Femoral nerve block at time of ACL reconstruction causes lasting quadriceps strength deficits and may increase short-term risk of re-injury.

PURPOSE: To determine whether femoral nerve blockade (FNB) at the time of primary ACL reconstruction is associated with meeting isokinetic extension strength return to sport criteria near completion of physical therapy and whether FNB affects 1-year or 2-year risk of ipsilateral ACL graft rupture or contralateral native ACL injury. METHODS: Three-hundred and sixty patients (n = 244 with FNB, n = 116 no FNB) underwent primary ACL reconstruction. All patients completed rehabilitation and underwent functional strength testing towards the end of knee rehabilitation (mean 5.6 months post-surgery). Association between FNB and isokinetic extension strength limb symmetry index (LSI) (goal LSI ≥ 90% for return to sport) as well as risk of recurrent ACL injury within first or second year after surgery was evaluated. RESULTS: Ipsilateral or contralateral ACL injury within 2 years occurred in 11.2% of patients with FNB and 5.7% without FNB (p = 0.01). Patients with FNB had higher incidence of ipsilateral graft rupture within the first year after surgery but no difference in graft rupture during the second. Two-year risk of contralateral ACL injury was similar in both groups. At the time of initial testing, patients who received FNB had lower fast isokinetic extension LSI versus patients without FNB and were less likely achieve a goal ≥ 90% LSI; slow extension LSI was unaffected. CONCLUSION: Use of FNB at the time of primary ACL reconstruction can negatively affect achievement of isokinetic extension strength return to sport criteria. FNB increases risk of graft rupture within the first year after surgery but does not affect re-injury risk during the second. FNB may not be appropriate for use in patients already at high risk of ACL re-injury. LEVEL OF EVIDENCE: III.

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.

Bacterial DNA is associated with tunnel widening in failed ACL reconstructions.

PURPOSE: To determine if tunnel widening, defined as change in maximal tunnel diameter from the time of initial bone tunnel drilling to revision surgery is associated with bacterial deoxyribonucleic acid (DNA) presence and concentration in torn graft tissue from failed anterior cruciate ligament reconstructions (ACLRs). METHODS: Thirty-four consecutive revision ACLRs were included (mean age 27.3 years SD 10.9; median time to failure 4.9 years range 105 days-20 years). Graft selection of the failed reconstruction was 68% autograft, 26% allograft, and 6% autograft/allograft hybrid with a mean drilled tunnel diameter of 8.4 mm SD 0.8. Maximal tunnel diameters prior to revision were measured on pre-operative three-dimensional imaging and compared to drilled tunnel diameters at the time of the previous reconstruction. Tissue biopsies of the failed graft were obtained from tibial, femoral, and intraarticular segments. Sterile water left open to air during revision ACLRs and tissue from primary ACLRs were used as negative controls. Clinical cultures were obtained on all revision ACLRs and PCR with universal bacterial primer on all cases and negative controls. Fluorescence microscopy was used to confirm the presence and location of biofilms in two patients with retrieved torn graft tissue and fixation material. Amount of tunnel widening was compared to bacterial DNA presence as well as bacterial DNA concentration via Welch ANOVA. RESULTS: Bacterial DNA was present in 29/34 (85%) revision ACLRs, 1/5 (20%) of primary ACLR controls and 0/3 (0%) sterile water controls. Cultures were positive (coagulase negative Staphylococcus sp.) in one case, which also had the greatest degree of tunnel widening. Femoral widening was greater in cases with detectable bacterial DNA (mean widening 2.6 mm SD 3.0) versus without (mean 0.3 mm SD 0.6) (p = 0.003) but was unaffected by bacterial DNA concentration (p = 0.44). Tibial widening was not associated with the presence of bacterial DNA (n.s.); however, higher bacterial DNA concentrations were observed in cases with tibial widening ≥ 3.0 mm (median 2.47 ng bacterial DNA/µg total DNA) versus widening < 3.0 mm (median 0.97 ng bacterial DNA/µg total DNA) (p = 0.046). Tunnel widening was not associated with time to failure, graft selection, or number of prior surgeries (n.s., all comparisons). Fluorescence microscopy confirmed the presence of biofilms on ruptured tendon graft as well as fixation material in 2/2 cases. CONCLUSION: Bacterial DNA is commonly encountered on failed ACLR grafts and can form biofilms. Bacterial DNA does not cause clinically apparent infection symptoms but is associated with tunnel widening. Further research is needed to determine whether graft decontamination protocols can reduce graft bacterial colonization rates, ACLR tunnel widening or ACLR failure risk. LEVEL OF EVIDENCE: Therapeutic III.

