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Introduction: Increasing incidence of fragility fractures has spurred development of protocols, largely focused on peri-operative care, with numerous proven benefits. The purpose of this investigation was to evaluate outcomes of our hip fracture treatment program regarding successful protocol implementation, compliance, effect on subsequent fracture rates, and mortality during the first decade of adoption. Methods: A retrospective review identified patients >65 years old with fragility hip fractures between 2010 and 2022. The HiROC (+) cohort consisted of patients who received a "High-Risk Osteoporosis Clinic" (HiROC) referral for bone health evaluation and bisphosphonate initiation as indicated. Additional fracture rates and mortality at 3 years were calculated. Protocol implementation and compliance over the first 10 years was analyzed in the four identified cohorts. Results: A total of 1671 fragility hip fractures were identified, with 386 excluded due to insufficient follow-up, with an average age of 81.6 years and a median follow-up of 36.4 months. Of the 1280 included cases, 56% (n = 717) had a HiROC referral placed. HiROC(+) groups had lower subsequent fracture rates at two years, compared to those without referral (28% vs 13%, P < 0.0001) and those completing more steps of the protocol had lower subsequent fracture rates (28% vs 15% vs 13% vs 5%, P < 0.0001). No statistically significant difference was observed between the cohorts for anatomic site of subsequent fractures. Discussion: Greater than half of all eligible patients were successfully captured by the protocol. Patients completing more steps of the protocol had lower subsequent fracture rates. Captured patients demonstrated reduced mortality rates when compared to current literature. Conclusion: Successful implementation of this geriatric hip fracture protocol was associated with reduced additional fractures and mortality rates. Identifying steps of process failures in the protocol can provide opportunities for increased compliance and reduction in future fracture occurrences. [ABSTRACT FROM AUTHOR]

Background: The association between inherent patellar anatomy and postoperative pain after trochleoplasty in patients with patellar instability is poorly understood. Purpose/Hypothesis: The study purpose was to evaluate outcomes after mini-open, thin-flap trochleoplasty. The hypothesis was that more severe patellar dysplasia would be correlated with increased postoperative pain after trochleoplasty. Study Design: Case series; Level of evidence 4. Methods: Patients with patellar instability who underwent mini-open, thin-flap trochleoplasty in combination with other individualized procedures between 2013 and 2022 were included. Patellar dysplasia was evaluated by calculating the Wiberg index at the widest and most distal cartilaginous parts of the patella on preoperative magnetic resonance imaging. At the postoperative follow-up, participants completed the visual analog scale for usual pain (VAS-U), Banff Patellofemoral Instability Instrument 2.0 (BPII), global rating of change scale, and an evaluation of their current symptom state. Redislocations and complications were recorded. The correlation between the Wiberg index and the VAS-U was calculated with the Spearman rho. Between-group analyses based on demographic and pathoanatomic features were conducted using the Mann-Whitney U test, independent-samples t test, and chi-square test. Results: Included were 75 knees in 63 patients (median age at surgery, 19.1 years; IQR, 16-22 years) with a median follow-up of 44 months (IQR, 23.8-83.2 months). The median BPII score was 78.2 (IQR, 54.8-92.5), with 88% reporting an improvement in knee function relative to before surgery, but 21.1% remained dissatisfied with their current knee symptom state. New episodes of patellar dislocation were seen in 3 knees (4%), and 14 knees (18.7%) underwent reoperation with either revision surgery (n = 7; 9.3%) or arthroscopic synovectomy (n = 7; 9.3%). A weak positive, nonsignificant correlation was found between increased postoperative pain and a higher Wiberg index, both at the widest (r S = 0.16; P =.23) and most distal (r S = 0.02; P =.89) parts of the patella. Significantly worse VAS-U scores were seen in female versus male patients (P =.013). Conclusion: Good patient-reported results with a low risk of redislocation were seen in the study cohort, but reoperation rates were high, and 21% of the patients remained dissatisfied with their current symptom state. More pronounced patellar dysplasia (increased Wiberg index) had only a poor association with more severe postoperative pain in the current study. [ABSTRACT FROM AUTHOR]

Background: Screws for graft fixation are available in 3 different materials for anterior cruciate ligament reconstruction (ACLR) with the Tape Locking Screw (TLS) technique: titanium, poly- l -lactic acid bioabsorbable, and polyetheretherketone (PEEK). Purpose: To compare the effect of the 3 different fixation materials on graft and implant survival after ACLR with the TLS technique. Study Design: Cohort study; Level of evidence, 3. Methods: Included were 521 patients from the French Prospective ACL Study (FAST) cohort who underwent primary surgical ACLR with the TLS technique. Patients were divided into 3 groups depending on the type of screw material used: titanium (TLS-T group), poly -l -lactic acid bioabsorbable (TLS-B group), or PEEK (TLS-P group). The primary endpoint was a retear within 2 years after ACLR. The secondary endpoints were complication rate, return to sports rate, and functional scores. Objective and subjective functional scores—including the International Knee Documentation Committee, the Knee injury and Osteoarthritis Outcome Score (KOOS), and the Lysholm score—were evaluated preoperatively and at the 2-year follow-up. Pain was assessed with the KOOS-Pain subscore recorded pre- and postoperatively every 6 months up to 2 years. Patient satisfaction was recorded at the 2-year follow-up. Results: No significant differences between the study groups were found in retear rates (4.4%, 4.5%, and 4.3% in the TLS-T, TLS-P, and TLS-B groups 2 years after surgery) or subjective and objective outcomes. The TLS-T group had the lowest rate of intraoperative implant-related complications (0.9%) compared with the TLS-P (4.3%) and TLS-B (7.7%) groups. Young age was a significant risk factor for retear in the TLS-T (P =.03) and TLS-B (P =.0001) groups, while a high level of sports was found to be a significant risk factor in the TLS-P (P =.04) group. All functional scores improved significantly at the 2-year follow-up (P <.0001), with no significant group difference. The KOOS-Pain subscore improved continuously with no significant group difference. The rate of return to preinjury sports was between 43.4% and 58.6%. The rate of highly satisfied patients at the final follow-up was between 86.2% and 91.8%. Conclusion: There was no difference in retear rate or objective and subjective functional scores between implant materials for TLS ACLR in this study. [ABSTRACT FROM AUTHOR]

Background: A serious complication after knee arthroscopy is venous thromboembolism (VTE), which includes both deep vein thrombosis (DVT) and pulmonary embolism (PE). However, asymptomatic VTE is frequently undetected. Purpose: To (1) report the incidence of VTE after knee arthroscopy using ultrasound examination and computed tomography pulmonary angiography (CTPA) and (2) discover the independent risk factors of VTE after knee arthroscopy and determine the corresponding cutoff values of these indicators. Study Design: Case-control study; Level of evidence, 3. Methods: Included were 222 patients (115 male) who underwent arthroscopic knee procedures between October 2022 and January 2023. Baseline characteristics, blood test results, and VTE assessments were collected. During the 2-week follow-up, routine lower extremity vascular ultrasound was applied for DVT measurement, with CTPA evaluation for suspected PE. Patients were allocated into VTE and no-VTE groups, and descriptive statistics were used to analyze baseline data. Logistic regression analysis was used to determine the correlation between binary variables and the presence of postoperative VTE. Multivariate logistic regression analysis was further performed to determine the independent risk factors of VTE. Results: Of the 222 patients, 37 (16.7%) had DVT and 1 (0.5%) had both DVT and PE. Compared to the no-VTE group, the VTE group was significantly older, with more female patients; higher body mass index (BMI) and postoperative D-dimer level; and higher rates of hypertension, hyperlipidemia, varicose veins of the lower extremity, and abnormal postoperative fibrin degradation product level (P ≤.043 for all). Notably, operative time >20 minutes was not significantly associated with postoperative VTE (P =.513). The independent risk factors for VTE included age >32 years (odds ratio [OR], 20.71 [95% CI, 4.40-97.47]; P <.001), BMI >23 kg/m2 (OR, 3.52 [95% CI, 1.11-11.14]; P =.032), hyperlipidemia (OR, 6.81 [95% CI, 1.86-24.88]; P =.004), and postoperative D-dimer level >0.63 mg/L (OR, 34.01 [95% CI, 7.36-157.07]; P <.001). Conclusion: The incidence of VTE after knee arthroscopy was 16.7% at the 2-week follow-up. Age >32 years, BMI >23 kg/m2, hyperlipidemia, and postoperative D-dimer >0.63 mg/L were independent risk factors of postoperative VTE within 2 weeks after knee arthroscopy. For patients with knee arthroscopy, the cutoff value of postoperative D-dimer for VTE was found to be 0.63 mg/L for timely intervention. [ABSTRACT FROM AUTHOR]

Background: Previous studies have reported on the impact of race and ethnicity on access to orthopaedic procedures in the United States. However, there are few studies evaluating racial disparities in elective foot and ankle surgeries. Recognizing and addressing disparities in the access of health resources are steps to improve care rationing. Our study specifically investigated potential racial disparities with utilization and perioperative metrics of lateral ankle ligament reconstruction. Methods: A retrospective study was performed using the National Surgical Quality Improvement Program (NSQIP) database. Current Procedural Terminology (CPT) code 27698 was used to identify patients who underwent LALR from 2011 to 2020. Sixty-one percent of these patients had available race/ethnicity data and were included in the study. Designations of race and ethnicity were standardized as White non-Hispanic, Black non-Hispanic, Hispanic, Asian American and Pacific Islander, and Other. Race/ethnicity stratifications of NSQIP patients were compared to 2010 and 2020 census data from the United States (US) Census Bureau. Thirty-day postoperative complications and total length of hospital stay, for all complications, were also compared between White patients and all other patients combined. Independent t tests, χ2, and Fisher exact tests were performed to compare differences including age, gender, and postoperative complications. Results: Overall, 1295 patients were included in the study. White non-Hispanic patients underwent 3.3 times more LALR than all other patients during the study period. This finding shows a higher prevalence of surgery on White non-Hispanic patients than all others reported in the US Census Bureau data for 2010 and 2020, where the ratio of White non-Hispanic vs all others were 1.9 and 1.5-fold, respectively. White patients were marginally older with a mean age of 38 years, compared with 36 years for Black patients (P <.05). There were no differences in 30-day complication rates or total length of hospital stay based on race and ethnicity. Conclusion: Our study found that there was increased utilization of LALR for White non-Hispanic patients compared with all other racial/ethnic groups. These numbers do not mimic the current population trends based on the national census data. Despite this discrepancy, no differences in postoperative complications and length of stay were found based on race and ethnicity. These results suggest that there may be barriers for patients who are not White non-Hispanic to undergo care for LALR. Level of Evidence: Level III, retrospective cohort study. [ABSTRACT FROM AUTHOR]

