Trial of Electronic Medical Record Integrated Next-Generation Sequencing Ordering in Veterans Affairs Cancer Care.

PURPOSE: Previous studies document underuse of next-generation sequencing (NGS). We examined the impact to oncology care for veterans of incorporating NGS ordering into the Veterans Affairs (VA) electronic medical record (EMR) at two New York City VA Medical Centers. METHODS: We identified patients with non-small cell lung cancer and prostate cancer with oncology clinic visits and NGS testing indications between January and December 2021. Patients were divided into external ordering (EO) with visits before we implemented an EMR ordering system for NGS in July 2021, and internal ordering (IO) with visits after this date. The primary outcome was proportion of NGS testing performed in EO versus IO groups. Secondary outcomes were time between metastatic disease diagnosis to receipt of test by vendor, time of metastatic diagnosis to result, and proportion of testing by race. RESULTS: A total of 168 patients were identified, 116 EO and 52 IO patients. Between IO and EO periods, testing significantly increased from 52% to 87% (P ≤ .01); it was conducted more quickly, with time from metastatic diagnosis to sample receipt by the NGS vendor improving to median 37 days from 299 days (P = .03); and the time from documented metastatic disease to a test result improved to median 56 days from 309 days (P = .03). The proportion of tissue received by the vendor was not significantly different between the two groups. There were no significant differences in testing according to self-reported race. CONCLUSION: Integration of NGS ordering in the EMR led to increased proportion and speed of testing for a vulnerable patient population served by the country's largest health system.

High performance in risk stratification of intraductal papillary mucinous neoplasms by confocal laser endomicroscopy image analysis with convolutional neural networks (with video).

BACKGROUND AND AIMS: EUS-guided needle-based confocal laser endomicroscopy (EUS-nCLE) can differentiate high-grade dysplasia/adenocarcinoma (HGD-Ca) in intraductal papillary mucinous neoplasms (IPMNs) but requires manual interpretation. We sought to derive predictive computer-aided diagnosis (CAD) and artificial intelligence (AI) algorithms to facilitate accurate diagnosis and risk stratification of IPMNs. METHODS: A post hoc analysis of a single-center prospective study evaluating EUS-nCLE (2015-2019; INDEX study) was conducted using 15,027 video frames from 35 consecutive patients with histopathologically proven IPMNs (18 with HGD-Ca). We designed 2 CAD-convolutional neural network (CNN) algorithms: (1) a guided segmentation-based model (SBM), where the CNN-AI system was trained to detect and measure papillary epithelial thickness and darkness (indicative of cellular and nuclear stratification), and (2) a reasonably agnostic holistic-based model (HBM) where the CNN-AI system automatically extracted nCLE features for risk stratification. For the detection of HGD-Ca in IPMNs, the diagnostic performance of the CNN-CAD algorithms was compared with that of the American Gastroenterological Association (AGA) and revised Fukuoka guidelines. RESULTS: Compared with the guidelines, both n-CLE-guided CNN-CAD algorithms yielded higher sensitivity (HBM, 83.3%; SBM, 83.3%; AGA, 55.6%; Fukuoka, 55.6%) and accuracy (SBM, 82.9%; HBM, 85.7%; AGA, 68.6%; Fukuoka, 74.3%) for diagnosing HGD-Ca, with comparable specificity (SBM, 82.4%; HBM, 88.2%; AGA, 82.4%; Fukuoka, 94.1%). Both CNN-CAD algorithms, the guided (SBM) and agnostic (HBM) models, were comparable in risk stratifying IPMNs. CONCLUSION: EUS-nCLE-based CNN-CAD algorithms can accurately risk stratify IPMNs. Future multicenter validation studies and AI model improvements could enhance the accuracy and fully automatize the process for real-time interpretation.

Failures, Reoperations, and Improvement in Knee Symptoms Following Matrix-Assisted Autologous Chondrocyte Transplantation: A Meta-Analysis of Prospective Comparative Trials.

