What makes an orthopaedic paper highly citable? A bibliometric analysis of top orthopeadic journals with 10-year follow up.

PURPOSE: To examine a series of papers from top ranked orthopaedic journals with respect to the number of citations over a 10-year observation period to identify factors that lead to high citation rates. METHODS: The Web of Science database was consulted to identify all published papers from the first-year term of 2010 (January-May) from four top orthopaedic journals: AJSM, Arthroscopy, JBJS Am and KSSTA. The database was used to analyze and compare the papers with respect to their characteristics and citations up to 2019. Basic information for each paper was collected including the author, country, study type and average citations per year (ACY). The most (Top20%) and least (Bottom20%) frequently cited papers were identified and differences were extracted. RESULTS: Five hundred sixteen papers were included with a total of 19,261 citations. Most of the published papers were from the United States (n = 245). On average, a paper received 37.3 citations over the 10-year observation period. The most cited paper was cited 322 times. The most cited study type was randomized controlled trial (RCT) (Ø80.8). The Top20% papers were cited 37 times more often than the Bottom20%. Among the Top20%, the largest group was cohort study (n = 20) followed by case series (n = 19). Among others, the number of authors, the number of keywords and the number of references significantly correlated with the number of citations (p < 0.001). CONCLUSIONS: Factors influencing citation frequency were identified.

Comparison between dedicated MRI and symphyseal fluoroscopic guided contrast agent injection in the diagnosis of cleft sign in athletic groin pain and association with pelvic ring instability.

OBJECTIVE: To compare dedicated MRI with targeted fluoroscopic guided symphyseal contrast agent injection regarding the assessment of symphyseal cleft signs in men with athletic groin pain and assessment of radiographic pelvic ring instability. METHODS: Sixty-six athletic men were prospectively included after an initial clinical examination by an experienced surgeon using a standardized procedure. Diagnostic fluoroscopic symphyseal injection of a contrast agent was performed. Additionally, standing single-leg stance radiography and dedicated 3-Tesla MRI protocol were employed. The presence of cleft injuries (superior, secondary, combined, atypical) and osteitis pubis was recorded. RESULTS: Symphyseal bone marrow edema (BME) was present in 50 patients, bilaterally in 41 patients and in 28 with an asymmetrical distribution. Comparison of MRI and symphysography was as followed: no clefts: 14 cases (MRI) vs. 24 cases (symphysography), isolated superior cleft sign: 13 vs. 10, isolated secondary cleft sign: 15 vs. 21 cases and combined injuries: 18 vs. 11 cases. In 7 cases a combined cleft sign was observed in MRI but only an isolated secondary cleft sign was visible in symphysography. Anterior pelvic ring instability was observed in 25 patients and was linked to a cleft sign in 23 cases (7 superior cleft sign, 8 secondary cleft signs, 6 combined clefts, 2 atypical cleft injuries). Additional BME could be diagnosed in 18 of those 23. CONCLUSION: Dedicated 3-Tesla MRI outmatches symphysography for purely diagnostic purposes of cleft injuries. Microtearing at the prepubic aponeurotic complex and the presence of BME is a prerequisite for the development of anterior pelvic ring instability. CLINICAL RELEVANCE STATEMENT: For diagnostic of symphyseal cleft injuries dedicated 3-T MRI protocols outmatch fluoroscopic symphysography. Prior specific clinical examination is highly beneficial and additional flamingo view x-rays are recommended for assessment of pelvic ring instability in these patients. KEY POINTS: • Assessment of symphyseal cleft injuries is more accurate by use of dedicated MRI as compared to fluoroscopic symphysography. • Additional fluoroscopy may be important for therapeutic injections. • The presence of cleft injury might be a prerequisite for the development of pelvic ring instability.

Knot tying in arthroplasty and arthroscopy causes lesions to surgical gloves: a potential risk of infection.

