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1.  Osteochondral Avulsion Fracture of the Anterior Cruciate Ligament Femoral Origin in a 10-Year-Old Child: A Case Report 
Journal of Athletic Training  2011;46(4):451-455.
To describe the case of a 10-year-old football player who sustained a comminuted osteochondral avulsion fracture of the femoral origin of the anterior cruciate ligament (ACL) via a low-energy mechanism.
In children, both purely cartilaginous and osteochondral avulsion fractures have been described; most such ACL avulsions are from the tibial eminence. In the few previous case reports describing femoral osteochondral avulsion fractures, high-energy injury mechanisms were typically responsible and resulted in a single fracture fragment.
Differential Diagnosis:
Femoral osteochondral avulsion fracture at the ACL origin, femoral cartilaginous avulsion fracture at the ACL origin, midsubstance ACL tear, meniscal tear.
Sutures and a button were used to repair the comminuted fragments. Postoperatively, a modified ACL reconstruction rehabilitation program was instituted.
Most injuries of this nature in youngsters are caused by a high-energy mechanism of injury, result in an osteochondral avulsion fracture of the tibial eminence, and involve a single fracture fragment.
Although they occur infrequently, ACL femoral avulsion fractures in children can result from a low-energy injury mechanism. Identifying the mechanism of injury, performing a thorough physical examination, and obtaining appropriate diagnostic studies will enable the correct treatment to be implemented, with the goal of safely returning the athlete to play.
PMCID: PMC3419159  PMID: 21944079
injury mechanisms; knee injuries; pediatric injuries
2.  Treatment principles for osteochondral lesions in foot and ankle 
International Orthopaedics  2013;37(9):1697-1706.
Osteochondral lesion of the talus (OLT) is a broad term used to describe an injury or abnormality of the talar articular cartilage and adjacent bone. A variety of terms have been used to refer to this clinical entity, including osteochondritis dissecans (OCD), osteochondral fracture and osteochondral defect. Whether OLT is a precursor to more generalised arthrosis of the ankle remains unclear, but the condition is often symptomatic enough to warrant treatment. In more than one third of cases, conservative treatment is unsuccessful, and surgery is indicated. There is a wide variety of treatment strategies for osteochondral defects of the ankle, with new techniques that have substantially increased over the last decade. The common treatment strategies of symptomatic osteochondral lesions include nonsurgical treatment, with rest, cast immobilisation and use of nonsteroidal anti-inflammatory drugs (NSAIDs). Surgical options are lesion excision, excision and curettage, excision combined with curettage and microfracturing, filling the defect with autogenous cancellous bone graft, antegrade (transmalleolar) drilling, retrograde drilling, fixation and techniques such as osteochondral transplantation [osteochondral autograft transfer system (OATS)] and autologous chondrocyte implantation (ACI). Furthermore, smaller lesions are symptomatic and when left untreated, OCDs can progress; current treatment strategies have not solved this problem. The target of these treatment strategies is to relieve symptoms and improve function. Publications on the efficacy of these treatment strategies vary. In most cases, several treatment options are viable, and the choice of treatment is based on defect type and size and preferences of the treating clinician.
PMCID: PMC3764304  PMID: 23982639
Osteochondral lesions; Osteochondritis dissecans; Talus; Foot and ankle; Cartilage damage; Subchondral bone
3.  Medial patellofemoral ligament injury patterns and associated pathology in lateral patella dislocation: an MRI study 
Lateral Patella dislocations are common injuries seen in the active and young adult populations. Our study focus was to evaluate medial patellofemoral ligament (MPFL) injury patterns and associated knee pathology using Magnetic Resonance Imaging studies.
MRI studies taken at one imaging site between January, 2007 to January, 2008 with the final diagnosis of patella dislocation were screened for this study. Of the 324 cases that were found, 195 patients with lateral patellar dislocation traumatic enough to cause bone bruises on the lateral femoral trochlea and the medial facet of the patella were selected for this study. The MRI images were reviewed by three independent observers for location and type of MPFL injury, osteochondral defects, loose bodies, MCL and meniscus tears. The data was analyzed as a single cohort and by gender.
This study consisted of 127 males and 68 females; mean age of 23 yrs. Tear of the MPFL at the patellar attachment occurred in 93/195 knees (47%), at the femoral attachment in 50/195 knees (26%), and at both the femoral and patella attachment sites in 26/195 knees (13%). Attenuation of the MPFL without rupture occurred in 26/195 knees (13%). Associated findings included loose bodies in 23/195 (13%), meniscus tears 41/195 (21%), patella avulsion/fracture in 14/195 (7%), medial collateral ligament sprains/tears in 37/195 (19%) and osteochondral lesions in 96/195 knees (49%). Statistical analysis showed females had significantly more associated meniscus tears than the males (27% vs. 17%, p = 0.04). Although not statistically significant, osteochondral lesions were seen more in male patients with acute patella dislocation (52% vs. 42%, p = 0.08).
