OBJECTIVES:To explore how sport-related concussions are recognised and managed in West African football, and to examine the applicability of international concussion tools in local contexts. DESIGN:Qualitative study using a grounded theory method. METHODS:Semi-structured interviews were conducted with eight physicians working in high-level football teams and national teams across Senegal, Mali and Gambia. Interviews were audio-recorded, transcribed, and then analysed through open, axial and selective coding. RESULTS:Six overarching categories emerged in the analysis: (1) the concussion burden is unclear due to under-reporting and lack of awareness, with concussion risks often overshadowed by other conditions perceived as more serious (e.g. cardiac); (2) protocols and tools such as SCAT are not applied; (3) organisational and resource gaps limit care; (4) clinical decisions are shaped by external pressures and absence of federation structures; (5) training remains insufficient and mostly theoretical; and (6) cultural norms (toughness, gender, mystical beliefs, and crowd influence) strongly affect practice. CONCLUSIONS:Concussion management in West Africa is marked by under-recognition, limited applicability of international tools, organisational deficiencies and cultural pressures. Current guidelines remain largely theoretical in this context. Broader access to context-sensitive and local education, federation-level structures such as concussion leads, as well as culturally adapted strategies are needed to improve recognition and management of sport-related concussion in this context.

La pubalgie est très fréquente chez les hockeyeurs sur glace, avec une incidence annuelle de 45–53 % et un taux élevé de récidive, en particulier pour les lésions des adducteurs. Bien que la hanche soit l’une des régions les plus étudiées dans la littérature, les atteintes intra-articulaires ne représentent qu’environ 10 % des causes de pubalgie dans le hockey sur glace. L’accord de Doha distingue la pubalgie aiguë et de longue durée, en proposant une classification qui comprend quatre entités cliniques principales : douleurs liées aux adducteurs, à la région inguinale, à l’ilio-psoas et à la symphyse pubienne. Toutefois, la région pubienne présente une anatomie particulièrement complexe, faisant intervenir de nombreuses structures musculo-aponévrotiques, osseuses et nerveuses étroitement liées. Cette organisation explique que l’évaluation clinique soit souvent délicate et que les tableaux cliniques soient mixtes, compliquant l’établissement du diagnostic et l’orientation de la prise en charge. L’objectif de cet article est de clarifier les mécanismes anatomiques et physiopathologiques de la pubalgie chez le hockeyeur sur glace, afin d’améliorer la compréhension des différentes entités cliniques et d’optimiser l’approche dans cette population à haut risque.

Control of the posterior tibial slope (PTS) is crucial in high tibial osteotomy (HTO), since unintended changes can alter the normal knee kinematics and ligament loading. This study investigated the influence of sagittal cutting plane orientations on PTS in bi-planar medial open wedge HTO (MOWHTO) on a Sawbone model. Sixty Sawbone® left-tibia models (A Pacific Research Company, USA) were used to perform biplanar MOWHTO with three sagittal orientations: (1) parallel to the medial tibial plateau (PO); (2) 10° anterior-inclined osteotomy (AIO); (3) 10° posterior-inclined osteotomy (PIO). The biplanar cut was performed distal to the tibial tuberosity in half the specimens and proximal in the remainder. Customized 3D-printed cutting guides ensured reproducibility. PTS and valgus correction were measured pre- and post-osteotomy using a navigation system. Group- and subgroup-specific ΔPTS were analyzed using a Bayesian multilevel model. Minimal clinically important difference (MCID) was set at 2.5°. Bayesian “power” analysis (assurance) was used to assess the sensitivity of ΔPTS and pairwise differences relative to the MCID. Across the three sagittal orientation and their distal/proximal subgroups, ΔPTS and pairwise ΔPTS did not exceed the predefined MCID of 2.5°. Bayesian assurance of equivalence exceeded 86

