No difference between single and staged posterolateral corner surgical procedures in the multiligament injured/dislocated knee.

PURPOSE: Posterolateral corner (PLC) injuries commonly occur in the setting of a dislocated knee and often require multiple procedures due to concomitant vascular, nerve, and soft tissue involvement. Debate persists regarding single vs staged surgery. The purpose of this study was to compare knee function after single and staged surgery for PLC injury. METHODS: Patients who underwent surgery for a PLC injury (KD I, IIIL, IV) with minimum follow-up of 2 years were included. Patients treated with staged and single surgery were matched according to age, sex, and KD grade. Lysholm and International Knee Documentation Committee (IKDC) subjective scores were obtained. Risk factors for poor knee function were assessed, including age, nerve, vascular, meniscal and articular cartilage injuries. RESULTS: Twenty single-surgery patients with a median age of 24 years (median follow-up 5.3 years, range 2-18.3) and 20 staged surgery patients with a median age of 26 years (median follow-up 4.3 years, range 2-19.8) were studied. The mean Lysholm score was 78.7 (± 20.3) in the single surgery and 84.2 (± 17.8) in the staged surgery cohort (n.s.). The mean IKDC score was 80.8 (± 21.1) in the single and 74.9 (± 18.9) in the staged surgery cohort (n.s.). Age at injury, peroneal, vascular, meniscal or cartilage injury were not associated with poor knee outcome. CONCLUSION: This study demonstrates similar knee function among patients with PLC injuries treated with single or staged surgical procedures. The need for staged surgery for the dislocated knee with PLC involvement should be individualized based on specific knee and patient-related factors. LEVEL OF EVIDENCE: III.

Chronic Effects of a High Sucrose Diet on Murine Gastrointestinal Nutrient Sensor Gene and Protein Expression Levels and Lipid Metabolism.

The gastrointestinal tract (GIT) plays a key role in regulating nutrient metabolism and appetite responses. This study aimed to identify changes in the GIT that are important in the development of diet related obesity and diabetes. GIT samples were obtained from C57BL/6J male mice chronically fed a control diet or a high sucrose diet (HSD) and analysed for changes in gene, protein and metabolite levels. In HSD mice, GIT expression levels of fat oxidation genes were reduced, and increased de novo lipogenesis was evident in ileum. Gene expression levels of the putative sugar sensor, slc5a4a and slc5a4b, and fat sensor, cd36, were downregulated in the small intestines of HSD mice. In HSD mice, there was also evidence of bacterial overgrowth and a lipopolysaccharide activated inflammatory pathway involving inducible nitric oxide synthase (iNOS). In Caco-2 cells, sucrose significantly increased the expression levels of the nos2, iNOS and nitric oxide (NO) gas levels. In conclusion, sucrose fed induced obesity/diabetes is associated with changes in GI macronutrient sensing, appetite regulation and nutrient metabolism and intestinal microflora. These may be important drivers, and thus therapeutic targets, of diet-related metabolic disease.

Adherence to UK dietary guidelines is associated with higher dietary intake of total and specific polyphenols compared with a traditional UK diet: further analysis of data from the Cardiovascular risk REduction Study: Supported by an Integrated Dietary Approach (CRESSIDA) randomised controlled trial.

Adherence to dietary guidelines (DG) may result in higher intake of polyphenols via increased consumption of fruits, vegetables and whole grains. We compared polyphenol dietary intake and urinary excretion between two intervention groups in the Cardiovascular risk REduction Study: Supported by an Integrated Dietary Approach study: a 12-week parallel-arm, randomised controlled trial (n 161; sixty-four males, ninety-seven females; aged 40-70 years). One group adhered to UK DG, whereas the other group consumed a representative UK diet (control). We estimated polyphenol dietary intake, using a 4-d food diary (4-DFD) and FFQ, and analysed 24-h polyphenol urinary excretion by liquid chromatography-tandem MS on a subset of participants (n 46 control; n 45 DG). A polyphenol food composition database for 4-DFD analysis was generated using Phenol-Explorer and USDA databases. Total polyphenol intake by 4-DFD at endpoint (geometric means with 95 % CI, adjusted for baseline and sex) was significantly higher in the DG group (1279 mg/d per 10 MJ; 1158, 1412) compared with the control group (1084 mg/d per 10 MJ; 980, 1197). The greater total polyphenol intake in the DG group was attributed to higher intake of anthocyanins, proanthocyanidins and hydroxycinnamic acids, with the primary food sources being fruits, cereal products, nuts and seeds. FFQ estimates of flavonoid intake also detected greater intake in DG compared with the control group. 24-h urinary excretion showed consistency with 4-DFD in their ability to discriminate between dietary intervention groups for six out of ten selected, individual polyphenols. In conclusion, following UK DG increased total polyphenol intake by approximately 20 %, but not all polyphenol subclasses corresponded with this finding.

