Barton J. Mann

Understanding and Preventing Noncontact Anterior Cruciate Ligament Injuries A Review of the Hunt Valley II Meeting, January 2005

The incidence of noncontact anterior cruciate ligament injuries in young to middle-aged athletes remains high. Despite early diagnosis and appropriate operative and nonoperative treatments, posttraumatic degenerative arthritis may develop. In a meeting in Atlanta, Georgia (January 2005), sponsored by the American Orthopaedic Society for Sports Medicine, a group of physicians, physical therapists, athletic trainers, biomechanists, epidemiologists, and other scientists interested in this area of research met to review current knowledge on risk factors associated with noncontact anterior cruciate ligament injuries, anterior cruciate ligament injury biomechanics, and existing anterior cruciate ligament prevention programs. This article reports on the presentations, discussions, and recommendations of this group.

The International Knee Documentation Committee Subjective Knee Evaluation Form Normative Data

Background The International Knee Documentation Committee Subjective Knee Evaluation Form may be used to measure symptoms, function, and sports activity for people with a variety of knee disorders, including ligamentous and meniscal injuries, osteoarthritis, and patellofemoral dysfunction. To date, normative data have not been established for this valid, reliable, and responsive outcomes instrument. Purpose To provide clinicians and researchers with normative data to facilitate the interpretation of results on the International Knee Documentation Committee Subjective Knee Evaluation Form. Study Design Cross-sectional survey. Methods The Subjective Knee Evaluation Form was mailed to 600 people in each of 8 age/gender categories (18-24 years, 25-34 years, 35-50 years, and 51-65 years for both male subjects and female subjects). Participants were drawn from a panel of 550 000 households (1 300 000 subjects) representative of noninstitutionalized persons in the United States and were matched to data from the United States Census Bureau on geographical region, market size, income, and household size. Results Complete data were available for 5246 knees. Twenty-eight percent of respondents reported an injury, weakness, or other problem with one or both knees. Normative data were determined for respondents as a whole and for the subset of respondents with no history of knee problems. Mean scores were determined for men aged 18 to 24 years (89 ± 18), 25 to 34 years (89 ± 16), 35 to 50 years (85 ± 19), and 51 to 55 years (77 ± 23); mean scores were also determined for women aged 18 to 24 years (86 ± 19), 25 to 34 years (86 ± 19), 35 to 50 years (80 ± 23), and 51 to 65 years (71 ± 26). Scores were higher for the subset of respondents with no history of current or prior knee problems. Conclusion Scores on the International Knee Documentation Committee Subjective Knee Evaluation Form vary by age, gender, and history of knee problems. The normative data collected in this article will allow clinicians to interpret how patients with knee injuries are functioning relative to their age-and gender-matched peers and will enable researchers to determine the clinical outcomes of treatment.

Allograft Update: The Current Status of Tissue Regulation, Procurement, Processing, and Sterilization

Allografts are commonly used during sports medicine surgical procedures in the United States, and their frequency of use is increasing. Based on surgeon reports, it is estimated that more than 60 000 allografts were used in knee surgeries by members of the American Orthopaedic Society for Sports Medicine in 2005. In the United States, there are governmental agencies and other regulatory bodies involved in the oversight of tissue banks. In 2005, the Food and Drug Administration finalized its requirements for current good tissue practice and has mandated new rules regarding the “manufacture” of allogenic tissue. In response to well-publicized infections associated with the implantation of allograft tissue, some tissue banks have developed methods to sterilize allograft tissue. Although many surgeons have significant concerns about the safety of allografts, the majority believe that sterilized allografts are safe but that the sterilization process negatively affects tissue biology and biomechanics. However, most know very little about the principles of sterilization and the proprietary processes currently used in tissue banking. This article will review the current status of allograft tissue regulation, procurement, processing, and sterilization in the United States.

