Prospective Functional Performance Testing and Lower Extremity Injury Incidence in Adolescent Athletes

M.S. University of Hawaii at Manoa 2015.Includes bibliographical references.The purpose of this study was to prospectively investigate if a battery of functional performance tests could be used as a preseason screening tool to identify adolescent athletes at risk for sports-related lower extremity injury via comparison of injured and uninjured subjects. Ninety-five adolescent volleyball, basketball and soccer athletes (female, n=62; male, n=38; mean age = 14.4±1.6) participated. Each subject performed a battery of functional performance tests during the preseason, referred to in the present study as the “Lower Extremity Grading System” (LEGS). The LEGS assessment included: triple hop for distance, star excursion balance test, double leg lowering maneuver, drop jump video test, and multi-stage fitness test. Subjects were monitored throughout their designated sport season(s), which consisted of a six-month surveillance period. The schools certified athletic trainer recorded all injuries. Subjects were divided into groups according to gender and injury incidence (acute lower extremity injury vs. uninjured). Univariate general linear model (GLM) was used to assess differences between groups. Pearson product moment correlation coefficients were determined between variables of interest. The receiver-operator characteristic (ROC) analysis was used to determine the cut-off score. The prospective mean LEGS composite scores were significantly lower between the injured and uninjured groups in both genders (males: 19.06±3.59 vs. 21.90±2.44; females: 19.48±3.35 vs. 22.10±3.06 injured and uninjured, respectively)(p < .05). The ROC analysis determined the cut-off at ≤20 for both genders (sensitivity=.71, specificity=.81, for males; sensitivity=.67, specificity=.69, for females)(p<.05), suggesting moderate predictability for acute noncontact lower extremity injuries. Furthermore, significant positive correlations were found between the LEGS composite score and the multi-stage fitness test (r=.474, p=.003) in male subjects, suggesting a relationship between functional performance, aerobic capacity, and potential injury risk. Identifying individuals who are at greatest risk and prescribing corrective, neuromuscular, and cardiovascular exercise at the appropriate time during developmental stages for adolescent athletes may reduce sports-related injury risk

Meniscal ramp lesions: Anatomy, biomechanics, and clinical outcomes

Introduction: Anterior cruciate ligament (ACL) tears are the most common researched pathology in all of sports medicine. Researchers and clinicians have dedicated their careers to investigating the treatment of ACL tears and why ACL reconstructions fail. The medial meniscus is a known secondary stabilizer to the ACL and recent clinical studies have reported that meniscal deficiency is the most significant factor to predict ACL reconstruction graft failure. Meniscal ramp lesions, originally defined as peripheral tears of the posterior horn of the medial meniscus, have been reported to occur in roughly a quarter of all patients who suffer an ACL tear and have become increasingly recognized in the field of sports medicine over the past decade. However, controversy exists regarding identification and treatment of these lesions and a consensus has yet to be made on their exact biomechanical role in ACL deficient and ACL reconstructed knees

Incidence of Displaced Posterolateral Tibial Plateau and Lateral Femoral Condyle Impaction Fractures in the Setting of Primary Anterior Cruciate Ligament Tear

Background: Bone bruising of the posterolateral tibial plateau and the lateral femoral condyle sulcus terminalis has a well-established association with anterior cruciate ligament (ACL) tears. Impaction fractures of the femur and tibia may occur in these locations; however, there is a paucity of literature describing these fractures. Purpose: The primary objective was to quantify the incidence, size, and location of impaction fractures of the posterolateral tibial plateau and lateral femoral condyle in patients with primary ACL tears. The secondary objective was to investigate the association between impaction fractures and concomitant meniscal and ligamentous injuries. Study Design: Case series; Level of evidence 4. Methods: Patients with available magnetic resonance imaging (MRI) scans who were treated for primary ACL tear by a single surgeon were identified. MRI scans were reviewed with denotation of posterolateral tibial and femoral condylar contusions and displaced impaction fractures. Measurements of the lateral tibial plateau were taken in all patients with displaced lateral tibial plateau fractures and in a subset of control patients without tibial plateau fracture present to characterize the size and location of the bony lesion. Associations of impaction fractures with concomitant meniscal or ligamentous injuries were evaluated through use of chi-square testing. Results: There were 825 knees identified with available MRI scans. Lateral tibial plateau bone bruising was present in 634 knees (76.8%), and lateral femoral condyle bone bruising was present in 407 knees (49.3%). Posterolateral tibial plateau impaction fractures were present in 407 knees (49.3%), and lateral femoral condylar impaction fractures were present in 214 knees (25.9%). Patients with posterolateral tibial plateau impaction fractures were older than patients without these fractures (42.6 vs 32.7 years; P < .001), whereas patients with lateral femoral condylar impaction fractures were younger (23.8 vs 32.7 years; P < .001). There were 71 knees (8.6%) with a posterolateral tibial plateau impaction fracture with greater than 10% loss of lateral tibial plateau depth, and this group had an increased incidence of lateral meniscus posterior root tears (22.1% vs 12.0%; P = .02). Conclusion: Posterolateral tibial plateau impaction fractures occurred with a high incidence (49.3%) in patients with primary ACL tears and demonstrated an increased association with lateral meniscus posterior horn root tears as their size increased. Lateral femoral condylar impaction fractures occurred in 25.9% of patients with primary ACL tears and entailed an increased incidence of lateral meniscal tears and medial meniscal ramp lesions

