Context:Reconstruction of the anterior cruciate ligament (ACL) is one of the most common surgical procedures, with more than 200,000 ACL tears occurring annually. Although primary ACL reconstruction is a successful operation, success rates still range from 75% to 97%. Consequently, several thousand revision ACL reconstructions are performed annually and are unfortunately associated with inferior clinical outcomes when compared with primary reconstructions.Evidence Acquisition:Data were obtained from peer-reviewed literature through a search of the PubMed database (1988-2013) as well as from textbook chapters and surgical technique papers.Study Design:Clinical review.Level of Evidence:Level 4.Results:The clinical outcomes after revision ACL reconstruction are largely based on level IV case series. Much of the existing literature is heterogenous with regard to patient populations, primary and revision surgical techniques, concomitant ligamentous injuries, and additional procedures performed at the time of the revision, which limits generalizability. Nevertheless, there is a general consensus that the outcomes for revision ACL reconstruction are inferior to primary reconstruction.Conclusion:Excellent results can be achieved with regard to graft stability, return to play, and functional knee instability but are generally inferior to primary ACL reconstruction. A staged approach with autograft reconstruction is recommended in any circumstance in which a single-stage approach results in suboptimal graft selection, tunnel position, graft fixation, or biological milieu for tendon-bone healing.Strength-of-Recommendation Taxonomy (SORT):Good results may still be achieved with regard to graft stability, return to play, and functional knee instability, but results are generally inferior to primary ACL reconstruction: Level B.

No abstract

Background The repair of rotator cuff tears is often complicated by fatty degeneration, which is the combination of lipid accumulation, fibrosis, inflammation and muscle weakness. p38 MAPK is a signaling molecule that plays a central role in these processes. The purpose of this study was to evaluate a small molecule inhibitor of p38 MAPK, SB203580, in reducing fatty degeneration in a preclinical model of rotator cuff injury and repair. Methods Adult rats underwent a bilateral supraspinatus tenotomy that was repaired 30 days later. Rats were treated with SB203580 or vehicle every 2 days with injections beginning 3 days prior to surgery, and continued until 7 days after surgery. Two weeks after surgical repair muscles were analyzed using histology, lipid profiling, gene expression and permeabilized muscle fiber contractility. Results Inhibition of p38 MAPK resulted in a nearly 49% reduction in fat accumulation and a 29% reduction in collagen content, along with changes in corresponding genes regulating adipogenesis and matrix accumulation. There was also a marked 40–80% decrease in the expression of several proinflammatory genes, including IL1β, IL6 and COX2, and a 360% increase in the antiinflammatory gene IL10. No differences were observed for muscle fiber force production. Conclusion Inhibition of p38 MAPK was found to have a significant decrease in intramuscular lipid accumulation and fibrosis that is usually seen in the degenerative cascade of rotator cuff tears, without having negative effects on the contractile properties of the rotator cuff muscle tissue.

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background Tranexamic acid (TXA) is often used to prevent excessive blood loss during bilateral TKA. Although it diminishes blood loss, TXA may have a potentially elevated thrombogenic risk with extra, unnecessary doses of TXA in this high-risk population. To date, the most efficacious dosing protocol in this setting has not yet been ascertained. Questions/purposes We compared one versus two doses of intravenous TXA in the setting of same-day bilateral TKA in terms of (1) perioperative blood loss that occurred during the hospital stay, (2) transfusion usage during the hospital stay, and (3) major complications occurring within 30 days of surgery.Methods Between August 2013 and October 2016, 309 patients underwent simultaneous bilateral TKA performed by one of five attending surgeons. During that time, indications for same-day bilateral TKA included bilateral knee pathology in which each knee was independently indicated for TKA and the patient preferred bilateral simultaneous TKAs versus staged bilateral surgeries. Patients who had cardiac disease or an American Society for Anesthesiologists physical classification score of greater than 2 were not generally indicated for bilateral simultaneous TKAs. After preoperative clearance from the primary physician and/or specialists as necessary, the decision for This study was funded by a grant from the Scripps Clinic Medical Group Foundation. One of the authors (WDB) certifies receipt of personal payments or benefits, during the study period (2013)(2014)(2015)(2016), in an amount of USD 10,000 to USD 100,000 from Zimmer Biomet; in an amount of USD 100,001 to USD 1,000,000 from DePuy; in an amount of USD 10,000 to USD 100,000 from Smith & Nephew; in an amount of less than USD 10,000 from Orthalign Inc; and in an amount of USD 10,000 to USD 100,000 from Medical Device Business Services Inc. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request. Clinical Orthopaedics and Related Research® neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDA approval status, of any drug or device before clinical use. Ethical approval for this study was obtained from the Scripps Institutional Review Board,