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Lima EBDS, Belangero PS, Lara PHS, Ribeiro LM, de Figueiredo EA, Andreoli CV, Pochini ADC, Ejnisman B, Pagura JR, Cohen M, Arliani GG. Shoulder injuries in Brazilian professional football players: epidemiological analysis of 3828 games. J ISAKOS 2024; 9:290-295. [PMID: 38296185 DOI: 10.1016/j.jisako.2024.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Revised: 01/22/2024] [Accepted: 01/23/2024] [Indexed: 02/25/2024]
Abstract
OBJECTIVES Football is a globally played sport that poses potential risks for musculoskeletal injuries. Upper-limb injuries have a lower incidence rate than lower-limb injuries but can still cause absenteeism and performance impairment in football players. This descriptive epidemiological study aimed to evaluate and compare the epidemiological data on shoulder injuries among professional football players in two major Brazilian football championships. METHODS Data were collected throughout the championships, and club physicians medically evaluated each player during official games using two online forms. The collected information included the player's age and position, injury diagnosis, laterality, location on the field where the injury occurred, playing time, imaging examinations performed, need for surgical treatment, time to return to play (TRP), and recurrence of the injury. The incidence of injuries was evaluated using the Federation Internationale de Football Association (FIFA) incidence formula. RESULTS A total of 107 shoulder injuries were recorded (4.3% of all injuries), with a FIFA incidence of 0.847. Glenohumeral dislocations (GHDs) and acromioclavicular dislocations (ACDs) accounted for 37.38% and 35.51% of all shoulder injuries, respectively. Goalkeepers and defenders presented, respectively, a 2.15 and 1.57 times increased risk of suffering shoulder injuries, while attackers presented a 0.63 times decreased risk. Injury recurrence was observed in 14.95% of cases, with GHDs and ACDs showing recurrence rates of 35.00% and 5.26%, respectively. Surgery was performed in 9.35% of cases, with GHDs representing 50% of all surgeries. The average TRP was 22.37 days, with severe and major injuries accounting for 11.21% and 10.28% of all injuries, respectively. Goalkeepers had the highest average TRP of 36.15 days. Recurring injuries had a higher average TRP of 33.44 days compared to nonrecurring injuries, which had an average TRP of 20.43 days. Surgically treated injuries had the highest average TRP of 112.5 days. CONCLUSION Shoulder injuries in the professional football scenario are of great concern due to the high recurrence rate and need for surgical treatment, which will lead to a long TRP. These findings emphasize the need to implement prevention protocols and effective treatments to reduce the consequences of such injuries, which are usually underestimated in this sport. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Ewerton Borges de Souza Lima
- Sports Traumatology Center, Discipline of Sports Medicine and Physical Activity, Department of Orthopedics and Traumatology, Federal University of São Paulo, R. Estado de Israel, 713 - Vila Clementino, São Paulo, SP 04022-002, Brazil
| | - Paulo Santoro Belangero
- Sports Traumatology Center, Discipline of Sports Medicine and Physical Activity, Department of Orthopedics and Traumatology, Federal University of São Paulo, R. Estado de Israel, 713 - Vila Clementino, São Paulo, SP 04022-002, Brazil
| | - Paulo Henrique Schmidt Lara
- Sports Traumatology Center, Discipline of Sports Medicine and Physical Activity, Department of Orthopedics and Traumatology, Federal University of São Paulo, R. Estado de Israel, 713 - Vila Clementino, São Paulo, SP 04022-002, Brazil
| | - Leandro Masini Ribeiro
- Sports Traumatology Center, Discipline of Sports Medicine and Physical Activity, Department of Orthopedics and Traumatology, Federal University of São Paulo, R. Estado de Israel, 713 - Vila Clementino, São Paulo, SP 04022-002, Brazil
| | - Eduardo Antônio de Figueiredo
- Sports Traumatology Center, Discipline of Sports Medicine and Physical Activity, Department of Orthopedics and Traumatology, Federal University of São Paulo, R. Estado de Israel, 713 - Vila Clementino, São Paulo, SP 04022-002, Brazil
| | - Carlos Vicente Andreoli
- Sports Traumatology Center, Discipline of Sports Medicine and Physical Activity, Department of Orthopedics and Traumatology, Federal University of São Paulo, R. Estado de Israel, 713 - Vila Clementino, São Paulo, SP 04022-002, Brazil
| | - Alberto de Castro Pochini
- Sports Traumatology Center, Discipline of Sports Medicine and Physical Activity, Department of Orthopedics and Traumatology, Federal University of São Paulo, R. Estado de Israel, 713 - Vila Clementino, São Paulo, SP 04022-002, Brazil
| | - Benno Ejnisman
- Sports Traumatology Center, Discipline of Sports Medicine and Physical Activity, Department of Orthopedics and Traumatology, Federal University of São Paulo, R. Estado de Israel, 713 - Vila Clementino, São Paulo, SP 04022-002, Brazil.
