Injury in Starting and Replacement Players from Five Professional Men's Rugby Unions.

OBJECTIVES: The aim of this study was to compare the incidence, severity, and burden of injury in starting and replacement players from professional men's teams of five rugby unions. METHODS: Match injuries of greater than 24 h time-loss (including data on the severity, match quarter, event, body region) and player minutes of match exposure data were collated for all starting and replacement players in the men's English Premiership, Welsh Pro14 (both 2016/17-2018/19 seasons), and Australian, New Zealand, and South African Super Rugby (all 2016-2018 seasons) teams. Injury incidences and mean injury burden (incidence × days missed) were calculated, and rate ratios (RRs) (95% confidence intervals [CIs]) were used to compare injury incidence and burden between starting (reference group) and replacement players. RESULTS: Overall injury incidence was not different between starters and replacements for all injuries (RR = 0.98, 95% CI 0.88-1.10), nor for concussions (RR = 0.85; 95% CI 0.66-1.11). Mean injury burden was higher for replacement players (RR = 1.31, 95% CI 1.17-1.46). Replacement injury incidence was lower than the starters in the third (RR = 0.68, 95% CI 0.51-0.92) and fourth (RR = 0.78, 95% CI 0.67-0.92) match quarters. Injury incidence was not different between starters and replacements for any match event or body region, but compared with starters, replacements' injury burden was higher in lower limbs (RR = 1.24, 95% CI 1.05-1.46) and in the tackled player (RR = 1.30, 95% CI 1.01-1.66). CONCLUSION: This study demonstrated a lower injury incidence in replacement players compared with starters in the second half of matches, with a higher injury burden for replacement players due to higher mean injury severity.

On-field rehabilitation in football: current practice and perceptions. A survey of the English Premier League and Football League.

INTRODUCTION: Return to play related research is increasing rapidly, with two recent competency-based frameworks offering conceptualised support for on-field rehabilitation (OFR) decision-making. It is still unknown, however, who is responsible for OFR and how they typically select, monitor, and progress OFR processes. AIMS: The purpose of this study was to investigate current OFR practice within English professional football to support practitioners with decision-making and highlight opportunities for future research related to the design, monitoring, and progression of OFR. METHODS: Sixty-nine practitioners responsible for the design and implementation of OFR at 69 clubs (75% of the English Premier League and Football League) responded to a survey containing 30 questions (14 open and 16 closed). RESULTS: The main findings were that therapists (physiotherapists/sports therapists) have the largest influence on OFR, followed by physical performance coaches (sports scientists/strength and conditioning coaches), technical coaches and medical doctors. There was more agreement for the ordering of specific OFR drills earlier in the process when activities are easier to control. The most frequently reported objective monitoring tool was global positioning systems (GPS), with functional/clinical experience/expertise remaining subjectively vital. GPS outputs (e.g., sprint metrics and accelerations/decelerations) were most used for between session decision-making, with verbal communication being key for within session decision-making. CONCLUSION: Future research should use evidence of current practice, such as drill design and monitoring techniques, to explore drill-level analysis and give practitioners greater insights into which stage of current OFR frameworks specific drills fall, and how they might be more objectively progressed/regressed.

Match injuries in English schoolboy rugby union.

Objective: This study describes the incidence, severity and burden of match injuries in schoolboy rugby union in England, across three age groups: under-13 (U13), under-15 (U15) and under-18 (U18). Methods: Data regarding 574 24-hour time-loss match injuries and 18 485 player-hours of match exposure were collected from a total of 35 schools (66 teams) in the 2017/18, 2018/19 and 2019/20 seasons. Injury incidence (injuries/1000 hours), severity (mean and median days lost) and burden (days lost/1000 hours) were calculated for each age group, injury region, event, playing position and match period and were compared using Z scores. Results: The U18 age group had a significantly higher injury incidence (34.6 injuries/1000 hours, 95% CI 31.5 to 38.1) and burden (941 days/1000 hours, 95% CI 856 to 1035) than both the U13 (incidence=20.7 injuries/1000 hours, 95% CI 14.1 to 30.3, p=0.03; burden=477 days lost/1000 hours, 95% CI 325 to 701, p<0.01) and U15 (incidence=24.6 injuries/1000 hours, 95% CI 20.6 to 29.5, p<0.01; burden=602 days lost/1000 hours, 95% CI 503 to 721, p<0.01) age groups, but no significant differences were found between the U13 and U15 age groups. Contact events accounted for 87% of known injury events, with the tackle responsible for 52% (U13), 48% (U15) and 62% (U18) of all injuries. Concussion was the most common injury type in all age groups (U13=4.8 injuries/1000 hours; U15=6.4 injuries/1000 hours; U18=9.2 injuries/1000 hours), but the incidence was not significantly different between age groups. Conclusion: Injury incidence and burden was higher in U18 than U13 and U15 age groups. Concussions and the tackle are priority areas at all age groups and should be the focus of injury prevention strategies.

