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Importance In patients with severe aortic valve stenosis at intermediate surgical risk, transcatheter aortic valve replacement (TAVR) with a self-expanding supra-annular valve was noninferior to surgery for all-cause mortality or disabling stroke at 2 years. Comparisons of longer-term clinical and hemodynamic outcomes in these patients are limited. Objective To report prespecified secondary 5-year outcomes from the Symptomatic Aortic Stenosis in Intermediate Risk Subjects Who Need Aortic Valve Replacement (SURTAVI) randomized clinical trial. Design, Setting, and Participants SURTAVI is a prospective randomized, unblinded clinical trial. Randomization was stratified by investigational site and need for revascularization determined by the local heart teams. Patients with severe aortic valve stenosis deemed to be at intermediate risk of 30-day surgical mortality were enrolled at 87 centers from June 19, 2012, to June 30, 2016, in Europe and North America. Analysis took place between August and October 2021. Intervention Patients were randomized to TAVR with a self-expanding, supra-annular transcatheter or a surgical bioprosthesis. Main Outcomes and Measures The prespecified secondary end points of death or disabling stroke and other adverse events and hemodynamic findings at 5 years. An independent clinical event committee adjudicated all serious adverse events and an independent echocardiographic core laboratory evaluated all echocardiograms at 5 years. Results A total of 1660 individuals underwent an attempted TAVR (n = 864) or surgical (n = 796) procedure. The mean (SD) age was 79.8 (6.2) years, 724 (43.6%) were female, and the mean (SD) Society of Thoracic Surgery Predicted Risk of Mortality score was 4.5% (1.6%). At 5 years, the rates of death or disabling stroke were similar (TAVR, 31.3% vs surgery, 30.8%; hazard ratio, 1.02 [95% CI, 0.85-1.22]; P = .85). Transprosthetic gradients remained lower (mean [SD], 8.6 [5.5] mm Hg vs 11.2 [6.0] mm Hg; P < .001) and aortic valve areas were higher (mean [SD], 2.2 [0.7] cm 2 vs 1.8 [0.6] cm 2 ; P < .001) with TAVR vs surgery. More patients had moderate/severe paravalvular leak with TAVR than surgery (11 [3.0%] vs 2 [0.7%]; risk difference, 2.37% [95% CI, 0.17%- 4.85%]; P = .05). New pacemaker implantation rates were higher for TAVR than surgery at 5 years (289 [39.1%] vs 94 [15.1%]; hazard ratio, 3.30 [95% CI, 2.61-4.17]; log-rank P < .001), as were valve reintervention rates (27 [3.5%] vs 11 [1.9%]; hazard ratio, 2.21 [95% CI, 1.10-4.45]; log-rank P = .02), although between 2 and 5 years only 6 patients who underwent TAVR and 7 who underwent surgery required a reintervention. Conclusions and Relevance Among intermediate-risk patients with symptomatic severe aortic stenosis, major clinical outcomes at 5 years were similar for TAVR and surgery. TAVR was associated with superior hemodynamic valve performance but also with more paravalvular leak and valve reinterventions.

AbstractPurposeThis study sought to develop and internally validate a machine learning model to identify risk factors and quantify overall risk of secondary meniscus injury in a longitudinal cohort after primary ACL reconstruction (ACLR).MethodsPatients with new ACL injury between 1990 and 2016 with minimum 2‐year follow‐up were identified. Records were extensively reviewed to extract demographic, treatment, and diagnosis of new meniscus injury following ACLR. Four candidate machine learning algorithms were evaluated to predict secondary meniscus tears. Performance was assessed through discrimination using area under the receiver operating characteristics curve (AUROC), calibration, and decision curve analysis; interpretability was enhanced utilizing global variable importance plots and partial dependence curves.ResultsA total of 1187 patients underwent ACLR; 139 (11.7%) experienced a secondary meniscus tear at a mean time of 65 months post‐op. The best performing model for predicting secondary meniscus tear was the random forest (AUROC = 0.790, 95% CI: 0.785–0.795; calibration intercept = 0.006, 95% CI: 0.005–0.007, calibration slope = 0.961 95% CI: 0.956–0.965, Brier’s score = 0.10 95% CI: 0.09–0.12), and all four machine learning algorithms outperformed traditional logistic regression. The following risk factors were identified: shorter time to return to sport (RTS), lower VAS at injury, increased time from injury to surgery, older age at injury, and proximal ACL tear.ConclusionMachine learning models outperformed traditional prediction models and identified multiple risk factors for secondary meniscus tears after ACLR. Following careful external validation, these models can be deployed to provide real‐time quantifiable risk for counseling and timely intervention to help guide patient expectations and possibly improve clinical outcomes.Level of evidenceIII.

