Glenoid erosion is a risk factor for recurrent instability after Hill-Sachs remplissage.

AIMS: The aim of this study was to identify risk factors for recurrent instability of the shoulder and assess the ability to return to sport in patients with engaging Hill-Sachs lesions treated with arthroscopic Bankart repair and Hill-Sachs remplissage (ABR-HSR). METHODS: This retrospective study included 133 consecutive patients with a mean age of 30 years (14 to 69) who underwent ABR-HSR; 103 (77%) practiced sports before the instability of the shoulder. All had large/deep, engaging Hill-Sachs lesions (Calandra III). Patients were divided into two groups: A (n = 102) with minimal or no (< 10%) glenoid bone loss, and B (n = 31) with subcritical (10% to 20%) glenoid loss. A total of 19 patients (14%) had undergone a previous stabilization, which failed. The primary endpoint was recurrent instability, with a secondary outcome of the ability to return to sport. RESULTS: At a mean follow-up of four years (1.0 to 8.25), ten patients (7.5%) had recurrent instability. Patients in group B had a significantly higher recurrence rate than those in group A (p = 0.001). Using a multivariate logistic regression, the presence of glenoid erosion of > 10% (odds ratio (OR) = 35.13 (95% confidence interval (CI) 8 to 149); p = 0.001) and age < 23 years (OR = 0.89 (0.79 to 0.99); p = 0.038) were associated with a higher risk of recurrent instability. A total of 80 patients (78%) could return to sport, but only 11 athletes (65%) who practiced high-risk (collision or contact-overhead) sports. All seven shoulders which were revised using a Latarjet procedure were stable at a mean final follow-up of 36 months (11 to 57) and returned to sports at the same level. CONCLUSION: Patients with subcritical glenoid bone loss (> 10%) and younger age (≤ 23 years) are at risk of failure and reoperation after ABR-HSR. Furthermore, following this procedure, one-third of athletes practicing high-risk sports are unable to return at their pre-instability level, despite having a stable shoulder. Cite this article: Bone Joint J 2021;103-B(4):718-724.

Knee Cartilage Defect Characteristics Vary among Symptomatic Recreational and Competitive Scholastic Athletes Eligible for Cartilage Restoration Surgery.

OBJECTIVE: To determine whether there are differences by sport or competitive level in symptomatic knee cartilage defects among recreational, high school, or collegiate competitive athletes undergoing initial arthroscopic knee surgery who meet criteria for cartilage restoration surgery. DESIGN: Three hundred recreational (n = 172) and high school or collegiate competitive athletes (n = 128) younger than 40 years and body mass index (BMI) <35 kg/m2 (63% male, mean age 24.3 years, SD 7.1; mean BMI 25.7 kg/m2, SD 3.7) with Outerbridge grade 2 or higher symptomatic cartilage defects who underwent arthroscopic knee surgery were identified. The independent relationship between sporting activity or competitive level and cartilage defect location, size, severity, and symptom chronicity were assessed by multivariate regression analysis. RESULTS: Full-thickness defects were present in 24% of competitive athletes and 31% of recreational athletes (P = 0.21). There was a trend toward an independent association with competitive level and high-grade (3 or 4) multicompartment disease (adjusted odds ratio [aOR] 3.99, 95% confidence interval 0.84-18.8; P = 0.08) or isolated anterior compartment defects (aOR 2.00, 95% CI 0.86-4.62, P = 0.10) but not isolated medial or lateral defects. High-grade defect size was similar among recreational and competitive athletes (P = 0.71). High-grade lateral defect prevalence differed by sport (running 24%, basketball 23%, soccer 18%, football 5%; P = 0.02) but not medial or anterior defect prevalence. CONCLUSIONS: Among recreational and high school or collegiate competitive athletes with symptomatic cartilage defects who meet criteria for cartilage restoration, competitive athletes may have higher risk of high-grade anterior and multicompartment defects but no difference in defect size.

Increased posterior shoulder capsule thickness in youth elite handball players: a sonographic investigation.