Incidence of post-surgical hypoparathyroidism (POSH) after total thyroidectomy.

Post-surgical hypoparathyroidism (POSH) is a recognised complication of total thyroidectomy, leading to hypocalcaemia and its associated adverse effects. This retrospective study aimed to determine the incidence of POSH and identify perioperative predictors for its development. Data from patients who underwent total or completion thyroidectomy between January 2017 and July 2022 were retrospectively analysed. The incidence of POSH was assessed, and patients were categorised into transient or prolonged POSH at six months postoperatively. Potential predictors for POSH were investigated including gender, histological diagnosis, and preoperative thyroid function. A total of 133 adult patients were included in the study. The incidence of patients recovering from transient POSH within six months was 15%, and 5% had prolonged POSH beyond six months of surgery. Parathyroid hormone (PTH) levels normalised in 83% of prolonged POSH patients within 14-33 months, reducing the incidence of persistent POSH to 0.75%. Despite normal PTH levels, overall, 3% had persistent marginally low calcium levels (mean 2.11 mmol/L) in keeping with relative parathyroid insufficiency. Histological diagnosis of malignancy was the only significant risk factor for both transient and prolonged POSH (RR 2.95, CI 1.54 to 5.67, p = 0.001) in this cohort. Cautious capsular dissection during thyroidectomy and protection of the parathyroid glands and vascular supply produce a low incidence of POSH. Although the vast majority of patients with POSH recover after six months, hypocalcaemia may persist due to relative parathyroid insufficiency, requiring long-term calcium supplementation. Further research is needed to determine the best strategies for preventing and treating this condition.

Surveying the youth-to-senior transition landscape in Major League Soccer: a new frontier.

PURPOSE: The aim of this study was to survey Major League Soccer stakeholders' attitudes and perspectives on the youth-to-senior transition with a particular interest in the league's evolving club structures, specifically the reserve team and youth academy entities. The survey assessed various stakeholders' views on clubs' organisational aims and structure, the capabilities of club entities to prepare players for the first team, and the transition process to the first team within MLS. METHODS: A total of 80 participants working in various 'player operation' roles for MLS clubs in the United States and Canada voluntarily completed the online survey. RESULTS: The predominant aim for both reserve teams and academies in MLS is to develop players for the first team. The organisational structure and governance of reserve teams are varied across the league, but an overarching feature is their function as a development team. When players are transitioning, communication between staff may or may not be clear and effective. Finally, for players within an MLS club's talent pathway, a variety of support strategies are made available during the transition into the first team, but psychological support in particular may be limited or unavailable. CONCLUSION: Similar to European soccer, the aim of MLS reserve teams and youth academies is to develop first team players for the club. However, while players are transitioning into the first team, communication may or may not be clear and effective, and psychological support may be absent, which may impair player development initiatives.

Methods to predict the timing and status of biological maturation in male adolescent soccer players: A narrative systematic review.

