Aims. The aim of this study was to investigate the long-term clinical and radiological outcome of patients who suffer recurrent injuries to the anterior cruciate ligament (ACL) after reconstruction and require revision surgery. Patients and Methods. From a consecutive series of 200 patients who underwent primary reconstruction following rupture of the ACL, we identified 36 who sustained a further rupture, 29 of whom underwent revision surgery. Patients were reviewed prospectively at one, two, seven, 15 and about 20 years after their original surgery. Primary outcome measures were the number of further ruptures, the posterior tibial slope (PTS), and functional and radiological outcomes. These were compared with a gender and age matched cohort of patients who underwent primary ACL reconstruction only. Results. At a mean follow-up of 18.3 years (14.3 to 20.2), 29 patients had undergone revision surgery and within this revision group 11 had sustained more than three ruptures of the ACL (3 to 6). The mean age at the time of revision reconstruction was 26.4 years (14 to 54). The mean PTS was significantly higher in those patients who suffered a further injury to the ACL (11°) compared with the control group (9°) (p < 0.001). The mean PTS in those patients who sustained more than three ruptures was 12°. Conclusion. Patients who suffer recurrent injuries to the ACL after reconstruction have poorer functional and radiological outcomes than those who suffer a single injury. The causes of further injury are likely to be multifactorial but an increased PTS appears to have a significant association with recurrent ACL injuries. Cite this article: Bone Joint J 2017;99-B:337–43

Injuries to the hamstring muscle complex are common in athletes, accounting for between 12% and 26% of all injuries sustained during sporting activities. Acute hamstring injuries often occur during sports that involve repetitive kicking or high-speed sprinting, such as American football, soccer, rugby, and athletics. They are also common in watersports, including waterskiing and surfing. Hamstring injuries can be career-threatening in elite athletes and are associated with an estimated risk of recurrence in between 14% and 63% of patients. The variability in prognosis and treatment of the different injury patterns highlights the importance of prompt diagnosis with magnetic resonance imaging (MRI) in order to classify injuries accurately and plan the appropriate management. Low-grade hamstring injuries may be treated with nonoperative measures including pain relief, eccentric lengthening exercises, and a graduated return to sport-specific activities. Nonoperative management is associated with highly variable times for convalescence and return to a pre-injury level of sporting function. Nonoperative management of high-grade hamstring injuries is associated with poor return to baseline function, residual muscle weakness and a high-risk of recurrence. Proximal hamstring avulsion injuries, high-grade musculotendinous tears, and chronic injuries with persistent weakness or functional compromise require surgical repair to enable return to a pre-injury level of sporting function and minimize the risk of recurrent injury. This article reviews the optimal diagnostic imaging methods and common classification systems used to guide the treatment of hamstring injuries. In addition, the indications and outcomes for both nonoperative and operative treatment are analyzed to provide an evidence-based management framework for these patients. Cite this article: Bone Joint J 2020;102-B(10):1281–1288

Anterior cruciate ligament (ACL) graft failure from rupture, attenuation, or malposition may cause recurrent subjective instability and objective laxity, and occurs in 3% to 22% of ACL reconstruction (ACLr) procedures. Revision ACLr is often indicated to restore knee stability, improve knee function, and facilitate return to cutting and pivoting activities. Prior to reconstruction, a thorough clinical and diagnostic evaluation is required to identify factors that may have predisposed an individual to recurrent ACL injury, appreciate concurrent intra-articular pathology, and select the optimal graft for revision reconstruction. Single-stage revision can be successful, although a staged approach may be used when optimal tunnel placement is not possible due to the position and/or widening of previous tunnels. Revision ACLr often involves concomitant procedures such as meniscal/chondral treatment, lateral extra-articular augmentation, and/or osteotomy. Although revision ACLr reliably restores knee stability and function, clinical outcomes and reoperation rates are worse than for primary ACLr.

Cite this article: Bone Joint J 2023;105-B(5):474–480.