OBJECTIVE: Though multiple high-level comparative studies have been performed for matrix-assisted autologous chondrocyte transplantation (MACT), quantitative reviews synthesizing best-available clinical evidence on the topic are lacking. DESIGN: A meta-analysis was performed of prospective randomized or nonrandomized comparative studies utilizing MACT. A total of 13 studies reporting 13 prospective trials (9 randomized, 5 nonrandomized) were included (658 total study participants at weighted mean 3.1 years follow-up, range 1-7.5 years). RESULTS: Reporting and methodological quality was moderate according to mean Coleman (59.4 SD 7.6), Delphi (3.0 SD 2.1), and MINORS (Methodological Index For Non-Randomized Studies) scores (20.2 SD 1.6). There was no evidence of small study or reporting bias. Effect sizes were not correlated with reporting quality, financial conflict of interest, sample size, year of publication, or length of follow-up (P > 0.05). Compared to microfracture, MACT had greater improvement in International Knee Documentation Committee (IKDC)-subjective and Knee Injury and Osteoarthritis Outcome Pain Subscale Score (KOOS)-pain scores in randomized studies (P < 0.05). Accelerated weight-bearing protocols (6 or 8 weeks) resulted in greater improvements in IKDC-subjective and KOOS-pain scores than standard protocols (8 or 11 weeks) for MACT in randomized studies (P < 0.05) with insufficient nonrandomized studies for pooled analysis. CONCLUSIONS: Compared to microfracture, MACT has no increased risk of clinical failure and superior improvement in patient-reported outcome scores. Compared to MACT with standardized postoperative weight-bearing protocols, accelerated weight-bearing protocols have no increased risk of clinical failure and show superior improvement in patient-reported outcome scores. There is limited evidence regarding MACT compared to first-generation autologous chondrocyte implantation, mosaicplasty, and mesenchymal stem cell therapy without compelling differences in outcomes.

CrossFit-related hip and groin injuries: a case series.

To provide descriptive data on injury presentation and treatment and to identify risk factors for requiring surgical treatment for athletes presenting with CrossFit-related hip and groin injuries. CrossFit-related injuries (n = 982) were identified within a single hospital system from 2010 to 2017, with 83 (8.5% of total) identified hip or groin injuries. Patient demographics, injury diagnosis, surgical procedure and rehabilitation were assessed. Independent predictors of requiring surgery were analyzed via multivariate logistic regression analysis. Patients with hip or groin injuries were more often female (hip injuries: 63%; all injuries: 50%; P < 0.001) with mean age 34.3 years (standard deviation 10.9). Median symptom duration was 4 months with 70% reporting insidious onset. Most common diagnoses were femoral-acetabular impingement syndrome (34%), hamstring strain (11%), non-specific hip/groin pain (imaging non-diagnostic) (11%), hernia (7%) and iliotibial band syndrome (6%). Most (90%) required physical therapy (median 2 months). Surgery occurred in 24% (n = 12 hip arthroscopy, n = 5 inguinal hernia repair, n = 3 total hip arthroplasty), with 100% return to sport after arthroscopy or hernia repair. The only predictor of surgery was complaint of primarily anterior hip/groin pain (82% surgical patients, 46% non-surgical) (odds ratio 5.78, 95% confidence interval 1.44-23.1; P = 0.005); age, sex, body mass index, symptom duration and symptom onset (insidious versus acute) were non-significant (P > 0.25). CrossFit athletes with hip and groin injuries often present with prolonged symptoms with insidious onset. Most patients require several months of physical therapy and approximately one quarter require surgery. Patients presenting with primarily anterior hip/groin pain are at increased risk for requiring surgery. LEVEL OF EVIDENCE: IV, case series.

Meniscus repair five-year results are influenced by patient pre-injury activity level but not age group.

