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PURPOSE: To determine whether leading, commercially-available LLMs provide treatment recommendations concordant with evidenced-based clinical practice guidelines (CPGs) developed by the American Academy of Orthopedic Surgeons (AAOS). METHODS: All CPGs concerning the management of rotator cuff tears(n=33) and anterior cruciate ligament (ACL) injuries(n=15) were extracted from the AAOS. Treatment recommendations from Chat-generative pretrained transformer version-4 [ChatGPT-4; OpenAI], Gemini (Google), Mistral-7B (Mistral AI), and Claude-3 (Anthropic) were graded by two blinded physicians as being "concordant," "discordant," or "indeterminate" (i.e., neutral response without definitive recommendation) with respect to AAOS CPGs. The overall concordance between LLM and AAOS recommendations were quantified, while the comparative overall concordance of recommendations amongst the four LLMs was evaluated through the Fischer's-exact test. RESULTS: Overall 135(70.3%) responses were concordant, 43(22.4%) indeterminate, and 14(7.3%) discordant. Inter-rater reliability for concordance classification was excellent (Kappa=0.92). Concordance with AAOS CPGs was most frequently observed with ChatGPT-4 (n=38, 79.2%), and least frequently with Mistral-7B (n=28,58.3%). Indeterminate recommendations were most frequently observed with Mistral-7B (n=17,35.4%) and least frequently with Claude-3 (n=8, 6.7%). Discordant recommendations were most frequently observed with Gemini (n=6,12.5%) and least frequently with ChatGPT-4 (n=1,2.1%). Overall, no statistically significant differences in concordant recommendations was observed across LLMs (p=0.12). Only 20 (10.4%) of all recommendations were transparent and provided references with full bibliographic details or links to specific peer-reviewed content to support recommendations. CONCLUSION: Among leading commercially-available LLMs, more than one-in-four recommendations concerning the evaluation and management of rotator cuff and ACL injuries do not reflect current evidenced-based CPGs. Although ChatGPT-4 demonstrated the highest performance, clinically significant rates of recommendations without concordance or supporting evidence were observed. Only 10% of responses by LLMs were transparent, precluding users from fully interpreting the sources from which recommendations were provided. CLINICAL RELEVANCE: While leading LLMs generally provide recommendations concordant with CPGs, a substantial error-rate exists, and the proportion of recommendations that do not align with these CPGs suggest that LLMs are not trustworthy clinical support tools at this time. Each off-the-shelf, closed-source LLM has strengths and weaknesses. Future research should evaluate and compare multiple LLMs to avoid bias associated with narrow evaluation of few models as observed in current literature.
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BACKGROUND: The interscalene nerve block provides analgesia for shoulder surgery. To extend block duration, provide adequate analgesia, and minimize opioid consumption, the use of adjuvants such as dexamethasone as well as the application of perineural liposomal bupivacaine have been proposed. This randomized, double-blinded, noninferiority trial hypothesized that perineural liposomal bupivacaine is noninferior to standard bupivacaine with perineural dexamethasone in respect to average pain scores in the first 72 h after surgery. METHODS: A total of 112 patients undergoing ambulatory shoulder surgery were randomized into two groups. The liposomal bupivacaine group received a 15-ml premixed admixture of 10 ml of 133 mg liposomal bupivacaine and 5 ml of 0.5% bupivacaine (n = 55), while the bupivacaine with dexamethasone group received an admixture of 15 ml of 0.5% standard bupivacaine with 4 mg dexamethasone (n = 56), respectively. The primary outcome was the average numerical rating scale pain scores at rest over 72 h. The mean difference between the two groups was compared against a noninferiority margin of 1.3. Secondary outcomes were analgesic block duration, motor and sensory resolution, opioid consumption, numerical rating scale pain scores at rest and movement on postoperative days 1 to 4 and again on postoperative day 7, patient satisfaction, readiness for postanesthesia care unit discharge, and adverse events. RESULTS: A liposomal bupivacaine group average numerical rating scale pain score over 72 h was not inferior to the bupivacaine with dexamethasone group (mean [SD], 2.4 [1.9] vs. 3.4 [1.9]; mean difference [95% CI], -1.1 [-1.8, -0.4]; P < 0.001 for noninferiority). There was no significant difference in duration of analgesia between the groups (26 [20, 42] h vs. 27 [20, 39] h; P = 0.851). Motor and sensory resolutions were similar in both groups: 27 (21, 48) h versus 27 (19, 40) h (P = 0.436) and 27 [21, 44] h versus 31 (20, 42) h (P = 0.862), respectively. There was no difference in opioid consumption, readiness for postanesthesia care unit discharge, or adverse events. CONCLUSIONS: Interscalene nerve blocks with perineural liposomal bupivacaine provided effective analgesia similar to the perineural standard bupivacaine with dexamethasone. The results show that bupivacaine with dexamethasone can be used interchangeably with liposomal bupivacaine for analgesia after shoulder surgery.
