Grinding, Clicking, and Pivot Pain Resolve in Most Patients After Knee Arthroscopy.

PURPOSE: To determine whether knee arthroscopy alleviates the symptom constellation of knee grinding/clicking, catching/locking, and pivot pain. METHODS: One-year follow-up data from 584 consecutive subjects who underwent knee arthroscopy from August 2012 to December 2019 were collected prospectively. Subjects reported frequency of knee grinding/clicking, catching/locking, and/or pivot pain preoperatively and 1 and 2 years postoperatively. A single surgeon performed each procedure and documented all intraoperative pathology. We measured the postoperative resolution or persistence of these symptoms and used multivariable regression models to identify preoperative demographic and clinical variables that predicted symptom persistence. We also assessed changes in the Pain, Activities of Daily Living, and Quality of Life subscales of the Knee Injury and Osteoarthritis Outcome Score (KOOS). RESULTS: Postoperative symptom resolution was more likely for grinding/clicking (65.6%) and pivot pain (67.8%) than for catching/locking (44.1%). Smoking status, overweight/obesity, absence of meniscal tear, and number of compartments with focal cartilage lesions predicted persistence of 1 or more patient-reported knee symptoms. KOOS subscale scores consistently improved by at least one standard deviation. Individuals who had resolution of patient-reported knee symptoms exhibited roughly 2-fold improvements in KOOS Pain, ADL and Quality of Life scores compared with those whose symptoms persisted. Persistence of pivot pain was associated with the least improvement of the 3 KOOS subscales. CONCLUSIONS: Two in three patients with grinding/clicking or pivot pain experience symptom resolution after knee arthroscopy, although catching/locking is more likely to persist. Smoking status, overweight/obesity, absence of meniscal tear, and number of compartments with focal cartilage lesions predict symptom persistence after knee arthroscopy. LEVEL OF EVIDENCE: Therapeutic Level IV, retrospective cohort analysis of prospective data.

Up to One-Half of Runners Return to Running One Year After Arthroscopic Partial Meniscectomy.

Purpose: To determine whether, and at which frequency, runners return to running after undergoing arthroscopic partial meniscectomy (APM). Methods: We identified patients who underwent surgery between August 2012 and December 2019 who were classified as runners (defined as running 2+ times per week according to Marx Activity Rating Scale Q1) and completed the 1-year follow-up to assess outcomes. Patients were followed using the Marx Activity Rating Scale, Knee Injury and Osteoarthritis Outcome Score (KOOS), Veterans RAND 12-item Health Survey mental and physical components, and visual analog pain scale scores preoperatively and 1 and 2 years postoperatively. The association between baseline characteristics and return to running was assessed using the unpaired t test or Wilcoxon rank sum test for continuous predictors and a χ2 test for categorical predictors, using the 1-year postoperative follow-up data. Results: A total of 185 patients were included in this study. One year after APM, 41% of runners returned to running at the same frequency or more frequently than before. Further, 50% of runners returned to running at least twice weekly. Return to running according to those definitions was similar at 2 years (38% and 47%, respectively). At both 1 and 2 years, runners exhibited significant improvements in KOOS (Pain), KOOS (Function in Sport and Recreation), visual analog pain scale, and Veterans RAND 12-item Health Survey physical component scores. Lower body mass index (P = .0248) and greater baseline running frequency (P = .0300) predicted return to running at least twice weekly at 1 year postoperatively. Medial versus lateral compartment partial meniscectomy and Outerbridge grade were not significant predictors of return to running. Conclusions: Roughly 1 in 2 runners return to their preoperative running frequency after undergoing APM. Obesity and lower baseline running frequency were significantly associated with inability to return to running. Level of Evidence: III, retrospective cohort study.

Patients with diabetes mellitus experience poorer outcomes after arthroscopic rotator cuff repair.

