American Journal of Sports Medicine最新文献

Background: The number of meniscal repairs being completed each year is increasing; however, the optimal, cost-effective postoperative assessment to determine the success or failure of a meniscal repair is not well known.

Purpose/hypothesis: The purpose of this systematic review was to identify the clinical examination testing that correlates with objective magnetic resonance imaging (MRI) or second-look arthroscopy (SLA) findings to determine an optimal clinical workup for assessing postoperative meniscal repair healing. It was hypothesized that specific clinical tests would correlate with meniscal repairs that did not heal.

Study design: Systematic review and meta-analysis; Level of evidence, 4.

Methods: This systematic review included all clinical studies investigating meniscal repairs, meniscal repair outcomes, and meniscal healing with clinical findings, MRI, and/or SLA, published in a peer-reviewed journal and with full English text available. All included studies were evaluated for bias using the Methodological Index for Non-Randomized Studies (MINORS). The clinical tests included those using "Barrett's criteria," with the assessment of effusion, joint line tenderness, locking, McMurray testing, and radiographs. This parameter has also been abbreviated to "modified Barrett's criteria" to include only joint line tenderness, effusion, and McMurray testing.

Results: No significant correlations were found between clinical tests and MRI or SLA. A subgroup meta-analysis between Barrett's and non-Barrett's studies reported no significant subgroup differences (χ₁² = 0.24; P = .62). A meta-analysis of diagnostic accuracy using a group of 7 studies that reported on true-positive, true-negative, false-positive, and false-negative data for SLA demonstrated that only a lack of joint line tenderness had a high specificity for a healed meniscal repair, with a log diagnostic odds ratio of 2.62 (95% CI, 0.47-4.76).

Conclusion: This study found no significant correlation with any specific clinical test for meniscal repair healing status using postoperative MRI and/or SLA findings. However, it was found that no healing (when compared with complete or incomplete healing) on MRI and joint line tenderness should be considered when assessing the status of postoperative meniscal repair healing. In addition, a subgroup meta-analysis found that a lack of joint line tenderness was highly correlated with a healed meniscal repair.

Background: Score cutoffs of clinically important outcome values such as the minimal clinically important improvement (MCII), substantial clinical benefit (SCB), and Patient Acceptable Symptom State (PASS) are population and treatment specific. In patients with nonarthritic hip-related pain, numerous score cutoffs have been calculated for use after surgical treatment, but they have not been established for patients who pursue nonoperative care.

Purpose: To determine the MCII, SCB, and PASS score cutoffs for the 12-item International Hip Outcome Tool (iHOT-12), the Hip Disability and Osteoarthritis Outcome Score (HOOS), and an 8-item abbreviated version of the HOOS (HOOS_global) among patients with nonarthritic hip-related pain who were managed nonoperatively.

Study design: Cohort study; Level of evidence, 4.

Methods: The cohort included 15- to 40-year-old patients who were diagnosed with nonarthritic hip-related pain by a surgical or nonsurgical orthopaedic clinician and were advised to pursue nonoperative management at the time of evaluation. At baseline and 12-month follow-up, patients completed the iHOT-12, HOOS, and HOOS_global. Receiver operating characteristic curves were used to generate MCII, SCB, and PASS score cutoffs using an anchor-based approach as well as score changes between baseline and 12 months. The anchor question for the MCII and SCB utilized a 9-item global rating of change scale. The anchor question for the PASS was as follows ("yes"/"no" response): "Taking into account all the activities you have during your daily life, your level of pain, and also your functional impairment, do you consider that your current state is satisfactory?"

Results: Among 61 patients (mean age, 28 ± 8 years; 50 [82%] female), for the iHOT-12, the MCII score cutoff was 14, the SCB score cutoff was 18, and the PASS score cutoff was 63. For the HOOS subscales, the MCII score cutoffs ranged from 4 (Activities of Daily Living) to 13 (Sport and Recreation), the SCB score cutoffs ranged from 10 (Symptoms and Activities of Daily Living) to 25 (Quality of Life), and the PASS score cutoffs ranged from 50 (Quality of Life) to 87 (Activities of Daily Living). For the HOOS_global, the MCII score cutoff was 5, the SCB score cutoff was 12, and the PASS score cutoff was 65. The models mostly had good responsiveness (area under the curve = 0.73-0.94).

