Higher Risk Of Reinjury Research Articles

Obstetric perineal trauma

Obstetric perineal trauma is a common pathology that complicates up to 90% of vaginal deliveries. The true incidence of injuries (and their severity) is usually underestimated and higher than reported. Obstetric perineal injuries have a serious impact on a woman’s well-being and have medical, emotional, social and psychological aspects. Their negative consequences can persist for many years after childbirth and have a potentially devastating impact on a woman’s quality of life, lead to severe morbidity due to persistent pain, pelvic floor dysfunction, urinary and faecal incontinence, sexual problems, high risk of re-injury during future childbirth, etc. The article presents an overview of existing national guidelines for the prevention and treatment of perineal injuries. The data on the frequency and risk factors of perineal tears are systematized, and a modern classification is presented. Particular attention is paid to obstetric anal sphincter injuries (OASIS) for a better understanding of this pathology by partitional doctors. Training and awareness of obstetricians about OASIS should help to identify patients at risk, more accurately diagnose and choose the right tactics. The article also describes the main preventive interventions during pregnancy and childbirth, discussing the advantages and disadvantages of each. Given the high frequency of episiotomy for the prevention of OASIS, the advantages and disadvantages of various options, as well as the correct 45-60˚ technique, are presented. The emphasis is placed on the fact that it is necessary to perform selective episiotomy rather than routine episiotomy in the presence of clear indications according to the national standard. Reducing the frequency of episiotomies should lead to a decreased number of iatrogenic perineal injuries. The general principles of surgical treatment of perineal injuries, various suturing techniques, suture material characteristics, postoperative management of patients and counselling for future births are also presented.The use of these recommendations by obstetricians will be useful for their practice and will help improve the quality of medical care.

Reinjury Anxiety and Return to Sport After Anterior Cruciate Ligament Reconstruction: A Cluster Analysis and Prospective Study Among 162 Athletes

Background: Recent studies have investigated the effect of psychological factors on return to sport (RTS), but none has tested the existence of psychological profiles linked to reinjury anxiety and its links with RTS and reinjury. Purpose: To assess the effect of different psychological profiles on RTS and reinjury. Study Design: Cohort study; Level of evidence, 2. Methods: The study screened patients who were involved in all types of sports for anterior cruciate ligament (ACL) reconstruction (hamstring and patellar tendon autografts). All participants were included during the RTS phase (90-180 days after ACL reconstruction). Reinjury anxiety, fear of reinjury, kinesiophobia, perceived stress, anxiety, depression, knee confidence, self-esteem, optimism, coping, and pain were measured. Hierarchical cluster analysis (Ward method) and analysis of variance were performed. In the second year after surgery, patients were recontacted by telephone to follow-up. RTS and reinjury were compared by profile type. Results: A total of 162 athletes were initially included, of whom 123 responded regarding RTS and reinjury. Cluster analysis showed a 4-cluster solution (χ2[21] = 428.59; λ = .064; P < .001). Profile 1 (27.8%) was characterized by moderate reinjury anxiety and no depression. Profile 2 (22.8%) was characterized by moderate reinjury anxiety and minor anxious-depressive reaction. Profile 3 (30.9%) was characterized by no reinjury anxiety, no depression, and high confidence. Profile 4 (18.5%) was characterized by high anxiety, high depression, and low confidence. Profile 4 had the lowest self-esteem and optimism scores compared with profile 3 (P < .001). In addition, a higher percentage of men was found in profile 3 as opposed to profile 4 (χ2[3] = 11.35; P < .01). Profile 4 had the highest rate of non-RTS with 54.2% (profile 1: 14.3%, P = .001; profile 2: 25.0%, P = .031; profile 3: 22.2%, P = .011). Finally, patients with profile 3 had a higher risk of reinjury (13.9%) than those with profile 4 (0%) (P = .047), who had an extremely conservative RTS. Conclusion: The different profiles will affect RTS, but also the risk of reinjury exclusively for profiles 3 and 4. Rehabilitation management will probably require all stakeholders to understand psychological profiles of athletes to develop an on-demand rehabilitation plan.

