Late-stage rehabilitation after anterior cruciate ligament reconstruction: A multicentre randomised controlled trial (PReP).

BACKGROUND: At the completion of formal rehabilitation after anterior cruciate ligament reconstruction, functional capacity is only restored in a small proportion of affected individuals. Therefore, the end of formal rehabilitation is not the end of functional rehabilitation. OBJECTIVE: To compare adherence to and effectiveness of a late-stage rehabilitation programme with usual care after anterior cruciate ligament (ACL) reconstruction. METHODS: This prospective, double-blind, multicentre, parallel group, randomised controlled trial, included people aged 18 to 35 years after formal rehabilitation completion (mean [SD] 241 [92] days post-reconstruction). Participants were block-randomised to a 5-month neuromuscular performance intervention (Stop-X group) or usual care (medically prescribed standard physiotherapy, individual formal rehabilitation, home-exercises). All outcomes were measured once/month. Primary outcome was the normalised knee separation distance on landing after drop jump. Baseline-adjusted linear mixed models were calculated. RESULTS: In total, 112 participants (Stop-X: 57; Usual care: 55,) were analysed. Initially, mean (SD) intervention frequency (units/week) was higher in the Stop-X than the Usual care group: 2.65 (0.96) versus 2.48 (1.14) units/week in the first and 2.28 (1.02) versus 2.14 (1.31) units/week in the second month. No between-group*time(*baseline)-differences were found for the primary outcome. Between-group*time-effects favoured the Stop-X-group at 2 months (fewer self-reported knee problems during sport, KOOS-SPORT) (estimate = 64.3, 95 % CI 24.4-104.3 for the Stop-X), more confidence to return to sport (ACL-RSI) (62.4, 10.7-114.2), fewer pain-associated knee problems (KOOS-PAIN) (82.8, 36.0-129.6), improved everyday activity abilities (KOOS-ADL) (71.1, 6.4-135.7), and improved limb symmetry index in the front hop for distance at 3 and 4 months (0.34, 0.10-0.57; 0.31, 0.08-0.54). No between-group*time-effects occurred for kinesiophobia, symptom-associated knee problems or balance hops performance. At the end of the intervention, 79 % of the Stop-X and 70 % of the Usual care participants (p < 0.05) had successfully returned to their pre-injury sport type and level. CONCLUSIONS: The Stop-X intervention was slightly superior to usual care as part of late-stage rehabilitation after ACL-reconstruction. The small benefit might justify its use after formal rehabilitation completion.

The End of the Formal Rehabilitation Is Not the End of Rehabilitation: Knee Function Deficits Remain After Anterior Cruciate Ligament Reconstruction.

OBJECTIVE: To rate athletes' functional ability and return to sport (RTS) success at the end of their individual, formal, medically prescribed rehabilitation after anterior anterior cruciate ligament (ACL) reconstruction. METHODS: In our prospective multicenter cohort study, 88 (42 females) adults aged 18-35 years after acute unilateral ACL rupture and subsequent hamstring grafting were included. All patients were prospectively monitored during their rehabilitation and RTS process until the end of their formal rehabilitation and RTS release. As outcome measures, functional hop and jump tests (front hop, balance hops, and drop jump screening test) and self-report outcomes (Knee Injury and Osteoarthritis Outcome Score, ACL-RTS after injury) were assessed. Literature-based cut-off values were selected to rate each performance as fulfilled or not. RESULTS: At 7.5 months (SD 2.3 months) after surgery, the percentage of participants meeting the functional thresholds ranged from 4% (Knee Injury and Osteoarthritis Outcome Score SPORT) and over 44% (ACL-RTS after injury sum score) to 59% (Knee Injury and Osteoarthritis Outcome Score activities of all daily living) in the self-report and from 29% (Balance side hop) to 69% (normalized knee separation distance) in performance testing. Only 4% fulfilled all the cut-offs, while 45% returned to the same type and level of sport. Participants who successfully returned to their previous sport (type and level) were more likely to be "over-cut-off-performers." CONCLUSIONS: The low share of the athletes who fulfilled the functional RTS criteria highlights the importance of continuing the rehabilitation measures after the formal completion to assess the need for and success of, inter alia, secondary-preventive therapies.

Management after acute injury of the anterior cruciate ligament (ACL). Part 3: Recommendation on surgical treatment.

