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Purpose: The purpose of this study is to describe the postoperative psychological state of patients following osteochondral allograft (OCA) transplantation in the knee and to determine whether patient-perceived kinesiophobia is associated with the rate of return to sport (RTS)., Methods: A retrospective review of the electronic medical record at a single institution was conducted for all patients that underwent OCA transplantation from January 2010 to 2020. Patient-reported outcomes including the visual analog scale (VAS), knee injury and osteoarthritis outcome score (KOOS) and the Tampa scale of kinesiophobia-11 (TSK-11) were collected. Patients were surveyed regarding their postoperative RTS status., Results: A total of 38 patients (52.6% female) were included in our analysis. Overall, 24 patients (63.2%) returned to sport with 12 (50%) of these patients returning at a lower level of play. When comparing patients that return to sport to those that did not, patients that return had significantly superior KOOS pain (p = 0.019) and KOOS QOL (p = 0.011). Measures of kinesiophobia (TSK-11) were significantly higher among patients that did not return to sport (p = 0.014), while satisfaction (n.s.) and pain intensity (n.s.) were comparable between groups. Logistic regression models controlling for demographic factors, VAS pain scores and lesion size showed that for every one-point increase in TSK-11 kinesiophobia score, patients were 1.33 times more likely to return to sport at a lower level (p = 0.009). For every one-point increase in TSK-11 scores KOOS QOL decreased by 2.4 points (p < 0.001)., Conclusion: Fear of reinjury decreases the likelihood that patients will return to their preoperative level of sport after OCA transplantation. Patients that do not return to sport report significantly greater fear of reinjury and inferior clinical outcomes, despite similar levels of satisfaction and pain compared to those that return., Level of Evidence: Level III., (© 2024 European Society of Sports Traumatology, Knee Surgery and Arthroscopy.)

Purpose: To investigate the combinations of variables that comprise the biopsychosocial model domains to identify clinical profiles of risk and protection of second anterior cruciate ligament injury., Methods: One hundred and forty-five patients for return-to-sport testing after anterior cruciate ligament (ACL) reconstruction (ACLR) were contacted, and 97 were deemed eligible. All were evaluated between 6 and 24 months and followed up for 2 years. Participants answered the International Knee Documentation Committee (IKDC) and Anterior Cruciate Ligament-Return to Sport after Injury Scale (ACL-RSI), performed the postural stability assessment using the Biodex Balance System, and assessed muscle strength at 60° and 300°/s on the isokinetic dynamometer. Personal factors (age, gender, body mass index), body structures (graft type and concomitant injuries), and environmental factors (time between surgery and evaluation) were also collected. The participants were asked about the occurrence of a second ACL injury and return to sport after 2 years of follow-up. Classification and regression tree (CART) analysis was used to determine predictors of a second ACL injury. The receiver operating characteristic (ROC) curve was performed to verify the accuracy of the CART analysis, in addition to the sensitivity, specificity, and relative risk (RR) of the model., Results: Of the initial 97 participants, 88 (89.8%) responded to follow-up and 14 (15.9%) had a second ACL injury (11 graft ruptures and three contralateral ACL). CART analysis identified the following variables as predictors of second ACL injury: return to sport, hamstring strength symmetry at 300°/s, ACL-RSI score, hamstrings/quadriceps ratio at 60°/s, and body mass index (BMI). CART correctly identified 9 (64.3%) of the 14 participants who were reinjured and 71 (95.9%) of the 74 participants who were not. The total correct classification was 90.9%. The area under the ROC curve was 0.88 (95% CI 0.72-0.99; p < 0.001), and the model showed a sensitivity of 75% (95% CI 42.8-94.5), specificity of 93.4% (95% CI 85.3-97.8), and RR of 15.9 (95% CI 4.9-51.4; p < 0.0001)., Conclusion: The combination of hamstring strength symmetry, hamstring/quadriceps ratio (body functions); return to sport (activity and participation); psychological readiness; and BMI (personal factors) could identify three clinical risk profiles for a second ACL injury with good accuracy., Level of Evidence: IV., (© 2023. The Author(s) under exclusive licence to European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA).)

