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

Medial meniscus posterior root tears, which may account for up to one fifth of meniscal tears, often go undiagnosed or mistreated, contributing to substantial morbidity. They can be detected on magnetic resonance imaging by the classic "ghost sign" on sagittal sequences-the absence of an identifiable dark meniscus or presence of high signal in place of the normal dark appearance of the meniscus. These tears result in a dramatic impairment in hoop stress force transmission and have been shown to have a similar effect as a subtotal medial meniscectomy, resulting in rapid joint degeneration and an increased risk of early joint replacement. While medial meniscus root repair affords the opportunity to restore meniscus function, failure rates remain high, which shows the need to further refine patient selection, surgical techniques, and rehabilitation strategies to improve outcomes.

Strategies to minimize damage to the iliofemoral ligament in hip arthroscopy for the treatment of femoroacetabular impingement syndrome have spawned increased curiosity among sports surgeons. Gone are the days when a large T-type capsulotomy or even capsulectomy is performed without some closure. Consensus to repair interportal capsulotomies seems strong. Under scrutiny now is whether the same rules apply to smaller periportal capsulotomies. If we continue to abide by our principles to respect anatomy and restore biomechanical properties, then capsular preservation should be upheld, especially in patients who need it the most.

Purpose: To compare adverse events, secondary surgery rates, opioid prescriptions, and medical resource utilization between patients undergoing hip arthroscopy with fibromyalgia and a propensity-matched control group without fibromyalgia.

Methods: A retrospective review of the TriNetX national database identified patients who underwent hip arthroscopy between October 2015 and July 2023 with a preoperative fibromyalgia diagnosis. Propensity 1:1 matching was performed with controls who underwent hip arthroscopy without fibromyalgia. Postoperative adverse events, medical service utilization, opioid prescriptions, and secondary surgery rates were compared within 90 days, 1 year, and/or 2 years using Mann-Whitney U and χ² tests.

Results: A total of 755 patients with fibromyalgia were matched to 755 controls. Mean age was similar (41.5 ± 10.7 vs 41.4 ± 11.6 years, P = .813), with comparable female representation (78.7% vs 78.4%, P = .900). No significant differences were found in revision arthroscopy (odds ratio [OR] 0.91, 95% confidence interval [CI]: 0.68-1.21, P = .502) or conversion to total hip arthroplasty (OR 1.07, 95% CI: 0.65-1.76, P = .798) within 2 years. Patients with fibromyalgia had higher odds of opioid prescription within 90 days (OR 1.56, 95% CI: 1.27-1.91, P < .001) and 1 year (OR 1.41, 95% CI: 1.15-1.74, P < .001) postoperatively. Rates of adverse medical events, mean prescriptions per patient (among those prescribed), secondary surgeries, and medical service utilization did not differ.

Conclusions: Contrary to the initial hypothesis, fibromyalgia was not associated with increased risk of postoperative adverse events, medical service utilization, revision surgery, or conversion to total hip arthroplasty after hip arthroscopy compared to the matched control. However, patients with fibromyalgia had significantly higher odds of receiving opioid prescriptions within both 90 days and 1 year postoperatively. Among those prescribed opioids, the mean number of prescriptions per patient did not differ significantly between cohorts.

Level of evidence: Level III, retrospective comparative case series.

Purpose: To present outcomes of patients who underwent arthroscopic biologic tuberoplasty (ABT) and evaluate differences in outcomes based on sex, Hamada grade, concomitant procedures, and length of follow-up with a minimum of 1-year follow-up.

Methods: Patients who underwent ABT between 2015 and 2022, with a minimum 1-year follow-up, were identified. Inclusion criteria were: (1) massive, irreparable rotator cuff tears, (2) active forward elevation >90⁰, (3) intact or reparable upper border subscapularis tear, and (4) Hamada 1 to 3. ABT was performed with a 3- mm-thick dermal allograft. American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and Visual Analog Scale for pain were recorded.

Results: Fifty patients (68% males) met the inclusion criteria. Mean follow-up was 22.9 ± 15.7 months (range: 12-109 months). The mean age was 64.8 ± 8.1 years (range: 46-79 years). There was a significant improvement in ASES (37.4 ± 14.1-85.8 ± 10.5, P < .0001), SANE (36.3 ± 16.7-83.5 ± 10.1, P < .0001), and Visual Analog Scale for pain (7.2 ± 1.8-1.4 ± 1.9, P < .0001). There was no significant difference in mean postoperative ASES based on sex (P = .6623), Hamada grade (P = .1098), and isolated ABT versus those with concomitant procedures (P = .1087). In addition, there was no difference in postoperative ASES between patients who had 1-year follow-up, those with 1 to 2 years follow-up, and those with >2 years follow-up (P = .3887). Minimal clinically important difference, substantial clinical benefit, and patient acceptable symptomatic state for ASES were 100%, 96%, and 80%, respectively, for SANE were 96%, 78%, and 46%, respectively, and for Visual Analog Scale were 98%, 84%, 92%, respectively. The maximal outcome improvement for ASES was 77.4 and for SANE was 74.1.

