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Patients with ligamentous hyperlaxity or knee hyperextension seem to be at a higher risk of failure following anterior cruciate ligament (ACL) reconstruction. The objective of this study was to better understand global practices for the treatment of ACL injuries in patients with knee hyperextension and ligamentous hyperlaxity among knee and sports medicine surgeons worldwide. A survey invitation was sent to members of the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS) who were identified as knee and sports surgeons. The survey consisted of a total of 25 questions, covering topics related to preoperative assessment, surgical technique, and postoperative management of patients with knee hyperextension. Survey responses were tabulated and reported using descriptive statistics. In total, 427 responses to the survey were obtained from ISAKOS members. All continents participated, with the largest number of responses coming from Latin America (36.8 ​%). 75.4 ​% of respondents believe that patients with knee hyperextension tend to have more ACL tears, and 90.4 ​% believe that those who undergo ACL reconstruction have higher rates of reconstruction failure. Regarding surgical technique and graft type, 66.7 ​% of respondents modify their approach when treating patients with knee hyperextension. 82.7 ​% of respondents do not change the position of the bone tunnels, while 12.9 ​% reported placing the tibial tunnel more posteriorly. The most used grafts are hamstrings (38.4 ​%) and bone-patellar tendon-bone (BTB) (37.2 ​%). Allografts are preferred by only 5.9 ​% of respondents, and 75.9 ​% of surgeons are not concerned about using autografts, even in cases of suspected collagen disorders. 89.5 ​% of respondents believe adding an extra-articular procedure could minimize failure risk. The most used extra-articular procedure is lateral extra-articular tenodesis (LET) (63.9 ​%). ACL surgeons across diverse regions, demographics, experience levels, and surgical volumes tend to modify their approach for patients with knee hyperextension or ligamentous hyperlaxity. Hamstring and BTB grafts are most commonly used, with the vast majority not changing tunnel positioning. Most fix the graft at 20-30° of knee flexion and believe that lateral augmentations reduce failure rates in this population, with LET being the preferred technique. Level V, expert opinion study.
Acromioclavicular joint (ACJ) stabilizations are associated with a high overall failure rate with 9.5% of these patients requiring subsequent revision surgery. Consequently, understanding the specific cause of primary ACJ stabilization failure is paramount to improving surgical decision-making in this challenging patient cohort. To (1) identify risk factors and mechanisms for failure following primary arthroscopically-assisted ACJ stabilization to highlight the importance of conducting a detailed failure analysis and to (2) establish revision strategies based on real-life cases of primary failed ACJ stabilization. Level of evidence IV. A survey was shared internationally among members of the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS) shoulder committee. The survey contained failure analysis of 11 real-life cases of failed primary arthroscopically-assisted ACJ stabilization. For each case, a thorough patient history, standardized radiographs, and CT scans were provided. Participants were asked to give their opinion on bone tunnel placement, cause of failure (biological, technical, traumatic, or combined), the stabilization technique used, as well as give a recommendation for revision. Seventeen members of the ISAKOS shoulder committee completed the survey. Biological failure was considered the most common cause of failure (47.1%), followed by technical (35.3%) and traumatic (17.6%) failure. The majority deemed two modifiable factors (i.e., patient's profession and sport) as well as non-modifiable factors (i.e., patient's age and time from trauma to initial surgery) to be risk factors for failure. In 10 of 11 cases, the correct fixation device was used in the primary setting (90.9%; 52.8-82.4% agreement); however, in eight of those cases, the technique was not performed correctly (80.0%; 58.8-100% agreement). In 8 of all 11 cases, the majority recommended an arthroscopically assisted technique with graft augmentation for revision (52.9-58.8% agreement). Biological failure and technical failure are the most common reason for failure in primary ACJ stabilization followed by traumatic failure. Besides, biological failure can be triggered by technical errors such as clavicular or coracoidal tunnel misplacement. Consequently, a detailed failure analysis including preoperative CT should be conducted on the causes of primary ACJ failure, and, if possible, an arthroscopically-assisted technique with graft augmentation should be prioritized in revision ACJ surgery. ACJ stabilizations are associated with a high overall failure rate - potentially due to biological and technical properties. When encountering failed arthroscopically-assisted ACJ stabilization, a detailed failure analysis should be conducted on the causes of primary ACJ failure. Furthermore, an arthroscopically-assisted revision stabilization is feasible in most cases.
