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Background: Treatment of large chondral defects of the knee among patients aged ≥40 years remains a difficult clinical challenge owing to preexisting joint degeneration and the lack of treatment options short of arthroplasty. Purpose: To characterize the survivorship, predictors of failure, and clinical outcomes of osteochondral allograft transplantation (OCA) of the knee among patients aged ≥40 years. Study Design: Case series; Level of evidence, 4. Methods: Prospectively collected data were reviewed for 54 consecutive patients aged ≥40 years who were treated with OCA. Preoperative levels of osteoarthritis (according to Kellgren-Lawrence classification) and meniscal volume and quality were graded from review of radiographs and magnetic resonance imaging. Complications, reoperations, and patient responses to validated outcome measures were reviewed. A minimum follow-up of 2 years was required for analysis. Failure was defined by any removal or revision of the allograft or conversion to arthroplasty. Results: Among 51 patients (mean age, 48 years; range, 40-63 years; 65% male), a total of 52 knees had symptomatic focal cartilage lesions (up to 2 affected areas) that were classified as Outerbridge grade 4 at the time of OCA and did not involve substantial bone loss requiring shell allografts or additional bone grafting. Mean duration of follow-up was 3.6 years (range, 2-11 years). After OCA, 21 knees (40%) underwent reoperation, including 14 failures (27%) consisting of revision OCA (n = 1), unicompartmental knee arthroplasty (n = 5), and total knee arthroplasty (n = 8). Mean time to failure was 33 months, and 2- and 4-year survivorship rates were 88% and 73%, respectively. Male sex (hazard ratio = 4.18, 95% CI = 1.12-27.13) and a higher number of previous ipsilateral knee operations (hazard ratio = 1.70 per increase in 1 surgical procedure, 95% CI = 1.03-2.83) were predictors of failure. A higher Kellgren-Lawrence osteoarthritis grade on preoperative radiographs was associated with higher failure rates in the Kaplan-Meier analysis but not the multivariate model. At final follow-up, clinically significant improvements were noted in the pain (mean score, 47.8 to 67.6) and physical functioning (56.8 to 79.1) subscales of the Short Form-36, as well as the International Knee Documentation Committee subjective form (45.0 to 63.6), Knee Outcome Survey–Activities of Daily Living (64.5 to 80.1), and overall condition statement (4.5 to 6.8) (P < .001). No significant changes were noted for the Marx Activity Rating Scale (5.1 to 3.9, P = .789). Conclusion: A higher failure rate was found in this series of patients aged ≥40 years who were treated with OCA as compared with other studies of younger populations. However, for select older patients, OCA can be a good midterm treatment option for cartilage defects of the knee. [ABSTRACT FROM AUTHOR]

Background: Static anterior tibial subluxation after an anterior cruciate ligament (ACL) injury highlights the abnormal relationship between the tibia and femur in patients with ACL insufficiency, although causal factors including injuries to secondary stabilizers or the time from injury to reconstruction have not been examined. Purpose: To determine static relationships between the tibia and femur in patients with various states of ACL deficiency and to identify factors associated with anterior tibial subluxation. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Patients treated for ACL injuries were identified from an institutional registry and assigned to 1 of 4 cohorts: intact ACL, acute ACL disruption, chronic ACL disruption, and failed ACL reconstruction (ACLR). Anterior tibial subluxation of the medial and lateral compartments relative to the femoral condyles were measured on magnetic resonance imaging (MRI), and an MRI evaluation for meniscal tears, chondral defects, and injuries to the anterolateral ligament (ALL) was performed. Results: One hundred eighty-six ACL-insufficient knees met inclusion criteria, with 26 patients without an ACL injury utilized as a control group. In the lateral compartment, the mean anterior tibial subluxation measured 0.78 mm for the control group (n = 26), 2.81 mm for the acute ACL injury group (n = 74), 3.64 mm for the chronic ACL injury group (n = 40), and 4.91 mm for the failed ACLR group (n = 72). In the failed ACLR group, 37.5% of patients demonstrated lateral compartment anterior subluxation ≥6 mm, and 11.1% of this group had anterior subluxation of the lateral compartment ≥10 mm. Multivariate regression revealed that the presence of both medial and lateral chondral defects was associated with a mean 1.09-mm increase in subluxation of the medial compartment (P = .013). The combination of medial and lateral meniscal tears was an independent predictor of increased lateral tibia subluxation by 1.611 mm (P = .0022). Additionally, across all knee states, an injury to the ALL was associated with increased anterior tibial subluxation in both the medial compartment (P = .0438) and lateral compartment (P = .0046). In 29.4% of knees with ALL injuries, lateral tibial subluxation was ≥6 mm, but with multivariate regression analysis, an ALL injury was not an independent predictor of anterior subluxation of the lateral compartment. Conclusion: Knees with failed ACLR are associated with more anterior tibial subluxation than those with primary ACL deficiency. Using previously reported thresholds of 6 to 10 mm of lateral compartment subluxation for a positive pivot shift, between 11.1% and 37.5% of knees with failed ACLR may be in a “resting pivoted position.” In primary ACL-deficient knees, anterior tibial subluxation is associated with chondral injuries and meniscal tears but not injury chronicity. [ABSTRACT FROM AUTHOR]