The April 2024 Wrist & Hand Roundup³⁶⁰ looks at: Lunocapitate versus four-corner fusion in scapholunate or scaphoid nonunion advanced collapse: a randomized controlled trial; Postoperative scaphoid alignment, smoking, and avascular necrosis determine outcomes; Grip strength signals broader health concerns in females with distal radius fractures; Clearing the smoke: how smoking status influences recovery from open carpal tunnel release surgery; Age matters: assessing the likelihood of corrective surgery after distal radius fractures; Is pronator quadratus muscle repair required after anterior plate fixation for distal radius fractures?; Efficacy of total wrist arthroplasty: a comparative analysis of inflammatory and non-inflammatory arthritis outcomes; A comprehensive review of the one-bone forearm as a salvage technique.

Injuries to the quadriceps muscle group are common in athletes performing high-speed running and kicking sports. The complex anatomy of the rectus femoris puts it at greatest risk of injury. There is variability in prognosis in the literature, with reinjury rates as high as 67% in the severe graded proximal tear. Studies have highlighted that athletes can reinjure after nonoperative management, and some benefit may be derived from surgical repair to restore function and return to sport (RTS). This injury is potentially career-threatening in the elite-level athlete, and we aim to highlight the key recent literature on interventions to restore strength and function to allow early RTS while reducing the risk of injury recurrence. This article reviews the optimal diagnostic strategies and classification of quadriceps injuries. We highlight the unique anatomy of each injury on MRI and the outcomes of both nonoperative and operative treatment, providing an evidence-based management framework for athletes.

Cite this article: Bone Joint J 2023;105-B(12):1244–1251.

Purpose of study:. The question of prolonged bracing following injury in patients diagnosed with SCIWORA remains controversial. Proponents of the ‘Segmental Spinal Instability’ hypothesis claim that there is occult ligamentous injury leading to instability and a risk of recurrent injury. Published reports of recurrent SCIWORA involve patients with minor, transient neurological symptoms and normal MRI findings. The contradicting ‘differential stretch hypothesis’ is based on the premise that the spinal column will deform elastically, exceeding the elastic deforming potential of the more fragile spinal cord, but will return to its baseline stability. The purpose of this study is to evaluate the need for bracing in patients with SCIWORA based on MRI evidence of instability. Methods:. A retrospective chart review was performed for a series of eleven patients with documented SCIWORA that presented to Red Cross Children's Hospital over the past 8 years. Details regarding mode of injury, age at presentation, neurological deficit at presentation, MRI findings and long term prognosis were documented. MRI's were reviewed by the authors as well as a consultant radiologist. Results:. There were 9 males and 2 females. The average age was 4.5 years. All patients were victims of motor vehicle accidents and had multiple injuries. Five patients had cervical, five thoracic and one had both cervical and thoracic injuries. There were 1 monoplegia, 4 hemiplegias, 3 paraplegias and 3 triplegias. None of the MRIs performed on these patients demonstrated ligamentous or bony injury. Patients with only T2 changes demonstrated progressive neurological recovery within a few months following injury. There were no recurrences and none of the patients were braced following the diagnosis of SCIWORA. Conclusion:. Our results from this small series support the ‘differential stretch hypothesis’ and we maintain that patient's with SCIWORA does not demonstrate spinal instability and therefore does not require bracing following injury

National Hunt jockeys suffer a disproportionate number of clavicular fractures and their return to riding may be considerably delayed by refracture and symptomatic nonunion, with obvious implications. We report six such cases in which excision of the clavicular fragment distal to the fracture was associated with an early return to work and no recurrent injury to the shoulder

