Incorporating Biologics Into Your Sports Medicine Practice: Who, What, When, Why, and How?

Orthobiologic techniques can be used in the treatment of a variety of sports medicine pathologies, using an evidence-based approach focused on the value of all available approaches. The orthopaedic surgeon should be aware of the indications for and any technical pearls and pitfalls related to the use of orthobiologic agents as treatment for, or as an adjunct to management of, common sports medicine injuries and pathologies. Expected outcomes, including return to sport/activity, as well as potential complications and how to avoid them, should be considered. Although promising results have been reported, significant lack of high-level studies, inconsistent findings, and variability among current research make it challenging to reach a definitive conclusion about application, target populations, and overall effectiveness.

Maxillofacial injuries among ice hockey players: a retrospective study from a Finnish trauma Centre.

OBJECTIVE: Ice hockey players are at risk of a variety of injuries. In our investigation, we aimed to evaluate the types of facial fractures, injury mechanisms and need for surgical intervention in professional and recreational ice hockey players. MATERIAL AND METHODS: This retrospective study included all patients presenting to a tertiary trauma centre with any ice hockey-related facial fracture during the period from January 2013 to July 2020. The primary outcome variable was the need for surgical treatment, and the primary predictor variable was the injury mechanism. Demographic and clinically relevant variables were statistically evaluated and presented. RESULTS: Of 66 total patients, the most frequent fracture type was isolated mandible fracture (56.1%). Males were overrepresented (98.5%) in the patient population. Puck strikes were the most common mechanism of injury (74.2%). Surgical intervention was performed in nearly half of the patients (48.5%), and was significantly more common in younger patients (p = 0.006). Associated dental injuries were present in 27.3% of the cases and they were significantly associated with puck strikes (p = 0.027). CONCLUSIONS: Mandible fractures and puck strikes, the most common injury site and fracture mechanism respectively, sustained by ice-hockey players required surgical intervention in the majority of cases.

Traumatic Primary Anterior Glenohumeral Joint Dislocation in Sports: A Systematic Review of Operative versus Nonoperative Management.

Anterior shoulder (glenohumeral joint [GHJ]) dislocations are relatively common injuries in sports. Previous studies have evaluated clinical outcomes of operative and nonoperative management for primary traumatic anterior GHJ dislocations. The purpose of this study was to systematically review the literature in an effort to provide a thorough analysis of patients after undergoing closed reduction of a traumatic anterior GHJ dislocation, particularly among the athletic population. Two independent reviewers performed a comprehensive search of PubMed and the Cochrane Library through February 23, 2020. Unfortunately, the quantity and quality of published articles on this subject is very limited. In many studies, younger age (between 21 and 30 years) was associated with greater risk for recurrence of GHJ dislocations. Twelve studies (total N = 753) directly compared outcomes of operative versus nonoperative management. It seems that operative management significantly reduces recurrence rates with patients treated operatively among the young and active population. Operative management should be considered as a treatment option for young and athletic patients presenting with a first-time anterior GHJ dislocation.

"I never made it to the pros " Return to sport and becoming an elite athlete after pediatric and adolescent anterior cruciate ligament injury-Current evidence and future directions.

The management of anterior cruciate ligament (ACL) injuries in the skeletally immature and adolescent patient remains an area of controversy in sports medicine. This study, therefore, summarizes and discusses the current evidence related to treating pediatric and adolescent patients who sustain an ACL injury. The current literature identifies a trend towards ACL reconstruction as the preferred treatment option for ACL injuries in the young, largely justified by the risk of further structural damage to the knee joint. Worryingly, a second ACL injury is all too common in the younger population, where almost one in every three to four young patients who sustain an ACL injury and return to high-risk pivoting sport will go on to sustain another ACL injury. The clinical experience of these patients emphasizes the rarity of an athlete who makes it to elite level after a pediatric or adolescent ACL injury, with or without reconstruction. If these patients are unable to make it to an elite level of sport, treatment should possibly be modified to take account of the risks associated with returning to pivoting and strenuous sport. The surveillance of young athletes may be beneficial when it comes to reducing injuries. Further research is crucial to better understand specific risk factors in the young and to establish independent structures to allow for unbiased decision-making for a safe return to sport after ACL injury. Level of evidence V.

