American Journal of Sports Medicine - AJSM

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Medizin, Sportwissenschaft, Sportmedizin / Gesundheit
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0363-5465
jährlich 14 mal
Englisch
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American Journal of Sports Medicine - AJSM

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The American Journal of Sports Medicine, founded in 1972, is the official publication of the American Orthopaedic Society for Sports Medicine. The Journal is published bimonthly by the AOSSM. It contains original articles that have undergone peer review.
Meine Notizen
Musculoskeletal Injury Risk After Sport-Related Concussion: Letter to the Editor
The American Journal of Sports Medicine, Volume 48, Issue 2, Page NP17-NP17, February 2020.
Musculoskeletal Injury Risk After Sport-Related Concussion: Response
The American Journal of Sports Medicine, Volume 48, Issue 2, Page NP17-NP18, February 2020.
Comparative Clinical Outcomes After Intra-articular Injection With Adipose-Derived Cultured Stem Cells or Noncultured Stromal Vascular Fraction for the Treatment of Knee Osteoarthritis: Letter to the Editor
The American Journal of Sports Medicine, Volume 48, Issue 2, Page NP19-NP19, February 2020.
Comparative Clinical Outcomes After Intra-articular Injection With Adipose-Derived Cultured Stem Cells or Noncultured Stromal Vascular Fraction for the Treatment of Knee Osteoarthritis: Response
The American Journal of Sports Medicine, Volume 48, Issue 2, Page NP19-NP20, February 2020.
Platelet-Rich Plasma for Patellar Tendinopathy: Letter to the Editor
The American Journal of Sports Medicine, Volume 48, Issue 2, Page NP21-NP22, February 2020.
Platelet-Rich Plasma for Patellar Tendinopathy: Response
The American Journal of Sports Medicine, Volume 48, Issue 2, Page NP22-NP22, February 2020.
Effect of Meniscal Ramp Lesion Repair on Knee Kinematics, Bony Contact Forces, and In Situ Forces in the Anterior Cruciate Ligament: Letter to Editor
The American Journal of Sports Medicine, Volume 48, Issue 2, Page NP23-NP25, February 2020.
Effect of Meniscal Ramp Lesion Repair on Knee Kinematics, Bony Contact Forces, and In Situ Forces in the Anterior Cruciate Ligament: Response
The American Journal of Sports Medicine, Volume 48, Issue 2, Page NP25-NP27, February 2020.
Positive Effect of Platelet-Rich Plasma on Pain in Plantar Fasciitis: Letter to the Editor
The American Journal of Sports Medicine, Volume 48, Issue 2, Page NP28-NP28, February 2020.
Positive Effect of Platelet-Rich Plasma on Pain in Plantar Fasciitis: Response
The American Journal of Sports Medicine, Volume 48, Issue 2, Page NP28-NP29, February 2020.
Corrigendum
The American Journal of Sports Medicine, Volume 48, Issue 2, Page NP30-NP30, February 2020.
ACL or ACL+
The American Journal of Sports Medicine, .
Society News
The American Journal of Sports Medicine, .
No Evidence for Effective Prevention of Venous Thromboembolism With Low-Molecular-Weight Heparin After Anterior Cruciate Ligament Reconstruction: Letter to the Editor
The American Journal of Sports Medicine, Volume 48, Issue 1, Page NP1-NP2, January 2020.
No Evidence for Effective Prevention of Venous Thromboembolism With Low-Molecular-Weight Heparin After Anterior Cruciate Ligament Reconstruction: Response
The American Journal of Sports Medicine, Volume 48, Issue 1, Page NP2-NP4, January 2020.
Adaptation of Running Biomechanics to Repeated Barefoot Running: Letter to the Editor
The American Journal of Sports Medicine, Volume 48, Issue 1, Page NP5-NP6, January 2020.
Adaptation of Running Biomechanics to Repeated Barefoot Running: Response
The American Journal of Sports Medicine, Volume 48, Issue 1, Page NP6-NP7, January 2020.
Efficacy of Platelet-Rich Plasma for the Treatment of Interstitial Supraspinatus Tears: Letter to the Editor
The American Journal of Sports Medicine, Volume 48, Issue 1, Page NP8-NP9, January 2020.
Efficacy of Platelet-Rich Plasma for the Treatment of Interstitial Supraspinatus Tears: Response
The American Journal of Sports Medicine, Volume 48, Issue 1, Page NP9-NP10, January 2020.
Timing of Surgery: Can It Predict Outcome? Letter to the Editor
The American Journal of Sports Medicine, Volume 48, Issue 1, Page NP11-NP11, January 2020.
Timing of Surgery: Can It Predict Outcome? Response
The American Journal of Sports Medicine, Volume 48, Issue 1, Page NP11-NP12, January 2020.
Problem of Multiplicity in Clinical Studies and Inferences Made When It Is Present: Letter to the Editor
The American Journal of Sports Medicine, Volume 48, Issue 1, Page NP13-NP13, January 2020.
Problem of Multiplicity in Clinical Studies and Inferences Made When It Is Present: Response
The American Journal of Sports Medicine, Volume 48, Issue 1, Page NP14-NP15, January 2020.
Problem of Multiplicity in Clinical Studies and Inferences Made When It Is Present: Response
The American Journal of Sports Medicine, Volume 48, Issue 1, Page NP15-NP16, January 2020.
Placing the Latarjet in Context
The American Journal of Sports Medicine, .
Outcomes of the Latarjet Procedure for the Treatment of Chronic Anterior Shoulder Instability: Patients With Prior Arthroscopic Bankart Repair Versus Primary Cases
The American Journal of Sports Medicine, .
Background:It remains unclear whether results differ between a Latarjet procedure performed after a failed arthroscopic Bankart repair and one performed as the primary operation.Purpose:To compare the postoperative outcomes of the Latarjet procedure when performed as primary surgery and as revision for a failed arthroscopic Bankart repair.Study Design:Cohort study; Level of evidence, 3.Methods:A multicenter retrospective comparative case-cohort analysis was performed for all patients undergoing a Latarjet procedure for recurrent anterior shoulder instability. Patients were separated into 2 groups depending on if the Latarjet procedure was performed after a failed arthroscopic Bankart repair (group 1) or as the first operation (group 2). Outcome measures included recurrent instability, reoperation rates, complications, pain, Walch-Duplay scores, and Simple Shoulder Test.Results:A total of 308 patients were eligible for participation in the study; 72 (23.4%) did not answer and were considered lost to follow-up, leaving 236 patients available for analysis. Mean follow-up was 3.4 ± 0.8 years. There were 20 patients in group 1 and 216 in group 2. Despite similar rates of recurrent instability (5.0% in group 1 vs 2.3% in group 2; P = .5) and revision surgery (0% in group 1 vs 6.5% in group 2; P = .3), group 1 demonstrated significantly worse pain scores (2.56 ± 2.7 vs 1.2 ± 1.7; P = .01) and patient-reported outcomes (Walch-Duplay: 52 ± 25.1 vs 72.2 ± 25.0; P = .0007; Simple Shoulder Test: 9.3 ± 2.4 vs 10.7 ± 1.9; P = .001) when compared with those patients undergoing primary Latarjet procedures.Conclusion:Functional outcome scores and postoperative pain are significantly worse in patients undergoing a Latarjet procedure after a failed arthroscopic Bankart repair when compared with patients undergoing primary Latarjet. The assumption that a failed a Bankart repair can be revised by a Latarjet with a similar result to a primary Latarjet appears to be incorrect. Surgeons should consider these findings when deciding on the optimal surgical procedure for recurrent shoulder instability.