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Anestésicos Locales/farmacología , Antiinflamatorios/farmacología , Bloqueo del Plexo Braquial/métodos , Bupivacaína/farmacología , Dexametasona/farmacología , Hombro/cirugía , Adulto , Procedimientos Quirúrgicos Ambulatorios , Método Doble Ciego , Femenino , Humanos , Masculino , Persona de Mediana Edad , Dolor PostoperatorioRESUMEN
PURPOSE: To evaluate the quality of orthopaedic cost-effectiveness analyses (CEAs) in accordance with the 2016 recommendations by the Second Panel on Cost-Effectiveness in Health and Medicine. METHODS: A systematic review of all CEAs from September 2017 to September 2019 in the 10 highest impact orthopaedic surgery journals was performed. Quality scoring used the Quality of Health Economic Studies (QHES) instrument and the Second Panel checklist. QHES scores ≥80 were considered high quality and <50 poor quality. Mann-Whitney U and independent samples Kruskal-Wallis tests compared individual and multiple groups, respectively. Linear regression analysis was performed to correlate QHES score, checklist item fulfillment, and impact factor. RESULTS: The 10 highest impact orthopaedic journals published 6,323 articles with 35 (0.55%) meeting inclusion criteria. Total joint arthroplasty (TJA) and sports medicine articles comprised 65.7% of included studies. Overall mean QHES score was 89.0 ± 7.6, with 82.8% considered high quality. Mean proportion of Second Panel checklist items fulfilled was 82.1% ± 13.3%, but no studies performed an impact inventory accounting for consequences within and outside the health care sector or discussed ethical implications. Mean QHES score and satisfied checklist items were significantly different by journal (P = .025 and P = .01, respectively). In addition, there was a moderate positive correlation between QHES score and impact factor (r = 0.446, P = .007). TJA CEAs satisfied a higher number of checklist items compared with spine surgery CEAs. CONCLUSIONS: Recent orthopaedic CEAs have generally been high quality according to updated Second Panel guidelines but consistently miss checklist items relating to societal impact and ethics. TJA and sports medicine continue to be the most frequently studied orthopaedic subspecialties in health economics, and the breadth of orthopaedic procedures analyzed by CEAs has improved. STUDY DESIGN: Level IV, systematic review.
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Procedimientos Ortopédicos , Ortopedia , Medicina Deportiva , Artroplastia , Análisis Costo-Beneficio , HumanosRESUMEN
PURPOSE: To determine which interventions optimize clinical outcomes in adhesive capsulitis by performing a network meta-analysis of randomized controlled trials. METHODS: A systematic review was conducted of all clinical trials on adhesive capsulitis published since 2008. Patient cohorts were grouped into treatment categories; data collected included range of motion (ROM) and patient-reported outcome measures (PROMs). Interventions were compared across groups by means of arm-based Bayesian network meta-analysis in a random-effects model. RESULTS: Sixty-six studies comprising 4042 shoulders (57.6% female patients, age 54.8 ± 3.2 years [mean ± standard deviation]) were included. The most commonly studied interventions were physical therapy (PT) or shoulder injections. Network meta-analysis demonstrated that arthroscopic surgical capsular release was the most effective treatment in increasing ROM. This effect was apparent in forward flexion (effect difference [ED] versus placebo, 44°, 95% confidence interval [CI] 31° to 58°), abduction (ED 58°, 45° to 71°), internal rotation (ED 34°, 24° to 44°), and external rotation (ED 59°, 37° to 80°). Interventions most effective for pain relief included PT supplemented with either medical therapy (ED -4.50, -9.80 to 2.80) or ultrasound therapy (ED -5.10, -5.10 to -1.40). Interventions most effective for improvement of functional status included PT, manipulation under anesthesia (MUA), intra-articular or subacromial steroid injection, surgical capsular release, and supplementation of PT with alternative therapy. CONCLUSIONS: No one treatment emerged superior in regard to ROM, pain symptoms, and functional status. Surgery (after failure of conservative treatment) ranked highest across all ROM domains. Treatments that ranked highest for treatment of pain included PT supplemented with either medical therapy or ultrasound. Finally, treatments that ranked highest for improvements in functional status included MUA, PT with medical therapy, surgical intervention, PT with ultrasound, PT with injection, and injection alone. LEVEL OF EVIDENCE: II, systematic review and network meta-analysis of level I and II studies.
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Bursitis , Articulación del Hombro , Artroscopía , Teorema de Bayes , Bursitis/cirugía , Femenino , Humanos , Masculino , Persona de Mediana Edad , Metaanálisis en Red , Ensayos Clínicos Controlados Aleatorios como Asunto , Rango del Movimiento Articular , Articulación del Hombro/cirugía , Resultado del TratamientoRESUMEN
PURPOSE: To report clinical and functional outcomes including return to preinjury activity level following arthroscopic-assisted coracoclavicular (CC) ligament reconstruction (AA-CCR) and to determine associations between return to preinjury activity level, radiographic outcomes, and patient-reported outcomes following AA-CCR. METHODS: A institutional registry review of all AA-CCR using free tendon grafts from 2007 to 2016 was performed. Clinical assessment included Single Assessment Numeric Evaluation (SANE) score and return to preinjury activity level at final follow-up. Treatment failure was defined as (1) revision acromioclavicular stabilization surgery, (2) unable to return to preinjury activity level, or (3) radiographic loss of reduction (RLOR, >25% CC distance compared with contralateral side). SANE scores, return to activity, and RLOR were compared between patients within each category of treatment failure, by grade of injury, and whether concomitant pathology was treated. RESULTS: There were 88 patients (89.8% male) with mean age of 39.6 years and minimum 2-year clinical follow-up (mean 6.1 years). Most injuries were Rockwood grade V (63.6%). Mean postoperative SANE score was 86.3 ± 17.5. Treatment failure occurred in 17.1%: 8.0% were unable to return to activity, 5.7% had RLOR, and 3.4% underwent revision surgery due to traumatic reinjury. SANE score was lower among patients who were unable to return to activity compared with those with RLOR and compared with nonfailures (P = .0002). There were no differences in revision surgery rates, return to activity, or SANE scores according to Rockwood grade or if concomitant pathology was treated. CONCLUSIONS: AA-CCR with free tendon grafts resulted in good clinical outcomes and a high rate of return to preinjury activity level. RLOR did not correlate with return to preinjury activity level. Concomitant pathology that required treatment did not adversely affect outcomes. Return to preinjury activity level may be a more clinically relevant outcome measure than radiographic maintenance of acromioclavicular joint reduction. LEVEL OF EVIDENCE: IV (Case Series).