| | - Jorge Roberto Pagura
- Brazilian Football Confederation, Avenida Luis Carlos Prestes, 130 - Barra da Tijuca, Rio de Janeiro, RJ 22775-055, Brazil
| | - Moisés Cohen
- Sports Traumatology Center, Discipline of Sports Medicine and Physical Activity, Department of Orthopedics and Traumatology, Federal University of São Paulo, R. Estado de Israel, 713 - Vila Clementino, São Paulo, SP 04022-002, Brazil
| | - Gustavo Gonçalves Arliani
- Sports Traumatology Center, Discipline of Sports Medicine and Physical Activity, Department of Orthopedics and Traumatology, Federal University of São Paulo, R. Estado de Israel, 713 - Vila Clementino, São Paulo, SP 04022-002, Brazil
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Bauer S, Neyton L, Collin P, Zumstein M. The open Latarjet-Patte procedure for the treatment of anterior shoulder instability in professional handball players at a mean follow-up of 6.6 years. J Shoulder Elbow Surg 2024; 33:924-931. [PMID: 37648015 DOI: 10.1016/j.jse.2023.07.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 07/12/2023] [Accepted: 07/21/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND The popularity of team handball is increasing, with >10 million children playing this overhead throwing and collision sport with highest demands on the shoulder joint. Because of the risk of recurrent instability, the Latarjet-Patte (LP) procedure has been recommended to treat young competitive players. This is the first LP outcome study in professional handball players. METHODS We retrospectively included 20 shoulders (18 players [17 male patients]; mean age, 22.9 years [range, 17-35 years]; minimum follow-up period, 2 years; mean follow-up period, 6.6 years) operated on by 3 expert surgeons (2011-2020) with the Walch LP technique. We documented preoperative hyperlaxity (25%, n = 5), affected throwing arm (55%, n = 11), position (backcourt, winger, and goalkeeper, 22% each; full back and pivot, 17% each), >2 dislocations prior (20%, n = 4), >10 dislocations prior (5%, n = 1), previous failed Bankart or humeral avulsion of glenohumeral ligament (HAGL) repair (10%, n = 2), and large Hill-Sachs lesions (HSLs) (20%, n = 4). Clinical and radiographic outcomes, visual analog scale score, Subjective Shoulder Value, Walch-Duplay score, Rowe score, and return-to-sport (RTS) rate were recorded. RESULTS The RTS rate was 85% (17 of 20 shoulders); rate of RTS at the same level, 80% (16 of 20); and rate of RTS with no throwing pain, 73% (8 of 11). The time to training with a ball was 3.2 months, and the time to competition was 4.9 months. The mean Rowe score, Walch-Duplay score, and Subjective Shoulder Value were 90 points, 88 points, and 89%, respectively. Shoulder symptoms led players to give up handball in 2 cases (10%), whereas 1 player (5%) stopped playing handball for other reasons. We recorded 1 recurrent dislocation (5%) (non-throwing arm, winger, no recurrence after rehabilitation). Persistent apprehension occurred in 1 goalkeeper (5%). Residual pain was seen in 4 shoulders (20%); this was relieved by screw removal in 1. Resistant pain (throwing shoulder) was seen in 2 backcourt players (10%, 1 of whom had a large HSL) and 1 goalkeeper (5%; large HSL with >10 dislocations prior), all 3 of whom were aged > 30 years. Bone block positioning was correct (no lateral overhang) in all shoulders. At final follow-up, 1 shoulder (5%) showed mild arthritic changes (>10 dislocations, large HSL). CONCLUSION The open LP procedure is consistent in providing shoulder stability combined with return-to-throwing performance in professional handball players with a short time to RTS and high same-level RTS rate without increasing the risk of arthritic changes. Throwing shoulders of backcourt players, large HSLs, or age > 30 years may have an increased risk of persistent symptoms.
