Heterotopic Ossification and Platelet-Rich Plasma in Core Muscle Injuries: A Single-Institution Experience Over 6 Years.

BACKGROUND: A 2015 study of platelet-rich plasma (PRP) for groin injuries in National Football League (NFL) players alerted the authors to the possibility that PRP is associated with heterotopic ossification (HO). The current study of athletes seen between 2014 and 2019 provides a more comprehensive analysis of that observation. PURPOSE/HYPOTHESIS: This report describes the early results of groin surgery for athletes who had experienced failed PRP therapy performed by different practitioners and with an assortment of PRP techniques. The primary goal of this cohort study was to determine short-term clinical outcomes after surgery of PRP-treated patients. It was hypothesized that previous PRP treatment would be associated with the presence of HO among patients with core muscle injuries (CMIs). STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: All athletes seen at 1 institution and identified at their first visit as having received PRP for a CMI were followed and compared with patients with a CMI who had not previously received PRP. Although in many cases HO was observed on clinical examination or imaging, HO was identified intraoperatively in all surgical cases and confirmed pathologically. Successful surgery was defined as return to play at previously high levels of performance or greater as determined by the athletes' own assessments. All patients who had received PRP were followed for ≥2 years. RESULTS: Among 3642 patients with a new CMI seen between 2014 and 2019, 68 (1.9%) patients developed HO within the core muscles and/or adjacent soft tissues. Of the 68 patients, 60 (88.2%) were men, and the mean age was 34.5 years. Of the 68 patients, 62 (91.2%) were athletes and 44 (64.7%) had been treated previously with PRP. HO was observed in 24 (0.7%) patients without previous PRP treatment. Three athletes who received PRP retired early from sports because of HO and scar issues. In total, 22 of 28 (78.6%) NFL players who received PRP developed HO, compared with 0 (0%) of 28 randomly selected, age-, position-, and injury-matched NFL players. After surgical repair, 3-month success rates were 67.9% and 96.4%, respectively, in the PRP and non-PRP groups (P = .006). By 6 months postoperatively, PRP-treated patients were back to similarly high success rates compared with the non-PRP cohort. Scar tissue issues played a prominent role in the relative delay in definitive success. CONCLUSION: The present, more comprehensive study confirms the previous preliminary analysis that treating CMIs with PRP may be associated with HO.

Postoperative MR Imaging of the Pubic Symphysis and Athletic Pubalgia.

MR imaging evaluation can be valuable in patients with prior surgery for athletic pubalgia presenting with new, recurrent, or persistent groin pain. The clinical and interventional history as well as comparison with preoperative imaging is essential for imaging interpretation. Imagers should be aware of expected and unexpected postoperative findings. MR imaging findings concerning for infection, new injury, contralateral injury, or concomitant sources of symptoms (such as hip pathology) should be reported when present.

Ultrasound-guided Procedures Allow Delay of Definitive Treatment for Core Muscle Injuries.

INTRODUCTION: Core muscle injuries (CMI) are common in every sport. To minimize lost playing time, providers apply various nonsurgical treatments, including platelet-rich plasma, corticosteroids, ultrasound (US)-guided percutaneous tenotomy, and prolotherapy. Limited data exist with regard to their effectiveness. We chose to review a cohort of consecutive professional and collegiate athletes who sustained CMI at various points within their seasons and underwent a combination of US-guided percutaneous needle "tenotomy" and corticosteroid injections to complete the remainder of their seasons. METHODS: Twenty-five consecutive collegiate or professional athletes with CMI involving the rectus abdominis-adductor aponeurotic plate were included in this retrospective study. Athletes with concomitant symptomatic hip femoroacetabular impingement were included in the study. The primary outcome measure was whether athletes completed their seasons. Secondary measures were weeks played after the procedures (delay until surgery), need for repeat procedures, and outcomes after eventual surgery. Postoperative performance was assessed via interviews at 6 wk and 6 months postoperatively. RESULTS: Twenty-one of 25 (84%) athletes completed their seasons. On average, athletes returned to play 3 d (range, 1-9 d) after the procedures. Surgical repair was delayed a mean of 18 wk (range, 2-44 wk). Seven athletes had concomitant symptomatic femoroacetabular impingement and six underwent combined hip arthroscopy and core muscle repairs. Among 17 patients who eventually had core muscle surgery alone (no hip surgery), 82% (14 of 17) reported performing at their preinjury level at 6 wk. At 6 months, 96% of postop athletes (22 of 23) reported performing at their preinjury level. CONCLUSIONS: Temporizing CMI with US-guided percutaneous tenotomy and corticosteroid injections is effective in allowing continued sport participation among high-level athletes and does not negatively affect postoperative outcomes.