Conclusion: These clinically important outcome values can assist clinicians and researchers with interpreting patients' clinical change during nonoperative treatment for nonarthritic hip-related pain.

Background: There is growing interest in sagittal plane malalignment as a risk factor for patellofemoral chondral wear and, correspondingly, as an important measure to correct when performing certain tibial tubercle osteotomy (TTO) procedures. However, a radiographic method to measure anteriorization after TTO has not been described.

Purpose: To develop and validate a radiographic method of measuring anteriorization after TTO.

Study design: Cross-sectional study (diagnosis); Level of evidence, 3.

Methods: Patients treated by 2 high-volume sports medicine surgeons at a single institution who underwent a TTO from 2015 to 2023 with available pre- and postoperative radiographic and magnetic resonance imaging (MRI) scans were identified. Approximately 10 mm and 0 mm of operative anteriorization were targeted for the anteromedializing and straight distalizing TTOs, respectively. Two methods to assess anteriorization after TTO on lateral knee radiographs were developed, using the preoperative to postoperative difference in distance between the anterior-most aspect of the tibial tubercle and either the center of the tibial shaft or the anterior tibial plateau. To validate the radiographic techniques, intraclass correlation coefficients (ICCs) were calculated between each method of radiographic measurement and the gold standard MRI measurement (preoperative to postoperative difference in sagittal tibial tubercle-trochlear groove distance).

Results: There were 70 patients (52 [74%] women) with a mean age of 31.5 ± 9.2 years. The mean anteriorization amount among the 57 anteriorizing TTOs was 4.9 ± 2.5 mm on the x-ray (XR) shaft technique, 4.6 ± 2.6 mm on the XR plateau technique, and 5.3 ± 2.7 mm on MRI (P = .35). The mean anteriorization amount among the 13 straight distalizing TTOs was 0.1 ± 2.5 mm on the XR shaft technique, -0.3 ± 2.2 mm on the XR plateau technique, and 0.6 ± 2.6 mm on MRI (P = .66). There was excellent agreement with MRI for both the XR shaft (ICC, 0.89) and XR plateau (ICC, 0.82) techniques. Interrater reliability was excellent for both techniques (ICC, 0.94-0.95).

Conclusion: Anteriorization after TTO can be measured using routine pre- and postoperative radiographs. Additionally, the amount of anteriorization achieved with modern anteromedializing TTO techniques was less than that traditionally targeted. Moving forward, surgeons can assess the amount of anteriorization achieved during TTO on standard radiographs, while researchers may investigate the potential role of anteriorization on postoperative outcomes.

Background: Tendons have a limited blood supply and form inferior scar tissue during repair, which increases the risk of reruptures, causes complications, and limits regenerative capacity. Current methods to repair injured tendon tissue use solid scaffolds, which carry the risk of contamination (infections) and require open surgery for transplantation.

Hypothesis: Alginate-cell cross-linked gels, which can be applied by a percutaneous injection and transmit mechanical stress to cells via direct cell interaction, could induce tendon tissue regeneration.

Study design: Controlled laboratory study.

Methods: A cross-linked gel was prepared to suspend azide-modified mesenchymal stromal cells (MSCs) in a dibenzocyclooctyne-modified branched alginic acid solution. The cross-linked gel was cultured in a bioreactor. In vivo, the Achilles tendon defects of 104 Lewis rats were injected with saline (control group), alginate gel alone (alginate group), alginate gel with MSCs (MSC group), and cross-linked gel (cross-link group). At 2 and 4 weeks postoperatively, histological and biochemical evaluations were performed. The biomechanical properties of repaired tissue were assessed at 4 weeks.

