Background: Compromised bone strength in proximal humerus osteoporosis predisposes patients with rotator cuff repair (RCR) to an increased anchor pull-out risk and healing failure.
Purpose: To explore the potential of locally administered alpha-ketoglutarate (αKG), a natural metabolite in the tricarboxylic acid cycle, to enhance rotator cuff healing by mitigating osteoporosis.
Study design: Controlled laboratory study.
Methods: A total of 48 female Sprague-Dawley rats were assigned into 4 groups: normal control (sham surgery), ovariectomy (OVX) control, OVX-rotator cuff tear (RCT) (RCR with fibrin application after OVX), and OVX-RCT-αKG (RCR with αKG-enriched fibrin treatment after OVX). Bilateral RCR was performed on rats in 2 RCT groups, with the respective application of fibrin or αKG-enriched fibrin gel at the tendon-bone interface (TBI). At 6 weeks and 12 weeks postoperatively, bone quality was evaluated using micro-computed tomography (CT), while histology and immunohistochemistry were used to assess bone, TBI, and tendon quality. Biomechanical tests determined the strength of the tendon-to-bone complex.
Results: Micro-CT analysis confirmed proximal humerus osteoporosis after OVX. Alpha-KG-enriched fibrin leads to improved bone quality compared with OVX-RCT, more prominent at 12 weeks after surgery, as evidenced by the higher bone volume/total volume fraction, trabecular number, and trabecular thickness. Histological and immunohistochemical analyses demonstrated enhanced bone regeneration and improved TBI integrity in the OVX-RCT-αKG group, which could be explained by decreased osteoclastic and increased osteoblastic activity. Biomechanical testing showed improved tendon-bone resilience, with higher ultimate failure load and stress after αKG treatment.
Conclusion: Local supplementation of αKG, a natural metabolite, along with the repair surgery could effectively improve proximal humerus osteoporosis, thereby enhancing RCR. It holds great potential for preventing anchor pullout and improving RCT outcomes in patients with osteoporosis.
Clinical relevance: Alpha-KG supplementation along with surgery may enhance RCR for patients with osteoporosis complications.
Background: Minimalist footwear and running retraining are often recommended by running coaches to reduce the risk of running-related injuries (RRIs) in endurance runners. However, despite the growing popularity of minimalist footwear and running retraining, there is limited scientific evidence supporting their effectiveness.
Purpose: To investigate the impact of minimalist footwear and running retraining on the incidence rate (primary outcome) and location (secondary outcome) of RRIs in recreational endurance runners.
Study design: Randomized controlled trial; Level of evidence, 1.
Methods: A total of 140 rearfoot runners were randomly assigned to 3 groups: minimalist footwear (n = 47), running retraining (n = 47), and control (n = 46). The minimalist footwear group received minimalist footwear, while the running retraining group completed 6 retraining sessions aimed at running softer, adopting a nonrearfoot strike, and increasing the initial step rate by 7.5%. The control group followed a stretching program. Running biomechanics were assessed at baseline and at 2, 6, and 12 months. RRIs were recorded according to recent consensus guidelines. The primary outcome was the RRI incidence rate, analyzed by adjusted (injury history) and unadjusted Cox regression models across 3 analyses: intention to treat, as treated, and per protocol.
Results: Sixty-four RRIs were reported: 55 overuse and 9 acute. No significant differences in the incidence rate of RRIs (primary outcome) were observed among groups across all analyses. There were also no differences in injury duration across groups in all analyses. However, the secondary outcome showed that injury distribution varied among groups in the as-treated and per-protocol analyses, with more hip injuries in the control group (P = .015 and P = .01, respectively) and more foot injuries in the running retraining group (P = .018 and P = .04).
Conclusion: Contrary to popular belief, neither minimalist footwear nor a softer running technique reduced the overall incidence rate of RRIs. However, running retraining altered injury patterns, decreasing hip injuries but increasing foot injuries.