Background: Plating of proximal phalangeal fracture is the commonly adopted fixation method. However, whether placing the implant at the dorsal or lateral aspect of the phalanx can yield a better clinical outcome is still under debate. Our study aims to compare the functional outcome of dorsal plating versus lateral plating in patients suffering from a proximal phalangeal fracture. Methods: A retrospective comparative study was performed comparing the clinical outcome of dorsal and lateral plating in proximal phalangeal fracture. Fourteen patients from our center with a total of 17 proximal phalangeal fractures (excluding the thumb) were included in this study. The total range of movement and range of movement of each finger joint together with grip strength were the main focuses of this study. Operative complications and the need for subsequent related operations were also analyzed. Results: Nine cases were treated by dorsal plating and eight cases adopted lateral plating. There was no significant difference in demographic data between the two groups with a mean follow-up period of 20.75 months. Lateral plating provided better total range of movement (dorsal plating (D): 203.9 ± 35.2 vs. lateral plating (L): 248.8 ± 23.7; p -value = 0.01) and percentage change in total range of movement (D: 79.41% ± 10.35, L: 94.47% ± 6.09; p -value < 0.01). There was less extension lag in lateral plating as evidenced by the sum of extension lag of the three finger joints being statistically significantly smaller (D: 32.8 ± 14.2 vs. L: 4.44 ± 6.2, p < 0.01). Less percentage decrease in grip strength compared with the contralateral normal hand was also noted in the lateral plating group (D: 68.17% ± 31.11 vs. L: 98.13% ± 10.88, p = 0.02). Conclusions: Based on this study, lateral plating provides better functional outcomes in terms of range of movement, extension lag, and grip strength than dorsal plating. Level of Evidence: Therapeutic, retrospective comparative study, Level III. [ABSTRACT FROM AUTHOR]

Introduction/Objectives: To assess the utility of the computerized cognitive function assessment tool, CogEvo, as a screening tool for mild cognitive impairment in primary care, we explored the relationship between CogEvo performance, age, and the severity of cognitive dysfunction evaluated by the Mini-Mental State Examination (MMSE). Methods: The observational cross-sectional study included 209 individuals' data (mean age 79.4 ± 8.9 years). We conducted a correlation analysis between CogEvo and MMSE scores, compared the performance among the 3 cognitive function groups (MMSE ≥ 28 group; MMSE24-27 group; MMSE ≤ 23 group) using the MMSE cut-off, and evaluated CogEvo's predictive accuracy for cognitive dysfunction through ROC analysis. Results: Both total CogEvo and MMSE scores significantly decreased with age. A significant positive correlation was observed between total CogEvo and MMSE scores, but a ceiling effect was detected in MMSE performance. Significant differences were observed in the total CogEvo score, including orientation and spatial cognitive function scores, among the 3 groups. CogEvo showed no educational bias. ROC analyses indicated moderate discrimination between the MMSE ≥ 28 group and the MMSE24-27 and MMSE ≤ 23 groups. Conclusions: The computer-administered CogEvo has the advantage of not exhibiting ceiling effects or educational bias like the MMSE, and was found to be able to detect age-related cognitive decline and impairment. [ABSTRACT FROM AUTHOR]

Background: Anterior cruciate ligament reconstruction (ACLR) performed by high-volume surgeons/clinics has been associated with increased graft individualization and decreased operating times, complication rates, and total costs. Purpose: To investigate the influence of surgeon/clinic volume on subjective knee function and revision surgery rates at 2 years after primary ACLR. Study Design: Cohort study; Level of evidence, 3. Methods: Data from the Swedish National Knee Ligament Registry were used to study patients who underwent primary ACLR between 2008 and 2019. Surgeons/clinics were categorized based on a combination of total caseload volume (cutoff: 50 ACLRs/surgeon, 500 ACLRs/clinic) and annual volume (cutoff: 29 ACLRs/year/surgeon, 56 ACLRs/year/clinic). The thresholds of minimal important change (MIC), Patient Acceptable Symptom State (PASS), and treatment failure (TF) relative to the Knee injury and Osteoarthritis Outcome Score (KOOS) and KOOS4 (mean score of the KOOS Pain, Symptoms, Sports/Rec, and QoL subscales) were applied. Adjusted multivariable logistic regression was performed to assess variables influencing the MIC, PASS, or TF of the KOOS and KOOS4. Adjusted Cox regression analysis was conducted to determine the hazard ratio of subsequent ACLR. Results: Of 35,371 patients, 16,317 had 2-year follow-up outcome data and were included. Patients who underwent primary ACLR by high-volume surgeons had significantly higher MIC and PASS rates and lower TF rates when compared with patients who underwent the procedure by low-volume surgeons: MICKOOS4: 70.6% vs 66.3%; PASSKOOS4: 46.0% versus 38.3%; and TFKOOS4: 8.7% versus 11.8% (all P <.02). Significantly decreased odds of achieving MICKOOS4 (OR, 0.74; 95% CI, 0.62-0.88) and PASSKOOS4 (OR, 0.71; 95% CI, 0.60-0.84) were found for ACLRs performed by low-volume surgeons. Clinic volume did not influence the odds of reaching MIC, PASS, or TF. Overall, 804 patients (2.3%) underwent subsequent ACLR at <2 years, with significantly higher revision rates among patients operated on at high-volume clinics (2.5% vs 1.7%; P <.001). However, in the adjusted Cox regression, surgeon/clinic volume had no influence on subsequent ACLR rates. High-volume surgeons/clinics had decreased time to surgery, operating time, perioperative complication rates, and use of thromboprophylaxis and nonroutine antibiotics (P <.001). Conclusion: Patients who underwent primary ACLR by high-volume surgeons experienced increased improvement and satisfaction regarding subjective knee function. Factors other than surgical volume influenced subsequent surgery rates. Patients might benefit from undergoing primary ACLR by high-volume providers. [ABSTRACT FROM AUTHOR]

Background: The coronal lateral collateral ligament (LCL) sign (the entire LCL being seen in 1 coronal slice on a magnetic resonance imaging [MRI] scan), is a new secondary sign of anterior cruciate ligament (ACL) tear. Purpose: To (1) evaluate the coronal LCL sign in adults with ACL tears and (2) compare the magnitude of the MRI scan parameters between adolescent and adult ACL-deficient knees with positive coronal LCL signs. Study design: Cross-sectional study; Level of evidence: 3. Methods: We retrospectively reviewed patients who underwent ACL reconstruction between February 1, 2013, and May 31, 2021, and divided them into adolescent (10-18 years) and adult (>18 years) groups. Tibial translation, femorotibial rotation, and presence of the coronal LCL sign were evaluated using MRI. The static femorotibial position parameters were also compared between positive and negative coronal LCL sign groups. Independent Student t tests were used to identify statistically significant differences for continuous variables, whereas the categorical variables were compared using the chi-square test. Results: A total of 65 adolescents and 300 adults with ACL tears were identified. The coronal LCL sign was present in a similar percentage of adolescents and adults with ACL tears (57% vs 58%; P = .873). The anterior tibial translation (ATT) in patients with positive coronal LCL signs (adolescents, 7.9 ± 3.4 mm; adults, 6.6 ± 3.5 mm) was significantly greater compared with those with negative signs (adolescents, 1.5 ± 2.6 mm, P < .001; adults, 2.3 ± 4.2 mm, P < .001). Femorotibial rotation was also statistically greater in positive coronal LCL sign groups (adolescents, 6.4°± 5.6°; adults, 7.0°± 5.0°) compared with negative sign groups (adolescents, 0.7°± 4.7°, P < .001; adults, 3.5°± 4.2°, P < .001). Conclusion: The occurrence of the coronal LCL sign on MRI scans was comparable between adolescents and adults with ACL-deficient knees. The presence of the LCL sign was associated with a greater ATT and femorotibial rotation in both adolescents and adults with ACL tears. [ABSTRACT FROM AUTHOR]

