Current Reviews in Musculoskeletal Medicine最新文献

Purpose of review: Provide a concise review of currently utilized functional metrics and patient reported outcomes measures (PROMs) determining appropriate return to sport following anterior cruciate ligament reconstruction (ACLR).

Recent findings: When determining return to sport following ACLR, a limb symmetry index (LSI) ≥ 90% when compared to the contralateral extremity is the most commonly reported functional metric. LSI is most commonly assessed using isokinetic quadriceps strength, followed by single-leg vertical hop and cross-over hop test. A minimum ACL-Return to Sport Index (ACL-RSI) score of 68.2 was reported, as well as a mean International Knee Documentation Committee (IKDC) score of 88.3%. A minimum Knee Injury and Osteoarthritis Outcome Score-Quality of Life (KOOS-QoL) of 62.5% was reported in a single investigation. There remains limited data on reported metrics guiding return to sport following ACLR. Evaluation of LSI when compared to the contralateral extremity is the most commonly reported functional measure, with ACL-RSI, IKDC and KOOS-QoL also being reported. Further investigations examining return to sport rate and the incidence of recurrent injury, factoring in differences in sex, competition level, and the presence or absence of concomitant meniscal injuries, based on functional metrics and PROMs is warranted to better understand which outcome measures are predictive of successful return to sport following ACLR.

Purpose of review: This review presents evidence for advanced non-operative interventions, including extracorporeal shockwave therapy (ESWT), prolotherapy, platelet-rich plasma (PRP), adipose tissue-derived cells, bone marrow aspirate concentrate, various additional non-corticosteroid injectates, and needle-based interventions for common causes of anterior knee pain in the adult population. These etiologies include osteoarthritis of the knee, patellofemoral pain syndrome, chondromalacia patella, Hoffa fat pad impingement syndrome, patellar/quadriceps tendinopathy, and prepatellar bursitis. This review discusses patient care options using a case-based understanding of interventions by condition while recognizing strength of evidence.

Recent findings: ESWT and PRP are the most robustly studied and have greatest evidence for treating tibiofemoral osteoarthritis and for long-term benefit in treating patellar tendinopathy. PRP may have evidence for treatment of chondromalacia and prolotherapy for management of tibiofemoral arthritis; both have limited evidence. Botulinum neurotoxin type A has strong evidence to support use in treating patellofemoral pain syndrome. There is limited evidence to support the use of viscosupplementation, percutaneous needle tenotomy, and medicinal signaling cell-based therapies beyond platelet-rich plasma for anterior knee pain. There is limited research on the management of quadriceps tendinopathy, prepatellar bursitis, patellofemoral osteoarthritis, and Hoffa's fat pad impingement syndrome. Further research and standardization of protocols are necessary to fully assess these treatments' efficacy. ESWT, cell-based, and needle-based interventions, may serve as effective treatment options for patients with anterior knee pain. Selection of each intervention requires understanding the evidence, level of risk, and appropriate application based on a patient's level of activity to enable clinicians to enhance patient outcomes and quality of life.

Purpose of review: The purpose of the current review is to analyze the current literature regarding the tools available to evaluate patient expectations and satisfaction. There have been an increasing number of tools that have been developed and validated for various orthopedic procedures. Despite the growing number of tools, there are a limited number of tools available for pediatric patients.

Recent findings: Several tools have been developed in orthopedics to evaluate patient expectations. However, there are no tools that have been validated in the pediatric population. In addition, pediatric patient expectations should be collected in conjunction with parent/caregiver expectations. Although not specifically validated for pediatric patients, there are several tools available that may pertain to pediatric patients including the HSS ACL Expectations Survey, HSS Shoulder Expectations Survey, HSS Knee Surgery Expectations Survey, HSS Foot and Ankle Surgery Expectation Survey, Sunnybrook Surgery Expectations Survey, Musculoskeletal Outcomes Data Evaluation and Management System (MODEMS) Instruments, Quick DASH, and DASH. In terms of patient satisfaction, there are even fewer tools available. Several tools have been developed to evaluate patient satisfaction and five additional tools within orthopedics. Of these tools, there are two that have been validated for pediatric patients: The Swedish Parents Satisfaction Questionnaire and the Scoliosis Research Society-22. There are a growing number of tools to evaluate patient's expectations and satisfaction in the orthopedic literature. Given most of these tools pertain to adult patients, there is a need for further development of tools specifically validated for pediatric patients and their parents/caregivers. Through the measurement of expectations and satisfaction, medical professionals can hope to improve satisfaction and outcomes.

