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JBJS Essential Surgical Techniques 2024A number of techniques have been described to enter the capsule and gain access to the hip joint during hip arthroscopy. Among these, the interportal and T-capsulotomies...
BACKGROUND
A number of techniques have been described to enter the capsule and gain access to the hip joint during hip arthroscopy. Among these, the interportal and T-capsulotomies are the most commonly utilized; however, these approaches transect the iliofemoral ligament, which normally resists anterior subluxation and stabilizes extension. Thus, these approaches may introduce capsuloligamentous instability and have been associated with complications such as dislocation, postoperative pain, microinstability, seroma, and heterotopic ossification. Although prior literature has demonstrated durable mid-term results for patients undergoing capsulotomies with capsular closure, avoidance of iatrogenic injury to the hip capsule altogether is preferable. Thus, the puncture capsulotomy technique we present is minimally invasive, preserves the biomechanics of the hip joint and capsule without disrupting the iliofemoral ligament, and allows for appropriate visualization of the joint through placement of multiple small portals.
DESCRIPTION
Following induction of anesthesia and with the patient supine on a hip traction table, the nonoperative leg is positioned at 45° abduction with support of a well-padded perineal post, and the operative hip is placed into valgus against the post. Intra-articular fluid distention with normal saline solution is utilized to achieve approximately 9 mm of inferior migration of the femoral head and decrease risk of iatrogenic nerve injury. Then, under fluoroscopic guidance, an anterolateral portal is created 1 cm anterior and 1 cm superior to the greater trochanter at an approximately 15° to 20° angle. Second, via arthroscopic visualization, the anterior portal is created 1 cm distal and 1 cm lateral to the intersection of a vertical line drawn at the anterior superior iliac spine and a horizontal line at the level of the anterolateral portal. Third, equidistant between the anterior and anterolateral portals, the mid-anterior portal is created distally. Finally, at one-third of the distance between the anterior superior iliac spine and the anterolateral portal, the Dienst portal is created. Thus, these 4 portals form a quadrilateral arrangement through which puncture capsulotomy can be performed.
ALTERNATIVES
Alternative approaches to the hip capsule include interportal and T-capsulotomies, with or without capsular closure. Although the most frequently utilized, these approaches transect the iliofemoral ligament and thus may introduce capsuloligamentous instability.
RATIONALE
The puncture capsulotomy technique has the advantage of maintaining the integrity of the capsule through the placement of 4 small portals. The technique does not transect the iliofemoral ligament and thus does not introduce capsuloligamentous instability. Furthermore, although good mid-term outcomes have been reported with capsular closure, the present technique avoids creating unnecessary injury to the capsule and complications of an unrepaired capsule or, conversely, of plication.
EXPECTED OUTCOMES
Patients who underwent the puncture capsulotomy technique showed significant improvements in multiple functional outcome scores at a mean follow-up of 30.4 months, including the International Hip Outcome Tool (iHOT-33) (39.6 preoperatively to 76.1 postoperatively), Hip Outcome Score-Activities of Daily Living subscale (HOS-ADL) (70.0 to 89.3), HOS Sport-Specific Subscale (HOS-SSS) (41.8 to 75.7), and modified Harris hip score (mHHS) (60.1 to 84.9). At 2 years postoperatively with respect to iHOT-33, 81.0% of patients achieved the minimal clinically important difference, 62.0% achieved the patient acceptable symptom state, and 58.9% achieved substantial clinical benefit. In addition, mean visual analog scale pain scores improved significantly over the follow-up period (6.3 to 2.2; p < 0.001). Finally, there were zero occurrences of infection, osteonecrosis of the femoral head, dislocation or instability, or femoral neck fracture in patients treated with puncture capsulotomy.