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Articulación Acromioclavicular/cirugía , Artroscopía , Procedimientos de Cirugía Plástica , Adulto , Femenino , Estudios de Seguimiento , Humanos , Ligamentos Articulares/cirugía , Masculino , Medición de Resultados Informados por el Paciente , Periodo Posoperatorio , Resultado del TratamientoRESUMEN
PURPOSE: To assess adverse effects of preoperative corticosteroid injections (CSIs) in patients with rotator cuff disease, especially before rotator cuff repair (RCR). METHODS: A systematic review of the MEDLINE database was performed according to guidelines from the Preferred Reporting Item for Systematic Reviews and Meta-Analyses for all studies reporting on adverse clinical effects of CSIs on rotator cuff tendon. RESULTS: A total of 8 articles were identified that report on adverse outcomes and risks associated with corticosteroid injections in the setting of rotator cuff tendinosis. Among these included articles, a single CSI for rotator cuff tendinosis was associated with increased risk of revision rotator cuff repair (odds ratio [OR]: range 1.3 [1.1-1.7] to 2.8 [2.2-3.4]) when administered up to a year before surgery and postoperative infections (OR: 2.1 [1.5-2.7]) when administered within a month before RCR. The risk of adverse outcomes after rotator cuff repair are greatest if a CSI is administered within 6 months of surgery (OR: 1.8 [1.3-2.6]) or if ≥2 injections are given within a year of surgery (OR: range 2.1 [1.8-2.5] to 3.3 [2.7-4.0]). CONCLUSION: Several recent clinical trials have demonstrated that CSIs are correlated with increased risk of revision surgery after RCR in a temporal and dose dependent matter. Caution should be taken when deciding to inject a patient, and this treatment should be withheld if an RCR is to be performed within the following 6 months. LEVEL OF EVIDENCE: IV, systematic review of Level III and IV studies.
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Artroscopía/métodos , Glucocorticoides/efectos adversos , Lesiones del Manguito de los Rotadores/terapia , Corticoesteroides/administración & dosificación , Glucocorticoides/administración & dosificación , Humanos , Inyecciones Intramusculares , Metaanálisis en Red , Reoperación , Manguito de los RotadoresRESUMEN
PURPOSE: To develop and validate a standardized patient satisfaction measurement tool for adult patients undergoing primary anterior cruciate ligament reconstruction (ACLR). METHODS: A 4-phase iterative process that included item generation and pilot survey development, item reduction, survey readability, and survey validation was used. To develop and validate the Hospital for Special Surgery ACL Satisfaction Survey (HSS ACL-SS), 70 patients were included in the survey development phase and 77 patients were included in the validation phase. The HSS ACL-SS was compared with other currently used ACLR outcome measures including the International Knee Documentation Committee score, Tegner-Lysholm score, Short Form 12 (SF-12) Mental Component Score, and SF-12 Physical Component Score. Test-retest reliability, internal consistency, convergent and discriminant validity, and floor and ceiling effects were assessed. RESULTS: The HSS ACL-SS consists of 10 items identified by patients as being important for satisfaction after ACLR. In the validation phase, the mean score on the HSS ACL-SS (of 50) among all patients was 37.9 ± 9.9 (range, 10-50). Statistically significant positive correlations were seen between the HSS ACL-SS score and the International Knee Documentation Committee score (r = 0.351, P = .002) and Tegner-Lysholm score (r = 0.333, P = .003). No statistically significant correlation was found between the satisfaction score and the SF-12 Mental or Physical Component Score. The lowest possible score (10 of 50 points) was achieved in 1 patient (1.3%) and the highest possible score (50 of 50 points) was achieved in 7 patients (9.1%), indicating no significant floor or ceiling effects of the instrument. Internal consistency for all 10 items was strong (Cronbach α, 0.995). The mean intraclass correlation coefficient between test and retest responses was 0.701, indicating moderate agreement. CONCLUSIONS: The HSS ACL-SS is a validated and reliable patient-derived satisfaction measure with excellent psychometric properties for active adults undergoing ACLR. The results of this study show that the HSS ACL-SS may be a useful tool to measure postoperative patient satisfaction. LEVEL OF EVIDENCE: Level II, development of diagnostic or monitoring criteria in consecutive patients.
