Experts Achieve Consensus on a Majority of Statements Regarding Platelet-Rich Plasma Treatments for Treatment of Musculoskeletal Pathology.

PURPOSE: To establish consensus statements on platelet-rich plasma (PRP) for the treatment of musculoskeletal pathologies. METHODS: A consensus process on the treatment of PRP using a modified Delphi technique was conducted. Thirty-five orthopaedic surgeons and sports medicine physicians participated in these consensus statements on PRP. The participants were composed of representatives of the Biologic Association, representing 9 international orthopaedic and musculoskeletal professional societies invited due to their active interest in the study of orthobiologics. Consensus was defined as achieving 80% to 89% agreement, strong consensus was defined as 90% to 99% agreement, and unanimous consensus was indicated by 100% agreement with a proposed statement. RESULTS: There was consensus on 62% of statements about PRP. CONCLUSIONS: (1) PRP should be classified based on platelet count, leukocyte count, red blood count, activation method, and pure-plasma versus fibrin matrix; (2) PRP characteristics for reporting in research studies are platelet count, leukocyte count, neutrophil count, red blood cell count, total volume, the volume of injection, delivery method, and the number of injections; (3) the prognostic factors for those undergoing PRP injections are age, body mass index, severity/grade of pathology, chronicity of pathology, prior injections and response, primary diagnosis (primary vs postsurgery vs post-trauma vs psoriatic), comorbidities, and smoking; (4) regarding age and body mass index, there is no minimum or maximum, but clinical judgment should be used at extremes of either; (5) the ideal dose of PRP is undetermined; and (6) the minimal volume required is unclear and may depend on the pathology. LEVEL OF EVIDENCE: Level V, expert opinion.

A modified Delphi consensus statement on patellar instability: part I.

Aims: The aim of this study was to establish consensus statements on the diagnosis, nonoperative management, and indications, if any, for medial patellofemoral complex (MPFC) repair in patients with patellar instability, using the modified Delphi approach. Methods: A total of 60 surgeons from 11 countries were invited to develop consensus statements based on their expertise in this area. They were assigned to one of seven working groups defined by subtopics of interest within patellar instability. Consensus was defined as achieving between 80% and 89% agreement, strong consensus was defined as between 90% and 99% agreement, and 100% agreement was considered to be unanimous. Results: Of 27 questions and statements on patellar instability, three achieved unanimous consensus, 14 achieved strong consensus, five achieved consensus, and five did not achieve consensus. Conclusion: The statements that reached unanimous consensus were that an assessment of physeal status is critical for paediatric patients with patellar instability. There was also unanimous consensus on early mobilization and resistance training following nonoperative management once there is no apprehension. The statements that did not achieve consensus were on the importance of immobilization of the knee, the use of orthobiologics in nonoperative management, the indications for MPFC repair, and whether a vastus medialis oblique advancement should be performed.

A modified Delphi consensus statement on patellar instability: part II.

Aims: The aim of this study was to establish consensus statements on medial patellofemoral ligament (MPFL) reconstruction, anteromedialization tibial tubercle osteotomy, trochleoplasty, and rehabilitation and return to sporting activity in patients with patellar instability, using the modified Delphi process. Methods: This was the second part of a study dealing with these aspects of management in these patients. As in part I, a total of 60 surgeons from 11 countries contributed to the development of consensus statements based on their expertise in this area. They were assigned to one of seven working groups defined by subtopics of interest. Consensus was defined as achieving between 80% and 89% agreement, strong consensus was defined as between 90% and 99% agreement, and 100% agreement was considered unanimous. Results: Of 41 questions and statements on patellar instability, none achieved unanimous consensus, 19 achieved strong consensus, 15 achieved consensus, and seven did not achieve consensus. Conclusion: Most statements reached some degree of consensus, without any achieving unanimous consensus. There was no consensus on the use of anchors in MPFL reconstruction, and the order of fixation of the graft (patella first versus femur first). There was also no consensus on the indications for trochleoplasty or its effect on the viability of the cartilage after elevation of the osteochondral flap. There was also no consensus on postoperative immobilization or weightbearing, or whether paediatric patients should avoid an early return to sport.