Background: Tibial tubercle osteotomy (TTO) is a well-established surgical treatment option for patients with patellofemoral disorders. Purpose: To determine the rate of early (≤90 day) postoperative complications after TTO and variables related to postoperative complications. Study Design: Case series; Level of evidence, 4. Methods: Patients who underwent TTO at a single academic institution within a 15-year period (2008-2022) were identified. All patients with a minimum 90-day follow-up were considered for study inclusion. Exclusion criteria were age younger than 14 years and revision surgery. Patient characteristics, surgical history, and concomitant procedures were identified, and risk factor analysis was performed to identify variables associated with early postoperative complications. Results: A total of 344 knees in 313 patients met eligibility criteria and were included in the final analysis. One intraoperative complication (0.3%), a premature closure of the incision before repair of the vastus medialis, was identified. There were 141 postoperative complications (138 surgical, 3 medical) in 118 patients for a complication rate of 34.3%. The most common complications were stiffness requiring a nonstandard-of-care intervention (16.3%), superficial wound infection/wound dehiscence (8.1%), and hemarthrosis/effusion requiring aspiration (5.8%). Patients experiencing postoperative complications were older (mean difference, 3.49 years; 95% CI, 1.26-5.73 years; P =.002), had a higher mean Charlson Comorbidity Index (mean difference, 0.26; 95% CI, 0.08-0.45; P =.006), and were more likely to be current smokers (P =.015) compared with patients with no complications. Inpatient surgery (defined as surgery in a hospital setting with at least 1 overnight stay) was associated with postoperative complications (odds ratio [OR], 2.29; 95% CI, 1.39-3.77; P =.001); this association remained significant generation of a multivariate model (OR, 2.07; 95% CI, 1.19-3.58; P =.010). Previous surgery on the ipsilateral knee (P <.001) and concomitant autologous chondrocyte implantation (P =.046) were also associated with postoperative complications. Conclusion: The study findings indicated a low intraoperative complication rate (0.3%) and a relatively high early postoperative (≤90 day) complication rate (34.3%) after TTO. Variables associated with postoperative complications included greater age, higher Charlson Comorbidity Index, surgery in an inpatient setting, previous surgery on the ipsilateral knee, and concomitant autologous chondrocyte implantation. [ABSTRACT FROM AUTHOR]

Background: Arthroscopic repair of longitudinal tears in the medial meniscal posterior horn (MMPH) has been reported to result in high rates of meniscal healing when performed alongside anterior cruciate ligament reconstruction (ACLR). However, studies that have focused on longitudinal tears and their impact on clinical outcomes after arthroscopic repair are insufficient. Purpose: To investigate the clinical outcome and healing status after concomitant arthroscopic ACLR and repair of MMPH peripheral longitudinal tears, with respect to the tear length. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 263 patients who underwent concurrent arthroscopic suture repair of longitudinal tears of the MMPH and ACLR were enrolled. All patients had 2-year postoperative magnetic resonance imaging (MRI) evaluations, and 61% of patients underwent a second-look arthroscopy. The exclusion criteria were partial meniscectomies and multiligament injuries. Patients were assessed pre- and postoperatively for clinical scores, amount of anterior translation, grade of pivot shift, and presence of meniscal tear extension. According to the length of longitudinal tears, patients were classified into 2 groups: (1) patients with tears that were located in the posterior compartment and (2) patients with tears that extended to the midbody of the meniscus. Binary stepwise logistic regression analysis was used to evaluate the risk factors for unhealed menisci as identified by MRI. Results: A total of 83 patients were included in this study—52 patients (group 1) had MMPH tears without tear extension and 31 patients (group 2) had MMPH tears with tear extension. There were no differences in outcomes between the groups, including the healing rate after meniscal repair (P >.05). Based on postoperative MRI scans, 67 patients (80.7%) were categorized as completely healed and 16 patients (19.3%) as unhealed. There were no significant differences between the completely healed and unhealed groups in outcomes or the rate of preoperative midbody tear extension. Higher body mass index and lower preoperative Lysholm scores were identified as risk factors for unhealed menisci. Conclusion: Overall, the rate of complete healing of MMPH tears repaired concomitantly with ACLR was 80.7% (67/83), and midbody tear extension did not affect the healing rate of the repaired meniscus. Results indicate that suture repair for unstable MMPH tears should be considered regardless of tear size. [ABSTRACT FROM AUTHOR]

Background: Large variations exist in the reported frequency and etiology of posterior and combined shoulder instability in the active-duty military population. Purpose: To compare imaging and clinical examination findings as well as reoperation rates between active-duty military patients who underwent surgery for anterior, posterior, and combined-type shoulder instability. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A retrospective review was conducted on patients treated surgically for shoulder instability from a single military base from January 2010 to December 2019. Each case was characterized as isolated anterior, isolated posterior, or combined, according to arthroscopic findings. Information was collected on patient characteristics, history of trauma, time to surgery, associated pathological findings, and survivorship at a minimum 2-year follow-up. Results: Overall, 416 patients (n = 394 men; n = 22 women), with a mean age of 29.1 years, underwent primary shoulder stabilization surgery during the study period. There were 158 patients (38%) with isolated anterior instability, 139 (33%) with isolated posterior instability, and 119 (29%) with combined instability. A history of trauma was more prevalent with isolated anterior instability (129 [81.7%]) than with either isolated posterior (95 [68.4%]) or combined instability (73 [61.3%]) (P =.047 and P =.001, respectively). Patients with anterior instability were significantly more likely to be diagnosed on the preoperative physical examination when compared with patients with posterior instability (93% vs 79.1%; P <.001) or combined instability (93% vs 75.6%; P <.001) and were also more likely to have a discrete labral tear detected on a preoperative magnetic resonance arthrogram than patients with posterior instability (82.9% vs 63.3%; P <.001). There was no significant difference in the rate of medical discharge or recurrent instability requiring reoperation between groups. Conclusion: The study findings indicated that young, active-duty military patients are at increased risk for isolated posterior and combined-type shoulder instability, with posterior and combined instability collectively accounting for over 60% of instability cases in this cohort. Orthopaedic surgeons should be aware of instability when evaluating and treating young, active-duty military patients with shoulder pain, even in the absence of diagnostic physical examinations or imaging findings. [ABSTRACT FROM AUTHOR]

Background: There are no studies on the nonoperative treatment of traumatic partial anterior cruciate ligament (ACL) graft rupture. Purpose/Hypothesis: The purpose of this study was to compare the clinical and radiological outcomes and failure rates between nonoperative treatment and revision ACL reconstruction for traumatic partial ACL graft rupture. We hypothesized that the outcomes and failure rates would be comparable and that nonoperative treatment of traumatic partial ACL graft rupture can produce satisfactory outcomes. Study Design: Cohort study; Level of evidence, 3. Methods: We retrospectively evaluated 2114 patients treated for isolated ACL rupture between January 2000 and June 2020. Patients with traumatic partial graft rupture after ACL reconstruction with minimum 2-year follow-up data were included. Patients who met all the following conditions were candidates for nonoperative treatment: (1) Lachman or pivot-shift grade 0 or 1 at 6 months after ACL reconstruction, (2) ACL graft with low to intermediate signal intensity on 1-year postoperative magnetic resonance imaging (MRI), and (3) MRI after reinjury showing definite evidence of trauma, some fibers remaining in continuity of the ACL graft, and no anterior tibial subluxation in the sagittal plane. The patients were divided into 2 groups according to treatment method: nonoperative treatment (group A) and revision ACL reconstruction (group B). Clinical scores, laxity test results, radiological outcomes, and graft failures were compared between the groups. Results: In total, 47 patients had traumatic partial graft rupture (group A, n = 10; group B, n = 37). There were no significant differences between the 2 groups in terms of clinical scores, laxity tests, radiological outcomes, or graft failure. Conclusion: The clinical and radiological outcomes of nonoperative treatment of traumatic partial graft rupture after ACL reconstruction were comparable with those of revision ACL reconstruction. Nonoperative treatment of traumatic partial ACL graft rupture can produce satisfactory outcomes in selected patients. [ABSTRACT FROM AUTHOR]

Background: The advantages of remnant tissue preservation in anterior cruciate ligament (ACL) reconstruction (ACLR) remain controversial. Hypothesis: It was hypothesized that a large amount of remnant tissue, especially if anatomically positioned, would improve patient-reported outcomes and second-look graft appearance after preserved double-bundle ACLR (DB-ACLR). Study Design: Cohort study; Level of evidence, 3. Methods: This retrospective study included 89 consecutive patients who underwent unilateral remnant-preserving DB-ACLR using 2 hamstring tendon autografts. The authors categorized the arthroscopic findings into 3 groups according to the location and volume of the ACL remnant tissue in the femoral notch: (1) anatomical attachment (group AA; n = 34); (2) nonanatomical attachment (group NA; n = 33); and (3) no remnant (group NR; n = 22). Based on second-look arthroscopy, the reconstructed graft was graded as excellent, fair, or poor. Patient-reported outcomes were evaluated at 2 years after surgery using the Knee injury and Osteoarthritis Outcome Score (KOOS) and the Japanese Anterior Cruciate Ligament Questionnaire–25 (JACL-25). Results: The AA and NA groups had a significantly shorter time from injury to surgery compared with the NR group (P =.0165). Considering the second-look arthroscopic findings, the authors found a significant difference in synovial coverage of the grafts between the 3 groups (P =.0018). There were no significant differences in the overall KOOS and JACL-25 score among the 3 groups; however, the KOOS–Sport and Recreation and KOOS–Quality of Life subscale scores were significantly higher in the AA group compared with the NA and NR groups (P =.0014 and.0039, respectively). The JACL-25 score for middle- to high-speed flexion and extension was significantly better in the AA group versus the NR group (P =.0261). Conclusion: This study showed that preserving anatomically positioned and adequate remnant tissue during DB-ACLR improved second-look graft appearance and KOOS–Sport and Recreation and KOOS–Quality of Life scores. [ABSTRACT FROM AUTHOR]

Introduction: The optimal route and dosing regimen of tranexamic acid (TXA) in primary total knee arthroplasty (TKA) remains unclear. This study aims to explore if there was a synergistic effect of intravenous (IV) and topical TXA on blood loss and risk of complications. Materials and methods: From Jan 2019 to June 2021, medical records of patients aged 65 years or older who underwent primary unilateral TKA for primary osteoarthritis were retrospectively reviewed. The included patients were divided into 3 groups according to the methods of TXA application: Intravenous (IV) group, topical group, or combined group. Propensity-score match was used to reduce the bias and imbalance of confounding variables. The primary outcome was total blood loss. Results: The total blood loss, hidden blood loss, and the reduction of Hb concentration in the combined group were significantly lower than in the IV group and topical group (all P <.01). There is no significant difference in the transfusion rate, length of hospital stay, and incidence of thromboembolic events (both P >.05). Conclusions: Combined administration of IV and topical TXA is the most effective approach to decrease blood loss and postoperative Hb drop in the treatment of TKA without increasing any risk of complications. [ABSTRACT FROM AUTHOR]

