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

Purpose: To systematically review factors affecting hip capsule thickness.

Methods: The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The terms "hip," "arthroscopy," "capsule," "capsular," and "thickness" were used to search the PubMed, Ovid [MEDLINE], Cochrane Database, and EMBASE databases from inception to January 15, 2024.

Results: The initial search identified 1,735 studies. Twenty-three studies were included in the systematic review. Eight reported the relationship between sex and capsule thickness. Seven reported that capsule thickness was significantly lower in women. Of the 4 studies reporting the relationship between capsular laxity and capsule thickness or Beighton test score (BTS), 4 studies showed the association of lower capsule thickness in patients with capsular laxity or BTS ≥4. Of the 6 studies reporting the relationship between arthroscopic surgery and capsular thickness, 2 showed significantly greater capsule thickness after capsulotomy with repair and 2 found significantly decreased postoperative capsule thickness without repair. One study illustrated that anterior capsule thickness was significantly smaller in patients with femoral torsion angle >20°. One study showed that neck-shaft angle was negatively corelated with anterior capsule thickness. Of the 3 studies that examined lateral central edge angle, 2 reported that lower angle correlated with thinner capsule thickness; one study reported the opposite result. Hip inflammatory disease was associated with thicker hip capsule.

Conclusions: Female sex, capsular laxity, BTS ≥4, greater femoral torsion angle, and greater neck-shaft angle were associated with a thinner hip capsule. Hip inflammatory disease and capsule repair after arthroscopic surgery were associated with a thicker capsule.

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

Purpose: To evaluate the diagnostic utility of measuring the maximum thickness of the medial meniscus (MTMM) for detecting medial meniscus posterior root tear (MMPRT).

Methods: This retrospective study evaluated patients with medial meniscus (MM) injuries who underwent arthroscopic procedures between January 2018 and February 2024. Patients with concomitant lateral meniscal injuries, ligament injuries, or a history of knee trauma were excluded. MTMM was measured as the maximum vertical length in the coronal plane, identified by systematically measuring all slices using digital calipers on proton density-weighted fat-suppressed magnetic resonance imaging sequences. A reference group consisted of anterior cruciate ligament reconstruction patients with no meniscal injuries confirmed during arthroscopy. Statistical analyses were performed to examine the relationships between MTMM and meniscal injury patterns.

Results: The study included 35 MMPRT patients (mean age, 56.9 years), 138 other MM injuries (51.8 years), and 60 reference patients undergoing anterior cruciate ligament reconstruction (28.4 years). MTMM was significantly greater in the MMPRT group compared to other MM injuries (10.7 ± 1.5 mm vs 8.1 ± 1.4 mm, P < .05) and intact medial meniscus (7.1 ± 0.9 mm, P < .05). Receiver operating characteristic analysis identified an optimal cutoff value of 10.05 mm (sensitivity, 77.1%; specificity, 92.8%; area under the curve, 0.906). Based on this analysis, MTMM >10 mm was designated as the "thickened meniscus sign." Twenty-seven of 35 MMPRT cases showed a positive thickened meniscus sign, while no cases in the reference group exceeded this threshold.

Conclusions: MTMM was significantly greater in MMPRT cases compared to other MM injuries. The thickened meniscus sign (MTMM >10 mm) had high diagnostic performance with 92.8% specificity, providing a simple and reliable screening tool for MMPRT detection.

Level of evidence: Level Ⅲ, retrospective diagnostic study.

Purpose: This propensity-matched cohort study aimed to determine if adding adductor canal block (ACB) to local infiltration analgesia (LIA) reduces immediate postoperative opioid use in anterior cruciate ligament (ACL) reconstruction and assess variations based on graft type.

Methods: This retrospective study analyzed ACL reconstructions performed from 2019 to 2021. Patients were included if they received either LIA alone or a combination of LIA and ACB. Patients were propensity-matched based on demographic and surgical factors, and perioperative opioid consumption was assessed. Subgroup analysis was conducted based on autograft type (hamstring, quadriceps tendon, and bone-patellar tendon-bone).

