of previous studies.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-08-28T04:51:32Z
      DOI: 10.1177/0363546519869326
       
  • Effects of Conditioned Medium From Osteoarthritic Cartilage Fragments on
           Donor-Matched Infrapatellar Fat Pad–Derived Mesenchymal Stromal Cells
    • Authors: Zhenlan Fu, Xiongbo Song, Lin Guo, Liu Yang, Cheng Chen
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Mesenchymal stromal cell (MSC)–based therapies have emerged as a promising strategy for osteoarthritis (OA) treatment. In particular, infrapatellar fat pad (IPFP)–derived MSCs have become a good option to treat knee OA.Purpose:To investigate the influence of the local microenvironment of the knee joint, especially OA cartilage, on the bioactivities of injected/implanted IPFP MSCs.Study Design:Controlled laboratory study.Methods:Conditioned medium (CM) derived from OA cartilage fragments was collected and characterized. Donor-matched IPFP MSCs were treated with control medium (Dulbecco’s modified Eagle medium (DMEM)/F-12 or chondrogenic medium), control medium + CM, or CM alone; and a series of behaviors including the viability, migration, chondrogenic and hypertrophic differentiation, and catabolic activity of IPFP MSCs were evaluated among groups.Results:There were 14 cytokines detected in CM. CM treatment improved the viability of IPFP MSCs. CM hindered the migration of IPFP MSCs. In chondrogenic differentiation, the presence of CM increased the expression of chondrogenic markers but also enhanced the state of hypertrophy and catabolism.Conclusion:OA cartilage–secreted factors could induce chondrogenic differentiation but also resulted in negative effects including the weakened migration, increased hypertrophy, and catabolism of IPFP MSCs in vitro.Clinical Relevance:These findings provide an insight on the fate of IPFP MSCs after intra-articular injections.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-08-28T04:36:54Z
      DOI: 10.1177/0363546519869241
       
  • Posteromedial Ligament Repair of the Knee With Suture Tape Augmentation: A
           Biomechanical Study
    • Authors: Julian T. Mehl, Cameron Kia, Matthew Murphy, Elifho Obopilwe, Mark Cote, Florian B. Imhoff, Andreas B. Imhoff, Robert A. Arciero, Knut Beitzel, Alexander Otto
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:In cases of acute combined posteromedial and anterior cruciate ligament (ACL) injuries, primary repair of the superficial medial collateral ligament (sMCL) and posterior oblique ligament (POL) with suture tape augmentation may be a reasonable alternative to standard tendon reconstruction techniques.Purpose/Hypothesis:The purpose was to examine the rotational and valgus laxity with ACL strain following sMCL and POL repair with suture tape augmentation at various degrees of knee flexion. It was hypothesized that this technique would restore knee laxity and kinematics comparable with those of the intact state.Study Design:Controlled laboratory study.Methods:Ten cadaveric knee specimens (mean ± SD, 57.9 ± 5.9 years) were obtained. Specimens were tested with the tibia fixed and the femur mobile on an X-Y table. Each specimen was tested in 4 conditions according to the state of the sMCL and POL: native, deficient, repaired with suture tape augmentation, and reconstructed with tendon allografts. Valgus laxity was tested with 40-N force applied in the lateral direction of the femur, and rotational motion was tested with 5-N torque applied to the tibia. ACL strain during valgus stress was also measured. Each condition was tested in 0°, 15°, 30°, 45°, and 60° of knee flexion.Results:Dissection of the sMCL and POL led to significantly increased valgus laxity in all flexion angles, with a significant increase in ACL strain at 30° (P < .001) and 45° (P < .001). Ligament repair with suture tape augmentation demonstrated similar valgus and rotational laxity as compared with intact specimens, with the exception of increased internal rotation at 30° (P = .005). Ligament reconstruction resulted in significantly increased valgus opening at 45° (P = .048) and significantly increased internal rotation at 30° (P < .001) as compared with the native state. Direct comparison between surgical techniques showed no significant differences.Conclusion:At time zero, ligament repair of the posteromedial knee with suture tape augmentation restored close-to-native valgus and rotatory laxity, as well as native ACL strain for cases of complete sMCL and POL avulsion.Clinical Relevance:Ligament repair of the sMCL and POL with suture tape augmentation may be a reasonable alternative to tendon reconstruction techniques in cases of acute combined posteromedial and ACL injuries with valgus and rotatory instability.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-08-27T05:30:21Z
      DOI: 10.1177/0363546519868961
       
  • Bone-Plug Versus Soft Tissue Fixation of Medial Meniscal Allograft
           Transplants: A Biomechanical Study
    • Authors: Luiz Felipe Ambra, Alexandre Barbieri Mestriner, Jakob Ackermann, Amy T. Phan, Jack Farr, Andreas H. Gomoll
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:It is controversial whether soft tissue fixation only and bone-plug techniques for medial meniscal allograft transplantation provide equivalent fixation and restoration of load distribution. Prior studies on this topic did not re-create the clinical situation with use of size-, side-, and compartment-matched meniscal transplants.Hypothesis:Both techniques will provide equivalent fixation of the meniscal transplant and restore load distribution and contact pressures similar to those of the native knee.Study Design:Controlled laboratory study.Methods:Nine fresh-frozen human cadaveric knees underwent mean contact pressure, mean contact area, and peak contact pressure evaluation in 4 medial meniscal testing conditions (native, total meniscectomy, bone-plug fixation, and soft tissue fixation) at 3 flexion angles (0°, 30°, and 60°) using Tekscan sensors under a 700-N axial load.Results:Medial meniscectomy resulted in significantly decreased contact area and increased contact pressure compared with the native condition at all flexion angles (P < .0001). Compared with the native state, soft tissue fixation demonstrated significantly higher mean contact pressure and lower mean contact area at 0° and 30° of flexion (P < .05), while bone-plug fixation showed no significant difference. There was no significant difference in peak contact pressure between study conditions.Conclusion:Total medial meniscectomy leads to significantly worsened load distribution within the knee. Medial meniscal allograft transplantation can restore load parameters close to those of the native condition. The bone-plug technique demonstrated improved tibiofemoral contact pressures compared with soft tissue fixation.Clinical Relevance:Medial meniscal allograft transplantation with bone-plug fixation is a viable option to restore biomechanics in patients with meniscal deficiency.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-08-27T05:08:54Z
      DOI: 10.1177/0363546519870179
       
  • The Kaplan Fibers of the Iliotibial Band Can Be Identified on Routine Knee
           Magnetic Resonance Imaging
    • Authors: Lachlan Batty, Jerome Murgier, Richard O’Sullivan, Kate E. Webster, Julian A. Feller, Brian M. Devitt
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:The Kaplan fibers (KFs) of the iliotibial band have been suggested to play a role in anterolateral rotational instability of the knee, particularly in the setting of an anterior cruciate ligament (ACL) rupture. Description of the normal magnetic resonance imaging (MRI) anatomy of the KFs may facilitate subsequent investigation into the MRI signs of injury.Purpose:To assess if the KF complex can be identified on 3-T MRI using standard knee protocols.Study Design:Cohort study (diagnosis); Level of evidence, 3.Methods:3-T MRI scans of 50 ACL-intact knees were reviewed independently by a musculoskeletal radiologist and 2 orthopaedic surgeons. Identification of the KFs was based on radiological diagnostic criteria developed a priori. Identification of the KFs in the sagittal, coronal, and axial planes was recorded. Interobserver reliability was assessed using the Kappa statistic. Detailed anatomy including distance to the joint line and relationship to adjacent structures was recorded.Results:The mean patient age was 43 years (range, 15-81 years), 58% were male, and 50% were right knees. The KFs were identified by at least 2 reviewers on the sagittal images in 96% of cases, on the axial images in 76% of cases, and on the coronal images in 4% of cases. The mean distance from the KF distal femoral insertion to the lateral joint line was 50.1 mm (SD, 6.6 mm) and the mean distance to the lateral gastrocnemius tendon origin was 10.8 mm (SD, 8.6 mm). The KFs were consistently identified immediately anterior to the superior lateral geniculate artery on sagittal imaging. Interobserver reliability for identification was best in the sagittal plane (Kappa 0.5) and worst in the coronal plane (Kappa 0.1).Conclusion:The KF complex can be identified on routine MRI sequences in the ACL-intact knee; however, there is low to moderate interobserver reliability. Imaging in the sagittal plane had the highest rate of identification and the coronal plane the lowest. There is a consistent relationship between the most distal KF femoral attachment and the lateral joint line, lateral gastrocnemius tendon, and superior lateral geniculate artery.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-08-21T10:36:36Z
      DOI: 10.1177/0363546519868219
       
  • Increased Chondrocytic Gene Expression Is Associated With Improved Repair
           Tissue Quality and Graft Survival in Patients After Autologous Chondrocyte
           Implantation
    • Authors: Jakob Ackermann, Gergo Merkely, Alexandre Barbieri Mestriner, Nehal Shah, Andreas H. Gomoll
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Assays to quantitate the quality of autologous chondrocyte implants have recently become available. However, the correlation of the assay score with radiological and clinical outcomes has not been established.Purpose/Hypothesis:The purpose was to assess the influence of cell identity (chondrocyte/synoviocyte gene expression ratio) and viability on patient-reported outcome measures, graft survival, and repair tissue quality. It was hypothesized that greater cell product quality as assessed through an identity assay and cell viability is associated with superior outcomes after autologous chondrocyte implantation (ACI) for symptomatic cartilage defects.Study Design:Cohort study; Level of evidence, 3.Methods:Seventy-nine patients with a minimum follow-up of 2 years were included in this study. Of these, 67 patients were available for imaging assessment utilizing the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) scoring system. Patients were assigned to groups either below or above the cohort’s mean based on their individual cell identity score and viability percentage.Results:Patients were predominantly female (57.7%) with a mean age of 30.0 ± 9.3 years. No differences were seen between Knee injury and Osteoarthritis Outcome Score, Lysholm, Tegner, or International Knee Documentation Committee Subjective Knee Evaluation Form within the viability and cell identity groups at a final follow-up of 3.8 ± 1.4 years after ACI (P> .05). In a subset of patients, the mean MOCART score was 68.3 ± 15.6 at an average magnetic resonance imaging follow-up of 17.7 ± 9.56 months. Low cell identity was significantly associated with the degree of defect filling (P = .025), integration of border zone (P = .01), effusion (P = .024), and ACI graft failure (P = .002). Patients with above-average cell identity scores had a significantly higher survival rate at 5-year follow-up compared with patients with below-average scores (95.8% vs 64.7%; P = .013). Cell viability did not influence MOCART subscales or graft failure (all P> .05). Cell viability and identity showed no significant correlation with each other (r = −0.045; P = .694).Conclusion:Cell identity was significantly correlated with structural repair quality and graft survival after second-generation ACI for symptomatic chondral lesions in the knee. While improved imaging outcome and higher graft survivorship were associated with a higher individual cell identity score indicating a higher chondrocyte/synoviocyte gene expression ratio in the final cell product, clinical outcome did not correlate with the identity score.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-08-21T07:46:15Z
      DOI: 10.1177/0363546519868213
       
