Revision Soft-Tissue Allograft Anterior Cruciate Ligament Reconstruction Is Associated With Lower Patient-Reported Outcomes Compared With Primary Anterior Cruciate Ligament Reconstruction in Patients Aged 40 and Older.

PURPOSE: To evaluate patient-reported outcomes (PROs) and graft failure rates in revision allograft anterior cruciate ligament reconstruction (ACLR) in patients aged 40 and older and compare them with primary ACLRs. METHODS: Patients aged 40 and older who underwent arthroscopic soft-tissue allograft ACLR between 2005 and 2016 with a minimum 2-year follow-up were retrospectively reviewed. Patients were grouped based on revision versus primary ACLR. The rate of achieving an International Knee Documentation Committee (IKDC) patient acceptable symptom state (PASS) score was recorded. Patient satisfaction, PROs, and graft failure were compared between groups using the χ2 test, Fisher exact test, and Mann-Whitney U test. RESULTS: We identified 32 patients who underwent revision ACLR and 201 patients who underwent primary ACLR aged 40 and older who met inclusion criteria with a mean follow-up of 6.2 and 6.9 years, respectively (P = .042). There was a lower rate of concomitant meniscal repair in the primary ACLR group (6% vs 21.9%, P = .007) There were no other differences in chondral injuries, mechanism of injury, or meniscal injuries between groups. The median IKDC score was greater in the primary ACLR group as compared with the revision ACLR group (83.9 vs 70.6, P < .001). Patients who underwent revision ACLR were less likely to achieve the IKDC PASS threshold (82.5% vs 56.3%, P = .001) and were less likely to report satisfaction as compared with patients who underwent primary ACLR (90.5% vs 78.1%, P =.038). No difference in graft failure rates was identified between groups (8% vs 15.6%, P = .180). CONCLUSIONS: Revision allograft ACLR in patients aged 40 and older was associated with lower PROs compared with primary ACLR. Patients who underwent revision ACLR failed to meet the IKDC PASS threshold more often and were dissatisfied with procedure results more than twice as often as patients that underwent primary ACLR. LEVEL OF EVIDENCE: III, retrospective cohort study.

Rethinking local resilience for extreme heat events.

OBJECTIVE: This study aims to provide insights into how local resilience structures in England can be leveraged to deliver a whole-of-society approach to managing a national response to extreme heat events during summer months. STUDY DESIGN: A communication based on the literature review of currently available research on health emergency response and extreme heat events in England. METHODS: This communication draws insights from the authors' research programmes, which examined national-level public health emergency response during the COVID-19 pandemic and literature review of the latest available English research on health and extreme heat events. RESULTS: Periods of extreme heat are on the rise in England. Local resilience forums (LRFs), due to their multiagency nature, offer a shared situational awareness and understanding of the need in their local communities. Such information is critical to ensure messaging about heat risks and available resources are tailored to reach specific targeted groups within their communities. Scenario planning and adaptation efforts require a more local articulation which LRFs are well placed to manage. CONCLUSIONS: LRFs are well suited as key structures in the English emergency response to extreme heat events. We suggest that English public health and hospital organisations, working with community partners via the LRFs, must develop their thinking about pressures from adverse weather in the summer months.

Preoperative factors associated with failure to reach the patient acceptable symptom state after anterior cruciate ligament reconstruction in patients aged 40 and older.