Risk of Retear Following Anterior Cruciate Ligament Reconstruction Using a Hybrid Graft of Autograft Augmented With Allograft Tissue: A Systematic Review and Meta-analysis.

PURPOSE: To compare the risk of anterior cruciate ligament reconstruction failure in patients who undergo anterior cruciate ligament reconstruction with either autograft tissue or hybrid grafts. METHODS: A systematic search was performed on February 28, 2018, on PubMed, Scopus, Arthroscopy, and Cochrane Library. Included studies were clinical outcome studies of primary anterior cruciate ligament reconstructions that compared failure risk for hybrid grafts versus autografts. Baseline and outcomes data were extracted, and reporting quality was assessed via modified Coleman criteria. A random effects meta-analysis was conducted for both randomized and nonrandomized studies. RESULTS: Nine studies were identified with a mean of 40.1 months of follow-up. The mean Coleman methodology score was 66.5 (standard deviation, 12.8). One randomized study (Level II evidence) was identified with no difference in failure rates (0% for both groups, 8-mm minimum graft diameter for all patients). Eight nonrandomized studies (all Level III evidence) were identified with no difference in failure risk for hybrid grafts versus autograft (pooled odds ratio, 1.29; 95% confidence interval, 0.57-2.92; P = .55; I2 = 34%). Mean graft diameters were significantly larger in hybrid groups (range, 8.5-9.9 mm) than in autograft groups (range, 6.4-8.8 mm) in nonrandomized studies (mean difference, 0.5-2.5 mm; P ≤ .003). There was no evidence of small study bias or bias owing to reporting quality, and adjustment for length of follow-up, mean patient age, percentage of male patients, year of publication, or reporting quality did not improve statistical heterogeneity. CONCLUSIONS: Based on the current literature, although it may be theoretically detrimental to add allograft to a small-diameter autograft, it cannot be definitively shown based on the findings of this review with meta-analysis. Currently, it remains unclear that there is an advantage or disadvantage to hybridization of small autograft with allograft, although randomized studies of patients with small (<8-mm) autograft diameters are lacking. LEVEL OF EVIDENCE: Level III, systematic review of Level II and III studies.

Prevalence of depression among diabetic patients attending the Armed Forces Hospital, Southern Region, Saudi Arabia: A prospective cross-sectional study.

Background: Depression associated with diabetes is one of major obstacles in diabetic patient management. This study aims to determine the prevalence of depression and its associated risk factors among diabetic patients of both types (I and II). Materials and Methods: A cross-sectional analytical study was conducted at Armed Forces Hospital, Southern Region, Kingdom of Saudi Arabia, among adult diabetic patients attending the diabetic center. An interview-validated questionnaire was utilized to collect data. It consists of three main parts: demographic data, diabetic assessment tool, and patient health questionnaire-9. Results: A total of 386 diabetic patients were included. The age of them ranged between 17 and 95 years with an arithmetic mean of 53.4 years and a standard deviation of ± 18.2 years. Almost two-thirds (62.2%) were males. The prevalence of depression among diabetic patients was 48.2%, mostly of mild (31.4%) or moderate severity (12.7%). Multivariate logistic regression analysis revealed that female diabetic patients were at almost double-fold risk of developing depression compared to males [adjusted odds ratio (AOR) =2.73, 95% confidence interval (CI): 1.70-4.38], P < 0.001. Also, type II diabetic patients were at almost double-fold risk of developing depression compared to type I diabetic patients (AOR = 2.07, 95% CI: 1.16-3.67), P = 0.013. Patients with history of any social issue with the family, relatives, or friends were at about three-fold risk of developing depression compared to those without such history (AOR = 3.45, 95% CI: 2.11-5.66), P < 0.001. Patients who reported compliance to diet were at higher risk for developing depression compared to their peers (AOR = 2.57, 95% CI: 1.25-5.28), P = 0.010, while those compliant to physical activity about 150 min/week or more were at significant lower risk to develop depression (AOR = 0.56, 95% CI: 0.35-0.89), P = 0.015. Patients with nephropathy or neuropathy were more likely to have depression compared to their counterparts (AOR = 2.52. 95% CI: 1.33-4.80, P = 0.005 and AOR = 1.80, 95% CI: 1.11-2.90, P = 0.016, respectively). Conclusion: Depression is a very prevalent problem affecting diabetic patients, particularly those of type II, female patients, and those with nephropathy or neuropathy. Therefore, regular screening of diabetic patients for depression and referral of severe cases to psychiatric care are highly warranted.

