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Background: Alcohol and obesity synergise to increase the risk of liver-related mortality. We examined the influence of adiposity on clinical outcomes in alcoholic hepatitis (AH) and the underlying inflammatory crosstalk between adipose tissue (AT) and the liver. Methods: A cohort of patients with AH from the UK and USA provided data to analyse the effects of obesity in AH. Body mass index was corrected for the severity of ascites, termed cBMI. Inflammatory and metabolic profiling was undertaken by proteome analysis of human serum samples. The effect of alcohol on adipose tissue and CXCL11 expression was studied in 3T3-derived adipocytes and in mice using the high-fat diet-plus-binge ethanol model. Findings: Obesity was common amongst patients with AH, seen in 19% of individuals. cBMI correlated with volume AT (r2= 0.623, p

Purpose To determine which patient and injury factors are associated with the detection of high-grade laxity on examination under anesthesia before anterior cruciate ligament (ACL) reconstruction. Methods We identified 2,318 patients who underwent primary ACL reconstruction without associated ligament injuries. Demographic data and information regarding meniscal tears were collected. Patients with high-grade Lachman (difference from contralateral side >10 mm), pivot-shift (International Knee Documentation Committee grade 3+), or anterior drawer (difference from contralateral side >10 mm) tests were identified by physical examination under anesthesia before ACL reconstruction. Logistic regression modeling was used to evaluate whether chronicity of the ACL injury, patient age, sex, body mass index, generalized ligamentous laxity, and presence of meniscal tears were associated with increased odds of high-grade laxity, while we controlled for examining surgeon. Results Patients with chronic tears (>6 months from injury) had greater than twice the odds of having high-grade Lachman, pivot-shift, and anterior drawer tests (all P P P P = .013) meniscus tears were associated with increased odds of a high-grade Lachman test. Age younger than 20 years (OR, 1.34; P = .023), female sex (OR, 1.49; P = .001), generalized ligamentous laxity (OR, 3.46; P P P = .041) meniscus tear were associated with increased odds of a high-grade pivot-shift test. Generalized ligamentous laxity (OR, 2.27; P P = .001) or lateral (OR, 1.50; P = .010) meniscus tear were associated with increased odds of a high-grade anterior drawer test. Conclusions Chronic ACL tears, generalized ligamentous laxity, and meniscus tears are associated with increased odds of high-grade laxity with all 3 tests. Female patients and age younger than 20 years are associated with increased odds of a high-grade pivot-shift test. Level of Evidence Level II, lesser-quality prospective study.

Background:Revision anterior cruciate ligament (ACL) reconstruction has been documented to have worse outcomes compared with primary ACL reconstructions.Purpose/Hypothesis:The purpose of this study was to determine if the prevalence, location, and/or degree of meniscal and chondral damage noted at the time of revision ACL reconstruction predicts activity level, sports function, and osteoarthritis symptoms at 2-year follow-up. The hypothesis was that meniscal loss and high-grade chondral damage noted at the time of revision ACL reconstruction will result in lower activity levels, decreased sports participation, more pain, more stiffness, and more functional limitation at 2 years after revision surgery.Study Design:Cohort study; Level of evidence, 2.Methods:Between 2006 and 2011, a total of 1205 patients who underwent revision ACL reconstruction by 83 surgeons at 52 hospitals were accumulated for study of the relationship of meniscal and articular cartilage damage to outcome. Baseline demographic and intraoperative data, including the International Knee Documentation Committee (IKDC) subjective knee evaluation, Knee injury and Osteoarthritis Outcome Score (KOOS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Marx activity score, were collected initially and at 2-year follow-up to test the hypothesis. Regression analysis was used to control for age, sex, body mass index, smoking status, activity level, baseline outcome scores, revision number, time since last ACL reconstruction, incidence of having a previous ACL reconstruction on the contralateral knee, previous and current meniscal and articular cartilage injury, graft choice, and surgeon years of experience to assess the meniscal and articular cartilage risk factors for clinical outcomes 2 years after revision ACL reconstruction.Results:At 2-year follow-up, 82% (989/1205) of the patients returned their questionnaires. It was found that previous meniscal injury and current articular cartilage damage were associated with the poorest outcomes, with prior lateral meniscectomy and current grade 3 to 4 trochlear articular cartilage changes having the worst outcome scores. Activity levels at 2 years were not affected by meniscal or articular cartilage pathologic changes.Conclusion:Prior lateral meniscectomy and current grade 3 to 4 changes of the trochlea were associated with worse outcomes in terms of decreased sports participation, more pain, more stiffness, and more functional limitation at 2 years after revision surgery, but they had no effect on activity levels.Registration:NCT00625885

Hepatitis C virus (HCV) entry inhibitors have been hypothesized to prevent infection of the liver after transplantation. ITX5061 is a scavenger receptor class B type I antagonist that blocks HCV entry and infection in vitro. We assessed the safety and efficacy of ITX5061 to limit HCV infection of the graft. The study included 23 HCV-infected patients undergoing liver transplantation. The first 13 "control" patients did not receive drug. The subsequent 10 patients received 150 mg of ITX5061 immediately before and after transplant and daily for 1 week thereafter. ITX5061 pharmacokinetics and plasma HCV RNA were quantified. Viral genetic diversity was measured by ultradeep pyrosequencing (UDPS). ITX5061 was well tolerated with measurable plasma concentrations during therapy. Although the median HCV RNA reduction was greater in ITX-treated patients at all time points in the first week after transplantation, there was no difference in the overall change in the area over the HCV RNA curve in the 7-day treatment period. However, in genotype (GT) 1-infected patients, treatment was associated with a sustained reduction in HCV RNA levels compared to the control group (area over the HCV RNA curve analysis, P = 0.004). UDPS revealed a complex and evolving pattern of HCV variants infecting the graft during the first week. ITX5061 significantly limited viral evolution where the median divergence between day 0 and day 7 was 3.5% in the control group compared to 0.1% in the treated group. In conclusion, ITX5061 reduces plasma HCV RNA after transplant notably in GT 1-infected patients and slows viral evolution. Following liver transplantation, the likely contribution of extrahepatic reservoirs of HCV necessitates combining entry inhibitors such as ITX5061 with inhibitors of replication in future studies.

Background:Knee laxity in the setting of anterior cruciate ligament (ACL) injury is often assessed through physical examination using the Lachman, pivot shift, and anterior drawer tests. The degree of laxity noted on these examinations may influence treatment decisions and prognosis.Hypothesis:Increased preoperative knee laxity is associated with increased risk of revision ACL reconstruction, increased risk of contralateral ACL reconstruction, and poorer patient-reported outcomes at 6 years postoperatively.Study Design:Cohort study; Level of evidence, 2.Methods:2333 patients who underwent primary isolated ACL reconstruction without additional ligament injury were identified. Patients reported by the operating surgeons to have an International Knee Documentation Committee (IKDC) grade D Lachman, anterior drawer, or pivot shift examination were classified as having a high-grade laxity. Multiple logistic regression models were used to evaluate whether having high-grade preoperative laxity was predictive of increased odds of undergoing subsequent revision or contralateral ACL reconstruction within 6 years of the index procedure, controlling for patient age, sex, body mass index, Marx activity level, sport, graft type, medial meniscal treatment, and lateral meniscal treatment. Multiple linear regression modeling was used to evaluate whether having high-grade preoperative laxity was predictive of poorer IKDC or Knee injury and Osteoarthritis Outcome Score Knee-Related Quality of Life (KOOS-QOL) scores at 6 years postoperatively, after controlling for baseline score, patient age, ethnicity, sex, body mass index, marital status, smoking status, sport participation, competition level, Marx activity rating score, graft type, and articular cartilage and meniscal status.Results:In total, 743 of 2325 patients (32.0%) were noted to have high-grade laxity on at least 1 physical examination test. High-grade Lachman was noted in 334 patients (14.4%), high-grade pivot shift was noted in 617 patients (26.5%), and high-grade anterior drawer was noted in 233 patients (10.0%). Six-year revision and contralateral ACL reconstruction data were available for 2129 patients (91.6%). High-grade prereconstruction Lachman was associated with significantly increased odds of ACL graft revision (odds ratio [OR], 1.76; 95% CI, 1.10-2.80, P = .02) and contralateral ACL reconstruction (OR, 1.68; 95% CI, 1.09-2.69; P = .019). High-grade prereconstruction pivot shift was associated with significantly increased odds of ACL graft revision (OR, 1.75; 95% CI, 1.19-2.54, P = .002) but not with significantly increased odds of contralateral ACL reconstruction (OR, 1.30; 95% CI, 0.89-1.87; P = .16). High-grade prereconstruction laxity was associated with statistically significantly lower 6-year IKDC (β = −2.26, P = .003), KOOS-QOL (β = −2.67, P = .015), and Marx activity scores (β = −0.54, P = .020), but these differences did not approach clinically relevant differences in patient-reported outcomes.Conclusion:High-grade preoperative knee laxity is predictive of increased odds of revision ACL reconstruction and contralateral ACL reconstruction 6 years after ACL reconstruction. Poorer patient-reported outcome scores in the high-grade laxity group were also noted, but the difference did not reach a level of clinical relevance.

