Symptom Chronicity and Tobacco Use: Differences in Athletic and Nonathletic Candidates for Cartilage Surgery.

OBJECTIVE: To determine whether there are differences in symptomatic knee cartilage defects and rates of tobacco use among age-matched athletes versus nonathletes undergoing initial arthroscopic knee surgery who meet demographic and radiographic criteria for cartilage restoration surgery. DESIGN: Age-matched athletes (n = 186) and nonathletes (n = 159) age 40 or less with a body mass index (BMI) of 35 kg/m2 or less (mean 26.8 SD 4.1) and <50% joint space narrowing on weight-bearing radiographs were included. All patients had a symptomatic Outerbridge grade 2 or higher cartilage defect visualized during knee arthroscopy. Relationship between athletic status and chronicity of knee symptoms prior to surgery and tobacco use status, cartilage defect Outerbridge grade, size, and location at time of surgery were characterized. RESULTS: Nonathletes were more likely to smoke (P < 0.001) and had higher BMI (P = 0.005). Duration of symptoms prior to surgery was shorter among athletes (P < 0.001). Grade 4 defects were equally prevalent (P = 0.96) as were multicompartment grade 3-4 lesions (P = 0.12). Mean grade 3-4 defect size was similar in lateral (P = 0.96) and medial compartments (P = 0.82). There was a trend toward larger anterior compartment defects in nonathletes (P = 0.07). CONCLUSIONS: Among age-matched athletes and nonathletes with symptomatic cartilage defects who meet demographic criteria for cartilage restoration, nonathletes were more likely to smoke and have a longer duration of symptoms prior to treatment. Athletes tended to present earlier but with similar size defects compared to nonathletes, supporting accelerated treatment of defects in athletes and caution toward allowing continued athletic participation in patients with known cartilage defects.

Interventional Efforts to Reduce Psychological Distress After Orthopedic Trauma: A Systematic Review.

BACKGROUND: Unanticipated severe injury to part of the musculoskeletal system, referred to as orthopedic trauma, can be debilitating. It can also be accompanied by equally debilitating psychological distress, but little is known about the effective interventions for psychological sequelae of orthopedic trauma. QUESTIONS/PURPOSES: We sought to determine the effectiveness of interventions on psychological outcomes, such as post-traumatic stress disorder (PTSD), depression, and pain catastrophizing (feelings of helplessness, excessive rumination, and exaggerated description of pain), after major orthopedic trauma. METHODS: Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement as guidelines, we systematically searched Scopus, PubMed, and Google Scholar. Studies included for review were English-language interventional studies in an orthopedic trauma population that included assessment of post-injury psychological distress or disability as either a primary or secondary aim. RESULTS: Twelve studies were identified, including six randomized trials, three prospective cohort studies, and three retrospective cohort studies. Study sample sizes ranged from 48 to 569 patients, the mean age ranged from 29 to 52.8 years, and the percentage of male patients ranged from 38 to 90%. We examined four categories of interventions. Peer group treatment (one study) significantly reduced rates of depression but had low participation rates. Brief interventions to teach coping and self-efficacy skills (two studies) decreased depression, pain catastrophizing, and anxiety scores while increasing self-efficacy on short-term follow-up. Individualized counseling and rehabilitation (four studies) resulted in a consistent reduction in the risk of PTSD. Early amputation was found to result in lower rates of PSTD than limb salvage in US military personnel (four studies). One study examined surgeons' confidence in dealing with possible psychological distress; surgeons who participated in a program on collaborative care were significantly more confident that they could help their patients with such issues. CONCLUSION: Interventional strategies, including group interventions, brief individual interventions, longitudinal counseling, and consideration of early amputation in selected populations have proved effective in reducing negative psychological sequelae of major orthopedic trauma. Further research that determines the effects of interventions in this population is needed.

Independent risk factors for recurrent or multiple new injuries in CrossFit athletes.

