Shoulder arthroplasty for inflammatory arthritis is associated with higher rates of medical and surgical complications: a nationwide matched cohort analysis from 2016-2020

BACKGROUND

Inflammatory arthritis (IA) represents a less common indication for anatomic and reverse total shoulder arthroplasty (TSA) than osteoarthritis (OA). The safety and efficacy of anatomic and reverse TSA in this population has not been as well studied compared to OA. We analyzed the differences in outcomes between IA and OA patients undergoing TSA.

METHODS

Patients who underwent primary anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA) from 2016-2020 were identified in the Premier Healthcare Database. Inflammatory arthritis (IA) patients were identified using International Classification of Diseases, Tenth Revision, diagnosis codes and compared to osteoarthritis controls. Patients were matched in a 1:8 fashion by age (±3 years), sex, race, and presence of pertinent comorbidities. Patient demographics, hospital factors, and patient comorbidities were compared. Multivariate regression was performed following matching to account for any residual confounding and 90-day complications were compared between the 2 cohorts. Descriptive statistics and regression analysis were employed with significance set at P < .05.

RESULTS

Prior to matching, 5685 IA cases and 93,539 OA controls were identified. Patients with IA were more likely to be female, have prolonged length of stay and increased total costs (P < .0001). After matching and multivariate analysis, 4082 IA cases and 32,656 controls remained. IA patients were at increased risk of deep wound infection (OR 3.14, 95% CI 1.38-7.16, P = .006), implant loosening (OR 4.11, 95% CI 1.17-14.40, P = .027), and mechanical complications (OR 6.34, 95% CI 1.05-38.20, P = .044), as well as a decreased risk of postoperative stiffness (OR 0.36, 95% CI 0.16-0.83, P = .002). Medically, IA patients were at increased risk of PE (OR 2.97, 95% CI 1.52-5.77, P = .001) and acute blood loss anemia (OR 1.27, 95% CI 1.12-1.44, P < .0001).

DISCUSSION AND CONCLUSION

Inflammatory arthritis represents a distinctly morbid risk profile compared to osteoarthritis patients with multiple increased surgical and postoperative medical complications in patients undergoing aTSA and rTSA. Surgeons should consider these potential complications and employ a multidisciplinary approach in preoperative risk stratification of IA undergoing shoulder replacement.

NCAA football players are at higher risk of upper extremity injury after first-time concussion

BACKGROUND

Previous research has demonstrated that concussions increase the risk of subsequent lower extremity musculoskeletal injury in athletes. However, the risk of upper extremity injury in athletes' post-concussion is poorly understood.

METHODS

All concussed football players within a National Collegiate Athletic Association (NCAA) Division I conference athletic database were identified between 2017 and 2021. After exclusions, each athlete experiencing their first concussion was then retrospectively reviewed for upper extremity injuries in the year prior to their concussion and in the year beginning at 90 days after their concussion. All upper extremity injuries were identified and the odds ratio, 95% confidence interval, and statistical significance between groups were calculated in Microsoft Excel.

RESULTS

160 de-identified football players from a single conference who were first diagnosed with concussions in the seasons from 2017 through 2021 met inclusion criteria. In these athletes the odds of upper extremity injury in year following first diagnosed concussion were 2.36 times higher than in the year prior (95% CI 1.13-4.95, p = 0.02). Shoulder was the most common site of injury with 57.7% of injuries compared to 19.2% in the hand, 15.4% in the elbow, 7.7% in the forearm, and 0% in the wrist.

CONCLUSION

This study demonstrates that collegiate football players are at a 2.36 times greater risk of upper extremity injury in the year following their first diagnosed concussion compared to the year preceding it. The most common site of upper extremity injury after concussion was the shoulder.

LEVEL OF EVIDENCE

III.