Biomarkers for Osteoarthritis Diseases

Growing evidence has revealed the pivotal role of inflammatory biomarkers in the pathogenesis of osteoarthritis. There is significant interest in the prognostic value of select biomarkers, given the potential for early identification and treatment of patients at risk of osteoarthritis prior to the development of irreversible clinical disease. Clinical trials of novel therapeutics that disrupt the inflammatory pathways of osteoarthritis are also ongoing. The purpose of this review is to summarize the current literature on key biomarkers within the context of osteoarthritis pathogenesis, clinical symptom development, and treatment capabilities. Multiple recent studies have established biomarkers that signal the existence of osteoarthritis pathology and the development of clinical symptomology. However, prior to implementation in clinical practice, additional research is required to precisely define the prognostic value for numerous biomarkers and standardize their measurement. Biomarker-driven investigations represent a promising avenue for the early diagnosis and treatment of osteoarthritis

Preventative and Disease-Modifying Investigations for Osteoarthritis Management Are Significantly Under-represented in the Clinical Trial Pipeline: A 2020 Review

Purpose: To conduct a review of active United States–based clinical trials investigating preventative, symptom resolution, and disease-modifying therapies for osteoarthritis (OA). Methods: We conducted a review of currently active clinical trials for OA using data obtained from the ClinicalTrials.gov database as of August 2020. The inclusion criteria were active studies registered in the United States that involved the prevention, symptom resolution, or disease modification of OA. Descriptive statistics were recorded and summarized. Results: A total of 3,859 clinical trials were identified, and 310 were included in the final analysis. Of the currently active trials, 89% (n = 275) targeted symptom resolution in patients with existing OA, 6% (n = 19) targeted OA disease-modifying therapeutics, and 5% (n = 16) targeted the prevention of OA in high-risk patients (P < .001). Primary interventions included medical devices (44%, n = 137), pharmaceutical drugs (14%, n = 42), surgical procedures (14%, n = 42), cellular biologics (13%, n = 41), and behavioral therapies (13%, n = 41). There was a significantly higher number of disease-modifying therapeutics for cellular biologics than pharmaceutical drugs (30% vs 14%) (P = .015). Most trials targeted the knee joint (63%, P = .042), with 38% of all trials evaluating joint arthroplasty. There were no significant differences between private sector and government funding sources (43% and 49%, respectively) (P = .288), yet there was a significantly lower rate of funding from industry (8%) (P = .026). Conclusions: There was a significantly higher number of clinical trials investigating symptomatic resolution therapy (89%) for existing OA in comparison to preventative (5%) and disease-modifying (6%) therapies. The most common interventions involved medical devices and joint replacement surgery, with the knee joint accounting for more than 60% of the current clinical trials for OA. There was a significantly higher number of disease-modifying therapeutics for cellular biologics than pharmaceutical drugs. Funding of clinical trials was split between the private sector and government, with a low rate of reported funding from industry partners

Efficacy of vitamin C supplementation on collagen synthesis and oxidative stress after musculoskeletal injuries: A systematic review

Background: Recent investigations on the biochemical pathways after a musculoskeletal injury have suggested that vitamin C (ascorbic acid) may be a viable supplement to enhance collagen synthesis and soft tissue healing. Purpose: To (1) summarize vitamin C treatment protocols; (2) report on the efficacy of vitamin C in accelerating healing after bone, tendon, and ligament injuries in vivo and in vitro; and (3) report on the efficacy of vitamin C as an antioxidant protecting against fibrosis and promoting collagen synthesis. Study Design: Systematic review; Level of evidence, 2. Methods: A systematic review was performed, with the inclusion criteria of animal and human studies on vitamin C supplementation after a musculoskeletal injury specific to collagen cross-linking, collagen synthesis, and biologic healing of the bone, ligament, and tendon. Results: The initial search yielded 286 articles. After applying the inclusion and exclusion criteria, 10 articles were included in the final analysis. Of the preclinical studies evaluating fracture healing, 2 studies reported significantly accelerated bone healing in the vitamin C supplementation group compared with control groups. The 2 preclinical studies evaluating tendon healing reported significant increases in type I collagen fibers and scar tissue formation with vitamin C compared with control groups. The 1 preclinical study after anterior cruciate ligament (ACL) reconstruction reported significant short-term (1-6 weeks) improvements in ACL graft incorporation in the vitamin C group compared with control groups; however, there was no long-term (42 weeks) difference. Of the clinical studies evaluating fracture healing, 1 study reported no significant differences in the rate of fracture healing at 50 days or functional outcomes at 1 year. Vitamin C supplementation was shown to decrease oxidative stress parameters by neutralizing reactive oxygen species through redox modulation in animal models. No animal or human studies reported any adverse effects of vitamin C supplementation. Conclusion: Preclinical studies demonstrated that vitamin C has the potential to accelerate bone healing after a fracture, increase type I collagen synthesis, and reduce oxidative stress parameters. No adverse effects were reported with vitamin C supplementation in either animal models or human participants; thus, oral

