Italian version of the anterior cruciate ligament-return to sport after injury scale (IT ACL-RSI): translation, cross-cultural adaptation, validation and ability to predict the return to sport at medium-term follow-up in a population of sport patients.

PURPOSE: The timing of psychological and physical recovery after anterior cruciate ligament reconstruction represents an open issue in current orthopedic practice. Several tools have been developed to evaluate these factors, with the most recent being represented by the anterior cruciate ligament (ACL) return to sport injury scale (ACL-RSI). The aims of this study were to provide a validated Italian translation of the ACL-RSI in a population of sport patients, and to identify a possible correlation of the ACL-RSI score with the return to sport (RTS) time and the level of sport participation in comparison to the pre-injury one. METHODS: The Italian translation and cultural adaptation of the scale were completed using a using the "translation-back translation" method. A total of 130 patients were enrolled and completed the study questionnaires 6 months after ACL reconstruction. Randomly, 65 of them were re-tested for the ACL-RSI within 2 weeks. The internal consistency, reliability, feasibility, and construct validity of the Italian version of ACL-RSI were assessed and compared to Italian version of the KOOS, the Lysholm Score, the AKPS and the IKDC subjective score. Responsiveness was tested comparing patients returning to sport at 6 and 12 months. The Tegner activity scale was collected at baseline, 6 and 12 months to identify the level of activity after return to sport, in relation to the ACL-RSI score. RESULTS: The Italian adaptation of the ACL-RSI demonstrated excellent internal consistency (Cronbach's alpha = 0.953), reliability (test-retest ICC = 0.916) and feasibility, with no ceiling or floor effect. Construct validity was confirmed by the moderate to strong correlation with all the other scales (p < 0.0001). Slight and non-significant higher ACL-RSI score was shown by patients returned to sport at 6 or 12 months after surgery. Nevertheless, the ACL-RSI score at 6 months was significantly different between patients who returned and those who did not returned to the same level of sport activity 12 months after the procedure. CONCLUSIONS: This study demonstrated that the Italian ACL-RSI is a reliable tool for evaluating the psychological readiness for return to sports of athletes who underwent ACL reconstruction, especially when collected at the end of the rehabilitation process. Since the IT ACL-RSI used in this study is a faithful translation of the original English version, this finding can be generalized to other cultural contexts and languages too. LEVEL OF EVIDENCE: Level II.

Different timing in allograft and autograft maturation after primary anterior cruciate ligament reconstruction does not influence the clinical outcome at mid-long-term follow-up.

PURPOSE: The use of allografts in primary anterior cruciate ligament reconstruction (ACLR) is increasing although they are still supposed to be associated to greater risk of re-rupture due to a slower and less efficient graft maturation. The aim of this prospective randomized controlled study was to compare the graft maturation after ACLR with allograft and autograft by MRI at 6- and 12-month follow-up and integrate these data with the functional and clinical results observed at 6-, 12- and 60-month follow-up. METHODS: Fifty patients with indication to primary ACLR were randomly and equally divided into hamstring autograft or allograft tendon groups. The graft maturation was measured at 6- and 12-month follow-up by the SNQ score and other radiological parameters on MRI scans. Clinical and functional recovery was evaluated by Lysholm score, Visual Analogues Scale, Tegner activity scale and modified Cincinnati knee rating system at 6, 12 and 60 months after surgery to estimate the predictive value of the radiological parameters for clinical outcomes. Return-to-sport (ACL-RSI) was measured 60 months after surgery. RESULTS: Three patients had retear of the neo-ligament (two from Auto group and one from Allo group). All the clinical/functional parameters significantly improved over time, with no statistically significant difference between the groups. At 6 months, the SNQ value was significantly higher in the Auto than in the Allo group (12.9 vs 7.9, p = 0.038), but at 12 months they were comparable (9.8 vs 10.4). The 6-month SNQ values did not correlate with the clinical scores, whereas the 12-month SNQ values significantly correlated with the Cincinnati score, Lysholm score and Tegner activity scale collected at 60-month follow-up. CONCLUSION: No clinical or functional differences have been found between the two treatment groups, supporting the suitability of using allograft in primary ACLR, when available. The results at MRI scans showed a different graft maturation trend in the two groups, with allografts being more reactive in the first 6 months. MRI together with the subjective evaluation allows to evaluate objectively the status of the neo-ligamentization process and therefore helps the surgeon to dictate the individual time for return-to-sport. LEVEL OF EVIDENCE: Level I.