High Compliance with the 11+ Injury Prevention Program Results in Better Win-Loss Records.

Background: The 11+ injury prevention program (IPP) has been shown to decrease injury rates. However, few studies have investigated compliance and its overall relationship to team performance. Hypothesis/Purpose: To examine if level of compliance while implementing the 11+ would impact team performance outcomes (wins, losses and ties). The authors hypothesized that higher team compliance to the IPP would be consistent with improved overall team performance (more wins and fewer losses). Study Design: Prospective, cluster randomized controlled trial. Methods: This study was conducted in NCAA men's soccer teams for one season and examined the efficacy of the 11+ IPP. The outcome variables examined were levels of compliance and team performance record: wins, losses, and ties. Twenty-seven teams (n=675 players) served as the intervention group (IG) and used the 11+ program while 34 teams (n=850 players) served as the control group (CG). Compliance and team performance were recorded. There were three compliance categories that were defined prospectively, low (LC, < 1 dose/week), moderate (MC, >1 and <2 doses/week), and high (HC, >2 doses/week). Descriptive and inferential tests were used to compare the CG, the IG, and compliance to team performance. Three independent t-tests were used to analyze outcome to group (IG vs. CG). A one way-MANOVA test was used to analyze compliance to win/loss/tie record, followed up by one-way ANOVA tests to analyze how compliance impacted wins, losses and ties, independently. Partial η2 measures were calculated to determine the effect size of level of compliance on outcome. A Tukey post-hoc analysis was used to analyze specific differences between levels of compliance and specific outcome measures. Results: There were significantly more wins (IG: 10.67±2.63 versus CG: 8.15±3.83, CI, 7.95 - 9.69, p = 0.005) and fewer losses (IG: 5.56±1.97 versus CG: 8.12±3.59, CI, 5.66 to 7.43, p = 0.002) recorded for the teams using the 11+ program. There was a statistically significant difference between levels of compliance (high, moderate or low) on the dependent variables (wins, losses, and ties), F(3, 22) = 3.780, p =0.004; Wilks' Λ = .435; partial η2 = .340. Conclusion: The 11+ has the capacity to improve overall team performance in male collegiate soccer teams. The higher the compliance, the more favorable the team performance. This research may be a vital addition when attempting to persuade coaching staffs to adopt an IPP into their training regimen. Level of Evidence: Level I.

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

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

Discoid Lateral Meniscus.

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

Quadriceps Weakness is Associated with Neuroplastic Changes Within Specific Corticospinal Pathways and Brain Areas After Anterior Cruciate Ligament Reconstruction: Theoretical Utility of Motor Imagery-Based Brain-Computer Interface Technology for Rehabilitation.

Persistent quadriceps weakness is a problematic sequela of anterior cruciate ligament reconstruction (ACLR). The purposes of this review are to summarize neuroplastic changes after ACL reconstruction; provide an overview of a promising interventions, motor imagery (MI), and its utility in muscle activation; and propose a framework using a brain-computer interface (BCI) to augment quadriceps activation. A literature review of neuroplastic changes, MI training, and BCI-MI technology in postoperative neuromuscular rehabilitation was conducted in PubMed, Embase, and Scopus. Combinations of the following search terms were used to identify articles: "quadriceps muscle," "neurofeedback," "biofeedback," "muscle activation," "motor learning," "anterior cruciate ligament," and "cortical plasticity." We found that ACLR disrupts sensory input from the quadriceps, which results in reduced sensitivity to electrochemical neuronal signals, an increase in central inhibition of neurons regulating quadriceps control and dampening of reflexive motor activity. MI training consists of visualizing an action, without physically engaging in muscle activity. Imagined motor output during MI training increases the sensitivity and conductivity of corticospinal tracts emerging from the primary motor cortex, which helps "exercise" the connections between the brain and target muscle tissues. Motor rehabilitation studies using BCI-MI technology have demonstrated increased excitability of the motor cortex, corticospinal tract, spinal motor neurons, and disinhibition of inhibitory interneurons. This technology has been validated and successfully applied in the recovery of atrophied neuromuscular pathways in stroke patients but has yet to be investigated in peripheral neuromuscular insults, such as ACL injury and reconstruction. Well-designed clinical studies may assess the impact of BCI on clinical outcomes and recovery time. Quadriceps weakness is associated with neuroplastic changes within specific corticospinal pathways and brain areas. BCI-MI shows strong potential for facilitating recovery of atrophied neuromuscular pathways after ACLR and may offer an innovative, multidisciplinary approach to orthopaedic care. Level of Evidence: V, expert opinion.

Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention.

The Academy of Orthopaedic Physical Therapy and the American Academy of Sports Physical Therapy have an ongoing effort to create evidence-based clinical practice guidelines (CPGs) for orthopaedic and sports physical therapy management and prevention of musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability and Health (ICF). This guideline focuses on the exercise-based prevention of knee injuries and provides an update on the 2018 guideline, J Orthop Sports Phys Ther. 2018;48(9):A1-A42. doi:10.2519/jospt.2018.0303 J Orthop Sports Phys Ther. 2023;53(1):CPG1-CPG34. doi:10.2519/jospt.2023.0301.

An Initial Injection and a Crossover Injection of Amniotic Suspension Allograft Following Failed Treatment with Hyaluronic Acid or Saline Are Equally Effective in the Treatment of Moderate Symptomatic Knee Osteoarthritis Over 12 Months.

PURPOSE: The purpose of this crossover study was to determine the efficacy of amniotic suspension allograft (ASA) for moderate symptomatic knee osteoarthritis following failed treatment with hyaluronic acid (HA) or saline through 12 months' postcrossover injection using patient-reported and safety outcomes. METHODS: In this multicenter study, 95 patients from a 200-patient single-blind randomized controlled trial were eligible to crossover and receive a single injection of ASA 3 months after failed treatment with HA or saline. Patient-reported outcomes, including Knee Injury and Osteoarthritis Outcome Score (KOOS) and visual analog scale (VAS), were collected out to 12 months postcrossover to determine pain and function. Radiographs and blood were collected for assessment of changes. Statistical analyses were performed using mixed effects model for repeated measures. RESULTS: Treatment with ASA following failed treatment with HA or saline resulted in significant improvements in KOOS and VAS scores compared with crossover baseline. There were no differences in radiographic measures or anti-human leukocyte antigen serum levels compared with baseline and no severe adverse events reported. In addition, more than 55% of patients were responders at months 3, 6, and 12 as measured by the Outcome Measures in Arthritis Clinical Trials-Osteoarthritis Research Society International simplified responder criteria. There were no significant differences between the original ASA randomized group and crossover cohorts at any of the time points evaluated, suggesting that prior failed treatment with HA or saline did not significantly impact outcomes following treatment with ASA. CONCLUSIONS: This study showed that patients who previously failed treatment with HA or saline had statistically significant improvements in pain and function scores following a crossover injection of ASA that was sustained for 12 months, as measured by KOOS and VAS. There were no serious adverse events reported, and the injection was safe. LEVEL OF EVIDENCE: II, prospective cohort study.

Conceptos actuales en el diagnóstico y tratamiento de las lesiones del hueso subcondral / Current concepts in the diagnosis and treatment of subchondral bone injuries