  • Equivalent 10-Year Outcomes After Implantation of Autologous Bone
           Marrow–Derived Mesenchymal Stem Cells Versus Autologous Chondrocyte
           Implantation for Chondral Defects of the Knee
    • Authors: Alex Quok An Teo, Keng Lin Wong, Liang Shen, Jia Ying Lim, Wei Seong Toh, Eng Hin Lee, James Hoi Po Hui
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:The use of bone marrow–derived mesenchymal stem cells (BMSCs) in cartilage repair procedures circumvents some of the limitations of autologous chondrocyte implantation (ACI), but long-term outcomes for this newer procedure are lacking. The authors previously reported comparable outcomes for the 2 procedures at 2-year follow-up.Purpose/Hypothesis:The purpose was to compare the long-term clinical outcomes of ACI versus BMSCs. It was hypothesized that there would be no significant difference between the groups in terms of patient-reported outcome scores and safety outcomes at 10-year follow-up.Study Design:Cohort study; Level of evidence, 2.Methods:Seventy-two patients who underwent either ACI or BMSC implantation—matched in terms of age and lesion site— were followed up to a median of at least 10 years. Patients were assessed with the 36-item Short Form Health Survey (SF-36), the International Knee Documentation Committee knee evaluation form, the Lysholm Knee Score, and the Tegner Activity Scale. In addition, information was obtained regarding any additional surgical procedures as well as safety data, with particular attention to infection and tumor formation.Results:There was an improvement in all patient-reported outcomes scores apart from the Mental Component Summary of the SF-36 after cartilage repair surgery. There was no significant difference in any of the patient-reported outcomes between cohorts at any time point. Six and 5 patients in the ACI and BMSC groups, respectively, underwent subsequent surgical procedures, including 1 total knee replacement in the BMSC group. None of the patients in either group developed any deep infection or tumor within the follow-up period.Conclusion:BMSC implantation used for the treatment of chondral defects of the knee appears to result in equivalent clinical outcomes to first-generation ACI at up to 10 years, with no apparent increased tumor formation risk.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-08-21T06:39:20Z
      DOI: 10.1177/0363546519867933
       
  • The Number of Injury Events Associated With the Critical Size of Bipolar
           Bone Defects in Rugby Players With Traumatic Anterior Shoulder Instability
           
    • Authors: Yoshinori Hasegawa, Takayuki Kawasaki, Shuko Nojiri, Shogo Sobue, Takefumi Kaketa, Yoshinori Gonda, Yoshiaki Itoigawa, Kazuo Kaneko
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:The size of a glenoid bone defect is responsible for reduction in shoulder stability and is correlated with the number of instability events. Biomechanical studies have suggested that it should be considered concomitantly with the Hill-Sachs lesion as “bipolar” bone defects for assessing structural degradation, but the definitive number of instability events associated with the critical size has not been investigated.Purpose:To (1) confirm that the number of instability events is the predictor of a critical size of bipolar bone defects and (2) demonstrate the cutoff value of the number of instability events for these defects in rugby players with traumatic anterior shoulder instability.Study Design:Cross-sectional study; Level of evidence, 3.Methods:One-hundred forty-four rugby players with anterior shoulder instability underwent morphologic evaluation for glenoid and Hill-Sachs lesions by computed tomography and determination of the critical (a glenoid bone defect of ≥25% or an off-track Hill-Sachs lesion) and subcritical (a glenoid bone defect of ≥13.5%) size of bipolar bone defects. In the primary analysis, the prevalence of the critical and subcritical size of bipolar bone defects was investigated. In the secondary analysis, the authors explored the predictors for these bone defects and determined the cutoff value correlating with the critical and subcritical size of bipolar bone defects by applying receiver operating characteristic curves.Results:The primary analysis revealed that the prevalence of critical and subcritical size of bipolar bone defects was 20.8% and 61.8% of 144 shoulders, respectively. In the secondary analysis, multiple logistic regression analysis demonstrated that the total number of shoulder instability events and dominant shoulder were the significant factors associated with the critical and subcritical size of bipolar bone defects. The cutoff value for the number of instability events that correlated with critical bipolar bone defects was 6 for the dominant and 9 for the nondominant shoulder, whereas it was 4 for the dominant and 5 for the nondominant shoulder for subcritical bipolar bone defects.Conclusion:The number of shoulder instability events and the dominant shoulder were the predictors for the critical and subcritical size of bipolar bone defects for a shoulder with traumatic instability. Four injury events should herald caution when treating rugby players with shoulder instability.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-08-19T11:11:19Z
      DOI: 10.1177/0363546519869673
       
  • The Association Among Trunk Rotation, Ball Velocity, and the Elbow Varus
           Moment in Collegiate-Level Baseball Pitchers
    • Authors: Andrew D. Cohen, Erin J. Garibay, Matthew J. Solomito
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:The incidence of upper extremity injuries in baseball pitchers is increasing. Over the past decade, research has attempted to elucidate the cause of these injuries, focusing mainly on pitching arm mechanics with little examination of other important segments, such as the trunk. This is surprising, as trunk motion has been shown to have significant effects on pitching mechanics.Purpose:To determine the associations between trunk rotation, ball velocity, and the moments about the elbow joint.Study Design:Descriptive laboratory study.Methods:Data collected using 3-dimensional motion analysis techniques from 99 collegiate pitchers (18.0-24.8 years) were analyzed. A random intercept mixed-effects regression model was used to determine if significant associations existed between trunk rotation and ball velocity or elbow varus moment.Results:Significant associations were found between trunk rotation angle at ball release and elbow varus moment (P = .019, β = 0.254) as well as ball velocity (P = .016, β = 0.060). For every 10° increase over the average trunk rotation angle at ball release, the elbow varus moment increased by 2.54 N·m and the ball velocity increased by 0.60 m/s. Additionally, the maximum rotational velocity of the trunk was positively associated with elbow varus moment (P < .001, β = 0.029) and ball velocity (P < .001, β = 0.007). For every 100 deg/s increase over the average maximum rotational velocity of the trunk, the elbow varus moment increased by 2.90 N·m and the ball velocity increased by 0.70 m/s.Conclusion:In collegiate pitchers, trunk rotation angle at ball release was significantly associated with ball velocity and elbow varus moment. Also, an increase in maximum rotational velocity of the trunk was significantly associated with an increase in the ball velocity and elbow varus moment. This work demonstrates the importance of trunk mechanics in the kinetic chain of the pitch cycle.Clinical Relevance:Pitching coaches and trainers can use the results to stress the importance of trunk mechanics in pitching, specifically, combining adequate core function with increased trunk rotational velocity in an effort to increase pitching velocity without increasing elbow joint stress.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-08-19T05:15:46Z
      DOI: 10.1177/0363546519867934
       
  • Nonabsorbable Suture Knot on the Tendon Affects Rotator Cuff Healing: A
           Comparative Study of the Knots on Tendon and Bone in a Rat Model of
           Rotator Cuff Tear
    • Authors: Yucheng Sun, Jae-Man Kwak, Erica Kholinne, Jun Tan, Kyoung-Hwan Koh, In-Ho Jeon
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Nonabsorbable suture knots are usually used to link the tendon and bone during rotator cuff repair surgery. There are many variations in the arthroscopic knot-tying technique; however, the location of suture knot placement for rotator cuff healing has rarely been studied.Hypothesis:The authors compared the rotator cuff healing between knots tied on tendon and bone in a rotator cuff tear rat model. It has been hypothesized that knots can cause chronic inflammation and create the weakest link between tendon and bone, thus affecting rotator cuff healing.Study Design:Controlled laboratory study.Methods:Bilateral supraspinatus tenotomy and rotator cuff repair at the greater tuberosity were performed on 24 Wistar rats. Nonabsorbable surgical suture knots were made on the right supraspinatus tendon tissue and left humerus inferior to the greater tuberosity, respectively. Twelve rats each were sacrificed at 3 and 9 weeks. Six of the 12 rats were used for biomechanical testing and the remaining 6 for histologic evaluation.Results:The surgical knots placed on the bursal side of the tendon migrated to the articular side, as noted on gross observation in 22 of 24 samples. The knots on the tendon group showed significantly inferior tendon-bone integration and significantly inferior biomechanical results in terms of maximum load to failure and stiffness. An obvious chronic foreign body inflammatory reaction was found in the knots on the tendon group at 3 and 9 weeks. Furthermore, inferior bone-tendon interface regeneration and weakest link formation were obtained in the knots on the tendon group compared with those on the bone group.Conclusion:Nonabsorbable suture knots placed on the tendon migrate to the articular side, causing chronic inflammation and weakening tendon-bone healing, which may explain some retears after rotator cuff repair.Clinical Relevance:The present animal study suggests that it is not recommended in clinical practice to make several bulky nonabsorbable suture knots on the rotator cuff tendon during rotator cuff repair surgery. It may be better to tie the knots at the bone side or do knotless repair.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-08-14T09:30:47Z
      DOI: 10.1177/0363546519867928
       
  • Portal Placement and Biomechanical Performance of Endoscopic Proximal
           Hamstring Repair
    • Authors: Michael K. Ryan, David P. Beason, Glenn S. Fleisig, Benton A. Emblom
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Proximal hamstring tendon avulsions are debilitating and commonly cause pain, weakness, and functional limitations. Open surgical repair has been the standard, but improved endoscopic techniques have enabled proximal hamstring fixation with decreased risk of infection and numbness, without the morbidity of a large incision.Purpose/Hypothesis:To (1) describe pertinent anatomy surrounding the proximal hamstring origin in relation to 4 endoscopic portal sites and (2) test for biomechanical differences between open and endoscopic repair. It was hypothesized that (1) endoscopic proximal hamstring repair is efficacious with respect to commonly used portals and (2) there is no biomechanical difference between open and endoscopic techniques.Study Design:Descriptive and controlled laboratory study.Methods:Proximal hamstring ruptures were simulated endoscopically in 10 fresh-frozen human cadaveric pelvis specimens. Endoscopic repair was then completed on 1 limb from each specimen through 4 portals. After repair, each specimen was dissected in layers and measurements from portal tracts to pertinent anatomy were obtained. Open repair was performed on all contralateral limbs, followed by cyclical biomechanical tensile testing to failure of both the open and endoscopically repaired hamstring tendons to assess failure load and local tissue strain.Results:On average, no portal tract was closer than 2.0 cm to the sciatic nerve or inferior gluteal neurovascular bundle. Anatomic landmarks were identified that could improve the reproducibility and safety of the procedure. Biomechanical testing revealed no differences between the open and endoscopic repair techniques for any measured parameter.Conclusion:This study supports the safety and efficacy of endoscopic proximal hamstring repair through anatomic and biomechanical analyses and helps establish reproducible and recognizable landmarks that define a safe working zone.Clinical Relevance:This study maps the anatomic landscape of the proximal hamstring as encountered endoscopically and demonstrates equivalent biomechanical strength of endoscopic proximal hamstring repair, supporting this technique’s safety and efficacy.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-08-14T09:05:46Z
      DOI: 10.1177/0363546519866453
       
