American Journal of Sports Medicine

American Journal of Sports Medicine

A Tribute to Billy

31-07-2019 – Bruce Reider

Journal Article

Injury Surveillance in Major League Soccer: A 4-Year Comparison of Injury on Natural Grass Versus Artificial Turf Field

15-07-2019 – Sean P. Calloway,David M. Hardin,Matthew D. Crawford,J. Michael Hardin,Lawrence J. Lemak,Eric Giza,Brian Forsythe,Yining Lu,Bhavik H. Patel,Daryl C. Osbahr,Michael B. Gerhardt,Bert R. Mandelbaum,William W. Baldwin

Journal Article

Artificial playing surfaces are becoming more common due to decreased cost of maintenance and increased field usability across different environmental conditions. The Fédération Internationale de Football Association (FIFA) has approved newer generation artificial turf for soccer competition at the elite level, but many elite-level athletes prefer to play on natural grass surfaces due to a perceived increase in injury rate, discomfort, and fatigability on artificial turf. Injury rates and rates of individually categorized types of injury experienced on artificial turf are noninferior to rates of injury on the standard comparator, natural grass, in elite-level Major League Soccer athletes. Cohort study; Level of evidence, 2. Over the course of 4 Major League Soccer seasons (2013-2016), athlete injury data were recorded electronically. Injury data recorded in matches between 2 Major League Soccer teams were then analyzed. Playing surface was known for each venue, and all artificial turf surfaces were rated as 2-star according to FIFA criteria. Incidence rate ratios (Artificial Turf ÷ Natural Grass) were calculated with a 95% CI (α = .05) for both overall injury incidence and individual injury subgroups. A noninferiority margin (δ) of 0.15 was used to determine noninferiority of injury incidence rates. A total of 2174 in-game injuries were recorded during the study period, with 1.54 injuries per game on artificial turf and 1.49 injuries per game on natural grass (incidence rate ratio, 1.033; 95% CI, 0.937-1.139). Within injury subgroups, overall ankle injury, Achilles injury, and ankle fracture were found to have a statistically higher incidence on artificial turf. Artificial turf was found to be noninferior to natural grass for overall foot injury and forefoot injury. No statistically significant differences were found in knee injuries between the 2 surfaces. The overall rate of injury on artificial turf was noninferior to that on natural grass. Within individual injury categories, a higher rate of ankle injury was found on artificial turf. No other injury subgroup demonstrated statistically significant differences between surfaces. FIFA 2-star rated artificial turf is a viable alternative to natural grass in elite-level soccer competition. Innovative research methods for comparing artificial turf versus natural grass may elucidate relative advantages with respect to player safety.

Concussion in American Versus European Professional Soccer: A Decade-Long Comparative Analysis of Incidence, Return to Play, Performance, and Longevity

15-07-2019 – Prem N. Ramkumar,Sergio M. Navarro,Heather S. Haeberle,Bryan C. Luu,Albert Jang,Salvatore J. Frangiamore,Lutul D. Farrow,Mark S. Schickendantz,Riley J. Williams

Journal Article

The incidence and effect of sports-related concussions (SRCs) within the global sport of professional soccer is poorly described. To comparatively examine the effects of SRC on athletes in Major League Soccer (MLS) and the English Premier League (EPL) in terms of incidence, return to play (RTP), performance, and career longevity. Cohort study; Level of evidence, 3. Contracts, transactions, injury reports, and performance statistics from 2008 to 2017 were obtained and cross-referenced across 6 publicly available websites detailing MLS and EPL data, including official league publications. For each league, players who sustained a concussion were compared with the 2008-2017 uninjured player pool. RTP and games missed were analyzed and compared. Career length was analyzed with Kaplan-Meier survival curves. Player performance changes were evaluated before and after concussion. Of the 1784 eligible MLS and 2001 eligible EPL players evaluated over the 10-year period, the incidence of publicly reported concussions per 1000 athlete-exposures was 20.22 and 18.68, respectively ( This study established the SRC incidence among elite soccer players in 2 international professional leagues and identified major RTP and performance differences between EPL and MLS players. While career longevity was unaffected, the approach to managing concussion as in MLS may better promote player safety and preserve on-field performance.

Effect of a New Rule Limiting Full Contact Practice on the Incidence of Sport-Related Concussion in High School Football Players

15-07-2019 – Adam Y. Pfaller,M. Alison Brooks,Scott Hetzel,Timothy A. McGuine

Journal Article

Sport-related concussion (SRC) has been associated with cognitive impairment, depression, and chronic traumatic encephalopathy. American football is the most popular sport among males in the United States and has one of the highest concussion rates among high school sports. Measured head impacts and concussions are approximately 4 times more common in contact practices compared with noncontact practices. The Wisconsin Interscholastic Athletic Association passed new rules defining and limiting contact during practice before the 2014 football season. To determine if the SRC rate is lower after a rule change that limited the amount and duration of full-contact activities during high school football practice sessions. Cohort study; Level of evidence, 2. A total of 2081 high school football athletes enrolled and participated in the study in 2012-2013 (before the rule change), and 945 players participated in the study in 2014 (after the rule change). Players self-reported previous concussion and demographic information. Athletic trainers recorded athlete exposures (AEs), concussion incidence, and days lost for each SRC. Chi-square tests were used to compare the incidence of SRC in prerule 2012-2013 seasons with the incidence in the postrule 2014 season. Wilcoxon rank sum tests were used to determine differences in days lost because of SRC. A total of 67 players (7.1%) sustained 70 SRCs in 2014. The overall rate of SRC per 1000 AEs was 1.28 in 2014 as compared with 1.58 in 2012-2013 ( The rate of SRC sustained in high school football practice decreased by 57% after a rule change limiting the amount and duration of full-contact activities, with no change in competition concussion rate. Limitations on contact during high school football practice may be one effective measure to reduce the incidence of SRC.

Multiple Platelet-Rich Plasma Injections Versus Single Platelet-Rich Plasma Injection in Early Osteoarthritis of the Knee: An Experimental Study in a Guinea Pig Model of Early Knee Osteoarthritis

03-07-2019 – Devendra K. Chouhan,Mandeep S. Dhillon,Sandeep Patel,Tungish Bansal,Alka Bhatia,Himanshu Kanwat

Journal Article

Platelet-rich plasma (PRP) has emerged as the forerunner among disease-modifying treatment options for early osteoarthritis (OA) of the knee. However, no consensus is available regarding optimum dosing schedules. To determine whether multiple injections of PRP (3 injections) provide better short-term and long-term results than a single injection of PRP in a guinea pig model of knee OA. Controlled laboratory study. 36 Dunkin-Hartley guinea pigs (weighing ~600-800 g) were chosen for this study. The animals were assigned to group DC (disease control group), group G1 (single-PRP group), and group G2 (multiple-PRP group) containing 10, 10, and 12 animals, respectively. Another 4 animals were used for preparation of allogenic PRP. Groups G1 and G2 received 1 and 3 injections of PRP, respectively, at weekly intervals in the intervention knee while the contralateral knee was injected with normal saline. Group DC received no intervention in either knee. Half of the animals from each group (subgroups DC.3, G1.3, and G2.3) were sacrificed at 3 months, and the remaining half (subgroups DC.6, G1.6, and G2.6) were sacrificed at 6 months after intervention. Both knee joints were harvested for histological assessment of articular cartilage and synovium. The mean synovial scores for groups G1 and G2 were significantly better than those for group DC at 3 months. No difference was found between groups G1 and G2 at 3 months. At 6 months, group G2 had significantly better mean synovial scores than group G1 and group DC. The mean articular cartilage scores in group G2 were significantly better than those in group DC at 3 months. However, at 6 months, no significant difference was found among any of the groups in terms of mean articular scores. Both single and multiple injections of PRP exert similar anti-inflammatory effects on the synovium in the short term. However, this effect is sustained in the long term only for multiple injections. Multiple injections of PRP exert a chondroprotective effect, but only in the short term. This effect is not seen with a single injection of PRP. This study provides insight into the histological basis for the superiority of multiple injections of PRP.

The Use of Particulated Juvenile Allograft Cartilage for the Repair of Porcine Articular Cartilage Defects

27-06-2019 – Yunong Ao,Zhong Li,Qi You,Chengchang Zhang,Liu Yang,Xiaojun Duan

Journal Article

The repair of porcine articular cartilage defects by using particulated juvenile allograft cartilage (PJAC) has demonstrated good short-term clinical efficacy, but the repair process and mechanism have not been fully elucidated. To study the efficacy of PJAC in repairing full-thickness cartilage defects and to provide an experimental basis for its clinical application. Controlled laboratory study. Thirty Guizhou minipigs were randomly divided into an experimental group and control group. An 8-mm cylindrical full-thickness cartilage defect was created in the femoral trochlea of either knee in all minipigs. The experimental group received the PJAC transplantation (PJAC group; n = 15) and the control group received autologous cartilage chips (ACC group; n = 15). Five minipigs were euthanized at 1, 3, and 6 months in each group to obtain samples, which were evaluated by general view of the knee joint and histomorphometry of the chondral defect area (hematoxylin and eosin, safranin O). International Cartilage Repair Society (ICRS) II semiquantitative evaluation and collagen type II staining immunohistochemistry were also performed. All 30 Guizhou minipigs were followed; there was no infection or incision healing disorder after the operation. At 1 month postoperatively, more hyaline cartilage was found in the ACC group (29.4%) compared with the PJAC group (20.1%) ( Both PJAC and ACC can produce a good repair effect on cartilage defects. At 1 and 3 months postoperatively, ACC resulted in better outcomes than PJAC, but there was no statistical difference in the repair effect between the 2 techniques at 6 months postoperatively. Based on this animal experiment, further clinical studies are needed to investigate PJAC as a possible alternative first-line treatment for cartilage defects.

Aptamer-Functionalized Bioscaffold Enhances Cartilage Repair by Improving Stem Cell Recruitment in Osteochondral Defects of Rabbit Knees

24-06-2019 – Xin Wang,Xiongbo Song,Tao Li,Jiajia Chen,Guotao Cheng,Liu Yang,Cheng Chen

Journal Article

Recruitment of endogenous stem cells has been considered an alternative to cell injection/implantation in articular cartilage repair. (1) To develop a cartilage tissue-engineering scaffold with clinically available biomaterials and functionalize the scaffold with an aptamer (Apt19s) that specifically recognizes pluripotent stem cells. (2) To determine whether this scaffold could recruit joint-resident mesenchymal stem cells (MSCs) when implanted into an osteochondral defect in a rabbit model and to examine the effects of cartilage regeneration. Controlled laboratory study. The reinforced scaffold was fabricated by embedding a silk fibroin sponge into silk fibroin/hyaluronic acid-tyramine hydrogel and characterized in vitro. A cylindrical osteochondral defect (3.2 mm wide × 4 mm deep) was created in the trochlear grooves of rabbit knees. The rabbits were randomly assigned into 3 groups: Apt19s-functionalized scaffold group, scaffold-only group, and control group. Animals were sacrificed at 6 and 12 weeks after transplantation. Repaired tissues were evaluated via gross examination, histologic examination, and immunohistochemistry. In vitro, this aptamer-functionalized scaffold could recruit bone marrow-derived MSCs and support cell adhesion. In vivo, the aptamer-functionalized scaffold enhanced cell homing in comparison with the aptamer-free scaffold. The aptamer-functionalized scaffold group also exhibited superior cartilage restoration when compared with the scaffold-only group and the control group. The Apt19s-functionalized scaffold exhibited the ability to recruit MSCs both in vitro and in vivo and achieved a better outcome of cartilage repair than the scaffold only or control in an osteochondral defect model. The findings demonstrate a promising strategy of using aptamer-functionalized bioscaffolds for restoration of chondral/osteochondral defects via aptamer-introduced homing of MSCs.

Stem Cell–Conditioned Medium Promotes Graft Remodeling of Midsubstance and Intratunnel Incorporation After Anterior Cruciate Ligament Reconstruction in a Rat Model

15-07-2019 – Yaying Sun,Wenbo Chen,Yuefeng Hao,Xueping Gu,Xingwang Liu,Jiangyu Cai,Shaohua Liu,Jiwu Chen,Shiyi Chen

Journal Article

Stem cell-conditioned medium (CM) has been increasingly used in regenerative medicine. However, its effect on graft-host integration after anterior cruciate ligament (ACL) reconstruction (ACLR) remains unclear. To examine the effect of human bone marrow stem cell (h
BMSC)-CM on graft-bone integration and graft midsubstance ligamentization in a rat model of ACLR. Controlled laboratory study. CM was obtained from the supernatant of commercially available h
BMSCs in serum-free Dulbecco’s modified Eagle medium (DMEM). In a rat model of an ACL injury, isometric ACLR was performed. Three groups were established: CM injection group (CM; n = 40), control injection group (CI; n = 40) with serum-free DMEM injections, and no injection group (NI; n = 40). An intra-articular injection was performed weekly. Micro-computed tomography was conducted at 2, 4, and 8 weeks postoperatively. Histological and biomechanical analyses were conducted at 4 and 8 weeks postoperatively. The NIH3T3 fibroblast was utilized as a model in vitro to examine the effect of CM using the cell counting kit-8 (CCK-8) assay and immunofluorescence staining of Ki-67, α-smooth muscle actin (α-SMA), and collagen 1 (Col 1). At 4 and 8 weeks, the femoral and tibial bone tunnel areas as well as the interface between the graft and host bone were smaller, while the bone volume/total volume ratio was higher, in the CM group. Sharpey-like fibers formed at 8 weeks in the CM group. At 4 and 8 weeks, more Col 1 was noticed in the CM group than in the NI group (both h
BMSC-CM accelerates graft-bone incorporation and midsubstance ligamentization and enhances the proliferation, differentiation, and collagen synthesis of fibroblasts. Graft-host integration is essential after ACLR. The current study identified a novel agent, that is, h
BMSC-CM, as a candidate for promoting integration.

Transplantation of Aggregates of Autologous Synovial Mesenchymal Stem Cells for Treatment of Cartilage Defects in the Femoral Condyle and the Femoral Groove in Microminipigs

15-07-2019 – Shimpei Kondo,Yusuke Nakagawa,Mitsuru Mizuno,Kenta Katagiri,Kunikazu Tsuji,Shinji Kiuchi,Hideo Ono,Takeshi Muneta,Hideyuki Koga,Ichiro Sekiya

Journal Article

Previous work has demonstrated that patients with cartilage defects of the knee benefit from arthroscopic transplantation of autologous synovial mesenchymal stem cells (MSCs) in terms of magnetic resonance imaging (MRI), qualitative histologic findings, and Lysholm score. However, the effectiveness was limited by the number of cells obtained, so large-sized defects (>500 mm To investigate whether transplantation of aggregates of autologous synovial MSCs with 2-step surgery could promote articular cartilage regeneration in microminipig osteochondral defects. Controlled laboratory study. Synovial MSCs derived from a microminipig were examined for in vitro colony-forming and multidifferentiation abilities. An aggregate of 250,000 synovial MSCs was formed with hanging drop culture, and 16 aggregates (for each defect) were implanted on both osteochondral defects (6 × 6 × 1.5 mm) created in the medial femoral condyle and femoral groove (MSC group). The defects in the contralateral knee were left empty (control group). The knee joints were evaluated at 4 and 12 weeks by macroscopic findings and histology. MRI T1rho mapping images were acquired at 12 weeks. For cell tracking, synovial MSCs were labeled with ferucarbotran before aggregate formation and were observed with MRI at 1 week. Synovial MSCs showed in vitro colony-forming and multidifferentiation abilities. Regenerative cartilage formation was significantly better in the MSC group than in the control group, as indicated by International Cartilage Repair Society score (macro), modified Wakitani score (histology), and T1rho mapping (biochemical MRI) in the medial condyle at 12 weeks. Implanted cells, labeled with ferucarbotran, were observed in the osteochondral defects at 1 week with MRI. No significant difference was noted in the modified Wakitani score at 4 weeks in the medial condyle and at 4 and 12 weeks in the femoral groove. Transplantation of autologous synovial MSC aggregates promoted articular cartilage regeneration at the medial femoral condyle at 12 weeks in microminipigs. Aggregates of autologous synovial MSCs could expand the indications for cartilage repair with synovial MSCs.

Redifferentiated Chondrocytes in Fibrin Gel for the Repair of Articular Cartilage Lesions

02-07-2019 – Vanessa J. Bianchi,Adrienne Lee,Jesse Anderson,Justin Parreno,John Theodoropoulos,David Backstein,Rita Kandel

Journal Article

Autologous chondrocyte implantation, which uses passaged chondrocytes, commonly leads to the formation of fibrocartilage. When chondrocytes are passaged to increase cell numbers, they lose their phenotype and ability to form hyaline cartilage. The use of transforming growth factor β (TGFβ) to redifferentiate passaged chondrocytes has been validated in vitro; however, it is unknown if redifferentiated chondrocytes will enhance defect repair when implanted in vivo. Furthermore, fibrin gel is used in orthopaedic surgery as a fixative and scaffold and could be an appropriate carrier to enhance retention of cells in the repair site. To investigate if passaged redifferentiated chondrocytes in fibrin gel have the ability to form cartilage tissue and if these redifferentiated cells will enhance the formation of hyaline cartilage in vivo when implanted into critical-size osteochondral defects. Controlled laboratory study. Rabbit and human chondrocytes were serially passaged twice in monolayer culture. Twice-passaged cells were used directly (dedifferentiated) or redifferentiated in high-density culture with TGFβ3. Dedifferentiated or redifferentiated cells were mixed with fibrin gel to form fibrin clots, which were cultured in vitro to assess the use of fibrin gel as a scaffold or implanted in vivo in a critical-size osteochondral defect in New Zealand White rabbit knee joints. Rabbits were sacrificed 6 weeks after implantation, and tissues were assessed histologically and by immunohistochemistry. Redifferentiation of passaged chondrocytes by means of 3-dimensional culture in the presence of TGFβ3 improved the formation of cartilaginous tissues in vitro, and culture in fibrin gel did not affect the cell phenotype. Implantation of dedifferentiated cells in vivo resulted in fibrocartilaginous repair tissues. Redifferentiated chondrocyte implants resulted in granulation tissues containing the hyaline cartilage marker collagen type 2. Redifferentiated chondrocytes will maintain their chondrogenic differentiation in fibrin clots. Implanted redifferentiated chondrocytes show a different reparative response than dedifferentiated chondrocytes and do not appear to enhance repair at an early time point. Another study of longer duration is required to assess tissue maturation over time. Redifferentiation of passaged chondrocytes with TGFβ3 before implantation does not improve defect repair in the first 6 weeks.

Epidemiology and Video Analysis of Achilles Tendon Ruptures in the National Basketball Association

03-07-2019 – Nicholas J. Lemme,Neill Y. Li,Justin E. Kleiner,Sydney Tan,Steven F. DeFroda,Brett D. Owens

Journal Article

There is a paucity of literature regarding risk factors and mechanisms of Achilles tendon (AT) ruptures in the National Basketball Association (NBA). To identify the risk factors and outcomes of AT ruptures in NBA athletes. Furthermore, using video analysis, to characterize the mechanisms of rupture by identifying the most common playing situations and lower extremity positions at the time of injury. Descriptive epidemiology study. AT ruptures in the NBA that occurred between the seasons of 1969-1970 and 2017-2018 were identified. Player data collected included age, position, body mass index, total games started before and after injury, and Player Efficiency Rating. Injury-related variables collected included date of injury, laterality, minutes played before injury, operative versus nonoperative treatment, and time to return to play. Available video footage was analyzed for the mechanism and body position at the time of injury. Univariable and multivariable linear regression was used to compare changes in performance before and after AT rupture. Statistical significance was set at Forty-four ruptures were identified between 1970 and 2018. The mean age was 28.3 years, with players averaging 6.8 seasons before AT rupture. AT ruptures were most prevalent during early-season game play (27.3%), followed by preseason (18.2%) and late season (18.2%). More than a third (36.8%) of players either did not return to play or started in fewer than 10 games in the remainder of their career, with 21% of ruptures leading to retirement. The mean time to return to play was 10.5 months. The Player Efficiency Rating declined by an average of 2.9 points (range, -11.5 to +2.3) ( In the NBA, a majority of AT ruptures occur early in the season, in veteran players, with almost half not returning to play or starting fewer than 10 games in the remainder of their career. The most common mechanism of injury is taking off from a stopped position just before toe-off in a dorsiflexed foot.

Osteochondral Autologous Transplantation Versus Dorsal Closing Wedge Metatarsal Osteotomy for the Treatment of Freiberg Infraction in Athletes: A Randomized Controlled Study With 3-Year Follow-up

12-07-2019 – Dimitrios Georgiannos,Kostas Tsikopoulos,Dimitrios Kitridis,Panagiotis Givisis,Ilias Bisbinas

Journal Article

Dorsiflexion closing wedge metatarsal osteotomy (DCWMO) has been considered the traditional treatment of Freiberg disease. Several case reports presented osteochondral autologous transplantation (OAT) as an alternative treatment. The purpose was to compare the results of DCWMO versus OAT for the treatment of Freiberg infraction in an athletic population. It was hypothesized that OAT was superior to DCWMO regarding functional outcomes, pain, and the time that the athletes returned to training and to previous sport level. Randomized controlled trial; Level of evidence, 2. Between 2008 and 2013, 27 consecutive patients with Freiberg disease were randomly assigned to either the DCWMO group (14 patients) or the OAT group (13 patients). The primary outcomes collected were as follows: postoperative complications, range of motion of the metatarsophalangeal joint, length of the metatarsal, function of the foot (measured with the American Orthopaedic Foot and Ankle Society-lesser metatarsophalangeal-interphalangeal [AOFAS-LMI] score), and pain (assessed with the visual analog scale-foot and ankle score). Mean follow-up was 46 months (range, 36-60 months). The mean ± SD AOFAS-LMI score in the DCWMO group was 63.4 ± 14.4 preoperatively, 81.8 ± 6.6 at 1 year postoperatively, and 84.4 ± 5.6 at 3 years postoperatively, while in the OAT group, it was 62.8 ± 14, 89.9 ± 7.1, and 92 ± 6.9, respectively ( The authors concluded that OAT is equal to DCWMO. Acceptable clinical results were reported, as well as very low morbidity and early return to sport activities. That makes the OAT procedure a safe, effective, and optimal treatment for an athletic population experiencing Freiberg infraction.