PURPOSE: Recent studies have shown that the incidence of glove lesions during arthroscopy is much lower than that during primary and revision arthroplasty. However, the rate of glove damage after knot tying has not yet been systematically recorded. Therefore, the aim of the study was to determine the impact of surgical knot tying on glove integrity. It was hypothesized that knot tying increases the rate of glove damage, especially in arthroscopic surgery, which could be of special relevance in the treatment of rotator cuff tears. METHODS: Gloves that were changed immediately before suturing and only worn during knot tying were investigated for their integrity by means of water tightening test according to EN455. A total of 234 gloves from 40 total hip arthroplasties (THAs), 42 total knee arthroplasties (TKAs) and 36 rotator cuff repairs (RCRs) were collected. A bacterial pass-through test (BPTT) on glove lesions was performed under simulated sterile surgical conditions for 3 surgeons after a wear duration of 45 min. RESULTS: Glove damage by knot tying occurred in 25% of THA, 36.6% of TKA and 25% of RCR surgeries. In THA, the pulling hand (PH) was affected in 46.2%, and the main area of damage (15.4%) was detected on the tip of the middle finger; in TKAs the PH was damaged in 75%, and in RCRs the PH was affected in 66.7%, with most of the lesions (20% each) occurring on the tip of the index finger and the ring finger. The BPTT showed Staphylococcus hominis and Bacillus cereus. CONCLUSION: Intraoperative knot tying causes damage to gloves, which is of special relevance for arthroscopic surgery. Whereas knot tying is only partly responsible for glove damage in arthroplasty, the general rate of glove damage in arthroscopic surgery is low without knot tying. The surgical knot tying process must be understood as a possible damaging impact on the glove. Therefore, single gloving is not recommended, which is especially important in arthroscopic surgery, where double gloving is not yet standard. LEVEL OF EVIDENCE: IV.

[Individual megaspacers in two-stage revision of infected total hip arthroplasty-clinical and functional results after 2 years : Individual metal-endoskeleton cement spacer (iMECS)]. / Individuelle Megaspacer für den zweizeitigen Wechsel infizierter Hüftendoprothesen ­ klinisches und funktionelles Outcome nach 2 Jahren : Individuelle Metallendoskelett-Zementspacer (iMECS).

BACKGROUND: Large femoral defects in late periprosthetic infection (PPI) after total hip arthroplasty (THA) often require the use of large, individual metal endoskeleton-reinforced cement spacers (iMECS). OBJECTIVES: The aim was to record the clinical, radiological and functional results (Harris Hip Score HHS) up to the 2 years after treatment of a PPI using an iMECS. Major patient-specific parameters were to be evaluated with regard to the treatment outcome. MATERIALS AND METHODS: The collective of this single-center retrospective cohort study comprised 29 patients. The mean follow-up was 24.4 months (range: 23.0 to 27.6 months). The absence of infection after endoprosthetic hip joint reconstruction was rated as successful treatment. The two patient groups (successful (S)/not successful (nS)) were compared with regard to gender distribution, the Charlson comorbidity index (CCI), the number of previous septic changes, and the rate of polymicrobial and difficult-to-treat infections. RESULTS: The average CCI in the total collective was 6.4 points. Joint reconstruction was possible in 23 of 29 patients (79%); 2 years after PPI treatment 4 patients were not available for a follow-up examination (2 deceased, 2 unable to participate). At the time of the follow-up, 17 of the 29 patients had received a joint reconstruction and were free of infection, with an average HHS of 75 points. There were no iMECS-associated complications requiring revision. Only the initial CCI (S: 4.1 points; nS: 9.7 points) differed significantly between the patient groups (p < 0.05). CONCLUSIONS: In the case of large femoral defects, iMECS provide secure temporary stabilization. The chance of a successful joint reconstruction is closely related to the individual comorbidities profile.

All-Arthroscopic Hydrogel-Based Autologous Chondrocyte Transplantation in the Knee Joint: Good Clinical and Magnetic Resonance Imaging Outcome After 24 Months.

PURPOSE: To evaluate subjective and objective clinical and magnetic resonance imaging-based radiologic outcomes after short-term follow-up in patients with focal full-size cartilage lesions of the knee joint treated with all-arthroscopic hydrogel-based autologous chondrocyte transplantation. METHODS: A retrospective study on patients with isolated focal cartilage defects of the knee joint who were treated with arthroscopically conducted matrix-induced autologous chondrocyte transplantation was performed. Clinical scores were assessed at baseline and final follow-up using the Tegner Score, visual analog scale, the International Knee Documentation Committee, and the 5 subscales of the Knee Injury and Osteoarthritis Outcome Score. Magnetic resonance imaging scans of the treated knee joints were evaluated with the updated MOCART (Magnetic Resonance Observation of Cartilage Repair Tissue) 2.0 scoring system at follow-up. RESULTS: Twenty-nine consecutive patients were included in the study. Mean time to follow-up was 24.9 ± 1.1 months. Average visual analog scale decreased significantly from 6.5 ± 3.1 preoperatively to 2.3 ± 1.6 at follow-up (P < .0001). Tegner score increased from 3.1 ± 1.3 to 4.3 ± 1.2 (P < .0001) and the International Knee Documentation Committee from 43.8 ± 21.9 to 64.9 ± 18.9 (P < .0001). Also, all Knee Injury and Osteoarthritis Outcome Score subscales displayed significant improvements. Patients showed similar improvements of nearly all clinical scores independent of the defect size. Average MOCART2.0 score was 70.0 ± 13.6 and 20 patients scored ≥70 points. All 8 patients with large defects (>5 cm2) scored ≥75 points. CONCLUSIONS: In this small study, injectable matrix-induced autologous chondrocyte transplantation therapy in the knee joint led to favourable clinical and radiologic short-term results with significant improvements in all clinical scores and MOCART2.0 scores, confirming morphologic integrity of the transplanted chondrocytes. Therefore, this minimally invasive procedure represents a promising operative technique for cartilage regeneration, even for large-diameter lesions. LEVEL OF EVIDENCE: IV, therapeutic case series.