No Relationship Between Strength and Power Scores and Anterior Cruciate Ligament Return to Sport After Injury Scale 9 Months After Anterior Cruciate Ligament Reconstruction
The American Journal of Sports Medicine, .
Background:Psychological factors including self-reported readiness to return to sport (RTS) after anterior cruciate ligament reconstruction (ACLR) measured with the Anterior Cruciate Ligament Return to Sport After Injury (ACL-RSI) scale have been shown to correlate with RTS. Physical deficits have been shown to exist in the later stages after ACLR rehabilitation. No previous studies have investigated the relationship between self-reported readiness to RTS and objective physical measures of power and strength.Purpose:To investigate the relationship between ACL-RSI scores and measures of strength and power scores after ACLR.Study Design:Case control study; Level of evidence, 3.Methods:This study recruited 452 male athletes who had undergone primary ACLR. Each athlete completed the ACL-RSI questionnaire, isokinetic strength testing, and jump testing approximately 9 months after surgery.Results:ACL-RSI scores showed a trivial or weak correlation with strength and power measures at 9 months after surgery (r = 0.06-0.16). Similar results were found for the relationship between ACL-RSI scores and limb symmetry index for strength and power measures (r = 0.04-0.15). Comparing the strength and power measures of athletes with higher (≥90) ACL-RSI scores (n = 93) versus athletes with lower (≤75) ACL-RSI scores (n = 92) showed no significant differences except for isokinetic hamstring strength, but with a trivial effect size (P = .040; effect size = 0.15).Conclusion:Self-reported readiness to RTS as measured by the ACL-RSI had little or no relationship with athletes’ strength and power measures, and there was no meaningful difference in strength and power between athletes with higher and lower ACL-RSI scores at 9 months after ACLR. The findings suggest that psychological recovery and physical recovery after ACLR are different constructs, and strategies to measure and address each construct separately may be necessary to ensure successful RTS after ACLR.
Arthroscopic Microfracture for Osteochondral Lesions of the Talus: Functional Outcomes at a Mean of 6.7 Years in 165 Consecutive Ankles
The American Journal of Sports Medicine, .
Background:Arthroscopic microfracture for osteochondral lesions of the talus (OLT) has shown good functional outcomes. However, some studies have reported that functional outcomes deteriorate over time after surgery.Purpose:To use various functional scoring systems to evaluate functional outcomes in a large sample of patients with OLT treated by arthroscopic microfracture.Study Design:Case series; Level of evidence, 4.Methods:The study cohort consisted of 165 ankles (156 patients) that underwent arthroscopic microfracture for small to mid-sized OLT. The mean lesion size was 73 mm2 (range, 17-146 mm2), and the mean follow-up period was 6.7 years (range, 2.0-13.6 years). The Foot and Ankle Outcome Score (FAOS), American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scale, visual analog scale (VAS) for pain, and 36-Item Short Form Health Survey (SF-36) were used to compare the functional outcomes between the preoperative and final follow-up assessments.Results:The mean FAOS significantly improved in regard to all subscores (P < .001). The AOFAS ankle-hindfoot scale showed an improvement from 71.0 points (range, 47.0-84.0) preoperatively to 89.5 points (range, 63.0-100) at the final follow-up (P < .001). The VAS score showed an improvement from 6.2 points (range, 4.0-9.0) preoperatively to 1.7 points (range, 0-6.0) at the final follow-up (P < .001). The mean SF-36 score improved from 62.4 points (range, 27.4-76.6) preoperatively to 76.2 points (range, 42.1-98.0) at the final follow-up (P < .001). Among 165 ankles, 22 ankles (13.3%) underwent repeat arthroscopic surgery for evaluation of repaired cartilage status.Conclusion:Arthroscopic microfracture showed good functional outcomes and improved quality of life with maintenance of satisfactory outcomes at a mean follow-up of 6.7 years. Therefore, arthroscopic microfracture seems to be reliable as a first-line treatment for OLT at an intermediate-term follow-up.
Radiographic and Demographic Factors Can Predict the Need for Primary Labral Reconstruction in Hip Arthroscopic Surgery: A Predictive Model Using 1398 Hips
The American Journal of Sports Medicine, .
Background:Labral tears are the most common findings in patients with symptomatic femoroacetabular impingement (FAI). The restoration of labral function is critical, and labral reconstruction has been proposed as an alternative for irreparable tears.Purpose:To compare preoperative radiographic measurements and demographics of patients who underwent primary arthroscopic labral reconstruction versus primary labral repair and to identify factors that are predictive of the need for reconstruction.Study Design:Case-control study; Level of evidence, 3.Methods:Patients who underwent their index hip arthroscopic procedure between October 2010 and November 2018 and underwent either labral reconstruction or repair were included in the study. A total of 18 variables (14 radiographic and 4 demographic) were assessed in a bivariate comparison and analyzed in a multivariate logistic model.Results:A total of 251 primary reconstruction and 1147 primary repair procedures were included. The logistic model selected age, body mass index (BMI), Tönnis grade, lateral center-edge angle (LCEA), and alpha angle. The odds of reconstruction were 2.52 times higher in patients with Tönnis grade 1 than 0 (odds ratio [OR], 2.52 [95% CI, 1.82-3.49]). Each additional degree in the LCEA was associated with a 6% increase in the odds of reconstruction (OR, 1.06 [95% CI, 1.04-1.09]) and 4% for each additional degree in the alpha angle (OR, 1.04 [95% CI, 1.03-1.05]). Higher age (per log 10 unit) and BMI also increased the likelihood of reconstruction (OR, 11.29 [95% CI, 4.23-30.10] and OR, 1.03 [95% CI, 1.00-1.06], respectively).Conclusion:In a multivariate analysis, factors identified as preoperative predictors for primary arthroscopic labral reconstruction in the setting of FAI and labral tears were Tönnis grade, LCEA, age, and BMI. These predictive factors may be useful for the clinician in determining the preoperative likelihood of primary labral reconstruction.
Spinopelvic Characteristics in Acetabular Retroversion: Does Pelvic Tilt Change After Periacetabular Osteotomy?
The American Journal of Sports Medicine, .
Background:Acetabular retroversion may lead to impingement and pain, which can be treated with an anteverting periacetabular osteotomy (aPAO). Pelvic tilt influences acetabular orientation; as pelvic tilt angle reduces, acetabular version reduces. Thus, acetabular retroversion may be a deformity secondary to abnormal pelvic tilt (functional retroversion) or an anatomic deformity of the acetabulum and the innominate bone (pelvic ring).Purpose:To (1) measure the spinopelvic morphology in patients with acetabular retroversion and (2) assess whether pelvic tilt changes after successful anteverting PAO (aPAO), thus testing whether preoperative pelvic tilt was compensatory.Study Design:Case series; Level of evidence, 4.Methods:A consecutive cohort of 48 hips (42 patients; 30 ± 7 years [mean ± SD]) with acetabular retroversion that underwent successful aPAO was studied. Spinopelvic morphology (pelvic tilt, pelvic incidence, anterior pelvic plane, and sacral slope) was measured from computed tomography scans including the sacral end plate in 21 patients, with adequate images. In addition, the change in pelvic tilt with aPAO was measured via the sacrofemoral-pubic angle with supine pelvic radiographs at an interval of 2.5 ± 2 years.Results:The spinopelvic characteristics included a pelvic tilt of 4° ± 4°, a sacral slope of 39° ± 9°, an anterior pelvic plane angle of 11° ± 5°, and a pelvic incidence of 42° ± 10°. Preoperative pelvic tilt was 4° ± 4° and did not change postoperatively (4° ± 4°) (P = .676).Conclusion:Pelvic tilt in acetabular retroversion was within normal parameters, illustrating “normal” sagittal pelvic balance and values similar to those reported in the literature in healthy subjects. In addition, it did not change after aPAO. Thus, acetabular retroversion was not secondary to a maladaptive pelvic tilt (functional retroversion). Further work is required to assess whether retroversion is a reflection of a pelvic morphological abnormality rather than an isolated acetabular abnormality. Treatment of acetabular retroversion should focus on correcting the deformity rather than attempting to change the functional pelvic position.
