Experts Achieve Consensus on a Majority of Statements Regarding Platelet-Rich Plasma Treatments for Treatment of Musculoskeletal Pathology.

PURPOSE: To establish consensus statements on platelet-rich plasma (PRP) for the treatment of musculoskeletal pathologies. METHODS: A consensus process on the treatment of PRP using a modified Delphi technique was conducted. Thirty-five orthopaedic surgeons and sports medicine physicians participated in these consensus statements on PRP. The participants were composed of representatives of the Biologic Association, representing 9 international orthopaedic and musculoskeletal professional societies invited due to their active interest in the study of orthobiologics. Consensus was defined as achieving 80% to 89% agreement, strong consensus was defined as 90% to 99% agreement, and unanimous consensus was indicated by 100% agreement with a proposed statement. RESULTS: There was consensus on 62% of statements about PRP. CONCLUSIONS: (1) PRP should be classified based on platelet count, leukocyte count, red blood count, activation method, and pure-plasma versus fibrin matrix; (2) PRP characteristics for reporting in research studies are platelet count, leukocyte count, neutrophil count, red blood cell count, total volume, the volume of injection, delivery method, and the number of injections; (3) the prognostic factors for those undergoing PRP injections are age, body mass index, severity/grade of pathology, chronicity of pathology, prior injections and response, primary diagnosis (primary vs postsurgery vs post-trauma vs psoriatic), comorbidities, and smoking; (4) regarding age and body mass index, there is no minimum or maximum, but clinical judgment should be used at extremes of either; (5) the ideal dose of PRP is undetermined; and (6) the minimal volume required is unclear and may depend on the pathology. LEVEL OF EVIDENCE: Level V, expert opinion.

An Initial Injection and a Crossover Injection of Amniotic Suspension Allograft Following Failed Treatment with Hyaluronic Acid or Saline Are Equally Effective in the Treatment of Moderate Symptomatic Knee Osteoarthritis Over 12 Months.

PURPOSE: The purpose of this crossover study was to determine the efficacy of amniotic suspension allograft (ASA) for moderate symptomatic knee osteoarthritis following failed treatment with hyaluronic acid (HA) or saline through 12 months' postcrossover injection using patient-reported and safety outcomes. METHODS: In this multicenter study, 95 patients from a 200-patient single-blind randomized controlled trial were eligible to crossover and receive a single injection of ASA 3 months after failed treatment with HA or saline. Patient-reported outcomes, including Knee Injury and Osteoarthritis Outcome Score (KOOS) and visual analog scale (VAS), were collected out to 12 months postcrossover to determine pain and function. Radiographs and blood were collected for assessment of changes. Statistical analyses were performed using mixed effects model for repeated measures. RESULTS: Treatment with ASA following failed treatment with HA or saline resulted in significant improvements in KOOS and VAS scores compared with crossover baseline. There were no differences in radiographic measures or anti-human leukocyte antigen serum levels compared with baseline and no severe adverse events reported. In addition, more than 55% of patients were responders at months 3, 6, and 12 as measured by the Outcome Measures in Arthritis Clinical Trials-Osteoarthritis Research Society International simplified responder criteria. There were no significant differences between the original ASA randomized group and crossover cohorts at any of the time points evaluated, suggesting that prior failed treatment with HA or saline did not significantly impact outcomes following treatment with ASA. CONCLUSIONS: This study showed that patients who previously failed treatment with HA or saline had statistically significant improvements in pain and function scores following a crossover injection of ASA that was sustained for 12 months, as measured by KOOS and VAS. There were no serious adverse events reported, and the injection was safe. LEVEL OF EVIDENCE: II, prospective cohort study.

Editorial Commentary: When Treating Cartilage Lesions With Osseous Involvement, Biologic "Chondrofacilitation" Using Either Bone Marrow Aspirate Concentrate or Mesenchymal Stem Cells Augments Microfracture.

The use of biologic augmentation following microfracture for symptomatic cartilage defects of the knee with osseous involvement shows encouraging results. Bone marrow aspirate concentrate provides growth factors to the injury site, such as vascular endothelial growth factor, platelet-derived growth factor, transforming growth factor-ßa, and bone morphogenetic proteins in addition to the mesenchymal stem cells present in the concentrate. Cellular-based therapies like mesenchymal stem cells are becoming more widely used in conjunction with surgical treatment of focal cartilage lesions with early promising results. Both treatment options improve clinical and radiographic outcomes. As for the efficacy of mesenchymal stem cells versus bone marrow aspirate concentrate, we believe that both have promising results.

