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Middle-aged subjects with meniscal tear treated with arthroscopic partial meniscectomy (APM) experience greater progression of damage to joint structures on imaging than subjects treated nonoperatively. It is unclear whether these changes are clinically relevant. The goal of this study was to assess whether worsening in magnetic resonance imaging (MRI)-assessed tissue damage over 18 months leads to subsequent worsening in knee pain over the subsequent 3.5 years.We used data from the Meniscal Tear in Osteoarthritis Research (MeTeOR) trial of APM versus physical therapy for subjects ages ≥45 years with knee pain, cartilage damage, and meniscal tear. We assessed whether change in cartilage surface area damage score (and other structural measures) from baseline to 18 months, assessed on MRI with the MRI Osteoarthritis Knee Score (MOAKS) system, was associated with change in Knee Injury and Osteoarthritis Outcome Score (KOOS) pain score (range 0-100; 100 = worst) from 18 to 60 months.The primary analysis included 168 subjects with complete MRI data at baseline and 18 months and KOOS data at 18 and 60 months. We did not observe clinically important associations between change in cartilage surface area score between baseline and 18 months and change in pain scores from 18 to 60 months. Pain scores in the worst tertile for cartilage surface area damage score progression worsened by 0.45 points more than in the best tertile (95% confidence interval -4.45, 5.35). Similarly, we did not observe clinically important associations between changes in bone marrow lesions, osteophytes, or synovitis and subsequent pain.We did not observe clinically important associations between early changes in cartilage damage and other structural measures and worsening in pain over the subsequent 3.5 years. Further follow-up is required to assess this association over a longer follow-up period.

To estimate the risk of magnetic resonance imaging (MRI)-based structural changes in knee osteoarthritis (OA) among individuals with meniscal tear and knee OA, using MRIs obtained at baseline and 18 and 60 months after randomization in a randomized controlled trial of arthroscopic partial meniscectomy (APM) versus physical therapy (PT).We used data from the Meniscal Tear in Osteoarthritis Research (METEOR) trial. MRIs were read using the MRI OA Knee Score (MOAKS). We used linear mixed-effects models to examine the association between treatment group and continuous MOAKS summary scores, and Poisson regression to assess categorical changes in knee joint structure. Analyses assessed changes in OA between baseline and month 18 and between months 18 and 60. We performed both intention-to-treat and as-treated analyses.The analytic sample included 302 participants. For both treatment groups, more OA changes were seen during the early interval than during the later interval. ITT analysis revealed that, between baseline and month 18, APM was significantly associated with an increased risk of having a worsening cartilage surface area score, involving both any worsening across all knee joint subregions (risk ratio [RR] 1.35 [95% confidence interval (95% CI) 1.14, 1.61]) and the number of subregions damaged (RR 1.44 [95% CI 1.13, 1.85]) having a worsening effusion-synovitis score (RR 2.62 [95% CI 1.32, 5.21]), and having ≥1 additional subregion with osteophytes (RR 1.24 [95% CI 1.02, 1.50]). Significant associations were detected between months 18 and 60 only for having any subregion with a worsening osteophyte score (RR 1.28 [95% CI 1.04, 1.58]).These findings suggest that the association between APM and MRI-based structural changes in knee OA is most apparent during the initial 18 months after surgery. The reason for attenuation of this association over longer follow-up merits further investigation.

Background: Patients undergoing shoulder stabilization surgery have been shown to have elevated activity levels. Factors associated with shoulder activity in this patient population at baseline and after surgery are unknown. Hypothesis: Patient-specific variables are associated with shoulder activity level at baseline and at 2-year follow-up in a cohort of patients undergoing shoulder stabilization surgery. Study Design: Cohort study; Level of evidence, 2. Methods: Patients undergoing shoulder stabilization surgery were prospectively enrolled. As part of the data collection process, patients completed a previously validated Shoulder Activity Scale. A regression analysis was performed to assess the association of patient characteristics with baseline and 2-year follow-up shoulder activity levels. Results: A total of 764 (n = 612 men, n = 152 women) out of 957 patients (80%) undergoing shoulder stabilization surgery with a median age of 25 years had baseline and 2-year follow-up data and were included in the current analysis. The baseline shoulder activity level was associated with race ( P < .0001) and preoperative duration of instability ( P < .0001). At 2 years, 52% of the cohort had returned to the same or higher activity level after surgery. Predictors of higher shoulder activity level at 2-year follow-up included higher baseline activity level ( P < .0001), male sex ( P < .0001), younger age ( P = .004), higher body mass index (BMI) ( P = .03), more dislocations ( P = .03), nonsmokers ( P = .04), and race ( P = .04). Conclusion: A longer duration of preoperative symptoms was associated with a lower baseline activity in this cohort. High baseline preoperative shoulder activity, younger age, male sex, higher BMI, number of dislocations, and nonsmoking status predicted higher shoulder activity 2 years after shoulder stabilization surgery. Registration: NCT02075775 ( ClinicalTrials.gov identifier).