Patients who present with lateral patella dislocation with the classic bone bruise pattern seen on MRI will likely rupture the MPFL at the patellar side. Females are more likely to have an associated meniscal tear than males; however, more males have underlying osteochondral lesions. Given the high percentage of associated pathology, we recommend a MRI of the knee in all patients who present with acute patella dislocation.
PMCID: PMC2732599  PMID: 19643022
4.  Fixation of osteochondral fragments in the human knee using Meniscus Arrows® 
The aim of this study is to compare the hold in bone of Meniscus Arrows® and Smart Nails®, followed by the report of the results of the clinical application of Meniscus Arrows® as fixation devices. First, pull-out tests were performed to analyse the holdfast of both nails in bone. Statistical analysis showed no significant difference; therefore, the thinner Meniscus Arrow® was chosen as fixation device in the patient series of two patients with a symptomatic Osteochondritis dissecans fragment and three patients with an osteochondral fracture of a femur condyle. The cartilage margins were glued with Tissuecoll®. All fragments consolidated. Second look arthroscopy in three patients showed fixed fragments with stable, congruent cartilage edges. At an average follow-up period of 5 years no pain, effusion, locking, restricted range of motion or signs of osteoarthritis were reported. Based on the results of the pull-out tests and available clinical studies, Meniscus Arrows® and Smart Nails® are both likely to perform adequately as fixation devices in the treatment of Osteochondritis dissecans and osteochondral fractures in the knee. They both provide the advantage of one stage surgery. However, based on their smaller diameter, the Meniscus Arrows® should be preferred for this indication.
PMCID: PMC3023860  PMID: 20464370
Osteochondritis dissecans; Osteochondral fragments; Biodegradable; Fixation devices; Meniscus Arrows®
5.  Treatment of Lateral Knee Pain Using Soft Tissue Mobilization in Four Female Triathletes 
Study Design
Prospective case series.
These case reports present results of the treatment of lateral knee pain in four female amateur triathletes. The athletes were referred to the author’s clinic with either a diagnosis of iliotibial band friction syndrome or patellofemoral pain syndrome, all four having symptoms for longer than seven months. Changes in training routines were identified as the possible cause of the overuse injuries that eventually developed into chronic conditions.
Treatment involved soft tissue mobilization of the musculotendinous structures on the lateral aspect of the knee.
At four weeks, three of the athletes improved 9 to 19 points on the Lower Extremity Functional Scale, 3 to 5 points on the Global Rating of Change Scale, and demonstrated improvement in hamstring and iliotibial band flexibility. At eight weeks the Global Rating of Change for these three athletes was a 7 (“a very great deal better”) and they had returned to triathlon training with no complaints of lateral knee pain. One athlete did not respond to treatment and eventually underwent arthroscopic surgery for debridement of a lateral meniscus tear.
After ruling out common causes for lateral knee pain such as lateral meniscus tear, lateral collateral ligament sprain, patellofemoral dysfunction, osteochondral injury, biceps femoris tendonitis, iliotibial band friction syndrome or osteoarthritis, soft tissue restriction should be considered a potential source of dysfunction. In some cases soft tissue restriction is overlooked; athletes go undiagnosed and are limited from sports participation.
PMCID: PMC4145001  PMID: 25184012
triathlete; lateral knee pain; soft tissue restriction; mobilization
6.  Osteochondral Repair of Primate Knee Femoral and Patellar Articular Surfaces: Implications for Preventing Post-Traumatic Osteoarthritis 
The risk of post-traumatic osteoarthritis following an intra-articular fracture is determined to large extent by the success or failure of osteochondral repair. To measure the efficacy of osteochondral repair in a primate and determine if osteochondral repair differs in the patella (PA) and the medial femoral condyle (FC) and if passive motion treatment affects osteochondral repair, we created 3.2 mm diameter 4.0 mm deep osteochondral defects of the articular surfaces of the PA and FC in both knees of twelve skeletally mature cynomolgus monkeys. Defects were treated with intermittent passive motion (IPM) or castimmobilization (CI) for two weeks, followed by six weeks of ad libitum cage activity. We measured restoration of the articular surface, and the volume, composition, type II collagen concentration and in situ material properties of the repair tissue. The osteochondral repair response restored a mean of 56% of the FC and 34% of the PA articular surfaces and filled a mean of 68% of the chondral and 92% of the osseous defect volumes respectively. FC defect repair produced higher concentrations of hyaline cartilage (FC 83% vs. PA 52% in chondral defects and FC 26% vs. PA 14% in osseous defects) and type II collagen (FC 84% vs. PA 71% in chondral defects and FC 37% vs. PA 9% in osseous defects) than PA repair. IPM did not increase the volume of chondral or osseous repair tissue in PA or FC defects. In both PA and FC defects, IPM stimulated slightly greater expression of type II collagen in chondral repair tissue (IPM 81% vs. CI 74%); and, produced a higher concentration of hyaline repair tissue (IPM 62% vs. CI 42%), but IPM produced poorer restoration of PA articular surfaces (IPM 23% vs. CI 45%). Normal articular cartilage was stiffer, and had a larger Poisson's ratio and less permeability than repair cartilage. Overall CI treated repair tissue was stiffer and less permeable than IPM treated repair tissue. The stiffness, Poisson's ratio and permeability of femoral condyle cast immobilized (FC CI) treated repair tissue most closely approached the normal values. The differences in osteochondral repair between FC and PA articular surfaces suggest that the mechanical environment strongly influences the quality of articular surface repair. Decreasing the risk of posttraumatic osteoarthritis following intra-articular fractures will depend on finding methods of promoting the osteochondral repair response including modifying the intra-articular biological and mechanical environments.