Responsiveness of the International Knee Documentation Committee Subjective Knee Form in Comparison to the Western Ontario and McMaster Universities Osteoarthritis Index, Modified Cincinnati Knee Rating System, and Short Form 36 in Patients With Focal Articular Cartilage Defects

Background The International Knee Documentation Committee Subjective Knee Form (IKDC SKF) is a patient-reported knee-specific outcome measure that has been shown to be a reliable, valid, and responsive measure for patients with a variety of knee conditions. Further testing is required to compare the reliability and responsiveness of the IKDC SKF to other commonly used patient-reported outcome measures for patients with articular cartilage lesions. Hypothesis The IKDC SKF has equal or better levels of reliability and responsiveness than the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), modified Cincinnati Knee Rating System (CKRS), and the Short Form 36 in patients with articular cartilage lesions. Study Design Cohort study (diagnosis); Level of evidence, 2. Methods Reliability was assessed by administering the 4 patient-reported outcome measures to 17 individuals who had undergone articular cartilage surgery 5 years before participation in this study. Responsiveness was determined by administering the 4 patient-reported outcome measures to 51 individuals with diagnosed focal articular cartilage defects who were scheduled to undergo surgical treatment. In both groups, the outcome measures were administered at baseline and at 6 and 12 months’ follow-up. Participants also provided a global rating of change in comparison to baseline at the 6- and 12-month follow-ups. Results Test-retest reliability coefficients were 0.91 and 0.93 for the IKDC SKF at the 6- and 12-month follow-ups, respectively. The effect sizes and standardized response means were large (>0.80) at 6 months after surgery for the WOMAC pain, physical function, and total scores and 12 months after surgery for the IKDC SKF; WOMAC pain, physical function, and total; and CKRS scores. Six months after surgery, significant differences between those who were improved compared with those who were unchanged or worse were found only for the IKDC SKF. Twelve months after surgery, significant differences between the improved and unchanged groups were found for all of the knee-specific patient-reported outcome measures. Finally, the IKDC SKF, WOMAC, and CKRS scores were able to differentiate between individuals who perceived themselves to be improved versus not improved and the minimum clinically important difference for the IKDC SKF was 6.3 at 6 months and 16.7 at 12 months. Conclusion The reliability and responsiveness of the IKDC SKF is comparable with other commonly used patient-reported outcome measures for patients with articular cartilage lesions. The IKDC SKF is a suitable alternative to other commonly used knee-specific instruments for measuring symptoms, daily function, and level of symptom-free sports activity in patients undergoing articular cartilage surgery.

A Survey of Sports Medicine Physicians Regarding Psychological Issues in Patient-Athletes

Purpose To determine the extent to which sports medicine physicians encounter and discuss psychological issues among athletes they treat and to evaluate physicians’ perceptions of the availability and efficacy of sport psychologists and other mental health resources. Study Design Cross-sectional study. Methods A survey was sent via e-mail to all physician members of 4 prominent sports medicine professional associations: the American Orthopaedic Society for Sports Medicine, American College of Sports Medicine, American Medical Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Results The extent to which respondents discuss psychological issues with athletes varied by subspecialty and by specific issues assessed. Fears about reinjury, fears related to surgery, and lack of patience with recovery/rehabilitation were the 3 most common injury-related topics discussed with patient-athletes. The 3 most common non—injury-related topics discussed were stress/pressure, anxiety, and burnout. Family practitioners were more likely to discuss injury-related psychological issues than were orthopaedic surgeons. Orthopaedic surgeons reported the lowest frequencies of discussing non—injury-related psychological issues. Only 19% of all respondents indicated there were adequate numbers of sport psychologists and other mental health professionals in their geographical area to treat the needs of athletes. Three quarters of respondents reported they rarely or never referred athletes to sport psychologists for injury-related issues, and two thirds indicated they rarely or never referred athletes to sport psychologists for non—injury-related problems. Respondents rated sport psychologists and athletic trainers/physical therapists to be moderately effective in working with athletes regarding psychological problems. Conclusion Sports medicine physicians frequently encounter psychological issues with patient-athletes. There is a need for tools to facilitate assessment of these problems as well as greater communication between the mental health community and sports medicine physicians. In addition, knowledge of and access to professionals who are specifically trained to deal with the sometimes unique psychological needs of athletes should be improved.

