Publications by authors named "Scott A Rodeo"

263 Publications

Evaluation of Osseous Incorporation After Osteochondral Allograft Transplantation: Correlation of Computed Tomography Parameters With Patient-Reported Outcomes.

Orthop J Sports Med 2021 Aug 31;9(8):23259671211022682. Epub 2021 Aug 31.

Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, Oregon, USA.

Background: Studies have reported favorable clinical outcomes after osteochondral allograft (OCA) transplantation to treat osteochondral defects and have demonstrated that healing of the osseous component may be critical to outcomes. However, there is currently no consensus on the optimal modality to evaluate osseous healing.

Purpose: To define parameters for OCA healing using computed tomography (CT) and to investigate whether osseous healing identified using CT is correlated with improved pain and function on patient-reported outcomes (PROs) collected closest in time to the postoperative CT scan and at final follow-up.

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

Methods: Of 118 patients who underwent OCA transplantation for articular cartilage defects of the knee over the 10-year study period, 60 were included in final analysis based on completion of CT scans at 5.8 ± 1.9 months postoperatively and PROs collected preoperatively and postoperatively. CT parameters, including osseous incorporation, bone density, subchondral bone congruency, and cystic changes, were summarized for each patient relative to the cohort. Parameters were assessed for inter- and intrarater reliability as well as for covariation with patient characteristics and surgical variables. Structural equation modeling was used to assess correlation of CT parameters with change in PROs from preoperatively to those collected closest in time to CT acquisition and at the final follow-up.

Results: Bone incorporation was the most reliable CT parameter. The summarized scores for CT scans were normally distributed across the study population. Variance in CT parameters was independent of age, sex, body mass index, prior surgery, number of grafts, lesion size, and location. No significant correlation ( > .12 across all comparisons) was identified for any combination of CT parameter and change in PROs from baseline for outcomes collected either closest to CT acquisition or at the final follow-up (mean, 38.2 ± 19.9 months; range, 11.6-84.9 months). There was a uniformly positive association between change in PROs and host bone density but not graft bone density, independent of patient characteristics and surgical factors.

Conclusion: CT parameters were independent of clinical or patient variables within the study population, and osseous incorporation was the most reliable CT parameter. Metrics collected from a single postoperative CT scan was not correlated with clinical outcomes at ≥6-month longitudinal follow-up.
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http://dx.doi.org/10.1177/23259671211022682DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8414629PMC
August 2021

Targeted transcriptomic analyses of RNA isolated from formalin-fixed and paraffin-embedded human menisci.

J Orthop Res 2021 Aug 9. Epub 2021 Aug 9.

Orthopaedic Soft Tissue Research Program, Hospital for Special Surgery, New York, New York, USA.

Formalin-fixed and paraffin-embedded (FFPE) biospecimens are a valuable and widely-available resource for diagnostic and research applications. With biobanks of tissue samples available in many institutions, FFPE tissues could prove to be a valuable resource for translational orthopaedic research. The purpose of this study was to characterize the molecular profiles and degree of histologic degeneration on archival fragments of FFPE human menisci obtained during arthroscopic partial meniscectomy. We used FFPE menisci for multiplexed gene expression analysis using the NanoString nCounter® platform, and for histological assessment using a quantitative scoring system. In total, 17 archival specimens were utilized for integrated histologic and molecular analyses. The median patient age was 22 years (range: 14-62). We found that the genes with the highest normalized counts were those typically expressed in meniscal fibrocartilage. Gene expression differences were identified in patient cohorts based on age (≤40 years), including genes associated with the extracellular matrix and tissue repair. The majority of samples showed mild to moderate histologic degeneration. Based on these data, we conclude that FFPE human menisci can be effectively utilized for molecular evaluation following a storage time as long as 11 years. Statement of Clinical Significance: The integration of histological and transcriptomic analyses described in this study will be useful for future studies investigating the basis for biological classification of meniscus specimens in patients. Further exploration into the genes and pathways uncovered by this study may suggest targets for biomarker discovery and identify patients at greater risk for osteoarthritis once the meniscus is torn.
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http://dx.doi.org/10.1002/jor.25153DOI Listing
August 2021

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

Orthop J Sports Med 2021 Mar 23;9(3):2325967120983604. Epub 2021 Mar 23.

Brigham and Women's Hospital, Boston, Massachusetts, USA.

Background: Osteochondral allograft (OCA) transplantation has evolved into a first-line treatment for large chondral and osteochondral defects, aided by advancements in storage protocols and a growing body of clinical evidence supporting successful clinical outcomes and long-term survivorship. Despite the body of literature supporting OCAs, there still remains controversy and debate in the surgical application of OCA, especially where high-level evidence is lacking.

Purpose: To develop consensus among an expert group with extensive clinical and scientific experience in OCA, addressing controversies in the treatment of chondral and osteochondral defects with OCA transplantation.

Study Design: Consensus statement.

Methods: A focus group of clinical experts on OCA cartilage restoration participated in a 3-round modified Delphi process to generate a list of statements and establish consensus. Questions and statements were initially developed on specific topics that lack scientific evidence and lead to debate and controversy in the clinical community. In-person discussion occurred where statements were not agreed on after 2 rounds of voting. After final voting, the percentage of agreement and level of consensus were characterized. A systematic literature review was performed, and the level of evidence and grade were established for each statement.

Results: Seventeen statements spanning surgical technique, graft matching, indications, and rehabilitation reached consensus after the final round of voting. Of the 17 statements that reached consensus, 11 received unanimous (100%) agreement, and 6 received strong (80%-99%) agreement.