Epidemiology of Posterior Cruciate Ligament Reconstructions in Italy: A 15-Year Study.

BACKGROUND: The posterior cruciate ligament (PCL) is an essential element in knee stability. PCL reconstructions represent an under-investigated topic in the literature due to the rarity of this type of knee injury. This study aims to investigate the incidence of PCL reconstructive surgeries in Italy, following their trend during a 15-year period. METHODS: The National Hospital Discharge records (SDO) collected by the Italian Ministry of Health between January 2001 and October 2015 were analyzed. The database reports anonymous data comprising patients' ages, genders, International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for diagnosis and intervention, census regions, regions of hospitalization, lengths of hospitalization and types of reimbursement. RESULTS: The overall incidence of PCL reconstructions in the Italian population during the study period was 0.46 surgeries per 100,000 inhabitants/year, ranging from 0.32 to 0.54. The median patient's age was 30 years old, and the male:female ratio was 5.3. PCL lesions were isolated in 39.7% of patients, while anterior cruciate ligament injuries were the most frequently associated lesions (31.1%). CONCLUSIONS: The incidence of PCL reconstruction in Italy was low and stable during the study period. Young men are the category at the highest risk for these procedures. Given the paucity of epidemiological data on PCL reconstructions, this data may represent a reference for the current and foreseeable needs in PCL surgeries for countries sharing similar cultural context.

Incidence of injuries in young soccer players: epidemiological study in an Italian elite club.

BACKGROUND: Football is the most popular sport in the world, increasingly played by the youngsters. However, little epidemiological data exists regarding injuries in young players. The aim of this study was to describe the most common types and sites of injury among the different classes of a single professional football club. METHODS: The present perspective study covered a three-season period, including 679 children divided in 9 age classes. All the athletes were managed by the same staff and for each injury, onset date, date of return to training, anatomic site and type of injury were recorded. RESULTS: The mean age of the population was 12.7 years old (Range 7.4-16.9). A total 975 injuries were recorded without significant differences among seasons (P=0.682). The most affected classes were U17 and U16, while the lowest rate of injury was in U11. The most common injury in U9 and U10 affected foot and ankle, while in all the other classes thigh was the most frequently site involved. Focusing on the type of injury, the most common cause was traumatic (40.9%), followed by muscular diseases. The mean value of absence from soccer was 19.7 days (±1.2). The highest rate of injuries occurred in September and August. In January and February, injuries were more frequent during competitions, whereas in the other months the rate was inverted. CONCLUSIONS: This study highlights that preseason and the final phase of the season are more at risk of injury and the type of injury differs between classes.

Autologous Matrix-Induced Chondrogenesis (AMIC) and AMIC Enhanced by Autologous Concentrated Bone Marrow Aspirate (BMAC) Allow for Stable Clinical and Functional Improvements at up to 9 Years Follow-Up: Results from a Randomized Controlled Study.

The aims of the study were to evaluate long-term outcomes after autologous matrix-induced chondrogenesis (AMIC) in the treatment of focal chondral lesions and to assess the possible improvements given by the combination of this technique with bone marrow aspirate concentrate (BMAC). Twenty-four patients (age range 18⁻55 years) affected by focal knee chondral lesions were treated with standard AMIC or AMIC enhanced by BMAC (AMIC+). Pain (Visual Analogue Scale (VAS)) and functional scores (Lysholm, International Knee Documentation Committee (IKDC), Tegner, Knee injury and Osteoarthritis Outcome Score (KOOS)) were collected pre-operatively and then at 6, 12, 24, 60, and 100 months after treatment. Magnetic resonance imaging (MRI) evaluation was performed pre-operatively and at 6, 12, and 24 months follow-ups. Patients treated with AMIC+ showed higher Lysholm scores (p = 0.015) and lower VAS (p = 0.011) in comparison with patients in the standard AMIC group at the 12 months follow-up. Both treatments allowed for functional and pain improvements with respect to pre-operative levels lasting up to 100 months. MRI revealed consistent cartilage repair at 24 months in both groups. This study shows that AMIC and AMIC+ are effective treatments for focal chondral lesions with beneficial effect lasting up to 9 years. AMIC+ allows for faster recovery from injury, and is thus more indicated for patients requiring a prompt return to activity. Level of evidence: II, randomized controlled trial in an explorative cohort.