La patología ósea subcondral incluye una amplia gama de patologías, como la artrosis, las fracturas por insuficiencia espontánea, la osteonecrosis y los traumatismos articulares. Todas muestran hallazgos típicos de imágenes de resonancia magnética (RM) denominados lesiones de la médula ósea (LMO). Sin embargo, la etiología y la evolución de las LMO en múltiples afecciones aún no están claras. Además, todavía no existe un protocolo de tratamiento estándar de oro para las LMO, es por esto que se están probando una variedad de modalidades de tratamiento con la esperanza de que puedan reducir el dolor y detener la progresión de la enfermedad. Nuestro propósito es presentar una revisión sobre los conceptos actuales para el diagnóstico y tratamiento de las LMO. Se realizó una revisión de la literatura que incluyó búsquedas en las bases de datos PubMed, Cochrane y Medline utilizando las siguientes palabras clave: lesiones de médula ósea subcondral, hueso subcondral, subcondroplastia, concentrado de médula ósea, plasma rico en plaquetas (PRP) y aumento óseo subcondral. Podemos concluir que el uso de nuevas técnicas biológicas para tratar las LMO, como el PRP y las células de la médula ósea, ha mostrado resultados clínicos prometedores. La investigación futura de las LMO será necesaria para abordar mejor las diferentes patologías y determinar las estrategias terapéuticas adecuadas. Todavía se necesitan estudios randomizados y controlados de alta calidad junto a revisiones sistemáticas para generar guías y recomendaciones para el tratamiento de las LMO.

Subchondral bone pathology includes a wide range of pathologies, such as osteoarthritis, spontaneous insufficiency fractures, osteonecrosis, and trauma. They show typical magnetic resonance imaging (MRI) findings termed bone marrow lesions (BMLs). However, the etiology and evolution of BMLs in multiple conditions remains unclear. There is still no gold standard treatment protocol in treating BML, and a variety of treatment modalities have been tested in the hope that they might reduce pain and stop disease progression.Our purpose was to write a current concepts review about diagnosis and treatment options for BMLs. A literature review was performed that included searches of PubMed, Cochrane, and Medline databases using the following keywords: Bone marrow lesions, subchondral bone, subchondroplasty, bone marrow concentrate, platelet-rich plasma (PRP), subchondral bone augmentation.The use of novel biologic techniques to treat BMLs, such as PRP and Bone Marrow Cells, has yielded promising clinical outcomes. Future research of BMLs will be mandatory to address the different pathologies better and determining appropriate treatment strategies. There is still a need for high-quality RCTs studies and systematic reviews in the future to enhance further treatment strategy in preventing or treating BMLs of the knee.

Regulatory and Ethical Aspects of Orthobiologic Therapies.

Orthobiologic therapies show significant promise to improve outcomes for patients with musculoskeletal pathology. There are considerable research efforts to develop strategies that seek to modulate the biological environment to promote tissue regeneration and healing and/or provide symptomatic relief. However, the regulatory pathways overseeing the clinical translation of these therapies are complex, with considerable worldwide variation. The introduction of novel biologic treatments into clinical practice raises several ethical dilemmas. In this review, we describe the process for seeking approval for biologic therapies in the United States, Europe, and Japan. We highlight a number of ethical issues raised by the clinical translation of these treatments, including the design of clinical trials, monitoring outcomes, biobanking, "off-label" use, engagement with the public, marketing of unproven therapies, and scientific integrity.

Predictors of Quadriceps Strength Asymmetry after Anterior Cruciate Ligament Reconstruction: A Chi-Squared Automatic Interaction Detection Decision Tree Analysis.