HYPOTHESIS: The purpose of this study was to identify potential differences using validated clinical outcome instruments between patients with and without diabetes mellitus (DM) after arthroscopic rotator cuff repair (RCR). METHODS: Six-hundred eighty-four patients (32 with and 652 without DM) who underwent arthroscopic RCR were prospectively followed using the visual analog pain scale, Simple Shoulder Test, Single Assessment Numeric Evaluation, American Shoulder and Elbow Surgeons score, and Veterans RAND 12-item Health Survey (mental and physical component scores) preoperatively and at 3, 6, 12, and 24 months postoperatively. RESULTS: Patients with DM experienced significantly more pain (P = .0172) and had lower Simple Shoulder Test (P = .0458) and American Shoulder and Elbow Surgeons (P = .0200) scores than patients without DM 6 months after surgery. Although differences between groups are seen at other postoperative time points, none are statistically significant.They also exhibited lower self-rated mental health status at 12 months (P = .0034) and 24 months (P = .0077), as well as lower self-rated physical health status at 12 months (P = .0223) and 24 months (P = .0077). Changes in scores from preoperatively to postoperatively were not different for patients with DM vs. without DM. CONCLUSION: Patients with DM experience significantly more pain, exhibit significantly poorer shoulder function, and report persistently diminished mental and physical health status compared with their counterparts without DM after undergoing arthroscopic RCR. Although these differences did not reach the minimal clinically important difference, orthopedic surgeons should be cognizant of DM as an outcome-modifying variable when selecting, counseling, and treating patients with rotator cuff tears. Glycemic control should be scrutinized and optimized during the perioperative medical evaluation and ultimately factored into the surgical risk profile and prognosis.

Defining the Opioid Requirement in Anterior Cruciate Ligament Reconstruction.

INTRODUCTION: The amount and duration of opioids necessary after anterior cruciate ligament reconstruction (ACLR) are inadequately defined. This study sought to prospectively (1) define the amount and duration of opioid consumption, (2) investigate the relationship between preoperative pain expectation and postoperative satisfaction with pain management, and (3) identify risk factors for increased opioid use after ACLR. METHODS: One hundred eight patients undergoing primary ACLR with hamstring graft were prospectively analyzed for preoperative pain expectation, using visual analog scale (VAS) rating, and postoperative satisfaction with pain management. Univariate and multivariate analyses were done to identify patient characteristics associated with satisfaction and/or amount and duration of opioid use. RESULTS: Mean duration and cumulative intake of opioid consumption after ACLR were 5.3 days and 15.3 tablets, respectively. Patients expected moderate postoperative pain: mean preoperative VAS = 68.9. The preoperative VAS rating was associated with a significantly greater amount (P = 0.0265) and longer duration (P = 0.0212) of opioid consumption. Baseline opioid users took opioids for twice as long postoperatively (10.0 versus 5.0 days; P = 0.0149) and consumed twice as many tablets (29.3 versus 14.8 tablets; P = 0.0280) compared with opioid-naive patients. DISCUSSION: This study demonstrated on average 15.3 opioid tablets over 5.3 days provided satisfactory pain management after ACLR. Risk factors for increased opioid consumption included preoperative opioid use.

Pigmented Villonodular Synovitis of the Glenohumeral Joint and Biceps Tendon Sheath.

A 34-year-old woman presented with paroxysmal, insidious shoulder pain with effusion. MRI demonstrated a permeative, intermediate-signal lesion on T1 and T2 sequences involving the glenohumeral joint and biceps tendon sheath. The patient was treated with arthroscopic synovectomy, debridement, and subpectoral biceps tenodesis, with histopathology demonstrating pigmented villonodular synovitis (PVNS). PVNS is an extremely rare lesion of the glenohumeral joint and surrounding extra-articular structures. Awareness of this condition is paramount for timely diagnosis and intervention before joint destruction occurs. Arthroscopic treatment with meticulous attention to surgical technique is a feasible treatment strategy in the absence of end-stage chondral damage.