PURPOSE: To perform a predictive analysis to identify preoperative patient factors associated with failure to achieve a newly defined patient acceptable symptom state (PASS) for the International Knee Documentation Committee (IKDC) Score after anterior cruciate ligament reconstruction (ACLR) in patients aged ≥ 40 years with a minimum of 2-year follow-up. METHODS: This was a secondary analysis of a retrospective review of all patients aged 40 years or older receiving a primary allograft ACLR at a single institution between the years of 2005 and 2016, with 2-year minimum follow-up. Using an updated PASS threshold of 66.7 for the International Knee Documentation Committee (IKDC) score previously established for this patient cohort, a univariate and multivariate analysis was performed to identify preoperative patient characteristics predictive of failure to achieve PASS. RESULTS: A total of 197 patients with a mean follow-up of 6.2 ± 2.1 years (range 2.7 - 11.2) were included in the analysis (48.5 ± 5.6 years, 51.8% female, Body Mass Index (BMI) 25.9 ± 4.4). PASS was achieved by 162 patients (82.2%). Patients who failed to achieve PASS more often had lateral compartment cartilage defects (P = 0.001) and lateral meniscus tears (P = 0.004), higher BMIs (P = 0.004), and Workers' Compensation status (P = 0.043) on univariable analysis. Factors predictive of failure to achieve PASS on multivariable analysis included BMI and lateral compartment cartilage defect (OR 1.12 [1.03-1.23], P = 0.013; OR 5.1 [1.87-13.9], P = 0.001). CONCLUSION: Among patients ≥ 40 years who receive a primary allograft ACLR, patients who fail to achieve PASS more often had lateral compartment cartilage defects and higher BMIs. LEVEL OF EVIDENCE: Level IV.

The Majority of Patients Aged 40 and Older Having Allograft Anterior Cruciate Ligament Reconstruction Achieve a Patient Acceptable Symptomatic State.

PURPOSE: To evaluate patient satisfaction, retear rates, and patient-reported outcomes (PROs) in patients aged 40 and older undergoing allograft anterior cruciate ligament reconstruction (ACLR). The secondary goal was to compare these parameters between groups of patients with intact versus failed grafts, and to evaluate these in relation to a historically reported International Knee Documentation Committee (IKDC) patient-acceptable symptoms state (PASS) score. METHODS: Records of patients aged 40 and older who underwent ACLR between 2005 and 2016 at a single institution with a minimum 2-year follow-up were retrospectively reviewed. Patient-reported satisfaction, outcome scores, and failure rates were analyzed. The rate of achieving a previously defined IKDC PASS score based on younger cohorts was reported, and an updated PASS threshold for older patients was calculated. RESULTS: 201 patients were included with a mean age of 48.6 years (range: 40-68) and mean follow-up of 6.2 years (range: 2.8-11.2). 182 (90.5%) patients reported satisfaction following surgery. 16 (8.0%) patients experienced failure of their ACLR, 10 of which underwent revision ACLR. The median IKDC score in the intact ACLR group was 86.2, compared to 66.7 in the failure group (P < .001). In total, 134 (72.4%) patients in the intact group achieved the historical PASS score of 75.9 on IKDC compared to only 4 (25%) in the failure group (χ2 = 15.396, P < .001). An updated IKDC PASS threshold for older cohorts was calculated to be 66.7. CONCLUSION: Patients aged 40 and older who underwent allograft ACLR had an 8.0% failure rate at a mean follow-up of 6 years. Graft failure in patients aged 40 and older was associated with worse PROs. The majority of patients achieved the historically reported IKDC PASS threshold. Additionally, an updated age-appropriate IKDC PASS score of 66.7 was calculated to aid in future ACLR studies assessing older patients. STUDY DESIGN: Level IV.

Nonsurgical Management of Osteoarthritis of the Knee: What You Should Be Injecting Now and in the Future.

Osteoarthritis of the knee affects many Americans. With the aging of the population and increasing comorbidities (eg, obesity, diabetes, hypertension, heart disease), the use of oral or topical NSAIDs is often contraindicated. Injectable treatment options are advantageous because of the ability to decrease or avoid the unwanted systematic adverse effects of NSAIDs. Injectable treatment options for osteoarthritis of the knee go back to the 1950s, beginning with corticosteroids, which remain widely used despite concerns that they may have adverse effects on articular chondrocytes and short duration of efficacy. The recent (FDA approval in 2017) introduction of a sustained-release corticosteroid (triamcinolone acetonide extended-release) offers significantly longer benefit than standard cortisone products and with substantially lower concentration levels of chondrocyte exposure to the steroid. Hyaluronic acid was added to the options for intra-articular injection in osteoarthritis of the knee in the late 1990s and remains widely used despite some controversy over its efficacy. Although guidelines for the use of hyaluronic acid for management of osteoarthritis of the knee have varied widely, careful analysis of the data and patient's perceived efficacy indicate its continued and important role in managing osteoarthritis of the knee. Finally, the past 15 years have seen an explosion in the use of biologics including platelet-rich plasma and pluripotential (often termed stem) cells. The science behind their use and efficacy is evolving and continued study is warranted.