Oral lacerations during motocross: A case report.

Motocross is a high-risk sport that can cause serious injuries including oral injuries. However, mouthguard use is not mandatory in motocross. This report describes a case of an oral laceration with exposure of bilateral inferior alveolar nerves as a result of a motocross accident in which the patient was not wearing a mouthguard.

Trancutaneous Versus Intraoral Approach to Isolated Zygomatic Arch Fractures: A Comparison of Two Techniques.

Zygomatic arch fractures are caused by a vector force orthogonal to the bone segment that causes the collapse of the arch through depression of the bone fragments. Reduction of isolated zygomatic arch fractures are usually only of esthetic interest, with the exception of those cases where the fracture causes an impingement with the underlying mandibular coronoid process, causing limitation of mandibular movements. Reduction is usually performed with an extraoral approach, more rarely through a transoral approach. In this article, authors compare the traditional transcutaneous technique with the intraoral approach in 2 groups for a total number of 42 patients.For what concerns the correct alignment of the fragments, the 2 techniques have shown being equivalent. Although the intraoral approach has shown being a faster surgical procedure leaving no visible incision, allowing faster recovering and reduced postoperative pain.

Crown reattachment with complicated chisel-type fracture using fiber-reinforced post.

INTRODUCTION: Maxillary incisors and specifically their crowns are the most common teeth involved in dental trauma because of their exposed position in the dental arch. Traumatized anterior teeth require quick functional and esthetic repair. In the case of a complex crown fracture, with the necessity of endodontic treatment, fiber-reinforced posts (FRC) were used to create a central support stump to restore the dental morphology. CASE REPORT: A 24-year-old male patient came to the dental clinic with dental injury to the maxillary left central incisor with a chisel-type fracture that extended subgingivally with a widely open pulp chamber. The patient reported a sports injury had occurred 1 day before. Provisional reposition of the crown was completed using a composite splint and after that endodontic treatment has been performed. Two days later, a fiber-reinforced composite resin post was placed into the canal and adhesive reattachment of the fragment also completed. The tooth was prepared for a composite resin veneer in the gingival third of the vestibular surface because of a visible fracture line. CONCLUSIONS: The combined use of a fiber-reinforced composite resin post and the original crown fragment is a simple and efficient procedure for the treatment of traumatized anterior teeth that appears to offer pleasing esthetic and functional results that is less invasive than conventional prosthodontic treatment.

Operative treatment in non-emergency sports injuries: a sports medicine clinic experience.

PURPOSE: To elucidate referrals from sports medicine clinic (SMC) to orthopedics, consensus rates among physicians and surgeons on surgical need in these patients, and reasoning of the patients who refused to have surgery despite the recommendations by both groups in non-emergency sports injury patients. METHODS: We conducted a retrospective cohort analysis by using the administrative and referral records of a sports medicine clinic for the 15 months between October 2017 and January 2019. Gender, age, diagnosis, and type of sport were compared between two groups (patients referred to orthopedics vs patients treated in SMC). Agreement between orthopedics and SMC on surgical need in those patients who were referred to orthopedics was evaluated. We additionally screened the hospital archive for surgery reports of patients recommended surgery, and, if a patient did not have a surgery record, we investigated the reasons by telephone interview and categorized these reasons. RESULTS: Surgical evaluation needed for 4.7% (n = 155) of the patients. Patients referred to orthopedics were younger (median: 22.0 years), mostly male (n = 119, 76.8%), and involved in contact sports (n = 108, 69.7%) (p < 0.001 for all) compared to patients treated conservatively. Majority of the consultations were made owing to certain diagnoses such as cruciate/collateral ligament sprain (n = 70, 45.2%), meniscal tear (n = 21, 13.5%), and cartilage injuries (n = 15, 9.7%). Most of the patients diagnosed with Achilles tendon rupture (n = 2, 100%) and patellar instability (n = 13, 81.3%) were referred to surgery. Orthopedics agreed with the sports medicine physicians' opinions in most cases (n = 110, 71.0%). Thirty-four patients (30.9%) recommended surgery by the surgeon postponed/refused the treatment for various reasons or had surgery in another hospital. CONCLUSION: Most non-emergency sports injuries can be treated conservatively. Young and male patients participating in contact sports are more likely to need surgical treatment. Non-surgeon musculoskeletal health-care providers may consider referring patients to orthopedics considering the data demonstrated in this study. Nevertheless, patient's motivation to undergo an operation should be considered before referring to orthopedics.