Epidemiologic Comparison of Pitching Mechanics, Pitch Type, and Pitch Counts Among Healthy Pitchers at Various Levels of Youth Competition.

PURPOSE: To determine differences among healthy pitchers at various levels of competition regarding pitching history, pitching mechanics, and prevalence of breaking pitches. METHODS: Demographic, anthropometric, pitching history, and kinematic data were collected on healthy youth pitchers using dual orthogonal high-speed video analysis. Players were grouped by maturity level (9 to 12 [prepubescent], 13 to 15 [pubescent], 16 to 17 [mature], and 18 to 22 years [adult]). Groups were compared regarding pitch counts, pitching mechanics, and use of breaking pitches. Mechanics were assessed for favorable observational parameters (e.g., closed foot orientation at foot-strike) and measurable parameters at cocking, foot-strike, and ball release (e.g., knee flexion). RESULTS: Two hundred ninety-five pitchers were included. Sixty-three were 9 to 12, 130 were 13 to 15, 78 were 16 to 17, and 24 were 18 to 22 years of age. Older pitchers threw more pitches per game (41, 52, 69, and 50 by age group; P < .001), per season (766, 975, 1,079, and 881; P = .017), and per year (901, 1,343, 2,064, and 1,302; P < .001). They were more likely to pitch for multiple teams, for more than 9 months, in showcases, and in violation of pitch count recommendations. Older pitchers were more likely to maintain their hand on top of the ball, maintain closed shoulders at foot-strike, achieve hip and shoulder separation, and lead with their hips. Older pitchers achieved greater relative stride-length, greater knee flexion at front-foot contact, and increased lead hip flexion at ball release. Pitchers began throwing curveballs and sliders at 12.6 and 13.5 years, respectively. CONCLUSIONS: As pitchers age, they throw more pitches per game, per season, and per year and are more likely than younger pitchers to violate pitch count recommendations. Older pitchers tend to pitch with improved mechanics and velocity. The proportion of pitchers throwing breaking pitches increases with age, with the greatest increase occurring between ages 12 and 13. LEVEL OF EVIDENCE: Level II, cross-sectional study.

Fixation of Soft Tissue to Bone: Techniques and Fundamentals.

A myriad of orthopaedic injuries require surgical fixation of torn connective tissue to an osseous insertion site with either direct repair or reconstruction with a soft-tissue graft. Numerous factors influence the strength of a soft-tissue-to-bone fixation construct, including tissue quality, implant strength, contact area and pressure, and tensioning. Each fixation technique differs with respect to biologic integration, biomechanical stability, and failure mechanism. Fixation methods may or may not require an implant, such as interference screws, staples, internal buttons, transfixion pins, or suture anchors. Understanding the optimal method of soft-tissue fixation for a given scenario is crucial for successful repair or reconstruction.

Assessment of outcome following the use of recombinant human bone morphogenetic protein-2 for spinal fusion in the elderly population.

INTRODUCTION: Although the use of recombinant human bone morphogenetic protein-2 (rhBMP-2) for spinal fusion has been fairly studied in the general population, relatively little research has been conducted on its use in the elderly patient demographic despite this population's growth. The authors sought to examine the clinical efficacy, complication rate, and cost-effectiveness of rhBMP-2 use in elderly patients undergoing spinal fusion surgery. EVIDENCE ACQUISITION: We conducted a systematic review of the published literature for elderly patients that underwent spinal fusion surgery with the use of rhBMP-2. A systematic search was performed utilizing the PUBMED and MEDLINE databases in order to identify all papers dealing with recombinant human Bone Morphogenic Protein-2 use in patients over the age of 60 years. EVIDENCE SYNTHESIS: Twenty-five papers were identified that met our inclusion criteria. While successful fusion, improvement in pain, and improved quality of life were encountered in elderly patients who were treated with fusions surgery along with rhBMP-2, there were several complications that were encountered including seroma formation, pleural effusions, and bone non-union. CONCLUSIONS: The literature demonstrated that BMP serves as a potent osteoinductive agent in the elderly with similar efficacy to bone autograft. Although use of BMP showed mixed results and had higher initial costs, when taken into account with complication correction and costs, BMP usage appears to be more economically beneficial overall. Future studies are needed to clarify the clinical significance of the complications encountered in elderly patients treated with rhBMP-2. Future research can assist in developing recommendations which can minimize these risks in the elderly patient demographic.

