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American Journal of Sports Medicine
Journal Prestige (SJR): 3.949
Citation Impact (citeScore): 6
Number of Followers: 249  
 
  Hybrid Journal Hybrid journal (It can contain Open Access articles)
ISSN (Print) 0363-5465 - ISSN (Online) 1552-3365
Published by Sage Publications Homepage  [1166 journals]
  • Radiographic Methods Are as Accurate as Magnetic Resonance Imaging for
           Graft Sizing Before Lateral Meniscal Transplantation: Letter to the Editor
           

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      Authors: Kaywan Izadpanah, Matthias Feucht, Moritz Mayr, Sebastian Ferdinand Bendak
      Abstract: The American Journal of Sports Medicine, Volume 49, Issue 12, Page NP59-NP60, October 2021.

      Citation: The American Journal of Sports Medicine
      PubDate: 2021-09-30T10:21:34Z
      DOI: 10.1177/03635465211040067
      Issue No: Vol. 49, No. 12 (2021)
       
  • Radiographic Methods Are as Accurate as Magnetic Resonance Imaging for
           Graft Sizing Before Lateral Meniscal Transplantation: Response

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      Authors: Luiz Felipe Ambra, Camila Cohen Kaleka, Pedro Debieux, Julio Cesar Almeida, Nehal Shah, Moises Cohen, Andreas H. Gomoll
      Abstract: The American Journal of Sports Medicine, Volume 49, Issue 12, Page NP60-NP61, October 2021.

      Citation: The American Journal of Sports Medicine
      PubDate: 2021-09-30T10:11:53Z
      DOI: 10.1177/03635465211037939
      Issue No: Vol. 49, No. 12 (2021)
       
  • The Critical Reader—Numerators and Denominators

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      Authors: James L. Carey
      Pages: 3170 - 3172
      Abstract: The American Journal of Sports Medicine, Volume 49, Issue 12, Page 3170-3172, October 2021.

      Citation: The American Journal of Sports Medicine
      PubDate: 2021-09-30T10:16:56Z
      DOI: 10.1177/03635465211047196
      Issue No: Vol. 49, No. 12 (2021)
       
  • Society News

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      Pages: 3453 - 3453
      Abstract: The American Journal of Sports Medicine, Volume 49, Issue 12, Page 3453-3453, October 2021.

      Citation: The American Journal of Sports Medicine
      PubDate: 2021-09-30T10:22:32Z
      DOI: 10.1177/03635465211045694
      Issue No: Vol. 49, No. 12 (2021)
       
  • Kenneth E. DeHaven, MD (1939-2021)

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      Authors: Michael D. Maloney
      Pages: 3454 - 3455
      Abstract: The American Journal of Sports Medicine, Volume 49, Issue 12, Page 3454-3455, October 2021.

      Citation: The American Journal of Sports Medicine
      PubDate: 2021-09-30T10:21:57Z
      DOI: 10.1177/03635465211049177
      Issue No: Vol. 49, No. 12 (2021)
       
  • Arthroscopic Revision Rotator Cuff Repair: The Role of Previously
           Neglected Subscapularis Tears

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      Authors: Tae-Hwan Yoon, Sung-Jae Kim, Yun-Rak Choi, Jin-Tae Cho, Yong-Min Chun
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Concomitant full-thickness tear of the subscapularis tendon is often neglected during primary posterosuperior rotator cuff repair, and its significance has not been investigated by any previous clinical study.Purpose:To investigate (1) the clinical and radiological outcomes of revision arthroscopic rotator cuff repair and (2) the number of neglected concomitant subscapularis full-thickness tears in the revision of posterosuperior rotator cuff retears and their structural integrity after repair.Study Design:Case series, Level of evidence, 4.Methods:This study retrospectively examined 58 patients who underwent arthroscopic rotator cuff revision for a retear of a previously repaired posterosuperior rotator cuff. Preoperative and postoperative functional scores and active range of motion (ROM) were assessed. The initial and most recent follow-up magnetic resonance imaging scans before revision and arthroscopic findings at the time of primary repair were reviewed to determine whether the concomitant subscapularis tear was newly developed or preexisting. Final confirmation of the tendon’s full-thickness tear was made during the revision procedure.Results:At final follow-up, mean functional shoulder scores and ROM improved significantly compared with the preoperative values (P < .001). Among the 58 revision cases, 25 (43.1%) had a neglected full-thickness tear of the subscapularis tendon. The fatty infiltration grade of the neglected subscapularis tear progressed from a mean of 1.1 before primary repair to a mean of 1.6 before revision, and the change indicated statistically significant deterioration (P < .001). Despite clinical improvement after revision surgery, the retear rate was considerable in the re-repaired cuff tendons (37.9%) as well as for the repaired concomitant subscapularis tears (24%).Conclusion:Among revision rotator cuff repairs, 43.1% had neglected subscapularis tears, and fatty infiltration of these initially neglected subscapularis tendons showed further progression at the time of revision. The retear rate after the repair of neglected subscapularis tears was higher than expected. Thus, detecting and treating subscapularis tear via meticulous preoperative evaluation and thorough inspection during primary arthroscopy are essential.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-10-15T03:11:16Z
      DOI: 10.1177/03635465211047485
       
  • Does Insurance Status Affect Treatment of Children With Tibial Spine
           Fractures'

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      Authors: Haley E. Smith, R. Justin Mistovich, Aristides I. Cruz, Tomasina M. Leska, Theodore J. Ganley, Julien T. Aoyama, Henry B. Ellis, Peter D. Fabricant, Daniel W. Green, Jason Jagodzinski, Benjamin Johnson, Indranil Kushare, Rushyuan J. Lee, Scott D. McKay, Jason T. Rhodes, Brant C. Sachleben, M. Catherine Sargent, Gregory A. Schmale, Yi-Meng Yen, Neeraj M. Patel
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Previous studies have reported disparities in orthopaedic care resulting from demographic factors, including insurance status. However, the effect of insurance on pediatric tibial spine fractures (TSFs), an uncommon but significant injury, is unknown.Purpose:To assess the effect of insurance status on the evaluation and treatment of TSFs in children and adolescents.Study Design:Cross-sectional study; Level of evidence, 3.Methods:We performed a retrospective cohort study of TSFs treated at 10 institutions between 2000 and 2019. Demographic data were collected, as was information regarding pre-, intra-, and postoperative treatment, with attention to delays in management and differences in care. Surgical and nonsurgical fractures were included, but a separate analysis of surgical patients was performed. Univariate analysis was followed by purposeful entry multivariate regression to adjust for confounding factors.Results:Data were collected on 434 patients (mean ± SD age, 11.7 ± 3.0 years) of which 61.1% had private (commercial) insurance. Magnetic resonance imaging (MRI) was obtained at similar rates for children with public and private insurance (41.4% vs 41.9%, respectively; P≥ .999). However, multivariate analysis revealed that those with MRI performed ≥21 days after injury were 5.3 times more likely to have public insurance (95% CI, 1.3-21.7; P = .02). Of the 434 patients included, 365 required surgery. Similar to the overall cohort, those in the surgical subgroup with MRI ≥21 days from injury were 4.8 times more likely to have public insurance (95% CI, 1.2-19.6; P = .03). Children who underwent surgery ≥21 days after injury were 2.5 times more likely to have public insurance (95% CI, 1.1-6.1; P = .04). However, there were no differences in the nature of the surgery or findings at surgery. Those who were publicly insured were 4.1 times more likely to be immobilized in a cast rather than a brace postoperatively (95% CI, 2.3-7.4; P < .001).Conclusion:Children with public insurance and a TSF were more likely to experience delays with MRI and surgical treatment than those with private insurance. However, there were no differences in the nature of the surgery or findings at surgery. Additionally, patients with public insurance were more likely to undergo postoperative casting rather than bracing.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-10-15T03:08:54Z
      DOI: 10.1177/03635465211046928
       
  • Labral Tear Management in Patients Aged 40 Years and Older Undergoing
           Primary Hip Arthroscopy: A Propensity-Matched Case-Control Study With
           Minimum 2-Year Follow-up

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      Authors: David R. Maldonado, Vivian W. Ouyang, Jade S. Owens, Andrew E. Jimenez, Benjamin R. Saks, Payam W. Sabetian, Ajay C. Lall, Benjamin G. Domb
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Previous literature has suggested that primary acetabular labral reconstruction leads to lower secondary surgery rates than does labral repair for patients aged ≥40 years.Purpose:To report minimum 2-year patient-reported outcome (PRO) scores, survivorship, and secondary surgeries in patients aged ≥40 years who underwent primary hip arthroscopy with labral reconstruction compared with a propensity-matched primary labral repair group.Study Design:Case-control study; Level of evidence, 3.Methods:Data were prospectively collected and retrospectively reviewed for patients who underwent a primary hip arthroscopy for femoroacetabular impingement syndrome between January 2014 and June 2018. Patients aged ≥40 years who underwent a labral reconstruction or a labral repair and had preoperative and minimum 2-year PROs for the modified Harris Hip Score, Nonarthritic Hip Score, and visual analog scale (VAS) for pain were included. Patients with previous ipsilateral hip conditions and surgery, Tönnis grade>1, hip dysplasia, or workers’ compensation status were excluded. Patients in the reconstruction group were propensity matched 1:2 to patients in the repair group based on age, sex, and body mass index. Secondary surgeries and achievement of the minimal clinically important difference (MCID), patient acceptable symptom state (PASS), and maximum outcome improvement (MOI) were recorded.Results:A total of 53 and 106 hips were included in the labral reconstruction and repair groups, respectively. The average follow-up time was 37.6 months. The average ages for the reconstruction and repair groups were 48.01 ± 5.4 years and 48.61 ± 6.0 years, respectively. Both groups achieved significant improvements in all PROs at a minimum of 2 years, with similar achievements of MCID, PASS, and MOI, and comparable secondary surgery rates.Conclusion:Patients aged ≥40 years who received primary labral repair and primary labral reconstruction achieved similar significant improvements in all PROs, VAS pain, and patient satisfaction at the minimum 2-year follow-up, with comparable rates of secondary surgeries and achieving MCID, PASS, and MOI. Based on these findings, labral repair remains the gold standard treatment for viable labrum in this population group, while reconstruction is a useful alternative for irreparable labrum.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-10-15T03:05:13Z
      DOI: 10.1177/03635465211046915
       
  • The Effectiveness of Intramedullary Screw Fixation Using the Herbert Screw
           for Fifth Metatarsal Stress Fractures in High-Level Athletes

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      Authors: Shota Morimoto, Tomoya Iseki, Takatoshi Morooka, Shinichi Yoshiya, Toshiya Tachibana, Juichi Tanaka
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Intramedullary screw fixation is the most common operative procedure used for treatment of fifth metatarsal stress fractures in athletes. However, the optimal implant in intramedullary screw fixation is still being investigated.Purpose:To review experiences with intramedullary screw fixation using the Herbert screw for fifth metatarsal stress fractures in high-level athletes.Study Design:Case series; Level of evidence, 4.Methods:The authors retrospectively analyzed 37 high-level athletes (Tegner activity score ≥7) who underwent intramedullary screw fixation using the Herbert screw for fifth metatarsal stress fractures between August 2005 and August 2017. The minimum follow-up period of the patients was 2 years. In assessing the surgical results, time to obtain bone union, time to return to original level of sport participation, and treatment failures/complications were reviewed. Additionally, the effect of intraoperative plantar gap widening caused by the screw insertion was analyzed. The surgical results of the 2 groups, the no-gap group (intraoperative plantar gap widening,
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-10-15T02:58:27Z
      DOI: 10.1177/03635465211045998
       
  • Histologic Analysis of Porcine Dermal Graft Augmentation in Treatment of
           Rotator Cuff Tears

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      Authors: Robert A. Christian, Kathryne J. Stabile, Anil K. Gupta, Bruce D. Leckey, Diana M. Cardona, Robert J. Nowinski, James D. Kelly, Alison P. Toth
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Biologic augmentation via extracellular matrix (ECM) scaffolds has been utilized to address rotator cuff tears with poor-quality tissue.Purpose:To evaluate the cellular changes in graft explants taken from patients treated with porcine dermal grafts for rotator cuff tears.Study Design:Case series; Level of evidence, 4Methods:Four graft biopsy specimens were obtained from patients treated with porcine dermal grafts in an interposition technique for rotator cuff tears and compared with a nonimplanted graft and a normal rotator cuff specimen. Biopsy of the graft site was performed at 18 days, 3 months, 7 months, and 10.5 months after implantation. Hematoxylin and eosin staining was used to evaluate for cellular and vascular changes. Picrosirius red (PSR) stain with 90° polarized light was performed to evaluate collagen fibril size and orientation. All biopsy specimens were analyzed by a pathologist.Results:There was evidence of progressive remodeling of the porcine dermal grafts. The most mature grafts demonstrated vessel infiltration and extensive remodeling without evidence of inflammation, foreign body reaction, or tissue rejection. PSR demonstrated increased organization of collagen domains, resembling normal tendon by 10.5 months postoperatively.Conclusion:This series suggests that ECM grafts may serve as an effective scaffold for host cell infiltration, collagen reorganization, and vascularization as a result of histologic changes demonstrated with retrieval of specimens from patients with rotator cuff tears that were augmented with porcine dermal grafts.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-10-15T02:49:57Z
      DOI: 10.1177/03635465211049434
       
  • Return to Sports and Minimum 2-Year Outcomes of Bilateral Hip Arthroscopy
           in High-Level Athletes With a Propensity-Matched Benchmarking Against a
           Unilateral Control Group

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      Authors: Jade S. Owens, Andrew E. Jimenez, Peter F. Monahan, David R. Maldonado, Cynthia Kyin, Benjamin R. Saks, Hari K. Ankem, Payam W. Sabetian, Ajay C. Lall, Benjamin G. Domb
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Return to sports (RTS) and patient-reported outcomes (PROs) for high-level athletes after bilateral hip arthroscopy have not been well established.Purpose:(1) To report minimum 2-year PROs and RTS rates in high-level athletes who underwent staged bilateral primary hip arthroscopies and (2) to compare clinical results against a propensity-matched control group of high-level athletes who underwent unilateral primary hip arthroscopy.Study Design:Cohort study; Level of evidence, 3.Methods:Data were prospectively collected and retrospectively reviewed for high-level athletes (professional, college, or high school) who underwent staged bilateral hip arthroscopy for femoroacetabular impingement syndrome between September 2009 and October 2018. Inclusion criteria were preoperative and minimum 2-year follow-up for modified Harris Hip Score, Non-arthritic Hip Score, Hip Outcome Score–Sports Specific Subscale (HOS-SSS), and visual analog scale for pain. Exclusion criteria were Tönnis grade>1, hip dysplasia (lateral center-edge angle .05).Conclusion:High-level athletes who undergo staged bilateral primary hip arthroscopy for femoroacetabular impingement syndrome may expect favorable PROs and RTS rates at minimum 2-year follow-up. These results were comparable with those of a propensity-matched control group of high-level athletes who underwent unilateral primary hip arthroscopy.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-10-15T02:34:33Z
      DOI: 10.1177/03635465211043491
       
  • Transtibial Versus Anteromedial Portal Technique for Femoral Tunnel
           Drilling in Primary Single-Bundle Anterior Cruciate Ligament
           Reconstruction: A Meta-analysis of Level 1 and 2 Evidence of Clinical,
           Revision, and Radiological Outcomes

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      Authors: Yunhe Mao, Kaibo Zhang, Jian Li, Weili Fu
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Although numerous clinical studies have compared transtibial (TT) and anteromedial portal (AMP) drilling of femoral tunnels during anterior cruciate ligament reconstruction (ACLR), there is no high-quality, evidence-based consensus regarding which technique affords the best outcome.Hypothesis:There would be no difference between the TT and AMP techniques in terms of knee stability, patient-reported outcomes, incidence of revision, and radiological results.Study Design:Meta-analysis; Level of evidence, 2.Methods:The PubMed and EMBASE databases were searched from inception to February 1, 2021. Level 1 and 2 clinical trials that compared TT and AM techniques were included. Data were meta-analyzed for the outcome measures of knee stability, patient-reported functional outcomes, incidence of revision, and radiological results. Dichotomous variables were presented as odds ratios (ORs), and continuous variables were presented as mean differences (MDs) and standard mean differences (SMDs).Results:The meta-analysis included 18 clinical studies, level of evidence 1 or 2, that involved 53,888 patients. Pooled data showed that the AMP group had a lower side-to-side difference (SMD, 0.22; 95% CI, 0.06 to 0.39; P = .009), a lower incidence of pivot-shift phenomenon (OR, 3.69; 95% CI, 1.26 to 10.79; P = .02), and a higher postoperative Lysholm score (SMD, −0.26; 95% CI, −0.44 to −0.08; P = .005) than the TT group. However, no statistically significant differences were seen in other outcomes, including subjective International Knee Documentation Committee scores (SMD, –0.11; 95% CI, –0.30 to 0.09; P = .30) or grades (OR, 0.93; 95% CI, 0.35 to 2.49; P = .89), postoperative activity level (MD, –0.14; 95% CI, –0.42 to 0.15; P = .35), and incidence of revision ACLR (OR, 1.04; 95% CI, 0.93 to 1.16; P = .45). The TT technique was more likely to create longer (SMD, 1.05; 95% CI, 0.05 to 2.06; P = .04) and more oblique (SMD, 0.81; 95% CI, 0.51 to 1.11; P < .001) femoral tunnels than the AMP technique, and a higher height ratio of the aperture position was detected with the TT technique (SMD, −3.51; 95% CI, −5.54 to −1.49; P < .001).Conclusion:The AMP technique for ACLR may be more likely to produce better knee stability and improved clinical outcomes than the TT technique, but no difference was found in the incidence of revision between the 2 groups.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-10-15T02:24:34Z
      DOI: 10.1177/03635465211044476
       
  • rAAV-Mediated sox9 Overexpression Improves the Repair of Osteochondral
           Defects in a Clinically Relevant Large Animal Model Over Time In Vivo and
           Reduces Perifocal Osteoarthritic Changes

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      Authors: Cliff Lange, Henning Madry, Jagadeesh K. Venkatesan, Gertrud Schmitt, Susanne Speicher-Mentges, David Zurakowski, Michael D. Menger, Matthias W. Laschke, Magali Cucchiarini
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Gene transfer of the transcription factor SOX9 with clinically adapted recombinant adeno-associated virus (rAAV) vectors offers a powerful tool to durably enhance the repair process at sites of osteochondral injuries and counteract the development of perifocal osteoarthritis (OA) in the adjacent articular cartilage.Purpose:To examine the ability of an rAAV sox9 construct to improve the repair of focal osteochondral defects and oppose perifocal OA development over time in a large translational model relative to control gene transfer.Study Design:Controlled laboratory study.Methods:Standardized osteochondral defects created in the knee joints of adult sheep were treated with rAAV-FLAG-hsox9 relative to control (reporter) rAAV-lacZ gene transfer. Osteochondral repair and degenerative changes in the adjacent cartilage were monitored using macroscopic, histological, immunohistological, and biochemical evaluations after 6 months. The microarchitecture of the subchondral bone was assessed by micro–computed tomography.Results:Effective, prolonged sox9 overexpression via rAAV was significantly achieved in the defects after 6 months versus rAAV-lacZ treatment. The application of rAAV-FLAG-hsox9 improved the individual parameters of defect filling, matrix staining, cellular morphology, defect architecture, surface architecture, subchondral bone, and tidemark as well as the overall score of cartilage repair in the defects compared with rAAV-lacZ. The overexpression of sox9 led to higher levels of proteoglycan production, stronger type II collagen deposition, and reduced type I collagen immunoreactivity in the sox9- versus lacZ-treated defects, together with decreased cell densities and DNA content. rAAV-FLAG-hsox9 enhanced semiquantitative histological subchondral bone repair, while the microstructure of the incompletely restored subchondral bone in the sox9 defects was not different from that in the lacZ defects. The articular cartilage adjacent to the sox9-treated defects showed reduced histological signs of perifocal OA changes versus rAAV-lacZ.Conclusion:rAAV-mediated sox9 gene transfer enhanced osteochondral repair in sheep after 6 months and reduced perifocal OA changes. These results underline the potential of rAAV-FLAG-hsox9 as a therapeutic tool to treat cartilage defects and afford protection against OA.Clinical Relevance:The delivery of therapeutic rAAV sox9 to sites of focal injuries may offer a novel, convenient tool to enhance the repair of osteochondral defects involving both the articular cartilage and the underlying subchondral bone and provide a protective role by reducing the extent of perifocal OA.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-10-13T02:50:11Z
      DOI: 10.1177/03635465211049414
       
  • Comparing Midterm Outcomes of High-Level Athletes Versus Nonathletes
           Undergoing Primary Hip Arthroscopy: A Propensity-Matched Comparison With
           Minimum 5-Year Follow-up

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      Authors: Andrew E. Jimenez, Peter F. Monahan, David R. Maldonado, Benjamin R. Saks, Hari K. Ankem, Payam W. Sabetian, Ajay C. Lall, Benjamin G. Domb
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:High-level athletes (HLAs) have been shown to have better short-term outcomes than nonathletes (NAs) after hip arthroscopy.Purpose:(1) To report midterm outcomes of HLAs after primary hip arthroscopy and (2) to compare their results with a propensity-matched cohort of NA patients.Study Design:Cohort study; Level of evidence, 3.Methods:Data were prospectively collected and retrospectively reviewed between February 2008 and November 2015 for HLAs (professional, college, or high school) who underwent primary hip arthroscopy in the setting of femoroacetabular impingement syndrome (FAIS). HLAs were included if they had preoperative, minimum 2-year, and minimum 5-year follow-up data for the modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), and Hip Outcome Score Sports-Specific Subscale (HOS-SSS). Radiographic and intraoperative findings, surgical procedures, patient-reported outcomes (PROs), patient acceptable symptomatic state (PASS), minimal clinically important difference (MCID), and return to sport were reported. The HLA study group was propensity-matched to a control group of NA patients for comparison.Results:A total 65 HLA patients (67 hips) were included in the final analysis with mean follow-up time of 74.6 ± 16.7 months. HLAs showed significant improvement in all PROs recorded, achieved high rates of MCID and PASS for mHHS (74.6% and 79.4%, respectively) and HOS-SSS (67.7% and 66.1%, respectively), and returned to sport at high rates (80.4%). When compared with the propensity-matched NA control group, HLAs reported higher baseline but comparable postoperative scores for the mHHS and NAHS. HLA patients achieved MCID and PASS for mHHS at similar rates as NA patients, but the HLA patients achieved PASS for HOS-SSS at higher rates that trended toward statistical significance (66.1% vs 48.4%; P = .07). NA patients underwent revision arthroscopic surgery at similar rates as HLA patients (14.9% vs 9.0%, respectively; P = .424).Conclusion:Primary hip arthroscopy results in favorable midterm outcomes in HLAs. When compared with a propensity-matched NA control group, HLAs demonstrated a tendency toward higher rates of achieving PASS for HOS-SSS but similar arthroscopic revision rates at minimum 5-year follow-up.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-10-13T02:44:11Z
      DOI: 10.1177/03635465211041763
       
  • Adipose-Derived Stem Cell Sheets Improve Early Biomechanical Graft
           Strength in Rabbits After Anterior Cruciate Ligament Reconstruction

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      Authors: Tatsuaki Matsumoto, Yuiko Sato, Tami Kobayashi, Kunika Suzuki, Atsushi Kimura, Tomoya Soma, Eri Ito, Toshiyuki Kikuchi, Shu Kobayashi, Kengo Harato, Yasuo Niki, Morio Matsumoto, Masaya Nakamura, Takeshi Miyamoto
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Although various reconstruction techniques are available for anterior cruciate ligament (ACL) injuries, a long recovery time is required before patients return to sports activities, as the reconstructed ACL requires time to regain strength. To date, several studies have reported use of mesenchymal stem cells in orthopaedic surgery; however, no studies have used adipose-derived stem cell (ADSC) sheets in ACL reconstruction (ACLR).Hypothesis:ADSC sheet transplantation can improve biomechanical strength of the autograft used in ACLR.Study Design:Controlled laboratory study.Methods:A total of 68 healthy Japanese white rabbits underwent unilateral ACLR with a semitendinosus tendon autograft after random enrollment into a control group (no sheet; n = 34) and a sheet group (ADSC sheet; n = 34). At 2, 4, 8, 16, and 24 weeks after surgery, rabbits in each group were sacrificed to evaluate tendon-bone healing using histological staining, micro–computed tomography, and biomechanical testing. At 24 weeks, scanning transmission electron microscopy of the graft midsubstance was performed.Results:The ultimate failure load for the control and sheet groups, respectively, was as follows: 17.2 ± 5.5 versus 37.3 ± 10.3 (P = .01) at 2 weeks, 28.6 ± 1.9 versus 47.4 ± 10.4 (P = .003) at 4 weeks, 53.0 ± 14.3 versus 48.1 ± 9.3 (P = .59) at 8 weeks, 66.2 ± 9.3 versus 95.2 ± 43.1 (P = .24) at 16 weeks, and 66.7 ± 27.3 versus 85.3 ± 29.5 (P = .39) at 24 weeks. The histological score was also significantly higher in the sheet group compared with the control group at early stages up to 8 weeks. On micro–computed tomography, relative to the control group, the bone tunnel area was significantly narrower in the sheet group at 4 weeks, and the bone volume/tissue volume of the tendon-bone interface was significantly greater at 24 weeks. Scanning transmission electron microscopy at 24 weeks indicated that the mean collagen fiber diameter in the midsubstance was significantly greater, as was the occupation ratio of collagen fibers per field of view, in the sheet group.Conclusion:ADSC sheets improved biomechanical strength, prevented bone tunnel enlargement, and promoted tendon-bone interface healing and graft midsubstance healing in an in vivo rabbit model.Clinical Relevance:ADSC sheets may be useful for early tendon-bone healing and graft maturation in ACLR.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-10-13T02:37:36Z
      DOI: 10.1177/03635465211041582
       
  • Complications Related to Latarjet Shoulder Stabilization: A Systematic
           Review

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      Authors: Chul-Hyun Cho, Sang Soo Na, Byung-Chan Choi, Du-Han Kim
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:In cases of recurrent anterior shoulder instability with a glenoid defect, Latarjet procedures are widely used for stabilization. Although complications with this procedure have been reported, few studies have comprehensively analyzed issues related to the Latarjet procedure.Purpose:To identify the overall complication rate of the Latarjet procedure used for anterior shoulder instability and to compare the rate of complications between arthroscopic and open approaches.Study Design:Systematic review; Level of evidence, 4.Methods:PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed by using the PubMed, EMBASE, Scopus, and Cochrane Library databases. Data on complications were extracted and classified as intraoperative, postoperative, or instability-related for further analysis. Quality assessments were performed with criteria from the Methodological Index for Nonrandomized Studies (MINORS). A quantitative synthesis of data was conducted to compare the complication rates between arthroscopic and open approaches.Results:A total of 35 articles were included in this analysis. The MINORS score was 11.89. A total 2560 Latarjet procedures (2532 patients) were included. The overall complication rate was 16.1% (n = 412). The intraoperative complication rate was 3.4% (n = 87) and included a 1.9% (n = 48) incidence of nerve injuries and a 1.0% (n = 25) incidence of iatrogenic fractures. Screw problems, vascular injuries, and conversion arthroscopic to open surgery each occurred at a rate of
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-10-11T04:04:07Z
      DOI: 10.1177/03635465211042314
       
  • Securing Transplanted Meniscal Allografts Using Bone Plugs Results in
           Lower Risks of Graft Failure and Reoperations: A Meta-analysis

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      Authors: Zachariah Gene Wing Ow, Chin Kai Cheong, Hao Han Hai, Cheng Han Ng, Dean Wang, Aaron J. Krych, Daniel B.F. Saris, Keng Lin Wong, Heng An Lin
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Meniscal allograft transplant (MAT) is an important treatment option for young patients with deficient menisci; however, there is a lack of consensus on the optimal method of allograft fixation.Hypothesis:The various methods of MAT fixation have measurable and significant differences in outcomes.Study Design:Meta-analysis; Level of evidence, 4.Methods:A single-arm meta-analysis of studies reporting graft failure, reoperations, and other clinical outcomes after MAT was performed. Studies were stratified by suture-only, bone plug, and bone bridge fixation methods. Proportionate rates of failure and reoperation for each fixation technique were pooled with a mixed-effects model, after which reconstruction of relative risks with confidence intervals was performed using the Katz logarithmic method.Results:A total of 2604 patients underwent MAT. Weighted mean follow-up was 4.3 years (95% CI, 3.2-5.6 years). During this follow-up period, graft failure rates were 6.2% (95% CI, 3.2%-11.6%) for bone plug fixation, 6.9% (95% CI, 4.5%-10.3%) for suture-only fixation, and 9.3% (95% CI, 6.2%-13.9%) for bone bridge fixation. Transplanted menisci secured using bone plugs displayed a lower risk of failure compared with menisci secured via bone bridges (RR = 0.97; 95% CI, 0.94-0.99; P = .02). Risks of failure were not significantly different when comparing suture fixation to bone bridge (RR = 1.02; 95% CI, 0.99-1.06; P = .12) and bone plugs (RR = 0.99; 95% CI, 0.96-1.02; P = .64). Allografts secured using bone plugs were at a lower risk of requiring reoperations compared with those secured using sutures (RR = 0.91; 95% CI, 0.87-0.95; P < .001), whereas allografts secured using bone bridges had a higher risk of reoperation when compared with those secured using either sutures (RR = 1.28; 95% CI, 1.19-1.38; P < .001) or bone plugs (RR = 1.41; 95% CI, 1.32-1.51; P < .001). Improvements in Lysholm and International Knee Documentation Committee scores were comparable among the different groups.Conclusion:This meta-analysis demonstrates that bone plug fixation of transplanted meniscal allografts carries a lower risk of failure than the bone bridge method and has a lower risk of requiring subsequent operations than both suture-only and bone bridge methods of fixation. This suggests that the technique used in the fixation of a transplanted meniscal allograft is an important factor in the clinical outcomes of patients receiving MATs.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-10-11T03:59:16Z
      DOI: 10.1177/03635465211042014
       
  • The Fragility of Statistical Significance in Patellofemoral Instability
           Research: A Systematic Review

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      Authors: Michael Constant, David P. Trofa, Bryan M. Saltzman, Christopher S. Ahmad, Xinning Li, Robert L. Parisien
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Fragility analysis is increasingly utilized to evaluate the robustness of results within the orthopaedic literature and has frequently revealed instability of reported outcomes.Purpose/Hypothesis:The purpose of this investigation was to utilize a fragility analysis to evaluate the stability of reported results in the patellofemoral instability (PFI) literature. We hypothesized the demonstration of significant fragility in patellofemoral research to be similar to that identified throughout other areas of the orthopaedic literature.Study Design:Systematic review; Level of evidence, 4.Methods:The PubMed database was queried from January 1, 2000, to October 10, 2020 for comparative trials in 10 prominent orthopaedic journals that reported dichotomous outcomes related to the management of PFI. The fragility index (FI) and the fragility quotient (FQ) were calculated for each individual outcome event, and the overall FI and FQ were determined for all included studies.Results:A total of 22 comparative studies comprising 11 randomized controlled trials and 11 nonrandomized trials were included for the analysis. A total of 75 outcome events underwent a fragility analysis and revealed a median FI and FQ of 3 (interquartile range [IQR], 1-5) and 0.043 (IQR, 0.018-0.081), respectively. Also 27% of included studies reported loss to follow-up greater than the overall FI, therefore suggesting the maintenance of the follow-up may have resulted in the reversal of significance.Conclusion:The result of the comprehensive fragility analysis demonstrated a lack of robustness in PFI research with the alteration of only a few outcome events required to reverse statistical significance. We therefore recommend the triple reporting of the P value, the FI, and the FQ to aid in the interpretation of the statistical integrity of future comparative trials in the PFI literature.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-10-11T03:47:46Z
      DOI: 10.1177/03635465211039202
       
  • Clinical and Functional Outcomes by Graft Type in Superior Capsular
           Reconstruction: A Systematic Review and Meta-analysis

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      Authors: Alexander Lee, Ali S. Farooqi, David Novikov, Xinning Li, John D. Kelly, Robert L. Parisien
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:In recent years, superior capsular reconstruction (SCR) has emerged as a promising treatment for massive rotator cuff tears and has been performed with an array of graft options, most commonly dermal allograft and tensor fascia lata (TFL) autograft.Purpose:To compare the clinical outcomes, functional outcomes, and complication rates after SCR performed with dermal allograft, TFL autograft, long head of the biceps tendon (LHBT) autograft, and porcine xenograft.Study Design:Meta-analysis; Level of evidence, 4.Methods:PubMed, Cochrane Library, and Embase were systematically reviewed for studies that enrolled ≥10 patients who underwent SCR and presented clinical outcome data at a minimum follow-up of 12 months. When available, pre- and postoperative patient-reported outcome scores and clinical examination data were extracted. Outcome data were then compared by graft type. A meta-analysis was also conducted of graft tear and reoperation rates after SCR with dermal allograft and TFL autograft.Results:Human dermal allograft and TFL autograft were each utilized in 7 studies, LHBT autograft in 2 studies, and porcine xenograft in 1 study. Dermal allograft, TFL autograft, and LHBT autograft demonstrated comparable median (range) postoperative American Shoulder and Elbow Surgeons scores of 85.3 (77.5-89), 88.6 (73.7-94.3), and 82.7 (80-85.4), respectively. The median postoperative pain scores per visual analog scale for dermal allograft, TFL autograft, and LHBT autograft were 0.8, 2.5, and 1.4. Median postoperative forward elevation was 159.0°, 147.0°, 163.8°, and 151.4° for dermal allograft, TFL autograft, LHBT autograft, and porcine xenograft. Meta-analysis demonstrated a comparable pooled graft tear rate between TFL autograft (9%; 95% CI, 4%-16%) and dermal allograft (7%; 95% CI, 2%-13%). Similarly, the pooled reoperation rate was similar for TFL autograft (3%; 95% CI, 0%-7%) and dermal allograft (6%; 95% CI, 2%-12%). Among the 3 studies with pre- and postoperative information on pseudoparalysis, 73 of 76 (96%) patients with an intact/repairable subscapularis had a reversal of their pseudoparalysis after SCR.Conclusion:Dermal allograft, TFL autograft, and LHBT autograft are all suitable options for SCR and demonstrate significant improvements in American Shoulder and Elbow Surgeons score, pain score per visual analog scale, and forward elevation. Moreover, dermal allograft and TFL autograft have comparable rates of graft tear and reoperation.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-10-11T03:21:04Z
      DOI: 10.1177/03635465211040440
       
  • Are Outcomes of Acute Meniscus Root Tear Repair Better Than Debridement or
           Nonoperative Management' A Systematic Review

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      Authors: Kelechi C. Eseonu, Jill Neale, Amy Lyons, Stefan Kluzek
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Meniscus root tears (MRTs) are defined as radial tears within 1 cm of the meniscus root insertion or an avulsion of the meniscus root itself. They lead to altered joint loading because of the failure to convert axial (compressive) loads into hoop stresses. Untreated MRTs can result in altered joint biomechanics and accelerated articular cartilage degeneration and the development of osteoarthritis (OA), yet optimal management remains unclear.Purpose:To review treatment outcomes after acute MRTs by surgical repair, debridement, meniscectomy, or nonoperative treatment.Design:Systematic review; Level of evidence, 4.Methods:A systematic review of the evidence from human clinical studies was conducted with electronic searches of the PUBMED, Medline, EMBASE, and the Cochrane Library databases. One reviewer extracted the data and 2 reviewers assessed the risk of bias and performed synthesis of the evidence.Results:Eleven studies of low to moderate methodological quality were identified. All treatment options improved functional scores after>12 months. Arthroscopic repair may be associated with better functional outcomes when compared with partial meniscectomy and nonoperative management at 12-month follow-up. Radiographic progression of OA occurred in all treatment groups; there was some evidence that this was delayed after repair when compared with other treatments. Baseline severity of meniscal extrusion, varus malalignment, and pretreatment degeneration were predictors of poor functional outcomes. Age was not found to be an independent predictor of functional outcome.Conclusion:The current level 3 and 4 evidence suggests that arthroscopic repair may result in slower progression of radiological deterioration compared with meniscectomy and nonoperative management. The current literature does not support the exclusion of patients from MRT repair on the basis of age. Patients undergoing acute MRT treatments (repair, debridement, or nonoperative) can be expected to experience improvement in functional outcomes after>12 months. The strength of conclusions are limited because of the paucity of high-quality studies on this subject. Further studies, preferably randomized sham controlled trials with function-oriented rehabilitation programs, are needed to compare treatment strategies and stratification of care based on the risk of meniscal extrusion.Registration:CRD42018085092 (PROSPERO).
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-10-11T03:15:01Z
      DOI: 10.1177/03635465211031250
       
  • Association of Preoperative Tibial Varus Deformity With Joint Line
           Orientation and Clinical Outcome After Open-Wedge High Tibial Osteotomy
           for Medial Compartment Osteoarthritis: A Propensity Score–Matched
           Analysis