The aim of this review was to summarise the methods used to predict and assess maturity status and timing in adolescent, male, academy soccer players. A systematic search was conducted on PubMed, Scopus, Web of Science, CINAHL, Medline and SPORTDiscus. Only experimental studies including male, academy players aged U9-U18 years registered with a professional soccer club were included. The methodological quality of the included studies was assessed using guidelines from the Framework of Potential Biases. Fifteen studies fulfilled our inclusion criteria. Studies were mainly conducted in European countries (n = 12). In total, 4,707 players were recruited across all 15 studies, with an age range of 8-18 years. Five studies were longitudinal, two studies were mixed-method designs and eight studies were cross-sectional. Due to high heterogeneity within the studies, a meta-analysis was not performed. Our findings provided no equivalent estimations of adult height, skeletal age, or age at PHV. Discrepancies were evident between actual and predicted adult height and age at PHV. The Bayley-Pinneau [1952], Tanner-Whitehouse 2 [1983] and Khamis-Roche [1994] methods produced estimates of adult height within 1cm of actual adult height. For age at PHV, both Moore [2015] equations produced the closest estimates to actual age at PHV, and the Fransen [2018] equation correlated highly with actual age at PHV (>90%), even when the period between chronological age and age at PHV was large. Medical imaging techniques (e.g., Magnetic Resonance Imaging, X-Ray, Dual energy X-ray Absorptiometry) demonstrated high intra/inter-rater reliability (ICC = 0.83-0.98) for skeletal maturity assessments. The poor concordance between invasive and non-invasive methods, is a warning to practitioners to not use these methods interchangeably for assessing maturational status and timing in academy soccer players. Further research with improved study designs is required to validate these results and improve our understanding of these methods when applied in this target population.

Surgical and long-term functional outcomes of patients with Duchenne muscular dystrophy following spinal deformity correction.

BACKGROUND: Life expectancy in patients with Duchenne muscular dystrophy (DMD) has improved due to advances in medical care. DMD patients develop progressive spinal deformity after loss of ambulatory function and onset of wheelchair dependence for mobility. There is limited published data on the effect of spinal deformity correction on long-term functional outcomes, quality of life (QoL), and satisfaction in DMD patients. AIM: To investigate the long-term functional outcomes following spinal deformity correction in DMD patients. METHODS: This was a retrospective cohort study from 2000-2022. Data was collected from hospital records and radiographs. At follow-up, patients completed the muscular dystrophy spine questionnaire (MDSQ). Statistical analysis was performed by linear regression analysis and ANOVA to analyse clinical and radiographic factors significantly associated with MDSQ scores. RESULTS: Forty-three patients were included with mean age 14.4 years at surgery. Spino-pelvic fusion was performed in 41.9% of patients. Mean surgical time was 352.1 min and mean blood loss was 36% of estimated total blood volume. Mean hospital stay was 14.1 d. Postoperative complications occurred in 25.6% of patients. Mean preoperative scoliosis was 58°, pelvic obliquity 16.4°, thoracic kyphosis 55.8°, lumbar lordosis 11.1°, coronal balance 3.8 cm, and sagittal balance + 6.1 cm. Mean surgical correction of scoliosis was 79.2% and of pelvic obliquity was 80.8%. Mean follow-up was 10.9 years (range: 2-22.5). Twenty-four patients had died at follow-up. Sixteen patients completed the MDSQ at mean age 25.4 years (range 15.2-37.3). Two patients were bed-ridden and 7 were on ventilatory support. Mean MDSQ total score was 38.1. All 16 patients were satisfied with the results of spinal surgery and would choose surgery again if offered. Most patients (87.5%) reported no severe back pain at follow-up. Factors significantly associated with functional outcomes (MDSQ total score) included greater duration of post-operative follow-up, age, scoliosis postoperatively, correction of scoliosis, increased lumbar lordosis postoperatively, and greater age at loss of independent ambulation. CONCLUSION: Spinal deformity correction in DMD patients leads to positive long-term effects on QoL and high patient satisfaction. These results support spinal deformity correction to improve long-term QoL in DMD patients.

A Randomized Trial of Autologous Chondrocyte Implantation Versus Alternative Forms of Surgical Cartilage Management in Patients With a Failed Primary Treatment for Chondral or Osteochondral Defects in the Knee.

