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.

Injury prevention strategies at the 2019 FIFA Women's World Cup display a multifactorial approach and highlight subjective wellness measurements.

OBJECTIVE: To report the injury prevention programs utilised by top-level female footballers competing internationally. METHODS: An online survey was administered to physicians of the 24 competing national teams at the 2019 Federation Internationale de Football Association (FIFA) Women's World Cup. The survey included 4 sections regarding perceptions and practices concerning non-contact injuries: (1) risk factors, (2) screening tests and monitoring tools, (3) preventative strategies, and (4) reflection on their World Cup experience. RESULTS: Following responses from 54% of teams, the most common injuries encountered included muscle strains, ankle sprains, and anterior cruciate ligament ruptures. The study also revealed the most important injury risk factors during the FIFA 2019 World Cup. Intrinsic risk factors include accumulated fatigue, previous injury, and strength endurance. Extrinsic risk factors include reduced recovery time between matches, congested match schedule, and the number of club team matches played. The 5 most used tests for risk factors were flexibility, joint mobility, fitness, balance, and strength. Monitoring tools commonly used were subjective wellness, heart rate, minutes/matches played, and daily medical screening. Specific strategies to limit the risk of an anterior cruciate ligament injury included the FIFA 11+ program and proprioception training. CONCLUSION: The present study revealed multifactorial approaches to injury prevention strategies for women's national football teams at the FIFA 2019 World Cup. Challenges to injury prevention program implementation reflect time limitations, schedule uncertainties, and varying club team recommendations. LEVEL OF EVIDENCE: IV.

Discoid Lateral Meniscus.

PURPOSE OF REVIEW: Discoid lateral meniscus (DLM) is a well-known meniscus variant, and comprises excess and thickened meniscal tissue, altered collagen ultrastructure, and peripheral instability. This article presents a comprehensive review on current knowledge of DLM, focusing on pathology in parallel with surgical techniques and outcomes. RECENT FINDINGS: A paradigm shift in surgical management of DLM is taking place as knee surgeons are seeing more patients with long-term sequelae of partial lateral meniscectomy, the standard treatment for DLM for many years. Surgical treatment has evolved alongside the understanding of DLM pathology. A new classification system has been proposed and optimal surgical techniques described in recent years. This article highlights up-to-date evidence and techniques in management of both acute DLM tears and joint restoration following subtotal meniscectomy for DLM. Surgical management of DLM must be tailored to individual pathology, which is variable within the diagnosis of DLM. We present an algorithm for management of DLM and discuss future directions for the understanding and treatment of this debilitating condition.

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.

Incidence of Injury for Professional Soccer Players in the United States: A 6-Year Prospective Study of Major League Soccer.

Background: Despite an abundance of injury research focusing on European professional soccer athletes, there are limited injury data on professional soccer players in the United States. Purpose: To describe the epidemiology of injury across multiple years in Major League Soccer (MLS) players. Study Design: Descriptive epidemiology study. Methods: A web-based health management platform was used to prospectively collect injury data from all MLS teams between 2014 and 2019. An injury was defined as an incident that required medical attention and was recorded into the health management platform anytime over the course of the 2014-2019 seasons. Injuries and exposure data were recorded in training and match settings to calculate injury incidence. Results: A total of 9713 injuries were recorded between 2014 and 2019. A mean 1.1 injuries per year per player were identified, with midfielders sustaining the largest number of injuries. The most common injuries were hamstring strains (12.3%), ankle sprains (8.5%), and adductor strains (7.6%). The mean time missed per injury was 15.8 days, with 44.2% of injuries resulting in no days missed. Overall injury incidence was 8.7 per 1000 hours of exposure, declining over the course of the investigation, with a 4.1-times greater mean incidence during matches (14.0/1000 h) than training (3.4/1000 h). Conclusion: Between 2014 and 2019, the most commonly reported injuries in MLS players were hamstring strains, ankle sprains, and adductor strains. Injury incidence during matches was 4.1 times greater when compared with training, while overall injury incidence was found to decline during the course of the study period.

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.

Outcomes of Surgically Treated Fifth Metatarsal Fractures in Major League Soccer Athletes.

