Short-Term Outcomes After Bipolar Osteochondral Allograft Transplantation (OCAT) in the Ankle.

Treatment options for symptomatic cartilage loss in the ankle are not consistently effective. This study documents initial outcomes for patients undergoing bipolar OCAT in the ankle after advances in tissue preservation, transplantation techniques, and patient management strategies were implemented. Patients were prospectively enrolled into a registry designed to follow outcomes after OCAT in the ankle. Fourteen patients were included for analyses (12 primary OCAT, 2 revision OCAT). Four patients underwent Bipolar OCAT (tibia, talus) and 10 Bipolar+ OCAT (tibia, talus, fibula). Short-term (median follow-up 43, range 13-73 months) success was documented for 13 patients. Radiographic assessments indicated OCA integration and maintenance of joint space in 12 patients. Statistically significant (p < .030) and clinically meaningful improvements in AAOS and VAS pain scores were noted at 3 months, 6 months, 1 year, and 2 years following OCA transplantation when compared to preoperative measures. For patients that were nonadherent to postoperative restriction and rehabilitation protocols, all 1-year postoperative PROs were significantly lower (p < .050) than for patients who were adherent. The successful outcomes documented in 13 of 14 patients in conjunction with significant and clinically meaningful improvements in patient-reported measures of pain and function support OCA transplantation as an appropriate treatment option in indicated patients. These improvements in outcomes were associated with advances in OCA preservation, preimplantation treatment, transplantation techniques, and patient management strategies, suggesting this shift in practice be considered for OCA transplantation in the ankle.

Human adenovirus lung disease: outbreaks, models of immune-response-driven acute lung injury and pandemic potential.

PURPOSE OF REVIEW: An overview of epidemic, human adenovirus (HAdV) lung infections with proposed studies of the viral/host immune response interface to better understand mechanisms of immunopathogenesis, for development of improved responses to a potential HAdV pandemic. RECENT FINDINGS: Emergent HAdV strains 7, 3, 4, 14 are the most common types associated with infection outbreaks. Recent outbreaks have revealed increased community spread, beyond epidemic group settings. The ongoing circulation of these virulent HAdV strains might allow for further HAdV adaptation, with increased HAdV spread and disease severity in the population that could theoretically result in expansion to a pandemic level. SUMMARY: Public health screening has revealed spread of HAdV outbreak strains to the general community. Despite expanded awareness of viral respiratory diseases during the SARS-CoV-2 pandemic, there has been limited, systematic monitoring of HAdV infection in the population. The shift in clinical laboratories to a focus on molecular diagnostics and away from classical methods of viral characterization has reduced the distribution of outbreak HAdV strains to the research community to study mechanisms of pathogenesis. This change risks reduced development of new preventive and therapeutic strategies that could be needed in the event of more widespread HAdV epidemics.

The Missouri Osteochondral Preservation System Is Associated With Better Short-Term Outcomes Than Standard Preservation Methods When Performing Osteochondral Allograft Transplantation Using Shell Grafts for Patellofemoral Lesions.

PURPOSE: To compare outcomes after whole-surface osteochondral allograft (OCA) transplantation using shell grafts for treatment of patellofemoral joint lesions with respect to surfaces treated and OCA preservation method. METHODS: With institutional review board approval and informed consent, patients were prospectively enrolled into a registry to follow outcomes after OCA transplantation. Patients who received patellofemoral shell OCA to treat the entire articular surface of the patella, trochlea, or both, and with a minimum of 2-year follow-up data, including patient-reported outcome measures (PROMs), failures, and complications, were included. Functional graft survival was determined based on patients returning to functional activities without need for OCA revision or arthroplasty surgery and calculated using the formula: 100% - (%revision + %failure). Minimum clinically important differences were determined based on previously validated data. Outcomes were compared based on differences in graft preservation methodology (Missouri Osteochondral Preservation System [MOPS] or standard preservation [SP]) and based on surfaces treated (patella, trochlea, or both). RESULTS: Fifty-eight patients met inclusion criteria. Mean age was 36.7 years (range 15-60 years) and mean body mass index was 28.9 (range 18-42). OCAs stored using SP methods were transplanted in 12 patients, mean follow-up was (66.1 months; range 54-70 months): OCAs stored using MOPS methods were transplanted in 46 patients, mean follow-up was (44.8 months; range 24-60 months). Graft survival rate at final follow-up was significantly greater (P = .025) for MOPS OCAs (98%) compared with SP OCAs (75%), whereas 2-year functional graft survival rates (MOPS 98% vs SP 83%; P = .1) were not. Reoperation rate was significantly greater (P = .0014) for SP cases compared with MOPS cases. PROMs showed statistically significant and clinically meaningful improvements through 4 years after unipolar patella, unipolar trochlea, and bipolar patellofemoral OCA transplantation using MOPS grafts. Unipolar patella OCA transplantations were associated with significantly more reduction in pain and significantly better PROMs at 1-year compared with unipolar trochlea and bipolar patellofemoral OCAs. CONCLUSIONS: OCA transplantation using MOPS shell grafts for unipolar and bipolar patellofemoral resurfacing was associated with statistically significant and clinically meaningful improvements from preoperative levels of pain and function. The 2-year functional graft survival rate was 83% in the SP group and 98% in the MOPS group, such that MOPS was associated with better short-term outcomes than SP methods when performing OCA transplantation using shell grafts for patellofemoral lesions. Patients who received unipolar patella allografts reported the best outcomes in terms of pain and function. LEVEL OF EVIDENCE: Level III, retrospective analysis of registry data.