Purpose: The purpose of this study was to assess the post-operative return to sport and re-injury rates following surgical repair of acute, first-time, high-grade intramuscular hamstring tendon injuries in high level athletes., Methods: Patients were identified using the databases of two sports surgeons. Once patients were identified their clinical notes and imaging were reviewed to confirm that all patients had injuries to the intramuscular portion of the distal aspect of the proximal biceps femoris tendon. All imaging was reviewed by an experienced musculoskeletal radiologist to confirm diagnosis. Surgery for such injuries was indicated in high-level athletes presenting with acute hamstring injuries. All patients were operated on within 4 weeks. Outcomes included Tegner scores, return to sport, Lower Extremity Functional Score (LEFS), current hamstring symptoms and complications including re-injury., Results: Eleven injuries (10 patients) were included in the study. All patients were male and Australian Rules Football players. Six patients were professional athletes and 4 semi-professional athletes. Median age was 24.5 (range 21-29) and median follow-up period was 33.7 months (range; 16-65). 91% were British Athletic Muscle Injury Classification (BAMIC) 3c and 9% were BAMIC 4c. 91% were classed as MR2 and 9% as MR3 on the simplified four-grade injury classification. Athletes achieved return to play (RTP) at an average of 3.1 months (SD 1.0) post repair. All but one patient achieved a Tegner score equal to pre-injury levels. Maximum LEFS was achieved by all patients. Minor pain scores (all with VAS < 1/10) on sciatic and functional stretch were recorded in 36% and 27% of patients respectively, with subtle neural symptoms (9%) and subjective tightness (36%) also noted. There were no surgical complications in our patient cohort. No patients had a re-injury or re-operation., Conclusions: Surgical repair of high-grade intramuscular tendon injuries of the biceps femoris hamstring muscle in athletes resulted in high levels of return to pre-injury sporting levels and no re-injuries. The intra-muscular tendon should be scrutinized when assessing hamstring injuries in elite sport and offer surgery in high-grade cases., Level of Evidence: IV., (© 2023. The Author(s) under exclusive licence to European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA).)

Purpose: To investigate the clinical outcome, level of patient satisfaction, re-injury and re-operation rates of patients 7-10 years after augmented hip abductor tendon repair., Methods: Between October 2012 and May 2015, 146 patients were referred to the senior author with symptomatic hip abductor tendon tears, of which 110 (101 female, 92%) were included in the current study and underwent hip abductor tendon repair augmented with LARS. Patients had a mean age of 63.2 years (range 43-82), body mass index of 27.8 (range 20.0-40.2) and duration of symptoms of 3.6 years (range 6 months-18 years). Patient-reported outcome measures (PROMs) were evaluated pre-operatively and at 3, 6, 12 and 24 months, as well as 7-10 years post-operatively, including the Oxford Hip Score (OHS), 12-item Short Form Health Survey (SF-12), a Visual Analogue Pain Scale (VAS) evaluating the frequency (VAS-F) and severity (VAS-S) of hip pain, and patient satisfaction. Adverse events, surgical failures, revisions and subsequent treatments on the ipsilateral hip were reported., Results: A significant improvement (p < 0.05) was observed for all PROMs and, while a mean deterioration was observed for all PROMs from 24 months to final review (7-10 years), these were not significant (n.s.). In the 90 patients retained and assessed at final review, 93% were satisfied with their hip pain relief and 89% with their ability to participate in recreational activities. Overall, 9 (of 110, 8.2%) surgical failures were observed over the 7-10-year follow-up period., Conclusions: Good clinical scores, a high level of patient satisfaction and an acceptable re-injury rate were observed at 7-10 years after augmented hip abductor tendon repair, demonstrating satisfactory repair longevity., Level of Evidence: IV., (© 2023. The Author(s).)

