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Anterior cruciate ligament (ACL) injuries are common knee ligament injuries. While generally successful, ACL reconstruction that uses a tendon graft to stabilize the knee is still associated with a notable percentage of failures and long-term morbidities. Preclinical research that uses small laboratory species (i.e., mice, rats, and rabbits) to model ACL reconstruction are important to evaluate factors that can impact graft incorporation or posttraumatic osteoarthritis after ACL reconstruction. Small animal ACL reconstruction models are also used for proof-of-concept studies for the development of emerging biological strategies aimed at improving ACL reconstruction healing. The objective of this review is to provide an overview on the use of common small animal laboratory species to model ACL reconstruction. The review includes a discussion on comparative knee anatomy, technical considerations including types of tendon grafts employed amongst the small laboratory species (i.e., mice, rats, and rabbits), and common laboratory evaluative methods used to study healing and outcomes after ACL reconstruction in small laboratory animals. The review will also highlight common research questions addressed with small animal models of ACL reconstruction.

Contains fulltext : 282770.pdf (Publisher’s version ) (Open Access) INTRODUCTION: HIV pre-exposure prophylaxis (PrEP) involves the use of antiretroviral medication in HIV-negative individuals considered to be at risk of acquiring HIV. It has been shown to prevent HIV and has been available in Wales since July 2017. Measuring and understanding adherence to PrEP is complex as it relies on the simultaneous understanding of both PrEP use and sexual activity. We aimed to understand the experiences of men who have sex with men (MSM) living in Wales initiating, implementing and persisting with HIV PrEP. METHODS: We conducted semistructured interviews with MSM PrEP users in Wales who participated in a cohort study of PrEP use and sexual behaviour. Following completion of the cohort study, participants were invited to take part in a semistructured interview about their experiences of taking PrEP. We aimed to include both individuals who had persisted with and discontinued PrEP during the study. The interview topic guide was informed by the ABC taxonomy for medication adherence and the theory of planned behaviour. We analysed our data using reflexive thematic analysis. RESULTS: Twenty-one participants were interviewed, five having discontinued PrEP during the cohort study. The developed themes focused on triggers for initiating PrEP, habitual behaviour, drivers for discontinuation and engagement with sexual health services. Stigma surrounding both PrEP and HIV permeated most topics, acting as a driver for initiating PrEP, an opportunity to reduce discrimination against people living with HIV, but also a concern around the perception of PrEP users. CONCLUSION: This is the first study to investigate PrEP-taking experiences incorporating established medication adherence taxonomy. We highlight key experiences regarding the initiation, implementation and persistence with PrEP and describe how taking PrEP may promote positive engagement with sexual health services. These findings may be useful for informing PrEP rollout programmes and need to be explored in other key populations. PATIENT AND PUBLIC CONTRIBUTION: PrEP users, in addition to PrEP providers and representatives of HIV advocacy and policy, were involved in developing the topic guide for this study.

Anterior cruciate ligament (ACL) injuries and surgeries are both increasing in incidence. A notable rate of reinjury and failure does occur after ACL surgery. As a result, interventions that may reduce ACL injury or reinjury are needed and are active areas of innovation. Knee bracing as a strategy to either prevent primary ACL injury, reduce reinjury, or failure after ACL surgery is common. The evidence for bracing around ACL injuries is not straightforward. Clinicians therefore need to understand the relevant literature on bracing around ACL injuries to make personalized decisions for individuals who may be at risk for ACL injury. The purpose of this review is to provide an overview on bracing for ACL injuries and summarize the current available clinical evidence for its use in ACL injuries.

Contains fulltext : 293619.pdf (Publisher’s version ) (Open Access) Stigma may influence the use of HIV pre-exposure prophylaxis (PrEP). However, there is an absence of robust measures for PrEP-related stigma. We describe an adaptation of a HIV stigma scale for use in PrEP users and experiences of PrEP users in Wales (UK) with regards to PrEP-related stigma. A mixed methods study was conducted where PrEP users completed questionnaire items about PrEP-related stigma and a subset were interviewed about their experiences of taking PrEP. We adapted items from the HIV stigma scale and assessed construct validity and internal consistency. We analysed interview data using a framework approach, with themes focussing on enacted and anticipated stigma in order to identify areas for scale refinement. Our measure had good psychometric properties but additional items may be useful (e.g. specific instances of enacted stigma, concerns around homonegativity). Further work is needed to develop this scale and validate it in a larger sample. 01 juli 2023

Contains fulltext : 292876.pdf (Publisher’s version ) (Open Access) We investigated the determinants of daily PrEP use and coverage of condomless anal sex (CAS) by PrEP among men who have sex with men in Wales, UK. We measured PrEP use by electronic monitors and CAS by secure online surveys. We defined PrEP use based on daily medication cap openings and coverage as CAS episodes preceded by ≥ 3 days of PrEP use and followed by ≥ 2 days of PrEP use. We included 57 participants (5463 observations). An STI diagnosis was associated with lower PrEP use but also lower PrEP coverage. Older adults had higher PrEP use. A belief that other PrEP users took PrEP as prescribed was associated with lower PrEP coverage. An STI diagnosis is an important cue for an intervention, reflecting episodes of high-risk sexual behaviour and low PrEP coverage. Other results provide a basis for the development of an evidence-informed intervention for promoting coverage of PrEP.

ACL injury and surgery are increasing in prevalence. Several challenges exist that can be obstacles to an individual achieving success after ACL surgery. A knowledge of these risk factors alongside a multidisciplinary collaborative team approach can result in a greater likelihood of achieving individual success after ACL surgery.

Numerous in vitro studies suggest higher osmolarity irrigation fluids potentiate a chondroprotective environment, and a recent clinical study using hyperosmolar saline for shoulder arthroscopy reported potential clinical advantages. This prospective randomized double-blind controlled clinical trial was designed to assess initial clinical outcomes associated with use of a hyperosmolar irrigation solution in patients undergoing arthroscopic knee surgery. With institutional review board approval and informed consent, patients scheduled for arthroscopic knee surgery were randomized to surgery with either isotonic lactated Ringer's (273 mOsm/L) or hyperosmolar saline (593 mOsm/L) irrigation solution. Outcomes included perioperative blood pressure, knee girth, visual analogue scale (VAS) pain scores, and narcotic pain medication consumption. Forty-six patients underwent arthroscopic knee surgery with isotonic (n = 23) or hyperosmolar (n = 23) irrigation fluids. There were 11 males and 12 females (mean age = 44.0 years) in the isotonic cohort and 8 males and 15 females (mean age = 40.2 years) in the hyperosmolar cohort. There were no significant differences with respect to surgical duration (pump time) or amount of irrigation fluid used between the two cohorts. There were no significant differences with respect to change in knee girth, blood pressure, or VAS pain scores. However, patients treated with hyperosmolar saline consumed less narcotic medication on postoperative day 3 (4.0 ± 7.6 vs. 15.5 ± 17.4 mg, p = 0.01). The results of this randomized clinical trial suggest that a hyperosmolar irrigation solution is safe and relatively inexpensive for use in patients undergoing arthroscopic knee surgery and contributes to a reduction in initial postoperative narcotic pain medication consumption. A hyperosmolar saline irrigation fluid was not associated with any detrimental effects on the execution of the surgical procedure, postoperative pain, or periarticular fluid extravasation. Taken together with previous basic science, translational, and clinical studies, hyperosmolar saline irrigation fluid is promising alternative to traditional isotonic irrigation fluids for knee arthroscopy. This study is a prospective trial and reflects level of evidence I.