Management of Hand and Wrist Injuries in NCAA Division I Football Players From a Single Institution: Factors Associated With Epidemiology, Surgical Intervention, and Return to Play

Background

Upper extremity injuries account for approximately 16.9% of football injuries in the National Collegiate Athletic Association (NCAA).

Purpose

To determine the epidemiology, management, and outcomes of hand/wrist injuries in collegiate football athletes so as to identify factors associated with surgical intervention and delayed return to play (RTP).

Study Design

Descriptive epidemiology study.

Methods

We retrospectively reviewed hand/wrist injuries that occurred within a single NCAA Division I football team from January 1, 2003, to December 31, 2020. Data analyzed included player position, college seniority, injury characteristics, injury management, surgical procedures performed, and timing of RTP. A univariate analysis was performed to identify factors associated with increased risk for surgical intervention and delayed (>21 days) RTP after hand and wrist injury in this cohort.

Results

Overall, 124 patients with 168 hand/wrist injuries were identified (9.9 wrist/hand injuries per year). Sprain of the thumb metacarpophalangeal (MCP) joint ulnar collateral ligament (UCL) was the most common diagnosis (19.6%). Surgery was required in 22% of injuries, with injury of the UCL of the thumb MCP joint (8/37) being the most common indication. Injuries occurring during competitive games (odds ratio = 4.29; 95% CI, 1.2-15.9) were associated with an increased risk for surgery. Most (70%) injuries did not lead to time missed from football, whereas the remaining 30% resulted in an average of 33 ± 36 days missed.

Conclusion

Over 17 athletic seasons, the annual incidence of hand and wrist injury in these NCAA Division I football players was 9.9 injuries per year, with 22% requiring surgical treatment. Injury to the UCL of the thumb MCP joint was the most common injury and indication for surgery, and 30% of injuries resulted in approximately 1 month lost. Injuries sustained in games were associated with operative management and delayed RTP.

Return to sport criteria following upper extremity surgery in athletes-part 4: shoulder arthroplasty procedures: a scoping review

PURPOSE

To describe the reported return to sports (RTS) criteria following all types of shoulder arthroplasty procedures in athletes.

METHODS

This scoping review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Scoping Review (PRISMA-ScR) as a guide. A comprehensive search was conducted in four electronic databases (Scopus, Pubmed/MEDLINE, Web of Science, and Google Scholar Advanced Search) in the English Language that reported a minimum of 1 RTS criterion in athletes after shoulder arthroplasty. The data were aggregated and summarized as frequencies, means, and standard deviations.

RESULTS

Thirteen studies were included, with a total of 942 athletes with a mean age of 68.7 years. The most commonly used RTS criterion was time from surgery (range 3-6 months), reported by 7/13 (54%) of all studies, followed by restrictions on contact sports (36%). Other reported RTS criteria included no lifting/limited lifting (3/13, 23%), physician clearance based on assessment (3/13, 23%), return per patient tolerance (2/13, 15%), and upon return to full range of motion (ROM) and strength in the operated shoulder (1/13, 8%). Three studies (3/13, 23%) allowed for an unrestricted RTSpostoperatively.

CONCLUSION

Thirteen studies reported one or more RTS criteria following shoulder arthroplasty, with time after surgery being the most common RTS criterion used. These results emphasise the need for interprofessional discussions and communication amongst surgeons, physical therapists, and athletic trainers to establish evidence-based RTS criteria following arthroplasty and promote a safe and effective return to sport.

Volume, indications, and number of surgeons performing reverse total shoulder arthroplasty continue to expand: a nationwide cohort analysis from 2016-2020

Background

Since its approval, reverse total shoulder arthroplasty (rTSA) has continued to increase in usage, with expanding indications beyond rotator cuff arthropathy. Existing literature has captured further increased utilization over the last decade through 2017. However, this data has not been updated to include a contemporary cohort of patients. This study sought to determine the trends of anatomic total shoulder arthroplasty (aTSA), rTSA, and hemiarthroplasty (HA) usage based on primary diagnosis and total number of surgeons performing each procedure annually from 2016-2020.

