We Can Do Better
30-09-2019 – Brett D. Owens
Management of the Failed Latarjet Procedure: Outcomes of Revision Surgery With Fresh Distal Tibial Allograft
09-09-2019 – Matthew T. Provencher,Liam A. Peebles,Zachary S. Aman,Andrew S. Bernhardson,Colin P. Murphy,Anthony Sanchez,Travis J. Dekker,Robert F. LaPrade,Giovanni Di Giacomo
Patients with recurrent anterior glenohumeral instability after a failed Latarjet procedure remain a challenge to address. Complications related to this procedure include large amounts of bone loss, bone resorption, and issues with retained hardware that necessitate the need for revision surgery. To determine the outcomes of patients who underwent revision surgery for a recurrent shoulder instability after a failed Latarjet procedure with fresh distal tibial allograft. Case series; Level of evidence, 4. All consecutive patients who underwent revision of a failed Latarjet procedure with distal tibial allograft were prospectively enrolled. Patients were included if they had physical examination findings consistent with recurrent anterior shoulder instability. Patients were excluded if they had prior neurologic injury, a seizure disorder, bone graft requirements to the humeral head, or findings of multidirectional or posterior instability. History of shoulder instability was documented, including initial dislocation history, duration of instability, number of prior surgeries, examination findings, plain radiographic and computed tomography (CT) data, and arthritis graded with Samilson and Prieto (SP) classification. All patients were treated with hardware removal, capsular release with subsequent repair, and fresh distal tibial allograft to the glenoid. Outcomes before and after revision were assessed according to the American Shoulder and Elbow Score (ASES), Single Assessment Numerical Evaluation (SANE), and Western Ontario Shoulder Index (WOSI) and statistically compared. All patients underwent a CT scan of the distal tibial allograft at a minimum 4 months after surgery. There were 31 patients enrolled (all males), with a mean age of 25.5 years (range, 19-38 years) and a mean follow-up time of 47 months (range, 36-60 months) after revision with distal tibial allograft. Before distal tibial allograft augmentation, the mean percentage glenoid bone loss was 30.3% (range, 25%-49%). All patients after their Latarjet stabilization had recurrent shoulder dislocation (11/31, 35.5%) or subluxation (20/31, 64.5%), and all patients had symptoms consistent with recurrent shoulder instability upon physical examination. Radiographs demonstrated 2 fixation screws in all cases, mean SP grade was 0.5 (range, 0-3), and CT scans revealed that a mean 78% of the Latarjet coracoid graft had resorbed (range, 37%-100%). Patient-reported outcome scores improved significantly pre- to postoperatively for ASES (40 to 92, The majority of the failed Latarjet procedures included in this study had near-complete resorption of the coracoid graft and hardware complications. At a minimum follow-up time of 36 months, patients who underwent revision treatment for a failed Latarjet procedure with a fresh distal tibial allograft demonstrated excellent clinical outcomes and near-complete osseous union at the glenoid-allograft interface. Although patients evaluated with recurrent anterior shoulder instability after a failed Latarjet procedure remain a challenge to address, fresh distal tibial allograft augmentation is a viable and highly effective revision procedure to treat this patient population.
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
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.
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
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.
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
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.
Relationship Between Glenohumeral Internal Rotation Deficit and Medial Elbow Torque in High School Baseball Pitchers
09-09-2019 – D. Grace Smith,Alexander J. Swantek,Caleb M. Gulledge,Vincent A. Lizzio,Angel Bermudez,Brian M. Schulz,Eric C. Makhni
Alterations in throwing mechanics have been identified as a risk factor for overuse injuries in baseball players. Glenohumeral internal rotation deficit (GIRD) has been found to adversely affect throwing mechanics, but the effect of GIRD on medial elbow torque is unclear. To investigate the relationship between GIRD and medial elbow torque in high school-aged baseball pitchers. Descriptive laboratory study. High school baseball pitchers (14-18 years old) were recruited for participation in this study. Players’ height, weight, body mass index, and arm measurements were recorded as well as shoulder and elbow range of motion measurements. GIRD was calculated from the difference between dominant and nondominant shoulder internal rotation. Participants then pitched 5 fastballs at maximum effort while wearing a wireless sensor that recorded elbow torque, arm slot, arm speed, shoulder rotation, and ball velocity. Principal component analysis was performed to determine which variables were associated with elbow torque or ball velocity. Twenty-three high school pitchers participated in this study; 35% (n = 8) of participants exhibited GIRD of at least 20°. The mean GIRD was 15.3°± 11.2° and was not a predictor of medial elbow torque ( In high school baseball pitchers, GIRD was not associated with medial elbow torque during the pitching motion. Instead, ball velocity, player age, and player height carried greater significance. This study suggests that high school pitchers with GIRD do not have an inherently greater risk for increased medial elbow torque during the throwing motion. It is recommended that pitchers instead assess their ball velocity to evaluate for relative differences in medial elbow torque.
The Effectiveness of a Hinged Elbow Orthosis in Medial Collateral Ligament Injuries: An In Vitro Biomechanical Study
28-08-2019 – Ranita H.K. Manocha,James A. Johnson,Graham J.W. King
Medial collateral ligament (MCL) injuries are common after elbow trauma and in overhead throwing athletes. A hinged elbow orthosis (HEO) is often used to protect the elbow from valgus stress early after injury and during early return to play. However, there is minimal evidence regarding the efficacy of these orthoses in controlling instability and their influence on long-term clinical outcomes. (1) To quantify the effect of an HEO on elbow stability after simulated MCL injury. (2) To determine whether arm position, forearm rotation, and muscle activation influence the effectiveness of an HEO. Controlled laboratory study. Seven cadaveric upper extremity specimens were tested in a custom simulator that enabled elbow motion via computer-controlled actuators and motors attached to relevant tendons. Specimens were examined in 2 arm positions (dependent, valgus) and 2 forearm positions (pronation, supination) during passive and simulated active elbow flexion while unbraced and then while braced with an HEO. Testing was performed in intact elbows and repeated after simulated MCL injury. An electromagnetic tracking device measured valgus angulation as an indicator of elbow stability. When the arm was dependent, the HEO increased valgus angle with the forearm in pronation (+1.0°± 0.2°, In this in vitro study, this HEO did not enhance mechanical stability when the arm was in the valgus and dependent positions after MCL injury. After MCL injury, an HEO likely does not provide mechanical elbow stability during rehabilitative exercises or when the elbow is subjected to valgus stress such as occurs during throwing.
Donor Site Evaluation After Osteochondral Autograft Transplantation for Capitellar Osteochondritis Dissecans
10-09-2019 – Takeshi Matsuura,Yusuke Hashimoto,Takuya Kinoshita,Kazuya Nishino,Yohei Nishida,Junsei Takigami,Hiroshi Katsuda,Nagakazu Shimada
Osteochondral autograft transplantation (OAT) for capitellar osteochondritis dissecans (OCD) requires harvesting of tissue from the asymptomatic knee joint. However, donor site morbidity (DSM) in such cases remains unclear. To evaluate DSM and postoperative radiographic findings in patients undergoing OAT for advanced capitellar OCD. Case series; Level of evidence, 4. Eighty-six juvenile athletes underwent OAT for advanced capitellar OCD. The 2000 International Knee Documentation Committee subjective score, rate of return to sports, and symptoms in the donor knee were assessed at a mean follow-up of 86 months (range, 28-185 months). Additionally, 49 of the 86 patients were assessed by radiographic and magnetic resonance imaging (MRI) findings of the knee donor site. DSM was defined according to the usual criterion (persistent symptoms for >1 year or the need for subsequent intervention) and a stricter criterion (the presence of any symptoms, such as effusion, patellofemoral complaints, crepitation, unspecified disturbance, stiffness, pain/instability during activities, and osteoarthritic change). The stricter criterion was also used to allocate patients into a DSM group and a no-DSM group. Two and 11 patients were determined to have DSM according to the usual and stricter criteria, respectively. All patients returned to the competitive level of their sports. The mean International Knee Documentation Committee score was 99.0. MRI findings showed abnormal signal intensity in 17 patients (35%) and hypertrophic changes in 11 patients (22%) at the donor harvest sites. The MOCART (magnetic resonance observation of cartilage repair tissue) score was higher in the no-DSM group (mean, 68.2) than in the DSM group (mean, 52.9) ( OAT for juvenile athletes with advanced capitellar OCD provided good clinical outcomes. The DSM rate was relatively low (2.3%) with the usual criterion but high (12.8%) with the stricter criterion. MRI showed an abnormal signal intensity and hypertrophy in some cases.
Implementation of the FIFA 11+ Injury Prevention Program by High School Athletic Teams Did Not Reduce Lower Extremity Injuries: A Cluster Randomized Controlled Trial
17-09-2019 – James R. Slauterbeck,Rebecca Choquette,Timothy W. Tourville,Mickey Krug,Bert R. Mandelbaum,Pamela Vacek,Bruce D. Beynnon
Lower extremity injuries are common in high school sports and are costly, and some have poor outcomes. The FIFA 11+ injury prevention program has been shown to decrease injuries in elite athletes by up to 72%. High schools in which coaches implement the FIFA 11+ injury prevention program in their athletic programs will have a decreased incidence of lower extremity injuries compared with schools using their usual prepractice warm-up. Randomized controlled trial; Level of evidence, 1. Fourteen high schools that employed an athletic trainer were randomly assigned to either the FIFA 11+ group or control group (usual warm-up routine). Exposure to sports and injuries were recorded and used to determine the incidence rates of lower extremity injuries per athlete-exposure (AE). The FIFA 11+ program was implemented by coaches and complicance with the program recorded. There were 196 lower extremity injuries among 1825 athletes in the FIFA 11+ group and 172 injuries among 1786 athletes in the control group (1.59 and 1.47 injuries per 1000 AEs, respectively; This study did not demonstrate a reduction in lower extremity injuries in schools randomized to use the FIFA 11+ program compared with schools using their usual prepractice warm-up program. Coach-reported compliance with performing the FIFA 11+ program at least twice a week was low.
Association Between Running Shoe Characteristics and Lower Extremity Injuries in United States Military Academy Cadets
09-09-2019 – Gary L. Helton,Kenneth L. Cameron,Rebecca A. Zifchock,Erin Miller,Donald L. Goss,Jinsup Song,Michael T. Neary
Running-related overuse injuries are very common among recreational runners, with the reported annual injury rates ranging from 39% to 85%. Relatively few large prospective cohort studies have been conducted to investigate injury risk associated with different running shoe characteristics, and the results of the existing studies are often contradictory. The purpose was to investigate the relationship between running shoe characteristics and lower extremity musculoskeletal injury. It was hypothesized that the risk of injury would be increased in individuals wearing shoes with minimal torsional stiffness and heel height compared with those wearing shoes with greater levels of torsional stiffness and heel height. Cohort study; Level of evidence, 2. The study included 1025 incoming cadets. Shoe torsional stiffness and heel height were calculated and recorded. Demographic data were recorded and analyzed as potential covariates. Lower extremity injuries sustained over 9 weeks during cadet basic training were documented by use of the Armed Forces Health Longitudinal Technology Application and the Cadet Illness and Injury Tracking System. Kaplan-Meier survival curves were estimated, with time to incident lower extremity injury as the primary outcome by level of the independent predictor variables. Risk factors or potential covariates were carried forward into multivariable Cox proportional hazards regression models. Absolute and relative risk reduction and numbers needed to treat were calculated. Approximately 18.1% of participants incurred a lower extremity injury. Cadets wearing shoes with moderate lateral torsional stiffness were 49% less likely to incur any type of lower extremity injury and 52% less likely to incur an overuse lower extremity injury than cadets wearing shoes with minimal lateral torsional stiffness, both of which were statistically significant observations. Injury risk was similar among cadets wearing shoes with minimal and extreme lateral torsional stiffness. Shoes with mild to moderate lateral torsional stiffness may be appropriate in reducing risk of lower extremity injury in cadets. Shoes with minimal lateral torsional stiffness should be discouraged in this population.
