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Peroneal nerve injuries are rare injuries and usually associated with multiligamentous knee injuries (MLKIs) involving one or both cruciate ligaments. The purpose of our study was to perform a multicenter retrospective cohort analysis to examine the rates of peroneal nerve injuries and to see whether a peroneal nerve injury was suggestive of a particular injury pattern.A retrospective chart review was conducted in patients who were diagnosed with MLKI at two level I trauma centers from January 2001 to March 2021. MLKIs were defined as complete injuries to two or more knee ligaments that required surgical reconstruction or repair. Peroneal nerve injury was clinically diagnosed in these patients by the attending orthopaedic surgeon. Radiographs, advanced imaging, and surgical characteristics were obtained through a chart review.Overall, 221 patients were included in this study. The mean age was 35.9 years, and 72.9% of the population was male. Overall, the incidence of clinical peroneal nerve injury was 19.5% (43 patients). One hundred percent of the patients with peroneal nerve injury had a posterolateral corner injury. Among patients with peroneal nerve injury, 95.3% had a complete anterior cruciate ligament (ACL) rupture as compared with 4.7% of the patients who presented with an intact ACL. There was 4.4 times of greater relative risk of peroneal nerve injury in the MLKI with ACL tear group compared with the MLKI without an ACL tear group. No statistical difference was observed in age, sex, or body mass index between patients experiencing peroneal nerve injuries and those who did not.The rate of ACL involvement in patients presenting with a traumatic peroneal nerve palsy is exceptionally high, whereas the chance of having a spared ACL is exceptionally low. More than 90% of the patients presenting with a nerve palsy will have sustained, at the least, an ACL and posterolateral corner injury.IV, Case Series.

Background: Despite the widespread use and sales of cannabidiol (CBD) products in the United States, there is a paucity of literature to evaluate its effectiveness, safety, or ideal route of administration for postoperative pain. Purpose: To evaluate the potential analgesic effects of buccally absorbed CBD in patients who have undergone arthroscopic rotator cuff repair (ARCR). Study Design: Randomized controlled trial; Level of evidence, 1. Methods: This was a US Food and Drug Administration–sanctioned, multicenter, placebo-controlled, randomized, double-blinded trial conducted in patients undergoing ARCR. Patients aged from 18 to 75 years undergoing ARCR were prospectively enrolled and randomized to the control and experimental groups. The experimental group received an oral, buccally absorbed tablet containing 25 mg of CBD 3 times a day if 80 kg, for 14 days postoperatively, while the control group received an identical placebo. Patients were followed up on days 1, 2, 7, and 14, and visual analog scale (VAS) for pain scores, opioid consumption, and satisfaction with pain control were recorded. Additionally, liver function tests were conducted on days 7 and 14 to assess safety, and nausea was monitored. P < .05 was considered to be statistically significant. Results: Overall, 100 patients were recruited, with 1 patient being excluded, for a total of 99 patients. There were no significant differences in patient demographics between the 2 groups. On day 1, the VAS pain score was significantly lower in the CBD group than in the control group (4.4 ± 3.1 vs 5.7 ± 3.2, respectively; P = .04), although this difference was no longer present on day 2 (4.7 ± 2.8 vs 5.3 ± 2.6, respectively; P = .32). On both days 1 and 2, patient satisfaction with pain control was significantly higher in the CBD group than in the control group (day 1: 7.0 ± 3.0 vs 5.6 ± 3.7, respectively [ P = .04]; day 2: 7.3 ± 2.5 vs 6.0 ± 3.3, respectively [ P = .03]). The quantity of opioids consumed was low in both groups, and there were no statistically significant differences in opioid consumption ( P > .05). On days 7 and 14, there were no statistically significant differences in VAS scores, opioid consumption, or patient satisfaction with pain control between the CBD and control groups ( P > .05 for all). There were no significant differences in liver function test results postoperatively ( P > .05). Conclusion: Buccally absorbed CBD demonstrated an acceptable safety profile and showed significant promise in the reduction of pain in the immediate perioperative period after ARCR compared with the control. Further studies are currently ongoing to confirm dosing and effectiveness in other orthopaedic conditions. Registration: NCT04672252 (ClinicalTrials.gov identifier).

The purpose of this study was to evaluate the outcomes of patients 5 years postoperatively following arthroscopic SLAP repair, and to evaluate factors associated with satisfaction.A retrospective review of patients who underwent SLAP repair with a minimum of 5-year follow-up was performed. Recurrence, visual analog scale (VAS) score, Subjective Shoulder Value (SSV), American ShoulderElbow Surgeons (ASES) score, satisfaction, whether they would undergo the same surgery again, and the rate, level and timing of return to play (RTP) were evaluated. Multilinear regression models were used to evaluate factors affecting postoperative satisfaction.Overall, 122 patients who underwent SLAP repair were included, with a mean age of 33.4 years. 81% were males, and 58.2% were participating in sport preoperatively. The mean follow-up was 86.4 ± 14.4 months. At final follow up, the mean satisfaction was 87.7%, and the mean SSV was 82.9. Overall, the rate of RTP was 85.9%, with 64.8% returning at the same level at a mean of 10.5 ± 8 months. Ultimately, 13 (10.7%) patients had a further surgery, including 10 (8.2%) patients that had a biceps tenodesis. VAS during sport (P = .025), SSV (P.001), and time to RTP (P = .0056), were associated with higher satisfaction.There was a high rate of satisfaction at 5-year follow-up, with excellent patient-reported outcomes but with one-tenth of patients requiring revision surgeries. Additionally, while there was an overall high rate of RTP, there was only a modest rate of RTP at their preinjury level, and overhead athletes took longer to RTP.IV, case series.

