Grinding, Clicking, and Pivot Pain Resolve in Most Patients After Knee Arthroscopy.

PURPOSE: To determine whether knee arthroscopy alleviates the symptom constellation of knee grinding/clicking, catching/locking, and pivot pain. METHODS: One-year follow-up data from 584 consecutive subjects who underwent knee arthroscopy from August 2012 to December 2019 were collected prospectively. Subjects reported frequency of knee grinding/clicking, catching/locking, and/or pivot pain preoperatively and 1 and 2 years postoperatively. A single surgeon performed each procedure and documented all intraoperative pathology. We measured the postoperative resolution or persistence of these symptoms and used multivariable regression models to identify preoperative demographic and clinical variables that predicted symptom persistence. We also assessed changes in the Pain, Activities of Daily Living, and Quality of Life subscales of the Knee Injury and Osteoarthritis Outcome Score (KOOS). RESULTS: Postoperative symptom resolution was more likely for grinding/clicking (65.6%) and pivot pain (67.8%) than for catching/locking (44.1%). Smoking status, overweight/obesity, absence of meniscal tear, and number of compartments with focal cartilage lesions predicted persistence of 1 or more patient-reported knee symptoms. KOOS subscale scores consistently improved by at least one standard deviation. Individuals who had resolution of patient-reported knee symptoms exhibited roughly 2-fold improvements in KOOS Pain, ADL and Quality of Life scores compared with those whose symptoms persisted. Persistence of pivot pain was associated with the least improvement of the 3 KOOS subscales. CONCLUSIONS: Two in three patients with grinding/clicking or pivot pain experience symptom resolution after knee arthroscopy, although catching/locking is more likely to persist. Smoking status, overweight/obesity, absence of meniscal tear, and number of compartments with focal cartilage lesions predict symptom persistence after knee arthroscopy. LEVEL OF EVIDENCE: Therapeutic Level IV, retrospective cohort analysis of prospective data.

Epidemiologic Comparison of Pitching Mechanics, Pitch Type, and Pitch Counts Among Healthy Pitchers at Various Levels of Youth Competition.

PURPOSE: To determine differences among healthy pitchers at various levels of competition regarding pitching history, pitching mechanics, and prevalence of breaking pitches. METHODS: Demographic, anthropometric, pitching history, and kinematic data were collected on healthy youth pitchers using dual orthogonal high-speed video analysis. Players were grouped by maturity level (9 to 12 [prepubescent], 13 to 15 [pubescent], 16 to 17 [mature], and 18 to 22 years [adult]). Groups were compared regarding pitch counts, pitching mechanics, and use of breaking pitches. Mechanics were assessed for favorable observational parameters (e.g., closed foot orientation at foot-strike) and measurable parameters at cocking, foot-strike, and ball release (e.g., knee flexion). RESULTS: Two hundred ninety-five pitchers were included. Sixty-three were 9 to 12, 130 were 13 to 15, 78 were 16 to 17, and 24 were 18 to 22 years of age. Older pitchers threw more pitches per game (41, 52, 69, and 50 by age group; P < .001), per season (766, 975, 1,079, and 881; P = .017), and per year (901, 1,343, 2,064, and 1,302; P < .001). They were more likely to pitch for multiple teams, for more than 9 months, in showcases, and in violation of pitch count recommendations. Older pitchers were more likely to maintain their hand on top of the ball, maintain closed shoulders at foot-strike, achieve hip and shoulder separation, and lead with their hips. Older pitchers achieved greater relative stride-length, greater knee flexion at front-foot contact, and increased lead hip flexion at ball release. Pitchers began throwing curveballs and sliders at 12.6 and 13.5 years, respectively. CONCLUSIONS: As pitchers age, they throw more pitches per game, per season, and per year and are more likely than younger pitchers to violate pitch count recommendations. Older pitchers tend to pitch with improved mechanics and velocity. The proportion of pitchers throwing breaking pitches increases with age, with the greatest increase occurring between ages 12 and 13. LEVEL OF EVIDENCE: Level II, cross-sectional study.

Vaccine therapies in malignant glioma.

