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PURPOSE: To identify risk factors associated with increased postoperative opioid consumption and inferior pain outcomes following knee and shoulder arthroscopy. METHODS: Using the data set from the NonOpioid Prescriptions after Arthroscopic Surgery in Canada (NO PAin) trial, eight prognostic factors were chosen a priori to evaluate their effect on opioid consumption and patient-reported pain following arthroscopic knee and shoulder surgery. The primary outcome was the number of oral morphine equivalents (OMEs) consumed at 2 and 6 weeks postoperatively. The secondary outcome was patient-reported postoperative pain using the Visual Analogue Scale (VAS) at 2 and 6 weeks postoperatively. A multivariable linear regression was used to analyse these outcomes with eight prognostic factors as independent variables. RESULTS: Tobacco usage was significantly associated with higher opioid usage at 2 (p < 0.001) and 6 weeks (p = 0.02) postoperatively. Former tobacco users had a higher 2-week (p = 0.002) and cumulative OME (p = 0.002) consumption compared to current and nonsmokers. Patients with a higher number of comorbidities (p = 0.006) and those who were employed (p = 0.006) reported higher pain scores at 6 weeks. Patients in the 'not employed/other' category had significantly lower pain scores at 6 weeks postoperatively (p = 0.046). CONCLUSION: Former smoking status was significantly associated with increased post-operative opioid consumption following knee and shoulder arthroscopy at 2 and 6 weeks postoperatively. Increased pain was found to be significantly associated with employment status and an increasing number of comorbidities at 6 weeks postoperatively. These findings can aid clinicians in identifying and mitigating increased opioid utilization as well as worse pain outcomes in high-risk patient populations. LEVEL OF EVIDENCE: Level III, cohort study.
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PURPOSE: The aim of this study was to determine how preoperative health-related quality of life (HRQoL) is affected by the duration of the wait time (WT) for anterior cruciate ligament reconstruction (ACLR) once a decision is made to proceed with surgery. METHODS: This was a multi-centre prospective cohort study. One hundred and twenty-two patients 14 years of age and above waiting for ACLR completed the International Knee Documentation Committee (IKDC) demographic, current health assessment and subjective knee evaluation (SKF) forms on the day of decision to operate and the day of surgery. Changes in scores were analyzed for the entire cohort, adjusted for WTs and a subset was compared for patients with isolated anterior cruciate ligament (ACL) tears and ACL tears with concurrent meniscal involvement. Changes in HRQoL scores from the day of the decision to operate to the 9-month postoperative appointments were also assessed. RESULTS: Energy/Fatigue (p < 0.05), Pain (p < 0.05), General Health (p < 0.05) and the IKDC-SKF Score (p < 0.05) significantly increased between the day of the decision to operate and the day of surgery. Only the change in IKDC-SKF score remained significantly higher after adjusting for WT. Baseline HRQoL scores significantly improved by the 9-month postoperative appointment. CONCLUSION: The length of time waiting for ACLR did not adversely influence HRQoL in this study. However, low preoperative HRQoL and the significant improvement in HRQoL of patients followed postoperatively suggest that timely surgery is beneficial for this patient population. LEVEL OF EVIDENCE: Level II.
