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Purpose: To systematically review the literature and provide a detailed summary of the current treatments and outcomes for arthrofibrosis following knee arthroscopy and anterior cruciate ligament reconstruction (ACLR) and to compare the treatment strategies in pediatric and adult populations. Methods: A systematic review was performed in March 2022 using PubMed, EMBASE, and Cochrane Library Databases per Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Search terms consisted of variations of the following: ("arthrofibrosis" OR "stiffness" OR "stiff" OR "complications") AND ("arthroscopy" OR "arthroscop" OR "ACL" OR "anterior cruciate") AND ("treat" OR "care" OR "management" AND "knee"). The inclusion criteria were studies that were written in English, were published since 2000, and that reported outcomes of knee arthroscopy or ACLR for treatment of arthrofibrosis of the knee. The study quality was assessed, and data about the patients and treatments were recorded. Treatments were compared between pediatric and adult patients. Results: A total of 1,208 articles were identified in the initial search, 42 (3.48%) of which met eligibility criteria, involving treatment regimens for arthrofibrosis following knee arthroscopy or ACLR. Of the 42 studies included, 29 (69.0%) were reported data for adults and 13 (31.0%) reported data for pediatric patients. Thirty-nine studies (92.8%) discussed manipulation under anesthesia and/or lysis of adhesions (LOA) as treatment for arthrofibrosis of the knee, whereas 2 (4.8%) described the use of medications. Conclusions: Within orthopaedic sports medicine literature, there is variability in the reported treatment options for arthrofibrosis of the knee. Most studies identified manipulation under anesthesia and/or LOA as the treatment among both adult and pediatric patients. Other variants include notchplasty, open posterior arthrolysis, total graft resection, removal of hardware with LOA, dynamic splinting, casting in extension, bracing, and medications. Level of Evidence: Level IV, systematic review of Level I-IV studies.
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BACKGROUND: Patients with a history of anterior shoulder instability (ASI) commonly progress to glenohumeral arthritis or even dislocation arthropathy and often require total shoulder arthroplasty (TSA). The purposes of this study were to (1) report patient-reported outcomes (PROs) after TSA in patients with a history of ASI, (2) compare TSA outcomes of patients whose ASI was managed operatively vs. nonoperatively, and (3) report PROs of TSA in patients who previously underwent arthroscopic vs. open ASI management. METHODS: Patients were included if they had a history of ASI and had undergone TSA ≥5 years earlier, performed by a single surgeon, between October 2005 and January 2017. The exclusion criteria included prior rotator cuff repair, hemiarthroplasty, or glenohumeral joint infection before the index TSA procedure. Patients were separated into 2 groups: those whose ASI was previously operatively managed and those whose ASI was treated nonoperatively. This was a retrospective review of prospective collected data. Data collected was demographic, surgical and subjective. The PROs used were the American Shoulder and Elbow Surgeons score, Single Assessment Numerical Evaluation score, QuickDASH (Quick Disabilities of the Arm, Shoulder and Hand) score, and 12-item Short Form physical component score. Failure was defined as revision TSA surgery, conversion to reverse TSA, or prosthetic joint infection. Kaplan-Meier survivorship analysis was performed. RESULTS: This study included 36 patients (27 men and 9 women) with a mean age of 56.4 years (range, 18.8-72.2 years). Patients in the operative ASI group were younger than those in the nonoperative ASI group (50.6 years vs. 64.0 years, P < .001). Operative ASI patients underwent 10 open and 11 arthroscopic anterior stabilization surgical procedures prior to TSA (mean, 2 procedures; range, 1-4 procedures). TSA failure occurred in 6 of 21 patients with operative ASI (28.6%), whereas no failures occurred in the nonoperative ASI group (P = .03). Follow-up was obtained in 28 of 30 eligible patients (93%) at an average of 7.45 years (range, 5.0-13.6 years). In the collective cohort, the American Shoulder and Elbow Surgeons score, Single Assessment Numerical Evaluation score, QuickDASH (Quick Disabilities of the Arm, Shoulder and Hand) score, and 12-item Short Form physical component score significantly improved, with no differences in the postoperative PROs between the 2 groups. We found no significant differences when comparing PROs between prior open and prior arthroscopic ASI procedures or when comparing the number of prior ASI procedures. Kaplan-Meier analysis demonstrated a 79% 5-year survivorship rate in patients with prior ASI surgery and a 100% survivorship rate in nonoperatively managed ASI patients (P = .030). CONCLUSION: At mid-term follow-up, patients with a history of ASI undergoing TSA can expect continued improvement in function compared with preoperative values. However, TSA survivorship is decreased in patients with a history of ASI surgery compared with those without prior surgery.
