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Localized cartilage lesions in early osteoarthritis and acute joint injuries are usually treated surgically to restore function and relieve pain. However, a persistent clinical challenge remains in how to repair the cartilage lesions. We expressed doublecortin (DCX) in human adipose-derived stromal/stem cells (hASCs) and engineered hASCs into cartilage tissues using an in vitro 96-well pellet culture system. The cartilage tissue constructs with and without DCX expression were implanted in the knee cartilage defects of rabbits (n = 42) and monkeys (n = 12). Cohorts of animals were euthanized at 6, 12, and 24 months after surgery to evaluate the cartilage repair outcomes. We found that DCX expression in hASCs increased expression of growth differentiation factor 5 (GDF5) and matrilin 2 in the engineered cartilage tissues. The cartilage tissues with DCX expression significantly enhanced cartilage repair as assessed macroscopically and histologically at 6, 12, and 24 months after implantation in the rabbits and 24 months after implantation in the monkeys, compared to the cartilage tissues without DCX expression. These findings suggest that hASCs expressing DCX may be engineered into cartilage tissues that can be used to treat localized cartilage lesions.

INTRODUCTION Rates of osteoporosis evaluation and management after primary fragility fractures have remained low in recent years. The extent to which this treatment gap affects patients with diabetes is unclear. This study aimed to compare the risk of secondary fractures and rates of osteoporosis diagnosis and management after sentinel fractures in patients with and without diabetes. METHODS A propensity score-matched cohort study was conducted using the PearlDiver database. Patients aged 50 years and older with primary fragility fractures of the hip, wrist, spine, pelvis, humerus, and other locations were identified. Rates of secondary fractures, dual radiograph absorptiometry (DXA) scans, charted osteoporosis diagnoses (International Classification of Diseases, Ninth and Tenth Revisions), and osteoporosis pharmacotherapy within 2 years were compared for patients with and without diabetes using multivariable logistic regression. RESULTS Matching yielded 27,052 patients in each cohort. Index humerus fractures were more common in the diabetic cohort (15.0% versus 11.6%, P < 0.001), whereas wrist fractures were more prevalent among the nondiabetic cohort (15.2% versus 19.3%, P < 0.001). Incidence of secondary fractures at 2 years was higher for diabetic patients than nondiabetic patients (5.2% versus 4.7%; odds ratio [OR] 1.08; 95% confidence interval [CI], 0.99 to 1.17). Diabetic patients were significantly less likely to receive a DXA scan (13.2% versus 13.5%; OR 0.93; 95% CI, 0.88 to 0.98), be diagnosed with osteoporosis (9.3% versus 11.9%; OR 0.77; 95% CI, 0.73 to 0.82), or start pharmacotherapy (8.1% versus 8.7; OR 0.93; 95% CI, 0.87 to 0.99). CONCLUSION Despite diabetes being a well-established risk factor for fragility fractures, diabetic patients were significantly less likely to receive DXA scan evaluation, be formally diagnosed with osteoporosis, or be treated with osteoporosis pharmacotherapy after a sentinel fragility fracture. Incidence of secondary fractures within 2 years was also higher among diabetic patients.

Rotator cuff tears are common shoulder injuries expected to increase with the growth of the aging population. Although a small subset of patients with low functional demands can be treated nonoperatively, surgical intervention is a cost-effective solution, which can restore shoulder function and help patients return to activity sooner. While multiple surgical options are available, rotator cuff repair is a highly utilized procedure with varying success. Due to a large proportion of rotator cuff repairs still failing to completely heal, this procedure requires careful planning to achieve anatomical and biomechanically stability. New technology and techniques are being explored to help increase the success of rotator cuff repairs with an increasing focus on augmentation. The current article gives a brief overview of pertinent anatomy, treatment options, and challenges in healing of rotator cuff repairs. Thereafter, the merits of different types of rotator cuff repair augmentation available will be discussed as well as the authors’ experience in utilizing biologic augmentation and surgical technique.

The purpose of this study was to demonstrate that arthroscopic Bankart repair with associated arthroscopic subscapularis augmentation (ASA) could be a valid surgical option in the treatment of anterior shoulder instability, in collision and contact sports athletes, affected by shoulder hyperlaxity.In total, 591 arthroscopic Bankart repairs plus ASA were performed in 6 shoulder centers from 2009 to 2017. Inclusion criteria were the following: collision and contact sports activities, recurrent anterior instability associated with hyperlaxity and glenoid bone loss (GBL)15%. Exclusion criteria were GBL15%, voluntary instability, multidirectional instability, pre-existing osteoarthritis and throwing athletes. The minimum follow-up was 24 months. Hyperlaxity was clinically evaluated according to Neer and Coudane-Walch tests. Before surgery, all patients underwent magnetic resonance imaging and computed tomography scanning. Pico area method was used to assess the percentage of GBL. Patients were operated on by 6 surgeons, and their functional outcomes were evaluated by 2 independent observers. The Western Ontario Shoulder Instability Index (WOSI), Rowe, American Shoulder and Elbow Surgeons (ASES) scores were used to assess results.Overall, 397 patients with evidence of shoulder hyperlaxity (positive sulcus sign in ER1 position and Coudane-Walch test85°) met all inclusion criteria. The mean WOSI score was 321; the mean Rowe score rose from 68.5 to 92.5 (P = .037), and the ASES score rose from 71.5 to 97.4 (P = .041). Seven patients (1.6%) had atraumatic redislocation, and 9 patients (2.2%) had post-traumatic redislocation. At final follow-up the mean functional deficit of external rotation was 15° with the arm in adduction (ER1 position) and 10° in abduction (ER2 position).The Bankart repair plus ASA has been demonstrated to be safe and effective for restoring joint stability in patients practicing collision and contact sports or affected by chronic anterior shoulder instability associated with GBL (15%) and hyperlaxity, without compromising external rotation.Level IV, case series.

Background The outcomes and complication rates of patients with isolated greater tuberosity fractures are not well documented. The present study aimed to evaluate the reoperation rates, types of reoperations, and complications for patients undergoing open reduction internal fixation and those undergoing initial nonoperative treatment of isolated greater tuberosity fractures. Methods An administrative claims database was queried from 2010 to 2018 for adult patients treated with open reduction internal fixation or initial nonoperative treatment within 6 weeks of sustaining a closed isolated greater tuberosity fracture. Reoperation rates, types of reoperations, local/surgical complications, and systemic complications for two cohorts were collected, and statistical analysis was performed using R statistical software for patients initially treated operatively and nonoperatively. Complication rates were compared using multivariate logistic regression, while demographic data were compared using chi-square analysis. Results Of the 8509 patients who were documented to have sustained a closed isolated greater tuberosity fracture, 333 patients underwent operative treatment and 8176 patients received initial nonoperative treatment within the first 6 weeks of diagnosis. The operative cohort had a reoperation rate of 2.7% at 90 days, 5.7% at 6 months, and 7.8% at 1 year, with the majority of reoperations being rotator cuff repair (40.6%). Within the initial nonoperative cohort, 7.3% had an operation within a year, with the majority of operations being open reduction internal fixation (41.3%). The subsequent reoperation rate for those patients was 3.5% at 2 years with the majority of reoperations being rotator cuff repair (32.4%). In the operative cohort, the 90-day infection rate was 3.0%. Nonunion was demonstrated in the operative cohort at a rate of 1.8% at 6 months and 2.7% at 1 year. Conclusion When surgical care was provided to patients sustaining isolated greater tuberosity fractures in the first 6 weeks, there was a 7.8% rate of reoperation within the first year. Patients initially treated nonoperatively had a future operation rate of 7.3% within the first year and a 3.5% reoperation rate within the second year. The most common reoperation regardless of initial treatment was rotator cuff repair. With an elevated rate of subsequent operations, education is paramount to provide patients with expectations for the sequelae of this injury especially when presenting with concomitant injuries.