Subscapularis Tendon Tears - Usefulness of Written MRI Reports for Guiding Patient Referral to Shoulder Specialists.

INTRODUCTION: Rotator cuff tears are one of the most common reasons for shoulder pain, and patients often present initially to general practitioners. However, subscapularis tears are especially difficult to diagnose and hence adequate therapy is often delayed. General practitioners or non-specialist orthopedic surgeons need reliable MRI findings to allow timely referral of patients to shoulder specialists. The purpose of this study was to determine the validity of the written MRI report of patients with arthroscopically proven subscapularis tendon tears. METHOD: In this retrospective study, 97 patients (mean age 62.4 ±â€Š10 years, 63 men) who underwent arthroscopic subscapularis repair between April 2013 and January 2015 by two experienced shoulder surgeons and who underwent a preoperative 1.5 T MRI study were included. All of these patients had high-field strength (i. e., ≥ 1.5 T) standard MRI scans performed within 4-164 (mean 57.4 ±â€Š38.4) days before their arthroscopic procedures. RESULTS AND CONCLUSION: Subscapularis tendon tears, verified by arthroscopy, were correctly identified in only 37 of 97 cases in the written report of the preoperative MRI. This resulted in an overall low sensitivity of 38.1 %. Correctly predicted lesions were as follows: Fox and Romeo I 29.4 % (5/17 patients), Fox and Romeo II 20 % (7/35 patients), Fox and Romeo III 46.7 % (14/30 patients) and Fox and Romeo IV 73.3 % (11/15 patients). In contrast, concurrent supraspinatus tendon tears were identified correctly in 88.2 % of patients (60/68 cases, sensitivity 88.2 %, specificity 96.5 %). Preoperative written radiology reports provided by a heterogeneous group of 39 presumably non-MSK-specialized radiologic centers do not reliably detect subscapularis tendon tears and are not sufficient for guiding patients to specialist centers. Compared to other rotator cuff injuries, this study shows difficulties in the correct diagnosis of subscapular tendon injuries. However, this is necessary to provide patients with timely therapy. It can be assumed that MRI review by musculoskeletal-specialized radiologists would more often than not lead to the correct diagnosis. KEY POINTS: · Subscapularis tendon ruptures are difficult to diagnose on standard shoulder MRI.. · Written MRI reports from non-musculoskeletal-specialized radiologists are not reliable, especially for smaller lesions.. · Reliable findings are required for referral allocation to shoulder specialists (specialized musculoskeletal radiologists).. CITATION FORMAT: · Lenz R, Kircher J, Schwalba K et al. Subscapularis Tendon Tears - Usefulness of Written MRI Reports for Guiding Patient Referral to Shoulder Specialists. Fortschr Röntgenstr 2021; 193: 797 - 803.

[Readmission rates of back pain patients after primarily conservative inpatient treatment at a university hospital]. / Wiederaufnahmeraten von Rückenschmerzpatienten an einer Universitätsklinik nach primär konservativer stationärer Therapie.

