Patients' under 25 subjective readiness to return to sport after ACL reconstruction with bone-patellar-bone grafts: Autograft vs. allograft

Purpose

To assess the difference in perceived readiness to return to sport (RTS) within the first year postoperative period between individuals undergoing anterior cruciate ligament (ACL) reconstruction with bone-patellar tendon-bone (BTB) autografts or allografts.

Methods

This was a prospective cohort study of patients undergoing primary ACL reconstruction done either with BTB autograft or allograft from 2010 to 2018. Skeletally mature patients aged 14 to 25 were eligible for inclusion. Patients completed the Marx Activity Rating Scale (MARS) questionnaire postoperatively evaluating perceived ability to perform various activities to compare subjective ability to RTS. Those patients who were outside outlined cohort age, failed to complete a single post-operative survey, underwent revision procedures, or underwent simultaneous or staged additional ligament surgery were excluded.

Results

Fifty-nine patients (20.1 ± 3.19 years, 57.6 % Male) were included in the study. Sixteen patients underwent ACL reconstruction with allograft (19.8 ± 3.43 years) while 43 patients received autograft (20.2 ± 3.13). At 3 months autograft recipients reported higher perceived ability to cut (P = .003). At 6-months, allograft recipients reported higher perceived ability to run (P = .033), cut (P = .048), and decelerate (P = .008) as well as a higher overall perceived ability to RTS (P = .032). At all other times, there was no significant difference between cohorts' subjective readiness to perform activities.

Conclusion

The results of this study indicate that at times within the first year of recovery following ACL reconstruction, patients who receive allografts and autografts may have significantly different perceived ability to perform activities or RTS. However, while present at various times throughout the first year of recovery, any difference in perceived ability to perform activities or in overall RTS is no longer present at 12 months.

Level of evidence

Level II, Prospective cohort study.

Association Between Draft Order and Stress Sonography of the Ulnar Collateral Ligament of the Elbow in Professional Baseball Pitchers: An 18-Year Study

BACKGROUND

The Major League Baseball (MLB) draft is a common route for players to enter professional baseball in the United States. Players taken in earlier rounds are typically higher-performing players. When looking at pitchers specifically, higher performance at the amateur level may be associated with an increased frequency of adaptive change in the throwing elbow.

PURPOSE

To determine whether pitchers taken in earlier rounds of the MLB draft have a greater frequency or extent of pathological change in the elbow, as measured by dynamic stress ultrasound.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

Dynamic stress ultrasounds (SUSs) were performed over 18 years on the dominant and nondominant arms of 651 professional pitchers. The 383 drafted players were grouped according to the round in which they were drafted (rounds 1-5, 6-10, 11-20, 21+). Groups were compared with respect to "relative" ulnar collateral ligament (UCL) thickness (dominant-nondominant), relative ulnohumeral joint laxity (joint space distance under stress minus joint space at rest), and the presence of pathology (calcifications, tears, hypoechoic foci, osteophytes). In addition, a subgroup analysis was done to compare the progression of SUS findings over 3 years in players for which data were available.

RESULTS

Draft round groups did not differ by age, number of previous spring training, or handedness. Comparing baseline measurements, there was no significant relationship between draft round and relative UCL thickness (P = .932), relative laxity (P = .996), or presence of pathology detectable on SUS (P = .642). However, increased relative UCL thickness was significantly associated with the presence of pathology on SUS (odds ratio, 1.45; 95% CI, 1.26-1.69; P < .001). Longitudinally, there was no significant relationship between draft round and 3-year progression of relative laxity, relative UCL thickness, or clinical progression of pathology.

CONCLUSION

Higher-performing pitchers are drafted earlier in the MLB draft. This may be attributable to peak pitch velocity, in-game performance, visibility gained during player showcases, or any number of other sport-specific variables. However, despite this, there was no significant relationship between draft round and adaptive changes to the elbow or specific properties of the UCL on stress ultrasound.