Glioblastoma is a grade IV astrocytoma that is widely accepted in clinical neurosurgery as being an extremely lethal diagnosis. Long-term survival rates remain dismal, and even when tumors undergo gross resection with confirmation of total removal on neuroimaging, they invariably recur with even greater virulence. Standard therapeutic modalities as well as more contemporary treatments have largely resulted in disappointing improvements. However, the therapeutic potential of vaccine immunotherapy for malignant glioma should not be underestimated. In contrast to many of the available treatments, vaccine immunotherapy is unique because it offers the means of delivering treatment that is highly specific to both the patient and the tumor. Peptide, heat-shock proteins, and dendritic cell vaccines collectively encapsulate the majority of research efforts involving vaccine-based treatment modalities. In this review, important recent findings for these vaccine types are discussed in the context of ongoing clinical trials. Broad challenges to immunotherapy are also considered.

Open versus endoscopic carpal tunnel release: a meta-analysis of randomized controlled trials.

BACKGROUND: Carpal tunnel syndrome is a common compressive neuropathy of the median nerve. The efficacy and safety of endoscopic versus open carpal tunnel release remain controversial. QUESTIONS/PURPOSES: The purpose of this study was to determine whether endoscopic compared with open carpal tunnel release provides better symptom relief, validated outcome scores, short- and long-term strength, and/or digital sensibility; entails a differential risk of complications such as nerve injury, scar tenderness, pillar pain, and reoperation; allows an earlier return to work; and takes less operative time. METHODS: The English-language literature was searched using MEDLINE, the Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Central Register of Controlled Trials. Randomized controlled trials that compared endoscopic and open carpal tunnel release were included in the meta-analysis. Methodologic quality was assessed with the Consolidated Standards Of Reporting Trials (CONSORT) checklist, and a sensitivity analysis was performed. Symptom relief, Boston Carpal Tunnel Questionnaire (BCTQ) scores, strength, digital sensibility, complications, reoperation, interval to return to work, and operative time were analyzed. Twenty-one randomized controlled trials containing 1859 hands were included. RESULTS: Endoscopically treated patients showed similar symptom relief and BCTQ scores; better early recovery of grip strength (mean difference [MD], 3.03 kg [0.08-5.98]; p = 0.04) and pinch strength (MD, 0.77 kg [0.33-1.22]; p < 0.001) but no advantage after 6 months; lower risk of scar tenderness (risk ratio [RR], 0.53 [0.35-0.82]; p = 0.005); higher risk of nerve injury (RR, 2.84 [1.08-7.46]; p = 0.03), most of which were transient neurapraxias. Similar risk of pillar pain and reoperation; an earlier return to work (MD, -8.73 days [-12.82 to -4.65]; p < 0.001); and reduced operative time (MD, -4.81 minutes [-9.23 to -0.39]; p = 0.03). CONCLUSIONS: High-level evidence from randomized controlled trials indicates that endoscopic release allows earlier return to work and improved strength during the early postoperative period. Results at 6 months or later are similar according to current data except that patients undergoing endoscopic release are at greater risk of nerve injury and lower risk of scar tenderness compared with open release. While endoscopic release may appeal to patients who require an early return to work and activities, surgeons should be cognizant of its elevated incidence of transient nerve injury amid its similar overall efficacy to open carpal tunnel release. Additional research is required to define the learning curve of endoscopic release and clarify the influence of surgeon volume on its safety.

Does nonsurgical treatment improve longitudinal outcomes of lateral epicondylitis over no treatment? A meta-analysis.