OBJECTIVES:To examine self-reported sport-related concussion (SRC) symptom duration and return to sport (RTS) timelines across countries and sport demographics in a large international cohort. METHODS:An anonymous survey collected sociodemographic data and concussion history from French-speaking athletes affiliated with the ReFORM IOC Research Center. SRC symptoms and RTS durations were analyzed by geographic origin (Canada, Europe) and a multivariate analysis examined the combined impact of geographic origin, sex, age group (minor, adult), professional status (amateur, professional) and SRC risk (low, moderate, high). RESULTS:Of 998 participants (Canada: 635; Europe: 363), 409 (41%) reported a history of SRC. Median [IQR] symptom duration was longer in Canada (30 [14, 91] days) than Europe (7 [2, 21] days; p < 0.001). RTS was also longer in Canada (28 [14, 61] vs. 10 [7, 21] days; p < 0.001).The binary logistic regression identified geographic origin (Canada) and sex (female) as significant predictors of prolonged symptom duration (i.e. >14 days) and return to sport (i.e. >20 days), while age group, professional status and SRC risk did not significantly influence these durations. CONCLUSION:SRC recovery times differ significantly by geography and sex in French-speaking athletes. European athletes and males report shorter symptom and RTS durations.

Background: T2 mapping is a recognized magnetic resonance imaging (MRI) technique that reflects collagen fiber organization and tissue hydration, making it sensitive to early biochemical changes in cartilage. Evaluating an accelerated GRAPPATINI sequence and comparing its performance to conventional methods is crucial for reliable cartilage evaluation. This study aims to evaluate and compare T2 relaxation times in healthy knee cartilage using a conventional multi-echo spin-echo (MESE) sequence and the accelerated GRAPPATINI sequence, and to assess their reliability in a test-retest design. Methods: All patients underwent a baseline MRI, followed by imaging at 3, 6, and 12 months as part of a prospective national study protocol. Sagittal T2 mapping with both MESE and GRAPPATINI sequences was acquired. Regions of interest were drawn in morphologically normal cartilage of the medial femoral condyle, lateral femoral condyle, and patella, segmented by depth (superficial, intermediate, deep). T2 values were compared using linear mixed-effects model. Agreement between methods was evaluated with Bland-Altman analysis, and repeatability was assessed with correlation, regression, and intraclass correlation coefficients (ICC). Results: Nine patients (mean age 38 years, 6 males and 3 females) underwent acquisition of both T2 mapping sequences in 22 MRI exams. Mean T2 values ranged from 30.1 to 45.2 ms with MESE, and from 27.8 to 47.7 ms with GRAPPATINI. T2 values varied significantly by cartilage depth, with longer relaxation times in superficial and intermediate layers compared to deep cartilage, independently of the sequence used. Overall, no significant differences in T2 values were observed between the MESE and GRAPPATINI sequences, except in the superficial layer of the lateral femoral condyle, where a significant difference was noted. The Bland-Altman analysis demonstrated no systematic bias between methods [mean difference: -0.26 ms; with limits of agreement of 15.7 ms (mean + 2SD) and-16.2 ms (mean-2SD)]. Concerning the repeatability the study, a stronger correlation and higher reliability were observed with the GRAPPATINI method (R=0.73, ICC =0.75) compared to the MESE method (R=0.53, ICC =0.61). The slope of the regression line for GRAPPATINI was 0.91, indicating a high level of reproducibility between visits, whereas the MESE method yielded a lower slope of 0.56. When considering all anatomical areas and cartilage depths combined, ICC values were consistently higher for GRAPPATINI than for MESE. Conclusions: Both MESE and GRAPPATINI provide consistent T2 mapping of knee cartilage, but GRAPPATINI achieves greater reliability with shorter acquisition time. Depth-dependent differences in T2 highlight the importance of layer-specific evaluation in quantitative cartilage assessment.