Routine Axillary Ultrasound for Patients with T1-T2 Breast Cancer Does Not Increase the Rate of Axillary Lymph Node Dissection Based on Predictive Modeling.

BACKGROUND: Since publication of the American College of Surgeons Oncology Group Z0011 trial results, demonstrating that many patients with nonpalpable axillary lymph nodes and one or two positive sentinel nodes do not require axillary lymph node dissection (ALND), preoperative axillary ultrasound (AUS) has become controversial. Clinicians are concerned that AUS may lead to unnecessary ALND. The authors developed an algorithm (Algorithm 1) in which the number of AUS-suspicious nodes and tumor biology direct management. For estrogen receptor-positive (ER+)/human epidermal growth factor receptor 2-negative (HER2-) breast cancer with a single AUS-suspicious node and a positive lymph node needle biopsy (LNNB), sentinel lymph node biopsy (SLNB) is performed with a specimen X-ray documenting retrieval of the clipped node. Other patients with positive LNNB receive neoadjuvant chemotherapy. The authors hypothesized that routine AUS and this algorithm could decrease ALND compared with a strategy of no preoperative AUS. METHODS: Decision-tree analysis and Monte Carlo simulation were used to assess the expected number of ALNDs under two strategies (routine AUS vs no AUS). Probabilities were drawn from a literature review and an institutional database. The authors assumed nodal pathologic complete response rates as reported in the literature. Four additional algorithms were created to assess whether any other treatment model could decrease the rate of ALND. RESULTS: Using the routine AUS and the authors' algorithm, the predicted ALND rate was 9%, versus 10% for a strategy of no AUS, with overlapping uncertainty intervals. The remaining treatment algorithms showed similar results. DISCUSSION: Use of AUS may help to tailor patient care without leading to overutilization of ALND, as long as neoadjuvant chemotherapy is administered when appropriate.

High rate of recurrent patellar dislocation in skeletally immature patients: a long-term population-based study.

PURPOSE: Patellar dislocation can occur in isolation or be associated with chronic instability. The goals of this study are to describe the rate and factors associated with additional patellar instability events (ipsilateral recurrence and contralateral dislocation), as well as the development of patellofemoral arthritis in patients who are skeletally immature at the time of first patellar dislocation. METHODS: The study included a population-based cohort of 232 skeletally immature patients who experienced a first-time lateral patellar dislocation between 1990 and 2010. A chart review was performed to collect information related to the initial injury, treatment, and outcomes. Subjects were followed for a mean of 12.1 years to determine the rate of subsequent patellar dislocation (ipsilateral recurrence or contralateral dislocation) as well as clinically significant patellofemoral arthritis. RESULTS: 104 patients had ipsilateral recurrent patellar dislocation. The cumulative incidence of recurrent dislocation was 11% at 1 year, 21.1% at 2 years, 37.0% at 5 years, 45.1% at 10 years, 54.0% at 15 years, and 54.0% at 20 years. Patella alta (HR 10.6, 95% CI 3.6, 36.1), TT-TG ≥ 20 mm (HR 18.7, 95% CI 1.7, 228.2), and trochlear dysplasia (HR 23.7, 95% CI 1.0, 105.2) were associated with recurrence. Similarly, 18 patients (7.8%) had contralateral patellar dislocation. The cumulative incidence of patellofemoral arthritis was 0% at 2 years, 1.0% at 5 years, 2.0% at 10 years, 10.1% at 15 years, 17% at 20 years, and 39.0% at 25 years. Osteochondral injury was associated with arthritis (HR 25.7, 95% CI 6.2, 143.8). There was no association with trochler dysplasia (HR 1.2, 95% CI 0.2, 5.0), recurrent patellar instability (HR 1.2, 95% CI 0.2, 7.2), gender (HR 1.3, 95% CI 0.3, 5.6), or patellar-stabilizing surgery (HR 0.7, 95% CI 0.2, 3.5) and arthritis. CONCLUSION: Skeletally immature patients had a high rate of recurrent patellar instability that was associated with structural abnormalities such as patella alta,TT-TG ≥ 20 mm, and trochlear dysplasia. Approximately 10% of patients experienced a contralateral dislocation and 20% of patients developed arthritis by 20 years following initial dislocation. Osteochondral injury was associated with arthritis. LEVEL OF EVIDENCE: Retrospective case series, Level IV.

