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

The fragility index (FI) is statistical significance in a costume. Perhaps attractive and amusing, but behind the mask it's nothing more than spin, dichotomizing results as "statistically significant" versus "not". In the medical literature, we must stop dichotomizing and start measuring the magnitude of effect and the uncertainty in this estimate. Statistical significance is thought stifling. Yet, it is the tool with which the medical research community has been provided. No wonder we dichotomize results; we've been encouraged to do so. The question is, "Will we recognize the folly in this exercise and move on to more critical questions of relevance and accuracy of published research?" The FI is heralded as a metric that provides insight beyond statistical significance. Rather than provide a measure of uncertainty, which is what fragility implies, it quantifies the number of patients needed to produce a p-value that's greater than 0.05. Unfortunately, while well intended the FI is not a surrogate for robustness of clinical trial data, nor the underlying statistical analysis. In contrast, reporting and interpreting a confidence interval more effectively provides a sense of uncertainty. While far from perfect, the confidence interval provides a range of values that are compatible with the observed study data. This makes the uncertainty of the data transparent. Advancing our understanding of the data starts with stepping away from statistical significance.

As a result of research supporting meniscus preservation, evidence shows that internationally, there has been a rise in rates of meniscus repair, especially in younger population, and a decline in rates of partial meniscectomy. The decline in partial meniscectomy has been rather rapid and has outpaced the rise in meniscal repair, likely due to increasing evidence against routine partial meniscectomy in degenerative tears with coexistent arthritis. However, despite the rise in meniscus repair, close to 95% of meniscus surgeries are still partial meniscectomies. The partial meniscectomy to meniscus repair ratio seems to be rather high. Optimistically, this will improve because successful repair outcomes have been demonstrated in situations previously considered "high-risk," including complex patterns, central tears, radial tears, and root and ramp tears. This may be due to multiple factors, many of which may be beyond the control of surgeons, including the fact that as many as 25% of repairs fail to heal. Yet, with improved techniques and instrumentation, the success rate of repair is improving. The cost of repair may be a limiting factor, especially in low-income countries with poor health insurance penetration and unfavorable reimbursement of repair cost. Every effort must be made to repair a tear, which has potential to heal.

When performing lateral extra-articular procedures (LEAPs) at the time of anterior cruciate ligament (ACL) reconstruction, it is essential to be aware of the possibility of tunnel collision and understand strategies to avoid it. The risk of tunnel collision is high, especially if an anteromedial portal ACL femoral tunnel is drilled. Tunnel collision can be avoided by using a single femoral tunnel for both procedures, outside-in femoral tunnel drilling to place the ACL tunnel a safe distance away from the LEAP, and cortical fixation techniques. Other strategies that have been explored have included anteromedial portal drilling in low degrees of flexion, anterior angulation of LEAP tunnels, and the use of an "anterior Lemaire" position. These alternative strategies are not preferred because they are associated with an increased risk of iatrogenic injuries to important posterolateral structures, penetration of trochlea articular cartilage, and overconstraint, respectively.

Purpose: To systematically review the current evidence to compare the differences in outcomes of suture button (SB) versus hook plate (HP) fixation for treating acute Rockwood type III acromioclavicular joint (ACJ) dislocation.

Methods: Two reviewers independently conducted a literature search based on the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. PubMed, Embase, MEDLINE, and the Cochrane Library were systematically searched for studies comparing SB and HP in the treatment of acute Rockwood type III ACJ dislocation. Constant score, visual analog scale (VAS) score, coracoclavicular distance, operation time, and occurrence of complications were assessed. Risk of bias was assessed using The Cochrane Collaboration and Risk Of Bias In Non-randomized Studies-of Interventions tools.

Results: A total of 16 studies were included, consisting of 2 randomized controlled trials and 14 non-randomized controlled trials, with 471 patients in the SB group and 445 patients in the HP group. Among the included studies that reported patient-reported outcomes, 4 indicated significantly higher Constant scores in the SB group compared with the HP group whereas the remaining 5 found no difference between the groups. Among the 5 included studies that reported VAS scores, 2 showed statistically significant differences favoring the SB group. Among the 10 included studies that reported operation time, 3 found a shorter operation time in the SB group than in the HP group whereas 2 indicated a longer operation time for SB surgery compared with HP treatment. However, there was no statistically significant difference in coracoclavicular distance or the incidence of complications between the 2 groups.

Conclusions: The evidence suggests no clear clinical superiority of SBs over HPs in treating acute Rockwood type III ACJ dislocations. Whereas some studies show that SB treatment may offer benefits such as higher Constant scores and lower VAS scores, most outcomes reveal no significant differences. LEVEL OF EVIDENCE: Level Ⅲ, systematic review of Level II and Ⅲ studies.

The InSpace subacromial balloon spacer (Stryker, USA) is indicated for the treatment of massive irreparable rotator cuff tears. The device is placed in the subacromial space with the aim of restoring shoulder function by limiting painful acromiohumeral contact and recentering the superiorly migrated humeral head. However, controversy exists because two randomized controlled trials have produced conflicting findings with regards to efficacy. These findings, along with narrow indications have led to low utilization of the balloon amongst European and Latin American Surgeons. The controversy generated by conflicting RCTs poses challenges in the interpretation of cost effectiveness especially when the role of the balloon amongst a plethora of other options including superior capsule reconstruction (either with long head of biceps or dermal allograft), graft augmentation, tendon transfer, biologic tuberoplasty, acromial resurfacing, and reverse shoulder arthroplasty is not well defined. However, it is my opinion that the balloon has particular value in older, low-demand patients, in whom severe co-morbidities make a shorter surgical duration and quicker recovery appealing.

