Comparable Clinical and Functional Outcomes Between Osteochondral Allograft Transplantation and Autologous Chondrocyte Implantation for Articular Cartilage Lesions in the Patellofemoral Joint at a Mean Follow-up of 5 Years.

PURPOSE: To assess clinical outcomes and return to sport (RTS) rates among patients that undergo osteochondral allograft (OCA) transplantation and autologous chondrocyte implantation (ACI) or matrix-induced autologous chondrocyte implantation (MACI), for patellofemoral articular cartilage defects. METHODS: A retrospective review of patients who underwent an OCA or ACI/MACI from 2010-2020 was conducted. Patient-reported outcomes (PROs) collected included: Visual Analog Scale for pain/satisfaction, Knee Injury and Osteoarthritis Outcome Score (KOOS), and RTS. The percentage of patients that met the Patient Acceptable Symptom State (PASS) for KOOS was recorded. Logistic regression was used to identify predictors of worse outcomes. RESULTS: A total of 95 patients were included (78% follow-up) with ACI or MACI performed in 55 cases (57.9%) and OCA in 40 (42.1%). A tibial tubercle osteotomy was the most common concomitant procedure for OCA (66%) and ACI/MACI (98%). Overall, KOOS pain was significantly poorer in OCA than ACI/MACI (74.7, 95% CI [68.1, 81.1] vs 83.6, 95% CI [81.3, 88.4], p= 0.012), while the remaining KOOS subscores were non-significantly different (all p>0.05). Overall, RTS rate was 54%, with no significant difference in return between OCA or ACI/MACI (52% vs 58%, p= 0.738). There were 26 (27%) reoperations and 5 (5%) graft failures in the entire group. Increasing age was associated with lower satisfaction in OCA and poorer outcomes in ACI/MACI, while larger lesion area was associated with lower satisfaction and poorer outcomes in ACI/MACI. CONCLUSION: Clinical and functional outcomes were similar in patients that underwent OCA or ACI/MACI for patellofemoral articular cartilage defects at a mean follow-up of 5 years. Patients who received OCA had a higher proportion of degenerative cartilage lesions and, among those with trochlear lesions, reported higher pain at final follow-up than their ACI/MACI counterparts. Overall, increasing age and a larger lesion size were associated with worse patient-reported outcomes.

Patients who undergo tibial tubercle anteromedialization with medial patellofemoral ligament reconstruction demonstrate similar rates of return to sport compared to isolated MPFL reconstruction.

PURPOSE: To investigate the rate of return to sports and sport psychological readiness between patients who underwent isolated MPFLR (iMPFLR) compared to a matched cohort of patients who underwent MPFLR with anteromedializing tibial tubercle osteotomy (MPFLR/TTO). METHODS: Patients who underwent primary MPFLR with or without TTO for recurrent patellar instability were retrospectively reviewed from 2012 to 2020 at a single institution. Preinjury sport and work information, Kujala, Tegner, Visual Analogue Score for pain, satisfaction and MPFL-Return to Sport after Injury (MPFL-RSI) score were collected. Two readers independently measured the tibial tuberosity-trochlear groove distance, Caton-Deschamps index and Dejour classification for trochlear dysplasia. Patients in iMPFLR and MPFLR/TTO groups were matched 1:1 on age, sex, body mass index and follow-up length. Multivariate regression analysis was performed to determine whether the MPFL-RSI was associated with a return to sport. RESULTS: This study included 74 patients at mean follow-up of 52.5 months (range: 24-117). These groups returned to sport at similar rates (iMPFLR: 67.6%, MPFLR/TTO: 73.0%, not significant [ns]), though iMPFLR patients returned more quickly (8.4 vs. 12.8 months, p = 0.019). Rates of return to preinjury sport level were also similar (45.9% vs. 40.5%, ns). Patients with Dejour B/C took more time to return to sport compared to patients with mild/no trochlear pathology (13.8 vs. 7.9 months, p = 0.003). Increasing MPFL-RSI score was significantly predictive of the overall return to sport (odds ratio [OR]: 1.08, 95% confidence interval [CI] [1.03, 1.13], p < 0.001) and return to preinjury level (OR: 1.07, 95% CI [1.04, 1.13], p < 0.001). Most patients in iMPFLR and MPFLR/TTO groups resumed work (95.7% vs. 88.5%, ns), though iMPFLR patients who returned to preinjury work levels did so more quickly (1.7 vs. 4.6 months, p = 0.005). CONCLUSION: Patients who underwent MPFLR with anteromedializing TTO demonstrated similar rates of return to sport and psychological readiness compared to an isolated MPFLR matched comparison group, though iMPFLRs returned more quickly. Patients with more severe trochlear pathology required more time to return to sports. LEVEL OF EVIDENCE: Level III.