PURPOSE: The aim of this consensus project was to give recommendations regarding surgical treatment of the anterior cruciate ligament (ACL) injured patient. METHODS: For this consensus process, an expert, steering and rating group was formed. In an initial online meeting, the steering group, together with the expert group, formed various key topic complexes for which multiple questions were formulated. For each key topic, a structured literature search was performed by the steering group. The results of the literature review were sent to the rating group with the option to give anonymous comments until a final consensus voting was performed. Sufficient consensus was defined as 80% agreement. RESULTS: During this consensus process, 30 topics regarding the surgical management and technique of ACL reconstruction were identified. The literature search for each key question resulted in 30 final statements. Of these 30 final statements, all achieved consensus. CONCLUSIONS: This consensus process has shown that surgical treatment of ACL injury is a complex process. Various surgical factors influence patient outcomes. The proposed treatment algorithm can be used as a decision aid for the surgeon. LEVEL OF EVIDENCE: Level V.

Pathogenesis and Diagnosis of Proximal Hamstring Tendinopathies.

The proximal hamstring complex is a highly vulnerable area that is especially prone to injury. Proximal hamstring tendinopathies (PHTs) remain challenging in diagnosis, treatment, rehabilitation, and prevention due to a large variety of different injuries, slow healing response, persistent symptoms, and functional impairments. PHTs are often misdiagnosed or underdiagnosed, leading to delayed treatment and therapy failure. In addition, many athletes are at a high risk of PHT recurrence, a leading cause of prolonged rehabilitation and impaired individual performance. Until now, there have been no clear criteria for the diagnosis and classification of PHT. Tendinopathies can be graded based on their symptoms and onset. Additionally, radiological characteristics exist that describe the severity of tendinopathies. The diagnosis usually includes a battery of pain provocation tests, functional tests, and imaging to ensure a proper classification. Understanding the specific tasks in the pathogenesis and diagnostic process of PHT requires knowledge of functional anatomy, injury pattern and pathophysiological mechanisms as well as examination and imaging techniques. This work provides a structured overview of the pathogenesis and diagnostic work-up of PHT, emphasizing structured examination and imaging to enable a reliable diagnosis and rapid treatment decisions.

Contributors to self-report motor function after anterior cruciate ligament reconstruction.

Numerous functional factors may interactively contribute to the course of self-report functional abilities after anterior cruciate ligament  (ACL)-reconstruction. This study purposes to identify these predictors using exploratory moderation-mediation models in a cohort study design. Adults with post unilateral ACL reconstruction (hamstring graft) status and who were aiming to return to their pre-injury type and level of sport were included. Our dependent variables were self-reported function, as assessed by the the KOOS subscales sport (SPORT), and activities of daily living (ADL). The independent variables assessed were the KOOS subscale pain and the time since reconstruction [days]. All other variables (sociodemographic, injury-, surgery-, rehabilitation-specific, kinesiophobia (Tampa Scale of Kinesiophobia), and the presence or absence of COVID-19-associated restrictions) were further considered as moderators, mediators, or co-variates. Data from 203 participants (mean 26 years, SD 5 years) were finally modelled. Total variance explanation was 59% (KOOS-SPORT) and 47% (KOOS-ADL). In the initial rehabilitation phase (< 2 weeks after reconstruction), pain was the strongest contributor to self-report function (KOOS-SPORT: coefficient: 0.89; 95%-confidence-interval: 0.51 to 1.2 / KOOS-ADL: 1.1; 0.95 to 1.3). In the early phase (2-6 weeks after reconstruction), time since reconstruction [days] was the major contributor (KOOS-SPORT: 1.1; 0.14 to 2.1 / KOOS-ADL: 1.2; 0.43 to 2.0). Starting with the mid-phases of the rehabilitation, self-report function was no longer explicitly impacted by one or more contributors. The amount of rehabilitation [minutes] is affected by COVID-19-associated restrictions (pre-versus-post: - 672; - 1264 to - 80 for SPORT / - 633; - 1222 to - 45 for ADL) and by the pre-injury activity scale (280; 103 to 455 / 264; 90 to 438). Other hypothesised contributors such as sex/gender or age were not found to mediate the time or pain, rehabilitation dose and self-report function triangle. When self-report function is rated after an ACL reconstruction, the rehabilitation phases (early, mid, late), the potentially COVID-19-associated rehabilitation limitations, and pain intensity should also be considered. As, for example, pain is the strongest contributor to function in the early rehabilitation phase, focussing on the value of the self-report function only may, consequently, not be sufficient to rate bias-free function.

