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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.  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®
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.  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
5.  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
6.  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
7.  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
8.  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
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.  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
11.  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
12.  Surgical management of osteochondritis dissecans of the knee 
Osteochondritis dissecans of the knee primarily affects subchondral bone, with a secondary effect on the overlying articular cartilage. This process can lead to pain, effusions, and loose body formation. While stable juvenile lesions often respond well to nonoperative management, unstable juvenile lesions, as well as symptomatic adult lesions, often require operative intervention. Short-term goals focus on symptomatic relief, while long-term expectations include the hope of preventing early-onset arthritis. Surgical options include debridement, loose body removal, microfracture, arthroscopic reduction and internal fixation, subchondral drilling, osteochondral autograft or allograft transplantation, and autologous chondrocyte implantation. Newer single-stage cell-based procedures have also been developed, utilizing mesenchymal stem cells and matrix augmentation. Proper treatment requires evaluation of both lesional (size, depth, stability) and patient (age, athletic level) characteristics.
PMCID: PMC3702780  PMID: 23378147
Osteochondritis dissecans; Knee; Microfracture; Osteochondral autologous transplant; Drilling; Internal fixation; Allograft; Autologous chondrocyte implantation; Loose body; Surgical treatment; Cartilage
13.  Does Extracorporeal Shock Wave Therapy Enhance Healing of Osteochondritis Dissecans of the Rabbit Knee?: A Pilot Study 
Severe osteochondritis dissecans (OCD) in children and adolescents often necessitates surgical interventions (ie, drilling, excision, or débridement). Since extracorporeal shock wave therapy (ESWT) enhances healing of long-bone nonunion fractures, we speculated ESWT would reactivate the healing process in OCD lesions.
We asked whether ESWT would enhance articular cartilage quality, bone and cartilage density, and histopathology of osteochondral lesions compared to nontreated controls in an OCD rabbit model.
We harvested a 4-mm-diameter plug of the weightbearing osteochondral surface on the medial femoral condyle of each knee in 20 skeletally immature (8-week-old) female rabbits. We placed a piece of acellular collagen-glycosaminoglycan matrix into the cavity and then replaced the plug. Two weeks after surgery, we sedated each rabbit and treated the right knee in a single setting with shock waves: 4000 impulses at 4 Hz and 18 kV. The left knee was a sham control. Ten weeks after surgery, we assessed cartilage morphology of the lesion using a modified Outerbridge Grading System, bone and cartilage density using histologic imaging, bone and cartilage morphology using the histopathology assessment system, and radiographic bone density and union and compared these parameters between ESWT-treated and control knees.
Histologically, we observed more mature bone formation and better healing (1.1 versus 3.4) and density of the cartilage (60 versus 49) on the treated side. Radiographically, we noted an increase in bony density (154 versus 138) after ESWT.
ESWT accelerated the healing rate and improved cartilage and subchondral bone quality in the OCD rabbit model.
Clinical Relevance
This therapeutic modality may be applicable in OCD treatment in the pediatric population. Future research will be necessary to determine whether it may play a role in healing of human osteochondral defects.
PMCID: PMC3586044  PMID: 22669551
14.  A Prospective Study of Overuse Knee Injuries Among Female Athletes With Muscle Imbalances and Structural Abnormalities 
Journal of Athletic Training  2004;39(3):263-267.
To prospectively examine the influence of hamstring-to-quadriceps (H:Q) ratio and structural abnormalities on the prevalence of overuse knee injuries among female collegiate athletes.
Design and Setting:
We used chi-square 2 × 2 contingency tables and the Fischer exact test to examine associations among H:Q ratios, structural abnormalities, and overuse knee injuries.
Fifty-three apparently healthy women (age = 19.4 ± 1.3 years, height = 167.6 ± 10.1 cm, mass = 65.0 ± 10.0 kg) from National Collegiate Athletic Association Division I women's field hockey (n = 23), soccer (n = 20), and basketball teams (n = 10) volunteered.
The H:Q ratio was determined from a preseason isokinetic test on a Biodex system at 60°/s and 300°/s. We measured athletes for genu recurvatum and Q-angles with a 14-in (35.56-cm) goniometer. Iliotibial band flexibility was assessed via the Ober test.