Correlates With History of Injury in Youth and Adolescent Pitchers.

PURPOSE: To determine the factors within pitcher demographic characteristics, pitching history, and pitch kinematics, including velocity, that correlate with a history of pitching-related injury. METHODS: Demographic and kinematic data were collected on healthy youth and adolescent pitchers aged 9 to 22 years in preseason training during a single preseason using dual orthogonal high-speed video analysis. Pitchers who threw sidearm and those who had transitioned to another position were excluded. Players were asked whether they had ever had a pitching-related shoulder or elbow injury. Multivariate logistic regression analysis was performed on those variables that correlated with a history of injury. RESULTS: Four hundred twenty pitchers were included, of whom 31% had a history of a pitching-related injury. Participant height (P = .009, R(2) = 0.023), pitching for more than 1 team (P = .019, R(2) = 0.018), and pitch velocity (P = .006, R(2) = 0.194) served as independent correlates of injury status. A model constructed with these 3 variables could correctly predict 77% of injury histories. Within our cohort, the presence of a 10-inch increase in height was associated with an increase in a history of injury by 20% and a 10-mph increase in velocity was associated with an increase in the likelihood of a history of injury by 12%. Playing for more than 1 team increased the likelihood of a history of injury by 22%. CONCLUSIONS: Pitch velocity, pitcher height, and pitching for more than 1 team correlate with a history of shoulder and elbow injury. Current recommendations regarding breaking pitches may not prevent injury. Pitchers should be cautioned about pitching for more than 1 team. Taller pitchers and high-velocity pitchers may be at risk of injury.

Predictors of throwing velocity in youth and adolescent pitchers.

BACKGROUND: Shoulder and elbow injuries are a common cause of pain, dysfunction, and inability to play in overhead throwers. Pitch velocity plays an integral part in the etiology of these injuries; however, the demographic and biomechanical correlates with throwing velocity remain poorly understood. We hypothesized that pitchers with higher velocity would have shared demographic and kinematic characteristics. METHODS: Normal preseason youth and adolescent pitchers underwent dual-orthogonal high-speed video analysis while pitch velocity was collected with a radar gun. Demographic and pitching history data were also collected. Kinematic data and observational mechanics were recorded. Multivariate regression analysis was performed. RESULTS: A total of 420 pitchers were included, with a mean pitching velocity of 64 ± 10 mph. After multivariate logistic regression analysis, the most important correlates with pitch velocity were age (P < .001; R(2) = 0.658), height (P < .001; R(2) = 0.076), separation of the hips and shoulders (P < .001; R(2) = 0.027), and stride length (P < .001; R(2) = 0.016); in combination, these 4 variables explained 78% of the variance in pitch velocity. Each year of age was associated with a mean 1.5 mph increase in velocity; each inch in height, with 1.2 mph; separation of the hips and shoulders, with 2.6 mph; and a 10% increase in stride length, with 1.9 mph. CONCLUSION: Pitch velocity is most strongly correlated with age, height, separation of the hips and shoulders, and stride length.

Survival impact of time to initiation of chemoradiotherapy after resection of newly diagnosed glioblastoma.