Le ski alpin est l’un des sports de montagne les plus pratiqués dans le monde, aussi bien en loisir qu’en compétition, mais il est souvent perçu comme intrinsèquement à haut risque. L’incidence des blessures chez les skieurs amateurs est relativement faible (environ 0,4 à 2,6 blessures pour 1000 journées-skieurs) et comparable à celle observée dans de nombreux autres sports, tandis que les athlètes d’élite présentent des taux de blessure nettement plus élevés, avec une proportion importante de lésions sévères. Ces contrastes suggèrent que le ski alpin n’est pas intrinsèquement dangereux, mais qu’il s’agit d’une discipline particulièrement exigeante nécessitant des capacités physiques, techniques et neuromusculaires adaptées. Le ski alpin se caractérise par des efforts intermittents de haute intensité, associés à des charges mécaniques importantes sur les membres inférieurs, en particulier lors des contractions musculaires excentriques. La performance et la sécurité dépendent d’une combinaison de force maximale, de puissance, d’endurance musculaire locale, d’équilibre, de coordination et de compétences techniques. Bien que les exigences aérobies soient modérées en moyenne, les capacités aérobies et anaérobies jouent un rôle déterminant dans la répétition des efforts, la récupération et le maintien de la vigilance. Les facteurs environnementaux, tels que l’altitude, l’exposition au froid, la qualité de la neige et la variabilité rapide des conditions, augmentent encore les contraintes physiologiques et neuromusculaires, en particulier chez les skieurs insuffisamment préparés. L’épidémiologie des blessures met en évidence une prédominance des lésions des membres inférieurs, notamment les ruptures du ligament croisé antérieur avec des mécanismes lésionnels différents entre skieurs amateurs et athlètes d’élite. Les stratégies de prévention doivent donc cibler les facteurs de risque individuels tels que la condition physique, la gestion de la fatigue, l’expérience et les comportements à risque, ainsi que l’adaptation du matériel, le port d’équipements de protection et l’ajustement aux conditions de neige et à l’environnement.

Anterior knee pain, which is common among both athletes and non-athletes, can have various underlying causes. This article proposes an integrative diagnostic model that identifies painful structures and associated functional and structural factors. Pain is classified based on its origin, which enables targeted treatment, whether conservative, medical, or surgical. The therapeutic approach must consider both the function and specific characteristics of the affected tissues to promote a patient-centered treatment plan. This analysis emphasizes the importance of a comprehensive clinical assessment for effective management of anterior knee pain.

Environmental degradation is a major global health threat, and the healthcare sector functions as both its victim and perpetrator. To effectively inform mitigation strategies it is essential to quantify the environmental burden originating from healthcare activities and then favour environmentally preferable treatment options.This Switzerland-based study evaluated and compared the environmental impacts from surgical and conservative care pathways after an anterior cruciate ligament injury using Life Cycle Assessment; it also identified the environmental hotspots stemming from the surgery itself, as well as from physiotherapy. Environmental impacts were quantified across 18 ReCiPe midpoint impact categories.Results indicated that, on average, after an anterior cruciate ligament injury, the surgical pathway imposes at least an 8.5-fold greater relative environmental burden than the conservative pathway. Regarding the anterior cruciate ligament surgery alone, the hotspots of environmental impacts were identified as the manufacturing of single-use products, transportation of patient and staff, and the use of heating-ventilation-air-conditioning and electricity. Regarding physiotherapy, results indicated that a large share of environmental impacts can be attributed to transportation of patient and staff, laundry, and space heating.This difference in environmental impacts emphasises the importance of a careful patient allocation between these two care pathways. Recommendations to reduce the environmental impacts from surgery should prioritise investing in reusable equipment, streamlining surgical instrument trays, and opting for occupancy-based heating-ventilation-air-conditioning. To reduce the environmental impacts originating from physiotherapy, recommendations should encourage soft mobility, patient's self-management, and the physiotherapist's following of evidence-based guidelines. Reducing laundry frequency can be relevant as well.

Focal cartilage lesions refer to localized damage or defects in the cartilage covering joint surfaces, often resulting from trauma, wear and tear or underlying joint conditions. These lesions can lead to pain, impaired joint function and, if left untreated, may contribute to the development of degenerative joint diseases. Challenges in treatment of focal cartilage lesion are mainly due to limited intrinsic healing capacity, difficulty in early detection of lesions and variability in symptoms make timely intervention tricky. Conservative treatments varies from addressing symptoms using physical therapy, corticosteroid injections and viscosupplementation, to regenerative attempts such as in platelet-rich plasma and mesenchymal stem cells therapy. These modalities provide a limited duration of improvement and are commonly used to delay more aggressive treatment. Traditional surgery options are mainly summed up by microfractures (MFX) for smaller lesions, osteochondral autograft transfer, osteochondral allograft transfer (OCA) and autologous matrix-induced chondrogenesis for moderate-to-large lesions. Cellular approaches encompass autologous chondrocyte implantation (ACI), which involve targeted transplantation of chondrocytes. Current research is concentrating on cell-based surgical approaches utilizing advanced biomaterials for both scaffold and scaffold-free implants. While gene therapy and tissue engineering approaches aim to optimize chondrocyte proliferation and differentiation for improved quality of the transplanted biomaterial and patient's outcomes.

