Arthroscopy-The Journal of Arthroscopic and Related Surgery最新文献

Purpose: To investigate the influence of surgical volume, and various patient-, injury-, and surgery-related factors, on meniscal treatment strategies in primary anterior cruciate ligament reconstruction (ACLR).

Methods: This retrospective cohort study analyzed patients with concomitant meniscal injuries undergoing primary ACLR, 2008-2022, using data from the Swedish National Knee Ligament Registry. Surgeons and clinics were stratified by total caseload (cutoff: 50 ACLRs/surgeon, 500 ACLRs/clinic) and annual volume (cutoff: 29 ACLRs/year/surgeon, 56 ACLRs/year/clinic). To assess factors influencing medial meniscus (MM) or lateral meniscus (LM) repair, adjusted multivariable logistic regression was conducted, with results presented as odds ratios (OR) and 95% confidence intervals (CI).

Results: 20,699 patients undergoing primary ACLR with concomitant meniscal injuries were included. Lower percentages of meniscus repair were seen among surgeons with low caseload and annual volume (LCLV) (13.3-20.8%) compared to high caseload and annual volume (HCHV) surgeons (19.0-29.8%), and at LCLV clinics (11.1-18.3%) compared to HCHV clinics (21.5-33.8%), all P<0.001. Significantly decreased odds of MM repair were seen for patients operated on by LCLV surgeons (OR 0.82, 95% CI 0.70-0.96; P=0.015) or at LCLV clinics (OR 0.56, 95% CI 0.50-0.64; P<0.001. Similar results were seen for LM repair with LCLV surgeons (OR 0.83, 95% CI 0.69-1.01; P=0.067) and LCLV clinics (OR 0.62, 95% CI 0.53-0.72; P<0.001). Additionally, younger age, female sex, shorter time from injury to surgery, and ACLRs performed more recently were associated with increased odds of repair.

Conclusions: Lower surgical volume significantly decreased the rates and odds of performing meniscal repair during primary ACLR. In contrast, ACLRs performed during more recent years in younger age, female sex, shorter time from injury to surgery, in absence of chondral injuries, and injuries sustained during nonpivoting activities, positively influenced meniscal preservation.

Level of evidence: Level III. Retrospective cohort study.

Purpose: To systematically review the representation of female athletes in the current primary literature available on rehabilitation following anterior cruciate ligament reconstruction (ACLR).

Methods: A systematic review was conducted using PubMed to provide a comprehensive analysis of female representation in ACLR postop rehabilitation protocols. PRISMA guidelines were followed. Studies were analyzed based on nine factors: study population, athletic caliber, menstrual status, research theme, journal impact factor, sample size of male and female participants, time to return to sport (RTS), and graft failure rate. Population categories included males-only, females-only, mixed-sex, and male vs. female comparisons. Athletic caliber had six tiers. Menstrual status was categorized as natural, hormonal contraception, irregularities, mixed, or unclassified. Research themes were health-focused, performance-focused, or combined. Study impact was assessed via journal impact factor.

Results: Thirty-three studies were included. Females comprised 3031/6798 (44.6%) of ACLR participants. No female-only studies were found; male-only studies accounted for 3/33 (9%), mixed-sex for 25/33 (69.7%), male vs. female sub-analysis for 3/33 (9%), and male vs. female features for 2/33 (6%). No studies investigated outcomes for the highest athletic levels. Menstrual status was not considered. No studies focused on performance outcomes; 25/33 (69.7%) had a health research focus. Females were underrepresented in studies evaluating RTS timeline and graft failure rate.

Conclusion: Females face a 2-8 times higher risk of ACL injury but are underrepresented in ACLR postop rehabilitation studies, with only 44.6% participation compared to 55.4% for males. In nine studies, females comprised 30% or less of participants. Even studies including female athletes at near-equal rates failed to address menstrual status or sex hormones on injury and rehabilitation.

Level of evidence: Level IV, Systematic Review of Level I - IV studies.

Purpose: The purpose of this systematic review was to explore the indications, outcomes, and complications related to slope reducing osteotomies in the setting of anterior cruciate ligament (ACL) tears or graft failure. A secondary aim was to create an algorithm based on the current literature and authors' opinions.

Methods: This study was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Studies were included if they reported on outcomes related to slope reducing osteotomies both for primary ACL tears and revision ACL graft tears. The studies were analyzed to determine the radiographic outcomes, patient reported outcomes (PROs), physical exam findings, and complications. Statistical analysis could not be performed due to the heterogeneity between studies.