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Lesiones del Ligamento Cruzado Anterior/psicología , Lesiones del Ligamento Cruzado Anterior/cirugía , Ligamento Cruzado Anterior/cirugía , Satisfacción del Paciente , Psicometría , Encuestas y Cuestionarios , Adulto , Reconstrucción del Ligamento Cruzado Anterior , Femenino , Hospitales , Humanos , Articulación de la Rodilla/cirugía , Masculino , Persona de Mediana Edad , Evaluación de Resultado en la Atención de Salud , Periodo Posoperatorio , Reproducibilidad de los Resultados , Adulto JovenRESUMEN
INTRODUCTION: The purpose of this study was to determine whether surgical arthroscopic decompression or ultrasound-guided aspiration of a paralabral cyst would result in suprascapular nerve recovery from axonal regeneration based on electrodiagnostic testing. METHODS: Nine patients with preoperative electromyography (EMG) evidence of suprascapular neuropathy due to paralabral cysts at the suprascapular or spinoglenoid notch were prospectively studied. Eight patients underwent arthroscopic surgical decompression, and 1 patient underwent ultrasound-guided aspiration. Postoperative EMG was performed in all patients to evaluate nerve regeneration. RESULTS: Three (33%) patients had cysts at the suprascapular notch, whereas 6 (67%) patients had cysts at the spinoglenoid notch. All patients showed complete electrophysiological recovery after decompression. DISCUSSION: Decompression of paralabral cysts at the suprascapular or spinoglenoid notch resulted in postoperative EMG evidence of nerve recovery. Long-term studies with a greater number of patients are required to elucidate time to recovery. Muscle Nerve 59:247-249, 2019.
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Descompresión Quirúrgica/métodos , Electromiografía , Síndromes de Compresión Nerviosa/cirugía , Recuperación de la Función/fisiología , Adulto , Quistes/complicaciones , Femenino , Humanos , Masculino , Persona de Mediana Edad , Síndromes de Compresión Nerviosa/etiología , Estudios Prospectivos , Hombro/inervación , Articulación del Hombro , Resultado del Tratamiento , Escala Visual AnalógicaRESUMEN
BACKGROUND: Interscalene nerve blockade remains one of the most commonly used anesthetic and analgesic approaches for shoulder surgery. The high incidence of hemidiaphragmatic paralysis associated with the block, however, precludes its use among patients with compromised pulmonary function. To address this issue, recent studies have investigated phrenic-sparing alternatives that provide analgesia. None, however, have been able to reliably demonstrate surgical anesthesia without significant risk for hemidiaphragmatic paralysis. The utility of the superior trunk block has yet to be studied. The hypothesis was that compared with the interscalene block, the superior trunk block will provide noninferior surgical anesthesia and analgesia while sparing the phrenic nerve. METHODS: This randomized controlled trial included 126 patients undergoing arthroscopic ambulatory shoulder surgery. Patients either received a superior trunk block (n = 63) or an interscalene block (n = 63). The primary outcomes were the incidence of hemidiaphragmatic paralysis and worst pain score in the recovery room. Ultrasound was used to assess for hemidiaphragmatic paralysis. Secondary outcomes included noninvasively measured parameters of respiratory function, opioid consumption, handgrip strength, adverse effects, and patient satisfaction. RESULTS: The superior trunk group had a significantly lower incidence of hemidiaphragmatic paralysis compared with the interscalene group (3 of 62 [4.8%] vs. 45 of 63 [71.4%]; P < 0.001, adjusted odds ratio 0.02 [95% CI, 0.01, 0.07]), whereas the worst pain scores in the recovery room were noninferior (0 [0, 2] vs. 0 [0, 3]; P = 0.951). The superior trunk group were more satisfied, had unaffected respiratory parameters, and had a lower incidence of hoarseness. No difference in handgrip strength or opioid consumption were detected. Superior trunk block was associated with lower worst pain scores on postoperative day 1. CONCLUSIONS: Compared with the interscalene block, the superior trunk block provides noninferior surgical anesthesia while preserving diaphragmatic function. The superior trunk block may therefore be considered an alternative to traditional interscalene block for shoulder surgery.
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Artroscopía , Bloqueo del Plexo Braquial/métodos , Dolor Postoperatorio/tratamiento farmacológico , Dolor Postoperatorio/cirugía , Nervio Frénico/efectos de los fármacos , Hombro/cirugía , Adulto , Diafragma/efectos de los fármacos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Parálisis/inducido químicamenteRESUMEN
PURPOSE: To critically review recent literature on outcomes following primary surgical repair of the anterior cruciate ligament (ACL). METHODS: In December 2018, a search of the MEDLINE database was conducted for English language articles reporting clinical outcomes of ACL repair from 2003 to 2018. Included studies were evaluated for patient demographics, patient-reported outcome measures, return to sports/work, patient satisfaction, and postoperative complications. Subgroup analysis was conducted for studies that included patients with only type 1/proximal ACL ruptures. RESULTS: Twenty-eight studies satisfied the inclusion criteria, comprising 2,401 patients (52.3% male, 35.7% female, 12.0% unspecified gender) with mean age ranging from 6.0 to 43.3 years. Most studies were conducted in Europe (82.1%), were level of evidence IV (60.7%), and were designed as case series (57.1%). Fourteen investigations (50.0%) used primary suture repair and 14 (50.0%) used dynamic intraligamentary stabilization. Preoperative ranges for Lysholm, International Knee Documentation Committee Score subjective, and Tegner scores were 28 to 100, 94.1 to 100, and 2 to 9, respectively. Postoperative ranges for the same measures were 80 to 100, 54.3 to 98, and 3.67 to 7, respectively. Time to return to sport/work ranged from 3.1 ± 3.3 to 17.4 ± 1.5 weeks. Frequency of rerupture, revision ACL surgery, and overall reoperations were as high as 23.1%, 33.3%, and 51.5%, respectively. Overall ACL repair survivorship ranged from 60.0% to 100.0%. In subgroup analysis for proximal ruptures treated with repair, the rates of revision ACL reconstruction (ACLR) and total reoperations were as high as 12.9% and 18.2%, respectively. CONCLUSIONS: Based on our cumulative findings across 2,401 patients from the 28 included studies, it appears that ACLR results in better survivorship and patient-perceived postoperative improvement when compared with ACL repair. At present, ACLR appears to remain the superior treatment strategy in the vast majority of cases. LEVEL OF EVIDENCE: Level IV, systematic review of Level II to IV studies.
