Multiligament knee injury (MLKI): an expert consensus statement on nomenclature, diagnosis, treatment and rehabilitation.

Multiligament knee injuries (MLKIs) represent a broad spectrum of pathology with potentially devastating consequences. Currently, disagreement in the terminology, diagnosis and treatment of these injuries limits clinical care and research. This study aimed to develop consensus on the nomenclature, diagnosis, treatment and rehabilitation strategies for patients with MLKI, while identifying important research priorities for further study. An international consensus process was conducted using validated Delphi methodology in line with British Journal of Sports Medicine guidelines. A multidisciplinary panel of 39 members from 14 countries, completed 3 rounds of online surveys exploring aspects of nomenclature, diagnosis, treatment, rehabilitation and future research priorities. Levels of agreement (LoA) with each statement were rated anonymously on a 5-point Likert scale, with experts encouraged to suggest modifications or additional statements. LoA for consensus in the final round were defined 'a priori' if >75% of respondents agreed and fewer than 10% disagreed, and dissenting viewpoints were recorded and discussed. After three Delphi rounds, 50 items (92.6%) reached consensus. Key statements that reached consensus within nomenclature included a clear definition for MLKI (LoA 97.4%) and the need for an updated MLKI classification system that classifies injury mechanism, extent of non-ligamentous structures injured and the presence or absence of dislocation. Within diagnosis, consensus was reached that there should be a low threshold for assessment with CT angiography for MLKI within a high-energy context and for certain injury patterns including bicruciate and PLC injuries (LoA 89.7%). The value of stress radiography or intraoperative fluoroscopy also reached consensus (LoA 89.7%). Within treatment, it was generally agreed that existing literature generally favours operative management of MLKI, particularly for young patients (LoA 100%), and that single-stage surgery should be performed whenever possible (LoA 92.3%). This consensus statement will facilitate clinical communication in MLKI, the care of these patients and future research within MLKI.

Editorial Commentary: Two-Year Follow-Up Is Too Short to Determine the Effectiveness of Anterior Cruciate Ligament Primary Repair.

Although recent studies have shown good results of anterior cruciate ligament primary repair at 2-year follow-up, one must be careful in adopting this technique. Historically, the classic study from West Point showed repair fails at 5 years. Perhaps future results will be improved with scaffolds, augmentation, or biologics. Only time will tell. For now, what's the (West) Point?

How to Recognize, Correct, and Avoid Intraoperative Complications During Anterior Cruciate Ligament Reconstructions.

Technical complications are a leading cause of graft failure following anterior cruciate ligament reconstructions. Complications can occur during any phase of the procedure, from graft harvesting to tunnel preparation to graft fixation. Predicting potential causes of technical difficulty and developing strategies to avoid potential pitfalls can limit the number of intraoperative complications. If adverse events do occur intraoperatively, prompt recognition and treatment can lead to favorable outcomes. It is important to discuss strategies to understand potential complications and develop tactics to avoid and correct adverse events that can occur during anterior cruciate ligament reconstruction.

Potential impacts of synthetic food dyes on activity and attention in children: a review of the human and animal evidence.

Concern that synthetic food dyes may impact behavior in children prompted a review by the California Office of Environmental Health Hazard Assessment (OEHHA). OEHHA conducted a systematic review of the epidemiologic research on synthetic food dyes and neurobehavioral outcomes in children with or without identified behavioral disorders (particularly attention and activity). We also conducted a search of the animal toxicology literature to identify studies of neurobehavioral effects in laboratory animals exposed to synthetic food dyes. Finally, we conducted a hazard characterization of the potential neurobehavioral impacts of food dye consumption. We identified 27 clinical trials of children exposed to synthetic food dyes in this review, of which 25 were challenge studies. All studies used a cross-over design and most were double blinded and the cross-over design was randomized. Sixteen (64%) out of 25 challenge studies identified some evidence of a positive association, and in 13 (52%) the association was statistically significant. These studies support a relationship between food dye exposure and adverse behavioral outcomes in children. Animal toxicology literature provides additional support for effects on behavior. Together, the human clinical trials and animal toxicology literature support an association between synthetic food dyes and behavioral impacts in children. The current Food and Drug Administration (FDA) acceptable daily intakes are based on older studies that were not designed to assess the types of behavioral effects observed in children. For four dyes where adequate dose-response data from animal and human studies were available, comparisons of the effective doses in studies that measured behavioral or brain effects following exposure to synthetic food dyes indicate that the basis of the ADIs may not be adequate to protect neurobehavior in susceptible children. There is a need to re-evaluate exposure in children and for additional research to provide a more complete database for establishing ADIs protective of neurobehavioral effects.