BACKGROUND: Lateral epicondylitis is a painful tendinopathy for which several nonsurgical treatment strategies are used. Superiority of these nonsurgical treatments over nontreatment has not been definitively established. QUESTIONS/PURPOSES: We asked whether nonsurgical treatment of lateral epicondylitis compared with observation only or placebo provides (1) better overall improvement, (2) less need for escape interventions, (3) better outcome scores, and (4) improved grip strength at intermediate- to long-term followup. METHODS: The English-language literature was searched using PubMed and the Cochrane Central Register of Controlled Trials. Randomized-controlled trials (RCTs) comparing any form of nonsurgical treatment with either observation only or placebo at followup of at least 6 months were included. Nonsurgical treatments included injections (corticosteroid, platelet-rich plasma, autologous blood, sodium hyaluronate, or glycosaminoglycan polysulfate), physiotherapy, shock wave therapy, laser, ultrasound, corticosteroid iontophoresis, topical glyceryl trinitrate, or oral naproxen. Methodologic quality was assessed with the Consolidated Standards of Reporting Trials (CONSORT) checklist, and 22 RCTs containing 2280 patients were included. Pooled analyses were performed to evaluate overall improvement; requirement for escape interventions (treatment of any kind, outside consultation, and surgery); outcome scores (Patient-Rated Tennis Elbow Evaluation [PRTEE]; DASH; Pain-Free Function Index [PFFI]; EuroQoL [EQ]-5D; and overall function); and maximum and pain-free grip strength. Sensitivity analyses were performed using only trials of excellent or good quality. Heterogeneity analyses were performed, and funnel plots were constructed to assess for publication bias. RESULTS: Nonsurgical treatment was not favored over nontreatment based on overall improvement (risk ratio [RR] = 1.05 [0.96-1.15]; p = 0.32), need for escape treatment (RR = 1.50 [0.84-2.70]; p = 0.17), PRTEE scores (mean difference [MD] = 1.47, [0.68-2.26]; p < 0.001), DASH scores (MD = -2.69, [-15.80 to 10.42]; p = 0.69), PFFI scores (standardized mean difference [SMD] = 0.25, [-0.32 to 0.81]; p = 0.39), overall function using change-from-baseline data (SMD = 0.11, [-0.14 to 0.36]; p = 0.37) and final data (SMD = -0.16, [-0.79 to 0.47]; p = 0.61), EQ-5D scores (SMD = 0.08, [-0.52 to 0.67]; p = 0.80), maximum grip strength using change-from-baseline data (SMD = 0.12, [-0.11 to 0.35]; p = 0.31) and final data (SMD = 4.37, [-0.65 to 9.38]; p = 0.09), and pain-free grip strength using change-from-baseline data (SMD = -0.20, [-0.84 to 0.43]; p = 0.53) and final data (SMD = -0.03, [-0.61 to 0.54]; p = 0.91). CONCLUSIONS: Pooled data from RCTs indicate a lack of intermediate- to long-term clinical benefit after nonsurgical treatment of lateral epicondylitis compared with observation only or placebo. LEVEL OF EVIDENCE: Level II, therapeutic study.

Surgical Treatment Options for Glenohumeral Arthritis in Young Patients: A Systematic Review and Meta-analysis.

PURPOSE: The aim of this study was to compare surgical treatment options for young patients with glenohumeral arthritis. METHODS: A systematic review of the English-language literature was conducted by searching PubMed, EMBASE, and Scopus with the following term: "(shoulder OR glenohumeral) AND (arthritis OR osteoarthritis) AND (young OR younger)." Studies that reported clinical or radiological outcomes of nonbiologic surgical treatment of generalized glenohumeral arthritis in patients younger than 60 years of age were included. Data were extracted to include study and patient characteristics, surgical technique, outcome scores, pain relief, satisfaction, functional improvement, return to activity, health-related quality of life, complications, need for and time to revision, range of motion, and radiological outcomes. Study quality was assessed with the Modified Coleman Methodology Score. RESULTS: Thirty-two studies containing a total of 1,229 shoulders met the inclusion criteria and were included in the review. Pain scores improved significantly more after total shoulder arthroplasty (TSA) than after hemiarthroplasty (HA) (P < .001). Patient satisfaction was similar after HA and TSA. Revision surgery was equally likely after HA, TSA, and arthroscopic debridement (AD). Complications were significantly less common after AD than after HA (P = .0049) and TSA (P < .001). AD and TSA afforded better recovery of active forward flexion and external rotation than did HA. At radiological follow-up, subluxation was similarly common after HA and TSA. CONCLUSIONS: According to current Level IV data, TSA provides greater improvement of pain and range of motion than does HA in the surgical treatment of young patients with glenohumeral arthritis. AD is an efficacious and particularly safe alternative in the short term for young patients with concerns about arthroplasty. LEVEL OF EVIDENCE: Level IV, systematic review of Level IV studies.