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PURPOSE: To evaluate the current body of evidence surrounding the diagnosis, management, and clinical outcomes of adhesions that developed after hip arthroscopy (HA). METHODS: A systematic search of the MEDLINE, Embase, Web of Science, and CENTRAL (Cochrane Central Register of Controlled Trials) databases was designed and conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. Eligible studies included patients with confirmed adhesions after HA that reported one or more of the following: (1) diagnostic procedures and criteria used; (2) indications for and details surrounding surgical management; and (3) clinical outcomes after the operative management of adhesions (e.g., patient-reported outcome measures). RESULTS: Nineteen studies involving a total of 4,145 patients (4,211 hips; 38% female sex) were included in this review. The quality of evidence was found to be fair for both comparative studies (mean, 17; range, 13-21) and noncomparative studies (mean, 10; range, 5-12) according to the Methodological Index for Non-randomized Studies (MINORS) instrument, with the level of evidence ranging from IIB to IV. Adhesions were often diagnosed intraoperatively at the time of revision surgery (10 of 19 studies, 53%), with only 3 studies specifying the criteria used to adjudicate adhesions. The most common indication for operative management (i.e., release or lysis of adhesions) was persistent pain (9 of 19, 47%), but this was often grossly stated for revision HA rather than being specific to adhesions. Patient-reported outcome measures were the most reported postoperative outcomes (9 of 19, 47%) and generally showed significant improvement from preoperative assessment across the short-term follow-up period (range, 24.5-38.1 months). There was a paucity of objective measures of clinical improvement (3 of 19, 16%) and of mid- and long-term follow-up (i.e., 5-7 years and ≥10 years, respectively). CONCLUSIONS: Despite the growing body of evidence suggesting that adhesions are highly contributory to revision HA, there is ambiguity in the diagnostic approach and indications for operative management of adhesions. Additionally, although the operative management of adhesions after HA has shown satisfactory clinical outcomes in the short term, there is a paucity of research elucidating the mid- to long-term outcomes, as well as minimal use of objective assessment of clinical improvement (e.g., biomechanics). LEVEL OF EVIDENCE: Level IV, systematic review of Level II to IV studies.
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PURPOSE: The purpose of the study was to identify prognostic risk factors for prolonged opioid use at 2 and 6 weeks after hip arthroscopy using data from the Femoroacetabular Impingement RandomiSed controlled Trial and its external validation cohort study. METHODS: Opioids were prescribed for postoperative pain management at the surgeon's discretion, with a majority being prescribed a combination of oxycodone and paracetamol (5/325 mg). Prolonged opioid use was defined as the ongoing use of any dosage of opioids reported at either 2 or 6 weeks after surgery to treat femoroacetabular impingement, as recorded in the patient's study medication log. Multivariable logistic regressions were performed to evaluate patient and surgical characteristics, such as preoperative opioid use, type of surgical procedure and intraoperative cartilage state that may be associated with prolonged opioid use at either 2 and 6 weeks postoperatively. RESULTS: A total of 265 and 231 patients were included for analysis at 2 and 6 weeks postoperatively, respectively. The median age of participants was 35 years (interquartile range [IQR]: 27-42) and 33% were female. At 2 weeks postoperatively, female sex (odds ratio [OR]: 2.56; 95% confidence interval: [CI] 1.34-4.98, p = 0.005), higher body mass index (BMI) (OR: 1.10; 95% CI: 1.02-1.18, p = 0.009), active tobacco use (OR: 4.06; 95% CI: 1.90-8.97, p < 0.001), preoperative opioid use (OR: 10.1; 95% CI: 3.25-39.1, p < 0.001) and an Outerbridge classification of ≥3 (OR: 2.33; 95% CI: 1.25-4.43, p = 0.009) were significantly associated with prolonged opioid use. At 6 weeks postoperatively, only preoperative opioid use was significantly associated with prolonged opioid consumption (OR: 10.6; 95% CI: 3.60-32.6, p < 0.001). CONCLUSION: Preoperative opioid use was significantly associated with continued opioid use at 2 and 6 weeks postoperatively. Specific patient factors including female sex, higher BMI, active tobacco use and more severe cartilage damage should be considered in developing targeted strategies to limit opioid use after surgery. LEVEL OF EVIDENCE: Level III.
