European Federation of National Associations of Orthopaedic Sports Traumatology

E-Newsletter | Volume # 6 | October 01, 2010 (Supplement)


Dear Colleagues, Here we are again with the October Vol 6 Supplement Newsletter after three months. First of all, on behalf of EFOST Board I wish to thank Dr. G Mann for his great effort to get complimentary permission from American Academy of Pediatrics for their great paper “Anterior Knee Pain Syndrome” was published in Adolescent Medicine to add new issue of Newsletter. And also special thanks to Dr. R. Debi for the abstract summary that he prepared for us. Enjoy them... As you will see at the following pages of Newsletter, 6th EFOST Meeting is getting closer. The 4th one was in Pavia and the 5th in Antalya in November 2008. I know, my friend Mr. President Dr. José Huylebroek, Organising and Program Committee are still working all day and night. Then I would like to give my respects to Dr. William G. Clancy and Dr. Rene Verdonk as “Honorary Presidents”. Also my old friends Dr. John Bergfeld, Dr. Mitsuo Ochi and Dr. Savio Woo will honour all of us with their kind contribution and high-level scientific lectures. As President says EFOST 2010 promises to be the year’s leading meeting on sports traumatology. Comprehensive Congress Program including 25 lectures, 18 special and minisymposiums, 5 video sessions, 3 debates and free papers also seems so exciting and promising for the best EFOST Meeting ever. Although EFOST 2010 will specially focus on osteoarthritis in the young patient and first time shoulder dislocation, a large spectrum program on sports injuries accompanied with radiological

symposiums and physiotherapy sessions, improve the expectations. Please do not forget to submit your abstracts until middle of October and visit congress website for detailed information. We are all looking forward to welcoming you to EFOST 2010 and to the “Capital of Europe”, Brussels. Dear President Dr. Huylebroek, I believe that the Congress of “Brusells EFOST 2010” will be the best of the year on sports traumatology. Congratulations in advance. Mahmut Nedim DORAL, M.D. Editor

September 2010 This is my last contribution to the EFOST newsletter as the President of EFOST. So I thought I would give you my impression on the past 3 years. The most striking fact for me is that these 3 years of Presidency (You might remember that Prof Benazzo had to leave the post of President rather early, due to his overwhelming work in his new job as responsible chief of Orthopaedics at the University of Pavia) passed by so quickly! That means that the years of Presidency were exciting, very well filled in and full of challenges. Let’s make a quick journey of the different items I wanted to achieve and of what the final review could be of my presidency. A lot of societies, enterprises or associations couple their success with their financial status. Today, with our treasurer Prof MN Doral, and our General Manager Mr H De Bock, I can say that the financial situation of EFOST is stable, sound and well structured. Of course, and that was one of my statements at the beginning of my legislature, the relationship with the Medical Industry has reached its maturity: today we have good support from the major Orthopaedic companies, either as a privileged partner or as a dedicated sponsor for our educational activities. Of course we cannot accept to stay on the same spot: stagnation means decline. A lot of work still needs to be done in this field, particularly all over Europe. Probably one of the nicest jobs as Your President, has been the representation of this Sports medicine group at different occasions, on many meetings. Not only the full recognition of our association by f.i. AAOS, ISAKOS, ESSKA etc. was worth the immense work of preparation speeches and talks, but also the invitations by small private meetings, national or regional societies all over the globe brought us to places we would never have been without that sort of meetings. Maybe the most wonderful experience for me, was the warm hospitality of so many

different groups of professionals and individuals: if it was the CEO of a big pharmaceutical company, the governor of Health of a small country in Africa or a group of enthusiastic physiotherapists in Turkey, the constant determinant was the feeling that EFOST means something for so many people. I must thank you all that you have given me the opportunity to go through this type of experiences. One of the major achievements I would like to mention, is the “ mise au point” of the EFOST-DJO travelling fellowship. Recognizing the immense work of Dr F

Kelberine, today we can say that the fellowship is well organised, very popular for young surgeons and the reports post-fellowship prove the unique once-in-a –lifeexperience for the elected fellows. The hands of Dr G Mann and Prof MN Doral are very well visible when you look at and particularly when you read the more and more regular Enewsletter, our preferred way of communication with the members on the field. Prof F Almqvist and Dr Ph Landreau, the two program chairmen of the upcoming 6th European congress of EFOST in Brussels, have prepared an outstanding program for the meeting at the end of November 2010: have a look at and you are immediately convinced about the amount of new stuff we will have to assimilate later on this year. EFOST, together with the GCO company, the organisers of the meeting, are waiting for your registration. For the first time in an EFOST meeting, we have included a few EAST MEETS WEST” meetings: experts from Eastern Europe will discuss and debate with speakers from Western Europe about common topics: our Eastern European colleagues, who register at a reduced fee, can ask questions in their own language. Bringing Eastern Europe again closer to Efost was one of my great wishes since the beginning of my Presidency: our good contacts today, not only with Poland, but also with Ukraine, Russia, Slovenia, Lithonia, etc have proven our successful promotional work in these countries. With the help of the Pharmaceutical Industry, we hope to start next year, regional instructional courses. London is the place to be in 2012: the Olympic games and the World congress on

although all of the Board members have been travelling extensively. co-organised with EFOST: we wish the English organisers and good friends. to be hold during the upcoming congress in Brussels. I am sure that EFOST will go from strength to strength under his leadership. It would have been an impossible job without their support and wise council. Karolien. to end with the wise words of Mike Bells. as it has been a difficult period for us. But. Charlotte and Sam. at the end of 2012. Barbara. Please join us for that meeting. who supported and helped me a lot during the last years: it has been a pleasure working together with such a group of International experts: they really became very good friends.Sports trauma. some interesting challenges for your next president. particularly about the Executive Board and the Board At Large. as many of you may be aware. Huylebroek M. Prof N Maffulli. Finally. I would say. will be voted. “Happily. Efost has not yet a full representation in the Sports medicine world of that area. Without their love and support I may have had big trouble to continue. I must thank my wife Martine and my four children. EFOST President (2007-2010) .D. the Board At Large. Dr F Kelberine: I wish him every success. in some European countries. some changes in the bylaws. At the General Assembly. Mr R Hackney and Mr M Carmont great success and a fantastic meeting in London. And still. even some of the larger ones. A closer contact with quite a few national societies is another critical item for the future. But a lot of work still has to be done: I am a bit disappointed not to have been able to reorganise the Delegates’ group: we still have to work on “ duties and rights” of the national representatives. the former BOA president. I survive to fight another day…” It has been a privilege and a pleasure to have served as your president! J. I would like to thank the wonderful group of friends.





Wingate Institute. Israel.ANTERIOR KNEE PAIN SYNDROME Gideon Mann. M. MSc. Anterior Knee Pain as a descriptive term would define the need to search further for a specific cause of pain (229. David MD3. Correspondence: Gideon Mann. the term "Anterior Knee Pain Syndrome (AKPS)" is an exclusion diagnosis. with no macroscopic gross pathology. that as apposed to the term "Anterior Knee Pain". Eran Dolev. would necessarily be correlated to pain. Omer Mei-Dan. Israel. 2 The Department of Orthopaedic Surgery. Israel.86. e-mail: drmann@regin-med. 230). Iftach Hetsroni. Netanya. Naama Constantini2. MD1. Ayala Mann.230).116. 972-52-251-4608 *** Printed with permission from the American Academy of Pediatrics: Adolescent Medicine: State of the Art Reviews "Anterior Knee Pain Syndrome" (AKPS) would best be defined as a painful condition arising in or around the patello-femoral joint. Kfar Saba. applied after Macroscopic pathology has been ruled out (298). following the above. The examining physician should be aware that specifically in adolescents the higher chance would be that eventually no clear-cut pathology would be found and thus. Tel: 972-2-6511220.3. as neither patellar cartilage damage (231) nor Malalignment (19. bilateral. Meir Nyska. . MD3.D. great caution should be taken before diagnosing AKPS as existing unilaterally. Hadassah University Hospital. Jerusalem. It could be claimed. insidious in onset. 3 The Meir Medical Center. MD3 1 The Ribstein Center for Research and Sports Medicine. MD3.

The condition is frequently observed in children and in adolescents (240). or located on the Medial Joint line in up to 30% of cases (232. Thus. Locking and Swelling are not unusual (230). . 30% of school children in one school year have been reported as suffering from anterior knee pain (116). When measured in flexion the QA is normally 0° and abnormal when over 10° (121).86. In the AKP patient.119). The onset of pain could be gradual or follow a physical stressful event (232). though. may be para-patellar.120) and may differ according to the foot position (67). The normal Q angle (Quadriceps Angle) reaches 10° in men and 15° in women (19. The term AKPS may be misleading as the pain is often neither constant. Giving-Way. which increases by about 1° in the standing position (220). 17% of a patient population visiting a hand injury clinic declared of suffering from anterior knee pain (115).273). posterior.272) rising to 50% in specific high demand units (118) or 60% in exceptionally physically demanding military courses (111. In the military. anterior knee pain syndrome occurs in 15-30% of recruits (41. At 90° flexion the quadriceps tendon will contact the femur and thus take its role in reducing patella-femoral joint pressure (53. nor well localized (232). AKPS could imitate other internal knee derangements. Others described a Q angle of approximately 13° for men and 16° for women.117. and its location though most often pre-patellar. Anatomy: On flexion the patella comes in contact with the femur from below upward until at 135° flexion only the lateral and medial aspects of the patella will contact the femur (53. The lateral force imposed on the patella by the QA is balanced by the medial pull or the oblique part of the vastus medialis muscle (66).84).84).Introduction: Anterior knee pain is the most frequent occurring disease of the knee. these symptoms should be interpreted with caution (230).219. especially as other "classic" symptoms as Crepitos.

Anterior knee pain syndrome carries a wide differential diagnosis (123.175. the Menisci and the Ligaments. nerve tissue or Neuromata in the lateral retinaculum (48.45.128. the Synovium and the Fat Pad.174. This would include almost any knee disease causing knee pain which should be probably excluded before the final diagnosis of AKPS is applied. Similar findings were demonstrated by Witonski & Wagrowska-Danielewicz in 1999 (239). Dye in 1998 (193.233.122. the Retinaculum.122. Various sources have been claimed to cause Anterior Knee Pain. Etiology: A good correlation has been shown between the physical finding and the patients complaints (123). excessive lateral pressure or hypertrophic.232).237.230).238) (Fig 1).230. with much less pain sensation located to the Articular Surfaces. Osgood Schlatter. 132.126.46. complain of vague.130. The most often mentioned is over use with no definite observed anomaly (116. bilateral pain.236. peripatellar syndrome or direct trauma all which should be seeked by history and physical examination (122). Accordingly a surgical procedure has been suggested by Kasim & Fulkerson in 2000 (241) in which painful sections of the retinaculum were . the Pes Ancerinus Tendons.44. A wide variety of causes are mentioned in the literature as possible causes of anterior knee pain. Biedert et al in 1992 (234) demonstrated nerve endings in the Patellar Tendon.129.235) showed by arthroscopy of his own knee the major pain sensitive structures to be the Fat Pad and the Synovium.237.236. insidious in onset and aggravated by stair climbing.Diagnosis and Differential Diagnosis: Anterior Knee Pain Syndrome patients most commonly. tight and painful lateral retinaculum (43. descending or prolonged sitting ( Unilateral complaints must always raise the suspicion of a diagnosis other than Anterior Knee Pain Syndrome (298) such as patellar instability.134.148.232. These would include cartilage degeneration or osteoarthritis (125.226.

