Citations

Background: There is a paucity of clinical information to guide the treatment of a combined anterior cruciate ligament (ACL) tear and Segond fracture. Purpose: To compare clinical outcomes, graft failure rates, and activity levels between patients undergoing ACL reconstruction (ACLR) with and without an untreated Segond fracture at a minimum 2-year follow-up. Study Design: Cohort study; Level of evidence, 3. Methods: This study included a group of patients with a combined ACL tear/untreated Segond fracture that was matched based on age, sex, body mass index, and graft type to a control group of patients with an ACL tear and no Segond fracture. All patients were treated with ACLR alone between the years of 2000 and 2015. The diagnosis of a Segond fracture, or bony avulsion of the anterolateral complex, was made by radiographic analysis. Data regarding the initial injury, surgical intervention, and physical examination findings were recorded. Clinical and functional outcomes were obtained using physical examination results, International Knee Documentation Committee (IKDC) subjective scores, and Tegner activity levels. Results: Twenty patients (16 male, 4 female) with a combined ACL tear/untreated Segond fracture with a mean age of 26.3 years (range, 13-44 years) were matched to a control group of 40 patients (32 male, 8 female) with an ACL tear and no Segond fracture with a mean age of 26.4 years (range, 13-47 years). The study group was followed for a mean of 59.1 months (range, 24-180 months) and the control group for a mean of 55.5 months (range, 24-120 months). The mean IKDC score was 86.5 (range, 54-100) for the study group compared with 93.0 (range, 54-100) for the control group ( P = .03). The graft rupture rate was 10% for both groups ( P = .97). The mean time to rupture was 33.0 months (range, 21-45 months) in the study group and 63.5 months (range, 39-88 months) in the control group ( P = .24). Patients in the study group had significantly more anteroposterior instability by preoperative Lachman testing than those in the control group (control group: 0 normal, 3 grade 1+, 37 grade 2+, 0 grade 3+; study group: 0 normal, 1 grade 1+, 10 grade 2+, 9 grade 3+; P = .0001). There was no significant difference between the 2 groups in regard to postoperative Lachman testing (control group: 35 normal, 3 grade 1+, 2 grade 2+, 0 grade 3+; study group: 17 normal, 3 grade 1+, 0 grade 2+, 0 grade 3+; P = .31). Patients in the study group had significantly more instability by preoperative pivot-shift testing than those in the control group (control group: 0 normal, 7 grade 1+, 33 grade 2+, 0 grade 3+; study group: 1 normal, 1 grade 1+, 11 grade 2+, 7 grade 3+; P = .0003). No significant difference was found between the 2 groups for postoperative pivot-shift testing (control group: 36 normal, 2 grade 1+, 2 grade 2+, 0 grade 3+; study group: 18 normal, 1 grade 1+, 1 grade 2+, 0 grade 3+; P = .61) or final Tegner activity level (median, 6). Conclusion: At midterm follow-up, patients undergoing ACLR with and without a Segond fracture had similar pivot-shift test results, graft failure rates, and activity levels. The IKDC score was statistically worse in the patients with a combined ACL tear/untreated Segond fracture, but the difference was less than the minimal clinically important difference for the IKDC score. These findings suggest that patients with a combined ACL tear/untreated Segond fracture can have comparable outcomes to patients with an ACL tear and no Segond fracture when treated with ACLR alone.

The effect of removing the airway epithelium on the responses of canine airways of decreasing diameter to contractile and relaxing agonists was explored. Three orders of canine bronchus were studied: second order (lobar bronchus), third order (segmental bronchus), and fourth order (subsegmental bronchus). Paired rings of tissue, with and without epithelium, were placed in organ chambers in physiological salt solution gassed with 95% O2–5% CO2 and maintained at 37 degrees C. For second- and third-order bronchi, epithelium removal caused significant left-ward shifts of the concentration-effect curves for 5-hydroxytryptamine, histamine, and acetylcholine. In fourth-order bronchi, there was no significant shift for any of the contractile agonists. Isoproterenol (during contractions evoked by acetylcholine) induced concentration-dependent relaxations that were significantly greater in bronchi with than in those without epithelium. This effect was most prominent in fourth-order bronchi. These results suggest that 1) the canine airway epithelium releases a relaxing factor, 2) in larger airways the major effect is reduction of contractile responses, and 3) in smaller airways the major effect is enhancement of relaxing responses.

Responses to arachidonate were examined in rings with and without epithelium of lobar, segmental, and subsegmental canine bronchi. Arachidonate evoked epithelium-dependent relaxations, which were less pronounced in subsegmental bronchi and abolished by indomethacin and meclofenamate. Nordihydroguairetic acid (NDGA) and nafazatrom reduced epithelium-dependent relaxations only in lobar but unmasked epithelium-independent relaxations to arachidonate in all bronchi. Prostaglandin E2 and prostacyclin relaxed all tissues similarly. In lobar bronchi without epithelium, basal release of prostaglandin E2 was reduced by indomethacin but unaffected by NDGA. Arachidonate augmented prostaglandin E2 release more in subsegmental than in lobar bronchi with epithelium; in bronchi without epithelium the rise was absent (lobar) or attenuated (subsegmental). Arachidonate augmented the release of 6-ketoprostaglandin F1 alpha more in lobar bronchi with than without epithelium; this was inhibited by indomethacin, but not NDGA. Thus arachidonate releases prostaglandin E2 (possibly produced by cyclooxygenase inaccessible to inhibitors and activated by lipoxygenase products) but not prostacyclin from the epithelium. Heterogeneity in response to arachidonate is not due to different sensitivity to, or production of, prostaglandins.