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Analgésicos Opioides , Artroscopía , Pinzamiento Femoroacetabular , Dolor Postoperatorio , Humanos , Femenino , Masculino , Pinzamiento Femoroacetabular/cirugía , Analgésicos Opioides/uso terapéutico , Analgésicos Opioides/administración & dosificación , Adulto , Dolor Postoperatorio/tratamiento farmacológico , Factores de Riesgo , Estudios de Cohortes , Factores Sexuales , Acetaminofén/uso terapéutico , Acetaminofén/administración & dosificaciónRESUMEN
Slipped capital femoral epiphysis (SCFE) is a common adolescent hip disorder that can lead to complex proximal femur deformities and devastating consequences such as avascular necrosis, femoroacetabular impingement syndrome and early-onset osteoarthritis. Existing surgical techniques are often insufficient to fully address the constellation of multiplanar deformities in patients with severe SCFE. Therefore, the McMaster Osteotomy, a novel intertrochanteric proximal femur osteotomy, was developed to improve anatomic correction and hip mechanics in patients with chronic SCFE. The McMaster Osteotomy was implemented in two patients (A: 16-year-old male, B: 17-year-old female) with proximal femur deformities due to chronic SCFE. Surgical planning was facilitated with a 3D-printed pelvic model generated from a CT scan of a patient with the SCFE deformity. Patient B also underwent concurrent arthroscopic osteochondroplasty and labral repair. Pre- and post-operative function and radiographic measurements were recorded. Post-operatively, patient A's neck-shaft angle improved from 125° to 136°, Southwick angle from 52° to 33°, neck length from 66 mm to 80 mm and hip internal rotation from 5° to 25°. Patient B's post-operative neck-shaft angle improved from 122° to 136°, Southwick angle from 25° to 15°, neck length from 76 mm to 84 mm, hip internal rotation from 5° to 20° and alpha angle from 87.6° to 44.3°. Both patients are pain-free and have obtained full union of their osteotomies. The McMaster Osteotomy is a versatile technique that can produce a more anatomic reconstruction of hip anatomy and restoration of abductor mechanics. As an extracapsular technique, the risk of femoral head avascular necrosis is minimized.
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PURPOSE: To review the postoperative outcomes of arthroscopic surgical options in treating irreparable and hypoplastic labrum of the hip. METHODS: Three online databases (PubMed, MEDLINE, and EMBASE) were searched from database inception to June 27, 2023 to identify literature on treatment strategies for hypoplastic/irreparable acetabular labrum. Data pertaining to classification of irreparable tears or labral hypoplasia, indication for surgery, description of treatment, radiographic findings, and clinical outcomes were recorded and described. The methodological quality of included studies was assessed by the Methodological Index for Non-Randomized Studies (MINORS) criteria. RESULTS: Seven level IV case series, eleven level III retrospective cohort studies, and two level II prospective cohort studies comprising 1937 patients were included for analysis. Studies were divided into an irreparable labral group comprising 1002 patients and a hypoplastic labral group comprising 935 patients. Treatments included repair, augmentation, or reconstruction. In the irreparable group, 12 studies recorded improvement of modified Harris Hip Score (mHHS) with preoperative scores ranging from 50.3 to 67.3 and postoperative scores ranging from 76.2 to 95.0. The rate of conversion to total hip arthroplasty (THA) and rate of revision arthroscopy were 6.6% and 5.9%, respectively across all studies. In the hypoplastic group, two studies that focused on repair noted no statistical difference in mHHS for repair in hypoplastic labrum vs repair in non-hypoplastic labrum. One study showed that there was a difference in post-operative mHHS for labral repair for hypoplastic vs non-hypoplastic labrum, with repair in non-hypoplastic labrum showing superior mHHS (p â< â0.001). CONCLUSION: The findings of this review suggest that treatment of irreparable labra with reconstruction or augmentation results in improved patient-reported outcome measures (PROMs). For the hypoplastic labrum, primary repair also results in improvement in PROMs. Future studies focusing on the hypoplastic labra alone with an appropriate control group, rather than irreparable labral tears, are needed to properly assess patient outcomes and guide surgical indications.