BACKGROUND: There are limited randomized controlled trials with long-term outcomes comparing autologous chondrocyte implantation (ACI) versus alternative forms of surgical cartilage management within the knee. PURPOSE: To determine at 5 years after surgery whether ACI was superior to alternative forms of cartilage management in patients after a failed previous treatment for chondral or osteochondral defects in the knee. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: In total, 390 participants were randomly assigned to receive either ACI or alternative management. Patients aged 18 to 55 years with one or two symptomatic cartilage defects who had failed 1 previous therapeutic surgical procedure in excess of 6 months prior were included. Dual primary outcome measures were used: (1) patient-completed Lysholm knee score and (2) time from surgery to cessation of treatment benefit. Secondary outcome measures included International Knee Documentation Committee and Cincinnati Knee Rating System scores, as well as number of serious adverse events. Analysis was performed on an intention-to-treat basis. RESULTS: Lysholm scores were improved by 1 year in both groups (15.4 points [95% CI, 11.9 to 18.8] and 15.2 points [95% CI, 11.6 to 18.9]) for ACI and alternative, with this improvement sustained over the duration of the trial. However, no evidence of a difference was found between the groups at 5 years (2.9 points; 95% CI, -1.8 to 7.5; P = .46). Approximately half of the participants (55%; 95% CI, 47% to 64% with ACI) were still experiencing benefit at 5 years, with time to cessation of treatment benefit similar in both groups (hazard ratio, 0.97; 95% CI, 0.72 to 1.32; P > .99). There was a differential effect on Lysholm scores in patients without previous marrow stimulation compared with those with marrow stimulation (P = .03; 6.4 points in favor of ACI; 95% CI, -0.4 to 13.1). More participants experienced a serious adverse event with ACI (P = .02). CONCLUSION: Over 5 years, there was no evidence of a difference in Lysholm scores between ACI and alternative management in patients who had previously failed treatment. Previous marrow stimulation had a detrimental effect on the outcome of ACI. REGISTRATION: International Standard Randomised Controlled Trial Number: 48911177.

Utilisation of specialist sonographers for head and neck ultrasound fine-needle aspiration cytology can help shorten waiting lists and improve efficiency of the service.

Head and neck ultrasonography with fine-needle aspiration cytology (FNAC) is recommended by the National Institute for Health and Care Excellence (NICE) and the British Association of Head and Neck Oncologists (BAHNO) for investigating neck masses. Finite specialist radiologists and increased demands on services have increased waiting lists and breached targets. Many patients are on a two-week cancer pathway and accurate investigation cannot be delayed. The implementation of a sonographer trained in neck ultrasound-guided FNAC was analysed together with its impact on the service. Over a 21-month period we have demonstrated a fall in waiting lists from 310 to 28 patients, without compromise to diagnostic accuracy. Additionally, a cost-saving of £60,000 was made. Improvements in efficiency and waiting lists can be achieved through targeted specialist training for allied health professionals, liberating specialists for other duties.

Paediatric Spinal Deformity Surgery: Complications and Their Management.

Surgical correction of paediatric spinal deformity is associated with risks, adverse events, and complications that must be preoperatively discussed with patients and their families to inform treatment decisions, expectations, and long-term outcomes. The incidence of complications varies in relation to the underlying aetiology of spinal deformity and surgical procedure. Intraoperative complications include bleeding, neurological injury, and those related to positioning. Postoperative complications include persistent pain, surgical site infection, venous thromboembolism, pulmonary complications, superior mesenteric artery syndrome, and also pseudarthrosis and implant failure, proximal junctional kyphosis, crankshaft phenomenon, and adding-on deformity, which may necessitate revision surgery. Interventions included in enhanced recovery after surgery protocols may reduce the incidence of complications. Complications must be diagnosed, investigated and managed expeditiously to prevent further deterioration and to ensure optimal outcomes. This review summarises the complications associated with paediatric spinal deformity surgery and their management.

Physical activity promoting teaching practices and children's physical activity within physical education lessons underpinned by motor learning theory (SAMPLE-PE).