Functional biomechanical comparison of Latarjet vs. distal tibial osteochondral allograft for anterior glenoid defect reconstruction.

INTRODUCTION: Glenoid reconstruction is indicated for recurrent glenohumeral instability with significant glenoid bone deficiency. Coracoid autograft (Latarjet) and distal tibial osteochondral allograft (DTA) reconstructions have been used to successfully restore glenohumeral stability. Relative advantages and disadvantages associated with each reconstruction technique have been described. However, direct comparisons of functional glenohumeral biomechanics associated with Latarjet vs. DTA reconstruction are lacking. This study was designed to compare these 2 glenoid reconstruction techniques with respect to joint kinematics and cartilage pressure mapping using a robotic testing system. METHODS: In accordance with institutional review board policies, human cadaveric shoulders (n = 8) were cyclically tested in the neutral position and 90° of external rotation with 60° and 90° of abduction under a 45-N joint-compression load to measure clinically relevant translations, loads, and torques. Joint contact pressure maps were obtained under a 120-N joint-compression load using pressure mapping sensors. After confirming that a 25% anterior glenoid defect resulted in glenohumeral dislocation, testing was performed to compare 3 conditions: native intact glenoid, 25% anterior glenoid defect with Latarjet reconstruction, and 25% anterior glenoid defect with DTA reconstruction. Analyses of variance and t tests were used to analyze data with statistical significance set at P < .05. RESULTS: Significant differences in anterior translation, inferior drawer, anterior drawer, compression loads, horizontal abduction, negative elevation (adduction), and external rotation torques during cyclical testing in 90° of external rotation with 60° and/or 90° of abduction were noted when comparing the 2 different glenoid bone reconstruction techniques to native, intact shoulders. The only significant difference between Latarjet and DTA reconstructions for measured translations, loads, and torques was a significantly higher absolute maximum compressive load for Latarjet compared to DTA at 60° of abduction. CONCLUSION: Latarjet coracoid osseous autograft and distal tibial osteochondral allograft reconstructions of large (25%) glenoid bone defects prevent failure (dislocation) and are associated with significant glenohumeral kinematic differences that largely confer less translation, load, and torque on the joint in abduction when compared to the native state. These findings suggest that these 2 surgical techniques exhibit similar glenohumeral kinematics such that each provides adequate functional stability following anterior glenoid bone reconstruction. Joint compression load and articular contact pressure distribution may favor distal tibial osteochondral allograft reconstruction for treatment of large (25%) anterior glenoid bone defects associated with shoulder instability.

Do Patients Living in Rural Areas Report Inferior 1-Year Outcomes After Total Knee Arthroplasty? A Matched Cohort Analysis.