Quantitative Magnetic Resonance Imaging Analysis of the Common Site of Acute Achilles Tendon Rupture: 5 to 8 cm Above the Distal End of the Calcaneal Insertion

09-07-2019 – Young Hwan Park,Jung Wook Lim,Gi Won Choi,Hak Jun Kim

Journal Article

Previous studies have not quantitatively analyzed the site of acute Achilles tendon rupture. To investigate the site of acute Achilles tendon rupture via magnetic resonance imaging (MRI). Cross-sectional study; Level of evidence, 4. The medical records and MRIs of 195 patients with acute Achilles tendon rupture were retrospectively reviewed. The rupture site was measured as the distance from the most distal fibers of the Achilles tendon at the calcaneal insertion to the proximal end of the distal stump. The relationship between the site of rupture and patient characteristics was analyzed, and the intra- and interobserver reliability of the measurements was assessed using intraclass correlation coefficients. The rupture site had a mean distance of 6.4 cm (SD, 1.5) and the 10th to 90th percentile range was 5.0 to 8.4 cm. There was no significant difference in location of the rupture according to patient characteristics and the time of imaging. The intra- and interobserver reliability of measurements was excellent. Most acute Achilles tendon ruptures visible on MRI occurred 5 to 8 cm above the distal end of the calcaneal insertion, which is more proximal than the previously reported 2 to 6 cm location.

Lower Signal Intensity of the Anterior Talofibular Ligament is Associated with a Higher Rate of Return to Sport After ATFL Repair for Chronic Lateral Ankle Instability

27-06-2019 – Hong Li,Yinghui Hua,Sijia Feng,Hongyun Li,Shiyi Chen

Journal Article

The treatment strategy for anterior talofibular ligament (ATFL) injury is usually determined by the ATFL remnant condition during surgery. Preoperative magnetic resonance imaging (MRI)-based signal intensity of the ATFL remnant, represented by the signal/noise ratio (SNR) value, can reveal the ATFL remnant condition. Thus far, there is a lack of evidence regarding the relationship between the ATFL remnant condition and functional outcomes. The purpose was to quantitatively evaluate whether the MRI-based ATFL ligament SNR value is related to functional outcomes after ATFL repair for ankles with chronic lateral ankle instability. The hypothesis was that a lower preoperative SNR is related to a better clinical outcome, particularly a higher rate of return to sport. Cohort study; Level of evidence, 3. First, a preliminary study was performed to measure the ATFL SNR in preoperative MRI, the results of which suggested that a preoperative SNR >10.4 was indicative of a poor ATFL condition. Then, a cohort study was retrospectively performed with consecutive patients who underwent open repair of ATFL injuries between January 2009 and August 2014. Accordingly, the patients were divided into 2 groups: high SNR (HSNR; ≥10.4) and low SNR (LSNR; <10.4). Functional outcomes based on the American Orthopaedic Foot and Ankle Society (AOFAS) score, Karlsson Ankle Functional Score (KAFS), and Tegner Activity Scale were then compared between the HSNR group and the LSNR group. Ultimately, 70 patients were available for the final follow-up: 37 in the HSNR group and 33 in the LSNR group. No significant difference was detected between the HSNR group and the LSNR group in terms of the AOFAS score, KAFS, or Tegner Activity Scale ( A lower signal intensity in the ATFL ligament based on preoperative MRI is associated with a better clinical outcome, particularly a higher rate of return to sport.

A Randomized Controlled Trial of PEEK Versus Titanium Interference Screws for Anterior Cruciate Ligament Reconstruction With 2-Year Follow-up

15-07-2019 – Sarah Shumborski,Emma Heath,Lucy J. Salmon,Justin P. Roe,James P. Linklater,Michael Facek,Leo A. Pinczewski

Journal Article

Graft fixation with interference screws for anterior cruciate ligament (ACL) reconstruction is a highly successful technique. Polyether ether ketone (PEEK) is a novel thermoplastic polymer with high biocompatibility and mechanical properties that mimic native bone, and it can be imaged on computed tomography or magnetic resonance imaging (MRI) without signal flare. To compare the clinical performance of ACL reconstruction with PEEK and titanium interference screws at 2 years and to evaluate a novel method of measuring tunnel volume. Randomized controlled trial; Level of evidence, 1. A total of 133 patients underwent arthroscopic ACL reconstruction with 4-strand hamstring autografts and were randomized to have titanium or PEEK interference screws for femoral and tibial tunnel fixation. At 2 years, subjective Lysholm and International Knee Documentation Committee scores were assessed and clinical examination performed. At 12 months, MRI was performed to assess graft incorporation and cyst formation, and a novel technique was employed to measure tunnel volumes. There were no significant differences in graft rerupture rate, contralateral ACL rupture rate, subjective outcomes, or objective outcomes. In the titanium and PEEK groups, MRI demonstrated high overall rates of graft integration (96%-100% and 90%-93%, respectively) and ligamentization (89% and 84%) and low rates of synovitis (22% and 10%) and cyst formation (0%-18% and 13%-15%). There was a higher proportion of patients with incomplete graft integration within the femoral tunnel in the PEEK group as compared with the titanium group (10% vs 0%, Two-year clinical analysis of PEEK interference screws for femoral and tibial fixation of ACL reconstructions showed equivalent clinical performance to titanium interference screws. Given the excellent mechanical characteristics, biological compatibility, and absence of metal artifact on MRI, PEEK has become our material of choice for interference screw fixation in ACL reconstruction.

Predictors of Patient-Reported Outcomes at 2 Years After Revision Anterior Cruciate Ligament Reconstruction

18-07-2019 – Rick W. Wright,Laura J. Huston,Amanda K. Haas,Christina R. Allen,Allen F. Anderson,Daniel E. Cooper,Thomas M. DeBerardino,Warren R. Dunn,Brett (Brick) A. Lantz,Barton Mann,Kurt P. Spindler,Michael J. Stuart,Samuel K. Nwosu,John P. Albright,Annunziato (Ned) Amendola,Jack T. Andrish,Christopher C. Annunziata,Robert A. Arciero,Bernard R. Bach,Champ L. Baker,Arthur R. Bartolozzi,Keith M. Baumgarten,Jeffery R. Bechler,Jeffrey H. Berg,Geoffrey A. Bernas,Stephen F. Brockmeier,Robert H. Brophy,Charles A. Bush-Joseph,J. Brad Butler V,John D. Campbell,James L. Carey,James E. Carpenter,Brian J. Cole,Jonathan M. Cooper,Charles L. Cox,R. Alexander Creighton,Diane L. Dahm,Tal S. David,David C. Flanigan,Robert W. Frederick,Theodore J. Ganley,Elizabeth A. Garofoli,Charles J. Gatt,Steven R. Gecha,James Robert Giffin,Sharon L. Hame,Jo A. Hannafin,Christopher D. Harner,Norman Lindsay Harris,Keith S. Hechtman,Elliott B. Hershman,Rudolf G. Hoellrich,Timothy M. Hosea,David C. Johnson,Timothy S. Johnson,Morgan H. Jones,Christopher C. Kaeding,Ganesh V. Kamath,Thomas E. Klootwyk,Bruce A. Levy,C. Benjamin Ma,G. Peter Maiers,Robert G. Marx,Matthew J. Matava,Gregory M. Mathien,David R. McAllister,Eric C. McCarty,Robert G. McCormack,Bruce S. Miller,Carl W. Nissen,Daniel F. O’Neill,Brett D. Owens,Richard D. Parker,Mark L. Purnell,Arun J. Ramappa,Michael A. Rauh,Arthur C. Rettig,Jon K. Sekiya,Kevin G. Shea,Orrin H. Sherman,James R. Slauterbeck,Matthew V. Smith,Jeffrey T. Spang,LTC Steven J. Svoboda,Timothy N. Taft,Joachim J. Tenuta,Edwin M. Tingstad,Armando F. Vidal,Darius G. Viskontas,Richard A. White,James S. Williams,Michelle L. Wolcott,Brian R. Wolf,James J. York

Journal Article

Patient-reported outcomes (PROs) are a valid measure of results after revision anterior cruciate ligament (ACL) reconstruction. Revision ACL reconstruction has been documented to have worse outcomes when compared with primary ACL reconstruction. Understanding positive and negative predictors of PROs will allow surgeons to modify and potentially improve outcome for patients. The purpose was to describe PROs after revision ACL reconstruction and test the hypothesis that patient- and technique-specific variables are associated with these outcomes. Cohort study; Level of evidence, 2. Patients undergoing revision ACL reconstruction were identified and prospectively enrolled by 83 surgeons over 52 sites. Data included baseline demographics, surgical technique and pathology, and a series of validated PRO instruments: International Knee Documentation Committee (IKDC), Knee injury and Osteoarthritis Outcome Score (KOOS), Western Ontario and Mc
Master Universities Osteoarthritis Index, and Marx Activity Rating Scale. Patients were followed up at 2 years and asked to complete the identical set of outcome instruments. Multivariate regression models were used to control for a variety of demographic and surgical factors to determine the positive and negative predictors of PRO scores at 2 years after revision surgery. A total of 1205 patients met the inclusion criteria and were successfully enrolled: 697 (58%) were male, with a median cohort age of 26 years. The median time since their most recent previous ACL reconstruction was 3.4 years. Two-year questionnaire follow-up was obtained from 989 patients (82%). The most significant positive predictors of 2-year IKDC scores were a high baseline IKDC score, high baseline Marx activity level, male sex, and having a longer time since the most recent previous ACL reconstruction, while negative predictors included having a lateral meniscectomy before the revision ACL reconstruction or having grade 3/4 chondrosis in either the trochlear groove or the medial tibial plateau at the time of the revision surgery. For KOOS, having a high baseline score and having a longer time between the most recent previous ACL reconstruction and revision surgery were significant positive predictors for having a better (ie, higher) 2-year KOOS, while having a lateral meniscectomy before the revision ACL reconstruction was a consistent predictor for having a significantly worse (ie, lower) 2-year KOOS. Statistically significant positive predictors for 2-year Marx activity levels included higher baseline Marx activity levels, younger age, male sex, and being a nonsmoker. Negative 2-year activity level predictors included having an allograft or a biologic enhancement at the time of revision surgery. PROs after revision ACL reconstruction are associated with a variety of patient- and surgeon-related variables. Understanding positive and negative predictors of PROs will allow surgeons to guide patient expectations as well as potentially improve outcomes.

Complex Tears, Extrusion, and Larger Excision Are Prognostic Factors for Worse Outcomes 1 and 2 Years After Arthroscopic Partial Meniscectomy for Degenerative Meniscal Tears: A Secondary Explorative Study of the Surgically Treated Group From the Odense-Oslo Meniscectomy Versus Exercise (OMEX) Trial

12-07-2019 – Nina Jullum Kise,Cathrine Aga,Lars Engebretsen,Ewa M. Roos,Rana Tariq,May Arna Risberg

Journal Article

Few studies have examined morphological findings from preoperative magnetic resonance imaging (MRI) and arthroscopic findings as prognostic factors for outcomes 1 and 2 years after arthroscopic partial meniscectomy (APM). The purpose was to evaluate prognostic factors of preoperative findings from MRI and arthroscopic evaluation on lower extremity performance at 1 year and patient-reported outcomes at 1 to 2 years after APM. The hypothesis was that medial compartment abnormalities would be prognostic for 1- and 2-year functional outcomes. Cohort study; Level of evidence, 2. This secondary analysis from the OMEX (Odense-Oslo Meniscectomy Versus Exercise) trial included 40 patients treated surgically. Regression analyses with adjustments for age, sex, and body mass index explored associations between MRI findings (tear complexity and extrusion), arthroscopic findings (tear length, cartilage injury, and amount of excised meniscal tissue), and the following: lower extremity performance tests and thigh muscle strength at 1 year and the 5 Knee injury and Osteoarthritis Outcome Score (KOOS) subscales at 1 and 2 years. A complex meniscal tear was a significant and clinically relevant prognostic factor for worse KOOS Symptoms subscores at 2 years (mean, 14.1 points [95% CI, 6.1-22.2]). Meniscal extrusion of at least 11%, 25%, and 20% were significant and clinically relevant prognostic factors for worse KOOS Activities of Daily Living (ADL) subscores at 1 year and worse KOOS Sports and Recreation (Sports/Rec) subscores at 1 and 2 years, respectively. Tear lengths of at least 7.0 mm, 6.7 mm, and 6.5 mm were significant and clinically relevant prognostic factors for better KOOS Symptoms subscores at 1 year and better KOOS Sports/Rec subscores at 1 and 2 years, respectively. A cartilage injury in the medial compartment was a significant and clinically relevant prognostic factor for worse KOOS ADL and Quality of Life (QoL) subscores at 2 years (mean, 10.4 and 19.4 points, respectively [95% CI, 3.4-17.4 and 7.7-31.1, respectively]). More than 20% meniscal tissue excised was a significant and clinically relevant prognostic factor for worse KOOS Pain, Symptoms, ADL, and Sports/Rec subscores at 1 and 2 years (mean, 8.9-41.5 points [95% CI, 2.2-15.5 to 21.0-62.0]) and worse KOOS QoL subscores at 2 years (mean, 25.3 points [95% CI, 13.6-37.0]). Complex meniscal tears, larger extrusion, cartilage injuries, and larger meniscal excision were significant and clinically relevant prognostic factors for worse outcomes 1 and 2 years after APM. NCT01002794 (Clinical identifier).

Outcomes and Patient Satisfaction With Arthroscopic Partial Meniscectomy for Degenerative and Traumatic Tears in Middle-Aged Patients With No or Mild Osteoarthritis

28-06-2019 – Alejandro Lizaur-Utrilla,Francisco A. Miralles-Muñoz,Santiago Gonzalez-Parreño,Fernando A. Lopez-Prats

Journal Article

There is controversy about the benefit of arthroscopic partial meniscectomy (APM) for degenerative lesions in middle-aged patients. To compare satisfaction with APM between middle-aged patients with no or mild knee osteoarthritis (OA) and a degenerative meniscal tear and those with a traumatic tear. Cohort study; Level of evidence, 2. A comparative prospective study at 5 years of middle-aged patients (45-60 years old) with no or mild OA undergoing APM for degenerative (n = 115) or traumatic (n = 143) tears was conducted. Patient satisfaction was measured by a 5-point Likert scale and functional outcomes by the Knee injury and Osteoarthritis Outcome Score (KOOS) and Western Ontario and Mc
Master Universities Osteoarthritis Index (WOMAC). Univariate and multivariate regression analyses were used to identify factors correlating with patient-reported satisfaction at 5 years postoperatively. Baseline patient characteristics were not different between groups. At the 5-year evaluation, the satisfaction rate in the traumatic and degenerative groups was 68.5% versus 71.3%, respectively ( There were no meaningful differences in patient satisfaction or clinical outcomes between patients with traumatic and degenerative tears and no or mild OA. Predictors of dissatisfaction with APM were female sex, obesity, and lateral meniscal tears. Our findings suggested that APM was an effective medium-term option to relieve pain and recover function in middle-aged patients with degenerative meniscal tears, without obvious OA, and with failed prior physical therapy.

Introducing the Lateral Femoral Condyle Index as a Risk Factor for Anterior Cruciate Ligament Injury

11-07-2019 – Sandro Hodel,Method Kabelitz,Timo Tondelli,Lazaros Vlachopoulos,Reto Sutter,Sandro F. Fucentese

Journal Article

The asymmetry of the medial and lateral knee compartments contributes significantly to femorotibial biomechanics and pivoting, and it is reported to be a relevant risk factor for an anterior cruciate ligament (ACL) injury. (1) To assess the role of femoral condyle sphericity as a risk factor for an ACL rupture and rerupture. (2) To compare the new risk factor with existing bony morphological risk factors via magnetic resonance imaging (MRI) and to assess the most predictive risk factor for an ACL rupture. Cohort study; Level of evidence, 3. A retrospective case-control study of 60 patients was conducted. Three age- and sex-matched cohorts (each n = 20) were analyzed: ACL reruptures, primary ACL ruptures, and a control group consisting of isolated meniscal tears or patients with anterior knee pain without signs of trochlear dysplasia. The lateral femoral condyle index (LFCI) as a novel MRI measurement was developed to quantify femoral sphericity. In addition, previously known MRI risk factors associated with ACL injury were analyzed (notch width index, medial tibial slope, lateral tibial slope, medial tibial depth, and lateral tibial height). Differences among groups were compared; cutoff values were defined; and diagnostic performance of the risk factors was assessed. The risk factors were subsequently analyzed with multiple logistic regression. The LFCI was significantly smaller in knees with ACL reruptures (median, 0.67; range, 0.59-0.75) and primary ACL ruptures (0.67; range, 0.60-0.75) than in the control group (0.76; range, 0.6-0.81; A decreased LFCI is associated with an ACL injury. The LFCI, lateral tibial height, and lateral tibial slope are the most predictive risk factors for an ACL injury. These findings might aid clinicians in identifying patients at risk for an ACL injury and inform the patient after reconstruction for a higher risk of rerupture.

Lateral Meniscal Allograft Transplantation With Bone Block and Suture-Only Techniques Partially Restores Knee Kinematics and Forces

28-06-2019 – João V. Novaretti,Jayson Lian,Andrew J. Sheean,Calvin K. Chan,Joon H. Wang,Moises Cohen,Richard E. Debski,Volker Musahl

Journal Article

The ability of lateral meniscal allograft transplantation (MAT) to improve knee stability and the meniscal load-bearing function in patients after meniscectomy is critical for surgical success. To compare the effects of 2 lateral MAT fixation techniques-bone block and suture only-on knee kinematics and forces. Controlled laboratory study. With a robotic testing system, loads were applied during flexion on 10 fresh-frozen cadaveric knees: 134-N anterior tibial load + 200-N axial compression, 5-N·m internal tibial + 5-N·m valgus torques, and 5-N·m external tibial + 5-N·m valgus torques. Kinematic data were recorded for 4 knee states: intact, total lateral meniscectomy, lateral MAT bone block, and lateral MAT suture-only fixation. In situ force in the anterior cruciate ligament and resultant forces in the lateral meniscus and in the meniscal allograft were quantified via the principle of superposition. A repeated measures analysis of variance was used to analyze variations in kinematics and forces at 0°, 30°, 60°, and 90° of knee flexion. Significance was set at When anterior loads were applied, a decrease in medial translation of the tibia that was increased after total lateral meniscectomy was observed at 30°, 60°, and 90° of knee flexion for both the lateral MAT bone block (54.2%, 48.0%, and 50.0%) and the MAT suture-only (50.0%, 40.0%, and 34.6%) fixation techniques ( Lateral MAT partially restored medial translation of the tibia, and the resultant forces in the meniscal allograft were only 50% to 60% of the intact lateral meniscus forces in the cadaver model. In the majority of testing conditions, no significant changes of the in situ force in the anterior cruciate ligament were observed. Surgeons should consider the potential benefits of lateral MAT when deciding the appropriate treatment for symptomatic patients after lateral meniscectomies. Both lateral MAT techniques functioned similarly. The load-bearing function of the meniscal allograft observed in this study may be beneficial in ameliorating the short- and long-term disability associated with lateral meniscal deficiency.

Lateral Meniscal Graft Transplantation: Effect of Fixation Method on Joint Contact Mechanics During Simulated Gait

17-07-2019 – Caroline Brial,Moira McCarthy,Olufunmilayo Adebayo,Hongsheng Wang,Tony Chen,Russell Warren,Suzanne Maher

Journal Article

Controversy exists regarding the optimal bony fixation technique for lateral meniscal allografts. The objective was to quantify knee joint contact mechanics across the lateral plateau for keyhole and bone plug meniscal allograft transplant fixation techniques throughout simulated gait. It was hypothesized that both methods of fixation would improve contact mechanics relative to the meniscectomized condition, while keyhole fixation would restore the distribution of contact stress closer to that of the intact knee. Controlled laboratory study. Six human cadaveric knees were mounted on a multidirectional dynamic simulator and subjected to the following conditions: (1) native intact meniscus, (2) keyhole fixation of the native meniscus, (3) bone plug fixation of the native meniscus, and (4) meniscectomy. Contact area, peak contact stress, and the distribution of stress across the tibial plateau were computed at 14% and 45% of the gait cycle, at which axial forces are at their highest. Translation of the weighted center of contact stress throughout simulated gait was computed. Both bony fixation techniques improved contact mechanics relative to the meniscectomized condition. The keyhole technique was not significantly different from the intact condition for the following metrics: contact area, peak contact stress, distribution of force between the meniscal footprint and cartilage-to-cartilage contact, and the position of the weighted center of contact. In contrast, bone plug fixation resulted in a significant decrease of 21% to 28% in contact area at 14% and 45% of the simulated gait cycle, a significant increase in peak contact stresses of 34% at 45% of the gait cycle, and a shift in the weighted center of contact, which increased forces in the cartilage-to-cartilage contact area at 45% of the gait cycle. While both keyhole and bone plug fixation methods improved lateral compartment contact mechanics relative to the meniscectomized knee, keyhole fixation restored contact mechanics closer to that of the intact knee. Method of meniscal fixation is under the direct control of the surgeon. From a biomechanics perspective, keyhole fixation is advocated for its ability to mimic intact knee joint contact mechanics.

