The work-up of patellofemoral instability is complex and multifactorial. Patient factors (i.e., age, activity demand, goals/expectations), clinical presentation (pain, instability, or both), and ...physical examination (i.e., J-sign, apprehension into flexion), must be correlated with imaging findings (radiographs, magnetic resonance imaging, computed tomography) and anatomic risk factors, including patella alta, trochlear dysplasia, patellar tilt, lateralized force vector, valgus, femoral anteversion, and tibial torsion. Thus, developing a standard battery of reliable and reproducible radiographic measures of patellofemoral instability is a challenge. Imaging cut-offs provide insight into relative risk of recurrent instability. We still fall short in using imaging parameters to predict when to operate, what procedure(s) to perform, and how the patient might do. Future directions include the use of artificial intelligence and 3-dimensional measurements to help simplify a complex problem.
Purpose
Anterior cruciate ligament reconstruction (ACLR) aims to restore knee function and stability, allowing patients to return to the activities they enjoy and minimize further injury to the ...meniscus and cartilage and their ultimate progression to osteoarthritis. This study aims to present the evolution of graft choice over the last three decades according to members of the ACL Study Group (SG).
Methods
Prior to the January 2020 ACL SG biannual meeting, a survey was administered consisting of 87 questions and 16 categories, including ACLR graft choice. A similar questionnaire has been administered prior to each meeting and survey results from the past 14 meetings (1992 through 2020, excluding 1994) are included in this work. Survey responses are reported as frequencies in percentages to quantify changes in practice over the surgery period.
Results
In 1992, the most frequent graft choice for primary ACLR was bone-patellar tendon-bone (BTB) autograft, at nearly 90%. Hamstring tendon (HT) autografts have increased in popularity, currently over 50%, followed by just under 40% BTB autograft. Recently, quadriceps tendon (QT) autograft has increased in popularity since 2014.
Conclusion
Autograft (HT, BTB, QT) is an overwhelming favorite for primary ACLR over allograft. The preference for HT autograft increased over the study period relative to BTB autograft, with QT autograft gaining in popularity in recent years. Graft selection should be individualized for each patient and understanding the global trends in graft choice can help orthopaedic surgeons discuss graft options with their patients and determine the appropriate graft for each case.
Level of evidence
Level V, Expert Opinion.
The standard of care for a first-time patellar dislocation without loose bodies or osteochondral fracture has been nonoperative treatment. However, studies that show high recurrent instability rates ...and low levels of return to unlimited activity have opened the door to consider early surgical stabilization in high-risk individuals. Risk stratification models have been developed to identify those at highest risk of recurrent dislocation. Although the decision to operate on patients with a first-time dislocation remains controversial, surgeons should at the very least use readily available information to counsel patients regarding their relative risk of recurrence.
Security at the suture-tendon interface is a critical component of soft tissue fixation. For more than 3 decades, the Krackow stitch has been considered the gold standard for soft tissue fixation. ...Modifications of the original configuration have withstood the test of time. Many have been evaluated in preclinical and clinical studies for multiple musculoskeletal applications. Most recently, double Krackow suture configurations have been shown to increase the ultimate failure load of the suture-tendon construct. I have learned this stitch and will add it to my soft tissue fixation arsenal.
Tibial tubercle osteotomy (TTO) is a procedure that may be used to address a wide array of patellofemoral joint pathology. The most common indications for TTO include (1) patellar instability, ...including either a lateralized force vector or abnormal patellar alta, and (2) patellar focal cartilage defects or chondromalacia. Customization of the TTO can effectively address the patellofemoral joint pathology by modifying patellar tracking in the trochlear groove and/or altering the contact pressures experienced by the patellofemoral cartilage. TTO may be most successful when performed in conjunction with soft-tissue stabilization and/or biological augmentation of chondral injuries. Specifically, isolated anteromedialization is recommended for focal, distal lateral patellar lesions; combined anteromedialization and cartilage restoration are recommended for medial, central, and/or panpatellar cartilage pathology; medialization with soft-tissue stabilization is recommended for a lateralized tubercle position (elevated tibial tubercle–trochlear groove distance); and distalization with soft-tissue stabilization is recommended for patella alta. Clinical studies have shown good to excellent results at long-term follow-up when a TTO is performed for patellar instability, whereas TTO performed for chondral defects has shown good to excellent outcomes that correlate strongly with the size and location of the chondral defect. With appropriate patient selection, TTO is a valuable tool for the treatment of patellofemoral joint pathology.
