Accuracy measures of 1.5-tesla MRI for the diagnosis of ACL, meniscus and articular knee cartilage damage and characteristics of false negative lesions: a level III prognostic study.

BACKGROUND: MRI is the most accurate imaging modality for diagnosing knee pathologies. However, there is uncertainty concerning factors predicting false negative MRI, such as meniscal tear patterns as well as patient factors. The aims of this study were to report 1.5-Tesla MRI accuracy of ACL, meniscus and articular cartilage damage and characterize false negative lesions. METHODS: Two hundred eighteen consecutive knee arthroscopies performed in our institution between 2013 and 2016 and their respective prospectively-collected MRI reports were reviewed. Inclusion criteria were age > 15 years-old, primary arthroscopy, 1.5-Tesla MRI performed at the same institution, and time interval MRI-surgery < 6 months. Exclusion criteria were revision arthroscopy and arthroscopic-assisted fracture fixation or multiligament surgery. Accuracy measures and Kappa coefficients were calculated comparing the MRI diagnosis to the arthroscopic findings. Moreover, the arthroscopic findings of false negative MRI were compared to the findings of true positive MRI using the Fisher-exact test. Pearson correlation was used for testing the correlation between MRI accuracy and patient age. RESULTS: The highest accuracy was observed in medial meniscus and in ACL findings. For the medial meniscus sensitivity, specificity, agreement, and Kappa coefficient were 77, 92, 86%, and 0.7, and for the ACL these measures were 82, 97, 87%, and 0.73. MRI accuracy was lower in the lateral meniscus and articular cartilage with Kappa coefficient 0.42 and 0.3, respectively. More specifically, short peripheral tears in the posterior horn of the medial meniscus were characteristic of false negative findings compared to true positive findings of the MRI (p <  0.01). MRI accuracy correlated negatively compared to arthroscopic findings with patient age for the medial meniscus (r = - 0.21, p = 0.002) and for articular cartilage damage (r = - 0.45, p <  0.001). CONCLUSION: 1.5-Tesla MRI will accurately diagnose ACL and medial meniscal tears and can reliably complete the diagnostic workup following physical examination, particularly in young adults. This modality however is not reliable for diagnosing short peripheral tears at the posterior horn of the medial meniscus and partial thickness articular cartilage lesion of the femoral condyles. For these lesions, definitive diagnosis may require cartilage-specific MRI sequences or direct arthroscopic evaluation. LEVEL OF EVIDENCE: Prognostic study, Level III.

Combined reconstruction of the medial patellofemoral and medial patellotibial ligaments: outcomes and prognostic factors.

PURPOSE: To report outcomes after combined medial patellofemoral ligament (MPFL) and medial patellotibial ligament (MPTL) reconstruction and test associations between prognostic factors and clinical outcomes. It was hypothesised that combined MPFL and MPTL reconstruction would result in significant improvement in function, and that outcomes would be associated with age, sex, Beighton score, concomitant articular lesions, and preoperative function. METHODS: All combined reconstructions of MPFL and MPTL were reviewed. Inclusion criterion was minimum 2-year follow-up. Exclusion criteria were age at surgery ≥ 35 years and concomitant osteotomies. Kujala, Tegner and Marx scores were completed prospectively. Patients were evaluated at a minimum 2-year follow-up. Associations between potential prognostic factors and Kujala and Tegner scores were tested using bivariate analyses followed by multivariate regression models. RESULTS: Of 22 patients (26 knees), 19 (23 knees) met inclusion criteria, and 16 (20 knees) were available for follow-up. Mean age at surgery was 18 years (range 14.5-23). Mean follow-up was 43 months (range 24-73). Postoperative Kujala score significantly improved compared to before surgery (86.4 ± 12.5 vs. 54.9 ± 15.2, p < 0.01). Postoperative Tegner score was nonsignificantly higher compared to before surgery (4.8 ± 2.4 vs. 4 ± 3, p = ns) and lower compared to before first patella dislocation (4.8 ± 2.4 vs. 5.9 ± 1.2, p < 0.01). Postoperative Kujala score was associated with male sex (p = 0.02), with medial patellofemoral chondral lesions (p = 0.01) and with preoperative Kujala score (p = 0.05). Postoperative Tegner score was associated with male sex (p < 0.01), with preoperative Tegner level (p < 0.01), and with Beighton score (p < 0.01). Patella apprehension was recorded in two knees (10%) in two patients. CONCLUSION: Combined MPFL and MPTL reconstruction in young adults results in significant improvement in subjective knee function with minimal risks, although preinjury activity levels are not consistently restored. Associated factors of improved outcome include higher preoperative knee scores and activity levels, medial patellofemoral chondral lesions, decreased Beighton scores, and male sex. This supports the advisability of the procedure and can also assist in setting realistic goals for specific groups of patients. LEVEL OF EVIDENCE: Case series, Level IV.