153).245. Quadriceps Tendon Cyst (249). a supra-patellar membrane (51.198.75. patellar or quadriceps tendinitis (70.224. 200).246) have been seriously considered as major contributing factors.140. Unusual causes described are retro-patellar calcification (248).233) (Fig 2).199.143. by Witvrouw in 2000 (245). Gastrochemius and Hamstring muscles (145.163. 165). Hoffa's disease representing injury and fibrosis of the fat pad (71. pinching of the synovium under the patella (49. by Cowan in 2001 (242). softening of the Synovial bed in the proximal groove (250). synovium in the patello-femoral space has been shown as a normal occurrence (69)]. 226.179) (Fig 3). a procedure which occasionally gives good results (130. 247).222. and by Owings in 2002 (243).245).164.167. Low flexibility of the Quadriceps. and low force and low electric activity of the Quadriceps especially on blasting force (150. further developed by Cesarelli in 1999 (244). stress fractures (76) or bipartite patella (166.139. and is further discussed below. When other pathology has been excluded it would be justified to remove the plica. has been repeatedly mentioned as a cause of AKPS.223. Sympathetic dystrophy of the patello-femoral joint (RSD) which would be disclosed by a positive bone scan (138.141. . Other causes that should be kept in mind concern various other internal knee derangements as an intermeniscal fibrous band (151). We should elaborate slightly on some of the more controversial etiologies: The Plica Syndrome: The Plica Syndrome which is the occurrence of an abnormally thick or fenestrated (hollowed) synovial fold warrants specific mentioning as the fold often occurs in the normal knee.142. a ganglion cyst in the ACL (152. Uncoordinated reaction of the muscles with the vastus lateralis firing before the vastus medialis while the vastus medialis is normally the first to fire was originally described by Voight and Wieder in 1991 (144).225.50) [though.resected with satisfactory results. Safenous Nerve Entrapment (146).52). the Sindig-Larsen-Johansen Syndrome or proximal patellar pole Apophysitis in children or adolescents (251) or Dorsal Defect of the adolescent patella (251).

The possible relation of his finding to core stability as discussed below should also be kept in mind.Fig 1: Lateral tilt in a normal and subluxing patella as seen on a skyline view: A: Normal positioned patella B: Lateral tilting patella The tilt is caused by a tight lateral retinaculum Proprioception: The relation of Proprioception to AKPS is little discussed and ill defined. Baker et al in 2002 disclosed Proprioception to be defective in AKPS (279) though it remains unclear whether this is a cause or a result. .

Fig 2: Sympathetic Dystrophy of the right patella: Intense uptake on the bone scan A. Lateral view . Anterior-Posterior view B.

. Both Knees .6% of 604 patients after ACL reconstruction using the Patellar Tendon continued to suffer from Anterior Knee Pain (159).Fig 2: Sympathetic Dystrophy of the right patella: Osteoporosis on the x-ray C.157.155.only left affected D. Left Knee Anterior Knee Pain after ACL Reconstruction: After ACL reconstruction.156. Jarvela et al noted that only 40 of 91 patients operated for ACL reconstruction using the Patellar Tendon were free of pain 7 years later (160). various reasons could cause anterior knee pain syndrome as roof impingement of the reconstructed ligament (154) or damage to the extensor mechanism when using the patellar tendon as a graft (92. though non had severe Patello-Femoral pain. Kartus et al in 1999 noted that 33. 158) though it should be mentioned that macroscopic damage to the patella was found by Tria in 24% (155) and by Krahl in 33% (91) of patients already at the time of operation for ACL reconstruction. The findings on a bone scan may be also related to excessive blood supply to the diseased PFJ as seen by thermography (225) or estimated by measuring the intra patellar pressure (32.257).Meniscal Injury: Meniscal injury imitating anterior knee pain syndrome should be excluded (122) as it has been claimed to be present in up to 25% of cases (55). focal arthritic change (161). 34) by direct measure or by phlebography (32.29. This may represent a sympathetic cause of knee pain as RSD (138.162).27. Bone Scan and its relation to Stress Fracture.225) (Fig 2).26. .142. is determined when clinically a lateral meniscus tear was suspected and often a lateral meniscus tear is eventually found when arthroscopy is performed for long standing diagnosed anterior knee pain syndrome. especially of the groove. The intensity of uptake on the bone scan may represent the severity and thus also the extent of the healing process of the patello-femoral joint (31. RSD and intra-osseous pressure: The bone scan has been shown to be positive in nearly half the cases of anterior knee pain syndrome ( It is our experience that a high degree of overlap exists between the lateral compartment of the knee and the patello-femoral joint as it is not unusual that PFJ arthritis. physiological reaction to blunt trauma (257) or possibly trabecular stress fractures which may heal or may lead to subchondral bone sclerosis and late cartilage degeneration (132).141.

42) though delayed emptying of the venous compartment of the painful patella was not demonstrated by Hominga in 1995 (162).36.Fig 3: Bipartite patella in a teenager: AP and lateral views A. The intra osseous patellar pressure as a cause of AKP was further investigated by Schneider in 2000 (271) and by Miltner in adolescents in 2003 (270).40.37. Schneider demonstrated 90% success in 50 knees (40 patients) by extra articular drilling when high intra-osseal pressure was demonstrated (271). Miltner showed good results in adolescents using the same drilling technique (270). .38.39.41. Anterior-Posterior view B. Lateral view C: Axial view (Skyline view) D: Magnetic Resonance Imaging This intra osseous pressure has been described as a cause of pain in osteoarthritis (35.

leg length discrepancy (21.22. 137.82. "squinting patella" with a high Q-Angle (QA) (169) or lateralization of the patella for any reason (131.79. No relation was found between the various measures of pronation and the later development of AKPS during their basic training. usually hyathrogenic following surgery) (20.25.23. a wide patella (72.171.80) (Fig 4). Sanchis-Alfonso & Rosello Sastre debated in 1999 the possibility that malalignment would cause soft tissue damage and bring on pain through neural over-growth and irritation (265).74) (Fig 5 & Fig 6). increased Q Angle (180). at 5 Km/hr. barefoot. Hetsroni et al (272) presented in 2006 a prospective study on 473 young adults before their recruitment to army service at the age of 18. which in itself could cause Osgood Schlatters disease or possibly SindigLarsen-Johansen's Disease due to excessive force exerted on the patellar ligament (73. Lateralization of the patella could be demonstrated by xray (63. combine to produce symptoms as result of abnormally directed loads which exceed the physiological threshold of the tissues".83) (Fig 1). 133. patella baja (low patella. foot pronation as shown by Kessler and Darlene in 1983 (13).131.13) many varieties of malalignment have been described: patella alta (high patella) (13. as demonstrated by Witonski and Goraj in 1999 (264). external rotation of the tibia and pronation of the feet (11.64.78. . Duffey in 2000 demonstrated in 70 long distance runners the dynamic malalignment as a cause of AKP.178.12.18. on passive flexion or on active extension.260). alongside Low Extension Peak Torque and frequent change of running shoes (246). Since the description of "malignant malalignment described by Brody in 1982.19. flat feet which could be observed in 43% of patients suffering from anterior knee pain syndrome as shown by Stanish in 1988 (15).137). tight ileo tibial band (13). inclusive of low pronation at the initiation of the stance and High Arch. on a computerized tomogram or by MRI (17. joint geometry.195. 73. including a wide pelvis. neuromuscular control and functional demands. 24).103). Teitge and Amis in 2002 (262) as follows: "… bony alignment.308). anteversion of the femur. soft tissue restraints. in whom dynamic pronation was measured on walking on a Tread Mill. valgus knees.Patello-Femoral Alignment: Malalignment has been defined by Post.

263). 233.Fulkerson & Arendt in 1999 and in 2000 (266. lateral thrust on walking or running along side sitting with legs together and using high healed shoes. and demonstrated 100% future occurrence of microscopic degenerative changes in the joint cartilage with 50% showing overt arthritic changes.230. . 172) which may be a rather major surgical intervention for the discussed syndrome as it cannot be overemphasized that virtually all the malalignments discussed have been often debated as having any significant effect at all on the anterior knee pain syndrome (19. .267) suggested in females that AKP may be caused by the wide pelvis. Kujala et al in 1986 have shown a relation between anterior knee pain syndrome and all measures presented in joint laxity namely drawer. Moller and his coworkers published in 1989 a paper which surgeons dealing with the patello-femoral joint should keep in mind (57): The author performed a Tibial Tuberosity Transfer (TTT) in rabbits.269) not excluding debates on the role of the Q angle (176.86. anterior knee pain syndrome (81. Joint Laxity: Joint laxity could possibly cause general joint pain (16).245).Isolated femoral anteversion (168) or external rotation of the tibia (171. Performing a TTT in an AKPS patient should not be undertaken lightly. In these cases transfer of the Tibial Tuberosity could be considered. though he found no relation to patellar height.261) (Fig 4).268. Outerbridge and Dunlop in 1975 suggested the relation between patellar instability and continued Anterior Knee Pain (254).15) or even osteoarthritis (17).116.86. possibly patellar dislocation (14.172) could be corrected by tibial or femoral rotational osteotomy (171. knee hyperextension and mediolateral mobility of the patella (86). patellar tilt (177) (Fig 1) and patella height (168. Metin-Cubuk in 2000 (261) suggested laterally placed Tibial Tuberosity as a cause of AKP (261).109.

The force exerted in squatting to the patello-femoral joint may reach 500 kg or x 6. Fig 6: Sindig-Larsen-Johansen Disease: note the heterotrophic calcification on the lower pole of the patella. 68. On jumping the forces may reach momentarily four times this measure (1) or 20 body weight (66.173).2. working eccentrically absorbs 42% of the actively absorbed energy of running at ground contact (180). with a moment five times as strong in running than in walking (124).5 body weight (1. The forces on the patello-femoral joint of the unloaded or loaded knee are appreciably higher on full horizontal extension than in flexion (3.173).84) and the forces in women are higher because of a shorter patellar tendon (4). . Step climbing exerts three times body weight on the patello-femoral joint (65) or far more in specific situations (66) as a combination of force and of the reduced area of the patello-femoral joint on flexion (59). The forces may be somewhat higher in a higher or lower than normal Q angle (2).Forces and Cartilage Degeneration of the Patello-Femoral Joint: The extensor mechanism of the knee.