Satisfactory knee function after single-stage posterolateral corner reconstruction in the multi-ligament injured/dislocated knee using the anatomic single-graft technique.

PURPOSE: Increasing importance has been placed on the posterolateral corner (PLC) in maintaining varus and rotational stability of the knee. The goal of this study was to evaluate knee function and clinical stability following a single-graft PLC reconstruction technique and identify factors associated with poor knee function. METHODS: This study identified patients with a multi-ligament knee injury between 2006 and 2013. Patients who received a single-graft fibular collateral ligament and PLC reconstruction with a single-stage surgery during the study period and had a minimum follow-up of 2 years after surgery were included. Functional outcomes were assessed using Lysholm and IKDC scores. Varus and rotational knee laxity and range of motion were assessed using physical examination. RESULTS: The final study cohort included 61 patients who underwent PLC reconstruction using a single-graft technique. The mean IKDC score was 74.1 (± 22.3) and the mean Lysholm score was 80.3 (± 21.8) at mean follow-up of 3.8 years (range 2-9 years). Mean range of motion at final follow-up measured from 0° to 126° [range flexion: 95-145, range extension: 0-5]. Fifty-eight patients (95%) had grade 0 varus laxity in full knee extension, and 54 patients (88.5%) had grade 0 varus laxity at 30° of knee flexion. Female gender was associated with a lower postoperative IKDC score (p = 0.04). CONCLUSION: Surgical treatment of the PLC using a single-graft technique can result in satisfactory knee function and stable physical examination findings at minimum 2 years after surgery. Female gender was predictive of poor knee function after PLC reconstruction. Surgical treatment of PLC injuries should be individualized based on the timing of surgery, specific injured knee structures, and physical examination findings. This study helps validate the use of a single-graft technique for PLC reconstruction and can be used to help counsel patients about expected knee function after surgical treatment of PLC injuries. Level of evidence IV.

Individualizing the tibial tubercle to trochlear groove distance to patient specific anatomy improves sensitivity for recurrent instability.

PURPOSE: An initial episode of patellar instability poses a treatment challenge given the absence of a valid, reproducible, and universally applicable predictor of recurrence. Recently, a series of patellar instability ratios (PIRs) were described. Each ratio consisted of the traditional tibial tubercle to trochlear groove (TT-TG) distance normalized to patient-specific measures. The purpose of this study was to investigate the reliability and validity of these novel measures. METHODS: Eighty-seven patients experiencing a first-time lateral patellar dislocation were identified in a retrospective manner. Magnetic resonance imaging (MRI) studies obtained at the time of injury were reviewed. The TT-TG distance, patellar width (PW), trochlear width (TW), patellar length (PL), and trochlear length (TL) were obtained by two observers in a blinded, randomized fashion. Measurement reliability was assessed using intra-class correlation coefficients (ICCs). Patients were divided into those having a single dislocation (Group 1) and those experiencing recurrent instability (Group 2). The ability of the TT-TG distance and each PIR to predict recurrent instability was assessed by calculating odds ratios (ORs) with 95% confidence intervals (CIs). Sensitivity and specificity were also calculated for each measure. RESULTS: Excellent inter-rater agreement was observed with ICCs > 0.75 for all patellofemoral joint measurements obtained on MRI. The TT-TG distance alone was predictive of recurrent patellar instability with an OR of 8.9 (p < 0.001). However, the isolated TT-TG distance had the lowest sensitivity at 25.6%. Among ratios, a TT-TG/PL ≥ 0.5 was the most predictive of recurrent instability with an ORs of 6.1 (p = < 0.001). A TT-TG/TL ≥ 0.8 was also predictive of recurrence (OR 4.9, p = 0.027) and had the highest sensitivity of any measure at 94.9%. CONCLUSION: The results of the current study support the reproducibility and predictive ability of PIRs. While a TT-TG ≥ 20 mm was the strongest predictor of recurrent patellar instability, it was a relatively insensitive measure. Sensitivity may be improved by normalizing the TT-TG distance to patient-specific axial and sagittal plane patellofemoral measurements on MRI. Ultimately, PIRs are reproducible measures that may serve as an additional tool when clinically assessing the unstable patellofemoral joint. LEVEL OF EVIDENCE: III.