Does HOXA9 Gene Expression in Egyptian Chronic Myelogenous Leukemia Patients Affect Disease Progression? A Retrospective Cohort Study.

OBJECTIVE: Chronic myelogenous leukemia (CML) is a clonal stem cell disease and is consistently associated with the BCR-ABL fusion gene. The chronic phase of the disease tends to pass into an accelerated phase and eventually leads to acute leukemia if left untreated. Oncoproteins necessary for leukemic transformation are both fundamentally and clinically relevant to identify as they might be new molecular targets for the development of specific anti-leukemic drugs. This study is an initial step to define the proportion of HOXA9 gene expression in some Egyptians with chronic-phase CML at diagnosis and to evaluate its relation with BCR-ABL expression and its clinical significance. MATERIALS AND METHODS: Sixty-two newly diagnosed CML patients (56 in chronic phase, 1 in accelerated phase, and 5 in blastic crises) were enrolled in the study. HOXA9 and BCR-ABL gene expressions were detected by one-step RT-PCR. ABL was chosen as a control gene to calculate HOXA9/ABL and BCR-ABL/ABL ratios from densitometric values of PCR product intensities. RESULTS: HOXA9 expression was encountered in 25/56 (44.6%) of newly diagnosed CML patients in the chronic phase. The median expression was 0.31 (range: 0.08-1.37) in relation to the ABL gene, with a higher frequency of expression in CML patients presenting with splenomegaly (p<0.001), high Sokal score (p<0.001), and BCR-ABL expression from the first round (p=0.004). No association could be detected with other clinical parameters, overall survival, or disease-free survival. CONCLUSION: HOXA9 expression is closely related to poor prognostic factors, but we could not demonstrate its relationship to patient survival. CONFLICT OF INTEREST: None declared.

Symptom Chronicity and Tobacco Use: Differences in Athletic and Nonathletic Candidates for Cartilage Surgery.

OBJECTIVE: To determine whether there are differences in symptomatic knee cartilage defects and rates of tobacco use among age-matched athletes versus nonathletes undergoing initial arthroscopic knee surgery who meet demographic and radiographic criteria for cartilage restoration surgery. DESIGN: Age-matched athletes (n = 186) and nonathletes (n = 159) age 40 or less with a body mass index (BMI) of 35 kg/m2 or less (mean 26.8 SD 4.1) and <50% joint space narrowing on weight-bearing radiographs were included. All patients had a symptomatic Outerbridge grade 2 or higher cartilage defect visualized during knee arthroscopy. Relationship between athletic status and chronicity of knee symptoms prior to surgery and tobacco use status, cartilage defect Outerbridge grade, size, and location at time of surgery were characterized. RESULTS: Nonathletes were more likely to smoke (P < 0.001) and had higher BMI (P = 0.005). Duration of symptoms prior to surgery was shorter among athletes (P < 0.001). Grade 4 defects were equally prevalent (P = 0.96) as were multicompartment grade 3-4 lesions (P = 0.12). Mean grade 3-4 defect size was similar in lateral (P = 0.96) and medial compartments (P = 0.82). There was a trend toward larger anterior compartment defects in nonathletes (P = 0.07). CONCLUSIONS: Among age-matched athletes and nonathletes with symptomatic cartilage defects who meet demographic criteria for cartilage restoration, nonathletes were more likely to smoke and have a longer duration of symptoms prior to treatment. Athletes tended to present earlier but with similar size defects compared to nonathletes, supporting accelerated treatment of defects in athletes and caution toward allowing continued athletic participation in patients with known cartilage defects.

Cost-efficacy of Knee Cartilage Defect Treatments in the United States.