BACKGROUND: The number of patients receiving inpatient treatment for back pain is increasing, as the current structures of outpatient care cannot meet the demand adequately. Although the infrastructure of the maximum care provider ensures possible emergency care and imaging procedures on the one hand, it is not geared to providing replacement services for outpatient care on the other. OBJECTIVES: Analysis of the readmission rates of primarily conservatively treated inpatients with back pain. MATERIALS AND METHODS: In this retrospective study, the recovery rate of patients with back pain who were admitted as emergency inpatients and treated primarily conservatively as inpatients was investigated within 6 months at a university orthopaedic clinic. The study period was 2 years with a follow-up of 6 months. 413 patients were evaluated. RESULTS: After primarily conservative therapy, 17.9% of the patients were readmitted to hospital. It took 25 (±33.25) days until the first readmission and 25.9 (±31.99) days until the second readmission. Pensioners were admitted to hospital significantly more often but were treated mainly conservatively during their stays; 66.8% of the presentations were emergencies without referral. CONCLUSIONS: Readmission after primarily conservative inpatient treatment is relatively high. In most cases, the return of the patient to outpatient care can be achieved by tight management with a rapid diagnostic procedure and targeted aftercare strategies. The patient may return to outpatient care for surgical treatment or, unplanned, due to failed conservative, outpatient treatment.

Predictors for an unsuccessful conservative treatment of patients with medial patellar plica syndrome.

INTRODUCTION: In several cases persistent medial knee pain remains after conservative treatment in patients with medial patellar plica syndrome. In recent literature accepted criteria for surgical indication are lacking. In this retrospective study patients after conservative treatment were evaluated to identify predictors for an unsuccessful outcome. MATERIALS AND METHODS: 117 Patients with medial patellar plica syndrome between 2016 and 2019 were retrospectively evaluated. All patients received conservative treatment for three months. Surgery was indicated due to failed conservative treatment (n = 76) with persistent medial knee pain and restriction of activity after 3 months. Preoperative MRI analysis, Lysholm score, pain by the visual analog scale (VAS), postoperative sports participation (RTS) and Tegner activity score were collected at least 12 months after definite treatment. Statistical analysis was performed to evaluate differences between patients with successful and unsuccessful conservative treatment. RESULTS: There were significant differences in the clinical and radiological findings between patients with successful and unsuccessful conservative treatment. Patients with failed conservative treatment showed a significant larger diameter of the medial patellar plica (0.8 ± 0.3 mm vs. 1.6 ± 0.4 mm; p < 0.05) and a significant higher rate of contact of the plica to the adjacent cartilage. Furthermore, these patients reported a significant higher rate of medial knee pain from flexion to extension and snapping symptoms. At final follow-up the patient-reported outcome by means of Lysholm score (96.25 vs. 95.93), RTS (96.2% vs. 97%) and Tegner activity score (6.0 vs. 6.01) was excellent after conservative and surgical treatment. There were no statistical differences in the preoperative and postoperative outcomes between both. CONCLUSIONS: The diameter of a medial patellar plica and contact of the plica to the retropatellar cartilage as well as clinical signs like persistent medial knee pain from flexion to extension with snapping symptoms might be predictors for an unsuccessful conservative treatment and the need for surgical intervention in patients with painful medial patellar plica syndrome.

[Pitfalls due to manufacturer instructions in modern joint surgery]. / Fallstricke durch Herstellerinstruktionen in der modernen Gelenkchirurgie.

Endoprosthetic implantations require the user to know numerous details of the installation process. Instructions from manufacturers are, therefore, always an essential part of legal proceedings in the event of premature implant failure. In addition to the application steps, the question of the application limits of the implants is also important. Patients' excessive safety expectations of the manufacturer or the medical user can also lead to avoidable product liability. Overall, there is a need to define standards and minimum requirements in package inserts and instructions, even if these can only be developed in accordance with the current state of science.

Hyperflexion Knee Injury with Anterior Cruciate Ligament Rupture and Avulsion Fractures of Both Posterior Meniscal Attachments: A Case Report.

CASE: A 54-year-old patient presented with low-velocity hyperflexion knee trauma while falling at a ski lift with anterior cruciate ligament (ACL) rupture and avulsion fractures of both posterior meniscal attachments. Meniscal avulsions were treated arthroscopically using transtibial sutures; a partial medial collateral ligament tear was treated conservatively. Six weeks later, reconstruction of the ACL was performed, and both meniscal attachments were stable. CONCLUSION: Hyperflexion of the knee puts direct shear and compressive force on the posterior tibia. This can result in ligament injuries combined with avulsion fractures of both posterior meniscal attachments. Arthroscopic treatment is a practicable technique for this type of injury.

The Spectrum of Response to Erenumab in Patients With Episodic Migraine and Subgroup Analysis of Patients Achieving ≥50%, ≥75%, and 100% Response.

