Low Femoral Tunnel Widening Incidence Rate After ACL Reconstruction Using Patellar Tendon Graft with Press-Fit Fixation.

Background: Femoral tunnel widening after ACL reconstruction is a common phenomenon. We hypothesized that using a patellar tendon graft with a press-fit fixation technique without any fixation device reduces the incidence of femoral tunnel widening. Methods: This study was conducted on 467 patients with ACL surgery between 2003 and 2015. Two hundred and nineteen of them had an ACL surgery with patellar tendon (PT) graft, and two hundred and forty-eight of them with hamstring tendon (HS). Exclusion criteria were history of previous ACL reconstruction of either knee, multiple ligament injury, or evidence of osteoarthritis on radiographs. The femoral tunnels were measured on the anteroposterior (ap) and lateral radiographs 6 months after the operation. Two independent orthopedic surgeons measured all radiographs twice and recorded the tunnel widenings. We hypothesized that using an implant-free press-fit technique with PT graft can reduce the femoral tunnel widening incidence rate. Results: The mean incidence rate of the tunnel widening in the HS group was, on the AP and the lateral femoral views, 88% (n = 217) and 83% (n = 205), while in the PT group, 17% (n = 37) and 2% (n = 4), respectively. There was a significant difference both on AP and lateral radiographs (HS vs. PT: fem. AP: 89% vs. 17% p < 0.001; HS vs. PT: fem. lat: 84% vs. 2% p < 0.001). Conclusion: The femoral tunnel widening incidence rate during an ACL reconstruction is significantly less when using PT tendon with femoral press-fit fixation than when using HT tendon with suspensory fixation method.

Short and mid-term characteristics of COVID-19 disease course in athletes: A high-volume, single-center study.

INTRODUCTION: At the pandemic's beginning, significant concern has risen about the prevalence of myocardial involvement after SARS-CoV-2 infection. We assessed the cardiovascular burden of SARS-CoV-2 in a large cohort of athletes and identified factors that might affect the disease course. We included 633 athletes in our study on whom we performed extensive cardiology examinations after recovering from SARS-CoV-2 infection. More than half of the athletes (n = 322) returned for a follow-up examination median of 107 days after the commencement of their infection. RESULTS: Troponin T positivity was as low as 1.4% of the athletes, where the subsequently performed examinations did not show definitive, ongoing myocardial injury. Altogether, 31% of the athletes' rapid training rebuild was hindered by persistent or reoccurring symptoms. Female athletes reported a higher prevalence of return to play (RTP) symptoms than their male counterparts (34% vs. 19%, p = 0.005). The development of long COVID symptoms was independently predicted by increasing age and acute symptoms' severity in a multiple regression model (AUC 0.75, CI 0.685-0.801). Athletes presenting with either or both cough and ferritin levels higher than >150 µg/L had a 4.1x (CI 1.78-9.6, p = 0.001) higher odds ratio of developing persistent symptoms. CONCLUSION: While SARS-CoV-2 rarely affects the myocardium in athletes, about one in three of them experience symptoms beyond the acute phase. Identifying those athletes with a predisposition to developing long-standing symptoms may aid clinicians and trainers in finding the optimal return-to-play timing and training load rebuild pace.

A Case Series of SARS-CoV-2 Reinfection in Elite Athletes.

OBJECTIVES: The actual frequency and the risk factors of SARS-CoV-2 reinfection is still a matter of intense scientific discussion. In this case series, we report three elite athletes who underwent COVID-19 reinfection with a short time frame. CASE PRESENTATIONS: As a part of contact tracing, three speed skaters (22-, 24-, and 29-year-old males) were found to be SARS-CoV-2 positive by polymerase chain reaction (PCR) tests. Later on, only one of the athletes experienced mild symptoms, such as fatigue, loss of smell and taste and subfebrility, while the other two athletes were asymptomatic. Following the quarantine period, detailed return-to-play examinations, including laboratory testing, ECG, 24-h Holter monitoring, transthoracic echocardiography and cardiac magnetic resonance imaging, revealed no apparent abnormality; therefore, the athletes restarted training. After a median of 74 days, all three athletes presented with typical symptoms of COVID-19, such as fever, marked fatigue and headache. SARS-CoV-2 PCR tests were performed again, showing recurrent positivity. Repeated return-to-play assessments were initiated, finding no relevant abnormality. Athletes were also tested for SARS-CoV-2 anti-nucleoprotein antibody titers, showing only modest increases following the second infection. CONCLUSIONS: We report a small cluster of elite athletes who underwent a PCR-proven SARS-CoV-2 reinfection. According to these findings, athletes may be considered as a high-risk group in terms of recurrent COVID-19.