PURPOSE: Range of motion adaptations in the shoulders of overhead throwing athletes have been reported, but knowledge about the development of soft-tissue adaptations is limited. The purpose of this study was to investigate differences in posterior shoulder capsule thickness and internal rotation between the throwing and non-throwing shoulder. METHODS: On the basis of the sample size calculation, we assessed 63 youth elite handball players (33 boys and 30 girls, mean age: 13.6 ± 0.9 years) for glenohumeral internal and external rotational range of motion, humeral retrotorsion, and posterior capsule thickness (PCT) with a manual goniometer and a portable ultrasound device and calculated sports-specific differences between the throwing and non-throwing shoulder as well as correlations with PCT. RESULTS: Youth handball players showed side-to-side differences in internal rotation, external rotation, and humeral retrotorsion between the throwing and non-throwing shoulder. Posterior shoulder capsules were 1.21 times thicker (95% confidence interval: 1.1-1.3) in the throwing shoulder than in the non-throwing shoulder (1.3 ± 0.3 mm vs. 1.2 ± 0.2 mm, P < .0001). Loss of internal rotation did not correlate with PCT. CONCLUSIONS: In youth elite handball athletes, posterior shoulder tightness and subsequent sports-specific loss of internal rotation in the throwing shoulder are not related to PCT. Thus, in this age class, other (soft-tissue) factors must be responsible for this condition.

Bilateral Looser zones or pseudofractures in the anteromedial tibia as a component of medial tibial stress syndrome in athletes.

PURPOSE: Medial tibial stress syndrome (MTSS) represents a common diagnosis in individuals exposed to repetitive high-stress loads affecting the lower limb, e.g., high-performance athletes. However, the diagnostic approach and therapeutic regimens are not well established. METHODS: Nine patients, diagnosed as MTSS, were analyzed by a comprehensive skeletal analysis including laboratory bone turnover parameters, dual-energy X-Ray absorptiometry (DXA), and high-resolution peripheral quantitative computed tomography (HR-pQCT). RESULTS: In 4/9 patients, bilateral pseudofractures were detected in the mid-shaft tibia. These patients had significantly lower levels of 25-hydroxycholecalciferol compared to patients with MTSS but similar levels of bone turnover parameters. Interestingly, the skeletal assessment revealed significantly higher bone mineral density (BMD) Z-scores at the hip (1.3 ± 0.6 vs. - 0.7 ± 0.5, p = 0.013) in patients with pseudofractures and a trend towards higher bone microarchitecture parameters measured by HR-pQCT at the distal tibia. Vitamin D supplementation restored the calcium-homeostasis in all patients. Combined with weight-bearing as tolerated, pseudofractures healed in all patients and return to competition was achieved. CONCLUSION: In conclusion, deficient vitamin D levels may lead to pseudofractures due to localized deterioration of mineralization, representing a pivotal component of MTSS in athletes with increased repetitive mechanical loading of the lower limbs. Moreover, the manifestation of pseudofractures is not a consequence of an altered BMD nor microarchitecture but appears in patients with exercise-induced BMD increase in combination with reduced 25-OH-D levels. The screening of MTSS patients for pseudofractures is crucial for the initiation of an appropriate treatment such as vitamin D supplementation to prevent a prolonged course of healing or recurrence. LEVEL OF EVIDENCE: III.

Posterior Ankle Impingement and Flexor Hallucis Longus Pathology.

Posterior ankle pain is a common complaint, and the potential causative pathologic processes are diverse. The constellation of these numerous etiologies has been collectively referred to as posterior ankle impingement syndrome. The pain associated with posterior ankle impingement is caused by bony or soft tissue impingement of the posterior ankle while in terminal plantar flexion. This condition is most frequently encountered in athletes who participate in sports that involve forceful, or repetitive, ankle plantar flexion. This article discusses the associated pathology, diagnosis, conservative treatment, and surgical techniques associated with flexor hallucis longus and posterior ankle impingement syndrome.

Hamstring muscle activation and morphology are significantly altered 1-6 years after anterior cruciate ligament reconstruction with semitendinosus graft.