IMPORTANT TIPS
Anterolateral portal placement should be performed using the intra-articular fluid distention technique with fluoroscopy to avoid risk of iatrogenic labral damage and distraction-induced neurapraxia. Subsequent portals must then be placed under direct arthroscopic visualization.On establishment of the anterolateral portal, the scope should be switched to the anterior portal to ensure that the anterolateral portal has not been placed through the labrum and to adjust its placement to better access pathology. This portal, as well as all others, may be subsequently modified by adjusting the angle of the cannula, without making a new skin incision.If a cam lesion is located more anteromedially or posterolaterally, an additional accessory portal may be made distal or proximal to the anterolateral portal, respectively, in order to enhance visualization.Intermittent traction is utilized throughout the surgery. No traction is utilized during preparing and draping, suture tensioning and tie-down, and femoroplasty, with minimal traction during acetabuloplasty; these precautions serve to prevent iatrogenic superficial peroneal nerve injury.There can be a steep learning curve for this technique. In particular, greater surgical experience is required to perform adequate femoral osteoplasty for large cam lesions with this approach.Instrument maneuverability and visualization can be somewhat constrained with this approach.It is more difficult to perform certain procedures with this technique, including segmental and circumferential labral reconstructions, particularly with remote grafts.
ACRONYMS AND ABBREVIATIONS
iHOT-33 = International Hip Outcome Tool-33HOS-ADL = Hip Outcome Score-Activities of Daily Living subscaleHOS-SSS = Hip Outcome Score-Sport-Specific SubscaleAP = anteroposteriorMRA = magnetic resonance arthrogramMRI = magnetic resonance imagingCT = computed tomographyASIS = anterior superior iliac spinemHHS = modified Harris hip score.
PubMed: 38903605
DOI: 10.2106/JBJS.ST.23.00061 -
Journal of Orthopaedic Surgery and... Jun 2024The effects of the timing of surgical repair on the outcomes of traumatic and non-traumatic rotator cuff injuries (RCI) remain elusive. Thus, this study aimed to compare... (Comparative Study)
Comparative Study
BACKGROUND
The effects of the timing of surgical repair on the outcomes of traumatic and non-traumatic rotator cuff injuries (RCI) remain elusive. Thus, this study aimed to compare differences in outcomes following the repair of traumatic and non-traumatic RCI at varying time points.
METHODS
The study population comprised 87 patients with traumatic and non-traumatic RCI who underwent arthroscopic rotator cuff repair and were followed up for a minimum of 6 months. Next, the trauma and the non-trauma groups were stratified into subgroups according to the time of injury (early repair: occurring within 3 months; delayed repair: occurring after 3 months). Measurements before and after surgical interventions were compared to evaluate the effect of the duration of RCI on the functional status of patients in the trauma and non-trauma groups. Primary evaluation indices included the Visual Analog Scale (VAS) pain score, American Shoulder and Elbow Surgeons (ASES) score, Constant shoulder function score, and the University of California, Los Angeles (UCLA) shoulder score. Secondary evaluation indices consisted of shoulder range of motion (ROM), postoperative rotator cuff retear rate, and incidence of joint stiffness.
RESULTS
Among the 40 patients in the trauma group, 22 underwent early repair, whereas the remaining 18 underwent delayed repair. In the non-trauma group consisting of 47 patients, 18 underwent early repair, whereas the remaining 29 underwent delayed repair. The minimum clinical follow-up time was 6 months, with an average follow-up time of 10.2 months. During postoperative follow-up, 1 and 6 patients who underwent early and delayed repair experienced re-tear in the trauma group, respectively. Contrastingly, 3 and 8 patients who underwent early and delayed repair presented with re-tear in the non-trauma group, respectively.
CONCLUSION
Early repair of traumatic RCI yielded superior outcomes, including improved range of motion, lower pain symptoms, and lower risk of postoperative re-tears compared to delayed repair. Additionally, non-surgical treatment is recommended as the preferred approach for patients with non-traumatic RCI.