Background: Patients with anterior cruciate ligament (ACL) revision report lower outcome scores on validated knee questionnaires postoperatively compared to cohorts with primary ACL reconstruction. In a previously active population, it is unclear if patient-reported outcomes (PROs) are associated with a return to activity (RTA) or vary by sports participation level (higher level vs. recreational athletes). Hypotheses: Individual RTA would be associated with improved outcomes (ie, decreased knee symptoms, pain, function) as measured using validated PROs. Recreational participants would report lower PROs compared with higher level athletes and be less likely to RTA. Study Design: Cohort study; Level of evidence, 2. Methods: There were 862 patients who underwent a revision ACL reconstruction (rACLR) and self-reported physical activity at any level preoperatively. Those who did not RTA reported no activity 2 years after revision. Baseline data included patient characteristics, surgical history and characteristics, and PROs: International Knee Documentation Committee questionnaire, Marx Activity Rating Scale, Knee injury and Osteoarthritis Outcome Score, and the Western Ontario and McMaster Universities Osteoarthritis Index. A binary indicator was used to identify patients with same/better PROs versus worse outcomes compared with baseline, quantifying the magnitude of change in each direction, respectively. Multivariable regression models were used to evaluate risk factors for not returning to activity, the association of 2-year PROs after rACLR surgery by RTA status, and whether each PRO and RTA status differed by participation level. Results: At 2 years postoperatively, approximately 15% did not RTA, with current smokers (adjusted odds ratio [aOR] = 3.3; P = .001), female patients (aOR = 2.9; P < .001), recreational participants (aOR = 2.0; P = .016), and those with a previous medial meniscal excision (aOR = 1.9; P = .013) having higher odds of not returning. In multivariate models, not returning to activity was significantly associated with having worse PROs at 2 years; however, no clinically meaningful differences in PROs at 2 years were seen between participation levels. Conclusion: Recreational-level participants were twice as likely to not RTA compared with those participating at higher levels. Within a previously active cohort, no RTA was a significant predictor of lower PROs after rACLR. However, among patients who did RTA after rACLR, approximately 20% reported lower outcome scores. Most patients with rACLR who were active at baseline improved over time; however, patients who reported worse outcomes at 2 years had a clinically meaningful decline across all PROs.

Background: An intra-articular infection after anterior cruciate ligament (ACL) reconstruction (ACLR) is a rare complication but one with potentially devastating consequences. The rare nature of this complication raises difficulties in detecting risk factors associated with it and with worse outcomes after one has occurred. Purpose: To (1) evaluate the association between an infection after ACLR and potential risk factors in a large single-center cohort of patients who had undergone ACLR and (2) assess the factors associated with ACL graft retention versus removal. Study Design: Case-control study; Level of evidence, 3. Methods: All ACLR procedures performed at our institution between January 2010 and December 2018 were reviewed; a total of 11,451 procedures were identified. A retrospective medical record review was performed to determine the incidence of infections, patient and procedure characteristics associated with an infection, infection characteristics, incidence of ACL graft retention, and factors associated with the retention versus removal of an ACL graft. Multivariable logistic regression analysis was used to identify potential risk factors for an infection after ACLR. Results: Of the 11,451 ACLR procedures, 48 infections were identified (0.42%). Multivariable logistic regression analysis revealed revision ACLR (odds ratio [OR], 3.13 [95% CI, 1.55-6.32]; P = .001) and younger age (OR, 1.06 [95% CI, 1.02-1.10]; P = .001) as risk factors for an infection. Compared with bone–patellar tendon–bone autografts, both hamstring tendon autografts (OR, 4.39 [95% CI, 2.15-8.96]; P < .001) and allografts (OR, 5.27 [95% CI, 1.81-15.35]; P = .002) were independently associated with an increased risk of infections. Overall, 15 ACL grafts were removed (31.3%). No statistically significant differences besides the number of irrigation and debridement procedures were found for retained versus removed grafts, although some trends were identified ( P = .054). Conclusion: In a large single-center cohort of patients who had undergone ACLR and those with an infection after ACLR, patients with revision cases and younger patients were found to have a higher incidence of infection. The use of bone–patellar tendon–bone autografts was found to be associated with the lowest risk of infection after ACLR compared with both hamstring tendon autografts and allografts. Larger cohorts with a larger number of infection cases are needed to determine the factors associated with graft retention versus removal.

Frazzini and Pedersen’s (2014) Betting Against Beta (BAB) factor is based on the same basic idea as Blacks’(1972) beta-arbitrage, but its astonishing performance has generated academic interest and made it highly influential with practitioners. This performance is driven by non-standard procedures used in its construction that effectively, but non-transparently, equal weight stock returns. For each dollar invested in BAB, the strategy commits on average $1.05 to stocks in the bottom 1% of total market capitalization. BAB earns positive returns after accounting for transaction costs, but earns these by tilting toward profitability and investment. Predictable biases resulting from Frazzini and Pedersen’s non-standard beta estimation procedure drive results presented as evidence supporting BAB’s underlying theory.