Risk-Prone Pitching Activities and Injuries in Youth Baseball Findings From a National Sample

Background: There are relatively few published epidemiological studies that have correlated pitching-related risk factors with increased pitching-related arm problems as well as injuries. Hypothesis: High pitching volume and limited recovery will lead to arm fatigue, thus placing young pitchers at a greater risk for elbow and shoulder problems and, subsequently, an increased risk for arm injuries. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A national survey was conducted among 754 youth pitchers (ages 9 to 18 years) who had pitched in organized baseball leagues during the 12 months before the survey. Self-reported risk-prone pitching activities were identified and compared with recommendations by the American Sports Medicine Institute. Relationships between self-reported pitching activities, shoulder and elbow problems, and injuries were assessed using multivariable logistic regression. Results: Of the 754 participating pitchers, 43.4% pitched on consecutive days, 30.7% pitched on multiple teams with overlapping seasons, and 19.0% pitched multiple games a day during the 12 months before the study. Pitchers who engaged in these activities had increased risk of pitching-related arm pain (odds ratio [OR] = 2.53, 95% confidence interval [CI] = 1.14-5.60; OR = 1.85, 95% CI = 1.02-3.38; OR = 1.89, 95% CI = 1.03-3.49, respectively). Nearly 70% of the sample reported throwing curveballs, which was associated with 1.66 (95% CI = 1.09-2.53) greater odds of experiencing arm pain while throwing. Pitching-related arm tiredness and arm pain were associated with increased risk of pitching-related injuries. Specifically, those who often pitched with arm tiredness and arm pain had 7.88 (95% CI = 3.88-15.99) and 7.50 (95% CI = 3.47-16.21) greater odds of pitching-related injury, respectively. However, pitching on a travel baseball club, playing baseball exclusively, or playing catcher were not associated with arm problems. Conclusion: The results of this study, along with those of others, reinforce the importance of avoiding risk-prone pitching activities to prevent pitching-related injuries among youth pitchers.

Biologic Treatments for Sports Injuries II Think Tank—Current Concepts, Future Research, and Barriers to Advancement, Part 1 Biologics Overview, Ligament Injury, Tendinopathy

Biologic therapies, including stem cells, platelet-rich plasma, growth factors, and other biologically active adjuncts, have recently received increased attention in the basic science and clinical literature. At the 2015 AOSSM Biologics II Think Tank held in Colorado Springs, Colorado, a group of orthopaedic surgeons, basic scientists, veterinarians, and other investigators gathered to review the state of the science for biologics and barriers to implementation of biologics for the treatment of sports medicine injuries. This series of current concepts reviews reports the summary of the scientific presentations, roundtable discussions, and recommendations from this think tank.

Osteoarthritis classification scales: Interobserver reliability and arthroscopic correlation

BACKGROUND Osteoarthritis of the knee is commonly diagnosed and monitored with radiography. However, the reliability of radiographic classification systems for osteoarthritis and the correlation of these classifications with the actual degree of confirmed degeneration of the articular cartilage of the tibiofemoral joint have not been adequately studied. METHODS As the Multicenter ACL (anterior cruciate ligament) Revision Study (MARS) Group, we conducted a multicenter, prospective longitudinal cohort study of patients undergoing revision surgery after anterior cruciate ligament reconstruction. We followed 632 patients who underwent radiographic evaluation of the knee (an anteroposterior weight-bearing radiograph, a posteroanterior weight-bearing radiograph made with the knee in 45° of flexion [Rosenberg radiograph], or both) and arthroscopic evaluation of the articular surfaces. Three blinded examiners independently graded radiographic findings according to six commonly used systems-the Kellgren-Lawrence, International Knee Documentation Committee, Fairbank, Brandt et al., Ahlbäck, and Jäger-Wirth classifications. Interobserver reliability was assessed with use of the intraclass correlation coefficient. The association between radiographic classification and arthroscopic findings of tibiofemoral chondral disease was assessed with use of the Spearman correlation coefficient. RESULTS Overall, 45° posteroanterior flexion weight-bearing radiographs had higher interobserver reliability (intraclass correlation coefficient = 0.63; 95% confidence interval, 0.61 to 0.65) compared with anteroposterior radiographs (intraclass correlation coefficient = 0.55; 95% confidence interval, 0.53 to 0.56). Similarly, the 45° posteroanterior flexion weight-bearing radiographs had higher correlation with arthroscopic findings of chondral disease (Spearman rho = 0.36; 95% confidence interval, 0.32 to 0.39) compared with anteroposterior radiographs (Spearman rho = 0.29; 95% confidence interval, 0.26 to 0.32). With respect to standards for the magnitude of the reliability coefficient and correlation coefficient (Spearman rho), the International Knee Documentation Committee classification demonstrated the best combination of good interobserver reliability and medium correlation with arthroscopic findings. CONCLUSIONS The overall estimates with the six radiographic classification systems demonstrated moderate (anteroposterior radiographs) to good (45° posteroanterior flexion weight-bearing radiographs) interobserver reliability and medium correlation with arthroscopic findings. The International Knee Documentation Committee classification assessed with use of 45° posteroanterior flexion weight-bearing radiographs had the most favorable combination of reliability and correlation. LEVEL OF EVIDENCE Diagnostic Level I. See Instructions for Authors for a complete description of levels of evidence.