OBJECTIVE: To assess the efficacy of erenumab at the ≥50%, ≥75%, and 100% reduction in monthly migraine days (MMD) response thresholds, using data from the 6-month double-blind treatment phase (DBTP) of the Study to Evaluate the Efficacy and Safety of Erenumab in Migraine Prevention (STRIVE) pivotal clinical trial. METHODS: Enrolled patients with episodic migraine (EM; ≥4 MMD and <15 monthly headache days) were randomized (1:1:1) to erenumab 70 mg (n = 312), erenumab 140 mg (n = 318), or placebo (n = 316) once monthly. We determined the proportions of patients with ≥50%, ≥75% and 100% reduction in MMD over the last 3 months of the STRIVE DBTP (months 4 through 6) and conducted post hoc analyses to contextualize the treatment benefit in patient subgroups achieving, and not achieving, these response thresholds. Outcome measures included changes in MMD, acute migraine-specific medication days (MSMD), and patient-reported outcomes. RESULTS: The proportions of patients with a reduction in MMD from baseline were greater for erenumab than for placebo at all response thresholds. As previously reported for the ≥50% response threshold, 135/312 (43.3%) of patients on erenumab 70 mg and 159/318 (50.0%) on erenumab 140 mg responded, vs 84/316 (26.6%) for placebo. At months 4 through 6, 65/312 (20.8%) and 70/318 (22.0%) of those on erenumab 70 mg and erenumab 140 mg, respectively, achieved ≥75% reductions vs 25/316 (7.9%) on placebo. A reduction of 100% response, which required no migraine days over 3 consecutive months based on observed data, was achieved by 10/312 (3.2%) of patients treated with erenumab 70 mg and 16/318 (5.0%) for erenumab 140 mg, vs 9/316 (2.8%) for placebo. At all response thresholds, responders achieved numerically greater reductions in mean MMD and MSMD, and greater improvements in disability than did the overall population; importantly, these remarkable responses were noted early. Meanwhile, 60/312 (19.2%) and 53/318 (16.7%) patients on erenumab 70 and 140 mg, respectively, had no reduction in MMD from baseline in months 4 through 6, compared with 104/316 (32.9%) patients on placebo. CONCLUSIONS: The responses at the ≥50%, ≥75%, and 100% thresholds provide context for establishing realistic patient and physician expectations regarding the magnitude of treatment benefit that may be achieved by patients with EM responding to erenumab (STRIVE, NCT02456740).

One-year sustained efficacy of erenumab in episodic migraine: Results of the STRIVE study.

OBJECTIVE: To assess efficacy and tolerability of 1-year erenumab treatment in patients with episodic migraine. METHODS: Patients were randomized (n = 955; 1:1:1) during the 24-week double-blind treatment phase (DBTP) to monthly subcutaneous placebo or erenumab 70 or 140 mg. At week 24, 845 patients were rerandomized (1:1) to erenumab 70 or 140 mg during the 28-week dose-blinded active-treatment phase (ATP). Monthly migraine days (MMD), achieving ≥50%, ≥75%, and 100% reduction in MMD, and safety/tolerability were assessed. RESULTS: Mean MMD at DBTP baseline was 8.3. At week 52, mean changes (SE) from pre-DBTP baseline/week 24 (pre-ATP baseline) in MMD were -4.2 (0.2)/-1.1 (0.2) (70 mg) and -4.6 (0.2)/-1.8 (0.2) (140 mg) irrespective of treatment during the DBTP. For patients reducing dose from 140 (DBTP) to 70 mg (ATP), change in MMD from week 24 to 52 was -0.1 (0.3), and for those increasing from 70 (DBTP) to 140 mg (ATP), -1.8 (0.3). At week 52, 61.0%, 38.5%, and 19.8% of patients on erenumab 70 mg, and 64.9%, 40.8%, and 21.2% on erenumab 140 mg, achieved ≥50%, ≥75%, and 100% reduction in MMD from DBTP baseline, respectively. Among erenumab-treated patients in DBTP who showed ≥50% reduction in MMD during the last 3 months of DBTP and completed ATP, 86% showed sustained responses at ≥50% during the last 3 months of ATP. Safety of erenumab in ATP was similar to DBTP; exposure-adjusted incidence rates of adverse events were similar for either dose. CONCLUSION: Over 52 weeks, erenumab provided sustained efficacy in episodic migraine; the safety profiles were similar between erenumab dose groups in the presence of dose blinding. CLINICALTRIALSGOV IDENTIFIER: NCT02456740. CLASSIFICATION OF EVIDENCE: Class II evidence that 52 weeks of treatment with erenumab 70 and 140 mg subcutaneously monthly results in sustained reductions in monthly migraine days and similar dose tolerability for patients with episodic migraine.

