The footballer's fracture

A practical, quantitative, fracture healing endpoint assessment criterion for tibial fractures treated with external fixation

There is a need for a quick, simple, repeatable, but quantifiable assessment tool to determine the fracture healing endpoint of tibial fractures that does not rely on the use of X-rays or on un-measured manipulation. This article presents an argument to support a 'maximum of 1° bending' criterion. The criterion was established from an examination of patient fracture stiffness profiles and following observations of stiffness measurements made in clinics. A proprietary mono-lateral external fixator was used to test the criterion. Sixty subjects had their fracture healing endpoint assessed using this criterion compared with the 15 N m/deg in two planes criterion, and it was deemed to be successful. The method of assessment for both mono-lateral and frame fixation (Ilizarov) is demonstrated.

Shinguards effective in preventing lower leg injuries in football: Population-based trend analyses over 25 years

OBJECTIVES

The majority of football injuries are caused by trauma to the lower extremities. Shinguards are considered an important measure in preventing lower leg impact abrasions, contusions and fractures. Given these benefits, Fédération Internationale de Football Association introduced the shinguard law in 1990, which made wearing shinguards during matches mandatory. This study evaluated the effect of the introduction of the shinguard law for amateur players in the Netherlands in the 1999/2000-football season on the incidence of lower leg injuries.

DESIGN

Time trend analyses on injury data covering 25 years of continuous registration (1986-2010).

METHODS

Data were retrieved from a system that records all emergency department treatments in a random, representative sample of Dutch hospitals. All injuries sustained in football by patients aged 6-65 years were included, except for injuries of the Achilles tendon and Weber fractures. Time trends were analysed with multiple regression analyses; a model was fitted consisting of multiple straight lines, each representing a 5-year period.

RESULTS

Patients were predominantly males (92%) and treated for fractures (48%) or abrasions/contusions (52%) to the lower leg. The incidence of lower leg football injuries decreased significantly following the introduction of the shinguard law (1996-2000: -20%; 2001-2005: -25%), whereas the incidence of all other football injuries did not. This effect was more prominent at weekends/match days. No gender differences were found.

CONCLUSIONS

The results significantly show a preventive effect of the shinguard law underlining the relevance of rule changes as a preventive measure and wearing shinguards during both matches and training sessions.

The effectiveness of shin guards used by football players

In football, injuries from opponent contact occur commonly in the lower extremities. FIFA the world's governing body for football requires players to wear shin guards. The aim of this study was to compare the protective effectiveness of polypropylene based shin guards with custom-made carbon fiber ones. Three commercial polypropylene shin guards (Adidas Predator™, Adidas UCL™, and Nike Mercurial™) and two custom-made carbon fiber shin guards were examined. The experimental setup had the following parts: 1) A pendulum attached a load cell at the tip (CAS Corp., Korea) and a fixed prosthetic foot equipped with a cleat to simulate an attacker's foot. 2) An artificial tibia prepared by condensed foam and reinforced by carbon fibers protected with soft clothing. 3) A multifunctional sensor system (Tekscan Corp., F-Socket System, Turkey) to record the impact on the tibia. In the low impact force trials, only 2.79-9.63 % of the load was transmitted to the sensors. When comparing for mean force, peak force and impulse, both carbon fiber shin guards performed better than the commercial ones (Adidas Predator™, Adidas UCL™, and Nike Mercurial™) (p = 0.000). Based on these same parameters, the Nike Mercurial™ provided better protection than the Adidas Predator™ and the Adidas UCL™ (p = 0.000). In the high impact force trials, only 5.16-10.90 % of the load was transmitted to the sensors. For peak force and impulse, the carbon fiber shin guards provided better protection than all the others. Carbon fiber shin guards possess protective qualities superior to those of commercial polypropylene shin guards. Key PointsShin guards decrease the risk of serious injuries.Carbon shin guards provide sufficient protection against high impact forces.Commercially available Polypropylene based shin guards do not provide sufficient protection against high impact forces.

An update on the epidemiology of pediatric fractures

Despite public health measures to prevent childhood injuries, the incidence of pediatric fractures is increasing. This fracture incidence is dependent on many demographic factors, the various contributors to bone health, and an individual's risk-taking behavior. Although traditional play activities continue to be the prevalent causes for fractures, there is an evolving array of new sport and recreation activities that carry significant fracture risk. The following review article outlines the developing epidemiology of pediatric fractures by analyzing some of the individual risk factors that influence fracture incidence as well as the variety of activities that are associated with these fractures.

