Comprehensive Evaluation of Hip Arthroscopy for Elite Athletes with Femoroacetabular Impingement and Associated Pathology

Femoroacetabular impingement (FAI) is a recognized source of debilitating hip pain among elite athletes. Hip arthroscopy, including labral repair, and FAI lesion correction have been gaining notoriety as methods to mitigate pain and enable athletes to return to their respective sports. PURPOSE: To provide a comprehensive understanding of the clinical presentation, surgical intervention, and outcomes of elite athletes suffering from hip pain attributed to FAI and associated pathology. METHODS: Elite athletes (n = 35; females = 12) from various sports, including basketball, soccer, martial arts, water polo, and weightlifting, participated. Following unsuccessful conservative management (e.g., analgesic medications, physical therapy), all participants consented to undergo hip arthroscopy. The surgical procedures were conducted under epidural anesthesia with patients in the supine position. We assessed the modified Harris hip score (MHHS) both preoperatively and at the 12-week postoperative mark. After surgery, athletes followed individualized physical therapy programs with physician supervision. RESULTS: The intraoperative findings revealed labral detachment in all 35 athletes, alongside various FAI lesions and cartilage defects. Surgical interventions included labral repair using bioabsorbable anchors, burring pincer and cam lesions, and inducing subchondral bone microfractures where necessary. Postoperatively, athletes exhibited statistically significant improvements, with a mean preoperative MHHS of 69 (at 1 week) rising to a mean postoperative MHHS of 92 (at 12 weeks) (t(34) = -9.62, p d = 2.29). Notably, 29 athletes (83%) reported being pain-free and returning to pre-surgical activity levels within 12 weeks. Three athletes (8.5%) endured residual pain due to iliopsoas tendinitis but resumed full activity between 15-18 weeks postoperatively. Three athletes (8.5%) developed heterotopic ossification but did not require reoperation. CONCLUSION: Hip arthroscopy involving classic labral and FAI lesion repair provides a successful approach for correcting hip pathology in elite athletes. This intervention, although continually evolving, remains a potent tool in the arsenal of sports medicine, allowing for the restoration of hip joint biomechanical function

Femur Stress Fracture - Marathon

HISTORY: During a race, a 35-year-old marathon runner complained of experiencing dull, achy pain in the right groin. After the race, he occasionally experienced radiating pain in the right thigh. The athlete was examined by a general practitioner (GP). During the clinical evaluation, the athlete had no signs of tenderness or swelling. The GP suggested rest and prescribed anti-inflammatory medication. PHYSICAL EXAMINATION: Ten days later, during training, the athlete felt the same discomfort after a challenging training session. He, then, decided to see an orthopedic physician. At the clinical examination, there was no localized pain. Focal pain was present during weight bearing activities only. Initial x-rays showed no significant abnormality or fracture. However, due to the complaints of the athlete, the doctor suggested additional x-rays and an MRI. DIFFERENTIAL DIAGNOSIS: Lumbar radiculopathy Rectus femoris strain Abductor strain Trochanteric bursitis TEST AND RESULTS: - X-ray showed a fracture of the middle shaft of the femur - MRI showed a medial periosteal reaction in the femoral shaft (high fluid signal) - Pain, especially during internal rotation - Pain on the affected side with a single-leg stance - Pain during activity, reproducible on passive range of motion FINAL / WORKING DIAGNOSIS: Stress fracture of the middle shaft of the right femur TREATMENT AND OUTCOMES: Tolerate weight bearing if no displacement occurs (four months max.) Treatment by a metabolic physician (Vitamin D deficiency or other) Continuing follow-up with repeated imaging: Verify resolution and minimize the progression to displacement Surgery if conservative management fails (see #1-3) Intramedullary rodding (surgical procedure