Purpose of review: The management options for anterior shoulder instability with minimal bone loss or with critical bone loss are well established. However, there is less clear evidence to guide management for patients with subcritical bone loss, the spectrum of pathology where soft tissue repair alone is prone to higher rates of failures. In this range of bone loss, likely around 13.5% to 20%, the goal of surgery is to restore function and stability while limiting morbidity. As with many procedures in the shoulder, this decision should be tailored to patient anatomy, functional goals, and risk factors. This article provides a review of our current understanding of subcritical bone loss and treatment strategies as well as innovations in management.

Recent findings: While surgeons have largely understood that restoration of anatomy is important to optimize outcomes after stabilization surgery, there is increasing evidence that reconstructing bony anatomy and addressing both osseous and soft tissue structures yields better results than either alone. Even in the setting of subcritical bone loss, there is likely a benefit to combined osseous augmentation with soft tissue management. Additionally, there is new evidence to support management of even on-track humeral lesions when the distance to dislocation is sufficiently small, particularly for athletes. Surgeons must balance bony and soft tissue restoration to achieve optimal outcomes for anterior instability with subcritical bone loss. There are still significant limitations in the literature and several emerging techniques for management will require further study to prove their long-term efficacy. Beyond surgery, there should be a focus on a collaborative treatment strategy with the surgeon, patient, and therapists to achieve high-level function and minimize recurrence.

Purpose of review: To provide an overview of the current evidence of the timing of surgery and rehabilitation after multiligamentous knee injuries (MLKIs) and offer insights into the ongoing multi-center randomized controlled study, the 'STaR trial'.

Recent findings: Due to the complexity of the MKLIs, they are usually treated surgically with the goal of either repairing or reconstructing the injured ligaments. Although the current literature on MLKIs is relatively extensive, the consensus on the timing of surgery or rehabilitation following surgery for MLKIs is still lacking. While current literature mostly suggests early treatment, there is also evidence preferring delayed treatment. Furthermore, evidence on the timing of postoperative rehabilitation is limited. Thus, the current multi-center randomized controlled study, the 'STaR trial', is expected to respond to these questions by adding new high-level evidence. The MLKIs are often associated with knee dislocation and constitute a highly complex entity, including concomitant injuries, such as neurovascular, meniscal, and cartilaginous injuries. The treatment of MLKIs usually aims to either repair or reconstruct the injured ligaments, however, there is no general consensus on the timing of surgery or rehabilitation following an MLKI surgery. This current review stresses the need for more high-level research to address the paucity of evidence-based treatment guidelines for the treatment of complex MLKIs.

Purpose of review: Reverse shoulder arthroplasty (rTSA) is a commonly performed procedure to treat degenerative conditions of the shoulder. With its growing utilization, techniques to reliably diagnose and treat prosthetic joint infection (PJI) have become increasingly important. In this review we outline the current research and prevention methods of prosthetic joint infection in rTSA. This includes preoperative considerations, intraoperative, and postoperative treatment algorithms.

Recent findings: There is currently no established standardized protocol for preoperative infection prevention or post operative management. However, recent studies have identified risk factors for infection, as well as successful prevention techniques that can be implemented to minimize infection risk. Although there is no standardized protocol currently utilized to diagnose and treat shoulder PJI, we outline a potential set of preventative measures and postoperative management strategies that clinicians can use to properly diagnose and treat patients with this difficult condition.

Purpose of review: Graft failure, one of the most common outcomes in anterior cruciate ligament reconstruction randomized controlled trials, lacks a consensus definition. The purpose of this study was to systematically summarize current practice and parameters in defining anterior cruciate ligament reconstruction graft 'failure'.