Outcomes After Arthroscopic Anterior Shoulder Stabilization in Professional Handball Players.

BACKGROUND: Although numerous studies have reported on the redislocation rate and functional results of arthroscopic treatment for anterior shoulder instability in athletes, they have not disclosed outcomes in the high-risk group of elite handball players. PURPOSE: To investigate the postoperative outcomes of arthroscopic treatment for anterior shoulder instability as well as the return-to-sport (RTS) rate in professional handball players. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Involved in this study were 44 competitive handball players (47 shoulders) who underwent arthroscopic anterior capsulolabral reconstruction between 2010 and 2018 and had a minimum follow-up of 24 months. After surgery, patients completed a questionnaire that collected Rowe and American Shoulder and Elbow Surgeons (ASES) scores and RTS data, and we compared these results with their preoperative scores. We also compared results according to the following subgroups: true dislocations versus recurrent subluxations, younger (<20 years) versus older (≥20 years) age, male versus female sex, and shorter versus longer duration of instability. Statistical analysis included the paired-samples t test and nonparametric Fisher exact test. RESULTS: The mean follow-up period was 52.2 ± 21.4 months. There were 4 shoulders (9%) with recurrent instability. There were significant preoperative to postoperative improvements in the mean Rowe score (from 45.2 to 91.8) and mean ASES score (from 70.6 to 95.7) (P < .001 for both). Overall, the RTS rate was 83%, and 64% (30/47 shoulders) were able to return to their preinjury level. The RTS rate was significantly lower in the younger players than in the older players (46% vs 86%, respectively; P = .005). CONCLUSION: The study results indicated that handball players with anterior shoulder instability can be treated using arthroscopic labral reconstruction successfully and 83% of the athletes were able to RTS activity. The handball players aged ≥20 years returned to their preinjury level of sport at a higher rate than did those aged <20 years.

Introducing the National Institute for Sports Medicine in Hungary: a complex sports medical healthcare and screening system.

The Hungarian National Institute for Sports Medicine (NISM) was founded in 1952 to provide medical coverage for national teams, screening and periodic health evaluation (PHE) for all Hungarian athletes. The system of 'all in one and ASAP' evolved by now to a specific state-funded healthcare provider with complex sports medical and sport-related services available for athletes. The NISM created a countrywide network to make health clearance available for all athletes close to their place of residency. This centralised system guarantees the uniformity and financial independence of the network, as it is directly financed by the government and free for every competitive athlete. Thus, it leaves no chance for conflict of interest in evaluating athletes' eligibility. In 2013, NISM established an online registry for preparticipation screening and PHE. This made the registry available for sports physicians and certain data for both sports physicians and athletes themselves. Furthermore, NISM created a nationwide, centrally coordinated, out of turn care with central coordination for elite athletes nationwide. Outpatient and inpatient clinics of NISM provide sports-specific care. Most of the minimally invasive techniques used at the Department of Sports Surgery are applied only here in the country. The medical staff of NISM has special experience in Sports Medicine and sport-related conditions. All tasks are managed within the same system, within institutional frames by professionals at Sports Medicine, which guarantees institutional expertise, competence and responsibility. Our aim is to introduce the complex system, the services and the recent achievements of the Hungarian NISM.

Comparative study of the use of computer assisted navigation system for axial correction in medial unicompartmental knee arthroplasty.

The aim of our study was to compare the use of the Orthopilot Navigation system with conventional non-navigation technique for medial UKA with respect to the intraoperative mechanical limb alignment measurements and correlation with the postoperative radiological measurements. The postoperative mechanical limb alignment axes of 51 consecutive medial unicompartmental knee arthroplasty performed by a single surgeon over a 12-month period were measured. The cases were randomly assigned to two groups of which 21 cases were performed using conventional non-navigation based technique and 30 cases were performed using the Orthopilot Navigation System. Computed tomography (CT) scanogram was performed for all cases within the same hospitalization stay to assess the postoperative mechanical limb alignment. Our results showed that the non-navigated group had a more neutral mechanical axis with a narrower range compared to the navigation assisted group. The difference in the mean mechanical axis between the two groups was statistically not significant. There was poor correlation between the intraoperative navigation system measurements and the postoperative radiological measurements. In conclusion, the use of computer navigation in UKA is not as well validated as compared to TKA. We did not demonstrate any improvement in postoperative axial limb alignment measurement in using a computer navigation system compared to conventional non-navigation technique.