Imaging of the Pelvis and Lower Extremity: Demystifying Uncommon Sources of Pelvic Pain.

Pelvic pain can result from gastrointestinal, gynecologic, urologic, neurologic, and musculoskeletal sources. This article focuses on the musculoskeletal lesions that contribute to acute and chronic pain throughout the musculoskeletal core. Armed with an understanding of musculoskeletal core anatomy and biomechanics, imagers play an integral role in the accurate diagnosis and treatment planning for patients with pain and dysfunction from pelvic sources. MR imaging is the primary imaging modality used, but focused sonographic and radiographic techniques have a role. Ultimately, radiologists can help guide patients to the most appropriate subspecialty clinicians based on the underlying source of symptoms.

Core Muscle Injuries in Athletes.

Lower abdominal and groin injuries are among the most common causes of pain and lost playing time in sports. Perhaps the most important obstacle in understanding these injuries is the lack of consensus on nomenclature. There have been numerous advances in recent years in the understanding, prevention, diagnosis, and treatment of these injuries. The purpose of this review is to provide a general perspective on the current understanding of these injuries and a summary of recent advances.

Editorial Commentary: Core Muscle Injuries or Athletic Pubalgia-Finally the Real Sausage, Not Just the Same Ole Baloney.

In their paper "Prevalence of Surgical Repair for Athletic Pubalgia and Impact on Performance in Football Athletes Participating in the National Football League Combine," Knapik et al. cut through the baloney in the literature on "sports hernia" and apply new eyes to the impact of the results of core muscle surgery on young elite athletes trying out for the National Football League (NFL). They found that the players who had surgery did just as well as all the others in and following NFL Combines. Even the players with presumptively residual, MRI findings did well. The paper is superb and identifies, in subtle ways, the importance of magnetic resonance imaging, as well as the role of experience in diagnosing and handling these injuries. The paper is a case control series that extracts tremendous beneficial information for sports physicians, athletic trainers, management, agents, players, and all of us Sunday afternoon, TV-watching football experts.

WHipple-ABACUS, a simple, validated risk score for 30-day mortality after pancreaticoduodenectomy developed using the ACS-NSQIP database.

BACKGROUND: Pancreaticoduodenectomy needs simple, validated risk models to better identify 30-day mortality. The goal of this study is to develop a simple risk score to predict 30-day mortality after pancreaticoduodenectomy. METHODS: We reviewed cases of pancreaticoduodenectomy from 2005-2012 in the American College of Surgeons-National Surgical Quality Improvement Program databases. Logistic regression was used to identify preoperative risk factors for morbidity and mortality from a development cohort. Scores were created using weighted beta coefficients, and predictive accuracy was assessed on the validation cohort using receiver operator characteristic curves and measuring area under the curve. RESULTS: The 30-day mortality rate was 2.7% for patients who underwent pancreaticoduodenectomy (n = 14,993). We identified 8 independent risk factors. The score created from weighted beta coefficients had an area under the curve of 0.71 (95% confidence interval, 0.66-0.77) on the validation cohort. Using the score WHipple-ABACUS (hypertension With medication + History of cardiac surgery + Age >62 + 2 × Bleeding disorder + Albumin <3.5 g/dL + 2 × disseminated Cancer + 2 × Use of steroids + 2 × Systemic inflammatory response syndrome), mortality rates increase with increasing score (P < .001). CONCLUSION: While other risk scores exist for 30-day mortality after pancreaticoduodenectomy, we present a simple, validated score developed using exclusively preoperative predictors surgeons could use to identify patients at risk for this procedure.

