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A double cortical button technique for ulnar collateral ligament reconstruction (UCLR) has advantages including significant control over graft tensioning, less concern about graft length, and minimized risk of bone tunnel fracture compared with traditional UCLR techniques. This double cortical button technique was recently found to be noninferior in mechanical performance to the traditional docking technique regarding joint strength, joint stiffness, and graft strain. However, clinical outcomes have not been compared between these UCLR techniques. Therefore, the purpose of this study was to determine whether baseball players who underwent UCLR with a double cortical button (double button) technique have similar return-to-sport (RTS) outcomes to baseball players who underwent UCLR with the traditional docking (docking) technique. Baseball players who underwent primary UCLR from 2011 to 2020 across 2 institutions were identified. Included patients were contacted to complete a follow-up survey evaluating reoperations, RTS, and functional outcome scores. Functional outcome surveys include the Kerlan-Jobe Orthopaedic Clinic score, the Conway-Jobe score, the Andrews-Timmerman elbow score, and the Single Assessment Numeric Evaluation score. Overall, 78 male baseball players (age: 18.9 ± 2.4 years) with an average follow-up of 3.1 ± 2.4 years were evaluated, with 73 of the players being baseball pitchers. Players in the double button group more frequently received palmaris longus autografts (78% vs. 30%) and less frequently received gracilis autografts (22% vs. 58%) compared with players in the docking group (P =.001); however, all other demographic factors were similar between the groups. All players in the double button group were able to RTS in 11.1 ± 2.6 months, whereas 96% of players in the docking group were able to RTS in 13.5 ± 3.4 months (P >.05). All postoperative outcomes and patient-reported outcomes were statistically similar between the groups and remained similar after isolating pitchers only and after separating partial-thickness from full-thickness UCL tears (all P >.05). RTS and other postoperative outcomes may be similar between baseball players who underwent UCLR with the double button technique and the docking technique. Although future research may be necessary to strengthen clinical recommendations, these findings provide the first clinical outcomes in light of a recent cadaveric study finding similar elbow strength, joint stiffness, and graft strain compared with the docking technique. [ABSTRACT FROM AUTHOR]

Diabetic patients have a greater incidence of adhesive capsulitis (AC) and a more protracted disease course than patients with idiopathic AC. The purpose of this study was to compare gene expression differences between AC with diabetes mellitus and AC without diabetes mellitus. Shoulder capsule samples were prospectively obtained from diabetic or nondiabetic patients who presented with shoulder dysfunction and underwent arthroscopy (N = 16). Shoulder samples of AC with and without diabetes (n = 8) were compared with normal shoulder samples with and without diabetes as the control group (n = 8). Shoulder capsule samples were subjected to whole-transcriptome RNA sequencing, and differential expression was analyzed with EdgeR. Only genes with a false discovery rate < 5% were included for further functional enrichment analysis. The sample population had a mean age of 47 years (range, 24-62 years), and the mean hemoglobin A 1c level for nondiabetic and diabetic patients was 5.18% and 8.71%, respectively. RNA-sequencing analysis revealed that 66 genes were differentially expressed between diabetic patients and nondiabetic patients with AC whereas only 3 genes were differentially expressed when control patients with and without diabetes were compared. Furthermore, 286 genes were differentially expressed in idiopathic AC patients, and 61 genes were differentially expressed in diabetic AC patients. On gene clustering analysis, idiopathic AC was enriched with multiple structural and muscle-related pathways, such as muscle filament sliding, whereas diabetic AC included a greater number of hormonal and inflammatory signaling pathways, such as cellular response to corticotropin-releasing factor. Whole-transcriptome expression profiles demonstrate a fundamentally different underlying pathophysiology when comparing diabetic AC with idiopathic AC, suggesting that these conditions are distinct clinical entities. The new genes expressed explain the differences in the disease course and suggest new therapeutic targets that may lead to different treatment paradigms in these 2 subsets. [ABSTRACT FROM AUTHOR]