Rockwood (RW) type VI acromioclavicular (AC) dislocations are exceptionally rare injuries, often associated with high-energy trauma and polytrauma. Limited evidence exists regarding their optimal management and long-term outcomes, making it crucial to synthesize available data to guide clinical decision-making. This study aims to systematically review existing literature on patient demographics, mechanisms of injury, treatment strategies, functional and radiographic outcomes, and complications of reported cases of RW type VI acromioclavicular (AC) injuries. A comprehensive literature search was conducted in multiple databases on February 5, 2025. Eligible studies included retrospective and prospective reports of patients with RW type VI AC dislocations. Case reports and case series were considered, given the rarity of the condition. Data extracted included demographics, mechanism of injury, treatment methods, functional outcomes, radiographic results, and complications. Due to the limited number of cases and heterogeneity of reporting, a qualitative synthesis was performed without formal meta-analysis. Twenty-four patients were identified across 20 case reports and 2 case series. Among them, 10 were classified as RW type VIa (subacromial) and 14 as type VIb (subcoracoid). The predominant mechanism of injury was motor vehicle accidents. Surgical intervention was the treatment of choice in 91.7% of cases, with techniques including K-wire fixation and coracoclavicular ligament repair. Two patients with type VIa dislocations experienced spontaneous reduction without surgical intervention. At follow-up, 21 of 24 patients regained full range of motion and reported pain-free function, accompanied by satisfactory radiographic findings. The overall complication rate was 8.3%, comprising persistent pain and muscle atrophy. No cases of recurrent dislocation or infection were reported. Hardware removal was performed in 45.8% of patients. RW type VI AC dislocations remain exceedingly rare, with only 24 cases reported to date. Subclassification into type VIa and VIb may assist orthopedic surgeons in tailoring management strategies due to differences in associated injury patterns. While the majority of cases are surgically managed, no single treatment approach demonstrates clear superiority. Overall outcomes appear favorable regardless of intervention, with high rates of return to function and low complication rates. Awareness of this injury pattern is essential to prevent missed diagnoses in the acute trauma setting. Future high-quality, multicenter studies are necessary to establish evidence-based treatment recommendations. V. Systematic reviews and meta-analyses are assigned a level of evidence equivalent to the lowest level of evidence used from the manuscripts analyzed (case series).
Anterior shoulder instability is common in the teenage population, especially among patients enrolled in contact or overhead sports. With the rise in teenage sports participation, there has been a concomitant increase in the prevalence of shoulder instability. Moreover, multiple studies have demonstrated that adolescents-particularly those between 14 and 20 years of age-are at the highest risk of recurrence, whereas patients younger than 14 tend to show lower recurrence rates. Redislocation has been associated with the development of off-track Hill-Sachs (HS) lesions and the impairment of quality of life and sports performance. Although there is still debate regarding the surgical management of the first dislocation episode, several studies have reported decreased rates of recurrent instability and improved outcomes in patients who undergo early surgical intervention. Given the increased incidence of anterior shoulder instability in the teenage athlete population, along with the recognition of the potential need for surgical intervention following a primary dislocation, the number of arthroscopic stabilization procedures has increased. Identifying a durable surgical solution for anterior shoulder instability in the teenage athlete has proved challenging. Although the arthroscopic Bankart repair has shown good short-term clinical and functional outcomes, high rates of recurrence have been observed in the long-term, especially in the young active population. These elevated failure rates have prompted a growing shift toward the use of remplissage and Latarjet procedures in adolescent athletes. Both techniques have proven to be effective in this population, demonstrating high rates of restored shoulder stability, successful return to sports (RTS), and a low incidence of complications. However, the role of the free graft position is yet to be determined. However, in cases with significant glenoid bone loss or off-track lesions, free bone grafting has emerged as a potential alternative. Still, the role of these grafts remains to be fully defined in this population.
The American Orthopaedic Foot and Ankle score (AOFAS) is an outcome measure for ankle and hindfoot conditions, which requires scoring from both the patients and the physician. A completely patient-reported version has been developed and used before, but its measurements properties are unknown. Our goal was to determine the measurement properties and the minimally important change (MIC) of a completely patient-reported AOFAS (PR-AOFAS) in patients with ankle osteoarthritis. Additionally, the MIC of both the PR-AOFAS and the AOFAS was estimated, which had not previously been done. The PR-AOFAS of 112 patients was evaluated for reliability, construct validity (using the AOFAS, Foot and Ankle Outcome Score, Ankle Osteoarthritis Score, Visual Analogue Scale, and Short Form-36), and responsiveness. The MIC was estimated using the optimal cut-off point of the receiver operating characteristic curve. This was a substudy of a randomized clinical trial on the efficacy of platelet-rich plasma injections for ankle osteoarthritis (OA). The PR-AOFAS had sufficient construct validity, internal consistency, test-retest reliability, and responsiveness. The smallest detectable change at group level was 2.34. The MIC was 6.5 points (95% confidence interval: 0.6-14.4). The measurement properties of the Dutch PR-AOFAS were sufficient in patients with ankle osteoarthritis who are willing to participate in a trial on injection therapy. The minimally important change of the PR-AOFAS is smaller than its smallest detectable change, making it more suitable for use in groups of patients, such as a research setting. 1.