PMCID: PMC1888400  PMID: 14575253
7.  Osteochondritis Dissecans of the Talar Dome in a Collegiate Swimmer: A Case Report 
Journal of Athletic Training  1998;33(4):365-371.
To present the case of an intercollegiate swimmer with a stage IV lateral talar dome injury and associated bony fragments.
Lack of distinct diagnostic symptoms, low index of clinical suspicion, and the difficulty of visualizing the early stages of this injury on standard x-rays cause frequent misdiagnosis of talar dome lesions.
Differential Diagnosis:
Ganglion cyst, with inflammatory synovitis secondary to rupture of cyst; loose bodies from previous occult fracture; osteochondral fracture.
Initial treatment with nonsteroidal antiinflammatory drugs and a posterior splint for comfort, followed by arthroscopic excision of loose bodies with abrasion and drilling arthroplasty.
Patient presented to the team physician for care of acute left medial ankle pain after the athletic trainer had attempted to rupture a ganglion cyst on the anterolateral aspect of the patient's ankle.
Increased clinical suspicion is necessary to correctly diagnose osteochondral lesions, particularly in the early stages. Aggressive treatment of talar dome lesions has a good success rate and may be an attractive option for competitive athletes.
PMCID: PMC1320590  PMID: 16558537
ganglion cyst; inflammatory synovitis; osteochondral fracture
8.  Refixation of osteochondral fractures by ultrasound-activated, resorbable pins 
Bone & Joint Research  2013;2(2):26-32.
Osteochondral injuries, if not treated adequately, often lead to severe osteoarthritis. Possible treatment options include refixation of the fragment or replacement therapies such as Pridie drilling, microfracture or osteochondral grafts, all of which have certain disadvantages. Only refixation of the fragment can produce a smooth and resilient joint surface. The aim of this study was the evaluation of an ultrasound-activated bioresorbable pin for the refixation of osteochondral fragments under physiological conditions.
In 16 Merino sheep, specific osteochondral fragments of the medial femoral condyle were produced and refixed with one of conventional bioresorbable pins, titanium screws or ultrasound-activated pins. Macro- and microscopic scoring was undertaken after three months.
The healing ratio with ultrasound-activated pins was higher than with conventional pins. No negative heat effect on cartilage has been shown.
As the material is bioresorbable, no further surgery is required to remove the implant. MRI imaging is not compromised, as it is with implanted screws. The use of bioresorbable pins using ultrasound is a promising technology for the refixation of osteochondral fractures.
PMCID: PMC3626216  PMID: 23610699
Osteochondral fracture; Ultrasound-activated pin; Bioresorbable implant; Sheep study; Cartilage; Polylactide
9.  Traumatic Hemarthrosis of the Knee Secondary to Hemophilia A in a Collegiate Soccer Player: A Case Report 
Journal of Athletic Training  2002;37(3):315-319.
Objective: To present the case of a collegiate soccer player who suffered from a traumatic knee hemarthrosis secondary to hemophilia A. This case presents an opportunity to discuss the participation status of athletes with hemophilia.
Background: Hemophilia is a hereditary blood disease characterized by impaired coagulability of the blood. Hemophilia A is the most common of the severe, inherited bleeding disorders. This type, also called classic hemophilia, is due to a deficiency of clotting factor VIII. The athlete with hemophilia A reported pain and loss of function of his knee during a soccer game despite the absence of injury.
Differential Diagnosis: Anterior cruciate ligament tear, intra-articular fracture, meniscus tear, capsular tear, hemarthrosis.
Treatment: After the injury, the athlete was admitted to the hospital, where his knee joint was aspirated and he was infused with factor VIII. Later, he participated in traditional knee rehabilitation and was returned to play at the discretion of the orthopaedist and the hematologist.
Uniqueness: In past participation guidelines, individuals with bleeding disorders were disqualified from athletic participation; however, with advances in medical care, these individuals may be permitted to participate in accordance with the law.
Conclusions: Individuals with hemophilia participate in athletics; therefore, team physicians and athletic trainers must be prepared to care for these individuals.