The Multicenter Orthopaedic Outcomes Network (MOON) study of anterior cruciate ligament (ACL) reconstruction has achieved >80% follow-up for study subjects who were enrolled from 2002 to 2005; patient-reported outcome measures (PROMs) were reported at 2, 6, and 10 years through a carefully designed protocol that included surgeon involvement to encourage subjects to complete and return questionnaires. The process included emails and telephone calls from the central coordinating center, from research coordinators at each local institution, and lastly, from the subjects' surgeons for those who were less inclined to complete the follow-up. In order to quantify the effect of site and surgeon involvement, the enrollment year of 2005 was monitored for the 10-year follow-up (n = 516 subjects). In contact efforts made by the coordinating center, 73.8% (381) of study subjects were reached by the central site coordinator, contact information was verified, and questionnaires were subsequently sent, completed, and returned. An additional 54 subjects (10.5% of the overall study population) returned the questionnaire after local study site involvement, indicating the importance of individual surgeon and local site involvement to improve follow-up rates in multicenter studies in orthopaedic surgery. Follow-up rates were higher when a specific individual (the surgeon or the research coordinator) was given the task of final follow-up.

PURPOSE OF REVIEW: Posterior cruciate ligament injuries can be treated conservatively with a structured rehabilitation program or with surgical reconstruction. Treatment algorithms are based on a variety of factors including the patient’s presentation, physical exam, and desired level of activity. The goal is to return the patient to their athletic pursuits with a stable and pain-free knee. Return to play and activities should be individualized based on the patient’s injury and progression through rehabilitation. This article provides a review of the current treatments for posterior cruciate ligament injuries and the respective rehabilitation protocols, outcomes after each treatment option, and specific return to play criteria. RECENT FINDINGS: Current research shows excellent outcomes and return to play with conservative treatment of isolated posterior cruciate ligament injuries. Return to play algorithms stress the importance of quadriceps strengthening throughout the recovery process and emphasize inclusion of plyometrics and sport-specific training. SUMMARY: Rehabilitation plays a critical role in the outcome after posterior cruciate ligament injury and the ability to return to athletics. The primary focus of post-injury or post-operative rehabilitation is to restore function, as it relates to range of motion, strength, and proprioception, while mitigating swelling and pain. The patients’ desired sport and level of play dictate return to play timelines. The literature supports the use of non-operative management of isolated PCL injuries in athletes and non-athletes with excellent functional and patient-reported outcomes.

Background: Although graft choice may be limited in the revision setting based on previously used grafts, most surgeons believe that graft choice for anterior cruciate ligament (ACL) reconstruction is an important factor related to outcome. Hypothesis: In the ACL revision setting, there would be no difference between autograft and allograft in rerupture rate and patient-reported outcomes (PROs) at 6-year follow-up. Study Design: Cohort study; Level of evidence, 2. Methods: Patients who had revision surgery were identified and prospectively enrolled in this cohort study by 83 surgeons over 52 sites. Data collected included baseline characteristics, surgical technique and pathology, and a series of validated PRO measures. Patients were followed up at 6 years and asked to complete the identical set of PRO instruments. Incidence of additional surgery and reoperation because of graft failure were also recorded. Multivariable regression models were used to determine the predictors (risk factors) of PROs, graft rerupture, and reoperation at 6 years after revision surgery. Results: A total of 1234 patients including 716 (58%) men were enrolled. A total of 325 (26%) underwent revision using a bone-patellar tendon-bone (BTB) autograft; 251 (20%), soft tissue autograft; 289 (23%), BTB allograft; 302 (25%), soft tissue allograft; and 67 (5%), other graft. Questionnaires and telephone follow-up for subsequent surgery information were obtained for 809 (66%) patients, while telephone follow-up was only obtained for an additional 128 patients for the total follow-up on 949 (77%) patients. Graft choice was a significant predictor of 6-year Marx Activity Rating Scale scores ( P = .024). Specifically, patients who received a BTB autograft for revision reconstruction had higher activity levels than did patients who received a BTB allograft (odds ratio [OR], 1.92; 95% CI, 1.25-2.94). Graft rerupture was reported in 5.8% (55/949) of patients by their 6-year follow-up: 3.5% (16/455) of patients with autografts and 8.4% (37/441) of patients with allografts. Use of a BTB autograft for revision resulted in patients being 4.2 times less likely to sustain a subsequent graft rupture than if a BTB allograft were utilized ( P = .011; 95% CI, 1.56-11.27). No significant differences were found in graft rerupture rates between BTB autograft and soft tissue autografts ( P = .87) or between BTB autografts and soft tissue allografts ( P = .36). Use of an autograft was found to be a significant predictor of having fewer reoperations within 6 years compared with using an allograft ( P = .010; OR, 0.56; 95% CI, 0.36-0.87). Conclusion: BTB and soft tissue autografts had a decreased risk in graft rerupture compared with BTB allografts. BTB autografts were associated with higher activity level than were BTB allografts at 6 years after revision reconstruction. Surgeons and patients should consider this information when choosing a graft for revision ACL reconstruction.