Patient-reported outcomes of meniscal repair and meniscectomy in patients 40 years of age and older show similar good results.

The purpose of this study is to evaluate patient-reported outcome measures (PROMs) in patients aged 40 years and older who underwent meniscal repair or meniscectomy. All patients aged 40 and older who underwent a meniscal repair at a single institution from 2006 to 2017 were included. Meniscal repair cases were matched with a meniscectomy control group in a 1:3 ratio, selected for an equal proportion of concomitant ACL reconstruction in each group. PROMs, collected at a minimum follow-up of 24 months, included International Knee Documentation Committee Subjective Knee Evaluation Form (IKDC), Marx activity scale, and a patient satisfaction scale. The primary outcome was IKDC score, which was compared between groups using a Mann-Whitney U test. Rate of failure, defined as repeat ipsilateral knee surgery or surgeon report of failure, was reported. Thirty-five meniscal repair patients and 131 meniscectomy patients were identified; 28 (80.0%) and 67 (51.1%) completed all PROMs with mean follow-up of 4.9 and 5.2 years, respectively. The mean age was 48.5 ± 7.0 years in the meniscal repair cohort and 52.8 ± 7.1 years in the meniscectomy cohort (p = 0.009). Concomitant ACL reconstruction was present in 46.4% and 49.3% of the meniscal repair and meniscectomy cohorts, respectively (n.s.). The median IKDC score was 78 (IQR 66, 87) in the repair cohort and 77 (IQR 56, 86) in the meniscectomy cohort (n.s.). The median Marx activity scale was 3.5 (IQR 0, 8) in the repair cohort and 3.0 (IQR 0, 9) in the meniscectomy cohort (n.s.). Over 85% of both groups were satisfied or very satisfied with no between-group differences (n.s.). In patients aged 40 years and older, patient-reported outcomes at an average of 5 years postoperatively were satisfactory and similar in patients undergoing meniscal repair and meniscectomy, indicating that age alone should not be a contraindication to meniscal repair.Level of evidence: Level III.

Editorial Commentary: Return to Sport Should Not Be Your Goal Following High Tibial Osteotomy With Concomitant Medial Meniscal Allograft Transplantation.

Meniscal allograft transplantation has been done for 3 decades as a salvage procedure for patients with painful compartments following total or near-total meniscectomy. In malaligned joints, periarticular osteotomies often are performed in conjunction with the transplantation. The goal has been to reduce pain and improve function. Early series showed that retear of transplanted menisci was common. Because many recipients of meniscal transplantations are young, the goal has been to reduce pain and restore function, and high-demand work or sporting activities have been discouraged.

The 2019 Arthroscopy Association of North America Traveling Fellowship-Los Gallos: New Friends on an Old Town Road.

We came in with high expectations, yet the Arthroscopy Association of North America (AANA) Traveling Fellowship far exceeded them. The 4 traveling fellows came from different backgrounds, different parts of North America, and different practice settings, including an independent private practice, a hybrid private-academic practice, the military, and academia. We were lucky to have been ushered along the way by our godfather, the distinguished John Richmond, M.D., Past-President of AANA and Associate Editor Emeritus of Arthroscopy, who was gracious enough to give his time to the expedition. Over the course of the journey, this gang came together quickly and forged relationships that will last a lifetime. We are extremely grateful to AANA for the privilege and will cherish the memories for years to come.

Low dose compared to variable dose Warfarin and to Fondaparinux as prophylaxis for thromboembolism after elective hip or knee replacement surgery; a randomized, prospective study.