PMCID: PMC164362  PMID: 12937588
Americans with Disabilities Act; desmopressin acetate; factor VIII; preparticipation physical examination; blood coagulation
10.  Treatment of osteochondral fractures of the knee: a meta-analysis of available scientific evidence 
International Orthopaedics  2013;37(12):2385-2394.
Although traumatic osteochondral fractures of the knee represent a common pathology of the knee joint, there is no general agreement concerning specific treatment of this entity. This meta-analysis was initiated in order to evaluate scientific evidence on different treatment options for acute osteochondral fractures of the knee.
For this purpose an OVID-based systematic literature search was performed including the following databases: MEDLINE, MEDLINE preprints, Embase, CINAHL, Life Science Citations, British National Library of Health and Cochrane Central Register of Controlled Trials. The literature search period was from 1946 to January 2012, which led to the identification of 1,226 articles. After applying study-specific inclusion criteria a total of 19 studies with clinical follow-up of 638 patients were included. The methodology of these studies was systematically analysed by means of the Coleman Methodology Score. Outcome and success rates were evaluated depending on treatment applied.
All studies (n = 19) identified represent case series (evidence-based medicine level IV) and included a total of 638 patients. The average post-operative follow-up was 46 ± 27 months (range 3.75–108). The mean number of study subjects per study was 33 ± 44 patients (range 4–169). The average Coleman Methodology Score was 29 ± 17 points (range 5–72). Six different scoring systems were used for clinical assessment. The overall clinical success rate was 83 % and varied between 45 and 100 %.
This meta-analysis reveals a significant lack of scientific evidence for treatment of osteochondral fractures of the knee. No valid conclusion can be drawn from this study concerning the recommendation of a specific treatment algorithm. Nevertheless, the overall failure rate of 17 % underlines that an acute osteochondral fracture of the knee represents an important pathology which is not a self-limiting injury and needs further investigation.
PMCID: PMC3843186  PMID: 24022737
Osteochondral fractures of the knee; Meta-analysis; No valid conclusions; High failure rate
11.  Cartilage lesions in patellofemoral dislocations: Incidents/locations/when to treat 
Patellofemoral dislocations are frequently associated with chondral injury. Chondral and osteochondral lesions are often associated with traumatic (high energy) patellofemoral dislocations whereas atraumatic (low energy) patellofemoral dislocations in patients with significant patellofemoral risk factors have a much lower incidence of osteochondral damage. This article provides a historical overview and delineates the current state of radiographic and clinical outcomes of osteochondral lesions after patellofemoral dislocation. The importance of understanding risk factors of redislocation is emphasized and the current treatment options for these cartilage lesions associated with patellofemoral dislocation are briefly summarized.
PMCID: PMC3968778  PMID: 22878659
patella dislocation; osteochondral lesions; articular cartilage
12.  Unusual Appearance of an Osteochondral Lesion Accompanying Medial Meniscus Injury 
Arthroscopy Techniques  2014;3(1):e111-e114.
An osteochondral lesion in the knee joint is caused by a focal traumatic osteochondral defect, osteochondritis dissecans, an isolated degenerative lesion, or diffuse degenerative disease. An osteochondral lesion with a cleft-like appearance accompanying medial meniscus injury is rare without trauma. We report the case of a 13-year-old boy who complained of right knee pain and swelling, with radiographic findings of an osteochondral defect. Arthroscopic inspection showed an osteochondral lesion in the medial condyle of the femur and tibial plateau accompanying a partial medial meniscus discoid tear. Partial meniscectomy was performed, and a microfracture procedure was carried out on the osteochondral defect. The patient was asymptomatic at 2 years' follow-up. This technique is a relatively easy, completely arthroscopic procedure that spares the bone and cartilage and has yielded a good clinical outcome in a skeletally immature patient who had an osteochondral lesion with a cleft-like appearance.
PMCID: PMC3986489  PMID: 24749028
13.  Establishing proof of concept: Platelet-rich plasma and bone marrow aspirate concentrate may improve cartilage repair following surgical treatment for osteochondral lesions of the talus 
World Journal of Orthopedics  2012;3(7):101-108.
Osteochondral lesions of the talus are common injuries in the athletic patient. They present a challenging clinical problem as cartilage has a poor potential for healing. Current surgical treatments consist of reparative (microfracture) or replacement (autologous osteochondral graft) strategies and demonstrate good clinical outcomes at the short and medium term follow-up. Radiological findings and second-look arthroscopy however, indicate possible poor cartilage repair with evidence of fibrous infill and fissuring of the regenerative tissue following microfracture. Longer-term follow-up echoes these findings as it demonstrates a decline in clinical outcome. The nature of the cartilage repair that occurs for an osteochondral graft to become integrated with the native surround tissue is also of concern. Studies have shown evidence of poor cartilage integration, with chondrocyte death at the periphery of the graft, possibly causing cyst formation due to synovial fluid ingress. Biological adjuncts, in the form of platelet-rich plasma (PRP) and bone marrow aspirate concentrate (BMAC), have been investigated with regard to their potential in improving cartilage repair in both in vitro and in vitro settings. The in vitro literature indicates that these biological adjuncts may increase chondrocyte proliferation as well as synthetic capability, while limiting the catabolic effects of an inflammatory joint environment. These findings have been extrapolated to in vitro animal models, with results showing that both PRP and BMAC improve cartilage repair. The basic science literature therefore establishes the proof of concept that biological adjuncts may improve cartilage repair when used in conjunction with reparative and replacement treatment strategies for osteochondral lesions of the talus.
