Clinical outcomes after anterior cruciate ligament injury: panther symposium ACL injury clinical outcomes consensus group

© 2020, The Author(s). Purpose: A stringent outcome assessment is a key aspect for establishing evidence-based clinical guidelines for anterior cruciate ligament (ACL) injury treatment. The aim of this consensus statement was to establish what data should be reported when conducting an ACL outcome study, what specific outcome measurements should be used and at what follow-up time those outcomes should be assessed. Methods: To establish a standardized approach to assessment of clinical outcome after ACL treatment, a consensus meeting including a multidisciplinary group of ACL experts was held at the ACL Consensus Meeting Panther Symposium, Pittsburgh, PA; USA, in June 2019. The group reached consensus on nine statements by using a modified Delphi method. Results: In general, outcomes after ACL treatment can be divided into four robust categories—early adverse events, patient-reported outcomes, ACL graft failure/recurrent ligament disruption and clinical measures of knee function and structure. A comprehensive assessment following ACL treatment should aim to provide a complete overview of the treatment result, optimally including the various aspects of outcome categories. For most research questions, a minimum follow-up of 2 years with an optimal follow-up rate of 80% is necessary to achieve a comprehensive assessment. This should include clinical examination, any sustained re-injuries, validated knee-specific PROs and Health-Related Quality of Life questionnaires. In the mid- to long-term follow-up, the presence of osteoarthritis should be evaluated. Conclusion: This consensus paper provides practical guidelines for how the aforementioned entities of outcomes should be reported and suggests the preferred tools for a reliable and valid assessment of outcome after ACL treatment. Level of evidence: V

Review : current concepts in computer-assisted hip arthroscopy

In the last 15 years, hip arthroscopy has become increasingly popular in addressing femoroacetabular impingement (FAI) because of its minimally invasive approach. However, assessing the adequacy of bone resection when correcting FAI can be difficult because visualisation and spatial awareness of the joint are poor. Recent advances in technology in the field of computer-assisted surgery and navigation and robotic surgery in orthopaedics as a resource for preoperative planning and intraoperative assistance have been widely reported. This technology is expected to upgrade surgical planning and operative techniques, decrease human error and improve patient outcomes by precisely defining the divergent anatomy and kinematics of the hip joint. This review attempts to bring the reader up-to-date with the current developments in the field of computer assisted hip arthroscopy, and discusses our experience with pre-operative planning, navigation and robotics and also provides a platform for future research in this arena

Joint distraction for the treatment of knee osteoarthritis

Knee osteoarthritis (OA) is a common degenerative joint disease characterized by cartilage destruction and changes in subchondral bone. Treatment options for end-stage OA are limited, with joint replacement and high tibial osteotomy as the common procedures. High tibial osteotomy may be preferable to joint replacement in the young active patient, malaligned knee, and limited to medial compartment OA. However, both procedures may lead to complications and have durability concerns in young patients. Fortunately, joint distraction (JD) has emerged as a joint-preserving treatment for end-stage OA. The reversal of tissue degeneration observed with JD could be the result of one or more proposed mechanisms, such as partial unloading, synovial fluid pressure oscillation, mechanical and biochemical changes in subchondral bone, or adhesion and chondrogenic commitment of joint-derived mesenchymal stem cells. The procedure involves the use of an external fixator to unload the cartilage and underlying bone for a short time period. In addition, new implantable knee devices, which create unloading instead of distraction and do not require removal, have also been developed. There is a lack of standardization for the JD technique which results in significant variation of implant type, duration of treatment, and rehabilitation. Nevertheless, clinical studies demonstrate long-term pain relief and improved patient outcomes. Interestingly, the increase in joint space width following treatment indicates that cartilage repair occurred throughout and after the distraction period. Although JD appears to be an effective therapeutic choice, the rate of complications remains high, with pin-tract infection being the most common

Osteochondral Allograft and High Tibial Osteotomy With Patient-Specific Instrumentation

Background: Medial compartment osteoarthritis in young active patients presents a unique challenge with regard to joint preservation. Interventions, including cartilage restoration procedures, in the setting of high tibial osteotomy (HTO) have the potential to obviate or delay joint replacement if performed with a high degree of accuracy and avoidance of complications. Indications: The procedure is indicated in patients less than 65 years with isolated medial knee arthrosis, good range of motion, and no ligamentous instability. Technique Description: We present our technique for valgus producing opening wedge HTO with patient-specific instrumentation and implant with concomitant osteochondral allograft of the medial femoral condyle and tibial microfracture. Results: The goal of this intervention is to provide a minimally painful knee with durable (>10 year) outcome while minimizing the risk of perioperative complications including iatrogenic fracture and nonunion. Discussion/Conclusion: High tibial osteotomy with concomitant cartilage repair techniques can lead to high satisfaction and return to sport rates in appropriately selected patients. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication

Effects of a Medial Knee Unloading Implant on Tibiofemoral Joint Mechanics During Walking

