Orthopaedic Journal of Sports Medicine最新文献

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.

Background: Improved patient outcomes and decreased patellar instability have been reported after medial patellofemoral ligament (MPFL) reconstruction for recurrent lateral patellar dislocation; however, there is a lack of comparative evidence on functional outcomes associated with different femoral attachment sites for the MPFL graft.

Purpose: To identify differences in MPFL reconstruction graft isometry with femoral tunnel malpositioning, specifically evaluating isometric differences as the femoral position is moved anterior, posterior, proximal, and distal relative to the Schöttle point, the femoral radiographic landmark of the MPFL.

Study design: Descriptive laboratory study.

Methods: A biomechanical study evaluating 11 fresh-frozen cadaveric knees was conducted. Nonelastic suture, used as an analog to the MPFL graft, was anchored with the knee at 30° flexion at the Schöttle point and at 5 and 10 mm anterior, posterior, superior, and distal to the Schöttle point. A draw wire displacement sensor was used to evaluate length changes of the MPFL graft analog through 0° to 120° knee flexion. Knee flexion position was continuously measured using a motion tracking system. Pairwise t tests with Bonferroni correction were used to compare isometry between the Schöttle point and the nonanatomic femoral insertion points.

Results: Grafts placed at the Schöttle point proved mildly anisometric, with tightening in extension and loosening in flexion. Similarly, grafts placed distally and posteriorly also demonstrated tightening in extension and loosening in flexion. Grafts placed anteriorly and proximally demonstrated tightening in flexion. Pairwise comparisons relative to the Schöttle point found that grafts placed proximally or distally demonstrated significant differences in total MPFL excursion magnitude (10 mm proximal: 0.36 [P = .03], 5 mm distal: 0.14 [P = .01], 10 mm distal: 0.22 [P < .001]).

Conclusion: When deviating from the Schöttle point, posterior and distal femoral tunnel positionings minimized the risk of MPFL graft tightening during knee flexion. Errant anterior and proximal positioning were concerning for MPFL overconstraint, and proximal tunnel placement was most at-risk.

Clinical relevance: An understanding of the effects that femoral tunnel malpositioning has on graft isometry is crucial to minimizing instability or overconstraint, which leads to anterior knee pain, increased patellofemoral contact pressures, or graft failure.

Background: After first-time lateral patellar dislocation, 44% to 70% of patients sustain redislocations. Increased femoral anteversion (FA) is considered to result in increased lateralizing forces on the patella, which might predispose one to patellar instability. When recurrent patellar dislocations (RPDs) are bilateral, it is unclear if the FA is even more increased.

Hypothesis: Patients with bilateral RPD would have greater FA than patients with unilateral RPD.

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

Methods: A total of 52 skeletally mature patients with RPD and a clinical suspicion of rotational malalignment underwent rotational computed tomography or magnetic resonance imaging. The uni- or bilaterality of the RPD was determined. A control group comprising 54 adult patients with trauma underwent computed tomography of both lower extremities as part of a multitrauma protocol. The FA values of both lower extremities were evaluated separately.

Results: In total, 20 of 52 (38.5%) patients in the study group had a history of unilateral RPD and 32 of 52 (61.5%) patients had a bilateral RPD diagnosis. The mean FA of the asymptomatic limb in unilaterally symptomatic patients was 18.0° (SD, 11.2°; range, 0.5°-40.0°; median, 16.5°). In the symptomatic limb, the mean FA was 19.2° (SD, 9.1°; range, 2.0°-33.0°; median, 19.0°) (mean difference, 1.2°; 95% CI -1.3° to 3.8°). In bilaterally symptomatic patients, the mean FA on the right side was 23.2°, and 22.5° on the left. The mean differences between the symptomatic limbs in the unilateral RPD group and the right or left limbs in the bilateral RPD group were 4.0° (P = .263) and 3.3° (P = .326), respectively. In the control group without RPD, the mean FA was 12.5° (SD, 8.5°; range, 0.8°-33.0°; median, 10.9°). The mean difference between right limbs of the patients with bilateral RPD and right limbs of controls was 10.8° (P = .001).

