Robin V. West

The Role of Concussion History and Gender in Recovery From Soccer-Related Concussion

Background This study was designed to investigate differences in recovery in male and female soccer athletes. Hypotheses Soccer players with a history of concussion will perform worse on neurocognitive testing than players without a history of concussion. Furthermore, female athletes will demonstrate poorer performance on neurocognitive testing than male athletes. Study Design Cohort study (prognosis): Level of evidence, 2. Methods Computer-based neuropsychological testing using reaction time, memory, and visual motor-speed composite scores of the ImPACT test battery was performed postconcussion in soccer players ranging in age from 8 to 24 years (N = 234; 141 females, 93 males). A multivariate analysis of variance was conducted to examine group differences in neurocognitive performance between male and female athletes with and without a history of concussion. Results Soccer players with a history of at least 1 previous concussion performed significantly worse on ImPACT than those who had not sustained a prior concussion (F = 2.92, P = .03). In addition, female soccer players performed worse on neurocognitive testing (F = 2.72, P = .05) and also reported more symptoms (F = 20.1, P = .00001) than male soccer players. There was no significant difference in body mass index between male and female players (F = .04, P = .85). Conclusion A history of concussion and gender may account for significant differences in postconcussive neurocognitive test scores in soccer players and may play a role in determining recovery. These differences do not appear to reflect differences in mass between genders and may be related to other gender-specific factors that deserve further study.

Graft selection in anterior cruciate ligament reconstruction.

Abstract The ideal graft for use in anterior cruciate ligament reconstruction should have structural and biomechanical properties similar to those of the native ligament, permit secure fixation and rapid biologic incorporation, and limit donor site morbidity. Many options have been clinically successful, but the ideal graft remains controversial. Graft choice depends on surgeon experience and preference, tissue availability, patient activity level, comorbidities, prior surgery, and patient preference. Patellar tendon autograft, the most widely used graft source, appears to be associated with an increased incidence of anterior knee pain compared with hamstring autograft. Use of hamstring autograft is increasing. Quadriceps tendon autograft is less popular but has shown excellent clinical results with low morbidity. Improved sterilization techniques have led to increased safety and availability of allograft, although allografts have a slower rate of incorporation than do most types of autograft. No graft has clearly been shown to provide a faster return to play. However, in general, patellar tendon autografts are preferable for high‐performance athletes, and hamstring autografts and allografts have some relative advantages for lower‐demand individuals. No current indications exist for synthetic ligaments.

Reduction of verbal pain scores after anterior cruciate ligament reconstruction with 2-day continuous femoral nerve block: A randomized clinical trial

Background:Single-injection femoral nerve block analgesia and spinal anesthesia have been associated with fewer postoperative nursing interventions and successful same-day discharge after anterior cruciate ligament reconstruction. In the current study, the authors prospectively determined the effect of continuous femoral nerve block on a numeric rating scale (NRS) of pain intensity with movement for 7 postoperative days. Methods:Patients undergoing this surgery with no history of previous invasive surgery on the same knee were recruited for this study. After standardized spinal anesthesia, intravenous sedation, and perioperative multimodal analgesia, patients received a femoral nerve catheter with (1) saline bolus (30 ml) plus saline infusion (270 ml at 5 ml/h, placebo group); (2) levobupivacaine (0.25%) bolus with saline infusion (group I), or (3) levobupivacaine (0.25%) bolus and infusion (group II). Patients were surveyed preoperatively and on postoperative days 1–4 and 7 to determine NRS scores (scale 0–10). Results:Data from 233 participants were analyzed. On days 1–2, 50% of placebo patients had NRS scores of 5 or above, whereas among group II patients, only 25% had scores of 5 or above (P < 0.001). In regression models for NRS scores during days 1–4, group II was the only factor predicting lower pain scores (odds ratios, 0.3–0.5; P = 0.001–0.03). Overall, patients with preoperative NRS scores greater than 2 were likely to report higher NRS scores during days 1–7 (odds ratios, 3.3–5.2; P < 0.001). Conclusions:Femoral nerve block catheters reliably keep NRS scores below the moderate-to-severe pain threshold for the first 4 days after anterior cruciate ligament reconstruction.