Prevalence of and Risk Factors for Total Hip and Knee Replacement in Retired National Football League Athletes
09-09-2019 – Madeleine A.M. Davies,Zachary Y. Kerr,J.D. DeFreese,Nigel K. Arden,Stephen W. Marshall,Kevin M. Guskiewicz,Darin A. Padua,Brian Pietrosimone
Osteoarthritis is a substantial cause of disability. Joint replacement prevalence relates to the burden of severe osteoarthritis, and identifying risk factors for end-stage disease may indicate intervention opportunities. American football has high youth and elite participation, and determining risk factors for severe osteoarthritis may support future morbidity prevention. To (1) determine the prevalence of hip and knee replacement in retired National Football League (NFL) athletes, (2) examine risk factors for replacement, and (3) identify the association between knee injuries and knee replacement. Case-control study; Level of evidence, 3. Retired NFL athletes who participated in a general health survey were included. This historical cohort included those playing between 1929 and 2001. The association between self-reported playing or injury history, and replacement after retirement, was assessed with prevalence ratios (PRs). Models were adjusted for potential confounders of age and weight. Data for 2432 retired male NFL players (69.3% response rate) who had participated in football for a mean 15.2 years were included, in which 277 players reported replacement after retirement (11.4%). More participants reported knee replacement (7.7%) than hip replacement (4.6%). The majority of participants reported previous severe knee injury (53%), and the most prevalent was meniscal tear (32.2%). In multivariable models, age (10-year increase, PR, 2.23; 95% CI, 1.99-2.51), current weight (PR, 1.10; 95% CI, 1.06-1.14), and reporting 1 (PR, 1.78; 95% CI, 1.14-2.77), 2 (PR, 1.91; 95% CI, 1.16-3.15), or ≥3 knee injuries (PR, 3.44; 95% CI, 2.33-5.09) were associated with knee replacement. Age (10-year increase, PR, 1.86; 95% CI, 1.59-2.18), linemen (PR, 1.62; 95% CI, 1.03-2.55), and reporting 1 (PR, 1.72; 95% CI, 1.05-2.80), 2 (PR, 2.77 95% CI, 1.58-4.84), or ≥3 (PR, 2.44; 95% CI, 1.52-3.91) hip injuries were associated with hip replacement. Each reported knee injury type was cross-sectionally associated with replacement after retirement ( Knee replacement was more prevalent than hip replacement. Risk factors differed between the hip and the knee, with age and severe joint injury associated with hip and knee replacement, weight with knee replacement, and playing position associated with hip replacement. Joint injury and weight management may be prevention opportunities to reduce morbidity and end-stage osteoarthritis in this population.
Exposure to American Football and Neuropsychiatric Health in Former National Football League Players: Findings From the Football Players Health Study
30-08-2019 – Andrea L. Roberts,Alvaro Pascual-Leone,Frank E. Speizer,Ross D. Zafonte,Aaron L. Baggish,Herman Taylor,Lee M. Nadler,Theodore K. Courtney,Ann Connor,Rachel Grashow,Alexandra M. Stillman,Dean A. Marengi,Marc G. Weisskopf
Former American football players have a higher prevalence of cognitive impairment than that of the US general population. It remains unknown what aspects of playing football are associated with neuropsychiatric outcomes. It was hypothesized that seasons of professional football, playing position, and experience of concussions were associated with cognition-related quality of life (QOL) and indicators of depression and anxiety. Descriptive epidemiology study. The authors examined whether seasons of professional football, playing position, and experience of concussions, as measured by self-report of 10 symptoms, were associated with cognition-related QOL and indicators of depression and anxiety in a cross-sectional survey conducted 2015 to 2017. Cognition-related QOL was measured by the short form of the Quality of Life in Neurological Disorders: Applied Cognition-General Concerns. The Patient Health Questionnaire-4 measured depression and anxiety symptoms. Of 13,720 eligible men with apparently valid contact information, 3506 players returned a questionnaire at the time of this analysis (response rate = 25.6%). Seasons of professional play (risk ratio [RR] per 5 seasons = 1.19, 95% CI = 1.06-1.34) and playing position were associated with cognition-related QOL. Each 5 seasons of play was associated with 9% increased risk of indicators of depression at borderline statistical significance ( The data suggest that seasons of play and playing position in the NFL are associated with lasting neuropsychiatric health deficits. Additionally, poor cognition-related QOL, depression, and anxiety appear to be associated with concussion in the long term.
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
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.
Outcomes More Than 2 Years After Meniscal Repair for Radial/Flap Tears of the Posterior Lateral Meniscus Combined With Anterior Cruciate Ligament Reconstruction
30-08-2019 – Akira Tsujii,Yasukazu Yonetani,Kazutaka Kinugasa,Tomohiko Matsuo,Kenji Yoneda,Tomoki Ohori,Masayuki Hamada
Meniscal function after repair of radial/flap tears of the posterior horn of the lateral meniscus (LM) with anterior cruciate ligament reconstruction (ACLR) has not been comprehensively investigated. To evaluate not only the clinical and radiographic outcomes of patients with repair of radial/flap tears of the posterior LM with ACLR but also the healing status of the repaired meniscus and changes of chondral status with second-look arthroscopy. Case series; Level of evidence, 4. From January 2008 to April 2016, 41 patients of a consecutive series of 505 primary anatomic ACLR cases had a concomitant radial/flap tear of the posterior horn of the LM and underwent side-to-side repair with an inside-out or all-inside technique. All patients were followed for >2 years, evaluated clinically and radiologically (radiograph and magnetic resonance imaging [MRI]), and compared with a control group without any concomitant injuries that underwent ACLR. Of the 41 patients, 30 were assessed by second-look arthroscopy 2 years postoperatively. The mean follow-up times of the study and control groups were 3.4 and 3.9 years, respectively. The study group showed no significant differences in clinical findings, lateral joint space narrowing on radiograph, and coronal extrusion on MRI as compared with the control group, whereas sagittal extrusion on MRI progressed significantly in the study group (1.2 ± 1.5 mm vs 0.32 ± 1.0 mm, The clinical and radiographic outcomes after repair of radial/flap tears of the posterior horn of the LM as combined with anatomic ACLR were successful and comparable with those after isolated ACLR without any other injuries at a mean postoperative follow-up of 3.4 years, except for sagittal extrusion on MRI. Chondral lesions of the lateral tibial plateau deteriorated regardless of meniscal healing at 2 years postoperatively. Surgeons should keep in mind that chondral injuries might progress over the midterm.
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
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.
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
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
Professional Athletes Are at Higher Risk of Septic Arthritis After Anterior Cruciate Ligament Reconstruction: An Analysis of 4421 Consecutive Patients Including 265 Elite Athletes From the SANTI Study Group
28-08-2019 – Bertrand Sonnery-Cottet,Adnan Saithna,Felipe Galvão Abreu,Florent Franck,Guilherme Venturi de Abreu,Thais D. Vieira,Matthew Daggett,Charles Pioger
Professional athletes are reported to be at greater risk of septic arthritis (SA) after anterior cruciate ligament reconstruction (ACLR) than the nonprofessional population. However, this finding has been controversial, and confusion has arisen in the literature owing to the underpowering of previous studies. The purpose was to report the differences in the rate of SA after ACLR in a large series of patients and to perform pooled data analysis including previously published studies. The hypothesis was that professional athletes have a significantly higher risk of SA than nonprofessional athletes. Case-control study; Level of evidence, 3. A retrospective analysis of prospectively collected data was performed. Patients who underwent ACLR between January 2009 and July 2017 (with a minimum follow-up of 12 months) were considered for study eligibility. The rate of SA was determined, and multivariate analysis was used to evaluate potentially important risk factors, including participation in professional sport. Furthermore, a literature search was performed, and data were extracted from all identified relevant studies. A pooled data analysis was performed to determine differences in the risk of SA between professional and nonprofessional populations. The current series comprised 4421 anterior cruciate ligament surgical procedures with 265 professional athletes. There were 15 cases of SA diagnosed over the study period (0.34%; 95% CI, 0.19%-0.56%). Ten cases occurred in professional athletes (3.8%; 95% CI, 1.82%-6.83%). The percentage of SA was 0.12% (95% CI, 0.04%-0.28%) in the nonprofessional population. Being a professional athlete was associated with a significantly increased risk of SA after ACLR (odds ratio, 21.038; 95% CI, 6.585-75.789; Professional athletes are at greater risk of SA after ACLR than nonprofessional athletes. The results of previous studies may have been conflicting owing to underpowering. The current study confirms the elevated risk by using a large clinical series and pooled data analysis to avoid the limitations of previous studies.
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
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.
Effects of Conditioned Medium From Osteoarthritic Cartilage Fragments on Donor-Matched Infrapatellar Fat Pad–Derived Mesenchymal Stromal Cells
28-08-2019 – Zhenlan Fu,Xiongbo Song,Lin Guo,Liu Yang,Cheng Chen
Mesenchymal stromal cell (MSC)-based therapies have emerged as a promising strategy for osteoarthritis (OA) treatment. In particular, infrapatellar fat pad (IPFP)-derived MSCs have become a good option to treat knee OA. To investigate the influence of the local microenvironment of the knee joint, especially OA cartilage, on the bioactivities of injected/implanted IPFP MSCs. Controlled laboratory study. Conditioned medium (CM) derived from OA cartilage fragments was collected and characterized. Donor-matched IPFP MSCs were treated with control medium (Dulbecco’s modified Eagle medium (DMEM)/F-12 or chondrogenic medium), control medium + CM, or CM alone; and a series of behaviors including the viability, migration, chondrogenic and hypertrophic differentiation, and catabolic activity of IPFP MSCs were evaluated among groups. There were 14 cytokines detected in CM. CM treatment improved the viability of IPFP MSCs. CM hindered the migration of IPFP MSCs. In chondrogenic differentiation, the presence of CM increased the expression of chondrogenic markers but also enhanced the state of hypertrophy and catabolism. OA cartilage-secreted factors could induce chondrogenic differentiation but also resulted in negative effects including the weakened migration, increased hypertrophy, and catabolism of IPFP MSCs in vitro. These findings provide an insight on the fate of IPFP MSCs after intra-articular injections.
Extracorporeal Shockwave Therapy Accelerates the Healing of a Meniscal Tear in the Avascular Region in a Rat Model
10-09-2019 – Shogo Hashimoto,Tsuyoshi Ichinose,Takashi Ohsawa,Noriyuki Koibuchi,Hirotaka Chikuda
The treatment of meniscal tears in the avascular region remains a clinical challenge. Extracorporeal shockwave therapy (ESWT) is a minimally invasive, safe, and effective therapy for various orthopaedic disorders. However, the therapeutic effect of ESWT on meniscal tears has not been reported.
To evaluate the therapeutic effect of ESWT in the treatment of meniscal tears.
Controlled laboratory study.
Twelve-week-old male Wistar rats were divided into 3 groups (normal, ESWT-, and ESWT+). The authors made a full-thickness 2-mm longitudinal tear in the avascular region of the anterior horn in the latter 2 groups. At 1 week after surgery, the ESWT+ group received 800 impulses of shockwave at 0.22-m
J/mm The meniscus healing scores in the ESWT+ group were significantly higher than those in the ESWT- group at 4 weeks and 8 weeks. The ratio of Brd
U-positive cells was the highest in the ESWT+ group at all observation periods. The ratio of CCN2-positive cells was highest in the ESWT+ group at 4 and 8 weeks. In the ESWT+ group, real-time polymerase chain reaction revealed that the levels of ESWT promoted the healing of meniscal tears in the avascular area. ESWT stimulated proliferation of meniscal cells and the upregulation of cartilage-repairing factors such as CCN2, with the upregulation of cartilage-specific extracellular matrix expression. ESWT may be an effective therapeutic option that promotes meniscal healing in the avascular region.