BACKGROUND: Multiple knee cartilage defect treatments are available in the United States, although the cost-efficacy of these therapies in various clinical scenarios is not well understood. PURPOSE/HYPOTHESIS: The purpose was to determine cost-efficacy of cartilage therapies in the United States with available mid- or long-term outcomes data. The authors hypothesized that cartilage treatment strategies currently approved for commercial use in the United States will be cost-effective, as defined by a cost <$50,000 per quality-adjusted life-year over 10 years. STUDY DESIGN: Systematic review. METHODS: A systematic search was performed for prospective cartilage treatment outcome studies of therapies commercially available in the United States with minimum 5-year follow-up and report of pre- and posttreatment International Knee Documentation Committee subjective scores. Cost-efficacy over 10 years was determined with Markov modeling and consideration of early reoperation or revision surgery for treatment failure. RESULTS: Twenty-two studies were included, with available outcomes data on microfracture, osteochondral autograft, osteochondral allograft (OCA), autologous chondrocyte implantation (ACI), and matrix-induced ACI. Mean improvement in International Knee Documentation Committee subjective scores at final follow-up ranged from 17.7 for microfracture of defects >3 cm2 to 36.0 for OCA of bipolar lesions. Failure rates ranged from <5% for osteochondral autograft for defects requiring 1 or 2 plugs to 46% for OCA of bipolar defects. All treatments were cost-effective over 10 years in the baseline model if costs were increased 50% or if failure rates were increased an additional 15%. However, if efficacy was decreased by a minimum clinically important amount, then ACI (periosteal cover) of femoral condylar lesions ($51,379 per quality-adjusted life-year), OCA of bipolar lesions ($66,255) or the patella ($66,975), and microfracture of defects >3 cm2 ($127,782) became cost-ineffective over 10 years. CONCLUSION: Currently employed treatments for knee cartilage defects in the United States are cost-effective in most clinically acceptable applications. Microfracture is not a cost-effective initial treatment of defects >3 cm2. OCA transplantation of the patella or bipolar lesions is potentially cost-ineffective and should be used judiciously.

Meniscus tears accelerate joint space loss and lateral meniscal extrusion increases risk of knee arthroplasty in middle-aged adults.

We sought to use publicly available data from the Osteoarthritis Initiative (OAI), a multicenter prospective cohort study, to determine the rate of joint space loss and likelihood of knee arthroplasty due to magnetic resonance imaging (MRI)-diagnosed meniscal tears or meniscal extrusion in middle-aged adults with no to mild knee osteoarthritis. Participants (n = 2199; mean age, 60.2 years) with Kellgren-Lawrence osteoarthritis grades 2 (mild) (48.7%) or 0 to 1 (none) (51.3%) underwent knee MRIs at enrollment and were followed radiographically for 8 years and for total knee arthroplasty (TKA) for 9 years. Rate of joint space loss and risk of arthroplasty due to meniscal tears and/or extrusion were determined by multivariate modeling. Prevalence of baseline medial meniscus tears was 21.3% and lateral tears was 12.8%; 26.9% had medial meniscal extrusion (79.6%, <2 mm; 20.4%, +2 mm) and 5.4% had lateral extrusion (75.9%, <2 mm; 24.1%, +2 mm). Median medial joint space loss was 0.06 mm/y and lateral was 0.05 mm/y. Medial tears regardless of extrusion were associated with accelerated medial joint space loss (additional mean, 0.05 mm/y; P = .001). Lateral tears were associated with accelerated lateral joint space loss (additional 0.09 mm/y; P < .001) as was lateral extrusion (additional 0.10 mm/y; P < .001). The yearly incidence of knee arthroplasty was 0.5% without lateral extrusion, 1.5% with extrusion less than 2.0 mm, and 3.7% with extrusion greater than or equal to 2.0 mm. Both medial and lateral tears accelerate joint space loss in middle-aged adults. Lateral meniscal extrusion further accelerates joint space loss and increases risk of progression to TKA within 9 years.

Lateral cartilage defects and medial subchondral surface ratio are associated with knee-related disability.