Revision ACL reconstruction in female athletes: current concepts

The challenge of revision anterior cruciate ligament (ACL) reconstruction lies in its complexity, varied presentation, and technical intricacies. A successful ACL reconstruction should allow patients to safely return to preinjury activities. However, it is only sometimes simple, and many risk factors and concurrent pathologies come into play. Evaluating and analysing the cause of failure and associated conditions is paramount to addressing them effectively. Despite a plethora of research and improvements in knowledge and technology, e gaps exist in issues such as optimal techniques of revision surgery, graft options, fixation, concurrent procedures, rehabilitation and protocol for return to sports of high-level athletes. Female athletes need additional focus since they are at higher risk of re-injury, suboptimal clinical outcomes, and lower rates of return to sport following revision reconstruction. Our understanding about injury prevention and the protection of ACL grafts in female athletes needs to be improved. This review focuses on the current state of revision ACL surgery in female athletes and provides recommendations and future directions for optimising outcomes in this high-risk group.

Decellularization of Dense Regular Connective Tissue-Cellular and Molecular Modification with Applications in Regenerative Medicine.

Healing of dense regular connective tissue, due to a high fiber-to-cell ratio and low metabolic activity and regeneration potential, frequently requires surgical implantation or reconstruction with high risk of reinjury. An alternative to synthetic implants is using bioscaffolds obtained through decellularization, a process where the aim is to extract cells from the tissue while preserving the tissue-specific native molecular structure of the ECM. Proteins, lipids, nucleic acids and other various extracellular molecules are largely involved in differentiation, proliferation, vascularization and collagen fibers deposit, making them the crucial processes in tissue regeneration. Because of the multiple possible forms of cell extraction, there is no standardized protocol in dense regular connective tissue (DRCT). Many modifications of the structure, shape and composition of the bioscaffold have also been described to improve the therapeutic result following the implantation of decellularized connective tissue. The available data provide a valuable source of crucial information. However, the wide spectrum of decellularization makes it important to understand the key aspects of bioscaffolds relative to their potential use in tissue regeneration.

Can Symmetry of Single-Leg Vertical Jump Height Represent Normal Lower Limb Biomechanics of Athletes After Anterior Cruciate Ligament Reconstruction?

After anterior cruciate ligament reconstruction (ACLR), single-leg horizontal hop distance limb symmetry index (LSI) >90% is recommended as a cutoff point for safe return to sport (RTS). However, athletes after ACLR have abnormal lower limb biomechanics despite an adequate single-leg hop distance LSI, implying that athletes are at high risk of reinjury. Symmetry of single-leg vertical jump height appears to be more difficult to achieve and can be a better representation of knee function than single-leg horizontal hop distance. Athletes after ACLR with single-leg jump height LSI >90% had similar biomechanical characteristics to healthy athletes. Controlled laboratory study. Level 3. A total of 46 athletes after ACLR were divided into low jump height (LJH, jump height LSI <90%, n = 23) and high jump height (HJH, jump height LSI >90%, n = 23) groups according to symmetry of single-leg vertical jump height, while 24 healthy athletes acted as a control (CONT) group. One-way analysis of variance was used to compare the kinematic and kinetic characteristics of the LJH, HJH, and CONT groups during single-leg vertical jump. Both the LJH and HJH groups demonstrated greater limb asymmetry (lower LSI) during landing compared with the CONT group in knee extension moment (P < 0.05), peak knee flexion angle (P < 0.05), and knee power (P < 0.05). Symmetry in single-leg vertical jump height does not represent normal lower limb biomechanics in athletes after ACLR. Symmetrical jump height may not signify ideal biomechanical or RTS readiness, but single-leg vertical jump test can be used as a supplement to horizontal hop test or other functional tests to reduce the likelihood of false-negative results in the absence of detailed biomechanical evaluation.

Sports activity level after ACL reconstruction is predicted by vastus medialis or vastus medialis obliquus thickness, single leg triple hop distance or 6-m timed hop, and quality of life score.

