Evolution of Functional Recovery using Hop Test Assessment after ACL Reconstruction.

The purpose of this study was to evaluate improvements in functional performance through the use of the Limb Symmetry Index of Single and Triple Hop tests between 12 and 52 weeks after anterior cruciate ligament reconstruction, and to compare these values with usual time-based and performance-based criteria used during the return to sport continuum. Repeated functional assessments using Single and Triple Hop Tests at 12, 16, 22, 26, 39 and 52 postoperative weeks were evaluated. At each session, the median and interquartile range of Limb Symmetry Index of tests were calculated and compared with the usual criteria: return to participation:≥85%, between 12-16 w; return to play:≥90%, between 26-39 w. The results indicate that the median increased over time to 39 postoperative weeks and then stabilized. For Single Hop Test, wide variability was seen at 12 and 16 weeks (interquartile range=20%); this was lower from 22 to 52 weeks (interquartile range=8-6%). At 12 weeks for Single Hop Test, the median was 83.6% and did not meet>85% criteria for return to participation. Hop tests could be interesting functional tests to follow the functional recovery and help decision-making regarding return to participation and return to play.

Change of Direction Assessment Following Anterior Cruciate Ligament Reconstruction: A Review of Current Practice and Considerations to Enhance Practical Application.

Change of direction (CoD) has been indicated as a key mechanism in the occurrence of anterior cruciate ligament (ACL) injury during invasion sports. Despite these associations, assessments of knee function in athletic populations at the time of return to sport following ACL reconstruction (ACLr) have often focused on strength and single-leg hop tests, with a paucity of evidence to describe the CoD characteristics. Therefore, the aim of this narrative review was to describe the movement strategies exhibited following ACLr during CoD tasks and to critically analyze the range of tests that have been used. Specifically, we examined their ability to identify between-limb deficits and individuals who display a heightened risk of secondary injury and/or reductions in their level of pre-injury performance. MEDLINE, PubMed and SPORT Discuss databases were used and 13 articles were identified that met the inclusion criteria. Examination of the available literature indicates that current field-based practices are not representative of relevant sport demands and are unable to effectively assess knee function following ACLr. Laboratory-based studies have identified residual deficits and altered movement strategies at the time of return to sport, and this in part may be related to risk of re-injury. However, these assessments exhibit inherent limitations and are not practically viable for monitoring progress during rehabilitation. Consequently, alternative solutions that are more-aligned with the multitude of factors occurring during CoD maneuvers in chaotic sports environments are warranted to allow practitioners to 'bridge the gap' between the laboratory and the sports field/court. This approach may facilitate a more informed decision-making process with the end goal being, a heightened 'return to performance' and a lower risk of re-injury.

Managing the Athlete with a Scaphoid Fracture.

Most minimally displaced scaphoid fractures and all displaced scaphoid fractures in elite athletes are treated with early fixation to maximally expedite the return to full function. Computed tomographic (CT) scans are recommended in all scaphoid fractures to facilitate a complete understanding of fracture anatomy and to allow for optimal screw placement. Screw placement is important to maximize healing capacity of the fracture and allow for return to sport. Postoperative CT scans can be helpful to evaluate the extent of healing and may allow patients to return to play sooner.

Responsiveness of the Victorian Institute for Sport Assessment for Gluteal Tendinopathy (VISA-G), modified Harris hip and Oxford hip scores in patients undergoing hip abductor tendon repair.