Purpose To compare the likelihood of spiral fracture of the humerus using torsional load to failure after intraosseous biceps tenodesis at the position of the arthroscopic suprapectoral tenodesis versus the subpectoral meta-diaphyseal location. Methods Eight matched pairs of humeri were dissected. Unicortical tenodesis holes were drilled, either at the bottom of the bicipital groove (group 1) or just below the pectoralis major tendon insertion (subpectoral) in the humeral diaphysis (group 2). Tenodesis was performed in a 7-mm bone tunnel, with suture fixation distal to this site using 2 separate 2-mm holes, secured with No. 2 polyester suture. Each humerus was potted in plaster and mounted to a hydraulic torsional load frame, consistent with previously validated models for creating humeral spiral fractures. External rotation torque was applied to each humerus distally until fracture occurred. The paired t test was used to compare the 2 groups. Results Fracture occurred at the subpectoral cortical drill hole in all 8 specimens in group 2. In group 1, only 2 fractures occurred through the tenodesis hole, with spiral fracture resulting in the diaphysis of the humerus in 6 of 8 specimens. Average torque to failure measured 31.35 Nm in group 1 and 25.08 Nm in group 2; the difference was statistically significant (P Conclusions Subpectoral cortical drill holes for biceps tenodesis were shown to be a stress riser for humeral spiral fracture. Suprapectoral cortical drill holes were shown to be significantly less of a stress riser. The amount of torque required to fracture the humerus through the subpectoral drill holes was less than with the suprapectoral drill holes. Only 2 fractures occurred through the suprapectoral tenodesis holes, and significantly more torque was required to create these fractures. Clinical Relevance Clinically, the difference between suprapectoral and subpectoral tenodesis fracture potential should be considered when selecting a tenodesis location.

This study was performed to analyze the effect that coronavirus 2019 (COVID-19) has had on orthopedic surgeons' practices, their patients, and orthopedic surgeons themselves through a survey distributed to members of the Louisiana Orthopaedic Association (LOA). An anonymous 22-question online survey was created and distributed to 323 LOA members. Of the 323 recipients of the survey, 99 (30.7%) responded. As a part of a multiple response set, in which respondents could choose more than one answer, the majority reported delayed care for routine orthopedic injuries (81 of 97, 83.5%). Almost every surgeon (n=95, 96.0%) reported stopping or delaying elective surgery because of COVID-19 and an increase in pain/disability/deformity in patients due to delay in elective procedures (73 of 97, 75.3%) and delay in seeking care (66 of 97, 68.0%). The majority reported an increased use of telehealth visits (68 of 97, 70.1%), a decrease in patient volume (88 of 97, 90.7%), and a reduction in income (79 of 98, 80.6%) during the past 6 months. A majority of surgeons (58 of 98, 59.2%) reported that they had applied for government assistance or took out loans. Via a multiple response set, respondents indicated that as a result of the pandemic, telehealth will become more widespread (64 of 98, 65.3%) and hospitals will exert a stronger influence over health care (64 of 98, 65.3%). The COVID-19 pandemic has had lasting effects on orthopedic surgeons in Louisiana and their practices, with a substantial decrease in the number of patients treated (90.5%), surgical volume, and revenue (80.6%). Orthopedic surgeons affected by the pandemic could use these data to further understand future challenges with patient care and changing orthopedic practice dynamics during this unique time. [ Orthopedics . 2020;43(6):351–355.]

Background Historically, anatomic total shoulder arthroplasty (TSA) has been the gold-standard of care for patients with glenohumeral osteoarthritis refractory to nonoperative treatment. With expanding indications, utilization of reverse total shoulder arthroplasty (RSA) has been rapidly increasing. The purpose of this study was to use a nationwide patient database with contemporary data to identify and compare joint and systemic complication rates following primary TSA and RSA. Methods Patients records of patients receiving TSA or RSA were queried from PearlDiver (Fort Wayne, IN), a commercially available administrative claims database, using International Classification of Diseases, Ninth Revision and Tenth Revision (ICD-9/ICD-10) and Current Procedural Technology (CPT) codes. Incidences of postoperative joint complications were measured at 90-days and 1-year post-discharge. Incidences of systemic complications were measured at 90-days post-discharge. Complication rates were compared using logistic regression. Demographic data was also compared using chi-square analysis. Results From 2007 to 2017, a total of 17,681 patients received primary total shoulder arthroplasty: 8,846 (50%) received TSA and 8,835 (50%) received RSA. A greater proportion of patients that underwent RSA were female (p Conclusion Patients undergoing RSA exhibited higher rates of joint complications at both 90-days and 1-year post-discharge. These patients also experienced higher rates of systemic complications in the 90-day postoperative period, likely due to overall poorer health status. Level of evidence Level III; Treatment Study

Increasing the specific energy, energy density, specific power, energy efficiency and energy retention of electrochemical storage devices are major incentives for the development of all-solid-state batteries. However, a general evaluation of all-solid-state battery performance is often difficult to derive from published reports, mostly due to the interdependence of performance measures, but also due to the lack of a basic reference system. Here, we present all-solid-state batteries reduced to the bare minimum of compounds, containing only a lithium metal anode, β-Li3PS4 solid electrolyte and Li(Ni0.6Co0.2Mn0.2)O2 cathode active material. We use this minimalistic system to benchmark the performance of all-solid-state batteries. In a Ragone-type graph, we compare literature data for thiophosphate-, oxide-, phosphate- and polymer-based all-solid-state batteries with our minimalistic cell. Using fundamental equations for key performance parameters, we identify research targets towards high energy, high power and practical all-solid-state batteries. Considering the interdependence of performance measures and the lack of a basic reference system for all-solid-state batteries, Jurgen Janek and co-workers analyse literature performance data for major types of all-solid-state batteries and benchmark them against minimalistic reference cells.

