Knee Surgery, Sports Traumatology, Arthroscopy最新文献

Purpose: The aim of this study was to conduct a meta-analysis of the literature regarding anterior cruciate ligament (ACL) injury prevention programmes (IPPs) in order to assess the effectiveness of ACL prevention programmes based on current high-quality studies. The hypothesis was that the implementation of ACL IPPs significantly reduces the incidence of ACL ruptures compared to standard practice.

Methods: A meta-analysis of the literature was conducted using the databases PubMed, EMBASE, MEDLINE, CINHAL and Cochrane Central Register of Controlled Trials. The search terms utilized were ACL, injury, knee, control and prevention. The collected data and reported clinical outcomes were independently gathered by three different individuals. After evaluating the heterogeneity of the studies, the DerSimonian-Laird random effects models were employed to determine the pooled risk ratios (RRs) and the risk differences (RDs) regarding ACL Injuries. The RD was utilized to ascertain the number needed to treat.

Results: The search strategy identified 743 studies, of which 11 met all inclusion and quality criteria for pooled analysis. The total number of study participants was 16,316. The overall RR of sustaining an ACL injury in the intervention group was 0.36 (95% confidence interval [CI]: 0.23 to 0.57) of the control group, showing a significant reduction in the ACL injury risk of the intervention group (p < 0.001). We identified an RD of -1.4% (95% CI: -2.4% to -0.4%) in favour of the intervention group. The number needed to treat in preventing one ACL rupture was 71.

Conclusion: In conclusion, the study clearly demonstrates a significant positive preventive effect of training programmes concerning ACL injuries (p < 0.001). The pooled estimates indicate that such programmes result in a significant reduction of ACL injury risks (p < 0.001). Despite the moderate quality of the included literature, the results exhibit robustness. However, based on the literature examined, no definitive superior training programme could be identified.

Level of evidence: II.

Purpose: To compare graft failure, nonrevision reoperation, complication, patient-reported outcome measures (PROMs) and return to sports (RTS) between patients who underwent anterior cruciate ligament reconstruction (ACLR) with and without suture augmentation (SA).

Methods: A systematic search was performed on PubMed, Cochrane, Embase and Web of Science databases from the inception of databases to 18 April 2024, according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies comparing clinical outcomes of SA- and standard ACLR with a minimum 2-year follow-up were included. Data extraction and quality appraisal were performed by two researchers independently.

Results: Eight retrospective cohort studies were included, with a total of 408 patients receiving SA-ACLR and 443 patients receiving standard ACLR. A meta-analysis of graft failure demonstrated a 62% relative risk reduction (RR [risk ratio], 0.38 [95% confidence interval {CI}, 0.19-0.73]; p = .004) in those receiving SA-ACLR compared with standard ACLR. An age-related heterogeneity in graft failure reduction was detected in the subgroup analysis, which was more pronounced in studies with mean ages of <20 years compared with ≥20 years (p = .05; I² = 73.9%). No significant difference was observed in nonrevision reoperation or complication rates. No clinically relevant difference was observed in PROMs. SA-ACLR was associated with a significantly higher RTS rate compared with the standard ACLR (RR, 1.12 [95% CI, 1.00-1.24]; p = .04), whereas no significant difference was observed in time to RTS.

Conclusion: SA-ACLR is associated with a reduced graft failure rate and increased RTS rate compared with standard ACLR without additional reoperations or complications. However, confidence in the evidence is limited by substantial heterogeneity. Future studies with a higher level of evidence are warranted to validate the benefit of SA and to determine the indication for different risk populations.

Level of evidence: Level III.

Purpose: To assess the incidence of ramp lesions in anterior cruciate ligament (ACL) injuries and to compare preoperative knee laxity between the patients with and without ramp lesions by using an electromagnetic measurement system (EMS).

Methods: Two hundred six patients who underwent primary ACL reconstruction with preoperative EMS measurements were retrospectively enrolled in the present study. The diagnoses of the ramp lesions were made by arthroscopic inspections. The patients with ramp lesions and no other meniscal lesions were allocated to 'ramp group', and the patients without any meniscal lesions were allocated to 'control group'. Before ACL reconstruction under general anaesthesia, the side-to-side difference (SSD) in anterior tibial translation (ATT) during Lachman test (mm) and tibial acceleration (m/s²) of posterior tibial reduction during the pivot-shift test was measured using the EMS. The SSD in tibial internal/external rotation angle (°) at 30, 60 and 90 were further measured using the EMS. The SSD in ATT using KT-2000 was also measured. Knee laxity measurements were compared between two groups using unpaired Student's t test.