Objectives: Abdominal aortic aneurysm ultrasound surveillance varies between hospitals in the United Kingdom. University Hospitals Bristol and Weston adopt a 6-monthly surveillance interval for 4.5–4.9 cm abdominal aortic aneurysm, which is a deviation from nationally recommended 3-monthly intervals. Assessment of abdominal aortic aneurysm growth rate, and the concurrent impact of abdominal aortic aneurysm risk factors and medications prescribed for risk factors, may inform whether this change in surveillance intervals is safe and appropriate. Methods: This analysis was conducted retrospectively. A total of 1312 abdominal aortic aneurysm ultrasound scans from 315 patients between January 2015 and March 2020 were split into 0.5 cm groups, ranging from 3.0 to 5.5 cm. Abdominal aortic aneurysm growth rate was assessed with one-way analysis of variance. The impact of risk factors and risk factor medication on abdominal aortic aneurysm growth rate was analysed using multivariate and univariate linear regression and Kruskal–Wallis tests. Patient cause of death among surveillance patients was recorded. Results: Abdominal aortic aneurysm growth rate was significantly associated with increased abdominal aortic aneurysm diameter (p < 0.001). There was a significant whole-group reduction in growth rate from 0.29 to 0.19 cm/year in diabetics compared to non-diabetics (p = 0.02), supported by univariate linear regression (p = 0.04). In addition, gliclazide patients had lower growth rate compared to patients not on the medication (p = 0.04). One abdominal aortic aneurysm rupture occurred <5.5 cm resulting in death. Conclusion: Abdominal aortic aneurysm measuring 4.5–4.9 cm had a mean growth rate of 0.3 cm/year (± 0.18 cm/year). Therefore, mean growth rate and variability suggest patients are unlikely to surpass surgical threshold of 5.5 cm between the 6-monthly surveillance scans, supported by low rupture rates. This suggests the surveillance interval for 4.5–4.9 cm abdominal aortic aneurysm is a safe and appropriate deviation from national guidance. In addition, it may be pertinent to consider diabetic status when designing surveillance intervals. [ABSTRACT FROM AUTHOR]

Introduction: The optimal route and dosing regimen of tranexamic acid (TXA) in primary total knee arthroplasty (TKA) remains unclear. This study aims to explore if there was a synergistic effect of intravenous (IV) and topical TXA on blood loss and risk of complications. Materials and methods: From Jan 2019 to June 2021, medical records of patients aged 65 years or older who underwent primary unilateral TKA for primary osteoarthritis were retrospectively reviewed. The included patients were divided into 3 groups according to the methods of TXA application: Intravenous (IV) group, topical group, or combined group. Propensity-score match was used to reduce the bias and imbalance of confounding variables. The primary outcome was total blood loss. Results: The total blood loss, hidden blood loss, and the reduction of Hb concentration in the combined group were significantly lower than in the IV group and topical group (all P < .01). There is no significant difference in the transfusion rate, length of hospital stay, and incidence of thromboembolic events (both P > .05). Conclusions: Combined administration of IV and topical TXA is the most effective approach to decrease blood loss and postoperative Hb drop in the treatment of TKA without increasing any risk of complications. [ABSTRACT FROM AUTHOR]

Background: Limited literature examines the relationship between surgical outcomes in chronic foot and ankle conditions and concurrent psychiatric care. The present study aimed to investigate patient-reported and surgical outcomes of patients treated for a psychiatric disorder undergoing first metatarsophalangeal (MTP) fusion for hallux rigidus. We hypothesized that patients on psychotropic medications would have greater subjective pain preoperatively and less improvement in physical and mental functionality postoperatively when compared with nonmedicated patients. Methods: A single-center, retrospective review of prospectively collected data was conducted on 92 patients undergoing first MTP fusion with a preoperative diagnosis of hallux rigidus from 2015 to 2019. At their preoperative, 6-month postoperative, and 1-year postoperative visits, patients were administered visual analog pain scale (VAS) and 36-Item Short Form Health Survey (SF-36) functionality surveys. Patients were subsequently identified by chronic use of psychotropic medication preoperatively and grouped for analysis (MED, n = 42; NO MED, n = 50). Results: Postoperative mean VAS pain scores were lower for all studied patients at 6 months (VAS = 1.6 ± 2.3) and 1 year postoperatively (VAS = 1.1± 1.8) relative to the preoperative visit (VAS = 4.7 ± 2.8) (P ≤.0001 and P ≤.0001, respectively). No differences in mean VAS pain scores nor SF-36 physical component summary scores were detected at preoperative, 6-month, or 1-year visits between NO MED and MED groups. Mean SF-36 mental component summary scores for those in the MED group were lower at preoperative (NO MED = 83.8, MED = 71.8, P =.006) and 6-month postoperative (NO MED = 86.1, MED = 72.7, P =.037) visits than those in the NO MED group, a trend not observed at the 1-year postoperative mark (NO MED = 84.1, MED = 76.8, P =.228). There were no observed differences in operative time (P =.219), tourniquet time (P =.359), nor time to full weightbearing (P =.512) between MED and NO MED groups. Additionally, no differences in postoperative complication rates were observed between groups. Conclusion: In patients treated with psychotropically active medications with hallux rigidus, MTP Fusion appears to be a reasonable treatment choice with similar outcomes for patients requiring psychotropically active medications to the outcomes of those patients not requiring psychotropically active medications. Level of Evidence: Level III, retrospective comparative study. [ABSTRACT FROM AUTHOR]

Background: Ankle fractures are among the most common injuries treated by orthopaedic surgeons, yet little guidance exists in postoperative protocols for ankle fractures concerning time of immobilization. Here, we aim to investigate the association between early mobilization and patient-reported outcomes. Our null hypothesis was that no difference in Patient-Reported Outcomes Measurement Information System (PROMIS) scores would be identified in patients when comparing the effect of time of immobilization. Methods: A retrospective review identified ankle fractures that underwent surgical fixation between 2015 and 2020 at a level 1 trauma center and its associated facilities. One hundred nineteen patients from 9 providers met inclusion criteria for our final analysis. Forty-seven patients were immobilized for <6 weeks (early) and 68 patients were immobilized for ≥6 weeks (late). Our primary outcome measures included the PROMIS questionnaire, time of immobilization, and time to full weightbearing. Our secondary outcome measures included time to return to work, wound complications (infection, delayed healing), and complications associated with fracture fixation (loss of reduction, delayed union, reoperation, hardware failure). Repeated measures analysis of variance as well as linear mixed outcome regression were used to predict each of the PROMIS outcomes of anxiety, depression, physical function, and pain interference. Each model included the predictors of age, sex, race, body mass index (BMI), diabetes, rheumatoid arthritis, smoking status, payor, provider, time to radiographic union, time to return to work, time to full weightbearing, and early vs late immobilized groups. Results: We found no differences in PROMIS scores between mobilization groups even when controlling for possible confounders such as age, BMI, rheumatoid arthritis, smoking status, and diabetes mellitus (P >.05). Furthermore, we found no differences in complications associated with fracture fixation (P >.05). Across our cohort, lower physical function scores were associated with higher BMI, increasing age, and longer time to return to work/play (P <.05). Our analysis further showed that depression, anxiety, pain interference, and physical function levels improve as a function of time (P <.05). Higher BMI was also noted to have a significant impact on PROMIS depression and anxiety when controlling for other variables. African Americans had greater pain interference scores (P <.05). Conclusion: Our study suggests that early mobilization in a walker boot after operative treatment of ankle fractures is a safe alternative to casting in non-neuropathic patients. When considering operative treatment of ankle fractures, factors such as increasing age and BMI are likely to negatively affect postoperative anxiety, physical function, and depression PROMIS scores regardless of immobilization time. Level of Evidence: Level III, retrospective cohort study. [ABSTRACT FROM AUTHOR]

The effect of the arrival day of the week, arrival time of the day, or discharge time of the day on emergency department (ED) patient experience (PE) scores has not been well studied. We performed a retrospective analysis of ED patients between July 1st, 2018 through March 31st, 2021. We recorded demographics, PE scores, arrival day, arrival and discharge times, and total ED and perceived ED times. We performed univariate and multivariable analyses. We sent 49,849 surveys and received back 2423 that we included in our study. The responding patients' median age was 52, with a majority of female gender (62%) and white race (57%). The average arrival time was 1:40 PM, and the average discharge time 2:38 PM. The average total ED time was 261 minutes, while the average perceived ED time was 540 minutes. We found a statistical association between worse PE scores and longer actual ED time but not longer perceived time. A later arrival time was significantly associated with worse PE scores on 4 out of 6 domains of the PE questionnaire. The discharge time and the day of the week were not significantly associated with PE scores. Conclusion: Actual longer ED time was significantly associated with worse PE scores, but not perceived time. Later arrival time was associated with worse PE scores, but not later discharge time. The arrival day of the week was not statistically associated with differences in PE. Further studies are needed to confirm these findings. [ABSTRACT FROM AUTHOR]