BACKGROUND: Sports-related fractures of the fifth metatarsal are common in professional athletes. Data regarding outcomes of surgical management including refracture, complications, and return-to-play statistics are available for other professional American sports with a notable exception of soccer. PURPOSE: To quantify the burden of operative fifth metatarsal fractures in Major League Soccer (MLS) athletes, to compare outcomes as well as refracture and complication rates with other professional sports, to analyze factors that may contribute to treatment failure, and to report on return-to-play characteristics for affected players. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: We searched all injuries in the prospectively collected HealtheAthlete database for MLS for operative fifth metatarsal fractures for seasons 2013 to 2017. Additional information regarding each fracture including demographics, treatment, postoperative course, and return-to-play statistics were compiled from HealtheAthlete and supplemented by teams' chief medical officers, coaches, trainers, and online sources. RESULTS: There were 21 fractures in 18 players during the study period. Mean time to radiographic healing was 8.5 weeks (n = 17). Mean time to return to play was 11.1 weeks (n = 19). Of 21 fractures, 20 (95%) players returned to sport. Of 18 players, 4 (22.2%) experienced refracture. Of 18 players, 5 (27.8%) and 2 (11.1%) reported previous stress injuries on the contralateral and ipsilateral limb, respectively. Player performance characteristics showed small declines in the first year of return that improved by the second year. CONCLUSION: MLS athletes who sustain a sports-related fifth metatarsal fracture can expect a high rate of return to sport with time to radiographic healing and return to play as well as risk of refracture similar to other professional cohorts.

Metrics of OsteoChondral Allografts (MOCA) Group Consensus Statements on the Use of Viable Osteochondral Allograft.

BACKGROUND: Osteochondral allograft (OCA) transplantation has evolved into a first-line treatment for large chondral and osteochondral defects, aided by advancements in storage protocols and a growing body of clinical evidence supporting successful clinical outcomes and long-term survivorship. Despite the body of literature supporting OCAs, there still remains controversy and debate in the surgical application of OCA, especially where high-level evidence is lacking. PURPOSE: To develop consensus among an expert group with extensive clinical and scientific experience in OCA, addressing controversies in the treatment of chondral and osteochondral defects with OCA transplantation. STUDY DESIGN: Consensus statement. METHODS: A focus group of clinical experts on OCA cartilage restoration participated in a 3-round modified Delphi process to generate a list of statements and establish consensus. Questions and statements were initially developed on specific topics that lack scientific evidence and lead to debate and controversy in the clinical community. In-person discussion occurred where statements were not agreed on after 2 rounds of voting. After final voting, the percentage of agreement and level of consensus were characterized. A systematic literature review was performed, and the level of evidence and grade were established for each statement. RESULTS: Seventeen statements spanning surgical technique, graft matching, indications, and rehabilitation reached consensus after the final round of voting. Of the 17 statements that reached consensus, 11 received unanimous (100%) agreement, and 6 received strong (80%-99%) agreement. CONCLUSION: The outcomes of this study led to the establishment of consensus statements that provide guidance on surgical and perioperative management of OCAs. The findings also provided insights on topics requiring more research or high-quality studies to further establish consensus and provide stronger evidence.

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.

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.

Retroarticular Core Decompression with Biologic Augmentation for Juvenile Osteochondritis Dissecans of the Knee.

Juvenile osteochondritis dissecans (OCD) of the knee is a rare condition of subchondral bone that has secondary effects on articular cartilage as the condition advances. Traditional treatment for early-stage OCD involves different types of drilling procedures that work to stimulate healthy bone formation via creeping substitution. This article describes a technique that involves a complete removal, or decompression of an early-stage OCD, while preserving the overlying articular cartilage that is augmented with bone grafting and bone marrow aspirate concentrate. This allows for quicker and more reliable healing of early-stage OCD and can minimize the chance for reoperation.

Ethical and Practical Considerations for Integrating Cellular ("Stem Cell") Therapy into Clinical Practice.

PURPOSE OF REVIEW: Cellular therapies, also known as "stem cell" interventions (SCI), have undergone a rapid popularization in the USA and worldwide. The current review aimed at outlining (1) the ethical challenges facing the implementation of SCI; (2) the applicability of the currently available SCI; and (3) recommendations to achieve ethical, well-regulated incorporation of SCI in the clinical setting. RECENT FINDINGS: Concerns regarding the inadequate characterization, poor adverse effects disclosure, and unorthodox, often inappropriate, market practices have engendered a genuine concern regarding the SCI compliance with ethical standards. Six instances of litigation on the basis of misrepresentation or inappropriate informed consent were recorded between 2012 and 2018. Such concerns have been furthered by the loopholes in the regulatory aspect governing the use of SCI coupled with the unclear literature-reported efficacy and diverse spectrum of profess indications. Similarly, the application of SCI in the clinical field is yet to prove its value. The uncertain efficacy, coupled with obscure true-costs of utilization, impedes a value-based assessment. A multidisciplinary approach involving legislative and medical professional societies should continue to advance regulations that govern SCI. A well-regulated system that allows for the ethical integration of SCI with appositely evidenced-based described benefits and risks should be sought.