Registration: NCT05499871 (ClinicalTrials.gov).
Background: Acromioclavicular (AC) joint dislocations are common in young athletes. The optimal management of Rockwood type 3 injuries, which involve a complete tear of both the AC and coracoclavicular (CC) ligaments, remains controversial.
Purpose/hypothesis: The purpose of this study was to compare the clinical outcomes of surgical and nonoperative treatment of type 3 AC joint dislocations. The hypothesis was that surgical treatment would result in superior functional outcomes.
Study design: Randomized controlled trial; Level of evidence, 1.
Methods: A total of 70 patients (mean age, 31.2 ± 8.1 years) with acute type 3 AC joint dislocations were randomized to the surgical (modified Weaver-Dunn technique) (n = 35) and nonoperative treatment group (n = 35). The inclusion criteria were as follows: adults aged >18 years diagnosed with grade 3 AC dislocation within 21 days of the injury; no history of AC dislocation or previous surgery in the affected shoulder; and no associated fractures involving the acromion, coracoid, or clavicle. The exclusion criteria were as follows: failure to adhere to the follow-up schedule; improper performance of radiological examinations; or noncompliance with the prescribed rehabilitation protocol. Ten patients were lost to follow-up, resulting in a final sample size of 60 patients (30 per group). The primary outcome was the Disabilities of the Arm, Shoulder, and Hand (DASH) score at 12 months. Secondary outcomes included the University of California-Los Angeles (UCLA) score, scapular dyskinesis, range of motion, radiographic alignment, cosmetic satisfaction, return to sport, and complications. Follow-up was conducted over 24 months. All statistical tests were 2-tailed, and P < .05 was considered statistically significant. No adjustments were made for multiple comparisons because of the exploratory nature of secondary outcomes.
Results: No significant differences were found in DASH scores (11.4 vs 10.63; P = .179) at final follow-up. The surgical group showed significantly higher UCLA scores (36.07 vs 33.74; P < .001) and lower rates of cosmetic dissatisfaction (14.8% vs 44%; P = .017), although the range of motion, return to sport, scapular dyskinesis, and complication rates did not differ between groups.
Conclusion: Surgical management of type 3 AC joint dislocations resulted in similar DASH scores and range of motion compared with nonoperative management, although some secondary outcomes-including higher UCLA scores and cosmetic satisfaction scores-favored surgery.The trial was registered in the Brazilian Registry of Clinical Trials (RBR-4r6jhy6).
Background: Currently, there is no uniform rehabilitation program concerning mobilization after a distal biceps tendon repair. A systematic review was conducted to investigate the effect of restrictions within the immediate postoperative period to evaluate clinical outcomes relative to mobilization after surgical repair of complete distal biceps tendon tears.
Hypothesis: Early mobilization will not have a significant difference on outcomes compared with delayed mobilization.
Study design: Meta-analysis; Level of evidence, 3.
Methods: The authors performed a systematic review in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines of studies reporting outcomes of the distal biceps tendon repair. The early mobilization cohort included studies with no restrictions beyond 2 weeks after surgery, and the delayed mobilization cohort included studies with continued restrictions beyond 2 weeks after surgery.
Results: A total of 26 studies with 1114 patients (643 in the delayed mobilization cohort and 471 in the early mobilization cohort) met the inclusion criteria, with a weighted mean patient age of 45.14 years (range, 18-76 years) and a mean follow-up of 27.9 months (range, 3-120 months). Meta-analysis at the 24-month follow-up found that range of motion (ROM) was not significantly different across early and delayed mobilization cohorts for flexion (mean, 137.38° vs 140.42°; P = .34) and extension (mean, 3.23° vs 1.5°; P = .91). Early mobilization was found to be significantly associated with less pronation (mean, 75.68° vs 83.18°; P = .0019) and supination (mean, 76.38° vs 83.93°; P = .0049). Analysis of patient-reported outcomes (PROs) found that Disabilities of the Arm, Shoulder and Hand scores (mean, 3.93 vs 4.21; P = .77) and Mayo Elbow Performance Score values (mean, 96.33 vs 97.11;P = .65) were not significantly different across cohorts. Failure analysis found a significant difference when comparing proportion (mean, 0.0006 vs 0.0185; P = .0029) but no difference when comparing incidence rate (mean, 0.0001 vs 0.0001; P = .647). Complication analysis found no statistical difference in proportion (mean, 0.2181 vs 0.1918; P = .7388) or incidence rate (mean, 0.0012 vs 0.008; P = .344).