Mortality and Complications Following Early Conversion Arthroplasty for Failed Hip Fracture Surgery.

BACKGROUND: Hip fracture in older patients leads to high morbidity and mortality. Patients who are treated surgically but fail acutely face a more complex operation with conversion total hip arthroplasty (THA). This study investigated mortalities and complications in patients who experienced failure within one year following hip fracture surgery requiring conversion THA. METHODS: Patients aged 60 years or more undergoing conversion THA within one year following intertrochanteric or femoral neck fracture were identified and propensity-matched to patients sustaining hip fractures treated surgically but not requiring conversion within the first year. Patients who had two-year follow-up (91 conversions; 247 comparisons) were analyzed for 6-month, 12-month, and 24-month mortalities, 90-day readmissions, surgical complications, and medical complications. RESULTS: Nonunion and screw cutout were the most common indications for conversion THA. Mortalities were similar between groups at 6 months (7.7% conversion versus 6.1% nonconversion, P = .774), 12 months (11% conversion versus 12% nonconversion, P = .999), and 24 months (14% conversion versus 22% nonconversion, P = .163). Survivorships were similar between groups for the entire cohort and by fracture type. Conversion THA had a higher rate of 90-day readmissions (14% versus 3.2%, P = .001), and medical complications (17% versus 6.1%, P = .006). Inpatient and 90-day orthopaedic complications were similar. CONCLUSION: Conversion THA for failed hip fracture surgery had comparable mortality rates to hip fracture surgery, with higher rates of perioperative medical complications and readmissions. Conversion THA following hip fracture represents a potential "second hit" that both surgeons and patients should be aware of with initial decision-making.

Trends in Irish hip fracture surgery over a 7-year period and international registry comparison.

BACKGROUND: Hip fractures are a significant cause of morbidity and mortality in elderly patients. Timely surgical fixation and early mobilisation are the cornerstone to successful outcomes. The Irish Hip Fracture Database (IHFD) was established in 2012 and publishes annual reports on hip fracture care. This paper describes the trends in surgical fixation in Ireland during a 7-year period (2013-2019), assesses for compliance with guidelines and compares the most recent published reports from ten international hip fracture registries. METHODS: All published IHFD reports were systematically reviewed and tabulated. Data corresponding to demographics, fracture type, surgical fixation and post-operative management was plotted and analysed. Ten international hip fracture registries were identified and reviewed. Data was extracted corresponding to the IHFD dataset. RESULTS: A total of 21,684 hip fractures were recorded during this period. The majority of patients were female (70.16%), >80 years old (58.26%), admitted from their own home (82.13%) and ASA grade 3 (53%). The majority of undisplaced and displaced intracapsular fractures were treated with hemiarthroplasty, 62% and 88% respectively. There has been a decline in the use of dynamic hip screw (DHS) for intertrochanteric fractures with intramedullary nails being favoured. CONCLUSION: Despite greater awareness of hip fracture care through the IHFD and the introduction of Best Practice Tariffs (BPT), further improvements are needed. Ireland compares well to international standards but has low rates of compliance to NICE guidelines for surgical fixation.

The majority of athletes fail to return to play following anterior cruciate ligament reconstruction due to reasons other than the operated knee.