Background: Foot injuries represent a small but important proportion of injuries to professional rugby union players. There are no detailed epidemiological studies regarding these injuries. Purpose: The aim of this study was to describe the epidemiology of foot injuries sustained by a cohort of professional rugby union players and identify areas that may be targeted for injury prevention in the future. Study design: Descriptive epidemiological study. Methods: Medical personnel prospectively recorded injuries in professional, premiership rugby union players in England over 4 seasons. Injuries to the foot were identified and the time away from training and playing was reported. Results: A total of 147-foot injuries were sustained resulting in 3,542 days of absence in total. Acute events accounted for 73% of all foot injuries, with chronic, mostly overuse conditions, accounting for 25% (undiagnosed 2%). Chronic conditions led to proportionately more time away from training and playing (p< 0.001). Specifically, stress fractures in the foot accounted for 8% of the total foot injuries but 22% of the absence. Navicular stress fractures had the longest recovery time with the mean return to training and match play of 188 days. Conclusions: In collision sports, such as rugby, injury is inevitable, but clinicians should always be seeking ways to minimise their occurrence and impact. This study revealed significant morbidity associated with chronic and overuse foot injuries in these professional athletes. With greater attention paid to risk factors, some of these injuries, and importantly, recurrent injuries may be avoided

Introduction. Knee injuries are common amongst footballers. The aim of this study was to establish frequency and variation of knee injuries within one English Premier League (EPL) professional football club over two seasons, to assess number of days missed due to injury, and analyse current treatment regimen for each injury type. Method. Data was collected prospectively for injuries suffered by players between 2009 and 2011, spanning two EPL seasons at one EPL club. Demographics were recorded along with various factors influencing injury, including playing surface, pitch condition, dominant side, type of injury, ability to continue playing, and mechanism of injury. Time taken for return to play, and treatment received was recorded. Results. 35 injuries occurred that were severe enough to cause players to miss at least one competitive match. The commonest injury was to the medial collateral ligament (MCL) in 34%. Patella tendon injuries were seen in 29%, other injuries included meniscus tears, ACL ruptures, and osteochondral defects. All grade II MCL Injuries received sclerosant injections. 40% of patella tendon injuries were given plasma-rich protein (PRP) injections, and 30% underwent surgery. The mean recovery time following MCL and patella tendon injuries was 44 days and 77 days respectively. 60% of injuries were sustained during training and 40% were suffered in competitive games. 26% were recurring injuries, recurrent meniscus and patella tendon injuries took twice as long to recover compared to the initial injury. Conclusion. Our findings suggest that MCL and patella tendon injuries are the most common knee injuries amongst professional footballers and that meniscus tears and ligament ruptures are relatively rare in comparison. Injuries appear to occur more frequently during training. A high proportion of injuries in the study received injection therapy in the form of PRP or sclerosant. The study suggests recurrent injuries can prolong recovery two-fold

Background. Boxer's fractures are the most common type of metacarpal fracture. It commonly occurs during fistfights or from punching a wall. Greer et al demonstrated that it is usually an intentional injury and these patients were at increased risk for recurrent injury (2). Further work suggested that patients with such injuries had higher features of antisocial, self- harm and impulsive behavior, compared with control groups (3). There is little that has been reported on children and adolescents who present with such fractures. This study aims to assess aggression scores in young patients with metacarpal fractures due to punching using a validated questionnaire. Methodology. Following ethical permission, 11–18 year olds, with a boxers fracture and willing to complete an anonymous questionnaire were included. If they were under 16, parental permission was sought. The Buss and Warren validated questionnaire included subscales of physical aggression and anger scales as well as overall aggression scoring. Results. 48 patients who had metacarpal fractures due to punching have completed the study to date. There were 46 males and 2 females. The physical aggression scores ranged from 11–40 with a mean of 25, median 35.5 and mode 14. 24 patients demonstrated high aggression scores. Anger scores ranged from 7–33. Mean 19, mode 13, median 18.5. 18 patients demonstrated high anger scores. Overall aggression scores ranged from 43–148 with a mean of 96 and median of 92.5. Nineteen patients demonstrated high scores. Discussion. This study shows that 40% of the patients had higher overall aggression levels than the normal population. The physical aggression subscale focused on the use of physical force and 50% had high physical aggression levels. High scores in this subscale indicate a lack of ability to control urges toward physical aggression and this is often seen in children with attention deficit disorder. Anger scores may indicate a number of conduct disorders/abusive situations and in this study 38% had raised anger scores. This may be relevant in assessing children with punch injuries as they may benefit from assessment by the CAMS team for investigation and management of their anger and aggression issues, which in turn may reduce recurrence of the injuries