PMCID: PMC3399015  PMID: 22816065
Osteochondral lesion; Cartilage repair; Platelet-rich plasma; Bone marrow aspirate concentrate
14.  Arthroscopic Delivery of Cancellous Tibial Autograft for Unstable Osteochondral Lesions in the Adolescent Knee 
Arthroscopy Techniques  2014;3(3):e339-e342.
The appropriate surgical technique for the treatment of unstable osteochondral lesions of the knee remains unclear and had been traditionally described with an open arthrotomy. Administration of bone grafting material in the knee may be performed for a variety of pathologic conditions, including unstable osteochondritis dissecans, traumatic osteochondral defects, or subchondral fracture nonunion, or for preparation of residual tunnels during revision anterior cruciate ligament reconstruction. Although various grafting materials have been described in the literature, cancellous autograft remains the gold standard for treatment safety and efficacy. We describe a successful technique for arthroscopic delivery of autogenous bone graft during fixation of unstable osteochondral lesions of the knee. When the indication for grafting is established, cancellous autograft is harvested from the proximal tibia, undergoes morcellation, and is soaked in bone marrow aspirate obtained through the harvest window. The bone graft is then packed into a modified tuberculin syringe. After arthroscopic preparation of the unstable osteochondral fragment and the respective donor surface, the tuberculin syringe is placed through a standard arthroscopy portal and the bone graft is introduced into the defect under direct visualization, followed by an appropriate osteochondral fixation technique.
PMCID: PMC4130127  PMID: 25126499
15.  Refixation of Osteochondral Fractures by an Ultrasound-Activated Pin System – An Ovine In Vivo Examination Using CT and Scanning Electron Microscope 
Osteochondral injuries, if not treated appropriately, often lead to severe osteoarthritis of the affected joint. Without refixation of the osteochondral fragment, human cartilage only repairs these defects imperfectly. All existing refixation systems for chondral defects have disadvantages, for instance bad MRI quality in the postoperative follow-up or low anchoring forces. To address the problem of reduced stability in resorbable implants, ultrasound-activated pins were developed. By ultrasound-activated melting of the tip of these implants a higher anchoring is assumed. Aim of the study was to investigate, if ultrasound-activated pins can provide a secure refixation of osteochondral fractures comparing to conventional screw and conventional, resorbable pin osteosynthesis. CT scans and scanning electron microscopy should proovegood refixation results with no further tissue damage by the melting of the ultrasound-activated pins in comparison to conventional osteosynthesis.
Femoral osteochondral fragments in sheep were refixated with ultrasound-activated pins (SonicPin™), Ethipins® and screws (Asnis™). The quality of the refixated fragments was examined after three month of full weight bearing by CT scans and scanning electron microscopy of the cartilage surface.
The CT examination found almost no statistically significant difference in the quality of refixation between the three different implants used. Concerning the CT morphology, ultrasound-activated pins demonstrated at least the same quality in refixation of osteochondral fragments as conventional resorbable pins or screws. The scanning electron microscopy showed no major surface damage by the three implants, especially any postulated cartilage damage induced by the heat of the ultrasound-activated pin. The screws protruded above the cartilage surface, which may affect the opposingtibial surface.
Using CT scans and scanning electron microscopy, the SonicPin™, the Ethipin® and screws were at least equivalent in refixation quality of osteochondral fragments.
PMCID: PMC4321208
Bioresorbable implant; CT; osteochondral fracture; scanning electron microscope; sheep study; ultrasound-activated pin.
16.  Juvenile Osteochondritis Dissecans in a 13-year-old male athlete: A case report 
To present the clinical management of juvenile osteochondritis dissecans (OCD) of the knee and highlight the importance of a timely diagnosis to optimize the time needed for less invasive, non-operative therapy.
Clinical Features:
A 13-year-old provincial level male soccer player presenting with recurrent anterior knee pain despite ongoing manual therapy.
Intervention and Outcome:
A multidisciplinary, non-operative treatment approach was utilized to promote natural healing of the osteochondral lesion. The plan of management consisted of patient education, activity modification, manual therapy, passive modalities and rehabilitation, while being overseen by an orthopaedic surgeon.