Ten overuse knee injuries (iliotibial band friction syndromes = 5, patellar tendinitis = 3, patellofemoral syndrome = 1, pes anserine tendinitis = 1) occurred in 9 athletes. The H:Q ratio below the normal range at 300°/s (P = 0.047) was associated with overuse knee injuries, as was the presence of genu recurvatum (P = 0.004). In addition, athletes possessing lower H:Q ratios at 300°/s and genu recurvatum incurred more overuse knee injuries than athletes without these abnormalities (P = 0.001).
The presence of genu recurvatum and an H: Q ratio below normal range was associated with an increased prevalence of overuse knee injuries among female collegiate athletes. Further investigation is needed to clarify which preseason screening procedures may identify collegiate athletes who are susceptible to overuse knee injuries.
PMCID: PMC522150  PMID: 15496997
genu recurvatum; isokinetic testing; hamstring-to-quadriceps ratio
15.  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
16.  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
17.  Non-terminal animal model of post-traumatic osteoarthritis induced by acute joint injury 
Develop a non-terminal animal model of acute joint injury that demonstrates clinical and morphological evidence of early post-traumatic osteoarthritis (PTOA).
An osteochondral (OC) fragment was created arthroscopically in one metacarpophalangeal (MCP) joint of 11 horses and the contralateral joint was sham operated. Eleven additional horses served as unoperated controls. Every 2 weeks, force plate analysis, flexion response, joint circumference, and synovial effusion scores were recorded. At weeks 0 and 16, radiographs (all horses) and arthroscopic videos (OC injured and sham joints) were graded. At week 16, synovium and cartilage biopsies were taken arthroscopically from OC injured and sham joints for histologic evaluation and the OC fragment was removed.
Osteochondral fragments were successfully created and horses were free of clinical lameness after fragment removal. Forelimb gait asymmetry was observed at week 2 (P=0.0012), while joint circumference (P<0.0001) and effusion scores (P<0.0001) were increased in injured limbs compared to baseline from weeks 2 to 16. Positive flexion response of injured limbs was noted at multiple time points. Capsular enthesophytes were seen radiographically in injured limbs. Articular cartilage damage was demonstrated arthroscopically as mild wear-lines and histologically as superficial zone chondrocyte death accompanied by mild proliferation. Synovial hyperemia and fibrosis were present at the site of OC injury.
Acute OC injury to the MCP joint resulted in clinical, imaging, and histologic changes in cartilage and synovium characteristic of early PTOA. This model will be useful for defining biomarkers of early osteoarthritis and for monitoring response to therapy and surgery.
PMCID: PMC3624059  PMID: 23467035
osteoarthritis; PTOA; animal model; cartilage; trauma; equine
18.  Talocrural Dislocation With Associated Weber Type C Fibular Fracture in a Collegiate Football Player: A Case Report 
Journal of Athletic Training  2008;43(3):319-325.
To present the case of a talocrural dislocation with a Weber type C fibular fracture in a National Collegiate Athletic Association Division I football athlete.
The athlete, while attempting to make a tackle during a game, collided with an opponent, who in turn stepped on the lateral aspect of the athlete's ankle, resulting in forced ankle eversion and external rotation. On-field evaluation showed a laterally displaced talocrural dislocation. Immediate reduction was performed in the athletic training room to maintain skin integrity. Post-reduction radiographs revealed a Weber type C fibular fracture and increased medial joint clear space. A below-knee, fiberglass splint was applied to stabilize the ankle joint complex.
Differential Diagnosis:
Subtalar dislocation, Maisonneuve fracture, malleolar fracture, deltoid ligament rupture, syndesmosis disruption.
The sports medicine staff immediately splinted and transported the athlete to the athletic training room to reduce the dislocation. The athlete then underwent an open reduction and internal fixation procedure to stabilize the injury: 2 syndesmosis screws and a fibular plate were placed to keep the ankle joint in an anatomically reduced position. With the guidance of the athletic training staff, the athlete underwent an accelerated physical rehabilitation protocol in an effort to return to sport as quickly and safely as possible.
