Patel, Karan A.

Objectives: Osteochondral allografts of the patellar are currently matched solely based on tibial width. It is currently unknown whether matching by tibial width is a reasonable surrogate measurement to allow for optimum chondral surface matching or if patellar size and/or surface morphology (i.e., Wiberg classification) should be taken into account. This consideration may be especially important for chondral defects on the patellar apex. The purpose of this study was to use circumferential step-off height and chondral surface mapping to determine if differences in patellar surface morphology (i.e., Wiberg classification) play a role in the ability of donor patellar osteochondral allografts to match the native patellar surface when treating osteochondral defects involving the central ridge of the patella. The secondary purpose was to explore the relationship between tibial width and patellar size (width and height) to determine if tibial width strongly related to patellar size to allow it to act as a surrogate measure for patellar size. Methods: Twenty (10 Wiberg I and 10 Wiberg II/III) fresh frozen patellae were designated as the recipient. Each recipient was size-matched (within ± 2mm tibial width) to both a Wiberg I and a Wiberg II/III patellar donor to produce 20 size-matched trios. All patellas were classified as Wiberg I, II, or III by visual inspection. The patellar height and widths were also measured. The recipient patella underwent initial nanoCT scanning to quantify the native chondral surface morphology. A 16mm circular osteochondral “defect” centered on the central ridge of the patella was then created in the recipient patella. Within each set of three patellae, the donor Wiberg I and Wiberg II/III patellae were randomly assigned, using a random number generator, to be transplanted first or second. The randomly ordered donor Wiberg I or Wiberg II/III plug was harvested from a homologous location and transplanted into the recipient. The recipient was then nano-CT scanned, digitally reconstructed, registered to the initial nano-CT scan of the recipient patella. It was then processed in Dragon Fly to determine circumferential step-off heights between the native and donor surfaces at three degree intervals. This was calculated for the entire circumference and for each quadrant (superior, medial, inferior, lateral) to determine if the ste-off heights varied by locations. MATLAB was used to determine the height deviation (dRMS) between the native and donor surfaces at over 3000 surface points (Figure 1). The initial transplant was carefully removed and the process was then repeated for the other donor allograft. Pearson correlation coefficient, 2-way ANOVA with Tukey’s multiple comparison, and paired t-tests were used when appropriate. Sample size of 10 trios was determined based on previous work in our lab (clinically relevant difference of 0.75mm, SD = 0.5mm, α = 0.05, power 0.8; 7 samples per group). Results: There was no significant difference in mean step-off heights between matched and unmatched Wiberg allograft plugs (Table 1). When analyzing all patellas, the superior (p = 0.01) and lateral (p = 0.001) quadrants demonstrated step-off heights that were significantly greater compared to the inferior quadrant, however these findings were not clinically significant. There was a statistically significant difference in height deviation over the whole surface between native and donor plugs when comparing matched and unmatched Wiberg plugs (p=0.049), however this finding was not clinically significant (Table 2). There was no difference across individual quadrants. There was a linear correlation when comparing tibial width to patellar width (r = 0.82) and patellar height (r = 0.68). Conclusions: Differences in Wiberg classification did not lead to clinically relevant differences in step-off height or surface height deviations for the whole donor plug or by quadrant. Tibial width is a reasonable measure to predict patellar size (width and height). It is therefore reasonable to continue matching osteochondral allografts of the patella based on the easy to measure value of tibial width without consideration for patellar size or Wiberg classification. [Table: see text][Table: see text]