Editorial Commentary: Prevention of Complications During Multiple Ligament Knee Injury Reconstruction: It's Complicated!

Treatment of multiple-ligament knee injuries is complex and complicated. Surgeons should strive to keep their operative times under 5 hours, limit inside-out meniscal repair, consider fibular-based only posterolateral corner reconstructions (except in cases with associated proximal tibia-fibular joint injuries or massive posterolateral corner injuries), avoid acute surgery when possible, and proceed cautiously with ultra-low-velocity dislocations. Multiple-ligament knee injury reconstruction is challenging and complicated but a sincere thank you is extended to those surgeons who take on complex knee surgery.

A novel meniscofemoral ligament variant intra-substance to the PCL.

While much detail is known about each anatomic structure of the knee and its contributory effect on biomechanics, our understanding is still evolving. In particular, the function of the meniscofemoral ligaments and their anatomical variants have yet to be fully described. In this report, a never-before-described anatomical meniscofemoral ligament variant intra-substance to the PCL is presented. Arthroscopists should be aware of the novel variant as a growing number of studies have demonstrated the biomechanical importance of the meniscofemoral ligaments in protecting the lateral meniscus and supporting the function of the PCL.Level of Evidence: IV.

Using High-Throughput Screening to Evaluate Perturbations Potentially Linked to Neurobehavioral Outcomes: A Case Study Using Publicly Available Tools on FDA Batch-Certified Synthetic Food Dyes.

There is growing evidence from human and animal studies indicating an association between exposure to synthetic food dyes and adverse neurobehavioral outcomes in children. However, data gaps persist for potential mechanisms by which the synthetic food dyes could elicit neurobehavioral impacts. We developed an approach to evaluate seven US FDA-batch-certified food dyes using publicly available high-throughput screening (HTS) data from the US EPA's Toxicity Forecaster to assess potential underlying molecular mechanisms that may be linked to neurological pathway perturbations. The dyes were screened through 270 assays identified based on whether they had a neurological-related gene target and/or were mapped to neurodevelopmental processes or neurobehavioral outcomes, and were conducted in brain tissue, targeted specific hormone receptors, or targeted oxidative stress and inflammation. Some results provided support for neurological impacts found in human and animal studies, while other results showed a lack of correlation with in vivo findings. The azo dyes had a range of activity in assays mapped to G-protein-coupled receptors and were active in assays targeting dopaminergic, serotonergic, and opioid receptors. Assays mapped to nuclear receptors (androgen, estrogen, and thyroid hormone) also exhibited activity with the food dyes. Other molecular targets included the aryl hydrocarbon receptor, acetylcholinesterase, and monoamine oxidase. The Toxicological Prioritization Index tool was used to visualize the results of the Novascreen assays. Our results highlight certain limitations of HTS assays but provide insight into potential underlying mechanisms of neurobehavioral effects observed in in vivo animal toxicology studies and human clinical studies.

Ureteral Arterial Fistula - A Role for Open Operation in the 21st Century.