Surgical repositioning of osseointegrated malposed dental implant with segmental osteotomy.

After extensive research, the practice with dental implants has been used on a large scale. With the increase in its indications in various local conditions, more complications have been observed. Among these, one of the most frequent is the installation of the implants in a three-dimensional altered position, making the prosthesis and aesthetics more difficult to achieve. For this reason, techniques such as segmental osteotomy have been developed and adapted to implantology to reestablish the adequate position of these implants with correct aesthetic outcome and function. The present clinical report shows the segmental osteotomy technique in a malposed osseointegrated dental position of the upper central incisor with 1-year follow-up.

Efficacy of NHP66 Bioactive Cage on Patients with Cervical Spine Injury in Short-Track Speed Skating.

BACKGROUND: Short-track speed skating (STSS) is an extreme sport in pursuit of extreme speed and explosive force. In such a sport, once athletes fall down, they are susceptible to serious cervical spine injury (CSI) under the inertia of high-velocity movement. Nanohydroxyapatite/polyamide 66 (NHP66) bioactive cage is a high-tech product of nanotechnology in the medical field in recent years. With a structure similar to that of human cortical bone, NHP66 bioactive cage has extremely high toughness and strength, which tailors to the needs of STSS. OBJECTIVE: This study mainly analyzed the therapeutic effect of NHP66 on patients with CSI in STSS, aiming to provide new opportunities for the treatment of this patient population. METHODS: A total of 51 patients with CSI treated in our hospital were enrolled, including 19 cases of short-track speed skaters (observation group) and 32 cases of car accidents, falls from heights, or collision injuries (control group). The relevant surgical indicators (operation time, intraoperative blood loss, etc.), the incidence of adverse reactions, the Cobb angle of cervical lordosis before and after surgery, and the fusion segment height of the cage were observed and compared between the two groups. Postoperative pain was evaluated by the visual analog scale (VAS), improvement of spinal cord injury was assessed by the American Spinal Cord Injury Association (ASIA) Impairment Scale, and bone fusion, bone subsidence, and other motor functions were assessed by the Japanese Orthopaedic Association (JOA) score rating system. RESULTS: The operation time, intraoperative blood loss, and incidence of adverse reactions in the observation group were significantly lower than those in the control group. The Cobb angle of cervical lordosis and the fusion segment height of cage increased significantly higher in both groups after surgery. In addition, the VAS scores of the observation group 2 h and 3 d after operation were significantly lower than those of the control group. In terms of improvement of spinal cord injury, ASIA and JOA scores in the observation group were significantly higher than those before treatment and in the control group. There was no significant difference in bone fusion activity between the two groups. CONCLUSIONS: In this study, it is found through experiments that NHP66 has higher safety and application value than autogenous iliac bone, confirming that NHP66 can achieve significant results as a cage for anterior cervical decompression and iliac bone graft fusion and internal fixation in short-track speed skaters after CSI.

Epidemiology of injuries requiring surgery among high school athletes in the United States, 2005 to 2010.