Objectives: The aim of this study is to directly compare clinical outcomes following the treatment of medium-sized osteochondral lesions of the talus (OLTs) using a microfracture technique augmented with Extracellular Matrix and Bone Marrow Aspirate Concentrate (MFX) versus OAT to determine which treatment is superior for medium-sized lesions. Methods: Patients treated for an OLT between 2015 and 2018 by a single surgeon, fellowship-trained in sports medicine and foot and ankle, were screened for this study. Retrospective chart review determined treatment, lesion size, lesion location, concurrent injuries, and demographic information. Patients at a minimum of 12 months follow-up, treated with MFX or OAT, and lesions sized 80-165mm2 were eligible for inclusion. All surgical repairs were augmented with an adjuvant mixture of micronized cartilage extracellular matrix and bone marrow aspirate concentrate (ECM-BMAC). Patient-reported functional outcomes were collected through our institution’s prospective Registry database. Patients treated prior to March 2016 were administered preoperative Foot and Ankle Outcome Score questionnaires. Those treated after this date were administered preoperative Physical Function, Pain Interference, Global Physical Health, Global Mental Health, Depression, and Pain Intensity Patient-Reported Outcome Information System (PROMIS) domains. Both FAOS and PROMIS were administered postoperatively. Postoperative MRIs were assessed using a modified magnetic resonance observation of cartilage repair tissue (MOCART) score. Student’s paired and two-group t-tests were used to evaluate for statistically significant pre-to-postoperative change and differences between procedure groups (p less than 0.05). Results: Twenty-seven patients treated with MFX (age range, 14-58) and twenty-three patients treated using OAT (age range, 22-64) were identified. All OAT patients received a single-plug transplantation. The final average lesion size ± standard deviation (SD) for patients treated with MFX was 115.44mm2± 22.51 (range, 156-80mm2) and 121.78mm2± 23.98 (range, 165-80mm2) for those treated using OAT (p=0.34). On average, functional outcome scores improved pre-to-postoperatively across all scales within both groups. Statistically significant improvements were detected in PROMIS Physical Function (Δ=8.32, p=0.01), Pain Interference (Δ=-7.15, p=0.02), Global Physical Health (Δ=5.87, p=0.03), and Pain Intensity (Δ=-7.06, p=0.05) domains for the MFX cohort. For the OAT patient group, significant pre-to-postoperative change was seen in the FAOS subcategories of Pain (Δ=28.70, p=0.03), Sports Activities (Δ=43.12, p<0.01), and Quality of Life (Δ=43.75, p=0.01); overall FAOS score (Δ=29.93, p=0.01); and PROMIS Physical Function (Δ=13.66, p=0.01), Pain Interference (Δ=-14.58, p<0.01), Global Physical Health (Δ=12.2, p=0.01), Depression (Δ=-4.13, p=0.02), and Pain Intensity (Δ=-16.56, p=0.02) domains. On average, with the exception of the postoperative Sports Activities subscale, postoperative FAOS and pre-to-postoperative change in FAOS were higher and greater in the OAT patient group. Similarly, on average, the OAT group had better PROMIS t-scores indicating higher function or less pain and greater pre-to-postoperative change in each PROMIS domain. The OAT cohort’s average postoperative Pain Interference t-score (± SD) of 43.09 (± 5.81) and Depression t-score of 40.06 (± 6.84) were significantly lower than their respective counterparts in the MFX cohort: 50.08 (± 9.47) for Pain Interference and 48.09 (± 7.86) in Depression. (Table 1) Finally, the mean overall MOCART score was 55.67 (± 24.11) within the MFX cohort, average follow-up 15.29 months, and 71 (± 15.60) within the OAT cohort average follow-up 15.8 months. This difference was also statistically significant (p=0.04). Conclusion: The OAT group had a higher MOCART score indicating the use of a single osteochondral autograft plug may result in better structural repair than microfracture abrasion chondroplasty augmented with a mixture of adjuvant ECM-BMAC. In addition, higher average FAOS scores, better average PROMIS t-scores, and greater pre-to-postoperative change in the OAT patient group indicate functional results may be better in this group as well. Specifically, significantly lower Pain Interference and Depression domains and significantly higher Global Mental Health scores indicate patients treated using OAT experience less pain and better psychological benefits postoperatively compared to patients treated using MFX. These results suggest filling the lesion with transplanted autograft bone and native, hyaline cartilage may perform better than and the biomechanically inferior fibrocartilage produced following microfracture even when augmented with adjuvant therapy. OAT may result in better overall clinical outcomes, specifically in a population of patients with medium sized lesions (range, 80 mm2 -165 mm2).

Abstract Isolated patellofemoral arthritis is a common debilitating condition in adults older than 40 years of age. Surgical options such as patellofemoral arthroplasty exist for those who failed to respond to nonoperative treatment. However, early patellofemoral arthroplasty techniques often resulted in poor outcomes due to mal‐tracking and malalignment of components. Robotic‐assisted surgery recently has been introduced as an alternative to classic patellofemoral arthroplasty, with the potential to improve the anatomical fit and reproducibility of implant positioning. We present the technique for minimally invasive robotic‐assisted patellofemoral arthroplasty system. Technique Video video See video under supplementary data.