The use of lattice structures produced using additive manufacturing (AM) is of great interest to the aerospace and medical industries because of their potential for strength/weight optimization. However, their use is often limited due to challenges in qualification. Recent standards proposed for the definition and verification of lattice structures created using AM attempt to address these gaps. In this work, a lattice component is designed using a repeated unit cell and theoretical supplemental surfaces (TSS), brought forth in ASME Y14.46, are used to define the bounding geometry of the component. Two planes and a sphere are used to define a datum hierarchy that will be used to qualify the component. A measurand is defined by a spherical TSS and is later used to evaluate the quality of datum registration. The component is produced using a laser powder bed fusion process and then measured using focus variation microscopy, X-Ray computed tomography, and a coordinate measuring machine (CMM). The three data sources are then registered using a refined sampling registration based on the CMM points. The effect of CMM data acquisition strategy on the quality of the registration is then examined. Results show that CMM planning based on optical measurements of the component, as opposed to the designed geometry, show significant improvement in the quality of registration. This work highlights the importance of sampling location in tactile measurements of components produced using additive manufacturing and recommends that definition of inspection locations/methods be integrated into the design cycle of AM parts.

Background: Proximal humerus fractures are the third most common fracture in older adults. Because of the aging population, the incidence of these fractures and their impact will continue to grow. With advancement in treatment options for proximal humeral fractures, the aim of this study was to evaluate the trends in acute management of proximal humerus fractures to determine how definitive treatment has changed over the past decade in patients older than 65 years. Methods: Using a commercially available database, patient records were queried from 2010 to 2019 for the incidence of proximal humerus fractures. For each individual year, data were queried to identify the incidence of closed reduction percutaneous pinning (CRPP), hemiarthroplasty (HA), intramedullary nailing (IMN), open reduction internal fixation (ORIF), total shoulder arthroplasty (TSA), reverse total shoulder arthroplasty (RSA), or nonoperative treatment for acute proximal humeral fractures. A Cochran-Armitage trend test was used to determine significant changes in the trends of proximal humerus fracture management. Logistic regression analyses were performed to generate odds ratios (OR) with associated 95% confidence intervals comparing each individual procedure performed in 2019 to 2010. Results: A total of 160,836 patients at least 65 years of age and older were diagnosed with a proximal humerus fracture. Of this total, 28,503 (17.72%) patients received operative treatment and 132,333 (82.28%) received nonoperative treatment. From 2010 to 2019, operative treatment trends of proximal humerus fractures changed such that CRPP decreased by 60.0%, HA decreased by 81.4%, IMN decreased by 81.9%, ORIF decreased by 25.7%, TSA decreased by 80.5%, and RSA increased by 1841.4% (all P

The COVID-19 pandemic affected consumers’ behavior worldwide. This paper aims to analyze consumers’ sustainable food behavior during the COVID-19 pandemic. The research was based on an online survey during May–October 2020 among 859 Romanian consumers. Principal component analysis and cluster analysis were employed to group the consumers based on their behavior. Furthermore, the binary-logistic regression was used to identify the socio-demographic profile of the identified groups. Based on the cluster analysis, the consumers were grouped into three main groups: indifferent, pro-environment protection, and health concerned. The results indicate a positive attitude towards sustainable food behavior. Consumers’ attitude towards sustainable food choice is mainly influenced by age and education level. The study offers valuable information for future public policy and marketing campaign regarding sustainable food behavior.

Injury to the lateral ulnar collateral ligament (LUCL) can be a complex problem in the adolescent as well as the adult athlete. Early recognition and treatment are paramount in giving the athlete the best chance to return to sport. Individuals who have sustained trauma to the elbow, particularly elbow dislocation, are at high risk of developing posterolateral rotatory instability (PLRI) as a result of injury to the LUCL. Arthroscopic and open repair in the acute or subacute setting has been shown to be effective in stabilizing the elbow and allowing athletes to return to pre-injury levels of performance. Additionally, arthroscopic plication with repair as well as open reconstruction have shown promising results as a surgical option in patients with chronic PLRI.

Endoscopic distal triceps tendon repair is a reliable and reproducible technique to address both degenerative and traumatic triceps tendon injuries. The most preferred technique for repairing a distal triceps tendon tear is through an open posterior approach and may be associated with wound healing problems and increased surgical site morbidity. Using an all-arthroscopic technique does give the treating surgeon the ability to fully assess the injury, debride the damage tissue, and anatomically repair the distal triceps tendon to its normal attachment footprint on the olecranon. Endoscopic repair allows for less wound complications, better cosmesis, and shortened postoperative recovery. Concomitant elbow pathology and injuries can be identified and addressed during the arthroscopic procedure. Patients should be braced to prevent full flexion initially during the postoperative period and gradual pain-free motion is increased until full range of motion is obtained. Gradual strengthening should be initiated by 4 weeks postoperatively in the brace and progressively out of the brace 6–8 weeks. Early results of the endoscopic distal triceps tendon repair are promising.

Background:When compared with fluid arthroscopy, carbon dioxide (CO2) insufflation offers an increased scope of view and a more natural-appearing joint cavity, and it eliminates floating debris that may obscure the surgeon’s view. Despite the advantages of CO2insufflation during knee arthroscopy and no reported cases of air emboli, the technique is not widely used because of concerns of hematogenous gas leakage and a lack of case series demonstrating safety.Purpose/Hypothesis:To investigate the safety profile of CO2insufflation during arthroscopic osteochondral allograft transplantation of the knee and report the midterm clinical outcomes using this technique. We hypothesized that patients undergoing CO2insufflation of the knee joint would have minimal systemic complications, allowing arthroscopic cartilage work in a dry field.Study Design:Case series; level of evidence, 4.Methods:A retrospective chart review was performed of electronic medical records for patients who underwent arthroscopic osteochondral allograft transplantation of the knee with the use of CO2insufflation. Included were patients aged 18 to 65 years who underwent knee arthroscopy with CO2insufflation from January 1, 2015, to January 1, 2021, and who had a minimum follow-up of 24 months. All procedures were performed by a single, fellowship-trained and board-certified sports medicine surgeon. The patients’ electronic medical records were reviewed in their entirety for relevant demographic and clinical outcomes.Results:We evaluated 27 patients (14 women and 13 men) with a mean age of 38 and a mean follow-up of 39.2 months. CO2insufflation was used in 100% of cases during the placement of the osteochondral allograft. None of the patients sustained any systemic complications, including signs or symptoms of gas embolism or persistent subcutaneous emphysema.Conclusion:The results of this case series suggest CO2insufflation during knee arthroscopy can be performed safely with minimal systemic complications and provide an alternative environment for treating osteochondral defects requiring a dry field in the knee.