Recovery after anterior cruciate ligament reconstruction (ACLR) may take > 2years, and younger athletes have higher re-injury risk. The purpose of this prospective longitudinal study was to determine how the early to mid-term Tegner Activity Level Scale (TALS) scores of athletically active males ≥ 2years post-ACLR follow-up was predicted by bilateral isokinetic knee extensor and flexor torque, quadriceps femoris thickness, single leg hop test performance, and self-reported knee function (Knee Injury and Osteoarthritis Outcome Score (KOOS); International Knee Documentation Committee(IKDC) Subjective Assessment score). After ACLR with a hamstring tendon autograft and safely returning to sports at least twice weekly, 23 men (18.4 ± 3.5years of age) were evaluated at final follow-up (mean = 4.5, range = 2-7years). Exploratory forward stepwise multiple regression was used to determine the relationship between independent surgical and non-surgical lower limb variables peak concentric isokinetic knee extensor-flexor torque at 60°/sec and 180°/sec, quadriceps femoris muscle thickness, single leg hop test profile results, KOOS subscale scores, IKDCSubjective Assessment scores, and time post-ACLR on TALS scores at final follow-up. Subject TALS scores were predicted by KOOS quality of lifesubscale score, surgical limb vastus medialis obliquus (VMO) thickness, and surgical limb single leg triple hop for distance (SLTHD) performance. Subject TALS scores were also predicted by KOOS quality of lifesubscale score, non-surgical limb vastus medialis (VM) thickness, and non-surgical limb 6m single leg timed hop (6MSLTH) performance. TALS scores were influenced differently by surgical and non-surgical lower extremity factors. At ≥ 2years post-ACLR, ultrasound VM and VMO thickness measurements, single leg hop tests that challenge knee extensor function, and self-reported quality of life measurements predicted sports activity levels. The SLTHD test may be better than the 6MSLTH for predicting long-term surgical limb function.

Effect of Quadriceps and Hamstring Strength Relative to Body Weight on Risk of a Second ACL Injury: A Cohort Study of 835 Patients Who Returned to Sport After ACL Reconstruction.

Anterior cruciate ligament (ACL) injuries are common sports-related injuries with a high risk of reinjury after return to sport (RTS). Rehabilitation aims to regain symmetrical knee strength and function to minimize the risk of a second ACL injury after RTS. To determine the effect of absolute quadriceps and hamstring strength, normalized by body weight, on the risk of a second ACL injury during the first 2 years after RTS in patients who have undergone ACL reconstruction (ACLR). Cohort study; Level of evidence, 3. Data from patients after index ACLR at the time of RTS were extracted from a rehabilitation registry-Project ACL. Patients who had performed isokinetic tests for quadriceps and hamstring strength and hop tests before RTS were included. The endpoint was a second ACL injury or a follow-up of 2 years after RTS after ACLR. A total of 835 patients (46% women), with a mean age of 23.9 ± 7.7 years, were included. During the study period, 69 (8.3%) second ACL injuries (ipsilateral and contralateral) occurred. Greater relative quadriceps strength in the injured leg increased the risk of a second ACL injury (relative risk [RR], 1.69 [95% CI, 1.05-2.74]; P = .032). In patients who had recovered symmetrical quadriceps strength (limb symmetry index ≥90%), there was no effect of quadriceps strength on the risk of second ACL injury (RR, 1.33 [95% CI, 0.69-2.56]; P = .39). Quadriceps strength on the healthy side or hamstring strength, regardless of side, had no effect on the risk of a second ACL injury. Greater relative quadriceps strength in the injured leg at the time of RTS after ACLR was associated with an increased risk of a second ACL injury. There was no effect of relative quadriceps strength on the risk of a second ACL injury in patients who had recovered symmetrical quadriceps strength.

MRI findings prior to return to play as predictors of reinjury in professional athletes: a novel decision-making tool

BackgroundBecause MRI has shown great accuracy in assessing acute muscle injuries, identification of risk factors for reinjury before return to play (RTP) in professional athletes during the healing process could be very relevant. We assessed the value of MRI findings prior to RTP as predictors of reinjury.MethodsRetrospective observational study of 59 professional athletes, mean age 26 years, with first-time acute muscle injury and successful rehabilitation ready to RTP. They underwent MRI within 6 days of the injury and within 7 days prior to RTP. The primary outcome was reinjury. Risk of reinjury was assessed using radiological signs in control MRI scans before RTP. The risk was classified as low, medium or high when none, one or two radiological signs were observed, respectively.ResultsReinjury occurred in 9 participants, with a rate of 15.2%. None of the baseline MRI-related variables was significantly associated with reinjury. In the control MRI scan performed within 7 days prior to RTP, three independent findings were significantly associated with reinjury. These included transversal and/or mixed connective tissue gap (p = 0.002), intermuscular oedema (p = 0.015) and callus gap (p = 0.046). In the predictive model of the risk of reinjury, the presence of two of these radiological signs, together with interstitial feathery oedema, was associated with a high risk of recurrence (OR 29.58, 95% CI 3.86–226.64; p = 0.001).ConclusionsIn professional athletes with acute muscle injuries of the lower limbs successfully rehabilitated, some radiological signs on MRI performed shortly before RTP were associated with a high risk of reinjury.