INTRODUCTION: The influence of graft type on the restoration of quadriceps strength symmetry after ACL reconstruction (ACLR) has been widely studied. However, an important consideration when evaluating quadriceps symmetry is the fact that this measure can be influenced by numerous factors beyond graft type. This study sought to determine if graft type is predictive of quadriceps strength asymmetry during the first 12 months post-ACLR taking into consideration potentially influential factors (i.e., age, sex, body mass index, time post-ACLR). METHODS: We retrospectively reviewed quadriceps strength data from 434 patients (303 female patients and 131 male patients) who had previously undergone ACLR with an autograft (hamstring tendon, quadriceps tendon [QT], patellar tendon [PT]) or allograft. Chi-Squared Automatic Interaction Detection decision tree analysis was used to evaluate if graft type is predictive of quadriceps strength asymmetry during the first 12 months post-ACLR taking into consideration age, sex, body mass index, and time post-ACLR. RESULTS: The best predictor of quadriceps strength asymmetry was graft type. Specifically, three graft categories were identified: 1) allograft and hamstring tendon autograft, 2) PT autograft, and 3) QT autograft. The average quadriceps strength asymmetry for each of the three identified categories was 0.91, 0.87, and 0.81, respectively, and differed statistically from each other ( P < 0.001). The second-best predictor of quadriceps strength asymmetry was sex, albeit only in the PT and QT groups (with female patients having increased asymmetry). Female patients post-ACLR with a QT autograft were at highest risk for quadriceps strength asymmetry. CONCLUSIONS: Graft type and sex are important predictors of quadriceps strength asymmetry after ACLR. Clinicians should take these factors into consideration when designing rehabilitation protocols to restore quadriceps strength symmetry during the postoperative period.

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

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

Confidence to Return to Play After ACL Reconstruction: An Evaluation of Quadriceps Strength Symmetry and Injury Mechanism in Male Athletes.

BACKGROUND: After anterior cruciate ligament reconstruction (ACLR), diminished quadriceps strength symmetry and reduced psychological readiness to return to play (RTP) increase the risk for subsequent injury. Although the relationship between quadriceps strength symmetry and psychological readiness to RTP has been reported to be influenced by injury mechanism in female athletes, it is unclear whether such a relationship exists in male athletes. HYPOTHESIS: Quadriceps strength symmetry would be positively associated with greater psychological readiness to RTP after ACLR, regardless of injury mechanism. STUDY DESIGN: Retrospective cohort. LEVEL OF EVIDENCE: Level 3 (cohort study). METHODS: Sixty male patients completed strength testing and the Injury-Psychological Readiness to Return to Sport Scale (I-PRRS) at an outpatient clinical facility as part of return to sport testing after ACLR. Linear regression analysis was used to assess the relationship between the I-PRRS and the independent variables of interest (quadriceps strength symmetry and injury mechanism). RESULTS: For all patients combined, no symmetry × mechanism interaction was found (P = 0.11). A significant positive relationship was found between quadriceps strength symmetry and the I-PRRS score (P < 0.001, R2 = 0.31), after adjusting for time post-ACLR and injury mechanism. CONCLUSION: Greater quadriceps strength symmetry was associated with greater psychological readiness to RTP after ACLR in male athletes. In contrast to what has been reported in female athletes, this relationship was independent of injury mechanism. CLINICAL RELEVANCE: Given the potential negative consequences of quadriceps strength deficits on one's confidence to RTP, the need to restore quadriceps symmetry during the postoperative period is readily apparent. Low confidence or low psychological readiness to RTP may be indicative of quadriceps strength asymmetry or poor physical function in general.

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

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

Editorial Commentary: When Treating Cartilage Lesions With Osseous Involvement, Biologic "Chondrofacilitation" Using Either Bone Marrow Aspirate Concentrate or Mesenchymal Stem Cells Augments Microfracture.

The use of biologic augmentation following microfracture for symptomatic cartilage defects of the knee with osseous involvement shows encouraging results. Bone marrow aspirate concentrate provides growth factors to the injury site, such as vascular endothelial growth factor, platelet-derived growth factor, transforming growth factor-ßa, and bone morphogenetic proteins in addition to the mesenchymal stem cells present in the concentrate. Cellular-based therapies like mesenchymal stem cells are becoming more widely used in conjunction with surgical treatment of focal cartilage lesions with early promising results. Both treatment options improve clinical and radiographic outcomes. As for the efficacy of mesenchymal stem cells versus bone marrow aspirate concentrate, we believe that both have promising results.

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

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

Biologic Association Annual Summit: 2020 Report.