Articular Joint-Simulating Mechanical Load Activates Endogenous TGF-β in a Highly Cellularized Bioadhesive Hydrogel for Cartilage Repair
The American Journal of Sports Medicine, .
Background:The treatment of osteochondral defects (OCDs) constitutes a major problem for orthopaedic surgeons. The altered mechanics and the cell types, with associated soluble factors derived from the exposed subchondral bone, are likely responsible for the mechanically and structurally inferior articular cartilage subsequently obtained as a repair tissue. There is therefore an unmet clinical need for bioresponsive biomaterials that allow cell delivery, reduce cell infiltration from the bone marrow, and support chondrogenesis in the presence of joint mechanical loading.Purpose:To develop a cell-laden injectable biomaterial, with bioadhesive properties, low cell invasion, and good mechanoresilience, in which simulated joint loading could induce tissue maturation through the production and activation of transforming growth factor beta 1 (TGF-β1).Study Design:Controlled laboratory study.Methods:Human bone marrow–derived mesenchymal stromal/stem cells were encapsulated in tyramine-modified hyaluronic acid (HA-Tyr) hydrogels, with crosslinking initiated by the addition of horseradish peroxidase (HRP) and various concentrations of hydrogen peroxide (H2O2; 0.3-2 mM). Cytocompatibility and biomechanical and adhesive properties were analyzed by live/dead staining, rheology, and push-out test, respectively. For multiaxial loading, cell-laden hydrogels were subjected to 10% compression superimposed onto a 0.5-N preload and shear loading (±25°) at 1 Hz for 1 hour per day and 5 times a week for 4 weeks. TGF-β1 production and activation were measured by enzyme-linked immunosorbent assay (ELISA).Results:The viscoelastic properties of the cell-laden HA-Tyr hydrogels, as crosslinked with different ratios of HRP and H2O2, were demonstrated for a range of cell densities and HRP/H2O2 concentrations. In the absence of serum supplementation, cell invasion into HA-Tyr hydrogels was minimal to absent. The bonding strength of HA-Tyr to articular cartilage compared favorably with clinically used fibrin gel.Conclusion:HA-Tyr hydrogels can be mechanically conditioned to induce activation of endogenous TGF-b1 produced by the embedded cells. HA-Tyr hydrogels function as cell carriers supporting biomechanically induced production and activation of TGF-β1 and as bioadhesive materials with low cell invasion, suggesting that they hold promise as a novel biomaterial for OCD repair strategies.Clinical Relevance:Leveraging physiological joint mechanics to support chondrogenic graft maturation in an optimized mechanosensitive hydrogel in the absence of exogenous growth factors is of highest interest for OCD repair.
Society News
The American Journal of Sports Medicine, .
Complications After Distal Biceps Tendon Repair: A Systematic Review
The American Journal of Sports Medicine, Ahead of Print.
Background:Distal biceps tendon injuries typically occur in the dominant arm of men in their fourth decade of life. Surgical repair restores flexion and supination strength, resulting in good functional outcome. The complication profile of each surgical approach and fixation technique has not been widely studied in the literature.Purpose:To report the rate of complications after repair of complete distal biceps ruptures, to classify them according to surgical approach and fixation technique, and to analyze risk factors and outcomes of the individual complications.Study Design:Systematic review.Methods:Studies published in English on primary repair of the distal biceps between January 1998 and January 2019 were identified. Data on complications were extracted and classified as major and minor for analysis. A quantitative synthesis of data was done to compare the complication rates between (1) limited anterior incision, extensile anterior incision, and double incision and (2) 4 fixation methods.Results:Seventy-two articles including 3091 primary distal biceps repairs were identified. The overall complication rate was 25% (n = 774). The major complication rate was 4.6% (n = 144) and included a 1.6% (n = 51) rate of posterior interosseous nerve injury; 0.3% (n = 10), median nerve injury; 1.4% (n = 43), rerupture; and a 0.1% (n = 4), synostosis. Brachial artery injury, ulnar nerve injury, compartment syndrome, proximal radius fracture, and chronic regional pain syndrome occurred at a rate of <0.1% each. The majority of nerve injuries resolved with an expectant approach. The minor complication rate was 20.4% (n = 630). The most common complication was lateral cutaneous nerve injury (9.2%, n = 283). An extensile single incision was associated with a higher rate of superficial radial nerve injury when compared to limited single incision(6% vs 2.1%, P = .002). Limited anterior single incision technique had a higher rate of lateral antebrachial cutaneous nerve injury compared to extensile single incision. (9.7% vs 5.2%, P = .03). Synostosis occurred only with double incision. Fixation technique had no significant effect on rerupture rate and posterior interosseous nerve injury rate.Conclusion:This is the largest analysis of complications after distal biceps repair, indicating a major complication rate of 4.6%. This study provides valuable data with regard to the choice of technique, surgical approach, and rate of complications, which is essential for surgical planning and patient consent.Registration:CRD42017074066 (PROSPERO).
Pathogenesis and Development of Patellar Tendon Fibrosis in a Rabbit Overuse Model
The American Journal of Sports Medicine, Ahead of Print.
Background:The pathogenesis of patellar tendon fibrosis caused by overuse remains unclear. In an effort to further investigate effective treatments for patellar tendon fibrosis attributed to overuse, it is necessary to construct a reliable animal model.Purpose:A rabbit patellar tendon fibrosis model was developed with the use of electrical stimulation to induce jumping. The pathogenesis and development of patellar tendon fibrosis were subsequently investigated with this model.Study Design:Controlled laboratory study.Methods:A total of 32 New Zealand White rabbits were randomly divided into a jumping group and a control group. Rabbits in the control group did not receive any treatment, while those in the jumping group jumped 150 times daily, 5 days per week. At 2, 4, 6, and 8 weeks after the initiation of treatment, the patellar tendons of 4 rabbits from each group were harvested and subjected to hematoxylin and eosin staining, immunohistochemical staining, and real-time polymerase chain reaction. The influence of jumping training on the expressions of histology- and fibrosis-related factors in the patellar tendon was assessed.Results:The histological changes of patellar tendon fibrosis in the jumping group were most pronounced at 4 weeks. When compared with the control group at corresponding time points, the mRNA and protein expressions of TGF-β1, CTGF, COL-I, and COL-III were upregulated significantly in the patellar tendon after jumping training for 4 weeks (P < .05). Intragroup comparison at different time points indicated that the mRNA and protein expressions of TGF-β1, COL-I, and COL-III were the highest at 4 weeks in the jumping group (P < .01).Conclusion:It was found that patellar tendon fibrosis occurred because of overuse and the peak changes occurred at 4 weeks. Jumping load increased the secretions of TGF-β1 and Smad3 in the patellar tendon, with CTGF upregulation and higher synthesis of COL-I and COL-III, which were considered the pathogenesis of fibrosis.Clinical Relevance:This study simulated the effects of jumping load on tendon fibrosis at different time points. Moreover, the time course relationship between jumping training and patellar tendon fibrosis in the rabbit model was determined, which provided a new animal model for the study of patellar tendon fibrosis.
Defining the Minimal Clinically Important Difference and Patient Acceptable Symptom State for Microfracture of the Knee: A Psychometric Analysis at Short-term Follow-up
The American Journal of Sports Medicine, Ahead of Print.