Summary Background Optimal ambulatory reflux monitoring methodology in symptomatic reflux patients continues to be debated. Aims To utilise published literature and expert opinion to develop recommendation statements addressing use of ambulatory reflux monitoring in clinical practice Methods The RAND Appropriateness Method (RAM) was utilised among 17 experts with discussion, revision and two rounds of ranking of recommendation statements. Ambulatory reflux monitoring protocol, methodology and thresholds ranked as appropriate by ≥80% of panellists met the criteria for appropriateness. Results Prolonged (96‐h recommended) wireless pH monitoring off proton pump inhibitor (PPI) was identified as the appropriate diagnostic tool to assess the need for acid suppression in patients with unproven gastro‐oesophageal reflux disease (GERD) and persisting typical reflux symptoms despite once‐daily PPI. Acid exposure time (AET) <4.0% on all days of monitoring with negative reflux‐symptom association excludes GERD and does not support ongoing PPI treatment. Conversely, AET >6.0% across ≥2 days is conclusive evidence for GERD and supports treatment for GERD, while AET >10% across ≥2 days identifies severe acid burden that supports escalation of anti‐reflux treatment. In previously proven GERD, impedance‐pH monitoring on PPI is helpful in defining refractory GERD and mechanisms of continued symptoms; the presence of <40 reflux events, AET <2.0% and a negative reflux‐symptom association does not support escalation of anti‐reflux treatment. In contrast, AET > 4.0% and positive reflux‐symptom association support escalation of anti‐reflux treatment, including use of invasive therapeutics. Conclusions Statements meeting appropriateness for average clinical care have been identified when utilising reflux monitoring in patients with typical reflux symptoms and PPI non‐response.

Objectives:Introduction: Wrestling is a physically demanding sport with young athletes prone to anterior cruciate ligament (ACL) injuries. However, there is a paucity of data evaluating the results of ACL reconstruction (ACLR) in this cohort. Purpose: To assess patient-reported outcomes, reoperation rates, graft survival, and return to play (RTP) following ACLR in a large cohort of competitive wrestlers Methods: All competitive wrestlers (high school, collegiate, or professional) with a history of an ACLR at a single institution between 2000 and 2019 were retrospectively identified. Graft failure was defined as a re-tear determined by clinical or advanced imaging evaluation, and/or revision ACL reconstruction. All patients were contacted for determination of reinjury rates, current sport status, visual analog scale (VAS), International Knee Documentation Committee (IKDC) and Tegner activity scores. Results: 118 knees in 114 wrestlers were included at a median follow-up time of 5.8 years (IQR: 3.6 – 10.3). The median age was 17 years (15 – 18) with 116 (98%) males. ACLR was most often performed with bone-patellar tendon-bone (BTB) autograft (n = 64; 54%) or hamstring tendon (HT) autograft (n = 43; 36%). At final follow-up, 80% of athletes were able to RTP at a median of 273 days (IQR: 203 – 379). Graft failure occurred in 17 (14%) patients at a median time of 1.4 years (IQR: 0.8 – 4.7) after the index ACLR. BTB autograft demonstrated a lower failure rate compared to HT autograft (8% vs. 21%; P = 0.044). Kaplan-Meier survivorship free from graft failure for the entire cohort was 95.3% at 1 year, 92.5% at 2 years, 89.8% at 5 years, 84.6 at 10 years, 77.6 at 20 years. BTB autograft was associated with better survival than HT autograft up to 15 years after the index ACLR (90.4% vs. 76.3%; P = 0.030). Conclusions: Return to competitive wrestling was observed in 80% of athletes after ACLR, with 14% of wrestlers experiencing graft failure. BTB autograft reconstruction may serve as a more durable graft for competitive wrestlers with lower rates of failure when compared to HT autograft even up to 15 years after surgery. [Table: see text][Figure: see text][Figure: see text][Figure: see text]