BACKGROUND: Ureteral arterial fistula is a rare and challenging clinical entity. The diagnosis and management of ureteral arterial fistula present a unique disease process that requires a dual specialty approach, involving both vascular and urologic surgeons. There are different options for repair, including both open and endovascular techniques. METHODS AND RESULTS: A 78-year-old male presented to the emergency department (ED) in septic shock secondary to a urinary tract infection and was admitted to the intensive care unit (ICU) for further management and resuscitation. The patient had previously undergone radical cystoprostatectomy with ileal conduit creation in 2011 for recurrent bladder cancer. Following creation of his ileal conduit, he required long-term indwelling ureteral stents bilaterally due to recurrent stricturing at the ureteroneocystostomy with stent exchanges performed 2-3 times per year due to frequent urinary tract infections. During his hospitalization for sepsis, the urology service performed an exchange of his left indwelling ureteral stent. However, pulsatile bleeding was observed from the junction of the ileal conduit and left ureter. The stent was replaced at the bedside, and the bleeding ceased. Vascular surgery consultation and a computed tomography angiogram (CTA) gave support to the diagnosis of a ureteral arterial fistula. A plan was developed to exchange the stent in the operating room with vascular surgery assistance. It was determined that a definitive open repair with excision of the fistula would be the most appropriate course. CONCLUSIONS: In the setting of hemodynamically significant bleeding, we recommend an endovascular approach to obtain hemostasis. However, an open approach provides both reconstruction and infectious resistance in an already soiled field. Open repair may provide a more definitive reconstruction.

Editorial Commentary: Anterior Cruciate Ligament Tunnel Aperture Overlap Determines Need for 1- Versus 2-Stage Revision: Setting the Stage.

Despite general agreement that tunnel widening ≥14 mm necessitates a 2-stage approach for revision anterior cruciate ligament (ACL) reconstruction, there is very little literature describing the effect of tunnel overlap between the previous tunnel and new tunnel with 1-stage ACL revisions. Tunnel overlap, particularly at the aperture, should be minimized without compromising anatomic tunnel location(s). This can often be accomplished with a 1-stage revision, but 2-stage revisions are sometimes required. Revision ACL reconstruction can be challenging and it is helpful for the surgeon to carefully plan preoperatively and have several options available to him/her intraoperatively, including the possibility of a 2-stage revision.

Allograft Bone Dowels Show Better Incorporation in Femoral Versus Tibial Tunnels in 2-Stage Revision Anterior Cruciate Ligament Reconstruction: A Computed Tomography-Based Analysis.

PURPOSE: The purpose of this study was to quantitatively evaluate the radiographic outcomes of allograft dowels used in 2-stage revision anterior cruciate ligament reconstruction (ACLR) and to compare the incorporation rates of dowels placed in tibial and femoral tunnels. METHODS: Prospective review of patients who underwent 2-stage revision ACLR with allograft bone dowels. Inclusion criteria were tibial/femoral tunnel diameter of ≥14 mm on preoperative computed tomography (CT) or overlapping of prior tunnels with planned tunnels. Second-stage timing was determined based on qualitative dowel integration on CT obtained at ∼3 months after the first stage. Quantitative analysis of incorporation rates was performed with the union ratio (UR) and occupying ratio (OR) on postoperative CT scans. RESULTS: Twenty-one patients, with a mean (SD) age of 32.1 (11.4; range, 18-50) years, were included. Second-stage procedures were performed at a mean (SD) of 6.5 (2.1; range, 2.4-11.5) months after first-stage revision. All dowels showed no signs of degradation at the host bone/graft junction at the second-stage procedure. The mean (SD) diameter of the dowels placed in tibial tunnels was greater than those placed in femoral tunnels (16.1 [2.3] mm vs 12.4 [1.6] mm; P < .05). CT was obtained at a mean (SD) of 121 (28; range, 59-192) days after the first-stage surgery. There was no difference between the OR of femoral and tibial tunnels (mean [SD], 87.6% [4.8%] vs 85.7% [10.1%]; P = .484), but the UR was significantly higher in femoral tunnels (mean [SD], 83% [6.2%] vs 74% [10.5%], P = .005). The intraclass correlation coefficients of OR and UR measurements indicated good reliability. CONCLUSIONS: Allograft bone dowels are a viable graft choice to replenish bone stock in the setting of a staged revision ACL reconstruction. Allograft dowels placed in femoral tunnels had a higher healing union ratio than tibial tunnel allografts and no evidence of degradation at the bone/graft junction, with no difference seen in occupying ratio. LEVEL OF EVIDENCE: Level IV, case series.