Methods

Patients who underwent primary rTSA, aTSA, and HA from 2016-2020 were identified in the Premier Healthcare Database. Primary indication diagnoses for procedures were identified using International Classification of Diseases 10th edition codes. Temporal trends in patient and hospital demographics, primary indication, and procedure utilization were captured on an annualized basis. The number of surgeons performing each procedure annually was noted. Descriptive statistics were employed with significance set at P < .05.

Results

From 2016 to 2020, 154,499 patients undergoing primary shoulder arthroplasty were identified: 48,890 aTSA, 95,808 rTSA, and 9801 HA. In 2016, rTSA comprised a slight majority (55%) of all arthroplasty cases but increased to nearly 70% of all arthroplasty cases in 2020. The absolute numbers of aTSA and HA cases decreased over time, while rTSA volume increased from 14,781 in 2016 to a high of 23,644 cases in 2019. There was a corresponding 12% increase in the number of surgeons performing rTSA across the same time period, contrasted with a 42.1% decrease in surgeons performing HA and a 14.3% decrease for aTSA. Glenohumeral osteoarthritis remains the most common indication for rTSA and aTSA, while HA is used primarily for proximal humerus fractures or hardware complications.

Conclusion

The volume of primary rTSA in the United States has continued to increase from 2016 to 2020 with concurrent decreases in the number of primary aTSA and HA cases performed. Primary rTSA accounts for nearly 70% of all primary shoulder arthroplasty cases. The number of surgeons performing rTSA continues to increase, while there has been a decrease in the number of surgeons performing aTSA and HA.

Off-Season Arthroscopic Partial Meniscectomy in National Collegiate Athletic Association Division I Football Players Has a Longer Return to Sport Time than In-Season Surgery

Purpose

To report the outcomes of routine arthroscopic meniscectomy in National Collegiate Athletic Association (NCAA) Division I Football players.

Methods

NCAA athletes who underwent arthroscopic meniscectomy over 5 years were included. Players who had incomplete data, previous knee surgery, ligamentous injury, and/or microfractures were excluded. Data collected were player position, timing of surgery, procedures performed, return to play (RTP) rate and time, and postoperative performance. Continuous variables were analyzed with Student t-tests or a one-way analysis of variance.

Results

Thirty-six athletes (38 knees) who underwent arthroscopic partial meniscectomy (31 lateral, 7 medial) were included. The mean RTP time was 71 ± 39 days. The mean RTP time in athletes who underwent in-season surgery) was significantly shorter than the RTP in athletes who had off-season surgery (58 ± 41 days vs 85 ± 33 days, P < .05). The mean RTP in 29 athletes (31 knees) with lateral meniscectomy was similar to the 7 athletes (7 knees) who had medial meniscectomy (70 ± 36 vs 77 ± 56, P = .6803). The mean RTP time was similar between football players who underwent isolated lateral meniscectomy and those who had lateral meniscectomy with chondroplasty (61 ± 36 days vs 75±41 days, P = .32). Athletes played an average of 7.7 ± 4.9 games the season they returned; position category and anatomical compartment of the knee lesion had no bearing on number of games played (P = .1864 and P = .425).

Conclusions

NCAA Division 1 football players who underwent arthroscopic partial meniscectomy RTP at approximately 2.5 months' postoperatively. Athletes who underwent off-season surgery had longer RTP time compared with those who underwent in-season surgery. RTP time and performance after surgery did not differ based on player position, anatomical location of the lesions, or chondroplasty at the time of meniscectomy.

Level of Evidence

Level IV, therapeutic case series.

Evaluation of spin in systematic reviews and meta-analyses of superior capsular reconstruction

BACKGROUND

Small, preliminary studies and the systematic reviews on superior capsular reconstruction (SCR) that collate data are at increased risk spin. This study's primary objective was to identify, describe, and account for the incidence of spin in systematic reviews of SCR. This study's secondary objective was to characterize the studies in which spin was identified to determine whether identifiable patterns of characteristics exist among studies with spin.