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      Authors: Jun-Gu Park, Seung-Beom Han, Ki-Mo Jang
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:The correction of lower limb deformity should be performed at the site of deformity to maintain knee joint orientation. However, the effectiveness of open-wedge high tibial osteotomy (OWHTO) for treatment of medial osteoarthritis in varus malalignment without definite tibial varus deformity has not been confirmed.Purpose/Hypothesis:This study aimed to compare the clinical and radiologic outcomes after OWHTO in patients without tibial varus deformity versus patients with tibial varus deformity after matching for confounding factors. We hypothesized that these outcomes would be inferior in patients without tibial varus deformity.Study Design:Cohort study; Level of evidence, 3.Methods:The outcomes of 133 OWHTO operations for medial osteoarthritis in 107 patients were retrospectively reviewed after follow-up for>2 years. The patients were divided into group 1 (tibia with varus deformity, preoperative medial proximal tibial angle [MPTA] 10 points in the KSS functional score and 15 points in the WOMAC functional score based on MCID or minimally important change. Meanwhile, 65.6% and 81.3% of patients in group 2, which were significantly lower than those of group 1, were improved beyond the MCID or minimally important change (P = .001 and .024, respectively).Conclusion:In varus malalignment, the knee joint line was more oblique in patients without tibial varus deformity after OWHTO pre- and postoperatively. The clinical outcomes in terms of functional scores were inferior in patients without tibial varus deformity. However, the radiologic outcomes and symptomatic improvement after OWHTO were comparable regardless of the preoperative tibial varus deformity on midterm follow-up.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-10-08T05:43:01Z
      DOI: 10.1177/03635465211044146
       
  • Higher Rate of Return to Preinjury Activity Levels After Anterior Cruciate
           Ligament Reconstruction With a Bone–Patellar Tendon–Bone Versus
           Hamstring Tendon Autograft in High-Activity Patients: Results From the New
           Zealand ACL Registry

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      Authors: Richard Rahardja, Hamish Love, Mark G. Clatworthy, Andrew Paul Monk, Simon W. Young
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:In primary anterior cruciate ligament (ACL) reconstruction, a bone–patellar tendon–bone (BTB) autograft is associated with lower ipsilateral failure rates. BTB autografts are associated with a higher rate of contralateral ACL injuries, which some clinicians view as a marker of success of the BTB autograft. However, there is a lack of evidence on whether BTB autografts improve the rate of return to activity and sport.Purpose:To compare the rate of return to preinjury activity levels in high-activity patients after ACL reconstruction with BTB autograft or hamstring tendon autograft.Study Design:Cohort study; Level of evidence, 3.Methods:In a high-activity cohort of patients recorded between 2014 and 2018 in the New Zealand ACL Registry, prospectively collected data on preinjury and postoperative Marx activity scores were analyzed. The proportion of patients who returned to their preinjury activity levels at 1- and 2-year follow-up was compared between graft types.Results:Overall, 11.3% (208/1844) of patients returned to their preinjury activity levels at 1-year follow-up, and 15.5% (184/1190) returned at 2-year follow-up. At 1-year follow-up, 17.2% of patients with a BTB autograft returned to their preinjury activity levels compared with 9.3% of patients with a hamstring tendon autograft (adjusted odds ratio, 1.59 [95% CI, 1.16-2.17]; P = .004). At 2-year follow-up, 23.3% of patients with a BTB autograft had returned to their preinjury activity levels compared with 13.3% of patients with a hamstring tendon autograft (adjusted odds ratio, 1.63 [95% CI, 1.14-2.34]; P = .008). Male sex and younger age were associated with a higher rate of return to activity at both follow-up time points.Conclusion:The use of BTB autografts increased the odds of returning to preinjury activity levels at early follow-up. A higher rate of return to activity is a possible explanation for the higher rate of contralateral ACL injuries with the use of BTB autografts.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-10-08T05:42:01Z
      DOI: 10.1177/03635465211044142
       
  • Irreparable Large to Massive Rotator Cuff Tears With Low-Grade Fatty
           Degeneration of the Infraspinatus Tendon: Minimum 7-Year Follow-up of
           Fascia Autograft Patch Procedure and Partial Repair

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      Authors: Daisuke Mori, Kazuha Kizaki, Noboru Funakoshi, Fumiharu Yamashita, Yasuyuki Mizuno, Takaaki Shirai, Masahiko Kobayashi
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:In shoulders with irreparable massive rotator cuff tears (RCTs) with high-grade fatty degeneration (Goutallier stage 3 or 4) of the supraspinatus tendon and low-grade fatty degeneration (Goutallier stage 1 or 2) of the infraspinatus tendon (ISP), arthroscopic patch grafting (PG) has been reported as superior to partial repair (PR) regarding the ISP retear rate at short-term to midterm follow-up. However, the longer term outcomes are unclear.Purpose:To compare clinical and structural outcomes in the PG and PR groups at a minimum of 7 years postoperatively.Study Design:Cohort study; Level of evidence, 3.Methods:We evaluated 24 patients in the PG group and 24 patients in the PR group. We primarily used the Constant score for clinical outcomes and performed magnetic resonance imaging for structural outcomes in the PG and PR groups. The risk factors for a retear of the ISP were identified by univariate and multivariate (forward stepwise selection method) logistic regression analyses. We primarily compared values at midterm follow-up (
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-10-08T05:40:57Z
      DOI: 10.1177/03635465211043501
       
  • Increased Shoulder Distraction Force and Shoulder Horizontal Abduction in
           Professional Baseball Pitchers With Discordant Torso Rotation Order

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      Authors: Joseph E. Manzi, Brittany Dowling, Joshua S. Dines, Alexander Richardson, Kathryn L. McElheny, James B. Carr
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Inefficient energy transfer from the pelvis and trunk has been shown to increase compensation at the level of the shoulder. Kinetic chain sequencing of the core segments is underexamined in professional baseball pitchers, especially as it relates to changes in upper extremity kinetics.Purpose:To evaluate elbow and shoulder kinetics in a cohort of professional pitchers differentiated by instances of discordant pelvic to upper torso sequencing during the pitch.Study Design:Descriptive laboratory study.Methods:285 professional baseball pitchers were evaluated using 3D motion capture (480 Hz). Pitchers were divided into “chronological” and “discordant” groups based on whether maximum pelvic rotation velocity occurred before (chronological) or after (discordant) maximum upper torso rotation velocity during the pitch motion. Pelvic, upper torso, and shoulder kinematic parameters, shoulder distraction force, shoulder internal rotation torque, and pitch efficiency (PE) were compared between groups.Results:Pitchers with discordant torso sequencing (n = 30; 110 pitches) had greater shoulder horizontal adduction at maximum external rotation (mean difference, 3.6°; 95% CI, −5.2° to −2.0°; t = −4.5; P < .001) and greater maximum shoulder external rotation (mean difference, 3.7°; 95% CI, 5.7° to 1.5°; t = −3.5; P < .001) than chronological pitchers (n = 255; 2974 pitches). PE did not differ between groups (P = .856), whereas ball velocity was significantly faster in the discordant group (mean difference, 0.6 m/s; 95% CI, −1.1 to −0.3 m/s; t = −3.3; P = .0012). Chronological pitchers had significantly reduced shoulder distraction force (mean difference, −4.7% body weight (BW); 95% CI, −7.9% to −1.5% BW; t = −2.9; P = .004) with no difference in shoulder internal rotation torque (P = .160). These kinematic and kinetic differences were not observed when accounting for interpitcher variability.Conclusion:Between pitchers, those who had a discordant pelvic to upper torso sequence experienced significantly greater shoulder distraction forces, potentially compensating by increasing maximum shoulder external rotation and horizontal abduction. Achieving maximal pelvic rotation velocity before maximal rotation velocity may be advantageous in preventing compensation at the upper extremity and excessive throwing arm loading.Clinical Relevance:Identifying risk factors for increased upper extremity forces has potential implications in injury prevention. Specifically, mitigating shoulder distraction forces may be beneficial in reducing risk of injury.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-10-08T05:34:54Z
      DOI: 10.1177/03635465211041381
       
  • High Risk of New Knee Injuries in Female Soccer Players After Primary
           Anterior Cruciate Ligament Reconstruction at 5- to 10-Year Follow-up

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      Authors: Anne Fältström, Joanna Kvist, Martin Hägglund
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:A new anterior cruciate ligament (ACL) injury after ACL reconstruction is a feared outcome.Purpose:To study the risk of new knee injuries in female soccer players 5 to 10 years after primary unilateral ACL reconstruction and to compare players who returned to soccer with (1) players who did not return and (2) knee-healthy soccer players (controls).Study Design:Cohort study; Level of evidence, 2.Methods:Demographic, soccer-specific, and surgical data were recorded at baseline for 317 female soccer players (mean ± SD age, 20.1 ± 2.7 years) 1.6 ± 0.7 years after ACL reconstruction and for 119 matched controls (mean age, 19.5 ± 2.5 years). Data on new knee injuries and soccer-playing status were collected 5 to 10 years after ACL reconstruction via a questionnaire.Results:Among players with ACL reconstruction, 222 (70%) responded at a mean 6.5 ± 1.0 years after primary ACL reconstruction. We compared 3 cohorts: (1) among 163 players with ACL reconstruction who returned to soccer, 68 (42%) sustained 44 reruptures and 29 contralateral ruptures; (2) among 59 players with ACL reconstruction who did not return to soccer, 11 (19%) sustained 9 reruptures and 2 contralateral ruptures; and (3) among 113 knee-healthy controls, 12 (11%) sustained 13 ACL injuries. Players who returned had a>2-fold higher risk of a new ACL injury than players who did not return (risk ratio, 2.24; 95% CI, 1.27-3.93; P = .005) and a 4-fold higher risk than controls (risk ratio, 3.93; 95% CI, 2.23-6.91; P
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-10-08T05:31:19Z
      DOI: 10.1177/03635465211044458
       
  • Association of the Psychological Response to the ACL-SPORTS Training
           Program and Self-reported Function at 2 Years After Anterior Cruciate
           Ligament Reconstruction

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      Authors: Ryan Zarzycki, Elanna Arhos, Mathew Failla, Jacob Capin, Angela H. Smith, Lynn Snyder-Mackler
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Psychological readiness to return to sport has emerged as an important factor associated with outcomes after anterior cruciate ligament reconstruction (ACLR). Psychological factors are potentially modifiable during the course of rehabilitation, and improving them may lead to better outcomes.Purpose:To determine whether athletes with a positive psychological response after participation in a neuromuscular training and second injury prevention program had better self-reported function and activity outcomes compared with athletes who did not have a meaningful change.Study Design:Cohort study; Level of evidence, 3.Methods:After ACLR and the completion of formal rehabilitation, 66 level I/II athletes completed the following self-reported measures at enrollment (pretraining): the Anterior Cruciate Ligament–Return to Sport after Injury (ACL-RSI) scale, the International Knee Documentation Committee (IKDC) subjective knee form, and the 5 subscales of the Knee injury and Osteoarthritis Outcome Score (KOOS). Participants completed these measures after 10 sessions of agility, plyometric, and progressive strength training and at 1 and 2 years after ACLR. Participants who displayed an increase in the ACL-RSI score from pretraining to posttraining that exceeded the minimal clinically important difference (≥10 points) were defined as having a positive psychological response (responders) to training, and those who did not were defined as nonresponders. A mixed-model analysis of variance was used to determine if group differences in IKDC and KOOS scores existed over the 4 time points (pretraining, posttraining, and the 1- and 2-year follow-ups).Results:The responders reported better self-reported function compared with the nonresponders, regardless of time, on the IKDC form (P = .001), KOOS–Sport and Recreation (P = .014), KOOS-Pain (P = .007), and KOOS-Symptoms (P = .002) but not on the KOOS–Quality of Life (P = .078). Overall, 77% of responders and 67% of nonresponders returned to their previous level of sport by 1 year after ACLR (P = .358), and 82% of responders and 78% of nonresponders returned to their previous level of sport by 2 years after ACLR (P = .668).Conclusion:Ultimately, 59% of the athletes in this study displayed a meaningful improvement in their psychological outlook over the course of the training program. Responders demonstrated persistently better self-reported function at posttraining and at 1 and 2 years after ACLR, but there were no between-group differences in return-to-sport rates.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-10-08T05:20:14Z
      DOI: 10.1177/03635465211045388
       
  • Hip Dislocation and Subluxation in Athletes: A Systematic Review

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      Authors: Deepak V. Chona, Paul D. Minetos, Christopher M. LaPrade, Mark E. Cinque, Geoffrey D. Abrams, Seth L. Sherman, Marc R. Safran
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Hip dislocation is a rare occurrence during sports but carries serious implications for athletes.Purpose:To systematically review treatment strategies and outcomes for hip dislocation in athletes, with the ultimate goal of providing sports medicine physicians with the information necessary to appropriately treat and counsel patients sustaining this injury.Study Design:Systematic review; Level of evidence, 4.Methods:PubMed, MEDLINE, and Embase were searched for studies relating to hip instability and athletics from January 1, 1989 to October 1, 2019. s and articles were evaluated on the basis of predefined inclusion and exclusion criteria. Inclusion criteria were the following: (1) data from ≥1 patients, (2) native hip dislocation or subluxation occurring during sports, (3) patients aged at least 10 years, and (4) written in English. Exclusion criteria were (1) patients younger than 10 years; (2) nonnative or postoperative hip dislocation or subluxation; (3) a native hip injury without dislocation or subluxation; (4) patients with dislocation or subluxation secondary to neuromuscular, developmental, or syndromic causes; (5) dislocation or subluxation not occurring during sports; (6) patients with physeal fractures; or (7) review articles or meta-analyses. Data were recorded on patient demographics, injury mechanism, treatment strategies, and clinical and radiographic outcomes. Where possible, pooled analysis was performed. Studies were grouped based on reported outcomes. Meta-analysis was then performed on these pooled subsets.Results:A total of 602 articles were initially identified, and after screening by 2 reviewers, 27 articles reporting on 145 patients were included in the final review. There were 2 studies that identified morphological differences between patients with posterior dislocation and controls, including decreased acetabular anteversion (P = .015 and .068, respectively), increased prevalence of a cam deformity (P < .0035), higher alpha angles (P≤ .0213), and decreased posterior acetabular coverage (P < .001). No differences were identified for the lateral center edge angle or Tonnis angle. Protected postreduction weightbearing was most commonly prescribed for 2 to 6 weeks, with 65% of reporting authors recommending touchdown, toe-touch, or crutch-assisted weightbearing. Recurrence was reported in 3% of cases. Overall, 4 studies reported on findings at hip arthroscopic surgery, including a 100% incidence of labral tears (n = 27; 4 studies), 92% incidence of chondral injuries, 20% incidence of capsular tears, and 84% incidence of ligamentum teres tears (n = 25; 2 studies). At final follow-up, 86% of patients reported no pain (n = 14; 12 studies), 87% reported a successful return to play (n = 39; 10 studies), and 11% had radiographic evidence of osteonecrosis (n = 38; 10 studies).Conclusion:Various treatment strategies have been described in the literature, and multiple methods have yielded promising clinical and radiographic outcomes in patients with native hip dislocation sustained during sporting activity. Data support nonoperative treatment with protected weightbearing for hips with concentric reduction and without significant fractures and an operative intervention to obtain concentric reduction if unachievable by closed means alone. Imaging for osteonecrosis is recommended, with evidence suggesting 4- to 6-week magnetic resonance imaging and follow-up at 3 months for those with suspicious findings in the femoral head.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-10-08T05:14:41Z
      DOI: 10.1177/03635465211036104
       
  • Mini-open Repair for Acute Achilles Tendon Rupture: Ring Forceps vs the
           Achillon Device

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      Authors: Chul Hyun Park, Hongfei Yan, Jeongjin Park, Min Cheol Chang
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Repair of acute Achilles tendon rupture using the Achillon device is a representative mini-open repair technique; however, the limitations of this technique include the need for special instruments and decreased repair strength. A modified mini-open repair using ring forceps might overcome these limitations.Purpose:To compare the Achillon device with ring forceps in mini-open repairs of acute Achilles tendon rupture.Study Design:Cohort study; Level of evidence, 3.Methods:Fifty patients (41 men and 9 women) with acute Achilles tendon rupture on 1 foot were consecutively treated using mini-open repair techniques. The first 20 patients were treated using the Achillon device (Achillon group), and the subsequent 30 were treated using a ring forceps (forceps group). Clinical, functional, and isokinetic results and postoperative complications were compared between the groups at the last follow-up. Clinical evaluations were performed using the AOFAS (American Orthopaedic Foot and Ankle Society) score, Achilles Tendon Total Rupture Score, length of incision, and operation time. Functional evaluations included active range of motion of the ankle joint, maximum calf circumference, hopping test, and single-limb heel rise (SLHR). Isokinetic evaluations were performed using the isokinetic test for ankle plantar flexion.Results:The AOFAS score (P = .669), Achilles Tendon Total Rupture Score (P = .753), and length of incision (P = .305) were not significantly different between the groups (mean ± SD, 90.1 ± 8.7, 88.3 ± 9.9, and 2.7 ± 0.3 cm in the Achillon group vs 92.2 ± 9.4, 89.9 ± 10.9, and 2.5 ± 0.4 cm in the forceps group, respectively). Operation times in the Achillon group were significantly shorter than those in the forceps group (41.4 ± 9.6 vs 62.8 ± 14.1 minutes, P < .001). The maximum height of the SLHR (P = .042) and the number of SLHRs (P = .043) in the forceps group (79.7% ± 7.4% and 72.9% ± 10.2%) were significantly greater than those in the Achillon group (75.3% ± 7.1% and 66.7% ± 11.0%). No significant differences were detected between the groups in mean peak torques for plantar flexion at angular speeds of 30 deg/s (P = .185) and 120 deg/s (P = .271). There was no significant difference in the occurrence of postoperative complications between the groups (P = .093).Conclusion:The ring forceps technique is comparable to the Achillon technique with respect to clinical, functional, and isokinetic results and postoperative complications. Given that no special instrument is required, the ring forceps technique could be a better option for acute Achilles tendon rupture repair.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-10-06T03:03:23Z
      DOI: 10.1177/03635465211044464
       
  • A High-Sensitivity International Knee Documentation Committee Survey Index
           From the PROMIS System: The Next-Generation Patient-Reported Outcome for a
           Knee Injury Population

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      Authors: Matthew S. Tenan, Richard J. Robins, Andrew J. Sheean, Travis J. Dekker, James R. Bailey, Husain M. Bharmal, Matthew W. Bradley, Kenneth L. Cameron, Travis C. Burns, Brett A. Freedman, Joseph W. Galvin, Eric S. Grenier, Chad A. Haley, Andrew P. Hurvitz, Lance E. LeClere, Ian Lee, Timothy Mauntel, Lucas S. McDonald, Leon J. Nesti, Brett D. Owens, Matthew A. Posner, Benjamin K. Potter, Matthew T. Provencher, Daniel I. Rhon, Christopher J. Roach, Paul M. Ryan, Matthew R. Schmitz, Mark A. Slabaugh, Christopher J. Tucker, William R. Volk, Jonathan F. Dickens, John A. Feagin
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Patient-reported outcomes (PROs) measure progression and quality of care. While legacy PROs such as the International Knee Documentation Committee (IKDC) survey are well-validated, a lengthy PRO creates a time burden on patients, decreasing adherence. In recent years, PROs such as the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function and Pain Interference surveys were developed as computer adaptive tests, reducing time to completion. Previous studies have examined correlation between legacy PROs and PROMIS; however, no studies have developed effective prediction models utilizing PROMIS to create an IKDC index. While the IKDC is the standard knee PRO, computer adaptive PROs offer numerous practical advantages.Purpose:To develop a nonlinear predictive model utilizing PROMIS Physical Function and Pain Interference to estimate IKDC survey scores and examine algorithm sensitivity and validity.Study Design:Cohort study (diagnosis); Level of evidence, 3.Methods:The MOTION (Military Orthopaedics Tracking Injuries and Outcomes Network) database is a prospectively collected repository of PROs and intraoperative variables. Patients undergoing knee surgery completed the IKDC and PROMIS surveys at varying time points. Nonlinear multivariable predictive models using Gaussian and beta distributions were created to establish an IKDC index score, which was then validated using leave-one-out techniques and minimal clinically important difference analysis.Results:A total of 1011 patients completed the IKDC and PROMIS Physical Function and Pain Interference, providing 1618 complete observations. The algorithms for the Gaussian and beta distribution were validated to predict the IKDC (Pearson = 0.84-0.86; R2 = 0.71-0.74; root mean square error = 9.3-10.0).Conclusion:The publicly available predictive models can approximate the IKDC score. The results can be used to compare PROMIS Physical Function and Pain Interference against historical IKDC scores by creating an IKDC index score. Serial use of the IKDC index allows for a lower minimal clinically important difference than the conventional IKDC. PROMIS can be substituted to reduce patient burden, increase completion rates, and produce orthopaedic-specific survey analogs.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-10-06T02:59:21Z
      DOI: 10.1177/03635465211041593
       
  • MRI Signal Intensity of Quadriceps Tendon Autograft and Hamstring Tendon
           Autograft 1 Year After Anterior Cruciate Ligament Reconstruction in
           Adolescent Athletes

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      Authors: Alexandra H. Aitchison, David Alcoloumbre, Douglas N. Mintz, Sofia Hidalgo Perea, Joseph T. Nguyen, Frank A. Cordasco, Daniel W. Green
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Hamstring tendon autograft (HTA) is a common graft choice for anterior cruciate ligament (ACL) reconstruction (ACLR) in skeletally immature patients. Recently, the use of quadriceps tendon autograft (QTA) has shown superior preliminary outcomes in this population.Purpose:To evaluate graft maturity by comparing magnetic resonance imaging (MRI) signal intensity of HTA versus QTA used in primary ACLR.Study Design:Cohort study; Level of evidence, 3.Methods:All patients under the age of 18 years who underwent a primary ACLR by the senior authors using either an HTA or a QTA were retrospectively reviewed. A total of 70 skeletally immature patients (37 in the HTA group and 33 in the QTA group) with an available MRI at 6 and 12 months postoperatively were included. Signal intensity ratio (SIR) was measured on sagittal MRI by averaging the signal at 3 regions of interest along the ACL graft and dividing by the signal of the tibial footprint of the posterior cruciate ligament. Statistical analysis was performed to determine interrater reliability and differences between time points and groups.Results:Age, sex, and type of surgery were not associated with any differences in SIR. There was no significant difference in SIR between groups on the 6-month MRI. However, the SIR of the QTA group was significantly less than in the HTA group on the 12-month MRI (2.33 vs 2.72, respectively; P = .028). Within the HTA group, there was no significant difference in SIR at either MRI time point. In the QTA group, there was a significant decrease in SIR between the 6-month and 12-month postoperative MRI (2.70 vs 2.33, respectively; P = .045).Conclusion:These findings suggest improved graft maturation, remodeling, and structural integrity of the QTA compared with the HTA between 6 and 12 months postoperatively. This provides evidence that, at 1 year postoperatively, QTA may have a superior rate of incorporation and synovialization as compared with the HTA.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-10-06T02:54:06Z
      DOI: 10.1177/03635465211040472
       
  • Corrigendum to “Back to Normal Symmetry' Biomechanical Variables
           Remain More Asymmetrical Than Normal During Jump and Change-of-Direction
           Testing 9 Months After Anterior Cruciate Ligament Reconstruction”

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      Abstract: The American Journal of Sports Medicine, Ahead of Print.

      Citation: The American Journal of Sports Medicine
      PubDate: 2021-10-01T10:12:09Z
      DOI: 10.1177/03635465211044740
       
  • Determining the Ratio of Wedge Height to Degree of Correction for Anterior
           Tibial Closing Wedge Osteotomies for Excessive Posterior Tibial Slope

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      Authors: Courtney A. Quinn, Mark D. Miller, Robert D. Turk, Daniel C. Lewis, Christopher M. Gaskin, Brian C. Werner
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Anterior closing wedge osteotomy of the proximal tibia may be considered in revision anterior cruciate ligament (ACL) reconstruction surgery for patients with excessive posterior tibial slope (PTS).Purpose:(1) To determine the ratio of wedge thickness to degrees of correction for supratubercle (ST) versus transtubercle (TT) osteotomies for anterior closing wedge osteotomies and (2) to evaluate the accuracy of ST and TT osteotomies in achieving slope correction.Study Design:Controlled laboratory study.Methods:The computed tomography (CT) scans of 38 knees in 37 patients undergoing revision ACL reconstruction were used to simulate both ST and TT osteotomies. A 10° wedge was simulated in all CT models. The height of the wedge along the anterior tibia was recorded for each of the 2 techniques. The ratio of wedge height to achieved degree of correction was calculated. ST and TT osteotomies were performed on 3-dimensional (3D)–printed tibias of the 12 patients from the study group with the greatest PTS, after the desired degree of correction was determined. Pre- and postosteotomy slopes were measured for each tibia, and the actual change in slope was compared with the intended slope correction.Results:According to CT measurements, the ratio of wedge height to degree of correction was 0.99 ± 0.07 mm/deg for the ST osteotomy and 0.83 ± 0.06 mm/deg for the TT osteotomy (P < .001). When these ratios were used to perform simulated osteotomies on the twelve 3D-printed tibias, the mean slope correction was within 1° to 2° of the intended slope correction, regardless of osteotomy location (ST or TT) or whether slope was measured on the medial or lateral plateau. The ST technique tended to undercorrect and the TT technique tended to overcorrect.Conclusion:When anterior tibial closing wedge osteotomies were removed to correct excessive PTS, removing a wedge with a ratio of 1 mm of wedge height for every 1° of intended correction for an ST technique and a ratio of 0.8 mm to 1° for a TT technique resulted in overall average slope correction within 1° to 2° of the target.Clinical Relevance:The calculated ratios will allow clinicians to more accurately correct PTS when performing anterior closing wedge tibial osteotomy.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-09-30T08:27:24Z
      DOI: 10.1177/03635465211044136
       
  • Biceps Tenodesis Versus Superior Labral Anterior and Posterior (SLAP)
           Lesion Repair for the Treatment of SLAP Lesion in Overhead Athletes: A
           Systematic Review and Meta-analysis

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      Authors: Myung Ho Shin, Samuel Baek, Tae Min Kim, HyunTae Kim, Kyung-Soo Oh, Seok Won Chung
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Superior labral anterior and posterior (SLAP) lesions are common injuries in overhead athletes. As a surgical treatment for SLAP lesions, SLAP repair has been traditionally performed. Recently, biceps tenodesis has been performed as an alternative treatment option; however, there is no review for outcome comparisons between these 2 procedures in overhead athletes.Purpose:The aim of this study was to compare the outcomes of SLAP repair versus biceps tenodesis, especially in overhead athletes with SLAP lesions.Study Design:Systematic review and meta-analysis; Level of evidence, 4.Methods:An electronic literature search was performed in Medline, Embase, Scopus, and the Cochrane Library. The studies were appraised using the Methodological Index for Non-randomized Studies (MINORS) tool. Studies that had a minimum follow-up of 2 years, included only patients with SLAP lesions without other major shoulder pathologies, and included only patients who engaged in overhead sports were included. The functional outcomes of the American Shoulder and Elbow Surgeons (ASES) score, rate of return to sport, rate of return to preinjury level of sport, and complication rate were subjected to meta-analysis.Results:A total of 332 articles were identified, and 13 were included in the systematic review. Even though the postoperative ASES scores were slightly higher in the biceps tenodesis group than in the SLAP repair group, no statistically significant differences were found between the groups (biceps tenodesis, 95% CI = 91.71-96.75, I2 = 0.00; SLAP repair, 95% CI = 85.47-94.46, I2 = 16.3; P = .085) The rate of return to sport and the return to preinjury level of sport were slightly higher in the biceps tenodesis group than in the SLAP repair group; however, in meta-analysis these factors did not reach statistical significance (return to sport: biceps tenodesis, 95% CI = 0.66-0.91, I2 = 0.00; SLAP repair, 95% CI = 0.68-0.93, I2 = 70.23; P = .94) (return to preinjury level of sport: biceps tenodesis, 95% CI = 0.61-0.89, I2 = 17.78; SLAP repair, 95% CI = 0.53-0.82, I2 = 58.07; P = .37). The biceps tenodesis group showed a lower complication rate compared with the SLAP repair group without statistical significance (biceps tenodesis, 95% CI = 0.013-0.145, I2 = 0.00; SLAP repair, 95% CI = 0.049-0.143, I2 = 0.00; P = .25).Conclusion:The results of biceps tenodesis, compared with SLAP repair, were not inferior in the surgical treatment of overhead athletes with SLAP lesions with regard to the ASES score, rate of return to sport, rate of return to preinjury level of sport, and complication rate. Further high-level, randomized controlled studies are needed to confirm this result.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-09-30T08:25:04Z
      DOI: 10.1177/03635465211039822
       
  • Criteria for Return to Play After Hip Arthroscopy in the Treatment of
           Femoroacetabular Impingement: A Systematic Review

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      Authors: Martin S. Davey, Eoghan T. Hurley, Matthew G. Davey, Jordan W. Fried, Andrew J. Hughes, Thomas Youm, Tom McCarthy
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Femoroacetabular impingement (FAI) is a common pathology in athletes that often requires operative management in the form of hip arthroscopy.Purpose:To systematically review the rates and level of return to play (RTP) and the criteria used for RTP after hip arthroscopy for FAI in athletes.Study Design:Systematic review; Level of evidence, 4.Methods:A systematic review of the literature, based on the PRISMA guidelines, was performed using PubMed, Embase, and Scopus databases. Studies reporting outcomes after the use of hip arthroscopy for FAI were included. Outcomes analyzed were RTP rate, RTP level, and criteria used for RTP. Statistical analysis was performed using SPSS software.Results:Our review found 130 studies, which included 14,069 patients (14,517 hips) and had a mean methodological quality of evidence (MQOE) of 40.4 (range, 5-67). The majority of patients were female (53.7%), the mean patient age was 30.4 years (range, 15-47 years), and the mean follow-up was 29.7 months (range, 6-75 months). A total of 81 studies reported RTP rates, with an overall RTP rate of 85.4% over a mean period of 6.6 months. Additionally, 49 studies reported the rate of RTP at preinjury level as 72.6%. Specific RTP criteria were reported in 97 studies (77.2%), with time being the most commonly reported item, which was reported in 80 studies (69.2%). A total of 45 studies (57.9%) advised RTP at 3 to 6 months after hip arthroscopy.Conclusion:The overall rate of reported RTP was high after hip arthroscopy for FAI. However, more than one-fourth of athletes who returned to sports did not return at their preinjury level. Development of validated rehabilitation criteria for safe return to sports after hip arthroscopy for FAI could potentially improve clinical outcomes while also increasing rates of RTP at preinjury levels.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-09-30T08:21:20Z
      DOI: 10.1177/03635465211038959
       
  • Age-Related Changes in the Microvascular Density of the Human Meniscus

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      Authors: Philipp A. Michel, Christoph J. Domnick, Michael J. Raschke, Anna Hoffmann, Christoph Kittl, Elmar Herbst, Johannes Glasbrenner, Jendrik Hardes, Arne Streitbürger, Georg Gosheger, Mirco Herbort
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:The microvascular anatomy of the meniscus of the human knee is regarded as a crucial factor in the injury response. Previous studies have investigated the zone-dependent distribution pattern, but no quantitative data exist on vascular density and its age-related changes.Hypothesis/Purpose:The aim of the present study was to histologically analyze the vascular anatomy of the meniscus as a function of age. It was hypothesized that vascular density would decrease with increasing age.Study Design:Descriptive laboratory study.Methods:Human menisci were retrieved from patients who underwent tumor resection or who received total knee replacement because of osteoarthritis. A total of 51 menisci were collected from 28 patients over 9 years (mean age, 25.6 ± 20.4 years; range 3-79 years). Immunohistological staining (alpha–smooth muscle actin) in combination with serial sections and standardized software-based contrast detection were used for the quantitative analysis. Data were analyzed using multiple t tests and the analysis of variance for trends, with a statistical significance level of P < .05.Results:The overall vascular density in the meniscus was lower in the 61- to 80-year age group than in the age groups of 0 to 10, 11 to 20, and 21 to 30 years (P < .01). A negative linear trend was detected with increasing age (slope, -0.007; P = .016). Within the red-white (RW) zone, a low vessel density was detected for the age groups of 0 to 10 and 11 to 20 years. Beyond these age groups, no vasculature was found in the RW zone. For the white-white (WW) zone, no vessel formations were noted in any age group. Almost 95% of the vessels in the meniscus were located in the capsule.Conclusion:This study reports quantitative histological data for microvascular anatomy as a function of age in a broad cohort of human knee menisci. The overall vascular density decreased with increasing age. No vessel formations were detected in the RW and WW zones after adolescence. Additionally, the capsule is far more densely vascularized than any other part of the meniscus.Clinical Relevance:Vascular density might be an additional factor to consider, along with tear location and patient age, for future treatment options.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-09-30T08:16:40Z
      DOI: 10.1177/03635465211039865
       
  • Twenty-Year Outcomes After Anterior Cruciate Ligament Reconstruction: A
           Systematic Review of Prospectively Collected Data

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      Authors: Joshua S. Everhart, Sercan Yalcin, Kurt P. Spindler
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Several long-term (≥20 years) follow-up studies after anterior cruciate ligament (ACL) reconstruction have been published in recent years, allowing for a systematic evaluation of outcomes.Purpose:To summarize outcomes at ≥20 years after ACL reconstruction and identify patient and surgical factors that affect these results.Study Design:Systematic review; Level of evidence, 4.Methods:Prospective studies of primary ACL reconstructions with hamstring or bone–patellar tendon—bone (BTB) autograft via an arthroscopic or a mini-open technique and with a mean follow-up of ≥20 years were identified. When possible, the mean scores for each outcome measure were calculated. Factors identified in individual studies as predictive of outcomes were described.Results:Five studies met the inclusion and exclusion criteria with a total of 2012 patients. The pooled mean follow-up for patient-reported outcome measures was 44.2% (range, 29.6%-92.7%) and in-person evaluation was 33.2% (range, 29.6%-48.9%). Four studies (n = 584) reported graft tears at a mean rate of 11.8% (range, 2%-18.5%) and 4 studies (n = 773) reported a contralateral ACL injury rate of 12.2% (range, 5.8%-30%). Repeat non-ACL arthroscopic surgery (4 studies; n = 177) to the ipsilateral knee occurred in 10.4% (range, 9.5%-18.3%) and knee arthroplasty (1 study; n = 217) in 5%. The pooled mean of the International Knee Documentation Committee subjective knee function (IKDC) score was 79.1 (SD, 21.8 [3 studies; n = 644]). In 2 studies (n'= 221), 57.5% of patients continued to participate in strenuous activities. The IKDC-objective score was normal or nearly normal in 82.3% (n = 496; 3 studies), with low rates of clinically significant residual laxity. Moderate-severe radiographic osteoarthritis (OA) (IKDC grade C or D) was present in 25.9% of patients (n = 605; 3 studies). Medial meniscectomy is associated with increased risk of radiographic OA. Radiographic OA severity is associated with worse patient-reported knee function, but the association with knee pain is unclear.Conclusion:Currently available prospective evidence for ACL reconstruction with hamstring or BTB autograft provides several insights into outcomes at 20 years. The rates of follow-up at 20 years range from 30% to 93%. IKDC-objective scores were normal or nearly normal in 82% and the mean IKDC-subjective score was 79 points.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-09-30T08:13:59Z
      DOI: 10.1177/03635465211027302
       
  • Revision Hip Arthroscopy in High-Level Athletes: Minimum 2-Year Outcomes
           Comparison to a Propensity-Matched Primary Hip Arthroscopy Control Group

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      Authors: Peter F. Monahan, Andrew E. Jimenez, Jade S. Owens, Benjamin R. Saks, David R. Maldonado, Hari K. Ankem, Payam W. Sabetian, Ajay C. Lall, Benjamin G. Domb
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Outcomes of revision hip arthroscopy in the athletic population have not been well established.Purpose:(1) To report clinical outcomes for high-level athletes undergoing revision hip arthroscopy in the setting of femoroacetabular impingement syndrome (FAIS) or labral tears and (2) to compare these outcomes against a propensity-matched group of high-level athletes undergoing primary hip arthroscopy.Study Design:Cohort study; Level of evidence, 3.Methods:Data for professional, college, and high school athletes were prospectively collected and retrospectively reviewed between January 2012 and October 2018. Patients were included if they underwent revision or primary hip arthroscopy and had preoperative and minimum 2-year patient-reported outcome (PRO) scores for modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score Sports-Specific Subscale (HOS-SSS), and visual analog scale (VAS) for pain. The findings and outcomes of revision athletes were compared with a propensity-matched control group of high-level athletes undergoing primary hip arthroscopy.Results:A total of 32 hips (29 patients) undergoing revision hip arthroscopy and 92 hips (88 patients) undergoing primary hip arthroscopy were included in our final analysis with a median follow-up time of 29.5 months (95% CI, 27.2-32.1 months) and 36.5 months (95% CI, 33.5-37.7 months), respectively. Athletes undergoing revision surgery showed significant improvement in all recorded PRO measurements and achieved patient acceptable symptomatic state (PASS) and minimal clinically important difference (MCID) for mHHS at high rates (80.6% and 83.9%, respectively). When compared with a propensity-matched primary control group, patients undergoing revision surgery demonstrated lower preoperative and postoperative scores for mHHS, NAHS, and HOS-SSS, but the magnitude of improvement in functional scores was similar between groups. Athletes undergoing revision surgery achieved PASS for HOS-SSS at lower rates than the control group (P = .005), and they were less likely to attempt to return to sport compared with the control group (62.5% vs 87.0%; P < .01).Conclusion:Revision hip arthroscopy is a viable treatment option to improve PROs in high-level athletes at minimum 2-year follow-up. The study group showed significant improvement in functional scores and a high rate of successful outcomes. They experienced similar magnitude of improvement as that of a propensity-matched control group; however, they achieved lower postoperative PRO scores and attempted to return to sport at lower rates.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-09-30T08:11:18Z
      DOI: 10.1177/03635465211041760
       
