Current Reviews in Musculoskeletal Medicine最新文献

Purpose of review: The purpose of the review is to provide an updated overview of a relatively novel but controversial surgical device (InSpace subacromial balloon, Stryker, Kalamazoo, MI) that can be readily incorporated into the armamentarium of the shoulder surgeon. The authors review the critical clinical and surgical decision-making aspects of InSpace. A recommended surgical technique and rehabilitation protocol are outlined. The authors present a nuanced view of the balloon spacer in the continuum of care of the irreparable rotator cuff tear.

Recent findings: Within the last year, two Level I clinical trials have been published, and the data from these studies offer conflicting evidence regarding the utility of the subacromial balloon spacer. The current review contrasts these two recent studies and offers a framework by which the available evidence can be practically understood with respect to clinical decision-making. The literature currently supports a limited indication for use of InSpace: the elderly, low-demand patient with preserved active range of motion with an operatively irreparable, posterosuperior rotator cuff tear with an intact subscapularis. The InSpace subacromial balloon spacer is a simple device that can yield substantial improvements in clinical outcomes among a subset of patients with irreparable rotator cuff tears. InSpace is not a panacea for the complex, irreparable rotator cuff tear. Individualized decision-making is necessary in this diverse and challening patient population.

Purpose of review: In this review, we present recent findings and advancements in the use of neuroimaging to evaluate neural activity relative to ACL injury risk and patellofemoral pain. In particular, we describe prior work using fMRI and EEG that demonstrate the value of these techniques as well as the necessity of continued development in this area. Our goal is to support future work by providing guidance for the successful application of neuroimaging techniques that most effectively expose pain and injury mechanisms.

Recent findings: Recent studies that utilized both fMRI and EEG indicate that athletes who are at risk for future ACL injury exhibit divergent brain activity both during active lower extremity movement and at rest. Such activity patterns are likely due to alterations to cognitive, visual, and attentional processes that manifest as coordination deficits during naturalistic movement that may result in higher risk of injury. Similarly, in individuals with PFP altered brain activity in a number of key regions is related to subjective pain judgements as well as measures of fear of movement. Although these findings may begin to allow objective pain assessment and identification, continued refinement is needed. One key limitation across both ACL and PFP related work is the restriction of movement during fMRI and EEG data collection, which drastically limits ecological validity. Given the lack of sufficient research using EEG and fMRI within a naturalistic setting, our recommendation is that researchers target the use of mobile, source localized EEG as a primary methodology for exposing neural mechanisms of ACL injury risk and PFP. Our contention is that this method provides an optimal balance of spatial and temporal resolution with ecological validity via naturalistic movement.

PURPOSE OF REVIEW: Posterior spinal fusion (PSF) is the preferred treatment for adolescent idiopathic scoliosis (AIS) patients with surgical range curves. Selection of the proper upper and lower instrumented vertebrae (UIV and LIV) is essential in curve correction and achieving a successful outcome, while preventing short and long-term complications. RECENT FINDINGS: The literature lacks high-level evidence, especially on outcomes of modern surgical techniques. However, evidence seems to show that a great majority of AIS patients have excellent clinical and functional long-term outcomes after PSF. We have reviewed the evidence and provided our level selection recommendations, which should be weighed against the body of evidence on the topic when selecting fusion levels in AIS.

Purpose of review: Acute knee injuries are commonly encountered in both the clinical and sideline setting and may be treated operatively or non-operatively. This article describes an evidence-based approach to non-operative acute knee injury. This includes history, physical exam, imaging, and initial management. In addition, the non-operative management of three such injuries-ligament injury, meniscus injury, and patellar dislocation injury-will be discussed via a case-based practical approach.

Recent findings: Aside from grade III ACL tears, most acute knee ligament injuries, especially in the absence of other concurrent injuries, can be treated non-operatively. There is new evidence that acute traumatic meniscus tears in those younger than 40 can be successfully treated non-operatively and can do equally, as well as those that undergo surgery, at 1 year out from injury. Based on the current literature, a short period of knee bracing in extension with progression to weightbearing to tolerance is recommended after initial patellar dislocation. Many of the most common acute knee injuries, including MCL tears, meniscus tears, and patellar dislocations, can be managed non-operatively. A detailed systemic approach to initial evaluation, including pertinent history, physical exam, and appropriate imaging, is essential and complementary to the subsequent non-operative treatment algorithm.

Purpose of review: Numerous cartilage restoration techniques have proven to be effective in the treatment of articular cartilage defects. The ultimate goal of these procedures is to improve pain and function, thereby increasing the likelihood of a patient's return to physical activity. Postoperative rehabilitation is a key component for a successful and expedient return to activities. The purpose of this article is to review the current literature regarding common surgical options, rehabilitation protocols, and performance outcomes after operative treatment of articular cartilage defects.

Recent findings: Studies have demonstrated improved short- to long-term outcomes in a majority of techniques. However, the clinical benefits of microfracture are short-lived, which has led to the use of alternative procedures. Rehabilitation protocols are not standardized, but emphasis has been placed on bracing, weightbearing, early continuous passive range of motion, and strengthening to improve function. There is growing evidence to suggest that accelerated rehabilitation after matrix-induced autologous chondrocyte implantation may result in superior outcomes compared to delayed rehabilitation. Overall, most techniques result in satisfactory rates of return to play, though existing comparative studies typically include patients with heterogeneous pathology, complicating effective synthesis of outcomes data. In appropriately selected patients, cartilage restoration procedures after articular cartilage injury result in favorable patient-reported clinical outcomes and high rates of return to play. While studies emphasize the critical role that rehabilitation plays with respect to outcomes after surgery, there are substantial inconsistencies in protocols across techniques.