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IMPORTANCE: Anterolateral augmentation during primary anterior cruciate ligament (ACL) reconstruction (ACLR) may lower rates of ACL graft failure. However, differences in costs between two techniques, lateral extra-articular tenodesis (LET) and anterolateral ligament reconstruction (ALLR), are unclear. OBJECTIVE: To perform a systematic review and subsequent cost-effectiveness analysis comparing LET versus ALLR in the setting of primary ACLR. The hypothesis was that LET is more cost-effective than ALLR. EVIDENCE REVIEW: A systematic review was conducted on studies in which patients underwent primary ACLR with a concomitant LET or ALLR with minimum 24 months follow-up published between January 2013 and July 2023. Primary outcomes included ACL graft failure rates and Knee Injury and Osteoarthritis Outcome Survey-Quality of Life (KOOS-QoL) subscale scores, which were used to determine health utilities measured by quality-adjusted life years (QALYs) gained. A decision tree model with one-way and two-way sensitivity analyses compared the cost of primary ACLR with a concomitant LET, independent autograft ALLR, or independent allograft ALLR. Costs were estimated using a combination of QALYs, institution prices, literature references, and a survey sent to 49 internationally recognized high-volume knee surgeons. FINDINGS: A total of 2505 knees undergoing primary ACLR with concomitant LET (n=1162) or ALLR (n=1343) were identified from 22 studies. There were 77 total ACL graft failures with comparable failure rates between patients receiving LET versus ALLR (2.9% vs. 3.2%, P=0.690). The average QALYs gained was slightly higher for those who received LET (0.77) compared to ALLR (0.75). Survey results revealed a 5 minute longer median self-reported operative time for ALLR (20 âmin) than LET (15 âmin). The estimated costs for LET, autograft ALLR, and allograft ALLR were $1,015, $1,295, and $3,068, respectively. CONCLUSIONS AND RELEVANCE: Anterolateral augmentation during primary ACLR with LET is more cost-effective than independent autograft and allograft ALLR given the lower costs and comparable clinical outcomes. Surgeons may utilize this information when determining the optimal approach to anterolateral augmentation during primary ACLR, although differences in preferred technique and health care systems may influence operative efficiency and material costs. LEVEL OF EVIDENCE: Systematic review; Level of evidence, IV.
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Lesiones del Ligamento Cruzado Anterior , Reconstrucción del Ligamento Cruzado Anterior , Análisis Costo-Beneficio , Tenodesis , Humanos , Reconstrucción del Ligamento Cruzado Anterior/métodos , Reconstrucción del Ligamento Cruzado Anterior/economía , Tenodesis/métodos , Tenodesis/economía , Lesiones del Ligamento Cruzado Anterior/cirugía , Años de Vida Ajustados por Calidad de Vida , Calidad de Vida , Ligamento Cruzado Anterior/cirugíaRESUMEN
The ligamentum teres (LT) is known to play a role as a secondary stabilizer of the hip joint. LT tears can be associated with hip instability. In patients with borderline developmental dysplasia of the hip (BDDH), the correlation between LT tears and microinstability is even more pronounced because of the increased mechanical stress placed on the ligament. This relationship may lead certain surgeons to consider new indications for LT reconstructions. However, caution is warranted regarding the potential role of LT reconstruction in these patients, particularly since the primary deficiency in BDDH is bony undercoverage. Addressing this bony undercoverage should be a primary consideration that may be supplemented with other procedures, which may include addressing soft-tissue injuries around the hip such as LT tears. This is especially the case in those patients with persistent symptoms after management of labral tears or LT disruption.
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Luxación de la Cadera , Ligamentos Redondos , Humanos , Luxación de la Cadera/cirugía , Articulación de la Cadera/diagnóstico por imagen , Articulación de la Cadera/cirugía , Ligamentos Redondos/lesiones , Artroscopía/métodosRESUMEN
Articular cartilage lesions of the acetabulum may result in significant pain and dysfunction for patients with treatment options consisting of either microfracture or various forms of cartilage restoration procedures. A systematic review of 529 patients demonstrated similar, if not lower, reoperation rates and patient-reported outcomes in patients receiving cartilage restoration procedures compared with microfracture. The primary outcomes examined in this review were reoperation rates and patient-reported outcomes with no clear mention of radiographic outcomes and no clearly defined indications as to who would benefit from a cartilage-based procedure. This raises the question as to whether there should be a consensus-based and standardized criteria established and standardized among the hip preservation expert community to evaluate the success of these cartilage restoration procedures from an imaging standpoint. These criteria can also be incorporated into a composite evaluation that combines clinical, imaging, and patient-reported outcomes to determine optimal patient candidacy for cartilage procedures as well. This would be a very useful steppingstone for much-needed future Level I randomized studies or prospective, registry-based data on this topic.