Anatomic Risk Factors for Focal Cartilage Lesions in the Patella and Trochlea: A Case-Control Study

09-07-2019 – Luiz Felipe Ambra,Betina B. Hinckel,Elizabeth A. Arendt,Jack Farr,Andreas H. Gomoll

Journal Article

Focal cartilage lesions in the patellofemoral (PF) joint are common. Several studies correlated PF risk factors with PF instability, anterior knee pain, and PF arthritis; however, there is a lack of evidence correlating those factors to PF focal cartilage lesions. To evaluate the influence of the anatomic PF risk factors in patients with isolated focal PF cartilage lesions. Cross-sectional study; Level of evidence, 3. Patients with isolated PF focal cartilage lesions were included in the cartilage lesion group, and patients with other pathologies and normal PF cartilage were included in the control group. Multiple PF risk factors were accessed on magnetic resonance imaging scans: patellar morphology (patellar width, patellar thickness, and patellar angle), trochlear morphology (trochlear sulcus angle, lateral condyle index, and trochlear sulcus depth), patellar height (Insall-Salvati ratio and Caton-Deschamps index), axial patellar positioning (patellar tilt, angle of Fulkerson), and quadriceps vector (tibial tuberosity-trochlear groove distance). A total of 135 patients were included in the cartilage lesion group and 100 in the control group. As compared with the control group, the cartilage lesion group had a higher sulcus angle ( PF anatomic abnormalities are significantly more common in patients with full-thickness PF cartilage lesions. Trochlear dysplasia, patella alta, and excessive lateral patellar tilt are the most common correlated factors, especially in patellar lesions.

Degree of Preoperative Subchondral Bone Marrow Lesion Is Associated With Postoperative Outcome After Medial Opening Wedge High Tibial Osteotomy

09-07-2019 – Man Soo Kim,In Jun Koh,Sueen Sohn,Hoon Seok Sung,Yong In

Journal Article

In osteoarthritis of the knee, subchondral bone marrow lesion (BML) is known to be significantly associated with the severity of pain. However, little is known about the influence of preoperative BML on postoperative outcomes after medial opening wedge high tibial osteotomy (MOWHTO). To compare patient-reported outcomes for those who underwent MOWHTO according to the severity of BML based on magnetic resonance imaging. Cohort study; Level of evidence, 3. A total of 136 patients who underwent MOWHTO between June 2011 and May 2016 with clinical and radiologic assessments before and after surgery were retrospectively enrolled. Patients were divided into 2 groups according to the presence or absence of BMLs. They were then subdivided into 4 or 3 groups based on the sum of BML scores of the medial femoral condyle and tibial plateau according to MRI (magnetic resonance imaging) Osteoarthritis Knee Score or Filardo classification, respectively. Associations between the severity of BML and postoperative 1- and 2-year Western Ontario and Mc
Master Universities Osteoarthritis Index (WOMAC) subscores were evaluated through linear regression analysis. At postoperative 2 years, the rate of patients having a WOMAC score improvement of 15 points based on minimum clinically important difference and patient satisfaction were compared between groups. BMLs were present in 96 (70.6%) of 136 cases. There were no significant differences in demographics or radiographic variables between groups according to the presence/absence or severity of BMLs (all Although worse clinical outcomes were associated with severe BML during the recovery period, MOWHTO provided a high degree of clinical improvement on patient-reported outcomes regardless of the severity of BML at 2 years postoperatively.

In Which Arm Position Is a Hill-Sachs Lesion Created?

27-06-2019 – Jun Kawakami,Nobuyuki Yamamoto,Taku Hatta,Kiyotsugu Shinagawa,Eiji Itoi

Journal Article

It has been believed that a Hill-Sachs lesion (HSL) is created with the arm in abduction and external rotation at the time of dislocation. However, no studies have clarified the arm position in which an HSL is created. To determine the arm position in which an HSL is created. Descriptive laboratory study. The computed tomography images of 100 shoulders of 100 patients (72 males and 28 females; mean age, 30 years old) with recurrent anterior dislocation of the shoulder were investigated using an image analyzing software. Three-dimensional surface bone models of the scapula and humerus were created separately. The humerus was moved so that the HSL perfectly fit the anterior rim of the glenoid. This arm position was recorded 3-dimensionally. Considering the scapulohumeral rhythm, the average arm position in which the HSL and the anterior glenoid rim best fit was 74° of abduction, 27° of external rotation, and 3° of horizontal flexion relative to the trunk. The arm position when an HSL and the anterior glenoid rim best fit is 74° of abduction, 27° of external rotation, and 3° of horizontal flexion, which seems to be the arm position when the HSL has been created. This result suggests 2 possibilities: dislocation occurred in this midrange position or HSL was not created at the time of dislocation but later in the mid-range of motion. However, as we have no information on the arm position at the time of dislocation, we cannot conclude which of these possibilities is true in our study. This study gives us a better understanding of the timing of HSL occurrence. Shoulder dislocation may occur at the end range of motion or in the mid-range of motion, but an HSL is created in the mid-range of motion.

Scapular Spine Dimensions and Suitability as a Glenoid Bone Graft Donor Site

16-07-2019 – Eric Rohman,Kyle Gronbeck,Marc Tompkins,Marcus Mittelsteadt,James A. Kirkham,Robert A. Arciero

Journal Article

Current structural bone graft options used for glenoid augmentation in glenohumeral instability have known drawbacks. The scapular spine may be a possible alternative graft choice, but its dimensions and anatomy are not fully reported. The scapular spine’s harvestable graft dimensions will be similar to harvestable dimensions of the coracoid and iliac crest. Descriptive laboratory study. The scapular spine, coracoid, and iliac crest dimensions were recorded and compared bilaterally in 50 patients with 3-dimensional computed tomography imaging. The portion of the scapular spine with the largest harvestable dimensions was quantified and its location defined. Measurements were independently taken by 2 investigators and averaged for the final result. The scapular spine has 81.5 mm of harvestable length and a “flare” located approximately 49.6 mm lateral to the medial scapular border, where the widest harvestable cross section is located (mean harvestable dimensions: 10.9-mm height, 11.5-mm width). Mean coracoid dimensions were 24-mm length, 14.2-mm height, and 10.6-mm width. Mean iliac crest width was 14.7 mm. In sum, 96% of scapular spines, 85% of coracoids, and 100% of iliac crests exceeded minimum dimensions of 8 mm × 8 mm × 20 mm. The coronal radius of curvature of the glenoid was significantly different from the corresponding plane of all measured structures. The scapular spine has dimensions similar to the coracoid and iliac crest in the majority of patients and is therefore appropriate for further investigation as a potential graft choice in glenohumeral instability. A harvest location 49.6 mm lateral to the medial scapular border will provide the largest cross-sectional graft while avoiding the acromial base.

Biomechanical Comparison of Onlay Distal Biceps Tendon Repair: All-Suture Anchors Versus Titanium Suture Anchors

19-07-2019 – Alexander Otto,Julian Mehl,Elifho Obopilwe,Mark Cote,Lucca Lacheta,Bastian Scheiderer,Andreas B. Imhoff,Augustus D. Mazzocca,Sebastian Siebenlist

Journal Article

A rupture of the distal biceps tendon is the most common tendon rupture of the elbow and has received increased attention in the past few years. Newly developed all-suture anchors have the potential to minimize surgical trauma and the risk of adverse events because of the use of flexible drills and smaller drill diameters. The purpose was to biomechanically compare all-suture anchors and titanium suture anchors for distal biceps tendon repair in cadaveric specimens. The hypothesis was that all-suture anchors would show no differences in load to failure or displacement under cyclic loading compared with titanium suture anchors. Controlled laboratory study. Sixteen unpaired, fresh-frozen human cadaveric elbows were randomized to 2 groups, which underwent onlay distal biceps tendon repair with 2 anchors. Bone mineral density at the radial tuberosity was evaluated in each specimen. In the first group, distal biceps tendon repair was performed using all-suture anchors. In the second group, titanium suture anchors were applied. After cyclic loading for 3000 cycles, the repair constructs were loaded to failure. The peak load to failure as well as repair construct stiffness and mode of failure were determined. The mean (±SD) peak load was 293.53 ± 122.15 N for all-suture anchors and 280.02 ± 69.34 N for titanium suture anchors ( All-suture anchors were biomechanically equivalent at time zero to titanium suture anchors for onlay distal biceps tendon repair. While the proximally placed all-suture anchors demonstrated greater displacement than titanium suture anchors, the comparable displacement at the distal position as well as the similar load and mechanism of failure make this difference unlikely to be clinically significant. All-suture anchors performed similarly to titanium suture anchors for onlay distal biceps tendon repair at time zero and represent a reasonable alternative.

Management of Recurrent Anterior Shoulder Instability With Bipolar Bone Loss: A Systematic Review to Assess Critical Bone Loss Amounts

27-08-2018 – Anirudh K. Gowd,Joseph N. Liu,Brandon C. Cabarcas,Grant H. Garcia,Gregory L. Cvetanovich,Matthew T. Provencher,Nikhil N. Verma

Hip Arthroscopic Surgery in Borderline Developmental Dysplastic Hips: A Systematic Review

27-11-2018 – Zheci Ding,Yaying Sun,Shaohua Liu,Jiwu Chen

Journal Article

It remains controversial whether hip arthroscopic surgery should be applied to patients with a borderline developmental dysplastic hip (BDDH). To review the outcomes of hip arthroscopic surgery for a BDDH and which factors influence these outcomes. Systematic review. PubMed, Embase, and the Cochrane Library were searched through March 2018 for studies reporting the outcomes of primary hip arthroscopic surgery in patients with a BDDH. Inclusion in the review was based on the definition of a BDDH, patient-reported outcomes, and duration of follow-up. The primary outcome was the modified Harris Hip Score (m
HHS). The failure rate, visual analog scale, satisfaction score, and patient-reported outcomes such as the Hip disability and Osteoarthritis Outcome Score were defined as secondary outcomes. Nine studies with 425 patients who underwent hip arthroscopic surgery were included in this review. The mean follow-up times ranged from 25.4 to 28.8 months across the studies. A significant improvement was obtained in the m
HHS, with a mean score of 61.8 preoperatively to 82.8 postoperatively; all other patient-reported outcomes also improved significantly, except the 12-Item Short Form Health Survey mental component summary. The overall failure rate was 14.1%, and the mean reoperation rate was 8.5%. The rate of conversion to total hip arthroplasty ranged from 4.4% to 26.0%, and the rate of conversion to periacetabular osteotomy was 4.0%. Combined defects such as cartilage damage, hip osteoarthritis, ligamentum teres tears, and femoroacetabular impingement could influence the outcomes after arthroscopic surgery in BDDHs. Hip arthroscopic surgery was demonstrated to be a promising approach for BDDHs, but the outcomes could be influenced by multiple risk factors. A higher level of evidence is still needed to support current findings.

Timeline for Maximal Subjective Outcome Improvement After Anterior Cruciate Ligament Reconstruction

13-11-2018 – Avinesh Agarwalla,Richard N. Puzzitiello,Joseph N. Liu,Gregory L. Cvetanovich,Anirudh K. Gowd,Nikhil N. Verma,Brian J. Cole,Brian Forsythe

Journal Article

Anterior cruciate ligament (ACL) tears are one of the most common traumatic knee injuries experienced by athletes. Return to sport is considered the pinnacle endpoint among patients receiving ACL reconstruction. However, at the time of return to sport, patients may not be participating at their previous levels of function, as defined by clinical metrics. To establish when patients perceive maximal subjective medical improvement according to patient-reported outcome measures (PROMs). Systematic review. A systematic review of the PubMed database was conducted to identify studies that reported sequential PROMs up to a minimum of 2 years after ACL reconstruction. Pooled analysis was conducted for PROMs at follow-up points of 3 months, 6 months, 1 year, and 2 years. Clinically significant improvement was determined between pairs of intervals with the minimal clinically important difference. This review contains 30 studies including 2253 patients who underwent ACL reconstruction. Clinically significant improvement in the KOOS (Knee injury and Osteoarthritis Outcome Score) was seen up to 1 year after ACL reconstruction, but no clinical significance was noted from 1 to 2 years. Clinically significant improvement in the IKDC (International Knee Documentation Committee) and Lysholm questionnaires was seen up to 6 months postoperatively, but no clinical significance was noted beyond that. After ACL reconstruction, maximal subjective medical improvement is established 1 year postoperatively, with no further perceived clinical improvement beyond this time point according to current PROMs. The KOOS may be a more responsive metric to subjective improvements in this patient cohort than other patient-reported outcomes, such as the IKDC and Lysholm. After ACL reconstruction, patients perceive interval subjective improvements until 1 year postoperatively.

Society News

31-07-2019 –

Adductor Canal Block Versus Femoral Nerve Block for Pain Control After Anterior Cruciate Ligament Reconstruction: Case Closed? Letter to the Editor

31-07-2019 – Kristi Pence

Journal Article

Adductor Canal Block Versus Femoral Nerve Block for Pain Control After Anterior Cruciate Ligament Reconstruction: Case Closed? Response

31-07-2019 – Kelechi R. Okoroha,Vasilios Moutzouros

Journal Article

Ankle Lateral Ligament Augmentation Versus the Modified Broström-Gould Procedure: Letter to the Editor

31-07-2019 – Nicolò Martinelli,Francesca Manfroni,Alberto Bianchi

Journal Article

Ankle Lateral Ligament Augmentation Versus the Modified Broström-Gould Procedure: Response

31-07-2019 – Mark D. Porter

Journal Article

Partial Meniscectomy for Degenerative Medial Meniscal Root Tears Shows Favorable Outcomes in Well-Aligned, Nonarthritic Knees: Letter to the Editor

31-07-2019 – Jorge Chahla,Robert F. LaPrade,Aaron J. Krych,Nikhil N. Verma,Brian J. Cole,Adam B. Yanke

Journal Article

Partial Meniscectomy for Degenerative Medial Meniscal Root Tears Shows Favorable Outcomes in Well-Aligned, Nonarthritic Knees: Response

31-07-2019 – Bum-Sik Lee,Seong-Il Bin,Jong-Min Kim,Min-Ho Park,Sang-Min Lee,Kun-Hyung Bae

Journal Article

Should We Rethink How to Define Success After ACL Surgery? Letter to the Editor

31-07-2019 – Gregory S. DiFelice,Bertrand Sonnery-Cottet,Wiemi A. Douoguih,Jelle P. van der List

Journal Article

Should We Rethink How to Define Success After ACL Surgery? Response

31-07-2019 – Alexia G. Gagliardi,Patrick M. Carry,Jessica L. Traver,Harin B. Parikh,David R. Howell,Jay C. Albright

Journal Article


31-07-2019 –

Journal Article, Published Erratum

The Kaplan Fibers of the Iliotibial Band Can Be Identified on Routine Knee Magnetic Resonance Imaging

21-08-2019 – Lachlan Batty,Jerome Murgier,Richard O’Sullivan,Kate E. Webster,Julian A. Feller,Brian M. Devitt

Journal Article

The Kaplan fibers (KFs) of the iliotibial band have been suggested to play a role in anterolateral rotational instability of the knee, particularly in the setting of an anterior cruciate ligament (ACL) rupture. Description of the normal magnetic resonance imaging (MRI) anatomy of the KFs may facilitate subsequent investigation into the MRI signs of injury. To assess if the KF complex can be identified on 3-T MRI using standard knee protocols. Cohort study (diagnosis); Level of evidence, 3. 3-T MRI scans of 50 ACL-intact knees were reviewed independently by a musculoskeletal radiologist and 2 orthopaedic surgeons. Identification of the KFs was based on radiological diagnostic criteria developed a priori. Identification of the KFs in the sagittal, coronal, and axial planes was recorded. Interobserver reliability was assessed using the Kappa statistic. Detailed anatomy including distance to the joint line and relationship to adjacent structures was recorded. The mean patient age was 43 years (range, 15-81 years), 58% were male, and 50% were right knees. The KFs were identified by at least 2 reviewers on the sagittal images in 96% of cases, on the axial images in 76% of cases, and on the coronal images in 4% of cases. The mean distance from the KF distal femoral insertion to the lateral joint line was 50.1 mm (SD, 6.6 mm) and the mean distance to the lateral gastrocnemius tendon origin was 10.8 mm (SD, 8.6 mm). The KFs were consistently identified immediately anterior to the superior lateral geniculate artery on sagittal imaging. Interobserver reliability for identification was best in the sagittal plane (Kappa 0.5) and worst in the coronal plane (Kappa 0.1). The KF complex can be identified on routine MRI sequences in the ACL-intact knee; however, there is low to moderate interobserver reliability. Imaging in the sagittal plane had the highest rate of identification and the coronal plane the lowest. There is a consistent relationship between the most distal KF femoral attachment and the lateral joint line, lateral gastrocnemius tendon, and superior lateral geniculate artery.

Increased Chondrocytic Gene Expression Is Associated With Improved Repair Tissue Quality and Graft Survival in Patients After Autologous Chondrocyte Implantation

21-08-2019 – Jakob Ackermann,Gergo Merkely,Alexandre Barbieri Mestriner,Nehal Shah,Andreas H. Gomoll

Journal Article

Assays to quantitate the quality of autologous chondrocyte implants have recently become available. However, the correlation of the assay score with radiological and clinical outcomes has not been established. The purpose was to assess the influence of cell identity (chondrocyte/synoviocyte gene expression ratio) and viability on patient-reported outcome measures, graft survival, and repair tissue quality. It was hypothesized that greater cell product quality as assessed through an identity assay and cell viability is associated with superior outcomes after autologous chondrocyte implantation (ACI) for symptomatic cartilage defects. Cohort study; Level of evidence, 3. Seventy-nine patients with a minimum follow-up of 2 years were included in this study. Of these, 67 patients were available for imaging assessment utilizing the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) scoring system. Patients were assigned to groups either below or above the cohort’s mean based on their individual cell identity score and viability percentage. Patients were predominantly female (57.7%) with a mean age of 30.0 ± 9.3 years. No differences were seen between Knee injury and Osteoarthritis Outcome Score, Lysholm, Tegner, or International Knee Documentation Committee Subjective Knee Evaluation Form within the viability and cell identity groups at a final follow-up of 3.8 ± 1.4 years after ACI ( Cell identity was significantly correlated with structural repair quality and graft survival after second-generation ACI for symptomatic chondral lesions in the knee. While improved imaging outcome and higher graft survivorship were associated with a higher individual cell identity score indicating a higher chondrocyte/synoviocyte gene expression ratio in the final cell product, clinical outcome did not correlate with the identity score.

Equivalent 10-Year Outcomes After Implantation of Autologous Bone Marrow–Derived Mesenchymal Stem Cells Versus Autologous Chondrocyte Implantation for Chondral Defects of the Knee

21-08-2019 – Alex Quok An Teo,Keng Lin Wong,Liang Shen,Jia Ying Lim,Wei Seong Toh,Eng Hin Lee,James Hoi Po Hui

Journal Article

The use of bone marrow-derived mesenchymal stem cells (BMSCs) in cartilage repair procedures circumvents some of the limitations of autologous chondrocyte implantation (ACI), but long-term outcomes for this newer procedure are lacking. The authors previously reported comparable outcomes for the 2 procedures at 2-year follow-up. The purpose was to compare the long-term clinical outcomes of ACI versus BMSCs. It was hypothesized that there would be no significant difference between the groups in terms of patient-reported outcome scores and safety outcomes at 10-year follow-up. Cohort study; Level of evidence, 2. Seventy-two patients who underwent either ACI or BMSC implantation-matched in terms of age and lesion site- were followed up to a median of at least 10 years. Patients were assessed with the 36-item Short Form Health Survey (SF-36), the International Knee Documentation Committee knee evaluation form, the Lysholm Knee Score, and the Tegner Activity Scale. In addition, information was obtained regarding any additional surgical procedures as well as safety data, with particular attention to infection and tumor formation. There was an improvement in all patient-reported outcomes scores apart from the Mental Component Summary of the SF-36 after cartilage repair surgery. There was no significant difference in any of the patient-reported outcomes between cohorts at any time point. Six and 5 patients in the ACI and BMSC groups, respectively, underwent subsequent surgical procedures, including 1 total knee replacement in the BMSC group. None of the patients in either group developed any deep infection or tumor within the follow-up period. BMSC implantation used for the treatment of chondral defects of the knee appears to result in equivalent clinical outcomes to first-generation ACI at up to 10 years, with no apparent increased tumor formation risk.