Conclusion: These results suggest there may be no clinically significant difference in failure rates, complications, ROM, or PROs for early versus delayed mobilization after primary distal biceps tendon repair.
Background: Anterior shoulder instability (ASI) is often seen in both contact and noncontact athletes, and the arthroscopic Bankart repair (ABR) procedure is among the most utilized procedures to treat patients with this condition. There is a lack of large studies comparing the return to sport (RTS), outcome, and recurrence rates after ABR in contact and noncontact athletes.
Purpose: To understand the differences in postoperative RTS, outcomes, and complications in contact and noncontact athletes after primary ABR for ASI.
Study design: Systematic review and meta-analysis; Level of evidence, 4.
Methods: A systematic review was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Included studies reported primary ABR without remplissage to treat ASI in athletes with a 1-year minimum follow-up. Random-effects meta-analysis was performed to compare outcomes.
Results: Of the 1575 screened studies, 31 studies (2387 shoulders) were included. The mean age was 23.3 years (range, 13-50 years; SD, 2.97 years), 89% of the athletes were male, and the mean follow-up was 55.1 months (range, 12-107 months; SD, 22.8 months). Contact and noncontact athletes had similar rates of RTS (79% [95% CI, 63%-89%] and 91% [95% CI, 82%-96%], respectively; P = .079) and return to preinjury level (71% [95% CI, 56%-82%] and 79% [95% CI, 73%-85%], respectively; P = .201). Contact and noncontact athletes also demonstrated similar rates of revision surgery (6% [95% CI, 3%-13%] and 4% [95% CI, 3%-7%], respectively; P = .334). Contact athletes, however, exhibited a significantly higher rate of recurrent instability than noncontact athletes (17% [95% CI, 10%-27%] vs 8% [95% CI, 6%-12%]; P = .023).
Conclusion: Compared with noncontact athletes, contact athletes demonstrate similar rates of RTS, return to preinjury level of play, and need for revision surgery but a higher rate of recurrent instability after primary ABR for ASI.
Background: Accurate femoral tunnel positioning is essential for successful anterior cruciate ligament (ACL) reconstruction. Tunnel malposition can happen due to limited arthroscopic visibility as well as anatomic variance. The use of customized patient-specific guides can optimize surgical planning and enhance accuracy.
Purpose: To compare femoral tunnel positioning in 3-dimensional (3D)-assisted ACL reconstruction versus conventional surgery.
Study design: Systematic review and meta-analysis; Level of evidence, 3.
Methods: This systematic review and meta-analysis was performed in line with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines with a search of the following databases: MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials. All randomized controlled trials (RCTs) and observational studies comparing the 2 interventions were included. Primary outcomes included tunnel positioning time (minutes) and accuracy rates (%). Secondary outcomes were Lysholm and International Knee Documentation Committee (IKDC) functional scores. Random effects modeling was used for analysis.
Results: Four RCTs and 1 retrospective study were included, enrolling a total of 299 patients. The 3D group had significantly shorter tunnel positioning times (mean difference, -2.80; 95% CI, -4.13 to -1.46; P < .0001) with significantly greater tunnel positioning accuracy (odds ratio, 4.62; 95% CI, 1.02 to 20.89; P = .05). No significant difference was noted in postoperative functional scores, including Lysholm and IKDC scores (P > .05).