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Artroplastía de Reemplazo de Hombro , Hemiartroplastia , Inestabilidad de la Articulación , Articulación del Hombro , Masculino , Humanos , Femenino , Persona de Mediana Edad , Articulación del Hombro/cirugía , Inestabilidad de la Articulación/etiología , Artroplastía de Reemplazo de Hombro/efectos adversos , Estudios de Seguimiento , Resultado del Tratamiento , Hombro/cirugía , Estudios Prospectivos , Estudios Retrospectivos , Hemiartroplastia/efectos adversosRESUMEN
Introduction: Intra-articular antibiotics have been proposed as a treatment for septic arthritis to allow for high local concentrations without subjecting a patient to the toxicity/side effects of systemic therapy. However, there is concern for chondrotoxicity with intra-articular use of these solutions in high concentrations. The purpose of this systematic review was to evaluate the intra-articular use of antibiotics and antiseptic solutions, and to determine their association with chondrolysis following in vitro or in vivo administration. Methods: A systematic review was conducted following PRISMA guidelines through PubMed, Clinical Key, OVID, and Google Scholar. Studies in English were included if they evaluated for chondrotoxicity following antibiotic exposure. Results: The initial search resulted in 228 studies, with 36 studies meeting criteria. These 36 studies included manuscripts that studied 24 different agents. Overall, 7 of the 24 (29%) agents were non-chondrotoxic: minocycline, tetracycline, chloramphenicol, teicoplanin, pefloxacin, linezolid, polymyxin-bacitracin. Eight (33%) agents had inconsistent results: doxycycline, ceftriaxone, gentamicin, vancomycin, ciprofloxacin, ofloxacin, chlorhexidine, and povidone iodine. Chondrotoxicity was evident with 9 (38%) agents, all of which were also dose-dependent chondrotoxic based on reported estimated half maximal inhibitory concentrations (est. IC50): amikacin (est. IC50 = 0.31-2.74 mg/mL), neomycin (0.82), cefazolin (1.67-3.95), ceftazidime (3.16-3.59), ampicillin-sulbactam (8.64 - >25), penicillin (11.61), amoxicillin (14.01), imipenem (>25), and tobramycin (>25). Additionally, chondroprotective effects of doxycycline and minocycline were reported. Conclusions: This systematic review identified agents that may be used in the treatment of septic arthritis. Nine agents should be avoided due to their dose-dependent chondrotoxic effects. Further studies are needed to clarify the safety of these medications for human intra-articular use.
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The primary indications for performing a medial closing wedge distal femoral osteotomy are valgus knee malalignment, lateral knee compartment overload, lateral meniscus insufficiency, and/or lateral compartment osteoarthritis or cartilage damage. Without correction of this malalignment, there is an increased risk for chondral damage in the lateral and patellofemoral compartment of the knee. The optimal candidates for this procedure are young, active individuals with moderate to severe arthritis in the lateral compartment. Recently, preoperative planning for high tibial and distal femoral osteotomies (HTOs and DFOs) using 3-dimensional (3D) patient-specific instrumentation (PSI) has increased in popularity. Successful patient outcomes have been reported using this technique. This Technical Note illustrates our preferred technique that uses 3D PSI in addition to a patellar OCA transplant when treating a symptomatic cartilage lesion associated with genu valgum.
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Ulnar collateral ligament (UCL) reconstruction of the medial elbow is considered to be the gold standard for treating valgus instability seen in overhead throwing athletes. The first UCL construction was performed by Frank Jobe in 1974, and this procedure has evolved over time to include multiple techniques that improved the biomechanical strength of the graft fixation and maximize the rate of return to athletic competition for these patients. The most common UCL-reconstruction technique used today is the docking technique. The purpose of this Technical Note is to describe our technique, including pearls and pitfalls, which combines the many advantages of the docking technique with a proximal single-tunnel suspensory fixation technique. This method allows for optimal tensioning of the graft, allowing for secure fixation that relies on metal implants as opposed to tying sutures over a proximal bone bridge.
