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Objective: The 2017 McDonald criteria continued the separation of diagnostic criteria for relapsing-remitting multiple sclerosis (RRMS) and primary progressive MS (PPMS) for historical, rather than biological, reasons. We aimed to explore the feasibility of a single, unified set of diagnostic criteria when applied to patients with suspected PPMS., Methods: We retrospectively identified patients evaluated for suspected PPMS at 5 European centers. The 2017 McDonald PPMS criteria was the gold standard against which the 2017 McDonald RRMS dissemination in space (DIS) and dissemination in time criteria were evaluated. We also investigated modified RRMS DIS criteria, including: (i) optic nerve lesions; (ii) ≥2 spinal cord lesions; and (iii) higher fulfilment of DIS criteria alone (lesions in ≥3 regions) without dissemination in time/positive cerebrospinal fluid, for a diagnosis of PPMS., Results: A total of 282 patients were diagnosed with PPMS using the 2017 McDonald criteria, and 40 with alternate disorders. The 2017 McDonald RRMS DIS criteria and the modified DIS criteria including the optic nerve or ≥2 spinal cord lesions performed well in PPMS diagnosis when combined with dissemination in time/positive cerebrospinal fluid (sensitivity 92.9-95.4%, specificity 95%, accuracy 93.2-95.3%). A diagnosis of PPMS based on high fulfillment of modified RRMS DIS criteria had high specificity, but low sensitivity. A diagnostic algorithm applicable to patients evaluated for suspected MS is proposed., Interpretation: The 2017 McDonald RRMS criteria and modifications to DIS criteria, currently under consideration, performed well in PPMS diagnosis. Forthcoming revisions to the McDonald criteria should consider a single, unified set of diagnostic criteria for MS. ANN NEUROL 2024., (© 2024 The Author(s). Annals of Neurology published by Wiley Periodicals LLC on behalf of American Neurological Association.)

Background: Marfan syndrome (MFS) guidelines recommend optimal pharmacologic therapy (OPT) and replacement of the ascending aorta (RAA) at 5.0 cm in diameter to prevent acute type A aortic dissection (ATAAD) and death. The effect of early MFS diagnosis and initiation of therapy on outcomes is not known. Therefore, we sought to evaluate the effect of age at MFS diagnosis and therapy initiation on delayed RAA and death., Methods: This retrospective observational cohort study with long-term follow-up included consecutive patients with MFS, pathogenic FBN1 variant, and regular visits to a European Reference Network Center. We considered MFS diagnosis at age ≥21 years late and OPT initiation at age <21 years early. Outcomes were delayed RAA with aneurysm diameter >5.0 cm or ATAAD and death from all causes. We used landmark design starting at age 21 years to determine associations with outcomes., Results: The study group consisted of 288 patients (45.1% male), including 169 patients with late diagnosis of MFS (58.7%) and 63 with early OPT (21.9%). During mean follow-up of 25 ± 14.7 years, 78 patients had delayed RAA, with 42 operations for ATAAD and 36 for aneurysms ≥5.0 cm. There were 33 deaths, including 11 deaths late after ATAAD. All deaths were cardiovascular. Late diagnosis, but not early OPT, showed univariate association with delayed RAA (P < .001) and death (P = .025). Multivariate Cox regression analysis confirmed late diagnosis as predictor of delayed RAA (hazard ratio, 8.01; 95% confidence interval, 2.52-25.45; P < .001) and death (hazard ratio, 4.68; 95% confidence interval, 1.17-18.80; P = .029)., Conclusions: Late diagnosis of MFS is associated with delayed surgery and death., Competing Interests: Conflict of Interest Statement J.B. receives consulting honoraria from VASCUTEK Deutschland GMBH, J.P. from Medtronic and Edwards Lifesciences, and E.D. from Terumo Aortic. T.D. was supported by Clinician Scientist Programme of the German Center for Cardiovascular Research [DZHK; FKZ81X3710109]. P.K. was partially supported by European Union AFFECT-AF (grant agreement 847770), MAESTRIA (grant agreement 965286), British Heart Foundation (PG/20/22/35093; AA/18/2/34218), DZHK (grant numbers DZHK FKZ 81X2800182, 81Z0710116, 81Z0710110), German Research Foundation (Ki509167694), and Leducq Foundation. He received research support from European Union, British Heart Foundation, Leducq Foundation, Medical Research Council (UK), German Center for Cardiovascular Research, from several drug and device companies active in atrial fibrillation, and honoraria from such companies, but not in the last 3 years. He is listed as inventor on 2 issued patents held by University of Hamburg (Atrial Fibrillation Therapy WO2015140571, Markers for Atrial Fibrillation WO2016012783). M.R. holds lectures for Novartis Pharma. All other authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Purpose: The purpose of this retrospective review was to determine the prevalence of osteochondral lesions (OCLs) of the lateral talar dome in patients with anterior ankle impingement with an associated hypertrophic distal fascicle of the anterior tibio-fibular ligament., Methods: Retrospective chart review identified 40 patients who underwent anterior ankle arthroscopy for the management of anterior ankle impingement. Clinical outcomes assessed included pre- and postoperative foot and ankle outcome score (FAOS), visual analogue scale (VAS), complications, failures, secondary surgical procedures, return-to-work data and return-to-sport data., Results: Thirty-two patients with a mean follow-up time of 29.3 ± 10.4 months were included. The hypertrophic distal fascicle of the anterior tibio-fibular ligament was hypertrophic in 29 patients (90.6%), with a mean thickness of 2.5 ± 0.4 mm on MRI. There were 22 OCLs of the lateral talar dome (75.9%) with an associated hypertrophic distal fascicle of the anterior tibio-fibular ligament visualized during arthroscopy. The international cartilage repair society gradings of the lesions included 3 (13.6%) grade I lesions, 15 (68.1%) grade II lesions, 3 (13.6%) grade III lesions, and 1 (4.6%) grade IV lesion. There was a statistically significant improvement in mean FAOS and VAS scores from preoperative to postoperative (p < 0.001). No cases of syndesmotic instability were observed following resection of hypertrophic distal fascicle of the anterior tibio-fibular ligament., Conclusion: This retrospective case series demonstrated that a hypertrophic distal fascicle of the anterior tibio-fibular ligament was associated with an OCL of the lateral talar dome identified during arthroscopic evaluation. In addition, preoperative MRI demonstrated poor sensitivity for the detection of these OCLs. Heightened awareness is warranted for potential lateral talar dome OCLs in patients presenting with anterolateral ankle impingement with a hypertrophic ATiFLdf identified on preoperative MRI in the absence of an associated OCLs., Level of Evidence: Level IV, Retrospective case series., (© 2024 European Society of Sports Traumatology, Knee Surgery and Arthroscopy.)