METHODS

This study was conducted per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using a predetermined protocol. A search was conducted on the PubMed and Embase databases for systematic reviews and meta-analyses on SCR. Screening and data extraction were conducted independently by 2 authors. Each included study's abstract was assessed for the presence of the 15 most common types of spin, with full texts reviewed during cases of disagreement or for clarification. General data that were extracted included study title, authors, publication year, journal, level of evidence, study design, funding source, reported adherence to PRISMA guidelines, preregistration of the study protocol, and primary and secondary outcome measures. Full texts were used in the assessment of study quality per AMSTAR 2.

RESULTS

We identified 53 studies during our search, of which 17 met the inclusion criteria. At least 1 form of spin was observed in all 17 studies. The most common types of spin were type 5 ("The conclusion claims the beneficial effect of the experimental treatment despite a high risk of bias in primary studies") and type 9 ("Conclusion claims the beneficial effect of the experimental treatment despite reporting bias"), both of which were observed in 11 studies (11 of 17, 65%). A statistically significant association between lower level of evidence and type 5 ("The conclusion claims the beneficial effect of the experimental treatment despite a high risk of bias in primary studies") was observed (P = .0175). A statistically significant association was also found between more recent year of publication and the spin category misleading interpretation (P = .0398), and between lower AMSTAR 2 score and type 13 ("Failure to specify the direction of the effect when it favors the control intervention") (P = .0260). No other statistical associations between other study characteristics were observed.

CONCLUSION

Spin is highly prevalent in abstracts of SCR systematic reviews and meta-analyses. An association was found between the presence of spin and lower level of evidence, year of publication, and AMSTAR 2 ratings.

Update on injury epidemiology in rowing: our experience with female NCAA Division I athletes and a systematic review of the literature

OBJECTIVES

(1) To report the distribution of injuries per body site and time lost from participation in female NCAA Division I rowers and (2) to present an updated summary of the existing evidence regarding the analysis of injuries per body site in rowers.

METHODS

Case series: The distribution of injuries per body site in female NCAA Division I rowers and the time lost from participation were retrieved from an institutional registry. Injuries per body site were reported as number of athletes with site-specific injury per total number of injured athletes. Systematic review: Based on the PRISMA guidelines for systematic reviews, three electronic databases were searched for studies reporting the epidemiology of injuries per body site in rowers and analyzed.

RESULTS

Case series: One-hundred and thirty-seven injuries were recorded in 92 female rowers over 5 years. The risk of injury (number of injured athletes over total number of athletes on roaster) was 52% (92/176). Among the 92 injured athletes, 38% sustained injury to the lower back, while 23% and 16% of these athletes sustained injury to the ribs and hip-groin area, respectively. Systematic review: Ten studies were included. The level of evidence was IV and the mean MINORS score was 13.2(9-15) (fair quality). Most studies reported injuries to the lower spine (8/10,80%) whereas injuries to the ribs or other anatomic sites were reported in ≤4 (40%) studies. Significant heterogeneity of the injury reporting methodologies (injury definition; measures of injury occurrence; description of the injury site) was detected and precluded meta-analysis.

CONCLUSIONS

Most injuries recorded in a single team of female NCAA Division I athletes occurred in the lower back followed by injuries to the ribs and the hip. The existing injury epidemiology literature in mostly focuses on injuries to the lower back, while injuries to other anatomic sites were less frequently analyzed. No conclusions can be made regarding the most common injuries in rowers based on the current evidence due to substantial heterogeneity of injury reported methodologies which warrants further investigation.

Epidemiology and Outcomes of Maxillofacial Injuries in NCAA Division I Athletes Participating in 13 Sports

Background:

Maxillofacial injuries account for an estimated 11% of National Collegiate Athletic Association (NCAA) sport-related injuries and occur at a rate of 0.2-1.5 injuries per 1000 athletic events/exposures.