Background:Different tendons are chosen for anterior cruciate ligament (ACL) reconstruction based on perceived advantages and disadvantages, yet there is a relative paucity of information regarding biologic responsiveness of commonly used tendon grafts to mechanical strain.Purpose:To evaluate the in vitro responses of graft fibroblasts derived from tendons used for ACL reconstruction to clinically relevant strain levels.Study Design:Controlled laboratory study.Methods:Twelve quadriceps tendons (QTs), 12 patellar tendons (PTs), and 9 hamstring tendons (HTs) were harvested from skeletally mature dogs (n = 16). Tendon fibroblasts were isolated and seeded onto BioFlex plates (1 × 105cells/well). Cells were subjected to 3 strain conditions (stress deprivation, 0%; physiologic, 4%; high, 10%) for 5 days. Media were collected for proinflammatory and metabolic assays. RNA was extracted for gene expression analysis using real-time reverse transcription polymerase chain reaction.Results:Stress deprivation elicited significantly higher metabolic activity from HT and PT cells than from QT cells ( P < .001 and P = .001, respectively). There were no differences in metabolic activity among all 3 graft fibroblasts at physiologic and high strain. COL-1 expression was significantly higher in PT versus HT during physiologic strain ( P = .007). No significant differences with COL-3 expression were seen. TIMP-1 ( P = .01) expression was higher in PT versus HT under physiologic strain. Scleraxis expression was higher in PT versus HT ( P = .007) under physiologic strain. A strain-dependent increase in PGE2 levels occurred for all grafts. At physiologic strain conditions, HT produced significantly higher levels of PGE2 versus QT ( P < .001) and PT ( P = .005).Conclusion:Fibroblasts from common ACL graft tissues exhibited different metabolic responses to mechanical strain. On the basis of these data, we conclude that early production of extracellular matrix and proinflammatory responses from ACL grafts are dependent on mechanical loading and graft source.Clinical Relevance:Graft-specific differences in ACL reconstruction outcomes are known to exist. Our results suggest that there are differences in the biologic responsiveness of cells from the tendon grafts used in ACL reconstruction, which are dependent on strain levels and graft source. The biologic properties of the tissue used for ACL reconstruction should be considered when selecting graft source.

The availability of non-invasive means to evaluate and monitor tendon-bone healing processesUnilateral autograft ACL reconstruction was performed in six rats. µPET/CT-scans usingSUVs in both bone tunnels showed an increasedSerial

Background The assessment of the prevalence of diseases is of primary importance in planning health policies. No complete data on the prevalence of skin diseases across European countries are available. Objective To estimate the prevalence of the most frequent skin conditions or diseases in 27 European countries (24 EU countries, plus Norway, Switzerland, and the United Kingdom). Methods We conducted a population-based study on representative and extrapolable samples of the general population aged 18 years or more in each of the 27 countries surveyed. Participants were selected using stratified, proportional sampling with a replacement design. Data were collected using a web-based online survey. All participants were asked to fill in a questionnaire with sociodemographic data and to declare if they have had one or more skin conditions or diseases during the previous 12 months. Results A total of 44 689 participants from 27 countries responded to the questionnaire, 21 887 (48.98%) men and 22 802 (51.02%) women. The proportion of participants who reported having suffered from at least one dermatological condition or disease during the previous 12 months was 43.35% (95% CI: 42.89%, 43.81%). The projection in the total population of the 27 countries included in the study resulted in 185 103 774 individuals affected by at least one dermatological condition or disease. Accordingly, we can estimate that more than 94 million Europeans complain of uncomfortable skin sensations like itch, burning, or dryness. The most frequent conditions were fungal skin infections (8.9%), acne (5.4%), and atopic dermatitis or eczema (5.5%). Alopecia, acne, eczema, and rosacea were more common in women, whereas men were more likely to suffer from psoriasis and sexually transmitted infections. Conclusion Skin diseases are an important public health concern. Their high prevalence has to be taken into account in planning access to dermatological care to address patient needs.

Background The availability of non-invasive means to evaluate and monitor tendon-bone healing processes in-vivo is limited. Micro Positron-Emission-Tomography (µPET) using 18F-Fluoride is a minimally invasive imaging modality, with which osteoblast activity and bone turnover can be assessed. The aim of this study was to investigate the use of serial in-vivo µPET/CT scans to evaluate bone turnover along the graft-tunnel interface in a rat ACL (anterior cruciate ligament) reconstruction model. Methods Unilateral autograft ACL reconstruction was performed in six rats. µPET/CT-scans using 18F-Fluoride were performed 7, 14, 21, and 28 days postoperatively. Standard uptake values (SUV) were calculated for three tunnel regions (intraarticular aperture (IAA), mid-tunnel, and extraarticular aperture (EAA)) of the proximal tibia. Animals were sacrificed at 28 days and evaluated with µCT and histological analysis. Results SUVs in both bone tunnels showed an increased 18F-Fluoride uptake at 7 days when compared to 14, 21, and 28 days. SUVs showed a gradient on the tibial side, with most bone turnover in the IAA and least in the EAA. At 7, 14, 21, and 28 days, there were significantly higher SUV values in the IAA compared to the EAA ( p = .01, < .01, < .01, < .01). SUVs positively correlated with new bone volumetric density obtained with μCT (r = 0.449, p = .013). Volumetric density of newly formed bone detected on μCT correlated with osteoblast numbers observed along the tunnels in histological sections (r = 0.452, p < .016). Conclusions Serial in-vivo µPET/CT-scanning has the potential to provide insight into bone turnover and therefore osteoblastic activity during the healing process. As a result, it allows us to directly measure the effect of interventional strategies in tendon-bone healing.