Purpose To identify factors predictive of a large labral tear at the time of shoulder instability surgery. Methods As part of the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability cohort, patients undergoing open or arthroscopic shoulder instability surgery for a labral tear were evaluated. Patients with >270° tears were defined as having large labral tears. To build a predictive logistic regression model for large tears, the Feasible Solutions Algorithm was used to add significant interaction effects. Results After applying exclusion criteria, 1235 patients were available for analysis. There were 222 females (18.0%) and 1013 males (82.0%) in the cohort, with an average age of 24.7 years (range 12 to 66). The prevalence of large tears was 4.6% (n = 57), with the average tear size being 141.9°. Males accounted for significantly more of the large tears seen in the cohort (94.7%, P = .01). Racquet sports (P = .01), swimming (P = .02), softball (P = .05), skiing (P = .04), and golf (P = .04) were all associated with large labral tears, as was a higher Western Ontario Shoulder Instability Index (WOSI; P = .01). Age, race, history of dislocation, and injury during sport were not associated with having a larger tear. Using our predictive logistic regression model for large tears, patients with a larger body mass index (BMI) who played contact sports were also more likely to have large tears (P = .007). Conclusions Multiple factors were identified as being associated with large labral tears at the time of surgery, including male sex, preoperative WOSI score, and participation in certain sports including racquet sports, softball, skiing, swimming, and golf. Level of Evidence I, prognostic study.

Return to sport (RTS) after ACL reconstruction (ACLR) has been recognized as an important outcome, which is associated with success of the surgery. This study aimed to assess the methods used to determine return to sport after ACLR in the published literature, report on variability of methods and evaluate their strength in establishing accurate RTS data. Electronic databases (PubMed, Cochrane Library and Embase) were searched via a defined search strategy with no limits, to identify relevant studies from January 2008 to December 2020 for inclusion in the review. Defined eligibility criteria included studies specifically measuring and reporting on return to sport after ACLR with a clear methodology. Each included study was assessed for the definition of successful RTS, successful return to pre-injury level of sport and for methods used to determine RTS. One hundred and seventy-one studies were included. Of the included studies, six studies (4%) were level of evidence 1 and seventy-two studies (42%) were level of evidence 4. Forty-one studies (24%) reported on return to a specific sport and 130 studies (76%) reported on return to multiple sports or general sport. Sixteen studies (9%) reported on RTS in the pediatric population, 36 (21%) in the adult population and 119 (70%) reported on a mixed-aged population. The most commonly used definition of successful RTS was return to the same sport (44 of 125 studies, 35%). The most common method used to determine RTS was a non-validated study-specific questionnaire (73 studies, 43%), which was administered in various ways to the patients. Time of RTS assessment was variable and ranged between 6 months and 27 years post-surgery. This review demonstrates high variability in defining, evaluating and reporting RTS following ACLR. The findings of this study reveal low reliability and unproven validity of methods used to evaluate RTS and highlight the challenges in interpreting and using RTS data reported in literature. IV.

Several devices used to harvest stem/progenitor cells from bone marrow are available to clinicians. This study compared three devices measuring stem cell yields and correlating those yields to bone regeneration. A flexible forward aspirating system Marrow Marxman (MM), a straight needle aspirating on withdrawal system Marrow Cellutions (MC), and a straight needle aspirating on withdrawal and centrifuging the aspirate (BMAC) were compared in a side-to-side patient comparison, as well as tissue engineered bone grafts. The FlexMetric system (MM) produced greater CFU-f values compared to the straight needle (MC) Δ = 1083/ml, p 0.001 and 1225/ml, p 0.001 than the BMAC system. This increased stem/progenitor cell yield also translated into a greater radiographic bone density at 6 months Δ = 88.3 Hu, p ≤ 0.001 versus MC and Δ = 116.7, p 0.001 versus BMAC at 6 months and Δ = 72.2, p 0.001 and Δ = 93.3, p 0.001 at 9 months respectively. The increased stem/progenitor cell yield of the MM system clinically translated into greater bone regeneration as measured by bone volume p 0.014 and p 0.001 respectively, trabecular thickness p 0.007 and p 0.002 respectively, and trabecular separation p = 0.011 and p 0.001. A flexible bone marrow aspirator produces higher yields of stem/progenitor cells. Higher yields of stem/progenitor cells translate into greater bone regeneration in tissue engineering. Flexmetric technology produces better bone regeneration due to a forward aspiration concept reducing dilution from peripheral blood and its ability to target lining cells along the inner cortex. Centrifugation systems are not required in tissue engineering procedures involving stem/progenitor cells due to nonviability or functional loss from g-forces.

