Regeneration of injured articular cartilage using the recombinant human amelogenin protein.

Aims: Cartilage injuries rarely heal spontaneously and often require surgical intervention, leading to the formation of biomechanically inferior fibrous tissue. This study aimed to evaluate the possible effect of amelogenin on the healing process of a large osteochondral injury (OCI) in a rat model. Methods: A reproducible large OCI was created in the right leg femoral trochlea of 93 rats. The OCIs were treated with 0.1, 0.5, 1.0, 2.5, or 5.0 µg/µl recombinant human amelogenin protein (rHAM+) dissolved in propylene glycol alginate (PGA) carrier, or with PGA carrier alone. The degree of healing was evaluated 12 weeks after treatment by morphometric analysis and histological evaluation. Cell recruitment to the site of injury as well as the origin of the migrating cells were assessed four days after treatment with 0.5 µg/µl rHAM+ using immunohistochemistry and immunofluorescence. Results: A total of 12 weeks after treatment, 0.5 µg/µl rHAM+ brought about significant repair of the subchondral bone and cartilage. Increased expression of proteoglycan and type II collagen and decreased expression of type I collagen were revealed at the surface of the defect, and an elevated level of type X collagen at the newly developed tide mark region. Conversely, the control group showed osteoarthritic alterations. Recruitment of cells expressing the mesenchymal stem cell (MSC) markers CD105 and STRO-1, from adjacent bone marrow toward the OCI, was noted four days after treatment. Conclusion: We found that 0.5 µg/µl rHAM+ induced in vivo healing of injured articular cartilage and subchondral bone in a rat model, preventing the destructive post-traumatic osteoarthritic changes seen in control OCIs, through paracrine recruitment of cells a few days after treatment.

Reliability of 2-Dimensional Video Analysis in Adolescent Runners.

Background: The literature on the reliability of qualitative and quantitative measures for running video analysis in the adolescent population is limited. Reliability of 2-dimensional (2D) video analysis has been reported in adult runners, but these findings may not apply to youth runners. Purpose: We sought to determine the intra-rater and inter-rater reliability of sagittal and frontal plane kinematics using 2D video analysis in healthy adolescent runners. Methods: High-definition (1080p) videos were recorded of 10 healthy runners between 14 and 18 years old running on a treadmill at self-selected speed with markers attached to the cervical spine, pelvis, and lower extremities. Kinematic variables in the sagittal and frontal planes were measured using Dartfish Motion Analysis Software by 3 raters (2 sports medicine physical therapists and a research assistant). Intra- and inter-rater reliability were calculated using intraclass correlation coefficients (ICCs). Results: Of the 10 runners, 4 (40%) were male and the mean age was 16 ± 1.5 years. The intra-rater ICC for all kinematic variables ranged from 0.574 to 0.999 for the experienced physical therapist, and 0.367 to 0.973 for the inexperienced research assistant. The inter-rater ICC for all raters ranged from -0.01 to 0.941. Eleven kinematic variables showed substantial agreement and 4 showed almost perfect agreement. Step width and foot progression showed fair and poor agreement, respectively. Conclusions: Running analysis using 2D video can be performed reliably in adolescents on all kinematic variables except for step width and foot progression. Inexperienced raters can be properly trained in the video analysis of running kinematics to consistently assess the same runner.

Backward Running on a Negative Slope as a Treatment for Achilles Tendinopathy in Runners: A Feasibility Pilot Study.