Influence of Injection Volume on Rate of Subsequent Intervention in Carpal Tunnel Syndrome Over 1-Year Follow-Up.

PURPOSE: The optimal volume and dose of corticosteroid injections for treatment of carpal tunnel syndrome (CTS) have not yet been established. It is unknown whether the volume of injectate influences the outcome of carpal tunnel injection. The purpose of this study was to assess whether there is an association between the volume of injectate and subsequent intervention in the treatment of CTS. METHODS: This study evaluated residents of Olmsted County, MN, who were treated with a corticosteroid injection for CTS between 2001 and 2010. Failure of treatment was the primary outcome, defined as a subsequent intervention: either a second injection or carpal tunnel release within 1 year of initial injection. General estimating equations logistic regression was used to assess the association between injectate volume and rate of treatment failure, adjusting for age, sex, effective dose of steroid, type of steroid injected, electrodiagnostic severity, and the presence of comorbidities such as rheumatoid arthritis, diabetes mellitus, peripheral neuropathy, and radiculopathy. RESULTS: There were 856 affected hands in 651 patients. A total of 56% (n = 484) of treated hands received subsequent treatment within 1 year. Multivariable analysis showed that a larger injectate volume was significantly associated with reduced rate of treatment failure within 1 year. Rheumatoid arthritis and ultrasound-guided procedures were also associated with a reduced rate of treatment failure, whereas severe electrodiagnostic results were associated with an increased rate of failure. CONCLUSIONS: This study showed that a larger volume of corticosteroid injection is associated with reduced odds of subsequent intervention after a single corticosteroid injection in CTS. Further research is needed to determine the optimal volume for steroid injections in the treatment of CTS. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Treatment of Pediatric Osteoid Osteomas Not Amenable to Radiofrequency Ablation: A Retrospective Review of Surgical Outcomes.

The purpose of this study is to describe the surgical treatment of osteoid osteomas in a pediatric cohort of patients who were found not to be candidates for percutaneous ablative therapies. Medical records for 29 pediatric patients who were treated surgically for osteoid osteomas were reviewed. Reasons for surgical management included diagnostic uncertainty or lesions that were in close proximity to an articular surface or neurovascular structure. Twenty-eight patients experienced complete symptom resolution. Surgical treatment may still be indicated in a select group of osteoid osteoma patients who are not candidates for percutaneous treatment. (Journal of Surgical Orthopaedic Advances 27(4):299-302, 2018).

Prospective Study Comparing Surgeons' Pain and Fatigue Associated with Nipple-Sparing versus Skin-Sparing Mastectomy.

BACKGROUND: Nipple-sparing mastectomy (NSM) is more technically challenging than skin-sparing mastectomy (SSM) but offers quality-of-life and cosmetic advantages. However, surgeon physical symptoms related to NSM workload have not been documented. METHODS: This was a prospective study using questionnaires to compare surgeon-reported physical symptoms before, during, and after NSM versus SSM. Surgeons also answered general questions about each mastectomy. Bilateral cases were performed simultaneously by two surgeons, who completed independent questionnaires. RESULTS: Questionnaires were completed after 82 SSMs and 44 NSMs. On a 0-10 scale, surgeons reported NSM was more physically demanding than SSM (7.0 vs. 4.5, p < 0.001). Mean visualization was more difficult (5.7 vs. 3.2, p < 0.001) and mean fatigue score was greater (5.6 vs. 3.1, p < 0.001) after NSM than SSM. The mean increase in neck pain (on a 0-4 scale) was greater for NSM than SSM, both from before-to-during surgery (0.8 vs. 0.2, p = 0.003) and before-to-after surgery (0.9 vs. 0.2, p = 0.002). The mean increase in lower back pain was greater for NSM than SSM, both from before-to-during surgery (0.7 vs. 0.2, p = 0.008) and before-to-after surgery (0.9 vs. 0.2, p = 0.003). Surgeons reported that NSM was more mentally demanding (p < 0.001), complex (p = 0.01), and difficult (p < 0.001) than SSM. CONCLUSION: Surgeons experienced greater physical symptoms, mental strain, and fatigue with NSM than SSM. This raises concern that mild but repetitive pain over the course of a breast surgeon's career may lead to repetitive stress injury.

