Publications by authors named "Niv Marom"

33 Publications

Differences in the Demographics and Preferred Management of Knee Cartilage Injuries in Soccer Players Across FIFA Centers of Excellence.

Cartilage 2021 May 30:19476035211018857. Epub 2021 May 30.

Sports Medicine Institute (FIFA Medical Center of Excellence), Hospital for Special Surgery, New York, NY, USA.

Objective: We sought to report on the demographics and epidemiology of knee cartilage injuries and preferred management in soccer players, across FIFA Medical Centers of Excellence (FMCE).

Design: A descriptive questionnaire focusing on characteristics of knee cartilage injuries and their management in soccer players during the 10-year period prior to the distribution of the questionnaire was sent to all FMCE around the world in September 2019 via an online platform. Voluntary responses from centers were processed and analyzed. Descriptive characteristics were reported using median and interquartile ranges (IQR) for continuous variables and frequencies and percentages (%) for discrete variables.

Results: A total of 15 centers from 5 continents responded to the questionnaire and reported on a total of 4526 soccer players. Among centers, the median age was 27 years (IQR: 23-38), the median rate of male players was 75% (IQR: 68-90), and the median rate of professional players was 10% (IQR: 5-23). The most common reported etiology for cartilage injury was traumatic (median 40%, IQR: 13-73). The most common nonoperative treatment utilized was physical therapy (median 90%, IQR: 51%-100%) and the most common operative treatment utilized was bone marrow stimulation/micro-fracture (median 40%, IQR: 19-54%). The utilization of other cartilage restoration procedures varied across centers.

Conclusions: Our findings highlight different tendencies in the management of these injuries across FMCE and emphasize the need for collaborative efforts focusing on establishing consensus guidelines for the optimal management of these challenging injuries in soccer players.
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http://dx.doi.org/10.1177/19476035211018857DOI Listing
May 2021

High variability and lack of standardization in the evaluation of return to sport after ACL reconstruction: a systematic review.

Knee Surg Sports Traumatol Arthrosc 2021 May 12. Epub 2021 May 12.

Sports Medicine Institute, Hospital for Special Surgery, New York, NY, USA.

Purpose: Return to sport (RTS) after ACL reconstruction (ACLR) has been recognized as an important outcome, which is associated with success of the surgery. This study aimed to assess the methods used to determine return to sport after ACLR in the published literature, report on variability of methods and evaluate their strength in establishing accurate RTS data.

Methods: Electronic databases (PubMed, Cochrane Library and Embase) were searched via a defined search strategy with no limits, to identify relevant studies from January 2008 to December 2020 for inclusion in the review. Defined eligibility criteria included studies specifically measuring and reporting on return to sport after ACLR with a clear methodology. Each included study was assessed for the definition of successful RTS, successful return to pre-injury level of sport and for methods used to determine RTS.

Results: One hundred and seventy-one studies were included. Of the included studies, six studies (4%) were level of evidence 1 and seventy-two studies (42%) were level of evidence 4. Forty-one studies (24%) reported on return to a specific sport and 130 studies (76%) reported on return to multiple sports or general sport. Sixteen studies (9%) reported on RTS in the pediatric population, 36 (21%) in the adult population and 119 (70%) reported on a mixed-aged population. The most commonly used definition of successful RTS was return to the same sport (44 of 125 studies, 35%). The most common method used to determine RTS was a non-validated study-specific questionnaire (73 studies, 43%), which was administered in various ways to the patients. Time of RTS assessment was variable and ranged between 6 months and 27 years post-surgery.

Conclusion: This review demonstrates high variability in defining, evaluating and reporting RTS following ACLR. The findings of this study reveal low reliability and unproven validity of methods used to evaluate RTS and highlight the challenges in interpreting and using RTS data reported in literature.

Level Of Evidence: IV.
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http://dx.doi.org/10.1007/s00167-021-06594-9DOI Listing
May 2021

Current Concepts on Tissue Adhesive Use for Meniscal Repair-We Are Not There Yet: A Systematic Review of the Literature.

Am J Sports Med 2021 Apr 15:3635465211003613. Epub 2021 Apr 15.

Sports Medicine Institute, Hospital for Special Surgery, New York, USA.

Background: Tissue adhesives (TAs) represent a promising alternative or augmentation method to conventional tissue repair techniques. In sports medicine, TA use has been suggested and implemented in the treatment of meniscal tears. The aim of this review was to present and discuss the current evidence and base of knowledge regarding the clinical usage of TAs for meniscal repair.

Study Design: Systematic review; Level of evidence, 4.

Methods: A systematic literature search was performed using the PubMed, Embase, and Cochrane Library databases for studies reporting on clinical outcomes of TA usage for meniscal repair in humans in the English language published before January 2020.

Results: Ten studies were eligible for review and included 352 meniscal repairs: 94 (27%) were TA-based repairs and 258 (73%) were combined suture and TA repairs. Concomitant anterior cruciate ligament reconstruction was performed in 224 repairs (64%). All included studies utilized fibrin-based TA. Of the 10 studies, 9 were evidence level 4 (case series), and 8 reported on a cohort of ≤40 meniscal repairs. Rates of meniscal healing were evaluated in 9 of 10 studies, with repair failure seen in 39 repairs (11%).

Conclusion: The use of TAs, specifically fibrin-based TAs, for meniscal repair shows good results as either an augmentation or primary repair of various configurations of meniscal tears. However, this review reveals an absence of comparative high-quality evidence supporting the routine use of TAs for meniscal repair and emphasizes the lack of an ideal TA designed for that purpose. Further high-quality research, basic science and clinical, will facilitate the development of new materials and enable testing their suitability for use in meniscal repair.
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http://dx.doi.org/10.1177/03635465211003613DOI Listing
April 2021

Editorial Commentary: The Pivot Shift and Lachman Examinations: Teammates With Distinct Roles.

Arthroscopy 2021 02;37(2):682-685

New York, New York.