Objectives: The medial patellofemoral ligament (MPFL) is the primary soft tissue restraint to lateral patellar translation and is often disrupted with a lateral patellar dislocation. Surgical management for recurrent patellar instability focuses on restoring MPFL function with repair or reconstruction techniques. Recent studies have favored reconstruction over repair, but no long-term, comparative studies are available in the literature. Methods: A total of 55 patients (58 knees) with recurrent lateral instability were treated between 2005 and 2012 with either MPFL repair or MPFL reconstruction. Exclusion criteria included prior or concomitant tibial tubercle osteotomy or trochleoplasty, and follow-up less than 8 years. Pre- and post-operative demographic, surgical, imaging and clinical data were recorded for each patient. Results: MPFL repair was performed on 26 patients (29 knees; 14 females, 15 males) at a mean age of 19.1 years. MPFL reconstruction was performed on 29 patients (29 knees; 18 females, 11 males) at a mean age of 18.2 years. Mean follow-up was 12.0 years (range 8.3-18.9). The reconstruction group had a significantly lower rate of recurrent dislocation compared to the repair group (14% vs 41%, p=0.019) at final follow up. There were no differences in the number of pre-operative dislocations (greater than or less than 3), degree of patellar facet chondromalacia, TT-TG distance, or Tegner scores. The reconstruction group had significantly more time from injury to surgery compared to the repair group (median, 1,460 days vs 627 days, p =0.007). There were no differences in post-operative Tegner, Lysholm or Kujala scores at final follow-up. Additionally, there were no differences in return to play rates (repair 80.8% vs reconstruction 75.0%, p=0.610) or reoperation rates (repair 20.7% vs reconstruction 13.8%, p=0.487). Conclusions: Repair of the MPFL leads to nearly 3-fold higher rate of recurrent patellar dislocation (41% vs. 14%) at long term follow-up compared to MPFL reconstruction. However, MPFL repair and reconstruction provide similar clinical results, return to play rates and reoperation rates. [Table: see text][Table: see text]

Objectives: Objectives: Previous analyses have characterized the incidence of lateral meniscus oblique radial tears (LMORT) commonly seen with ACL tears, and their impact on joint and meniscus stability in the presence of ACL deficiency. Purpose: To determine the clinically relevant kinematics associated with LMORT lesions untreated versus arthroscopic repair versus partial meniscectomy in combination with anterior cruciate ligament reconstruction (ACLR). Methods: Sixteen cadaver knees underwent robotic testing for anterior drawer (AD) and pivot shift (PS) simulations at multiple knee flexion angles in intact and ACL-deficient states, followed by sequential testing of arthroscopic ACL reconstruction (ACLR), creation of a LMORT 3 lesion, LMORT 3 repair, and partial meniscectomy (PM; n=8). The same testing sequence was performed for LMORT 4 lesions (n=8). Changes (Δ) from the intact