BACKGROUND: Rural status has been associated with poor outcomes for several health problems, but its relationship and outcomes following total knee arthroplasty (TKA) has not been fully characterized. Patient-reported outcomes (PROs) are key measures of success following TKA. Therefore, this matched cohort study was designed to test the hypothesis that patients who live in rural settings will report significantly worse PRO scores 1 year after TKA when compared to those who live in urban or suburban settings. METHODS: Patients undergoing TKA at our institution were categorized into urban, suburban, and rural cohorts based on Rural Urban Commuting Area scores using reported living setting zip codes. Cohorts were matched for body mass index classification. Demographic data were extracted from the medical records, and PRO data (Knee Injury and Osteoarthritis Outcome Score, Joint Replacement (KOOS JR), Patient-Reported Outcomes Measurement Information System (PROMIS) Global Health and Mental Health, University of California, Los Angeles (UCLA) Activity Score, and Visual Analog Scale Pain were collected preoperatively and 1-year postoperatively. Comparisons across living settings were made using analysis of variance (ANOVA) tests or Chi-square tests. A total of 882 TKA patients (n = 294 per cohort) were analyzed. RESULTS: Patients living in urban areas had significantly lower preoperative pain scores compared to suburban and rural residents. All measured PROs significantly improved from preoperative levels at 1 year post-TKA with no significant differences among living setting cohorts. CONCLUSIONS: In cohorts matched for body mass index, living in a rural setting was not associated with inferior PROs 1 year after TKA. LEVEL OF EVIDENCE: Level 4, retrospective cohort study.

Lumbar spine intervertebral disc desiccation is associated with medical comorbidities linked to systemic inflammation.

INTRODUCTION: Symptomatic disc degeneration is a common cause of low back pain. Recently, the prevalence of low back pain has swiftly risen leading to increased patient disability and loss of work. The increase in back pain also coincides with a rapid rise in patient medical comorbidities. However, a comprehensive study evaluating a link between patient's medical comorbidities and their influence on lumbar intervertebral disc morphology is lacking in the literature. METHODS: Electronic medical records (EMR) were retrospectively reviewed to determine patient-specific medical characteristics. Magnetic resonance imaging (MRI) was evaluated for lumbar spine intervertebral disc desiccation and height loss according to the Griffith-modified Pfirrmann grading system. Bivariate and multivariable linear regression analyses assessed strength of associations between patient characteristics and lumbar spine Pfirrmann grade severity (Pfirrmann grade of the most affected lumbar spine intervertebral disc) and cumulative grades (summed Pfirrmann grades for all lumbar spine intervertebral discs). RESULTS: In total, 605 patients (304 diabetics and 301 non-diabetics) met inclusion criteria. Bivariate analysis identified older age, diabetes, American Society of Anesthesiologists (ASA) class, hypertension, chronic obstructive pulmonary disease (COPD), peripheral vascular disease, and hypothyroidism as being strongly associated with an increasing cumulative Pfirrmann grades. Multivariable models similarly found an association linking increased cumulative Pfirrmann grades with diabetes, hypothyroidism, and hypertension, while additionally identifying non-white race, heart disease, and previous lumbar surgery. Chronic pain, depression, and obstructive sleep apnea (OSA) were associated with increased Pfirrmann grades at the most affected level without an increase in cumulative Pfirrmann scores. Glucose control was not associated with increasing severity or cumulative Pfirrmann scores. CONCLUSION: These findings provide specific targets for future studies to elucidate key mechanisms by which patient-specific medical characteristics contribute to the development and progression of lumbar spine disc desiccation and height loss. LEVEL OF EVIDENCE: III (retrospective cohort).

Household Income and Parental Educational Level Affect Post-Operative Opioid Usage in Pediatric Orthopaedic Patients.

Opioid medications are commonly prescribed after pediatric orthopaedic surgery, but there is a critical need to optimize prescribing practice. This study identifies socio-economic characteristics, surgical characteristics, and patient reported psychological factors influencing postoperative opioid use in this population and found that post-operative opioid use in this pediatric orthopaedic population is multifactorial. Physicians should consider implementing protocols for initial opioid prescriptions to cover two to three days following common orthopaedic surgeries for most pediatric patients.

An Injectable Containing Morphine, Ropivacaine, Epinephrine, and Ketorolac Is Not Cytotoxic to Articular Cartilage Explants From Degenerative Knees.