Smoking is a poor prognostic factor for healing after rotator cuff repair and is associated with inferior results. We hypothesized that smokers would have higher recurrent tear rates and more postoperative myotendinous junction (MTJ) retraction in healed repairs than nonsmokers three months postoperatively. Rotator cuff repairs (RCRs) were retrospectively reviewed over a 2-year period. Patients underwent magnetic resonance imaging (MRI) within 6 months prior to surgery and again at 3 months postoperatively. Seventy-nine patients were included and stratified by smokers versus nonsmokers. Baseline patient demographics, tear characteristics, and surgical factors were collected. Preoperative and postoperative MRIs were assessed to quantify the MTJ position and to establish the recurrent tear rate. For the total cohort (nonsmokers, n = 56; smokers, n = 23), significant differences in age, race, and traumatic onset of injury existed between groups. There were no significant differences in recurrent tear between smokers (26%) and nonsmokers (27%), but nonsmokers were more satisfied. For patients with healed RCRs (nonsmokers, n = 41; smokers, n = 17), there were significant differences in race. On univariate analysis, nonsmokers had a significantly more lateral MTJ postoperatively (P = 0.05). On multivariable regression analysis, medialized postoperative MTJ position in healed cuffs was driven only by greater preoperative rotator cuff retraction preoperatively. There were no significant differences in MTJ position based on smoking status for patients with healed RCRs. Smoking does not appear to be an independent risk factor for postoperative MTJ retraction in healed RCRs, also known as failure in continuity. Preoperative tear size and retraction play the biggest roles in predicting postoperative MTJ position, regardless of smoking status. There are no significant differences in patient-reported outcomes for patients with healed RCRs, but nonsmokers had more satisfaction following RCR in the total cohort. Level III; Retrospective cohort study; Diagnostic study [ABSTRACT FROM AUTHOR]

Purpose: The goals of this study were 2-fold: (1) to determine the risk factors for cerebral desaturation events (CDEs) after implementation of a comprehensive surgical and anesthetic protocol consisting of patient risk stratification, maintenance of normotensive anesthesia, and patient positioning in a staged fashion, and (2) to assess for subclinical neurologic decline associated with intraoperative ischemic events through cognitive testing.Methods: One hundred patients undergoing shoulder surgery in the beach chair position were stratified for risk of CDE based on Framingham stroke criteria, body mass index (BMI), and history of cerebrovascular accidents. Cerebral oxygen saturation was monitored with near-infrared spectroscopy. As per a standardized protocol, mean arterial pressure was maintained between 70 and 90 mm Hg. The head was raised in 2 stages separated by 3 minutes. CDE were defined as >20% drop from baseline or <55% O2 absolute threshold. Patients completed a Mini-Mental State Examination during preoperative examination and at the first postoperative visit.Results: The CDE rate was 4% overall and 4.3% in patients undergoing general anesthesia. Forty-five patients were in the higher risk category, and all CDEs occurred in that group. Patients with a Framingham score ≥ 10 or BMI ≥ 35 who underwent general anesthesia had an increased risk of CDE (P = .04). No significant change was noted in Mini-Mental State Examination scores between pre- and postoperative visits. No correlation was shown between CDE and history of diabetes, smoking, cardiovascular disease, or left ventricular hypertrophy.Conclusions: Our observed CDE rate was lower than previously reported rates, likely because of risk stratification, staged positioning, and normotensive anesthesia. Framingham score ≥ 10 and BMI ≥ 35 are risk factors for CDE in the beach chair position.Level Of Evidence: Level II, prospective observational study with >80% follow-up. [ABSTRACT FROM AUTHOR]

Abstract Constraining the speed of sea level rise at the start of an interglacial is important to understanding the size of the 'window of opportunity' available for hominin migration. This is particularly important during the last interglacial when there is no evidence for significant hominin occupation anywhere in Britain. There are very few finer grained fossiliferous sequences in the Channel region that can be used to constrain sea level rise and they are preserved only to the north of the Channel, in England. Of these, the sequence at Stone Point SSSI is by far the most complete. Data from this sequence has been previously reported, and discussed at a Quaternary Research Association Field Meeting, where a number of further questions were raised that necessitated further data generation. In this paper, we report new data from this sequence – thin section analysis, isotopic determinations on ostracod shells, new Optical Stimulated Luminescence ages and Amino Acid Recem analyses. These show early sea level rise in this sequence, starting during the pre-temperate vegetation zone IpI, but no early warming. The implications of this almost certainly last interglacial sequence for the human colonisation of Britain and our understanding of the stratigraphic relationship of interglacial estuarine deposits with their related fluvial terrace sequences is explored. [ABSTRACT FROM AUTHOR]