Bone tissue engineering: a review in bone biomimetics and drug delivery strategies

Critical-sized defects in bone, whether induced by primary tumor resection, trauma, or selective surgery have in many cases presented insurmountable challenges to the current gold standard treatment for bone repair. The primary purpose of a tissue-engineered scaffold is to use engineering principles to incite and promote the natural healing process of bone which does not occur in critical-sized defects. A synthetic bone scaffold must be biocompatible, biodegradable to allow native tissue integration, and mimic the multidimensional hierarchical structure of native bone. In addition to being physically and chemically biomimetic, an ideal scaffold is capable of eluting bioactive molecules (e.g., BMPs, TGF-betas, etc., to accelerate extracellular matrix production and tissue integration) or drugs (e.g., antibiotics, cisplatin, etc., to prevent undesired biological response such as sepsis or cancer recurrence) in a temporally and spatially controlled manner. Various biomaterials including ceramics, metals, polymers, and composites have been investigated for their potential as bone scaffold materials. However, due to their tunable physiochemical properties, biocompatibility, and controllable biodegradability, polymers have emerged as the principal material in bone tissue engineering. This article briefly reviews the physiological and anatomical characteristics of native bone, describes key technologies in mimicking the physical and chemical environment of bone using synthetic materials, and provides an overview of local drug delivery as it pertains to bone tissue engineering is included.

Soccer injuries in children

Soccer is the most popular sport in the world, with FIFA recognising more than 265 million amateur players. Despite the fact that soccer is a contact sport, it is perceived to be relatively safe to play, a factor that has contributed to its status as the fastest growing team sport in the USA. Acute and minor injuries predominate in the statistics, with contusions and abrasions being the most commonly recorded. As would be expected, the majority of soccer injuries are to the lower limbs, with serious truncal and spinal trauma being rare. This article examines the type and anatomic location of injuries sustained by children and adolescents who play soccer, and the main mechanisms whereby such injuries occur. The risk factors underpinning injury occurrence are considered, along with injury avoidance tactics.

Pretibial injury: key factors and their use in developing laboratory test methods

Aims were to 1 characterize pretibial injuries and evaluate protection offered by garments/fabrics; and 2 develop a laboratory test to determine the potential protection provided by such fabrics. Most (>85%) of 75 patients treated for pretibial injury at Hutt Hospital, New Zealand sustained injury to one site and required surgery. Injuries were typically grade 3 or 4, 10-250 mm wide 30-350 mm long, and at the mid- to lower third of the tibia. The severity grade was lower when at least one fabric layer covered the site, slightly lower again with more than one layer, and when a knitted fabric/garment was worn, and a trouser type garment. Laboratory test methods and their application reflected these known variables. The force transmitted through multiple fabric layers was less then through one layer: thick pantyhouse and either denim or fabrics used in 'sweat pants' would minimize transmitted force and maximize impulse.

Regenerative medicine for the musculoskeletal system based on muscle-derived stem cells

The identification and characterization of stem cells is introducing a paradigm shift in the field of orthopaedic surgery. Whereas in the past, diseased tissue was replaced with allograft material, current trends in research revolve around regenerating damaged tissue. Muscle-derived stem cells have an application in regeneration of articular cartilage, bone, and skeletal muscle. These postnatal (ie, adult) stem cells can be readily isolated via muscle biopsy. They can display long-term proliferation, high self-renewal, and multipotent differentiation. They also can be genetically modified to secrete growth factors important to tissue healing, thereby functioning as implantable, long-lasting reservoirs for these molecules. Taken together, this evidence suggests that muscle-derived stem cells are well suited for gene therapy and tissue engineering applications for the musculoskeletal system. Effective implementation of even just a few applications of muscle-derived stem cell-based tissue engineering has the potential to revolutionize the way certain musculoskeletal diseases are managed.

Tibial shaft fractures in football players

Background

Football is officially the most popular sport in the world. In the UK, 10% of the adult population play football at least once a year. Despite this, there are few papers in the literature on tibial diaphyseal fractures in this sporting group. In addition, conflicting views on the nature of this injury exist. The purpose of this paper is to compare our experience of tibial shaft football fractures with the little available literature and identify any similarities and differences.

Methods and Results

A retrospective study of all tibial football fractures that presented to a teaching hospital was undertaken over a 5 year period from 1997 to 2001. There were 244 tibial fractures treated. 24 (9.8%) of these were football related. All patients were male with a mean age of 23 years (range 15 to 29) and shin guards were worn in 95.8% of cases. 11/24 (45.8%) were treated conservatively, 11/24 (45.8%) by Grosse Kemp intramedullary nail and 2/24 (8.3%) with plating. A difference in union times was noted, conservative 19 weeks compared to operative group 23.9 weeks (p < 0.05). Return to activity was also different in the two groups, conservative 27.6 weeks versus operative 23.3 weeks (p < 0.05). The most common fracture pattern was AO Type 42A3 in 14/24 (58.3%). A high number 19/24 (79.2%) were simple transverse or short oblique fractures. There was a low non-union rate 1/24 (4.2%) and absence of any open injury in our series.