Conclusion: Patients with bilateral RPD have bilaterally greater FA than patients without a history of RPD. Patients with unilateral RPD have greater FA on both sides compared with the control group without a history of lateral patellar dislocation. No statistically significant difference of FA can be seen between patients with bilateral or unilateral RPD.

Background: Changes in graft length according to knee flexion and the ideal knee flexion angle at the time of graft fixation for posterolateral corner (PLC) reconstruction have yet to be clearly defined.

Purposes: To investigate graft length changes according to knee flexion and determine the optimal graft fixation angle for knee flexion in PLC reconstruction.

Study design: Descriptive laboratory study.

Methods: Ten healthy male volunteers underwent computed tomography at varying knee flexion angles (0°, 30°, 45°, 60°, and 90°). The Larson, LaPrade, Arciero, and Kim techniques were performed on 3-dimensional knee models reconstructed from the computed tomography scans. The lengths of each theoretically reconstructed graft were recorded and compared according to knee flexion angle changes.

Results: In the Larson technique, the lengths of both arms of the sling were the longest at 30° of knee flexion but were not significantly different between 45° and 60° of knee flexion. In the LaPrade, Arciero, and Kim techniques, the length of the lateral collateral ligament arm at 30° of knee flexion was significantly longer than that at other knee flexion angles (P < .05), except at 0° of knee flexion. The length of the popliteus tendon arm in the LaPrade and Kim techniques, and the length of the popliteofibular ligament arm in the Arciero technique, increased with knee flexion and became the longest at 60° of knee flexion (P < .05).

Conclusion: In the LaPrade, Arciero, and Kim techniques, the lengths of the lateral collateral ligament and popliteus complex component arms were greatest at 30° and 60° of knee flexion, respectively. In the Larson technique, the lengths of the anterior and posterior arms were greatest at 30° of knee flexion. The authors recommend securing each arm of the graft at the point of its greatest length.

Clinical relevance: This study presents in vivo data regarding graft length changes according to knee flexion and offers an optimal graft fixation angle for PLC reconstructions through various techniques.

Background: There are limited evidence-based guidelines to predict which osteochondritis dissecans (OCD) lesions will heal with nonoperative treatment.

Purpose: To train a set of classification algorithms to predict nonoperative OCD healing while identifying new clinically meaningful predictors.

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

Methods: Patients with OCD of the knee with open physes undergoing nonoperative management were prospectively queried from the Research on OCD of the Knee (ROCK) cohort (https://kneeocd.org) in April 2022. Patients were included if they met the study criteria for nonoperative treatment success or failure. Nonoperative treatment success was defined as complete healing on magnetic resonance imaging (MRI) and total return to sports participation. Failure was defined as the crossover from nonoperative management to surgery at any point at or beyond the 3-month follow-up. If a patient did not meet one of these criteria, they were not included. Normalized lesion size, lesion location, patient characteristics, and symptoms were used as clinically relevant predictors.

Results: A total of 64 patients were included, of whom 24 (37.5%) patients successfully healed with nonoperative management. Multivariate logistic regression revealed that a 1% increase in normalized lesion width was associated with an increase in the likelihood of nonoperative failure (odds ratio [OR], 1.41 [95% CI, 1.17-1.81]; P < .01). By contrast, lesions in the posterior sagittal zone (OR, 0.08 [95% CI, 0.009-0.43]; P < .01) or the medial-most coronal zone (for lesions of the medial femoral) and lateral-most coronal zone (for lesions of the lateral femoral condyle) on MRI (OR, 0.05 [95% CI, 0.004-0.44]; P < .01) were associated with a decrease in the likelihood of nonoperative treatment failure. Support vector machines had a cross-validated area under the receiver operating characteristic curve of 0.89 and a classification accuracy of 83.3%.

Conclusion: Lesion location in the posterior aspect of the condyle on sagittal MRI and lesion location in the medial-most or lateral-most locations on coronal MRI were identified as statistically significant predictors of increased nonoperative treatment success on multivariate analysis. Machine learning models can predict which OCD lesions will heal with nonoperative management with superior accuracy compared with previously published models.