Developing and implementing core competencies in children's environmental health for students, trainees and healthcare providers: a narrative review.

Knowledge of the health impacts of environmental exposures (such as pollution disasters, poor air quality, water contamination, climate change) on children's health has dramatically increased in the past 40 years. The World Health Organization (WHO) estimated that 23% of all deaths worldwide were attributable to the environment, and 26% of deaths in children less than 5 years old could be prevented with removal of environmental risks factors. Yet, little has permeated medical education, leaving pediatric providers ill equipped to address these issues. To address this gap, members from the Pediatric Environmental Health Specialty Units, a United States nationwide network of academically affiliated experts who have created numerous environmental health educational materials and programs, have identified fifteen core environmental health (EH) competencies needed by health care providers to enable them to effectively address environmental health concerns. These competencies can serve as the foundation for the development and implementation of relevant educational programs. The core EH competencies are based upon these foundational elements: 1) Definition of "children's environmental health" that describes how environmental exposures (positive and negative) in early life influence the health and development in childhood and across the entire human life span 2) Children are not "little adults" and so have unique vulnerabilities to environmental hazards; 3) Environmental health inequities exist, causing some children to have a disproportionate amount of unhealthy exposures and consequently a greater risk of adverse effects; 4) Climate change will translate to numerous adverse health effects that will particularly affect children worldwide. In this article, the authors describe the core environmental health competencies and provide resources, online tools, strategies, and examples targeted to all levels of training and practice to better enable leaders and educators to bring this important content to the forefront.

Editorial Commentary: Caveat Medicus-Beware of Meniscal Repair.

Perform meniscal repair with care and beware! Because of the well-known adverse consequences of meniscectomy, especially in the lateral compartment, meniscal repair should be considered for every meniscal tear even if it requires pushing the envelope. Nevertheless, the surgeon must be keenly aware of neuromuscular risks associated with this technique. For the posterior horn of the lateral meniscus, extreme caution must be exercised, particularly in younger and presumably smaller female patients. When a surgeon is performing all-inside repair of the posterior horn of the lateral meniscus, a medial portal 1 cm medial to the patellar tendon is recommended for placement of sutures. In addition, he or she should limit the depth of penetration of all-inside needles and exercise extreme vigilance during and after surgery (checking for potential neurovascular injury in the recovery room).

Associated Morbidity After the Percutaneous Release of the Medial Collateral Ligament for Knee Arthroscopy.

PURPOSE: To summarize available data on the morbidity associated with percutaneous release of the medial collateral ligament (MCL) of the knee during arthroscopy via a "pie-crusting" technique. METHODS: A search of the literature was performed using the MEDLINE and Web of Science databases to identify studies examining the morbidity of percutaneous MCL release during arthroscopy. Only English-language articles were included; technical articles and studies not focused on the use of this technique were omitted. Two independent reviewers performed the literature search, data extraction, and quality assessment. The outcomes analyzed included resultant knee instability, functional outcome scores, visual analog scale pain scores, and saphenous nerve or greater saphenous vein injury. RESULTS: Six studies met the eligibility criteria. The studies included a total of 234 knees undergoing MCL release, with a mean patient age of 41.1 years. This MCL release typically generated grade I MCL laxity, which usually diminished or resolved over time and did not require brace application. The functional outcome scores of patients undergoing MCL release did not differ from those of patients undergoing the same procedure without MCL release. Postoperative pain was not significantly different between patients who underwent MCL release and those who did not. There was a 0% incidence of injury to the saphenous nerve or greater saphenous vein with MCL release in the included studies. CONCLUSIONS: Percutaneous MCL release during knee arthroscopy is a method of increasing the medial tibiofemoral joint space without causing any significant short- or long-term complications including residual valgus instability, pain, loss of function, or damage to surrounding structures. LEVEL OF EVIDENCE: Level IV, systematic review of Level IV studies.