PURPOSE: The purpose of this study is to evaluate the reasons why athletes do not return to play (RTP) following anterior cruciate ligament (ACL) reconstruction from a large single-centre database. METHODS: The institutional ACL registry was screened for patients that had undergone a primary ACLR and had RTP status reported at 24-month follow-up. The reasons that patients were unable to RTP at 24 months were evaluated. The ACL-Return to Sport Index (ACL-RSI) was evaluated at baseline and 24-month follow-up to evaluate psychological ability to RTP. RESULTS: At 2 years, 1140 patients returned to play, and 222 had not returned to play. The most common reasons athletes were unable to return was fear of reinjury (27.5%), lack of confidence in performance on return (19.4%) and external life factors (16.6%), i.e. work commitments and family reasons. Other reasons for athletes not returning to play were residual knee pain (10%) and subsequent injury (5%). The ACL-RSI score was significantly lower at diagnosis (40.3 vs. 49.3; p = 0.003) and 2 years (41.8 vs. 78.7; p < 0.0001) in athletes who did not return to play vs. those that did RTP. CONCLUSION: The majority of patients that report they have not returned to play do so due to external life and psychological factors associated with their injury, including fear of reinjury and lack of confidence in performance. A small minority of patients were unable to return due to residual knee symptoms or reinjury. Pre-operative psychological assessment and intervention may identify those less likely to RTP and provide an opportunity for targeted interventions to further improve RTP outcomes. LEVEL OF EVIDENCE: III.

Comfort Level and Barriers to the Appropriate Use of Clozapine: a Preliminary Survey of US Psychiatric Residents.

OBJECTIVE: Clozapine is the gold standard treatment for treatment-resistant schizophrenia. Prior surveys of mental health providers have identified multiple causes for underutilization of clozapine; however, no previous survey has been conducted to assess US psychiatry residents' level of comfort in prescribing clozapine. METHODS: A survey was sent via email to program directors of Accreditation Council for Graduate Medical Education-affiliated psychiatry residency programs requesting the survey to be distributed to current residents. The survey included questions regarding demographics, clozapine-prescribing practices, comfort levels with prescription, and perceived barriers to prescription. RESULTS: A total of 164 psychiatric residents completed the survey, 37% PGY-1 and 2 residents and 63% PGY-3 or higher. One-third of the respondents had a clozapine clinic in their program. Only 18% of the residents felt "very" comfortable in initiating clozapine and 41% felt "somewhat" comfortable. Two main reasons for not starting clozapine were (1) side effect profile (41%) and (2) limited experience and inadequate training in clozapine use (38%). More than 4/5ths of the residents (83%) responded that they would feel more comfortable in prescribing clozapine if they were trained in a clozapine clinic. Major limitation of this study has been the small sample size, lack of representativeness, and generalization. CONCLUSIONS: Forty-one percent of the respondents did not feel comfortable with clozapine prescription. Major concerns cited included the side effect profile as well as lack of experience and training. The majority of the respondents felt that they would be more comfortable prescribing clozapine if they had the opportunity to train in a clozapine clinic.

Second-site prosthetic joint infection in patients with multiple prosthetic joints.

INTRODUCTION: Prosthetic joint infections (PJIs) are among the most serious complications in arthroplasty. A second-site PJI in patients with multiple prosthetic joints increases morbidity, with many requiring further revision procedures. We aimed to establish why some patients with multiple joints develop second-site infections. METHODS: Our institution's arthroplasty database was reviewed from 2004 to 2017. All PJIs were identified, and all patients with more than one prosthetic joint in situ were included. We recorded risk factors, causative organisms, number of procedures and length of stay. RESULTS: Forty-four patients meeting the criteria were identified. Four patients (9.1%) developed second-site infection. Eight patients (18.2%) developed re-infection of the primary PJI. Positive MRSA carrier status and PJI of a total knee replacement were associated with an increased risk of a second episode of infection. Patients who developed further infection had more frequent admission and longer lengths of stay than isolated PJIs. DISCUSSION: Higher morbidity and use of hospital resources are associated with this cohort of patients. PJIs in total knee replacements and positive MRSA status are associated with higher rates of second infection. Identifying this vulnerable cohort of patients at an early stage is critical to ensure measures are taken to reduce the risks of further infection.

Changes in health in England, with analysis by English regions and areas of deprivation, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013.

