Journal of ISAKOS Joint Disorders & Orthopaedic Sports Medicine最新文献

Objectives: Septic arthritis after anterior cruciate ligament (ACL) reconstruction is a rare but potentially devastating complication. The imaging findings associated with such infections are not well-described or quantified. The purpose of this study was to describe and quantify the frequency of the characteristic MRI findings of infection following ACL reconstruction.

Methods: Seventeen cases were identified from 2010 to 2018, confirmed to meet established definitions for deep infections, and had an MRI obtained within ten days of diagnosis of infection. Two board-certified musculoskeletal radiologists evaluated and scored MRI studies with a predetermined set of imaging characteristics. Cohen's kappa (±) was utilized to determine the extent of agreement between the radiologists. Associations between graft type and microbiologic results and MRI findings were assessed.

Results: The overall infection rate was 0.42%, diagnosed at a median 35 days postoperatively (range 9-411). Grafts were retained in 11 of 17 (64.7%) infected cases and 9 patients (52.9%) required repeat irrigation and debridement. Common imaging findings included complex lamellated effusions (k=0.86), fluid within the femoral tunnel (k=0.91), and femoral tunnel resorption (k=0.83). Subcutaneous edema and edema surrounding the femoral tunnel were also identified in the majority of cases. There was no evidence of cortical destruction of the tunnels or chondrolysis. All acute infections demonstrated complex lamellated effusions, whereas all simple effusions were seen in chronic cases. No associations were found between index ACL graft type or microbiologic results and MRI findings.

Conclusion: Interrater agreement for common imaging findings including effusion pattern, edema surrounding the graft tunnels and tunnel resorption was near perfect within infected ACL reconstructed knees. MRI can provide value information regarding postoperative infection after ACL reconstruction.

Level of evidence: Level IV- epidemiological observational study.

Medial meniscus ramp tears are tears of the posteromedial capsule or peripheral rim of the posteromedial meniscus that frequently occur with anterior cruciate ligament (ACL) tears. The incidence and prevalence of medial meniscus ramp tears has been increasing in the recent literature due to the increased understanding of the anatomy and diagnosis of these tears. When a patient presents with an ACL tear, a medial meniscus ramp tear should be suspected if the patient has a grade 3+ Lachman or pivot-shift exam, a vertical line of increased signal intensity in the posterior capsule or peripheral meniscus on magnetic resonance imaging (MRI), or posteromedial tibial plateau bone bruising on MRI. When a ramp tear is suspected, proper arthroscopic probing, including utilizing the transnotch view (or potentially an accessory posteromedial portal) or performing a medial collateral ligament trephination should be considered as part of the diagnostic workup. Once a tear is identified, a surgical repair depends on the location and stability of the tear and the surgeon's preference. The most frequently utilized techniques include the all-inside device, an all-inside suture hook, and an inside-out repair. Studies reporting on clinical outcomes for patients with ramp tears generally report no difference in outcomes compared to isolated ACL reconstruction patients. No consensus has been made on the best repair technique; however, it is generally accepted that repair is superior to leaving a ramp tear in situ as ramp tears have the potential to progress into bucket-handle tears. Further studies should work to establish a surgically and anatomically relevant classification system that clearly defines tear locations and stability to better study patient outcomes for those with a medial meniscus ramp tear. The purpose of this article is to review the anatomy, diagnosis, and treatment of medial meniscus ramp tears.

Knee osteoarthritis (OA) is a chronic disease characterized by increasing prevalence and significant physical, psychological, and economic burdens. Despite extensive research, the definition, risk factors, and effective cost-efficient treatments for knee OA remain unclear. This article aims to revisit primary knee OA, understanding its etiology, and focusing on prevention and individualized nonoperative treatment modalities. This study reviews various aspects of knee OA, including its global prevalence, economic impact, and current treatment strategies. It explores the role of mechanical loading pathways in the disease's onset, highlighting the importance of considering not only the knee but the entire kinetic chain in diagnosis and treatment. Also, it discusses knee anatomy and biomechanics during functional activities, emphasizing the role of neuromuscular control and the influence of proximal and distal joints on knee health. Current treatments focus mainly on symptom management, with limited success in disease prevention and curative interventions. This review underlines the importance of understanding the biomechanical risk factors contributing to knee OA and the necessity of individualized interventions based on biokinetic profile analysis. Knee OA management and prevention necessitate a paradigm shift from viewing it as a localized knee disease to recognizing related mechanical overloads of the human complex motion system. Identifying individual inductive elements is paramount for effective knee OA prevention, management, and rehabilitation. Future research should endeavor to identify movement profile subgroups to establish an early-stage prognosis and the impact of interventions for each group. LEVEL OF EVIDENCE V: Expert opinion based on nonsystematic review.