BACKGROUND: A lack of consensus exists on which patient-reported outcome measures (PROMs) best evaluate change following hip abductor tendon (HAT) repair. OBJECTIVES: To compare the responsiveness of the Victorian Institute for Sport Assessment for Gluteal Tendinopathy (VISA-G), Oxford Hip (OHS) and modified Harris Hip (mHHS) scores in patients undergoing HAT repair. STUDY DESIGN: Prospective case series. METHODS: 56 patients underwent HAT repair and were evaluated pre-surgery and 3, 6 and 12 months post-operatively using the VISA-G, OHS, mHHS and a Global Rating of Change (GRC) scale. Internal and external responsiveness, the minimal clinically important change (MIC) and the presence of ceiling effects were evaluated. The extent to which VISA-G change was associated with mHHS and OHS change was investigated, as was the extent to which PROM changes were discriminatory for GRC improvement. RESULTS: All PROMs demonstrated large standardized effect sizes (>1), with the VISA-G demonstrating responsiveness similar to the mHHS and OHS. At 12 months, the GRC correlated similarly with VISA-G (0.42, 95% CI: 0.17-0.61), mHHS (0.44, 95% CI: 0.17-0.61) and OHS (0.53, 95% CI: 0.31-0.70) changes. Using a GRC anchor of ≥4, an MIC of 29/100, 29/91 (32/100) and 16/48 (33/100) was observed for the VISA-G, mHHS and OHS, respectively. At 12 months ceiling effects existed for the mHHS (18/56, 32.1%) and OHS (13/56, 23.2%), but not VISA-G (1/56, 1.8%). CONCLUSION: The VISA-G demonstrated acceptable responsiveness and was more resistant to ceiling effects, though demonstrated similar change scores and correlations with perceived improvement to the mHHS and OHS. CLINICAL TRIAL REGISTRATION: This research trial is registered in the Australian New Zealand Clinical Trials Registry (ACTRN12616001655437).

Professional Athletes Are Not at a Higher Risk of Infections After Anterior Cruciate Ligament Reconstruction: Incidence of Septic Arthritis, Additional Costs, and Clinical Outcomes From the French Prospective Anterior Cruciate Ligament Study (FAST) Cohort.

BACKGROUND: The rate of septic arthritis in the knee after anterior cruciate ligament (ACL) reconstruction varies in the literature but is generally less than 1%. It has been reported to be higher in professional athletes (5.7%). PURPOSE: The primary goal was to evaluate the rate of septic arthritis after ACL reconstruction in professional athletes compared with other patients. The secondary goals were to analyze the risk factors; increased cost of infections; return to sport, satisfaction, and functional results at 1-year follow-up; and resolution rate of infections at final follow-up. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: This retrospective analysis of prospective data included a continuous series of patients who underwent isolated ACL reconstruction between 2012 and 2016. The main outcome criterion was the development of intra-articular infections in the operated knee. An infection was suggested clinically (knee pain with fever and/or chills) and confirmed bacteriologically in deep tissue samples obtained during revision surgery. All infected patients underwent an emergency reoperation with lavage and debridement along with dual antibiotic therapy first by an intravenous route and then orally for 6 weeks. RESULTS: A total of 1809 of 1859 patients included in the cohort during this period fulfilled inclusion criteria; there were 1632 (90.2%) who underwent primary reconstruction and 177 (9.8%) who underwent revision. The series included 1249 (69%) men and 560 (31%) women, with a mean age of 29.1 ± 9.8 years. Ninety-eight percent of the patients participated in a sport, including 90 (5.0%) at a professional level and 712 (39.4%) competitively. Septic arthritis of the knee developed after a mean 15.7 ± 5.5 days in 7 (0.38%) patients: 5 of 1632 (0.31%) who underwent primary reconstruction and 2 of 177 (1.13%) who underwent revision. Septic arthritis did not develop in any professional or competitive athletes; all affected patients were recreational athletes ( P = .02). The risk factors identified for the development of septic arthritis on multivariate analysis were prior knee surgery (odds ratio [OR], 15; P = .002) and hemarthrosis during the immediate postoperative period (OR, 127.2; P = .002). There were no recurrent infections after a mean follow-up of 2.8 ± 1.2 years. CONCLUSION: None of the professional athletes in this cohort had septic arthritis after ACL reconstruction. There are no particular precautions to be taken in this population. The risk factors identified for the development of septic arthritis on multivariate analysis were prior knee surgery and hemarthrosis during the immediate postoperative period. Similar to all studies published on the subject, there were very few infected patients, which limits the identification of risk factors. REGISTRATION: NCT02511158 (ClinicalTrials.gov identifier).

Validation of a Composite Test for Assessment of Readiness for Return to Sports After Anterior Cruciate Ligament Reconstruction: The K-STARTS Test.