Surgical excision of symptomatic mature posttraumatic myositis ossificans: characteristics and outcomes in 32 athletes.

PURPOSE: The purpose of this study was to report characteristics and outcomes of surgical excision of symptomatic mature posttraumatic myositis ossificans in adult athletes. The hypothesis was that surgical excision of the ossified mass in these circumstances can effectively relief symptoms and result in return to high-level sports with minimal postoperative complications. METHODS: All operations involving excision of posttraumatic heterotopic ossifications performed between 1987 and 2015 were reviewed. Included cases had isolated excision of posttraumatic myositis ossificans, whereas excluded cases had: (1) concomitant reattachment of tendon to bone; (2) chronic overuse injuries which preceded the development of the heterotopic mass or large calcifications which were excised from tendon-to-bone insertions; and (3) excision of heterotopic ossification from a ligament, capsule, or tendon insertion following avulsion injury without tendon-to-bone repair. After surgery, return to sports was allowed at 4-6 weeks. RESULTS: Of 57 athletes undergoing excision of heterotopic ossifications, 32 were eligible as isolated excision of posttraumatic myositis ossificans. Twenty-four (75%) were ice hockey or soccer players. Median age was 23 years. Prior to surgery, patients were unable to continue their sports. At surgery, the ossification was excised from a thigh muscle in 27 (84%) cases. Median follow-up was 2 years (range 1-20 years). Outcome was Good/Excellent in 26 (81%) patients, corresponding to return to preinjury sports with minimal symptoms at sports activities. Preinjury Tegner activity level was resumed after surgery in 30 of 32 (94%) athletes, of whom 28 (94%) were involved in high-level sports corresponding to Tegner levels 8-10. No postoperative complications were recorded other than minimal insensitive areas at the periphery of skin incisions. CONCLUSION: In high-level athletes who present chronic disabling mature posttraumatic myositis ossificans that interferes with their sports career, surgical excision of the heterotopic mass results in effective clinical improvement with return to sports and minimal postoperative risks. LEVEL OF EVIDENCE: Case series, Level IV.

[SPORT MEDICINE].

Sports Medicine is a relatively new subject in medicine and includes a variety of medical and paramedical fields. Although sports medicine is mistakenly thought to be mainly for sports professionals/athletes, it actually encompasses the entire population, including the active and non-active healthy populations, as well as the sick. Sports medicine also engages amateur sportsmen and strives to promote physical activity and quality of life in the general population. Hence, the field involves all ages from childhood to old age, aiming to preserve and support every person at every age. Sports medicine, which started developing in the 19th century, is today a specialty, primary or secondary, in many countries, while in others it is a fellowship or under the jurisdiction of local or sports authorities. In Israel, the field exists since the 1950's and is advanced. The Sports Medicine Society founded a 3-year course of continued education in sport medicine as part of the Tel-Aviv University Faculty of Medicine. Later on, a fellowship in general Sports Medicine and in Orthopedic Sports Medicine were developed within the Israel Medical Association. A year ago, Israel formally became a member of the global "Exercise is Medicine" foundation, and under this title promotes education for health care providers on exercise prescription. The understanding of the importance of physical activity and fitness as part of a healthy lifestyle is increasing in Israel, as well as the number of amateur athletes, and the profession of sports medicine takes a big part in this process.