High quality rehabilitation to optimize return to sport following lateral meniscus surgery in football players.

There is a paucity of studies in the literature pertaining about how to guide rehabilitation and return to sport (RTS) progression for football players that have sustained a lateral meniscus injury and subsequent surgery. These patients are clinically challenging. If they return to sport too soon, before the rehabilitation process is completed and RTS criteria have been met, functional outcomes could be non-optimal and/or associated with higher reinjury risk. The aims of this paper are (I) to provide a brief overview of the current trends in acute lateral meniscus tears surgery in football players and (II) to suggest a framework for clinicians on how to progress the player following lateral meniscus surgery. Post-operative rehabilitation approaches are different for meniscus repair and for the other surgical techniques. The main goal of all involved practitioners should be to balance the "short term success" with the "long term protection" of the athlete's health. Specific key goals and interventions in early-, mid-, and late-stage rehabilitation are provided. The most important principle is to manage the progressive increase in loading through multiple measurements including frequent medical control consultations and functional tests detailing movement quantity and quality. RTS monitoring needs to be comprehensive and interdisciplinary, incorporating state of the art tests, to achieve recovery of sport-specific fitness, optimal movement quality and on-field rehabilitation progression.

Return to sport and beyond following intramuscular tendon hamstring injury: A case report of an English Premier League football player

BackgroundHamstring strain injuries are the most common type of injury in elite football and are associated with a high risk of reinjury, particularly those involving the intramuscular tendon (IMT). Limited information is available regarding the rehabilitation and return to sport (RTS) processes following such injuries. This case study describes the clinical presentation of an elite football player following IMT hamstring injury, their on- and off-pitch rehabilitation alongside performance monitoring throughout RTS and beyond. Case scenarioAn elite football player suffered a grade 2c hamstring injury during an English Premier League (EPL) match. The player underwent early post-injury management, alongside progressive off-pitch physical preparation. The ‘control-chaos continuum’ was used as a framework for on-pitch rehabilitation to prepare the player for a return to full team training and competition. Objective and subjective markers of the player's response to progressive on- and off-pitch loading were monitored throughout RTS and beyond. OutcomesThe player returned to on-pitch rehabilitation after 11 days, to full team training having achieved weekly pre-injury chronic running load outputs after 35 days and played in the EPL 40 days post-injury. The player did not suffer reinjury for the rest of the EPL season. ConclusionAn understanding the unique structural and mechanical properties of the IMT, alongside expected RTS timeframes are important to inform rehabilitation and decision-making processes post-injury. Performance and frequent load-response monitoring throughout RTS and beyond, in conjunction with practitioner experience and effective communication are critical in facilitating effective RTS and reduce risk of reinjury following IMT injury.

Return to Play Prediction Accuracy of the MLG-R Classification System for Hamstring Injuries in Football Players: A Machine Learning Approach.