Purpose:

The purpose of this study was to report the epidemiology, treatment, and outcomes of maxillofacial injuries in NCAA Division I athletes participating in 13 sports. It was hypothesized that the rate of maxillofacial injuries would be greater than previously reported in national registry studies.

Study Design:

Descriptive epidemiology study.

Methods:

A single-institution registry was utilized to retrieve the maxillofacial injuries and surgical procedures recorded over 4 athletic seasons, for the years 2015 through 2019, across 13 NCAA Division I sports. The incidence of injuries per sport was reported as the number per 1000 athlete-exposure (AE) hours. The time lost from participation and time to complete injury resolution per sport were reported as the mean and range.

Results:

A total of 193 maxillofacial injuries occurred over 4 seasons. The overall incidence of maxillofacial injuries was 2.06 injuries per 1000 AE hours. The injury incidence for male and female athletes was 1.92 and 2.43 injuries per 1000 AE hours, respectively. Men’s basketball (8.30 injuries per 1000 AE hours) and men’s water polo (8.15 injuries per 1000 AE hours) had the highest rates of all sports. Overall, 20 athletes (10.4%) required surgery. The mean time to resolution across all sports was 33.3 days (range, 0-336 days) per injury. The mean time lost across all sports was 17.1 days (range, 0-336 days) per injury.

Conclusion:

At a single NCAA Division I institution, maxillofacial injuries occurred at a higher rate than previously thought and could lead to significant time lost from sport participation. Basketball players were at the highest risk of this injury. Across all sports, male athletes took longer to return to sport after a maxillofacial injury compared to female athletes, but the latter required more time to fully recover. Maxillofacial injuries may require surgical treatment, and their prevention is critical.

Shoulder Arthroplasty in the Aging Athlete: Considerations in the Younger Patient

Shoulder arthroplasty has become an increasingly common option for the management of glenohumeral osteoarthritis in younger, higher demand, and athletic individuals. Patients with shoulder arthritis in whom nonsurgical measures fail and who are not candidates for arthroscopic treatment may be evaluated for shoulder arthroplasty. Available options include shoulder hemiarthroplasty, with or without biologic glenoid resurfacing, total shoulder arthroplasty, and less commonly reverse total shoulder arthroplasty. The orthopaedic surgeon should be aware of the evolution and current use of the different shoulder replacement techniques in young active patients with glenohumeral osteoarthritis. In addition, it is important to review practical guidelines and issues with the implementation of those techniques when treating patients with shoulder arthritis who want to return to sport activity postoperatively.

Nonarthroplasty Management of Shoulder Arthritis in the Aging Athlete: Biologics and Arthroscopy

Glenohumeral arthritis in athletes or young and active individuals constitutes a challenging clinical problem, and multiple factors should be taken into consideration when deciding on nonsurgical or surgical treatment in this patient cohort. Selection of therapy should be based on clinical evidence, but the therapeutic strategy should align with patient expectations. Patient education on the nature and progression of shoulder osteoarthritis may facilitate the decision-making process regarding the selection of treatment. The orthopaedic surgeon should be knowledgeable about the nonarthroplasty options for the management of shoulder osteoarthritis in the aging athlete, with special focus on nonsurgical treatment options and shoulder arthroscopy.

Reliability of Plain Radiographs Versus Magnetic Resonance Imaging to Measure Tibial Slope in Sports Medicine Patients: Can They Be Used Interchangeably?

Background:

The slope of the tibial plateau has been proposed as a reason for failure of anterior cruciate ligament reconstruction.

Purpose:

To evaluate the interobserver reliability of measurements of tibial slope on radiographs versus magnetic resonance imaging (MRI) scans and to assess whether the modalities can be used interchangeably for this purpose.