Results: Ramp lesions were observed in 30 patients (14.7%). Subsequently, 17 patients were allocated to 'ramp group' and 77 patients to 'control group', and there were no statistical differences with regard to background demographics. ATT-SSD during Lachman test was significantly greater in 'ramp group' (9.1 [95% confidence interval, CI: 5.7-12.5] mm vs. 6.2 [95% CI: 5.1-7.3] mm, p = 0.037). However, SSD in ATT with KT-2000, tibial acceleration during pivot-shift test, and SSD in tibial rotational angles were not significantly different between the two groups.

Conclusion: Presence of ramp lesion was associated with increased anterior knee laxity during Lachman test, suggesting ramp lesions may need to be addressed at the time of ACL reconstruction.

Level of evidence: IV.

Purpose: Due to a lack of consensus regarding effective treatment options in young patients, the indications of meniscal allograft transplantation (MAT) have widened to include those with substantial cartilage disease. The aim of this study was to report the long-term patient-reported outcome measures (PROMs) and allograft survival rates for patients with substantial cartilage disease.

Methods: A review of the prospectively maintained database was performed. Patients with International Cartilage Repair Society 3b or above cartilage grading in either their femur or tibia were classified as having substantial cartilage disease. Postoperative International Knee Documentation Committee, Tegner, Knee Injury and Osteoarthritis Outcome Score and Lysholm were compared between those with and without substantial cartilage disease. Kaplan-Meir analysis was used to assess the survival rates. Survival was defined as revision or removal of allograft or conversion to arthroplasty.

Results: Data from 422 patients were included in the analysis with 129 patients found to have full-thickness chondral lesions and 281 patients without full-thickness chondral lesions. The mean follow-up was 6.33 (SD 3.48) years for the cohort. The mean age for the entire cohort was 30 (SD 9.23). Patients in substantial cartilage disease group underwent meniscal transplantation at an older age (32 [standard deviation {SD} 8.47] years vs. 29 [SD 9.35] years [p < 0.001]). There was no significant difference in PROMs between the two groups up to 10 years postoperatively (p > 0.05). The substantial cartilage disease group had significantly lower survival rates compared to those without (80.62% vs. 94.32%).

Conclusions: MAT in the context of substantial cartilage disease was associated with an improvement in PROMs up to 10 years with no difference to the group without substantial cartilage disease. The PROMs in combination with the long-term survival rates in this study can be used to counsel patients preoperatively.

Level of evidence: Level IV.

Purpose: The purpose of this study was to compare the incidence of knee osteoarthritis (OA) between the anatomic single-bundle (SB) and anatomic double-bundle (DB) anterior cruciate ligament (ACL) reconstruction technique after 5-year follow-up (FU). Secondary objectives were to compare patient-reported outcome measures (PROMs), clinical examination, activity level, functional tests and graft failures between the two groups.

Methods: The study was a secondary analysis after 5-year FU of a randomized controlled trial (RCT) (Clinical Trials NCT01033188). One hundred and twenty patients between 18 and 40 years were randomized to either anatomic SB or anatomic DB reconstruction. The Kellgren-Lawrence (KL) classification grade ≥2 and the Osteoarthritis Research Society International (OARSI) atlas criteria score ≥2 were used for defining OA. Additionally, PROMs were obtained and clinical examinations of the knees were performed. Finally, the number of patients experiencing graft failure in each group was recorded.

Results: Radiographic imaging was performed in 39 patients in the SB group and in 37 patients in the DB group. Four patients (10%) in the SB group and two (5%) in the DB group developed osteoarthritis according to the KL classification (p = 0.28). Five (13%) in the SB group and three (8%) in the DB group developed osteoarthritis according to the OARSI atlas criteria (p = 0.59; difference 5.0% [95% confidence interval, CI: -0.10 to 0.20]). There were no significant differences in the PROMs, clinical examinations, activity levels, or functional tests when comparing the two groups. Of initially 62 SB patients, 14 (23%) experienced graft failure compared to 4 (7%) of the 58 DB patients (p = 0.015; difference 0.016 [95% CI: 0.03-0.29]).

Conclusion: At 5-year FU, there were no significant differences in the incidence of OA, PROMS, or other clinical findings comparing the anatomic DB to anatomic SB ACL reconstructed patients. There were fewer graft failures among patients treated with anatomic DB ACL reconstruction.

Level of evidence: II.

Purpose: To evaluate the infection rate following anterior cruciate ligament reconstruction (ACLR) using all-soft tissue quadriceps tendon (ASTQT) autograft.

Methods: All primary ASTQT autograft ACLRs within a single surgeon's prospectively collected database from 2011 to 2021 were retrospectively reviewed. No topical antibiotics were administered and no graft-soaking with antibiotics was performed during the study period. Patients who underwent multiligament knee reconstruction or a cartilage restoration procedure were excluded. Patients who underwent a subsequent procedure, including irrigation and debridement (I&D) of the knee joint, were included. Case-specific data, including fluid culture analysis, antibiotics (type, route of administration and duration), time to debridement and method of debridement, were collected. Descriptive statistics were utilized to analyze demographics, incidence and possible association between the need for I&D and concomitant meniscus surgery.

