Increased posterior tibial slope is an independent risk factor of anterior cruciate ligament reconstruction graft rupture irrespective of graft choice.

INTRODUCTION: Anterior cruciate ligament (ACL) reconstruction failure remains a commonly seen complication despite advances in technique and graft options. Recently, several studies have shown that the inclination of the tibial plateau in the sagittal plane affects the stability of the knee joint. The purpose of this study was to determine if an increased posterior slope of the tibia is associated with failure of ACL reconstruction irrespective of the graft used. METHODS: From June 2002 to August 2003, a total of 100 patients with a symptomatic ACL-deficient knee were randomised to receive either a hamstring autograft or posterior tibialis allograft. All allografts were from a single tissue bank, aseptically processed, and fresh-frozen without terminal irradiation. ACL graft failures requiring reoperation with a minimum of 10-year follow-up were identified via telephone survey. Lateral radiographs of the knee of all patients were reviewed, and the slope of the tibia was measured using a standardised technique. Two fellowship-trained orthopaedic sports medicine specialists, one board-certified general orthopaedic surgeon, and two fellowship-trained musculoskeletal radiologists measured the tibial slope in all patients. RESULTS: At a minimum of 10-year follow-up, there were four (8.3%) autograft and 13 (26.5%) allograft failures that required revision reconstruction. The overall average tibial slope of the nonfailure cohort was 9.4°. The overall average tibial slope of the failure cohort was 11.9° (P â€‹= â€‹0.0002). The average slope of the allograft failures was 11.5°compared with an average slope of 9.6° in the nonfailures (P â€‹= â€‹0.01). The average slope of the autograft failures was 13.1° compared with 9.3° in the nonfailures (P â€‹= â€‹0.011). The mean difference in tibial slope measurements was 0.665 (95% confidence interval: 0.569-0.750). The interrater reliability, as measured by the intraclass correlation coefficient, for tibial slope was 0.898 (95% confidence interval: 0.859-0.928). The Cronbach α was 0.904. CONCLUSION: In a prospective, randomised trial of ACL reconstructions using either autograft or allograft, failures were associated with a significantly increased slope of the tibia compared with the nonfailures at 10-year follow-up.

Historical changes in plant water use and need in the continental United States.

A robust method for characterizing the biophysical environment of terrestrial vegetation uses the relationship between Actual Evapotranspiration (AET) and Climatic Water Deficit (CWD). These variables are usually estimated from a water balance model rather than measured directly and are often more representative of ecologically-significant changes than temperature or precipitation. We evaluate trends and spatial patterns in AET and CWD in the Continental United States (CONUS) during 1980-2019 using a gridded water balance model. The western US had linear regression slopes indicating increasing CWD and decreasing AET (drying), while the eastern US had generally opposite trends. When limits to plant performance characterized by AET and CWD are exceeded, vegetation assemblages change. Widespread increases in aridity throughout the west portends shifts in the distribution of plants limited by available moisture. A detailed look at Sequoia National Park illustrates the high degree of fine-scale spatial variability that exists across elevation and topographical gradients. Where such topographical and climatic diversity exists, appropriate use of our gridded data will require sub-setting to an appropriate area and analyzing according to categories of interest such as vegetation communities or across obvious physical gradients. Recent studies have successfully applied similar water balance models to fire risk and forest structure in both western and eastern U.S. forests, arid-land spring discharge, amphibian colonization and persistence in wetlands, whitebark pine mortality and establishment, and the distribution of arid-land grass species and landscape scale vegetation condition. Our gridded dataset is available free for public use. Our findings illustrate how a simple water balance model can identify important trends and patterns at site to regional scales. However, at finer scales, environmental heterogeneity is driving a range of responses that may not be simply characterized by a single trend.

Arthroscopic Versus Open Anterior Shoulder Stabilization: A Prospective Randomized Clinical Trial With 15-Year Follow-up With an Assessment of the Glenoid Being "On-Track" and "Off-Track" as a Predictor of Failure.

BACKGROUND: Recent studies have demonstrated equivalent short-term results when comparing arthroscopic versus open anterior shoulder stabilization. However, none have evaluated the long-term clinical outcomes of patients after arthroscopic or open anterior shoulder stabilization, with inclusion of an assessment of preoperative glenoid tracking. PURPOSE: To compare long-term clinical outcomes of patients with recurrent anterior shoulder instability randomized to open and arthroscopic stabilization groups. Additionally, preoperative magnetic resonance imaging (MRI) studies were used to assess whether the shoulders were "on-track" or "off-track" to ascertain a prediction of increased failure risk. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: A consecutive series of 64 patients with recurrent anterior shoulder instability were randomized to receive either arthroscopic or open stabilization by a single surgeon. Follow-up assessments were performed at minimum 15-year follow-up using established postoperative evaluations. Clinical failure was defined as any recurrent dislocation postoperatively or subjective instability. Preoperative MRI scans were obtained to calculate the glenoid track and designate shoulders as on-track or off-track. These results were then correlated with the patients' clinical results at their latest follow-up. RESULTS: Of 64 patients, 60 (28 arthroscopic and 32 open) were contacted or examined for follow-up (range, 15-17 years). The mean age at the time of surgery was 25 years (range, 19-42 years), while the mean age at the time of this assessment was 40 years (range, 34-57 years). The rates of arthroscopic and open long-term failure were 14.3% (4/28) and 12.5% (4/32), respectively. There were no differences in subjective shoulder outcome scores between the treatment groups. Of the 56 shoulders, with available MRI studies, 8 (14.3%) were determined to be off-track. Of these 8 shoulders, there were 2 surgical failures (25.0%; 1 treated arthroscopically, 1 treated open). In the on-track group, 6 of 48 had failed surgery (12.5%; 3 open, 3 arthroscopic [P = .280]). CONCLUSION: Long-term clinical outcomes were comparable at 15 years postoperatively between the arthroscopic and open stabilization groups. The presence of an off-track lesion may be associated with a higher rate of recurrent instability in both cohorts at long-term follow-up; however, this study was underpowered to verify this situation.