[CLINICAL AND ARTHROSCOPIC FINDINGS IN MENISCAL INJURY AND KNEE INSTABILITY: A PROSPECTIVE STUDY].

INTRODUCTION: Medical history and physical examination are expected to provide the basic knowledge allowing diagnosis of a disease and thus enabling to plan the course of treatment. OBJECTIVE: This study aimed to examine this hypothesis by comparing pre-operative diagnosis of meniscal and anterior cruciate ligament (ACL) injuries to final surgical findings. MATERIAL AND METHODS: We prospectively compared the pre-surgical diagnosis to the arthroscopic findings in 753 arthroscopic procedures. RESULTS: Clinical diagnosis of a medial meniscal (MM) tear was proven by arthroscopy in 65% of cases. Clinical diagnosis of a lateral meniscal (LM) tear was proven by arthroscopy in 54% of cases. Clinical complaints of instability correlated with partial or complete ACL rupture in 85% of cases. The accuracy of the clinical examination concerning ACL integrity ranged from 86% to 90%. Lachman and Pivot tests were slightly superior to the Drawer test. DISCUSSION: Arthroscopic surgery is the most common surgical procedure in orthopedics. The diagnosis, which is based on history and physical examination in most cases, allows proper management of the case and an appropriate treatment plan. In most scenarios, these operations are conducted based on the diagnosis and treatment performed before surgery. In this study we showed that even in experienced and skilled hands, a clinical diagnosis of meniscal tear was approved by arthroscopy in only 54% to 65% of cases. A clinical diagnosis of ACL injury was approved by arthroscopy, in 99% of cases. CONCLUSION: When planning conservative treatment or surgical intervention for a knee injury, it should be kept in mind that the clinical diagnosis of ACL rupture is highly reliable, while the clinical diagnosis of meniscal injury is only moderately reliable. Thus, especially when planning surgical intervention, the utilization of further imaging would be desirable when isolated meniscal injury is suspected.

[A NOVEL GENDER-SPECIFIC VEST FOR FEMALE INFANTRY RECRUITS DOES NOT REDUCE THE INCIDENCE OF OVERUSE PAIN SYNDROMES: A PROSPECTIVE RANDOMIZED STUDY AMONG 240 RECRUITS].

INTRODUCTION: Overuse pain syndromes constitute a troublesome byproduct of military infantry training, particularly in female fighters. These injuries result in lost days of training, pain and discomfort and can affect fitness and fighting abilities. We hypothesized that a gender specific vest would reduce the incidence of overuse pain syndromes in a population of female recruits during basic training. OBJECTIVE: The purpose of this study was therefore to examine the effect of a novel gender-specific combat vest on the incidence of lower back pain (LBP), anterior knee pain syndrome (AKPS), and plantar heel foot pain (PHFP) among female recruits. MATERIAL AND METHODS: A prospective randomized study was conducted among 243 female border police infantry recruits who were followed over 4-months of basic training. In this group, 101 females were equipped with standard unisex special unit fighting vest (SUFV) and compared to 139 females who were equipped with a novel well-padded new fighting vest (NFV), specifically designed to fit the upper body morphology of females. This novel vest was supplied in three sizes, and equipped with adjustable straps. Information regarding the occurrence of overuse injuries was collected every two weeks. Medical records and clinic visits were evaluated. Attention was given to complaints of low back pain (LBP), anterior knee pain (AKP) and plantar heel foot pain (PHFP). RESULTS: Two hundred and forty recruits completed the study. Three recruits were lost to follow-up. Anterior knee pain was recorded in 65% of recruits in the SUFV group versus 62% in the NFV group (p = ns). Lower back pain was recorded in 86% of the SUFV group versus 82% in the NFV group (p = ns), and plantar heel foot pain was recorded in 73% of the SUFV group versus 69% in the NFV group (p = ns). DISCUSSION: Overuse pain injuries are more commonly reported among female fighters. These injuries result in lost days of training, pain and discomfort and can affect combat ability. Several researchers have found that changes in fighting equipment, such as size and weight, can affect the rates of these injuries. There is still a lack of information regarding changes related to gender-based fighting equipment and their effects. CONCLUSION: A gender-specific combat vest, designed to fit the upper female body, did not have any protective effect on the occurrence of overuse pain syndromes of the back, knee and foot in this study. It seems that in order to reduce the incidence of these injuries in female recruits, emphasis should be directed at other factors such as modifications in equipment weight, as well as modifications in the intensity of the training programs.