Conclusion: The outcomes of this study led to the establishment of consensus statements that provide guidance on surgical and perioperative management of OCAs. The findings also provided insights on topics requiring more research or high-quality studies to further establish consensus and provide stronger evidence.
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http://dx.doi.org/10.1177/2325967120983604DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8237219PMC
March 2021

Biologics in professional and Olympic sport: a scoping review.

Bone Joint J 2021 Jul;103-B(7):1189-1196

Department of Orthopaedic Surgery, Stanford University School of Medicine, California, USA.

Aims: The aim of this study was to prepare a scoping review to investigate the use of biologic therapies in the treatment of musculoskeletal injuries in professional and Olympic athletes.

Methods: Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews and Arksey and O'Malley frameworks were followed. A three-step search strategy identified relevant published primary and secondary studies, as well as grey literature. The identified studies were screened with criteria for inclusion comprising clinical studies evaluating the use of biologic therapies in professional and Olympic athletes, systematic reviews, consensus statements, and conference proceedings. Data were extracted using a standardized tool to form a descriptive analysis and a thematic summary.

Results: A total of 202 studies were initially identified, and 35 met criteria for the scoping review; 33 (94.3%) were published within the last eight years, and 18 (51.4%) originated from the USA. Platelet rich plasma was the most studied biologic therapy, being evaluated in 33 (94.3%) studies. Ulnar collateral ligament and hamstring injuries were the conditions most studied (nine (25.7%) studies and seven (20.0%) studies, respectively). Athletes most frequently participated in baseball, soccer, and American football. Only two (5.7%) studies were level 1 evidence, with interpretation and comparison between studies limited by the variations in the injury profile, biologic preparations, and rehabilitation protocols.

Conclusion: There is diverse use of biologic therapies in the management of musculoskeletal injuries in professional and Olympic athletes. There is currently insufficient high-level evidence to support the widespread use of biologic therapies in athletes. Further research priorities include the development of condition/pathology-specific preparations of biologic therapies, and of outcome measures and imaging modalities sufficiently sensitive to detect differences in outcomes, should they exist. Cite this article:  2021;103-B(7):1189-1196.
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http://dx.doi.org/10.1302/0301-620X.103B7.BJJ-2020-2282.R1DOI Listing
July 2021

Infographic: Biologics in professional and Olympic sport: a scoping review.

Bone Joint J 2021 Jul;103-B(7):1187-1188

Department of Orthopaedic Surgery, Stanford University School of Medicine, California, USA.

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http://dx.doi.org/10.1302/0301-620X.103B7.BJJ-2021-0864DOI Listing
July 2021

Is Antiplatelet Therapy Contraindicated After Platelet-Rich Plasma Treatment? A Narrative Review.

Orthop J Sports Med 2021 Jun 10;9(6):23259671211010510. Epub 2021 Jun 10.

Area of Concentration Program, Weill Cornell Medical College, New York, New York, USA.

Background: Antiplatelet therapies are often withheld before and after platelet-rich plasma product (PRPP) administration due to theoretical concerns that therapies that inhibit the function of platelets would inhibit the effects of PRPP.

Purpose/hypothesis: The purpose of this study was to evaluate the effect that antiplatelet therapies have on the ability of PRPP to stimulate wound healing and tissue regeneration. Our hypothesis was that antiplatelet therapies would have highly heterogeneous effects on the biological activity of PRPP.

Study Design: Narrative review.

Methods: The Medline database was searched via PubMed to identify all studies related to PRPP and antiplatelet therapies, yielding 1417 publications. After the search was confined to articles published after 1995, there were 901 articles remaining. All abstracts were then screened to identify animal or human clinical studies that focused on growth factor or inflammatory cytokine production or treatment outcomes. We limited our analysis to studies reporting on orthopaedic pathologies and in vitro studies of antiplatelet therapies. Ultimately, 12 articles fit the search criteria.

Results: The majority of studies reported on the use of nonsteroidal anti-inflammatory drugs as antiplatelet therapy. The majority of studies were in vitro analyses of growth factors, inflammatory cytokines, or cell viability, whereas 1 study examined clinical outcomes in an animal model. None of the studies investigated clinical outcomes in humans. All of the studies showed no effect or mixed effects of antiplatelet therapies on PRPP efficacy. One study showed PRPP recovery to baseline function after a 1-week washout period.

Conclusion: The literature did not provide support for the common clinical practice of withholding antiplatelet therapies in patients being treated with PRPP.
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http://dx.doi.org/10.1177/23259671211010510DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8202276PMC
June 2021

Biologic Association Annual Summit: 2020 Report.

Orthop J Sports Med 2021 Jun 7;9(6):23259671211015667. Epub 2021 Jun 7.

University of Colorado School of Medicine, Aurora, Colorado, USA.

Interest and research in biologic approaches for tissue healing are exponentially growing for a variety of musculoskeletal conditions. The recent hype concerning musculoskeletal biological therapies (including viscosupplementation, platelet-rich plasma, and cellular therapies, or "stem cells") is driven by several factors, including demand by patients promising regenerative evidence supported by substantial basic and translational work, as well as commercial endeavors that complicate the scientific and lay understanding of biological therapy outcomes. While significant improvements have been made in the field, further basic and preclinical research and well-designed randomized clinical trials are needed to better elucidate the optimal indications, processing techniques, delivery, and outcome assessment. Furthermore, biologic treatments may have potential devastating complications when proper methods or techniques are ignored. For these reasons, an association comprising several scientific societies, named the Biologic Association (BA), was created to foster coordinated efforts and speak with a unified voice, advocating for the responsible use of biologics in the musculoskeletal environment in clinical practice, spearheading the development of standards for treatment and outcomes assessment, and reporting on the safety and efficacy of biologic interventions. This article will introduce the BA and its purpose, provide a summary of the 2020 first annual Biologic Association Summit, and outline the future strategic plan for the BA.
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http://dx.doi.org/10.1177/23259671211015667DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8191082PMC
June 2021

Effect of Preoperative Imaging and Patient Factors on Clinically Meaningful Outcomes and Quality of Life After Osteochondral Allograft Transplantation: A Machine Learning Analysis of Cartilage Defects of the Knee.

