Citations

AbstractInfection 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 postoperative infections. Allografts had a higher risk of infection than autografts (odds ratio, 6.8; 95% CI, 0.9–54.5; p = .045). Diabetes (odds ratio, 28.6; 95% CI, 5.5–149.9; p = .004) was a risk factor for infection. Patient age, sex, BMI, and smoking status were not associated with risk of infection after rACLR.

Background: Abdominal aortic aneurysm (AAA) is an important cause of cardiovascular mortality; however, its genetic determinants remain incompletely defined. In total, 10 previously identified risk loci explain a small fraction of AAA heritability. Methods: We performed a genome-wide association study in the Million Veteran Program testing ≈18 million DNA sequence variants with AAA (7642 cases and 172 172 controls) in veterans of European ancestry with independent replication in up to 4972 cases and 99 858 controls. We then used mendelian randomization to examine the causal effects of blood pressure on AAA. We examined the association of AAA risk variants with aneurysms in the lower extremity, cerebral, and iliac arterial beds, and derived a genome-wide polygenic risk score (PRS) to identify a subset of the population at greater risk for disease. Results: Through a genome-wide association study, we identified 14 novel loci, bringing the total number of known significant AAA loci to 24. In our mendelian randomization analysis, we demonstrate that a genetic increase of 10 mm Hg in diastolic blood pressure (odds ratio, 1.43 [95% CI, 1.24–1.66]; P =1.6×10 −6 ), as opposed to systolic blood pressure (odds ratio, 1.06 [95% CI, 0.97–1.15]; P =0.2), likely has a causal relationship with AAA development. We observed that 19 of 24 AAA risk variants associate with aneurysms in at least 1 other vascular territory. A 29-variant PRS was strongly associated with AAA (odds ratio PRS , 1.26 [95% CI, 1.18–1.36]; P PRS =2.7×10 −11 per SD increase in PRS), independent of family history and smoking risk factors (odds ratio PRS+family history+smoking , 1.24 [95% CI, 1.14–1.35]; P PRS =1.27×10 −6 ). Using this PRS, we identified a subset of the population with AAA prevalence greater than that observed in screening trials informing current guidelines. Conclusions: We identify novel AAA genetic associations with therapeutic implications and identify a subset of the population at significantly increased genetic risk of AAA independent of family history. Our data suggest that extending current screening guidelines to include testing to identify those with high polygenic AAA risk, once the cost of genotyping becomes comparable with that of screening ultrasound, would significantly increase the yield of current screening at reasonable cost.

AbstractPurposeThere is limited data comparing the outcomes of knee arthroplasty for arthritis secondary to meniscus root tear versus primary osteoarthritis. The aim of this 2:1 matched case control series was to compare outcomes in patients who underwent arthroplasty for arthritis following a meniscus root tear (root tear cohort—“RTC”) with a control group of patients with primary osteoarthritis (primary osteoarthritis—“controls”). The authors hypothesized that the meniscus root tear patients would have similar clinical outcomes, return to activity, complication and reoperation rates as their matched controls.MethodsA consecutive series of patients who had a clinically and radiographically confirmed meniscus root tear between 2002 and 2017 at a mean 4.8 year follow‐up that developed secondary arthritis were matched 2:1 by laterality, surgery, age at surgery, date of surgery, sex, and surgeon to a control group of patients with primary osteoarthritis, without a root tear, who underwent arthroplasty. No patients were lost to follow‐up. Patient demographics, Kellgren–Lawrence grades at the time of surgery, pre‐ and post‐operative Knee Society Score pain and function scores, Tegner score, complications, and survival free of reoperation were analyzed between groups.ResultsA total of 225 subjects were identified, including 75 root tear cohort patients (13 UKA, 62 TKA) and 150 control patients. The root tear cohort had significantly lower Kellgren–Lawrence grades than the control group at the time of arthroplasty (p ≤ 0.001), but similar baseline pre‐operative Knee Society Score pain, Knee Society Score function, and Tegner activity scale score. Post‐operatively, Knee Society Score pain scores were comparable, and root tear cohort Knee Society Score function scores statistically significantly improved (p ≤ 0.007). Complication rates and survival free of reoperation at final follow‐up were not statistically significantly different between groups.ConclusionPatients treated with arthroplasty for secondary arthritis after a meniscus root tear demonstrated less severe radiographic arthritis, but similar pre‐operative pain levels compared to matched controls with primary osteoarthritis. The root tear cohort patients demonstrated improved outcomes with respect to function, and similar outcomes with respect to pain, activity level, complication rates, and reoperation rates. The authors conclude that arthroplasty can be a reliable option for selected patients with an irreparable root tear and ongoing pain and dysfunction refractory to non‐operative management, even in the setting of less advanced osteoarthritis on X‐ray.Level of evidenceIII.