BACKGROUND: Deep vein thrombosis (DVT) and pulmonary emboli (PE), known together as venous thromboembolic (VTE) disease remain major complications following elective hip and knee surgery. This study compares three chemoprophylactic regimens for VTE following elective primary unilateral hip or knee replacement, one of which was designed to minimize risk of post-operative bleeding. METHODS: Patients were randomized and stratified for hip vs. knee to receive A: variable dose warfarin (first dose on the night preceding surgery with subsequent target INR 2.0-2.5), B: 2.5 mg fondaparinux daily starting 6-18 h postoperatively, or C: fixed 1.0 mg dose warfarin daily starting 7 days preoperatively. All treatments continued until bilateral leg venous ultrasound day 28 ± 2 or earlier upon a VTE event. The study examined primary endpoints including leg DVT, PE or death due to VTE and secondary endpoints including effects on D-dimer, estimated blood loss (EBL) at surgery and hemorrhagic complications. RESULTS: Three hundred fifty-five patients were randomized. None was lost to follow-up. Taking 1.0 mg warfarin for seven days preoperatively did not prolong the prothrombin time (PT). Two patients in Arm C had asymptomatic distal DVT. One major bleed occurred in Arm B and one in Arm C (ischemic colitis). Elevated d-dimer did not predict delayed VTE for one year. CONCLUSIONS: Fixed low dose warfarin started preoperatively is equivalent to two other standards of care under study (95 % CI: -0.0428, 0.0067 for both) as VTE prophylaxis for the patients having elective major joint replacement surgery. TRIAL REGISTRATION: ClinicalTrials.gov identifier # NCT00767559 FDA IND: 103,716.

Health system adaptations for extreme heat: Protocol for an international scoping review of reviews.

OBJECTIVE: The objective of this study is to map the international evidence for extreme heat related adaptation strategies by health systems, with a particular focus on how heat-vulnerable populations and local situational awareness are considered in these strategies. INTRODUCTION: Since the Paris Climate Accords in 2015, awareness has increased of the health risks posed by extreme heat along with interest in adaptations which aim to reduce heat-health-risks for vulnerable populations. However, the extant literature on these adaptations suggest they are insufficient, and call for research to examine whether, how, and what adaptations for extreme heat are effective as public health interventions. INCLUSION CRITERIA: We will include English-language review articles describing and/or evaluating health system adaptations for extreme heat. Health systems will be defined broadly using the WHO Building Blocks model [1] and adaptations will range from the individual level to institutional, regional and national levels, with particular attention to localisation and the protection of vulnerable individuals. METHODS: A comprehensive literature search of the published literature will be conducted using MEDLINE, Embase, CINAHL, the Cochrane Library and Web of Science. Searches will be limited to reviews published since 2015 in the English language. Results will be exported to EndNote for screening (with a sample checked by two reviewers to ensure consistency). A complementary search for related reports by major international agencies (e.g. WHO; International Association of Emergency Managers), as well as local searches for current guidance and case studies, will be conducted in parallel. Data from included papers will be presented in tables with a narrative commentary.

Exploring community level multi-agency communication and collaboration during the emergency response to the covid-19 pandemic.

Objectives: This study assesses multi-agency communication and collaboration during the community emergency response to the covid-19 pandemic. Study design: Qualitative case-study research. Methods: Semi-structured qualitative interviews were conducted with ten officers from organisations involved in the community response to the pandemic, at strategic or tactical level, within an English local authority (LA) area. Interviews were thematically analysed. Results: Horizontal (local/regional) communication and collaboration between the multi-agencies was found to be effective. Participants felt multi-agency groups had a sense of shared identity, partly from pre-existing relationships and a sense of shared common fate. The unified command model, with incident management co-chaired by the local authority, fire and police was found to support joint working, bolstering response effectiveness. There was frustration with vertical (national) communication and collaboration. Messages to local responders were often delivered via daily Government briefings to the public, meaning local responders had little time to consider and implement appropriate actions. Conclusions: The study provides new and impactful insights into the community response in an English MBC area during the Covid-19 pandemic. However, findings apply to any high-or-low-income country if their emergency planning/response considers community level integration with multiple-agencies to improve the public health emergency response. Set against existing international literature, show good command-and-control structures, including leadership, training and positive local culture were important for successful communication and collaboration between the multi-agencies. This study highlights some beneficial practices which support recovery and preparedness for future emergencies.

Prosocial voice in the hierarchy of healthcare professionals: the role of emotions after harmful patient safety incidents.