The pivot shift and Lachman examinations are "teammates" with complementary but distinct roles in the successful diagnosis and treatment of anterior cruciate ligament rupture and injury to the surrounding soft-tissue envelope of the knee. The Lachman test measures anterior tibial translation in response to an applied anterior tibial load. This test assesses the integrity of the native or reconstructed anterior cruciate ligament and the secondary medial restraints including the medial meniscus and medial collateral ligament. In contrast, the pivot shift exam creates coupled tibiofemoral motions in response to a complex combination of multiplanar loads. This test assesses the stabilizing role of the native or reconstructed anterior cruciate ligament and the secondary lateral restraints including the lateral meniscus and anterolateral complex. The pivot shift grade depends not only on the soft the tissue stabilizers of the knee but also on the shape of the proximal tibia and the distal femur including lateral tibial slope and femoral condylar offset. Both examinations have unique strengths and weaknesses, but when combined as diagnostic tools, they achieve far more collectively than what each can achieve alone.
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http://dx.doi.org/10.1016/j.arthro.2020.12.001DOI Listing
February 2021

Pre-operative Static Anterior Tibial Translation Assessed on MRI Does Not Influence Return to Sport or Satisfaction After Anterior Cruciate Ligament Reconstruction.

HSS J 2020 Dec 17;16(Suppl 2):475-481. Epub 2019 Oct 17.

Hospital for Special Surgery, 535 E. 70th St., New York, NY 10021 USA.

Background: It has been suggested that the degree of anterior tibial translation (ATT) as measured passively on imaging studies (static ATT) after an anterior cruciate ligament (ACL) injury may influence outcomes after ACL reconstruction. However, there is a lack of evidence supporting these suggestions.

Questions/purposes: The purpose of this retrospective prognostic study was to assess the predictive value of pre-operative static ATT in knees with ACL injury on return to sport and in satisfaction after ACL reconstruction. Our hypothesis was that greater static ATT would be associated with lower rates of return to sport and lower levels of satisfaction.

Methods: Patients treated with ACL reconstruction were identified from an institutional registry and assigned to one of three groups according to their ACL injury type: acute ACL injury, chronic ACL injury, and failed ACL reconstruction. ATT in each knee compartment was measured using magnetic resonance imaging, and a retrospective telephone questionnaire was used to investigate post-ACL reconstruction return to sport and subjects' satisfaction.

Results: One hundred thirty patients (52 acute with ACL injury, 29 with chronic ACL injury, and 49 with failed ACL reconstruction) completed the questionnaire, with a mean follow-up of 5.67 years. Ninety-seven patients (74.6%) returned to their primary sport, of whom 63 (65%) returned to the same level of sport. The mean time to return to sport was 10.1 months (range, 2 to 24 months). Overall, 113 patients (87%) were either very satisfied or satisfied with their outcomes. No difference in medial or lateral ATT was found between patients who returned to sport and those who did not. The failed-ACL reconstruction group had significantly lower rates of return to sport than did acutely and chronically injured patients (60.4% versus 88.5% and 75.9%, respectively).

Conclusion: The degree of pre-operative ATT in an ACL-deficient knee was not correlated with return to sport or satisfaction after ACL reconstruction. In this study cohort, only failed-ACL reconstruction patients undergoing revision ACL reconstruction were significantly less likely to return to their main sport. They were also less likely to return to sport at their pre-operative level, if they did return to sport.
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http://dx.doi.org/10.1007/s11420-019-09724-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7749907PMC
December 2020

Clinical outcomes and reoperation rates of stable and unstable ramp lesions in the setting of ACL rupture.

Knee Surg Sports Traumatol Arthrosc 2020 12 10;28(12):4034-4036. Epub 2020 Oct 10.

Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, USA.

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http://dx.doi.org/10.1007/s00167-020-06315-8DOI Listing
December 2020

Lateral Extra-articular Tenodesis Reduces Anterior Cruciate Ligament Graft Force and Anterior Tibial Translation in Response to Applied Pivoting and Anterior Drawer Loads.

Am J Sports Med 2020 11 5;48(13):3183-3193. Epub 2020 Oct 5.

Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA.

Background: The biomechanical effect of lateral extra-articular tenodesis (LET) performed in conjunction with anterior cruciate ligament (ACL) reconstruction (ACLR) on load sharing between the ACL graft and the LET and on knee kinematics is not clear.

Purpose/hypothesis: The purpose was to quantify the effect of LET on (1) forces carried by both the ACL graft and the LET and (2) tibiofemoral kinematics in response to simulated pivot shift and anterior laxity tests. We hypothesized that LET would decrease forces carried by the ACL graft and anterior tibial translation (ATT) in response to simulated pivoting maneuvers and during simulated tests of anterior laxity.

Study Design: Controlled laboratory study.

Methods: Seven cadaveric knees (mean age, 39 ± 12 years [range, 28-54 years]; 4 male) were mounted to a robotic manipulator. The robot simulated clinical pivoting maneuvers and tests of anterior laxity: namely, the Lachman and anterior drawer tests. Each knee was assessed in the following states: ACL intact, ACL sectioned, ACL reconstructed (using a bone-patellar tendon-bone autograft), and after performing LET (the modified Lemaire technique after sectioning of the anterolateral ligament and Kaplan fibers). Resultant forces carried by the ACL graft and LET at the peak applied loads were determined via superposition. ATT was determined in response to the applied loads.

Results: With the applied pivoting loads, performing LET decreased ACL graft force up to 80% (44 ± 12 N; < .001) and decreased ATT of the lateral compartment compared with that of the intact knee up to 7.6 ± 2.9 mm ( < .001). The LET carried up to 91% of the force generated in the ACL graft during isolated ACLR (without LET). For simulated tests of anterior laxity, performing LET decreased ACL graft force by 70% (40 ± 20 N; = .001) for the anterior drawer test with no significant difference detected for the Lachman test. No differences in ATT were deteced between ACLR with LET and the intact knee on both the Lachman and the anterior drawer tests ( = .409). LET reduced ATT compared with isolated ACLR on the simulated anterior drawer test by 2.4 ± 1.8 mm ( = .032) but not on the simulated Lachman test.

Conclusion: In a cadaveric model, LET in combination with ACLR transferred loads from the ACL graft to the LET and reduced ATT with applied pivoting loads and during the simulated anterior drawer test. The effect of LET on ACL graft force and ATT was less pronounced on the simulated Lachman test.