To determine interobserver and intraobserver reliabilities of the combination of classification systems, including the Beck and acetabular labral articular disruption (ALAD) systems for transition zone cartilage, the Outerbridge system for acetabular and femoral head cartilage, and the Beck system for labral tears. Additionally, we sought to determine interobserver and intraobserver agreements in the location of injury to labrum and cartilage. Three fellowship trained surgeons reviewed 30 standardized videos of the central compartment with one surgeon re-evaluating the videos. Labral pathology, transition zone cartilage and acetabular cartilage were classified using the Beck, Beck and ALAD systems, and Outerbridge system, respectively. The location of labral tears and transition zone cartilage injury was assessed using a clock face system, and acetabular cartilage injury using a five-zone system. Intra- and interobserver reliabilities are reported as Gwet’s agreement coefficients. Interobserver and intraobserver agreement on the location of acetabular cartilage lesions was highest in superior and anterior zones (0.814–0.914). Outerbridge interobserver and intraobserver agreement was >0.90 in most zones of the acetabular cartilage. Interobserver and intraobserver agreement on location of transition zone lesions was 0.844–0.944. The Beck and ALAD classifications showed similar interobserver and intraobserver agreement for transition zone cartilage injury. The Beck classification of labral tears was 0.745 and 0.562 for interobserver and intraobserver agreements, respectively. The Outerbridge classification had almost perfect interobserver and intraobserver agreement in classifying chondral injury of the true acetabular cartilage and femoral head. The Beck and ALAD classifications both showed moderate to substantial interobserver and intraobserver reliabilities for transition zone cartilage injury. The Beck system for classification of labral tears showed substantial agreement among observers and moderate intraobserver agreement. Interobserver agreement on location of labral tears was highest in the region where most tears occur and became lower at the anterior and posterior extents of this region. The available classification systems can be used for documentation regarding intra-articular pathology. However, continued development of a concise and highly reproducible classification system would improve communication.

Background The purpose of this study was to identify differences related to race in preoperative and intraoperative findings of patients undergoing operative treatment for shoulder instability. Methods Data from the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability cohort were used. Of 1010 patients, 995 provided race and ethnicity information and were included in the analyses. Demographic characteristics, injury history, radiographic and intraoperative findings, and preoperative patient-reported instability, pain, and function were compared (1) between white and minority patients and (2) in a subgroup analysis between white patients and the 3 largest minority groups. The Distressed Communities Index (DCI) score was recorded for each patient’s home ZIP code. Multiple logistic regressions were performed to determine whether models consisting of race/ethnicity, insurance carrier, and/or DCI score were predictive of bone and cartilage loss at the time of surgery. Results Compared with white patients, a greater percentage of US minority patients had ≥2 dislocations (68.0% vs. 57.1%, P = .01), which corresponded with more frequent articular cartilage lesions (62.2% vs. 51.0%, P = .007) and increased frequencies of glenoid bone loss > 10% (16.2% vs. 8.7%, P = .03) and Hill-Sachs lesions (68.6% vs. 56.0%, P = .004). Specifically, when compared with white patients, African American and Asian patients showed significantly increased frequencies of glenoid bone loss > 10% (19.7% of African American patients, 18.4% of Asian patients, and 8.9% of white patients; P = .01) and Hill-Sachs lesions (65.6%, 71.7%, and 52.4%, respectively; P = .02). Race was an independent predictor of articular cartilage lesions (P = .04) and the presence of Hill-Sachs lesions (P = .01). A higher DCI score (P = .03) and race (P = .04) were both predictive of having glenoid bone loss > 10%. Conclusion We found that minority race was associated with increased number of preoperative dislocations and increased frequency of articular cartilage and Hill-Sachs lesions at the time of surgery, and both minority race and an increased DCI score were associated with glenoid bone loss > 10%. Further research is needed to understand the underlying reason for these differences and to optimize care for all patients with shoulder instability.