Purpose: The purpose of this study was to evaluate whether generalized joint hypermobility (GJH) influences postoperative results, including return to sport, patientreported outcomes, functional performance (hop tests), muscular strength, and the occurrence of ACL re-injury, in patients 1 year after anterior cruciate ligament (ACL) reconstruction., Methods: Data was extracted from a regional rehabilitation-specific registry containing information on patients with ACL injury. Patients between the ages of 16-50 years previously undergoing ACL reconstruction with available 1 year follow-up data were eligible for inclusion. Generalized joint hypermobility was assessed using the Beighton score (BS). Patients were examined one year postoperatively in terms of return to sport, patient-reported outcome, hop tests, muscular strength and the occurrence of reinjury. For purpose of analysis, patients were allocated into two groups, depending on the existence of GJH. The KOOS subscale of sports and recreation was considered the primary outcome. Analyses were performed both dichotomously and by using adjusted logistic regression, to consider potential confounders., Results: A total of 356 patients (41% males) were included, of which 76 (24% male) were categorized as having GJH. Patients with GJH had an inferior limb symmetry index preoperatively in terms of knee extension (mean 81.6 [SD 16.4] vs. 91.4 [SD 15.9], p = 0.02) and flexion strength (mean 91.9 vs. 99.1, p = 0.047) compared to patients without GJH. There was no difference between the groups in terms of the primary outcome, nor in any of the other postoperative outcomes. Nine patients (11.8%) in the group with GJH suffered ACL re-injury, compared with 13 patients (4.6%) in the control group (n.s.)., Conclusion: One year after ACL reconstruction the existence of GJH did not affect postoperative patient satisfaction, strength or functional outcome. No conclusive statements can be made regarding the influence of GJH on the risk of ACL re-injury in this particular study., Level of Evidence: Level II., (© 2022. The Author(s).)

Purpose: The purpose of this qualitative study was to describe women's experiences with anterior cruciate ligament reconstruction (ACLR) and a subsequent ACL rupture, and to identify potential facilitators and barriers for coping with rehabilitation after the second injury., Methods: Eight women between 17 and 36 years (mean 26, SD 6.5) who had experienced ACLR, followed by another ACL rupture, participated in the study. Semi-structured interviews were conducted, and data were analyzed using qualitative content analysis., Results: One overarching theme, "Rehabilitation after a second ACL injury-A lifelong adaptive coping process", emerged from analyses. Undergoing a second rehabilitation is described as a process of adaptation, beginning with the first injury and still ongoing, more than 5 years later. Participants applied different coping strategies to adapt to these life-altering injuries, but the common denominator was of major life adjustments with no return to previous activity levels. Initially, after the reinjury, it was about coping with the catastrophe of the dreaded second injury. Over time, they accepted their "new" life and reset their recovery/rehabilitation goal not just as "return to sport" but rather as a "personal life goal"., Conclusion: Undergoing a second ACL injury is a long process that challenges the patient's coping skills. Given these results, rehabilitation programs need to be more person centred according to the patients-adjusted life goals., (© 2021. The Author(s).)

Purpose: The femoroacetabular impingement randomised controlled trial (FIRST) is a multi-center randomized controlled trial (RCT), comparing arthroscopic osteochondroplasty with arthroscopic lavage in adults aged 18-50 years diagnosed with non-arthritic femoroacetabular impingement (FAI) syndrome. The purpose of the present study is to report the prevalence, distribution and severity of adverse events during and within 24-month follow-up period., Methods: Of the 220 patients included, 6 were adjudicated as ineligible, for a total of 214 patients included in the final analysis. An independent Adjudication Committee evaluated operatively treated and non-operatively treated adverse events that were related to the hip. Adverse events were also reported directly by each participating clinical site. Continuous variables were reported as mean and standard deviation, categorical variables were reported as counts and percentages., Results: There were a total of 52 (24.2%, 52/214) adverse events in 46 (21.5%) patients (mean age 34.2 ± 7.9 years, 58.7% male) during the 24-month follow-up. There were 12.6% (27/214) operatively treated adverse events for: hip pain, re-injury of labrum and heterotopic ossification. There were 11.7% (25/214) non-operatively treated adverse events for predominantly: hip pain, hip tendinopathy and hip popping/snapping. Approximately, 87% of adverse events resolved within the 24-month follow-up time., Conclusion: Given the inherent challenges with conducting RCTs, the results of this adverse event study from the FIRST trial demonstrate that it is safe to perform an RCT addressing FAI syndrome., Level of Evidence: Level III.