Living related donor allograft for revision anterior cruciate ligament reconstruction in a child: a case report.

Revision ACL reconstruction poses several challenges for the surgeon in terms of the timing of surgery and the limited graft choices. To our knowledge, there is currently no published data with regards to revision ACL reconstruction in a child. We describe the case of a 12-year-old girl who had a re-injury 4.5 months after her index primary ACL reconstruction at the age of 11 years. She sustained a repeat injury to the reconstructed knee following a road traffic accident and developed significant instability despite an intensive rehabilitation program. After careful consideration of the available graft materials--known all the advantages and disadvantages of the autografts, allografts and synthetic materials--we decided to use the patient's mother's hamstrings as a graft. The parents of our patient refused the use of allograft and synthetic materials. We discuss our management of this case, the reasons for our revision graft choice, and the theoretical disadvantages of some of the alternative graft choices available in this scenario. We believe in such cases, performing ACL revision with a donor graft of the patient's mother could be good alternative to allografts or synthetic grafts.

Anatomical study of the human anterior cruciate ligament stump's tibial insertion footprint.

The aim of this study is to define the topographical relationship of the anatomical bundles of the human anterior cruciate ligament's (ACL) stump over the tibial insertion site. Between January and April 2007, a total of 36 resected tibial plateaus were retrieved from patients who underwent total knee replacements. These samples had intact cruciate ligaments with no major osteophyte around the ACL tibial insertion footprint. The anatomical bundles of the ACL were identified and mapped, based on the topographical relationship over the tibial insertion footprint. Measurements of the dimensions of the ACL tibial footprint and tibial plateau were performed. The mean width and midsagittal depth of the tibia plateau was 78.7 +/- 6.5 and 46.4 +/- 5.0 mm, respectively. The mean width and midsagittal depth of the ACL tibial footprint was 10.3 +/- 1.9 and 19.5 +/- 2.6 mm, respectively. Out of the 36 freshly dissected ACL stumps, it was not possible to distinguish separate bundles in 14 (38.9%) cases. The average distance between the centers of the two bundles was 9.3 +/- 1.8 mm. The mean AP alignment of the tibial footprint was 89.6 degrees +/- 26.4 degrees , with a very wide range of 23 degrees -158 degrees . Of the 22 specimens with separate anatomical bundles, the alignment of the tibial footprint was AM-PL in six (27.3%), sagittal (85 degrees -95 degrees ) in five (22.7), AL-PM in nine (40.9%), and lateral-medial (L-M) in two (9.1%) cases. This study provides new information about the topographical anatomy of the ACL tibial insertion footprint. Based on gross anatomy, separate anatomical bundles of the ACL can be distinguished in 61.1% [22] of the specimens. The topographical alignment of the separate bundles is varied on a very wide range.

Femoral press-fit fixation technique in anterior cruciate ligament reconstruction using bone-patellar tendon-bone graft: a prospective clinical evaluation of 285 patients.

BACKGROUND: The security of the graft fixation is an important factor of anterior cruciate ligament reconstruction, especially in the early postoperative period. HYPOTHESIS: The femoral press-fit fixation technique is a safe, alternative technique for the fixation of the bone-patellar tendon-bone graft. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Between January 1, 1998, and June 30, 2002, 285 patients, with a mean age of 29.1 years, underwent operation and observation in our department. All patients had arthroscopic anterior cruciate ligament reconstruction using bone-patellar tendon-bone graft with femoral press-fit and tibial interference screw fixation. The mean follow-up period was 35.8 months (range, 24-77 months). During each patient's evaluation, a physical examination, a subjective evaluation, the International Knee Documentation Committee and Lysholm scores, KT-1000 arthrometer testing, and radiological evaluation were performed. The paired Student t test or chi(2) test was used for statistical analysis. RESULTS: According to the International Knee Documentation Committee score, 241 patients (85%) had good (46 normal and 195 nearly normal) results, whereas 39 patients had abnormal and 5 patients had severely abnormal overall results. The preoperative mean Lysholm score was 63.5 +/- 12.7 points. At the final examination, the mean value was 93.5 +/- 7.8 points (P < .01). One hundred ninety-seven athletes could return to their previous sports activity level, whereas 13 patients gave up their sports career. The KT-1000 arthrometer results showed a side-to-side difference of 1.91 +/- 2.1 mm at the maximum manual strength tests. CONCLUSION: The femoral press-fit fixation is an alternative fixation method for the bone-patellar tendon-bone graft and provides good stability for the anterior cruciate ligament reconstruction. The use of press-fit fixation technique avoids most interference screw or other hardware-induced complications at the femoral side.