Results: In the bioreactor culture, the cell orientation in the cross-linked gel was parallel to the direction of tension. Histological analysis of the cross-link group showed significantly more repaired tendon tissue and improved collagen fiber orientation compared with the alginate group or MSC group. The biomechanical properties of the cross-link group included higher stiffness.

Conclusion: The cross-linked gel was injectable at the injury site and was able to induce tissue regeneration with cell-oriented adaptability to the mechanical environment of tissue defects.

Clinical relevance: Intercellular cross-linking technology holds the potential for clinical application as a minimally invasive therapeutic approach that can contribute to the qualitative improvement of tendon tissue regeneration.

Background: Countermovement jump (CMJ) analyses can predict ulnar collateral ligament (UCL) injuries in professional baseball pitchers, yet a biomechanical determinant linking CMJ analytics to UCL sprains is unknown.

Purpose/hypothesis: The purpose of this study was to evaluate CMJ parameters in collegiate pitchers with high and low elbow varus torque (EVT) and investigate multilinear regression relationships between CMJ and EVT kinetics. It was hypothesized that pitchers with greater EVT would have greater CMJ measures, and CMJ kinetics would explain the variance in EVT kinetics.

Study design: Descriptive laboratory study.

Methods: Analyses of 19 Division I collegiate baseball pitchers (age, 19.9 ± 1.5 years; body height, 1.87 ± 0.08 m; body mass, 90.0 ± 13.4 kg) were performed with integrated ball release speed, 3-dimensional motion capture, and ground reaction force (GRF) technology. A 1-way between-participant analysis of variance was used to compare CMJ and ball velocity metrics, while Pearson correlations (r) were used to evaluate the association between EVT and CMJ kinetic variables. An alpha level of .05 indicated statistical significance for all tests that included effect size calculations (η²) for mean differences.

Results: The EVT rate of torque development (EVTRTD) was significantly greater in pitchers with a higher EVT (high EVT: 605 ± 74 vs low EVT: 353 ± 103 N·m·s^-1; P < .001; η² = 0.41). CMJ data were similar between groups, yet correlation models indicated that changes in peak CMJ GRF (r = 0.60, P < .001) and power (r = 0.53, P < .05) can explain variance in EVTRTD.

Conclusion: Compared with absolute EVT, CMJ kinetics were more associated with the rate of EVT in collegiate pitchers.

Clinical relevance: Therefore, as it relates to injury surveillance, identifying pitchers who display increases in peak GRF, concentric impulse, and peak CMJ power may provide early detection in protecting athletes from elbow valgus overload.

Background: Osteochondritis dissecans (OCD) lesions in the knee are most commonly found in the medial femoral condyle (MFC). However, a paucity of literature has explored the characteristics or morphology of patellar OCD lesions.

Purpose/hypothesis: The purpose of this study was to analyze patellar tracking and patellofemoral measurements of pediatric patients with patellar OCD compared with patients with MFC OCD. It was hypothesized that the patients with patellar OCD would demonstrate an increased bony sulcus angle, cartilaginous sulcus angle, and tibial tubercle-trochlear groove (TT-TG) distance compared with patients with MFC OCD.

Study design: Case series; Level of evidence, 3.

Methods: Patients aged ≤18 years diagnosed with either a patellar or MFC OCD lesion at a single tertiary care hospital between January 2016 and May 2023 were analyzed. Patients with a history of patellar instability were excluded. The Caton-Deschamps index, cartilaginous bony height, trochlear depth, patellar tilt, lateral patellar displacement, cartilaginous sulcus angle, bony sulcus angle, and TT-TG distance were assessed on magnetic resonance imaging (MRI). Patients were matched 1:2 based on sex and chronological age within 2 years between the patellar and MFC OCD groups.