  • Influence of Risky Pathoanatomy and Demographic Factors on Clinical
           Outcomes After Isolated Medial Patellofemoral Ligament Reconstruction: A
           Regression Analysis
    • Authors: Laurie A. Hiemstra, Sarah A. Kerslake, Mark R. Lafave
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Multiple studies have demonstrated that a number of demographic and pathoanatomic characteristics are associated with patellofemoral instability, recurrence of instability, and less satisfactory results following medial patellofemoral ligament reconstruction (MPFL-R). Despite the growing volume of research, the relationship of risk factors to patient-reported outcome after MPFL-R is unclear.Purpose:To determine if certain pathoanatomic and demographic factors predict disease-specific quality-of-life outcome after isolated MPFL-R for symptomatic patellofemoral instability.Study Design:Cohort study; Level of evidence, 3.Methods:The study analyzed 224 isolated MPFL-Rs. Demographic data were collected, including age at first dislocation, sex, and presence of bilateral instability. Pathoanatomic risk factors included the presence of high-grade trochlear dysplasia, tibial tubercle–trochlear groove (TT-TG) distance, patella alta ratio, Beighton score, and patellar tilt. Other factors included femoral tunnel position accuracy and WARPS/STAID score. Descriptive analyses were conducted, followed by calculation of individual Spearman rank correlation coefficients for the predictor variables versus the Banff Patellofemoral Instability Instrument (BPII) scores. A multivariable regression with stepwise selection was employed to establish the final model predicting BPII score, with all significant variables for alpha ≤ .05 included in the final model.Results:The cohort of 224 patients included 66 (29.5%) males and 158 (70.5%) females, with a mean age of 24.1 years and a mean body mass index of 23.9 kg/m2. The mean age of first patellar dislocation was 15.7 years, and 41.4% of patients had bilateral instability. Pathoanatomic variables within the cohort included the following: high-grade trochlear dysplasia = 41%; mean TT-TG = 14.6 mm, with 16.8% of patients demonstrating a TT-TG ≥18 mm; mean Caton-Deschamps ratio = 1.09, with 22% of patients demonstrating a ratio ≥1.2; and positive Beighton score = 37.5%. The mean BPII score at postoperative 2 years was 67.1 out of 100. A stepwise elimination in the regression model demonstrated no statistically significant 3- or 2-way relationships. Assessment of individual variables indicated that bilateral symptoms (P = .004), higher age at first dislocation (P = .024), and femoral tunnel position>10 mm from the Schöttle point (P = .042) were statistically significant predictors of lower quality-of-life scores. The R2 value for the regression analysis model was 0.07.Conclusion:In this large cohort of patients undergoing isolated MPFL-R for symptomatic lateral patellofemoral instability, a multivariable forward stepwise regression demonstrated that bilateral symptoms, femoral tunnel position, and age at first dislocation were statistically significant predictors of lower postoperative BPII scores. No anatomic risk factors were predictive of quality-of-life outcome score 2 years after MPFL-R surgery. The R2 value indicated that there were many other important contributing factors affecting BPII outcome scores than those explored in this study.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-08-14T08:57:06Z
      DOI: 10.1177/0363546519866452
       
  • 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
       
  • 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
      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
       
  • 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
       
  • Return to Sport After Surgical Treatment for Anterior Shoulder
           Instability: A Systematic Review
    • Authors: Eoghan T. Hurley, Connor Montgomery, M. Shazil Jamal, Yoshiharu Shimozono, Zakariya Ali, Leo Pauzenberger, Hannan Mullett
      Abstract: The American Journal of Sports Medicine, Ahead of Print.

      Citation: The American Journal of Sports Medicine
      PubDate: 2019-04-30T07:44:38Z
      DOI: 10.1177/0363546519831005
       
  • 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
       
  • 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
      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
       
  • Rates of Adverse Outcomes and Revision Surgery After Anterior Cruciate
           Ligament Reconstruction: A Study of 104,255 Procedures Using the National
           Hospital Episode Statistics Database for England, UK
    • Authors: Simon G.F. Abram, Andrew Judge, David J. Beard, Andrew J. Price
      First page: 2533
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:After an anterior cruciate ligament (ACL) injury, ACL reconstruction is an elective procedure, and therefore, an understanding of the attributable risk from undergoing ACL reconstruction is necessary for patients to make a fully informed treatment decision.Purpose:To determine the absolute risk of adverse outcomes including reoperation after ACL reconstruction with comparison, where possible, to the rate of adverse events reported in the general population.Study Design:Descriptive epidemiology study.Methods:National hospital data on all ACL reconstructions performed in England between April 1, 1997, and March 31, 2017, were analyzed. Revision cases, bilateral procedures within 6 months, and cases with concurrent cartilage or multiple ligament surgery were excluded. The primary outcome was the occurrence of at least 1 serious complication (myocardial infarction, stroke, pulmonary embolism, infection requiring surgery, fasciotomy, neurovascular injury, or death) within 90 days. Additionally, 5-year rates of revision ACL reconstruction, contralateral ACL reconstruction, and meniscal surgery were investigated.Results:There were 133,270 ACL reconstructions performed, of which 104,255 were eligible for analysis. Within 90 days, serious complications occurred in 675 (0.65% [95% CI, 0.60-0.70]), including 494 reoperations for infections (0.47% [95% CI, 0.43-0.52]) and 129 for pulmonary embolism (0.12% [95% CI, 0.10-0.15]). Of 54,275 procedures with at least 5 years’ follow-up, 1746 (3.22% [95% CI, 3.07-3.37]) underwent revision ACL reconstruction in the same knee, 1553 underwent contralateral ACL reconstruction (2.86% [95% CI, 2.72-3.01]), and 340 underwent meniscal surgery (0.63% [95% CI, 0.56-0.70]). The overall risk of serious complications fell over time (adjusted odds ratio [OR], 0.96 per year [95% CI, 0.95-0.98]); however, older patients (adjusted OR, 1.11 per 5 years [95% CI, 1.07-1.16]) and patients with a greater modified Charlson Comorbidity Index (adjusted OR, 2.41 per 10 units [95% CI, 1.65-3.51]) were at a higher risk. For every 850 (95% CI, 720-1039) ACL reconstructions, 1 pulmonary embolism could be provoked. For every 213 (95% CI, 195-233), 1 native knee joint infection could be provoked.Conclusion:The overall risk of adverse events after ACL reconstruction is low; however, some rare but serious complications, including infections or pulmonary embolism, may occur. Around 3% of patients undergo further ipsilateral or contralateral ACL reconstruction within 5 years. These data will inform shared decision making between clinicians and patients considering their treatment options.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-07-26T09:01:19Z
      DOI: 10.1177/0363546519861393
       
  • Complications After Anterior Cruciate Ligament Reconstruction and Their
           Relation to the Type of Graft: A Prospective Study of 958 Cases
    • Authors: Romain Rousseau, Charlotte Labruyere, Charles Kajetanek, Olivia Deschamps, Konstantinos G. Makridis, Patrick Djian
      First page: 2543
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Complications and adverse events after anterior cruciate ligament (ACL) reconstruction are well known, but they have been underestimated in previous studies.Purpose:To describe the complications and adverse events after ACL reconstruction within a 2-year follow-up and analyze them in relation to the type of graft.Study Design:Cohort study; Level of evidence, 3.Methods:From 2000 to 2012, 958 patients with an isolated ACL injury underwent surgery by a single knee surgeon. ACL reconstruction was performed with the medial portal technique for the femoral tunnel and the use of bone–patellar tendon–bone (BPTB) or hamstring tendon graft. Patients were reviewed at 6 weeks and 3, 6, 12, and 24 months after surgery with the International Knee Documentation Committee score, plain radiographs, and the KT-1000 arthrometer.Results:Of 958 patients enrolled, 147 (15%) were lost at last follow-up. The 2 groups (bone–patellar tendon–bone [n = 257] and hamstring [n = 554]) were similar regarding the mean age at the time of surgery and preoperative anterior laxity. The main complications were as follows: anterior knee pain (n = 130 of 811, 16%), stiffness (n = 72, 8.8%), secondary meniscal lesions (n = 59, 7.2%), pain attributed to fixation (n = 79, 9.7%), ACL rerupture (n = 47, 5.7%), contralateral ACL ruptures (n = 24, 3%), patellar fractures (n = 3, 0.3%), infections (n = 9, 1%), and thromboembolic complications (n = 5, 0.6%). There was no significant difference between the grafts with respect to the frequency of joint stiffness, secondary meniscal lesions, or anterior knee pain. During the first 2 postoperative years, the percentage of patients with anterior knee pain was higher in the patellar tendon group (23.3% vs 12.6%, P < .001); however, this difference was not significant after the 2-year interval (3.1% vs 2.5%, P = .63). The percentage of patients with a rerupture of the graft was significantly lower in the patellar tendon group than in the hamstring group (25 of 811 [3.1%] vs 57 of 811 [7%], P = .023). Similar results were recorded regarding the pain related to the hardware material (7 of 811 [0.8%] in the BPTB group vs 113 of 811 [13.9%] in the hamstring group, P = .001). The percentage of ACL ruptures contralateral to the repair was higher in the patellar tendon group (41 of 811 [5%] vs 17 of 811 [2%], P = .016).Conclusion:The total rate of complications after an ACL reconstruction was 39%, and the surgical revision rate for any reason was 28%. Problems with the hardware material were more frequent in the hamstring group, leading to an increased rate of surgical revision. Anterior knee pain was initially higher in the patellar tendon group, but there was no significant difference in a 2-year interval. The rerupture rate was statistically higher in the hamstring group.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-08-12T08:10:49Z
      DOI: 10.1177/0363546519867913
       
  • Subsequent Surgery for Loss of Motion After Anterior Cruciate Ligament
           Reconstruction Does Not Influence Function at 2 Years: A Matched
           Case-Control Analysis
    • Authors: Jacob Worsham, Walter R. Lowe, Dorcas Copa, Shelby Williams, Jaquelyn Kleihege, Kyle Lauck, Randhir Mascarenhas, Lane Bailey
      First page: 2550
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Loss of motion (LOM) remains a common complication after anterior cruciate ligament (ACL) reconstruction and can be detrimental to patient outcomes after surgery. LOM is multifactorial, but nonsurgical and surgical solutions to this complex problem are available. A paucity of quality data exists evaluating clinical outcomes after the surgical treatment of patients with LOM after ACL reconstruction.Hypothesis:Patients undergoing surgical lysis of adhesions and manipulation under anesthesia for LOM after ACL reconstruction will exhibit decreased function, lower outcome scores, and delayed time of release to play when compared with matched controls without LOM.Study Design:Cohort study; Level of evidence, 3Methods:A database of 1572 patients undergoing ACL reconstruction was sampled from 2013 to 2017 to identify a total of 58 patients (LOM group [n = 29] vs matched control group [n = 29]). Group comparisons were examined for patients requiring a second surgical procedure for LOM versus matched controls after ACL reconstruction for differences in surgical timing, self-reported International Knee Disability Committee scores, objective function at release to play, and subjective knee function at 2 years with the Single Assessment Numeric Evaluation. The risk of a type I error was set at α = .05 for all statistical analyses.Results:Patients who underwent lysis of adhesions and manipulation under anesthesia for LOM after ACL reconstruction exhibited no differences in Single Assessment Numeric Evaluation knee function at 2 years when compared with matched controls (85.8 ± 14.9 vs 88.0 ± 10.8, P = .606). All patients met release-to-play criteria. Only International Knee Disability Committee scores (P = .046) and single-legged hop testing (P = .050) reached statistically significant differences, with higher scores in the control group. There was no difference in the time to release to play (P = .034) or level of participation (P = .180) between the control and surgical groups. Subjective function scores at 2 years were not significantly different between groups. Tourniquet time during the index ACL reconstruction was shorter in the control group (P = .034).Conclusion:The findings of this study suggest that patients who undergo surgical treatment for LOM after ACL reconstruction can release to play at similar times but display relative deficits in single-legged-hop symmetry and lower self-reported function when compared with matched controls. Longer surgical times may increase the risk for LOM after ACL reconstruction.Registration:NCT03704376 (ClinicalTrials.gov identifier)
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-07-26T09:21:21Z
      DOI: 10.1177/0363546519863347
       