PURPOSE: Supporting and nurturing effective communication between healthcare professionals is vital to protect patients from harm. However, not all forms of employee voice are effective. Fear can lead to defensive voice, while the role of other emotions to drive voice behaviour is less well understood. This paper aims to understand what role the broader range of emotions, including compassion and shame, experienced by healthcare professionals following patient safety incidents (PSI) play in the subsequent enactment of prosocial voice, a positive and other-oriented form of communication. DESIGN/METHODOLOGY/APPROACH: This study is based on data from a single English NHS hospital: interviews with healthcare professionals involved in PSIs (N = 40), observations at quality and risk committees and meetings (N = 26 h) and review of investigative documents (N = 33). Three recent PSIs were selected for cross-case analysis based upon organisational theory related to professional hierarchy, employee voice and literature on emotions. FINDINGS: Among three cases, the authors found variance in context, emotional experience and voice behaviour. Where professionals feared blame and repercussion, voice was defensive. Meanwhile where they experienced shame and compassion, prosocial voice was enacted to protect patients. PRACTICAL IMPLICATIONS: Healthcare organisations seeking to foster prosocial voice should: (1) be more considerate of professionals' emotional experiences post-PSI and ensure adequate support for recovery (2) establish norms for professionals to share their struggles with others (3) reward professionals who demonstrate caring behaviour (4) buffer professionals from workplace pressures. ORIGINALITY/VALUE: The authors' study highlights how emotional experiences, such as shame and compassion, can mediate blame and defensiveness and lead to the enactment of prosocial voice in the professional hierarchy.

Subjective Outcomes After Allograft Reconstruction and Nonoperative Treatment of Anterior Cruciate Ligament Ruptures Are Similar in Patients Aged 40 Years and Older: A 2:1 Propensity Score-Matched Analysis.

Purpose: To compare subjective outcomes and rates of subsequent operations for patients aged 40 years and older with anterior cruciate ligament (ACL) ruptures who elected nonoperative management or allograft ACL reconstruction (ACLR). Methods: This was a retrospective study comparing 2-year minimum results of nonoperative treatment and primary allograft ACLR among patients aged 40 years and older presenting to a single institution between the years 2005 and 2016. Patients who elected nonoperative management were 2:1 propensity score (PS)-matched to patients who elected ACLR based on age, sex, body mass index, sports-related mechanism of injury, Outerbridge grade III or IV chondral lesions, and medial or lateral meniscus tears. Univariate analysis was performed to compare subjective outcome measures of International Knee Documentation Committee and Marx activity level scores, subsequent operations, and satisfaction rates. Results: After 2:1 PS matching, 40 ACLR and 20 nonoperative patients with mean ages of 52.2 years and 54.5 years, respectively, were included with a mean follow-up of 5.7 years (SD 2.1 years, range 2.3-10.6 years). There were no significant differences between the groups in any of the matching variables. There were no significant differences in International Knee Documentation Committee scores (81.9 ± 14.1, CI 77.4-86.5 vs 84.3 ± 12.8, CI 78.3-90.3, P = .53), Marx activity level scores (5.8 ± 4.8, CI 4.2-7.3 vs 5.7 ± 5.1, CI 3.3-8.1, P = .96), or satisfaction rates (100% vs 90%, P = .11) between the ACLR and nonoperative groups. Four (10%) patients who underwent ACLR sustained a graft treated with revision ACLR. 7 (17.5%) ACLR and 0 nonoperative patients subsequently received further ipsilateral knee surgeries (P = .08), including 2 total knee arthroplasties. Conclusions: In this PS-matched analysis of patients aged 40 years and older with ACL ruptures, patients who elected nonoperative management had similar subjective outcomes compared with those who elected allograft ACLR. Patients who elected allograft ACLR did not have fewer subsequent operations than those who elected nonoperative treatment. Level of Evidence: Level III, retrospective cohort study.

High Levels of Satisfaction and Adequate Patient-Reported Outcomes After Operative Reconstruction of Multiligament Knee Injury With Allograft Among Patients Aged 40 Years and Older.