Labral tears are increasingly recognized as a source of hip pain. These rarely occur in normal hips, but in individuals with subtle femoral deformities. Anterior impingement of the femoral neck on the acetabulum due to loss of anterior offset results in a labral tear in active individuals. Future surgeries should be directed at this anterior offset deficiency in order to completely alleviate pain and prevent further recurrences. To determine the incidence of anterior hip impingement and femoral pathology in patients undergoing hip arthroscopy for labral tear. Anterior labral tears occur in the presence of abnormal femoral anatomy, which results in anterior hip impingement. Future treatment of labral tears should include addressing the hip impingement. Labral tears of the hip are increasingly being recognized as a source of hip pain in young, active individuals. Athroscopic labral debridement is commonly associated with poor results. As a result, it is likely that other hip pathology is present at the time of labral tear. The purpose of this study was to determine the incidence of anterior hip impingement secondary to a pistol grip deformity in patients undergoing hip arthroscopy for labral tears. The charts and radiographs of forty consecutive patients who underwent hip arthroscopy were evaluated. X-rays were evaluated for presence of acetabular or femoral pathology. Femoral pathology was then graded based on degree of slip and posterior slip angle. All patients who underwent hip arthroscopy for labral tears had abnormal femoral or acetabular anatomy. In those patients without acetabular dysplasia, a pistol grip deformity of the femoral head was present in all cases. Evidence of anterior hip impingement with osteophyte formation was present in ninety-two percent. In these patients, hip arthroscopy results in complete resolution of mechanical symptoms, but hip pain was still present. Labral tears of the hip appear to be secondary to anterior femoral impingement. This is analogous to a rotator cuff tear in the presence of shoulder impingement. Anterior impingement of the femoral neck on the acatabulum due to an anterior femoral offset deformity results in both pain and labral tears. Future surgeries should be directed at this anterior offset deficiency in order to prevent recurrent injuries or residual pain

Background. Isolated fractures of the distal fourth or fifth metacarpal bones, known as boxer's fractures (BF), are the most common type of metacarpal fracture. Boxer's fractures received their name from one of their most common causes — punching an object with a closed fist. This injury has been described as “a tolerable fracture in an intolerable patient” (1) It occurs commonly during fistfights or from punching a hard object such as a wall. Greer and William demonstrated that it is usually an intentional injury and these patients were at increased risk for recurrent injury (2). Further work suggested that patients with such injuries had higher features of antisocial, self-defeating personality disorders, self harm and impulsive behaviour, compared with control groups (3). It has been suggested that all patients presenting with such an injury should have psychiatric assessment. The majority of studies in the literature have concentrated on adults and little has been reported on children and adolescents who present with such fractures. This study aims to assess aggression scores in young patients discharged with metacarpal fractures due to punching using a validated questionnaire and this abstract presents the interim analysis. Methodology. Following ethical permissions patients between 11 and 18 years of age, discharged with a metacarpal fracture caused by punching diagnosis codes S622, S623 or S624 and willing to complete an anonymous quetionnairre were included. All patients recieved an information sheet and for young people under 16 parental permission was sought. The Bus and Warren validated questionnaire was completed by post, in person or over the telephone. The questionnaire included subscales of physical aggression and anger scales as well as overall aggression scoring and patients were asked to complete all sections. Results. Twenty one patients who had metacarpal fractures due to punching have. completed the study to date. All were males aged between the age of 11 and 18. The physical aggression scores ranged from 13-39 with a mean of 27.5, median 31 and mode 33. Fifteen patients demonstrated high aggression scores. Six patients demonstrated average scores. Anger scores ranged from 7-31. Median 18.5, mode 13, median 20. Thirteen patients had high anger scores compared with their peers. Eight patients were within the average range. Overall aggression scores ranged from 66-133 with a mean of 100 and median of 100. Eleven patients demonstrated high scores and 5 were in the high average range. Discussion/Conclusions. The initial interim results of this study show that over half the patients had higher overall aggression levels than the normal population. The physical aggression subscale focussed on the use of physical force and 71% had high physical aggression levels. High scores in this subscale indicate a lack of ability to control urges toward physical aggression and this is often seen in children with attention deficit disorder. Anger scores may indicate a number of conduct disorders or abusive situations and in this study 62% had raised anger scores. This may be relevant in assessing children with punch injuries as they may benefit from assessment by the CAMS team for investigation and management of their anger and aggression issues which in turn may reduce recurrence of the injuries