state for anterior translation, internal rotation, and valgus displacements, as well as ultrasoundographic measurements of meniscal extrusion, were measured and comparatively analyzed. Results: ACLR restored kinematics in ACL-deficient knees to intact levels for all metrics tested. For AD, ACLR + LMORT3 tear and PM resulted in significantly greater anterior translation (0.8-2.1 mm differences) compared to ACL-intact at all angles ( P < 0.05) and compared to ACLR at 60 o and 90 o ( P < 0.014). For PS, ACLR + LMORT3 tear had significantly more anterior translation (1-1.4 mm differences) at 15 o than intact knees (P=0.041), and at 0 o and 15 o for PM ( P < 0.03). ACLR + LMORT4 tear and PM resulted in significantly greater anterior translation (0.9-2.3 mm differences) for AD ( P < 0.04) and PS testing ( P < 0.05) compared to intact and ACLR knees at all angles tested. ACLR+LMORT 3 repair and ACLR+LMORT4 repair restored kinematics to ACLR and intact levels at all angles tested. ACLR + LMORT3 tear ( P < 0.008) and both LMORT4 tear and PM ( P < 0.05) resulted in increased meniscal extrusion (1.8-11 mm differences) compared to intact and ACLR statuses at all tested angles for AD and PS while repairs restored meniscus stability to ACLR and intact levels. Conclusions: Untreated LMORT 3 and 4 tears increased anterior translation, pivot shift, and meniscus extrusion even after ACLR, while partial meniscectomy further exacerbated these detrimental effects. In contrast, arthroscopic side-to-side repair of LMORT lesions effectively restored measured knee kinematics. UPLOAD- https://planion-client-files.s3.amazonaws.com/AOSSM/blobs/6bf43418-abf1-49bd-b78b-cc0c501a2da0/1/AOSSM_Abstract_Images.docx UPLOAD- https://planion-client-files.s3.amazonaws.com/AOSSM/blobs/b0f0bf53-a166-4cec-bf73-176ea452b905/1/AOSSM_Abstract_CHART.docx

Objective: To define benchmark values for liver transplantation (LT) in patients with perihilar cholangiocarcinoma (PHC) enabling unbiased comparisons. Background: Transplantation for PHC is used with reluctance in many centers and even contraindicated in several countries. Although benchmark values for LT are available, there is a lack of specific data on LT performed for PHC. Methods: PHC patients considered for LT after Mayo-like protocol were analyzed in 17 reference centers in 2 continents over the recent 5-year period (2014–2018). The minimum follow-up was 1 year. Benchmark patients were defined as operated at high-volume centers (≥50 overall LT/year) after neoadjuvant chemoradiotherapy, with a tumor diameter <3 cm, negative lymph nodes, and with the absence of relevant comorbidities. Benchmark cutoff values were derived from the 75th to 25th percentiles of the median values of all benchmark centers. Results: One hundred thirty-four consecutive patients underwent LT after completion of the neoadjuvant treatment. Of those, 89.6% qualified as benchmark cases. Benchmark cutoffs were 90-day mortality ≤5.2%; comprehensive complication index at 1 year of ≤33.7; grade ≥3 complication rates ≤66.7%. These values were better than benchmark values for other indications of LT. Five-year disease-free survival was largely superior compared with a matched group of nodal negative patients undergoing curative liver resection (n=106) (62% vs 32%, P<0.001). Conclusion: This multicenter benchmark study demonstrates that LT offers excellent outcomes with superior oncological results in early stage PHC patients, even in candidates for surgery. This provocative observation should lead to a change in available therapeutic algorithms for PHC.

