Intracardiac thrombosis and pulmonary thromboembolism during liver transplantation: A systematic review and meta-analysis.

Intracardiac thrombosis and/or pulmonary thromboembolism (ICT/PE) is a rare but devastating complication during liver transplantation. Its pathophysiology remains poorly understood, and successful treatment remains a challenge. This systematic review summarizes the available published clinical data regarding ICT/PE during liver transplantation. Databases were searched for all publications reporting on ICT/PE during liver transplantation. Data collected included its incidence, patient characteristics, the timing of diagnosis, treatment strategies, and patient outcomes. This review included 59 full-text citations. The point prevalence of ICT/PE was 1.42%. Thrombi were most often diagnosed during the neohepatic phase, particularly at allograft reperfusion. Intravenous heparin was effective in preventing early-stage thrombus from progressing further and restoring hemodynamics in 76.32% of patients it was utilized for; however, the addition of tissue plasminogen activator or sole use of tissue plasminogen activator offered diminishing returns. Despite all resuscitation efforts, the in-hospital mortality rate of an intraoperative ICT/PE was 40.42%, with nearly half of these patients dying intraoperatively. The results of our systematic review are an initial step for providing clinicians with data that can help identify higher-risk patients. The clinical implications of our results warrant the development of identification and management strategies for the timely and effective treatment of these tragic occurrences during liver transplantation.

Editorial Commentary: Haven't We Seen This Somewhere Before? Laying the Foundation for Cartilage Restoration in Hip Preservation.

Since its inception in the early 1980s, the microfracture procedure has been successfully used throughout the body to treat isolated full-thickness cartilage lesions. Although treatment of such injuries can be challenging, and outcomes variable, microfracture has afforded surgeons the ability to treat cartilage lesions in a single-stage fashion at the time of treatment for concomitant injuries. Whereas most research relating to the use of microfracture has focused on managing lesions in the knee, there continues to be interest in applying the same principles in other regions of the body. With the recent enthusiasm and procedural increase in hip arthroscopy and hip preservation procedures, evaluating the use of microfracture in the femoroacetabular joint is the next logical step in establishing treatment principles for cartilage defects in this location. Although we continue to innovate as orthopedic surgeons, and there have been recent declines in ardor for the use of microfracture, this sentiment has arisen only after decades of research and clinical advances. Because of this, continued work will be necessary to understand the limits of the microfracture procedure in hip preservation surgery. Early outcome studies are encouraging and continue to be an important platform on which to lay the foundation for further research and refinement of techniques and indications.

Anterior Cruciate Ligament Injury at the Time of Anterior Tibial Spine Fracture in Young Patients: An Observational Cohort Study.

BACKGROUND: Anterior tibial spine fractures (ATSF) in the skeletally immature parallel anterior cruciate ligament (ACL) tears in adult patients, yet these injuries are generally regarded as mutually exclusive. Biomechanical analysis suggests that intrinsic ACL damage occurs during ATSF, and long-term clinical studies demonstrate residual anteroposterior knee laxity following ATSF. We aim to describe prevalence, demographics, and characteristics of pediatric patients who sustained ATSF with concomitant ACL injury. METHODS: We included 129 patients with ATSF over a 16-year period. Age, sex, injury mechanism, ATSF type, magnetic resonance imaging (MRI) evaluation, treatment modality, ACL injury, and concomitant meniscal/chondral injuries were analyzed. Concurrent ACL injury was confirmed either from MRI or intraoperatively. RESULTS: Nineteen percent (n=25) of ATSF patients had concomitant ACL injury, with ACL injury significantly more likely in type II or type III ATSF compared with type I ATSF (P=0.03). Patients with combined ATSF/ACL injury were significantly older (P=0.02) and more likely to be male (P=0.01). Mechanism of ATSF injury was not associated with ACL injury (P=0.83). Preoperative MRI had low sensitivity (0.09) for recognizing ACL injury at the time of ATSF relative to intraoperative assessment. Half of ATSF/ACL-injured patients had additional meniscal or chondral injury, with meniscal repair or debridement required in 37.5% of the type II ATSF/ACL injury. CONCLUSIONS: There are demographic characteristics, such as age (older) and sex (male), associated with a higher risk of concomitant ACL injury at the time of ATSF. Type II and type III ATSF patterns had a higher prevalence of ACL injury. MRI failed to correctly identify ACL injury at the time of ATSF. Concomitant ACL injury at the time of ATSF is highly prevalent in the skeletally immature, occurring in 19.4% of patients with ATSF. LEVEL OF EVIDENCE: Level IV-case series.

