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Skeletal Radiology Mar 2024The purpose of this systematic review was to summarize the results of original research studies evaluating the characteristics and performance of deep learning models...
OBJECTIVE
The purpose of this systematic review was to summarize the results of original research studies evaluating the characteristics and performance of deep learning models for detection of knee ligament and meniscus tears on MRI.
MATERIALS AND METHODS
We searched PubMed for studies published as of February 2, 2022 for original studies evaluating development and evaluation of deep learning models for MRI diagnosis of knee ligament or meniscus tears. We summarized study details according to multiple criteria including baseline article details, model creation, deep learning details, and model evaluation.
RESULTS
19 studies were included with radiology departments leading the publications in deep learning development and implementation for detecting knee injuries via MRI. Among the studies, there was a lack of standard reporting and inconsistently described development details. However, all included studies reported consistently high model performance that significantly supplemented human reader performance.
CONCLUSION
From our review, we found radiology departments have been leading deep learning development for injury detection on knee MRIs. Although studies inconsistently described DL model development details, all reported high model performance, indicating great promise for DL in knee MRI analysis.
Topics: Humans; Anterior Cruciate Ligament Injuries; Artificial Intelligence; Ligaments, Articular; Magnetic Resonance Imaging; Meniscus
PubMed: 37584757
DOI: 10.1007/s00256-023-04416-2 -
Arthroscopy : the Journal of... Mar 2024To analyze the statistical stability of randomized controlled trials (RCTs) evaluating the surgical management of autografts versus allografts in the anterior cruciate... (Review)
Review
PURPOSE
To analyze the statistical stability of randomized controlled trials (RCTs) evaluating the surgical management of autografts versus allografts in the anterior cruciate ligament reconstruction (ACLR) literature and calculate the fragility index (FI) and fragility quotient and explore a subgroup analysis by calculating the proportion of outcome events where the FI was less than the number of patients lost to follow-up.
METHODS
Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we conducted a systematic search in the PubMed and Cochrane databases to identify RCTs published between 2000 and 2022 that investigated the use of autografts versus allografts in ACLR literature and reported dichotomous data. The fragility index of each dichotomous variable was calculated through the reversal of a single outcome event until significance was reversed. The fragility quotient was calculated by dividing each fragility index by the study sample size. The interquartile range also was calculated.
RESULTS
Of the 4407 articles screened, 23 met the search criteria, with 11 RCTs evaluating ALCR using autografts and allografts included for analysis. Two hundred and 18 outcome events with 32 significant (P < .05) outcomes and 186 nonsignificant (P ≥ .05) outcomes were identified. The overall fragility index and fragility quotient for all 218 outcomes were 6 subjects (interquartile range 5-8) and 0.058 (interquartile range 0.039-0.077). Fragility analysis of statistically significant outcomes and nonsignificant outcomes had a fragility index of 3.5 (interquartile range 1-5.5) and 6 (interquartile range 5-8), respectively. All of the studies reported a loss to follow-up where 45.5% (5) reported a loss to follow-up greater or equal to 6.
CONCLUSIONS
The RCTs in the ACLR peer-reviewed literature evaluating autograft versus allograft use are vulnerable to a small number of outcome event reversals and exemplify significant statistical fragility in statistically significant findings.
LEVEL OF EVIDENCE
Level I, systematic review of Level I studies.
Topics: Humans; Autografts; Anterior Cruciate Ligament; Knee Joint; Allografts; Randomized Controlled Trials as Topic; Anterior Cruciate Ligament Reconstruction; Anterior Cruciate Ligament Injuries
PubMed: 37579956
DOI: 10.1016/j.arthro.2023.07.055 -
Journal of Orthopaedic Surgery and... Aug 2023To perform a systematic review of the clinical outcomes of anterior cruciate ligament reconstruction using either contralateral or ipsilateral tendon autografts.
PURPOSE
To perform a systematic review of the clinical outcomes of anterior cruciate ligament reconstruction using either contralateral or ipsilateral tendon autografts.
METHODS
A systematic review of literature published from inception to December 9, 2022, in multiple databases (PubMed, Embase, Scopus, and the Cochrane Library) was conducted in accordance with the 2020 PRISMA (Preferred Reporting Items for Systematic Reviews) guidelines. Two reviewers independently screened the literature, extracted the data, performed the risk of bias assessment and assessed the study quality. At least one of the following outcomes was evaluated for each study: muscle strength (isometric strength of the quadriceps or hamstring muscles, isokinetic peak flexion torque of the hamstring, or isokinetic peak extension torque of the hamstring), knee laxity examination, Lysholm score, pivot shift, International Knee Documentation Committee (IKDC) score, Knee Injury and Osteoarthritis Outcome Score (KOOS), Lachman test result, return to sports time, or incidence of complications. A random effects model was used for all analyses.