Most talocrural dislocations and associated Weber type C fibular fractures are due to motor vehicle accidents or falls. We are the first to describe this injury in a Division I football player and to present a general rehabilitation protocol for a high-level athlete.
Sports medicine practitioners must recognize that this injury can occur in the athletic environment. Prompt reduction, early surgical intervention, sufficient resources, and an accelerated rehabilitation protocol all contributed to a successful outcome in the patient.
PMCID: PMC2386426  PMID: 18523569
ankle dislocations; fibular fractures; syndesmosis injuries; athletic injuries
19.  Fracture of the First Cervical Vertebra in a High School Football Player: A Case Report 
Journal of Athletic Training  1997;32(2):159-162.
To present the case of a high school football player with a burst fracture of the ring of C1 resulting from a “spearing” tackle.
Cervical spine fractures are rare in collision sports, but their potentially grave consequences mean that they must be given special attention. Spearing was banned by the National Collegiate Athletic Association and the National Federation of High School Athletic Associations in 1976, and the number of cervical spine fractures in high school and college football players has fallen dramatically. However, cervical spine fractures do still occur, and they present a diagnostic challenge to sports medicine professionals.
Differential Diagnosis:
Cervical sprain.
Treatment consists of halo-vest immobilization. Surgical fusion may be necessary for unstable C1-C2 fractures, although initial halo-vest treatment is usually attempted.
A 17-year-old defensive back attempted to make a tackle with his head lowered. He was struck on the superolateral aspect of the helmet by the opposing running back. He remained in the game for another play, but then left the field under his own power, complaining of neck stiffness and headache. Physical examination revealed upper trapezius and occiput tenderness, bilateral cervical muscle spasm, and pain at all extremes of voluntary cervical movement. He was alert and oriented, with a normal neurologic examination. Treatment with ice was attempted but was discontinued due to increased pain and stiffness. Heat resulted in decreased pain and stiffness, but his symptoms persisted, and he was trans- ported to the emergency room. Plain radiographs were read as negative, but a CT scan demonstrated a burst fracture of Cl. He was treated with halo-vest immobilization for 8 weeks and a rigid cervical collar for 8 additional weeks. Physical therapy was then initiated, and normal cervical range of motion and strength were restored within 6 weeks. The athlete competed in track 6 months after the injury and continues to play recreational sports without difficulty. At clinical follow-up 8 months after injury, he had full, painless cervical range of motion and a normal neurologic examination.
A potentially devastating cervical spine injury can present insidiously, without dramatic signs or symptoms. Therefore, sports medicine professionals must retain a high index of suspicion when evaluating athletes with cervical spine complaints.
PMCID: PMC1319821  PMID: 16558448
Jefferson fracture; C1; atlas; athletic injury
20.  Sex Differences and the Incidence of Concussions Among Collegiate Athletes 
Journal of Athletic Training  2003;38(3):238-244.
To compare sex differences regarding the incidence of concussions among collegiate athletes during the 1997–1998, 1998–1999, and 1999–2000 seasons.
Design and Setting:
A cohort study of collegiate athletes using the National Collegiate Athletic Association (NCAA) Injury Surveillance System; certified athletic trainers recorded data during the 1997–2000 academic years.
Collegiate athletes participating in men's and women's soccer, lacrosse, basketball, softball, baseball, and gymnastics.
Certified athletic trainers from participating NCAA institutions recorded weekly injury and athlete-exposure data from the first day of preseason practice to the final postseason game. Injury rates and incidence density ratios were computed. Incidence density ratio is an estimate of the relative risk based on injury rates per 1000 athlete-exposures.
Of 14 591 reported injuries, 5.9% were classified as concussions. During the 3-year study, female athletes sustained 167 (3.6%) concussions during practices and 304 (9.5%) concussions during games, compared with male athletes, who sustained 148 (5.2%) concussions during practices and 254 (6.4%) concussions during games. Chi-square analysis revealed significant differences between male and female soccer players (χ21 = 12.99, P = .05) and basketball players (χ21 = 5.14, P = .05).
Female athletes sustained a higher percentage of concussions during games than male athletes. Of all the sports, women's soccer and men's lacrosse were found to have the highest injury rate of concussions. Incidence density ratio was greatest for male and female soccer players.