Am J Sports Med 2021 07 28;49(8):2177-2186. Epub 2021 May 28.

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

Background: Fresh osteochondral allograft transplantation (OCA) is an effective method of treating symptomatic cartilage defects of the knee. This restoration technique involves the single-stage implantation of viable, mature hyaline cartilage into a chondral or osteochondral lesion. The extent to which preoperative imaging and patient factors predict achieving clinically meaningful outcomes among patients undergoing OCA for cartilage lesions of the knee remains unknown.

Purpose: To determine the predictive relationship of preoperative imaging, preoperative patient-reported outcome measures (PROMs), and patient demographics with achievement of the minimal clinically important difference (MCID) and substantial clinical benefit (SCB) for functional and quality-of-life PROMs at 2 years after OCA for symptomatic cartilage defects of the knee.

Study Design: Case-control study; Level of evidence, 3.

Methods: Data were analyzed for patients who underwent OCA before May 1, 2018, by 2 high-volume fellowship-trained cartilage surgeons. The International Knee Documentation Committee (IKDC) subjective form, Knee Outcome Survey-Activities of Daily Living (KOS-ADL), and mental and physical component summaries of the SF-36 were administered preoperatively and at 2 years postoperatively. A total of 42 predictive models were created using 7 unique architectures to detect achievement of the MCID for each of the 4 outcome measures and the SCB for the IKDC and KOS-ADL. Data inputted into the models included sex, age, body mass index, baseline PROMs, lesion size, concomitant ligamentous or meniscal tear, and presence of "bone bruise" or osseous edema. Shapley additive explanations plot analysis identified predictors of reaching the MCID and SCB.

Results: Of the 185 patients who underwent OCA for the knee and met eligibility criteria from an institutional cartilage registry, 153 (83%) had 2-year follow-up. Preoperative magnetic resonance imaging (MRI), baseline PROMs, and patient demographics best predicted reaching the 2-year MCID and SCB of the IKDC and KOS-ADL PROMs, with areas under the receiver operating characteristic curve of the top-performing models ranging from good (0.88) to excellent (0.91). MRI faired poorly (areas under the curve, 0.60-0.68) in predicting the MCID for the mental and physical component summaries. Higher body mass index, knee malalignment, absence of preoperative osseous edema, concomitant anterior cruciate ligament or meniscal injury, larger defect size, and the implantation of >1 OCA graft were consistent findings contributing to failure to achieve the MCID or SCB at 2 years postoperatively.

Conclusion: Our machine learning models demonstrated that preoperative MRI, baseline PROMs, and patient demographics reliably predict the ability to reach clinically meaningful thresholds for functional knee outcomes 2 years after OCA for cartilage defects. Although clinical improvement in knee function can be reliably predicted, improvements in quality of life after OCA depend on a comprehensive preoperative assessment of the patient's perception of his or her mental and physical health. Absence of osseous edema, concomitant anterior cruciate ligament or meniscal injury, larger lesion size on MRI, knee malalignment, and elevated body mass index are predictive of failure to achieve 2-year functional benefits after OCA of the knee.
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http://dx.doi.org/10.1177/03635465211015179DOI Listing
July 2021

Quantitative assessment of the vascularity of the skeletally immature patella: a cadaveric study using MRI.

J Child Orthop 2021 Apr;15(2):157-165

Miami Orthopedic and Sports Medicine Institute, Baptist Health South Florida, Miami, FL, USA.

Purpose: While predominant blood supply to the adult patella enters inferomedially, little is known about skeletally immature patellar perfusion. Improved knowledge of immature patella vascularity can further understanding of osteochondritis dissecans, dorsal defects of the patella and bipartite patella, and help ensure safe surgical approaches. We hypothesized that the immature patella would exhibit more uniform blood flow. The study purpose was to quantify immature patella regional perfusion in comparison with adults.

Methods: Ten cadaveric knees were utilized (five immature, five mature). The superficial femoral artery was cannulated proximally. Signal enhancement increases were compared from pre- to post-contrast MRI to assess relative arterial contributions to patella regions (quadrants, anterior/posterior, superior/inferior, medial/lateral, and outer/inner).

Results: Quantitative-MRI analysis revealed similar distribution of enhancement between the immature and mature patella. The inferior pole exhibited significantly higher arterial contribution superior pole in both immature and mature groups (p = 0.009; both groups), while the inferomedial quadrant had the highest arterial contribution of all quadrants in both groups. The superolateral quadrant demonstrated the lowest arterial contribution in the immature group and second lowest in the adult group. The patella outer periphery had significantly greater arterial contribution than the inner central region in both immature (p = 0.009) and mature (p = 0.009) groups.

Conclusion: Distribution of arterial contributions between the immature and mature patella was similar. Our results highlight the importance of inferior and inferomedial blood supply in both immature and mature patellas. These findings have implications for paediatric and adult patients; surgical damage to inferior patellar vessels should be avoided to prevent associated complications.
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http://dx.doi.org/10.1302/1863-2548.15.200261DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8138784PMC
April 2021

The 2020 NBA Orthobiologics Consensus Statement.

Orthop J Sports Med 2021 May 6;9(5):23259671211002296. Epub 2021 May 6.

Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan, USA.