PURPOSE: Movement competence is a key outcome for primary physical education (PE) curricula. As movement development in children emerges through physical activity (PA), it is important to determine the extent of PA promotion within movement competence focused teaching pedagogies. Therefore, this study aimed to assess children's moderate-to-vigorous PA (MVPA) and related teaching practices in primary PE within Linear pedagogy and Nonlinear pedagogy and to compare this to current practice within PE delivery in primary schools. METHODS: Participants (n = 162, 53% females, 5-6y) were recruited from 9 primary schools within the SAMPLE-PE cluster randomised controlled trial. Schools were randomly-allocated to one of three conditions: Linear pedagogy, Nonlinear pedagogy, or control. Nonlinear and Linear pedagogy intervention schools received a PE curriculum delivered by trained deliverers over 15 weeks, while control schools followed usual practice. Children's MVPA was measured during 3 PE lessons (44 PE lessons in total) using an ActiGraph GT9X accelerometer worn on their non-dominant wrist. Differences between conditions for children's MVPA were analysed using multilevel model analysis. Negative binomial models were used to analyse teaching practices data. RESULTS: No differences were found between Linear pedagogy, Nonlinear pedagogy and the control group for children's MVPA levels during PE. Linear and Nonlinear interventions generally included higher percentages of MVPA promoting teaching practices (e.g., Motor Content) and lower MVPA reducing teaching practices (e.g., Management), compared to the control group. Teaching practices observed in Linear and Nonlinear interventions were in line with the respective pedagogical principles. CONCLUSIONS: Linear and Nonlinear pedagogical approaches in PE do not negatively impact MVPA compared to usual practice. Nevertheless, practitioners may need to refine these pedagogical approaches to improve MVPA alongside movement competence.

Effectiveness of the Activate injury prevention exercise programme to prevent injury in schoolboy rugby union.

OBJECTIVE: The efficacious Activate injury prevention exercise programme has been shown to prevent injuries in English schoolboy rugby union. There is now a need to assess the implementation and effectiveness of Activate in the applie setting. METHODS: This quasi-experimental study used a 24-hour time-loss injury definition to calculate incidence (/1000 hours) and burden (days lost/1000 hours) for individuals whose teams adopted Activate (used Activate during season) versus non-adopters. The dose-response relationship of varying levels of Activate adherence (median Activate sessions per week) was also assessed. Player-level rugby exposure, sessional Activate adoption and injury reports were recorded by school gatekeepers. Rate ratios (RR), adjusted by cluster (team), were calculated using backwards stepwise Poisson regression to compare rates between adoption and adherence groups. RESULTS: Individuals in teams adopting Activate had a 23% lower match injury incidence (RR 0.77, 95% CI 0.55 to 1.07), 59% lower training injury incidence (RR 0.41, 95% CI 0.17 to 0.97) and 26% lower match injury burden (95% CI 0.46 to 1.20) than individuals on non-adopting teams. Individuals with high Activate adherence (≥3 sessions per week) had a 67% lower training injury incidence (RR 0.33, 95% CI 0.12 to 0.91) and a 32% lower match injury incidence (RR 0.68, 95% CI 0.50 to 0.92) than individuals with low adherence (<1 session per week). While 65% of teams adopted Activate during the season, only one team used Activate three times per week, using whole phases and programme progressions. CONCLUSION: Activate is effective at preventing injury in English schoolboy rugby. Attention should focus on factors influencing programme uptake and implementation, ensuring Activate can have maximal benefit.

Ketone Monoester Ingestion Alters Metabolism and Simulated Rugby Performance in Professional Players.

Ketone ingestion can alter metabolism but effects on exercise performance are unclear, particularly with regard to the impact on intermittent-intensity exercise and team-sport performance. Nine professional male rugby union players each completed two trials in a double-blind, randomized, crossover design. Participants ingested either 90 ± 9 g carbohydrate (CHO; 9% solution) or an energy matched solution containing 20 ± 2 g CHO (3% solution) and 590 mg/kg body mass ß-hydroxybutyrate monoester (CHO + BHB-ME) before and during a simulated rugby union-specific match-play protocol, including repeated high-intensity, sprint and power-based performance tests. Mean time to complete the sustained high-intensity performance tests was reduced by 0.33 ± 0.41 s (2.1%) with CHO + BHB-ME (15.53 ± 0.52 s) compared with CHO (15.86 ± 0.80 s) placebo (p = .04). Mean time to complete the sprint and power-based performance tests were not different between trials. CHO + BHB-ME resulted in blood BHB concentrations that remained >2 mmol/L during exercise (p < .001). Serum lactate and glycerol concentrations were lower after CHO + BHB-ME than CHO (p < .05). Coingestion of a BHB-ME with CHO can alter fuel metabolism (attenuate circulating lactate and glycerol concentrations) and may improve high-intensity running performance during a simulated rugby match-play protocol, without improving shorter duration sprint and power-based efforts.