PURPOSE: The purpose of this study was to determine the effects of a multidrug injectate containing morphine, ropivacaine, epinephrine, and ketorolac, commonly referred to as the "Orthococktail," on cartilage tissue viability and metabolic responses using an established in vitro model. METHODS: With institutional review board approval and informed patient consent, tissues normally discarded after total knee arthroplasty (TKA) were recovered. Full-thickness cartilage explants (n = 72, Outerbridge grade 1 to 3) were created and bisected. Paired explant halves were treated with either 1 mL Orthococktail or 1 mL of saline and cultured for 8 hours at 37°C, with 0.5 mL of the treatment being removed and replaced with tissue culture media every hour. Explants were cultured for 6 days, and media were changed and collected on days 3 and 6. After day 6, tissues were processed for cell viability, weighed, and processed for histologic grading. Outcome measures were compared for significant differences between treated and untreated samples. RESULTS: There were no significant differences in cartilage viability between control and Orthococktail-treated samples across a spectrum of cartilage pathologies. Orthococktail treatment consistently resulted in a significant decrease in the release of PGE2, MCP-1, MMP-7, and MMP-8 on day 3 of culture and PGE2, MMP-3, MMP-7, and MMP-8 on day 6 of culture, compared with saline controls. CONCLUSION: The results of the present study indicate that an Orthococktail injection composed of morphine, ropivacaine, epinephrine, and ketorolac is associated with a transient decrease in degradative and inflammatory mediators produced by more severely affected articular cartilage and may mitigate perioperative joint pain such that postoperative narcotic drug use could be reduced. CLINICAL RELEVANCE: The Orthococktail solution used in this study may be a safe intraoperative, intra-articular injection option for patients undergoing joint arthroplasty and other joint preservation surgical procedures.

Survey of Orthopaedic Trauma Providers: Is MRI Superior to CT Scan for Evaluating and Preoperative Planning for Tibial Plateau Fractures?

A computerized tomography (CT) scan is the current advanced imaging standard of care for evaluation and preoperative planning for tibial plateau fractures, but magnetic resonance imaging (MRI) is emerging as a better method to identify soft tissue injuries. This study compares MRI and CT for fracture classification, associated soft tissue injuries, and preoperative planning for tibial plateau fractures. MRI offers lack of radiation and enhanced soft tissue evaluation, and as a result improved preoperative planning. MRI was favored among survey respondents for preoperative planning, Schatzker classification, and surgical approach planning.

Biologic Joint Restoration: A Translational Research Success Story.

Treatment options that result in consistently successful outcomes for young and active patients with joint disorders are needed. This article summarizes two decades of rigorous research using a bedside-to-bench- to-bedside translational approach based on the One Health - One Medicine concept that culminated in successful clinical use of biologic joint restoration options for treatment of knee, hip, ankle, and shoulder problems in this growing patient population.

Superior Capsular Reconstruction Using Dermal Allograft Is a Safe and Effective Treatment for Massive Irreparable Rotator Cuff Tears: 2-Year Clinical Outcomes.

PURPOSE: To evaluate functional, symptomatic, and diagnostic imaging outcomes after arthroscopic superior capsular reconstruction (SCR) using dermal allograft in patients with massive irreparable rotator cuff tears. METHODS: From 2015 to 2017, this multicenter study retrospectively evaluated patients undergoing arthroscopic SCR for treatment of symptomatic massive rotator cuff tears. Study criteria included the presence of a massive irreparable rotator cuff tear with retraction to the glenoid without diffuse bipolar cartilage loss, Grade 4 or 5 Hamada classification, and subscapularis pathology that could not be addressed. All SCR procedures were performed with neutral abduction of the arm at the time of implantation. Outcome measures included visual analog pain scale (VAS) score, the American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numeric Evaluation (SANE) score, and active forward elevation (FE) through 2 years postoperatively. Imaging analyses included radiographs, ultrasound, and magnetic resonance imaging at 6 months and 1 year. RESULTS: Fourteen patients met all study criteria including required follow-up. There were statistically significant improvements in VAS pain (3.3-0.6, P = .001), ASES (55.0-86.5, P < .0001), SANE (33.1-71.5, P < .0001), and active FE (128-172, P = .0005) with mean follow-up of 2.1 years. Twelve patients (86%) met the minimum clinically important difference in VAS pain, ASES, and SANE. Thirteen grafts (93%) had ultrasonographic evidence for vascularity by 1 year postoperatively. There were 2 graft complications (14%) with one (7%) requiring revision to reverse total shoulder arthroplasty. CONCLUSIONS: Arthroscopic SCR using dermal allograft can be a safe and effective treatment option for patients with massive irreparable rotator cuff tears with statistically significant improvements in VAS pain, ASES, SANE, and active FE at 2-years postoperatively, with 93% of grafts demonstrating vascularity at 1-year postoperatively. Neutral abduction of the arm at the time of implantation resulted in positive clinical outcomes and may decrease graft failure rate. LEVEL OF EVIDENCE: Level IV, case series.