Considering the serious consequences of misdiagnosing osteochondritis dissecans, such as the potential for future joint instability and accelerated joint degeneration, a high degree of suspicion should be considered with young individuals presenting with nonspecific, recurrent knee pain. A narrative review of the literature is provided to allow practitioners to apply current best practices to appropriately manage juvenile OCD and become more cognizant of the common knee differential diagnoses in the young athletic population.
PMCID: PMC4262807  PMID: 25550663
case report; osteochondritis dissecans; knee injuries; non-specific knee pain; osteochondral lesions; medial femoral condyle; ROCK; observation; ostéochondrite disséquante; blessures du genou; douleurs non spécifiques du genou; lésions ostéochondrales; condyle fémoral médial; ROCK; chiropratique
17.  Epidemiology of United States High School Sports-Related Fractures, 2008-09 to 2010-11 
The American journal of sports medicine  2012;40(9):10.1177/0363546512453304.
High school athletes sustain millions of injuries annually, many of which are fractures. Fractures can severely affect athletes physically, emotionally, and financially and should be targeted with focused prevention methods.
Patterns and primary mechanisms of fractures differ by sport and gender.
Study Design
Descriptive epidemiology study.
High school sports-related injury data were collected from academic years 2008-09 to 2010-11 for 18 sports and from 2009-10 to 2010-11 for 2 additional sports. We used linear regression to describe annual fracture rate trends and calculated fractures rates, rate ratios (RRs), and injury proportion ratios (IPRs).
From 2008-09 to 2010-11, certified athletic trainers reported a total of 21,251 injuries during 11,544,455 athlete exposures (AEs), of which 2103 (9.9%) were fractures, with an overall rate of 1.82 fractures per 10,000 AEs. Fracture rates were highest in football (4.37 per 10,000 AE), boys' ice hockey (3.08), and boys' lacrosse (2.59). Boys sustained 79.1% of all fractures, and the overall rates of fractures were greater in boys' sports than in girls' sports for competition (RR, 2.82; 95% CI, 2.45-3.24) and practice (RR, 2.43; 95% CI, 2.07-2.86). The most commonly fractured body sites were the hand/finger (32.1%), lower leg (10.1%), and wrist (9.5%). Overall, 17.2% of fractures required surgery, which was higher than for all other injuries combined (IPR, 3.14; 95% CI, 2.81-3.52). The most common mechanism of fracture involved contact with another player (45.5%). Using linear regression, we found the proportion of all injuries that were fractures was inversely correlated with the athlete's age (P = .02) but was not correlated with the athletes' age- and gender-adjusted body mass index.
Fractures are a significant problem for high school athletes. Targeted preventive interventions should be implemented to reduce the burdens these injuries cause the athletes.
PMCID: PMC3852886  PMID: 22837429
surveillance; injury; high school RIO; reinjury
18.  Subsequent Injury Patterns in Girls' High School Sports 
Journal of Athletic Training  2007;42(4):486-494.
Context: Girls' participation in high school sports has increased 79.5% since 1975–1976. The incidence of injury among boys in high school sports has been well documented, but information regarding the incidence, severity, and type of injury among girls in high school sports is limited.
Objective: To examine the effects of subsequent injuries among high school girls in 5 sports.
Design: Observational cohort.
Setting: Existing data from the 1995–1997 National Athletic Trainers' Association High School Injury Surveillance database.
Patients or Other Participants: Girl athletes (n = 25 187 player-seasons) participating in 5 varsity high school sports: basketball, field hockey, soccer, softball, and volleyball.
Main Outcome Measure(s): Injury status, body location, injury type, time lost from injury, and number of players at risk for injury as recorded by athletic trainers and submitted to the Sports Injury Monitoring System.
Results: Overall, 23.3% of the athletes had 2 or more injuries within a sport; basketball and soccer athletes were most vulnerable. Overall, the probability of an athlete sustaining 3 or more injuries was 38.6%, and the risk was highest for field hockey players (61.9%). The risk of subsequent injury at a new body location was almost 2 times higher than reinjury at the same body location (risk ratio = 1.7, 95% confidence interval = 1.6, 1.8) and was similar for all sports except volleyball. Only in softball was the proportion of reinjuries causing 8 or more days lost from participation greater than the proportion of new injuries causing similar time loss. Softball and volleyball had the highest proportion of reinjuries at the shoulder, especially rotator cuff strains. The proportion of knee reinjuries was significantly higher than new injuries for all sports except soccer. The proportion of anterior cruciate ligament injuries was significantly higher for volleyball players only. Overall, the proportion of reinjuries was significantly higher for stress fractures and musculoskeletal condition injuries.
Conclusions: Patterns of subsequent injury risk appear to vary among these 5 sports. Almost one quarter of the athletes incurred 2 or more injuries over a 3-year period, so the effects of subsequent injuries deserve more consideration.