Wetland drying linked to variations in snowmelt runoff across Grand Teton and Yellowstone national parks.

In Grand Teton and Yellowstone national parks wetlands offer critical habitat and play a key role in supporting biological diversity. The shallow depths and small size of many palustrine wetlands in these protected areas and elsewhere make them vulnerable to changes in climate compared with larger and deeper aquatic habitats. Here, we use a simple water balance model to generate estimates of biophysical drivers of wetland change. We then examine the relationship between wetland inundation status and four principal drivers (i.e., temperature, precipitation, evapotranspiration, and runoff) spanning varying meteorological conditions over an 8-year time series from Grand Teton and Yellowstone national parks. We found that models containing snowmelt runoff outperformed models with other meteorological drivers and determined that a higher percentage of surveyed wetlands were dry in years characterized by lower runoff. Our work further shows that wetland drying was widespread across both parks, but sub-regional variations were best described at the hydrologic subbasin-level. Documenting the varying responses of wetlands to meteorological drivers is a necessary first step to identifying which subbasins are most sensitive to recent climatic change and contemplating how future change may alter the distribution of wetlands and their dependent taxa.

Multistate occupancy modeling improves understanding of amphibian breeding dynamics in the Greater Yellowstone Area.

Discerning the determinants of species occurrence across landscapes is fundamental to their conservation and management. In spatially and climatologically complex landscapes, explaining the dynamics of occurrence can lead to improved understanding of short- vs. long-term trends and offer novel insight on local vs. regional change. We examined the changes in occupancy for two species of anurans with different life histories over a decade using hundreds of wetland sites in Yellowstone and Grand Teton National Parks. To account for the joint dynamics of wetland drying and amphibian breeding, we adopted a multistate occupancy model as a means to investigate mechanistic relationships of observed occurrence patterns with climatological drivers of wetland hydrologic variability. This approach allowed us to decompose occupancy dynamics into habitat changes caused by wetland drying and amphibian breeding activity, conditional on available water and previous breeding state. Over our 10-yr time series, we observed considerable variability in climate drivers and the proportion of dry wetlands. Boreal chorus frogs (Pseudacris maculata) were more responsive to changes in wetland inundation status than Columbia spotted frogs (Rana luteiventris), as indicated by higher breeding colonization probabilities under favorable (wet) conditions. Both species had high probabilities of breeding persistence in permanently inundated wetlands with prior breeding. Despite the absence of multi-year drought in our time series, mechanistic relationships described here offer insights on how future climate variation may result in reduced and/or shifted occurrence patterns for pond-breeding anurans in the Greater Yellowstone Area. Further, our modeling approach may prove valuable in evaluating determinants of occurrence for other species that are dependent on wetlands or other dynamic habitats.

Injury Surveillance and Reporting for Trainees with Bone Stress Injury: Current Practices and Recommendations.

Background: Musculoskeletal injuries, including lower extremity bone stress injuries (BSI) significantly impact initial entry training (IET) in the U.S. Army due to limited duty days, trainee attrition, early medical discharge, and related financial costs. Factors complicating trainee BSI surveillance include inconsistent BSI coding practices, attrition documentation as both administrative separations and medical discharges and the inability to code for BSI grade or severity when using International Statistical Classification of Diseases and Related Health Problems 10th revision (ICD-10) codes. Methods: A multidisciplinary expert panel developed policy guidance to enhance clinical and administrative management of BSI, following extensive analysis of current, peer-reviewed literature. Policy guidance incorporates leading practices concerning clinical BSI management, including imaging procedures, recommended notifications, early intervention, and ICD-10 diagnostic coding procedures. Policy guidance also standardizes BSI grading criteria for magnetic resonance imaging and skeletal scintigraphy (bone scan). Findings: Multidisciplinary expert opinion indicates inconsistent BSI diagnosis and management across IET due to variability in trainee BSI grading, documentation, and coding practices. Injury surveillance conducted by the United States Army Medical Command (USAMEDCOM) will benefit from routine, standardized musculoskeletal injury data base searches by BSI severity/grade and anatomical location upon implementation of BSI policy guidance. Discussion: Effective injury surveillance is critical for determining trainee BSI incidence and attrition, developing anticipated return to duty (RTD) timelines, and assessing long-term outcomes. BSI RTD timelines should account for gender, BSI grade/severity, anatomical location, and type of intervention. Well-defined RTD timelines would benefit administrative decision-making purposes, including whether to grant convalescent leave or enroll in the Warrior Training and Rehabilitation Program during BSI recovery. Enhanced management procedures may improve initial enlistment completion rates for trainees sustaining at least one BSI who eventually complete IET.