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Lesiones del Ligamento Cruzado Anterior/cirugía , Reconstrucción del Ligamento Cruzado Anterior/métodos , Lesiones del Ligamento Cruzado Anterior/fisiopatología , Humanos , Satisfacción del Paciente , Rotura , Resultado del TratamientoRESUMEN
PURPOSE: The purpose of this study was to perform a population-level analysis to evaluate the effect of socioeconomic markers on the use of meniscus surgery in patients with meniscus tears. METHODS: We queried all hospital-based clinic visits from 2011 to 2014 in the Statewide Planning and Research Cooperative System database, which also contains all New York inpatient/outpatient visits. Patients with known prior knee surgery, meniscus tear before 2011, or other ligament injuries were excluded. The primary outcome was a meniscus procedure (meniscectomy or meniscus repair). Survival analysis was used to calculate the rate of meniscus surgery within 6 months. A multivariate model identified patient factors (age, sex, race, and payer) associated with surgical intervention. RESULTS: There were 32,012 patients identified who met the inclusion criteria. The rate of meniscus procedure within 6 months of diagnosis was 49.6%. Meniscectomy was performed in 98.8% of cases compared with 1.2% for meniscus repair. Rates of meniscus procedures were higher in patients who were older, male, and white, as well as those first diagnosed by a surgeon. The highest rates of meniscus procedures were in those with private, worker's compensation, or other insurance types. Multivariable analysis showed that female sex, non-white race, and public or self-pay insurance were independently associated with lower rates of meniscus surgery. CONCLUSIONS: These results suggest both insurance-based and race-based disparities regarding surgical treatment. Additionally, the strongest variable for surgical management was a meniscus tear being first diagnosed by a surgeon. LEVEL OF EVIDENCE: Level of Evidence IV, retrospective case-control study.
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Cobertura del Seguro/estadística & datos numéricos , Meniscectomía/estadística & datos numéricos , Procedimientos Ortopédicos/estadística & datos numéricos , Grupos Raciales/estadística & datos numéricos , Lesiones de Menisco Tibial/cirugía , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Estudios de Casos y Controles , Niño , Preescolar , Bases de Datos Factuales , Femenino , Financiación Personal/estadística & datos numéricos , Humanos , Masculino , Medicaid/estadística & datos numéricos , Medicare/estadística & datos numéricos , Persona de Mediana Edad , New York/epidemiología , Estudios Retrospectivos , Factores Sexuales , Lesiones de Menisco Tibial/epidemiología , Estados Unidos , Adulto JovenRESUMEN
PURPOSE: To investigate differences between sport types for patient-reported outcome after anterior cruciate ligament reconstruction (ACLR). METHODS: Included patients were enrolled as part of a prospective institutional ACL registry. Inclusion criteria were preoperative self-identification as a competitive athlete, maximum score on the preoperative Marx Activity Scale, and minimum 2-year follow-up. Demographic, intraoperative, and outcome data were extracted from the registry. Outcome tools administered as part of the registry included International Knee Documentation Committee (IKDC), Lysholm-Tegner Scales, Marx Activity Scale (MAS), and 12-Item Short Form Health Survey (SF-12). RESULTS: A total of 294 patients with a mean age of 25.5 years (standard deviation 12.1) met the study inclusion criteria; mean follow-up was 3.7 years. Included sports categories were soccer (n = 92; 31.3%), skiing (n = 67; 22.8%), basketball (n = 56; 19.1%), lacrosse (n = 38; 12.9%), football (n = 29; 9.9%), and Tennis (n = 12; 4.1%). At baseline, compared with other sports, lacrosse players have higher outcome scores while skiers had lower scores. At 2-year follow-up, however, across all outcome tools, football players demonstrated significantly higher outcome scores than all other athletes (IKDC, 93.2, P = .001; Lysholm, 93.2, P = .03; MAS, 13.1, P = .03; SF-12 Mental Component Summary, 57.9, P = .0002). Conversely, at 2-year follow-up, soccer players demonstrated a significantly lower Lysholm (86.7, P = .02) and a trend toward lower IKDC (85.6, P = .09) scores. CONCLUSIONS: Patient-reported outcomes after ACLR among active athletes are comparable. Football players demonstrate quantitatively higher outcome scores whereas soccer players have lower scores. However, these outcome score differences may not be clinically significant and may be subject to confounding variables. Continued attention should be paid to understanding sport-specific outcome after ACLR. LEVEL OF EVIDENCE: Level IV, therapeutic case series.