Epidemiology of Anterior Tibial Spine Fractures in Young Patients: A Retrospective Cohort Study of 122 Cases.

BACKGROUND: Historically, bicycle accidents were described as the most common mechanism for pediatric anterior tibial spine fractures (ATSFs). There is a paucity of current literature examining the demographic factors associated with these injuries. The purpose of this cohort study was to characterize the epidemiology of ATSFs presenting to a single tertiary referral pediatric hospital. METHODS: A consecutive cohort of 122 pediatric patients with ATSFs between 1996 and 2014 were reviewed. Radiographic variables, classification of fractures (Meyers and McKeever type), age, sex, height, weight, body mass index, and mechanism of injury were retrieved. Categories of mechanism of injury included organized sports (football, soccer, basketball, lacrosse, wrestling, and gymnastics), bicycling, outdoor sports (skiing, skateboarding, and sledding), fall, motor vehicle collision/pedestrian versus motor vehicle, and trampoline. RESULTS: Organized sports-related injuries represented the most common cause of ATSFs (36%). Other common mechanisms of injury included bicycle accidents (25%), outdoor sports (18%), and falls (11%). There was a higher proportion of males (69%) compared with females (31%). Males (mean age, 11.6 y) were significantly older than females (mean age, 9.8 y) (P=0.004). Younger patients (aged 11.5 y and below) were more likely to have displaced fractures (type III), whereas type I and type II were more common in patients above 11.5 years (P=0.02). Patients with fracture type I were significantly taller than patients with fracture type III. No other variables were found to differ significantly according to fracture severity, including sex, weight, and body mass index. CONCLUSIONS: To our knowledge, our study represents both the largest (n=122) and most up-to-date epidemiological ATSF study in pediatric patients. A higher rate of ATSF occurs due to organized sports rather than bicycling or motor vehicle collision. This 18-year data collection represents a change in the paradigm, and is likely multifactorial, including increased participation in youth sports and early sport specialization. LEVEL OF EVIDENCE: Level IV-retrospective, cohort study.

Outcomes of Arthroscopic Management of Trochanteric Bursitis in Patients With Femoroacetabular Impingement: A Comparison of Two Matched Patient Groups.

PURPOSE: To determine the prevalence of chronic trochanteric bursitis (TB) in patient being treated for femoroacetabular impingement (FAI) and determine the effectiveness of arthroscopic bursectomy and iliotibial band lengthening (AB-ITB-L) at the time of hip arthroscopy for FAI. METHODS: Patients diagnosed with primary FAI and chronic TB were included in the study. Patients were included if they underwent hip arthroscopy with labral repair, femoral and/or acetabular osteoplasty, and AB-ITB-L. Patients were matched by age and gender to patients without chronic TB. RESULTS: The prevalence of chronic TB with FAI was 7% (90/1,278). Females were 5.3 times more likely to have TB compared with males (95% confidence interval: 3.2-8.7). Patients more than 30 years of age were 2.5 times more likely to have TB (95% confidence interval: 1.48-4.4). Of the 90 patients diagnosed with TB, 72 (54 female, 18 male) with an average age of 36.7 years underwent AB-ITB-L at the time of their index hip arthroscopy for FAI. All 72 patients had associated intra-articular pathology consisting of a combined cam and pincer pathology. The TB (average follow-up = 42 ± 9.9 months) and non-TB group (average follow-up = 42 ± 9.1 months) both had significant improvement from preoperative to postoperative scores for Hip Outcome Score Activities Daily Living, Hip Outcome Score Sport, Modified Harris Hip Score, Western Ontario and McMaster Universities Arthritis Index, Short Form (SF)-12 Physical Component score, and SF-12 Mental Component Score. There was no significant difference between the 2 groups in postoperative patient reported outcome scores. CONCLUSIONS: The occurrence of chronic TB in the FAI population, which did not adequately respond to nonoperative management, for a single surgeon high volume hip arthroscopy practice was 7%, and was more commonly seen in women older than 30 years. Patients who undergo concomitant AB-ITB-L for chronic TB report excellent pain relief, and have equivalent results and outcome scores that are not inferior when compared with patients with primary FAI without chronic TB. LEVEL OF EVIDENCE: Level III, retrospective matched case control study.