Assessing the Resident Progenitor Cell Population and the Vascularity of the Adult Human Meniscus.

PURPOSE: To identify, characterize, and compare the resident progenitor cell populations within the red-red, red-white, and white-white (WW) zones of freshly harvested human cadaver menisci and to characterize the vascularity of human menisci using immunofluorescence and 3-dimensional (3D) imaging. METHODS: Fresh adult human menisci were harvested from healthy donors. Menisci were enzymatically digested, mononuclear cells isolated, and characterized using flow cytometry with antibodies against mesenchymal stem cell surface markers (CD105, CD90, CD44, and CD29). Cells were expanded in culture, characterized, and compared with bone marrow-derived mesenchymal stem cells. Trilineage differentiation potential of cultured cells was determined. Vasculature of menisci was mapped in 3D using a modified uDisco clearing and immunofluorescence against vascular markers CD31, lectin, and alpha smooth muscle actin. RESULTS: There were no significant differences in the clonogenicity of isolated cells between the 3 zones. Flow cytometry showed presence of CD44+CD105+CD29+CD90+ cells in all 3 zones with high prevalence in the WW zone. Progenitors from all zones were found to be potent to differentiate to mesenchymal lineages. Larger vessels in the red-red zone of meniscus were observed spanning toward red-white, sprouting to smaller arterioles and venules. CD31+ cells were identified in all zones using the 3D imaging and co-localization of additional markers of vasculature (lectin and alpha smooth muscle actin) was observed. CONCLUSIONS: The presence of resident mesenchymal progenitors was evident in all 3 meniscal zones of healthy adult donors without injury. In addition, our results demonstrate the presence of vascularization in the WW zone. CLINICAL RELEVANCE: The existence of progenitors and presence of microvasculature in the WW zone of the meniscus suggests the potential for repair and biologic augmentation strategies in that zone of the meniscus in young healthy adults. Further research is necessary to fully define the functionality of the meniscal blood supply and its implications for repair.

Complications Following Biologic Therapeutic Injections: A Multicenter Case Series.

PURPOSE: To describe the complications that occur following biologic therapeutic injections. METHODS: We queried physician members of the Biologic Association, a multidisciplinary organization dedicated to providing a unified voice for all matters related to musculoskeletal biologics and regenerative medicine. Patients included in this study must have (1) received a biologic injection, (2) sustained an adverse reaction, and (3) had a minimum of 1-year follow-up after the injection. Patient demographic information, medical comorbidities, diagnoses, and previous treatments were recorded. The type of injection, injection setting, injection manufacturers, and specific details about the complication and outcome were collected. RESULTS: In total, 14 patients were identified across 6 institutions in the United States (mean age 63 years, range: 36-83 years). The most common injections in this series were intra-articular knee injections (50%), followed intra-articular shoulder injections (21.4%). The most common underlying diagnosis was osteoarthritis (78.5%). Types of injections included umbilical cord blood, platelet-rich plasma, bone marrow aspirate concentrate, placental tissue, and unspecified "stem cell" injections. Complications included infection (50%), suspected sterile inflammatory response (42.9%), and a combination of both (7.1%). The most common pathogen identified from infection cases was Escherichia coli (n = 4). All patients who had isolated infections underwent treatment with at least one subsequent surgical intervention (mean: 3.6, range: 1-12) and intravenous antibiotic therapy. CONCLUSIONS: This study demonstrates that serious complications can occur following treatment with biologic injections, including infections requiring multiple surgical procedures and inflammatory reactions. LEVEL OF EVIDENCE: Level IV, case series.

Safety and Efficacy of an Amniotic Suspension Allograft Injection Over 12 Months in a Single-Blinded, Randomized Controlled Trial for Symptomatic Osteoarthritis of the Knee.