BACKGROUND: In the Global Burden of Disease Study 2013 (GBD 2013), knowledge about health and its determinants has been integrated into a comparable framework to inform health policy. Outputs of this analysis are relevant to current policy questions in England and elsewhere, particularly on health inequalities. We use GBD 2013 data on mortality and causes of death, and disease and injury incidence and prevalence to analyse the burden of disease and injury in England as a whole, in English regions, and within each English region by deprivation quintile. We also assess disease and injury burden in England attributable to potentially preventable risk factors. England and the English regions are compared with the remaining constituent countries of the UK and with comparable countries in the European Union (EU) and beyond. METHODS: We extracted data from the GBD 2013 to compare mortality, causes of death, years of life lost (YLLs), years lived with a disability (YLDs), and disability-adjusted life-years (DALYs) in England, the UK, and 18 other countries (the first 15 EU members [apart from the UK] and Australia, Canada, Norway, and the USA [EU15+]). We extended elements of the analysis to English regions, and subregional areas defined by deprivation quintile (deprivation areas). We used data split by the nine English regions (corresponding to the European boundaries of the Nomenclature for Territorial Statistics level 1 [NUTS 1] regions), and by quintile groups within each English region according to deprivation, thereby making 45 regional deprivation areas. Deprivation quintiles were defined by area of residence ranked at national level by Index of Multiple Deprivation score, 2010. Burden due to various risk factors is described for England using new GBD methodology to estimate independent and overlapping attributable risk for five tiers of behavioural, metabolic, and environmental risk factors. We present results for 306 causes and 2337 sequelae, and 79 risks or risk clusters. FINDINGS: Between 1990 and 2013, life expectancy from birth in England increased by 5·4 years (95% uncertainty interval 5·0-5·8) from 75·9 years (75·9-76·0) to 81·3 years (80·9-81·7); gains were greater for men than for women. Rates of age-standardised YLLs reduced by 41·1% (38·3-43·6), whereas DALYs were reduced by 23·8% (20·9-27·1), and YLDs by 1·4% (0·1-2·8). For these measures, England ranked better than the UK and the EU15+ means. Between 1990 and 2013, the range in life expectancy among 45 regional deprivation areas remained 8·2 years for men and decreased from 7·2 years in 1990 to 6·9 years in 2013 for women. In 2013, the leading cause of YLLs was ischaemic heart disease, and the leading cause of DALYs was low back and neck pain. Known risk factors accounted for 39·6% (37·7-41·7) of DALYs; leading behavioural risk factors were suboptimal diet (10·8% [9·1-12·7]) and tobacco (10·7% [9·4-12·0]). INTERPRETATION: Health in England is improving although substantial opportunities exist for further reductions in the burden of preventable disease. The gap in mortality rates between men and women has reduced, but marked health inequalities between the least deprived and most deprived areas remain. Declines in mortality have not been matched by similar declines in morbidity, resulting in people living longer with diseases. Health policies must therefore address the causes of ill health as well as those of premature mortality. Systematic action locally and nationally is needed to reduce risk exposures, support healthy behaviours, alleviate the severity of chronic disabling disorders, and mitigate the effects of socioeconomic deprivation. FUNDING: Bill & Melinda Gates Foundation and Public Health England.

Enhancing the ecological validity of tests of lateralization and hemispheric interaction: Evidence from fixated displays of letters or symbols of varying complexity.

Two experiments expand upon behavioural evidence of interactions among lateralization, hemispheric interaction, and task complexity with findings from an ecologically valid procedure. Target displays of letters or symbols were presented at fixation in go/no-go matching tasks of physical or categorical identity. Simultaneously with the target, a distractor appeared in the left visual field or right visual field to weight processing of the target to the hemisphere ipsilateral to the distractor, or the distractor did not appear at all. Comparison of the respective distractor-present trials with distractor-absent trials measures the relative costs or benefits of hemispheric interaction. Both experiments found that 3-item displays were processed faster and more accurately than displays of 5 items, suggesting they are relatively simple. Accuracy to the simple tasks showed left-hemisphere lateralization in the lexical task, right-hemisphere lateralization in the spatial task, a cost of hemispheric interaction compared to the advantaged hemisphere, and a benefit of hemispheric interaction compared to the less-advantaged hemisphere, suggesting that the contributions of the less-advantaged hemisphere interfere with processing, and that the advantaged hemisphere controls the lion's share. In contrast, 5-item displays for physical match in both experiments showed a significant benefit to accuracy of hemispheric interaction compared to the left hemisphere, an insignificant benefit compared to the right hemisphere, no lateralization, no cost of hemispheric interaction, and a consequence to performance that was more costly to the hemisphere that had been advantaged in simple tasks, suggesting that the advantaged hemisphere relinquishes control as tasks become more complex and complementary processing results from both increased collaboration and decreased lateralization between the hemispheres. The findings expand upon behavioural evidence, converge with imaging evidence, and suggest future directions for brain mapping.

