American Journal of Sports Medicine最新文献

Background: Continued advancements in cartilage surgery and an accumulating body of evidence warrants a contemporary synthesis of return to sport (RTS) outcomes to provide updated prognostic data and to better understand treatment response.

Purpose: To perform an updated systematic review of RTS in athletes after knee cartilage restoration surgery.

Study design: Systematic review; Level of evidence, 4.

Methods: PubMed, OVID/Medline, and Cochrane databases were queried in October 2023 for studies reporting any RTS outcome after knee cartilage restoration surgery. Meta-analyses with inverse-variance proportion and DerSimonian-Laird random-effects estimators were applied to quantify overall RTS. Comparative proportional subgroup meta-analyses with relative odds ratios (ORs) were constructed to quantify (1) the influence of the procedure on RTS and (2) RTS ability (lower vs same/greater level of play) based on procedure, competition level, and specific sport.

Results: A total of 52 studies (n = 2387) were included. The overall pooled RTS was 80.3% (95% CI, 73.3%-86.5%). Matrix-assisted chondrocyte implantation (MACI) (OR, 2.15) and osteochondral autograft transplantation system (OATS) (OR, 1.83) demonstrated the highest likelihoods of RTS at the same/greater level, while microfracture (MF) (OR, 0.78) was the only treatment demonstrating a higher likelihood of RTS at a lower level. The fastest mean RTS was observed after OATS (6.6 ± 2.6 months). Professional athletes demonstrated an OR of 1.01 for RTS at the same/greater level, whereas recreational/amateur athletes demonstrated an OR of 1.63; however, all professional athletes underwent MF, and recreational/amateur athletes who underwent MF demonstrated lower likelihoods of RTS (OR, 0.78), indicating a consistent association between MF and low RTS propensity. Basketball players demonstrated the lowest likelihood of RTS at the same/greater level (OR, 1.1), while American football and soccer were associated with high likelihoods of RTS (OR, 3 and 2.4, respectively) across all procedure types.

Conclusion: Cartilage restoration allows for high overall RTS, with OATS and MACI conferring the greatest propensity for RTS, while OATS allowed for the fastest RTS. Undergoing MF was associated with consistently poor RTS ability. This study identified several important associations between the level of RTS and clinically relevant factors when discussing RTS, with recreational/amateur athletes, soccer players, and American football players demonstrating a higher relative propensity to RTS.

Background: Randomized controlled trials (RCTs) evaluating the efficacy of platelet-rich plasma (PRP) for the management of lateral epicondylitis (LE) have been characterized by substantial variability in reported outcomes. The source of this heterogeneity is uncertain.

Purpose: To determine the effect of estimated platelet concentration on the efficacy of PRP for the management of LE.

Study design: Systematic review and meta-analysis; Level of evidence, 2.

Methods: All RCTs evaluating the efficacy of PRP in managing LE were identified. RCTs were classified according to whether the study documented a platelet concentration factor of PRP representing a greater than 3-fold increase over whole blood or a supraphysiological platelet dose (high-dose vs low-dose PRP). The primary outcome was the mean difference (MD) in the visual analog scale (VAS) score at latest follow-up. Random-effects and mixed-effects meta-analyses were performed, and meta-regression was used to evaluate whether differences in outcomes after treatment with PRP could be explained by differences in the concentration of PRP used.

Results: Overall, 13 RCTs with a total of 791 patients were included in this analysis, with 5 that utilized low-dose PRP and 8 that used high-dose PRP. Meta-analysis of VAS scores reported by studies that used high-dose PRP resulted in an MD of -1.31 (95% CI, -1.87 to -0.75) in favor of PRP over all alternative treatment strategies (P < .001). Meta-analysis of VAS scores reported by studies that used low-dose PRP resulted in an MD of 0.08 (95% CI, -0.51 to 0.68), suggesting no difference in the effect between PRP and all alternative treatment strategies (P = .79). The platelet concentration factor of PRP used in each RCT was found to be strongly predictive of the VAS score at final follow-up in meta-regression (P < .001), with 58.5% of the heterogeneity in the outcomes of PRP between studies explained by the platelet concentration factor alone.