Study Design:

Cohort study (diagnosis); Level of evidence, 3.

Methods:

This retrospective study included 81 patients aged 18 to 30 years who were evaluated in a sports medicine setting for knee pain and who had lateral knee radiographs as well as knee MRI scans on file. Medial and lateral tibial plateau slope measurements were made by 3 blinded reviewers from the radiographs and MRI scans using graphic overlay software. The paired t test was used to compare measurements of the medial tibial plateau slope (MTPS) and lateral tibial plateau slope (LTPS) from radiographs and MRI scans. Intraclass correlation coefficients (ICCs) were calculated to determine intra- and interobserver reliability of measurements within each imaging modality, and Pearson correlation coefficients were calculated to determine the relationship between measurements on radiographs versus MRI scans.

Results:

Imaging from 81 patients were included. The average MTPS was significantly larger on radiographs compared with MRI scans (8.7° ± 3.6° vs 3.7° ± 3.4°; P < .001), and the average LTPS was also significantly larger on radiographs compared with MRI scans (7.9° ± 3.4° vs 5.7° ± 3.7°; P < .001). ICC values indicated good to excellent intraobserver agreement for all imaging modalities (ICC, 0.81-0.97; P ≤ .009). The ICCs for interobserver reliability of MTPS and LTPS measurements were 0.92 and 0.85 for radiographs, 0.87 and 0.83 for MRI based off the subchondral bone, and 0.86 and 0.71 for MRI based off the cartilage, respectively (P < .001). Medium correlation was noted between radiographic and MRI measurements; Pearson correlation coefficients for radiographic versus subchondral MRI measurements were 0.30 and 0.37 for MTPS and LTPS, respectively.

Conclusion:

The average MTPS and LTPS were significantly larger on radiographs compared with MRI scans. Although tibial slope measurements using radiography and those using MRI are reliable between individuals, the measurements from radiographs and MRI scans cannot be used interchangeably, and caution should be used when interpreting and comparing studies using measurements of the tibial slope.

Return-to-Sport Criteria After Upper Extremity Surgery in Athletes-A Scoping Review, Part 2: Ulnar Collateral Ligament of the Elbow Procedures

Background:

There is a lack of consensus to guide patient return to sport (RTS) after elbow ulnar collateral ligament surgery (eUCLS).

Purpose:

To describe the reported RTS criteria after eUCLS in the athletic population.

Study Design:

Scoping review; Level of evidence, 4.

Methods:

This scoping review was performed by adhering to the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses–Scoping Review) guidelines. We searched 5 electronic databases (MEDLINE, Scopus, SPORTDiscus, Embase, Google Scholar Advanced) and the gray literature for English-language studies that reported at least 1 RTS criterion in athletes after eUCLS. Data were extracted and summarized as frequencies or arithmetic mean and standard deviation.

Results:

Included were 14 studies and 1335 athletes with a mean age of 21.4 ± 1.1 years. Time from surgery (range, 6-16 months) was the most common RTS criterion used, and it was reported by all 14 of the included articles. RTS criteria reported less often were pain (3/14; 21%), successful completion of a throwing program (3/14; 21%), muscle strength of the forearm muscles (1/14; 7%), and “normal” range of motion and muscle strength of the elbow and shoulder joints on the operated upper extremity (1/14; 7%). All studies used 1 to 5 of the above RTS criteria.

Conclusion:

Only 14 studies reported 1 or more RTS criteria after eUCLS in athletes, and time was the most common RTS criterion used. Our results highlight the need for a coordinated effort among surgeons, physical therapists, and athletic trainers in order to establish evidence-based RTS criteria after eUCLS in athletes so athletes can safely to sport and prolong their athletic careers.

Return-to-Sport Criteria After Upper Extremity Surgery in Athletes-A Scoping Review, Part 1: Rotator Cuff and Shoulder Stabilization Procedures

Background:

Standardized criteria are lacking to guide patient return to sport (RTS) after rotator cuff surgery (RCS) or shoulder stabilization surgery (SSS).