OBJECTIVE:Evaluating sports-related concussion (SRC) knowledge, awareness of evaluation tools and management protocols, and access to educational resources within the French-speaking sports community in Canada and Europe. DESIGN:Cross-sectional, anonymous online survey. PARTICIPANTS:French-speaking athletes, coaches, and health care professionals (HCPs). INTERVENTION:The electronic survey consisted of 33 questions that can be grouped into the following 3 categories: (1) SRC knowledge assessment through self-report and general knowledge questions, (2) awareness of internationally recommended detection tools and managements protocols, and (3) access to educational resources. The survey was codeveloped with athletes, coaches, and HCP and validated by and expert panel. MAIN OUTCOME MEASURES:A SRC knowledge score was built based on answers to 4 questions on SRC mechanisms, symptoms, and management. Awareness of the Sport Concussion Assessment Tool 5, the Concussion Recognition Tool 5, and the 6-step return to sport protocol were collected with coaches and HCPs. RESULTS:Overall, 2073 participants responded to the survey, comprising 48% athletes, 33% coaches and 19% HCP. Knowledge scores (/100, median [IQR]) were highest among HCPs [98.1 (96.2, 100)], followed by coaches [96.2 (73.1, 98.1)], and athletes [90.4 (67.3, 92.3)] with significant differences between the groups ( P < 0.001). Participants from Canada demonstrated higher knowledge scores [92.3 (75.0, 98.1)] than those from Europe [75.0 (67.3, 96.2); P < 0.001]. Similar differences were observed for the awareness of recommended tools and the access to educational resources. CONCLUSIONS:Knowledge translation strategies should be adapted to better reach the French-speaking sports community in Europe and further individualized according to professional role.

This study examines concussion knowledge, attitudes, and behaviors among European American football athletes using an online survey. Data from 256 players (mean age 26.8 years (SD 4.9); 7.4 (SD 4.5) years of experience) across some of the highest leagues (Austrian Football League, German Football League, European League of Football) revealed an average concussion knowledge index of 17.9 (SD 2.3) of 25 and an attitude index of 63 (SD 6.3) of 75. Notably, 43.1 % of athletes reported they would continue to play despite experiencing concussion symptoms indicating a gap between knowledge, attitudes, and safe behavior. These findings underscore the need for targeted educational measures to improve the transfer of knowledge toward safer decision-making processes and to strengthen the prevention and management of concussions.

BACKGROUND:Chondrocyte-based cell therapy remains a promising method for cartilage repair, despite limitations faced during the last 30 years. PURPOSE/HYPOTHESIS:This work presents hyaline-like bioengineered beads from donor chondrocytes as a novel treatment option for cartilage lesions. It was hypothesized that the implanted cartilage minigrafts would be able to treat cartilage lesions by complete fusion among themselves and by integration with surrounding tissue. No tissue rejection was expected because of cartilage's reported immunological privilege. STUDY DESIGN:Controlled laboratory study. METHODS:Allogenic cartilage beads with hyaline characteristics were produced from frozen chondrocytes of a minipig donor. A total of 8 Göttingen minipigs underwent the implantation of bioengineered cartilage beads into 8 to 10 mm-diameter full-thickness chondral lesions (3 lesions/knee). Animals were sacrificed at 6 weeks (n = 2) and 6 months (n = 6) after implantation. The safety and efficacy of implantation were assessed by macroscopic and histological analyses as well as by magnetic resonance imaging. RESULTS:No signs of acute or chronic rejection were observed in any study animals upon implantation. For 6 minipigs at 6 months, magnetic resonance imaging results showed better coverage of the grafted lesions compared with empty (control) lesions. When the cartilage beads were maintained in the lesion, complete integration of the minigrafts with surrounding subchondral bone and native cartilage was observed. Repair tissue in grafted lesions maintained hyaline-like quality and showed evidence of a chondral zonal arrangement at 6 months' follow-up. Additionally, grafted lesions (n = 17) had better macroscopic repair scores than empty lesions (n = 7) (mean inverse Goebel score, 4.24 and 5.57, respectively). Graft-filled lesions showed only a slight superiority in histological repair scores (mean Bern score, 5.76 and 5.43, respectively). CONCLUSION:Allogenic cartilage beads hold potential as an advanced therapy medicinal product for treating cartilage lesions in 1-step surgery with established safety and efficacy. CLINICAL RELEVANCE:This successful preclinical study highlights allogenic cartilage beads as a promising method for cartilage repair. Moreover, using donor chondrocytes may allow reduced patient morbidity and 1-step surgery. Hence, this advanced therapy medicinal product is suitable for treating large lesions and older patients and is currently being evaluated in a phase I/IIa clinical trial.