Interest and research in biologic approaches for tissue healing are exponentially growing for a variety of musculoskeletal conditions. The recent hype concerning musculoskeletal biological therapies (including viscosupplementation, platelet-rich plasma, and cellular therapies, or "stem cells") is driven by several factors, including demand by patients promising regenerative evidence supported by substantial basic and translational work, as well as commercial endeavors that complicate the scientific and lay understanding of biological therapy outcomes. While significant improvements have been made in the field, further basic and preclinical research and well-designed randomized clinical trials are needed to better elucidate the optimal indications, processing techniques, delivery, and outcome assessment. Furthermore, biologic treatments may have potential devastating complications when proper methods or techniques are ignored. For these reasons, an association comprising several scientific societies, named the Biologic Association (BA), was created to foster coordinated efforts and speak with a unified voice, advocating for the responsible use of biologics in the musculoskeletal environment in clinical practice, spearheading the development of standards for treatment and outcomes assessment, and reporting on the safety and efficacy of biologic interventions. This article will introduce the BA and its purpose, provide a summary of the 2020 first annual Biologic Association Summit, and outline the future strategic plan for the BA.

Hamstring muscle injury in the athlete: state of the art.

Hamstring injuries (HSI) are the source of significant impairment and disability for both professional and recreational athletes. The incidence and prevalence of HSIs has been well documented in the literature, as they are among the most common soft tissue injuries reported. The significant time loss due to injury and the inherent risk of reinjury pose a significant issue to the athlete, their career longevity and the success of their respective team. This review will deal predominantly with describing the prevalence and incidence of HSI in athletes, discuss risk factors and the mechanisms of injury for HSI, how to properly diagnose, image and prognosticate appropriate return to sport (RTS) for individuals who have sustained an HSI, prescribe treatment and prevention strategies and to discuss relevant options to decrease overall risk of primary and secondary recurrence of HSI.Current treatments of acute HSI necessitate a thorough understanding of the mechanism of injury, identifying muscle imbalances and/or weakness, inclusion of eccentric and concentric hamstring (HS) and hip extension (HE) exercises, evaluation of pathokinematic movement patterns and use non-surgical methods to promote healing and RTS. This methodology can be used prospectively to mitigate the overall risk of HSI. Injection therapies for HSI, including ultrasound-guided platelet-rich plasma and corticosteroids, may impart some short-term benefit, but the existing literature is largely inconclusive with respect to long-term functional outcomes. Future directions should prioritise injury prevention, early diagnosis and targeted interventions that combine both non-surgical and minimally invasive orthobiological approaches and identifying biomechanical risk factors prospectively to mitigate risk.

Complications Following Biologic Therapeutic Injections: A Multicenter Case Series.

PURPOSE: To describe the complications that occur following biologic therapeutic injections. METHODS: We queried physician members of the Biologic Association, a multidisciplinary organization dedicated to providing a unified voice for all matters related to musculoskeletal biologics and regenerative medicine. Patients included in this study must have (1) received a biologic injection, (2) sustained an adverse reaction, and (3) had a minimum of 1-year follow-up after the injection. Patient demographic information, medical comorbidities, diagnoses, and previous treatments were recorded. The type of injection, injection setting, injection manufacturers, and specific details about the complication and outcome were collected. RESULTS: In total, 14 patients were identified across 6 institutions in the United States (mean age 63 years, range: 36-83 years). The most common injections in this series were intra-articular knee injections (50%), followed intra-articular shoulder injections (21.4%). The most common underlying diagnosis was osteoarthritis (78.5%). Types of injections included umbilical cord blood, platelet-rich plasma, bone marrow aspirate concentrate, placental tissue, and unspecified "stem cell" injections. Complications included infection (50%), suspected sterile inflammatory response (42.9%), and a combination of both (7.1%). The most common pathogen identified from infection cases was Escherichia coli (n = 4). All patients who had isolated infections underwent treatment with at least one subsequent surgical intervention (mean: 3.6, range: 1-12) and intravenous antibiotic therapy. CONCLUSIONS: This study demonstrates that serious complications can occur following treatment with biologic injections, including infections requiring multiple surgical procedures and inflammatory reactions. LEVEL OF EVIDENCE: Level IV, case series.