OBJECT There are few and conflicting reports on the effects of delayed initiation of chemoradiotherapy on the survival of patients with glioblastoma. The standard of care for newly diagnosed glioblastoma is concurrent radiotherapy and temozolomide chemotherapy after maximal safe resection; however, the optimal timing of such therapy is poorly defined. Given the lack of consensus in the literature, the authors performed a retrospective analysis of The Cancer Genome Atlas (TCGA) database to investigate the effect of time from surgery to initiation of therapy on survival in newly diagnosed glioblastoma. METHODS Patients with primary glioblastoma diagnosed since 2005 and treated according to the standard of care were identified from TCGA database. Kaplan-Meier and multivariate Cox regression analyses were used to compare overall survival (OS) and progression-free survival (PFS) between groups stratified by postoperative delay to initiation of radiation treatment. RESULTS There were 218 patients with newly diagnosed glioblastoma with known time to initiation of radiotherapy identified in the database. The median duration until therapy was 27 days. Delay to radiotherapy longer than the median was not associated with worse PFS (HR = 0.918, p = 0.680) or OS (HR = 1.135, p = 0.595) in multivariate analysis when controlling for age, sex, KPS score, and adjuvant chemotherapy. Patients in the highest and lowest quartiles for delay to therapy (≤ 20 days vs ≥ 36 days) did not statistically differ in PFS (p = 0.667) or OS (p = 0.124). The small subset of patients with particularly long delays (> 42 days) demonstrated worse OS (HR = 1.835, p = 0.019), but not PFS (p = 0.74). CONCLUSIONS Modest delay in initiation of postoperative chemotherapy and radiation does not appear to be associated with worse PFS or OS in patients with newly diagnosed glioblastoma, while significant delay longer than 6 weeks may be associated with worse OS.

Flexor digitorum profundus laceration in association with closed middle phalangeal fracture: case report.

We report a patient with a flexor digitorum profundus laceration caused by the volarly displaced proximal fragment of a middle phalangeal fracture. Awareness of this association may allow timely recognition and appropriate treatment.

Does Operative Treatment of First-Time Patellar Dislocations Lead to Increased Patellofemoral Stability? A Systematic Review of Overlapping Meta-analyses.

PURPOSE: To conduct a systematic review of meta-analyses comparing nonoperative and operative treatment of patellar dislocations to elucidate the cause of the variation and to determine which meta-analysis provides the current best available evidence. METHODS: A systematic review of the literature to identify meta-analyses was performed. Data were extracted for patient outcomes and recurrent dislocations. Meta-analysis quality was assessed using the Oxman-Guyatt and Quality of Reporting of Meta-analyses systems. The Jadad algorithm was then applied to determine which meta-analysis provided the highest level of evidence. RESULTS: Four meta-analyses met the eligibility criteria: 1 Level I evidence, 2 Level II evidence, and 1 Level III evidence. A total of 1,984 patients were included (997 underwent surgery whereas 987 underwent conservative treatment). Three meta-analyses found a lower subsequent patellar dislocation rate in patients managed operatively compared with nonoperatively, whereas one did not find a difference in recurrent dislocation rates between the operative and nonoperative groups. When the results of all the studies were combined, the overall redislocation rate was 29.4% and the rate of recurrent instability episodes was 32.8%. Patients treated operatively had a 24.0% rate of repeat patellar dislocation and a 32.7% rate of recurrent patellar instability, whereas patients treated nonoperatively had a 34.6% rate of repeat patellar dislocation and a 33.0% rate of recurrent instability. In addition, 1 meta-analysis found a significantly higher rate of patellofemoral osteoarthritis in the operative group. No differences in functional outcomes scores were seen between treatments. Two meta-analyses had low Oxman-Guyatt scores (<4), indicative of major flaws. CONCLUSIONS: According to the best available evidence, operative treatment of acute patellar dislocations may result in a lower rate of recurrent dislocations than nonoperative treatment but does not improve functional outcome scores. LEVEL OF EVIDENCE: Level III, systematic review of Level I, II, and II studies.

Bioabsorbable versus metallic interference screws in anterior cruciate ligament reconstruction: a systematic review of overlapping meta-analyses.