Do arthroscopic and open stabilization techniques restore equivalent stability to the shoulder in the setting of anterior glenohumeral instability? a systematic review of overlapping meta-analyses.

PURPOSE: Shoulder instability frequently recurs in young patients without operative treatment. Both open and arthroscopic approaches to shoulder stabilization with labral repair and capsulorrhaphy have been described and are routinely used. Multiple trials have been conducted to compare these approaches, with multiple meta-analyses performed to synthesize these trials; however, the results remain controversial. The purpose of this study was to critically evaluate the current meta-analyses to identify the current state of the art. METHODS: In this study we evaluate available scientific support for the ability of both arthroscopic and open soft-tissue stabilization techniques to restore stability of the shoulder by performing a systematic review of the literature for previous meta-analyses. Data were extracted for rates of recurrence and patient outcomes. Study quality was measured with the Oxman-Guyatt and QUOROM (Quality of Reporting of Meta-analyses) systems. The Jadad algorithm was applied independently by 4 authors to determine which meta-analysis provided the highest level of available evidence. RESULTS: After application of the inclusion and exclusion criteria, 8 meta-analyses were included. Both studies published prior to 2007 concluded that open stabilization provided lower recurrence rates than arthroscopic stabilization, the 3 studies published in 2007 are discordant, and all 3 studies published after 2008 concluded that open and arthroscopic stabilization provided equivalent results. Two meta-analyses had low Oxman-Guyatt scores (<3) signifying major flaws. Four authors independently selected the same meta-analysis as providing the highest quality of evidence using the Jadad algorithm, and this meta-analysis found no difference in recurrence rates between open and arthroscopic stabilization. CONCLUSIONS: This systematic review of overlapping meta-analyses comparing arthroscopic and open shoulder stabilization suggests that according to current best available evidence, there are no significant differences in failure rates. LEVEL OF EVIDENCE: Level IV, systematic review of Level I through IV studies.

Is there a higher failure rate of allografts compared with autografts in anterior cruciate ligament reconstruction: a systematic review of overlapping meta-analyses.

PURPOSE: Multiple meta-analyses of randomized controlled trials (RCTs), the highest available level of evidence, have been conducted to determine whether autograft or allograft tissue provides superior clinical outcomes and structural healing in anterior cruciate ligament reconstruction (ACLR); however, results are discordant. The purpose of this study was to conduct a systematic review of meta-analyses comparing ACLR with autografts and allografts to elucidate the cause of discordance and to determine which meta-analyses provide the current best available evidence. METHODS: In this study we evaluated available scientific support for autograft versus allograft use in ACLR by systematically reviewing the literature for published meta-analyses. Data regarding patient outcomes and structural healing were extracted from these meta-analyses. Meta-analysis quality was assessed using the Oxman-Guyatt and Quality of Reporting of Meta-analyses (QUOROM) systems. The Jadad algorithm was then applied to determine which meta-analyses provided the highest level of evidence. RESULTS: Eight meta-analyses containing a total of 15,819 patients met the eligibility criteria, 2 of which included Level II evidence and 6 of which included Level III/IV evidence. Four meta-analyses found no differences between autografts and allografts for patient outcomes, whereas 4 found autografts superior in one or more respects. Four meta-analyses reported higher graft rupture rates in the allograft group, and 2 found superior hop test performance in autograft-treated patients. Six meta-analyses had low Oxman-Guyatt scores (<4) indicative of major flaws. CONCLUSIONS: According to this systematic review of overlapping meta-analyses comparing autografts and allografts for ACLR, the current best available evidence suggests no differences in rupture rates and clinical outcomes. Lower quality meta-analyses indicate that autografts may provide a lower rerupture rate, better hop test performance, and better objective knee stability than do allografts. LEVEL OF EVIDENCE: Systematic review of Level II, III, and IV meta-analyses.

Bioabsorbable versus metallic interference screws in anterior cruciate ligament reconstruction: a systematic review of overlapping meta-analyses.