PURPOSE: The purpose of this study is to determine the efficacy of amniotic suspension allograft (ASA) compared to hyaluronic acid (HA) and saline at up to 12 months of follow-up through the use of patient-reported outcomes, immunoglobulin levels, and anti-human leukocyte antigen (HLA) levels. METHODS: Within this multicenter study, 200 patients were randomized 1:1:1 to a single intra-articular injection of saline, HA, or ASA. Patient-reported outcomes, including Knee Injury and Osteoarthritis Outcome Score (KOOS) and visual analog scale (VAS) score, were collected at multiple time points (baseline, 1 week, 6 weeks, 3 months, 6 months) out to 12 months to assess improvements in pain and function. Radiographs at baseline and 12 months were taken to determine radiographic changes, while blood was collected at baseline, 6 weeks, and 6 months to determine changes in immunoglobulins and anti-HLA levels. Statistical analyses were performed using last observation carried forward and mixed effects model for repeated measures. RESULTS: Treatment with ASA resulted in significant improvements in KOOS and VAS scores that were maintained through 12 months (P < .05). Treatment with ASA resulted in a 63.2% responder rate at 12 months using the Outcome Measures in Arthritis Clinical Trials-Osteoarthritis Research Society International simplified definition. There were no significant differences between groups for radiographic measures in the index knee, immunoglobulins, C-reactive protein, or anti-HLA serum levels (P > .05). The number and type of adverse events (AEs) reported for ASA were comparable to the HA injection group, while no treatment-emergent AEs were reported for the saline group. CONCLUSIONS: This randomized controlled trial of ASA vs HA and saline for the treatment of symptomatic knee osteoarthritis demonstrated clinically meaningful improved outcomes with ASA over the controls out to 12 months postinjection. No concerning immunologic or adverse reactions to the ASA injection were identified with regards to severe AEs, immunoglobulin, or anti-HLA levels. LEVEL OF EVIDENCE: Level I, randomized controlled multicenter trial.

How to Address the Medial Patellofemoral Ligament, Tibial Tubercle, and Articular Cartilage in Patients With Recurrent Patellar Instability.

Patellofemoral instability is a common pathology especially in the adolescent female population.1,2 Prompt diagnosis and management is critical to prevent future episodes of instability as well as to reduce the risk of cartilaginous injury to the patellofemoral articular surface. Initial management of a first-time patellar dislocation has historically been nonsurgical; however, the presence of intra-articular loose bodies or osseocartilaginous injury may require surgical intervention.3,4 More recent evidence has shown patients with specific risk factors such as skeletal immaturity, an incompetent medial soft-tissue sleeve, family history of patellar dislocation, elevated tibial tubercle to trochlear groove distance, patella alta, and high-grade trochlear dysplasia experience high rates of re-dislocation after initial nonsurgical management.4-9 Based on this, the provider needs to consider these risk factors and the possibility of initial surgical management in these patient populations following a first-time patellar dislocation. Surgical options for management of patellar instability and cartilaginous injury include medial patellofemoral ligament repair, medial patellofemoral ligament reconstruction, tibial tubercle osteotomy, and various cartilaginous repair/restoration procedures. It is important to be knowledgeable about the clinical and anatomic/radiographic risk factors associated with patients presenting with patellar instability, the algorithm for treatment, the indications and surgical technique for medial patellofemoral ligament reconstruction and tibial tubercle osteotomy, and management of cartilaginous injury to the patellofemoral joint.

Editorial Commentary: Anterior Cruciate Ligament Injury and Reconstruction in Soccer Players: The Major Challenge Is Always Going for Our Goals!

Anterior cruciate ligament (ACL) injury affects a large number of athletes worldwide, and long-term rate of return to soccer is approximately 50% or less. ACL injury, which is noncontact in approximately 90% of cases, has a complex multifactorial etiology. Younger and higher-level players do better, and 10-year outcomes are superior to baseline. The role of genomics, hormonal status, neuromuscular deficiencies, anatomy, and the environment are all potential contributory risk factors that vary with respect to the individual, especially the female athlete. Furthermore, ACL injury results in a local and regional catabolic cascade and cytokine release, creating an intra-articular environment that is a homeostatic perfect storm and spectrum of scalable articular cartilage and meniscal injury. Once these complexities in the knee organ are defined and understood, the surgeon's early objectives are stabilization, repair, and restoration with full harmonization of biomechanics, neuromuscular control, and homeostasis. The goal is optimizing long-term outcomes, decreasing the rate of subsequent ACL injury, and preventing osteoarthritis.

Degenerative Meniscus Lesions: An Expert Consensus Statement Using the Modified Delphi Technique.