PMCID: PMC2140074  PMID: 18176621
epidemiology; surveillance; sports injuries; reinjuries; female athletes
19.  Osteochondral Allograft of the Talus 
Osteochondral lesions of the talus are being recognized as an increasingly common injury. They are most commonly located postero-medially or antero-laterally, while centrally located lesions are uncommon. Large osteochondral lesions have significant biomechanical consequences and often require resurfacing with osteochondral autograft transfer, mosaicplasty, autologous chondrocyte implantation (or similar methods) or osteochondral allograft transplantation. Allograft procedures have become popular due to inherent advantages over other resurfacing techniques. Cartilage viability is one of the most important factors for successful clinical outcomes after transplantation of osteochondral allografts and is related to storage length and intra-operative factors. While there is abundant literature about osteochondral allograft transplantation in the knee, there are few papers about this procedure in the talus. Failure of non-operative management, initial debridement, curettage or microfractures are an indication for resurfacing. Patients should have a functional ankle motion, closed growth plates, absence of cartilage lesions on the tibial side. This paper reviews the published literature about osteochondral allograft transplantation of the talus focusing on indications, pre-operative planning, surgical approaches, postoperative management, results and complications of this procedure.
PMCID: PMC4127728  PMID: 25328456
20.  Radiologic Assessment of Patellofemoral Pain in the Athlete 
Sports Health  2011;3(2):195-210.
Although disorders of the patellofemoral joint are common in the athlete, their management can be challenging and require a thorough physical examination and radiologic evaluation, including advanced magnetic resonance imaging techniques.
Evidence Acquisition:
Relevant articles were searched under OVID and MEDLINE (1968 to 2010) using the keywords patellofemoral joint, patellofemoral pain or patella and radiography, imaging, or magnetic resonance imaging, and the referenced sources were reviewed for additional articles. The quality and validity of the studies were assessed on the basis of careful analysis of the materials and methods before their inclusion in this article.
Physical examination and imaging evaluation including standard radiographs are crucial in identifying evidence of malalignment or instability. Magnetic resonance imaging provides valuable information about concomitant soft tissue injuries to the medial stabilizers as well as injuries to the articular cartilage, including chondral shears and osteochondral fractures. Quantitative magnetic resonance imaging assessing the ultrastructure of cartilage has shown high correlation with histology and may be useful for timing surgery.
Evaluation of patellofemoral disorders is complex and requires a comprehensive assessment. Recent advancements in imaging have made possible a more precise evaluation of the individual anatomy of the patient, addressing issues of malalignment, instability, and underlying cartilage damage.
PMCID: PMC3445133  PMID: 23016009
Patellofemoral joint; patellofemoral pain; chondromalacia patella; Magnetic Resonance Imaging
21.  Case Report: Osteochondral Avulsion Fracture of the Posteromedial Bundle of the PCL in Knee Hyperflexion 
Injury of the PCL of the knee in adults usually results in rupture rather than avulsion fracture and avulsions usually occur at the tibial insertion.
Case Description
We report an avulsion of the PCL with a femoral origin in a 22-year-old man who was injured by hyperflexion of the knee and was treated with arthroscopy. There were two parts in the partial osteochondral avulsion fracture of the PCL posteromedial (PM) bundle. One part was fixed with polydioxanone suture through drill holes and the other was removed. The fracture healed after 3 months and the knee was stable. At 11 months postoperatively the patient had returned to full-time work without pain or restrictions. The Lysholm II knee score was 95 points. Physical examination showed a negative posterior drawer sign.
Literature Review
We identified four other reported cases of PCL femoral origin avulsion fractures in adults. The subjects were 20 to 25 years old in four of five reports, including our patient. Three of the five patients had involvement of only the lateral cortex of the medial femoral condyle whereas two other patients including our patient, had an osteochondral fracture. The mechanism of PCL avulsion seems to be similar to that of a PCL rupture.
Purposes and Clinical Relevance
The hyperflexion injury may result in injury of the PM bundle of the PCL. Our case and one other in the literature suggest such avulsions need not involve the entire PCL.
PMCID: PMC3492605  PMID: 23054525
22.  Transient Patellar Dislocation Resulting in Simultaneous Osteochondral Fractures of Patella and Lateral Femoral Condyle – A Case Report 
Transient Patellar dislocations are commonly associated with bony contusions or osteochondral fractures involving the medial facet of patella or lateral femoral condyle. Simultaneous osteochondral fractures are rare and have not been reported in the adult. The authors report a case of combined osteochondral fracture of patella and lateral femoral condyle following acute patellar dislocation in an adult, which was misdiagnosed as meniscal injury. Both the osteochondral fracture fragments were rigidly fixed with headless compression screws and repair of the medial retinaculum was done. At latest follow up after two years, patient had regained full range of motion with no further episodes of patellar dislocation. The rarity of this combination of injury along with difficulty in interpreting radiographs makes this case interesting.
PMCID: PMC4253196  PMID: 25478378
Lateral femoral condyle; Medial facet patella; Osteochondral fracture; Patellar dislocation
23.  Unilateral Hypoglossal Nerve Injury in a Collegiate Wrestler: A Case Report 
Journal of Athletic Training  2009;44(5):534-537.