La rupture du ligament croisé antérieur (LCA) est l’une des causes les plus fréquentes d’une arthrose post-traumatique, avec un risque relatif de 3,84 fois plus élevé au cours des dix premières années par rapport au côté non blessé. Les causes de l’arthrose post-traumatique suite à une rupture du LCA sont multiples. Le facteur primaire étant l’instabilité rotatoire plus que l’instabilité translatoire antérieure, la méniscectomie partielle, l’obésité et des facteurs en lien avec la rééducation et l’inflammation post-traumatique et postopératoire. Il existe des preuves dans la littérature scientifique que la reconstruction du LCA réduit le taux de lésions secondaires méniscales et cartilagineuses, chez l’enfant comme chez l’adulte. Cependant, d’après les revues systématiques les plus récentes, il semble que cette chirurgie n’ait pas d’effet sur la progression arthrosique à 10 ans ou plus. Il reste à démontrer, par de futures études de haute qualité, que les nouvelles procédures chirurgicales résultant à une meilleure stabilité postopératoire, moins de ré-rupture et en préservant au maximum l’intégrité méniscale, amènent aussi à une réduction de l’arthrose post-traumatique.

Background: The side hop test (SHT) measures the number of jumps performed over 30 s. Although this measure has demonstrated its value in clinical practice, the temporal parameters of the SHT allow for a deeper analysis of the execution strategy. The aim of this study is to assess the reliability and construct validity of contact time parameters during the SHT recorded by a video analysis system in anterior cruciate ligament reconstructed (ACLR) patients. Methods: We investigated the reliability (intra-rater, standard error of measurement (SEM), and minimum detectable change (MDC)), discriminant validity (operated (OP) versus non-operated (NOP) side), and convergent validity (relationship with strength and psychological readiness) of SHT contact time parameters, number of valid hops and limb symmetry index (LSI) in 38 ACLR patients. Contact time parameters are presented as mean, standard deviation (SD), and coefficient of variation (CV) of contact time. Results: Intra-tester reliability was good to excellent for all contact time parameters. For discriminant validity, the mean and SD contact times of the OP leg were significantly longer than those of the NOP leg, although the difference was smaller than the SEM and MDC values. The number of valid jumps and CV contact time parameters were not significantly different. Isokinetic quadriceps strength (60°/s) was strongly correlated with mean contact time for both legs. However, psychological readiness was not correlated with any of the contact time parameters. Conclusions: Temporal parameters of the SHT measured on video analysis are valid and reliable parameters to assess the performance strategy of the SHT. The results should be interpreted with caution regarding the SEM and MDC values. Further studies are needed to measure criterion validity, inter-rater reliability, and responsiveness.

Objective To assess the current state of knowledge and practice regarding sport-related concussion (SRC) within a Francophone international consortium in order to tailor the educational approaches. Design Multicentric cross sectional survey. Setting An anonymous online French survey was sent through mailing lists and social networks. It included between up to 33 questions about SRC knowledge, prevention and management and access to educational resources. Participants Athletes, healthcare professionals and coaches from Belgium, Canada, France, Luxembourg and Switzerland related to the ReFORM IOC Research Centre network. Outcome Measures Tested (score/10) level of concussion knowledge across occupations and origin; relationship between knowledge and behaviour in athletes. Main Results 2072 participants took part in the survey. The sample included 998 (48%) athletes, 677 (33%) coaches and 398 (19%) healthcare professionals. Participants originated from France (35%), Canada (32%), Belgium (12%), Switzerland (10%), Luxembourg (5%) and other countries (15%). The tested level of knowledge significantly differed between occupations (healthcare professionals: 9.42 ± 1.28; athletes; 7.84 ± 1.75; coaches: 8.53 ± 1.79; p<0.001). It was significantly higher in Canada as compared to European countries (p<0.001). Among the athletes, 91% answered ‘no’ to the knowledge question ‘can you continue to play sport in the presence of concussion symptoms’ although 39% later report having played in presence of symptoms. This raises questions about the impact of knowledge on behaviour change. Conclusions There is an inhomogeneous distribution of knowledge about SRC in the Francophone sport community. The impact of knowledge vs. behavioural changes should be considered in future training.