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CASE: An 18-year-old male polytrauma patient sustained a high-energy posterior fracture dislocation of his left elbow associated with a comminuted and irreparable O'Driscoll type 2 subtype 3 anteromedial facet coronoid fracture. He underwent early coronoid reconstruction using ipsilateral olecranon osteoarticular autograft with incorporation of the sublime tubercle attachment of the medial collateral ligament and repair of the lateral ulnar collateral ligament. A 3-year follow-up revealed a functional, painless, congruent, and stable elbow. CONCLUSION: Early reconstruction of a highly comminuted coronoid fracture may be a useful salvage option for the polytrauma patient, thereby avoiding complications associated with late reconstruction of posttraumatic elbow instability.
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Articulación del Codo , Fracturas Óseas , Fracturas Conminutas , Luxaciones Articulares , Inestabilidad de la Articulación , Traumatismo Múltiple , Olécranon , Fracturas del Cúbito , Masculino , Humanos , Adolescente , Articulación del Codo/cirugía , Olécranon/cirugía , Fracturas del Cúbito/cirugía , Fracturas del Cúbito/complicaciones , Autoinjertos , Inestabilidad de la Articulación/cirugía , Fracturas Óseas/complicaciones , Fracturas Conminutas/cirugía , Fracturas Conminutas/complicaciones , Luxaciones Articulares/diagnóstico por imagen , Luxaciones Articulares/cirugía , Luxaciones Articulares/complicaciones , Traumatismo Múltiple/cirugía , Traumatismo Múltiple/complicacionesRESUMEN
BACKGROUND: Glenoid bone loss is a critical factor in the management of anterior shoulder instability (ASI). Computed tomography (CT) is often considered the gold standard to evaluate glenoid bone loss, but it is associated with negative factors such as radiation. Thus, interest exists as to when orthopaedic surgeons need a CT scan to guide decision-making when treating ASI. PURPOSE: To determine whether information gained from a shoulder CT scan alters orthopaedic surgeons' management plan for ASI and, secondarily, to determine whether surgeon- and patient-specific factors affect whether a CT scan changes treatment and which clinical factors are most important in surgical decision-making. STUDY DESIGN: Cross-sectional study. METHODS: A questionnaire composed of 24 ASI vignettes was administered to Herodicus Society members, American Shoulder and Elbow Surgeons Neer Circle members, and sports medicine fellowship-trained orthopaedic surgeons. Participants chose their recommended surgical treatment from the options of arthroscopic Bankart repair, open Bankart repair, bony reconstruction procedure, or other based on patient history, radiographs, and magnetic resonance imaging. Participants were then shown CT images and asked whether their treatment plan changed and, if not, whether the CT scan was not necessary or had reinforced their decision. Generalized linear mixed-effects logistic regression modeling was performed to assess the influence of vignette and respondent characteristics on treatment decisions. RESULTS: A total of 74 orthopaedic surgeons completed the survey; 96% were fellowship trained (sports medicine, 50%; shoulder and elbow surgery, 41%), and 66% practiced in academic settings. CT imaging did not change the selected treatment strategy in 75.6% of responses. In cases when management did not change, surgeons reported that the CT scan reinforced their decision in 53.4% of responses and was not necessary for decision-making in 22.2% of responses. Decision-making was more likely to be changed after CT in male patients and those with off-track lesions. CONCLUSION: Information gained from a CT scan did not alter treatment decision-making in three-quarters of vignettes among surgeons experienced in the management of ASI. The finding that CT scans did alter the treatment plan in nearly a quarter of cases is not insignificant, and it appears that in patients with borderline glenoid track status and few other risk factors for recurrence after arthroscopic stabilization, CT imaging is more likely to change management.