183. Seedholm has shown softening of the PFJ cartilage in areas not involved in daily activity (181. 187.110. Cartilage degeneration has been mentioned above as a possible cause of anterior knee pain syndrome.191.188.133) no damage was noted even over 120. is generally accepted by various authorities (185. differed from degeneration of the cartilage over the patella. In dogs running uphill 4 Km a day the thickness of the uncalcified cartilage increased 3-23% and the proteoglycan content increased up to 59% (192).253). Most authorities note lack of use to cause softening and eventual degeneration of the articular cartilage (30. though continuous and not traumatic in nature. concerning the joints preservation effect offered by dynamic continuous activity.190) and as the subject of "running and osteoarthrities" is discussed in detail else where we shall refrain from further discussion on this matter.Fig 7: Habitual dislocation of the left patella in a teenage girl. giving a stiffer articular cartilage. This has been attributed to loss of proteoglycan from the cartilage matrix (149) causing softening and eventual break down of the cartilage and sub-chondral bone sclerosis causing loss of shock absorption and eventual cartilage degeneration of the patellar surface (132) or overt degeneration of the groove (147). Though cartilage softening or degeneration has been claimed to arise from excessive stress (95. In dogs running 20 to 40 Km a day bone formation was increased.000 cycles when pressures did not exceed 250-500 psi (95). 54.53.192. the cartilage thickness and proteoglycan content increased in both aspects of the .131.221. This view.189. trabecular bone volume was increased in the patello-femoral area.182) an observation obviating the necessity for continuous life long physical activity.186.

They also noted Basal Degeneration of the deep cartilage Layers. Mild patellar subluxation as a cause of AKP or cartilage damage in female adolescents was also pointed out by Outerbridge & Dunlop in 1975 (254).192.7. and liable to surgical excision. painful. Sensitivity of MRI in diagnosis of patellar cartilage damage. while 68% continued to suffer moderate to severe pain in 46 patients who suffered direct patellar trauma. though with low specificity. macroscopic cartilage damage and roengenographic appearance seems to questionable at the best (194).53.191. . Working with 83 patients (98 knees) he described the AKPS group. Lack of use as causing cartilage degeneration has been widely discussed by others as mentioned above (30. These observations were later repeated (6. Mori et al in 1991 (125) pointed out three groups of adolescents suffering from Anterior Knee Pain.193) and the general relation between pain. Joensen et al in 2001 (255) claimed chondral patellar damage to be located by MRI in 17 of 24 athletes suffering AKP as opposed to similar findings in only 4 of 17 controls. The changes could often be considered normal especially as even advanced cases may not show any clinical symptoms (109. the Idiopathic Chondropathy group and the group of Unstable Patella. Price in 2000 (256) demonstrated that healing occurred in 4% only. and the damaged cartilage would tend to heal.181.8). was shown by Lee in 2001 (258) and better accuracy using the SPIR view of MRI was pointed out by Marcarini in 2004 (259). though loss of proteoglycan and mild cartilage softening was noticed in the lateral femuro-tibial compartment (192) possibly due to acute overtraining. Observations have shown changes on the cartilage surface to be apparent in cadavers as early as the age of 10 (5.221).183.182.patello-femoral joint. In 1936 Owra (5) described the surprisingly high occurrence of macroscopic cartilage changes on the patellar surface.54. Goodfellow et al in 1976 pointed out the appearance of surface degeneration because of lack of use (253). He pointed out that the condition tends not to advance.110.6) described in up to 85% of cadavers in the 3rd decade and up to 100% in the 7th decade (8).

The success of the Insall procedure (lateral release. Exposed bone . In general there is misclarity concerning the relation between the existence and location of cartilage damage at the patelo-femoral joint to the success or failure of surgical procedures devised for anterior knee pain syndrome (56). The same authors failed to show a reduction of the patello-femoral joint pressure when a lateral release was performed (59).109). Grading Cartilage Damage: The grades of cartilage damage or chondromalacia were outlined by Outerbridge in 1961 (9). medial plication and vastus medialis advancement) has been reported to stand in correlation with the congruence angle and to the grade of chondromalacia (88. Another element related to the success of lateral and more so of medial arthrotomies is the denervation caused by the procedure to the patello-femoral joint (96. Cracking or partial thickness damage 4. Softening 2. Even though in joints with subluxing patella the contact of the medial facet of the patella to the femur occurred in a more flexed angle of the knee no difference was noted between normal and subluxing cadaver joints concerning the occurrence of the medial facet chondro-malacia (87). He described four grades of cartilage degeneration: 1. Fibrillation 3. Cadaver studies have failed to show a lower PF contact area when chondromalacia occurs (59).In symptomatic patients about half will show no cartilage damage and vice versa approximately half of asymptomatic patients may show cartilage damage (85.89. Surgical Interventions merit a few words concerning their relation to the observations discussed above.90).

narrowing 2. is seen more in full thickness cartilage defects (202) and may be assisted by passive motion (202). Similar findings were noted by Eckstein et al in 1993 (252) claiming the medial patellar cartilage lesions to be located over less calcified bone and not to progress.108. Mori et al in 1991 reported macroscopic healing of malacic cartilage of the patella (125) of 98 adolescent knees in 83 patients suffering from AKPS. Slight bone defect 4. 1984 and 1985 that only the 3% chondromalacia patients affecting the lateral facet may lead to overt osteoarthitis while 97% affecting the medial facet do not (105. Severe bone defect 6.114). Joint Subluxation The Ahlbach classification has little to do with anterior knee pain syndrome and its obvious that outerbridge grade I.259). Moderate bone defect 5.197. Meachin and their co-authors claimed in 1977. ability to heal and regenerate (105. Does anterior knee pain syndrome lead to osteoarthritis? Bently.106. This ability.107.Ahlbach in 1968 (10) graded the roentgenological appearance to six grades: 1. 2. It has also a certain. though limited.258. Loss of joint space 3. II and even III will not even show up on roentgenographic evaluation and may be shown occasionally only on MRI (126. In other words no more than 3% of cartilage lesions in AKP patients will progress to osteoarthritis.255. 196.113). Karlson back in 1940 claimed that no osteoarthritis developed in these patients after 20 years follow up (112). .109. Two questions must be presented in conclusion of this section: 1. though limited.109. Does the injured cartilage regenerate? Cartilage has the ability to thicken in the human patella (104) or in experimental animals (192).

Arthroscopy will show contact of the patellar ridge and the medial facet at deeper flexion than Fig 4: Patellar height in AP and lateral views: Lateral views (note Osgood-Schlatter disease) A. though arthritic changes seem to be more prevalent in patellar dislocation. High positioned Patella B. Joint laxity seems to comprise a risk factor (14) and a low sulcus angle as seen on CT or MRI will predispose to this condition (64).Patellar Dislocation: Patellar dislocation (Fig 7) is out of the scope of this paper and will be discussed only briefly. Normal positioned Patella . The general measurements concur to those in patellar subluxation (19). as patellar Subluxation (254) and dislocation are recognized as causes of AKP.

Fig 4: Patellar height in AP and lateral views: Anterior-Posterior views C. High positioned Patella D. . Normal positioned Patella Fig 5: Osgood Schlatter Disease A-B:note the heterotrophic calcification over and proximal to the tibial tuberosity. In acute dislocation some advocate immediate surgery (201) though even then a 17% reoccurrence rate has been reported (201). in anterior knee pain syndrome patients (87). It seems that treatment of acute dislocation should be conservative (93) and no advantage has been shown using a cylinder cast when compared to a simple elastic bandage (94).

Psychological Factors in AKPS:

In 1982 Mr. Nordon Trickey of the Royal National Orthopaedic Hospital in Stanmore, London, was requested to speak of Anterior Knee Pain in the Arthroscopy course of Cambridge. Many remember his opening words when he said: "To ask an Orthopaedic Surgeon to speak on Anterior Knee Pain is like asking a Psychiatrist to speak on Gun-Shot wounds of the abdomen".

Thomee et al in 2002 noted that AKPS patients score high on the "catastrophizing scale" (274) and Fulkerson in 2004 (230) pointed out the necessity to identify any hysterical tendency in these patients.

Witonski in 1999 (275) pointed out the possibility of AKPS existing as a psychosomatic disease with only sub-clinical patellar instability and little, if any, relation to physical activity.

Dr. Jack Andrish allowed us to mention their Research in Cleveland concerning Chronic Pain in children inclusive of AKPS as presented recently at the International Patello-Femoral Study Group Meeting and at the Rocky Mountain Trauma Society. He showed 30.7% of the children to have suffered some sort of psychological trauma, with 12.5% of the children suffering chronic pain disclosing a story of sexual abuse.

It is interesting to note the study of Witvrouw et al in 2000 (245), whom in a prospective study in 282 young adults aged 18.6 years in average, found no correlation between the occurrence of AKPS and a psychological test performed prior to the AKP occurrence.

The Concept of Core Stability:

The term "Core Stability" is more popular among Physical Therapists and Athletic Trainers than among Physicians (277). As described by Wilson in 2005 (277) the "Core" is composed of the Lumbar Vertebrae, the Pelvis, the Hip joints, and the active and passive structures that either produce or restrict movement of these

segments. The "Core" would probably affect Lower and Upper Limb function, Trunk function and Pain Syndromes, and may not yet be fully understood.

Sutter et al in 1999 described the change in the Quadriceps Muscle reaction after Sacro-Ileac or spine manipulation in AKPS patients (278) and raised the question whether similar maneuvers would affect AKPS. Baker et al in 2002 pointed out the deficient Proprioception in AKPS (279), though this would not necessarily be related to Core Stability. Ireland and Wilson in 2003 (280) in females aged 12 to 21 and suffering from AKPS showed a reduction of 26% in peak hip abduction force and a reduction of 36% in peak hip external rotation force. Zhang et al in 2000 (281) showed the hip extensor muscles to absorb 25% of the landing impact, and thus deficient hip extensors would over load the knee, possibly enhancing the occurrence of AKPS.

Measurements in Anterior Knee Pain Syndrome:

Various authors have attempted to correlate certain clinical and roentgenographic measurements with pain or subluxation of the patello-femoral joint (19). These

include the Q-Angle in extension (120) or flexion (the tubercle-sulcus angle)(121), the patellar height estimated by the Insall-Salveti index (60)or Blackboure index (61) (Fig 4), the sulcus or congruence angle according to Merchant (63) and Laurin's sulcus measurements (63,82,83,98,228). The various groove

measurements are probably best achieved by computerized tomography or MRI (25,64,137,170,178,195,260). All measurements have been correlated to

occurrence of anterior knee pain or patellar subluxation (13,18,19,77,78,79,80) (Fig 1).