BACKGROUND: The proportion of high school sports-related injuries requiring surgery, which pose monetary and time loss burdens, has significantly increased during the last decade. The objective was to investigate the epidemiology of high school athletic injuries requiring surgery. METHODS: High school sports-related injury data were collected for nine sports from 2005 to 2010 from 100 nationally representative US high schools. RESULTS: Athletes sustained 1,380 injuries requiring surgery for a rate of 1.45 injuries per 10,000 athlete exposures. Boys' football had the highest injury rate (2.52) followed by boys' wrestling (1.64). Among gender comparable sports, girls' sports has a higher injury rate (1.20) than boys' (0.94) (rate ratio, 1.28; 95% confidence interval, 1.08-1.51; p=0.004). The rate of injuries was higher in competition (3.23) than practice (0.79) (rate ratio, 4.08; 95% confidence interval, 3.67-4.55; p<0.001) overall and in each sport. Commonly injured body sites were the knee (49.4%), head/face/mouth (9.7%), and shoulder (8.7%). Common diagnoses were complete ligament strain (32.1%) and fracture (26.4%). Nearly half (48.0%) resulted in medical disqualification for the season. CONCLUSIONS: Rates and patterns of injuries requiring surgery differ by sport, type of exposure, and gender. Future studies should identify sport-specific risk factors to drive effective interventions to decrease the incidence and severity of such injuries.

Fixation of detached osteochondritis dissecans lesions with bioabsorbable pins: clinical and histologic evaluation.

PURPOSE: The purpose was to evaluate the effect of fixation of detached free fragments of osteochondritis dissecans (OCD) (International Cartilage Repair Society OCD IV) on not only the clinical outcome, including functional and radiographic assessment, but also postoperative second-look arthroscopic and histologic evaluation. METHODS: Nine International Cartilage Repair Society OCD IV fragments were fixed with bioabsorbable pins made of poly-L-lactic acid after curettage of the bed and bone grafting. In 4 cases with severe cartilage damage in the fragments, after resection of the damaged part, trimmed fragments were fixed and osteochondral autologous transplantation was performed to cover the remaining defects. The follow-up period was at least 2 years (range, 2 to 3 years). Lysholm score and computed tomography (CT)/magnetic resonance imaging (MRI), second-look arthroscopy, and biopsy findings were examined postoperatively. RESULTS: All patients ultimately could return to previous sports activity, and the mean postoperative Lysholm score was 97 (range, 90 to 100). At 6 months, CT/MRI scans showed complete union and smooth continuity of articular surface in all cases. Second-look arthroscopy in 7 cases showed that fixed fragments were stable and that there were no progressive degenerative changes in the cartilage. Postoperative histologic examination in 4 cases showed almost normal cartilage from surface to bottom in terms of viability and quality. In addition, new bone trabeculae were covering dead bone trabeculae, which is called creeping substitution. CONCLUSIONS: Our study shows good short-term clinical results, as well as confirmation of healing on CT/MRI and second-look arthroscopy. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

[Non-union of the clavicle after intramedullary nailing with a steel Kirschner wire]. / Pseudarthrose nach intramedullärer Nagelung der Klavikula mit einem Stahl-Kirschner-Draht.

Elastically stable intramedullary nailing is a safe surgical procedure used to treat mid-shaft clavicular fractures of types A and B according to the Orthopaedic Trauma Association (OTA) classification. In the case reported intramedullary fixation with a Kirschner wire and an incorrectly performed surgical technique led to pseudoarthrosis (non-union). After revision surgery with an elastically stable titanium nail and a correct surgical technique, fracture healing was achieved.

Female Team Physician Representation in Professional and Collegiate Athletics.