A Systematic Review of Arthroscopic Versus Open Tenotomy of Iliopsoas Tendonitis After Total Hip Replacement.

PURPOSE: To conduct a systematic review of the literature comparing patient outcomes following arthroscopic and open operative management of iliopsoas tendonitis (IPT) following total hip replacement (THR). METHODS: This review study was conducted in accordance with the Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA) statement. Inclusion criteria were as follows: outcome studies following open or arthroscopic iliopsoas tendon release after THR with at least 6 months of follow-up, English language, and human studies. The exclusion criteria included case reports, articles evaluating nonsurgical management or cup revision, and articles without a specific diagnosis of IPT or in which results between open and arthroscopic treatment were reported in conjunction. RESULTS: A total of 131 studies were initially retrieved, with 7 satisfying all inclusion criteria (4 studies on arthroscopic tenotomy and 3 studies on open tenotomy). The review included a total of 88 patients with IPT-61 patients treated arthroscopically and 27 patients treated with open tenotomy. In total, 77 of the 88 patients demonstrated successful outcomes following surgery. In the group treated with arthroscopy, 91.8% (56/61) of patients had successful outcomes, whereas in those treated with open tenotomy, 77.8% (21/27) of patients had successful outcomes. Of patients with signs of mechanical impingement from acetabular component overhang, those who underwent open tenotomy had complete pain relief in 6/8 patients (75%) compared to arthroscopic tenotomy in which there was relief in 40/43 patients (93%). CONCLUSIONS: Arthroscopic iliopsoas release for management of IPT is suggested to be an effective minimally invasive operative technique that may also yield a lower complication rate in comparison to open tenotomy. Tenotomy, both arthroscopic and open, are successful treatment options for IPT, including those with signs of mechanical impingement, and are recommended prior to cup revision. LEVEL OF EVIDENCE: Level IV, systematic review of level IV studies.

Primary Versus Revision Anterior Cruciate Ligament Reconstruction: Patient Demographics, Radiographic Findings, and Associated Lesions.

PURPOSE: The purpose of this study was to evaluate the differences in intra-articular pathology, demographic characteristics, and radiographic characteristics of the knee associated with primary anterior cruciate ligament reconstruction (ACLR) versus revision ACLR at the time of initial presentation with either a native anterior cruciate ligament tear or an anterior cruciate ligament graft tear. Secondarily, we aimed to investigate risk factors for concomitant medial and lateral meniscal tears and cartilage injuries at the time of ACLR. METHODS: This was a retrospective review of patients who underwent primary or revision ACLR by a single surgeon. The exclusion criteria were as follows: skeletally immature patients; patients with an intra-articular fracture; patients with an ipsilateral knee infection; or patients who underwent an osteotomy, cartilage restoration procedure, or meniscal transplantation either previously or concomitantly with the ACLR. Detailed patient demographic data, radiographic long-standing alignment, tibial slope, and intraoperative findings including articular cartilage injury grade and meniscus integrity were documented at surgery. RESULTS: There were 487 patients included in this study (363 with primary ACLR and 124 with revision ACLR). There were no significant differences in age (P = .119), sex (P = .917), body mass index (P = .468), allograft versus autograft reconstruction (P = .916), or prevalence of meniscal tears (P = .142) between the primary and revision groups. Patients who underwent revision ACLR had a significantly increased medial tibial slope (P = .048) and a higher prevalence of chondral defects on both the medial (P < .001) and lateral (P = .003) femoral condyles when compared with primary ACLR patients. Logistic regression showed that a decreased tibial slope was correlated with femoral medial-sided chondral injuries and that varus or valgus coronal-plane malalignment was correlated with lateral meniscal tears in both groups. CONCLUSIONS: The findings of this study show that patients undergoing a revision ACLR have significantly more chondral lesions, as well as higher-grade chondral lesions, at the time of presentation. Furthermore, coronal malalignment and a decreased tibial slope may contribute to injury patterns of the lateral meniscus and medial compartment cartilage, respectively. LEVEL OF EVIDENCE: Level III, retrospective case-control study.