Outcomes of Osteochondral Allograft Transplantation: A Comparative Study of BioUni and Snowman Techniques for Ovoid Lesions

BACKGROUND

Treatment of large articular cartilage lesions of the knee includes surgical options one of which includes cartilage replacement therapies. Among these therapies include osteochondral allograft (OCA) transplantation, which can be performed utilizing a BioUni® (Arthrex BioUni® Instrumentation System; Arthrex, Naples, FL) replacement and a 'snowman' technique of repair.

HYPOTHESIS/PURPOSE

To compare clinical and radiographic outcomes in patients who have undergone multiplug OCA transplantations utilizing a BioUni® replacement and a 'snowman' technique of repair.

METHODS

Patients who underwent OCA transplantation utilizing a snowman technique or BioUni® replacement between January 1st, 2012 and December 31st, 2018, and who had a minimum 1-year follow-up at the same institution were identified for inclusion in this study via current procedural terminology (CPT) codes. Charts of included patients were reviewed for injury and treatment details as well as demographic information. Imaging studies and operative reports were reviewed and pre and postoperative subjective and objective outcome measures were recorded.

RESULTS

Twenty-eight patients underwent OCA transplantation with either BioUni® replacement (n=5) or with snowman technique repair (n=23). Defects in both groups had similar characteristics including size, area, location, and classifications. Patient-reported outcomes using the Knee Injury and Osteoarthritis Outcome Score-Joint Replacement (KOOS-JR), International Knee Documentation Committee (IKDC), and Physical Health Composite Score (PCS-12) were similar at baseline and increased post-operatively for both groups with no significant differences between techniques after a mean follow-up of 2.77 ± 0.83. Although it did not reach significance, the snowman group had higher rates of knee-related complications (13%) and need for revision surgery (22%) when compared to BioUni® (0% and 0%, respectively).

CONCLUSION

The use of both BioUni® and snowman techniques for large, unicondylar articular cartilage lesions of the femoral condyle demonstrate improved patient-reported outcomes at short-term follow-up. The use of the snowman technique presents relatively higher rates of revision similar to previous studies with no statistical difference in patient-reported outcomes when compared to those of a single plug OCA using a BioUni® system.

A Study of Treatments of Congenital Clubfoot in Cerebral Palsy: A Systematic Review

Category:

Ankle; Other

Introduction/Purpose:

Cerebral palsy (CP) can lead to various foot deformities, including equinovarus, or clubfoot position. Patients with CP present a challenge when treating clubfoot as there is aberrant muscle tone and motor dysfunction. Many interventions with variable outcomes are available for patients with clubfoot and cerebral palsy, however, no studies exist that compare existing treatments and outcome measures. The purpose of this study is to investigate the existing body of evidence surrounding the treatments and outcomes of clubfoot in cerebral palsy by way of a systematic review.

Methods:

Using PRISMA guidelines a comprehensive search was conducted of PubMed, Cochrane, CINAHL, Scopus, and Web of Science. Publications were collected which represent all available literature on clubfoot. Articles were screened at the title, abstract, and then full-text level. Only articles that detailed the treatment of pediatric patients with clubfoot, CP, and contained three or more human subjects were included. Publications were excluded from further screening if they were found to be duplicate articles, historical reviews, professional opinions, case reports, or if subjects were non-human. At each level of screening, articles were screened by two independent reviewers to verify that each paper met the predetermined inclusion criteria. Following this, data extraction from primary sources was conducted for; number of patients, age of patients, follow-up length, treatment modality applied, and outcome measures. T-tests were performed using SAS statistical software to determine the relationship between age and type of intervention.

