Radiographic and functional outcomes of bisphosphonate use in lumbar fusion: a systematic review and meta-analysis of comparative studies.

PURPOSE: To date, there are conflicting reports with no consensus on the influence of bisphosphonates on lumbar fusion. The goal of this study was to compare the radiographic and functional outcomes of patients that had lumbar fusion with and without bisphosphonates. METHODS: A systematic search of multiple medical reference databases was conducted for studies comparing bisphosphonate use to controls following spinal fusion. Meta-analysis was performed using the random-effects model for heterogeneity. Radiographic outcome measures included fusion rates and risk of screw loosening, cage subsidence and vertebral fracture. Functional outcomes measures included Oswestry Disability Index and visual analog scale score for back and leg pain. RESULTS: Bisphosphonate use was statistically suggestive of a higher fusion rate compared to controls (OR 2.2, 95% CI 0.87-5.56, p = 0.09). There was no difference in screw loosening rates between the bisphosphonate group and controls (OR 0.45, 95% CI 0.14-1.48, p = 0.19). However, bisphosphonate use was associated with decreased odds of cage subsidence and vertebral fractures compared to controls (cage subsidence: OR 0.29, 95% CI 0.11-0.75, p = 0.01; vertebral fracture: OR 0.18, 95% CI 0.07-0.48, p = 0.0007). CONCLUSION: Bisphosphonate use does not appear to impair successful lumbar fusion compared to controls. Additionally, bisphosphonate use was associated with decreased odds of cage subsidence and vertebral fractures compared to controls that had lumbar fusion. These slides can be retrieved under Electronic Supplementary Material.

Return-to-Sport Criteria After Upper Extremity Surgery in Athletes-A Scoping Review, Part 2: Ulnar Collateral Ligament of the Elbow Procedures.

BACKGROUND: There is a lack of consensus to guide patient return to sport (RTS) after elbow ulnar collateral ligament surgery (eUCLS). PURPOSE: To describe the reported RTS criteria after eUCLS in the athletic population. STUDY DESIGN: Scoping review; Level of evidence, 4. METHODS: This scoping review was performed by adhering to the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Scoping Review) guidelines. We searched 5 electronic databases (MEDLINE, Scopus, SPORTDiscus, Embase, Google Scholar Advanced) and the gray literature for English-language studies that reported at least 1 RTS criterion in athletes after eUCLS. Data were extracted and summarized as frequencies or arithmetic mean and standard deviation. RESULTS: Included were 14 studies and 1335 athletes with a mean age of 21.4 ± 1.1 years. Time from surgery (range, 6-16 months) was the most common RTS criterion used, and it was reported by all 14 of the included articles. RTS criteria reported less often were pain (3/14; 21%), successful completion of a throwing program (3/14; 21%), muscle strength of the forearm muscles (1/14; 7%), and "normal" range of motion and muscle strength of the elbow and shoulder joints on the operated upper extremity (1/14; 7%). All studies used 1 to 5 of the above RTS criteria. CONCLUSION: Only 14 studies reported 1 or more RTS criteria after eUCLS in athletes, and time was the most common RTS criterion used. Our results highlight the need for a coordinated effort among surgeons, physical therapists, and athletic trainers in order to establish evidence-based RTS criteria after eUCLS in athletes so athletes can safely to sport and prolong their athletic careers.

Return-to-Sport Criteria After Upper Extremity Surgery in Athletes-A Scoping Review, Part 1: Rotator Cuff and Shoulder Stabilization Procedures.

BACKGROUND: Standardized criteria are lacking to guide patient return to sport (RTS) after rotator cuff surgery (RCS) or shoulder stabilization surgery (SSS). PURPOSE: To describe RTS criteria used after RCS and SSS in athletic populations. STUDY DESIGN: Scoping review; Level of evidence, 4. METHODS: This scoping review was based on the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Scoping Review) guidelines. A total of 5 electronic databases (MEDLINE, Scopus, SPORTDiscus, Embase, Google Scholar Advanced search) and the gray literature were searched for English-language studies that reported at least 1 RTS criterion in athletes after shoulder surgery. Studies were assigned to the RCS or SSS subgroup based on the primary procedure performed. Data were extracted and summarized as frequencies or arithmetic mean and standard deviation. RESULTS: Included were 52 studies and 2706 athletes (2206 male, 500 female, with a mean age of 28.8 ± 1.8 years). The RCS group consisted of 14 studies and the SSS group consisted of 38 studies. Time from surgery was the most common RTS criterion reported overall (37/52 studies; 71%) as well as within the RCS (93%) and SSS (63%) subgroups. Muscle strength (25/52 studies; 48%) and range of motion (23/52; 44%) were used by almost half of the included articles. RTS criteria reported less often were absence of pain, successful completion of sport-specific or position-specific test, proprioception, radiographic evaluation, patient-surgeon agreement, minimum time required to participate in pain-free throwing, and satisfactory scapulothoracic mechanics. All studies used 1 to 3 of the above RTS criteria; however, the definition of each criterion differed among the included articles. CONCLUSION: Time from surgery was the most commonly reported RTS criterion after RCS or SSS in athletes, whereas muscle strength and range of motion were used by almost half of the articles. There was high heterogeneity in the definition of each RTS criterion used among the included studies, which also used different combinations of 1 to 3 RTS criteria. These results suggest the need to better define quantitative and qualitative RTS criteria in athletes undergoing rotator cuff and shoulder stabilization procedures in order to safely return athletes to sport.