PURPOSE: Harvest of the semitendinosus (ST) tendon for anterior cruciate ligament reconstruction (ACLR) causes persistent hypotrophy of this muscle even after a return to sport, although it is unclear if hamstring activation patterns are altered during eccentric exercise. It was hypothesised that in comparison with contralateral control limbs, limbs with previous ACLR involving ST grafts would display (i) deficits in ST activation during maximal eccentric exercise; (ii) smaller ST muscle volumes and anatomical cross-sectional areas (ACSAs); and (iii) lower eccentric knee flexor strength. METHODS: Fourteen athletes who had successfully returned to sport after unilateral ACLR involving ST tendon graft were recruited. Median time since surgery was 49 months (range 12-78 months). Participants underwent functional magnetic resonance imaging (MRI) of their thighs before and after the Nordic hamstring exercise (NHE) and percentage change in transverse (T2) relaxation time was used as an index of hamstring activation. Muscle volumes and ACSAs were determined from MRI and distal ST tendons were evaluated via ultrasound. Eccentric knee flexor strength was determined during the NHE. RESULTS: Exercise-induced T2 change was lower for ST muscles in surgical than control limbs (95% CI - 3.8 to - 16.0%). Both ST muscle volume (95% CI - 57.1 to - 104.7 cm3) and ACSA (95% CI - 1.9 to - 5.0 cm2) were markedly lower in surgical limbs. Semimembranosus (95% CI 5.5-14.0 cm3) and biceps femoris short head (95% CI 0.6-11.0 cm3) volumes were slightly higher in surgical limbs. No between-limb difference in eccentric knee flexor strength was observed (95% CI 33 N to - 74 N). CONCLUSION: ST activation is significantly lower in surgical than control limbs during eccentric knee flexor exercise 1-6 years after ACLR with ST graft. Lower levels of ST activation may partially explain this muscle's persistent hypotrophy post ACLR and have implications for the design of more effective rehabilitation programs. LEVEL OF EVIDENCE: IV.

Risk factors for auricular hematoma and recurrence after drainage.

OBJECTIVES/HYPOTHESIS: To review an institutional experience with auricular hematoma across all clinical settings including the emergency department (ED) and outpatient clinics at an urban tertiary care academic hospital, characterize practice patterns across setting and specialty, and assess for factors predictive of treatment success. METHODS: Patients presenting to the ED, admitted to an inpatient ward, or seen in the outpatient setting between 2000 and 2017 with a diagnosis of auricular hematoma were reviewed. A number of relevant patient features including demographic factors, medications, and social risk factors were analyzed, as were several factors related to the presentation and management of the hematoma to identify variables of clinical significance. RESULTS: A total of 87 individual cases were identified. Auricular hematomas most commonly occurred in males after sports-related trauma (e.g., martial arts, wrestling, boxing). Factors associated with lower rates of recurrence included initial treatment by or in consultation with an otolaryngologist and application of a bolster dressing. CONCLUSIONS: In our cohort, initial management of auricular hematoma by an otolaryngologist or with an otolaryngology consultation and placement of a bolster dressing was associated with lower rates of hematoma recurrence. LEVEL OF EVIDENCE: 2b Laryngoscope, 130:628-631, 2020.

Return to sports after glenoid reconstruction using an implant-free iliac crest bone graft.

PURPOSE: The purpose of this study was to evaluate sports ability and the rate of return to sports after implant-free iliac bone graft for recurrent, anterior shoulder instability and anterior glenoid bone loss. Subgroups of younger and older patients and patients who had previous arthroscopic Bankart surgery and those who did not have such surgery before implant-free iliac bone graft were formed and compared. METHODS: We retrospectively analyzed 34 patients; 14 patients had previous arthroscopic Bankart surgery, and 20 patients did not have the surgery; The median age at the time of iliac bone graft was 35.3 years (range, 23 to 75), 17 patients were over the age of 35, and 17 patients were under the age of 35. The mean follow-up was 40 months (range: 25 to 56). RESULTS: All the 34 patients were engaged in pre- and post-operative sport, which represents a return to sport rate of 100%. Although the number of sport disciplines decreased significantly from 6 before the operation to 4.8 after the operation (p=0.002), the number of sports sessions per week did not change significantly, and the duration per session did not change significantly. More than two-thirds of all patients returned to sports within 6 months. Overall, 41% of patients changed sport disciplines, 15% of whom cited shoulder-related causes; however, all patients returned to the same sport level. CONCLUSIONS: Overall and within the subgroups, the return to sport rate after implant-free iliac bone grafting was high, with a high sense of well-being. The number of sport disciplines decreased significantly and more than one-third of the patients changed disciplines, of which 15% percent changed due to shoulder-related causes. The sport level remained equal, and no other parameters changed significantly compared with the time before the onset of restrictive shoulder symptoms.

Ibuprofen inhibited migration of skeletal muscle cells in association with downregulation of p130cas and CrkII expressions.