Immediate physical therapy without postoperative restrictions following open subpectoral biceps tenodesis: low failure rates and improved outcomes at a minimum 2-year follow-up.

HYPOTHESIS: We aimed to determine patient-reported outcomes in patients undergoing open subpectoral biceps tenodesis with a dual-fixation construct who had no postoperative range-of-motion or weight-bearing restrictions. Our hypothesis was that patients without postoperative restrictions would have low failure rates with improved patient-reported outcomes. We further hypothesized that this technique would allow an earlier return to activity and similar functional outcomes when compared with those reported in the literature. METHODS: In this institutional review board-approved retrospective outcome study, we evaluated 105 patients who underwent primary open subpectoral biceps tenodesis with a bicortical suture button and interference screw construct without postoperative restrictions. The primary outcome measure was failure of the biceps tenodesis. Postoperative outcome scores included the Short Form 12 (SF-12) Physical Component Score; SF-12 Mental Component Score; American Shoulder and Elbow Surgeons total score and subscales; and Disabilities of the Arm, Shoulder and Hand score. RESULTS: A total of 98 patients (85%) were available for final follow-up at an average of 3.5 years. There were 2 failures (2.2%), at 5 weeks and 9 weeks postoperatively. Four patients underwent additional surgery unrelated to the previous tenodesis procedure. Final outcome scores indicated high levels of function, including the SF-12 Physical Component Score (mean, 51.5; SD, 7.8), SF-12 Mental Component Score (mean, 54.7; SD, 6.7), American Shoulder and Elbow Surgeons total score (mean, 89.4; SD, 14.2), and Disabilities of the Arm, Shoulder and Hand score (mean, 11.3; SD, 13.4). CONCLUSION: Open subpectoral biceps tenodesis using a dual-fixation construct with no postoperative motion restrictions resulted in excellent outcomes with a low incidence of failure.

Truncated Glucagon-like Peptide-1 and Exendin-4 α-Conotoxin pl14a Peptide Chimeras Maintain Potency and α-Helicity and Reveal Interactions Vital for cAMP Signaling in Vitro.

Glucagon-like peptide-1 (GLP-1) signaling through the glucagon-like peptide 1 receptor (GLP-1R) is a key regulator of normal glucose metabolism, and exogenous GLP-1R agonist therapy is a promising avenue for the treatment of type 2 diabetes mellitus. To date, the development of therapeutic GLP-1R agonists has focused on producing drugs with an extended serum half-life. This has been achieved by engineering synthetic analogs of GLP-1 or the more stable exogenous GLP-1R agonist exendin-4 (Ex-4). These synthetic peptide hormones share the overall structure of GLP-1 and Ex-4, with a C-terminal helical segment and a flexible N-terminal tail. Although numerous studies have investigated the molecular determinants underpinning GLP-1 and Ex-4 binding and signaling through the GLP-1R, these have primarily focused on the length and composition of the N-terminal tail or on how to modulate the helicity of the full-length peptides. Here, we investigate the effect of C-terminal truncation in GLP-1 and Ex-4 on the cAMP pathway. To ensure helical C-terminal regions in the truncated peptides, we produced a series of chimeric peptides combining the N-terminal portion of GLP-1 or Ex-4 and the C-terminal segment of the helix-promoting peptide α-conotoxin pl14a. The helicity and structures of the chimeric peptides were confirmed using circular dichroism and NMR, respectively. We found no direct correlation between the fractional helicity and potency in signaling via the cAMP pathway. Rather, the most important feature for efficient receptor binding and signaling was the C-terminal helical segment (residues 22-27) directing the binding of Phe(22) into a hydrophobic pocket on the GLP-1R.