The Ideal Location of the Lateral Hinge in Medial Closing Wedge Osteotomy of the Distal Femur: Analysis of Soft Tissue Coverage and Bone Density
29-08-2019 – Tae Woo Kim,Myung Chul Lee,Jae Ho Cho,Jong Seop Kim,Yong Seuk Lee
Although an appropriate hinge position to prevent unstable lateral hinge fractures is well established in medial opening wedge high tibial osteotomy, the position during medial closing wedge distal femoral osteotomy has not been elucidated. The purpose was to evaluate the ideal hinge position that would prevent an unstable lateral hinge fracture during biplanar medial closing wedge distal femoral osteotomy based on soft tissue coverage and bone density around the hinge area. The hypothesis was that the ideal hinge position could be clarified by analyzing soft tissue coverage and bone density around the lateral hinge area. Controlled laboratory study. In 20 cadaveric knees (mean age, 70.3 ± 19.2 years), the femoral attachment of the gastrocnemius lateral head was quantitatively analyzed as a soft tissue stabilizer using digital photography and fluoroscopy. Then, medial closing wedge distal femoral osteotomy was performed, locating the lateral hinge either inside (group 1) or outside (group 2) the femoral attachment of the gastrocnemius lateral head, and the incidence of unstable lateral hinge fractures was compared between the 2 groups. Cortical bone density around the lateral hinge was measured using Hounsfield units on 30 computed tomography scans and reconstructed as a 3-dimensional mapping model. The transitional zone with low bone density was regarded as the safe hinge position with an increased capacity for bone deformation. The upper and lower margins of the femoral attachment of the gastrocnemius lateral head were 9.1 ± 0.9 mm above and 8.0 ± 1.4 mm below the upper border of the lateral femoral condyle, respectively, and the femoral attachment of the gastrocnemius lateral head was widest in the anteroposterior dimension 0.4 ± 1.7 mm above the upper border of the lateral femoral condyle. The incidence of unstable lateral hinge fractures during osteotomy was significantly decreased in group 1 compared with group 2 (group 1: 0/10; group 2: 5/10; Only the upper border of the lateral femoral condyle can be recommended as an ideal hinge position to prevent unstable lateral hinge fractures during biplanar medial closing wedge distal femoral osteotomy based on soft tissue coverage and bone density. When the hinge is positioned at the upper border of the lateral femoral condyle during biplanar medial closing wedge distal femoral osteotomy, the risk of unstable hinge fractures can be minimized.
Posteromedial Ligament Repair of the Knee With Suture Tape Augmentation: A Biomechanical Study
27-08-2019 – Julian T. Mehl,Cameron Kia,Matthew Murphy,Elifho Obopilwe,Mark Cote,Florian B. Imhoff,Andreas B. Imhoff,Robert A. Arciero,Knut Beitzel,Alexander Otto
In cases of acute combined posteromedial and anterior cruciate ligament (ACL) injuries, primary repair of the superficial medial collateral ligament (s
MCL) and posterior oblique ligament (POL) with suture tape augmentation may be a reasonable alternative to standard tendon reconstruction techniques. The purpose was to examine the rotational and valgus laxity with ACL strain following s
MCL and POL repair with suture tape augmentation at various degrees of knee flexion. It was hypothesized that this technique would restore knee laxity and kinematics comparable with those of the intact state. Controlled laboratory study. Ten cadaveric knee specimens (mean ± SD, 57.9 ± 5.9 years) were obtained. Specimens were tested with the tibia fixed and the femur mobile on an X-Y table. Each specimen was tested in 4 conditions according to the state of the s
MCL and POL: native, deficient, repaired with suture tape augmentation, and reconstructed with tendon allografts. Valgus laxity was tested with 40-N force applied in the lateral direction of the femur, and rotational motion was tested with 5-N torque applied to the tibia. ACL strain during valgus stress was also measured. Each condition was tested in 0°, 15°, 30°, 45°, and 60° of knee flexion. Dissection of the s
MCL and POL led to significantly increased valgus laxity in all flexion angles, with a significant increase in ACL strain at 30° ( At time zero, ligament repair of the posteromedial knee with suture tape augmentation restored close-to-native valgus and rotatory laxity, as well as native ACL strain for cases of complete s
MCL and POL avulsion. Ligament repair of the s
MCL and POL with suture tape augmentation may be a reasonable alternative to tendon reconstruction techniques in cases of acute combined posteromedial and ACL injuries with valgus and rotatory instability.
Bone-Plug Versus Soft Tissue Fixation of Medial Meniscal Allograft Transplants: A Biomechanical Study
27-08-2019 – Luiz Felipe Ambra,Alexandre Barbieri Mestriner,Jakob Ackermann,Amy T. Phan,Jack Farr,Andreas H. Gomoll
It is controversial whether soft tissue fixation only and bone-plug techniques for medial meniscal allograft transplantation provide equivalent fixation and restoration of load distribution. Prior studies on this topic did not re-create the clinical situation with use of size-, side-, and compartment-matched meniscal transplants. Both techniques will provide equivalent fixation of the meniscal transplant and restore load distribution and contact pressures similar to those of the native knee. Controlled laboratory study. Nine fresh-frozen human cadaveric knees underwent mean contact pressure, mean contact area, and peak contact pressure evaluation in 4 medial meniscal testing conditions (native, total meniscectomy, bone-plug fixation, and soft tissue fixation) at 3 flexion angles (0°, 30°, and 60°) using Tekscan sensors under a 700-N axial load. Medial meniscectomy resulted in significantly decreased contact area and increased contact pressure compared with the native condition at all flexion angles ( Total medial meniscectomy leads to significantly worsened load distribution within the knee. Medial meniscal allograft transplantation can restore load parameters close to those of the native condition. The bone-plug technique demonstrated improved tibiofemoral contact pressures compared with soft tissue fixation. Medial meniscal allograft transplantation with bone-plug fixation is a viable option to restore biomechanics in patients with meniscal deficiency.
Patient-Specific 3-D Magnetic Resonance Imaging–Based Dynamic Simulation of Hip Impingement and Range of Motion Can Replace 3-D Computed Tomography–Based Simulation for Patients With Femoroacetabular Impingement: Implications for Planning Open Hip Preservation Surgery and Hip Arthroscopy
05-09-2019 – Till D. Lerch,Celia Degonda,Florian Schmaranzer,Inga Todorski,Jennifer Cullmann-Bastian,Guoyan Zheng,Klaus A. Siebenrock,Moritz Tannast
Femoroacetabular impingement (FAI) is a complex 3-dimensional (3D) hip abnormality that can cause hip pain and osteoarthritis in young and active patients of childbearing age. Imaging is static and based on 2-dimensional radiographs or computed tomography (CT) scans. Recently, CT-based 3D impingement simulation was introduced for patient-specific assessments of hip deformities, whereas magnetic resonance imaging (MRI) offers a radiation-free alternative for surgical planning before hip arthroscopic surgery. To (1) investigate the difference between 3D models of the hip, (2) correlate the location of hip impingement and range of motion (ROM), and (3) correlate diagnostic parameters while comparing CT- and MRI-based osseous 3D models of the hip in symptomatic patients with FAI. Cohort study (Diagnosis); Level of evidence, 2. The authors performed an institutional review board-approved comparative and retrospective study of 31 hips in 26 symptomatic patients with FAI. We compared CT- and MRI-based osseous 3D models of the hip in the same patients. 3D CT scans (slice thickness, 1 mm) of the entire pelvis and the distal femoral condyles were obtained. Preoperative MRI of the hip was performed including an axial-oblique T1 VIBE sequence (slice thickness, 1 mm) and 2 axial anisotropic (1.2 × 1.2 × 1 mm) T1 VIBE Dixon sequences of the entire pelvis and the distal femoral condyles. Threshold-based semiautomatic reconstruction of 3D models was performed using commercial software. CT- and MRI-based 3D models were compared with specifically developed software. (1) The difference between MRI- and CT-based 3D models was less than 1 mm for the proximal femur and the acetabulum (median surface distance, 0.4 ± 0.1 mm and 0.4 ± 0.2 mm, respectively). (2) The correlation for ROM values was excellent ( Patient-specific and radiation-free MRI-based dynamic 3D simulation of hip impingement and ROM can replace CT-based 3D simulation for patients with FAI of childbearing age. On the basis of these excellent results, we intend to change our clinical practice, and we will use MRI-based 3D models for future clinical practice instead of CT-based 3D models. This allows radiation-free and patient-specific preoperative 3D impingement simulation for surgical planning and simulation of open hip preservation surgery and hip arthroscopic surgery.
The “Outside-In” Lesion of Hip Impingement and the “Inside-Out” Lesion of Hip Dysplasia: Two Distinct Patterns of Acetabular Chondral Injury
06-09-2019 – Matthew J. Kraeutler,Jesse A. Goodrich,Matthew J. Fioravanti,Tigran Garabekyan,Omer Mei-Dan
Femoroacetabular impingement (FAI) and acetabular dysplasia lead to acetabular cartilage damage that commonly results in the chondral flaps seen during hip arthroscopy. To compare the acetabular chondral flap morphology seen during hip arthroscopy (“outside-in” vs “inside-out”) with clinical and radiographic parameters underlying FAI and hip dysplasia. Cohort study; Level of evidence, 3. Patients who underwent hip arthroscopy by the senior author between 2013 and 2017 with a finding of Outerbridge grade IV acetabular chondral flap were included. Each procedure was retrospectively reviewed on video and chondral flaps were categorized as inside-out or outside-in. An inside-out designation was made for flaps exhibiting an intact chondrolabral junction with a detached sleeve of chondrolabral tissue from the central acetabulum, and an outside-in designation was made for centrally anchored flaps exhibiting a break in the chondrolabral junction. Radiographic markers of hip impingement/dysplasia were noted for each patient during assignment into 1 of 2 radiographic groups: group 1, lateral center edge angle (LCEA) >20 with FAI, and group 2, LCEA ≤20 with or without cam FAI. Associations between chondral flap morphology and clinical diagnosis were tested using a chi-square test. Overall, 95 patients (103 hips) were included (group 1, 78 hips; group 2, 25 hips). Among hips in group 2, 24 had concurrent cam FAI. There was a significant relationship between chondral flap type and radiographic diagnosis ( Acetabular chondral flap type visualized during hip arthroscopy correlates with radiographic markers of hip impingement and hip instability. Outside-in flaps are highly predictive of FAI, whereas inside-out flaps are highly predictive of acetabular dysplasia.
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
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. The purpose was 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.
Optimal Outcomes for Acute Avulsion Fracture of the Achilles Tendon Treated With the Insertional Reattachment Technique: A Case Series of 31 Cases With Over 2 Years of Follow-up
04-09-2019 – Yanbin Pi,Yuelin Hu,Chen Jiao,Yingfang Ao,Qinwei Guo
Avulsion fracture of the Achilles tendon is a less common but debilitating disorder. There is a paucity of literature on this problem. To present a retrospective case series assessing the clinical outcomes of avulsion fracture of the Achilles tendon after a reattachment procedure and to identify potential factors predicting postoperative outcomes. Case series; Level of evidence, 4. A consecutive case series of 35 patients with acute insertional rupture of the Achilles tendon who received a reattachment procedure between 2011 and 2017 were reviewed. All patients were measured and classified by magnetic resonance imaging (MRI) and surgical findings. Patient-reported outcomes were evaluated using the visual analog scale (VAS) for pain, American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot Scale, Foot Function Index (FFI), Tegner score, and Ankle Activity Score (AAS). The range of motion and single-legged heel raise test were also conducted for both ankles. Thirty-one out of 35 (88.57%) patients were followed up for an average of 43.65 months. The VAS pain score and AOFAS Ankle-Hindfoot score improved from 4.87 ± 1.61 preoperatively to 2.07 ± 1.57 postoperatively and from 58.32 ± 18.66 preoperatively to 87.32 ± 7.53 postoperatively, respectively (both This study demonstrated that the reattachment procedure for acute avulsion fracture of the Achilles tendon can achieve firm fixation and promising outcomes.
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
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.