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Affiliation(s)
- Stefan Bauer
- Shoulder Surgery and Upper Limb Center, Ensemble Hospitalier de la Côte, Morges, Switzerland; School of Surgery, University of Western Australia, Perth, Australia.
| | - Lionel Neyton
- Ramsay Santé, Hôpital Privé Jean Mermoz, Centre Orthopédique Santy, Lyon, France
| | - Philippe Collin
- Orthopedics and Traumatology, American Hospital of Paris, Neuilly-sur-Seine, France; Shoulder Surgery, Clinique Victor Hugo, Paris, France
| | - Matthias Zumstein
- Shoulder, Elbow and Orthopaedic Sports Medicine, Orthopädie Sonnenhof, Bern, Switzerland; Shoulder, Elbow Unit, SportsClinic#1, Bern, Switzerland
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Arzu U, Ersin M, Chodza M, Şahin K, Kiliçoğlu Ö, Erşen A. FIXATION METHODS IN LATARJET: BIOMECHANICAL COMPARISON OF SCREW TYPES AND PLATE FIXATION. ACTA ORTOPEDICA BRASILEIRA 2023; 31:e260966. [PMID: 37323153 PMCID: PMC10263413 DOI: 10.1590/1413-785220233102e260966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 09/21/2022] [Indexed: 06/17/2023]
Abstract
Objective Latarjet procedure is often preferred in recurrent shoulder dislocations accompanied by glenoid bone loss. It is observed that the superiority of bone graft fixation methods is still controversial. The aim of this study is to biomechanically compare the bone graft fixation methods in the Latarjet procedure. Methods 15 third-generation scapula bone models were divided into 3 groups. Graft was fixated in the first group with fully-threaded cortical screws of 3.5mm diameter, in the second group two 16 mm partially-threaded cannulated screws of 4.5mm diameter, and in the third group via a mini plate and screw. The hemispherical humeral head was placed on the tip of the cyclic charge device, and thus, the charge applied to the coracoid graft was homogeneous. Results No statistically significant difference was found between paired comparisons (p>0.05). The forces in 5 mm displacement in total vary between 502-857N. Total stiffness measurements ranged between 105 and 625; the mean value was 258.13±53.54 with no statistically significant difference by groups (p = 0.958). Conclusion This biomechanical study showed that there is no difference between three coracoid fixation options in terms of fixation strength. Unlike previous assumptions, plate fixation is not biomechanically superior to screw fixation. Surgeons should consider their personal preferences and experience in choosing fixation methods.
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Affiliation(s)
- Ufuk Arzu
- . VKV American Hospital, Department of Orthopaedics and Traumatology, Istanbul, Turkey
| | - Mehmet Ersin
- . Haseki Education and Research Hospital, Department of Orthopaedics and Traumatology, Istanbul, Turkey
| | - Mehmet Chodza
- . VKV American Hospital, Department of Orthopaedics and Traumatology, Istanbul, Turkey
| | - Koray Şahin
- . Bezmialem Vakıf University, Department of Orthopaedics and Traumatology, Istanbul, Turkey
| | - Önder Kiliçoğlu
- . Koc University, Department of Orthopaedics and Traumatology, Istanbul, Turkey
| | - Ali Erşen
- . Istanbul Faculty of Medicine, Istanbul, Turkey
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Nkosi CS, Chauke NZ. Quality of life following an open Latarjet-Bristow procedure in a general population with recurrent anterior shoulder instability. JSES Int 2023; 7:201-205. [PMID: 36911776 PMCID: PMC9998728 DOI: 10.1016/j.jseint.2022.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background Despite the extensive literature on anterior glenohumeral instability, to date, there are no studies that report on the quality of life following a Latarjet-Bristow procedure with recurrent anterior shoulder instability. The purpose of this study was to evaluate the quality of life in patients who had a Latarjet-Bristow procedure. Methods A single-center retrospective review with a prospective recall of patients who underwent a Latarjet-Bristow technique for recurrent anterior glenohumeral instability between January 2017 and March 2020. Outcomes measures included health-related quality of life using the Short Form-36 (SF-36) questionnaire and patient-related outcome measures using the Western Ontario Shoulder Instability Index and Rowe scores. Results A total of 66 patients were identified to participate in the study; 40 (60.6%) responded and were included in the analysis. There were nine females and 31 males, with a median age of 32 years (27.5‒41 years). Three cases had bilateral anterior shoulder instability with a single joint being operated and three patients were epileptic. Physical and mental components summary of the SF-36 showed a better health-related quality of life in the general population. There was a significant strong correlation between SF-36 and Western Ontario Shoulder Instability Index. However, SF-36 and Rowe score showed a fair correlation. Conclusion The Latarjet-Bristow procedure improves the quality of life in a general population similarly to an athletic population. The number of episodes of dislocation before surgery and the delayed surgical intervention did not increase the recurrent anterior shoulder instability rates postoperatively.
