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ObjectiveTo investigate if treatment with a single injection of autologous micro-fragmented adipose tissue improved patient-reported health compared with a placebo saline injection in patients suffering from pain and functional impairment due to knee osteoarthritis.MethodsWe conducted a randomised controlled trial with patients blinded to the treatment and allocated in a 1:1 ratio to one of two parallel groups. Patients aged 18–70 years with Kellgren-Lawrence grades 2–3 in the tibiofemoral joint and suffering from pain and functional impairment of the knee were eligible for inclusion. Abdominal adipose tissue was harvested by liposuction in all patients. The active treatment group was treated with an intra-articular injection of autologous micro-fragmented adipose tissue, and the placebo group with isotonic saline. The primary outcome was the Knee injury and Osteoarthritis Outcome Score (KOOS4) evaluated at 6 months.Results238 patients were assessed for eligibility and 120 (mean age 52.2, 58% female) included from January 2019 to February 2022. There were no statistically significant differences between the active treatment and the placebo group at any time point. Both groups showed statistically significant and clinically relevant improvements from baseline to 6, 12 and 24 months. Mean KOOS4 at 6 months was 55.5 (95% CI 51.4 to 59.6) for the active treatment group and 51.5 (95% CI 47.4 to 55.6) for the placebo group.ConclusionThis study did not show superiority of micro-fragmented adipose tissue compared with a placebo saline injection for the treatment of knee osteoarthritis.Trial registration number NCT03771989.

Purpose The aim of the study was to perform a systematic review and best knowledge synthesis of the present literature concerning biomechanical risk factors for developing first-time and recurrent patella dislocation. Methods The study was performed as a systematic review following PRISMA guidelines. PubMed and EMBASE were systematically searched. Studies investigating participants with risk factors for first-time as well as recurrent patella dislocation were included. The records were screened, and data extracted independently by two researchers supervised by a third independent assessor. The study was registered in PROSPERO. Results A total of 6233 records were screened, and 50 studies met the inclusion criteria. The biomechanical risk factors: trochlear dysplasia, increased tibial tuberosity–trochlear groove distance (TT-TG), and patella alta were found to be statistically significantly associated with patella dislocation in several publications and were thus recognized as risk factors for patella dislocation. The soft-tissue stabilizers: longer and thinner MPFL ligament, increased number of type 2C and decreased number of type 1 muscle fibers, and joint laxity were found to be statistically significantly associated with patella dislocation in a few publications, but due to limited evidence, no conclusion was made on this matter. Conclusion There is strong evidence in the literature that abnormalities of bony stabilizers, trochlear dysplasia, increased TT–TG distance, and patella alta are risk factors for patella dislocation. There is less evidence that soft-tissue stabilizers are risk factors. The study emphasizes the importance of a thorough investigation of bony stabilizers in clinical decision-making. Level of evidence Level IV.

ObjectiveInvestigate the incidence and burden of injuries by age group in youth football (soccer) academy players during four consecutive seasons.MethodsAll injuries that caused time-loss or required medical attention (as per consensus definitions) were prospectively recorded in 551 youth football players from under 9 years to under 19 years. Injury incidence (II) and burden (IB) were calculated as number of injuries per squad season (s-s), as well as for type, location and age groups.ResultsA total of 2204 injuries were recorded. 40% (n=882) required medical attention and 60% (n=1322) caused time-loss. The total time-loss was 25 034 days. A squad of 25 players sustained an average of 30 time-loss injuries (TLI) per s-s with an IB of 574 days lost per s-s. Compared with the other age groups, U-16 players had the highest TLI incidence per s-s (95% CI lower-upper): II= 59 (52 to 67); IB=992 days; (963 to 1022) and U-18 players had the greatest burden per s-s: II= 42.1 (36.1 to 49.1); IB= 1408 days (1373 to 1444). Across the cohort of players, contusions (II=7.7/s-s), sprains (II=4.9/s-s) and growth-related injuries (II=4.3/s-s) were the most common TLI. Meniscus/cartilage injuries had the greatest injury severity (95% CI lower-upper): II= 0.4 (0.3 to 0.7), IB= 73 days (22 to 181). The burden (95% CI lower-upper) of physeal fractures (II= 0.8; 0.6 to 1.2; IB= 58 days; 33 to 78) was double than non-physeal fractures.SummaryAt this youth football academy, each squad of 25 players averaged 30 injuries per season which resulted in 574 days lost. The highest incidence of TLI occurred in under-16 players, while the highest IB occurred in under-18 players.