Topics: Humans; Rotator Cuff Injuries; Arthroscopy; Male; Middle Aged; Female; Treatment Outcome; Range of Motion, Articular; Adult; Time Factors; Aged; Follow-Up Studies; Recovery of Function; Rotator Cuff; Time-to-Treatment
PubMed: 38902793
DOI: 10.1186/s13018-024-04858-x -
World Journal of Clinical Cases Jun 2024This article provides a discussion and commentary around the recent advances in arthroscopic anterior cruciate ligament reconstruction (ACLR), with a focus on the...
This article provides a discussion and commentary around the recent advances in arthroscopic anterior cruciate ligament reconstruction (ACLR), with a focus on the aspects of lateral femoral tunnel preparation and graft fixation techniques. The paper explores and comments on a recently published review by Dai , titled "Research progress on preparation of lateral femoral tunnel and graft fixation in ACLR", while providing insight into its relevance within the field of ACLR, and recommendations for future research.
PubMed: 38898836
DOI: 10.12998/wjcc.v12.i17.3277 -
BMC Musculoskeletal Disorders Jun 2024This study aimed to investigate the feasibility and precision of using a 3D-printed template for femoral tunnel placement in guiding the optimal positioning of the... (Comparative Study)
Comparative Study
A comparative study on 3D printing-assisted arthroscopic IDEAL point femoral tunnel positioning for anterior cruciate ligament reconstruction versus conventional arthroscopic positioning.
BACKGROUND
This study aimed to investigate the feasibility and precision of using a 3D-printed template for femoral tunnel placement in guiding the optimal positioning of the Internal anatomical stop and Low tension maintenance (IDEAL) bone tunnel during single-bundle anterior cruciate ligament (ACL) reconstruction.
METHODS
A retrospective analysis was conducted on 40 patients who underwent arthroscopic single-bundle ACL reconstruction at our hospital between April 2021 and November 2021. In the direct vision group, the IDEAL bone tunnel was positioned using radiofrequency localization directly visualized at the stump. In the 3D-printed positioning group, preoperative CT scans and Digital Imaging and Communications in Medicine (DICOM) data were employed. Following the Quadrant method by Bernard, the femoral tunnel's depth was set at 25% and its height at 29%. Postoperative plain CT scans enabled the reconstruction of 3D models for both groups. The accuracy of femoral tunnel placement was then compared.
RESULTS
The central locations of the bone tunnels in the direct vision group were at a mean depth of 25.74 ± 1.84% and a height of 29.22 ± 2.97%. In the 3D printing localization group, these values were 25.39 ± 2.98% for depth and 28.89 ± 2.50% for height, respectively. No significant differences were found in tunnel positioning between the groups. Both groups demonstrated statistically significant improvements in International Knee Documentation Committee Subjective Knee Form (IKDC) and Lysholm scores postoperatively, with no significant differences observed 12 months post-surgery.
CONCLUSION
The findings of this study suggest that 3D printing-assisted arthroscopic IDEAL point femoral tunnel positioning and conventional arthroscopic positioning are feasible and effective for ACL reconstruction. Using 3D printing technology to design femoral anchor points in ACL reconstruction allows for the customization of anterior fork reconstruction and precise bone tunnel positioning, supporting the goal of individualized and accurate reconstruction.
Topics: Humans; Anterior Cruciate Ligament Reconstruction; Printing, Three-Dimensional; Retrospective Studies; Femur; Arthroscopy; Male; Female; Adult; Young Adult; Anterior Cruciate Ligament Injuries; Tomography, X-Ray Computed; Anterior Cruciate Ligament; Feasibility Studies; Adolescent; Surgery, Computer-Assisted; Middle Aged; Treatment Outcome
PubMed: 38898426
DOI: 10.1186/s12891-024-07591-y -
Journal of ISAKOS : Joint Disorders &... Jun 2024There is paucity of literature on the impact of patients' gender on recovery and treatment success after arthroscopic rotator cuff repair. This study investigates the...
Gender-Based Differences In Mid-Term Clinical Outcomes And Patient Acceptable Symptomatic State Attainment After Arthroscopic Rotator Cuff Repair: Minimum 2-Year Follow Up.