Purpose: To assess outcomes following Achilles in-office needle tendoscopy (IONT) for the treatment of chronic Achilles tendinopathy (cAT) at a minimum 12-month follow-up., Methods: A retrospective case series was conducted to evaluate patients who underwent Achilles IONT for cAT between January 2019 and December 2022. Inclusion criteria were patients ≥18 years of age and clinical history, physical history, and magnetic resonance imaging findings consistent with cAT who did not respond to a minimum of 3 months of conservative management for which each patient underwent Achilles IONT and had a minimum 12-month follow-up. Clinical outcomes were evaluated using the Victorian Institute of Sport Assessment-Achilles and visual analog scale scores. Patient satisfaction was measured at the final follow-up visit with a 5-point Likert scale., Results: Twelve patients (13 Achilles) with a mean age of 50.9 ± 14.6 years were included in the study. The mean follow-up time was 26.3 ± 6.3 months. The mean Victorian Institute of Sport Assessment-Achilles scores improved from a preoperative score of 35.6 ± 5.9 to a postoperative score of 83.6 ± 14.1 ( P < .001). The mean visual analog scale score improved from a preoperative score of 6.6 ± 1.0 to a postoperative score of 1.3 ± 1.7 ( P < .001). There were 10 patients (83.3%) who participated in sports activities before the IONT procedure. Within this group, 9 patients (90.0%) returned to play at a mean time of 5.9 ± 2.6 weeks. The mean time to return to work was 4.2 ± 1.2 days. Patients reported an overall positive IONT experience with a mean rating scale of 4.5 ± 0.9., Conclusions: This retrospective review demonstrated that Achilles IONT for the treatment of cAT results in significant improvements in subjective clinical outcomes and a low complication rate together with high patient satisfaction scores at short-term follow-up., Level of Evidence: Level IV, therapeutic case series., Competing Interests: The authors report the following potential conflicts of interest or sources of funding: J.G.K. is a consultant for Arteriocyte, In2Bones, and 10.13039/100007307Arthrex and receives financial support from the 10.13039/100014852Ohnell Family Foundation, Mr Winston Fischer, and Tatiana Rybak. All other authors (J.J.B, G.W.R. L.S, M.R., M.B.W., A.L.G.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Full ICMJE author disclosure forms are available for this article online, as supplementary material., (© 2024 The Authors.)