Sacral Stress Fracture — Wrestling

CASE HISTORY: During preseason, a 35-year-old wrestler complained of pain in his lower back concurrently with a tingling sensation in the left thigh and buttocks. PHYSICAL EXAM: The wrestler was examined by a physical therapist (PT) and, while discussing prior medical history, the athlete mentioned a previous diagnosis of a mild herniated disk (Grade 1). Upon clinical examination, the athlete demonstrated a full range of motion with some discomfort in passive hip extension. The PT suggested rest and rehabilitation through electrical stimulation, alongside the strengthening of the lumbar spine and hip abductor muscles. Ten days later, the athlete presented to an orthopedic surgeon (Ortho) complaining of the same discomfort. During the examination, the Ortho noticed the same localized tenderness over the left sacroiliac joint. Results for both the Lasegue and FABER tests were negative. Although there was no significant sign of fracture or edema, the Ortho suggested obtaining lumbar and pelvis X-Rays. He prescribed anti-inflammatory medication and performed a corticosteroid injection in the left sacroiliac joint. After treatment, the athlete had immediate relief and was able to compete the following day in his competitive event. One week later, the athlete returned to the outpatient clinic complaining that the pain was still localized in the left sacroiliac joint. The Ortho performed the hop test, which was positive. The athlete was then referred for an MRI of the spine and pelvis followed by a CT scan. DIFFERENTIAL DIAGNOSIS: 1. Spinal Disc Herniation Aggravation; 2. Sacroiliac Joint Misalignment; 3. Sciatic Neuritis; 4. Musculotendinous Strain; and 5. Sarcoma. TESTS & RESULTS: X-Ray: Clear; Hop test: Positive; MRI: a) Lumbar region: Mild L5-S1 herniation (Grade 1) with the lumbar spine curvature found to be within normal limits and b) Pelvis: Edema with associated marrow changes due to a non-displaced sacral stress fracture; CT Scan: Fracture line along with sclerosis parallel to the sacroiliac joint. FINAL DIAGNOSIS: Stress fracture on the left, anterior column of the sacrum. DISCUSSION: Clear X-Rays are associated with 20%-38% of misdiagnoses of sacral fractures. When a stress fracture is suspected, MRI should be the indicated exam, followed by a CT scan. Our clinical case gives an indication of the decision-making process so that other physicians can apply lateral thinking to their own cases. OUTCOME OF THE CASE: 1. Rehabilitation: Rest and light weight-bearing exercises (4 months) and 2. Anti-osteoporotic treatment: Calcium and Vitamin D. RETURN TO ACTIVITY AND FURTHER FOLLOW-UP: Return to participation: 5-12 months

Shoulder Arthroscopy After a Proximal Humeral Fracture Malunion: Athlete Care and Clinical Medicine in Middle-Aged Athletes

Malunion of the proximal humerus is operationally defined as healing of the fractured bone in a non-anatomical position, resulting in a painful and disabling deformity (e.g., a bone being shorter than normal, twisted or rotated in a bad position, or bent), which affects the range of motion (ROM) and functional movement. A correction and functional restoration are often needed in athletes, since their profession requires superior physical functioning. Shoulder arthroscopy has evolved dramatically over the past 15 years and has been used in cases of malunion of the humerus in athletes. However, there is a scarcity of evidence concerning middle-aged athletes. PURPOSE: To examine the benefits of shoulder arthroscopy after a proximal humeral fracture unified in malposition in middle-aged athletes. METHODS: Physical examination and imaging evaluation using 3D Computed Tomography(3D-CT), Magnetic Resonance Imaging (MRI), and shoulder radiographs (anteroposterior, internal rotation, and lateral scapular view) were used to evaluate shoulder dysfunction after proximal humeral fracture in malposition. Fourteen athletes (9 males, 5 females; Mage = 43.1, SD = 3.5) were included in this research. According to Neer classification before surgery, 11 (78%) had one part displaced and the rest three (22%) had two parts displaced. Post-operative clinical results were evaluated with self-reported pain score (1-10), UCLA scores, and shoulder abduction ROM measured with a goniometer. RESULTS: There was significant difference in pain scores (Mbefore = 8, Range: 6-9; Mafter = 4, Range: 2-6; p \u3c .001), in UCLA scores (Mbefore = 12, Range: 9-16; Mafter = 28, Range: 20-31; p \u3c .01), and in shoulder abduction ROM (Mbefore = 80, Range: 70-100; Mafter = 135, Range: 120-150; p \u3c .05). CONCLUSION: Our research provides evidence for clinical translation in improving health outcomes in middle-aged athletes with a history of proximal humeral fracture union in malposition: shoulder arthroscopy can be simultaneously beneficial in terms of decreasing pain level, increasing ROM, and restoring limb function

Microsurgical repair of nerve lesions with nerve and inside-out vein grafts: the effects of nerve growth factor