Background: The intra-articular immune response after ligamentous, meniscal, or focal chondral knee injuries likely plays a role in intra-articular healing and the onset and progression of posttraumatic osteoarthritis. Purpose: To evaluate the association of synovial fluid cytokine concentrations measured at the time of knee arthroscopy with intermediate-term functional outcomes after knee arthroscopy based on the Lysholm score. Study Design: Cohort study; Level of evidence, 2. Methods: This was a prospective cohort study of patients undergoing arthroscopic knee surgery. Synovial fluid was aspirated from the injured knee immediately before surgical incision, and the concentrations of 10 cytokines were analyzed using immunoassay. Principal component regression was used to create a model to predict patient-reported Lysholm score at a minimum of 5 years postoperatively. Hierarchical clustering was performed to identify groups of patients with similar synovial fluid inflammatory phenotypes. Lysholm scores and cytokine concentrations were compared between clusters. Results: A total of 26 patients (mean age, 40.33 ± 16.40 years) were included in the analysis. The mean duration between surgery and follow-up was 6.69 ± 0.72 years. A model consisting of 2 principal components (PC1, PC2) explained 62.48% of the variance in the cytokine data and 52.03% of the variance in intermediate-term Lysholm score. Hierarchical clustering resulted in 3 patient clusters based on the principal components used in the regression model. Despite no baseline differences in Lysholm score, cluster 3 demonstrated significantly greater intermediate-term Lysholm score compared with cluster 2 (94.33 vs 76.09, respectively; 95% CI, 5.96-30.52; P = .006) and cluster 1 (94.33 vs 52.33, respectively; 95% CI, 24.09-59.91; P = .003). Cluster 3, when compared with the overall means, was characterized by greater PC1 value (1.01 vs 0.00, respectively; P = .030) and greater PC2 value (0.86 vs 0.00, respectively; P = .002). Conclusion: The concentrations of select synovial fluid cytokines assessed at the time of knee arthroscopy can be used to explain more than half of the variance in intermediate-term functional outcomes.

Background The purpose of this study was to review the literature to ascertain the functional outcomes, recurrence rates, and subsequent revision rates following revision arthroscopic Bankart repair. Methods Two independent reviewers performed a literature search based on PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines using the Embase, MEDLINE, and Cochrane Library databases. Studies in which arthroscopic Bankart repair was performed as a revision procedure were included. The clinical outcomes extracted and analyzed were functional outcomes, return to play, and recurrent instability. Results Fourteen studies with 433 patients met the inclusion criteria. The majority of patients were male patients (63.7%); the average age was 26.1 years (range, 14-58 years), and the mean follow-up period was 37.6 months (range, 10-144 months). The mean Rowe score was 84.2, and 79.7% of patients had good to excellent outcomes. The rate of return to play was 78.5%, with 47.5% of patients returning to their preinjury level of play across 10 studies. The rate of recurrent instability was reported in 12 studies, with 328 shoulders demonstrating 86 instability events (26.2%). The rate of recurrent instability due to dislocation was reported in 7 studies (n = 176), with 19 events (10.8%), whereas the rate of subluxation was reported in 4 studies (n = 76), with 6 events (7.9%). Conclusions Revision arthroscopic Bankart repair for anterior shoulder instability was shown to result in a high rate of recurrent shoulder instability. There was a relatively poor rate of return to sport among athletes, and only about half of the patients were able to return at or above their preoperative level of ability.

OBJECTIVES An isolated MPFL reconstruction (MPFLR) has been demonstrated to be an effective treatment option in the prevention of patellar instability, but there is growing support for performing a tibial tubercle osteotomy (TTO) in patients with an elevated tibial tubercle-trochlear groove distance. The purpose of this study was to evaluate the impact of adding a TTO to MPFLR on patient reported outcomes. METHODS A retrospective review of patients who underwent MPFLR with or without TTO with a minimum of 12-month follow-up was performed. Patients in both groups were matched based on age, gender, and follow-up time. Recurrent instability (including re-dislocation and subluxation), Visual Analogue Scale (VAS) score, Kujala score, and satisfaction were evaluated. RESULTS There were 59 patients who underwent MPFLR with concomitant TTO performed at our institution and met our inclusion and exclusion criteria. These patients were then matched to patients undergoing isolated MPFLR based on demographics and follow up time. The mean age was 25.0, 76.3% were female, and the mean follow up time was 49 months. There was a significant difference in mean tibial tubercle-trochlear groove distance (19.8 ± 3.9 vs. 14.1 ± 2.8) between groups. There was no significant difference in VAS (1.48 ± 2.0 vs. 1.49 ± 2.1, p = 0.972), satisfaction (86.1% ± 24.2% vs. 81.2% ± 27.9, p=0.311), or revision surgeries (10.2% vs 10.2%) between groups. CONCLUSION Matched patients undergoing MPFLR with TTO compared to isolated MPFLR demonstrate no statistically significant difference in patient reported outcomes, levels of pain and satisfaction post-operatively. Furthermore, the addition of a TTO does not increase the risk of further surgery or complications. Level of evidence III, retrospective comparative study.