Background: Tuberculosis (TB) has become a public health problem among elderly in developing countries with the gradual increase in life expectancy. Aim/Objective: This study aimed to analyze the prognosis factors and chronological trends of TB in elderly in Southern Tunisia. Methods: A retrospective study was conducted. All TB patients aged ≥60 years, recorded in the Center of TB Control between 1995 and 2016, were included. Chronological trends of TB were analyzed by calculating the correlation coefficient of Spearman (Rho). Multivariate analysis was done by binary logistic regression (Adjusted Odds ratio (AOR); CI; p) to determine the independent risk factors associated with unsuccessful outcome in elderly. A p value <0.05 was considered as statistically significant. Results: Overall, 512 new elderly TB cases were notified between 1995 and 2016, with an average of 23.3 new cases/year. The mean TB incidence rate for elderly was 2.31/100,000 population/year. The case-fatality rate of 8.6%. Multivariate analysis showed that factors independently associated with unsuccessful outcome among elderly patients were age between 80 and 89 (AOR = 4.5; [95% CI: 2, 10.2]; p < 0.001), male gender (AOR = 2.2; [95% CI: 1.1, 4.4]; p = 0.026) and neuro-meningeal involvement (AOR = 4.6; [95% CI: 1.4, 14.8]; p = 0.011). The incidence of TB in elderly patients increased significantly from 0.95/100,000 population in 1995 to 2.17/100,000 population in 2016 (Rho = 0.48; p = 0.024). Discussion: A better understanding of TB features in elderly and its chronological trends overtime would facilitate to put in place, in the national TB control program, strategies geared towards this group of people. [ABSTRACT FROM AUTHOR]

Background: Corrective osteotomy around the knee is based on deformity profiles of the femoral and tibial sides. Opening-wedge high tibial osteotomy (OWHTO) can be favored if the outcomes are not different, even if there is a certain degree of abnormal parameters after correction. Purpose/Hypothesis: The purpose of this study was to identify the factors associated with unfavorable radiological outcomes after OWHTO for varus knees. Our hypothesis was that there would be an optimal situation in which double-level osteotomy (DLO) has advantages over isolated OWHTO and an optimal cutoff value of structural parameters for which DLO should be considered in patients with severe varus knees. Study Design: Case-control study; Level of evidence, 3. Methods: The radiological and clinical outcomes of 337 patients who underwent OWHTO were retrospectively evaluated. A subgroup analysis was performed according to the weightbearing line ratio (WBLR) (group 1: <25th percentile; group 2: 25th-75th percentile; and group 3: >75th percentile) and factors associated with unfavorable radiological outcomes. For the assessment of cutoff values of the parameters favoring DLO, unfavorable radiological outcomes were categorized as follows: (1) medial proximal tibial angle (MPTA) >95°, (2) joint-line convergence angle (JLCA) >4° (insufficient medial release), (3) JLCA <0° (medial instability), (4) recurrence of a varus deformity, and (5) lateral hinge fracture. Results: The mean follow-up period was 66.2 ± 19.1 months. A low preoperative WBLR was related to a larger preoperative to postoperative change (Δ) in the WBLR, a larger reduction in coronal translation, a larger ΔMPTA, a wide preoperative lateral joint space, and a narrow preoperative medial joint space (P <.001, P <.001, P <.001, P =.016, and P =.003, respectively). However, only an MPTA >95° was significantly related to a low WBLR in the subgroup analysis according to unfavorable radiological outcomes (P =.038). The cutoff value of ΔWBLR causing an MPTA >95° was 46.5%, which showed a good area under the curve of 0.800, with a sensitivity of 74.4% and a specificity of 82.7%. The clinical outcomes significantly improved at the final follow-up compared with those preoperatively, with no significant differences between the WBLR groups. Conclusion: A ΔWBLR ≥46.5% led to an MPTA >95°. However, clinical outcomes were not affected. DLO should be considered if the surgeon desires a postoperative MPTA ≤95°. [ABSTRACT FROM AUTHOR]

Background: The high prevalence of carbapenem-resistant Klebsiella imposes optimizing antibiotic consumption. We aimed to evaluate the impact of antibiotic stewardship program on carbapenem consumption and the Klebsiella resistance. Method: We retrospectively evaluated critically ill patients with isolated Klebsiella species from Elaraby hospital, Egypt during the period from April 2017 to January 2019. We collected data related to carbapenems consumption and Klebsiella clinical isolates with their antimicrobial susceptibility. Based on susceptibility, Klebsiella isolates were classified into sensitive, extended spectrum beta-lactamase (ESBL) producer, and carbapenem-resistant Klebsiella (CRK), respectively. Our primary outcome was the change in carbapenems consumption after implementing the program, while the secondary outcomes were the changes in the incidence of CRK. Results: The study included 205 patients with isolated Klebsiella species during the study period. The antibiotic stewardship program started in March 2018. Out of the 205 patients, 61 patients (29.8%) represented the pre-intervention sample, and 144 patients (70.2%) represented the post-intervention sample. Applying the antibiotic stewardship program was associated with a significant decrease in the carbapenems consumption from 38.9 to 26.6 defined daily dose/1000 patient-days (p = 0.02). The incidence of CRK was decreased from 85.25% of total Klebsiella isolates to 48.6% (p < 0.001). Klebsiella species were more likely to be in a lower category of resistance after applying the program with an odds ratio of 6.3 (2.88–13.73) using ordinal logistic regression. Conclusion: Applying the antibiotic stewardship program could reduce the unnecessary carbapenems use in the ICU with a subsequent decrease in the emergence of the Klebsiella- resistant strains. [ABSTRACT FROM AUTHOR]

Background: While surgeons with high caseload volumes deliver higher value care when performing primary anterior cruciate ligament reconstruction (ACLR), the effect of surgeon volume in the revision setting is unknown. Purposes: To determine the percentage of revision ACLR procedures that comprise the practice of high-, medium-, and low-volume surgeons and to analyze associated referral and practice patterns. Study Design: Cross-sectional study; Level of evidence, 3. Methods: We retrospectively investigated all revision ACLR procedures performed between 2015 and 2020 in a single health care system. Surgeons were categorized as low (≤17), medium (18-34), or high (≥35) volume based on the number of annual ACLR procedures performed. Patient characteristics, activity level, referral source, concomitant injuries, graft type, and treatment variables were recorded, and a comparison among surgeon groups was performed. Results: Of 4555 ACLR procedures performed during the study period, 171 (4%) were revisions. The percentage of revision ACLR procedures was significantly higher for high-volume (5%) and medium-volume (4%) surgeons compared with low-volume surgeons (2%) (P <.01). Patients undergoing revision ACLR by a high-volume surgeon had a significantly higher baseline activity level (P =.01). Allografts were used significantly more often by low-volume surgeons (70%) compared with medium-volume (35%) and high-volume (25%) surgeons (P <.01). Bone–patellar tendon–bone (BPTB) and quadriceps tendon (QT) autografts were used significantly more often by high-volume (32% BPTB, 39% QT) and medium-volume (38% BPTB, 14% QT) surgeons compared with low-volume surgeons (15% BPTB, 10% QT) (P <.01). High-volume surgeons were more likely to perform revision on patients with cartilage injuries (P =.01), perform staged revision ACLR (P =.01), and choose meniscal repair (54% high vs 22% medium and 36% low volume; P =.03), despite similar rates of concomitant meniscal tears, compared with low- and medium-volume surgeons. Conclusion: In this registry study of an integrated health care system, high-volume surgeons were more likely to perform revision ACLR on patients with higher activity and competition levels. Additionally, high-volume surgeons more commonly performed staged revision ACLR, chose meniscus-sparing surgery, and favored the use of autografts compared with low-volume surgeons. [ABSTRACT FROM AUTHOR]

Background: Partial-thickness rotator cuff tears (PTRCTs) often progress to full-thickness rotator cuff tears (FTRCTs). Thus, it is important to analyze the risk factors for tear progression to determine the proper timing of repair. Purpose: To identify the risk factors associated with progression of PTRCT. Study Design: Case-control study; Level of evidence, 3. Methods: Included were 89 patients diagnosed with PTRCT on magnetic resonance imaging (MRI) scans who underwent nonoperative treatment at the authors' institution between August 2012 and August 2019. Patient characteristics, shoulder stiffness (compared with the contralateral shoulder); work level (classified as high [heavy manual labor], medium [manual labor with less activity], and low [sedentary activity]); and radiological factors including initial tear size, acromion type (flat, curved, hooked, or heel-shaped), and initial tear involvement (as a percentage of the rotator cuff tendon footprint length) were analyzed to assess their association with tear progression, defined as >20% increase in tear involvement. Results: The mean MRI follow-up period was 22.3 ± 17.2 months (median, 16.1 months; range, 6.4-89.5 months), and tear progression was observed in 12 patients (13.5%). In these 12 patients, tear involvement increased by 60% of the rotator cuff footprint, while mediolateral (ML) and anteroposterior (AP) tear sizes progressed by 1.1 and 1.8 mm, respectively. Univariate regression analysis showed that shoulder stiffness (P =.031), work level (P =.001), initial tear involvement (P <.001), ML and AP tear sizes (P <.001 and P =.005, respectively), and acromion type (P =.003) were significantly associated with tear progression. Multivariate regression analysis showed that initial tear involvement (odds ratio [OR], 1.053; 95% CI, 1.006-1.102; P =.026) and high work level (OR, 15.831; 95% CI, 1.150-217.856; P =.039) were independent risk factors for tear progression. The cutoff value for initial tear involvement was 47.5% (sensitivity, 81.8%; specificity, 85.7%). Conclusion: Tear progression was observed in 14% of patients with PTRCT in this study. To predict tear progression, evaluating the tear involvement during initial MRI is essential. The risk of tear progression increased with initial tear involvement >47.5% and a heavy work level. [ABSTRACT FROM AUTHOR]