Ultrasound-guided Interventions for Core and Hip Injuries in Athletes.

Trauma and the mechanical strain of high-energy activity predispose athletes to pelvic injuries. Magnetic resonance imaging remains the primary modality for diagnosing these conditions, but ultrasonography-guided interventions are important in the management of core muscle, hip, and other pelvic conditions. This article reviews ultrasonography-guided interventions for injuries at the core, including the pelvis and hips. It reviews common injuries, procedure optimization, medication preparation, clinical evidence behind injections, tenotomy, and platelet-rich plasma. These interventions are especially important in athletes, because ultrasonography-guided procedures are often undertaken early in the treatment process, paralleling conservative rehabilitation to facilitate a faster return to play.

Doha agreement meeting on terminology and definitions in groin pain in athletes.

BACKGROUND: Heterogeneous taxonomy of groin injuries in athletes adds confusion to this complicated area. AIM: The 'Doha agreement meeting on terminology and definitions in groin pain in athletes' was convened to attempt to resolve this problem. Our aim was to agree on a standard terminology, along with accompanying definitions. METHODS: A one-day agreement meeting was held on 4 November 2014. Twenty-four international experts from 14 different countries participated. Systematic reviews were performed to give an up-to-date synthesis of the current evidence on major topics concerning groin pain in athletes. All members participated in a Delphi questionnaire prior to the meeting. RESULTS: Unanimous agreement was reached on the following terminology. The classification system has three major subheadings of groin pain in athletes: 1. Defined clinical entities for groin pain: Adductor-related, iliopsoas-related, inguinal-related and pubic-related groin pain. 2. Hip-related groin pain. 3. Other causes of groin pain in athletes. The definitions are included in this paper. CONCLUSIONS: The Doha agreement meeting on terminology and definitions in groin pain in athletes reached a consensus on a clinically based taxonomy using three major categories. These definitions and terminology are based on history and physical examination to categorise athletes, making it simple and suitable for both clinical practice and research.

Imaging of athletic pubalgia and core muscle injuries: clinical and therapeutic correlations.

Athletes frequently injure their hips and core muscles. Accurate diagnosis and proper treatment of groin pain in the athlete can be tricky, frequently posing vexing problem for trainers and physicians. Clinical presentations of the various hip problems overlap with respect to history and physical examination. This article reviews clinical presentations and magnetic resonance imaging findings specific to the various causes of groin pain in the athlete. The focus is on the core muscle injuries (athletic pubalgia or "sports hernia"). The goal is to raise awareness about the variety of injuries that occur and therapeutic options.

Magnetic resonance imaging of athletic pubalgia and the sports hernia: current understanding and practice.

Magnetic resonance imaging (MRI) has become the standard imaging modality for activity-related groin pain. Lesions, including rectus abdominis/adductor aponeurosis injury and osteitis pubis, can be accurately identified and delineated in patients with clinical conditions termed athletic pubalgia, core injury, and sports hernia. A dedicated noncontrast athletic pubalgia MRI protocol is easy to implement and should be available at musculoskeletal MR imaging centers. This article will review pubic anatomy, imaging considerations, specific lesions, and common MRI findings encountered in the setting of musculoskeletal groin pain.

High incidence of athletic pubalgia symptoms in professional athletes with symptomatic femoroacetabular impingement.