Conclusion

Our series compared similarly with the few reports available in the literature. However, a striking finding noted by the authors was a drop in the incidence of tibial shaft football fractures. It is likely that this is a reflection of recent compulsory FIFA regulations on shinguards as well as improvements in the design over the past decade since its introduction.

Descriptive epidemiology of collegiate men's soccer injuries: National Collegiate Athletic Association Injury Surveillance System, 1988-1989 through 2002-2003

OBJECTIVE

To review 15 years of National Collegiate Athletic Association (NCAA) injury surveillance data for men's soccer and to identify potential areas for injury prevention initiatives.

BACKGROUND

The NCAA sanctioned its first men's soccer championship in 1959. Since then, the sport has grown to include more than 18 000 annual participants across 3 NCAA divisions. During the 15 years from 1988-1989 to 2002-2003, the NCAA Injury Surveillance System accumulated game and practice injury data for men's soccer across all 3 NCAA divisions.

MAIN RESULTS

The injury rate was 4 times higher in games compared with practices (18.75 versus 4.34 injuries per 1000 athlete-exposures, rate ratio = 4.3, 95% confidence interval = 4.2, 4.5), and preseason practices had a higher injury rate than in-season practices (7.98 versus 2.43 injuries per 1000 athlete-exposures, rate ratio = 3.3, 95% confidence interval = 3.1, 3.5). In both games and practices, more than two thirds of men's soccer injuries occurred to the lower extremities, followed by the head and neck in games and the trunk and back in practices. Although player-to-player contact was the primary cause of injury during games, most practice injuries occurred without direct contact to the injured body part. Ankle ligament sprains represented the most common injury during practices and games, whereas knee internal derangements were the most common type of severe injury (defined as 10+ days of time loss).

RECOMMENDATIONS

Sprains, contusions, and strains of the lower extremities were the most common injuries in men's collegiate soccer, with player-to-player contact the primary injury mechanism during games. Preventive efforts should focus on the player-to-player contact that often leads to these injuries and greater enforcement of the rules that are in place to limit their frequency and severity. Emphasis also should be placed on addressing the high rate of first-time and recurrent ankle ligament sprains.

Gene therapy in orthopaedics

Impressive advances in our knowledge of the molecular genetic basis of skeletal disorders and fracture healing have led to the development of novel therapeutics based on ectopic expression of one or more genes in patient cells that can influence repair or regenerative processes in bone. Gene therapy is an attractive new approach to the treatment of bone disorders. Orthopaedics has become one of the most promising areas of research into gene therapy. This is because many potential orthopaedic targets for gene therapy, unlike traditional targets such as cancer and severe genetic disorders, neither present difficult delivery problems nor require prolonged periods of gene expression. Gene therapy offers new possibilities for the clinical management of orthopaedic conditions that are difficult to treat by traditional surgical or medical means. Impaired bone healing, need for extensive bone formation, cartilage repair and metabolic bone diseases are all conditions where alterations of the signalling peptides involved may provide cure or improvement. In orthopaedic oncology, gene therapy may achieve induction of tumour necrosis and increased tumour sensitivity to chemotherapy. An increasing amount of evidence indicates that gene transfer can aid the repair of articular cartilage, menisci, intervertebral disks, ligaments and tendons. These developments have the potential to transform many areas of musculoskeletal care, leading to treatments that are less invasive, more effective and less expensive than existing modalities.

Tibial shaft fractures in amateur footballers

BACKGROUND

Footballers constitute a unique group of patients with tibial shaft fractures. They tend to have excellent general health and well developed musculature in the leg, and their fractures are generally closed injuries caused by low velocity trauma. However, little has been reported on the outcome after tibial shaft fractures in this group.

OBJECTIVE

To identify patterns of injury, response to treatment, and functional outcome in such a group.

METHOD

Fifty consecutive tibial shaft fractures in adult footballers treated at Merlin Park Regional Hospital over a five year period were analysed.

RESULTS

Most of the fractures were type A injuries (AO/ASIF classification). The incidence of complications was low. All patients reported good or excellent satisfaction with their outcome. However, only 54% of patients returned to playing competitive football.

CONCLUSION

Tibial shaft fractures in amateur footballers are associated with good results when traditional outcome criteria are used, but many patients do not regain their previous level of function.