Medial patellofemoral ligament reconstruction (MPFLR) is often indicated in athletes with lateral patellar instability to prevent recurrence and allow for a successful return to play. In this patient population, the ability to return to play is one of the most important clinical outcomes. The purpose of the current study was to analyze the characteristics of patients who were unable return to play following MPFL reconstruction. A retrospective review of patients who underwent MPFL reconstruction and subsequently did not return to play after a minimum of 12-months of follow-up was performed. Patients were evaluated for their psychological readiness to return to sport using the MPFL-Return to Sport after Injury (MPFL-RSI) score, which is a modification of the ACL-RSI score. A MPFL-RSI score > 56 is considered a passing score for being psychologically ready to return to play. Additionally, reasons for not returning to play including Visual Analog Scale for pain (VAS), Kujala score, satisfaction, and recurrent instability (including dislocations and subluxations) were evaluated. The study included a total of 35 patients who were unable to return to play out of a total cohort of 131 patients who underwent MPFL reconstruction as treatment for patellar instability. Overall, 60% were female with a mean age of 24.5, and a mean follow-up of 38 months. Nine patients (25.7%) passed the MPFL-RSI benchmark of 56 with a mean overall score of 44.2 ± 21.8. The most common primary reasons for not returning to play were 14 were afraid of re-injury, 9 cited other lifestyle factors, 5 did not return due to continued knee pain, 5 were not confident in their ability to perform, and 2 did not return due to a feeling of instability. The mean VAS score was 1.9 ± 2.3, the mean Kujala score was 82.5 ± 14.6, and the mean satisfaction was 76.9%. Three patients (8.7%) reported experiencing a patellar subluxation event post-operatively. No patient sustained a post-operative patellar dislocation. Following MPFL reconstruction, patients that do not return to play exhibit poor psychological readiness with the most common reason being fear of re-injury. IV.

Background: Performing open subpectoral biceps tenodesis in overhead athletes with a superior labrum anterior to posterior (SLAP) tear may affect their ability to return to overhead sports. Purpose: To investigate clinical outcomes in overhead athletes undergoing biceps tenodesis for the treatment of symptomatic, isolated SLAP tears involving the biceps-labral complex. Study Design: Case series; Level of evidence, 4. Methods: A retrospective review of overhead athletes who underwent biceps tenodesis for a SLAP tear was performed. The American Shoulder and Elbow Surgeons (ASES) score, visual analog scale (VAS) score for pain, subjective shoulder value (SSV), patient satisfaction, willingness to undergo surgery again, revision procedures, and return to play were evaluated. Psychological readiness to return to sport was evaluated using the SLAP–Return to Sport after Injury (SLAP-RSI) score. A P value of Results: The current study included 44 overhead athletes. The mean age was 34.9 years (range, 16-46 years), 79.5% were male, and the mean follow-up was 49.0 months (range, 18-107 months). Overall, 81.8% of patients returned to play their overhead sport after biceps tenodesis, and 59.1% of patients returned to the same or higher level of play. It took patients, on average, 8.7 months to return to play after biceps tenodesis. The mean SLAP-RSI score was 69.4, and 70.5% of patients passed the SLAP-RSI threshold of 56. The mean ASES score, VAS score, SSV, and satisfaction were 92.0, 0.8, 80.6, and 87.9%, respectively. No patients in our cohort required revision surgery. Conclusion: This study found that athletes undergoing biceps tenodesis for the treatment of a symptomatic, isolated SLAP tear had a high rate of return to play, good functional outcomes, and a low rate of revision surgery.

A 17-year-old adolescent boy presented with continued knee pain, swelling, and mechanical symptoms after anterior cruciate ligament (ACL) reconstruction with partial meniscectomy. The patient eventually underwent ACL revision surgery that was without complications. Postoperatively, the well leg grew firm with associated neurological deficits, and physical examination confirmed compartment syndrome of the lower leg compartments that resolved with emergency fasciotomy. The patient proceeded on normal postoperative course.Compartment syndrome of the well leg is a rare complication in the field of sports medicine, owing to the relatively healthy and young demographic, but providers should nonetheless be vigilant to prevent disastrous sequalae.