Purpose of review: Hip arthroscopy is widely used for the management of intra-articular pathology and there has been growing interest in strategies for management of the hip capsule during surgery. The hip capsule is an essential structure that provides stability to the joint and it is necessarily violated during procedures that address intra-articular pathology. This article reviews different approaches to capsular management during hip arthroscopy including anatomical considerations for capsulotomy, techniques, clinical outcomes, and the role of routine capsular repair. This article also reviews the concept of hip microinstability and its potential impact on capsular management options as well as iatrogenic complications that can occur as a result of poor capsular management.

Recent findings: Current research highlights the key functional role of the hip capsule and the importance of preserving its anatomy during surgery. Capsulotomies that involve less tissue violation (periportal and puncture-type approaches) do not appear to require routine capsular repair to achieve good outcomes. Many studies have investigated the role of capsular repair following more extensive capsulotomy types (interportal and T-type), with most authors reporting superior outcomes with routine capsular repair. Strategies for capsular management during hip arthroscopy range from conservative capsulotomy techniques aimed to minimize capsular violation to more extensive capsulotomies with routine capsule closure, all of which have good short- to mid-term outcomes. There is a growing trend towards decreasing iatrogenic capsular tissue injury when possible and fully repairing the capsule when larger capsulotomies are utilized. Future research may reveal that patients with microinstability may require a more specific approach to capsular management.

Purpose of review: The evaluation of a young athlete with an overuse injury to the knee involves a comprehensive approach. There are a number of elements to consider including assessments of skeletal maturity (biologic maturation), workload (training load + competition load), sport specialization status, and biomechanics. The type of injury and treatment, as well as future prognosis, may be influenced by these and other factors.

Recent findings: Calculating the percentage of predicted adult height (PPAH) is a valuable tool in assessing overuse injury patterns and diagnoses in youth athletes. Modifiable and non-modifiable overuse injury risk factors require monitoring from clinicians as young athletes mature and develop over time. Training and rehabilitation programs should be adapted to account for these. In this manuscript, we seek to introduce a novel, comprehensive approach: S.P.O.R.R.T. (Skeletal Maturity, Prior Injury Risk, One Sport Specialization, Rehabilitation, Return to Play, Training Recommendations) (Fig. 1). Overuse, non-traumatic injuries to the knee in youth athletes will be presented in a case-based and evidence-based model to provide a framework for a comprehensive approach to the assessment and treatment of youth athletes with overuse injuries.

Purpose of review: Femoroacetabular impingement (FAI) is a pathomechanical process whereby abnormal contact between proximal femur and acetabulum at end range of hip motion induces chondrolabral lesions within the hip joint. Surgery followed by a rehabilitation program or physical therapy with possible addition of an intra-articular corticosteroid injection are the two predominant treatments. The majority of authors recognize that a well-designed rehabilitation protocol is essential to achieve good outcomes with both nonoperative and surgical treatment. However, there is little evidence about what is the best rehabilitation protocol and most of the literature available is based on expert level opinion. This current review investigates the recent literature on nonoperative and postoperative rehabilitation protocol and return to play in FAI patients and describes our approach.

Recent findings: Historically, rehabilitation protocols for treatment of FAI as well as return to play protocols were based on experts' opinion and low-level evidence studies. In order to improve standardization of protocols and to allow a better comparison in between different protocols, different authors have created standardized rehabilitation protocols with consensus building methods comparing them with other treatment options in high-level evidence trials (FASHIoN trial, etc.). Despite the excellent results reported after nonoperative and post-surgical rehabilitation, and the high RTP rate after FAI treatment, there is a significant variability in between protocols. Further high-level evidence studies are necessary in order to establish a gold standard in rehabilitation and RTP protocols.

Purpose of review: Spinal ligament is an important component of the spinal column in mitigating biomechanical stress. Particularly the posterior ligamentous complex, which is composed of the ligamentum flavum, interspinous, and supraspinous ligaments. However, research characterizing the biomechanics and role of ligament health in spinal pathology and clinical context are scarce. This article provides a comprehensive review of the implications of spinal pathology on the structure, function, and biomechanical properties of the posterior ligamentous complex.

Recent findings: Current research characterizing biomechanical properties of the posterior ligamentous complex is primarily composed of cadaveric studies and finite element modeling, and more recently incorporating patient-specific anatomy into finite element models. The ultimate goal of current research is to understand the relative contributions of these ligamentous structures in healthy and pathological spine, and whether preserving ligaments may play an important role in spinal surgical techniques. At baseline, posterior ligamentous complex structures account for 30-40% of spinal stability, which is highly dependent on the intrinsic biomechanical properties of each ligament. Biomechanics vary widely with pathology and following rigid surgical fixation techniques and are generally maladaptive. Often secondary to morphological changes in the setting of spinal pathology, but morphological changes in ligament may also serve as a primary pathology. Biomechanical maladaptations of the spinal ligament adversely influence overall spinal column integrity and ultimately predispose to increased risk for surgical failure and poor clinical outcomes. Future research is needed, particularly in living subjects, to better characterize adaptations in ligaments that can provide targets for improved treatment of spinal pathology.

Purpose of review: To update and concepts for pediatric physeal-sparing patellofemoral stabilization surgery.

Recent findings: Recent studies have demonstrated positive results in patellofemoral stabilization in pediatric populations with physeal-sparing techniques that limit the potential for physeal damage. Comprehensive analysis remains limited by population and technique heterogeneity. Physeal-sparing patellofemoral stabilization, most significantly through physeal-sparing reconstruction of the medial patellofemoral ligament complex remains a viable option for pediatric patients with recurrent patellofemoral instability.