Purpose: To describe injury characteristics and patient-reported outcomes (PROs) among patients aged 40 years and older who underwent allograft reconstruction for multiligament knee injury (MLKI). Methods: Records of patients aged 40 years and older who underwent allograft multiligament knee reconstruction at a single institution between 2007 and 2017 with a minimum of 2 years of follow-up were retrospectively reviewed. Demographic information, concomitant injuries, patient satisfaction, and PROs including International Knee Documentation Committee and Marx activity scores were obtained. Results: Twelve patients were included with a minimum follow-up time of 2.3 years (mean, 6.1; range, 2.3-10.1 years) and a mean age at surgery of 49.8 years. Seven patients were male, and the most common mechanism of injury was sport-related. The most frequently reconstructed MLKIs were anterior cruciate ligament and medial collateral ligament (4), anterior cruciate ligament and posterolateral corner (2), and posterior cruciate ligament and posterolateral corner (2). The majority of patients reported satisfaction with their treatment (11). Median International Knee Documentation Committee and Marx scores were 73 (interquartile range, 45.5-88.0) and 3 (interquartile range 0-5), respectively. Conclusions: Patients aged 40 years and older can expect a high level of satisfaction and adequate PROs at 2-years follow-up after operative reconstruction for a MLKI with allograft. This demonstrates that allograft reconstruction for a MLKI in older patients may have clinical utility. Level of Evidence: IV, therapeutic case series.

Synovial inflammation in patients undergoing arthroscopic meniscectomy: molecular characterization and relationship to symptoms.

OBJECTIVE: Traumatic and degenerative meniscal tears have different anatomic features and different proposed etiologies, yet both are associated with the development or progression of osteoarthritis (OA). In established OA, synovitis is associated with pain and progression, but a relationship between synovitis and symptoms in isolated meniscal disease has not been reported. Accordingly, we sought to characterize synovial pathology in patients with traumatic meniscal injuries and determine the relationships between inflammation, meniscal and cartilage pathology, and symptoms. METHODS: Thirty-three patients without evidence of OA who were undergoing arthroscopic meniscectomy for meniscal injuries were recruited. Pain and function were assessed preoperatively; meniscal and cartilage abnormalities were documented at the time of surgery. Inflammation in synovial biopsy specimens was scored, and associations between inflammation and clinical outcomes were determined. Microarray analysis of synovial tissue was performed, and gene expression patterns in patients with and those without inflammation were compared. RESULTS: Synovial inflammation was present in 43% of the patients and was associated with worse preoperative pain and function scores, independent of age, sex, or cartilage pathology. Microarray analysis and real-time polymerase chain reaction revealed a chemokine signature in synovial biopsy specimens with increased inflammation scores. CONCLUSION: Our findings indicate that in patients with traumatic meniscal injury undergoing arthroscopic meniscectomy without radiographic evidence of OA, synovial inflammation occurs frequently and is associated with increased pain and dysfunction. Synovia with increased inflammation scores exhibit a unique chemokine signature. Chemokines may contribute to the development of synovial inflammation in patients with meniscal pathology; they also represent potential therapeutic targets for reducing inflammatory symptoms.

Canadian health emergency management professionals' perspectives on the prevalence and effectiveness of disaster preparedness activities in response to COVID-19.

Emergency management (EM) professionals play an integral role in preparing healthcare organizations for disasters but evidence of their pervasiveness in Canadian healthcare is limited. Through an exploratory Canada-wide survey of EM in healthcare organizations, we aim to develop understanding of the prevalence and effectiveness of the disaster preparedness activities enacted in preparation for COVID-19. The online survey generated 161 responses; 150 (93%) had EM responsibility. EM reported that reviewing infectious disease (pandemic) plans and protocols was the most widespread activity (82%), while simulation-based exercises was the least (26%). Organizational incident management response to COVID-19 was led by a sole 'incident commander' 61% of the time, while 39% of 'incident commands' were led by multiple individuals. Of all those assigned to lead IM, only 68% received training in that role. Overall, the prevalence of disaster preparedness activities in healthcare organizations was positively associated with leaders who received training in incident response and having a dedicated EM resource. Meanwhile, the overall effectiveness of activities was positively correlated with having a sole 'incident commander' and was found to improve as the overall prevalence of activities rose. The study provides strong evidence for regional, organizational, and EM resource variation in the delivery of disaster preparedness activities and training for leaders in Canadian healthcare. Hence, we recommend the creation of a national health emergency preparedness system which includes legislated standards and a national training centre to ensure Canadian healthcare is bolstered against future disasters including pandemics.