To provide a proof-of-concept analysis of the appropriateness and performance of ChatGPT-4 to triage, synthesize differential diagnoses, and generate treatment plans concerning common presentations of knee pain. Twenty knee complaints warranting triage and expanded scenarios were input into ChatGPT-4, with memory cleared prior to each new input to mitigate bias. For the 10 triage complaints, ChatGPT-4 was asked to generate a differential diagnosis that was graded for accuracy and suitability in comparison to a differential created by 2 orthopaedic sports medicine physicians. For the 10 clinical scenarios, ChatGPT-4 was prompted to provide treatment guidance for the patient, which was again graded. To test the higher-order capabilities of ChatGPT-4, further inquiry into these specific management recommendations was performed and graded. All ChatGPT-4 diagnoses were deemed appropriate within the spectrum of potential pathologies on a differential. The top diagnosis on the differential was identical between surgeons and ChatGPT-4 for 70% of scenarios, and the top diagnosis provided by the surgeon appeared as either the first or second diagnosis in 90% of scenarios. Overall, 16 of 30 diagnoses (53.3%) in the differential were identical. When provided with 10 expanded vignettes with a single diagnosis, the accuracy of ChatGPT-4 increased to 100%, with the suitability of management graded as appropriate in 90% of cases. Specific information pertaining to conservative management, surgical approaches, and related treatments was appropriate and accurate in 100% of cases. ChatGPT-4 provided clinically reasonable diagnoses to triage patient complaints of knee pain due to various underlying conditions that were generally consistent with differentials provided by sports medicine physicians. Diagnostic performance was enhanced when providing additional information, allowing ChatGPT-4 to reach high predictive accuracy for recommendations concerning management and treatment options. However, ChatGPT-4 may show clinically important error rates for diagnosis depending on prompting strategy and information provided; therefore, further refinements are necessary prior to implementation into clinical workflows. Although ChatGPT-4 is increasingly being used by patients for health information, the potential for ChatGPT-4 to serve as a clinical support tool is unclear. In this study, we found that ChatGPT-4 was frequently able to diagnose and triage knee complaints appropriately as rated by sports medicine surgeons, suggesting that it may eventually be a useful clinical support tool.
The management of posterior cruciate ligament (PCL) injuries in children is complex and varies depending on the specific nature of the injury. Avulsions of the PCL can often be addressed with proximal or distal repair, whereas intrasubstance tears and cases with persistent instability generally require more extensive reconstruction. Despite the prevalence of such cases, the literature is predominantly composed of case reports, indicating a lack of comprehensive research in this area. The purpose of this systematic review was to analyze growth disturbance in skeletally immature patients after PCL reconstruction or repair. A systematic review was conducted on the basis of the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. The following search terms were used in the title, abstract, and keyword fields: "PCL" or "posterior cruciate ligament" AND "children" or "open physis" or "immature." The main outcome data extracted from the studies was to assess growth disturbance at a minimum 1-year follow-up after surgery. A total of 34 patients, from 17 articles, were included of which 30 (88.24%) were male and 4 (11.76%) female. Mean age at surgery was 10.18 ​± ​2.88 years. The mean interval from injury to surgery was 178.9 ​± ​288.04 days. Average follow-up duration was 50.64 ​± ​22.69 months. Six studies reported on PCL reconstructions using various grafts, including autologous allografts (hamstring or tibialis anterioris), Achilles tendon allografts with bone plugs, and parental donated hamstrings allografts. Only one study reported the use of internal brace to repair PCL, whereas in all the other studies, a repair of the PCL was performed with fixation of the bone fragment (to the femur or tibia) using screws or suture. Growth disturbances (≥10 ​mm) were reported in 2 of the 13 (15.38%) patients who underwent PCL, whereas in PCL, repair was noted in 2 of the 21 patients (9.52%) (p ​= ​0.63). Only 1 patient belonging to PCL reconstruction reported a slight increase in the valgus alignment of the operated knee compared to the contralateral knee, representing medial overgrowth at the distal femur (p ​= ​0.33). There is scarce literature on the risk of growth disturbance in skeletally immature patients after PCL reconstruction or repair. Nevertheless, PCL reconstruction in children indicates a low risk of growth disturbance, in particular for length leg-length discrepancy (<15%) in the mid- to long-term follow-up, and a low rate of angular deviations (<8%). This surgery remains a major challenge for orthopedic surgeons, and many unknowns remain regarding ideal grafts, technique, and time for surgery to prevent growth disturbance. Systematic review of Level IV. PROSPERO - (CRD42024584768).