BACKGROUND: The purpose of the study is to determine whether patient age group (≥40 years versus <40 years) and pre-injury activity level are independently predictive of symptomatic failure rates and patient-reported outcomes after meniscus repair with or without concomitant anterior cruciate ligament reconstruction (ACLR) at mean five years of follow-up. METHODS: Two hundred and twenty-five patients (n = 61, age ≥40 years; n = 164, age <40; 11% sedentary, 63% recreational athletes, 26% competitive athletes; 72% cutting-pivoting sports, 28% non-cutting or non-pivoting sports) who underwent meniscal repair were assessed for symptomatic failure and subjective knee function at mean 5.4 years of follow-up. Symptoms were assessed with Knee Osteoarthritis Outcome Score (KOOS) and International Knee Documentation Committee Subjective (IKDC-S) scores. RESULTS: Repair failure was 20% overall with no association with age group (<40 vs. ≥40 years) or level of activity. When compared with sedentary patients, IKDC-S scores were not associated with age group but were lower among sedentary patients (mean: 59.6, SE: 4.9) compared with recreational (mean: 78.9, SE: 2.5; p = 0.007) or competitive athletes (mean: 79.2, SE: 3.8; p = 0.02). KOOS-ADL scores were independently associated with age and were higher among patients <40 years. KOOS-pain, KOOS-sport, or KOOS-QOL were not associated with age group. Sedentary status was independently associated with lower KOOS scores for all sub-scores. CONCLUSIONS: Meniscal repair failure rates and patient-reported outcomes do not differ substantially between older or younger patients of similar pre-injury activity level. Sedentary patients regardless of age have worse self-reported subjective outcomes compared with active patients.

Age of 40 Years or Older Does Not Affect Meniscal Repair Failure Risk at 5 Years.

PURPOSE: To compare meniscal repair failure rates in patients aged 40 years or older versus patients younger than 40 years. METHODS: A total of 276 patients underwent meniscal repair surgery by a single sports medicine fellowship-trained surgeon between 2006 and 2012 and were eligible for study inclusion. Patients were followed up for meniscal repair failure, defined as meniscectomy, repeated meniscal repair, or total knee arthroplasty. Logistic regression analysis was used to determine the risk of failure while controlling for potential confounding variables including body mass index, sex, anterior cruciate ligament status, time from injury to surgery, number of implants used, tear pattern, and chondral status at the time of the repair. RESULTS: Among the 276 eligible patients, 221 (80%) were successfully contacted for follow-up at an average of 5 years after surgery. Of these patients, 56 were aged 40 years or older (mean, 47.2 years; standard deviation [SD], 5.3 years) and 165 were younger than 40 years (mean, 24.7 years; SD, 6.7 years). The overall meniscal repair failure rate over a 5-year period was 20%. Among patients aged 40 years or older, the failure risk was 18% versus 21% in patients younger than 40 years. After adjustment for confounding variables, age of 40 years or older was not associated with increased failure risk (adjusted odds ratio, 0.83; 95% confidence interval, 0.36-1.81; P = .65). The mean time to failure tended to be shorter in older patients, at 16.9 months (SD, 10.2 months) versus 28.5 months in the group younger than 40 years (SD, 23.3 months) (P = .04). CONCLUSIONS: Age of 40 years or older is not associated with an increased risk of meniscal repair failure at 5 years, although a shorter time to failure was noted in this age cohort. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Medial compartment defects progress at a more rapid rate than lateral cartilage defects in older adults with minimal to moderate knee osteoarthritis (OA): data from the OA initiative.

PURPOSE: To determine: (1) rates and risk factors for progression of lateral and medial full-thickness cartilage defect size in older adults without severe knee osteoarthritis (OA), and (2) whether risk factors for defect progression differ for knees with Kellgren-Lawrence OA grade 3 (moderate) OA versus grades 0-2 (none to mild) OA. METHODS: Three-hundred and eighty adults enrolled in the Osteoarthritis Initiative were included (43% male, mean age 63.0 SD 9.2 years). Ethical approval was obtained at all study sites prior to enrollment. All participants had full-thickness tibial or weight-bearing femoral condylar cartilage defects on baseline knee MRIs. Baseline OA grade was KL grade 3 in 71.3% and grades 0-2 in 21.7% of participants. Repeat MRIs were obtained at a minimum 2-year follow-up. Independent risk of progression in defect size due to demographic factors, knee alignment, OA grade, knee injury and surgery history, and baseline knee symptoms was determined by multivariate Cox proportional hazards and linear regression modeling. RESULTS: The average increase in defect size over 2 years for lateral defects was 0.18 cm2 (SD 0.60) and for medial defects was 0.49 cm2 (SD 1.09). Independent predictors of medical defect size progression were bipolar defects (beta 0.47 SE 0.08; p < 0.001), knee varus (per degree, beta 0.08 SE 0.03; p = 0.02) and increased weight (per kg, beta = 0.01 SE 0.004; p = 0.01). Independent predictors for lateral defect progression were larger baseline defect size (per 1.0 cm2, beta 0.14 SE 0.03; p < 0.001) and tibial sided defects (beta 0.12 SE 0.04) and degrees valgus (per degree, beta 0.04 SE 0.01; p = 0.001). CONCLUSIONS: Medial compartment full-thickness defects progress at a more rapid rate than lateral defects in older adults with minimal to moderate OA. Medial defect progression was greatest for bipolar defects in heavier adults with varus knees. Lateral defect progression was greatest for large tibial-sided defects in adults with valgus knees. LEVEL OF EVIDENCE: II.