Conclusion: The platelet concentration of PRP may play a significant role in the outcomes of patients with LE. A direct linear relationship was observed between the platelet concentration factor of PRP used and the magnitude of patient-reported symptom relief after the management of LE with PRP. Clinicians should ensure a supraphysiological platelet concentration when preparing PRP for the management of LE.

Background: Turf toe is a plantar plate injury of the first metatarsophalangeal joint that commonly occurs in athletes participating in outdoor cutting sports. However, there is a lack of evidence-based consensus on treatment guidelines and surgical outcomes in the current literature.

Purpose/hypothesis: The purpose of this study was to report on postoperative clinical outcomes and return to sport for athletic patients treated for both acute and chronic grade 3 turf toe injuries at the authors' institution. It was hypothesized that patients would have significant improvement in pre- to postoperative clinical outcomes and quickly return to sport after surgical repair.

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

Methods: The records of patients who received plantar plate repair at the first metatarsophalangeal joint between February 2016 to July 2022 by 3 fellowship-trained foot and ankle orthopaedic surgeons were reviewed. Inclusion criteria included athletes of at least high school-level competition who underwent plantar plate repair for a primary diagnosis of turf toe injury. Excluded were patients with histories of ipsilateral forefoot surgeries, rheumatoid arthritis, or gout. In total, 28 patients were identified and screened for inclusion. Patient-reported outcomes via Patient-Reported Outcomes Measurement Information System (PROMIS) scores were collected preoperatively and at least 1 year postoperatively for all patients. Return-to-sport data were collected via telephone call. Bilateral preoperative and postoperative radiographs were analyzed to measure preoperative and postoperative sesamoid diastasis.

Results: The improvement in pre- to postoperative PROMIS scores was found to be significant for Physical Function, Pain Interference, Pain Intensity, and Global Physical Health. A total of 21 return-to-sport surveys were completed from the patient cohort. Nineteen of 21 (90.5%) of patients were able to return to preinjury levels of physical competition. The mean time to return to sport was 20.4 weeks (range, 12-32 weeks). Both medial and lateral sesamoids demonstrated a significant pre- to postoperative improvement in sesamoid diastasis. No difference in outcomes was observed between acute and chronic injuries.

Conclusion: Patients who received plantar plate repair for a grade 3 turf toe injury demonstrated significant improvement in patient-reported outcomes and were able to quickly return to sport at a high rate.

Background: Prior studies have shown that adolescent patients achieve more favorable outcomes after hip arthroscopic surgery for femoroacetabular impingement syndrome (FAIS) compared to adult patients at short-term and midterm follow-up, but a limited number of studies have compared these groups at a minimum 10-year follow-up.

Purpose: To compare patient-reported outcome (PRO) scores, achievement rates of clinically significant outcomes, and reoperation-free survivorship between adolescent and adult patients after hip arthroscopic surgery for FAIS at a minimum 10-year follow-up.

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

Methods: A retrospective chart review was performed on patients who underwent primary contemporary hip arthroscopic surgery for FAIS, including chondrolabral preservation, surgical correction of FAIS, and capsular repair, between January 2012 and November 2013 with a minimum 10-year follow-up. Adolescent patients (aged 10-19 years) were propensity score matched 1:1 to adult patients (aged ≥20 years), controlling for sex, body mass index, Tönnis grade, duration of pain, physical activity status, and back pain. PRO scores were collected preoperatively and at 10-year follow-up, including those for the Hip Outcome Score-Activities of Daily Living (HOS-ADL), Hip Outcome Score-Sports Subscale (HOS-SS), modified Harris Hip Score (mHHS), International Hip Outcome Tool-12 (iHOT-12), visual analog scale (VAS) for pain, and VAS for satisfaction. The cohort-specific minimal clinically important difference, Patient Acceptable Symptom State (PASS), and substantial clinical benefit (SCB) were calculated and compared between groups. Reoperation-free survivorship was compared.