Physical Examination:

Along side a full medical history concerning the knee a full standardized knee examination should be undertaken (227). This would include swelling, sensitivity, range of motion, stability, meniscal tests and examination of the patello-femoral joint. Examination of the patello-femoral joint should include the longitudinal

compression test performed by applying firm pressure on the patella as the knee is

actively extended from a moderately flexed position and the transverse friction test. These should never be done in full extension as the synovium will be pinched under the patella causing acute pain. Both lateral and medial articular surfaces of the patella should be palpated and the upper and lower poles for quadriceps or patellar tendon disease (Fig 5 & Fig 6). Attention should be directed to the superolateral aspect of the patella in an attempt to diagnose a bipartite patella (Fig 3). Lateral tilting of the patella should be performed while checking for a tight lateral retinaculum (120,121,221) (Fig 1). Normally when lifting the lateral border of the patella with the knee extended, the lateral edge of the patella should achieve a horizontal or over horizontal position (122). The patello-femoral tracking should Patellar glide

be assessed (122) and the patella and limb alignment evaluated. should be performed (122) by shifting the patella to lateral.

We estimate the

patellar stability by dividing the patella to quadrants: gliding of the patella up to one quadrant would mean the patella is hypo-mobile, one to two quadrants is normal, two to three quadrants is slightly hyper-mobile, three to four quadrants is moderately hyper-mobile and when the whole patella may be shifted out of the groove the patella is severely hyper-mobile. This examination should be

completed by performing the apprehension test when the patient is requested to flex his knee while the patella is shifted laterally. If the patient tends to dislocate his patella he will be apprehensive to flex his knee feeling the patella may dislocate (227). Eventually, quadriceps tightness should be checked (122) and leg length

discrepancy excluded. Good correlation between patients complaints and physical examination has been reported (123).

Natural Course and Treatment:

Natural Course of the Disease: The natural course of anterior knee pain syndrome is not always predictable and its course may be treacherous and frustrating both to the doctor and to the patient. Though arthritic changes generally do not develop as previously discussed (109) Anterior Knee Pain Syndrome may not always yield to conservative treatment and often it may seem that far more than 10% may need further intervention. Older patients may react unfavorably to any type of treatment, conservative or surgical (206). Presence of anatomic cartilage softening may prevent conservative therapy

to alleviate the symptoms (134) and possibly also malalignment caused by a "squinting patella" (172). 3.5% of recruits were reported by Wilson in 1983 to

have been released from the service because of anterior knee pain syndrome (205) and lack of improvement in 35% of over use injuries with only 37% totally healed was reported by Almekinders twice in 1994 (206,213). The author remarked that the worst of these were the anterior knee pain syndrome patients (206,213). Conservative treatment has been reported to be successful in 34% of patients only, as has been reported by Eden in army personnel in 1992 (211) and a 66% failure rate was reported by Quaile in 1969 (212).

Others claim relatively good results with 90% success with conservative therapy (122) and spontaneous healing especially in the younger patient has been reported by Cascells in 1982 (207). Whitelaw in 1989 (208) reported successful treatment in 87%, 68% of these staying permanently well. Over 80% success of conservative therapy was also reported by Ruffin in 1993 (209) and by Jensen & Albrektsen in 1990 (210) who specifically warned of unessential surgical procedures (210).

Conservative Treatment: Treatment of anterior knee pain syndrome is conservative. Conservative treatment will suffice in 90% of patients (122). This would include activity modification, non steroid anti-inflammatories, stretching, strengthening, endurance training and agility (122). A course of taping accompanied by muscle training and

maintenance, possibly assisted by EM6 and biofeedback, is often helpful (203). A soft knee brace may affect the position of the patella as determined by the "Sulcus Angle" (292) and is often useful both in treatment and in prevention (119,282). We find a custom made insole is often of major assistance (219). In certain situations a simple silicon rubber heel cushion may have a positive preventive effect on the occurrence of anterior knee pain syndrome (118). Conservative treatment should continue for 3-12 months (122) before arthroscopy or further surgical intervention is advised.

A relatively large amount of research has been directed to various modalities of treatment for AKPS. Doucett and Goble in 1992 (283) using strengthening and stretching of the Quadriceps showed an 84% improvement over eight weeks.

and stretching the Quadriceps and Hamstrings. who in a randomized and controlled trial showed improvement by stretching and strengthening. Herbert in 2001 (287) demonstrated the superiority of strengthening exercise over taping. would probably reduce AKP following three months of treatment (233). Reduced Quadriceps and Gastrochemius Flexibility has been shown as a causative factor in AKPS by Witvrouw in 2000 (245) and Hartig and Henderson in 1999 (293) showed the effect of Hamstring stetching in prevention of the disease in young military recruits. In 1996 Dye proposed the concept of "The Envelope of Function". as was also shown by Clark et al in 2000 (291). Roush et al in 2000 (290) demonstrated improvement in AKPS patients in a blind and controlled trial using the MUNCIE method to strengthen the Vastus Medialis Muscle. Both the placebo treated group and the research group improved. The technique of taping could be claimed to account for the failure or success of this method. rest and NSA medication showed 75% of patients to still be free of pain 6 months to 7 years after treatment. according to the works of MacConnell in 1986 (203). Stretching especially of the Quadriceps. The treatment group received Taping. though the treatment group improved significantly more. Lam and Ng in 2001 (286) advised using EMG for effectively strengthening the Vastus Medialis Muscle in variable positions.Kannus et al in 1999 (284) using Quadriceps strengthening. Bennett & Stauber in 1986 (285) showed Eccentric Quadriceps Torque to be reduced in 41 of 130 patients suffering from AKPS and these improved following two to four week of Eccentric Training using an Isokinetic Dynamometer. The concept was described as the "Range of load that can be applied across an individual joint in a given period without Supra-physiologic overload or structural failure". biofeedback assisted muscle training. AKPS could be treated by reducing patient activity to within the Envelope of Function and . Gluteal strengthening. Quadriceps strengthening. A placebo controlled treatment course was held by Crossley et al in 2002 (294). but not by taping. As opposed to these findings Powers in 1997 (288) and Cowan in 2002 (289) showed the positive effect of taping both on pain as on the Vastus Medialis versus Vastus Lateralis firing sequence.

tibial rotation osteotomy or tibial tuberosity transfer. stretching and training (307). Surgical procedures are mostly designed to improve alignment: lateral retinacular release. the Insall procedure. possibly better using Bipolar Radiofrequency (296) though use of radiofrequency may lead to detrimental future negative effects on bone and cartilage (297). Lateral retinacular release may be used for releasing excessive lateral pressure or lateral retinacular tightness.gradually extending the Envelope by gradual strengthening. In more severe damage Micro-Fracture or Abrasion Chondroplasty exposing the sub-chondral bone and letting access to the joint surface of bone marrow cells would be the next line . while Fulkerson in 2002 (306) drew attention to pain originating from iatrogenic Medial Patellar Subluxation. surgical debriedment would offer moderate results (295).270. The first two are proximal realignment procedures consisting of soft tissue manipulation and the second two are distal bony procedures. well selected cases. especially secondary arthrosis as discussed earlier in this text (57). Patelectomy has been used in persistent cases.217). Surgical Treatment: Surgery in anterior knee pain should be reserved for the most exceptional cases and then kept to the minimum possible and directed to specific and clear pathology. When cartilage damage to the patella has been unequivocally demonstrated. Tibial tuberosity transfer may be used for relieving excessive patello-femoral pressure by elevating the tibial tuberosity.271). and thinning of the patella aimed to reduce patello-femoral pressure has been described (216). Late complications of this procedure should be kept in mind. Extreme caution should be used when deciding on surgical means In (210) and most so when symptoms are vague and especially when bilateral. occasionally with good results (215. Post in 2005 (233) warned against severe failures. Patella drilling or osteotomy has been devised in order to reduce intra osseous pressure (218. success of surgery may reach 80% (214) but as many of us know from experience every major hospital has one or two total disasters. Shea and Fulkerson in 1992 (305) showed a 92% success rate when patellar tilt was evident and cartilage lesions not severe.

302. while autologous cartilage cell implantation (ACI) (299.300. 301. 20 of the 40 complained of anterior knee pain during the course while only 2 of the 15 who used the heel complained of this problem.013). In a second study we used a custom made insole in 100 police recruits while 100 continued training with the standard military boot.of treatment (304). In this group 10. 24% suffered from Anterior Knee Pain Syndrome using their unmodified boot while 18% suffered anterior knee pain syndrome using the insole. In a third study conducted with the Army Center of Physical Education 81 men and women due to start an intensive course were randomly divided into two groups. Further details on the surgical procedures are beyond the scope of this manuscript. built by New Balance to specified request). In a further study in the same group. we supplied 50 recruits with a specially designed shoe with a flexible shock absorbing and supportive sole and a snug fitting upper ("A-T 100". The first research project utilized a silicon shock absorbing heel in the police anti-terrorist unit where anterior knee pain syndrome reached 50% occurrence (118). one of which was supplied with a knee brace for all activities while the other was not given a knee support unless medically requested for other reasons. 57% of the group not using the brace developed .303) with or without realignment (233) would be reserved as the last cause of treatment. This finding was significant (p=0. Previous research in our unit seems to indicate prevention is possible or at least enables some reduction in the severity of the disease.5% only complained of anterior knee pain as opposed to 24% using the standard military boot and the "injury score" was 39 compared to 96 (219). 15 fighters were given a silicon heel in training and 40 continued training without the heel. Prevention: There is little known about prevention of anterior knee pain syndrome. In the study we did not differentiate anterior knee pain syndrome from patellar tendinitis (Jompur's knee). When comprising an "injury score" based on multiple pathology sights and severity we found a score of 96 in the group using the military boot and a score of 56 in those who had the insole added in the same shoe (219).

developing proprioceptive ability and keeping within the expanding limits of the "Envelope Of Function". or may even be associated with injured cohorts (311). which would be gradually extended though progressive training. roentgenology. showed again the importance of Quadriceps and Gastrochemius flexibility. On the other hand. the natural history of the disease. pathology. Dye in 1996 (307) discussed. including occurrence.5% developed AKP during their basic training as opposed to 37% of the control group.Anterior Knee Pain Syndrome during the course while only 15% of the brace group developed similar complaints. prevention . This was slightly more emphasized in the women. In summary. conservative and surgical We have specified the physical examination and dealt with the question of cartilage degeneration. especially in adolescents. 18. etiology.6 years in average. along side good muscle power and flexibility. Van Tiggelen et al repeated this trial in the Belgian Army in 2004 (282). anatomy. well designed shoes and a knee brace. In 167 military recruits. Summary: We have discussed various aspects and controversies of Anterior Knee Pain Syndrome. differential diagnosis. treatments. it may be concluded that prevention of anterior knee pain syndrome may be possible by the preventative use of a heel shock absorber. The results were statistically significant (p<0001) (111. stretching should probably be practiced as part of the preventive program in reducing the occurrence of AKPS (246). as mentioned above. Nevertheless. Witvrouw in 2000 (245) in a prospective study inclusive of 282 young adults aged 18. Hartig & Henderson in 1999 (293) in 150 military recruits and 148 controls showed reduction of the occurrence of over use injuries inclusive of AKPS using a Hamstrings stretching program. good custom made insoles. the preventive role of stretching may not be proven (310). the importance of remaining within "the Envelope of Function". though stretching is widely prescribed in order to prevent over use injuries (309).119). until shown otherwise.

