Anterior Cruciate Ligament Graft Removal Versus Retention in the Setting of Septic Arthritis After Reconstruction: A Systematic Review and Expected Value Decision Analysis.

PURPOSE: To provide further guidance on the optimal decision between anterior cruciate ligament (ACL) graft removal versus retention in the setting of septic arthritis following reconstruction using an expected value decision analysis. METHODS: A systematic review and expected value decision analysis and sensitivity analyses were performed to quantify the clinical decision. A decision tree was created with 5 outcomes of interest: nonoperative complications, revision surgery, early reoperation, late reoperation, and "well." Pooled probabilities of each outcome were generated through a systematic literature review. We included only peer-reviewed studies, published in English, with at least 6 months of follow-up. One hundred randomly selected volunteers were given descriptions of the clinical scenario, the 2 treatment options, and outcomes of interest. Patients younger than 18 and older than 50 years and those previously treated for either ACL injury or septic arthritis, or both, were excluded from the analysis to minimize bias. These hypothetical patients indicated preferences for each outcome on a visual analog scale and responses were averaged to generate overall "utility values." Fold-back analysis summed products of pooled outcomes probabilities with respective averaged utility values. The resulting overall expected values for graft removal and debridement were compared, with the highest expected value considered to be superior. We then performed 1-way sensitivity analyses to mitigate sample bias. RESULTS: Fold-back analysis revealed graft removal to be strongly favored over retention, with overall expected values of 17.2 and 8.64, respectively. The most important contributor to the difference in overall expected values was late reoperation (8.59 vs 2.50 for removal and retention, respectively). Despite adjustments made to the rates of revision and early reoperation during the 1-way sensitivity analyses, graft removal remained the optimal strategy. CONCLUSIONS: This expected value decision analysis revealed that ACL graft removal was strongly favored by patients over graft retention in the setting of postoperative septic arthritis when consideration was given to the probabilities of wellness, nonoperative complications, revision surgery, early reoperation, and late reoperation. Sensitivity analysis revealed that although variation in rates of other outcomes did not impact this preference, the rate of late reoperation had a substantial impact. Only a sizable increase in the probability of late reoperation (from 0% to 60%) after graft removal would cause potential patients to favor graft retention. LEVEL OF EVIDENCE: Level IV, systematic review and decision analysis.

Failure Rates After Anterior Cruciate Ligament Repair With Suture Tape Augmentation in an Active-Duty Military Population.

Background: Anterior cruciate ligament (ACL) repair had previously been considered the standard of care for a ruptured ACL; however, ACL reconstruction has became the standard of care because of poor midterm outcomes after ACL repair. Recently, studies have suggested that the treatment paradigm should shift back to ACL repair. Purpose/Hypothesis: The purpose of this study was to evaluate the outcomes of ACL repair augmented with suture tape in a high-demand military population. We hypothesized that for proximal ACL avulsions, ACL repair with suture tape augmentation would lead to acceptable failure rates, satisfactory knee stability, excellent functional outcomes, and high rates of return to preinjury activity levels. Study Design: Case series; Level of evidence, 2. Methods: Patients who were treated with ACL repair by a single surgeon between March 2017 and June 2019 and who had a minimum of 2 years of follow-up were included. Intraoperatively, all patients first underwent an arthroscopic examination. If an ACL avulsion of the proximal insertion with adequate remaining tissue was visualized, then ACL repair was performed. The primary outcome assessed was ACL repair failure, defined as reruptures or clinical instability requiring revision to ACL reconstruction. Analysis of the risk factors for ACL repair failure was conducted, with age at surgery, sex, body mass index, level of competition, and tobacco use evaluated. Results: Included were 46 patients (32 male and 14 female; mean age, 28.3 ± 8.4 years) who underwent ACL repair with suture tape augmentation. There were 12 cases of failure (26.1%; 8 male and 4 female). The mean time from injury to surgery in the failure group was 164.1 ± 59.4 days compared to 107.3 ± 98.0 days in the nonfailure group (P = .02). According to multivariate regression analysis, patients aged ≤17 and ≥35 years, elite/competitive/operational patients, and current smokers had a higher chance of ACL repair failure. The mean time to pass a military physical fitness test was 5.0 months. There were no complications other than ACL repair failure. Conclusion: Primary arthroscopic ACL repair with suture tape augmentation resulted in unacceptably high failure rates at a minimum of 2 years of follow-up in a highly active military population. Age ≤17 and ≥35 years, elite level of competition, time from injury to surgery, and active tobacco use were independent risk factors for ACL repair failure.

Too many sheep in the flock? Span of control attenuates the influence of ethical leadership.

There has been growing interest in ethical leadership from both scholars and practitioners because of the positive effects that ethical leaders can have on their subordinates. These benefits come not only from ethical leaders acting as moral exemplars, but also from the tendency for ethical leaders to forge high-quality social exchange relationships with subordinates that help to establish expectations for appropriate conduct and ensure accountability through reciprocal obligation. However, the act of developing and maintaining strong social exchange relationships is resource intensive and requires considerable personal investment from ethical leaders. Extending current theory, we propose that wider spans of control attenuate the positive relationship between ethical leadership and leader-member exchange (LMX). Across two organizational samples, we developed and tested a moderated mediation model in which the effects of ethical leadership on performance, organizational citizenship behavior, and reduced production deviance via LMX were weakened by a widened span of control. Results in both studies supported the hypothesized model. Although it may be tempting to increase the number of subordinates assigned to ethical leaders in an effort to maximize their positive impact, the current findings suggest that the benefits of ethical leadership are diminished as span of control widens. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Targeted delivery of CRISPR-Cas9 ribonucleoprotein into arthropod ovaries for heritable germline gene editing.

Cas9-mediated gene editing is a powerful tool for addressing research questions in arthropods. Current approaches rely upon delivering Cas9 ribonucleoprotein (RNP) complex by embryonic microinjection, which is challenging, is limited to a small number of species, and is inefficient even in optimized taxa. Here we develop a technology termed Receptor-Mediated Ovary Transduction of Cargo (ReMOT Control) to deliver Cas9 RNP to the arthropod germline by injection into adult female mosquitoes. We identify a peptide (P2C) that mediates transduction of Cas9 RNP from the female hemolymph to the developing mosquito oocytes, resulting in heritable gene editing of the offspring with efficiency as high as 0.3 mutants per injected mosquito. We demonstrate that P2C functions in six mosquito species. Identification of taxa-specific ovary-specific ligand-receptor pairs may further extend the use of ReMOT Control for gene editing in novel species.