Current Reviews in Musculoskeletal Medicine最新文献

Purpose of review: To analyze advances in labral reconstruction, and to discuss the literature relating to efficacy, outcomes, and technical considerations of labral reconstruction.

Recent findings: The available evidence suggests that labral reconstruction is a safe and effective procedure that can improve pain and function in patients with severe and/or complex labral tears. The superiority of labral reconstruction over labral repair is uncertain, and it remains unclear what graft type and technique should be used in labral reconstructions. Labral reconstruction assists in restoring the function of the labrum of the hip. It consistently restores stability of the hip joint and demonstrates good clinical outcomes at follow-up. The optimal graft type, technique, and extent are still debated, and more research is needed. Ultimately, despite this uncertainty, labral reconstruction is proving to be a valuable tool for hip preservation specialists.

Purpose of review: Open reduction and internal fixation with locking plates (ORIF-LP) has been used for decades for the surgical management of proximal humerus fractures. Despite good outcomes have been widely published in the literature, unacceptably high rates of complications (up to 40%), many of them yielding poor outcomes and requiring reoperation (up to 25%), have also been reported, especially in elderly patients. Most common complications are related to implant failure, with intra-articular screw penetration as the most frequent and devastating.

Recent findings: Advances in patient selection and surgical technique, and implementation of bone or cement augmentation, have been developed to hopefully decrease complication rates. Mayo-FJD Classification offers prognostic information that can aid in the decision-making process for proximal humeral fractures. Displaced valgus impacted fractures seem to be associated with well over a 10% rate of avascular necrosis after ORIF-LP. A principle-based and stepwise surgical technique combining anatomic reduction and a short screw configuration can provide good outcome in most patients, even the elderly, decreasing implant failures to less than 10%. Acrylic cement augmentation has the potential to further decrease implant failure rate to 1%. Reoperation rates are higher partly due to the need to remove hardware for painful subacromial conflict. However, no studies to date definitively demonstrated the superiority of ORIF-LP compared to non-operative treatment, intramedullary nailing, or reverse shoulder arthroplasty. ORIF-LP can provide good results for the surgical management of displaced proximal humerus fractures even in elderly patients provided adequate patient selection and a principle based and stepwise surgical technique, supplemented with bone graft or acrylic cement when needed. Poor outcomes and high complication and reoperation rates should be expected when these recommendations are not followed.

Purpose of review: This article provides a review of recent published research studying racial, ethnic, and socioeconomic disparities in pediatric musculoskeletal care.

Recent findings: Disparities in pediatric musculoskeletal care are demonstrated in two general realms: access to care and health outcomes. Though initiatives have been proposed or enacted to address disparities, underrepresented minorities and patients from lower socioeconomic statuses continue to face barriers across the spectrum of orthopedic care and poorer ultimate outcomes after both non-operative and operative management. Minority pediatric patients and those from lower socioeconomic statuses experience delays across the spectrum of orthopedic care for both urgent and non-urgent conditions. They wait longer between injury date and initial orthopedic evaluation, longer to receipt of diagnostic imaging, and longer to ultimate treatment than their counterparts. When finally able to obtain musculoskeletal care and treatment, they are at higher risk of poor in-hospital outcomes and inpatient complications, worse patient reported outcomes, and suboptimal pain management. In the outpatient setting, they receive less physical therapy and follow-up clinic visits, resulting in greater stiffness and strength deficits, and are ultimately less likely to meet return to sport criteria.

Purpose of review: Return to sport (RTS) is an important metric tied to patient satisfaction after receiving treatment for a sports-related injury. Recently, there has been an explosion of literature on RTS; yet a comprehensive review encompassing multiple injuries does not exist. Furthermore, RTS has historically been defined by quantitative measures that assess strength, function, and pain but little consideration has been given to psychologic factors nor has there been an open-ended forum for athletes to share with health care providers which factors they feel are most influential for RTS. This review also serves to heighten surgeons' awareness of underlying psychologic/psychosocial factors affecting RTS.

Recent findings: Qualitative studies which employ open-ended questioning of athletes who have undergone surgical management of superior labral anterior-posterior (SLAP) tears, shoulder instability, ulnar collateral ligament (UCL) rupture, femoral acetabular impingement (FAI), and anterior cruciate ligament (ACL) tear demonstrate that fear of reinjury, lack of social support, and unrealistic expectations are all barriers to RTS. Qualitative studies give health care providers unique insight into the perspectives of their patients so that unmet postoperative needs can be addressed to facilitate RTS. Sports psychologists, coaches, athletic trainers, and physical therapists should create a positive environment to address these needs and provide optimal, holistic care to return athletes to the field safely. Though time consuming, further qualitative research is necessary to understand the unique factors affecting RTS in athletes.

Purpose of review: Fractures of the tibial tubercle are a relatively uncommon injury, representing 3% of all proximal tibia fractures and < 1% of all physeal fractures, primarily seen in the adolescent demographic. While recognition of the injury and its management is being more widely reported in the literature and recognized in the hospital setting, reports of its outcomes and complications have still been limited. This article provides an updated review of the outcomes and complications of tibial tubercle fractures.

Recent findings: Current research shows both radiographic outcomes, specifically osseous union, and functional outcomes, such as return to play and full knee range of motion, are excellent in patients treated either operatively or nonoperatively. Complication rates overall remain relatively low, with the most common complication being bursitis and hardware prominence and the most common associated injuries being patellar tendon avulsions and meniscus tears. With appropriate management, tibial tubercle fractures have an excellent overall outcome and a low complication rate. Although complications are uncommon, treating providers should be vigilant and recognize the signs of devastating complications resulting from acute vascular injuries or compartment syndrome. Further research should aim to analyze patients' experiences and satisfaction following treatment of this injury and examine the long-term functional and patient-reported outcomes.