BACKGROUND: CrossFit is a relatively new sport with rapidly growing participation rates in the United States and around the world. We sought to determine risk factors for sustaining multiple CrossFit-related injuries requiring medical evaluation. METHODS: CrossFit-related musculoskeletal injuries evaluated at a single hospital system (N.=837) were identified. For musculoskeletal injuries, use of physical therapy, injection, advanced diagnostic imaging including CT or MRI, and surgery were documented. Independent risk factors for sustaining multiple injuries requiring medical evaluation were assessed by multivariate logistic regression analysis. RESULTS: A total of 94/837 (11.2%) underwent evaluation for 2 or more CrossFit-Related injuries (74% new injury to different body part; 26% subsequent injury, same body part). Independent risk factors for repeat injury (recurrent injury or second new injury) included increased length of follow-up (per year: OR 1.50 CI: 1.29, 1.75; P<0.001), initial injury during spring season (OR 2.03 CI: 1.27, 3.26; P=0.004), advanced imaging not obtained for evaluation of initial injury (OR 2.62 CI: 1.37, 5.02; P=0.002), course of physiotherapy completed for initial injury (2.00 CI: 1.17, 3.41; P=0.008), corticosteroid injection administered for initial injury (OR 2.43 CI: 1.21, 4.88; P=0.01), and increased age (per 5 year increase: OR 1.12 CI: 1.01, 1.24; P=0.03). These risk factors in combination had moderate discriminatory ability for identifying athletes at risk for multiple injuries. CONCLUSIONS: There are multiple risk factors for sustaining a recurrent or second new CrossFit-related injury requiring medical evaluation including older age, length of participation, and spring season participation. Risk factors for repeat injury related to initial evaluation and treatment include not receiving advanced imaging, receiving a corticosteroid injection, or undergoing physical therapy. The anatomic site of initial injury was not related to risk of subsequent injury in this population.

CrossFit-related hip and groin injuries: a case series.

To provide descriptive data on injury presentation and treatment and to identify risk factors for requiring surgical treatment for athletes presenting with CrossFit-related hip and groin injuries. CrossFit-related injuries (n = 982) were identified within a single hospital system from 2010 to 2017, with 83 (8.5% of total) identified hip or groin injuries. Patient demographics, injury diagnosis, surgical procedure and rehabilitation were assessed. Independent predictors of requiring surgery were analyzed via multivariate logistic regression analysis. Patients with hip or groin injuries were more often female (hip injuries: 63%; all injuries: 50%; P < 0.001) with mean age 34.3 years (standard deviation 10.9). Median symptom duration was 4 months with 70% reporting insidious onset. Most common diagnoses were femoral-acetabular impingement syndrome (34%), hamstring strain (11%), non-specific hip/groin pain (imaging non-diagnostic) (11%), hernia (7%) and iliotibial band syndrome (6%). Most (90%) required physical therapy (median 2 months). Surgery occurred in 24% (n = 12 hip arthroscopy, n = 5 inguinal hernia repair, n = 3 total hip arthroplasty), with 100% return to sport after arthroscopy or hernia repair. The only predictor of surgery was complaint of primarily anterior hip/groin pain (82% surgical patients, 46% non-surgical) (odds ratio 5.78, 95% confidence interval 1.44-23.1; P = 0.005); age, sex, body mass index, symptom duration and symptom onset (insidious versus acute) were non-significant (P > 0.25). CrossFit athletes with hip and groin injuries often present with prolonged symptoms with insidious onset. Most patients require several months of physical therapy and approximately one quarter require surgery. Patients presenting with primarily anterior hip/groin pain are at increased risk for requiring surgery. LEVEL OF EVIDENCE: IV, case series.

Psychological Assessment Tools Utilized in Sports Injury Treatment Outcomes Research: A Review.

The use of self-report psychological assessment tools in outcomes research has become increasingly frequent, though many sports medicine providers and researchers are unfamiliar with these instruments. We conducted a systematic search of the sports medicine literature in PubMed, Scopus, SPORTDiscus, and Google Scholar of studies published on or before November 1st, 2019. Included psychological self-assessment tools were limited to those in a written self-assessment format and were used in musculoskeletal sports injury or concussion treatment outcome studies. Both pre- or post-treatment psychological assessments were included. Thirty-four assessment scales of psychological factors were utilized across 152 sports injury treatment outcomes studies. Six assessment tools were utilized in 5 or more studies and the remaining 28 were utilized in 4 or fewer studies. Many of the utilized scales have adequate assessment and reporting of internal consistency reliability, supporting further reliability and validation studies for use in sports injury treatment outcomes research.

The relationship between lateral epicondyle morphology and iliotibial band friction syndrome: A matched case-control study.

BACKGROUND: Iliotibial band friction syndrome (ITBFS) is an overuse injury with pain at the level of the knee lateral epicondyle. We sought to determine whether there is greater knee lateral epicondyle prominence among patients with ITBFS versus matched controls. METHODS: Seventy five patients with ITBFS and 75 age-, height-, and sex-matched controls (n = 150 total patients) with knee magnetic resonance imaging from 2015 to 2017 were included. All cases had a diagnosis of ITBFS and a lack of other identified lateral knee injuries on magnetic resonance imaging. Controls had medial knee pain with medial meniscus tear on MRI and no clinical evidence of ITBFS. Lateral knee epicondyle height in millimeters was measured. RESULTS: Mean patient age was 39.1 years (SD 15.1), 57% were female, and mean height was 170.0 cm (SD 9.3) with no difference between cases and controls. Mean lateral epicondyle height for cases was 13.1 mm (SD 1.6) and for controls was 12.2 (SD 1.4) with a mean difference of 0.9 mm (95% CI 0.4-1.3 mm) between matched pairs (p < 0.001). Mean epicondyle height:condylar AP width ratio was 0.211 (SD 0.023) for cases and 0.198 (SD 0.020) for controls with a mean difference of 0.013 (95% CI 0.006-0.020) between matched pairs (p < 0.001). CONCLUSIONS: There is a significant association between greater lateral epicondyle prominence and IT band friction syndrome, suggesting another anatomic risk factor for this multifactorial condition.