Quantitative Magnetic Resonance Imaging UTE-T2* Mapping of Cartilage and Meniscus Healing After Anatomic Anterior Cruciate Ligament Reconstruction

Background: An anterior cruciate ligament (ACL) injury greatly increases the risk for premature knee osteoarthritis (OA). Improved diagnosis and staging of early disease are needed to develop strategies to delay or prevent disabling OA. Purpose: Novel magnetic resonance imaging (MRI) ultrashort echo time (UTE)–T2* mapping was evaluated against clinical metrics of cartilage health in cross-sectional and longitudinal studies of human participants before and after ACL reconstruction (ACLR) to show reversible deep subsurface cartilage and meniscus matrix changes. Study Design: Cohort study (diagnosis/prognosis); Level of evidence, 2. Methods: Forty-two participants (31 undergoing anatomic ACLR; 11 uninjured) underwent 3-T MRI inclusive of a sequence capturing short and ultrashort T2 signals. An arthroscopic examination of the medial meniscus was performed, and modified Outerbridge grades were assigned to the central and posterior medial femoral condyle (cMFC and pMFC, respectively) of ACL-reconstructed patients. Two years after ACLR, 16 patients underwent the same 3-T MRI. UTE-T2* maps were generated for the posterior medial meniscus (pMM), cMFC, pMFC, and medial tibial plateau (MTP). Cross-sectional evaluations of UTE-T2* and arthroscopic data along with longitudinal analyses of UTE-T2* changes were performed. Results: Arthroscopic grades showed that 74% (23/31) of ACL-reconstructed patients had intact cMFC cartilage (Outerbridge grade 0 and 1) and that 90% (28/31) were Outerbridge grade 0 to 2. UTE-T2* values in deep cMFC and pMFC cartilage varied significantly with injury status and arthroscopic grade (Outerbridge grade 0-2: n = 39; P = .03 and .04, respectively). Pairwise comparisons showed UTE-T2* differences between uninjured controls (n = 11) and patients with arthroscopic Outerbridge grade 0 for the cMFC (n = 12; P = .01) and arthroscopic Outerbridge grade 1 for the pMFC (n = 11; P = .01) only and not individually between arthroscopic Outerbridge grade 0, 1, and 2 of ACL-reconstructed patients (P > .05). Before ACLR, UTE-T2* values of deep cMFC and pMFC cartilage of ACL-reconstructed patients were a respective 43% and 46% higher than those of uninjured controls (14.1 ± 5.5 vs 9.9 ± 2.3 milliseconds [cMFC] and 17.4 ± 7.0 vs 11.9 ± 2.4 milliseconds [pMFC], respectively; P = .02 for both). In longitudinal analyses, preoperative elevations in UTE-T2* values in deep pMFC cartilage and the pMM in those with clinically intact menisci decreased to levels similar to those in uninjured controls (P = .02 and .005, respectively), suggestive of healing. No decrease in UTE-T2* values for the MFC and new elevation in UTE-T2* values for the submeniscus MTP were observed in those with meniscus tears. Conclusion: This study shows that novel UTE-T2* mapping demonstrates changes in cartilage deep tissue health according to joint injury status as well as a potential for articular cartilage and menisci to heal deep tissue injuries. Further clinical studies of UTE-T2* mapping are needed to determine if it can be used to identify joints at risk for rapid degeneration and to monitor effects of new treatments to delay or prevent the development of OA.

Anterior cruciate ligament injury-prevention programs.

A good anterior cruciate ligament injury-prevention program should: ➤ Incorporate feedback on technique ➤ Be performed throughout the year ➤ Focus on flexibility, strengthening, and plyometrics. Language: en

Anatomic Anterior Cruciate Ligament Reconstruction with Quadriceps Tendon Autograft

A multitude of graft options exist including both allograft and autograft sources for reconstruction of the anterior cruciate ligament. With recent concerns regarding the early graft failure and cost-effectiveness of allograft sources, more attention has been directed toward autograft options. However, autograft harvest has been associated with specific morbidity that can result in suboptimal outcomes. The quadriceps tendon is an excellent biomechanical and biologic option.