Background A variety of techniques currently exist for ulnar collateral ligament (UCL) reconstruction in symptomatic overhead athletes, all with the potential complication of fracture about the humeral or ulnar tunnels. Far cortical button fixation is a reproducible, biomechanically attractive option; however, no clinical series has been published on this technique to date. This study reports the clinical outcomes, with minimum 2-year follow-up, of a dual far cortical button suspension technique for UCL reconstruction in athletes. Methods A retrospective evaluation was performed of 23 consecutive athletes who underwent UCL reconstruction with the use of ulnar and humeral-sided far cortical button fixation with minimum 2 years of follow-up. Data were collected from electronic medical records and patient telephone calls. The primary outcome was return to sport. Secondary outcomes included Disabilities of the Arm, Shoulder and Hand score, range of motion, and complications. Results We included 23 athletes with a mean follow-up of 47.2 months (range, 24-81 months). Autograft was used in 22 patients (16 palmaris, 6 gracilis, 1 semitendinosus, and 1 gracilis allograft). Overall, 82.6% (19 of 23) of patients returned to sport. At final follow-up, the average Disabilities of the Arm, Shoulder and Hand score was 3.8, and range of motion averaged 0° to 140°, with 87% (20 of 23) of patients achieving full motion. The visual analog scale score improved from 3.8 preoperatively to 0.2 at the final follow-up ( P  < .0001). There was 1 reconstruction failure. Conclusions The humeral and ulnar far cortical button suspension technique provides a new UCL fixation option with theoretically lower concern for tunnel fracture and with predictable return to sport and good functional outcomes. [ABSTRACT FROM AUTHOR]

Background Little is known about the time dependence of the failure rate of surgically repaired rotator cuffs. Retears are significant, as they are common and may lead to less satisfactory outcomes and additional operations. Their timing is critical foundational information for understanding failure mechanisms. However, this remains unclear. Currently, there exist a number of studies that have reported retear rates at specific time points. Combining data from these publications can reveal when cuffs retear, which will help inform expectations and guidelines for progression of activity after surgery. Methods PubMed, Medline, and Embase were searched for studies relating to rotator cuff repair. Abstracts and articles were evaluated on the basis of predefined inclusion and exclusion criteria. Data were extracted from those publications that satisfied all requirements, and regression analysis was performed. Results Thirteen articles were included in the final meta-analysis. Retear rates for medium tears increased for approximately 15 months and leveled off at approximately 20%. Retear rates for large tears progressed steadily for about 12 months and approached an upper limit of approximately 40%. Retear rates for massive tears ranged from 20% to 60%, but the distribution of retear rate over time for these cuff tears is not clear from these data. Conclusion Retear rates for medium and large tears generally increase until at least 10-15 months after surgery, after which they are likely to level off. Retear rates for massive tears are variable and may follow a time course different from that of other tear sizes. Retear rates depend on size of the original tear. [ABSTRACT FROM AUTHOR]

Background Clinical laboratory patient databases are an untapped source of valuable diagnostic and prognostic information. However, the lack of associated clinical and/or demographic information and questionable generalizability to nonpatient populations often limit utility of these data. Objectives This study compared levels of cardiometabolic biomarkers between a national clinical laboratory patient cohort (Health Diagnostic Laboratory [HD Lab]) and the US population as inferred from the National Health and Nutrition Examination Survey (NHANES, 2011–2012). Methods Sample sizes for HD Lab ranged from 199,000 to 739,000 and for NHANES from 2200 to 5300. The latter were weighted to represent the adult US population (∼220 million). Descriptive statistics were compared for body mass index, 5 lipid biomarkers, and 3 glycemic biomarkers. Results Using age- and sex-matched data, mean biomarker values (mg/dL unless noted) and percent differences (%) for HD Lab vs NHANES were body mass index (kg/m 2 ), 29.1 vs 28.6 (1.7%); total cholesterol, 185 vs 193 (–4.1%); apolipoprotein B, 92 vs 90 (2.2%); low-density lipoprotein cholesterol, 107 vs 115 (–7%); high-density lipoprotein cholesterol, 53 vs 53 (0%); triglycerides, 128 vs 127 (0.8%); glucose, 99 vs 108 (–8.3%); insulin (uU/mL), 13.7 vs 13.4 (2.2%); and hemoglobin A1c (%), 5.6 vs 5.8 (–3.4%). Although all differences were statistically significant, only low-density lipoprotein cholesterol and glucose differed by more than 5%. These may reflect a greater use of medications among HD Lab patients and/or preanalytical factors. Conclusions Cardiometabolic risk markers from a national clinical laboratory were broadly similar to those of the US population; thus, with certain caveats, data from the former may be generalizable to the latter. [ABSTRACT FROM AUTHOR]

Background Recent studies have identified Propionibacterium acnes as the causal organism in an increasing number of postoperative shoulder infections. Most reports have found a high rate of P acnes infection after open surgery, particularly shoulder arthroplasty. However, there are limited data regarding P acnes infections after shoulder arthroscopy. Materials and methods We prospectively collected data on all shoulder arthroscopies performed by the senior author from January 1, 2009, until April 1, 2013. Cultures were taken in all revision shoulder arthroscopy cases performed for pain, stiffness, or weakness. In addition, 2 cultures were taken from each of a cohort of 32 primary shoulder arthroscopy cases without concern for infection to determine the false-positive rate. Results A total of 1,591 shoulder arthroscopies were performed during this period, 68 (4.3%) of which were revision procedures performed for pain, stiffness, or weakness. A total of 20 revision arthroscopies (29.4%) had positive culture findings, and 16 (23.5%) were positive for P acnes . In the control group, 1 patient (3.2%) had P acnes growth. Conclusions The rate of P acnes infection in patients undergoing revision shoulder arthroscopy is higher than previously published and should be considered in cases characterized by refractory postoperative pain and stiffness. [ABSTRACT FROM AUTHOR]