Purpose: The purpose of this systematic review was to evaluate the clinical and radiological outcomes together with the complication rates and failure rates at short-term follow-up following particulated juvenile cartilage allograft (PJCA) for the management of osteochondral lesions of the talus (OLT)., Methods: During October 2023, the PubMed, Embase and Cochrane library databases were systematically reviewed to identify clinical studies examining outcomes following PJCA for the management of OLTs. Data regarding study characteristics, patient demographics, lesion characteristics, subjective clinical outcomes, radiological outcomes, complications and failures were extracted and analysed., Results: Twelve studies were included. In total, 241 patients underwent PJCA for the treatment of OLT at a weighted mean follow-up of 29.0 ± 24.9 months. The weighted mean lesion size was 138.3 ± 59.6 mm 2 . Prior surgical intervention was recorded in seven studies, the most common of which was microfracture (65.9%). The weighted mean American Orthopaedic Foot and Ankle Society score improved from a preoperative score of 58.5 ± 3.2 to a postoperative score of 83.9 ± 5.3. The weighted mean postoperative magnetic resonance observation of cartilage repair tissue (MOCART) score was 48.2 ± 3.3. The complication rate was 25.2%, the most common of which was allograft hypertrophy (13.2%). Thirty failures (12.4%) were observed at a weighted mean time of 9.8 ± 9.6 months following the index procedure., Conclusion: This systematic review demonstrated a moderate improvement in subjective clinical outcomes following PJCA for the treatment of OLT at short term follow-up. However, postoperative MOCART scores were reported as poor. In addition, a high complication rate (25.2%) and a high failure rate (12.4%) at short-term follow-up was observed, calling into question the efficacy of PJCA for the treatment of large OLTs. In light of the available evidence, PJCA for the treatment of large OLTs cannot be currently recommended., Level of Evidence: Level IV., (© 2024 European Society of Sports Traumatology, Knee Surgery and Arthroscopy.)

Complex regional pain syndrome (CRPS) is an uncommon cause of residual pain after total knee arthroplasty (TKA). The presentation is variable, and there is no gold standard diagnostic test. Diagnosis is more difficult after TKA because some classic signs of CRPS may be unreliable and imaging may be difficult to interpret. Early intervention is the most important factor in predicting improvement, necessitating high suspicion in patients with exaggerated pain and stiffness after excluding more common causes. This article reviews the literature regarding CRPS following TKA, explains the diagnosis, and discusses treatment. [Orthopedics. 2020;43(6):e486-e491.]., (Copyright 2020, SLACK Incorporated.)

Introduction: Improper cup positioning and leg length discrepancy (LLD) are two of the most common errors following total hip arthroplasty (THA) and are associated with potentially significant consequences. Obesity is associated with increased risk of mechanical complications, including dislocations, which may be secondary to cup malposition and failure to restore leg length and offset. 3D Optical Camera computerassisted navigation (CAN) system may reduce the risk of component malposition and LLD with real time intraoperative feedback. The aim of this study was to investigate whether the use of CAN influences acetabular component placement (CP) accuracy and leg length restoration in obese (body mass index(BMI)≥35kg/m 2 ) patients undergoing primary THA., Methods: A multi-center retrospective review was conducted identifying consecutive THA cases with BMI > 35kg/m 2 using CAN (Intellijoint Hip, Waterloo, CA) from 2015-2019. These patients were then matched with patients undergoing conventional THA (control) at a 1:1 ratio according to BMI, American Society of Anesthesiologists score, and gender. TraumaCad™ software (Brainlab, Chicago, IL) was used to measure cup anteversion, inclination, and change (Δ) in LLD between pre- and postoperative radiographic images. The safety target zones used as reference for precision analysis of CP were 15°-30° for anteversion and 30°-50° for inclination., Results: 176 patients were included: 88 CAN and 88 control cases. CAN cases were found to have a lower ΔLLD than controls (3.53±2.12mm vs. 5.00±4.05mm; p=0.003). Additionally, more CAN cases fell within the target safe zone than controls (83% vs.60%, p=0.00083)., Conclusion: Our findings suggest that the use of a CAN system may be more precise in component placement, and useful in facilitating the successful restoration of preoperative leg length following THA than conventional methodology., (© 2020 Delhi Orthopedic Association. All rights reserved.)