PURPOSE: The purpose of this study was to perform an evidence-based, expert consensus survey using the Delphi panel methodology to develop recommendations for the treatment of degenerative meniscus tears. METHODS: Twenty panel members were asked to respond to 10 open-ended questions in rounds 1 and 2. The results of the first 2 rounds served to develop a Likert-style questionnaire for round 3. In round 4, the panel members outside consensus were contacted and asked to either change their score in view of the group's response or argue their case. The level of agreement for round 4 was defined as 80%. RESULTS: There was 100% agreement on the following items: insidious onset, physiological part of aging, tears often multiplanar, not all tears cause symptoms, outcomes depend on degree of osteoarthritis, obesity is a predictor of poor outcome, and younger patients (<50 years) have better outcomes. There was between 90% and 100% agreement on the following items: tears are nontraumatic, radiographs should be weightbearing, initial treatment should be conservative, platelet-rich plasma is not a good option, repairable and peripheral tears should be repaired, microfracture is not a good option for chondral defects, the majority of patients obtain significant improvement and decrease in pain with surgery but results are variable, short-term symptoms have better outcomes, and malalignment and root tears have poor outcomes. CONCLUSIONS: This consensus statement agreed that degenerative meniscus tears are a normal part of aging. Not all tears cause symptoms and, when symptomatic, they should initially be treated nonoperatively. Repairable tears should be repaired. The outcome of arthroscopic partial meniscectomy depends on the degree of osteoarthritis, the character of the meniscus lesion, the degree of loss of joint space, the amount of malalignment, and obesity. The majority of patients had significant improvement, but younger patients and patients with short-term symptoms have better outcomes. LEVEL OF EVIDENCE: Level V - expert opinion.

Biomechanical Evaluation of Pediatric Anterior Cruciate Ligament (ACL) Reconstruction Techniques With and Without the Anterolateral Ligament (ALL).

BACKGROUND: Two popular physeal-sparing procedures used in the management of anterior cruciate ligament (ACL) injuries in skeletally immature patients are the iliotibial band (ITB) ACL reconstruction (ACLR) and the all-epiphyseal (AE) ACLR. Although there has been concern for overconstraint of the lateral compartment of the knee with the ITB ACLR technique, rotational stability, as provided by the anterolateral ligament (ALL) and ACL, has not been assessed in the setting of pediatric ACLR techniques. Our hypothesis is that the ITB ACLR and AE ACLR with ALL reconstruction (ALLR) will best replicate the biomechanical profile of the intact ACL that is lost with transection of the ACL and ALL. METHODS: Eight cadaveric legs were statically loaded with an anterior drawer force and varus, valgus, internal and external rotational moments at 0, 30, 60, and 90 degrees of flexion. Displacement and rotation were recorded in the following conditions: intact ACL/intact ALL, ACL-deficient/intact ALL, ITB ACLR/intact ALL, ITB ACLR/ALL-deficient, ACL-deficient/ALL-deficient, AE ACLR/ALL-deficient, AE ACLR/ALLR. RESULTS: Both ACLR techniques reduced anterior tibial translation from the ACL-deficient state, but neither restored it to the intact state (P<0.05), except in full extension. ALL deficiency increased anterior tibial translation in the ACL-deficient state (P<0.05). In rotational testing, no significant increase was seen with transection of the ACL, but the ACL-deficient/ALL-deficient state had a significant increase in internal rotation (P<0.05). This was significantly restored to the intact state at most flexion angles with the ITB ACLR without rotational overconstraint of the lateral compartment. The AE ACLR/ALL-deficient state and AE ACLR/ALLR improved rotational stability at lower flexion angles, but not at 60 and 90 degrees. There were no significant changes in varus/valgus moments. CONCLUSIONS: In this model, the ITB ACLR provided the superior biomechanical profile between our tested reconstructions. It best corrected both AP and rotatory stability without overconstraining the knee. The AE ACLR and AE ACLR/ALLR improved both parameters but not at all flexion angles and not as robustly. ACL deficiency in the knee increased anterior tibial translation, but did not affect rotatory stability. ALL deficiency in the knee increased anterior displacement and rotational moments in the ACL-deficient state. CLINICAL RELEVANCE: Cadaveric Laboratory Study. The ITB ACLR seems to be the biomechanically superior pediatric ACLR technique to regain translational and rotational stability.

Head Injury in Soccer: From Science to the Field; summary of the head injury summit held in April 2017 in New York City, New York.

