Background: National Football League (NFL) athletes face a substantial risk for anterior cruciate ligament (ACL) injuries, particularly during special team plays. ACL injuries commonly occur during change-of-direction (CoD) scenarios. Player tracking is standardized for all NFL games and can be used to quantify player motion intensity during CoD injury scenarios.
Purpose: The purpose was to identify ACL injuries during CoD scenarios in the NFL. We investigated whether player tracking metrics derived from on-field play can predict an increased ACL injury risk during CoD scenarios.
Study design: Descriptive epidemiology study.
Methods: For all ACL injuries (n = 216) occurring in games during the 2018 to 2022 NFL seasons, the injury timing and injury scenario were identified through a video review. Motion characteristics of ACL injuries during CoD scenarios were identified from player tracking data, and a generalized linear mixed model (GLMM) was developed to quantify whether player tracking metrics were predictive of the ACL injury risk during CoD scenarios.
Results: Among the ACL injuries reviewed, 32% were noncontact, 42% were indirect contact, and 46% were classified as CoD scenarios. Of the athletes involved in a CoD scenario, 98% were decelerating at the time of their ACL injury. Maximum speed (odds ratio, 1.52 per 1-m/s increase in maximum speed) and normalized maximum deceleration power (odds ratio, 1.08 per 1-W/kg increase in maximum deceleration power) were both significant predictors of the CoD ACL injury risk. Punt and kickoff returns had a significantly increased CoD ACL injury risk only when maximum speed and normalized maximum deceleration power metrics were excluded from the GLMM.
Conclusion: ACL injuries in NFL games primarily occurred during CoD scenarios. Player tracking data analyzed for CoD ACL injuries demonstrated a consistent movement pattern involving high speeds and deceleration at the time of the injury. Both a player's maximum speed and normalized maximum deceleration power were significant predictors of an increased CoD ACL injury risk. The inclusion of these metrics in a GLMM helped to explain the variation in CoD ACL injury rates observed across different play types.
Background: There has been an increased interest in meniscus preservation over the last decade. Several risk factors for the failure of meniscal repair have been identified. However, the timing of meniscal repair has not been extensively assessed in the literature, and there is currently no high-quality evidence on the optimal timing of performing meniscal repair after an injury with regard to outcomes.
Purpose: To assess the role of the timing of meniscal repair on outcomes in the literature.
Study design: Systematic review and meta-analysis; Level of evidence, 4.
Methods: The databases of PubMed, Embase, and the Cochrane Library were searched in October 2023 for studies comparing the outcomes of early versus delayed meniscal repair. Studies were eligible for inclusion if they reported outcomes within and after a time threshold (eg, within and after 3 weeks). Random-effects models were used.
Results: A total of 35 studies with 3556 patients and 3767 menisci were included (mean age, 27.5 years; 66% male; mean follow-up, 4.5 years). Most studies were level 3 or 4 evidence, and the overall quality was low. The failure rates of meniscal repair were 11.3% versus 24.1% within versus after 2 weeks, respectively (7 studies, 511 patients; odds ratio [OR], 0.50 [95% CI, 0.22-1.16]; P = .11); 7.2% versus 15.3% within versus after 3 weeks, respectively (5 studies, 556 patients; OR, 0.28 [95% CI, 0.10-0.79]; P = .02); 15.7% versus 21.3% within versus after 6 weeks, respectively (7 studies, 746 patients; OR, 0.63 [95% CI, 0.33-1.18]; P = .15); and 10.2% versus 18.7% within versus after 8 weeks, respectively (7 studies, 652 patients; OR, 0.47 [95% CI, 0.26-0.87]; P = .02); these were significant for 3 and 8 weeks. No differences were seen for within versus after 3 months (7 studies, 1305 patients; 22.4% vs 18.5%, respectively; OR, 1.04 [95% CI, 0.47-2.33]; P = .92).
Conclusion: The timing of meniscal surgery was correlated with the likelihood of success, and meniscal repair should preferably be performed within 8 weeks of the injury, with the earliest benefit at 3 weeks. Clinicians should take this into consideration when recommending operative treatment or initial nonoperative treatment.
Background: The knee is the most commonly afflicted joint in osteoarthritis (OA). Injection of intra-articular of hyaluronic acid (IAHA) is a frequently used therapy for the management of knee OA with varying product characteristics.