Histologic evidence for a humoral immune response in synovitis associated with cranial cruciate ligament disease in dogs.

OBJECTIVE: To investigate histopathological features of synovium from dogs with cranial cruciate ligament disease (CCLD) to seek mechanisms of osteoarthritis (OA) associated with CCLD. STUDY DESIGN: Retrospective, single-institution case series. ANIMALS: Thirty client-owned dogs. METHODS: Synovial biopsies (n = 30) obtained from stifles with CCLD were assessed by using two synovitis histopathology grading systems (Krenn and Hospital for Special Surgery [HSS]). The Krenn synovitis score was interpreted as "no synovitis," "low-grade," or "high-grade," while inflammatory subtype (low, mixed, or high) was determined by a computational algorithm within the HSS system. Comparison of synovitis scores was based on degree of CCL rupture and presence of meniscal tears. RESULTS: Histopathological changes and synovitis scores were similar regardless of degree of rupture (partial n = 5, complete n = 25) or presence of meniscal injury (n = 12) and were characterized by hyperplastic and lymphoplasmacytic synovitis with increased vascularity (30/30) and the presence of hemosiderin deposits (28/30), binucleated plasma cells (28/30), mucoid change (25/30), and Mott cells (16/30). Thirteen (43%) specimens were consistent with high-grade synovitis according to the Krenn system, while 11 (37%) specimens fit into the high-inflammatory subtype with the HSS system. CONCLUSION: Synovitis associated with canine CCLD in this study population was lymphoplasmacytic and was often highly inflammatory, with the presence of cells pertaining to humoral immunity. Humoral immune responses may play key roles in the synovitis associated with CCLD. CLINICAL SIGNIFICANCE: Modulation of biological factors that provoke humoral immune responses may mitigate symptoms of OA that persist and progress even after surgical treatment of CCLD in dogs.

What Are the Risk Factors for an Upper Extremity Deep Venous Thrombosis After Orthopaedic Irrigation and Debridement and Peripherally Inserted Central Catheter Placement?

BACKGROUND: Peripherally inserted central catheter (PICC) placement is necessary for delivery of intravenous (IV) antibiotics to treat bone and soft tissue infections. Upper extremity deep venous thrombosis (DVT) after PICC placement is a complication with unknown incidence in the orthopaedic literature. The major objectives of this study are Identifying the rate of upper extremity PICC-associated DVTs after orthopaedic procedures;Which orthopaedic subspecialties are most likely to encounter an upper extremity PICC-associated DVT?What surgeries or medical comorbidities are risk factors for upper extremity PICC-associated DVTs?Does type of DVT chemoprophylaxis decrease the risk of an upper extremity PICC-associated DVT? METHODS: A retrospective review of electronic medical records (EMR) was performed to include all patients undergoing irrigation and debridement (I&D) for treatment of orthopaedic surgery-related infections over a 10-year period. All patients with PICC placement were included for analyses. Age, sex, and medical comorbidities were extracted from the EMR. Mann-Whitney non-parametric tests, Fisher's exact tests, Chi-square tests, and Cochran-Mantel-Haenszel (CMH) tests were used to determine associations with DVT events for those with PICCs based on medical comorbidities, PICC lumen size, team placing the PICC, impact of implant removal, and protective effect of DVT chemoprophylaxis. Significance was set at p<0.05. RESULTS: Twenty-one of 660 patients (3.18% rate) were found to have an upper extremity PICC-associated DVT. A history of DVT (OR=8.99 [95% CI: 3.39, 49.42]) was significantly associated with an upper extremity PICC-associated DVT. The greatest risk for an upper extremity PICC-associated DVT was intramedullary implant removal (OR=12.43 [95% CI: 3.13, 49.52]). The type of DVT chemoprophylaxis did not significantly affect the likelihood of an upper extremity PICC-associated DVT. CONCLUSION: Intramedullary implant removal and a history of DVT are risk factors for an upper extremity PICC-associated DVT. The results of this study should be of particular interest to surgeons who do not typically give DVT prophylaxis and plan to perform surgery on patients with CHF, a history of a DVT, or plan to manipulate the intramedullary canal.

