Anterior cruciate ligament reconstruction with bone-patellar tendon-bone autograft versus allograft in young patients

Objectives: Traditionally, bone-patella tendon-bone (BTB) autograft has been the gold standard graft choice for younger, athletic patients requiring ACL reconstruction. However, donor site morbidity, post-operative patella fracture, and increased operative time have led many surgeons to choose BTB allograft for their reconstructions. Opponents of allografts feel that slower healing time, higher rate of graft failure, and potential for disease transmission makes them undesirable graft choices in athletic patients. The purpose of this study is to evaluate the clinical outcomes, both subjective and objective, of young patients that who have undergone either BTB autograft or allograft reconstructions with a minimum of 2-year follow-up. Methods: One hundred and twenty patients (60 autograft, 60 allograft), age 25 and below at time of surgery, were contacted after being retrospectively identified as patients having an ACL reconstruction with either a BTB allograft or autograft by one senior surgeon. Patients were administered the Lysholm Knee Scoring Scale and IKDC Subjective Knee Evaluation questionnaires. Fifty (25 BTB autograft and 25 BTB allograft) of the 120 returned for physical examination as well as completion of a single leg hop test and laxity evaluation using a KT-1000 arthrometer evaluation. Of the 120 patients contacted, there were a total of 7 failures (5.8%) requiring revision, 6 in the allograft group (86%) and 1 in the autograft group (14%). Results: The average Lysholm scores were 89.0 and 89.56 and the average IKDC scores were 90.8 and 92.1 in the autograft and allograft groups respectively. The differences in the Lysholm scores and the IKDC scores were not significant. The single leg hop and KT-1000 scores were also not significantly different. One autograft patient had a minor motion deficit. Three allograft patients had a grade 1 Lachman and pivot glide. One autograft patient and two allograft patients had mild patellafemoral crepitus. There was no significant difference in anterior knee pain between the two groups Conclusion: There is no significant difference in patient-rated outcome between ACL reconstructions using BTB autografts versus allografts. However, the overall study group did reveal an increased failure rate requiring revision in the allograft group. © The Author(s) 2015

BHPR research: qualitative1. Complex reasoning determines patients' perception of outcome following foot surgery in rheumatoid arhtritis

Background: Foot surgery is common in patients with RA but research into surgical outcomes is limited and conceptually flawed as current outcome measures lack face validity: to date no one has asked patients what is important to them. This study aimed to determine which factors are important to patients when evaluating the success of foot surgery in RA Methods: Semi structured interviews of RA patients who had undergone foot surgery were conducted and transcribed verbatim. Thematic analysis of interviews was conducted to explore issues that were important to patients. Results: 11 RA patients (9 ♂, mean age 59, dis dur = 22yrs, mean of 3 yrs post op) with mixed experiences of foot surgery were interviewed. Patients interpreted outcome in respect to a multitude of factors, frequently positive change in one aspect contrasted with negative opinions about another. Overall, four major themes emerged. Function: Functional ability & participation in valued activities were very important to patients. Walking ability was a key concern but patients interpreted levels of activity in light of other aspects of their disease, reflecting on change in functional ability more than overall level. Positive feelings of improved mobility were often moderated by negative self perception ("I mean, I still walk like a waddling duck”). Appearance: Appearance was important to almost all patients but perhaps the most complex theme of all. Physical appearance, foot shape, and footwear were closely interlinked, yet patients saw these as distinct separate concepts. Patients need to legitimize these feelings was clear and they frequently entered into a defensive repertoire ("it's not cosmetic surgery; it's something that's more important than that, you know?”). Clinician opinion: Surgeons' post operative evaluation of the procedure was very influential. The impact of this appraisal continued to affect patients' lasting impression irrespective of how the outcome compared to their initial goals ("when he'd done it ... he said that hasn't worked as good as he'd wanted to ... but the pain has gone”). Pain: Whilst pain was important to almost all patients, it appeared to be less important than the other themes. Pain was predominately raised when it influenced other themes, such as function; many still felt the need to legitimize their foot pain in order for health professionals to take it seriously ("in the end I went to my GP because it had happened a few times and I went to an orthopaedic surgeon who was quite dismissive of it, it was like what are you complaining about”). Conclusions: Patients interpret the outcome of foot surgery using a multitude of interrelated factors, particularly functional ability, appearance and surgeons' appraisal of the procedure. While pain was often noted, this appeared less important than other factors in the overall outcome of the surgery. Future research into foot surgery should incorporate the complexity of how patients determine their outcome Disclosure statement: All authors have declared no conflicts of interes

