The mechanism of hamstring injuries - a systematic review.

BACKGROUND: Injuries to the hamstring muscles are among the most common in sports and account for significant time loss. Despite being so common, the injury mechanism of hamstring injuries remains to be determined. PURPOSE: To investigate the hamstring injury mechanism by conducting a systematic review. STUDY DESIGN: A systematic review following the PRISMA statement. METHODS: A systematic search was conducted using PubMed, EMBASE and the Cochrane Library. Studies 1) written in English and 2) deciding on the mechanism of hamstring injury were eligible for inclusion. Literature reviews, systematic reviews, meta-analyses, conference abstracts, book chapters and editorials were excluded, as well as studies where the full text could not be obtained. RESULTS: Twenty-six of 2372 screened original studies were included and stratified to the mechanism or methods used to determine hamstring injury: stretch-related injuries, kinematic analysis, electromyography-based kinematic analysis and strength-related injuries. All studies that reported the stretch-type injury mechanism concluded that injury occurs due to extensive hip flexion with a hyperextended knee. The vast majority of studies on injuries during running proposed that these injuries occur during the late swing phase of the running gait cycle. CONCLUSION: A stretch-type injury to the hamstrings is caused by extensive hip flexion with an extended knee. Hamstring injuries during sprinting are most likely to occur due to excessive muscle strain caused by eccentric contraction during the late swing phase of the running gait cycle. LEVEL OF EVIDENCE: Level IV.

Ruxolitinib versus standard therapy for the treatment of polycythemia vera.

BACKGROUND: Ruxolitinib, a Janus kinase (JAK) 1 and 2 inhibitor, was shown to have a clinical benefit in patients with polycythemia vera in a phase 2 study. We conducted a phase 3 open-label study to evaluate the efficacy and safety of ruxolitinib versus standard therapy in patients with polycythemia vera who had an inadequate response to or had unacceptable side effects from hydroxyurea. METHODS: We randomly assigned phlebotomy-dependent patients with splenomegaly, in a 1:1 ratio, to receive ruxolitinib (110 patients) or standard therapy (112 patients). The primary end point was both hematocrit control through week 32 and at least a 35% reduction in spleen volume at week 32, as assessed by means of imaging. RESULTS: The primary end point was achieved in 21% of the patients in the ruxolitinib group versus 1% of those in the standard-therapy group (P<0.001). Hematocrit control was achieved in 60% of patients receiving ruxolitinib and 20% of those receiving standard therapy; 38% and 1% of patients in the two groups, respectively, had at least a 35% reduction in spleen volume. A complete hematologic remission was achieved in 24% of patients in the ruxolitinib group and 9% of those in the standard-therapy group (P=0.003); 49% versus 5% had at least a 50% reduction in the total symptom score at week 32. In the ruxolitinib group, grade 3 or 4 anemia occurred in 2% of patients, and grade 3 or 4 thrombocytopenia occurred in 5%; the corresponding percentages in the standard-therapy group were 0% and 4%. Herpes zoster infection was reported in 6% of patients in the ruxolitinib group and 0% of those in the standard-therapy group (grade 1 or 2 in all cases). Thromboembolic events occurred in one patient receiving ruxolitinib and in six patients receiving standard therapy. CONCLUSIONS: In patients who had an inadequate response to or had unacceptable side effects from hydroxyurea, ruxolitinib was superior to standard therapy in controlling the hematocrit, reducing the spleen volume, and improving symptoms associated with polycythemia vera. (Funded by Incyte and others; RESPONSE ClinicalTrials.gov number, NCT01243944.).

Editorial Commentary: When Is Too Small, Too Small? Allograft Augmentation of Autologous Hamstring Grafts During Anterior Cruciate Ligament Reconstruction.

Soft tissue allograft augmentation of small hamstring autografts, so-called hybrid grafts, has been proposed as an option during anterior cruciate ligament reconstruction (ACL-R). However, notable concerns exist with both small autograft use and allograft use during ACL-R, particularly in young, active patients. We currently choose to augment hamstring autografts with diameters <8.0 mm, adding only enough allograft to create a hybrid graft with an overall diameter no larger than 8.5 mm. Based on the available evidence, surgeons continue to seek the tipping point where the benefit of additional allograft tissue exceeds the consequence of its use.