PURPOSE: Multiple meta-analyses of randomized controlled trials have been conducted to compare clinical and functional outcomes after anterior cruciate ligament (ACL) reconstruction using metallic interference screw (MIS) versus bioabsorbable interference screw (BIS) fixation, but discrepancies in their findings have prevented a consensus conclusion. The purposes of this study were (1) to conduct a systematic review of meta-analyses comparing MISs and BISs in ACL reconstruction, (2) to provide surgical treatment recommendations for ACL graft fixation based on the highest available evidence, and (3) to propose future research avenues in areas of practice lacking high-level evidence. METHODS: The literature was systematically reviewed to identify meta-analyses comparing MISs and BISs in ACL reconstruction. Data were extracted for clinical and functional outcomes, and methodologic quality was assessed using the validated Quality of Reporting of Meta-analyses and Oxman-Guyatt systems. To determine which meta-analyses provided the current best available evidence, the Jadad decision algorithm was used. RESULTS: One Level I and 2 Level II meta-analyses were included. None showed differences between BISs and MISs in validated outcome scores, pivot-shift testing, KT arthrometry (MEDmetric, San Diego, CA), or loss of knee motion. Subgroup analyses found no differences in clinical outcomes or knee stability across biomaterials. All meta-analyses were of high quality according to the Quality of Reporting of Meta-analyses and Oxman-Guyatt systems. Two meta-analyses were determined by the Jadad algorithm to represent the current best available evidence. Both studies showed prolonged knee effusion with BIS use, with 1 also showing an increased incidence of femoral tunnel widening and screw breakage with BIS use. CONCLUSIONS: Whereas clinical and functional outcomes are similar with MISs and BISs, prolonged knee effusion, femoral tunnel widening, and screw breakage are more common with BIS use. Future cost-effectiveness analyses may help weigh the known advantages of BISs against their costs and adverse-event profile. LEVEL OF EVIDENCE: Level II, systematic review of Level I and II studies.

Does Double-Bundle Anterior Cruciate Ligament Reconstruction Improve Postoperative Knee Stability Compared With Single-Bundle Techniques? A Systematic Review of Overlapping Meta-analyses.

PURPOSE: Multiple meta-analyses of randomized controlled trials, the highest available level of evidence, have been conducted to determine whether double-bundle (DB) or single-bundle (SB) anterior cruciate ligament reconstruction (ACL-R) provides superior clinical outcomes and knee stability; however, results are discordant. The purpose of this study was to conduct a systematic review of meta-analyses comparing SB and DB ACL-R to discern the cause of the discordance and to determine which of these meta-analyses provides the current best available evidence. METHODS: We evaluated available scientific support for SB as compared with DB ACL-R by systematically reviewing the literature for published meta-analyses. Data on patient clinical outcomes and knee stability (as measured by KT arthrometry and pivot-shift testing) were extracted. Meta-analysis quality was judged using the Oxman-Guyatt and Quality of Reporting of Meta-analyses systems. The Jadad algorithm was then applied to determine which meta-analyses provided the highest level of evidence. RESULTS: Nine meta-analyses were included, of which 3 included Level I Evidence and 6 included both Level I and Level II Evidence. Most studies found significant differences favoring DB reconstruction on pivot-shift testing, KT arthrometry measurement of anterior tibial translation, and International Knee Documentation Committee objective grading. Most studies detected no significant differences between the 2 techniques in subjective outcome scores (Tegner, Lysholm, and International Knee Documentation Committee subjective), graft failure, or complications. Oxman-Guyatt and Quality of Reporting of Meta-analyses scores varied, with 2 studies exhibiting major flaws (Oxman-Guyatt score <3). After application of the Jadad decision algorithm, 3 concordant high-quality meta-analyses were selected, with each concluding that DB ACL-R provided significantly better knee stability (by KT arthrometry and pivot-shift testing) than SB ACL-R but no advantages in clinical outcomes or risk of graft failure. CONCLUSIONS: The current best available evidence suggests that DB ACL-R provides better postoperative knee stability than SB ACL-R, whereas clinical outcomes and risk of graft failure are similar between techniques. LEVEL OF EVIDENCE: Level II, systematic review of Level I and II studies.