Muscle injuries are one of the main daily problems in sports medicine, football in particular. However, we do not have a reliable means to predict the outcome, i.e. return to play from severe injury. The aim of the present study was to evaluate the capability of the MLG-R classification system to grade hamstring muscle injuries by severity, offer a prognosis for the return to play, and identify injuries with a higher risk of re-injury. Furthermore, we aimed to assess the consistency of our proposed system by investigating its intra-observer and inter-observer reliability. All male professional football players from FC Barcelona, senior A and B and the two U-19 teams, with injuries that occurred between February 2010 and February 2020 were reviewed. Only players with a clinical presentation of a hamstring muscle injury, with complete clinic information and magnetic resonance images, were included. Three different statistical and machine learning approaches (linear regression, random forest, and eXtreme Gradient Boosting) were used to assess the importance of each factor of the MLG-R classification system in determining the return to play, as well as to offer a prediction of the expected return to play. We used the Cohen's kappa and the intra-class correlation coefficient to assess the intra-observer and inter-observer reliability. Between 2010 and 2020, 76 hamstring injuries corresponding to 42 different players were identified, of which 50 (65.8%) were grade 3r, 54 (71.1%) affected the biceps femoris long head, and 33 of the 76 (43.4%) were located at the proximal myotendinous junction. The mean return to play for grades 2, 3, and 3r injuries were 14.3, 12.4, and 37days, respectively. Injuries affecting the proximal myotendinous junction had a mean return to play of 31.7days while those affecting the distal part of the myotendinous junction had a mean return to play of 23.9days. The analysis of the grade 3r biceps femoris long head injuries located at the free tendon showed a median return to play time of 56days while the injuries located at the central tendon had a shorter return to play of 24days (p = 0.038). The statistical analysis showed an excellent predictive power of the MLG-R classification system with a mean absolute error of 9.8days and an R-squared of 0.48. The most important factors to determine the return to play were if the injury was at the free tendon of the biceps femoris long head or if it was a grade 3r injury. For all the items of the MLG-R classification, the intra-observer and inter-observer reliability was excellent (k > 0.93) except for fibres blurring (κ = 0.68). The main determinant for a long return to play after a hamstring injury is the injury affecting the connective tissue structures of the hamstring. We developed a reliable hamstring muscle injury classification system based on magnetic resonance imaging that showed excellent results in terms of reliability, prognosis capability and objectivity. It is easy to use in clinical daily practice, and can be further adapted to future knowledge. The adoption of this system by the medical community would allow a uniform diagnosis leading to better injury management.

Predictors of Graft Failure in Young Active Patients Undergoing Hamstring Autograft Anterior Cruciate Ligament Reconstruction With or Without a Lateral Extra-articular Tenodesis: The Stability Experience

Background: Anterior cruciate ligament (ACL) reconstruction (ACLR) has higher failure rates in young active patients returning to sports as compared with older, less active individuals. Augmentation of ACLR with an anterolateral procedure has been shown to reduce failure rates; however, indications for this procedure have yet to be clearly defined. Purpose/Hypothesis: The purpose of this study was to identify predictors of ACL graft failure in high-risk patients and determine key indications for when hamstring ACLR should be augmented by a lateral extra-articular tenodesis (LET). We hypothesized that different preoperative characteristics and surgical variables may be associated with graft failure characterized by asymmetric pivot shift and graft rupture. Study Design: Case-control study; Level of evidence, 3. Methods: Data were obtained from the Stability 1 Study, a multicenter randomized controlled trial of young active patients undergoing autologous hamstring ACLR with or without a LET. We performed 2 multivariable logistic regression analyses, with asymmetric pivot shift and graft rupture as the dependent variables. The following were included as predictors: LET, age, sex, graft diameter, tear chronicity, preoperative high-grade knee laxity, preoperative hyperextension on the contralateral side, medial meniscal repair/excision, lateral meniscal repair/excision, posterior tibial slope angle, and return-to-sports exposure time and level. Results: Of the 618 patients in the Stability 1 Study, 568 with a mean age of 18.8 years (292 female; 51.4%) were included in this analysis. Asymmetric pivot shift occurred in 152 (26.8%) and graft rupture in 43 (7.6%). The addition of a LET (odds ratio [OR], 0.56; 95% CI, 0.37-0.83) and increased graft diameter (OR, 0.62; 95% CI, 0.44-0.87) were significantly associated with lower odds of asymmetric pivot shift. The addition of a LET (OR, 0.40; 95% CI, 0.18-0.91) and older age (OR, 0.83; 95% CI, 0.72-0.96) significantly reduced the odds of graft rupture, while greater tibial slope (OR, 1.15; 95% CI, 1.01-1.32), preoperative high-grade knee laxity (OR, 3.27; 95% CI, 1.45-7.41), and greater exposure time to sport (ie, earlier return to sport) (OR, 1.18; 95% CI, 1.08-1.29) were significantly associated with greater odds of rupture. Conclusion: The addition of a LET and larger graft diameter were significantly associated with reduced odds of asymmetric pivot shift. Adding a LET was protective of graft rupture, while younger age, greater posterior tibial slope, high-grade knee laxity, and earlier return to sport were associated with increased odds of graft rupture. Orthopaedic surgeons should consider supplementing hamstring autograft ACLR with a LET in young active patients with morphological characteristics that make them at high risk of reinjury.

Augmentation of Primary ACL Reconstruction With a Modified Ellison Lateral Extra-articular Tenodesis in High-Risk Patients: A Pilot Study.