BACKGROUND: Although a sex-based balance in US graduate medical education has been well-documented, a discrepancy remains in orthopaedic surgery. In orthopaedic sports medicine, the representation of women as team physicians has not previously been characterized. PURPOSE: To quantify the sex-related composition of team physicians of select National Collegiate Athletic Association (NCAA) Division I collegiate and professional teams. Additionally, the authors assess the sex-related composition of orthopaedic surgeon team physicians specifically and compare these proportions to the sex-related composition of orthopaedic surgeon membership of the American Orthopaedic Society for Sports Medicine (AOSSM). STUDY DESIGN: Cross-sectional study. METHODS: Publicly available sex-related data were collected for team physicians in select NCAA Division I collegiate conferences and professional sports organizations. Subspecialty characteristics and sex distribution were described by use of percentages. Chi-square tests were used to assess whether sex distributions of team physicians in collegiate and professional sports were (1) representative between the populations of female and male physicians compared with the general public and (2) representative of the sex-based composition of orthopaedic surgeons nationally. RESULTS: Women represented 12.7% (112/879) of all team physicians and 6.8% (30/443) of all orthopaedic surgeons (P < .0001). More than half (53.9%; 413/767) of male and 26.8% (30/112) of female team physicians were orthopaedic surgeons. In collegiate athletics, women comprised 18.1% of all team physicians and 7.7% of orthopaedic surgeon team physicians. In professional sports, women comprised 6.7% of all team physicians and 6.3% of orthopaedic surgeon team physicians, with the greatest proportion in the Women's National Basketball Association (31.3%). CONCLUSION: Women comprise a minority of team physicians in select NCAA Division I collegiate and professional sports organizations. When compared with the composition of AOSSM orthopaedic surgeon membership, expected female orthopaedic surgeon representation varies between conferences and leagues with little statistical significance. Although efforts have been made to increase sex-based diversity in orthopaedic surgery, results of this study suggest that barriers affecting female orthopaedic surgeons as team physicians should be identified and addressed.

Evidence-based Risk Stratification for Sport Medicine Procedures During the COVID-19 Pandemic.

Orthopaedic practices have been markedly affected by the emergence of the COVID-19 pandemic. Despite the ban on elective procedures, it is impossible to define the medical urgency of a case solely on whether a case is on an elective surgery schedule. Orthopaedic surgical procedures should consider COVID-19-associated risks and an assimilation of all available disease dependent, disease independent, and logistical information that is tailored to each patient, institution, and region. Using an evidence-based risk stratification of clinical urgency, we provide a framework for prioritization of orthopaedic sport medicine procedures that encompasses such factors. This can be used to facilitate the risk-benefit assessment of the timing and setting of a procedure during the COVID-19 pandemic.

Comparison of 4.5- and 5.5-mm cannulated stainless steel screws for fifth metatarsal Jones fracture fixation.

BACKGROUND: Complications including delayed and nonunions, and extensive time nonweightbearing with conservative treatment of fifth metatarsal Jones fractures, have led authors to recommend surgical fixation for this fracture in athletes who wish to return to activity quickly. The optimal surgical procedure, however, has not been determined. The purpose of this study was to evaluate the effectiveness of 5.5-mm cannulated screw fixation for fifth metatarsal stress fractures in athletes and compare them to an earlier cohort treated with a 4.5-mm screw. MATERIALS AND METHODS: Twenty athletes were treated surgically with a 5.5-mm cannulated screw and postoperatively wore a removable walking boot, applied cold compression, initiated immediate range of motion, and used crutches for 1 week. Fractures were evaluated for clinical and radiographic healing. These findings were compared to a group that used 4.5-mm screws. RESULTS: Average radiographic healing was 96.7% and all fractures healed clinically. Athletes returned to sports in an average of 9.3 weeks. There were three re-injuries that were treated with 2 weeks in a walking boot. No patients have required screw removal or have experienced pain at the hardware site, besides the three re-injuries. When compared to the earlier study, no differences were found. However, there were no re-fractures in the 4.5-mm study, but there were three bent screws. CONCLUSION: The current study demonstrates the clinical effectiveness of the 5.5-mm screw. However, with the numbers available, we were unable to demonstrate significant improvement over the 4.5-mm screw and thus cannot conclude that a larger screw is more effective.