Annals of Joint最新文献

Subchondral bone plays a critical yet often underappreciated role in osteochondral health, injury response, and the pathophysiology of osteoarthritis (OA). A limited understanding of subchondral bone behavior limits the accurate evaluation of cartilage repair outcomes. Alterations in the subchondral bone-such as changes in bone density and structure, subchondral cyst (SCC) formation, impairment of osseous microarchitecture, and overgrowth of the subchondral plate-can compromise the mechanical osteochondral unit's integrity, leading to compromised joint function and poor outcomes. Moreover, neuropathy and subchondral bone changes, both significant contributors to OA-related pain and progression, are rarely assessed in treatment strategies. A deeper understanding of subchondral bone dynamics could improve both the assessment of repair outcomes and the development of more effective therapeutic strategies for OA. In the context of cartilage procedures, clinical and translational studies revealed that up to one-third of patients undergoing microfracture or similar subchondral venting procedures exhibit clinically pathologic subchondral bone changes. These include cyst formation and upward migration of the bone plate, which negatively affect repair outcomes. Translational models further support these findings by elucidating the mechanisms of subchondral bone remodeling and its critical influence on cartilage health. This review focuses on recent translational research on the subchondral bone in both osteochondral health, injury, and OA, highlighting the need to preserve its integrity during cartilage repair and ensuring that subchondral bone is considered in OA therapy. Understanding subchondral bone alterations may guide repair strategies, including biologic therapies and biomaterial-based approaches aimed at restoring osteochondral function, paving the way for improved clinical outcomes.

Background and objective: The optimal management of proximal humeral bone loss (PHBL) in shoulder arthroplasty is a debated topic. PHBL is a challenging problem for surgeons due to its effect on implant fixation and stability. Supplemental fixation options in the form of allograft-prosthetic composites (APCs) or reverse shoulder arthroplasty (RSA) endoprostheses are options to consider, each with its own benefits and complication profiles. This narrative review aims to evaluate current strategies for managing PHBL.

Methods: A comprehensive literature search was performed using databases including PubMed, Cochrane Library, and Google Scholar using appropriate search terms. Studies published between 2013 and 2024 were included. All included studies were peer-reviewed and addressed PHBL in the setting of shoulder arthroplasty or proximal humerus resection.

Key content and findings: A total of nineteen studies were included, comprising 7 retrospective case series, 4 prospective case series or cohort studies, 2 systematic reviews, 1 retrospective registry study, 3 descriptive papers of proposed classification systems, and 2 technique papers. Described classification systems categorize PHBL by integrity of the epiphysis, greater tuberosity, calcar, metaphysis, diaphysis, and cortices. Depending on the degree of bone loss, revision RSA without allograft, revision RSA with APC augmentation, and endoprosthesis are described as management options. In patients with greater than 5 cm of PHBL, use of APC or endoprosthesis has proven effective but with high complication profiles and revision rates. No paper directly compares endoprosthesis and APC outcomes.

Conclusions: PHBL is a rare but important problem in the setting of tumor resection and revision shoulder arthroplasty. While small cohort studies have reported successful outcomes with both APC and endoprosthesis, systematic reviews have failed to demonstrate a clear benefit of one option over the other. Complication and reoperation rates can be high with both surgical options. With a focus on standardized classification and evaluation of patients with PHBL, we can hope to refine the surgical techniques and indications for optimal patient outcomes.

Background and objective: Perioperative pain management is of considerable interest in shoulder surgery due to its association with severe postoperative pain. Over time, regional anesthesia has become widely utilized in postoperative pain control. Because poor pain management after orthopedic surgery remains an issue, optimal utilization of regional anesthesia should continue to be a focus for shoulder surgeons. This review seeks to summarize the most commonly used regional anesthesia techniques in shoulder surgery while highlighting key innovations in these areas. Furthermore, it will appraise the available high-quality evidence on these topics, providing a snapshot of the most current practices and conclusions.

Methods: PubMed was queried for studies published within the previous 20 years on topics of regional anesthesia procedures for shoulder surgery. The most recent high-quality studies-systematic reviews, meta-analyses, and randomized controlled trials-were prioritized for selection. Additional references were identified from the reference lists of these articles.