Introduction Exercise programmes are used in the prevention and treatment of adductor-related groin injuries in soccer; however, there is a lack of knowledge concerning the intensity of frequently used exercises. Objective Primarily to investigate muscle activity of adductor longus during six traditional and two new hip adduction exercises. Additionally, to analyse muscle activation of gluteals and abdominals. Materials and methods 40 healthy male elite soccer players, training >5 h a week, participated in the study. Muscle activity using surface electromyography (sEMG) was measured bilaterally for the adductor longus during eight hip adduction strengthening exercises and peak EMG was normalised (nEMG) using an isometric maximal voluntary contraction (MVC) as reference. Furthermore, muscle activation of the gluteus medius, rectus abdominis and the external abdominal obliques was analysed during the exercises. Results There were large differences in peak nEMG of the adductor longus between the exercises, with values ranging from 14% to 108% nEMG (p<0.0001). There was a significant difference between legs in three of the eight exercises (35–48%, p<0.0001). The peak nEMG results for the gluteals and the abdominals showed relatively low values (5–48% nEMG, p<0.001). Conclusions Specific hip adduction exercises can be graded by exercise intensity providing athletes and therapists with the knowledge to select appropriate exercises during different phases of prevention and treatment of groin injuries. The Copenhagen Adduction and the hip adduction with an elastic band are dynamic high-intensity exercises, which can easily be performed at any training facility and could therefore be relevant to include in future prevention and treatment programmes.

Background/aim Reference values are needed in order to interpret the Copenhagen Hip and Groin Outcome Score (HAGOS) in male soccer players with hip and groin pain. The aim of this study was to establish reference values for HAGOS in hip and groin injury-free male soccer players. Methods We included 444 groin injury-free soccer players from 40 clubs (divisions 1–4) in Eastern Denmark, mean age (SD) 23.6 (4.4), training soccer 3.4 (1) times per week. All players were hip and groin injury-free at the time of inclusion (beginning of season, 2011). Results Of the 444 hip and groin injury-free players, 301 reported no hip and/or groin pain in either the present or the previous season, and 143 reported that they had experienced hip and/or groin pain in the previous season. Players (n=143) with hip and groin pain in the previous season displayed lower scores than players without (n=301), for all HAGOS subscales (p<0.001). Age and playing level were not related to HAGOS. The 95% reference ranges for HAGOS subscales in hip and groin injury-free soccer players, with no pain in the previous or present season (n=301), are: pain: 80.1–100, symptoms: 64.3–100, activities of daily living: 80.3–100, sport and recreational activities: 71.9–100, participation in physical activity: 75–100 and quality of living: 75–100. Conclusions Lower HAGOS subscales are seen in soccer players who have experienced hip and/or groin pain in the previous season, compared with those who have not. Median HAGOS subscale scores in hip and groin injury-free soccer players are in proximity to the maximum score (100 points).

Background Osteoarthritis is a destructive joint disease that leads to degeneration of cartilage and other morphological changes in the joint. No medical treatment currently exists that can reverse these morphological changes. Intra-articular injection with autologous, micro-fragmented adipose tissue has been suggested to relieve symptoms. Methods/Design The study is a blinded randomized controlled trial with patients allocated in a 1:1 ratio to 2 parallel groups. Patients suffering from pain and functional impairment due to osteoarthritis Kellgren-Lawrence grades 2–3 in the tibiofemoral joint are eligible for inclusion. The intervention group is treated with an intra-articular injection with autologous, micro-fragmented adipose tissue prepared using the Lipogems® system. The control group receives an intra-articular injection with isotonic saline. In total, 120 patients are to be included. The primary outcome is The Knee injury and Osteoarthritis Outcome Score (KOOS4) evaluated at 6 months. Secondary outcomes are KOOS at 3, 12 and 24 months; the Tegner activity score; treatment failure; and work status of the patient. The analysis will be conducted both as intention-to-treat and per-protocol analysis. Discussion This trial is the first to investigate the efficacy of autologous, micro-fragmented adipose tissue in a randomized controlled trial. The study uses the patient-reported outcome measure Knee Injury and Osteoarthritis Outcome Score (KOOS4) after 6 months as the primary outcome, as it is believed to be a valid measure to assess the patient’s opinion about their knee and associated problems when suffering from osteoarthritis.