OBJECTIVE
There is paucity of literature on the impact of patients' gender on recovery and treatment success after arthroscopic rotator cuff repair. This study investigates the effect of gender on patient-reported outcomes preoperatively and postoperatively (minimum 2 years), and to determine if gender affects attainment of patient acceptable symptomatic state (PASS) thresholds.
METHODS
266 patients (117 males, 149 female), who underwent primary arthroscopic rotator cuff repair for atraumatic, full-thickness tears, were included. Functional outcomes and pain scores were collected preoperatively and postoperatively. Percentage of attainment of PASS for the various outcome scores was calculated and compared between males and females.
RESULTS
Women had statistically significantly poorer functional outcome and pain scores preoperatively and at 1 and 2 years postoperatively (P<0.01). They also experienced less improvement in outcome scores throughout the postoperative period. Women had statistically significantly lower rates of PASS attainment at 2 years postoperatively.
CONCLUSION
Women experience greater pain and poorer shoulder function compared with men preoperatively, and up to 2 years postoperatively. Women are less likely to achieve patient acceptable symptom state thresholds postoperatively, compared to their male counterparts.
STUDY DESIGN
Retrospective Cohort Study LEVEL OF EVIDENCE: III.
PubMed: 38897415
DOI: 10.1016/j.jisako.2024.06.002 -
Diagnostics (Basel, Switzerland) May 2024This study delves into the cutting-edge field of deep learning techniques, particularly deep convolutional neural networks (DCNNs), which have demonstrated unprecedented... (Review)
Review
OBJECTIVES
This study delves into the cutting-edge field of deep learning techniques, particularly deep convolutional neural networks (DCNNs), which have demonstrated unprecedented potential in assisting radiologists and orthopedic surgeons in precisely identifying meniscal tears. This research aims to evaluate the effectiveness of deep learning models in recognizing, localizing, describing, and categorizing meniscal tears in magnetic resonance images (MRIs).
MATERIALS AND METHODS
This systematic review was rigorously conducted, strictly following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Extensive searches were conducted on MEDLINE (PubMed), Web of Science, Cochrane Library, and Google Scholar. All identified articles underwent a comprehensive risk of bias analysis. Predictive performance values were either extracted or calculated for quantitative analysis, including sensitivity and specificity. The meta-analysis was performed for all prediction models that identified the presence and location of meniscus tears.
RESULTS
This study's findings underscore that a range of deep learning models exhibit robust performance in detecting and classifying meniscal tears, in one case surpassing the expertise of musculoskeletal radiologists. Most studies in this review concentrated on identifying tears in the medial or lateral meniscus and even precisely locating tears-whether in the anterior or posterior horn-with exceptional accuracy, as demonstrated by AUC values ranging from 0.83 to 0.94.
CONCLUSIONS
Based on these findings, deep learning models have showcased significant potential in analyzing knee MR images by learning intricate details within images. They offer precise outcomes across diverse tasks, including segmenting specific anatomical structures and identifying pathological regions. Contributions: This study focused exclusively on DL models for identifying and localizing meniscus tears. It presents a meta-analysis that includes eight studies for detecting the presence of a torn meniscus and a meta-analysis of three studies with low heterogeneity that localize and classify the menisci. Another novelty is the analysis of arthroscopic surgery as ground truth. The quality of the studies was assessed against the CLAIM checklist, and the risk of bias was determined using the QUADAS-2 tool.
