The Use of Biologics in NFL Athletes: An Expert Consensus of NFL Team Physicians.

Background: There is a lack of published information outlining the use of biologics in National Football League (NFL) athletes and limited data to guide biologic treatment strategies. Purpose: To develop a consensus on the use of biologics among NFL team physicians. Study Design: Consensus statement. Methods: A working group of 6 experts convened a consensus process involving NFL team physicians using validated Delphi methodology. Physicians from 32 NFL teams as well as NFL London were invited to take part. This iterative process was used to define statements on the use of biologics in NFL athletes. A recent scoping review exploring biologics in professional athletes was used to inform the first of 3 rounds of surveys, with statements considered under 7 headings: biologics in general, challenges of treating NFL athletes, terminology/nomenclature, autologous blood products, cell-based therapies, guidance for NFL team physicians, and biologic research in the NFL. In addition to rating agreement, experts were encouraged to propose further items or modifications. Predefined criteria were used to refine item lists after each survey. For a consensus within the final round, defined a priori, items were included in the final information set if a minimum of 75% of respondents agreed and fewer than 10% disagreed. Results: Physicians from 26 NFL teams and NFL London responded to the initial invitation to participate in the Delphi process; 88.9% of participating team physicians completed the round 1 survey, with response rates of 87.5% in round 2 and 95.2% in round 3. After 3 rounds, 47 statements reached a consensus. A consensus was achieved that platelet-rich plasma has a positive impact on patellar tendinopathy and on symptoms in early osteoarthritis but not for other indications. NFL team physicians agreed that while cell therapies have the potential to improve symptoms, the misrepresentation of uncharacterized preparations as "stem cells" has contributed to the widespread use of unproven therapies. Conclusion: This study established an expert consensus on 47 statements relating to the use of biologics in NFL athletes. In addition to providing clinical guidance for the use of biologics in NFL athletes, this study identified key areas for future focus including the development of athlete education materials.

High Return to Play and Low Reinjury Rates in National Collegiate Athletic Association Division I Football Players Following Anterior Cruciate Ligament Reconstruction Using Quadrupled Hamstring Autograft.

PURPOSE: The purpose of this study was to examine the outcomes of anterior cruciate ligament (ACL) reconstruction using quadrupled hamstring (QH) autograft in a cohort of National Collegiate Athletic Association (NCAA) Division I football players. METHODS: A retrospective analysis was performed on NCAA Division I football players at a single institution who had transtibial ACL reconstruction using QH autograft between 2001 and 2016. Primary outcomes were ACL reinjury and return to play (RTP). Secondary outcomes were position, percent of eligibility used after surgery, graft diameter, Tegner-Lysholm scores, concomitant injuries/surgeries, and postcollegiate professional play. RESULTS: Between 2001 and 2016, 34 players had QH autograft ACL reconstruction, and 29 players achieved RTP. Of the 29, 2 (6.9%) sustained ACL reinjuries. The average RTP was 318 days (range 115-628) after surgery. Players used 79.5% of their remaining collegiate eligibility after surgery. Nine players sustained multiligamentous knee injuries. This did not have a significant effect on RTP (P = 0.709; mean 306±24 days for isolated ACL, mean of 353±51 for 2 ligaments, mean of 324±114 for 3 + ligaments) and none sustained reinjury. Associated meniscal injuries were sustained by 28, and 8 sustained chondral injuries. The mean postoperative Tegner-Lysholm score was 90.7 of 100, with mean follow-up of 102 months. Of these players, 18 went on to play professionally, with 17 joining National Football League rosters and 1 an arena team roster. CONCLUSION: QH demonstrated an ACL reinjury and RTP rates similar to those in previously published, predominantly bone-patella tendon-bone ACL reinjury data in elite athletes. This study demonstrates that QH autograft may be a viable option in elite athletes. LEVEL OF EVIDENCE: IV, case series.

Functional outcome following intramedullary nailing of the femur: a prospective randomized comparison of piriformis fossa and greater trochanteric entry portals.