Objective: To describe associations between patients' demographic characteristics and access to telemedicine services in an urban tertiary academic medical system across the COVID-19 pandemic, and to identify potential barriers to access. Methods: This was a retrospective cohort study conducted at a single-center tertiary academic medical center. The study included adult patients undergoing outpatient otolaryngologic care in person or via telemedicine during 8 week timeframes: before the pandemic, at the onset of the pandemic, and during later parts of the pandemic. Patients were characterized by age, sex, race, insurance type, primary language, portal activation status, income estimate, and visit type. Where appropriate, chi-squared tests, Wilcoxon signed-rank tests, and logistic regression were used to compare demographic factors between the cohorts. Results: A total of 14,240 unique patients [median age, 58 years (range, 18-107 years); 56.5% were female] resulting in a total of 29,457 visits (94.8% in-person and 5.2% telemedicine) were analyzed. Patients seen in person were older than those using telemedicine. Telemedicine visits included a higher proportion of patients with private insurance, and fewer patients with government or no insurance compared to in-person visits. Race, income, and English as primary language were not found to have a significant effect on telemedicine use. Conclusion: In an urban tertiary medical center, we found significant differences in sociodemographic characteristics between patients who accessed otolaryngologic care in person versus via telemedicine through different phases of the COVID pandemic, reflecting possible barriers to care associated with telemedicine. Further studies are needed to develop interventions to improve access. [ABSTRACT FROM AUTHOR]

Background: Osteochondral lesions of the talus (OLTs) are a common condition found in patients with chronic ankle pain after previous ankle sprains. Surgical management is indicated after conservative management has failed. Hypothesis/Purpose: This study evaluates the influence of body mass index (BMI) on the early clinical outcomes of arthroscopic debridement and microfracture of OLTs. Methods: A total of 252 patients with symptomatic OLTs who failed conservative management underwent arthroscopic debridement and microfracture of OLTs over the affected ankle between 2007 and 2017. Patients from this cohort were divided into 2 groups based on BMI: the normal BMI group (NB Group) (BMI 18.5-25.0) and overweight and obese BMI group (OB Group) (BMI ≥25). Visual analogue scale (VAS), American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score, and the physical and mental component summaries of the 36-Item Short-Form Health Survey (PCS and MCS, respectively) were prospectively collected from the cohort during their standard postoperative outpatient follow-up. Results: The NB Group (n=105) and OB Group (n=147) were well matched demographically. The operative duration was significantly shorter for the NB Group compared to the OB Group. Patients from both groups had significant improvements in VAS, AOFAS, and PCS scores postoperatively at 6 and 24 months after surgery (P < .05). Between both groups, patients had comparable VAS, AOFAS, and PCS scores at preoperation, 6 months postoperation, and 24 months postoperation (P > .05). However, MCS in the OB Group was lower at 24 months postoperatively compared with the NB Group (P < .05). The OB Group reported better satisfaction scores (82.4% vs 72.6%, P < .05), and a greater proportion had their expectations met (88.2% vs 77.9%, P < .05). Conclusion: A BMI ≥25 was not associated with worse postoperative pain and functional outcomes, but rather was found to be associated with greater satisfaction and fulfillment. However, patients with BMI ≥25 required longer procedure duration and had poorer MCS scores at 24 months after surgery. [ABSTRACT FROM AUTHOR]

Background: Many of the conditions of the COVID-19 pandemic were consistent with factors shown to be predictive of parental stress and burnout. The purpose of the current study was to use a retrospective pretest method to gain an understanding of the effects of the COVID-19 pandemic on levels of parental burnout and on parenting practices. Method: A brief survey was conducted using a retrospective pretest method to examine parental burnout (The Parental Burnout Assessment, Roskam et al, 2018) and parenting practices (The Alabama Parenting Questionnaire, Frick, 1991). The survey asked parent participants to answer questions about their experiences before and during the pandemic. Results: Findings indicated that the pandemic had a significant impact on parents, increasing overall levels of parental burnout and impacting parenting practices by reducing use of positive parenting strategies and increasing use of inconsistent discipline and corporal punishment. These changes in parenting practices were even more pronounced for parents whose levels of parental burnout moved from "normal" levels before the pandemic to clinical levels during the pandemic. Conclusion: The findings of the current study suggest that the COVID-19 pandemic has had a negative impact on levels of parental burnout and parenting practices. Although additional research is needed, the results suggest that there is a need for clinicians to understand the effects that the pandemic may have had on parents and families with an understanding that families may be at ongoing risk despite a relaxation of COVID-19 restrictions. [ABSTRACT FROM AUTHOR]

Background: The utility of magnetic resonance imaging (MRI) in the primary care setting is uncertain, with a perception that there is less likelihood for surgery after MRI ordered by general practitioners (GPs) when compared with orthopaedic surgeons and sports medicine physicians. Additionally, the influence of patient age and sex on subsequent surgical intervention is currently unknown. Purpose/Hypothesis: The purpose of this study was to compare surgical incidence after MRI referrals by orthopaedic surgeons, GPs, and sports medicine physicians, including a subset analysis for GP patients based on type of approval given by the radiologist. The authors also wanted to explore the association of age and sex on subsequent surgical intervention. They hypothesized that surgical incidence after MRI ordered by orthopaedic surgeons and sports medicine physicians would be higher than after MRI ordered by GPs. Study Design: Cohort study; Level of evidence, 3. Methods: Knee MRI referrals by the 3 physician cohorts during May to December 2017 were assessed. For GP patients, the types of approval or recommendation from a radiologist were categorized. Subsequent surgical intervention status was then compared among referral groups up to 2 years after MRI. Associations of age and sex with surgical occurrence were also assessed. Chi-square test, analysis of variance, and univariate/multivariable logistic regression were used for statistical analysis. Results: Overall, 407 referrals were evaluated (GP, n = 173; orthopaedic, n = 176; sports medicine, n = 58). Surgical incidence was not significantly higher for orthopaedic and sports medicine than GP referrals at 3 months (10%, 3%, and 6%, respectively; P =.23), 6 months (20%, 17%, and 15%; P =.49), and 2 years (30%, 35%, and 24%; P =.25). Surgical incidence for GP patients was higher after discussion with a radiologist or when evaluating specific pathology on prior imaging versus less defined reasons (30.4% vs 15.7%, respectively; P =.03). Surgical incidence was lower for older patients (11% vs 31% for >60 years vs all other age groups combined; P =.002), and women were less likely to undergo surgery than men (22% vs 35%, respectively; P =.008). Conclusion: Surgical incidence after MRI was likely appropriately lower for older patients. Lower incidence for female patients is of uncertain cause and warrants further study. [ABSTRACT FROM AUTHOR]

Background: The treatment strategy for pediatric anterior cruciate ligament (ACL) tears, especially in patients with open physes, remains controversial. Purpose: To assess clinical outcomes and postoperative complications after all-epiphyseal double-bundle ACL (DB-ACL) reconstruction for patients with open physes. Study Design: Cohort study; Level of evidence, 3. Methods: Included were 102 patients aged ≤15 years who underwent ACL reconstruction at a single institution and had a minimum of 2 years of follow-up. Of these patients, 18 had undergone all-epiphyseal DB-ACL reconstruction (mean age, 12.4 ± 1.2 year) and 84 had undergone conventional DB-ACL reconstruction (mean age, 14.1 ± 0.9 year). The outcomes of the all-epiphyseal group were compared with those of the conventional group. Objective clinical outcomes included KT-1000 arthrometer measurements of side-to-side difference in anterior tibial translation, Lachman test grade, and pivot-shift test grade. Radiographic angular deformity (defined as >3° of the side-to-side difference in femorotibial angle) and incidence of second ACL injury were also compared. Results: The postoperative side-to-side difference in laxity significantly improved from 6.1 ± 2.4 to 0.6 ± 0.9 mm in the all-epiphyseal group (P =.001), and postoperative laxity was similar to that of the conventional group (0.4 ± 0.8 mm; P =.518). A Lachman grade 1 positive result was observed in 20% of the all-epiphyseal group and 3% of the conventional group (P =.042), and a pivot-shift grade 1 positive result was observed in 22% of the all-epiphyseal group and 4% of the conventional group (P =.074). A total of 4 patients (26.7%) in the all-epiphyseal group and 4 (6.1%) in the conventional group demonstrated angular deformity (P =.035). The incidence of postoperative ipsilateral ACL tear was 16.7% in the all-epiphyseal group and 23.8% in the conventional group (P =.757). The incidence of contralateral ACL tear was 11.1% in the all-epiphyseal group and 14.3% in the conventional group (P ≥.999). Conclusion: All-epiphyseal DB-ACL reconstruction for skeletally immature patients achieved satisfactory clinical outcomes compared with conventional DB-ACL reconstruction. The incidence of ipsilateral graft rupture was relatively high in both groups. The all-epiphyseal group had a significantly higher incidence of angular deformity. [ABSTRACT FROM AUTHOR]

Background: Meniscal injuries are commonly associated with anterior cruciate ligament (ACL) tears. Treatment of meniscal injuries can impart delayed weightbearing and range of motion restrictions, which can affect the rehabilitation protocol. The effect of meniscal treatment and subsequent restrictions on strength recovery after ACL reconstruction is unclear. Purpose/Hypothesis: The purpose of this study was to compare strength, jumping performance, and patient-reported outcomes between patients who underwent isolated ACL reconstruction (ACLR) and those who underwent surgical intervention for meniscal pathology at the time of ACLR. Our hypothesis was that patients who underwent concurrent meniscal repair (MR) would have lower strength recovery owing to postoperative restrictions. Study Design: Cohort study; Level of evidence, 3. Methods: Patients with ACLR were stratified into isolated ACLR, ACLR and meniscectomy (ACLR-MS), or ACLR-MR groups and were compared with healthy controls. The ACLR-MR group was restricted to partial weightbearing and to 90° of knee flexion for the first 6 weeks postoperatively. All participants completed patient-reported outcomes (International Knee Documentation Committee [IKDC] and Knee injury and Osteoarthritis Outcome Score [KOOS]) and underwent bilateral isokinetic and isometric strength tests of the knee extensor and flexor groups as part of a return-to-sports test battery at 5 to 7 months postoperatively. Results: A total of 165 patients with ACLR (50 with isolated ACLR, 44 with ACLR-MS, and 71 with ACLR-MR) and 140 healthy controls were included in the study. Follow-up occurred at a mean of 5.96 ± 0.47 months postoperatively. The control group demonstrated higher subjective knee function, unilateral peak extensor torque, and limb symmetry than did the ACLR-MS and ACLR-MR groups combined (P <.001 for all). There were no differences in IKDC, KOOS subscales, or unilateral or limb symmetry measures of peak knee extensor or flexor torque among the isolated ACLR, ACLR-MS, and ACLR-MR groups. Conclusion: Persistent weakness, asymmetry, and reduced subjective outcome scores at 6-month follow-up after ACLR were not influenced by meniscal treatment. These findings suggested that the weightbearing and range of motion restrictions associated with meniscal repair recovery do not result in loss of early strength or worse patient-reported outcomes. [ABSTRACT FROM AUTHOR]