Purpose:

To describe RTS criteria used after RCS and SSS in athletic populations.

Study Design:

Scoping review; Level of evidence, 4.

Methods:

This scoping review was based on the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses–Scoping Review) guidelines. A total of 5 electronic databases (MEDLINE, Scopus, SPORTDiscus, Embase, Google Scholar Advanced search) and the gray literature were searched for English-language studies that reported at least 1 RTS criterion in athletes after shoulder surgery. Studies were assigned to the RCS or SSS subgroup based on the primary procedure performed. Data were extracted and summarized as frequencies or arithmetic mean and standard deviation.

Results:

Included were 52 studies and 2706 athletes (2206 male, 500 female, with a mean age of 28.8 ± 1.8 years). The RCS group consisted of 14 studies and the SSS group consisted of 38 studies. Time from surgery was the most common RTS criterion reported overall (37/52 studies; 71%) as well as within the RCS (93%) and SSS (63%) subgroups. Muscle strength (25/52 studies; 48%) and range of motion (23/52; 44%) were used by almost half of the included articles. RTS criteria reported less often were absence of pain, successful completion of sport-specific or position-specific test, proprioception, radiographic evaluation, patient-surgeon agreement, minimum time required to participate in pain-free throwing, and satisfactory scapulothoracic mechanics. All studies used 1 to 3 of the above RTS criteria; however, the definition of each criterion differed among the included articles.

Conclusion:

Time from surgery was the most commonly reported RTS criterion after RCS or SSS in athletes, whereas muscle strength and range of motion were used by almost half of the articles. There was high heterogeneity in the definition of each RTS criterion used among the included studies, which also used different combinations of 1 to 3 RTS criteria. These results suggest the need to better define quantitative and qualitative RTS criteria in athletes undergoing rotator cuff and shoulder stabilization procedures in order to safely return athletes to sport.

Surveillance testing for SARS-COV-2 infection in an asymptomatic athlete population: a prospective cohort study with 123 362 tests and 23 463 paired RT-PCR/antigen samples

Objective

To assess the diagnostic accuracy of antigen compared with reverse transcriptase (RT)-PCR testing in an asymptomatic athlete screening programme and to monitor infection in college athletes.

Methods

Quidel Sofia-2 SARS-CoV-2 Antigen Tests were performed daily before sports participation for football, basketball, wrestling and water polo from 29 September 2020 to 28 February 2021. Paired RT-PCR and antigen tests were performed at least once a week. Positive antigen tests were confirmed with RT-PCR.

Results

81 175 antigen and 42 187 RT-PCR tests were performed, including 23 462 weekly paired antigen/RT-PCR screening tests in 1931 athletes. One hundred and seventy-two athletes had a positive screening RT-PCR (0.4%), of which 83 (48%) occurred on paired testing days. The sensitivity of antigen tests varied with the frequency of RT-PCR testing and prevalence of COVID-19. The sensitivity of antigen testing was 35.7% (95% CI: 17% to 60%) and specificity 99.8% (95% CI: 99.7% to 99.9%) with once-a-week RT-PCR testing after adjusting for school prevalence. Daily antigen testing was similar to RT-PCR testing two to three times a week in identifying infection. Antigen testing identified infection before the next scheduled PCR on 89 occasions and resulted in 234 days where potentially infectious athletes were isolated before they would have been isolated with RT-PCR testing alone. Two athletic-related outbreaks occurred; 86% of total infections were community acquired.

Conclusion

Antigen testing has high specificity with a short turnaround time but is not as sensitive as RT-PCR. Daily antigen testing or RT-PCR testing two to three times a week is similar. There are benefits and drawbacks to each testing approach.