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Artroscopía , Cartílago Articular , Medición de Resultados Informados por el Paciente , Humanos , Cartílago Articular/cirugía , Cartílago Articular/lesiones , Cartílago Articular/diagnóstico por imagen , Articulación de la Cadera/cirugía , Articulación de la Cadera/diagnóstico por imagen , Acetábulo/cirugía , Acetábulo/diagnóstico por imagen , Acetábulo/lesionesRESUMEN
BACKGROUND: Evidence-based care relies on robust research. The fragility index (FI) is used to assess the robustness of statistically significant findings in randomized controlled trials (RCTs). While the traditional FI is limited to dichotomous outcomes, a novel tool, the continuous fragility index (CFI), allows for the assessment of the robustness of continuous outcomes. PURPOSE: To calculate the CFI of statistically significant continuous outcomes in RCTs evaluating interventions for managing anterior shoulder instability (ASI). STUDY DESIGN: Meta-analysis; Level of evidence, 2. METHODS: A search was conducted across the MEDLINE, Embase, and CENTRAL databases for RCTs assessing management strategies for ASI from inception to October 6, 2022. Studies that reported a statistically significant difference between study groups in ≥1 continuous outcome were included. The CFI was calculated and applied to all available RCTs reporting interventions for ASI. Multivariable linear regression was performed between the CFI and various study characteristics as predictors. RESULTS: There were 27 RCTs, with a total of 1846 shoulders, included. The median sample size was 61 shoulders (IQR, 43). The median CFI across 27 RCTs was 8.2 (IQR, 17.2; 95% CI, 3.6-15.4). The median CFI was 7.9 (IQR, 21; 95% CI, 1-22) for 11 studies comparing surgical methods, 22.6 (IQR, 16; 95% CI, 8.2-30.4) for 6 studies comparing nonsurgical reduction interventions, 2.8 for 3 studies comparing immobilization methods, and 2.4 for 3 studies comparing surgical versus nonsurgical interventions. Significantly, 22 of 57 included outcomes (38.6%) from studies with completed follow-up data had a loss to follow-up exceeding their CFI. Multivariable regression demonstrated that there was a statistically significant positive correlation between a trial's sample size and the CFI of its outcomes (r = 0.23 [95% CI, 0.13-0.33]; P < .001). CONCLUSION: More than a third of continuous outcomes in ASI trials had a CFI less than the reported loss to follow-up. This carries the significant risk of reversing trial findings and should be considered when evaluating available RCT data. We recommend including the FI, CFI, and loss to follow-up in the abstracts of future RCTs.
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PURPOSE: To develop a standardized scoring system to evaluate pre- to post-operative repair or reconstruction of hip cartilage using magnetic resonance imaging (MRI). METHODS: A two-phase modified Delphi study was conducted. Phase 1 involved a survey with suggested criteria and diagrams to define various stages of articular cartilage repair and phase 2 involved an expert consensus meeting that discussed the survey responses and voted on final scoring criteria. The survey was emailed to members of the Canadian Hip Preservation Research Collaborative (CHIPR) and respondents included both board certified orthopedic surgeons as well as musculoskeletal radiologists. RESULTS: Overall, there were 17 survey respondents from Canada and most (47%, 8/17) participants agreed that the minimum MRI protocol needed to evaluate cartilage repair was a 3.0 T MRI and 94% (17/18) agreed that the minimum time post-operatively that they felt they would be able to accurately evaluate cartilage repair on an MRI was 12 months. Following phases 1 and 2, the final Magnetic Resonance Evaluation of the Repair of Cartilage in the Hip (MERCH) score was developed with 7 domains, 3 criteria per domain: 1) volume fill of cartilage defect, 2) integration into adjacent cartilage, 3) surface of the repair tissue, 4) structure of the repair tissue, 5) bony overgrowth, 6) subchondral changes, and 7) delamination. The score ranges from 60 (optimal) to -20 points (worst/none). CONCLUSIONS: This consensus project established a new MRI scoring system to evaluate post-operative cartilage restoration of the hip. The implementation of the MERCH score is essential in our ability to guide patient management and expectations in a rapidly evolving field and will help with standardizing our evaluation of cartilage repair in future research trials. LEVEL OF EVIDENCE: Level II Diagnostic.