The aim of this study was to investigate the effect of local administration of Nerve Growth Factor-7S (NGF-7S) on the axonal regrowth of mixed peripheral nerves through nerve or inside-out vein grafts. One hundred twenty male Wistar rats were randomized in four groups of thirty animals each. A defect, 12 mm long in the right sciatic nerve, was inflicted and repaired either with a nerve autograft (group A and B) or with inside-out vein graft (group C and D). NGF-7S (group A and C) or normal saline (group B and D, control groups) was locally administered daily during the first 2 weeks, every second day the third and one single dose the fourth week. For this purpose, a subcutaneously implanted reservoir connected to a silicone tube was used. Electrophysiologic and histologic - morphometric studies were carried out at 4, 6, 8, 10 and 12 weeks post- operatively (subgroups a, b, c, d and e, respectively, n=6 each). Data analysis showed that: a. the evoked muscle action potential and b. the orientation, the number, the myelin thickness, and the diameter of myelinated fibers were better in the NGF-7S than in the control groups. According to these findings, there is a strong evidence of the beneficial effect of NGF-7S on peripheral nerve regeneration through nerve and inside-out vein grafts.Σκοπός: Η αξιολόγηση της επίδρασης του Νευρικού Αυξητικού Παράγοντα στην αναγέννηση των νευραξόνων επί ελλειμμάτων περιφερικών νεύρων των οποίων η αποκατάσταση έγινε είτε με ελεύθερα νευρικά είτε με αντίστροφα φλεβικά μοσχεύματα. Υλικό και Μέθοδος: 120 άρρενες επίμυες τύπου Wistar, βάρους 280-320 gr., χωρίστηκαν κατά τυχαίο τρόπο σε 4 ομάδες των 30. Έλλειμμα μήκους 12 mm προκλήθηκε στο αριστερό ισχιακό νεύρο. Η βλάβη αποκαταστάθηκε είτε με νευρικό αυτομόσχευμα (ομάδες A και Β) είτε με φλεβικό μόσχευμα από την σφαγίτιδα φλέβα στο οποίο αντιστράφηκε ο προσανατολισμός των χιτώνων του (ομάδες Γ και Δ). Διάλυμα NGF-7S (ομάδες A και Γ) ή φυσιολογικού ορού (ομάδες Β και Δ) χορηγήθηκε τοπικά, καθημερινά τις πρώτες 2 εβδομάδες, κάθε δεύτερη ημέρα την τρίτη εβδομάδα και μία εφάπαξ δόση την τέταρτη εβδομάδα. Γι’ αυτό τον σκοπό, ρεζερβουάρ σιλικόνης τοποθετήθηκε υποδόρια στην ραχιαία επιφάνεια του πειραματόζωου, το οποίο φέρει αγωγό με το περιφερικό άκρο του να εκτείνεται έως την θέση του μοσχεύματος. Ηλεκτροφυσιολογική και ιστολογική-μορφομετρική αξιολόγηση έγινε στις 4, 6, 8, 10 και 12 εβδομάδες (Υποομάδες α, β, γ, δ και ε αντίστοιχα, 6 επίμυες η κάθε μία). Αποτελέσματα: Η ανάλυση των αποτελεσμάτων έδειξε ότι: α. Το σύνθετο προκλητό μυϊκό δυναμικό και β. Ο προσανατολισμός, ο αριθμός, το πάχος του ελύτρου μυέλινης και η διάμετρος των εμμύελων ινών ήταν καλύτερα στις ομάδες που χορηγήθηκε NGF. Συμπεράσματα: Η τοπική εφαρμογή NGF είχε σαν αποτέλεσμα τον καλύτερο προσανατολισμό των υπό αναγέννηση αξόνων, την γρηγορότερη και ποιοτικά καλύτερη νευρική αναγέννηση προλαμβάνοντας σε μεγάλο βαθμό την ατροφία των κυττάρων- στόχων

Championship Suspensions due to COVID-19 Pandemic: Preliminary Results on Mental Toughness Levels of Greek Athletes