Management after acute injury of the anterior cruciate ligament (ACL), part 2: management of the ACL-injured patient.

PURPOSE: The aim of this consensus project was to create a treatment algorithm for the management of the ACL-injured patient which can serve as an aid in a shared decision-making process. METHODS: For this consensus process, a steering and a rating group were formed. In an initial face-to-face meeting, the steering group, together with the expert group, formed various key topic complexes for which various questions were formulated. For each key topic, a structured literature search was performed by the steering group. The results of the literature review were sent to the rating group with the option to give anonymous comments until a final consensus voting was performed. Sufficient consensus was defined as 80% agreement. RESULTS: During this consensus process, 15 key questions were identified. The literature search for each key question resulted in 24 final statements. Of these 24 final statements, all achieved consensus. CONCLUSIONS: This consensus process has shown that ACL rupture is a complex injury, and the outcome depends to a large extent on the frequently concomitant injuries (meniscus and/or cartilage damage). These additional injuries as well as various patient-specific factors should play a role in the treatment decision. The present treatment algorithm represents a decision aid within the framework of a shared decision-making process for the ACL-injured patient. LEVEL OF EVIDENCE: Level V.

Management after acute rupture of the anterior cruciate ligament (ACL). Part 1: ACL reconstruction has a protective effect on secondary meniscus and cartilage lesions.

PURPOSE: The aim of this consensus project was to validate which endogenous and exogenous factors contribute to the development of post-traumatic osteoarthritis and to what extent ACL (anterior cruciate ligament) reconstruction can prevent secondary damage to the knee joint. Based on these findings, an algorithm for the management after ACL rupture should be established. METHODS: The consensus project was initiated by the Ligament Injuries Committee of the German Knee Society (Deutsche Kniegesellschaft, DKG). A modified Delphi process was used to answer scientific questions. This process was based on key topic complexes previously formed during an initial face-to-face meeting of the steering group with the expert group. For each key topic, a comprehensive review of available literature was performed by the steering group. The results of the literature review were sent to the rating group with the option to give anonymous comments until a final consensus voting was performed. Consensus was defined a-priori as eighty percent agreement. RESULTS: Of the 17 final statements, 15 achieved consensus, and 2 have not reached consensus. Results of the consensus were summarized in an algorithm for the management after ACL rupture (infographic/Fig. 2). CONCLUSION: This consensus process has shown that the development of post-traumatic osteoarthritis is a complex multifactorial process. Exogenous (primary and secondary meniscus lesions) and endogenous factors (varus deformity) play a decisive role. Due to the complex interplay of these factors, an ACL reconstruction cannot always halt post-traumatic osteoarthritis of the knee. However, there is evidence that ACL reconstruction can prevent secondary joint damage such as meniscus lesions and that the success of meniscus repair is higher with simultaneous ACL reconstruction. Therefore, we recommend ACL reconstruction in case of a combined injury of the ACL and a meniscus lesion which is suitable for repair. LEVEL OF EVIDENCE: Level V.

Treatment of Combined Injuries to the ACL and the MCL Complex: A Consensus Statement of the Ligament Injury Committee of the German Knee Society (DKG).

BACKGROUND: Different indications and treatment options for combined injuries to the anterior cruciate ligament (ACL) and medial collateral ligament complex (MCL) are not clearly defined. PURPOSE: To perform a modified Delphi process with the Committee for Ligament Injuries of the German Knee Society (DKG) in order to structure and optimize the process of treating a combined injury to the ACL and MCL. STUDY DESIGN: Consensus statement. METHODS: Scientific questions and answers were created based on a comprehensive literature review using the central registers for controlled studies of Medline, Scopus, and Cochrane including the terms medial collateral ligament, anterior cruciate ligament, MCL, ACL, and outcome used in various combinations. The obtained statements passed 3 cycles of a modified Delphi process during which each was readjusted and rated according to the available evidence (grades A-E) by the members of the DKG Ligament Injuries Committee and its registered guests. RESULTS: The majority of answers, including several questions with >1 graded answer, were evaluated as grade E (n = 16) or C (n = 10), indicating that a low level of scientific evidence was available for most of the answers. Only 5 answers were graded better than C: 3 answers with a grade of A and 2 answers with a grade of B. Only 1 answer was evaluated as grade D. An agreement of >80% (range, 83%-100%) among committee members was achieved for all statements. CONCLUSION: The results of this modified Delphi process offer a guideline for standardized patient care in cases of combined injuries to the ACL and MCL.