BACKGROUND: Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used to treat sports-related muscle injuries. However, NSAIDs were recently shown to impede the muscle healing process after acute injury. Migration of skeletal muscle cells is a crucial step during the muscle healing process. The present study was performed to investigate the effect and molecular mechanisms of action of ibuprofen, a commonly used NSAID, on the migration of skeletal muscle cells. METHODS: Skeletal muscle cells isolated from the gastrocnemius muscle of Sprague-Dawley rats were treated with ibuprofen. MTT assay (3-[4,5-dimethylthiazol-2-yl]-2,5-diphenyltetrazolium bromide) was used to evaluate cell viability, and cell apoptosis was evaluated by TUNEL assay, after ibuprofen treatment. Skeletal muscle cell migration and spreading were evaluated using the transwell filter migration assay and F-actin staining, respectively. The protein expression of p130cas and CrkII, which are cell migration facilitating genes, was determined by western blot analysis. The overexpression of p130cas of muscle cells was achieved by p130cas vector transfection. RESULTS: The results demonstrated that ibuprofen did not have a significant negative effect on cell viability and apoptosis. Ibuprofen inhibited the migration and spreading of skeletal muscle cells in a dose-dependent manner. Ibuprofen also dose-dependently decreased the protein expression of p130cas and CrkII. Furthermore, overexpression of p130cas resulted in the promotion of cell migration and spreading and counteracted ibuprofen-mediated inhibition. CONCLUSION: This study suggested that ibuprofen exerts a potentially adverse effect on the migration of skeletal muscle cells by downregulating protein expression of p130cas and CrkII. These results indicate a possible mechanism underlying the possible negative effect of NSAIDs on muscle regeneration.

An Anterior Cruciate Ligament Failure Mechanism.

BACKGROUND: Nearly three-quarters of anterior cruciate ligament (ACL) injuries occur as "noncontact" failures from routine athletic maneuvers. Recent in vitro studies revealed that repetitive strenuous submaximal knee loading known to especially strain the ACL can lead to its fatigue failure, often at the ACL femoral enthesis. HYPOTHESIS: ACL failure can be caused by accumulated tissue fatigue damage: specifically, chemical and structural evidence of this fatigue process will be found at the femoral enthesis of ACLs from tested cadaveric knees, as well as in ACL explants removed from patients undergoing ACL reconstruction. STUDY DESIGN: Controlled laboratory study. METHODS: One knee from each of 7 pairs of adult cadaveric knees were repetitively loaded under 4 times-body weight simulated pivot landings known to strain the ACL submaximally while the contralateral, unloaded knee was used as a comparison. The chemical and structural changes associated with this repetitive loading were characterized at the ACL femoral enthesis at multiple hierarchical collagen levels by employing atomic force microscopy (AFM), AFM-infrared spectroscopy, molecular targeting with a fluorescently labeled collagen hybridizing peptide, and second harmonic imaging microscopy. Explants from ACL femoral entheses from the injured knee of 5 patients with noncontact ACL failure were also characterized via similar methods. RESULTS: AFM-infrared spectroscopy and collagen hybridizing peptide binding indicate that the characteristic molecular damage was an unraveling of the collagen molecular triple helix. AFM detected disruption of collagen fibrils in the forms of reduced topographical surface thickness and the induction of ~30- to 100-nm voids in the collagen fibril matrix for mechanically tested samples. Second harmonic imaging microscopy detected the induction of ~10- to 100-µm regions where the noncentrosymmetric structure of collagen had been disrupted. These mechanically induced changes, ranging from molecular to microscale disruption of normal collagen structure, represent a previously unreported aspect of tissue fatigue damage in noncontact ACL failure. Confirmatory evidence came from the explants of 5 patients undergoing ACL reconstruction, which exhibited the same pattern of molecular, nanoscale, and microscale structural damage detected in the mechanically tested cadaveric samples. CONCLUSION: The authors found evidence of accumulated damage to collagen fibrils and fibers at the ACL femoral enthesis at the time of surgery for noncontact ACL failure. This tissue damage was similar to that found in donor knees subjected in vitro to repetitive 4 times-body weight impulsive 3-dimensional loading known to cause a fatigue failure of the ACL. CLINICAL RELEVANCE: These findings suggest that some ACL injuries may be due to an exacerbation of preexisting hierarchical tissue damage from activities known to place larger-than-normal loads on the ACL. Too rapid an increase in these activities could cause ACL tissue damage to accumulate across length scales, thereby affecting ACL structural integrity before it has time to repair. Prevention necessitates an understanding of how ACL loading magnitude and frequency are anabolic, neutral, or catabolic to the ligament.

