Nathan L. Grimm

Anterior Cruciate Ligament and Knee Injury Prevention Programs for Soccer Players A Systematic Review and Meta-analysis

Background: Soccer has one of the highest incidences of anterior cruciate ligament (ACL) injuries for both males and females. Several injury prevention programs have been developed to address this concern. However, an analysis of the pooled effect has yet to be elicited. Purpose: To conduct a systematic review and meta-analysis of ACL and knee injury prevention programs for soccer players, assess the heterogeneity among the studies, and evaluate the reported effectiveness of the prevention programs. Study Design: Systematic review and meta-analysis. Methods: A systematic search of the literature was conducted on PubMed (Medline), Embase, CINAHL, and Central-Cochrane Database. Studies were limited to randomized controlled trials (RCTs) of injury prevention programs specific to the knee and/or ACL in soccer players. The Cochrane Q test and I 2 index were independently used to assess heterogeneity among the studies. The pooled risk difference, assessing knee and/or ACL injury rates between intervention and control groups, was calculated by random-effects models with use of the DerSimonian-Laird method. Publication bias was assessed with a funnel plot and Egger weighted regression technique. Results: Nine studies met the inclusion criteria as RCTs. A total of 11,562 athletes were included, of whom 7889 were analyzed for ACL-specific injuries. Moderate heterogeneity was found among studies of knee injury prevention (P = .041); however, there was insignificant variation found among studies of ACL injury prevention programs (P = .222). For studies of knee injury prevention programs, the risk ratio was 0.74 (95% CI, 0.55-0.89), and a significant reduction in risk of knee injury was found in the prevention group (P = .039). For studies of ACL injury prevention programs, the risk ratio was 0.66 (95% CI, 0.33-1.32), and a nonsignificant reduction in risk of ACL injury was found in the prevention group (P = .238). No evidence of publication bias was found among studies of either knee or ACL injury prevention programs. Conclusion: This systematic review and meta-analysis of ACL and knee injury prevention program studies found a statistically significant reduction in injury risk for knee injuries but did not find a statistically significant reduction of ACL injuries.

Novel Radiographic Feature Classification of Knee Osteochondritis Dissecans A Multicenter Reliability Study

Background: Osteochondritis dissecans (OCD) is a vexing condition for patients, parents, and physicians because of the frequent slow healing and nonhealing that leads to prolonged treatment. Several features on plain radiographs have been identified as predictors of healing, but the reliability of their measurement has not been established. Purpose: To determine the inter- and intrarater reliability of several radiographic features used in the diagnosis, treatment, and prognosis of OCD femoral condyle lesions. Study Design: Cohort study (Diagnosis); Level of evidence, 3. Methods: Pretreatment anteroposterior, lateral, and notch radiographs of 45 knees containing OCD lesions of the medial or lateral femoral condyle were reviewed in blinded fashion by 7 orthopaedic physician raters from different institutions over a secure web portal at 2 time points over a month apart. Classification variables included lesion location, growth plate maturity, parent bone radiodensity, progeny bone fragmentation, progeny bone displacement, progeny bone contour, lesion boundary, and radiodensity of the lesion center and rim. Condylar width and lesion size were measured on all views. Interrater reliability was assessed using free-marginal kappa and intraclass correlations. Intrarater reliability was assessed using the Cohen kappa, linear-weighted kappa, and intraclass correlations based on measurement type. Results: Raters had excellent reliability for differentiating medial and lateral lesions and growth plate maturity and for measuring condylar width and lesion size. In the subset of knees with visible bone in the lesion, the fragmentation, displacement, boundary, central radiodensity, and contour (concave/nonconcave) of the lesion bone were classified with moderate to substantial reliability. The radiodensity of the lesion rim and surrounding epiphyseal bone were classified with poor to fair reliability. Conclusion: Many diagnostic features of femoral condyle OCD lesions can be reliably classified on plain radiographs, supporting their future testing in multifactorial classification systems and multicenter research to develop prognostic algorithms. Other radiographic features should be excluded, however, because of poor reliability.

