Orthopaedic Journal of Sports Medicine最新文献

Background: Although osteochondritis dissecans (OCD) lesions are well-described in the femoral condyles and have been associated with varus limb alignment, there is limited data on OCD lesions in the trochlea.

Purpose: To compare the baseline imaging characteristics in pediatric patients with trochlear OCD with those with medial femoral condyle (MFC) OCD to understand whether measures of coronal plane alignment predispose to OCD development by anatomic location.

Study design: Cross-sectional study; Level of evidence, 3.

Methods: This study retrospectively reviewed all pediatric patients (age ≤18 years) diagnosed with isolated trochlear OCD at a tertiary-care medical center from January 2016 to May 2023; all included patients had weight-bearing hip-to-ankle alignment radiographs. Hip-knee-ankle angle (HKA), mechanical lateral distal femoral angle (mLDFA), medial proximal tibial angle (MPTA), mechanical axis deviation (MAD), Caton-Deschamps Index (CDI), patellar tilt, and sulcus angle were measured on initial/preoperative anteroposterior and lateral knee radiographs. Tibial tubercle-trochlear groove (TT-TG) distance and OCD lesion size were measured on initial/preoperative magnetic resonance imaging sequences. Patients were 1 to 2 matched based on age (±2 years) and sex to a cohort with isolated MFC OCD.

Results: A total of 18 extremities in 16 patients were included in the trochlear OCD cohort and matched to 36 extremities in the MFC OCD cohort. The mean age at the first clinical visit for all patients was 14.8 ± 1.5 years and did not differ significantly between the two groups (P = .40). The extremities with trochlear OCD had significantly less varus HKA (1°± 2° vs -1°± 2°; P = .004) and MAD (4 ± 8 vs -3 ± 8 mm; P = .004) compared with the MFC cohort as well as lower mLDFA (86°± 2° vs 88°± 2°; P = .004). There were no differences in MPTA, CDI, patellar tilt, sulcus angle, TT-TG distance, or OCD lesion size between groups.

Conclusion: Pediatric patients with trochlear OCD had statistically less varus coronal plane alignment compared with age- and sex-matched patients with MFC OCD, with the latter exhibiting more significant varus based on the HKA and MAD.

Background: The use of all-suture anchors (ASAs) for onlay patellar and femoral fixation of medial patellofemoral ligament (MPFL) grafts may provide clinical benefit, particularly in the small or pediatric knee; however, biomechanical data supporting the use of ASAs are lacking.

Purpose/hypothesis: The purpose of this study was to compare ASAs to larger interference implants for MPFL reconstruction in a time-zero biomechanical model. It was hypothesized that ASAs would have comparable cyclic elongation to interference fixation and would exceed published biomechanical values for the native human MPFL.

Study design: Controlled laboratory study.

Methods: Eighteen fresh-frozen porcine patellas and femurs were divided into equal groups (n = 9 per group) for MPFL reconstructions. Patellar fixation utilized two 3.9-mm interference suture anchors (ISAs) or two 2.6-mm ASAs, while femoral fixation utilized one 6×20-mm interference screw (IS) or one 2.6-mm ASA. Human gracilis tendon grafts were used. Specimens were dynamically loaded for 100 cycles each in sequential 5- to 30-N (phase 1) and 5- to 50-N (phase 2) blocks at 1 Hz followed by load-to-failure testing at 305 mm/min.

Results: No differences were found in cyclic elongation after phase 1 and phase 2 loading between ASA and interference implants on either the femoral or patellar side. On the femur, IS had significantly greater ultimate stiffness (54.2 vs 46.1 N/mm; P < .001) and ultimate load (366 vs 278 N; P = .019) compared to ASA. On the patella, ISAs had significantly greater ultimate stiffness (70.5 vs 53.1 N/mm; P < .001) but a significantly lower ultimate load (244 vs 307 N; P = .014) compared to ASAs. All groups significantly exceeded the published physiological values for native human MPFL stiffness and failure load.

Conclusion: ASA onlay fixation had comparable cyclic elongation to that of interference fixation for femoral and patellar MPFL reconstruction. Although differences in ultimate stiffness and ultimate load were noted between implants, all of the values exceeded published values for the human MPFL.

Clinical relevance: This biomechanical study presents ASA cortical onlay fixation as a viable option for MPFL reconstruction. ASAs require less bone removal, potentially reducing the risk of patellar fracture and minimizing fixation complexity in the setting of open femoral growth plates. Future clinical studies will provide insight into successful tendon-to-bone healing, failure rates, and near- and long-term patient-reported outcomes.