  • Prediction of Hamstring Injuries in Australian Football Using Biceps
           Femoris Architectural Risk Factors Derived From Soccer

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      Authors: Connor Lee Dow, Ryan G. Timmins, Joshua D. Ruddy, Morgan D. Williams, Nirav Maniar, Jack T. Hickey, Matthew N. Bourne, David A. Opar
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Hamstring strain injuries are the most common injuries in team sports. Biceps femoris long head architecture is associated with the risk of hamstring injury in soccer. To assess the overall predictive ability of architectural variables, risk factors need to be applied to and validated across different cohorts.Purpose:To assess the generalizability of previously established risk factors for a hamstring strain injury (HSI), including demographics, injury history, and biceps femoris long head (BFlh) architecture to predict HSIs in a cohort of elite Australian football players.Study Design:Cohort study; Level of evidence, 3.Methods:Demographic, injury history, and BFlh architectural data were collected from elite soccer (n = 152) and Australian football (n = 169) players at the beginning of the preseason for their respective competitions. Any prospectively occurring HSIs were reported to the research team. Optimal cut points for continuous variables used to determine an association with the HSI risk were established from previously published data in soccer and subsequently applied to the Australian football cohort to derive the relative risk (RR) for these variables. Logistic regression models were built using data from the soccer cohort and utilized to estimate the probability of an injury in the Australian football cohort. The area under the curve (AUC) and Brier score were the primary outcome measures to assess the performance of the logistic regression models.Results:A total of 27 and 30 prospective HSIs occurred in the soccer and Australian football cohorts, respectively. When using cut points derived from the soccer cohort and applying these to the Australian football cohort, only older athletes (aged ≥25.4 years; RR, 2.7 [95% CI, 1.4-5.2]) and those with a prior HSI (RR, 2.5 [95% CI, 1.3-4.8]) were at an increased risk of HSIs. Using the same approach, height, weight, fascicle length, muscle thickness, pennation angle, and relative fascicle length were not significantly associated with an increased risk of HSIs in Australian football players. The logistic regression model constructed using age and prior HSIs performed the best (AUC = 0.67; Brier score = 0.14), with the worst performing model being the one that was constructed using pennation angle (AUC = 0.53; Brier score = 0.18).Conclusion:Applying cut points derived from previously published data in soccer to a dataset from Australian football identified older age and prior HSIs, but none of the modifiable HSI risk factors, to be associated with an injury. The transference of HSI risk factor data between soccer and Australian football appears limited and suggests that cohort-specific cut points must be established.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-09-30T08:06:18Z
      DOI: 10.1177/03635465211041686
       
  • Inconsistencies in Controlling for Risk Factors for Recurrent Shoulder
           Instability After Primary Arthroscopic Bankart Repair: A Systematic Review
           

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      Authors: Nicholas A. Trasolini, Navya Dandu, Eric N. Azua, Grant E. Garrigues, Nikhil N. Verma, Adam B. Yanke
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Failure rates after arthroscopic shoulder stabilization are highly variable in the current orthopaedic literature. Predictive factors for risk of failure have been studied to improve patient selection, refine surgical techniques, and define the role of bony procedures. However, significant heterogeneity in the analysis and controlling of risk factors makes evidence-based management decisions challenging.Purpose:The goals of this systematic review were (1) to critically assess the consistency of reported risk factors for recurrent instability after arthroscopic Bankart repair, (2) to identify the existing studies with the most comprehensive inclusion of confounding factors in their analyses, and (3) to give recommendations for which factors should be reported consistently in future clinical studies.Study Design:Systematic review; Level of evidence, 4.Methods:A systematic review of the literature was performed in accordance with the PRISMA guidelines. An initial search yielded 1754 titles, from which 56 full-text articles were screened for inclusion. A total of 29 full-text articles met the following inclusion criteria: (1) clinical studies regarding recurrent anterior shoulder instability; (2) surgical procedures performed including arthroscopic anterior labral repair; (3) reported clinical outcome data including failure rate; and (4) assessment of risk factors for surgical failure. Further subanalyses were performed for 15 studies that included a multivariate analysis, 17 studies that included glenoid bone loss, and 8 studies that analyzed the Instability Severity Index Score.Results:After full-text review, 12 of the most commonly studied risk factors were identified and included in this review. The risk factors that were most consistently significant in multivariate analyses were off-track lesions (100%), glenoid bone loss (78%), Instability Severity Index Score (75%), level of sports participation (67%), number of anchors (67%), and younger age (63%). In studies of bone loss, statistical significance was more likely to be found using advanced imaging, with critical bone loss thresholds of 10% to 15%. Several studies found predictive thresholds of 2 to 4 for Instability Severity Index Score by receiver operating characteristic or multivariate analysis.Conclusion:Studies reporting risk factors for failure of arthroscopic Bankart repair often fail to control for known confounding variables. The factors with the most common statistical significance among 15 multivariate analyses are off-track lesions, glenoid bone loss, Instability Severity Index Score, level of sports participation, number of anchors, and younger age. Studies found significance more commonly with advanced imaging measurements or arthroscopic assessment of glenoid bone loss and with lower thresholds for the Instability Severity Index Score (2-4). Future studies should attempt to control for all relevant factors, use advanced imaging for glenoid bone loss measurements, and consider a lower predictive threshold for the Instability Severity Index Score.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-09-30T08:02:57Z
      DOI: 10.1177/03635465211038712
       
  • An Anterior Cruciate Ligament Rupture Increases Levels of Urine N-terminal
           Cross-linked Telopeptide of Type I Collagen, Urine C-terminal Cross-linked
           Telopeptide of Type II Collagen, Serum Aggrecan ARGS Neoepitope, and Serum
           Tumor Necrosis Factor–α

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      Authors: Frans J.A. Hagemans, Staffan Larsson, Max Reijman, Richard B. Frobell, Andre Struglics, Duncan E. Meuffels
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:An anterior cruciate ligament (ACL) rupture results in an increased risk of developing knee osteoarthritis (OA) at an early age. Before clinical signs become apparent, the OA process has already been initiated. Therefore, it is important to look at the cascade of changes, such as the activity of cytokines and proteases, which might be associated with the later development of OA.Purpose:To compare biomarker levels in patients with a recent ACL rupture with those in controls with a healthy knee and to monitor biomarker levels over 2 years after an ACL rupture.Study Design:Descriptive laboratory study.Methods:Patients were enrolled after an ACL tear was identified. Serum and urine samples were collected at the time of enrollment in the study (3-25 weeks after the injury) and then at 14 and 27 months after the injury between January 2009 and November 2010. Reference samples were obtained from participants with healthy knees. The following biomarkers were measured with immunological assays: aggrecan ARGS neoepitope (ARGS-aggrecan), tumor necrosis factor–α (TNF-α), interferon-γ, interleukin (IL)–8, IL-10, IL-13, N-terminal cross-linked telopeptide of type I collagen (NTX-I), and C-terminal cross-linked telopeptide of type II collagen (CTX-II).Results:Samples were collected from 152 patients with an acute ACL rupture, who had a median age of 25 years (interquartile range [IQR], 21-32 years). There were 62 urine reference samples (median age, 25 years [IQR, 22-36 years]) and 26 serum reference samples (median age, 35 years [IQR, 24-39 years]). At a median of 11 weeks (IQR, 7-17 weeks) after trauma, serum levels of both ARGS-aggrecan and TNF-α were elevated 1.5-fold (P < .001) compared with reference samples and showed a time-dependent decrease during follow-up. Urine NTX-I and CTX-II concentrations were elevated in an early phase after trauma (1.3-fold [P < .001] and 3.7-fold [P < .001], respectively) compared with reference samples, and CTX-II levels remained elevated compared with reference samples at 2-year follow-up. Strong correlations were found between serum ARGS-aggrecan, urinary NTX-I, and urinary CTX-II (rs = 0.57-0.68).Conclusion:In the first few months after an ACL injury, there was a measurable increase in serum levels of ARGS-aggrecan and TNF-α as well as urine levels of NTX-I and CTX-II. These markers remained high compared with those of controls with healthy knees at 2-year follow-up.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-09-30T05:09:30Z
      DOI: 10.1177/03635465211042310
       
  • Corrigendum to “Surface-Related High School Football Game Injuries on
           Pad and No-Pad Fields”

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      Abstract: The American Journal of Sports Medicine, Ahead of Print.

      Citation: The American Journal of Sports Medicine
      PubDate: 2021-09-29T03:45:56Z
      DOI: 10.1177/03635465211051380
       
  • Rotator Cuff Tendon Healing Using Human Dermal Fibroblasts: Histological
           and Biomechanical Analyses in a Rabbit Model of Chronic Rotator Cuff Tears
           

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      Authors: Ji-Hye Lee, Yun Hee Kim, Sung-Min Rhee, Jikhyon Han, Hyeon Jang Jeong, Joo Hyun Park, Joo Han Oh, Saewha Jeon
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Tenocytes derived from tendons have been reported to be effective in the treatment of rotator cuff tears through the expression of extracellular matrix proteins. Human dermal fibroblasts, known to express collagen types I and III as tenocytes do, may likely be substitutes for tenocytes to enhance healing rotator cuff tears.Purpose:To demonstrate the capability of human dermal fibroblasts to enhance healing of rotator cuff tears.Study Design:Controlled laboratory study.Methods:The cellular properties and expression profiles of growth factors were compared between human dermal fibroblasts and tenocytes. In both cell types, a series of extracellular matrix proteins were analyzed along with matrix metalloproteinases and tissue inhibitors of metalloproteinases involved in the collagenolytic system. A total of 35 rabbits were divided into 5 groups: normal (n = 2), saline control (n = 9), fibrin control (n = 9), low dose of human fibroblasts (HF-LD; n = 9), and high dose of human fibroblasts (HF-HD; n = 6). Cells were injected into the sutured lesions at 6 weeks after creation of bilateral rotator cuff tears, followed by histological and biomechanical analyses at 12 weeks.Results:Human dermal fibroblasts exhibited a protein expression pattern similar to that of tenocytes. More specifically, the expression levels of collagen types I and III were comparable between fibroblasts and tenocytes. The histological analysis of 30 surviving rabbits showed that collagen fibers were more continuous and better oriented with a more mature interface between the tendon and bone in the sutured lesions in the HF-LD and HF-HD groups. Most importantly, biomechanical strength, measured using the load to failure at the injection site, was 58.8 ± 8.9 N/kg in the HF-HD group, increasing by approximately 2-fold (P = .0003) over the saline control group.Conclusion:Human dermal fibroblasts, showing cellular properties comparable with tenocytes, effectively enhanced healing of chronic rotator cuff tears in rabbits.Clinical Relevance:Human dermal fibroblasts can be used in place of tenocytes to enhance healing of rotator cuff tears.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-09-23T04:21:26Z
      DOI: 10.1177/03635465211041102
       
  • Allograft Versus Autograft Osteochondral Transplant for Chondral Defects
           of the Talus: Systematic Review and Meta-analysis

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      Authors: Filippo Migliorini, Nicola Maffulli, Alice Baroncini, Jörg Eschweiler, Matthias Knobe, Markus Tingart, Hanno Schenker
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:It is unclear whether the results of osteochondral transplant using autografts or allografts for talar osteochondral defect are equivalent.Purpose:A systematic review of the literature was conducted to compare allografts and autografts in terms of patient-reported outcome measures (PROMs), MRI findings, and complications.Study Design:Systematic review; Level of evidence, 4.Methods:This study was conducted according to the PRISMA guidelines. The literature search was conducted in February 2021. All studies investigating the outcomes of allograft and/or autograft osteochondral transplant as management for osteochondral defects of the talus were accessed. The outcomes of interest were visual analog scale (VAS) score for pain, American Orthopaedic Foot and Ankle Society (AOFAS) score, and Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score. Data concerning the rates of failure and revision surgery were also collected. Continuous data were analyzed using the mean difference (MD), whereas binary data were evaluated with the odds ratio (OR) effect measure.Results:Data from 40 studies (1174 procedures) with a mean follow-up of 46.5 ± 25 months were retrieved. There was comparability concerning the length of follow-up, male to female ratio, mean age, body mass index, defect size, VAS score, and AOFAS score (P> .1) between the groups at baseline. At the last follow-up, the MOCART (MD, 10.5; P = .04) and AOFAS (MD, 4.8; P = .04) scores were better in the autograft group. The VAS score was similar between the 2 groups (P = .4). At the last follow-up, autografts demonstrated lower rate of revision surgery (OR, 7.2; P < .0001) and failure (OR, 5.1; P < .0001).Conclusion:Based on the main findings of the present systematic review, talar osteochondral transplant using allografts was associated with higher rates of failure and revision compared with autografts at midterm follow-up.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-09-23T04:15:45Z
      DOI: 10.1177/03635465211037349
       
  • Shoulder External Rotational Properties During Physical Examination Are
           Associated With Injury That Requires Surgery and Shoulder Joint Loading
           During Baseball Pitching

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      Authors: Hannah Stokes, Koco Eaton, Naiquan (Nigel) Zheng
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Throwing arm injuries are common because of the demand on the shoulder. The shoulder is qualitatively checked regularly by team physicians. Excessive instability and joint loading in baseball pitching are risk factors for throwing arm injuries. Knowledge of shoulder flexibility, range of motion, and joint loading may provide new insights for treatments to reduce the likelihood of injury incidence.Purpose:To investigate the relationship among injuries, shoulder external rotational properties, and shoulder joint loading in baseball pitchers.Study Design:Descriptive laboratory study.Methods:Pitching kinetics, shoulder rotational tests, and self-reported injury questionnaires were used to study 177 collegiate baseball pitchers. Pitching motion data were collected at 240 Hz using a motion capture system. A custom program calculated the shoulder joint loading. The shoulder rotational test quantitatively records shoulder range of motion and flexibility using a custom-made wireless device. Self-reported injury questionnaires were filled out during tests and yearly follow-ups. The total length of the study was 5 years. Analysis of variance, chi-square, and regression tests were performed to compare differences among groups and detect correlations with surgery and shoulder joint loadings.Results:There were significant differences in shoulder flexibility among surgery groups. Shoulder external rotational properties during physical examination were significantly associated with shoulder joint loading in baseball pitching. High shoulder external rotation was associated with 14% to 36% lower shoulder posterior force and adduction, internal rotation, and horizontal adduction torque (P < .05). High shoulder flexibility was associated with 13% higher anterior force (P < .05). High shoulder external rotation before external rotation torque was applied was associated with 13% to 33% lower shoulder inferior force and adduction, internal rotation, and horizontal adduction torque (P < .05). There were no significant differences in shoulder joint loading among the surgery groups.Conclusion:Shoulder injuries that require surgery were associated with shoulder external rotation flexibility. High shoulder external rotation may be advantageous because it lowers the force and torque on the shoulder joint.Clinical Relevance:The ability to understand shoulder external rotational properties, joint loading, and injury during baseball pitching helps further our understanding of injury mechanisms. The shoulder rotational test should be used as a screening tool to identify players at risk.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-09-23T04:08:47Z
      DOI: 10.1177/03635465211039850
       
  • Surgical Management of Focal Chondral Defects of the Talus: A Bayesian
           Network Meta-analysis

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      Authors: Filippo Migliorini, Nicola Maffulli, Hanno Schenker, Jörg Eschweiler, Arne Driessen, Matthias Knobe, Markus Tingart, Alice Baroncini
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:No consensus has been reached regarding the optimal surgical treatment for focal chondral defects of the talus.Purpose:A Bayesian network meta-analysis was conducted to compare the clinical scores and complications of mosaicplasty, osteochondral auto- and allograft transplant, microfracture, matrix-assisted autologous chondrocyte transplant, and autologous matrix-induced chondrogenesis (AMIC) for chondral defects of the talus at midterm follow-up.Study Design:Bayesian network meta-analysis; Level of evidence, 4.Methods:This Bayesian network meta-analysis followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) extension statement for reporting of systematic reviews incorporating network meta-analyses of health care interventions. PubMed, Embase, Google Scholar, and Scopus databases were accessed in February 2021. All clinical trials comparing 2 or more surgical interventions for the management of chondral defects of the talus were accessed. The outcomes of interest were visual analog scale (VAS) score, American Orthopaedic Foot and Ankle Society (AOFAS) score, rate of failure, and rate of revision surgery. The network meta-analysis were performed through the routine for Bayesian hierarchical random-effects model analysis. The log odds ratio (LOR) effect measure was used for dichotomous variables, and the standardized mean difference (SMD) was used for continuous variables.Results:Data from 13 articles (521 procedures) were retrieved. The median length of the follow-up was 47.8 months (range, 31.7-66.8 months). Analysis of variance revealed no difference between the treatment groups at baseline in terms of age, sex, body mass index, AOFAS score, VAS score, and mean number of defects. AMIC demonstrated the greatest AOFAS score (SMD, 11.27) and lowest VAS score (SMD, –2.26) as well as the lowest rates of failure (LOR, 0.94) and revision (LOR, 0.94). The test for overall inconsistency was not significant.Conclusion:At approximately 4 years of follow-up, the AMIC procedure for management of focal chondral defects of the talus produced the best outcome.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-09-20T04:11:07Z
      DOI: 10.1177/03635465211029642
       
  • Corrigendum to “Predictive Accuracy of the Sport Concussion Assessment
           Tool 3 and Vestibular/Ocular-Motor Screening, Individually and In
           Combination: A National Collegiate Athletic Association–Department of
           Defense Concussion Assessment, Research and Education Consortium
           Analysis”

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      Abstract: The American Journal of Sports Medicine, Ahead of Print.

      Citation: The American Journal of Sports Medicine
      PubDate: 2021-09-20T02:00:36Z
      DOI: 10.1177/03635465211045401
       
  • Current Trends in Orthobiologics: An 11-Year Review of the Orthopaedic
           Literature

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      Authors: Kyle K. Obana, Michael S. Schallmo, Ian S. Hong, Christopher S. Ahmad, Claude T. Moorman, David P. Trofa, Bryan M. Saltzman
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:The use of “orthobiologics” or regenerative therapies in orthopaedic surgery has grown in recent years. Particular interest has been raised with regard to platelet-rich plasma, bone marrow aspirate, adipose-derived cells, and amniotic cells. Although studies have analyzed outcomes after orthobiologic treatment, no study has analyzed how the literature as a whole has evolved.Purpose:To evaluate trends in platelet-rich plasma, bone marrow aspirate, adipose-derived cells, and amniotic cell publications and to assess how these might inform efforts to establish minimum reporting standards and forecast future use.Study Design:Systematic review; Level of evidence, 4.Methods:A database was compiled systematically using PubMed to identify articles published between 2009 and 2019 within 9 prominent orthopaedic journals and pertaining to the use of platelet-rich plasma, bone marrow aspirate, adipose-derived cells, and amniotic cells in the treatment of musculoskeletal conditions. Included articles were classified as clinical, nonclinical (translational or basic science), or review, and a variety of study parameters were recorded for each. Additional queries were performed to identify articles that utilized minimum reporting standards.Results:A total of 474 articles (132 clinical, 271 nonclinical, 71 review) were included, consisting of 244 (51.5%) platelet-rich plasma, 146 (30.8%) bone marrow aspirate, 72 (15.2%) adipose-derived cells, and 12 (2.5%) amniotic cells. The greatest annual increase in publications for each orthobiologic topic was from 2018 to 2019. The American Journal of Sports Medicine demonstrated the highest number of overall (34.2%) and clinical (50.0%) publications, and accounted for 44.3% of all platelet-rich plasma publications. The Journal of Orthopaedic Research accounted for the second highest overall number of publications (24.9%) and highest nonclinical publications (41.0%). Platelet-rich plasma accounted for 91.5% of all level 1 clinical studies, while much greater than half of bone marrow aspirate, adipose-derived cells, and amniotic cell publications were level 3 or lower. Out of the 207 articles that used some form of reporting protocol, 59 (28.5%) used an established algorithm and 125 (60.4%) used their own.Conclusion:Interest in orthobiologics continues to grow, as evidenced by an increasing trend in publications over an 11-year period. However, current reporting on orthobiologic formulations is largely heterogeneous, emphasizing the need for minimum reporting standards and higher-quality studies.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-09-16T11:55:28Z
      DOI: 10.1177/03635465211037343
       
  • Relationship Between Timing of Anterior Cruciate Ligament Reconstruction
           and Chondral Injuries: A Systematic Review and Meta-analysis

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      Authors: Apostolos D. Prodromidis, Chrysoula Drosatou, Anastasios Mourikis, Paul M. Sutton, Charalambos P. Charalambous
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:After anterior cruciate ligament (ACL) injury, the optimal timing of ACL reconstruction and the influence of this timing on chondral damage remain unclear.Purpose:To assess the effect of timing of ACL reconstruction on the presence of chondral injuries via a systematic review and meta-analysis.Study Design:Systematic review and meta-analysis; Level of evidence, 4.Methods:Two reviewers independently performed systematic literature searches of 5 online databases using the Cochrane methodology for systematic reviews. Eligibility criteria were any comparative study of patients aged>16 years that assessed the relationship between timing of primary ACL reconstruction surgery and rates of chondral injuries. Meta-analysis was conducted using a random-effects model.Results:After screening, 14 studies (n = 3559 patients) out of 2363 titles met the inclusion criteria: 3 randomized controlled trials (n = 272), 3 prospective cohort studies (n = 398), and 8 retrospective cohort studies (n = 2889). In analysis of the studies, chondral injury rates were compared between ACL reconstructions performed before and after 3 time points: 3, 6, and 12 months after injury (eg, ≤3 vs>3 months). The rates of chondral injury increased with each time point. The increase was mostly due to low-grade injuries at 3 months (estimated odds ratio, 1.914; 95% CI, 1.242-2.949; P = .003), with the increase in high-grade injuries becoming predominant after 12 months (estimated odds ratio, 3.057; 95% CI, 1.460-6.40; P = .003).Conclusion:Our findings suggest that delaying ACL reconstruction surgery results in a higher rate of chondral injuries and the severity of these lesions worsens with time. These findings are comparable with those of our previously published study, which demonstrated a higher risk of meniscal tears associated with delayed ACL surgery. When ACL reconstruction is indicated, surgery ≤3 months after injury is associated with a lower risk of intra-articular damage.Registration:CRD42016032846 (PROSPERO).
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-09-15T11:36:48Z
      DOI: 10.1177/03635465211036141
       
  • Salvage Iliac Crest Bone Grafting for a Failed Latarjet Procedure:
           Analysis of Failed and Successful Procedures

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      Authors: Lukas Ernstbrunner, Torsten Pastor, Manuel Waltenspül, Christian Gerber, Karl Wieser
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:The Latarjet is a successful procedure but can be associated with significant complications, including failure. Iliac crest bone grafting (ICBG) is one of the salvage options for such failure.Purpose:To analyze factors associated with failure or success to restore shoulder stability with ICBG after Latarjet failure.Study Design:Case series; Level of evidence, 4.Methods:Twenty consecutive patients with recurrence of instability after a Latarjet procedure underwent revision using ICBG. Sixteen patients (80%) with a mean age of 35.0 years (range, 25-55) could be personally reexamined clinically and radiographically (including computed tomography scan) after a mean follow-up of 4.5 years (range, 2-8). Twelve patients had redislocation and 4 had recurrent subluxation after the Latarjet.Results:Salvage ICBG failed in 7 patients because of recurrent dislocations, with 5 necessitating reoperations: 2 arthrodeses, 1 reverse total shoulder arthroplasty, 1 repeat ICBG, and 1 Hill-Sachs allograft reconstruction and Bankart repair. Factors associated with ICBG failure were multidirectional instability (n = 2), subscapularis insufficiency (n = 1), uncontrolled seizures (n = 1), static inferior glenohumeral subluxation (n = 1), total graft resorption (n = 1), and voluntary dislocation attributed to schizoaffective disorder (n = 1). The initial Latarjet graft was malpositioned (too medial) in 3 of these patients. In patients without recurrent instability (n = 9), reasons for Latarjet failure were graft related: 6 graft avulsions, 2 graft resorptions, and 1 medial graft malpositioning. The mean absolute Constant score (62 to 87 points, P = .012) and relative Constant score (66% to 91%, P = .012), pain (10 to 15 points, P < .001), and Subjective Shoulder Value (31% to 85%, P = .011) in the group with a successful procedure were significantly improved over the preoperative state, and the total Western Ontario Shoulder Instability Index averaged 64% at final follow-up. Except in 1 case of major resorption, mild graft resorption or none was observed in successful procedures. Axial and sagittal graft positioning was good in all 9 patients.Conclusions:Salvage ICBG for failed Latarjet procedures failed in 7 of 16 patients. It was successful in patients with clearly graft-related factors of the initial Latarjet procedure. However, patients with unclear instability symptoms, subscapularis insufficiency, inferior subluxation, uncontrolled seizures, or psychological disorders were poor candidates for salvage ICBG, underlining the importance of careful patient selection for the initial Latarjet procedure and for salvage ICBG.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-09-15T10:35:53Z
      DOI: 10.1177/03635465211040468
       
  • Erratum to “Age Is More Predictive of Safe Movement Patterns Than Are
           Physical Activity or Sports Specialization: A Prospective Motion Analysis
           Study of Young Athletes”

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      Abstract: The American Journal of Sports Medicine, Ahead of Print.

      Citation: The American Journal of Sports Medicine
      PubDate: 2021-09-15T04:00:11Z
      DOI: 10.1177/03635465211047896
       
  • Evaluation of Commercially Available Knee Cartilage Restoration Techniques
           Stratified by FDA Approval Pathway

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      Authors: Andrew Scott Gudeman, Betina B. Hinckel, Lasun Oladeji, Taylor E. Ray, Wayne Gersoff, Jack Farr, Seth L. Sherman
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Commercially available products used in knee cartilage reconstructive and restorative surgical practices fall under unique US Food and Drug Administration (FDA) regulatory pathways that determine the level of evidence required to market each product.Purpose:To evaluate the levels of evidence in the literature supporting commercially available cartilage repair procedures stratified by FDA regulatory pathway (section 351 vs section 361 of “Human Cells, Tissues, and Cellular and Tissue-Based Products” [HCT/P] in the Code of Federal Regulation) with the hypothesis that products requiring approval under a stringent regulatory pathway (351 HCT/P) have higher levels of evidence in the literature supporting use and that products with a less stringent regulatory pathway (361 HCT/P) have a higher number of products available for use in the United States.Study Design:Systematic review; Level of evidence, 4.Methods:A search of the PubMed database was performed to identify all peer-reviewed articles pertaining to either allograft or autologous cartilage repair technologies. Predefined inclusion and exclusion criteria were used to find clinical, preclinical, and laboratory studies while excluding duplicates, systematic reviews, and products not available in the United States. Articles were categorized by regulatory pathway (351 and 361 HCT/P), and variables including publication year, type of publication, level of evidence, and number of publications were analyzed.Results:After application of predefined criteria, 470 of 1924 articles were included in this study. The 351 HCT/P group was composed entirely of autologous chondrocyte implantation (ACI) technology; 94% of the 361 HCT/P group was composed of osteochondral allografts (OCA). The articles regarding 351 HCT/P were more likely to be clinical in nature than the articles on 361 HCT/P (80% vs 48%, respectively; P = .0001) and entailed significantly more level 1 studies (25 vs 0, respectively; P < .0001). Twice as many articles in the 351 HCT/P group were published in the American Journal of Sports Medicine compared with the 361 HCT/P group (71 vs 38, respectively; P = .18).Conclusion:Both ACI and OCA have robust evidence supporting their use, whereas the remaining regulated products have little or no supporting evidence. Technologies regulated by 351 HCT/P were more likely to be level 1 clinical studies and published in the highest impact journal. The 361 HCT/P pathway regulated many more products, with fewer articles supporting their use.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-09-15T03:58:20Z
      DOI: 10.1177/03635465211037233
       
  • Arthroscopic Centralization for Lateral Meniscal Injuries Reduces Laxity
           in the Anterior Cruciate Ligament–Reconstructed Knee

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      Authors: Tomomasa Nakamura, Brandon D. Marshall, Taylor M. Price, Yongtao Mao, Monica A. Linde, Hideyuki Koga, Patrick Smolinski, Freddie H. Fu
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:A lateral meniscal (LM) disorder is one factor that causes rotational laxity after anterior cruciate ligament (ACL) reconstruction (ACLR). There are different types of irreparable meniscal disorders, one of which is a massive meniscal defect.Hypothesis/Purpose:The purpose of this study was to evaluate the kinematic effects of arthroscopic centralization on an irreparable LM defect. The hypothesis was that arthroscopic centralization for an irreparable LM defect with concomitant ACLR would improve knee rotational stability.Study Design:Controlled laboratory study.Methods:A total of 14 fresh-frozen human cadaveric knees were tested in 4 states: (1) intact ACL and intact lateral meniscus, (2) reconstructed ACL and intact lateral meniscus, (3) reconstructed ACL and lateral meniscus defect, and (4) reconstructed ACL and centralized lateral meniscus. Anatomic ACLR was performed using an 8 mm–diameter hamstring tendon graft. An LM defect (20% of the anteroposterior length) was created arthroscopically, and arthroscopic centralization was performed. Kinematics were analyzed using a 6 degrees of freedom robotic system under 4 knee loads: (1) an 89.0-N anterior tibial load, (2) a 5.0-N·m external rotation tibial torque, (3) a 5.0-N·m internal rotation tibial torque, and (4) a simulated pivot-shift load with a combined 7.0-N·m valgus and 5.0-N·m internal rotation tibial torque.Results:LM centralization reduced anterior tibial translation similar to that of the ACLR intact LM state under anterior tibial loading (~2 mm at 30° of flexion) and showed 40% to 100% of tibial displacement in the 4 knee states under simulated pivot-shift loading. The procedure overconstrained the knee under internal rotation tibial torque and simulated pivot-shift loading.Conclusion:Arthroscopic centralization reduced knee laxity after ACLR for a massive LM defect in a cadaveric model.Clinical Relevance:In cases involving irreparable LM injuries during ACLR, consideration should be given to arthroscopic centralization for reducing knee laxity. However, the procedure may overconstrain the knee in certain motions.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-09-15T03:48:25Z
      DOI: 10.1177/03635465211041747
       
  • Ability of Medial Patellofemoral Ligament Reconstruction to Overcome
           Lateral Patellar Motion in the Presence of Trochlear Flattening: A
           Cadaveric Biomechanical Study

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      Authors: Amrit V. Vinod, Alex M. Hollenberg, Melissa A. Kluczynski, John M. Marzo
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Medial patellofemoral ligament (MPFL) reconstruction is an established operative procedure to restore medial restraining force in patients with patellar instability. In the setting of a shallow sulcus, it is unclear whether an isolated MPFL reconstruction is sufficient to restore patellofemoral stability.Hypothesis:Progressively increasing the sulcus angle would have an adverse effect on the ability of an MPFL reconstruction to restrain lateral patellar motion.Study Design:Controlled laboratory study.Methods:Seven fresh-frozen human cadaveric knees were harvested and prepared for experimentation. Each specimen was run through the following test conditions: native, lateral retinacular release, lateral retinacular repair, MPFL release, MPFL reconstruction, and MPFL reconstruction with trochlear flattening. Four 3-dimensional printed wedges (10°, 20°, 30°, and 40°) were created to insert beneath the native trochlea to raise the sulcus angle incrementally and simulate progressive trochlear flattening. For each test condition, the knee was positioned at 0°, 15°, 30°, and 45° of flexion, and the force required to displace the patella 1 cm laterally at 10 mm/s was measured. Group comparisons were made with repeated measures analysis of variance.Results:In the setting of an MPFL reconstruction, as the trochlear groove was incrementally flattened, the force required to laterally displace the patella progressively decreased. A 10° increase in the sulcus angle significantly reduced the force at 15° (P = .01) and 30° (P = .03) of knee flexion. The force required to laterally displace the patella was also significantly lower at all knee flexion angles after the addition of the 20°, 30°, and 40° wedges (P≤ .05). Specifically, a 20° increase in the sulcus angle reduced the force by 29% to 36%; a 30° increase, by 35% to 43%; and a 40° increase, by 40% to 47%.Conclusion:Despite an MPFL reconstruction, the force required to laterally displace the patella decreased as the sulcus angle was increased in our cadaveric model.Clinical Relevance:An isolated MPFL reconstruction may not be sufficient to restore patellar stability in the setting of a shallow or flat trochlea. Patients with an abnormal sulcus angle may have recurrent instability postoperatively if treated with an isolated MPFL reconstruction.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-09-15T03:39:43Z
      DOI: 10.1177/03635465211041087
       
  • What Is the Most Reliable Method of Measuring Glenoid Bone Loss in
           Anterior Glenohumeral Instability' A Cadaveric Study Comparing
           Different Measurement Techniques for Glenoid Bone Loss

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      Authors: Antonio Arenas-Miquelez, Danè Dabirrahmani, Gaurav Sharma, Petra L. Graham, Richard Appleyard, Desmond J. Bokor, John W. Read, Kalman Piper, Sumit Raniga
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Preoperative quantification of bone loss has a significant effect on surgical decision making and patient outcomes. Various measurement techniques for calculating glenoid bone loss have been proposed in the literature. To date, no studies have directly compared measurement techniques to determine which technique, if any, is the most reliable.Purpose/Hypothesis:To identify the most consistent and accurate techniques for measuring glenoid bone loss in anterior glenohumeral instability. Our hypothesis was that linear measurement techniques would have lower consistency and accuracy than surface area and statistical shape model–based measurement techniques.Study Design:Controlled laboratory study.Methods:In 6 fresh-frozen human shoulders, 3 incremental bone defects were sequentially created resulting in a total of 18 glenoid bone defect samples. Analysis was conducted using 2D and 3D computed tomography (CT) en face images. A total of 6 observers (3 experienced and 3 with less experience) measured the bone defect of all samples with Horos imaging software using 5 common methods. The methods included 2 linear techniques (Shaha, Griffith), 2 surface techniques (Barchilon, PICO), and 1 statistical shape model formula (Giles). Intraclass correlation (ICC) using a consistency model was used to determine consistency between observers for each of the measurement methods. Paired t tests were used to calculate the accuracy of each measurement technique relative to physical measurement.Results:For the more experienced observers, all methods indicated good consistency (ICC> 0.75; range, 0.75-0.88), except the Shaha method, which indicated moderate consistency (0.65 < ICC < 0.75; range, 0.65-0.74). Estimated consistency among the experienced observers was better for 2D than 3D images, although the differences were not significant (intervals contained 0). For less experienced observers, the Giles method in 2D had the highest estimated consistency (ICC, 0.88; 95% CI, 0.76-0.95), although Giles, Barchilon, Griffith, and PICO methods were not statistically different. Among less experienced observers, the 2D images using Barchilon and Giles methods had significantly higher consistency than the 3D images. Regarding accuracy, most of the methods statistically overestimated the actual physical measurements by a small amount (mean within 5%). The smallest bias was observed for the 2D Barchilon measurements, and the largest differences were observed for Giles and Griffith methods for both observer types.Conclusion:Glenoid bone loss calculation presents variability depending on the measurement technique, with different consistencies and accuracies. We recommend use of the Barchilon method by surgeons who frequently measure glenoid bone loss, because this method presents the best combined consistency and accuracy. However, for surgeons who measure glenoid bone loss occasionally, the most consistent method is the Giles method, although an adjustment for the overestimation bias may be required.Clinical Relevance:The Barchilon method for measuring bone loss has the best combined consistency and accuracy for surgeons who frequently measure bone loss.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-09-08T04:31:02Z
      DOI: 10.1177/03635465211041386
       
  • Clinical Outcomes of Meniscal Allograft Transplantation With Respect to
           the Minimal Clinically Important Difference

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      Authors: Lisa Su, Ignacio Garcia-Mansilla, Benjamin Kelley, Armin Arshi, Peter Fabricant, Seth L. Sherman, Kristofer J. Jones
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Arthroscopic-assisted meniscal allograft transplantation (MAT) has become a viable and effective treatment option for young active patients with postmeniscectomy pain. The minimal clinically important difference (MCID) of patient-reported outcome measures (PROMs) is imperative to evaluate the clinical significance of surgical interventions and inform clinical practice guidelines in orthopaedic surgery.Purpose:To perform a systematic review of clinical outcome studies of patients undergoing MAT and compare postoperative improvement with established MCID thresholds.Study Design:Systematic review and meta-analysis; Level of evidence, 4.Methods:A systematic review was performed using the PubMed, Web of Science, and Cochrane Library databases. A meta-analysis was performed using data obtained from studies reporting patient-reported outcomes. Subgroup analysis was performed on patients undergoing isolated lateral MAT using fresh-frozen grafts. Weighted mean postoperative improvements in the International Knee Documentation Committee (IKDC), Lysholm, and visual analog scale for pain (VAS pain) were calculated and compared with MCID values to determine if they met the MCID threshold.Results:A total of 35 studies were identified, including 1658 unique patients. Weighted mean postoperative score improvements exceeded MCID thresholds for the VAS pain, IKDC, and Lysholm. Subgroup analysis of patients undergoing isolated lateral fresh-frozen MAT demonstrated postoperative improvements exceeding the MCID for the Lysholm and VAS pain.Conclusion:Evaluating postoperative PROMs with respect to the MCID is crucial to evaluate the effect of MAT on functional improvement. The results of the present meta-analysis suggest that postoperative improvements after MAT are clinically meaningful as reflected by PROMs exceeding the MCID threshold for the IKDC, Lysholm, and VAS pain.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-09-08T04:23:38Z
      DOI: 10.1177/03635465211036116
       