RESULTS
Four hundred scientific manuscripts were recovered in the initial search. After screening, 12 studies (2 randomized controlled trials, 9 cohort studies, and 1 case- control study) met the search criteria for the qualitative analysis. Among them, 9 cohort studies were used for the quantitative analysis. The results showed few statistically significant differences in terms of muscle strength (contralateral group versus ipsilateral group or donor site group versus ipsilateral group or donor site group versus nonoperative group), Lysholm score, and return to sports time. A comparison showed no significant differences in knee laxity, IKDC score, Tegner activity score, Lachman test score, or incidence of complication, or contralateral rupture.
CONCLUSIONS
In anterior cruciate ligament reconstruction, the contralateral autologous tendon has a similar effect as the ipsilateral autologous tendon.
Topics: Humans; Anterior Cruciate Ligament; Anterior Cruciate Ligament Injuries; Knee Joint; Anterior Cruciate Ligament Reconstruction; Tendons; Autografts; Transplantation, Autologous; Treatment Outcome; Hamstring Tendons
PubMed: 37568165
DOI: 10.1186/s13018-023-04082-z -
Arthroscopy : the Journal of... Mar 2024To assess the statistical fragility of recently published randomized controlled trials (RCTs) comparing the use of hamstring tendon autograft with bone-patellar... (Review)
Review
Randomized Controlled Trials Comparing Bone-Patellar Tendon-Bone Versus Hamstring Tendon Autografts in Anterior Cruciate Ligament Reconstruction Surgery Are Statistically Fragile: A Systematic Review.
PURPOSE
To assess the statistical fragility of recently published randomized controlled trials (RCTs) comparing the use of hamstring tendon autograft with bone-patellar tendon-bone autograft for anterior cruciate ligament (ACL) reconstruction.
METHODS
The PubMed, Embase, and MEDLINE databases were queried for RCTs published since 2010 comparing autograft type (bone-patellar tendon-bone vs hamstring tendon) in ACL reconstruction surgery. The fragility index (FI) and reverse FI (rFI) were determined for significant and nonsignificant outcomes, respectively, as the number of outcome reversals required to change statistical significance. The fragility quotient (FQ) and reverse FQ, representing fragility as a proportion of the study population, were calculated by dividing the FI and rFI, respectively, by the sample size.
RESULTS
We identified 19 RCTs reporting 55 total dichotomous outcomes. The median FI of the 55 total outcomes was 5 (interquartile range [IQR], 4-7), meaning a median of 5 outcome event reversals would alter the outcomes' significance. Five outcomes were reported as statistically significant with a median FI of 4 (IQR, 2-6), meaning a median of 4 outcome event reversals would change outcomes to be nonsignificant. Fifty outcomes were reported as nonsignificant with a median rFI of 5 (IQR, 4-7), meaning a median of 5 outcome event reversals would change outcomes to be significant. The FQ and reverse FQ for significant and nonsignificant outcomes were 0.025 (IQR, 0.018-0.045) and 0.082 (IQR, 0.041-0.106), respectively. For 61.8% of outcomes, patients lost to follow-up exceeded the corresponding FI or rFI.
CONCLUSIONS
There is substantial statistical fragility in recent RCTs on autograft choice in ACL reconstruction surgery given that altering a few outcome events is sufficient to reverse study findings. For over half of outcomes, maintaining patients lost to follow-up may have been sufficient to reverse study conclusions.
CLINICAL RELEVANCE
We recommend co-reporting FIs and P values to provide a more comprehensive representation of a study's conclusions when conducting an RCT.
Topics: Humans; Patellar Ligament; Autografts; Hamstring Tendons; Bone-Patellar Tendon-Bone Grafting; Anterior Cruciate Ligament Injuries; Randomized Controlled Trials as Topic; Anterior Cruciate Ligament Reconstruction; Transplantation, Autologous
PubMed: 37543146
DOI: 10.1016/j.arthro.2023.07.039 -
BMC Musculoskeletal Disorders Aug 2023Different types of grafts can be used for anterior cruciate ligament reconstruction (ACLR). There is little published data regarding skeletally immature patients. The...