Objective. Personal health records (PHRs) may address the needs of children with attention deficit hyperactivity disorder. Among parents, we assessed acceptance, barriers, and intentions regarding use of PHR for their children with attention deficit hyperactivity disorder. Methods. Survey of parents from 3 practices in Rochester, NY. Stepwise logistic regression analysis explored factors predicting respondents’ intentions for future use of PHR, accounting for care coordination needs, caregiver education, socioeconomic status, and satisfaction with providers. Results. Of 184 respondents, 23% had used the PHR for their child, 82% intended future use. No difference was observed between users and nonusers regarding gender, age, race, or education. Users were more likely than nonusers to reside in the suburbs (P = .03). Caregivers were more likely to plan future use of the PHR if they felt engaged as partners in their child’s care (adjusted odds ratio = 2.3, 95% confidence interval = 1.2, 4.5). Conclusions. Parents are enthusiastic about PHRs. Future work should focus on engaging them as members of the health care team. [ABSTRACT FROM PUBLISHER]

Background: Distal biceps brachii tendon repairs performed with a tension slide technique using a cortical button (CB) and interference screw are stronger than those based on suture fixation through bone tunnels (BTs) in biomechanical studies. However, clinical comparison of these 2 techniques is lacking in the literature. Purpose: To perform a clinical comparison of the single-incision CB and double-incision BT techniques. Study Design: Cohort study; Level of evidence, 3. Methods: Distal biceps tendon ruptures repaired through either the single-incision CB or double-incision BT technique were retrospectively identified at a single institution. Patients .1 year out from surgery were assessed for range of motion, strength, and complications, and they completed a DASH questionnaire (Disabilities of the Arm, Shoulder, and Hand). Results: Patients in the CB group (n = 20) were older (52 ± 9.5 vs 43.7 ± 8.7 years; P = .008), had a shorter interval from surgery to evaluation (17.7 ± 5 vs 30.8 ± 16.5 months; P = .001), and were less likely to smoke (0% vs 28.5%; P = .02) compared with the BT patients (n = 21). DASH scores were similar between groups (4.46 ± 4.4 [CB] vs 5.7 ± 7.5 [BT]; P = .65). Multivariate analysis revealed no differences in range of motion or strength between groups. More CB patients (30%; n = 6) experienced a complication compared with those in the BT group (4.8%; n = 1) (P = .04), and these complications were predominantly paresthesias of the superficial radial nerve that did not resolve. There were no reoperations or repair failures in either group. Conclusion: Both the single-incision CB and double-incision BT techniques provided excellent clinical results. Complications were more common in the single-incision CB group and most commonly involved paresthesias of the superficial radial nerve. [ABSTRACT FROM AUTHOR]