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Affiliation(s)
- Collen S. Nkosi
- Corresponding author: Collen S. Nkosi, MBChB (UL), Orthopaedic Surgery Department, 26 Chris Hani Rd, Diepkloof 319-Iq, Johannesburg, 1864.
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Malavolta EA, Souza JABDE, Assunção JH, Gracitelli MEC, Silva FBDEAE, Ferreira AA. TREATMENT OF RECURRENT ANTERIOR SHOULDER DISLOCATION USING THE LATARJET TECHNIQUE. ACTA ORTOPEDICA BRASILEIRA 2023; 31:e261896. [PMID: 36844123 PMCID: PMC9949290 DOI: 10.1590/1413-785220233101e261896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 07/05/2022] [Indexed: 02/22/2023]
Abstract
Objective To describe the functional results, recurrence rate, postoperative radiographic appearance, and complications of patients undergoing the Latarjet procedure over 24 months. Methods Retrospective case series, including adult patients with recurrent traumatic anterior glenohumeral dislocation undergoing the Latarjet procedure. We clinically evaluated patients preoperatively by the Rowe score and at six, 12, and 24 months after the procedure. The positioning, consolidation, and resorption of the graft were analyzed by plain radiography. The recurrence rates and other complications were also described. Results We analyzed 40 patients (41 shoulders). The Rowe score median increased from 25 before surgery to 95 at 24 months after surgery (p < 0.001). We observed graft resorption in three cases (7.3%) and consolidation in 39 (95.1%). Most grafts presented adequate placement. We observed two recurrences (4.8%), one case of dislocation and one of subluxation. Seven patients (17.1%) had a positive apprehension test. The study had no cases of infection, neuropraxia, or graft breakage. Conclusion Latarjet surgery is a safe and effective procedure in the treatment of recurrent anterior dislocation of the shoulder. This surgery enables a statistically significant improvement according to the Rowe score, with a low number of recurrences. Level of Evidence IV, Case Series.
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Affiliation(s)
- Eduardo Angeli Malavolta
- Hospital das Clínicas, School of Medicine, Universidade de São Paulo, São Paulo, SP, Brazil
- Hospital do Coração. São Paulo, SP, Brazil
| | | | | | | | | | - Arnaldo Amado Ferreira
- Hospital das Clínicas, School of Medicine, Universidade de São Paulo, São Paulo, SP, Brazil
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[Chronic posttraumatic shoulder instability]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2023; 126:145-154. [PMID: 36729203 PMCID: PMC9898333 DOI: 10.1007/s00113-022-01283-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 12/14/2022] [Indexed: 02/03/2023]
Abstract
Chronic posttraumatic shoulder instability is characterized by trauma-associated, recurrent dislocations. Surgical treatment is indicated in most cases but it remains controversial how risk factors should be weighted to decide between arthroscopic Bankart repair (ABR), Latarjet or alternative procedures. Known risk factors for recurrence are patient age, hyperlaxity, sports profile and bone loss. Surgical techniques are discussed in detail. The ABR leads to high patient satisfaction and return to sports; however, in association with risk factors, recurrent dislocations are seen even several years later. Latarjet or bone block procedures lead to high patient satisfaction, sustainable stability as a revision procedure, but can also be primarily indicated for chronic instability depending on risk factors. Early complications are more frequent but of a minor nature in most cases. All techniques are known for a serious learning curve. If performed well, they do not seem to increase the risk of arthritis, which is most affected by the number of lifetime dislocations and higher energy trauma.