Plasma rich in growth factors (PRGF) as a treatment for high ankle sprain in elite athletes: a randomized control trial.

PURPOSE: Syndesmotic sprains are uncommon injuries that require prolonged recovery. The influence of ultrasound-guided injections of platelet-rich plasma (PRP) into the injured antero-inferior tibio-fibular ligaments (AITFL) in athletes on return to play (RTP) and dynamic stability was studied. METHODS: Sixteen elite athletes with AITFL tears were randomized to a treatment group receiving injections of PRP or to a control group. All patients followed an identical rehabilitation protocol and RTP criteria. Patients were prospectively evaluated for clinical ability to return to full activity and residual pain. Dynamic ultrasound examinations were performed at initial examination and at 6 weeks post-injury to demonstrate re-stabilization of the syndesmosis joint and correlation with subjective outcome. RESULTS: All patients presented with a tear to the AITFL with dynamic syndesmosis instability in dorsiflexion-external rotation, and larger neutral tibia-fibula distance on ultrasound. Early diagnosis and treatment lead to shorter RTP, with 40.8 (±8.9) and 59.6 (±12.0) days for the PRP and control groups, respectively (p = 0.006). Significantly less residual pain upon return to activity was found in the PRP group; five patients (62.5 %) in the control group returned to play with minor discomfort versus one patient in the treatment group (12.5 %). One patient in the control group had continuous pain and disability and subsequently underwent syndesmosis reconstruction. CONCLUSIONS: Athletes suffering from high ankle sprains benefit from ultrasound-guided PRP injections with a shorter RTP, re-stabilization of the syndesmosis joint and less long-term residual pain. LEVEL OF EVIDENCE: II.

Young men undergoing anterior cruciate ligament reconstruction with patellar tendon autograft and anteromedial drilling outperform at 5- to 10-year follow-up in terms of graft stability and activity levels compared to those undergoing reconstruction with hamstring autograft and transtibial drilling.

OBJECTIVE: To compare 5- to 10-year outcomes of anterior cruciate ligament (ACL) reconstruction in young men performed with bone-patellar tendon bone (BPTB) autograft and anteromedial portal to reconstruction with hamstring autograft and transtibial technique. It was hypothesised that in young adult men, at 5- to 10-year follow-up, superior restoration of knee laxity and activity levels would be demonstrated using BPTB autograft and anteromedial portal technique. METHODS: Ninety-four men who had ACL reconstruction with BPTB autograft and anteromedial portal were eligible for comparison to 106 men who had reconstruction with hamstring autograft and transtibial technique. Inclusion criteria were: (1) age 18-35 years, (2) ACL tear caused by sports trauma only, (3) no concomitant ligament reconstruction and (4) 5- to 10-year follow-up. Outcome measures compared between the two groups included Lachman and pivot shift tests, KT side-to-side difference, Tegner and Marx scores, International Knee Documentation Committee (IKDC)-subjective score, Knee Osteoarthritis Outcome Scale (KOOS), Short Form (SF)-36, and single hop test for distance. P value â€‹< â€‹0.05 indicated statistical significance. RESULTS: Forty-five patients with BPTB and 55 patients with hamstring ACL reconstruction were available for in-person assessment at 5-10 years after surgery. Outcomes in the BPTB group compared to the hamstring group showed KT difference 1.4 â€‹± â€‹1.9 mm vs. 2.8 â€‹± â€‹2.3 mm (p â€‹< â€‹0.01), pivot shift grade 2-3 in 4% vs. 34% (p â€‹< â€‹0.01), return to preinjury Tegner level in 51% vs. 36% (p â€‹= 0.1) and to preinjury Marx score in 29% vs. 11% (p â€‹= 0.02), and IKDC-subjective 88 â€‹± â€‹10 vs. 82 â€‹± â€‹13 vs (p â€‹< â€‹0.01), respectively. Statistically significant inter-relationships were found between KT side-to-side difference and the Tegner, Marx and IKDC-subjective scores at follow-up (r â€‹= â€‹-0.314, p â€‹< â€‹0.01; r â€‹= â€‹-0.263, p â€‹< â€‹0.01; r â€‹= â€‹-0.218, p â€‹= â€‹0.03, respectively). CONCLUSION: Young men undergoing ACL reconstruction with patellar tendon autograft and anteromedial drilling outperform at 5- to 10-year follow-up in terms of graft stability and activity levels compared to young men undergoing reconstruction with hamstring autograft and transtibial drilling. LEVEL OF EVIDENCE: III (Retrospective cross-sectional comparative study).