ObjectiveTo update a previous individual participant data meta-analysis and determine the accuracy of the Patient Health Questionnaire-9 (PHQ-9), the most commonly used depression screening tool in general practice, for detecting major depression overall and by study or participant subgroups.DesignSystematic review and individual participant data meta-analysis.Data sourcesMedline, Medline In-Process, and Other Non-Indexed Citations via Ovid, PsycINFO, Web of Science searched through 9 May 2018.Review methodsEligible studies administered the PHQ-9 and classified current major depression status using a validated semistructured diagnostic interview (designed for clinician administration), fully structured interview (designed for lay administration), or the Mini International Neuropsychiatric Interview (MINI; a brief interview designed for lay administration). A bivariate random effects meta-analytic model was used to obtain point and interval estimates of pooled PHQ-9 sensitivity and specificity at cut-off values 5-15, separately, among studies that used semistructured diagnostic interviews (eg, Structured Clinical Interview for Diagnostic and Statistical Manual), fully structured interviews (eg, Composite International Diagnostic Interview), and the MINI. Meta-regression was used to investigate whether PHQ-9 accuracy correlated with reference standard categories and participant characteristics.ResultsData from 44 503 total participants (27 146 additional from the update) were obtained from 100 of 127 eligible studies (42 additional studies; 79% eligible studies; 86% eligible participants). Among studies with a semistructured interview reference standard, pooled PHQ-9 sensitivity and specificity (95% confidence interval) at the standard cut-off value of ≥10, which maximised combined sensitivity and specificity, were 0.85 (0.79 to 0.89) and 0.85 (0.82 to 0.87), respectively. Specificity was similar across reference standards, but sensitivity in studies with semistructured interviews was 7-24% (median 21%) higher than with fully structured reference standards and 2-14% (median 11%) higher than with the MINI across cut-off values. Across reference standards and cut-off values, specificity was 0-10% (median 3%) higher for men and 0-12 (median 5%) higher for people aged 60 or older.ConclusionsResearchers and clinicians could use results to determine outcomes, such as total number of positive screens and false positive screens, at different PHQ-9 cut-off values for different clinical settings using the knowledge translation tool atwww.depressionscreening100.com/phq.Study registrationPROSPERO CRD42014010673.

In 2020, the coronavirus disease 2019 (COVID-19) pandemic limited musculoskeletal care to urgent or “nonelective” office visits and procedures. No guidelines exist to inform patients or physicians what meets these criteria. The purpose of this multi-institutional study was to describe the differences in perceptions of urgency for musculoskeletal complaints between patients and providers during the COVID-19 pandemic. An anonymous survey was distributed to patients who visited the authors' orthopedic clinics in January and February 2020 and practicing orthopedic surgeons. The surveys were administered in May 2020 after COVID-19 was officially labeled a pandemic and included questions regarding demographic information and perceptions of orthopedic urgency. A total of 1491 patients and 128 physicians completed the surveys. A significantly higher percentage of physicians considered the following diagnoses an appropriate indication for an urgent visit compared with patients: fracture ( P P P P P P P P P P P =1.00), joint/extremity deformity without pain ( P =.113), and loss of range of motion of a joint ( P =.467). Younger patients and those with higher levels of education were significantly more likely to consider their conditions urgent. Patients may require additional education to prevent delay in treatment of urgent conditions—especially time-sensitive conditions such as neurologic compromise, tumors, and infections—when access to physicians is limited. [ Orthopedics . 2021;44(4):e534–e538.]

PURPOSE OF REVIEW: Reverse total shoulder arthroplasty (RTSA) is a procedure that has been increasingly utilized since its inception over 20 years ago. The purpose of this review is to present the most up to date practice and advances to the RTSA literature from the last 5 years. RECENT FINDINGS: Recent literature on RTSA has focused on identifying complications, maximizing outcomes, and determining its cost-effectiveness. RTSA has become a valuable tool in the treatment of various shoulder pathologies from fractures to massive-irreparable rotator cuff tears. Maximizing outcomes, proper patient counseling, and limiting complications are vital to a successful procedure. SUMMARY: RTSA can be a difficult procedure; however, when utilized appropriately, it can be an invaluable tool in the orthopedic surgeon’s armament. Recent evidence suggests, more and more, that RTSA not only provides value to the patient, but it is also cost-effective.

Despite the first successful applications of nonviral delivery vectors for small interfering RNA in the treatment of illnesses, such as the respiratory syncytial virus infection, the preparation of a clinically suitable, safe, and efficient delivery system still remains a challenge. In this study, we tackle the drawbacks of the existing systems by a combined experimental-computational in-depth investigation of the influence of the polymer architecture over the binding and transfection efficiency. For that purpose, a library of diblock copolymers with a molar mass of 30 kDa and a narrow dispersity (Đ1.12) was synthesized. We studied in detail the impact of an altered block size and/or composition of cationic diblock copolymers on the viability of each respective structure as a delivery agent for polynucleotides. The experimental investigation was further complemented by a computational study employing molecular simulations as well as an analytical description of systemic properties. This is the first report in which molecular dynamics simulations of RNA/cationic polymer complexes have been performed. Specifically, we developed and employed a coarse-grained model of the system at the molecular level to study the interactions between polymer chains and small interfering RNA. We were further able to confirm a threshold length

Context Although in recent times more research has been done on interactions of metallic dental objects in magnetic resonance imaging (MRI), radiologists are often uncertain whether the objects should be removed or can be retained prior to an impending examination. On the one hand, they want to avoid unnecessary material removal which is associated with costs and potential damage of the dental object. On the other hand, they fear material-induced susceptibility artefacts will impair the diagnostic workup so that examinations will have to be repeated. The lack of information complicates adequate decision making for radiologists. Aim The aim of this survey was to evaluate the information that is currently available to radiologists regarding orthodontic appliances of the head and neck region in the MRI and determine how to handle these situations in a radiologist's every day routine. Therefore, this study can reveal the need for further research. Materials and methods The questionnaire was published in the 9/2017 issue of the journal Der Radiologe and sent as an electronic version by the BDR (Professional Association of German Radiologists) to their approximately 1800 members. In addition, the radiological institutes of 55 German university and maximum care clinics were contacted. Results In all, 74 evaluable responses were received within a period of 16 weeks, representing a response rate of 3.7%. Altogether, the participants rate the risks of a detachment or heating of orthodontic appliances as too high. The interviewed radiologists categorize the available data as insufficient and they almost unanimously (97.3%) demand a declaration requirement for the manufacturers. There is a clear need for further education (78.3%). Intraoral measurement of the magnetic permeability is considered as a useful tool to determine possible interactions with the MRI by 40.5%.

Es wurde die Gegenfeldfestigkeit hoch koerzitiver Dentalmagnete in der 1,5- und 3‑T-Magnetresonantomographie (MRT) untersucht und gepruft, ob dadurch geschadigte Magnete durch Remagnetisieren in den alten Zustand versetzbar sind. Es wurden in einer justierbaren Halterung je 20 SmCo-Magnete in sechs simulierten Positionen der zahnarztlichen Prothetik/Epithetik exponiert: P : im Unterkiefer, parallel zum Hauptfeld B0, A: im Oberkiefer, antiparallel zu B0, Ad: antiparallel mit um 45° rekliniertem Kopf, Av: antiparallel um 45° inkliniert, G: Glabella, 90° zu B0, M: Mastoid, 90° zu B0. Im Ausenfeld vor dem Portal wurden die parallele (Pex), antiparallele (Aex), Glabella (Gex) und Mastoid (Mex) -Positionen erneut gepruft. Nach jeder Exposition wurden die Magnete remagnetisiert. Als Aquivalent der Magnetkraft wurde die relative Anderung der Flussdichte bestimmt. Bei 1,5 T kam es nur in den abgewinkelten Positionen Ad und Av und in der Ausenposition Aex zu klinisch relevanten Verlusten der Flussdichte zwischen 7 % und 10 %. Das starke Gegenfeld von 3 T erzeugte bei den antiparallelen Positionen A und Aex mit 72 % und 33 % sehr hohe Verluste. In den antiparallel inklinierten und reklinierten Positionen Ad und Av wurden die Magnete durch den Verlust von 96 % ihrer ursprunglichen Flussdichte nahezu entmagnetisiert. Unabhangig von ihrer Schadigung liesen sich alle Magnete anschliesend wieder vollstandig aufmagnetisieren. Sofern die induzierten Artefakte diagnostisch irrelevant sind, konnen hoher koerzitive SmCo-Magnete bei 1,5 T in situ bleiben. Im antiparallel wirkenden 3‑T-Hauptfeld kann ihre Haftkraft komplett verloren gehen. Dann sollten sie vom Hersteller remagnetisiert werden. Die In- oder Reklination des Kopfes verstarkt den Einfluss des Hauptfeldes.