We sought to determine the relationship between (i) full-thickness cartilage defects and tibiofemoral subchondral surface ratio (SSR) and (ii) disability and quality of life in patients with mild radiographic osteoarthritis (OA) (Kellgren-Lawrence grade 2) or without radiographic OA (Kellgren-Lawrence grades 0 or 1)? A total of 642 participants from the Osteoarthritis Initiative (OAI) with baseline knee MRIs and a Kellgren-Lawrence grade 2 or less on both bilateral screening radiographs were included. The independent relationship was assessed between (i) full-thickness cartilage defect presence and tibiofemoral SSR and (ii) Knee Injury and Osteoarthritis Outcome Score (KOOS) quality of life (QOL), KOOS function in sports and recreation (KOOS-sport/rec), and Western Ontario and McMaster Universities Arthritis Index (WOMAC) disability score after adjustment for relevant confounders with multivariate regression modeling. The prevalence of medial full-thickness defects was 10.4% (67/642) and lateral was 18.1% (116/642). Lateral defect presence was associated with worse KOOS-QOL (beta -3.61 SE 1.04; p = 0.001), KOOS-sport/rec (beta -4.70 SE 1.38; p = 0.001) and WOMAC-disability scores (beta 0.02 SE 0.01; p = 0.001); these associations were not influenced by defect size. A larger medial compartment SSR was associated with worse KOOS-QOL (beta -27.20 SE 6.80; p < 0.001), KOOS-sports/rec (beta -22.30 SE 9.01; p = 0.01) and WOMAC-disability scores (beta 0.16 SE 0.04; p < 0.001). In older adults with little to no radiographic osteoarthritis, lateral full-thickness cartilage defects, irrespective of size, and a larger medial compartment tibiofemoral SSR are potential sources of knee-related symptoms that are not appreciated on standard radiographs. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:378-385, 2019.

Role of full-thickness cartilage defects in knee osteoarthritis (OA) incidence and progression: Data from the OA Initiative.

The purpose of this study is to determine whether full-thickness tibiofemoral cartilage defects are predictive of incident radiographic OA, progression of radiographic OA, and progression to severe radiographic OA. Participants in the OA Initiative (n = 1317, 38.1% male, mean age 60.9 years SD 9.2) with baseline MRIs and Kellgren-Lawrence (KL) OA grade 0-3 (none to moderate OA) were included. All participants had follow-up radiographs at mean 4.9 years (max 8.0). The effect of full-thickness defect presence, size, and location on risk of incident OA (KL grade 2+), overall progression of OA (increase in KL grade 1+ points), or compartment-specific OA progression was assessed with Cox proportional hazards modeling with adjustment for demographic factors, weight, and knee alignment. The yearly incidence of tibiofemoral OA was 0.3% (CI 0.2-0.4%); defect presence, size, and location were not associated with incident OA risk. The yearly rate of OA progression was 3.8% in participants without tibiofemoral full-thickness defects, 6.7% with medial defects, and 6.3% with lateral defects. Medial bipolar (kissing) lesions were an independent risk factor for OA progression as well as medial compartment progression. Lateral tibial-sided full-thickness defects increased risk of lateral progression (increase in lateral OARSI grade). In older adults, isolated full-thickness cartilage defects do not increase short-term risk of incident OA. However, in the setting of preexisting mild or moderate OA, medial bipolar (kissing) defects increase risk of overall OA progression (KL grade) as well as progression of medial compartment OA. Lateral tibial defects increase risk of lateral compartment OA progression. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res.

Full-Thickness Cartilage Defects Are Important Independent Predictive Factors for Progression to Total Knee Arthroplasty in Older Adults with Minimal to Moderate Osteoarthritis: Data from the Osteoarthritis Initiative.