The Number of Injury Events Associated With the Critical Size of Bipolar Bone Defects in Rugby Players With Traumatic Anterior Shoulder Instability

19-08-2019 – Yoshinori Hasegawa,Takayuki Kawasaki,Shuko Nojiri,Shogo Sobue,Takefumi Kaketa,Yoshinori Gonda,Yoshiaki Itoigawa,Kazuo Kaneko

Journal Article

The size of a glenoid bone defect is responsible for reduction in shoulder stability and is correlated with the number of instability events. Biomechanical studies have suggested that it should be considered concomitantly with the Hill-Sachs lesion as “bipolar” bone defects for assessing structural degradation, but the definitive number of instability events associated with the critical size has not been investigated. To (1) confirm that the number of instability events is the predictor of a critical size of bipolar bone defects and (2) demonstrate the cutoff value of the number of instability events for these defects in rugby players with traumatic anterior shoulder instability. Cross-sectional study; Level of evidence, 3. One-hundred forty-four rugby players with anterior shoulder instability underwent morphologic evaluation for glenoid and Hill-Sachs lesions by computed tomography and determination of the critical (a glenoid bone defect of ≥25% or an off-track Hill-Sachs lesion) and subcritical (a glenoid bone defect of ≥13.5%) size of bipolar bone defects. In the primary analysis, the prevalence of the critical and subcritical size of bipolar bone defects was investigated. In the secondary analysis, the authors explored the predictors for these bone defects and determined the cutoff value correlating with the critical and subcritical size of bipolar bone defects by applying receiver operating characteristic curves. The primary analysis revealed that the prevalence of critical and subcritical size of bipolar bone defects was 20.8% and 61.8% of 144 shoulders, respectively. In the secondary analysis, multiple logistic regression analysis demonstrated that the total number of shoulder instability events and dominant shoulder were the significant factors associated with the critical and subcritical size of bipolar bone defects. The cutoff value for the number of instability events that correlated with critical bipolar bone defects was 6 for the dominant and 9 for the nondominant shoulder, whereas it was 4 for the dominant and 5 for the nondominant shoulder for subcritical bipolar bone defects. The number of shoulder instability events and the dominant shoulder were the predictors for the critical and subcritical size of bipolar bone defects for a shoulder with traumatic instability. Four injury events should herald caution when treating rugby players with shoulder instability.

The Association Among Trunk Rotation, Ball Velocity, and the Elbow Varus Moment in Collegiate-Level Baseball Pitchers

19-08-2019 – Andrew D. Cohen,Erin J. Garibay,Matthew J. Solomito

Journal Article

The incidence of upper extremity injuries in baseball pitchers is increasing. Over the past decade, research has attempted to elucidate the cause of these injuries, focusing mainly on pitching arm mechanics with little examination of other important segments, such as the trunk. This is surprising, as trunk motion has been shown to have significant effects on pitching mechanics. To determine the associations between trunk rotation, ball velocity, and the moments about the elbow joint. Descriptive laboratory study. Data collected using 3-dimensional motion analysis techniques from 99 collegiate pitchers (18.0-24.8 years) were analyzed. A random intercept mixed-effects regression model was used to determine if significant associations existed between trunk rotation and ball velocity or elbow varus moment. Significant associations were found between trunk rotation angle at ball release and elbow varus moment ( In collegiate pitchers, trunk rotation angle at ball release was significantly associated with ball velocity and elbow varus moment. Also, an increase in maximum rotational velocity of the trunk was significantly associated with an increase in the ball velocity and elbow varus moment. This work demonstrates the importance of trunk mechanics in the kinetic chain of the pitch cycle. Pitching coaches and trainers can use the results to stress the importance of trunk mechanics in pitching, specifically, combining adequate core function with increased trunk rotational velocity in an effort to increase pitching velocity without increasing elbow joint stress.

Patients With Borderline Hip Dysplasia Achieve Clinically Significant Outcome After Arthroscopic Femoroacetabular Impingement Surgery: A Case-Control Study With Minimum 2-Year Follow-up

16-08-2019 – Edward C. Beck,Benedict U. Nwachukwu,Jorge Chahla,Kyleen Jan,Timothy C. Keating,Sunikom Suppauksorn,Shane J. Nho

Journal Article

There is a growing trend for hip arthroscopists to treat patients with borderline hip dysplasia (BHD) for femoroacetabular impingement syndrome (FAIS) without addressing the acetabular coverage. However, the literature of outcomes and failure rates for these patients is conflicting. (1) To identify whether patients with BHD achieved 2-year similar patient-reported outcome, minimal clinically important difference (MCID), and patient acceptable symptomatic state (PASS) when compared with patients without BHD and (2) to identify predictors for achieving the MCID and PASS among patients with BHD who are undergoing hip arthroscopy for FAIS. Cohort study; Level of evidence, 3. Data from consecutive patients who underwent primary hip arthroscopy with routine capsular closure for the treatment of FAIS between January 2012 and January 2017 were collected and retrospectively analyzed. Patients with BHD (lateral center-edge angle [LCEA], 20°-25°) were matched 2:1 by age, sex, and body mass index (BMI) to control patients with normal acetabular coverage (LCEA, >25°-40°). Patient-reported outcome, MCID, and PASS were compared between the groups. Multivariate logistic regression analysis identified significant predictors of achieving the MCID and PASS in the BHD group. The MCID in the BHD group was defined as 9.2, 13.7, 8.5, and 15.2 for the Hip Outcome Score-Activities of Daily Living, Hip Outcome Score-Sport Specific, modified Harris Hip Score, and i
HOT-12, respectively. Threshold scores for achieving the PASS in both groups were 87.9, 76.4, 78.1, and 60.0. A total of 112 patients were identified as having BHD (LCEA, 20°-25°) and were matched to 224 controls. Both groups saw statistically significant increases in score averages over the 2-year period; however, the differences between them were not statistically significant ( Outcome improvements in patients with BHD who are undergoing arthroscopic treatment with capsular closure for FAIS are not significantly different from patients with normal acetabular coverage. Lower BMI, lower alpha angle, absence of limp, and female sex are preoperative predictors of achieving meaningful clinically significant outcome improvements in patients with BHD.

Nonabsorbable Suture Knot on the Tendon Affects Rotator Cuff Healing: A Comparative Study of the Knots on Tendon and Bone in a Rat Model of Rotator Cuff Tear

14-08-2019 – Yucheng Sun,Jae-Man Kwak,Erica Kholinne,Jun Tan,Kyoung-Hwan Koh,In-Ho Jeon

Journal Article

Nonabsorbable suture knots are usually used to link the tendon and bone during rotator cuff repair surgery. There are many variations in the arthroscopic knot-tying technique; however, the location of suture knot placement for rotator cuff healing has rarely been studied. The authors compared the rotator cuff healing between knots tied on tendon and bone in a rotator cuff tear rat model. It has been hypothesized that knots can cause chronic inflammation and create the weakest link between tendon and bone, thus affecting rotator cuff healing. Controlled laboratory study. Bilateral supraspinatus tenotomy and rotator cuff repair at the greater tuberosity were performed on 24 Wistar rats. Nonabsorbable surgical suture knots were made on the right supraspinatus tendon tissue and left humerus inferior to the greater tuberosity, respectively. Twelve rats each were sacrificed at 3 and 9 weeks. Six of the 12 rats were used for biomechanical testing and the remaining 6 for histologic evaluation. The surgical knots placed on the bursal side of the tendon migrated to the articular side, as noted on gross observation in 22 of 24 samples. The knots on the tendon group showed significantly inferior tendon-bone integration and significantly inferior biomechanical results in terms of maximum load to failure and stiffness. An obvious chronic foreign body inflammatory reaction was found in the knots on the tendon group at 3 and 9 weeks. Furthermore, inferior bone-tendon interface regeneration and weakest link formation were obtained in the knots on the tendon group compared with those on the bone group. Nonabsorbable suture knots placed on the tendon migrate to the articular side, causing chronic inflammation and weakening tendon-bone healing, which may explain some retears after rotator cuff repair. The present animal study suggests that it is not recommended in clinical practice to make several bulky nonabsorbable suture knots on the rotator cuff tendon during rotator cuff repair surgery. It may be better to tie the knots at the bone side or do knotless repair.

Portal Placement and Biomechanical Performance of Endoscopic Proximal Hamstring Repair

14-08-2019 – Michael K. Ryan,David P. Beason,Glenn S. Fleisig,Benton A. Emblom

Journal Article

Proximal hamstring tendon avulsions are debilitating and commonly cause pain, weakness, and functional limitations. Open surgical repair has been the standard, but improved endoscopic techniques have enabled proximal hamstring fixation with decreased risk of infection and numbness, without the morbidity of a large incision. To (1) describe pertinent anatomy surrounding the proximal hamstring origin in relation to 4 endoscopic portal sites and (2) test for biomechanical differences between open and endoscopic repair. It was hypothesized that (1) endoscopic proximal hamstring repair is efficacious with respect to commonly used portals and (2) there is no biomechanical difference between open and endoscopic techniques. Descriptive and controlled laboratory study. Proximal hamstring ruptures were simulated endoscopically in 10 fresh-frozen human cadaveric pelvis specimens. Endoscopic repair was then completed on 1 limb from each specimen through 4 portals. After repair, each specimen was dissected in layers and measurements from portal tracts to pertinent anatomy were obtained. Open repair was performed on all contralateral limbs, followed by cyclical biomechanical tensile testing to failure of both the open and endoscopically repaired hamstring tendons to assess failure load and local tissue strain. On average, no portal tract was closer than 2.0 cm to the sciatic nerve or inferior gluteal neurovascular bundle. Anatomic landmarks were identified that could improve the reproducibility and safety of the procedure. Biomechanical testing revealed no differences between the open and endoscopic repair techniques for any measured parameter. This study supports the safety and efficacy of endoscopic proximal hamstring repair through anatomic and biomechanical analyses and helps establish reproducible and recognizable landmarks that define a safe working zone. This study maps the anatomic landscape of the proximal hamstring as encountered endoscopically and demonstrates equivalent biomechanical strength of endoscopic proximal hamstring repair, supporting this technique’s safety and efficacy.

Influence of Risky Pathoanatomy and Demographic Factors on Clinical Outcomes After Isolated Medial Patellofemoral Ligament Reconstruction: A Regression Analysis

14-08-2019 – Laurie A. Hiemstra,Sarah A. Kerslake,Mark R. Lafave

Journal Article

Multiple studies have demonstrated that a number of demographic and pathoanatomic characteristics are associated with patellofemoral instability, recurrence of instability, and less satisfactory results following medial patellofemoral ligament reconstruction (MPFL-R). Despite the growing volume of research, the relationship of risk factors to patient-reported outcome after MPFL-R is unclear. To determine if certain pathoanatomic and demographic factors predict disease-specific quality-of-life outcome after isolated MPFL-R for symptomatic patellofemoral instability. Cohort study; Level of evidence, 3. The study analyzed 224 isolated MPFL-Rs. Demographic data were collected, including age at first dislocation, sex, and presence of bilateral instability. Pathoanatomic risk factors included the presence of high-grade trochlear dysplasia, tibial tubercle-trochlear groove (TT-TG) distance, patella alta ratio, Beighton score, and patellar tilt. Other factors included femoral tunnel position accuracy and WARPS/STAID score. Descriptive analyses were conducted, followed by calculation of individual Spearman rank correlation coefficients for the predictor variables versus the Banff Patellofemoral Instability Instrument (BPII) scores. A multivariable regression with stepwise selection was employed to establish the final model predicting BPII score, with all significant variables for alpha ≤ .05 included in the final model. The cohort of 224 patients included 66 (29.5%) males and 158 (70.5%) females, with a mean age of 24.1 years and a mean body mass index of 23.9 kg/m In this large cohort of patients undergoing isolated MPFL-R for symptomatic lateral patellofemoral instability, a multivariable forward stepwise regression demonstrated that bilateral symptoms, femoral tunnel position, and age at first dislocation were statistically significant predictors of lower postoperative BPII scores. No anatomic risk factors were predictive of quality-of-life outcome score 2 years after MPFL-R surgery. The

Prevalence and Clinical Implications of Chondral Injuries After Hip Arthroscopic Surgery for Femoroacetabular Impingement Syndrome

14-08-2019 – Jorge Chahla,Edward C. Beck,Kelechi Okoroha,Jourdan M. Cancienne,Kyle N. Kunze,Shane J. Nho

Journal Article

Studies on the effect of partial- and full-thickness chondral damage of the hip on outcomes and the ability to achieve meaningful clinical outcomes are limited. To determine the effect of full- and partial-thickness chondral injuries on 2-year outcomes in patients undergoing hip arthroscopic surgery for femoroacetabular impingement syndrome (FAIS) compared with patients without chondral damage, and to identify significant predictors of achieving the patient acceptable symptomatic state (PASS) and minimal clinically important difference (MCID). Case-control study; Level of evidence, 3. Data from consecutive patients with evidence of chondromalacia at the time of primary hip arthroscopic surgery with routine capsular closure for the treatment of FAIS by a single fellowship-trained surgeon between January 2012 and September 2016 were reviewed. Patients were divided into groups with partial-thickness (grade I-III) or full-thickness (grade IV) chondral defects and matched by age and body mass index (BMI) to patients without chondral injuries. Preoperative and postoperative outcomes were compared among the 3 groups, and a binary logistic regression analysis was utilized to identify significant predictors of achieving the MCID and PASS. There were 634 patients included in the analysis, with a mean age of 34.5 ± 10.9 years and a mean BMI of 25.2 ± 4.7 kg/m Patients with grade IV chondral defects experienced worse functional outcomes, lower satisfaction, and increased pain when compared with both patients without chondral damage or grade I-III chondromalacia at 2-year follow-up. Several predictors were associated with achieving clinically significant function in patients undergoing hip arthroscopic surgery for FAIS.

Long-term Results of Arthroscopic Rotator Cuff Repair: Initial Tear Size Matters: A Prospective Study on Clinical and Radiological Results at a Minimum Follow-up of 10 Years

14-08-2019 – Pietro Simone Randelli,Alessandra Menon,Elisabetta Nocerino,Alberto Aliprandi,Francesca Maria Feroldi,Manuel Giovanni Mazzoleni,Sara Boveri,Federico Ambrogi,Davide Cucchi

Journal Article

Arthroscopic techniques are now considered the gold standard for treatment of most rotator cuff (RC) tears; however, no consensus exists on the maintenance of results over time, and long-term follow-up data have been reported for few cohorts of patients. To present the long-term results associated with the arthroscopic treatment of RC tears and to evaluate associations between preoperative factors and RC integrity at final follow-up. Cohort study; Level of evidence, 3. A total of 169 patients were contacted at least 10 years after arthroscopic RC surgery and were invited to a clinical evaluation. Information on preoperative conditions, tear size, subjective satisfaction, and functional scores was collected; isometric strength and range of motion were also measured; and each patient underwent an ultrasound examination to evaluate supraspinatus integrity and a shoulder radiograph to evaluate osteoarthritis. A total of 149 patients (88.2% of the eligible patients) were available for a complete telephonic interview, and 102 patients were available for the final evaluation. Ultrasound revealed an intact supraspinatus in 54 patients (53.47%). By adding the 10 patients who underwent revision surgery to the nonintact group, this percentage would drop to 48.65%. Tear size was associated with supraspinatus integrity in univariate analysis (hazard ratio, 3.04; 95% CI, 1.63-5.69; RC tear size at the time of surgery significantly affects supraspinatus integrity at a minimum follow-up of 10 years. However, a larger tear is not associated with an inferior subjective result, although it negatively influences abduction and flexion strength, range of motion, and osteoarthritis progression. Intraoperative efforts to obtain a durable RC repair are encouraged, since supraspinatus integrity at final follow-up influences clinical and functional outcomes, patient satisfaction, and osteoarthritis progression.

Complications After Anterior Cruciate Ligament Reconstruction and Their Relation to the Type of Graft: A Prospective Study of 958 Cases

12-08-2019 – Romain Rousseau,Charlotte Labruyere,Charles Kajetanek,Olivia Deschamps,Konstantinos G. Makridis,Patrick Djian

Journal Article

Complications and adverse events after anterior cruciate ligament (ACL) reconstruction are well known, but they have been underestimated in previous studies. To describe the complications and adverse events after ACL reconstruction within a 2-year follow-up and analyze them in relation to the type of graft. Cohort study; Level of evidence, 3. From 2000 to 2012, 958 patients with an isolated ACL injury underwent surgery by a single knee surgeon. ACL reconstruction was performed with the medial portal technique for the femoral tunnel and the use of bone-patellar tendon-bone (BPTB) or hamstring tendon graft. Patients were reviewed at 6 weeks and 3, 6, 12, and 24 months after surgery with the International Knee Documentation Committee score, plain radiographs, and the KT-1000 arthrometer. Of 958 patients enrolled, 147 (15%) were lost at last follow-up. The 2 groups (bone-patellar tendon-bone [n = 257] and hamstring [n = 554]) were similar regarding the mean age at the time of surgery and preoperative anterior laxity. The main complications were as follows: anterior knee pain (n = 130 of 811, 16%), stiffness (n = 72, 8.8%), secondary meniscal lesions (n = 59, 7.2%), pain attributed to fixation (n = 79, 9.7%), ACL rerupture (n = 47, 5.7%), contralateral ACL ruptures (n = 24, 3%), patellar fractures (n = 3, 0.3%), infections (n = 9, 1%), and thromboembolic complications (n = 5, 0.6%). There was no significant difference between the grafts with respect to the frequency of joint stiffness, secondary meniscal lesions, or anterior knee pain. During the first 2 postoperative years, the percentage of patients with anterior knee pain was higher in the patellar tendon group (23.3% vs 12.6%, The total rate of complications after an ACL reconstruction was 39%, and the surgical revision rate for any reason was 28%. Problems with the hardware material were more frequent in the hamstring group, leading to an increased rate of surgical revision. Anterior knee pain was initially higher in the patellar tendon group, but there was no significant difference in a 2-year interval. The rerupture rate was statistically higher in the hamstring group.

The Incidence of Traumatic Posterior and Combined Labral Tears in Patients Undergoing Arthroscopic Shoulder Stabilization

08-08-2019 – Saqib Javed,Daniel Gheorghiu,Emma Torrance,Puneet Monga,Lennard Funk,Michael Walton

Journal Article

Posterior and combined shoulder instabilities have been reported as accounting for only 2% to 5% of cases. More recently, an increased incidence of posterior capsulolabral tear has been reported. To assess the incidence of posterior and combined labral tears in a large cohort of patients with surgically treated shoulder labral tears. Case series; Level of evidence, 4. This was a retrospective study that evaluated 442 patients who underwent an arthroscopic capsulolabral repair over a 3-year period. Patients were categorized according to the location of their labral tear and whether their injury was sustained during sporting or nonsporting activity. Proportions of labral tears between sporting and nonsporting populations were compared using the chi-square test. Patients had a mean age of 25.9 years and 89.6% were male. Isolated anterior labral tears occurred in 52.9%, with posterior and combined anteroposterior labral tears accounting for 16.3% and 30.8%, respectively. The frequency of posterior and combined lesions was greater in the sporting population compared with the nonsporting population ( Posterior and combined labral tears are more prevalent than previously reported, particularly in the sporting population.

Ankle Sprains in the National Basketball Association, 2013-2014 Through 2016-2017

07-08-2019 – Mackenzie M. Herzog,Christina DeFilippo Mack,Nancy A. Dreyer,Erik A. Wikstrom,Darin A. Padua,Mininder S. Kocher,John P. DiFiori,Stephen W. Marshall

Journal Article

Ankle sprains are one of the most common injuries in basketball. Despite this, the incidence and setting of ankle sprains among elite basketball players are not well described. To describe the epidemiology of ankle sprains among National Basketball Association (NBA) players. Cohort study; Level of evidence, 3. All players on an NBA roster for ≥1 NBA game (preseason, regular season, or playoffs) during the 2013-14 through 2016-17 seasons were included. Data were collected with the NBA electronic medical record system. All NBA teams used the electronic medical record continuously throughout the study period to record comprehensive injury data, including onset, mechanism, setting, type, and time lost. Game incidence rates were calculated per 1000 player-games and per 10,000 player-minutes of participation, stratified by demographic and playing characteristics. There were 796 ankle sprains among 389 players and 2341 unique NBA player-seasons reported in the league from 2013-14 through 2016-17. The overall single-season risk of ankle sprain was 25.8% (95% CI, 23.9%-28.0%). The majority of ankle sprains occurred in games (n = 565, 71.0%) and involved a contact mechanism of injury (n = 567, 71.2%). Most ankle sprains were lateral (n = 638, 80.2%). The incidence of ankle sprain among players with a history of prior ankle sprain in the past year was 1.41 times (95% CI, 1.13-1.74) the incidence of those without a history of ankle sprain in the past year ( Ankle sprains affect approximately 26% of NBA players on average each season and account for a large number of missed NBA games in aggregate. Younger players and players with a history of ankle sprain have elevated rates of incident ankle sprains in games, highlighting the potential benefit for integrating injury prevention programs into the management of initial sprains. Research on basketball- and ankle-specific injury prevention strategies could provide benefits.

Long-term Evaluation of Meniscal Tissue Formation in 3-dimensional–Printed Scaffolds With Sequential Release of Connective Tissue Growth Factor and TGF-β3 in an Ovine Model

06-08-2019 – Yusuke Nakagawa,Lisa A. Fortier,Jeremy J. Mao,Chang Hun Lee,Margaret B. Goodale,Matthew F. Koff,Tyler J. Uppstrom,Brett Croen,Susumu Wada,Camila B. Carballo,Hollis G. Potter,Scott A. Rodeo

Journal Article

Artificial meniscal scaffolds are being developed to prevent development of osteoarthritis after meniscectomy. Previously, it was reported that 3-dimensional (3D) anatomic scaffolds loaded with connective tissue growth factor (CTGF) and transforming growth factor β3 (TGF-β3) achieved meniscal regeneration in an ovine model. This was a relatively short-term study (3 months postoperative), and outcome analyses did not include magnetic resonance imaging (MRI). To evaluate long-term outcome of meniscal replacement with growth factor-laden poly-ε-caprolactone (PCL) scaffolds. Controlled laboratory study. Anatomically shaped ovine meniscal scaffolds were fabricated from PCL with a 3D printer based on MRI data. Skeletally mature sheep (N = 34) were randomly allocated to 3 groups: scaffold without growth factor (0-µg group), scaffold with CTGF microspheres (µS) (5 µg) + TGF-β3 µS (5 µg) (5-µg group), and scaffold with CTGF µS (10 µg) + TGF-β3 µS (10 µg) (10-µg group). Unilateral medial meniscal replacement was performed. Animals were euthanized at 6 or 12 months. Regenerated meniscus, articular cartilage status, and synovial reaction were evaluated quantitatively with gross inspection, histology, and MRI. Kruskal-Wallis and Dunn tests were used to compare the 3 groups. Remnants of the PCL scaffold were evident in the 6-month specimens and were decreased but still present at 12 months in most animals. There were no significant differences among groups in gross inspection, histology, or MRI for either meniscal regeneration or articular cartilage protection. All experimental groups exhibited articular cartilage degeneration as compared with control (nonoperated). In terms of synovitis, there were no clear differences among groups, suggesting that growth factors did not increase inflammation and fibrosis. MRI revealed that meniscal extrusion was observed in most animals (82.7%). Previously, the combination of CTGF and TGF-β3 was shown to stimulate mesenchymal stem cells into a fibrochondrocyte lineage. CTGF and TGF-β3 did not aggravate synovitis, suggesting no adverse response to the combination of 3D-printed PCL scaffold combined with CTGF and TGF-β3. Further work will be required to improve scaffold fixation to avoid meniscal extrusion. A significant advantage of this technique is the ability to print custom-fit scaffolds from MRI-generated templates. In addition, average-size menisci could be printed and available for off-the-shelf applications. Based on the 1-year duration of the study, the approach appears to be promising for meniscal regeneration in humans.