Pulsed electromagnetic fields promote repair of focal articular cartilage defects with engineered osteochondral constructs.

Articular cartilage injuries are a common source of joint pain and dysfunction. We hypothesized that pulsed electromagnetic fields (PEMFs) would improve growth and healing of tissue-engineered cartilage grafts in a direction-dependent manner. PEMF stimulation of engineered cartilage constructs was first evaluated in vitro using passaged adult canine chondrocytes embedded in an agarose hydrogel scaffold. PEMF coils oriented parallel to the articular surface induced superior repair stiffness compared to both perpendicular PEMF (p = .026) and control (p = .012). This was correlated with increased glycosaminoglycan deposition in both parallel and perpendicular PEMF orientations compared to control (p = .010 and .028, respectively). Following in vitro optimization, the potential clinical translation of PEMF was evaluated in a preliminary in vivo preclinical adult canine model. Engineered osteochondral constructs (∅ 6 mm × 6 mm thick, devitalized bone base) were cultured to maturity and implanted into focal defects created in the stifle (knee) joint. To assess expedited early repair, animals were assessed after a 3-month recovery period, with microfracture repairs serving as an additional clinical control. In vivo, PEMF led to a greater likelihood of normal chondrocyte (odds ratio [OR]: 2.5, p = .051) and proteoglycan (OR: 5.0, p = .013) histological scores in engineered constructs. Interestingly, engineered constructs outperformed microfracture in clinical scoring, regardless of PEMF treatment (p < .05). Overall, the studies provided evidence that PEMF stimulation enhanced engineered cartilage growth and repair, demonstrating a potential low-cost, low-risk, noninvasive treatment modality for expediting early cartilage repair.

Metabolic responses of meniscal tissue to focal collagenase degeneration.

Purpose: The objective of this study was to determine the responses of normal meniscus to collagenase activity. It was hypothesized that meniscal explants exposed to collagenase would significantly increase release of pro-inflammatory cytokines and degradative enzymes, in a dose-dependent manner, compared to control.Methods: Menisci were harvested from adult dogs (n = 6) euthanized for reasons unrelated to this study. Meniscal explants were created from the central portion of lateral and medial meniscus. Explants were injected with 100 µl collagenase at a concentration of 50 µg/ml, 5 µg/ml, or 0 µg/ml of collagenase. Explants were cultured for 12 days, and media were changed and collected every 3 days for biomarker analyses. Differences among collagenase concentrations were determined by a three factor ANOVA with adjustment for multiple comparisons, with pre-adjustment statistical significance set at p < 0.05.Results: When data from all explants were compared, the 50 µg group released significantly higher IL-6 and PGE2, and the 5 µg group released significantly higher levels of MMP-3 and CTX-II compared to the 0 µg group. Explants from the medial meniscus released significantly more MMP-1, MMP-2, MMP-3, and MMP-13 in response to stimulation with 5 µg/ml of collagenase compared to explants from the lateral meniscus.Discussion: The data from this study indicate that in response to localized degradative enzyme activity, the meniscus increases the release of pro-inflammatory and degradative biomarkers in a dose-dependent manner. Further, these data indicate potential differences in metabolic responses of lateral versus medial menisci to collagenase insult.

Does Blood Flow Restriction Therapy in Patients Older Than Age 50 Result in Muscle Hypertrophy, Increased Strength, or Greater Physical Function? A Systematic Review.