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Aims: The aim of this study was to establish consensus statements on the diagnosis, nonoperative management, and indications, if any, for medial patellofemoral complex (MPFC) repair in patients with patellar instability, using the modified Delphi approach. Methods: A total of 60 surgeons from 11 countries were invited to develop consensus statements based on their expertise in this area. They were assigned to one of seven working groups defined by subtopics of interest within patellar instability. Consensus was defined as achieving between 80% and 89% agreement, strong consensus was defined as between 90% and 99% agreement, and 100% agreement was considered to be unanimous. Results: Of 27 questions and statements on patellar instability, three achieved unanimous consensus, 14 achieved strong consensus, five achieved consensus, and five did not achieve consensus. Conclusion: The statements that reached unanimous consensus were that an assessment of physeal status is critical for paediatric patients with patellar instability. There was also unanimous consensus on early mobilization and resistance training following nonoperative management once there is no apprehension. The statements that did not achieve consensus were on the importance of immobilization of the knee, the use of orthobiologics in nonoperative management, the indications for MPFC repair, and whether a vastus medialis oblique advancement should be performed.
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Traumatismos del Tobillo , Cartílago Articular , Inestabilidad de la Articulación , Articulación Patelofemoral , Humanos , Niño , Inestabilidad de la Articulación/diagnóstico , Inestabilidad de la Articulación/cirugía , Técnica Delphi , Traumatismos del Tobillo/cirugía , Articulación del Tobillo/cirugía , Cartílago Articular/cirugíaRESUMEN
Background: Despite the ongoing opioid epidemic, most patients are still prescribed a significant number of opioid medications for pain management after arthroscopic surgery. There is a need for consensus among orthopaedic surgeons and solutions to aid providers in analgesic strategies that reduce the use of opioid pain medications. Purpose: This position statement was developed with a comprehensive systematic review and meta-analysis of exclusively randomized controlled trials (RCTs) to synthesize the best available evidence for managing acute postoperative pain after arthroscopic surgery. Study Design: Position statement. Methods: The Embase, MEDLINE, PubMed, Scopus, and Web of Science databases were searched from inception until August 10, 2022. Keywords included arthroscopy, opioids, analgesia, and pain, and associated variations. We included exclusively RCTs on adult patients to gather the best available evidence for managing acute postoperative pain after arthroscopic surgery. Patient characteristics, pain, and opioid data were extracted, data were analyzed, and trial bias was evaluated. Results: A total of 21 RCTs were identified related to the prescription of opioid-sparing pain medication after arthroscopic surgery. The following recommendations regarding noninvasive, postoperative pain management strategies were made: (1) multimodal oral nonopioid analgesic regimens-including at least 1 of acetaminophen-a nonsteroidal anti-inflammatory drug-can significantly reduce opioid consumption with no change in pain scores; (2) cryotherapy is likely to help with pain management, although the evidence on the optimal method of application (continuous-flow vs ice pack application) is unclear; (3) and (4) limited RCT evidence supports the efficacy of transcutaneous electrical nerve stimulation and relaxation exercises in reducing opioid consumption after arthroscopy; and (5) limited RCT evidence exists against the efficacy of transdermal lidocaine patches in reducing opioid consumption. Conclusion: A range of nonopioid strategies exist that can reduce postarthroscopic procedural opioid consumption with equivalent vocal pain outcomes. Optimal strategies include multimodal analgesia with education and restricted/reduced opioid prescription.
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CONTEXT: Femoroacetabular impingement syndrome (FAIS) is a common cause of hip pain in young adults. Flexibility athletes represent an interesting subset due to the extreme range of motion requirements of their sport. OBJECTIVE: The objective of this review was to provide a summary of the outcomes of hip arthroscopy for FAIS in patients who participate in flexibility sports. DATA SOURCES: Three online databases (Medline, Embase, and PubMed) were searched from database inception (1946, 1974, and 1966, respectively) to January 10, 2023. STUDY SELECTION: Studies were screened for literature addressing surgical outcomes for flexibility athletes undergoing hip arthroscopy for FAIS. STUDY DESIGN: Systematic review. LEVEL OF EVIDENCE: Level 4. DATA EXTRACTION: Various patient-reported outcomes that evaluated the efficacy of hip arthroscopy in this patient population were abstracted and presented in descriptive and analytical format. Abstraction was performed by 2 reviewers. RESULTS: Overall, a total of 8 Level 3 or 4 studies and 295 patients (312 hips) were included in this review. The pooled standardized mean differences for the Visual Analog Scale for pain score, Modified Harris Hip Score, Hip Outcome Score - Activity of Daily Living scale, and Hip Outcome Score - Sport-Specific Subscale all demonstrated significant improvement after undergoing arthroscopy for FAIS between 12 and 116 months (N = 175, -1.97, 95% CI -2.5 to -1.4, P < 0.01, I2 = 76%; N = 211, 1.82, 95% CI 1.49 to 2.16, P < 0.01, I2 = 52%; N = 164, 1.75, 95% CI 1.42 to 2.05, P < 0.01, I2 = 28%; N = 211, 1.71, 95% CI 1.38 to 2.04, P < 0.01, I2 = 52%, respectively). Across 289 patients, 75.6% to 98% returned to sport at a similar or higher level than presurgery. CONCLUSION: This review demonstrates a trend of improvement in patient-reported pain, function, quality of life, and return to sport at a minimum of 12 months among flexibility athletes after hip arthroscopy to treat FAIS.