Establishing Safe Extra-articular Parameters for Cortical Button Distal Fixation During Ulnar Collateral Ligament Reconstruction

06-08-2019 – Perry O. Hooper,Jared Warren,Christopher Silko,Salvatore J. Frangiamore,Dominic King,Lutul D. Farrow,Mark S. Schickendantz

Journal Article

A variety of methods exist for fixation during ulnar collateral ligament (UCL) reconstruction on the ulna for the overhead throwing athlete. Current biomechanical evidence suggests that cortical button fixation may fail at a higher load and under more cycles than interference screw fixation alone, while also minimizing the risk of fracture. A safe angle for placement of this cortical button has not yet been determined. To define a safe angle for cortical button deployment during UCL reconstruction to avoid violation of the proximal radioulnar joint (PRUJ). Descriptive laboratory study. Measurements on 100 cadaveric ulna bones, 50 women and 50 men, were obtained referencing the entry point for ulnar fixation, which is 1 cm distal to the ulnar humeral joint line along the medial UCL ridge. Ulnar width at the entry point and distance to the PRUJ were obtained to calculate safe distal angulation, while distance from the entry point to the posterior ulnar crest ulnarly and distance from the PRUJ to the posterior ulnar crest radially were obtained to calculate safe posterior angulation. Ten bony measurements on the same group of specimens were performed by 3 authors to establish an interobserver reliability. Means, quartiles, and outliers were obtained for the calculated angles. Finally, recommended angles of entry were determined to be approximately 1 interquartile range above the upper limit. The mean distal angle of entry that was obtained was 11.32° (SD, ±4.80°; 95% CI, 10.37°-12.27°; To be safely outside of the PRUJ utilizing a cortical button construct, we recommend 30° distal angulation and 60° posterior angulation for ulnar fixation during UCL reconstruction. Both parameters are 1 quartile above the highest calculated angle of entry. These data define safe parameters for distal fixation during UCL reconstruction and highlight a clear entry point for reference.

Effect of Concussions on the Performance of Running Backs and Wide Receivers in the National Football League

06-08-2019 – Toufic R. Jildeh,Kelechi R. Okoroha,Kevin A. Taylor,Patrick Buckley,Samir Mehta,Nima Mehran,Vasilios Moutzouros

Journal Article

Concussion injuries are common in professional football players; however, their effect on player performance remains unclear. To quantify the effect of concussions on the performance of running backs and wide receivers in professional football players. Cohort study; Level of evidence, 3. Concussion data from the National Football League were collected for a period of 4 seasons (2012-2015) for running backs and wide receivers. Age, experience, position, time to return to play, yearly total yards, and touchdowns were recorded. A power rating (total yards divided by 10 plus touchdowns multiplied by 6) was calculated for each player’s injury season as well as for the 3 seasons before and after their respective injury. A control group of running backs and wide receivers without an identified concussion injury who competed in the 2012 season was assembled for comparison. Player performance up to 3 seasons before and after the injury season was examined to assess acute and longitudinal changes in player performance. A total of 38 eligible running backs and wide receivers sustained a concussion during the study period. Thirty-four (89%) players were able to return to competition in the same season, missing an average of 1.5 ± 0.9 games; the remaining 4 players returned in the subsequent season. Power ratings for concussed players were similar to those of controls throughout the study period. Concussed players did not suffer an individual performance decline upon returning within the same season. Furthermore, no significant difference in change of power rating was observed in concussed players in the acute (±1 year from injury; -1.2 ± 4.8 vs -1.1 ± 3.9, A high rate of National Football League running backs and wide receivers are able to return to play after a concussion injury. These players were found to perform at a similar level in both the acute and long-term period after concussion.

Factors Associated With a Return to Preinjury Level of Sport Performance After Anterior Cruciate Ligament Reconstruction Surgery

05-08-2019 – Kate E. Webster,April L. McPherson,Timothy E. Hewett,Julian A. Feller

Journal Article

Many studies have investigated factors that predict a return to sport participation after anterior cruciate ligament (ACL) reconstruction, but it is unclear whether the same factors are associated with a return to preinjury level of sport performance. To identify factors that contribute to an athlete’s return to preinjury level of performance after ACL reconstruction. Cohort study; Level of evidence, 2. A cohort of 222 patients (132 male, 90 female) who had ACL reconstruction surgery and completed a 12-month postoperative assessment were followed out to a mean 3 years (range, 2-4 years) to determine whether they had returned to their self-reported preinjury levels of sport performance. Rates of return to preinjury performance were calculated. Measures that had been recorded at the 12-month postoperative review-demographic (age, sex), sport activity level (Marx Activity Rating Scale, return to competition sport), knee laxity, limb symmetry (single and triple crossover hop), subjective function/symptoms (International Knee Documentation Committee subjective), and psychological readiness (Anterior Cruciate Ligament Return to Sport After Injury scale)-were compared between patients who returned to their preinjury levels of performance and those who did not. Univariate and multivariate logistic regression models were also used to prospectively determine the association between these measures and return to preinjury level of sport performance. A total of 135 (61%) patients reported that they had returned to their preinjury levels of performance, with return rates similar between males (59%) and females (63%) and between those who had returned to competition at 12 months (62%) and those who had not (60%). There was no significant age difference between patients who returned to their preinjury levels of sport performance and those who did not; however, higher psychological readiness ( A majority of athletes who returned to sport after ACL reconstruction reported that their performance was comparable with preinjury. Having a greater psychological readiness to return during rehabilitation was the most significant predictor of a subsequent return to comparable performance.

Radiographic Landmarks for Femoral Tunnel Positioning in Lateral Extra-articular Tenodesis Procedures

05-08-2019 – Vera Jaecker,Jan-Hendrik Naendrup,Thomas R. Pfeiffer,Bertil Bouillon,Sven Shafizadeh

Journal Article

Lateral extra-articular tenodesis (LET) is being increasingly performed as an additional procedure in both primary and revision anterior cruciate ligament reconstruction in patients with excessive anterolateral rotatory instability. Consistent guidelines for femoral tunnel placement would aid in intraoperative reproducible graft placement and postoperative evaluation of LET procedures. To determine radiographic landmarks of a recently described isometric femoral attachment area in LET procedures with reference to consistent radiographic reference lines. Descriptive laboratory study. Ten fresh-frozen cadaveric knees were dissected. The footprints of the lateral femoral epicondyle (LFE) apex and the deep aspects of the iliotibial tract, with its Kaplan fiber attachments (KFAs) on the distal femur, were marked with a 2.5-mm steel ball. True lateral radiographic images were taken. Mean absolute LFE and KFA distances were measured from the posterior cortex line (anterior-posterior direction) and from the perpendicular line intersecting the contact of the posterior femoral condyle (proximal-distal direction), respectively. Furthermore, positions were measured relative to the femur width. Finally, radiographic descriptions of an isometric femoral attachment area were developed. The mean LFE and KFA positions were found to be 4 ± 4 mm posterior and 4 ± 3 mm anterior to the posterior cortex line, and 6 ± 4 mm distal and 20 ± 5 mm proximal to the perpendicular line intersecting the posterior femoral condyle, respectively. The mean LFE and KFA locations, relative to the femur width, were found at -12% and 11% (anterior-posterior) and -17% and 59% (proximal-distal), respectively. Femoral tunnel placement on or posterior to the femoral cortex line and proximal to the posterior femoral condyle within a 10-mm distance ensures that the tunnel remains safely located in the isometric zone. Radiographic landmarks for an isometric femoral tunnel placement in LET procedures were described. These findings may help to intraoperatively guide surgeons for an accurate, reproducible femoral tunnel placement and to reduce the potential risk of tunnel misplacement, as well as to aid in the postoperative evaluation of LET procedures in patients with residual complaints.

Low-Profile Dual Small Plate Fixation Is Biomechanically Similar to Larger Superior or Anteroinferior Single Plate Fixation of Midshaft Clavicle Fractures

05-08-2019 – Connor G. Ziegler,Zachary S. Aman,Hunter W. Storaci,Hannah Finch,Grant J. Dornan,Mitchell I. Kennedy,Matthew T. Provencher,Thomas R. Hackett

Journal Article

Limited biomechanical data exist for dual small plate fixation of midshaft clavicle fractures, and no prior study has concurrently compared dual small plating to larger superior or anteroinferior single plate and screw constructs. To biomechanically compare dual small orthogonal plating, superior plating, and anteroinferior plating of midshaft clavicle fractures by use of a cadaveric model. Descriptive laboratory study. The study used 18 cadaveric clavicle specimens (9 pairs total), and 3 plating techniques were studied: anteroinferior, superior, and dual. The dual plating technique used smaller diameter plates and screws (1.6-mm thickness) than the other, single plate techniques (3.3-mm thickness). Each of the 9 clavicle pairs was randomly assigned a combination of 2 plating techniques, and randomization was used to determine which techniques were used for the right and left specimens. Clavicles were plated and then osteotomized to create an inferior butterfly fracture model, which was then fixed with a single interfragmentary screw. Clavicle specimens were then potted for mechanical testing. Initial bending, axial, and torsional stiffness of each construct was determined through use of a randomized nondestructive cyclic testing protocol followed by load to failure. No significant differences were found in cyclical axial ( Dual plating with a smaller plate-screw construct is biomechanically similar to superior and anteroinferior single plate fixation that uses larger plate-screw constructs. No significant differences were found between dual plating and either superior or anteroinferior single plating in axial, bending, or torsional stiffness or in bending load to failure. Dual small plating is a viable option for fixing midshaft clavicle fractures and may be a useful low-profile technique that avoids a larger and more prominent plate-screw construct. Plate prominence and hardware irritation are commonly reported complaints and reasons for revision surgery after plate fixation of midshaft clavicle fractures. Dual small plate fixation has been used to improve cosmetic acceptability, minimize hardware irritation, and decrease reoperation rate. Biomechanically, dual small plate fixation performed similarly to larger single plate fixation in this cadaveric model of butterfly fracture.

Single-Stage Multiple-Ligament Knee Reconstructions for Sports-Related Injuries: Outcomes in 194 Patients

05-08-2019 – Robert F. LaPrade,Jorge Chahla,Nicholas N. DePhillipo,Tyler Cram,Mitchell I. Kennedy,Mark Cinque,Grant J. Dornan,Luke T. O’Brien,Lars Engebretsen,Gilbert Moatshe

Journal Article

Outcomes after sports-related multiple-ligament knee reconstructions are limited. To evaluate outcomes after single-stage surgical treatment of sports-related multiple-ligament knee injuries and to compare outcomes after anterior cruciate ligament (ACL)-based and posterior cruciate ligament (PCL)-based multiple-ligament knee reconstructions. Case series; Level of evidence, 4. Skeletally mature patients with at least 2 major knee ligaments torn during a sporting activity that required surgery with a minimum of 2 years’ follow-up were included. The Lysholm score, Tegner activity scale, Western Ontario and Mc
Master Universities Osteoarthritis Index (WOMAC), and 12-Item Short Form Health Survey Physical Component Summary were collected preoperatively and at a minimum of 2 years’ follow-up. Clinical data, including range of motion and knee stability, were also recorded at final follow-up. A total of 276 patients with multiple-ligament knee injuries incurred during sport participation from 2010 to 2016 were identified. Of the 276 patients, 194 (70.5%) had complete follow-up at a mean 3.5 years (range, 2-8 years). There was a significant improvement in all outcome scores as compared with the preoperative scores ( These results demonstrated that single-stage anatomic-based knee ligament reconstructions with immediate postoperative rehabilitation in the setting of sports-related multiligament injuries yielded significantly improved outcomes irrespective of the ligament injury pattern. In addition, there was no difference in outcomes between ACL- and PCL-based injuries in the setting of sports-related multiligament injuries.

Anterior Cruciate Ligament Reconstruction Within 3 Weeks Does Not Increase Stiffness and Complications Compared With Delayed Reconstruction: A Meta-analysis of Randomized Controlled Trials

05-08-2019 – Luca Deabate,Davide Previtali,Alberto Grassi,Giuseppe Filardo,Christian Candrian,Marco Delcogliano

Journal Article

Injury-to-surgery time has been identified as a key point in anterior cruciate ligament (ACL) reconstruction, with early versus delayed treatment remaining a debated and controversial topic in the management of ACL tears. The aim was to quantitatively synthesize the best literature evidence by including only randomized controlled trials (RCTs) comparing early versus delayed ACL reconstruction, with a clear and univocal definition of cutoffs of early or delayed surgery. The hypothesis was that early treatment would lead to similar final clinical results compared with the delayed approach while providing a faster recovery without an increase in complications after ACL reconstruction. Meta-analysis. A systematic literature search was performed on February 12, 2019, using PubMed, Web of Science, Cochrane Library, and gray literature databases. According to previous literature, 2 analyses with different cutoffs for injury-to-surgery time (3 weeks and 10 weeks) were performed to distinguish early and delayed reconstruction. The influence of timing was analyzed through meta-analyses in terms of patient-reported outcome measures (PROMs), risk of complications, range of motion (ROM) limitation, risk of retears, and residual laxity. Risk of bias and quality of evidence were assessed following the Cochrane guidelines. Eight studies (5 in 3-week cutoff analysis and 3 in 10-week cutoff analysis) were included. No differences were found in terms of PROMs, risk of complications, ROM limitation, risk of retears, and residual laxity either in the 3-week cutoff analysis or in the 10-week cutoff analysis ( This meta-analysis did not confirm the previously advocated benefits of delaying ACL surgery to avoid the acute posttraumatic phase. In fact, RCTs demonstrated that timing of surgery after ACL tears has no influence on the final functional outcome, risk of retears, or residual instability. While no data were available about the recovery time, literature results showed that early ACL reconstruction could be performed without increasing the risk of complications. CRD42019119319 (PROSPERO).

Pulse Lavage Fails to Significantly Reduce Bone Marrow Content in Osteochondral Allografts: A Histological and DNA Quantification Study

02-08-2019 – Luiz Felipe Ambra,Laura de Girolamo,Andreas H. Gomoll

Journal Article

Current clinical practice calls for pulse lavage of fresh osteochondral allografts (OCAs) to reduce immunogenicity; however, there is limited evidence of its effectiveness in reducing allogenic bone marrow elements. To evaluate the effectiveness of pulse lavage in removing marrow elements from trabecular bone in fresh OCA transplantation. Controlled laboratory study. The authors evaluated 48 fresh OCA plugs with 4 different common sizes (14- and 24-mm diameter, 6- and 10-mm thickness). Within each size group, half of the samples underwent pulse lavage (n = 6) with saline solution and half were left untreated (no lavage; control group, n = 6). For each treatment and size group, 3 samples were analyzed for DNA content as an indicator of the number of residual nucleated cells; the other 3 samples were histologically analyzed to assess the presence and distribution of cells within subchondral bone pores in 3 specific locations within the plug: peripheral, intermediate, and core. Osteochondral plugs treated with pulse lavage did not show a significant decrease in DNA content in comparison with untreated plugs. Overall, histological analysis did not show a significant difference between the treated and untreated groups ( Pulse lavage has limited effectiveness in removing marrow elements, in particular in plugs that are larger in diameter and, more importantly, in thickness. Better techniques for subchondral bone treatment are required for more thorough removal of potentially immunogenic marrow elements. OCA transplantation has become an established treatment modality. Unfortunately, OCA is not without limitations, chiefly its mode of failure through inadequate integration of the allograft subchondral bone with subsequent collapse. In an effort to improve integration, current clinical practice calls for pulse lavage to remove allogenic bone marrow from the subchondral bone in hopes of decreasing the immunogenicity of the graft and facilitating revascularization.

Change in Drop-Landing Mechanics Over 2 Years in Young Athletes After Anterior Cruciate Ligament Reconstruction

02-08-2019 – Matthew P. Ithurburn,Mark V. Paterno,Staci Thomas,Michael L. Pennell,Kevin D. Evans,Robert A. Magnussen,Laura C. Schmitt

Journal Article

While between-limb landing asymmetries after anterior cruciate ligament reconstruction (ACLR) are linked with poor function and risk of additional injury, it is not currently understood how landing symmetry changes over time after ACLR. The purpose was to investigate how double-legged drop vertical jump (DVJ) landing and single-legged drop-landing symmetry changed from the time of return-to-sport (RTS) clearance to 2 years later in a prospective cohort of young athletes after ACLR. It was hypothesized that double-legged DVJ landing and single-legged drop-landing symmetry would improve from the time of RTS to 2 years later. Descriptive laboratory study. The authors followed 64 young athletes with primary, unilateral ACLR for 2 years after RTS clearance. At the time of RTS and 2 years later, between-limb symmetry values for biomechanical variables of interest (VOIs) were calculated with 3-dimensional motion analysis during double-legged DVJ and single-legged drop-landing tasks. VOIs included knee flexion excursion, peak internal knee extension moment, peak vertical ground-reaction force, and peak trunk flexion (for single-legged task only). Symmetry values and proportions of participants meeting 90% symmetry cutoffs were compared between time points. For double-legged DVJ landing, symmetry values for all VOIs and the proportions meeting 90% cutoffs for peak internal knee extension moment and peak vertical ground-reaction force were higher at 2 years after RTS as compared with RTS. For single-legged drop-landing, symmetry values were higher for knee flexion excursion and lower for peak trunk flexion at 2 years after RTS as compared with RTS, but the proportions meeting 90% cutoffs for all VOIs did not differ between time points. Double-legged DVJ landing symmetry improved across VOIs over the 2 years after RTS following ACLR, while single-legged drop-landing did not improve as consistently. The implications of longitudinal landing asymmetry after ACLR should be further studied.

Comparative Clinical Outcomes After Intra-articular Injection With Adipose-Derived Cultured Stem Cells or Noncultured Stromal Vascular Fraction for the Treatment of Knee Osteoarthritis

02-08-2019 – Naomasa Yokota,Mari Hattori,Tadahiko Ohtsuru,Masaki Otsuji,Stephen Lyman,Kazunori Shimomura,Norimasa Nakamura

Journal Article

Intra-articular injection of adipose-derived stem cells (ASCs) has shown promise for improving symptoms and cartilage quality in the treatment of osteoarthritis (OA). However, while most preclinical studies have been performed with plastic-adherent ASCs, most clinical trials are being conducted with the stromal vascular fraction (SVF), prepared from adipose tissue without prior culture. To directly compare clinical outcomes of intra-articular injection with ASCs or SVF in patients with knee OA. Cohort study; Level of evidence, 3. The authors retrospectively compared 6-month outcomes in 42 patients (59 knees) receiving intra-articular injection with 12.75 million ASCs and 38 patients (69 knees) receiving a 5-m
L preparation of SVF. All patients had Kellgren-Lawrence grade 2, 3, or 4 knee OA and had failed standard medical therapy. The visual analog scale (VAS) pain score and Knee injury and Osteoarthritis Outcome Score (KOOS) at baseline and 1, 3, and 6 months after injection were considered as outcomes. Outcome Measures in Rheumatology-Osteoarthritis Research Society International (OMERACT-OARSI) criteria were also used to assess positive response. A repeated measures analysis of variance was used for comparison between the treatment groups. No major complications occurred in either group. The SVF group had a higher frequency of knee effusion (SVF 8%, ASC 2%) and minor complications related to the fat harvest site (SVF 34%, ASC 5%). Both groups reported improvements in pain VAS and KOOS domains. Specifically, in the ASC group, symptoms improved earlier (by 3 months; It was observed that both ASCs and SVF resulted in clinical improvement in patients with knee OA, but that ASCs outperform SVF in the early reduction of symptoms and pain with less comorbidity.