Abstract Central giant cell granuloma (CGCG) is a relatively uncommon benign bony lesion accounting for approximately 7% of all non-neoplastic lesions of the jaw. The clinical behavior of CGCG can vary from a slow-growing, painless lesion to fast-growing and locally destructive. When such a lesion involves the mandible, this can be quite debilitating for the patient, inhibiting oral intake and requiring an extensive resection and bone graft reconstruction. The authors present a case of effectively decreasing the surgical morbidity associated with a large and rapidly growing CGCG of the mandible in a pediatric patient. Neoadjuvant immunotherapy with denosumab (human monoclonal antibody) facilitated treatment of the tumor without the need for a large resection which would have otherwise necessitated a vascularized bony mandibular reconstruction. Consideration of neoadjuvant medical management of CGCG as the primary treatment is advocated.

Abstract Background and study aims The Full-Thickness Resection Device (FTRD) provides a novel treatment option for lesions not amenable to conventional endoscopic resection techniques. There are limited data on the efficacy and safety of FTRD for resection of upper gastrointestinal tract (GIT) lesions. Patients and methods This was an international multicenter retrospective study, including patients who had an endoscopic resection of an upper GIT lesion using the FTRD between January 2017 and February 2019. Results Fifty-six patients from 13 centers were included. The most common lesions were mesenchymal neoplasms (n = 23, 41 %), adenomas (n = 7, 13 %), and hamartomas (n = 6, 11 %). Eighty-four percent of lesions were located in the stomach, and 14 % in the duodenum. The average size of lesions was 14 mm (range 3 to 33 mm). Deployment of the FTRD was technically successful in 93 % of patients (n = 52) leading to complete and partial resection in 43 (77 %) and 9 (16 %) patients, respectively. Overall, the FTRD led to negative histological margins (R0 resection) in 38 (68 %) of patients. A total of 12 (21 %) mild or moderate adverse events (AEs) were reported. Follow-up endoscopy was performed in 31 patients (55 %), on average 88 days after the procedure (IQR 68–138 days). Of these, 30 patients (97 %) did not have any residual or recurrent lesion on endoscopic examination and biopsy, with residual adenoma in one patient (3 %). Conclusions Our results suggest a high technical success rate and an acceptable histologically complete resection rate, with a low risk of AEs and early recurrence for FTRD resection of upper GIT lesions.

Abstract The incidence of sport-related concussion coupled with a doubling of the participation rate in youth hockey over the past two decades provides impetus for the review of the most promising concussion treatment options. This narrative review summarizes the future treatment options for sport-related concussions in ice hockey, while acknowledging their generalizability to concussion in all sports. Symptom assessment, sign observation, as well as cognitive and balance testing, have historically been used to diagnose a concussion. These methods continue to improve, but the need for effective treatments is clear. Pharmacologic, transcranial light, and nutritional supplement treatment options for concussion warranting further investigation have been identified. Dimethyl fumarate is an immunomodulatory compound thought to trigger antioxidant gene expression. Memantine reduces apoptosis and astrogliosis by inhibiting the calcium influx into cells normally caused by glutamate's activation of N -methyl- d -aspartate receptors. Thioredoxin-mimetic peptides and transcranial photobiomodulation temper the effects of the energy crisis by acting as free radical scavengers. In addition, seven neuroprotective nutritional supplements have been identified: berberine, creatine, curcumin, melatonin, omega-3 fatty acids, resveratrol, and vitamins. An estimated US $1.1 billion has been spent on unsuccessful traumatic brain injury clinical trials. As our ability to accurately diagnose concussion improves, dimethyl fumarate, memantine, thioredoxin-mimetic peptides, transcranial photobiomodulation, and nutritional supplements (berberine, creatine, curcumin, melatonin, omega-3 fatty acids, resveratrol, and vitamins) warrant further preclinical and clinical examination in advancing the treatment of sport-related concussions.

Fair Play (FP) is a behavioral modification program originally created in Quebec, Canada, by Edmund Vaz when injuries, violence, aggressive infractions, and expense drastically decreased ice hockey registration numbers. He found that emphasizing sportsmanship had the potential to reduce dangerous plays. FP awards teams one additional point in the district standings after each game if the following criteria are met: (a) the team remained below the predetermined penalty minute threshold, (b) a coach was not assessed a game misconduct, and (c) none of the spectators were ejected from the arena. In collaboration with the Mayo Clinic, Minnesota Hockey adopted FP successfully in 2004. However, it was only applied to district games, accounting for just 36% of the games in a team's season. FP is currently a loosely recommended model in tournaments and plays no role in nondistrict games. In a study of two youth hockey tournaments, the tournament governed by intensified FP found significantly fewer head hits than the tournament without FP. Junior gold-level tournaments also experienced fewer injuries and concussions when using FP. Despite its established effectiveness, FP is underutilized by Minnesota Hockey. The Mayo Clinic Ice Hockey Research Team (MCIHRT) has therefore determined that FP requires a complete relaunch. The Minnesota Hockey board members, district leaders, and MCIHRT have agreed that increasing visibility and establishing universal application by Minnesota Hockey leadership are the most urgent needs. The MCIHRT action plan addressing shortcomings includes: (a) making a FP announcement before and after games; (b) publishing shortened, universal booklets solely regarding FP; (c) coordinating a distribution of new booklets to coaches, officials, and players/parents; and (d) creating webpages on all district and association sites including the rules of FP and access to the FP standings. Finally, creative ways to increase FP's power to favorably modify behavior will be solicited.