A comparison of heart rate variability, n-3 PUFA status and lipid mediator profile in age- and BMI-matched middle-aged vegans and omnivores.

Low heart rate variability (HRV) predicts sudden cardiac death. Long-chain (LC) n-3 PUFA (C20-C22) status is positively associated with HRV. This cross-sectional study investigated whether vegans aged 40-70 years (n 23), whose diets are naturally free from EPA (20 : 5n-3) and DHA (22 : 6n-3), have lower HRV compared with omnivores (n 24). Proportions of LC n-3 PUFA in erythrocyte membranes, plasma fatty acids and concentrations of plasma LC n-3 PUFA-derived lipid mediators were significantly lower in vegans. Day-time interbeat intervals (IBI), adjusted for physical activity, age, BMI and sex, were significantly shorter in vegans compared with omnivores (mean difference -67 ms; 95 % CI -130, -3·4, P50 % and high-frequency power) were similarly lower in vegans, with no differences during sleep. In conclusion, vegans have higher 24 h SDNN, but lower day-time HRV and shorter day-time IBI relative to comparable omnivores. Vegans may have reduced availability of precursor markers for pro-resolving lipid mediators; it remains to be determined whether there is a direct link with impaired cardiac function in populations with low-n-3 status.

Compliance with dietary guidelines affects capillary recruitment in healthy middle-aged men and women.

PURPOSE: Healthy microcirculation is important to maintain the health of tissues and organs, most notably the heart, kidney and retina. Single components of the diet such as salt, lipids and polyphenols may influence microcirculation, but the effects of dietary patterns that are consistent with current dietary guidelines are uncertain. It was hypothesized that compliance to UK dietary guidelines would have a favourable effect on skin capillary density/recruitment compared with a traditional British diet (control diet). METHODS: A 12-week randomized controlled trial in men and women aged 40-70 years was used to test whether skin microcirculation, measured by skin video-capillaroscopy on the dorsum of the finger, influenced functional capillary density (number of capillaries perfused under basal conditions), structural capillary density (number of anatomical capillaries perfused during finger cuff inflation) and capillary recruitment (percentage difference between structural and functional capillary density). RESULTS: Microvascular measures were available for 137 subjects out of the 165 participants randomized to treatment. There was evidence of compliance to the dietary intervention, and participants randomized to follow dietary guidelines showed significant falls in resting supine systolic, diastolic and mean arterial pressure of 3.5, 2.6 and 2.9 mmHg compared to the control diet. There was no evidence of differences in capillary density, but capillary recruitment was 3.5 % (95 % CI 0.2, 6.9) greater (P = 0.04) on dietary guidelines compared with control. CONCLUSIONS: Adherence to dietary guidelines may help maintain a healthy microcirculation in middle-aged men and women. This study is registered at www.isrctn.com as ISRCTN92382106.

How expensive is a cardioprotective diet? Analysis from the CRESSIDA study.

OBJECTIVE: To determine whether a cardioprotective dietary intervention based on UK dietary guidelines was more expensive than a conventional UK diet. DESIGN: Cost analysis of food records collected at baseline and after a 12-week dietary intervention of a cardioprotective diet v. conventional UK diet. SETTING: A randomized controlled dietary intervention study (CRESSIDA; ISRCTN 92382106) investigating the impact of following a diet consistent with UK dietary guidelines on CVD risk. SUBJECTS: Participants were healthy UK residents aged 40-70 years. A sub-sample of participants was randomly selected from those who completed the cardioprotective dietary intervention (n 20) or the conventional UK dietary intervention (n 20). RESULTS: Baseline diet costs did not differ between groups; mean daily food cost for all participants was £6·12 (sd £1·83). The intervention diets were not more expensive: at end point the mean daily cost of the cardioprotective diet was £6·43 (sd £2·05) v. the control diet which was £6·53 (sd £1·53; P=0·86). CONCLUSIONS: There was no evidence that consumption of a cardioprotective diet was more expensive than a conventional dietary pattern. Despite the perception that healthier foods are less affordable, these results suggest that cost may not be a barrier when modifying habitual intake and under tightly controlled trial conditions. The identification of specific food groups that may be a cost concern for individuals may be useful for tailoring interventions for CVD prevention for individuals and populations.