  • Factors Associated With a Return to Preinjury Level of Sport Performance
           After Anterior Cruciate Ligament Reconstruction Surgery
    • Authors: Kate E. Webster, April L. McPherson, Timothy E. Hewett, Julian A. Feller
      First page: 2557
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Many studies have investigated factors that predict a return to sport participation after anterior cruciate ligament (ACL) reconstruction, but it is unclear whether the same factors are associated with a return to preinjury level of sport performance.Purpose:To identify factors that contribute to an athlete’s return to preinjury level of performance after ACL reconstruction.Study Design:Cohort study; Level of evidence, 2.Methods:A cohort of 222 patients (132 male, 90 female) who had ACL reconstruction surgery and completed a 12-month postoperative assessment were followed out to a mean 3 years (range, 2-4 years) to determine whether they had returned to their self-reported preinjury levels of sport performance. Rates of return to preinjury performance were calculated. Measures that had been recorded at the 12-month postoperative review—demographic (age, sex), sport activity level (Marx Activity Rating Scale, return to competition sport), knee laxity, limb symmetry (single and triple crossover hop), subjective function/symptoms (International Knee Documentation Committee subjective), and psychological readiness (Anterior Cruciate Ligament Return to Sport After Injury scale)—were compared between patients who returned to their preinjury levels of performance and those who did not. Univariate and multivariate logistic regression models were also used to prospectively determine the association between these measures and return to preinjury level of sport performance.Results:A total of 135 (61%) patients reported that they had returned to their preinjury levels of performance, with return rates similar between males (59%) and females (63%) and between those who had returned to competition at 12 months (62%) and those who had not (60%). There was no significant age difference between patients who returned to their preinjury levels of sport performance and those who did not; however, higher psychological readiness (P < .0001), greater limb symmetry (P < .05), higher subjective knee scores (P = .01), and a higher activity level (P < .04) were all associated with a return to performance. In the multivariate model, psychological readiness was the only variable that remained a significant predictor (odds ratio = 1.03; 95% CI, 1.01-1.04; P < .0001).Conclusion:A majority of athletes who returned to sport after ACL reconstruction reported that their performance was comparable with preinjury. Having a greater psychological readiness to return during rehabilitation was the most significant predictor of a subsequent return to comparable performance.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-08-05T06:49:52Z
      DOI: 10.1177/0363546519865537
       
  • Single-Stage Multiple-Ligament Knee Reconstructions for Sports-Related
           Injuries: Outcomes in 194 Patients
    • Authors: Robert F. LaPrade, Jorge Chahla, Nicholas N. DePhillipo, Tyler Cram, Mitchell I. Kennedy, Mark Cinque, Grant J. Dornan, Luke T. O’Brien, Lars Engebretsen, Gilbert Moatshe
      First page: 2563
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Outcomes after sports-related multiple-ligament knee reconstructions are limited.Purpose:To evaluate outcomes after single-stage surgical treatment of sports-related multiple-ligament knee injuries and to compare outcomes after anterior cruciate ligament (ACL)–based and posterior cruciate ligament (PCL)–based multiple-ligament knee reconstructions.Study Design:Case series; Level of evidence, 4.Methods:Skeletally mature patients with at least 2 major knee ligaments torn during a sporting activity that required surgery with a minimum of 2 years’ follow-up were included. The Lysholm score, Tegner activity scale, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and 12-Item Short Form Health Survey Physical Component Summary were collected preoperatively and at a minimum of 2 years’ follow-up. Clinical data, including range of motion and knee stability, were also recorded at final follow-up.Results:A total of 276 patients with multiple-ligament knee injuries incurred during sport participation from 2010 to 2016 were identified. Of the 276 patients, 194 (70.5%) had complete follow-up at a mean 3.5 years (range, 2-8 years). There was a significant improvement in all outcome scores as compared with the preoperative scores (P < .001 for all scores). The median (first and third quartiles) Tegner activity score improved from 1 (0, 2) preoperatively to 6 (4, 7) postoperatively. Significant improvements were from 41 (22, 57) to 90 (78, 95) and 44 (24, 60) to 3 (1, 8) for median Lysholm and WOMAC scores, respectively. There was no significant difference in postoperative outcome scores between patients treated in the acute and chronic phases. Furthermore, there was no significant difference between PCL- and ACL-based multiple-ligament knee injuries. Eighteen (9.3%) patients developed arthrofibrosis requiring reintervention surgery.Conclusion:These results demonstrated that single-stage anatomic-based knee ligament reconstructions with immediate postoperative rehabilitation in the setting of sports-related multiligament injuries yielded significantly improved outcomes irrespective of the ligament injury pattern. In addition, there was no difference in outcomes between ACL- and PCL-based injuries in the setting of sports-related multiligament injuries.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-08-05T06:49:12Z
      DOI: 10.1177/0363546519864539
       
  • Radiographic Landmarks for Femoral Tunnel Positioning in Lateral
           Extra-articular Tenodesis Procedures
    • Authors: Vera Jaecker, Jan-Hendrik Naendrup, Thomas R. Pfeiffer, Bertil Bouillon, Sven Shafizadeh
      First page: 2572
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Lateral extra-articular tenodesis (LET) is being increasingly performed as an additional procedure in both primary and revision anterior cruciate ligament reconstruction in patients with excessive anterolateral rotatory instability. Consistent guidelines for femoral tunnel placement would aid in intraoperative reproducible graft placement and postoperative evaluation of LET procedures.Purpose:To determine radiographic landmarks of a recently described isometric femoral attachment area in LET procedures with reference to consistent radiographic reference lines.Study Design:Descriptive laboratory study.Methods:Ten fresh-frozen cadaveric knees were dissected. The footprints of the lateral femoral epicondyle (LFE) apex and the deep aspects of the iliotibial tract, with its Kaplan fiber attachments (KFAs) on the distal femur, were marked with a 2.5-mm steel ball. True lateral radiographic images were taken. Mean absolute LFE and KFA distances were measured from the posterior cortex line (anterior-posterior direction) and from the perpendicular line intersecting the contact of the posterior femoral condyle (proximal-distal direction), respectively. Furthermore, positions were measured relative to the femur width. Finally, radiographic descriptions of an isometric femoral attachment area were developed.Results:The mean LFE and KFA positions were found to be 4 ± 4 mm posterior and 4 ± 3 mm anterior to the posterior cortex line, and 6 ± 4 mm distal and 20 ± 5 mm proximal to the perpendicular line intersecting the posterior femoral condyle, respectively. The mean LFE and KFA locations, relative to the femur width, were found at –12% and 11% (anterior-posterior) and –17% and 59% (proximal-distal), respectively. Femoral tunnel placement on or posterior to the femoral cortex line and proximal to the posterior femoral condyle within a 10-mm distance ensures that the tunnel remains safely located in the isometric zone.Conclusion:Radiographic landmarks for an isometric femoral tunnel placement in LET procedures were described.Clinical Relevance:These findings may help to intraoperatively guide surgeons for an accurate, reproducible femoral tunnel placement and to reduce the potential risk of tunnel misplacement, as well as to aid in the postoperative evaluation of LET procedures in patients with residual complaints.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-08-05T06:49:42Z
      DOI: 10.1177/0363546519864580
       
  • Comparative Clinical Outcomes After Intra-articular Injection With
           Adipose-Derived Cultured Stem Cells or Noncultured Stromal Vascular
           Fraction for the Treatment of Knee Osteoarthritis
    • Authors: Naomasa Yokota, Mari Hattori, Tadahiko Ohtsuru, Masaki Otsuji, Stephen Lyman, Kazunori Shimomura, Norimasa Nakamura
      First page: 2577
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Intra-articular injection of adipose-derived stem cells (ASCs) has shown promise for improving symptoms and cartilage quality in the treatment of osteoarthritis (OA). However, while most preclinical studies have been performed with plastic-adherent ASCs, most clinical trials are being conducted with the stromal vascular fraction (SVF), prepared from adipose tissue without prior culture.Purpose:To directly compare clinical outcomes of intra-articular injection with ASCs or SVF in patients with knee OA.Study Design:Cohort study; Level of evidence, 3.Methods:The authors retrospectively compared 6-month outcomes in 42 patients (59 knees) receiving intra-articular injection with 12.75 million ASCs and 38 patients (69 knees) receiving a 5-mL preparation of SVF. All patients had Kellgren-Lawrence grade 2, 3, or 4 knee OA and had failed standard medical therapy. The visual analog scale (VAS) pain score and Knee injury and Osteoarthritis Outcome Score (KOOS) at baseline and 1, 3, and 6 months after injection were considered as outcomes. Outcome Measures in Rheumatology–Osteoarthritis Research Society International (OMERACT-OARSI) criteria were also used to assess positive response. A repeated measures analysis of variance was used for comparison between the treatment groups.Results:No major complications occurred in either group. The SVF group had a higher frequency of knee effusion (SVF 8%, ASC 2%) and minor complications related to the fat harvest site (SVF 34%, ASC 5%). Both groups reported improvements in pain VAS and KOOS domains. Specifically, in the ASC group, symptoms improved earlier (by 3 months; P < .05) and pain VAS decreased to a greater degree (55%; P < .05) compared with the SVF group (44%). The proportion of OMERACT-OARSI responders in the ASC group was slightly higher (ASCs, 61%; SVF, 55%; P = .25).Conclusion:It was observed that both ASCs and SVF resulted in clinical improvement in patients with knee OA, but that ASCs outperform SVF in the early reduction of symptoms and pain with less comorbidity.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-08-02T06:37:00Z
      DOI: 10.1177/0363546519864359
       
  • Surgeon Ability to Appropriately Address the Calcified Cartilage Layer: An
           In Vitro Study of Arthroscopic and Open Techniques
    • Authors: Adam B. Yanke, Andrew S. Lee, Vasili Karas, Geoffrey Abrams, Mark L. Riccio, Nikhil N. Verma, Bernard R. Bach, Brian J. Cole
      First page: 2584
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Microfracture is a commonly utilized cartilage restoration technique for articular cartilage defects. While the removal of the calcified cartilage layer (CCL) has been shown to be critical with in vivo models, little is known with regard to surgeon reliability to adequately perform the technique.Purpose:To evaluate surgeon reliability in removing the CCL utilizing open and arthroscopic techniques.Study Design:Controlled laboratory study.Methods:Eleven cadaveric knees were utilized to create four 12-mm diameter defects in the anterior and posterior medial femoral condyles. Eleven fellowship-trained surgeons were asked to perform the following procedures: remove the CCL open, retain the CCL open, remove the CCL arthroscopically, and retain the CCL arthroscopically. Samples underwent histologic staining and analysis with 3-dimensional micro–computed tomography. The latter was used to calculate the percentage of the CCL that was removed or retained across the entire defect.Results:When surgeons were asked to retain the CCL arthroscopically, 48% ± 41% (mean ± SD) remained. When surgeons were asked to remove the CCL arthroscopically, 24% ± 35% remained. There was no statistical difference between these groups (P> .05). When the CCL was retained during open preparation, 60% ± 39% remained. During attempts to remove the CCL in an open manner, 19% ± 28% remained. There was a significant difference in the amount of CCL remaining between the open removal and open retaining groups (P = .03). There were no significant differences in the percentage of CCL remaining between the open and arthroscopic preservation groups and between the open and arthroscopic removal groups.Conclusion/Clinical Relevance:This study highlights the significant variability in surgeon ability to reliably retain or remove the CCL. However, there appears to be improved ability of surgeons to more reliably remove or retain the CCL in an open fashion as compared with the arthroscopic approach.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-07-23T09:44:19Z
      DOI: 10.1177/0363546519859851
       