Results: No significant differences were observed in intraoperative, postanesthesia care unit, or total perioperative opioid consumption between the ACB + LIA group (27.76 ± 14.01 mg) and the LIA-only group (28.58 ± 12.56 mg). This finding was consistent across all autograft types. However, in the hamstring autograft subgroup, the addition of ACB led to a statistically significant reduction in postanesthesia care unit opioid consumption (30.99 vs 26.45 mg, P = .039), although this difference was not deemed clinically significant. Additionally, the ACB + LIA group experienced a significantly longer mean time to discharge (495 ± 113 minutes) compared to the LIA-only group (463 ± 116 minutes; P = .017).

Conclusions: Our findings suggest that adding ACB to LIA does not provide additional opioid-sparing benefits in ACL reconstruction, except in patients with hamstring grafts, where the difference observed may not be of clinical significance. The increased discharge time with ACB highlights the need to balance benefits with operational efficiency.

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

Purpose: To evaluate the accuracy of suggestions given by ChatGPT and Gemini (previously known as "Bard"), 2 widely used publicly available large language models, to evaluate the management of rotator cuff injuries.

Methods: The 2020 American Academy of Orthopaedic Surgeons (AAOS) Clinical Practice Guidelines (CPGs) were the basis for determining recommended and non-recommended treatments in this study. ChatGPT and Gemini were queried on 16 treatments based on these guidelines examining rotator cuff interventions. The responses were categorized as "concordant" or "discordant" with the AAOS CPGs. The Cohen κ coefficient was calculated to assess inter-rater reliability.

Results: ChatGPT and Gemini showed concordance with the AAOS CPGs for 13 of the 16 treatments queried (81%) and 12 of the 16 treatments queried (75%), respectively. ChatGPT provided discordant responses with the AAOS CPGs for 3 treatments (19%), whereas Gemini provided discordant responses for 4 treatments (25%). Assessment of inter-rater reliability showed a Cohen κ coefficient of 0.98, signifying agreement between the raters in classifying the responses of ChatGPT and Gemini to the AAOS CPGs as being concordant or discordant.

Conclusions: ChatGPT and Gemini do not consistently provide responses that align with the AAOS CPGs.

Clinical relevance: This study provides evidence that cautions patients not to rely solely on artificial intelligence for recommendations about rotator cuff injuries.

Purpose: To conduct a systematic review evaluating subjective patient-reported outcomes, reoperations, and graft failure after concomitant osteochondral allograft (OCA) transplantation and meniscal allograft transplantation (MAT).

Methods: A literature search was performed by querying the MEDLINE, Embase, and PubMed databases according to the 2020 Preferred Reporting Items for Systematic Reviews and Meta-analyses statement. The inclusion criteria were limited to peer-reviewed, English-language, Level I to IV studies with at least 10 patients that reported clinical outcomes and complications after OCA transplantation with concomitant MAT for osteochondral defects and meniscal deficiency with minimum 2-year follow-up. For most of the included studies, failure was defined as conversion to arthroplasty, revision OCA, or graft failure on postoperative imaging.

Results: Six studies with a total of 188 patients met the inclusion and exclusion criteria. The mean patient age was 32.4 years (range, 15-66 years). Improvement in the following outcome scores was observed across all included studies from preoperatively to postoperatively: Lysholm knee score (+21 to +26.69); International Knee Documentation Committee Subjective Knee Form score (+19 to +26.55); Knee Injury and Osteoarthritis Outcome Score (KOOS) Pain subscale (+17.91 to +26), KOOS Symptom subscale (+9 to +18.16), KOOS Activities of Daily Living subscale (+11.91 to +23.4), KOOS Sport subscale (+19 to +26.04), KOOS Quality of Life subscale (+22 to +35.01), 12-Item Short Form Survey physical score (+5 to +12.26), and 12-Item Short Form Survey mental score (+1.8 to +4) (P < .05 for all). The reoperation rate was between 6.7% and 54%. The failure rate was between 13% and 22.9%. Although patient satisfaction data were only available in 2 studies, 82% to 90% of patients would choose to undergo OCA transplantation with MAT again.