Background: Previous biomechanical analyses of baseball pitching report similar kinematics between pitch types. However, prior studies were conducted in a controlled laboratory environment.

Purpose/hypothesis: This study aimed to compare in-game trunk and upper extremity kinematics between fastballs, breaking balls, and changeups to determine whether there are kinematic differences that may affect performance as well as to provide new insights into potential risk factors for injury. It was hypothesized that there would be kinematic differences between pitch types.

Study design: Descriptive laboratory study.

Methods: A retrospective analysis was conducted of markerless motion capture data collected during National Collegiate Athletic Association Division I baseball games. Included were 34 pitchers who pitched at least 3 pitches of each type (fastball, breaking ball, changeup) during competition. A 1-way repeated-measures multivariate analysis of variance (MANOVA) was used to test differences between pitch types, and Bonferroni post hoc tests were used to test pairwise comparisons.

Results: The MANOVA revealed a significant effect of pitch type (P < .001), and follow-up univariate tests found a significant main effect of pitch type for 12 of the 15 kinematic variables analyzed. Post hoc Bonferroni tests revealed that maximum shoulder external rotation was significantly greater during fastballs than breaking balls. At foot contact, significantly less shoulder external rotation was seen during changeups compared with fastballs and breaking balls. At the time of ball release, changeups had significantly less trunk lean and less trunk flexion than fastballs and breaking balls, and fastballs had a significantly smaller arm slot angle than breaking balls and changeups.

Conclusion: Collegiate baseball pitchers displayed numerous kinematic differences between pitch types during competitive play, some of which are known influencers of pitching kinetics.

Clinical relevance: This study offers a novel perspective regarding kinematic differences between different pitch types during competition. These results are comparable to the findings of laboratory studies and provide valuable insights into potential injury mechanisms.

Background: Joint effusion at 3 months after anterior cruciate ligament (ACL) reconstruction is a risk factor for ACL reinjury. However, factors associated with joint effusion at 3 months postoperatively and the effect of joint effusion on subsequent quadriceps muscle strength and graft remodeling remain unknown.

Purposes: To identify factors associated with joint effusion and investigate the association between joint effusion and quadriceps muscle strength and graft remodeling in the postoperative period.

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

Methods: In this retrospective multicenter study, the medical records of patients who underwent single-bundle ACL reconstruction between 2015 and 2021 were reviewed. The study included the data of 174 patients (mean age, 23.5 ± 10.6 years). Demographic data, including sex, age at surgery, time from injury to surgery in months, body mass index, preinjury Tegner activity score, presence of meniscus, and chondral injuries, were collected. Magnetic resonance imaging was performed 3 months postoperatively. Joint effusion was defined as grade 3 (range of grades, 0-3) according to the ACL Osteoarthritis Score. Isokinetic strength testing was performed at 60 deg/s, while the limb symmetry index (LSI) of quadriceps strength was evaluated at 6 months postoperatively. Moreover, graft remodeling was evaluated using magnetic resonance imaging-derived signal intensity ratio (SIR) measures at 1 year postoperatively. The authors used multivariate logistic and linear regression analyses to identify the factors influencing joint effusion at 3 months and those associated with postoperative quadriceps strength LSI and SIR values, respectively.

Results: Greater preinjury Tegner activity scores (odds ratio, 1.59; 95% CI, 1.08 to 2.34; P = .02) increased the odds of joint effusion at 3 months postoperatively. Multivariable linear regression analysis revealed that joint effusion (β = -23.8; 95% CI, -36.0 to -11.7; P < .001) was an independent factor associated with LSI of the quadriceps. Furthermore, joint effusion (β = 1.33; 95% CI, 0.53 to 2.14; P = .001) was associated with a higher SIR value of the reconstructed graft.

Conclusion: The preinjury Tegner activity score was a factor associated with joint effusion at 3 months postoperatively, and joint effusion was associated with subsequent muscle weakness and delayed graft remodeling.