  • Influence of Fatty Infiltration on Hip Abductor Repair Outcomes: A
           Systematic Review and Meta-analysis

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      Authors: Austin M. Looney, Blake M. Bodendorfer, Stiles T. Donaldson, Robert B. Browning, Jorge A. Chahla, Shane J. Nho
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Increasing evidence supports surgical intervention for hip abductor tears; however, the influence of fatty infiltration (FI) on outcomes after repair remains uncertain and has been addressed only in small case series.Purpose:To clarify the relationship between FI and surgical outcomes for hip abductor tears.Study Design:Meta-analysis; Level of evidence, 4.Methods:A systematic review and meta-analysis was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. FI severity was assessed by Goutallier-Fuchs (G-F) grade. The relationship between FI and improvement in Harris Hip Score (HHS)/modified Harris Hip Score (mHHS) and visual analog scale (VAS) score for pain was examined with mixed-effects metaregression. Outcomes with open and endoscopic techniques were also compared.Results:A total of 4 studies (206 repairs in 201 patients) were eligible. High-grade FI was associated with significantly less improvement in HHS/mHHS than both no FI (6.761 less; 95% CI, 3.983-11.570; P = .002) and low-grade FI (7.776 less; 95% CI, 2.460-11.062; P < .001) but did not significantly influence VAS score (P> .05). Controlling for FI severity, we found no significant difference in HHS/mHHS improvement between open versus endoscopic repair (P> .05 at each level), but open repair resulted in significantly greater improvement in VAS score for every G-F grade (all P < .005).Conclusion:Surgical intervention for symptomatic hip abductor tendon tears improved outcomes as reflected by change in HHS/mHHS; however, the presence of high-grade FI resulted in less improvement. FI severity did not influence VAS scores for pain. Although no differences were found between open and endoscopic repairs in terms of FI-adjusted improvement in HHS/mHHS, open repairs resulted in significantly greater pain relief at each FI level.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-09-08T04:17:30Z
      DOI: 10.1177/03635465211027911
       
  • Rehabilitation and Return to Sport Criteria Following Ulnar Collateral
           Ligament Reconstruction: A Systematic Review

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      Authors: Bryson R. Kemler, Somnath Rao, Donald P. Willier, Robert A. Jack, Brandon J. Erickson, Steven B. Cohen, Michael G. Ciccotti
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Ulnar collateral ligament (UCL) reconstruction (UCLR) is a viable treatment option for patients with UCL insufficiency, especially in the overhead throwing athlete. Within the clinical literature, there is still no universally agreed upon optimal rehabilitation protocol and timing for return to sport (RTS) after UCLR.Hypothesis:There will be significant heterogeneity with respect to RTS criteria after UCLR. Most surgeons will utilize time-based criteria rather than functional or performance-based criteria for RTS after UCLR.Study Design:Systematic review; Level of evidence, 4.Methods:All level 1 to 4 studies that evaluated UCLR with a minimum 1-year follow-up were eligible for inclusion. Studies lacking explicit RTS criteria, studies that treated UCL injury nonoperatively or by UCL repair, or studies reporting revision UCLR were excluded. Each study was analyzed for methodologic quality, RTS, timeline of RTS, and RTS rate.Results:Overall, 1346 studies were identified, 33 of which met the inclusion criteria. These included 3480 athletes across 21 different sports. All studies reported RTS rates either as overall rates or via the Conway-Jobe scale. Timelines for RTS ranged from 6.5 to 16 months. Early bracing with progressive range of motion (ROM) (93.9%), strengthening (84.8%), and participation in an interval throwing program (81.8%) were the most common parameters emphasized in these rehabilitation protocols. While all studies included at least 1 of 3 metrics for the RTS value assessment, most commonly postoperative rehabilitation (96.97%) and set timing after surgery (96.97%), no article completely defined RTS criteria after UCLR.Conclusion:Overall, 93.9% of studies report utilizing bracing with progressive ROM, 84.8% reported strengthening, and 81.8% reported participation in an interval throwing program as rehabilitation parameters after UCLR. In addition, 96.97% reported timing after surgery as a criterion for RTS; however, there is a wide variability within the literature on the recommended time from surgery to return to activity. Future research should focus on developing a comprehensive checklist of functional and performance-based criteria for safe RTS after UCLR.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-09-08T02:40:26Z
      DOI: 10.1177/03635465211033994
       
  • Quadriceps Tendon Autograft Versus Bone–Patellar Tendon–Bone and
           Hamstring Tendon Autografts for Anterior Cruciate Ligament Reconstruction:
           A Systematic Review and Meta-analysis

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      Authors: Wenli Dai, Xi Leng, Jian Wang, Jin Cheng, Xiaoqing Hu, Yingfang Ao
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:The best type of autograft for anterior cruciate ligament (ACL) reconstruction remains debatable.Hypothesis:Compared with bone–patellar tendon–bone (BPTB) and hamstring tendon (HT) autografts, the quadriceps tendon (QT) autograft has comparable graft survival as well as clinical function and pain outcomes.Study Design:Meta-analysis; Level of evidence, 4.Methods:A systematic literature search was conducted in PubMed, Embase, Scopus, and the Cochrane Library to July 2020. Randomized controlled trials (RCTs) and observational studies reporting comparisons of QT versus BPTB or HT autografts for ACL reconstruction were included. All analyses were stratified according to study design: RCTs or observational studies.Results:A total of 24 studies were included: 7 RCTs and 17 observational studies. The 7 RCTs included 388 patients, and the 17 observational studies included 19,196 patients. No significant differences in graft failure (P = .36), the International Knee Documentation Committee (IKDC) subjective score (P = .39), or the side-to-side difference in stability (P = .60) were noted between QT and BPTB autografts. However, a significant reduction in donor site morbidity was noted in the QT group compared with the BPTB group (risk ratio [RR], 0.17 [95% CI, 0.09-0.33]; P < .001). No significant differences in graft failure (P = .57), the IKDC subjective score (P = .25), or the side-to-side stability difference (P = .98) were noted between QT and HT autografts. However, the QT autograft was associated with a significantly lower rate of donor site morbidity than the HT autograft (RR, 0.60 [95% CI, 0.39-0.93]; P = .02). A similar graft failure rate between the QT and control groups was observed after both early and late full weightbearing, after early and late full range of motion, and after using the QT autograft with a bone plug and all soft tissue QT grafts. However, a significantly lower rate of donor site morbidity was observed in the QT group compared with the control group after both early and late full weightbearing, after early and late full range of motion, and after using the QT autograft with a bone plug and all soft tissue QT grafts. No difference in effect estimates was seen between RCTs and observational studies.Conclusion:The QT autograft had comparable graft survival, functional outcomes, and stability outcomes compared with BPTB and HT autografts. However, donor site morbidity was significantly worse with the QT autograft than with BPTB and HT autografts.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-09-08T02:30:05Z
      DOI: 10.1177/03635465211030259
       
  • No Difference in Complications Between Elbow Ulnar Collateral Ligament
           Reconstruction With the Docking and Modified Jobe Techniques: A Systematic
           Review and Meta-analysis

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      Authors: Austin M. Looney, Nathan P. Fackler, Mark A. Pianka, Blake M. Bodendorfer, Caroline M. Fryar, Christine M. Conroy, Jacob E. Israel, David X. Wang, Michael G. Ciccotti, Edward S. Chang
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:The most commonly used techniques for elbow ulnar collateral ligament reconstruction (UCLR) are the docking and modified Jobe figure-of-8 techniques. Previous literature has suggested that UCLR with the docking technique is associated with fewer complications; however, these studies included results from the original classic Jobe technique without controlling for the effects of flexor pronator mass (FPM) detachment and routine submuscular ulnar nerve transposition (UNT).Purpose/Hypothesis:This study sought to compare the rates of complications and subsequent unplanned surgical procedures between the docking and figure-of-8 techniques. We hypothesized that there would be no significant difference in the rates of complications or subsequent unplanned surgical procedures between the techniques when the FPM was preserved and no routine submuscular UNT was performed.Study Design:Systematic review and meta-analysis; Level of evidence, 4.Methods:This study was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A series of mixed-effects multivariate metaregression models were implemented using the restricted maximum likelihood method. Complications and subsequent unplanned surgical procedures were modeled as Freeman-Tukey transformed incidence rates for variance stabilization, and nerve-specific complications were assessed as the Freeman-Tukey transformed proportion of cases, with back-transformation to estimate summary effects.Results:There were 19 studies eligible for qualitative analysis, consisting of 1788 cases of UCLR (303 docking, 1485 figure-of-8), 18 of which were suitable for quantitative analysis (1769 cases; 291 docking, 1478 figure-of-8). A total of 338 complications were reported (17 for docking, 321 for figure-of-8), the majority of which were nerve related. Additionally, a total of 75 subsequent unplanned surgical procedures were related to the index UCLR procedure. There was no significant difference in the rate of complications (P = .146) or proportion of cases with nerve-specific complications (P = .127) between the docking and figure-of-8 techniques when controlling for FPM preservation versus detachment with submuscular UNT. FPM detachment with submuscular UNT was independently associated with a significantly higher proportion of postoperative nerve-related complications (P = .004). There was also no significant difference in the rates of subsequent unplanned surgical procedures between the docking and figure-of-8 techniques (P = .961), although FPM detachment with routine submuscular UNT was independently associated with a significantly higher incidence of subsequent unplanned surgical procedures.Conclusion:The results of this study demonstrate no significant difference in the rates of complications or subsequent unplanned surgical procedures between the figure-of-8 and docking techniques for UCLR when controlling for FPM preservation versus detachment with submuscular UNT. With modern muscle-sparing approaches and avoiding submuscular UNT, the modified Jobe technique does not differ significantly from the docking technique in terms of complication rates, proportions of cases with nerve-specific complications, or rates of subsequent unplanned surgical procedures.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-09-07T01:58:37Z
      DOI: 10.1177/03635465211023952
       
  • Quadriceps Tendon Versus Hamstring Tendon Autografts for Anterior Cruciate
           Ligament Reconstruction: A Systematic Review and Meta-analysis

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      Authors: Tze Khiang Tan, Arjun Gopal Subramaniam, Jay R. Ebert, Ross Radic
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Autograft choice in anterior cruciate ligament reconstruction (ACLR) remains controversial, with increasing interest in the usage of quadriceps tendon (QT) autograft versus traditional hamstring tendon (HT) use. The current study undertakes an in-depth review and comparison of the clinical and functional outcomes of QT and HT autografts in ACLR.Hypothesis:The QT autograft is equivalent to the HT autograft and there will be little or no significant difference in the outcomes between these 2 autografts.Study Design:Systematic review and meta-analysis; Level of evidence, 4.Methods:The PUBMED, EMBASE, MEDLINE, and CENTRAL databases were systematically searched from their inception until November 2020. All observational studies comparing ACLR QT and HT autografts were assessed for their methodological quality. Patient outcomes were compared according to patient-reported outcome measures (International Knee Documentation Committee [IKDC], Cincinnati, Lysholm, Tegner, and visual analog scale [VAS] measures), knee extensor and flexor torque limb symmetry indices (LSIs), hamstring to quadriceps (H/Q) ratios, functional hop capacity, knee laxity, ipsilateral graft failure, and contralateral injury.Results:A total of 20 observational studies comprising 28,621 patients (QT = 2550; HT = 26,071) were included in the quantitative meta-analysis. In comparison with patients who received an HT autograft, those who received a QT autograft had similar postoperative Lysholm (mean difference [MD], 0.67; P = .630), IKDC (MD, 0.48; P = .480), VAS pain (MD, 0.04; P = .710), and Cincinnati (MD, -0.85; P = .660) scores; LSI for knee flexor strength (MD, 6.06; P = .120); H/Q ratio (MD, 3.22; P = .160); hop test LSI (MD, -1.62; P = .230); pivot-shift test grade 0 (odds ratio [OR], 0.80; P = .180); Lachman test grade 0 (OR, 2.38; P = .320), side-to-side laxity (MD, 0.09; P = .650); incidence of graft failure (OR, 1.07; P = .830) or contralateral knee injury (OR, 1.22; P = .610); and Tegner scores (MD, 0.11; P = .060). HT autografts were associated with a higher (better) side-to-side LSI for knee extensor strength (MD, -6.31; P = .0002).Conclusion:In this meta-analysis, the use of the QT autograft was equivalent to the HT autograft in ACLR, with comparable graft failure and clinical and functional outcomes observed. However, HT autografts were associated with better LSI knee extensor strength.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-09-02T07:59:06Z
      DOI: 10.1177/03635465211033995
       
  • Changes From Baseline in Patient- Reported Outcomes at 1 Year Versus 2
           Years After Rotator Cuff Repair: A Systematic Review and Meta-analysis

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      Authors: Sambit Sahoo, Martina Stojanovska, Peter B. Imrey, Yuxuan Jin, Richard J. Bowles, Jason C. Ho, Joseph P. Iannotti, Eric T. Ricchetti, Kurt P. Spindler, Kathleen A. Derwin, Vahid Entezari
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Most orthopaedic journals currently require reporting outcomes of surgical interventions for at least 2 postoperative years, but there have been no rigorous studies on this matter. Various patient-reported outcome (PRO) measures (PROMs) have been used to assess the status of the shoulder after rotator cuff repair (RCR).Hypothesis:We hypothesized that the mean shoulder-specific PROMs at 1 year improve substantially over baseline but that there is no clinically meaningful difference between the mean 1- and 2-year PROMs after RCR.Study Design:Meta-analysis; Level of evidence, 2.Methods:We conducted a systematic review of published randomized controlled trials (RCTs) and prospective cohort studies (level of evidence 1 and 2) reporting the shoulder-specific American Shoulder and Elbow Surgeons (ASES), the Constant, or the Western Ontario Rotator Cuff (WORC) Index scores at baseline, 1 year, and 2 years after RCR. The methodologic quality of studies was assessed. Also, the random effects meta-analyses of changes in PROMs for each of the first and second postoperative years were conducted.Results:Fifteen studies (n = 11 RCTs; n = 4 cohort studies) with a total of 1371 patients were included. Studies were highly heterogeneous, but no visual evidence of major publication bias was observed. The weighted means of the baseline PROMs were 46.2 points for the ASES score, 46.4 points for the Constant score, and 38.8 points for the WORC Index. The first-year summary increments were 41.1 (95% CI, 36.0-46.2) points for the ASES score, 34.2 (95% CI, 28.8-39.6) points for the Constant score, and 42.9 (95% CI, 37.3-48.4) points for the WORC Index. In contrast, the second-year summary increments were 2.3 (95% CI, 1-3.6) points for the ASES score, 3.2 (95% CI, 1.9-4.4) points for the Constant score, and 2 (95% CI, -0.1 to 4) points for the WORC Index.Conclusion:All PROMs improved considerably from baseline to 1 year, but only very small gains that were below the minimal clinically important differences were observed between 1 year and 2 years after RCR. This study did not find any evidence for requiring a minimum of 2 years of follow-up for publication of PROs after RCR. Our results suggest that focusing on 1-year PROMs after RCR would foster more timely reporting, better control of selection bias, and better allocation of research resources.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-09-02T04:50:28Z
      DOI: 10.1177/03635465211023967
       
  • Do Sideline Tests of Vestibular and Oculomotor Function Accurately
           Diagnose Sports-Related Concussion in Adults' A Systematic Review and
           Meta-analysis

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      Authors: Sarah A. Harris, Alasdair R. Dempsey, Katherine Mackie, Doug King, Mark Hecimovich, Myles C. Murphy
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Sports-related concussion (SRC) assessment tools are primarily based on subjective assessments of somatic, cognitive, and psychosocial/emotional symptoms. SRC symptoms remain underreported, and objective measures of SRC impairments would be valuable to assist diagnosis. Measurable impairments to vestibular and oculomotor processing have been shown to occur after SRC and may provide valid objective assessments.Purpose:Determine the diagnostic accuracy of sideline tests of vestibular and oculomotor dysfunction to identify SRC in adults.Study Design:Systematic review; Level of evidence, 4.Methods:Electronic databases and gray literature were searched from inception until February 12, 2020. Physically active individuals (>16 years of age) who participated in sports were included. The reference standard for SRC was a combination of clinical signs and symptoms (eg, the Sport Concussion Assessment Tool [SCAT]), and index tests included any oculomotor assessment tool. The QUADAS tool was used to assess risk of bias, with the credibility of the evidence being rated according to GRADE.Results:A total of 8 studies were included in this review. All included studies used the King-Devick test, with no other measures being identified. Meta-analysis was performed on 4 studies with a summary sensitivity and specificity of 0.77 and 0.82, respectively. The overall credibility of the evidence was rated as very low.Conclusion:Caution must be taken when interpreting these results given the very low credibility of the evidence, and the true summary sensitivity and specificity may substantially differ from the values calculated within this systematic review. Therefore, we recommend that clinicians using the King-Devick test to diagnose SRC in adults do so in conjunction with other tools such as the SCAT.PROSPERO Registration:CRD42018106632.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-08-25T05:45:45Z
      DOI: 10.1177/03635465211027946
       
  • Controversy on the Association of the Critical Shoulder Angle and the
           Development of Degenerative Rotator Cuff Tears: Is There a True
           Association' A Meta-analytical Approach

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      Authors: Jorge Rojas Lievano, Maria Bautista, Santiago Woodcock, Guido Fierro, Juan Carlos González
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:The role of the critical shoulder angle (CSA) as a risk factor for rotator cuff tear (RCT) remains controversial. Studies on the association between the CSA and RCT show considerable differences in design, and this could be responsible for the variation in study results.Purpose:To (1) describe the reliability of CSA measurement and (2) evaluate the results of the studies reporting the association between the CSA and RCT using meta-analytical techniques to explore potential sources of variation of study results.Study Design:Systematic review and meta-analysis; Level of evidence, 4.Methods:MEDLINE, EMBASE, and CINAHL electronic databases were searched through June 30, 2019. Case-control and cross-sectional studies reporting the association of the CSA and RCT were selected. The weighted mean difference in the CSA was estimated using a random-effects model. Prediction interval was computed to better express uncertainties in the effect estimate. Metaregression and subgroup analyses were performed to explore potential sources of heterogeneity.Results:A total of 14 studies, including 1154 cases and 1271 controls, were identified. Of these studies, 79% (11/14) assessed the reliability of the CSA measurement, demonstrating an excellent intraobserver (range, 0.91-0.99) and interobserver (range, 0.87-0.99) reliability. Compared with controls, cases with RCT showed larger measurements of the CSA (3.3° [95% CI, 2.3°- 4.4°]). However, there was a high heterogeneity (I2 = 93%), and the 95% prediction interval (-0.4° to 7.1°) included no difference in the CSA. Results of the metaregression analysis showed a significant association of several methodological aspects with the heterogeneity. The difference in the CSA tended to be larger when only full-thickness tears were included, when no specific defined criterion for assessing radiographic viewing perspective was used, in studies with smaller sample sizes, and in studies at higher risk of bias.Conclusion:While the CSA can be reliably measured, the difference in the CSA between cases and controls varied from very large to modest or almost no difference. Several determinants of heterogeneity were determined. Owing to this heterogeneity, it is difficult to gain an insight into the strength and exact nature of the association between the CSA and RCT with the current evidence.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-08-25T05:24:41Z
      DOI: 10.1177/03635465211027305
       
  • Does the Type of Sport Influence Morphology of the Hip' A Systematic
           Review

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      Authors: Chantelle Doran, Matthew Pettit, Yash Singh, Karadi Hari Sunil Kumar, Vikas Khanduja
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Femoroacetabular impingement (FAI) has been extensively investigated and is strongly associated with athletic participation.Purpose:To assess (1) the prevalence of cam-type FAI across various sports; (2) whether kinematic variation among sports influences hip morphology; and (3) whether performance level, duration, and frequency of participation or other factors influence hip morphology in a sporting population.Study Design:Systematic review; Level of evidence, 4.Methods:A systematic search of Embase, PubMed, and the Cochrane Library was undertaken following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Prospective and retrospective case series, case reports, and review articles published after 1999 were screened, and those that met the inclusion criteria decided a priori were included for analysis.Results:The literature search identified 58 relevant articles involving 5683 participants. A total of 49 articles described a higher prevalence of FAI across various “hip-heavy” sports, including soccer, basketball, baseball, ice hockey, skiing, golf, and ballet. In studies including nonathlete controls, a greater prevalence of FAI was reported in 66.7% of studies (n = 8/12). The highest alpha angle was identified at the 1-o’clock position (n = 9/9) in football, skiing, golf, ice hockey, and basketball. The maximum alpha angle was located in a more lateral position in goalkeepers versus positional players in ice hockey (1 vs 1:45 o’clock). A positive correlation was also identified between the alpha angle and both age and activity level (n = 5/8 and n = 2/3, respectively) and between prevalence of FAI and both age and activity level (n = 2/2 and n = 4/5).Conclusion:Hip-heavy sports show an increased prevalence of FAI, with specific sporting activities influencing hip morphology. There is some evidence to suggest that a longer duration and higher level of training also result in an increased prevalence of FAI.Registration:CRD4202018001 (PROSPERO).
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-08-24T04:36:01Z
      DOI: 10.1177/03635465211023500
       
  • The Effects of Blood Flow Restriction in Patients Undergoing Knee Surgery:
           A Systematic Review and Meta-analysis

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      Authors: Lawrence Wengle, Filippo Migliorini, Timothy Leroux, Jaskarndip Chahal, John Theodoropoulos, Marcel Betsch
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Blood flow restriction (BFR) training has been shown to have beneficial effects in reducing quadriceps muscle atrophy and improving strength in patients with various knee pathologies. Furthermore, the effectiveness of BFR training in patients undergoing knee surgery has been investigated to determine if its use can improve clinical outcomes.Purpose/Hypothesis:The purpose of this study was to conduct a systematic review and meta-analysis to examine the effectiveness of BFR training in patients undergoing knee surgery. We hypothesized that BFR, before or after surgery, would improve clinical outcomes as well as muscle strength and volume.Study Design:Systematic review and meta-analysis; Level of evidence, 4.Methods:This systematic review and meta-analysis of peer-reviewed literature was conducted using PubMed, Embase, and Cochrane databases from 1980 to present. Search results were limited to those assessing BFR training in patients undergoing knee surgery published in a scientific peer-reviewed journal in English. Selected studies subsequently underwent data extraction, methodological quality assessment, and data analysis.Results:Eleven studies were eligible, including anterior cruciate ligament reconstruction (n = 10) and knee arthroscopy (n = 1). Two studies specifically assessed BFR use in the preoperative time frame. For the meta-analysis, including 4 studies, the primary outcome variables included the cross-sectional area of the quadratus femoris muscle group assessed with magnetic resonance imaging or ultrasonography, and patient-reported outcome measure scores. The results demonstrated that BFR use in the postoperative time period can lead to a significant improvement in the cross-sectional area when quantifying muscle atrophy. However, there were no significant differences found for patient-reported outcome measures between the included studies. It should be noted that 4 of the included papers in this review reported increases in clinical strength when using BFR in the postoperative setting. Last, preoperative BFR training did not show any significant clinical benefit between the 2 studies.Conclusion:This is the first systematic review and meta-analysis to study the effects of BFR in patients undergoing knee surgery. The results of this analysis show that BFR in the postoperative period after knee surgery can improve quadriceps muscle bulk compared with a control group. However, future research should examine the effects of preconditioning with BFR before surgery. Lastly, BFR protocols need to be further investigated to determine which provide the best patient outcomes. This will help standardize this type of treatment modality for future studies.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-08-18T03:40:29Z
      DOI: 10.1177/03635465211027296
       
  • Relative Efficacy of Intra-articular Injections in the Treatment of Knee
           Osteoarthritis: A Systematic Review and Network Meta-analysis

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      Authors: Harsh Singh, Derrick M. Knapik, Evan M. Polce, Carlo K. Eikani, Amanda H. Bjornstad, Safa Gursoy, Allison K. Perry, Jennifer C. Westrick, Adam B. Yanke, Nikhil N. Verma, Brian J. Cole, Jorge A. Chahla
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:In younger patients and those without severe degenerative changes, the efficacy of intra-articular (IA) injections as a nonoperative modality for treating symptomatic knee osteoarthritis (OA)–related pain while maintaining function has become a subject of increasing interest.Purpose:To assess and compare the efficacy of different IA injections used for the treatment of knee OA, including hyaluronic acid (HA), corticosteroids (CS), platelet-rich plasma (PRP), and plasma rich in growth factors (PRGF), with a minimum 6-month patient follow-up.Study Design:Meta-analysis of randomized controlled trials; Level of evidence, 1.Methods:A systematic review was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using the following databases: PubMed/MEDLINE, Scopus, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Google Scholar. Mean or mean change from baseline and standard deviation for outcome scores regarding pain and function were recorded at the 6-month follow-up and converted to either a 0 to 100 visual analog scale score for pain or a 0 to 100 Western Ontario and McMaster Universities Osteoarthritis Index score for function. A frequentist network meta-analysis model was developed to compare the effects of HA, CS, PRP, PRGF, and placebo on patient-reported outcomes.Results:All IA treatments except CS were found to result in a statistically significant improvement in outcomes when compared with placebo. PRP demonstrated a clinically meaningful difference in function-related improvement when compared with CS and placebo due to large effect sizes. Studies evaluating outcomes of PRGF reported significant improvement when compared with placebo due to large effect sizes, whereas a potential clinically significant difference was detected in the same comparison parameters in pain evaluation. With regard to improvements in pain, function, and both combined, PRP was found to possess the highest probability of efficacy, followed by PRGF, HA, CS, and placebo.Conclusion:PRP yielded improved outcomes when compared with PRGF, HA, CS, and placebo for the treatment of symptomatic knee OA at a minimum 6-month follow-up. Further investigations evaluating different IA and other nonoperative treatment options for patients with knee OA are warranted to better understand the true clinical efficacy and long-term outcomes of nonsurgical OA management.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-08-17T05:12:14Z
      DOI: 10.1177/03635465211029659
       
  • Routine Capsular Closure With Hip Arthroscopic Surgery Results in Superior
           Outcomes: A Systematic Review and Meta-analysis

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      Authors: Austin M. Looney, Julia A. McCann, Patrick T. Connelly, Spencer M. Comfort, Andrew J. Curley, William F. Postma
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:In hip arthroscopic surgery, capsulotomy is performed to improve visualization and allow instrumentation of the joint. Traditionally, the defect has been left unrepaired; however, increasing evidence suggests that this may contribute to persistent pain and iatrogenic capsular instability. Nevertheless, the clinical benefit of performing routine capsular repair remains controversial.Purpose/Hypothesis:We conducted a systematic review and meta-analysis to investigate the effects of routine capsular closure on patient-reported outcomes (PROs), hypothesizing that superior PROs would be observed with routine capsular closure.Study Design:Meta-analysis and systematic review; Level of evidence, 4.Methods:A systematic review and meta-analysis was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The terms “hip,”“arthroscopy,”“capsule,”“capsular,”“repair,” and “closure” were used to query Ovid MEDLINE, Embase, CENTRAL (Cochrane Central Register of Controlled Trials), CINAHL (Cumulative Index to Nursing and Allied Health Literature), SPORTDiscus, and PubMed. Articles with PROs stratified by capsular management were included. Multivariate mixed-effects metaregression models were implemented with study-level random-effects and fixed-effects moderators for capsular closure versus no repair and after controlling for surgical indication and preoperative PROs. The effect of repair on both the postoperative score and the change in scores was evaluated via the Harris Hip Score (HHS)/modified HHS (mHHS), Hip Outcome Score (HOS)–Activities of Daily Living (ADL), and HOS–Sport Specific Subscale (SSS), with a supplemental analysis of additional outcomes.Results:Of 432 initial articles, 36 were eligible for analysis, with results for 5132 hip arthroscopic procedures. The capsule was repaired in 3427 arthroscopic procedures and unrepaired in 1705. Capsular repair was associated with significantly higher postoperative HHS/mHHS (2.011; SE, 0.743 [95% CI, 0.554-3.467]; P = .007), HOS-ADL (3.635; SE, 0.873 [95% CI, 1.923-5.346]; P < .001), and HOS-SSS (4.137; SE, 1.205 [95% CI, 1.775-6.499]; P < .001) scores as well as significantly superior improvement on the HHS/mHHS (2.571; SE, 0.878 [95% CI, 0.849-4.292]; P = .003), HOS-ADL (3.315; SE, 1.131 [95% CI, 1.099-5.531]; P = .003), and HOS-SSS (3.605; SE, 1.689 [95% CI, 0.295-6.915]; P = .033).Conclusion:This meta-analysis is the largest to date evaluating the effect of capsular closure on PROs and demonstrates significantly higher mean postoperative scores and significantly superior improvement with repair, while controlling for the effects of preoperative score and surgical indication. The true magnitude of the benefit of capsular repair may be clarified by large prospective randomized studies using PRO measures specifically targeted and validated for hip arthroscopic surgery/preservation.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-08-17T05:06:16Z
      DOI: 10.1177/03635465211023508
       
  • Management of Patellar Instability: A Network Meta-analysis of Randomized
           Control Trials

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      Authors: Eoghan T. Hurley, Christopher A. Colasanti, Delon McAllister, Bogdan A. Matache, Michael J. Alaia, Eric J. Strauss, Kirk A. Campbell
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Multiple surgical options exist for the treatment of patellar instability; however, the most common procedures involve either a reconstruction of the medial patellofemoral ligament (MPFL) or a repair/plication of the MPFL and medial soft tissues.Purpose:To perform a network meta-analysis of the randomized controlled trials (RCTs) in the literature to compare MPFL reconstruction, MPFL repair, and nonoperative management for patellar instability.Study Design:Systematic review and network meta-analysis; Level of evidence, 1.Methods:The literature search was performed based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. RCTs comparing MPFL reconstruction, MPFL repair, and nonoperative management for patellar instability were included. Clinical outcomes included recurrent instability (including both dislocations and subluxations), redislocation, and Kujala score. Clinical outcomes were compared using a frequentist approach to network meta-analysis, with statistical analysis performed using the statistical software R. The treatment options were ranked using P scores.Results:There were 13 RCTs with a total of 789 patients, all with a minimum follow-up of 24 months. There were 150 patients treated using MPFL reconstruction, 353 treated using MPFL repair, and 286 treated nonoperatively. Overall, MPFL reconstruction had the highest P score (0.9967) and resulted in a significantly lower recurrence rate than did MPFL repair (odds ratio [OR], 0.42; 95% CI, 0.07-0.72) and nonoperative management (OR, 0.09; 95% CI, 0.03-0.32). In addition, MPFL repair resulted in a significantly lower recurrence rate than did nonoperative management (OR, 0.42; 95% CI, 0.25-0.70). MPFL reconstruction had the highest P score (0.9651) and resulted in a significantly higher Kujala score than did nonoperative management (mean difference, 10.45; 95% CI, 0.41-20.49) but not MPFL repair (mean difference, 0.15; 95% CI, 0.03-0.68). Subgroup analysis revealed that MPFL reconstruction had the highest P score for all outcomes in those with first-time dislocation.Conclusion:The current study demonstrated that MPFL reconstruction results in the lowest rate of recurrent patellar instability and best functional outcomes as measured using the Kujala score.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-08-02T04:27:16Z
      DOI: 10.1177/03635465211020000
       
  • Return to Baseline Physical Activity After Bone–Patellar Tendon–Bone
           Versus Hamstring Tendon Autografts for Anterior Cruciate Ligament
           Reconstruction: A Systematic Review and Meta-analysis of Randomized
           Controlled Trials

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      Authors: Jeremy J. Bergeron, Quentin P. Sercia, Justin Drager, Stéphane Pelet, Etienne L. Belzile
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Bone–patellar tendon–bone (BPTB) and hamstring tendon (HT) autografts are the most utilized grafts for primary anterior cruciate ligament (ACL) reconstruction. The ability of a patient to return to a preinjury level of physical activity is a key consideration in choice of graft; the influence of graft choice on this metric lacks consensus in the literature.Purpose:To assess the effects of autograft choice (BPTB vs HT) for primary ACL reconstruction on return to baseline level of physical activity and/or sports participation.Study Design:Meta-analysis; Level of evidence, 1.Methods:A systematic review of randomized controlled trials comparing the use of BPTB and HT autografts for primary ACL reconstruction was conducted. The electronic databases EMBASE, MEDLINE, Cochrane CENTRAL, and Web of Science were comprehensively queried through September 23, 2019. The primary outcome was return to preinjury level of activity/sports. Secondary outcomes included knee stability testing (Lachman, KT-1000 arthrometer, and pivot-shift tests) and clinical subjective knee scores (Tegner, Cincinnati, International Knee Documentation Committee, and Lysholm). Two independent reviewers were involved in the screening of titles and abstracts, data extraction, and the assessment of risk of bias. Meta-analyses were performed respecting the Cochrane Handbook for Systematic Reviews of Intervention.Results:A total of 29 studies (N = 3099 patients) were eligible for this review, of which 13 (n = 1029 patients) reported on return to baseline level of sports as an endpoint. The risk ratio (RR) of using BPTB vs HT on return to baseline sport level was 1.03 (0.91-1.17; P = .63). Absence of a positive pivot-shift test was the only secondary outcome, with a statistically significant RR of 0.66 (95% CI, 0.50-0.86) in favor of BPTB autografts (P = .002).Conclusion:In reviewing the current literature, no recommendation can be made on the optimal graft choice when using a return to baseline level of physical activity and/or sports participation as a primary metric.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-07-26T05:26:54Z
      DOI: 10.1177/03635465211017522
       
  • Fresh Osteochondral and Chondral Allograft Preservation and Storage Media:
           A Systematic Review of the Literature

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      Authors: Suzanne M. Tabbaa, Farshid Guilak, Robert L. Sah, William D. Bugbee
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Storage procedures and parameters have a significant influence on the health of fresh osteochondral allograft (OCA) cartilage. To date, there is a lack of agreement on the optimal storage conditions for OCAs.Purpose:To systematically review the literature on (1) experimental designs and reporting of key variables of ex vivo (laboratory) studies, (2) the effects of various storage solutions and conditions on cartilage health ex vivo, and (3) in vivo animal studies and human clinical studies evaluating the effect of fresh OCA storage on osteochondral repair and outcomes.Study Design:Systematic review; Level of evidence, 5.Methods:A systematic review was performed using the PubMed, Embase, and Cochrane databases. The inclusion criteria were laboratory studies (ex vivo) reporting cartilage health outcomes after prolonged storage (>3 days) of fresh osteochondral or chondral tissue explants and animal studies (in vivo) reporting outcomes of fresh OCA. The inclusion criteria for clinical studies were studies (>5 patients) that analyzed the relationship of storage time or chondrocyte viability at time of implantation to patient outcomes. Frozen, cryopreserved, decellularized, synthetic, or tissue-engineered grafts were excluded.Results:A total of 55 peer-reviewed articles met the inclusion criteria. Ex vivo studies reported a spectrum of tissue sources and storage solutions and conditions, although the majority of studies lacked complete reporting of key variables, including storage solution formula and environmental conditions. The effect of various conditions (eg, temperature) and storage solutions on cartilage health were inconsistent. Although 60% of animal models suggest that storage time may influence outcomes and 80% indicate inferior outcomes with frozen OCA as compared with fresh OCA, 75% of clinical studies report no correlation between storage time and outcomes.Conclusion:Given the variability in experimental designs and lack of reporting across studies, it is still not possible to determine optimal storage conditions, although animal studies suggest that storage time and chondrocyte viability influence osteochondral repair outcomes. A list of recommendations was developed to encourage reporting of key variables, such as media formulation, environmental factors, and methodologies used. High-quality clinical data are needed to investigate the effects of storage and graft health on outcomes.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-07-26T04:49:06Z
      DOI: 10.1177/03635465211016832
       
  • Comparison of Long-term Radiographic Outcomes and Rate and Time for
           Conversion to Total Knee Arthroplasty Between Repair and Meniscectomy for
           Medial Meniscus Posterior Root Tears: A Systematic Review and
           Meta-analysis