Anterior cruciate ligament (ACL) and medial collateral ligament (MCL) injuries are common knee injuries, which can result from contact and noncontact during sports, recreation, or work-related activities. Prophylactic knee braces (PKBs) have been designed to protect the knee and decrease risk of recurrence of these injuries. Despite their success, PKBs have not been proven to be consistently effective and cost of the device must be evaluated to optimize its use in sports, particularly American football. Biomechanical studies have suggested that increased hip and knee flexion angles may reduce frontal plane loading with bracing which can protect the knee joint. This is essential with knee loading and rotational moments because they are associated with jumping, landing, and pivoting movements. The clinical efficacy of wearing PKBs can have an impact on athletic performance with respect to speed, power, motion, and agility, and these limitations are evident in athletes who are unaccustomed to wearing a PKB. Despite these concerns, use of PKBs increases in patients who have sustained an MCL injury or recovering from an ACL reconstruction surgery. As the evidence continues to evolve in sports medicine, there is limited definitive data to determine their beneficial or detrimental effects on overall injury risk of athletes, therefore leading those recommendations and decisions for their usage in the hands of the athletic trainers and team physicians' experience to determine the specific brace design, brand, fit, and situations for use.

BackgroundThe first wave of lockdown measures to control the COVID-19 pandemic in the UK resulted in suspension of ‘non-essential’ services, including contraceptive care.AimTo examine women’s perceptions and experiences of contraceptive care in the UK during the first lockdown.Design & settingA cross-sectional survey during the lockdown period from March–June 2020.MethodAn online questionnaire was designed asking women aged 16–54 years their experiences of contraceptive care during lockdown. Questions were based on Maxwell’s evaluation framework on access, acceptability, relevance or appropriateness, and equity. It was promoted on social media from 27 May–9 June 2020. A descriptive analysis was conducted of quantitative data and thematic analysis of free-text data.ResultsIn total, 214 responses were analysed. General practice was the source of contraception for 43.4% (n = 49) and 52.3% (n = 34) of responders before and during the lockdown, respectively. The study found 55.1% (n = 118) of responders, including regular and new users, were uncertain where or how to get contraception during the pandemic. Responders reported reduced access to contraception during lockdown, and some thought sexual health clinics and general practices were closed. Remote consultations and electronic prescriptions facilitated contraceptive access for some responders. Long-acting reversible contraception (LARC) was unavailable in some areas owing to restrictions, and alternatives were not acceptable to those who used methods for non-contraceptive benefits to treat medical conditions; for example, menorrhagia.ConclusionThe study highlighted the need for better information and signposting for contraception during lockdown. Contraception, including LARC, should be reframed as an essential service with robust signposting for pandemic planning and beyond.

Three-dimensional (3-D) printing technology is affecting how orthopaedic surgeries are planned and executed. Like many innovations, 3-D printers are becoming smaller, more affordable, and more accessible. Free access to open-source 3-D imaging software has also made clinical implementation of this technology widely feasible. Within the last decade, 3-D printing advancements have improved the way orthopaedic surgeons can approach both common and complex cases. Advanced imaging studies can be used to create musculoskeletal models, which can then be used to create custom orthopaedic guides and instruments. Similarly, 3-D printing is being applied to improve the field of biologic therapies in orthopaedics. Application of 3-D printing technology has been associated with important improvements in education, preoperative planning, surgical care, and patient-specific devices and treatments. Improvements in cost-effectiveness, access, and usability of 3-D printing technology have made it possible for orthopaedic surgeons to use this powerful tool using desktop 3-D printers in their clinic or office. The types of printers and materials available to print are constantly expanding, but many of the basic 3-D printing principles persist throughout these advances in the field. A clear understanding of this technology is important to the clinical implementation of 3-D printing for current and future practice of orthopaedic care.

A radial tear of the meniscus can lead to significant loss of meniscus function, resulting in deleterious cartilage changes. Repair of radial meniscus tears has several challenges, including suture pull-out, which can reduce healing success. We present an arthroscopic repair technique in a complete radial lateral meniscus tear using vertical reinforced bars (rebar) of suture tapes to reduce suture pull-out and approximate the radial tear., Technique Video Video 1 The lateral meniscus repair is performed with the patient in a supine position with a lateral hip post. This is preferable for lateral meniscus work where the leg can be placed in a figure-four position without the constant need of an assistant to maintain varus force to open the lateral compartment. The repair of a radial tear of the lateral meniscus is done with the knee in the figure-four position. An arthroscopic cannula (PassPort Cannula) is typically placed in the medial portal for the lateral meniscus repair. The most optimal external location is identified that corresponds to the site of the intraarticular meniscus tear. An accessory posterolateral incision (typically 2-3 cm) is then made in this location so that a retractor (speculum) can be placed to protect the posterolateral structures. The high-grade complex lateral meniscus radial tear is shown (00:15-00:40 seconds). The torn lateral meniscus tissue is then mechanically prepared to active the tissue for healing (00:15-00:40 seconds). We abrade the torn meniscus tissue and the adjacent synovium with a meniscus rasp to optimize the local environment for healing. Given radial tears traverse often poorly vascularized portion of the meniscus, we also trephinate the meniscus tear to induce localized bleeding using an 18-G spinal needle. A single or double lumen zone-specific arthroscopic meniscus repair cannula can then be used to place the vertically orientated parallel suture tape rebars (2-0 Mini SutureTape Meniscus Repair Needles; Arthrex, Naples, FL) approximately 5 mm from on either side of the radial tear (0:41-01:14 seconds). A horizontal mattress is then placed just anterior or posterior to the rebars in the anterior and posterior portion of the torn meniscus respectively (01:15-01:40 seconds). The most inner one third of the radial tear is fixed with an all-inside mattress suture as a capsular based fixation with another horizontal mattress may iatrogenically contract the meniscus toward the joint capsule (01:42-02:29 seconds). While we recognize the healing of the inner one third of the meniscus is unpredictable, it may help shield and protect the more peripheral portions of the repair in the middle and outer one third of the lateral meniscus by providing some resistance toward gapping during the early rehabilitation process. The sequence of tensioning the meniscus repair usually start with tying the vertical suture tape rebars to the posterolateral joint capsule, which tensions the suture tape rebars to the torn portion of the lateral meniscus. We then tie the horizontal mattress suture tape from peripheral toward central in the meniscus. If a horizontal mattress was placed in the inner one third of the lateral meniscus, the is typically tied intra-articularly in arthroscopic fashion last (02:29-03:33 seconds). The repair can then be re-examined arthroscopically (03:36-03:47 seconds). We conclude the arthroscopic lateral meniscus repair with microfracture of the intercondylar notch to induce egress of bone marrow elements and intraarticular bleeding, which may provide an internal milieu more conducive to meniscus healing (03:48-04:15 seconds).