Experiments were conducted in canine bronchi to determine whether the effect of epithelium removal on relaxations was affected by the contractile agent used to induce active force and the degree of contraction. Pairs of fourth-order bronchi with and without epithelium were suspended in organ chambers in physiological salt solution (95% O2-5% CO2, 37 degrees C). The bronchi were contracted to the concentration of acetylcholine or 5-hydroxytryptamine that resulted in a contraction that was 40 or 80% of the response to 10(-4) M of the agonist (ED40 or ED80). Epithelium removal reduced relaxations to isoproterenol and sodium nitroprusside during contraction to the ED80 but not the ED40 of acetylcholine. Responses to forskolin were not affected. Bronchi were significantly more sensitive to relaxing agonists in the presence of 5-hydroxytryptamine; there was no effect on epithelium removal or level of contraction. Thus 1) the influence of epithelium on bronchial relaxation is greatest during high degrees of cholinergic tone and 2) experimental conditions influence the effect of epithelium removal on relaxation.

Purpose To (1) assess clinical outcomes of revision multiligament knee injury (MLKI) reconstruction at a minimum of 2 years' follow‐up and (2) present a standardized treatment algorithm used in treating revision MLKI patients. Methods A retrospective review of our institution's MLKI database was performed to identify all patients who underwent revision MLKI reconstructions (≥2 ligaments reconstructed) after implementation of a standardized treatment algorithm in 2000 and had a minimum of 2 years' follow‐up. Patient demographic information, injury description (mechanism of injury, neurovascular status, knee dislocation grade, associated chondral or meniscal injury), surgical technique (repair vs reconstruction, staged vs nonstaged, concomitant procedures), mechanism of failure, knee stability, and range of motion, as well as International Knee Documentation Committee and Lysholm scores, were obtained. Results We assessed 23 patients (8 female and 15 male patients), with an average age of 26.7 ± 11.5 years at primary surgery and 30.8 ± 11.0 years at revision surgery. The mean follow‐up period was 7.5 ± 5.3 years. Of the 23 patients, 10 (43.4%) underwent staged revision procedures: isolated bone grafting in 3, osteotomy in 4, hardware removal with osteochondral allograft in 1, hardware removal with bone grafting in 1, and meniscus repair for a locked knee in 1. The average International Knee Documentation Committee and Lysholm scores were 74.5 ± 22.3 and 79.4 ± 20.2, respectively. High‐energy injury and increasing age at revision surgery were the only risk factors found to be associated with significantly worse outcomes ( P < .05). Conclusions Patients with recurrent instability after MLKI reconstruction present with many concomitant pathologies, including limb malalignment, bone tunnel widening, retained hardware, meniscal incompetence, and cartilage defects. Revision MLKI reconstruction can provide these patients with modest functional outcomes when a standardized treatment algorithm is used focusing on identification and treatment of the concomitant pathology, often in a staged manner. Level of Evidence Level IV, case series.

Background: Efforts to safely reduce length of stay for emergency department patients with symptoms suggestive of acute coronary syndrome (ACS) have had mixed success. Few system-wide efforts affecting multiple hospital emergency departments have ever been evaluated. We evaluated the effectiveness of a nationwide implementation of clinical pathways for potential ACS in disparate hospitals. Methods: This was a multicenter pragmatic stepped-wedge before-and-after trial in 7 New Zealand acute care hospitals with 31 332 patients investigated for suspected ACS with serial troponin measurements. The implementation was a clinical pathway for the assessment of patients with suspected ACS that included a clinical pathway document in paper or electronic format, structured risk stratification, specified time points for electrocardiographic and serial troponin testing within 3 hours of arrival, and directions for combining risk stratification and electrocardiographic and troponin testing in an accelerated diagnostic protocol. Implementation was monitored for >4 months and compared with usual care over the preceding 6 months. The main outcome measure was the odds of discharge within 6 hours of presentation Results: There were 11 529 participants in the preimplementation phase (range, 284–3465) and 19 803 in the postimplementation phase (range, 395–5039). Overall, the mean 6-hour discharge rate increased from 8.3% (range, 2.7%–37.7%) to 18.4% (6.8%–43.8%). The odds of being discharged within 6 hours increased after clinical pathway implementation. The odds ratio was 2.4 (95% confidence interval, 2.3–2.6). In patients without ACS, the median length of hospital stays decreased by 2.9 hours (95% confidence interval, 2.4–3.4). For patients discharged within 6 hours, there was no change in 30-day major adverse cardiac event rates (0.52% versus 0.44%; P =0.96). In these patients, no adverse event occurred when clinical pathways were correctly followed. Conclusions: Implementation of clinical pathways for suspected ACS reduced the length of stay and increased the proportions of patients safely discharged within 6 hours. Clinical Trial Registration: URL: https://www.anzctr.org.au/ (Australian and New Zealand Clinical Trials Registry). Unique identifier: ACTRN12617000381381.

Abstract Patellar tendon ruptures are rare but potentially devastating injuries. Acute repair after patellar tendon rupture affords the best opportunity for tension‐free restoration of the extensor mechanism. Biological augmentation of primary repair is believed to decrease strain across the repair site and reduce the risk of rerupture. We present a technique for primary patellar tendon repair with bidirectional fixation using transosseous tunnels, suture anchor fixation, and ipsilateral hamstring autograft augmentation in a distal patellar pole socket. Technique Video video See video under supplementary data.