PURPOSE: The purpose of this study was to identify the incidence of symptoms consistent with athletic pubalgia (AP) in athletes requiring surgical treatment for femoroacetabular impingement (FAI) and the frequency of surgical treatment of both AP and FAI in this group of patients. METHODS: Thirty-eight consecutive professional athletes, with a mean age of 31 years, underwent arthroscopic surgery for symptomatic FAI that limited their ability to play competitively. In all cases a cam and/or focal rim osteoplasty with labral refixation or debridement was performed. In 1 case concomitant intramuscular lengthening of the psoas was performed. Retrospective data regarding prior AP surgery and return to play were collected. RESULTS: Thirty-two percent of patients had previously undergone AP surgery, and 1 patient underwent AP surgery concomitantly with surgical treatment of FAI. No patient returned to his previous level of competition after isolated AP surgery. Thirty-nine percent had AP symptoms that resolved with FAI surgery alone. Of the 38 patients, 36 returned to their previous level of play; all 12 patients with combined AP and FAI surgery returned to professional competition. The mean duration before return to play was 5.9 months (range, 3 to 9 months) after arthroscopic surgery. CONCLUSIONS: There is a high incidence of symptoms of AP in professional athletes with FAI of the hip. This study draws attention to the overlap of these 2 diagnoses and highlights the importance of exercising caution in diagnosing AP in a patient with FAI. LEVEL OF EVIDENCE: Level IV, therapeutic, retrospective case series.

Review of MRI technique and imaging findings in athletic pubalgia and the "sports hernia".

The clinical syndrome of athletic pubalgia has prematurely ended many promising athletic careers, has made many active, fitness conscious adults more sedentary, and has served as a diagnostic and therapeutic conundrum for innumerable trainers and physicians worldwide for decades. This diagnosis actually arises from one or more lesions within a spectrum of musculoskeletal and visceral injuries. In recent years, MRI has helped define many of these syndromes, and has proven to be both sensitive and specific for numerous potential causes of athletic pubalgia. This text will provide a comprehensive, up to date review of expected and sometimes unexpected MRI findings in the setting of athletic pubalgia, and will delineate an imaging algorithm and MRI protocol to help guide radiologists and other clinicians dealing with refractory, activity related groin pain in an otherwise young, healthy patient. There is still more to be learned about prevention and treatment plans for athletic pubalgia lesions, but accurate diagnosis should be much less nebulous and difficult with the use of MRI as a primary imaging modality.

Magnetic resonance imaging for pain after surgical treatment for athletic pubalgia and the "sports hernia".

Magnetic resonance (MR) imaging technique and findings in the setting of athletic pubalgia, including injury at the rectus abdominis/adductor aponeurosis, are becoming widely recognized. A subset of these patients is treated with various pelvic floor repairs, mesh reinforcements, and tendon releases. Most of these patients do well after intervention, but some have persistent or refractory groin pain, and others eventually develop new injuries in the pubic region or elsewhere about the pelvic girdle. This review describes the expected and some unexpected MRI findings in patients with recurrent or persistent groin pain after a "sports hernia" repair.

Current analysis of women athletes with pelvic pain.

BACKGROUND AND METHODS: Accurate diagnosis and effective management of pelvic pain in women have become more challenging now that the number of women athletes and the number of diagnostic possibilities are increasing. We conducted a prospective study of women athletes with pelvic pain seen during a 2-yr period within a large well-defined clinical practice to clarify some of the current causes and treatment possibilities. RESULTS: One hundred fourteen females, 14% of the total male/female cohort, were referred for treatment of suspected musculoskeletal injury. On the basis of history and physical and radiological examinations, 74 (64.9% of females) turned out to have injuries of the hip (group A) and/or soft tissues surrounding the hip (group B), and 40 (35.1%) had other sometimes more threatening diagnoses. In groups A and B, 40 (90.1%) of 44 patients who chose surgery achieved previous performance levels within 1 yr compared with only 4 (13.8%) of 29 who did not have surgery. Factors such as sport type, competitive status, and age did not affect the outcomes. Most diagnoses in group C, e.g., inflammatory bowel disease, reflex sympathetic dystrophy, and malignancy, usually eclipsed the potential musculoskeletal diagnoses in terms of long-term importance. CONCLUSIONS: In this series of patients, most pelvic pain in women athletes was identifiable and treatable. Most had benign musculoskeletal causes, and surgery played an important role in treatment of those causes. Still, we found a large number of other causes that required longer specialized care. Health care professionals seeing such patients need to be alert to the new concepts of pelvic injury and the various roles for surgery and the broad list of other considerations.