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      Authors: Laura M. Krivicich, Kyle N. Kunze, Kevin C. Parvaresh, Kyleen Jan, Annie DeVinney, Amar Vadhera, Robert F. LaPrade, Jorge Chahla
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Previous meta-analyses have demonstrated superior outcomes in patients undergoing arthroscopic repair of medial meniscus posterior root tears (MMPRTs) compared with meniscectomy. However, these analyses have considered only short- or midterm outcomes and low-quality evidence.Purpose:To compare the mid- to long-term rates of radiographic osteoarthritis (OA) between repair and meniscectomy for MMPRT.Study Design:Systematic review and meta-analysis; Level of evidence, 4.Methods:PubMed, EMBASE, Ovid/MEDLINE, and Cochrane Central Register of Controlled Trials databases were queried for articles evaluating repair and meniscectomy for MMPRT. Articles were eligible if they had a minimum mean 4-year follow-up for radiographic OA or conversion to total knee arthroplasty (TKA) and were at least level 3 evidence. Radiographic OA was assessed using Kellgren-Lawrence (KL) progression. Rates of conversion to TKA and International Knee Documentation Committee (IKDC) scores were also extracted. DerSimonian-Laird binary random-effects models were created to evaluate differences in radiographic OA and TKA conversion rates, with odds ratios (ORs) representing pooled estimates. Continuous random-effects models with standardized mean differences (SMDs) were used to compare postoperative IKDC scores.Results:Repair and meniscectomy cohorts were followed for a mean of 64.8 months and 62.5 months, respectively, for KL progression; and 82.8 months and 73.8 months, respectively, for TKA rates and IKDC scores. Overall, 59 of 144 (41%) patients undergoing surgical intervention for MMPRT demonstrated OA progression; 18 of 82 (22%) who underwent repair for MMPRT exhibited OA progression compared with 41 of 62 (66%) who underwent meniscectomy (OR, 0.17; 95% CI, 0.03-0.83; P = .029). Overall, 30 of 143 (21%) patients converted to TKA; 9.8% (8/82) of patients who underwent repair converted to TKA (range, 47-131 months), while 36% (22/61) who underwent meniscectomy converted to TKA (range, 17.8-101 months) (OR, 0.15; 95% CI, 0.05-0.44; P < .001). No significant differences between postoperative IKDC scores were observed (SMD, 0.51; 95% CI, -0.02 to 1.05; P = .06).Conclusion:Medial meniscus posterior root repair results in significantly lower rates of radiographic OA progression and conversion to TKA at>60-month follow-up. On the basis of these findings, we recommend consideration of repair of MMPRTs when degenerative changes are not severe, as it can yield improved outcomes.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-07-12T08:37:31Z
      DOI: 10.1177/03635465211017514
       
  • Bone Marrow Aspirate Concentrate for the Treatment of Knee Osteoarthritis:
           A Systematic Review

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      Authors: Laura E. Keeling, John W. Belk, Matthew J. Kraeutler, Alexandra C. Kallner, Adam Lindsay, Eric C. McCarty, William F. Postma
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Bone marrow aspirate concentrate (BMAC) has emerged as a therapeutic option for symptomatic knee osteoarthritis (OA).Purpose:To systematically review the literature to evaluate the efficacy of isolated BMAC injection in the treatment of OA of the knee joint.Study Design:Systematic review; Level of evidence, 4.Methods:A systematic review was performed by searching the PubMed, Embase, and Cochrane Library databases up to July 2020 to identify human studies that assessed the clinical outcomes of isolated BMAC injection for the treatment of knee OA. The electronic search strategy used was “bone marrow aspirate concentrate knee osteoarthritis.”Results:Eight studies met the inclusion criteria, including a total of 299 knees with a mean follow-up of 12.9 months (range, 6-30 months). Of all patient-reported outcomes assessed across studies, 34 of 36 (94.4%) demonstrated significant improvement from baseline to latest follow-up (P < .05). Five studies evaluating numerical pain scores (visual analog scale and Numeric Rating Scale) reported significant improvements in pain level at final follow-up (P < .01). However, 3 comparative studies evaluating BMAC in relation to other therapeutic injections failed to demonstrate the clinical superiority of BMAC.Conclusion:The BMAC injection is effective in improving pain and patient-reported outcomes in patients with knee OA at short- to midterm follow-up. Nevertheless, BMAC has not demonstrated clinical superiority in relation to other biologic therapies commonly used in the treatment of OA, including platelet-rich plasma and microfragmented adipose tissue, or in relation to placebo. The high cost of the BMAC injection in comparison with other biologic and nonoperative treatment modalities may limit its utility despite demonstrable clinical benefit.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-07-08T04:29:25Z
      DOI: 10.1177/03635465211018837
       
  • Systematic Review of Injuries in the Men’s and Women’s
           National Basketball Association

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      Authors: Jayson Lian, Faraz Sewani, Isaac Dayan, Pramod B. Voleti, David Gonzalez, I. Martin Levy, Volker Musahl, Answorth Allen
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Numerous studies have reported the incidence and outcomes of injuries in the men’s and women’s National Basketball Association (NBA and WNBA, respectively).Purpose:To synthesize published data regarding the incidence and outcomes of all injuries in the NBA and WNBA in a comprehensive review.Study Design:Systematic review; Level of evidence, 4.Methods:Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we searched 3 electronic databases (PubMed, MEDLINE, Embase) for studies of all levels of evidence since 1990 pertaining to injuries sustained by active players in the NBA and WNBA. Studies were excluded if the cohort of interest included ≤3 active players.Results:The initial search of the 3 databases yielded 1253 unique studies, of which 49 met final inclusion criteria for this review. Only 4 studies included athletes in the WNBA. Based on the mean annual incidence, the 5 most common orthopaedic sports injuries sustained in the NBA were concussions (9.5-14.9 per year), fractures of the hand (3.5-5.5 per year), lower extremity stress fractures (4.8 per year), meniscal tears (2.3-3.3 per year), and anterior cruciate ligament tears (1.5-2.6 per year). Cartilage defects treated using microfracture, Achilles tendon ruptures, and anterior cruciate ligament injuries were 3 injuries that led to significant reductions in performance measurements after injury.Conclusion:With advances in sports technology and statistical analysis, there is rapidly growing interest in injuries among professional basketball athletes. High-quality prospective studies are needed to understand the prevalence and effect of injuries on player performance and career length. This information can inform preventative and treatment measures taken by health care providers to protect players and guide safe return to play at a high level.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-07-02T03:36:32Z
      DOI: 10.1177/03635465211014506
       
  • Return-to-Competition Criteria After Ulnar Collateral Ligament
           Reconstruction: A Systematic Review and Meta-analysis

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      Authors: Matthew J.J. Anderson, William K. Crockatt, John D. Mueller, Justin E. Hellwinkel, Frank J. Alexander, David P. Trofa, Christopher S. Ahmad
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Injury to the ulnar collateral ligament of the elbow is common among overhead throwing athletes and can result in significant functional limitations. While surgical reconstruction offers high rates of return to competition, there are no validated or universally accepted guidelines for determining when an athlete can safely resume play.Purpose:To assess the existing scientific literature for return-to-competition criteria utilized after ulnar collateral ligament reconstruction.Study Design:Systematic review and meta-analysis; Level of evidence, 4.Methods:The PubMed database was searched for clinical investigations of ulnar collateral ligament reconstruction in overhead throwing athletes published between January 2000 and June 2020. Only studies that had a minimum follow-up of 1 year and included at least 1 specific return-to-competition criterion were considered.Results:A total of 15 studies were included in the final analysis, encompassing 1156 patients with an average age of 20.7 years (SD, 2.0 years). Baseball players composed 96.3% of patients for whom sport was specified, and 92.4% of baseball players were pitchers. The most common return-to-competition criterion, identified in 87% of studies, was completion of a return-to-throwing program, which started on average 16.7 weeks (range, 12-18 weeks) after surgery. A return-to-mound program was utilized in 53% of studies, starting on average 7.4 months (range, 6-9 months) postoperatively. Minimum time from surgery was used in 73% studies, with players waiting 7 to 12 months (mean, 9.7; SD, 1.4 months) after surgery before return-to-competition consideration. The overall rate of return to competition at the preinjury level or higher was 85.7% (SD, 8.5%) at an average of 12.2 months (SD, 0.6 months).Conclusion:In general, we observed a paucity of literature describing the return-to-competition process after ulnar collateral ligament reconstruction in overhead throwing athletes. Only 3 explicit return-to-competition criteria were identified across all studies: completion of a return-to-throwing program, completion of a return-to-mound program for pitchers, and minimum time from surgery. Increased transparency regarding postoperative rehabilitation protocols and further research are necessary to identify and validate sport-specific return-to-competition criteria, which will ultimately help athletes return to play in a safe and timely fashion after ulnar collateral ligament reconstruction.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-06-28T04:35:23Z
      DOI: 10.1177/03635465211016839
       
  • Validity of Research Based on Public Data in Sports Medicine: A
           Quantitative Assessment of Anterior Cruciate Ligament Injuries in the
           National Football League

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      Authors: Paul M. Inclan, Peter S. Chang, Christina D. Mack, Gary S. Solomon, Robert H. Brophy, Richard Y. Hinton, Kurt P. Spindler, Allen K. Sills, Matthew J. Matava
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Numerous researchers have leveraged publicly available Internet sources to publish publicly obtained data (POD) studies concerning various orthopaedic injuries in National Football League (NFL) players.Purpose:To provide a comprehensive systematic review of all POD studies regarding musculoskeletal injuries in NFL athletes and to use anterior cruciate ligament (ACL) injuries in NFL players to quantify the percentage of injuries identified by these studies.Study Design:Systematic review; Level of evidence, 4.Methods:A systematic review was conducted to identify all published studies utilizing POD regarding ACL injury in NFL athletes from 2000 to 2019. Data regarding player demographics were extracted from each publication. These results were compared with prospectively collected data reported by the teams’ medical staff to the NFL Injury Surveillance System database linked to the League’s electronic health record. An ACL “capture rate” for each article was calculated by dividing the number of ACL injuries in the POD study by the total number of ACL injuries in the NFL injury database occurring in the study period of interest.Results:A total of 42 studies were extracted that met the definition of a POD study: 28 evaluated a variety of injuries and 14 dealt specifically with ACL injuries, with 35 (83%) of the 42 studies published during or since 2015. POD studies captured a mean of 66% (range, 31%-90%) of ACL injuries reported by the teams’ medical staff. This inability to capture all injury rates varied by position, with 86% capture of ACL injuries in skill athletes, 72% in midskill athletes, and 61% in linemen. POD studies captured 35% of injuries occurring during special teams play.Conclusion:The frequency of studies leveraging publicly obtained injury data in NFL players has rapidly increased since 2000. There is significant heterogeneity in the degree to which POD studies correctly identify ACL injuries from public reports. Sports medicine research relying solely on publicly obtained sources should be interpreted with an understanding of their inherent limitations and biases. These studies underreport the true incidence of injuries, with a bias toward capturing injuries in more popular players.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-06-24T08:21:37Z
      DOI: 10.1177/03635465211015435
       
  • What Is the Failure Rate After Arthroscopic Repair of Bucket-Handle
           Meniscal Tears' A Systematic Review and Meta-analysis

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      Authors: Giuseppe Gianluca Costa, Alberto Grassi, Gianluca Zocco, Angelo Graceffa, Michele Lauria, Giuseppe Fanzone, Stefano Zaffagnini, Arcangelo Russo
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Meniscal repair has become the treatment of choice for meniscal tears, especially in the subset of bucket-handle meniscal tears (BHMTs). However, a comprehensive estimate of the corresponding failure rate is not available, thus maintaining doubts about the healing potential of these tears. Furthermore, a wide range of factors to predict high failure rates have been reported but with conflicting evidence.Purpose:To determine the failure rate after arthroscopic repair of BHMTs as reported in the literature, compare this with the failure rate of simple meniscal tears extracted from the same studies, and analyze the influence of factors previously reported to be predictive of meniscal repair failure.Study Design:Systematic review and meta-analysis; Level of evidence, 4.Methods:A systematic search was conducted by 2 independent reviewers using principal bibliographic databases (PubMed, Scopus, Cochrane Library, and EMBASE). After a stepwise exclusion process, 38 articles met the inclusion criteria. Failure rate data were analyzed with a random-effects proportional meta-analysis (weighted for individual study size), and forest plots were constructed to determine any statistically significant differences between BHMTs versus simple tears (longitudinal, radial, or horizontal), medial versus lateral BHMTs, isolated procedures versus repairs with concomitant anterior cruciate ligament reconstruction, and tears in red-red versus red-white zones. Moreover, a meta-regression analysis was conducted to evaluate the effect of patient age and sex, suture technique (in-out or all-inside), time from injury to surgery, mean number of stitches, and length of follow-up on failure rates.Results:The pooled failure rate was 14.8% (95% CI, 11.3%-18.3%; I2 = 77.2%). A total of 17 studies provided failure rates of both BHMT repairs (46/311 repairs) and simple tear repairs (54/546 repairs), demonstrating a significantly higher failure rate for BHMT repairs (risk ratio [RR] = 1.50; 95% CI, 1.05-2.15; I2 = 0%; P = .03). Medial BHMT repairs (RR = 1.94; 95% CI, 1.25-3.01; I2 = 0%; P = .003) and isolated repairs (RR = 1.77; 95% CI, 1.15-2.72; I2 = 0%; P = .009) had statistically higher risk of failure, but no statistically significant difference was found between tears in red-red versus red-white zones. Among the other factors evaluated with meta-regression, only the mean number of stitches showed a statistically significant effect on failure rates.Conclusion:Based on the currently available literature, this systematic review provides a reasonably comprehensive analysis of failure rate after arthroscopic BHMT repair; failure is estimated to occur in 14.8% of cases. Medial tears and isolated repairs were the 2 major predictors of failure.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-06-23T09:10:36Z
      DOI: 10.1177/03635465211015425
       
  • Outcome Comparison of Latissimus Dorsi Transfer and Pectoralis Major
           Transfer for Irreparable Subscapularis Tendon Tear: A Systematic Review

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      Authors: Zhiwen Luo, Jinrong Lin, Yaying Sun, Kesen Zhu, Chenghui Wang, Jiwu Chen
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Latissimus dorsi transfer (LDT) and pectoralis major transfer (PMT) were developed to treat an irreparable subscapularis tendon tear (ISScT); however, the difference in their outcomes remains unclear.Purpose:To systematically review and compare the outcomes of LDT and PMT for ISScT.Study Design:Systematic review; Level of evidence, 4.Methods:A systematic review was performed through a comprehensive search of Embase, PubMed, and the Cochrane Library. Studies of LDT or PMT were included according to the inclusion and exclusion criteria. The primary outcome was the Constant-Murley score (CMS) at the final follow-up. Secondary outcomes included the subjective shoulder value (SSV), visual analog scale (VAS) score for pain, active shoulder range of motion, and the belly-press and lift-off tests. Postoperative failure and complication rates were the safety outcome measures. Outcomes were summarized into the LDT and PMT groups, and results were compared statistically (P < .05).Results:Twelve studies were included in this review: 184 shoulders from 9 studies for the PMT group and 85 shoulders from 3 studies for the LDT group. For the PMT and LDT groups, the mean ages were 58.9 and 55.1 years, respectively, and the mean follow-up was 66.9 and 17.4 months, respectively. Overall, the LDT and PMT groups improved in the primary outcome (CMS) and secondary outcomes (SSV, VAS, ROM, and belly-press and lift-off tests), with low rates of failure and complication. When compared with the PMT group, the LDT group showed more significant improvements in CMS (35.2 vs 24.7; P < .001), active forward flexion (44.3° vs 14.7°; P < .001), abduction (35.0° vs 17.6°; P < .002), and positive belly-press test rate (45% vs 27%; P < .001). No statistically significant difference was seen between the groups in postoperative failure rate, complication rate, mean improvement of active internal rotation, VAS, or SSV.Conclusion:In general, LDT showed significantly better clinical outcomes postoperatively than did PMT. The available fair-quality evidence suggested that LDT might be a better choice for ISScT. Further evaluations on the relative benefits of the 2 surgical approaches are required, with more high-quality randomized controlled studies.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-06-17T05:33:34Z
      DOI: 10.1177/03635465211018216
       
  • Clinical Efficacy of Bone Marrow Aspirate Concentrate Versus Stromal
           Vascular Fraction Injection in Patients With Knee Osteoarthritis: A
           Systematic Review and Meta-analysis

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      Authors: Ioanna K. Bolia, Sofia Bougioukli, William J. Hill, Nicholas A. Trasolini, Frank A. Petrigliano, Jay R. Lieberman, Alexander E. Weber
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Knee injection using either bone marrow aspirate concentrate (BMAC) or stromal vascular fraction (SVF) from adipose tissue has been shown to result in symptomatic improvement in patients with knee osteoarthritis (OA). It is still unclear whether one of these therapies is superior over the other.Purpose:To systematically report the clinical studies evaluating BMAC and SVF in the treatment of knee OA and to compare the clinical efficacy of these 2 injection therapies.Study Design:Meta-analysis; Level of evidence, 4.Methods:This meta-analysis was performed per the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines. Studies were included if they reported the clinical outcomes after a single BMAC or SVF injection in the knee joint of patients with OA. Studies evaluating preparations of culture-expanded stem cells were excluded. A random effects model was used; the clinical efficacy of BMAC or SVF injection was assessed using the standardized mean difference (SMD) and compared. Visual analog scale (VAS) scores for pain and Western Ontario and McMaster Universities Osteoarthritis (WOMAC) knee index were the primary outcomes. The level of statistical significance was set at P < .05.Results:Ten studies and 472 patients with knee OA who received either BMAC (233 patients) or SVF (239 patients) were included. Patients who received an injection had improved VAS outcomes (mean ± SD): from 5.8 ± 1.3 to 2.6 ± 17 for BMAC and from 6.4 ± 1.4 to 3.4 ± 0.5 for SVF. They also experienced significantly reduced pain (SMD [VAS], 2.6 for BMAC and 3.4 for SVF) and improved function (SMD [WOMAC], 1.4 for BMAC and 1.2 for SVF). However, the SVF injection had a significantly greater effect on pain reduction than did the BMAC injection (P < .0001). Based on WOMAC, the clinical effect of BMAC versus SVF knee injection in patients with knee OA was equivalent (P = .626). Results were limited by the presence of publication bias as well as variability in the preparation methods utilized in the BMAC and SVF injection protocols. Complications were reported in 50% of the BMAC studies (knee stiffness, persistent knee swelling) and 67% of the SVF studies (knee swelling, knee pain, positive SVF cultures without symptoms of infection, and bleeding at the abdominal harvest site).Conclusion:A single BMAC or SVF injection into the knee joint of patients with OA resulted in symptomatic improvement at short-term follow-up. However, SVF seemed to be more effective than did BMAC in the reduction of knee pain. There was significant variation in the BMAC and SVF injection preparation techniques used across the studies and a lack of stratification of outcomes based on the radiologic classification of OA. Therefore, these results should be taken with caution.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-06-08T10:20:23Z
      DOI: 10.1177/03635465211014500
       
  • Revision Surgery and Progression to Total Hip Arthroplasty After Surgical
           Correction of Femoroacetabular Impingement: A Systematic Review

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      Authors: Filippo Migliorini, Nicola Maffulli, Alice Baroncini, Jörg Eschweiler, Markus Tingart, Marcel Betsch
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Femoroacetabular impingement (FAI) is a major cause of hip pain in young adults and athletes. Surgical treatment of FAI is recommended in cases of failed nonoperative treatment that have the typical clinical and radiographic findings. At present, the role of risk factors for revision surgery and progression to total hip arthroplasty (THA) in patients with FAI is still unclear.Purpose:To investigate the possible association between (1) rate of revision and progression to THA and (2) patient characteristics, type of lesion, family history of hip disease, type of intervention, radiographic parameters, physical examination, and pre- and postoperative scores.Study Design:Systematic review; Level of evidence, 4.Methods:The present systematic review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. In October 2020, the main online databases were accessed. All articles concerning surgical correction for selected patients with FAI were accessed. Patient characteristics, type of intervention, radiographic parameters, physical examination, and pre- and postoperative scores were assessed. The outcomes of interest were the possible association between these variables and the rate of revision and subsequent progression to THA using a multivariate analysis through the Pearson product-moment correlation coefficient.Results:Data from 99 studies (9357 procedures) were collected. The median follow-up was 30.9 months (interquartile range, 24.0-45.0). The mean ± SD age was 33.4 ± 9.3 years; mean body mass index (BMI), 24.8 ± 4.8; percentage right side, 55.8% ± 8.0%; and percentage female sex, 47.5% ± 20.4%. The overall rate of revision was 5.29% (351 of 6641 patients), while the rate of subsequent progression to THA was 3.78% (263 of 6966 patients). Labral debridement (P < .0001), preoperative acetabular index (P = .01), and BMI (P = .03) all showed evidence of a statistically positive association with increased rates of THA. No other statistically significant associations were found between patient characteristics, type of lesion, family history of hip disease, type of intervention, radiographic parameters, physical examination, or pre- and postoperative scores and the rate of revision and/or progression to THA.Conclusion:Although surgical procedures to treat FAI led to satisfactory outcomes, there was a revision rate of 5.29% in the 9357 procedures in the present systematic review. The rate of progression to THA after a median follow-up of 30 months was 3.78%. Patients who have a higher BMI and/or have a pathologic acetabular index and/or undergo labral debridement during correction of FAI are more at risk for a subsequent THA. We advocate additional education of this patient population in terms of expected outcomes and suggest surgical labral repair instead of debridement if needed.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-06-03T04:34:50Z
      DOI: 10.1177/03635465211011744
       
  • Open Versus Endoscopic Surgical Treatment of Posterior Ankle Impingement:
           A Meta-analysis

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      Authors: Ruben Zwiers, Thymen Miedema, Johannes I. Wiegerinck, Leendert Blankevoort, C. Niek van Dijk
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Surgical treatment of symptomatic posterior ankle impingement consists of resection of the bony impediment and/or debridement of soft tissue. Historically, open techniques were used to perform surgery with good results. However, since the introduction of endoscopic techniques, advantages attributed to these techniques are shorter recovery time, fewer complications, and less pain.Purpose:The primary purpose was to determine whether endoscopic surgery for posterior ankle impingement was superior to open surgery in terms of functional outcome (American Orthopaedic Foot & Ankle Society [AOFAS] score). The secondary aim was to determine differences in return to full activity, patient satisfaction, and complications.Study Design:Systematic review and meta-analysis.Methods:MEDLINE, EMBASE (Classic), and CINAHL databases were searched. Publication characteristics, patient characteristics, surgical techniques, AOFAS scores, time to return to full activity, patient satisfaction, and complication rates were extracted. The AOFAS score was the primary outcome measure. Data were synthesized, and continuous outcome measures (postoperative AOFAS score and time to return to full activity) were pooled using a random-effects inverse variance method. Random-effects meta-analysis of proportions using continuity correction methods was performed to determine the proportion of patients who were satisfied and who experienced complications.Results:A total of 32 studies were included in this review. No statistically significant difference was found in postoperative AOFAS scores between open surgery (88.0; 95% CI, 82.1-94.4) and endoscopic surgery (94.4; 95% CI, 93.1-95.7). There was no difference in the proportion of patients who rated their satisfaction as good or excellent, 0.91 (95% CI, 0.86-0.96) versus 0.86 (95% CI, 0.79-0.94), respectively. No significant difference in time to return to activity was found, 10.8 weeks (95% CI, 7.4-15.9 weeks) versus 8.9 weeks (95% CI, 7.6-10.4 weeks), respectively. Pooled proportions of patients with postoperative complications were 0.15 (95% CI, 0.11-0.19) for open surgery versus 0.08 (95% CI, 0.05-0.14) for endoscopic surgery. Without the poor-quality studies, this difference was statistically significant for both total and minor complications, 0.24 (95% CI, 0.14-0.35) versus 0.02 (95% CI, 0.00-0.06) and 0.14 (95% CI, 0.09-0.20) versus 0.03 (95% CI, 0.01-0.05), respectively.Conclusion:We found no statistically significant difference in postoperative AOFAS scores, patient satisfaction, and return to preinjury level of activity between open and endoscopic techniques. The proportion of patients who experienced a minor complication was significantly lower with endoscopic treatment when studies of poor methodological quality were excluded.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-05-28T05:09:54Z
      DOI: 10.1177/03635465211004977
       
  • Radiographic and Clinical Outcomes After Tibial Tubercle Osteotomy for the
           Treatment of Patella Alta: A Systematic Review and Meta-analysis

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      Authors: Derrick M. Knapik, Kyle N. Kunze, Eric Azua, Amar Vadhera, Adam B. Yanke, Jorge Chahla
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Patella alta is a known risk factor for patellar instability and, in the setting of recurrent patellar instability with significant patella alta, correction of patellar height with a tibial tubercle osteotomy (TTO) may help decrease the failure of soft tissue–based stabilization.Purpose:To perform a systematic review and meta-analysis of radiographic and clinical outcomes after TTO for patella alta.Study Design:Systematic review and meta-analysis; Level of evidence, 4.Methods:PubMed, OVID/Medline, and Cochrane databases were queried in June 2020 for studies reporting outcomes of TTO for patella alta. Data pertaining to study characteristics and design, radiographic and clinical outcome values, and incidence of complications and reoperations were extracted. DerSimonian-Laird continuous and binary random-effects models were constructed to (1) perform subgroup-based analysis of mean changes in radiographic indices after TTO and (2) quantify the pooled incidence of complications and reoperations.Results:Eight studies including 340 patients (420 knees) with a mean age of 24.7 ± 8.4 years were included. The mean follow-up was 53.1 months (range, 3-120 months), with 1 study reporting a mean follow-up of less than 2 years. The pooled mean anterior transfer was 5.6 mm; the mean medial transfer was 8.7 ± 1.3 mm; and the pooled mean distalization of the tibial tubercle was 12.2 ± 4.5 mm. Continuous random-effects meta-analysis determined that significant reductions in the mean Insall-Salvati ratio (1.40 vs 0.98, P < .001), Caton-Deschamps index (1.26 vs 0.97, P < .001), and tibial tubercle to trochlear groove ratio (18.27 vs 10.69, P < .001) were observed after TTO. The overall incidence of complications was 7.6% (95% CI, 4.8%-10.5%), while the overall incidence of reoperations was 14.3% (95% CI 6.2%-22.4%).Conclusion:TTO for patellar instability in the setting of patella alta results in a significant decrease in patellar height with varying degrees of medialization depending on the utilized technique. A mean postoperative complication rate of 7.6% was reported with a reoperation incidence of 14.3%, related primarily to hardware removal.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-05-26T04:48:11Z
      DOI: 10.1177/03635465211012371
       
  • Assessment of Skeletal Maturity and Postoperative Growth Disturbance After
           Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients:
           A Systematic Review

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      Authors: Matthew S. Fury, Nikolaos K. Paschos, Peter D. Fabricant, Christian N. Anderson, Michael T. Busch, Henry G. Chambers, Melissa A. Christino, Frank A. Cordasco, Eric W. Edmonds, Theodore J. Ganley, Daniel W. Green, Benton E. Heyworth, J. Todd R. Lawrence, Matthew J. Matava, Lyle J. Micheli, Matthew D. Milewski, Jeffrey J. Nepple, Shital N. Parikh, Andrew T. Pennock, Crystal A. Perkins, Paul M. Saluan, Kevin G. Shea, Eric J. Wall, Samuel C. Willimon, Mininder S. Kocher
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Growth disturbance is an uncommon but potentially serious complication after anterior cruciate ligament (ACL) reconstruction in skeletally immature patients.Purpose:To describe how the pediatric ACL literature has assessed preoperative skeletal maturity and the amount of growth remaining and to comprehensively review the incidence, reporting, and monitoring of postoperative growth disturbance.Study Design:Systematic review; Level of evidence, 4.Methods:This review included studies reporting original research of clinical outcomes of skeletally immature patients after ACL reconstruction. Patient characteristics, surgical techniques, preoperative assessments of skeletal maturity or growth remaining, and postoperative assessments of growth disturbances were extracted.Results:A total of 100 studies met inclusion criteria. All studies reported chronological age, and 28 studies (28%) assessed skeletal age. A total of 44 studies (44%) used Tanner staging, and 12 studies (12%) obtained standing hip-to-ankle radiographs preoperatively. In total, 42 patients (2.1%) demonstrated a leg length discrepancy (LLD)>10 mm postoperatively, including 9 patients (0.5%) with LLD>20 mm; furthermore, 11 patients (0.6%) with LLD underwent growth modulation. Shortening was the most common deformity overall, but overgrowth was reported more frequently in patients who had undergone all-epiphyseal techniques. Most LLDs involved the femur (83%). A total of 26 patients (1.3%) demonstrated a postoperative angular deformity ≥5°, and 9 of these patients underwent growth modulation. The most common deformities were femoral valgus (41%), tibial recurvatum (33%), and tibial varus (22%). Although standing hip-to-ankle radiographs were the most common radiographic assessment of growth disturbance, most studies inadequately reported the clinical and radiographic methods of assessment for growth disturbance. Additionally, only 35% of studies explicitly followed patients to skeletal maturity.Conclusion:This systematic review described significant variability in the reporting and monitoring of growth-related complications after ACL reconstruction in skeletally immature patients. The incidence of LLD and angular deformity appeared to be low, but the quality of research was not comprehensive enough for accurate assessment.Registration:CRD42019136059 (PROSPERO)
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-05-13T09:45:30Z
      DOI: 10.1177/03635465211008656
       
  • Return to Sport After Surgical Management of Posterior Shoulder
           Instability: A Systematic Review and Meta-analysis

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      Authors: Kyle Gouveia, Jeffrey Kay, Muzammil Memon, Nicole Simunovic, Asheesh Bedi, Olufemi R. Ayeni
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Posterior shoulder instability accounts for a small proportion of all shoulder instability, although it can affect athletes of all types, from contact to overhead athletes. Surgical treatment is quite successful in these patients; however, the literature reports a wide range of rates of return to sport.Purpose/Hypothesis:The purpose was to determine the return-to-sport rates after surgical stabilization for posterior shoulder instability. It was hypothesized that patients would experience a high rate of return to sport.Study Design:Systematic review and meta-analysis; Level of evidence, 4.Methods:Embase, PubMed, and MEDLINE were searched for relevant literature from database inception until April 2020, and studies were screened by 2 reviewers independently and in duplicate for studies reporting rates of return to sport after surgical management of posterior shoulder instability. Demographic data as well as data on return to sport and functional outcomes were recorded. A meta-analysis of proportions was used to combine the rates of return to sport using a random effects model. A risk of bias was assessed for all included studies.Results:Overall, 32 studies met inclusion criteria and comprised 1100 patients (1153 shoulders) with a mean age of 22.8 years (range, 11-65) and a mean follow-up of 43.2 months (range, 10-228). The pooled rate of return to any level of sport was 88% (95% CI, 84%-92%; I2 = 68.7%). In addition, the pooled rate of return to the preinjury level was 68% (95% CI, 60%-76%; I2 = 79%). Moreover, the pooled return-to-sport rate for contact athletes was 94% (95% CI, 90%-97%; I2 = 0%), while for throwing athletes it was 88% (95% CI, 83%-92%; I2 = 0%).Conclusion:Surgical management of posterior shoulder instability resulted in a high rate of return to sport, as well as significant pain reduction and functional improvement in most patients. However, only two-thirds of athletes can return to their preinjury levels of sport.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-05-11T09:04:49Z
      DOI: 10.1177/03635465211011161
       
  • Inconsistencies in Reporting Risk Factors for Medial Patellofemoral
           Ligament Reconstruction Failure: A Systematic Review

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      Authors: William M. Cregar, Hailey P. Huddleston, Stephanie E. Wong, Jack Farr, Adam B. Yanke
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Medial patellofemoral ligament (MPFL) reconstruction is a common surgical treatment for patients with recurrent patellar instability. A variety of risk factors, such as age, trochlear dysplasia, patella alta, and increased tibial tubercle–trochlear groove (TT-TG) distance, have been identified and may lead to postoperative failure or poor outcomes.Purpose:While a large number of risk factors have been identified, significant heterogeneity exists in evaluating and reporting these risk factors in the literature. The goal of this study was to perform a systematic review to determine risk factors associated with worse outcomes after MPFL reconstruction and their consistency of being controlled for or analyzed among studies.Study Design:Systematic review; Level of evidence, 4.Methods:A systematic review of the literature was performed using the MEDLINE database to identify relevant clinical outcome studies after MPFL reconstruction for recurrent patellar instability. Eligible studies were evaluated for risk factors that were associated with MPFL failure, defined as recurrent instability or lack of improvement on patient-reported outcome (PRO) scores. Each study was then evaluated for inclusion of these risk factors.Results:Ten studies were included in the final analysis, comprising 1287 knees from 1275 patients who underwent isolated MPFL reconstruction. Of these 10 studies, 8 defined outcomes based on PROs and 3 defined outcomes based on postoperative recurrent instability (1 study included both outcomes). In the PRO failure group, 12 risk factors were found across all studies: trochlear dysplasia, trochlear bump height, elevated TT-TG, patellar tilt, hyperlaxity, age at first dislocation, age at surgery, body mass index, bilateral symptoms, WARPS/STAID score (weak atraumatic, risky anatomy, pain, and subluxation/strong, traumatic, anatomy normal, instability, and dislocation), femoral tunnel malposition, and femoral tunnel widening. In the recurrent instability failure group, 7 risk factors were found across all studies: trochlear dysplasia, bump height, patella alta, higher sulcus angle, higher congruence angle, preoperative J sign, and femoral tunnel malposition. Trochlear dysplasia and femoral tunnel malposition were consistently cited in several studies as risk factors for worse PROs and higher rates of recurrent instability. Patella alta was indicated as a significant risk factor for recurrent instability in 1 of 2 studies analyzing postoperative instability failures and was not associated with worse PROs in any of the studies analyzed. Similarly, elevated TT-TG distance was not a significant risk factor in any of the studies that analyzed recurrent instability as the failure endpoint.Conclusion:While various risk factors are postulated to affect outcomes after MPFL reconstruction, there remains inconsistency within the literature regarding the inclusion of all risk factors in a given analysis. Furthermore, the significance of these risk factors varies among studies in terms of whether they affect postoperative outcomes. We found that more severe trochlear dysplasia (types C and D) and femoral tunnel malposition (>10 mm from Schöttle’s point) appear to have the most consistent effect on producing higher rates of recurrent dislocation as well as worse PROs. Despite this, the role of concomitant bony procedures to adjust certain pathoanatomic risk factors in addition to MPFL reconstruction remains unknown. Future high-level studies must be conducted that respect the multifactorial nature of patellar instability and should analyze all risk factors (demographic, anatomic, and radiographic) reported to affect outcomes.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-04-29T08:31:43Z
      DOI: 10.1177/03635465211003342
       
  • Sports Medicine and Artificial Intelligence: A Primer

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      Authors: Prem N. Ramkumar, Bryan C. Luu, Heather S. Haeberle, Jaret M. Karnuta, Benedict U. Nwachukwu, Riley J. Williams
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Artificial intelligence (AI) represents the fourth industrial revolution and the next frontier in medicine poised to transform the field of orthopaedics and sports medicine, though widespread understanding of the fundamental principles and adoption of applications remain nascent. Recent research efforts into implementation of AI in the field of orthopaedic surgery and sports medicine have demonstrated great promise in predicting athlete injury risk, interpreting advanced imaging, evaluating patient-reported outcomes, reporting value-based metrics, and augmenting the patient experience. Not unlike the recent emphasis thrust upon physicians to understand the business of medicine, the future practice of sports medicine specialists will require a fundamental working knowledge of the strengths, limitations, and applications of AI-based tools. With appreciation, caution, and experience applying AI to sports medicine, the potential to automate tasks and improve data-driven insights may be realized to fundamentally improve patient care. In this Current Concepts review, we discuss the definitions, strengths, limitations, and applications of AI from the current literature as it relates to orthopaedic sports medicine.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-04-26T03:26:15Z
      DOI: 10.1177/03635465211008648
       
  • Marrow Stimulation Has Relatively Inferior Patient-Reported Outcomes in
           Cartilage Restoration Surgery of the Knee: A Systematic Review and
           Meta-analysis of Randomized Controlled Trials

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      Authors: Torgom Abraamyan, Alicia J. Johnson, Jack Wiedrick, Dennis C. Crawford
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Multiple cartilage repair techniques are available for chondral defects in the knee. Optimal treatment is controversial.Purpose:To evaluate change from baseline in the 5 Knee injury and Osteoarthritis Outcome Score (KOOS) subscales among different cartilage repair techniques of the knee.Study Design:Systematic review and meta-analysis; Level of evidence, 1A.Methods:Medline and Cochrane Central Register of Controlled Trials (CENTRAL) databases were searched for randomized controlled trials with minimum 1 year follow-up reporting change from baseline KOOS (delta KOOS) subscale values. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed. A meta-analysis was performed on the following surgery types: microfracture (Mfx); augmented microfracture techniques (Mfx+Augment); and culture-based therapies, including autologous chondrocyte implantation (ACI) and matrix-assisted autologous chondrocyte implantation (MACI). A random-effects metaregression model was used.Results:A total of 14 randomized trials with a total of 775 patients were included. The KOOS Sport and Recreation (Sport) and KOOS Quality of Life (QOL) were the 2 most responsive subscales after operative intervention. Outcomes from Mfx and Mfx+Augment were not different in any of the 5 KOOS subscales (minimum P> .3). The mean delta KOOS Sport after ACI/MACI was 9.9 points greater than after Mfx (P = .021) and 11.7 points greater than after Mfx+Augment (P = .027). Longer follow-up time correlated with greater delta KOOS Sport (P = .028). Larger body mass index led to greater delta KOOS QOL (P = .045). Larger cartilage defect size correlated with greater delta KOOS Pain and KOOS Activities of Daily Living scores (P = .023 and P = .002, respectively).Conclusion:The KOOS Sport and QOL were the most responsive subscales after cartilage restoration surgery of the knee. Culture-based therapies (ACI/MACI) led to clinically relevant improvements in the KOOS Sport score compared with marrow stimulation and may be a more appropriate treatment in younger and more active individuals. There were no benefits to Mfx+Augment over Mfx alone in any of the KOOS subscales.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-04-23T03:45:30Z
      DOI: 10.1177/03635465211003595
       
  • Anterior Cruciate Ligament Reconstruction Alone Versus With Lateral
           Extra-articular Tenodesis With Minimum 2-Year Follow-up: A Meta-analysis
           and Systematic Review of Randomized Controlled Trials