Results:

An initial search yielded 6,469 articles, after review and cross selection, 32 remained as shown in Table 1. Of these, 53.13% (n=17) articles documented surgical tibial tendon transfer (TT): anterior TT (n=5) (mean-age 10.12 +-3.40yrs), posterior TT (n=12) (mean-age 9.30 +-2.57yrs). Botox & casting was referenced in 15.63% (n=5) articles (mean age 5.34 +-1.21yrs), lengthening of tendon or muscle procedures 12.50% (n=4) (mean age 6.30 +-1.69yrs), botox alone 12.50% (n=4) (mean age 6.83 +-1.72yrs), and osteotomy 6.25% (n=2) (mean age 10.94 +-1.51yrs). There was a difference in age for patients receiving TT versus those receiving botox & casting (9.54+-2.75 years old vs 5.34 +-1.21yrs years, p<.05).

Conclusion:

These results indicate the preferred modality of clubfoot correction in the setting of cerebral palsy is tibial transfer. The average age of patients receiving surgical treatments was higher than those with casting, Botox, or orthotics. Due to a lack of standardized outcome measurements reported across studies, we recommend further research aimed specifically at evaluating intervention selection based on patient desired functional outcomes.

Successful Neuromuscular Blockade Reversal Using Sugammadex and Neostigmine Failed to Prevent Myasthenic Crisis After Emergency Surgery: A Case Report

Recent literature suggests that the use of sugammadex for the reversal of neuromuscular blocking agents (NMBAs) reduces the risk of postoperative myasthenic crisis (MC) in patients with myasthenia gravis (MG), particularly after thymectomy, but studies are lacking on emergency surgeries. We achieved successful intraoperative reversal of neuromuscular blockade (NMB) using a combination of sugammadex and neostigmine (with glycopyrrolate). However, MC was not avoided and reintubation was required on postoperative day 1.

A 65-year-old male with a longstanding history of MG presented to the emergency department with complaints of abdominal pain, diarrhea, vomiting, chills, and fatigue for three days. A computed tomography (CT) scan of the abdomen showed acute appendicitis, for which he underwent a laparoscopic appendectomy on hospital day 1. The patient received successful general anesthesia with a rapid sequence induction using a smaller than average dose of rocuronium, given his history of MG. At the conclusion of the case, sugammadex followed by neostigmine/glycopyrrolate and a subsequent dose of sugammadex were given, with reversal of NMB. The patient was successfully extubated but required reintubation on postoperative day 1 for hypercapnic respiratory failure.

Our case report on this patient with MG yields two topics that have not been extensively examined. First, dual therapy with sugammadex and neostigmine/glycopyrrolate may provide significant clinical benefit over individual therapy for NMBA reversal, given that their mechanisms of action are different and particularly when sugammadex is given prior to neostigmine/glycopyrrolate. Second, anesthesia literature is lacking on MG patients undergoing emergency surgeries. While sugammadex has been promising in medically optimized non-emergent surgeries, we discuss here a case where sugammadex failed to prevent MC in the emergency surgery setting and a look into what may provide patients with the best chance for avoiding postoperative MC.

Tuberculosis and sudden death in Baghdad

Tuberculosis deaths represent a recognizable proportion of all medicolegal statistics in and around Baghdad. Out of the total number of autopsies performed at the Medicolegal Institute at Baghdad, Iraq, in the years, 1948, 1953, 1958, 1963, 1968, 1973, and 1978, 168 sudden deaths were attributed to tuberculosis. Bilateral pulmonary tuberculosis was the principle lesion in the majority of the victims. Tuberculosis cavitation was the major finding in 126 cases, followed by advanced pulmonary TB without cavitation in 25. There was no gross abnormality, except for a histological basis of pulmonary TB associated with miliary TB involving hepatic, renal, meningeal, and mesenteric organs in the remaining 17 autopsies. The abrupt and suspicious deaths in older people, especially during cold months, is more likely due to TB. Autopsy should be performed in all cases of sudden and suspicious deaths. Histological study of different body organs, whether death is attributed by the investigative authority or not related to TB, should be required in all medicolegal autopsies, in order to obtain a true picture of TB as a natural cause of death.