Background Discordance between measures of atherogenic lipoprotein particle number (apolipoprotein B [ApoB] and low-density lipoprotein [LDL] particle number by nuclear magnetic resonance spectroscopy [LDL-P NMR ]) is not well understood. Appropriate treatment considerations in such cases are unclear. Objectives To assess discordance between apoB determined by immunoassay and LDL-P NMR in routine clinical practice, and to characterize biomarker profiles and other clinical characteristics of patients identified as discordant. Methods Two retrospective cohorts were evaluated. First, 412,013 patients with laboratory testing performed by Health Diagnostic Laboratory, Inc., as part of routine care; and second, 1411 consecutive patients presenting for risk assessment/reduction at 6 US outpatient clinics. Discordance was quantified as a percentile difference (LDL-P NMR percentile − apoB percentile) and attainment of percentile cutpoints (LDL-P NMR ≥ 1073 nmol/L or apoB ≥ 69 mg/dL). A wide range of cardiovascular risk factors were compared. Results ApoB and LDL-P NMR values were highly correlated ( R 2 = 0.79), although substantial discordance was observed. Similar numbers of patients were identified as at-risk by LDL-P NMR when apoB levels were < 69 mg/dL (5%-6%) and by apoB values when LDL-P NMR was < 1073 nmol/L (6%-7%). Discordance (LDL-P NMR > apoB) was associated with insulin resistance, smaller LDL particle size, increased systemic inflammation, and low circulating levels of “traditional” lipids, whereas discordance (apoB > LDL-P NMR ) was associated with larger LDL particle size, and elevated levels of lipoprotein(a) and lipoprotein-associated phospholipase A2 (Lp-PLA 2 ). Conclusion Discordance between apoB and LDL-P NMR in routine clinical practice is more widespread than currently recognized and may be associated with insulin resistance. [ABSTRACT FROM AUTHOR]

The importance of lipoprotein (a)—Lp(a)—as a cardiovascular (CV) risk marker has been underscored by recent findings that CV risk is directly related to baseline Lp(a) levels, even in well-treated patients. Although there is currently little that can be done pharmacologically to lower Lp(a) levels, knowledge of its serum concentration is important in overall risk assessment. This review focuses on 1 aspect of Lp(a) that is rarely discussed directly: how to express its levels in serum. There is considerable confusion on this point, and a fuller understanding of what the concentration units mean will help improve study-to-study comparisons and thereby advance our understanding of the pathobiology of this lipoprotein particle. As discussed here, the term Lp(a) mass refers to the entire mass of the particle: lipids, proteins, and carbohydrates combined. At present, there are no commercially available assays that are completely insensitive to the variability in particle mass, which arises not only from differences in apo(a) isoform mass but also from variations in lipid mass. Because lipoprotein “particle number” (molar concentration) has been found to be superior to component-based metrics (ie, low-density lipoprotein particle vs cholesterol concentrations) for CV disease risk prediction, the development of a mass-insensitive Lp(a) assay should be a high priority. [ABSTRACT FROM AUTHOR]

Glenoid bone deficiency and eccentric posterior wear are difficult problems faced by shoulder arthroplasty surgeons. Numerous options and techniques exist for addressing these issues. Hemiarthroplasty with concentric glenoid reaming may be a viable alternative in motivated patients in whom glenoid component failure is a concern. Total shoulder arthroplasty has been shown to provide durable pain relief and excellent function in patients, and numerous methods and techniques can assist in addressing bone loss and eccentric wear. However, the ideal amount of version correction in cases of severe retroversion has not yet been established. Asymmetric reaming is a commonly used technique to address glenoid version, but correction of severe retroversion may compromise bone stock and component fixation. Bone grafting is a technically demanding alternative for uncontained defects and has mixed clinical results. Specialized glenoid implants with posterior augmentation have been created to assist the surgeon in correcting glenoid version without compromising bone stock, but clinical data on these implants are still pending. Custom implants or instruments based on each patient's unique glenoid anatomy may hold promise. In elderly, sedentary patients in whom bone stock and soft-tissue balance are concerns, reverse total shoulder arthroplasty may be less technically demanding while still providing satisfactory pain relief and functional improvements. [Copyright &y& Elsevier]