Overview of venous pathology related to repetitive vascular trauma in athletes.

BACKGROUND: Athletes are generally young, high-functioning individuals. Pathology in this cohort is associated with a decrease in function and consequently has major implications on quality of life. Venous disorders can be attributed to a combination of vascular compression with a high burden of activity. OBJECTIVE: This article promotes increased awareness of these uncommon conditions specific to the athlete by summarizing pathophysiology, clinical features, investigation, and treatment protocols for use in clinical practice. Prognostic outcomes of these management regimens are also discussed, allowing for clinicians to counsel these high-functioning individuals appropriately. With the aim of providing an overview of sport-related venous pathology, a literature review was undertaken identifying articles that were independently reviewed by the authors. RESULTS: Lower limb venous thrombosis has been identified in young, high-functioning athletes attributed to both compression-related venous trauma, associated with repetitive movements resulting in intimal damage, and blunt trauma. The diagnosis and treatment follow the same protocols as for the general population. Of note, early ambulation is advocated, with an aim to return to premorbid (noncontact) function within 6 weeks. Athletes performing high-intensity repetitive upper limb movement, such as baseball players, are predisposed to upper limb deep venous thrombosis (DVT). Diagnosis follows the same protocols as for lower extremity DVT; however, the optimal treatment strategy remains debated. Current guidelines advocate the use of anticoagulation alone. A specific subset of primary upper limb DVT is effort thrombosis, where there is compression at the level of the thoracic outlet. Thrombolysis with first rib resection is indicated in the acute setting within 14 days. In cases of complete occlusion, surgical decompression with venous reconstruction may be required. Popliteal vein entrapment syndrome is also discussed. This entity has been identified as an overuse injury associated with popliteal vein compression. Duplex ultrasound examination is indicated as a first-line investigation, with conservative noninvasive options considered as an initial management strategy. Chronic venous insufficiency or persistent symptoms may require subsequent surgical decompression. CONCLUSIONS: Key conditions including upper extremity and lower extremity venous thrombosis, venous aneurysms, Paget-Schroetter syndrome (effort thrombosis), and popliteal vein entrapment syndrome are discussed. Further studies evaluating long-term outcomes on morbidity for current treatment regimens in upper extremity DVT, effort thrombosis, venous thoracic outlet syndrome, and popliteal venous entrapment syndrome are required.

Overview of arterial pathology related to repetitive trauma in athletes.

BACKGROUND/OBJECTIVE: Sport-related vascular trauma is an important consequence of increased physical activity. Repetitive, high-intensity movements predispose athletes to vascular disease, including arterial pathology, by exerting increased pressure on neurovascular structures. This is an important source of morbidity in an otherwise young and healthy population. Arterial pathology associated with repetitive trauma is often misdiagnosed as musculoskeletal injury. This article increases awareness of sport-related arterial disease by reviewing the symptomatology, investigation, and treatment modalities of this pathology. In addition, prognostic outcomes specific to the athlete are discussed. RESULTS: Arterial thoracic outlet syndrome and vascular quadrilateral space syndrome are associated with athletes involved in overhead throwing exercises. Sport-related arterial pathology of the lower limb include external iliac artery endofibrosis (EIAE), popliteal artery entrapment syndrome (PAES), and adductor canal syndrome. Vascular stress and kinking secondary to vessel tethering are important contributors to pathology in EIAE. Chronic exertional compartment syndrome must also be considered, presenting with clinical features similar to PAES. In addition, athletes are predisposed to blunt mechanical trauma. Hypothenar hammer syndrome is one such example, contributing to a high burden of morbidity in this population. CONCLUSIONS: In arterial thoracic outlet syndrome and vascular quadrilateral space syndrome, surgery is advocated in symptomatic individuals, with postoperative outcomes favorable for the athlete. Acute limb ischemia may occur as a result of secondary thrombosis or embolization, often without preceding claudication. PAES and adductor canal syndrome are associated with functional entrapment in the athlete, secondary to muscular hypertrophy. Surgical exploration may be indicated. Poorer outcomes are noted when this process is associated with vascular reconstruction. Surgical treatment of EIAE follows failure of conservative management, with limited data available on postoperative prognosis. Investigations for all these conditions should be targeted based on clinical suspicion. A delay in diagnosis can have severe consequences on return to competition in these high-functioning individuals.

Bennett lesions in overhead athletes and associated shoulder abnormalities on MRI.