Clinical Relevance: LET in addition to ACLR may be a suitable option to offload the ACL graft and to reduce ATT in the lateral compartment to magnitudes less than that of the intact knee with clinical pivoting maneuvers. In contrast, LET did not offload the ACL graft or add to the anterior restraint provided by the ACL graft during the Lachman test.
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http://dx.doi.org/10.1177/0363546520959322DOI Listing
November 2020

The Incidence of Kaplan Fiber Injury Associated With Acute Anterior Cruciate Ligament Tear Based on Magnetic Resonance Imaging.

Am J Sports Med 2020 11 24;48(13):3194-3199. Epub 2020 Sep 24.

Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA.

Background: Kaplan fibers are distinct deep layers of the distal iliotibial band (ITB) that anchor the ITB to the distal femur and have a role in rotational stability of the knee. However, the incidence of Kaplan fiber injury in the setting of acute anterior cruciate ligament (ACL) tear is unknown.

Purpose: To determine the reliability of identifying and evaluating Kaplan fibers on magnetic resonance imaging (MRI) examinations based on previously reported characteristics and to report on the incidence of combined ACL and Kaplan fiber injuries based on MRI examinations.

Study Design: Cohort study (diagnosis); Level of evidence, 3.

Methods: Patients with an acute primary ACL tear who obtained a postinjury MRI scan at our institution and were treated with ACL reconstruction between January 1, 2007, and May 31, 2012, were identified from an institutional registry. Each patient's postinjury MRI scan was reviewed by 2 musculoskeletal radiologists, who identified Kaplan fibers and graded them as intact, injured, or not visualized. Intrarater reliability was measured using the intraclass correlation coefficient (ICC), and interrater reliability was measured using the kappa statistic.

Results: A total of 72 patients were identified. For the proximal Kaplan fibers, 50% versus 58% were identified as injured, 32% versus 29% were identified as intact, and 18% versus 13% were not visualized by radiologist 1 and 2, respectively. For the distal Kaplan fibers, 46% versus 60% were identified as injured, 43% versus 28% were identified as intact, and 11% versus 12% were not visualized by radiologist 1 and 2, respectively. The ICC intrarater reliability measurements were 0.89 (95% CI, 0.83-0.93) for proximal Kaplan fibers and 0.66 (95% CI, 0.51-0.78) for distal Kaplan fibers. The interrater reliability measurements for both radiologists showed substantial agreement (kappa = 0.7) for proximal Kaplan fibers and moderate agreement (kappa = 0.51) for distal Kaplan fibers.

Conclusion: Kaplan fibers were visualized on MRI studies in the majority of cases, with substantial reliability for the proximal fibers and moderate reliability for the distal fibers. There was an associated injury to either the proximal or distal or both Kaplan fibers in the majority of acute primary ACL tears.
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http://dx.doi.org/10.1177/0363546520956302DOI Listing
November 2020

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

Am J Sports Med 2020 11 23;48(13):3255-3264. Epub 2020 Sep 23.

Sports Medicine Institute and Hip Preservation Service, Hospital for Special Surgery, New York, New York, USA.

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°; < .001), lower alpha angles (57.5° vs 68.5°; < .001), and lower-grade AIIS morphology ( = .003). Acute injury as the reason for hip symptoms was most likely in the highly competitive group ( < .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.
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http://dx.doi.org/10.1177/0363546520958697DOI Listing
November 2020

Symmetries in Muscle Torque and Landing Kinematics Are Associated With Maintenance of Sports Participation at 5 to 10 Years After ACL Reconstruction in Young Men.

Orthop J Sports Med 2020 Jun 9;8(6):2325967120923267. Epub 2020 Jun 9.

The Academic College at Wingate, Netanya, Israel.

Background: Long-term maintenance of sports participation is important for young men undergoing anterior cruciate ligament (ACL) reconstruction. Identifying biomechanical characteristics in patients who achieve this goal can assist in elaborating rehabilitation programs and in identifying successful recovery, but this has rarely been investigated.

Purpose: To test the association between maintenance of sports participation at 5 to 10 years after ACL reconstruction and measures of force production and landing biomechanics in men.

Study Design: Cross-sectional study; Level of evidence, 3.

Methods: A total of 30 men who underwent isolated ACL reconstruction were examined. At 5- to 10-year follow-up, associations were tested between reported outcomes of sports maintenance and objective biomechanical measures. The biomechanical tests included isokinetic knee torque and lower limb kinetics and kinematics during landing tasks. Measurements for each limb were conducted separately, and side-to-side symmetry indices (SI) were calculated. Subgroups included SI greater than +10% (ie, extreme positive), SI lower than -10% (ie, extreme negative), and SI between -10% and +10% (ie, symmetric).

Results: At follow-up, concentric knee torque in the operated limb correlated with Tegner and Marx scores ( = 0.42-0.47; ≤ .05). Regarding the SI of knee torque, the highest Tegner, Marx, and KOOS (Knee injury and Osteoarthritis Outcome Score) results were associated with symmetry, as opposed to patients with extreme positive or extreme negative SIs ( < .05). As for landing kinematics, Tegner score negatively correlated with knee range of motion (ROM) in the operated limb ( = -0.38; ≤ .05). With regard to SI, hip and knee ROM correlated with Tegner, IKDC, and KOOS scores ( = 0.41-0.51; ≤ .05). Specifically, the highest sports participation levels were associated with achieving symmetric hip and knee ROM but also with extreme positive SIs, as opposed to patients with extreme negative SIs ( < .03), indicating substantially higher ROM in the uninjured limb as compared with the operated limb.

Conclusion: At 5 to 10 years after ACL reconstruction, maintenance of sports participation was associated with symmetric side-to-side concentric knee torque and with producing greater attenuation of hip and knee ROM during the drop jump landing in the operated limb. Therefore, eccentric load programs that can improve attenuation-phase kinematics during landing tasks may be valuable in addition to concentric training and may facilitate enhanced long-term outcomes.
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http://dx.doi.org/10.1177/2325967120923267DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7285949PMC
June 2020

Non-treatment of stable ramp lesions does not degrade clinical outcomes in the setting of primary ACL reconstruction.

Knee Surg Sports Traumatol Arthrosc 2020 Nov 1;28(11):3576-3586. Epub 2020 May 1.

Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, NY, USA.

Purpose: The purpose of this study was to evaluate the clinical outcomes of various methods of treatment of stable and unstable ramp lesions compared to patients with no meniscal pathology at the time of primary ACL reconstruction.