Background:Several studies have investigated failure rates and magnitude of improvement in patient-reported outcome measures after microfracture surgery for focal chondral defects of the knee; however; what constitutes clinically significant improvement in this patient population is poorly understood.Purpose:To (1) establish the minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) thresholds for microfracture surgery including the time-dependent nature of these thresholds and (2) identify predictors of achieving the MCID and PASS in patients specifically undergoing microfracture of the knee.Study Design:Case series; Level of evidence, 4.Methods:A secure institutional cartilage preservation repository was queried for all patients who underwent microfracture between 2004 and 2017. The distribution method was used to calculate MCID thresholds for the International Knee Documentation Committee (IKDC) score and the Knee injury and Osteoarthritis Outcome Score (KOOS), whereas an anchor-based method was used for the PASS. Multivariate logistic regressions were constructed to determine predictors of achieving the MCID and PASS.Results:A total of 206 patients with a mean ± SD age of 33.7 ± 13.2 years and body mass index of 26.9 ± 5.3 kg/m2 were included. All thresholds for the MCID and PASS increased over time except for the MCID thresholds for the KOOS Sports and Symptoms subscales. The proportion of patients who achieved the MCID (6 months, 78.4%; 12 months, 83.9%; 24 months, 88.6%) and PASS (6 months, 67.7%; 12 months, 79.2%; 24 months, 76.1%) generally increased over time. Older age and larger lesion size were negative independent predictors of MCID achievement. Older age was also a negative predictor of the PASS, whereas male sex and higher preoperative KOOS Symptoms and Pain scores were positive independent predictors of the PASS.Conclusion:The MCID and PASS thresholds for the IKDC and KOOS in patients undergoing microfracture of the knee are dynamic, with an increasing number of patients achieving the MCID over time. The percentage achieving the PASS increased between 6 and 12 months and then declined slightly at 24 months. Independent predictors of achieving the MCID were lesion size and age at surgery, whereas predictors of achieving the PASS included lesion size, male sex, and greater preoperative KOOS Symptoms and Pain scores.
Lateral Meniscus Posterior Root Lesion Influences Anterior Tibial Subluxation of the Lateral Compartment in Extension After Anterior Cruciate Ligament Injury
The American Journal of Sports Medicine, Ahead of Print.
Background:The lateral meniscus posterior root (LMPR) lesion further decreases dynamic knee stability after anterior cruciate ligament (ACL) injury owing to the loss of the “wedge effect” maintained by the posterior horn of the lateral meniscus. However, the effect of LMPR lesions on the static tibiofemoral relationship in extension after ACL injuries is not determined.Purpose:To (1) determine the effect of LMPR lesions on anterior tibial subluxation of the lateral compartment (ATSLC) in extension in patients with ACL injuries and to (2) identify the LMPR-related factors associated with excessive ATSLC in extension.Study Design:Cohort study; Level of evidence, 3.Methods:Between January 2015 and December 2017, 405 consecutive patients with diagnosed ACL injuries who underwent primary ACL reconstructions were retrospectively reviewed. Among them, 45 patients with combined ACL injuries and LMPR lesions (ACL+LMPR group) and 51 patients with isolated ACL injuries (ACL group) were identified. Values of ATSLC in extension were measured on preoperative supine magnetic resonance imaging and classified into high grade (≥6 mm) and low grade (<6 mm). The mean ATSLC in extension and the proportion of patients with high-grade ATSLC in extension were compared between the groups by univariate analysis. In the ACL+LMPR group, predictors of high-grade ATSLC in extension—including age, sex, body mass index, affected side, cause of injury, period from injury (<12 or ≥12 weeks), LMPR lesion pattern (radial tear or root avulsion), and meniscofemoral ligament integrity (intact or impaired)—were assessed by univariate analysis and multivariate logistic regression analysis.Results:The mean ATSLC in extension in the ACL+LMPR group was significantly greater than that in the ACL group (5.6 mm vs 3.1 mm; P = .001). The proportion of patients with high-grade ATSLC in extension in the ACL+LMPR group was also significantly larger than that in the ACL group (44.4% vs 15.7%; P = .002). In addition, the root avulsion (instead of radial tear) (odds ratio, 28.750; 95% CI, 2.344-352.549; P = .009) and the period from injury ≥12 weeks (odds ratio, 17.095; 95% CI, 1.207-242.101; P = .036) were determined to be the 2 independent predictors of high-grade ATSLC in extension. However, age, sex, body mass index, affected side, cause of injury, and meniscofemoral ligament integrity were not.Conclusion:After ACL injuries, concomitant LMPR lesion further increased ATSLC in extension. Chronic LMPR avulsion was associated with high-grade ATSLC in extension.
How Does Isolated Medial Patellofemoral Ligament Reconstruction Influence Patellar Height?
The American Journal of Sports Medicine, Ahead of Print.
Background:Reconstruction of the medial patellofemoral ligament (MPFL) is the gold standard treatment for recurrent patellar dislocation. Patella alta has been reported in about half of patients with recurrent patellofemoral instability.Hypothesis:MPFL reconstruction (MPFLr) has a beneficial role in the correction of patellar height in patients with mild patella alta (Caton-Deschamps index [CDI] between 1.20 and 1.40).Study Design:Case series; Level of evidence, 4.Methods:Skeletally mature patients, with no history of previous or concomitant knee surgical procedures, who underwent isolated MPFLr using hamstring autograft for recurrent patellar instability between 2005 and 2018, were included in this study. The authors calculated CDI, modified Insall-Salvati index (MISI), and Blackburne-Peel index (BPI) ratios. Measurements done by 2 independent observers were calculated and used to compare pre- and postoperative patellar height (patella alta: CDI >1.20).Results:A total of 89 patients (95 knees) were included in the study, with a mean age of 25.0 years (range, 15.0-45.0 years). There were 70% women and 30% men. We found patella alta in 35.8% of cases preoperatively. Among them, 79.4% had reduced patellar height indices, within normal limits, postoperatively (mean follow-up, 18.4 ± 12.0 months). All the ratios showed a significant reduction in patellar height after surgery (CDI: 0.19 [range, –0.05, 0.60]; MISI: 0.22 [–0.14, 0.76]; BPI: 0.18 [–0.08, 0.59]; P < .00001). The CDI of 79.4% of the study knees was reduced to within normal limits postoperatively. The CDI was maintained within normal limits postoperatively in 93.4% of the knees with normal patellar height and reduced to normal in 50% of the knees with severe patella alta before surgery . No patient reported patella infera before surgery, whereas this condition was found in 8.2% of study patients postoperatively. A moderate correlation was reported between preoperative radiographic indices and their reduction after surgery (CDI: P < .001, ρ = 0.39; MISI: P < .001, ρ = 0.39; BPI: P < .001, ρ = 0.48).Conclusion:The higher the preoperative patellar height, the more important is the lowering effect of MPFLr using the hamstring for patellar instability. Bony procedures should not be indicated in patients with patellar instability and a CDI between 1.20 and 1.40.
Effect of Initial Graft Tension During Anterior Talofibular Ligament Reconstruction on Ankle Kinematics, Laxity, and In Situ Forces of the Reconstructed Graft
The American Journal of Sports Medicine, Ahead of Print.