BACKGROUND: Blood flow restriction (BFR) is a process of using inflatable cuffs to create vascular occlusion within a limb during exercise. The technique can stimulate muscle hypertrophy and improve physical function; however, most of these studies have enrolled healthy, young men with a focus on athletic performance. Furthermore, much of the information on BFR comes from studies with small samples sizes, limited follow-up time, and varied research designs resulting in greater design, selection, and sampling bias. Despite these limitations, BFR's popularity is increasing as a clinical rehabilitation tool for aging patients. It is important for practitioners to have a clear understanding of the reported effects of BFR specifically in older adults while simultaneously critically evaluating the available literature before deciding to employ the technique. QUESTIONS/PURPOSES: (1) Does BFR induce skeletal muscle hypertrophy in adults older than 50 years of age? (2) Does BFR improve muscle strength and/or physical function in adults older than 50 years? METHODS: Using PubMed, Google Scholar, Web of Science, and Science Direct, we conducted a systematic review of articles using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to assess the reported effects of BFR on skeletal muscle in older adults. Included articles enrolled participants 50 years of age or older and used BFR in conjunction with exercise to study the effects of BFR on musculoskeletal outcomes and functionality. The following search terms were used: "blood flow restriction" OR "KAATSU" OR "ischemic training" AND "clinical" AND "elderly." After duplicates were removed, 1574 articles were reviewed for eligibility, and 30 articles were retained with interventions duration ranging from cross-sectional to 16 weeks. Sample sizes ranged from 6 to 56 participants, and exercise tasks included passive mobilization or electrical stimulation; walking; resistance training using machines, free weights, body weight, or elastic bands; and water-based activities. Furthermore, healthy participants and those with cardiovascular disease, osteoarthritis, osteoporosis, sporadic inclusion body myositis, spinal cord injuries, and current coma patients were studied. Lastly, retained articles were assigned a risk of bias score using aspects of the Risk of Bias in Nonrandomized Studies of Interventions and the Cochrane Collaboration's tool for assessing the risk of bias in randomized trials. RESULTS: BFR, in combination with a variety of exercises, was found to result in muscle hypertrophy as measured by muscle cross-sectional area, thickness, volume, mass, or circumference. Effect sizes for BFR's ability to induce muscle hypertrophy were calculated for 16 of the 30 papers and averaged 0.75. BFR was also shown to improve muscle strength and functional performance. Effect sizes were calculated for 21 of the 30 papers averaging 1.15. CONCLUSIONS: Available evidence suggests BFR may demonstrate utility in aiding rehabilitation efforts in adults older than 50 years of age, especially for inducing muscle hypertrophy, combating muscle atrophy, increasing muscle strength, and improving muscle function. However, most studies in this systematic review were at moderate or high risk of bias; that being so, the findings in this systematic review should be confirmed, ideally using greater sample sizes, randomization of participants, and extended follow-up durations. LEVEL OF EVIDENCE: Level II, systematic review.

Use of a Hyperosmolar Saline Solution to Mitigate Proinflammatory and Degradative Responses of Articular Cartilage and Meniscus for Application to Arthroscopic Surgery.

PURPOSE: This study was designed to evaluate differences in proinflammatory and degradative mediator production and extracellular matrix degradation from osteoarthritic knee articular cartilage and meniscus explants treated with either hyperosmolar saline or isotonic saline. METHODS: 6 mm-diameter full-thickness explants were created from articular cartilage and menisci recovered after patients underwent knee surgery. One explant half was treated for 3 hours with hyperosmolar saline (600 mOsm/L) and the corresponding half with isotonic saline (300 mOsm/L). Explants were subsequently cultured for 3 days in tissue culture media. On day 3, media were collected for biomarker analyses. Results were normalized to tissue wet weight and analyzed statistically. RESULTS: Articular cartilage was collected from 10 patients (5 male, 5 female; mean age = 66.9 years) and menisci were collected from 8 patients (2 male, 6 female; mean age = 66 years). Articular cartilage media concentrations of monocyte chemoattractant protein-1 (P = .001) and interleukin (IL)-6 (P = .049) were significantly lower in explants treated with hyperosmolar saline. Meniscus media concentrations of prostaglandin E2 (P = .008), monocyte chemoattractant protein-1 (P = .011), IL-6 (P = .029), IL-8 (P = .012), matrix metalloproteinase-2 (P = .011), and glycosaminoglycan (P = .008) were significantly lower in explants treated with hyperosmolar saline. CONCLUSIONS: Treatment of cartilage and meniscus explants with hyperosmolar saline effectively mitigated key proinflammatory mediator production, as well as degradative mediator production and glycosaminoglycan loss from meniscus, with no detrimental effects noted compared to isotonic saline. CLINICAL RELEVANCE: These results suggest that hyperosmolar saline irrigation fluid may provide a safe alternative to standard isotonic saline irrigation fluid, and could mitigate untoward effects associated with inflammatory responses after standard-of-care knee arthroscopy.

Comparison of biologic scaffolds for augmentation of partial rotator cuff tears in a canine model.