Factors Predicting the Outcome After Arthroscopically Assisted Stabilization of Acute High-Grade Acromioclavicular Joint Dislocations

02-08-2019 – Nina Maziak,Laurent Audige,Carmen Hann,Marvin Minkus,Markus Scheibel

Journal Article

Factors influencing the outcome after arthroscopically assisted stabilization of acute high-grade acromioclavicular (AC) joint dislocations remain poorly investigated. To identify determinants of the radiological outcome and investigate associations between radiological and clinical outcome parameters. Cohort study; Level of evidence, 3. The authors performed a retrospective analysis of patients who underwent arthroscopically assisted stabilization for acute high-grade AC joint dislocations. The following potential determinants of the radiological outcome were examined using univariable and multivariable regression analyses: timing of surgery, initial AC joint reduction, isolated coracoclavicular (CC) versus combined CC and AC stabilization, ossification of the CC ligaments, age, and overweight status. In addition, associations between radiological (ie, CC difference, dynamic posterior translation [DPT]) and clinical outcome parameters (Subjective Shoulder Value, Taft score [TS] subjective subcategory, and Acromioclavicular Joint Instability Score [ACJI] pain subitem) were evaluated using univariable analysis. One hundred four patients with a mean (±SD) age of 38.1 ± 11.5 years were included in this study. The mean postoperative follow-up was 2.2 ± 0.9 years. Compared with patients with an overreduced AC joint after surgery, the CC difference was 4.3 mm (95% CI, 1.3-7.3; Clinicians should consider overreduction of the AC joint because it may lead to favorable radiological results. Because of its association with superior radiographic outcomes, consideration should also be given to the use of additional AC cerclage.

Correlation of Single Assessment Numerical Evaluation Score for Sport and Activities of Daily Living to Modified Harris Hip Score and Hip Outcome Score in Patients Undergoing Arthroscopic Hip Surgery

26-07-2019 – Brian C. Lau,Melissa Scribani,Tally Lassiter,Jocelyn Wittstein

Journal Article

The Single Assessment Numerical Evaluation (SANE) is a single-question outcome score that has been shown to be a reliable measure of outcomes for shoulder and knee injuries but has not been compared with other validated outcome scores in hip pathology managed arthroscopically. To correlate SANE Activities of Daily Living (ADL) and Sport subscales with the modified Harris Hip Score (m
HHS) and Hip Outcome Score (HOS) ADL and Sport subscales before and after arthroscopic hip surgery. Cohort study (diagnosis); Level of evidence, 3. A retrospective review of a prospectively filled database of patients undergoing arthroscopic hip surgery by a single surgeon was conducted. Inclusion criteria included patients scheduled for arthroscopic hip surgery for femoroacetabular impingement, labral tear, or gluteus medius tear. Exclusion criteria included previous surgery to the hip. Outcome scores, including the m
HHS, HOS ADL and Sport, and SANE ADL and Sport, were measured preoperatively and postoperatively at 3 months, 1 year, and then annually. Pearson correlation coefficients between preoperative SANE ADL and Sport and the m
HHS, HOS ADL, and HOS Sport were calculated. Pearson correlation coefficients between postoperative SANE ADL and Sport and the m
HHS, HOS ADL, and HOS Sport were also calculated. Eighty-five patients (mean age, 37.9 years; range, 14-66 years; 57 females, 28 males) underwent arthroscopic hip surgery for assorted pathology. Mean follow-up was 8 months (range, 3-64 months). Based on the Pearson correlation coefficient, preoperative SANE ADL and Sport had a moderate correlation with the m
HHS ( This study showed a significant correlation between SANE and m
HHS in patients undergoing arthroscopic hip surgery both pre- and postoperatively. SANE ADL and Sport had a strong correlation with HOS ADL and Sport preoperatively and short-term postoperatively. SANE scores are more highly correlated with traditional subjective outcome measures during the short-term postoperative period than they are preoperatively. The SANE score provides an efficient method of assessing outcomes after hip arthroscopy.

Predictors of Unsuccessful Nonoperative Management of Capitellar Osteochondritis Dissecans

26-07-2019 – Tadanao Funakoshi,Kozo Furushima,Azusa Miyamoto,Hiroshi Kusano,Yukio Horiuchi,Yoshiyasu Itoh

Journal Article

Osteochondritis dissecans of the humeral capitellum (capitellar OCD) is a common injury among adolescent throwing athletes. Some younger patients with incomplete maturity of the epiphysis and early-stage capitellar OCD are good candidates for nonoperative treatment. However, during initial examination, predicting the need for surgical treatment in patients with capitellar OCD is difficult. To perform multivariate ordered logistic regression analysis of data obtained from patients’ medical records and images on initial examination and identify the predictors of unsuccessful nonoperative management of capitellar OCD. Cohort study (prognosis); Level of evidence, 2. This study included 245 elbows with capitellar OCD (all male; mean age, 14 years [range, 10-27 years]). Patients were divided into 3 groups comprising 148 elbows requiring an immediate operation on initial examination, 48 requiring nonsurgical treatment, and 49 requiring an operation after nonoperative management. Baseline data and radiographic parameters, such as lesion location, lesion size, modified Minami classification, radial head size, skeletal age difference between both elbows on initial examination, lesion size on computed tomography, and staging on magnetic resonance imaging, were retrospectively reviewed. Univariate and multivariate ordered logistic regression analyses of spontaneous healing of the lesion were conducted. Univariate logistic regression analysis showed that radial head enlargement and skeletal age difference were significantly associated with spontaneous healing. In multivariate ordered logistic regression analysis, radial head enlargement (anteroposterior and lateral) and skeletal age difference were significant predictors of lack of spontaneous healing (odds ratio [OR], 2.76, To predict spontaneous healing in the moderate stage, plain radiographs would be important to evaluate radiocapitellar congruity and skeletal age. This study showed that preoperative radiographic findings of radial head enlargement and advanced skeletal age of the throwing side compared with that of the nonthrowing side were predictors of advanced-stage capitellar OCD. Despite several limitations, the statistical significance and correlations herein provide important information on preoperative surgical planning to surgeons.

Subsequent Surgery for Loss of Motion After Anterior Cruciate Ligament Reconstruction Does Not Influence Function at 2 Years: A Matched Case-Control Analysis

26-07-2019 – Jacob Worsham,Walter R. Lowe,Dorcas Copa,Shelby Williams,Jacquelyn Kleihege,Kyle Lauck,Randy Mascarenhas,Lane Bailey

Journal Article

Loss of motion (LOM) remains a common complication after anterior cruciate ligament (ACL) reconstruction and can be detrimental to patient outcomes after surgery. LOM is multifactorial, but nonsurgical and surgical solutions to this complex problem are available. A paucity of quality data exists evaluating clinical outcomes after the surgical treatment of patients with LOM after ACL reconstruction. Patients undergoing surgical lysis of adhesions and manipulation under anesthesia for LOM after ACL reconstruction will exhibit decreased function, lower outcome scores, and delayed time of release to play when compared with matched controls without LOM. Cohort study; Level of evidence, 3. A database of 1572 patients undergoing ACL reconstruction was sampled from 2013 to 2017 to identify a total of 58 patients (LOM group [n = 29] vs matched control group [n = 29]). Group comparisons were examined for patients requiring a second surgical procedure for LOM versus matched controls after ACL reconstruction for differences in surgical timing, self-reported International Knee Disability Committee scores, objective function at release to play, and subjective knee function at 2 years with the Single Assessment Numeric Evaluation. The risk of a type I error was set at α = .05 for all statistical analyses. Patients who underwent lysis of adhesions and manipulation under anesthesia for LOM after ACL reconstruction exhibited no differences in Single Assessment Numeric Evaluation knee function at 2 years when compared with matched controls (85.8 ± 14.9 vs 88.0 ± 10.8, The findings of this study suggest that patients who undergo surgical treatment for LOM after ACL reconstruction can release to play at similar times but display relative deficits in single-legged-hop symmetry and lower self-reported function when compared with matched controls. Longer surgical times may increase the risk for LOM after ACL reconstruction. NCT03704376 (Clinical identifier).

Rates of Adverse Outcomes and Revision Surgery After Anterior Cruciate Ligament Reconstruction: A Study of 104,255 Procedures Using the National Hospital Episode Statistics Database for England, UK

26-07-2019 – Simon G.F. Abram,Andrew Judge,David J. Beard,Andrew J. Price

Journal Article

After an anterior cruciate ligament (ACL) injury, ACL reconstruction is an elective procedure, and therefore, an understanding of the attributable risk from undergoing ACL reconstruction is necessary for patients to make a fully informed treatment decision. To determine the absolute risk of adverse outcomes including reoperation after ACL reconstruction with comparison, where possible, to the rate of adverse events reported in the general population. Descriptive epidemiology study. National hospital data on all ACL reconstructions performed in England between April 1, 1997, and March 31, 2017, were analyzed. Revision cases, bilateral procedures within 6 months, and cases with concurrent cartilage or multiple ligament surgery were excluded. The primary outcome was the occurrence of at least 1 serious complication (myocardial infarction, stroke, pulmonary embolism, infection requiring surgery, fasciotomy, neurovascular injury, or death) within 90 days. Additionally, 5-year rates of revision ACL reconstruction, contralateral ACL reconstruction, and meniscal surgery were investigated. There were 133,270 ACL reconstructions performed, of which 104,255 were eligible for analysis. Within 90 days, serious complications occurred in 675 (0.65% [95% CI, 0.60-0.70]), including 494 reoperations for infections (0.47% [95% CI, 0.43-0.52]) and 129 for pulmonary embolism (0.12% [95% CI, 0.10-0.15]). Of 54,275 procedures with at least 5 years’ follow-up, 1746 (3.22% [95% CI, 3.07-3.37]) underwent revision ACL reconstruction in the same knee, 1553 underwent contralateral ACL reconstruction (2.86% [95% CI, 2.72-3.01]), and 340 underwent meniscal surgery (0.63% [95% CI, 0.56-0.70]). The overall risk of serious complications fell over time (adjusted odds ratio [OR], 0.96 per year [95% CI, 0.95-0.98]); however, older patients (adjusted OR, 1.11 per 5 years [95% CI, 1.07-1.16]) and patients with a greater modified Charlson Comorbidity Index (adjusted OR, 2.41 per 10 units [95% CI, 1.65-3.51]) were at a higher risk. For every 850 (95% CI, 720-1039) ACL reconstructions, 1 pulmonary embolism could be provoked. For every 213 (95% CI, 195-233), 1 native knee joint infection could be provoked. The overall risk of adverse events after ACL reconstruction is low; however, some rare but serious complications, including infections or pulmonary embolism, may occur. Around 3% of patients undergo further ipsilateral or contralateral ACL reconstruction within 5 years. These data will inform shared decision making between clinicians and patients considering their treatment options.

Demographic and Radiographic Factors Associated With Intra-articular Hip Cartilage Injury: A Cross-sectional Study of 1511 Hip Arthroscopy Procedures

26-07-2019 – Lasse Ishøi,Kristian Thorborg,Otto Kraemer,Bent Lund,Bjarne Mygind-Klavsen,Per Hölmich

Journal Article

Moderate to severe (grade 3-4) hip joint cartilage injury seems to impair function in patients with femoroacetabular impingement syndrome. To investigate whether demographic and radiographic factors were associated with moderate to severe hip joint cartilage injury. Cross-sectional study; Level of evidence, 3. Patients were identified in the Danish Hip Arthroscopy Registry. The outcome variables were acetabular cartilage injury (modified Beck grade 0-2 vs 3-4) and femoral head cartilage injury (International Cartilage Repair Society grade 0-2 vs 3-4). Logistic regressions assessed the association with the following: age (<30 vs 30-50 years); sex; sport activity level (Hip Sports Activity Scale); alpha angle (AA) assessed as normal (AA <55°), cam (55°≤ AA 39°), or borderline dysplasia (LCEA 4.0 mm), mild reduction (3.1 mm ≤ JSW ≤ 4.0 mm), or severe reduction (2.1 mm ≤ JSW ≤ 3.0 mm). A total of 1511 patients were included (mean ± SD age: 34.9 ± 9.8 years). Male sex (odds ratio [OR], 4.42), higher age (OR, 1.70), increased AA (cam: OR, 2.23; severe cam: OR, 4.82), and reduced JSW (mild: OR, 2.04; severe: OR, 3.19) were associated ( Several demographic and radiographic factors were associated with moderate to severe hip joint cartilage injury. Most notably, increased cam severity and borderline dysplasia substantially increased the risk of grade 3-4 acetabular and femoral head cartilage injury, respectively, indicating that specific deformity may drive specific cartilage injury patterns in the hip joint.

Tendon-to-Bone Healing in a Rat Extra-articular Bone Tunnel Model: A Comparison of Fresh Autologous Bone Marrow and Bone Marrow–Derived Mesenchymal Stem Cells

24-07-2019 – Jun Lu,Connie S. Chamberlain,Ming-liang Ji,Erin E. Saether,Ellen M. Leiferman,Wan-Ju Li,Ray Vanderby

Journal Article

Despite widespread acceptance of fresh autologous bone marrow (BM) for use in clinical practice, limited information exists to analyze if tendon-to-bone healing could be accelerated with local use of fresh autologous BM. To investigate the effect of fresh autologous BM on tendon-to-bone healing with a novel rat model. Controlled laboratory study. An extra-articular bone tunnel was created and filled with an autologous tendon graft in skeletally mature Sprague-Dawley rats (N = 60). They were then randomly divided into 3 groups: BM group (injection of fresh autologous BM into the tendon-bone interface, n = 20), BM-derived mesenchymal stem cell (BMSC) group (injection of allogenic cultured BMSCs, n = 20), and the control group (tendon-bone interface without injection of BM or BMSCs, n = 20). Biomechanical, histological, and immunohistochemical analyses were performed at 2 and 6 weeks after surgery. The BM group showed a relatively well-organized and dense connective tissue interface with better orientation of collagen fibers as compared with the BMSC group. At 2 weeks, the tendon-bone interface tissue thickness of the BMSC group was 140 ± 25 μm (mean ± SEM), which was significantly greater than the BM group (58 ± 15 μm). The BM group showed fewer M1 macrophages at the tendon-bone interface at 2 and 6 weeks ( These findings indicate that local delivery of fresh autologous BM enhances tendon-to-bone healing better than the alternative treatments in this study. This effect may be partially due to the observed modulation of inflammatory processes, especially in M2 macrophage polarization. Fresh autologous BM could be a treatment option for this disorder.

Association Between a Rule Change to Reduce Home Plate Collisions and Mild Traumatic Brain Injury and Other Injuries in Professional Baseball Players

23-07-2019 – Gary Green,John D’Angelo,Jon Coyles,Ian Penny,John G. Golfinos,Alex Valadka

Journal Article

Improved player safety is an important goal of professional baseball. Prevention of mild traumatic brain injury (concussion) is an area of emphasis because of the potential for long-term as well as short-term sequelae. A rule change can lower the incidence of concussions and other injuries in professional baseball. Cohort study; Level of evidence, 3. This study included a retrospective review of data entered concurrently into professional baseball’s electronic medical record system. All minor and major league teams are required to use this system. All injuries are captured by creation of a new record in the system at the time of the injury. All active minor and major league players from 2011 to 2017 were included. The 30 major league clubs have 1200 roster players and play 162 games per season. The approximately 200 minor league clubs have about 7500 active players and play 56 to 144 games annually that combine for approximately 330,000 athlete-exposures per season. Before the 2014 season, Major League Baseball, in conjunction with its players association, instituted a rule limiting home plate collisions between base runners and catchers that applied to both Major League Baseball and Minor League Baseball. All concussions and other injuries at home plate from 2011 to 2017 were analyzed by mechanism and player position. From 2011 to 2013, an annual mean of 100 injuries occurred from home plate collisions in the minor and major leagues, resulting in a mean loss of 2148 days annually. After the rule change, there was a mean 55 home plate collision injuries with 936 days lost per season ( This rule change was associated with significant reductions in the numbers of concussions and other injuries caused by collisions at home plate as well as significant decreases in time lost from play.

Throwing Injuries in Youth Baseball Players: Can a Prevention Program Help? A Randomized Controlled Trial

23-07-2019 – Jun Sakata,Emi Nakamura,Tatsuhiro Suzuki,Makoto Suzukawa,Masaki Akeda,Tetsuya Yamazaki,Todd S. Ellenbecker,Norikazu Hirose

Journal Article

Throwing injuries of the shoulder and elbow are common among youth baseball players. A prevention program will reduce the incidence of throwing injuries of the shoulder and elbow by 50% among youth baseball players. Randomized controlled trial; Level of evidence, 1. The authors block randomized 16 youth baseball teams consisting of 237 players aged 9 to 11 years into an intervention group (8 teams, 117 players) and a control group (8 teams, 120 players). The intervention program consisted of 5 stretching, 2 dynamic mobility, and 2 balance training exercises performed during warm-up. Both groups were followed up for 12 months, during which the incidence of shoulder and elbow injuries was recorded. In addition, ball speed during pitching as a performance-related factor and variables of physical function (passive range of motion of the elbow, shoulder and hip, dynamic balance, and thoracic kyphosis angle) were assessed during the pre- and postintervention periods. The incidence of shoulder and elbow injuries in the intervention group (1.7 per 1000 athlete-exposures) was significantly lower than that in the control group (3.1 per 1000 athlete-exposures) (hazard ratio, 1.940; 95% CI, 1.175-3.205; A prevention program decreases throwing injuries of the shoulder and elbow and enhances the parameter of pitching performance in youth baseball players.

In Vivo Imaging of Exogenous Progenitor Cells in Tendon Regeneration via Superparamagnetic Iron Oxide Particles

23-07-2019 – Thomas J. Kremen,Maxim Bez,Dmitriy Sheyn,Shiran Ben-David,Xiaoyu Da,Wafa Tawackoli,Shawn Wagner,Dan Gazit,Gadi Pelled

Journal Article

Although tendon injuries and repairs are common, treatment of these injuries has limitations. The application of mesenchymal progenitor cells (MPCs) is increasingly used to optimize the biological process of tendon repair healing. However, clinically relevant technologies that effectively assess the localization of exogenous MPCs in vivo are lacking. Exogenous MPCs labeled with superparamagnetic iron oxide (SPIO) particles would allow monitoring of the localization and retention of cells within the site of implantation via magnetic resonance imaging (MRI) without negatively affecting cell survival or differentiation. Descriptive laboratory study. Genetically modified C3H10T1/2 MPCs engineered to express luciferase (Luc+) reporter gene were implanted into surgically created Achilles tendon defects of 10 athymic nude rats (Hsd:RH-Foxn1 Optical imaging demonstrated that the implanted cells not only survived but also proliferated in vivo, and these cells remained viable for at least 4 weeks after implantation. In addition, SPIO labeling did not appear to affect MPC survival or proliferation, as assessed by quantitative bioluminescence imaging ( MRI of exogenous MPCs labeled with SPIO particles allows for effective in vivo assessments of cell localization and retention in the setting of tendon regeneration for at least 4 weeks after implantation. This SPIO labeling does not appear to impair cell survival, transgene expression, or differentiation. SPIO labeling of MPCs appears to be safe for in vivo assessments of MPCs in tendon regeneration therapies and may be used for future clinical investigations of musculoskeletal regenerative medicine.

Surgeon Ability to Appropriately Address the Calcified Cartilage Layer: An In Vitro Study of Arthroscopic and Open Techniques

23-07-2019 – Adam B. Yanke,Andrew S. Lee,Vasili Karas,Geoffrey Abrams,Mark L. Riccio,Nikhil N. Verma,Bernard R. Bach,Brian J. Cole

Journal Article

Microfracture is a commonly utilized cartilage restoration technique for articular cartilage defects. While the removal of the calcified cartilage layer (CCL) has been shown to be critical with in vivo models, little is known with regard to surgeon reliability to adequately perform the technique. To evaluate surgeon reliability in removing the CCL utilizing open and arthroscopic techniques. Controlled laboratory study. Eleven cadaveric knees were utilized to create four 12-mm diameter defects in the anterior and posterior medial femoral condyles. Eleven fellowship-trained surgeons were asked to perform the following procedures: remove the CCL open, retain the CCL open, remove the CCL arthroscopically, and retain the CCL arthroscopically. Samples underwent histologic staining and analysis with 3-dimensional micro-computed tomography. The latter was used to calculate the percentage of the CCL that was removed or retained across the entire defect. When surgeons were asked to retain the CCL arthroscopically, 48% ± 41% (mean ± SD) remained. When surgeons were asked to remove the CCL arthroscopically, 24% ± 35% remained. There was no statistical difference between these groups ( This study highlights the significant variability in surgeon ability to reliably retain or remove the CCL. However, there appears to be improved ability of surgeons to more reliably remove or retain the CCL in an open fashion as compared with the arthroscopic approach.

Suture Button Versus Hook Plate for Acute Unstable Acromioclavicular Joint Dislocation: A Meta-analysis

17-07-2019 – Cong Wang,Jia-Hong Meng,Yi-Wen Zhang,Ming-Min Shi

Journal Article

Surgical treatment is indicated for unstable acromioclavicular (AC) joint dislocation. The hook plate (HP) technique is a commonly used treatment method, but the use of the suture button (SB) technique is increasing. To conduct a meta-analysis of clinical studies evaluating patient outcomes between the SB and HP techniques for acute unstable AC joint dislocation. Meta-analysis. A literature search of the Embase, PubMed, and Cochrane Library databases was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Cohort studies and case-control studies comparing the SB and HP procedures for acute unstable AC joint dislocation were included. Statistical analysis was performed with Rev
Man (v 5.3.5). Eight clinical studies that met the inclusion criteria were identified and included a total of 204 patients treated with the SB technique and 195 patients with the HP technique. Patients treated with the SB technique had a higher Constant score (mean difference [MD], 3.95; 95% CI, 1.20-6.70; This meta-analysis demonstrated that the SB technique resulted in better functional outcomes and a reduced visual analog scale pain score when compared with the HP technique. However, for operation time, coracoclavicular distance, complications, and loss of reduction, there were no statistically significant differences between the techniques. Compared with the open procedure, arthroscopic SB may be superior for better functional outcomes.

