Current Reviews in Musculoskeletal Medicine最新文献

Purpose of review: This review focuses on the etiology, diagnosis, and management of patellar instability in pediatric patients.

Recent findings: Radiological outcomes such as tibial-tubercle to trochlear groove (TT-TG) distance used in diagnosis are subject to factors of influence such as femoral anteversion and knee flexion angle, and new measure such as tibial-tubercle to posterior cruciate ligament distance as well as TT-TG/trochlear width (TT-TG/TW) are under investigation. To prevent recurrent instability, surgical intervention for acute patellar dislocations may be advantageous compared to conservative management. Patellar instability is a common pathology found in pediatric cohorts. Diagnosis can be performed via a combination of history, physical examination maneuvers, and radiological risk factors such as patella alta, patellar tilt, trochlear dysplasia, and elevated TT-TG distances. Current literature advocates the usage of additional radiological measures to TT-TG such as TT-TG/TW, especially as TT-TG varies with age in younger patients. Recent literature potentially suggests the utilization of surgical procedures such as MPFL reconstruction or repair for acute dislocations in the hope of preventing recurrent instability. Special indications for pediatric patients include osteochondral fracture identification to help prevent patellofemoral osteoarthritis. A comprehensive workup and understanding of current literature can aid clinicians in aiming to prevent recurrent patellar dislocation in pediatric patients.

Purpose of review: The lateral meniscus oblique radial tear (LMORT) of the posterior horn is a relatively new term for one of the more common types of lateral meniscal tears found in patients with acute anterior cruciate ligament (ACL) injuries. Given the importance of anatomical reduction and preservation of the lateral meniscus to maintain normal knee stability and slow the progression of early-onset osteoarthritis, LMORT classification and treatment guidelines have been formulated. This article provides a review of the prevalence, classification, biomechanics, surgical repair techniques, and outcomes related to LMORT injuries.

Recent findings: Current research demonstrates favorable clinical results when LMORTs are surgically treated based on recent evidence. Biomechanically, repair of the higher grade 3 and 4 LMORT lesions have led to comparable results when compared to an intact lateral meniscus, and superior results when compared to partial meniscectomy and untreated tears. Ongoing research is aimed to determine the difference between LMORT repairs compared to intact lateral menisci at the time of ACL surgery regarding comparable patient outcomes. LMORT lesions are common tears of the lateral meniscus that should be treated surgically based on tear type at the time of ACL surgery. The benefit of doing so has already been demonstrated biomechanically.

Purpose of review: Septic arthritis of the knee following anterior cruciate ligament reconstruction is a rare but potentially deleterious complication. The main approach to the management of this potentially devastating complication in recent years has involved a more aggressive attempt at preventing graft contamination during surgery with the adoption of the pre-soaking of the graft in broad-spectrum antibiotic solution, and early and adequate treatment of established cases of knee sepsis, with or without retention of the graft. However, what constitutes an early and adequate initial treatment may be a challenging decision for the surgeon to make in certain instances.

Recent findings: Graft pre-soaking in vancomycin has been noted to significantly reduce the incidence of septic arthritis of the knee following anterior cruciate ligament reconstruction. Other studies have recorded similar satisfactory results with graft pre-soaking in gentamycin. In established cases of infection, irrigation and debridement with either graft retention or graft excision with delayed re-construction of the anterior cruciate ligament have both given satisfactory results in well-selected patients. Septic arthritis of the knee following anterior cruciate ligament reconstruction can be prevented by careful patient selection, use of prophylactic antibiotics, strict asepsis during surgery, and graft pre-soaking in antibiotic solution. The choice of antibiotic solution for graft pre-soaking is influenced by the surgeon's preference, tissue penetrance, effect on graft tensile strength, local bio-gram of the micro-organisms, and the sensitivity pattern. The treatment option in established cases would depend on the stage of infection, state of the graft, and the extent of bony involvement.

Purpose of review: Traumatic and atraumatic shoulder instability is common in pediatric and adolescent patients. It is well-established that young patients with anterior shoulder dislocation are at high risk of recurrent instability. This review assesses the current literature pertaining to management of both anterior instability and MDI in the pediatric and adolescent populations.