BACKGROUND: The purpose of the study was to prospectively compare the functional outcome of intramedullary nailing of the femur performed with use of a trochanteric and a piriformis fossa entry portal. METHODS: One hundred and ten patients with a femoral shaft fracture were enrolled in a prospective, randomized study. Fifty-four patients were randomized to Group A (piriformis fossa portal) and fifty-six to Group B (trochanteric portal). Outcome measures included the Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index hip function score, pain, and blinded functional evaluation by a physical therapist. RESULTS: Most measures of hip function did not differ between the two groups. The WOMAC score at three, six, and twelve months did not differ significantly between the piriformis fossa and trochanteric nailing groups. Functional tests included the chair stand test and the timed up and go test. Patients in Group B had significantly better scores on the chair stand test (13.3 compared with 11.1 in Group A, p = 0.04) at six months postoperatively, but there was no difference at twelve months (14.0 compared with 13.6). The two groups did not differ significantly on the timed up and go test at either six or twelve months. The two groups also did not differ on the muscle strength testing. Intraoperative parameters differed significantly between the groups with respect to operative time, fluoroscopy time, and incision length, with the difference favoring Group B for each parameter. Analog pain scale values were similar in Group A (2.49) and Group B (2.15) at twelve months postoperatively. CONCLUSIONS: Patients in our prospective randomized study who were treated with trochanteric nailing did not differ in hip function at one year postoperatively compared with patients treated with intramedullary nailing through the piriformis fossa. The values of several intraoperative parameters were significantly better in the trochanteric nailing group. Our data indicate that the functional hip outcome of femoral intramedullary nailing performed through the greater trochanter is equal to that of intramedullary nailing performed through the piriformis fossa.

Evolving management of middle-third clavicle fractures in the National Football League.

BACKGROUND: Clavicle fractures have historically been managed nonoperatively. Recent literature suggests a subset of clavicle fractures may be best treated with primary surgical treatment. PURPOSE: To review the National Football League (NFL) experience in the management of middle-third clavicle fractures over a 5-year period. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A retrospective review of clavicle fractures that occurred during a 5-season period was obtained from the NFL Injury Surveillance System. A detailed questionnaire was also sent to the medical staff of all 32 NFL teams. RESULTS: Nineteen players sustained a middle-third clavicle fracture over the 5-year period. Six fractures were nondisplaced or minimally displaced. All 6 healed at an average time of 7.3 weeks. Thirteen fractures were 100% displaced. Six of the 13 underwent acute surgical fixation that resulted in fracture healing without complication at an average of 8.8 weeks. The remaining 7 players with a completely displaced fracture were initially treated nonoperatively. Three of these 7 healed clinically without sequela at an average of 13.3 weeks after injury; however, 4 players sustained a refracture within 1 year of the initial injury. CONCLUSION: Over the past 5 years, nearly 50% of NFL players with a completely displaced middle-third clavicle fracture were treated successfully with acute surgical fixation without sequela and healed at an average of 8.8 weeks. Three of these players were able to return to play during the same season. In addition, 4 of 7 players initially treated nonoperatively for a completely displaced middle-third clavicle fracture refractured their clavicle within a 1-year period from their initial injury. The 4 players missed an average of 1.5 seasons because of their clavicle injury and subsequent clinical course. Based on this review, it may be reasonable to consider acute surgical treatment of this injury in the NFL player to enable a successful clinical outcome in a predictable time frame.

A biomechanical evaluation of ulnar collateral ligament reconstruction using a novel technique for ulnar-sided fixation.

BACKGROUND: Techniques for ulnar collateral ligament (UCL) reconstruction have evolved since its original description. HYPOTHESIS: Ulnar collateral ligament reconstruction using the ZipLoop for ulnar-sided fixation, as combined with the humeral docking technique supplemented with an interference screw, will restore valgus stability similar to that of the Jobe technique and the native ligament. STUDY DESIGN: Controlled laboratory study. METHODS: Kinematic testing was performed on 8 matched pairs of cadaver elbows with an electromagnetic tracking system through an arc of motion for the intact, disrupted, and reconstructed states of the UCL in an unloaded and loaded condition. From each pair, the docking technique using the ZipLoop for ulnar fixation and humeral docking technique supplemented with an interference screw and the traditional Jobe technique were performed with matched gracilis allograft tendons. After kinematic testing, both reconstruction groups were tested to failure at 70 degrees of flexion. RESULTS: Kinematic results for the unloaded condition showed that both reconstruction techniques significantly overcorrected (less valgus angulation) the specimens between 40 degrees and 120 degrees of flexion when compared with the intact ligament (all P values < .027). Under loaded conditions, the ulnar trajectories for both reconstruction techniques exhibited significantly greater valgus angulation (undercorrection) at 20 degrees of flexion (Jobe, P = .0084; ZipLoop, P = .0289) when compared with the intact ligament but were not significantly different over the remaining arc of motion. Failure testing resulted in no significant statistical difference between the 2 reconstruction groups. Failure testing demonstrated that humeral tunnel egress, midsubstance elongation, and ulnar tunnel egress of the ligament were similar between the reconstruction techniques. CONCLUSION: The docking technique using the ZipLoop for ulnar-sided fixation is biomechanically equivalent to the Jobe technique for UCL reconstruction. Both reconstruction techniques restore valgus stability similar to that of the native UCL ligament. CLINICAL RELEVANCE: This modification in the docking technique restores elbow kinematics while eliminating the risk of ulnar bone bridge fracture, and it allows for retensioning of the graft after cortical fixation.