Purpose of review: The aim of this review is to interpret the existing evidence regarding the psychological aspects of sport specialization within the context of a developmental framework.

Recent findings: The growing trend toward early sport specialization is associated with increased risk for injury and burnout, both of which have significant implications for mental health. Mental health literacy programs designed to promote awareness, decrease stigma, and encourage help-seeking behaviors can be an effective way to increase resilience and early recognition of those in need. The trend toward early sport specialization is likely motivated in large part by the expectation that it will increase the likelihood of long-term athletic success. However, recent studies suggest that the majority of elite athletes delay specialization at least until mid to late adolescence. It is essential to consider the developmental psychology of children and adolescents and to avoid imposing expectations that are beyond their neurocognitive capabilities. In addition to depression, anxiety, and burnout, young athletes who are pressured to perform to excessively high standards are likely to internalize athletic failures as feelings of shame. This can lead to maladaptive perfectionistic traits and potentially overtraining, clinical eating disorders, or other harmful behaviors that will result in declines in performance, physical health, and overall wellbeing. Further work is needed to better inform sport-specific recommendations regarding sport specialization and to optimize the beneficial effects of sport participation while limiting the risks of harm.

Purpose of review: This article reviews the basics of 3D printing and provides an overview of current and future applications of this emerging technology in pediatric orthopedic surgery.

Recent findings: Both preoperative and intraoperative utilization of 3D printing technology have enhanced clinical care. Potential benefits include more accurate surgical planning, shortening of a surgical learning curve, decrease in intraoperative blood loss, less operative time, and fluoroscopic time. Furthermore, patient-specific instrumentation can be used to improve the safety and accuracy of surgical care. Patient-physician communication can also benefit from 3D printing technology. 3D printing is rapidly advancing in the field of pediatric orthopedic surgery. It has the potential to increase the value of several pediatric orthopedic procedures by enhancing safety and accuracy while saving time. Future efforts in cost reduction strategies, making patient-specific implants including biologic substitutes and scaffolds, will further increase the relevance of 3D technology in the field of pediatric orthopedic surgery.

Purpose of review: Cervical disc arthroplasty (CDA) for the treatment of symptomatic cervical disc herniations (CDH) is a promising treatment for professional athletes. In recent years, a number of high-profile athletes have returned to professional play within three months after CDA, raising important questions about the potential of this procedure within this patient group. We provide the first comprehensive review of available literature for the safety and efficacy of CDA in professional contact sport athletes.

Recent findings: CDA provides theoretical biomechanical advantages over anterior cervical discectomy and fusion (ACDF) and posterior foraminotomy (PF), as CDA is the only operation for treatment of CDH that provides neural decompression, stability and height restoration, with preserved range of motion. While the comparative long-term results from each procedure are unknown, CDA has provided encouraging promise in its use in professional contact athletes. We aim to aid ongoing discussions regarding the controversies in spine surgery for professional athletes by providing a scientific review of the available evidence-based literature involving cervical disc arthroplasty in this population. In general, we believe that CDA is a viable alternative to ACDF and PF for the contact professional athlete who requires full neck range of motion and desires an expedited return to play. For collision athletes, the short- and long-term safety and efficacy profile of this procedure is promising but still unclear.

Purpose of review: Congenital cervical stenosis (CCS) is a phenomenon in which an individual has a narrow canal due to abnormal anatomy which can present with earlier degenerative symptoms due to a reduced sagittal diameter. The diagnosis of CCS is important to individual treatment and preventative measures. Often, athletes are warned against sport participation that may cause damage to the cervical spine. There may be a predisposition in certain populations, but lack of data limits conclusions. The current review investigates recent literature on the definition, pathoanatomy, clinical presentation, and management of CCS. It specifically interrogates potential populations predisposed to this condition.

Recent findings: The current literature reveals a potential predisposition for CCS in the black population when compared to the white population; however, many studies do not report race when discussing CCS patients. The lack of data limits a consensus on specific populations with a congenitally narrow canal. CCS may be more prevalent in specific populations. With knowledge of populations more at risk for this condition, physicians and teams can be alert when evaluating players and young adults. Furthermore, this may provide insight into risk for symptoms with degenerative disease. These findings introduce an avenue for further research into CCS.

Purpose of review: Femoroacetabular impingement syndrome (FAIS) is a common cause of hip pain that may potentially lead to osteoarthritis. Operative management of FAIS seeks to arthroscopically reshape the abnormal hip morphology and repair the labrum. For rehabilitation following operative management, a structured physical therapy program is unanimously recommended for the patient to return to their previous level of physical activity. Yet, despite this unanimous recommendation, significant heterogeneity exists among the current recommendations for postoperative physical therapy programs.

Recent findings: A four-phase postoperative physical therapy protocol is favored among current literature, with each phase being comprised of its own goals, restrictions, precautions, and rehabilitation techniques. Phase 1 aims to protect the integrity of the surgically repaired tissues, reduce pain and inflammation, and regain ~ 80% of full ROM. Phase 2 guides a smooth transition to full weightbearing, so the patient may regain functional independence. Phase 3 helps the patient become recreationally asymptomatic and restores muscular strength and endurance. Finally, phase 4 culminates in the pain-free return to competitive sports or recreational activity. At this time, there exists no single, unanimously agreed upon postoperative physical therapy protocol. Among the current recommendations, variation exists regarding specific timelines, restrictions, precautions, exercises, and techniques throughout the four phases. It is imperative to reduce ambiguity in current recommendations and more specifically define postoperative physical therapy following operative management of FAIS to more expeditiously return patients to functional independence and physical activity.