Background:Failure of repair of large and massive rotator cuff tears is a challenging problem within orthopaedics. Poor tendon tissue and vascularity are known causes for failure of rotator cuff repairs.Purpose:To assess the safety, outcomes, and healing rates when large and massive rotator cuff repairs are augmented with a bioinductive collagen scaffold patch in a proof-of-principle design.Study Design:Case series; Level of evidence, 4.Methods:Twenty-three patients undergoing repair of full-thickness large (2-tendon) or massive (3-tendon) rotator cuff tears augmented with a bioinductive collagen patch were enrolled in a prospective single-arm proof-of-principle study. No partial repairs were performed, and a complete rotator cuff repair was successfully achieved in each case. Sixteen patients underwent revision rotator cuff repairs versus 7 primary repairs. Safety was determined by any implant-related adverse event. A single magnetic resonance imaging (MRI) scan was utilized to confirm tendon healing and thickness at a minimum of 6 months postoperatively. Postoperative ultrasound (US) was used in office by the treating surgeon to assess tendon thickness at 3-, 6-, 12-, and 24-month intervals. American Shoulder and Elbow Surgeons (ASES) scores were collected at final follow-up.Results:Overall, a 96% (22 of 23) healing rate was confirmed on US and MRI. However, incidence of treatment clinical failure was 9% (2 of 23), as 1 patient’s tendon healed but eventually underwent additional surgery. There were no adverse events attributed to the implant reported. Final US rotator cuff thickness was 7.28 ± 0.85 mm (mean ± SD), and final MRI rotator cuff thickness was 5.13 ± 1.06 mm. The mean ASES score at final follow-up was 82.87 ± 16.68 (range, 53.33-100).Conclusion:No complications attributed to the implant were reported, and new tendon formation was apparent on US and MRI, with relatively high healing rates at 2-year follow-up. Arthroscopic application of this bioinductive collagen scaffold when combined with rotator cuff repair is a safe and effective treatment for healing of large and massive rotator cuff repairs.

Elbow arthroscopy can be a challenge, however, indications and benefits compared to open elbow surgery are rapidly evolving. The elbow has seemed to lag behind other joints including the knee, shoulder, ankle and the hip, both in number of cases and in widespread acceptance, as a joint amenable to arthroscopic management. This has occurred despite literature demonstrating successful utilization of arthroscopy in the management of a variety of injuries. The purpose of this review is to clarify and expand the indications for arthroscopy of the elbow in 2021. We will also offer tips and tricks to help make elbow arthroscopy more successful. Since originally publishing these guidelines in 2007, elbow arthroscopy has evolved, although the principles and progressions remain the same.

Heterogeneous multi-robot systems are advantageous for operations in unknown environments because functionally specialised robots can gather environmental information, while others perform tasks. We define this decomposition as the scout-task robot architecture and show how it avoids the need to explicitly balance exploration and exploitation~by permitting the system to do both simultaneously. The challenge is to guide exploration in a way that improves overall performance for time-limited tasks. We derive a novel upper confidence bound for simultaneous exploration and exploitation based on mutual information and present a general solution for scout-task coordination using decentralised Monte Carlo tree search. We evaluate the performance of our algorithms in a multi-drone surveillance scenario in which scout robots are equipped with low-resolution, long-range sensors and task robots capture detailed information using short-range sensors. The results address a new class of coordination problem for heterogeneous teams that has many practical applications., Comment: 7 pages, 5 figures. To appear in IEEE ICRA 2021

PURPOSE The purpose of this study was to quantify and compare the biomechanical properties and change in graft size when adding the sartorius tendon as a fifth strand to a four-strand ST-G hamstring autograft. Additionally, the sartorius tendon was tested individually to quantify its independent biomechanical properties. METHODS Four-strand and five-strand hamstring tendon grafts were harvested from matched cadaveric knees (mean age, 81.6 ± 9.8). These matched grafts were biomechanically tested using a MTS servohydraulic test system at a rate of testing representative of physiologic tears. The mean diameter, cross-sectional area, and ultimate load to failure were quantified and compared with a one-sided, paired Student's t-test. A p < 0.05 was considered statistically significant. RESULTS The mean diameter of the five-strand graft was significantly larger than the four-strand graft (9.30 ± 0.84 mm vs. 8.10 ± 0.42 mm, p = 0.002). The average ultimate load to failure of the five-strand graft was 65.3% higher than the four-strand graft (2984.05 ± 1085.11 N vs. 1805.03 ± 557.69 N, p = 0.009) and added 14.8% to the diameter of the four strand ST-G autograft. CONCLUSIONS The addition of the sartorius tendon to a four-strand hamstring autograft significantly increased ultimate load to failure by 65%, graft cross-sectional area by 32%, and graft diameter by 15% compared to a traditional four-strand ST-G autograft. This information can be helpful to surgeons who wish to improve the strength of a four-strand ST-G autograft and for undersized grafts as an alternative to allograft supplementation. CLINICAL RELEVANCE The addition of the sartorius to the four-strand ST-G hamstring autograft significantly increases the ultimate load to failure and overall graft diameter, which can be particularly helpful in undersized autografts as an alternative to allograft supplementation.

As the incidence of retears after a rotator cuff repair remain high, a comprehensive treatment and rehabilitation protocol must be chosen depending on the circumstances of the injury. When choosing between an operative versus a nonoperative approach, surgeons must consider multiple factors including patient presentation and goals of the patient. Rotator cuff revision surgery should be explored in younger and active patients presenting with a traumatic tear. Whereas, in older patients, a nonoperative rehabilitation approach might be indicated, especially for atraumatic failed rotator cuff repairs. However, the surgeon must raise patients’ awareness that an operative approach has an increased risk of retear or that a nonoperative approach requires compliance with a long-term rehabilitation program. To this, nonoperative rehabilitation has been moderately successful in the treatment of initial rotator cuff ruptures, thus, might be translated in the rehabilitation of rotator cuff retears. The goals of rehabilitation are pain relief, improved shoulder range of motion, strengthening of rotator cuff, deltoid and periscapular musculature.