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Aims: The aim of this study was to establish consensus statements on medial patellofemoral ligament (MPFL) reconstruction, anteromedialization tibial tubercle osteotomy, trochleoplasty, and rehabilitation and return to sporting activity in patients with patellar instability, using the modified Delphi process. Methods: This was the second part of a study dealing with these aspects of management in these patients. As in part I, a total of 60 surgeons from 11 countries contributed to the development of consensus statements based on their expertise in this area. They were assigned to one of seven working groups defined by subtopics of interest. Consensus was defined as achieving between 80% and 89% agreement, strong consensus was defined as between 90% and 99% agreement, and 100% agreement was considered unanimous. Results: Of 41 questions and statements on patellar instability, none achieved unanimous consensus, 19 achieved strong consensus, 15 achieved consensus, and seven did not achieve consensus. Conclusion: Most statements reached some degree of consensus, without any achieving unanimous consensus. There was no consensus on the use of anchors in MPFL reconstruction, and the order of fixation of the graft (patella first versus femur first). There was also no consensus on the indications for trochleoplasty or its effect on the viability of the cartilage after elevation of the osteochondral flap. There was also no consensus on postoperative immobilization or weightbearing, or whether paediatric patients should avoid an early return to sport.
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Inestabilidad de la Articulación , Luxación de la Rótula , Articulación Patelofemoral , Humanos , Niño , Inestabilidad de la Articulación/cirugía , Luxación de la Rótula/cirugía , Articulación Patelofemoral/cirugía , Técnica Delphi , Articulación de la Rodilla/cirugía , Ligamentos Articulares/cirugíaRESUMEN
PURPOSE: To identify and assess the clinical impact of randomised controlled trials (RCTs) assessing the surgical management of femoroacetabular impingement syndrome (FAIS) through a citation analysis. METHODS: MEDLINE, EMBASE and CENTRAL were searched from inception to April 22, 2023 for RCTs assessing the surgical management of FAIS. Study characteristics were directly abstracted from included trials and citation metrics were obtained from the Clarivate Web of Knowledge database on May 19, 2023. The continuous fragility index (CFI) was calculated for eligible outcomes. Univariate regression models were used to explore correlations between total citations per year and various study characteristics. RESULTS: Ten studies comprising one thousand two hundred ninetypatients were eligible for analysis. Studies were published from 2013 to 2023. Eight countries were represented across various trials with 91% being either North American or European. The mean journal impact factor of published studies was 39.684 (median 2.982; range 1.31-202.73). The mean citation density was 14.17 (range 0.33-48.67). The median CFI was 4.8 (range 1-32.2). Correlation analysis demonstrated strong and statistically significant correlations to study sample size (R = 0.75, p = 0.012), journal impact factor (R = 0.80, p = 0.006) and continuous fragility index (R = 0.95, p = 0.015). CONCLUSION: Trials assessing the surgical management of FAIS present with a wide range of clinical uptake based on citation density and are published in journals of broadly variable impact factor. Despite promising citation metrics, high-quality evidence on arthroscopy for FAIS is limited to the United States and Europe with an unclear international impact. Future knowledge translation efforts are warranted to maximise the international uptake of evidence regarding arthroscopic management of FAIS. LEVEL OF EVIDENCE: I.