Background: Lytic or malpositioned tunnels may require bone grafting during revision anterior cruciate ligament reconstruction (rACLR) surgery. Patient characteristics and effects of grafting on outcomes after rACLR are not well described. Purpose: To describe preoperative characteristics, intraoperative findings, and 2-year outcomes for patients with rACLR undergoing bone grafting procedures compared with patients with rACLR without grafting. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 1234 patients who underwent rACLR were prospectively enrolled between 2006 and 2011. Baseline revision and 2-year characteristics, surgical technique, pathology, treatment, and patient-reported outcome instruments (International Knee Documentation Committee [IKDC], Knee injury and Osteoarthritis Outcome Score [KOOS], Western Ontario and McMaster Universities Osteoarthritis Index, and Marx Activity Rating Scale [Marx]) were collected, as well as subsequent surgery information, if applicable. The chi-square and analysis of variance tests were used to compare group characteristics. Results: A total of 159 patients (13%) underwent tunnel grafting—64 (5%) patients underwent 1-stage and 95 (8%) underwent 2-stage grafting. Grafting was isolated to the femur in 31 (2.5%) patients, the tibia in 40 (3%) patients, and combined in 88 patients (7%). Baseline KOOS Quality of Life (QoL) and Marx activity scores were significantly lower in the 2-stage group compared with the no bone grafting group ( P≤ .001). Patients who required 2-stage grafting had more previous ACLRs ( P < .001) and were less likely to have received a bone–patellar tendon–bone or a soft tissue autograft at primary ACLR procedure ( P≤ .021) compared with the no bone grafting group. For current rACLR, patients undergoing either 1-stage or 2-stage bone grafting were more likely to receive a bone–patellar tendon–bone allograft ( P≤ .008) and less likely to receive a soft tissue autograft ( P≤ .003) compared with the no bone grafting group. At 2-year follow-up of 1052 (85%) patients, we found inferior outcomes in the 2-stage bone grafting group (IKDC score = 68; KOOS QoL score = 44; KOOS Sport/Recreation score = 65; and Marx activity score = 3) compared with the no bone grafting group (IKDC score = 77; KOOS QoL score = 63; KOOS Sport/Recreation score = 75; and Marx activity score = 7) ( P≤ .01). The 1-stage bone graft group did not significantly differ compared with the no bone grafting group. Conclusion: Tunnel bone grafting was performed in 13% of our rACLR cohort, with 8% undergoing 2-stage surgery. Patients treated with 2-stage grafting had inferior baseline and 2-year patient-reported outcomes and activity levels compared with patients not undergoing bone grafting. Patients treated with 1-stage grafting had similar baseline and 2-year patient-reported outcomes and activity levels compared with patients not undergoing bone grafting.

Background: Lateral meniscal oblique radial tears (LMORTs) affect joint and meniscal stability in anterior cruciate ligament (ACL)–deficient knees. Purpose: To determine the clinically relevant kinematics associated with the most common posterior horn LMORT lesion types, types 3 (LMORT3) and 4 (LMORT4), untreated versus arthroscopic repair versus partial meniscectomy in combination with ACL reconstruction (ACLR). Study: Controlled laboratory study. Methods: Sixteen cadaveric knees underwent robotic testing for anterior drawer and pivot-shift simulations at multiple knee flexion angles in ACL-intact and ACL-deficient states, followed by sequential testing of arthroscopic ACLR, LMORT3 lesion, LMORT3 repair, and partial meniscectomy (n = 8). The same testing sequence was performed for LMORT4 lesions (n = 8). Results: ACLR restored kinematics in ACL-deficient knees to intact levels for all metrics tested. For anterior drawer, ACLR + LMORT3 tear and partial meniscectomy resulted in significantly greater anterior translation compared with ACL-intact at all angles ( P < .05) and compared with ACLR at 60° and 90° ( P < .014). For pivot shift, compared with ACL-intact knees, ACLR + LMORT3 tear resulted in significantly more anterior translation at 15° ( P = .041); and for ACLR + partial meniscectomy, at both 0° and 15° ( P < .03). ACLR + LMORT4 tear and partial meniscectomy resulted in significantly greater anterior translation for anterior drawer ( P < .04) and pivot-shift testing ( P < .05) compared with intact and ACLR knees at all angles tested. ACLR + LMORT3 repair and ACLR + LMORT4 repair restored kinematics to ACLR and intact levels at all angles tested. ACLR + LMORT3 tear ( P < .008) and both LMORT4 tear and partial meniscectomy ( P < .05) resulted in increased meniscal extrusion compared with intact and ACLR statuses at all tested angles for anterior drawer and pivot shift, while repairs restored meniscal stability to ACLR and intact levels. Conclusion: Untreated LMORT tears increased anterior translation, pivot shift, and meniscal extrusion after ACLR, while partial meniscectomy further exacerbated these detrimental effects in this cadaveric model. In contrast, arthroscopic side-to-side repair of LMORT lesions effectively restored measured knee kinematics. Clinical Relevance: LMORT lesions are common with ACL tears and adversely affect joint stability and meniscal extrusion. This study highlights the importance of repair of LMORT 3 and 4 lesions at the time of ACLR.