Orthopaedic Journal of Sports Medicine最新文献

Background: Atrophy and fatty infiltration of the supraspinatus (SS) muscle are prognostic indicators of poor functional outcomes and higher retear rates after rotator cuff repair. While older patients, female patients, and those with massive and retracted rotator cuff tears are at a higher risk for these indicators, it is unclear whether tear characteristics, acromion morphology, and acromioclavicular (AC) joint arthritis affect SS atrophy in older patients with chronic shoulder pain.

Purpose: To investigate the multifactorial influences associated with SS atrophy in rotator cuff tears.

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

Methods: A review was conducted on 391 patients with atraumatic shoulder pain (mean age, 60.88 ± 8 years; range, 50-93 years; 200 men and 191 women) who underwent magnetic resonance imaging between May 2019 and April 2020. SS atrophy was calculated using the occupation ratio. Logistic regression was performed to evaluate the association of SS atrophy with patient age and sex, rotator cuff tear type (partial- vs full-thickness), anteroposterior (AP) tear size, AC and glenohumeral (GH) joint arthritis, and acromion shape. A subgroup analysis was performed in patients without tears to investigate whether SS atrophy and fatty infiltration were independent phenomena.

Results: Overall, 91 patients had full-thickness tears without retraction, 131 had partial-thickness tears, and 169 had no tears. The prevalence of SS atrophy was associated with patient age and was more prevalent in women (67.6%), full-thickness tears (91.1%), an AP tear size of >15 mm (92.6%), and GH joint arthritis (100%) (P < .001 for all). The severity of atrophy (indicated by a decrease in the occupation ratio) increased with older age. In the patients without tears, SS atrophy prevalence was 33.1%. Logistic regression analysis showed significant independent associations of SS atrophy with age (P < .001), female sex (P < .001), nonretracted full-thickness tears (P < .001), an AP tear size of >15 mm (P < .001), and hook-shaped acromion (P = .007). A subgroup analysis of the nontear group revealed a significant association of SS atrophy with fatty infiltration (P < .001).

Conclusion: This study identified significant associations between SS atrophy and older age, female sex, full-thickness tear without retraction, an AP tear size of >15 mm, and hook-shaped acromion. Notably, partial-thickness tears were not significantly associated with SS atrophy.

Background: Postoperative knee arthrofibrosis after arthroscopic ligament reconstruction is a serious complication. Among adolescents, risk factors for postoperative arthrofibrosis are not well characterized and the effectiveness of early manipulation under anesthesia (MUA) is not well established.

Purposes: To identify risk factors for arthrofibrosis after arthroscopic knee ligament reconstruction in adolescent patients and to evaluate the safety and effectiveness of early MUA.

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

Methods: The charts of all adolescent patients (<19 years of age) who underwent early MUA (<3 months) for knee stiffness after anterior cruciate ligament (ACL) or medial patellofemoral ligament (MPFL) reconstructions between 2008 and 2021 were retrospectively reviewed. Patients were matched 2:1 with patients without MUA from the same study period. The primary outcome was the final range of motion (ROM) after MUA. Logistic regression analysis was performed to identify predictors of MUA.

Results: A total of 25 patients (10 with ACL reconstruction and 15 with MPFL reconstruction) with a mean age of 14.8 ± 2.6 years were included for analysis. Overall, 44% were skeletally immature. Patients underwent MUA at a mean of 63.3 ± 19.5 days after the index surgery. The mean ROM improved significantly from 96.3°± 20.5° to 135°± 9.7° after MUA after a median follow-up of 8.1 months (interquartile range, 5.4-15.0 months). There were no complications associated with MUA, but 2 patients (8.0%) had MUA treatment failure. There were no differences in body mass index, type and frequency of associated procedures, or patellar height on lateral radiographs between the cohorts. The MUA cohort had statistically significant increased operative time, decreased preoperative motion, decreased ROM at 6 weeks postoperatively, and increased pain at 6 weeks postoperatively when compared with the non-MUA cohort. Regression analysis demonstrated that ROM at 6 weeks (OR: 0.83, 95% CI, 0.69-0.98, p = .034) was significantly associated with the need for MUA.