The ability to decide if a solution to a pose-graph problem is globally optimal is of high significance for safety-critical applications. Converging to a local-minimum may result in severe estimation errors along the estimated trajectory. In this paper, we propose a graph neural network based on a novel implementation of a graph convolutional-like layer, called PoseConv, to perform classification of pose-graphs as optimal or sub-optimal. The operation of PoseConv required incorporating a new node feature, referred to as cost, to hold the information that the nodes will communicate. A training and testing dataset was generated based on publicly available bench-marking pose-graphs. The neural classifier is then trained and extensively tested on several subsets of the pose-graph samples in the dataset. Testing results have proven the model’s capability to perform classification with 92 – 98% accuracy, for the different partitions of the training and testing dataset. In addition, the model was able to generalize to previously unseen variants of pose-graphs in the training dataset. Our method trades a small amount of accuracy for a large improvement in processing time. This makes it faster than other existing methods by up-to three orders of magnitude, which could be of paramount importance when using computationally-limited robots overseen by human operators.

Preparation of the tissue is as important, if not more important, than the repair technique itself in the setting of failed or revision rotator cuff repair. Tissue preparation including thorough debridement of adhesions, removal of old sutures and anchors, and various tissue releases allows for adequate mobilization of the rotator cuff muscle and tendon, ultimately allowing an easier repair for the surgeon. These techniques also allow for less tension on the repaired tendon which increases the chances of a successful repair. While tissue preparation adds time to the rotator cuff procedure, it is an important step to maximize outcomes.

A stable shoulder requires significant coordination and muscle balance to effectively position the upper extremity in space. Treating an unstable shoulder creates a considerable challenge as both static and dynamic stabilizers must be restored. Much time and effort has been focused on understanding the anatomy of the shoulder and the biomechanical failures that take place in glenohumeral instability. The bony anatomy, glenohumeral ligaments, and capsule have been identified as static restraints to instability while the periscapular musculature and rotator cuff provide dynamic stability. Biomechanical studies on these anatomic structures had helped develop treatment strategies for restoring stability to the unstable shoulder in a variety of pathologic states. This chapter provides an in-depth understanding of normal shoulder anatomy, reviews the pathophysiology of different types of instability, and discusses various treatment options and their biomechanical basis.

Despite technical advancements and rising numbers of rotator cuff repair (RCR) procedures, the rate of failure and re-tearing remains a significant issue. An effort to augment the repair with various types of patches or implants has made its way into practice in an attempt to increase successful outcomes. The goal of augmentation is to decrease the incidence of re-tearing of the repair and necessary revisions. Augmentation of the RCR is one method by which surgeons are trying to improve the quality and durability of the repaired rotator cuff.

Subscapularis failure and insufficiency after prior repair surgery represent a difficult problem. Although one option is revision to reverse shoulder prosthesis, in many cases of a young, active patient, other options should be considered. The problem of subscapularis failure after surgery becomes even more debilitating in the setting of a failed shoulder arthroplasty. Pectoralis major tendon transfer and latissimus dorsi tendon transfer remain a reasonable salvage option to address this difficult problem, with reliable improvements in pain, range of motion, and patient satisfaction and functional outcomes.

Since its invention by Dr. Paul Gramont, the reverse shoulder replacement has been a miracle for both the rotator cuff tear arthropathy patient with pseudoparalysis and the patient with a failed rotator cuff surgery. Results are generally quite good in restoring function and alleviating pain. This has led to an expansion of indications, which has unfortunately resulted in an increase in failures that require revision surgery. In this chapter, we will preview the more common causes of failure and discuss possible approaches to restore function.

Background:Medial ulnar collateral ligament (MUCL) repair has been proven to be effective in nonprofessional overhead-throwing athletes, with faster and higher rates of return to play (RTP) than the more traditional Tommy John reconstruction. Biomechanical studies and clinical data suggest that MUCL repair augmented with a collagen-coated internal brace may be an effective treatment option in this patient population.Purpose:To evaluate the functional outcomes of young nonprofessional athletes who underwent MUCL repair with internal brace augmentation for medial elbow instability. The hypothesis was that these patients will have high rates of RTP and improved functional outcomes.Study Design:Case series; Level of evidence, 4.Methods:Nonprofessional overhead athletes treated with MUCL repair with internal brace augmentation between 2015 and 2017 were prospectively evaluated for a minimum of 1 year. Preoperatively, all patients had evidence of medial elbow pain caused by MUCL insufficiency, as confirmed by signal changes on magnetic resonance imaging and valgus instability on arthroscopic examination. These findings did not allow them to participate in their chosen sport or profession, and each patient had failed nonoperative treatment. Postoperative outcomes were evaluated using the Overhead Athlete Shoulder and Elbow Score of the Kerlan-Jobe Orthopaedic Clinic. Complications were recorded and detailed.Results:A total of 40 nonprofessional overhead athletes were included in this study (35 men and 5 women; mean age, 17.8 years [range, 14-28 years]). The mean follow-up time was 23.8 months (range, 12-44 months). The mean postoperative Kerlan-Jobe Orthopaedic Clinic score was 92.6 (range, 64-100). Overall, 37 athletes (92.5%) returned to play or profession at the same level or higher at a mean time of 6.9 months (range, 2-12 months). Three patients did not RTP: 1 was limited by a concomitant medical diagnosis, and the other 2 chose not to resume athletics after the procedure but remained symptom free.Conclusion:In the nonprofessional athlete, primary MUCL repair with internal brace augmentation is a viable alternative to traditional repair techniques or reconstruction, allowing for a rapid RTP and promising functional outcomes.

Contains fulltext : 226464.pdf (Publisher’s version ) (Open Access) Evolutionary models show that human cooperation can arise through direct reciprocity relationships. However, it remains unclear which psychological mechanisms proximally motivate individuals to reciprocate. Recent evidence suggests that the psychological motives for choosing to reciprocate trust differ between individuals, which raises the question whether these differences have a stable distribution in a population or are rather an artifact of the experimental task. Here, we combine data from three independent trust game studies to find that the relative prevalence of different reciprocity motives is highly stable across participant samples. Furthermore, the distribution of motives is relatively unaffected by changes to the salient features of the experimental paradigm. Finally, the motive classification assigned by our computational modeling analysis corresponds to the participants' own subjective experience of their psychological decision process, and no existing models of social preference can account for the observed individual differences in reciprocity motives. These findings support the view that reciprocal decision-making is not just regulated by individual differences in 'pro-social’ versus 'pro-self' tendencies, but also by trait-like differences across several alternative pro-social motives, whose distribution in a population is stable. 13 p.