Reverse total shoulder arthroplasty provides stability and better function than hemiarthroplasty following resection of proximal humerus tumors.

BACKGROUND: Tumors may necessitate resection of a substantial portion of the proximal humerus and surrounding soft tissues, making reconstruction challenging. We evaluated outcomes in patients undergoing treatment of tumors of the proximal humerus with reverse total shoulder arthroplasty (rTSA) or shoulder hemiarthroplasty. METHODS: Patients who underwent rTSA (n = 10) or shoulder hemiarthroplasty (n = 37) for tumors of the proximal humerus in 2009 to 2017 were reviewed. Of these patients, 27 had died, leaving 20 for review. The mean follow-up period of the survivors was 27.1 months. They were evaluated clinically and contacted to determine the American Shoulder and Elbow Surgeons score, Simple Shoulder Test score, and visual analog scale score. RESULTS: Postoperative complications occurred in 13 hemiarthroplasty patients (34%). Tumor recurrence occurred in 3 hemiarthroplasty patients (7.9%), whereas in the rTSA group, 1 patient (10%) had a postoperative complication, with no recurrences. One hemiarthroplasty patient required revision surgery with rTSA to improve shoulder function. Six dislocations and two subluxations occurred in the hemiarthroplasty group, whereas no subluxations occurred in the rTSA group (P = .14). Mean range of motion was 85° of forward flexion for rTSA patients (n = 10) compared with 28° for hemiarthroplasty patients (P < .001). The mean American Shoulder and Elbow Surgeons score was 63 for hemiarthroplasty patients (n = 5) and 59 for rTSA patients (n = 4). The mean Simple Shoulder Test scores were 3.8 and 2.4, respectively. The mean visual analog scale pain scores were 2.4 and 2.5, respectively. CONCLUSION: Reverse total shoulder arthroplasty can reproducibly reconstruct the shoulder in patients requiring oncologic proximal humerus resection. Patients have good outcomes, better range of motion, and no increase in instability rates compared with hemiarthroplasty.

Biomechanical Properties of Posterior Meniscal Root Repairs: A Systematic Review.

PURPOSE: To systematically review the literature regarding the biomechanical properties of various meniscal root repair techniques. METHODS: A systematic review of multiple databases was performed. The inclusion criteria included English language, studies relevant to meniscal root repairs, studies comparing 2 or more different discrete techniques, posterior root repairs, controlled laboratory studies, and human cadaveric or animal studies. Abstracts, case reports, cohort studies, case-control studies, systematic reviews and meta-analyses, and studies of meniscal body repairs were excluded. RESULTS: Seventeen controlled laboratory studies were included for final analysis. There is no consensus on biomechanical superiority between transtibial pullout repair (TPR) and suture anchor repair. For TPR, there is no significant difference between 1 and 2 tibial tunnels. Nonanatomic repairs result in significantly lower joint surface contact areas and higher contact pressures, but suture placement farther from the root results in higher maximum load to failure. Two-suture repair has a greater maximum load to failure than 1-suture repair. Use of more than 2 sutures has diminishing returns. The modified Mason-Allen suture configuration is superior to a simple suture configuration, but there is no consensus regarding the superiority or feasibility of more complex sutures. There is no consensus on the superiority of a single suture material or shape. CONCLUSIONS: Anatomic meniscal root repairs with either TPR or suture anchor repair have better joint surface contact pressures and contact surface areas than nonanatomic repairs. The use of 2 sutures results in better fixation than 1 suture. There is evidence that the modified Mason-Allen suture configuration is superior to a simple suture configuration in a TPR, although the benefits of more complicated configurations are unclear. CLINICAL RELEVANCE: This study suggests that, in general, more complex sutures exhibit higher maximum loads. Increasing the number of sutures to up to 2 of the same configuration also increases the maximum load.

The Treatment of Adult Osteochondritis Dissecans with Autologous Cartilage Implantation: A Systematic Review.