CONTEXT: Achilles tendinopathy (AT) is a common musculoskeletal injury among runners. Eccentric exercises are considered first-line treatment. However, during the early stages of rehabilitation, patients are usually instructed to stop running. Backward running (BR) on a negative slope provides a similar eccentric load while enabling ongoing physical activity; thus, it may be suggested as an alternative treatment. OBJECTIVES: To determine the feasibility of a BR program as a treatment option for AT in runners. DESIGN: Prospective, single-arm feasibility study. SETTING: Outpatient clinic. PATIENTS: Recreational runners diagnosed with AT and referred to the Meuhedet Health Services Physical Therapy Clinic in Jerusalem, Israel, from September 2019 to February 2020. INTERVENTION: The patients completed a 5-week (9 sessions) rehabilitation program of supervised BR on a negatively inclined treadmill. MAIN OUTCOME MEASURES: Compliance with the program was evaluated by calculating the percentage of patients who completed the full protocol with no adverse events. Personal running-related goals were set before the program and were assessed following rehabilitation using the goal attainment scaling method. Forward-running time until the onset of relevant Achilles tendon pain, and the Victorian Institute of Sports Assessment Scale-Achilles were measured at baseline (T0), before treatment session 6 (T1), and after the last session (T2). RESULTS: Among the 15 patients recruited, 14 (93%), average age 48.8 (10.4) years (86% males), completed the full protocol with no adverse events. Almost all participants (85.7%) achieved their running-related functional goals. Postintervention, the median forward-running time increased from 52.5 (92.5) to 900 (522.5) seconds (P = .008, effect size = .858), and the median Victorian Institute of Sports Assessment Scale-Achilles score improved by 28 points (P = .003, effect size = .881). CONCLUSIONS: BR on a negative slope may be a feasible treatment method for runners suffering from AT. Future randomized control trials are required to further validate the efficacy of this method.

Photobiomodulation as an Adjunctive Treatment to Physiotherapy for Reduction of Anterior Knee Pain in Combat Soldiers: A Prospective, Double-Blind, Randomized, Pragmatic, Sham-Controlled Trial.

BACKGROUND AND OBJECTIVES: Anterior knee pain (AKP) is the most common knee pathology in athletes and occurs in 15% of army recruits of elite units during basic training. Of these, 50% are symptomatic 6 years later. Photobiomodulation (PBM) is a nonthermal red-to-near-infrared irradiation used for pain reduction of a variety of etiologies. This study was designed to determine whether addition of PBM to physiotherapy (PT) for AKP in combat soldiers is superior to PT alone. STUDY DESIGN/MATERIALS AND METHODS: In this prospective, double-blind, sham-controlled, randomized clinical trial (NCT02845869), 26 combat soldiers/policemen (male:female, 15:11; body mass index [BMI] = 24.2 ± 3.9, n = 46 knees), with AKP due to overuse/load, received 4 weeks of PT + sham (PT + Sham) or active PBM (wavelength = 660 and 850 nm, pulsing = 2.5 Hz, LED power = 50 mW/cm2 [local tissue/regional lymph nodes]; 810 nm continuous beam, laser cluster 6 W/cm2 [analgesia] and laser pointer 4.75 W/cm2 [trigger points]) (PT + PBM). The main outcome measures were subjective pain by visual analog scale (VAS) (0 [none]-100 [intolerable]) and functional disability by Kujala score (0 [worst]-100 [best]). Evaluations were carried out at baseline, end of treatments, and 3-month follow-up. RESULTS: All participants completed the treatment protocol without any reported adverse device effects. Post-treatment pain was significantly reduced in the PT+PBM group, compared with baseline and sham (Δpain, VAS, mean ± SD: PT + PBM = -19 ± 23, P = 0.002; PT + Sham = -6 ± 21, P = 0.16; between groups, P = 0.032). At 3-month follow-up, pain reduction was similar between groups; however, the Kujala score was significantly improved only in the PBM-treated group (ΔKujala: PT + PBM = 11 ± 10, P = 0.003; PT + Sham = 5 ± 7, P = 0.059). CONCLUSIONS: Addition of PBM to PT for AKP resulted in earlier reduction in pain and improved functionality, compared with PT alone. This noninvasive, nonpharmacologic, adjunctive therapeutic modality can be easily incorporated into team healthcare frameworks or end units and may lead to earlier return to competition or combat-level service. Lasers Surg. Med. © 2021 Wiley Periodicals LLC.

Medial tibial stress fracture diagnosis and treatment guidelines.