Background: There has been a recent surge in health-care providers offering stem cell therapy (SCT) to patients with musculoskeletal disease. The purpose of this study was to identify and quantify the misinformation present in online direct-to-consumer (DTC) advertising of SCT targeting patients with musculoskeletal disease in the U.S. It was hypothesized that DTC advertising of SCT contains substantial misinformation., Methods: A list of keywords was used to identify web sites of practices advertising SCT directly to patients with musculoskeletal disease. Web sites were evaluated to determine the specialties of providers offering SCT, types of SCT being advertised, and misinformation presented. Categories of misinformation included false general claims, inaccurate statements regarding mechanism of action, unfounded results, and scare tactics., Results: Of the 896 practice web sites included in the analysis, 95.9% contained at least 1 statement of misinformation, with a mean of 4.65 ± 3.66 statements of misinformation among the sites. Practices associated with an orthopaedic surgeon provided 22% fewer statements of misinformation than practices without an orthopaedic surgeon when we controlled for the effects of other specialties. Practices associated with a podiatrist also provided 22% fewer statements of misinformation., Conclusions: Nearly all practices failed to accurately represent the clinical efficacy of SCT in DTC advertising. While practices associated with an orthopaedic surgeon were less likely to provide misinformation, the majority of all web sites contained some type of misinformation, ranging from errors in the basic science of stem cells to outright false and misleading claims of their clinical effectiveness.

Background: Pathogenic variants in TGFBR1 , TGFBR2 and SMAD3 genes cause Loeys-Dietz syndrome, and pathogenic variants in FBN1 cause Marfan syndrome. Despite their similar phenotypes, both syndromes may have different cardiovascular outcomes. Methods: Three expert centers performed a case-matched comparison of cardiovascular outcomes. The Loeys-Dietz group comprised 43 men and 40 women with a mean age of 34 ± 18 years. Twenty-six individuals had pathogenic variants in TGFBR1 , 40 in TGFBR2 , and 17 in SMAD3 . For case-matched comparison we used 83 age and sex-frequency matched individuals with Marfan syndrome. Results: In Loeys-Dietz compared to Marfan syndrome, a patent ductus arteriosus ( p = 0.014) was more prevalent, the craniofacial score was higher ( p < 0.001), the systemic score lower ( p < 0.001), and mitral valve prolapse less frequent ( p = 0.003). Mean survival for Loeys-Dietz and Marfan syndrome was similar (75 ± 3 versus 73 ± 2 years; p = 0.811). Cardiovascular outcome was comparable between Loeys-Dietz and Marfan syndrome, including mean freedom from proximal aortic surgery (53 ± 4 versus 48 ± 3 years; p = 0.589), distal aortic repair (72 ± 3 versus 67 ± 2 years; p = 0.777), mitral valve surgery (75 ± 4 versus 65 ± 3 years; p = 0.108), and reintervention (20 ± 3 versus 14 ± 2 years; p = 0.112). In Loeys-Dietz syndrome, lower age at initial presentation predicted proximal aortic surgery (HR = 0.748; p < 0.001), where receiver operating characteristic analysis identified ≤33.5 years with increased risk. In addition, increased aortic sinus diameters (HR = 6.502; p = 0.001), and higher systemic score points at least marginally (HR = 1.175; p = 0.065) related to proximal aortic surgery in Loeys-Dietz syndrome. Conclusions: Cardiovascular outcome of Loeys-Dietz syndrome was comparable to Marfan syndrome, but the severity of systemic manifestations was a predictor of proximal aortic surgery.

Objective: Incompetence of the lower esophageal sphincter (LES) is a key factor in the pathogenesis of gastroesophageal reflux disease (GERD). Drugs with anticholinergic properties, such as tricyclic antidepressants (TCAs), may facilitate GERD by a relaxing effect on the LES., Aim: To investigate whether the use of TCAs is associated with an increased risk of reflux esophagitis (RE)., Method: A population-based case-control study was conducted within a large Dutch primary care database over the period 1996-2005. Cases with endoscopy-confirmed RE were identified and matched with up to 10 controls on gender, age, GP practice, and calendar time. Exposure to TCAs was assessed in the year prior to diagnosis and categorized as current (last prescription covered or ended within one month prior to the index date), past, and no use. The relative risk of RE was estimated by odds ratios (OR) with 95% confidence intervals (95% CI) using multivariate conditional logistic regression analysis., Results: During the study period, 1,462 cases with endoscopy-confirmed RE were identified. The risk of RE was increased in current TCA users (OR(adj) 1.61, 95% CI 1.04-2.50). Drug-specific analyses revealed that only clomipramine was associated with an increased risk of RE (OR(adj) 4.6, 95% CI 2.0-10.6) in a duration- and dose-dependent manner (OR(adj) 7.1, 95% CI 2.7-19.2 for use >180 days and OR(adj) 9.2, 95% CI 1.6-51.5 for >1 DDD equivalent/day)., Conclusion: No association was observed between the risk of RE and the use of TCAs other than clomipramine. The association between RE and clomipramine might be drug-related or a result of the underlying indication.