Background: Anterior cruciate ligament (ACL) reinjury risk is high in young athletes, with graft failure rates as high as 23%. The optimal autograft choice to minimize reinjury risk in this population is unclear.

Purpose: To compare graft failure rates between bone-patellar tendon-bone (BPTB), hamstring tendon (HT), and quadriceps tendon (QT) autografts in patients aged ≤18 years with a minimum follow-up (FU) of 24 months.

Study design: Systematic review; Level of evidence, 4.

Methods: A systematic review of the literature between database inception and March 2022 encompassed PubMed/MEDLINE, Cochrane CENTRAL, Embase, and Web of Science Core Collection databases. Studies on autograft ACL reconstruction (ACLR) using HT, QT, or BPTB autograft in patients ≤18 years old with a minimum FU of 2 years were included. Graft failure rates were pooled and estimated using random-effects models via the inverse variance method and logit transformations. Meta-analyses were used to estimate failure rates and pairwise comparisons were conducted by autograft type when appropriate.

Results: A total of 24 studies comprising 2299 patients (HT: n = 1237, 44.8% female, 59.1-month mean FU; BPTB: n = 913, 67.3% female, 79.9-month mean FU; QT: n = 149, 36.4% female, 35.3-month mean FU) were included. HT exhibited the highest failure rate at 11.8% (95% CI, 9.0%-15.4%); failure rates for BPTB and QT were 7.9% (95% CI, 6.2%-10.0%) and 2.7% (95% CI, 1.0%-7.5%), respectively. HT had a significantly higher failure rate than both BPTB (Q = 5.01; P = .025) and QT (Q = 7.70; P = .006); BPTB had a significantly higher failure rate than QT (Q = 4.01; P = .045). Male patients were less likely than their female counterparts to experience graft failure after HT ACLR (odds ratio, 0.48; 95% CI, 0.25-0.95).

Conclusion: While the HT remains a common choice for ACLR, the current aggregate data indicate that BPTB and QT demonstrated significantly lower failure rates than HT ACLR in adolescent athletes ≤18 years old. The QT demonstrated the lowest failure rate in adolescents but also the lowest proportion of patients represented due to a paucity of published QT data, indicating a need for future studies with larger sample sizes that include QT autografts, reduced risk of bias, and consistent reporting on skeletal maturity and surgical technique to better determine the ideal autograft for active athletic populations ≤18 years old.

Background: Ulnar collateral ligament (UCL) injuries have been on the rise for the past 3 decades. Current epidemiological studies on the incidence of UCL injuries have been limited to state or regional data.

Purpose: To utilize a large national claims database to determine the rates of UCL injuries and UCL surgical procedures over the past decade (2010-2019) and whether there has been a change in UCL surgical procedure patterns in the United States.

Study design: Descriptive epidemiology study.

Methods: The PearlDiver patient claims database was used to identify UCL injuries occurring from 2010 and 2019 that were sustained by male patients between 10 and 34 years of age. The study cohort was divided into 5 age groups (10-14, 15-19, 20-24, 25-29, and 30-34 years). Primary outcomes included the number of patients in each age group who sustained a UCL injury, the number of patients in each age group who underwent surgery, and the mean time from injury to surgery.

Results: A total of 19,348 UCL injuries occurred between 2010 and 2019, and 13% required a surgical intervention. Most of the injuries (54%) occurred in the 15- to 19-year group. Patients in the 20- to 24-year group were more likely to undergo surgery versus the 15- to 19-year group. Results demonstrated a trend toward delayed surgical interventions in patients in the 20- to 24-year group in the latter part of the decade.

Conclusion: Data suggested that male patients <20 years account for the majority of UCL injuries, while male patients aged between 20 and 24 years are most likely to undergo surgery. Despite a number of targeted injury-prevention strategies and rule changes in sports, the UCL injury rate remained high. Therefore, there is a clear and present need to continue to develop UCL injury-prevention strategies for the younger population.

Background: Acetabular labral tear morphology or orientation may influence hip stability.

Hypothesis: A radial tear of the acetabular labrum would result in greater rotational and translational motion compared with a chondrolabral separation.

Study design: Controlled laboratory study.