Matrix metalloproteinase activity and prostaglandin E2 are elevated in the synovial fluid of meniscus tear patients.

PURPOSE: Meniscus tears are a common knee injury and are associated with the development of post-traumatic osteoarthritis (OA). The purpose of this study is to evaluate potential OA mediators in the synovial fluid and serum of meniscus tear subjects compared to those in the synovial fluid of radiographic non-OA control knees. MATERIALS AND METHODS: Sixteen subjects with an isolated unilateral meniscus injury and six subjects who served as reference controls (knee Kellgren-Lawrence grade 0-1) were recruited. Twenty-one biomarkers were measured in serum from meniscus tear subjects and in synovial fluid from both groups. Meniscus tear subjects were further stratified by tear type to assess differences in biomarker levels. RESULTS: Synovial fluid total matrix metalloproteinase (MMP) activity and prostaglandin E2 (PGE2) were increased 25-fold and 290-fold, respectively, in meniscus tear subjects as compared to reference controls (p < 0.05). Synovial fluid MMP activity and PGE2 concentrations were positively correlated in meniscus tear subjects (R = 0.83, p < 0.0001). In meniscus tear subjects, synovial fluid levels of MMP activity, MMP-2, MMP-3, sGAG, COMP, IL-6, and PGE2 were higher than serum levels (p < 0.05). Subjects with complex meniscus tears had higher synovial fluid MMP-10 (p < 0.05) and reduced serum TNFα and IL-8 (p < 0.05) compared to other tear types. CONCLUSIONS: Given the degradative and pro-inflammatory roles of MMP activity and PGE2, these molecules may alter the biochemical environment of the joint. Our findings suggest that modulation of PGE2 signaling, MMP activity, or both following a meniscus injury may be targets to promote meniscus repair and prevent OA development.

Lower Extremity Movement Differences Persist After Anterior Cruciate Ligament Reconstruction and When Returning to Sports.

OBJECTIVE: To examine how landing mechanics change in patients after anterior cruciate ligament reconstruction (ACL-R) between 6 months and 12 months after surgery. DESIGN: Case-series. SETTING: Laboratory. PARTICIPANTS: Fifteen adolescent patients after ACL-R participated. INTERVENTIONS: Lower extremity three-dimensional motion analysis was conducted during a bilateral stop jump task in patients at 6 and 12 months after ACL-R. Joint kinematic and kinetic data, in addition to ground reaction forces, were collected at each time point. MAIN OUTCOME MEASURES: During the stop jump landing, the peak joint moments and the initial and peak joint motion at the ankle, knee, and hip were examined. The peak vertical ground reaction force was also examined. RESULTS: Interactions were observed for both the peak knee (P = 0.03) and hip extension moment (P = 0.07). However, only the hip extension moment was symmetrical level at 12 months. Statistically significant (P < 0.05) side-to-side differences existed for the ankle angle at initial contact, peak plantarflexion moment, peak hip flexion angle, and peak impact vertical ground reaction force independent of time. CONCLUSIONS: The findings of this study suggest that sagittal plane moments at the knee and hip demonstrate an increase in symmetry between 6 months and 1 year after ACL-R surgery, however, symmetry of the knee extension moment is not established by 12 months after surgery. The lack of change in the variables across time was unexpected. As a result, it is inappropriate to expect a change in landing mechanics solely as a result of time alone after discharge from rehabilitation.

Gender Differences in Plantar Loading During an Unanticipated Side Cut on FieldTurf.