[When nothing else works: patellofemoral joint arthroplasty]. / Wenn nichts mehr geht: Der patellofemorale Gelenkersatz.

Patellofemoral joint replacement is the best treatment option available for isolated patellofemoral arthritis. Especially young patients should be operated on with bone-sparing techniques that also preserve the soft tissues, since these patients are very likely to be revised at some point in their lifetime. Correct patient selection is important for the success of surgery and should include a meticulous clinical examination and imaging. Special attention should be paid to additional pathologies that may also need to be addressed. For the trochlea, there are two different options for treatment with the inlay and onlay system. The retropatellar surface should be replaced. Patellofemoral joint replacement is still rarely performed, so treatment in specialised centres is recommended. National joint registry data show high revision rates, while data from centres show promising results.

Predictive Factors Influencing Functional Results After Proximal Hamstring Tendon Avulsion Surgery: A Patient-Reported Outcome Study After 227 Operations From a Single Center.

BACKGROUND: Although debilitating, proximal hamstring tendon avulsion injuries are rare and often overlooked or misdiagnosed. Consequently, delayed diagnosis and surgical treatment may result in poor outcomes. Studies investigating a correlation between postoperative functional outcomes and this delay in surgical treatment or other concomitant factors in large cohorts have not yet been performed to our knowledge. PURPOSE/HYPOTHESIS: The purpose of this study was to conduct an investigation in a large patient group regarding factors that could influence a patient's functional outcome after hamstring surgery. We hypothesized that this outcome would significantly correlate to the time between trauma and surgery. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Patients who received surgical treatment of proximal hamstring tendon avulsion injuries in our institution between the years 2010 and 2020 were asked to complete a validated, injury-specific outcome measurement, the Perth Hamstring Assessment Tool (PHAT; 0-100 points). In addition to calculating these outcomes, we evaluated the association of the obtained results with possible predictive factors such as age, sex, stump retraction shown on magnetic resonance imaging (MRI), and timing and duration of surgery. RESULTS: A total of 226 patients (227 operations) were eligible for the study, and 204 cases of hamstring tendon avulsion injury met our inclusion criteria. The return rate for the PHAT questionnaire was 85.3%. The mean PHAT score revealed good results (79.8 ± 19.1). Irrespective of concomitant factors, the scores of male patients were significantly higher compared with those of female patients (83.8 ± 16.9 vs 75.8 ± 20.6 respectively; P = .004). The mean time to surgery was 5.7 weeks after trauma, and more delayed surgery correlated significantly with lower PHAT scores (P = .003; r = -0.228). The mean degree of stump retraction on MRI (5 cm) did not significantly influence PHAT scores (P = .525; r = -0.06). CONCLUSION: Delay of surgery and female sex were disadvantageous in terms of a good functional outcome measure (PHAT score) after hamstring tendon refixation surgery. By contrast, patient age as well as the retraction of the tendon stump on preoperative MRI did not influence PHAT scores in the present study.

Surgical repair techniques, functional outcome, and return to sports after apophyseal avulsion fractures of the ischial tuberosity in adolescents.