Purpose To evaluate differences in repair and nonoperatively managed grade III medial collateral ligament (MCL) injuries during anterior cruciate ligament (ACL) reconstruction. Methods Patients enrolled in a multicenter prospective longitudinal group who underwent unilateral primary ACL reconstruction between 2002 and 2008 were evaluated. Patients with concomitant grade III MCL injuries treated either operatively or nonoperatively were identified. Concurrent injuries, subsequent surgeries, surgical chronicity, and MCL tear location were analyzed. Patient-reported outcomes were measured at time of ACL reconstruction and 2-year follow-up. Results Initially, 3,028 patients were identified to have undergone primary ACL reconstruction during the time frame; 2,586 patients completed 2-year follow-up (85%). Grade III MCL tears were documented in 1.1% (27 of 2,586): 16 operatively managed patients and 11 nonoperatively treated MCLs during ACL reconstruction. The baseline Knee Injury and Osteoarthritis Outcome Score (KOOS) and International Knee Documentation Committee scores were lower in patients who underwent operative MCL treatment. Reoperation rates for arthrofibrosis were 19% after repair and 9% after conservative management (P = .48). At 2 years, both groups significantly improved; however, the nonoperative MCL group maintained superior patient-reported outcomes in terms of minimal clinically important differences, but these differences did not reach statistical significance (KOOS sports/recreation [88.2 vs 74.4, P = .10], KOOS knee-related quality of life [81.3 vs 68.4, P = .13], and International Knee Documentation Committee [87.6 vs 76.0, P = .14]). Tibial-sided MCL injuries were associated with clinically inferior baseline scores compared with femoral-sided MCL (KOOS knee-related quality of life, 34.4 vs 18.5, P = .09), but these differences resolved by 2 years. Surgical chronicity did not influence 2-year outcome. Conclusions Both operative and nonoperative management of MCL tears in our patient group demonstrated clinical improvements between study enrollment and 2-year follow-up. MCL surgery during ACL reconstruction was assigned to patients with worse symptoms at enrollment and was associated with worse outcomes at 2 years. A subset of patients with severe combined ACL and medial knee injuries may benefit from operative management; however, that population has yet to be defined. Level of Evidence Level III, retrospective cohort.

Background: The occurrence of physiologic knee hyperextension (HE) in the revision anterior cruciate ligament reconstruction (ACLR) population and its effect on outcomes have yet to be reported. Hypothesis/Purpose: The prevalence of knee HE in revision ACLR and its effect on 2-year outcome were studied with the hypothesis that preoperative physiologic knee HE ≥5° is a risk factor for anterior cruciate ligament (ACL) graft rupture. Study Design: Cohort study; Level of evidence, 2. Methods: Patients undergoing revision ACLR were identified and prospectively enrolled between 2006 and 2011. Study inclusion criteria were patients undergoing single-bundle graft reconstructions. Patients were followed up at 2 years and asked to complete an identical set of outcome instruments (International Knee Documentation Committee, Knee injury and Osteoarthritis Outcome Score, WOMAC, and Marx Activity Rating Scale) as well as provide information regarding revision ACL graft failure. A regression model with graft failure as the dependent variable included age, sex, graft type at the time of the revision ACL surgery, and physiologic preoperative passive HE ≥5° (yes/no) to assess these as potential risk factors for clinical outcomes 2 years after revision ACLR. Results: Analyses included 1145 patients, for whom 2-year follow-up was attained for 91%. The median age was 26 years, with age being a continuous variable. Those below the median were grouped as “younger” and those above as “older” (age: interquartile range = 20, 35 years), and 42% of patients were female. There were 50% autografts, 48% allografts, and 2% that had a combination of autograft plus allograft. Passive knee HE ≥5° was present in 374 (33%) patients in the revision cohort, with 52% being female. Graft rupture at 2-year follow-up occurred in 34 cases in the entire cohort, of which 12 were in the HE ≥5° group (3.2% failure rate) and 22 in the non-HE group (2.9% failure rate). The median age of patients who failed was 19 years, as opposed to 26 years for those with intact grafts. Three variables in the regression model were significant predictors of graft failure: younger age (odds ratio [OR] = 3.6; 95% CI, 1.6-7.9; P = .002), use of allograft (OR = 3.3; 95% CI, 1.5-7.4; P = .003), and HE ≥5° (OR = 2.12; 95% CI, 1.1-4.7; P = .03). Conclusion: This study revealed that preoperative physiologic passive knee HE ≥5° is present in one-third of patients who undergo revision ACLR. HE ≥5° was an independent significant predictor of graft failure after revision ACLR with a >2-fold OR of subsequent graft rupture in revision ACL surgery. Registration: NCT00625885 ( ClinicalTrials.gov identifier).

Background: The long-term prognosis and risk factors for quality of life and disability after anterior cruciate ligament (ACL) reconstruction remain unknown. Hypothesis/Purpose: Our objective was to identify patient-reported outcomes and patient-specific risk factors from a large prospective cohort at a minimum 10-year follow-up after ACL reconstruction. We hypothesized that meniscus and articular cartilage injuries, revision ACL reconstruction, subsequent knee surgery, and certain demographic characteristics would be significant risk factors for inferior outcomes at 10 years. Study Design: Therapeutic study; Level of evidence, 2. Methods: Unilateral ACL reconstruction procedures were identified and prospectively enrolled between 2002 and 2004 from 7 sites in the Multicenter Orthopaedic Outcomes Network (MOON). Patients preoperatively completed a series of validated outcome instruments, including the International Knee Documentation Committee (IKDC), Knee injury and Osteoarthritis Outcome Score (KOOS), and Marx activity rating scale. At the time of surgery, physicians documented all intra-articular abnormalities, treatment, and surgical techniques utilized. Patients were followed at 2, 6, and 10 years postoperatively and asked to complete the same outcome instruments that they completed at baseline. The incidence and details of any subsequent knee surgeries were also obtained. Multivariable regression analysis was used to identify significant predictors of the outcome. Results: A total of 1592 patients were enrolled (57% male; median age, 24 years). Ten-year follow-up was obtained on 83% (n = 1320) of the cohort. Both IKDC and KOOS scores significantly improved at 2 years and were maintained at 6 and 10 years. Conversely, Marx scores dropped markedly over time, from a median score of 12 points at baseline to 9 points at 2 years, 7 points at 6 years, and 6 points at 10 years. The patient-specific risk factors for inferior 10-year outcomes were lower baseline scores; higher body mass index; being a smoker at baseline; having a medial or lateral meniscus procedure performed before index ACL reconstruction; undergoing revision ACL reconstruction; undergoing lateral meniscectomy; grade 3 to 4 articular cartilage lesions in the medial, lateral, or patellofemoral compartments; and undergoing any subsequent ipsilateral knee surgery after index ACL reconstruction. Conclusion: Patients were able to perform sports-related functions and maintain a relatively high knee-related quality of life 10 years after ACL reconstruction, although activity levels significantly declined over time. Multivariable analysis identified several key modifiable risk factors that significantly influence the outcome.