Background: Anterior cruciate ligament (ACL) tears are debilitating injuries frequently suffered by athletes. ACL reconstruction is indicated to restore knee stability and allow patients to return to prior levels of athletic performance. While existing literature suggests that patient-reported outcomes are similar between bone–patellar tendon–bone (BTB) and hamstring tendon (HT) autografts, there is less information comparing return-to-sport (RTS) rates between the 2 graft types. Purpose: To compare RTS rates among athletes undergoing primary ACL reconstruction using a BTB versus HT autograft. Study Design: Systematic review; Level of evidence, 4. Methods: The MEDLINE, Embase, and Cochrane Library databases were searched, and studies that reported on RTS after primary ACL reconstruction using a BTB or HT autograft were included. Studies that utilized ACL repair techniques, quadriceps tendon autografts, graft augmentation, double-bundle autografts, allografts, or revision ACL reconstruction were excluded. RTS information was extracted and analyzed from all included studies. Results: Included in the review were 20 articles investigating a total of 2348 athletes. The overall RTS rate in our cohort was 73.2%, with 48.9% returning to preinjury levels of performance and a rerupture rate of 2.4%. The overall RTS rate in patients after primary ACL reconstruction with a BTB autograft was 81.0%, with 50.0% of athletes returning to preinjury levels of performance and a rerupture rate of 2.2%. Patients after primary ACL reconstruction with an HT autograft had an overall RTS rate of 70.6%, with 48.5% of athletes returning to preinjury levels of performance and a rerupture rate of 2.5%. Conclusion: ACL reconstruction using BTB autografts demonstrated higher overall RTS rates when compared with HT autografts. However, BTB and HT autografts had similar rates of return to preinjury levels of performance and rerupture rates. Less than half of the athletes were able to return to preinjury sport levels after ACL reconstruction with either an HT or BTB autograft.

Background There is a lack of injury data for the new Olympic sport of Rugby-7s, particularly for involved youth. Objective To determine injury rates and characteristics for players participating in U.S. Rugby-7s U19 (under 19 years of age) tournaments. Methods Injury data were collected, using the Rugby Injury Survey & Evaluation report methodology, at 24 U.S. Rugby-7 s U19 tournaments over 30 tournament days (2010–2014). Tournament medical-attention injuries and time-loss injuries (days absent before return to training/competition including post tournament) were recorded. Results During the 2101 playing hours (3072 males, aged 17.2 ± 1.5 years; 732 females, 16.6 ± 1.3 years of age), there were 173 tournament injuries with an overall injury incidence of 82.4/1000 player-match-hours (ph) (CI 70.5–95.6). Acute injuries (79.5/1000 ph) occurred during tackling (56.2/1000 ph) and involved joints/ligaments (32.8/1000 ph) of lower extremities (31.9/1000 ph). Head and neck injuries, including concussions, were common (males 21.9/1000 ph; females 22.0/1000 ph). Medical-attention injury incidences (49.5/1000 ph; n = 104; 95% CI 40.5–60.0) were higher than time loss (32.8/1000 ph; n = 69; 95% CI 25.5–41.6). Overall, injury incidences found no difference between sex (RR 0.78; p = 0.369). Time-loss injuries resulted in an average of 35.5 d to return to sport. Discussion This study is the first to report match injury incidences for U19 participants in Rugby-7s. Overall, match injury incidence among U.S. U19 Rugby-7s tournaments was similar compared to adult U.S. community Rugby-7s. Recurrent injury risk was notable in this population. Community injury surveillance studies are essential to understand risk from participation in amateur sports. Knowledge of these injury patterns in U19 Rugby-7s will help identify areas to direct resources to enable growth of Rugby-7s in youths and emerging countries being exposed to Rugby-7 s. Age-based injury frequency and patterns in rugby and its various formats are needed for the development of evidence-based, sport-specific, and population-specific injury prevention initiatives. Conclusions The match injury incidence of U19 participants in U.S. Rugby-7s was similar to the incidence among adult participants. Recurrent match injury risk was high at 23%. There were no significant differences in injury incidences between males and females. The first three matches of a tournament day result in the most injuries.

Background: Biceps tenodesis is a surgical treatment for both superior labral anterior-posterior (SLAP) tears and long head of the biceps tendon (LHBT) abnormalities. Biceps tenodesis can be performed either above or below the pectoralis major tendon with arthroscopic or open techniques. Purpose: To analyze the outcomes and complications comparing primary arthroscopic suprapectoral versus open subpectoral biceps tenodesis for either SLAP tears or LHBT disorders. Study Design: Systematic review; Level of evidence, 4. Methods: A search strategy based on the PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) protocol was used to include 18 articles (471 patients) from a total of 974 articles identified. Overall exclusion criteria included the following: non–English language, non–full text, biceps tenodesis with concomitant rotator cuff repair, review articles, meta-analyses, and case reports. Data were extracted and analyzed according to procedure type and tenodesis location: arthroscopic suprapectoral biceps tenodesis (295 patients) versus open subpectoral bicepts tenodesis (176 patients). Results: For arthroscopic suprapectoral biceps tenodesis, the weighted mean American Shoulder and Elbow Surgeons (ASES) score was 90.0 (97 patients) and the weighted mean Constant score was 88.7 (108 patients); for open subpectoral biceps tenodesis, the mean ASES score was 91.1 (199 patients) and mean Constant score was 84.7 (65 patients). Among the 176 patients who underwent arthroscopic biceps tenodesis, there was an overall complication rate of 9.1%. Among the 295 patients who underwent open biceps tenodesis, there was an overall complication rate of 13.5%. Both residual pain (5.7% vs 4.7%, respectively) and Popeye deformity (1.7% vs 1.0%, respectively) rates were similar between the groups. Open subpectoral biceps tenodesis had higher reoperation (3.0% vs 0.0%, respectively), wound complication (1.0% vs 0.0%, respectively), and nerve injury (0.7% vs 0.0%, respectively) rates postoperatively. A meta-analysis of 3 studies demonstrated that both methods had similar ASES scores ( P = .36) as well as all-cause complication rates (odds ratio, 0.76 [95% CI, 0.13-4.48]; P = .26). Conclusion: Patients undergoing arthroscopic suprapectoral biceps tenodesis for either SLAP tears or LHBT abnormalities had similar outcome scores and complication rates compared with those undergoing open subpectoral biceps tenodesis. Additionally, both residual pain and Popeye deformity rates were similar between the 2 groups.