PURPOSE: Among juvenile apophyseal avulsion injuries of the pelvis in adolescents, fractures of the ischial tuberosity are rare but sustainably debilitating. Also because informations on surgical repair options are very sparse and so far limited to general reviews, reports of individual cases or heterogeous small case series, practitioners, patients and their parental environment still feel a comprehensible hesitation regarding operative treatment. Therefore we intended to investigate patient related outcome measurements and return to sports rates after different types of surgical intervention in an own case series, so far unprecendented in its size. METHODS: Patient data of adolescents that underwent surgical intervention for a displaced apophyseal avulsion fracture of the ischial tuberosity between 01/2015 and 12/2019 in our institution were gathered. Patients were then evaluated using the hamstring injury specific Perth Hamstring Assessment Tool (PHAT). Furthermore the return to sports level in comparison to the particular pre-injury level was rated. RESULTS: Eleven adolescents with an acute or chronic mean fragment dislocation of 3.3 cm (SD ± 1.7) underwent surgical intervention in the assigned period. The mean post-operative PHAT score was 86.9 (0-100, SD ± 11.9) and thus good to excellent. The majority of adolescents (10/11) was able to return to their pre-injury sports, whereas 63.6% achieved full or nearly full level. CONCLUSIONS: Surgical refixation or restoration of aphoyseal avulsion fractures of the ischial tuberosity result in good to excellent outcomes and return to sport rates, irrespective of the type of intervention. Here prompt diagnosis with a timely intervention seems more promising than delayed interventions in chronic cases. Beyond 1.5 cm of fragment displacement affected patients should be counselled for surgical intervention.

Additional periarticular catheter shows no superiority over single-shot local infiltration analgesia alone in unicondylar knee replacement.

PURPOSE: Local infiltration analgesia (LIA) has attracted growing interest in recent years. To prolong the positive effects of LIA, a continuous intraarticular perfusion has been introduced in total knee arthroplasty with good clinical results. The purpose of the present study was to evaluate if similar results can be obtained with the use of a continuous periarticular perfusion in unicondylar knee arthroplasty (UKA). METHODS: 50 consecutively selected patients undergoing UKA received either a single-shot LIA (control group; n = 25) or single-shot LIA combined with a continuous postoperative periarticular perfusion for 2 postoperative days (intervention group, n = 25). VAS (visual analogue scale) for pain, pain medication consumption and range of flexion were recorded postoperatively for 6 days. The catheter was removed after 2 days. RESULTS: Only minor advantages of using a continuous periarticular catheter could be shown. Patients in the intervention group showed significant lower VAS scores on day 1 and required significant less pain medication on day 6. Further, there was a significant difference in the range of flexion on day 3, on which patients of the intervention group were able to bend the knee joint on average by 12° more than patients of the control group. On the other days, any significant differences between the two groups were not observed. CONCLUSION: In summary, the present study could not identify any superiority of a periarticular catheter over single-shot LIA in UKA. Because of additional costs and the potential risk of infection, the conclusion of this study is to not recommend adding a periarticular catheter to the single-shot LIA in UKA. LEVEL OF EVIDENCE: II.

Variations in medial and lateral slope and medial proximal tibial angle.

PURPOSE: The primary objective of this study was to quantify the variations of the medial posterior tibial slope (MPTS) and the lateral posterior tibial slope (LPTS), as well as of the medial proximal tibial angle (MPTA), and to determine the fraction of patients for which standard techniques including different alignment techniques would result in alteration of the patient's individual posterior tibial slope (PTS) and MPTA. Furthermore, it was of interest if a positive correlation between PTS and MPTA or between medial and lateral slope exists. METHODS: A retrospective study was performed on CT-scans of 234 consecutively selected European patients undergoing individual total knee replacement. All measurements were done on three-dimensional CAD models, which were generated on the basis of individual CT-scans, including the hip, knee, and ankle center. Measurements included the medial and lateral PTS and the MPTA. PTS was measured as the angle between the patient's articular surface and a plane perpendicular to the mechanical axis of the tibia in the sagittal plane. MPTA was defined as the angle between the tibial mechanical axis and the proximal articular surface of the tibia in the coronal plane. RESULTS: Analysis revealed a wide variation of the MPTS, LPTS, and MPTA among the patients. MPTS and LPTS varied significantly both interindividually and intraindividually. The range of PTS was up to 20° for MPTS (from - 4.3° to 16.8°) and for LPTS (from - 2.9 to 17.2°). The mean intraindividual difference between MPTS and LPTS in the same knee was 2.6° (SD 2.0) with a maximum of 9.5°. MPTA ranged from 79.8 to 92.1° with a mean of 86.6° (SD ± 2.4). Statistical analysis revealed a weak positive correlation between MPTA and MPTS. CONCLUSION: The study demonstrates a huge interindividual variability in PTS and MPTA as well as significant intraindividual differences in MPTS and LPTS. Therefore, the question arises, whether the use of standard techniques, including fixed PTSs and MPTAs, is sufficient to address every single patient's individual anatomy. LEVEL OF EVIDENCE: III.