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Inestabilidad de la Articulación , Luxación del Hombro , Articulación del Hombro , Humanos , Masculino , Articulación del Hombro/diagnóstico por imagen , Articulación del Hombro/cirugía , Articulación del Hombro/patología , Luxación del Hombro/diagnóstico por imagen , Luxación del Hombro/cirugía , Luxación del Hombro/complicaciones , Hombro , Inestabilidad de la Articulación/diagnóstico por imagen , Inestabilidad de la Articulación/cirugía , Inestabilidad de la Articulación/complicaciones , Estudios Transversales , Artroscopía/métodos , Tomografía Computarizada por Rayos X/métodos , Recurrencia , Estudios RetrospectivosRESUMEN
Background: Despite technical advancement, elbow ulnar collateral ligament (UCL) reconstruction is a challenging procedure due to the limitations regarding the challenging tunnel placement and potential injury to the ulnar nerve. Furthermore, current techniques for reconstruction and repair are inferior functionally and biomechanically when compared to native UCL tissue. A modified docking technique using a single-tunnel proximal suspensory fixation may reduce complications and potentially provide a technique for UCL reconstruction that is biomechanically superior. Decreasing the number of bone tunnels decreases the number of places that bone tear through could occur. The purpose was to evaluate and compare the biomechanical performances for 2 elbow UCL reconstruction techniques: (1) standard docking technique (SD) and (2) a proximal single tunnel (PST) technique using a suspensory fixation. We hypothesized that the PST technique would be biomechanically superior to the SD technique. Methods: Twelve matched pairs of cadaveric elbows were dissected and fixed at 70 degrees for biomechanical testing. Gracilis grafts were used for a docking reconstruction and the modified reconstruction with a PST suspensory fixation. A cyclic valgus torque protocol was used to precondition specimens for either reconstruction technique and the ulnohumeral gapping was then assessed. Following gapping measurements, postsurgical specimens underwent a valgus rotation applied at a rate of 5°/s until the anterior band of the UCL failed or fracture occurred. Ultimate load to failure, stiffness, and mode of failure were recorded. Results: There were no statistical differences between the two groups. Mean rotational stiffness of the SD (2.3 ± 0.6 Nm/deg) compared to the PST (1.9 ± 0.7 Nm/deg) (P = .41) and mean ultimate failure torque of the SD (30.5 ± 9.2 Nm) compared to the PST (30.9 ± 8.6 Nm) (P = .86) were similar. There was also no statistically significant difference (P = .83) when comparing the native UCL ulnohumeral gapping (6.0 ± 2.0 mm) to the mean ulnohumeral gapping of the SD reconstruction (6.0 ± 1.8 mm). Conclusions: This study compares the biomechanical strength of elbow UCL reconstructions performed using the SP technique to that of a PST technique. Among all tested parameters, including ultimate failure torque, stiffness, and ulnohumeral gapping, there were no statistically significant differences between the 2 techniques.
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While functional reconstruction of massive irreparable rotator cuff tears remains a challenge, current techniques aimed at recentering and preventing superior migration of the humeral head allow for clinical and biomechanical improvements in shoulder pain and function. Recentering of the glenohumeral joint reduces the moment arm and helps the deltoid to recruit more fibers, which compensates for insufficient rotator cuff function and reduces joint pressure. In the past, the concept of a superior capsular reconstruction with a patch secured by suture anchors has been used. However, several innovative arthroscopic treatment options have also been developed. The purpose of this article is to present an overview of new strategies and surgical techniques and if existing present initial clinical results. Techniques that will be covered include rerouting the long head of the biceps tendon, utilization of the biceps tendon as an autograft to reconstruct the superior capsule, utilization of a semitendinosus tendon allograft to reconstruct the superior capsule, superior capsular reconstruction with dermal allografts, and subacromial spacers.
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Superior capsular reconstruction (SCR) was developed as a minimally invasive, innovate technique to restore normal shoulder biomechanics for patients who present with massive, irreparable rotator cuff tear (MIRCTs) that preclude shoulder arthroplasty. Current studies have shown that SCR for MIRCTs result in excellent short-term clinical outcomes, adequate pain relief, and functional improvement with low graft failure and complication rates. This article aims to critically evaluate the biomechanics, indications, procedural considerations, clinical outcomes, rehabilitation program, and complications associated with the SCR procedure.