Conclusion: The findings of this study suggest that early (<3 months) MUA is safe and effective in treating knee arthrofibrosis in adolescent patients. MUA is a treatment alternative for patients with restricted ROM at 6 weeks that may help them recover full ROM.

Background: A new "terrible triad" has been reported to be an anterior cruciate ligament (ACL) tear with a concomitant medial meniscus ramp tear and lateral meniscus root tear. Patient-reported outcomes (PROs) for isolated ACL reconstruction (ACLR) versus an ACLR with concomitant medial meniscus ramp and lateral meniscus root repairs are not well known.

Purpose: To compare postoperative outcomes between isolated ACLR and ACLR with concomitant medial meniscus ramp and lateral meniscus root repairs.

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

Methods: An initial cohort of 1228 patients with ACLRs were retrospectively identified between April 2016 and November 2021. A total of 41 patients with isolated ACLR (isolated cohort) were age and sex matched to 41 patients who had an ACLR with concomitant medial meniscus ramp and lateral meniscus root repairs (triad cohort). Patients in the triad cohort were identified consecutively by date of surgery. Preoperative and ≥2-year postoperative PROs were evaluated to compare the isolated cohort with the triad cohort. Statistical analysis was performed with unpaired t tests and chi-square tests.

Results: Both the isolated cohort and triad cohort demonstrated significant differences between preoperative and postoperative PROs in all questionnaire categories assessed. Postoperative scores for the International Knee Documentation Committee (isolated, 88.8; triad, 86.2; P = .392), Cincinnati (isolated, 91.1; triad, 88.1; P = .295), and Lysholm (isolated, 92.1; triad, 90.1; P = .472) PROs demonstrated no significant differences between the cohorts. No significant difference was found between the isolated and triad cohorts for all preoperative questionnaire categories. Additionally, no significant difference was found in revision or reoperation rates between isolated and triad patients (P = .733).

Conclusion: No significant differences in PROs were found at minimum follow-up of 2 years postoperatively between the patients who underwent isolated ACLR (isolated cohort) and those who underwent ACLR with concomitant medial meniscus ramp and lateral meniscus root repairs (triad cohort). Inferior outcomes were not observed in the triad cohort when revision rates, reoperation rates, and postoperative PROs were compared. Given the optimistic short-term outcomes for isolated versus triad ACLR patients and the known biomechanical consequences of these untreated meniscal injuries, medial meniscus ramp and lateral meniscus root repairs should be performed when encountered concurrently with an ACL tear when possible.

Background: Approximately 20% of acute ankle sprains progress to chronic lateral ankle instability (CLAI), requiring surgical intervention. When only the anterior talofibular ligament (ATFL) is ruptured, it is controversial whether to perform arthroscopic inferior extensor retinacular (IER) reinforcement.

Purpose: To assess the postoperative outcomes of IER reinforcement versus nonreinforcement in arthroscopic treatment of CLAI with ATFL-only injury.

Study design: Systematic review; Level of evidence, 3.

Methods: Using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, the PubMed, Cochrane Library, Embase, and Web of Science databases were searched for publications on arthroscopic ATFL repair with versus without IER reinforcement. The final search date was July 7, 2023. Through a comprehensive meta-analysis, functional outcomes (American Orthopaedic Foot & Ankle Society Ankle-Hindfoot [AOFAS], Karlsson-Peterson [K-P], and Foot and Ankle Outcome Score [FAOS] scores), radiological outcomes (talar anterior translation and talar tilt), and complication rates (superficial peroneal nerve injury, knot irritation, and total complications) were evaluated. The mean difference (MD) was compared for continuous outcomes, and the odds ratios (ORs) were compared for categorical outcomes between the patients with versus without IER reinforcement.

Results: A total of 4 studies (n = 271 patients; 157 male, 114 female; 141 patients with IER reinforcement, 130 without IER reinforcement) were included in the final analysis. There were no significant differences between the patients with versus without reinforcement regarding AOFAS score (MD = 0.72 [95% CI, -2.17 to 3.61]; P = .63; I ² = 0%), any of the FAOS subscores, talar anterior translation (MD = 0.10 [95% CI, -0.53 to 0.73]; P = .76; I ² = 0%), talar tilt (MD = 0.14 [95% CI, -0.86 to 1.13]; P = .79; I ² = 0%), or total complications (OR = 2.29 [95% CI, 0.92 to 5.71]; P = .07; I ² = 24%). However, the IER reinforcement group showed superior postoperative K-P scores compared with the nonreinforcement group (MD = 6.22 [95% CI, 2.17 to 10.26]; P = .003; I ² = 0%).

