Current Reviews in Musculoskeletal Medicine最新文献

Purpose of review: The management of shoulder instability in throwing athletes remains a challenge given the delicate balance between physiologic shoulder laxity facilitating performance and the inherent need for shoulder stability. This review will discuss the evaluation and management of a throwing athlete with suspected instability with a focus on recent findings and developments.

Recent findings: The vast majority of throwing athletes with shoulder instability experience subtle microinstability as a result of repetitive microtrauma rather than episodes of gross instability. These athletes may present with arm pain, dead arms or reduced throwing velocity. Recent literature reinforces the fact that there is no "silver bullet" for the management of these athletes and an individualized, tailored approach to treatment is required. While initial nonoperative management remains the hallmark for treatment, the results of rehabilitation protocols are mixed, and some patients will ultimately undergo surgical stabilization. In these cases, it is imperative that the surgeon be judicious with the extent of surgical stabilization as overtightening of the glenohumeral joint is possible, which can adversely affect athlete performance. Managing shoulder instability in throwing athletes requires a thorough understanding of its physiologic and biomechanical underpinnings. Inconsistent results seen with surgical stabilization has led to a focus on nonoperative management for these athletes with surgery reserved for cases that fail to improve non-surgically. Overall, more high quality studies into the management of this challenging condition are warranted.

Purpose: Osteoporosis, the most prevalent metabolic bone disease, significantly impacts global public health by increasing fracture risks, particularly among post-menopausal women and the elderly. Osteoporosis is characterized by decreased bone mineral density (BMD) and deterioration of bone tissue, which leads to enhanced fragility. The disease is predominantly diagnosed using dual X-ray absorptiometry (DXA) and is significantly influenced by demographic factors such as age and hormonal changes. This chapter delves into the condition's complex nature, emphasizing the pervasive gender and racial disparities in its screening, diagnosis, and treatment.

Recent findings: Recent findings highlight a substantial gap in the management of osteoporosis, with many individuals remaining under-screened and under-treated. Factors contributing to this include the asymptomatic early stages of the disease, lack of awareness, economic barriers, and inconsistent screening practices, especially in under-resourced areas. These challenges are compounded by disparities that affect different genders and races unevenly, influencing both the prevalence of the disease and the likelihood of receiving adequate healthcare services. The summary of this chapter underscores the urgent need for targeted strategies to overcome these barriers and improve health equity in osteoporosis care. Proposed strategies include enhancing public and healthcare provider awareness of osteoporosis, broadening access to diagnostic screenings, and integrating personalized treatment approaches. These efforts aim to align with global health objectives to mitigate the impacts of osteoporosis and ensure equitable health outcomes across all demographic groups.

Purpose of review: To evaluate the current evidence and literature on treatment options for proximal hamstring injuries.

Recent findings: Patients with 3-tendon complete tears with greater than 2 cm of retraction have worse outcomes and higher complication rates compared to those with less severe injuries. Endoscopic and open proximal hamstring repair both have favorable patient reported outcomes at 5-year follow up. Proximal hamstring repair in patients who are male, with isolated semimembranosus injury, and have proximal hamstring free tendon rupture are more likely to have earlier return to sports. The Parisian Hamstring Avulsion Score (PHAS) is a validated patient-reported outcome measure to predict return to sports. Proximal hamstring injuries may occur in both elite and recreational athletes and may present with varying degrees of chronicity and severity. Injuries occur most commonly during forceful eccentric contraction of the hamstrings and often present with ischial tuberosity tenderness, ecchymosis, and hamstring weakness. Treatment decision-making is dictated by the tendons involved and chronicity. Many proximal hamstring injuries can be successfully treated with non-surgical measures. However, operative treatment of appropriately indicated proximal hamstring tendon injuries can result in significantly better functional outcomes and faster and more reliable return to sports compared to nonoperative treatment. Both endoscopic and open surgical repair techniques show high satisfaction levels and excellent patient-reported outcomes at short- and mid-term follow-up. Postoperative rehabilitation protocols vary across the literature and ongoing study is needed to clarify the optimal program, though emphasis on eccentric hamstring strengthening may be beneficial.

Purpose of review: To reduce pain, improve function and possibly mitigate the risk for development of osteoarthritis in patients with functionally deficient meniscus pathology, meniscal allograft transplantation (MAT) can be used to restore native joint biomechanics and increase knee joint longevity. This review explores the senior author's preferred bridge-in-slot technique and recently published long-term clinical and radiographic outcomes following MAT.