Results: A total of 148 studies were screened for inclusion in this systematic review and after full-text review, a total of 16 studies were included in this systematic review. Fourteen of the studies reported on pre- vs. postoperative PTS and all but one reported significant decrease in posterior tibial slope. Seven studies reported on pre- vs. postoperative PROs and all studies reported significant improvements in postoperative scores. Anterior tibial translation (ATT) was measured in 8 studies, and all reported a significant decrease in ATT postoperatively. The most common complication was postoperative hyperextension and hardware irritation. Hardware irritation was only reported in studies that used plates to fixate the osteotomy.

Conclusions: In conclusion, slope reducing proximal tibial osteotomies performed concurrently or as a second stage surgery with an ACLR resulted in improved patient reported outcomes and decreased ACLR failure rates. Slope reducing proximal tibial osteotomies are an important treatment consideration for those patients with an increased PTS, especially for patients with a failed ACLR and a PTS ≥ 12° to reduce the risk of ACLR failure.

Level of evidence: IV.

Purpose: The purpose of this systematic review was to compare the clinical and radiographic outcomes and complications between medial opening wedge and lateral closing wedge high tibial osteotomies in the setting of medial compartment osteoarthritis with genu varus alignment.

Methods: This study was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Studies that reported on MOW- or LCWHTOs in the setting of medial compartment osteoarthritis were included. Analysis was performed based on radiographic and patient reported outcomes (PROs) and complications.

Results: A total of 40 studies were included. Hip-knee-ankle (HKA) angles and PROs including Lysholm and VAS showed significant improvements postoperatively for both MOW- and LCWHTO for all included studies. For the studies that reported on it, posterior tibial slope (PTS) was significantly increased in 4 of the 9 MOW studies and significantly decreased in 8 of the 9 LCW studies, and patellar height was significantly decreased in 4 of the 5 MOW studies, while none of the 4 LCW studies reported any changes. Three comparison studies reported a higher conversion to total knee arthroplasty (TKA) in the LCW cohort, otherwise, survivorship at 10-years was comparable between studies. The MOW cohort had higher rates of tibial fractures while the LCW cohort had higher rates of nerve injuries.

Conclusions: This systematic review found comparable HKA angle correction and PROs between patients undergoing MOW- or LCWHTOs to treat medial compartment osteoarthritis. Survivorship at 10-years was comparable between MOW- and LCWHTOs; however, some MOW- and LCWHTO comparison studies reported higher conversion to TKA for LCWHTO. Medial opening wedge HTO typically results in an increased PTS, decreased patellar height, and tibial fractures, while LCWHTO typically results in decreased PTS, no change in patellar height, and common peroneal nerve injuries.

Level of evidence: Level IV, systematic review of Level I to IV studies.

Purpose: To assess the risk of revision surgery following repair versus reconstruction of the medial ulnar collateral ligament (UCL) of the elbow in a national sample of patients in the United States.

Methods: This was a retrospective cohort study of young patients (≤35 years old) who underwent primary UCL reconstruction or repair for an isolated medial UCL injury of the elbow from October 2015 through October 2022 in a large national database (PearlDiver). Patient demographic data, comorbidities, surgical details, and concomitant ulnar nerve procedures were collected. Time-to-event analyses were used to assess the risk of revision UCL surgery between groups. Two-year complication rates, including ulnar neuropathy, were also assessed.

Results: In total, 1,820 patients (69.9% reconstruction, 30.1% repair) with an average follow-up of 2.9 years met inclusion criteria. The estimated 2-year revision-free survival (95% confidence interval [CI]) was 99.5% (99.1%-99.9%) for UCL reconstruction compared to 97.9% (96.4%-99.3%) for UCL repair (unadjusted Log-rank p=0.032). UCL repair remained associated with an increased risk of revision UCL surgery after adjusting for confounding variables (hazard ratio 2.94, 95% CI 1.07-8.09, p=0.037). Complication rates were similar between reconstruction and repair, including the incidence of ulnar neuropathy (13.8% vs. 14.5%, p=0.78).

Conclusion: In this study, we found that UCL repair was associated with a significantly higher risk of revision UCL surgery than UCL reconstruction in a national sample. Importantly, however, overall failure rates were low and complication rates were similar between procedures. These findings support the overall favorable outcomes of UCL repair, while suggesting it may not necessarily be the optimal treatment for all patients.

Level of evidence: 3 - retrospective cohort study.