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Zeng Z, Liu C, Liu Y, Huang Y. Early outcomes of the arthroscopic Latarjet procedure in a series of 37 patients with shoulder instability. BMC Musculoskelet Disord 2021; 22:845. [PMID: 34600519 PMCID: PMC8487569 DOI: 10.1186/s12891-021-04726-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 09/17/2021] [Indexed: 11/18/2022] Open
Abstract
Background Anterior shoulder dislocation remains a clinical challenge. This study aimed to assess the graft position and clinical outcomes of the arthroscopic Latarjet procedure and capsular repair for the treatment of recurrent anterior shoulder dislocation with significant glenoid bone loss in 37 patients. Methods Between 2017 and 2017, 37 patients underwent arthroscopic Latarjet plus capsular repair procedure for recurrent anterior shoulder dislocation combined with significant glenoid bone loss. In follow-up examinations, Walch-Duplay scores, subjective shoulder value (SSV) scores, Rowe scores, and active range of motion (AROM) were assessed. Three-dimensional computed tomography (CT) was used to evaluate coracoid graft position and bone resorption. A new method of evaluating the position of the coracoid bone block after Latarjet (H-Z method) was developed. Results Thirty-seven patients were included in this study. Follow-up ranged from 6 to 36 months postoperatively (with an average of 13 months). No recurrent dislocation occurred at the final follow-up, and there was no significant effect on the AROM (all p > 0.05). Rowe (from 42.2 ± 5.6 to 91.1 ± 3.3), Walch-Duplay (from 31.5 ± 8.0 to 92.6 ± 3.7), and SSV (from 63.9 ± 6.1 to 79.3% ± 5.0%) scores were improved significantly after surgery (all p < 0.001). CT showed that the 29 patients had varying degrees of bone resorption, and 23 recovered to the preinjury level of motional function within 6–12 months after surgery. Conclusions In active patients with recurrent anterior shoulder dislocations and significant glenoid bone loss, the arthroscopic Latarjet procedure plus capsular repair could restore shoulder stability satisfactory.
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Affiliation(s)
- Zheng Zeng
- Department of Orthopaedic Surgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
| | - Chuan Liu
- Department of Orthopaedic Sports Medicine, the 7th center of PLAGH, Beijing, 100700, China
| | - Yang Liu
- Department of Orthopaedic Surgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China.
| | - Yan Huang
- Department of Orthopaedic Sports Medicine, the 7th center of PLAGH, Beijing, 100700, China.
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Griffith R, Fretes N, Bolia IK, Murray IR, Meyer J, Weber AE, Gamradt SC, Petrigliano FA. Return-to-Sport Criteria After Upper Extremity Surgery in Athletes-A Scoping Review, Part 1: Rotator Cuff and Shoulder Stabilization Procedures. Orthop J Sports Med 2021; 9:23259671211021827. [PMID: 34395687 PMCID: PMC8358521 DOI: 10.1177/23259671211021827] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 03/02/2021] [Indexed: 11/30/2022] Open
Abstract
Background: Standardized criteria are lacking to guide patient return to sport (RTS) after rotator cuff surgery (RCS) or shoulder stabilization surgery (SSS). Purpose: To describe RTS criteria used after RCS and SSS in athletic populations. Study Design: Scoping review; Level of evidence, 4. Methods: This scoping review was based on the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses–Scoping Review) guidelines. A total of 5 electronic databases (MEDLINE, Scopus, SPORTDiscus, Embase, Google Scholar Advanced search) and the gray literature were searched for English-language studies that reported at least 1 RTS criterion in athletes after shoulder surgery. Studies were assigned to the RCS or SSS subgroup based on the primary procedure performed. Data were extracted and summarized as frequencies or arithmetic mean and standard deviation. Results: Included were 52 studies and 2706 athletes (2206 male, 500 female, with a mean age of 28.8 ± 1.8 years). The RCS group consisted of 14 studies and the SSS group consisted of 38 studies. Time from surgery was the most common RTS criterion reported overall (37/52 studies; 71%) as well as within the RCS (93%) and SSS (63%) subgroups. Muscle strength (25/52 studies; 48%) and range of motion (23/52; 44%) were used by almost half of the included articles. RTS criteria reported less often were absence of pain, successful completion of sport-specific or position-specific test, proprioception, radiographic evaluation, patient-surgeon agreement, minimum time required to participate in pain-free throwing, and satisfactory scapulothoracic mechanics. All studies used 1 to 3 of the above RTS criteria; however, the definition of each criterion differed among the included articles. Conclusion: Time from surgery was the most commonly reported RTS criterion after RCS or SSS in athletes, whereas muscle strength and range of motion were used by almost half of the articles. There was high heterogeneity in the definition of each RTS criterion used among the included studies, which also used different combinations of 1 to 3 RTS criteria. These results suggest the need to better define quantitative and qualitative RTS criteria in athletes undergoing rotator cuff and shoulder stabilization procedures in order to safely return athletes to sport.
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Affiliation(s)
- Rebecca Griffith
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, California, USA
| | - Nickolas Fretes
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, California, USA
| | - Ioanna K Bolia
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, California, USA
| | - Iain R Murray
- Department of Orthopaedic Sports Medicine, Stanford University, Redwood City, California, USA
| | - John Meyer
- Meyer Institute of Sport, Los Angeles, California, USA
| | - Alexander E Weber
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, California, USA
| | - Seth C Gamradt
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, California, USA
| | - Frank A Petrigliano
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, California, USA
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