Objectives: Graft choice for anterior cruciate ligament (ACL) reconstruction remains controversial. Quadriceps autograft has emerged as an alternative graft choice. However, there remains a paucity of comparative outcomes. Our purpose is to compare subjective outcomes and complications of ACL reconstruction using either BTB or quadriceps autograft. Our hypothesis is that there will be no difference in subjective outcome or complications between groups. Methods: Following IRB approval, retrospective review of prospectively collected data identified consecutive cohorts of patients undergoing ACL reconstruction with either BTB or quadriceps autograft. Surgery was performed by a single sports fellowship trained surgeon between 2011-2019. Patients undergoing concomitant osteotomies, cartilage restoration, and other ligament reconstruction procedures were excluded. Pre- and post-surgical patient reported outcomes (PROs) including IKDC, KOOS, PROMIS, SANE, Tegner, and Marx were compared between groups. Complications requiring re-operation (infection, stiffness, reconstruction failure) were recorded. Results were analyzed statistically. Results: 141 patients met inclusion criteria. There were 72 BTB and 69 quadriceps autografts. Mean age was 20.5 years in the BTB group and 20.7 years in the quadriceps group (p=0.9). 28 of 69 (40.6%) BTB and 34 of 72 (47.2%) quadriceps were female. Pre-operative KOOS Pain (64.5, 78.0, p=0.0007), KOOS QOL (29.6, 37.7, p=0.05), IKDC (44.5, 52.6, p=0.05), and PROMIS Physical Function (39.0, 42.7 p=0.04) scores were significantly higher in the BTB cohort. There were no differences in other baseline PROs. At minimum 6-month follow-up (range 6 - 57 months), patients in both quadriceps and BTB autograft cohorts reported statistically significant improvements in all KOOS domains, Tegner (76.4%, p=0.0002; 94.0%, p=0.000000003), IKDC (67.3%, p=0.0000009; 54.0%, p=0.000000009), SANE (69.4%, p=0.0000001; 70.7%, p=0.000000002), PROMIS Mobility T-Score (30.6%, p=0.0000003; 24.6%, p=0.000002), PROMIS Global Physical Health (15.3%, p=0.00002; 14.3%, p=0.00004), PROMIS Physical Function (33.2%, p=0.0000000008; 29.6%, p=0.00000002), PROMIS Pain Interference (-17.9%, p=0.00000002; -20.8%, p=0.00000000007). Post-operative Tegner (4.7, 6.0, p=0.04) and Global Mental Health (55.7, 60.1, p=0.008) scores were significantly higher in the BTB cohort. Complications were low and not significant between groups. Both quadriceps and BTB autograft cohorts required post-operative re-operations (4.4% and 6.9%, p=0.5). Quadriceps had 2 ligament reconstructions (2.9%) and 1 surgery for stiffness (1.4%). BTB group had 3 ligament reconstructions (4.2%) and 2 surgeries for stiffness (2.8%). Conclusion: Patients undergoing either BTB and quadriceps autograft ACL reconstruction demonstrated significant subjective improvements and low rates of complications requiring re-operation. At mid-term follow-up, the BTB cohort had higher activity and mental health scores.

Background: Return to sport (RTS) after osteochondral allograft (OCA) transplantation for large unipolar femoral condyle defects has been consistent, but many athletes are affected by more severe lesions. Purpose: To examine outcomes for athletes who have undergone large single-surface, multisurface, or bipolar shell OCA transplantation in the knee. Study Design: Case series; Level of evidence, 4. Methods: Data from a prospective OCA transplantation registry were assessed for athletes who underwent knee transplantation for the first time (primary transplant) between June 2015 and March 2018 for injury or overuse-related articular defects. Inclusion criteria were preinjury Tegner level ≥5 and documented type and level of sport (or elite unit active military duty); in addition, patients were required to have a minimum of 1-year follow-up outcomes, including RTS data. Patient characteristics, surgery type, Tegner level, RTS, patient-reported outcome measures (PROMs), compliance with rehabilitation, revisions, and failures were assessed and compared for statistically significant differences. Results: There were 37 included athletes (mean age, 34 years; range, 15-69 years; mean body mass index, 26.2 kg/m2; range, 18-35 kg/m2) who underwent large single-surface (n = 17), multisurface (n = 4), or bipolar (n = 16) OCA transplantation. The highest preinjury median Tegner level was 9 (mean, 7.9 ± 1.7; range, 5-10). At the final follow-up, 25 patients (68%) had returned to sport; 17 (68%) returned to the same or higher level of sport compared with the highest preinjury level. The median time to RTS was 16 months (range, 7-26 months). Elite unit military, competitive collegiate, and competitive high school athletes returned at a significantly higher proportion ( P < .046) than did recreational athletes. For all patients, the Tegner level at the final follow-up (median, 6; mean, 6.1 ± 2.7; range, 1-10) was significantly lower than that at the highest preinjury level ( P = .007). PROMs were significantly improved at the final follow-up compared with preoperative levels and reached or exceeded clinically meaningful differences. OCA revisions were performed in 2 patients (5%), and failures requiring total knee arthroplasty occurred in 2 patients (5%), all of whom were recreational athletes. Noncompliance was documented in 4 athletes (11%) and was 15.5 times more likely ( P = .049) to be associated with failure or a need for revision than for compliant patients. Conclusion: Large single-surface, multisurface, or bipolar shell OCA knee transplantations in athletes resulted in two-thirds of these patients returning to sport at 16 to 24 months after transplantation. Combined, the revision and failure rates were 10%; thus, 90% of patients were considered to have successful 2- to 4-year outcomes with significant improvements in pain and function, even when patients did not RTS.