Background: Omega-3 fatty acid (n-3 FA) biostatus can be estimated with red blood cell (RBC) membranes or plasma. The matrix that exhibits the lower within-person variability and is less affected by an acute dose of n-3 FA is preferred in clinical practice. Objective: We compared the acute effects of a large dose of n-3 FA on RBC and plasma levels of eicosapentaenoic acid (EPA) plus docosahexaenoic acid (DHA). Methods: Healthy volunteers (n = 20) were given 4 capsules containing 3.6 g of n-3 FA with a standardized breakfast. Blood samples were drawn at 0, 2, 4, 6, 8, and 24 hours. The EPA + DHA content of RBC membranes and plasma (the latter expressed as a percentage of total FA and as a concentration) were determined. General linear mixed models were used to analyze the mean response profiles in FA changes over time for plasma and RBCs. Results: At 6 hours after load, the plasma concentration of EPA + DHA had increased by 47% (95% confidence interval [CI], 24% to 73%) and the plasma EPA + DHA percentage of total FA by 19% (95% CI, 4.7% to 36%). The RBC EPA + DHA percentage of composition was unchanged [–0.6% (95% CI, −2.6% to 1.5%)]. At 24 hours, the change in both of the plasma EPA + DHA markers was 10-fold greater than that in RBCs. Conclusions: An acute dose of n-3 FA (eg, a meal of oily fish or fish oil supplements) taken within a day before a doctor’s visit can elevate levels of EPA + DHA in plasma, whether expressed as a percentage or a concentration, but not in RBC membranes. Similar to hemoglobin A1c, which is not affected by an acute glycemic deviation, RBCs provide a more reliable estimate of a patient’s chronic EPA + DHA status than does plasma. [Copyright &y& Elsevier]

Background: The number of times an article has been cited has been used as a marker of its influence in a medical specialty. The purpose of this study was to determine the 50 most cited articles in shoulder surgery and their characteristics. Methods: Science Citation Index Expanded was searched for citations of articles published in any of the 61 journals in the category “Orthopedics.” Each of the journals was searched to determine the 50 most often cited articles specific to shoulder surgery. The following characteristics were determined for each article: authors, year of publication, source journal, geographic origin, article type, and level of evidence for clinical articles. Citation density (total number of citations/years since publication) was also determined. Results: The number of citations ranged from 1211 to 192. The 50 most often cited articles were published in 8 journals. The majority of the articles (42) were clinical, with the remaining representing some type of basic science research. The most common level of evidence was IV (23). The mean number of citations for methodologic articles (437 citations per article) was greater than that for non-methodologic articles (301 citations per article) (P = .034). Conclusions: Articles that introduced instruments for outcome evaluation or that introduced classification systems (methodologic) were highly cited regardless of the date of publication. The top 50 list presented provides residency and fellowship directors with a group of “classic” articles in the subspecialty of orthopedic shoulder surgery that can be included in reading curriculums for their trainees. [ABSTRACT FROM AUTHOR]

Purpose: This study investigates factors associated with failure and reoperation after glenoid labrum repair. Methods: We studied a nonconcurrent cohort of consecutive patients undergoing arthroscopic superior labrum repair at a single institution by 2 fellowship-trained surgeons over a 10-year period. Results: There were 348 patients included in this study with a mean age of 33.4 years (95% confidence interval [CI], 32.1 to 35.9) and a mean clinical follow-up of 12.3 months (95% CI, 10.9 to 13.8). The overall reoperation rate was 6.3%, with a revision labrum repair rate of 4.3%. Subsequent surgery and failure after arthroscopic labrum repair were significantly correlated with Workers'' Compensation claims (odds ratio [OR], 4.6; P < .001; 95% CI, 1.8 to 11.7), the use of tobacco (OR, 12.0; P = .03; 95% CI, 1.2 to 114.9), and the use of absorbable poly-L/D-lactic acid (PLDLA) anchors (100% correlation, P < .001). The OR for having repeat surgery was 12.7 (95% CI, 4.9 to 32.9; P < .001) with poly-96L/4D-lactic acid (Mini-Revo; Linvatec, Largo, FL) and also increased with the use of poly-70L/30D-lactic acid (Bio-Fastak and Bio-Suturetak; Arthrex, Naples, FL) anchor material (P = .04) after removal of the patients exposed to poly-96L/4D-lactic acid anchors. The rates of repeat surgery with PLDLA anchors from Linvatec and PLDLA anchors from Arthrex were 24% and 4%, respectively. None of the patients treated with nonabsorbable suture anchors (polyether ether ketone or metallic) returned to the operating room (P < .001). After we controlled for associated factors in a multivariate analysis, the use of absorbable anchors, in particular poly-96L/4D-lactic acid anchors (OR, 14.7; P < .001), and having a work-related injury (OR, 8.1; P < .001) remained independent factors associated with both repeat surgery and revision superior labrum repair. Conclusions: Bioabsorbable PLDLA anchor material led to significantly more SLAP repair failures and reoperations compared with nonabsorbable suture anchors. Our recommendation is that glenoid labrum repairs be performed with nondegradable material and, specifically, that the use of anchors composed of PLDLA material should be avoided. Level of Evidence: Level III, retrospective comparative study. [Copyright &y& Elsevier]