There has been an increased focus and awareness of head injury and sport-related concussion (SRC) across all sports from the medical and scientific communities, sports organisations, legislators, the media and the general population. Soccer, in particular, has been a focus of attention due to the popularity of the game, the frequency of SRC and the hypothesised effects of repetitive heading of the ball. Major League Soccer, US Soccer and the National Women's Soccer League jointly hosted a conference entitled, 'Head Injury in Soccer: From Science to the Field', on 21-22 April 2017 in New York City, New York. The mission of this conference was to identify, discuss and disseminate evidence-based science related to the findings and conclusions of the fifth International Conference on Concussion in Sport held by the Concussion in Sport Group and apply them to the sport of soccer. In addition, we reviewed information regarding the epidemiology and mechanism of head injuries in soccer at all levels of play, data regarding the biomechanics and effects of repetitive head impacts and other soccer-specific considerations. We discussed how to release the information raised during the summit to key stakeholders including athletes, parents, coaches and healthcare providers. We identified future areas for research and collaboration to enhance the health and safety of soccer (football) players.

Editorial Commentary: Platelet-Rich Plasma Details Are Critical to Outcome Catching Is Always Better Than Fishing.

The use of platelet-rich plasma (PRP) and the spectrum of orthobiological interventions has been a major innovation in orthopedic surgery and medicine. Biological-based therapies for musculoskeletal disorders and injuries have gained popularity in the past decade and created significant expectation as the future of sports medicine, based on theoretical advantages including minimal invasiveness, greater healing potential, faster recovery, and a less expensive alternative to surgery. These therapies for musculoskeletal intervention include PRP, bone marrow aspirate concentrate, cellular-based therapies, and tissue engineering. Surgeons must always identify and respect the gap between hope, knowledge, and evidence to be successful and efficient in the care of patients. Age, body mass index, and dietary factors may have significant impact on the performance of PRP as a therapeutic intervention. It is imperative that the clinician be armed with a meticulous, comprehensive, and refined technique, protocol, and algorithm to be successful in the use of the PRP.

Editorial Commentary: Second-Generation Microfracture-We Are Only As Strong As Our Weakest Link.

Injuries to the articular cartilage of the knee are increasingly common, especially in athletes. The operative management of these focal chondral lesions continues to be a regenerative challenge. The microfracture (MFx) procedure has become a first-line arthroscopic treatment method for small, symptomatic chondral lesions, and it frequently serves as the standard technique against which other cartilage repair procedures are compared. Over time, outcome studies have defined the weaknesses and limitations of first-generation MFx. The second iteration of MFx seeks to optimize regeneration using the trilogy of cells, scaffolds, and growth factors. As surgeons, we are only as strong as our weakest link.

How to Manage Cartilage Injuries?

Although small cartilage injuries are commonly found in knee arthroscopy procedures, significant chondral and osteochondral injuries are relatively infrequent. Incidence of cartilage injury rises when considering traumatic origin, especially when approaching significant ligamentous or meniscal pathology. Options for restoration span the gamut from benign neglect to open procedures that restore both cartilage and subchondral bone. The best choice of procedure largely depends on lesion size, depth, and location. Smaller lesions isolated to cartilage <2 cm2 can be treated with marrow stimulation techniques such as microfracture with or without biologic options (bone marrow aspirate concentrate or platelet-rich plasma with or without cartilage precursors or scaffolds). Microfracture alone in larger lesions has been reported to be less durable and it is therefore not recommended for larger lesions. Smaller lesions <2 cm2 that include a subchondral injury can be treated with osteochondral autograft implantation, in which a core of cartilage and bone is transferred from a relative non-weightbearing surface to the lesion. Larger osteochondral lesions >2 cm2 are better treated with osteochondral allograft transplantation, where osteochondral cores from a size-matched, fresh cadaver are matched to the patient's lesion. This option may require multiple cores to be placed in a "snowman" pattern; however, recent literature demonstrated that a single plug might produce better outcomes. Alternatively, for large chondral-only lesions, a resurfacing procedure may be chosen that may include biologic options. Autologous chondrocyte implantation (ACI), currently in its third iteration (matrix ACI [MACI]), is an excellent choice with good long-term durability. In addition, MACI may be used for chondral lesions in the patellofemoral joint where matching the native joint topology may be more difficult. If the patient has an underlying bone marrow lesion but an intact cartilage cap that appears healthy on arthroscopic examination, one may consider a core decompression and injection with biologics such as BMAC and bony scaffold with fibrin glue (also known as bioplasty). It is also critical that the surgeon address any concomitant knee pathology that would compromise cartilage restoration. This includes addressing malalignment with distal femoral, proximal tibial, or tibial tubercle osteotomy, significant meniscal deficiency with meniscal transplant, and any instability from lack of cruciate or collateral ligaments with ligament reconstruction.