Arthroscopic treatment of global pincer-type femoroacetabular impingement.

PURPOSE: Few studies have evaluated the role of hip arthroscopy in patients with coxa profunda. The purposes of this study are to (1) report functional hip outcomes after arthroscopic treatment of patients with femoroacetabular impingement (FAI) associated with radiographic coxa profunda and (2) evaluate factors associated with poor hip function at minimum 2 years following surgery in this specific cohort. METHODS: This retrospective review included patients with radiographic sign of coxa profunda who underwent hip arthroscopy to treat FAI. Preoperative and post-operative radiographs were reviewed to determine changes in lateral centre-edge angle (CEA), the presence and correction of Cam deformity, and Tönnis grade of osteoarthritis. Hip functional scores, including modified Harris Hip Score, Hip Outcome Score, and IHOT score, were obtained at a minimum of 2 years following surgery. RESULTS: The study cohort included 46 patients with a mean preoperative CEA of 39.9 (±2.4)° which decreased to a mean of 30.8 (±1.8)° post-operatively. At a mean follow-up of 2.5 years (±0.5), the mean mHHS and IHOT scores were 79.5 (±20.2) and of 69.7 (±28.3), respectively. Increased preoperative (p = 0.02) and post-operative (p = 0.001) Tönnis Osteoarthritis Grade was associated with a lower mHHS. CONCLUSIONS: Patients with coxa profunda can achieve similar functional scores to more traditional FAI cohorts after arthroscopic treatment. Baseline osteoarthritis is predictive of lower hip function after hip arthroscopy. This study demonstrates that patients with global over-coverage can benefit from hip arthroscopy and may influence surgeons to treat these patients with less invasive arthroscopic techniques which avoid the morbidity of open surgical procedures. LEVEL OF EVIDENCE: Retrospective case series, Level IV.

Procedural intervention for arthrofibrosis after ACL reconstruction: trends over two decades.

PURPOSE: Arthrofibrosis is a rare complication after anterior cruciate ligament (ACL) reconstruction. The purpose of this study was to (1) report a population-based incidence of arthrofibrosis (as defined by manipulation under anaesthesia or surgical lysis of adhesions) following ACL injury and reconstruction, (2) identify risk factors associated with development of arthrofibrosis, and (3) report outcomes of intervention for arthrofibrosis. METHODS: This was a historical cohort study performed in Olmsted County, Minnesota. The Rochester Epidemiology Project (REP) was used to identify a population-based cohort of individuals with new-onset, isolated ACL tears between 1 January 1990 and 31 December 2010. The REP database provides access to all medical records for each resident of Olmsted County, regardless of the facility where the care was delivered. A total of 1841 individuals were identified with new-onset, isolated ACL tears and were confirmed with chart review. The intervention incidence for arthrofibrosis was then calculated, and various predictive factors including age, sex, calendar year, and meniscal injury were investigated. RESULTS: During follow-up, 5 patients (1.0 %) in the non-operative cohort and 23 patients (1.7 %) in the ACL reconstruction cohort received intervention for arthrofibrosis, corresponding to an incidence of 0.7 per 1000 person-years in the non-operative cohort and 1.9 per 1000 person-years in the ACL reconstruction cohort. Female patients were 2.5 times more likely to have arthrofibrosis than males. The mean preoperative range of motion was -8° to 83° and improved to a mean of -2° to 127° post-operatively. CONCLUSIONS: Arthrofibrosis remains a rare but potentially devastating complication after ACL reconstruction, and roughly 2 % of patients had post-operative stiffness that required intervention. Female patients are at higher risk of arthrofibrosis. However, when patients develop severe motion complications after ACL injury, interventions are generally effective in preventing permanent arthrofibrosis.

Incidence and long-term follow-up of isolated posterior cruciate ligament tears.