Abstract: There is little understanding of the reliability of laboratory measurements among clinicians. Low-density lipoprotein cholesterol (LDL-C) measurement is the cornerstone of cardiovascular risk assessment and prevention, but it is fraught with error. Therefore, we have reviewed issues related to accuracy and precision for the measurement of LDL-C and the related markers non-high-density lipoprotein cholesterol (non-HDL-C) and apolipoprotein B. Despite the widespread belief that LDL-C is standardized and reproducible, available data suggest that results can vary significantly as the result of methods from different manufacturers. Similar problems with direct HDL-C assays raise concerns about the reliability of non-HDL-C measurement. The root cause of method-specific bias relates to the ambiguity in the definition of both LDL and HDL, and the heterogeneity of LDL and HDL particle size and composition. Apolipoprotein B appears to provide a more reliable alternative, but assays for it have not been as rigorously tested as direct LDL-C and HDL-C assays. [Copyright &y& Elsevier]

Hypothesis: The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire has been validated as an effective upper extremity specific outcome measure. Normative scores have not been established for young athletes. This study was conducted to establish normative DASH scores for intercollegiate athletes. We hypothesized that DASH scores in intercollegiate athletes differ from published values obtained from the general population. Materials and methods: The DASH questionnaire was administered to 321 athletes cleared for full participation in intercollegiate sports. Their scores were compared with normative values in the general population and 2 other age-matched cohorts. Results: Intercollegiate athletes had significantly better upper extremity function compared with the general population (1.37 ± 2.96 vs 10.10 ± 14.68, P < .001) and an age-matched cohort of employed adults (1.37 ± 2.96 vs 5.40 ± 7.57, P < .0001). The DASH was 0 for 65.1%. Within this cohort, men reported better upper extremity function than women (0.98 vs 1.82, P = .010). Athletes participating in overhead sports reported worse upper extremity function than nonoverhead athletes (1.81 vs 0.98, P = .042). Discussion: We report normative DASH values for a group of intercollegiate athletes and show a significant difference between the scores of these athletes and the general population. Within our cohort of competitive athletes, overhead sports and female gender are associated with significantly lower DASH scores and sports module scores. The utility of using these results are limited by a substantial ceiling effect in this population of competitive athletes. Differences within our cohort and differences between our cohort and other populations are minimized by this ceiling effect. Various upper extremity outcome measures may be similarly limited by a ceiling effect and should be examined for appropriateness before use. Conclusion: Intercollegiate athletes report significantly greater upper extremity function than the general population; however, validity of the DASH in these athletes is limited and population differences may be minimized by a substantial ceiling effect. [Copyright &y& Elsevier]

Summary: Objective: Injuries to the avascular regions of the meniscus fail to heal and so are treated by resection of the damaged tissue. This alleviates symptoms but fails to restore normal load transmission in the knee. Tissue engineering functional meniscus constructs for re-implantation may improve tissue repair. While numerous studies have developed scaffolds for meniscus repair, the most appropriate autologous cell source remains to be determined. In this study, we hypothesized that the debris generated from common meniscectomy procedures would possess cells with potential for forming replacement tissue. We also hypothesized that donor age and the disease status would influence the ability of derived cells to generate functional, fibrocartilaginous matrix. Methods: Meniscus derived cells (MDCs) were isolated from waste tissue of 10 human donors (seven partial meniscectomies and three total knee arthroplasties) ranging in age from 18 to 84 years. MDCs were expanded in monolayer culture through passage 2 and seeded onto fiber-aligned biodegradable nanofibrous scaffolds and cultured in a chemically defined media. Mechanical properties, biochemical content, and histological features were evaluated over 10 weeks of culture. Results: Results demonstrated that cells from every donor contributed to increasing biochemical content and mechanical properties of engineered constructs. Significant variability was observed in outcome parameters (cell infiltration, proteoglycan and collagen content, and mechanical properties) amongst donors, but these variations did not correlate with patient age or disease condition. Strong correlations were observed between the amount of collagen deposition within the construct and the tensile properties achieved. In scaffolds seeded with particularly robust cells, construct tensile moduli approached maxima of ∼40MPa over the 10-week culture period. Conclusions: This study demonstrates that cells derived from surgical debris are a potent cell source for engineered meniscus constructs. Results further show that robust growth is possible in MDCs from middle-aged and elderly patients, highlighting the potential for therapeutic intervention using autologous cells. [Copyright &y& Elsevier]

