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

Purpose: To compare rates of postoperative complications, health care utilization, opioid prescribing patterns, and secondary knee surgery in patients with versus without a pre-existing anxiety or depressive disorder (ADD) undergoing isolated primary arthroscopic partial meniscectomy (APM).

Methods: The TriNetX database was queried from inception to compare patients older than 18 years who underwent isolated primary APM with versus without a pre-existing ADD. Patients were matched in a 1:1 ratio based on demographic factors and comorbidities, including diabetes and hypertension. The following outcomes were collected: (1) postoperative complications and health care utilization within 90 days, (2) proportion of patients prescribed an opioid within 1 year, and (3) subsequent knee surgery within 2 years, specifically ipsilateral or contralateral meniscus surgery or total knee arthroplasty. Two subgroup analyses were conducted. Opioid-naive patients with and without an ADD were compared based on the proportion of patients prescribed an opioid within 1 year of APM. Rates of revision meniscus surgery on the ipsilateral knee were also compared within 2 years of APM.

Results: Within 90 days, patients with a pre-existing ADD (n = 26,507), compared to those without (n = 26,507), had higher rates of health care utilization, including readmission (P < .001), and medical complications, like cerebrovascular accident (P = .002). A greater proportion of patients with an ADD were prescribed opioids at all chosen time points within 1 year of APM. Similarly, a greater proportion of opioid-naive patients with an ADD were prescribed opioids within 6 months (P < .001) and 1 year (P < .001). Patients with an ADD also had higher rates of total knee arthroplasty (P = .001) and ipsilateral revision meniscus surgery (left knee: P = .020; right knee: P = .019) within 2 years.

Conclusions: Patients with an anxiety or depressive disorder have higher rates of health care utilization, medical complications, opioid prescriptions, and subsequent knee surgery after isolated primary arthroscopic partial meniscectomy.

Level of evidence: Level III, retrospective cohort study.

Purpose: To examine the effects of timing of anterior cruciate ligament (ACL) reconstruction on the odds to recover muscle (quadriceps and hamstring) strength, return to preinjury physical activity level, and achieve rehabilitation goals at 12 months follow-up.

Methods: Data were extracted from a local rehabilitation registry in Sweden in November 2023. Patients ≥16 years old who underwent primary ACL reconstruction with hamstring tendon autografts, who underwent isokinetic muscle strength assessment, and responded to patient-reported outcomes 12-months after surgery were included. A multivariable logistic regression analysis was used to analyze the association between timing of ACL reconstruction and the recovery of muscle strength, return to preinjury physical activity level, and achievement of rehabilitation goals. The results of the logistic regression analysis were expressed as odds ratios (OR) for every 1-unit increase in the predictor variable (months between ACL injury and reconstruction).

Results: In total, 715 patients were included, of which 53.4% (n=383) were women. The mean age at ACL reconstruction was 28.3±10.5 years, and the median time between ACL injury to reconstruction was 4.9 months (IQR 2.9;9.4). Delayed ACL reconstruction significantly decreased the odds of returning to preinjury physical activity level at 12-months in patients with a Tegner score of 6-10 (OR 0.97 [95% CI 0.94;0.99], p=0.009) and regardless of age. Shorter median time in months from ACL injury to reconstruction was observed for patients who returned to preinjury physical activity level, especially in younger patients (16-30 years old) (3.9 [IQR 2.5;6.5] versus 4.7 [IQR 2.9;9.1], p=0.007) and in patients who participated in pivoting activities (Tegner scale 6-10) preinjury (3.4 [IQR 2.3-6.2] versus 5.0 [IQR 2.9-9.7], p<0.001).

Conclusion: Delayed ACL reconstruction reduces the odds of returning to preinjury physical activity level in patients active in pivoting activities preinjury (Tegner 6-10), and in patients regardless of age 12 months after surgery.

Level of evidence: III. Retrospective study.

Purpose: To compare the changes in labral size after primary hip arthroscopy between patients requiring revision surgery and those did not.

Methods: Data collected between August 2016 and September 2021 were retrospectively reviewed. Patients diagnosed with femoroacetabular impingement syndrome and undergoing primary and revision hip arthroscopy at our institute were included in the revision group. Exclusion criteria were Tönnis grade >1, concomitant hip conditions, and incomplete magnetic resonance imaging (MRI) data. Patients who did not undergo revision surgery or conversion to total hip arthroplasty at minimum 2-year follow-up were matched in a 1:2 ratio and included in the control group. The labral size (width and height at 11:30, 1:30, and 3:00) on MRI (noncontrast, 3.0 T) before and after 12 months of primary surgery was compared.

Results: Twenty-one patients were included in the revision group, and 42 patients were matched in the control group. In the revision group, significant reduction in labral width and height at 11:30 and 1:30, and labral width at 3:00 was observed at 12 months after primary hip arthroscopy (all with P < .05), whereas the control group did not show significant difference of changes in labral size (all with P > .05). Smaller postoperative labral width at 1:30 and 3:00 was observed in the revision group compared with the control group (all with P < .05). The revision group presented with greater reduction of labral width at all 3 positions and labral height at 1:30 compared with the control group (all with P < .05).

