American Journal of Sports Medicine最新文献

Background: Current research focused on clinical outcomes suggests that lateral extra-articular procedures (LEAPs) can reduce rotational instability and graft failure rates in primary anterior cruciate ligament reconstructions (ACLRs). Limited studies have investigated the functional outcomes after LEAPs, including patient-reported outcome measures, sports participation, and physical performance.

Purpose: To conduct a systematic literature review and meta-analysis to determine whether the addition of a LEAP to an ACLR results in superior functional and clinical outcomes as compared with an isolated ACLR.

Study design: Systematic review and meta-analysis; Level of evidence, 1.

Methods: Five databases were searched to identify randomized controlled trials comparing clinical and functional outcomes after the addition of LEAPs to an isolated primary ACLR. Study selection was performed in accordance with the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-analyses). Assessment of methodological quality for included studies was undertaken using the Cochrane Risk of Bias 2 tool for randomized controlled trials. Studies were eligible for meta-analysis if an outcome measure utilizing similar time points was present across ≥2 studies and reported in mean difference or standard deviation.

Results: Meta-analysis of 10 studies showed that the addition of LEAPs to an ACLR can reduce rates of rotatory instability (risk ratio, 1.45 [95% CI, 1.17-1.79]; P = .0006; I² = 0%) and graft rupture (risk ratio, 0.21 [95% CI, 0.08-0.55]; P < .001; I² = 0%). As supported by studies eligible for meta-analysis, this review showed that the addition of LEAPs to an ACLR can reduce rotatory instability. Short-term morbidity, including increased pain, joint stiffness, and muscle weakness, as compared with isolated ACLRs was resolved by 12 months after surgery.

Conclusion: ACLR in combination with a LEAP results in superior clinical outcomes when compared with an isolated ACLR. Despite early postoperative outcomes concerning pain and function favoring isolated ACLRs, any negative effects were not still observed 6 months after surgery. A conclusion around the correlation between LEAPs and accelerated knee osteoarthritis could not be drawn, owing to the lack of long-term prospective studies available.

Background: Sex differences exist in injury rates, and one contributing factor may be sex hormone effects on the musculoskeletal system.

Purpose/hypothesis: The goal of this systematic review and meta-analysis was to understand the effects of sex hormones on ligaments in females as determined by preclinical and clinical studies. The hypothesis was that sex hormones would affect ligament mechanical properties, histological features, cellular function, and clinically measurable outcomes.

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

Methods: A literature search of PubMed, PEDro, CINAHL, and CENTRAL was performed to identify preclinical and clinical studies assessing sex hormone effects on ligament properties. Overall, 2 independent reviewers performed title, abstract, and full-text screening. Rigor and reproducibility were assessed using the ARRIVE guidelines and the modified Downs and Black checklist. Meta-analyses were also performed.

Results: There were 54 articles included in this review. The majority of studies focused on the anterior cruciate ligament (ACL; n = 27), the menstrual cycle (n = 23), and 17β-estradiol (n = 35). Meta-analyses revealed that there was no effect of the menstrual cycle on knee laxity or anterior tibial translation but that 17β-estradiol decreased the production of types I and III procollagen in ACL fibroblasts in vitro. In examining other ligaments, data suggest that sex hormone changes may affect the mechanical and cellular properties of the medial collateral ligament, intrapubic ligaments, hip ligaments, and ligamentum flavum. Additionally, the literature suggests that hormonal shifts that occur with oral contraceptive pill use, pregnancy, and menopause can affect ligament properties. These effects appear to be mediated, at least in part, by the hormone relaxin.

Conclusion: Of the sex hormones examined in this body of literature, 17β-estradiol and relaxin appear to have the most effect on both the mechanical and cellular properties of ligaments in females. The ACL, medial collateral ligament, intrapubic ligaments, hip ligaments, and ligamentum flavum may be impacted by changes in sex hormone concentrations. The menstrual cycle does not likely affect ligament laxity in a clinically meaningful way, but pregnancy, oral contraceptive pill use, and menopause may.

Background: Both autologous osteochondral transplantation (AOCT) and autologous osteoperiosteal transplantation (AOPT) are available for large cystic osteochondral lesions of the talus (OLTs). However, there is a lack of valid prospective evidence directly comparing the efficacy between AOPT and AOCT.

Purpose/hypothesis: The purpose of this study was to compare the efficacy and safety of AOPT versus AOCT in patients with large cystic OLTs (>8 mm in cystic diameter) at 2 years of follow-up. It was hypothesized that compared with AOCT, AOPT would be associated with noninferior efficacy and less donor site morbidity in the treatment of large cystic OLTs.

Study design: Randomized controlled trial; Level of evidence, 2.

Methods: This was a prospective randomized controlled trial of 70 consecutive patients who underwent AOPT or AOCT between May 2018 and July 2022. Perioperatively, patient characteristics, clinical data, and surgical records were collected. Clinical outcomes were assessed using patient-reported outcome measures, including the visual analog scale for pain (VAS), the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, and the ankle activity score (AAS), at 3, 6, 12, and 24 months postoperatively. Radiological outcomes were evaluated according to the magnetic resonance observation of cartilage repair tissue (MOCART) score. The arthroscopic examination was performed using the International Cartilage Repair Society (ICRS) score. Donor site morbidity in both groups was recorded over the 24-month follow-up period.