Healthy Air, Healthy Brains: Advancing Air Pollution Policy to Protect Children's Health.

Evidence is growing on the adverse neurodevelopmental effects of exposure to combustion-related air pollution. Project TENDR (Targeting Environmental Neurodevelopmental Risks), a unique collaboration of leading scientists, health professionals, and children's and environmental health advocates, has identified combustion-related air pollutants as critical targets for action to protect healthy brain development. We present policy recommendations for maintaining and strengthening federal environmental health protections, advancing state and local actions, and supporting scientific research to inform effective strategies for reducing children's exposures to combustion-related air pollution. Such actions not only would improve children's neurological development but also would have the important co-benefit of climate change mitigation and further improvements in other health conditions.

The Timing of Corticosteroid Injections Following Simple Knee Arthroscopy Is Associated With Infection Risk.

PURPOSE: To examine any association between the timing of ipsilateral postoperative corticosteroid injection following simple knee arthroscopy and infection. METHODS: Private payer (PP) and Medicare (MC) national insurance databases were queried for patients who underwent simple arthroscopic knee procedures. Patients undergoing concomitant open or more complex procedures with grafts were excluded. Patients who underwent ipsilateral corticosteroid injections within 2, 4, 6, and 8 weeks postoperatively were then identified. Postoperative infection within 90 days after the injection was assessed using International Classification of Diseases, 9th Revision, and Current Procedural Terminology coding and compared using a multivariate binomial logistic regression analysis. RESULTS: A total of 5,533 patients were identified, including 725 that received an injection within 2 weeks; 1,236 patients within 4 weeks; 1,716 patients within 6 weeks; and 1,856 patients that received an injection within 8 weeks postoperatively. In both the PP and MC datasets, the rate of infection was significantly higher in the 2-week group compared with the 6- (PP: odds ratio [OR] 3.81, P = .012; MC: OR 9.36, P = .001) and 8-week (PP: OR 8.59, P = .003; MC: OR 7.80, P = .001) groups. The rate of infection was also higher in the 4-week group compared with the 6- (PP: OR 2.54, P = .024; MC: OR 8.91, P = .001) and 8-week (PP: OR 5.64, P = .009; MC: OR 7.80, P = .001) groups. There was no difference in infection rates between the 2- and 4-week groups in either dataset (PP: P = .278; MC: P = .861). CONCLUSIONS: There is a significant association between intra-articular knee corticosteroid injections within 4 weeks of surgery and an increased incidence of postoperative infection in both MC and PP patients after knee arthroscopy compared with patients with steroid injections more than 4 weeks postoperatively and matched controls who did not receive injections. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Comprehensive Case-Based Review of Knee Ligament Injuries.

The management of knee ligament injuries continues to evolve, and much debate persists over the timing of surgery, repair versus reconstruction, surgical technique, postoperative rehabilitation, graft selection, and fixation. Surgeons should be aware of updates on the best management strategies of knee ligament injuries in 2018 and understand the important history and physical examination findings of the knee with ligamentous injury; the anterior cruciate ligament; the role of the anterolateral ligament and lateral extra-articular tenodesis; combined anterior cruciate ligament and medial collateral ligament injuries; the posterior cruciate ligament; medial collateral ligament repair versus reconstruction; posterolateral corner repair versus reconstruction; the role of coronal plane osteotomies, including high tibial osteotomy and distal femoral osteotomy; the role of sagittal plane osteotomies, including anterior closing wedge osteotomy and anterior opening wedge osteotomy; the initial management of the multiligament-injured knee; and five keys to avoiding complications in the multiligament-injured knee. The best available evidence and sample case presentations help guide surgical decision making and improve patient outcomes.

A Two-Tiered Strategy for Preventing Complications of Bereavement in the First Thirteen Months Post-Loss: A Pilot Study Using Peer Supports with Professional Therapist Back-up.