Cartilage lesions around the knee are common injuries in the orthopedic practice. The spontaneous healing capacity of the articular cartilage is limited, and therefore surgical intervention may be necessary. The goal is to improve patients' symptoms, articular functionality, and potentially delay the progression of knee osteoarthritis. Extensive knowledge is available regarding the efficacy of cartilage restoration procedures for tibiofemoral chondral and osteochondral lesions; however, evidence on patellofemoral surgery remains more limited and controversial. The complex biomechanics and morphology of the patellofemoral joint represents a challenge in the setting of knee cartilage surgery and, as a result, inferior outcomes have been reported when compared to treatment of condylar lesions. Furthermore, patellofemoral cartilage restoration can be combined with procedures such as a tibial tuberosity osteotomy and/or other realigning osteotomies when pathological deformities are present. Finally, when the aforementioned strategies fail or when severe osteoarthritis develops, and preservation procedures are contraindicated, arthroplasty and other options can be considered. This State of the Art review aims to critically examine the current concepts of conservative and surgical treatment of patellofemoral cartilage lesions, reporting the latest clinical evidence and describing potential future perspectives in this field.
Football is a globally played sport that poses potential risks for musculoskeletal injuries. Upper-limb injuries have a lower incidence rate than lower-limb injuries but can still cause absenteeism and performance impairment in football players. This descriptive epidemiological study aimed to evaluate and compare the epidemiological data on shoulder injuries among professional football players in two major Brazilian football championships. Data were collected throughout the championships, and club physicians medically evaluated each player during official games using two online forms. The collected information included the player's age and position, injury diagnosis, laterality, location on the field where the injury occurred, playing time, imaging examinations performed, need for surgical treatment, time to return to play (TRP), and recurrence of the injury. The incidence of injuries was evaluated using the Federation Internationale de Football Association (FIFA) incidence formula. A total of 107 shoulder injuries were recorded (4.3% of all injuries), with a FIFA incidence of 0.847. Glenohumeral dislocations (GHDs) and acromioclavicular dislocations (ACDs) accounted for 37.38% and 35.51% of all shoulder injuries, respectively. Goalkeepers and defenders presented, respectively, a 2.15 and 1.57 times increased risk of suffering shoulder injuries, while attackers presented a 0.63 times decreased risk. Injury recurrence was observed in 14.95% of cases, with GHDs and ACDs showing recurrence rates of 35.00% and 5.26%, respectively. Surgery was performed in 9.35% of cases, with GHDs representing 50% of all surgeries. The average TRP was 22.37 days, with severe and major injuries accounting for 11.21% and 10.28% of all injuries, respectively. Goalkeepers had the highest average TRP of 36.15 days. Recurring injuries had a higher average TRP of 33.44 days compared to nonrecurring injuries, which had an average TRP of 20.43 days. Surgically treated injuries had the highest average TRP of 112.5 days. Shoulder injuries in the professional football scenario are of great concern due to the high recurrence rate and need for surgical treatment, which will lead to a long TRP. These findings emphasize the need to implement prevention protocols and effective treatments to reduce the consequences of such injuries, which are usually underestimated in this sport. III.