Tuberosity malpositioning commonly occurs and is associated with a decline in clinical function after prosthetic shoulder reconstruction for proximal humeral fractures. This study assesses the biomechanical effects of inferior tuberosity position on glenohumeral joint forces and humeral head position at multiple positions. Eight fresh-frozen cadaveric shoulders were tested. Hemiarthroplasty was performed with preservation of anatomic tuberosity height and with 10 mm and 20 mm of inferior tuberosity displacement. The rotator cuff, deltoid, pectoralis major, and latissimus dorsi muscles were statically loaded. Contact forces and humeral head position were recorded within a functional range of motion. Glenohumeral joint forces shifted significantly superiorly (P < .05) at 30° of abduction after both 10 mm and 20 mm of tuberosity displacement. At 60° of glenohumeral abduction, glenohumeral joint forces remained significantly altered after tuberosity displacement of 10 mm and 20 mm compared with the intact height (P < .005). This study demonstrates that, during hemiarthroplasty performed for proximal humeral fractures, malpositioning the tuberosities inferiorly results in significant superior glenohumeral joint force displacement. These findings suggest that the mechanical advantage of the shoulder abductor muscles is compromised with inferior tuberosity malpositioning and may help to explain inferior functional results seen in these patients. [Copyright &y& Elsevier]

Purpose: The overall purpose of our study was to examine the sensitivity of physical examination, magnetic resonance imaging (MRI), and magnetic resonance (MR) arthrogram for the identification of arthroscopically confirmed SLAP lesions of the shoulder. Methods: An analysis of 51 consecutive patients with arthroscopically confirmed SLAP lesions and no history of shoulder dislocation was performed. Before undergoing surgery, all patients underwent a standardized physical examination and had either an MRI and/or MR arthrogram performed. Sensitivity analysis was then performed on the results of both the physical examination maneuvers and the radiologic imaging compared to the arthroscopic findings at surgery. Results: The sensitivity of O’Brien’s (active compression) test was 90%, whereas the Mayo (dynamic) shear was 80% and Jobe’s relocation test was 76%. The sensitivity of a physical examination with any 1 of these 3 SLAP provocative tests being positive was 100%. Neer’s sign (41%) and Hawkin’s impingement tests (31%) each had low sensitivity for SLAP lesions. The sensitivity of MRI for SLAP lesions was 67% when interpreted by the performing surgeon, 53% when read by a radiologist. When the MR arthrograms were analyzed alone, the sensitivity was 72% (surgeon) and 50% (radiologist), respectively. Conclusions: All 3 physical examination maneuvers traditionally considered provocative for SLAP pathology (O’Brien’s, Mayo shear, and Jobe’s relocation) were sensitive for the diagnosis of SLAP lesions. MRI and MR arthrogram imaging had lower sensitivity than these physical examination tests in diagnosing SLAP lesions. Patient history, demographics, and the surgeon’s physical examination should remain central to the diagnosis of SLAP lesions. Level of Evidence: Level II, development of diagnostic criteria on basis of consecutive patients with universally applied gold standard. [Copyright &y& Elsevier]

Purpose: The purpose of this report is to present a systematic review of the literature to compare surgical success of lateral retinacular release (LRR) or LRR with medial soft-tissue realignment (MR) for recurrent lateral patellar instability. Methods: We searched MEDLINE and PubMed databases for all English-language studies reporting surgical management of recurrent lateral patellar instability with LRR or with LRR and MR. Exclusion criteria included a minimum follow-up <2 years, mean age <18 years old, bony realignment procedures, surgical treatment of an initial patellar instability episode, or surgical treatment of patellofemoral pain without instability. Surgical failure was defined as an episode of patellar dislocation or subluxation during the postoperative period. Statistical analysis compared the failure rate of LRR versus combined LRR with MR by using a Fisher exact test and assessed for publication bias. Results: Fourteen studies met inclusion criteria. There were 247 knees with a minimum 2-year follow-up after LRR and 220 after LRR with MR. In the LRR patients, there were 56 cases (probability 0.227, odds 0.293) of recurrent lateral patellar instability, 26 of which were postoperative patellar dislocations. In the LRR with MR patients, there were 14 cases (probability 0.064, odds 0.068) of recurrent instability, 12 of which were dislocations. The frequency-weighted mean success with respect to instability in the LRR studies was 77.3% compared with 93.6% in the LRR with MR studies. The odds of subsequent instability after LRR were significantly greater than after LRR with MR with respect to any postoperative instability (P < .001), recurrent dislocation (P = .045), and recurrent subluxation (P < .001). Conclusions: This systematic review found that isolated LRR yields significantly inferior long-term results with respect to symptoms of recurrent lateral patellar instability compared with LRR with MR. Level of Evidence: Level III, systematic review of level III and IV studies. [Copyright &y& Elsevier]