OBJECTIVE: To determine if a Bennett lesion and its size are associated with additional MRI shoulder abnormalities in an overhead athlete. MATERIALS AND METHODS: An IRB-approved retrospective review of our database from 1 January 2012 to 1 April 2018 identified 35 overhead athletes with a Bennett lesion on MRI. A control group consisting of 35 overhead athletes without a Bennett lesion were matched for age, level of play (professional vs non-professional), and type of study (arthrogram vs non-arthrogram). Each study was assessed independently by two MSK fellowship trained radiologists. The sizes of the Bennett lesions were measured. Each MRI was assessed for the presence of a labral tear, posterior glenoid cartilage abnormality, humeral head notching or cysts, and fraying or tear of the supraspinatus or infraspinatus tendons. Statistical analyses were performed using Student's t test, Fisher's exact test, and Chi-squared test. RESULTS: There was an increased incidence of posterior glenoid cartilage abnormalities in athletes with Bennett lesions vs those without (23% vs 3%, p value = 0.01). There was no difference in any other MRI abnormalities, including labral tears and findings of internal impingement between these two groups (p value range = 0.09-0.46). There was no association between the size of a Bennett lesion and the presence of glenoid cartilage lesions, labral tears, internal impingement, age, professional status, or need for surgery (p value range = 0.08-0.96). CONCLUSION: Symptomatic overhead athletes with Bennett lesions have an increased frequency of posterior glenoid cartilage abnormalities, but not labral tears or findings of internal impingement compared to those without Bennett lesions.

Using Cartilage MRI T2-Mapping to Analyze Early Cartilage Degeneration in the Knee Joint of Young Professional Soccer Players.

OBJECTIVE: To evaluate and characterize the appearance of articular cartilage in the tibiofemoral joint of young professional soccer players using T2-relaxation time evaluation on magnetic resonance imaging (MRI). DESIGN: In this study, we included 57 male adolescents from the youth academy of a professional soccer team. The MRI scans were acquired of the knee joint of the supporting leg. An "early unloading" (minute 0) and "late unloading" (minute 28) T2-sequence was included in the set of images. Quantitative T2-analysis was performed in the femorotibial joint cartilage in 4 slices with each 10 regions of interest (ROIs). Statistical evaluation, using Wilcoxon signed-rank tests, was primarily performed to compare the T2 values of the "early unloading" and "late unloading." RESULTS: When comparing "early unloading" with "late unloading," our findings showed a significant increase of T2-relaxation times in the weightbearing femoral cartilage of the medial (P < 0.001) and lateral (P < 0.001) compartment of the knee and in the tibial cartilage of the medial compartment (P < 0.001). CONCLUSION: In this study, alterations of the cartilage were found with a maximum in the medial condyle where the biomechanical load of the knee joint is highest, as well as where most of the chronic cartilage lesions occur. To avoid chronic damage, special focus should be laid on this region.

Bone bruise in anterior cruciate ligament rupture entails a more severe joint damage affecting joint degenerative progression.

PURPOSE: During anterior cruciate ligament (ACL) injury, the large external forces responsible for ligament rupture cause a violent impact between tibial and femoral articular cartilage, which is transferred to bone resulting in bone bruise detectable at MRI. Several aspects remain controversial and await evidence on how this MRI finding should be managed while addressing the ligament lesion. Thus, the aim of the present review was to document the evidence of all available literature on the role of bone bruise associated with ACL lesions. METHODS: A systematic review of the literature was performed on bone bruise associated with ACL injury. The search was conducted in September 2017 on three medical electronic databases: PubMed, Web of Science, and the Cochrane Collaboration. Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines were used. Relevant articles were studied to investigate three main aspects: prevalence and progression of bone bruise associated with ACL lesions, its impact on the knee in terms of lesion severity and joint degeneration progression over time and, finally, the influence of bone bruise on patient prognosis in terms of clinical outcome. RESULTS: The search identified 415 records and, after an initial screening according to the inclusion/exclusion criteria, 83 papers were used for analysis, involving a total of 10,047 patients. Bone bruise has a high prevalence (78% in the most recent papers), with distinct patterns related to the mechanism of injury. This MRI finding is detectable only in a minority of cases the first few months after trauma, but its presence and persistence have been correlated to a more severe joint damage that may affect the degenerative progression of the entire joint, with recent evidence suggesting possible effects on long-term clinical outcome. CONCLUSION: This systematic review of the literature documented a growing interest on bone bruise associated with ACL injury, highlighting aspects which could provide to orthopaedic surgeons evidence-based suggestions in terms of clinical relevance when dealing with patients affected by bone bruise following ACL injury. However, prospective long-term studies are needed to better understand the natural history of bone bruise, identifying prognostic factors and targets of specific treatments that should be developed in light of the overall joint derangements accompanying ACL lesions. LEVELS OF EVIDENCE: IV, Systematic review of level I-IV studies.