Background: Hip and groin injuries are common in competitive soccer players and have been shown to be significant sources of time loss. There are few studies describing the epidemiology of hip and groin injuries in female National Collegiate Athletic Association (NCAA) soccer players. Purpose: To describe the epidemiology of hip and groin injuries in women’s collegiate soccer players. Study Design: Descriptive epidemiology study. Methods: The NCAA Injury Surveillance System/Program (ISS/ISP) was analyzed from 2004 through 2014 for data related to hip and groin injuries in female collegiate soccer players. Injuries and athlete-exposures (AEs) were reported by athletic trainers. Data were stratified by time of season, event type, injury type, treatment outcome, time loss, and player field position. Results: Between 2004 and 2014, there were 439 recorded hip or groin injuries in female soccer players and an overall rate of injury of 0.57 per 1000 AEs. Injuries were 12.0 times more likely to occur during the preseason (4.41/1000 AEs) as opposed to during the regular season (0.37/1000 AEs) (injury rate ratio [IRR], 12.01; 95% confidence interval [CI], 9.92-14.55) or postseason (0.38/1000 AEs) (IRR, 11.55; 95% CI, 7.06-18.91). Rates of injury were similar during the regular season and postseason (IRR, 0.96; 95% CI, 0.59-1.58). Rates of injury were higher during competition (0.69/1000 AEs) than during practice (0.52/1000 AEs) (IRR, 1.33; 95% CI, 1.08-1.63). Most injuries were new (87.5%; n = 384) and unlikely to recur (12.5%; n = 55). Conclusion: Hip and groin injuries in female NCAA soccer players are uncommon, and fortunately, most players return to play quickly without recurrence. Future prospective studies should evaluate the effectiveness of strength and conditioning programs in preventing these injuries.

Background: Lumbar spine injuries (LSIs) are common in both men’s and women’s National Collegiate Athletic Association (NCAA) basketball players and can frequently lead to reinjuries and persistent pain. Purpose: To describe the epidemiology of an LSI in collegiate men’s and women’s basketball during the 2009-2010 through 2013-2014 academic years. Study Design: Descriptive epidemiology study. Methods: The incidence and characteristics of LSIs were identified utilizing the NCAA Injury Surveillance Program (ISP). Rates of injury were calculated as the number of injuries divided by the total number of athlete-exposures (AEs). AEs were defined as any student participation in 1 NCAA-sanctioned practice or competition. Incidence rate ratios (IRRs) were then calculated to compare the rates of injury between season, event type, mechanism, injury recurrence, and time lost from sport. Results: The NCAA ISP reported 124 LSIs from an average of 28 and 29 men’s and women’s teams, respectively. These were used via validated weighting methodology to estimate a total of 5197 LSIs nationally. The rate of LSIs in women was 2.16 per 10,000 AEs, while men suffered LSIs at a rate of 3.47 per 10,000 AEs. Men were 1.61 times more likely to suffer an LSI compared with women. In men, an LSI was 3.48 times more likely to occur in competition when compared with practice, while in women, an LSI was 1.36 times more likely to occur in competition than in practice. Women suffered the highest LSI rate during the postseason, while the highest rate in men was during the regular season. The majority of both female (58.9%; n = 1004) and male (73.1%; n = 2353) athletes returned to play within 24 hours of injury. Conclusion: To date, this is the largest study to characterize LSIs in NCAA basketball and provides needed information on the prevalence and timing of these injuries. The majority of injuries in both sexes were new, and most athletes returned to play in less than 24 hours. Injury rates were highest during competition in both sexes.

Background: National Collegiate Athletic Association (NCAA) football players are at a high risk of injuries. Elbow injuries are uncommon, but there are insufficient data specifically on elbow injuries sustained in NCAA football players. Purpose: To define the epidemiology of elbow injuries in NCAA football players during the 2009-2010 to 2013-2014 seasons using data from the NCAA Injury Surveillance Program (NCAA-ISP). Study Design: Descriptive epidemiology study. Methods: Using the NCAA-ISP database, a convenience sample of NCAA football athletes was reviewed to determine the types, rates, and trends in elbow injuries. Several factors were examined, including the diagnosis, injury setting, time lost from sport, surgical necessity, and injury recurrence. Raw injury data were obtained as well as weighted totals from the NCAA-ISP to generate national estimates and adjust for underreporting. Injury rates were calculated by dividing the number of injuries by the total number of athlete-exposures (AEs). The rate ratios of injuries during competition versus practice were compared, as were the rate ratios of preseason, regular-season, and postseason injuries by type. Results: We identified 4874 total elbow injuries from the 2009-2010 to 2013-2014 seasons. The rate of injuries overall was 1.892 per 10,000 AEs. The rate for competition was 9.053 per 10,000 AEs and 1.121 per 10,000 AEs for practice. The rate ratio between competition and practice was 8.08 (95% CI, 6.04-10.80). Injury rates for the preseason, regular season, and postseason were 1.851, 1.936, and 1.406 per 10,000 AEs, respectively. Acute elbow instability was the most common injury type (65.43%). The most common mechanism was a contact injury (86.77%); 96.82% of injuries did not require surgery, and most elbow injuries required less than 24 hours of participation restriction (67.33%). Conclusion: Although elbow injuries in NCAA football players are uncommon, it is important to recognize and treat these injuries appropriately. Dislocations and ulnar collateral ligament injuries caused athletes to miss extended periods of play. Fortunately, a majority of injuries resulted in less than 24 hours of participation restriction. Particular attention should be given to preventing elbow injuries, especially ulnar collateral ligament strains, hyperextension injuries, and acute instability.