Purpose: To describe and characterize the mechanism of action (MoA) of IAHA products concerning nociception, chondroprotection, and anti-inflammatory properties via a targeted literature review.
Study design: Systematic review; Level of evidence, 2.
Methods: We followed the standard methodologies for conducting and reporting targeted reviews as recommended by the Cochrane Handbook for Systematic Reviews of Interventions, adapted for conducting a targeted literature review. Relevant studies were identified by searching the Embase database using predefined search strategies via the Ovid platform. The results of the review were reported according to the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-analyses).
Results: A total of 182 studies were included in this targeted literature review. Of these, 107 reported chondroprotective action, 59 anti-inflammatory activity, 18 analgesic properties, 30 proteoglycan or glycosaminoglycan synthesis, 8 subchondral bone effects, 2 mechanical effects, and 1 other effects of IAHA. These MoAs were studied through diverse types of studies: in vitro biochemistry, animal physiological studies, or human physiological and clinical studies. The chondroprotective effect was the most studied MoA and showed an increase in anabolic biomarkers, such as collagen types II, IX, and XI, and a reduction in catabolic biomarkers, such as matrix metalloproteinases, which play a primary role in the downstream signaling pathways in OA and cartilage degradation in the synovial fluid. IAHA was widely reported by studies to reduce soluble inflammatory mediators, such as interleukins 1β and 6 and tumor necrosis factor α, thereby decreasing the production of degradative enzymes (eg, matrix metalloproteinases, aggrecanases). IAHA was also reported to enhance the synthesis of intrinsic proteoglycan (eg, aggrecan) and glycosaminoglycans, thus delaying the progression of OA. IAHA also reported improvement in the mechanical function of the knee by increasing the viscosity of the synovial fluid, reducing the coefficient of friction, and improving its lubrication. Overall, a significant decrease in knee pain was observed after IAHA treatments.
Conclusion: Preclinical and clinical studies established evidence for varied MoAs by which IAHA preparations may produce a desired effect in patients with knee OA.
Background: Current research focused on clinical outcomes suggests that lateral extra-articular procedures (LEAPs) can reduce rotational instability and graft failure rates in primary anterior cruciate ligament reconstructions (ACLRs). Limited studies have investigated the functional outcomes after LEAPs, including patient-reported outcome measures, sports participation, and physical performance.
Purpose: To conduct a systematic literature review and meta-analysis to determine whether the addition of a LEAP to an ACLR results in superior functional and clinical outcomes as compared with an isolated ACLR.
Study design: Systematic review and meta-analysis; Level of evidence, 1.
Methods: Five databases were searched to identify randomized controlled trials comparing clinical and functional outcomes after the addition of LEAPs to an isolated primary ACLR. Study selection was performed in accordance with the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-analyses). Assessment of methodological quality for included studies was undertaken using the Cochrane Risk of Bias 2 tool for randomized controlled trials. Studies were eligible for meta-analysis if an outcome measure utilizing similar time points was present across ≥2 studies and reported in mean difference or standard deviation.
Results: Meta-analysis of 10 studies showed that the addition of LEAPs to an ACLR can reduce rates of rotatory instability (risk ratio, 1.45 [95% CI, 1.17-1.79]; P = .0006; I2 = 0%) and graft rupture (risk ratio, 0.21 [95% CI, 0.08-0.55]; P < .001; I2 = 0%). As supported by studies eligible for meta-analysis, this review showed that the addition of LEAPs to an ACLR can reduce rotatory instability. Short-term morbidity, including increased pain, joint stiffness, and muscle weakness, as compared with isolated ACLRs was resolved by 12 months after surgery.
Conclusion: ACLR in combination with a LEAP results in superior clinical outcomes when compared with an isolated ACLR. Despite early postoperative outcomes concerning pain and function favoring isolated ACLRs, any negative effects were not still observed 6 months after surgery. A conclusion around the correlation between LEAPs and accelerated knee osteoarthritis could not be drawn, owing to the lack of long-term prospective studies available.
Background: Sex differences exist in injury rates, and one contributing factor may be sex hormone effects on the musculoskeletal system.