Health services should collect feedback from inpatients at the point of service: opinions from patients and staff in acute and subacute facilities.

OBJECTIVE: Point of service feedback (POSF) enables patients to give health services feedback about their experiences during or immediately after care. Despite the increasing use of POSF, little is known regarding patients' and staffs' opinions of this practice and whether they consider it acceptable or useful. The study aimed to determine patient and staff opinions regarding POSF. DESIGN: A cross-sectional survey. SETTING: Acute and subacute healthcare facilities. PARTICIPANTS: Two hundred and forty-seven patients and 221 staff. RESULTS: Participants indicated that patients should be invited to evaluate health services when they are in hospital or subacute care and improving services was the most important reason for doing so. Staff indicated that: collecting patients' feedback during their stay was an important part of providing care and not an interruption to it (n = 187 of 221, 85%); collecting patients' feedback was best done with a variety of methods; talking directly with patients during their stay was the preferred option (n = 161 of 219, 74%). More patients preferred to: give feedback during their stay (51%) than after discharge from care (15%); give feedback by talking with someone (45%) than completing a questionnaire (31%). Some patients (14%) were concerned about reprisals from staff if they gave negative feedback. CONCLUSIONS: POSF can be acceptable and useful for evaluating health services and should be incorporated into a person-centred approach that allows patients to choose from a variety of feedback options both during and after their stay. To be most useful, feedback should be incorporated into a quality improvement system.

Discharge communication from inpatient care: an audit of written medical discharge summary procedure against the new National Health Service Standard for clinical handover.

OBJECTIVE: To audit written medical discharge summary procedure and practice against Standard Six (clinical handover) of the Australian National Safety and Quality Health Service Standards at a major regional Victorian health service. METHODS: Department heads were invited to complete a questionnaire about departmental discharge summary practices. RESULTS: Twenty-seven (82%) department heads completed the questionnaire. Seven (26%) departments had a documented discharge summary procedure. Fourteen (52%) departments monitored discharge summary completion and 13 (48%) departments monitored the timeliness of completion. Seven (26%) departments informed the patient of the content of the discharge summary and six (22%) departments provided the patient with a copy. Seven (26%) departments provided training for staff members on how to complete discharge summaries. Completing discharge summaries was usually delegated to the medical intern. CONCLUSIONS: The introduction of the National Service Standards prompted an organisation-wide audit of discharge summary practices against the external criterion. There was substantial variation in the organisation's practices. The Standards and the current audit results highlight an opportunity for the organisation to enhance and standardise discharge summary practices and improve communication with general practice.

Anterior Cruciate Ligament Allograft Reconstruction Augmented With a Reinforced, Bioinductive Collagen Scaffold in the Setting of Multiligamentous Knee Injury.

The gold standard for surgical treatment of anterior cruciate ligament (ACL) injuries is reconstruction. There are a variety of graft options, from autograft to allograft, using bone-patellar tendon-bone (BTB), hamstrings, quadriceps, or Achilles, and, in the case of a multiligamentous knee injury (MLKI), allograft may be preferred to decrease operative time and graft harvest morbidity. The BioBrace (ConMed, New Haven, CT) is a bioinductive collagen scaffold designed to provide an environment for soft tissue remodeling with time zero biomechanical support and can be used to augment graft reconstructions in the case of concerns for allograft strength, healing, or width. The purpose of this Technical Note is to describe the technique for performing an ACL reconstruction with BioBrace-augmented allograft in the setting of a MLKI, with special consideration for 2 methods of graft preparation (BTB and soft tissue).

Clinical and Functional Outcomes of Documented Knee Dislocation Versus Multiligamentous Knee Injury: A Comparison of KD3 Injuries at Mean 6.5 Years Follow-up.