LYS006 is a potent leukotriene A4 hydrolase inhibitor currently in clinical development for long-term treatment of various neutrophil-driven inflammatory conditions. Here, we present pharmacokinetics from the first-in-human study with complementary metabolism and transporter profiling data. The randomized first-in-human study included nine cohorts receiving 5-2*100 mg of LYS006 or placebo, a crossover food-effect part, and a multiple-dose part consisting of two fasted (5 mg and 15 mg once daily) and three fed cohorts (20-80 mg twice a day) of LYS006 or placebo. LYS006 and metabolites were assessed in plasma and urine, and transporters involved in LYS006 disposition were analyzed in vitro. Systemic plasma exposure increased with dose; steady-state exposure was dose proportional up to 40 mg twice a day. Steady state was achieved after ∼3 days, with mean accumulation of 2.1-fold for 5 mg once daily and ≤1.4-fold for all higher doses. Despite limited accumulation, a long terminal half-life (T

Biceps tendon pathologies include a spectrum of injuries that range from mild tendinosis to complete tendon rupture.Tendinosis, the most common pathology, occurs more frequently with age and is likely related to chronic degeneration. On the other side of the spectrum of severity lies a rupture of the long head of the biceps tendon (LHBT), which may be accompanied by injury to the glenoid labrum.Superior labral anterior-posterior (SLAP) tears are frequently associated with biceps pathology. Surgical management for injuries of the bicipital-labral complex includes biceps tenodesis or tenotomy and SLAP repair. A consensus as to which of these procedures is the optimal choice has not been reached, and management may ultimately depend on patient-specific characteristics.Due to the relatively low incidence of distal biceps tendon rupture, agreement on the optimal management strategy has not been reached. Surgical repair, or reconstruction in the case of a chronic rupture, is often chosen. However, nonoperative management has also been utilized in older, less-active patients.

To compare satisfaction and return to play (RTP) rates between patients undergoing primary biceps tenodesis for a symptomatic SLAP tear and patients undergoing secondary biceps tenodesis following a failed SLAP repair.A retrospective review of patients who underwent subpectoral mini-open biceps tenodesis following failed SLAP repair between January 2011 and October 2019 was performed. Inclusion criteria included age older than 16 years, skeletal maturity, and a minimum follow-up of 12 months. Both athletes and nonathletes were included across all types of sport. Patients who had anterior or posterior instability or rotator cuff tears were excluded; in addition, those requiring concomitant procedures were excluded. Case-control matching was performed using age, sex, indication, follow-up, and type of sport, to generate a 3:1 control group for the primary biceps tenodesis cohort. Primary outcome measurements were collected via telephone in 2020 and included the American Shoulder and Elbow Surgeons score, visual analog scale score, Subjective Shoulder Value score, patient satisfaction, willingness to undergo surgery again, and revisions. RTP and timing of RTP were evaluated as secondary outcomes. AThe current study included 76 patients in total; 57 patients with primary biceps tenodesis, and 19 patients with secondary biceps tenodesis. The mean age was 39 years (19-48 years), 100% were male, and the mean follow-up was 54 months (16-99 months). Patient reported outcomes were obtained postoperatively via telephone survey. Overall, we found that primary biceps tenodesis patients reported greater American Shoulder and Elbow Surgeons scores (89.9 vs 76.4,In this study, patients undergoing primary biceps tenodesis had significantly better functional outcomes compared with secondary biceps tenodesis following a failed SLAP repair.III, retrospective comparative study.

Objectives: Patients with a superior labral anterior to posterior (SLAP) tear of the shoulder are often initially treated non-operatively, but many do not respond and require surgery. Identifying patients who are likely to fail non-operative management and would benefit from early surgical intervention can shorten time of disability and limit resources utilized on unsuccessful treatments. The purpose of this study is to create a clinical prediction model to determine which patients are likely to fail non-operative treatment of SLAP tears and require surgical intervention. Methods: This was a case-control study consisting of patients treated at a single institution for isolated, non-degenerative SLAP tears. Patients with concomitant rotator cuff tears were excluded from this analysis. Patients were retrospectively surveyed using the Research Electronic Data Capture (REDCap) system regarding clinical features of their shoulder injury, non-operative treatments that they received, and key functional outcomes during their post-injury period. Responders underwent additional medical record review to identify other variables related to the clinical presentation and treatment of their shoulder injury. In order to simplify the predictive model and optimize its interpretability, the lasso (least absolute shrinkage and selection operator) method of penalized logistic regression analysis was used to identify the characteristics that were most closely associated with failure of nonoperative treatment. The data was randomly split into a training set and test set. Using the training set, the value of lambda which minimized cross-validation prediction error rate was determined (Figure 1). The final lasso model was then computed. The predictive accuracy of the final model was assessed using the test data set. Results: Overall, 189 patients were contacted and included in the analysis. The mean age of included patients was 29.9 +/- 6.7 years. Thirty-eight patients (20.1%) were female. One hundred and six patients (56.1%) failed non-operative management and required surgical intervention. The final lasso model identified a total of 9 variables that were significantly associated with failure of non-operative management of SLAP tears (Table 1). These predictors included pre-injury overhead sports participation, presence of specific symptoms, severity of pain, and the type of non-operative treatment modalities used. Injury to the dominant extremity, history of prior shoulder injury, patient age, use of NSAIDs, and occupation involving manual labor or overhead work were not associated with failure of nonoperative treatment. The predictive accuracy of the model was 70.3% (95% CI 53.0%, 84.1%). Sensitivity of the model was 81.0% and specificity was 56.3%. Conclusions: A clinical prediction model consisting of variables describing patient characteristics, specific symptoms, and the type of non-operative treatment modalities utilized was found to predict failure of non-operative management of SLAP tears with moderate accuracy. Further refinements of this prediction model, including the inclusion of additional physical examination and imaging variables, will be required before future iterations are tested in clinical practice.