Recent findings: Current research suggests that pediatric and adolescent patients with shoulder instability have excellent outcomes following arthroscopic Bankart repair; however, higher rates of recurrent instability requiring revision surgical management have been identified in patients with more than one dislocation episode pre-operatively, those with Hill-Sachs lesions and those under age 16. The addition of the remplissage procedure to an arthroscopic Bankart repair may be useful in preventing recurrent instability for patients with large Hill-Sachs lesions. Open procedures with bony glenoid augmentation may be indicated in patients with significant glenoid bone loss, or those who have failed primary surgical management, with promising outcomes reported following the Latarjet coracoid process transfer procedure in the adolescent population. Pediatric and adolescent patients with hyperlaxity, and those participating in swimming or gymnastics are more likely to have multidirectional instability (MDI). Non-surgical management with physical therapy is the mainstay of treatment for MDI with positive outcomes reported overall. In young patients with MDI who continue to have symptoms of instability and pain that effects daily activities or sports despite an adequate and appropriate course of rehabilitation, surgical management with capsulorrhaphy may be considered, with promising outcomes reported for both open and arthroscopic techniques. Attentive selection of timing and surgical procedure for pediatric and adolescent patients with anterior shoulder instability may help to prevent recurrent instability following shoulder stabilization. Although most pediatric and adolescent patients with MDI do well following non-surgical management alone, those that fail conservative management have good outcomes following arthroscopic or open capsulorrhaphy.

Purpose of review: The use of hip arthroscopy has expanded substantially over the last decade, including in pediatric and adolescent populations. Indications for hip arthroscopy in the pediatric population continue to be refined and research of outcomes following hip arthroscopy has increased. The purpose of this review is to provide an overview of current indications for hip arthroscopy in the pediatric population and the outcomes for each indication.

Recent findings: Hip arthroscopy is used in the treatment of a range of pediatric hip conditions, spanning from the infant to young adult. In femoroacetabular impingement, hip arthroscopy in young adolescents has shown improvement in patient-reported outcome measures, high return to sport rates, and low complications. Intra-articular hip pathology secondary to Legg-Calve-Perthes and the persistent deformities following slipped capital femoral epiphysis can be managed with primary hip arthroscopy, and outcomes show significant improvements in patient-reported outcomes. Arthroscopy can be used safely as a reduction aid in developmental hip dysplasia, and as a primary treatment for borderline hip dysplasia in adolescents. In septic hip arthritis, arthroscopic drainage is a safe and effective treatment. Hip arthroscopy is used in the pediatric and adolescent population in the management of femoroacetabular impingement, Legg-Calve-Perthes disease, the sequelae of slipped capital femoral epiphysies, developmental hip dysplasia, and septic arthritis. Research for each of these conditions shows that arthroscopy is a safe and effective treatment when performed for the correct indications, and results are comparable to open surgical options.

Purpose of review: The concept of meniscal extrusion has recently been recognized as a hallmark of meniscus dysfunction. This review examines contemporary literature regarding the pathophysiology, classification, diagnosis, treatment, and future directions for investigation regarding meniscus extrusion.

Recent findings: Meniscus extrusion, defined as >3 mm of radial displacement of the meniscus, leads to altered knee biomechanics and accelerated knee joint degeneration. Meniscus extrusion has been associated with degenerative joint disease, posterior root and radial meniscal tears, and acute trauma. Meniscus centralization and meniscotibial ligament repair have been proposed as techniques to address meniscal extrusion with promising biomechanical, animal model, and early clinical reports. Further studies on the epidemiology of meniscus extrusion and associated long-term nonoperative outcomes will help to elucidate its role in meniscus dysfunction and resultant arthritic development. Understanding and appreciation for the anatomic attachments of the meniscus will help to inform future repair techniques. Long-term reporting on the clinical outcomes of meniscus centralization techniques will yield insights into the clinical significance of meniscus extrusion correction.

Purpose of review: Anterior glenohumeral instability is a common injury in contact and collision athletes, and in-season management remains a controversial topic.