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      Authors: James Randolph Onggo, Hari Krishnan Rasaratnam, Mithun Nambiar, Jason Derry Onggo, Vishal Pai, Iswadi Damasena, Arash Riazi, Sina Babazadeh
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Lateral extra-articular tenodesis (LEAT) aims to improve anterolateral stability of the injured knee during anterior cruciate ligament reconstruction (ACLR) surgery. Inconclusive evidence surrounding the efficacy and safety of LEAT has propelled clinical interest and ongoing discussions.Purpose:To establish level 1 evidence by assessing randomized controlled trials (RCTs) with minimum 2-year follow-up that directly compared ACLR with LEAT (LEAT group) and ACLR alone (non-LEAT group) in terms of clinical outcomes and complications.Study Design:Meta-analysis and systematic review; Level of evidence, 1.Methods:Meta-analysis was performed with a multidatabase search (Cochrane, EMBASE, OVID Medline, PubMed, and Web of Science) according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines on September 9, 2020. Data from published RCTs meeting inclusion criteria were extracted and analyzed with an inverse variance statistical model.Results:A total of 7 RCTs were included, consisting of 517 LEAT and 589 non-LEAT patients. Only autografts were used for ACLR and LEAT. A variety of LEAT techniques and autograft fixation methods were used. We found improved stability (residual positive pivot shift: risk ratio [RR], 0.59; 95% CI, 0.39-0.88; P = .01) and better clinical outcomes (International Knee Documentation Committee [IKDC] score: mean difference [MD], 2.31; 95% CI, 0.54-4.09; P = .01; and Lysholm score: MD, 2.71; 95% CI, 0.68-4.75; P = .009) in the LEAT than non-LEAT group. Graft rerupture rate was 3 times less likely (RR, 0.31; 95% CI, 0.17-0.58; P < .001) in the LEAT group than the non-LEAT group.Conclusion:Good-quality evidence is available to support the efficacy of LEAT in improving anterolateral knee stability and reducing graft reruptures in primary ACLR. LEAT should be considered in patients with high risk factors. Although Lysholm and IKDC scores were statistically better in the LEAT group, these are unlikely to be clinically significant. Future studies should aim to identify patient populations that would best benefit from LEAT with ACLR.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-04-22T06:16:50Z
      DOI: 10.1177/03635465211004946
       
  • Treatment Strategies and Outcomes for Osteochondritis Dissecans of the
           Capitellum

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      Authors: Junaid Sayani, Tobias Plotkin, Daniel Timothy Burchette, Joideep Phadnis
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:The optimum management of osteochondritis dissecans (OCD) of the capitellum is a widely debated subject.Purpose:To better understand the efficacy of different surgical modalities and nonoperative treatment of OCD as assessed by radiological and clinical outcomes and return to sports.Study Design:Systematic review; Level of evidence, 4.Methods:A systematic review of all treatment studies published between January 1975 and June 2020 was performed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A total of 76 clinical studies, including 1463 patients, were suitable for inclusion. Aggregate analysis and subgroup analysis of individual patient data were performed to compare the functional and radiographic outcomes between the various nonoperative and surgical treatment options for capitellar OCD. A unified grading system (UGS; grades 1-4) was developed from existing validated classification systems to allow a comparison of patients with similar-grade OCD lesions in different studies according to their treatment. Patient-level data were available for 352 patients. The primary outcome measures of interest were patient-reported functional outcome, range of motion (ROM), and return to sports after treatment. The influences of the capitellar physeal status, location of the lesion, and type of sports participation were also assessed. Each outcome measure was evaluated according to the grade of OCD and treatment method (debridement/microfracture, fragment fixation, osteochondral autograft transplantation [OATS], or nonoperative treatment).Results:No studies reported elbow scores or ROM for nonoperatively treated patients. All surgical modalities resulted in significantly increased postoperative ROM and elbow scores for stable (UGS grades 1 and 2) and unstable lesions (UGS grades 3 and 4). There was no significant difference in the magnitude of improvement or overall scores according to the type of surgery for stable or unstable lesions. Return to sports was superior with nonoperative treatment for stable lesions, whereas surgical treatment was superior for unstable lesions. Patients with an open capitellar physis had superior ROM for stable and unstable lesions, but there was no correlation with lesion location and the outcomes of OATS versus fragment fixation for high-grade lesions.Conclusion:Nonoperative treatment was similar in outcomes to surgical treatment for low-grade lesions, whereas surgical treatment was superior for higher grade lesions. There is currently insufficient evidence to support complex reconstructive techniques for high-grade lesions compared with microfracture/debridement alone.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-04-22T05:50:01Z
      DOI: 10.1177/03635465211000763
       
  • Current Concepts on Tissue Adhesive Use for Meniscal Repair—We Are Not
           There Yet: A Systematic Review of the Literature

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      Authors: Niv Marom, Gabriella Ode, Francesca Coxe, Bridget Jivanelli, Scott A. Rodeo
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Tissue adhesives (TAs) represent a promising alternative or augmentation method to conventional tissue repair techniques. In sports medicine, TA use has been suggested and implemented in the treatment of meniscal tears. The aim of this review was to present and discuss the current evidence and base of knowledge regarding the clinical usage of TAs for meniscal repair.Study Design:Systematic review; Level of evidence, 4.Methods:A systematic literature search was performed using the PubMed, Embase, and Cochrane Library databases for studies reporting on clinical outcomes of TA usage for meniscal repair in humans in the English language published before January 2020.Results:Ten studies were eligible for review and included 352 meniscal repairs: 94 (27%) were TA-based repairs and 258 (73%) were combined suture and TA repairs. Concomitant anterior cruciate ligament reconstruction was performed in 224 repairs (64%). All included studies utilized fibrin-based TA. Of the 10 studies, 9 were evidence level 4 (case series), and 8 reported on a cohort of ≤40 meniscal repairs. Rates of meniscal healing were evaluated in 9 of 10 studies, with repair failure seen in 39 repairs (11%).Conclusion:The use of TAs, specifically fibrin-based TAs, for meniscal repair shows good results as either an augmentation or primary repair of various configurations of meniscal tears. However, this review reveals an absence of comparative high-quality evidence supporting the routine use of TAs for meniscal repair and emphasizes the lack of an ideal TA designed for that purpose. Further high-quality research, basic science and clinical, will facilitate the development of new materials and enable testing their suitability for use in meniscal repair.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-04-15T05:25:53Z
      DOI: 10.1177/03635465211003613
       
  • Treating Knee Osteoarthritis With Platelet-Rich Plasma and Hyaluronic Acid
           Combination Therapy: A Systematic Review

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      Authors: Michael R. Baria, W. Kelton Vasileff, James Borchers, Alex DiBartola, David C. Flanigan, Evan Plunkett, Robert A. Magnussen
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Platelet-rich plasma (PRP) and hyaluronic acid (HA) are injectable treatments for knee osteoarthritis. The focus of previous studies has compared their efficacy against each other as monotherapy. However, a new trend of combining these 2 injections has emerged in an attempt to have a synergistic effect.Purpose:To systematically review the clinical literature examining the combined use of PRP + HA.Design:Systematic review.Methods:A systematic review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using PubMed and Embase. The following search terms were used: knee osteoarthritis AND platelet rich plasma AND hyaluronic acid. The review was performed by 2 independent reviewers who applied the inclusion/exclusion criteria and independently extracted data, including methodologic scoring, PRP preparation technique, HA composition, and patient-reported outcomes (PROs).Results:A total of 431 articles were screened, 12 reviewed in full, and 8 included in the final analysis: 2 case series, 3 comparative, and 3 randomized studies. Average follow-up was 9 months. The modified Coleman Methodology Score was 38.13 ± 13.1 (mean ± SD). Combination therapy resulted in improved PROs in all studies. Of the comparative and randomized studies, 2 demonstrated that combination therapy was superior to HA alone. However, when PRP alone was used as the control arm (4 studies), combination therapy was not superior to PRP alone.Conclusion:Combination therapy with PRP + HA improves PROs and is superior to HA alone but is not superior to PRP alone.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-04-08T09:19:56Z
      DOI: 10.1177/0363546521998010
       
  • Treatment of Acute Achilles Tendon Ruptures: A Systematic Review and
           Meta-analysis of Complication Rates With Best- and Worst-Case Analyses for
           Rerupture Rates

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      Authors: Dexter Seow, Youichi Yasui, James D.F. Calder, John G. Kennedy, Christopher J. Pearce
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:An acute Achilles tendon rupture (AATR) is a common injury. The controversy that has surrounded the optimal treatment options for AATRs warrants an updated meta-analysis that is comprehensive, accounts for loss to follow-up, and utilizes the now greater number of available studies for data pooling.Purpose:To meta-analyze the rates of all complications after the treatment of AATRs with a “best-case scenario” and “worst-case scenario” analysis for rerupture rates that assumes that all patients lost to follow-up did not or did experience a rerupture, respectively.Study Design:Systematic review and meta-analysis; Level of evidence, 1.Methods:Two authors performed a systematic review of the PubMed and Embase databases according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines on February 17, 2020. The included studies were assessed in terms of the level of evidence, quality of evidence, and quality of the literature. A meta-analysis by fixed-effects models was performed if heterogeneity was low (I2 < 25%) and by random-effects models if heterogeneity was moderate to high (I2≥ 25%).Results:Surgical treatment was significantly favored over nonsurgical treatment for reruptures. Nonsurgical treatment was significantly favored over surgical treatment for complications other than reruptures, notably infections. Minimally invasive surgery was significantly favored over open repair for complications other than reruptures (no difference for reruptures), in particular for minor complications.Conclusion:This meta-analysis demonstrated that surgical treatment was superior to nonsurgical treatment in terms of reruptures. However, the number needed to treat analysis produced nonmeaningful values for all treatment options, except for surgical versus nonsurgical treatment and minimally invasive surgery versus open repair. No single treatment option was revealed to be profoundly favorable with respect to every complication. The results of this meta-analysis can guide clinicians and patients in their treatment decisions that should be made jointly and on a case-by-case basis.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-03-30T03:31:31Z
      DOI: 10.1177/0363546521998284
       
  • Overuse Elbow Injuries in Youth Gymnasts

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      Authors: Nicholas A. Bonazza, Eliana B. Saltzman, Jocelyn R. Wittstein, Marc J. Richard, Whitney Kramer, Jonathan C. Riboh
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Gymnastics is a unique sport that places significant loads across the growing elbow, resulting in unique overuse injuries, some of which are poorly described in the current literature.Purpose:To provide a comprehensive review of the unique overuse elbow injuries seen in youth gymnasts and to provide an up-to-date synthesis of the available literature and clinical expertise guiding treatment decisions in this population.Study Design:Narrative review.Methods:A review of the PubMed database was performed to include all studies describing elbow biomechanics during gymnastics, clinical entities of the elbow in gymnasts, and outcomes of operative and/or nonoperative treatment of elbow pathology in gymnasts.Results:Participation in gymnastics among youth athletes is high, being the sixth most common sport in children. Early specialization is the norm in this sport, and gymnastics also has the highest number of participation hours of all youth sports. As a result, unique overuse elbow injuries are common, primarily on the lateral side of the elbow. Beyond common diagnoses of radiocapitellar plica and osteochondritis dissecans of the capitellum, we describe a pathology unique to gymnasts involving stress fracture of the radial head. Additionally, we synthesized our clinical experience and expertise in gymnastics to provide a sport-specific rehabilitation program that can be used by providers treating surgical and nonsurgical conditions of the elbow and wishing to provide detailed activity instructions to their athletes.Conclusion:Overuse injuries of the elbow are common in gymnastics and include osteochondritis dissecans of the capitellum, radiocapitellar plica syndrome, and newly described radial head stress fractures. A thorough understanding of the psychological, cultural, and biomechanical aspects of gymnastics are necessary to care for these athletes.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-03-29T09:01:15Z
      DOI: 10.1177/03635465211000776
       
  • Midterm Outcomes of Posterior Medial Meniscus Root Tear Repair: A
           Systematic Review

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      Authors: Peter S. Chang, Logan Radtke, Patrick Ward, Robert H. Brophy
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Whereas there has been growing interest in surgical repair of posterior medial meniscus root tears (PMMRTs), our understanding of the medium- and long-term results of this procedure is still evolving.Purpose:To report midterm clinical outcomes from PMMRT repairs.Study Design:Systematic review.Methods:A literature review for this systematic analysis was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. We identified studies that reported the results of arthroscopic repair of PMMRTs. Functional and imaging outcomes were reviewed and summarized.Results:In total, 28 studies with a total of 994 patients (83% female) with an overall mean age of 57.1 were included in this review. Clinical outcomes (Lysholm, International Knee Documentation Committee, Hospital for Special Surgery, and Tegner scores) were improved at final follow-up in all studies. Of patients, 49% had radiographic progression of at least 1 grade in the Kellgren-Lawrence scale at a mean follow-up of 4.0 years in 11 studies. Cartilage degeneration had progressed at least 1 grade on magnetic resonance imaging scans in 23% of patients at a mean follow-up of 31.6 months in 4 studies.Conclusion:PMMRT repairs provide a functional benefit with consistent improvements in clinical outcome scores. There is some evidence that PMMRT repair slows the progression of osteoarthritis but does not prevent it at midterm follow-up.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-03-29T08:53:14Z
      DOI: 10.1177/0363546521998297
       
  • Higher Incidence of Radiographic Posttraumatic Osteoarthritis With
           Transtibial Femoral Tunnel Positioning Compared With Anteromedial Femoral
           Tunnel Positioning During Anterior Cruciate Ligament Reconstruction: A
           Systematic Review and Meta-analysis

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      Authors: Mark E. Cinque, Kyle N. Kunze, Brady T. Williams, Gilbert Moatshe, Robert F. LaPrade, Jorge Chahla
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Anteromedial (AM) femoral tunnel positioning in anterior cruciate ligament reconstruction (ACLR) has been reported by some authors to yield superior clinical and functional outcomes compared with the transtibial (TT) approach; however, differences in the subsequent rates of posttraumatic osteoarthritis (PTOA) are not clear.Purpose:To perform a systematic review and meta-analysis of the literature to evaluate the influence of femoral tunnel positioning during primary ACLR on the development of radiographic PTOA.Study Design:Systematic review and Meta-analysis.Methods:The Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed (1980-2019), and MEDLINE (1980-2019) were queried for all studies describing the development of PTOA after TT or AM ACLR. Data pertaining to patient demographics, ACLR technique, and radiographic PTOA were extracted. A meta-analysis utilizing the DerSimonian-Laird method for random effects was used to compare the weighted proportion of PTOA after ACLR between the TT and AM approaches.Results:There were 16 studies identified for inclusion with a total of 1546 patients. The mean follow-up across all studies was 10.9 years (range, 5.4-17.8 years). The mean follow-up in the AM and TT groups was 10.8 years (range, 5.4-17 years) and 11.4 years (range, 6-17.8 years), respectively. A total of 783 (50.6%) patients underwent TT ACLR. Of these patients, 401 (weighted mean, 49.3%) developed radiographic PTOA. A total of 763 (49.4%) patients underwent AM ACLR. Of these patients, 166 (mean, 21.8%) went on to develop radiographic PTOA. The meta-analysis demonstrated a significantly greater rate of PTOA after ACLR using a TT technique compared with an AM technique overall (49.3% vs 25.4%, respectively; P < .001) and when studies were stratified by 5- to 10-year (53.7% vs 14.2%, respectively; P < .001) and greater than 10-year (45.6% vs 31.2%, respectively; P < .0001) follow-up.Conclusion:TT ACLR was associated with higher overall rates of radiographic PTOA compared with the AM ACLR approach. The rates of radiographic PTOA after ACLR with a TT approach were also significantly higher than using an AM approach when stratified by length of follow-up (5- to 10-year and>10-year follow-up).
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-03-26T05:53:50Z
      DOI: 10.1177/0363546521993818
       
  • Use of Suture Tapes Versus Conventional Sutures for Arthroscopic Rotator
           Cuff Repairs: A Systematic Review and Meta-analysis

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      Authors: Khalis Boksh, Aziz Haque, Ashwini Sharma, Pip Divall, Harvinder Singh
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Various suture materials are available for arthroscopic rotator cuff repair. More recently, suture tapes have become popular as they are perceived to be easier to use with less soft tissue irritation. However, little is known about their biomechanical and clinical properties compared with conventional sutures in rotator cuff repairs.Purpose:To perform a systematic review and meta-analysis on whether suture tapes are biomechanically superior to conventional sutures in arthroscopic rotator cuff repairs and whether this translates to superior functional outcomes and a lower incidence of retears.Study Design:Meta-analysis.Methods:The Cochrane Controlled Register of Trials, PubMed, Medline, and Embase were used to perform a systematic review and meta-analysis using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria with the following search terms: (rotator cuff repair OR arthroscopic rotator cuff repair) AND (“tape” OR “wire” OR “cord” OR “suture”). Data pertaining to certain biomechanical properties (contact area, contact pressure, gap formation, load to failure, and stiffness), retears, and patient-reported outcome measures (PROMs) were extracted. The pooled outcome data were analyzed by random- and fixed-effects models.Results:After abstract and full-text screening, 7 biomechanical and 6 clinical studies were included. All biomechanical studies were on animals, with 91 suture tapes and 91 conventional sutures compared. Suture tapes had higher contact pressure (mean difference [MD], 0.04 MPa; 95% CI, 0.01-0.08; P = .02), higher load to failure (MD, 52.62 N; 95% CI, 27.34-77.90; P < .0001), greater stiffness (MD, 4.47 N/mm; 95% CI, 0.57-8.38; P = .02), and smaller gap formation (MD, −0.30 mm; 95% CI, −0.45 to −0.15; P < .0001) compared with conventional sutures. From the clinical analysis of the 681 rotator cuff repairs treated with a suture tape (n = 380) or conventional suture (n = 301), there were no differences in retear rates between the groups (16% vs 20% suture tape and wire, respectively; P = .26) at a mean of 11.2 months. Qualitatively, there were no differences in PROMs between the groups at a mean of 36.8 months.Conclusion:Although biomechanically superior, suture tapes showed similar retear rates and postoperative function to conventional sutures. However, higher-quality clinical studies are required to investigate whether there are no true differences.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-03-19T09:44:01Z
      DOI: 10.1177/0363546521998318
       
  • Arthroscopic Management of Femoroacetabular Impingement in Adolescents: A
           Systematic Review

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      Authors: Filippo Migliorini, Nicola Maffulli
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Femoroacetabular impingement (FAI) is highly prevalent in adolescent athletes. There has been an increasing trend for arthroscopic surgery for FAI, and the results of several clinical studies on outcome after arthroscopic surgery for FAI are available.Purpose:To conduct a systematic review to investigate the role of arthroscopic management for FAI in adolescents.Study Design:Systematic review.Methods:This systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. In August 2020, PubMed, Scopus, Google Scholar, and EMBASE were accessed. All clinical trials concerning the arthroscopic treatment for adolescents with FAI were identified. Only studies on patients aged less than 18 years at the time of surgery reporting data over a minimum follow-up of 12 months were considered.Results:Data from 406 adolescents (470 procedures; mean age at surgery, 15.9 years; mean follow-up, 30.4 months) with FAI were retrieved. At a mean of 28.0 months of follow-up, 94% of the adolescents had already returned to sport. All the scores of interest were improved at the final follow-up: visual analog scale (P = .01), modified Harris Hip Score (P < .0001), Non-Arthritic Hip Score (P = .03), Hip Outcome Score–Activities of Daily Living (P = .01), Hip Outcome Score–Sport-Specific Subscale (P < .0001), and Tegner score (P < .0001). Complications occurred in 1.1% (5/470) of procedures, and revision arthroscopy was performed in 4.7% (22/470) of procedures.Conclusion:Arthroscopic surgery in adolescents with FAI achieves excellent outcomes and a high rate of return to sport, with rates of complication and revision surgery of 1% and 5%, respectively.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-03-19T09:37:20Z
      DOI: 10.1177/0363546521997138
       
  • Influence of Cognitive Performance on Musculoskeletal Injury Risk: A
           Systematic Review

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      Authors: Jason M. Avedesian, Warren Forbes, Tracey Covassin, Janet S. Dufek
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:While a large number of studies have investigated the anatomic, hormonal, and biomechanical risk factors related to musculoskeletal (MSK) injury risk, there is growing evidence to suggest that cognition is an important injury contributor in the athletic population. A systematic review of the available evidence regarding the influence of cognitive performance on MSK injury risk has yet to be published in the sports medicine literature.Purpose/Hypothesis:The purpose was to determine the effects of cognition on (1) MSK biomechanics during sports-specific tasks and (2) MSK injury occurrence in the athletic population. It was hypothesized that athletes with lower cognitive performance would demonstrate biomechanical patterns suggestive of MSK injury risk and that injured athletes would perform worse on baseline measures of cognition as compared with their noninjured counterparts.Study Design:Systematic review.Methods:PubMed and SPORTDiscus were searched from January 2000 to January 2020. Manual searches were performed on the reference lists of the included studies. A search of the literature was performed for studies published in English that reported MSK biomechanics as a function of cognitive performance and MSK injury occurrence after baseline measures of cognition. Two independent reviewers extracted pertinent study data in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2009 guidelines and assessed study quality using the Quality Assessment Tool for Observational Cohort and Cross-sectional Studies from the National Institutes of Health. A meta-analysis was not performed, owing to the heterogeneous nature of the study designs.Results:Ten studies met inclusion criteria: 4 cognition–MSK biomechanics studies and 6 cognition–MSK injury studies. All 4 cognition–MSK biomechanics studies demonstrated that worse performance on measures of cognition was associated with lower extremity MSK biomechanical patterns suggestive of greater risk for MSK injury. The majority of the cognition–MSK injury studies demonstrated that injured athletes significantly differed on baseline cognition measures versus matched controls or that cognitive performance was a significant predictor for subsequent MSK injury.Conclusion:Although the literature exploring cognitive contributions to MSK injury risk is still in its infancy, it is suggested that sports medicine personnel conduct baseline assessments of cognition—in particular, reaction time and working memory—to identify which athletes may be at elevated risk for future MSK injury.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-03-19T05:38:08Z
      DOI: 10.1177/0363546521998081
       
  • Does Magnetic Resonance Imaging Grading Correlate With Return to Sports
           After Bone Stress Injuries' A Systematic Review and Meta-analysis

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      Authors: Tim Hoenig, Adam S. Tenforde, André Strahl, Tim Rolvien, Karsten Hollander
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:While some studies have failed to reveal any significant relationship between magnetic resonance imaging (MRI) grading and return to sports after bone stress injuries, others have reported either a linear or nonlinear relationship.Purpose:To evaluate the prognostic value of MRI grading for time to return to sports and rate of return to sports after bone stress injuries.Study Design:Systematic review and meta-analysis.Methods:A systematic search was performed in PubMed, Web of Science, SPORTDiscus, and Google Scholar. Studies reporting return to sports data after bone stress injuries using MRI grading systems were included in this review. The risk of bias was evaluated using the Quality in Prognosis Studies tool. Meta-analyses were performed to summarize the mean time to return to sports. The Pearson correlation was used to determine the relationship between time to return to sports and MRI grade. A meta-analysis of proportions was conducted to determine the percentage of athletes who successfully returned to sports.Results:A total of 16 studies with 560 bone stress injuries met inclusion criteria. Higher MRI-based grading was associated with an increased time to return to sports (P < .00001). Pooled data revealed that higher MRI-based grading correlated with a longer time to return to sports (r = 0.554; P = .001). Combining all anatomic locations, the mean time to return to sports was 41.7 days (95% CI, 30.6-52.9), 70.1 days (95% CI, 46.9-93.3), 84.3 days (95% CI, 59.6-109.1), and 98.5 days (95% CI, 85.5-112.6) for grade 1, 2, 3, and 4 injuries, respectively. Trabecular-rich sites of injury (eg, pelvis, femoral neck, and calcaneus) took longer to heal than cortical-rich sites of injury (eg, tibia, metatarsal, and other long-bone sites of injury). Overall, more than 90% of all athletes successfully returned to sports.Conclusion:The findings from this systematic review indicate that MRI grading may offer a prognostic value for time to return to sports after the nonsurgical treatment of bone stress injuries. Both MRI grade and location of injury suggest that individually adapted rehabilitation regimens and therapeutic decisions are required to optimize healing and a safe return to sports.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-03-15T05:12:48Z
      DOI: 10.1177/0363546521993807
       
  • Early Operative Versus Delayed Operative Versus Nonoperative Treatment of
           Pediatric and Adolescent Anterior Cruciate Ligament Injuries: A Systematic
           Review and Meta-analysis

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      Authors: Evan W. James, Brody J. Dawkins, Jonathan M. Schachne, Theodore J. Ganley, Mininder S. Kocher, Christian N. Anderson, Michael T. Busch, Henry G. Chambers, Melissa A. Christino, Frank A. Cordasco, Eric W. Edmonds, Daniel W. Green, Benton E. Heyworth, J. Todd R. Lawrence, Lyle J. Micheli, Matthew D. Milewski, Matthew J. Matava, Jeffrey J. Nepple, Shital N. Parikh, Andrew T. Pennock, Crystal A. Perkins, Paul M. Saluan, Kevin G. Shea, Eric J. Wall, Samuel C. Willimon, Peter D. Fabricant
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Treatment options for pediatric and adolescent anterior cruciate ligament (ACL) injuries include early operative, delayed operative, and nonoperative management. Currently, there is a lack of consensus regarding the optimal treatment for these injuries.Purpose/Hypothesis:The purpose was to determine the optimal treatment strategy for ACL injuries in pediatric and adolescent patients. We hypothesized that (1) early ACL reconstruction results in fewer meniscal tears than delayed reconstruction but yields no difference in knee stability and (2) when compared with nonoperative management, any operative management results in fewer meniscal tears and cartilage injuries, greater knee stability, and higher return-to-sport rates.Study Design:Systematic review and meta-analysis; Level of evidence, 4.Methods:A systematic search of databases was performed including PubMed, Embase, and Cochrane Library using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Inclusion criteria were a pediatric and adolescent patient population (≤19 years old at surgery), the reporting of clinical outcomes after treatment of primary ACL injury, and original scientific research article. Exclusion criteria were revision ACL reconstruction, tibial spine avulsion fracture, case report or small case series (12 weeks) for the presence of any meniscal tear (odds ratio, 0.23; P = .006) and irreparable meniscal tear (odds ratio, 0.31; P = .001). Comparison of any side-to-side differences in KT-1000 arthrometer testing did not favor early or delayed ACL reconstruction in either continuous mean differences (P = .413) or proportion with difference ≥3 mm (P = .181). Return to preinjury level of competition rates for early and delayed ACL reconstruction ranged from 57% to 100%.Conclusion:Delaying ACL reconstruction in pediatric or adolescent patients for>12 weeks significantly increased the risk of meniscal injuries and irreparable meniscal tears; however, early and delayed operative treatment achieved satisfactory knee stability. Nonoperative management resulted in high rates of residual knee instability, increased risk of meniscal tears, and comparatively low rates of return to sports.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-03-15T04:55:04Z
      DOI: 10.1177/0363546521990817
       
  • Return to Sport After Medial Patellofemoral Ligament Reconstruction: A
           Systematic Review and Meta-analysis

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      Authors: Brooks N. Platt, Lucy C. Bowers, Justin A. Magnuson, Sean M. Marx, Joseph N. Liu, Jack Farr, Austin V. Stone
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Patellar instability is frequently encountered in the athletic population. Medial patellofemoral ligament (MPFL) reconstruction is a common strategy to treat recurrent patellar dislocation and demonstrates good clinical outcomes.Purpose/Hypothesis:The purpose was to examine return to sport after MPFL reconstruction for patellar instability. We hypothesized that patients would resume athletic activity at a high rate and that a large proportion would return to their preoperative level of performance.Study Design:Systematic review and meta-analysis.Methods:A systematic review of the literature was conducted using PubMed and Cochrane Library databases to identify articles reporting return to sport after MPFL reconstruction for recurrent patellar dislocation. Athletes were defined as those reporting a preoperative sport. A random-effects model was used to evaluate return to sport rates, subsequent level, and rate of instability recurrence. Meta-regression was used to compare return to sport rates in patients undergoing MPFL reconstruction without osteotomy compared with those treated with simultaneous tibial tubercle osteotomy or trochleoplasty.Results:In total, 23 articles met inclusion criteria after full-text review. A total of 930 patients were analyzed, including 786 athletes. Women represented 61.3% of all patients. The overall mean age was 21.1 years (range, 9.5-60.0 years), with a mean follow-up time of 3.0 years (range, 0.8-8.5 years). The return to sport rate was 92.8% (95% CI, 86.4-97.6). Patients returned to or surpassed their preoperative level of activity in 71.3% (95% CI, 63.7-78.4) of cases. An osteotomy was performed on 10.5% of athletes. Return to sport did not differ significantly in patients undergoing MPFL reconstruction without osteotomy versus those receiving additional osteotomy (95.4% vs 86.9%; P = .22). Patients returned to sport at a mean of 6.7 months (range, 3.0-6.4 months) postoperatively. Osteotomy did not affect return time. Complications occurred at an overall rate of 8.8%. The most common complication was recurrence of instability (1.9%; 95% CI, 0.4-4.0). The Kujala score was reported by 13 studies, with pre- and postoperative combined means of 60.3 and 90.0, respectively.Conclusion:MPFL reconstruction is an effective and reliable treatment in the setting of patellofemoral instability. Surgeons can counsel their patients that they can expect a high rate of return to sport after MPFL reconstruction surgery alone or with concomitant osteotomy.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-03-15T04:48:19Z
      DOI: 10.1177/0363546521990004
       
  • Fascia Iliaca Block for Postoperative Pain Control After Hip Arthroscopy:
           A Systematic Review of Randomized Controlled Trials

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      Authors: John-Rudolph H. Smith, Matthew J. Kraeutler, Laura E. Keeling, Anthony J. Scillia, Eric C. McCarty, Omer Mei-Dan
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Various analgesic modalities have been used to improve postoperative pain in patients undergoing hip arthroscopy.Purpose:To systematically review the literature to compare the efficacy of the fascia iliaca block (FIB) with that of other analgesic modalities after hip arthroscopy in terms of postoperative pain scores and analgesic consumption.Study Design:Systematic review.Methods:A systematic review was performed by searching PubMed, the Cochrane Library, and Embase up to April 2020 to identify randomized controlled trials that compared postoperative pain and analgesic consumption in patients after hip arthroscopy with FIB versus other pain control modalities. The search phrase used was “hip arthroscopy fascia iliaca randomized.” Patients were evaluated based on postoperative pain scores and total postoperative analgesic consumption.Results:Five studies (3 level 1, 2 level 2) were identified that met inclusion criteria, including 157 patients undergoing hip arthroscopy with FIB (mean age, 38.3 years; 44.6% men) and 159 patients among the following comparison groups: lumbar plexus block (LPB), intra-articular ropivacaine (IAR), local anesthetic infiltration (LAI), saline placebo, and a no-block control group (overall mean age, 36.2 years; 36.5% men). No significant differences in pain scores were reported in the postanesthesia care unit (PACU) between the FIB and LPB (3.4 vs 2.9; P = .054), IAR (7.7 vs 7.9; P = .72), control group (no FIB: 4.1 vs 3.8; P = .76); or saline placebo (difference, –0.2 [95% CI, –1.1 to 0.7]). One study reported significantly higher pain scores at 1 hour postoperation in the FIB group compared with the LAI group (5.5 vs 3.4; P = .02). Another study reported significantly greater total analgesic consumption (in morphine equivalent dosing) in the PACU among the FIB group compared with the LPB group (20.8 vs 17.0; P = .02). No significant differences were observed in total PACU analgesic consumption between FIB and other analgesic modalities.Conclusion:In patients undergoing hip arthroscopy, the FIB does not appear to demonstrate superiority to other forms of analgesics in the immediate postoperative period. Therefore, it is not recommended as a routine form of pain control for these procedures.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-03-12T06:21:55Z
      DOI: 10.1177/0363546521996713
       
  • Tranexamic Acid in Anterior Cruciate Ligament Reconstruction: A Systematic
           Review and Meta-analysis

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      Authors: William L. Johns, Kempland C. Walley, Sommer Hammoud, Tyler A. Gonzalez, Michael G. Ciccotti, Nirav K. Patel
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Hemarthrosis after anterior cruciate ligament (ACL) reconstruction procedures can delay rehabilitation and have toxic effects on the cartilage and synovium. Tranexamic acid is widely used in adult reconstruction procedures; however, its use in ACL reconstruction is a novel topic of study.Purpose:To analyze the available literature on hemarthrosis, pain, functional outcomes, and complications after administration of tranexamic acid in ACL reconstruction procedures.Study Design:Meta-analysis.Methods:A literature search was performed to retrieve randomized controlled trials examining the use of tranexamic acid at the time of ACL reconstruction procedures. The studied outcomes included postoperative joint drain output, hemarthrosis grade, visual analog scale scores for pain, range of motion, Lysholm score, postoperative rates of deep venous thrombosis, and pulmonary embolism. Outcomes were pooled to perform a meta-analysis.Results:Five prospective randomized controlled trials met inclusion criteria for analysis. Four studies administered intravenous tranexamic acid in bolus or infusion form before ACL reconstruction, while 2 studies administered tranexamic acid via intra-articular injection. Specifically, tranexamic acid was administered intravenously (preoperative 15-mg/kg bolus 10 minutes before tourniquet inflation with or without 10 mg/kg/h for 3 hours postoperatively) or intra-articularly (10 mL [100 mg/mL] intraoperatively), and 1 study consisted of tranexamic acid administration in combined intravenous and intra-articular forms (15-mg/kg bolus 10 minutes before tourniquet inflation and intra-articular 3 g 10 minutes before tourniquet deflation). Tranexamic acid use in ACL reconstruction cases resulted in a mean reduction of 61.5 mL in postoperative drain output at 24 hours (95% CI, –95.51 to −27.46; P = .0004), lower hemarthrosis grade (P < .00001), improved Lysholm scores, and reduction in visual analog scale scores for pain (−1.96 points; 95% CI, −2.19 to −1.73; P < .00001) extending to postoperative week 6. Range of motion was improved in the immediate postoperative period, and the need for joint aspiration within 2 weeks was reduced (P < .001). There was no difference in venous thromboembolic event rate between the experimental and control groups.Conclusion:The use of intravenous tranexamic acid in ACL reconstruction surgery results in reduced joint drain output and hemarthrosis and improved pain scores and range of motion in the initial postoperative period without increased complications or thromboembolic events.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-02-25T08:52:44Z
      DOI: 10.1177/0363546521988943
       
  • Risk Factors for Ramp Lesions of the Medial Meniscus: A Systematic Review
           and Meta-analysis

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      Authors: Kyle N. Kunze, Joshua Wright-Chisem, Evan M. Polce, Nicholas N. DePhillipo, Robert F. LaPrade, Jorge Chahla
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Failure to appropriately identify and repair medial meniscal ramp lesions at the time of anterior cruciate ligament (ACL) reconstruction (ACLR) may result in increased anterior tibial translation and internal rotation, increasing the risk for graft failure. Knowledge of the risk factors leading to the development of ramp lesions may enhance clinicians’ vigilance in specific ACL-deficient populations and subsequently repair of these lesions at the time of ACLR.Purpose:To perform a systematic review and meta-analysis of factors tested for associations with ramp lesions and to determine which were significantly associated with the presence of ramp lesions.Study Design:Systematic review and meta-analysis; Level of evidence, 4.Methods:PubMed, OVID/Medline, and Cochrane databases were queried in April 2020. Data pertaining to study characteristics and reported risk factors for ramp lesions were recorded. DerSimonian-Laird binary random-effects models were constructed to quantitatively evaluate the association between risk factors and ramp lesions by generating effect estimates in the form of odds ratios (ORs) with 95% CIs. Qualitative analysis was performed to describe risk factors that were variably reported.Results:The review included 12 studies with 8410 patients. The overall pooled prevalence of ramp lesions was 21.9% (range, 9.0%-41.7%). A total of 45 risk factors were identified, of which 8 were explored quantitatively. There was strong evidence to support that posteromedial tibial edema on magnetic resonance imaging (MRI) (OR, 2.12; 95% CI, 1.27-3.56; P = .004), age
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-02-10T04:53:43Z
      DOI: 10.1177/0363546520986817
       
  • Mesenchymal Stem Cells in the Treatment of Cartilage Defects of the Knee:
           A Systematic Review of the Clinical Outcomes

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      Authors: Monketh Jaibaji, Rawan Jaibaji, Andrea Volpin
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Osteochondral lesions are a common clinical problem and their management has been historically challenging. Mesenchymal stem cells have the potential to differentiate into chondrocytes and thus restore hyaline cartilage to the defect, theoretically improving clincal outcomes in these patients. They can also be harvested with minimal donor site morbidity.Purpose:To assess the clinical and functional outcomes of mesenchymal stem cell implantation to treat isolated osteochondral defects of the knee. A secondary purpose is to assess the quality of the current available evidence as well as the radiological and histological outcomes. We also reviewed the cellular preparation and operative techniques for implantation.Study Design:Systematic review.Methods:A comprehensive literature search of 4 databases was carried out: CINAHL, Embase, MEDLINE, and PubMed. We searched for clinical studies reporting the outcomes on a minimum of 5 patients with at least 12 months of follow-up. Clinical, radiological, and histological outcomes were recorded. We also recorded demographics, stem cell source, culture technique, and operative technique. Methodological quality of each study was assessed using the modified Coleman methodology score, and risk of bias for the randomized controlled studies was assessed using the Cochrane Collaboration tool.Results:Seventeen studies were found, encompassing 367 patients. The mean patient age was 35.1 years. Bone marrow was the most common source of stem cells utilized. Mesenchymal stem cell therapy consistently demonstrated good short- to medium-term outcomes in the studies reviewed with no serious adverse events being recorded. There was significant heterogeneity in cell harvesting and preparation as well as in the reporting of outcomes.Conclusion:Mesenchymal stem cells demonstrated a clinically relevant improvement in outcomes in patients with osteochondral defects of the knee. More research is needed to establish an optimal treatment protocol, long-term outcomes, and superiority over other therapies.Registration:CRD42020179391 (PROSPERO).
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-02-08T05:13:59Z
      DOI: 10.1177/0363546520986812
       