Background: Little is known regarding the effect of early active elbow range of motion (ROM) protocols on failure rates and outcomes after open subpectoral biceps tenodesis. Hypothesis: We hypothesized that patients managed using an early active ROM protocol after open subpectoral biceps tenodesis would demonstrate similar failure rates and functional outcomes compared to patients managed using a traditional delayed active ROM protocol. Study Design: Cohort study; Level of evidence, 3. Methods: We evaluated 63 patients who underwent open subpectoral biceps tenodesis with unicortical suture button fixation. Based on surgeon preference, 22 patients were managed using an early active motion protocol consisting of no restrictions on elbow flexion or forearm supination, while 41 patients were managed using a delayed motion protocol postoperatively. Primary outcome measures included failure of biceps tenodesis and American Shoulder and Elbow Surgeons (ASES) and Single Assessment Numeric Evaluation (SANE) scores. Secondary outcomes included shoulder and elbow ROM at 6 months postoperatively. Results: The mean follow-up for the 63 patients was 24.2 months postoperatively. One patient (2.4%) in the delayed active motion cohort and no patients in the early active motion cohort experienced failure. Final outcome scores as well as 6-month shoulder and elbow ROM indicated excellent functional outcomes, with no significant difference between motion cohorts. The median postoperative ASES scores were 97.99 in the early active motion cohort (mean ± standard deviation [SD], 95.49 ± 7.68) and 95.42 in the delayed motion cohort (mean ± SD, 90.93 ± 16.08), while median postoperative SANE scores were 96 in the early motion cohort (mean ± SD, 94.23 ± 6.68) and 95 in the delayed motion cohort (mean ± SD, 88.39 ± 17.98). Subgroup analysis demonstrated no significant difference in outcome scores based on the performance of concomitant rotator cuff repair or hand dominance. Conclusion: Early active ROM after open subpectoral biceps tenodesis with unicortical suture button fixation resulted in low failure rates and excellent clinical outcomes, comparable to the results of patients managed using delayed active ROM protocols. This suggests that patients undergoing open subpectoral biceps tenodesis may be managed using either early or delayed active motion protocols without compromising functional outcome. [ABSTRACT FROM AUTHOR]

Background: Compared with the single-row technique, the double-row rotator cuff repair technique is known to have a higher load to failure and a lower frequency of gap formation, leading to a lower retear rate. There are some patients with poor clinical outcomes or poor muscle strength without radiologic retear. Purpose/Hypothesis: To assess the postoperative position of suture knots via serial ultrasonography in patients who had undergone arthroscopic rotator cuff repair with the suture-bridge technique. Our hypothesis was that the suture would pull out of the lateral anchor (suture slippage), changing the positions of the medial suture knots during healing. Study Design: Case series; Level of evidence, 4. Methods: This study included 53 patients (55 shoulders) who underwent arthroscopic suture-bridge repair and were evaluated for a minimum of 24 months. On serial ultrasonography, a straight line was drawn between the top of the greater tuberosity and the medial cortex of the anchor hole. The distances between the knots of the medial rows and the perpendicular line through the center of the anchor hole were measured in longitudinal plane images of the supraspinatus. Follow-up ultrasonography was performed at 2, 3, and 6 months postoperatively as well as at the final visit. The visual analog scale, the American Shoulder and Elbow Surgeons score, the Constant score, and the University of California, Los Angeles shoulder score were recorded preoperatively and on the final follow-up. Results: Of the 55 shoulders, 6 developed retears at repaired sites. The mean follow-up duration was 37.5 months (range, 24-65 months). Slippage distance increased significantly over time (P <.001). The slippage at the final visit did not differ between patients with retear and no retear (13.4 mm for retear group; 10.6 mm for no retear group [ P =.096]). Conclusion: Suture knots of the medial row migrated medially via a suture pullout from the lateral row anchor of suture-bridge technique. Suture slippage distance did not differ significantly between retear and no retear groups. [ABSTRACT FROM AUTHOR]

Background: Total hip (THA) and total knee arthroplasty (TKA) are becoming an increasingly standard procedure in the whole world. In conjunction with an aging population and increased prevalence of osteoporosis, proper management of periprosthetic, and interprosthetic fractures is of great interest to orthopedic surgeons. This study aims to report the clinical and radiographic outcomes, complications and reoperations of IFFs in geriatric patients. Methods: A retrospective single-institution case series study was conducted. Between 2011 and 2019, 83 patients underwent surgical treatment for periprosthetic femoral fractures. Thirteen fractures were identified as IFFs. Patient demographics and comorbidities were collected preoperatively, and fractures were classified with the Vancouver and AO unified classification system (AO-UCS). Results: We included 12 patients (13 hips) with IFFs (AO-UCS type IV.3 B (2/13) type IV.3 C (3/13), type IV.3 D (8/13)). The average patient age was 86.54 (range, 79-89) years. There were 10 females and 2 males. Perioperative morbidity has been identified in 10 of the 12 patients, and the 3-month and 1-year mortality were reported in 2 and 3 patients, respectively. Cerclage cables were used in 9 of 12 patients. One of 12 patients showed a local complication, with no documented implant failure or revision. Patients achieved complete union and returned to their preoperative ambulatory status, and full weight-bearing at an average of 5 (range, 2 to 7) months later. Conclusion: Management of IFF can be challenging because these fractures require extensive surgical expertise. Locking plate seems to be a valuable treatment option for geriatric patients with IFFs. Despite the complexity of this type of fracture, the overall complication and revision rate, as well as the radiographic outcome are good to excellent. Level of Evidence: Level III, Therapeutic study. [ABSTRACT FROM AUTHOR]

Background: The effect of leg dominance on short-term functional outcomes and return to sports after arthroscopic anterior cruciate ligament reconstruction (ACLR) has been evaluated. However, postoperative medium- to long-term recovery and revision rates are not well known. Purpose: To investigate whether leg dominance affects medium- to long-term clinical and functional scores and revision rates after ACLR. Study Design: Cohort study; Level of evidence, 3. Methods: Included in this study were 235 patients (205 male and 30 female) who underwent isolated arthroscopic ACLR. Patients were divided according to the leg dominance status of their injured limb into 2 groups: dominant leg injured (120 patients) and nondominant leg injured (115 patients). Preoperative and postoperative functional outcomes and health-related quality of life (HRQoL) were evaluated using the visual analog scale for pain, Tegner activity scale, Lysholm knee score, International Knee Documentation Committee (IKDC) subjective knee evaluation form, 36-Item Short Form Health Survey (SF-36), and overall patient satisfaction. Moreover, the revision rates of the 2 groups were compared according to leg dominance, patient characteristics, and operative features. Results: The mean follow-up period was 8.0 ± 2.3 years (range, 5-13 years). A significant preoperative to postoperative improvement in range of motion and functional scores was noticed in both groups (P < .001 for all). However, the improvement was significantly higher in the dominant leg group for the Tegner (P ¼ .001), Lysholm (P ¼ .006), and IKDC (P < .001) scores as well as for the SF-36 domain scores for general health (P ¼ .009), social role (P ¼ .048), and emotional role (P ¼ .032). Also, patient satisfaction was significantly higher in the dominant leg group (P ¼ .007). The dominant leg group was associated with a lower revision rate compared with the nondominant leg group (5.8% vs 15.7%, respectively; P ¼ .015). Conclusion: High recovery rates were seen after arthroscopic ACLR, regardless of leg dominance. However, leg dominance had a significant effect on postoperative medium- to long-term functional outcomes, HRQoL, and revision rates. [ABSTRACT FROM AUTHOR]

Purpose: To document the mammographic breast density (MBD) distribution of Jordanian women and the relationship with MBD with age. Correlation between breast cancer diagnosis and density was also explored. Methods: A retrospective review of 660 screening mammograms from King Abdullah University Hospital was conducted. Mammograms were classified into 2 groups: normal (return to routine screening) and breast cancer and rated using the American College of Radiology (ACR) Breast Imaging-Reporting and Data System (BI-RADS) 5th edition for MBD. The association between MBD and age was assessed by descriptive analyses and Kruskal-Wallis test. To compare between normal and breast cancer groups, chi-square post hoc tests with Bonferroni adjustment was used. Results: Groups consisted of 73.9% (n = 488) normal group and 26.1% (n = 172) breast cancer group. A significant inverse relationship was demonstrated between age and MBD among the normal (r = −.319, P <.01) and breast cancer group (r = −.569, P <.01). In total, 69% (n = 336) of women in the normal group and 71% (n = 122) in the breast cancer group and 79.1% (n = 159) of the normal group and 100% (n = 48) of the breast cancer group aged 40 to 49 years reported high MBD (ACR BI-RADS c or d). Conclusions: Most of women in both the normal and breast cancer groups evidenced increased MBD. Increased MBD was inversely proportional to age. As MBD has a known link to increased breast cancer risk and the decreased sensitivity of mammography and it is vital that future screening guidelines for Jordanian women consider the unique breast density distribution of this population. [ABSTRACT FROM AUTHOR]