Surgical Treatment of Combined ACL Medial and Lateral Side Injuries: Acute and Chronic

The assessment of a patient with a multiple-ligament-injured knee requires a careful history and clinical evaluation. Missed concomitant ligament disruptions in the setting of an anterior cruciate ligament (ACL) tear can increase the failure rate of the ACL graft. Additionally, unrecognized and/or untreated posterolateral corner (PLC) or medial-sided knee injuries can lead to chronic disability. A thorough history and physical examination, combined with proper imaging studies, can facilitate an accurate diagnosis. These complex injuries require a systematic approach for treatment. Acute grade one or two medial collateral ligament (MCL) tears in the setting of an ACL tear can often be treated with bracing of the MCL, depending on the location, followed by ACL reconstruction. Combined ACL and PLC injuries are best treated acutely with ACL reconstruction and primary repair of the posterolateral knee injuries. However, the vascular status, soft tissue swelling, and medical comorbidities must be taken into account when determining the optimal time for surgical intervention. Chronic ACL and PLC tears are best treated with anatomic ACL and PLC reconstructions.

Comparison of Clinical Outcomes Following Anatomic Single vs. Double-Bundle ACL Reconstruction: A Randomized Clinical Trial:

Objectives: The shortcomings of anterior cruciate ligament reconstruction (ACL), including failure to restore normal structure and function of the knee, limited return to pre-injury level of sports participation and failure to prevent the development of post-traumatic knee osteoarthritis (OA) have recently been recognized. Anatomic methods to reconstruct the ACL, including anatomic single-bundle (SB) and double-bundle (DB) reconstruction, have been proposed to improve clinical outcomes after ACL reconstruction. We performed a double-blinded randomized clinical trial to compare clinical outcomes of anatomic SB to anatomic DB ACL reconstruction. We hypothesized that anatomic DB ACL reconstruction with a quadriceps tendon autograft with bone block would result in reduced knee laxity, better range of motion, patient-reported outcomes (PROs), return to sports and reduced risk of re-injury compared to anatomic SB ACL reconstruction. Methods: Individuals between 14 and 50 years of age participating in at least 100 hours of Level 1 or 2 sports activities that presented within 12 months of injury to both bundles of the ACL with or without injury to the medial or lateral meniscus were eligible to participate in this study. Individuals with prior injury or surgery of the ipsilateral or contralateral knee or greater than a grade 1 concomitant knee ligament injury were excluded. If the ACL insertion sites were between 14 and 18mm, as measured with an arthroscopic ruler at the time of arthroscopy, the subject was randomized to undergo SB or DB ACL reconstruction with a 10 mm quadriceps tendon autograft harvested with a patellar bone block. A single, anatomically placed femoral tunnel was used for all cases. For DB ACL reconstruction, the graft was split into to two arms and passed through two anatomically placed tibial tunnels. Subjects were followed at 3, 6, 12 and 24 months after randomization, with the primary endpoints occurring at 24 months. Outcome measures included the KT-1000 (side to side difference) and pivot shift tests, range of motion (ROM), IKDC Subjective Knee Form (IKDC-SKF) and return to pre-injury level of sports participation. Results: Fifty-seven subjects were randomized (29 DB) and two-year follow-up was attained from 51 (89.5%). There were no differences between groups in terms of age, proportion of males, body mass index (BMI), participation in competitive or recreational sports or concomitant meniscus procedures. At 24-month follow-up there were no between groups differences for the pivot shift and KT-1000 tests, ROM and IKDC-SKF scores (Table 1). Twenty-three (85.2%) DB’s and 24 (87.5%) SB’s reported returning to pre-injury level of sports 2 years after surgery (p=0.81). Three subjects (2 SB’s, 5.9% of total) suffered a graft rupture and 5 individuals (4 SB’s, 9.8% of total) had a subsequent meniscus injury. Conclusion: With the available sample size, we were unable to demonstrate significant differences in clinical outcome between anatomic SB and DB ACL reconstruction when performed with a quadriceps tendon autograft with a bone block in individuals with ACL insertion sites that ranged from 14 to 18 mm. Furthermore, both anatomic SB and DB ACL reconstruction lead to clinical outcomes that are comparable or superior to those reported for non-anatomical ACL reconstruction with minimal recurrent instability. Table 1 Clinical Outcomes at 24 Months Double Bundle (n=27) Single Bundle (n=24) p value6 Normal Pivot Shift (n, %) 25, 92.6% 23, 95.8% 0.48 KT Arthrometer1 (30 lb) (mean ± SD) 0.5 ± 1.3 0.6 ± 1.6 0.80 KT Arthrometer1 (max manual) (mean ± SD) 0.7 ± 1.2 0.8 ± 1.5 0.79 Passive Extension of Involved Knee2 (mean ± SD) 3.9 ± 3.0 3.8 ± 2.8 0.90 Passive Extension Difference3 (mean ± SD) 2.1 ± 1.9 1.7 ± 2.6 0.53 Active Flexion of Involved Knee4 (mean ± SD) 140.7 ± 5.7 140.2 ± 6.3 0.76 Active Flexion Difference5 (mean ± SD) 0.3 ± 4.2 -1.1 ± 9.0 0.47 IKDC Subjective Knee Score (mean ± SD) 89.4 ± 10.3 90.2 ± 11.1 0.79 1 Values are involved minus non-involved side to side difference in millimeters2Values are in degrees. Positive values indicate hyperextension 3 Non-involved minus involved knee difference in passive knee extension. Values are in degrees. Positive values indicate a loss of extension of the involved knee 4 Values are in degrees 5 Non-involved minus involved knee difference in active knee flexion. Values are in degrees. Positive values indicate a loss of flexion of the involved knee. 6 Independent t-tests were used for continuous variables and Fisher Exact Tests were used for nominal variables. p values were not adjusted for multiple comparisons.