2018 International Olympic Committee consensus statement on prevention, diagnosis and management of paediatric anterior cruciate ligament (ACL) injuries.

In October 2017, the International Olympic Committee hosted an international expert group of physiotherapists and orthopaedic surgeons who specialise in treating and researching paediatric ACL injuries. Representatives from the American Orthopaedic Society for Sports Medicine, European Paediatric Orthopaedic Society, European Society for Sports Traumatology, Knee Surgery & Arthroscopy, International Society of Arthroscopy Knee Surgery and Orthopaedic Sports Medicine, Pediatric Orthopaedic Society of North America and Sociedad Latinoamericana de Artroscopia, Rodilla y Deporte attended. Physiotherapists and orthopaedic surgeons with clinical and research experience in the field, and an ethics expert with substantial experience in the area of sports injuries also participated. Injury management is challenging in the current landscape of clinical uncertainty and limited scientific knowledge. Injury management decisions also occur against the backdrop of the complexity of shared decision-making with children and the potential long-term ramifications of the injury. This consensus statement addresses six fundamental clinical questions regarding the prevention, diagnosis and management of paediatric ACL injuries. The aim of this consensus statement is to provide a comprehensive, evidence-informed summary to support the clinician, and help children with ACL injury and their parents/guardians make the best possible decisions.

Biological Treatment for Osteoarthritis of the Knee: Moving from Bench to Bedside-Current Practical Concepts.

Biological-based therapies for cartilage pathology have gained considerable recognition in the last few decades due to their potential benefits including their minimal invasiveness, capacity for unprecedented healing, and potential for rapid recovery. Consequently, these therapies are likely to have the most noteworthy impact on patients with degenerative joint changes who want to remain active. Currently, the most researched treatments include platelet-rich plasma (PRP), bone marrow aspirate concentrate (BMAC), and cell-based therapies. Although further basic science research and well-designed randomized clinical trials are needed to elucidate the long-term role of these therapies in the treatment of osteoarthritis, there is compelling evidence for their use for certain indications. This article aims to review the existing literature for biological-based treatment options for osteoarthritis, critically assessing the current evidence-based recommendations and identify potential avenues for development.

Clinical Outcomes After Arthroscopic Release of Patellofemoral Arthrofibrosis in Patients With Prior Anterior Cruciate Ligament Reconstruction.

PURPOSE: The purpose of this study was to review our results of arthroscopic release in patients diagnosed with refractory patellofemoral arthrofibrosis (PFA) after having undergone anterior cruciate ligament (ACL) reconstruction. METHODS: From 2006 to 2016, all patients who underwent arthroscopic release for refractory PFA after ACL reconstruction were reviewed retrospectively. All patients then completed surveys containing the International Knee Documentation Committee (IKDC) and the Western Ontario and McMaster Universities Arthritis Index (WOMAC) and were asked 2 subjective questions. Patients included in the study exhibited at least one finding of PFA and failed conservative treatment for at least 3 months. Included patients also had a minimum of 12 months of postoperative follow-up after PFA release. Patients who underwent any other concomitant surgery in the same operative setting as arthroscopic release for PFA were excluded from the study. RESULTS: Thirty-two patients were included in the study. The mean age was 32.8 years (range, 19-58 years) with an average follow-up of 43.6 months (range, 16-98 months). There was a statistically significant increase preoperatively to postoperatively in the IKDC score from 49.6 to 69.4 (P < .00001), and 16 of 32 patients (50%) achieved a minimal clinically important difference (MCID). WOMAC scores also significantly increased from 74 to 85.3 (P < .00001), with 15 of 32 patients (47%) achieving MCID. Thirty-one patients (97%) reported that the procedure helped, and 25 patients (78%) said they would have the procedure again. CONCLUSIONS: Arthroscopic release, consisting of an extended lateral release, debridement of the notch/fat pad, and manual manipulation of the patella, results in significant increases in validated outcome measures and is well tolerated by patients. LEVEL OF EVIDENCE: Level IV, case series.