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Reconstrucción del Ligamento Cruzado Anterior , Medición de Resultados Informados por el Paciente , Deportes/estadística & datos numéricos , Adolescente , Adulto , Anciano , Lesiones del Ligamento Cruzado Anterior/cirugía , Traumatismos en Atletas/cirugía , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Sistema de Registros , Adulto JovenRESUMEN
PURPOSE: To evaluate the effects of retensioning and knot tying on the biomechanical properties of an adjustable loop anterior cruciate ligament (ACL) reconstruction device. METHODS: Testing consisted of 3 phases, which used both adjustable loop devices (ALD) and closed loop devices (CLD) tested under cyclic loading to 4,500 cycles. Phase 1 consisted of implant-only testing using cyclic loading from 50 to 250 N. Phase 2 used relatively unloaded cyclic loading of 10 to 250 N. Phase 3 used a tendon/bone/implant model. Subsets of the ALD implants were subjected to isolated retensioning, isolated knot tying, or a combination of both to allow for independent examination of these interventions. RESULTS: In phase 1, retensioning and knot tying reduced final ALD elongation by 60% (0.38 v 0.96 mm; P = .00004). In phase 2, retensioning and knot tying reduced final ALD elongation by 88% (0.51 v 4.22 mm, P = .014). In phase 3, retensioning and knot tying reduced final ALD elongation by 45% (1.5 v 2.7 mm; P = .001), which was half of the elongation of the CLD (3.0 mm; P = .0007). CONCLUSIONS: The ALD did demonstrate an increase in cyclic elongation as compared with the CLD during both extended loading conditions. The phase 1 ALD elongation (0.96 mm), while statistically greater than the CLD (0.52 mm), was likely not of clinical importance. However, the ALD elongation in phase 2 (4.22 mm) could be of clinical concern. Both of these increased elongations were eliminated by retensioning and knot tying. Furthermore, when evaluating in a graft-femur construct, retensioning and knot tying of the ALD reduced final cyclic elongation by 50% when compared with CLD. CLINICAL RELEVANCE: Retensioning and knot tying after initial reduction of the tendon graft with an adjustable loop ACL fixation device may help to further reduce concerns of loop slippage and displacement with cyclic loading during postoperative rehabilitation.
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Reconstrucción del Ligamento Cruzado Anterior/instrumentación , Reconstrucción del Ligamento Cruzado Anterior/métodos , Dispositivos de Fijación Ortopédica , Animales , Fenómenos Biomecánicos , Bovinos , Humanos , Modelos Biológicos , Estrés Mecánico , Porcinos , Tendones/trasplanteRESUMEN
Background: Primary anterior cruciate ligament (ACL) repair has gained renewed interest in select centers for patients with proximal or midsubstance ACL tears. Therefore, it is important to reassess contemporary clinical outcomes of ACL repair to determine whether a clinical benefit exists over the gold standard of ACL reconstruction (ACLR). Purpose: To (1) perform a meta-analysis of comparative trials to determine whether differences in clinical outcomes and adverse events exist between ACL repair versus ACLR and (2) synthesize the midterm outcomes of available trials. Study Design: Systematic review; Level of evidence, 3. Methods: The PubMed, OVID/Medline, and Cochrane databases were queried in August 2023 for prospective and retrospective clinical trials comparing ACL repair and ACLR. Data pertaining to tear location, surgical technique, adverse events, and clinical outcome measures were recorded. DerSimonian-Laird random-effects models were constructed to quantitatively evaluate the association between ACL repair/ACLR, adverse events, and clinical outcomes. A subanalysis of minimum 5-year outcomes was performed. Results: Twelve studies (893 patients; 464 ACLR and 429 ACL repair) were included. Random-effects models demonstrated a higher relative risk (RR) of recurrent instability/clinical failure (RR = 1.64; 95% confidence interval [CI], 1.04-2.57; P = .032), revision ACLR (RR = 1.63; 95% CI, 1.03-2.59; P = .039), and hardware removal (RR = 4.94; 95% CI, 2.10-11.61; P = .0003) in patients who underwent primary ACL repair versus ACLR. The RR of reoperations and complications (knee-related) were not significantly different between groups. No significant differences were observed when comparing patient-reported outcome scores. In studies with minimum 5-year outcomes, no significant differences in adverse events or Lysholm scores were observed. Conclusion: In contemporary comparative trials of ACL repair versus ACLR, the RR of clinical failure, revision surgery due to ACL rerupture, and hardware removal was greater for primary ACL repair compared with ACLR. There were no observed differences in patient-reported outcome scores, reoperations, or knee-related complications between approaches. In the limited literature reporting on minimum 5-year outcomes, significant differences in adverse events or the International Knee Documentation Committee score were not observed.
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PURPOSE: To prospectively evaluate the return-to-sports rates after arthroscopic anterior stabilization in patients aged younger than 25 years. METHODS: Fifty-eight patients underwent arthroscopic capsulolabral repair for isolated anterior instability. The mean age at the time of surgery was 19.5 years (range, 12 to 24 years). At a mean follow-up of 27 months (range, 20 to 32 months), 53 patients (42 male and 11 female patients) were assessed with American Shoulder and Elbow Surgeons, L'Insalata, and visual analog scale scores, as well as physical examination. The rate of return to sports and risk factors for postoperative recurrence were evaluated. RESULTS: The overall rate of return to sports at final follow-up was 87%. Forty patients returned to a preinjury level of sports activity after surgery. Six patients returned to less competitive activities. Seven patients who had a subsequent traumatic event resulting in dislocation or subluxation did not return to sports activities. Open revision repairs were performed in 5 patients with recurrent instability. The American Shoulder and Elbow Surgeons and L'Insalata scores improved from 66.9 to 83.2 and from 60.4 to 79.2, respectively (P < .001). The visual analog scale score improved from 3.1 to 1 (P < .001). No significant loss of external rotation was noted postoperatively (mean, 79°). Mattress repair was associated with a higher return-to-sports rate (P < .05). Multiple instability episodes (>5) and the presence of a Hill-Sachs lesion were associated with postoperative failure (P < .05). CONCLUSIONS: Arthroscopic stabilization is a feasible surgical option in the young, athletic population. Mattress labral repair was associated with a higher rate of return to sports, whereas patients who had ligamentous laxity, multiple instability episodes (>5), and Hill-Sachs lesions had the greatest risk of recurrence. These factors should be given consideration in planning the appropriate treatment for anterior instability in this age group. LEVEL OF EVIDENCE: Level IV, therapeutic case series.