We sought to evaluate the effectiveness of autologous chondrocyte implantation (ACI) for the treatment of adult osteochondritis dissecans (OCD) lesions according to patient-reported outcomes, complication rates, and failure rates. A search of MEDLINE, Scopus, and Cochrane Library was performed to identify clinical studies (levels I-IV) reporting outcomes after ACI treatment for OCD in adult knees. Our inclusion criteria included the following: (1) published between January 2000 and April 2017, (2) stable and unstable OCD lesions of the knee, (3) use of ACI in at least one group, (4) subjects ≥18 years old or skeletally mature, (5) inclusion of at least one patient-reported clinical outcome measure, and (6) written in English. A total of nine studies (179 patients), mean age of 27.6 years (range: 18-49 years), were included. There were 227 OCD lesions with an average size of 4.1 cm2 (range: 1.2-9.4 cm2). The average follow-up was 61.3 months (range: 6.5-120 months). In general, there was significant improvement in symptoms, but better results occurred among active male patients with smaller lesions as well as younger patients. Statistically significant improvement in patient-reported outcomes was reported in all studies. There were 23 complications reported (15.6%), including 12 failures (8.2%). Significant improvement in clinical outcome measures demonstrates clinical efficacy of autologous cartilage therapies for the treatment of OCD in adult patients. Better outcomes are often observed with males, active patients, smaller lesion sizes, and younger age at the time of surgery.

Variation in tibial tuberosity lateralization and distance from the tibiofemoral joint line: An anatomic study.

BACKGROUND: To describe variation in tibial tuberosity position in a normal adult population and inter-rater reliability of measurements of tibial tuberosity position. METHODS: Surface models of 161 proximal tibia specimens (83 female, 78 male; 80 black, 81 white; age 28.7years, SD 7.5) were created with a three-dimensional laser scanner. Percent lateralization, tuberosity-eminence angle, and distance from joint surface were measured for each specimen. Variation in tuberosity position by sex, race, age, height, and BMI was calculated. Multivariate regression was used to assess for demographic factors independently associated with tuberosity positioning. RESULTS: Mean percent lateralization was 57.9% (SD 2.4, range 52.4-64.9%). Tuberosity-eminence angle mean was 11.03° (SD 2.8, range 0-18.7°). Percent lateralization and tuberosity-eminence angle were not influenced by sex, race, age, height or, BMI (p>0.05). Mean tuberosity distance from joint surface was 29.2mm (SD 3.5, range 16.6-38.6mm) and larger in males than females (30.7mm (SD 2.9), 27.6mm (SD 3.3); p<0.001). Tuberosity distance from joint surface increased 0.18mm on average per 1.0cm increase in height (p<0.001). Inter-rater reliability was high for distance from joint surface (Cronbach alpha=0.99) and percent lateralization. CONCLUSIONS: Tibial tuberosity percent lateralization falls in a narrow range for individuals, whereas tuberosity-eminence angle and distance from joint line are more variable. Inter-rater reliability is high for percent lateralization and distance for the joint surface. Distance of tibial tuberosity from joint surface is associated with sex and height.

Return to Work or Sport After Multiligament Knee Injury: A Systematic Review of 21 Studies and 524 Patients.

PURPOSE: To systematically review multiligament knee injury (MLKI) outcome studies to determine overall rates of return to work or sport after MLKI and risk factors for lack of return to work or sport after MLKI. METHODS: A search was performed of MLKI outcome studies from 1950 to March 1, 2017. Ninety-two studies were identified. All included reported return to work, return to sport, or Tegner activity scores. Rates of return to work or sport were determined for overall population and by obesity status, injury severity, and presence of peroneal nerve or vascular injury. RESULTS: A total of 524 patients (21 studies) were included. Return to high-level sport was low (22%-33%). Return to any level of sport was 53.6% overall (178/332), with a higher rate reported in studies with all surgical patients (59.1%, 114/193 patients) versus studies with mixed surgical and nonoperative treatment (46.0%, 64/139 patients) (P = .02). Rate of return to work with little or no modifications was 62.1% (146/200) and return to any work was 88.4% (190/215). Obese patients had lower postoperative Tegner scores than a general population (obese: mean 1.7 ± 1.2; nonobese: mean 4.5 ± 1.0; P < .001). Among studies without Schenck grade IV and V injuries, return to work with no or minimal modifications (100%, 12/12 patients) was higher than studies including grade IV and V patients (66.0%, 70/106 patients) (P = .017). Return to any work was higher in studies without vascular injuries (96.3%, 105/109) versus those including them (80.2%, 85/106) (P < .001). CONCLUSIONS: Return to sport after MLKI occurs in approximately 60% of surgically treated patients, though return to high-level sport is lower. Return to work is frequently possible after MLKI though it may require workplace or job duty modifications. Obesity, nonoperative treatment, higher injury severity, and vascular injury are associated with poorer functional outcomes. LEVEL OF EVIDENCE: Level IV, systematic review of level III and IV studies.