Background: Graft choice for ACL reconstruction in patients under 18 years old remains controversial. BTB autograft has long been considered for young athletes who are at or near skeletal maturity. Quadriceps autograft has emerged as an alternative graft choice in the young patient population. However, there remains a paucity of comparative outcomes. Hypothesis/Purpose: Our purpose is to compare subjective outcomes and complications of ACL reconstruction in patients under 18 years old using either BTB or quadriceps autograft. Our hypothesis is that there will be no difference in subjective outcome or complication between groups. Methods: Following IRB approval, retrospective review of prospectively collected data identified consecutive cohorts of patients under 18 years old undergoing ACL reconstruction with either BTB or quadriceps autograft. Surgery was performed by a single sports fellowship trained surgeon between 2011-2019. Patients undergoing concomitant osteotomies, cartilage restoration, and other ligament reconstruction procedures were excluded. Pre- and post-surgical patient reported outcomes (PROs) including IKDC, KOOS, PROMIS, SANE, Tegner, and Marx were compared between groups. Complications requiring re-operation (i.e., infection, stiffness, reconstruction failure) were recorded. Results were analyzed statistically. Results: 71 patients met inclusion criteria. There were 41 BTB and 30 quadriceps autografts. Mean age was 16.5 years in the BTB group and 14.5 in the quadriceps group (p=0.0000006). 27 of 41 (66%) BTB and 13 of 30 (43%) quadriceps were female. There were no significant differences in PROs between groups. At minimum 6-month follow-up (range 6-25.7 months), patients in both quadriceps and BTB autograft cohorts reported statistically significant improvements in IKDC scores (31.10%, p=0.0009; 34.25%, p=0.00000008), all KOOS domains, SANE (41.80%, p=0.0000006; 42.42%, p=0.000000002), and Tegner scores (2.99%, p=0.0002; 3.35%, p=0.000004). Post-operative PROs were not significantly different between groups (p>0.05). Complications were low and not significant between groups. Both quadriceps and BTB autograft cohorts required 3 post-operative re-operations (10% and 7%, p=0.7), each group including 2 revision reconstructions (7% and 5%, p=0.8) and 1 procedure for stiffness (3% and 2%, p=0.8). Conclusion: For ACL reconstruction in patients under 18 years old, both BTB and quadriceps autografts demonstrated significant subjective improvements and low rates of complications requiring re-operation. Quadriceps autograft appears to be a safe and effective alternative to BTB autograft in this challenging patient population. Table 1. Pre-Operative PROs KOOS Sub-scale Graft Pre-op N P-value Mean SD 95% CI Lower Bound Upper Bound ADL Quadriceps 75.13 16.13 72.43 77.83 17 0.425 BTB 79.16 15.77 77.00 81.32 25 Pain Quadriceps 66.99 19.50 63.73 70.26 17 0.065 BTB 77.20 14.99 75.11 79.30 24 Sport Quadriceps 38.82 23.29 34.93 42.72 17 0.806 BTB 40.60 22.47 37.52 43.68 25 Symptoms Quadriceps 63.43 19.91 60.10 66.76 17 0.713 BTB 65.53 16.65 63.25 67.81 25 QOL Quadriceps 28.69 20.50 25.26 32.13 17 0.229 BTB 36.02 18.07 33.54 38.49 25 PROMIS Sub-scale Graft Pre-op N P-value Mean SD 95% CI Lower Bound Upper Bound Physical Health Quadriceps 49.15 6.53 48.05 50.24 17 0.332 BTB 51.24 6.05 50.26 52.22 18 Mental Health Quadriceps 57.59 7.54 56.33 58.85 17 0.418 BTB 59.54 6.51 58.48 60.60 18 Physical Function Quadriceps 39.52 5.73 38.56 40.48 17 0.183 BTB 42.60 7.49 41.38 43.81 18 Pain Interference Quadriceps 57.93 6.33 56.87 58.99 17 0.892 BTB 58.27 8.29 56.92 59.62 18 MobilityT-Score Quadriceps 40.91 6.52 39.46 42.36 10 0.372 BTB 43.69 7.87 42.23 45.14 14 Variable Graft Pre-op N P-value Mean SD 95% CI Lower Bound Upper Bound Marx Quadriceps 14.18 4.14 13.48 14.87 17 0.964 BTB 14.20 3.24 13.76 14.64 25 SANE Quadriceps 45.65 26.51 41.21 50.08 17 0.968 BTB 46.00 24.84 41.84 50.16 17 Tegner Quadriceps 2.47 1.42 2.23 2.71 17 0.158 BTB 3.21 1.74 2.96 3.45 24 IKDC Quadriceps 44.83 15.07 41.92 47.74 13 0.313 BTB 50.63 16.37 48.12 53.15 20 Other Table 2. Post-Operative PROs KOOS Sub-scale Graft >6 Months Post-op N P-value Mean SD 95% CI Lower Bound Upper Bound ADL Quadriceps 98.88 1.67 98.63 99.13 21 0.326 BTB 97.86 4.48 97.33 98.40 33 Pain Quadriceps 94.57 6.71 93.57 95.58 21 0.637 BTB 93.43 9.64 92.29 24.57 33 Sport Quadriceps 92.20 9.87 90.73 93.68 21 0.108 BTB 83.64 22.61 80.95 86.32 33 Symptoms Quadriceps 91.43 8.93 90.09 92.77 21 0.563 BTB 89.59 12.59 88.10 91.09 33 QOL Quadriceps 70.54 19.68 67.59 73.49 21 0.251 BTB 77.04 20.46 74.64 79.43 34 PROMIS Sub-scale Graft >6 Months Post-op N P-value Mean SD 95% CI Lower Bound Upper Bound Physical Health Quadriceps 58.30 7.98 57.07 59.53 20 0.651 BTB 59.24 6.52 58.42 60.05 30 Mental Health Quadriceps 58.24 8.33 56.92 59.55 19 0.131 BTB 61.83 7.74 60.87 62.80 30 Physical Function Quadriceps 51.79 7.99 50.57 53.02 20 0.205 BTB 55.32 10.49 54.04 56.61 31 Pain Interference Quadriceps 47.16 7.04 46.10 48.21 21 0.589 BTB 46.00 7.81 45.04 46.96 31 MobilityT-Score Quadriceps 53.98 7.55 52.58 55.38 14 0.456 BTB 55.72 6.34 54.81 56.63 23 Variable Graft >6 Months Post-op N P-value Mean SD 95% CI Lower Bound Upper Bound Marx Quadriceps 11.17 5.02 10.16 12.18 12 0.572 BTB 12.22 5.24 11.47 12.97 23 SANE Quadriceps 87.44 10.60 85.72 89.17 18 0.805 BTB 88.42 14.58 86.63 90.21 31 Tegner Quadriceps 5.46 2.40 5.00 5.92 13 0.221 BTB 6.56 2.66 6.20 6.92 25 IKDC Quadriceps 75.93 26.33 71.38 80.47 16 0.219 BTB 84.88 16.38 82.37 87.40 20 Other

The purpose of this study is to establish a small animal anterior cruciate ligament (ACL) reconstruction research model where ACL graft force can be varied to create different graft force patterns with controlled knee motion. Cadaveric (n = 10) and in vivo (n = 10) rat knees underwent ACL resection followed by reconstruction using a soft tissue autograft. Five cadaveric and five in vivo knees received a nonisometric, high-force femoral graft tunnel position. Five cadaveric and five in vivo knees received a more isometric, low-force graft tunnel position. ACL graft force (N) was then recorded as the knee was ranged from extension to 90 degrees using a custom knee flexion device. Our results demonstrate that distinct ACL graft force patterns were generated for the high-force and low-force femoral graft tunnels. For high-force ACL grafts, ACL graft forces increased as the knee was flexed both in cadaveric and in vivo knees. At 90 degrees of knee flexion, high-force ACL grafts had significantly greater mean graft force when compared with baseline (cadaver: 7.76 ± 0.54 N at 90 degrees vs. 4.94 ± 0.14 N at 0 degree, p = 0.004; in vivo: 7.29 ± 0.42 N at 90 degrees vs. 4.74 ± 0.13 N at 0 degree, p = 0.007). In contrast, the graft forces for low-force ACL grafts did not change with knee flexion (cadaver: 4.94 ± 0.11 N at 90 degrees vs. 4.72 ± 0.14 N at 0 degree, p = 0.41; in vivo: 4.78 ± 0.26 N at 90 degrees vs. 4.77 ± 0.06 N at 0 degree, p = 1). Compared with nonisometric ACL grafts, the graft force for grafts placed in an isometric position had significantly lower ACL graft forces at 15, 30, 45, 60, 70, and 90 degrees in both cadaveric and in vivo knees. In conclusion, we have developed a novel ACL reconstruction model that can reproducibly produce two ACL graft force patterns. This model would permit further research on how ACL graft forces may affect subsequent graft healing, maturation, and function.