Meniscal repair in patients age 40 years and older: A systematic review of 11 studies and 148 patients.

PURPOSE: The purpose of this review is to evaluate published outcomes for reported failure rates following meniscus repair in patients age 40 years or older. METHODS: A systematic search was performed, and 225 meniscus repair outcome studies on adults were identified in the English literature. Included studies reported either individual patient data with at least one patient age ≥40 years or summary data with all patients' age ≥40 years. Failure rates were determined based on previously reported risk factors (regardless of age) including concomitant anterior cruciate ligament (ACL) reconstruction (ACLR), tear location, and tear pattern. RESULTS: Meniscus repair outcomes for 148 patients from 11 studies were included (125 inside-out repairs and 23 all-inside repairs). The overall failure rate was 10% (15/148) and ranged from 0 to 23% in individual studies with more than one patient age ≥40 years. One comparative study of patients over versus under age 40 years was identified, with no difference in failure rates between groups. Most tears were peripheral tears with avascular extension (nine-percent overall failure rate) or without avascular extension (nine-percent failure rate). Among studies that reported tear pattern, overall failure rates for vertical-longitudinal or bucket handle tears were nine percent and complex and/or horizontal tears were 23%. Repairs with concomitant ACL reconstruction had a five-percent overall failure rate versus 15% in ACL intact patients. CONCLUSION: Meniscus repair failure rates in patients age 40 years and older are comparable to rates quoted for younger patients. LEVEL OF EVIDENCE: Level IV. Systematic review of Level III and IV studies.

Clinical Outcomes of Osteochondral Allograft Transplantation for Secondary Treatment of Osteochondritis Dissecans of the Knee in Skeletally Mature Patients.

PURPOSE: To report clinical outcomes of osteochondral allograft transplantation (OCA) for skeletally mature patients with osteochondritis dissecans (OCD) lesions of the knee in whom prior surgical intervention has failed, and to describe return-to-sport (RTS) rates and any predictive demographic or preoperative variables associated with a higher likelihood to RTS. METHODS: Patients who underwent OCA by a single surgeon (B.J.C.) between October 1, 2002, and November 30, 2014, for a diagnosis of OCD with a minimum of 2 years' follow-up were included. Demographic, surgical history, operative, and postoperative data points including RTS were analyzed for all patients collectively, with subanalysis to identify any demographic and operative variables associated with the ability to RTS. Failure was defined as revision OCA, gross appearance of graft failure on second-look arthroscopy, or conversion to arthroplasty. RESULTS: We identified 41 consecutive patients (43 knees), with 37 patients (39 knees, comprising 26 male and 13 female knees) available for clinical follow-up at an average of 7.29 ± 3.30 years. There was significant improvement (P < .05) in all patient-reported outcome scores, with the exception of the Short Form 12 mental subscale (P = .910). Most patients (81.6%) reported being either mostly satisfied or completely satisfied at final follow-up. Of patients self-identifying as athletes preoperatively (n = 22), 18 (81.8%) achieved RTS at an average of 14.0 ± 8.7 months. Athletes with failure to RTS had a significantly greater body mass index (RTS, 24.68 ± 3.67; no RTS, 27.82 ± 0.69; P = .005). Subsequent surgery was performed in 14 patients (35.9%), and primary OCA failed in 2 patients at an average of 6.2 ± 3.8 years. CONCLUSIONS: OCA is a successful secondary surgical treatment for OCD of the knee in skeletally mature patients and leads to clinically meaningful improvements in patient-reported outcome scores and high patient satisfaction and RTS rates in low-level athletes at an average of 7.29 years' follow-up. Athletes with failure to RTS were found to have a significantly higher body mass index. Although reoperation may be common after OCA (35.9%), the failure rate is low (5.1%) in this series. LEVEL OF EVIDENCE: Level IV, case series.