Clinical outcomes of different autografts used for all-epiphyseal, partial epiphyseal or transphyseal anterior cruciate ligament reconstruction in skeletally immature patients - a systematic review.
BACKGROUND
Different types of grafts can be used for anterior cruciate ligament reconstruction (ACLR). There is little published data regarding skeletally immature patients. The purpose of this systematic review was to assess the clinical outcomes and complications for different autograft types used in all-epiphyseal, transphyseal and partial epiphyseal/hybrid ACLR in skeletally immature children and adolescents.
METHODS
PubMed, Embase and Cochrane databases were systematically searched for literature regarding ACLR using hamstrings, quadriceps or bone-patellar-tendon-bone (BPTB) autografts in skeletally immature patients. Studies were included if they examined at least one of the following outcomes: graft failure, return to sport(s), growth disturbance, arthrofibrosis or patient reported outcomes and had a minimum follow-up of 1 year. Case reports, conference abstracts and studies examining allografts and extra-articular or over-the-top ACL reconstruction techniques were excluded. Graft failure rates were pooled for each graft type using the quality effects model of MetaXL. A qualitative synthesis of secondary outcomes was performed.
RESULTS
The database search identified 242 studies. In total 31 studies were included in this review, comprising of 1358 patients. Most patients (81%) were treated using hamstring autograft. The most common used surgical technique was transphyseal. The weighted, pooled failure rate for each graft type was 12% for hamstring tendon autografts, 8% for quadriceps tendon autografts and 6% for BPTB autografts. Confidence intervals were overlapping. The variability in time to graft failure was high. The qualitative analysis of the secondary outcomes showed similar results with good clinical outcomes and low complication rates across all graft types.
CONCLUSIONS
Based on this review it is not possible to determine a superior graft type for ACLR in skeletally immature. Of the included studies, the most common graft type used was the hamstring tendon. Overall, graft failure rates are low, and most studies show good clinical outcomes with high return to sports rates.
Topics: Adolescent; Child; Humans; Autografts; Anterior Cruciate Ligament; Anterior Cruciate Ligament Injuries; Anterior Cruciate Ligament Reconstruction; Transplantation, Autologous
PubMed: 37537529
DOI: 10.1186/s12891-023-06749-4 -
The Knee Oct 2023Treatment of patellar instability remains up for debate, and a combination of tibial tubercle osteotomy and medial patellofemoral ligament reconstruction (MPFLr) of the... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Treatment of patellar instability remains up for debate, and a combination of tibial tubercle osteotomy and medial patellofemoral ligament reconstruction (MPFLr) of the medial patellofemoral ligament (MPFL) has become the mainstay treatment for recurrent lateral patellar dislocation. Due to limited small studies, there remains a variety of surgical techniques still being practiced. The use of MPFL reconstruction, in isolation, has demonstrated promise.
PURPOSE
The purpose of this systematic review and meta-analysis is to investigate if isolated medial patellofemoral ligament reconstruction (iMPFLr) can safely and efficaciously restore knee stability and to present the patient demographics, surgical techniques, graft choices, clinical outcomes, and complications after iMPFLr for recurrent patellar dislocation (RPD).
METHODS
A review of the current literature according to Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines, yielded 299 abstracts. Twenty-seven articles met the inclusion/exclusion criteria accounting for 1200 patients. Data was pooled and analyzed focusing on patient demographics, graft type used, Kujala, International Knee Documentation Committee (IKDC), Lysholm, Tegner, and complications.
RESULTS
Across all studies the weighted mean age was found to be an average of 24.5 years, BMI was 24.9 kg/m, follow-up was 47.3 months, as 67% were female, TT-TG distance was 15.3 mm, and Caton Deschamps index 1.11. The pooled effect size difference of pre versus post assessment of Kujala was -2.8, IKDC was -4.5, Lysholm was -6.4, and Tegner was -0.74. The pooled complication rate was found to be 8% across all included studies. A subgroup analysis was also performed, specifically looking at how single bundle, double bundle, gracilis, semitendinosus and knee angle during fixation effect outcome data.
CONCLUSION
This systematic review and meta-analysis demonstrates that isolated MPFL reconstruction is a safe and effective treatment for recurrent patellar dislocations. Given the efficacy of isolated MPFL reconstruction, future investigations should aim to uncover the exact TT-TG distance, trochlear dysplasia, and patella alta grade for selecting patients to undergo this procedure. Furthermore, more primary research needs to be conducted on this topic due to the overall lack of published data from randomized controlled studies and no broad standardization of outcome measurements.