Biologic Treatments for Sports Injuries II Think Tank—Current Concepts, Future Research, and Barriers to Advancement, Part 3: Articular Cartilage

Focal chondral defects of the articular surface are a common occurrence in the field of orthopaedics. These isolated cartilage injuries, if not repaired surgically with restoration of articular congruency, may have a high rate of progression to posttraumatic osteoarthritis, resulting in significant morbidity and loss of function in the young, active patient. Both isolated and global joint disease are a difficult entity to treat in the clinical setting given the high amount of stress on weightbearing joints and the limited healing potential of native articular cartilage. Recently, clinical interest has focused on the use of biologically active compounds and surgical techniques to regenerate native cartilage to the articular surface, with the goal of restoring normal joint health and overall function. This article presents a review of the current biologic therapies, as discussed at the 2015 American Orthopaedic Society for Sports Medicine (AOSSM) Biologics Think Tank, that are used in the treatment of focal cartilage deficiencies. For each of these emerging therapies, the theories for application, the present clinical evidence, and specific areas for future research are explored, with focus on the barriers currently faced by clinicians in advancing the success of these therapies in the clinical setting.

Meniscal and Articular Cartilage Predictors of Clinical Outcome After Revision Anterior Cruciate Ligament Reconstruction

Background: Revision anterior cruciate ligament (ACL) reconstruction has been documented to have worse outcomes compared with primary ACL reconstructions. Purpose/Hypothesis: The purpose of this study was to determine if the prevalence, location, and/or degree of meniscal and chondral damage noted at the time of revision ACL reconstruction predicts activity level, sports function, and osteoarthritis symptoms at 2-year follow-up. The hypothesis was that meniscal loss and high-grade chondral damage noted at the time of revision ACL reconstruction will result in lower activity levels, decreased sports participation, more pain, more stiffness, and more functional limitation at 2 years after revision surgery. Study Design: Cohort study; Level of evidence, 2. Methods: Between 2006 and 2011, a total of 1205 patients who underwent revision ACL reconstruction by 83 surgeons at 52 hospitals were accumulated for study of the relationship of meniscal and articular cartilage damage to outcome. Baseline demographic and intraoperative data, including the International Knee Documentation Committee (IKDC) subjective knee evaluation, Knee injury and Osteoarthritis Outcome Score (KOOS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Marx activity score, were collected initially and at 2-year follow-up to test the hypothesis. Regression analysis was used to control for age, sex, body mass index, smoking status, activity level, baseline outcome scores, revision number, time since last ACL reconstruction, incidence of having a previous ACL reconstruction on the contralateral knee, previous and current meniscal and articular cartilage injury, graft choice, and surgeon years of experience to assess the meniscal and articular cartilage risk factors for clinical outcomes 2 years after revision ACL reconstruction. Results: At 2-year follow-up, 82% (989/1205) of the patients returned their questionnaires. It was found that previous meniscal injury and current articular cartilage damage were associated with the poorest outcomes, with prior lateral meniscectomy and current grade 3 to 4 trochlear articular cartilage changes having the worst outcome scores. Activity levels at 2 years were not affected by meniscal or articular cartilage pathologic changes. Conclusion: Prior lateral meniscectomy and current grade 3 to 4 changes of the trochlea were associated with worse outcomes in terms of decreased sports participation, more pain, more stiffness, and more functional limitation at 2 years after revision surgery, but they had no effect on activity levels. Registration: NCT00625885