Eight Weeks of Self-Resisted Neck Strength Training Improves Neck Strength in Age-Grade Rugby Union Players: A Pilot Randomized Controlled Trial.

BACKGROUND: Greater neck strength is associated with fewer head and neck injuries. Neck-strengthening programs are commonly burdensome, requiring specialist equipment or significant time commitment, which are barriers to implementation. HYPOTHESIS: Completing a neck-strengthening program will increase isometric neck strength in age-group rugby players. STUDY DESIGN: A pilot randomized controlled exercise intervention study. LEVEL OF EVIDENCE: Level 2. METHODS: Twenty-eight U18 (under 18) male regional age-group rugby union players were randomized (intervention n =15/control n = 13). An 8-week exercise program was supervised during preseason at the regional training center. Control players continued their "normal practice," which did not include neck-specific strengthening exercises. The 3-times weekly trainer-led intervention program involved a series of 15-second self-resisted contractions, where players pushed maximally against their own head, in forward, backward, left, and right directions. OUTCOME MEASURE: Peak isometric neck strength (force N) into neck flexion, extension, and left and right side flexion was measured using a handheld dynamometer. RESULTS: Postintervention between-group mean differences (MDs) in isometric neck strength change were adjusted for baseline strength and favored the intervention for total neck strength (effect size [ES] = 1.2, MD ± 95% CI = 155.9 ± 101.9 N, P = 0.004) and for neck strength into extension (ES = 1.0, MD ± 95% CI = 59.9 ± 45.4 N, P = 0.01), left side flexion (ES = 0.7, MD ± 95% CI = 27.5 ± 26.9 N, P = 0.05), and right side flexion (ES = 1.3, MD ± 95% CI = 50.5 ± 34.4 N, P = 0.006). CONCLUSION: This resource-efficient neck-strengthening program has few barriers to implementation and provides a clear benefit in U18 players' neck strength. While the present study focused on adolescent rugby players, the program may be appropriate across all sports where head and neck injuries are of concern and resources are limited. CLINICAL RELEVANCE: Greater neck strength is associated with fewer head and neck injuries, including concussion. Performing this neck exercise program independently, or as part of a whole-body program like Activate, an interactive guide for players and coaches, could contribute to lower sports-related head and neck injuries.

Critical Appraisal of Paralyzed Veterans of America Guidelines in Spinal Cord Injury: An International Collaborative Study Using the Appraisal of Guidelines for Research and Evaluation II Instrument (AGREE II).

INTRODUCTION: Spinal cord injuries (SCI) in military personnel, veterans, and others require an evidence-based, multidisciplinary approach to their care. This appraisal used the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument to evaluate the methodological quality of clinical guidelines for the management of SCI published by the Paralyzed Veterans of America (PVA) organization. MATERIALS AND METHODS: We searched clinical guidelines on SCI published by PVA until December 2019. Four appraisers across three international centers independently evaluated the quality of eligible clinical guidelines using AGREE II. Mean AGREE II scores for each domain were calculated. In higher quality domains, scores for individual items were analyzed. RESULTS: A total of 12 guidelines published by PVA on SCI were assessed. Mean scores for all six domains were as follows: Scope and Purpose (78.8%), Stakeholder Involvement (63.7%), Rigor of Development (68.4%), Clarity of Presentation (80.1%), Applicability (53.0%), and Editorial Independence (28.5%). The mean score for the overall quality of all PVA guidelines was 71.9% (95% CI: 69.7-74.1). No guideline was assessed as "not recommended" by any appraiser. Overall quality was significantly associated with year of publication (rs = 0.754, P = 0.0046). Overall agreement among appraisers was excellent (intraclass correlation coefficients for each guideline ranged from 0.96 to 0.99). CONCLUSIONS: PVA guidelines for the management of SCI demonstrated acceptable or good quality across most domains. We recommend the use of PVA guidelines for the assessment and treatment of SCI and related disorders. The quality of PVA guidelines for the management of SCI have improved over time.

Contralateral strength training attenuates muscle performance loss following anterior cruciate ligament (ACL) reconstruction: a randomised-controlled trial.