BACKGROUND: This study was designed to test the hypothesis that biologic scaffold augmentation of articular-sided partial-thickness supraspinatus tendon tears would be associated with superior functional, imaging, biomechanical, and histologic properties compared with untreated tears in a preclinical canine model. METHODS: With Institutional Animal Care and Use Committee approval, dogs (n = 16) underwent half-thickness resection of the articular portion of the supraspinatus tendon (SST). Defects were treated by débridement (DB) (n = 8) or scaffold augmentation on the bursal side using amnion matrix cord scaffold (AM) (n = 8), decellularized human dermal allograft (AF) (n = 8), or bovine collagen patch (RMP) (n = 8). Control dogs (n = 4; 8 normal shoulders) were included. Assessments included lameness, function, comfortable shoulder range of motion (CROM), pain, ultrasonography, magnetic resonance imaging (MRI), arthroscopy, gross examination, biomechanical testing, and histopathology. RESULTS: At 3 months, CROM was significantly lower and pain significantly higher in DB compared with all other groups. At 6 months, CROM was significantly lower and pain significantly higher in RMP compared with AM and AF, and AM and AF showed significantly less thickening than DB and RMP. AF had the least severe MRI pathology and AM had significantly less MRI pathology than DB. AF SSTs and biceps tendons showed the least severe histopathology, and AM SSTs showed significantly less histopathology than DB and RMP SSTs. CONCLUSION: Biologic scaffolds can be effective in augmenting healing of articular-sided partial-thickness SST tears when compared with débridement in a preclinical canine model. Decellularized human dermal allograft and amnion matrix cord may have advantages over the bovine collagen patch for use in this indication.

Effect of NSAID Use on Bone Healing in Pediatric Fractures: A Preliminary, Prospective, Randomized, Blinded Study.

BACKGROUND: This study aimed to investigate if nonsteroidal anti-inflammatory drugs (NSAIDs) used in the acute phase of bone healing in children with fractures result in delayed union or nonunion as compared with patients who do not take NSAIDs for pain control during this same time period. METHODS: In this prospective, randomized, parallel, single-blinded study, skeletally immature patients with long bone fractures were randomized to 1 of 2 groups for their postfracture pain management. The NSAID group was prescribed weight-based ibuprofen, whereas the control group was not allowed any NSAID medication and instead prescribed weight-based acetaminophen. Both groups were allowed to use oxycodone for breakthrough pain. The primary outcome was fracture healing assessed at 2, 6, and 10 weeks. RESULTS: One-hundred-two patients were enrolled between February 6, 2014 and September 23, 2016. Ninety-five patients (with 97 fractures) completed a 6-month follow-up (46 patients with 47 fractures in the control group and 49 patients 50 fractures in the NSAID group). None achieved healing at 1 to 2 weeks. By 6 weeks, 37 of 45 patients (82%) of control group and 46 out of 50 patients (92%) of ibuprofen group had healed fractures (P=0.22). At 10 to 12 week follow-up, 46 (98%) of the control group fractures were healed and 50 (100%) of the ibuprofen group fractures were healed. All were healed by 6 months. Healing was documented at a mean of 40 days in the control group and 31 days in the ibuprofen group (P=0.76). The mean number of days breakthrough oxycodone was used was 2.4 days in the control group and 1.9 days in the NSAID group (P=0.48). CONCLUSION: Ibuprofen is an effective medication for fracture pain in children and its use does not impair clinical or radiographic long bone fracture healing in skeletally immature patients. LEVEL OF EVIDENCE: Level I-therapeutic.

Editorial Commentary: Bone Marrow Aspirate Biologics for Osteochondral Allografts-Because We Can or Because We Should?

Orthobiologics are all the rage these days, and one of the hottest areas of study involves the use of autogenous bone marrow-derived biologics for preimplantation treatment of osteochondral allografts. Three recent Level III cohort studies based on shifts in practice have reported early imaging-based assessments of osteochondral allograft bone integration in the knee. Each study had unique, major limitations, and each reported disparate results. Based on this limited and contrasting available evidence, bone marrow aspirate-with or without concentration, for preimplantation treatment of osteochondral allografts-can be used based on safety, regulatory compliance, and basic science rationale. It does appear, however, to have the greatest clinical impact in "higher demand" cases in which allograft bone integration may be hampered based on patient factors, graft size and geometry, and/or implantation technique.