OBJECTIVES: To validate and make evidence based changes to the Israel Defense Forces medial tibial stress fracture diagnosis and treatment protocol. DESIGN: Prospective cohort study. METHODS: 429 Elite infantry recruits were reviewed for signs and symptoms of medial tibial stress fracture during 14 weeks of basic training. Suspicion of medial tibial stress fracture was based on the presence of pain, tenderness <1/3 the length of the tibia and a positive fulcrum and/or hop test. Recruits with suspected medial tibial stress fractures were initially treated with 10-14 days of rest. Bone scan was performed only when recruits failed to respond to the rest regimen or required immediate diagnosis. RESULTS: 31 Out of 49 recruits with a suspicion of medial tibial stress fracture underwent bone scan, including 8/26 recruits whose symptoms did not resolve after being treated clinically as stress fractures. There was a significantly greater incidence of medial tibial stress fractures when a positive hop test was present in addition to tibial pain and tenderness (p=0.0001), odds ratio 52.04 (95% CL, 2.80-967.74). Medial tibial stress fracture was found to occur when the band of tibial tenderness was ≤10cm in length. Tibial pain scores were not predictive of stress fracture. CONCLUSIONS: This validation study provides the clinician with evidence based guidelines for the clinical diagnosis and treatment of medial stress fractures and their differentiation from shin splints. An initial treatment protocol without the use of imaging was found to be effective in more than two-thirds of the cases.

A New Preoperative Planning Technique Can Reduce Radiation Exposure During the Performance of Medial Opening-Wedge High Tibial Osteotomy.

BACKGROUND: Medial opening-wedge high tibial osteotomy (HTO) is one of the most common and effective HTO techniques, in which the proximal tibia is cut medially, leaving an intact lateral hinge of bone that can be opened to a variable amount for the desired correction, but the technical complications of lateral cortex fracture and intra-articular fracture are well described. The lateral bone hinge for medial opening-wedge HTO is crucial. If the hinge is too small, the tibia can fracture and become unstable, requiring further fixation. If the hinge is too large, the osteotomy can propagate into the joint as an intra-articular fracture when opening the osteotomy. PURPOSE: We propose a new technique that utilizes digital preoperative templating to improve the accuracy of the cut. Preoperative digital templating may allow the surgeon to reproducibly obtain a lateral bone hinge of 10 mm, while also reducing radiation exposure relative to the traditional fluoroscopically assisted technique. METHODS: Ten cadaver extremities from five cadavers were matched into pairs and randomized into two groups: those with and without preoperative templating. The templating protocol measures the distance between two points on the medial and lateral cortices, and 20 mm is subtracted to determine the depth of the saw cut (10 mm for the hinge and another 10 mm because the proximal tibia is oval in shape). The control method was done by making the cut using fluoroscopy with tactile feedback. Postoperative computed tomography scans were obtained of all legs to measure the width of the lateral bone hinge. Intraoperative fluoroscopy used during both techniques and the numbers of fluoroscopy shots were recorded. RESULTS: We found neither the treatment group with preoperative planning nor the control group with the conventional technique had bone hinge widths that were different from the ideal 10 mm. The average hinge widths for the treatment and control groups were 11.2 and 11.5 mm, respectively. However, the treatment group was exposed to significantly less intraoperative fluoroscopy during the osteotomy cut. The average total number of fluoroscopy shots was 2.2 in the treatment group versus 6.3 for the control group. CONCLUSIONS: This new preoperative planning technique achieves similar accuracy of the lateral bone hinge when compared to current methods but exposes the patient, surgeon, and staff to significantly less intraoperative radiation.

Pediatric and adolescent anterior shoulder instability: clinical management of first-time dislocators.

PURPOSE OF REVIEW: The purpose of this review is to discuss the epidemiology, pathoanatomy, diagnosis, and clinical management of pediatric and adolescent patients following a first-time shoulder dislocation. RECENT FINDINGS: Shoulder instability is becoming increasingly common as pediatric and adolescent patients engage in earlier organized sports competition. Recommended treatment following a first-time glenohumeral dislocation event in adolescents depends on several factors, but surgical stabilization is becoming more frequently performed. Surgical indications include bony Bankart lesion, ALPSA lesion, bipolar injury (e.g. Hill-Sachs humeral head depression fracture) or off-season injury in an overhead or throwing athlete. Complications following surgical treatment are rare but most commonly are associated with recurrent instability. Young children (eg. open proximal humerus growth plate), individuals averse to surgery, or in-season athletes who accept the risk of redislocation may complete an accelerated rehabilitation program for expedited return to play in the absence of the structural abnormalities listed above. SUMMARY: Following a first-time dislocation event in pediatric and adolescent patients, a detailed discussion of the risks and benefits of nonoperative versus operative management is critical to match the recommended treatment with the patient's injury pattern, risk factors, and activity goals.