Novel Arthroscopic Classification of Osteochondritis Dissecans of the Knee: A Multicenter Reliability Study

Background: Several systems have been proposed for classifying osteochondritis dissecans (OCD) of the knee during surgical evaluation. No single classification includes mutually exclusive categories that capture all of the salient features of stability, chondral fissuring, and fragment detachment. Furthermore, no study has assessed the reliability of these classification systems. Purpose: To determine the intra- and interobserver reliability of a novel, comprehensive arthroscopic classification system with mutually exclusive OCD lesion types. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: The Research in OsteoChondritis of the Knee (ROCK) study group developed a classification system for arthroscopic evaluation of OCD of the knee that includes 6 arthroscopic categories—3 immobile types and 3 mobile types. To optimize comprehensibility and applicability, each was developed with a memorable name, a brief description, a line diagram corresponding to the archetypal arthroscopic appearance, and an arthroscopic photograph depicting this archetype. Thirty representative arthroscopic videos were evaluated by 10 orthopaedic surgeon raters, who classified each lesion. After 4 weeks, the raters again classified the OCD lesions depicted in the 30 videos in a new, randomly selected order. Reliability was assessed via the intraclass correlation coefficient (ICC). Results: The interobserver reliability of this novel arthroscopy classification was estimated by an ICC of 0.94 (95% CI, 0.91-0.97) for the first round and 0.95 (95% CI, 0.93-0.98) for the second round. According to the standards for the magnitude of the reliability coefficient of Altman, these ICCs indicate that interobserver reliability was very good. The intraobserver reliability was estimated by an ICC of 0.96 (95% CI, 0.95-0.97), which indicates that the intraobserver reliability was similarly very good. Conclusion: The ROCK OCD knee arthroscopy classification system demonstrated excellent intra- and interobserver reliability. In light of this reliability, this classification system may be used clinically and to facilitate future research, including multicenter studies for OCD.

Treatment Algorithm for Osteochondritis Dissecans of the Knee

The authors preferred treatment algorithm for osteochondritis dissecans (OCD) of the knee is based on skeletal maturity, OCD lesion stability, and OCD lesion salvageability. For unstable yet salvageable OCD lesions, the senior authors preferred treatment is fixation with bone grafting. For unstable and unsalvageable OCD lesions, the senior authors preferred treatment is autologous chondrocyte implantation with bone grafting.

A review of arthroscopic classification systems for osteochondritis dissecans of the knee.

Multiple systems for classifying osteochondritis dissecans (OCD) of the knee have been reported. These existing classification systems have some similar characteristics, such as stable lesion/intact articular cartilage and presence of a loose body. However, variations are found in the number of stages and specific lesion characteristics assessed. Currently, no system has been universally accepted. A future classification system should be developed that reconciles the discrepancies among the current systems and provides a clear, consistent, and reliable method for classifying OCD lesions of the knee during arthroscopy.

A Review of Arthroscopic Classification Systems for Osteochondritis Dissecans of the Knee

Multiple systems for classifying osteochondritis dissecans (OCD) of the knee have been reported. These existing classification systems have some similar characteristics, such as stable lesion/intact articular cartilage and presence of a loose body. However, variations are found in the number of stages and specific lesion characteristics assessed. Currently, no system has been universally accepted. A future classification system should be developed that reconciles the discrepancies among the current systems and provides a clear, consistent, and reliable method for classifying OCD lesions of the knee during arthroscopy.

The Reliability of Assessing Radiographic Healing of Osteochondritis Dissecans of the Knee

Background: The reliability of assessing healing on plain radiographs has not been well-established for knee osteochondritis dissecans (OCD). Purpose: To determine the inter- and intrarater reliability of specific radiographic criteria in judging healing of femoral condyle OCD. Study Design: Cohort study (Diagnosis); Level of evidence, 3. Methods: Ten orthopedic sports surgeons rated the radiographic healing of 30 knee OCD lesions at 2 time points, a minimum of 1 month apart. First, raters compared pretreatment and 2-year follow-up radiographs on “overall healing” and on 5 subfeatures of healing, including OCD boundary, sclerosis, size, shape, and ossification using a continuous slider scale. “Overall healing” was also rated using a 7-tier ordinal scale. Raters then compared the same 30 pretreatment knee radiographs in a stepwise progression to the 2-, 4-, 7-, 12-, and 24-month follow-up radiographs on “overall healing” using a continuous slider scale. Interrater and intrarater reliability were assessed using intraclass correlations (ICC) derived from a 2-way mixed effects analysis of variance for absolute agreement. Results: Overall healing of the OCD lesions from pretreatment to 2-year follow-up radiographs was rated with excellent interrater reliability (ICC = 0.94) and intrarater reliability (ICC = 0.84) when using a continuous scale. The reliability of the 5 subfeatures of healing was also excellent (interrater ICCs of 0.87-0.89; intrarater ICCs of 0.74-0.84). The 7-tier ordinal scale rating of overall healing had lower interrater (ICC = 0.61) and intrarater (ICC = 0.68) reliability. The overall healing of OCD lesions at the 5 time points up to 24 months had interrater ICCs of 0.81-0.88 and intrarater ICCs of 0.65-0.70. Conclusion: Interrater reliability was excellent when judging the overall healing of OCD femoral condyle lesions on radiographs as well as on 5 specific features of healing on 2-year follow-up radiographs. Continuous scale rating of OCD radiographic healing yielded higher reliability than the ordinal scale rating. Raters showed substantial to excellent agreement of OCD overall radiographic healing measured on a continuous scale at 2, 4, 7, 12, and 24 months after starting treatment.