PURPOSE: Multiple meta-analyses of randomized controlled trials have been conducted to compare clinical and functional outcomes after anterior cruciate ligament (ACL) reconstruction using metallic interference screw (MIS) versus bioabsorbable interference screw (BIS) fixation, but discrepancies in their findings have prevented a consensus conclusion. The purposes of this study were (1) to conduct a systematic review of meta-analyses comparing MISs and BISs in ACL reconstruction, (2) to provide surgical treatment recommendations for ACL graft fixation based on the highest available evidence, and (3) to propose future research avenues in areas of practice lacking high-level evidence. METHODS: The literature was systematically reviewed to identify meta-analyses comparing MISs and BISs in ACL reconstruction. Data were extracted for clinical and functional outcomes, and methodologic quality was assessed using the validated Quality of Reporting of Meta-analyses and Oxman-Guyatt systems. To determine which meta-analyses provided the current best available evidence, the Jadad decision algorithm was used. RESULTS: One Level I and 2 Level II meta-analyses were included. None showed differences between BISs and MISs in validated outcome scores, pivot-shift testing, KT arthrometry (MEDmetric, San Diego, CA), or loss of knee motion. Subgroup analyses found no differences in clinical outcomes or knee stability across biomaterials. All meta-analyses were of high quality according to the Quality of Reporting of Meta-analyses and Oxman-Guyatt systems. Two meta-analyses were determined by the Jadad algorithm to represent the current best available evidence. Both studies showed prolonged knee effusion with BIS use, with 1 also showing an increased incidence of femoral tunnel widening and screw breakage with BIS use. CONCLUSIONS: Whereas clinical and functional outcomes are similar with MISs and BISs, prolonged knee effusion, femoral tunnel widening, and screw breakage are more common with BIS use. Future cost-effectiveness analyses may help weigh the known advantages of BISs against their costs and adverse-event profile. LEVEL OF EVIDENCE: Level II, systematic review of Level I and II studies.

Does Double-Bundle Anterior Cruciate Ligament Reconstruction Improve Postoperative Knee Stability Compared With Single-Bundle Techniques? A Systematic Review of Overlapping Meta-analyses.

PURPOSE: Multiple meta-analyses of randomized controlled trials, the highest available level of evidence, have been conducted to determine whether double-bundle (DB) or single-bundle (SB) anterior cruciate ligament reconstruction (ACL-R) provides superior clinical outcomes and knee stability; however, results are discordant. The purpose of this study was to conduct a systematic review of meta-analyses comparing SB and DB ACL-R to discern the cause of the discordance and to determine which of these meta-analyses provides the current best available evidence. METHODS: We evaluated available scientific support for SB as compared with DB ACL-R by systematically reviewing the literature for published meta-analyses. Data on patient clinical outcomes and knee stability (as measured by KT arthrometry and pivot-shift testing) were extracted. Meta-analysis quality was judged using the Oxman-Guyatt and Quality of Reporting of Meta-analyses systems. The Jadad algorithm was then applied to determine which meta-analyses provided the highest level of evidence. RESULTS: Nine meta-analyses were included, of which 3 included Level I Evidence and 6 included both Level I and Level II Evidence. Most studies found significant differences favoring DB reconstruction on pivot-shift testing, KT arthrometry measurement of anterior tibial translation, and International Knee Documentation Committee objective grading. Most studies detected no significant differences between the 2 techniques in subjective outcome scores (Tegner, Lysholm, and International Knee Documentation Committee subjective), graft failure, or complications. Oxman-Guyatt and Quality of Reporting of Meta-analyses scores varied, with 2 studies exhibiting major flaws (Oxman-Guyatt score <3). After application of the Jadad decision algorithm, 3 concordant high-quality meta-analyses were selected, with each concluding that DB ACL-R provided significantly better knee stability (by KT arthrometry and pivot-shift testing) than SB ACL-R but no advantages in clinical outcomes or risk of graft failure. CONCLUSIONS: The current best available evidence suggests that DB ACL-R provides better postoperative knee stability than SB ACL-R, whereas clinical outcomes and risk of graft failure are similar between techniques. LEVEL OF EVIDENCE: Level II, systematic review of Level I and II studies.

Does Operative Treatment of First-Time Patellar Dislocations Lead to Increased Patellofemoral Stability? A Systematic Review of Overlapping Meta-analyses.