Intra-articular injections of hyaluronic acid in osteoarthritis of the subtalar joint: a pilot study.

We evaluated the efficacy of intra-articular viscosupplementation with sodium hyaluronate in the management of osteoarthritis of the subtalar joint. A total of 22 patients, aged 22 to 72 years (mean 53), with symptomatic subtalar joint osteoarthritis of 1 to 20 years' duration (mean 4.2) and a severity of Kellgren-Lawrence grade II to IV and Paley and Hall grade 1 to 3, were entered into the present study. Intra-articular injections of 10 mg sodium hyaluronate (Euflexxa) were administered weekly to the subtalar joint for 3 weeks. Clinical evaluations and objective scoring using the American Orthopaedic Foot and Ankle Society Ankle Hindfoot score, visual analog scale, maximum walking distance, pain frequency, and subjective global function were performed at baseline and 4, 12, and 28 weeks after treatment. Significant improvement occurred in the American Orthopaedic Foot and Ankle Society Ankle Hindfoot scores (baseline score 54.5, week 28 score 73.7; p < .01) and visual analog scale assessment (baseline pain, stiffness, and function score 5.4, 5.8, and 6.9; week 28 pain, stiffness, and function score 2.8, 3.1, and 3.8, respectively; p < .01). Global assessment showed improvement in 18 of 20 patients completing the study (p < .01). The tolerated walking distance significantly improved from 770 ± 886 m to 2,075 ± 1,500 m (p < .001). Improvement lasted for more than 6 months. Intra-articular injection of sodium hyaluronate should be considered in the conservative management of subtalar osteoarthritis.

[The importance and composition of pre-season examination in sportsmen].

Every competitive athlete in Israel is required by law to undergo a periodical pre-participation physical examination (PPE), before the competitive season. The PPE is intended to discover medical problems which might affect the health of the athletes, and rarely, may even pose a risk to their lives. It includes a sports-oriented medical questionnaire, a thorough physical examination, and a resting electrocardiogram (ECG). From a certain age onwards, it also includes a graded exercise test (GXT). Numerous studies and standpoints of several professional committees and sports medicine organizations in Europe have emphasized the importance of the first 3 parts of the PPE, namely the questionnaire, physical examination, and resting ECG. Currently, the role of the GXT in the PPE remains debatable. In this review, we will discuss the latest available scientific information in favor of including a resting ECG and, sometimes, a GXT in the PPE of competitive athletes, as mandated by the Israeli Sports Law.

Ipsilateral Quadriceps Tendon-Bone ACL Revision Reconstruction to Address Failed Primary Bone-Patellar Tendon-Bone ACL Reconstruction with Persistent Patellar Bone Defect.