Context—Cytomegalovirus (CMV) is an opportunistic infection that causes profound morbidity and mortality after orthotopic liver transplant (OLT). The CMV immunoglobulin G serostatuses of donors and recipients are the main factors influencing risk for development of CMV infection after transplant. Objective—To compare acyclovir and valganciclovir for preventing CMV infection after OLT. Design, Setting, and Patients—Retrospective assessment of adult OLT recipients at intermediate risk for CMV infection at New York Presbyterian Hospital. Intervention—All patients received ganciclovir 5 mg/kg intravenously every 12 hours or valganciclovir 900 mg orally every 12 hours for 7 days after transplant. On postoperative day 8, patients received antiviral prophylaxis according to risk stratification: acyclovir 800 mg orally 3 times daily in donor seronegative/recipient seropositive (D-/R+) patients or valganciclovir 900 mg orally once daily in donor seropositive/recipient seropositive (D+/R+) patients. Main Outcome Measure—Composite incidence of CMV infection, syndrome, or tissue-invasive disease. Results—Of 275 OLT recipients, 89 were at intermediate risk for CMV infection (29 D-/R+, 60 D+/R+). CMV infection, syndrome, or tissue-invasive disease occurred in 1 patient (3%) in the D-/R+ group and 5 patients (8%) in the D+/R+ group (P=.66). One patient (3%) in the D-/R+ group had a CMV infection develop. Five D+/R+ recipients (8%) had CMV infection; 3 of them had CMV syndrome (5%), 1 had CMV hepatitis (1.6%), and the other had CMV esophagitis (1.6%); all events occurred after prophylaxis was discontinued. The rates of CMV infection were similar in D-/R+ patients treated with acyclovir and D+/R+ patients receiving valganciclovir. This risk-stratified approach to viral prophylaxis after OLT resulted in an acceptable rate of CMV infection in D-/R+ recipients and may avoid the costs and adverse effects associated with valganciclovir therapy. [ABSTRACT FROM AUTHOR]

The article presents research which examined the risk factors for anterior glenohumeral instability. Topics covered include the prevalence of this condition in young athletes as well as lack of studies about the injury. Also mentioned is the measurement of the condition by examining glenoid height, glenoid version, glenoid depth as well as rotator interval height.

Background. The extent to which pediatricians inform parents about gestation-adjusted age growth plotting is unclear. Uninformed parents may have decreased satisfaction of infant growth. Subsequent early introduction of solid foods may lead to avoidant feeding behaviors and poor parental perception of infant feeding patterns. Methods. Questionnaires regarding infant growth and feeding behaviors were given to parents (n = 76) of premature infants. The Wilcoxon rank-sum and χ2/Fisher’s exact tests were used. Results. Uninformed parents were less satisfied with their infant’s growth (P < .002). Uninformed parents had more developmentally unready infants at the time of solid food introduction compared with informed parents (P = .03). Significant differences were found in avoidant feeding behaviors and parental perception of infant feeding patterns between developmentally ready and unready infants. Conclusion. Pediatricians should adjust for gestational age when plotting growth and assess for developmental readiness for premature infants when recommending solid foods. [ABSTRACT FROM PUBLISHER]

Objective. This study discusses the impact of mental health screening in pediatric primary care on the management of mental health concerns. Methods. Youth aged 11 years and their parents completed the Pediatric Symptom Checklist and chart reviews were used to gather information about discussion of mental health concerns and connection with mental health services. The study design was a post-intervention study with a concurrent comparison group of youth aged 12 years who were not offered a screening. The χ2 or Fisher’s exact tests and logistic regression were used to compare groups on outcome variables. Results. Parents who completed a mental health screening for their child were more likely to be referred and attend mental health services, attend a psychiatrist appointment, and discuss their concerns with the primary care provider compared with the comparison group. Conclusions. Screening by parents improves detection of problems and fosters conversations with providers and subsequent connection with services. [ABSTRACT FROM PUBLISHER]

Background:While posterior glenohumeral instability is becoming increasingly common among young athletes, little is known of the risk factors for injury.Purpose:To determine the modifiable and nonmodifiable risk factors for posterior shoulder instability in a high-risk cohort.Study Design:Case-control study (prognosis); Level of evidence, 2.Methods:A prospective cohort study in which 714 young athletes were followed from June 2006 through May 2010 was conducted. Baseline testing included a subjective history of instability, instability testing by a sports medicine fellowship–trained orthopaedic surgeon, range of motion, strength measurement with a handheld dynamometer, and bilateral noncontrast magnetic resonance imaging of the shoulder. A musculoskeletal radiologist measured glenoid version, height, depth, rotator interval (RI) height, RI width, RI area, and RI index. Participants were followed to document all acute posterior shoulder instability events during the 4-year follow-up period. The time to the posterior shoulder instability event during the follow-up period was the primary outcome of interest. Univariate and multivariable Cox proportional hazards regression models were used to analyze the data.Results:Complete data on 714 participants were obtained. During the 4-year surveillance period, 46 shoulders sustained documented glenohumeral instability events, of which only 7 were posterior in direction. The baseline factors that were associated with subsequent posterior instability during follow-up were increased glenoid retroversion (P < .0001), increased external rotation strength in adduction (P = .029) and at 45° of abduction (P = .015), and increased internal rotation strength in adduction (P = .038).Conclusion:This is the largest known prospective study to follow healthy participants in the development of posterior shoulder instability. Posterior instability represents 10% of all instability events. The most significant risk factor was increased glenoid retroversion. While increased internal/external strength was also associated with subsequent instability, it is unclear whether these strength differences are causative or reactive to the difference in glenoid anatomy. This work confirms that increased glenoid retroversion is a significant prospective risk factor for posterior instability. [ABSTRACT FROM AUTHOR]