  • Bridging Allograft Reconstruction Is Superior to Maximal Repair for the
           Treatment of Chronic, Massive Rotator Cuff Tears: Results of a
           Prospective, Randomized Controlled Trial

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      Authors: Ivan Wong, Sara Sparavalo, John-Paul King, Catherine M. Coady
      First page: 3173
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Despite advances in surgical techniques, the use of maximal repair to treat large or massive rotator cuff tears results in a high retear rate postoperatively. Currently, no randomized controlled trials have compared the outcomes of maximal repair with interposition dermal allograft bridging reconstruction.Hypothesis:We hypothesized that large or massive rotator cuff tendon tears reconstructed using bridging dermal allograft would have better clinical outcomes 2 years postoperatively, as measured using the Western Ontario Rotator Cuff (WORC) index, than would those receiving the current gold standard treatment of debridement and maximal repair alone. We also expected that patients treated via bridging reconstruction using dermal allograft would have fewer postoperative failures as assessed using postoperative magnetic resonance imaging scans.Study Design:Randomized controlled trial; Level of evidence 1.Methods:A sample size of 30 patients (determined using a priori sample size calculation) with massive, retracted rotator cuff tears were randomly allocated to 1 of 2 groups: maximal repair or bridging reconstruction using dermal allograft. All patients completed questionnaires (WORC and Disabilities of the Arm, Shoulder and Hand [DASH]) preoperatively and postoperatively at 3 months, 6 months, 1 year, and 2 years. The primary outcome of this study was the WORC index at 2 years. Secondary outcomes included healing rate, progression of rotator cuff arthropathy, and postoperative acromiohumeral distance in both groups.Results:Patients treated via bridging reconstruction using dermal allograft had better postoperative WORC and DASH scores (23.93 ± 24.55 and 15.77 ± 19.27, respectively) compared with patients who received maximal repair alone (53.36 ± 31.93 and 34.32 ± 23.31, respectively). We also noted increased progression to rotator cuff arthropathy in the maximal repair group with an increased retear rate when compared with the reconstruction group (87% and 21%, respectively; P < .001). The acromiohumeral distance was maintained in the reconstruction group but significantly decreased in the maximal repair group.Conclusion:Rotator cuff bridging reconstruction using a dermal allograft demonstrated improved patient-reported outcomes as measured using the WORC index 2 years postoperatively. This technique also showed favorable structural healing rates and decreased progression to arthropathy compared with maximal repair.Trial Registration:ClinicalTrials.gov (NCT01987973)
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-09-08T02:10:20Z
      DOI: 10.1177/03635465211039846
       
  • Arthroscopic Versus Mini-open Rotator Cuff Repair: A Randomized Trial and
           Meta-analysis

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      Authors: Joy C. MacDermid, Dianne Bryant, Richard Holtby, Helen Razmjou, Kenneth Faber, Robert Balyk, Richard Boorman, David Sheps, Robert McCormack, George Athwal, Robert Hollinshead, Ian Lo, Ryan Bicknell, Nicholas Mohtadi, Martin Bouliane, Donald Glasgow, Marie-Eve Lebel, Aleem Lalani, Farhad O. Moola, Robert Litchfield, Jaydeep Moro, Peter MacDonald, J.W. Bergman, Jeff Bury, Darren Drosdowech
      First page: 3184
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Patients with complete rotator cuff tears who fail a course of nonoperative therapy can benefit from surgical repair.Purpose:This randomized trial compared mini-open (MO) versus all-arthroscopic (AA) rotator cuff repair.Study Design:Randomized controlled trial; Level of evidence, 1.Methods:Patients with rotator cuff tears were randomized to undergo MO or AA repair at 9 centers by 23 surgeons. The primary outcome (Western Ontario Rotator Cuff Index [WORC]) and secondary outcomes (American Shoulder and Elbow Surgeons [ASES] score, Shoulder Pain and Disability Index [SPADI] pain subscale, 12-Item Short Form Health Survey [SF-12], reported medication use, adverse events), as well as measurements of range of motion and strength, were collected at 1 month before surgery; at 2 and 6 weeks postoperatively; and at 3, 6, 12, 18, and 24 months postoperatively. A blinded radiologist evaluated rotator cuff integrity on magnetic resonance imaging (MRI) at baseline and 1 year. Intention-to-treat analysis of covariance with the preoperative WORC score, age, and tear size as covariates assessed continuous outcomes. Sex differences were assessed. A meta-analysis synthesized the primary outcome between MO and AA repair with previous trials.Results:From 954 patients screened, 411 were ineligible (276 because of recovery with physical therapy), 449 were screened at surgery (175 ineligible), and 274 completed follow-up (138 MO and 136 AA). The AA and MO groups were similar before surgery. WORC scores improved from 40 preoperatively to 89 (AA) and 93 (MO) at 2 years, for an adjusted mean difference of 3.4 (95% CI, –0.4 to 7.2). There were no statistically significant differences between the AA and MO groups at any time point. All secondary patient-reported outcomes were not significantly different between the MO and AA groups, except the 2-year SPADI pain score (8 vs 12, respectively; P = .02). A similar recovery in range of motion and strength occurred in both groups over time. MRI indicated minimal improvement in muscle relative to fat (AA: n = 3; MO: n = 2), with most worsening (AA: n = 25; MO: n = 24) or remaining unchanged (AA: n = 70; MO: n = 70). Opioid use was significantly reduced after surgery (from 21% to 5%). The meta-analysis indicated no significant standardized mean difference between groups in the primary outcome across all pooled studies (standardized mean difference, –0.06 [95% CI, –0.34 to 0.22]).Conclusion:Both AA and MO rotator cuff repair provide large clinical benefits, with few adverse events. There is strong evidence of equivalent clinical improvements.Trial Registration:NCT00128076.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-09-15T01:37:34Z
      DOI: 10.1177/03635465211038233
       
  • Clinical and Structural Results of Rotator Cuff Repair Compared With
           Rotator Cuff Debridement in Arthroscopic Treatment of Calcifying
           Tendinitis of the Shoulder

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      Authors: Olaf Lorbach, Alexander Haupert, Catharina Berger, Matthias Brockmeyer
      First page: 3196
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Arthroscopic treatment of calcifying tendinitis of the shoulder reveals good to excellent results. However, whether the tendon needs to be repaired after removal of the calcific deposit or simply debrided remains unclear.Purpose:To evaluate the structural and clinical results after arthroscopic calcific deposit removal with additional rotator cuff repair or rotator cuff debridement.Study Design:Cohort study; Level of evidence, 3.Methods:A total of 44 patients (46 shoulders) were enrolled in this retrospective cohort study with a mean follow-up of 58.4 months. Patients underwent arthroscopic removal of a calcific deposit and bursectomy after failed nonoperative treatment. A total of 22 patients received additional rotator cuff repair irrespective of the degree of debridement (the repair group), whereas 22 patients received a simple rotator cuff debridement without additional repair (the debridement group). Groups were comparable in sex, age, and size and consistency of the deposits according to the Gärtner and Bosworth classifications. Clinical evaluation was performed by the Constant score, Simple Shoulder Test, American Shoulder and Elbow Surgeons (ASES) score, and numerical rating scales for pain, function, and satisfaction. In 29 patients (14 in the debridement group and 15 in the repair group), additional magnetic resonance imaging at follow-up was performed to evaluate the structural results using the Sugaya classification.Results:All patients were satisfied with the results of surgery; 100% of the repair group and 95.7% of the debridement group reported they would undergo the surgical procedure again. Comparison of the clinical results showed significantly better results in the repair group versus the debridement group for the Constant score (86.2 vs 80.6, respectively; P = .04), the ASES score (98.3 vs 88.9; P = .004), the Simple Shoulder Test (11.6 vs 10; P = .005), and the numerical rating scales for pain (0.1 vs 0.8; P = .007), function (9.6 vs 8.8; P = .008), and satisfaction (9.8 vs 9.1; P = .036). Comparison of the postoperative tendon integrity showed 80% Sugaya grade I in the rotator cuff repair group and 64% Sugaya grade II in the debridement group, with a statistically significant difference in favor of the repair group (P = .004). Postoperative clinical evaluation revealed no positive O’Brien tests in the repair group, whereas approximately one-third of the debridement group showed a positive O’Brien test during examination.Conclusion:Arthroscopic removal of calcific deposits with rotator cuff debridement or cuff repair showed good to excellent clinical and structural midterm results. However, patients who underwent additional repair of the tendon defect had significantly better clinical results as well as better structural results in terms of tendon integrity.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-09-16T03:01:34Z
      DOI: 10.1177/03635465211037690
       
  • Transtendon Suture Bridge Repair of Both-Sided Partial-Thickness Rotator
           Cuff Tears: Midterm Outcomes

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      Authors: Dongwhan Suh, Sang-Eun Park, Young-Hun Han, Eung-Sic Kim, Jong-Hun Ji
      First page: 3202
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Among symptomatic partial-thickness rotator cuff tears (PTRCT) indicated for surgery, both-sided (concurrent articular and bursal side) PTRCT are rarely reported and discussed in the literature. Without clinical data on and definite guidelines for treating these rare partial tears, appropriate management cannot be expected.Purpose:To calculate the prevalence of both-sided PTRCT and to evaluate clinical outcomes after arthroscopic transtendon suture bridge repair of both-sided PTRCT at a minimum 3-year follow-up.Study Design:Case series; Level of evidence, 4.Methods:Among symptomatic PTRCT that required arthroscopic surgery (765 patients) between March 2008 and December 2014, 178 both-sided partial tears were confirmed arthroscopically, and arthroscopic transtendon suture bridge repair was performed in 100 patients enrolled in our study after exclusion criteria were applied. The presence of concurrent articular and bursal side partial tears was confirmed via arthroscopy, with Ellman grade>2 on either the bursal or the articular side of these both-sided partial tears. Without tear completion, transtendon suture bridge repair was performed in all cases. Clinical outcomes including clinical scores and range of motion were evaluated at a mean of 5.3 ± 1.4 years (range, 3-8 years). Follow-up magnetic resonance imaging (MRI) was performed at 6 to 12 months (mean ± SD, 11 ± 5.20 months) after surgery to evaluate the tendon integrity (Sugaya classification) of the repaired rotator cuff.Results:The mean age was 57.5 ± 7.8 years, and 65% of patients were women. Mean preoperative American Shoulder and Elbow Surgeons, University of California Los Angeles, Simple Shoulder Test, and Constant-Murley outcome scores of 52 ± 14, 19 ± 4, 6 ± 2, and 69 ± 10 significantly improved postoperatively to 94 ± 5, 33 ± 2, 11 ± 1, and 93 ± 5, respectively (P < .001). Mean forward flexion, abduction, external rotation, and internal rotation improved significantly from 148°± 31°, 134°± 39°, 22°± 13°, and L2 preoperatively to 154°± 17°, 151°± 60°, 29°± 14°, and T10 postoperatively, respectively (P < .001). The retear rate on follow-up MRI scans was 2%. As per Sugaya classification on postoperative MRI scans, type 1 healing was found in 29%; type 2, in 60%; type 3, in 9%; and type 4, in 2%.Conclusion:Among all symptomatic PTRCT that required surgery, both-sided PTRCT were more common than expected. Arthroscopic transtendon suture bridge repair of these both-sided PTRCT showed satisfactory clinical outcomes at a minimum 3-year follow-up.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-09-14T04:43:47Z
      DOI: 10.1177/03635465211034503
       
  • A “Comma Sign”–Directed Subscapularis Repair in Anterosuperior
           Rotator Cuff Tears Yields Biomechanical Advantages in a Cadaveric Model

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      Authors: Michael Hackl, Eduard Buess, Sandra Kammerlohr, Julia Nacov, Manfred Staat, Tim Leschinger, Lars P. Müller, Kilian Wegmann
      First page: 3212
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Additional stabilization of the “comma sign” in anterosuperior rotator cuff repair has been proposed to provide biomechanical benefits regarding stability of the repair.Purpose:This in vitro investigation aimed to investigate the influence of a comma sign–directed reconstruction technique for anterosuperior rotator cuff tears on the primary stability of the subscapularis tendon repair.Study Design:Controlled laboratory study.Methods:A total of 18 fresh-frozen cadaveric shoulders were used in this study. Anterosuperior rotator cuff tears (complete full-thickness tear of the supraspinatus and subscapularis tendons) were created, and supraspinatus repair was performed with a standard suture bridge technique. The subscapularis was repaired with either a (1) single-row or (2) comma sign technique. A high-resolution 3D camera system was used to analyze 3-mm and 5-mm gap formation at the subscapularis tendon-bone interface upon incremental cyclic loading. Moreover, the ultimate failure load of the repair was recorded. A Mann-Whitney test was used to assess significant differences between the 2 groups.Results:The comma sign repair withstood significantly more loading cycles than the single-row repair until 3-mm and 5-mm gap formation occurred (P≤ .047). The ultimate failure load did not reveal any significant differences when the 2 techniques were compared (P = .596).Conclusion:The results of this study show that additional stabilization of the comma sign enhanced the primary stability of subscapularis tendon repair in anterosuperior rotator cuff tears. Although this stabilization did not seem to influence the ultimate failure load, it effectively decreased the micromotion at the tendon-bone interface during cyclic loading.Clinical Relevance:The proposed technique for stabilization of the comma sign has shown superior biomechanical properties in comparison with a single-row repair and might thus improve tendon healing. Further clinical research will be necessary to determine its influence on the functional outcome.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-08-16T05:57:19Z
      DOI: 10.1177/03635465211031506
       
  • Coracoid or Clavicle Fractures Associated With Coracoclavicular Ligament
           Reconstruction

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      Authors: Nicholas M. Panarello, Donald F. Colantonio, Colin J. Harrington, Scott M. Feeley, Tahler D. Bandarra, Jonathan F. Dickens, Kelly G. Kilcoyne
      First page: 3218
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Coracoclavicular (CC) ligament reconstruction is a commonly performed procedure for high-grade acromioclavicular (AC) joint separations. Although distal clavicle and coracoid process fractures represent potential complications, they have been described in only case reports and small case series.Purpose:To identify the incidence and characteristics of clavicle and coracoid fractures after CC ligament reconstruction.Study Design:Case series; Level of evidence, 4.Methods:The US Military Health System Data Repository was queried for patients with a Current Procedural Terminology code for CC ligament repair or reconstruction between October 2013 and March 2020. The electronic health records, including patient characteristics, radiographs, operative reports, and clinical notes, were evaluated for intraoperative or postoperative clavicle or coracoid fractures. Initial operative technique, fracture management, and subsequent clinical outcomes were reviewed for these patients.Results:A total of 896 primary CC ligament repairs or reconstructions were performed during the study period. There were 21 postoperative fractures and 1 intraoperative fracture in 20 patients. Of these fractures, 12 involved the coracoid and 10 involved the clavicle. The overall incidence of fracture was 3.81 fractures per 1000 person-years. In 5 patients who sustained a fracture, bone tunnels were not drilled in the fractured bone during the index procedure. A total of 17 fractures were ultimately treated operatively, whereas 5 fractures had nonoperative management. Of the 16 active-duty servicemembers who sustained intraoperative or postoperative fractures, 11 were unable to return to full military duty after their fracture care.Conclusion:Fracture of the distal clavicle or coracoid process after CC ligament repair or reconstruction is a rare but serious complication that can occur independent of bone tunnels created during the index procedure. Fractures associated with CC ligament procedures occurred at a rate of 2.46 per 100 cases. Most patients were ultimately treated surgically with open reduction and internal fixation or revision CC ligament reconstruction. Although the majority of patients with intraoperative or postoperative fractures regained full range of motion, complications such as anterior shoulder pain, AC joint asymmetry, and activity-related weakness were common sequelae resulting in physical limitations and separation from military service.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-09-08T03:46:43Z
      DOI: 10.1177/03635465211036713
       
  • Radial Head Lag: A Possible Biomechanical Mechanism for Osteochondritis
           Dissecans of the Capitellum in Baseball Pitchers

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      Authors: Dani Rotman, Jae-Man Kwak, Jorge Rojas Lievano, Alexander Hooke, Christopher L. Camp, James S. Fitzsimmons, Shawn W. O’Driscoll
      First page: 3226
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Osteochondritis dissecans (OCD) of the capitellum is common in throwing athletes and is believed to result from repetitive overloading on the radiocapitellar (RC) joint, although the cause and mechanism remain unclear. The torsional forces (moments) generated by the triceps during elbow extension pull only on the ulna; therefore, the radial head moves passively across the capitellum and is effectively “dragged along” by the ulna. Any laxity in the proximal radioulnar joint could lead to asynchronous motion between the radius and ulna, resulting in the radial head lagging behind the coronoid and possibly malarticulating with the capitellum during such motion.Hypothesis:Radial head motion on the capitellum lags behind ulnohumeral joint motion during simulated throwing.Study Design:Controlled laboratory study.Methods:A total of 8 cadaveric elbows were tested under simulated throwing, including active extension of the elbow generated by pulling of the triceps under valgus stress, as well as during passive extension under valgus stress to serve as a reference. Ulnohumeral motion was tracked using a video camera. Radial head motion was tracked using an intra-articular, thin-film pressure sensor mounted on the capitellum, and the longitudinal movement of the center of force (COF) of the radial head was measured. Radial head motion was compared between passive and active motion for each 10° of elbow extension from 90° to 20°.Results:Elbow motion during simulated active extension reached an angular velocity of 366 deg/s. Radial head motion during simulated active extension significantly lagged compared with its motion during passive extension at every elbow extension angle examined between 70° and 20° (P < .001). The maximal lag reached a mean of 4 mm (range, 2-7 mm). In other words, RC and ulnohumeral motion were asynchronous during simulated throwing.Conclusion:This study describes a novel phenomenon: motion of the radial head across the capitellum during rapid extension, such as in baseball pitching, lags behind that seen during passive elbow motion. According to a new proposed theory of OCD lesion development, this lag should result in RC incongruency and elevated shear forces on the capitellum due to edge loading.Clinical Relevance:We propose a new biomechanical explanation for OCD of the capitellum in baseball pitchers: radial head lag. Understanding this process is the first step in efforts to prevent this common injury.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-09-15T10:29:16Z
      DOI: 10.1177/03635465211033971
       
  • Implementation of Percutaneous Transforaminal Endoscopic Discectomy in
           Competitive Elite Athletes With Lumbar Disc Herniation: Original Study and
           Review of the Literature

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      Authors: Stylianos Kapetanakis, Nikolaos Gkantsinikoudis, Georgios Charitoudis
      First page: 3234
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Lumbar disc herniation (LDH) represents a frequent clinical entity in athletes. Surgical treatment of LDH with endoscopic spine surgical techniques has been proposed as a feasible alternative in these patients.Purpose:To study the particular outcomes of percutaneous transforaminal endoscopic discectomy (PTED) in competitive elite athletes with surgically treatable LDH.Study Design:Case series; Level of evidence, 4.Methods:A total of 55 competitive elite athletes with diagnosed LDH based on clinical and radiologic criteria were enrolled in this prospectively designed study. All patients underwent successful PTED. Clinical evaluation was conducted with the well-established visual analog scale for lower limb and low back pain separately. The 36-Item Short Form Health Survey (SF-36) was implemented for health-related quality of life analysis. Patients were assessed preoperatively and at regular postoperative intervals: 6 weeks and 3, 6, and 12 months, as well as 2 years.Results:Operated levels were L3-L4 (5.5%), L4-L5 (69.1%), and L5-S1 (25.4%). No major perioperative complications were observed. All patients successfully reached the end of follow-up at 2 years. Both visual analog scale scores (lower limb and low back pain) showed clinically and statistically significant improvement at 6 weeks postoperatively, with subsequent minor improvement and stabilization. All recorded SF-36 parameters demonstrated major clinical amelioration at 6 weeks, with subsequent minor but constant statistically significant improvement until the end of follow-up. Comparative evaluation of the SF-36 revealed that the physical function, bodily pain, role-emotional, and mental health parameters showed quantitatively greater improvement in comparison with rest indices.Conclusion:PTED constitutes a feasible and effective technique for surgical management of LDH in athletes, providing favorable outcomes in terms of postoperative pain and health-related quality of life. Proper performance of technique for specific cases of L5-S1 LDH may be more challenging, and these cases should be evaluated selectively for suitability for this procedure.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-09-07T01:42:35Z
      DOI: 10.1177/03635465211032612
       
  • Patient-Reported Outcome Scores and Rate of Return to Sport After Hip
           Arthroscopic Surgery: A Sex-Based Comparison in Professional and
           Collegiate Athletes

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      Authors: Rachel M. Glein, Andrew E. Jimenez, Kara B. Miecznikowski, Benjamin R. Saks, Hari K. Ankem, Payam W. Sabetian, David R. Maldonado, Ajay C. Lall, Benjamin G. Domb
      First page: 3242
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:No studies have compared outcomes and return to sport (RTS) after hip arthroscopic surgery between matched groups of male and female athletes with a minimum 2-year follow-up.Purpose:(1) To report minimum 2-year postoperative patient-reported outcome (PRO) scores and the RTS rate for elite female athletes undergoing hip arthroscopic surgery for femoroacetabular impingement (FAI) and (2) to compare clinical results with a matched control group of elite male athletes.Study Design:Cohort study; Level of evidence, 3.Methods:Data on all consecutive female athletes who underwent primary hip arthroscopic surgery performed at our institution between March 2009 and July 2018 were collected. Patients were eligible if they underwent hip arthroscopic surgery for labral tears or FAI and participated in collegiate or professional athletics within 1 year of surgery. Minimum 2-year postoperative PRO scores were collected for the modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), Hip Outcome Score–Sport-Specific Subscale (HOS-SSS), and visual analog scale (VAS) for pain as well as RTS status. The percentages of patients achieving the minimal clinically important difference (MCID) and patient acceptable symptomatic state were recorded. These patients were matched to elite male athletes for comparison.Results:A total of 73 female hips were included, with a mean follow-up of 65.1 ± 27.9 months. They demonstrated a significant improvement from preoperatively to latest follow-up on the mHHS, NAHS, HOS-SSS, and VAS (P < .05). When outcomes were compared with a control group of male athletes, female athletes demonstrated lower preoperative scores, similar postoperative scores, and a significantly greater magnitude of improvement (delta value) on the mHHS, NAHS, and VAS. Female athletes also achieved the MCID at higher rates than did male athletes for the HOS-SSS (85.1% vs 70.0%, respectively; P = .035) and NAHS (79.1% vs 62.9%, respectively; P = .037). RTS rates among patients who attempted were similar between the 2 groups (female: 75.4%; male: 83.1%; P = .409).Conclusion:Elite female athletes undergoing primary hip arthroscopic surgery for FAI demonstrated a significant improvement in PRO scores and a high RTS rate. Female athletes exhibited a greater improvement in PRO scores (mHHS, NAHS, VAS) and achieved the MCID (HOS-SSS, NAHS) at higher rates compared with a control group of male athletes.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-09-08T04:08:46Z
      DOI: 10.1177/03635465211039834
       
  • The Natural Course of Recovery After Hip Arthroscopy for Femoroacetabular
           Impingement According to the International Hip Outcome Tool–12 and Hip
           Outcome Score Sports Subscale

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      Authors: Blake M. Bodendorfer, Ian M. Clapp, Steven F. DeFroda, Philip Malloy, Thomas D. Alter, Kevin C. Parvaresh, Jorge Chahla, Shane J. Nho
      First page: 3250
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:A paucity of literature exists regarding trajectories of functional and sports-specific recovery after hip arthroscopy for femoroacetabular impingement syndrome (FAIS).Purpose:To determine if subgroups of patients exist based on the recovery trajectory of patient-reported outcomes (PROs) after hip arthroscopy for FAIS in the short-term period and to determine clinical predictors for these subgroups of patients.Study Design:Case-control study; Level of evidence, 3.Methods:A prospectively maintained repository was queried for patients who had undergone primary hip arthroscopy for the treatment of FAIS between January 2012 and May 2018. Patients who completed the preoperative, 1-year, and 2-year International Hip Outcome Tool–12 (iHOT-12) or the Hip Outcome Score Sports Subscale (HOS-SS) were included. The latent class growth analysis (LCGA) and growth mixture models (GMMs) were used to identify subgroups of patients based on trajectories of recovery for the iHOT-12 and the HOS-SS utilizing preoperative, 1-year, and 2-year follow-ups. LCGA and GMM models using 1 to 6 classes for each PRO were performed, and the best-fit model for each PRO was selected. After final model selection, a multivariable multinomial logistic regression was performed, with the largest class being the reference group to determine clinical predictors of subgroup membership.Results:A total of 443 and 556 patients were included in the iHOT-12 and HOS-SS analyses, respectively. For the iHOT-12, we identified the following 3 subgroups: early progressors (70%), late regressors (22.3%), and late progressors (7.7%). Predictors of late regression were workers’ compensation status, psychiatric history, preoperative chronic pain, and lower preoperative iHOT-12 scores; and late progressors were less likely to participate in sports. For the HOS-SS, we identified the following 4 subgroups: early progressors (47.7%), late regressors (17.4%), late progressors (6.8%), and steady progressors (28.1%). Predictors of less favorable recovery trajectories (late regressors and late progessors) were older age, male sex, back pain, psychiatric history, preoperative chronic pain, greater alpha angle, and lower preoperative HOS-SS scores.Conclusion:Using the growth mixture modeling, 3 natural courses of health-related quality of life (early progression, late regression, and late progression) and 4 natural courses of recovery of athletic function (steady progression, late regression, late progression, and early progression) were identified. Preoperative psychiatric conditions, chronic pain, workers’ compensation status, and lower iHOT-12 scores were predictive of less than favorable trajectories of recovery according to the iHOT-12, and male sex, older age, back pain, preoperative narcotic use, and lower preoperative HOS-SS were predictors of less favorable recovery trajectories according to the HOS-SS.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-09-08T03:24:47Z
      DOI: 10.1177/03635465211034511
       
  • Return to Sports and Minimum 2-Year Outcomes of Primary Arthroscopic Hip
           Labral Reconstruction for Irreparable Tears in High-Level Athletes With a
           Propensity-Matched Benchmarking Against a Labral Repair Control Group

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      Authors: Andrew E. Jimenez, Peter F. Monahan, Jade S. Owens, David R. Maldonado, Benjamin R. Saks, Hari K. Ankem, Payam W. Sabetian, Ajay C. Lall, Benjamin G. Domb
      First page: 3261
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Labral reconstruction has shown promise for the treatment of irreparable labral tears in high-level athletes. The literature is scarce regarding outcomes and timing of return to sports (RTS) in these patients.Purpose:(1) To report minimum 2-year patient-reported outcome (PRO) scores and RTS characteristics for high-level athletes undergoing primary labral reconstruction for irreparable labral tears and (2) to compare clinical results with a matched control group of athletes undergoing labral repair.Study Design:Cohort study; Level of evidence, 3.Methods:Data were prospectively collected and retrospectively reviewed for high school, college, and professional athletes who underwent a primary arthroscopic labral reconstruction between January 2010 and June 2018. Minimum 2-year PROs were compared for the modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), and Hip Outcome Score–Sport Specific Subscale (HOS-SSS), as well as the visual analog scale (VAS) pain score, patient satisfaction, and RTS. The percentages of patients achieving the Patient Acceptable Symptom State (PASS) and minimal clinically important difference (MCID) for the mHHS (PASS,>74 points; MCID,>8 points) and HOS-SSS (PASS,>75 points; MCID,>6 points) were also recorded. These patients were propensity score matched in a 1:3 ratio to other high-level athletes undergoing labral repair.Results:A total of 17 high-level athletes with primary arthroscopic labral reconstruction were included with a median follow-up time of 37.1 months (95% CI, 37.2-60.3 months). They demonstrated significant improvement from preoperatively to the latest follow-up for mHHS, NAHS, HOS-SSS, and VAS for pain (P < .05). Further, patients achieved PASS/MCID for mHHS at high rates (PASS, 84.2%; MCID, 68.4%). Athletes were able to return to sport-specific training at a median of 3.33 months (95% CI, 3.07-4.71 months) and RTS at a median of 6.2 months (95% CI, 5.08-11.98 months). Fourteen (82.4%) of reconstructions and 29 (82.8%) of repairs either returned to sport or decided not to do so for reasons unrelated to the hip. PROs, RTS rate, and PASS/MCID rates were similar between the labral reconstruction group and a control labral repair group (P> .05).Conclusion:Primary arthroscopic labral reconstruction for irreparable labral tears was associated with significant improvement in PROs and high rates of RTS in high-level athletes. These results were comparable with those of a control group of athletes undergoing labral repair.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-09-01T03:15:19Z
      DOI: 10.1177/03635465211032593
       
  • Morphological Changes in the Residual Meniscus After Reshaping Surgery for
           a Discoid Lateral Meniscus

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      Authors: Kazuya Nishino, Yusuke Hashimoto, Syuko Tsumoto, Shinya Yamasaki, Hiroaki Nakamura
      First page: 3270
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Arthroscopic reshaping surgery is the first treatment option for a symptomatic discoid lateral meniscus (DLM) to preserve the peripheral rim. However, the degree of postoperative morphological change in the residual meniscus is unclear.Purpose/Hypothesis:The purpose of this study was to measure the meniscus after reshaping surgery for a DLM, to verify when the morphological change occurred, and to examine the related risk factors. The hypothesis was that the residual meniscal width would decrease throughout the postoperative course.Study Design:Case-control study; Level of evidence, 3.Methods:We retrospectively reviewed the medical records of patients who underwent reshaping surgery for a symptomatic DLM and had undergone follow-up for ≥2 years. Magnetic resonance imaging (MRI) was routinely performed preoperatively and at 3, 6, 12, and 24 months postoperatively, and the width, height, and extrusion of the residual meniscus were measured. According to the width of the midbody on final MRI scans, we compared the preoperative and postoperative data for the preserved group (≥5 mm) and decreased group (
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-08-20T03:58:34Z
      DOI: 10.1177/03635465211033586
       
  • Biomechanical Analysis of Segmental Medial Meniscal Transplantation in a
           Human Cadaveric Model

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      Authors: Daniel B. Haber, Brenton W. Douglass, Justin W. Arner, Jon W. Miles, Liam A. Peebles, Grant J. Dornan, Armando F. Vidal, CAPT Matthew T. Provencher
      First page: 3279
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Meniscal deficiency has been reported to increase contact pressures in the affected tibiofemoral joint, possibly leading to degenerative changes. Current surgical options include meniscal allograft transplantation and insertion of segmental meniscal scaffolds. Little is known about segmental meniscal allograft transplantation.Purpose:To evaluate the effectiveness of segmental medial meniscal allograft transplantation in the setting of partial medial meniscectomy in restoring native knee loading characteristics.Study Design:Controlled laboratory study.Methods:Ten fresh-frozen human cadaveric knees underwent central midbody medial meniscectomy and subsequent segmental medial meniscal allograft transplantation. Knees were loaded in a dynamic tensile testing machine to 1000 N for 20 seconds at 0°, 30°, 60°, and 90° of flexion. Four conditions were tested: (1) intact medial meniscus, (2) deficient medial meniscus, (3) segmental medial meniscal transplant fixed with 7 meniscocapsular sutures, and (4) segmental medial meniscal transplant fixed with 7 meniscocapsular sutures and 1 suture fixed through 2 bone tunnels. Submeniscal medial and lateral pressure-mapping sensors assessed mean contact pressure, peak contact pressure, mean contact area, and pressure mapping. Two-factor random-intercepts linear mixed effects models compared pressure and contact area measurements among experimental conditions.Results:The meniscal-deficient state demonstrated a significantly higher mean contact pressure than all other testing conditions (mean difference, ≥0.35 MPa; P < .001 for all comparisons) and a significantly smaller total contact area as compared with all other testing conditions (mean difference, ≤140 mm2; P < .001 for all comparisons). There were no significant differences in mean contact pressure or total contact area among the intact, transplant, or transplant-with-tunnel groups or in any outcome measure across all comparisons in the lateral compartment. No significant differences existed in center of pressure and relative pressure distribution across testing conditions.Conclusion:Segmental medial meniscal allograft transplantation restored the medial compartment mean contact pressure and mean contact area to values measured in the intact medial compartment.Clinical Relevance:Segmental medial meniscal transplantation may provide an alternative to full meniscal transplantation by addressing only the deficient portion of the meniscus with transplanted tissue. Additional work is required to validate long-term fixation strength and biologic integration.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-09-08T03:31:21Z
      DOI: 10.1177/03635465211036441
       
  • Platelet-Rich Plasma Augmentation of Meniscal Repair in the Setting of
           Anterior Cruciate Ligament Reconstruction

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      Authors: Lane Bailey, Matthew Weldon, Jacquelyn Kleihege, Kyle Lauck, Mohammad Syed, Randy Mascarenhas, Walter R. Lowe
      First page: 3287
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:The increasing incidence of anterior cruciate ligament (ACL) and meniscal injuries has led to strong interest in discovering new methods to enhance the biological healing response of these tissues. Platelet-rich plasma (PRP) contains various growth factors associated with a positive healing response, but few existing clinical studies are available to determine the risks and benefits of these therapies.Purpose:To determine the effects of intraoperative PRP on postoperative knee function and complications at 2 years after ACL reconstruction with meniscal repair.Study Design:Cohort study; Level of evidence, 3.Methods:A retrospective matched case-control study was conducted between 2013 and 2017 using a single surgeon database of 1014 patients undergoing primary ACL reconstruction with concomitant meniscal repair, resulting in 324 patients (162 PRP patients and 162 control patients) who met the study criteria. Patients were matched by age, sex, graft type, and meniscal injury. The Single Assessment Numeric Evaluation (SANE) was administered at 2 years, and injury surveillance was conducted. Secondary outcomes included the time to return to activity (months), self-reported knee function (International Knee Documentation Committee [IKDC] score), functional performance testing (knee range of motion, single-leg balance, single-leg hopping, agility testing), and postoperative complications (graft failure, infection, loss of motion [requiring repeat arthroscopy for lysis of adhesions], venous thrombosis, etc). Univariate models were used for between-group comparisons, and alpha was set at .05 for all analyses.Results:No differences were found in SANE knee function scores between the PRP and matched-control groups at 2 years (91.6 ± 11.2 vs 92.4 ± 10.6, respectively; P = .599). Additionally, no differences were reported between groups for self-reported function (IKDC score, 87.6 ± 13.3 vs 88.1 ± 12.6; P = .952), functional performance testing (P> .05), and timing of return to activity (7.8 ± 1.9 vs 8.0 ± 1.9 months; P = .765). The PRP group demonstrated a higher rate of postoperative knee motion loss compared with the control group (13.6% vs 4.6%; P < .001). No other differences were observed in postoperative complications (P> .05).Conclusion:The added use of intraoperative PRP did not improve self-reported knee function, functional performance, and timing of return to activity for patients undergoing ACL reconstruction with meniscal repair. Furthermore, the use of PRP may have negative consequences for regaining knee range of motion after surgery. On the basis of these data, surgeons should cautiously consider the application of PRP when planning surgery for intra-articular injuries of the knee.Registration:NCT03704376 (ClinicalTrials.gov identifier).
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-09-03T10:45:06Z
      DOI: 10.1177/03635465211036471
       
  • Kinematic Alterations After Anterior Cruciate Ligament Reconstruction via
           Transtibial Techniques With Medial Meniscal Repair Versus Partial Medial
           Meniscectomy

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      Authors: Ming Wang, Zefeng Lin, Wanshun Wang, Lingling Chen, Hong Xia, Yu Zhang, Wenhan Huang
      First page: 3293
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:The treatment strategies for meniscal injuries during anterior cruciate ligament (ACL) reconstruction remain a topic of debate.Hypothesis:After ACL reconstruction, knee kinematics would be affected by different medial meniscal treatment (partial medial meniscectomy [PMM] and medial meniscal repair [MMR]).Study Design:Controlled laboratory study.Methods:A total of 161 patients underwent primary single-bundle ACL reconstruction and simultaneous medial meniscal treatment. Of these, 32 patients were eligible to participate in the kinematic assessment at 24.8 ± 1.7 months after surgery. Patients were divided into 2 groups: (1) those who underwent MMR (Group MMR; n = 18) and (2) those who underwent PMM (Group PMM; n = 14). Twenty healthy participants (Group Intact) were recruited who were comparable in age, body mass index, and sex. The kinematic parameters were collected using an optical tracking system during treadmill gait. Range of motion and kinematic parameters at key events during the gait cycle were compared between the 3 groups. The primary outcomes were the differences in adduction/abduction and internal/external rotation.Results:Patients in Group PMM walked with increased adduction as compared with those in Group Intact during the early stance phase (P = .003; η2 = 0.172) and midstance phase (P = .003; η2 = 0.167). In terms of internal/external rotation, patients in Group PMM walked with significantly larger tibial external rotation when compared with Group MMR by approximately 3.4° to 3.7° (loading response: P = .026, η2 = 0.090; midstance: P = .035, η2 = 0.093) and Group Intact (P = .028; η2 = 0.095) in the early stance phase. In addition, there was significantly increased anterior tibial translation in Groups MMR and PMM compared with Group Intact.Conclusion:ACL reconstruction (via transtibial technique) with concurrent PMM demonstrated larger adduction and external tibial rotation at 24 months of follow-up during level walking.Clinical Relevance:Patients undergoing different medial meniscal treatment strategies in the presence of ACL reconstruction showed distinct knee kinematics. These results suggest that MMR is strongly recommended during ACL reconstructive surgery to reduce the abnormal kinematics close to that of the ACL-intact condition.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-08-24T04:20:10Z
      DOI: 10.1177/03635465211033982
       