Volumetric Damage to the Femoral Physis During Double-Bundle Posterior Cruciate Ligament Reconstruction: A Magnetic Resonance Imaging Computer Modeling Study

PURPOSEnThe purpose of this study was to use computer models to evaluate the volume of femoral physeal disruption in double-bundle posterior cruciate ligament (PCL) reconstruction in patients with open physes.nnnMETHODSnTen skeletally immature patients (6 girls and 4 boys) were selected for this study. The magnetic resonance imaging scans of each patient were converted into a 3-dimensional model using computer-aided design/computer-aided manufacturing software. The software allowed the users to differentiate the epiphyseal, physeal, and metaphyseal tissues. This allowed for quantification of volume removed of each tissue type. Furthermore, we used the 3-dimensional models to simulate an anatomic double-bundle technique using 6-, 7-, 8-, and 9-mm-diameter tunnels. The software method reflects an inside-out drilling technique.nnnRESULTSnFor drill holes of all diameters, the posteromedial tunnels exited the knee inferior to the physis, thus avoiding physeal damage. In contrast, all the anterolateral tunnels perforated the physis. The results for the percent of total physis removed are as follows: 6-mm tunnel, 1.79% ± 0.99%; 7-mm tunnel, 2.23% ± 1.19%; 8-mm tunnel, 3.00% ± 1.54%; and 9-mm tunnel, 3.84% ± 1.73%.nnnCONCLUSIONSnThis computer modeling simulation of double-bundle PCL reconstruction in skeletally immature knees found that the posteromedial tunnel avoided disruption of the distal femoral physis. In contrast, the anterolateral tunnel did disrupt the physis with all drill hole sizes (6 to 9xa0mm), but all had a less than 4% volume of total physis removed.nnnCLINICAL RELEVANCEnA clear understanding of the drill hole position may reduce the volume of physeal injury during double-bundle PCL reconstruction. This study shows that physeal disruption of less than the experimental 7% threshold that has been shown to cause physeal arrest may not cause arrest, but this is still speculative.

The Knee: Internal Fixation Techniques for Osteochondritis Dissecans

For the athlete with a newly diagnosed osteochondritis dissecans of the knee, the first step in formulating a treatment plan is determining the stability of the lesion. When the lesion is found to be unstable but salvageable, several methods for fixation are available. Fixation of osteochondritis dissecans in the athletic population has been described and each has its own advantages and disadvantages. Determining the most appropriate method for fixation depends on several variables and should include the athletes level of play, sport, and overall goals.

Ankle injury prevention programs for soccer athletes are protective: a level-i meta-analysis

BACKGROUNDnSoccer has one of the highest rates of ankle injury in sports for both males and females. Several injury prevention programs have been developed to address this concern. The purposes of this study were to conduct a meta-analysis of ankle injury prevention programs for soccer players, assess the heterogeneity among the studies, and evaluate the reported effectiveness of the prevention programs.nnnMETHODSnA systematic search of the literature was conducted in PubMed (MEDLINE), Embase, CINAHL (Cumulative Index to Nursing and Allied Health), and the Cochrane Central Register of Controlled Trials (CENTRAL) database. Studies were limited to clinical investigations of injury prevention programs specific to the ankle in soccer players. Title, abstract, and full-text review were utilized to identify articles that met the inclusion criteria. The Cochrane Q test and I(2) index were independently used to assess heterogeneity among the studies. Sensitivity analyses were performed to assess heterogeneity. The pooled risk difference was calculated by random-effects models with use of the DerSimonian-Laird method. Publication bias was assessed with a funnel plot and Egger weighted regression technique.nnnRESULTSnTen studies met the inclusion criteria as randomized controlled trials. A total of 4,121 female and male soccer athletes were analyzed for ankle injuries. Significant heterogeneity was found among studies of ankle injury prevention (p = 0.002), with an I(2) index of 65.2%. For studies of ankle injury prevention programs, the risk ratio was 0.60 (95% confidence interval, 0.40 to 0.92) and a significant reduction in the risk of ankle injury was found in the prevention group (p = 0.002). No evidence of publication bias was found among the included studies.nnnCONCLUSIONSnThis meta-analysis of studies regarding ankle injury prevention programs identified a significant reduction in the risk of ankle injury. Future high-quality research designs with a low risk of bias are necessary to further evaluate the effectiveness of specific exercises and the optimal timing and age at intervention for the prevention of ankle injuries in the athletic soccer player.nnnLEVEL OF EVIDENCEnTherapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.