Background:Although a variety of surgical procedures for anterior talofibular ligament (ATFL) reconstruction have been reported, the effect of initial graft tension during ATFL reconstruction remains unclear.Purpose/Hypothesis:This study investigated the effects of initial graft tension on ATFL reconstruction. We hypothesized that a high degree of initial graft tension would cause abnormal kinematics and laxity.Study Design:Controlled laboratory study.Methods:Twelve cadaveric ankles were tested with a robotic system with 6 degrees of freedom to apply passive plantarflexion and dorsiflexion motions and a multidirectional load. A repeated measures experiment was designed with the intact ATFL, transected ATFL, and reconstructed ATFL at initial tension conditions of 10, 30, 50, and 70 N. The 3-dimensional path and reconstructed graft tension were simultaneously recorded, and the in situ forces of the ATFL and reconstructed graft were calculated with the principle of superposition.Results:Initial tension of 10 N was sufficient to imitate normal ankle kinematics and laxity, which were not significantly different when compared with those of the intact ankles. The in situ force on the reconstructed graft tended to increase as the initial tension increased. In situ force on the reconstructed graft >30 N was significantly greater than that of intact ankles. The in situ force on the ATFL was 19 N at 30° of plantarflexion. In situ forces of 21.9, 30.4, 38.2, and 46.8 N were observed at initial tensions of 10, 30, 50, and 70 N, respectively, at 30° of plantarflexion.Conclusion:Approximate ankle kinematic patterns and sufficient laxity, even with an initial tension of 10 N, could be obtained immediately after ATFL reconstruction. Moreover, excessive initial graft tension during ATFL reconstruction caused excessive in situ force on the reconstructed graft.Clinical Relevance:This study revealed the effects of initial graft tension during ATFL reconstruction. These data suggest that excessive tension during ATFL reconstruction should be avoided to ensure restoration of normal ankle motion.
Early Radiographic Healing and Functional Results After Autologous Osteochondral Grafting for Osteochondritis Dissecans of the Capitellum: Introduction of a New Magnetic Resonance Imaging–Based Scoring System
The American Journal of Sports Medicine, Ahead of Print.
Background:Autologous osteochondral grafting (OG) is an option in the treatment of capitellar osteochondritis dissecans (COCD). However, radiographic healing after this procedure has not been well documented.Purpose:To develop a magnetic resonance imaging (MRI)–based scoring system specific for evaluating healing after single-plug OG in COCD and to evaluate correlation between radiographic healing and early clinical outcomes.Study Design:Cohort study (diagnosis); Level of evidence, 3.Methods:Between 2014 and 2017, 183 elbows with COCD were enrolled in a prospective registry. A total of 61 elbows in 59 patients underwent single-plug OG. Of these, 52 elbows in 50 patients had pre- and postoperative MRI scans. Postoperative MRI and clinical outcome data from this group were used to develop the novel BOGIE score (Boston Osteochondral Graft Incorporation in the Elbow), with a possible range of 4 to 12.Results:Median age at surgery was 14.2 years (interquartile range, 13.1-15.0 years). Median clinical follow-up after OG was 12.4 months (interquartile range, 9.5-16.9 months; range, 6-53 months). Compared with before surgery, elbow function at 6 months after surgery and at latest follow-up was significantly improved as measured by the Timmerman and Andrews score (TAS; median: 145 before surgery, 185 at 6 months after surgery, 190 at latest follow-up; P < .001, before vs after surgery), as well as the short version of Disabilities of the Arm, Shoulder and Hand score; median: 21 before surgery, 7 at 6 months after surgery, and 0 at latest follow-up; P < .001 before surgery vs after surgery). Median BOGIE score at 6 months after surgery was 10 (range, 4-12). BOGIE score intraobserver reliability was 0.90 (95% CI, 0.82-0.94) for reader 1 and 0.91 (95% CI, 0.86-0.95) for reader 2. Interobserver reliability between the readers was 0.86 (95% CI, 0.78-0.92). Correlation was observed between the 6-month BOGIE score and the concurrent postoperative objective TAS (P < .001) as well as total TAS (P = .01) but not the subjective TAS (P = .08). Patients who underwent subsequent secondary surgery for persistent symptoms had a significantly lower postoperative BOGIE score at 6 months than those who did not (median, 7.8 vs 10.3; P = .016)Conclusion:Quantitative evaluation for radiologic healing after single-plug OG in COCD is possible. The MRI-based BOGIE score appears to correlate with early clinical function and may be useful as an adjunct tool in decision making on activity progression. The use of a standardized MRI score may improve comparability of outcomes after OG in the literature.
Autologous Chondrocyte Implantation and Osteochondral Allograft Transplantation Render Comparable Outcomes in the Setting of Failed Marrow Stimulation
The American Journal of Sports Medicine, Ahead of Print.
Background:Marrow stimulation techniques (MSTs) such as subchondral drilling and microfracture are often chosen as first-line treatment options for symptomatic cartilage defects of the knee. When an MST fails, many cartilage restoration techniques are employed, including autologous chondrocyte implantation (ACI) and osteochondral allograft (OCA). However, a few series in the literature suggest that ACI after a failed MST results in inferior outcomes as compared with primary ACI.Purpose/Hypothesis:The purpose of this study was (1) to evaluate the clinical outcomes of ACI and OCA after a failed MST (secondary ACI and OCA) and compare them with the outcomes of primary ACI and OCA and (2) to compare clinical outcomes of secondary ACI and secondary OCA for refractory lesions involving the femoral condyle. The hypotheses were as follows: (1) secondary ACI will render inferior functional outcomes and an increased clinical failure rate as compared with primary ACI, (2) secondary OCA will render comparable results to primary OCA, and (3) secondary OCA will render superior outcomes to secondary ACI.Study Design:Cohort study; Level of evidence, 3.Methods:Patients were retrospectively identified who underwent ACI and OCA for symptomatic chondral lesions of the knee refractory to a previous MST. Age-, sex-, and body mass index–matched groups of patients undergoing primary ACI and OCA were used as controls. Postoperative data were prospectively collected using several subjective scoring systems (Tegner, Lysholm, International Knee Documentation Committee, Knee injury and Osteoarthritis Outcome Score, 12-Item Short Form Health Survey). Groups were compared with regard to patient-reported outcomes, subjective satisfaction, clinical failure rate, and reoperation. Student t tests were used for continuous data, and chi-square tests were performed for categorical data.Results:A total of 359 patients were examined: 92 patients undergoing secondary ACI, 100 primary ACI, 88 secondary OCA, and 79 primary OCA. The mean patient age was 30.3 years (range, 14.9-49.9 years) at the time of ACI and 35.4 (range, 15-54.5) at the time of OCA. There was no difference between the primary and secondary groups with regard to postoperative functional scores, subjective satisfaction, reoperation rate, and clinical failure rate.Conclusion:ACI and OCA are both viable treatment options for chondral defects of the knee, even in the setting of a failed MST. Secondary ACI renders functional outcomes, subjective satisfaction, and reoperation and failure rates comparable with primary ACI and secondary OCA.
Screw and Sheath Tibial Fixation Associated With a Higher Likelihood of Deep Infection After Hamstring Graft Anterior Cruciate Ligament Reconstruction
The American Journal of Sports Medicine, Ahead of Print.