The neutrophil–lymphocyte ratio (NLR) is an inflammatory marker of major adverse cardiac events (MACEs) in both acute coronary syndromes and stable coronary artery disease. The use of NLR as a predictive tool for MACEs among diabetic patients has not been elucidated. An observational study included 338 diabetic patients followed at our clinic between 2007 and 2011. Patients were arranged into equal tertiles according to the 2007 NLR. The MACEs included acute myocardial infarction, coronary revascularization, and mortality. The lowest NLR tertile (NLR <1.6) had fewer MACEs compared with the highest NLR tertile (NLR >2.36; MACEs were 6 of 113 patients vs 24 of 112 patients, respectively; P < .0001). In a multivariate model, the adjusted hazard ratio of third NLR tertile compared with first NLR tertile was 2.8 (95% confidence interval 1.12-6.98, P = .027). The NLR is a significant independent predictor of MACEs in diabetic patients. Further studies with larger numbers are needed. [ABSTRACT FROM AUTHOR]

The article reports a study which researches the potential effect of specific injuries on the round drafted into the WNBA by evaluating the spectrum of injuries in athletes entering the Women's National Basketball Association (WNBA) combine. The results revealed that, reconstruction is the most common surgery in elite female athletes participating in the WNBA combine. Therefore the history of injury or surgery does not affect the round drafted or career length.

The article reports a study which was conducted to identify patient characteristics and compartment pressure values in patients with chronic exertional compartment syndrome (CECS) that lead to improved postoperative outcomes. The results revealed that high school and college patients and isolated anterior compartment release were associated with improved subjective function and satisfaction after fasciotomy. High school and college patients had improved postoperative satisfaction.

Background: Fresh-stored osteochondral allografts have been used successfully to resurface large chondral and osteochondral defects of the knee. However, there are limited data available for the return to athletic activity.Purpose: To review the rate of return to athletic activity after osteochondral allograft transplantation in the knee and to identify any potential risk factors for not returning to sport.Study Design: Case series; Level of evidence, 4.Methods: Forty-three athletes were treated with fresh-stored osteochondral allograft transplantation for symptomatic large chondral or osteochondral defects of the knee from 2000 to 2010. The average age of the athletes (30 men, 13 women) was 32.9 years (range, 18-49 years). Patients were prospectively evaluated by International Knee Documentation Committee (IKDC), activities of daily living scale of the Knee Injury and Osteoarthritis Outcome Score (KOOS), Marx Activity Rating Scale, and Cincinnati Sports Activity Scale scores. A multivariable regression analysis was performed to identify potential risk factors for failure to return to sport at the preinjury level.Results: At an average 2.5-year follow-up, limited return to sport was possible in 38 of 43 athletes (88%), with full return to the preinjury level achieved in 34 of 43 athletes (79%). In these 34 athletes, time to return to sport was 9.6 ± 3.0 months. Age ≥25 years (P = .04) and preoperative duration of symptoms greater than 12 months (odds ratio, 37; P = .003) negatively affected the ability to return to sport. In the athletes who returned to their previous level of competition, IKDC (P < .001), KOOS (P = .02), and Marx Activity Rating Scale (P < .001) scores were all significantly greater than in those athletes who did not return to sport.Conclusion: Osteochondral allograft transplantation in an athletic population for chondral and osteochondral defects in the knee allows for a high rate of return to sport. Risk factors for not returning to sport included age ≥25 years and preoperative duration of symptoms ≥12 months. [ABSTRACT FROM PUBLISHER]