Results: A total of 40 extremities in 34 patients with patellar OCD were matched to 80 extremities in 73 patients with MFC OCD. The mean age at the time of MRI was 14.1 ± 2.3 years, and 23% were female. Compared with patients with MFC OCD, patients with patellar OCD had a significantly greater TT-TG distance (11.55 ± 4.15 vs 13.35 ± 4.07 mm, respectively; P = .03). The cartilaginous sulcus angle (150.63°± 7.20° vs 128.09°± 14.07°, respectively; P < .001) and bony sulcus angle (144.70°± 7.78° vs 137.37°± 9.62°, respectively; P < .001) were higher in the patellar OCD group compared with the MFC OCD group. Of patients with patellar OCD, 40% had a TT-TG distance >15 mm, and of patients with MFC OCD, 20% had a TT-TG distance >15 mm. The patellar OCD group had 3.7 times the risk of having a patellar dislocation compared with the MFC OCD group.

Conclusion: An increased TT-TG distance and sulcus angle were associated with patellar OCD in pediatric patients. Patients with abnormal patellofemoral morphology who undergo treatment for a patellar OCD lesion may subsequently develop a patellar dislocation; in this study, patients with patellar OCD without a history of patellar dislocations demonstrated a nearly 4-fold higher dislocation rate compared with an age- and sex-matched group of patients with MFC OCD.

Background: Lateral elbow pain, often attributed to lateral epicondylitis, presents diagnostic complexities. Lateral epicondylitis, or tennis elbow, is the most frequent cause of lateral elbow pain, but a differential diagnosis among all the potential causes of lateral elbow pain is not easy.

Purpose: To evaluate the rate of misdiagnoses in patients previously diagnosed with lateral epicondylitis, identify at-risk patient profiles, and determine sensitive clinical tests for a misdiagnosis.

Study design: Case series; Level of evidence, 4.

Methods: A prospective analysis was conducted on 189 consecutive patients with a previous diagnosis of lateral epicondylitis and failed nonoperative treatment. According to medical history and a physical examination, patients were preliminarily classified into the typical or atypical lateral epicondylitis group. Atypical epicondylitis was defined as one of the following: atypical lateral pain location, history of trauma, limited range of motion (ROM), elbow swelling, negative Cozen test finding, and physical examination findings suggesting a misdiagnosis. Patients in the atypical group were further investigated for a potential lateral epicondylitis misdiagnosis using magnetic resonance imaging, computed tomography, and/or analysis of intraoperative samples according to suspected underlying abnormalities. Univariate and logistic regression analyses were conducted to assess the risk of a misdiagnosis. A standardized diagnostic analysis was performed to evaluate the clinical tests used during the physical examination to identify misdiagnosed patients.

Results: A misdiagnosis occurred in 21 of 189 (11%) patients. The most common misdiagnoses were posterolateral elbow instability in 6 patients; radial nerve compression and inflammatory osteoarthritis in 3 patients each; and osteochondritis dissecans, posterolateral plica, and primary osteoarthritis in 2 patients each. The variables associated with a misdiagnosis were young age (≤30 years; odds ratio [OR], 66.90; P < .001), history of trauma (OR, 17.85; P = .0027), history of a limitation of ROM and/or mechanical symptoms (OR, 16.68; P = .0278), history of elbow swelling (OR, 14.32; P = .0032), and number of corticosteroid injections (OR, 2.00; P = .0007). Atypical lateral pain location highly predicted a misdiagnosis, with a sensitivity of 90.5%.

Conclusion: A misdiagnosis can occur in patients affected by longstanding lateral elbow pain. Young patients and patients with a history of elbow trauma, a limitation of ROM, swelling, corticosteroid injections, and atypical lateral pain should be highly suspected for a misdiagnosis.

Background: Recent biomechanical evidence for adjustable suture anchor (ASA)-based posterior medial meniscus root (PMMR) fixation has shown promising results compared with conventional transtibial pull-out repair (TPOR). However, ASA fixation has not been evaluated in human tissue to 100,000 cycles.

Hypothesis: ASA repair would lead to increased primary fixation strength and less cyclic displacement than conventional TPORs.

Study design: Controlled laboratory study.