Patient Reported Outcome (PRO) measures are critical to understand the influence and benefits of orthopedic surgery. While clinically important outcome values (CIOVs) have been developed to allow clinical interpretation of PRO values, gaps in outcome metrics still remain. The CIOVs can be utilized to describe specific populations of interest, such as in patients with hip dysplasia undergoing combined hip arthroscopy and periacetabular osteotomy. With differing populations, however, the presence and/or absence of modifying factors limits cross-comparison of CIOVs. Utilizing a different perspective, such as the use of simple questions that are important for both the patient and the surgeon, can provide important information that helps fill in the gaps left from traditional PROs.

Purpose: To compare clinical outcomes in patients undergoing endoscopic proximal hamstring repair with and without dermal allograft augmentation.

Methods: A retrospective review of prospectively collected data was performed on patients undergoing endoscopic proximal hamstring repair (PHR) and proximal hamstring repair with dermal allograft augmentation (PHR-A) by a single surgeon between 2016 and 2023. Augmentation was utilized for cases of chronic degenerative tears (> 6 weeks from the time of initial injury) where hamstring tissue quality was deemed poor intraoperatively. A survey of patient-reported outcome measures (PROMs) was completed at a minimum of 1 year postoperatively. PROMs included a Visual Analogue Scale (VAS) for pain; University of California, Los Angeles (UCLA) Activity Scale; modified Harris Hip Score (mHHS); Hip Outcome Score-Sports-Specific Subscale (HOS-SSS); and a Single Assessment Numeric Evaluation (SANE). The proportion of patients achieving the minimal clinically important difference (MCID), patient acceptable symptom state (PASS), and substantial clinical benefit (SCB) for PROMs were compared between groups.

Results: Sixty-four patients were included (42 PHR, 22 PHR-A). No differences were seen between the PHR and PHR-A groups in terms of age at surgery (49 ± 12 vs. 54 ± 9, p=0.08), sex, or body-mass index (BMI). There was a significantly longer time to follow-up (41.5±23.4 vs. 20.1±10.2 months, p<0.001) in the PHR group. There were significantly greater postoperative mHHS (82.7±15.1 vs. 72.0±18.0, p=0.02) and SANE (89.6±9.9 vs. 73.6±22.5, p=0.002) scores in the PHR group. There were no significant differences in postoperative VAS, UCLA, or HOS-SSS between groups. A greater proportion of patients in the PHR group achieved a SCB for mHHS (71% vs. 36%, p=0.008).

Conclusions: Our study demonstrates inferior clinical outcomes in patients undergoing endoscopic proximal hamstring repair with dermal allograft augmentation compared to patients undergoing endoscopic proximal hamstring repair without augmentation.

Level of evidence: III, retrospective comparative case series.

Purpose: To compare the clinical results of the arthroscopic foveal repair of the triangular fibrocartilage complex (TFCC) for distal radio-ulnar joint (DRUJ) instability in patients with or without generalized joint laxity.

Methods: Patients who underwent arthroscopic transosseous foveal TFCC repair of Palmer 1B foveal TFCC tears (Atzei classification class II or III) from January 2018 to October 2021 were identified. Patients treated for symptomatic DRUJ instability for more than 3 months, and with at least 2 years of follow-up, were included. Patients were categorized into two groups based on the Beighton and Horan criteria: those with generalized joint laxity (group L) and those without (group N). Clinical outcomes were measured by the Disabilities of the Arm, Shoulder, and Hand (DASH) score, modified Mayo wrist score (MMWS), wrist range of motion (ROM), grip strength, sports/recreation activity level, recurrent DRUJ instability, and achievement of minimal clinically important differences (MCID).

Results: One-hundred-and-twenty patients (Group L, 51 patients; Group N, 69 patients) were included. Both groups showed significant improvements in preoperative DASH and MMWS at the final follow-up. Overall, 103 patients (85.8%) achieved MCID, with 82.4% in Group L and 88.4% in Group N, and no significant differences between the two groups (P = .347). At the final follow-up, ROM and sports/recreation activity levels were similar between the groups. Significantly, the rates of postoperative DRUJ instability recurrence were 17.7% in group L (9/51) and 5.8% in group N (4/69) (P=0.039). Beighton scores were an independent risk factor for recurrent DRUJ instability in the multivariable analysis (P=0.024; odds ratio=1.62).

Conclusions: Clinical outcomes after arthroscopic TFCC foveal repair in patients with generalized joint laxity are comparable to those without, with 82.4% achieving MCID. Generalized joint laxity impacts DRUJ instability recurrence over a minimum two-year follow-up period.

Level of evidence: Level III, retrospective comparative study.