This 2020 NBA Orthobiologics Consensus Statement provides a concise summary of available literature and practical clinical guidelines for team physicians and players. We recognize that orthobiologic injections are a generally safe treatment modality with a significant potential to reduce pain and expedite early return to play in specific musculoskeletal injuries. The use of orthobiologics in sports medicine to safely reduce time loss and reinjury is of considerable interest, especially as it relates to the potential effect on a professional athlete. While these novel substances have potential to enhance healing and regeneration of injured tissues, there is a lack of robust data to support their regular use at this time. There are no absolutes when considering the implementation of orthobiologics, and unbiased clinical judgment with an emphasis on player safety should always prevail. Current best evidence supports the following: Key Points There is support for the use of leukocyte-poor platelet-rich plasma in the treatment of knee osteoarthritis. There is support for consideration of using leukocyte-rich platelet-rich plasma for patellar tendinopathy. The efficacy of using mesenchymal stromal cell injections in the management of joint and soft tissue injuries remains unproven at this time. There are very few data to suggest that current cell therapy treatments lead to any true functional tissue regeneration. Meticulous and sterile preparation guidelines must be followed to minimize the risk for infection and adverse events if these treatments are pursued.Given the high variability in orthobiologic formulations, team physicians must stay up-to-date with the most recent peer-reviewed literature and orthobiologic preparation protocols for specific injuries.Evidence-based treatment algorithms are necessary to identify the optimal orthobiologic formulations for specific tissues and injuries in athletes.Changes in the regulatory environment and improved standardization are required given the exponential increase in utilization as novel techniques and substances are introduced into clinical practice.
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http://dx.doi.org/10.1177/23259671211002296DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8114275PMC
May 2021

The Virtual Shoulder Physical Exam.

HSS J 2021 Feb 21;17(1):59-64. Epub 2021 Feb 21.

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

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http://dx.doi.org/10.1177/1556331620975033DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8077973PMC
February 2021

Complications Following Biologic Therapeutic Injections: A Multicenter Case Series.

Arthroscopy 2021 08 17;37(8):2600-2605. Epub 2021 Apr 17.

Hospital for Special Surgery, New York, New York, U.S.A.

Purpose: To describe the complications that occur following biologic therapeutic injections.

Methods: We queried physician members of the Biologic Association, a multidisciplinary organization dedicated to providing a unified voice for all matters related to musculoskeletal biologics and regenerative medicine. Patients included in this study must have (1) received a biologic injection, (2) sustained an adverse reaction, and (3) had a minimum of 1-year follow-up after the injection. Patient demographic information, medical comorbidities, diagnoses, and previous treatments were recorded. The type of injection, injection setting, injection manufacturers, and specific details about the complication and outcome were collected.

Results: In total, 14 patients were identified across 6 institutions in the United States (mean age 63 years, range: 36-83 years). The most common injections in this series were intra-articular knee injections (50%), followed intra-articular shoulder injections (21.4%). The most common underlying diagnosis was osteoarthritis (78.5%). Types of injections included umbilical cord blood, platelet-rich plasma, bone marrow aspirate concentrate, placental tissue, and unspecified "stem cell" injections. Complications included infection (50%), suspected sterile inflammatory response (42.9%), and a combination of both (7.1%). The most common pathogen identified from infection cases was Escherichia coli (n = 4). All patients who had isolated infections underwent treatment with at least one subsequent surgical intervention (mean: 3.6, range: 1-12) and intravenous antibiotic therapy.

Conclusions: This study demonstrates that serious complications can occur following treatment with biologic injections, including infections requiring multiple surgical procedures and inflammatory reactions.

Level Of Evidence: Level IV, case series.
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http://dx.doi.org/10.1016/j.arthro.2021.03.065DOI Listing
August 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

Mitochondrial dysfunction and potential mitochondrial protectant treatments in tendinopathy.

Ann N Y Acad Sci 2021 04 11;1490(1):29-41. Epub 2021 Apr 11.

Orthopedic Soft Tissue Research Program, Hospital for Special Surgery, New York, New York.

Tendinopathy is a common musculoskeletal condition that affects a wide range of patients, including athletes, laborers, and older patients. Tendinopathy is often characterized by pain, swelling, and impaired performance and function. The etiology of tendinopathy is multifactorial, including both intrinsic and extrinsic mechanisms. Various treatment strategies have been described, but outcomes are often variable, as tendons have poor intrinsic healing potential compared with other tissues. Therefore, several novel targets for tendon regeneration have been identified and are being explored. Mitochondria are organelles that generate adenosine triphosphate, and they are considered to be the power generators of the cell. Recently, mitochondrial dysfunction verified by increased reactive oxygen species (ROS), decreased superoxide dismutase activity, cristae disorganization, and decreased number of mitochondria has been identified as a mechanism that may contribute to tendinopathy. This has provided new insights for studying tendinopathy pathogenesis and potential treatments via antioxidant, metabolic modulation, or ROS inhibition. In this review, we present the current understanding of mitochondrial dysfunction in tendinopathy. The review summarizes the potential mechanism by which mitochondrial dysfunction contributes to the development of tendinopathy, as well as the potential therapeutic benefits of mitochondrial protectants in the treatment of tendinopathy.
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http://dx.doi.org/10.1111/nyas.14599DOI Listing
April 2021

Histologic and molecular features in pathologic human menisci from knees with and without osteoarthritis.

J Orthop Res 2021 Apr 1. Epub 2021 Apr 1.

Hospital for Special Surgery, Lab. for Soft Tissue Research, New York, New York, USA.