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Artroscopía/estadística & datos numéricos , Traumatismos en Atletas/rehabilitación , Traumatismos en Atletas/cirugía , Reinserción al Trabajo/estadística & datos numéricos , Lesiones del Hombro , Articulación del Hombro/cirugía , Deportes/estadística & datos numéricos , Adolescente , Niño , Femenino , Estudios de Seguimiento , Humanos , Inestabilidad de la Articulación/diagnóstico , Inestabilidad de la Articulación/cirugía , Masculino , Dimensión del Dolor , Examen Físico , Cuidados Posoperatorios , Estudios Prospectivos , Rango del Movimiento Articular , Recurrencia , Reoperación , Rotación , Manguito de los Rotadores/cirugía , Lesiones del Manguito de los Rotadores , Luxación del Hombro/diagnóstico , Luxación del Hombro/cirugía , Resultado del Tratamiento , Adulto JovenRESUMEN
Costal cartilage fracture of the rib cage, or costochondral, is a rare sporting injury. For contact athletes, the instability of the rib cage may lead to potential serious complications, similar to rib fractures or thorax disruption. Most authors recommend initial conservative treatment with surgery reserved for only recalcitrant cases. We report a case of an amateur American male rugby football player who sustained a costal cartilage fracture and disruption involving the anterior left fifth and sixth rib costal cartilages. The case highlights the difficulty in establishing the diagnosis based on clinical examination and standard radiographs alone. Computed tomography was used to assist in diagnosing this destabilizing injury to the rib cage. Costal cartilage fractures and disruptions in athletes are rarely reported in the literature and can have serious implications for the athlete's ability to return to play if the rib cage is destabilized.
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Cartílago/lesiones , Fútbol Americano/lesiones , Fracturas del Cartílago/diagnóstico por imagen , Costillas/lesiones , Adulto , Tomografía Computarizada Cuatridimensional , Fracturas del Cartílago/terapia , Humanos , Masculino , Resultado del TratamientoRESUMEN
HYPOTHESIS: Acromioclavicular (AC) joint injuries vary in severity and damage to the AC and coracoclavicular (CC) ligaments. We hypothesized that transclavicular-transcoracoid drilling techniques, which allow for arthroscopic passage and fixation of tendon grafts in bone sockets to replace the insufficient conoid and trapezoid ligaments, cannot restore the footprints of the conoid and trapezoid ligaments without significant risk of cortical breach and coracoid fracture. MATERIALS AND METHODS: Data from a prospective computed tomography shoulder registry were used to create 23 distinct shoulders. Three-dimensional models were constructed the shoulders in which virtual CC ligament reconstruction tunnels were superimposed using previously described anatomic distances and landmarks. RESULTS: Transclavicular-transcoracoid techniques resulted in mean remaining medial and lateral wall thicknesses before cortical breach of 7.3 ± 1.7 and 7.0 ± 1.6 mm, respectively. The distance from the entry point of this tunnel from the anatomic midpoint of the CC ligaments was 9.9 ± 2.2 mm. Attempts to recapitulate the CC ligament anatomy by using anatomic distances and landmarks with transcoracoid, transclavicular techniques resulted in medial cortical breach of the coracoid in 91.3% of the shoulders. CONCLUSION: Transclavicular-transcoracoid reconstructive techniques cannot restore the footprints of the conoid and trapezoid ligaments without significant risk of cortical breach and fracture. Attempts to correct this nonanatomic configuration by creating a tunnel based on the anatomic footprints results in a nearly universal medial cortical breach of the coracoid process.
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Articulación Acromioclavicular/anatomía & histología , Ligamentos Articulares/cirugía , Procedimientos Ortopédicos/métodos , Adolescente , Adulto , Femenino , Humanos , Masculino , Adulto JovenRESUMEN
BACKGROUND: As measured via static stability tests, the PCL is the dominant restraint to posterior tibial translation while the posterolateral corner is the dominant restraint to external tibial rotation. However, these uniplanar static tests may not predict multiplanar instability. The reverse pivot shift is a dynamic examination maneuver that may identify complex knee instability. QUESTIONS/PURPOSES: In this cadaver study, we asked whether (1) isolated sectioning or (2) combined sectioning of the PCL and posterolateral corner increased the magnitude of the reverse pivot shift and (3) the magnitude of the reverse pivot shift correlated with static external rotation or posterior drawer testing. METHODS: In Group I, we sectioned the PCL followed by structures of the posterolateral corner. In Group II, we sectioned the posterolateral corner structures before sectioning the PCL. We performed posterior drawer, external rotation tests, and mechanized reverse pivot shift for each specimen under each condition and measured translations via navigation. RESULTS: Isolated sectioning of the PCL or posterolateral corner had no effect on the reverse pivot shift. Conversely, combined sectioning of the PCL and posterolateral corner structures increased the magnitude of the reverse pivot shift. The magnitude of the reverse pivot shift correlated with the posterior drawer and external rotation tests. CONCLUSIONS: Combined sectioning of the PCL and posterolateral corner was required to cause an increase in the magnitude of the mechanized reverse pivot shift. The reverse pivot shift correlated with both static measures of stability. CLINICAL RELEVANCE: Combined injury to the PCL and posterolateral corner should be considered in the presence of a positive reverse pivot shift.