Introduction: Chronic shoulder pain caused by a rotator cuff tear is commonly treated with arthroscopic rotator cuff repair surgery (ARCR). However, ARCR may be associated with moderate-to-severe postoperative pain, and poorly controlled pain can result in delayed functional recovery and the development of frozen shoulder. Terminal sensory articular nerve radiofrequency ablation (RFA) has been shown to be clinically effective in patients with severe refractory shoulder pain from multiple etiologies. We aimed to investigate whether preoperative RFA would improve the postoperative pain and functional outcomes after ARCR.

Methods: In this prospective pilot study, participants were randomized to receive fluoroscopic-guided terminal sensory articular nerve cooled RFA (CRFA) (supraspinatus nerve, axillary nerve, lateral pectoral nerve) 1-5 days prior to elective ARCR as an intervention group compared to ARCR without prior RFA as a control group. Constant score (CS), American Shoulder and Elbow Surgeon score (ASES), and Pain numerical rating score (NRS) were assessed at 1, 2, 3, 4, 5, and 6 weeks and 3 months following ARCR.

Results: Twenty-one participants were enrolled in this study, including 11 in the control group and 10 in the cooled RFA group. The cooled RFA group showed statistically significantly better CS and ASES both at 6 weeks and 3 months. The two groups showed no differences in pain outcomes at all time points. No intervention-related complications were noted.

Conclusion: Cooled RFA of the terminal sensory articular branches of the supraspinatus, axillary, and lateral pectoral nerves performed 1-5 days prior to elective ARCR as part of a multimodal postoperative pain management regimen can improve functional outcomes as early as 6 weeks.

Level of evidence: III.

Introduction: A chest radiograph (CXR), whether supine or upright, is the primary tool for assessing blunt thoracic and abdominal trauma. Thoracic injuries often come with shoulder girdle injuries such as scapular or clavicular fractures, and acromioclavicular joint (ACJ) dislocations. The Zanca view is standard for diagnosing ACJ dislocation. While upright CXR can screen for high-grade ACJ dislocation, its diagnostic value in these cases remains unreported.

Objective: This study aimed to determine the diagnostic value of upright CXR, compared to the standard Zanca view in diagnosing ACJ dislocation.

Methods: Upright CXRs from 70 patients with ACJ dislocation were matched 1:1 by age and gender with 70 control CXRs from individuals with no shoulder disorders. A total of 140 CXRs were randomized and blinded to clinical information, then assessed for coracoclavicular distance (CCD) differences by two independent evaluators. The study compared the diagnostic accuracy of the upright CXR against the Zanca view, the gold standard. Interobserver and intraobserver agreements on ACJ dislocation categorization using upright CXRs were also measured.

Results: There were 55 male and 15 female patients, with an average age of 46 in both cases and controls. In the disease group, the percentage of CCD difference compared to the unaffected side (DCCD) was not statistically significantly different (p value ​= ​0.052) between the upright CXR and Zanca view. The median of DCCD was 121.64 (interquartile range ​= ​69.45, 159.76) and 135.57 (interquartile range ​= ​88.64, 200.18) in upright CXR and Zanca view, respectively. Totally, 140 CXRs, Zanca as the gold standard, the upright CXRs with the definition of an abnormal CCD difference of ≥25%, revealed 95.71% sensitivity, 85.71% specificity, 6.7 of the positive likelihood ratio, and 0.05 of the negative likelihood ratio. The accuracy was 90.71%. The intraobserver reliability was 94.29% agreement and 0.94 of weighted kappa coefficient (95% confidence interval [CI] ​= ​0.89-0.98). The interobserver reliability was 95.7% agreement and 0.95 with a weighted kappa coefficient (95% CI ​= ​0.92-0.99).

Conclusion: Upright CXR is a reliable diagnostic screening tool for ACJ dislocation, particularly for displacements of ≥25%. It provides high sensitivity and specificity compared to the Zanca view, with nearly perfect interobserver and intraobserver reliabilities.

Level of evidence: 3: This was a retrospective matched case-control study.

Objectives: This study aimed to evaluate the accuracy of ChatGPT in answering patient questions about femoroacetabular impingement (FAI) and arthroscopic hip surgery, comparing the performance of versions ChatGPT-3.5 (free) and ChatGPT-4 (paid).