  • Long-term Evaluation of Meniscal Tissue Formation in
           3-dimensional–Printed Scaffolds With Sequential Release of Connective
           Tissue Growth Factor and TGF-β3 in an Ovine Model
    • Authors: Yusuke Nakagawa, Lisa A. Fortier, Jeremy J. Mao, Chang Hun Lee, Margaret B. Goodale, Matthew F. Koff, Tyler J. Uppstrom, Brett Croen, Susumu Wada, Camila B. Carballo, Hollis G. Potter, Scott A. Rodeo
      First page: 2596
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Artificial meniscal scaffolds are being developed to prevent development of osteoarthritis after meniscectomy. Previously, it was reported that 3-dimensional (3D) anatomic scaffolds loaded with connective tissue growth factor (CTGF) and transforming growth factor β3 (TGF-β3) achieved meniscal regeneration in an ovine model. This was a relatively short-term study (3 months postoperative), and outcome analyses did not include magnetic resonance imaging (MRI).Purpose:To evaluate long-term outcome of meniscal replacement with growth factor–laden poly-ε-caprolactone (PCL) scaffolds.Study Design:Controlled laboratory study.Methods:Anatomically shaped ovine meniscal scaffolds were fabricated from PCL with a 3D printer based on MRI data. Skeletally mature sheep (N = 34) were randomly allocated to 3 groups: scaffold without growth factor (0-µg group), scaffold with CTGF microspheres (µS) (5 µg) + TGF-β3 µS (5 µg) (5-µg group), and scaffold with CTGF µS (10 µg) + TGF-β3 µS (10 µg) (10-µg group). Unilateral medial meniscal replacement was performed. Animals were euthanized at 6 or 12 months. Regenerated meniscus, articular cartilage status, and synovial reaction were evaluated quantitatively with gross inspection, histology, and MRI. Kruskal-Wallis and Dunn tests were used to compare the 3 groups.Results:Remnants of the PCL scaffold were evident in the 6-month specimens and were decreased but still present at 12 months in most animals. There were no significant differences among groups in gross inspection, histology, or MRI for either meniscal regeneration or articular cartilage protection. All experimental groups exhibited articular cartilage degeneration as compared with control (nonoperated). In terms of synovitis, there were no clear differences among groups, suggesting that growth factors did not increase inflammation and fibrosis. MRI revealed that meniscal extrusion was observed in most animals (82.7%).Conclusion:Previously, the combination of CTGF and TGF-β3 was shown to stimulate mesenchymal stem cells into a fibrochondrocyte lineage. CTGF and TGF-β3 did not aggravate synovitis, suggesting no adverse response to the combination of 3D-printed PCL scaffold combined with CTGF and TGF-β3. Further work will be required to improve scaffold fixation to avoid meniscal extrusion.Clinical Relevance:A significant advantage of this technique is the ability to print custom-fit scaffolds from MRI-generated templates. In addition, average-size menisci could be printed and available for off-the-shelf applications. Based on the 1-year duration of the study, the approach appears to be promising for meniscal regeneration in humans.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-08-06T06:25:28Z
      DOI: 10.1177/0363546519865513
       
  • Change in Drop-Landing Mechanics Over 2 Years in Young Athletes After
           Anterior Cruciate Ligament Reconstruction
    • Authors: Matthew P. Ithurburn, Mark V. Paterno, Staci Thomas, Michael L. Pennell, Kevin D. Evans, Robert A. Magnussen, Laura C. Schmitt
      First page: 2608
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:While between-limb landing asymmetries after anterior cruciate ligament reconstruction (ACLR) are linked with poor function and risk of additional injury, it is not currently understood how landing symmetry changes over time after ACLR.Purpose/Hypothesis:The purpose was to investigate how double-legged drop vertical jump (DVJ) landing and single-legged drop-landing symmetry changed from the time of return-to-sport (RTS) clearance to 2 years later in a prospective cohort of young athletes after ACLR. It was hypothesized that double-legged DVJ landing and single-legged drop-landing symmetry would improve from the time of RTS to 2 years later.Study Design:Descriptive laboratory study.Methods:The authors followed 64 young athletes with primary, unilateral ACLR for 2 years after RTS clearance. At the time of RTS and 2 years later, between-limb symmetry values for biomechanical variables of interest (VOIs) were calculated with 3-dimensional motion analysis during double-legged DVJ and single-legged drop-landing tasks. VOIs included knee flexion excursion, peak internal knee extension moment, peak vertical ground-reaction force, and peak trunk flexion (for single-legged task only). Symmetry values and proportions of participants meeting 90% symmetry cutoffs were compared between time points.Results:For double-legged DVJ landing, symmetry values for all VOIs and the proportions meeting 90% cutoffs for peak internal knee extension moment and peak vertical ground-reaction force were higher at 2 years after RTS as compared with RTS. For single-legged drop-landing, symmetry values were higher for knee flexion excursion and lower for peak trunk flexion at 2 years after RTS as compared with RTS, but the proportions meeting 90% cutoffs for all VOIs did not differ between time points.Conclusion:Double-legged DVJ landing symmetry improved across VOIs over the 2 years after RTS following ACLR, while single-legged drop-landing did not improve as consistently. The implications of longitudinal landing asymmetry after ACLR should be further studied.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-08-02T06:41:00Z
      DOI: 10.1177/0363546519864688
       
  • Demographic and Radiographic Factors Associated With Intra-articular Hip
           Cartilage Injury: A Cross-sectional Study of 1511 Hip Arthroscopy
           Procedures
    • Authors: Lasse Ishøi, Kristian Thorborg, Otto Kraemer, Bent Lund, Bjarne Mygind-Klavsen, Per Hölmich
      First page: 2617
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Moderate to severe (grade 3-4) hip joint cartilage injury seems to impair function in patients with femoroacetabular impingement syndrome.Purpose:To investigate whether demographic and radiographic factors were associated with moderate to severe hip joint cartilage injury.Study Design:Cross-sectional study; Level of evidence, 3.Methods:Patients were identified in the Danish Hip Arthroscopy Registry. The outcome variables were acetabular cartilage injury (modified Beck grade 0-2 vs 3-4) and femoral head cartilage injury (International Cartilage Repair Society grade 0-2 vs 3-4). Logistic regressions assessed the association with the following: age (
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-07-26T08:20:57Z
      DOI: 10.1177/0363546519861088
       
  • Prevalence and Clinical Implications of Chondral Injuries After Hip
           Arthroscopic Surgery for Femoroacetabular Impingement Syndrome
    • Authors: Jorge Chahla, Edward C. Beck, Kelechi Okoroha, Jourdan M. Cancienne, Kyle N. Kunze, Shane J. Nho
      First page: 2626
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Studies on the effect of partial- and full-thickness chondral damage of the hip on outcomes and the ability to achieve meaningful clinical outcomes are limited.Purpose:To determine the effect of full- and partial-thickness chondral injuries on 2-year outcomes in patients undergoing hip arthroscopic surgery for femoroacetabular impingement syndrome (FAIS) compared with patients without chondral damage, and to identify significant predictors of achieving the patient acceptable symptomatic state (PASS) and minimal clinically important difference (MCID).Study Design:Case-control study; Level of evidence, 3.Methods:Data from consecutive patients with evidence of chondromalacia at the time of primary hip arthroscopic surgery with routine capsular closure for the treatment of FAIS by a single fellowship-trained surgeon between January 2012 and September 2016 were reviewed. Patients were divided into groups with partial-thickness (grade I-III) or full-thickness (grade IV) chondral defects and matched by age and body mass index (BMI) to patients without chondral injuries. Preoperative and postoperative outcomes were compared among the 3 groups, and a binary logistic regression analysis was utilized to identify significant predictors of achieving the MCID and PASS.Results:There were 634 patients included in the analysis, with a mean age of 34.5 ± 10.9 years and a mean BMI of 25.2 ± 4.7 kg/m2. A total of 493 (77.8%) patients had no evidence of chondral damage, 92 (14.5%) patients had partial-thickness chondral defects, and 49 (7.7%) patients had full-thickness chondral defects. There were statistically significant differences in the Hip Outcome Score (HOS)–Activities of Daily Living, HOS–Sports Subscale, modified Harris Hip Score, pain, and satisfaction (P < .01) among the 3 groups. Patients with grade IV chondromalacia experienced the poorest outcomes and lowest percentage of achieving the PASS. Predictors for achieving any PASS threshold included preoperative alpha angle (odds ratio [OR], 0.96; P = .016), absence of preoperative limping (OR, 7.25; P = .002), absence of preoperative chronic pain (OR, 5.83; P = .019), primary hip arthroscopic surgery (OR, 0.17; P = .050), patients who self-identified as runners (OR, 2.27; P = .037), and Tönnis grade 0 (OR, 2.86; P = .032). Male sex (OR, 2.49; P = .015) was the only predictor of achieving any MCID threshold.Conclusion:Patients with grade IV chondral defects experienced worse functional outcomes, lower satisfaction, and increased pain when compared with both patients without chondral damage or grade I-III chondromalacia at 2-year follow-up. Several predictors were associated with achieving clinically significant function in patients undergoing hip arthroscopic surgery for FAIS.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-08-14T08:49:26Z
      DOI: 10.1177/0363546519865912
       
  • Patients With Borderline Hip Dysplasia Achieve Clinically Significant
           Outcome After Arthroscopic Femoroacetabular Impingement Surgery: A
           Case-Control Study With Minimum 2-Year Follow-up
    • Authors: Edward C. Beck, Benedict U. Nwachukwu, Jorge Chahla, Kyleen Jan, Timothy C. Keating, Sunikom Suppauksorn, Shane J. Nho
      First page: 2636
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:There is a growing trend for hip arthroscopists to treat patients with borderline hip dysplasia (BHD) for femoroacetabular impingement syndrome (FAIS) without addressing the acetabular coverage. However, the literature of outcomes and failure rates for these patients is conflicting.Purpose:(1) To identify whether patients with BHD achieved 2-year similar patient-reported outcome, minimal clinically important difference (MCID), and patient acceptable symptomatic state (PASS) when compared with patients without BHD and (2) to identify predictors for achieving the MCID and PASS among patients with BHD who are undergoing hip arthroscopy for FAIS.Study Design:Cohort study; Level of evidence, 3.Methods:Data from consecutive patients who underwent primary hip arthroscopy with routine capsular closure for the treatment of FAIS between January 2012 and January 2017 were collected and retrospectively analyzed. Patients with BHD (lateral center-edge angle [LCEA], 20°-25°) were matched 2:1 by age, sex, and body mass index (BMI) to control patients with normal acetabular coverage (LCEA,>25°-40°). Patient-reported outcome, MCID, and PASS were compared between the groups. Multivariate logistic regression analysis identified significant predictors of achieving the MCID and PASS in the BHD group.Results:The MCID in the BHD group was defined as 9.2, 13.7, 8.5, and 15.2 for the Hip Outcome Score–Activities of Daily Living, Hip Outcome Score–Sport Specific, modified Harris Hip Score, and iHOT-12, respectively. Threshold scores for achieving the PASS in both groups were 87.9, 76.4, 78.1, and 60.0. A total of 112 patients were identified as having BHD (LCEA, 20°-25°) and were matched to 224 controls. Both groups saw statistically significant increases in score averages over the 2-year period; however, the differences between them were not statistically significant (P> .05 for all). There was no statistical difference in the frequency of the BHD and non-BHD cohorts achieving the MCID on at least 1 threshold score (86.6% vs 85.6%, P = .837) and the PASS (78.6% vs 79.8%, P = .79). There was, however, a statistically significant difference between the rates of patients with and without BHD achieving the PASS on the modified Harris Hip Score threshold (62.5% vs 74.5%, P = .028). The final logistic models demonstrated that lower BMI (odds ratio [OR], 0.872; P = .029), lower preoperative alpha angle (OR, 0.965; P = .014), and female sex (OR, 3.647; P = .03) are independent preoperative predictors of achieving the MCID, while lower preoperative alpha angle (OR, 0.943; P = .018) and self-reported limp (OR, 18.53; P = .007) are independent preoperative predictors of achieving the PASS.Conclusion:Outcome improvements in patients with BHD who are undergoing arthroscopic treatment with capsular closure for FAIS are not significantly different from patients with normal acetabular coverage. Lower BMI, lower alpha angle, absence of limp, and female sex are preoperative predictors of achieving meaningful clinically significant outcome improvements in patients with BHD.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-08-16T05:31:58Z
      DOI: 10.1177/0363546519865919
       