Purpose: The purpose of this systematic review was to assess the surgical techniques, indications outcomes and complications for pediatric patients (≤ 19 years old) undergoing shoulder stabilization procedures for anterior shoulder instability., Methods: The electronic databases MEDLINE, EMBASE, CINAHL, and Web of Science were searched from data inception to March 14, 2019 for articles addressing surgery for pediatric patients with anterior shoulder instability. The Methodological Index for Non-randomized Studies (MINORS) tool was used to assess the quality of included studies., Results: Overall 24 studies, with a total of 688 patients (696 shoulders) and a mean age of 16.6 ± 2.5 years met inclusion criteria. Mean follow-up was 49 ± 26 months. The majority (59%) of studies only offered shoulder stabilization procedures to patients with more than one shoulder dislocation, however, three studies reported operating on pediatric patients after first time dislocations. Of the included patients 525 had arthroscopic Bankart repair (78%), 75 had open Bankart repair (11%), 34 had modified Bristow (5%), and 26 had Latarjet (4%) procedures. The overall complication rate was 26%. Patients undergoing arthroscopic Bankart repair experienced the highest recurrence rate of 24%. There were no significant differences in recurrent instability (n.s.) or loss of external rotation (n.s.) in pediatric patients treated with arthroscopic Bankart repair compared to open Latarjet. Patients had a 95% rate of return to sport at any level (i.e. preinjury level or any level of play) postoperatively (95%)., Conclusions: Pediatric patients are at high risk of recurrent instability after surgical stabilization. The majority of pediatric patients with anterior shoulder instability were treated with arthroscopic Bankart repair. Most studies recommend surgical stabilization only after more than one dislocation. However, given the high rates of recurrence with non-operative management, it may be reasonable to perform surgery at a first-time dislocation, particularly in those with other risk factors for recurrence. With the current evidence and limited sample sizes, it is difficult to directly compare the surgical interventions and their post-operative efficacy (i.e. re-dislocation rates or range of motion). There was an overall high rate of return to sport after surgical stabilization at final follow-up., Level of Evidence: IV.

Purpose: Achilles tendon rupture (ATR) is a common injury. The knowledge of seasonal factors´ impact is incomplete, but may provide means for preventive approaches for Achilles tendon related morbidity. The aim of this study was to investigate seasonal variations in ATR incidence in relation to injury mechanism, adverse events including risk of re-rupture, and patient-reported outcome in adults in Stockholm, Sweden., Methods: In total, 349 patients with unilateral acute Achilles tendon rupture, prospectively treated with standardized surgical techniques, were retrospectively assessed. Date of injury was assigned to one of the four internationally defined meteorological seasons in the northern hemisphere. Injury mechanism and the rate of adverse events; deep venous thrombosis, infection and re-rupture in relation to per-operative complications. Patient-reported outcome at 1 year was assessed with the validated Achilles tendon Total Rupture Score., Results: ATR incidence was significantly highest during winter and spring, and lowest during summer (p < 0.05). The most common sporting activities associated with ATR were badminton, floorball and soccer (> 50%). The rate of soccer-related ATR was highest during summer (p < 0.05). Patients sustaining an ATR during summer, compared to other seasons, exhibited more per-operative complications (p < 0.05), a significantly higher risk of re-rupture (p < 0.05) and a lower rate of good outcome (n.s.). The risk of other adverse events after ATR did not differ between the seasons., Conclusion: Winter and spring are the high risk seasons for sports-related ATR and the risk sports are badminton, soccer and floorball. The reason for the higher risk of re-rupture after ATR repair during summer should be further investigated., Level of Evidence: III.