The spectrum of MR imaging in athletic pubalgia.

Many athletes struggle with groin pain for years without ever receiving a clear diagnosis or being offered an effective treatment plan. Confusion among treatment providers can also frequently lead to suboptimal surgeries for presumed hernias or nerve entrapment syndromes. Imaging, and in particular magnetic resonance (MR) imaging, should play a primary role in the workup, diagnosis, and treatment of athletic pubalgia. This review outlines standard of care, cutting-edge MR imaging techniques for athletic pubalgia, and reviews the spectrum of imaging findings that are encountered in this patient group.

Gender differences in cholesterol nucleation in native bile: estrogen is a potential contributory factor.

The incidence of gallstone disease is two to three times higher in women than in men, and female sex hormones, particularly estrogens, have been implicated as contributory factors. Cholesterol nucleation is the initial step in gallstone pathogenesis and proceeds from cholesterol-rich phospholipid vesicles. The aim of this study was to investigate if there is a difference in cholesterol nucleation rates in male and female bile and whether estrogen influences nucleation rates by interacting with cholesterol-rich regions known as "lipid rafts" that exist within the cholesterol-phospholipid vesicles of the bile. Cholesterol nucleation from native prairie dog bile and the interaction of estrogens with lipid rafts in model bile solutions were investigated using Förster resonance energy transfer (FRET). Female native bile samples showed a greater reduction in energy transfer than did male native bile, indicating that cholesterol nucleation occurred more readily in female bile than in male bile. Model bile experiments demonstrated that the addition of estrogen has a significant effect, either cholesterol nucleation or raft disruption, but only in samples containing cholesterol-rich rafts. These results suggest that estrogen interacts with cholesterol-rich rafts in vesicles within bile to promote cholesterol nucleation and predispose females to gallstone formation.

Experience with "sports hernia" spanning two decades.

OBJECTIVE AND BACKGROUND: Athletic pubalgia (AP) is a leading cause of athlete loss from competitive sports. Commonly misnamed "sports hernia," AP is a set of pelvic injuries involving the abdominal and pelvic musculature outside the ball-and-socket hip joint and on both sides of the pubic symphysis. Prospective studies show that timely intervention and appropriate repair of selected injuries results in greater than 95% success. METHODS: The senior author reviewed his experience with 8,490 patients and 5,460 operations, looking primarily at the changes in patient characteristics over the last 2 decades and at some of the advances. RESULTS: Female proportion, age, numbers of sports, and soft tissue structures involved have all increased as have the number of syndromes identified and number of operations. MRI has improved greatly for both the diagnosis of hip and nonhip pathology in the pelvis. Increased understanding has led also to new rehabilitation and performance protocols. CONCLUSIONS: Better understanding and recognition of the injuries has led to more satisfactory care and returned many athletes to successful careers, which has had a major impact on modern sport.

Athletic pubalgia and "sports hernia": optimal MR imaging technique and findings.

Groin injuries are common in athletes who participate in sports that require twisting at the waist, sudden and sharp changes in direction, and side-to-side ambulation. Such injuries frequently lead to debilitating pain and lost playing time, and they may be difficult to diagnose. Diagnostic confusion often arises from the complex anatomy and biomechanics of the pubic symphysis region, the large number of potential sources of groin pain, and the similarity of symptoms in athletes with different types or sites of injury. Many athletes with a diagnosis of "sports hernia" or "athletic pubalgia" have a spectrum of related pathologic conditions resulting from musculotendinous injuries and subsequent instability of the pubic symphysis without any finding of inguinal hernia at physical examination. The actual causal mechanisms of athletic pubalgia are poorly understood, and imaging studies have been deemed inadequate or unhelpful for clarification. However, a large-field-of-view magnetic resonance (MR) imaging survey of the pelvis, combined with high-resolution MR imaging of the pubic symphysis, is an excellent means of assessing various causes of athletic pubalgia, providing information about the location of injury, and delineating the severity of disease. Familiarity with the pubic anatomy and with MR imaging findings in athletic pubalgia and in other confounding causes of groin pain allows accurate imaging-based diagnoses and helps in planning treatment that targets specific pathologic conditions.