Recent findings: Several recent studies have examined non-operative and operative management of in-season athletes after instability events. Non-operative treatment is associated with faster return to play and higher rates of recurrent instability. Dislocations and subluxations have similar rates of recurrent instability but non-operatively treated subluxations have a quicker return to play than dislocations. Operative treatment is often a season ending decision but is associated with high rates of return to sport and significantly lower rates of recurrent instability. Indications for in-season operative intervention may include critical glenoid bone loss (>15%), an off-track Hill-Sachs lesion, an acutely reparable bony Bankart lesion, high-risk soft tissue injures such as a humeral avulsion of the glenohumeral ligament or displaced anterior labral periosteal sleeve avulsion, recurrent instability, insufficient time remaining in season to rehabilitate from injury, and inability to successfully return to sport with rehabilitation. It is the role of the team physician to appropriately educate athletes on risks and benefits of operative and non-operative treatment strategies and guide athletes through the shared decision-making process that balances these risks against their long-term health and athletic career goals.

Purpose of review: The addition of lateral extra-articular tenodesis (LET) to anterior cruciate ligament (ACL) reconstruction (ACLR) has become increasingly popular to address residual rotatory knee instability. The purpose of this article is to review the anatomy and biomechanics of the anterolateral complex (ALC) of the knee, outline different LET techniques, and provide biomechanical and clinical evidence for its use as an augmentation procedure with ACLR.

Recent findings: Rotatory knee instability has been identified as a common contributor to ACL rupture in both the primary and revision settings. Several biomechanical studies have shown that LET reduces strain on the ACL by decreasing excess tibial translation and rotation. Additionally, in vivo studies have demonstrated restoration of side-to-side differences in anterior-posterior knee translation, higher rates of return to play, and overall increased patient satisfaction following combined ACLR and LET. As a result, various LET techniques have been developed to help offload the ACL graft and lateral compartment of the knee. However, conclusions are limited by a lack of concrete indications and contraindications for use of LET in the clinical setting. Recent studies have shown that rotatory knee instability contributes to native ACL and ACL graft rupture and LET may provide further stability to reduce rates of failure. Further investigation is needed to establish concrete indications and contraindications to determine which patients would most benefit from added stability of the ALC.

Purpose of review: To review the recent literature regarding the epidemiology of injuries in the volleyball athlete across all levels of play and to discuss areas where further studies are needed.

Recent findings: Injury epidemiology for volleyball at the collegiate and high school level has been supported by a longitudinal injury surveillance program through the NCAA Injury Surveillance System (NCAA ISS) and High School Reporting Information Online (HS RIO) for the past 30 years. The creation of the FIVB Injury Surveillance System (FIVB ISS) in 2010 shows promise in advancing the literature on the injury at the professional level, and further studies on beach volleyball injuries are needed. Overall, injury patterns in volleyball in the past decade showed similar distribution to prior studies, but the rate of injury may be decreasing. Common injuries in volleyball include ankle sprains, patellar tendinopathy, finger and thumb sprains, overuse injuries of the shoulder, and concussions. Injury surveillance from the NCAA has demonstrated injury trends at the collegiate level, but further longitudinal studies are needed to evaluate injury at the professional level and for beach volleyball to help develop injury prevention strategy.

Purpose of review: Although developing PROMs is arduous and measuring their psychometric characteristics is even more so, the number of available PROMs has grown dramatically in the foot and ankle community over the past few years. The psychometric properties of foot and ankle PROMs vary considerably, which could explain why there are so many of them used in the literature. This review aims to shed light on the most commonly used PROMs in foot and ankle literature and assess the evidence supporting their use.

Recent findings: In this study, very limited evidence was found to support the use of most of the commonly used PROMs in foot and ankle literature, and no evidence was found that supports the use of the most common tool, the AOFAS Clinical Rating System. The quality of the studies examining PROMs was also questioned. Prior to making a conclusive determination regarding each instrument, however, additional research on the evidence is necessary. It is extremely challenging to perform systematic reviews comparing data across foot and ankle studies, and it is almost impossible to pool such data into high-quality meta-analyses. So, we need a foot and ankle score for measuring trauma-related outcomes, a score for measuring elective procedure outcomes, and a score for measuring pediatric foot and ankle.