OBJECTIVE: To determine whether force-time integral (FTI) and maximum force (MF) are significantly different between genders when performing an unanticipated side cut on FieldTurf. DESIGN: Thirty-two collegiate athletes (16 men and 16 women) completed 12 unanticipated cutting trials, while plantar pressure data were recorded using Pedar-X insoles. SETTING: Controlled Laboratory Study. PARTICIPANTS: Division I cleated sport athletes with no previous foot and ankle surgery, no history of lower extremity injury in the past 6 months, and no history of metatarsal stress fracture. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Maximum force and the FTI in the total foot, medial midfoot (MMF), lateral midfoot (LMF), medial forefoot (MFF), middle forefoot (MiddFF), and the lateral forefoot (LFF). RESULTS: Males had a greater FTI beneath the entire foot (TF) (P < 0.001). Females had a significantly higher MF beneath the LMF (P = 0.001), MiddFF (P < 0.001), and LFF (P = 0.001). Males had a significantly greater MF beneath the MMF (P = 0.003) and greater FTI beneath the MMF (P < 0.001) and MFF (P = 0.002). CONCLUSIONS: Significant differences in plantar loading exist between genders with males demonstrating increased loading beneath the TF in comparison with females. Females had overall greater loading on the lateral column, whereas males had greater loading on the medial column of the foot. CLINICAL RELEVANCE: The results of this study indicate that plantar loading is different between genders; therefore, altering cleated footwear to be gender specific may result in more optimal foot loading patterns. Optimizing cleated shoe design could decrease the risk for metatarsal stress fractures.

British Society of Gastroenterology/Association of Coloproctologists of Great Britain and Ireland guidelines for the management of large non-pedunculated colorectal polyps.

These guidelines provide an evidence-based framework for the management of patients with large non-pedunculated colorectal polyps (LNPCPs), in addition to identifying key performance indicators (KPIs) that permit the audit of quality outcomes. These are areas not previously covered by British Society of Gastroenterology (BSG) Guidelines.A National Institute of Health and Care Excellence (NICE) compliant BSG guideline development process was used throughout and the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool was used to structure the guideline development process. A systematic review of literature was conducted for English language articles up to May 2014 concerning the assessment and management of LNPCPs. Quality of evaluated studies was assessed using the Scottish Intercollegiate Guidelines Network (SIGN) Methodology Checklist System. Proposed recommendation statements were evaluated by each member of the Guideline Development Group (GDG) on a scale from 1 (strongly agree) to 5 (strongly disagree) with >80% agreement required for consensus to be reached. Where consensus was not reached a modified Delphi process was used to re-evaluate and modify proposed statements until consensus was reached or the statement discarded. A round table meeting was subsequently held to finalise recommendations and to evaluate the strength of evidence discussed. The GRADE tool was used to assess the strength of evidence and strength of recommendation for finalised statements.KPIs, a training framework and potential research questions for the management of LNPCPs were also developed. It is hoped that these guidelines will improve the assessment and management of LNPCPs.

Management of sexually transmitted infections in New York State health care organizations: who is thinking about the quality of STI care?

BACKGROUND: Rising rates of sexually transmitted infections (STIs) warrant a renewed focus on the management of STIs in health care organizations. The extent to which hospitals and community health centers (CHCs) have established processes and allocated staff for the management of STIs within their organizations remains poorly understood. METHODS: A New York State Department of Health survey was distributed electronically through a closed state communication network to targeted administrators at New York State hospitals and CHCs. The survey asked if STI management in their facilities included the following: the ability to measure and report rates of STIs, a process to assess the quality of STI care and treatment outcomes, and a centralized person/unit to coordinate its work throughout the facility. Multivariate analysis was performed to identify whether organizational characteristics were associated with survey findings. RESULTS: Ninety-five percent (243/256) of hospitals and CHCs responded to the survey. Fifty percent of respondents had a person or unit to report rates of STIs; 30% reported an organization-wide process for monitoring the quality of STI care, which, according to the multivariate analysis, was associated with CHCs; only 23% reported having a centralized person or unit for coordinating STI management. CONCLUSIONS: Most facilities report STI cases to comply with public health surveillance requirements but do not measure infection rates, assess the quality of STI care, or coordinate its work throughout the facility. The development of this organizational capacity would likely decrease STI rates, improve treatment outcomes, and address local public health goals.

Time to get rid of the clock: intraobserver and interobserver reliability in determination of the o'clock position of the femoral tunnel in ACL reconstruction.