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Lesiones del Manguito de los Rotadores , Articulación del Hombro , Humanos , Lesiones del Manguito de los Rotadores/cirugía , Articulación del Hombro/cirugía , Rango del Movimiento Articular , Fenómenos BiomecánicosRESUMEN
Background: While sex-based differences in outcomes after hip arthroscopic surgery for femoroacetabular impingement syndrome (FAIS) are often recorded, no studies have been dedicated to analyzing the literature as a whole. Purpose: To investigate whether sex is a predictor of outcomes in studies evaluating hip arthroscopic surgery for FAIS. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review was conducted following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. We searched the PubMed, Embase, Cochrane, Ovid, and PubMed Central databases for English-language studies that evaluated sex-specific outcomes in human populations. The search terms used were as follows: ("Hip Arthroscopy") AND ("Femoroacetabular Impingement" OR "FAI") AND ("Sex" OR "Gender" OR "Male" OR "Female"). Studies with evidence levels 2 through 4 were included. The studies were then screened, followed by data extraction. Modified Harris Hip Score (mHHS) outcomes and return-to-sport (RTS) rates were recorded. These were analyzed using random-effects meta-analysis. Heterogeneity was calculated using the I 2 statistic. Results: Of 256 full-text articles screened, 48 articles were included in this analysis; of these, 14 studies (29%) concluded that female sex was a negative predictor of postoperative outcomes, while 6 studies (13%) found female sex to be positive predictor. The remaining 28 studies (58%) found no sex-based differences in postoperative outcomes. Of 7 studies (416 male and 519 female) included in the mHHS analysis, 2 studies concluded that male patients had significantly higher postoperative mHHS scores. Of 6 studies (502 male and 396 female) included in the RTS analysis, 1 study concluded that male patients had a significantly higher RTS rate. Conclusion: Almost one-third of the included studies determined that female sex was a negative predictor of postoperative outcomes, 13% found female sex to be a positive predictor, and 58% found no sex-based differences. Our study illustrates an insufficiency of high-level evidence supporting sex-specific differences in outcomes after hip arthroscopic surgery, but findings indicated that the postoperative mHHS score and RTS rate may be influenced by sex.
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Background: Anterior shoulder instability (ASI) is a frequently encountered pathology. Patients with a history of ASI have an increased rate of developing glenohumeral osteoarthritis and becoming candidates for shoulder arthroplasty. This systematic review aims to synthesize outcomes for patients undergoing shoulder arthroplasty with a history of ASI. Methods: A comprehensive literature review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) using PubMed, Embase, OVID Medline, Scopus, CINAHL, Web of Science, and Cochrane databases for studies evaluating the impact of prior ASI on total shoulder arthroplasty (TSA), reverse TSA, and/or hemiarthroplasty outcomes, with a minimum follow-up of 12 months. Studies were graded by level of evidence and data concerning patient demographics and outcomes were extracted. Results: Sixteen articles met the inclusion criteria, including 596 patients (413 male, 181 female). The average age of the control and prior ASI groups were 57.5 and 57.0 years, respectively. Overall, 251 patients were treated operatively, 132 nonoperatively, and 213 were controls without a history of prior ASI. Shoulder arthroplasty techniques included TSA (436 shoulders), reverse TSA (130 shoulders), and hemiarthroplasty (14 shoulders). Prior anterior stabilization management included soft tissue repair, bony augmentation, and nonoperative treatment. Almost all studies reported no significant difference in subjective and functional arthroplasty outcomes between control and prior ASI groups, or between patients with prior ASI treated nonoperatively vs. surgically. Conclusion: Shoulder arthroplasty in the setting of prior ASI results in improved subjective and functional outcome scores that are comparable to patients without a history of instability.
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Platelet-rich plasma (PRP) is a promising therapy treatment option for multiple orthopedic conditions, which has demonstrated expanding clinical use. With increased clinical use of PRP, there has been a greater demand for point-of-care (POC) biologic devices. For this review, publicly available information provided by the device corporations, PubMed, Medline, and Embase databases were searched for studies related to POC device function. A scoping review study design was selected to explore the breadth of knowledge in the literature regarding PRP POC devices. ProofPoint Biologics demonstrated the highest laboratory platelet increase (5.2 ± 0.28-fold) and the longest processing time (49 ± 1.4 minutes). Celling demonstrated the lowest laboratory platelet increase (2.7 ± 0.8-fold), while AcCELLerated had the fastest processing time (18 ± 1.4 minutes for PurePRP® AB60 Pure (Pure Accelerated Biologics, Tequesta, FL) and 13.5 ± 2.1 minutes for AbsolutePRP® (Emcyte Corporation, Fort Myers, FL)). Celling had the lowest cost out of the various biologic devices. There is significant variability in the technical features, cost, processing time, and centrifugation parameters of the different commercially available point-of-care devices.