The objective of this study was to evaluate histologic and molecular features of meniscus degeneration in cohorts of patients with and without osteoarthritis (OA) of the knee. Menisci were obtained from patients undergoing total knee arthroplasty for OA (TKA) or arthroscopic partial meniscectomy (APM) for a torn knee meniscus. Degenerative meniscal tears were among the most common tear type in the APM group based on the pattern. Using an integrative workflow for molecular evaluation of formalin-fixed and paraffin-embedded tissues, human menisci underwent blinded histologic evaluation and NanoString gene expression analyses. Histology revealed increased proteoglycan content in TKA menisci compared to APM menisci, but otherwise no significant differences in the total pathology score or sub-scores between patients based on age or cohort. NanoString analyses revealed differential expression of genes primarily associated with the PI3K-AKT signaling pathway, cell cycle, and apoptosis. These data provide new insights into histological and molecular features of meniscus degeneration in patients with and without knee OA. Histologic assessment of menisci showed similar severity of overall degeneration between cohorts, but there were differences at the molecular level. The dysregulated pathways identified in this study could contribute to early-onset meniscus degeneration, or to a predisposition to meniscus tears and subsequent knee OA. Further studies that validate genes and pathways uncovered in this study will allow us to evaluate novel approaches to assess and treat meniscal degeneration.
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http://dx.doi.org/10.1002/jor.25047DOI Listing
April 2021

The Virtual Shoulder and Knee Physical Examination.

Orthop J Sports Med 2020 Oct 20;8(10):2325967120962869. Epub 2020 Oct 20.

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

The COVID-19 crisis has forced a sudden and dramatic shift in the way that clinicians interact with their patients, from outpatient encounters to telehealth visits utilizing a variety of internet-based videoconferencing applications. Although many aspects of pre-COVID-19 outpatient sports medicine care will ultimately resume, it is likely that telehealth will persist because of its practicality and because of patient demand for access to efficient and convenient health care. Physical examination is widely considered a critical obstacle to a thorough evaluation of sports medicine patients during telehealth visits. However, a closer reflection suggests that a majority of the examination maneuvers are possible virtually with limited, if any, modifications. Thus, we provide a comprehensive shoulder and knee physical examination for sports medicine telehealth visits, including (1) verbal instructions in layman's terms that can be provided to the patient before or read verbatim during the visit, (2) multimedia options (narrated videos and annotated presentations) of the shoulder and knee examination that can be provided to patients via screen-share options, and (3) a corresponding checklist to aid in documentation.
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http://dx.doi.org/10.1177/2325967120962869DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7871077PMC
October 2020

In Vivo Imaging of Fibroblast Activity Using a 68Ga-Labeled Fibroblast Activation Protein Alpha (FAP-α) Inhibitor: Study in a Mouse Rotator Cuff Repair Model.

J Bone Joint Surg Am 2021 May;103(10):e40

Orthopedic Soft Tissue Research Program, Hospital for Special Surgery, New York, NY.

Background: Rotator cuff repair site failure is a well-established clinical concern. Tendon-to-bone healing is initiated by inflammatory mediators followed by matrix synthesis by fibroblasts. The kinetics of fibroblast accumulation and activity are currently poorly understood.

Methods: Ninety-six mice underwent supraspinatus tendon repair. Six were used for imaging using a novel 68Gallium (Ga)-labeled fibroblast activation protein alpha (FAP-α) inhibitor and positron emission tomography-computed tomography (PET/CT) at days 0 (before surgery), 3, 7, 14, and 28. Sixty-eight animals were divided into 4 groups to be evaluated at 3, 7, 14, or 28 days. Twenty-two native shoulders from mice without surgery were used as the control group (intact tendon). Six animals from each group were used for histological analysis; 6 from each group were used for evaluation of fibroblastic response-related gene expression; and 10 mice each from the intact, 14-day, and 28-day groups were used for biomechanical testing.

Results: There was minimal localization of 68Ga-labeled FAP-α inhibitor in the shoulders at day 0 (before surgery). There was significantly increased uptake in the shoulders with surgery compared with the contralateral sides without surgery at 3, 7, and 14 days. 68Ga-labeled FAP-α inhibitor uptake in the surgically treated shoulders increased gradually and peaked at 14 days followed by a decrease at 28 days. Gene expression for smooth muscle alpha (α)-2 (acta2), FAP-α, and fibronectin increased postsurgery followed by a drop at 28 days. Immunohistochemical analysis showed that FAP-α-positive cell density followed a similar temporal trend, peaking at 14 days. All trends matched closely with the PET/CT results. Biomechanical testing demonstrated a gradual increase in failure load during the healing process.

Conclusions: 68Ga-labeled FAP-α inhibitor PET/CT allows facile, high-contrast in vivo 3-dimensional imaging of fibroblastic activity in a mouse rotator cuff repair model.

Clinical Relevance: Noninvasive imaging of activated fibroblasts using labeled radiotracers may be a valuable tool to follow the progression of healing at the bone-tendon interface.
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http://dx.doi.org/10.2106/JBJS.20.00831DOI Listing
May 2021

Association Between Preoperative Mental Health and Clinically Meaningful Outcomes After Osteochondral Allograft for Cartilage Defects of the Knee: A Machine Learning Analysis.

Am J Sports Med 2021 03 8;49(4):948-957. Epub 2021 Feb 8.

Sports Medicine and Shoulder Service-Institute for Cartilage Repair, Hospital for Special Surgery, New York, New York, USA.

Background: Fresh osteochondral allograft transplantation (OCA) is an effective method of treating symptomatic cartilage defects of the knee. This cartilage restoration technique involves the single-stage implantation of viable, mature hyaline cartilage into the chondral or osteochondral lesion. Predictive models for reaching the clinically meaningful outcome among patients undergoing OCA for cartilage lesions of the knee remain under investigation.

Purpose: To apply machine learning to determine which preoperative variables are predictive for achieving the minimal clinically important difference (MCID) and substantial clinical benefit (SCB) at 1 and 2 years after OCA for cartilage lesions of the knee.

Study Design: Case-control study; Level of evidence, 3.