Purpose: Despite the publication of several randomized controlled trials (RCTs), it is not clear which technique for the treatment of focal chondral and osteochondral defects of the knee grants the best clinical outcome. The aim of this network meta-analysis (NMA) was to compare the efficacy and safety of microfractures (MF), autologous chondrocyte implantation (ACI), autologous matrix-induced chondrogenesis (AMIC), osteochondral autograft transplantation (OCT) at short (< 1 year), intermediate (1–5 years) and long-term (> 5 years). Methods: We carried out an NMA with Bayesian random-effect model, according to PRISMA guidelines. The search was performed in MEDLINE, EMBASE, Web of Science, CENTRAL, CINAHL, SPORTDiscus, clinicaltrials.gov, WHO ICTRP, from inception to November 2022. The eligibilities were randomized controlled trials on patients with knee chondral and osteochondral defects, undergoing microfractures, OCT, AMIC, ACI, without restrictions for prior or concomitant surgery on ligaments, menisci or limb alignment, prior surgery for fixation or ablation of osteochondritis dissecans fragments, and prior cartilage procedures as microfractures, drilling, abrasion, or debridement. Results: Nineteen RCTs were included. No difference among treatments was shown in the pooled comparison of patient reported outcome measures (PROMs) at any timepoint. Safety data were not available for all trials due to the heterogeneity of reporting, but chondrospheres seemed to have lower failure and reoperation rates. Conclusion: This NMA showed no difference for PROMs with any technique. The lower failure and reoperation rates with chondrospheres must be interpreted with caution since adverse event data was heterogenous among trials. The standardization of the efficacy and safety outcome measures for future trials on knee cartilage repair and regeneration is necessary.

Background Sport-related concussions (SRCs) pose significant physical, emotional, and economic burdens on athletes and the sports community. With the long-lasting consequences of SRCs, effective prevention strategies are imperative. Objective To investigate the relationship between demographic data, history of concussion and sports' characteristics with the number of SRC, symptoms' duration and resting period. Design Cross-sectional online survey Setting A three-month online survey was conducted among athletes in five French-speaking countries. The survey was created on an online platform and distributed through institutional networks, professional associations, regional clubs, and research centers. Communication efforts included newsletters and social media platforms. Participants Athletes over 14 years old. Main Outcome Measurements Data on demographic, history of concussion, sport category (high-risk, moderate-risk, low-risk), sport level, symptoms duration and recovery duration were extracted from the database. We investigated if the number of SRC, duration of symptoms and duration of recovery period differ depending to demographics, sport category and sport level. Results Out of the 998 participating athletes, 939 complete answers were analysed with balanced gender distribution. The duration of symptoms was longer for women (132.54±21.34 days) compared to men (81.37±19.93 days; z=-4.674, p<0.001). Athletes from Canada had higher number of repeated SRCs (23 athletes with 4 and 11 athletes with 5 SRCs) than European countries (7 athletes with 4, and one athlete with 5 SRCs) (X2=39.718, p<0.001), with symptoms lasting 88 days longer on average (p<0.001) in similar population. The number of SRCs was influenced by the sport category. A positive correlation was observed between the number of SRCs and symptom duration. Professional athletes had shorter recovery periods than non-professionals. Conclusions These findings highlight the need for tailored prevention strategies in high-risk sports and among athletes. Additionally, the prolonged symptom duration exceeding recommended recovery periods raises crucial concerns in SRC management, emphasizing the importance of preventive measures.

Posterior cruciate ligament (PCL) ruptures can cause severe knee instability and disability and thus, appropriate management is crucial for the successful restoration of patients' knee function. Rupture of the PCL can occur during sporting activity but more often, as a part of high-energy trauma. The diagnosis can be made using various clinical tests, such as the posterior drawer test or the quadriceps active test. MRI is the gold standard in imaging. PCL injuries can be classified from grade I to grade III, with increasing severity. Treatment can be conservative or surgical and should be personalized based on patients' demographic characteristics, grade of injury, level of instability, associated injuries and activity levels.