PURPOSE: To conduct a systematic review of meta-analyses comparing nonoperative and operative treatment of patellar dislocations to elucidate the cause of the variation and to determine which meta-analysis provides the current best available evidence. METHODS: A systematic review of the literature to identify meta-analyses was performed. Data were extracted for patient outcomes and recurrent dislocations. Meta-analysis quality was assessed using the Oxman-Guyatt and Quality of Reporting of Meta-analyses systems. The Jadad algorithm was then applied to determine which meta-analysis provided the highest level of evidence. RESULTS: Four meta-analyses met the eligibility criteria: 1 Level I evidence, 2 Level II evidence, and 1 Level III evidence. A total of 1,984 patients were included (997 underwent surgery whereas 987 underwent conservative treatment). Three meta-analyses found a lower subsequent patellar dislocation rate in patients managed operatively compared with nonoperatively, whereas one did not find a difference in recurrent dislocation rates between the operative and nonoperative groups. When the results of all the studies were combined, the overall redislocation rate was 29.4% and the rate of recurrent instability episodes was 32.8%. Patients treated operatively had a 24.0% rate of repeat patellar dislocation and a 32.7% rate of recurrent patellar instability, whereas patients treated nonoperatively had a 34.6% rate of repeat patellar dislocation and a 33.0% rate of recurrent instability. In addition, 1 meta-analysis found a significantly higher rate of patellofemoral osteoarthritis in the operative group. No differences in functional outcomes scores were seen between treatments. Two meta-analyses had low Oxman-Guyatt scores (<4), indicative of major flaws. CONCLUSIONS: According to the best available evidence, operative treatment of acute patellar dislocations may result in a lower rate of recurrent dislocations than nonoperative treatment but does not improve functional outcome scores. LEVEL OF EVIDENCE: Level III, systematic review of Level I, II, and II studies.

Correlates With History of Injury in Youth and Adolescent Pitchers.

PURPOSE: To determine the factors within pitcher demographic characteristics, pitching history, and pitch kinematics, including velocity, that correlate with a history of pitching-related injury. METHODS: Demographic and kinematic data were collected on healthy youth and adolescent pitchers aged 9 to 22 years in preseason training during a single preseason using dual orthogonal high-speed video analysis. Pitchers who threw sidearm and those who had transitioned to another position were excluded. Players were asked whether they had ever had a pitching-related shoulder or elbow injury. Multivariate logistic regression analysis was performed on those variables that correlated with a history of injury. RESULTS: Four hundred twenty pitchers were included, of whom 31% had a history of a pitching-related injury. Participant height (P = .009, R(2) = 0.023), pitching for more than 1 team (P = .019, R(2) = 0.018), and pitch velocity (P = .006, R(2) = 0.194) served as independent correlates of injury status. A model constructed with these 3 variables could correctly predict 77% of injury histories. Within our cohort, the presence of a 10-inch increase in height was associated with an increase in a history of injury by 20% and a 10-mph increase in velocity was associated with an increase in the likelihood of a history of injury by 12%. Playing for more than 1 team increased the likelihood of a history of injury by 22%. CONCLUSIONS: Pitch velocity, pitcher height, and pitching for more than 1 team correlate with a history of shoulder and elbow injury. Current recommendations regarding breaking pitches may not prevent injury. Pitchers should be cautioned about pitching for more than 1 team. Taller pitchers and high-velocity pitchers may be at risk of injury.

Flexor digitorum profundus laceration in association with closed middle phalangeal fracture: case report.

We report a patient with a flexor digitorum profundus laceration caused by the volarly displaced proximal fragment of a middle phalangeal fracture. Awareness of this association may allow timely recognition and appropriate treatment.

Predictors of throwing velocity in youth and adolescent pitchers.