This feasibility and acceptance pilot study for preventing complications of bereavement within the first year post loss recruited 20 adult grievers within 9 months of becoming bereft and assigned consenting subjects to peer supporters trained by a non-profit bereavement support organization for weekly or bi-weekly telephone-based peer support until month 13 post-loss. Subjects who met DSM-5 criteria for major depressive disorder or showed an Inventory of Complicated Grief (ICG) score exceeding 19, 6 months or more post loss, were assigned to 12 to 16 weeks of interpersonal psychotherapy (IPT) with an experienced therapist. Eight and six subjects completed the protocol assigned to peer support and IPT, respectively, with pre/post Patient Health Questionnaire-9 scores of 5.38 (2.45) versus 3.25 (4.13) (p = 0.266) and 16.67 (7.17) versus 8.40 (5.73) (p =0.063); and pre/post ICG scores of 12.50 (4.72) versus 5.00 (2.51) (p = 0.016) and 35.17 (5.12) versus 8.4 (5.73) (p = 0.063). Implications of this two-tiered model of early intervention for preventing complications of grief are discussed.

Editorial Commentary: Anterior Cruciate Ligament Graft Tunnel Mismatch: The Long and Short of It.

Anterior cruciate ligament graft size is an important consideration when planning the length of the tibial tunnel. In general, longer grafts require longer tunnels to accommodate the graft. Ideally, the tibial bone plug should be flush with the tibial cortex after graft passage and femoral fixation. Alternatively, allograft bone-patellar tendon-bone grafts can be selected based on their lengths to assure an ideal fit in the tibial tunnel. However, there are increased risks of allograft failure in young patients that anterior cruciate ligament surgeons should recognize.

Editorial Commentary: Outside the Scope of Practice-Wrong-Site Surgery Should NEVER Happen.

Malpractice lawsuits involving arthroscopic surgical procedures are relatively common. Fortunately, many of them are avoidable. Wrong-site surgery results in a successful verdict for the plaintiff all the time, so it needs to be avoided. Deep venous thrombosis, another common reason for lawsuits, especially after knee arthroscopy, can be stratified based on risk factors and managed accordingly. Effective communication is the arthroscopist's best defense against potential lawsuits.

Not All Patients With Diabetes Have the Same Risks: Perioperative Glycemic Control Is Associated With Postoperative Infection Following Knee Arthroscopy.

PURPOSE: To determine the association between glycemic control and infection following knee arthroscopy, and to determine the clinical utility of a threshold HbA1c level. METHODS: A national database identified patients who underwent knee arthroscopy from 2007 to 2016. Patients with concomitant open portions, more complex knee procedures, procedures performed for infection and patients with prior septic knee arthritis were excluded. Patients with an HbA1c level checked within 3 months of surgery were compared to control groups of nondiabetics and diabetics undergoing knee arthroscopy without a perioperative HbA1c. The study group was then stratified based on their HbA1c. The incidence of deep infection within 6 months was identified and compared to those in the control groups. A subgroup analysis was performed to investigate any trend in the timing of postoperative infection. A receiver operating characteristic (ROC) analysis was performed to determine and test a threshold value of HbA1c. RESULTS: 13,470 study patients were included, with an overall rate of infection of 0.33%. The rate of infection ranged from 0.25% to 1.03%. The rate of infection in study patients was greater than the nondiabetes control group's (P < .0001) and not significantly different from that in the nonstudy diabetes control (P = .765). The inflection point of the ROC curve corresponded to an HbA1c level of 8.0 mg/dL (P = .006, specificity = 76%, sensitivity = 44%, area under curve [AUC] = 0.619). CONCLUSIONS: The risk of infection following knee arthroscopy increases as the perioperative HbA1c increases. ROC analysis determined that an HbA1c above 8.0 mg/dL could serve as a threshold level; however, the AUC and low sensitivity reflected the poor utility of this test as an independent predictor for infection. LEVEL OF EVIDENCE: Level III, retrospective comparative study.