Primary mediastinal ectopic goiters are very rare. We report a case in which an ectopic goiter with blood supply from the thoracic vessels necessitated a transternal approach for removal, resulting in a favorable outcome. [Copyright &y& Elsevier]

Background & Aims: Liver disease has been associated with cardiovascular disorders, but little is known about the relationship between serum levels of alanine aminotransferase (ALT) and markers of atherogenesis. We investigated the relationship between low–normal and high–normal levels of ALT and an extended panel of cardiovascular risk factors among individuals with no known diseases in a primary care setting. Methods: We performed a retrospective analysis of data collected from 6442 asymptomatic patients at wellness visits to a primary care setting in central Virginia from 2010 through 2011. Serum levels of ALT were compared with levels of lipids and lipoproteins, as well as metabolic, inflammatory, and coagulation-related factors associated with risk for cardiovascular disease. Results: Serum levels of ALT were higher than 40 IU/L in 12% of subjects, and in the high–normal range (19–40 IU/L in women and 31–40 IU/L in men) in 25% of subjects. ALT level was associated with the apolipoprotein B level, concentration and particle size of very-low-density lipoproteins, concentration of low-density lipoprotein (LDL) particles (LDL-P), and percentages of small dense LDL (sdLDL) and sdLDL-cholesterol (sdLDL-C) (P < .0001 for all). A high–normal level of ALT was associated with higher levels of LDL-C, LDL-P, sdLDL-C, and sdLDL particles (P < .001 for all). These effects were independent of age, body mass index, and hyperinsulinemia. Increasing levels of ALT and fasting hyperinsulinemia (>12 μU/mL) synergized with increasing levels of triglycerides, very-low-density lipoprotein particles, LDL-P, sdLDL-C, and percentage of sdLDL-C. Levels of APOA1, high-density lipoprotein-cholesterol, and high-density lipoprotein-class 2 were associated inversely with serum level of ALT (P < .0001 for all). Conclusions: In an analysis of asymptomatic individuals, increased serum levels of ALT (even high–normal levels) are associated with markers of cardiovascular disease. [Copyright &y& Elsevier]

Introduction: There has been limited data regarding failure after arthroscopic repair of superior glenoid labrum tears. This study investigates factors associated with failure and re-operation in this patient population. Methods: This is a non-concurrent cohort of consecutive patients undergoing arthroscopic labrum repair at a single institution by two fellowship-trained surgeons over a ten year period. Results: There were 348 patients included in this study with a mean age of 33.4 (95% CI 32.1-35.9) and an average clinical follow-up of 12.3 months (95% CI 10.9-13.8). The overall re-operation rate was 6.3% with a revision labrum repair rate of 4.3%. The interval between the index procedure to the second procedure was approximately 50 weeks. Subsequent surgery and failure after arthroscopic labrum repair were significantly correlated with workers'' compensation (OR 4.6, p < 0.001, CI 1.8-11.7), the use of tobacco (OR 12.0, p=0.03, CI 1.2-114.9) and the use of absorbable anchors (100% correlation, p<0.001). The Odds Ratio (OR) of having a repeat surgery was 12.7 (95% CI 4.9-32.9, p<0.001) with poly-96L/4D-lactic acid (PLDLA, Mini-Revo, Linvatec) and also increased with the use of poly-70L/30D-lactic acid (PLDLA, Bio-Fastak, Bio-Suturetak) anchor material manufactured by Arthrex (p=0.04) after removing the patients exposed to PLDLA anchors from Linvatec. The rates of repeat surgery with PLDLA anchors from Linvatec and PLDLA anchors from Arthrex were 24% and 4%, respectively. None of the patients treated with non-absorbable suture anchors (PEEK or metallic) returned to operating room (p < 0.001). After controlling for associated factors in a multivariate analysis, the use of absorbable anchors, in particular PLDA anchors from Linvatec (OR 14.7, p<0.001) and having a work-related (OR 8.1, p<0.001) injury remained independent factors associated with both repeat surgery and after labrum repair. Conclusion: The results of this study strongly support a recommendation against the use of poly-lactic acid suture anchors for glenoid labrum repair surgery. [Copyright &y& Elsevier]