Medial Meniscus Root Repair in Patients With Open Physes

Meniscal root tears have become increasingly recognized in the past decade. Lateral meniscus root tears typically occur in active, younger patients who sustain acute anterior cruciate ligament tears. Conversely, medial meniscus root tears typically occur in isolation and affect middle-aged patients. However, recent reports have described the incidence of meniscal root tears occurring in pediatric populations who are skeletally immature. The purpose of this technical note is to describe the authors' surgical technique for medial meniscal root repair for patients with open physes

Low-Energy Multiligament Knee Injuries Are Associated With Higher Postoperative Activity Scores Compared With High-Energy Multiligament Knee Injuries: A Systematic Review and Meta-analysis of the Literature

Background: Multiligament knee injuries (MLKIs) can result from high-energy injury mechanisms such as motor vehicle accidents or low-energy injury mechanisms such as activities of daily living or sports. Purpose/Hypothesis: The purpose was to conduct a systematic review on postoperative patient-reported outcomes after MLKIs and to conduct a meta-analysis of comparable outcome variables based upon high- versus low-energy injury mechanisms. It was hypothesized that MLKIs with low-energy injury mechanisms would demonstrate significantly improved subjective clinical outcome scores compared with high-energy injuries. Study design: Meta-analysis and systematic review. Methods: A systematic review was performed with the inclusion criteria of postoperative MLKI outcomes based upon high-versus low-energy mechanisms of injury with a minimum 2-year follow-up. Outcome scores included were the Lysholm knee scoring scale, Tegner activity scale, and the International Knee Documentation Committee (IKDC) score. High-energy mechanisms included motor vehicle accidents or falls from a height >5 feet; low-energy mechanisms included sports-related injuries, activities of daily living, or falls from .05). The low-energy injury group demonstrated significantly higher Tegner activity scale scores (5.0 vs 3.9; P = .03). There was no significant difference in failure rates between groups (3.5% vs 2.0%; P = .23). Conclusion: We found in this systematic review and meta-analysis that patients with low-energy mechanisms of MLKI surgery had improved postoperative Tegner activity scores compared with those patients with high-energy mechanisms after MLKI surgery. However, there were no differences in Lysholm score, IKDC score, or failure rates between high- and low-energy MLKI patients at an average of 5.3 years postoperatively

Posterior Tibial Slope and Risk of Posterior Cruciate Ligament Injury

Background: Recent biomechanical studies have identified sagittal plane posterior tibial slope as a potential risk factor for posterior cruciate ligament (PCL) injury because of its effects on the kinematics of the native and surgically treated knee. However, the literature lacks clinical correlation between primary PCL injuries and decreased posterior tibial slope. Purpose/Hypothesis: The purpose of this study was to retrospectively compare the amount of posterior tibial slope between patients with PCL injuries and age/sex-matched controls with intact PCLs. It was hypothesized that patients with PCL injuries would have a significantly decreased amount of posterior tibial slope when compared with patients without PCL injuries. Study Design: Case-control study; Level of evidence, 3. Methods: Patients who underwent primary PCL reconstruction without anterior cruciate ligament injury between 2010 and 2017 by a single surgeon were retrospectively analyzed. Measurements of posterior tibial slope were performed with lateral radiographs of PCL-injured knees and matched controls without clinical or magnetic resonance imaging evidence of ligamentous injury. Mean values of posterior tibial slope were compared between the groups. Inter- and intrarater agreement was assessed for the tibial slope measurement technique via a 2-way random effects model to calculate the intraclass correlation coefficient (ICC). Results: In sum, 104 patients with PCL tears met the inclusion criteria, and 104 controls were matched according to age and sex. There were no significant differences in age (P = .166), sex (P = .345), or body mass index (P = .424) between the PCL-injured and control groups. Of the PCL tear cohort, 91 patients (87.5%) sustained a contact mechanism of injury, while 13 (12.5%) reported a noncontact mechanism of injury. The mean ± SD posterior tibial slopes were 5.7°± 2.1° (95% CI, 5.3°-6.1°) and 8.6°± 2.2° (95% CI, 8.1°-9.0°) for the PCL-injured and matched control groups, respectively (P < .0001). Subgroup analysis of the PCL-injured knees according to mechanism of injury demonstrated significant differences in posterior tibial slope between noncontact (4.6°± 1.8°) and contact (6.2°± 2.2°) injuries for all patients with PCL tears (P = .013) and among patients with isolated PCL tears (P = .003). The tibial slope measurement technique was highly reliable, with an ICC of 0.852 for interrater reliability and an ICC of 0.872 for intrarater reliability. Conclusion: A decreased posterior tibial slope was associated with patients with PCL tears as compared with age- and sex-matched controls with intact PCLs. Decreased tibial slope appears to be a risk factor for primary PCL injury. However, further clinical research is needed to assess if decreased posterior tibial slope affects posterior knee stability and outcomes after PCL reconstruction