Methods: Data were analyzed for patients who underwent OCA of the knee by 2 high-volume fellowship-trained cartilage surgeons before May 1, 2018. The International Knee Documentation Committee questionnaire (IKDC), Knee Outcome Survey-Activities of Daily Living (KOS-ADL), and Mental Component (MCS) and Physical Component (PCS) Summaries of the 36-Item Short Form Health Survey (SF-36) were administered preoperatively and at 1 and 2 years postoperatively. A total of 84 predictive models were created using 7 unique architectures to detect achievement of the MCID for each of the 4 outcome measures and the SCB for the IKDC and KOS-ADL at both time points. Data inputted into the models included previous and concomitant surgical history, laterality, sex, age, body mass index (BMI), intraoperative findings, and patient-reported outcome measures (PROMs). Shapley Additive Explanations (SHAP) analysis identified predictors of reaching the MCID and SCB.

Results: Of the 185 patients who underwent OCA for the knee and met eligibility criteria from an institutional cartilage registry, 135 (73%) patients were available for the 1-year follow-up and 153 (83%) patients for the 2-year follow-up. In predicting outcomes after OCA in terms of the IKDC, KOS-ADL, MCS, and PCS at 1 and 2 years, areas under the receiver operating characteristic curve (AUCs) of the top-performing models ranged from fair (0.72) to excellent (0.94). Lower baseline mental health (MCS), higher baseline physical health (PCS) and knee function scores (KOS-ADL, IKDC Subjective), lower baseline activity demand (Marx, Cincinnati sports), worse pain symptoms (Cincinnati pain, SF-36 pain), and higher BMI were thematic predictors contributing to failure to achieve the MCID or SCB at 1 and 2 years postoperatively.

Conclusion: Our machine learning models were effective in predicting outcomes and elucidating the relationships between baseline factors contributing to achieving the MCID for OCA of the knee. Patients who preoperatively report poor mental health, catastrophize pain symptoms, compensate with higher physical health and knee function, and exhibit lower activity demands are at risk for failing to reach clinically meaningful outcomes after OCA of the knee.
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http://dx.doi.org/10.1177/0363546520988021DOI Listing
March 2021

Author Correction: Tendinopathy.

Nat Rev Dis Primers 2021 Feb 3;7(1):10. Epub 2021 Feb 3.

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

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http://dx.doi.org/10.1038/s41572-021-00251-8DOI Listing
February 2021

Computed Tomography-Based Preoperative Planning Provides a Pathology and Morphology-Specific Approach to Glenohumeral Instability With Bone Loss.

Arthroscopy 2021 06 27;37(6):1757-1766.e2. Epub 2021 Jan 27.

Sports Medicine Institute, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, U.S.A.. Electronic address:

Purpose: To use computed tomography (CT) to determine a reproducible method of coracoid measurement to compare the ability of the classic Latarjet technique and the congruent arc modification (CAM) to restore native glenoid diameter and to develop a preoperative planning algorithm for glenoid restoration with a goal of achieving an on-track shoulder.

Methods: Coracoid dimensions were measured on multiplanar reconstructed shoulder CT scans of patients aged 18 to 45 years obtained between December 1, 2019, and March 13, 2020. Patients were excluded if CT demonstrated osteophyte formation, glenoid dysplasia, coracoid fracture, or tumor. The proportion of glenoid diameter able to be restored using classic Latarjet technique and CAM were calculated. A treatment algorithm was proposed considering the amount of bone loss present and coracoid dimensions.

Results: Coracoid dimensions of 117 consecutive patients were measured and varied considerably (length: 17.5-31.8 mm, width: 9.1-20.5 mm, thickness: 6.1-15.7 mm). While most patients had harvestable coracoid length ≥20 mm (male: 96.3% vs female: 94.4%, P = .65), only 27.8% of female patients had coracoid thickness ≥10 mm. When comparing Latarjet techniques, there was no difference in the proportion of patients in whom 30% glenoid diameter could be fully restored, but CAM was able to restore at least 35% in more male and female patients (98.8% vs 79.0% and 100% vs 61.1%, respectively, P = .00001). Intra- and inter-rater reliability was excellent ( intraclass correlation coefficient ≥0.950 for all dimensions).

Conclusions: We describe a reliable method of measuring coracoid dimensions for preoperative planning of glenoid restoration. The classic Latarjet technique reliably restores the glenoid anteroposterior diameter with bone loss of up to 30%. The majority of female patients have coracoid thickness <10 mm, which may increase the risk of graft fracture when using CAM. The decision to use the classic Latarjet technique or CAM considers each individual's glenoid and coracoid dimensions with a goal of achieving an on-track shoulder.

Clinical Relevance: Our reliable method of coracoid measurement demonstrated the differing abilities of the classic Latarjet and CAM to restore the native glenoid diameter. An evidence-based algorithm using these measurements was developed to assist in preoperative planning for glenohumeral instability in the setting of bone loss, with a goal of achieving an on-track shoulder. Alternative techniques may be considered if an on-track shoulder cannot be achieved with Latarjet.
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http://dx.doi.org/10.1016/j.arthro.2021.01.021DOI Listing
June 2021

Lower Extremity Compartment Syndrome in National Football League Athletes.

Sports Health 2021 Mar 11;13(2):198-202. Epub 2021 Jan 11.

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

Background: The purpose of this study was to evaluate the incidence of lower extremity compartment syndrome in National Football League (NFL) athletes and report the mechanisms of injury, methods of treatment, and subsequent days missed. We review the existing literature on lower extremity compartment syndrome in athletic populations.

Hypothesis: Lower extremity compartment syndrome occurs with a low incidence in NFL athletes, and there is a high return-to-play rate after surgical management of acute compartment syndrome.