Surgery for osteoarthritis of the knee.

The role of surgical treatment in osteoarthritis of the knee continues to evolve. The indications for arthroscopy have narrowed. Orthopedic surgeons continue to explore options less invasive than total knee replacement for isolated unicompartmental arthritis of the knee joint. In addition to arthroscopy, this article discusses the merits and drawbacks of and indications for osteotomy, interpositional arthroscopy, patellofemoral replacements, and emerging technologies for total knee replacements.

Treatment of osteoarthritis of the knee (nonarthroplasty).

The clinical practice guideline was explicitly developed to include only treatments less invasive than knee replacement (ie, arthroplasty). Patients with symptomatic osteoarthritis of the knee are to be encouraged to participate in self-management educational programs and to engage in self-care, as well as to lose weight and engage in exercise and quadriceps strengthening. The guideline recommends taping for short-term relief of pain as well as analgesics and intra-articular corticosteroids, but not glucosamine and/or chondroitin. Patients need not undergo needle lavage or arthroscopy with débridement or lavage. Patients may consider partial meniscectomy or loose body removal or realignment osteotomy, as conditions warrant. Use of a free-floating interpositional device should not be considered for symptomatic unicompartmental osteoarthritis of the knee. Lateral heel wedges should not be prescribed for patients with symptomatic medial compartmental osteoarthritis of the knee. The work group was unable either to recommend or not recommend the use of braces with either valgus- or varus-directing forces for patients with medial unicompartmental osteoarthritis; the use of acupuncture or of hyaluronic acid; or osteotomy of the tibial tubercle for isolated symptomatic patellofemoral osteoarthritis.

Poor outcomes after SLAP repair: descriptive analysis and prognosis.

PURPOSE: In the first part of this study, we analyzed a subset of patients to determine what factors may have been present in those with poor outcomes after SLAP repair. In part 2, we evaluated clinical outcomes of these patients after further treatment. METHODS: We completed a retrospective medical record review of consecutive patients presenting between 2000 and 2007 with pain, stiffness, and/or mechanical symptoms after a SLAP repair. To evaluate for similarities among this cohort, data collection included demographics, age at initial SLAP repair, history of trauma, medical history, nonoperative and operative treatments, and physical examination. Outcome measures included patient satisfaction and the Simple Shoulder Test questionnaire. Subsequent treatment was then reviewed, investigating whether patients received physical therapy, cortisone injection, and/or revision surgery in an attempt to improve satisfaction. Outcome measures again included patient satisfaction and the Simple Shoulder Test questionnaire. RESULTS: We found 40 shoulders in 39 patients who met inclusion criteria. The mean age at the time of initial SLAP repair was 43 years. Of the patients, 30 (75%) presented with pain and decreased range of motion, 9 (22.5%) presented with pain but full range of motion, and 1 (2.5%) presented with pain and mechanical symptoms but full range of motion. The mean Simple Shoulder Test score upon presentation after SLAP repair was 3.04 out of 12 (SD, 2.18; range, 0 to 7). We included 34 shoulders in the analysis of treatment outcome. Of these, 29% (10 of 34) were satisfied after conservative treatment, 62% (13 of 21) were satisfied after revision surgery, and 68% (23 of 34) were satisfied overall after either type of further treatment. The mean Simple Shoulder Test score after further treatment was 8.73 out of 12 (SD, 3.45; range, 0 to 12). CONCLUSIONS: In this study 71% of patients (mean patient age, 43 years) with a poor outcome after SLAP repair were dissatisfied with conservative treatment. Therefore, once a patient has a poor outcome after SLAP repair, there is a high chance of conservative treatment failing. Although patients have better outcomes with operative intervention, 32% will continue to have a suboptimal result. LEVEL OF EVIDENCE: Level IV, therapeutic case series.