Background:Hamstring autograft anterior cruciate ligament reconstructions (ACLRs) have exhibited higher infection rates compared with bone–patellar tendon–bone (BPTB) autograft. The reason for this observed difference is unclear, warranting investigation.Purpose:To evaluate the association between tibial fixation, either with or without a sheath and screw construct, and the risk of deep infection after hamstring autograft ACLR, using BPTB autograft as a reference group for comparison.Study Design:Cohort study; Level of evidence, 3.Methods:Using the Kaiser Permanente ACLR Registry, we identified all primary isolated, unilateral, single-bundle ACLRs with a BPTB or hamstring autograft (January 1, 2008, to September 30, 2016). The exposure groups included the following: (1) BPTB ACLR, (2) hamstring ACLR using a screw and sheath construct for tibial fixation (HS with screw and sheath), and (3) hamstring ACLR using a method other than a screw and sheath construct for tibial fixation (HS without screw and sheath). We used logistic regression to evaluate the likelihood of 90-day postoperative deep infection using BPTB autograft as the reference group and adjusting for age, sex, and body mass index. The number needed to be exposed (NNE) was calculated.Results:Of 15,671 ACLRs, 6745 (43.0%) used a BPTB graft, 2852 (18.2%) used HS with screw and sheath tibial fixation, and 6074 (38.8%) used HS without screw and sheath tibial fixation. There were 38 (0.2%) 90-day deep infections: 11 (0.2%) for BPTB, 14 (0.5%) for HS with screw and sheath, and 13 (0.2%) for HS without screw and sheath. Staphylococcus aureus for the BPTB group and Staphylococcus epidermidis in both hamstring groups were the most common infecting organisms. HS with screw and sheath had a higher likelihood of 90-day deep infection compared with BPTB ACLR (odds ratio [OR], 2.87; 95% CI, 1.29-6.38). We failed to observe a difference for HS without screw and sheath compared with BPTB ACLR (OR, 1.23; 95% CI, 0.54-2.77). The NNE was 330 and 2701 for HS with and HS without screw and sheath, respectively.Conclusion:Although the overall infection rate after ACLR is low, the higher likelihood of infections when sheath and screw combined are used for tibial fixation of a hamstring autograft ACLR should be a consideration when this procedure is performed.
Effect of Diagnosed Sleep Disorders on Baseline Concussion Symptom, Cognitive, and Balance Assessments in Collegiate Athletes
The American Journal of Sports Medicine, Ahead of Print.
Background:Symptoms, cognition, balance, and other domains are commonly assessed at baseline testing as part of comprehensive preseason evaluations among collegiate student-athletes. Although approximately 27% of college students have at least 1 sleep disorder, researchers have yet to examine the role of a preexisting sleep disorder on preinjury baseline performance.Purpose:To compare athletes with and without a reported history of diagnosed sleep disorders on commonly used baseline concussion assessments.Study Design:Cross-sectional study; Level of evidence, 3.Methods:A total of 666 National Collegiate Athletic Association student-athletes completed baseline measures including the Balance Error Scoring System (BESS), Brief Symptom Inventory–18 (BSI-18), Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT), Post-Concussion Symptom Scale (PCSS), Sport Concussion Assessment Tool–5th Edition (SCAT5), and Standardized Assessment of Concussion (SAC). There were 333 athletes with a history of diagnosed sleep disorders who were matched on age, sex, sport, and concussion history to 333 athletes with no history of diagnosed sleep disorders. Participants in both groups had a mean age of 19.89 ± 1.36 years and included 182 (54.7%) male athletes, and 126 (37.8%) reported a history of ≥1 concussions.Results:A series of 1-way analyses of covariance with Bonferroni corrections revealed significant group differences on the BESS (F1,559 = 8.88; P < .01); BSI-18 somatization (F1,640 = 18.48; P < .01), depression (F1,640 = 18.78; P < .01), anxiety (F1,640 = 19.42; P < .01), and global severity index (F1,640 = 27.18; P < .01); PCSS (F1,424 = 29.42; P < .01); SCAT5 symptom number (F1,634 = 28.79; P < .01) and symptom severity (F1,634 = 31.74; P < .01); and SAC (F1,578 = 4.36; P = .037). Specifically, while the sleep disorder group did perform better on the BESS, they also reported higher symptoms on the BSI-18, PCSS, and SCAT5 and performed worse on the SAC. There were no group differences on ImPACT performance.Conclusion:Collegiate student-athletes with diagnosed sleep disorders reported elevated affective and concussion symptoms at baseline that could affect the interpretation of postinjury impairments and symptoms. Based on the small effect sizes of our findings, however, the magnitude of these differences is of questionable clinical significance. Still, clinicians should consider diagnosed sleep disorders as reported during preparticipation sports physical examinations when interpreting baseline and postinjury concussion assessments.
Are Patients Who Undergo the Latarjet Procedure Ready to Return to Play at 6 Months? A Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Group Cohort Study
The American Journal of Sports Medicine, Ahead of Print.
Background:The Latarjet procedure is growing in popularity for treating athletes with recurrent anterior shoulder instability, largely because of the high recurrence rate of arthroscopic stabilization, particularly among contact athletes with bone loss.Purpose:(1) To evaluate return of strength and range of motion (ROM) 6 months after the Latarjet procedure and (2) to determine risk factors for failure to achieve return-to-play (RTP) criteria at 6 months.Study Design:Case-control study; Level of evidence, 3.Methods:A total of 65 athletes (83% contact sports, 37% overhead sports; mean ± SD age, 24.5 ± 8.2 years; 59 male, 6 female) who enrolled in a prospective multicenter study underwent the Latarjet procedure for anterior instability (29% as primary procedure for instability, 71% for failed prior stabilization procedure). Strength and ROM were assessed preoperatively and 6 months after surgery. RTP criteria were defined as return to baseline strength and <20° side-to-side ROM deficits in all planes. The independent likelihood of achieving strength and motion RTP criteria at 6 months was assessed through multivariate logistic regression modeling with adjustment as needed for age, sex, subscapularis split versus tenotomy, preoperative strength/motion, percentage bone loss, number of prior dislocations, preoperative subjective shoulder function (American Shoulder and Elbow Surgeons and Western Ontario Shoulder Instability Index percentage), and participation in contact versus overhead sports.Results:Of the patients, 55% failed to meet ≥1 RTP criteria: 6% failed for persistent weakness and 51% for ≥20° side-to-side loss of motion. There was no difference in failure to achieve RTP criteria at 6 months between subscapularis split (57%) versus tenotomy (47%) (P = .49). Independent risk factors for failure to achieve either strength or ROM criteria were preoperative American Shoulder and Elbow Surgeons scores (per 10-point decrease: adjusted odds ratio [aOR], 1.61; 95% CI, 1.14-2.43; P = .006), Western Ontario Shoulder Instability Index percentage (per 10% decrease: aOR, 0.61; 95% CI, 0.38-0.92; P = .01), and a preoperative side-to-side ROM deficit ≥20° in any plane (aOR, 5.01; 95% CI, 1.42-21.5; P = .01) or deficits in external rotation at 90° of abduction (per 10° increased deficit: aOR, 1.64; 95% CI, 1.06-2.88; P = .02).Conclusion:A large percentage of athletes fail to achieve full strength and ROM 6 months after the Latarjet procedure. Greater preoperative stiffness and subjective disability are risk factors for failure to meet ROM or strength RTP criteria.
Ischemic Therapy in Musculoskeletal Medicine
The American Journal of Sports Medicine, Ahead of Print.
Background:The competitive environment of athletics has promoted the exploration of any technology application that may offer an edge with performance and recovery from injury. Ischemic therapy is one such technology that has rapidly been incorporated into training rooms and physical therapy clinics worldwide. This therapy modality is reported to increase an athlete’s ability to improve muscle mass, strength, and endurance.Purpose:To provide the sports medicine physician with an understanding of the current state of ischemic therapy technology, including treatment specifications, known physiological effects, hypothesized mechanisms, biochemical effects, athletic applications, medical applications, animal models, and future research recommendations.Study Design:Literature review.Methods:A computer-based search of the PubMed database was used to perform a comprehensive literature review on musculoskeletal ischemic therapy.Results:The current research on ischemic therapy is largely composed of case series with varying equipment, methods, and therapy specifications. The publication of case series has value in identifying this technology for future research, but the results of these studies should not be justification for application to athletes without validation of safety and effectiveness.Conclusion:To date, ischemic therapy remains unvalidated, and the mechanism by which it improves muscle performance is not clear.
Effect of Normal Saline Injections on Lateral Epicondylitis Symptoms: A Systematic Review and Meta-analysis of Randomized Clinical Trials
The American Journal of Sports Medicine, Ahead of Print.