Balancing the patellofemoral joint (PFJ) in total knee arthroplasty (TKA) involves avoiding over-stuffing. The purpose of this study was to assess how often a strategy of recreating the anterior space of the trochlea (full extension) led to the trochlea depth being recreated in both mid-flexion (30-40°) and deep flexion (80-90°). One hundred and twenty two consecutive patients undergoing robotic-assisted TKA had femoral components placed according to functional alignment principals and were assessed. The femoral component was sized and positioned in order to ensure that the anterior flange was within 2 ​mm of the native anatomy, corresponding to a patella position of full extension (0° flexion). Trochlea depth restoration in 3 positions along the floor of the trochlea groove was compared and measured. The trochlea was defined as balanced if the prosthesis was within 2 ​mm of the native anatomy. Patients were divided into over-stuffed (prosthesis >2 ​mm above the native anatomy) or under-stuffed (prosthesis >2 ​mm beneath the native anatomy). All patients 122/122 (100%) had a balanced trochlea in full extension. In total 54 TKA were over or under-stuffed at either mid-flexion or deep flexion. In mid-flexion, 3/122 (2.5%) trochlea were over-stuffed and 39/122 (32%) trochlea were under-stuffed. In deep flexion, 25/122 (20.5%) of trochlea's were overstuffed and 30/122 (24.6%) were under-stuffed. In mid-flexion, balanced trochlea components were more externally rotated relative to the posterior condylar axis compared to unbalanced components (2.35° external rotation vs 1.21°, p=0.004). There were no other significant differences observed between the balanced and unbalanced trochlea groups in mid or deep flexion. Over 40% of TKA over or under-stuff the trochlea in deeper flexion despite the anterior flange being positioned within 2 ​mm of the native anatomy in full extension. The rate of over or under-stuffing in mid and deep flexion was similar (>40%); however, in mid-flexion, under-stuffing of the native trochlea was more common. The concept of PFJ over or under-stuffing in TKA needs to be redefined to consider the full arc of flexion of the trochlea groove, and the biomechanical and clinical consequences of under-stuffing the trochlea investigated further. Level IV.
This classic discusses Arthur E. Ellison's (1926-2010) contributions to our understanding of anterolateral rotatory laxity of the knee. Ellison was a distinguished orthopaedic surgeon and one of the founding members of the American Orthopaedic Society for Sports Medicine (AOSSM). He served as the team physician for the United States ski team and Williamsburg football team. Ellison's publications focussed on the pathodynamics of knee stability, shedding light on the biomechanical functions of the iliotibial band. This led to the development of his lateral extra-articular procedure designed to control excessive tibial rotation in the anterior cruciate ligament (ACL) deficient knee. His work has made a significant contribution to our understanding of knee stability today, and many surgeons still use a modified version of Ellison's original technique to augment ACL reconstruction. This article summarises Ellison's original publications and the first description of his operative technique. The impact of his work is discussed in the context of modern practice. The aim of this study is to add these valuable insights to the current discussion regarding the optimal method for lateral extra-articular tenodesis. LEVEL OF EVIDENCE: V - Expert Opinion.
The aim was to provide international guidelines to enhance decision-making regarding the definition and evaluation of increased posterior tibial slope (PTS) and the role of anterior closing wedge high tibial osteotomy (ACWHTO) in the setting of revision anterior cruciate ligament reconstruction (ACLR). This guideline is based on responses from 46 international orthopaedic surgeons with expert experience in knee pathologies and osteotomy. Based on a literature review, each expert drafted and commented on a set of core statements. The provided comments were blinded and discussed within the working group to refine the statements. In a subsequent round of surveys, all experts discussed with the final 32 statements. Consensus was achieved when at least 80 ​% of survey respondents fully agreed. With respect to ACWHTO for PTS reduction, there was consensus achieved for using the medial plateau as a measurement for PTS measuring, aiming for PTS correction of 5-7°, individualizing osteotomy wedge thickness, and performing ACWHTO and revision ACLR in a single stage. There was no consensus on the type of radiographs to be used, a cut-off value for increased PTS, an absolute indication for ACWHTO the osteotomy technique, nor type of fixation. The International consensus statements aim to bridge the gap between research and clinical application to enhance clinicians' decision-making in revision ACLR management and to focus future areas of required research. The literature review confirmed a paucity of evidence to guide clinicians in the diagnosis and surgical management of increased PTS. An agreement could be achieved for 25/32 statements (78 ​%) on the definition and assessment of PTS, indication, planning, surgical decision-making, and peri- and postoperative management for ACWHTO. While no consensus could be achieved for the definition of a cut-off value for pathological PTS, consensus was reached for a variety of statements on diagnostic and surgical aspects. V, expert opinion.