Background:Lateral extra-articular tenodesis (LET) has been used to augment primary anterior cruciate ligament (ACL) reconstruction to reduce the risk of reinjury. Most LET procedures result in a construct that is fixed to both the femur and the tibia. In a modified Ellison procedure, the construct is only fixed distally, reducing the risk of inadvertently overconstraining the lateral compartment.Purpose:To evaluate the use of the modified Ellison procedure in a cohort of patients deemed to be at a high risk of further ACL injury after primary ACL reconstruction.Study Design:Case series; Level of evidence, 4.Methods:Included were 25 consecutive patients with at least 2 of the following risk factors: age <20 years at the time of surgery, previous contralateral ACL reconstruction, positive family history of ACL rupture (parent or sibling), generalized ligamentous laxity (Beighton ≥4), grade 3 pivot shift in the consulting room, a desire to return to a pivoting sport, and an elite or professional status. All patients underwent primary ACL reconstruction with an additional modified Ellison procedure. Postoperatively, patients completed the IKDC subjective knee evaluation form (International Knee Documentation Committee), KOOS Quality of Life subscale (Knee injury and Osteoarthritis Outcome Score), ACL–Return to Sport After Injury Scale, Marx Activity Rating Scale, and SANE score (Single Assessment Numeric Evaluation).Results:At 12-month follow-up, the mean outcome scores were as follows: SANE, 94/100; IKDC, 92/100; Marx, 13/16; ACL–Return to Sport, 85/100; and KOOS, 77/100. At 24 months, return-to-sport data were available for 23 of 25 patients; 17 (74%) were playing at the same level or higher than preinjury and 2 at a lower level. One patient (4%) sustained a contact mechanism graft rupture at 12 months. There were 2 (9%) contralateral ACL injuries, including 1 ACL graft rupture, at 11 and 22 months postoperatively. There was a further contralateral ACL graft rupture at 26 months.Conclusion:The use of the modified Ellison procedure as a LET augmentation of a primary ACL reconstruction to produce a low graft rupture rate appeared to be safe in a cohort considered to be at a high risk of reinjury. The procedure showed promise in terms of reducing further graft injuries.

The Evaluation of Equine Allogeneic Tenogenic Primed Mesenchymal Stem Cells in a Surgically Induced Superficial Digital Flexor Tendon Lesion Model.

Background: Tendon injuries are very common in horses and jeopardize the athletic performance, and due to the high risk of reinjury may lead to early retirement. The use of mesenchymal stem cells for the treatment of equine tendon disease is widely investigated because of their regenerative potential. The objective of this study is to investigate the safety and efficacy of equine allogeneic tenogenic primed mesenchymal stem cells (tpMSCs) for the management of tendinitis in horses.Methods: A core lesion was surgically induced in the superficial digital flexor tendon of both forelimbs of eight horses. After 7 days, one forelimb was treated with tpMSCs, while the contralateral forelimb served as an intra-individual control and was treated with saline. A prescribed exercise program was started. All horses underwent a daily clinical evaluation throughout the entire study period of 112 days. Blood samples were taken at different time points for hematological and biochemical analysis. Tendon assessment, lameness examination, ultrasound assessment and ultrasound tissue characterization (UTC) were performed at regular time intervals. At the end of the study period, the superficial digital flexor tendons were evaluated macroscopically and histologically.Results: No suspected or serious adverse events occurred during the entire study period. There was no difference in local effects including heat and pain to pressure between a single intralesional injection of allogeneic tpMSCs and a single intralesional injection with saline. A transient moderate local swelling was noted in the tpMSC treated limbs, which dissipated by day 11. Starting at a different time point depending on the parameter, a significant improvement was observed in the tpMSC treated limbs compared to the placebo for echogenicity score, fiber alignment score, anterior-posterior thickness of the tendon and echo type by UTC assessment. Immunohistochemistry 112 days post-injection revealed that the amount of collagen type I and Von Willebrand factor were significantly higher in the tendon tissue of the tpMSC group, while the amount of collagen type III and smooth muscle actin was significantly lower.Conclusion: Equine allogeneic tenogenic primed mesenchymal stem cells were shown to be well-tolerated and may be effective for the management of tendon injuries.