Purpose: To better define the rate of return to work in patients undergoing Latarjet surgery for anterior shoulder instability.

Methods: A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed, Cochrane Center Register of Controlled Trials, and Scopus were queried in October 2023 with the following keywords: ((latarjet) OR (anterior shoulder instability)) AND ((work) or (compensation)). Articles were included if they reported return to work in patients (including military members) undergoing Latarjet surgery for traumatic anterior shoulder instability with bone loss and were written in English. This study was registered in Prospero (ID blinded).

Results: Six studies reporting on 419 shoulders were included in the review. Five studies reported on patients in the general population, and 1 reported on military members. Mean age ± standard deviation of patients ranged from 23.1 ± 5.8 to 32.0 ± 12.3 years. Moreover, there were 286 primary Latarjet procedures, 131 revision Latarjet procedures, and 2 unspecified as primary or revision surgery. Mean glenoid bone loss ranged from 14.5% to 22.9%. Return-to-work rates ranged from 89.1% to 100%, with 2 studies reporting all patients were able to return to work. Among military members, 89.1% were able to return to duty. Mean time to return to work ranged from 8.69 to 34.8 weeks after surgery. Four studies also reported return to sport, which ranged from 60.9% to 100%. Mean time for returning to sport varied between 10.0 and 35.2 weeks after the Latarjet procedure.

Conclusions: Patients with anterior shoulder instability who undergo an arthroscopic or open Latarjet procedure can expect high rates of return to work and sport. All studies reported return-to-work rates over 89%, with 89.1% of military members able to return to duty.

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

Purpose: The aim of this study is to assess the statistical fragility of randomized controlled trials that assess the use of platelet rich plasma (PRP) for the treatment of knee osteoarthritis (OA) and report a continuous primary outcome measure with statistical significance.

Methods: A systematic electronic search of MEDLINE, EMBASE, and Cochrane database was performed on July 26, 2023. All randomized controlled trials addressing the use of PRP for the treatment of symptomatic knee osteoarthritis were included that reported statistically significant primary continuous outcomes. The continuous fragility index (CFI) and continuous fragility quotient (CFQ) was calculated using approximative method as previously described using the mean and standard deviation of the outcomes of interest.

Results: There was a total of 34 eligible outcomes for analysis. The overall median CFI across all included studies was 5.7 (IQR, 4.8 - 9.9). The overall median CFQ across all included studies was 0.131 (IQR, 0.055 - 0.243). Loss to follow-up was greater than the CFI in only 3 of 34 eligible outcomes (8.8%). The most analyzed outcome was the WOMAC total score (n=9) with a median CFI of 6.6 and median CFQ of 0.250. The outcome with the highest median CFI was the WOMAC stiffness subscale at 93. Spearman correlation analysis demonstrated a non-statistically significant trend towards decreasing CFI (-0.497) and a statistically significant decrease in CFQ (-0.681, p = 0.03) with increasing grades of osteoarthritis.

Conclusion: The was an overall median CFI of 5.7 and CFQ of 0.131 for RCTs that report statistically significant continuous outcomes for the use of PRP for symptomatic knee OA. Although there are no current guidelines regarding statistical fragility of continuous outcomes, these results can be considered fragile given statistical significance may be reversed with only a few changes in patient outcomes.

Level of evidence: 2; systematic review of Level I and II studies.

Purpose: The aims of this systematic review were to determine (1) which criteria are used to determine return to sport (RTS), (2) the number of patients that are unable to RTS following any superior labral pathophysiology treatment and (3) which reasons are reported for not returning.

Methods: A systematic review was performed across 5 databases, including studies that report rates for RTS following any treatment of superior labral pathophysiology. Study quality was assessed using the MINORS criteria. Definitions for nRTS were extracted as reported in the studies. The ranges of no return to sport (nRTS) and no return to pre-injury level (nRTPL) were summarized. Reasons for nRTS and nRTPL were categorized using a predefined coding scheme.

Results: Among 45 studies with level of evidence ranging from II to IV, 1857 patients were involved in sports, 78% (n=1453) of whom underwent superior labral reattachment, 21% (n=381) biceps tenodesis, and 9.4% (n=175) non-operative treatment. None of the studies provided criteria for RTS and two studies provided criteria for return to pre-injury level (RTPL). The ranges of nRTS and nRTPL varied following superior labral reattachment (0-60%, n=206; 0-89%, n=424, respectively), biceps tenodesis (0-25%, n=43; 3,8-48%, n =78) and nonoperative treatment (11-75%, n=62; 18-100%, n=78). Reasons for nRTS and nRTPL were related to physical sensations (pain, feeling of instability, discomfort, weakness, lack of motion), psychological factors (fear of reinjury, lack of confidence), personal factors (lifestyle change, social reasons) and injury at another site.

Conclusion: Criteria for determining successful RTS and RTPL following superior labral pathophysiology treatment were not reported by the majority of studies. The nRTS and nRTPL rates varied greatly within and between treatments. The reasons for this unsuccessful return were diverse and related to physical sensations, psychological factors, personal factors and injury unrelated to treatment.

Level of evidence: Level IV; Systematic Review.