  • Correlation of Single Assessment Numerical Evaluation Score for Sport and
           Activities of Daily Living to Modified Harris Hip Score and Hip Outcome
           Score in Patients Undergoing Arthroscopic Hip Surgery
    • Authors: Brian C. Lau, Melissa Scribani, Tally Lassiter, Jocelyn Wittstein
      First page: 2646
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:The Single Assessment Numerical Evaluation (SANE) is a single-question outcome score that has been shown to be a reliable measure of outcomes for shoulder and knee injuries but has not been compared with other validated outcome scores in hip pathology managed arthroscopically.Purpose:To correlate SANE Activities of Daily Living (ADL) and Sport subscales with the modified Harris Hip Score (mHHS) and Hip Outcome Score (HOS) ADL and Sport subscales before and after arthroscopic hip surgery.Study Design:Cohort study (diagnosis); Level of evidence, 3.Methods:A retrospective review of a prospectively filled database of patients undergoing arthroscopic hip surgery by a single surgeon was conducted. Inclusion criteria included patients scheduled for arthroscopic hip surgery for femoroacetabular impingement, labral tear, or gluteus medius tear. Exclusion criteria included previous surgery to the hip. Outcome scores, including the mHHS, HOS ADL and Sport, and SANE ADL and Sport, were measured preoperatively and postoperatively at 3 months, 1 year, and then annually. Pearson correlation coefficients between preoperative SANE ADL and Sport and the mHHS, HOS ADL, and HOS Sport were calculated. Pearson correlation coefficients between postoperative SANE ADL and Sport and the mHHS, HOS ADL, and HOS Sport were also calculated.Results:Eighty-five patients (mean age, 37.9 years; range, 14-66 years; 57 females, 28 males) underwent arthroscopic hip surgery for assorted pathology. Mean follow-up was 8 months (range, 3-64 months). Based on the Pearson correlation coefficient, preoperative SANE ADL and Sport had a moderate correlation with the mHHS (r = 0.66; 95% CI, 0.47-0.79; P < .0001; r = 0.54; 95% CI, 0.31-0.71; P < .0001, respectively). Preoperative SANE ADL and Sport had a moderate correlation with HOS ADL (r = 0.60; 95% CI, 0.39-0.75; P < .0001) and HOS Sport (r = 0.65; 95% CI, 0.45-0.79; P < .0001). Postoperative SANE ADL and Sport had a strong correlation with the mHHS (r = 0.69; 95% CI, 0.50-0.82; P < .0001; r = 0.78; 95% CI, 0.61-0.88; P < .0001). Postoperative SANE ADL and Sport had a strong correlation with HOS ADL (r = 0.79; 95% CI, 0.65-0.88; P < .0001) and HOS Sport (r = 0.88; 95% CI, 0.78-0.94; P < .0001).Conclusion:This study showed a significant correlation between SANE and mHHS in patients undergoing arthroscopic hip surgery both pre- and postoperatively. SANE ADL and Sport had a strong correlation with HOS ADL and Sport preoperatively and short-term postoperatively. SANE scores are more highly correlated with traditional subjective outcome measures during the short-term postoperative period than they are preoperatively. The SANE score provides an efficient method of assessing outcomes after hip arthroscopy.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-07-26T09:44:40Z
      DOI: 10.1177/0363546519863411
       
  • Ankle Sprains in the National Basketball Association, 2013-2014 Through
           2016-2017
    • Authors: Mackenzie M. Herzog, Christina DeFilippo Mack, Nancy A. Dreyer, Erik A. Wikstrom, Darin A. Padua, Mininder S. Kocher, John P. DiFiori, Stephen W. Marshall
      First page: 2651
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Ankle sprains are one of the most common injuries in basketball. Despite this, the incidence and setting of ankle sprains among elite basketball players are not well described.Purpose:To describe the epidemiology of ankle sprains among National Basketball Association (NBA) players.Study Design:Cohort study; Level of evidence, 3.Methods:All players on an NBA roster for ≥1 NBA game (preseason, regular season, or playoffs) during the 2013-14 through 2016-17 seasons were included. Data were collected with the NBA electronic medical record system. All NBA teams used the electronic medical record continuously throughout the study period to record comprehensive injury data, including onset, mechanism, setting, type, and time lost. Game incidence rates were calculated per 1000 player-games and per 10,000 player-minutes of participation, stratified by demographic and playing characteristics.Results:There were 796 ankle sprains among 389 players and 2341 unique NBA player-seasons reported in the league from 2013-14 through 2016-17. The overall single-season risk of ankle sprain was 25.8% (95% CI, 23.9%-28.0%). The majority of ankle sprains occurred in games (n = 565, 71.0%) and involved a contact mechanism of injury (n = 567, 71.2%). Most ankle sprains were lateral (n = 638, 80.2%). The incidence of ankle sprain among players with a history of prior ankle sprain in the past year was 1.41 times (95% CI, 1.13-1.74) the incidence of those without a history of ankle sprain in the past year (P = .002). Fifty-six percent of ankle sprains did not result in any NBA games missed (n = 443); among those that did, players missed a median of 2 games (interquartile range, 1-4) resulting in a cumulative total of 1467 missed player-games over the 4-season study period.Conclusion:Ankle sprains affect approximately 26% of NBA players on average each season and account for a large number of missed NBA games in aggregate. Younger players and players with a history of ankle sprain have elevated rates of incident ankle sprains in games, highlighting the potential benefit for integrating injury prevention programs into the management of initial sprains. Research on basketball- and ankle-specific injury prevention strategies could provide benefits.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-08-07T03:38:45Z
      DOI: 10.1177/0363546519864678
       
  • Long-term Results of Arthroscopic Rotator Cuff Repair: Initial Tear Size
           Matters: A Prospective Study on Clinical and Radiological Results at a
           Minimum Follow-up of 10 Years
    • Authors: Pietro Simone Randelli, Alessandra Menon, Elisabetta Nocerino, Alberto Aliprandi, Francesca Maria Feroldi, Manuel Giovanni Mazzoleni, Sara Boveri, Federico Ambrogi, Davide Cucchi
      First page: 2659
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Arthroscopic techniques are now considered the gold standard for treatment of most rotator cuff (RC) tears; however, no consensus exists on the maintenance of results over time, and long-term follow-up data have been reported for few cohorts of patients.Purpose:To present the long-term results associated with the arthroscopic treatment of RC tears and to evaluate associations between preoperative factors and RC integrity at final follow-up.Study Design:Cohort study; Level of evidence, 3.Methods:A total of 169 patients were contacted at least 10 years after arthroscopic RC surgery and were invited to a clinical evaluation. Information on preoperative conditions, tear size, subjective satisfaction, and functional scores was collected; isometric strength and range of motion were also measured; and each patient underwent an ultrasound examination to evaluate supraspinatus integrity and a shoulder radiograph to evaluate osteoarthritis.Results:A total of 149 patients (88.2% of the eligible patients) were available for a complete telephonic interview, and 102 patients were available for the final evaluation. Ultrasound revealed an intact supraspinatus in 54 patients (53.47%). By adding the 10 patients who underwent revision surgery to the nonintact group, this percentage would drop to 48.65%. Tear size was associated with supraspinatus integrity in univariate analysis (hazard ratio, 3.04; 95% CI, 1.63-5.69; P = .001) and multivariable analysis (hazard ratio, 2.18; 95% CI, 1.03-4.62; P = .04). However, no significant differences were encountered in the subjective and functional scores collected, with the exception of the Constant-Murley Score, which was significantly higher in patients with smaller tears at the index procedure. Strength testing also revealed significantly superior abduction and flexion strength in this group, and radiographs showed a significantly higher acromion-humeral distance and lower grades of osteoarthritis. Patients with an intact supraspinatus at final follow-up showed superior results in all functional scores, greater satisfaction, superior abduction and flexion strength, higher acromion-humeral distance, and lower grades of osteoarthritis.Conclusion:RC tear size at the time of surgery significantly affects supraspinatus integrity at a minimum follow-up of 10 years. However, a larger tear is not associated with an inferior subjective result, although it negatively influences abduction and flexion strength, range of motion, and osteoarthritis progression. Intraoperative efforts to obtain a durable RC repair are encouraged, since supraspinatus integrity at final follow-up influences clinical and functional outcomes, patient satisfaction, and osteoarthritis progression.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-08-14T06:53:12Z
      DOI: 10.1177/0363546519865529
       
  • Factors Predicting the Outcome After Arthroscopically Assisted
           Stabilization of Acute High-Grade Acromioclavicular Joint Dislocations
    • Authors: Nina Maziak, Laurent Audige, Carmen Hann, Marvin Minkus, Markus Scheibel
      First page: 2670
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Factors influencing the outcome after arthroscopically assisted stabilization of acute high-grade acromioclavicular (AC) joint dislocations remain poorly investigated.Purpose:To identify determinants of the radiological outcome and investigate associations between radiological and clinical outcome parameters.Study Design:Cohort study; Level of evidence, 3.Methods:The authors performed a retrospective analysis of patients who underwent arthroscopically assisted stabilization for acute high-grade AC joint dislocations. The following potential determinants of the radiological outcome were examined using univariable and multivariable regression analyses: timing of surgery, initial AC joint reduction, isolated coracoclavicular (CC) versus combined CC and AC stabilization, ossification of the CC ligaments, age, and overweight status. In addition, associations between radiological (ie, CC difference, dynamic posterior translation [DPT]) and clinical outcome parameters (Subjective Shoulder Value, Taft score [TS] subjective subcategory, and Acromioclavicular Joint Instability Score [ACJI] pain subitem) were evaluated using univariable analysis.Results:One hundred four patients with a mean (±SD) age of 38.1 ± 11.5 years were included in this study. The mean postoperative follow-up was 2.2 ± 0.9 years. Compared with patients with an overreduced AC joint after surgery, the CC difference was 4.3 mm (95% CI, 1.3-7.3; P = .006) higher in patients with incomplete reduction. Patients with anatomic reduction were 3.1 times (95% CI, 1.2-7.9; P = .017) more likely to develop DPT than those with an overreduced AC joint. An incompletely reduced AC joint was 5.3 times (95% CI, 2.1-13.4; P < .001) more likely to develop DPT versus an overreduced AC joint. Patients who underwent isolated CC stabilization were 4.8 times (95% CI, 1.1-21.0; P = .039) more likely to develop complete DPT than patients with additional AC stabilization. Significantly higher CC difference values were noted for patients who reported pain on the subjective TS (P = .025). Pain was encountered more commonly in patients with DPT (PTS = .049; PACJI = .038).Conclusion:Clinicians should consider overreduction of the AC joint because it may lead to favorable radiological results. Because of its association with superior radiographic outcomes, consideration should also be given to the use of additional AC cerclage.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-08-02T06:33:40Z
      DOI: 10.1177/0363546519862850
       