Key content and findings: The interscalene brachial plexus block (ISB), the supraclavicular brachial plexus block (SCB), and the suprascapular nerve block (SSNB) are at the forefront of regional anesthesia for shoulder surgery. ISB remains the gold standard, offering the most complete anesthesia. SCB and SSNB have important roles as well, having a lower risk of complications but the additional requirement of general anesthesia (GA). Continuous catheter infusion (CCI), while effective in extending analgesia, has fallen out of favor due to its safety concerns, such as catheter migration. Adjuvant medications have become more popular in recent years and have been shown to prolong nerve blockade, with intravenous dexamethasone and dexmedetomidine gaining significant traction. Liposomal bupivacaine (LB), a newer advancement, increases nerve block duration but has shown mixed evidence in improving patient outcomes.

Conclusions: Regional anesthesia plays a major role in postoperative pain management and has changed the landscape of how patients can recover from shoulder surgery. ISB, SCB, and SSNB techniques all have their place, each offering unique advantages and disadvantages. CCI and adjuvant medications have shown benefit, while LB requires further investigation. Future research should aim to refine regional anesthesia techniques to further improve outcomes.

Background and objective: Quadriceps tendon ruptures can occur in both the native knee and in knees which have undergone prior total knee arthroplasty (TKA). Complete ruptures require surgical treatment to optimize patient function. Debate exists surrounding the ideal repair technique for native ruptures, and there is little consensus regarding the optimal surgical treatment option for post-TKA ruptures. The objective of this narrative review is to provide an overview of quadriceps tendon ruptures occurring in both native knees and in the setting of TKA, with a focus on contemporary treatment options and their results.

Methods: A narrative review of the relevant literature was performed in November 2024. English language articles published up to November 2024 which related to quadriceps tendon ruptures, involving both the native knee and the post-TKA knee, were reviewed. All types of published articles were considered.

Key content and findings: Quadriceps tendon ruptures almost always occur in patients with antecedent tendon pathology. Primary repair of acute native quadriceps ruptures is supported by a large body of literature, and most patients have reasonable outcomes. The clinical outcomes of transosseous and suture anchor repair techniques seem to be comparable in this setting. Quadriceps ruptures, which occur in the setting of TKA, are much more difficult to treat. In this setting, the complication rates of primary repair, repair with augmentation, and reconstruction are high. Even with improvements in the contemporary reconstructive options, including allograft and synthetic mesh, outcomes remain suboptimal. More work is needed to improve outcomes for patients with post-TKA quadriceps tendon ruptures.

Conclusions: Generally reliable results can be achieved when treating native quadriceps tendon ruptures with contemporary techniques. Quadriceps ruptures, which occur in the setting of TKA, on the other hand, are much more challenging to treat. Various surgical techniques have been explored and developed in an effort to improve outcomes. While modest improvements have been realized, these injuries remain problematic, with very high complication and failure rates, regardless of technique.

Background and objective: Kabaddi is an athletic contact sport that involves power, aggression, fine mind-body balance, agility, and swift reflexes. Since Kabaddi is a contact sport, athletes face a higher risk of injuries during competition and training. There is a paucity of literature regarding sports injuries during this game. This review article lays down a plinth-stone for global recognition of this game and associated sports injuries, intending to improve awareness in the sports medicine fraternity and boost further research related to this topic.

Methods: A comprehensive synthesis of the relevant literature was conducted to provide insights for clinicians, trainers, and players to enhance injury prevention and rehabilitation strategies.

Key content and findings: Kabaddi, a traditional Indian sport, is gaining popularity worldwide. Its physically demanding nature poses a significant risk for sports injuries among players. Anterior cruciate ligament (ACL) ruptures with concurrent meniscal injuries are the most common soft tissue injuries in Kabaddi. However, due to the sport's aggressive and physical nature, nearly all types of injuries are possible.

Conclusions: This review article highlights the mechanisms of injury and common injuries associated with Kabaddi. It also offers a comprehensive overview of the sport's origin, regulations, and etiquette. This review concludes that a multidisciplinary approach involving physiotherapists, sports orthopaedic specialists, and medical teams is crucial for conditioning players and minimizing injury risk.