Conclusions: Excellent clinical outcomes can be achieved in patients undergoing ABT with significant functional improvement and pain reduction in patients with massive, irreparable rotator cuff tears. These outcomes can be equally achieved in males and females, and in shoulders that are Hamada 1 to 3. Outcomes of patients with >2 years follow-up were similar to those with 1-year follow-up and 1 to 2 years follow-up.

Level of evidence: Level IV, retrospective case series.

Purpose: To evaluate the in vivo biomechanical effects of periportal capsulotomies, single (modified anterior portal [MAP]) portal repair, and complete (MAP + anterolateral portal [ALP]) repair on altering the resistance to axial distraction compared to the native state (i.e., precapsulotomy).

Methods: Consecutive patients undergoing primary hip arthroscopy with periportal capsulotomies received intraoperative axial distraction testing at 0, 50, and 100 pounds of force (lbf). Patients were excluded if they did not break their suction seal with 100 lbf. Distraction testing was performed prior to capsulotomy (native), postcapsulotomy, after repair of just the MAP (partial repair), and after repair of both the MAP and ALP (complete repair). Distraction distances were calculated in millimeters (mm) as the difference in joint space between 0 and 50 or 100 lbf on intraoperative fluoroscopy from the lateral sourcil edge of the acetabulum to the femoral head. Repeated measures analysis of variance and Bonferroni-corrected P values were used for comparison.

Results: Eighty-six patients were included (58% female; mean age, 33.6 ± 11.7 years). There was a significant increase in distraction distance in the unreparied capsulotomy state compared to the native state at 100 lbf (1.14 [0.33-1.96] mm, P = .03). After partial and complete repair, the distraction distance was significantly decreased compared to the native state at 100 pounds of traction by 1.09 mm (0.28-1.90, P < .001) and 2.84 mm (2.09-3.59, P < .001), respectively. In a subgroup analysis, males also had a substantial decrease in distraction distance with MAP closure alone compared to the native state at 100 lbf (1.33 [0.32-2.35] mm, P = .04), whereas females did not (0.92 [0.09-1.75] mm, P = .19).

Conclusions: The periportal capsulotomy causes a significant increase in hip distractibility compared to the native state, and both partial and complete capsular repair restore distraction resistance to levels at or greater than the native state.

Level of evidence: Level IV, retrospective case series.

Purpose: To evaluate outcomes of endoscopic isolated gluteus medius (GM) repairs at minimum 5-year follow-up with a secondary comparison between short- and mid-term functional outcomes.

Methods: Prospectively collected data were retrospectively analyzed for all patients who underwent endoscopic GM repairs between May 2009 and December 2018. Included patients had completed preoperative and minimum 5-year questionnaires for at least one patient-reported outcome (PRO) measure: the modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), International Hip Outcome Tool (iHOT-12), Visual Analogue Scale (VAS), and patient satisfaction. Patients who were deceased or had revision surgeries were also included. The minimal clinically important difference (MCID) was calculated using a distribution-based method for all PROs and included in the analysis. A durability comparison between the mentioned PRO scores between 2- and 5-year postoperative was performed. Complications and secondary surgery were reported.

Results: Of 31 eligible hips, 26 hips (83.87%) were included in this study and demonstrated significant mean improvements in all evaluated PROs (mHHS from 54.67 to 80.75, NAHS from 58.88 to 84.38, iHOT-12 from 32.96 to 72.16, and VAS from 5.85 to 2.93, P < .01), with high patient satisfaction reported. Moreover, a high percentage of patients had delta values that met MCID for mHHS (82.35%), NAHS (82.35%), and iHOT-12 (80.00%). Score improvements were sustained from 2 to 5 years across all PROs, with continued improvement in mHHS seen at the 5-year timepoint. Three hips (11.54%) underwent secondary surgery, all of which had full-thickness or high-grade partial-thickness (>50%) GM tear at the time of the primary endoscopic GM repair.

Conclusions: Endoscopic GM repairs yield significant improvement in functional PROs at 5-year minimum follow-up with a high percentage of patients meeting clinically relevant thresholds. Moreover, patients showed continued improvement over time, with score enhancements observed from 2 to 5 years postsurgery. An 88.46% revision-free survival rate was observed, with all revision endoscopies being females who had high-grade to full-thickness GM tears.

Level of evidence: Level IV, retrospective case series.

Purpose: To evaluate the isolated and combined biomechanical effect of suture retensioning and the addition of a posteroinferior (PI) anchor during Bankart repair.

Methods: Ten fresh-frozen cadaveric shoulders (age, 61.3 ± 5.1 years; sex, 90.0% males) were tested in the present study. After preconditioning, Bankart lesions were created, and each shoulder underwent 4 different repair states using knotless soft body anchors: (1) 3-anchor Bankart repair (5:30, 4:30, and 3:30 o'clock), (2) 4-anchor Bankart repair with a PI anchor (6:30 o'clock), (3) 3-anchor Bankart repair with suture retensioning, and (4) 4-anchor Bankart repair with a PI anchor and suture retensioning. Repair sutures were passed through 1 cm of capsulolabral tissue and tensioned to 50 N. Retensioning of each suture was performed to 50 N twice. Stiffness and elongation were evaluated before and after 100 cycles of cyclic loading to 25 N.