Athletes tie their identity to sports competition. Athletic identity loss has been mainly examined in the contexts of injury and/or retirement. The restrictive measures that have taken place during the COVID-19 pandemic have created a unique environment for athletic identity to be investigated in unprecedented numbers. One way to group the measures that have been taken against the COVID-19 is between pharmaceutical and non-pharmaceutical interventions (NPIs). During this pandemic, Greece has included the suspension of athletic seasons of most championships in the adopted NPIs. Preliminary evidence has shown that suspending championships during the pandemic has led to changes in athletic role identity and social connectedness, which negatively affected athletes’ mental health (MH). MT has been proven efficient against stressors in the sporting environment and positively correlated with MH outcomes. PURPOSE: To investigate if MT scores differ between competing and non-competing Greek athletes. METHODS: This study followed an observational and cross-sectional design. Several professional and semi-professional athletes were contacted via the authors’ professional networks. In total, 113 athletes (Mage = 24.80, SD = 6.89) agreed to participate. Both sexes were represented almost evenly in the sample. The athletes had to first state if they were competing (n = 13) or not (even if they would practice with the team/by themselves or not at all; n = 100) and then, fill out the Mental Toughness Index (MTI). A two-sample t-test was performed in Microsoft Excel RESULTS: There was a significant difference in the scores of non-competing (M = 44.9, SD = 6.38) and competing athletes (M = 47.85, SD = 3.36); t(25) = -2.61, d = 0.58, p = 0.0152. CONCLUSION: This preliminary evidence provides supports for the continuation of data collection. These findings indicate that such shifts in competitive circumstances may have varying effects on athletes\u27 perceptions on MT and, potentially, mental health. Future COVID-19 research should administer the Athletic Identity Measure Survey (AIMS) and a MH inventory, such as the Mental Health Continuum – Short Form (MHC-SF) in order to investigate the relationships between MT and athletic identity and MH, respectively. Future studies should also examine the impact of promoting social connectedness on MT during suspended championships/athletic identity loss

Bilateral ACL Tear — Basketball

HISTORY: A 16-year-old, amateur female basketball player sustained a non-contact injury on her left knee during a game (sudden cutting movement combined with a dynamic valgus collapse). PHYSICAL EXAMINATION: The acute clinical examination (signs of swelling, tenderness, or instability) did not indicate any signs of an anterior cruciate ligament (ACL) tear. Three days later, a magnetic resonance imaging (MRI) revealed a complete ACL tear. The orthopedic doctor recommended reconstructive surgery, and subsequent KT-2000 arthrometer tests revealed an anterior tibial translation (ATT) consistent with an 80% tear of the ACL. However, the player opted to seek a second opinion and consulted another orthopedic doctor ten days later. He conducted a new MRI revealing a partial ACL tear, and another KT-2000 test indicating a 20% tear. DIFFERENTIAL DIAGNOSIS: Complete ACL tear Partial ACL tear Meniscus tear, collateral ligament injury, patellar dislocation Knee osteoarthritis/bursitis TEST AND RESULTS: - Clinical examination: No signs of ACL tear of the left knee - MRI (initial): Complete ACL tear - KT-2000 (initial): 80% ACL tear - MRI (second): Partial ACL tear - KT-2000 (second): 20% ACL tear FINAL / WORKING DIAGNOSIS: Partial ACL tear of the left knee TREATMENT AND OUTCOMES: 6-month abstinence from basketball for conservative treatment Clinical guidance from trainer and sports medicine doctor for identified risk factors: anterior-posterior knee laxity, narrow notch (\u3c17mm), impaired hamstring ability, and gluteus maximus fatigue During first game back, player injured right knee (complete ACL tear) due to dynamic knee valgus while protecting left knee ACL surgery of the right knee followed by 8 months off court Perform strengthening/proprioception exercises 3 times a week on both knee

Chronic Exertional Compartment Syndrome — Female Soccer Player

HISTORY: An 18-year-old female soccer player reported experiencing a dull ache and sensation of tightness in her right leg, accompanied by a burning pain, during a match. Post-match, she noticed tingling in the dorsal aspect of her right foot. The athlete sought consultation from a general practitioner (GP), who found no evidence of tenderness or swelling during the clinical assessment. The GP recommended rest and prescribed anti-inflammatory medication. PHYSICAL EXAMINATION: Persistent discomfort and significant weakness in dorsiflexion prompted the athlete to consult an orthopedic physician. Clinical examination revealed no localized pain or other symptoms. Initial radiographs were unremarkable. Given the athlete’s persistent complaints, an MRI and a STIC intra-compartmental pressure measurement were ordered. DIFFERENTIAL DIAGNOSIS: 1. Stress fracture 2. Gastrocnemius/soleus strain 3. Medial tibial stress syndrome 4. Popliteal artery entrapment 5. Lumbar disc herniation TESTS AND RESULTS: - MRI: T2-weighted imaging showed increased signal intensity within the affected compartment - Compartment pressure testing: Needle insertion into the muscle pre- and post-exercise revealed elevated pressures (\u3e 15mm Hg) FINAL/WORKING DIAGNOSIS: Chronic exertional compartment syndrome TREATMENT AND OUTCOMES: Management included NSAIDs, diuretics, compression therapy, stretching exercises, orthotic supports, massage, extended rest, modifications to training surface and footwear, heat therapy, electrostimulation, and hydrotherapy. Surgical intervention via fasciotomy was determined to be the most effective treatment, aiming to decompress the affected compartments. Post-surgery, the patient utilized crutches for initial mobility, followed by non-impact aerobic exercises ranging for 4 weeks, with a gradual return to sport-specific training in 3 months