Purpose: The purpose of this study was to evaluate whether tendoscopic peroneal retinaculum repair for patients with recurrent peroneal tendon dislocation (RPTD) is more useful than an open procedure., Methods: Twenty-five patients with RPTD were retrospectively reviewed. Twelve patients (13 ankles) with RPTD underwent the open procedure (Group A) between 2008 and 2014, and 13 patients (14 ankles) underwent the tendoscopic procedure (Group B) between 2014 and 2017. Evaluation parameters included clinical results [the Japanese Society for Surgery of the Foot (JSSF) ankle-hind foot scale], operation time, complications, return to sports, and recurrence., Results: Postoperative JSSF ankle/hindfoot scale scores were significantly better than the pre-surgical scores in both groups. The mean operation time was significantly longer in Group B than in Group A (75.7 ± 20.5 vs 38.4 ± 10.5 min). There was one recurrence in Group A, but none in Group B. Group A had no complications, and Group B had one wound infection. Group B, excluding the case of infection, could return to sports earlier than Group A, excluding the recurrent case (13.4 ± 1.5 vs 12.2 ± 0.6 weeks)., Conclusions: This tendoscopic procedure needs longer operation time and is more technically demanding, but it is a useful procedure, because it is less invasive and can accelerate return to sports., Level of Evidence: III.

Purpose: To determine outcomes of transphyseal ACL reconstruction using a living parental hamstring tendon allograft in a consecutive series of 100 children., Methods: One hundred consecutive juveniles undergoing ACL reconstruction with a living parental hamstring allograft were recruited prospectively and reviewed 2 years after ACL reconstruction with IKDC Knee Ligament Evaluation, and KT1000 instrumented laxity testing. Skeletally immature participants obtained annual radiographs until skeletal maturity, and long leg alignment radiographs at 2 years. Radiographic Posterior tibial slope was recorded., Results: Of 100 juveniles, the median age was 14 years (range 8-16) and 68% male. At surgery, 30 juveniles were graded Tanner 1 or 2, 21 were Tanner 3 and 49 were Tanner 4 or 5. There were no cases of iatrogenic physeal injury or leg length discrepancy on long leg radiographs at 2 years, despite a median increase in height of 8 cm. Twelve patients had an ACL graft rupture and 9 had a contralateral ACL injury. Of those without further ACL injury, 82% returned to competitive sports, IKDC ligament evaluation was normal in 52% and nearly normal in 48%. The median side to side difference on manual maximum testing with the KT1000 was 2 mm (range - 1 to 5). A radiographic PTS of 12° or more was observed in 49%., Conclusions: ACL reconstruction in the juvenile with living parental hamstring tendon allograft is a viable procedure associated with excellent clinical stability, patient-reported outcomes and return to sport over 2 years. Further ACL injury to the reconstructed and the contralateral knee remains a significant risk, with identical prevalence observed between the reconstructed and contralateral ACL between 12 and 24 months after surgery., Level of Evidence: III (Cohort Study).

Purpose: There is paucity in studies regarding double-bundle anterior cruciate ligament reconstruction (DB-ACLR) in teenagers. The purpose of this study is to investigate clinical outcome after DB-ACLR and analyze whether any differences exist between teenagers and young adults., Methods: A retrospective study was performed between 2009 and 2017. Teenagers were defined as patients between 15 and 19 years and young adults between 20 and 25 years old. Isolated anterior cruciate ligament (ACL) injuries with DB-ACLR with minimum two-year follow up were included. Pre and post-operative Lysholm score, Tegner activity scale, KT-2000 arthrometer, manual pivot-shift grade, were assessed with post-operative one-leg hop test, isokinetic knee extensor strength test at 60°/sec, International Knee Documentation Committee Score (IKDC score), and re-injury rate., Results: One-hundred and thirty-one patients, 75 patients in the teenage group (Group A) and 56 patients in the young adult group (Group B), were enrolled. Lysholm score was significantly lower in Group A (89.6 ± 21.1) compared to Group B (95.9 ± 4.6) (p = 0.04). Side to side difference in KT-2000 arthrometer (2.3 ± 2.2 mm vs 1.0 ± 2.3 mm, Group A vs Group B, respectively, p < 0.01) and ratio of post-operative positive pivot shift was significantly greater in Group A (30.7%) compared to Group B (7.1%) (p < 0.01). No significant difference was seen in re-injury rate (n.s.)., Conclusion: Teenage patients have a greater tendency for residual knee joint laxity after DB-ACLR. Although teenagers and patients in the early twenties are close in age, characteristic in knee joint laxity may be different and, therefore, may require attention upon surgery and post-operative follow-up., Level of Evidence: III.