Dynamic Stabilization of Syndesmosis Injuries Reduces Complications and Reoperations as Compared With Screw Fixation: A Meta-analysis of Randomized Controlled Trials

12-06-2019 – Alberto Grassi,Kristian Samuelsson,Pieter D’Hooghe,Matteo Romagnoli,Massimiliano Mosca,Stefano Zaffagnini,Annunziato Amendola

Journal Article

Several devices for obtaining dynamic fixation of the syndesmosis have been introduced in recent years, but their efficacy has been tested in only a few randomized controlled trials (RCTs), without demonstrating any clear benefit over the traditional static fixation with screws. To perform a level 1 meta-analysis of RCTs to investigate the complications, subjective outcomes, and functional results after dynamic or static fixation of acute syndesmotic injuries. Meta-analysis of RCTs. A systematic literature search was performed of the Medline/PubMed, Cochrane Central Register of Controlled Trials, and Embase electronic databases, as well as Clinical for unpublished studies. Eligible studies were RCTs comparing dynamic fixation and static fixation of acute syndesmosis injuries. A meta-analysis was performed, while bias and quality of evidence were rated according to the Cochrane Database questionnaire and the Grading of Recommendations Assessment, Development and Evaluation guidelines. Dynamic fixation had a significantly reduced relative risk (RR = 0.55, The dynamic fixation of syndesmotic injuries was able to reduce the number of complications and improve clinical outcomes as compared with static screw fixation-especially malreduction and clinical instability or diastasis-at a follow-up of 2 years. A lower risk of reoperation was found with dynamic fixation as compared with static fixation with permanent screws. However, the lack of patients or personnel blinding, treatment heterogeneity, small samples, and short follow-up limit the overall quality of this evidence.

Hamstring Autograft Versus Hybrid Graft for Anterior Cruciate Ligament Reconstruction: A Systematic Review

05-06-2019 – Hong-De Wang,Shi-Jun Gao,Ying-Ze Zhang

Journal Article

Hamstring tendon autografts are commonly used for primary anterior cruciate ligament (ACL) reconstruction. Some patients have small hamstring tendons however, which may compromise the clinical outcome of the autograft. To solve this problem, many surgeons use hybrid grafting that involves augmentation of small hamstring autografts with allograft tissue. The purpose was to compare the clinical outcomes between primary ACL reconstructions performed with hamstring autografts and those performed with hybrid grafts in terms of patient-reported evaluation, failure rate, and knee stability. The hypothesis was that primary ACL reconstruction performed with hamstring autograft alone will not differ significantly from that performed with a hybrid graft in terms of patient-reported evaluation, failure rate, or knee stability. Systematic review. A systematic review was performed to identify prospective and retrospective comparative studies and cohort studies (evidence levels 1-3) comparing outcomes of primary ACL reconstructions performed with hamstring autografting alone and hybrid grafting. Outcomes included patient-reported evaluation, failure rate, and knee stability. Ten studies were included: 1 of level 2 and 9 of level 3. Collectively, they included 398 autografts and 341 hybrid grafts. Mean respective follow-up durations ranged from 24.0 to 69.6 months and from 24.0 to 70.8 months. Patient-reported evaluations, including Lysholm, Tegner, and subjective International Knee Documentation Committee scores, were reported in 8 of 10 studies. Failure rates were reported in all 10 studies. Results of knee stability examinations-including KT-1000 arthrometer measurements, the pivot-shift test, Lachman test, and overall International Knee Documentation Committee results-were reported in 4 of 10 studies. In this review, there were no statistically significant differences between autografts and hybrid grafts in terms of patient-reported evaluations, failure rates, or KT-1000 measurements. In this systematic review, there was no significant difference in patient-reported evaluation or failure rate between primary ACL reconstructions performed with autografts alone and those performed with hybrid grafts. Whether there is a substantial difference in knee stability examination results between autografts and hybrid grafts remains unknown, given a relative lack of reports on knee stability.

Two-Stage Revision Anterior Cruciate Ligament Reconstruction: A Systematic Review of Bone Graft Options for Tunnel Augmentation

22-05-2019 – Hytham S. Salem,Derek P. Axibal,Michelle L. Wolcott,Armando F. Vidal,Eric C. McCarty,Jonathan T. Bravman,Rachel M. Frank

Journal Article

No consensus is available regarding the optimal choice of bone graft material for bone tunnel augmentation in revision anterior cruciate ligament (ACL) surgery. To compare the outcomes of different bone graft materials for staged revision ACL reconstruction. Systematic review. A systematic review using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was performed. PubMed, EMBASE, and the Cochrane Library were queried through use of the terms anterior cruciate ligament and revision to identify all studies reporting outcomes of bone tunnel grafting in 2-stage revision ACL reconstruction. Data extracted included indications for 2-stage surgery, surgical technique, graft material, time between surgeries, rehabilitation protocols, physical examination findings, patient-reported outcomes, and radiographic and histologic findings. The analysis included 7 studies with a total of 234 patients. The primary outcome in 2 studies was graft incorporation (mean follow-up, 8.8 months), whereas the other 5 studies reported clinical outcomes with follow-up mean ± SD of 4.2 ± 2.1 years. The indication for bone grafting and between-stage protocol varied among studies. Autograft was used in 4 studies: iliac crest bone autograft (ICBG, n = 3) and tibial bone autograft (TBA, n = 1). In 2 studies, the authors investigated the outcomes of allograft: allograft bone matrix (ABM) and allograft bone chips (AC). Finally, 1 study compared ICBG to a synthetic bone substitute. Radiographic evaluation of bone graft integration after the first stage was reported in 4 studies, with an average duration of 4.9 months. In 4 studies, the authors reported the time interval between first and second surgeries, with an average of 6.1 months for ICBG compared with 8.7 months for allogenic and synthetic grafts. Revision ACL graft failure rates were reported by 5 studies, including 1 study with ABM (6.1%), 1 study with AC (8.3%), 1 study with TBA (0%), and 2 studies with ICBG (0% and 2%). The indications for staged ACL reconstruction and the rehabilitation protocol between stages need to be clearly established. The available data indicate that autograft for bone tunnel grafting in 2-stage ACL revision may be associated with a lower risk of revision ACL reconstruction graft failure compared with allograft bone.

Properties and Function of the Medial Patellofemoral Ligament: A Systematic Review

15-05-2019 – Christian Huber,Qiang Zhang,William R. Taylor,Andrew A. Amis,Colin Smith,Seyyed Hamed Hosseini Nasab

Journal Article

As the main passive structure preventing patellar lateral subluxation, accurate knowledge of the anatomy, material properties, and functional behavior of the medial patellofemoral ligament (MPFL) is critical for improving its reconstruction. To provide a state-of-the-art understanding of the properties and function of the MPFL by undertaking a systematic review and statistical analysis of the literature. Systematic review. On June 26, 2018, data for this systematic review were obtained by searching PubMed and Scopus. Articles containing numerical information regarding the anatomy, mechanical properties, and/or functional behavior of the MPFL that met the inclusion criteria were reviewed, recorded, and statistically evaluated. A total of 55 articles met the inclusion criteria for this review. The MPFL presented as a fanlike structure spanning from the medial femoral epicondyle to the medial border of the patella. The reported data indicated ultimate failure loads from 72 N to 208 N, ultimate failure elongation from 8.4 mm to 26 mm, and stiffness values from 8.0 N/mm to 42.5 N/mm. In both cadaveric and in vivo studies, the average elongation pattern demonstrated close to isometric behavior of the ligament in the first 50° to 60° of knee flexion, followed by progressive shortening into deep flexion. Kinematic data suggested clear lateralization of the patella in the MPFL-deficient knee during early knee flexion under simulated muscle forces. A lack of knowledge regarding the morphology and attachment sites of the MPFL remains. The reported mechanical properties also lack consistency, thus requiring further investigations. However, the results regarding patellar tracking confirm that the lack of an MPFL leads to lateralization of the patella, followed by delayed engagement of the trochlear groove, plausibly leading to an increased risk of patellar dislocations. The observed isometric behavior up to 60° of knee flexion plausibly suggests that reconstruction of the ligament can occur at flexion angles below 60°, including the 30° and 60° range as recommended in previous studies.

Comparative Effectiveness of Cartilage Repair With Respect to the Minimal Clinically Important Difference

13-05-2019 – Kristofer J. Jones,Benjamin V. Kelley,Armin Arshi,David R. McAllister,Peter D. Fabricant

Journal Article

Recent studies demonstrated a 5% increase in cartilage repair procedures annually in the United States. There is currently no consensus regarding a superior technique, nor has there been a comprehensive evaluation of postoperative clinical outcomes with respect to a minimal clinically important difference (MCID). To determine the proportion of available cartilage repair studies that meet or exceed MCID values for clinical outcomes improvement over short-, mid-, and long-term follow-up. Systematic review and meta-analysis. A systematic review was performed via the Medline, Scopus, and Cochrane Library databases. Available studies were included that investigated clinical outcomes for microfracture (MFX), osteoarticular transfer system (OATS), osteochondral allograft transplantation, and autologous chondrocyte implantation/matrix-induced autologous chondrocyte implantation (ACI/MACI) for the treatment of symptomatic knee chondral defects. Cohorts were combined on the basis of surgical intervention by performing a meta-analysis that utilized inverse-variance weighting in a Der
Simonian-Laird random effects model. Weighted mean improvements in International Knee Documentation Committee (IKDC), Lysholm, and visual analog scale for pain (VAS pain) scores were calculated from preoperative to short- (1-4 years), mid- (5-9 years), and long-term (≥10 years) postoperative follow-up. Mean values were compared with established MCID values per 2-tailed 1-sample Student t tests. A total of 89 studies with 3894 unique patients were analyzed after full-text review. MFX met MCID values for all outcome scores at short- and midterm follow-up with the exception of VAS pain in the midterm. OATS met MCID values for all outcome scores at all available time points; however, long-term data were not available for VAS pain. Osteochondral allograft transplantation met MCID values for IKDC at short- and midterm follow-up and for Lysholm at short-term follow-up, although data were not available for other time points or for VAS pain. ACI/MACI met MCID values for all outcome scores (IKDC, Lysholm, and VAS pain) at all time points. In the age of informed consent, it is important to critically evaluate the clinical outcomes and durability of cartilage surgery with respect to well-established standards of clinical improvement. MFX failed to maintain VAS pain improvements above MCID thresholds with follow-up from 5 to 9 years. All cartilage repair procedures met MCID values at short- and midterm follow-up for IKDC and Lysholm scores; ACI/MACI and OATS additionally met MCID values in the long term, demonstrating extended maintenance of clinical benefits for patients undergoing these surgical interventions as compared with MFX.

Hop Testing Lacks Strong Association With Key Outcome Variables After Primary Anterior Cruciate Ligament Reconstruction: A Systematic Review

07-05-2019 – Justin M. Losciale,Garrett Bullock,Christina Cromwell,Leila Ledbetter,Laura Pietrosimone,Timothy C. Sell

Journal Article

Single-legged hop tests are commonly used assessments in return to sport (RTS) testing after anterior cruciate ligament reconstruction (ACLR). Although these tests are commonly used, their predictive validity has not yet been established. To determine the strength of association between hop testing and RTS, knee reinjury, subjective report of knee function, and posttraumatic knee osteoarthritis (PTOA) after primary ACLR. Secondarily, to determine whether hop testing is able to predict a favorable result on the same outcome variables. Systematic review. A systematic, computer-assisted literature search was performed in PubMed/MEDLINE, CINAHL, EMBASE, SPORTDiscus, Cochrane Library, and Clinical The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed when conducting and reporting this review. Primary outcome variables for this review were self-report of knee function, return to preinjury level of activity, presence of reinjury, and presence of PTOA. The Oxford Centre for Evidence-Based Medicine Levels of Evidence tool was used to assess the level of evidence for each included study. Quality assessment of each included study was performed through use of a modified Downs and Black scale. Available metrics were tabulated based on outcome variables. Overall, 21 studies (4476 patients) met inclusion for this review. The majority of evidence (95.2%) was of moderate to high methodologic quality. The most commonly associated outcome measure was the International Knee Documentation Committee (IKDC) score, with Pearson correlation coefficients ranging from 0.20 to 0.60. The strength of association between the Knee injury and Osteoarthritis Outcome Score (KOOS) and hop testing ranged from -0.10 to 0.62 in 4 studies. In all, 10 studies examined the relationship between hop testing and RTS, with variable association statistics reported. No meaningful association was found between hop testing and knee reinjury in 2 studies. Worse preoperative hop testing was associated with PTOA in 1 study. Hop testing appears to possess fair association to subjective report of knee function measured by the KOOS and IKDC and a patient’s ability to RTS after ACLR. Insufficient evidence is available to determine the relationship between hop testing and PTOA and knee reinjury. Predictive validity cannot be established based on available literature.

A Practical Guide for the Current Use of Biologic Therapies in Sports Medicine

30-04-2019 – Joseph D. Lamplot,Scott A. Rodeo,Robert H. Brophy

Journal Article

Over the past decade, there has been an increased interest in the use of biologic therapies in sports medicine. Although these technologies are in relatively early stages of development, there have been substantial increases in marketing, patient demand, and clinical utilization of biologics, including platelet-rich plasma, bone marrow aspirate concentrate, and other cell-derived therapies. Direct-to-consumer marketing of biologics has also proliferated but is largely unregulated, and clinicians must accurately convey the safety and efficacy profiles of these therapies to patients. Because most insurance companies consider biologic treatments to be experimental or investigational for orthopaedic applications given the lack of high-quality evidence to support their efficacy, patients receiving these treatments often make substantial out-of-pocket payments. With a range of treatment costs among centers offering biologics, there is a need for appropriate and sustainable pricing and reimbursement models. Clinicians utilizing biologics must also have a thorough understanding of the recently clarified Food and Drug Administration guidelines that regulate the clinical use of cell and tissue products. There is a lack of consensus on the optimal preparation, source, delivery method, and dosing of biologic therapies, which has been exacerbated by a lack of sufficient experimental detail in most published studies. Future research must better identify the biologic target of treatment, adhere to better standards of reporting, and better integrate researchers, industry, and regulatory bodies to optimize applications.

Repair of Rotator Cuff Tears in the Elderly: Does It Make Sense? A Systematic Review

30-04-2019 – Burak Altintas,Nicole L. Anderson,Rafael Pitta,Patrick S. Buckley,Sanjeev Bhatia,Matthew T. Provencher,Peter J. Millett

Journal Article

The indications and outcomes for rotator cuff repair (RCR) among patients ≥70 years old are not widely reported. Many active patients in this age range desire a joint-preserving option, and several small series reported successful clinical outcomes after RCR among patients aged ≥70 years. The purpose of this study was to systematically review the literature on the outcomes of RCR among patients ≥70 years old. Systematic review; Level of evidence, 4. A systematic review of the literature was performed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The electronic databases of PubMed and Cochrane were used for the literature search. The quality of the included studies was evaluated according to the Coleman Methodology Score. Studies in English evaluating repair of full-thickness rotator cuff tears among patients aged ≥70 years were included. Eleven studies were reviewed, including 680 patients (694 shoulders) who were treated with arthroscopic and/or open RCR with a mean follow-up of 24.2 months (range, 12-40.8 months). Forty patients were lost to follow-up, leaving 654 shoulders with outcome data. This age group demonstrated a significant increase in clinical and functional outcomes after RCR with high satisfaction. American Shoulder and Elbow Surgeons scores showed an improvement from 44.2 (range, 35.4-56) preoperatively to 87.9 (range, 84-90.3) postoperatively, while Constant scores improved from 41.7 (range, 22.6-53.6) to 70.8 (range, 58.6-76). Postoperative imaging evaluation was performed on 513 shoulders, revealing a retear rate of 27.1% (139 shoulders). There were 45 retears after open repair and 94 after arthroscopic repair. The difference in retear rate among patients receiving arthroscopic repairs was not significantly different than open repairs ( P = .831). Pain according to a visual analog scale improved from 5.5 (range, 4.6-6.4) preoperatively to 1.3 (range, 0.5-2.3) postoperatively. RCR among patients ≥70 years old shows high clinical success rates with good outcomes and overall excellent pain relief. Although patients in this age group have a high potential for retear or persistent defects on imaging studies, RCR offers a joint-preserving option with significant functional and clinical improvement for the appropriately indicated patient.

Return to Play After the Latarjet Procedure for Anterior Shoulder Instability: A Systematic Review

30-04-2019 – Eoghan T. Hurley,Connor Montgomery,M. Shazil Jamal,Yoshiharu Shimozono,Zakariya Ali,Leo Pauzenberger,Hannan Mullett

Journal Article

Traumatic anterior shoulder instability is a common clinical problem among athletic populations. The Latarjet procedure is a widely used treatment option to address shoulder instability in high-demand athletes at high risk of recurrence. However, rates and timing of full return to sports have not been systematically analyzed. To systematically review the evidence in the literature to ascertain the rate and timing of return to play and the availability of specific criteria for safe return to play after the Latarjet procedure. Systematic review. A systematic literature search was conducted based on PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, using the EMBASE, MEDLINE, and Cochrane Library databases. Eligible for inclusion were clinical studies reporting on return to play after the Latarjet procedure. Statistical analysis was performed by use of SPSS. Our review found 36 studies including 2134 cases meeting our inclusion criteria. The majority of patients were male (86.9%), with a mean age of 25.4 years (range, 15-59 years) and a mean follow-up of 83.5 months. The overall rate of return to play was 88.8%, with 72.6% returning to the same level of play. Among collision athletes, the overall rate of return to play was 88.2%, with 69.5% returning to the same level of play. In overhead athletes, the overall rate of return to play was 90.3%, with 80.6% returning to the same level of play. The mean time to return to play was 5.8 months (range, 3.2-8 months). Specific return to play criteria were reported in the majority of the studies (69.4%); time to return to sport was the most commonly reported item (66.7%). The overall rate of return to play was reportedly high after the Latarjet procedure. However, almost a fifth of athletes returning to sports were not able to return at the same level. Further development of validated criteria for safe return to sports could potentially improve clinical outcomes and reduce recurrence rates.

Cost-efficacy of Knee Cartilage Defect Treatments in the United States

30-04-2019 – Joshua S. Everhart,Andrew B. Campbell,Moneer M. Abouljoud,J. Caid Kirven,David C. Flanigan

Journal Article

Multiple knee cartilage defect treatments are available in the United States, although the cost-efficacy of these therapies in various clinical scenarios is not well understood. The purpose was to determine cost-efficacy of cartilage therapies in the United States with available mid- or long-term outcomes data. The authors hypothesized that cartilage treatment strategies currently approved for commercial use in the United States will be cost-effective, as defined by a cost 3 cm Currently employed treatments for knee cartilage defects in the United States are cost-effective in most clinically acceptable applications. Microfracture is not a cost-effective initial treatment of defects >3 cm

Horizontal Instability of the Acromioclavicular Joint: A Systematic Review

23-04-2019 – Gianna M. Aliberti,Matthew J. Kraeutler,Jeffrey D. Trojan,Mary K. Mulcahey

Journal Article

Injuries to the acromioclavicular (AC) joint are common and should be suspected in patients who have shoulder pain in the region of the acromion and clavicle. Injuries to the AC ligament can cause horizontal instability and are often neglected or underdiagnosed, which can lead to poor patient outcomes. To perform a systematic review of the literature on the diagnosis and treatment of horizontal instability of the AC joint. Systematic review. The authors performed a systematic review using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. PubMed and EMBASE were searched for studies that investigated diagnosis, treatment, and failure of operative management of acute and chronic AC separations. Studies that did not specifically evaluate AC joint injuries, were not written in English, or were specific only to vertical instability of the AC joint were excluded. Overall, 23 articles met the inclusion criteria and were therefore included in this systematic review. Diagnosing horizontal AC instability is difficult using plain radiographs; dynamic views were shown in some cases to better detect horizontal instability than with static views. More than 60 procedures for treating AC joint injuries have been published, but many focus on vertical rather than horizontal instability. Modifications to current surgical procedures to incorporate reconstruction of the horizontal component showed improved patient outcomes. Such modifications included additional AC joint suture cord cerclage, combined AC and coracoclavicular ligament reconstruction, and the Twin Tail Tight
Rope triple button technique. Failure after surgical stabilization of AC joint separation has been reported to occur in 15% to 80% of cases. No consensus is available regarding the best practices for diagnosis, evaluation, and treatment of acute or chronic horizontal instability of the AC joint. Moreover, horizontal instability injuries are often neglected or poorly understood, making diagnosis difficult, which may lead to high complication rates and failure after surgical stabilization.

Current Workload Recommendations in Baseball Pitchers: A Systematic Review

23-04-2019 – Neil K. Bakshi,Paul M. Inclan,Jacob M. Kirsch,Asheesh Bedi,Cristine Agresta,Michael T. Freehill

Journal Article

Several recommendations have been made regarding pitch counts and workload for baseball players of different levels, including Little League, high school, collegiate, and professional baseball. However, little consensus is found in the literature regarding the scientific basis for many of these recommendations. The primary purpose of this study was to summarize the evidence regarding immediate and long-term musculoskeletal responses to increasing pitching workload in baseball pitchers of all levels. A secondary purpose of this review was to evaluate the extent to which workload influences injury and/or performance in baseball pitchers. Systematic review. We performed a systematic search in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for studies addressing physiologic and/or pathologic musculoskeletal changes in response to a quantifiable pitching workload. We included studies examining the effects of pitching workload on performance, injury rate, and musculoskeletal changes in Little League, high school, collegiate, and professional baseball players. We identified 28 studies that met our inclusion and exclusion criteria: 16 studies regarding Little League and high school pitchers and 12 studies regarding collegiate and professional pitchers. The current evidence presented suggests that increased pitching workload may be associated with an increased risk of pain, injury, and arm fatigue in Little League and high school pitchers. However, little consensus was found in the literature regarding the association between pitching workload and physiologic or pathologic changes in collegiate and professional pitchers. Evidence, although limited, suggests the use of pitch counts to decrease injury rates and pain in Little League and high school baseball pitchers. However, further research must be performed to determine the appropriate number of pitches (or throws) for players of different ages. This systematic review reported conflicting evidence regarding the use of pitch counts in college and professional baseball. Future high-quality research is required to determine the role, if any, of pitch counts for collegiate and professional pitchers.