Conclusions: Patients requiring revision surgery after primary hip arthroscopy for femoroacetabular impingement syndrome presented with smaller postoperative labral size (less than 1 mm difference) and greater reduction of labral size (at or less than 1mm difference) on MRI 12 months after primary surgery compared with those patients that did not require later revision surgery.

Level of evidence: Level III, retrospective case control.

Hamstring pathology is both a common, and commonly missed, source of pain. Acute traumatic tears can be missed or underappreciated, and hamstring tendinopathy and partial-thickness tears are often atraumatic with insidious onset. Partial-thickness hamstring tears or tendinopathy can be underappreciated on magnetic resonance imaging or missed in conjunction with concomitant pathology. Ultrasound-guided diagnostic injections are invaluable tools when sorting through concomitant pathologic processes. If noninvasive treatment options are unsuccessful, injections and surgery are options. Corticosteroid injections have limited utility; platelet-rich plasma injections have shown promise. When surgical treatment is warranted, both endoscopic and open techniques allow for improvement. Although technically demanding, endoscopic hamstring repair allows minimally invasive access to the entirety of the ischial tuberosity, magnified viewing of the tendon structure, and the ability to visualize both the sciatic nerve as well as the posterior femoral cutaneous nerve. These latter 2 structures are most at risk. Maintaining orientation with fluoroscopy enhances arthroscopic understanding of the deep gluteal space, with the posterior aspect of the ischium acting as a safe zone from which careful surgical dissection can begin.

The purpose of this article is to evaluate the application of artificial intelligence (AI) from the perspective of the orthopaedic industry with respect to the specific opportunities offered by AI. It is clear that AI has the potential to impact the entire continuum of musculoskeletal and orthopaedic care. The following areas may experience improvements from integrating AI into surgical applications: surgical trainees can learn more easily at lower costs in extended reality simulations; physicians can receive support in decision-making and case planning; efficiencies can be driven with improved case management and hospital episodes; performing surgery, which until recently was the only element industry engaged with, can benefit from intraoperative AI-derived inputs; and postoperative care can be tailored to the individual patient and their circumstances. AI delivers the potential for industry to offer valuable augments to patient experience and enhanced surgical insights along the digital episode of care. However, the true value is in considering not just how AI can be applied in each silo but also across the patient's entire continuum of care. This opportunity was first opened with the advent of robotics. The data derived from the robotic systems have added something akin to a black box flight recorder to the operation, which now offers 2 critical outcomes for industry. First, together we can now start to stitch preoperative elements like demographics, morphological phenotyping, and pathology that can be integrated with intraoperative elements to produce surgical plans and on-the-fly anatomic data like ligament tension. Second, postoperative elements such as recovery protocols and outcomes can be considered through the lens of the intraoperative experience. In forming this bridge, AI can accelerate the development of a truly integrated digital ecosystem, facilitating a shift from providing implants to providing patient experience pathways. LEVEL OF EVIDENCE: Level V, expert opinion.

Sports-related injuries are costly to treat and have many associated intangible effects. Musculoskeletal health care professionals in rehabilitation strive to keep athletes at their peak performance with a principal focus on injury prevention. "Prevention is better than a cure" remains relevant to all athletes and nonathletes alike. In this special issue of Arthroscopy, Sports Medicine, and Rehabilitation, "Injury Prevention and Rehabilitation," which can be found at https://www.arthroscopysportsmedicineandrehabilitation.org/injury-prevention-and-rehabilitation, we bring a multifaceted approach and diverse perspectives in helping athletes and active individuals remain injury free with prevention and training strategies while optimizing performance and providing key rehabilitation strategies for common sports-related injuries.

Recurrent anterior shoulder instability with subcritical bone loss is a challenging clinical scenario. Many treatment options have been described, including arthroscopic Bankart repair, arthroscopic Bankart repair plus remplissage, open Bankart repair, and the Latarjet procedure. Arthroscopic Bankart repair alone has higher rates of failure in high-risk patient populations, especially at long-term follow-up. These high-risk populations include patients with significant glenoid bone loss (>20%), bipolar bone loss (including subcritical bone loss and off-track or "near-track" [8-10 mm] Hill-Sachs lesions), and demographic risk factors including young age, hyperlaxity, contact sports participation, and number of prior dislocations. Treatment algorithms favor arthroscopic Bankart repair plus remplissage or the Latarjet procedure for high-risk patients, but they go from "A" (arthroscopy) to "C" (coracoid transfer) and forget about "B" (open Bankart repair). Open Bankart repair has decreased in use by 65% across the United States since 2008, whereas the popularity of the Latarjet procedure has risen by 250% over the same time frame. With its reported success at long-term follow-up (1.6%-17.5% failure rates at 17-21 years), open Bankart repair must be reconsidered for properly indicated patients. Ongoing large-scale multicenter trials such as the Open Versus Arthroscopic Surgery for Shoulder Instability (OASIS) trial are looking at arthroscopic Bankart repair with or without remplissage versus open Bankart repair versus the Latarjet procedure in the setting of 10% to 20% anterior glenoid bone loss. We highly recommend open Bankart repair in contact athletes with an acute bony Bankart fracture and thoughtfully consider open Bankart repair in contact athletes with approximately 10% glenoid bone loss.