Nationwide Outcomes and Risk Factors for Reinjury After Penetrating Trauma

BackgroundPrevious studies have shown that a notable portion of patients who are readmitted for reinjury after penetrating trauma present to a different hospital. The purpose of this study was to identify the risk factors for reinjury after penetrating trauma including reinjury admissions to different hospitals. MethodsThe 2010-2014 Nationwide Readmissions Database was queried for patients surviving penetrating trauma. E-codes identified patients subsequently admitted with a new diagnosis of blunt or penetrating trauma. Univariable analysis was performed using 44 injury, patient, and hospital characteristics. Multivariable logistic regression using significant variables identified risk factors for the outcomes of reinjury, different hospital readmission, and in-hospital mortality after reinjury. ResultsThere were 443,113 patients identified. The reinjury rate was 3.5%. Patients presented to a different hospital in 30.0% of reinjuries. Self-inflicted injuries had a higher risk of reinjury (odds ratio [OR]: 2.66, P < 0.05). Readmission to a different hospital increased risk of mortality (OR: 1.62, P < 0.05). Firearm injury on index admission increased risk of mortality after reinjury (OR: 1.94, P < 0.05). ConclusionsThis study represents the first national finding that one in three patients present to a different hospital for reinjury after penetrating trauma and have a higher risk of mortality due to this fragmentation of care. These findings have implications for quality and cost improvements by identifying areas to improve continuity of care and the implementation of penetrating injury prevention programs.

Lower extremity kinematic analysis in male athletes with unilateral anterior cruciate reconstruction in a jump-landing task and its association with return to sport criteria

BackgroundReturn to sport (RTS) criteria are widely being used to identify anterior cruciate ligament reconstructed (ACLR) athletes ready to return to sportive activity and reduce risk of ACL re-injury. However, studies show a high rate of ACL re-injury in athletes who passed RTS criteria. This indicates that the current RTS criteria might not be sufficient to determine return to sport time in ACLR athletes. Previous studies have reported a close association between altered lower limb kinematics and ACL re-injury. However, it is not clear how lower extremity kinematics differs between ACLR athletes who passed the RTS-criteria and who failed. This study compared lower extremity kinematics in a jump-landing task between ACLR athletes who passed the RTS criteria (Limb symmetry in hop tests, quadriceps strength and questionnaires) to those who failed and to the healthy individuals.MethodsParticipants were 27 male football players with unilateral ACLR including 14 who passed -RTS criteria and 13 failed, and 15 healthy football players. A 3D motion capture system recorded participants’ lower extremity motion while performing 10 trials of a bilateral jump-landing task. Hip, knee and ankle angular motion were examined at initial contact. Two-way mixed analysis of variances (2 limbs × 3 groups) and Bonferroni post-hoc tests were performed to compare the joint angles between the limbs and groups.Resultslower hip abduction angle was found in the failed (involved limb 4.1 ° ± 4.2) and passed RTS (involved limb 6.8° ± 3.3) groups compared to the healthy group (non-dominant limb 10.7° ± 3.7). Ankle inversion in the failed RTS (0.4° ± 4.9) group was significantly lower than both passed RTS (4.8° ± 4.8, p = 0.05) and healthy (8.2° ± 8.1, p < 0.001) groups. There were no significant differences between the groups in knee kinematics.ConclusionsOur findings indicate reduced hip abduction during initial contact phase of landing in athletes returned to sport. Reduced hip abduction during the complex multiplanar movement of jump-landing is a risk factor for ACL re-injury. Current RTS criteria may not be sufficient to identify ACLR athletes at high risk of re-injury. The kinematic analysis in conjunction with current RTS criteria can provide additional insight into the return to sport decision making.

High resolution ultrasound for imaging complications of muscle injury: Is there an additional role for elastography?

Muscle healing after injury occurs within a period of weeks following a three-phase physiological process. Disruption of the normal healing process may lead to a number of complications, including excessive scar formation, myositis ossificans, muscle atrophy, muscle cysts and hernias. Complications of muscle injury are important because they may be symptomatic, are associated with high risk of re-injury and compromise muscle performance, thus delaying return to sporting activity and requiring special treatment. High-resolution ultrasound imaging equipped with high-frequency probes and advanced B-mode and Doppler technology has emerged as a promising modality for the diagnosis, grading and follow-up of muscle injury. Ultrasound allows imaging of minimal scar formation, early detection of myositis ossificans and cysts, and dynamic evaluation of small muscle hernias. Ultrasound imaging combined with strain and shear wave elastography can also provide information on the mechanical properties of intact and diseased muscle tissue, thus allowing assessment of muscle biomechanics in the clinical setting. This article reviews the histology and ultrasound appearance of normal and abnormal muscle healing with an emphasis on the sonographic appearances of muscle injury complications. It also discusses pitfalls, provides tips for an less experienced sonographer and presents the possible role of strain elastography in the diagnosis of complications, such as scar tissue.