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â¤: Orthobiologics encompass numerous substances that are naturally found in the human body including platelet-rich plasma (PRP), isolated growth factors, and cell therapy approaches to theoretically optimize and improve the healing of cartilage, fractures, and injured muscles, tendons, and ligaments. â¤: PRP is an autologous derivative of whole blood generated by centrifugation and is perhaps the most widely used orthobiologic treatment modality. Despite a vast amount of literature on its use in osteoarthritis as well as in tendon and ligament pathology, clinical efficacy results remain mixed, partly as a result of insufficient reporting of experimental details or exact compositions of PRP formulations used. â¤: Mesenchymal stromal cells (MSCs) can be isolated from a variety of tissues, with the most common being bone marrow aspirate concentrate. Similar to PRP, clinical results in orthopaedics with MSCs have been highly variable, with the quality and concentration of MSCs being highly contingent on the site of procurement and the techniques of harvesting and preparation. â¤: Advances in novel orthobiologics, therapeutic targets, and customized orthobiologic therapy will undoubtedly continue to burgeon, with some early promising results from studies targeting fibrosis and senescence.
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Osteoartritis , Plasma Rico en Plaquetas , Tratamiento Basado en Trasplante de Células y Tejidos , Humanos , Ligamentos/lesiones , Osteoartritis/terapia , Plasma Rico en Plaquetas/fisiología , Tendones/metabolismoRESUMEN
Background: Rotator cuff repair (RCR) is a well-studied procedure. However, the impact of patient sex on outcomes after RCR has not been well studied. Purpose: To conduct a systematic review and meta-analysis of sex-based differences in outcomes after RCR and to record what proportion of studies examined this as a primary or secondary purpose. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review was performed using multiple databases according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Studies were included if they were written in English, performed on humans, consisted of patients who underwent RCR, evaluated at least 1 of the selected outcomes based on patient sex, and had statistical analysis available for their sex-based claim. Excluded were case reports, review studies, systematic reviews, cadaveric studies, and studies that did not report at least 1 sex-specific outcome or included certain other injuries associated with a rotator cuff injury. Results: Of 9998 studies screened and 1283 full-text studies reviewed, 11 (0.11%) studies with 2860 patients (1549 male and 1329 female) were included for quantitative analysis. None of these 11 studies examined the impact of patient sex on outcomes after RCR as a primary outcome. Postoperative Constant-Murley scores were analyzed for 7 studies. Male patients had a postoperative Constant-Murley score of 76.77 ± 15.94, while female patients had a postoperative Constant-Murley score of 69.88 ± 17.02. The random-effects model showed that male patients had significantly higher scores than female patients, with a mean difference of 7.33 (95% CI, 5.21-9.46; P < .0001). Analysis of retear rates in 5 studies indicated that there was no difference in the retear rate between sexes (odds ratio, 0.91 [95% CI, 0.49-1.67]). Conclusion: Female patients had lower postoperative Constant-Murley scores compared with male patients, but there was no difference in the retear rate. However, these results were based on an analysis of only 11 studies. The paucity of studies examining the impact of sex suggests that more research is needed on the impact of patient sex on outcomes after RCR.
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Purpose: To analyze the literature to compare outcomes and complications following primary lateral ankle ligament repair compared with lateral ankle ligament reconstruction and the suture tape augmentation in patients with lateral ankle instability. Methods: Following the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) criteria, a systematic literature review using the PubMed/Ovid Medline database was performed (October 11, 1947, to October 1, 2019). Clinical trials that included all the following criteria were considered eligible; published in the English language; patients undergoing primary lateral ankle repair or reconstruction with/without autograft or allograft (anterior talofibular ligament, anterior talofibular ligament + calcaneofibular ligament) or suture tape augmentation; a follow-up at least 1 year; reported least 1 of the measured outcomes (The American Orthopaedic Foot Ankle Score, Karlsson Score, return to sport [RTS], complications, skin wound complications, reoperation). Surgical techniques were evaluated, and studies were subdivided by the following categories: primary repair (PR), reconstruction with graft (GR), and suture tape augmentation (STA). Complications, radiographic outcomes, functional outcome scores, and RTS were analyzed. Results: A total of 41 of 1,991 studies met the criteria for final analysis. This included 1,920 patients who underwent surgical intervention for chronic lateral instability with at least a 1-year follow-up. There were 350 patients who had GR, 1,486 who underwent the PR, and 84 who had STA. GR group appeared to have the lowest rate of complications: GR 3.1% (11 of 350), PR 4.2% (63 of 1486), and STA 10.7% (9 of 84). Postoperative American Orthopaedic Foot Ankle Score ranged from 89.0 to 95.1 for GR and 90.0 to 98.8 for PR. Postoperative Karlsson scores ranged from 80.9 to 94.4 for GR and from 89.2 to 94.1 for PR. Anterior drawer postoperative scores ranged from 1.4 to 30.3 mm for GR, 2.7 to 8.6 mm for PR, and 4.1 to 4.2 mm for STA. Postoperative talar tilt ranged from 2.4 to 7.3° for GR, 1.9 to 6.0° for PR, and 3.6 to 4.5° for STA. RTS ranged from 9.5 to 20.4 weeks for the PR group; one study reported a RTS of 10.6 weeks for STA. Conclusions: Excellent outcomes were noted across all intervention groups. Current literature may suggest there is no difference in functional outcomes between patients treated with PR versus GR. However, there may be a potential improvement in functional outcomes with PR versus STA. Level of Evidence: Level IV, systematic review of Level I to Level IV studies.