The biological respect of the posterolateral bundle in ACL partial injuries. Retrospective analysis of 2 different surgical management of ACL partial tear in a population of high-demanding sport patients.

INTRODUCTION: Most of the techniques described in the literature for the repair of chronic partial ACL tears do not spare the intact portion of the ligament. Aim of this study was to perform a retrospective analysis of the results obtained from the same ACL reconstructive surgical technique applicated by sparing or not AM bundle in a population of 42 sports patients. MATERIALS AND METHODS: From 2010 to 2012, 42 patients who suffered ACL partial tear injury with rupture of posterolateral bundle were randomly divided in two groups homogenous for sex, age and sport-level activities. The first group with 22 patients performed ACL reconstruction with ST-GR over-the-top technique sacrificing the anteromedial (Removing AMT Group) remaining bundle intact; otherwise, the second group with 20 patients performed the same ACL reconstruction using only ST and maintaining AM bundle (Sparing AMT Group). All the patients were followed up by MRI evaluation at 12 months and clinical evaluation with IKDC score, Tegner score at 6, 12, 24, 36, 48 and 60 months. KT-1000 instrument was performed at 12 months. The results were analyzed statistically to evaluate differences between the two groups in terms of subjective outcome, and stability and for all the tests P < 0.05 was considered significant. RESULTS: We did not observe any failure at final follow-up. IKDC subjective score at final follow-up in Removing AMT Group was 91.2 ± 2.3 in Sparing AMT Group was 92.4 ± 2.7. Tegner score at final follow-up was 7.2 ± 2.1 for Removing AMT Group and 7.8 ± 1.8 for Sparing AMT Group. Arthrometric evaluation performed with KT-1000 at final follow-up showed a side-to-side difference of 0.9 ± 1.3 mm in the Removing AMT Group against 0.8 ± 1.0 mm in the Sparing AMT Group. Return time to the sport was 7.1 months for Removing AMT Group otherwise 6.1 months for the Sparing AMT Group. CONCLUSIONS: Both the described techniques in this study demonstrated to be able to guarantee a successful outcome. However, although no statistically significant differences were evident in terms of subjective and objective outcome between these techniques some evident benefits were evident using the sparing bundle technique in Sparing AMT Group such as better clinical scores at the final follow-up and an earlier return to sport activity.

Achilles tendinosis does not always precede Achilles tendon rupture.

PURPOSE: Degenerative change is a typical histologic finding of Achilles tendinosis and is thought to be a factor associated with Achilles tendon rupture; however, this relationship remains controversial. Therefore, the aim of this study was to review the histological findings of ruptured Achilles tendons and analyze demographics and injury patterns. METHODS: Retrospective analysis was performed for all patients who underwent Achilles tendon repair for acute Achilles tendon rupture at our institution between 2008 and 2015. The presence of Achilles tendinosis was determined by light microscopic histology of ruptured Achilles tendons. Patients were grouped according to the presence of Achilles tendinosis and patient demographics, sports activities, and clinical outcomes were compared. Ankle activity score was used to evaluate the level of sports activity and Achilles tendon total rupture score (ATRS) was used to evaluate clinical outcomes. RESULTS: A total of 152 Achilles tendon ruptures were included: 112 (77%) showed Achilles tendinosis at a ruptured Achilles tendon on histology and 40 (23%) did not. Patients who had no Achilles tendinosis prior to rupture had a lower ankle activity score (P < 0.05) and higher incidence of non-sports related injury (P < 0.05). ATRS was not significantly different between the groups at final follow-up (P = n.s.). CONCLUSION: In contrast to previous reports, Achilles tendon rupture can occur without prior Achilles tendinosis, especially in non-sports-related injuries and in patients with low sports activity. Although the direct clinical applications of these results are limited, the findings of this study can improve our understanding of the etiology of Achilles tendon rupture. LEVEL OF EVIDENCE: Prognostic, Level III.