Single-Bundle and Double-Bundle Posterior Cruciate Ligament Reconstructions: A Systematic Review and Meta-analysis of 441 Patients at a Minimum 2 Years' Follow-up.

PURPOSE: To perform a systematic review on the techniques and a meta-analysis on the functional and objective outcomes after single-bundle (SB) versus double-bundle (DB) posterior cruciate ligament (PCL) reconstructions. METHODS: A systematic review of the techniques, as well as functional and objective outcomes of clinical studies comparing SB versus DB PCL reconstruction with a mean follow-up of at least 24 months and minimum level of evidence of III were performed. After review of the literature, a quality analysis of the studies (Detsky score) and a meta-analysis comparing raw mean differences in data between SB and DB PCL groups were performed. Clinical outcome measures included in the meta-analysis were functional outcomes (Lysholm, Tegner, and objective International Knee Documentation Committee [IKDC] scores) and objective measurements (arthrometer and stress radiographs). RESULTS: The systematic search identified 11 studies (441 patients). Three studies were prospective randomized controlled trials and the other 8 studies were case-control studies. Two hundred thirty-two patients were treated with SB PCL reconstruction, whereas 209 were treated with DB PCL reconstruction. Only 4 studies satisfied the threshold for a satisfactory level of methodologic quality (>75%). There were no significant differences between SB and DB PCL reconstructions in postoperative Lysholm (P = .6, 95% confidence interval [CI], -0.98, 2.18) or Tegner scores (P = .37, 95% CI, -0.19, 0.92). DB PCL reconstruction provided significantly better objective posterior tibial translation stability than the SB technique using the Telos technique at 90° (P = -.58, 95% CI, -1.06, -0.10). CONCLUSIONS: Improved patient-reported outcomes and knee stability were achieved with both SB and DB PCL reconstruction surgery. DB PCL reconstruction provided significantly improved objective posterior tibial stability and objective IKDC scores when compared with SB PCL reconstruction in randomized clinical trials. No significant difference was found for the other patient-reported outcomes. LEVEL OF EVIDENCE: Level III, systematic review and meta-analysis of Level II and III studies.

Arthroscopic Treatment of Snapping Scapula Syndrome: Outcomes at Minimum of 2 Years.

PURPOSE: To investigate clinical outcomes after primary and revision arthroscopic treatment for snapping scapula syndrome (SSS) and identify predictive factors associated with outcomes. METHODS: Patients who underwent arthroscopic treatment for SSS between October 2005 and December 2013 were identified in a prospectively collected database. The inclusion criteria were patients with a diagnosis of symptomatic SSS, in whom extensive nonoperative modalities failed, who underwent arthroscopic surgery for SSS, and who had undergone surgery a minimum of 2 years earlier. Postoperative clinical outcomes were assessed with the American Shoulder and Elbow Surgeons score; short version of the Disabilities of the Arm, Shoulder and Hand questionnaire; and general health Short Form 12 (SF-12) scores, including both physical component summary and mental component summary. Patient satisfaction was recorded on a 10-point visual analog scale. Scapular bony morphology was determined on preoperative magnetic resonance imaging. RESULTS: Ninety-two scapulae underwent arthroscopic treatment for SSS. There were 74 scapulae that met the inclusion criteria, including having undergone surgery a minimum of 2 years earlier. An outcome questionnaire was completed for 60 of 74 (81%). The mean age was 33 years (range, 12-65 years), and the mean duration of symptoms before surgery was 4 years (range, 90 days to 20.4 years). The mean follow-up period was 3.4 years (range, 2-7 years). Eight scapulae failed initial surgical management (10.9%) because of recurrent pain and underwent revision surgery at a mean of 309 days (range, 120-917 days). After surgery, there was a significant improvement in all outcome scores, including SF-12 physical component summary score, from 39.2 to 45.4 (P = .002); SF-12 mental component summary score, from 45.0 to 49.6 (P = .023); American Shoulder and Elbow Surgeons score, from 52.6 to 75.8 (P < .001); and score on the short version of the Disabilities of the Arm, Shoulder and Hand questionnaire, from 40.2 to 24.2 (P = .001). The median patient satisfaction rating was 7 of 10. Greater age, lower preoperative psychological score, and longer duration of symptoms before surgery correlated with lower postoperative outcome scores. CONCLUSIONS: Arthroscopic surgery is an effective treatment for SSS in both primary and revision cases, showing significant improvements in all postoperative outcome scores at a mean of 3.4 years. Lower preoperative mental status score, longer duration of symptoms, and greater age were associated with poorer outcomes. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Quantitative and Computed Tomography Anatomic Analysis of Glenoid Fixation for Superior Capsule Reconstruction: A Cadaveric Study.