Knee hyperextension and a small lateral condyle are associated with greater quantified antero-lateral rotatory instability in the patients with a complete anterior cruciate ligament (ACL) rupture.

PURPOSE: To identify factors associated with quantified rotatory stability (pivot-shift phenomenon) in the anterior cruciate ligament (ACL)-injured knee joint. METHODS: A consecutive sample of 54 patients who were diagnosed with an ACL injury and admitted to our hospital to undergo ACL reconstruction were enrolled in this study. Antero-lateral rotatory laxity of the knee joint was quantified using a Kinematic Rapid Assessment device (KiRA; Orthokey LTD) under spinal block before initiating reconstruction of the ACL. Univariate and multivariate regressions were performed assuming relationships between patient characteristics (independent variables) and quantified antero-lateral rotatory stability (a dependent variable). RESULTS: It was observed that a low BMI (t = - 1.659, n.s.), greater passive knee extension angle (t = 2.374, P = 0.023), and a narrower lateral femoral condyle width index (t = - 1.712, n.s.) could be candidates associated with the antero-lateral rotatory instability, using univariate analysis. Employing multivariate analysis controlling for these three variables, that the range of passive knee extension was found to be significantly associated with antero-lateral rotatory instability in the ACL-injured knee joint (t = 2.21, P = 0.035). Patients were then divided into two groups (pivot-shift negative versus positive groups) based on the KiRA-documented quantified pivot-shift test. Interestingly, 23.3% of patients were pivot-shift negative, even though their ACL was confirmed as a complete rupture by arthroscopic observations. The degree of passive knee extension was 2.3 ± 4.5 (mean ± SD) in the pivot-shift negative group, while it was 6.8 ± 6.6 in the pivot-shift positive group (n.s.). The lateral femoral condyle width index was 36.6 ± 2.0% in the pivot-shift negative group, and it was significantly wider than in the pivot-shift positive group (33.8 ± 2.6%, P = 0.0046). Finally, we estimated that the risk of positive pivot-shift depends on the degree of knee extension. The logistic regression analysis revealed that genu recurvatum significantly increased the odds ratio for positive pivot-shift (OR = 3.08, P = 0.047, 95% CI = 1.017-9.350). CONCLUSIONS: This study revealed that greater antero-lateral rotatory instability in patients with a complete ACL rupture was associated with genu recurvatum and small lateral femoral condyle. These factors should be considered as predictors of a poor outcome from an ACL reconstruction due to a higher load on the ACL graft, and therefore, the attending physicians should modify the treatment strategies accordingly. This study indicates that joint hyperlaxity and bone morphology contribute to the rotational stability of the knee joint, in addition to the ACL and antero-lateral complex (ALC). LEVEL OF EVIDENCE: IV.

Physiological and Physical Profile of Snowboarding: A Preliminary Review.

The sport of snowboarding has grown in popularity as both a recreational winter activity as well as a prominent Olympic sport. Both forms are comprised of one of three different disciplines within the sport: freestyle, alpine, and snowboard-cross. In recent years, the increased professionalism and substantial growth of snowboarding as a global sport has increasingly attracted the interest of exercise physiologists and sport scientists. Given the small (but growing) number of studies that have been published, the research analyzing the physiological and performance characteristics and requirements of snowboarding remains limited. The absence of such studies signifies a lack of examination into this important but under-explored area of research, which could contribute valuable information to the scientific community and international snowboarding teams. The studies conducted thus far have indicated different requirements of physiological and physical traits dependent upon the specific discipline of snowboarding in question. For example, in order to meet the divers demands of each discipline, athletes must develop various qualities, such as muscular strength and power. This can increase their ability to withstand the high forces and loads on the muscular system during competition, and further decrease their risk of lower limbs injuries. At the same time, the studies acknowledge the potential advantages of aerobic fitness in terms of recovery, to more efficiently sustain the athlete through both competitive and on- and off-snow training sessions. Given the value and breadth of application of these limited studies, further analysis and research could contribute greater knowledge and benefits to the field of snowboarding. Therefore, it is the purpose of this preliminary review to explore the current literature, providing further insight into the physiological and physical demands of snowboarding performance. This preliminary review is intended to stimulate interest among the communities of exercise physiologists, sport scientists and particularly coaches in order to improve our current understanding of snowboarding and its demands as a sport. This preliminary review further seeks to develop protocols and strategies to assess physiological and performance characteristics of snowboarding, monitor athletic performance, provide practical recommendations for training, identify new areas of scientific research, and develop accurate talent identification programs.