Conclusions: OCA transplantation with concomitant MAT for the treatment of focal chondral defects in the presence of meniscal deficiency results in improved patient-reported outcome measures with high patient satisfaction rates. The mean reoperation rate and failure rate at a mean follow-up time of 4.7 years are 37.3% and 17.1%, respectively, which are expected and consistent with the existing literature on isolated procedures.

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

Purpose: To explore the healing status of interportal capsulotomies without repair after arthroscopy in patients with femoroacetabular impingement syndrome (FAIS), and to examine its correlation with clinical outcomes, including the relationship with age and gender subgroups.

Methods: Data collected between August 2015 and January 2022 were reviewed. Patients with FAIS aged 18-65 years who underwent hip arthroscopy with interportal capsulotomies without repair with a minimum 2-year follow-up were included. Patients with a lateral center-edge angle (LCEA) of less than 25°, a Tönnis grade of greater than 1, Perthes' disease, slipped upper femoral epiphysis, avascular necrosis, prior ipsilateral hip injury or surgery, and absence of magnetic resonance imaging (MRI) at final follow-up were excluded. Patients were divided into healed and unhealed capsular groups according to MRI evaluation. The primary patient-reported outcomes (PROs) were the modified Harris Hip Score (mHHS). The secondary PROs were the Hip Outcome Score-Activity of Daily Living Scale (HOS-ADL), Hip Outcome Score-Sport Specific Subscale (HOS-SSS), University of California at Los Angeles (UCLA) score, and visual analog scale (VAS) for pain at final follow-up. The percentages of patients achieving the minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) for the PROs were also calculated.

Results: The cohort comprised 69 patients (72 hips), with 28 hips (38.89%) in the unhealed capsular group and 44 (61.11%) in the healed capsular group. The cohort comprised 32 male and 37 female patients and the mean age of these patients was 44.15 years. Within each group, there were significant pre- to postoperative increase in the mHHS, HOS-ADL, HOS-SSS, UCLA score, and decrease in VAS for pain (all P < .001). There were no significant differences between the healed and unhealed groups in the PROs and the achievement rates of the MCID and PASS (all P > 0.05). In addition, compared with healed group, the age over 40 years (P = 0.003) or female groups (P = 0.036) showed worse mHHS in unhealed group, respectively.

Conclusion: At a minimum 2-year follow-up, 38.89% of patients with FAIS who underwent arthroscopic surgery with inter-portal capsulotomy without repair had unhealed hip capsules. There were no significant differences in PROs, achieving rates of MCID and PASS between the healed and unhealed groups. Subgroup analysis showed age over 40 years old, female may be associated with worse efficacy in unhealed patients.

Study design: Level III, retrospective case-control study.

Purpose: To investigate the efficacy of exosomes derived from dermal fibroblasts (DF-Ex) on bone-to-tendon interface (BTI) healing in a chronic rotator cuff tear (RCT) model of rabbit.

Methods: After extraction of DF-Ex, the characterization of DF-Ex was identified in the in vitro study. In the in vivo experiment, 48 rabbits were randomly allocated into 3 groups. To create chronic RCT models, transected tendons were left untreated for 6 weeks and then were repaired in a transosseous manner. Different materials were injected into repair site according to the allocated group (group A: saline, group B: fibrin glue only, group C: DF-Ex with fibrin glue; n = 16 for each). Genetic and immunofluorescence analyses were conducted at 4 weeks post-surgery. Furthermore, genetic, histologic, and biomechanical analyses were conducted at 12 weeks post-surgery.