PURPOSE: To investigate glenoid fixation for superior capsule reconstruction (SCR) and evaluate anchor positions, intraosseous trajectories, and proximity to the suprascapular nerve (SSN) and glenoid fossa. The secondary purpose was to provide technical pearls and pitfalls for anchor insertion on the superior glenoid during SCR. METHODS: Three beath pins were arthroscopically inserted into 12 (n = 12) nonpaired human cadaveric shoulders through Neviaser, anterior, and posterior portals to simulate anchor placement on the superior glenoid during SCR. Computed tomography scans were performed to evaluate anchor positioning and insertion trajectories. Specimens were then dissected to delineate the anatomic relations of the beath pins to the SSN and glenoid fossa. RESULTS: The superior glenoid anchor position was a mean 15.0 ± 4.0 mm to the SSN and 6.5 ± 1.7 mm to the glenoid fossa. The posterior glenoid anchor position was a mean 11.8 ± 2.1 mm to the SSN and 2.9 ± 2.9 mm to the glenoid fossa. On average, the superior pin was placed at 12:30 ± 0:30 (left-sided glenoid clock face) and inserted at 19° ± 9° with respect to the sagittal plane of the glenoid, the anterior pin was placed at 11:00 ± 0:30 and inserted 40° ± 17° off the glenoid, and the posterior pin was placed at 3:00 ± 1:00 and inserted at 52° ± 12° off the glenoid. CONCLUSIONS: The results of the present cadaveric study showed that glenoid fixation was safe with respect to the SSN and delineated technical guidelines and trajectories for inserting 3 anchors into the glenoid. CLINICAL RELEVANCE: This study shows that 3 anchors can be inserted into the glenoid without a risk of SSN damage and delineates technical guidelines for anchor insertion.

Posteromedially placed plates with anterior staple reinforcement are not successful in decreasing tibial slope in opening-wedge proximal tibial osteotomy.

PURPOSE: To document the effectiveness of a novel technique to decrease tibial slope in patients who underwent a proximal opening-wedge osteotomy with an anteriorly sloped plate placed in a posteromedial position. The hypothesis was that posteromedial placement of an anteriorly sloped osteotomy plate with an adjunctive anterior bone staple on the tibia would decrease, and maintain, the tibial slope correction at a minimum of 6 months following the osteotomy. METHODS: All patients who underwent biplanar medial opening-wedge proximal tibial osteotomy with anterior staple augmentation to decrease sagittal plane tibial slope were included, and data were collected prospectively and reviewed retrospectively. Indications for decreasing tibial slope included medial compartment osteoarthritis with at least one of the following: ACL deficiency, posterior meniscus deficiency, or flexion contracture. Preoperative, immediate postoperative, and 6-month postoperative radiographs were reviewed. RESULTS: Twenty-one patients (14 males and 7 females) were included in the study with a mean age of 36.5 years. Intrarater and interrater reliability of slope measurements were excellent at all time points (ICC ≥ 0.94, ICC ≥ 0.85). The osteotomy resulted in an average tibial slope decrease of 0.8 from preoperative (n.s.). At 6-month postoperative, average slope was not significantly different from time-zero postoperative slope (mean = +0.2°). CONCLUSIONS: The most important finding of this study was that posteromedial placement of an anteriorly angled osteotomy plate augmented with an anterior staple during a biplanar medial opening-wedge proximal tibial osteotomy did not decrease sagittal plane tibial slope. Whether a staple was effective in maintaining tibial slope from time zero to 6 months postoperatively was unable to be assessed due to no significant change in tibial slope from the preoperative postoperative states. The results of this study note that current osteotomy plate designs and surgical techniques are not effective in decreasing sagittal plane tibial slope. LEVEL OF EVIDENCE: IV.