  • Association Between Meniscal Allograft Tears and Early Surgical Meniscal
           Allograft Failure

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      Authors: Philipp W. Winkler, Nyaluma N. Wagala, Jonathan D. Hughes, James J. Irrgang, Freddie H. Fu, Volker Musahl
      First page: 3302
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Meniscal allograft transplantation (MAT) has become a viable treatment option for patients with symptomatic meniscal deficiency. Some patients experience early surgical meniscal allograft failure attributed to causes that have not yet been sufficiently clarified.Purpose:To evaluate the prevalence, types, and distribution of arthroscopically confirmed meniscal allograft tears and the associated effect on surgical meniscal allograft survival.Study Design:Cohort study; Level of evidence, 3.Methods:Patients undergoing MAT with a minimum 2-year follow-up were retrospectively reviewed. Descriptive and surgical data were collected. Type and location of arthroscopically confirmed meniscal allograft tears were recorded and compared between medial and lateral allografts and suture-only and bone block fixation. A survival analysis was conducted to evaluate the effect of meniscal allograft tears on surgical meniscal allograft survival.Results:This study included 142 patients (54% male; mean ± SD age, 29.6 ± 10.4 years) with a mean follow-up of 10.3 ± 7.5 years. The prevalence of meniscal allograft tears was 32%, observed at a median of 1.2 years (interquartile range, 2.8 years) after MAT. The posterior horns were most frequently affected, followed by the posterior roots, midbodies, anterior horns, and anterior roots. The most frequently observed tear types were root tears (43%), followed by longitudinal, horizontal, radial, complex, bucket-handle, and meniscocapsular separation tears. A statistically significant association was found between meniscal allograft tear types and fixation techniques (P = .027), with root tears predominant after suture-only as compared with bone block fixation (57% vs 22%). Patients with meniscal allograft root tears were a mean of 5.4 years (95% CI, 1.6-9.2 years; P = .007) younger than were patients without root tears. The 1-year surgical meniscal allograft survival rate was significantly lower for torn versus intact meniscal allografts (75% vs 99%; P < .001).Conclusion:Meniscal allograft root tears were predominant, associated with younger patient age, and more often observed when using the suture-only fixation technique versus the bone block fixation technique. Torn meniscal allografts were associated with early surgical graft failure when compared with intact meniscal allografts, resulting in a significantly lower 1-year survival rate.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-08-16T11:05:19Z
      DOI: 10.1177/03635465211032970
       
  • Familial Risk and Its Interaction With Body Mass Index and Physical
           Activity in Anterior Cruciate Ligament Injury Among First-Degree
           Relatives: A Population-Based Cohort Study

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      Authors: Hyeong Sik Ahn, Dae-Hee Lee, Sayada Zartasha Kazmi, Taeuk Kang, Young Sung Lee, Ryunsu Sung, Jaewoo Cha, Yoon Jung Choi, Gahwi Hong, Hoo Jae Hann, Hyun Jung Kim
      First page: 3312
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Genetic and behavioral risk factors have been suggested to play a role in anterior cruciate ligament (ACL) injury. However, population-based familial risk estimates are unavailable.Purpose:To quantify familial risk of ACL injury among first-degree relatives (FDRs) after controlling for certain behavioral risk factors. To estimate the combined effect of family history and body mass index (BMI) or physical activity on the risk of ACL injury.Study Design:Cohort study; Level of evidence, 3.Methods:Using nationwide data from the Korean National Health Insurance and National Health Screening Program databases on kinship, lifestyle habits, and anthropometrics, 5,184,603 individuals with blood-related FDRs were identified from 2002 to 2018. Familial risk of ACL injury, as represented as incidence risk ratios (IRRs) with 95% CIs, was analyzed using Cox proportional hazards models among individuals with versus without affected FDRs. Analyses were adjusted for age, sex, and behavioral risk factors. Interaction testing between familial history and BMI or physical activity was performed on an additive scale.Results:The risk of ACL injury was 1.79-fold higher (IRR, 1.79; 95% CI, 1.73-1.85) among individuals with versus without affected FDRs, and the incidence was 12.61 per 10,000 person-years. The IRR (95% CI) was highest with affected twins at 4.49 (3.01-6.69), followed by siblings at 2.31 (2.19-2.44), the father at 1.58 (1.49-1.68), and the mother at 1.52 (1.44-1.61). High BMI and high level of physical activity were significantly associated with the risk of ACL injury. Individuals with positive family history and either high BMI or physical activity had a 2.59- and 2.45-fold increased risk of injury as compared with the general population, respectively, and the combined risks exceeded the sum of their independent risks.Conclusion:Familial factors are risk factors for ACL injury with an additional contribution of 2 behavioral factors: BMI and physical activity level. A significant interaction was observed between family history of ACL injury and high BMI/level of physical activity.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-09-07T03:43:17Z
      DOI: 10.1177/03635465211032643
       
  • Effects of Pubertal Maturation on ACL Forces During a Landing Task in
           Females

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      Authors: Azadeh Nasseri, David G. Lloyd, Clare Minahan, Timothy A. Sayer, Kade Paterson, Christopher J. Vertullo, Adam L. Bryant, David J. Saxby
      First page: 3322
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Rates of anterior cruciate ligament (ACL) rupture in young people have increased by>70% over the past two decades. Adolescent and young adult females are at higher risk of ACL injury as compared with their prepubertal counterparts.Purpose:To determine ACL loading during a standardized drop-land-lateral jump in females at different stages of pubertal maturation.Study Design:Controlled laboratory study.Methods:On the basis of the Tanner classification system, 19 pre-, 19 early-/mid-, and 24 late-/postpubertal females performed a standardized drop-land-lateral jump while 3-dimensional body motion, ground-reaction forces, and surface electromyography data were acquired. These data were used to model external biomechanics, lower limb muscle forces, and knee contact forces, which were subsequently used in a validated computational model to estimate ACL loading. Statistical parametric mapping analysis of variance was used to compare ACL force and its causal contributors among the 3 pubertal maturation groups during stance phase of the task.Results:When compared with pre- and early-/midpubertal females, late-/postpubertal females had significantly higher ACL force with mean differences of 471 and 356 N during the first 30% and 48% to 85% of stance, and 343 and 274 N during the first 24% and 59% to 81% of stance, respectively, which overlapped peaks in ACL force. At the point of peak ACL force, contributions from sagittal and transverse plane loading mechanisms to ACL force were higher in late-/postpubertal compared with pre- and early-/midpubertal groups (medium effect sizes from 0.44 to 0.77). No differences were found between pre- and early-/midpubertal groups in ACL force or its contributors.Conclusion:The highest ACL forces were observed in late-/postpubertal females, consistent with recently reported rises of ACL injury rates in females aged 15 to 19 years. It is important to quantify ACL force and its contributors during dynamic tasks to advance our understanding of the loading mechanism and thereby provide guidance to injury prevention.Clinical Relevance:Growth of ACL volume plateaus around 10 years of age, before pubertal maturation, meaning that a late-/postpubertal female could have an ACL of similar size to their less mature counterparts. However, late-/postpubertal females have higher body mass requiring higher muscle forces to accelerate the body during dynamic tasks, which may increase ACL loading. Thus, if greater forces develop in these females, in part because of their increased body mass, these higher forces will be applied to an ACL that is not proportionally larger. This may partially explain the higher rates of ACL injury in late-/postpubertal females.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-09-08T03:08:17Z
      DOI: 10.1177/03635465211038332
       
  • Clinical Comparison of Medial Patellofemoral Ligament Reconstruction With
           or Without Tibial Tuberosity Transfer for Recurrent Patellar Instability

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      Authors: Jong-Min Kim, Jae-Ang Sim, HongYeol Yang, Young-Mo Kim, Joon-Ho Wang, Jong-Keun Seon
      First page: 3335
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:No clear guidelines or widespread consensus has defined a threshold value of tibial tuberosity–trochlear groove (TT-TG) distance for choosing the appropriate surgical procedures when additional tibial tuberosity osteotomy (TTO) should be added to augment medial patellofemoral ligament (MPFL) reconstruction for recurrent patellar instability.Purpose:To compare the clinical outcomes between MPFL reconstruction and MPFL reconstruction with TTO for patients who have patellar instability with a TT-TG distance of 15 to 25 mm.Study Design:Cohort study; Level of evidence, 3.Methods:We retrospectively analyzed 81 patients who underwent surgical treatment using either MPFL reconstruction or MPFL reconstruction with TTO for recurrent patellar instability with a TT-TG distance of 15 to 25 mm; the mean follow-up was 25.2 months (range, 12.0-53.0 months). The patients were divided into 2 groups: isolated MPFL reconstruction (iMPFL group; n = 36) performed by 2 surgeons and MPFL reconstruction with TTO (TTO group; n = 45) performed by another 2 surgeons. Clinical outcomes were assessed using the Kujala score, Knee injury and Osteoarthritis Outcome Score, and Tegner activity score. Radiological parameters, including patellar height, TT-TG distance, patellar tilt, and congruence angle were compared between the 2 groups. Functional failure based on clinical apprehension sign, repeat subluxation or dislocation, and subjective instability and complications was assessed at the final follow-up. We also compared clinical outcomes based on subgroups of preoperative TT-TG distance (15 mm ≤ TT-TG ≤ 20 mm vs 20 mm < TT-TG ≤ 25 mm).Results:All of the clinical outcome parameters significantly improved in both groups at the final follow-up (P < .001), with no significant differences between groups. The radiological parameters also showed no significant differences between the 2 groups. The incidence of functional failure was similar between the 2 groups (3 failures in the TTO group and 2 failures in the iMPFL group; P = .42). In the TTO group, 1 patient experienced a repeat dislocation postoperatively and 2 patients had subjective instability; in the iMPFL group, 2 patients had subjective instability. The prevalence of complications did not differ between the 2 groups (P = .410). In the subgroup analysis based on TT-TG distance, we did not note any differences in clinical outcomes between iMPFL and TTO groups in subgroups of 15 mm ≤ TT-TG ≤ 20 mm and 20 mm < TT-TG ≤ 25 mm.Conclusion:MPFL reconstruction with and without TTO provided similar, satisfactory clinical outcomes and low redislocation rates for patients who had patellar instability with a TT-TG distance of 15 to 25 mm, without statistical difference. Thus, our findings suggest that iMPFL reconstruction is a safe and reliable treatment for patients with recurrent patellar dislocation with a TT-TG distance of 15 to 25 mm, without the disadvantages derived from TTO.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-09-08T10:08:09Z
      DOI: 10.1177/03635465211037716
       
  • Dysplastic Patellofemoral Joints Lead to a Shift in Contact Forces: A
           3D-Printed Cadaveric Model

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      Authors: Robert C. Spang, Amirhossein Jahandar, Kathleen N. Meyers, Joseph T. Nguyen, Suzanne A. Maher, Sabrina M. Strickland
      First page: 3344
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:The distribution of contact forces across the dysplastic patellofemoral joint has not been adequately quantified because models cannot easily mimic the dysplasia of both the trochlea and the patella. Thus, the mechanical consequences of surgical treatments to correct dysplasia cannot be established.Purpose/Hypothesis:The objective of this study was to quantify the contact mechanics and kinematics of normal, mild, and severely dysplastic patellofemoral joints using synthetic mimics of the articulating surfaces on cadavers. We tested the hypothesis that severely dysplastic joints would result in significantly increased patellofemoral contact forces and abnormal kinematics.Study Design:Controlled laboratory study.Method:Patellofemoral dysplasia was simulated in 9 cadaveric knees by replacing the native patellar and trochlear surfaces with synthetic patellar and trochlear implants. For each knee, 3 synthetic surface geometries (normal, showing no signs of dysplasia; mild, exemplifying Dejour type A; and severe, exemplifying Dejour type B) were randomized for implantation and testing. Patellar kinematics and the sum of forces acting on the medial and lateral patellar facets were computed for each knee and for each condition at 10° increments from 0° to 70° of flexion.Results:A pronounced lateral shift in the weighted center of contact of the lateral facet occurred for severely dysplastic knees from 20° to 70° of flexion. Compared with normal geometries, lateral patellar facet forces exhibited a significant increase only with mild dysplasia from 50° to 70° of flexion and with severe dysplasia at 70° of flexion. No measurable differences in medial patellar facet mechanics or joint kinematics occurred.Conclusion:Our hypothesis was rejected: Severely dysplastic joints did not result in significantly increased patellofemoral contact forces and abnormal kinematics in our cadaveric simulation. Rather, severe dysplasia resulted in a pronounced lateral shift in contact forces across the lateral patellar facet, while changes in kinematics and the magnitude of contact forces were not significant.Clinical Relevance:Including dysplasia of both the patella and trochlea is required to fully capture the mechanics of this complex joint. The pronounced lateralization of contact force in severely dysplastic patellofemoral joints should be considered to avoid cartilage overload with surgical manipulation.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-08-20T03:44:32Z
      DOI: 10.1177/03635465211031427
       
  • Detection of Lateral Hinge Fractures After Medial Closing Wedge Distal
           Femoral Osteotomy: Computed Tomography Versus Plain Radiography

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      Authors: Kyung Wook Nha, Kun Woo Kim, Ji Hoon Bae, Ki-Mo Jang, Sang-Gyun Kim
      First page: 3350
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Limited evidence exists in the literature regarding the detection rates of lateral hinge fracture (LHF) on computed tomography (CT) after medial closing wedge distal femoral osteotomy (MCDFO). Moreover, the effect of LHF on bone healing after MCDFO remains unclear.Hypothesis:The detection rates of LHF after MCDFO would be higher on CT than on plain radiography. The incidence of problematic bone healing would be higher in the knees with LHF than in those without LHF.Study Design:Cohort study (diagnosis), Level of evidence, 3.Methods:Patients who underwent MCDFO between May 2009 and July 2019 were retrospectively evaluated. The presence of LHF was evaluated using immediate postoperative plain radiography and CT. The detection rates of LHF on plain radiography and CT were compared. The incidence of problematic bone healing (nonunion, delayed union, and loss of correction) was also compared between the knees with LHF and those without LHF.Results:A total of 55 knees of 43 patients (mean age, 37.7 ± 16.7 years) were included in the study. Although 33 LHFs were detected on CT, only 19 LHFs were detected on plain radiography. The detection rate of LHF was significantly higher on CT than on plain radiography (60% vs 34.5%; P = .008). At 1-year follow-up, 10 cases of problematic bone healing (1 nonunion, 4 delayed unions, and 5 losses of correction) were identified. The incidence of problematic bone healing was significantly higher in the knees with LHF than in those without LHF as shown on plain radiography (36.8% vs 8.3%; P = .001) and CT (30.3% vs 0%; P = .004).Conclusion:LHF can be detected better on CT than on plain radiography and has a negative effect on bone healing after MCDFO. For patients with LHF detected on either plain radiography or CT, careful rehabilitation with close follow-up is recommended.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-08-16T07:21:55Z
      DOI: 10.1177/03635465211031434
       
  • Early-Stage Primary Anti-inflammatory Therapy Enhances the Regenerative
           Efficacy of Platelet-Rich Plasma in a Rabbit Achilles Tendinopathy Model

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      Authors: Dengfeng Ruan, Yang Fei, Shengjun Qian, Zizhan Huang, Weishan Chen, Chenqi Tang, Xinyu Xiang, Jialu Xu, Zi Yin, Xiao Chen, Boon Chin Heng, Wanlu Liu, Weiliang Shen, Hongwei Ouyang
      First page: 3357
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Tendinopathy is a pervasive clinical problem that afflicts both athletes and the general public. Although the inflammatory changes in tendinopathy are well characterized, how the therapeutic effects of platelet-rich plasma (PRP) on tendinopathy are being modulated by the inflammatory environment is not well defined.Purpose/Hypothesis:In this study, we aimed to compare the therapeutic effects of PRP alone versus a combination of PRP with a primary glucocorticoid (GC) injection at the early stage of tendinopathy. We hypothesized that PRP treatment could promote better tendon regeneration through the suppression of inflammation with GC.Study Design:Controlled laboratory study.Methods:The gene expression profile of tendon stem/progenitor cells (TSPCs) cultured with PRP was analyzed with RNA sequencing. To evaluate the cell viability, senescence, and apoptosis of TSPCs under different conditions, TSPCs were treated with 0.1 mg/mL triamcinolone acetonide (TA) and/or 10% PRP in an IL1B–induced inflammatory environment. To further verify the effects of the sequential therapy of GCs and PRP, an early tendinopathy animal model was established through a local injection of collagenase in the rabbit Achilles tendon. The tendinopathy model was then treated with isopycnic normal saline (NS group), TA (TA group), PRP (PRP group), or TA and PRP successively (TA+PRP group). At 8 weeks after treatment, the tendons were assessed with magnetic resonance imaging (MRI), histological examination, transmission electron microscopy (TEM), and mechanical testing.Results:Gene Ontology enrichment analysis indicated that PRP treatment of TPSCs induced an inflammatory response, regulated cell migration, and remodeled the extracellular matrix. Compared with the sole use of PRP, successive treatment with TA followed by PRP yielded similar results in cell viability and senescence but less cell apoptosis in vitro. In vivo experiments demonstrated that the TA+PRP group achieved significantly better tendon regeneration, as confirmed by MRI, histological examination, TEM, and mechanical testing.Conclusion:This study showed that the primary use of GCs did not exert any obvious deleterious side effects on the treated tendon but instead enhanced the regenerative effects of PRP in early inflammatory tendinopathy.Clinical Relevance:The sequential therapy of GCs followed by PRP provides a promising treatment strategy for tendinopathy in clinical practice. PRP combined with the primary use of GCs appears to promote tendon regeneration in early inflammatory tendinopathy.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-09-22T09:39:29Z
      DOI: 10.1177/03635465211037354
       
  • State-Level Implementation of Health and Safety Policies to Prevent Sudden
           Death and Catastrophic Injuries Within High Schools: An Update

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      Authors: Samantha E. Scarneo-Miller, Christianne M. Eason, William M. Adams, Rebecca L. Stearns, Douglas J. Casa
      First page: 3372
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Mandated sports safety policies that incorporate evidence-based best practices have been shown to mitigate the risk of mortality and morbidity in sports. In 2017, a review of the state-level implementation of health and safety policies within high schools was released.Purpose:To provide an update on the assessment of the implementation of health and safety policies pertaining to the leading causes of death and catastrophic injuries in sports within high school athletics in the United States.Study Design:Cross-sectional study.Methods:A rubric composed of 5 equally weighted sections for sudden cardiac arrest, traumatic head injuries, exertional heatstroke, appropriate health care coverage, and emergency preparedness was utilized to assess an individual state’s policies. State high school athletic/activities association (SHSAA) policies, enacted legislation, and Department of Education policies were extensively reviewed for all 50 states and the District of Columbia between academic year (AY) 2016-2017 (AY16/17) and 2019-2020 (AY19/20). To meet the specific rubric criteria and be awarded credit, policies needed to be mandated by all SHSAA member schools. Weighted scores were tabulated to calculate an aggregate score with a minimum of 0 and a maximum of 100.Results:A total of 38 states had increased their rubric scores since AY16/17, with a mean increase of 5.57 ± 6.41 points. In AY19/20, scores ranged from 30.80 to 85.00 points compared with 23.00 to 78.75 points in AY16/17. Policies related to exertional heatstroke had the greatest change in scores (AY16/17 mean, 6.62 points; AY19/20 mean, 8.90 points; Δ = 2.28 points [11.40%]), followed by emergency preparedness (AY16/17 mean, 8.41 points; AY19/20 mean, 10.29 points; Δ = 1.88 points [9.40%]).Conclusion:A longitudinal review of state high school sports safety policies showed progress since AY16/17. A wide range in scores indicates that continued advocacy for the development and implementation of policies at the high school level is warranted.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-08-16T08:00:37Z
      DOI: 10.1177/03635465211031849
       
  • Prevalence and Burden of Self-Reported Health Problems in Junior Male
           Elite Ice Hockey Players: A 44-Week Prospective Cohort Study

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      Authors: Anine Nordstrøm, Roald Bahr, Ben Clarsen, Ove Talsnes
      First page: 3379
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Little is known about the burden of overuse injuries and illnesses in junior elite ice hockey.Purpose:To describe the prevalence and burden of all health problems in junior male elite ice hockey players in Norway during 1 school year.Study Design:Descriptive epidemiological study.Methods:A total of 206 junior male ice hockey players (mean age, 17 years; range, 15-20 years) attending specialized sports academy high schools in Norway reported all health problems, acute injuries, overuse injuries, and illnesses, weekly during the 2018-2019 school year (44 weeks). The players self-reported injuries and illnesses using the Oslo Sports Trauma Research Center Questionnaire on Health Problems.Results:Of the players included, 25% (95% CI, 23%-27%) reported at least 1 health problem at any given time, while 16% (95% CI, 14%-17%) experienced health problems with a substantial negative effect on training and performance. Of the total burden of health problems, acute injuries accounted for 44%, overuse injuries 31%, and illnesses 25%. For acute injuries, the greatest burden was caused by injuries to the ankle, knee, and hand, whereas for overuse injuries the most burdensome location was the hip/groin and knee.Conclusion:This study documented that while acute injuries did represent the greatest problem among junior elite ice hockey players, overuse injuries, especially to the knee and hip/groin, also had a substantial effect.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-08-16T10:52:24Z
      DOI: 10.1177/03635465211032979
       
  • Association of Pitch Timing and Throwing Arm Kinetics in High School and
           Professional Pitchers

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      Authors: Joseph E. Manzi, Brittany Dowling, Zhaorui Wang, Kyle N. Kunze, Jennifer Estrada, Michael C. Fu, Kathryn L. McElheny, James B. Carr, Joshua S. Dines
      First page: 3386
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Understanding the relationship between the temporal phases of the baseball pitch and subsequent joint loading may improve our understanding of optimal pitching mechanics and contribute to injury prevention in baseball pitchers.Purpose:To investigate the temporal phases of the pitching motion and their associations with ball velocity and throwing arm kinetics in high school (HS) and professional (PRO) baseball pitchers.Study Design:Descriptive laboratory study.Methods:PRO (n = 317) and HS (n = 54) baseball pitchers were evaluated throwing 8 to 12 fastball pitches using 3-dimensional motion capture (480 Hz). Four distinct phases of the pitching motion were evaluated based on timing of angular velocities: (1) Foot-Pelvis, (2) Pelvis-Torso, (3) Torso-Elbow, and (4) Elbow-Ball. Peak elbow varus torque, shoulder internal rotation torque, and shoulder distraction force were also calculated and compared between playing levels using 2-sample t tests. Linear mixed-effect models with compound symmetry covariance structures were used to correlate pitch velocity and throwing arm kinetics with the distinct temporal phases of the pitching motion.Results:PRO pitchers had greater weight and height, and faster ball velocities than HS pitchers (P < .001). There was no difference in total pitch time between groups (P = .670). PRO pitchers spent less time in the Foot-Pelvis (P = .010) and more time in the Pelvis-Torso (P < .001) phase comparatively. Shorter time spent in the earlier phases of the pitching motion was significantly associated with greater ball velocity for both PRO and HS pitchers (Foot-Pelvis: B = −6.4 and B = −11.06, respectively; Pelvis-Torso: B = −6.4 and B = −11.4, respectively), while also associated with increased shoulder proximal force (Pelvis-Torso: B = −76.4 and B = −77.5, respectively). Decreased time in the Elbow-Ball phase correlated with greater shoulder proximal force for both cohorts (B = −1150 and B = −645, respectively) with no significant correlation found for ball velocity.Conclusion:Significant differences in temporal phases exist between PRO and HS pitchers. For all pitchers, increased time spent in the final phase of the pitching motion has the potential to decrease shoulder distraction force with no significant loss in ball velocity.Clinical Relevance:Identifying risk factors for increased shoulder and elbow kinetics, acting as a surrogate for loading at the respective joints, has potential implications in injury prevention.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-08-18T03:45:10Z
      DOI: 10.1177/03635465211031853
       
  • Early Failure of a Polyvinyl Alcohol Hydrogel Implant With Osteolysis and
           Foreign Body Reactions in an Ovine Model of Cartilage Repair

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      Authors: Marta Cercone, Jacqueline Chevalier, John G. Kennedy, Andrew D. Miller, Lisa A. Fortier
      First page: 3395
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Hemiarthroplasty using a polyvinyl alcohol (PVA) hydrogel synthetic implant has been suggested as a good alternative to arthrodesis for the treatment of hallux rigidus. However, failure rates as high as 20% have been recorded.Purpose:To characterize the pathological processes in bone, cartilage, and the synovial membrane after PVA hemiarthroplasty in an ovine model with 6 months of follow-up.Study Design:Controlled laboratory study.Methods:A unilateral osteochondral defect (8-mm diameter × 10-mm depth) was made in the medial femoral condyle in 6 sheep. Animals were randomized to receive a PVA implant (n = 4) or to have an empty defect (n = 2) and were monitored for 6 months. Patellofemoral radiographs were obtained at monthly intervals, and quantitative computed tomography was performed at the end of the study. After death, the joints were macroscopically evaluated and scored. Osteochondral and synovial membrane histological findings were assessed using modified Osteoarthritis Research Society International (OARSI) and aseptic lymphocyte-dominated vasculitis-associated lesion (ALVAL) scoring systems. Immunohistochemistry using Iba1 was performed to evaluate activated macrophage infiltration.Results:Overall, 2 sheep with PVA implants were euthanized at 1 and 5 months because of uncontrollable pain and lameness (failed implants). Quantitative computed tomography showed that sheep with failed implants had 2.1-fold more osteolysis than those with successful implants. The sheep with failed implants had osteoarthritis with extensive glycosaminoglycan loss and cartilage fibrillation of the condyle and opposing tibial surface on histological examination. A foreign body reaction with severe chronic lymphoplasmacytic and granulomatous inflammation with giant cells was detected surrounding the implant. The synovial membrane ALVAL score was 9 of 19 and 14 of 19 in failed implants with synovial hyperplasia and lymphoplasmacytic and macrophage infiltration. In contrast, the synovial membrane in successful implants and empty defects was normal (ALVAL score = 0/19). Immunolabeling for Iba1 in failed implants confirmed extensive and dense macrophage infiltration within the condyle and synovial membrane, with the highest immunoreactive score (9/9).Conclusion:PVA hydrogel implants had a 50% failure rate with uncontrollable pain, severe osteolysis, inflammation, and foreign body reactions.Clinical Relevance:The failure rate and pathological characteristics of the PVA implants suggest that their use should not be continued in human patients without further in vivo safety studies.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-08-23T03:50:43Z
      DOI: 10.1177/03635465211033601
       
  • Colony Forming Potential and Protein Composition of Commercial Umbilical
           Cord Allograft Products in Comparison With Autologous Orthobiologics

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      Authors: Dustin R. Berger, Christopher J. Centeno, John D. Kisiday, C. Wayne McIlwraith, Neven J. Steinmetz
      First page: 3404
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Umbilical cord (UC) connective tissues contain plastic-adherent, colony forming unit–fibroblasts (CFU-Fs) amenable to culture expansion for potential therapeutic use. Recently, UC-derived allograft products have been made available to practitioners in orthopaedics and other specialties, by companies purporting “stem cell”–based healing. However, such marketing claims conflict with existing regulations for these human tissues, generating questions over the cellular and protein composition of current commercially available UC allograft products.Purpose:To evaluate commercial UC allograft products for viable cells, CFU-Fs, and protein makeup.Study Design:Descriptive laboratory study.Methods:Five commercial UC allograft products claiming to contain viable, undescribed “stem cells,” 2 obtained from UC blood (UCB) and 3 from UC tissue (UCT), were analyzed. Image-based methods were used to measure cell concentration and viability, a traditional CFU-F assay was used to evaluate in vitro behavior indicative of a connective tissue progenitor cell phenotype often referred to as mesenchymal stem/stromal cells, and quantitative immunoassay arrays were used to measure a combination of cytokines and growth factors. Bone marrow concentrate (BMC) and plasma derived from the blood and bone marrow of middle-aged individuals served as comparative controls for cell culture and protein analyses, respectively.Results:Viable cells were identified within all 5 UC allograft products, with those derived from UCB having greater percentages of living cells (40%-59%) than those from UCT (1%-22%). Compared with autologous BMC (>95% viability and>300 million living cells), no CFU-Fs were observed within any UC allograft product ( UCB) or inclusion of cells without colony forming potential (UCB> UCT).
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-08-16T06:32:26Z
      DOI: 10.1177/03635465211031275
       
  • Food and Drug Administration’s Position on Commonly Injected Biologic
           Materials in Orthopaedic Surgery

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      Authors: William H. Fang, C. Thomas Vangsness
      First page: 3414
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      The use of biologically based therapies is becoming a popular less-invasive therapy for relieving pain and promoting tissue regeneration. The most commonly used biologics are autologous adipose-derived products, bone marrow aspirations, and platelet-rich plasma (PRP). Birth tissue is a common allogenic source of biologics, including umbilical cord, placental membranes, and amniotic fluid. Injected biologics, depending on the indication and how they are processed, formulated, delivered, and promoted, can be subject to different regulatory pathways. The aim of this review is to provide an overview of these products and procedures and educate the musculoskeletal community about the relevant current Food and Drug Administration (FDA) regulations.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-03-26T05:28:44Z
      DOI: 10.1177/0363546521990900
       
  • Return to Play and Fracture Union After the Surgical Management of Jones
           Fractures in Athletes: A Systematic Review and Meta-analysis

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      Authors: Ahmed Khalil Attia, Tarek Taha, Geraldine Kong, Abduljabbar Alhammoud, Karim Mahmoud, Mark Myerson
      First page: 3422
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Proximal fifth metatarsal fractures are among the most common forefoot injuries in athletes. The management of this injury can be challenging because of delayed union and refractures. Intramedullary (IM) screw fixation rather than nonoperative management has been recommended in the athletic population.Purpose:To provide an updated summary of the return-to-play (RTP) rate and time to RTP after Jones fractures in athletes with regard to their management, whether operative or nonoperative, and to explore the union rate and time to union as well as the rate of complications such as refractures.Study Design:Meta-analysis.Methods:Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, 2 independent team members searched several databases including PubMed, MEDLINE, Embase, Google Scholar, Web of Science, Cochrane Library, and ClinicalTrials.gov through November 2019 to identify studies reporting on Jones fractures of the fifth metatarsal exclusively in athletes. The primary outcomes were the RTP rate and time to RTP, whereas the secondary outcomes were the number of games missed, time to union, and union rate as well as the rates of nonunion, delayed union, and refractures.Results:Of 168 studies identified, 22 studies were eligible for meta-analysis with a total of 646 Jones fractures. The overall RTP rate was 98.4% (95% CI, 97.3%-99.4%) in 626 of 646 Jones fractures. The RTP rate with IM screw fixation only was 98.8% (95% CI, 97.8%-99.7%), with other surgical fixation methods (plate, Minifix) was 98.4% (95% CI, 95.8%-100.0%), and with nonoperative management was 71.6% (95% CI, 45.6%-97.6%). There were 3 studies directly comparing RTP rates with surgical versus nonoperative management, which showed significant superiority in favor of surgery (odds ratio, 0.033 [95% CI, 0.005-0.215]; P < .001). The RTP rate according to type of sport was 99.0% (95% CI, 97.5%-100.0%) in football, 91.1% (95% CI, 82.2%-99.4%) in basketball, and 96.6% (95% CI, 92.6%-100.0%) in soccer. The overall time to RTP was 9.6 weeks (95% CI, 8.5-10.7 weeks). The time to RTP in the surgical group (IM screw fixation) was 9.6 weeks (95% CI, 8.3-10.9 weeks), which was significantly less than that in the nonoperative group of 13.1 weeks (95% CI, 8.2-18.0 weeks). The pooled union rate in the operative group (excluding refractures) was 97.3% (95% CI, 95.1%-99.4%), whereas the pooled union rate in the nonoperative group was 71.4% (95% CI, 49.1%-93.7%). The overall time to union was 9.1 weeks (95% CI, 7.7-10.4 weeks). The time to union with IM screw fixation (8.2 weeks [95% CI, 7.5-9.0 weeks]) was shorter than that with nonoperative treatment (13.7 weeks [95% CI, 12.7-14.6 weeks]). The rate of delayed union was 2.5% (95% CI, 1.2%-3.7%), and the overall refracture rate was 10.2% (95% CI, 5.9%-14.5%).Conclusion:The RTP rate and time to RTP after the surgical management of Jones fractures in athletes were excellent, regardless of the implant used and type of sport. IM screw fixation was superior to nonoperative management, as it led to a higher rate of RTP, shorter time to RTP, higher rate of union, shorter time to union, and improved functional outcomes. We recommend surgical fixation for all Jones fractures in athletes.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-03-19T09:48:23Z
      DOI: 10.1177/0363546521990020
       
  • The Statistical Fragility of Platelet-Rich Plasma in Rotator Cuff Surgery:
           A Systematic Review and Meta-analysis

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      Authors: Robert L. Parisien, Cooper Ehlers, Antonio Cusano, Paul Tornetta, Xinning Li, Dean Wang
      First page: 3437
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:The practice of evidence-based medicine relies on objective data to guide clinical decision-making with specific statistical thresholds conveying study significance.Purpose:To determine the utility of applying the fragility index (FI) and the fragility quotient (FQ) analysis to randomized controlled trials (RCTs) evaluating the utilization of platelet-rich plasma (PRP) in rotator cuff repairs (RCRs).Study Design:Systematic review and meta-analysis.Methods:RCTs pertaining to the utilization of PRP in surgical RCRs published in 13 peer-reviewed journals from 2000 to 2020 were evaluated. The FI was determined by manipulating each reported outcome event until a reversal of significance was appreciated. The associated FQ was determined by dividing the FI by the sample size.Results:Of the 9746 studies screened, 19 RCTs were ultimately included for analysis. The overall FI incorporating all 19 RCTs was only 4, suggesting that the reversal of only 4 events is required to change study significance. The associated FQ was determined as 0.092. Of the 43 outcome events reporting lost to follow-up data, 13 (30.2%) represented lost to follow-up>4.Conclusion:Our analysis suggests that RCTs evaluating PRP for surgical RCRs may lack statistical stability with only a few outcome events required to alter trial significance. Therefore, we recommend the reporting of an FI and an FQ in conjunction with P value analysis to carefully interpret the integrity of statistical stability in future comparative trials.Clinical Relevance:Clinical decisions are often informed by statistically significant results. Thus, a true understanding of the robustness of the statistical findings informing clinical decision-making is of critical importance.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-03-01T05:08:55Z
      DOI: 10.1177/0363546521989976
       
  • Incidence of Intraoperative and Postoperative Complications After
           Posterolateral Corner Reconstruction or Repair: A Systematic Review of the
           Current Literature

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      Authors: Bhargavi Maheshwer, Justin Drager, Nalin S. John, Brady T. Williams, Robert F. LaPrade, Jorge Chahla
      First page: 3443
      Abstract: The American Journal of Sports Medicine, Ahead of Print.
      Background:Posterolateral corner (PLC) injuries of the knee are being increasingly recognized and treated in current orthopaedic practice. While there are numerous systematic reviews evaluating the management and outcomes after PLC injuries, there are limited data investigating complications after PLC reconstruction or repair.Purpose:To systematically review the literature to determine the incidence of postoperative complications after the surgical treatment of PLC injury.Study Design:Systematic review; Level of evidence, 4.Methods:The Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed (2008-2019), Embase (2008-2019), and MEDLINE (2008-2019) were queried for literature reporting on PLC reconstruction or repair, with or without concomitant ligamentous or meniscal surgery. Data including type of surgery performed, concomitant procedures, and follow-up time were extracted. Complications recorded included intra- and postoperative complications.Results:After the intra- and postoperative complication data of 60 studies (1747 cases) were combined, surgical management of PLC injuries was associated with an intraoperative complication rate of 0.34% (range, 0%-2.8%) and a postoperative complication rate of 20% (range, 0%-51.2%). The most common postoperative complication was arthrofibrosis (range, 0%-20%). The overall infection rate was 1.3% (range, 0%-10%). Four cases of postoperative common peroneal nerve palsy were reported. Failure of reconstruction or repair was reported in 164 (9.4%) of all cases examined (range, 0%-37.1%).Conclusion:Although the intraoperative rate of complications during PLC reconstructions is low, postoperative complications rates of 20% can be expected, including arthrofibrosis, infection, and neurovascular injury. PLC structures repaired or reconstructed failed in 9.4% of the cases.
      Citation: The American Journal of Sports Medicine
      PubDate: 2021-01-27T05:27:58Z
      DOI: 10.1177/0363546520981697
       
 
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