Methods: All patients with a preoperative MRI performed at our facility who were enrolled in an institutional ACL registry and 1-year clinical follow-up were identified. A musculoskeletal radiologist reviewed preoperative MRI scans for evidence of a ramp lesion. Ramp lesions were classified as stable if a peripheral tear of the posterior horn of the medial meniscus was identified by MRI, but did not displace into the medial compartment with anteriorly directed probing at the time of surgery. Ramp lesions were classified as unstable if a tear was identified by preoperative MRI at the meniscocapsular junction and the meniscus was displaceable into the medial compartment with probing. Reoperation rates for ACL graft failure or recurrent medial meniscus pathology were collected. Patient-reported outcome scores (IKDC, SF12 PCS, SF12 MCS, and Marx Activity scale) were recorded at baseline and final follow-up.

Results: A total of 162 patients were included in the analysis with median 2-year (range 1-5 years) clinical follow-up. Patients with a repaired unstable ramp lesion had a significantly higher likelihood of reoperation for recurrent medial meniscus pathology than patients without meniscal pathology at the time of index surgery. Patients with an untreated stable ramp lesion had a similar rate of reoperation when compared to patients without meniscal pathology. At final follow-up, there was no difference between groups in IKDC score, SF12 PCS/MCS, or Marx activity score or change in any score.

Conclusions: Patients with untreated stable ramp lesions have similar clinical outcomes at median 2-year (range 1-5 years) follow-up when compared to patients without a ramp lesion. Treatment of stable ramp lesions at the time of ACL reconstruction does not have clinical benefit.

Level Of Evidence: III.
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http://dx.doi.org/10.1007/s00167-020-06017-1DOI Listing
November 2020

Graft Selection in Anterior Cruciate Ligament Reconstruction.

Sports Med Arthrosc Rev 2020 Jun;28(2):41-48

Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, NY.

Surgical reconstruction of the anterior cruciate ligament (ACL) is often indicated to restore functional stability and prevent early degeneration of the knee joint, as there is little biological healing capacity of the native ACL. Although a reconstructed ACL does not fully restore the original structure or biomechanics properties of the native ACL, the graft used for reconstruction must not only have structural and mechanical properties that closely resemble those of the native ligament, it must also have minimal antigenicity and enough biological potential to incorporate into host bone. There are several considerations in graft selection: autograft versus allograft, and soft tissue grafts versus grafts with bone plugs. Commonly used grafts include bone-patella tendon-bone, hamstring, and quadriceps; among allografts, options further include tibias anterior and posterior, Achilles, an peroneal tendons. Optimal graft selection is not only dependent on graft properties, but perhaps more importantly on patient characteristics and expectations. The purpose of this review is to summarize the relevant biological, biomechancial, and clinical data regarding various graft types and to provide a basic framework for graft selection in ACL reconstruction.
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http://dx.doi.org/10.1097/JSA.0000000000000265DOI Listing
June 2020

Time interval affects physical activity scores: a comparison of the Marx Activity Rating Scale and the Hospital for Special Surgery Pediatric Functional Activity Brief Scale.

Knee Surg Sports Traumatol Arthrosc 2020 Aug 19;28(8):2619-2625. Epub 2020 Feb 19.

Sports Medicine Institute, Hospital for Special Surgery, 541 E 71st St, New York, 10021, USA.

Purpose: The Marx Activity Rating Scale (Marx Scale) is a commonly used activity-related patient-reported outcome which evaluates the highest activity level within the last year, whereas the Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS) assesses highest activity level within the last month. This study aims to determine whether the different timeframes used for the common items of Marx Scale and HSS Pedi-FABS affect scores, and if so, to determine whether age or injury status affect this difference.

Methods: The Marx Scale and four analogous items on the HSS Pedi-FABS were administered in random order to patients being evaluated for knee injuries and in addition to healthy controls to enroll an uninjured comparison group. Responses to each question were scored from 0 to 4 for a maximum overall score of 16. Paired and independent-sample t tests were used to determine mean differences between groups.

Results: The final cohort included 88 participants of which 47% were children (ages 10-17) and 51% had a knee injury. All participants except for healthy adults scored significantly lower on the HSS Pedi-FABS than the Marx Scale (p < 0.05). On the HSS Pedi-FABS activity scale, healthy participants scored significantly higher than injured participants (p < 0.01), but there were no significant differences based on age. Conversely, on the Marx Scale, children scored higher than adults (p ≤ 0.001), but there were no significant differences based on injury.

Conclusion: Physical activity level differs when evaluated with the Marx Scale or the analogue part of HSS Pedi-FABS with timeframe being the only difference between the two. The lower scores on the HSS Pedi-FABS are likely due to seasonal changes in activity which do not affect the Marx Scale. HSS Pedi-FABS analyzes a shorter window and it is more likely to capture changes in physical activity due to a recent injury than the Marx Scale which is better suited for assessing general physical activity level unaffected by seasonality or recent injury. Understating the differences between these physical activity scales can better guide clinicians when using them and interpreting scores.

Level Of Evidence: II.
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http://dx.doi.org/10.1007/s00167-020-05895-9DOI Listing
August 2020

Complications in Posterior Cruciate Ligament Injuries and Related Surgery.

Sports Med Arthrosc Rev 2020 Mar;28(1):30-33

Department of Sports and Shoulder Service, Hospital for Special Surgery, New York City, NY.

Posterior cruciate ligament (PCL) injury, especially in isolation, is a less frequent injury than injury to the anterior cruciate ligament and other ligaments of knee. In addition, the complex injury patterns involving the PCL, the technically demanding nature of surgical treatments, the anatomic proximity to vital neurovascular structures and the controversy surrounding optimal management of PCL injuries, make these injuries and their treatment potentially prone to more complications. This chapter will review the common complications of PCL injuries and related surgery.
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http://dx.doi.org/10.1097/JSA.0000000000000247DOI Listing
March 2020

Engagement of the Secondary Ligamentous and Meniscal Restraints Relative to the Anterior Cruciate Ligament Predicts Anterior Knee Laxity.

Am J Sports Med 2020 01 25;48(1):109-116. Epub 2019 Nov 25.

Hospital for Special Surgery, New York, New York, USA.