Recurrent patellar instability is often managed with medial patellofemoral ligament (MPFL) reconstruction. Recent work has demonstrated poorer outcomes of MPFL reconstruction in patients with articular cartilage damage. We quantified prevalence and location of articular cartilage injuries in patients treated for patellar instability with MPFL reconstruction and identified factors associated with cartilage damage. One hundred ninety-nine patients undergoing isolated MPFL reconstruction at 6 centers on 5 continents between 2016 and 2020 were prospectively enrolled. All procedures were performed for recurrent patellar instability. All patients underwent a diagnostic arthroscopy. Patellofemoral articular cartilage damage location and severity were recorded according to the International Cartilage Restoration Society (ICRS) system, with damage of ICRS grade 2 or greater defined as substantial cartilage damage. Patient and injury factors were compared based on the presence or absence of substantial cartilage damage. Multiple logistic regression models were created to identify factors associated with cartilage damage. One hundred eleven patients (56 ​%) were noted to have substantial patellofemoral articular cartilage injury (72 grade 2, 27 grade 3, 12 grade 4). Most patients (106) had patellar cartilage damage, with trochlear damage less common (19). Sixty-nine of the 106 patients (65 ​%) with patellar cartilage damage had medial patellar damage. The cartilage damage group demonstrated significantly increased age at surgery (p ​= ​0.022) and trends toward higher body mass index (BMI) (p ​= ​0.059), and lower Beighton score (0.059). Increased age at surgery (odds ratio ​= ​1.079, p ​= ​0.010) was the only significant predictor of substantial cartilage injury. Increased age at surgery, increased BMI, and increased tibial tubercle-trochlear groove (TT-TG) distance were associated with distal and lateral patellar chondral damage, while presence of knee hyperextension greater than 10° was associated with a decreased risk of medial chondral damage. Substantial cartilage damage was present in 56 ​% of patients who underwent isolated MPFL reconstruction for recurrent patellar instability, with medial patellar lesions being the most common. Increased age at surgery was associated with increased risk of substantial patellofemoral cartilage damage. Increased age at surgery, increased BMI, and increased TT-TG distance were associated with distal and lateral patellar chondral damage. Level 3-case control study.
This study aimed to update previously published clinical and radiographic outcomes of Dejour sulcus-deepening trochleoplasty and medial patellofemoral ligament reconstruction (MPFL-R) at mid-term follow-up and monitor trends in patient-reported outcome scores and satisfaction. Using the same cohort of patients from our previously published short-term series of 2-year follow-up, an interval follow-up was performed on 67 patients (76 knees) with severe trochlear dysplasia and recurrent patellar instability who were prospectively enrolled and underwent Dejour sulcus-deepening trochleoplasty and MPFL-R combined with other patellar stabilization procedures. Patients with less than 2 years of follow-up were excluded. Evaluation involved radiographic analysis, physical examination, clinical follow-up, and patient-reported outcome scores. A total of 37 patients (45 knees) were included in the current study, with a mean follow-up of 6.1 years postoperatively (standard deviation: 2.7 years). Two interval reoperations were performed (arthroscopic lysis of adhesions; hardware removal and arthroscopic shaving chondroplasty). There remained no occurrences of reoperation for recurrent patellar instability. Patient-reported outcomes were largely stable from early (mean: 3.6 years) to mid-term (mean: 6.1 years) follow-up, with no statistically significant difference between early and mid-term International Knee Documentation Committee (IKDC) (P ​= ​0.75), Kujala (P ​= ​0.47), or visual analog scale (VAS) pain (P ​= ​0.06) scores. Compared to preoperative knee scores, there was a significant difference in IKDC (49.3 vs 82.0, P ​< ​0.001, d ​= ​1.85), Kujala (56.5 vs 89.3, P ​< ​0.001, d ​= ​2.03), and VAS pain (3.8 vs 1.9, P ​= ​0.003, d ​= ​0.33) scores at mid-term follow-up (mean: 6.1 years). Mean Kellgren-Lawrence grading of patellofemoral arthritis showed no statistically significant change from 0.56 to 0.52 (P ​= ​0.511) on sunrise radiographs at the most recent follow-up. At the mid-term follow-up, Dejour sulcus-deepening trochleoplasty and MPFL-R, combined with other patellar stabilization procedures, achieves durable resolution of patellar instability with maintained patient-reported outcome scores and satisfaction rates and is without interval evidence of clinical or radiographic progression of patellofemoral arthritis. IV, Case Series.