Background: Management of the capsulotomy at termination of hip arthroscopic procedures in the treatment of femoroacetabular impingement syndrome (FAIS) is debated. Clinical outcomes in favor of capsular closure were demonstrated in a retrospective study; nonetheless, this finding could not be confirmed in a recent randomized, controlled trial comparing capsular closure with unrepaired capsulotomy. Purpose/Hypothesis: This randomized, controlled multicenter trial aimed to evaluate the effect of capsular closure on subjective postoperative outcomes and revision rates in patients undergoing hip arthroscopy for FAIS. It was hypothesized was that capsular closure would result in better patient-reported outcome scores compared with no closure of the interportal capsulotomy. Study Design: Randomized controlled clinical trial; Level of evidence, 1. Methods: All eligible patients with FAIS from 4 surgical centers in Denmark, referred for hip arthroscopy (n = 200), were randomly assigned to either closure or no closure of the interportal capsulotomy at termination of the arthroscopic procedure. The capsular closure was performed with 2 to 3 absorbable sutures, using the “Quebec City Slider” knot technique. The primary outcome was the Copenhagen Hip and Groin Outcome Score (HAGOS) Sport/Recreation subscale. The secondary outcomes were the other HAGOS subscales, International Hip Outcome Tool (iHOT-12), Hip Sports Activity Scale (HSAS), pain during rest and activity measured on a numerical rating scale (NRS), and a measure of the overall well-being by the European Quality of Life–5 dimensions (EQ-5D). Furthermore, the rate of revision procedures and the rate of conversion to total hip replacement were recorded. Results: Baseline epidemiological and morphological characteristics were comparable between the treatment groups, except for a higher percentage of women in the capsular closure group (65% vs 48%; P < .05). Both cohorts had significantly improved scores 1 year after surgery, with no difference between the 2 groups, except for the HSAS: HAGOS-Pain (P = .19), HAGOS-Symptoms (P = .33), HAGOS-Activities of Daily Living (P = .21), HAGOS-Sport/Recreation (P = .52), HAGOS-Physical Activity (P = .59), HAGOS-Quality of Life (P = .16), iHOT-12 (P = .15), HSAS (P = .03), EQ-5D (P = .12), NRS-rest (P = .20), and NRS-activity (P = 0.23). Five patients received revision hip arthroscopy after 1 year—1 in the unrepaired versus 4 in the repaired cohort. No patients had conversion to total hip replacement. Conclusion: This randomized, controlled multicenter trial showed no effect on clinical outcomes (HAGOS, iHOT-12, EQ-5D, and NRS) 1 year after hip arthroscopy for FAIS of closure of the interportal capsulotomy at termination of surgery. Registration: NCT03158454 (ClinicalTrials.gov identifier); 1-10-72-279-16.