The Effect of Three Different Suture Anchors for Rotator Cuff Repair on Primary Cultures of Human Bone Marrow Mesenchymal Stem Cells.

Purpose The purpose of this study is to investigate the in vitro biocompatibility of three different suture anchors (all-suture anchor, metal anchor, and polyetheretherketone anchor), commonly used for the rotator cuff repair. Methods To assess the biocompatibility of the anchors, the possible cytotoxicity and the immunogenicity of the devices were assessed by cell viability assay and cell count on cultures of bone marrow stem cells (BMSCs) and peripheral blood leucocytes (PBLs), respectively. The possible inhibitory effect of the devices on BMSCs osteogenic potential was evaluated by alkaline phosphatase activity and matrix deposition assay. Results The viability of BMSCs was slightly reduced when cultured in the presence of the devices (-24 ± 3%). Nevertheless, they were able to differentiate toward the osteogenic lineage in all culture conditions. The proliferation of PBLs and the production of interleukin-2 were not enhanced by the presence of any device. Conclusion The analyzed devices did not significantly affect the normal cells functions when directly cultured with human primary BMSCs or PBLs, in terms of osteogenic differentiation and inflammatory reaction. Clinical Relevance A deeper knowledge of the biological reactions to different devices used in rotator cuff surgeries would improve the clinical outcome of these procedures.

Changes in Muscle Architecture of Vastus Lateralis Muscle After an Alpine Snowboarding Race.

Vernillo, G, Pisoni, C, Sconfienza, LM, Thiébat, G, and Longo, S. Changes in muscle architecture of vastus lateralis muscle after an alpine snowboarding race. J Strength Cond Res 31(1): 254-259, 2017-This study aimed to assess acute changes of vastus lateralis (VL) muscle architecture after an alpine snowboarding simulated race and to compare architecture characteristics between the front and rear legs on elite alpine snowboarders. Using ultrasonography, VL muscle thickness (MT), pennation angles (θ), and fascicle lengths (Lf) were assessed in 8 elite alpine snowboarders (25.6 ± 4.4 years; stature: 178.4 ± 9.8 cm; body mass: 78.1 ± 12.1 kg) before and directly after an alpine snowboarding simulated race under competition rules. Muscle thickness, θ, and Lf showed no meaningful changes (P > 0.05, differences reported as trivial) after the race for both legs. The rear leg tended to have a 14.0% lower θ (P = 0.04, differences rated as moderate) and a 13.6% higher Lf (P = 0.04, differences rated as moderate) compared with the front leg. Changes in muscle architecture are not observable immediately after an alpine snowboarding simulated race. The ∼14.0% difference in muscle architecture between the front and the rear leg suggests the presence of a morphological asymmetry in elite alpine snowboarders with direct implications for injury prevention and training prescription.

Strength Asymmetry Between Front and Rear Leg in Elite Snowboard Athletes.

OBJECTIVE: To examine possible bilateral strength asymmetries between the front (FL) and the rear leg (RL) in elite snowboard athletes due to the imposed asymmetrical position on the board. DESIGN: Observational study. SETTING: Department of Biomedical Sciences for Health, University of Milan. PARTICIPANTS: Thirty-three elite male snowboarders: 12 alpine athletes (SBalp), 11 snowboardcross athletes (SBx), and 10 freestyle athletes (SBfs). INTERVENTION: Open and closed kinetic chain exercises. MAIN OUTCOME MEASURES: Maximal isometric voluntary contraction (MVC) and vertical jump force (VJFT). RESULTS: Only SBalp athletes presented MVC and VJFT values in RL 9.9% and 11.3% greater than the corresponding value in FL (P < 0.001), respectively. No significant differences were observed in SBx and SBfs. CONCLUSIONS: A muscle strength asymmetry between FL and RL was detected only in elite SBalp. This asymmetry is lower than the ±15% cutoff interval used to define clinically relevant bilateral strength asymmetry and is likely to be explained by technical aspects. Indeed, only SBalp athletes naturally distributed the center of mass, and thus, the weight toward RL to have a good board control. This feature likely reflects a greater adaptation of the muscle characteristics.

Physiological characteristics of elite snowboarders.