Methods: A total of 32 human medial menisci were used, 8 of which were intact specimens and served as native controls. For the others, PMMR tears were created and repaired using 3 different techniques (n = 8 group). Two conventional PMMR repairs were prepared consisting of two No. 2 simple sutures (TSS) and two No. 2 sutures in a Mason-Allen (MA) configuration, all tied over a cortical button. The knotless ASA repair was fixed in MA with repair sutures tensioned at 120 N (MA-120). The repairs' initial force, stiffness, and relief displacement from the tensioned state toward repair unloading (2 N) were measured after fixation. All repair constructs were loaded for 100,000 cycles, with displacement and stiffness measured, and finally were pulled to failure.

Results: The TPORs demonstrated similar primary fixation and cyclic loading behavior except for initial cyclic displacement (cycle 10). The ASA repair provided a higher initial repair load (P < .001) and stiffness (P < .001) with relief displacement similar to conventional TPORs. Lower initial cyclic displacement (P < .011; cycle 10) with overall higher repair stiffness (P < .011) resulted in significantly lower displacement (P < .001) throughout testing for ASA repair. Although both TPORs were completely loose after 100,000 cycles, the ASA repair achieved near-native dynamic meniscal stabilization. The TSS repair had lower overall ultimate load (P < .001) and ultimate stiffness (P < .023) compared with the ASA repair. All repairs had lower ultimate stiffness and loads than the native meniscus (P < .001).

Conclusion: The ASA repair resulted in improved primary PMMR fixation that was stiffer with less cyclic displacement than conventional TPORs and approached that of the human meniscal function after 100,000 load cycles in a cadaveric model. However, all repair techniques had lower ultimate strength than the native human PMMR.

Clinical relevance: Knotless ASA meniscus root fixation resulted in higher tissue compression and less displacement in a cadaveric model; however, future clinical series with surveillance imaging will define the overall significance of healing rates.

Background: In the presence of anterior glenoid bone loss (aGBL), options for bony glenoid augmentation include Latarjet procedures and free bone block transfers. Bone graft placement is challenging, and malposition causes complications, such as recurrent instability or osteoarthritis.

Hypothesis: With minimal changes in bone block positioning, osteochondral shoulder stability cannot be restored sufficiently.

Study design: Controlled laboratory study.

Methods: In a robotic test setup, 14 human cadaveric scapulae were included. Soft tissue was resected, and matching artificial humeri were selected for each specimen. Testing was performed in 60° of glenohumeral abduction with 50 N of glenohumeral compression and anterior-directed translational force to the humerus. Application of 20% aGBL and screw fixation of artificial bone blocks (artBBs) with different buildup shells allowed the following testing stages: (1) intact, (2) 20% aGBL, (3) flush artBB, (4) 1-mm medialized artBB, and (5) 1-mm lateralized artBB. The stability ratio (SR) and medial-lateral humeral head starting position were assessed.

Results: Specimens with 20% aGBL provided lower mean SRs than native joints (20.6% [SD, 4.7%] vs 27.8% [SD, 6.7%]; P < .0001). Flush artBB placement (mean, 35.4%; SD, 7.7%) led to an increased SR compared with both native joints (P = .002) and 20% aGBL (P < .0001). The mean SR in 1-mm medialized artBBs (21.5%; SD, 5.7%) did not differ compared with that for 20% aGBL (P = .908). One-millimeter lateralized artBBs (mean, 40.8%; SD, 5%) provided higher SR and more lateral humeral head starting positions compared with flush artBB (P = .003 and P = .003, respectively).

Conclusion: In the presence of aGBL, flush bone block placement restores osteochondral glenohumeral stability, while a 1-mm medialized bone block fails to increase stability. Bone block lateralization of 1 mm provides higher stability but is associated with humeral head lateralization.

Clinical relevance: Glenoid bone block augmentations are established in patients with glenohumeral instability and aGBL. In the case of bone block malposition, complications like recurrent instability or the development of osteoarthritis can occur. This study underlines the importance of accurate bone block placement since only minimum bone block malposition relevantly affects osteochondral shoulder biomechanics.