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Israel Israel 3. Netanya. Queen Mary University of Centre for Sports and Exercise Medicine. Gideon Mann 1. http://www. sports medicine Autologous platelet-rich plasma (PRP) is perceived to accelerate healing in musculoskeletal injuries. translates to fame and money. Ribstein Center for Sport Medicine Sciences and Research. Department of Orthopaedic Surgery.Platelet rich plasma: any substance into it? Omer Mei-Dan 1. was a February 2009 article in the lay press (New York Times. It is astonishing but understandable that the most influential stimulus for PRP therapy in the US. in the professional sports arena. years after the method had been popularized in Europe. PRP is increasingly used in situations that require rapid return-to-play. Meir University Hospital. Sports Injury Unit. Barts and The London School of Medicine and Dentistry Mile End Hospital. which. . platelet-rich plasma. 275 Bancroft Road London E1 4DG England Tel: + 44 20 8223 8839 Fax: + 44 20 8223 8930 n.html?_r=1&scp=2&sq=prp& st=cse).nytimes. Wingate Institute. 2 . Alan Schwarz. Nicola Maffulli 3 *** This paper has been printed with permission of British Journal of Sports Medicine Keywords: PRP. Kfar-Saba.

with a high variation (3. Reports vary regarding the platelet concentration and different growth factors (GF) present in the PRP concentrate. The same is true for application methods. and higher ones to inhibitory effects 5. 3. or leukocyte and platelet-rich plasma (L-PRP) 2.Biological background: Human blood platelet counts are approximately 200. 6 . A few studies have categorized the different platelet concentrates according to the presence or absence of white blood cells (WBC): either pure platelet-rich plasma (P-PRP). there are many preparation protocols. Some claim to produce a better quantity and quality of PRP than their competitors from the same amount of blood from the same patient.000/mL. in which WBC have been intentionally eliminated from the PRP. Most techniques yield a PRP concentrate of around 10% of the blood volume taken (e. Each method to concentrate platelets leads to a different product with different biology and potential uses 2.g 20 mL of whole blood would result in approximately 2 mL of PRP). and methods to trigger platelet activation before use. kits. optimal timing of injection. These differences might be of relevance to clinical management 2 . with lower platelet concentrations leading to suboptimal effects. Also. possibly from the inability of the kit . although they have not been systematically studied. 8 . and the specific volume to 27-fold) in GF concentration and in the kinetics of release 2. and there is no evidence that gender or age affects platelet count or GF concentrations 9 . Almost every major manufacturer in the orthopedic and sports medicine world markets a different commercial kit. Costs vary tremendously: a commercial kit yields a PRP concentrate at the cost of several hundred dollars. 4 . Other authors have stated that the ‘therapeutic dose’ of PRP would be at least 4-6 times higher than the normal platelet count 7. centrifuges. the actual GF content is not well correlated with the platelet count in whole blood or in PRP. To complicate things. but in house nonautomatised techniques produce a PRP concentrate for around 10 dollars. including using injectable activated PRP liquid concentrate versus implanting a fibrin scaffold. PRP preparations containing only moderately elevated platelet concentrations may be the ones to induce optimal biological benefit. PRP is an autologous concentration of human platelets above this in a small volume of plasma 1.

to around 5%. 10 . Typically. using endocrine. or speed up an acute injury repair process. The idea behind PRP treatment is that all stages of the repair process are controlled by a wide variety of cytokines and growth factors acting locally as regulators of the most basic cell functions. L-PRP reduces post-operative pain. L-PRP injected for soft tissue injuries might induce more local pain than P-PRP. More than 95% of pre-synthesized GF are secreted within one hour of activation from the alpha granules. We do know that neutrophils promote additional muscle damage soon after the initial injury. This exacerbation of injury and/or delay in muscle regeneration may be of major importance for injuries managed with PRP. including many of the proteins responsible for differentiate between the WBC and the PRP layers. a small amount of platelets (6%). but there is no direct evidence that neutrophils play a beneficial role in muscle repair or regeneration 3. such as the haematoma formed in a muscle tear. which are less useful in the healing process. A positive or negative effect of WBC cannot be generalized to all tissues and clinical conditions. and revascularization. autocrine and intracrine mechanisms 5. 8 . blood. supports some PRP production techniques that claim to be clinically superior 11 3. Platelets by themselves do reduce pain . platelets synthesize and secrete additional GF for the remaining sevento-ten days of their life span 8. as the WBC content in the preparation injected has never been systematically studied. and less than 1% leukocytes. After the initial burst of PRPrelated GF. paracrine. synthesis of new connective tissue. This. Clinical rationale: Platelets contain many biologically active factors. although here 12 the contribution of the WBC to the overall effect observed remains unclear . 13 . and increasing platelet amount to 94% to stimulate recovery 3. The rationale for PRP therapy lies in reversing the blood ratio by decreasing RBC. . contains about 94% red blood cells (RBC). They can stimulate a supra-physiologic release of GF to jumpstart healing in chronic injuries. 5 . This issue requires further investigation. together with the improved homogeneity of P-PRP and its reduced donor-to-donor variability.

concluding that further research is necessary. and insulin-like growth factor (IGF-I). epithelial growth factor (EGF). vascular endothelial growth factor (VEGF). and prevent and reverse intervertebral disc degeneration spinal fusion has been questioned 13 . The 2008 “Aspetar Consensus”. improve the outcome of operated 25 . hepatocyte growth factor (HGF). the efficacy of PRP in . The position statement concludes that “WADA will not be in a position to evaluate its clinical utility for either assessment of TUE applications or . its 23. Most early studies concentrated on purified isolated GF which were known to have a specific role in tissue healing. reduce pain in chronic tendinopathies 26 . platelet-derived growth factor (PDGF). and formation of extracellular matrix 14. epithelialization. However. 24 primary repair or its reconstruction ruptured Achilles tendons 14 . PRP has been used to enhance the healing of meniscus defects 19 17 and muscle injuries 16 18. Most of these GF play key roles in tendon. stimulate the healing of an ACL central defect. use appropriate outcome measures.The main GF in the PRP concentrate are the transforming growth factor-ß1 (TGFß1). 16 . cell differentiation. “The application of the WADA Therapeutic Use Exemption (TUE) process is the preferred approach when wishing to utilize GF technology in elite athletes.replication-proliferation. and have decent follow up. and even less trials are adequately powered. as isolated GF would not be able to satisfy the multiple requirements of the injured tissue. muscle. reduce pain and 20 produce better and more balanced synovial fluid in arthritic knees outcomes after total knee arthroplasty accelerate bone formation 22 21 . however the ability of the TUE committee to appropriately evaluate such applications is inhibited by the current level of scientific evidence”. organized by the World Anti-doping Association (WADA) and the International Olympic Committee (IOC) to debate possible conflicts with the WADA code. 15. Only in the past decade has it been recognized and put into practice that the need to target various signaling pathways requires the administration of a balanced combination of mediators. ligament. improve 18 and subacromial decompression . . discussed the use of PRP in muscle injuries 27 . It is remarkable that very few randomized controlled trials have been performed. cartilage and bone healing by stimulating angiogenesis. . and stimulate chondrocytes to engineer cartilaginous tissue .

it is not easy to understand how a single or even a few injections of a cocktail of growth factors at variable. concerning any autologous product that contains GF. The use of NSAIDs in the early post-injection period may exert an inhibitory effect on healing. GFs act on cell membranes rather than on the cell nucleus. and at present not well codified. and the myriad of extremely favourable retrospective and prospective . and the use of local anaesthesia at the injection site is controversial 13 . times from the injury will produce a lasting beneficial effect on a wide variety of condition. gene expression 1. given the well concerted healing cascade which has evolved over millions of years. the anecdotal nearly miraculous recovery reported in the lay press in some famous athletes. Despite the hype of the technique and its biological plausibility. In section S2 of the Aspetar Consensus. and act through gene regulation and normal wound healing feedback control mechanisms. Oversimplification: Over this background. The modalities of use of PRP vary. should be evacuated and replaced with PRP. which promote normal. available and active.the prohibited list”. which ideally would reach the high mechanical performance and functional levels of native tissue in the shortest time possible. not abnormal. the sceptics point out that. while present in PRP. and it is suggested that the haematoma. potentially leading to neoplasms. Extra-articular injections are performed under ultrasound guidance. the only actual factor mentioned in connection with PRP is IGF-1 which. if present. Another concern is that PRP might produce genetic instability. the systemic effects on circulating GF from a local PRP injection showed a very brief reduction of blood GF 29 . and activate gene expression via internal cytoplasmic signal proteins. The aim of PRP injections is to achieve predictable and fast tissue repair through a new well-organized extracellular matrix.28). Furthermore. GF are not directly mutagenic. with a half life of 10 minutes (3. is systemically subtherapeutic by a factor of 500: only 1% of it is unbound.

4. Mazzucco L. 3.” Competing interest statement All authors declare that the answer to the questions on your competing interest form are all No and therefore have nothing to declare Competing interests None declared.27(3):158-67. 2009. Marx. Borzini P. Plateltex and one manual . as set out in our licence (bmj. Rasmusson L. and its Licensees to permit this article (if accepted) to be published in BMJ editions and any other BMJPGL products and to exploit all subsidiary rights. R. level I investigations are lacking: we prompt researchers to undertake appropriately powered level I studies with adequate and relevant outcome measures and clinically appropriate follow up. Not every PRP-gel is born equal. Sports Med. Balbo V. Mujika I. Classification of platelet concentrates: from pure platelet-rich plasma (P-PRP) to leucocyte. Anitua E. 2.and platelet-rich fibrin (L-PRF).shtml). Trends Biotechnol. Copyright The Corresponding Author has the right to grant on behalf of all authors and does grant on behalf of all authors. Evaluation of growth factor availability for tissues through four PRP-gel preparations: Fibrinet. Platelet-rich plasma (PRP): What is PRP and what is not PRP? Implant Dent 10. Guaschino R. References: 1.studies published. Orive G.39(5):34554. an exclusive licence (or non exclusive for government employees) on a worldwide basis to the BMJ Publishing Group Ltd. Albrektsson RegenPRP-Kit. Dohan Ehrenfest DM. Cattana E. Andia I. Sánchez M. Platelet-rich therapies in the treatment of orthopaedic sport injuries. 2001. 2009. 225.