Study Design. Descriptive epidemiology study. Objective. The purpose of this study was to describe the epidemiology of neck and cervical spine injuries in collegiate athletes over a 5-year period. Summary of Background Data. The incidence and etiology of neck and cervical spine injuries in National Collegiate Athletic Association (NCAA) athletes has not been well defined in recent years. Methods. The incidence and characteristics of neck and cervical spine injuries were identified utilizing the NCAA Injury Surveillance Program database. Rates of injury were calculated as the number of injuries divided by the total number of athlete-exposures (AEs). AEs were defined as any student participation in one NCAA-sanctioned practice or competition. Results. Nationally, there were an estimated 11,510 neck and cervical spine injuries over the 5-year period. These occurred at a rate of 7.05 per 100,000 athlete-exposures (AEs). The rate of neck and cervical spine injuries in men was 2.66 per 100,000 AEs, while women suffered injuries at a rate of 1.95 per 100,000 AEs. In sex-comparable sports, men were 1.36 times more likely to suffer a neck or cervical spine injury compared with women. Men's football (29.09 per 100,000 AEs) and women's field hockey (11.51 per 100,000 AEs) were the sports with the highest rates of injuries. These injuries were 3.94 times more likely to occur during competition compared with practice. In-season injury rates were the highest, at 8.18 per 100,000 AEs. Conclusion. The vast majority of neck and cervical spine injuries in NCAA athletes are minor and uncommon. Across all sports in both sexes, the majority of injuries were new, and occurred during in-season competitions. Most athletes returned to play within 24 hours of injury. These data can inform players, parents, coaches, athletic trainers, and physicians regarding the prevalence and rates of these injuries and potentially inform decision-making regarding injury prevention, treatment, and rehabilitation. Level of Evidence: 4

Background: Little research has focused on the rates and patterns of elbow injuries in National Collegiate Athletic Association (NCAA) student-athletes. Purpose: To describe the epidemiological patterns of elbow injuries in NCAA athletes during 5 seasons over the academic years 2009 through 2014 using the NCAA Injury Surveillance Program (NCAA-ISP) database. Study Design: Descriptive epidemiology study. Methods: A voluntary convenience sample of NCAA varsity teams from 11 sports was examined to determine the rates and patterns of elbow injuries. Rates and distributions of elbow injuries were identified within the context of sport, event type, time in season, mechanism, time lost from sport, surgical treatment, and injury type. Rates of injury were calculated as the number of injuries divided by the total number of athlete-exposures (AEs). An AE was defined as any student participation in 1 NCAA-sanctioned practice or competition with an inherent risk of exposure to potential injury. Injury rate ratios (IRRs) and injury proportion ratios (IPRs) were then calculated to compare the rates within and between sports by event type, season, sex, mechanism, surgical treatment, and time lost from sport. Comparisons between sexes were made using only sports data that had both male and female samples. Results: Overall, 373 elbow injuries were reported in the NCAA-ISP data set during the 2009-2010 through 2013-2014 academic years among 11 varsity sports. The overall rate of injury was 1.76 per 10,000 AEs. The rate of elbow injuries in men was 0.74 per 10,000 AEs, while women experienced injuries at a rate of 0.63 per 10,000 AEs. In sex-comparable sports, men were 1.17 times more likely to experience an elbow injury compared with women. Men’s wrestling (6.00/10,000 AEs) and women’s tennis (1.86/10,000 AEs) were the sports with the highest rates of elbow injuries by sex, respectively. The top 3 highest injury rates overall occurred in men’s wrestling, baseball, and tennis. Elbow injuries were 3.5 times more likely to occur during competition compared with practice. Athletes were 0.76 times less likely to sustain an elbow injury during the preseason compared with in-season. Contact events were the most common mechanism of injury (67%). For sex-comparable sports, men were 2.41 times more likely than women to have contact as their injury mechanism (95% CI, 0.78-7.38). The majority of athletes missed less than 24 hours of participation time (67%), and only a minority (3%) of patients with elbow injuries went on to have surgical intervention. Elbow ulnar collateral ligament injuries were most common (26% of total injuries). Conclusion: Analysis of the study data demonstrated a significant rate of elbow injuries, 1.76 injuries per 10,000 AEs in NCAA collegiate athletes. Higher injury rates can be expected in males within sex-comparable sports. Elbow injuries are most common in the setting of competitions and most commonly occur secondary to contact-type mechanisms. Injuries were more likely to occur during in-season play. The majority of injuries required less than 24 hours of time away from sport and did not require surgical intervention.