BACKGROUND: Knee osteoarthritis (OA) severity on radiographs is not a reliable predictor of symptom severity. The purpose of this study was to determine whether full-thickness defects or OA grade are predictive of the progression to total knee arthroplasty in older patients without end-stage arthritis. METHODS: This study included 1,319 adults aged 45 to 79 years (mean age [and standard deviation], 61.0 ± 9.2 years) who were enrolled in the Osteoarthritis Initiative, a prospective multicenter study with median 9-year follow-up data. All participants had Kellgren-Lawrence grade-0 to 3 (no to moderate) OA on bilateral radiographs; patients with grade-4 (severe) OA were excluded. The presence and total surface area of full-thickness cartilage defects on the tibia or the weight-bearing portion of the femoral condyle were determined. The risk of total knee arthroplasty due to defect presence and size as well as OA grade was determined with Cox proportional-hazards modeling after controlling for baseline variables including, but not limited to, age, sex, race, weight, knee alignment, symptom severity, quality-of-life scores, and activity level. RESULTS: Four hundred and ninety-six patients (37.6%) had full-thickness defects. The incidence of knee arthroplasty was 0.57% per person-year for adults without a full-thickness defect and 2.15% for those with a defect. After adjusting for confounders, the presence of a full-thickness defect increased the risk of total knee arthroplasty regardless of OA grade, with higher risk demonstrated for larger (≥2 cm) defects (hazard ratio [HR] = 5.27 [95% confidence interval (CI) = 2.70 to 10.3]; p < 0.001) compared with smaller (<2 cm) defects (HR = 2.65 [95% CI = 1.60 to 4.37]; p < 0.001). Compared with nonarthritic knees (grade 0 to 1), mild arthritis (grade 2) did not increase total knee arthroplasty risk (HR = 0.71 [95% CI = 0.31 to 1.60]); moderate arthritis (grade 3) increased total knee arthroplasty risk in adults without a full-thickness defect (HR = 3.15 [95% CI = 1.34 to 7.40]; p = 0.009) but not in adults with a defect (HR = 0.64 [95% CI = 0.28 to 1.49]; p = 0.30). CONCLUSIONS: Full-thickness cartilage defects were a major determinant of future knee arthroplasty in older adults with minimal to moderate OA, even after adjusting for baseline knee symptom severity. Baseline radiographic severity grade was only associated with future total knee arthroplasty risk in the absence of a full-thickness defect. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Effect of Delayed Primary Anterior Cruciate Ligament Reconstruction on Medial Compartment Cartilage and Meniscal Health.

BACKGROUND: The time required to develop a secondary cartilage or meniscal injury in the medial compartment after anterior cruciate ligament (ACL) injury is not well understood. PURPOSE: To determine the association between time delay until ACL reconstruction and the presence of medial compartment Outerbridge grade 3 or 4 chondral injury or medial meniscal tear requiring treatment. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A total of 609 patients underwent primary ACL reconstruction at a single institution at a median 46 days between injury and surgery (61.4% male; mean age, 26.5 years [SD, 11.1]). Chondral status was graded according to Outerbridge criteria at the time of surgery. Multivariate regression analysis was used to assess the relationship between time delay until surgery and medial compartment chondral injury or meniscal injury requiring treatment. Adjustment was performed as needed for patient demographics, sporting activity, and prior knee injuries. Time until surgery had a nonlinear association with medial compartment health and was more effectively described in discrete intervals rather than as a continuous variable. The optimal time intervals to predict medial compartment health were determined by comparison of Bayes information criterion values between fully adjusted regression models. RESULTS: After controlling for relevant confounders, delay of surgery >8 weeks had an increased likelihood of a medial meniscal tear requiring partial meniscectomy (adjusted odds ratio [aOR], 2.30; 95% CI, 1.04-5.12; P = .04) and a decreased likelihood of a meniscal tear requiring repair (aOR, 0.50; 95% CI, 0.32-0.76; P = .001). Delay of surgery >5 months had an increased likelihood of a medial Outerbridge grade ≥3 chondral defect (aOR, 3.11; 95% CI, 1.64-5.87; P = .001) or a grade 4 defect (aOR, 3.84; 95% CI, 1.75-8.45; P = .001). CONCLUSION: From the time of ACL injury, risk of an irreparable medial meniscal tear found at the time of ACL reconstruction is significantly increased by 8 weeks, and risk of high-grade medial chondral damage is increased by 5 months.

The Treatment of Adult Osteochondritis Dissecans with Autologous Cartilage Implantation: A Systematic Review.