Ivanovski S. Eur Surg Res. Ducci F. Vox Sang. Nguyen C. Tonetti M. Papez MD. and platelet count.35(2):245-51.30(2):97-102. sex.24(5):227-34. Chapman K. Everts PA.procedure. 14. J Oral Maxillofac Surg 62. Steinhoff M. Cenac N. Andia I. Inflammatory processes in muscle injury and repair. Gabriele M. Bone. Weibrich G. Brown Mahoney C. Andia I. 2005. 13. Higgins J. Sanchez M. Clin Oral Implants Res. Curr Rev Musculoskelet Med. 15. Hitzler WE. 12. Nurden AT. Anitua E. Protease-activated receptor-4: a novel mechanism of inflammatory pain modulation. 2009. 2006. van Erp A. A prospective randomized double-blind study. Zamponi GW.1(3-4):165-74. 7. 2007. Anitua E.Platelet quantification and growth factor analysis from platelet-rich plasma: implications for wound healing. Orive G. 5.34(4):665-71. 11. Am J Physiol Regul Integr Comp Physiol. Comparison of surgically repaired achilles tendon tears using platelet-rich fibrin matrices. van Zundert A. Plast . Platelet rich plasma injection grafts for musculoskeletal injuries: a review.17(2):212-9. 6. Knape JT.40(2):203-10.97(2):110-8. Platelet-rich plasma: evidence to support its use. J Craniomaxillofac Surg. Altier C. Mujika I. 2007.288(2):R345-53. Exogenous application of plateletleukocyte gel during open subacromial decompression contributes to improved patient outcome. Growth factor levels in plateletrich plasma and correlations with donor age. 8. Hitzler WE. 2008. Weibrich G. Kleis WK. Oosterbos CJ. Am J Sports Med. Mandelbaum B. New insights into and novel applications for platelet-rich fibrin therapies. 2002. 2008. Asfaha S. Graziani F. Azofra J. 2006. 2004. Trends Biotechnol. Buch R. Eppley BL. Sampson S. Kleis W. Woodell JE. Br J Pharmacol. Tidball JG. Nurden P. Effect of platelet concentration in platelet-rich plasma on peri-implant bone regeneration. Hafner G. 489. The in vitro effect of different PRP concentrations on osteoblasts and fibroblasts. Houle S. Vergnolle N. Stellenboom M. RE. Sanchez M. 10. Padilla S.150(2):176-85. 2004. Gerhardt M. Hansen T. 9. Marx. Cei S. Devilee RJ.

25(8):588-93. Use of a collagen-platelet rich plasma scaffold to stimulate healing of a central defect in the canine ACL. 19. Platelet-rich plasma stimulates porcine articular chondrocyte proliferation and matrix biosynthesis. Wehling P. Miwa M. 2008. Spindler KP.37(6):1135-42. Knape JT. Sánchez M. 2006.24(4):820-30. Lovering RM.14(12):1272-80. Sasaki K. 2009.26(5):910-3. Anitua E. 23. The effect of the platelet concentration in platelet-rich plasma gel on the regeneration of bone. 2007. Devilee RJ.114(6):1502-8. Miyamoto K. decreased length of stay and a reduced incidence of arthrofibrosis. Hammond JW. Collagenplatelet composites improve the biomechanical properties of healing . Appell HJ. Ishiguro N. Treatment of muscle injuries by local administration of autologous conditioned serum: a pilot study on sportsmen with muscle strains. 18. 16. Thonar EJ. Mahoney CB. Use of autologous platelet-rich plasma to treat muscle strain injuries. 17. 20. Murray MM. Aguirre JJ. Attawia M. J Bone Joint Surg Br. van Zundert A. Snyder BS. 2007. Int J Sports Med. Nanney LB. Magarian EM. Devin C. J Orthop Res. Tissue Eng. Andia I. Schäferhoff P. Okuma M. Azofra J. Curl LA. 22. Am J Sports Med. An HS. Fleming BC.15(7):888-94. Kawasumi M. Siwicka KA. 2004. Oosterbos CJ. 24. Murray MM. Kitoh H.The regenerative effects of platelet-rich plasma on meniscal cells in vitro and its in vivo application with biodegradable gelatin hydrogel. Akeda K. Osteoarthritis Cartilage. Everts PA. Zurakowski D. Autologous platelet gel and fibrin sealant enhance the efficacy of total knee arthroplasty: improved range of motion. Sah RL. Mir LM. Muriel JM. 21. Lenz ME. Palmer MP. Intra-articular injection of an autologous preparation rich in growth factors for the treatment of knee OA: a retrospective cohort study.Reconstr Surg. Hinton RY. Hokugo A. Knee Surg Sports Traumatol Arthrosc. Klein P. 2004. Takahashi M. Spindler KP. Kurosaka M. Ishida K. 2008. Masuda K. Kawamoto T. Wright-Carpenter T. Muller J. Kuroda R. Clin Exp Rheumatol.13(5):1103-12. Ballard P. 2006. Tabata Y. Doita M.90(7):966-72. Schattenkerk ME.

Tissue Eng. 2008. Ikeda T. Volpi P. Matsuda K. . Am J Sports Med.anterior cruciate ligament grafts in a porcine model. 27. 2006. 28.42(5):314-20. Grantham J. 2006. 25. Br J Sports Med.34(11):1774-8. Nagae M. Sakamoto H. Hase H.40(10):816. Pavelko T. 2008. Use of complex growth factor preparations in the manegment of muscle strain injury. Ozawa H. Corsi MM. Intervertebral disc regeneration using plateletrich plasma and biodegradable gelatin hydrogel microspheres. Aspetar Consensus. Am J Sports Med. 29. Growth factor delivery methods in the management of sports injuries: the state of play. 2007. Tabata Y. Mishra A.37(8):1554-63. Mikami Y. Kawata M. 2009. Hamilton B. 26. Hamilton B. Banfi G. QATAR. Chalabi H. Creaney L. Could platelet rich plasma have effects on systemic circulating growth factors and cytokine release in orthopaedic applications? Br J Sports Med. Treatment of chronic elbow tendinosis with buffered platelet-rich plasma. Kubo T.13(1):147-58.

The 4 groups did not differ in terms of age. However. 10 ACL-deficient subjects. Iosifidis M. Kotzamitelos D. 12 patients with single-bundle reconstruction. Ronen Debi * * Chairmen of the Dept. Arthroscopic and Related Surgery July 2010: 26(7).869-1010 Arthroscopy: The Journal of Objective.SELECTED ABSTRACTS FROM SPORTS INJURY LITERATURE AND RELATED ISSUES Dr. There was no significant difference in tibial rotation either between the 4 groups or between sides. of Orthopaedics in Barzilay Hospital. Using an 8-camera optoelectronic system and a force plate. To investigate whether anatomic restoration of the anterior cruciate ligament (ACL) functional bundles results in significant reduction in transverseplane instability compared with the conventional single-bundle technique during a dynamic 60° pivoting maneuver with the supporting knee in extension Methods.and doublebundle groups was lower than the control group. Giakas G. duration of follow-up.and Double-Bundle Anterior Cruciate Ligament Reconstruction Tsarouhas A. Results. Rotational moment values were substantially reduced on the affected side of the reconstructed and the ACLdeficient groups. Maximum range of motion for internalexternal knee rotation and maximum knee rotational moment were examined.and Double-Bundle Anterior Cruciate Ligament Reconstruction. The mean knee rotation for the single. Kinematic and kinetic data were collected from these subjects while performing a pivoting maneuver on each side with the supporting knee in extension. body mass index. we examined 10 patients with double-bundle ACL reconstruction. ISRAEL Three-Dimensional Kinematic and Kinetic Analysis of Knee Rotational Stability After Single. Spyropoulos G. Tsatalas T. ThreeDimensional Kinematic and Kinetic Analysis of Knee Rotational Stability After Single. and 10 healthy control individuals. and number of meniscectomies performed. Ashkelon. rotational moment was not found to affect the degree .

Group 2 (control group) had 29 patients who were laid supine after injection. Group 1 (treatment group) had 28 patients who were placed in the lateral decubitus position after injection. Conclusion. They were reassessed after 6 weeks using the same outcome measures. To investigate the effect of the lateral decubitus position. Results. Methods. Fifty-seven patients undergoing caudal epidural injection for low back pain associated with radicular leg pain were randomly allocated into 2 groups.of angular displacement significantly. on outcome. Objective. Various measures have been used to improve the efficacy of these injections in previous studies. The affected side of ACL-deficient or -reconstructed individuals is subjected to reduced knee rotational moments compared with the intact side during stressful functional maneuvers. Patients were assessed before injection using the Verbal Pain Score (VPS) and the Oswestry Disability Index (ODI). after a caudal epidural injection. 2010. July 1. Francis R. Both groups demonstrated improvement after injection. Our aim was to investigate the effect of the lateral decubitus position. Is the Outcome of Caudal Epidural Injections Affected by Patient Positioning? Spine. on outcome. Hussein AA. Hamed AR. after administering a caudal epidural injection. 35(15):E687-E690. Is the Outcome of Caudal Epidural Injections Affected by Patient Positioning? Makki D. The degree of . Caudal epidural injections are used widely in the treatment of low back pain and radicular leg pain. Nawabi DH. Double-bundle ACL reconstruction does not reduce knee rotation further compared with the single-bundle reconstruction technique.

and 2 years. Methods. Back and leg pains were initially reduced by >50%. Results. The degree of improvement in the ODI was not statistically significant (P = 0. Objective. Bretschneider W. 2010. Conclusion.00007). 35(15):1478-1481. July 1. and Short Form health survey. Laying a patient on the side of their leg pain after a caudal epidural injection has a beneficial effect on the degree of pain relief. Life Quality After Instrumented Lumbar Fusion in the Elderly.improvement in the VPS was significantly greater in group 1 compared with group 2 (P = 0. Conclusion. Pain medication was reduced in 69% of the patients. Oswestry Disability Index. there are only few and conflicting results regarding the clinical outcome. . Elderly patients benefit from spinal fusion. All 195 patients had follow-ups after 6 weeks. This retrospective review evaluated 195 patients aged 70 to 89 who underwent lumbar spinal fusion.14).7% of the patients were satisfied. including clinical evaluation as well as visual analog scale score. Life Quality After Instrumented Lumbar Fusion in the Elderly Becker P. Ogon M. To review the clinical outcome on elderly patients after spinal instrumented fusion. We recommend that this simple and safe maneuver be introduced routinely after administering a caudal epidural injection. Although lumbar fusion in elderly patients has increased rapidly. Age itself cannot be considered a contraindication. Tuschel A. with a slight deterioration over a 2-year period.Spine. 1 year. to aid in the eventual outcome of a potentially difficult clinical problem. and 89.