Purpose/Background We aimed to describe changes in survival in alcoholic hepatitis (AH) over time by examining published data. Methods A systematic literature search of Ovid Embase and PubMed was undertaken using the MESH terms ‘hepatitis, alcoholic’ to identify randomised controlled trials (RCT) and observational studies (OS) in alcoholic hepatitis. Data were extracted from included studies regarding 28-day, 90-day, 180-day mortality, as well as biochemical and clinical data. Results After review of the literature search results, 77 studies published between 1971 and 2016 were analysed, which included data from a total of 8,184 patients. Overall mortality from AH was 26% at 28 days, 29% at 90 days and 44% at 180 days after admission. No changes in mortality over time were observed in univariable analysis at 28 days or 90 days after admission (Pearson correlation r -0.216, p = 0.098, and r 0.121 p = 0.503 respectively). A small but statistically significant increase in mortality was seen in 180-day mortality (r 0.461 p = 0.036). However, after meta-regression to adjust for other factors associated with mortality at each time point, no changes in mortality were seen. Sub-group analysis did not reveal any changes in mortality over time in different study types, or when only biopsy-proven or severe disease were considered. Conclusion There has been no improvement in mortality from AH. This is not explained by changes in severity of disease. This emphasises the urgent need for effective treatments for this alcoholic hepatitis.

SummaryObjectiveThe prevalence of radiographic osteoarthritis (OA) after anterior cruciate ligament reconstruction (ACLR) approaches 50%, yet the prevalence of significant knee pain is unknown. We applied three different models of Knee injury and Osteoarthritis Outcome Score (KOOS) thresholds for significant knee pain to an ACLR cohort to identify prevalence and risk factors.DesignMulticenter Orthopaedic Outcomes Network (MOON) prospective cohort patients with a unilateral primary ACLR and normal contralateral knee were assessed at 2 and 6 years. Independent variables included patient demographics, validated Patient Reported Outcomes (PRO; Marx activity score, KOOS), and surgical characteristics. Models included: (1) KOOS criteria for a painful knee = quality of life subscale

SummaryObjectiveTo identify risk factors for radiographic signs of post-traumatic osteoarthritis (OA) 2–3 years after anterior cruciate ligament (ACL) reconstruction through multivariable analysis of minimum joint space width (mJSW) differences in a specially designed nested cohort.MethodsA nested cohort within the Multicenter Orthopaedic Outcomes Network (MOON) cohort included 262 patients (148 females, average age 20) injured in sport who underwent ACL reconstruction in a previously uninjured knee, were 35 or younger, and did not have ACL revision or contralateral knee surgery. mJSW on semi-flexed radiographs was measured in the medial compartment using a validated computerized method. A multivariable generalized linear model was constructed to assess mJSW difference between the ACL reconstructed and contralateral control knees while adjusting for potential confounding factors.ResultsUnexpectedly, we found the mean mJSW was 0.35 mm wider in ACL reconstructed than in control knees (5.06 mm (95% CI 4.96–5.15 mm) vs 4.71 mm (95% CI 4.62–4.80 mm), P

With an estimated 200,000 anterior cruciate ligament reconstructions performed annually in the United States, there is an emphasis on determining patient-specific information to help educate patients on expected clinically relevant outcomes. The Multicenter Orthopaedic Outcomes Network consortium was created in 2002 to enroll and longitudinally follow a large population cohort of anterior cruciate ligament reconstructions. The study group has enrolled >4,400 anterior cruciate ligament reconstructions from seven institutions to establish the large level I prospective anterior cruciate ligament reconstruction outcomes cohort. The group has become more than a database with information regarding anterior cruciate ligament injuries; it has helped to establish a new benchmark for conducting multicenter, multisurgeon orthopaedic research. The changes in anterior cruciate ligament reconstruction practice resulting from the group include the use of autograft for high school, college, and competitive athletes in their primary anterior cruciate ligament reconstructions. Other modifications include treatment options for meniscus and cartilage injuries, as well as lifestyle choices made after anterior cruciate ligament reconstruction.

Background: Alcoholic hepatitis (AH) is a severe manifestation of alcohol-related liver disease characterised by jaundice and liver failure. It is not known what might trigger an episode of AH. We interviewed patients to investigate changes in behaviour before the onset of AH. Methods: Structured interviews were performed with patients with AH to examine their alcohol use, diet, drug use and smoking habit. Clinical and laboratory results were noted. Patients were followed up for 12 months after interview. Results: Data from 39 patients was analysed. No single behavioural change occurred before the onset of jaundice, although reductions in alcohol and/or dietary intake were common. Reduction in alcohol use was seen to occur approximately 14 days before the onset of jaundice. Increased alcohol intake was not common. Clinical and laboratory data varied between types of behaviour changes, although these were not statistically significant. No changes in drug use or tobacco were reported before AH. Those who had not reduced alcohol intake or had increased their drinking had better survival. Conclusions: No single type of behaviour change is associated with AH. Contrary to previous assertions, increased alcohol intake was not common; in fact, participants were much more likely to have reduced their alcohol intake.

To analyze failure rate in 2-year increments to determine if graft choice changed over time and graft failure rate.A prospective 2002-2008 database was used to identify risk factors for anterior cruciate ligament (ACL) retear. Subjects who had primary ACL retear with no history of contralateral surgery and 2-year follow-up were included. Subjects who underwent a multiligament reconstruction were excluded. Graft type, age, sex, smoking status, body mass index, Marx activity level at index surgery, medial and lateral meniscus status at time of ACL retear, sport played after ACL reconstruction, and clinical site were evaluated. Analysis was repeated using 2002-2003 (early) and 2007-2008 (late) 2-year databases. Analysis of variance with post hoc analysis was performed to detect significant differences in age and Marx score by graft type over time.Two-year follow-up for graft failure was obtained on 2,497 of 2,692 (93%) subjects. There were 112 of 2,497 (4.5%) ACL retears identified at 2-year follow-up. The only predictor that changed between early/late periods was allograft use. Allograft odds ratio decreased from 13.1 to 9.5 (P.01). Allografts were used in older patients (31-40 years) and with lower Marx scores (10-8) from early to late periods. The mean age of subjects who received bone-patellar tendon-bone autografts did not significantly change over time (22.8-23.5). The mean age of subjects who received hamstring autografts fell (27.9-25.5). The mean age of subjects who received allografts rose significantly (31.3-39.8, P.01). The mean Marx score of subjects who received bone-patellar tendon-bone and hamstring autografts did not significantly change over time. The mean Marx score of subjects who received allografts decreased significantly (P.01).After early recognition, allograft use in young active patients was a risk factor for retear; graft choice by surgeons changed in the late period to use of allografts in older and less-active patients, which correlated with a significant decrease in retear risk.Level III, case control study.