Surgery for patellofemoral instability is usually considered in patients with recurrent patellar dislocation and after a first-time patellar dislocation in the presence of either an associated osteochondral fracture or high risk of recurrence due to the presence of several risk factors. Risk factors include demographics such as age, contralateral dislocation, as well as anatomic risk factors (ARF) such as abnormal coronal and rotational alignment, trochlear dysplasia, lateral quadriceps vector, and patella alta. Surgery with soft tissue procedures includes restoring the medial patellar restraints and balancing the lateral side of the joint, which can be successful in most patients. However, patients that have excessive and/or several ARFs have a high risk of failure with isolated soft tissue stabilization procedures; associated surgical correction of select ARFs is recommended. This article will discuss an approach to evaluate the risk-benefit of adding bony procedures which may decrease the chances of recurrence of patellar instability but can increase surgery-related complications. Approaching patellofemoral instability in a patient-specific approach and combining corrective osteotomies and trochleoplasties with a shared decision with the patient/family, guides surgeons to deliver optimal care for the patellar instability patient.
To evaluate 1) whether portable ultrasonography can evaluate syndesmotic instability in the sagittal plane, and 2) how portable ultrasound measurements compare to arthroscopic evaluation. Eight fresh, above-knee cadaveric specimens were used. The syndesmosis was evaluated with portable ultrasound and arthroscopy in the intact state, and thereafter with progressive sectioning of, 1) anterior-inferior tibiofibular ligament (AITFL), 2) interosseous ligament (IOL), and 3) posterior-inferior tibiofibular ligament (PITFL). Sagittal plane translation was simulated with 50N and 100N of anterior to posterior (A to P) and posterior to anterior (P to A) directed force using a bone hook. Separately, a 50N manual force was applied to the fibular tip and measured with portable ultrasound to simulate a fibular "shuck test" performed in the clinical setting. Agreement between portable ultrasound and arthroscopic measurements of fibular translation was assessed using BlandAltman analysis. When all three syndesmotic ligaments were transected, there was a statistically significant increase in fibular motion in the sagittal plane when evaluated using portable ultrasonography with application of 50N of manual pressure and when applying a 100N hook test when measuring total sagittal plane motion (p=<0.001 and p = 0.009). Arthroscopy demonstrated a statistically significant increased motion with a 100N hook test when measuring total sagittal plane motion (p < 0.001). Bland-Altman analysis between 50N manual portable ultrasound and 100N hook arthroscopy showed a mean difference of -0.24 with 95% limits of agreement ranging from -1.58 to 1.10. Portable ultrasound could detect increased fibular motion in the sagittal plane after progressive syndesmotic ligamentous injury and demonstrated acceptable agreement with arthroscopy. Portable ultrasound also offers several advantages over arthroscopy, including availability, non-invasiveness, low cost, and affording contralateral comparison. The promise of this technique suggests it should be further explored as a potential future standard for the diagnostic assessment of occult syndesmotic instability in the sagittal plane. Not Applicable, diagnostic cadaver study.
Ligamentous ankle lesions are among the most frequent sports injuries. One of the key intrinsic stabilizers of the ankle joint is the incisura fibularis (IF), as it interlocks the distal tibia and fibula. Despite an abundant amount of studies related to ligamentous ankle injuries, scant attention has been given to the specific role of the IF morphology. We systematically reviewed all literature focused on the relation between ligamentous ankle lesions and IF morphology. A systematic literature search was conducted on PubMed, Embase, and Web of Science according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines and registered on the International Prospective Register of Systematic Reviews (PROSPERO) database (CRD42021282862). In general, search terms were related to ankle and syndesmosis trauma/instability in combination with morphology parameters of the IF. Studies categorizable as original research (randomized controlled trial or observational) were included. Studies concerning degenerative ankle disease and cadavers were excluded. Thirteen studies were confirmed eligible and consisted of a prospective cohort (n ​= ​1), retrospective comparative (n ​= ​10), and observational (n ​= ​2) study design. Several studies have found an increased number of ankle ligament injuries and a higher incidence of chronic ankle instability in association with a shallow IF depth. In addition, statistically significant differences in incisura height and angle were also noted: a shorter incisura and more obtuse angle were more present in patients with ankle ligament injuries. Most studies found distinct characteristics of the IF morphology associated with ligamentous ankle lesions, potentially due to lower osseous resistance against tibiofibular displacement. However, not all studies could identify this association and presented a heterogeneous methodological quality. Therefore, further prospective studies are warranted to clarify the relationship between the IF morphology and ligamentous ankle injuries. Level III, systematic review.