PubMed: 38893617
DOI: 10.3390/diagnostics14111090 -
Journal of Clinical Medicine May 2024: Recurrent shoulder instability following Bankart lesion repair often necessitates surgical revision. This systematic review aims to understand the failure rates of... (Review)
Review
: Recurrent shoulder instability following Bankart lesion repair often necessitates surgical revision. This systematic review aims to understand the failure rates of arthroscopic revision Bankart repair. : Following the PRISMA guidelines and registered on PROSPERO, this systematic review examined twenty-five articles written between 2000 and 2024. Two independent reviewers assessed eligibility across three databases, focusing on recurrent instability as the primary endpoint, while also noting functional measures, adverse events, revision operations, and return-to-sport rates when available. : The key surgical techniques for recurrent instability post-Bankart repair were identified, with revision arthroscopic Bankart being the most common (685/1032). A comparative analysis revealed a significantly lower recurrence for open coracoid transfer compared to arthroscopic revision Bankart repair (9.67% vs. 17.14%; < 0.001), while no significant difference was observed between remplissage plus Bankart repair and Bankart repair alone (23.75% vs. 17.14%; = 0.24). The majority of studies did not include supracritical glenoid bone loss or engaging Hill-Sachs lesions, and neither subcritical nor non-engaging lesions significantly influenced recurrence rates ( = 0.85 and = 0.80, respectively). : Revision arthroscopic Bankart repair remains a viable option in the absence of bipolar bone loss; however, open coracoid transfer appears to have lower recurrence rates than arthroscopic Bankart repair, consistent with prior evidence. Further studies should define cutoffs and investigate the roles of critical glenoid bone loss and off-track Hill-Sachs lesions. Preoperative measurements of GBL on three-dimensional computed tomography and characterizing lesions based on glenoid track will help surgeons to choose ideal candidates for arthroscopic revision Bankart repair.
PubMed: 38892778
DOI: 10.3390/jcm13113067 -
Journal of Clinical Medicine May 2024: Bucket-handle meniscal tears are mostly treated arthroscopically. However, there is no clear evidence as to whether the time to surgery impacts the outcome and whether...
Bucket-Handle Meniscal Tears Might Not Be an Urgency: The Time to Meniscus Repair Does Not Seem to Affect the Mid-Term Outcome-A Retrospective Study of Sixty Tears with a Mean Follow-Up of 6 Years.
: Bucket-handle meniscal tears are mostly treated arthroscopically. However, there is no clear evidence as to whether the time to surgery impacts the outcome and whether or not lesions should be treated urgently. : Sixty patients were interviewed about the current status of their knee with a mean follow-up of 6.1 years (SD = 3.5). Forty-one patients underwent meniscus repair, and fifteen patients received partial resections. The primary outcome was the rate of reoperation after meniscus repair. Secondary outcomes were pain at rest and during exercise, return to sports, and Tegner and Lysholm scores. : The average time to surgery was 14.4 days, with no significant impact of surgical timing on the rate of reoperation. Furthermore, no significant differences were found in pain levels, return to sports, or Tegner and Lysholm scores based on the timing of surgery. : In our cohort, the time to surgery was not a prognostic factor for the reoperation rate or postoperative outcome in repairing bucket-handle meniscal tears. Therefore, arthroscopic repair should not be performed in an emergency setting but conducted after careful planning by experienced arthroscopy surgeons. Regarding the return to sports, postoperative factors such as rehabilitation protocols or surgical techniques could be more important than the time to surgery.
PubMed: 38892759
DOI: 10.3390/jcm13113048 -
Journal of Orthopaedic Surgery and... Jun 2024The purpose of this study was to analyse the difference between arthroscopic fixation and open reduction internal fixation (ORIF) of posterior cruciate ligament (PCL)... (Comparative Study)
Comparative Study
PURPOSE
The purpose of this study was to analyse the difference between arthroscopic fixation and open reduction internal fixation (ORIF) of posterior cruciate ligament (PCL) tibial avulsion fractures.
METHODS
This retrospective study analysed patients with an acute PCL tibial avulsion fracture who underwent surgical treatment at our hospital and follow-up for at least 24 months. Variables based on sex, age, Meyers-McKeever type, surgical method, meniscus tear, external fixation, labour or sports, Lysholm knee score, IKDC score, and KT-1000 value were also recorded. Multifactor unconditional logistic regression and Student's t test with 1:1 propensity score matching (PSM) to remove confounding factors were used for analysis.