PURPOSE: To investigate the effects of cross-education (CE) exercise on strength and performance at 10 and 24 weeks post anterior cruciate ligament (ACL) surgery. METHODS: Design: randomised controlled trial. N = 44 ACL-reconstruction patients, randomly-allocated into: CE: strength training of the non-operative limb, or CON: sham exercise of upper limb stretching. Each patient underwent standardised ACL rehabilitation, plus 8 weeks of thrice weekly CE or CON, commencing at 2 weeks post surgery. The primary outcome was quadriceps peak force (QPF) of the ACL-reconstructed limb at 10 weeks post surgery. Secondary measures were hamstrings peak force (HPF), rate of force development (RFD) and International Knee Documentation Committee score (IKDC) at 10 and 24 weeks; QPF and hop for distance (HOP) at 24 weeks post surgery. RESULTS: CE significantly attenuated the decline in QPF of the ACL-reconstructed limb at 10 weeks compared to CON (16.6% decrease vs. 32.0%, respectively); that advantage was not retained at 24 weeks. A training effect was observed in the trained limb for HPF and QPF, which was retained at 24 weeks. No significant differences were observed for IKDC, HOP, RFD, or HPF of the reconstructed limb. Inter-limb symmetry (ILS) ranged from 0.78 to 0.89 and was not significantly different between groups. CONCLUSION: High-intensity CE strength training attenuated the post-operative decline in QPF and should be considered in early-phase ACL rehabilitation. ILS data showed good symmetry, but it masked significantly inferior performance between groups and should be used with caution. TRIAL REGISTRATION NUMBER: NCT02722876.

Preclinical characterization of dostarlimab, a therapeutic anti-PD-1 antibody with potent activity to enhance immune function in in vitro cellular assays and in vivo animal models.

Inhibitors of programmed cell death protein 1 (PD-1) and its ligand (PD-L1) have dramatically changed the treatment landscape for patients with cancer. Clinical activity of anti-PD-(L)1 antibodies has resulted in increased median overall survival and durable responses in patients across selected tumor types. To date, 6 PD-1 and PD-L1, here collectively referred to as PD-(L)1, pathway inhibitors are approved by the US Food and Drug Administration for clinical use. The availability of multiple anti-PD-(L)1 antibodies provides treatment and dosing regimen choice for patients with cancer. Here, we describe the nonclinical characterization of dostarlimab (TSR-042), a humanized anti-PD-1 antibody, which binds with high affinity to human PD-1 and effectively inhibits its interaction with its ligands, PD-L1 and PD-L2. Dostarlimab enhanced effector T-cell functions, including cytokine production, in vitro. Since dostarlimab does not bind mouse PD-1, its single-agent antitumor activity was evaluated using humanized mouse models. In this model system, dostarlimab demonstrated antitumor activity as assessed by tumor growth inhibition, which was associated with increased infiltration of immune cells. Single-dose and 4-week repeat-dose toxicology studies in cynomolgus monkeys indicated that dostarlimab was well tolerated. In a clinical setting, based on data from the GARNET trial, dostarlimab (Jemperli) was approved for the treatment of adult patients with mismatch repair-deficient recurrent or advanced endometrial cancer that had progressed on or following prior treatment with a platinum-containing regimen. Taken together, these data demonstrate that dostarlimab is a potent anti-PD-1 receptor antagonist, with properties that support its continued clinical investigation in patients with cancer.

Long-term follow-up of untreated Scheuermann's kyphosis.