BACKGROUND:: There is limited information on the appropriate timing of return to sports after anterior cruciate ligament (ACL) reconstruction. A composite test was developed to assess the athlete's ability to return to sports after ACL reconstruction: the Knee Santy Athletic Return To Sport (K-STARTS) test. HYPOTHESIS:: The K-STARTS test meets validation criteria for an outcome score assessing readiness for return to sports after ACL reconstruction. STUDY DESIGN:: Diagnostic study. LEVEL OF EVIDENCE:: Level 3. METHODS:: A prospective comparative study identified 410 participants: 371 participants who had undergone ACL reconstruction and a control group of 39 healthy participants. The K-STARTS score is calculated as the sum of 7 tests (8 components), for a maximal value of 21 points. Construct validity, internal consistency, discriminant validity, and sensitivity to change were used to validate this new test. RESULTS:: The K-STARTS assessment showed a high completion rate (100%), high reproducibility (intraclass correlation coefficient, 0.87; coefficient of variation, 7.8%), and high sensitivity to change. There was moderate correlation with the ACL Return to Sports after Injury scale (ACL-RSI) and hop tests. There were no ceiling or floor effects. There was a significant difference between K-STARTS scores assessed at 6 and 8 months postoperatively (11.2 ± 2.7 vs 17.1 ± 3.2; P < 0.001). The K-STARTS score in the control group was significantly higher than that in the ACL reconstruction group (17.3 ± 2.1 and 13.7 ± 3.8, respectively; P < 0.001). CONCLUSION:: The K-STARTS test is an objective outcome measure for functional improvement after ACL reconstruction. CLINICAL RELEVANCE:: It is important for the clinician to determine when return to sports is optimal after ACL reconstruction to reduce the current high risk of reinjury.

Cross-cultural adaptation and validation of the Italian version of the Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow score.

BACKGROUND: The Kerlan-Jobe Orthopaedic Clinic (KJOC) Shoulder and Elbow score is a reliable and sensitive tool to measure the performance of overhead athletes. The purpose of this study was to carry out a cross-cultural adaptation and validation of the KJOC questionnaire in Italian and to assess its reliability, validity, and responsiveness. MATERIALS AND METHODS: Ninety professional athletes with a painful shoulder were included in this study and were assigned to the "injury group" (n = 32) or the "overuse group" (n = 58); 65 were managed conservatively and 25 were treated by arthroscopic surgery. To assess the reliability of the KJOC score, patients were asked to fill in the questionnaire at baseline and after 2 weeks. To test the construct validity, KJOC scores were compared to those obtained with the Italian version of the Disabilities of the Arm, Shoulder, and Hand (DASH) scale, and with the DASH sports/performing arts module. To test KJOC score responsiveness, the follow-up KJOC scores of the participants treated conservatively were compared to those of the patients treated by arthroscopic surgery. RESULTS: Statistical analysis demonstrated that the KJOC questionnaire is reliable in terms of the single items and the overall score (ICC 0.95-0.99); that it has high construct validity (r s = -0.697; p < 0.01); and that it is responsive to clinical differences in shoulder function (p < 0.0001). CONCLUSIONS: The Italian version of the KJOC Shoulder and Elbow score performed in a similar way to the English version and demonstrated good validity, reliability, and responsiveness after conservative and surgical treatment. LEVEL OF EVIDENCE: II.

Anterior cruciate ligament deficiency reduces walking economy in "copers" and "non-copers".