Methods: Included were 12 unpaired nonarthritic hip specimens, none of which had capsular laxity (8 male; mean age, 34.5 years). The specimens were stripped of all soft tissue except the hip capsule and labrum and, then potted using a custom jig. In 6 specimens, a 1-cm anterosuperior separation of the labrum from the acetabular rim (chondrolabral junction tear; CLJT) was created. In the other 6 specimens, a radial tear was created at the anterosuperior acetabulum. Subsequently, a complex labral tear was created in all specimens by adding a radial tear to the CLJT specimens and vice versa. The specimens were mounted on a load frame, and the femoral head displacement in the neutral and hyperextended positions was recorded at 5 N·m of internal/external rotation (IR/ER) torque and at 50 N of superior-inferior (S-I), anterior-posterior (A-P), and medial-lateral (M-L) force. Testing occurred at 0° extension and at maximal extension both before and after initial labral tear creation and again after creation of the complex labral tear. Before testing (intact state), the joint was vented to remove the effect of intra-articular pressure difference between the intact capsule and after capsulotomy for labral tear creation. The t test was used to calculate group differences by each range of motion measure (IR/ER and S-I, A-P, and M-L translations) for neutral and hyperextension.

Results: Neither the radial labral injury nor the CLJT produced differences from the vented state in any combination of hip position or plane of motion. The complex labral tear showed increased IR/ER rotation at maximal hip extension. There was no difference between CLJT and radial labral tear in any combination of hip position or plane of motion.

Conclusion: A simple labral tear did not affect hip joint stability when the capsule was intact, and no capsular laxity was present. A complex labral tear caused increased rotational laxity at maximal extension. Capsular laxity or a complex labral tear may be a prerequisite for labral injury to cause increased hip joint motion and/or translation.

Clinical relevance: Study findings suggest that labral tears in the absence of capsular laxity may not play a role in producing microinstability by increasing motion or translation.

Background: Orthopaedic surgery regularly employs opioids for postoperative pain management. Multimodal pain protocols have been shown to reduce opioid prescriptions in orthopaedic surgery.

Purpose: To analyze the impact of a division-level multimodal pain protocol for orthopaedic sports medicine surgery on opioid prescription reduction and pain level postoperatively.

Study design: Cohort study; Level of evidence, 3.

Methods: All orthopaedic sports medicine procedures at a military treatment facility were categorized into 1 of 3 pain tiers. A pain protocol emphasizing multimodal pain control was implemented for each tier. A retrospective cohort study compared pre- and postprotocol pain groups for each respective tier (n = 40 in each) for visual analog scale (VAS) for pain scores 2 weeks postoperatively, postoperative opioid prescription, and time to discontinuation of postoperative opioids.

Results: The mean number of opioid pills prescribed for all tiers decreased by 43.6% (preprotocol 35.7 ± 3.1; postprotocol 20.1 ± 1.5; P < .0001) after pain protocol implementation. Of the total opioids prescribed in the postprotocol cohort, a mean of 64.1% were consumed. There was no significant difference in overall visual analog scale for pain scores at 2 weeks postoperatively (preprotocol 2.72 ± 0.41; postprotocol 2.99 ± 0.43; P = .40). At 2 weeks postoperatively, only 1 patient continued opioids in the postprotocol group compared with 20 patients with continued opioid use in the preprotocol group (P < .001).

Conclusion: A division-level multimodal pain protocol applied to orthopaedic sports medicine procedures led to decreased opioid prescription postoperatively with no significant difference in 2-week postoperative pain scores compared with more opioid reliant and variable protocols in a cohort of military service members. Despite the reduced prescription, patients consumed a mean of 64.1% of pills, indicating continued overprescription.

Background: A retear after anterior cruciate ligament (ACL) reconstruction remains a common and devastating complication. Knee bone morphology is associated with the risk of ACL injuries, ACL retears, and osteoarthritis, and a combination of tools that derive bone shape from clinical imaging, such as magnetic resonance imaging (MRI) and statistical shape modeling, could identify patients at risk of developing these joint conditions.

Purpose: To identify bone shape features before primary ACL reconstruction in patients with an eventual retear compared to those with a known intact ACL graft.

Study design: Case-control study; Level of evidence, 3.

Methods: Bone was automatically segmented on 2-dimensional proton density-weighted MRI of the knee in patients at the time of the initial ACL injury using deep convolutional neural networks. Patients with a subsequent retear after reconstruction within 3 years (22 femurs, 19 tibias) were compared with those with an intact ACL graft at 3 years (20 femurs, 22 tibias) using statistical shape modeling to identify preoperative bone shape features predictive of a retear after ACL reconstruction.