Background:Lateral epicondylitis, or tennis elbow, is a painful degenerative disorder that commonly occurs in adults between 40 and 60 years of age. Normal saline (NS) injections have been used as placebo through a large number of randomized controlled trials (RCTs) focused on the treatment of lateral epicondylitis.Purpose:This meta-analysis of RCTs aimed to assess the therapeutic effect of NS injections on lateral epicondylitis symptoms and compare results with established minimal clinically important difference criteria.Study Design:Systematic review and meta-analysis.Methods:MEDLINE, Embase, Web of Science, and Scopus databases were searched for clinical trials reporting pain and joint function with the visual analog scale, Patient-Rated Tennis Elbow Evaluation, and Disabilities of the Arm, Shoulder and Hand in patients with lateral epicondylitis. The meta-analysis was conducted with a random effects model and generic inverse variance method. Heterogeneity was tested with the I2 statistic index.Results:A total of 15 RCTs included in this meta-analysis revealed a significant improvement in pain (mean difference, 3.61 cm [95% CI, 2.29-4.92 cm]; P < .00001; I2 = 88%; visual analog scale) and function (mean difference, 25.65 [95% CI, 13.30-37.99]; P < .0001; I2 = 82%; Patient-Rated Tennis Elbow Evaluation / Disabilities of the Arm, Shoulder and Hand) after NS injection (≥6 months).Conclusion:NS injections yielded a statistically significant and clinically meaningful improvement in pain and functional outcomes in patients with lateral epicondylitis. New research should focus on better methods to diminish the potential confounders that could lead to this effect because NS injections could mask the real effect of an active therapeutic intervention in RCT.Registration:CRD42019127547 (PROSPERO).
Retears and Concomitant Functional Impairments After Rotator Cuff Repair: Shoulder Activity as a Risk Factor
The American Journal of Sports Medicine, Ahead of Print.
Background:Most patients return successfully to shoulder involving sports or activity after rotator cuff repairs. It has not been decided yet whether postoperative participation in shoulder activity adds to the risk of retear.Purpose/Hypothesis:The purpose was to verify whether patients who participate in shoulder activities after rotator cuff repair have a higher risk of structural failure than nonactive patients and to investigate the relationship between postoperative shoulder function and tendon integrity in active and nonactive patients. The hypotheses were that (1) active patients have a higher retear rate than nonactive patients and (2) structural failure is associated with worse functional outcomes in active patients.Study Design:Cohort study; Level of evidence, 3.Methods:A cohort study was performed using 145 patients who underwent arthroscopic rotator cuff repair from 2015 to 2017. Functional assessments and magnetic resonance imaging were performed at least 24 months postoperatively. Shoulder activities since 6 months after surgery were rated in 4 categories (sports, job, activities of daily life, and weight of general lifting) as sedentary, light, moderate, or strenuous. The activity level of each patient was defined by the highest rated category. Patients who were involved in light, moderate, and strenuous activity were identified as active for the present study, and the rest were defined as sedentary. The proportion of retears between groups and the functional conditions between retorn and intact tendons were compared.Results:A total of 48 patients were enrolled in the active group, and 97 were enrolled in the sedentary group. The active group demonstrated a significantly higher retear rate than the sedentary group (27.1% vs 11.3%, respectively; P = .016; risk ratio, 2.39 [95% CI, 1.16-4.93]). In the active group, patients with retears showed higher visual analog scale scores for pain, decreased abduction strength, and lower shoulder functional scores (American Shoulder and Elbow Surgeons score, Fudan University Shoulder Score, and Constant-Murley score) than those with healed tendons, whereas in the sedentary group, functional outcomes were generally similar across patients with and without retears.Conclusion:Shoulder activity after the early postoperative period was associated with a high risk of retears in patients who underwent rotator cuff repair. A correlation between inhibited function and structural failure was detected but only in active patients, while sedentary patients with retears retained functional improvements similar to those with intact tendons.
Minimum 5-Year Clinical Outcomes, Survivorship, and Return to Sports After Hamstring Tendon Autograft Reconstruction for Sternoclavicular Joint Instability
The American Journal of Sports Medicine, Ahead of Print.
Background:Instability of the sternoclavicular (SC) joint is a rare but potentially devastating pathologic condition, particularly when it occurs in young or active patients, where it can lead to persistent pain and impairment of shoulder function. SC joint reconstruction using a hamstring tendon autograft is a commonly used treatment option, but midterm results are still lacking.Purpose/Hypothesis:The purpose of this study was to assess the clinical outcomes, survivorship, and return-to-sports rate after SC joint reconstruction using a hamstring tendon autograft in patients suffering from SC joint instability. We hypothesized that SC joint reconstruction would result in good clinical outcomes, high rate of survivorship, and a high rate of return to sports.Study Design:Case series; Level of evidence, 4.Methods:All patients who underwent SC joint reconstruction with a hamstring tendon autograft for SC joint instability, with a minimum 5-year follow-up, were included. Patient-reported outcomes were assessed prospectively by the use of the American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numerical Evaluation (SANE) score, short version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH) score, 12-Item Short Form Health Survey (SF-12) physical component summary (PCS), and patient satisfaction. Survivorship of reconstruction was defined as no further revision surgery or clinical failure such as recurrent instability or subluxation events. Return to sports and pain were assessed using a customized questionnaire.Results:A total of 22 shoulders that underwent SC joint reconstruction, with a mean patient age of 31.3 years (range, 15.8-57.0 years) at the time of surgery, were included. At the final evaluation, 18 shoulders, with a mean follow-up of 6.0 years (range, 5.0-7.3 years), completed a minimum 5-year follow-up. All clinical outcome scores improved significantly from preoperatively to postoperatively: ASES (50.0 to 91.0; P = .005), SANE (45.9 to 86.0; P = .007), QuickDASH (44.2 to 12.1; P = .003), and SF-12 PCS (39.4 to 50.9; P = .001). Median postoperative satisfaction was 9 (range, 7-10). The construct survivorship was 90% at 5-year follow-up. There were 2 patients with failed treatment at 82 and 336 days postoperatively because of instability or pain who underwent revision SC joint reconstruction and capsulorrhaphy. Another patient had a superficial wound infection, which was debrided once and resulted in a good clinical outcome. Of the patients who answered optional sports activity questions, 15 (17 shoulders, 77%) participated in recreational or professional sports before the injury. At final follow-up, 14 patients (16 of 17 shoulders, 94%) returned to their preinjury level of sports. The visual analog scale score for pain today (P = .004) and pain at its worst (P = .004) improved significantly from preoperatively to postoperatively.Conclusion:SC joint reconstruction with a hamstring tendon autograft for SC joint instability resulted in significantly improved clinical outcomes with high patient satisfaction and 90% survivorship at midterm follow-up. Furthermore, 94% of this young and high-demand patient population returned to their previous level of sports. Concerns in terms of advanced postinstability arthritis were not confirmed because a significant decrease in pain was found after a minimum 5-year follow-up.
Factors Influencing Return to Play and Second Anterior Cruciate Ligament Injury Rates in Level 1 Athletes After Primary Anterior Cruciate Ligament Reconstruction: 2-Year Follow-up on 1432 Reconstructions at a Single Center
The American Journal of Sports Medicine, Ahead of Print.