BACKGROUND: The aim of this study was to profile the physiological qualities of elite snowboarders and quantified the relationships with snowboarding performance. METHODS: Ten alpine (ALP, mean±SD age: 25.6±4.4 yrs; body mass 78.1±12.1; height 178.4±9.8 cm; sum of 7 skinfolds 74.8±19.4 mm; body fat 13.8±3.7%) and ten snowboard cross (SBX, mean±SD age: 23.5±4.3 yrs; body mass 77.2±9.2; height 181.0±4.9 cm; sum of 7 skinfolds 70.1±21.1 mm; body fat 11.9±3.5%) elite male athletes undertook aerobic power (cycle ergometer maximum oxygen uptake), muscular isometric strength (maximal isometric voluntary contraction, MVC), and muscle-power (vertical jumps), as well as ALP (parallel giant slalom [PGS] and parallel slalom [PSL]) and SBX simulated competitions. Associations between measurements were assessed by correlation analysis. RESULTS: Absolute (ALP 383.1±38.0 W, P<0.01; SBX 339.7±41.3 W, P<0.05) and relative (ALP, 4.6±0.5 W·kg-1, P<0.01; SBX 4.5±0.3 W·kg-1, P<0.05) power output, power at the first (ALP 196.0±53.7 W, P<0.01; SBX 192.8±24.3, P<0.01) and second (ALP 285.4±60.6 W, P<0.01; SBX 280.4±20.3 W, P<0.01) ventilatory threshold, MVC (ALP 731.9±181.9 N·m-1, P<0.001; SBX 680.1±76.8 N·m-1, P<0.001) and leg stiffness (ALP 31.4±4.8 N·m-1·kg-1, P<0.01; SBX 25.4±3.0 N·m-1·kg-1, P<0.01) were highly correlated with PGS (r=-0.88 to -0.97), PSL (r=-0.84 to -0.94), and SBX (r=-0.89 to -0.93) performance times. CONCLUSIONS: To meet the demands of snowboarding competition, elite snowboarders require highly developed muscular strength and power. This study provides criteria for the selection of appropriate physiological variables for the longitudinal monitoring of relevant parameters in snowboarding.

In vitro characterization of stem/progenitor cells from semitendinosus and gracilis tendons as a possible new tool for cell-based therapy for tendon disorders.

PURPOSE: this study was conducted to characterize tendon stem/progenitor cells (TSPCs) isolated from human semitendinosus and gracilis tendons in terms of stemness properties and multi-differentiation potential. METHODS: TSPCs were isolated from waste portions of semitendinosus and gracilis tendons from three donors who underwent anterior cruciate ligament reconstruction. TSPCs were plated in culture until passage 4, when experiments to assess cell proliferation, viability and clonogenic ability were performed. The immunophenotype of TSPCs was evaluated by cytofluorimetric analysis. The in vitro osteogenic, chondrogenic, adipogenic and tenogenic potential was evaluated using biochemical, histological and gene expression analysis to detect specific differentiation markers. Statistical analysis was performed using Student's t-test. RESULTS: after a few passages in culture the cell populations showed a homogeneous fibroblast-like morphology typical of mesenchymal stem cells. The average doubling time of TSPCs increased from 52.4±4.8 at passage 2 to 100.8±23.4 hours at passage 4. The highest percentage of colonies was also found at passage 4 (4.7±2.3%). TSPCs showed the typical mesenchymal phenotype, with high expression of CD73, CD90 and CD105 and no expression of CD34 and CD45. Cells induced to differentiate toward osteogenic lineage showed significant upregulations of ALP activity (+189%, p<0.05) and calcified matrix deposition (+49%, p<0.05) compared with undifferentiated cells; culture in chondrogenic medium also provoked a significant increase in glycosaminoglycan levels (+108%, p<0.05). On the other hand, TSPCs were not able to respond to adipogenic stimuli. Scleraxis gene expression and decorin gene expression, considered tenogenic markers, were already very high in control cells, and culture in tenogenic medium further increased these values although not significantly. CONCLUSIONS: our data show that it is possible to isolate TSPCs from very small fragments of tissue and that they show the typical features of MSCs and multi-differentiation potential, above all toward osteogenic and chondrogenic lineages. CLINICAL RELEVANCE: this study can be considered one of the first attempts to clarify the biology of tendon cell populations, focusing in particular on the potential applicability of this cell source for future regenerative medicine purposes.