Background: Anterior cruciate ligament (ACL) grafts that are placed for reconstruction are subject to complex forces. Current “anatomic” ACL reconstruction techniques may result in greater in situ graft forces. The biological effect of changing magnitudes of ACL graft force on graft-tunnel osseointegration is not well understood. Purpose: The research objective is to determine how mechanical force on the ACL graft during knee motion affects tendon healing in the tunnel. Study Design: Controlled laboratory study. Methods: Male rats (N = 120) underwent unilateral ACL reconstruction with a soft tissue flexor tendon autograft. ACL graft force was modulated by different femoral tunnel positions at the time of surgery to create different graft force patterns with knee motion. External fixators were used to eliminate graft load during cage activity. A custom knee flexion device was used to deliver graft load through controlled daily knee motion. Graft-tunnel healing was then assessed via biomechanical, micro–computed tomography, and histological analyses. Results: ACL graft-tunnel healing was sensitive to dynamic changes in graft forces with postoperative knee motion. High ACL graft force with joint motion resulted in early inferior ACL graft load to failure as compared with knees that had low-force ACL grafts and joint motion and knees that were immobilized (mean ± SD: 5.50 ± 2.30 N vs 9.91 ± 3.54 N [ P = .013] and 10.90 ± 2.8 N [ P = .001], respectively). Greater femoral bone volume fraction was seen in immobilized knees and knees with low-force ACL grafts when compared with high-force ACL grafts at 3 and 6 weeks. Conclusion: The authors were able to demonstrate that ACL graft-tunnel incorporation is sensitive to dynamic changes in ACL graft force with joint motion. Early high forces on the ACL graft appear to impair graft-tunnel osseointegration. Clinical Relevance: Current “anatomic” techniques of ACL reconstruction may result in greater graft excursion and force with knee motion. Our results suggest that the postoperative rehabilitation regimen may need to be modified during the early phase of healing to protect the reconstruction.

The objectives of this review are to evaluate the current evidence-based literature and concepts surrounding rehabilitation in patients with anterior shoulder instability injuries and surgical repair. The current literature evidence for shoulder rehabilitation for anterior shoulder instability and labral repair is limited. As a result, there are variations among surgeons and physical therapists in rehabilitation protocols after anterior shoulder instability injuries and repair. While general consensus on certain rehabilitation parameters exists, the evidence for the importance of rehabilitation and functional performance test for return to sport in future injury prevention is still lacking in literature. Rehabilitation after anterior shoulder instability injury and anterior labral repair is paramount in the injured or post-operative shoulder. Restoration of soft tissue mobility, dynamic glenohumeral joint stability, and balance and strength around the shoulder not only protect healing of injured or repaired soft tissues but also potentially minimizes future re-injury or recurrence risk.

The purpose of this study is to determine the effect of the magnitude of static mechanical tension on the anterior cruciate ligament (ACL) graft at the time of surgery on healing within the graft tunnels. Ninety male rats underwent unilateral ACL resection followed by reconstruction with a soft tissue tendon autograft. The ACL graft mechanical environment was modulated by different ACL graft pretension levels at the time of surgery (no pretension: 0N; moderate tension: 5N; over tension: 10N). External fixators were used to eliminate graft and joint motion during cage activity. Graft–tunnel healing was assessed at 3- and 6-week postoperatively, and articular joint surfaces were assessed at 9 weeks. Our results demonstrate that the ACL graft–tunnel healing was sensitive to different static graft pretension levels as demonstrated by different load-to-failure and stiffness properties among the different pretension levels. Pretensioning the graft to 5N (7–8% of the rat ACL ultimate load to failure) resulted in the best graft–tunnel healing as shown by higher graft–tunnel failure load and stiffness. Higher bone volume fraction was also seen in the 5N group relative to other pretension levels. Histological analysis of the graft–tunnel interface revealed differences in cellularity of the ACL graft between the 5N group and the other two groups. Furthermore, the highest graft pretension level (10N) resulted in loss of proteoglycan content among articular joint surfaces. In conclusion, we found that ACL graft–tunnel healing is sensitive to the magnitude of graft pretension at the time of surgery in a preclinical model of ACL reconstruction with joint immobilization. The combination of high-graft tension and immobilization is also deleterious for the articular surface. Further study is necessary to understand the interaction between the magnitude of graft tensioning and joint motion.

The objective of this study is to determine incidence (injuries/1000 playing hours (ph)), severity (days of absence), and cause of match injuries in US women's Rugby-7s.We performed a prospective epidemiological study (2010-2013) of injury of 3876 under-19 to elite/national female Rugby-7s players (nonelite = 3324, elite = 552) on 323 teams (nonelite = 277, elite = 46), applying methodology and injury definitions compliant with the international consensus statement on rugby research. Injuries occurred in USA Rugby-sanctioned tournament series: USA Rugby Local Area (2010), Territorial Union (2011-2013), National and All-Star Sevens Series, and USA Sevens Invitational (2011-2012) and Collegiate Rugby Championships (2012).One hundred and twenty time-loss injuries were encountered (elite, n = 15; 13%) with an injury rate of 46.3 injuries/1000 ph. Injury rates in nonelite were 49.3/1000 ph, and in national level (elite) candidates, 32.6/1000 ph (RR = 1.5, P = 0.130). Mean days missed found elite level players at 74.9 d per injury, whereas nonelite at 41.8 d (P = 0.090). Acute injuries were significant (95%, RR = 1.9, P0.001), resulting in immediate removal from the pitch (56%, P0.001). The main mechanism of injury occurred when tackling players (73%, P0.001). The most common type of injury seen were ligament sprains (37%, 13.9/1000 ph), involving the lower extremity (45%, 20.5/1000 ph). The most common body parts injured were the knee and head/face (16%, 7.3/1000 ph).Time-loss injuries occurred with frequency in the US women's Rugby-7s tournaments. Overall injury rates in US women are lower than those in international elite men and women's Rugby-7s. The head and neck area in our female players was injured at greater rates (16%) than in international male Rugby-7s (5%). Injury prevention in US women's Rugby-7s must focus on injuries of the knee, head, and neck. Understanding risk factors will allow safe return-to-play decisions and formulate injury prevention protocols.