Background: Revision anterior cruciate ligament (ACL) reconstruction has been documented to have worse outcomes compared with primary ACL reconstruction. Hypothesis: Certain factors under the control of the surgeon at the time of revision surgery can both negatively and positively affect outcomes. Study Design: Case-control study; Level of evidence, 3. Methods: Patients undergoing revision ACL reconstruction were identified and prospectively enrolled between 2006 and 2011. Data collected included baseline demographics, intraoperative surgical technique and joint disorders, and a series of validated patient-reported outcome instruments (International Knee Documentation Committee [IKDC] subjective form, Knee Injury and Osteoarthritis Outcome Score [KOOS], Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC], and Marx activity rating scale) completed before surgery. Patients were followed up for 2 years and asked to complete an identical set of outcome instruments. Regression analysis was used to control for age, sex, body mass index (BMI), activity level, baseline outcome scores, revision number, time since last ACL reconstruction, and a variety of previous and current surgical variables to assess the surgical risk factors for clinical outcomes 2 years after revision ACL reconstruction. Results: A total of 1205 patients (697 male [58%]) met the inclusion criteria and were successfully enrolled. The median age was 26 years, and the median time since their last ACL reconstruction was 3.4 years. Two-year follow-up was obtained on 82% (989/1205). Both previous and current surgical factors were found to be significant contributors toward poorer clinical outcomes at 2 years. Having undergone previous arthrotomy (nonarthroscopic open approach) for ACL reconstruction compared with the 1-incision technique resulted in significantly poorer outcomes for the 2-year IKDC ( P = .037; odds ratio [OR], 2.43; 95% CI, 1.05-5.88) and KOOS pain, sports/recreation, and quality of life (QOL) subscales ( P ≤ .05; OR range, 2.38-4.35; 95% CI, 1.03-10.00). The use of a metal interference screw for current femoral fixation resulted in significantly better outcomes for the 2-year KOOS symptoms, pain, and QOL subscales ( P ≤ .05; OR range, 1.70-1.96; 95% CI, 1.00-3.33) as well as WOMAC stiffness subscale ( P = .041; OR, 1.75; 95% CI, 1.02-3.03). Not performing notchplasty at revision significantly improved 2-year outcomes for the IKDC ( P = .013; OR, 1.47; 95% CI, 1.08-1.99), KOOS activities of daily living (ADL) and QOL subscales ( P ≤ .04; OR range, 1.40-1.41; 95% CI, 1.03-1.93), and WOMAC stiffness and ADL subscales ( P ≤ .04; OR range, 1.41-1.49; 95% CI, 1.03-2.05). Factors before revision ACL reconstruction that increased the risk of poorer clinical outcomes at 2 years included lower baseline outcome scores, a lower Marx activity score at the time of revision, a higher BMI, female sex, and a shorter time since the patient’s last ACL reconstruction. Prior femoral fixation, prior femoral tunnel aperture position, and knee flexion angle at the time of revision graft fixation were not found to affect 2-year outcomes in this revision cohort. Conclusion: There are certain surgical variables that the physician can control at the time of revision ACL reconstruction that can modify clinical outcomes at 2 years. Whenever possible, opting for an anteromedial portal or transtibial surgical exposure, choosing a metal interference screw for femoral fixation, and not performing notchplasty are associated with significantly better 2-year clinical outcomes.

Introduction We aimed to describe changes in survival in alcoholic hepatitis (AH) over time by examining published data. Method A systematic literature search of Ovid Embase and PubMed was undertaken using the MESH terms ‘hepatitis, alcoholic’ to identify randomised controlled trials (RCT) and observational studies (OS) in alcoholic hepatitis. Data were extracted from included studies regarding 28 day, 90 day, 180 day mortality, as well as biochemical and clinical data. Results After review of the literature search results, 79 studies published between 1971 and 2016 were analysed, which included data from a total of 8318 patients. Overall mortality from AH was 25% at 28 days, 29% at 90 days and 38% at 180 days after admission. No changes in mortality over time were observed in univariable analysis at 28 days or 90 days after admission (Pearson correlation r −0.207, p=0.107, and r 0.109 p=0.553 respectively) (figure 1A and 1B). A statistically significant increase in mortality was seen in 180 day mortality (r 0.446 p=0.048) (figure 1C). However, after meta-regression to adjust for other factors associated with mortality at each time point, no changes in mortality were seen. Sub-group analysis of RCT and OS did not reveal any differences between type of study. Conclusion There has not been a significant improvement short-medium mortality from AH over the last four decades, despite much research and general medical innovation. This is not explained by changes in severity of disease. This emphasises the urgent need for effective treatments for this alcoholic hepatitis. Disclosure of Interest None Declared

Background: While revision anterior cruciate ligament reconstruction (ACLR) can be performed to restore knee stability and improve patient activity levels, outcomes after this surgery are reported to be inferior to those after primary ACLR. Further reoperations after revision ACLR can have an even more profound effect on patient satisfaction and outcomes. However, there is a current lack of information regarding the rate and risk factors for subsequent surgery after revision ACLR. Purpose: To report the rate of reoperations, procedures performed, and risk factors for a reoperation 2 years after revision ACLR. Study Design: Case-control study; Level of evidence, 3. Methods: A total of 1205 patients who underwent revision ACLR were enrolled in the Multicenter ACL Revision Study (MARS) between 2006 and 2011, composing the prospective cohort. Two-year questionnaire follow-up was obtained for 989 patients (82%), while telephone follow-up was obtained for 1112 patients (92%). If a patient reported having undergone subsequent surgery, operative reports detailing the subsequent procedure(s) were obtained and categorized. Multivariate regression analysis was performed to determine independent risk factors for a reoperation. Results: Of the 1112 patients included in the analysis, 122 patients (11%) underwent a total of 172 subsequent procedures on the ipsilateral knee at 2-year follow-up. Of the reoperations, 27% were meniscal procedures (69% meniscectomy, 26% repair), 19% were subsequent revision ACLR, 17% were cartilage procedures (61% chondroplasty, 17% microfracture, 13% mosaicplasty), 11% were hardware removal, and 9% were procedures for arthrofibrosis. Multivariate analysis revealed that patients aged Conclusion: There was a significant reoperation rate after revision ACLR at 2 years (11%), with meniscal procedures most commonly involved. Independent risk factors for subsequent surgery on the ipsilateral knee included age

Background: Most surgeons believe that graft choice for anterior cruciate ligament (ACL) reconstruction is an important factor related to outcome; however, graft choice for revision may be limited due to previously used grafts. Hypotheses: Autograft use would result in increased sports function, increased activity level, and decreased osteoarthritis symptoms (as measured by validated patient-reported outcome instruments). Autograft use would result in decreased graft failure and reoperation rate 2 years after revision ACL reconstruction. Study Design: Cohort study; Level of evidence, 2. Methods: Patients undergoing revision ACL reconstruction were identified and prospectively enrolled by 83 surgeons at 52 sites. Data collected included baseline demographics, surgical technique, pathologic abnormalities, and the results of a series of validated, patient-reported outcome instruments (International Knee Documentation Committee [IKDC], Knee injury and Osteoarthritis Outcome Score [KOOS], Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC], and Marx activity rating score). Patients were followed up at 2 years and asked to complete the identical set of outcome instruments. Incidences of additional surgery and reoperation due to graft failure were also recorded. Multivariate regression models were used to determine the predictors (risk factors) of IKDC, KOOS, WOMAC, Marx scores, graft rerupture, and reoperation rate at 2 years after revision surgery. Results: A total of 1205 patients (697 [58%] males) were enrolled. The median age was 26 years. In 88% of patients, this was their first revision, and 341 patients (28%) were undergoing revision by the surgeon who had performed the previous reconstruction. The median time since last ACL reconstruction was 3.4 years. Revision using an autograft was performed in 583 patients (48%), allograft was used in 590 (49%), and both types were used in 32 (3%). Questionnaire follow-up was obtained for 989 subjects (82%), while telephone follow-up was obtained for 1112 (92%). The IKDC, KOOS, and WOMAC scores (with the exception of the WOMAC stiffness subscale) all significantly improved at 2-year follow-up ( P < .001). In contrast, the 2-year Marx activity score demonstrated a significant decrease from the initial score at enrollment ( P < .001). Graft choice proved to be a significant predictor of 2-year IKDC scores ( P = .017). Specifically, the use of an autograft for revision reconstruction predicted improved score on the IKDC ( P = .045; odds ratio [OR] = 1.31; 95% CI, 1.01-1.70). The use of an autograft predicted an improved score on the KOOS sports and recreation subscale ( P = .037; OR = 1.33; 95% CI, 1.02-1.73). Use of an autograft also predicted improved scores on the KOOS quality of life subscale ( P = .031; OR = 1.33; 95% CI, 1.03-1.73). For the KOOS symptoms and KOOS activities of daily living subscales, graft choice did not predict outcome score. Graft choice was a significant predictor of 2-year Marx activity level scores ( P = .012). Graft rerupture was reported in 37 of 1112 patients (3.3%) by their 2-year follow-up: 24 allografts, 12 autografts, and 1 allograft and autograft. Use of an autograft for revision resulted in patients being 2.78 times less likely to sustain a subsequent graft rupture compared with allograft ( P = .047; 95% CI, 1.01-7.69). Conclusion: Improved sports function and patient-reported outcome measures are obtained when an autograft is used. Additionally, use of an autograft shows a decreased risk in graft rerupture at 2-year follow-up. No differences were noted in rerupture or patient-reported outcomes between soft tissue and bone–patellar tendon–bone grafts. Surgeon education regarding the findings of this study has the potential to improve the results of revision ACL reconstruction.