LEVEL OF EVIDENCE
(4) Systematic Review and Meta-Analysis.
Topics: Humans; Female; Young Adult; Adult; Male; Patellar Dislocation; Patellofemoral Joint; Joint Instability; Knee Joint; Joint Dislocations; Ligaments, Articular; Patella
PubMed: 37531844
DOI: 10.1016/j.knee.2023.07.003 -
Journal of ISAKOS : Joint Disorders &... Apr 2024A reliable evaluation of anterolateral rotatory instability in the anterior cruciate ligament (ACL) deficient knee is important to help surgeons determine which patients... (Review)
Review
IMPORTANCE
A reliable evaluation of anterolateral rotatory instability in the anterior cruciate ligament (ACL) deficient knee is important to help surgeons determine which patients might need concurrent anterolateral augmentation procedures.
OBJECTIVE
The purpose of this study was to systematically review studies that assess the intra-observer and inter-observer reliability of instruments used to measure anterolateral rotatory laxity of the knee.
EVIDENCE REVIEW
A comprehensive literature review was conducted according to the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, using PubMed, Embase, Scopus, and Google Scholar databases for original, English-language studies evaluating the reliability of objective or instrument-based anterolateral rotatory laxity of the knee until October 31, 2022. Reliability data were extracted from text, tables, and figures.
FINDINGS
Twelve studies, with patients between the ages of 14-63 years, were included. The instruments used to measure anterolateral rotatory knee laxity included inertial sensors (n = 9), magnetic resonance imaging (n = 1), and navigation systems (n = 2). The global intra-observer intraclass correlation coefficient for these devices was between 0.63 and 0.97, and the global inter-observer reliability was between 0.63 and 0.99.
CONCLUSION AND RELEVANCE
Instrument-based anterolateral rotatory knee laxity assessment has moderate to good intra- and inter-observer reliability. Evaluating anterolateral instability in ACL-deficient knees with these devices could help in decision-making when considering anterolateral augmentation.
LEVEL OF EVIDENCE
IV.
Topics: Humans; Adolescent; Young Adult; Adult; Middle Aged; Anterior Cruciate Ligament Injuries; Reproducibility of Results; Joint Instability; Knee Joint; Anterior Cruciate Ligament
PubMed: 37495018
DOI: 10.1016/j.jisako.2023.07.007 -
European Journal of Orthopaedic Surgery... Jan 2024The anterolateral ligament (ALL) was first described in 1879 in the context of Segond fractures, which correlate with a 75-100% chance of an anterior cruciate ligament...
The anterolateral ligament (ALL) was first described in 1879 in the context of Segond fractures, which correlate with a 75-100% chance of an anterior cruciate ligament (ACL) tear or a 66-75% chance of a meniscal tear. The purpose of this paper is to provide an updated comprehensive review on the anterolateral ligament complex of the knee focusing on the: (1) anatomy of the ALL/ALC; (2) associated biomechanics/function; and (3) important surgical considerations in contemporary anterior cruciate ligament (ACL) reconstruction and total knee arthroplasty (TKA). A systematic review of studies on ALL was conducted on Pubmed/MEDLINE and Cochrane databases (May 7th, 2020 to February 1st, 2022), with 20 studies meeting inclusion/exclusion criteria. Studies meeting inclusion criteria were anatomical/biomechanical studies assessing ALL function, cadaveric and computer simulations, and comparative studies on surgical outcomes of ALLR (concomitant with ACL reconstruction). Eight studies were included and graded by MINOR and Newcastle-Ottawa scale to identify potential biases. The anatomy of the ALL is part of the anterolateral ligament complex (ALC), which includes the superficial/deep iliotibial band (including the Kaplan fiber system), iliopatellar band, ALL, and anterolateral capsule. Multiple biomechanical studies have characterized the ALC as a secondary passive stabilizer in resisting tibial internal rotation. Given the role of the ALC in resisting internal tibial rotation, lateral extra-articular procedures including ALL augmentation may be considered for chronic ACL tears, ACL revisions, and a high-grade pivot shift test. In the context of TKA, in the event of injury to the ALC, a more constrained implant or soft-tissue reconstruction may be necessary to restore appropriate knee stability.