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
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
High Risk of Tunnel Convergence in Combined Anterior Cruciate Ligament Reconstruction and Lateral Extra-articular Tenodesis: Letter to the Editor
30-09-2019 – Bertrand Sonnery-Cottet,Hervé Ouanezar,Thais Dutra Vieira,Benjamin Freychet,Matthew Daggett,Julien Clechet,Adnan Saithna
High Risk of Tunnel Convergence in Combined Anterior Cruciate Ligament Reconstruction and Lateral Extra-articular Tenodesis: Response
30-09-2019 – Sven Shafizadeh,Vera Jaecker
Low-Molecular-Weight Heparin for the Prevention of Venous Thromboembolism in Patients Undergoing Knee Arthroscopic Surgery and Anterior Cruciate Ligament Reconstruction: Letter to the Editor
30-09-2019 – Klaus Mieth,Gamal Zayed,Germán Carrillo,Claudia Calderón,Abelardo Camacho
Low-Molecular-Weight Heparin for the Prevention of Venous Thromboembolism in Patients Undergoing Knee Arthroscopic Surgery and Anterior Cruciate Ligament Reconstruction: Response
30-09-2019 – Jing Zhu,Ling Li,Hai Jiang,Jian Li,Xin Tang
Journal Article, Published Erratum
Location of the Glenoid Defect in Shoulders With Recurrent Posterior Glenohumeral Instability
16-10-2019 – Travis J. Dekker,Liam A. Peebles,Brandon T. Goldenberg,Peter J. Millett,James P. Bradley,Matthew T. Provencher
Posterior glenoid bone deficiency is an increasingly recognized entity in the setting of recurrent posterior shoulder instability; however, little is known about the subject. Due to the paucity of literature on posterior bone loss, historical comparisons with anterior bone loss may not be fully accurate. To systematically describe the morphology of posterior bone defects in the setting of recurrent posterior shoulder instability based on several quantitative parameters, including the mean location, orientation, and extent of bone loss on a clockface model, as well as the angle of the defect relative to the long axis of the glenoid. Cross-sectional study; Level of evidence, 4. Three-dimensional reconstructed computed tomography scans of serially collected patients with a history of recurrent posterior shoulder instability were evaluated by 3 separate reviewers. The posterior glenoid bone defect was characterized using the following measures: (1) the mean lesion location and orientation based on a clockface model with 6 o’clock denoted as inferior and 9 o’clock as directly posterior for all patients; (2) the total extent of the posterior bone defect based on the clockface; and (3) the average angle of the bone loss relative to the long axis of the glenoid. A total of 70 male patients and 1 female patient with a mean age of 29.3 years (range, 24.4-35.1 years) were included in the analysis. The mean clockface location of the posterior glenoid defect originated at 6:44 (range, 4:16-8:12) and extended to a mean of 9:28 (range, 7:02-10:38). The mean extent of the posterior glenoid defect was 2:43 (range, 1:08-4:50), which corresponds to a mean total bone loss arc of 81.5° (range, 34.2°-144.9°), nearly 1 quadrant of the glenoid. Posterior bone loss occurred in a posteroinferior direction at a mean angle of 30.7° (range, 8.0°-80.0°) relative to the long axis of the glenoid. Posterior bone defects in the setting of posterior shoulder instability most commonly occur in the posteroinferior quadrant of the glenoid and extend on average from 6:44 to 9:28 (81.5° total degrees of arc) on a clockface model. Posterior bone loss occurs at a mean of 30° off the long axis of the glenoid in a posteroinferior direction, which is historically different from anterior bone loss, which occurs parallel to the long axis of the glenoid. This study serves to highlight the location and orientation of bone loss that one can expect in a patient with recurrent posterior shoulder instability, although additional work is needed to assess why this develops.
Defining Minimal Clinically Important Difference and Patient Acceptable Symptom State After Isolated Endoscopic Gluteus Medius Repair
16-10-2019 – Kelechi R. Okoroha,Edward C. Beck,Benedict U. Nwachukwu,Kyle N. Kunze,Shane J. Nho
Endoscopic surgical repair has become a common procedure for treating patients with gluteus medius tears. However, meaningful clinical outcomes after the procedure have not been defined.
To (1) define the minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS) in patients undergoing endoscopic gluteus medius repair and (2) determine correlations between preoperative patient characteristics and achievement of MCID/PASS.
Case series; Level of evidence, 4.
A retrospective review was performed of prospectively collected data from all patients undergoing primary endoscopic repair of gluteus medius tears between January 2012 and February 2017 with a minimum 2-year follow-up. Patient data collected included patient characteristics, radiographic parameters, preoperative clinical function scores, and postoperative patient-reported outcomes (PROs). Paired
A total of 60 patients were included in the study. A majority of patients were female (91.7%), with an average age and body mass index of 57.9 ± 9.91 years and 27.6 ± 6.1, respectively. The MCIDs of the Activities of Daily Living (ADL) and Sport-Specific (SS) subscales of the Hip Outcome Score (HOS) and the modified Harris Hip Score (m
HHS) were calculated to be 15.02, 14.53, and 14.13, respectively. The PASS scores of HOS-ADL, HOS-SS, and m
HHS were calculated to be 81.32, 67.71, and 77.5, respectively. In addition, 76.7% of patients achieved either MCID or PASS postoperatively, with 77.8% and 69.0% reaching at least 1 threshold score for achieving MCID and PASS, respectively, and 48.3% achieving both MCID and PASS. Smoking had a negative and weak association with achieving PASS ( In patients undergoing endoscopic gluteus medius repair, our study defined MCID and PASS for HOS-ADL, HOS-SS, and m
HHS outcome scores. A large percentage of patients (76.7%) achieved meaningful clinical outcomes at 2 years after surgery.
The Contribution of Partial Meniscectomy to Preoperative Laxity and Laxity After Anatomic Single-Bundle Anterior Cruciate Ligament Reconstruction: In Vivo Kinematics With Navigation
15-10-2019 – Alberto Grassi,Stefano Di Paolo,Gian Andrea Lucidi,Luca Macchiarola,Federico Raggi,Stefano Zaffagnini
Limited in vivo kinematic information exists on the effect of clinical-based partial medial and lateral meniscectomy in the context of anterior cruciate ligament (ACL) reconstruction. In patients with ACL deficiency, partial medial meniscus removal increases the anteroposterior (AP) laxity with compared with those with intact menisci, while partial lateral meniscus removal increases dynamic laxity. In addition, greater postoperative laxity would be identified in patients with partial medial meniscectomy. Cross-sectional study; Level of evidence, 3. A total of 164 patients with ACL tears were included in the present study and divided into 4 groups according to the meniscus treatment they underwent: patients with partial lateral meniscectomy (LM group), patients with partial medial meniscectomy (MM group), patients with partial medial and lateral meniscectomy (MLM group), and patients with intact menisci who did not undergo any meniscus treatment (IM group). A further division in 2 new homogeneous groups was made based on the surgical technique: 46 had an isolated single-bundle anatomic ACL reconstruction (ACL group), while 13 underwent a combined single-bundle anatomic ACL reconstruction and partial medial meniscectomy (MM-ACL group). Standard clinical laxities (AP translation at 30° of knee flexion, AP translation at 90° of knee flexion) and pivot-shift (PS) tests were quantified before and after surgery by means of a surgical navigation system dedicated to kinematic assessment. The PS test was quantified through 3 different parameters: the anterior displacement of the lateral tibial compartment (lateral AP); the posterior acceleration of the lateral AP during tibial reduction (posterior acceleration); and finally, the area included by the lateral AP translation with respect to the flexion/extension angle (area). In the ACL-deficient status, the MM group showed a significantly greater tibial translation compared with the IM group ( Before ACL reconstruction, partial medial meniscectomy increased AP laxity at 30° and 90° and lateral meniscectomy increased dynamic PS laxity with respect to intact menisci. Anatomic single-bundle ACL reconstruction decreased laxities, but a residual anterior translation of 1.3 mm at 90° remained in patients with partial medial meniscectomy, with respect to those with intact menisci.
Partial-Thickness Rotator Cuff Tear by Itself Does Not Cause Shoulder Pain or Muscle Weakness in Baseball Players
14-10-2019 – Teruhisa Mihata,Rei Morikura,Akihiko Hasegawa,Kunimoto Fukunishi,Takeshi Kawakami,Yukitaka Fujisawa,Mutsumi Ohue,Masashi Neo
Partial-thickness rotator cuff tears are common shoulder injuries in baseball players. For some tears, the symptoms can be relieved through physical therapy or debridement without rotator cuff repair. To assess whether partial-thickness rotator cuff tear by itself causes shoulder pain and muscle weakness in baseball players. Cross-sectional study; Level of evidence, 3. We studied 87 university baseball players (age, 19.5 ± 0.8 years; baseball career, 11.5 ± 1.6 years). All data were obtained during a full-participation annual medical check in 1 team. Rotator cuff tendons were examined ultrasonographically and allocated to 4 groups: (1) no tear, (2) supraspinatus tendon tear, (3) infraspinatus tendon tear, and (4) both supraspinatus and infraspinatus tendon tears. Current shoulder pain and shoulder muscle strength (dominant/nondominant) in abduction, external rotation, and internal rotation were compared by using chi-square and Of the 87 players, 41 (47%) had articular-sided partial-thickness rotator cuff tears diagnosed on ultrasonography; the remaining 46 athletes were tear-free. Of the 41 affected patients, 19 had tears in the supraspinatus, 13 in the infraspinatus, and 9 in both the supraspinatus and infraspinatus tendons. Tear depth (mean ± SD) was 4.6 ± 2.3 mm in the supraspinatus and 6.2 ± 3.6 mm in the infraspinatus. Neither the rate of shoulder pain nor muscle strength differed significantly among the 4 groups ( Articular-sided partial-thickness rotator cuff tear-by itself-did not cause shoulder pain and muscle weakness in university baseball players. Most so-called articular-sided partial-thickness rotator cuff tears may not be pathologic tendon tears.
Influence of Test Environment, Age, Sex, and Sport on Baseline Computerized Neurocognitive Test Performance
14-10-2019 – Jonathan French,Patrick Huber,Joseph McShane,Cyndi L. Holland,Robert J. Elbin,Anthony P. Kontos
Baseline computerized testing is a common component of concussion assessments, and the testing environment has been suggested to influence test performance and validity.
To compare concussion baseline computerized neurocognitive test performance and validity among adolescent athletes based on testing environment (group, individual), age group (10-12, 13-15, 16-18 years), sex (male, female), and sport type (collision/combat, contact, noncontact).
Cohort study; Level of evidence, 3.
Through a concussion community outreach program, participants completed baseline computerized neurocognitive testing using Immediate Post-Concussion Assessment and Cognitive Testing (Im
PACT). A total of 2845 athletes aged 10 to 18 years completed the baseline assessment. A total of 2241 (79%) athletes completed baseline testing in a group environment, and 604 (21%) completed testing in an individual environment. A random subsample of 500 athletes from each group was selected for statistical comparison. No significant differences were supported in baseline computerized neurocognitive test performance between the group and individual administration environments. Test validity was statistically similar across testing environment, age group, and sex. However, patients of older age (16-18 years), female sex, and collision/combat and contact sports performed better on Im
PACT. There were differences in total symptom severity scores ( The findings indicated that concussion baseline neurocognitive test performance is similar when administered in group and individual testing environments. However, differences based on age group, sex, and sport type should be considered when interpreting baseline computerized neurocognitive test scores. The finding of higher symptom scores in older adolescents in the individual testing environment suggests that they may be less forthcoming about symptoms in a group setting.
How Can We Define Clinically Important Improvement in Pain Scores After Hip Arthroscopy for Femoroacetabular Impingement Syndrome? Minimum 2-Year Follow-up Study
11-10-2019 – Edward C. Beck,Benedict U. Nwachukwu,Kyle N. Kunze,Jorge Chahla,Shane J. Nho
Patient postoperative pain is being increasingly reported in the field of hip preservation surgery. The visual analog scale (VAS) for pain is one of the most commonly utilized measures for perioperative pain assessment. Currently, there is limited understanding of clinically significant improvement in VAS pain. (1) To define the substantial clinical benefit (SCB), patient acceptable symptomatic state (PASS), and minimal clinically important difference (MCID) for the VAS pain score in patients undergoing hip arthroscopy for femoroacetabular impingement syndrome after 2 years from surgery and (2) to identify preoperative predictors of achieving each outcome endpoint. Case series; Level of evidence, 4. Data from consecutive patients who underwent primary hip arthroscopy between November 2014 and March 2017 were collected and analyzed. Baseline data and postoperative patient-reported outcome scores were recorded at 2 years postoperatively. To quantify clinical significance of outcome achievement for the VAS pain score, the MCID, PASS, and SCB were calculated. A total of 976 patients were included in the final analysis. The VAS pain score threshold for achieving the MCID was defined as a decrease of 14.8; the PASS was defined as achieving a 2-year postoperative score of 21.6 points; and the SCB was defined as a decrease of 25.5 or a score of 15.4 points at 2 years. The rates of achieving the MCID, PASS, and SCB were 97.6%, 66.4%, and 71.2%, respectively. Regression analysis demonstrated that sports involvement, low body mass index, smaller preoperative alpha angle, and absence of articular damage and chondromalacia were predictive of achieving the PASS (all This study identified scores for VAS pain that can be used to define clinically significant outcome after arthroscopic treatment of femoroacetabular impingement syndrome. Specifically, a decrease in pain score of 14.8 was a clinically important improvement in VAS pain, while an absolute score <15.4 or a change of 25.5 represented the upper threshold of VAS pain improvement. Additionally, there were both modifiable and nonmodifiable factors that predicted achieving clinically significant levels of postoperative pain improvement.