Results: Overall, 50 adolescent patients (mean age, 17.0 ± 1.7 years) were matched to 50 adult patients (mean age, 33.0 ± 9.3 years) with a mean follow-up of 10.4 ± 0.4 years. No differences in preoperative PRO scores were observed. Adolescents achieved greater 10-year HOS-ADL, HOS-SS, mHHS, iHOT-12, VAS pain, and VAS satisfaction scores compared to adults (P < .05 for all). Adolescents showed superior achievement rates of the PASS (98% vs 79%, respectively; P = .015) and SCB (88% vs 67%, respectively; P = .035) for any PRO measure compared with adults. No differences in total hip arthroplasty-free survivorship (100% vs 94%, respectively; P = .083) or revision-free survivorship (90% vs 94%, respectively; P = .473) were found.

Conclusion: Adolescent patients treated with contemporary hip arthroscopic surgery for FAIS, including chondrolabral preservation, surgical correction of FAIS, and capsular repair, showed superior 10-year PRO scores and achievement rates of the PASS and SCB compared to a propensity score-matched group of adult patients, despite comparable short-term and midterm PROs.

Background: In athletes with an acute ligamentous ankle injury, cartilage and osteochondral lesions ([O]CLs) have been reported in 8% using 1.5-T magnetic resonance imaging (MRI). Visualization of cartilage injuries improves with the use of higher field strengths.

Purpose: To evaluate the prevalence, size, and anatomic location of (O)CLs in athletes with an acute ligamentous ankle injury using 3-T MRI, as well as to determine the association of (O)CLs with injury of (1) the lateral ankle ligaments and (2) anterior syndesmosis.

Study design: Cohort study; Level of evidence, 3.

Methods: For this prospective cohort study, all acute ligamentous ankle injuries in athletes (≥18 years of age) evaluated in the outpatient department of a specialized orthopaedic and sports medicine hospital within 7 days after injury were assed for eligibility. Acute ankle injuries were excluded if 3-T MRI could not be obtained within 10 days after injury or if imaging demonstrated a frank fracture. A musculoskeletal radiologist assessed MRI scans for the presence, location, and size of (O)CLs. Morphology was graded using the modified Berndt and Harty score, Griffith MRI score, and International Cartilage Regeneration & Joint Preservation Society score. In addition, injuries of the lateral ankle ligaments and anterior syndesmosis were graded. A multivariate logistic regression analysis was performed to evaluate the association between (O)CLs and injury of the (1) lateral ankle ligaments and (2) anterior syndesmosis.

Results: Between September 2016 and February 2020, 171 acute ankle injuries in 166 athletes were included in this study. The overall prevalence of (O)CLs was 14%. (O)CLs of the talus and tibia were observed in 24 (14%) and 9 (5%) acute ankle injuries, respectively. Of 33 (O)CLs, 28 (85%) were classified as cartilage lesions. Lateral ligament injury was observed in 73% of acute ankle injuries, and anterior syndesmosis injury in 38%. Multivariate logistic regression analysis did not show significantly higher odds of (O)CLs in the presence of anterior syndesmosis injury (OR, 2.16; 95% CI, 0.90-5.16).

Conclusion: In athletes with an acute ligamentous ankle injury, a prevalence for (O)CLs of 14% was established using 3-T MRI. The majority were cartilage lesions. No statistically significant association was established between (O)CLs and lateral ligament or syndesmosis injury was established.

Background: Patients with recurrent instability underwent isolated medial patellofemoral ligament (MPFL) reconstruction regardless of anatomic risk factors within the confines of strict exclusion criteria. Previous publications from this cohort have been limited in the ability to identify risk factors for failure of isolated MPFL reconstruction when recurrent instability was defined as the only mode of failure, likely because of the small patient numbers who experienced this outcome.

Purpose: To investigate whether persistence of postoperative apprehension and J-sign indicate suboptimal outcomes after isolated MPFL reconstruction and to determine if they may help identify patients who need bony realignment in addition to a soft tissue stabilization.