A Prospective, Blinded, Multicenter Clinical Trial to Compare the Efficacy, Accuracy, and Safety of In-Office Diagnostic Arthroscopy With Magnetic Resonance Imaging and Surgical Diagnostic Arthroscopy.

PURPOSE: The purpose of this study was to compare the efficacy, accuracy, and safety of in-office diagnostic arthroscopy with magnetic resonance imaging (MRI) and surgical diagnostic arthroscopy. METHODS: A prospective, blinded, multicenter, clinical trial was performed on 110 patients, ages 18 to 75 years, who presented with knee pain. The study period was April 2012 to April 2013. Each patient underwent a physical examination, an MRI, in-office diagnostic imaging, and a diagnostic arthroscopic examination in the operating room. The attending physician completed clinical report forms comparing the in-office arthroscopic examination and surgical diagnostic arthroscopy findings on each patient. Two blinded experts, unaffiliated with the clinical care of the study's subjects, reviewed the in-office arthroscopic images and MRI images using the surgical diagnostic arthroscopy images as the "control" group comparison. Patients were consecutive, and no patients were excluded from the study. RESULTS: In this study, the accuracy, sensitivity, and specificity of in-office arthroscopy was equivalent to surgical diagnostic arthroscopy and more accurate than MRI. When comparing in-office arthroscopy with surgical diagnostic arthroscopy, all kappa statistics were between 0.766 and 0.902. For MRI compared with surgical diagnostic arthroscopy, kappa values ranged from a low of 0.130 (considered "slight" agreement) to a high of 0.535 (considered "moderate" agreement). The comparison of MRI to in-office arthroscopy showed very similar results as the comparison of MRI with surgical diagnostic arthroscopy, ranging from a low kappa of 0.112 (slight agreement) to a high of 0.546 (moderate agreement). There were no patient-related or device-related complications related to the use of in-office arthroscopy. CONCLUSIONS: Needle-based diagnostic imaging that can be used in the office setting is statistically equivalent to surgical diagnostic arthroscopy with regard to the diagnosis of intra-articular, nonligamentous knee joint pathology. In-office diagnostic imaging can provide a more detailed and accurate diagnostic assessment of intra-articular knee pathology than MRI. Based on the study results, in-office diagnostic imaging provides a safe, accurate, real-time, minimally invasive diagnostic modality to evaluate intra-articular pathology without the need for surgical diagnostic arthroscopy or high-cost imaging. LEVEL OF EVIDENCE: Level II, comparative prospective trial.

Higher compliance to a neuromuscular injury prevention program improves overall injury rate in male football players.

PURPOSE: The 11+ injury prevention program has been shown to decrease injury rate. However, few studies have investigated compliance and if it is correlated to time loss. The purpose of this study was to (1) analyze how differences in compliance may impact injury rate and (2) if compliance may impact time loss due to injury. METHODS: This study was a Level 1 prospective cluster randomized controlled trial conducted in NCAA men's football (soccer) teams that examined the efficacy of the 11+ injury prevention program. The two outcome variables examined were number of injuries and number of days missed from competition. Twenty-seven teams (n = 675 players) used the 11+ program. Compliance, injuries and time loss were recorded. There were three compliance categories, low (LC, 1-19 doses/season), moderate (MC, 20-39 doses/season), and high (HC, > 40 doses/season). RESULTS: There was a significant difference among the groups for injuries, p = 0.04, pη2 = 0.23. The LC group [mean (M) = 13.25, 95% confidence interval (CI) 9.82-16.68, injury rate (IR) = 10.35 ± 2.21] had a significantly higher injury rate than the HC group (M = 8.33, 95%CI 6.05-10.62, IR = 10.35 ± 2.21), p = 0.02. The MC group (M = 11.21, 95%CI 9.38-13.05, IR = 8.55 ± 2.46) was not significantly different than the LC group, p = 0.29, but was significantly greater than the HC group, p = 0.05. When examined as a continuous variable, compliance was significantly negatively related to injury rate (p = 0.004). It was also significantly negatively related to number of days missed (p = 0.012). CONCLUSIONS: When compliance was high, there was a significant reduction in injury and time loss. This evidence reinforces the importance of consistent injury prevention program utilization. Clinically, these findings have important implications when discussing the importance of consistent utilization of an injury prevention protocol in sport. LEVEL OF EVIDENCE: Level 1-Randomized controlled trial (RCT).