Recent findings: Recent literature demonstrates MAT to be a safe and largely successful procedure for patients with functional meniscus deficiency. A majority of patients reach established minimal clinically important difference (MCID) values. Graft survivorship is approximately 80% at 10 years, significantly delaying and in some cases, preventing the need for future joint reconstruction procedures in these young patients. Return to sport rates are over 70%, revealing meniscal allografts can withstand high impact activities. Cartilage damage at the time of MAT increases the risk for graft and clinical failure, though this may be mitigated with a concomitant cartilage restoration procedure. Meniscal allograft transplantation can provide a durable and effective long-term solution to meniscal deficiency in symptomatic patients who wish to decrease the risk of symptomatic progression and possibly further osteoarthritis and continue activities of daily life and sports with less pain and more function. By restoring more normal joint biomechanics, MAT can mitigate the potential need for future knee arthroplasty in this young active patient population.

Purpose of review: Spinal fusion, vital for treating various spinal disorders, has evolved since the introduction of the minimally invasive Lateral Lumbar Interbody Fusion (LLIF) by Pimenta in 2001. Traditionally performed in the lateral decubitus position, LLIF faces challenges such as intraoperative repositioning, neurological complications, and lack of access to lower lumbar levels. These challenges lead to long surgery times, increased rates of perioperative complications, and increased costs. The more recently popularized prone lateral approach mitigates these issues primarily by eliminating patient repositioning, thereby enhancing surgical efficiency, and reducing operative times. This review examines the progression of spinal fusion techniques, focusing on the advantages and recent findings of the prone lateral approach compared to the traditional LLIF.

Recent findings: The prone lateral approach has shown improved patient outcomes, including lower blood loss and shorter hospital stays, and has been validated by multiple studies for its safety and efficacy compared to the LLIF approach. Significant enhancements in postoperative metrics, such as the Oswestry Disability Index, Visual Analog Scale, and radiological improvements have been noted. Comparatively, the prone lateral approach offers superior segmental lordosis correction and potentially better subjective outcomes than the lateral decubitus position. Despite these advances, both techniques present similar risks of neurological complications. Overall, the prone lateral approach has emerged as a promising alternative in lumbar interbody fusion, combining efficiency, safety, and improved clinical outcomes.

Purpose of review: Youth sports are increasingly shifting towards a "pay to play" model which has introduced financial barriers to participation. The Amateur Athletic Union (AAU) is the main organization for club basketball, serving as a platform where young athletes can compete beyond the recreational level. Outside the realm of athletes who have access to state-of-the-art facilities and top-tier coaching, the pathway to playing basketball at the next level may be predominantly available to those who can afford the considerable costs of AAU participation. The objective of this study is to determine the accessibility of AAU teams of active National Basketball Association (NBA) players through use of the Area Deprivation Index (ADI).

Recent findings: We identified 114 AAU teams with physical addresses for 250 (50%) currently active domestic NBA players. The State ADI of the high schools as well as national and state ADIs of prior AAU teams of active NBA players were significantly skewed toward lower ADI rankings (higher socioeconomic status) (p < 0.05). The mean distance between high school location and AAU location was 170 miles. Prior AAU teams of currently active NBA players are more frequently located in areas of higher socioeconomic status with nearly 50% being within the top 3rd lower state decile as measured by the area deprivation index. Similarly, we found the high schools these players attended, as a proxy for areas they grew up in, were also more frequently located in areas of higher socioeconomic status.

Purpose of review: The purpose of this review is to summarize current clinical knowledge on the prevalence and types of meniscus pathology seen with concomitant anterior cruciate ligament (ACL) injury, as well as surgical techniques, clinical outcomes, and rehabilitation following operative management of these pathologies.

Recent findings: Meniscus pathology with concomitant ACL injury is relatively common, with reports of meniscus pathology identified in 21-64% of operative ACL injuries. These concomitant injuries have been associated with increased age and body mass index. Lateral meniscus pathology is more common in acute ACL injury, while medial meniscus pathology is more typical in chronic ACL deficiency. Meniscus tear patterns associated with concomitant ACL injury include meniscus root tears, lateral meniscus oblique radial tears of the posterior horn (14%), and ramp lesions of the medial meniscus (8-24%). These meniscal pathologies with concomitant ACL injury are associated with increased rotational laxity and meniscal extrusion. There is a paucity of comparative studies to determine the optimal meniscus repair technique, as well as rehabilitation protocol, depending on specific tear pattern, location, and ACL reconstruction technique. There has been a substantial increase in recent publications demonstrating the importance of meniscus repair at the time of ACL repair or reconstruction to restore knee biomechanics and reduce the risk of progressive osteoarthritic degeneration. Through these studies, there has been a growing understanding of the meniscus tear patterns commonly identified or nearly missed during ACL reconstruction. Surgical management of meniscal pathology with concomitant ACL injury implements the same principles as utilized in the setting of isolated meniscus repair alone: anatomic reduction, biologic preparation and augmentation, and circumferential compression. Advances in repair techniques have demonstrated promising clinical outcomes, and the ability to restore and preserve the meniscus in pathologies previously deemed irreparable. Further research to determine the optimal surgical technique for specific tear patterns, as well as rehabilitation protocols for meniscus pathology with concomitant ACL injury, is warranted.