Do arthroscopic and open stabilization techniques restore equivalent stability to the shoulder in the setting of anterior glenohumeral instability? a systematic review of overlapping meta-analyses.

PURPOSE: Shoulder instability frequently recurs in young patients without operative treatment. Both open and arthroscopic approaches to shoulder stabilization with labral repair and capsulorrhaphy have been described and are routinely used. Multiple trials have been conducted to compare these approaches, with multiple meta-analyses performed to synthesize these trials; however, the results remain controversial. The purpose of this study was to critically evaluate the current meta-analyses to identify the current state of the art. METHODS: In this study we evaluate available scientific support for the ability of both arthroscopic and open soft-tissue stabilization techniques to restore stability of the shoulder by performing a systematic review of the literature for previous meta-analyses. Data were extracted for rates of recurrence and patient outcomes. Study quality was measured with the Oxman-Guyatt and QUOROM (Quality of Reporting of Meta-analyses) systems. The Jadad algorithm was applied independently by 4 authors to determine which meta-analysis provided the highest level of available evidence. RESULTS: After application of the inclusion and exclusion criteria, 8 meta-analyses were included. Both studies published prior to 2007 concluded that open stabilization provided lower recurrence rates than arthroscopic stabilization, the 3 studies published in 2007 are discordant, and all 3 studies published after 2008 concluded that open and arthroscopic stabilization provided equivalent results. Two meta-analyses had low Oxman-Guyatt scores (<3) signifying major flaws. Four authors independently selected the same meta-analysis as providing the highest quality of evidence using the Jadad algorithm, and this meta-analysis found no difference in recurrence rates between open and arthroscopic stabilization. CONCLUSIONS: This systematic review of overlapping meta-analyses comparing arthroscopic and open shoulder stabilization suggests that according to current best available evidence, there are no significant differences in failure rates. LEVEL OF EVIDENCE: Level IV, systematic review of Level I through IV studies.

Is there a higher failure rate of allografts compared with autografts in anterior cruciate ligament reconstruction: a systematic review of overlapping meta-analyses.

PURPOSE: Multiple meta-analyses of randomized controlled trials (RCTs), the highest available level of evidence, have been conducted to determine whether autograft or allograft tissue provides superior clinical outcomes and structural healing in anterior cruciate ligament reconstruction (ACLR); however, results are discordant. The purpose of this study was to conduct a systematic review of meta-analyses comparing ACLR with autografts and allografts to elucidate the cause of discordance and to determine which meta-analyses provide the current best available evidence. METHODS: In this study we evaluated available scientific support for autograft versus allograft use in ACLR by systematically reviewing the literature for published meta-analyses. Data regarding patient outcomes and structural healing were extracted from these meta-analyses. Meta-analysis quality was assessed using the Oxman-Guyatt and Quality of Reporting of Meta-analyses (QUOROM) systems. The Jadad algorithm was then applied to determine which meta-analyses provided the highest level of evidence. RESULTS: Eight meta-analyses containing a total of 15,819 patients met the eligibility criteria, 2 of which included Level II evidence and 6 of which included Level III/IV evidence. Four meta-analyses found no differences between autografts and allografts for patient outcomes, whereas 4 found autografts superior in one or more respects. Four meta-analyses reported higher graft rupture rates in the allograft group, and 2 found superior hop test performance in autograft-treated patients. Six meta-analyses had low Oxman-Guyatt scores (<4) indicative of major flaws. CONCLUSIONS: According to this systematic review of overlapping meta-analyses comparing autografts and allografts for ACLR, the current best available evidence suggests no differences in rupture rates and clinical outcomes. Lower quality meta-analyses indicate that autografts may provide a lower rerupture rate, better hop test performance, and better objective knee stability than do allografts. LEVEL OF EVIDENCE: Systematic review of Level II, III, and IV meta-analyses.