PURPOSE: Isolated posterior cruciate ligament (PCL) tears are an uncommon injury. The goals of this study are to (1) determine the population-based incidence of isolated PCL tears, (2) compare the occurrence of secondary meniscal tears or arthritis in patients with PCL deficiency to patients without PCL tears, and (3) evaluate factors associated with long-term sequelae among patients with PCL deficiency. METHODS: This retrospective study included a population-based incidence cohort of 48 patients with new-onset, isolated PCL tears between 1990 and 2010, as well as an age and sex-matched cohort of individuals without PCL tears. A chart review was performed to collect information related to the initial injury, treatment, and outcomes. Subjects were retrospectively followed to determine the development of subsequent meniscal tears, arthritis, or total knee arthroplasty (TKA). RESULTS: The age- and sex-adjusted annual incidence of isolated, complete PCL tears was 1.8 (95 % CI 1.3, 2.3) per 100,000. During a mean 12.2-year follow-up, patients with isolated PCL tears had a significantly higher likelihood (HR 6.2, 95 % CI 1.8, 21.2) of symptomatic arthritis compared to individuals without PCL tears. The likelihood of subsequent meniscal tears (HR 2.1, 95 % CI 0.4, 10.7) and TKA (HR 3.2, 95 % CI 0.5, 19.6) was more frequent among patients with PCL tears compared to subjects without PCL tears. Older age at injury was significantly associated with future arthritis (P = 0.003) and TKA (P = 0.02). CONCLUSION: Isolated PCL tears remain a rare injury with an estimated annual incidence of 2 per 100,000 persons. Patients with isolated PCL tears have a significantly higher risk of symptomatic arthritis than patients without PCL tears. Older age at injury is associated with a higher risk of arthritis and the need for TKA. The results of this study can be used to educate patients about the natural history of isolated PCL tears and provide a baseline of expectations for the future development of arthritis and subsequent meniscal injury following isolated PCL injury. LEVEL OF EVIDENCE: Retrospective comparative study, Level III.

Long-term rate of graft failure after ACL reconstruction: a geographic population cohort analysis.

PURPOSE: Graft failure following anterior cruciate ligament reconstruction (ACLR) is a devastating injury among patients returning to activity. The goals of this study were to define the long-term rate of graft failure after ACLR in the general population and evaluate factors associated with graft failure. METHODS: This long-term observational study included a population-based incidence cohort of patients who underwent primary ACLR after diagnosis with new-onset, isolated ACL tears between 1990 and 2010. For all patients, a chart review was performed to collect information related to the initial injury, treatment, and outcomes. Patients were retrospectively followed to determine the incidence of graft failure following ACLR. RESULTS: The study cohort consisted of 1355 patients with new-onset, isolated ACL tears treated with ACLR. At a mean follow-up of 10.0 years (±6.4 years) following ACLR, a total of 72 patients (5.3 %) sustained ipsilateral graft failure. The graft survival following ACLR was 99.7 % at 1 year, 96 % at 5 years, 94 % at 10 years, 93 % at 15 years, 92 % at 20 years and 91 % at 25 years. Among patients 22 years or younger (n = 571), the rate of graft failure was significantly higher compared to patients older than 22 years (6.3 vs. 4.6 %, p = 0.04). The rate of graft failure decreased significantly over the 21-year observation period of this study (p < 0.0001). CONCLUSIONS: Among all patients receiving primary ACLR, graft failure remains an uncommon but functionally devastating outcome with an estimated graft survival rate of 91 % at 25 years following surgery. Patients aged 22 or younger had a significantly higher rate of graft failure than older patients. The rate of graft failure decreased over the 21-year span of this study. LEVEL OF EVIDENCE: Retrospective case series, Level IV.

Long-term follow-up of isolated ACL tears treated without ligament reconstruction.