  • Low-Profile Dual Small Plate Fixation Is Biomechanically Similar to Larger
           Superior or Anteroinferior Single Plate Fixation of Midshaft Clavicle
           Fractures
    • Authors: Connor G. Ziegler, Zachary S. Aman, Hunter W. Storaci, Hannah Finch, Grant J. Dornan, Mitchell I. Kennedy, Matthew T. Provencher, Thomas R. Hackett
      First page: 2678
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Limited biomechanical data exist for dual small plate fixation of midshaft clavicle fractures, and no prior study has concurrently compared dual small plating to larger superior or anteroinferior single plate and screw constructs.Purpose:To biomechanically compare dual small orthogonal plating, superior plating, and anteroinferior plating of midshaft clavicle fractures by use of a cadaveric model.Study Design:Descriptive laboratory study.Methods:The study used 18 cadaveric clavicle specimens (9 pairs total), and 3 plating techniques were studied: anteroinferior, superior, and dual. The dual plating technique used smaller diameter plates and screws (1.6-mm thickness) than the other, single plate techniques (3.3-mm thickness). Each of the 9 clavicle pairs was randomly assigned a combination of 2 plating techniques, and randomization was used to determine which techniques were used for the right and left specimens. Clavicles were plated and then osteotomized to create an inferior butterfly fracture model, which was then fixed with a single interfragmentary screw. Clavicle specimens were then potted for mechanical testing. Initial bending, axial, and torsional stiffness of each construct was determined through use of a randomized nondestructive cyclic testing protocol followed by load to failure.Results:No significant differences were found in cyclical axial (P = .667) or torsional (P = .526) stiffness between plating groups. Anteroinferior plating demonstrated significantly higher cyclical bending stiffness than superior plating (P = .005). No significant difference was found in bending stiffness between dual plating and either anteroinferior (P = .129) or superior plating (P = .067). No significant difference was noted in load to failure among plating methods (P = .353).Conclusion:Dual plating with a smaller plate-screw construct is biomechanically similar to superior and anteroinferior single plate fixation that uses larger plate-screw constructs. No significant differences were found between dual plating and either superior or anteroinferior single plating in axial, bending, or torsional stiffness or in bending load to failure. Dual small plating is a viable option for fixing midshaft clavicle fractures and may be a useful low-profile technique that avoids a larger and more prominent plate-screw construct.Clinical Relevance:Plate prominence and hardware irritation are commonly reported complaints and reasons for revision surgery after plate fixation of midshaft clavicle fractures. Dual small plate fixation has been used to improve cosmetic acceptability, minimize hardware irritation, and decrease reoperation rate. Biomechanically, dual small plate fixation performed similarly to larger single plate fixation in this cadaveric model of butterfly fracture.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-08-05T06:49:32Z
      DOI: 10.1177/0363546519865251
       
  • The Incidence of Traumatic Posterior and Combined Labral Tears in Patients
           Undergoing Arthroscopic Shoulder Stabilization
    • Authors: Saqib Javed, Daniel Gheorghiu, Emma Torrance, Puneet Monga, Lennard Funk, Michael Walton
      First page: 2686
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Posterior and combined shoulder instabilities have been reported as accounting for only 2% to 5% of cases. More recently, an increased incidence of posterior capsulolabral tear has been reported.Purpose:To assess the incidence of posterior and combined labral tears in a large cohort of patients with surgically treated shoulder labral tears.Study Design:Case series; Level of evidence, 4.Methods:This was a retrospective study that evaluated 442 patients who underwent an arthroscopic capsulolabral repair over a 3-year period. Patients were categorized according to the location of their labral tear and whether their injury was sustained during sporting or nonsporting activity. Proportions of labral tears between sporting and nonsporting populations were compared using the chi-square test.Results:Patients had a mean age of 25.9 years and 89.6% were male. Isolated anterior labral tears occurred in 52.9%, with posterior and combined anteroposterior labral tears accounting for 16.3% and 30.8%, respectively. The frequency of posterior and combined lesions was greater in the sporting population compared with the nonsporting population (P = .013).Conclusion:Posterior and combined labral tears are more prevalent than previously reported, particularly in the sporting population.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-08-08T04:05:54Z
      DOI: 10.1177/0363546519865910
       
  • Predictors of Unsuccessful Nonoperative Management of Capitellar
           Osteochondritis Dissecans
    • Authors: Tadanao Funakoshi, Kozo Furushima, Azusa Miyamoto, Hiroshi Kusano, Yukio Horiuchi, Yoshiyasu Itoh
      First page: 2691
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Osteochondritis dissecans of the humeral capitellum (capitellar OCD) is a common injury among adolescent throwing athletes. Some younger patients with incomplete maturity of the epiphysis and early-stage capitellar OCD are good candidates for nonoperative treatment. However, during initial examination, predicting the need for surgical treatment in patients with capitellar OCD is difficult.Purpose:To perform multivariate ordered logistic regression analysis of data obtained from patients’ medical records and images on initial examination and identify the predictors of unsuccessful nonoperative management of capitellar OCD.Study Design:Cohort study (prognosis); Level of evidence, 2.Methods:This study included 245 elbows with capitellar OCD (all male; mean age, 14 years [range, 10-27 years]). Patients were divided into 3 groups comprising 148 elbows requiring an immediate operation on initial examination, 48 requiring nonsurgical treatment, and 49 requiring an operation after nonoperative management. Baseline data and radiographic parameters, such as lesion location, lesion size, modified Minami classification, radial head size, skeletal age difference between both elbows on initial examination, lesion size on computed tomography, and staging on magnetic resonance imaging, were retrospectively reviewed. Univariate and multivariate ordered logistic regression analyses of spontaneous healing of the lesion were conducted.Results:Univariate logistic regression analysis showed that radial head enlargement and skeletal age difference were significantly associated with spontaneous healing. In multivariate ordered logistic regression analysis, radial head enlargement (anteroposterior and lateral) and skeletal age difference were significant predictors of lack of spontaneous healing (odds ratio [OR], 2.76, P =.025; OR, 7.92, P =.026; and OR, 1.84, P =.0089, respectively).Conclusion:To predict spontaneous healing in the moderate stage, plain radiographs would be important to evaluate radiocapitellar congruity and skeletal age. This study showed that preoperative radiographic findings of radial head enlargement and advanced skeletal age of the throwing side compared with that of the nonthrowing side were predictors of advanced-stage capitellar OCD. Despite several limitations, the statistical significance and correlations herein provide important information on preoperative surgical planning to surgeons.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-07-26T09:37:00Z
      DOI: 10.1177/0363546519863349
       
  • Establishing Safe Extra-articular Parameters for Cortical Button Distal
           Fixation During Ulnar Collateral Ligament Reconstruction
    • Authors: Perry O. Hooper, Jared Warren, Christopher Silko, Salvatore J. Frangiamore, Dominic King, Lutul D. Farrow, Mark S. Schickendantz
      First page: 2699
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:A variety of methods exist for fixation during ulnar collateral ligament (UCL) reconstruction on the ulna for the overhead throwing athlete. Current biomechanical evidence suggests that cortical button fixation may fail at a higher load and under more cycles than interference screw fixation alone, while also minimizing the risk of fracture. A safe angle for placement of this cortical button has not yet been determined.Purpose:To define a safe angle for cortical button deployment during UCL reconstruction to avoid violation of the proximal radioulnar joint (PRUJ).Study Design:Descriptive laboratory study.Methods:Measurements on 100 cadaveric ulna bones, 50 women and 50 men, were obtained referencing the entry point for ulnar fixation, which is 1 cm distal to the ulnar humeral joint line along the medial UCL ridge. Ulnar width at the entry point and distance to the PRUJ were obtained to calculate safe distal angulation, while distance from the entry point to the posterior ulnar crest ulnarly and distance from the PRUJ to the posterior ulnar crest radially were obtained to calculate safe posterior angulation. Ten bony measurements on the same group of specimens were performed by 3 authors to establish an interobserver reliability. Means, quartiles, and outliers were obtained for the calculated angles. Finally, recommended angles of entry were determined to be approximately 1 interquartile range above the upper limit.Results:The mean distal angle of entry that was obtained was 11.32° (SD, ±4.80°; 95% CI, 10.37°-12.27°; P < .001). Three upper limit outliers were discovered: 24.20°, 23.4°, and 21.1°. The mean posterior angle of entry was 40.44° (SD, ±6.18°; 95% CI, 39.22°-41.67°; P < .001). There were no outliers for the posterior angle of entry. Interobserver reliabilities were strong for the 4 measurements.Conclusion:To be safely outside of the PRUJ utilizing a cortical button construct, we recommend 30° distal angulation and 60° posterior angulation for ulnar fixation during UCL reconstruction. Both parameters are 1 quartile above the highest calculated angle of entry.Clinical Relevance:These data define safe parameters for distal fixation during UCL reconstruction and highlight a clear entry point for reference.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-08-06T06:22:08Z
      DOI: 10.1177/0363546519864718
       
  • Association Between a Rule Change to Reduce Home Plate Collisions and Mild
           Traumatic Brain Injury and Other Injuries in Professional Baseball Players
           
    • Authors: Gary Green, John D’Angelo, Jon Coyles, Ian Penny, John G. Golfinos, Alex Valadka
      First page: 2704
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Improved player safety is an important goal of professional baseball. Prevention of mild traumatic brain injury (concussion) is an area of emphasis because of the potential for long-term as well as short-term sequelae.Hypothesis:A rule change can lower the incidence of concussions and other injuries in professional baseball.Study Design:Cohort study; Level of evidence, 3.Methods:This study included a retrospective review of data entered concurrently into professional baseball’s electronic medical record system. All minor and major league teams are required to use this system. All injuries are captured by creation of a new record in the system at the time of the injury. All active minor and major league players from 2011 to 2017 were included. The 30 major league clubs have 1200 roster players and play 162 games per season. The approximately 200 minor league clubs have about 7500 active players and play 56 to 144 games annually that combine for approximately 330,000 athlete-exposures per season. Before the 2014 season, Major League Baseball, in conjunction with its players association, instituted a rule limiting home plate collisions between base runners and catchers that applied to both Major League Baseball and Minor League Baseball. All concussions and other injuries at home plate from 2011 to 2017 were analyzed by mechanism and player position.Results:From 2011 to 2013, an annual mean of 100 injuries occurred from home plate collisions in the minor and major leagues, resulting in a mean loss of 2148 days annually. After the rule change, there was a mean 55 home plate collision injuries with 936 days lost per season (P < .0001 for injuries and days lost). A mean 11 concussions attributed to these collisions occurred annually in the minor and major leagues before the rule change, as compared with 2.3 per year after (P = .0029). There were no major league concussions from these collisions after the rule change. The mean annual number of days missed because of concussions at home plate dropped from 276 before 2014 to 36 per year after 2014 (P = .0001).Conclusion:This rule change was associated with significant reductions in the numbers of concussions and other injuries caused by collisions at home plate as well as significant decreases in time lost from play.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-07-23T10:36:20Z
      DOI: 10.1177/0363546519861525
       