We sought to evaluate the effectiveness of autologous chondrocyte implantation (ACI) for the treatment of adult osteochondritis dissecans (OCD) lesions according to patient-reported outcomes, complication rates, and failure rates. A search of MEDLINE, Scopus, and Cochrane Library was performed to identify clinical studies (levels I-IV) reporting outcomes after ACI treatment for OCD in adult knees. Our inclusion criteria included the following: (1) published between January 2000 and April 2017, (2) stable and unstable OCD lesions of the knee, (3) use of ACI in at least one group, (4) subjects ≥18 years old or skeletally mature, (5) inclusion of at least one patient-reported clinical outcome measure, and (6) written in English. A total of nine studies (179 patients), mean age of 27.6 years (range: 18-49 years), were included. There were 227 OCD lesions with an average size of 4.1 cm2 (range: 1.2-9.4 cm2). The average follow-up was 61.3 months (range: 6.5-120 months). In general, there was significant improvement in symptoms, but better results occurred among active male patients with smaller lesions as well as younger patients. Statistically significant improvement in patient-reported outcomes was reported in all studies. There were 23 complications reported (15.6%), including 12 failures (8.2%). Significant improvement in clinical outcome measures demonstrates clinical efficacy of autologous cartilage therapies for the treatment of OCD in adult patients. Better outcomes are often observed with males, active patients, smaller lesion sizes, and younger age at the time of surgery.

Clinical factors associated with successful meniscal root repairs: A systematic review.

PURPOSE: To systematically review the literature to determine what clinical factors influence patient outcomes after meniscal root repairs. METHODS: A systematic review of multiple databases was performed. The inclusion criteria included English language, studies evaluating clinical and/or radiographic factors related to meniscal root repair outcomes, medial or lateral posterior root repairs, and human studies. The exclusion criteria included meniscectomy studies, meniscal body studies, technique descriptions, studies reporting only failure rate of meniscal repairs, multiligament repairs, abstracts, controlled laboratory studies, meta-analyses, and systematic reviews. RESULTS: Five studies were included for final analysis including four case series and one retrospective cohort study. A total of 178 patients in the five studies underwent posterior meniscal root repair (179 knees total). The mean age was 51.4 years. The mean duration of follow-up was 34.5 months. The mean Moga quality rating for case series studies was 15 points (83.3%) and NOS score for the retrospective comparative study was 8. Body mass index (BMI) was not associated with outcomes in 3/3 studies assessing BMI. Increased age was associated with worse outcome in 1/5 studies and had no association in 4/5 studies. Knee varus >5° was associated with worse outcomes in 3/3 studies. CONCLUSIONS: Risk factors for poor clinical outcomes after posterior meniscal root repair include pre-existing high-grade (Outerbridge grade ≥ 3) chondral lesions and severe varus knee alignment (>5°) for medial root repairs. LEVEL OF EVIDENCE: IV, systematic review.

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.

Outcome of HER2 positive luminal operable breast cancer in comparison with outcome of other operable luminal breast cancer patients: Long follow-up of single center randomized study.

INTRODUCTION: In clinical practice, there is increasing recognition that HER2-positive breast cancer patients are not a homogeneous group. Especially patients with luminal B breast cancers which are now subdivided to more than two groups. AIM OF THE STUDY: The aim of this study is to know the effect of HER2 positivity on luminal breast cancer patients by comparing disease free survival DFS luminal of HER2 positive breast cancer patients with other luminal cases with HER2 negative disease. Also we explored the effect of HER2 positivity on different risk factors for breast cancer. PATIENTS AND METHODS: We compared the outcome of 25 HER2 positive luminal breast cancer patients with a control group of other luminal operable breast cancer at the same period of time with the same eligibility and exclusive criteria. RESULTS: Total of 59 operable luminal breast cancer patients were eligible for the study, 25 of them were luminal HER2 positive and the 34 were control group of luminal HER2 negative. We found that HER2 positive luminal breast cancer patients were having more unfavorable risk factors and have more incidence of relapse mainly after 48 months follow-up than other luminal patients: after 24 months follow-up period HER2 positive luminal patients have cumulative DFS of 91% compared with 93% in luminal HER2 negative patients but after 48 months follow-up the difference between the two groups became more obvious as it was 66% for luminal HER2 positive group and 90 % for the control group. High risk patients for luminal HER2 positive breast cancer patients have higher risk of relapse (60% compared with 86%), and this appeared also in other subgroups. CONCLUSION: HER2 positive luminal breast cancer patients have a higher incidence of relapse compared with other luminal breast cancer, and this difference appear mainly after 48 months of follow-up. High risk patients for luminal HER2 positive breast cancer have higher risk of relapse than high risk patients of other luminal patients.