Results: In vitro analyses revealed the exosomal marker proteins CD9, CD63, and ALIX were positively expressed in DF-Ex, whereas negative control Calnexin was nearly absent. In vivo analyses showed that group C had the highest mRNA expression levels of COL1A1, COL3A1, and ACAN among all groups (P < .001, P = .007, and P = .002, respectively) at 4 weeks postsurgery. Meanwhile, there were more preliminary fibrocartilaginous matrix (aggrecan+/collagen II+) formation in group C. At 12 weeks postsurgery, group C had better collagen fiber continuity and orientation, denser collagen fibers, more mature bone-to-tendon junction, and greater fibrocartilage layer formation compared with the other groups (all P < .05). Moreover, group C also had greater load-to-failure value (53.3 ± 6.1 N/kg, P < .001).

Conclusions: Topical DF-Ex administration effectively promoted BTI healing by upregulating the COL1A1, COL3A1, and ACAN mRNA expression levels at an early stage and enhancing the structural and biomechanical properties at 12 weeks after surgical repair of a chronic RCT model of rabbit.

Clinical relevance: The study could be a transitional study to investigate the efficacy of DF-Ex on BTI healing for surgical repair of chronic RCTs as a powerful biological agent in humans.

Purpose: To investigate whether the quadratus lumborum (QL) block is associated with reduced postoperative pain and opioid consumption in patients undergoing hip arthroscopy.

Methods: A search following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed in PubMed, Embase, Scopus, and Cochrane Library databases to identify comparative studies of patients undergoing the QL block before hip arthroscopy. The primary outcomes of interest included postoperative pain and opioid consumption.

Results: Eight studies (5 randomized, 3 nonrandomized) with 274 patients receiving the QL block were included. Control groups included no block (3 studies), sham block (2 studies), pericapsular injection of anesthetic (1 study), lumbar plexus block (1 study), and femoral nerve/fascia iliaca block (1 study). In 1 randomized and 2 nonrandomized studies, the pain scores were significantly lower, at all postoperative time points, in the QL block versus sham, no block, and femoral nerve/fascia iliaca control groups. The same 3 studies reported significantly less opioid consumption in the QL group at all measured postoperative time points. The remaining 5 studies reported mostly no significant differences in pain scores and opioid consumption at multiple postoperative time points. In no study did the QL block group have significantly more pain or opioid consumption relative to the control groups.

Conclusions: Compared to a variety of control groups, the QL block provides similar or reduced postoperative pain and opioid consumption in patients undergoing hip arthroscopy.

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

Identifying the cause of pain after total hip arthroplasty (THA) may be one of the more challenging tasks in orthopaedic surgery. Causes of symptoms after surgery may include infection, periarticular pain (including iliopsoas impingement/tendonitis), referred pain, polyethylene liner wear, component loosening, trunnionosis or metallosis, instability, component misplacement, or idiopathic pain. Psoas impingement, which is reported in up to 8% of patients after THA, may be caused by anatomic, technical, and prosthetic factors. A malpositioned or oversized acetabular component is the most common cause of mechanical irritation of the tendon. Ultrasound-guided diagnostic injections have become an important in-office tool to confirm the diagnosis, and if conservative measures fail, arthroscopic iliopsoas fractional lengthening shows excellent outcomes, with no loss of flexion strength or range of motion. Accurate diagnosis and a minimally invasive, cost-effective arthroscopic solution with excellent postoperative results can avoid the need for revision THA.

Endocrinologists and family medicine physicians prescribe testosterone replacement therapy (TRT) for decreased levels of androgens in aging males. Benefits include improvements in mood, cognition, libido, energy, and quality of life. In orthopaedic surgery patients of both sexes, benefits could also include improvements in functional outcomes, bone mineral density, lean body mass, and early mobilization. A challenge is that patients may request supplementation with TRT and other supplements, including vitamin D (which may benefit fracture healing, bone metabolism, muscle recovery, and healing of tendons and wounds) and growth hormones (specifically BPC 157, which may optimize endurance training, metabolism, tissue repair, and surgical recovery). However, TRT and other supplements have risks and may not be indicated. TRT is not recommended for routine use in the perioperative management of orthopaedic surgery patients.