The ACL Graft Has Different Cross-sectional Dimensions Compared With the Native ACL: Implications for Graft Impingement.

BACKGROUND: Impingement of anterior cruciate ligament (ACL) grafts against the femoral notch and the posterior cruciate ligament (PCL) is thought to be influenced primarily by tunnel position and graft orientation. Recent data have implied that the native ACL is ribbon-shaped. PURPOSE: To evaluate the 3-dimensional shape and cross-sectional area of the native ACL versus the ACL graft and to compare the degree of impingement against the femoral notch and PCL. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Bilateral knee magnetic resonance images were analyzed for 27 patients with unilateral bone-patellar tendon-bone (BPTB) ACL reconstruction performed via transtibial or anteromedial portal femoral tunneling techniques. Three-dimensional models of the ACL, PCL, femur, and tibia were digitally rendered. The cross-sectional area and dimensions of the native ACL and the reconstructed graft were determined at 3 equally spaced locations and compared via Wilcoxon-Mann-Whitney and Kruskal-Wallis tests. In addition, impingement of the ACL on the PCL and femoral notch was graded in 3 groups. Chi-square or Fisher exact tests were used to compare the proportional differences of impingement of the native and reconstructed ACL on the PCL and femoral notch, respectively. All analyses were performed using 2-sided hypothesis testing, with statistical significance at P < .05. RESULTS: Cross-sectional areas at all 3 points on the ACL graft were significantly greater than those of the native ACL (P < .001). The long- to short-axis ratio for the native ACL was significantly greater at each location compared with the corresponding locations along the ACL graft (P < .001), implying that the native ACL is "flatter" than is an ACL graft. There were 19 operated knees (70%) with contact or impingement between the ACL graft and the femoral notch compared with zero knees with a native ACL (P < .001). In addition, 22 operated knees (81%) showed contact or impingement between the ACL graft and the PCL, compared with 7 knees (26%) with a native ACL (P < .001). No significant differences in impingement frequency were noted between the transtibial and anteromedial tunneling techniques for ACL graft specimens (P > .05). CONCLUSION: Native ACLs have a smaller cross-sectional area, are "flatter," and experience less incidence of impingement compared with anatomically placed BPTB ACL grafts.

Skeletal ligament healing using the recombinant human amelogenin protein.

Injuries to ligaments are common, painful and debilitating, causing joint instability and impaired protective proprioception sensation around the joint. Healing of torn ligaments usually fails to take place, and surgical replacement or reconstruction is required. Previously, we showed that in vivo application of the recombinant human amelogenin protein (rHAM(+)) resulted in enhanced healing of the tooth-supporting tissues. The aim of this study was to evaluate whether amelogenin might also enhance repair of skeletal ligaments. The rat knee medial collateral ligament (MCL) was chosen to prove the concept. Full thickness tear was created and various concentrations of rHAM(+), dissolved in propylene glycol alginate (PGA) carrier, were applied to the transected MCL. 12 weeks after transection, the mechanical properties, structure and composition of transected ligaments treated with 0.5 µg/µl rHAM(+) were similar to the normal un-transected ligaments, and were much stronger, stiffer and organized than control ligaments, treated with PGA only. Furthermore, the proprioceptive free nerve endings, in the 0.5 µg/µl rHAM(+) treated group, were parallel to the collagen fibres similar to their arrangement in normal ligament, while in the control ligaments the free nerve endings were entrapped in the scar tissue at different directions, not parallel to the axis of the force. Four days after transection, treatment with 0.5 µg/µl rHAM(+) increased the amount of cells expressing mesenchymal stem cell markers at the injured site. In conclusion application of rHAM(+) dose dependently induced mechanical, structural and sensory healing of torn skeletal ligament. Initially the process involved recruitment and proliferation of cells expressing mesenchymal stem cell markers.

Outcomes of Surgical Treatment of Posterolateral Instability of the Knee.