The Atlas™ unicompartmental knee system is a second‐generation extra‐articular unloading implant for patients with mild to moderate medial knee osteoarthritis. The technology acts to reduce a portion of the weight‐bearing load exerted on the medial knee during physical activity thereby, reducing the mechanical stress imposed on a degenerative joint. The purpose of the present study was to evaluate the effects of the Atlas™ on tibiofemoral joint mechanics during walking. A computer‐aided design assembly of the Atlas™ was virtually implanted on the medial aspect of a previously validated finite element tibiofemoral joint model. Data for knee joint forces and moments from an anthropometrically matched male were applied to the model to quasi‐statically simulate the stance phase of gait. Predictions of tibiofemoral joint mechanics were computed pre‐ and post‐virtual implantation of the Atlas™. Compressive force in the medial tibiofemoral compartment was reduced by a mean of 53%, resulting in the decrement of mean cartilage–cartilage and cartilage–meniscus von Mises stress by 31% and 32%, respectively. The Atlas™ was not predicted to transfer net loading to the lateral compartment. The tibiofemoral joint model exhibited less internal–external rotation and anterior–posterior translation post‐Atlas™, indicating a change in the kinematic environment of the knee. From a biomechanical perspective, extra‐articular joint unloading may serve as a treatment option for patients recalcitrant to conservative care. Evaluation of mechanical changes in the tibiofemoral joint demonstrate the potential treatment mechanism of the Atlas™, in accordance with the available clinical data

Characteristics of Soccer Players Undergoing Primary Hip Arthroscopy for Femoroacetabular Impingement: A Sex- and Competitive Level–Specific Analysis

Background: Radiographic features of femoroacetabular impingement (FAI) are prevalent in kicking athletes, especially soccer players. However, there remains a paucity of data on the characteristics of symptomatic soccer players with an established diagnosis of FAI. Purpose: To report on patient demographics, injury, and clinical and radiographic characteristics in a large cohort of soccer players who underwent primary hip arthroscopy for FAI and to perform a sex- and competition level–specific analysis of these data. Study Design: Cross-sectional study; Level of evidence, 3. Methods: An institutional hip preservation registry containing 3318 consecutive primary hip arthroscopies for FAI performed between March 2010 and January 2016 was retrospectively reviewed for patients identified as soccer players. Patient demographics, injury characteristics, and clinical and radiographic findings were recorded, and sex- and competition level–specific differences were analyzed. Results: A total of 421 hips (336 soccer players) were identified, including 257 (61.0%) men and 164 (39.0%) women. Of these, 105 (24.9%) were reported as highly competitive, 194 (46.1%) as competitive, 75 (17.8%) as recreational, and 47 (11.2%) did not report a level. The majority of the 336 soccer players (231 hips; 55%) reported chronic hip pain lasting >6 months with no acute injury at the initial visit. Alpha angle, coronal center-edge angle, and femoral version on computed tomography scan measured 64.5°± 12°, 32.3°± 9°, and 13.7°± 10° (mean ± SD), respectively. There were 230 (55%) hips with a type 2 anterior inferior iliac spine (AIIS), 78 (18.5%) with a type 1 AIIS, and 19 (4.5%) with a type 3 AIIS. When compared with male athletes, female athletes had more hip internal rotation on physical examination (14.9° vs 8°; P <.001), lower alpha angles (57.5° vs 68.5°; P <.001), and lower-grade AIIS morphology (P =.003). Acute injury as the reason for hip symptoms was most likely in the highly competitive group (P <.001). Conclusion: Female soccer players were more likely to have less severe clinical and radiographic findings than were male soccer players. Acute injury as the cause of hip symptoms was more common in highly competitive players. Clinical Relevance: Focusing on soccer players with an established FAI diagnosis, the findings of this study suggest that there are sex- and competition level–based differences in the presentation, physical examination, and imaging characteristics among the players. These findings can better guide clinicians in the diagnostic evaluation of symptomatic soccer players with FAI and in tailoring treatment recommendations to specific cohorts

The Impact of Workload on the Evolution of Hip Internal and External Rotation in Professional Baseball Players Over the Course of the Season.

Background:Although restricted hip range of motion (ROM) is associated with an increased risk for injuries in baseball players, the evolution of hip ROM over the season remains undefined. Hypothesis:Hip ROM profiles would be symmetric between hips and positions (pitchers vs position players) but would decrease from preseason to postseason. Additionally, it was hypothesized that this decrease in motion would correlate with workload. Study Design:Cohort study; Level of evidence, 2. Methods:Bilateral hip ROM was assessed in 96 professional baseball players (54 pitchers, 42 position players) preseason and postseason. ROM comparisons were made between lead and trailing hips, pitchers and position players, and preseason and postseason measures. The change from preseason to postseason was correlated with player demographics and measures of workload for pitchers and position players. Results:Preseason hip ROM was symmetric between hips; however, pitchers demonstrated increased preseason lead hip internal rotation (IR) (P = .018) and bilateral hip total ROM (TROM) (P &lt; .020) compared with position players. From preseason to postseason, position players lost 7° of external rotation (ER) (P ≤ .005 ). In pitchers, the loss of IR correlated with increased pitches (P = .016) and innings (P = .037), while the loss of ER (P = .005 ) and TROM (P = .014) correlated with increasing mean fastball velocity. Workload for position players did not correlate with motion loss. Conclusion:Symmetric hip ROM profiles should be anticipated in baseball players; however, pitchers may have increased preseason IR and TROM and postseason ER and TROM relative to position players. Although loss of motion correlated with workload in pitchers, this was not the case for position players. Hip motion should be monitored over the course of the season. This is particularly true for pitchers who lose IR as workload increases, which may place them at a greater risk for injuries