Gene therapy and tissue engineering for sports medicine

Sports injuries usually involve tissues that display a limited capacity for healing. The treatment of sports injuries has improved over the past 10 to 20 years through sophisticated rehabilitation programs, novel operative techniques, and advances in the field of biomechanical research. Despite this considerable progress, no optimal solution has been found for treatment of various sports-related injuries, including muscle injuries, ligament and tendon ruptures, central meniscal tears, cartilage lesions, and delayed bone fracture healing. New biological approaches focus on the treatment of these injuries with growth factors to stimulate and hasten the healing process. Gene therapy using the transfer of defined genes encoding therapeutic proteins represents a promising way to efficiently deliver suitable growth factors into the injured tissue. Tissue engineering, which may eventually be combined with gene therapy, may potentially result in the creation of tissues or scaffolds for regeneration of tissue defects following trauma. In this article we will discuss why gene therapy and tissue engineering are becoming increasingly important in modern orthopaedic sports medicine practice. We then will review recent research achievements in the area of gene therapy and tissue engineering for sports-related injuries, and highlight the potential clinical applications of this technology in the treatment of patients with musculoskeletal problems following sports-related injuries.

Prevention of soccer injuries: a prospective intervention study in youth amateur players

BACKGROUND

Risk factors for soccer injuries and possibilities for prevention have been discussed by several authors, but only a few have investigated the effectiveness of preventive interventions.

PURPOSE

The aim of the present study was to evaluate the effects of a prevention program on the incidence of soccer injuries in male youth amateur players.

STUDY DESIGN

Prospective controlled intervention study.

METHODS

Seven soccer teams took part in a prevention program that focused on education and supervision of coaches and players, while seven other teams were instructed to train and play soccer as usual. Over 1 year all injuries were documented weekly by physicians. Complete weekly injury reports were available for 194 players.

RESULTS

The incidence of injury per 1000 hours of training and playing soccer was 6.7 in the intervention group and 8.5 in the control group, which equates to 21% fewer injuries in the intervention group. The greatest effects were observed for mild injuries, overuse injuries, and injuries incurred during training. The prevention program had greater effects in low-skill than in high-skill teams.

CONCLUSIONS

The incidence of soccer injuries can be reduced by preventive interventions, especially in low skill level youth teams. Coaches and players need better education regarding injury prevention strategies and should include such interventions as part of their regular training.

Complications of tibial shaft soccer fractures

A retrospective study of AO type 42 tibial diaphyseal fractures that presented to a teaching hospital over a 54 month period was made to identify the proportion sustained whilst playing soccer, determine their characteristics and report treatment and outcome. Sport accounts for 73/329 (22.1%) of these fractures and soccer 58/73 (79. 5%) of these. All patients were male with mean age of 24.3 years (range 8-48). Fifty-four fractures were closed and 93.1% (54/58) were situated in the middle third or at the junction of the middle and distal thirds of the diaphysis. Fifty-six (96.6%) had simple or wedge patterns and 45 (77.6%) were right sided. Forty-four (76.2%) were treated non-operatively in plaster, 12 (20.3%) by intramedullary nails and two (3.4%) with external fixators. Two patients were lost to follow-up and the remaining 56 fractures united at a mean of 6.5 months. There were 21 complications in 19/56 (33.9%) patients which included 8/56 (14.3%) delayed/non-unions requiring surgery. There was a significantly higher complication rate for operated fractures (p<0.005) but no significant link to AO fracture type. Thus we cannot assume that treatment of these common fractures is without risk, especially if they are treated operatively.

Comparison of soccer shin guards in preventing tibia fracture

The goal of this study was to evaluate the effectiveness of a number of shin guards in protecting against tibia fracture in soccer players. A secondary purpose was to determine the relationship between the material and structural differences in shin guard design and the protection provided. Twenty-three commercially available shin guards were tested on a model leg containing a synthetic tibia that had been calibrated against human cadaver specimens. Each guard was categorized into one of four material types: plastic (N = 9), fiberglass (N = 6), compressed air (N = 4), and Kevlar (N = 4). The maximum combined force at the ends of the tibia, the principal strain on the posterior side of the tibia, and the contact time of the impact were measured using a drop track impact simulation. Shin guards provided significant protection from tibia fracture at all drop heights. The average guard reduced force by 11% to 17% and strain by 45% to 51% compared with the unguarded leg. At the higher drop heights, material composition and structural characteristics of the shin guards showed significant differences in protective abilities. These findings indicate that all shin guards provide some measure of protection against tibia fracture, although the level of protection may vary significantly among the different guards.

Ankle injuries: same joint, different sports

Specific information on the incidence of ankle injury is not easy to establish, and studies use variable methodology and recording systems. There are problems in recording injury in many sports injury studies (23) as we often cannot calculate the relative risks without denominator data. Although we can estimate that ankle injuries make up about 10-15% of sports-related injury and that soccer and rugby are responsible for most sports-related injury in the United Kingdom, it is difficult to be more specific. Prevention and treatment strategies are also different, and taping and strapping is not widely practiced. Soccer has a particular injury pattern with some injuries particularly associated with the sport.