Objectives: Medial patellofemoral ligament reconstruction (MPFLR) using allograft tissue has several potential benefits including the absence of donor site morbidity, ability to predict graft parameters, and decreased operative time. The purpose of this study was to evaluate the outcomes of patients following MPFLR with allograft. Our hypothesis was that there would be a low rate of recurrent instability, and excellent clinical outcomes reported. Methods: A retrospective review of athletes who underwent MPFL Reconstruction, with a minimum of 12-month follow-up was performed. Recurrent instability (including re-dislocation and subluxation), Visual Analogue Scale (VAS) score, Kujala score, satisfaction, and whether they would undergo the same surgery again, were evaluated. Results: Overall, follow up was attained for 131 patients with 141 knees (73.4%). The mean patient age of 25.0 years, 67.4% females, and mean time to follow-up was 46.8 months (12-111). At final follow up, the mean VAS score was 1.4 ± 2.0, the mean Kujala score was 84.8 ± 15.6, the mean satisfaction score was 84% ± 26.0, and 117 (83.0%) would undergo the same procedure again if required. There was 17 (12.0%) patients that had recurrent instability, with 2 being re-dislocations (1.4%). A further procedure was performed in 14 patients (9.9%). There were no intra-operative complications in our series. Conclusions: There was a low rate of recurrent instability following MPFLR with allograft, with excellent patient reported outcomes, and a low complication rate.

Objective: The purpose of this study was to evaluate the efficacy of osteochondral allograft (OCA) in patients older than 45 years of age, particularly with respect to return to sport. Design: A retrospective review was performed to evaluate patients greater than 45 who underwent an OCA for a symptomatic osteochondral defect of the knee between June 2011 and January 2019. Results: Overall, there were 18 patients (76% male) that met our inclusion and exclusion criteria. Follow-up was attained in 14 of these patients (78%). The mean age of patients included was 52.6 years (48-57) with a mean of 37 months of follow-up (18-60). Visual Analogue Scale scores decreased significantly from the preoperative baseline to final follow-up (7.7 ± 1.7 vs. 2.0 ± 2.0, P < 0.01). Furthermore, the mean Visual Analogue Scale while playing sport was 3.4 ± 3.2, and the mean Knee Injury and Osteoarthritis Outcome Score was 77.5 ± 12.7 at final follow-up. Overall, 11 patients (78.6%) were able to return to their desired sport. No clinical failures were identified during the follow-up period. Conclusion: In our series of patients 45 years and older who were treated with OCA for focal osteochondral injuries of the knee, we found a significant improvement in clinical outcome scores at a midterm follow-up of 37 months with no revision OCA procedures or conversion to any form of knee arthroplasty. In addition, a high percentage of patients were able to return to their preferred level of athletic activity.

» While the gross mechanical abnormalities contributing to posttraumatic osteoarthritis (PTOA) have been well described, new research is demonstrating that these insults to the articular cartilage may also initiate changes in the joint microenvironment that seed the development of PTOA. » A growing amount of literature has identified key biomarkers that exhibit altered expression in the synovial fluid following a knee injury, with a portion of these molecules remaining elevated in the years following an injury. » These biomarkers have the potential to aid in the early detection of PTOA before radiographic evidence becomes apparent. Furthermore, deciphering the processes that occur within the articular microenvironment after trauma may allow for better identification of therapeutic targets for the prevention and earlier treatment of PTOA.

Objective The purpose of the current study is to evaluate the clinical and radiographic outcomes at early to midterm follow-up between fresh precut cores versus hemi-condylar osteochondral allograft (OCAs) in the treatment of symptomatic osteochondral lesions. Design A retrospective review of patients who underwent an OCA was performed. Patient matching between those with OCA harvested from an allograft condyle/patella or a fresh precut allograft core was performed to generate 2 comparable groups. The cartilage at the graft site was assessed with use of a modified Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) scoring system and patient-reported outcomes were collected. Results Overall, 52 total patients who underwent OCA with either fresh precut OCA cores ( n = 26) and hemi-condylar OCA ( n = 26) were pair matched at a mean follow-up of 34.0 months (range 12 months to 99 months). The mean ages were 31.5 ± 10.7 for fresh precut cores and 30.9 ± 9.8 for hemi-condylar ( P = 0.673). Males accounted for 36.4% of the overall cohort, and the mean lesion size for fresh precut OCA core was 19.6 mm2 compared to 21.2 mm2 for whole condyle ( P = 0.178). There was no significant difference in patient-reported outcomes including Visual Analogue Scale, Knee Injury and Osteoarthritis Outcome Score for Joint Replacement, and Tegner ( P > 0.5 for each), or in MOCART score (69.2 vs. 68.3, P = 0.93). Conclusions This study found that there was no difference in patient-reported clinical outcomes or MOCART scores following OCA implantation using fresh precut OCA cores or size matched condylar grafts at early to midterm follow-up.