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BACKGROUND: Numerous studies have demonstrated an increase in the number of anterior cruciate ligament (ACL) reconstruction procedures performed in pediatric patients. Despite this, most knowledge of surgical site infection rates after these procedures are based on adult studies and data is currently limited in pediatric patients. The purpose of this study was to describe and analyze the rates of infection after ACL reconstruction among pediatric patients and adolescent patients (compared with young adult patients) utilizing the MarketScan Commercial Claims and Encounters Database. METHODS: The Truven Health Analytics MarketScan Commercial Claims and Encounters database was assessed to access health care utilization data for privately insured individuals aged 5 to 30 years old. ACL reconstruction records performed between 2006 and 2018 were identified using Current Procedures Terminology (CPT) codes. International Classification of Diseases Ninth Revision (ICD-9), Tenth (ICD-10) codes and CPT codes were used to identify patients requiring treatment for infection. All patients had at least 180 days of insurance coverage after intervention. RESULTS: A total of 44,501 individuals aged below 18 years old and 63,495 individuals aged 18 to 30 years old that underwent arthroscopic ACL reconstruction were identified. There were no differences in infection rates between those below 18 years old (0.52%) and those above 18 years old (0.46%, P=0.227). However, among patients below 18 years old, patients below 15 years old had a significantly lower rate of infection at 0.37% compared with adolescents (15 to 17 y old) at 0.55% (P=0.039). Among young adults, males had higher rates of infection than females (0.52% vs. 0.37%), while no difference was observed in the pediatric and adolescent population (0.58% vs. 0.47%, P=0.109). CONCLUSION: Utilizing an insurance database, this study demonstrated that rates of infection after ACL Reconstruction in a pediatric/adolescent population are low (0.52%) and similar to rates in young adults. Infection rates after ACLR reconstruction appear to be slightly lower in patients under 15 years of age (0.37%). LEVEL OF EVIDENCE: Level III-Retrospective comparative study.
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Lesiones del Ligamento Cruzado Anterior , Reconstrucción del Ligamento Cruzado Anterior , Infección de la Herida Quirúrgica , Adolescente , Adulto , Lesiones del Ligamento Cruzado Anterior/epidemiología , Lesiones del Ligamento Cruzado Anterior/cirugía , Reconstrucción del Ligamento Cruzado Anterior/efectos adversos , Niño , Preescolar , Bases de Datos Factuales , Femenino , Humanos , Masculino , Estudios Retrospectivos , Infección de la Herida Quirúrgica/epidemiología , Adulto JovenRESUMEN
BACKGROUND: Despite the significant difference between men and women in incidence of anterior cruciate ligament (ACL) injuries, there is a paucity of consistent information on the influence of patient sex on outcomes after ACL reconstruction. A previous meta-analysis has demonstrated that female patients have worse outcomes with regard to laxity, revision rate, Lysholm score, and Tegner activity score and are less likely to return to sports (RTS). PURPOSE: To conduct a systematic review and meta-analysis to evaluate and compare sex-specific outcomes after ACL reconstruction. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: A systematic review was performed using PubMed, PubMed Central, Embase, OVID, and Cochrane databases per PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The following search terms were used: "anterior cruciate ligament reconstruction" OR "ACL reconstruction" OR "anterior cruciate ligament" OR "ACL" AND "gender" OR "sex" OR "male" OR "female" AND "outcome" AND "2015-Present" to gather all relevant articles between 2015 and 2020. A risk-of-bias assessment and quality assessment was conducted on included studies. RESULTS: Of 9594 studies initially identified, 20 studies with 35,935 male and 21,455 female patients were included for analysis. The 7 studies reporting International Knee Documentation Committee (IKDC) scores showed that male patients had statistically significantly higher postoperative scores (mean difference, 3.02 [95% CI, 1.19-4.84]; P< .01; I 2 = 66%), and 7 studies that reported the rate of ACL revision showed there was no significant difference between male and female patients (odds ratio, 0.85 [95% CI, 0.45-1.60]; P = .61; I 2 = 94%). The 7 studies that reported rates of rerupture showed that males were significantly more likely than females to have a graft rerupture (odds ratio, 1.35 [95% CI, 1.22-1.50]; P < .01; I 2 = 0%). Male patients reported a higher RTS rate than did their female counterparts (59.82% compared with 42.89%); however, no formal statistical analysis could be done because of the variability in reporting techniques. CONCLUSION: Male and female patients with ACL injuries demonstrated similar outcomes regarding their rates of revision; however, male patients were found to have statistically significantly higher postoperative IKDC scores but at the same time higher rerupture rates. Our findings suggest that sex-based differences in outcomes after ACL reconstruction vary based on which metric is used. These results must be considered when counseling patients with ACL injuries.