Purpose: To establish consensus statements via a modified Delphi process about ethics, transparency, regulation and best practices for the use of orthobiologics in clinical practice for musculoskeletal pathology.

Methods: A consensus process on the regulation of orthobiologics at the provider-level was conducted using a modified Delphi technique. Twenty orthopaedic surgeons, sports medicine physicians, or basic scientists participated. Each participant was a Biologic Association member organization representative and asked to participate due to their active interest in the field of orthobiologics. Levels of consensus were delineated according to the number of votes for each statement: no consensus, <80%; consensus, 80% to 89%; strong consensus, 90% to 99%; unanimous, 100%.

Results: The twenty-six consensus statements on orthobiologics resulted in 14 achieving unanimous consensus, 8 achieving strong consensus, 3 achieving consensus, and 1 did not achieve consensus. Overall, 85% of the statements reached either a unanimous or strong consensus. Of the statements regarding communication and transparency, 9 reached unanimous consensus, including information to convey and helpful tools to describe current orthobiologics, persistent misinformation, use of the word "stem cells", "off-label" use, and problems with the present regulatory environment. Five statements discussing the regulation of novel orthobiologics achieved unanimous consensus. These statements highlighted research regulation, safety, and suggested improvements to regulatory issues. The statement that did not achieve any consensus was on the regulatory processes that should be in place by an institution providing novel orthobiologic treatments. No statement reached a unanimous agreement on cost or ethical considerations.

Conclusions: This study successfully identified key consensus statements emphasizing the importance of ethics, transparency, and regulation in the use of orthobiologics, with 85% of statements reaching unanimous or strong consensus. These findings underscore the need for standardized communication, improved regulatory frameworks, and enhanced safety measures while highlighting persistent challenges in addressing cost and ethical considerations.

Level of evidence: Level V, Expert Opinion.

Purpose: To compare clinical outcomes, return-to-play (RTP) outcomes, and incidence of postoperative complications in overhead throwing athletes with SLAP lesions undergoing SLAP repair versus biceps tenodesis (BT) with minimum 1-year follow-up.

Methods: Using the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a literature search was conducted on July 9, 2024, by querying PubMed, Scopus, and EMBASE databases. Inclusion criteria consisted of Level I to IV human clinical studies reporting RTP rate, complications, and/or failure rates following SLAP repair versus BT for SLAP lesions in overhead throwing athletes with a minimum 1-year follow-up. Study quality was determined using the Methodological Index for Non-Randomized Studies criteria.

Results: A total of 16 studies from 2005 to 2023, reporting on 547 patients with a mean age ranging from 17.4 to 36.0 years and a mean follow-up ranging from 2.7 to 7.2 years, met inclusion criteria. Twelve studies (n = 459 athletes) reported outcomes following SLAP repair and 5 (n = 88 athletes) following BT. A total of 15 studies reported on baseball players, 8 on softball players, and 2 on handball players. There were 220 pitchers who underwent SLAP repair compared to 34 pitchers who underwent BT. RTP rates for all throwers ranged from 37.5% to 94.7% following SLAP repair and 35.3% to 93.1% following BT. The RTP rate for pitchers and position players following SLAP repair ranged from 40% to 80% and 76.3% to 91.3%, respectively, compared to 16.7% and 80%, respectively, following BT. Complication rates ranged from 0% to 21.8% following SLAP repair compared to 0% following BT. Failure rates and revisions ranged from 7.5% to 12.5% for SLAP repair versus 0% for BT.

Conclusions: In overhead throwing athletes with SLAP tears, an analysis of 547 patients from 16 studies shows variable RTP rates following SLAP repair and BT, with baseball pitchers having lower RTP rates compared to position players for both procedures. Outcomes for both SLAP repair and BT exhibit massive variability when treating SLAP tears in overhead throwers.

Level of evidence: Level IV, systematic review of Level III and IV studies.

Despite multiple advancements in rotator cuff repair fixation and technique that have allowed for stronger and more anatomic constructs, failure remains commonplace. As is a common theme throughout orthopaedics, both biomechanics and biology play a role in successful healing. The new frontier in tendon-to-bone healing appears to be pairing biologic augmentation, such as bone marrow aspirate concentrate (BMAC), with previous biomechanical advancements. However, only 8 studies have specifically investigated the utility of BMAC in rotator cuff repair, and as of yet, there are minimal data to suggest that recent biologic technologies have shown clinical effectiveness. The technology has been more comprehensively studied in knee arthritis with similarly disappointing clinical results. Rotator cuff repair outcomes are dependent on many factors inherent to the injury (e.g., chronicity, bone quality, tendon quality, retraction), the patient (e.g., age, smoking, diabetes, adherence to postoperative protocol), and the surgeon (e.g., quality of technique, repair tension, patient education). Trying to decide the efficacy of BMAC or other cell-based technology is going to be very difficult.