Recent evidence that smaller hamstring graft diameter is associated with increased failure risk following anterior cruciate ligament (ACL) reconstruction has increased the popularity of graft configurations that increase graft diameter at the expense of graft length. A key question is how much graft needs to be in contact with the femoral tunnel to ensure that healing occurs. We hypothesize that no difference in two-year patient-reported outcomes or failure risk exists based on the amount of graft in the femoral tunnel. Through the use of prospectively collected cohort data augmented with retrospective chart review, 120 of 181 consecutive patients (66.3 %) undergoing primary ACL reconstruction with hamstring autograft were evaluated. Patient and surgical factors along with pre-operative and two-year postoperative knee injury and osteoarthritis outcome score (KOOS) and International Knee Documentation Committee (IKDC) scores and whether each patient underwent revision ACL reconstruction during the two-year follow-up period were recorded. No differences in two-year patient-reported outcome scores were noted between patients with graft length in the femoral tunnel less than 25 mm and those with graft length in the femoral tunnel of at least 25 mm. Controlling for age, sex, BMI, and femoral tunnel technique, no correlation was noted between KOOS or IKDC scores and either the length of graft in the femoral tunnel or the contact area between the graft and the tunnel. Variation of the length of hamstring autograft in the femoral tunnel between 14 and 35 mm does not predict KOOS or IKDC scores at 2 years postoperative.

Background: An initial anterior cruciate ligament (ACL) tear can be treated with surgical reconstruction or focused rehabilitation. The KANON (Knee Anterior cruciate ligament, NON-surgical versus surgical treatment) randomized controlled trial compared rehabilitation plus early ACL reconstruction (ACLR) to rehabilitation plus optional delayed ACLR and found no difference at 2 years by an intention-to-treat analysis of total Knee injury and Osteoarthritis Outcome Score (KOOS) results. Purpose: To compare the cost-effectiveness of early versus delayed ACLR. Study Design: Economic and decision analysis; Level of evidence, 2. Methods: A Markov decision model was constructed for a cost-utility analysis of early reconstruction (ER) versus rehabilitation plus optional delayed reconstruction (DR). Outcome probabilities and effectiveness were derived from 2 sources: the KANON study and the Multicenter Orthopaedic Outcomes Network (MOON) database. Collectively, these 2 sources provided data from 928 ACL-injured patients. Utilities were measured by the Short Form–6 dimensions (SF-6D). Costs were estimated from a societal perspective in 2012 US dollars. Costs and utilities were discounted in accordance with the United States Panel on Cost-Effectiveness in Health and Medicine. Effectiveness was expressed in quality-adjusted life-years (QALYs) gained. Principal outcome measures were average incremental costs, incremental effectiveness (as measured by QALYs), and net health benefits. Willingness to pay was set at $50,000, which is the currently accepted standard in the United States. Results: In the base case, the ER group resulted in an incremental gain of 0.28 QALYs over the DR group, with a corresponding lower overall cost to society of $1572. Effectiveness gains were driven by the low utility of an unstable knee and the lower utility for the DR group. The cost of rehabilitation and the rate of additional surgery drove the increased cost of the DR group. The most sensitive variable was the rate of knee instability after initial rehabilitation. When the rate of instability falls to 51.5%, DR is less costly, and when the rate of instability falls below 18.0%, DR becomes the preferred cost-effective strategy. Conclusion: An economic analysis of the timing of ACLR using data exclusively from the KANON trial, MOON cohort, and national average reimbursement revealed that early ACLR was more effective (improved QALYs) at a lower cost than rehabilitation plus optional delayed ACLR. Therefore, early ACLR should be the preferred treatment strategy from a societal health system perspective.

A transjugular intrahepatic portosystemic shunt (TIPS) is an expandable metal stent inserted via the jugular vein that creates a shunt from the portal vein to the systemic circulation via an artificial communication through the liver. It is used to treat complications of portal hypertension. In addition to rescue treatment in variceal bleeding, TIPS can play an important role in prevention of rebleeding. TIPS can improve symptoms if medical treatment of ascites or hepatic hydrothrorax has failed, but may not improve survival. Selected cases of Budd-Chiari syndrome improve with TIPS. This article discusses the indications, evidence, and complications of TIPS.

Background: Identifying risk factors for inferior outcomes after anterior cruciate ligament reconstruction (ACLR) is important for prognosis and future treatment. Hypothesis: Articular cartilage lesions and meniscus tears/treatment would predict International Knee Documentation Committee (IKDC) score, Knee injury and Osteoarthritis Outcome Score (KOOS) (all 5 subscales), and Marx activity level at 6 years after ACLR. Study Design: Cohort study (prognosis); Level of evidence, 1. Methods: Between 2002 and 2004, a total of 1512 ACLR patients were prospectively enrolled and followed longitudinally, with the IKDC, KOOS, and Marx activity score completed at entry, 2 years, and 6 years. A logistic regression model was built incorporating variables from patient demographics, surgical technique, articular cartilage injuries, and meniscus tears/treatment to determine the predictors (risk factors) of IKDC and KOOS scores and Marx activity level at 6 years. Results: A minimum follow-up on 86% (1307/1512) of the cohort was completed at 6 years. The cohort was 56% male and had a median age of 23 years at the time of enrollment, with 76% reporting a noncontact injury mechanism. Incidence of concomitant injury at the time of surgery consisted of the following: articular cartilage (medial femoral condyle [MFC], 25%; lateral femoral condyle [LFC] 20%; medial tibial plateau [MTP], 6%; lateral tibial plateau [LTP], 12%; patella, 20%; trochlear, 9%) and meniscus (medial, 38%; lateral, 46%). Both articular cartilage lesions and meniscus tears were significant predictors of 6-year outcomes on the IKDC and KOOS. Grade 3 or 4 articular cartilage lesions (excluding patella) significantly reduced IKDC and KOOS scores at 6 years. The IKDC demonstrated worse outcomes with the presence of a grade 3 or 4 chondral lesion on the MFC, MTP, and LFC. Likewise, the KOOS score was negatively affected by cartilage injury. The sole significant predictor of reduced Marx activity level was the presence of a grade 4 lesion on the MFC. Lateral meniscus repairs did not correlate with inferior results, but medial meniscus repairs predicted worse IKDC and KOOS scores. Lateral meniscus tears left alone significantly improved prognosis. Small partial meniscectomies (50%) on either the medial or lateral menisci improved prognosis. Analogous to previous studies, other significant predictors of lower outcome scores were lower baseline scores, higher body mass index, lower education level, smoking, and anterior cruciate ligament revisions. Conclusion: Both articular cartilage injury and meniscus tears/treatment at the time of ACLR were significant predictors of IKDC and KOOS scores 6 years after ACLR. Similarly, having a grade 4 MFC lesion significantly reduced a patient’s Marx activity level score at 6 years.

BACKGROUND Prognostic scores are used to assess the likelihood of mortality in cirrhosis and the necessity of liver transplantation. These models are imperfect and refinement would allow more accurate prognostication and selection of patients for transplant. This study investigated association of red cell parameters and mortality in liver transplant candidates. METHODS Data from patients with cirrhosis assessed for transplantation from 2008 to 2010 at Queen Elizabeth Hospital Birmingham, UK were reviewed retrospectively. Kaplan-Meier analysis and Cox regression models were used to generate indices predicting mortality. Accuracy of existing and updated models was tested by calculation of c-statistics. Results were validated in a cohort of patients assessed for liver transplant in Jena, Germany. RESULTS Data were collected from 386 patients in the study cohort. Median follow-up was 15 months (0-45). During follow-up, 151 patients (39%) were transplanted, 138 (36%) died, and 97 (25%) survived without transplant. Abnormal reticulocyte count (P