Recent findings: Forty studies (4466 participants) satisfied the inclusion criteria. Of these, 90% either defined failure formally or referenced the etiology of failure, the remaining 10% used the term failure without referencing the anterior cruciate ligament reconstruction graft. Among the included studies, there was a high level of inconsistency between the definitions of graft failure. The extracted data was categorized into broader groups, revealing abnormal knee laxity (80%) and graft re-rupture (37.5%) as the most common parameters incorporated in the definitions of graft failure in high-level randomized controlled trials. This review shows that anterior cruciate ligament reconstruction randomized controlled trials lack a consistent definition for graft failure. A universal definition is vital for clarity in medical practice and research, ideally incorporating both objective (e.g. graft re-rupture) and subjective (e.g. validated questionnaires) parameters. A composite outcome should be established which includes some of the common parameters highlighted in this review. In the future, this review can be used to assist orthopaedic surgeons to establish a formal definition of anterior cruciate ligament reconstruction graft 'failure'.

Purpose of review: The tibial tubercle osteotomy (TTO) is a versatile surgical technique used to treat a range of patellofemoral disorders, including patellar instability, painful malalignment, focal chondral defects, and patellar maltracking that have failed conservative therapies. TTO is a personalized procedure that can be tailored to the pathoanatomy of the patient based on physical examination and imaging. The complication rate associated with TTO strongly depends on the indication for surgery, the severity of the patient's condition, and the surgical approach. Despite the literature on TTO, to our knowledge, no single source has addressed the indications, techniques, outcomes, and complications of this procedure. The purpose of this article is to serve as such a valuable resource.

Recent findings: Highlights from recent studies we would like to emphasize are two-fold. First, maintaining a distal cortical hinge yields lower complication rates than osteotomies involving complete tubercle detachment with classic or standard techniques. Second, based on current evidence, TTO consistently provides symptomatic relief, and most patients can return to work or sport at their pre-operative level within 3 and 6 months, respectively. TTO is a personalizable surgical technique that may be utilized for multiple patellofemoral disorders and is associated with good outcomes.

Purpose of review: Healthcare disparities influence multiple dimensions of orthopaedic care including access, burden and incidence of disease, and outcome in varying populations. These disparities impact healthcare at both the micro and macro scale of the healthcare experience from individual patient-physician relationships to reimbursement rates across the United States. This article provides a review of how healthcare disparities contribute to the landscape of orthopaedic care and specifically highlights how disparities affect outpatient visits, discretionary and unplanned surgical care, and postoperative outcomes.

Recent findings: Current research demonstrates the widespread presence of healthcare disparities in the field of orthopaedics and gives both objective and subjective evidence confirming disparities' measurable influence. The disparities most highlighted by our review include differences in orthopaedic care based on insurance type and race. Currently disparities in orthopaedic care are deeply connected to patient insurance status and race. In the outpatient setting insurance significantly impacts access to care, travel burden, and utilization of services. The emergent setting is similarly influenced with measurable differences in lack of access to acute care, rates of inappropriate triage, and timeliness of care based on insurance status and race. Additionally, the postoperative period is not immune to disparities with likelihood of follow up, experience of catastrophic medical expenses, and postoperative outcomes also being affected. Addressing these disparities is a pressing need and may include solutions like wider expansion and acceptance of publicly funded insurance and the development of readily available and easily measurable metrics for healthcare equity and quality in vulnerable populations.

Purpose of review: The burden of musculoskeletal disease is increasing globally and disproportionately affecting people in low and middle income countries (LMIC). We sought to review global access to orthopaedic care, burden of trauma, research infrastructure, impact of surgical mission trips, implant availability, and the effect of COVID-19 upon the delivery of orthopaedic care worldwide.

Recent findings: The majority of people in LMIC do not have access to safe, quality surgical care, and there are few fellowship-trained orthopaedic traumatologists. Road traffic accidents are the leading cause of long bone fractures in LMIC and result in significant morbidity and mortality. Of the orthopaedic literature published globally in the last 10 years, less than 15% had authors from LMIC. There has been growth in surgical mission trips to LMIC, but few organizations have established bidirectional partnerships. Among the challenges to delivering quality musculoskeletal care in LMIC is timely access to quality orthopaedic implants. Implant options in LMIC are more limited and subjected to less rigorous testing and regulation than high income countries (HIC). The COVID-19 pandemic dramatically reduced elective surgeries but saw the increase in telemedicine utilization which has prevailed in both HIC and LMIC. Awareness of global inequities in orthopaedic care is growing. Much can be learned through collaborations between orthopaedic surgeons from HIC and LMIC to advance patient care worldwide. There is a need for high quality, accurate data regarding incidence and prevalence of musculoskeletal disease, care utilization/availability, and postoperative outcomes so resources can be allotted to make orthopaedic care more equitable globally.