Computation of the role of kinetics, kinematics, posterior tibial slope and muscle cocontraction on the stability of ACL-deficient knee joint at heel strike – Towards identification of copers from non-copers

Rupture of anterior cruciate ligament (ACL) undermines normal activity and function of the knee joint and places it at higher risk of re-injury and degeneration. ACL reconstruction surgery neither necessarily ensures return to pre-injury activities nor alleviates risk of long-term degeneration. Here in this computational investigation of a lower-extremity hybrid model at heel strike (HS) of gait, we search for factors that influence the stability of the joint and hence the distinct performances between post-ACL injury copers and non-copers. Due to the very unstable state of the joint under the mean gait input data, joint rotations-moments, posterior tibial slope (PTS), and cocontraction were altered within the reported data in the literature and the effects on the joint stability (anterior tibial translation (ATT) and critical muscle stiffness coefficient (qcr)) were investigated. Results indicate that, in presence of both a small extension moment (0.1 or 0.2 Nm/kg) and a flexion rotation (∼5–8°), ACL-deficient (ACL-D) knee joint stability substantially improves to levels computed in the pre-injury intact joint. In addition, low cocontraction levels of 1–3% (in hamstrings and quads only and not in gastrocnemii) and reduced PTS (by 5°) further improve ACL-D joint stability. Therefore for a stable joint with ATT < 3 mm and qcr < 25 similar to those in the intact knee at HS, higher flexion angles (>5°) and a small extension moment (∼0.1–0.2 Nm/kg) (i.e., higher activity in hamstrings than quads) are required. A lower posterior tibial slope (by 5°) and a small minimum cocontraction level (1–3%) in hamstrings and quads (but not in gastrocnemii) are also beneficial. These results identify mechanisms likely in play at HS in gait of copers when compared to non-copers.

Validation of a Composite Test for Assessment of Readiness for Return to Sports After Anterior Cruciate Ligament Reconstruction: The K-STARTS Test.

Background:There is limited information on the appropriate timing of return to sports after anterior cruciate ligament (ACL) reconstruction. A composite test was developed to assess the athlete’s ability to return to sports after ACL reconstruction: the Knee Santy Athletic Return To Sport (K-STARTS) test.Hypothesis:The K-STARTS test meets validation criteria for an outcome score assessing readiness for return to sports after ACL reconstruction.Study Design:Diagnostic study.Level of Evidence:Level 3.Methods:A prospective comparative study identified 410 participants: 371 participants who had undergone ACL reconstruction and a control group of 39 healthy participants. The K-STARTS score is calculated as the sum of 7 tests (8 components), for a maximal value of 21 points. Construct validity, internal consistency, discriminant validity, and sensitivity to change were used to validate this new test.Results:The K-STARTS assessment showed a high completion rate (100%), high reproducibility (intraclass correlation coefficient, 0.87; coefficient of variation, 7.8%), and high sensitivity to change. There was moderate correlation with the ACL Return to Sports after Injury scale (ACL-RSI) and hop tests. There were no ceiling or floor effects. There was a significant difference between K-STARTS scores assessed at 6 and 8 months postoperatively (11.2 ± 2.7 vs 17.1 ± 3.2; P < 0.001). The K-STARTS score in the control group was significantly higher than that in the ACL reconstruction group (17.3 ± 2.1 and 13.7 ± 3.8, respectively; P < 0.001).Conclusion:The K-STARTS test is an objective outcome measure for functional improvement after ACL reconstruction.Clinical Relevance:It is important for the clinician to determine when return to sports is optimal after ACL reconstruction to reduce the current high risk of reinjury.

Recurrence of Achilles tendon injuries in elite male football players is more common after early return to play: an 11-year follow-up of the UEFA Champions League injury study

BackgroundThere is limited information about Achilles tendon disorders in professional football.AimsTo investigate the incidence, injury circumstances, lay-off times and reinjury rates of Achilles tendon disorders in male professional football.MethodsA total...