Results: Stiffness after cyclic loading was highest in the 4-anchor Bankart repair with suture retensioning and was significantly stiffer than the 3-anchor and the 4-anchor Bankart repair (P = .013 and .040, respectively). It was not significantly stiffer than the 3-anchor Bankart repair with suture retensioning (P > .127). Elongation after cyclic loading was lowest in the 4-anchor Bankart repair with suture retensioning and was significantly lower than the 3-anchor and 4-anchor Bankart repair (P = .042 and .020, respectively). It was not significantly different than the 3-anchor Bankart repair with suture retensioning (P > .232).

Conclusions: The addition of suture retensioning and a PI anchor to the Bankart repair showed a modest increase in stiffness and a reduction in elongation after cyclic loading.

Clinical relevance: Adding both suture retensioning and a PI anchor to the Bankart repair may decrease the risk for instability recurrence.

Purpose: To report the 2-year clinical and radiological outcomes of arthroscopic distal tibial allograft (DTA) reconstruction with labral repair, with or without remplissage for restoring glenoid bone loss in traumatic anterior shoulder instability.

Methods: Between March 2019 and February 2022, patients undergoing arthroscopic DTA reconstruction, performed by 3 fellowship-trained surgeons across 3 centers, were recruited to participate in this study. All patients had some degree of glenoid bone loss and recurrent traumatic anterior shoulder instability. Clinical and radiological outcomes included Western Ontario Stability Index, American Shoulder and Elbow Surgeons, and range of motion preoperatively and at 3, 6, 12, and 24 months postoperatively. Patients underwent computed tomography scanning at 6 months to determine graft union and position.

Results: Thirty-two patients were enrolled into the study (24 males, 8 females). Mean preoperative glenoid bone loss was 19.5% (standard deviation [SD] 6.3%, range 10%-34%). Seven of thirty-two patients underwent a remplissage procedure in addition to the labral repair and distal tibia allograft reconstruction. Compared to baseline, outcome scores improved to 2 years postoperatively (mean Western Ontario Stability Index 37.4% [SD 14.9] to 81.7% [SD 14.1]; mean American Shoulder and Elbow Surgeons score 60 [SD 19] to 92.3 [SD 7.6]). Mean forward elevation returned to normal by 2 years. The mean deficit in external rotation at 2 years was 7° (SD 13°) compared to the contralateral side. Thirty-one patients had computed tomography scans at 6 months to confirm healing and graft position. Partial or full graft healing at 6 months was 94%. In the axial plane, grafts were a mean 12.9° (SD 13.0°) to the native glenoid face and translated a mean 0.8 mm (SD 2.4) medial to the anterior glenoid rim. In the sagittal plane, the graft was positioned 1.6 mm (SD 2.1) superior to the midpoint of the native glenoid defect. One patient experienced an subluxation event postoperatively without further instability. Another required revision to Latarjet procedure. There were no perioperative complications.

Conclusions: Arthroscopic DTA bone block glenoid reconstruction using 2 pairs of suture buttons to treat recurrent traumatic anterior instability with significant bone loss yields improved clinical and acceptable radiological outcomes.

Level of evidence: Level IV, retrospective case series.

Purpose: To evaluate the anti-inflammatory and disease-modifying potential of bone marrow aspirate concentrate (BMAC) and amniotic suspension allograft (ASA) in a chondrocyte and synovium coculture model of osteoarthritis.

Methods: Seventeen patients were enrolled for cartilage, synovium, and bone marrow aspirate tissue donation prior to a total knee arthroplasty. Cartilage and synovium explants were cocultured into four different groups: one baseline group, one control group (96-hour coculture), BMAC group, and ASA group. Interleukin-1β (IL-1β), interleukin-6 (IL-6), and tumor necrosis factor-alpha (TNF-α) were measured at 96 hours in the media with enzyme-linked immunosorbent assay. Collagen type 1 α 1, Collagen type 2 α 2, Collagen type 3 α 1, aggrecan, and Cartilage Oligomeric Matrix Protein were measured in the cartilage and synovium by reverse transcription polymerase chain reaction. Safranin-O staining were performed on all groups and scored by the modified Mankin scoring system.

Results: Samples treated with ASA showed a significantly lower concentration of IL-1β when compared to control samples (11.2 ± 13.9 vs 20.2 ± 39.5 pg/mL, P = .04). Treatment with BMAC was associated with a significantly lower concentrations of IL-6 when compared to control samples (607.32 ± 271.07 vs 767.11 ± 30.84, P = .02). No significant differences were observed in gene expression within chondrocytes and synoviocytes or for Mankin scoring between treatment and control groups.

Conclusions: Osteoarthritic chondrocytes and synovial tissue may respond to BMAC and ASA by a reduction in IL-1β and IL-6 concentrations, but short-term cytokine responses are variable. The mechanism of response remains unknown.

Clinical relevance: This study aims to reveal the mechanism of BMAC and ASA by which these biologics function in a model of an arthritic joint.