Growing evidence suggests that many non-contact mechanical fatigue-related anterior cruciate ligament (ACL) injuries are related to the accumulated microtrauma that leads to sudden failure. These factors may play a critical role in enhancing both sports performance and adherence to ACL injury prevention programs among youth and adolescent athletes. This clinical practice review synthesizes existing literature on sustainable performance plan principles that integrate active rest and recovery, with an emphasis on boredom mitigation and self-control development. A comprehensive literature search was conducted using PubMed, Web of Science, and OVID MEDLINE databases to identify key themes presented in the following sub-sections: The elite training industry and rise of specialization; Lessons from sports diversity and delayed specialization; Developing more than muscles; Mitigating boredom, developing self-control; Active rest and recovery; Culture, context, and compliance; and Blending performance training and injury prevention. By fostering engagement and adherence among all stakeholders, sustainable performance plans that incorporate boredom mitigation, self-control development, and structured active rest and recovery may enhance compliance with neuromuscular training programs aimed at reducing non-contact ACL injury risk in youth and adolescent athletes. Further research is needed to assess the most effective strategies for integrating these principles into existing training models.

Background and objective: Anterior shoulder instability (ASI) is a common occurrence in the athletic population with specific management challenges in contact athletes due to the high activity demand and repetitive trauma during sport. This study aims to provide a narrative review of the current literature on ASI in contact athletes, with an emphasis on pathophysiology, mechanisms of injury, clinical presentation, diagnostic strategies, treatment options, including in-season management, and outcomes.

Methods: A narrative review of the current literature on ASI in contact athletes was conducted, including key studies on the management and outcomes of conservative and surgical interventions.

Key content and findings: ASI typically occurs from abduction and external rotation forces. Diagnosis relies on clinical assessment and imaging (magnetic resonance imaging or computed tomography), to evaluate soft tissue and bony injuries. Non-operative management is associated with high recurrence rates in contact athletes. Surgical options include arthroscopic Bankart repair (ABR) with or without remplissage, open Bankart repair (OBR), or bone block procedure such as Latarjet procedure or distal tibia allograft. All of which have been shown to decrease risk of recurrence and have a high rate of return to sport. The choice of procedure depends on the extent of soft tissue and bony involvement and the athlete's individual demands. ABR with glenoid bone loss >13.5% have high recurrence rates, therefore, additional procedures such as remplissage or bone block procedures should be considered.

Conclusions: ASI in the contact athlete is a common and challenging injury to manage. Surgical intervention provides superior outcomes in terms of stability and recurrence prevention compared to non-operative management of ASI in the contact athlete. Patient-specific considerations including level of sport, patient goals, and timing of season are considerations for treatment. Labral injury with <13.5% of glenoid bone loss and on-track Hill-Sachs lesion ABR is recommended, labral injury with 13.5-20% of glenoid bone loss with off-track Hill-Sachs lesion ABR with remplissage or OBR with capsule shift is recommended, and if >20% then bone block procedure is recommended.

Background and objective: Osteoarthritis (OA) is a multifactorial disease, involving biomechanical, inflammatory, and metabolic processes that ultimately impact the structure and function of a joint. Current therapeutic options can improve symptoms and prolong the time to surgery, yet they are not curative and are limited by their systemic side-effects and their inability to provide site-specific delivery. Nanomedicine takes advantage of the unique properties held by technology on the nanoscale (1-100 nm), including surface effects and quantum effects, that allow for novel mechanical, thermal, and magnetic functions. The primary aim of this narrative review is to summarize the recent advances made in nanotechnology and their uses in joint arthroplasty.

Methods: This narrative review was performed following a computerized search of the electronic database on PubMed in September 2024. Papers related to the use of nanotechnology in orthopaedic arthroplasty surgery were included for review.

Key context and findings: Nanotechnology holds the promise of optimizing OA treatment, refining the implants used during joint arthroplasty, and aiding in the diagnosis and treatment of post-operative joint infections. With the increasingly aging population and growing demand for joint replacement, this review aims to cover the novel applications of nanoparticles (NPs) within the realm of joint replacement surgery.

Conclusions: Future studies are needed to further investigate the clinical translation of NPs in joint arthroplasty. Additionally, the potential of NPs needs to be considered within their limitations and their safety profile that is still being defined.

Background: Since the introduction of large language models (LLMs) such as ChatGPT, there has been a race to test its capability in medical problem solving across specialties to varying degrees of success. Retrieval augmented generation (RAG) allows LLMs to leverage subject specific knowledge to provide context, a greater number of sources, and the ability to cite medical literature to increase the accuracy and credibility of its answers. The use of LLM + RAG has not yet been used in the appraisal of artificial intelligence's capability of orthopedic problem solving. The purpose of this study is to assess the performance of ChatGPT + RAG against the performance of ChatGPT without RAG as well as against humans on orthopedic examination assessment questions.