Conclusion: The use of 3D guides helps reduce tunnel positioning time and increases tunnel positioning accuracy with comparable postoperative functional outcomes.
Background: Understanding clinical and tissue adaptations to the throwing shoulder is important for optimizing injury prevention and rehabilitation programs in baseball players.
Purpose/hypothesis: The purpose of this study was to determine the chronic clinical (range of motion [ROM] and strength) and tissue adaptations of the throwing shoulder in baseball pitchers. It was hypothesized that the throwing shoulder would have increased external rotation (ER) ROM and decreased internal rotation (IR) ROM compared with the nonthrowing shoulder, but that calculations of soft tissue glenohumeral IR deficit (GIRD) and soft tissue ER gain (ERG) would show that the true soft tissue restrictions were instead in the direction of ER ROM.
Study design: Systematic review; Level of evidence, 4.
Methods: This systematic review was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using various keywords related to the shoulder and baseball. Studies were included if chronic adaptations of the shoulder were evaluated bilaterally in nonrecreational baseball pitchers. Outcomes of interest collected include IR and ER ROM measured in 90° of shoulder abduction, humeral retroversion (HR), GIRD, ERG, and various structural adaptations. All other chronic adaptations were compiled and reported qualitatively because of the heterogeneity of variables assessed.
Results: Overall, 1273 studies were screened and 36 met final inclusion criteria, with 24 studies (67%) evaluating professional pitchers. Across 13 studies and 1101 professional pitchers, the mean clinical GIRD was 10.0° and the mean clinical ERG was 6.5°, leading to a total arc of ROM deficit of 3.5° in the throwing shoulder. Across 498 included pitchers with HR measures, the mean bilateral difference in HR was 15.4°. After calculating soft tissue GIRD, 3 of 4 studies found that pitchers do not have any soft tissue restrictions in IR ROM. In contrast, after calculating soft tissue ERG, all 4 studies found pitchers to have soft tissue restrictions in ER ROM with a mean of 8° to 13°.
Conclusion: When isolating for soft tissue restrictions through calculation of soft tissue GIRD and ERG, previously reported IR ROM deficits are currently not as prevalent, and soft tissue restrictions in ER ROM are now being observed. Clinicians should focus on better isolating soft tissue restrictions to evaluate whether an athlete has deficits in IR or ER ROM.
Background: Meniscal allograft transplantation replaces damaged meniscal tissue with grafts, aiming to restore knee stability and function. The method employed in the fixation of the meniscal graft-suture or bony fixation-has sparked clinical interest and ongoing discussions.
Purpose: To compare suture fixation with bony fixation of the meniscal graft, with the focus on functional and clinical outcomes.
Study design: Meta-analysis and systematic review; Level of evidence, 4.
Methods: Meta-analyses were performed with a multidatabase search according to PRISMA guidelines on August 15, 2023. Data from published articles meeting inclusion criteria were extracted and analyzed with an inverse variance statistical model.
Results: A total of 6 studies were included consisting of 334 patients: 184 suture fixation and 150 bony fixation. No statistical analysis could be performed for clinical outcomes given the heterogeneity of raw data, but no observable trends were observed from individual studies. Suture and bony fixation showed no statistically significant difference in the risks of infection (relative risk [RR], 1.52; 95% CI, 0.29-7.80; P = .62), graft failure (RR, 0.86; 95% CI, 0.19-3.78; P = .84), graft tear (RR, 1.14; 95% CI, 0.10-13.21; P = .91), minor graft extrusion (RR, 0.77; 95% CI, 0.20-2.92; P = .70), and major graft extrusion (RR, 1.20; 95% CI, 0.28-5.07; P = .81).
Conclusion: There was no significant difference in clinical outcomes or complications between suture and bony fixation of meniscal grafts. However, the short- to medium-term follow-up in this meta-analysis prompts the need for studies with long-term follow-up, given that meniscal allograft transplantation longevity is of utmost importance in this patient group to restore function and potentially reduce the risk of arthritis progression.
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