Stand-up paddle-boarding (SUP) is an increasingly popular water sport. To our knowledge no published data exists regarding injuries sustained whilst participating in this new sport. This study investigates the frequency, pattern, and mechanism of SUP injuries. Data was collected from UK SUP and surfing clubs via an online survey. Completed surveys were obtained from 31 paddle-boarders (M:F 25:6, median age 27, range 21–65) reporting 18 injuries and 130 surfers reporting 4 SUP-related injuries. 50% of paddle-boarders reported an injury. All SUP injuries were sustained when surfing waves, rather than paddling on calm water. Sprains accounted for 50%, lacerations 22%, contusions 17% and fractures 5%. 78% of injuries were to the lower extremity, and 17% to the head and neck. 17% sustained recurrent twisting injuries, two suffering recurrent knee injuries and one suffering recurrent ankle injuries, resulting in sprains. 17% of injuries resulted from contact with one's own paddle-board, 17% from another paddle-board, and 5% from the sea floor. Despite surfer concerns regarding paddle-board mass and control, paddle-board related injuries only accounted for 1% of the 335 injuries reported by surfers. SUP is relatively safe in calm water conditions, with a similar injury pattern to surfers when used in waves

Aims

To investigate the risk factors for progression of articular cartilage damage after anatomical anterior cruciate ligament (ACL) reconstruction.

Hip and groin injuries are common in athletes who take part in high level sports. Adductor muscle tendon injuries represent a small but important number of these injuries. Avulsion of the tendons attached to the symphysis pubis has previously been described: these can be managed both operatively and non-operatively. We describe an uncommon variant of this injury, namely complete avulsion of the adductor sleeve complex: this includes adductor longus, pectineus and rectus abdominis. We go on to describe a surgical technique which promotes a full return to the pre-injury level of sporting activity.

Over a period of ten years, 15 high-level athletes with an MRI-confirmed acute adductor complex avulsion injury (six to 34 days old) underwent surgical repair. The operative procedure consisted of anatomical re-attachment of the avulsed tissues in each case and mesh reinforcement of the posterior inguinal wall in seven patients. All underwent a standardised rehabilitation programme, which was then individualised to be sport-specific.

One patient developed a superficial wound infection, which was successfully treated with antibiotics. Of the 15 patients, four complained of transient local numbness which resolved in all cases. All patients (including seven elite athletes) returned to their previous level of participation in sport.

Cite this article: Bone Joint J 2015;97-B:1488–92.

The August 2012 Hip & Pelvis Roundup³⁶⁰ looks at: whether cemented hip replacement might be bad for your health; highly cross-linked polyethylene; iHOT-33 - a new hip outcome measure; hamstring injuries; total hip replacement; stemmed metal-on-metal THR; bipolar hemiarthroplasty, neuromuscular disease and dislocation; the high risk of secondary hemiarthroplasty; and whether we have to repair the labrum after all?

We undertook a retrospective review of 24 arthroscopic procedures in patients with symptomatic ossicles around the malleoli of the ankle. Most of the patients had a history of injury and localised tenderness in the area coinciding with the radiological findings. Contrast-enhanced three-dimensional fast-spoiled gradient-echo MRI was performed and the results compared with the arthroscopic findings. An enhanced signal surrounding soft tissue corresponding to synovial inflammation and impingement was found in 20 patients (83%). The arthroscopic findings correlated well with those of our MRI technique and the sensitivity was estimated to be 91%. At a mean follow-up of 30.5 months (20 to 86) the mean American Orthopaedic Foot and Ankle Society score improved from 74.5 to 93 points (p < 0.001). Overall, the rate of patient satisfaction was 88%.

Our results indicate that symptomatic ossicles of the malleoli respond well to arthroscopic treatment.