Salvaging a Failed Total Nasal Reconstruction Using Radial Forearm and Forehead Flaps

Reconstruction of a saddle nose deformity, as a result of subtotal septum and hard palate necrosis due to cocaine abuse, requires a stepwise, multistaged approach using a free flap for lining and a forehead flap for cover including careful preparation and monitoring of the patient. The patient presented with a collapsed and contracted nose and scarred forehead and cheeks after previously failed nasal reconstruction attempts with multiple rib and concha cartilage grafts, local intranasal and buccogingival transposition flaps, a paramedian forehead flap, nasolabial flaps, and a facial artery musculomucosal (FAMM) flap. A stepwise nasal reconstruction consisting of nine stages was subsequently performed with a folded radial forearm free flap, cartilage rib grafts, and two forehead flaps for reconstruction of the nasal inner lining, support, and cover, respectively. The reconstruction was complicated by partial flap necrosis of the radial forearm free flap and extrusion of the tissue expander due to breakdown of the forehead skin. This case demonstrates that in patients with substance abuse cessation is essential, and that free flap surgery is a preferred choice for reconstruction of the inner lining in this population. It shows that, despite multiple previous operations and the occurrence of complications, still a satisfactory functional and esthetic outcome may be achieved, provided that the reconstructive plan and handling of complications are good

Type IV, Salter Harris Fracture - Adolescent Male Soccer Player

CASE HISTORY: An amateur, 14-year-old soccer player celebrated his goal by attempting a backflip. He ended up landing abnormally on his left foot. He complained about pain and swelling in the lateral aspect of the left ankle. PHYSICAL EXAM: The athlete was admitted to Children’s Hospital. The diagnosis based on the first X-Ray was Type II, Salter Harris fracture. The patient was treated conservatively. A short, leg cast was placed and per os analgesics were given. He was hospitalized for two days. Before getting discharged, a second X-Ray showed a well-aligned fracture. Two days later, the patient was still in pain. He decided to visit a private orthopedic doctor who made the plaster rounded and placed the foot in tip-toe gait. Two days after that, the athlete decided to visit a different private doctor since the pain was not subsiding. That doctor suspected that the fracture may continue into the posterior malleolus with the fracture line going through the growth plate inside the joint of the ankle. Therefore, he ordered a MRI and spiral CT for the left ankle. DIFFERENTIAL DIAGNOSES: Salter Harris II, Salter Harris III, Salter Harris IV, Salter Harris V, or additional fractures. TESTS & RESULTS: A) Radiological evaluation: a) Posterior and anterior view: Fracture passes through most of the growth plate and up through the metaphysis. Orthopedic Classification: Salter Harris Type II and b) Lateral view: Fracture passes along the growth plate and down through the epiphysis. Orthopedic Classification: Salter Harris Type III. B) CT SCAN: The fracture line goes through the metaphysis, growth plate and down through the epiphysis. Orthopedic Classification: Salter Harris Type IV. FINAL DIAGNOSIS: Fracture across the metaphysis, physis and epiphysis: Salter Harris Type IV. DISCUSSION: Type IV Salter Harris fracture involves all three elements of the bone and is an intra-articular fracture. Chronic disability is a potential outcome as these fractures can cause premature focal fusion. Therefore, these injuries can result in growth retardation, altered joint mechanics, and functional impairment. Urgent orthopedic evaluation and surgical restoration are crucial, especially in children and adolescents. OUTCOME OF THE CASE: Due to delayed treatment, doctors had the following surgical options: 1. Close reduction and osteosynthesis with k-wires; 2. Open reduction and internal fixation with cannulated screws; and 3. Ankle joint arthroscopy in case of non-satisfactory alignment of the fracture. The final treatment decision included closed reduction with one k-wire and circular cast. RETURN TO ACTIVITY AND FURTHER FOLLOW-UP: Post operation X-Rays showed success. A month later and after additional X-Rays, the circular cast and the k-wire were removed. The athlete gradually proceeded to muscle-strengthening exercises and reached full active ROM