Bone-patellar tendon-bone (BPTB) autograft is a popular graft choice for anterior cruciate ligament reconstruction (ACLR) in active young adults. In case of BPTB ACLR failure, the 3 most popular autograft choices for a revision surgery include contralateral BPTB, contralateral or ipsilateral hamstrings autograft, and contralateral or ipsilateral quadriceps tendon autograft. Quadriceps tendon autograft has been gaining increasing popularity in recent years in this respect, but using quadriceps tendon-bone autograft in the setup of a previous use of ipsilateral BPTB autograft deserves special technical considerations, with emphasis on preserving patellar bone integrity. We describe a technique for performing revision ACLR after failed primary BPTB ACLR by using ipsilateral quadriceps tendon-bone autograft in the setup of persistent distal patellar bone defect. Using this autograft benefits the advantages of highly resilient graft tissue in addition to fast bone-to-bone healing on the femoral side, and it can be an excellent choice in revision reconstruction for surgeons who prefer tendon-bone autograft for highly active young adults and specifically when the patients underwent bilateral primary autologous BPTB ACLRs.

[Guidelines for wise utilization of knee imaging].

BACKGROUND: The knee is a complex structure afflicted with diverse pathologies. Correct management of knee complaints demands wise utilization of imaging modalities, considering their accuracy in the specific clinical situation, the patient's safety and availability and financial issues. Some of these considerations are universal, while others are local, depending on medical and insurance systems. There is controversy and unclearness regarding the best imaging modality in different clinical situations. PURPOSE: To develop clinical guidelines for utilizing knee imaging. METHODS: Leading physicians in specialties associated with knee disease and imaging were invited to participate in a panel on the guidelines. Controversies were settled in the main panel or in sub-panels. RESULTS: The panel agreed on the principles in choosing from the various modalities, primarily medical accuracy, followed by patient safety, availability and cost. There was agreement that the physician is responsible to choose the most appropriate diagnostic tool, consulting, when necessary, on the advantages, limitations and risks of the various imaging modalities. A comprehensive table was compiled with the importance of the different imaging modalities in various clinical situations. DISCUSSION AND SUMMARY: For the first time, Israeli guidelines on wise utilization of knee imaging are presented. They take into consideration the clinical situations and also availability and financial issues specific to Israel. These guidelines will serve physicians of several disciplines and medical insurers to improve patient management efficiently.

Analysis of foot and ankle kinematics after operative reduction of high-grade intra-articular fractures of the calcaneus.

BACKGROUND: High-grade calcaneal fractures represent a complex injury, with limited data to support the advisability of open reduction. Restoration of foot and ankle kinematics during walking, which has been previously shown to be significantly limited after nonoperative treatment, has never been studied after the operation. This study was designed to address this lack of information to assess the advisability of the operation in this respect. METHODS: Twenty patients with a minimum of 2 years after Open Reduction Internal Fixation (ORIF) for high-grade fractures were evaluated with a computerized gait analysis system, in addition to the radiographic assessment and functional questionnaires. Foot and ankle kinematic variables in the operated limbs were compared with contralateral limbs and with matched healthy control individuals. RESULTS: The kinematical gait analysis demonstrated recreation of normal ankle motions in operated patients. Subtalar motion demonstrated relative symmetry between operated and contralateral limbs, but it was still significantly limited compared with healthy controls. Bohler angle was between 15° and 35°. Functional questionnaires and rate of postoperative complications supported the generalizability of our operated group compared with previous literature assessing similar injuries. CONCLUSIONS: In high-grade calcaneal fractures, when recreation of gross calcaneal anatomy is obtained during the operation, walking ankle motion is recreated as well. However, subtalar motions, although recreated to a certain extent, still demonstrate limitations when compared with noninjured individuals. These results support the advisability of the operation in these complex injuries, but they demonstrate that subtalar motion is not completely normalized despite a favorable anatomic outcome.

Arthroscopy-assisted fracture fixation.