Objectives: Multiple studies have shown patients are susceptible to post-traumatic osteoarthritis (PTOA) after anterior cruciate ligament (ACL) injury even with ACL reconstruction (ACLR). Prospective studies using multivariate analysis to identify risk factors for PTOA are lacking. This study aims to identify baseline predictors of radiographic PT OA after ACLR at an early time point and hypothesizes that meniscal injury and cartilage lesions will be associated with worse radiographic OA using the Osteoarthritis Research Society International (OARSI) atlas criteria. Methods: 421 patients who underwent ACLR returned onsite for standardized posteroanterior metatarsophalangeal radiographs a minimum of 2 years after surgery. At baseline, demographics, graft type, meniscal status/treatment, and cartilage status were collected. OARSI atlas criteria were used to grade all knee radiographs. Multivariable ordinal regression models identified baseline predictors of radiographic OARSI grades at follow-up. Results: The mean age was 19.8 years with 51.3% females. Higher age (odds ratio (OR) 1.06) and BMI (OR 1.05) were statistically significantly associated with higher OARSI grade in the medial compartment. Patients with a meniscal repair and a partial meniscectomy had statistically significantly higher OARSI grades in the medial compartment (meniscal repair OR 1.92 and meniscectomy OR 2.11) and in the lateral compartment (meniscal repair OR 1.96 and meniscectomy OR 2.97). Graft type, cartilage lesion, sex, and Marx activity scales had no significant association with OARSI grade. Conclusion: Older patients with a higher BMI who have an ACL tear with concurrent meniscal tear requiring partial meniscectomy or meniscal repair should be advised of their increased risk of developing radiographic OA. Alternatively, patients with an ACL tear with an articular cartilage lesion can be reassured that they are not at increased risk of developing radiographic knee OA at 2-3 years following ACLR.

This review focuses on alcohol and substance abuse in the context of solid-organ transplantation. Alcohol and substance abuse are common and may lead to a need for solid-organ transplantation and may also contribute to significant physical and psychologic problems that impact upon the recipient. Damaging levels of alcohol intake can occur in the absence of dependence. Alcohol or substance abuse after transplantation is associated with poor medication compliance and this may increase risk of graft loss. Intravenous drug use is associated with increased risk of infections (especially secondary to opportunistic organisms-bacterial, viral, protozoal, and others-and such infections may be more severe in the immunosuppressed), but there is only anecdotal evidence that such behavior has a worse outcome in transplant recipients. Whereas previous alcohol excess and drug use in kidney recipients are both associated with a small but statistically significantly increased risk of adverse outcomes (hazard ratio, 1.16-1.56), alcohol use within recommended guidelines after transplantation appears safe and possibly beneficial. Robust data are lacking for other organs, but those available suggest that heart transplantation is safe in individuals with a history of alcohol or substance abuse. Health specialists in drug or alcohol addiction should carefully screen all potential transplant candidates for these conditions, and where there is evidence of dependency or abuse, effective psychologic and physical treatment should be offered. Studies have shown that interventions such as psychologic intervention have improved alcohol behavior in the context of liver transplantation. Although there are no comparable studies with other solid-organ recipients, it is reasonable to expect transferable outcomes.

Hepatitis C virus (HCV) is a major cause of global morbidity, causing chronic liver injury that can progress to cirrhosis and hepatocellular carcinoma. The liver is a large and complex organ containing multiple cell types, including hepatocytes, sinusoidal endothelial cells (LSEC), Kupffer cells, and biliary epithelial cells. Hepatocytes are the major reservoir supporting HCV replication; however, the role of nonparenchymal cells in the viral lifecycle remains largely unexplored. LSEC secrete factors that promote HCV infection and transcript analysis identified bone morphogenetic protein 4 (BMP4) as a candidate endothelial-expressed proviral molecule. Recombinant BMP4 increased HCV replication and neutralization of BMP4 abrogated the proviral activity of LSEC-conditioned media. Importantly, BMP4 expression was negatively regulated by vascular endothelial growth factor A (VEGF-A) by way of a VEGF receptor-2 (VEGFR-2) primed activation of p38 MAPK. Consistent with our in vitro observations, we demonstrate that in normal liver VEGFR-2 is activated and BMP4 expression is suppressed. In contrast, in chronic liver disease including HCV infection where there is marked endothelial cell proliferation, we observed reduced endothelial cell VEGFR-2 activation and a concomitant increase in BMP4 expression. Conclusion: These studies identify a role for LSEC and BMP4 in HCV infection and highlight BMP4 as a new therapeutic target for treating individuals with liver disease. (Hepatology 2014;59:375–384)

Background Fibroscan is a quick, non-invasive technique used to measure liver stiffness (kPa), which correlates with fibrosis. To achieve a valid liver stiffness evaluation (LSE) the operator must obtain all the following three criteria: (1) ≥10 successful liver stiffness measurements; (2) IQR/median ratio Objectives To assess the operator training requirements and the importance of adhering to the LSE validity criteria in routine clinical practice. Methods We retrospectively analysed the LSE validity rates of 2311 Fibroscans performed (1 August 2008 to 31 July 2011) in our tertiary liver outpatients department at the University Hospital Birmingham, UK. The diagnostic accuracy of Fibroscan was assessed in 153 patients, by comparing LSE (valid and invalid) with the modified Ishak fibrosis stage on liver biopsy. Results Learning curve analysis highlighted that the greatest improvement in validity of LSE rates occurs in the operator's first 10 Fibroscans, reaching 64.7% validity by the 50th Fibroscan. The correlation between LSE and the fibrosis stage on liver biopsy was superior in patients with a valid LSE (n=97) compared with those with an invalid LSE (n=56) (rs 0.577 vs 0.259; p=0.022). Area under receiving operating characteristics for significant fibrosis was greater when LSE was valid (0.83 vs 0.66; p=0.048). Using an LSE cut-off of 8 kPa, the negative predictive value of valid LSE was superior to invalid LSE for the detection of significant (84% vs 71%) and advanced fibrosis (100% vs 93%). Conclusions Fibroscan requires minimal operator training (≥10 observed on patients), and when a valid LSE is obtained, it is an accurate tool for excluding advanced liver fibrosis. To ensure the diagnostic accuracy of Fibroscan it is essential that the recommended LSE validity criteria are adhered to in routine clinical practice.

Achilles tendon rupture within professional athletes has been shown to lead to devastating consequences regarding return to athletic performance. Not only can this devastating injury affect performance for the remainder of player’s career, it frequently becomes a career-ending event. Considering these significant risks associated with complete rupture, the purpose of this study was to evaluate NBA players with a spectrum of reported Achilles tendon pathology, from tendinopathy (insertional and non-insertional) to complete rupture. Between the 1988-1989 and 2010-2011 NBA seasons, we identified 43 cases of Achilles tendon pathology treated non-operatively. A control group was matched for the players able to return to play with the following parameters: age, position played, number of seasons played in the league, and similarly rated career performance statistics. Considering the medical staff, trainers and facilities available to a professional athlete, a “weekend warrior” should be counseled that even in optimal conditions, 14% of NBA players were unable to return to function/play after Achilles tendinopathy, and that those who were able to return did so at a decreased level of performance. In conclusion, players with Achilles tendinopathy have a better chance to return if they are younger in age and early in their professional career. Furthermore, the association between Achilles pathology and decline in player performance is an important message to convey to coaching staff and team management to allow properly informed decisions when these conditions arise.

OBJECTIVES: To prospectively use a non-invasive algorithm to identify asymptomatic, advanced non-alcoholic fatty liver disease (NAFLD) in a secondary care diabetes clinic and to determine the short-term effect of a multi-disciplinary team (MDT) approach in a liver clinic. RESEARCH DESIGN AND METHODS: NAFLD Fibrosis Score (NFS) was calculated in 64 asymptomatic patients with type 2 diabetes. Advanced fibrosis was identified using transient elastography and confirmed with liver biopsy. In a subsequent retrospective study, 95 patients newly referred to the NAFLD MDT clinic were investigated and the impact of the MDT approach assessed. RESULTS: 25/64 (39.0%) of patients with diabetes had a low NFS (5% weight loss. CONCLUSIONS: A significant proportion of asymptomatic patients attending type 2 diabetes clinics have undiagnosed advanced NAFLD fibrosis. An MDT approach to NAFLD results in short-term improvements in metabolic and liver parameters.