Background: Subacromial pain syndrome has no universally accepted definition. Patients with shoulder pain are often diagnosed with subacromial pain syndrome without consideration of conflicting or concomitant diagnoses. Purpose: To investigate the prevalence of conflicting and concomitant diagnoses in patients with signs and symptoms of subacromial pain syndrome. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Using standardized diagnostic criteria, a prospective cohort of patients with signs and symptoms of subacromial pain syndrome was divided into 2 mutually exclusive groups: (1) patients with conflicting diagnoses—e.g., frozen shoulder or glenohumeral osteoarthritis (OA); (2) patients with subacromial pain syndrome. Patients with subacromial pain syndrome were further divided into 2 groups: (1) isolated subacromial pain syndrome; (2) subacromial pain syndrome with concomitant diagnoses—e.g., acromioclavicular OA, full-thickness rotator cuff tears, shoulder instability, long head biceps tendon pathology, labral lesions, and calcified tendinopathy. Standardized physical examination tests, radiographs, ultrasound, and magnetic resonance imaging scans were utilized. Tests were performed by experienced orthopaedic specialists in accordance with predefined standardized protocols. Results: We systematically screened 3321 patients, of whom 576 had signs and symptoms of subacromial pain syndrome (mean age, 56 years; 57% women). Of these, 168 (29%) patients had conflicting diagnoses, with frozen shoulder accounting for the majority of these diagnoses. The remaining 408 patients were diagnosed with subacromial pain syndrome. Of these, 172 (42%) had at least 1 concomitant diagnosis, and 55 (13%) had multiple concomitant diagnoses. In total, 22 different combinations of concomitant diagnoses were observed across the 172 patients. Acromioclavicular OA and full-thickness rotator cuff tears, particularly of the supraspinatus, were the most common concomitant diagnoses. Biceps tendon pathology, calcified tendinopathy, minor shoulder instability, and superior labrum anterior to posterior (SLAP) lesions were less common. Conclusion: Patients presenting with signs and symptoms of subacromial pain syndrome have a high prevalence of conflicting and concomitant diagnoses. This heterogeneity is a clinical challenge that necessitates a systematic and transparent diagnostic approach in patients presenting with signs and symptoms of subacromial pain syndrome. ClinicalTrials.gov: NCT05549674.

Background: Despite being one of the most common sports injuries, there are no criteria-based rehabilitation programs published for acute adductor injuries. Purpose: To evaluate return-to-sport (RTS) outcomes and reinjuries after criteria-based rehabilitation for athletes with acute adductor injuries. Study Design: Cohort study; Level of evidence, 2. Methods: Male adult athletes with an acute adductor injury underwent a supervised, standardized criteria-based exercise rehabilitation program. Magnetic resonance imaging (MRI) was used to grade the injury extent from 0 (negative finding) to 3 (complete tear/avulsion). There were 3 milestones used to evaluate the RTS continuum: (1) clinically pain-free, (2) completion of controlled sports training, and (3) return to full team training. Subsequent injuries were registered within the first year. Results: We included 81 athletes with an acute adductor injury (MRI grade 0: n = 14; grade 1: n = 20; grade 2: n = 30; grade 3: n = 17). Of these, 61 (75%) athletes achieved RTS milestone 1, 50 (62%) achieved RTS milestone 2, and 75 (93%) achieved RTS milestone 3. There were no statistical differences in the RTS duration between MRI grade 0, 1, and 2 at any RTS milestone; thus, these were grouped together as grade 0-2. The median time (interquartile range [IQR]) for athletes with grade 0-2 injuries to become clinically pain-free was 13 days (IQR, 11-21 days), to complete controlled sports training was 17 days (IQR, 15-27 days), and to return to full team training was 18 days (IQR, 14-27 days). For athletes with a grade 3 injury, median times were 55 days (IQR, 31-75 days), 68 days (IQR, 51-84 days), and 78 days (IQR, 68-98 days), respectively. The overall 1-year reinjury rate was 8%. Athletes who achieved RTS milestone 1 had a statistically significantly lower reinjury rate than athletes who did not (5% vs 21%, respectively; ϕ = –0.233; P = .048). Athletes who achieved RTS milestone 2 had a nonstatistically significantly lower reinjury rate than athletes who did not (6% vs 13%, respectively; ϕ = –0.107; P = .366). Conclusion: We analyzed the results of a criteria-based rehabilitation protocol for athletes with acute adductor injuries. Athletes with an MRI grade 0-2 adductor injury were clinically pain-free after approximately 2 weeks and returned to full team training after approximately 3 weeks. Most athletes with an MRI grade 3 adductor injury were pain-free and returned to full team training within 3 months. Meeting the clinically pain-free criteria resulted in fewer reinjuries compared with not meeting the criteria.