Radial Head Arthroplasty in the Active Duty Military Service Member With Minimum 2-Year Follow-Up.

PURPOSE: Radial head arthroplasty (RHA) is a viable treatment for complex radial head fracture. Whereas elbow stability and function is typically restored at short- to mid-term follow-up, the outcome in higher-demand populations is not well defined. We sought to characterize the functional and occupational outcomes following RHA in an active duty military population with intense upper extremity demands. METHODS: We retrospectively reviewed the records of all U.S. military service members undergoing primary RHA from 2010 and 2013 with a minimum of 2-year follow-up. Patient-based, injury-related, and surgical variables were extracted from the military-wide electronic medical record. Functional and occupational outcomes including pain, and Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire were recorded. The primary outcomes of interest were the rate and level of return to upper extremity activity. Secondary outcome measures included return to duty, complications, and revision surgery. RESULTS: Nineteen patients were included with average age 31 years and median 37 months' follow-up. Ten were Mason III, 6 were part of a terrible triad injury, and the remainder were fracture-dislocations. At an average follow-up of 3.7 years, 15 patients returned to active military duty, and 9 resumed their regular upper extremity military function. At the time of final follow-up, the average DASH score was 13. Seven patients returned to their usual level of sport and exercise, 6 at a reduced level, and 6 did not resume physical exercises secondary to pain or stiffness. Sixteen adverse outcomes among 14 patients included symptomatic heterotopic ossification (5 of 19) and neurological sequelae (4 of 19). Three elected to have a revision procedure at an average of 13 months for heterotopic ossification or loosening. CONCLUSIONS: Among active patients with radial head fractures treated with RHA, three-quarters will return to active duty military service, push-ups, and sport; however, half may report an adverse outcome unrelated to the prosthesis and only about half of patients will return to their preinjury level of function. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Editorial Commentary: Limited Data Shows How Little We Know.

Lateral compartment osteoarthritis of the knee can be a challenging problem to address in the younger, active population. The challenge is compounded by limited treatment options and high patient expectations, with patients often desiring a return to impact high intensity activity. Distal femoral osteotomy has been reported to be one potential treatment option; however, a highly heterogeneous literature exists for both opening and closing wedge distal femoral osteotomies for the treatment of isolated lateral compartment osteoarthritis with valgus malalignment. The literature does not provide significant direction for surgeons on the appropriate surgical approach; however, opening wedge osteotomies allow for fine adjustment and maintain leg length and joint alignment, and are our preferred approach.

Outcomes and Risk Factors of Rerevision Anterior Cruciate Ligament Reconstruction: A Systematic Review.

PURPOSE: The purpose of this study was to systematically review the literature on rerevision anterior cruciate ligament (ACL) reconstruction, focusing on patient outcomes. The secondary aims of this study were to (1) identify risk factors that contribute to multiple ACL reconstruction failures (defined as a complete tear of a revision ACL graft with knee instability) and (2) assess concomitant knee injuries, such as articular cartilage and menisci lesions. METHODS: A systematic review of the literature was performed. Inclusion criteria were as follows: outcomes of rerevision ACL reconstruction, English language, minimum of 2 years of follow-up, and human studies. We excluded cadaveric studies, animal studies, basic science articles, editorial articles, surgical technique descriptions, surveys, and rerevision ACL articles in which rerevision reconstruction subgroups were not reported independently of first-time ACL revision groups. RESULTS: Six studies met the inclusion criteria and were considered for review. One was a case-control study (Level III evidence), and 5 studies were case series (Level IV evidence). Compared with preoperative scores, patient outcomes improved after rerevision ACL reconstruction. However, more meniscal and cartilage pathologies were present in rerevision cases compared with after primary and revision ACL reconstruction. CONCLUSIONS: Although rerevision ACL reconstruction can restore stability and improve functional outcomes compared with the preoperative state, outcomes remained inferior when compared with primary ACL reconstructions, particularly regarding a patient's ability to return to his or her preinjury level of activity. Additional factors that place increased stress on the ACL graft, such as increased posterior tibial sagittal plane slope or undiagnosed concomitant ligament injuries, should be investigated, especially in atraumatic failures. If present, operative treatment of these factors should be considered. LEVEL OF EVIDENCE: Level IV, systematic review of Level III and IV studies.