Conclusion: The results of the meta-analysis suggest that IER reinforcement may not be necessary for achieving satisfactory postoperative outcomes in CLAI with ATFL-only injury. Further research is required to investigate the impact of ligament injury severity, body weight, and concomitant calcaneofibular ligament injuries on the results.

Registration: CRD42023447669 (PROSPERO).

Background: Injury to the posterior vasculature is a potential complication in orthopaedic knee surgery that may be associated with variations in its anatomy, such as the type II-A2 variant, which places the anterior tibial artery (ATA) in closer proximity to the tibia. However, how close surgical instrumentation comes to injuring the ATA is not well described.

Purpose: To determine how the type II-A2 variant of the popliteal vasculature affects proximity of the ATA to instrumentation for orthopaedic knee procedures.

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

Methods: A total of 222 knee magnetic resonance imaging (MRI) scans from a single academic tertiary referral center were evaluated, and ATA branching patterns were characterized. The distances from the ATA to simulated instrumentation of high tibial osteotomy (HTO), posterolateral corner anatomic reconstruction, posterior cruciate ligament (PCL) reconstruction, lateral meniscus posterior horn repair, and lateral meniscus posterior root repair on axial plane MRI scans were measured by 2 authors independently using imaging software. Intrarater and interrater reliability of the measurements was calculated using the intraclass correlation coefficient.

Results: ATAs with the type II-A2 pattern passed anterior to the popliteus on 3.15% (n = 7) of the 222 MRI scans. The distance between the ATA and the simulated instrumentation was significantly closer in type II-A2 compared with normal (type I) knees for the lateral meniscus posterior root repair tunnel (11.1 vs 15.7 mm; P = .014), HTO cuts (0.6 vs 8.2 mm; P < .001), and PCL reconstruction tunnel (4.1 vs 11.7 mm; P < .001). Interrater reliability was good to excellent for all measurements, and intrarater reliability ranged from moderate to excellent.

Conclusion: HTO cut, PCL reconstruction tunnel, and lateral meniscus posterior root tunnel instrumentation were significantly closer to the ATA in knees with type II-A2 anatomy compared with normal (type I) anatomy. Careful analysis of vasculature using MRI may be of utility for select surgery about the knee to guide surgical technique.

Background: Young athletes who undergo surgery for a rotator cuff tear (RCT) are expected to return to sports (RTS) at the preinjury level.

Purpose: To determine the rate and level of RTS and associated factors after RCT surgery in young athletes.

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

Methods: A literature search was performed in PubMed, Embase, and Cochrane Library the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The inclusion criteria were studies in English evaluating RTS after surgical treatment of RCTs in athletes <40 years. Study quality was evaluated according to the Methodological Index for Nonrandomized Studies scores. Fixed-effects and random-effects meta-analyses were conducted to investigate the overall RTS rate and the ability to RTS at the preinjury level and explore the heterogeneity of the studies.

Results: Of 168 studies initially identified, 13 studies (332 athletes; 270 competitive and 62 recreational) were included. The mean age of the athletes was 26.1 years (range, 13.2-39 years). Eleven studies (289 athletes) reported the type of sports; the most common sports were baseball (n = 195), football (n = 47), and tennis (n = 13). A total of 25 athletes were lost to follow-up, leaving 307 athletes with postoperative RTS data for meta-analysis. The combined rate of RTS according to the fixed-effects model was 84% (95% CI, 80%-88%). The level of RTS was evaluated in 11 studies (251 athletes), and according to the random-effects models, the combined rate of RTS at the preinjury level was 63% (95% CI, 49%-77%). In a subgroup analysis, the rate of RTS at the preinjury level was significantly different between competitive athletes (61% [95% CI, 46%-76%]) and recreational athletes (89% [95% CI, 78%-99%]) (P = .004).