Cost Analysis in Shoulder Surgery: A Systematic Review.

BACKGROUND: Cost analysis studies in medicine were uncommon in the past, but with the rising importance of financial considerations, it has become increasingly important to use available resources most efficiently. PURPOSE: To analyze the current state of cost-effectiveness analyses in shoulder surgery. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: A systematic review of the current literature was performed following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. All full economic analyses published since January 1, 2010 and including the terms "cost analysis" and "shoulder" were checked for usability. The methodological quality of the studies was assessed using the Oxford Centre for Evidence-Based Medicine levels of evidence and established health economic criteria (Quality of Health Economic Studies [QHES] instrument). RESULTS: A total of 34 studies fulfilled the inclusion criteria. Compared with older studies, recent studies were of better quality: one level 1 study and eight level 2 studies were included. The mean QHES score was 87 of 100. The thematic focus of most studies (n = 13) was rotator cuff tears, with the main findings as follows: (1) magnetic resonance imaging is a cost-effective imaging strategy, (2) primary (arthroscopic) rotator cuff repair (RCR) with conversion to reverse total shoulder arthroplasty in case of failure is the most cost-effective strategy, (3) the platelet-rich plasma augmentation of RCR seems not to be cost-effective, and (4) the cost-effectiveness of double-row RCR remains unclear. Other studies included shoulder instability (n = 3), glenohumeral osteoarthritis (n = 3), proximal humeral fractures (n = 4), subacromial impingement (n = 4), and other shoulder conditions (n = 7). CONCLUSION: Compared with prior studies, the quality of recently available studies has improved significantly. Current studies could help decision makers to appropriately and adequately allocate resources. The optimal use of financial resources will be of increasing importance to improve medical care for patients. However, further studies are still necessary.

Mechanisms of Acute Knee Injuries in Bouldering and Rock Climbing Athletes.

BACKGROUND: There is limited insight into the mechanisms of knee injuries in rock climbing and bouldering in noncompetitive and competitive athletes. PURPOSE: To examine the traumatic mechanisms of injury, demographics, distribution, and severity of knee injuries in affected athletes. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: During a 4-year period, we performed a retrospective multicenter analysis of acute knee injuries in competitive and noncompetitive climbing athletes. Traumatic mechanisms were inquired and severity levels, therapies, and outcomes recorded with visual analog scale, Tegner, Lysholm, and climbing-specific outcome scores. RESULTS: Within the observation period, 71 patients (35% competitive athletes, 65% noncompetitive athletes) with 77 independent acute knee injuries were recorded. Four trauma mechanisms were identified: high step (20.8%), drop knee (16.9%), heel hook (40.3%), and (ground) fall (22.1%). The leading structural damage was a medial meniscal tear (28.6%), found significantly more often in the noncompetitive group. A specific climbing injury is iliotibial band strain during the heel hook position. Most injuries resulted from indoor bouldering (46.8%). Surgical procedures were predominantly necessary in noncompetitive climbers. One year after the injury, the Tegner score was 5.9 ± 0.8 (mean ± SD; range, 3-7); the Lysholm score was 97 ± 4.8 (range, 74-100); and the climbing-specific outcome score was 4.8 ± 0.6 (range, 2-5). CONCLUSION: Increased attention should be placed on the climber's knee, especially given the worldwide rise of indoor bouldering. Sport-specific awareness and training programs for noncompetitive and competitive climbing athletes to reduce knee injuries should be developed, and sports medical supervision is mandatory.

The spectrum of response to erenumab in patients with chronic migraine and subgroup analysis of patients achieving ≥50%, ≥75%, and 100% response.