Health informatics applications reduce time intervals in acute coronary syndromes, but their impact on guideline adherence is unknown. This pre–post intervention study compared guideline adherence between telemedically supported (n = 101, April 2014–July 2015) and conventional on-scene care (n = 120, January 2014–March 2014) in acute coronary syndrome. A multivariate logistic regression was performed for dependent variables: adverse events 0 versus 0, p = NA; electrocardiogram 101 versus 120, p = NA; acetylic salicylic acid 91 versus 102, p = 0.21; heparin 92 versus 112, p = 0.99; morphine 96 versus 107, p = 0.33; oxygen 83 versus 102, p = 0.92; glyceroltrinitrate 55 versus 90, p = 0.038; correct destination: 100 versus 119, p = 1.0. The time from ambulance arrival to hospital arrival was prolonged with telemedicine: 48.7 ± 11 min versus 35.5 ± 8.1 min, p < 0.001. Guideline adherence showed no differences except for glyceroltrinitrate. Prolonged time requirements are critical, though explainable. However, this approach enables a timely and high-quality backup strategy if only paramedics are on-scene. [ABSTRACT FROM AUTHOR]

Background: Rapid identification of gram-positive bacteria and resistance determinants from blood cultures can reduce the time to optimal antibiotic therapy. Objective: This study evaluates the use of technology to rapidly identify gram-positive bacteria in combination with a pharmacist-directed antimicrobial stewardship protocol in a tertiary-care facility. Methods: Rapid diagnostic testing was performed on gram-positive blood cultures. Pharmacists were instructed to notify prescribers of results and recommend appropriate antimicrobial therapy based on targeted treatment chart. The primary outcomes were mean time to optimal antibiotic therapy, mean time antibiotics were avoided before traditional culture results, and percent of patients with time to optimal antibiotic therapy reached in less than or equal to 2 hours. Results: Inclusion criteria were met for 297 patients. Mean time to identify bacteria was 26.8 hours with nucleic acid assay versus 75.3 hours with traditional culture (difference = 48.5 hours, p < .0001). The rapid identification of gram-positive bacteria combined with accepted pharmacist intervention improved time to optimal antibiotic therapy (8.4 vs 15.4 hours, p = .0095). When contaminants were identified, antibiotics were avoided for 39.5 hours before traditional culture with pharmacist intervention versus 37.2 hours (p > .05). Antibiotic change occurred in less than or equal to 2 hours in more patients in the pharmacist intervention group (28% vs 10.5%, p = .0002). Conclusions: Rapid identification combined with pharmacist intervention significantly improved time to optimal antibiotic therapy and significantly increased the number of patients receiving optimal antibiotic therapy in less than or equal to 2 hours over rapid identification alone. A pharmacist- directed protocol combined with rapid identification enhanced antimicrobial stewardship. [ABSTRACT FROM AUTHOR]

Purpose: Chondromalacia patellae is a common cause of anterior knee pain in young patients and can be detected noninvasively with magnetic resonance imaging (MRI). The purpose of our study was to evaluate the correlation between subcutaneous fat thickness around the knee joint on axial MRIs as a surrogate marker of obesity, with the presence or absence of chondromalacia patellae. Methods: A retrospective review was conducted of knee MRIs in 170 patients who satisfied the inclusion criteria. Imaging was performed over a 12-month period on a 1.5T MRI system with a dedicated extremity coil. Two radiologists experienced in musculoskeletal imaging assessed each examination in consensus for the presence or absence of chondromalacia patellae and graded positive studies from 0 (absent) to 3 (full cartilage thickness defect). Measurement of subcutaneous knee fat thickness was obtained on the medial aspect of the knee. Results: MRI findings of chondromalacia patellae were present in 33 patients (19.4%), of which, there were 11 grade 1 lesions (33.3%), 9 grade 2 lesions (27.3%), and 13 grade 3 lesions (39.4%). The mean subcutaneous knee fat thickness was significantly higher in the chondromalacia patellae group for all grades compared with the normal group (P < .001), and there was a significant correlation between subcutaneous knee fat thickness and grades of chondromalacia patellae (R = 0.48 [95% confidence interval, 0.38-0.68]; P < .001). Female patients had thicker subcutaneous knee fat and more severe grades of chondromalacia patellae. Conclusion: Subcutaneous knee fat thickness as a surrogate marker of obesity was positively associated with the presence and severity of chondromalacia patellae on MRI. [ABSTRACT FROM AUTHOR]

Introduction: Breast cancer is the most common cancer among Egyptian women. The disease is often advanced at diagnosis. Since molecular profiling is not feasible in routine practice, we sought to examine the association of age distribution with hormone receptor profile, disease stage and outcome among Egyptian women. Patients and methods: We conducted a retrospective review of breast cancer patients treated at Mansoura University Cancer Center in the Nile Delta from 2006 through 2011. Age groups were examined in relation to hormone receptors status and tumor clinicopathological criteria. Additionally, the effect of receptor status on disease relapse and disease-free survival was examined with logistic regression and Kaplan-Meier analysis. Results: A total of 263 patients were included in the current analysis. About 66.9% (n = 176) of patients were hormone receptor positive, 14.1% (n = 37) were Her2/neu positive, and 19.0% (n = 50) were triple negative. Median age of the patients was 52 years and was equal across all receptor status types. Triple negative status correlated with increased risk of disease relapse (odds ratio = 1.8, P = 0.03) and with shortened disease-free survival (hazards ratio = 2.6, P < 0.01). Conclusion: The age distribution and receptor status pattern in the Nile Delta region does not explain the aggressive behavior of the disease. The age of the patients at diagnosis is older than patients in earlier studies from Egypt emphasizing the importance of implementing mammographic screening programs. [ABSTRACT FROM AUTHOR]

Background: To compare current guidelines for diagnosis of gestational diabetes mellitus (GDM) and to identify the ones that are the most relevant for application among pregnant Bulgarian population. Methods: A total of 800 pregnant women at high risk for GDM underwent 75 g oral glucose tolerance test between 24 and 28 weeks of gestation as antenatal screening. The results were interpreted and classified according to the guidelines of the International Association of Diabetes and Pregnancy Study Groups (IADPSG), American Diabetes Association (ADA), Australasian Diabetes in Pregnancy Society, Canadian Diabetes Association, European Association for the Study of Diabetes, New Zealand Society for the study of Diabetes and World Health Organization. Results: The application of different diagnostic criteria resulted in prevalences of GDM between 10.8% and 31.6%. Using any two sets of criteria, women who were classified differently varied between 0.1% and 21.1% (P, 0.001).The IADPSG criteria were the most inclusive criteria and resulted in the highest prevalence of GDM. There was a significant difference in the major metabolic parameters between GDM and control groups, regardless of which of the diagnostic criteria applied. GDM diagnosed according to all criteria resulted in increased proportion of delivery by caesarean section (CS). However, only ADA and IADPSG criteria identified both increased macrosomia (odds ratio, 2.36; 2.29) and CS rate. Conclusion: The need for GDM screening is indisputable. In our view, the new IADPSG guidelines offer a unique opportunity for a unified national and global approach to GDM. [ABSTRACT FROM AUTHOR]

Objectives: To compare the underestimation of ductal carcinoma in situ (DCIS) vs DCIS with "possible invasion" at breast biopsy and to determine if any factors related to clinical indication, imaging abnormality, biopsy, or DCIS-grade affected the likelihood of underestimation. Methods: Of 3836 consecutive lesions that were biopsied by using a 14-gauge needle, 117 lesions revealed DCIS. Surgical pathology results of invasive carcinoma were compared with needle biopsy results of DCIS or DCIS with possible invasion. Clinical indication, imaging abnormality, biopsy guidance modality, sample number, and histologie grade were recorded. Yates corrected x2 and Fisher exact tests were used to determine differences between groups. Results: A total of 101 lesions were DCIS and 16 were DCIS with possible invasion at biopsy. Thirty-six of 117 lesions (31%) revealed invasive carcinoma at resection pathology. Invasive carcinoma was present more often when DCIS with possible invasion was diagnosed compared with pure DCIS (7/16 [44%] vs 29/101 [29%], P = .36). No factor, including clinical indication, imaging abnormality, biopsy guidance method, sample number, or grade, was found to significantly affect the likelihood of underestimation for lesions diagnosed as DCIS vs DCIS with "possible invasion." The likelihood of pure DCIS underestimation significantly increased when lesions were high grade compared with either intermediate or low grade (18/44 [41%] vs 9/44 [21%] vs 2/10 [20%], P = .03). Conclusion: For lesions biopsied by using a 14-gauge needle, there is a trend towards underestimation of the presence of invasive carcinoma when pathology reveals DCIS with possible invasion compared with pure DCIS. High-grade DCIS was significantly more likely to be underestimated. [ABSTRACT FROM AUTHOR]

Background: Rotational atherectomy (RA) has been used in percutaneous coronary intervention (PCI) for 30 years. With advances in technology, this observational study looks at how rates of RA have changed over the past decade in Australia in relation to PCI and coronary artery bypass graft (CABG) rates. Methods: Retrospective analysis of RA, PCI, and CABG rates per Australian state from Australian Government Department of Human Services' data on Medicare items from 2007 to 2017 was carried out. Results: There were 149 RA procedures in 2007, increasing to 452 in 2017. Rotational atherectomy accounted for 0.67% of PCI procedures in 2007, increasing to 1.48% in 2018 (+0.81%, 95% confidence interval [CI] = [0.64%-0.91%]; P <.001). Most of this increase has come from procedures in New South Wales (441% increase). Australian PCI rate increased from 22 301 to 30 480. Rate of CABG decreased from 5418 to 5206. Conclusions: From 2007 to 2017, rates of RA trebled in Australia. This is despite stable rates of PCI and a fall in rates of CABG. There are several clinical explanations for this trend. [ABSTRACT FROM AUTHOR]