Positive Effect of Platelet-Rich Plasma on Pain in Plantar Fasciitis: A Double-Blind Multicenter Randomized Controlled Trial
11-10-2019 – Joost C. Peerbooms,Paul Lodder,Brenda L. den Oudsten,Kamiel Doorgeest,Hans M. Schuller,Taco Gosens
When nonoperative treatment for chronic plantar fasciitis fails, often a corticosteroid injection is given. Corticosteroid injection gives temporary pain reduction but no healing. Platelet-rich plasma (PRP) has proven to be a safe therapeutic option in the treatment of tendon, muscle, bone, and cartilage injuries.
To determine the effectiveness of PRP as compared with corticosteroid injections for chronic plantar fasciitis.
Randomized controlled trial; Level of evidence, 1.
Patients with chronic plantar fasciitis were allocated to have steroid injection or PRP. The primary outcome measure was the Foot Function Index (FFI) Pain score. Secondary outcome measures were function, as scored by the FFI Activity, FFI Disability, and American Orthopaedic Foot & Ankle Society, and quality of life, as scored with the short version of the World Health Organization Quality of Life (WHOQOL-BREF). All outcomes were measured at baseline and at 4, 12, and 26 weeks and 1 year after the procedure.
Of the 115 patients, 63 were allocated to the PRP group, of which 46 (73%) completed the study, and 52 were allocated to the control group (corticosteroid injection), of which 36 (69%) completed the study. In the control group, FFI Pain scores decreased quickly and then remained stable during follow-up. In the PRP group, FFI Pain reduction was more modest but reached a lower point after 12 months than the control group. After adjusting for baseline differences, the PRP group showed significantly lower pain scores at the 1-year follow-up than the control group (mean difference, 14.4; 95% CI, 3.2-25.6). The number of patients with at least 25% improvement (FFI Pain score) between baseline and 12-month follow-up differed significantly between the groups. Of the 46 patients in the PRP group, 39 (84.4%) improved at least 25%, while only 20 (55.6%) of the 36 in the control group showed such an improvement (
Treatment of patients with chronic plantar fasciitis with PRP seems to reduce pain and increase function more as compared with the effect of corticosteroid injection.
Collagenous Ultrastructure of the Torn Medial Meniscus Posterior Root: A Transmission Electron Microscopy Study
11-10-2019 – Young-Jin Seo,Sung-Jae Kim,Dawoon Jung,Jeehyoung Kim,Young-Soo Shin,Seungbi Choi,Eun Shin,Si Young Song
The collagen ultrastructure of torn medial meniscus posterior roots (MMPRs) has not been precisely defined. To investigate the ultrastructure of torn MMPRs, focusing on their collagen fibers, and to compare the collagen net architecture between intact and torn MMPRs using the Collagen Meniscal Architecture (CMA) scoring system. Descriptive laboratory study. Forty-three human meniscal specimens were obtained from 32 patients with osteoarthritis during total knee arthroplasty between January 2018 and November 2018. There were 23 specimens taken from patients with an MMPR tear and 20 taken from patients without an MMPR tear served as a control group. The presence of an MMPR tear was defined as a complete radial tear within 9 mm of the posterior root attachment. The collagen ultrastructure of the meniscal specimens was assessed with transmission electron microscopy using the CMA scoring system. Patient demographics included sex, age, and body mass index, and radiographic assessments included the Kellgren-Lawrence (K-L) grading system and the mechanical axis angle. The median CMA score was significantly higher in torn MMPRs (5.5 [interquartile range, 3.5-6.0]) than in intact MMPRs (2.0 [interquartile range, 1.5-3.8]) ( This study showed that torn MMPRs had decreased numbers and disorganized courses of collagen fibers. The structural problem of torn MMPRs can negatively affect meniscal healing, function, and long-term survival after root repair. These results might provide a histopathological reason for the low healing rate after MMPR repair.
Can the FEAR Index Be Used to Predict Microinstability in Patients Undergoing Hip Arthroscopic Surgery?
11-10-2019 – Jeremy N. Truntzer,Daniel J. Hoppe,Lauren M. Shapiro,Marc R. Safran
Atraumatic hip instability, or microinstability, is a challenging diagnosis for clinicians to make. Several radiographic parameters have been proposed to help identify patients with instability as a means to direct treatment. The Femoro-epiphyseal Acetabular Roof (FEAR) index was recently offered as a parameter to predict instability in a borderline dysplastic population. To evaluate the FEAR index in a series of predominantly nondysplastic patients undergoing hip arthroscopic surgery to determine if it can accurately predict patients with diagnosed microinstability at the time of surgery. Cohort study (diagnosis); Level of evidence, 2. A consecutive series of 200 patients undergoing hip arthroscopic surgery were evaluated for microinstability intraoperatively. Microinstability was diagnosed based on previously published criteria. Retrospectively, radiographic parameters were measured including the lateral center edge angle of Wiberg (LCEA), Tönnis angle, physeal scar angle, and FEAR index. Patients were excluded if they previously had any type of bony procedures performed, underwent prior open hip surgery or total hip arthroplasty of the ipsilateral hip, had osteoarthritis (Tönnis grade >1), or had any radiographic features of moderate-to-severe acetabular dysplasia including an LCEA <18°. After applying exclusion criteria, 167 hips in 150 patients were analyzed. Based on an intraoperative assessment, 96 hips (57.5%) were considered stable, and 71 hips (42.5%) had signs of microinstability (unstable group). Patients in the unstable group had fewer radiographic findings of femoroacetabular impingement and higher rates of borderline dysplasia. All 4 measured angles were found to have excellent interobserver agreement. The FEAR index was significantly more positive in the unstable group compared with the stable group (-7.8° vs -11.3°, respectively; The FEAR index was validated to improve the recognition of unstable patients preoperatively across a population with both borderline dysplastic and nondysplastic features.
In Vivo Anterior Cruciate Ligament Deformation During a Single-Legged Jump Measured by Magnetic Resonance Imaging and High-Speed Biplanar Radiography
08-10-2019 – Zoë A. Englander,Edward L. Baldwin,Wyatt A.R. Smith,William E. Garrett,Charles E. Spritzer,Louis E. DeFrate
The in vivo mechanics of the anterior cruciate ligament (ACL) and its bundles during dynamic activities are not completely understood. An improved understanding of how the ACL stabilizes the knee is likely to aid in the identification and prevention of injurious maneuvers. The purpose was to measure in vivo ACL strain during a single-legged jump through use of magnetic resonance imaging (MRI) and high-speed biplanar radiography. We hypothesized that ACL strain would increase with the knee near extension, and a peak in ACL strain would occur just before landing from the jump, potentially due to quadriceps contraction in anticipation of landing. Descriptive laboratory study. Models of the femur, tibia, and ACL attachment sites of 8 male participants were generated from MRI scans through use of solid modeling. High-speed biplanar radiographs were obtained from these participants as they performed a single-legged jump. The bone models were registered to the biplanar radiographs, thereby reproducing the in vivo positions of the joint throughout the jump. ACL and bundle elongations were defined as the centroid to centroid distances between attachment sites for each knee position. ACL strain was defined as ACL length normalized to its length measured in the position of the knee at the time of MRI. Peaks in ACL strain were observed before toe-off and 55 ± 35 milliseconds before initial ground contact. These peaks were associated with the knee positioned at low flexion angles. Mean ACL strain was inversely related to mean flexion angle (rho = -0.73, These findings provide insight into how landing in extension can increase the risk of ACL injury. Specifically, this study shows that peak ACL strain can occur just before landing from a single-legged jump. Thus, when an individual lands on an extended knee, the ACL is relatively taut, which may make it particularly vulnerable to injury, especially in the presence of a movement perturbation or unanticipated change in landing strategy. This study provides a novel measurement of dynamic ACL strain during an athletic maneuver and lends insight into how landing in extension can increase the likelihood of ACL failure.
Risk Factors for Loss to Follow-up in 3202 Patients at 2 Years After Anterior Cruciate Ligament Reconstruction: Implications for Identifying Health Disparities in the MOON Prospective Cohort Study
07-10-2019 – Prem N. Ramkumar,Muhammad B. Tariq,Annunziato Amendola,Jack T. Andrish,Robert H. Brophy,Warren R. Dunn,David C. Flanigan,Laura J. Huston,Morgan H. Jones,Christopher C. Kaeding,Michael W. Kattan,Robert G. Marx,Matthew J. Matava,Eric C. McCarty,Richard D. Parker,Armando F. Vidal,Michelle L. Wolcott,Brian R. Wolf,Rick W. Wright,Kurt P. Spindler
Understanding the risk factors for loss to follow-up in prospective clinical studies may allow for a targeted approach to minimizing follow-up bias and improving the generalizability of conclusions in anterior cruciate ligament reconstruction (ACLR) and other sports-related interventions.
To identify independent risk factors associated with failure to complete (ie, loss to follow-up) patient-reported outcome measures (PROMs) at 2 years after ACLR within a well-funded prospective longitudinal cohort.
Cohort study (prognosis); Level of evidence, 2.
All patients undergoing primary or revision ACLR enrolled in the prospectively collected database of the multicenter consortium between 2002 and 2008 were included. Multivariate regression analyses were conducted to determine which baseline risk factors were significantly associated with loss to follow-up at a minimum of 2 years after surgery. Predictors assessed for loss to follow-up were as follows: consortium site, sex, race, marital status, smoking status, phone number provided (home or cell), email address provided (primary or secondary), years of school completed, average hours worked per week, working status (full-time, part-time, homemaker, retired, student, or disabled), number of people living at home, and preoperative PROMs (Knee injury and Osteoarthritis Outcome Score, Marx Activity Rating Scale, and International Knee Documentation Committee).
A total of 3202 patients who underwent ACLR were enrolled. The 2-year PROM follow-up rate for this cohort was 88% (2821 of 3202). Multivariate analyses showed that patient sex (male: odds ratio [OR], 1.80) and race (black: OR, 3.64; other nonwhite: OR, 1.81) were independent predictors of 2-year loss to follow-up of PROMs. Education level was a nonconfounder.
While education level did not predict loss to follow-up, patients who are male and nonwhite are at increased risk of loss to follow-up of PROM at 2 years. Capturing patient outcomes with minimal loss depends on equitable, not equal, opportunity to maximize generalizability and mitigate potential population-level health disparities.
Survival Analysis of Revision Autologous Chondrocyte Implantation for Failed ACI
07-10-2019 – Takahiro Ogura,Tim Bryant,Gergo Merkely,Brian A. Mosier,Tom Minas
Autologous chondrocyte implantation (ACI) provides a successful outcome for treating articular cartilage lesions. However, there have been very few reports on the clinical outcomes of revision ACI for failed ACI. To evaluate clinical outcomes in patients who underwent revision ACI of the knee for failure of an initial ACI and to determine the factors affecting the survival rate. Case series; Level of evidence, 4. A review of a prospectively collected data set was performed from patients who underwent revision ACI of the knee for failure of an initial ACI between 1995 and 2014 by a single surgeon. The authors evaluated 53 patients (53 knees; mean age, 38 years) over a mean 11.2-year follow-up (range, 2-20). A total of 62 cartilage lesions were treated for failed graft lesions after an initial ACI, and 31 new cartilage lesions were treated at revision ACI, as there was progression of disease. Overall, 93 cartilage lesions (mean, 1.8 lesions per knee) with a total surface area of 7.4 cm Survival rates were 71% and 53% at 5 and 10 years, respectively. Survival subanalysis revealed a trend that patients without previous cartilage repair procedures before an initial ACI had better survival rates than those with such procedures (81% vs 62% at 5 years, 64% vs 42% at 10 years, Results of revision ACI for patients who failed ACI showed acceptable clinical outcomes. Revision ACI may be an option for young patients after failed initial ACI, particularly patients without previous cartilage repair procedures and those who desire to maintain their native knees.