Study design: Case series; Level of evidence, 4Methods:Patients with recurrent patellar instability were prospectively enrolled from March 2014 to December 2019 and underwent primary, unilateral MPFL reconstruction by the senior author within the confines of strict exclusion criteria. Imaging measurements were obtained at baseline. Patient-reported outcome measures (PROMs) were collected at baseline and annually. Recurrent instability events (patellar dislocations or subluxations), return-to-sport (RTS) rates, presence of postoperative apprehension, and J-sign were collected at 1- and 2-year follow-ups.

Results: A total of 138 knees (72% female; mean age, 20.1 ± 6.1 years) underwent isolated MPFL reconstruction between March 2014 and December 2019. The mean Beighton score was 5.3 ± 3.0, and knee hyperextension beyond 0° was 5.4° ± 2.8°. Of the knees evaluated, 95 (81%) had a preoperative J-sign and 89 (65%) had preoperative knee hyperextension. At 2 years, recurrent instability was reported in 6 knees (5%), postoperative apprehension in 9 knees (8%), and a postoperative J-sign in 44 knees (37%). No patients with postoperative apprehension reported recurrent instability. At 2 years, 89% of patients were able to RTS. Patients with both preoperative knee hyperextension and postoperative apprehension had worse RTS rates compared with patients without either (P = .034). Patients with postoperative J-signs had a significantly worse International Knee Documentation Committee score (P = .022), Knee injury and Osteoarthritis Outcome Score Physical Function Short Form score (P = .011), and Kujala score (P = .035) at the 2-year follow-up. For patients with recurrent instability or postoperative apprehension, the Kujala score was statistically significantly lower at 1 year compared with those without (84.9 vs 91.7; P = .019).

Conclusion: In this prospective study of knees undergoing isolated MPFL reconstruction for recurrent patellofemoral instability, patients with postoperative J-signs showed worse PROMs at 2 years, a higher percentage of patients with preoperative k

Background: The hamstring tendon autograft used for anterior cruciate ligament reconstruction commonly entails both the semitendinosus and gracilis (ST/G) tendons for sufficient graft thickness, but they may impair function. To mitigate this, a tendon-sparing ST-only graft has been explored. However, less is known of the mid- to long-term outcomes comparing these configurations.

Purpose/hypothesis: The purpose was to investigate differences between the quadrupled ST tendon graft and the doubled ST/G graft configuration. The primary hypothesis was that there would be no difference in the International Knee Documentation Committee 2000 Subjective Knee Form (IKDC-SF) outcomes between groups. The secondary hypothesis was that there would be no differences in knee flexion strength, KT-1000 arthrometer side-to-side measurements, or need for secondary surgery (including revision) between the 2 techniques.

Study design: Randomized controlled trial; Level of evidence, 1.

Methods: At baseline, 98 patients were randomized to receive either the quadrupled ST tendon graft or the doubled ST/G graft configuration. Preoperatively and after 2 and median 8 years (range, 5-10 years) postoperatively, the investigators collected results for the IKDC-SF, Knee injury and Osteoarthritis Outcome Score, Tegner Activity Scale, a sports and activity participation questionnaire, knee laxity (KT-1000 arthrometer) side-to-side measurements, Lachman test, and flexion rotation drawer test. Need for secondary knee surgery was evaluated 5 to 10 years postoperatively.

Results: Seventy-seven patients completed median 8-year follow-up (range, 5-10 years): 38 patients in the ST group and 39 patients in the ST/G group. No statistically significant differences were observed between the ST and ST/G groups in IKDC-SF scores (81.7 vs 82.1; P = .93), knee stability, or revision rates. Both groups demonstrated statistically significant improvements in self-reported function (P < .001) until final follow-up. The overall anterior cruciate ligament revision rate was 10.4%, and no increased risk of graft failure or excessive residual laxity was associated with the ST-only graft.