Study Design: Case series.

Level Of Evidence: Level 4.

Methods: A retrospective review of recorded cases of lower extremity compartment syndrome from 2000 to 2017 was performed using the NFL Injury Surveillance System and electronic medical record system. Epidemiological data, injury mechanism, rates of surgery, and days missed due to injury were recorded.

Results: During the study period, 22 cases of leg compartment syndrome in 21 athletes were recorded. Of these injuries, 50% occurred in games and 73% were the result of a direct impact to the leg. Concomitant tibial fracture was noted in only 2 cases (9.1%) and there was only 1 reported case of chronic exertional compartment syndrome. Surgery was documented in 15 of 22 cases (68.2%). For acute nonfracture cases, the average time missed due to injury was 24.2 days (range, 5-54 days), and all were able to return to full participation within the same season.

Conclusion: NFL athletes with acute leg compartment syndrome treated with surgery exhibited a high rate of return to play within the same season.

Clinical Relevance: Although compartment syndrome is a relatively rare diagnosis among NFL players, team physicians and athletic trainers must maintain a high index of suspicion to expediently diagnose and treat this potentially limb-threatening condition.
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http://dx.doi.org/10.1177/1941738120973674DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8167353PMC
March 2021

Tendinopathy.

Nat Rev Dis Primers 2021 01 7;7(1). Epub 2021 Jan 7.

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

Tendinopathy describes a complex multifaceted pathology of the tendon, characterized by pain, decline in function and reduced exercise tolerance. The most common overuse tendinopathies involve the rotator cuff tendon, medial and lateral elbow epicondyles, patellar tendon, gluteal tendons and the Achilles tendon. The prominent histological and molecular features of tendinopathy include disorganization of collagen fibres, an increase in the microvasculature and sensory nerve innervation, dysregulated extracellular matrix homeostasis, increased immune cells and inflammatory mediators, and enhanced cellular apoptosis. Although diagnosis is mostly achieved based on clinical symptoms, in some cases, additional pain-provoking tests and imaging might be necessary. Management consists of different exercise and loading programmes, therapeutic modalities and surgical interventions; however, their effectiveness remains ambiguous. Future research should focus on elucidating the key functional pathways implicated in clinical disease and on improved rehabilitation protocols.
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http://dx.doi.org/10.1038/s41572-020-00234-1DOI Listing
January 2021

The glenohumeral ligaments: Superior, middle, and inferior: Anatomy, biomechanics, injury, and diagnosis.

Clin Anat 2021 Mar 13;34(2):283-296. Epub 2021 Jan 13.

Department of Orthopaedic Surgery and Sports Medicine, Hospital for Special Surgery, New York, New York, USA.

The three glenohumeral ligaments (superior, middle, and inferior) are discrete thickenings of the glenohumeral joint capsule and are critical to shoulder stability and function. Injuries to this area are a cause of significant musculoskeletal morbidity. A literature search was performed by a review of PubMed, Google Scholar, and OVID for all relevant articles published up until 2020. This study highlights the anatomy, biomechanical function, and injury patterns of the glenohumeral ligaments, which may be relevant to clinical presentation and diagnosis. A detailed understanding of the normal anatomy and biomechanics is a necessary prerequisite to understanding the injury patterns and clinical presentations of disorders involving the glenohumeral ligaments of the shoulder.
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http://dx.doi.org/10.1002/ca.23717DOI Listing
March 2021

Chronic subacromial impingement leads to supraspinatus muscle functional and morphological changes: Evaluation in a murine model.

J Orthop Res 2021 Oct 29;39(10):2243-2251. Epub 2020 Dec 29.

Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA.

Muscle atrophy and fatty infiltration have been directly correlated with higher rates of incomplete or failed healing following surgical repair of the rotator cuff. The purpose of this study was to evaluate clinically relevant functional and morphological changes in the supraspinatus muscle at various time points in this model of rotator cuff tendinopathy. Subacromial impingement was induced in 47, male C57BL/6 mice (total 94 limbs) by implantation of a metal clip in the subacromial space. Specimens were evaluated at 4, 6, and 12 weeks postoperatively. Gait analysis was used to measure various kinematic parameters. Supraspinatus muscle wet weight, histology, and quantitative reverse-transcription polymerase chain reaction analysis of genes related to muscle atrophy and adipogenesis were performed to characterize the structural, cellular, and molecular changes. Muscle atrophy and fatty infiltration was evident beginning at 6 weeks, with progression out to 12 weeks. Gait analysis identified significant functional changes in many aspects of gait and abnormal stance tracing as early as 4 weeks, verifying alterations in upper extremity function. We have demonstrated that clinically relevant changes to the supraspinatus muscle are seen starting 6 weeks after induction of subacromial impingement. Furthermore, the gait analysis provides key functional outcome measurements that may be useful for future evaluation of new therapeutic strategies.
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http://dx.doi.org/10.1002/jor.24964DOI Listing
October 2021

Mesenchymal stromal cells and platelet-rich plasma promote tendon allograft healing in ovine anterior cruciate ligament reconstruction.

Knee Surg Sports Traumatol Arthrosc 2020 Dec 17. Epub 2020 Dec 17.

University of Portsmouth, Portsmouth, UK.

Purpose: The effect of bone marrow mesenchymal stromal cells (BMSCs) and platelet-rich plasma (PRP) on tendon allograft maturation in a large animal anterior cruciate ligament (ACL) reconstruction model was reported for the first time. It was hypothesised that compared with non-augmented ACL reconstruction, BMSCs and PRP would enhance graft maturation after 12 weeks and this would be detected using magnetic resonance imaging (MRI).