BACKGROUND: Shoulder and elbow injuries are a common cause of pain, dysfunction, and inability to play in overhead throwers. Pitch velocity plays an integral part in the etiology of these injuries; however, the demographic and biomechanical correlates with throwing velocity remain poorly understood. We hypothesized that pitchers with higher velocity would have shared demographic and kinematic characteristics. METHODS: Normal preseason youth and adolescent pitchers underwent dual-orthogonal high-speed video analysis while pitch velocity was collected with a radar gun. Demographic and pitching history data were also collected. Kinematic data and observational mechanics were recorded. Multivariate regression analysis was performed. RESULTS: A total of 420 pitchers were included, with a mean pitching velocity of 64 ± 10 mph. After multivariate logistic regression analysis, the most important correlates with pitch velocity were age (P < .001; R(2) = 0.658), height (P < .001; R(2) = 0.076), separation of the hips and shoulders (P < .001; R(2) = 0.027), and stride length (P < .001; R(2) = 0.016); in combination, these 4 variables explained 78% of the variance in pitch velocity. Each year of age was associated with a mean 1.5 mph increase in velocity; each inch in height, with 1.2 mph; separation of the hips and shoulders, with 2.6 mph; and a 10% increase in stride length, with 1.9 mph. CONCLUSION: Pitch velocity is most strongly correlated with age, height, separation of the hips and shoulders, and stride length.

Immunocompetent murine models for the study of glioblastoma immunotherapy.

Glioblastoma remains a lethal diagnosis with a 5-year survival rate of less than 10%. (NEJM 352:987-96, 2005) Although immunotherapy-based approaches are capable of inducing detectable immune responses against tumor-specific antigens, improvements in clinical outcomes are modest, in no small part due to tumor-induced immunosuppressive mechanisms that promote immune escape and immuno-resistance. Immunotherapeutic strategies aimed at bolstering the immune response while neutralizing immunosuppression will play a critical role in improving treatment outcomes for glioblastoma patients. In vivo murine models of glioma provide an invaluable resource to achieving that end, and their use is an essential part of the preclinical workup for novel therapeutics that need to be tested in animal models prior to testing experimental therapies in patients. In this article, we review five contemporary immunocompetent mouse models, GL261 (C57BL/6), GL26 (C57BL/6) CT-2A (C57BL/6), SMA-560 (VM/Dk), and 4C8 (B6D2F1), each of which offer a suitable platform for testing novel immunotherapeutic approaches.

Vaccine therapies for patients with glioblastoma.

Glioblastoma (GBM) is a high-grade glial tumor with an extremely aggressive clinical course and a median overall survival of only 14.6 months following maximum surgical resection and adjuvant chemoradiotherapy. A central feature of this disease is local and systemic immunosuppression, and defects in patient immune systems are closely associated with tumor progression. Immunotherapy has emerged as an important adjuvant in the therapeutic armamentarium of clinicians caring for patients with GBM. The fundamental aim of immunotherapy is to augment the host antitumor immune response. Active immunotherapy utilizes vaccines to stimulate adaptive immunity against tumor-associated antigens. A vast array of vaccine strategies have advanced from preclinical study to active clinical trials in patients with recurrent or newly diagnosed GBM, including those that employ peptides, heat shock proteins, autologous tumor cells, and dendritic cells. In this review, the rationale for glioma immunotherapy is outlined, and the prevailing forms of vaccine therapy are described.

Allograft reconstruction for glenoid bone loss in glenohumeral instability: a systematic review.

PURPOSE: The aim of this study was to assess clinical outcomes and radiological outcomes after osteochondral allograft reconstruction for glenoid bone loss. METHODS: Glenoid bone loss can occur in the setting of recurrent glenohumeral instability and poses a challenge for surgeons. Reconstruction of these defects with allografts has been proposed as an alternative to both arthroscopic stabilization and nonanatomic bony augmentation procedures with autografts. We conducted a systematic review of the literature for studies of any level of evidence that reported clinical or radiological outcomes (or both) after allograft reconstruction for glenoid deficiency in the setting of recurrent shoulder instability. Data collected included study and patient characteristics, surgical technique, outcome scores, range of motion, strength, subjective outcomes, radiological outcomes, and complications. Data from studies with a sample size of at least 5 were pooled in the main analysis. Studies were assessed for the presence of methodological bias. RESULTS: Eight studies met the inclusion criteria and were included in the review. Three studies were deemed eligible for pooled analysis. The study group consisted of 70 shoulders with a mean age of 27.7 years (74.6% of participants were men) and a mean follow-up period of 44.5 ± 17.7 (range, 32 to 90) months. The mean final Rowe score was 90.6, representing a mean improvement of 57.5. Only 9.8% of patients complained of persistent or unimproved pain, and 93.4% were satisfied. Bony integration of the allograft was documented in 100% of shoulders. Recurrence of glenohumeral dislocation and overall instability were seen in 2.9% and 7.1% of cases, respectively. CONCLUSIONS: The current body of Level IV data suggests that allograft reconstruction for glenoid bone loss provides excellent clinical outcomes, low rates of recurrent instability, and high osseous incorporation rates with no evidence of graft resorption. LEVEL OF EVIDENCE: Level IV, systematic review of Level IV studies.