Background: Patients with high-grade preoperative side-to-side differences in anterior laxity as assessed via the Lachman test after unilateral anterior cruciate ligament (ACL) rupture are at heightened risk of early ACL graft failure. Biomechanical factors that predict preoperative side-to-side differences in anterior laxity are poorly understood.

Purpose: To assess, in a cadaveric model, whether the increase in anterior laxity caused by sectioning the ACL (a surrogate for preoperative side-to-side differences in anterior laxity) during a simulated Lachman test is associated with two biomechanical factors: (1) the tibial translation at which the secondary anterior stabilizers, including the remaining ligaments and the menisci, begin to carry force, or , relative to that of the ACL or (2) the forces carried by the ACL and secondary stabilizers at the peak applied anterior load.

Study Design: Controlled laboratory study.

Methods: Seventeen fresh-frozen human cadaveric knees underwent Lachman tests simulated through a robotic manipulator with the ACL intact and sectioned. The net forces carried by the ACL and secondary soft tissue stabilizers (the medial meniscus and all remaining ligaments, measured as a whole) were characterized as a function of anterior tibial translation. The engagement points of the ACL (with the ACL intact) and each secondary stabilizer (with the ACL sectioned) were defined as the anterior translation at which they began to carry force, or engaged, during a simulated Lachman test. Then, the relative engagement point of each secondary stabilizer was defined as the difference between the engagement point of each secondary stabilizer and that of the ACL. Linear regressions were performed to test each association ( < .05).

Results: The increase in anterior laxity caused by ACL sectioning was associated with increased relative engagement points of both the secondary ligaments (β = 0.87; < .001; = 0.75) and the medial meniscus (β = 0.66; < .001; = 0.58). Smaller changes in anterior laxity were also associated with increased in situ medial meniscal force at the peak applied load when the ACL was intact (β = -0.06; < .001; = 0.53).

Conclusion: The secondary ligaments and the medial meniscus require greater anterior tibial translation to engage (ie, begin to carry force) relative to the ACL in knees with greater changes in anterior laxity after ACL sectioning. Moreover, with the ACL intact, the medial meniscus carries more force in knees with smaller changes in anterior laxity after ACL sectioning.

Clinical Relevance: Relative tissue engagement is a new biomechanical measure to characterize in situ function of the ligaments and menisci. This measure may aid in developing more personalized surgical approaches to reduce high rates of ACL graft revision in patients with high-grade laxity.
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http://dx.doi.org/10.1177/0363546519888488DOI Listing
January 2020

Return to Play After Bipolar Patellofemoral Osteochondral Allograft Transplantation for a Professional Basketball Player: A Case Report.

JBJS Case Connect 2019 Jul-Sep;9(3):e0291

Sports Medicine and Shoulder Surgery Division, Hospital for Special Surgery, New York, New York.

Case: Extensive and multiple symptomatic chondral lesions in the knee of a professional athlete presents unique challenges when considering optimal management. We present the case of a professional National Basketball Association player with symptomatic and extensive patellofemoral chondral lesions, who failed 24 months of nonoperative management and was treated surgically with bipolar patellofemoral osteochondral allograft transplantation (OCA) consisting of 3 large grafts to the patella, medial trochlea, and lateral trochlea. The player was able to return to his preinjury level of play 10 months postoperatively and remains asymptomatic at same level of play 3 years after surgery. Postoperative magnetic resonance imaging at 16 months demonstrated good restoration of the articular architecture of the patellofemoral joint.

Conclusions: Bipolar OCA treatment for extensive chondral patellofemoral injury may be considered in high-level, high-demand athletes who wish to return to play professionally.
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http://dx.doi.org/10.2106/JBJS.CC.18.00291DOI Listing
June 2020

Ramp Lesions of the Medial Meniscus in Patients Undergoing Primary and Revision ACL Reconstruction: Prevalence and Risk Factors.

Orthop J Sports Med 2019 May 15;7(5):2325967119843509. Epub 2019 May 15.

Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, New York, USA.

Background: Ramp lesions are peripheral tears of the posterior horn of the medial meniscus that involve the meniscocapsular attachments or red-red zone and typically occur in conjunction with anterior cruciate ligament (ACL) ruptures.

Purpose: To identify the prevalence of, and risk factors for, ramp lesions in a large cohort of patients undergoing primary and revision ACL reconstruction.

Study Design: Case series; Level of evidence, 4.

Methods: We queried our institutional registry of patients who underwent primary or revision surgical treatment for an ACL injury. Those who underwent preoperative magnetic resonance imaging (MRI) at our facility were included in the study. Clinical details were extracted and verified using electronic records. All preoperative MRI scans were reviewed by a musculoskeletal radiologist for the presence of a ramp lesion. Stable ramp lesions were defined as a peripheral posterior horn medial meniscal tear identified on MRI but either not identifiable with viewing and probing from the anterior portals or, if identified, not displaceable with anteriorly directed probing. Unstable ramp lesions were defined as peripheral posterior horn medial meniscal tears at the meniscocapsular junction that were identifiable at the time of surgery and displaced into the medial compartment with probing. The prevalence of stable and unstable ramp lesions was calculated. Demographic, injury, and imaging parameters were determined using univariate statistics.

Results: A total of 372 patients were included. The overall prevalence of ramp lesions was 42% (155/372). Unstable ramp lesions were present in 73 (20%) patients, and stable ramp lesions were present in 82 (22%) patients. The presence of any ramp lesion (stable or unstable) was associated with bone marrow edema of the posteromedial tibia on MRI (odds ratio [OR], 3.0; < .0001), a contact injury mechanism (OR, 1.8; = .02), and a concurrent lateral meniscal tear (OR, 1.7; = .02). No demographic, injury, surgical, or radiological variable was associated with a stable versus unstable ramp lesion.

Conclusion: The overall prevalence of a ramp lesion in patients treated for ACL ruptures at our institution was 42%. The presence of bone marrow edema of the posteromedial tibia, a contact injury mechanism, or a lateral meniscal tear should alert surgeons to the potential presence of a medial meniscal ramp lesion.
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http://dx.doi.org/10.1177/2325967119843509DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6537250PMC
May 2019

Preoperative Grades of Osteoarthritis and Meniscus Volume Correlate with Clinical Outcomes of Osteochondral Graft Treatment for Cartilage Defects in the Knee.