Do Outcomes of Osteochondral Allograft Transplantation Differ Based on Age and Sex? A Comparative Matched Group Analysis.

BACKGROUND: The effect of patient age or sex on outcomes after osteochondral allograft transplantation (OCA) has not been assessed. PURPOSE: To determine clinical outcomes for male and female patients aged ≥40 years undergoing OCA compared with a group of patients aged <40 years. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A review of prospectively collected data of consecutive patients who underwent OCA by a single surgeon with a minimum follow-up of 2 years was conducted. The reoperation rate, failure rate, and patient-reported outcome scores were reviewed. All outcomes were compared between patients aged <40 or ≥40 years, with subgroup analyses conducted based on patient sex. Failure was defined as revision OCA, conversion to knee arthroplasty, or gross appearance of graft failure at second-look arthroscopic surgery. Descriptive statistics, Fisher exact or chi-square testing, and Mann-Whitney U testing were performed, with P < .05 set as significant. RESULTS: A total of 170 patients (of 212 eligible patients; 80.2% follow-up) who underwent OCA with a mean follow-up of 5.0 ± 2.7 years (range, 2.0-15.1 years) were included, with 115 patients aged <40 years (mean age, 27.6 ± 7.3 years; 58 male, 57 female) and 55 patients aged ≥40 years (mean age, 44.9 ± 4.0 years; 33 male, 22 female). There were no differences in the number of pre-OCA procedures between the groups ( P = .085). There were no differences in the reoperation rate (<40 years: 38%; ≥40 years: 36%; P = .867), time to reoperation (<40 years: 2.12 ± 1.90 years; ≥40 years: 3.43 ± 3.43 years; P = .126), or failure rate (<40 years: 13%; ≥40 years: 16%; P = .639) between the older and younger groups. Patients in both groups demonstrated significant improvement in Lysholm (both: P < .001), International Knee Documentation Committee (IKDC) (both: P < .001), Knee Injury and Osteoarthritis Outcome Score (KOOS) (both: P < .001), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) (both: P < .001), and Short Form-12 (SF-12) physical (both: P < .001) scores compared with preoperative values. Patients aged ≥40 years demonstrated significantly higher KOOS symptom ( P = .015) subscores compared with patients aged <40 years. There were no significant differences in the number of complications, outcome scores, or time to failure between the sexes. In patients aged <40 years, female patients experienced failure significantly more quickly than male patients ( P = .039). In contrast, in patients aged ≥40 years, male patients experienced failure significantly more quickly than female patients ( P = .046). CONCLUSION: This study provides evidence that OCA is a safe and reliable treatment option for osteochondral defects in patients aged ≥40 years. Male and female patients had similar outcomes. Patients aged <40 years demonstrated lower KOOS symptom subscores postoperatively compared with older patients, potentially attributable to higher expectations of return to function postoperatively as compared with older patients.

Effectiveness of Lavage Techniques in Removing Immunogenic Elements from Osteochondral Allografts.