Context Data from the National Collegiate Athletic Association (NCAA) Injury Surveillance Program (ISP) have indicated that ankle injuries are the most common injuries among NCAA soccer players. Objective To review 10 years of NCAA-ISP data for soccer players' ankle injuries to understand how the time period (2004–2005 through 2008–2009 versus 2009–2010 through 2013–2014), anatomical structure injured, and sex of the athlete affected the injury rate, mechanism, and prognosis. Design Descriptive epidemiology study. Setting Online injury surveillance. Main Outcome Measure(s) The NCAA-ISP was queried for men's and women's soccer ankle data from 2004 to 2014. Ankle-injury rates were calculated on the basis of injuries per 1000 athlete-exposures. Rate ratios (RRs) were used to compare injury rates. Injury proportion ratios (IPRs) were used to compare injury characteristics. Results When compared with the 2004–2005 through 2008–2009 seasons, the 2009–2010 through 2013–2014 seasons showed a similar rate of injuries (RR = 0.94, 95% confidence interval [CI] = 0.85, 1.04) but fewer days missed (P &lt; .001) and fewer recurrent injuries (IPR = 0.55, 95% CI = 0.41, 0.74). The 4 most common ankle injuries, which accounted for 95% of ankle injuries, were lateral ligament complex tears (65.67%), tibiofibular ligament (high ankle) sprains (10.3%), contusions (10.1%), and medial (deltoid) ligament tears (9.77%). Of these injuries, high ankle sprains were most likely to cause athletes to miss ≥30 days (IPR = 1.9, 95% CI = 1.24, 2.90). Men and women had similar injury rates (RR = 1.02, 95% CI = 0.94, 1.11). Men had more contact injuries (IPR = 1.28, 95% CI = 1.16, 1.41) and contusion injuries (IPR = 1.34, CI = 1.03, 1.73) but fewer noncontact injuries (IPR = 0.86, 95% CI = 0.78, 0.95) and lateral ligamentous complex injuries (IPR = 0.92, 95% CI = 0.86, 0.98). Conclusions Although the rate of ankle injuries did not change between the 2004–2005 through 2008–2009 seasons and the 2009–2010 through 2013–2014 seasons, the prognoses improved. Among the 4 most common ankle injuries, high ankle sprains resulted in the worst prognosis. Overall, male and female NCAA soccer players injured their ankles at similar rates; however, men were more likely to sustain contact injuries.

Background: Low back injuries are common in collegiate football players and can frequently lead to persistent pain, reinjuries, and time lost from participation. Purpose: To describe the epidemiology of back injuries in National Collegiate Athletic Association (NCAA) football players during the 2009/2010 through 2013/2014 academic years utilizing the NCAA Injury Surveillance Program (ISP) database. Study Design: Descriptive epidemiology study. Methods: A convenience sample of NCAA varsity football teams was utilized to determine the rates and patterns of back injuries as well as to generate national injury estimates. The rates and distribution of back injuries were identified within the context of mechanism of injury, injury chronicity, and time lost from sport. Injury rates were calculated as the number of injuries divided by the total number of athlete-exposures (AEs). Incidence rate ratios were calculated to compare the rates of injury between season, event type, mechanism of injury, injury chronicity, and time lost from sport. Results: Nationally, there were 267 low back injuries reported in the database. These were used to estimate 7076 back injuries over the 5-year period, approximately 82% of which were new injuries. The injuries occurred at a rate of 2.70 per 10,000 AEs. Overall, injuries were 3.12 times more likely to occur in competitions than in practices. Athletes were 4.67 times more likely to sustain a back injury during the preseason compared with the postseason but were 1.41 times more likely to sustain a low back injury during the preseason compared with the regular season. Both contact and noncontact were reported equally as the mechanism of injury (37.8% and 38.3%, respectively), and unspecified low back pain was the most common injury (64.2%). Only 1.6% of patients required surgery for their injury, and the majority of athletes (59.6%) returned to play within 24 hours. Conclusion: There was a relatively high rate of lumbar back injuries at the collegiate level (2.70/10,000 AEs), the majority of which were new injuries. About 18% of reported injuries were reinjuries. Although very few required surgery, a careful examination and work-up should be conducted to evaluate each injury. Regimented physical therapy and reconditioning programs are recommended to avert reinjuries.