BACKGROUND: Previous research has found that the incidence of neurovascular injury is greatest among multiligamentous knee injuries (MLKIs) with documented knee dislocation (KD). However, it is unknown whether there is a comparative difference in functional recovery based on evidence of a true dislocation. PURPOSE: To determine whether the knee dislocation-3 (KD3) injury pattern of MLKI with documented tibiofemoral dislocation represents a more severe injury than KD3 MLKI without documented dislocation, as manifested by poorer clinical outcomes at long-term follow-up. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A multicenter retrospective cohort study was performed of patients who underwent surgical treatment for KD3 MLKI between May 2012 and February 2021. Outcomes were assessed using the International Knee Documentation Committee (IKDC) score, Lysholm score, Tegner activity scale, and visual analog scale (VAS) for pain. Documented dislocation was defined as a radiographically confirmed tibiofemoral disarticulation, the equivalent radiology report from outside transfer, or emergency department documentation of a knee reduction maneuver. Subgroup analysis was performed comparing lateral (KD3-L) versus medial (KD3-M) injuries. Multivariable linear regression was conducted to determine whether documented dislocation was predictive of outcomes. RESULTS: A total of 42 patients (25 male, 17 female) were assessed at a mean 6.5-year follow-up (range, 2.1-10.7 years). Twenty patients (47.6%) were found to have a documented KD; they reported significantly lower IKDC (49.9 vs 63.0; P = .043), Lysholm (59.8 vs 74.5; P = .023), and Tegner activity level (2.9 vs 4.7; P = .027) scores than the patients without documented dislocation. VAS pain was not significantly different between groups (36.4 vs 33.5; P = .269). The incidence of neurovascular injury was greater among those with documented dislocation (45.0% vs 13.6%; P = .040). Subgroup analysis found that patients with KD3-L injuries experienced a greater deficit in Tegner activity level than patients with KD3-M injuries (Δ: -3.4 vs -1.2; P = .006) and had an increased incidence of neurovascular injury (41.7% vs 11.1%; P = .042). Documented dislocation status was predictive of poorer IKDC (ß = -2.15; P = .038) and Lysholm (ß = -2.85; P = .007) scores. CONCLUSION: Patients undergoing surgical management of KD3 injuries with true, documented KD had significantly worse clinical and functional outcomes than those with nondislocated joints at a mean 6.5-year follow-up. The current MLKI classification based solely on ligament involvement may be obscuring outcome research by not accounting for true dislocation.

Patient-reported outcomes and return to pre-injury activities after surgical treatment of multi-ligamentous knee injuries in patients over 40-years-old: Average 5-years follow-up.

BACKGROUND: Multi-ligamentous knee injuries (MLKI) are potentially devastating injuries, though existing prognostic research among older patients who sustain MLKI is limited. The purpose was to investigate clinical outcomes and rates of return to pre-injury activities following surgical treatment of MLKI in patients at least 40 years old. METHODS: This study was a multi-center retrospective case series of patients who underwent surgical treatment for MLKI from 2013-2020 and were ≥ 40 years old at time of injury. Outcomes were assessed via e-mail and telephone using the International Knee Documentation Committee (IKDC) score, Lysholm score, Tegner activity scale, a satisfaction rating, and return to pre-injury sport and work surveys. Stepwise linear regression was used to assess the impact of preoperative characteristics on IKDC and Lysholm scores. RESULTS: Of 45 patients eligible for inclusion, 33 patients (mean age: 48.6 years [range: 40-72]) were assessed at a mean follow-up of 59.1 months (range 24-133). The cohort reported a mean IKDC of 63.4 ± 23.5, Lysholm of 72.6 ± 23.6, and Tegner of 3.8 ± 2.0. There was a 41.2% rate of return to sports, and 82.1% returned to work. Documented knee dislocation was predictive of poorer IKDC (ß:-20.05, p = 0.025) and Lysholm (ß:-19.99, p = 0.030). Patients aged > 50 were more satisfied compared to those 40-50 years old (96.2 ± 4.9 vs 75.6 ± 23.3, p = 0.012). CONCLUSIONS: Patients who sustained MLKI aged at least 40 at injury demonstrated fair clinical outcomes at a mean 5-year follow-up. Older patients who sustained MLKI reported a relatively high rate of return to work but were less likely to return to sports. LEVEL OF EVIDENCE: IV, Case series.