BACKGROUND Patients with a patient-reported penicillin allergy may be at greater risk for postoperative prosthetic joint infection (PJI) after total joint arthroplasty of the hip, knee, or shoulder. The increased risk of PJI in these patients has been attributed to these patients receiving a less-effective perioperative antibiotic. However, prior reports did not fully address the clinical characteristics of these unique patients, who may inherently be at greater risk of having a PJI, which may confound prior findings. QUESTIONS/PURPOSES After controlling for risk factors for PJI such as BMI, anxiety, depression, and other comorbidities, we asked: Are patients with a patient-reported penicillin allergy more likely to have a PJI after THA, TKA, or total shoulder arthroplasty than patients without such a reported allergy? METHODS We queried patient records from 2010 to 2017 from a nationwide administrative claims database of 122 million patients to adequately power an investigation comparing the 1-year incidence of PJI after TKA, total shoulder arthroplasty, and THA in patients with patient-reported penicillin allergy versus patients without a patient-reported penicillin allergy. Operative treatments for deep joint infection, identified by Current Procedural Terminology and ICD-9 and ICD-10 codes were used as a surrogate for PJI. Clinical characteristics such as age, sex, BMI, length of stay, and Charlson comorbidity index and specific comorbidities including alcohol abuse, anemia, anxiety, cardiac disease, diabetes, immunocompromised status, rheumatoid arthritis, depression, liver disease, chronic kidney disease, tobacco use, and peripheral vascular disease were queried for each study group. The odds of PJI within 1 year of THA, TKA, or total shoulder arthroplasty were compared using multiple logistic regression after adjusting for potential confounders. RESULTS After adjusting for potential confounding factors such as BMI, anxiety, depression and other comorbidities, we found that patient-reported penicillin allergy was independently associated with an increased odds of PJI after TKA (odds ratio 1.3 [95% confidence interval 1.1 to 1.4]; p < 0.01) and total shoulder arthroplasty (OR 3.9 [95% CI 2.7 to 5.4]; p < 0.01). However, patient-reported penicillin allergy was not independently associated with an increased odds of PJI after THA (OR 1.1 [95% CI 0.9 to 1.3]; p = 0.36) after controlling for the same risk factors. CONCLUSIONS In this study, we found that patients with patient-reported penicillin allergy were at an increased risk for PJI after TKA and total shoulder arthroplasty, which we suspect-but cannot prove-is likely a function of those patients receiving a second-line antibiotic for presurgical prophylaxis. Since prior research has found that many patients listed in medical records as having a penicillin allergy are in fact not allergic to penicillin, we suggest that surgeons consider preoperative allergy testing, such as using an intraoperative test dose, to aid in choosing the most appropriate antibiotic choice before knee or shoulder arthroplasty and to amend patient medical records based on testing results. Future studies should determine whether this additional diagnostic maneuver is cost-effective. LEVEL OF EVIDENCE Level III, therapeutic study.

This document provides details on the data and files generated from post-build X-ray computedtomography (XCT) measurements of the four parts built as part of the “Overhang Part X4” dataset. The “Overhang Part X4” dataset was a three-dimensional (3D) additive manufacturing (AM) build performed on the Additive Manufacturing Metrology Testbed (AMMT) by Ho Yeung and Brandon Lane on June 28, 2019. The files discussed in this document include image sequences for each part, stereolithography files (.STL) of the surface data extracted from XCT. This data is one of a set of “AMMT Process Monitoring Datasets”, as part of the Metrology for Real-Time Monitoring of Additive Manufacturing project at the National Institute of Standards and Technology (NIST). In-situ sensor data, part design, build command and scan strategy data, materials, and associated metadata for this build are described in Ref. [1]. Readers should refer to the AMMT datasets web page for updates.

Case A 58-year-old man presented with acute respiratory distress syndrome and coagulopathy secondary to COVID-19. He developed acute compartment syndrome (ACS) of the left hand. He underwent a bedside 10-compartment decompression of the hand with volar forearm and carpal tunnel release while in the ICU. This report adds to the scarce body of literature regarding orthopaedic complications related to COVID-19. Conclusion Coagulopathy secondary to COVID-19 can be a risk factor for the development of ACS. Frequent examinations of lines, restraints, and extremities are recommended. The COVID-19 pandemic presents unique challenges, necessitating clinical adjustments to best care for patients.

Purpose To establish an international expert consensus, using the modified Delphi technique, on the evaluation and management of glenohumeral instability with associated bone loss. Methods A working group of 6 individuals generated a list of statements related to history and physical examination, imaging and specialized diagnostic tests, bone loss quantification and classification, treatment outcomes and complications, and rehabilitation for the management of glenohumeral instability associated with bone loss to form the basis of an initial survey for rating by a group of experts. The expert group (composed of 22 high-volume glenohumeral instability experts) was surveyed on 3 occasions to establish a consensus on the statements. Items with over 70% agreement and less than 10% disagreement achieved consensus. Results After a total of 3 rounds, 31 statements achieved consensus. Eighty-six percent of the experts agreed that a history of multiple dislocations and failed soft-tissue surgery should raise suspicion about the possibility of an associated bone deficit. Ninety-five percent of the experts agreed that 3-dimensional (3D) computed tomography (CT) is the most accurate diagnostic method to evaluate and quantify bone loss. Eighty-six percent of the experts agreed that any of the available methods to measure glenoid bone deficiency is adequate; however, 91% of the experts thought that an en face view of the glenoid using 3D CT provides the most accurate method. Ninety-five percent of the experts agreed that Hill-Sachs lesions are poorly quantified and classified by current imaging systems. Ninety percent of the experts agreed that in cases with a glenoid bone deficit greater than 20%, glenoid bone graft reconstruction should be performed and any of the available options is valid. There was no consensus among experts on how Hill-Sachs injuries should be managed or on how postoperative rehabilitation should be carried out. Conclusions The essential statements on which the experts reached consensus included the following: A history of multiple dislocations and failed soft-tissue surgery should make surgeons consider the possibility of an associated bone deficit. Three-dimensional CT is the most accurate diagnostic method to evaluate and quantify bone loss. Although any of the available methods to measure glenoid bone deficiency is adequate, an en face view of the glenoid using 3D CT provides the most accurate method. Hill-Sachs lesions are poorly quantified and classified by current imaging systems. Finally, in cases with a glenoid bone deficit greater than 20%, glenoid bone graft reconstruction should be performed. Level of Evidence Level V, consensus statement.

Background: This study was undertaken to characterize the effects of upper eyelid blepharoplasty on blink dynamics and to evaluate the hypothesis that changes in blink dynamics following blepharoplasty are associated with postoperative dry eye. // Methods: The voluntary blink of 14 eyes of 7 patients with dermatochalasis undergoing upper eyelid blepharoplasty was recorded with a high-speed camera preoperatively and 6–8 months postoperatively, alongside a group of 11 controls. The images were analyzed for palpebral aperture, blink duration, and maximum velocity during opening and closing phases. Patients undergoing blepharoplasty were assessed for dry eye symptoms pre- and postoperatively at 6–8 months using the ocular surface disease index score. // Results: Despite intraoperative orbicularis oculi resection, there was no significant compromise of blink duration or maximum velocity of eyelid opening or closure post-blepharoplasty. Postoperatively, patients had an increase in palpebral aperture compared with both preoperatively (8.71 versus 7.85mm; P = 0.013) and control groups (8.71 versus 7.87mm; P = 0.04). Postoperatively at 6–8 months, there was an increase in dry eye symptoms in 6 of 7 patients compared with preoperatively (ocular surface disease index, 16.6 versus 12.5; P < 0.05). There was no positive correlation between the increase in palpebral aperture and the increase in dry eye symptoms (r = –0.4; P = 0.30). // Conclusions: Using modern videographic technology, this study demonstrates that upper eyelid blepharoplasty results in an increase in resting palpebral aperture but has no effect on dynamic blink parameters. Changes in palpebral aperture or blink dynamics are unlikely to be the cause of dry eye syndrome following blepharoplasty.