Objective This study aimed to compare standard saline lavage to combination saline and high-pressure carbon dioxide (CO2) lavage in removing marrow elements from osteochondral allografts. Design Six fresh hemicondyles were obtained. Three osteochondral allograft plugs (15-mm diameter, 6-mm depth) were harvested from each hemicondyle and randomized to 1 of 3 treatment arms: A, no lavage; B, 1 L standard saline lavage; C, simultaneous saline (1 L) and 1-minute high-pressure CO2 lavage. After hematoxylin and eosin staining, a "percentage fill" of remaining marrow elements was calculated for each overall sample and then repeated in 3 distinct compartments for each sample based on depth from surface: 1, deepest third; 2, middle third; and 3, most superficial third. Trial arms B and C were compared with 1-tailed Student t tests. Results Group A had an overall percentage fill of 51.2% ± 8.8%. While both lavage techniques decreased overall remaining marrow elements, group B yielded significantly higher percentages of remaining marrow elements than group C (28.6% ± 16.5%, 14.6% ± 8.7%, P = 0.045). On depth analysis, group A exhibited homogenous filling of trabecular space (63.0% ± 15.5%, 67.6% ± 13.7%, and 55.2% ± 10.1% in zones 1, 2, and 3, respectively). Both lavage arms equally removed marrow elements from superficial zone 3 (B, 17.4% ± 9.2%; C, 15.6% ± 12.4%, P = 0.41) and middle zone 2 (B, 30.2% ± 17.7%; C, 21.4% ± 15.5%, P = 0.18). However, group C lavage removed significantly more marrow elements in deep zone 1 than group B (29.7% ± 10.9%, 58.5% ± 25.2%, P = 0.01). Conclusion Combination saline and high-pressure CO2 lavage more effectively clears marrow elements from osteochondral allografts than saline alone.

Prospective Clinical and Radiographic Outcomes After Concomitant Anterior Cruciate Ligament Reconstruction and Meniscal Allograft Transplantation at a Mean 5-Year Follow-up.

BACKGROUND: Concomitant anterior cruciate ligament reconstruction and meniscal allograft transplantation (ACLR/MAT) has demonstrated short-term success in small, retrospective cohort studies. Patient- and disease-specific predictors of success after ACLR/MAT are largely unknown. PURPOSE: To (1) prospectively evaluate the subjective and objective clinical and radiographic outcomes after ACLR/MAT and (2) conduct a subgroup analysis to identify patient- or disease-related factors that correlate with failure. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Patient-reported outcomes (PROs) were prospectively collected on 40 patients undergoing concomitant ACLR/MAT. Nineteen athletes responded to return-to-sport data. Clinical data (physical examination including Lachman and pivot-shift testing and KT-1000 arthrometer testing) were obtained on 28 patients who returned for an evaluation, while 24 of those patients additionally had radiographic data (progression of Kellgren-Lawrence [KL] grade and joint-space narrowing) evaluated. Reoperations and failures were documented for all patients at their final follow-up. RESULTS: The overall cohort of 40 patients had a mean age of 30.3 ± 9.6 years (range, 16.0-54.0 years) and a mean body mass index of 27.7 ± 4.2 kg/m2. The mean follow-up time was 5.7 ± 3.2 years (range, 1.7-16.5 years). There were 33 (83%) medial meniscal transplants performed compared with 7 (17%) lateral meniscal transplants. Patients underwent a mean of 2.9 ± 1.9 prior surgical procedures. Nineteen patients underwent concomitant procedures, including, most commonly, 9 hardware removals and 9 osteochondral allografts. There were significant improvements in 11 of 14 PRO measures as well as a 50% return-to-sport rate. Knee stability significantly improved in 28 patients who returned for a physical examination, and KT-1000 arthrometer testing indicated no differences between the affected and unaffected sides at final follow-up (mean, 0.9 ± 1.5 mm [range, -2 to 4 mm] in comparison to contralateral knee at 30 lb of testing; mean, 0.9 ± 1.9 mm [range, -4 to 4 mm] in comparison to contralateral knee at maximum manual strength). Significant improvements were seen in patients with Lachman grade ≥2A at final follow-up (18% vs 97%, respectively; P < .01) and with pivot shift ≥1+ at final follow-up (36% vs 94%, respectively; P < .01) compared with preoperatively. For the 24 patients with radiographic data, no significant joint-space decrease was recorded in the medial compartment for medial MAT-treated patients or the lateral compartment for lateral MAT-treated patients. The mean KL grade increased from 0.7 ± 0.8 to 1.6 ± 0.9 at final follow-up ( P < .01). There were no major (0%) and 2 minor (5%) complications, which constituted early postoperative drainage treated successfully with oral antibiotics. While 35% of patients underwent reoperations, the majority of these were simple arthroscopic debridements and occurred after nearly 4 years from the index surgery. The overall survival rate at final follow-up was 80%. Failures occurred at a mean of 7.3 years, and those who converted to arthroplasty did so at a mean of 8.3 years from the time of index ACLR/MAT. Patients with failed grafts were more frequently associated with workers' compensation claims (38% vs 13%, respectively) and less frequently self-identified as athletes (13% vs 56%, respectively) compared with patients with intact grafts. CONCLUSION: Concomitant ACLR/MAT can provide significant improvements in clinical outcomes and enhancement in objective knee stability and was associated with an insignificant degree of radiographic joint-space narrowing changes with a 5-year survivorship of more than 80% for those with data available. Athlete status may be a preoperative predictor of midterm survival.