The integration of artificial intelligence (AI), the rise of mega-journals, and the manipulation of impact factors present challenges to scientific integrity. These trends threaten the core principles of objectivity, reproducibility, and transparency. This editorial highlights two categories of threats: (1) external pressures, such as AI misuse and metric-driven publishing models, and (2) internal systemic flaws, including the 'publish or perish' culture and methodological fragility. Mega-journals, characterized by high-volume publishing and broad interdisciplinary scopes, improve accessibility and accelerate dissemination. However, the emphasis on publication volume might weaken the rigor of peer review. To navigate these challenges, the authors propose a balanced approach that harnesses innovation without compromising scientific integrity. Proposed solutions include mandating AI transparency through frameworks like CONSORT-AI, and redefining impact metrics to emphasize reproducibility, mentorship, and societal impact alongside citations. Scientific journals should promote career opportunities based less on publication quantity and more on quality. Global cooperation, via initiatives like the San Francisco Declaration on Research Assessment (DORA) and the Committee on Publication Ethics (COPE), is essential to standardize ethics and address resource disparities. This editorial proposes solutions for researchers, journals, and policymakers to realign academic incentives and uphold the ethical foundation of the science. By fostering transparency, accountability, and equity, the scientific community can preserve its ethical foundations while embracing transformative tools-ultimately advancing knowledge and serving society. FOR CLINICAL TRIALS: n/a. LEVEL OF EVIDENCE: V.
Glenohumeral osteoarthritis (OA) is one of the most common causes of shoulder pain. Conservative treatment options include physical therapy, pharmacological therapy, and biological therapy. Patients with glenohumeral OA present shoulder pain and decreased shoulder range of motion (ROM). Abnormal scapular motion is also seen in patients as adaptation to the restricted glenohumeral motion. Physical therapy is performed to (1) decrease pain, (2) increase shoulder ROM, and (3) protect the glenohumeral joint. To decrease pain, it should be assessed whether the pain appears at rest or during shoulder motion. Physical therapy may be effective for motion pain rather than rest pain. To increase shoulder ROM, the soft tissues responsible for the ROM loss need to be identified and targeted for intervention. To protect the glenohumeral joint, rotator cuff strengthening exercises are recommended. Administration of pharmacological agents is the major part next to physical therapy in the conservative treatment. The main aim of pharmacological treatment is the reduction of pain and diminution of inflammation in the joint. To achieve this aim, non-steroidal anti-inflammatory drugs are recommended as first-line therapy. Additionally, the supplementation of oral vitamin C and vitamin D can help to slow down cartilage degeneration. Depending on the individual comorbidities and contraindications, sufficient medication with good pain reduction is thus possible for each patient. This interrupts the chronic inflammatory state in the joint and, in turn, enables pain-free physical therapy. Biologics such as platelet-rich plasma, bone marrow aspirate concentrate, and mesenchymal stem cells have gathered increased attention. Good clinical outcomes have been reported, but we need to be aware that these options are helpful in decreasing shoulder pain but neither stopping the progression nor improving OA. Further evidence of biologics needs to be obtained to determine their effectiveness. In athletes, a combined approach of activity modification and physical therapy can be effective. Oral medications can provide patients with transient pain relief. Intra-articular corticosteroid injection, which provides longer-term effects, must be used cautiously in athletes. There is mixed evidence for the efficacy of hyaluronic acid injections. There is still limited evidence regarding the use of biologics.
Knee osteoarthritis (OA) is a chronic disease characterized by increasing prevalence and significant physical, psychological, and economic burdens. Despite extensive research, the definition, risk factors, and effective cost-efficient treatments for knee OA remain unclear. This article aims to revisit primary knee OA, understanding its etiology, and focusing on prevention and individualized nonoperative treatment modalities. This study reviews various aspects of knee OA, including its global prevalence, economic impact, and current treatment strategies. It explores the role of mechanical loading pathways in the disease's onset, highlighting the importance of considering not only the knee but the entire kinetic chain in diagnosis and treatment. Also, it discusses knee anatomy and biomechanics during functional activities, emphasizing the role of neuromuscular control and the influence of proximal and distal joints on knee health. Current treatments focus mainly on symptom management, with limited success in disease prevention and curative interventions. This review underlines the importance of understanding the biomechanical risk factors contributing to knee OA and the necessity of individualized interventions based on biokinetic profile analysis. Knee OA management and prevention necessitate a paradigm shift from viewing it as a localized knee disease to recognizing related mechanical overloads of the human complex motion system. Identifying individual inductive elements is paramount for effective knee OA prevention, management, and rehabilitation. Future research should endeavor to identify movement profile subgroups to establish an early-stage prognosis and the impact of interventions for each group. LEVEL OF EVIDENCE V: Expert opinion based on nonsystematic review.