AB Purpose: Diabetes has been associated with adverse outcomes after various types of surgery. There are no previously published data regarding the effect of diabetes on outcomes from anterior cruciate ligament reconstruction (ACLR). The purpose of this study was to test the hypotheses that diabetes is associated with worse clinical outcomes and a higher prevalence of subsequent surgeries after ACLR. Methods: Anterior cruciate ligament-deficient patients (n = 2198) undergoing unilateral ACLR from a multicenter prospective study were included. Patients who self-reported diabetes on the basis of comorbidity questions before surgery were identified from the database. They were compared with the remainder of the cohort who did not self-report diabetes. All patients were followed up for a minimum of 2 yr after their index surgery. A minimum 2-yr follow-up was attained on 1905/2198 (87%) via completed outcome questionnaires and 2096/2198 (95%) regarding subsequent surgery. The primary outcome measures were three validated outcome instruments. The secondary outcome measure was the incidence of additional surgery on the ipsilateral and contralateral knees. Results: Patients with diabetes had a significantly higher activity level at 2 yr (OR = 2.96; 95% CI, 1.30-6.77; P = 0.01), but otherwise slightly worse clinical outcomes, compared with patients without diabetes (OR range = 0.42-0.59). The prevalence of subsequent surgeries in patients with diabetes was not significantly different from the prevalence in patients without diabetes. Conclusions: Patients with diabetes maintain a higher activity level after ACLR despite slightly lower patient-reported outcome scores compared with patients without diabetes and do not have a higher rate of subsequent surgery.

Magnetic resonance imaging (MRI) is a commonly used tool for the diagnosis of intra-articular knee pathologies. Although many studies have reported the accuracy of MRI in the adult population, fewer studies have investigated these tests in younger patients. Furthermore, these studies have shown a higher variability in both the sensitivity and the specificity of MRI for these knee injuries in this age group. Advancements in MRI technology, such as the 3-Tesla (3T) MRI magnet, have shown promising results for musculoskeletal injury diagnosis in adults. This study aims to evaluate 3 T MRI for the diagnosis of intra-articular knee pathologies in a pediatric and adolescent patient population.The records of 116 patients (119 knees) under the age of 20 years who underwent 3 T MRI studies of the knee and subsequent knee arthroscopy were reviewed retrospectively. The MRI report from the musculoskeletal radiology staff, the interpretation from the staff orthopedic surgeon, and the operative note dictations were compared, with a focus on meniscus and anterior cruciate ligament (ACL) pathologies. Seventeen orthopedic staff reads were not obtainable. Arthroscopy was used as the gold standard for diagnosis.The average age at MRI exam was 16.0 years and at surgery was 16.2 years. Using the musculoskeletal radiologist interpretation, the sensitivity and the specificity of 3 T MRI were 81.0% and 90.9% for medial meniscus injuries, 68.8% and 93% for lateral meniscus injuries, and 97.9% and 98.6% for ACL injuries, respectively. The orthopedic surgeon's interpretation of 3 T MRI had a sensitivity and specificity of 75.7% and 92.4% for medial meniscus injuries, 69.8% and 98.3% for lateral meniscus injuries, and 100% and 98.6% for ACL injuries, respectively. Posterior horn tears had the greatest discrepancies.When performed on pediatric and adolescent patients, newer 3 T MRI studies have excellent accuracy for diagnosing ACL tears. These studies also show a higher accuracy for the diagnosis of medial meniscal tears than lateral meniscal tears.Diagnostic study--Level 2.

Background:Septic arthritis is a rare but potentially devastating complication of anterior cruciate ligament (ACL) reconstruction surgery. Several studies, including one by this group, have reported short- and medium-term outcomes, but to our knowledge there are no long-term follow-up studies.Hypothesis:Postoperative septic arthritis after ACL reconstruction surgery will lead to diminished long-term outcomes compared with surgery without infectious complications, likely related to the development of arthritis.Study Design:Case series; Level of evidence, 4.Methods:Four of 831 consecutive patients undergoing arthroscopically guided ACL reconstruction surgeries performed by 1 surgeon were previously reported on by this group at an average follow-up of 36 months. These same patients were contacted and reevaluated. Each patient underwent a physical examination, functional testing, and subjective evaluations with the SF-36, Lysholm, International Knee Documentation Committee (IKDC), and Tegner activity scale scores. Plain film radiographs and magnetic resonance imaging (MRI) scans were analyzed by 2 musculoskeletal radiologists.Results:Average follow-up time for this study was 17.9 years, and average age was 44.3 years. No other injuries or surgeries had occurred from the time of the previous study. Each patient had a decline in SF-36, Lysholm, and IKDC score, and the average Tegner score was unchanged. Average vertical hop test performance and Biodex dynamometry were both improved. The average side-to-side displacement measured via the KT-1000 arthrometer was increased. Radiographic and MRI studies revealed progression of arthritis in all patients and ACL graft rupture in 1 patient.Conclusion:Patients who develop septic arthritis as a complication of ACL reconstruction surgery have diminished long-term subjective, functional, and radiographic outcomes compared with historical reports of uncomplicated cases, likely related to pain from advanced arthritis. As compared with their own earlier follow-up, these patients had declines in pain-related subjective measures but remained stable or improved in both functional testing and activity-related subjective scales.

Injury to the anterior cruciate ligament (ACL) threatens an active lifestyle and exposes the patient to risk of early osteoarthritis (OA). ACL reconstruction is typically chosen by individuals to allow a return to their previous work and sports activities. Primary ACL reconstruction (ACLR) has in general been effective at restoring functional stability, but patients' modifiable predictors of both short- and long-term validated outcomes and OA are largely unknown. The Multicenter Orthopaedic Outcomes Network (MOON) consortium was established in 2002 to enroll and longitudinally follow a population cohort of ACL reconstructed patients. The objective was to establish patient-specific predictive models of clinically important outcomes. Over the past 10 years, the overarching aims of this NIAMS-funded prospective multicenter cohort of ACL reconstructions has been threefold: (1) to identify both short- and long-term prognosis and predictors of sports function, activity level, and general health through validated patient-reported outcomes, (2) to identify the symptoms and signs of OA, and (3) to quantify the incidence of ACL reconstruction graft and/or contralateral ACL failures and additional surgical procedures. This manuscript summarizes the Kappa Delta Ann Doner Vaughan Award paper and presentation at the 2012 ORS/AAOS Annual Meeting.

Although a number of new methods have improved our ability to treat articular injuries of the knee, no procedures have yet been proven to restore injured hyaline cartilage to its original state. Multiple techniques are used to address full-thickness chondral or osteochondral defects. This review briefly examines surgical options for this pathology. If amenable, all attempts should be made to repair osteochondral injuries. If unable to do so, preoperative anatomic factors, such as alignment, ligamentous stability, and meniscal integrity, should be carefully considered. Additionally, indications for surgery and patient factors must be thoroughly reviewed to identify appropriate candidates for treatment. Size and previous attempts at treatment often dictate care, which may include microfracture, osteochondral transplantation (osteoarticular transfer system and mosaicplasty), or autologous chondrocyte implantation. Upcoming advances intend to minimize surgical morbidity while improving cartilage regeneration and articular incorporation. Despite the new developments surrounding this field, much is still unknown, and novel treatments should be addressed with caution.

We report herein deep medial collateral ligament (MCL) tear of the knee with application of valgus stress during arthroscopic partial medial meniscectomy. With symptomatic treatment only, the patient went on to heal this injury without incident and recovered in an expected fashion from arthroscopic surgery. There is no earlier report in the literature of deep MCL tear during knee arthroscopy. Awareness of this entity, its consequences, and optimal management are essential as arthroscopic partial meniscectomy is the most common surgery performed by orthopedic surgeons.

The electrodeposition conditions that contribute to microvoid formation during isothermal aging of Pb-free solder-electrodeposited copper were evaluated in a systematic series of processing experiments. The results of 2K full-factorial design of experiment are presented to show the effect of prescreened electroplating parameters such as brighteners, wetting agent, bath age, and current density on the propensity for microvoiding at solder–copper interfaces after annealing at 125°C for 40 days. It was found that the amount of microvoiding is greatly affected by bath age, wetting agent, brightener, and their interactions. Time-of-flight secondary-ion mass spectroscopy and glow discharge spectroscopy allowed us to establish a correlation between impurities incorporated in copper during electroplating and microvoiding at the solder–copper interface.