Purpose of review: The field of meniscus replacement is changing continuously, with new devices emerging and others disappearing from the market. With the current tendency to preserve the knee joint, meniscus implants may become more relevant than ever. The purpose of this review is to provide an overview of the current state of partial and total meniscus replacements that have been developed beyond the academic phase. The available clinical and pre-clinical data is evaluated, and omissions are identified.

Recent findings: Recent systematic reviews have shown a lack of homogenous clinical data on the CMI and Actifit meniscal scaffolds, especially regarding long-term performance without concomitant surgical interventions. Clinical studies on the medial total meniscus prostheses NUsurface and Artimis are ongoing, with the NUsurface being several years ahead. New techniques for meniscus replacement are rapidly developing, including the Artimis lateral meniscus prosthesis and the MeniscoFix 3D-printed scaffold. All evaluated clinical studies point towards improved clinical outcomes after implantation of partial and total meniscus replacements. Long-term data on survival and performance is of low quality for CMI and Actifit and is unavailable yet for NUsurface and Artimis. It is of major importance that future research focuses on optimizing fixation methods and identifying the optimal treatment strategy for each patient group. New techniques for total and partial replacement of the medial and lateral meniscus will be followed with interest.

Purpose of review: Management of meniscal injuries in the elite athlete is a difficult problem secondary to the high demands of athletic competition, the need for a timely return to sport, and the desire to maximize performance over time. The purpose of this review is to provide an up-to-date summary on the current literature and trends regarding the management of meniscus injuries with a special consideration for elite athletes.

Recent findings: Historically, partial meniscectomy has been the primary treatment option for meniscus injuries. However, in recent years there has been an increased emphasis on meniscus preservation due to the increased risk of cartilage degeneration over time. Moreover, while partial meniscectomy still provides a quicker return to sport (RTS), recent literature has demonstrated similar rates of RTS and return to pre-injury levels between partial meniscectomy and meniscus repair. In the setting of symptomatic meniscal deficiency, meniscus allograft transplantation has become an increasingly utilized salvage procedure with promising yet variable outcomes on the ability to withstand elite competition. Currently, there is no uniform approach to treating meniscal injuries in elite athletes. Therefore, an individualized approach is required with consideration of the meniscus tear type, location, concomitant injuries, athlete expectations, rehabilitation timeline, and desire to prevent or delay knee osteoarthritis. In athletes with anatomically repairable tears, meniscus repair should be performed given the ability to restore native anatomy, provide high rates of RTS, and mitigate long-term chondral damage. However, partial meniscectomy can be indicated for unrepairable tears.

Purpose of review: With an aging population, extending healthy life expectancy is a global challenge. Maintaining healthy knee joint function is one of the essential factors to preserve the ability to walk and extend healthy life expectancy. Meniscus centralization was introduced in 2012 as a procedure for meniscus extrusion, one of the causes of knee osteoarthritis (OA). Initially, it was performed only for lateral meniscus (LM) extrusion, and favorable 2-year results were reported in 2016. Gradually, basic studies supporting the effectiveness of meniscus centralization have been reported, and it has also been performed for medial meniscus (MM) extrusion, with some positive results reported. Although the surgical procedures vary among the institutions, the basic concept is to reattach the loosened meniscotibial ligament to the edge of the tibial plateau to re-tension it. This review will discuss the history of development and the current status of meniscus centralization.

Recent findings: Current research shows that meniscus centralization is not performed in isolation but is often used as an augmentation along with the conventional repair of meniscus injuries, particularly posterior root tears. Biomechanical studies demonstrated that MM centralization with a posteromedial anchor can better restore meniscus function.

Conclusion: Despite its relatively short publication history of just over ten years, meniscus centralization has shown potential as a treatment to curb the progression of knee OA and extend a healthy life. While more evidence is needed, this conclusion underscores the promising role for meniscus centralization, making it a topic of significant interest for knee surgeons and researchers.