[Femoral press-fit fixation in anterior cruciate ligament reconstruction: postoperative histological examination of bone block incorporation in pigs]. / Femoralis press-fit rögzítés elülso keresztszalag pótlás során. A csontblokk beépülésének posztoperatív szövettani vizsgálata sertéseken.

INTRODUCTION: The histological properties of the femoral press-fit fixation in anterior cruciate ligament reconstruction have not been extensively examined. The purpose of the study was to analyse the histological properties of the bone-patellar tendon graft in the bone tunnel area during the early stages of healing in an animal model. Furthermore the authors wanted to draw conclusions for the postoperative rehabilitation program on the basis of their data. MATERIAL AND METHODS: ACL reconstruction was performed in pigs using femoral press-fit fixation. After 3 and 6 weeks the incorporation of the bone block in the femur in 2 pigs was histological and radiological evaluated. RESULTS: After 3 and 6 weeks the examination showed almost similar histology on the bony side the grafts except (1) a higher amount of fibrotic tissue in-between the lamellae of the inserted patellar bone after 6 weeks, (2) the presence of direct osseous unions between the two lamellar systems and (3) thicker lamellae at the base than toward the condylar tissue. CONCLUSIONS: Concerning the progression of graft healing by histological findings our study showed, that after 6 weeks the femoral press-fit fixation appear to have good incorporation after ACL reconstruction.

[Prevalence of patellofemoral pain syndrome. Evaluation of the role of biomechanical malalignments and the role of sport activity]. / A patellofemoralis fájdalom szindróma prevalenciája. A biomechanikai tengelyeltérések es a sportaktivitás szerepének elemzése.

INTRODUCTION: Disorders around the patella are the most frequent knee complaints seen in adolescents. In the literature many intrinsic and extrinsic risk factors have been linked to Patellofemoral Pain Syndrome (PFPS), but the role of these risk factors is controversial. AIM: The goal of this study was to evaluate the prevalence of PFPS in a group of adolescents aged 12-20 years in Hungary, and to gain more information on the relationship between the biomechanical anomalies of the lower extremity and the PFPS. MATERIAL AND METHODS: In this epidemiological study the authors investigated the effect of sporting activity in the maturation of symptoms among 586 randomly selected students. Different physical examinations, anthropometric measurements, stability tests, footscan analysis were performed. RESULTS: Concerning the prevalence of this syndrome they could not find any differences between males (n = 60, 20.41%) and females (n = 61, 20.89%). The authors could not identify any statistically significant intrinsic risk factors, although changes in the Q angle may be linked to increased prevalence of PFPS. The study supports the theory of the importance of "overload", for there was a significant correlation between the prevalence of PFPS and the different levels of sporting activities (competitive, recreational and non-athletes). CONCLUSION: The authors concluded that the prevalence of PFPS among Hungarian students is 20.65%.

Development of a new activity score for the evaluation of ankle instability.

BACKGROUND: Tegner and Lysholm described their generally acknowledged activity score in 1985. It was originally tested for knee ligament injuries, but for the past 17 years it has been used for other joint evaluations as well. The development of already existing and new kinds of sports, differences between knee and ankle loading, and different injury rates provided reasons for developing an ankle-specific activity score. HYPOTHESIS: The new score should have a higher reliability, validity, and sensitivity than the Tegner score when evaluating ankle-related activity changes. STUDY DESIGN: Methodological study. METHODS: Fifty-three sports, 3 working activities, and 4 general activities were inserted into a 0-to-10 category system based on the rankings of a 7 x 2-point pre-evaluation system, followed by a direct comparison with the Tegner score and reliability, validity, and sensitivity testing on 2 different patient populations. RESULTS: In direct comparison, there is a strong overall correlation of the 2 activity-scoring systems (r = 0.7565), but the ankle activity score proved to be different from the Tegner score in the higher categories, especially in the top 4 ankle score categories (r = 0.1450). Further tests demonstrated the high reliability (1.00) of the new score. Analysis of variance proved that activity changes measured by the ankle score correspond well to the difference between the patients' subjective results and their Karlsson functional scores (P =.0119). This is not the case when we measure ankle activity changes using the knee-specific Tegner score (P =.0987). Furthermore, ankle score differences spread over a wider range (-1.18 +/- 2.12) than did Tegner score differences (-0.68 +/- 1.29), which demonstrates the higher sensitivity of the new score. CONCLUSIONS: Based on these results, the new ankle activity score could be a better complement in the complex evaluation of ankle instability.