RESULTS
Sixty-five cases achieved knee function graded as "good" or better, and 9 cases not. Single-factor analysis indicated that Meyers-McKeever type (χ = 4.669, P = 0.031) and surgical approach (χ = 9.428, P = 0.002) are related to functional outcomes. Multifactorial logistic regression analysis further confirmed that Meyers-McKeever typing (OR = 10.763, P = 0.036, [95% CI 1.174-98.693]) and surgical approach (OR = 9.274, P = 0.008, [95% CI 1.794-47.934]) are independent risk factors affecting prognosis. In addition, PSM verified significant differences in the Lysholm score (t = 3.195, P = 0.006), IKDC score (t = 4.703, P = 0.000) and A-KT/H-KT (t = 2.859, P = 0.012). However, the affected-side KT-1000 value (A-KT, mm, t = 1.225, P = 0.239) and healthy-side KT-1000 value (H-KT, mm, t = 1.436, P = 0.172) did not significantly differ between the two groups. The proportions of cases in which the Lysholm score, IKDC and A-KT/H-KT exceeded the minimal clinically important difference (MCID) were 62.5% (20/32), 62.5% (20/32) and 93.75% (30/32), respectively.
CONCLUSION
Compared with ORIF, an arthroscopic approach for PCL tibial avulsion fractures achieves better results.
LEVEL OF EVIDENCE
Retrospective cohort study; Level II.
Topics: Humans; Male; Female; Adult; Retrospective Studies; Tibial Fractures; Arthroscopy; Posterior Cruciate Ligament; Middle Aged; Fractures, Avulsion; Young Adult; Treatment Outcome; Open Fracture Reduction; Lysholm Knee Score; Follow-Up Studies; Adolescent; Fracture Fixation, Internal
PubMed: 38890683
DOI: 10.1186/s13018-024-04851-4 -
American Journal of Translational... 2024To investigate the risk factors influencing the postoperative outcome of arthroscopic rotator cuff repair (ARCR) and develop a nomogram prediction model.
OBJECTIVE
To investigate the risk factors influencing the postoperative outcome of arthroscopic rotator cuff repair (ARCR) and develop a nomogram prediction model.
METHODS
A retrospective study was conducted on 302 patients who underwent ARCR from January 2019 to August 2023. Patients were categorized into two groups: a control group with 150 patients showing good recovery and an observation group with 152 patients exhibiting poor recovery. Relevant clinical data were collected and statistically analyzed. A nomogram model was constructed based on the results of multivariate logistic regression analysis. The model's accuracy, discrimination, and clinical utility were evaluated using calibration charts, AUC, c-index, and decision curve analysis. Internal validation was performed through self-random sampling.
RESULTS
Univariate and multivariate regression analysis identified having a frozen shoulder, large rotator cuff tear, increased intraoperative rivet use, diabetes, and traumatic tear as predictive risk factors for poor postoperative outcomes. These factors were utilized to develop a clinical predictive nomogram. The nomogram model demonstrated excellent predictive accuracy for poor postoperative outcomes, both internally and externally. The unadjusted concordance index (C-index) was 0.793 [95% confidence interval (CI), 0.825-0.995]. The AUC for the nomogram was 0.788. Decision curve analysis revealed that the predictive model was clinically useful when the threshold probability ranged from 20 to 60%.
CONCLUSION
The presence of a frozen shoulder, large rotator cuff tear, increased intraoperative rivet use, diabetes, and traumatic tear elevate the risk of suboptimal outcomes following ARCR. Conversely, having a higher preoperative University of California at Los Angeles Shoulder Rating Scale score mitigates this risk. This study introduces a novel nomogram model, exhibiting relatively high accuracy, which enables clinicians to precisely assess the postoperative adverse risk among patients with rotator cuff injuries requiring arthroscopic repair at the outset of treatment.
PubMed: 38883395
DOI: 10.62347/OBQN3015