OBJECTIVE: To assess the efficacy of erenumab across the spectrum of response thresholds (≥50%, ≥75%, 100%) based on monthly migraine days (MMD) reduction in patients with chronic migraine from a 12-week, randomized study (NCT02066415). METHODS: Patients (n = 667) received (3:2:2) placebo or erenumab 70/140 mg once-monthly. The proportion of patients achieving a given response threshold was assessed. A post-hoc analysis was conducted to contextualize the actual treatment benefit in subgroups of patients achieving (or not) specified response thresholds. Outcome measures included MMD, acute migraine-specific medication treatment days (MSMD) and disability. RESULTS: The proportion of patients responding to erenumab exceeded that of placebo at the ≥50% and ≥75% response thresholds. At month 3, 39.9% and 41.2% of patients on erenumab 70 and 140 mg, respectively, achieved ≥50% response versus placebo (23.5%). Similarly, at month 3, 17.0% and 20.9% of patients on erenumab 70 and 140 mg, respectively, achieved ≥75% response versus placebo (7.8%). Compared with the overall erenumab-treated population (change in MMD: -6.6 [both 70 and 140 mg]), ≥50% responders showed MMD reductions of -12.2/-12.5 for 70 mg/140 mg versus -2.6/-2.2 for those not achieving ≥50% response. ≥75% responders showed MMD reductions of -13.9/-14.8 for 70 mg/140 mg versus -5.0/-4.3 for those not achieving ≥75% response. Relative improvements in MSMD and disability were observed in responders versus overall erenumab-treated population. CONCLUSION: For erenumab-treated patients achieving ≥50% response, the actual reduction in MMD was almost twice that of the overall population. These findings provide context for setting realistic expectations regarding actual treatment benefit experienced by patients responding to treatment.

Evaluation of Rock Climbing Related Injuries in Older Athletes.

INTRODUCTION: With the growing enthusiasm from people of all ages about rock climbing and bouldering, adaptions and medical conditions of the older athlete have become increasingly important. We aimed to analyze injury demographics, distribution, and severity for the older rock-climbing athlete. METHODS: During a 3-y period, we performed a single-center injury surveillance in athletes ≥35 y of age presenting with rock climbing-related injuries or complaints. A standard questionnaire and examination protocol were conducted. RESULTS: A total of 198 patients (age 44.2±7.1 [35-77] y) (mean±SD, with range) with 275 independent injuries were recorded. Ninety percent of all injuries affected the upper extremity, 6% the lower extremity, and 4% other body regions. The Union Internationale des Associations d'Alpinisme injury scores were 2.0±0.3 (1-4), and no fatalities occurred. Acute injuries were observed in 32% and overuse injuries in 68% of all injuries. Among the overuse injuries, 47% were classified as degenerative overuse conditions. Athlete age did not significantly correlate with the development of overuse injuries and UIAA injury score, but subgroup analysis showed a weak correlation of the climber age with the development of degenerative conditions (P<0.05). The leading diagnosis of degenerative conditions was subacromial impingement syndrome of the shoulder. CONCLUSIONS: Compared to younger athletes, older rock climbers demonstrate a higher proportion of overuse injuries, especially degenerative conditions. Profound knowledge of climbing injuries patterns and conditions in older rock climbers is crucial to prevent injuries among all age groups and to decrease the number of degenerative injuries.

A Randomized Phase 2 Study of Erenumab for the Prevention of Episodic Migraine in Japanese Adults.

OBJECTIVE: A phase 2, double-blind, placebo-controlled study to evaluate the efficacy and safety of erenumab for the prevention of episodic migraine in Japanese patients was conducted. BACKGROUND: Previous global clinical studies have demonstrated the efficacy of erenumab in the prevention of migraine. METHODS: Patients were randomized to placebo or erenumab 28, 70, or 140 mg administered subcutaneously once per month for 6 months. The primary endpoint was change from baseline in mean monthly migraine days over months 4-6 of the double-blind treatment phase. Secondary endpoints included the proportion of patients achieving ≥50% reduction from baseline in mean monthly migraine days (≥50% response) and change from baseline in mean monthly acute migraine-specific medication treatment days (MSMD) and mean Headache Impact Test (HIT-6™) scores. Efficacy outcomes were also determined at months 1, 2, and 3. RESULTS: Four hundred and seventy five patients were randomized 2:1:2:2 to placebo and erenumab 28, 70, and 140 mg, respectively. Greater reductions in monthly migraine days were observed for erenumab vs placebo with differences of -1.25 (95% CI: -2.10 to -0.41; P = .004), -2.31 (95% CI: -3.00 to -1.62; P < .001), and -1.89 (95% CI: -2.58 to -1.20; P < .001) days for erenumab 28, 70, and 140 mg. The odds of having a ≥50% response were 3.2, 5.6, and 4.7 times greater for erenumab 28 mg (95% CI: 1.30-7.88; P = .009), 70 mg (95% CI: 2.60-12.06; P < .001), and 140 mg (95% CI: 2.24-9.99; P < .001) than for placebo. Greater reductions from baseline in mean acute monthly MSMD were observed for erenumab vs placebo with differences of -1.07 (95% CI: -1.80 to -0.35; P = .004), -2.07 (95% CI: -2.66 to -1.49; P < .001), and -2.04 (95% CI: -2.63 to -1.45; P < .001) days for erenumab 28, 70, and 140 mg. Erenumab 70 and 140 mg also resulted in greater improvements in HIT-6™ scores. The safety profile was similar across treatment groups. The most common adverse event was nasopharyngitis, which occurred in 29.4% of patients in the placebo group and 28.9%-33.3% of patients in the erenumab groups. CONCLUSION: Monthly subcutaneous injections of erenumab 70 mg demonstrated statistically significant and numerically maximal efficacy with a favorable safety profile, suggesting that erenumab is a potential new therapy for migraine prevention in Japan.