Tumor-to-tumor metastasis: breast carcinoma to meningioma.

Metastasis of breast carcinoma to meningioma is a rare phenomenon with relatively few reports in the literature, although it is the most common type of carcinoma-to-meningioma metastasis. Several factors have been implicated in the pathogenesis of these lesions, including the microenvironment and vascular network of the meningioma, expression of cell-cell adhesion molecules, local immunosuppression, and hormonal factors, including estrogen and progesterone, whose receptors have been well-characterized in these two tumor types. While histopathologic study is the cornerstone of diagnosis of these lesions, newer radiological modalities such as magnetic resonance spectroscopy and perfusion MRI have shown promise, particularly in screening patients at risk for developing these lesions. Because their detection is problematic, it is imperative that clinicians thoroughly examine tissue samples of resected meningiomas, as this may alter the patient's treatment plan and prognosis. Furthermore, as both of these neoplasms often co-occur in women with breast cancer, clinicians should be vigilant of the potential for intrameningioma metastasis when neurological involvement becomes apparent in late-stage disease. While these unusual lesions should be managed surgically, as with meningiomas, it is unclear whether proposed adjuvants such as hormonal and radiation therapy improve survival.

Open versus endoscopic carpal tunnel release: a meta-analysis of randomized controlled trials.

BACKGROUND: Carpal tunnel syndrome is a common compressive neuropathy of the median nerve. The efficacy and safety of endoscopic versus open carpal tunnel release remain controversial. QUESTIONS/PURPOSES: The purpose of this study was to determine whether endoscopic compared with open carpal tunnel release provides better symptom relief, validated outcome scores, short- and long-term strength, and/or digital sensibility; entails a differential risk of complications such as nerve injury, scar tenderness, pillar pain, and reoperation; allows an earlier return to work; and takes less operative time. METHODS: The English-language literature was searched using MEDLINE, the Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Central Register of Controlled Trials. Randomized controlled trials that compared endoscopic and open carpal tunnel release were included in the meta-analysis. Methodologic quality was assessed with the Consolidated Standards Of Reporting Trials (CONSORT) checklist, and a sensitivity analysis was performed. Symptom relief, Boston Carpal Tunnel Questionnaire (BCTQ) scores, strength, digital sensibility, complications, reoperation, interval to return to work, and operative time were analyzed. Twenty-one randomized controlled trials containing 1859 hands were included. RESULTS: Endoscopically treated patients showed similar symptom relief and BCTQ scores; better early recovery of grip strength (mean difference [MD], 3.03 kg [0.08-5.98]; p = 0.04) and pinch strength (MD, 0.77 kg [0.33-1.22]; p < 0.001) but no advantage after 6 months; lower risk of scar tenderness (risk ratio [RR], 0.53 [0.35-0.82]; p = 0.005); higher risk of nerve injury (RR, 2.84 [1.08-7.46]; p = 0.03), most of which were transient neurapraxias. Similar risk of pillar pain and reoperation; an earlier return to work (MD, -8.73 days [-12.82 to -4.65]; p < 0.001); and reduced operative time (MD, -4.81 minutes [-9.23 to -0.39]; p = 0.03). CONCLUSIONS: High-level evidence from randomized controlled trials indicates that endoscopic release allows earlier return to work and improved strength during the early postoperative period. Results at 6 months or later are similar according to current data except that patients undergoing endoscopic release are at greater risk of nerve injury and lower risk of scar tenderness compared with open release. While endoscopic release may appeal to patients who require an early return to work and activities, surgeons should be cognizant of its elevated incidence of transient nerve injury amid its similar overall efficacy to open carpal tunnel release. Additional research is required to define the learning curve of endoscopic release and clarify the influence of surgeon volume on its safety.