Conclusion: Results of this review indicated that most young athletes were able to RTS after RCT surgery, and more than half were able to RTS at the preinjury level. Compared with competitive athletes, a higher proportion of recreational athletes were able to RTS at the preinjury level after surgery.

Background: Bucket-handle meniscal tears (BHMTs) are a common subtype of meniscal tears that represent a clinical challenge. Arthroscopic inside-out repair has been considered the gold standard in treatment; however, an all-inside approach has gained widespread popularity, with limited long-term evidence.

Purpose/hypothesis: The purpose of this study was to (1) compare long-term clinical outcomes and rates of failure after surgical repair of BHMTs using the all-inside versus inside-out technique, and 2) identify risk factors for failure at long-term follow-up. It was hypothesized that clinical outcomes and rates of failure would be similar between the 2 techniques.

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

Methods: Patients who had undergone surgical repair of BHMTs between 2003 and 2013 at a single institution were identified. Patient-reported outcome measures (PROMs) were assessed preoperatively and at the latest follow-up using the Tegner scale, International Knee Documentation Committee questionnaire, and visual analog scale pain at rest and with activity. A univariate Cox proportional hazards model was used to identify predictors for repair failure, defined as revision meniscal surgery and/or documented meniscal retear.

Results: In total, 63 patients were included (37 with inside-out repair, 26 with all-inside repair). At a mean follow-up of 11.2 years, the survival rate for BHMT repair was 63% overall, 70% for all-inside repairs, and 60% for inside-out repairs (P = .37). The mean time to failure was 2.6 years for all-inside repairs and 2.5 years for inside-out repairs (P = .98). PROM scores were not significantly different between the 2 repair groups (P > .22). Univariate Cox proportional hazards model for failure demonstrated that increasing age at surgery was associated with lower failure rates (hazard ratio, 0.91 change per 1-year increase in age; 95% CI, 0.84-0.98) and medial meniscus repair was associated with higher failure rates (hazard ratio, 3.12; 95% CI, 1.14-8.77).

Conclusion: Long-term follow-up of BHMT repair demonstrated satisfactory clinical outcomes and failure rates. In appropriately selected patients, the all-inside technique did not compromise outcome as compared with the inside-out repair techniques. For both methods, older age was associated with lower failure rates and medial meniscus repair was associated with increased failure.

Background: Anterior cruciate ligament reconstruction (ACLR) is a commonly performed orthopaedic procedure. As the number of ACLRs continues to increase in incidence, understanding the variability and drivers of cost to the health care system may help target cost-saving measures.

Purposes: To examine the variability in overall 90-day reimbursements (amount paid for health care services) for ACLR using a national, multi-insurance, administrative database and to assess factors associated with variability.

Study design: Cross-sectional study.

Methods: Using the M151 PearlDiver data set (data from 2010 to April 30, 2021), the authors identified the 90-day total reimbursements in patients who underwent ACLR. Patient age, sex, and comorbidity burden; insurance type; inpatient versus outpatient surgery status; and 90-day postoperative adverse events were determined and were correlated with overall reimbursements using multivariable logistic regression.

Results: A total of 249,484 patients who underwent ACLR during the study period were identified. The mean patient age was 31.6 ± 13.58 years, 50.3% were female, the mean Elixhauser Comorbidity Index (ECI) was 1.4 ± 1.8, and procedures were performed on an outpatient basis for 245,507 patients (98.4%). Insurance type was commercial for 220,284 patients (88.3%), Medicaid for 17,660 (7.1%), and Medicare for 3500 (1.4%). The mean overall 90-day reimbursement was $4281.91 ± $4982.61 (median [interquartile range], $3032 [$1681-5142]), and the total reimbursement for the patient cohort was $1,049,250,747. On multivariable linear regression, the variables independently associated with the greatest changes in overall reimbursement were (in decreasing order) hospital readmission (+$17,675.23), adverse events (+$1554.14), inpatient procedure (+$1246.51), and emergency department visits (+$784.06). Lesser but significant associations were found with greater ECI (+$252.30) and female sex (+$101.01). Decreased overall reimbursement was associated with older age (-$12.19) and Medicare (-$883.48)/Medicaid (-$493.18) relative to commercial insurance.