Results: Out of 1053 cases (mean age: 20.2 ± 6.3, 44.6% female), four patients (0.38%) (mean age: 18.5 ± 4.0, 25% female) underwent subsequent I&D (arthroscopic I&D only [n = 1], graft harvest site I&D only [n = 1], combined graft harvest site and arthroscopic I&D [n = 1] and tibia wound and arthroscopic I&D [n = 1]). There was no significant difference with regard to demographics. No joint fluid cultures returned positive; one wound culture returned positive for Methicillin-susceptible Staphylococcus aureus from their graft harvest site. The time to I&D ranged from 18 to 23 days. Concomitant meniscectomy or meniscal repair was not associated with requiring surgical I&D. All patients who underwent I&D were prescribed antibiotics for a minimum of 10 days and a maximum of 31 days (mean: 16.25 days). Three patients (75%) who underwent I&D ultimately returned to sport. One patient was lost to follow-up. ACL grafts were retained in all patients.

Conclusion: The incidence of culture-positive septic arthritis following ASTQT autograft ACLR is 0%, while the overall need for I&D of 0.38% is low and not related to concomitant meniscal procedures or patient-specific factors.

Level of evidence: Level IV.

Purpose: Despite the clinical utility of the pivot shift exam, the requisite applied forces and torques to elicit a pivot shift remain unclear. The purposes of this study are (1) to identify the greatest forces and torques applied to the knee during the pivot shift exam and (2) to evaluate if the applied loads differ among experienced surgeons.

Methods: Three cadaveric hemipelvis-to-toe specimens (ages 53, 36 and 31 years; two males and one female) with no history of knee or hip injury were utilized. The experimental setup consisted of securing the hemipelvis to a mounting frame via an external fixator to simulate patient positioning during the clinical exam. The hemipelvis, femur, and tibia were spatially tracked by motion capture and the applied loads were measured using a 6-axis force-torque sensor. After sectioning the anterior cruciate ligament (ACL), three board-certified sports medicine surgeons then performed the pivot shift exam on each specimen utilizing their preferred technique. Forces (compression-distraction, anterior-posterior, and medial-lateral) and torques (varus-valgus, internal-external rotation, and flexion-extension) applied to the knee joint immediately preceding the reduction of the proximal lateral tibia during each pivot shift exam were calculated.

Results: Compression was the largest applied force averaging 95 N ± 15 N for all surgeons and knees, which was at least 4.5 times greater, on average, than the applied anterior and applied medial tibial forces (p < 0.0001). Valgus was the largest of the three applied torques, averaging 8.5 ± 2.1 Nm. Internal rotation torque was 3.7 times less, on average, than the applied valgus torque (p < 0.0001). Each surgeon applied compressive force. However, anterior force was more variable among surgeons, with one of the three surgeons applying minimal anterior force (p ≤ 0.024). The magnitude of applied torques was similar among examiners (n.s).

Conclusion: Compressive force and valgus torque were the predominant applied loads during the pivot shift exam. A lower magnitude of internal rotation torque was also applied. The anterior force was not consistently applied among examiners. These data can better inform clinical, cadaveric, and computational studies utilizing the pivot shift exam to assess knee biomechanics and can be used to educate trainees in conducting this complex manoeuvre.

Level of evidence: An in vitro biomechanic study.

Purpose: To compare functional outcomes such as muscle strength, neuromuscular control and patient-reported outcomes (PROs) between patients with healed rotator cuffs and those with retears after arthroscopic rotator cuff repair (RCR).

Methods: One hundred and nine patients who underwent arthroscopic RCR were included (85 in the healed group, 24 in the retear group). Shoulder muscle strength and neuromuscular control index (acceleration time [AT]) were evaluated using an isokinetic device. PROs were assessed using the pain visual analogue scale (VAS), Simple Shoulder Test (SST), American Shoulder and Elbow Surgeons (ASES) and University of California at Los Angeles (UCLA) scores. Continuous variables were compared using independent t tests. Multiple linear regression analysis was used to identify the influence of the predictor variables on the dependent variable.

Results: The muscle strength and ATs for external rotators (ERs), internal rotators (IRs) and forward flexors as well as PROs including VAS, SST and ASES scores, were not significantly different between the two groups pre- and postoperatively (n.s.). Multiple linear regression analysis revealed that postoperative ATs for the IRs (p = 0.006) and ERs (p = 0.028) in the operated shoulders were closely associated with the postoperative UCLA score.