Methods: Twelve frequently asked questions (FAQs) relating to FAI were selected and posed to ChatGPT-3.5 and ChatGPT-4. The responses were assessed for accuracy by three hip arthroscopy surgeons using a four-tier grading system. Statistical analyses included Wilcoxon signed-rank tests and Gwet's AC2 coefficient for interrater agreement corrected for chance and employing quadratic weights.

Results: The median ratings for responses ranged from "excellent not requiring clarification" to "satisfactory requiring moderate clarification." No responses were rated as "unsatisfactory requiring substantial clarification." The median accuracy scores were 2 (range 1-3) for ChatGPT-3.5 and 1.5 (range 1-3) for ChatGPT-4, with 25 ​% of ChatGPT-3.5's responses and 50 ​% of ChatGPT-4's responses rated as "excellent." There was no statistical difference in performance between the two versions (p ​= ​0.279) although ChatGPT-4 showed a tendency towards higher accuracy in some areas. Interrater agreement was substantial for ChatGPT-3.5 (Gwet's AC2 ​= ​0.79 [95% confidence interval (CI) ​= ​0.6-0.94]) and moderate to substantial for ChatGPT-4 (Gwet's AC2 ​= ​0.65 [95% CI ​= ​0.43-0.87]).

Conclusion: Both versions of ChatGPT provided mostly accurate responses to FAQs on FAI and arthroscopic surgery, with no significant difference between the versions. The findings suggest potential utility of ChatGPT in patient education, though cautious implementation and further evaluation are recommended due to variability in response accuracy and low power of the study.

Level of evidence: IV.

Background: The treatment decisions for shoulder instability often necessitate surgical intervention, with glenoid bone loss being a key factor. Currently, various techniques exist to identify glenoid bone loss, each with its own advantages and disadvantages. This study introduces the Coraco-Gleno-Scapular (CGS) line as a tool for assessing critical glenoid bone defects. The objective is to define the CGS line and evaluate its utility in guiding clinical decisions regarding bone loss, proposing that defects extending posterior to this line indicate critical bone involvement requiring surgical intervention.

Methods: The study analyzed 50 normal right shoulders from individuals aged 18-40 years. Using 3D en face views of the glenoid, the CGS line was defined from the anteroinferior base of the coracoid process, crossing the anterior glenoid, to the anteroinferior pole of the scapula. The best-fit circle area method and the glenoid index linear method were used to calculate the percentage of the bone area located anterior to the CGS line.

Results: The best fit circle area method revealed a mean glenoid surface area anterior to the CGS line of 22.19%, while the glenoid index linear method indicated a mean area of 27.2% anterior to the CGS line. Of the 50 shoulders, 14 had a glenoid surface area <20% anterior to the CGS line using the best-fit circle method, with no cases below 17.5%, while 36 individuals had a glenoid surface area >20%.

Conclusion: The Coraco-Gleno-Scapular line is a reliable and simple tool for assessing glenoid bone loss, providing valuable guidance in managing shoulder instability. Its ease of use makes it a promising candidate for standard application in clinical practice.

Level of evidence: Prospective observational study, Level III.

The subscapularis (SSC) muscle is a crucial anterior glenohumeral stabilizer and internal rotator of the shoulder joint. The partial tears of the SSC might result from traumatic injury or intrinsic degeneration. Partial SSC tears can range in severity and be classified into different categories based on the location of the tear, size of the lesion, and associated pathology. The tear usually begins from the superolateral margin in the first facet and propagates downwards. It is frequently associated with biceps pathology or anterosuperior lesions. These tears are now increasingly recognized as distinct pathology that requires specific diagnostic and management approaches. The current management approaches are shifting towards operative, as partial SSC tears are increasingly recognized as a distinct pathology. At present, there is no consensus regarding the timing of repair, but the relative tendency of the SSC to retract much faster than other rotator cuff muscles, and difficulty in mobilization, advocates an early repair for SSC irrespective of the lesion size. An associated biceps pathology can be treated with either tenotomy (biceps delamination/erosion) or tenodesis. The techniques of partial SSC repair are constantly improving. There is no reported difference in use of 2-anchor-based conventional single-row (SR), a 3-anchor-based interconnected double-row technique, or a 2-anchor-based interconnected hybrid double-row construct in the repair construct. However, the 2-anchor-based interconnected double-row provides an advantage of better superolateral coverage with leading-edge protection, as it helps in placing the superolateral anchor superior and lateral to the original footprint. A timely intervention and restoration of the footprint will help restore and rehabilitate the shoulder. Future directions should prioritise injury prevention, early diagnosis with clinic-radiological cues and targeted interventions to mitigate risk.