Conclusion: No statistically significant differences were found between the ST group and the ST/G group in terms self-reported function, knee laxity, or need for secondary surgery at median 8 years (range, 5-10 years) after surgery. The ST-only graft configuration did not increase the risk of graft failure or excessive residual laxity compared with the ST/G graft configuration.

Background: Surgical options for septic arthritis include open arthrotomy or an arthroscopic procedure. The optimal surgical technique remains a matter of debate as acceptable results have been reported for both.

Purpose: To evaluate the efficacy of arthroscopy versus arthrotomy for the treatment of septic arthritis in large and intermediate-sized joints.

Study design: Systematic review; Level of evidence, 3.

Methods: A literature search was performed of the PubMed and Cochrane online databases through September 2023 identifying articles comparing arthroscopy with arthrotomy for the treatment of septic arthritis. Eligible articles included retrospective or prospective comparative studies investigating reoperation, perioperative complications, or clinical outcomes after arthroscopic or open treatment for septic arthritis of the shoulder, elbow, wrist, hip, knee, or ankle in adults.

Results: In total, 23 articles with 34,248 patients met the inclusion criteria comparing arthroscopy with arthrotomy. In 14 of the 20 (70%) studies that reported on reoperation rates, there was no significant difference in arthroscopic versus open surgical management for septic arthritis. Four (20%) studies reported lower reoperation rates when arthroscopy was utilized compared with open arthrotomy. One single-institution study found arthrotomy to be more effective for shoulder septic arthritis, and another favored open surgery only in the presence of erosions. In 11 of 23 (47.8%) studies, no difference in complications or clinical outcomes was found. However, 11 of 23 (47.8%) studies comprising the shoulder, wrist, hip, knee, and ankle reported a significant benefit to arthroscopy for improved outcomes.

Conclusion: Arthroscopic surgery for the treatment of septic arthritis involving the shoulder, wrist, hip, knee, and ankle appears to be safe and effective. Reoperation rates, short-term complications, and functional outcomes tend to be similar or in favor of arthroscopy when compared with arthrotomy.

Background: The amount of glenoid bone loss (GBL) in anterior shoulder instability helps determine management options. Unfortunately, there is no consensus on how to accurately measure GBL.

Hypothesis: The best-fit circle missing area method has better accuracy and interrater reliability than the ratio and diameter methods.

Study design: Controlled laboratory study.

Methods: Three-dimensional computed tomography shoulder scans were collected and segmented on 4 healthy male participants (mean age, 22.5 ± 3.4 years). For each scapula, 5 GBL models were created with known levels of GBL (5%-30%) in the anteroinferior glenoid rim. Ground-truth GBL was determined using the glenoid fossa edge and best-fit circle of the anteroinferior edge. Six blinded reviewers with varying expertise measured GBL for 20 randomized models using 3 different best-fit circle methods (missing area, ratio, and diameter). Accuracy was assessed by root mean square error and obtained by comparing measured and ground truth for bone loss for each model. Interrater reliability was assessed using intraclass correlation coefficients (ICCs) with a 2-way random-effects model with consistency.

Results: On average, the missing area method overestimated GBL by 1%, while the ratio method and diameter method overestimated GBL by 2.4% and 6.3%, respectively. The interrater reliabilities of the missing area (ICC, 0.89), ratio (ICC, 0.91), and diameter (ICC, 0.90) methods were good, excellent, and good, respectively. For all reviewers, the overall root mean square error of the missing area method (3.6%) was better than that of the ratio (5%) and diameter (7.9%) methods. When stratifying reviewer accuracy by level of training, the missing area method remained superior at all levels when compared with the ratio and diameter methods (attending [3.1% vs 3.8% and 8.9%], fellow [4.2% vs 6.3% and 8.4%], and resident [3.5% vs 4.6% and 6.3%]).

Conclusion: The best-fit circle missing area method was reliable and more accurate at measuring GBL than the other methods. This held true at all levels of surgical experience (resident, fellow, and attending).

Clinical relevance: The best-fit circle missing area method is accurate, has good reliability, and is simple. This can enhance preoperative planning for shoulder surgeons.