Arthroscopic Versus Open Bankart Repairs in Recurrent Anterior Shoulder Instability: A Systematic Review of the Association Between Publication Date and Postoperative Recurrent Instability in Systematic Reviews.

PURPOSE: To systematically review the results of systematic studies regarding open versus arthroscopic Bankart repairs for recurrent anterior shoulder instability and quantitatively analyze the effect of primary-literature publication dates on reported outcomes in these systematic studies. METHODS: A systematic search was conducted to identify systematic studies reporting outcomes of both arthroscopic and open Bankart repairs for recurrent anterior shoulder instability. Patient-reported outcome measures, recurrent instability rates, definitions of instability, and procedure types reported by included study characteristics were qualitatively analyzed. Correlation coefficient analyses were performed to investigate if a systematic study's proportion of included primary literature published after 1999, 2000, 2001, or 2002 affected that study's reported mean difference in instability recurrence between open and arthroscopic procedures. The Assessment of Multiple Systematic Reviews criteria were used to assess the risk of bias of the included studies. RESULTS: Of 130 identified articles, 6 met the inclusion criteria. Patient-reported outcome measures were poorly reported. Among mean differences in instability recurrence rates, the results were indeterminate: Although 5 studies reported arthroscopic surgical procedures as having a higher recurrence rate, only 1 reported a statistically significant difference. Within the 5 included systematic reviews reporting the number of included studies, 37 of 56 observations were published after 2000. The proportion of studies published after 2000 (Pearson r = 0.88, P = .052) was positively associated with differences in instability recurrence rates between open and arthroscopic procedures. CONCLUSIONS: Systematic studies that included newer studies (published after 2000) were associated with more favorable arthroscopic outcomes. LEVEL OF EVIDENCE: Level IV, systematic review of Level III and IV studies.

Mechanisms of Bone Tunnel Enlargement Following Anterior Cruciate Ligament Reconstruction.

Although anterior cruciate ligament reconstruction (ACL-R) yields generally favorable results, bone tunnel enlargement (BTE) commonly has been reported after ACL-R. While the exact clinical ramifications of tibial widening on functional outcomes are variable, it is thought that widening may potentially play a role in late failure following ACL-R. The prevalence of tunnel enlargement is related particularly to hamstring autografts, with some authors reporting rates ranging from 25% to 100% in femoral tunnels and 29% to 100% in tibial tunnels after ACL-R. BTE is difficult to manage, particularly in the setting of revision ACL-R. The mechanisms underlying BTE after ACL-R are associated with a complex interplay between biological and mechanical factors.

Accuracy of internet images of ligamentous knee injuries.

BACKGROUND: The internet is an easily accessible resource for both providers and patients. Despite this, the internet is not peer reviewed, leaving searches subject to inaccuracies, especially with regards to medical information. The purpose of this study was to review internet images of anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (MCL), and lateral collateral ligament (LCL) tears using two popular search engines: Google and Bing. METHODS: A search query was performed on both Google and Bing for the following terms: 'ACL tear', 'PCL tear', 'MCL tear' and 'LCL tear'. The first 100 images of each individual search were analyzed by three independent orthopedists. RESULTS: The inter-rater reliability was very good for PCL tear on Bing (Cronbach's alpha = 0.89) and excellent (Cronbach's alpha > 0.9) for the remainder of the search queries. When comparing Google to Bing, the only significant difference occurred in the ACL group, with Bing returning a significantly greater number of correct images 60%, 95% CI: 53.2 - 66.7%) compared to Google (45% correct, 95% CI: 38.1-51.8%), p = 0.034. With regards to the other ligaments Bing was more accurate than Google for PCL (39% versus 38%), and LCL (32% to 30%). Both sites were 48% accurate for MCL tear. CONCLUSION: Ultimately, our study revealed that physicians should take an active role in making high quality, easy to understand medical resources and anatomic diagrams available to their patients to avoid confusion and enhance understanding when querying the internet for additional information regarding their condition.

Tibial tunnel widening following anterior cruciate ligament reconstruction: A retrospective seven-year study evaluating the effects of initial graft tensioning and graft selection.

PURPOSE: To investigate tibial tunnel widening in ACL reconstruction patients over seven years to establish the effects of initial graft tension on tibial widening and clinical outcomes when using both patellar tendon (BTB) and hamstring tendon (HS) grafts. METHODS: Ninety patients, who were reconstructed with BTB or HS autografts, were randomized using one of two initial graft tension protocols; 1) tensioned to restore normal anteroposterior laxity ("low-tension"; n = 46) and 2) tensioned to over-constrain anteroposterior (AP) laxity by two millimeters ("high-tension"; n = 44). Seventy patients had post-surgical data with 45 available for review at seven years. Tunnel widening was assessed via radiographs at one-, three-, and seven-year follow-up. Patient-reported outcomes were compared. RESULTS: The mean ±â€¯95% confidence intervals of the initial diameters for the BTB autografts were 10.3 ±â€¯0.5 mm (Low-tension) and 10.2 ±â€¯0.6 mm (High-tension) with final diameters of 10.8 ±â€¯0.6 mm (Low-tension) and 9.9 ±â€¯0.6 mm (High-tension). The initial diameters for HS autografts were 8.1 ±â€¯0.9 mm (Low-tension) and 8.4 ±â€¯0.7 mm (High-tension) with final diameters of 11.5 ±â€¯1.1 mm (Low-tension) and 11.1 ±â€¯0.9 mm (High-tension). For subjects with HS autografts, mean tunnel diameters significantly changed over time (p < .001); no significant changes were observed in BTB autografts (p = .29). Change in diameter of the HS autograft group remained significantly greater than the BTB group at all time points for both tension groups (p < .05). No differences in patient-reported outcomes were found between tension groups or graft types. CONCLUSIONS: Patients who underwent ACL-R with HS autograft exhibited tibial tunnel widening over seven years. Patients with BTB autografts did not experience widening, regardless of initial graft tension. Patient-reported outcomes were equivalent.