Nonoperative Treatment of Elbow Ulnar Collateral Ligament Injuries With and Without Platelet-Rich Plasma in Professional Baseball Players: A Comparative and Matched Cohort Analysis
07-10-2019 – Aakash Chauhan,Peter McQueen,Peter N. Chalmers,Michael G. Ciccotti,Christopher L. Camp,John D’Angelo,Hollis G. Potter,Stephen A. Fealy,Brandon J. Erickson,Heinz R. Hoenecke,Daniel Keefe,Julie McCauley,Jan Fronek
Recent studies evaluating nonoperative treatment of elbow ulnar collateral ligament (UCL) injuries augmented with platelet-rich plasma (PRP) have shown promising results. To date, no comparative studies have been performed on professional baseball players who have undergone nonoperative treatment with or without PRP injections for UCL injuries.
Players who received PRP injections would have better outcomes than those who did not receive PRP.
Cohort study; Level of evidence, 3.
The Major League Baseball (MLB) Health and Injury Tracking System identified 544 professional baseball players who were treated nonoperatively for elbow UCL injuries between 2011 and 2015. Of these, 133 received PRP injections (PRP group) before starting their nonoperative treatment program, and 411 did not (no-PRP group). Player outcomes and a Kaplan-Meier survival analysis were compared between groups. In addition, to reduce selection bias, a 1:1 matched comparison of the PRP group versus the no-PRP group was performed. Players were matched by age, position, throwing side, and league status: major (MLB) and minor (Minor League Baseball [Mi
LB]). A single radiologist with extensive experience in magnetic resonance imaging (MRI) interpretation of elbow injuries in elite athletes analyzed 243 MRI scans for which images were accessible for tear location and grade interpretation. Nonoperative treatment of UCL injuries resulted in an overall 54% rate of return to play (RTP). Players who received PRP had a significantly longer delay in return to throwing ( In this retrospective matched comparison of MLB and Mi
LB pitchers and position players treated nonoperatively for a UCL tear, PRP did not improve RTP outcomes or ligament survivorship, although there was variability with respect to PRP preparations, injection protocols, time from injury to injection, and rehabilitation programs. MRI grade and tear location also did not significantly affect RTP outcomes or progression to surgery.
The Effect of Preexisting and Shoulder-Specific Depression and Anxiety on Patient-Reported Outcomes After Arthroscopic Rotator Cuff Repair
04-10-2019 – Brian C. Lau,Melissa Scribani,Jocelyn Wittstein
Few studies have considered the potential effect of depression or anxiety on outcomes after rotator cuff repair. To evaluate the effect of a preexisting diagnosis of depression or anxiety, as well as the feeling of depression and anxiety directly related to the shoulder, on the American Shoulder and Elbow Surgeons (ASES) score. Cohort study; Level of evidence, 3. This study is a retrospective review of prospectively collected data on patients who underwent arthroscopic rotator cuff repair and were evaluated by the ASES score preoperatively and at a minimum 12 months postoperatively as part of the senior author’s shoulder registry. Preexisting diagnoses of depression and/or anxiety were recorded, and questions from the Western Ontario Rotator Cuff Index directed at feelings of depression or anxiety related to the shoulder were also evaluated. The Wilcoxon rank sum test was used to compare ASES scores between patients with and without anxiety and/or depression. Spearman correlation was used to correlate questions on depression and anxiety with ASES scores. A total of 187 patients (63 females, 124 males; mean age, 58.6 years, SD, 8.7 years) undergoing arthroscopic rotator cuff repair were evaluated with a mean follow-up of 47.5 months (SD, 17.4 months; range, 12-77 months). Fifty-three patients (mean age, 60 years; SD, 8.6 years) had preexisting diagnoses of depression and/or anxiety and 134 patients (mean age, 58.1 years; SD, 8.7 years) did not. Patients with depression and/or anxiety had significantly lower preoperative and postoperative ASES scores (60.7 vs 67.8, Patients with a history of depression and/or anxiety have lower outcome scores preoperatively and postoperatively; however, they should expect the same amount of relief from arthroscopic rotator cuff repair as those without a history of depression or anxiety. Stronger feelings of depression or anxiety directly related to the shoulder correlated with lower preoperative and postoperative outcome scores, but a greater amount of improvement from surgery. The results from this study suggest that a preexisting diagnosis of depression or anxiety, as well as feelings of depression or anxiety directly related to the shoulder, should be considered during the management of patients with rotator cuff tears.
Are Implant Choice and Surgical Approach Associated With Biceps Tenodesis Construct Strength? A Systematic Review and Meta-regression
04-10-2019 – Hiroshi F. Aida,Brendan Y. Shi,Eric G. Huish,Edward G. McFarland,Uma Srikumaran
Despite the increasing use of biceps tenodesis, there is a lack of consensus regarding optimal implant choice (suture anchor vs interference screw) and implant placement (suprapectoral vs subpectoral). The purpose was to determine the associations of procedural parameters with the biomechanical performance of biceps tenodesis constructs. The authors hypothesized that ultimate failure load (UFL) would not differ between sub- and suprapectoral repairs or between interference screw and suture anchor constructs and that the number of implants and number of sutures would be positively associated with construct strength. Meta-analysis. The authors conducted a systematic literature search for studies that measured the biomechanical performance of biceps tenodesis repairs in human cadaveric specimens. Two independent reviewers extracted data from studies that met the inclusion criteria. Meta-regression was then performed on the pooled data set. Outcome variables were UFL and mode of failure. Procedural parameters (fixation type, fixation site, implant diameter, and numbers of implants and sutures used) were included as covariates. Twenty-five biomechanical studies, representing 494 cadaveric specimens, met the inclusion criteria. The use of interference screws (vs suture anchors) was associated with a mean 86 N-greater UFL (95% CI, 34-138 N; These findings suggest that fixation with interference screws, rather than suture anchors, and the use of more sutures are associated with greater biceps tenodesis strength, as well as higher odds of native tissue failure versus implant pullout. Although constructs with suture anchors show inferior UFL compared with those with interference screws, incorporation of additional sutures may increase the strength of suture anchor constructs. Supra- and subpectoral repairs provide equivalent biomechanical strength when controlling for potential confounders.
Humeral Retroversion and Injury Risk After Proximal Humeral Epiphysiolysis (Little Leaguer’s Shoulder)
04-10-2019 – Atsushi Ito,Teruhisa Mihata,Yuji Hosokawa,Akihiko Hasegawa,Masashi Neo,Munekazu Doi
The increased humeral retroversion on the dominant side of throwing athletes is thought to result from repetitive throwing motion. Little Leaguer’s shoulder-a rotational stress fracture of the proximal humeral epiphyseal plate-may influence the risk of humeral retroversion and injury of the shoulder or elbow joint. To investigate the effect of Little Leaguer’s shoulder on humeral retroversion and the rates of shoulder and elbow injuries. Cohort study; Level of evidence, 3. 10 high school baseball players (average age, 16.6 years; range, 16-18 years) who had experienced Little Leaguer’s shoulder during elementary or junior high school (average age, 12.6 years; range, 11-15 years) were enrolled in the study. As a control group, 22 high school baseball players (average age, 16.9 years; range, 16-18 years) who had never had any shoulder or elbow injury during elementary and junior high school were included. Humeral retroversion on ultrasonographic measurement, shoulder range of motion, and rates of shoulder and elbow injuries were evaluated. Humeral retroversion was significantly greater on the dominant side than on the nondominant side in both players with Little Leaguer’s shoulder (dominant, 104°± 8°; nondominant, 84°± 12°; Humeral retroversion was increased in baseball players without any history of shoulder or elbow injury during elementary and junior high school and was further increased in players who had had Little Leaguer’s shoulder. Increased humeral retroversion after Little Leaguer’s shoulder may be a risk factor for future shoulder or elbow injury.
Symptomatic Venous Thromboembolism After Achilles Tendon Rupture: A Nationwide Danish Cohort Study of 28,546 Patients With Achilles Tendon Rupture
01-10-2019 – Melissa Hornbæk Pedersen,Liv Riisager Wahlsten,Henrik Grønborg,Gunnar Hilmar Gislason,Michael Mørk Petersen,Anders Nissen Bonde
Venous thromboembolism (VTE) is a well-known complication of Achilles tendon rupture (ATR) and carries a high risk of morbidity and mortality. Although routine thromboprophylaxis for patients with ATR is not recommended, sparse knowledge is available regarding risk factors associated with VTE in patients with ATR. To use Danish nationwide registers to identify incidence rates for symptomatic VTE and risk factors associated with increased risk of developing VTE in patients with ATR. Cohort study; Level of evidence, 3. By crosslinking nationwide registers, we identified all patients with diagnosed ATR in Denmark from 1997 to 2015. We stratified patients into 4 groups by age and treatment modality (ie, operative vs nonoperative treatment). The main outcome was VTE within 180 days. We calculated crude incidence rates and considered age, sex, year, comorbidities, and medications as risk factors for VTE in Poisson regression models. We identified 28,546 patients with ATR, of whom 389 (1.36%) were hospitalized with VTE during the follow-up period: 278 due to deep vein thromboses and 138 due to pulmonary embolism. Incidence rates were highest during the first month and ranged from 4.6 to 14.6 events per 100 person-years. VTEs were most frequent among nonoperatively treated patients aged ≥50 years. In Poisson regression analyses, having had VTE beforehand was associated with an increased risk of VTE, as was male sex in the nonoperative treatment group aged ≥50 years; among women <50 years of age, hormonal contraceptives led to a 4- to 6-fold higher risk of VTE compared with patients in the same group without the equivalent risk factor. In this nationwide cohort of patients with ATR, 1.36% developed symptomatic VTE during follow-up. Hormonal contraception, previous VTE, older age group, and male sex increased the risk of VTE. Taken together, the results of the present study suggest that focus on risk stratification and initiatives to prevent VTE might be warranted. A randomized controlled trial could answer this question.
Exosomes Isolated From Adipose-Derived Stem Cells: A New Cell-Free Approach to Prevent the Muscle Degeneration Associated With Torn Rotator Cuffs
27-09-2019 – Chongyang Wang,Wei Song,Bi Chen,Xudong Liu,Yaohua He
Fatty infiltration, inflammation, and apoptosis are common degenerative changes in patients with chronic rotator cuff tears that can lead to muscle atrophy and can even result in massive irreparable rotator cuff tears. Some data have demonstrated the proregenerative, anti-inflammatory, and anti-apoptotic properties of stem cell-derived exosomes in some orthopaedic disorders, but their effect on torn rotator cuff muscles has never been investigated. To study the effect of exosomes isolated from human adipose-derived stem cells (ASCs-Exos) on muscle degeneration, regeneration, and biomechanical properties in a rat model of a massive rotator cuff tear (MRCT). Controlled laboratory study. A bilateral supraspinatus and infraspinatus tenotomy was performed on rats to create an MRCT model. Forty-two rats were randomly assigned to 3 groups: the sham surgery group, the saline group (lesions treated with a saline injection), and the ASCs-Exos group (lesions treated with an ASCs-Exos injection). Wet muscle weight, fatty infiltration, inflammation, vascularization, regeneration, and biomechanical properties were evaluated at 8 and 16 weeks after surgery. The results revealed that the ASCs-Exos treatment could prevent the atrophy, fatty infiltration, inflammation, and vascularization of muscles in the MRCT model ( This study demonstrates that ASCs-Exos can effectively decrease atrophy and degeneration and improve muscle regeneration and biomechanical properties in torn rotator cuff muscles. ASCs-Exos can be used as a new cell-free approach to prevent the muscle degeneration associated with torn rotator cuffs and may be helpful to repair torn rotator cuffs. Nevertheless, further work needs to be done in a large animal model owing to the inherent regenerative potential possessed by rodents.