Risk factors for recurrent Mycobacterium ulcerans disease after exclusive surgical treatment in an Australian cohort.

OBJECTIVE: To describe risk factors for recurrence after exclusive surgical treatment of Mycobacterium ulcerans infection. DESIGN, SETTING AND PARTICIPANTS: Prospective observational cohort study of all M. ulcerans cases managed with surgery alone at Barwon Health, a tertiary referral hospital, from 1 January 1998 to 31 December 2011. A random-effects Poisson regression model was used to assess rates and associations of treatment failure. MAIN OUTCOME MEASURES: Rates of treatment failure and rate ratios (RRs) for factors associated with treatment failure. RESULTS: Of 192 patients with M. ulcerans infection, 50 (26%) had exclusive surgical treatment. Median age was 65.0 2013s (interquartile range [IQR], 45.5-77.7 2013s), and median duration of symptoms was 46 days (IQR, 26-90 days). There were 20 recurrences in 16 patients. For first lesions, the recurrence incidence rate was 41.8 (95% CI, 25.6-68.2) per 100 person-2013s, and median time to recurrence was 50 days (IQR, 30-171 days). Recurrence occurred ≤ 3 cm from the original lesion in 13 cases, and > 3 cm in nine. On univariable analysis, age ≥ 60 2013s (RR 13.84; 95% CI, 2.21-86.68; P < 0.01), distal lesions (RR, 20.43; 95% CI, 1.97-212.22; P < 0.01), positive histological margins (RR, 21.02; 95% CI, 5.51-80.26; P < 0.001), immunosuppression (RR, 17.97; 95% CI, 4.17-77.47; P < 0.01) and duration of symptoms > 75 days (RR, 10.13; 95% CI, 1.76-58.23; P = 0.02) were associated with treatment failure. On multivariable analysis, positive margins (RR, 7.72; 95% CI, 2.71-22.01; P < 0.001) and immunosuppression (RR, 6.45; 95% CI, 2.42-17.20; P = 0.01) remained associated with treatment failure. CONCLUSIONS: Recurrence rates after exclusive surgical treatment of M. ulcerans disease in an Australian cohort are high, with increased rates associated with immunosuppression or positive histological margins.

Hemispheric interaction, task complexity, and emotional valence: evidence from naturalistic images.

Two experiments extend the ecological validity of tests of hemispheric interaction in three novel ways. First, we present a broad class of naturalistic stimuli that have not yet been used in tests of hemispheric interaction. Second, we test whether probable differences in complexity within the class of stimuli are supported by outcomes from measures of hemispheric interaction. Third, we use a procedure that presents target stimuli at fixation rather than at a lateralized location in order to more closely approximate normal viewing behavior. Images of positive or negative valence were presented with a lateralized distractor or no distractor at all. Response time and accuracy to determine whether an image was pleasant or unpleasant was measured. Results found that positive images were more quickly and accurately processed by the left hemisphere alone, while negative images were more quickly processed when the hemispheres interacted, and were more accurately processed when the hemispheres interacted than the left hemisphere alone. The findings support the idea that hemispheric interaction costs the performance of a simple task and benefits the performance of a complex task, and that the respective cost or gain is mediated by the pattern of laterality for emotional processing.

Return to Sport After Hip and Knee Arthroplasty: Counseling the Patient on Resuming an Active Lifestyle.

PURPOSEOF REVIEW: The purpose of this review is to summarize the available literature on the epidemiology, biomechanics, clinical outcomes, and complications of return to sport after TJA, as well as provide guidelines for patients' safe return to athletic activity. RECENT FINDINGS: As volume and indications for total joint arthroplasty (TJA) expand, arthroplasty candidates today are demographically younger, more physically active, and have higher expectations for postoperative function. Many TJA patients wish to resume sports activity that may theoretically place their reconstruction under more biomechanical stress and risk for early wear or failure. Recommendations for postoperative patient activity following TJA have historically largely been surgeon-dependent and in the context of evolving prosthetic design and surgical techniques. We endorse a three-tiered framework for return to sporting activities: (1) low-impact sports are generally recommended, (2) intermediate-impact sports are generally recommended with experience, and (3) high-impact sports are generally not recommended though activity-specific joint decisions between patient and surgeon can be made.