Background:Despite the importance of return-to-play (RTP) rates, second anterior cruciate ligament (ACL) injury rates, and patient-reported outcomes of athletes returning to sports after ACL reconstruction (ACLR), these outcomes have not been evaluated together across a single cohort nor the pre- and intraoperative factors influencing outcomes explored.Purpose:To prospectively report outcomes after ACLR relating to RTP, second ACL injury, and International Knee Document Committee (IKDC) scores in a large cohort of athletes at a single center to examine the influence of pre- and intraoperative variables on these outcomes.Design:Cohort study; Level of evidence, 3.Methods:A consecutive cohort of 1432 athletes undergoing primary ACLR by 2 orthopaedic surgeons was followed up prospectively more than 2 years after surgery. Pre- and intraoperative findings were reported with outcomes at follow-up relating to RTP, second ACL injury, and IKDC. Between-group differences for each outcome were reported and the predictive ability of pre- and intraoperative variables relating to each outcome assessed with logistic regression.Results:There was >95% follow-up 2 years after surgery. The RTP rate was 81%, and of those who returned, 1.3% of those with patellar tendon grafts and 8.3% of those with hamstring grafts experienced ipsilateral rerupture (hazard ratio, 0.17). The contralateral ACL injury rate was 6.6%, and the IKDC score at follow-up was 86.8, with a greater proportion of patients with patellar tendon grafts scoring <80 on the IKDC (odds ratio, 1.56; 95% CI, 1.15-3.12). There was no relationship between time to RTP and second ACL injury, and there was a moderate correlation between ACL–Return to Sport After Injury score and RTP at follow-up (P < .001, rho = 0.46). There were a number of differences in pre- and intraoperative variables between groups for each outcome, but they demonstrated a poor ability to predict outcomes in level 1 athletes at 2-year follow-up.Conclusion:Findings demonstrated high overall RTP rates, lower reinjury rates with patellar tendon graft after 2-year follow-up in level 1 athletes, and no influence of time to RTP on second ACL injury. Despite differences between groups, there was poor predictive ability of pre- and intraoperative variables. Results suggest pre- and intraoperative variables for consideration to optimize outcomes in level 1 athletes after ACLR, but future research exploring other factors, such as physical and psychological recovery, may be needed to improve outcome prediction after ACLR.Registration:NCT02771548 (ClinicalTrials.gov identifier).
Biologically Regulated Marrow Stimulation by Blocking TGF-β1 With Losartan Oral Administration Results in Hyaline-like Cartilage Repair: A Rabbit Osteochondral Defect Model
The American Journal of Sports Medicine, Ahead of Print.
Background:Microfracture or bone marrow stimulation (BMS) is often the first choice for clinical treatment of cartilage injuries; however, fibrocartilage, not pure hyaline cartilage, has been reported because of the development of fibrosis in the repair tissue. Transforming growth factor β1 (TGF-β1), which can promote fibrosis, can be inhibited by losartan and potentially be used to reduce fibrocartilage.Hypothesis:Blocking TGF-β1 would improve cartilage healing in a rabbit knee BMS model via decreasing the amount of fibrocartilage and increasing hyaline-like cartilage formation.Study Design:Controlled laboratory study.Methods:An osteochondral defect was made in the patellar groove of 48 New Zealand White rabbits. The rabbits were divided into 3 groups: a defect group (defect only), a BMS group (osteochondral defect + BMS), and a BMS + losartan group (osteochondral defect + BMS + losartan). For the rabbits in the BMS + losartan group, losartan was administrated orally from the day after surgery through the day of euthanasia. Rabbits were sacrificed 6 or 12 weeks postoperatively. Macroscopic appearance, microcomputed tomography, histological assessment, and TGF-β1 signaling pathway were evaluated at 6 and 12 weeks postoperatively.Results:The macroscopic assessment of the repair revealed that the BMS + losartan group was superior to the other groups tested. Microcomputed tomography showed superior healing of the bony defect in the BMS + losartan group in comparison with the other groups. Histologically, fibrosis in the repair tissue of the BMS + losartan group was significantly reduced when compared with the other groups. Results obtained with the modified O’Driscoll International Cartilage Repair Society grading system yielded significantly superior scores in the BMS + losartan group as compared with both the defect group and the BMS group (F value: 15.8, P < .001, P = .012, respectively). TGF-β1 signaling and TGF-β-activated kinase 1 of the BMS + losartan group were significantly suppressed in the synovial tissues.Conclusion:By blocking TGF-β1 with losartan, the repair cartilage tissue after BMS was superior to the other groups and consisted primarily of hyaline cartilage. These results should be easily translated to the clinic because losartan is a Food and Drug Administration–approved drug and it can be combined with the BMS technique for optimal repair of chondral defects.Clinical Relevance:Biologically regulated marrow stimulation by blocking TGF-β1 (oral intake of losartan) provides superior repair via decreasing fibrocartilage formation and resulting in hyaline-like cartilage as compared with outcomes from BMS only.
Excessive Preoperative Anterior Tibial Subluxation in Extension Is Associated With Inferior Knee Stability After Anatomic Anterior Cruciate Ligament Reconstruction
The American Journal of Sports Medicine, Ahead of Print.
Background:Anterior tibial subluxation (ATS) in extension after anterior cruciate ligament (ACL) injury highlights an increased anterior position of the tibia relative to the femur. Recent studies demonstrated that subluxation is sometimes irreducible and the normal tibiofemoral relationship is not restored by ACL reconstruction (ACLR), which raises concerns regarding clinical outcomes after ACLR.Hypothesis:Excessive preoperative ATS in extension is associated with inferior knee stability after anatomic ACLR.Study Design:Cohort study; Level of evidence, 3.Methods:From March 2016 to January 2017, a total of 487 consecutive patients with clinically diagnosed noncontact ACL injuries who underwent primary anatomic ACLR were retrospectively analyzed. Of these patients, 430 met the criteria for inclusion in this study. Anterior subluxation of the lateral and medial compartments (ASLC and ASMC) in extension relative to the femoral condyles was measured on preoperative magnetic resonance imaging. Twenty patients (study group) who demonstrated excessive (>10 mm) ASLC and ASMC in extension were matched 1:2 to 40 participants (control group) who showed minimal or no (<3 mm) ASLC and ASMC in extension. The amount of ASLC and ASMC in extension relative to the femoral condyles at 2 years postoperatively was the primary outcome. Moreover, the Lysholm score, IKDC grade (International Knee Documentation Committee), and stability assessments (pivot-shift test and KT-1000 arthrometer side-to-side difference) were evaluated preoperatively and at the last follow-up visit.Results:The preoperative mean ASLC and ASMC in extension of the study group were both significantly larger than those of the control group (study group vs control group: ASLC, 13.5 mm vs 1.2 mm; ASMC, 12.4 mm vs 1.0 mm; P < .05). Moreover, patients in the study group showed significantly larger posterior tibial slope than the patients in the control group (17.8°± 2.5° vs 9.5°± 1.5°; P < .05). At the final follow-up visit, the mean ASLC and ASMC of the study group were 8.1 mm and 7.3 mm, which were significantly larger than those of the control group (ASLC, 0.9 mm; ASMC, 0.7 mm; P < .05). In addition, the study group showed inferior knee stability when compared with the control group in terms of both the pivot-shift test (study group vs control group: 2 grade 2, 10 grade 1, and 8 grade 0 vs 1 grade 1 and 39 grade 0; P < .05) and the KT-1000 arthrometer side-to-side difference (study group vs control group: 4.4 ± 1.2 mm vs 1.5 ± 0.6 mm; P < .05). Furthermore, the study group showed significantly lower mean Lysholm score (study group vs control group: 80.3 ± 6.3 vs 93.3 ± 4.3, P < .05) and IKDC grading results (study group vs control group: 3 grade C, 16 grade B, and 1 grade A vs 3 grade B and 37 grade A; P < .05) as compared with the control group.Conclusion:In this short-term study, the excessive (>10 mm) preoperative ATS in extension after ACL injury was associated with inferior knee stability after anatomic ACLR.
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