Treatment patterns and characteristics of patients with migraine in Japan: A retrospective analysis of health insurance claims data.

OBJECTIVE: To describe treatment patterns of migraine patients in the Japan Medical Data Center (JMDC) database. METHODS: Patients aged ≥18 years with ≥1 inpatient or ≥2 outpatient migraine diagnoses, ≥1 outpatient diagnosis and ≥1 migraine-specific acute treatment (triptan or ergotamine), or ≥2 migraine-specific acute treatments from 1 May 2011 to 30 April 2014 were identified. Patients were required to be enrolled in a health plan for ≥1 year before and after the index date. The first migraine diagnosis or acute treatment defined the index date. Patients were stratified by the migraine treatments observed after the index date (i.e. migraine-specific acute treatment only [AT], prophylactic with or without migraine-specific acute treatment [PT], or no treatment [NT]) and described regarding the first migraine treatment regimen and subsequent treatment patterns during up to 1 year of follow-up. RESULTS: A total of 16,443 patients met the eligibility criteria (9873 AT, 3022 PT, and 3548 NT). AT patients had mean (SD) 10.3 (20.5) acute treatment days during 1-year follow-up, and 81.9% received triptans. When assessing the first migraine treatment regimen during follow-up in PT patients, 29.2% received prophylactic treatment only and 51.7% received both acute and prophylactic treatment. Calcium-channel blockers with or without concomitant triptans (34.4%) were the most common first regimen. Approximately 62.2% discontinued initial prophylactic treatment after an average of 61.2 days (SD = 65.3) of persistent treatment. Among discontinuers, 15.2% reinitiated original treatment and 7.0% switched treatment post-discontinuation within a year, while the remaining patients did not receive prophylactic therapy following discontinuation. CONCLUSIONS: Among Japanese migraine patients, prophylactic use was low and associated with a high rate of discontinuation following a brief treatment period. Many patients reinitiated or switched treatment following discontinuation, while a significant proportion of patients remained discontinued from prophylactic therapy, suggesting a high unmet need.

Impact of compression stockings on leg swelling after arthroscopy - a prospective randomised pilot study.

BACKGROUND: Post-operative limb swelling may negatively affect the outcome of arthroscopic surgery and prolong rehabilitation. The aim of this pilot study was to evaluate the effect of compression stockings versus no compression on post-operative swelling and pain in the early post-operative phase. METHODS: A single-centre, randomised controlled trial was performed. Patients who underwent minor knee arthroscopy were randomised to wear class II compression stockings (23-32 mmHg) (CS) or no compression stockings (NCS) immediately post-operatively for ten days. All patients received low molecular weight heparin (LMWH) at prophylactic dosage. The primary outcome variable was post-operative swelling of the limb, quantified by using an optical 3D measurement system (Bodytronic© 600). Pain was rated on a visual analogue scale (VAS). From a total of 76 patients assessed, 19 patients were eligible for final analysis. The trial followed the CONSORT criteria, was registered at clinicaltrial.gov and approved by the local ethics committee. RESULTS: The circumference at the middle thigh (cF) was significantly different between groups at day 10 (p = 0.032; circumference - 1.35 ± 2.15% (CS) and + 0.79 ± 3.71% (NCS)). Significant differences were also noted around the knee (cD) at day 10 (p = 0.026) and a significant trend at cD and at the mid lower leg (cB1) at day 4. The volume of the thigh was also different with marked difference between days 1 and 4 between the two groups (p = 0.021; volume + 0.54 ± 2.03% (CS) and + 4.17 ± 4.67 (NCS)). Pain was lower in compression group (not statistically significant). CONCLUSIONS: Post-operative limb swelling can be reduced significantly by wearing compression stockings in the early post-operative phase when compared to not wearing stockings. This may improve the rehabilitation process after arthroscopic surgery. The optimal duration of compression therapy seems to be between three and ten days. TRIAL REGISTRATION: clinicaltrials.gov ( NCT02096562 , date of registration 11.11.2013).