PURPOSE: The incidence of subsequent meniscal tears and arthritis among patients with isolated ACL tears treated without ligament reconstruction has not been clearly established. The purpose of this study was to (1) compare the risk of subsequent meniscal tears and osteoarthritis (OA) between patients with isolated ACL tears treated without ligament reconstruction and a matched cohort of individuals without ACL tears and (2) examine factors predictive of long-term sequelae after non-operative treatment of isolated ACL tears. METHODS: This study compared a population-based incidence cohort of 364 patients with new-onset, isolated ACL tears between 1990 and 2000, to an age and sex-matched cohort of 364 individuals without ACL tears. A chart review was performed to collect information related to the initial injury, treatment, and outcomes. Subjects were retrospectively followed for mean follow-up of 14.3 years (±7.4 years) to determine the development of subsequent meniscal injury, arthritis, or total knee arthroplasty (TKA). RESULTS: Patients treated without ligament reconstruction after ACL tears had a significantly higher risk of secondary meniscal tears (HR 18.0, 95 % CI 9.7, 33.3), arthritis (HR 14.2, 95 % CI 8.0, 25.2), and need of TKA (HR 5.0, 95 % CI 2.1, 12.2) than individuals without ACL tears. Lateral meniscal tear at diagnosis was associated with a higher risk of arthritis (HR 2.7, 95 % CI 1.4, 5.7) and TKA (HR 4.3, 95 % CI 1.3, 13.7). Treatment with meniscectomy was associated with an increased risk of additional meniscal tears (HR 51.5, 95 % CI 10.3, 936.8). CONCLUSIONS: Patients treated non-operatively after isolated ACL tears are at a significantly higher risk of secondary meniscal tears, arthritis, and TKA when compared to age and sex-matched subjects without ACL tears. Additionally, baseline lateral meniscal tears were significantly associated with an increased probability of developing arthritis and the need for TKA. This information may be helpful when counselling patients about the natural history of ACL tears treated without ligament reconstruction. LEVEL OF EVIDENCE: III.

Exploring experiences, barriers, and enablers to home- and class-based exercise in rotator cuff tendinopathy: A qualitative study.

STUDY DESIGN: Qualitative study. INTRODUCTION: Adherence is paramount to the successful outcome of exercise-based treatment. PURPOSE OF STUDY: The barriers and enablers to adherence to a home- and class-based exercise program were explored in this qualitative study. METHODS: Semi-structured interviews were carried out to establish common themes relating to the participants' experiences during a year-long randomized controlled trial. RESULTS/DISCUSSION: Twelve participants were interviewed. The main enablers to exercise were highlighted as equipment, perceived benefit from the exercises, and longer and more intensive monitoring. Barriers included the lack of motivation, lack of equipment, and pain. CONCLUSIONS: Implications for practice are incorporating enablers and addressing barriers including self-discharge from classes; the importance of longer term follow-up and the benefits of adopting exercise into a well-established routine may provide potential benefits. LEVEL OF EVIDENCE: N/A.

Dietary patterns in obese pregnant women; influence of a behavioral intervention of diet and physical activity in the UPBEAT randomized controlled trial.

BACKGROUND: Understanding dietary patterns in obese pregnant women will inform future intervention strategies to improve pregnancy outcomes and the health of the child. The aim of this study was to investigate the effect of a behavioral intervention of diet and physical activity advice on dietary patterns in obese pregnant woman participating in the UPBEAT study, and to explore associations of dietary patterns with pregnancy outcomes. METHODS: In the UPBEAT randomized controlled trial, pregnant obese women from eight UK multi-ethnic, inner-city populations were randomly assigned to receive a diet/physical activity intervention or standard antenatal care. The dietary intervention aimed to reduce glycemic load and saturated fat intake. Diet was assessed using a food frequency questionnaire (FFQ) at baseline (15+0-18+6 weeks' gestation), post intervention (27+0-28+6 weeks) and in late pregnancy (34+0-36+0 weeks). Dietary patterns were characterized using factor analysis of the baseline FFQ data, and changes compared in the control and intervention arms. Patterns were related to pregnancy outcomes in the combined control/intervention cohort (n = 1023). RESULTS: Four distinct baseline dietary patterns were defined; Fruit and vegetables, African/Caribbean, Processed, and Snacks, which were differently associated with social and demographic factors. The UPBEAT intervention significantly reduced the Processed (-0.14; 95% CI -0.19, -0.08, P <0.0001) and Snacks (-0.24; 95% CI -0.31, -0.17, P <0.0001) pattern scores. In the adjusted model, baseline scores for the African/Caribbean (quartile 4 compared with quartile 1: OR = 2.46; 95% CI 1.41, 4.30) and Processed (quartile 4 compared with quartile 1: OR = 2.05; 95% CI 1.23, 3.41) patterns in the entire cohort were associated with increased risk of gestational diabetes. CONCLUSIONS: In a diverse cohort of obese pregnant women an intensive dietary intervention improved Processed and Snack dietary pattern scores. African/Caribbean and Processed patterns were associated with an increased risk of gestational diabetes, and provide potential targets for future interventions. TRIAL REGISTRATION: Current controlled trials; ISRCTN89971375.