Tunnel Widening Following All-Inside Anterior Cruciate Ligament Reconstruction Varies Depending on Soft Tissue Graft Type.

PURPOSE: Bone tunnel widening (TW) is a well-described complication after anterior cruciate ligament reconstruction (ACLR). The purpose of this study was to evaluate radiographic bone TW and clinical outcomes in patients with ACLR performed with suspensory fixation on both the femoral and tibial tunnels using different soft tissue grafts. METHODS: Patients who underwent primary ACLR with a soft tissue graft (hamstring autograft or allograft or quadriceps autograft) using an all-inside technique were included for analysis. Anterior cruciate ligament tunnel width was measured postoperatively on anteroposterior and lateral plain radiographs at a minimum of 12 months of follow-up. Clinical outcomes were assessed using the International Knee Documentation Committee (IKDC) subjective knee form as well as assessing patient records for complication data. RESULTS: Fifty patients (15 quadriceps autografts, 24 hamstring autografts, 11 hamstring allografts) were included in this study. The quadriceps autograft cohort was the youngest, (16.6 ± 2.8 years), followed by the hamstring autograft cohort (27.7 ± 9.0 years), and the hamstring allograft cohort (48.2 ± 9.4 years; p < 0.001) for all comparisons. Quadriceps autografts experienced less tibial tunnel-widening (0.6 ± 0.6 mm) than hamstring autografts (2.0 ± 1.1 mm; p = 0.011), which, in turn, experienced less widening than hamstring allografts (3.9 ± 2.3 mm; p < 0.001). Quadriceps autografts also experienced less femoral tunnel widening (0.3 ± 0.6 mm) than hamstring autografts (2.1 ± 1.2 mm; p < 0.001) which, in turn, experienced less tunnel-widening than hamstring allografts (4.0 ± 2.1; p < 0.001). At follow-up, mean IKDC for hamstring autografts, quadriceps autografts, and hamstring allografts were 79.9 ± 17.9, 88.5 ± 7.1, and 77.7 ± 20.4, respectively (p = 0.243). There was no statistically significant difference between groups with respect to postoperative complications; p = 0.874. CONCLUSIONS: Anterior cruciate ligament reconstruction with quadriceps autograft resulted in the least tunnel widening compared to hamstring autograft and allograft when using an all-inside suspensory fixation device. Both autograft groups resulted in less widening than the allograft group. Despite the greatest increased radiographic tunnel widening in the allograft group, there was no significant difference in clinical outcomes or knee laxity.

Trochlear Dysplasia as Shown by Increased Sulcus Angle Is Associated With Osteochondral Damage in Patients With Patellar Instability.

PURPOSE: The primary study objective was to describe the incidence of osteochondral damage (OD) in our cohort of patients with patellar instability (PI). The secondary objective was to assess for associations between patient demographic characteristics, duration of PI, and quantitative radiographic measurements of anatomic risk factors for PI and OD in this cohort. METHODS: A retrospective chart review identified patients treated for PI at a tertiary referral center between 2013 and 2018. Patients were evaluated for osteochondral injury with either magnetic resonance imaging if treated nonoperatively or operative reports if treated surgically. The Caton-Deschamps ratio, proximal tibial tubercle-to-trochlear groove (pTT-TG) distance, distal tibial tubercle-to-trochlear groove (dTT-TG) distance, lateral trochlear inclination (LTI) angle, lateral patellar inclination (LPI) angle, and sulcus angle were calculated from magnetic resonance imaging scans. Trochlear dysplasia is an important risk factor for PI that can be reliability quantified by the pTT-TG distance, dTT-TG distance, LTI angle, sulcus angle, and LPI angle. Demographic data including age at first instability event, sex, body mass index, symptom duration, and number of dislocations were documented. RESULTS: A total of 125 knees in 118 patients (average age, 13.9 ± 3.4 years; 48% female patients) with PI were identified. Within this cohort, 67% were treated surgically and 53% had OD. No association was identified between osteochondral injury and age, sex, body mass index, symptom duration, LTI angle, LPI angle, dTT-TG distance, pTT-TG distance, or number of dislocations. An increased sulcus angle (more dysplasia) showed a statistically significant association with osteochondral pathology (P = .021), and higher sulcus angles were statistically significantly associated with acute osteochondral fracture compared with chondral injury (P = .001). CONCLUSIONS: Using quantitative analysis of trochlear dysplasia, this study identified a significant association between trochlear dysplasia (sulcus angle) and the incidence of OD in our cohort of patients with PI. The frequency of dislocation or subluxation and patient demographic characteristics were not significantly associated with OD. LEVEL OF EVIDENCE: Level III, retrospective prognostic study.

Effects of a Multimodal Program Including Simulation on Job Strain Among Nurses Working in Intensive Care Units: A Randomized Clinical Trial.