Chronic exertional compartment syndrome: current management strategies.

Chronic exertional compartment syndrome (CECS) is an underdiagnosed condition that causes lower and upper extremity pain in certain at-risk populations. Lower-extremity CECS is most often observed in running athletes and marching military members. Upper-extremity CECS is most commonly seen in rowers and professional motorcyclists. Although early outcome research on CECS has been based mostly on adult male patients, there has been an increase in the number of studies in pediatric and adolescent patient populations, particularly in females. Evaluation of CECS must include a thorough history and physical exam to rule out other causes of exertional leg pain, but differential diagnosis must remain high on the list. Needle manometry can be used to confirm diagnosis of CECS by measuring intracompartmental pressure. Operative treatment of CECS with fasciotomy has been shown to be effective in resolution of CECS, and new surgical techniques are being developed. In the pediatric population, endoscopy-assisted compartment release has provided high success rates with low complication rates. Nonoperative management of CECS is more commonly described in the literature, and consists of cessation of activities, altering foot-strike pattern, physical therapy, taping, and injections of botulinum toxin A. Nonetheless, larger samples and a more diverse population are needed to better understand the outcomes of nonoperative management. There have been fewer studies on upper-extremity CECS, given its rarity. Success has been found in the treatment of upper-extremity CECS with open fasciotomy, but more studies are needed to understand the efficacy of minimally invasive techniques in the upper extremity. Further research also needs to be done to understand why a large portion (approximately 20%) of the patient population does not experience full resolution of symptoms after fasciotomy.

Preoperative Vitamin D Deficiency Is Associated With Higher Postoperative Complications in Arthroscopic Rotator Cuff Repair.

INTRODUCTION: Rotator cuff tears are one of the most common injuries worldwide, yet it is difficult to predict which patients will have poor outcomes after arthroscopic rotator cuff repair (RCR). The purpose of this study was to identify an association between preoperative vitamin D (25D) levels and postoperative complications in arthroscopic RCR. METHODS: From a national claims database, patients undergoing arthroscopic RCR with preoperative 25D levels were reviewed. Patients were stratified into 25D-sufficient (≥20 ng/dL) or 25D-deficient (<20 ng/dL) categories and examined for development of postoperative complications. Multivariate logistic regression was performed using age, sex, and Charlson Comorbidity Index (CCI) as covariates. From this, risk-adjusted odds ratios (ORs) were calculated comparing complications between the two groups. RESULTS: One thousand eight hundred eighty-one patients with measured preoperative 25D levels were identified; 229 patients were 25D deficient (12.2%). After adjusting for age, sex, and Charlson Comorbidity Index, 25D-deficient patients had increased odds of revision RCR (OR 1.54, 95% confidence interval 1.21 to 1.97, P < 0.001) and stiffness requiring manipulation under anesthesia (OR 1.16, 95% confidence interval 1.03 to 2.03, P = 0.035). CONCLUSIONS: Vitamin D deficiency is associated with a greater risk of postoperative surgical complications after arthroscopic RCR and may be a modifiable risk factor. Further investigation on preoperative vitamin D repletion is warranted.

Mechanism of dengue virus broad cross-neutralization by a monoclonal antibody.

The dengue virus (DENV) complex is composed of four distinct but serologically related flaviviruses, which together cause the present-day most important emerging viral disease. Although DENV infection induces lifelong immunity against viruses of the same serotype, the antibodies raised appear to contribute to severe disease in cases of heterotypic infections. Understanding the mechanisms of DENV neutralization by antibodies is, therefore, crucial for the design of vaccines that simultaneously protect against all four viruses. Here, we report a comparative, high-resolution crystallographic analysis of an "A-strand" murine monoclonal antibody, Mab 4E11, in complex with its target domain of the envelope protein from the four DENVs. Mab 4E11 is capable of neutralizing all four serotypes, and our study reveals the determinants of this cross-reactivity. The structures also highlight the mechanism by which A-strand Mabs disrupt the architecture of the mature virion, inducing premature fusion loop exposure and concomitant particle inactivation.