Case A 71-year-old man presented with extreme anterior knee pain. His history, physical examination, and imaging were consistent with prepatellar bursitis, but his pain seemed out of proportion for these findings. The patient eventually underwent marginal excision of the inflamed prepatellar bursa which histopathology identified as a glomangioma. Postoperatively, he has complete resolution of his pain and has returned to his daily activities. Conclusion Glomus tumors are a rare cause of severe knee pain that completely resolves after excision. In the patient with extreme, localized knee sensitivity, it is important to consider this pathology even if no mass is identified on imaging.

Purpose The purpose of the current study is to perform a systematic review of the literature and evaluate maximum medical improvement and minimal clinically important difference (MCID) of different injectables in the treatment of symptomatic knee osteoarthritis. Methods A systematic review was performed to evaluate maximum medical improvement and MCID in patients undergoing injections of different modalities for knee osteoarthritis. Demographic factors of the patients being reviewed were analyzed, with patient-reported outcomes as reported by visual analog scale (VAS) and Western Ontario and McMaster Universities Arthritis Index (WOMAC) being used to evaluate the clinical trajectory of patients receiving intra-articular injections. Results Overall, 79 (level of evidence I: 79) studies met inclusion criteria, with 8761 patients. Corticosteroid (CS) injections, middle molecular weight hyaluronic acid (MMW-HA), and leukocyte-rich platelet rich plasma (LR-PRP) injections reached their maximum pain control at 4 to 6 weeks after injection, as measured by VAS. The lowest VAS scores were reached for low molecular weight hyaluronic acid (LMW-HA), high molecular weight hyaluronic acid (HMW-HA), and leukocyte-poor platelet rich plasma (LP-PRP) by 3 months after injection. Similarly, the WOMAC scores were lowest at 4 to 6 weeks after CS and MMW-HA injections, and at 3 months after HMW-HA and LP-PRP injections. LR-PRP demonstrated the most prolonged pain relief relative to the other injection types, with the lowest VAS score of all groups measured at final follow-up. LP-PRP showed the lowest WOMAC scores at final follow-up, one year post-injection. Conclusion PRP injections provide continued pain relief at up to 1 year after injection. Corticosteroids and hyaluronic acid have good efficacy and are suitable for many patients but lack this longevity. Level of Evidence Level I, a systematic review of Level I studies.

Medial patellofemoral ligament reconstruction (MPFLR) is often indicated in athletes with lateral patellar instability to prevent recurrence and allow for a successful return to play. In this patient population, the ability to return to play is one of the most important clinical outcomes. The purpose of the current study was to analyze the characteristics of patients who were unable return to play following MPFL reconstruction.A retrospective review of patients who underwent MPFL reconstruction and subsequently did not return to play after a minimum of 12-months of follow-up was performed. Patients were evaluated for their psychological readiness to return to sport using the MPFL-Return to Sport after Injury (MPFL-RSI) score, which is a modification of the ACL-RSI score. A MPFL-RSI score 56 is considered a passing score for being psychologically ready to return to play. Additionally, reasons for not returning to play including Visual Analog Scale for pain (VAS), Kujala score, satisfaction, and recurrent instability (including dislocations and subluxations) were evaluated.The study included a total of 35 patients who were unable to return to play out of a total cohort of 131 patients who underwent MPFL reconstruction as treatment for patellar instability. Overall, 60% were female with a mean age of 24.5, and a mean follow-up of 38 months. Nine patients (25.7%) passed the MPFL-RSI benchmark of 56 with a mean overall score of 44.2 ± 21.8. The most common primary reasons for not returning to play were 14 were afraid of re-injury, 9 cited other lifestyle factors, 5 did not return due to continued knee pain, 5 were not confident in their ability to perform, and 2 did not return due to a feeling of instability. The mean VAS score was 1.9 ± 2.3, the mean Kujala score was 82.5 ± 14.6, and the mean satisfaction was 76.9%. Three patients (8.7%) reported experiencing a patellar subluxation event post-operatively. No patient sustained a post-operative patellar dislocation.Following MPFL reconstruction, patients that do not return to play exhibit poor psychological readiness with the most common reason being fear of re-injury.IV.