Importance: Nurses working in an intensive care unit (ICU) are exposed to occupational stressors that can increase the risk of stress reactions, long-term absenteeism, and turnover. Objective: To evaluate the effects of a program including simulation in reducing work-related stress and work-related outcomes among ICU nurses. Design, Setting, and Participants: Multicenter randomized clinical trial performed at 8 adult ICUs in France from February 8, 2016, through April 29, 2017. A total of 198 ICU nurses were included and followed up for 1 year until April 30, 2018. Interventions: The ICU nurses who had at least 6 months of ICU experience were randomized to the intervention group (n = 101) or to the control group (n = 97). The nurses randomized to the intervention group received a 5-day course involving a nursing theory recap and situational role-play using simulated scenarios (based on technical dexterity, clinical approach, decision making, aptitude to teamwork, and task prioritization), which were followed by debriefing sessions on attitude and discussion of practices. Main Outcomes and Measures: The primary outcome was the prevalence of job strain assessed by combining a psychological demand score greater than 21 (score range, 9 [best] to 36 [worst]) with a decision latitude score less than 72 (score range, 24 [worst] to 96 [best]) using the Job Content Questionnaire and evaluated at 6 months. There were 7 secondary outcomes including absenteeism and turnover. Results: Among 198 ICU nurses who were randomized (95 aged ≤30 years [48%] and 115 women [58%]), 182 (92%) completed the trial for the primary outcome. The trial was stopped for efficacy at the scheduled interim analysis after enrollment of 198 participants. The prevalence of job strain at 6 months was lower in the intervention group than in the control group (13% vs 67%, respectively; between-group difference, 54% [95% CI, 40%-64%]; P < .001). Absenteeism during the 6-month follow-up period was 1% in the intervention group compared with 8% in the control group (between-group difference, 7% [95% CI, 1%-15%]; P = .03). Four nurses (4%) from the intervention group left the ICU during the 6-month follow-up period compared with 12 nurses (12%) from the control group (between-group difference, 8% [95% CI, 0%-17%]; P = .04). Conclusions and Relevance: Among ICU nurses, an intervention that included education, role-play, and debriefing resulted in a lower prevalence of job strain at 6 months compared with nurses who did not undergo this program. Further research is needed to understand which components of the program may have contributed to this result and to evaluate whether this program is cost-effective. Trial Registration: ClinicalTrials.gov Identifier: NCT02672072.

The Impact of a Motor-Cognitive Remediation Program on Attentional Functions of Preschoolers With ADHD Symptoms.

OBJECTIVE: The purpose of this study was to measure the impact of the motor-cognitive remediation program (MCRP) that uses sensorimotor and visual-motor imagery techniques on attentional functions in preschoolers with ADHD symptoms. METHOD: A total of 15 high-risk preschoolers were selected based on high ADHD symptoms. An experimental group participated in the MCRP and was compared with a control group. The MCRP consisted of 30 activities, 3 times a week, during 12 weeks. RESULTS: Children in the experimental group improved significantly for orienting (selective attention) and executive control (inhibition, stopping, and engaging mental operations) compared with the control group. CONCLUSION: These results are a first step to support the postulate that training specific attentional functions by sensorimotor activities and visual-motor imagery has an impact on the cognitive network of attention. This study suggests the potential value of MCRP addressed to preschoolers with ADHD symptoms.

Impact of North Atlantic Treaty Organization Policies and Procedures on Combined Medical Operations: Food and Water Safety and Veterinary Support.

Effective multilateral military operations such as those conducted by the North Atlantic Treaty Organization (NATO) require close cooperation and standardization between member nations to ensure interoperability. Failure to standardize policies, procedures, and doctrine prior to the commencement of military operations will result in critical interoperability gaps, which jeopardize the health of NATO forces and mission success. To prevent these gaps from occurring, US forces must be actively involved with NATO standardization efforts such as the Committee of the Chiefs of Medical Services to ensure US interests are properly represented when NATO standards are developed and US doctrine and procedures will meet the established NATO requirements.

Excess of neuromuscular spindles in a fetus with Costello syndrome: a clinicopathological report.

The neuromuscular spindle (NMS) is a proprioceptive myofibrillar component of skeletal muscles that is necessary to maintain normal muscle tone and coordination. Recently, an excess of NMS has been reported as a congenital neuromuscular syndrome with a Noonan phenotype, now linked to Costello syndrome (CS). The vast majority of patients with CS have a de novo heterozygous mutation in the HRAS gene involved in the Ras/mitogen-activated protein kinase (MAPK) pathway. CS has many features in common with Noonan and cardiofaciocutaneous syndromes, also linked to activating mutations (but in other genes) of the Ras/MAPK pathway. This makes the orientation of molecular screening difficult. The observation of excess NMS in a 26-weeks'-gestation stillborn prompted us to screen the HRAS gene for mutation. The identification of a HRAS mutation made it possible to establish a diagnosis of CS. We conclude that the excess of NMS is the most reliable sign for the diagnosis of CS. Our findings also show the instrumental role of histological study of the skeletal muscles in the context of polyhydramnios and fetal hydrops.