Is double-row rotator cuff repair clinically superior to single-row rotator cuff repair: a systematic review of overlapping meta-analyses.

PURPOSE: Multiple meta-analyses of randomized clinical trials, the highest available level of evidence, have been conducted to determine whether double-row (DR) or single-row (SR) rotator cuff repair (RCR) provides superior clinical outcomes and structural healing; however, results are discordant. The purpose of this study was to conduct a systematic review of meta-analyses comparing SR and DR RCR to elucidate the cause of discordance and to determine which meta-analysis provides the current best available evidence. METHODS: In this study we evaluated available scientific support for SR versus DR RCR by systematically reviewing the literature for published meta-analyses. Data were extracted from these meta-analyses for patient outcomes and structural healing. Meta-analysis quality was assessed with the Oxman-Guyatt and Quality of Reporting of Meta-analyses (QUOROM) systems. The Jadad algorithm was then applied to determine which meta-analyses provided the highest level of evidence. RESULTS: Eight meta-analyses met the eligibility criteria: 4 including Level I evidence and 4 including both Level I and Level II evidence. Six meta-analyses found no differences between SR and DR RCR for patient outcomes, whereas 2 favored DR RCR for tears greater than 3 cm. Two meta-analyses found no structural healing differences between SR and DR RCR, whereas 3 found DR repair to be superior for tears greater than 3 cm and 2 found DR repair to be superior for all tears. Four meta-analyses had low Oxman-Guyatt scores (<3) indicative of major flaws. After application of the Jadad algorithm, 3 concordant high-quality meta-analyses were selected, all of which found significantly better structural healing with DR compared with SR RCR. CONCLUSIONS: According to this systematic review of overlapping meta-analyses comparing SR and DR RCR, the current highest level of evidence suggests that DR RCR provides superior structural healing to SR RCR. LEVEL OF EVIDENCE: Level II, systematic review of Level I and II studies.

Graft choice in the management of unstable scaphoid nonunion: a systematic review.

PURPOSE: To systematically compare outcomes between corticocancellous (CC) and cancellous-only (C-only) bone grafts for unstable scaphoid nonunions. METHODS: The English-language literature was searched using PubMed, the Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Library with the following keywords: scaphoid, nonunion, malunion, unstable, collapse, humpback, dorsal intercalated segment instability, and deformity. Studies whose patient populations were characterized as possessing unstable scaphoid nonunion and/or collapse deformity or who met radiological definitions of such deformity were included. The union rate, interval to union, clinical assessments, strength, range of motion, correction of deformity, pain, and return to activity were analyzed. RESULTS: Twenty-three studies published between the beginning of 1987 and the end of 2013 met the eligibility criteria and contained 604 patients. The union rate was statistically equivalent for C-only (95%) and CC grafts (92%). However, the frequency-weighted mean interval to union was significantly shorter for C-only (11 wk) than for CC grafts (16 wk). CC grafts were associated with a significantly higher frequency-weighted mean Mayo wrist score (86) than C-only grafts (80), whereas C-only grafting provided significantly greater improvement of wrist flexion. Of the 3 measures of carpal geometry analyzed, CC grafts significantly improved the scapholunate and radiolunate angles more than C-only grafts. CONCLUSIONS: Based on retrospective data from uncontrolled studies, C-only grafts provide the shortest interval to union for unstable scaphoid nonunions. CC grafts are associated with consistent deformity correction and superior Mayo wrist scores. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.