To introduce the case of a collegiate wrestler who suffered a traumatic unilateral hypoglossal nerve injury. This case presents the opportunity to discuss the diagnosis and treatment of a 20-year-old man with an injury to his right hypoglossal nerve.
Injuries to the hypoglossal nerve (cranial nerve XII) are rare. Most reported cases are the result of malignancy, with traumatic causes less common. In this case, a collegiate wrestler struck his head on the wrestling mat during practice. No loss of consciousness occurred. The wrestler initially demonstrated signs and symptoms of a mild concussion, with dizziness and a headache. These concussion symptoms cleared quickly, but the athlete complained of difficulty swallowing (dysphagia) and demonstrated slurred speech (dysarthria). Also, his tongue deviated toward the right. No other neurologic deficits were observed.
Differential Diagnosis:
Occipital-cervical junction fracture, syringomyelia, malignancy, iatrogenic causes, cranial nerve injury.
After initial injury recognition, the athletic trainer placed the patient in a cervical collar and transported him to the emergency department. The patient received prednisone, and the emergency medicine physician ordered cervical spine plain radiographs, brain computed tomography, and brain and internal auditory canal magnetic resonance imaging. The physician consulted a neurologist, who managed the patient conservatively, with rest and no contact activity. The neurologist allowed the patient to participate in wrestling 7 months after injury.
To our knowledge, no other reports of unilateral hypoglossal nerve injury from relatively low-energy trauma (including athletics) exist.
Hypoglossal nerve injury should be considered in individuals with head injury who experience dysphagia and dysarthria. Athletes with head injuries require cranial nerve assessments.
PMCID: PMC2742465  PMID: 19771294
twelfth cranial nerve; tongue paralysis; dysarthria; dysphagia
A common in vitro model for studying acute mechanical damage in cartilage is to impact an isolated osteochondral or cartilage specimen with a metallic impactor. The mechanics of a cartilage-on-cartilage (COC) impact, as encountered in vivo, are likely different than those of a metal-on-cartilage (MOC) impact. The hypothesis of this study was that impacted in vitro COC and MOC specimens would differ in their impact behavior, mechanical properties, chondrocyte viability, cell metabolism, and histologic structural damage. Osteochondral specimens were impacted with either an osteochondral plug or a metallic cylinder at the same delivered impact energy per unit area, and processed after 14 days in culture. The COC impacts resulted in about half of the impact maximum stress and a quarter of the impact maximum stress rate of change, as compared to the MOC impacts. The impacted COC specimens had smaller changes in mechanical properties, smaller decreases in chondrocyte viability, higher total proteoglycan content, and less histologic structural damage, as compared to the impacted MOC specimens. If metal-on-cartilage impact conditions are to be used for modeling of articular injuries and post-traumatic osteoarthritis, the differences between COC and MOC impacts must be kept in mind.
PMCID: PMC3740544  PMID: 23335281
Articular cartilage; biochemical analysis; histology; impact testing; post-traumatic osteoarthritis
25.  Epidemiology of Basketball, Soccer, and Volleyball Injuries in Middle-School Female Athletes 
The Physician and sportsmedicine  2014;42(2):146-153.
An estimated 30 to 40 million school children participate in sports in the United States; 34% of middle-school participants become injured and seek medical treatment at an annual cost close to $2 billion. The purpose of the current study was to evaluate the injury incidence and rates in female athletes in the middle-school setting during the course of 3 seasons.
Female basketball, soccer, and volleyball players were recruited from a single county public school district in Kentucky consisting of 5 middle schools. A total of 268 female athletes (162 basketball, 26 soccer, and 80 volleyball) participated. Athletes were monitored for sports-related injury and number of athlete exposures (AEs) by an athletic trainer. Injury rates were calculated for specific types of injuries within each sport. Injury rates for games and practices were also calculated and compared for each sport.
A total of 134 injuries were recorded during the 3 sport seasons. The knee was the most commonly injured body part (99 injuries [73.9%]), of which patellofemoral dysfunction (31.3%), Osgood-Schlatter disease (10.4%), and Sinding-Larsen-Johansson/patella tendinosis (9%) had the greatest incidence. The ankle was the second most commonly injured body part, accounting for 16.4% of all injuries. The overall rates of injury by sport were as follows: soccer, 6.66 per 1000 AEs; volleyball, 3.68 per 1000 AEs; and basketball, 2.86 per 1000 AEs.
Female middle-school athletes displayed comparable injury patterns to those seen in their high-school counterparts. Future work is warranted to determine the potential for improved outcomes in female middle-school athletes with access to athletic training services.
Clinical Relevance
As the participation levels and number of injuries continue to rise, middle-school athletes demonstrate an increasing need for medical services provided by a certified athletic trainer.
PMCID: PMC4217285  PMID: 24875981
epidemiology; middle-school athletics; sports injuries; injury rates

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