PMCID: PMC233178  PMID: 14608434
mild traumatic brain injury; concussion rates; athletic injury
21.  Traumatic Acetabular Fracture in an Intercollegiate Football Player: A Case Report 
Journal of Athletic Training  2000;35(1):103-107.
To present the case of a 22-year-old football player who sustained an acute posterior-wall acetabular fracture.
Acetabular fractures can be a difficult injury for the athletic trainer to assess. Aside from the obvious immediate ramifications, proper assessment and care are necessary to decrease the chance of developing posttraumatic arthritis and other long-term complications.
Differential Diagnosis:
Anterior column fracture, T-shaped acetabular fracture, segmental fracture of the femoral head, femoral neck fracture, capsular tear, retroperitoneal hematoma, posterior column acetabular fracture.
The athlete was treated with open reduction internal fixation using 5 screws and a plate. He pursued a rehabilitation program and returned to full activity 9 months later.
Acetabular fractures are usually associated with motor vehicle accidents. However, this athlete sustained an injury mechanism that rarely occurs in athletes.
Certified athletic trainers need to recognize the signs and symptoms associated with acetabular fractures. Initial recognition and appropriate management and treatment are essential to avoid long-term complications.
PMCID: PMC1323449  PMID: 16558600
posterior wall segment; antalgic gait; avascular necrosis; open reduction; internal fixation
22.  Bone scintigraphy after osteochondral autograft transplantation in the knee 
Acta Orthopaedica  2010;81(2):206-210.
Background and purpose Autologous osteochondral transplantation (OCT) is an established method of treating articular cartilage defects in the knee. However, the potential for donor site morbidity remains a concern. Both the restoration of the original cartilage defect and the evolution of the donor site defects can be evaluated by bone scintigraphy. Thus, we performed a prospective bone scintigraphic evaluation in patients who were treated with OCT.
Patients and methods In 13 patients with a symptomatic articular cartilage defect, bone scintigraphies were obtained preoperatively, 1 year after osteochondral transplantation, and finally at an average follow-up of 4 (2.5–5.5) years. The evolution of scintigraphic activity was evaluated for both the recipient and the donor site. Parallel, clinical scoring was performed using the Lysholm knee scoring scale, the Cincinnati knee rating system, and the Tegner activity score.
Results The bone scintigraphic uptake was elevated at the involved femoral condyle preoperatively, and gradually decreased to normal levels in 7 of 11 cases. The originally normal uptake at the trochlea increased 1 year after transplantation. Then, a gradual decrease in uptake occurred again at this donor site to remain elevated at the final scintigraphy. A correlation was found between elevated scintigraphic activity and the presence of retropatellar crepitus. The mean Lysholm and Cincinnati scores had increased 1 year after transplantation. The mean Tegner score had increased 3 years after transplantation.
Interpretation Elevated bone scintigraphic activity from an osteochondral lesion in the knee can be restored with OCT. However, increased scintigraphic activity is introduced at the donor site, which becomes reduced with longer follow-up. The use of fairly large osteochondral plugs appears to correlate with retropatellar crepitus and increased scintigraphic activity, and is not therefore recommended.
PMCID: PMC2852158  PMID: 21301491
23.  A cadaveric analysis of contact stress restoration after osteochondral transplantation of a cylindrical cartilage defect 
Osteochondral transplantation is a successful treatment for full-thickness cartilage defects, which without treatment would lead to early osteoarthritis. Restoration of surface congruency and stability of the reconstruction may be jeopardized by early mobilization. To investigate the biomechanical effectiveness of osteochondral transplantation, we performed a standardized osteochondral transplantation in eight intact human cadaver knees, using three cylindrical plugs on a full-thickness cartilage defect, bottomed on one condyle, unbottomed on the contralateral condyle. Surface pressure measurements with Tekscan pressure transducers were performed after five conditions. In the presence of a defect the border contact pressure of the articular cartilage defect significantly increased to 192% as compared to the initially intact joint surface. This was partially restored with osteochondral transplantation (mosaicplasty), as the rim stress subsequently decreased to 135% of the preoperative value. Following weight bearing motion two out of eight unbottomed mosaicplasties showed subsidence of the plugs according to Tekscan measurements. This study demonstrates that a three-plug mosaicplasty is effective in restoring the increased border contact pressure of a cartilage defect, which may postpone the development of early osteoarthritis. Unbottomed mosaicplasties may be more susceptible for subsidence below flush level after (unintended) weight bearing motion.