Knee Kinematics Following Anatomic Single vs. Double Bundle ACL Reconstruction: A Randomized Clinical Trial

Objectives: A randomized clinical trial was conducted to compare knee kinematics during gait and running 24 months after ACL reconstruction, using either single-bundle (SB) or double-bundle (DB) quadriceps tendon grafts. We hypothesized that DB reconstruction would better restore kinematics than SB reconstruction, in comparison to the uninjured, contralateral knee. Methods: Subjects were between 14 and 50 years of age, participated in at least 100 hours of Level 1 or 2 sports activities and presented within 12 months of injury to both bundles of the ACL (with or without meniscal injury). Exclusion criteria included prior injury or surgery of the ipsilateral or contralateral knee or greater than a grade 1 concomitant knee ligament injury. Subjects were randomized to undergo SB or DB ACL reconstruction with a 10 mm quadriceps tendon autograft harvested with a patellar bone block. A single, anatomically placed femoral tunnel was used for all cases. For DB ACL reconstruction, the soft tissue portion of the graft was split and passed through two anatomically placed tibial tunnels. Biplane radiographic images were acquired 24 months after surgery while subjects performed downhill running on a treadmill (3.0 m/s, 10 degree slope, 150 images/s) and level gait (1.3 m/s, 100 images/s). Subject specific bone models were generated from computed tomography images and matched to the biplane radiographs using a previously validated model-based tracking process to determine tibiofemoral kinematics. Rotations of the tibia relative to the femur were calculated using the rotational component of the Joint Coordinate System originally described by Grood and Suntay. Displacements of the tibia relative to the femur were expressed in an orthogonal anatomical coordinate system fixed to the tibia. Primary outcome variables were based on previous findings of abnormalities in knee kinematics after ACL injury/reconstruction, and included peak knee external rotation, adduction and anterior translation during heelstrike to mid-stance. Three trials were collected for each limb and each task, and averaged for statistical analysis. Differences between SB and DB kinematics were determined using Wilcoxon Signed Rank tests, with significance level p < 0.05. Results: No significant differences were found in any of the primary kinematic variables between single and double bundle anatomic ACL reconstruction (Table). Differences between reconstructed and contralateral (uninjured) limbs were small, averaging less than 2 degrees in rotation and 2 mm in translation. Rotational differences were smaller during gait than during downhill running. Conclusion: Conclusions: Contrary to the study hypothesis, DB reconstruction was not found to be superior to SB reconstruction. While some abnormalities remained (particularly during the more stressful downhill running evaluation), both anatomical reconstructions were equally effective at restoring normal knee kinematics. kinematic differences between limbs (affected-contralateral) during gait and downhill running Single Bundle Single Bundle Single Bundle Double Bundle Double Bundle Double Bundle N Mean Std Dev N Mean Std Dev Wilcoxon p Running Peak Knee Adduction 25 -0.23 1.12 21 -0.21 1.16 0.71 Running Peak External Rotation 25 -1.56 4.04 21 -0.17 3.12 0.20 Running Peak Anterior Translation 25 0.57 2.62 21 2.02 2.75 0.13 Gait Peak Knee Adduction 26 -0.06 1.19 21 -0.05 1.11 0.83 Gait Peak External Rotation 26 -0.44 4.34 21 -0.11 3.55 0.77 Gait Peak Anterior Translation 26 0.83 2.97 21 2.00 2.56 0.20

The Patellofemoral Joint in the Athlete

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