PURPOSE: Patients with ACL injury requiring surgical treatment (non-copers) demonstrate altered neuromuscular control and gait pattern compared with those returning to their pre-injury activities without surgery (copers). Pathological gait pattern may increase the energy cost of walking. We compared the energy cost of flat, uphill, and downhill walking between ACL-deficient and healthy individuals and between "copers" and "non-copers". METHODS: Nineteen young males with unilateral ACL injury were allocated into "copers" and "non-copers" according to their ability to return to pre-injury activity without ACL reconstruction. Lysholm and IKDC scales were recorded, and a control group (n = 10) matched for physical characteristics and activity levels was included. All participants performed 8-min walking tasks at 0, +10, and -10 % gradients. Energy cost was assessed by measurement of oxygen consumption (VO2). HR and ventilation (VE), respiratory exchange ratio (RER), and VE/VO2 were also measured. RESULTS: VO2 and HR were higher in ACL-deficient patients than in controls during walking at 0, +10, and -10 % gradients (p < 0.01-0.05). There were no differences between "copers" and "non-copers" in VO2 and HR for any gradient. No differences were observed in VE, RER, and VE/VO2 among the three groups. CONCLUSIONS: The walking economy of level, uphill, and downhill walking is reduced in ACL-deficient patients. Despite the improved functional and clinical outcome of "copers", their walking economy appears similar to that of "non-copers" but impaired compared with healthy individuals. The higher energy demand and effort during locomotion in "copers" and "non-copers" has clinical implications for designing safer rehabilitation programmes. The increased energy cost in "copers" may be another parameter to consider when deciding on the most appropriate therapeutic intervention (operative and non-operative), particularly for athletes. LEVEL OF EVIDENCE: II.

Assessment of Gait Symmetry Improvements in National Athletes after Anterior Cruciate Ligament Reconstruction during Rehabilitation.

This study aimed to quantify changes in gait parameters and their symmetries among athletes with anterior cruciate ligament (ACL) reconstructions during a rehabilitation program. Twenty-two national players with ACL reconstructions and 15 healthy athletes were recruited. The gait data were collected between postoperative weeks 4-5, 8-9 and 12-13 using a three-dimensional motion analysis system. The spatio-temporal gait parameters and symmetry indexes (SIs) were evaluated for the patients and the control group. One-way and repeated-measures multivariate analysis of variance were used to analyse the data. The results demonstrated significant differences among spatio-temporal (P<0.001) and SIs (P=0.007) of patients for Test 1 and the control group. Repeated measure analysis revealed significant changes in the linear combinations of spatio-temporal gait variables (P=0.002) and SIs (P=0.043) over time. The injured limb's step length, cadence and weight acceptance time presented significant improvement across time (P<0.001). Moreover, the SI of the stance time was reduced significantly by 46.48% (P=0.004) among SI parameters. After three months, no significant differences were found between patients and healthy controls for the measured gait components (P>0.05). The rehabilitation program allowed national athletes to restore symmetry in spatio-temporal gait parameters toward the control group's range 12-13 weeks post-reconstruction.

Prevention and rehabilitation of paediatric anterior cruciate ligament injuries.

PURPOSE: To review the current knowledge on anterior cruciate ligament (ACL) injury prevention and ACL rehabilitation in individuals who have not yet reached musculoskeletal maturity. METHODS: This is a narrative review based on a targeted and systematic literature search for paediatric ACL injury risk factors, injury prevention and rehabilitation. RESULTS: The search strategies resulted in 119 hits on risk factor studies, 57 hits on prevention and 37 hits on rehabilitation. Modifiable risk factors for ACL injury are largely unknown in the paediatric population. ACL injury prevention using neuromuscular training is highly successful in the adolescent population, and existing injury prevention programmes are cost-effective. The efficacy of ACL injury prevention programmes in children is, however, investigated to a markedly lesser degree. Paediatric ACL injury rehabilitation is poorly described, although supervised active rehabilitation progressed through phases with functional milestones is generally encouraged. CONCLUSION: Although limited, current evidence supports implementation of injury prevention programmes in female football players from the age of 12. Supervised active rehabilitation where progression is guided by functional milestones is also advocated. Future identification of modifiable risk factors is needed to design prevention programmes for younger children. There is a need for international multicentre studies on treatment algorithms and rehabilitation to increase knowledge on the short- and long-term outcomes following existing algorithms. STUDY DESIGN: Narrative review, level III.

Economic analysis of athletic team coverage by an orthopedic practice.