Sports medicine physicians have a keen clinical and research interest in the anterior cruciate ligament (ACL). The biomechanical, biologic, and clinical data researchers generate, help drive injury ...management and prevention practices globally. The current concepts in ACL injury and surgery are being shaped by technological advances, expansion in basic science research, resurging interest in ACL preservation, and expanding efforts regarding injury prevention. As new methods are being developed in this field, the primary goal of safely improving patient outcomes will be a unifying principle. With this review, we provide an overview of topics currently in controversy or debate, and we identify paradigm shifts in the understanding, management, and prevention of ACL tears.
Exposures to extreme ambient temperature and air pollution are linked to adverse birth outcomes, but the associations with small for gestational age (SGA) and term low birthweight (tLBW) are unclear. ...We aimed to investigate exposures to site-specific temperature extremes and selected criteria air pollutants in relation to SGA and tLBW.
We linked medical records of 220,572 singleton births (2002–2008) from 12 US sites to local temperature estimated by the Weather Research and Forecasting model, and air pollution estimated by modified Community Multiscale Air Quality models. Exposures to hot (>95th percentile) and cold (<5th percentile) were defined using site-specific distributions of daily temperature over three-month preconception, each trimester, and whole-pregnancy. Average concentrations of five criteria air pollutants and six fine particulate matter constituents were also calculated for these pregnancy windows. Poisson regression with generalized estimating equations calculated the relative risks (RR) and 95% confidence intervals for SGA (weight <10th percentile conditional on gestational age and sex) and tLBW (≥37 weeks and <2500g) associated with an interquartile range increment of air pollutants, and cold or hot compared to mild (5–95th percentile) temperature. Models were adjusted for maternal demographics, lifestyle, and clinical factors, season, and site.
Compared to mild temperature, cold exposure during trimester 2 RR: 1.21 (1.05–1.38), trimester 3 RR: 1.18 (1.03–1.36), and whole-pregnancy RR: 2.57 (2.27–2.91); and hot exposure during trimester 3 RR: 1.31 (1.15–1.50) and whole-pregnancy RR: 2.49 (2.20–2.83) increased tLBW risk. No consistent association was observed between temperature and SGA. Air pollutant analyses were generally null but preconception elemental carbon was associated with a 4% increase in SGA while dust particles increased tLBW by 10%. Particulate matter ≤10µm in the second trimester and whole pregnancy also appeared related to tLBW.
Our findings suggest prenatal exposures to extreme ambient temperature relative to usual environment may increase tLBW risk. Given concerns related to climate change, these findings merit further investigation.
•Whole-pregnancy cold or hot temperature increased term low birthweight (tLBW) risk.•Cold exposures during trimesters 2 and 3 & hot during trimester 3 increased tLBW risk.•There was no association between temperature and small for gestational age (SGA).•Most associations between air pollution and SGA or tLBW were null.
Abstract Surgeon administered intraoperative shoulder suprascapular nerve block appears to be a safe, effective, “low tech,” and inexpensive alternative to a preoperative interscalene block performed ...by an anesthesia provider. Surgeons should thoughtfully weigh the pros and cons of this technique and consider “taking back the block.”
To compare postoperative infection rates following ACL reconstruction performed with grafts presoaked in vancomycin versus those without vancomycin.