Comparison of four different immunosuppression protocols without long-term steroid therapy in kidney recipients monitored by surveillance biopsy: five-year outcomes.

Induction and maintenance immunosuppression protocols with or without long-term steroid therapy in kidney transplant recipients are variable and are transplant center-specific. The aim of this prospective randomized pilot study was to compare 5-year outcomes in kidney recipients maintained on 4 different calcineurin inhibitor (CNI)-based immunosuppression protocols without long-term steroid therapy. Two hundred consenting patients who received kidney transplants between June 2000 and October 2004 were enrolled in 4 immunosuppression protocol groups, with 50 patients in each group: cyclosporine (CSA)/mycophenolate mofetil (MMF), CSA/sirolimus (SRL), tacrolimus (TAC)/MMF, and TAC/SRL. Induction therapy was done with basiliximab and methylprednisolone. Steroids were withdrawn on post-transplant day 2, and long-term steroid therapy was not used. Demographic characteristics among the four groups were comparable; approximately 50% of the recipients were African American and > or =80% of the kidneys transplanted were from deceased donors. Clinical acute rejection (CAR) was confirmed by biopsy and treated with intravenous pulse steroid therapy. Steroid-unresponsive CAR was treated with Thymoglobulin. Surveillance biopsies were performed at 1, 6, 12, 24, 36, 48, and 60 months to evaluate subclinical acute rejection (SCAR), chronic allograft injury (CAI), and other pathological changes per the Banff 2005 schema. The primary end point was CAR, and secondary end points were 5-year patient and graft survival rates, renal function, SCAR, CAI, and adverse events. In the first year post-transplant, the incidence of CAR was 18% in the CSA/MMF group, 8% in the CSA/SRL group, 14% in the TAC/MMF group, and 4% in the TAC/SRL group (CSA/MMF vs. TAC/SRL; p=0.05). The incidence of SCAR was 22% in the CSA/MMF group, 8% in the CSA/SRL group, 16% in the TAC/MMF group, and 6% in the TAC/SRL group (CSA/MMF vs. CSA/SRL and TAC/SRL; p=0.05). After the first year, the incidences of CAR and SCAR decreased and were comparable in all 4 groups. At 5 years post-transplant, cumulative CAI due to interstitial fibrosis/tubular atrophy (IF/TA), hypertension (HTN), and chronic calcineurin inhibitor (CNI) toxicity was observed in 54%, 48%, and 8% of the CSA/MMF group vs. 16%, 36%, and 12% of the CSA/SRL group vs. 38%, 24% and 6% of the TAC/MMF group vs. 14%, 25% and 12% of the TAC/SLR group (IF/TA: CSA/MMF vs. CSA/SRL and TAC/SRL; p=0.04, HTN: CSA/MMF vs. TAC/MMF and TAC/SRL; p=0.05, CNI toxicity: TAC/SRL and CSA/SRL vs. TAC/MMF; p=0.05). Five-year patient and graft survival rates were 82% and 60% in the CSA/MMF group, 82% and 60% in the CSA/SRL group, 84% and 62% in the TAC/MMF group, and 82% and 64% in the TAC/SRL group (p=0.9). Serum creatinine levels and creatinine clearances at 5 years were comparable among the groups. Our data show that the rates of CAR and SCAR in the first year post-transplant were significantly lower in the CSA/SRL and TAC/SRL groups and that cumulative CAI rates due to IF/TA and HTN at 5 years were significantly lower in the TAC/MMF, TAC/SRL, and CSA/SRL groups than in the CSA/MMF group. Despite significant differences in the incidences of CAR and SCAR and prevalence of different types of CAI at 5 years, renal function and patient and graft survival rates at 5 years were comparable among kidney recipients maintained on 4 different immunosuppression protocols without long-term steroid therapy.