Return to Sport After Arthroscopic Rotator Cuff Repair: Is There a Difference Between the Recreational and the Competitive Athlete?

11-03-2019 – Burak Altintas,Nicole Anderson,Grant J. Dornan,Robert E. Boykin,Catherine Logan,Peter J. Millett

Journal Article

Return to sport (RTS) remains an important challenge and measure of success for athletes undergoing arthroscopic rotator cuff repair (RCR). To determine the rate of RTS after RCR and to analyze predictive factors associated with a lower rate of return. Systematic review and meta-analysis. A systematic review of the literature was performed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The electronic databases of PubMed, MEDLINE, Cochrane, and Google Scholar were used for the literature search. Study quality was evaluated according to the Coleman Methodology Score. Studies in English evaluating RTS after arthroscopic repair of partial- or full-thickness rotator cuff tears among athletes of all levels, ages, and sports were included. Random effects meta-analysis and metaregression were performed to investigate RTS activity rate after arthroscopic RCR and to explore study heterogeneity, respectively. Fifteen studies were reviewed, including 486 patients (499 shoulders) who were treated with arthroscopic RCR and who had a mean follow-up of 40.1 months (range, 18-74.4 months). Eighteen patients were lost to follow-up, leaving 468 patients with outcome data; 347 identified themselves as athletes (81 competitive, 266 recreational). The most commonly included sports were baseball (n = 45), golf (n = 38), football (n = 23), and tennis (n = 18). RTS specific to the type of athlete was reported for 299 of 347 athletes. According to the meta-analysis, the overall rate of RTS at a similar level of play or higher was 70.2%, with 73.3% of recreational athletes and 61.5% of competitive athletes able to return. A subset of 43 baseball and softball players across 4 studies yielded a 79% rate of RTS; however, only 38% returned to the same level of play or higher. Subgroup meta-analysis revealed no significant difference in the rate of RTS between competitive and recreational athletes. Metaregression analysis revealed that the mean follow-up time and mean age at surgery were not significantly associated with RTS rate. Most athletes (70.2%) were able to return to a preinjury level of play after arthroscopic RCR. While recreational sports participation (73.3%) was associated with higher return, competitive sports (61.5%) and overhead sports (38%) were associated with lower return. Exactly why all athletes do not return remains uncertain and likely multifactorial.

Midshaft Clavicle Fractures: Surgery Provides Better Results as Compared With Nonoperative Treatment: A Meta-analysis

05-03-2019 – Enrico Guerra,Davide Previtali,Simone Tamborini,Giuseppe Filardo,Stefano Zaffagnini,Christian Candrian

Journal Article

There is no agreement on the best treatment for displaced midshaft clavicle fractures (MCFs), which are currently addressed by nonoperative or surgical approaches. The aim of this meta-analysis was to compare fracture healing and functional outcome after surgical versus nonsurgical treatment of MCFs, to help specialists in deciding between these different strategies by providing a synthesis of the best literature evidence. Meta-analysis. A systematic research of the literature was performed in different online databases: PubMed, Web of Science, Cochrane library, and grey literature. PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) guidelines were used. The risk of bias was evaluated with the Cochrane Collaboration’s “risk of bias” tool, and the quality of evidence was graded according to Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines. Randomized controlled trials investigating differences between surgery and nonoperative treatment for displaced MCFs were included. The primary outcome was the nonunion rate. Other outcomes analyzed were time to union and to return to activities, Constant score, and Disabilities of the Arm, Shoulder and Hand (DASH) index. Patients’ satisfaction, secondary operations, and complications were also recorded. Out of 832 records found, 14 randomized controlled trials with 1546 patients were included. A significantly lower risk ratio was found for nonunion (10%; 95% CI, 6%-18%, P < .001) favoring surgery. Time to union was 5.1 weeks shorter with surgery ( P = .007). The complication rate (including the number of reinterventions) was higher in the surgical group (31.3% vs 20.5%, P < .001). Shoulder function at short-term follow-up was significantly better in the surgical group (DASH index mean difference = 4.0 points), while no statistical difference was found in the Constant score and in the DASH index at midterm follow-up ( P = .41 and .80, respectively). At long-term follow-up, both shoulder functional scores were significantly better in the surgery group: the overall Constant score mean difference was 5.3 points (95% CI, 2.3-8.4 points; P < .001), and the DASH index mean difference was 4.3 points (95% CI, 0.2-8.4 points; P = .04). Surgical treatment of MCFs significantly reduces the nonunion rate and shortens the time to union as compared with the nonoperative approach and, despite a slightly higher incidence of complications, leads to better shoulder functional scores at short- and long-term follow-up. Further studies should address the clinical significance of the documented improvement.

Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis of Outcomes for Quadriceps Tendon Autograft Versus Bone–Patellar Tendon–Bone and Hamstring-Tendon Autografts

21-02-2019 – Dany Mouarbes,Jacques Menetrey,Vincent Marot,Louis Courtot,Emilie Berard,Etienne Cavaignac

Journal Article

Comprehensive studies evaluating quadriceps tendon (QT) autograft for anterior cruciate ligament (ACL) reconstruction are lacking. The optimal choice of graft between bone-patellar tendon-bone (BPTB), hamstring tendon (HT), and QT is still debatable. The current literature supports the use of QT as a strong autograft with good outcomes when used in ACL reconstruction. Meta-analysis; Level of evidence, 2. A systematic search of the literature was performed in PubMed, MEDLINE, Cochrane, and Ovid databases to identify published articles on clinical studies relevant to ACL reconstruction with QT autograft and studies comparing QT autograft versus BPTB and HT autografts. The results of the eligible studies were analyzed in terms of instrumented laxity measurements, Lachman test, pivot-shift test, Lysholm score, objective and subjective International Knee Documentation committee (IKDC) scores, donor-site pain, and graft failure. Twenty-seven clinical studies including 2856 patients with ACL reconstruction met the inclusion criteria. Comparison of 581 QT versus 514 BPTB autografts showed no significant differences in terms of instrumented mean side-to-side difference ( P = .45), Lachman test ( P = .76), pivot-shift test grade 0 ( P = .23), pivot-shift test grade 0 or 1 ( P = .85), mean Lysholm score ( P = .1), mean subjective IKDC score ( P = .36), or graft failure ( P = .50). However, outcomes in favor of QT were found in terms of less donor-site pain (risk ratio for QT vs BPTB groups, 0.25; 95% CI, 0.18-0.36; P < .00001). Comparison of 181 QT versus 176 HT autografts showed no significant differences in terms of instrumented mean side-to-side difference ( P = .75), Lachman test ( P = .41), pivot-shift test grade 0 ( P = .53), Lysholm score less than 84 ( P = .53), mean subjective IKDC score ( P = .13), donor-site pain ( P = .40), or graft failure ( P = .46). However, outcomes in favor of QT were found in terms of mean Lysholm score (mean difference between QT and HT groups, 3.81; 95% CI, 0.45-7.17; P = .03). QT autograft had comparable clinical and functional outcomes and graft survival rate compared with BPTB and HT autografts. However, QT autograft showed significantly less harvest site pain compared with BPTB autograft and better functional outcome scores compared with HT autograft.

Efficacy of Pharmacological Therapies for Adhesive Capsulitis of the Shoulder: A Systematic Review and Network Meta-analysis

08-02-2019 – Dimitrios Kitridis,Konstantinos Tsikopoulos,Ilias Bisbinas,Paraskevi Papaioannidou,Panagiotis Givissis

Journal Article

Several pharmacological interventions are used for the management of adhesive capsulitis of the shoulder, although the optimal treatment has yet to be defined. To conduct a network meta-analysis to compare the effects of different pharmacological interventions for adhesive capsulitis, administered either alone or after distension of the shoulder capsule. Network meta-analysis. The authors searched Scopus, PubMed, and the Cochrane Central Register of Controlled Trials up to April 22, 2018, for completed studies. They enrolled trials that assessed the results of different pharmacological treatments for the primary management of adhesive capsulitis. The primary outcome was pain relief as measured by self-administered questionnaires. The secondary outcome included the assessment of composite instruments that evaluated, at a minimum, pain and function. The authors clinically interpreted the results after back-transforming the standardized mean differences into mean differences in simple instruments and assessed the quality of the source studies using the Cochrane “risk of bias” tool. The authors considered 30 trials with a total of 2010 participants in this systematic review. For pain relief, there was a significant difference in favor of intra-articular corticosteroids and distension of the shoulder capsule with steroids as compared with control in the short term (mean difference in visual analog scale (VAS): -1.4 [95% CI, -2.5 to -0.4] and -1.7 [95% CI, -3.2 to -0.1], respectively). Furthermore, rotator-interval injections were found to be superior to placebo (mean difference in VAS: -7.2; 95% CI, -10.1 to -4.4), although the intervention was considered in only 1 trial. Finally, there was a statistically significant difference in favor of multiple-site corticosteroid injections compared to placebo in both the short- (mean difference in Shoulder Pain and Disability Index [SPADI]: -86.7; 95% CI, -133.6 to -40) and intermediate-term assessment (mean difference in SPADI: -102.9; 95% CI, -163.9 to -41.8). Intra-articular corticosteroid intervention, administered either alone or after distension of the shoulder capsule, provided clinically meaningful improvements in the short term. Likewise, rotator-interval corticosteroid injections yielded promising results in terms of pain relief. However, these short-term benefits of steroids dissipated over time. Multiple-site corticosteroid injections showed clinical advantage over placebo for short- and intermediate-term composite outcome assessments.

Age-Appropriate Pediatric Sports Patient-Reported Outcome Measures and Their Psychometric Properties: A Systematic Review

16-01-2019 – Joash R. Suryavanshi,Rie Goto,Bridget Jivanelli,Jamila Aberdeen,Timothy Duer,Kenneth C. Lam,Corinna C. Franklin,James MacDonald,Kevin G. Shea,Peter D. Fabricant

Journal Article

Phenomena including early sport specialization and year-round training and competition have contributed to an increase in pediatric sports injuries. There has been a concomitant increase in clinical studies focusing on physically active children and adolescents. These studies include investigations of patient-reported outcome measures (PROMs). While the use of PROMs in pediatric orthopaedics has been increasing, PROMs are often inappropriately applied to study populations for whom they are not specifically validated. The purpose of this study was to establish a comprehensive list of pediatric- and adolescent-validated PROMs and catalog their psychometric properties as a resource for clinicians and researchers. Systematic review; Level of evidence, 4. A systematic review of articles in PubMed, Embase, and the Cochrane library was performed to identify articles developing and validating PROMs appropriate for use in pediatric sports medicine research. The inclusion criteria were as follows: age <18 years, the use of surveys and questionnaires, and the presence of sports-related injuries. The psychometric properties of included PROMs were entered into an electronic database. Our search strategy identified 14,708 unique articles, among which 139 studies (0.9%) were included in the final data analysis. Forty-seven distinct PROMs were identified, as well as 160 cross-cultural adaptations. While all identified PROMs were validated in physically active young participants, only 12 (26%) were specifically created initially for active children. Thirty (64%) PROMs were health-related quality-of-life measures; 13 (28%) were psychosocial measures; and 4 (9%) were activity scales. No studies validated PROMs for use with wrist/hand injuries, and only 1 PROM each was valid for hip, back/spinal, and foot/ankle injuries in pediatric sports. This systematic review yielded 47 unique PROMs reliable and valid for use in pediatric and adolescent sports medicine. This list will unify clinicians and researchers in using these age-appropriate measures while identifying areas that are still in need of appropriate PROMs for young athletes.

Outcomes With a Focus on Return to Play for Revision Ulnar Collateral Ligament Surgery Among Elite-Level Baseball Players: A Systematic Review

31-12-2018 – Georgina Glogovac,Brian M. Grawe

Journal Article

Ulnar collateral ligament (UCL) reconstruction is commonly performed among overhead throwing athletes. Previous studies demonstrated relatively high rates of return to sport after primary reconstruction. Outcomes after revision UCL reconstruction have not been widely studied. To report the rate of return to sport after revision UCL reconstruction among elite-level baseball players. Systematic review. A systematic review of the literature following the PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) guidelines was performed for high-level baseball players undergoing revision UCL reconstruction. Study bias was assessed with the Methodological Index for Non-Randomized Studies scoring system. The primary outcome measure was whether the study participants were able to return to sport after revision UCL reconstruction. Secondary outcome measures included career length after revision and pitching performance statistics. Data were summarized with ranges, tables, and weighted averages. A subjective analysis was performed. A total of 5 studies met inclusion criteria. The rate of return to sport at preinjury level was 62.8%. Among Major League Baseball pitchers, the rate of return to sport at the preinjury level was 68.8%. The rate of return to sport at the same level or lower (Major League Baseball, minor league, collegiate) was 78.1%. Time to return to sport ranged from 1.3 to 1.7 years. Mean earned run average after revision ranged from 4.87 to 5.04. Mean number of innings pitched per season after revision ranged from 36.95 to 50.5. This systematic review demonstrated a limited rate of return to preinjury level of sport among elite-level baseball players who underwent revision UCL reconstruction. Pitching durability and career longevity were inferior to results that were reported for players who underwent primary UCL reconstruction alone. This study suggests that outcomes after revision UCL reconstruction are not reliable and elite-level players should be counseled accordingly.

It’s Not All About Redislocation: A Systematic Review of Complications After Anterior Shoulder Stabilization Surgery

11-12-2018 – Huw Lloyd Morgan Williams,Jonathan Peter Evans,Nicholas Duncan Furness,Christopher David Smith

Journal Article

The surgical treatment of recurrent shoulder instability has evolved in recent years to include a variety of soft tissue and bone block procedures, undertaken with either an open or arthroscopic approach. Although the utilization of such techniques has rapidly expanded, the associated risk of complications remains poorly defined. This information is vital for clinical decision making and patient counseling. To quantify the complication rate associated with all types of surgery for anterior glenohumeral joint dislocation. Systematic review. A systematic search was undertaken of studies reporting complications from anterior shoulder stabilization surgery. Inclusion criteria were studies published in English between 2000 and 2017 with a minimum 2-year follow-up. Methodological quality of the included studies was assessed with the Methodological Index for Non-Randomized Studies criteria. Complication rates for all undesirable events contributing to the patient outcome were extracted and cumulative rates calculated. Out of 1942 references, 56 studies were included, totaling 4362 procedures among 4336 patients. Arthroscopic soft tissue repair had a complication rate of 1.6% (n = 2805). When repair was combined with arthroscopic remplissage, the rate was 0.5% (n = 219). Open soft tissue repair had a complication rate of 6.2% (n = 219) and open labral repair with remplissage, a rate of 2.3% (n = 79). An open bone block procedure had a complication rate of 7.2% (n = 573) and an arthroscopic bone block procedure, a rate of 13.6% (n = 163). This large systematic review demonstrates the overall complication rates (not purely recurrence rates) in modern shoulder stabilization surgery. With the growing interest in bone block stabilization procedures, including those performed arthroscopically, surgeons should be aware of the 10-fold increase in complications for these procedures over soft tissue arthroscopic surgery and counsel their patients accordingly.

Osteochondral Allograft Transplantation in the Patellofemoral Joint: A Systematic Review

07-12-2018 – Jorge Chahla,Matthew C. Sweet,Kelechi R. Okoroha,Benedict U. Nwachukwu,Betina Hinckel,Jack Farr,Adam B. Yanke,William D. Bugbee,Brian J. Cole

Journal Article

The initial focus of cartilage restoration algorithms has been on the femur; however, the patellofemoral compartment accounts for 20% to 30% of significant symptomatic chondral pathologies. While patellofemoral compartment treatment involves a completely unique subset of comorbidities, with a comprehensive and thoughtful approach many patients may benefit from osteochondral allograft treatment. To perform a systematic review of clinical outcomes and failure rates after osteochondral allograft transplantation (OCA) of the patellofemoral joint at a minimum 18-month follow-up. Systematic review; Level of evidence, 4. A systematic review of the literature regarding the existing evidence for clinical outcomes and failure rates of OCA for patellofemoral joint chondral defects was performed with the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed, and MEDLINE from studies published between 1990 and 2017. Inclusion criteria were as follows: clinical outcomes and failure rates of OCA for the treatment of chondral defects in the patellofemoral joint, English language, minimum follow-up of 18 months, minimum study size of 5 patients, and human studies. The methodological quality of each study was assessed with a modified version of the Coleman methodology score. The systematic search identified 8 studies with a total of 129 patients. The methods of graft procurement and storage time included fresh (121 patients, 93.8%), and cryopreserved (8 patients, 6.2%) grafts. The mean survival rate was 87.9% at 5 years and 77.2% at 10 years. The following outcome scores showed significant improvement from pre- to postoperative status: modified d’Aubigné-Postel, International Knee Documentation Committee, Knee Society Score-Function, and Lysholm Knee Score. OCA of the patellofemoral joint results in improved patient-reported outcome measures with high patient satisfaction rates. Five- and 10-year survival rates of 87.9% and 77.2%, respectively, can be expected after this procedure. These findings should be taken with caution, as a high percentage of patellofemoral osteochondral allografts were associated with concomitant procedures; therefore, further research is warranted to determine the effect of isolated osteochondral transplantations.

Suture Button Versus Syndesmotic Screw for Syndesmosis Injuries: A Meta-analysis of Randomized Controlled Trials

26-11-2018 – Yoshiharu Shimozono,Eoghan T. Hurley,Charles L. Myerson,Christopher D. Murawski,John G. Kennedy

Journal Article

Operative treatment is indicated for unstable syndesmosis injuries, and approximately 20% of all ankle fractures require operative fixation for syndesmosis injuries. To perform a meta-analysis of randomized controlled trials evaluating clinical outcomes between suture button (SB) and syndesmotic screw (SS) fixation techniques for syndesmosis injuries of the ankle. Meta-analysis. A literature search was performed according to the PRISMA guidelines to identify randomized controlled trials comparing the SB and SS techniques for syndesmosis injuries. Level of evidence was assessed per the criteria of the Oxford Centre for Evidence-Based Medicine. Statistical analysis was performed with Rev
Man, and a P value ≤.05 was considered statistically significant. Five clinical studies were identified, allowing comparison of 143 patients in the SB group with 142 patients in the SS group. Patients treated with the SB technique had a higher postoperative American Orthopaedic Foot & Ankle Society score at a mean 20.8 months (95.3 vs 86.7, P < .001). The SB group resulted in a lower rate of broken implants (0.0% vs 25.4%, P < .001), implant removal (6.0% vs 22.4%, P = .01), and joint malreduction (0.8% vs 11.5%, P = .05) as compared with the SS group. The SB technique results in improved functional outcomes as well as lower rates of broken implant and joint malreduction. Based on the findings of this meta-analysis, the SB technique warrants a grade A recommendation by comparison with the SS technique for the treatment of syndesmosis injuries.

Comparative Efficacy and Safety of Nonsurgical Treatment Options for Enthesopathy of the Extensor Carpi Radialis Brevis: A Systematic Review and Meta-analysis of Randomized Placebo-Controlled Trials

31-10-2018 – Jayson Lian,Amin Mohamadi,Jimmy J. Chan,Phillip Hanna,David Hemmati,Aron Lechtig,Ara Nazarian

Journal Article

Numerous treatment options have been proposed for enthesopathy of the extensor carpi radialis brevis (e
ECRB). To (1) compare the efficacy and safety of nonsurgical treatment options for e
ECRB described in randomized placebo-controlled trials at short-term, midterm, and long-term follow-up and (2) evaluate outcomes in patients receiving placebo. Systematic review and meta-analysis. Following PRISMA guidelines, 4 electronic databases were searched for randomized placebo-controlled trials for e
ECRB. Studies reporting visual analog scale (VAS) for pain scores and/or grip strength were included. Random- or fixed-effects meta-analysis was employed to compare treatments with at least 2 eligible studies using the standardized mean difference and odds ratio. The study protocol was registered at PROSPERO (ID: CRD42018075009). Thirty-six randomized placebo-controlled trials, evaluating 11 different treatment modalities, with a total of 2746 patients were included. At short-term follow-up, only local corticosteroid injection improved pain; however, it was associated with pain worse than placebo at long-term follow-up. At midterm follow-up, laser therapy and local botulinum toxin injection improved pain. At long-term follow-up, extracorporeal shock wave therapy provided pain relief. With regard to grip strength, only laser therapy showed better outcomes in comparison with placebo. While there was no difference among various treatments in the odds ratio of an adverse event, they all increased adverse events compared with placebo. In placebo-receiving patients, a sharp increase in the percentage of patients reporting mild pain or less was observed from 2% at short-term follow-up to 92% at midterm follow-up. Most patients experienced pain resolution after receiving placebo within 4 weeks of follow-up. At best, all treatments provided only small pain relief while increasing the odds of adverse events. Therefore, if clinicians are inclined to provide a treatment for particular patients, they may consider a pain relief regimen for the first 4 weeks of symptom duration. Patient-specific factors should be considered when deciding on treatment or watchful waiting.

Current Concepts in the Operative Management of Acromioclavicular Dislocations: A Systematic Review and Meta-analysis of Operative Techniques

01-10-2018 – Anirudh K. Gowd,Joseph N. Liu,Brandon C. Cabarcas,Gregory L. Cvetanovich,Grant H. Garcia,Brandon J. Manderle,Nikhil N. Verma