PURPOSE: the purpose of this article was to systematically analyze the results of published studies in the literature which evaluated the use of arthroscopically assisted techniques in intra-articular fracture fixation. METHODS: published investigations to date were analyzed by classifying them according to joints that were involved with intra-articular fractures including: knee, ankle, hip, shoulder, elbow, and wrist joints. The results were studied to assess the feasibility, efficiency, and outcomes of arthroscopy-assisted fracture fixation. RESULTS: arthroscopy-assisted techniques have been used successfully for the treatment of fractures of the tibial plateau, tibial eminence, malleoli, pilon, calcaneus, femoral head, glenoid, greater tuberosity, distal clavicle, radial head, coronoid, distal radius, and scaphoid. The major advantages of arthroscopic fracture fixation over open methods are direct visualization of the intra-articular space, decreased invasiveness, and the possibility for multitask interventions through which fixation of the fracture, and repair of the soft tissues and the cartilage can be performed simultaneously. The time-consuming and technically demanding nature of the procedures with a prolonged learning curve and limited fixation alternatives are the main disadvantages of this technique. CONCLUSION: arthroscopic fixation is increasingly utilized for certain intra-articular fracture types due to the minimally invasive nature of the procedures and high accuracy. Randomized controlled trials are needed to justify wider use of arthroscopy-assisted techniques for treatment of intra-articular fractures.

[Platelet rich plasma--a new biotechnology for treatment of sports injuries].

Autologous platelet-rich plasma (PRP) is a relatively new biotechnology backed by over two decades of research in diverse areas. With its growing use for the treatment of musculoskeletal injuries, Orthopaedic Sports Medicine may be the discipline in which translational use of PRP has progressed most rapidly. PRP therapy involves the injection of a small volume of plasma or the application of PRP gel foam directly to the site of injury. It is composed of numerous growth factors (GF) secreted from large numbers of 'activated' platelets, directed at facilitating and enhancing physiological wound healing and rapid tissue regeneration. With wide variations in preparation protocols, kits, activation methods, platelet concentrations and growth factors, many questions are still unanswered. Similarly, application methods, timing of treatment and volume of injection are inconsistent, emphasizing the need for appropriately powered level 1 and 2 studies with adequate and relevant outcome measures and clinically appropriate follow-up in order to assess the efficacy and effectiveness of all elements of PRP therapy. Clinical interventions in sports and musculoskeletal medicine aim to achieve predictable, rapid tissue repair and enhance wound heating and to restore the high mechanical performance and functional levels of non-injured tissue in the shortest possible time. PRP may be a remarkable step forward in this quest. This review will evaluate the evolution and most recent contributions of PRP treatment.

Inside-out Repair of Extensive Meniscal Tears Using Posteromedial and Posterolateral Neurovascular Protective Windows.

Three popular repair techniques for preserving the torn meniscus are the all-inside, outside-in, and inside-out techniques. Among these, the inside-out technique has shown low failure rates, and it therefore remains the gold-standard technique for repairing the torn meniscus. For extensive and chronic meniscal tears, proper use of this technique has become fundamental for knee surgeons. Nevertheless, challenges in using this technique include a higher risk of catching the neurovascular bundles on the posteromedial and posterolateral sides of the knee and difficulties in reducing and stabilizing chronically displaced meniscal fragments. In this article, the inside-out technique is revisited with an emphasis on anatomic details of how to avoid the neurovascular bundles while addressing extensive and chronic meniscal lesions.

All-Autograft Multiligament Knee Reconstruction of the Posterior Cruciate Ligament, Anterior Cruciate Ligament, and Posterolateral Corner (KD-IIIL).

Multiligament knee reconstruction constitutes a challenging entity. While allograft use gained popularity in this scenario because it can reduce surgery time and the risk of donor-site morbidities, in some places high-quality allografts are not readily available. In addition, allografts are subjected to some disadvantages compared with autografts, including slower biological incorporation and risk of disease transmission. Choosing and using wisely autografts to address these cases becomes valuable for these reasons. In this manuscript a technique is described for performing all-autograft multiligament knee reconstruction of the posterior cruciate ligament, anterior cruciate ligament and posterolateral corner.

