Traditionally, sports Injuries have been sub-optimally managed through Emergency Departments (ED) in the public health system due to a lack of adequate referral processes. Fractures are ruled out through plain radiographs followed by a reactive process involving patient initiated further follow up and investigation. Consequently, significant soft tissue and chondral injuries can go undiagnosed during periods in which early intervention can significantly affect natural progression. The purpose of this quality improvement project was to assess the efficacy of an innovative Sports Injury Pathway introduced to detect and treat significant soft tissue injuries.

A Sports Injury Pathway was introduced at Fiona Stanley Hospital (WA, Australia) in April 2019 as a collaboration between the ED, Physiotherapy and Orthopaedic Departments. ED practitioners were advised to have a low threshold for referral, especially in the presence of a history of a twisting knee injury, shoulder dislocation or any suggestion of a hip tendon injury. All referrals were triaged by the Perth Sports Surgery Fellow with early follow-up in our Sports Trauma Clinics with additional investigations if required. A detailed database of all referrals was maintained, and relevant data was extracted for analysis over the first 3 years of this pathway.

570 patients were included in the final analysis. 54% of injuries occurred while playing sport, with AFL injuries constituting the most common contact-sports injury (13%). Advanced Scope Physiotherapists were the largest source of referrals (60%). A total of 460 MRI scans were eventually ordered comprising 81% of total referrals. Regarding Knee MRIs, 86% identified a significant structural injury with ACL injuries being the most common (33%) followed by isolated meniscal tears (16%) and multi-ligament knee injuries (11%). 95% of Shoulder MRI scans showed significant pathology. 39% of patients required surgical management, and of these 50% were performed within 3 months from injury.

The Fiona Stanley Hospital Sports Injury Pathway has demonstrated its clear value in successfully diagnosing and treating an important cohort of patients who present to our Emergency Department. This low threshold/streamlined referral pathway has found that the vast majority of these patients suffer significant structural injuries that may have been otherwise missed, while providing referring practitioners and patients access to prompt imaging and high-quality Orthopaedic sports trauma services. We recommend the implementation of a similar Sports Injury Pathway at all secondary and tertiary Orthopaedic Centres.

Hamstring grafts have been associated with reduced strength, donor site pain and muscle strains following Anterior Cruciate Ligament Reconstruction (ACLR). Traditional graft fixation methods required both semitendinosus and gracilis tendons to achieve a graft of sufficient length and diameter, but newer techniques allow for shorter, broad single tendon grafts.

This study seeks to compare the outcomes between Single Tendon (ST) and Dual Tendon (DT) ACLR, given there is no prospective randomised controlled trial (RCT) in the literature comparing outcomes between these options.

In this ongoing RCT: (ANZ Clinical Trials Registry ACTRN126200000927921) patients were recruited and randomised into either ST or DT groups. All anaesthetic and surgical techniques were uniform aside from graft technique and tibial fixation. 13 patients were excluded at surgery as their ST graft did not achieve a minimum 8mm diameter. 70 patients (34 ST, 36DT) have been assessed at 6 months, using PROMS including IKDC2000, Lysholm and Modified Cincinnati Knee, visual analog scale for pain frequency (VAS-F) and severity (VAS-S), dedicated donor site morbidity score, KT-1000 assessment, and isokinetic strength.

Graft diameters were significantly lesser in the ST group compared to the DT group (8.44mm/9.11mm mean difference [MD],-0.67mm; P<0.001). There was a significant and moderate effect in lower donor site morbidity in the ST group compared to the DT group (effect size [ES], 0.649; P = .01). No differences between groups were observed for knee laxity in the ACLR limb (P=0.362) or any of the patient-reported outcome measures (P>0.05). Between-group differences were observed for hamstrings strength LSI favouring the ST group, though these were small-to-moderate and non-significant (ES, 0.351; P = .147).

ST (versus DT) harvest results in significantly less donor site morbidity and this is the first prospective RCT to determine this. There were no differences between ST and DT hamstring ACLR were observed in PROMs, knee laxity and hamstring strength. Younger female patients tend to have inadequate single tendon size to produce a graft of sufficient diameter, and alternative techniques should be considered. Further endpoints include radiological analysis, longer term donor site morbidity, revision rates and return to sport and will continue to be presented in the future.