Annals of Joint最新文献

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.

Background and objective: Brachial plexus injuries (BPIs) are a rare but potentially devastating injury among contact athletes. More common injuries, such as "burners" or "stingers", indicate a temporary and less severe insult to either the nerve roots or plexus. The aim of this review is to discuss this spectrum of injuries in their epidemiology, mechanism in contact sports, diagnosis, and treatment.

Methods: This literature review utilized key terms to search manuscripts available in English from inception to October 2024 within three research databases.

Key content and findings: BPIs among contact athletes occur on a spectrum from neuropraxia to neurotmesis. Neuropraxia is very common among contact athletes with approximately a 49-65% incidence among career football players with the most common mechanism being a traction injury. Most of these resolve within minutes to hours. Axonotmesis and neurotmesis can be far more severe injuries and require further investigation if not resolved by 2-3 weeks. The majority of athletes who suffer neuropraxic injuries will return to sport with minimal to no time missed, however, more severe injuries portend variable outcomes.

Conclusions: BPIs are common among contact athletes and involve a spectrum of nerve damage, of which most are self-limiting. However, further evaluation is warranted when symptoms last beyond 2-3 weeks. Future studies should focus on treatment algorithms and long-term outcomes, including return to sport.

Background: Managing complex fracture-dislocations of the proximal interphalangeal (PIP) joint poses significant clinical challenges, necessitating innovative treatment strategies.

Case description: This case report highlights the successful treatment of a severe PIP joint fracture-dislocation in a 49-year-old male carpenter who sustained a traumatic laceration to the right index finger. The injury's complexity led to the pioneering use of an osteochondral autograft from the patient's second toe proximal phalanx, marking a novel approach in autologous tissue utilization for joint reconstruction. This method effectively achieved fracture resolution and joint stabilization. A comprehensive literature search was conducted up to May 2024 across multiple databases, including PubMed, Embase, Cochrane Library, Scopus, and Web of Science. The search strategy employed a combination of Medical Subject Headings (MeSH) terms and keywords related to PIP joint fracture-dislocations and osteochondral autografts. Inclusion criteria were articles in English involving human subjects, focusing on osteochondral autografts for PIP joint fracture-dislocations. Exclusion criteria included studies involving animals or cadaveric models and those not focused on osteochondral grafts. Postoperative assessments of the patient revealed successful graft integration and notable recovery in finger mobility, alongside positive functional hand outcomes as confirmed by patient-reported measures.

Conclusions: The significant enhancements in structural and functional aspects highlight the potential of this technique. Despite its sparse representation in the literature, the favourable outcomes of this case strongly support further exploration of using second toe proximal phalanx osteochondral autografts. This report underscores the need for extensive, prospective research to comprehensively ascertain the method's effectiveness and safety in addressing intricate PIP joint fracture dislocations.

Osteotomies around the knee are an effective method for preserving the knee joint by correcting overall alignment. Although osteotomies have historically been used in treatment of knee pathology, they have recently regained a renewed interest as a treatment strategy for alignment correction, ligamentous stability, and cartilage preservation. Osteotomies are a powerful way to correct alignment in both the sagittal and coronal plane to preserve and/or protect the cartilage in the medial, lateral, and patellofemoral compartments of the knee and improve the ligamentous stability of the knee. Medial opening wedge high tibial osteotomy (MOW-HTO) and lateral closing wedge high tibial osteotomy (LCW-HTO) are commonly performed osteotomies for correcting varus malalignment, each with distinct indications, surgical techniques, and associated complications. Similarly, distal femoral osteotomy (DFO) plays a critical role in the correction of both varus and valgus malalignment, and may be particularly important in cases where a tibial osteotomy alone would lead to excessive joint line obliquity (JLO). In complex cases where single-level osteotomy does not provide optimal correction, double-level osteotomy may be necessary to achieve appropriate mechanical axis restoration while maintaining joint congruence. Beyond coronal plane corrections, increasing attention has been given to sagittal plane osteotomies for managing ligamentous instability, particularly anterior and posterior cruciate ligament (PCL) deficiencies. Modifying the posterior tibial slope (PTS) through anterior closing wedge or anterior opening wedge high tibial osteotomy can improve knee biomechanics and stability in both anterior cruciate ligament (ACL) and PCL-deficient patients. Additionally, tibial tubercle osteotomies (TTO) have emerged as an important surgical adjunct in the treatment of patellofemoral malalignment and cartilage preservation strategies. The goal of knee osteotomies is to offload the affected compartment, preserve and protect cartilage and menisci, and enhance ligamentous stability, thereby delaying the need for arthroplasty. Therefore, osteotomies represent an intriguing procedure for young and active patients. Recently, with the renewed interest in osteotomy procedures about the knee, studies have demonstrated that osteotomies continue to play a critical role in treatments for limb alignment and cartilage protection.

Background and objective: The evaluation of both femoral and tibial torsional profiles remains a challenge in the orthopedic practice since there is no agreement on the most precise and reliable measurement method and technique. The aim of this review is to collect and critically report the most relevant and up-to-date evidence on the radiological techniques available to determine lower limb torsional deformities and to discuss the advantages and limitations of each technique to better define their optimal field of application.

Methods: Literature research on PubMed, Embase, and Google Scholar databases was performed, utilizing the following search string: "torsion" AND ("lower limb" OR "femur" OR "tibia"). Relevant clinical and preclinical studies evaluating different radiological techniques to assess lower limb torsional deformities, and possibly comparing them, were collected and critically reviewed.

Key content and findings: Computed tomography (CT) is still considered the best method to measure both femoral and tibial torsional angles. Its main limitation, the radiation exposure, has been recently addressed with ultra-low dose protocols that were proven to be as accurate as standard protocols. On the other hand, magnetic resonance imaging (MRI) offers a nonionizing, radiation-free option that is now considered almost equivalent to CT. However, MRI consists in a long and expensive procedure that can be hindered by issues linked to metal implants, patient's positioning and measurement variabilities. Lastly, three-dimensional (3D) reconstructions derived from low-dose biplanar radiographies (LD-BRs) have been proposed as a low-radiating, quick and reliable solution to overcome the limitations of both MRI and CT scans.

Conclusions: To date, CT has still to be considered the gold standard for the radiological assessment of lower limb torsional deformities. Nonetheless, MRI and LD-BR have been proven to be valid and reliable alternatives, especially in specific clinical settings.

An understanding of the embryonic and fetal formation of the knee can help elucidate the relationships between the various structures and clinical conditions. While there have been studies published on the steps of knee development by sectioning human embryos and fetuses, the goal of this review is to consolidate these findings and images into one cohesive work. The timing and appearance of the structures in the knee are outlined with a focus on the cruciate and meniscofemoral ligaments (MFLs). In particular, the posterior cruciate ligament is emphasized with its relationship to other intraarticular structures and congenital anomalies that may arise. The steps of embryological development are outlined by the 23 stages of Carnegie embryonic staging system, which are distinguished by morphological criteria seen on histology of embryo sections. These images highlight the mesenchymal tissue within the interzone of the knee that form the primitive cruciate ligaments and menisci and the subsequent development of the cavitations within the knee that start to give it an appearance similar to that of an adult knee. The steps of fetal development are outlined by the weeks of development with the histological images showing the development of articulations between structures. This review paper consolidates various sources throughout the literature to outline the embryological and fetal appearance and relationship of intraarticular structures in the knee, such as the cruciate and MFLs, and how their altered development may contribute to the congenital anomalies and clinical conditions that may arise.