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INTRODUCTION: Rehabilitation after a superior labral anterior posterior (SLAP) repair is an important aspect of patient outcomes; however, no standardized rehabilitation protocol has been defined. The purpose of this paper is to assess the variability of rehabilitation after a SLAP repair to understand the need for standardization to improve patient outcomes. METHODS: Protocols for SLAP repairs were collected through a search for Academic Orthopedic Programs and a general Google search using the terms "[Program Name (if applicable)] SLAP Repair Rehab Protocol". Protocols were compared by sling, range of motion (ROM), physical therapy, return to sport (RTS), return to throwing, and biceps engagement and tenodesis recommendations. Protocols for non-operative or generalized shoulders were excluded. RESULTS: Sixty protocols were included. A total of 61.7% (37/60) recommended a sling for four to six weeks and 90% (54/60) included a full ROM recommendation, but time was variable. There were different exercises recommended, but pendulum swings were recommended by 53% (32/60), submaximal isometrics by 55% (33/60), and scapular strengthening by 65% (39/60). Of the sixty protocols, 33% (20/60) recommended return to sports in 24 weeks and 38.3% (23/60) recommended allowing throwing in 16 weeks. CONCLUSIONS: There was variability in protocols for SLAP repair, especially time until full ROM, RTS, and biceps strengthening. Time in sling and scapular strengthening were the least variable. A lack of specificity within protocols in what return to throwing meant for functional ability made it difficult to compare protocols. Considering the large number of orthopedic programs, a relatively small number had published protocols. Further studies are needed to evaluate a standardized post-operative rehabilitation for SLAP repairs to improve outcomes.
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BACKGROUND: The glenoid track (GT) concept illustrates how the degree of glenoid bone loss and humeral bone loss in the glenohumeral joint can guide further treatment in a patient with anterior instability. The importance of determining which lesions are at risk for recurrent instability involves imaging of the glenohumeral joint, but no studies have determined which type of imaging is the most appropriate. PURPOSE/HYPOTHESIS: The purpose of this study was to determine the validity and accuracy of different imaging modalities for measuring the GT in shoulders with recurrent anterior instability. We hypothesized that 3-dimensional computed tomography (3D-CT) would be the most accurate imaging technique. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: A systematic review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using PubMed, Scopus, Medline, and Cochrane libraries between database inception and July 2019. We included all clinical trials or cadaveric studies that evaluated imaging modalities for assessing the GT. RESULTS: A total of 13 studies were included in this review: 1 study using 2-dimensional CT, 6 studies using 3D-CT, 4 studies using magnetic resonance imaging (MRI), 1 study using magnetic resonance arthrography (MRA)/MRI, and 1 study combining CT and MRI. The mean sensitivity, specificity, and accuracy for 2D-CT was 92%, 100%, and 96%, respectively. For MRI, the means were 72.2%, 87.9%, and 84.2%, respectively. No papers included 3D-CT metrics. The mean intraclass correlation coefficients (ICCs) for intraobserver reliability were 0.9046 for 3D-CT and 0.867 for MRI. ICCs for interobserver reliability were 0.8164, 0.8845, and 0.43 for 3D-CT, MRI, and MRA/MRI, respectively. CONCLUSION: There is evidence to support the use of both CT and MRI imaging modalities in assessing the GT. In addition, few studies have compared radiographic measurements with a gold standard, and even fewer have looked at the GT concept as a predictor of outcomes. Thus, future studies are needed to further evaluate which imaging modality is the most accurate to assess the GT.