Purpose: There is a comparative lack of concussion incidence data on the new Olympic sport Rugby 7s. This study aimed to determine the incidence (number of concussions per 1000 playing hours [ph]), mean and median severity (days absence), and cause of concussive injuries. Methods: This is a prospective epidemiology study, amateur to elite/national candidate, male (9768) and female (3876) players in USA Rugby sanctioned tournaments, compliant with the international consensus statement for studies in rugby union. Results: Concussions in US Rugby 7s were 7.7/1000 ph (n = 67). Women encountered concussions at 8.1/1000 ph, and men at 7.6/1000 ph (risk ratio [RR] = 1.10, P = 0.593). Elite/national-level players encountered concussions at higher rates (18.3/1000 ph) than lower levels (6.4/1000 ph; RR = 5.48, P < 0.001). Nonelite backs had higher concussive injury rates compared with forwards (7.7/1000 ph; 3.6/1000 ph; RR = 1.28, P = 0.024). Women missed 36.7 d absence from play, meanwhile men missed 27.9 d (P = 0.245). Retrospective history recall reflected previous concussive injuries occurred in 43% of the current study’s cohort; of these, 57% encountered multiple concussions within 1 yr. The incidence of repetitive concussions was not statistically different between genders (RR = 1.09, P = 0.754). Most concussions occurred from tackles (63%) and collisions (24%) (P = 0.056). Conclusions: Sports-related concussions occurred with frequency among US amateur Rugby 7s players. US Elite tournament players sustained concussions at much higher rates than international male Rugby 7s counterparts. A substantial portion of US players who sustained a concussion had previous concussion injuries. Given the high rate of concussion, including repetitive concussive injuries, US Rugby 7s may benefit from concussion prevention measures similar to other contact sports such as instruction on proper tackling techniques, in-game and postgame medical assessment, and a standardized return-to-play protocol.

Objectives: Knee arthroscopy using isotonic irrigation fluids is performed safely in millions of patients each year. However, arthroscopic procedures can disrupt the native biology of the joint when hyperosmolar synovial fluid (400 mOsm/L) is replaced by isotonic irrigation fluid (270-300 mOsm/L). Potential ramifications include cell apoptosis and necrosis, alterations in gene expression, protein synthesis and calcium signaling, and extracellular matrix compositional changes with resultant material property perturbations. Recent in vitro studies suggest higher osmolarity irrigation fluids potentiate a chondroprotective environment and a clinical study using hyperosmolar saline for shoulder arthroscopy reported potential clinical advantages. To date, there are no studies examining the use of a hyperosmolar irrigation solution in patients undergoing knee arthroscopy to the authors’ knowledge. Therefore, this prospective randomized double-blind controlled clinical trial was designed to assess safety and efficacy of a hyperosmolar irrigation solution in patients undergoing arthroscopic knee surgery. Methods: With institutional review board approval and informed consent, adult patients scheduled to undergo arthroscopic knee surgery (i.e., chondroplasty, diagnostic, meniscectomy, meniscus repair) were randomized to surgery with either isotonic Lactated Ringer’s (273mOsm/L) or hyperosmolar saline (593 mOsm/L) irrigation solution. The hyperosmolar solution was created by adding 120cc of 23.4% NS solution to a 3L bag of 0.9% NS (Figure). Primary outcomes included perioperative blood pressure, knee girth, pain, and narcotic pain medication consumption. Blood pressure and knee girth measurements were performed before and after surgery. Visual Analogue Scale (VAS) pain scores and narcotic pain medication consumption were logged on post-operative days (POD) 1-3. Data from each cohort were pooled and analyzed for statistical significance (P

The use of 3-dimensional (3D) printing in orthopedics is developing rapidly and impacting the areas of preoperative planning, surgical guides, and simulation. As this technology continues to improve, the greatest impact of 3D printing may be in low- and middle-income countries where surgical items are in short supply. This study investigated sterility of 3D-printed ankle fracture fixation plates and cortical screws. The hypothesis was that the process of heated extrusion in fused deposition modeling printing would create sterile prints in a timely fashion that would not require postproduction sterilization. A free computer-assisted design program was used to design the implant models. One control group and 8 study groups were printed. Print construct, orientation, size, and postproduction sterilization differed among the groups. Sterility was assessed using thioglycollate broth cultures at 24 hours, 48 hours, and 7 days. Positive growth was speciated for aerobic and anaerobic bacteria. Print time and failed prints were recorded. Control samples were 100% positive for bacterial growth. All test samples remained sterile at all time points (100%). Speciation of control samples was obtained, and Staphylococcus was the most common species. Print times varied; however, no print time exceeded 6.75 minutes. Eighteen prints (17%) failed in the printing process. These findings demonstrate an intrinsic sterilization process associated with fused deposition modeling 3D printing and indicate the feasibility of 3D-printed surgical implants and equipment for orthopedic applications. With future research, 3D-printed implants may be a treatment modality to assist orthopedic surgeons in low- and middle-income countries. [ Orthopedics . 2020; 43(1): 46–51.]

Background: Universal health coverage (UHC) aims to improve child health through preventive primary care and vaccine coverage. Yet, in many developed countries with UHC, unplanned and ambulatory care sensitive (ACS) hospital admissions in childhood continue to rise. We investigated the relation between preventive primary care and risk of unplanned and ACS admission in children in a high-income country with UHC. Methods: We followed 319,780 children registered from birth with 363 English practices in Clinical Practice Research Datalink linked to Hospital Episodes Statistics, born between January 2000 and March 2013. We used Cox regression estimating adjusted hazard ratios (HR) to examine subsequent risk of unplanned and ACS hospital admissions in children who received preventive primary care (development checks and vaccinations), compared with those who did not. Results: Overall, 98% of children had complete vaccinations and 87% had development checks. Unplanned admission rates were 259, 105 and 42 per 1000 child-years in infants (aged < 1 year), preschool (1-4 years) and primary school (5-9 years) children, respectively. Lack of preventive care was associated with more unplanned admissions. Infants with incomplete vaccination had increased risk for all unplanned admissions (HR 1.89, 1.79-2.00) and vaccine-preventable admissions (HR 4.41, 2.59-7.49). Infants lacking development checks had higher risk for unplanned admission (HR 4.63, 4.55-4.71). These associations persisted across childhood. Children who had higher consulting rates with primary care providers also had higher risk of unplanned admission (preschool children: HR 1.17, 1.17-1.17). One third of all unplanned admissions (62,154/183,530) were for ACS infectious illness. Children with chronic ACS conditions, asthma, diabetes or epilepsy had increased risk of unplanned admission (HR 1.90, 1.77-2.04, HR 11.43, 8.48-15.39, and HR 4.82, 3.93-5.91, respectively). These associations were modified in children who consulted more in primary care. Conclusions: A high uptake of preventive primary care from birth is associated with fewer unplanned and ACS admissions in children. However, the clustering of poor health, a lack of preventive care uptake, and social deprivation puts some children with comorbid conditions at very high risk of admission. Strengthening immunisation coverage and preventive primary care in countries with poor UHC could potentially significantly reduce the health burden from hospital admission in children.