OBJECTIVE: Coverage of high school football by orthopedic sports medicine specialists is considered standard of care in many localities. Determining the economic viability of this endeavor has never been investigated. The primary purpose of the present investigation was to perform an economic analysis of local high school sports coverage by an orthopedic sports medicine practice. METHODS: From January 2010 to June 2012, a prospective injury report database was used to collect sports injuries from five high school athletic programs covered by a single, private orthopedic sports medicine practice. Patients referred for orthopedic care were then tracked to determine expected cost of care (potential revenue). Evaluation and management codes and current procedure terminology codes were obtained to determine the value of physician visits and surgical care rendered. Overhead costs were calculated based on historical rates within our practice and incorporated to determine estimated profit. RESULTS: 19,165 athletic trainer contacts with athletes playing all sports, including both those 'on-field' and in the training room, resulted in 473 (2.5%) physician referrals. The covering orthopedic practice handled 89 (27.9%) of the orthopedic referrals. Of orthopedic physician referrals, 26 (5.4%) required orthopedic surgical treatment. The covering team practice handled 17/26 (65%) surgical cases. The total revenue collected by the covering team practice was $26,226.14. The overhead cost of treatment was $9441.41. Overall estimated profit of orthopedic visits and treatment during this period for the covering practice was $16,784.73. CONCLUSIONS: The covering team practice handled 28% of the orthopedic referrals, 65% of the surgical cases and captured 59% of the potential profit. An increase in physician referrals could increase the benefit for orthopedic surgeons.

Pediatric spinal injury in the US: epidemiology and disparities.

OBJECT: In the US, race and economic status have pervasive associations with mechanisms of injury, severity of injury, management, and outcomes of trauma. The goal of the current study was to examine these relationships on a large scale in the setting of pediatric spinal injury. METHODS: Admissions for spinal fracture without or with spinal cord injury (SCI), spinal dislocation, and SCI without radiographic abnormality were identified in the Kids' Inpatient Database (KID) and the National Trauma Data Bank (NTDB) registry for 2009. Patients ranged in age from birth up to 21 years. Data from the KID were used to estimate nationwide annual incidences. Data from the NTDB were used to describe patterns of injury in relation to age, race, and payor, with corroboration from the KID. Multiple logistic regression was used to model rates of mortality and spinal fusion. RESULTS: In 2009, the estimated incidence of hospital admission for spinal injury in the US was 170 per 1 million in the population under 21 years of age. The incidence of SCI was 24 per 1 million. Incidences varied regionally. Adolescents predominated. Patterns of injury varied by age, race, and payor. Black patients were more severely injured than patients of other races as measured by Injury Severity Scale scores. Among black patients with spinal injury in the NTDB, 23.9% suffered firearm injuries; only 1% of white patients suffered firearm injuries. The overall mortality rate in the NTDB was 3.9%. In a multivariate analysis that included a large panel of clinical and nonclinical factors, black race retained significance as a predictor of mortality (p = 0.006; adjusted OR 1.571 [1.141-2.163]). Rates of spinal fusion were associated with race and payor in the NTDB data and with payor in the KID: patients with better insurance underwent spinal fusion at higher rates. CONCLUSIONS: The epidemiology of pediatric spinal injury in the US cannot be understood apart from considerations of race and economic status.

Subpectoral biceps tenodesis for bicipital tendonitis with SLAP tear.

The purpose of this study was to evaluate the outcomes of patients undergoing subpectoral biceps tenodesis for bicipital tendonitis with a superior labral anterior-posterior (SLAP) tear. Patients undergoing primary subpectoral biceps tenodesis for arthroscopically confirmed SLAP tears with signs or findings of bicipital tendonitis were included. An independent observer collected data prospectively as part of a data repository, which was then analyzed retrospectively. Primary outcome measures were the American Shoulder and Elbow Surgeons (ASES) score and pain relief via visual analog scale (VAS). Secondary outcome measures included the Simple Shoulder Test (SST), Constant, Single Assessment Numeric Evaluation (SANE), and Short Form 12 (SF-12) scores. Twenty-eight patients with a mean±SD age of 43.7±13.4 years and a mean±SD follow-up of 2.0±1.0 years met inclusion criteria. Workers' compensation was involved with 43% of cases, and 46% of the included patients were manual laborers. Eight (32%) patients were athletes, and 88% of the athletes were overhead athletes. Intraoperatively, 15 (54%) patients had type I SLAP tears, 10 (36%) had type II SLAP tears, 1 (3%) had a type III SLAP tear, and 2 (7%) had type IV SLAP tears. Significant improvements were seen in the following outcome measures pre- vs postoperatively: ASES score (58±23 vs 89±18; P=.001), SST score (6.3±3.6 vs 10.6±3.3; P=.001), SANE score (54±24 vs 88±25; P=.003), VAS score (3.8±2.0 vs 1.1±1.8; P=.001), SF-12 overall score (35±6 vs 42±6; P=.001), and SF-12 physical component score (39±6 vs 50±10; P=.001). Overall satisfaction was excellent in 80% of patients. Subpectoral biceps tenodesis demonstrates excellent clinical outcomes in select patients with SLAP tears. [Orthopedics. 2015; 38(1):e48-e53.].