Percutaneous Achilles tendon repair with and without endoscopic control.

One hundred and fifty six patients were treated using the modified double suture technique for percutaneous Achilles tendon repair between 1994 and 1998. Endoscopy was used in 67 cases. The first ten cases were dropped (learning curve), 57 were followed (E-group). Percutaneous suture without endoscopy was performed in 89 patients. Two could not be followed (went abroad), so this group consists of 87 patients (P-group). Mean age: E-group 37.8 (22-60) years, P-group 38.9 (20-68) years. Male-female ratio: E 49/8, P 74/13. There were 54 and 83 athletes in groups E and P respectively. Follow-up period was 12-60 months. Overall re-rupture rate was 6/144 (4.2%). Two total and 3 partial re-ruptures were in the P-group, and 1 partial was in the E-group. Fusiform thickening of the tendon (delayed healing) occurred in 4 cases in each group. The mean plantar flexion strength compared with the non-affected side was 89% in the P-group and 86% in the E-group. The length of time before returning to sports activity ranged from 4 to 6 months after surgery in both groups. Subjective results were excellent to good in 88% (P-group) and in 89% (E-group) of the cases. On the basis of the results, the percutaneous double suture technique proved to be a simple and safe method for Achilles tendon repair with or without the use of an endoscope. The re-rupture rate was lower in the endoscopic controlled group. The basic goal of the endoscopy was to control the adaptation of the tendon ends. This method yielded further operative possibilities and benefits as well.

[Femoral press-fit fixation technique in anterior cruciate ligament reconstruction. Preliminary report]. / Elülsó keresztszalag pótlás során alkalmazott femoralis press-fit rögzítés. Korai eredmények.

UNLABELLED: The authors have reported the experiences at femoral press-fit fixation technique used in anterior cruciate ligament reconstruction with bone-patellar tendon-bone autograft. Their surgical technique have been described and early results have been compared with those from anterior cruciate ligament plasties with the interference screw fixation technique during a prospective study. PATIENTS AND METHODS: 665 anterior cruciate ligament reconstructions were performed between September 1997 and August 1999 at the Department of Sports Surgery of the National Institute for Sports Medicine. 418 of them were operated on by transtibial technique using free bone--patellar tendon--bone autografts with 265 femoral press-fit and 153 interference screw fixations. 110 patients from the press-fit and 72 from the interference screw group could be followed-up (average follow-up period: 19 months). Physical examination, evaluation by International Knee Documentation Committee and Lysholm scores, radiology, and stability test by KT-1000 arthrometer were used as follow-up tests with statistical comparison. RESULTS: According to the International Knee Documentation Committee score, 77% of the patients with the interference screw and 87% of the patients from the press-fit group turned out to get to the normal or nearly normal categories. Neither the Lachman, anterior drawer and pivot shift tests, nor the results of the KT-1000 measurements have shown statistically significant difference between the two groups of patients. Mild (3-5 degrees) extension deficit has been detected at 14% of the patients with interference screw and 8% of the patients in the press-fit group. Mild (6-15 degrees) flexion deficit has been observed at 22% of the patients with interference screw and 24% of the patients from press-fit group with moderate (16-25 degrees) of flexion deficit at 4% of the patients. The subjective opinions of more than 90% of the patients were that the operation proved to be excellent or good. Based on the functional and stability data of the follow-up study, 87% of the patients operated on with femoral press-fit autograft fixation technique for their anterior cruciate ligament have shown excellent or good results. CONCLUSIONS: When compared with the interference screw technique well-accepted in the literature, no statistically significant difference could be found, therefore this method can be recommended as alternative one for the femoral fixation of the anterior cruciate ligament graft.