Comparison of results from several AOGCMs for global and regional sea-level change 1900-2100

Sea-level rise is an important aspect of climate change because of its impact on society and ecosystems. Here we present an intercomparison of results from ten coupled atmosphere-ocean general circulation models (AOGCMs) for sea-level changes simulated for the twentieth century and projected to occur during the twenty first century in experiments following scenario IS92a for greenhouse gases and sulphate aerosols. The model results suggest that the rate of sea-level rise due to thermal expansion of sea water has increased during the twentieth century, but the small set of tide gauges with long records might not be adequate to detect this acceleration. The rate of sea-level rise due to thermal expansion continues to increase throughout the twenty first century, and the projected total is consequently larger than in the twentieth century; for 1990-2090 it amounts to 0.20-0.37 in. This wide range results from systematic uncertainty in modelling of climate change and of heat uptake by the ocean. The AOGCMs agree that sea-level rise is expected to be geographically non-uniform, with some regions experiencing as much as twice the global average, and others practically zero, but they do not agree about the geographical pattern. The lack of agreement indicates that we cannot currently have confidence in projections of local sea- level changes, and reveals a need for detailed analysis and intercomparison in order to understand and reduce the disagreements

Taking climate model evaluation to the next level

Earth system models are complex and represent a large number of processes, resulting in a persistent spread across climate projections for a given future scenario. Owing to different model performances against observations and the lack of independence among models, there is now evidence that giving equal weight to each available model projection is suboptimal. This Perspective discusses newly developed tools that facilitate a more rapid and comprehensive evaluation of model simulations with observations, process-based emergent constraints that are a promising way to focus evaluation on the observations most relevant to climate projections, and advanced methods for model weighting. These approaches are needed to distil the most credible information on regional climate changes, impacts, and risks for stakeholders and policy-makers

The seasonal cycle in coupled ocean-atmosphere general circulation models

We examine the seasonal cycle of near-surface air temperature simulated by 17 coupled ocean-atmosphere general circulation models participating in the Coupled Model Intercomparison Project (CMIP). Nine of the models use ad hoc “flux adjustment” at the ocean surface to bring model simulations close to observations of the present-day climate. We group flux-adjusted and non-flux-adjusted models separately and examine the behavior of each class. When averaged over all of the flux-adjusted model simulations, near-surface air temperature falls within 2?K of observed values over the oceans. The corresponding average over non-flux-adjusted models shows errors up to ?6?K in extensive ocean areas. Flux adjustments are not directly applied over land, and near-surface land temperature errors are substantial in the average over flux-adjusted models, which systematically underestimates (by ?5?K) temperature in areas of elevated terrain. The corresponding average over non-flux-adjusted models forms a similar error pattern (with somewhat increased amplitude) over land. We use the temperature difference between July and January to measure seasonal cycle amplitude. Zonal means of this quantity from the individual flux-adjusted models form a fairly tight cluster (all within ?30% of the mean) centered on the observed values. The non-flux-adjusted models perform nearly as well at most latitudes. In Southern Ocean mid-latitudes, however, the non-flux-adjusted models overestimate the magnitude of January-minus-July temperature differences by ?5?K due to an overestimate of summer (January) near-surface temperature. This error is common to five of the eight non-flux-adjusted models. Also, over Northern Hemisphere mid-latitude land areas, zonal mean differences between July and January temperatures simulated by the non-flux-adjusted models show a greater spread (positive and negative) about observed values than results from the flux-adjusted models. Elsewhere, differences between the two classes of models are less obvious. At no latitude is the zonal mean difference between averages over the two classes of models greater than the standard deviation over models. The ability of coupled GCMs to simulate a reasonable seasonal cycle is a necessary condition for confidence in their prediction of long-term climatic changes (such as global warming), but it is not a sufficient condition unless the seasonal cycle and long-term changes involve similar climatic processes. To test this possible connection, we compare seasonal cycle amplitude with equilibrium warming under doubled atmospheric carbon dioxide for the models in our data base. A small but positive correlation exists between these two quantities. This result is predicted by a simple conceptual model of the climate system, and it is consistent with other modeling experience, which indicates that the seasonal cycle depends only weakly on climate sensitivity