1 and 2 years postoperatively.4. Roos EM. 2. There were 4438 (44%) of these patients (42% females) who had completed the knee-specific questionnaire. 9. 10164 patients (mean age. At 1 year postoperatively. 95% CI.4) and KOOS sport/recreation (mean difference. little is known about possible sex differences in patients with ACL injury/reconstruction. Objective: To study sex differences in patient-reported outcomes before and at 1 and 2 years after ACL reconstruction and to present reference values.Sex Differences in Patient-Reported Outcomes After Anterior Cruciate Ligament Reconstruction Ageberg E.0-6. Female patients reported less improvement from 1 to 2 years postoperatively than male patients in KOOS sport/recreation (mean difference.2. 0. female patients reported a clinically relevant worse KOOS sport/recreation score than male patients (mean difference ≥8).4-2. quality of life) and EQ-5D. Herbertsson P.4. 3. 95% CI.94. Am J Sports Med July 2010. . 95% CI. 4.7) and KOOS quality of life (mean difference. 0. 95% confidence interval [CI]. Methods: Between 2005 and 2008.7. Knee injury and Osteoarthritis Outcome Score (KOOS). 95% CI. before surgery and were included in this study. 38:1334-1342 Background: Female gender is a risk factor for sustaining anterior cruciate ligament (ACL) injury.4). Forssblad M. female patients reported worse scores than male patients in KOOS pain (mean difference. Independent t tests were used to study sex differences in KOOS and EQ-5D preoperatively.4-4.3-6. In some age groups. sport/recreation. Results: Preoperatively. 2.7. and 5255 (52%) who had completed the generic score of health status.4. with the largest difference seen in KOOS sport/recreation (mean difference.3).1). female patients reported worse scores than male patients in 4 KOOS subscales (pain. However. 42% females) with primary ACL reconstruction were registered in the Swedish national knee ligament register. 1. 27 years. 2. 0. 4. 3. EQ-5D. 95% CI.1-6. Sex Differences in PatientReported Outcomes After Anterior Cruciate Ligament Reconstruction: Data From the Swedish Knee Ligament Register.4) and at 2 years postoperatively in KOOS sport/recreation (mean difference. SD. symptoms.8. 0. and over time.

The anatomic double-bundle procedure will be better than the single-bundle procedure at resisting anterior laxity. internal rotation laxity. There were no clinically relevant sex differences in improvements over time. and a simulated pivot-shift test. Amis AA. Yasuda K. this difference was also clinically relevant. . However. Merican AM. Biomechanical Comparisons of Knee Stability After Anterior Cruciate Ligament Reconstruction Between 2 Clinically Available Transtibial Procedures: Anatomic Double Bundle Versus Single Bundle Kondo E. (3) anatomic doublebundle reconstruction.Conclusion: Female patients reported statistically significant worse outcomes than male patients before and at 1 and 2 years after ACL reconstruction. 5-N—m internal and external tibial torques. it remains controversial whether the anatomic double-bundle procedure is superior to the single-bundle procedure. Methods: Eight cadaveric knees were tested in a 6 degrees of freedom rig using the following loading conditions: 90-N anterior tibialforce. We suggest that possible sex differences be analyzed in future studies on evaluation after ACL injury/reconstruction. Biomechanical Comparisons of Knee Stability After Anterior Cruciate Ligament Reconstruction Between 2 Clinically Available Transtibial Procedures: Anatomic Double Bundle Versus Single Bundle Am J Sports Med July 2010 38:1349-1358 Background: Several trials have compared the clinical results between anatomic double-bundle and single-bundle anterior cruciate ligament reconstruction procedures. Tibiofemoral kinematics during the flexion-extension cycle were recorded with an optical tracking system for (1) intact. and (4) single-bundle reconstruction placed at 11 o’clock in the intercondylar notch. In some age groups. (2) anterior cruciate ligament–deficient knee. and pivot-shift instability.

Constant score. There were no significant differences between the 2 procedures for external rotation laxity. Kyung Hwan K. rotator cuff repair was performed.Results: There were significant reductions of anterior laxity of 3. This report explores the usefulness of the modified impingement test for prognosis in cases of rotator cuff repair. in both static tests and the pivot shift. the visual analog scale for pain and satisfaction. and University of California. The amount of pain reduction after injection of lidocaine into the subacromial space preoperatively correlates with the level of pain reduction after rotator cuff repair. Sae Hoon K. Subsequently. Modified Impingement Test Can Predict the Level of Pain Reduction After Rotator Cuff Repair. internal rotational laxity of 2. However.5 mm at 20° of flexion. Simple Shoulder Test. American Shoulder and Elbow Surgeons (ASES) score. Correlation analyses were performed between the change in . Hyun Sik G. Conclusion: The postoperative anterior translation and internal rotation stability after anatomic double-bundle anterior cruciate ligament reconstruction were significantly better than after single-bundle reconstruction. a visual analog scale for pain was measured in 153 patients (59 males and 94 females) with a rotator cuff tear before and after injection of lidocaine into the subacromial space. At least 1 year after surgery. Am J Sports Med July 2010 38:1383-1388 Background: Most patients experience a significant reduction in pain after rotator cuff repair. and anterior translations (2 mm) and internal rotations (5°) in the simulated pivot-shift test in the doublebundle reconstruction com-pared with the single-bundle reconstruction. there is currently no method to predict the level of pain reduction that each patient will experience.5° at 20° of flexion. Methods: Preoperatively. Chung Hee O. Modified Impingement Test Can Predict the Level of Pain Reduction After Rotator Cuff Repair Joo Han O. Los Angeles shoulder rating scale were evaluated.

Briggs KK.visual analog scale after the modified impingement test and after surgery. the other tests showed no statistical significance (P > .05). as measured using the visual analog scale for pain. Chondral Resurfacing and High Tibial Osteotomy in the Varus Knee: Survivorship Analysis William I. Objective: To determine the length of time patients with varus gonarthrosis can avoid knee arthroplasty with chondral resurfacing (microfracture) and medial opening wedge high tibial osteotomy (HTO). Matheny LM. High tibial osteotomy has been recommended for the treatment of varus osteoarthritis to decrease pressure on the damaged medial compartment. Huang MJ.001). . Arthroplasty. Conclusion: The amount of pain reduction after the modified impingement test preoperatively correlated with the improvement of pain after rotator cuff repair. however. Univariate regression analysis revealed that a 0. This simple preoperative test could help patients understand the subjective level of pain reduction that they may experience after rotator cuff repair. Am J Sports Med July 2010 38:1420-1424 Active patients with arthritic malalignment of the knee are difficult to manage. Results: The amount of pain reduction after the modified impingement test was significantly related to improvement of pain postoperatively (P < . may not be appropriate in patients who desire to remain highly active. unicompartmental or total knee replacement.001). Sterett WI. The change in ASES score was also related to the amount of pain reduction after the modified impingement test (P = . Chondral Resurfacing and High Tibial Osteotomy in the Varus Knee: Survivorship Analysis.621-unit reduction in postoperative pain on the visual analog scale could be expected for each 1 unit (on a scale of 10) reduction in pain after lidocaine injection preoperatively. Steadman JR.

. Twelve patients proceeded to arthroplasty at a mean of 81 months (range.5. the mean Lysholm score was 67. 19-116 months). the mean Lysholm score was 73. Generalized Joint Hypermobility and Risk of Lower Limb Joint Injury During Sport. Results: At 5 years.4-13. Conclusion: With 91% survivorship at 7 years. Systematic reviews have not been conclusive and no metaanalysis has been performed. range. Adams RD. Follow-up was obtained for 90% of patients. Tegner score was 2. the mean Lysholm score was 73. and patient satisfaction was 7.Methods: From 1995 to 2001. A Systematic Review With Meta-Analysis. At 3 years. Nicholson LL.9. The current literature has conflicting reports of the risk of joint injury in hypermobile sporting participants compared with their nonhypermobile peers. Generalized Joint Hypermobility and Risk of Lower Limb Joint Injury During Sport: A Systematic Review With Meta-Analysis Pacey V.015). 5-100). P = . 52 years. Tegner score was 3. Patients who proceeded to knee arthroplasty after combined HTO/microfracture had a mean delay of 81. Tegner score was 3. and patient satisfaction was 7. the mean Lysholm score was 71 (range. Munns CF. At most recent follow-up. At 5 years.2 times more likely to undergo arthroplasty than patients without (95% confidence interval [CI].3 months. and patient satisfaction was 7. Am J Sports Med July 2010 38:1487-1497 Generalized joint hypermobility is a highly prevalent condition commonly associated with joint injuries.8. 1. the senior authors performed a medial opening wedge HTO/microfracture in 106 knees (mean age. 30-71 years). survivorship was 97%.8.5. microfracture/HTO seems to contribute to a delay of knee replacement in active patients with varus gonarthrosis. survivorship was 91%. Survivorship was defined as not requiring knee arthroplasty after microfracture and HTO.1. Patients with medial meniscus injury at surgery were 9. At 9 years.5. At 7 years. Munn J.

Inclusion criteria for studies were determined before searching and all included studies underwent methodological quality assessment by 2 independent reviewers. 1.001). and SportDiscus databases from the earliest date through February 2009 with subsequent handsearching of reference lists. The difference in injury proportions between hypermobility categories was tested with the z statistic.69 (95% confidence interval. P = . Methods: Studies were identified through a search without language restrictions of PubMed. knee. indicating a significantly increased risk for hypermobile participants playing contact sports. a significantly increased risk of knee joint injury for hypermobile and extremely hypermobile participants compared with their nonhypermobile peers was demonstrated (P < .52. Results: Of 4841 identified studies. whereas no increased risk was found for ankle joint injury. a combined odds ratio of 4. Study Design: Systematic review with meta-analysis. 18 met all inclusion criteria with methodological quality ranging from 1 of 6 to 5 of 6. Conclusion: Sport participants with generalized joint hypermobility have an increased risk of knee joint injury during contact activities but have no altered risk of ankle joint injury. A variety of tests of hypermobility and varied cutoff points to define the presence of generalized joint hypermobility were used.33-16. Using this criterion. Metaanalyses for joint injury of the lower limb. . so the authors determined a standardized cutoff to indicate generalized joint hypermobility. and ankle were performed using a random effects model.02) was calculated.Objective: This review was undertaken to determine whether individuals with generalized joint hypermobility have an increased risk of lower limb joint injury when undertaking sporting activities. CINAHL. For knee joint injury. Embase.