This study evaluates intraobserver and interobserver agreement in reporting the o'clock position of the femoral tunnel during anterior cruciate ligament (ACL) reconstruction. Four PGY2 residents, four PGY5 residents, and four sports medicine orthopedic surgeons reported the o'clock position of the femoral ACL tunnel in 10 arthroscopic pictures on two occasions 3 months apart. Intraobserver agreement was determined using the intraobserver correlation coefficient (r > 0.576 for 0.05 significance level). Interobserver agreement between members of each group and between reviewer groups was evaluated with the intraclass correlation coefficient (ICC > 0.75 considered good agreement). Poor interobserver agreement was demonstrated between the attending and PGY2 groups (ICC = 0.1685), between the attending and PGY5 groups (ICC = 0.2982), and between the PGY5 and PGY2 groups (ICC = 0.267). Attending surgeons, PGY5s, and PGY2s demonstrated poor interobserver agreement amongst themselves (ICC = 0.2244, 0.471, and 0.0859, respectively). PGY2s and PGY5s demonstrated good intraobserver agreement, but attending surgeons demonstrated poor intraobserver agreement. Attending orthopedic surgeons and residents of different levels of training interpret the o'clock position of the femoral tunnel differently. Greater years of experience does not improve intraobserver or interobserver agreement on the o'clock position. The clock face terminology for femoral tunnel placement may not be a reliable descriptor for scientific investigations or clinical instruction.

Advantages and techniques of utilizing anterolateral portal in delaminated rotator cuff repair.

Typically, rotator cuff repair is performed two-dimensionally while visualizing the subacromial space. To achieve a more complete repair, sutures can be retrieved from inside the joint utilizing a penetrating suture device through the anterolateral portal, which permits visualization of the articular side and bursal side of the rotator cuff tear. Utilizing other portals can leave the sutures out of sight and reach. The anterolateral portal helps capture both leaves of a delaminated tear and places the sutures in the center of the field for retrieval and tying. The anterolateral portal is located with a spinal needle just off the anterolateral corner of the acromion, and the suture anchor is inserted into the greater tuberosity through this portal. The sutures are passed into the joint through the tear in the rotator cuff with a suture grasper. The scope is redirected intraarticularly, and the suture is visualized. The sutures are positioned, and the penetrator is passed through the tendon. The scope is placed back in the bursa for tying sutures and capturing both leaves of a delaminated tear. It works equally well for simple complete tears and partial articular-sided supraspinatus tendon avulsion lesions.

Tram-track appearance of the posterior cruciate ligament (PCL): correlations with mucoid degeneration, ligamentous stability, and differentiation from PCL tears.

OBJECTIVE: The purpose of our study was to describe the MRI findings in the posterior cruciate ligament (PCL) analogous to mucoid degeneration in the anterior cruciate ligament (ACL); to correlate MRI findings in the PCL with ligamentous stability; to differentiate the PCL tram-track appearance from the appearance of PCL tears; and to emphasize the coexistence of PCL and ACL mucoid degeneration, cruciate ganglia, and meniscal cysts. CONCLUSION: The tram-track PCL appearance commonly coexists with ACL mucoid degeneration; ganglia; and, less frequently, meniscal cysts. Both PCL tears and MRI findings suggestive of PCL mucoid degeneration show ligament thickening and increased PCL signal intensity. Tram-track PCLs are usually asymptomatic and typically have no ligamentous instability.

Intercondylar synovial septum in two patients with nail-patella syndrome.

This case report describes the arthroscopic findings in two patients with nail-patella syndrome (NPS). In both cases, a midline synovial septum was encountered that completely subdivided the knee into medial and lateral compartments. One patient required two subsequent arthroscopic procedures, and the synovial septum was found to have recurred even after it had been resected at the initial surgery. The etiology and clinical significance of this anatomic anomaly are unknown, however, surgeons should be aware of its existence and the potential difficulties it may present during knee arthroscopy in patients with NPS.

Racial Disparities in Psychiatric Decisional Capacity Consultations.