PMCID: PMC2358931  PMID: 18292989
Biomechanics; Cartilage; Articular/pathology; Humans; Knee Joint/Surgery; Pressure; Surface Properties; Transplantation; Autologous; Weight-bearing
24.  Imaging biopsy composition at ACL reconstruction 
Early-stage osteoarthritis (OA) includes glycosaminoglycan (GAG) loss and collagen disruption that cannot be seen on morphological magnetic resonance imaging (MRI). T1ρ MRI is a measurement that probes the low-frequency rate of exchange between protons of free water and those from water associated with macromolecules in the cartilage’s extracellular matrix. While it has been hypothesized that increased water mobility resulting from early osteoarthritic changes cause elevated T1ρ MRI values, there remain several unknown mechanisms influencing T1ρ measurements in cartilage. The purpose of this work was to relate histological and biochemical metrics directly measured from osteochondral biopsies and fluid specimens with quantitative MRI-detected changes of in vivo cartilage composition.
Patients and methods
Six young patients were enrolled an average of 41 days after acute anterior cruciate ligament (ACL) rupture. Femoral trochlear groove osteochondral biopsies, serum, and synovial fluid were harvested during ACL reconstruction to complement a presurgery quantitative MRI study (T1ρ, T2, delayed gadolinium-enhanced MRI of cartilage [dGEMRIC] relaxation times). A high-resolution MRI scan of the excised osteochondral biopsy was also collected. Analyses of in vivo T1ρ images were compared with ex vivo T1ρ imaging, GAG assays and histological GAG distribution in the osteochondral biopsies, and direct measures of bone and cartilage turnover markers and “OA marker” 3B3 in serum and synovial fluid samples.
T1ρ relaxation times in patients with a torn ACL were elevated from normal, indicating changes consistent with general fluid effusion after blunt joint trauma. Increased chondrogenic progenitor cell (CPC) production of chondroprotective lubricin may relate to cartilage surface disruption by blunt trauma and CPC amplification of joint inflammation. Disparity between ex vivo and matched in vivo MRI of trochlear cartilage suggests MRI signal differences that may be related to the synovial fluid environment. T1ρ is emerging as a promising MRI biomarker to relate noninvasive measures of whole-joint condition and cartilage composition to direct measures of cartilage changes in the acute phase of joint injuries.
PMCID: PMC4028072  PMID: 24855396
proteoglycan; osteochondral biopsy; T1ρ; biomarker
25.  Hip Arthroscopy Update 
HSS Journal  2005;1(1):40-48.
The management of hip injuries in the athlete has evolved significantly in the past few years with theadvancement of arthroscopic techniques. The application of minimally invasive surgical techniques has facilitated relatively rapid returns to sporting activity in recreational and elite athletes alike. Recent advancements in both hip arthroscopy and magnetic resonance imaging have elucidated several sources of intraarticular pathology that result in chronic and disabling hip symptoms. Many of these conditions were previously unrecognized and thus, left untreated. Current indications for hip arthroscopy include management of labral tears, osteoplasty for femoroacetabular impingement, thermal capsulorrhaphy and capsular plication for subtle rotational instability and capsular laxity, lateral impact injury and chondral lesions, osteochondritis dissecans, ligamentum teres injuries, internal and external snapping hip, removal of loose bodies, synovial biopsy, subtotal synovectomy, synovial chondromatosis, infection, and certain cases of mild to moderate osteoarthritis with associated mechanical symptoms. In addition, patients with long-standing, unresolved hip joint pain and positive physical findings may benefit from arthroscopic evaluation. Patients with reproducible symptoms and physical findings that reveal limited functioning, and who have failed an adequate trial of conservative treatment will have the greatest likelihood of success after surgical intervention. Strict attention to thorough diagnostic examination, detailed imaging, and adherence to safe and reproducible surgical techniques, as described in this review, are essential for the success of this procedure.
PMCID: PMC2504137  PMID: 18751808

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