Cost-effectiveness analyses in orthopaedic sports medicine: a systematic review.

BACKGROUND: As increasing attention is paid to the cost of health care delivered in the United States (US), cost-effectiveness analyses (CEAs) are gaining in popularity. Reviews of the CEA literature have been performed in other areas of medicine, including some subspecialties within orthopaedics. Demonstrating the value of medical procedures is of utmost importance, yet very little is known about the overall quality and findings of CEAs in sports medicine. PURPOSE: To identify and summarize CEA studies in orthopaedic sports medicine and to grade the quality of the available literature. STUDY DESIGN: Systematic review. METHODS: A systematic review of the literature was performed to compile findings and grade the methodological quality of US-based CEA studies in sports medicine. The Quality of Health Economic Studies (QHES) instrument and the checklist by the US Panel on Cost-effectiveness in Health and Medicine were used to assess study quality. One-sided Fisher exact testing was performed to analyze the predictors of high-quality CEAs. RESULTS: Twelve studies met inclusion criteria. Five studies examined anterior cruciate ligament reconstruction, 3 studies examined rotator cuff repair, 2 examined autologous chondrocyte implantation, 1 study examined hip arthroscopic surgery, and 1 study examined the operative management of shoulder dislocations. Based on study findings, operative intervention in sports medicine is highly cost-effective. The quality of published evidence is good, with a mean quality score of 81.8 (range, 70-94). There is a trend toward higher quality in more recent publications. No significant predictor of high-quality evidence was found. CONCLUSION: The CEA literature in sports medicine is good; however, there is a paucity of studies, and the available evidence is focused on a few procedures. More work needs to be conducted to quantify the cost-effectiveness of different techniques and procedures within sports medicine. The QHES tool may be useful for the evaluation of future CEAs.

Results of 45 arthroscopic Bankart procedures: Does the ISIS remain a reliable prognostic assessment after 5 years?

PURPOSE: The Instability Severity Index Score (ISIS) includes preoperative clinical and radiological risk factors to select patients who can benefit from an arthroscopic Bankart procedure with a low rate of recurrence. Patients who underwent an arthroscopic Bankart for anterior shoulder instability with an ISIS lower than or equal to four were assessed after a minimum of 5-year follow-up. METHODS: Forty-five shoulders were assessed at a mean of 79 months (range 60-118 months). Average age was 29.4 years (range 17-58 years) at the time of surgery. Postoperative functions were assessed by the Walch and Duplay and the Rowe scores for 26 patients; an adapted telephonic interview was performed for the 19 remaining patients who could not be reassessed clinically. A failure was defined by the recurrence of an anterior dislocation or subluxation. Patients were asked whether they were finally very satisfied, satisfied or unhappy. RESULTS: The mean Walch and Duplay score at last follow-up was 84.3 (range 35-100). The final result for these patients was excellent in 14 patients (53.8 %), good in seven cases (26.9 %), poor in three patients (11.5 %) and bad in two patients (7.7 %). The mean Rowe score was 82.6 (range 35-100). Thirty-nine patients (86.7 %) were subjectively very satisfied or satisfied, and six (13.3 %) were unhappy. Four patients (8.9 %) had a recurrence of frank dislocation with a mean delay of 34 months (range 12-72 months). Three of them had a Hill-Sachs lesion preoperatively. Two patients had a preoperative ISIS at 4 points and two patients at 3 points. CONCLUSION: The selection based on the ISIS allows a low rate of failure after an average term of 5 years. Lowering the limit for indication to 3 points allows to avoid the association between two major risk factors for recurrence, which are valued at 2 points. The existence of a Hill-Sachs lesion is a stronger indicator for the outcome of instability repair. LEVEL OF EVIDENCE: Level IV, Retrospective Case Series, Treatment Study.