Fevipiprant, an oral, nonsteroidal, highly selective, reversible, and competitive prostaglandin D2 receptor 2 antagonist, is eliminated by glucuronidation and by direct renal excretion predominantly via organic anion transporter (OAT) 3. This study aimed to assess the effect of simultaneous UDP-glucuronosyltransferase (UGT) and OAT3 inhibition by probenecid on the pharmacokinetics of fevipiprant and its acyl glucuronide (AG) metabolite to support the dosing recommendation of fevipiprant in the presence of drugs inhibiting these pathways; however, phase III clinical trial results did not support its submission. This was a single-center, open-label, single-sequence, two-period crossover study in healthy subjects. Liquid chromatography with tandem mass spectrometry was used to measure concentrations of fevipiprant and its AG metabolite in plasma and urine. In the presence of probenecid, the mean maximum concentrations of fevipiprant increased approximately 1.7-fold, and the area under the concentration-time curve in plasma increased approximately 2.5-fold, whereas the mean apparent volume of distribution and the AG metabolite:fevipiprant ratio decreased. The apparent systemic clearance decreased by approximately 60% and the renal clearance decreased by approximately 88% in the presence of probenecid. Using these data and those from previous studies, the relative contribution of OAT and UGT inhibition to the overall effect of probenecid was estimated. Furthermore, a general disposition scheme for fevipiprant was developed, showing how a perpetrator drug such as probenecid, which interferes with two key elimination pathways of fevipiprant, causes only a moderate increase in exposure and allows estimation of the drug-drug inhibition when only one of the two pathways is inhibited. SIGNIFICANCE STATEMENT: In this drug-drug interaction (DDI) study, probenecid was used as a tool to inhibit both glucuronidation and active renal secretion of fevipiprant. The combination of plasma and urine pharmacokinetic data from this study with available data allowed the development of a quantitative scheme to describe the fate of fevipiprant in the body, illustrating why the DDI effect on fevipiprant is weak-to-moderate even if a perpetrator drug inhibits several elimination pathways.

Objectives: Injury-induced molecular changes in the intra-articular microenvironment of the knee are thought to play a role in the development of post-traumatic osteoarthritis. The purpose of this study was to evaluate the association between post-traumatic synovial fluid biomarker concentrations and intermediate-term functional outcomes. Methods: Patients undergoing primary knee arthroscopy for ACL injury, meniscus injury, and/or focal chondral lesions were prospectively enrolled. Synovial fluid aspirate, collected immediately prior to surgical incision, was processed and analyzed using a multiplex magnetic bead immunoassay to determine the concentration of 10 pre-determined cytokines and chemokines. Patients with a minimum of five years of postoperative follow-up were surveyed with Visual Analog Pain Scale (VAS), Lysholm Knee Scoring Scale, and Knee Injury and Osteoarthritis Outcome Score Physical Function Shortform (KOOS-PS). Stepwise regression was used to fit a linear regression model and model accuracy was evaluated using k-fold cross validation. Results: 39 patients (mean age: 41.56 +/- 15.98 years, mean postoperative follow-up: 6.79 +/- 0.72 years) were included in the study. Mean Lysholm, KOOS-PS, and VAS scores were 83.67 +/- 17.64, 88.37 +/- 12.79, and 11.03 +/- 19.84, respectively. 11 patients had undergone further ipsilateral knee surgery during the follow-up period. Of the remaining 28 patients, a model consisting of VEGF, TIMP-2, and MMP-3 was found to most accurately predict intermediate-term functional outcomes. Regardless of the type or extent of injury, these three biomarkers were able to explain 60.35%, 34.75%, and 39.38% of the variability in Lysholm, KOOS-PS, and VAS scores, respectively. Conclusions: By measuring the concentrations of MMP-3, TIMP-2, and VEGF at the time of surgery, functional outcomes and level of pain can be predicted at 5 years postoperatively with moderate accuracy. This suggests that these biomarkers may play an important role in the development of post-traumatic osteoarthritis and may serve as potential targets for therapeutic intervention. [Table: see text]

This drug-drug interaction (DDI) study determined the effect of cyclosporine, an inhibitor of OATP1B3 and P-gp, on the pharmacokinetics (PK) of fevipiprant, an oral, highly selective, competitive antagonist of the prostaglandin D2 receptor 2 and a substrate of the two transporters. The concomitant administration of an intravenous (IV) microdose of stable isotope-labeled fevipiprant provided the absolute bioavailability of fevipiprant, as well as mechanistic insights in its PK and sensitivity to drug interactions. Liquid chromatography-mass spectrometry/mass spectrometry was used to measure plasma and urine concentrations. Geometric mean ratios (90% CI) for oral fevipiprant with or without cyclosporine were: for Cmax, 3.02 (2.38, 3.82); for AUClast, 2.50 (2.17, 2.88); and for AUCinf, 2.35 (1.99, 2.77). The geometric mean ratios (90% CI) for fevipiprant IV microdose with or without cyclosporine were: for Cmax, 1.04 (0.86, 1.25); for AUClast, 2.04 (1.83, 2.28) and for AUCinf, 1.95 (1.76, 2.16). The absolute bioavailability for fevipiprant was approximately 0.3-0.4 in the absence and 0.5 in the presence of cyclosporine. The IV microdose allowed differentiation between systemic and pre-systemic effects of cyclosporine on fevipiprant, demonstrating a small (approximately 1.2-fold) pre-systemic effect of cyclosporine and a larger (approximately 2-fold) effect on systemic elimination of fevipiprant. Uptake by OATP1B3 appears to be the rate-limiting step in the hepatic elimination of fevipiprant while P-gp does not have a relevant effect on oral absorption. SIGNIFICANCE STATEMENT The drug interaction investigated here with cyclosporine, an inhibitor of several drug transporters, provides a refined quantitative understanding of the role of active transport processes in liver and intestine for the absorption and elimination of fevipiprant, as well as the basis to assess the need for dose adjustment in the presence of transporter inhibitors. The applied IV microdose approach presents a strategy to maximize learnings from a trial, limit the number and duration of clinical trials, and enhance mechanistic DDI understanding.