  • Throwing Injuries in Youth Baseball Players: Can a Prevention Program
           Help' A Randomized Controlled Trial
    • Authors: Jun Sakata, Emi Nakamura, Tatsuhiro Suzuki, Makoto Suzukawa, Masaki Akeda, Tetsuya Yamazaki, Todd S. Ellenbecker, Norikazu Hirose
      First page: 2709
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Throwing injuries of the shoulder and elbow are common among youth baseball players.Hypothesis:A prevention program will reduce the incidence of throwing injuries of the shoulder and elbow by 50% among youth baseball players.Study Design:Randomized controlled trial; Level of evidence, 1.Methods:The authors block randomized 16 youth baseball teams consisting of 237 players aged 9 to 11 years into an intervention group (8 teams, 117 players) and a control group (8 teams, 120 players). The intervention program consisted of 5 stretching, 2 dynamic mobility, and 2 balance training exercises performed during warm-up. Both groups were followed up for 12 months, during which the incidence of shoulder and elbow injuries was recorded. In addition, ball speed during pitching as a performance-related factor and variables of physical function (passive range of motion of the elbow, shoulder and hip, dynamic balance, and thoracic kyphosis angle) were assessed during the pre- and postintervention periods.Results:The incidence of shoulder and elbow injuries in the intervention group (1.7 per 1000 athlete-exposures) was significantly lower than that in the control group (3.1 per 1000 athlete-exposures) (hazard ratio, 1.940; 95% CI, 1.175-3.205; P = .010). The factors related to pitching performance, as assessed by ball speed, tended to increase in the intervention group as compared with the control group (P = .010). The program also improved shoulder horizontal adduction deficits on the dominant side, hip internal rotation on the nondominant side, and the thoracic kyphosis angle.Conclusion:A prevention program decreases throwing injuries of the shoulder and elbow and enhances the parameter of pitching performance in youth baseball players.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-07-23T10:02:38Z
      DOI: 10.1177/0363546519861378
       
  • Effect of Concussions on the Performance of Running Backs and Wide
           Receivers in the National Football League
    • Authors: Toufic R. Jildeh, Kelechi R. Okoroha, Kevin A. Taylor, Patrick Buckley, Samir Mehta, Nima Mehran, Vasilios Moutzouros
      First page: 2717
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Concussion injuries are common in professional football players; however, their effect on player performance remains unclear.Purpose:To quantify the effect of concussions on the performance of running backs and wide receivers in professional football players.Study Design:Cohort study; Level of evidence, 3.Methods:Concussion data from the National Football League were collected for a period of 4 seasons (2012-2015) for running backs and wide receivers. Age, experience, position, time to return to play, yearly total yards, and touchdowns were recorded. A power rating (total yards divided by 10 plus touchdowns multiplied by 6) was calculated for each player’s injury season as well as for the 3 seasons before and after their respective injury. A control group of running backs and wide receivers without an identified concussion injury who competed in the 2012 season was assembled for comparison. Player performance up to 3 seasons before and after the injury season was examined to assess acute and longitudinal changes in player performance.Results:A total of 38 eligible running backs and wide receivers sustained a concussion during the study period. Thirty-four (89%) players were able to return to competition in the same season, missing an average of 1.5 ± 0.9 games; the remaining 4 players returned in the subsequent season. Power ratings for concussed players were similar to those of controls throughout the study period. Concussed players did not suffer an individual performance decline upon returning within the same season. Furthermore, no significant difference in change of power rating was observed in concussed players in the acute (±1 year from injury; −1.2 ± 4.8 vs –1.1 ± 3.9, P = .199) or chronic (±3 years from injury; –3.6 ± 8.0 vs –3.0 ± 4.5, P = .219) setting compared with controls. All concussed players successfully returned to competition in either the index or next season.Conclusion:A high rate of National Football League running backs and wide receivers are able to return to play after a concussion injury. These players were found to perform at a similar level in both the acute and long-term period after concussion.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-08-06T06:19:28Z
      DOI: 10.1177/0363546519864581
       
  • Pulse Lavage Fails to Significantly Reduce Bone Marrow Content in
           Osteochondral Allografts: A Histological and DNA Quantification Study
    • Authors: Luiz Felipe Ambra, Laura de Girolamo, Andreas H. Gomoll
      First page: 2723
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Current clinical practice calls for pulse lavage of fresh osteochondral allografts (OCAs) to reduce immunogenicity; however, there is limited evidence of its effectiveness in reducing allogenic bone marrow elements.Purpose:To evaluate the effectiveness of pulse lavage in removing marrow elements from trabecular bone in fresh OCA transplantation.Study Design:Controlled laboratory study.Methods:The authors evaluated 48 fresh OCA plugs with 4 different common sizes (14- and 24-mm diameter, 6- and 10-mm thickness). Within each size group, half of the samples underwent pulse lavage (n = 6) with saline solution and half were left untreated (no lavage; control group, n = 6). For each treatment and size group, 3 samples were analyzed for DNA content as an indicator of the number of residual nucleated cells; the other 3 samples were histologically analyzed to assess the presence and distribution of cells within subchondral bone pores in 3 specific locations within the plug: peripheral, intermediate, and core.Results:Osteochondral plugs treated with pulse lavage did not show a significant decrease in DNA content in comparison with untreated plugs. Overall, histological analysis did not show a significant difference between the treated and untreated groups (P = .23). Subgroup analysis by size demonstrated decreased marrow content in treated versus untreated groups in the thinner plug sizes (14 × 6 mm and 24 × 6 mm). Histological evaluation by zone demonstrated a significant difference between groups only in the peripheral zone (P = .04).Conclusion:Pulse lavage has limited effectiveness in removing marrow elements, in particular in plugs that are larger in diameter and, more importantly, in thickness. Better techniques for subchondral bone treatment are required for more thorough removal of potentially immunogenic marrow elements.Clinical Relevance:OCA transplantation has become an established treatment modality. Unfortunately, OCA is not without limitations, chiefly its mode of failure through inadequate integration of the allograft subchondral bone with subsequent collapse. In an effort to improve integration, current clinical practice calls for pulse lavage to remove allogenic bone marrow from the subchondral bone in hopes of decreasing the immunogenicity of the graft and facilitating revascularization.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-08-02T06:44:20Z
      DOI: 10.1177/0363546519864716
       
  • Tendon-to-Bone Healing in a Rat Extra-articular Bone Tunnel Model: A
           Comparison of Fresh Autologous Bone Marrow and Bone Marrow–Derived
           Mesenchymal Stem Cells
    • Authors: Jun Lu, Connie S. Chamberlain, Ming-liang Ji, Erin E. Saether, Ellen M. Leiferman, Wan-Ju Li, Ray Vanderby
      First page: 2729
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Despite widespread acceptance of fresh autologous bone marrow (BM) for use in clinical practice, limited information exists to analyze if tendon-to-bone healing could be accelerated with local use of fresh autologous BM.Purpose:To investigate the effect of fresh autologous BM on tendon-to-bone healing with a novel rat model.Study Design:Controlled laboratory study.Methods:An extra-articular bone tunnel was created and filled with an autologous tendon graft in skeletally mature Sprague-Dawley rats (N = 60). They were then randomly divided into 3 groups: BM group (injection of fresh autologous BM into the tendon-bone interface, n = 20), BM-derived mesenchymal stem cell (BMSC) group (injection of allogenic cultured BMSCs, n = 20), and the control group (tendon-bone interface without injection of BM or BMSCs, n = 20). Biomechanical, histological, and immunohistochemical analyses were performed at 2 and 6 weeks after surgery.Results:The BM group showed a relatively well-organized and dense connective tissue interface with better orientation of collagen fibers as compared with the BMSC group. At 2 weeks, the tendon-bone interface tissue thickness of the BMSC group was 140 ± 25 μm (mean ± SEM), which was significantly greater than the BM group (58 ± 15 μm). The BM group showed fewer M1 macrophages at the tendon-bone interface at 2 and 6 weeks (P < .001). In contrast, there were more M2 macrophages at the interface in the BM group 2 and 6 weeks postoperatively when compared with controls and the BMSC group (P < .001). Biomechanical tests revealed significantly higher stiffness in the BM group versus the control and BMSC groups at 2 and 6 weeks after surgery (P < .05). Load to failure showed similar trends to stiffness.Conclusion:These findings indicate that local delivery of fresh autologous BM enhances tendon-to-bone healing better than the alternative treatments in this study. This effect may be partially due to the observed modulation of inflammatory processes, especially in M2 macrophage polarization.Clinical Relevance:Fresh autologous BM could be a treatment option for this disorder.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-07-24T06:25:09Z
      DOI: 10.1177/0363546519862284
       
  • In Vivo Imaging of Exogenous Progenitor Cells in Tendon Regeneration via
           Superparamagnetic Iron Oxide Particles
    • Authors: Thomas J. Kremen, Maxim Bez, Dmitriy Sheyn, Shiran Ben-David, Xiaoyu Da, Wafa Tawackoli, Shawn Wagner, Dan Gazit, Gadi Pelled
      First page: 2737
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Although tendon injuries and repairs are common, treatment of these injuries has limitations. The application of mesenchymal progenitor cells (MPCs) is increasingly used to optimize the biological process of tendon repair healing. However, clinically relevant technologies that effectively assess the localization of exogenous MPCs in vivo are lacking.Hypothesis:Exogenous MPCs labeled with superparamagnetic iron oxide (SPIO) particles would allow monitoring of the localization and retention of cells within the site of implantation via magnetic resonance imaging (MRI) without negatively affecting cell survival or differentiation.Study Design:Descriptive laboratory study.Methods:Genetically modified C3H10T1/2 MPCs engineered to express luciferase (Luc+) reporter gene were implanted into surgically created Achilles tendon defects of 10 athymic nude rats (Hsd:RH-Foxn1rnu). Of these animals, 5 animals received Luc+ C3H10T1/2 MPCs colabeled with SPIO nanoparticles (+SPIO). These 2 groups of animals then underwent optical imaging with quantification of bioluminescence and MRI at 7, 14, and 28 days after surgery. Statistical analysis was conducted by use of 2-way analysis of variance. At 28 days after surgery, animals were euthanized and the treated limbs underwent histologic analysis.Results:Optical imaging demonstrated that the implanted cells not only survived but also proliferated in vivo, and these cells remained viable for at least 4 weeks after implantation. In addition, SPIO labeling did not appear to affect MPC survival or proliferation, as assessed by quantitative bioluminescence imaging (P> .05, n = 5). MRI demonstrated that SPIO labeling was an effective method to monitor cell localization, retention, and viability for at least 4 weeks after implantation. Histologic and immunofluorescence analyses of the repaired tendon defect sites demonstrated tenocyte-like labeled cells, suggesting that cell differentiation was not affected by labeling the cells with the SPIO nanoparticles.Conclusion:MRI of exogenous MPCs labeled with SPIO particles allows for effective in vivo assessments of cell localization and retention in the setting of tendon regeneration for at least 4 weeks after implantation. This SPIO labeling does not appear to impair cell survival, transgene expression, or differentiation.Clinical Relevance:SPIO labeling of MPCs appears to be safe for in vivo assessments of MPCs in tendon regeneration therapies and may be used for future clinical investigations of musculoskeletal regenerative medicine.
      Citation: The American Journal of Sports Medicine
      PubDate: 2019-07-23T09:52:38Z
      DOI: 10.1177/0363546519861080
       
 
 
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