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Inestabilidad de la Articulación/diagnóstico , Articulación de la Rodilla/fisiopatología , Ligamento Cruzado Posterior/fisiopatología , Adulto , Humanos , Inestabilidad de la Articulación/fisiopatología , Persona de Mediana Edad , Examen Físico , Ligamento Cruzado Posterior/cirugía , Rotación , Tibia/fisiopatologíaRESUMEN
HYPOTHESIS: Lateral ulnar collateral ligament (LUCL) reconstruction is a commonly used surgical approach for the treatment of posterolateral rotatory instability (PLRI). We hypothesized that favorable clinical results could be obtained using the docking technique. MATERIALS AND METHODS: Between 1996 and 2009, the docking technique was used for surgical reconstruction of the LUCL in 8 patients with purely ligamentous posterolateral rotatory instability of the elbow. The clinical results of these patients were retrospectively reviewed. RESULTS: At a mean follow-up of 7.1 years (range, 5.2-9.4 years), 6 patients (75%) demonstrated complete resolution of lateral elbow instability, and 2 (25%) reported occasional instability with activities of daily living. The mean Mayo Elbow Performance Score was 87.5 (range, 75-100). Subjective assessment revealed that all patients were satisfied with their clinical outcome. CONCLUSION: LUCL reconstruction using the docking technique facilitates simple graft tensioning and excellent graft fixation. Clinical results are comparable with previously reported studies with a low complication rate.
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Ligamentos Colaterales/cirugía , Articulación del Codo/cirugía , Procedimientos de Cirugía Plástica/métodos , Rango del Movimiento Articular/fisiología , Tendones/trasplante , Estudios de Cohortes , Ligamentos Colaterales/fisiopatología , Articulación del Codo/fisiopatología , Femenino , Estudios de Seguimiento , Humanos , Cápsula Articular/cirugía , Inestabilidad de la Articulación/diagnóstico , Inestabilidad de la Articulación/cirugía , Masculino , Dimensión del Dolor , Cuidados Posoperatorios/métodos , Recuperación de la Función , Estudios Retrospectivos , Medición de Riesgo , Técnicas de Sutura , Resistencia a la Tracción , Resultado del TratamientoRESUMEN
PURPOSE: The purpose of this study was to objectively evaluate the anatomic and biomechanical outcomes of anterior cruciate ligament (ACL) reconstruction with transtibial versus anteromedial portal drilling of the femoral tunnel. METHODS: Ten human cadaveric knees (5 matched pairs) without ligament injury or pre-existing arthritis underwent ACL reconstruction by either a transtibial or anteromedial portal technique. A medial arthrotomy was created in all cases before reconstruction to determine the center of the native ACL tibial and femoral footprints. A 10-mm tibial tunnel directed toward the center of the tibial footprint was prepared in an identical fashion, starting at the anterior border of the medial collateral ligament in all cases. For transtibial femoral socket preparation (n = 5), a guidewire was placed as close to the center of the femoral footprint as possible. With anteromedial portal reconstruction (n = 5), the guidewire was positioned centrally in the femoral footprint and the tunnel drilled through the medial portal in hyperflexion. An identical graft was fixed and tensioned, and knee stability was assessed with the following standardized examinations: (1) anterior drawer, (2) Lachman, (3) maximal internal rotation at 30°, (4) manual pivot shift, and (5) instrumented pivot shift. Distance from the femoral guidewire to the center of the femoral footprint and dimensions of the tibial tunnel intra-articular aperture were measured for all specimens. Statistical analysis was completed with a repeated-measures analysis of variance and Tukey multiple comparisons test with P ≤ .05 defined as significant. RESULTS: The anteromedial portal ACL reconstruction controlled tibial translation significantly more than the transtibial reconstruction with anterior drawer, Lachman, and pivot-shift examinations of knee stability (P ≤ .05). Anteromedial portal ACL reconstruction restored the Lachman and anterior drawer examinations to those of the intact condition and constrained translation with the manual and instrumented pivot-shift examinations more than the native ACL (P ≤ .05). Despite optimal guidewire positioning, the transtibial technique resulted in a mean position 1.94 mm anterior and 3.26 mm superior to the center of the femoral footprint. The guidewire was positioned at the center of the femoral footprint through the anteromedial portal in all cases. The tibial tunnel intra-articular aperture was 38% larger in the anteroposterior dimension with the transtibial versus anteromedial portal technique (mean, 14.9 mm v 10.8 mm; P ≤ .05). CONCLUSIONS: The anteromedial portal drilling technique allows for accurate positioning of the femoral socket in the center of the native footprint, resulting in secondary improvement in time-zero control of tibial translation with Lachman and pivot-shift testing compared with conventional transtibial ACL reconstruction. This technique respects the native ACL anatomy but cannot restore it with a single-bundle ACL reconstruction. Eccentric, posterolateral positioning of the guidewire in the tibial tunnel with the transtibial technique results in iatrogenic re-reaming of the tibial tunnel and significant intra-articular aperture expansion. CLINICAL RELEVANCE: Anteromedial portal drilling of the femoral socket may allow for improved restoration of anatomy and stability with ACL reconstruction compared with conventional transtibial drilling techniques.