An Expert Consensus Statement on the Management of Large Chondral and Osteochondral Defects in the Patellofemoral Joint.

BACKGROUND: Cartilage lesions of the patellofemoral joint constitute a frequent abnormality. Patellofemoral conditions are challenging to treat because of complex biomechanics and morphology. PURPOSE: To develop a consensus statement on the functional anatomy, indications, donor graft considerations, surgical treatment, and rehabilitation for the management of large chondral and osteochondral defects in the patellofemoral joint using a modified Delphi technique. STUDY DESIGN: Consensus statement. METHODS: A working group of 4 persons generated a list of statements related to the functional anatomy, indications, donor graft considerations, surgical treatment, and rehabilitation for the management of large chondral and osteochondral defects in the patellofemoral joint to form the basis of an initial survey for rating by a group of experts. The Metrics of Osteochondral Allografts (MOCA) expert group (composed of 28 high-volume cartilage experts) was surveyed on 3 occasions to establish a consensus on the statements. In addition to assessing agreement for each included statement, experts were invited to propose additional statements for inclusion or to suggest modifications of existing statements with each round. Predefined criteria were used to refine statement lists after each survey round. Statements reaching a consensus in round 3 were included within the final consensus document. RESULTS: A total of 28 experts (100% response rate) completed 3 rounds of surveys. After 3 rounds, 36 statements achieved a consensus, with over 75% agreement and less than 20% disagreement. A consensus was reached in 100.00% of the statements relating to functional anatomy of the patellofemoral joint, 88.24% relating to surgical indications, 100.00% relating to surgical technical aspects, and 100.00% relating to rehabilitation, with an overall consensus of 95.5%. CONCLUSION: This study established a strong expert consensus document relating to the functional anatomy, surgical indications, donor graft considerations for osteochondral allografts, surgical technical aspects, and rehabilitation concepts for the management of large chondral and osteochondral defects in the patellofemoral joint. Further research is required to clinically validate the established consensus statements and better understand the precise indications for surgery as well as which techniques and graft processing/preparation methods should be used based on patient- and lesion-specific factors.

Rogue stem cell clinics.

Cell therapies hold significant promise for the treatment of injured or diseased musculoskeletal tissues. However, despite advances in research, there is growing concern about the increasing number of clinical centres around the world that are making unwarranted claims or are performing risky biological procedures. Such providers have been known to recommend, prescribe, or deliver so called 'stem cell' preparations without sufficient data to support their true content and efficacy. In this annotation, we outline the current environment of stem cell-based treatments and the strategies of marketing directly to consumers. We also outline the difficulties in the regulation of these clinics and make recommendations for best practice and the identification and reporting of illegitimate providers. Cite this article: Bone Joint J 2020;102-B(2):148-154.

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.

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.

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.

Implementation of the FIFA 11+ Injury Prevention Program by High School Athletic Teams Did Not Reduce Lower Extremity Injuries: A Cluster Randomized Controlled Trial.

BACKGROUND: Lower extremity injuries are common in high school sports and are costly, and some have poor outcomes. The FIFA 11+ injury prevention program has been shown to decrease injuries in elite athletes by up to 72%. HYPOTHESIS: High schools in which coaches implement the FIFA 11+ injury prevention program in their athletic programs will have a decreased incidence of lower extremity injuries compared with schools using their usual prepractice warm-up. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: Fourteen high schools that employed an athletic trainer were randomly assigned to either the FIFA 11+ group or control group (usual warm-up routine). Exposure to sports and injuries were recorded and used to determine the incidence rates of lower extremity injuries per athlete-exposure (AE). The FIFA 11+ program was implemented by coaches and complicance with the program recorded. RESULTS: There were 196 lower extremity injuries among 1825 athletes in the FIFA 11+ group and 172 injuries among 1786 athletes in the control group (1.59 and 1.47 injuries per 1000 AEs, respectively; P = .771). The distribution of the types of injury in the 2 groups did not differ, but the body locations where the injuries occurred differed somewhat (P = .051). The FIFA 11+ group had larger proportions of thigh and foot injuries, while the control group had higher proportions of knee and ankle injuries. Group differences in injury rates varied with sport (P = .041 for interaction), but there were no significant differences in injury rates between the FIFA 11+ and control groups by sport, level of play, and sex. In the FIFA 11+ group, 62% of the coaches reported that their teams completed the full FIFA 11+ program at least once a week, and 32% reported that they completed it at least twice a week. CONCLUSION: This study did not demonstrate a reduction in lower extremity injuries in schools randomized to use the FIFA 11+ program compared with schools using their usual prepractice warm-up program. Coach-reported compliance with performing the FIFA 11+ program at least twice a week was low.