Results: A total of 67 patients completed 2-year follow-up: 33 in the AOPT group and 34 in the AOCT group. Baseline characteristics were comparable. No significant differences were observed between the 2 groups in terms of the VAS, AOFAS, and AAS scores throughout the 2-year follow-up period. The AOCT group exhibited higher MOCART and ICRS scores within the first 12 months after surgery. However, by 24-month follow-up, the MOCART score in the AOPT group had reached a level comparable with that in the AOCT group. Additionally, the AOPT group had a lower incidence of donor site morbidity and lower VAS scores across the follow-up period compared with the AOCT group.

Conclusion: This trial demonstrated that at 2-year follow-up, AOPT was noninferior to AOCT with regard to clinical outcomes and cartilage repair quality in patients with large cystic OLTs. Long-term follow-up is needed to confirm these results.

Registration: NCT03347877 (ClinicalTrials.gov).

Background: Osteochondritis dissecans of the humeral capitellum can occur in adolescent baseball players owing to repetitive compressive shear forces within the radiocapitellar joint.

Purpose: To quantify the relationship between valgus angle and radiocapitellar joint contact with varying size and location of osteochondral defects and to compare these effects with a native and strained medial ulnar collateral ligament (UCL).

Study design: Controlled laboratory study.

Methods: Twenty-four cadaveric elbows were tested (mean ± SD, 62.5 ± 8.1 years old). Capitellar osteochondral defects were created at 2 locations (proximal and distal) and with 2 sizes (smaller central and larger laterally extended). Three conditions were tested: proximal defect with a native UCL, distal defect with a native UCL, and distal defect with a strained UCL. Valgus angulation and radiocapitellar contact characteristics were measured with 0, 2, and 3 N·m of additional valgus torque.

Results: When compared with no additional load, there were statistically significant increases in valgus angle with an intact capitellum at both torques for elbows with native and strained UCLs at all elbow flexion angles (P < .001). Elbows with a strained UCL had a higher increase in valgus angulation with 3-N·m valgus torque when compared with the native UCL (P < .048). Larger proximal defects significantly increased the valgus angle at 45° and 105° (P < .012) of flexion, whereas larger distal defects increased the valgus angle at 15° to 75° of flexion (P < .022). There was a significantly decreased radiocapitellar contact area for both osteochondral defect locations (P < .05).

Conclusion: Osteochondral defects show location- and size-dependent alterations in valgus angulation and radiocapitellar contact characteristics in the UCL-strained and native conditions. Relatively low valgus loads with a native UCL increase radiocapitellar contact, which can serve as a rationale for the basis of the formation of an osteochondral defect, with exacerbation of valgus instability and changes in contact characteristics demonstrable with progressively enlarging osteochondral defects.

Clinical relevance: This study provides a biomechanical rationale to understand the interplay between the medial and lateral sides of the elbow in pitchers when considering osteochondral defect pathogenesis and pathomechanics.

Background: Surgical limb underloading is a common biomechanical adaptation after anterior cruciate ligament reconstruction (ACLR) and has been linked to early degenerative changes in knee cartilage, which are considered precursors to posttraumatic osteoarthritis. Split-belt treadmill training is an emerging rehabilitation approach that modifies load through asymmetric gait behavior, in which one limb walks faster than the other. While previous research has indicated that split-belt treadmill training can modify limb loading, its effects on post-ACLR biomechanics remain unexplored.

Purpose/hypothesis: The purpose of this study was to examine the effects of decoupling speed on knee biomechanics and limb loading and model their relationship. It was hypothesized that at faster decoupling speeds, knee loads would increase, and at slower speeds, they would decrease.

Study design: Controlled laboratory study.

Methods: Knee joint biomechanics were evaluated while 24 participants (15 females; mean age, 23.5 ± 6.5 years; mean height, 1.72 ± 0.08 m; mean mass, 75.61 ± 13.83 kg; mean postoperative time, 7.94 ± 1.74 months) with ACLR walked on an instrumented treadmill (2000 Hz) synced with a 12-camera motion capture system (200 Hz). Participants completed 5 minutes of baseline walking at 1.1 m/s on tied treadmill belts. Afterward, the authors manipulated the speed of the belt under the ACL-reconstructed leg with 8 randomized 5-minute decoupled speed configurations (ACL-reconstructed limb at 30%-170% of 1.1 m/s in 20% increments) with 2 minutes of tied-belt walking between each speed. Bilateral sagittal plane knee moments, angles, and vertical ground-reaction forces were calculated. Statistical parametric mapping was used to evaluate the effects of decoupling speed on the dependent variables during the stance phase of the gait.

Results: A clear dose-response relationship between decoupling speed and knee/limb loading was found. Specifically, faster decoupling speeds (130%-170% of 1.1m/s) generally increased peak loads and slower speeds (30% and 50% of 1.1 m/s) decreased peak loads during early stance compared with tied-belt walking for both limbs. In contrast, slower decoupling speeds (30%-90% of 1.1 m/s) led to higher bilateral knee/limb loads at midstance, while faster decoupling speeds (130%-170% of 1.1 m/s) resulted in less knee/limb loading during midstance.

Conclusion: These findings suggest that split-belt treadmill training offers a promising method for modulating knee/limb loading post-ACLR.

Clinical relevance: Split-belt treadmill training could be a viable intervention to target the loading asymmetry that is prevalent in persons post-ACLR.

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.