Total Hip Arthroplasty in Patients With Neurological Conditions: A Systematic Review.

Background: As operative techniques and implant design have evolved over time, total hip arthroplasty (THA) is increasingly being carried out for patients with neurological impairment. This patient group places unique surgical challenges to the arthroplasty surgeon, which may include contractures, instability, and altered muscular tone. The purpose of this systematic review is to report the patient outcomes, complications, and implant survival following THA for patients with neurological conditions affecting the hip. Thus, we aim to support orthopaedic surgeon decision-making when considering and planning THA for these patients. Methods: A systematic review was performed as per Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines using the PubMed/Medline OVID, Cochrane, and Embase databases. All studies reporting the outcomes of THA in the neurological population which met defined inclusion criteria were included. Results: From an initial screen of 1820 studies, 45 studies with a total of 36,251 THAs were included in the final selection. All 45 studies reported complication rates, with controls included in 16 for comparison. High complication rates were observed following THA in the neurologically impaired population, most notably dislocation with observed rates up to 10.6%. An improvement was noted in all 36 studies (1811 THAs) which reported upon patient-reported outcomes. Conclusions: THA may be beneficial in the selected patients with neurological conditions, to reduce pain and improve function. There is an increased risk of complications which require careful consideration when planning the operation and open discussion with prospective patients and caregivers before proceeding with surgery.

Total Hip Arthroplasty in the Setting of Post-Traumatic Arthritis Following Acetabular Fracture: A Systematic Review.

Background: Acetabular fractures are frequently associated with post-traumatic arthritis (PTA), for which total hip arthroplasty (THA) has emerged as the established procedure. The purpose of this systematic review is to report the patient outcomes, complications, and implant survival of delayed THA for patients with PTA following acetabular fracture. Methods: A systematic review was performed in December 2021 as per Preferred Reporting Items for Systematic Review and Meta-Analysis Guidelines to identify all studies reporting outcomes of delayed THA performed for PTA with a history of acetabular fracture. From an initial screen of 893 studies, 29 studies which met defined inclusion criteria including minimum 12 months of follow-up and minimum 10 THA were included in the final review. Results: A total of 1220 THA were reported across 29 studies, with 1174 THA completing a minimum of 1-year follow-up at a mean of 86 months. All 29 studies reported upon complications, with a control included in 6 for comparison. Higher complication rates were observed both in patients who had prior open reduction internal fixation and conservative treatment, most notably infection which was observed following 3.6% THA. The total joint revision rate was 9.7%. An improvement was noted in all 25 studies which recorded patient-reported outcomes, with a mean rise in the Harris hip score from 45 to 86 across 18 studies. Conclusions: THA may reduce reported pain levels and improve functional outcomes in selected patients experiencing PTA following acetabular fractures. There is an increased risk of complications, necessitating careful consideration when planning the operation and open discussion with prospective patients and caregivers.

A modified Delphi consensus statement on patellar instability: part II.

Aims: The aim of this study was to establish consensus statements on medial patellofemoral ligament (MPFL) reconstruction, anteromedialization tibial tubercle osteotomy, trochleoplasty, and rehabilitation and return to sporting activity in patients with patellar instability, using the modified Delphi process. Methods: This was the second part of a study dealing with these aspects of management in these patients. As in part I, a total of 60 surgeons from 11 countries contributed to the development of consensus statements based on their expertise in this area. They were assigned to one of seven working groups defined by subtopics of interest. Consensus was defined as achieving between 80% and 89% agreement, strong consensus was defined as between 90% and 99% agreement, and 100% agreement was considered unanimous. Results: Of 41 questions and statements on patellar instability, none achieved unanimous consensus, 19 achieved strong consensus, 15 achieved consensus, and seven did not achieve consensus. Conclusion: Most statements reached some degree of consensus, without any achieving unanimous consensus. There was no consensus on the use of anchors in MPFL reconstruction, and the order of fixation of the graft (patella first versus femur first). There was also no consensus on the indications for trochleoplasty or its effect on the viability of the cartilage after elevation of the osteochondral flap. There was also no consensus on postoperative immobilization or weightbearing, or whether paediatric patients should avoid an early return to sport.