Effect of Meniscal Ramp Lesion Repair on Knee Kinematics, Bony Contact Forces, and In Situ Forces in the Anterior Cruciate Ligament
27-09-2019 – Jan-Hendrik Naendrup,Thomas R. Pfeiffer,Calvin Chan,Kanto Nagai,João V. Novaretti,Andrew J. Sheean,Sven T. Shafizadeh,Richard E. Debski,Volker Musahl
Meniscal ramp lesions are possible concomitant injuries in cases of anterior cruciate ligament (ACL) deficiency. Although recent studies have investigated the influence of ramp lesions on knee kinematics, the effect on the ACL reconstruction graft remains unknown. The purpose was to determine the effects of ramp lesion and ramp lesion repair on knee kinematics, the in situ forces in the ACL, and bony contact forces. It was hypothesized that ramp lesions will significantly increase in situ forces in the native ACL and bony contact forces and that ramp lesion repair will restore these conditions comparably with those forces of the intact knee. Controlled laboratory study. Investigators tested 9 human cadaveric knee specimens using a 6 degrees of freedom robotic testing system. The knee was continuously flexed from full extension to 90° while the following loads were applied: (1) 90-N anterior load, (2) 5 N·m of external-rotation torque, (3) 134-N anterior load + 200-N compression load, (4) 4 N·m of external-rotation torque + 200-N compression load, and (5) 4 N·m of internal-rotation torque + 200-N compression load. Loading conditions were applied to the intact knee, a knee with an arthroscopically induced 25-mm ramp lesion, and a knee with an all-inside repaired ramp lesion. In situ forces in the ACL, bony contact forces in the medial compartment, and bony contact forces in the lateral compartment were quantified. In response to all loading conditions, no differences were found with respect to kinematics, in situ forces in the ACL, and bony contact forces between intact knees and knees with a ramp lesion. However, compared with intact knees, knees with a ramp lesion repair had significantly reduced anterior translation at flexion angles from full extension to 40° in response to a 90-N anterior load ( In this biomechanical study, ramp lesions did not significantly affect knee biomechanics at the time of surgery. From a biomechanical time-zero perspective, the indications for ramp lesion repair may be limited.
Outcomes of Hip Arthroscopic Surgery in Adolescents With a Subanalysis on Return to Sport: A Systematic Review
20-09-2019 – Sarah L. Chen,David R. Maldonado,Cammille C. Go,Cynthia Kyin,Ajay C. Lall,Benjamin G. Domb
There is a plethora of literature on outcomes after hip arthroscopic surgery in the adult population; however, outcomes in the adolescent population have not been as widely reported. Additionally, as adolescents represent a very active population, it is imperative to understand their athletic activity and return to sport after hip arthroscopic surgery.
To analyze patient-reported outcomes (PROs) after hip arthroscopic surgery in adolescents (aged 10-19 years) and present a return-to-sport analysis in the athletic adolescent subgroup.
Systematic review; Level of evidence, 4.
The PubMed, Embase, and Cochrane databases were searched according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to identify articles that reported PROs after hip arthroscopic surgery in adolescents. The standardized mean difference was calculated to compare the effect size of hip arthroscopic surgery on various PROs. For the athletic subgroup, a return-to-sport summary was also provided.
Ten studies, with 618 adolescent hips and a collective study period of December 2004 to February 2015, were included in this systematic review. Across all studies, the mean age was 15.8 years (range, 11.0-19.9 years), and female patients composed approximately 56.7% of the entire cohort. The mean follow-up was 34.5 months (range, 12-120 months). The modified Harris Hip Score (m
HHS) was reported in 9 studies, and at latest follow-up, scores were excellent in 4 studies (range, 90-95) and good in the remaining 5 studies (range, 82.1-89.6). All adolescents also showed significant improvement on the Non-Arthritic Hip Score (NAHS), the Hip Outcome Score-Activities of Daily Living (HOS-ADL), the HOS-Sport-Specific Subscale (HOS-SSS), the physical component of the 12-Item Short Form Health Survey (SF-12P), a visual analog scale for pain (VAS), and both versions of the International Hip Outcome Tool (i
HOT-12 and i
HOT-33) at latest follow-up ( In the setting of labral tears and femoroacetabular impingement, hip arthroscopic surgery can safely be performed in adolescents and leads to significant functional improvement. Furthermore, athletic adolescents return to sport at high levels after hip arthroscopic surgery.
Femoroacetabular Impingement Patients With Decreased Femoral Version Have Different Impingement Locations and Intra- and Extraarticular Anterior Subspine FAI on 3D-CT–Based Impingement Simulation: Implications for Hip Arthroscopy
20-09-2019 – Till D. Lerch,Adam Boschung,Inga A.S. Todorski,Simon D. Steppacher,Florian Schmaranzer,Guoyan Zheng,Michael K. Ryan,Klaus A. Siebenrock,Moritz Tannast
It remains unclear whether decreased femoral version (FV) causes anterior intra- or extra-articular femoroacetabular impingement (FAI). Therefore, we evaluated symptomatic hips with decreased FV, with and without cam and pincer FAI, by using computed tomography (CT)-based virtual 3-dimensional (3D) impingement simulation and compared this group with patients with normal FV and with asymptomatic hips. To investigate (1) the osseous range of motion, (2) the osseous femoral and acetabular impingement zones, and (3) whether hip impingement is extra- or intra-articular in symptomatic hips with FAI. Cross-sectional study; Level of evidence, 3. An institutional review board-approved, retrospective comparative analysis was performed on a total of 84 hips in 68 participants. Of these, 37 hips in 24 symptomatic patients with FAI had decreased FV. These hips were compared with 21 hips of 18 symptomatic patients with anterior FAI with normal FV (10°-25°) and 26 asymptomatic hips with no FAI and normal FV. All patients with FAI were symptomatic and had anterior hip pain and a positive anterior impingement test. They underwent pelvic CT scans to measure FV. Decreased FV was defined as FV less than 5°. The 37 hips with decreased FV presented both with and without cam and pincer FAI. All 84 hips were evaluated by use of CT-based 3D models and a validated 3D range of motion and impingement simulation. Asymptomatic hips were contralateral normal hips imaged in patients undergoing total hip arthroplasty. Hips with FAI combined with decreased FV had a significantly ( Hips with FAI and decreased FV had less flexion and internal rotation in 90° of flexion compared with the asymptomatic control group. The majority of hip impingement due to low FV was intra-articular, but one-third of samples had combined intra- and extra-articular subspine FAI. Anterior extra- and intra-articular hip impingement can be present in patients who have FAI with decreased FV. This could be important for patients undergoing hip arthroscopy.
Changes of Supraspinatus Muscle Volume and Fat Fraction After Successful or Failed Arthroscopic Rotator Cuff Repair
19-09-2019 – Karl Wieser,Jethin Joshy,Lukas Filli,Philipp Kriechling,Reto Sutter,Philipp Fürnstahl,Paola Valdivieso,Sabine Wyss,Dominik C. Meyer,Martin Flück,Christian Gerber
Muscle atrophy and fatty infiltration are limiting factors for successful rotator cuff (RC) repair. Quantitative data regarding these hallmarks of degenerative muscle changes after RC repair in humans are scarce. By utilizing a new application of the 6-point Dixon magnetic resonance imaging technology, 3-dimensional volume and fat fraction analysis of the whole RC muscle have become possible. Quantitative analysis of atrophy and fatty infiltration of the supraspinatus muscle after healed and failed RC tendon-to-bone repair. Cohort study; Level of evidence, 3. Muscle volume and fat fraction were measured preoperatively and at 3 and 12 months postoperatively in 19 failed and 21 healed arthroscopic supraspinatus tendon repairs, with full muscle volume segmentation and magnetic resonance Dixon sequences. In both groups, the muscle volume initially decreased 3 months after RC repair by -3% in intact ( After successful arthroscopic repair, RC tendon tear-induced fatty infiltration can be almost stopped, and muscle atrophy can even be slightly reversed. In case of a failed repair, however, these changes are further pronounced during the first 3 postoperative months but seem to stabilize thereafter.
Effect of Fatty Acid–Binding Protein 4 Inhibition on Rotator Cuff Muscle Quality: Histological, Biomechanical, and Biomolecular Analysis
13-09-2019 – Yong-Soo Lee,Ja-Yeon Kim,Kwang Il Kim,Se-Young Ki,Seok Won Chung
A rotator cuff tear (RCT) induces fatty acid-binding protein 4 (FABP4) expression, resulting in ectopic fat accumulation in the rotator cuff muscle.
To evaluate whether FABP4 inhibition reduces fatty infiltration and improves muscle physiology after RCT in a rat model.
Controlled laboratory study.
Human supraspinatus muscle and deltoid muscle tissues were acquired from patients with RCTs during arthroscopic surgery, and FABP4 expression in the supraspinatus muscle was evaluated as compared with the intact deltoid muscle. A rat RCT model was established by detaching the supraspinatus tendon, after which a specific FABP4 inhibitor was locally injected into the supraspinatus muscle 4 times at 3-day intervals starting 2 weeks after the surgery. Body weight and blood glucose levels were measured at 2 and 4 weeks after the RCT, and the m
RNA and protein expressions of various target molecules (including FABP4), histological changes, and biomechanical tensile strength were assessed in the supraspinatus muscles at 4 weeks after the RCT. The expression of human FABP4 was significantly increased in the torn rotator cuff muscle as compared with the intact deltoid muscle. In the rat model, the m
RNA and protein expressions of FABP4 and HIF1α were significantly increased by the RCT as compared with the control. The FABP4 inhibitor treatment significantly decreased FABP4 expression when compared with the vehicle treatment; however, HIF1α expression was not significantly decreased versus the vehicle treatment. Histologically, RCT induced noticeable muscle fatty infiltration, which was remarkably reduced by the local injection of the FABP4 inhibitor. Biomechanically, the tensile strength of the rotator cuff muscle after the RCT was significantly improved by the FABP4 inhibitor in terms of load to failure and total energy to failure. RCT induces FABP4 expression in human and rat rotator cuff muscles. The FABP4 inhibitor drastically decreased the histological fatty infiltration caused by RCT and improved the tensile strength of the rotator cuff muscle. FABP4 inhibitor may have a beneficial effect on the muscle quality after RCT.
Comparative Effectiveness of Operative Versus Nonoperative Treatment for Rotator Cuff Tears: A Propensity Score Analysis From the ROW Cohort
13-09-2019 – Nitin B. Jain,Gregory D. Ayers,Run Fan,John E. Kuhn,Jon J.P. Warner,Keith M. Baumgarten,Elizabeth Matzkin,Laurence D. Higgins
The evidence to support operative versus nonoperative treatment for rotator cuff tears is sparse and inconclusive. To assess pain and functional outcomes in patients undergoing operative and nonoperative treatments for rotator cuff tears. Cohort study; Level of evidence, 3. From March 2011 to February 2015, a multicenter cohort of patients with rotator cuff tears undergoing operative and nonoperative treatments was recruited. Patients completed a detailed history questionnaire, the Shoulder Pain and Disability Index (SPADI), and the American Shoulder and Elbow Surgeons (ASES) standardized form and underwent magnetic resonance imaging. In addition to baseline assessments, patients received follow-up questionnaires at 3, 6, 12, and 18 months. Propensity score weighting was used to balance differences in characteristics of the operative and nonoperative groups. Adjusted for propensity scores, the operative (n = 50) and nonoperative (n = 77) groups had similar characteristics, as evidenced by the small standardized mean differences between the groups. Adjusted mean differences in the SPADI and ASES scores between the operative and nonoperative groups were -22.0 points (95% CI, -32.1 to -11.8) and -22.2 points (95% CI, -32.8 to -11.6) at 18 months, respectively. The operative group had a significantly higher proportion of patients who showed ≥30% ( In this prospective cohort study, patients undergoing operative treatment had significantly better pain and functional outcomes as compared with patients undergoing nonoperative treatment for rotator cuff tears. Differences between the 2 groups in SPADI and ASES scores at the 6- to 18-month time points met the minimal clinically important difference (depending on the threshold used). A large randomized controlled trial is needed to answer this question more definitively.