Purpose: To determine whether range of motion (ROM) varies with the location and extent of labral tear seen in patients undergoing arthroscopic anterior shoulder stabilization. Methods: Consecutive patients undergoing arthroscopic anterior shoulder stabilization who were enrolled in the Multicenter Orthopaedic Outcomes Network Shoulder Instability database underwent a preoperative physical examination and intraoperative examination under anesthesia in which ROM was recorded. Intraoperatively, the location and extent of the labral tear was recorded using conventional clock-face coordinates. Patients were grouped by combinations of quadrants involved in the labral tear (G1-G7): G1 = anterior only, G2 = anterior + inferior, G3 = anterior + inferior + posterior, G4 = all quadrants, G5 = superior + anterior, G6 = superior + anterior + inferior, and G7 = posterior + superior + anterior. Statistical analyses were performed with the Kruskal–Wallis rank-sum test. When P < .05, a post-hoc Dunn’s test was performed. For categorical variables, the χ2 test was performed. We performed a series of bivariate negative binomial regression models testing pairwise combinations of ROM parameters predicting the count of labral tear locations (possible: 0-5) within each quadrant. Results: A total of 467 patients were included, with 13 (2.8%) in G1, 221 (47.3%) in G2, 40 (8.6%) in G3, 51 (10.9%) in G4, 18 (3.9%) in G5, 121 (25.9%) in G6, and 3 (0.6%) in G7. Multiple statistically significant differences were noted in ROM, specifically active internal rotation at side (IRS) (P = .005), active abduction (P = .02), passive IRS (P = .02), and passive external rotation in abduction (P = .0007). Regression modeling revealed a positive correlation between passive abduction and predicted count of labral tear locations in the superior quadrant and between passive IRS and predicted count of labral tear location in the inferior quadrant. Conclusions: In patients undergoing arthroscopic shoulder stabilization for anterior instability, ROM varies with location and extent of labral tear. However, the clinical relevance of such small ROM differences remains undetermined. Level of evidence: II, prospective comparative study.

Infection is a rare occurrence after revision anterior cruciate ligament reconstruction (rACLR). Because of the low rates of infection, it has been difficult to identify risk factors for infection in this patient population. The purpose of this study was to report the rate of infection following rACLR and assess whether infection is associated with patient- and surgeon- dependent risk factors. We reviewed two large prospective cohorts to identify patients with postoperative infections following rACLR. Age, sex, body mass index (BMI), smoking status, history of diabetes, and graft choice were recorded for each patient. The association of these factors with postoperative infection following rACLR was assessed. There were 1423 rACLR cases in the combined cohort, with 9 (0.6%) reporting post-operative infections. Allografts had a higher risk of infection than autografts (odds ratio=6.8; 95% CI: 0.9-54.5; p=0.045). Diabetes (odds ratio=28.6; 95% CI: 5.5-149.9; p=0.004) was a risk factor for infection. Patient age, sex, BMI and smoking status were not associated with risk of infection after rACLR. STATEMENT OF CLINICAL SIGNIFICANCE: While there is a low rate of infection following rACLR, use of allograft and comorbidity with diabetes are associated with a higher risk of infection following this surgery.

Background: Meniscal preservation has been demonstrated to contribute to long-term knee health. This has been a successful intervention in patients with isolated tears and tears associated with anterior cruciate ligament (ACL) reconstruction. However, the results of meniscal repair in the setting of revision ACL reconstruction have not been documented. Purpose: To examine the prevalence and 2-year operative success rate of meniscal repairs in the revision ACL setting. Study Design: Case-control study; Level of evidence, 3. Methods: All cases of revision ACL reconstruction with concomitant meniscal repair from a multicenter group between 2006 and 2011 were selected. Two-year follow-up was obtained by phone and email to determine whether any subsequent surgery had occurred to either knee since the initial revision ACL reconstruction. If so, operative reports were obtained, whenever possible, to verify the pathologic condition and subsequent treatment. Results: In total, 218 patients (18%) from 1205 revision ACL reconstructions underwent concurrent meniscal repairs. There were 235 repairs performed: 153 medial, 48 lateral, and 17 medial and lateral. The majority of these repairs (n = 178; 76%) were performed with all-inside techniques. Two-year surgical follow-up was obtained on 90% (197/218) of the cohort. Overall, the meniscal repair failure rate was 8.6% (17/197) at 2 years. Of the 17 failures, 15 were medial (13 all-inside, 2 inside-out) and 2 were lateral (both all-inside). Four medial failures were treated in conjunction with a subsequent repeat revision ACL reconstruction. Conclusion: Meniscal repair in the revision ACL reconstruction setting does not have a high failure rate at 2-year follow-up. Failure rates for medial and lateral repairs were both

Background: The cause of subsequent surgery after anterior cruciate ligament (ACL) reconstruction varies, but if risk factors for specific subsequent surgical procedures can be identified, we can better understand which patients are at greatest risk. Purpose: To report the incidence and types of subsequent surgery that occurred in a cohort of patients 6 years after their index ACL reconstruction and to identify which variables were associated with the incidence of patients undergoing subsequent surgery after their index ACL reconstruction. Study Design: Cohort study; Level of evidence, 2. Methods: Patients completed a questionnaire before their index ACL surgery and were followed up at 2 and 6 years. Patients were contacted to determine whether any underwent additional surgery since baseline. Operative reports were obtained, and all surgical procedures were categorized and recorded. Logistic regression models were constructed to predict which patient demographic and surgical variables were associated with the incidence of undergoing subsequent surgery after their index ACL reconstruction. Results: The cohort consisted of 3276 patients (56.3% male) with a median age of 23 years. A 6-year follow-up was obtained on 91.5% (2999/3276) with regard to information on the incidence and frequency of subsequent surgery. Overall, 20.4% (612/2999) of the cohort was documented to have undergone at least 1 subsequent surgery on the ipsilateral knee 6 years after their index ACL reconstruction. The most common subsequent surgical procedures were related to the meniscus (11.9%), revision ACL reconstruction (7.5%), loss of motion (7.8%), and articular cartilage (6.7%). Significant risk factors for incurring subsequent meniscus-related surgery were having a medial meniscal repair at the time of index surgery, reconstruction with a hamstring autograft or allograft, higher baseline Marx activity level, younger age, and cessation of smoking. Significant predictors of undergoing subsequent surgery involving articular cartilage were higher body mass index, higher Marx activity level, reconstruction with a hamstring autograft or allograft, meniscal repair at the time of index surgery, or a grade 3/4 articular cartilage abnormality classified at the time of index ACL reconstruction. Risk factors for incurring subsequent surgery for loss of motion were younger age, female sex, low baseline Knee injury and Osteoarthritis Outcome Score symptom subscore, and reconstruction with a soft tissue allograft. Conclusion: These findings can be used to identify patients who are at the greatest risk of incurring subsequent surgery after ACL reconstruction.