Motives for sports participation as predictions of self-reported outcomes after anterior cruciate ligament injury of the knee.

Aim of the study was to access how individual's motives for participation in sports impact on self-reported outcomes 2 years after an anterior cruciate ligament injury. Based on a longitudinal cohort study, this secondary analysis present data from the Knee Anterior Cruciate Ligament, Nonsurgical versus Surgical Treatment (KANON) study, a randomized controlled trial. At baseline, 121 patients recorded in an initial questionnaire that their motives for sports participation fell into four categories: achievement, health, social integration, or fun and well-being. These four categories were used as variables in the analyses. All 121 subjects completed the 2-year follow-up. The largest improvement was seen in the Knee Injury and Osteoarthritis Outcome Score (KOOS) subscale sports and recreation function, with an effect size of 2.43. KOOS sports and recreation function was also the subscale score best predicted by the motives for sports participation. Baseline motives achievement and fun and well-being predicted worse levels of pain and function 2 years after the injury, even after adjusting for age, gender, treatment and baseline scores. Psychological aspects, such as motives for participation in sport, can be factors in predicting of patient-reported outcomes 2 years after injury. Evaluating motives for sports participation may help predict the outcome 2 years after ACL injury.

Prevention and screening programs for anterior cruciate ligament injuries in young athletes: a cost-effectiveness analysis.

BACKGROUND: Anterior cruciate ligament (ACL) injuries are common among young athletes. Biomechanical studies have led to the development of training programs to improve neuromuscular control and reduce ACL injury rates as well as screening tools to identify athletes at higher risk for ACL injury. The purpose of this study was to evaluate the cost-effectiveness of these training methods and screening strategies for preventing ACL injuries. METHODS: A decision-analysis model was created to evaluate three strategies for a population of young athletes participating in organized sports: (1) no training or screening, (2) universal neuromuscular training, and (3) universal screening, with neuromuscular training for identified high-risk athletes only. Risk of injury, risk reduction from training, and sensitivity and specificity of screening were based on published data from clinical trials. Costs of training and screening programs were estimated on the basis of the literature. Sensitivity analyses were performed on key model parameters to evaluate their effect on base case conclusions. RESULTS: Universal neuromuscular training of all athletes was the dominant strategy, with better outcomes and lower costs compared with screening. On average, the implementation of a universal training program would save $100 per player per season, and would reduce the incidence of ACL injury from 3% to 1.1% per season. Screening was not cost-effective within the range of reported sensitivity and specificity values. CONCLUSIONS AND CLINICAL RELEVANCE: Given its low cost and ease of implementation, neuromuscular training of all young athletes represents a cost-effective strategy for reducing costs and morbidity from ACL injuries. While continued innovations on inexpensive and accurate screening methods to identify high-risk athletes remain of interest, improving existing training protocols and implementing neuromuscular training into routine training for all young athletes is warranted.

Acromioclavicular joint injuries in the National Football League: epidemiology and management.