Cartilage 2019 Jun 4:1947603519852402. Epub 2019 Jun 4.

2 Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, NY, USA.

Objective: To identify preoperative imaging-based indicators of knee degeneration that correlate with graft failure risk and postoperative clinical outcome scores after osteochondral graft treatment for chondral defects of the knee.

Design: Prospectively collected data from 113 patients (mean age, 34 years; 65% male) treated with mosaicplasty or osteochondral allograft transplantation (OCA) was reviewed. Four different aspects of knee degeneration were examined based on preoperative radiographs or magnetic resonance imaging: (1) Osteoarthritis using the Kellgren-Lawrence (KL) grading system, (2) meniscus volume, (3) meniscus quality, and (4) synovitis. Primary outcomes included graft failure, defined by removal/revision of the graft or conversion to arthroplasty, and patient responses to clinical outcome scores.

Results: Forty-one knees (36%) underwent mosaicplasty, and 72 knees (64%) underwent OCA. Mean duration of follow-up was 4.5 years (range, 2-14 years). A preoperative KL grade of ≥3 was correlated with increased failure rates ( P = 0.01), lower postoperative International Knee Documentation Committee form (IKDC), Activities of Daily Living of the Knee Outcome Survey (KOS-ADL), and Overall Condition scores ( P < 0.01), and decreased improvement in Overall Condition scores ( P = 0.01). Within an individual tibiofemoral compartment, a preoperative meniscus volume grade of ≥3 (indicating <50% meniscus volume remaining) was correlated with increased condylar graft failure rates ( P < 0.01). Preoperative meniscus quality and synovitis grades were not associated with graft failure rates or clinically meaningful differences in postoperative outcome scores.

Conclusions: Greater preoperative osteoarthritis and meniscus volume loss were correlated with increased graft failure rates after osteochondral graft treatment for chondral defects of the knee.
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http://dx.doi.org/10.1177/1947603519852402DOI Listing
June 2019

Osteotomies in the Multiple Ligament Injured Knee: When Is It Necessary?

Clin Sports Med 2019 Apr 30;38(2):297-304. Epub 2019 Jan 30.

Mayo Clinic, 201 West Center Street, Rochester, MN 55902, USA.

The multiple ligament-injured knee is a complex injury requiring a comprehensive and thorough evaluation prior to tailoring an appropriate treatment plan. Surgical repair and reconstruction of the involved ligaments are frequently discussed in the literature; however, osteotomy to correct limb malalignment may be just as important to obtaining a good outcome. Limb realignment must be carefully evaluated and treated. Isolated soft tissue procedures are prone to failure if significant malalignment, deformity, and thrust are ignored. In select cases, osteotomy can lead to restored mechanical stability, optimal joint load distribution, improved survival of simultaneous soft tissue procedures, and better patient outcomes.
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http://dx.doi.org/10.1016/j.csm.2018.11.003DOI Listing
April 2019

Upper Extremity Injuries in Soccer.

Am J Orthop (Belle Mead NJ) 2018 Oct;47(10)

535 East 70th Street, New York, NY 10021, USA. Email:

Upper limb injuries in soccer represent only a marginal portion of injuries, however this is mainly true for outfield players. Goalkeepers are reported to have up to 5 times more upper extremity injuries, many of them requiring substantial time-loss for treatment and rehabilitation. The most common upper extremity injury locations are the shoulder/clavicle followed by the hand/finger/thumb, elbow, wrist, forearm, and upper arm. The mechanism of injury, presentation, physical examination, and imaging features all play a significant role in reaching the correct diagnosis. Taking to consideration the position the player plays and his demands will also enable tailoring the optimal treatment plan that allows timely and safe return to play. This article discusses common upper extremity injuries observed in soccer players, focusing on proper diagnosis and optimal management.
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http://dx.doi.org/10.12788/ajo.2018.0091DOI Listing
October 2018

Measuring Quality and Outcomes in Sports Medicine.

Clin Sports Med 2018 Jul;37(3):463-482

Department of Sports Medicine, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA. Electronic address:

Patient-reported outcome measures (PROMs) are objective metrics critical to evaluating outcomes throughout orthopedic surgery. New instruments continue to emerge, increasing the breadth of information required for those intending to use these measures for research or clinical care. Although earlier metrics were developed using the principles of classic test theory, newer instruments constructed using item response theory are amenable to computer-adaptive testing and may change the way these instruments are administered. This article aims to define the psychometric properties that are important to understand when using all PROMs and to review the most widely used instruments in sports medicine.
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http://dx.doi.org/10.1016/j.csm.2018.03.001DOI Listing
July 2018

Knee MLI Injuries: Common Problems and Solutions.

Clin Sports Med 2018 Apr;37(2):281-291

Sports Medicine, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA. Electronic address:

The multiple ligament injured knee presents a challenge with regard to management and treatment. Immediate management of the acute injury requires special attention and thorough examination because knee dislocations have been associated with significant complications. Treatment options range from closed reduction and immobilization to surgical repair and/or reconstruction of the injured ligaments. This article focuses on complications that may result from surgical treatments of the multiple ligament injured knee and ways of prevention. These complications include vascular and neurologic complications, venous thromboembolic events, arthrofibrosis, compartment syndrome, wound problems, heterotopic ossification, fractures and avascular necrosis, tunnels positioning complications, and malalignment.
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http://dx.doi.org/10.1016/j.csm.2017.12.011DOI Listing
April 2018

Editorial Commentary: Revision Multiligament Knee Reconstruction Can Restore Stability in a High Percentage of the Cases When Well Executed.

Arthroscopy 2018 03;34(3):745-746

New York, New York.

A thorough and comprehensive evaluation of failed multiligament knee reconstructions is a key component for optimal outcomes of revision cases. Addressing all associated injuries during surgery, either staged or not, will potentially guarantee better subjective and objective scores. Older age and high-energy mechanism of injury are associated with worse functional outcomes.
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http://dx.doi.org/10.1016/j.arthro.2017.11.011DOI Listing
March 2018

Thrombophilia-Associated Factors in Patients with Spontaneous Osteonecrosis of the Knee.

Cartilage 2019 01 7;10(1):53-60. Epub 2018 Jan 7.