OBJECTIVE: In this study, the authors examined potential disparities and biases in the placement and outcomes of decisional capacity evaluations across races, controlling for patient characteristics. METHODS: The authors reviewed 181 patient decisional capacity consultations requested for the consultation-liaison psychiatry service at a tertiary care medical center from 2018 to 2019. The racial distribution of patients in these consultations was compared with the racial distribution of hospital inpatient admissions from 2018 to 2019. The authors analyzed patient outcomes by using logistic regression that controlled for race, gender, age, education, primary insurance, type of capacity assessment, and psychiatric diagnosis. RESULTS: Decisional capacity consultations were placed disproportionately for Black (43% of consultations vs. 18% of total admissions) and Hispanic patients (26% of consultations vs. 21% of admissions) compared with White and Asian patients. Among 130 patients with a capacity determination, 95 (53% of total sample) were determined not to have capacity, an outcome that did not differ by race but was more likely to occur among patients diagnosed as having delirium. Sixty-seven patients with no capacity (37% of total sample) experienced a change in treatment, an outcome that was less likely to occur among Hispanic patients in the univariable analysis. CONCLUSIONS: Significant racial disparities were observed during the placement of a decisional capacity consultation. These findings reveal the potential biases introduced with both the initial challenge to a patient's capacity and the subsequent outcomes of the consultation. As such, the balance of risk versus benefit or utility of these consultations in certain populations must be carefully considered.

Hemi-bucket-handle tears of the meniscus: appearance on MRI and potential surgical implications.

OBJECTIVES: To describe a type of meniscus flap tear resembling a bucket-handle tear, named a "hemi-bucket-handle" tear; to compare its imaging features with those of a typical bucket-handle tear; and to discuss the potential therapeutic implications of distinguishing these two types of tears. MATERIALS AND METHODS: Five knee MR examinations were encountered with a type of meniscus tear consisting of a flap of tissue from the undersurface of the meniscus displaced toward the intercondylar notch. A retrospective analysis of 100 MR examinations prospectively interpreted as having bucket-handle type tears yielded 10 additional cases with this type of tear. Cases of hemi-bucket-handle tears were reviewed for tear location and orientation, appearance of the superior articular surface of the meniscus, presence and location of displaced meniscal tissue, and presence of several classic signs of bucket-handle tears. RESULTS: A total of 15/15 tears involved the medial meniscus, had tissue displaced toward the notch, and were mainly horizontal in orientation. The superior surface was intact in 11/15 (73.3%). In 1/15 (6.7%) there was an absent-bow-tie sign; 6/15 (40%) had a double-PCL sign; 14/15 (93.3%) had a double-anterior horn sign. CONCLUSION: We describe a type of undersurface flap tear, named a hemi-bucket-handle tear, which resembles a bucket-handle tear. Surgeons at our institution feel this tear would likely not heal if repaired given its predominantly horizontal orientation, and additionally speculate the tear could be overlooked at arthroscopy. Thus, we feel it is important to distinguish this type of tear from the typical bucket-handle tear.

Graft size and patient age are predictors of early revision after anterior cruciate ligament reconstruction with hamstring autograft.

PURPOSE: To evaluate whether decreased hamstring autograft size and decreased patient age are predictors of early graft revision. METHODS: Of 338 consecutive patients undergoing primary anterior cruciate ligament (ACL) reconstruction with hamstring autograft, 256 (75.7%) were evaluated. Graft size and patient age, gender, and body mass index at the time of ACL reconstruction were recorded, along with whether subsequent ACL revision was performed. RESULTS: The 256 patients comprised 136 male and 120 female patients and ranged in age from 11 to 52 years (mean, 25.0 years). The mean follow-up was 14 months (range, 6 to 47 months). Revision ACL reconstruction was performed in 18 of 256 patients (7.0%) at a mean of 12 months after surgery (range, 3 to 31 months). Revision was performed in 1 of 58 patients (1.7%) with grafts greater than 8 mm in diameter, 9 of 139 patients (6.5%) with 7.5- or 8-mm-diameter grafts, and 8 of 59 patients (13.6%) with grafts 7 mm or less in diameter (P = .027). There was 1 revision performed in the 137 patients aged 20 years or older (0.7%), but 17 revisions were performed in the 119 patients aged under 20 years (14.3%) (P < .0001). Most revisions (16 of 18) were noted to occur in patients aged under 20 years with grafts 8 mm in diameter or less, and the revision rate in this population was 16.4% (16 of 97 patients). Age less than 20 years at reconstruction (odds ratio [OR], 18.97; 95% confidence interval [CI], 2.43 to 147.06; P = .005), decreased graft size (OR, 2.20; 95% CI, 1.00 to 4.85; P = .05), and increased follow-up time (OR, 1.07; 95% CI, 1.02 to 1.12) were associated with increased risk of revision. CONCLUSIONS: Decreased hamstring autograft size and decreased patient age are predictors of early graft revision. Use of hamstring autografts 8 mm in diameter or less in patients aged under 20 years is associated with higher revision rates. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Prevention of ACL injury, part I: injury characteristics, risk factors, and loading mechanism.