STUDY DESIGN: Long-term cross-sectional study. OBJECTIVES: To investigate the long-term effects of untreated Scheuermann's kyphosis on quality of life, and its relationship to radiographic parameters of spinal deformity. Previous studies reported reduced self-image, increased pain and impaired physical status. Little is known of the long-term impact of sagittal plane deformity in untreated SK. METHODS: One hundred and thirteen consecutive untreated patients with SK were identified from a national service database prior to 2000, when surgery was not offered at this unit. 81 of these patients were available for evaluation; 66 (81%) consented to questionnaire and clinical evaluation, and 47 (58%) consented to additional radiological evaluation. Health-related quality of life (HRQoL) was compared to normative population values. Mean age was 45.1 years (31-65), and mean follow-up was 27 years (16-36). 57 patients had thoracic kyphosis and 9 had thoracolumbar deformity. RESULTS: SRS-22 and SF-36 scores were lower, and ODI was greater in patients with untreated SK compared to normative population values. Kyphosis progressed from mean 66° at skeletal maturity to 78° (p < 0.001) after mean follow-up of 27 years. Long-term progression of untreated SK was 0.45°/year (n = 47). Multilinear regression showed good correlation between increasing SVA and worse ODI scores (r = 0.59; p = 0.001). Increasing SVA also correlated with worse function, pain and mental health scores reported by SRS-22, and with worse physical function and bodily pain scores reported by SF-36. Increasing CL correlated with worse SF-36 physical function scores. Increasing cSVA and increasing TK correlated with worse SRS-22 self-image scores. CONCLUSION: SRS-22 and SF-36 scores were lower, and ODI was greater in patients with untreated SK compared to normative data. Long-term progression of untreated SK was 0.45°/year (n = 47). Increasing SVA correlated with worse SF-36 physical function, SRS-22 function, SRS-22 pain and higher ODI scores. Total kyphosis (TK) and cSVA were independent predictors of low SRS self-image. LEVEL OF EVIDENCE: III.

Simultaneous Bilateral Total Knee Arthroplasty Is Associated With Shorter Length of Stay but Increased Mortality Compared With Staged Bilateral Total Knee Arthroplasty: A Systematic Review and Meta-Analysis.

BACKGROUND: Primary total knee arthroplasty (TKA) is associated with high patient satisfaction. However, controversy remains regarding the safety and efficacy of conducting simultaneous bilateral (simBTKA) versus staged bilateral TKA (staBTKA). The objective of this systematic review and meta-analysis was to evaluate the current evidence for simBTKA versus staBTKA and compare clinical outcomes including mortality, complications and length of stay (LOS). METHODS: A search was performed of PubMed, MEDLINE, EMBASE and Cochrane central databases between January 2000 and March 2020. Search terms included "simultaneous," "staged," and "bilateral TKA." Inclusion criteria comprised studies comparing outcomes of simBTKA versus staBTKA. Quality of included studies was assessed and meta-analyses of pooled data was conducted. RESULTS: 29 articles published between 2001 and 2020 were included in qualitative synthesis from 927 potentially relevant titles, comprising 257,284 patients. 104,207 patients underwent simBTKA and 153,632 patients underwent staBTKA. simBTKA was associated with significantly increased 90-day mortality rate (P < .00001, OR 2.24, 95% CI 1.79-2.81), increased incidence of pulmonary embolism (P < .00001, OR 1.69, 95% CI 1.51-1.89), venous thrombosis (P < .00001, OR 1.33, 95% CI 1.23-1.43), and neurological complications (P = .002, OR 1.42, 95% CI 1.13-1.77). Incidence of superficial and deep infection was significantly increased with staBTKA (P = .02, P < .00001 respectively). Revision rate within one year was equivocal. Mean LOS was 2.1 days shorter for simBTKA. CONCLUSION: SimBTKA was associated with decreased incidence of infection and LOS but increased incidence of 90-day mortality, venous thromboembolism and neurological complications. Revision rates were equivocal. Patients should be selected and counseled based on the risks respective to each strategy.

Padded Headgear does not Reduce the Incidence of Match Concussions in Professional Men's Rugby Union: A Case-control Study of 417 Cases.

Concussion is the most common match injury in rugby union. Some players wear padded headgear, but whether this protects against concussion is unclear. In professional male rugby union players, we examined: (i) the association between the use of headgear and match concussion injury incidence, and (ii) whether wearing headgear influenced time to return to play following concussion. Using a nested case-control within a cohort study, four seasons (2013-2017) of injury data from 1117 players at the highest level of rugby union in England were included. Cases were physician-diagnosed concussion injuries. Controls were other contact injuries (excluding all head injuries). We determined headgear use by viewing video footage. Sixteen percent of cases and controls wore headgear. Headgear use had no significant effect on concussion injury incidence (adjusted odds ratio=1.05, 95% CI: 0.71-1.56). Median number of days absent for concussion whilst wearing headgear was 8 days, compared with 7 days without headgear. Having sustained a concussion in the current or previous season increased the odds of concussion more than four-fold (odds ratio=4.55, 95% CI: 3.77-5.49). Wearing headgear was not associated with lower odds of concussions or a reduced number of days' absence following a concussion.