BACKGROUND: Previous studies investigating acromioclavicular (AC) joint injuries in professional American football players have only been reported on quarterbacks during the 1980s and 1990s. These injuries have not been evaluated across all position players in the National Football League (NFL). PURPOSE: The purpose of this study was 4-fold: (1) to determine the incidence of AC joint injuries among all NFL position players; (2) to investigate whether player position, competition setting, type of play, and playing surface put an athlete at an increased risk for this type of injury; (3) to determine the incidence of operative and nonoperative management of these injuries; and (4) to compare the time missed for injuries treated nonoperatively to the time missed for injuries requiring surgical intervention. STUDY DESIGN: Descriptive epidemiological study. METHODS: All documented injuries of the AC joint were retrospectively analyzed using the NFL Injury Surveillance System (NFLISS) over a 12-season period from 2000 through 2011. The data were analyzed by the anatomic location, player position, field conditions, type of play, requirement of surgical management, days missed per injury, and injury incidence. RESULTS: Over 12 NFL seasons, there were a total of 2486 shoulder injuries, with 727 (29.2%) of these injuries involving the AC joint. The overall rate of AC joint injuries in these athletes was 26.1 injuries per 10,000 athlete exposures, with the majority of these injuries occurring during game activity on natural grass surfaces (incidence density ratio, 0.79) and most often during passing plays. These injuries occurred most frequently in defensive backs, wide receivers, and special teams players; however, the incidence of these injuries was greatest in quarterbacks (20.9 injuries per 100 players), followed by special teams players (20.7/100) and wide receivers (16.5/100). Overall, these athletes lost a mean of 9.8 days per injury, with quarterbacks losing the most time to injury (mean, 17.3 days). The majority of these injuries were low-grade AC joint sprains that were treated with nonoperative measures; only 13 (1.7%) required surgical management. Players who underwent surgical management lost a mean of 56.2 days. CONCLUSION: Shoulder injuries, particularly those of the AC joint, occur frequently in the NFL. These injuries can result in time lost but rarely require operative management. Quarterbacks had the highest incidence of injury; however, this incidence is lower than in previous investigations that evaluated these injuries during the 1980s and 1990s.

Injuries and abnormalities of the cervical spine and return to play criteria.

Cervical spine injury has a wide spectrum of consequences for the contact athlete, ranging from minimal to catastrophic. Because of the potentially grave sequelae of cervical injury, it is incumbent on team physicians or treating spine surgeons to be knowledgeable of postinjury treatment and return-to-play algorithms. Sideline physicians must have a rehearsed, comprehensive protocol for ensuring rapid treatment should an on-field injury occur with contingency plans to transport an injured player to a medical facility if necessary. Likelihood of return to play is variable with the extent of injury, but high for stingers, relatively low for patients who suffer episodes of transient neuropraxia, and intermediate for players who undergo cervical fusion for disk herniation based on the best available evidence. However, patients must be evaluated carefully on a case-by-case basis because of the heterogeneity of injury severity and associated pathology.

Long-term outcome after arthroscopic repair of type II SLAP lesions: results according to age and workers' compensation status.

PURPOSE: The purpose of this study was to determine the long-term functional outcome of anatomic arthroscopic repair of type II SLAP lesions with suture anchors. METHODS: We examined all arthroscopic repairs of isolated type II SLAP lesions from January 2002 through December 2007. Fifty-five patients were available for long-term follow-up at a mean of 77 months. The mean patient age at the time of surgery was 39.7 years (range, 17 to 65 years); 23 patients were aged younger than 40 years, and 32 patients were aged 40 years or older. Fourteen cases involved Workers' Compensation claims. RESULTS: Overall, functional outcome was improved from baseline compared with final follow-up for both American Shoulder and Elbow Surgeons scores (44.1 points v 86.2 points, P < .001) and University of California, Los Angeles scores (19.1 points v 31.2 points, P < .001). According to the University of California, Los Angeles grading system, 87% of cases had good or excellent results. Although the percentage of good and excellent results among patients aged 40 years or older (81%) was lower than that among patients aged younger than 40 years (97%), this difference did not reach statistical significance (P = .219). The percentage of good and excellent results among the non-Workers' Compensation cases (95%) was significantly higher than that in Workers' Compensation cases (65%) (P = .009). Overall, patient satisfaction was reported in 91% of cases, and return to normal sport or activity was reported in 82% of cases. CONCLUSIONS: In 87% of cases, a good or excellent functional outcome can be anticipated after arthroscopic repair of type II SLAP lesions with the described techniques. Variables associated with a poor outcome include Workers' Compensation cases and possibly older age (≥40 years). LEVEL OF EVIDENCE: Level IV, therapeutic case series.