A systematic review was performed using PRISMA ...guidelines. PubMed, SCOPUS, and Cochrane Central Register of Controlled Trials were searched for therapeutic level I to III studies that compared outcomes of presoaking ACL grafts with vancomycin versus without vancomycin in human patients. Included graft types were tendon autografts or allografts, and included studies documented infection with a minimum follow-up of 30 days. Postoperative infection rates and knee-specific patient-reported outcome scores were extracted from each study and compared between groups. Study methodological quality was analyzed using the Methodological Index for Non-Randomized Studies (MINORS) and Modified Coleman Methodology Score (MCMS). Infection rates and retear rates were pooled and weighted for meta-analysis using a random-effects model. All P values were reported with an α level of 0.05 set as significant.
The initial search yielded 144 articles (44 duplicates, 100 screened, 29 full-text review). Ten articles (21,368 subjects 7,507 vancomycin and 13,861 no vancomycin, 67% males, mean ± standard deviation age 29.5 ± 1.5 years) were included and analyzed. Eight of the 10 studies included only autografts, with 94.5% of grafts being hamstring autografts. Soaking grafts in vancomycin resulted in significantly fewer infections (0.013% versus 0.77%; odds ratio 0.07; 95% confidence interval 0.03, 0.18; P < .001). Only 2 studies included patient-reported outcomes, and both demonstrated no difference in International Knee Documentation Committee scores 1 year after surgery for patients with grafts presoaked in vancomycin versus without vancomycin.
Soaking ACL tendon grafts with vancomycin before implantation is associated with a nearly 15 times decrease in odds of infection compared with grafts not soaked in vancomycin. Few studies investigated patient-reported outcomes and retear rates after soaking ACL grafts in vancomycin.
III, systematic review of level III studies
Extreme temperature is associated with adverse birth outcomes but it is unclear whether it increases early delivery risk.
We aimed to determine the association between ambient temperature and early ...delivery.
Medical records from 223,375 singleton deliveries from 12 U.S. sites were linked to local ambient temperature. Exposure to hot (> 90th percentile) or cold (< 10th percentile) using site-specific and window-specific temperature distributions were defined for 3-months preconception, 7-week periods during the first two trimesters, 1 week preceding delivery, and whole pregnancy. Poisson regression with generalized estimating equations calculated the relative risk (RR) and 95% confidence interval for early deliveries associated with hot/cold exposures, adjusting for conception month, humidity, site, sex, maternal demographics, parity, insurance, prepregnancy body mass index, pregnancy complications, and smoking or drinking during pregnancy. Acute temperature associations were estimated separately for warm (May-September) and cold season (October-April) in a case-crossover analysis using conditional logistic regression.
Compared with mild temperature (10-90th percentile), exposure to hot or cold during weeks 1-7 increased risk for early preterm (< 34 weeks) RR
: 1.11 (95% CI: 1.01, 1.21); RR
: 1.20 (95% CI: 1.11, 1.30), late preterm (34-36 weeks) RR
: 1.09 (95% CI: 1.04, 1.15), and early term (37-38 weeks) RR
: 1.04 (95% CI: 1.02, 1.07); RR
: 1.03 (95% CI: 1.00, 1.05) delivery. Findings were similar for hot exposures during weeks 15-21. Examining deliveries at each week from 23 through 38, whole-pregnancy hot exposures increased delivery risk by 6-21% at weeks 34 and 36-38. In the case-crossover analysis, a 5°F increase during the week preceding delivery was associated with 12-16% higher and 4-5% lower early delivery risk during warm and cold season, respectively.
Both acute and chronic ambient temperature extremes may affect early delivery risk. Citation: Ha S, Liu D, Zhu Y, Kim SS, Sherman S, Mendola P. 2017. Ambient temperature and early delivery of singleton pregnancies. Environ Health Perspect 125:453-459; http://dx.doi.org/10.1289/EHP97.
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