Conclusions: Compared with the healed group after arthroscopic RCR, the retear group had no clinically relevant differences in muscle strength, ATs and PROs, including VAS, SST, ASES and UCLA scores. However, postoperative ATs for IRs and ERs in the operated shoulders were a significant predictor of postoperative UCLA scores. Therefore, clinicians and therapists need to be aware of the importance of neuromuscular control in patients who have undergone arthroscopic RCR and prioritize therapeutic exercises to restore neuromuscular control.

Level of evidence: Level III.

Purpose: To determine the statistical fragility of randomized controlled trials (RCTs) which compare the use of quadriceps tendon (QT) autografts to either hamstring tendon (HT) or bone-patellar tendon-bone (BPTB) autografts in anterior cruciate ligament reconstruction (ACLR).

Methods: A search was conducted across PubMed, MEDLINE and EMBASE databases for RCTs comparing QT autografts to HT or BPTB autografts in ACLR from inception to 21 April 2024. Studies that reported ≥1 statistically significant continuous outcome, statistically significant dichotomous outcome and/or nonsignificant dichotomous outcome were included for analysis. The fragility index (FI), continuous fragility index (CFI) and reverse fragility index (RFI) were calculated for significant dichotomous outcomes, significant continuous outcomes and nonsignificant dichotomous outcomes, respectively.

Results: A total of 11 RCTs comprising 716 patients were included. The mean sample size was 65.8 patients. The median FI among nine outcomes from four studies was 1.0 (interquartile range [IQR], 0.5; 95% confidence interval [CI], 0.6-1.4; range 0.5-1.5). The number of patients lost to follow-up at the final follow-up period was more than the study-specific FI in three (75%) studies. The median CFI among 30 outcomes from six studies was 4.9 (IQR, 10.1, 95% CI, 3.9-8.2; range 0-18.2). The number of patients lost to follow-up at the final follow-up period was more than the study-specific CFI in four (66.7%) studies. The median RFI among 10 outcomes from five studies was 5.0 (IQR, 3.5; 95% CI, 3.4-6.6; range 1.0-9.0). The number of patients lost to follow-up at the final follow-up period was more than the study-specific RFI in four (80%) studies.

Conclusion: This systematic review revealed that regardless of the metric used, RCTs comparing QT autografts to HT or BPTB autograft options in ACLR are statistically fragile. While the indices of statistical fragility evaluated in this study are important metrics of robustness to consider, their application in research and clinical practice needs to be further elucidated.

Level of evidence: Level I.

Purpose: Previous studies have reported on the outcomes of autologous chondrocyte implantation (ACI) versus matrix-induced ACI (MACI) and microfracture. Specific clinical outcomes of ACI, MACI, osteochondral autograft transplantation (OAT) and osteochondral allograft (OCA) have not been well studied. The purpose of this systematic review and meta-analysis was to analyze the outcomes of these regenerative surgical techniques with an emphasis on comparing their effectiveness using the International Knee Documentation Committee (IKDC) subjective score, the Lysholm Knee Scoring Scale, the Tegner Activity Scale and the Visual Analogue Scale (VAS) score for the surgical treatment of tibiofemoral joint cartilage defects.

Methods: An electronic search of MEDLINE, Embase and Cochrane Library was performed to identify studies that reported clinical outcomes for ACI, MACI, OAT and OCA procedures. The literature review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and only studies involving cartilage defects in the tibiofemoral joint were included. Outcomes were measured with the IKDC evaluation, Lysholm Knee Scoring Scale, Tegner Activity Scale and the VAS. Outcomes were compared to the minimal clinically important difference (MCID) and patient acceptable symptom state (PASS). The methodological quality of the included studies was analyzed by the Methodological Index for Nonrandomized Studies and the Jadad scale.

Results: Forty-seven studies were included representing a total of 1993 patients with a mean follow-up time of 57.2 ± 40.3 months (range: 4.0-160.0 months). The location of cartilage defects was reported in 46 studies, with a total of 1922 cartilage defects. There were 1277 medial femoral condyle cartilage defects, 488 lateral femoral condyle cartilage defects, 139 unspecified femoral condyle cartilage defects and 18 tibial plateau cartilage defects. All four procedures reported significant improvements in the Lysholm, IKDC, Tegner and VAS scores with no significant differences between them. The OAT technique surpassed the PASS threshold for the IKDC score while all four techniques surpassed the PASS threshold for Tegner and Lysholm scores. Additionally, all procedures met the MCID for each clinical outcome.

Conclusion: This systematic review and meta-analysis indicate that ACI, MACI, OAT and OCA all result in significant improvements in knee function and pain for cartilage defects of the tibiofemoral joint. When selecting a procedure, patient and cartilage defect characteristics should be assessed to determine the best technique for each individual patient.

Study design: Systematic review and meta-analysis.

Level of evidence: Level III.