Triceps tendon ruptures (TTRs) are rare and often occur as a result of falling on an outstretched hand, forceful eccentric contraction, direct trauma to the elbow, or lifting against resistance. TTRs are most commonly seen in middle-aged men, football players, and weightlifters. Radiography, ultrasonography, and magnetic resonance imaging may be utilized for diagnosis and to guide treatment. Acute partial TTRs may have good outcomes with nonoperative management. Surgery should be considered if nonoperative treatment is unsuccessful or if substantial musculotendinous retraction is present. Surgical repair is strongly recommended for complete TTRs.

Medial ulnar collateral ligament (MUCL) insufficiency is becoming common in younger, nonprofessional athletes. In contrast to elite athletes who develop valgus extension overload syndrome and associated chronic pathologic changes in the MUCL, younger patients present with sprains and partial tears that can often be managed non-operatively with successful outcome and rapid return to play. In the younger throwing athlete with medial-sided elbow pain, a hinged elbow brace and rehabilitation of dysfunctional muscles often lead to successful recovery and return to play within 1-2 months. In more severe injuries, direct repair of the partial tear with or without added internal bracing supplementation allows restoration of stability with a return to play with 4 to 6 months.

Ulnar collateral ligament (UCL) injury is commonly seen in overhead throwing athletes resulting from the repetitive valgus stress placed on the medial elbow. UCL injuries (attenuation, insufficiency, or rupture) can result in medial elbow pain, a loss of pitch velocity and accuracy, and increased fatigue. Diagnosis can be made by performing a thorough physical examination along with imaging if indicated, such as ultrasound or magnetic resonance imaging. Treatment options include nonoperative in recreational athletes or those whose primary positions in sport are not high-volume throwing, such as position players in baseball. If nonoperative treatment fails, or the patient has potential for future high-level overhead activity such as a baseball pitcher, surgical repair or reconstruction may be indicated. This article describes our surgical technique for UCL repair in pediatric baseball pitchers.

The novel coronavirus pandemic, also known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has placed an immense strain on healthcare systems across the entire world. Consequently, multiple federal and state governments have placed restrictions on hospitals such as limiting "elective surgery" and recommending social or physical distancing. We review the literature on several areas that have been affected including surgical selection, inpatient care, and physician well-being. These areas affecting inpatient paradigms include surgical priority, physical or social distancing, file sharing for online clinical communications, and physician wellness. During this crisis, it is important that orthopaedic departments place an emphasis on personnel safety and slowing the spread of the virus so that the department can still maintain vital functions. Physical distancing and emerging technologies such as inpatient telemedicine and online file sharing applications can enable orthopaedic programs to still function while attempting to protect medical staff and patients from the novel coronavirus spread. This literature review sought to provide evidence-based guidance to orthopaedic departments during an unprecedented time. Orthopaedic surgeons should follow the Centers for Disease Control and Prevention guidelines, wear personal protective equipment (PPE) when appropriate, have teams created using physical distancing, understand the department's policy on elective surgery, and engage in routines which enhance physician wellness.

Splenomegaly measured by spleen length has been an imaging evidence for cirrhosis. However, data remains lacking on the value of other US findings for diagnosing cirrhosis. This study evaluated the value of spleen two-dimensional measurements (2D, i.e., length × thickness) in diagnosing cirrhosis by comparing with other US parameters. A retrospective study on 297 cohort 1 patients with clinical/imaging diagnosis of cirrhosis was conducted. Spleen length and thickness were measured via US imaging and compared with other US parameters using statistical analysis to assess their value in diagnosing cirrhosis. A separate 161 cohort 2 patients with histological fibrosis staging was used to validate the findings from the cohort 1. Using 297 cohort 1 patients, US findings of spleen length > 12 cm (50.6% vs. 9.6%, p 4 cm (78.2% vs. 21%, p 46 cm2 (81.6% vs. 15.3%, p 46 cm2 (95% CI 7.9–92.8, p 46 cm2 carried the best sensitivity and specificity (93.5% and 95.3%) and was the only US parameter independently associated with histological stage 3–4 fibrosis, i.e., cirrhosis (95% CI 3.1–87, p = 0.006). Using both testing and validation cohorts, we demonstrated that spleen 2D > 46 cm2 carries 93.5% sensitivity and 95.3% specificity and is superior to other US parameters in diagnosing cirrhosis.

Background Studies investigating the association between direct-acting antivirals (DAAs) and the recurrence of hepatocellular carcinoma (HCC) related to hepatitis C (HCV) have yielded conflicting results. The objective of this meta-analysis was to define the short- and long-term recurrence rates of HCC after DAA treatment. Methods A search of multiple databases was performed, including Scopus, Cochrane, MEDLINE/PubMed and abstracts from gastroenterology meetings. Only studies reporting the recurrence of HCC in patients receiving DAA treatment, compared to HCV controls without DAA treatment, were evaluated. A meta-analysis was completed using the Mantel-Haenszel model. Results A comprehensive literature search resulted in 32 abstracts and papers. Six papers met our inclusion criteria and were included in the analysis. Follow up ranged from 1.25-4 years. Analysis of these 6 studies found a >60% lower risk of HCC recurrence in patients exposed to DAA compared to controls (odds ratio [OR] 0.36, 95% confidence interval [CI] 0.27-0.47; P

Upper extremity (UE) stress fractures are less common than lower extremity stress fractures and account for 2.8% of all stress fractures among high school athletes (Changstrom et al. Am J Sports Med 43:26–33, 2015). Early diagnosis hinges on understanding the etiology and having an index of suspicion. Repetitive stress and loading of upper extremity bones at the point of muscular attachments can lead to stress fractures (Crasto JA, Jain S, Jones GL. Upper extremity stress fractures. In: Stress Fractures in Athletes: Diagnosis and Management: Springer International Publishing; 2015. p. 205–22). Stress fractures can often be missed on X-ray radiographs initially (Greaney et al. Radiology [Internet] 146:339–46, 1983; Nielsen et al. Acta Orthop Scand [Internet] 62:531–4, 1991). Radionuclide scanning has been shown to be extremely sensitive in detecting early-stage osseous stress injury. Most upper extremity stress fractures can be managed non-operatively with rest and activity modification when diagnosed early in the process, with a rapid return to sport. A specific sport-related rehabilitation program targeting correct technique use may also help the athlete recover from this injury and help prevent future injuries. More chronic injuries may require surgical intervention to achieve a satisfactory outcome.