Arthroscopic Bankart Repair for the Management of Anterior Shoulder Instability: Indications and Outcomes.

PURPOSE OF REVIEW: Arthroscopic Bankart repair is commonly utilized for shoulder stabilization in patients with anterior shoulder instability with minimum glenoid bone loss. The purpose of this review is to provide the indications, surgical technique, complications, and recent outcomes in arthroscopic Bankart repair for shoulder instability. RECENT FINDINGS: Improvements in arthroscopic techniques have led to better patient outcomes, as well as an improved understanding of the pathoanatomy of instability. More recent studies have shown that one of the potential failures of primary arthroscopic repair may be due to unaddressed bone loss. This underscores the importance of evaluating glenoid bone loss and proper patient selection for this procedure to ensure successful outcome. When indicated, arthroscopic stabilization is the treatment of choice for many surgeons due to its lower morbidity and low overall complication rate. Future work must focus on longer-term outcomes in patients undergoing arthroscopic Bankart repair, as well as the clinical outcomes of new fixation techniques, augmentation techniques, and the effect of glenoid bone loss in outcome.

Dual fitness benefits of post-mating sugar meals for female hawkmoths (Hyles lineata).

The white-lined sphinx moth (Hyles lineata: Sphingidae) is the most widespread and abundant hawkmoth pollinator in North America and plays a major role in the reproductive biology of many plant species. H. lineata visits a wide range of plants, which differ in the quality and quantity (e.g. caloric content, volume) of the nectar reward that they offer in exchange for pollination services. Some of these plants represent a suitable oviposition substrate as well as a profitable nectar source, allowing mated H. lineata females to mix foraging and oviposition bouts. We investigated the effects of post-mating nectar intake on the reproductive success of female H. lineata. While all experimental females had access to a 20% sucrose solution during the pre-mating phase (avg. 2.7 days) we manipulated the post-mating diet, assigning mated females to three experimental groups (sucrose fed, water fed, or unfed). Mated females with access to sucrose lived twice as long and produced more fertile eggs at double the rate of control moths that were starved or water-fed after mating. Thus, the sugar component of floral nectar positively affects the physiology of mated H. lineata at multiple levels, which translates into strong selection for mated females to continue nectar foraging during or between oviposition bouts.

Stat3-targeted therapies overcome the acquired resistance to vemurafenib in melanomas.

Vemurafenib (PLX4032), a selective inhibitor of Braf, has been approved by the US Food and Drug Administration for the treatment of unresectable or metastatic melanoma in patients with Braf(V600E) mutations. Many patients treated with vemurafenib initially display dramatic improvement, with decreases in both risk of death and tumor progression. Acquired resistance, however, rapidly arises in previously sensitive cells. We attempted to overcome this resistance by targeting the signal transducer and activator of transcription 3 (STAT3)-paired box homeotic gene 3 (PAX3)-signaling pathway, which is upregulated, owing to fibroblast growth factor 2 (FGF2) secretion or increased kinase activity, with the Braf(V600E) mutation. We found that activation of Stat3 or overexpression of PAX3 induced resistance to vemurafenib in melanoma cells. In addition, PAX3 or Stat3 silencing inhibited the growth of melanoma cells with acquired resistance to vemurafenib. Furthermore, treatment with the Stat3 inhibitor, WP1066, resulted in growth inhibition in both vemurafenib-sensitive and -resistant melanoma cells. Significantly, vemurafenib stimulation induced FGF2 secretion from keratinocytes and fibroblasts, which might uncover, at least in part, the mechanisms underlying targeting Stat3-PAX3 signaling to overcome the acquired resistance to vemurafenib. Our results suggest that Stat3-targeted therapy is a new therapeutic strategy to overcome the acquired resistance to vemurafenib in the treatment of melanoma.

Rapid healing of femoral defects in rats with low dose sustained BMP2 expression from PEGDA hydrogel microspheres.

Current strategies for bone regeneration after traumatic injury often fail to provide adequate healing and integration. Here, we combined the poly (ethylene glycol) diacrylate (PEGDA) hydrogel with allogeneic "carrier" cells transduced with an adenovirus expressing BMP2. The system is unique in that the biomaterial encapsulates the cells, shielding them and thus suppressing destructive inflammatory processes. Using this system, complete healing of a 5 mm-long femur defect in a rat model occurs in under 3 weeks, through secretion of 100-fold lower levels of protein as compared to doses of recombinant BMP2 protein used in studies which lead to healing in 2-3 months. New bone formation was evaluated radiographically, histologically, and biomechanically at 2, 3, 6, 9, and 12 weeks after surgery. Rapid bone formation bridged the defect area and reliably integrated into the adjacent skeletal bone as early as 2 weeks. At 3 weeks, biomechanical analysis showed the new bone to possess 79% of torsional strength of the intact contralateral femur. Histological evaluation showed normal bone healing, with no infiltration of inflammatory cells with the bone being stable approximately 1 year later. We propose that these osteoinductive microspheres offer a more efficacious and safer clinical option over the use of rhBMP2.