Methods: The American Academy of Orthopaedic Surgeons (AAOS) OrthoWizard question bank was used as the source of questions. After 13 textbooks and 28 clinical guidelines were made available for RAG, text-only multiple-choice questions were presented in a zero-shot learning fashion to ChatGPT-4 + RAG, ChatGPT-4, and ChatGPT-3.5.

Results: On 1,023 questions tested, ChatGPT-3.5, ChatGPT-4, ChatGPT-4+RAG, and humans scored 52.98%, 64.91%, 73.80%, and 73.97%, respectively. There was no statistical difference between orthopedic surgeons and ChatGPT-4 + RAG on overall accuracy (P>0.99). Both orthopedic surgeons and ChatGPT4 + RAG scored better than ChatGPT-4 (P<0.001) and ChatGPT-3.5 (P<0.001). Of the 13 textbooks available to RAG, RAG used AAOS Comprehensive Review 3 Volume 3 for 39.6% of questions, more often than any other resource available to it.

Conclusions: ChatGPT-4 + RAG was able to answer 1,023 questions from the OrthoWizard question bank at the same accuracy as Orthopedic surgeons. Both ChatGPT-4 + RAG and orthopedic surgeons had superior accuracy on these specialty exam questions compared to ChatGPT-4 and ChatGPT-3.5. Artificial intelligence is becoming increasingly accurate in its ability to answer orthopaedic surgery test questions with the guidance of orthopaedic surgery textbooks. RAG enables an LLM to effectively cite its sources after providing an answer to a question, which is an important tool for the integration of LLMs to orthopaedic surgery education and can function as a valuable tool for anyone studying for an orthopedic examination.

Background: The Achilles tendon rupture is a common injury of the lower extremity, inducing pain and physical impairment. Surgical treatment methods include open, percutaneous, and mini-open repair techniques. This study aims to compare the outcomes of these three techniques.

Methods: PubMed, Google Scholar, and EMBASE were searched until November 2023. Randomized controlled trials (RCT) and retrospective comparative studies (RCS) comparing either open versus percutaneous repair, open versus mini-open repair, or percutaneous vs. mini-open repair of the Achilles tendon rupture were included with at least one of the following outcomes: American Orthopedic Foot & Ankle Society (AOFAS) score, Achilles Tendon Total Rupture Score (ATRS) score, re-ruptures, sural nerve injuries, infections, wound dehiscence, deep vein thrombosis (DVT), and average operating time. Meta-analysis was mostly processed by RevMan 5. A P value of ≤0.05 was considered statistically significant. Risk of bias was assessed with RevMan 5 and the Newcastle-Ottawa scale.

Results: Twenty-six studies, including 1,898 patients, were included. The percutaneous group had significantly more sural nerve injuries [risk ratio (RR) =0.28; 95% confidence interval (CI): 0.14 to 0.57; P<0.001], fewer infections (RR =2.99; 95% CI: 1.37 to 6.49; P=0.006), higher AOFAS score [standardized mean difference (SMD) =-0.32; 95% CI: -0.61 to -0.03; P=0.03], higher ATRS (SMD =-0.24; 95% CI: -0.47 to -0.02; P=0.03), and a shorter average operating period (SMD =2.29; 95% CI: 1.63 to 2.96; P<0.001) than the open repair group. The mini-open group had a significantly higher AOFAS score (SMD =-0.58; 95% CI: -1.06 to -0.09; P=0.02), higher ATRS (SMD =-0.65; 95% CI: -1.05 to -0.26; P=0.001), longer average operating time (SMD =-0.95; 95% CI: -1.46 to -0.45; P<0.001), and lower rates of re-ruptures and sural nerve injuries than the percutaneous group. The open group had significantly more infections than the mini-open group (RR =2.99; 95% CI: 1.07 to 8.37; P=0.04).

Conclusions: The mini-open repair technique demonstrated superior function scores and lower complication rates than percutaneous repair and open repair. It should be the first choice when treating Achilles tendon ruptures, with percutaneous repair being a reliable alternative.