Association of Preoperative Gluteal Muscle Fatty Infiltration With Patient Outcomes in Women After Hip Abductor Tendon Repair Augmented With LARS
12-09-2019 – Jay R. Ebert,Anne Smith,William Breidahl,Michael Fallon,Gregory C. Janes
Hip abductor tendon repair has demonstrated encouraging outcomes. The influence of fatty infiltration (FI) on outcome has not been explored. To investigate the association between preoperative hip abductor FI and clinical outcome after hip abductor tendon repair. Case series; Level of evidence, 4. A total of 84 women underwent hip abductor tendon repair. The mean age was 64.6 years (range, 43-84 years); body mass index, 27.7 (range, 20.0-40.2); and duration of symptoms, 3.4 years (range, 6 months-20 years). The 6-minute walk test, isometric hip abduction strength assessment, and patient-reported outcome measures, including the Harris Hip Score and Oxford Hip Score, were completed presurgery and 2 years after surgery. Patient satisfaction and perceived improvement were assessed 2 years after surgery. All patients underwent preoperative magnetic resonance imaging on the affected hip, and the Goutallier system was used to grade the degree of FI in the anterior, middle, and posterior thirds of the gluteus medius and minimus on a 0-4 ordinal scale. A single FI score for the gluteus medius and minimus was calculated, as was a combined FI score. All clinical scores significantly improved over time ( Preoperative FI was not associated with pertinent parameters of patient outcome after hip abductor tendon repair, including pain, symptoms, functional capacity, perceived improvement, and satisfaction. Based on these outcomes, surgical repair may be considered in the presence of more severe FI.
Evaluating the Accuracy of Tibial Tunnel Placement After Anatomic Single-Bundle Anterior Cruciate Ligament Reconstruction
12-09-2019 – Christopher Pedneault,Carl Laverdière,Adam Hart,Mathieu Boily,Mark Burman,Paul A. Martineau
Anatomic anterior cruciate ligament (ACL) reconstruction improves knee kinematics and joint stability in symptomatic patients who have ACL deficiency. Despite a concerted effort to place the graft within the ACL’s native attachment sites, the accuracy of tunnel placement using contemporary techniques is not well established. The present study uses 3-dimensional magnetic resonance imaging (3D MRI) to prospectively evaluate the accuracy of tibial tunnel placement after anatomic ACL reconstruction. Case series; Level of evidence, 4. 40 patients with symptomatic, ACL-deficient knees were prospectively enrolled in the study and underwent 3D MRI of both their injured and uninjured knees before and after surgery through use of a validated imaging protocol. The root ligament of the anterior horn of the lateral meniscus was used as a radiographic reference, and the center of the reconstructed graft was compared with that of the contralateral normal knee. The tunnel angles and intra-articular graft angles were also measured, as was the percentage overlap between the native tibial footprint and tibial tunnel. The reconstructed tibial footprint was placed at a mean ± SD of 2.14 ± 2.45 mm ( Despite the use of contemporary surgical techniques to perform anatomic ACL reconstruction, a significant positioning error in tibial tunnel placement remains.
Bone Bruise and Anterior Cruciate Ligament Tears: Presence, Distribution Pattern, and Associated Lesions in the Pediatric Population
12-09-2019 – Vittorio Bordoni,Giorgio di Laura Frattura,Davide Previtali,Simone Tamborini,Christian Candrian,Marirosa Cristallo Lacalamita,Filippo Del Grande,Giuseppe Filardo
Bone bruise characteristics after anterior cruciate ligament (ACL) injury have been correlated with the level of joint derangement in adults. However, the literature lacks information about younger patients, whose higher ligamentous laxity may lead to different lesion patterns. To investigate the prevalence, size, location, and role of bone bruise associated with ACL rupture in the pediatric population. Cross-sectional study; Level of evidence, 3. Knee magnetic resonance imaging scans (MRIs) of patients aged 8 to 16 years with ACL tears from 2010 to 2018 were selected from the institution database. Inclusion criteria were open or partially open physes, less than 90 days between trauma and MRI, and no history of injury or surgery. Presence, localization, and size of bone bruise were analyzed by 2 blinded researchers and scored with the Whole-Organ Magnetic Resonance Imaging Score (WORMS) bone bruise subscale. Ligamentous, cartilaginous, meniscal, and other lesions were documented. Of the 78 pediatric patients selected from the database, 54 (69%) had bone bruise. The mean area of bone bruise was larger in males than in females (femur, 3.8 ± 2.8 vs 2.2 ± 1.4 cm The prevalence of bone bruises in pediatric patients with ACL tears is high, although it seems slightly lower than the prevalence documented in adults but with similar localization. The area and the distribution pattern of bone bruises are similar among different ages. The pediatric patients had a lower presence of cartilage and meniscal lesions compared with that reported in adults, which suggests a different effect of this trauma on the knee of pediatric patients.
Multiple Concussions Increase Odds and Rate of Lower Extremity Injury in National Collegiate Athletic Association Athletes After Return to Play
12-09-2019 – Garrett K. Harada,Caitlin M. Rugg,Armin Arshi,Jeremy Vail,Sharon L. Hame
Concussion in collegiate athletics is one of the most prevalent sport-related injuries in the United States, with recent studies suggesting persistent deficits in neuromuscular control after a concussion and an associated increase in risk of lower extremity injury. To expand on the relationship between concussion and lower extremity injury by examining the effect of multiple concussions (MC) on rate and odds of future lower extremity injury in collegiate athletes after return to play (RTP) compared with matched controls. Cohort study; Level of evidence, 3. From 2001 to 2016, 48 National Collegiate Athletic Association Division I athletes sustaining multiple concussions at a single institution were identified. Athletes with multiple concussions (MC) were matched directly to athletes with a single concussion (SC) and to athletes with no concussion history (NC) by sex, sport, position, and games played. Incidence of, time to, and location of lower extremity injury were recorded for each group after RTP from their first reported concussion until completion of their collegiate career. Logistic regression was used to analyze odds ratios (ORs) for sustaining lower extremity injury, whereas time to injury was summarized by use of Kaplan-Meier curves and log rank test analysis. The incidence of lower extremity injury after RTP was significantly greater ( Collegiate athletes with MC were more likely to sustain a lower extremity injury after RTP in a shorter time frame than were the matched SC and NC athletes. This may suggest the presence of a cohort more susceptible to neuromuscular deficits after concussion or more injury prone due to player behavior, and it may imply the need for more stringent RTP protocols for athletes experiencing MC.
Long-term Results of the Open Latarjet Procedure for Recurrent Anterior Shoulder Instability in Patients Older Than 40 Years
12-09-2019 – Lukas Ernstbrunner,Lara Wartmann,Stefan M. Zimmermann,Pascal Schenk,Christian Gerber,Karl Wieser
Subgroup analyses of the Latarjet procedure have suggested that age over 40 years is a risk factor for dislocation arthropathy. To analyze long-term results of the open Latarjet procedure for recurrent anterior shoulder dislocation in patients at least 40 years of age. Case series; Level of evidence, 4. 39 consecutive patients (40 shoulders) with a mean age of 48 years (range, 40-66 years) at surgery were evaluated at a mean follow-up of 11.0 years (range, 8-16 years). Of these, 15 patients (38%) had undergone previous soft tissue stabilization surgery. Long-term results were assessed clinically and radiographically, including computed tomography scanning at final follow-up. No recurrence of dislocation was noted. Subluxation had occurred in 3 patients (8%), and apprehension persisted in 5 patients (13%). The total Walch-Duplay score averaged 89 points at the final follow-up, and the mean Subjective Shoulder Value (60%-91%) had improved significantly ( The open Latarjet procedure for recurrent anterior shoulder instability in patients older than 40 years reliably restores stability and leads to high patient satisfaction. This procedure is, however, associated with a substantial rate of advanced but clinically mild symptomatic dislocation arthropathy, which is associated with the degree of preoperative joint degeneration, older age at surgery, and lateral graft placement.
Outcomes of Revision Hip Arthroscopic Surgery: A Systematic Review and Meta-analysis
10-09-2019 – Michaela O’Connor,Gabrielle K. Steinl,Ajay S. Padaki,Kyle R. Duchman,Robert W. Westermann,T. Sean Lynch
While the indications for primary hip arthroscopic surgery in treating femoroacetabular abnormalities continue to be defined, the indications and outcomes for revision hip arthroscopic surgery remain ambiguous. However, revision hip arthroscopic surgery is performed in 5% to 14% of patients after their index procedure. While patient-reported outcomes (PROs) generally improve after revision procedures, the extent of their improvement is not well defined.
To determine the outcomes and efficacy of revision hip arthroscopic surgery in patients who remain symptomatic after their index procedure.
Meta-analysis and systematic review.
The terms “hip arthroscopy,”revisions,”outcomes,” and “femoroacetabular impingement” were searched in PubMed, Web of Science, Scopus, Cochrane Library, and Google Scholar. After screening, 15 studies were included for review. In addition to hip-specific metrics, functional outcome measures were included. Pooled estimates and 95% CIs were calculated using inverse variance methods.
A total of 4765 hips in 4316 patients were identified. The most common indication for revision surgery was inadequate bony resection during the index procedure. Meta-analysis showed that all PROs improved significantly from baseline to final follow-up after revision hip arthroscopic surgery. Notably, the modified Harris Hip Score (m
HHS) increased a mean of 17.20 points after revision hip arthroscopic surgery, the Hip Outcome Score-Activities of Daily Living (HOS-ADL) improved by 13.98, and the visual analog scale (VAS) for pain decreased by 3.16. However, when compared with primary hip arthroscopic surgery, the mean PRO scores after revision hip arthroscopic surgery were lower. After revision hip arthroscopic surgery, the rates of conversion to total hip arthroplasty ranged from 0% to 14.3%, and the rates of further arthroscopic revision ranged from 2% to 14%. Inadequate bony resection represents the most common indication for revision hip arthroscopic surgery. PROs improve significantly after revision hip arthroscopic surgery but remain lower than those of patients undergoing primary hip arthroscopic surgery.
A Majority of Anterior Cruciate Ligament Injuries Can Be Prevented by Injury Prevention Programs: A Systematic Review of Randomized Controlled Trials and Cluster–Randomized Controlled Trials With Meta-analysis
30-08-2019 – Yu-Lun Huang,Jaehun Jung,Colin M.S. Mulligan,Jaekeun Oh,Marc F. Norcross
Anterior cruciate ligament (ACL) injury prevention programs (IPPs) are generally accepted as being valuable for reducing injury risk. However, significant methodological limitations of previous meta-analyses raise questions about the efficacy of these programs and the extent to which meeting current best-practice ACL IPP recommendations influences the protective effect of these programs. To (1) estimate the protective effect of ACL IPPs while controlling for common methodological limitations of previous meta-analyses and (2) systematically categorize IPP components and factors related to IPP delivery to assess the validity of current best-practice IPP recommendations. Systematic review with meta-analysis. A systematic search of 5 electronic scientific databases was conducted to identify studies testing the efficacy of ACL IPPs. Studies were included if (1) the intervention aimed to prevent ACL injury, (2) the incidence rate (IR) or other outcome data that made it possible to calculate the IR for both the intervention and control groups were reported, and (3) the study design was a prospective randomized controlled trial (RCT) or cluster-RCT. Of the 2219 studies screened, 8 studies were included in the quantitative synthesis, and their analysis revealed a significant reduction in ACL IR when athletes received IPPs (IR ratio = 0.47; 95% CI, 0.30-0.73; Despite limiting the analysis to only high-quality studies and controlling for time at risk and potential clustering effects, the study showed that ACL IPPs had a significant protective effect and reduced injury rates by 53%. However, significant variability in the specific exercises and the manner of program delivery suggests that ACL IPPs may be able to be designed within an overarching best-practice framework. This may allow practitioners the flexibility to develop IPPs that meet the specific characteristics of the target population and potentially increase the likelihood that these programs will be widely adopted and implemented.
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
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).
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
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.
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
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
Trials.gov for unpublished studies. Eligible studies were RCTs comparing dynamic fixation and static fixation of acute syndesmosis injuries. A meta-analysis was performed, while bias and quality of evidence were rated according to the Cochrane Database questionnaire and the Grading of Recommendations Assessment, Development and Evaluation guidelines. 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
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
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
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
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
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.
A systematic, computer-assisted literature search was performed in PubMed/MEDLINE, CINAHL, EMBASE, SPORTDiscus, Cochrane Library, and Clinical
Trials.gov. 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
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
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.
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
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
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.
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
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
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
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
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
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
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.