Conclusion: In the current study, large variability was found in overall ACLR reimbursement/cost within the health care system. Hospital admissions (inpatient surgery and readmission) and adverse events were associated with the greatest increase in costs and emphasize the need to optimize these metrics above and beyond patient experience.

Background: The return-to-sports rate is often used as an outcome measure after anterior cruciate ligament (ACL) reconstruction (ACLR). Although most soccer players want to return to sports after their ACL injury, up to 40% do not believe they will return to soccer after their ACL injury.

Purpose: To investigate whether self-reported presurgical beliefs regarding return to soccer correspond to registered official match participation after ACLR.

Study design: Cohort study; Level of evidence, 2.

Methods: Included were soccer players with a primary unilateral ACL injury who were ≥15 years at the time of ACLR and who had completed a presurgical question about their future sports participation beliefs. ACLR surgical data were extracted from the Swedish National Knee Ligament Registry, and game participation data were extracted from the Swedish Football Association's administrative data system.

Results: A total of 959 soccer players (617 [64%] male and 342 [36%] female) were included. The follow-up time after ACLR ranged from 18 months to 5.5 years. Of 720 soccer players (75%) who believed that they would return to play (RTP), 462 (64%) players actually did. Of the players who believed that they would not RTP, 181 (76%) did not. Presurgical beliefs predicted RTP (odds ratio [OR], 5.59; P < .001). Younger age at the time of ACLR favored RTP, where 61% of the players aged 15-20 years had RTP (OR, 3.85; P < .001). At the top competitive level, 84% of the players RTP compared to 14% at the recreational level. Players active at higher levels were more likely to believe that they would RTP, and they also actually did so (OR, 33.06; P < .001). Overall, 67% of players followed their presurgical intention to return to soccer.

Conclusion: The findings indicated that presurgical beliefs, age, and level of play helped to predict the actual RTP of soccer players after ACLR.

Background: Little information is available on the embryology of the structures that connect the lateral meniscus to its nearby structures (proximal tibia, fibular head, and popliteus tendon), which restrict lateral meniscal extrusion.

Purpose: To describe the menisco-tibio-popliteus-fibular complex (MTPFC)-conformed by the lateral meniscotibial ligament (LMTL), popliteofibular ligament, meniscofibular ligament, and the 2 popliteomeniscal ligaments (superior and inferior)-and anterolateral ligament (ALL) of the knee in human embryos/fetuses from weeks 9 to 37 of gestation.

Study design: Descriptive laboratory study.

Methods: The authors analyzed 36 formalin-fixed embryos/fetus knees, ranging between weeks 9 and 37 of gestation. All had normal external morphological characteristics. A microdissection was performed by meticulously searching the structures of the MTPFC and the ALL, their anatomic relationships, and their appearance over time. Histological sections were taken of the entire knee, the lateral meniscus, the ALL, and the LMTL to observe its structure from its early stages, junctions, and cellularity. In addition, the composition and orientation of the fibers were evaluated.

Results: The MTPFC was not found in the youngest knees (9 weeks). The ligaments of this complex could not be seen until week 11 of development. Moreover, the ALL was a consistent finding from the 13th week of development onward. All the ligaments of the MTPFC were seen between developmental weeks 11 and 16 in all the specimens. The histological results showed that the histology of the ALL showed dense connective tissue organized into thick bundles of collagen fibers in its central portion, with a parallel and undulating arrangement and the anterolateral capsule demonstrated 3 easily distinguishable layers corresponding to the fibrous membrane, the subsynovial membrane formed by loose connective tissue, and the synovial membrane.

Conclusion: All the structures of the MTPFC were visualized from week 11, with the LMTL being the first to form. Moreover, the ALL was a consistent finding from week 13 of development onward.

Clinical relevance: Understanding the embryological development of the MTPFC and the ALL of the knee is clinically relevant, as it can provide crucial insights into the pathogenesis of knee conditions and inform treatment strategies. By elucidating the timeline and characteristics of these structures' formation, clinicians can better diagnose and manage conditions affecting the lateral meniscus and related structures, ultimately improving patient outcomes and surgical interventions.