High variability of proximal tibial asymmetry and slope: a CT data analysis of 15,807 osteoarthritic knees before TKA.

PURPOSE: As the correct rotational and sagittal alignment of the tibial tray are of key importance for optimal total knee arthroplasty (TKA) function, the objective of this study was to determine these individual variations in the proximal tibial geometry in terms of posterior tibial slope (PTS) and tibial surface asymmetry by analysing a large dataset of computer tomography (CT) information. METHODS: A retrospective two-part review was performed on 15,807 datasets that were generated during the design phase for a customized TKA implant. First, 15807 CAD (computer-aided-design) models derived from CT data were used to conduct the analysis on the variation of the PTS. Second, the axial cut of each proximal tibia in a consecutively selected subset of 2202 datasets was used to measure the tibial asymmetry. RESULTS: The majority (65.5%) of tibiae had a posterior slope between 5° and 10°, while 26.5% of knees had a slope > 10°. The asymmetry measured as offset between the lateral and medial posterior boundaries was highly variable, with overall an increasing proportion of patients with high asymmetry with increasing tibial ML width. Only 14% of tibiae exhibited symmetric (< 2 mm offset) lateral and medial plateaus, and 22% had an offset > 5 mm. CONCLUSION: This study from an extraordinary large data base reveals that tibial posterior slope and asymmetry of the tibial profile vary largely between patients receiving TKA with increasing tibial asymmetry with ML width. CT scans might help to preoperatively better select the best fitting TKA, otherwise surgeons intraoperatively will often have to deal with compromises regarding fitting, sizing and rotational issues. LEVEL OF EVIDENCE: Retrospective case series, Level IV.

Effectiveness of a home-based re-injury prevention program on motor control, return to sport and recurrence rates after anterior cruciate ligament reconstruction: study protocol for a multicenter, single-blind, randomized controlled trial (PReP).

BACKGROUND: Although anterior cruciate ligament (ACL) tear-prevention programs may be effective in the (secondary) prevention of a subsequent ACL injury, little is known, yet, on their effectiveness and feasibility. This study assesses the effects and implementation capacity of a secondary preventive motor-control training (the Stop-X program) after ACL reconstruction. METHODS AND DESIGN: A multicenter, single-blind, randomized controlled, prospective, superiority, two-arm design is adopted. Subsequent patients (18-35 years) with primary arthroscopic unilateral ACL reconstruction with autologous hamstring graft are enrolled. Postoperative guideline rehabilitation plus Classic follow-up treatment and guideline rehabilitation plus the Stop-X intervention will be compared. The onset of the Stop-X program as part of the postoperative follow-up treatment is individualized and function based. The participants must be released for the training components. The endpoint is the unrestricted return to sport (RTS) decision. Before (where applicable) reconstruction and after the clearance for the intervention (aimed at 4-8 months post surgery) until the unrestricted RTS decision (but at least until 12 months post surgery), all outcomes will be assessed once a month. Each participant is consequently measured at least five times to a maximum of 12 times. Twelve, 18 and 24 months after the surgery, follow-up-measurements and recurrence monitoring will follow. The primary outcome assessement (normalized knee-separation distance at the Drop Jump Screening Test (DJST)) is followed by the functional secondary outcomes assessements. The latter consist of quality assessments during simple (combined) balance side, balance front and single-leg hops for distance. All hop/jump tests are self-administered and filmed from the frontal view (3-m distance). All videos are transferred using safe big content transfer and subsequently (and blinded) expertly video-rated. Secondary outcomes are questionnaires on patient-reported knee function, kinesiophobia, RTS after ACL injury and training/therapy volume (frequency - intensity - type and time). All questionnaires are completed online using the participants' pseudonym only. Group allocation is executed randomly. The training intervention (Stop-X arm) consists of self-administered home-based exercises. The exercises are step-wise graduated and follow wound healing and functional restoration criteria. The training frequency for both arms is scheduled to be three times per week, each time for a 30 min duration. The program follows current (secondary) prevention guidelines. Repeated measurements gain-score analyses using analyses of (co-)variance are performed for all outcomes. TRIAL REGISTRATION: German Clinical Trials Register, identification number DRKS00015313 . Registered on 1 October 2018.