Methods: Fifteen sheep underwent unilateral tendon allograft ACL reconstruction using aperture fixation and were randomised into three groups (n = 5). Group 1 received 10 million allogeneic BMSCs in 2 ml fibrin sealant; Group 2 received 12 ml PRP in a plasma clot injected into the graft and bone tunnels; and Group 3 (control) received no adjunctive treatment. At autopsy at 12 weeks, a graft maturation score was determined by the sum for graft integrity, synovial coverage and vascularisation, graft thickness and apparent tension, and synovial sealing at tunnel apertures. MRI analysis (n = 2 animals per group) of the signal-noise quotient (SNQ) and fibrous interzone (FIZ) was used to evaluate intra-articular graft maturation and tendon-bone healing, respectively. Spearman's rank correlation coefficient (r) of SNQ, autopsy graft maturation score and bone tunnel diameter were analysed.

Results: The BMSC group (p = 0.01) and PRP group (p = 0.03) had a significantly higher graft maturation score compared with the control group. The BMSC group scored significantly higher for synovial sealing at tunnel apertures (p = 0.03) compared with the control group. The graft maturation score at autopsy significantly correlated with the SNQ (r = - 0.83, p < 0.01). The tunnel diameter of the femoral tunnel at the aperture (r = 0.883, p = 0.03) and mid-portion (r = 0.941, p = 0.02) positively correlated with the SNQ.

Conclusions: BMSCs and PRP significantly enhanced graft maturation, which indicates that orthobiologics can accelerate the biologic events in tendon allograft incorporation. Femoral tunnel expansion significantly correlated with inferior maturation of the intra-articular graft. The clinical relevance of this study is that BMSCs and PRP enhance allograft healing in a translational model, and biological modulation of graft healing can be evaluated non-invasively using MRI.
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http://dx.doi.org/10.1007/s00167-020-06392-9DOI Listing
December 2020

Arthroscopic-Assisted Coracoclavicular Ligament Reconstruction: Clinical Outcomes and Return to Activity at Mean 6-Year Follow-Up.

Arthroscopy 2021 04 2;37(4):1086-1095.e1. Epub 2020 Dec 2.

Sports Medicine Institute, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, U.S.A.

Purpose: To report clinical and functional outcomes including return to preinjury activity level following arthroscopic-assisted coracoclavicular (CC) ligament reconstruction (AA-CCR) and to determine associations between return to preinjury activity level, radiographic outcomes, and patient-reported outcomes following AA-CCR.

Methods: A institutional registry review of all AA-CCR using free tendon grafts from 2007 to 2016 was performed. Clinical assessment included Single Assessment Numeric Evaluation (SANE) score and return to preinjury activity level at final follow-up. Treatment failure was defined as (1) revision acromioclavicular stabilization surgery, (2) unable to return to preinjury activity level, or (3) radiographic loss of reduction (RLOR, >25% CC distance compared with contralateral side). SANE scores, return to activity, and RLOR were compared between patients within each category of treatment failure, by grade of injury, and whether concomitant pathology was treated.

Results: There were 88 patients (89.8% male) with mean age of 39.6 years and minimum 2-year clinical follow-up (mean 6.1 years). Most injuries were Rockwood grade V (63.6%). Mean postoperative SANE score was 86.3 ± 17.5. Treatment failure occurred in 17.1%: 8.0% were unable to return to activity, 5.7% had RLOR, and 3.4% underwent revision surgery due to traumatic reinjury. SANE score was lower among patients who were unable to return to activity compared with those with RLOR and compared with nonfailures (P = .0002). There were no differences in revision surgery rates, return to activity, or SANE scores according to Rockwood grade or if concomitant pathology was treated.

Conclusions: AA-CCR with free tendon grafts resulted in good clinical outcomes and a high rate of return to preinjury activity level. RLOR did not correlate with return to preinjury activity level. Concomitant pathology that required treatment did not adversely affect outcomes. Return to preinjury activity level may be a more clinically relevant outcome measure than radiographic maintenance of acromioclavicular joint reduction.

Level Of Evidence: IV (Case Series).
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http://dx.doi.org/10.1016/j.arthro.2020.11.045DOI Listing
April 2021

The use of biologics in professional and Olympic sport: a scoping review protocol.

Bone Jt Open 2020 Nov 17;1(11):715-719. Epub 2020 Nov 17.

Department of Orthopaedic Surgery, Stanford University School of Medicine, California, USA.

Aims: The use of biologics in the treatment of musculoskeletal injuries in Olympic and professional athletes appears to be increasing. There are no studies which currently map the extent, range, and nature of existing literature concerning the use and efficacy of such therapies in this arena. The objective of this scoping review is to map the available evidence regarding the use of biologics in the treatment of musculoskeletal injuries in Olympic and professional sport.

Methods: Best-practice methodological frameworks suggested by Arksey and O'Malley, Levac et al, and the Joanna Briggs Institute will be used. This scoping review will aim to firstly map the current extent, range, and nature of evidence for biologic strategies to treat injuries in professional and Olympic sport; secondly, to summarize and disseminate existing research findings; and thirdly, to identify gaps in existing literature. A three-step search strategy will identify peer reviewed and non-peer reviewed literature, including reviews, original research, and both published and unpublished ('grey') literature. An initial limited search will identify suitable search terms, followed by a search of five electronic databases (MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, Web of Science, and Google Scholar) using keyword and index terms. Studies will be screened independently by two reviewers for final inclusion.

Dissemination: We will chart key concepts and evidence, and disseminate existing research findings to practitioners and clinicians, through both peer reviewed and non-peer reviewed literature, online platforms (including social media), conference, and in-person communications. We will identify gaps in current literature and priorities for further study.
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http://dx.doi.org/10.1302/2633-1462.111.BJO-2020-0159DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7684394PMC
November 2020
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