Results: Statistical shape modeling revealed 2 specific bone shape features (modes) in the femur and 1 mode in the tibia that demonstrated significant differences at the time of the initial injury in patients with subsequent retears. In the femur, a narrower intercondylar notch width, a widened medial condylar width, an increased femoral condylar offset ratio, increased surface area along the lateral femoral condyle relative to the medial condyle, and a more prominent trochlear sulcus at the time of the initial injury were associated with retears after ACL reconstruction. In the tibia, a diminished ACL facet prominence, a squared lateral and medial tibial plateaus, and a broader and flattened tibial spine at the time of the initial injury were associated with retears after ACL reconstruction.

Conclusion: Using the automatic bone segmentation pipeline on preoperative MRI, the authors identified bone shape features associated with a retear after ACL reconstruction. The use of this pipeline enables large-scale studies of bone shape on MRI and could predict patients at risk of ACL retears to alter treatment decisions.

Background: The Kerlan-Jobe Orthopaedic Clinic shoulder and elbow score (KJOC) is sensitive enough to detect subtle changes in the functional level of the shoulder or elbow in overhead athletes. However, a Japanese version of the KJOC is not yet available. Moreover, the original KJOC uses a visual analog scale (VAS) assessment format that requires a print version so that users can add a check mark along a horizontal line. The KJOC can be completed using online tools such as Google Forms if a 10-point scale format can be used with comparable results.

Purposes: To (1) translate and cross-culturally adapt the KJOC into Japanese (KJOC-J) and assess its validity and (2) evaluate the correlation between a standard VAS format and a 10-point scale format (KJOC-J10).

Study design: Cohort study (Diagnosis); Level of evidence, 3.

Methods: In total, 318 athletes participated in the validation study, 255 in the test-retest reliability study for the KJOC-J, and 273 in the validation study for the KJOC-J10. Internal consistency was evaluated using the Cronbach alpha. Validity was evaluated by calculating the correlation between the KJOC-J and the Disability of the Arm, Shoulder and Hand (DASH). Test-retest reliability was assessed using the intraclass correlation coefficient (ICC). The validity of the KJOC-J10 was evaluated by calculating the correlation between the KJOC-J10 and KJOC-J.

Results: The Cronbach alpha was 0.914, indicating good internal consistency. The KJOC-J was moderately correlated with the DASH (r = -0.581; P < .001) and had good test-retest reliability (ICC, 0.874). A strong correlation was found between the KJOC-J and KJOC-J10 (r = 0.846; P < .001).

Conclusion: The study results demonstrated good internal consistency, validity, and reliability for the KJOC-J, indicating that it is a valid assessment tool for shoulder and elbow functions in Japanese overhead athletes. Moreover, a strong correlation was found between the VAS and 10-point formats of the KJOC-J.

Background: More than half of all youth baseball pitchers report throwing-related pain in their throwing arm throughout a season.

Purpose/hypothesis: The purpose of this study was to investigate differences in elbow flexion throughout the pitching cycle between youth baseball pitchers with and without throwing-arm pain. It was hypothesized that pitchers with throwing-arm pain would have decreased elbow flexion throughout the pitching cycle compared with those who were pain-free.

Study design: Controlled laboratory study.

Methods: A total of 38 youth baseball pitchers (mean age, 13.3 ± 1.7 years; height, 164.4 ± 12.9 cm; weight, 57.1 ± 14 kg) were retrospectively selected from a database. Based on responses to a health history questionnaire, the pitchers were placed into a pain group if they indicated they were experiencing throwing-arm pain. Pitchers who indicated they were not experiencing throwing-arm pain were matched according to age, height, and weight to the pain group. All pitchers threw 3 fastballs to a catcher at the regulation distance. The mean elbow flexion of the 3 trials was used during analysis to investigate peak elbow flexion and time-normalized (0%-100%) elbow flexion across the pitch cycle (stride-foot contact to ball release). Elbow flexion was compared between the pain and pain-free groups using 1-dimensional statistical nonparametric mapping, and the mean peak elbow flexion between groups was compared using the Mann-Whitney U test.

Results: No significant differences were observed between the groups in elbow flexion throughout the pitching cycle (P > .05) and no group differences in peak elbow flexion (U = 122; P = .09).

Conclusion: Study findings indicated no significant differences in elbow flexion between youth baseball pitchers with versus without throwing-arm pain, unlike previous research reporting that pitchers with a history of medial elbow pain had altered elbow flexion and higher pitch velocities compared with those without a history of pain.

Clinical relevance: Clinicians should consider other potential factors related to throwing-arm pain beyond elbow flexion. Moreover, it is advisable to focus on evidence-based modifiable factors shown to increase the risk of pain and injury in youth pitchers, such as exceeding pitch counts, number of innings pitched, increased training time, range-of-motion, and strength deficits.