Topics: Humans; Arthroplasty, Replacement, Knee; Range of Motion, Articular; Knee Joint; Anterior Cruciate Ligament; Anterior Cruciate Ligament Injuries; Anterior Cruciate Ligament Reconstruction; Biomechanical Phenomena; Joint Instability; Cadaver
PubMed: 37490068
DOI: 10.1007/s00590-023-03647-2 -
European Journal of Orthopaedic Surgery... Jan 2024Popliteomeniscal fascicles (PMFs) are a component of the popliteal hiatus complex in the knee, and their injury primarily affects young athletes participating in sports... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
Popliteomeniscal fascicles (PMFs) are a component of the popliteal hiatus complex in the knee, and their injury primarily affects young athletes participating in sports activities involving twisting movements. The identification of PMFs tears presents a challenge, often accompanied by lateral pain and a locking sensation. The objective of this systematic review (SR) and meta-analysis is to enhance the suspicion and recognition of PMFs tears, aiming to facilitate the treatment of this condition, particularly in symptomatic young patients.
METHODS
A comprehensive search, focused on studies examining PMFs injuries and their treatment, was conducted in four databases, PubMed, Scopus, Embase, and Web of Science. The ROBINS-I tool was used to evaluate the risks of bias. The PRISMA flow diagram was used to conduct the research and select the included studies. A meta-analysis was conducted for the Lysholm score, the Tegner Activity Scale, and the subjective IKDC score. The present SR and meta-analysis was registered on PROSPERO.
RESULTS
Five clinical studies were included in the final analysis, comprising 96 patients. All the patients underwent a preoperative MRI assessment and a diagnostic arthroscopy to detect the PMFs tears, with a subsequent surgical procedure either open or arthroscopically performed. Surgery was associated with the resolution of symptoms. A statistically significant improvement in the Lysholm score (p: 0.0005) and the subjective IKDC score (p: 0.003) after the surgical procedure with respect to the preoperative evaluation was found.
CONCLUSION
This SR and meta-analysis showed a significant improvement in the Lysholm score and subjective IKDC score following surgery for PMFs tears. However, controversy persists regarding the optimal surgical approach, with current literature favoring arthroscopic procedures.
LEVEL OF EVIDENCE
IV.
Topics: Humans; Knee Joint; Lysholm Knee Score; Arthroscopy; Sports; Ligaments, Articular; Treatment Outcome
PubMed: 37481735
DOI: 10.1007/s00590-023-03645-4 -
World Neurosurgery Oct 2023Thoracic ossification of ligamentum flavum (TOLF) is a rare disease that often results in worsening neurologic sequelae if left untreated. Although the gold standard...
BACKGROUND
Thoracic ossification of ligamentum flavum (TOLF) is a rare disease that often results in worsening neurologic sequelae if left untreated. Although the gold standard treatment for TOLF is open posterior laminectomy, it is often accompanied by high rates of complications and perioperative morbidity. There have been studies looking into feasibility of endoscopic posterior decompression for TOLF, citing potential for lower perioperative morbidity and achieving similar functional outcomes to its open laminectomy counterparts. We provide an up-to-date systematic review of clinical outcomes after endoscopic posterior decompression for TOLF from the latest assemblage of evidence.
METHODS
A systematic review of the technique was conducted from May 2000 to May 2023. Articles were selected based on PRISMA guidelines. Eligibility of studies was independently by 2 reviewers, with disagreements resolved by a third author.
RESULTS
Nineteen primary references comprising 337 patients with TOLF who underwent endoscopic posterior decompression were included in the systematic review. Mean follow-up time across all studies ranged from 8.9 to 65.3 months. Mean age ranged from 51.2 to 63 years, with mean intraoperative blood loss ranging from 15 to 62 mL. There is significant improvement in visual analog scale (VAS) score, VAS back, VAS leg, modified Japanese Orthopaedic Association score, and Oswestry Disability Index compared with preoperative recorded values across all studies, with low rates of complications reported.
CONCLUSIONS
Endoscopic posterior spinal decompression is a safe and effective technique for treatment of TOLF, with a low rate of complications and improvement in pain and function.
Topics: Humans; Middle Aged; Laminectomy; Osteogenesis; Ligamentum Flavum; Ossification, Heterotopic; Retrospective Studies; Thoracic Vertebrae; Decompression, Surgical; Treatment Outcome
PubMed: 37480986
DOI: 10.1016/j.wneu.2023.07.066