Osteochondral Allograft Transplantation of the Knee: Analysis of Failures at 5 Years.

BACKGROUND: Osteochondral allograft transplantation (OAT) is being performed with increasing frequency, and the need for reoperations is not uncommon. PURPOSE: To quantify survival for OAT and report findings at reoperations. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A review of prospectively collected data of 224 consecutive patients who underwent OAT by a single surgeon with a minimum follow-up of 2 years was conducted. The reoperation rate, timing of reoperation, procedure performed, and findings at surgery were reviewed. Failure was defined by revision OAT, conversion to knee arthroplasty, or gross appearance of graft failure at second-look arthroscopic surgery. RESULTS: A total of 180 patients (mean [±SD] age, 32.7 ± 10.4 years; 52% male) who underwent OAT with a mean follow-up of 5.0 ± 2.7 years met the inclusion criteria (80% follow-up). Of these, 172 patients (96%) underwent a mean of 2.5 ± 1.7 prior surgical procedures on the ipsilateral knee before OAT. Forty-eight percent of OAT procedures were isolated, while 52% were performed with concomitant procedures including meniscus allograft transplantation (MAT) in 65 (36%). Sixty-six patients (37%) underwent a reoperation at a mean of 2.5 ± 2.5 years, with 32% (21/66) undergoing additional reoperations (range, 1-3). Arthroscopic debridement was performed in 91% of patients with initial reoperations, with 83% showing evidence of an intact graft; of these, 9 ultimately progressed to failure at a mean of 4.1 ± 1.9 years. A total of 24 patients (13%) were considered failures at a mean of 3.6 ± 2.6 years after the index OAT procedure because of revision OAT (n = 7), conversion to arthroplasty (n= 12), or appearance of a poorly incorporated allograft at arthroscopic surgery (n = 5). The number of previous surgical procedures was independently predictive of reoperations and failure; body mass index was independently predictive of failure. Excluding the failed patients, statistically and clinically significant improvements were found in the Lysholm score, International Knee Documentation Committee score, Knee injury and Osteoarthritis Outcome Score, and Short Form-12 physical component summary at final follow-up ( P < .001 for all), with inferior outcomes (albeit overall improved) in patients who underwent a reoperation. CONCLUSION: In this series, there was a 37% reoperation rate and an 87% allograft survival rate at a mean of 5 years after OAT. The number of previous ipsilateral knee surgical procedures was predictive of reoperations and failure. Of the patients who underwent arthroscopic debridement with an intact graft at the time of arthroscopic surgery, 82% experienced significantly improved outcomes, while 18% ultimately progressed to failure. This information can be used to counsel patients on the implications of a reoperation after OAT.

Cool and hot executive function as predictors of aggression in early childhood: Differentiating between the function and form of aggression.

Executive function (EF) has been implicated in childhood aggression. Understanding of the role of EF in aggression has been hindered, however, by the lack of research taking into account the function and form of aggression and the almost exclusive focus on cool EF. This study examined the role of cool and hot EF in teacher reported aggression, differentiating between reactive and proactive as well as physical and relational aggression. Children (N = 106) completed laboratory tasks measuring cool (inhibition, planning, working memory) and hot EF (affective decision-making, delay of gratification). Cool, but not hot, EF significantly contributed to understanding of childhood aggression. Inhibition was a central predictor of childhood aggression. Planning and working memory, in contrast, were significant independent predictors of proactive relational aggression only. Added to this, prosocial behaviour moderated the relationship between working memory and reactive relational aggression. This study therefore suggests that cool EF, particularly inhibition, is associated with childhood aggression across the different functions and forms.