1 Department of Orthopedic Surgery, Meir General Hospital, Kfar Saba, Israel.

Objective: To test whether patients with spontaneous osteonecrosis of the knee (SONK) are characterized by abnormal levels of thrombophilia-associated factors.

Design: Twenty-five patients with SONK were recruited. Inclusion criteria were (1) age >40 years, (2) acute onset knee pain not precipitated by trauma, and (3) MRI findings consistent with SONK. Exclusion criteria were (1) history of cancer and chemotherapy and (2) factors associated with secondary osteonecrosis. Blood tests included 13 thrombophilia-associated factors that were either heritable mutations or acquired factors. Descriptive statistics included medians, ranges, means, and standard deviations. Mann-Whitney test was used to compare thrombophilia-associated factor levels between the sexes. Spearman's rank test was used to test correlations between smoking status and each thrombophilia-associated factor. Level of significance was set at 0.05.

Results: Median patient age was 62 years (range, 44-77 years). There were 16 (64%) men. Thirteen (52%) patients had thrombophilia-associated factor abnormalities of which 9 were elevated fibrinogen but this was less than 1 standard deviation above norm threshold. Other findings were 3 patients with marginally decreased antithrombin below norm threshold, low protein S Ag in only 1 patient, and factor V Leiden mutation heterozygosity in 2 patients, which was not higher than normal population prevalence. Thrombophilia-associated factors neither differed between sexes ( P = nonsignificant) nor correlated with smoking status ( P = nonsignificant).

Conclusion: Thrombophilia-associated factor abnormalities in patients with SONK were minimal. Therefore, clinical workup and treatment strategy in this disease should focus on addressing alternative etiologies leading to abnormal subchondral bone metabolism with focal osteopenia.
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http://dx.doi.org/10.1177/1947603517749920DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6376567PMC
January 2019

The correlation of supraspinatus outlet view with computed tomography for visualization of the anterior acromial undersurface.

Eur J Orthop Surg Traumatol 2018 Feb 20;28(2):207-212. Epub 2017 Sep 20.

Orthopedic Department, Meir General Hospital, Sapir Medical Center, Kfar Saba, Israel.

Introduction: Understanding the real shape of the undersurface of the acromion prior to acromioplasty is indispensable. Today, Supraspinatus outlet view (SSOV) is a standard view used to determine the shape of the anterior acromion. Three types of acromial undersurface were described by Bigliani and Morrison. The purpose of this study was to find out whether the real acromial type can be visualized on X-ray SSOV and compare the shape of the anterior undersurface of the acromion visualized on SSOV, with the shape revealed on 2D CT reconstructions.

Methods: The SSOV X-rays and CT scans of 30 consecutive patients suffering from rotator cuff dysfunction were retrospectively analyzed. The shape of the acromion visualized on plain X-rays was classified according to Bigliani and Morrison classification system. Two-dimensional CT reconstructions were performed, reproducing the lateral, middle, and medial sections of the acromion. The acromial type that was visualized on each of those reconstructions was separately classified according to the Bigliani and Morrison system. A complete profile of the acromial undersurface was constructed from the integration of acromial types seen on each CT section. The acromial morphology seen on X-rays and CTs was compared.

Results: A total of 30 patients comprised the study cohort; mean age was 57 (STD = 8.5) years. Three Type I, 22 Type II, and 5 Type III acromions were visualized on the SSOV X-rays. CT reconstructions revealed seven different morphological acromial profiles (I,I,I; I,II,II; I,II,III, etc.), which we divided into 3 groups: (1) Uniform (30%), (2) Internally curved (20%), and (3) Internally hooked (50%). The acromial type visualized on X-ray correlated with the acromial type on at least one CT section in all of the cases. In the case of uniform acromial profile, there is a full correlation between the acromial type visualized on X-rays and the type visualized on CT. In non-uniform profiles, there was an incomplete correlation between the types of the acromion visualized on SSOV and CT. SSOV X-rays correlated with or underestimated, but never overestimated, the acromial morphological type.

Discussion: The curved or hooked portion of the acromial undersurface is not always visualized on the SSOV. On X-rays, the middle and lateral sections are seen more accurate than the medial section.

Conclusion: Surgeons should be aware that SSOV X-rays may underestimate the true type of the acromial undersurface.
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http://dx.doi.org/10.1007/s00590-017-2036-3DOI Listing
February 2018

The incidence of life threatening iatrogenic vessel injury following closed or open reduction and internal fixation of intertrochanteric femoral factures.

Int Orthop 2017 09 1;41(9):1845-1850. Epub 2017 Jul 1.

Department of Orthopaedic Surgery, Meir Medical Center, 57 Tshernichovsky St., 4428164, Kfar Saba, Israel.

Aim Of The Study: Bleeding due to a vascular injury is a possible life-threatening complication of intertrochanteric femoral fracture internal fixation. Our goals were to find the current incidence of these events, and to describe the reasons, the presentation, and the treatment options.

Method: We conducted a retrospective record review of 1,469 patients who were operated upon at our institution due to AO31A femoral fractures from 2011 through 2015 and were treated with closed reduction and internal fixation.

Results: Three patients were diagnosed with iatrogenic vascular bleeding, which constitute an incidence of 0.2%. The vascular injuries were detected as deep femoral artery bleeding adjacent to the distal locking screws. The patients were treated with ultrasound guided thrombin injection, endovascular coil embolization or with no endovascular intervention.

Discussion: Vascular injuries are caused mainly by perforating a vessel while drilling the distal locking screw holes. A high level of suspicion and immediate imaging work-up are mandatory.

Conclusions: A vascular injury due to internal fixation of a proximal AO31A femoral fracture is a rare complication.
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http://dx.doi.org/10.1007/s00264-017-3545-8DOI Listing
September 2017

[TREATMENT OF ACHILLES TENDON RUPTURES].

Harefuah 2016 Jul;155(7):443-447

Sports Medicine and Hip Preservation Service, Department of Orthopedics, University of Colorado, Aurora, Colorado, USA.