Background: There are few long-term studies evaluating functional outcomes and rates of arthrosis after arthroscopic Bankart repair with bioabsorbable tacks.Purpose: We evaluated the clinical and radiographic results of arthroscopic Bankart repair using intra-articular bioabsorbable tacks at a minimum of 10 years’ follow-up.Study Design: Case series; Level of evidence, 4.Methods: Thirty-two consecutive patients were retrospectively identified. Twenty patients (63%) were evaluated at a mean follow-up of 13.5 years (range, 10.75-17.5 years) and average age of 43 years (range, 28-73 years). The surgical shoulder (SS) was compared with a healthy control shoulder (CS) in 15 of 20 patients. Outcome tools included the Western Ontario Shoulder Instability Index (WOSI) and Disabilities of the Shoulder, Arm, and Hand (DASH). Blinded, independent evaluators performed physical examinations and reviewed radiographs.Results: Thirteen patients (65%) had stable shoulders, 5 of 7 (25%) failed by dislocation, and 2 of 7 (10%) failed by signs of anterior instability on examination. Three patients underwent revision stabilization surgery. Average time to failure was 4.2 years (range, 0.25-14.7 years). Average WOSI and DASH scores were 80% and 7.3, respectively. The CS faired better than SS in WOSI scores (97% vs 83%, respectively; P = .008), main DASH scores (0.39 vs 6.79, respectively; P = .024), and the DASH sports module (0.00 vs 10.94, respectively; P = .043). Patients lost 5.9° of passive forward flexion (P = .031) and 4.3° of passive external rotation (P = .001). Forty percent returned to their preoperative sports level. Higher grades of arthrosis were seen in the SS (20% absent, 40% mild, 25% moderate, and 15% severe) versus CS (P = .002).Conclusion: At long-term follow-up, 65% of patients treated with an arthroscopic Bankart repair using bioabsorbable tacks had a well-functioning, stable shoulder. Disability scores were greatest with sports; however, the majority of patients had well-preserved ranges of motion and good functional WOSI scores. Despite this, 40% had evidence of moderate to severe glenohumeral arthrosis. [ABSTRACT FROM PUBLISHER]

The aim was to systematically review genetic testing guidelines in the evaluation of children with autism spectrum disorders (ASDs). The Clinical Report published by the American Academy of Pediatrics (AAP)1 recommended individualizing the workup, including karyotype and specific DNA testing for fragile X syndrome. A recent publication reported higher rates of abnormalities on CGH microarray (CMA) testing on children with ASD.2 The medical records of 507 children seen through the Kirch Developmental Services Center were abstracted for genetic testing and factors associated with this testing. Abnormalities were found on karyotype in 2.3% and in DNA for fragile X in 0.04%. The author concludes that the diagnostic yield of the genetic testing was low in this population. Furthermore, their findings support the theory that CMA can be considered as part of the initial genetic screening in children with ASD in most situations. Future studies will need to be done prospectively to evaluate children in a standard fashion. [ABSTRACT FROM PUBLISHER]

Objectives: We evaluated the clinical characteristics of patients treated for angioedema, and determined the factors associated with the clinical course. Methods: We performed a chart review of 367 episodes presenting from 1997 through 2008. Results: The mean (±SD) age was 51.8 ± 20.1 years; 65.7% of the episodes occurred in female patients; 62.4% of the episodes were in African American patients. The patients were on angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) for 49.1 % of the episodes, and an inciting factor (diet change, minor trauma, or exposure to fumes) was present for 21.5%. We found that 75.7% of the episodes were type 1 angioedema. 5.7% were type 2, 1.4% were type 3, and 17.2% involved multiple sites; 58% of the episodes required admission. For 3.3% of the episodes, the patients were intubated, and in 0.3% of the episodes, the patients required a tracheostomy. Logistic regression identified non-African American race, allergies, alcohol use. use of ACE inhibitors or ARBs. multiple sites, and age as associated with the need for admission. Bivariate analysis identified age. multiple affected sites, stridor, hoarseness, dysphagia. and drooling as associated with intubation or tracheostomy. Conclusions: The novel findings of this study are lower rates of airway intervention than reported previously and the fact that multiple affected sites were associated with admission and intubation or tracheostomy, particularly when the edema involved the larynx or hypopharynx. [ABSTRACT FROM AUTHOR]