The purpose of this review is to assess the outcomes of surgical treatment of posterolateral instability of the knee in an evidence-based manner. The majority of the existing outcomes literature on posterolateral instability consists of small, level IV case series and level III retrospective studies. Outcomes of surgical treatment of posterolateral instability of the knee are difficult to compare because of the heterogeneous presentation of posterolateral corner (PLC) injuries, the variability of their associated injuries, and their relative rarity. As such, three common types of surgical intervention for posterolateral instability are explored separately in this article, including acute repair, acute reconstruction, and chronic reconstruction. In general, the current literature supports early anatomic repair of all soft tissues and concomitant PLC reconstruction; however, because of the variability of posterolateral injury, surgical treatment options should be tailored to the patient, depending on the severity and chronicity of the posterolateral instability, as well as the associated injuries present.

Weight-bearing ankle dorsiflexion range of motion-can side-to-side symmetry be assumed?

CONTEXT: In clinical practice, the range of motion (ROM) of the non involved side often serves as the reference for comparison with the injured side. Previous investigations of non-weight-bearing (NWB) ankle dorsiflexion (DF) ROM measurements have indicated bilateral symmetry for the most part. Less is known about ankle DF measured under weight-bearing (WB) conditions. Because WB and NWB ankle DF are not strongly correlated, there is a need to determine whether WB ankle DF is also symmetrical in a healthy population. OBJECTIVE: To determine whether WB ankle DF is bilaterally symmetrical. A secondary goal was to further explore the correlation between WB and NWB ankle DF ROM. DESIGN: Cross-sectional study. SETTING: Training facility of the Israeli Defense Forces. PATIENTS OR OTHER PARTICIPANTS: A total of 64 healthy males (age = 19.6 ± 1.0 years, height = 175.0 ± 6.4 cm, and body mass = 71.4 ± 7.7 kg). MAIN OUTCOME MEASURE(S): Dorsiflexion ROM in WB was measured with an inclinometer and DF ROM in NWB was measured with a universal goniometer. All measurements were taken bilaterally by a single examiner. RESULTS: Weight-bearing ankle DF was greater on the nondominant side compared with the dominant side (P < .001). Non-weight-bearing ankle DF was not different between sides (P = .64). The correlation between WB and NWB DF was moderate, with the NWB DF measurement accounting for 30% to 37% of the variance of the WB measurement. CONCLUSIONS: Weight-bearing ankle DF ROM should not be assumed to be bilaterally symmetrical. These findings suggest that side-to-side differences in WB DF may need to be interpreted while considering which side is dominant. The difference in bilateral symmetry between the WB and NWB measurements, as well as the only moderate level of correlation between them, suggests that both measurements should be performed routinely.

Ankle dorsiflexion among healthy men with different qualities of lower extremity movement.

CONTEXT: Lower extremity movement patterns have been implicated as a risk factor for various knee disorders. Ankle-dorsiflexion (DF) range of motion (ROM) has previously been associated with a faulty movement pattern among healthy female participants. OBJECTIVE: To determine the association between ankle DF ROM and the quality of lower extremity movement during the lateral step-down test among healthy male participants. DESIGN: Cross-sectional study. SETTING: Training facility of the Israel Defense Forces. PATIENTS OR OTHER PARTICIPANTS: Fifty-five healthy male Israeli military recruits (age = 19.7 ± 1.1 years, height = 175.4 ± 6.4 cm, mass = 72.0 ± 7.6 kg). INTERVENTION(S): Dorsiflexion ROM was measured in weight-bearing and non-weight-bearing conditions using a fluid-filled inclinometer and a universal goniometer, respectively. Lower extremity movement pattern was assessed visually using the lateral step-down test and classified categorically as good or moderate. All measurements were performed bilaterally. MAIN OUTCOME MEASURE(S): Weight-bearing and non-weight-bearing DF ROM were more limited among participants with moderate quality of movement than in those with good quality of movement on the dominant side (P = .01 and P = .02 for weight-bearing and non-weight-bearing DF, respectively). Non-weight-bearing DF demonstrated a trend toward a decreased range among participants with moderate compared with participants with good quality of movement on the nondominant side (P = .03 [adjusted P = .025]). Weight-bearing DF was not different between participants with good and moderate movement patterns on the nondominant side (P = .10). Weight-bearing and non-weight-bearing ankle DF ROM correlated significantly with the quality of movement on both sides (P < .01 and P < .05 on the dominant and nondominant side, respectively). CONCLUSIONS: Ankle DF ROM was associated with quality of movement among healthy male participants. The association seemed weaker in males than in females.