Claims of “rights” involve abstraction - to some extent anyway - from immediate social and political context. Academic discussion of the topic very often magnifies the abstraction. At the same time, abstraction is itself sometimes identified as the central “problem” in rights theory - and so becomes the focus of discussion of the topic. It is the focus of Professor Denninger's paper. It is also the focus of mine.

Background: Tearing an anterior cruciate ligament (ACL) graft is a devastating occurrence after ACL reconstruction (ACLR). Identifying and understanding the independent predictors of ACLR graft failure is important for surgical planning, patient counseling, and efforts to decrease the risk of graft failure. Hypothesis: Patient and surgical variables will predict graft failure after ACLR. Study Design: Prospective cohort study. Methods: A multicenter group initiated a cohort study in 2002 to identify predictors of ACLR outcomes, including graft failure. First, to control for confounders, a single surgeon’s data (n = 281 ACLRs) were used to develop a multivariable regression model for ACLR graft failure. Evaluated variables were graft type (autograft vs allograft), sex, age, body mass index, activity at index injury, presence of a meniscus tear, and primary versus revision reconstruction. Second, the model was validated with the rest of the multicenter study’s data (n = 645 ACLRs) to evaluate the generalizability of the model. Results: Patient age and ACL graft type were significant predictors of graft failure for all study surgeons. Patients in the age group of 10 to 19 years had the highest percentage of graft failures. The odds of graft rupture with an allograft reconstruction are 4 times higher than those of autograft reconstructions. For each 10-year decrease in age, the odds of graft rupture increase 2.3 times. Conclusion: There is an increased risk of ACL graft rupture in patients who have undergone allograft reconstruction. Younger patients also have an increased risk of ACL graft failure. Clinical Relevance: Given these risks for ACL graft rupture, allograft ACLRs should be performed with caution in the younger patient population.

Background: The predictors of anterior cruciate ligament reconstruction (ACLR) outcome at 6 years as measured by validated patient-based outcome instruments are unknown. Hypothesis: Certain variables evaluated at the time of ACLR will predict return to sports function (as measured by the International Knee Documentation Committee [IKDC] questionnaire and the Knee injury and Osteoarthritis Outcome Score [KOOS] Sports and Recreation subscale), knee-related quality of life (KOOS Knee Related Quality of Life subscale), and activity level (Marx Activity Scale). Potential predictor variables include demographic factors, surgical technique and graft choice for ACLR, and intra-articular injuries and treatment. Study Design: Cohort study; Level of evidence, 2. Methods: All patients with unilateral ACLRs from 2002 currently enrolled in the MOON (Multicenter Orthopaedic Outcomes Network) cohort were evaluated. Patients completed the validated outcome instruments preoperatively. Physicians documented intra-articular pathologic abnormalities, treatment, and surgical techniques used at the time of surgery. At 2 and 6 years postoperatively, patients completed the same validated outcome instruments. Results: Follow-up was obtained at 2 years (88%) and at 6 years (84%). The cohort was 57% male with a median age of 23 years at enrollment. The ability to perform sports function was maintained at 6 years, but the Marx activity level continued to decline from baseline. Revision ACLR and use of allograft predicted worse outcomes on the IKDC and both KOOS subscales. Lateral meniscus treatment, smoking status, and body mass index at baseline were each predictors on 2 of 3 scales. The predictors of lower activity level were revision ACLR and female sex. Conclusion: Six years after ACLR, patients could perform sports-related functions and maintain a high knee-related quality of life similar to their 2-year level, although their physical activity level (Marx) dropped over time. Choosing autograft rather than allograft, not smoking, and having normal body mass index are advised to improve long-term outcomes.

Cartilage restoration may be a misnomer as our current technologies fail to produce true native hyaline cartilage. There are multiple techniques and technologies available as a potential solution for symptomatic full thickness chondral or osteochondral defects. This review will discuss the indications and contraindications of various procedures. It should be emphasized that any effort to repair an osteochondral defect should be made if possible. If not, then factors such as alignment, status of the meniscus, patient factors such as obesity, and more should be considered and addressed before any restoration technologies. Specific lesion-specific parameters, most importantly size, should be considered before deciding which procedure should be used. Multiple technologies are on the forefront of cartilage regeneration and the answer of which to use is unknown. Future research to create the ideal cartilage regeneration system will include a favorable biological and biomechanical environment in an effort to truly restore articular cartilage.

Revision ACL surgery is a technically demanding enterprise that requires meticulous preoperative planning and tempered postoperative expectations on the patient's part. Despite the complexities of the procedure, it is becoming more common as an increasing number of primary ACL reconstructions are being performed, expanding the pool of patients at risk for failure. Candidates for revision surgery should be selected carefully, focusing on those patients with recurrent instability rather than pain as their primary complaint. A thorough history and physical examination is essential, taking care to identify additional patholaxity that might contribute to a failed ACL reconstruction. To optimize outcomes, surgeons must take care to avoid common pitfalls in index and revision procedures. Femoral and tibial tunnels should be positioned anatomically, and staged bone grafting procedures should be considered if revision graft fixation may be compromised by tunnel defects. The type of graft must be carefully selected, appropriately tensioned, and securely fixed. Surgeons should have a number of techniques and instruments at their disposal for performing each of these steps, as the highly variable presentation of failed ACL reconstructions demands a versatile approach. Ultimately, with cautious rehabilitation, these techniques will allow for restoration of knee stability and, in many cases, an improvement in activity level.

With global warming, the clearance of the Northwest Passage and the rising demands for new energy resources, the sovereignty of Canadian and other national land claims in the Arctic north is coming into question by those wishing to control access to this region. The present paper examines issues involving emerging landmasses, maritime rights, strategic control and navigation, perhaps the most important variable, and the consequences in terms of commercial economies and geopolitical impacts. We consider many variables such as the 1982 Falkland Islands war as a demonstrative example that may have translatable impact in future years. Our purpose in this paper is to raise awareness of impending geopolitical activities that are inevitable during the 21st century as the Arctic pack ice retreats.

Data from large prospectively collected anterior cruciate ligament (ACL) cohorts are being utilized to address clinical questions regarding ACL injury demographics and outcomes of ACL reconstruction. These data are affected by patient and injury factors as well as surgical factors associated with the site of data collection. The aim of this article is to compare primary ACL reconstruction data from patient cohorts in the United States and Norway, demonstrating the similarities and differences between two large cohorts. Primary ACL reconstruction data from the Multicenter Orthopaedic Outcomes Network (MOON) in the United States and the Norwegian National Knee Ligament Registry (NKLR) were compared to identify similarities and differences in patient demographics, activity at injury, preoperative Knee injury and Osteoarthritis Outcome Score (KOOS), time to reconstruction, intraarticular pathology, and graft choice. Seven hundred and thirteen patients from the MOON cohort were compared with 4,928 patients from the NKLR. A higher percentage of males (NKLR 57%, MOON 52%; P < 0.01) and increased patient age (NKLR 27 years, MOON 23 years; P\0.001) were noted in the NKLR population. The most common sports associated with injury in the MOON cohort were basketball (20%), soccer (17%), and American football (14%); while soccer (42%), handball (26%), and downhill skiing (10%) were most common in the NKLR. Median time to reconstruction was 2.4 (Interquartile range [IQR] 1.2-7.2) months in the MOON cohort and 7.9 (IQR 4.2-17.8) months in the NKLR cohort (P < 0.001). Both meniscal tears (MOON 65%, NKLR 48%; P < 0.001) and articular cartilage defects (MOON 46%, NKLR 26%; P < 0.001) were more common in the MOON cohort. Hamstring autografts (MOON 44%, NKLR 63%) and patellar tendon autografts (MOON 42%, NKLR 37%) were commonly utilized in both cohorts. Allografts were much more frequently utilized in the MOON cohort (MOON 13%, NKLR 0.04%; P < 0.001). Significant diversity in patient, injury, and surgical factors exist among large prospective cohorts collected in different locations. Surgeons should investigate and consider the characteristics of these cohorts when applying knowledge gleaned from these groups to their own patient populations.