Purpose/hypothesis: The goal of this systematic review and meta-analysis was to understand the effects of sex hormones on ligaments in females as determined by preclinical and clinical studies. The hypothesis was that sex hormones would affect ligament mechanical properties, histological features, cellular function, and clinically measurable outcomes.
Study design: Systematic review and meta-analysis; Level of evidence, 4.
Methods: A literature search of PubMed, PEDro, CINAHL, and CENTRAL was performed to identify preclinical and clinical studies assessing sex hormone effects on ligament properties. Overall, 2 independent reviewers performed title, abstract, and full-text screening. Rigor and reproducibility were assessed using the ARRIVE guidelines and the modified Downs and Black checklist. Meta-analyses were also performed.
Results: There were 54 articles included in this review. The majority of studies focused on the anterior cruciate ligament (ACL; n = 27), the menstrual cycle (n = 23), and 17β-estradiol (n = 35). Meta-analyses revealed that there was no effect of the menstrual cycle on knee laxity or anterior tibial translation but that 17β-estradiol decreased the production of types I and III procollagen in ACL fibroblasts in vitro. In examining other ligaments, data suggest that sex hormone changes may affect the mechanical and cellular properties of the medial collateral ligament, intrapubic ligaments, hip ligaments, and ligamentum flavum. Additionally, the literature suggests that hormonal shifts that occur with oral contraceptive pill use, pregnancy, and menopause can affect ligament properties. These effects appear to be mediated, at least in part, by the hormone relaxin.
Conclusion: Of the sex hormones examined in this body of literature, 17β-estradiol and relaxin appear to have the most effect on both the mechanical and cellular properties of ligaments in females. The ACL, medial collateral ligament, intrapubic ligaments, hip ligaments, and ligamentum flavum may be impacted by changes in sex hormone concentrations. The menstrual cycle does not likely affect ligament laxity in a clinically meaningful way, but pregnancy, oral contraceptive pill use, and menopause may.
Background: Both autologous osteochondral transplantation (AOCT) and autologous osteoperiosteal transplantation (AOPT) are available for large cystic osteochondral lesions of the talus (OLTs). However, there is a lack of valid prospective evidence directly comparing the efficacy between AOPT and AOCT.
Purpose/hypothesis: The purpose of this study was to compare the efficacy and safety of AOPT versus AOCT in patients with large cystic OLTs (>8 mm in cystic diameter) at 2 years of follow-up. It was hypothesized that compared with AOCT, AOPT would be associated with noninferior efficacy and less donor site morbidity in the treatment of large cystic OLTs.
Study design: Randomized controlled trial; Level of evidence, 2.
Methods: This was a prospective randomized controlled trial of 70 consecutive patients who underwent AOPT or AOCT between May 2018 and July 2022. Perioperatively, patient characteristics, clinical data, and surgical records were collected. Clinical outcomes were assessed using patient-reported outcome measures, including the visual analog scale for pain (VAS), the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, and the ankle activity score (AAS), at 3, 6, 12, and 24 months postoperatively. Radiological outcomes were evaluated according to the magnetic resonance observation of cartilage repair tissue (MOCART) score. The arthroscopic examination was performed using the International Cartilage Repair Society (ICRS) score. Donor site morbidity in both groups was recorded over the 24-month follow-up period.
Results: A total of 67 patients completed 2-year follow-up: 33 in the AOPT group and 34 in the AOCT group. Baseline characteristics were comparable. No significant differences were observed between the 2 groups in terms of the VAS, AOFAS, and AAS scores throughout the 2-year follow-up period. The AOCT group exhibited higher MOCART and ICRS scores within the first 12 months after surgery. However, by 24-month follow-up, the MOCART score in the AOPT group had reached a level comparable with that in the AOCT group. Additionally, the AOPT group had a lower incidence of donor site morbidity and lower VAS scores across the follow-up period compared with the AOCT group.
Conclusion: This trial demonstrated that at 2-year follow-up, AOPT was noninferior to AOCT with regard to clinical outcomes and cartilage repair quality in patients with large cystic OLTs. Long-term follow-up is needed to confirm these results.
Registration: NCT03347877 (ClinicalTrials.gov).
Background: Osteochondritis dissecans of the humeral capitellum can occur in adolescent baseball players owing to repetitive compressive shear forces within the radiocapitellar joint.