Surgical reconstruction of the anterior cruciate ligament (ACL) is often indicated to restore functional stability and prevent early degeneration of the knee joint, as there is little biological healing capacity of the native ACL. Although a reconstructed ACL does not fully restore the original structure or biomechanics properties of the native ACL, the graft used for reconstruction must not only have structural and mechanical properties that closely resemble those of the native ligament, it must also have minimal antigenicity and enough biological potential to incorporate into host bone. There are several considerations in graft selection: autograft versus allograft, and soft tissue grafts versus grafts with bone plugs. Commonly used grafts include bone-patella tendon-bone, hamstring, and quadriceps; among allografts, options further include tibias anterior and posterior, Achilles, an peroneal tendons. Optimal graft selection is not only dependent on graft properties, but perhaps more importantly on patient characteristics and expectations. The purpose of this review is to summarize the relevant biological, biomechancial, and clinical data regarding various graft types and to provide a basic framework for graft selection in ACL reconstruction.

Objective The present study was undertaken to evaluate changes in knee magnetic resonance imaging (MRI) findings over the course of 18 months in subjects with osteoarthritic change and meniscal tear treated with arthroscopic partial meniscectomy (APM) or nonoperatively with physical therapy (PT). Methods We used 18-month follow-up data from the Meniscal Tear in Osteoarthritis Research Trial. MRI results were read with reference to the MRI Osteoarthritis Knee Score. We focused on 18-month change in bone marrow lesions (BMLs), cartilage thickness, cartilage surface area, osteophyte size, effusion-synovitis, and Hoffa-synovitis. We used multinomial logistic regression to assess associations between MRI-based changes in each feature and treatment type. Results A total of 351 subjects were randomized, and 225 had both baseline and 18-month MRI results. In both treatment groups, patients experienced substantial changes in several MRI-based markers. In 60% of the APM group, versus 33% of the PT group, cartilage surface area damage advanced in ≥2 subregions (adjusted odds ratio 4.2 [95% confidence interval 2.0-9.0). Patients who underwent APM also had greater advancement in scores for osteophytes and effusion-synovitis. We did not find significant associations between treatment type and change in cartilage thickness, BMLs, or Hoffa-synovitis. Conclusion This cohort of patients with meniscal tear and osteoarthritis showed marked advancement in MRI-based features over 18 months. Patients treated with APM showed more advancement in some features compared to those treated nonoperatively. The clinical relevance of these early findings is unknown and requires further study.

Background: Neuromuscular training (NMT) has demonstrated efficacy as an intervention to decrease the risk of anterior cruciate ligament injuries and improve sports performance. The effect of this training on the mechanisms that contribute to improved physical performance has not been well defined. Hypothesis: Athletes in the NMT group will have better mechanisms of fundamental movements and agility tests that may contribute to improved sports performance. Study Design: Prospective cohort study Level of Evidence: Level 2 Methods: Eight high school teams (111 athletes, 53% male, mean age 16 years) participated, with half performing NMT. Physical performance was measured using the dorsaVi ViPerform system, a US Food and Drug Administration-cleared wireless sensor system. Agility was assessed using a timed 3-cone test. Independent sample t tests were used to compare differences between the intervention and control groups. Results: Matched pre- and postseason data were collected from 74 athletes after excluding athletes with injury and those lost to follow-up. Significant improvements were observed in the NMT group for loading/landing speed ratios during a single-leg hop test (right lower extremity = −0.19 [–0.37, 0.03], P = 0.03 and left lower extremity = −0.27 [–0.50, −0.03], P = 0.03). The control group had lower ground reaction forces compared with the NMT group ( P < 0.02), while significant improvements were found in the NMT group for initial peak acceleration ( P < 0.02) and cadence ( P = 0.01) during a straight-line acceleration/deceleration test. For the 3-cone agility test, the postseason time decreased compared with preseason in the NMT group, whereas the time for the control group increased (–0.37 s vs 0.14 s, P < 0.00). Conclusion: The results demonstrate that NMT administered by sports medicine clinicians can significantly improve some physical performance of fundamental movements in high school athletes. Clinical Relevance: Coaches should be trained to effectively deliver NMT in order to improve sports performance.