Hockey is known for speed, skill, hard hits, and fighting. The violence and aggression present in professional hockey contrasts greatly with the skill and finesse of international play. Aggressive behavior across all levels of hockey has devastating long-term consequences resulting from the high prevalence of head trauma. Retired National Hockey League (NHL) players attribute their cognitive difficulties to the repetitive concussive events sustained during their careers. Some retired professional players, such as Daniel Carcillo and Nick Boynton, claim they would trade their name on the Stanley Cup to have known about the long-term consequences of repetitive head trauma. Many retired professional players, such as Ken Dryden, believe the aggressive intent to injure in hockey is completely unnecessary. Junior A hockey is consistently accompanied by a high risk of head trauma. For example, a single Tier III Junior A team experienced thirteen concussions to ten players in one season. Of six players who perceived it “definitely true” that their role on the team was to be an aggressive, forceful, and physical player, four were objectively diagnosed with a concussion during the season. Hypothesized was that intrinsic psychological factors, such as perceived aggression and willingness to fight, and extrinsic factors, such as role modeling by NHL players and feeling pressured by others to fight, contribute to sustaining concussions in hockey. For example, players perceiving themselves as aggressive and physical are at greater risk of concussion than those who see themselves as finesse, skilled players.

Abstract PURPOSE We investigated the long term impact of SRS and WBRT in two large prospective phase III trials. METHODS Patients with 1–4 BMs +/- resection were randomized to SRS or WBRT. Cognitive deterioration was a drop of >1 standard deviation from baseline in >2/6 cognitive measures (CM). Quality of life (QOL) scores were scored 0–100 point scale. CM and QOL scores were modeled using baseline adjusted Linear Mixed Models (LMM) with uncorrelated random intercept for subject and random slopes for time. Differences in trend over time between groups and the effect of >2 cognitive scores with >2 SD change from baseline were assessed. RESULTS 88 patients were included with median follow up of 24 months. We observed decreasing CM over time (SRS: 4/6; WBRT: 5/6). Mean CM was significantly higher in SRS for Total recall and Delayed Recall at 3, 6, 9, 12 months. More patients in WBRT arm declined 1 SD in >1 and >2 CM at the 3, 6, 9, and 12 months. A 1 SD decline in >3 CM at 1 year was 21% SRS vs 47% WBRT (p=0.02). SRS had fewer patients with a 2 SD decline in >1 CM at every time point. SRS had fewer patients with a 2 SD decline at >2 and >3 CM. WBRT had lower QOL at 3 months, but switched to SRS having lower QOL at 24 months for PWB, EWB, FWB, FactG, BR, and FactBR (p<0.05). A 2 SD decline in cognition decreased mean FWB by 6.4 units (95% CI: -11, -1.75; p=0.007) and decreased QOL by 5.1 units (95% CI: -7.7, -2.5; p<0.001). CONCLUSIONS We report the first pooled prospective study demonstrating the long term outcomes of patients with BMs after cranial radiation. WBRT was associated with worse cognitive outcomes. Impaired cognition is associated with worse QOL.

Objectives: Meniscal root disruption results in a loss of hoop strain resistance, increased articular cartilage contact pressure, and acceleration of degenerative changes. There is limited data comparing the outcomes of similarly matched patients with a medial meniscus posterior root tear treated with non-operative management, partial meniscectomy, or repair. The purpose of this study is to compare treatment failure, clinical outcome scores, and radiographic findings for a matched cohort of patients who underwent either non-operative management, partial meniscectomy, or transtibial pull-through repair for a medial meniscus posterior root tear (MMPRT). Our hypothesis is that patients who underwent meniscus root repair will have lower rates of progression to arthroplasty than patients who were treated with non-operative management or partial meniscectomy. Methods: Patients who underwent transtibial medial meniscus posterior horn root repair were matched by meniscus laterality, age, sex and K-L grades to patients treated non-operatively or with a partial meniscectomy. Progression to arthroplasty rates, IKDC and Tegner scores, and radiographic outcomes were analyzed between groups. Results: Forty-five patients were included in this study (15 non-operative, 15 partial meniscectomy, 15 root repair). Progression to arthroplasty demonstrated significant differences among treatment groups at a mean 74 months (non-operative 4/15, partial meniscectomy 9/15, meniscus repair 0/15, p=.0003). The meniscus root repair group had significantly less arthritic progression, as measured by change in K-L grade from pre-op to post-op (non-operative 1.0, partial mensicectomy 1.1, and meniscus repair 0.1, p=.001). Conclusion: Meniscus root repair leads to significantly less arthritis progression and subsequent knee arthroplasty compared to non-operative management and partial meniscectomy in a demographically matched cohort.