Introduction: Achilles tendon ruptures cause considerable morbidity and functionality reduction. There is lack of consensus regarding the best option for treatment following acute Achilles tendon rupture. Recent studies have failed to show substantial difference in outcome following conservative or operative treatment using an early active rehabilitation program. Meta-analyses have shown that conservative management has increased the risk of re-rupture, whereas operative intervention carries risks of complications related to the wound and iatrogenic nerve injury. This article reviews the updated literature-based guidelines for the treatment of Achilles tendon tears.
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July 2016

Factors Associated With Improved Function and Maintenance of Sports Activities at 5 to 10 Years After Autologous Hamstring ACL Reconstruction in Young Men.

Orthop J Sports Med 2017 Apr 13;5(4):2325967117700841. Epub 2017 Apr 13.

Department of Orthopedic Surgery, Meir General Hospital, Kfar Saba, Israel.

Background: There are limited data regarding associated factors of return to sports activities at more than 5 years after anterior cruciate ligament (ACL) reconstruction.

Purpose: To test interrelationships between patient characteristics, concomitant articular lesions, graft laxity, and maintenance of sports activities at 5 to 10 years after ACL reconstruction. It was hypothesized that at 5 to 10 years after the operation in young adult men, maintenance of greater activity level and better knee function would be associated with greater preinjury activity level, younger age at reconstruction, absence of concomitant articular lesions, and minimal graft laxity at follow-up.

Study Design: Case series; Level of evidence, 4.

Methods: One hundred six men with autologous hamstring ACL reconstruction between the ages of 18 and 35 years were reviewed at 5 to 10 years after surgery. Excluded patients had contralateral ACL tear, revision reconstruction, or another injury impairing function. Fifty-five patients were eligible and available for follow-up. Independent variables included preinjury Tegner score, time interval from injury to surgery, smoking status, age, articular lesions, KT side-to-side difference, and pivot-shift grade. Main outcome measures were Tegner activity level, International Knee Documentation Committee (IKDC) subjective score, and Knee injury and Osteoarthritis Outcome Scale (KOOS) score at 5 to 10 years after surgery.

Results: Greater Tegner activity level at follow-up was associated in a regression model with greater preinjury Tegner activity level (correlation coefficient, 0.423; = .01), lower KT difference (correlation coefficient, -0.278; = .04), and negative pivot shift (correlation coefficient, -0.277; = .05). Younger age at operation predicted return to greater Tegner activity level in a univariate analysis (correlation coefficient, -0.266; = .05) but not in a regression model (not significant). Chondral lesions at surgery predicted lower IKDC subjective scores (71.4 ± 14.3 vs 84.1 ± 11.5; < .01) and KOOS scores but did not affect maintenance of sports activities.

Conclusion: At 5 to 10 years after autologous hamstring ACL reconstruction in young men, predictors of greater sports activity level are primarily high preinjury activity level and reestablishment of knee laxity. Younger age at operation and moderate chondral lesions have lower impact in this respect.
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http://dx.doi.org/10.1177/2325967117700841DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5400220PMC
April 2017

PRP for Degenerative Cartilage Disease: A Systematic Review of Clinical Studies.

Cartilage 2017 Oct 1;8(4):341-364. Epub 2016 Sep 1.

2 O.A.S.I. Bioresearch Foundation Gobbi NPO, Milan, Italy.

Objective: To explore the utilization of platelet-rich plasma (PRP) for degenerative cartilage processes and evaluate whether there is sufficient evidence to better define its potential effects.

Design: Systematic literature reviews were conducted in PubMed/MEDLINE and Cochrane electronic databases till May 2015, using the keywords "platelet-rich plasma OR PRP OR autologous conditioned plasma OR ACP AND cartilage OR chondrocyte OR chondrogenesis OR osteoarthritis (OA) OR arthritis."

Results: The final result yielded 29 articles. Twenty-six studies examined PRP administration for knee OA and 3 involved PRP administration for hip OA. The results included 9 prospective randomized controlled trials (RCTs) (8 knee and 1 hip), 4 prospective comparative studies, 14 case series, and 2 retrospective comparative studies. Hyaluronic acid (HA) was used as a control in 11 studies (7 RCTs, 2 prospective comparative studies, and 2 retrospective cohort). Overall, all RCTs reported on improved symptoms compared to baseline scores. Only 2 RCTs-one for knee and one for hip-did not report significant superiority of PRP compared to the control group (HA). Nine out of 11 HA controlled studies showed significant better results in the PRP groups. A trend toward better results for PRP injections in patients with early knee OA and young age was observed; however, lack of uniformity was evident in terms of indications, inclusion criteria, and pathology definitions in the different studies.

Conclusion: Current clinical evidence supports the benefit in PRP treatment for knee and hip OA, proven to temporarily relieve pain and improve function of the involved joint with superior results compared with several alternative treatments. Further research to establish the optimal preparation protocol and characteristics of PRP injections for OA is needed.
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http://dx.doi.org/10.1177/1947603516670709DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5613892PMC
October 2017

Pubic Osteomyelitis in a Combat Training Soldier: A Case Report.

Mil Med 2017 03;182(3):e1840-e1842

Orthopedic Department, Meir Medical Center, 59 Tchernichovsky Street, 44281 Kfar-Saba, Israel.

Introduction: Infectious osteomyelitis of the symphysis pubis, known as pubic osteomyelitis is a rare condition with potentially devastating consequences. To the best of our knowledge, this article is the first reported case of a military trainee presenting with pubic osteomyelitis.

Materials And Methods: We present a unique case of a patient who simultaneously suffered a combination of local recurrent stress to the symphysis pubis area, and slow-healing multiple palm and finger lacerations which probably acted as distant ports of bacterial entry that concomitantly led to his illness.

Results: The patient went through a 6-month period of a complex diagnostic process and an antibiotic treatment with strict activity limitations, after which a full recovery was achieved.

Conclusions: Although rare, when treating combat trainees or athletes whose daily life combines extensive physical training and potential ports of entry for bacteria, the treating physician should be aware of the potential for infectious osteomyelitis. Understanding the pathophysiology described would aid physicians when taking the patient history, and conducting an appropriate physical examination. The combination of a relevant history, pubic pain, high fever, and skin lacerations should alert the physician to the possibility of pubic osteomyelitis. When considering prevention, along with a well-designed training course for both soldiers in training camps and athletes, the significance of hygiene and treatment of superficial wounds or skin abrasions cannot be overemphasized.
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http://dx.doi.org/10.7205/MILMED-D-16-00171DOI Listing
March 2017