Objectives: Superior-labrum anterior-posterior (SLAP) tears are common among athletic populations and may require surgical treatment. Return to play post-operatively may be complicated by a number of factors, including psychological readiness to return. The purpose of this study was to evaluate the use of the SLAP Return to Sport Index (SLAP-RSI) score to quantify psychological readiness to return to play following operative management of SLAP tears. Methods: A retrospective review of athletes who underwent operative management of SLAP tears with a minimum of 12-month follow-up was performed. Patients were evaluated for their psychological readiness to return to sport using the SLAP-RSI score. The SLAP-RSI score was created by adapting the terms in the Anterior (ACL-RSI score) with terms related to SLAP tears. A SLAP-RSI score > 56 is considered a passing score for being psychologically ready to return to play. Results: The study included 174 athletes who underwent operative management of SLAP tears. Overall, 73.5% percent of patients were able to return to play, and the mean SLAP-RSI score in this cohort was 74.1±20.9, as compared to 46.7±27.7 in those who were unable to return (pConclusions: Following the operative management of SLAP repair, patients that are unable to return to play exhibit poor psychological readiness to return which may be due to residual pain or fear of re-injury.

Objectives: Socioeconomic factors have been shown to impact patient care in many surgical fields; however, their effects have not been thoroughly evaluated in the context of anterior cruciate ligament reconstruction (ACLR) outcomes. The purpose of this study is to investigate the effects of socioeconomic factors on time to surgery, knee function, and subjective outcomes measures following ACLR. Methods: A retrospective query of primary ACLR surgeries at a single institution performed from 2011 to 2015 with minimum two-year follow-up was conducted. Patient demographics, insurance type, worker’s compensation status, surgical variables, IKDC score, and failure were recorded from chart review. Education level and income were obtained via phone interview. Differences between functional outcome were compared between Medicaid and non-Medicaid groups. Results: 268 patients were included in the analysis (43 patients in the Medicaid group and 225 patients in the non-Medicaid group). The Medicaid group demonstrated lower annual income (pConclusions: Socioeconomic factors impacted care in the setting of ACL injury. Medicaid insurance patients were seen significantly later after initial injury when compared to non-Medicaid carriers, and had worse outcomes compared to their non-Medicaid peers. Higher annual income brackets had significantly higher clinical outcomes scores at a minimum of two years postoperatively. Education level did not affect outcomes.

Premature labor is a cause of high rates of perinatal morbidity and mortality. The use of tocolytics is one of the efforts to handle the risk of preterm labor. Tocolytics which are widely used in Indonesia is isoxsuprine and nifedipine. The purpose of this study was to identify the difference of effectiveness and safety of isoxsuprine as tocolytics in the risk of preterm labor. This was an observational study in the form of a case study that was done in detail and depth to the patients who were diagnosed as imminent preterm labor. In conclusion, there were differences in the effectiveness and safety of isoxsuprine and nifedipine as tocolytics in the risk of preterm labor.

Selective serotonin reuptake inhibitors (SSRIs) are one of the most commonly prescribed antidepressants worldwide and recent data show significant impairment of fracture healing after treatment with the SSRI fluoxetine in mice. Here, we provide evidence that the negative effects of SSRIs can be overcome by administration of the beta-blocker propranolol at the time of fracture. First, in vitro experiments established that propranolol does not affect osteogenic differentiation. We then used a murine model of intramembranous ossification to study the potential rescue effect of propranolol on SSRI-induced impaired fracture healing. Micro-CT analysis revealed that fluoxetine treatment resulted in a smaller bony regenerate and that this decrease in bone formation can be overcome by co-treatment with propranolol. We then tested this in a clinically relevant model of endochondral ossification. Fluoxetine-treated mice with a femur fracture were treated with propranolol initiated at the time of fracture, and a battery of analyses demonstrated a reversal of the detrimental effect of fluoxetine on fracture healing in response to propranolol treatment. These experiments show for the first time to our knowledge that the negative effects of SSRIs on fracture healing can be overcome by co-treatment with a beta-blocker. © 2019 American Society for Bone and Mineral Research.