Incidence of meniscal injury and chondral pathology in anterior tibial spine fractures of children.

BACKGROUND: Pediatric avulsion fractures of the anterior tibial spine are injuries similar to anterior cruciate ligament injuries in adults. Sparse data exists on the association between anterior tibial spine fractures (ATSFs) and injury to the meniscus or cartilage of the knee joint in children. This research presents a retrospective review of clinical records, imaging, and operative reports to characterize the incidence of concomitant injury in cases of ATSFs in children. The purpose of this study was to better delineate the incidence of associated injuries in fractures of the anterior tibial spine in the pediatric population. METHODS: We identified 58 patients who sustained an ATSF and met inclusion criteria for this study between 1996 and 2011. The subjects were separated by the Myers and McKeever classification into type I, II, and III fractures, and each of these were subclassified by associated injury pattern. RESULTS: 59% of children with an ATSF had an associated soft tissue or other bony injury diagnosed by magnetic resonance imaging or arthroscopy. The most prevalent associated injuries were meniscal entrapment, meniscal tears, and chondral injury. We found no meniscal or chondral injury associated with type I fractures. Twenty-nine percent of type II injuries demonstrated meniscal entrapment, 33% showing meniscal tears. Seven percent demonstrated chondral injury. Forty-eight percent of type III fractures had entrapment, whereas 12% showed meniscal tears. Eight percent had a chondral injury. CONCLUSIONS: A majority (59%) of displaced ATSF had either concomitant meniscal, ligamentous, or chondral injury. This finding suggests that magnetic resonance imaging evaluation is an important aspect of the evaluation of these injuries, particularly in type II and type III patterns. To date, this study reports the largest number of patients to evaluate the specific question of concomitant injuries in ATSFs in the pediatric population. LEVEL OF EVIDENCE: Level IV.

Insulin secretion from beta cells in intact mouse islets is targeted towards the vasculature.

AIMS/HYPOTHESIS: We set out to test the hypothesis that insulin secretion from beta cells is targeted towards the vasculature. METHODS: The spatial location of granule fusion was identified by live-cell two-photon imaging of mouse pancreatic beta cells within intact islets, using sulforhodamine B labelling. Three-dimensional (3D) immunofluorescence of pancreatic slices was used to identify the location of proteins associated with neuronal synapses. RESULTS: We demonstrated an asymmetric, non-random, distribution of sites of insulin granule fusion in response to glucose and focal targeting of insulin granule secretion to the beta cell membrane facing the vasculature. 3D immunofluorescence of islets showed that structural proteins, such as liprin, piccolo and Rab2-interacting molecule, normally associated with neuronal presynaptic targeting, were present in beta cells and enriched at the vascular face. In contrast, we found that syntaxin 1A and synaptosomal-associated protein 25 kDa (SNAP25) were relatively evenly distributed across the beta cells. CONCLUSIONS/INTERPRETATION: Our results show that beta cells in situ, within intact islets, are polarised and target insulin secretion. This evidence for an 'endocrine synapse' has wide implications for our understanding of stimulus-secretion coupling in healthy islets and in disease.

A deadly digital dressing: a case of surgical decompression for finger ischemia due to circumferential finger dressing.

BACKGROUND: Tubular gauze dressings are commonly used, but have potential to cause iatrogenic finger ischemia. OBJECTIVES: To inform health care providers of an avoidable complication and to discuss appropriate methods of prevention and treatment. CASE REPORT: We discuss a teenage female's finger that narrowly avoided amputation after a tubular gauze dressing caused iatrogenic ischemia. Surgical decompression using a novel technique successfully salvaged the finger. Operative intervention for this complication has previously been unreported. CONCLUSION: It is important that circumferential digital dressings are applied correctly. Vascular insufficiency from an occlusive dressing is an iatrogenic and avoidable complication. Successful operative decompression may be indicated to minimize tissue loss and improve circulation.