The Shifting Climate Portfolio of the Greater Yellowstone Area.

Knowledge of climatic variability at small spatial extents (< 50 km) is needed to assess vulnerabilities of biological reserves to climate change. We used empirical and modeled weather station data to test if climate change has increased the synchrony of surface air temperatures among 50 sites within the Greater Yellowstone Area (GYA) of the interior western United States. This important biological reserve is the largest protected area in the Lower 48 states and provides critical habitat for some of the world's most iconic wildlife. We focused our analyses on temporal shifts and shape changes in the annual distributions of seasonal minimum and maximum air temperatures among valley-bottom and higher elevation sites from 1948-2012. We documented consistent patterns of warming since 1948 at all 50 sites, with the most pronounced changes occurring during the Winter and Summer when minimum and maximum temperature distributions increased. These shifts indicate more hot temperatures and less cold temperatures would be expected across the GYA. Though the shifting statistical distributions indicate warming, little change in the shape of the temperature distributions across sites since 1948 suggest the GYA has maintained a diverse portfolio of temperatures within a year. Spatial heterogeneity in temperatures is likely maintained by the GYA's physiographic complexity and its large size, which encompasses multiple climate zones that respond differently to synoptic drivers. Having a diverse portfolio of temperatures may help biological reserves spread the extinction risk posed by climate change.

Documenting measurement sensitivity and bias of field-measured parameters in water quality monitoring programs.

Measurement sensitivity and bias quality control metrics are commonly reported for water-quality parameters measured in the laboratory. Less commonly recognized is that they should also be reported for field-measured parameters. Periodic evaluation helps document data quality and can help serve as early warning if there are problems with methods or techniques that could negatively affect ability to interpret threshold values and trends over time. This study focuses on traditional assessment of bias and introduces a new method for estimating measurement sensitivity of water-quality parameters measured monthly in the field. Alternative measurement sensitivity is a new data quality indicator used to demonstrate how quantifying sensitivity at the measurement level can improve understanding the uncertainty affecting each reported data value. That, in turn, can help interpret the meaning of results from many separate data points measured in the field. In this 30-month study, pH and specific conductance consistently met, and dissolved oxygen did not always meet NPS and USGS quality control standards for bias. Evaluation of dissolved oxygen bias and sensitivity during the study provided impetus to improve calibration techniques that resulted in data that later met quality goals.

Ruptured ectopic pregnancy presenting 3 years after supracervical hysterectomy.

An ectopic pregnancy after a hysterectomy is a rare event, with about 40 reported cases since it was first identified by Wendeler in 1895. There are even fewer cases reported of an ectopic pregnancy occurring years after a hysterectomy has been performed. This case illustrates the sonographic and computed tomographic (CT) findings in the setting of abdominal pain in a woman of childbearing age and highlights the need to obtain a urine pregnancy test as part of the workup for abdominal pain in women, even if a history of a hysterectomy has been given. Many providers may automatically exclude an ectopic pregnancy as a possibility in the aforementioned clinical scenario if the patient has a history of a hysterectomy. Such automatic exclusion may result in life-threatening consequences.

Tillage and nutrient source effects on water quality and corn grain yield from a flat landscape.

Beneficial effects of leaving residue at the soil surface are well documented for steep lands, but not for flat lands that are drained with surface inlets and tile lines. This study quantified the effects of tillage and nutrient source on tile line and surface inlet water quality under continuous corn (Zea mays L.) from relatively flat lands (<3%). Tillage treatments were either fall chisel or moldboard plow. Nutrient sources were either fall injected liquid hog manure or spring incorporated urea. The experiment was on a Webster-Canisteo clay loam (Typic Endoaquolls) at Lamberton, MN. Surface inlet runoff was analyzed for flow, total solids, NO(3)-N, NH(4)-N, dissolved P, and total P. Tile line effluent was analyzed for flow, NO(3)-N, and NH(4)-N. In four years of rainstorm and snowmelt events there were few significant differences (p < 0.10) in water quality of surface inlet or tile drainage between treatments. Residue cover minimally reduced soil erosion during both snowmelt and rainfall runoff events. There was a slight reduction in mineral N losses via surface inlets from manure treatments. There was also a slight decrease (p = 0.025) in corn grain yield from chisel-plow plots (9.7 Mg ha(-1)) compared with moldboard-plow plots (10.1 Mg ha(-1)). Chisel plowing (approximately 30% residue cover) alone is not sufficient to reduce nonpoint source sediment pollution from these poorly drained flat lands to the extent (40% reduction) desired by regulatory agencies.