The purpose of the present study is to compare the characteristics of dog bite wounds to the face and that of the rest of the body among the pediatric population in the United States and to determine independent risk factors for dog bite wounds to the face.A retrospective cohort study was conducted using the Kids' Inpatient Database. There were multiple, heterogenous predictor variables. The primary outcome variable was a facial dog bite. A multivariate logistic regression was employed to identify independent risk factors for the primary outcome variable. A P value less than .05 was the threshold for statistical significance.Our final sample consisted of 9,057 patients who suffered dog bite injuries, of which 2,913 (32.2%) occurred on the face. Relative to individuals aged 16-20 years, individuals aged 0-5 (odds ratio [OR] 5.7; confidence interval [CI] 4.0, 8.1), 6-10 (OR 3.8; CI 2.6, 5.5), and 11-15 years (OR 1.6; CI 1.1, 2.5) were all independently associated with increased odds of incurring a facial dog bite injury. Patients who were not admitted electively were 2.5 times (CI 1.4, 4.6) more likely to incur a facial dog bite injury relative to patients who were admitted electively.Young children (0-5 years) were at the greatest risk for facial dog bites relative to children aged 16-20 years. Dog bites that were admitted on emergency were more likely to occur on the face relative to those that were electively admitted to the hospital. To reduce the risk for facial dog bites and the host of chronic psychological ramifications that accompany them, established preventative strategies ought to be exercised.

Previous studies have demonstrated that psychosocial factors and comorbid depression are associated with worse preoperative baseline measures, clinical outcomes, and recovery in patients undergoing shoulder surgery. It is unknown whether this potential link would differ between those with traumatic vs. atraumatic shoulder instability, as symptoms may persist longer in atraumatic instability prior to surgical intervention. The purpose of this study was to determine if psychosocial factors and/or comorbid depression more heavily influence preoperative symptoms for patients with traumatic vs. atraumatic shoulder instability.Prospective baseline data from 1552 patients in the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability cohort were analyzed based on mechanism of injury while controlling for age, sex, and direction of instability. Multivariable linear regressions were performed to determine whether psychological factors (RAND 36 Mental Component Score [MCS], depression diagnosis, Personality Assessment Screener-22) were predictive of preoperative American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) and Western Ontario Shoulder Instability Index (WOSI) scores in the atraumatic group. The same model was repeated for the traumatic instability group, and the model fit was compared between groups, with P .05 considered statistically significant.Female sex and lower MCS were significantly associated with worse preoperative ASES and WOSI scores for the group with atraumatic instability (ASES RWorse preoperative psychosocial factors were found to be more strongly associated with shoulder-related pain and function for patients with atraumatic instability. Across multiple orthopedic conditions, depression and emotional well-being have been associated with worse preoperative symptoms and inferior postoperative patient-reported outcomes. Despite the stronger and significant association in atraumatic patients, worse psychosocial factors did not have as large an impact as has been seen in other, more chronic conditions such as osteoarthritis or rotator cuff tears. In addition to medically optimizing patients prior to surgery, the current findings identify a subset of shoulder instability patients that may benefit from a behavioral health intervention either prior to surgery or early in the postoperative period to potentially improve postoperative outcomes.

Ce livre reconstitue les mécanismes humoristiques de la vie politique romaine, entre la seconde moitié du IIIe s. a.C. et la fin du principat de Domitien, dans le but de montrer les adaptations du risum mouere face aux changements politiques et sociaux intervenus durant cette période. Il s’agit de dépasser une lecture centrée sur le rire de l’homo urbanus et du bon orateur, proposée par Cicéron et Quintilien, pour lui préférer une lecture historicisée et combinatoire qui considère les orateurs, les traits d’esprit, les auditoires et les causes politiques comme un tout à l’agencement variable de ce que les Modernes nomment l’« humour politique ». Scrutant les divers contextes politiques de cet humour, cette recherche souligne le passage, selon des rythmes syncopés résultant d’un repli de la causticité aristocratique face à César mais qui perdure à l’époque triumvirale, d’un « faire rire » frontal articulé autour du succès oratoire vers un humour fondé sur l’anonymat des correspondances, des graffitis ou des chants du triomphe. La dernière partie de l’ouvrage, centrée sur le Ier s. p. C., part de l’opposition établie par les sources entre les « bons princes » et les « tyrans » afin de montrer que, ne se limitant pas à refuser ou à accepter le rire politique selon son degré de dangerosité directe pour leur autorité, les princes l’utilisèrent à leur profit, entretenant une « inaccessible accessibilité » au fondement d’un charisme singulier qui permit l’aboutissement de la « Révolution romaine ».