The anterior cruciate ligament (ACL) injury is one of the most common injuries in sports. ACL injuries are not only costly from financial and health services consumption standpoints, but also can have devastating consequences on patients' activity levels and quality of life. Tremendous efforts have been made over the past two decades toward the goal of preventing ACL injuries. A substantial number of studies have been performed to determine the characteristics of ACL injury events, identify risk factors for ACL injury, and develop prevention strategies. The purpose of this review was to objectively summarize the current literature regarding the characteristics of ACL injury, ACL loading mechanisms, and risk factors for injury to provide a comprehensive understanding of the current state of research and how our current level of knowledge may inform clinical practice in this area.

Prevention of ACL injury, part II: effects of ACL injury prevention programs on neuromuscular risk factors and injury rate.

Prevention strategies have been developed based on existing knowledge in an attempt to alter neuromuscular control and lower extremity biomechanics in order to reduce anterior cruciate ligament (ACL) injury rates. These strategies have included different training programs ranging from injury education to multicomponent training. Many training programs have been demonstrated as resulting in altered lower extremity movement patterns. The effects of current training programs on ACL injury rate, however, are inconsistent. This review was focused on the effects of current ACL injury training programs on neuromuscular risk factors and ACL injury rate. Recommendations were made based on the available evidence for clinicians and coaches to implement ACL injury prevention programs.

Ultrasound-guided microinvasive trigger finger release technique using an 18-gauge needle with a blade at the tip: A prospective study.

BACKGROUND: Open surgical trigger finger release has limited success and the risk of complications; however, percutaneous techniques offer a successful alternative. There is limited understanding of the success of percutaneous trigger finger release. OBJECTIVE: To prospectively evaluate the functional outcomes of patients with Green classification Grade 2 to 4 trigger finger treated with an ultrasound-guided microinvasive trigger finger release using a special 18-gauge needle with a blade at the tip. DESIGN: Prospective, case-series study. SETTING: This study took place at an academic institution by one sports medicine physician (R.E.C.) with subspecialty training and certification in musculoskeletal ultrasound. PATIENTS: Sixty patients (79 cases) met criteria and agreed to participate in this study; 19 patients had multiple fingers treated. Average patient age was 62.8 years (SD 10.2). Average trigger finger severity diagnosis was Grade 3. INTERVENTIONS: Patients were treated with an ultrasound-guided microinvasive trigger finger release using a special 18-gauge needle with a blade at the tip. MAIN OUTCOME MEASUREMENTS: Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH), numerical rating scale (NRS), and Nirschl scores were captured preprocedure, at various time points, and at final follow-up. Changes between preprocedure and final follow-up were analyzed by paired t test (p < .05). Differences were also analyzed between finger, grade level, and gender by repeated measures analyses of variance (p < .05). RESULTS: No adverse events were documented perioperatively or postoperatively. Average follow-up time was 18.4 months (SD 4.6). At final follow-up, 100% of patients reported no recurrence of catching/locking, 97% had complete resolution of symptoms and significant improvement in QuickDASH scores, and 99% required no further treatment. All measurements showed a decrease in pain and symptoms over time. The improvements in QuickDASH score, NRS, and Nirschl scale and the resolution of mechanical symptoms were all statistically significant. CONCLUSIONS: Ultrasound-guided release using the 18-gauge needle with a blade provides significant functional improvement and full resolution of mechanical symptoms with minimal adverse events.