Purpose: To quantify the relationship between valgus angle and radiocapitellar joint contact with varying size and location of osteochondral defects and to compare these effects with a native and strained medial ulnar collateral ligament (UCL).
Study design: Controlled laboratory study.
Methods: Twenty-four cadaveric elbows were tested (mean ± SD, 62.5 ± 8.1 years old). Capitellar osteochondral defects were created at 2 locations (proximal and distal) and with 2 sizes (smaller central and larger laterally extended). Three conditions were tested: proximal defect with a native UCL, distal defect with a native UCL, and distal defect with a strained UCL. Valgus angulation and radiocapitellar contact characteristics were measured with 0, 2, and 3 N·m of additional valgus torque.
Results: When compared with no additional load, there were statistically significant increases in valgus angle with an intact capitellum at both torques for elbows with native and strained UCLs at all elbow flexion angles (P < .001). Elbows with a strained UCL had a higher increase in valgus angulation with 3-N·m valgus torque when compared with the native UCL (P < .048). Larger proximal defects significantly increased the valgus angle at 45° and 105° (P < .012) of flexion, whereas larger distal defects increased the valgus angle at 15° to 75° of flexion (P < .022). There was a significantly decreased radiocapitellar contact area for both osteochondral defect locations (P < .05).
Conclusion: Osteochondral defects show location- and size-dependent alterations in valgus angulation and radiocapitellar contact characteristics in the UCL-strained and native conditions. Relatively low valgus loads with a native UCL increase radiocapitellar contact, which can serve as a rationale for the basis of the formation of an osteochondral defect, with exacerbation of valgus instability and changes in contact characteristics demonstrable with progressively enlarging osteochondral defects.
Clinical relevance: This study provides a biomechanical rationale to understand the interplay between the medial and lateral sides of the elbow in pitchers when considering osteochondral defect pathogenesis and pathomechanics.
Background: Surgical limb underloading is a common biomechanical adaptation after anterior cruciate ligament reconstruction (ACLR) and has been linked to early degenerative changes in knee cartilage, which are considered precursors to posttraumatic osteoarthritis. Split-belt treadmill training is an emerging rehabilitation approach that modifies load through asymmetric gait behavior, in which one limb walks faster than the other. While previous research has indicated that split-belt treadmill training can modify limb loading, its effects on post-ACLR biomechanics remain unexplored.
Purpose/hypothesis: The purpose of this study was to examine the effects of decoupling speed on knee biomechanics and limb loading and model their relationship. It was hypothesized that at faster decoupling speeds, knee loads would increase, and at slower speeds, they would decrease.
Study design: Controlled laboratory study.
Methods: Knee joint biomechanics were evaluated while 24 participants (15 females; mean age, 23.5 ± 6.5 years; mean height, 1.72 ± 0.08 m; mean mass, 75.61 ± 13.83 kg; mean postoperative time, 7.94 ± 1.74 months) with ACLR walked on an instrumented treadmill (2000 Hz) synced with a 12-camera motion capture system (200 Hz). Participants completed 5 minutes of baseline walking at 1.1 m/s on tied treadmill belts. Afterward, the authors manipulated the speed of the belt under the ACL-reconstructed leg with 8 randomized 5-minute decoupled speed configurations (ACL-reconstructed limb at 30%-170% of 1.1 m/s in 20% increments) with 2 minutes of tied-belt walking between each speed. Bilateral sagittal plane knee moments, angles, and vertical ground-reaction forces were calculated. Statistical parametric mapping was used to evaluate the effects of decoupling speed on the dependent variables during the stance phase of the gait.
Results: A clear dose-response relationship between decoupling speed and knee/limb loading was found. Specifically, faster decoupling speeds (130%-170% of 1.1m/s) generally increased peak loads and slower speeds (30% and 50% of 1.1 m/s) decreased peak loads during early stance compared with tied-belt walking for both limbs. In contrast, slower decoupling speeds (30%-90% of 1.1 m/s) led to higher bilateral knee/limb loads at midstance, while faster decoupling speeds (130%-170% of 1.1 m/s) resulted in less knee/limb loading during midstance.
Conclusion: These findings suggest that split-belt treadmill training offers a promising method for modulating knee/limb loading post-ACLR.
Clinical relevance: Split-belt treadmill training could be a viable intervention to target the loading asymmetry that is prevalent in persons post-ACLR.
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