Los Angeles activity score of 6. The University of California. Conclusions: Using a modified surgical technique. J Bone Joint Surg Br 2010 92-B: 922-928 We performed 96 Birmingham resurfacing arthroplasties of the hip in 71 consecutive patients with avascular necrosis of the femoral head. We also describe the combined abduction-valgus angle of the bearing couple. With failure of the femoral component as the endpoint.4%.4 years (4. Methods: A modified neck-capsule-preserving approach was used which is described in detail.Resurfacing arthroplasty of the hip for avascular necrosis of the femoral head Bose VC. Los Angeles outcome score.1). the radiological parameters and survival rates were assessed.0%. All the patients remained active with a mean University of California. Results: The mean follow-up was for 5. Three hips failed.0 to 8. it is possible to preserve the femoral head in avascular necrosis by performing hip resurfacing in patients with good results. Baruah BD. as an index of the optimum positioning of the components in the coronal plane. .86 (6 to 9). Resurfacing arthroplasty of the hip for avascular necrosis of the femoral head: A Minimum follow-up of four years. the cumulative survival rate was 98. which is the sum of the inclination angle of the acetabular component and the stem-shaft angle. giving a cumulative survival rate of 95.

Injury to the proximal deep medial collateral ligament Narvani A. The surgical finding was a failure of healing of a tear of the deep MCL at its femoral origin which could be repaired. All the patients returned to their sports and remained asymptomatic at a mean of 48 weeks (28 to 60) postoperatively. We have identified a subgroup of injuries to the deep portion of the MCL which is refractory to conservative treatment and causes persistant symptoms. They usually occur in high-level football players and may require surgical repair. Injury to the proximal deep medial collateral ligament: A Problematical subgroup of injuries. Conclusions: Recognition of this subgroup is important since the clinical features. J Bone Joint Surg Br 2010 92-B: 949-953 Most injuries to the medial collateral ligament (MCL) heal well after conservative treatment. Results: The mean time from injury to presentation was 23. After a period of postoperative protective bracing and subsequent rehabilitation the outcome was good. the course of recovery and surgical requirement differ from those of most injuries to the MCL. Following a minor injury to the MCL there was persistent tenderness at the site of the proximal attachment of the deep MCL. Mahmud T. Methods: We describe a consecutive series of 17 men with a mean age of 29 years (18 to 44) who were all engaged in high levels of sport. Williams A.6 weeks (10 to 79) and none of the patients had responded to conservative treatment. . Lavelle J. It could be precipitated by rapid external rotation at the knee by clinical testing or during sport.

which cannot be learnt for books or in the . Falls to the side tend to result in lower limb injuries. Research has shown that the downhill form of racing has a significantly higher injury rate (4.34 per 100 hours riding) than X country racing (0. face and cervical spine injuries. Mountain biking is a fast fun adventure sport. Education campaigns have led to a reduction of head injuries with helmet use. World Championships and Olympic competitions. commonest dislocation is the ACJ. Falls over the handlebars have a more severe injury profile with exposure to head.37 per 100hrs) and injured riders are typically male aged 20-39 years.efost. abdominal injuries with the avoidance of bar ends and the use of a face mask is recommended to reduce facial injury. Riders are recommended to race within the level of their capability although the risk of injury adds to the excitement. The majority of riders injured will have sustained soft tissue injuries such as abrasions and contusions and the commonest fracture is the clavicle. © 2010 EFOST www.Mountain Biking Injuries: Current Concepts Mike Carmont Mountain biking has now developed as a recreational adventure pastime to a professional competitive sport with a World Cup Series.

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P.Key Invited Lectures Knee Ligaments: • • • • • • • • • • • Anatomical ACL Reconstruction – What Have We Learned? Technique and Results of PCL Inlay Reconstruction Concept and Technique of Treatment in Knee Dislocation Arthroscopic Treatment of Tibia plateau fracture Primary Repair Combined with Bone Marrow Stimulation in Acute ACL Lesions: Results in a group of athletes at 3 year follow up Single versus Double bundle technique in ACL reconstruction using the Semitendinosus Tendon Principles of Revision ACL reconstruction ACL tears: to reconstruct or augment Algorithm Based ACL Reconstruction: Graft Choice and Technique Current Treatment Options for PCL Injuries ACL reconstruction with one hamstring: all inside technique Cartilage • Mesenchymal Stem Cells Implantation for Full-Thickness Cartilage Lesions Treatment: Results at 2 year follow up Subjects of Interest • • • • • Arthroscopic Treatment of Tibia plateau fracture Infiltrative Treatment with Autologous Platelet Rich Plasma (P.) in early Osteoarthritis: Results at 12 month follow up Distraction arthroplasty: a new surgical technique for the treatment of basal thumb Osteotomies About the Knee: Joint Preservation and Osteoarthritis Neuromuscular control and exercise-related leg pain in triathletes .R.

what you always wanted to know………… Optimising corticosteroid injection for lateral elbow tendinopathy with the addition of physiotherapy Anterior Knee Pain • • • "Put your foot in it" . Finger injuries Knee Meniscus • • Meniscal repair: when to repair and technique Meniscal Tears: Repair.orthoses in the management of anterior knee pain.General Sports • • • • • Predictive Factors for a Safe Return-to-sport The Identification and Treatment of Eating Disorders Among Elite Athletes Child Neurodevelopment and Sports Participation Medical Disorders and Sports Participation by Children and Adolescents Concussion in Pediatric Sports: Current Issues Imaging • • • • Ergonomic Factors by Radiology. . Replace? Upper Limp • • • • Massive Rotator Cuff Tears: A Case-Based Approach Shoulder Instability: Posterior-MDI Treatment Options Lateral elbow tendinopathy – Examination and treatment . Resect. Muscle Injuries Post operative imaging of the knee. Predictors of short and long term outcome in patellofemoral pain syndrome Targeted physiotherapy for patellofemoral joint osteoarthritis Foot and Ankle • Modified Watson-Jones technique for chronic lateral ankle instability in athletes.


© 2010 EFOST .efost.


The meeting will be held in early November 2012. We are pleased to have the support of the BOA (British Orthopaedic Association). All the major attractions of this magnificent city are in easy reach of this top class centre. and the British Association for Sport and Exercise Medicine. the new Faculty for Sport and Exercise Medicine. Put it in your calendar now! Roger Hackney Privileged Partners DJO GLOBAL STRYKER ORTHOMED NICE MITEK .DE PUY SMITH .EFOST 2012 WORLD SPORTS TRAUMA CONGRESS 2012 These events are being combined in a meeting to be held in London. We will be including an Allied Health professionals programme. This promises to be a top class academic meeting with the opportunity to experience all of the unique sight-seeing wonders of London. The venue is likely to be the Queen Elizabeth 2nd Conference centre. The specialist societies of the BOA (Orthopaedic) have been invited to run programmes within the meeting. the BOA (British Olympic Association) doctors group. the host city for the 2012 Olympic games.NEPHEW © 2010 EFOST . The meeting will run over 4 days. which is in the heart of the city of London.


B-3001 LEUVEN. a higher incidence of arthrofibrosis and decreased joint range of motion was observed in a subgroup of patients with a patellar lesion (8. controlled trial alone.4% of the patients over a 36-months postoperative followup period.8% compared to 25% in the randomized. Adverse reactions occurred in 78. The most common adverse reactions were arthralgia (47. Therapeutic indications: Repair of single symptomatic cartilage defects of the femoral condyle of the knee (International Cartilage Repair Society [ICRS] grade III or IV) in adults. a physical seal of the lesion (placement of a biological membrane. cartilage hypertrophy (27. as recommended by the physician. 2006. controlled study in the target population.000 cells/microlitre. ChondroCelect must not be used in case of advanced osteoarthritis of the knee. Contraindications: Hypersensitivity to any of the excipients or to bovine serum. QUALITATIVE AND QUANTITATIVE COMPOSITION : General description : Characterized viable autologous cartilage cells expanded ex vivo expressing specific marker proteins. Demonstration of efficacy is based on a randomized controlled trial evaluating the efficacy of Chondrocelect in patients with lesions between 1-5cm². In these patients. Posology: The amount of cells to be administered is dependent on the size (surface in cm²) of the cartilage defect. Belgium.4%). The implantation should be followed by an appropriate rehabilitation schedule for approximately one year.6% respectively). Undesirable effects: In a randomized. Concomitant asymptomatic cartilage lesions (ICRS grade I or II) might be present. Name of the MA holder: TiGenix NV... 2008). Niemeyer et al. ChondroCelect is solely intended for autologous use and should be administered in conjunction with debridement (preparation of the defect bed). 51 patients were treated with ChondroCelect. arthralgia and pyrexia. the incidence of cartilage hypertrophy was reported to be 1. Most of the reported adverse reactions were expected as related to the open-knee surgical procedure. PHARMACEUTICAL FORM: Implantation suspension.7%).8 to 1 million cells/cm². Adverse reactions of special interest: Arthrofibrosis: In the compassionate use patients. According to current literature the incidence of cartilage hypertrophy can be reduced by using a collagen membrane to cover the lesion site instead of using a periosteal flap (Gooding et al. a periosteal flap was used to secure the implant. joint crepitation (17.6% and 2. a collagen membrane instead of a periosteal flap was used to seal the defect. These were generally mild and disappeared in the weeks following surgery. V1_E_091022/mpo . Romeinse straat 12/2. corresponding with 80 to 100 microlitre of product/cm² of defect. Medicinal product to restricted medical prescription – restricted to hospital use only.1%). Product authorization number: EU/1/09/563/001. The recommended dose of ChondroCelect is 0.1% respectively) compared to nonpatellar lesions (0.4 ml cell suspension. The most frequently occurring reactions reported immediately after surgery include joint swelling. Method of administration: ChondroCelect is intended solely for use in autologous cartilage repair and is administered to patients in an Autologous Chondrocyte Implantation procedure (ACI).000 cells/microlitre implantation suspension. Each product contains an individual treatment dose with sufficient number of cells to treat the pre-defined lesion size. Posology and method of administration: ChondroCelect must be administered by an appropriately qualified surgeon and is restricted to hospital use only.6%) and joint swelling (13. When a collagen membrane was used to seal the lesion site after application of ChondroCelect.Product information: brief summary NAME OF THE MEDICINAL PRODUCT: ChondroCelect 10. Cartilage hypertrophy: In the majority of the 370 patients included in the Compassionate Use Program. Qualitative and quantitative composition : Each vial of product contains 4 million autologous human cartilage cells in 0. preferentially a collagen membrane) and rehabilitation. Before resuspension the cells are settled to the bottom of the container forming an off-white layer and the excipient is a clear colourless liquid.2% and 13. as measured at biopsy procurement. corresponding to a concentration of 10. Adverse reactions collected from 370 patients included in a Compassionate Use Program are similar to those reported in the target population.

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