Analysis of foot structure in athletes sustaining proximal fifth metatarsal stress fracture.

BACKGROUND: In the past, several studies provided anecdotal descriptions of high-arched feet in individuals sustaining proximal fifth metatarsal stress fractures. This relationship has never been supported by scientific evidence. Our objective was to examine whether athletes who sustained this injury had an exceptional static foot structure or dynamic loading pattern. MATERIALS AND METHODS: Ten injured professional soccer players who regained full professional activity following a unilateral proximal fifth metatarsal stress fracture and ten control soccer players were examined. Independent variables included static evaluation of foot and arch structure, followed by dynamic plantar foot pressure evaluation. Each variable was compared between injured, contra-lateral uninjured, and control feet. RESULTS: Static measurements of foot and arch structure did not reveal differences among the groups. However, plantar pressure evaluation revealed relative unloading of the fourth metatarsal in injured and uninjured limbs of injured athletes compared with control, while the fifth metatarsal revealed pressure reduction only in the injured limbs of injured athletes. CONCLUSION: Athletes who sustained proximal fifth metatarsal stress fracture were not characterized by an exceptional static foot structure. Dynamically, lateral metatarsal unloading during stance may either play a role in the pathogenesis of the injury, or alternately represent an adaptive process. CLINICAL RELEVANCE: Footwear fabrication for previously injured athletes should not categorically address cushioning properties designed for high-arch feet, but rather focus on individual dynamic evaluation of forefoot loading, with less attention applied to static foot and arch characteristics.

Equipment modification is associated with fewer stress fractures in female Israel border police recruits.

PURPOSE: The study was planned to assess whether combat equipment weight reduction would lead to a reduction in the incidence of stress fractures in female border police infantry recruits taking a 4-month course of basic combat training. METHOD: 213 female border police recruits, 18-19 years of age, undergoing 16 weeks of basic combat training with lighter rifle and lighter closely fitted combat vest, (total 9.4 kg) were followed prospectively for stress fracture (SFx) incidence, compared to a historical control group of 1,210 recruits who trained with traditional equipment (12.5 kg). RESULTS: Equipment modification was associated with a significant reduction in SFx from 18.3% in the control group to 8.0% in the intervention group (p < 0.0001). CONCLUSIONS: This study implies that equipment weight reduction may achieve a significant effect in SFx reduction, Approximating fighting gear to body center of gravity may enhance this effect.

Subtalar kinematics following resection of tarsal coalition.

BACKGROUND: Pain relief and functional improvement in the short term have been demonstrated in the majority of patients with tarsal coalition following resection. Recreation of normal subtalar kinematics is an important goal in these patients as well, and may have long term implications. The purpose of our study was to examine whether kinematic variables of foot motion are normalized following resection of tarsal coalition. MATERIALS AND METHODS: This study compared three groups: nine candidates for resection of tarsal coalition, nine patients between 2 and 4 years after bar resection, and nine control subjects. Ankle hindfoot scoring was evaluated according to the AOFAS. Kinematic analysis of subtalar motion in the coronal plane and in the sagittal plane was performed using a computerized gait analysis system. RESULTS: Significantly increased passive subtalar range of motion and AOFAS ankle hindfoot scoring were demonstrated in postoperative subjects relative to preoperative subjects (p = 0.000). However, the kinematic analysis performed during walking, revealed similar, severe restriction of the subtalar eversion-inversion motion in postoperative and preoperative subjects. Angular velocity of the subtalar motion was also similar in both coalition groups, and was significantly increased compared with control. Kinematic analysis of foot motion in the sagittal plain demonstrated improved motion in postoperative subjects, which was comparable with the control group. CONCLUSION: Foot kinematics are not recreated following tarsal coalition resection, despite the favorable clinical outcome observed. CLINICAL RELEVANCE: Following resection of a tarsal coalition, patients continue to be subjected to increased loading and torque in their subtalar and adjacent articulations. This may promote further articular deterioration in the long term. Additional operative procedures or rehabilitation protocols should be examined to improve foot kinematics in this population.