Superior Capsular Reconstruction of the Shoulder

For irreparable rotator cuff tears, superior capsular reconstruction (SCR) has become an option for restoring glenohumeral joint stability and reversing proximal humeral migration. Signs of irreparable rotator cuff tears include pain from subacromial impingement, muscle weakness, and pseudoparalysis. In biomechanical studies, Mihata et al. showed SCR with fascia lata graft and side-to-side suturing to remaining infraspinatus tendon restored superior stability of the shoulder joint. Adding acromioplasty decreased the subacromial contact area without altering the humeral head position, superior translation, or subacromial peak contact pressure. The same research group showed that using an 8-mm thick fascia lata graft attached at 15° to 45° of shoulder abduction optimized superior stability of the shoulder joint. Adams et al. performed SCR using a dermal allograft and found that greater glenohumeral abduction angle (60°) decreased applied deltoid force. SCR can be performed with the patient in the lateral decubitus or beach chair position. Arthroscopic exploration, debridement, and infraspinatus and supraspinatus repair attempt is completed before proceeding with SCR. To restore the superior capsule of the shoulder, the graft (fascia lata autograft, dermal allograft) can be attached to the superior glenoid medially and the rotator cuff footprint on the greater tuberosity of the humerus laterally, after debriding bone to enhance healing. SCR with side-to-side suturing to the remnant rotator cuff yields promising clinical results. Using a fascia lata autograft, Mihata et al. showed a reversal of pseudoparalysis in 93% to 96% of patients and mean active elevation, external rotation, and acromiohumeral distance on radiography all improved. Using a dermal allograft and a unique graft delivery technique, Burkhart et al. reversed pseudoparalysis in 9 of 10 patients and 70% of patients had completely intact grafts. Recommendations for rehabilitation and return to activity vary, but adequate time for graft healing is recommended.

Return to Sport Following Operative Treatment of Displaced Medial Sesamoid Fractures in NCAA Division I Football Players

Level of Evidence: Level V.

Injury Epidemiology and Time Lost From Participation in Women's NCAA Division I Indoor Versus Beach Volleyball Players

Background:

Beach volleyball officially became a National Collegiate Athletic Association (NCAA) Division I sport in 2015-2016. Few studies have examined the epidemiology of injuries in indoor versus beach volleyball in NCAA Division I athletes.

Purpose:

To compare the epidemiology of injuries and time lost from participation between female NCAA Division I athletes who participate in indoor versus beach volleyball.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Injury surveillance data (2003-2020) were obtained using an institutional database for all NCAA Division I women’s beach or indoor volleyball athletes. The total injury rate was expressed per 1000 hours played. The injury rate per body site was calculated by dividing the number of injuries in each body region by the total number of injuries. The frequency of injury per body site was also expressed as number of injuries per 1000 hours of practice or number of injuries per 1000 hours of game. The injury rate (total and per body site) and time lost from participation were compared between indoor and beach volleyball athletes.

Results:

Participants were 161 female NCAA Division I volleyball athletes (53 beach volleyball and 108 indoor volleyball athletes). In total, 974 injuries were recorded: 170 in beach volleyball and 804 in indoor volleyball. The injury rates for beach versus indoor volleyball were 1.8 versus 5.3 injuries per 1000 hours played (P < .0001). Indoor volleyball athletes had significantly higher injury rates compared with beach volleyball players for concussion (7.5% vs 6.5%; P < .0001) and knee injury (16.7% vs 7.6%; P = .0004); however, the rate of abdominal muscle injury was significantly higher in beach versus indoor volleyball (11.8% vs 4.7%; P = .0008). Time lost from sport participation was significantly longer in beach versus indoor volleyball for knee (24 vs 11 days; P = .047), low back (25 vs 17 days; P = .0009), and shoulder (52 vs 28 days; P = .001) injuries.

Conclusion:

Based on this study, injury was more likely to occur in indoor compared with beach volleyball. Sport-related concussion and knee injuries were more common in indoor volleyball, but the rate of abdominal muscle injury was higher in beach volleyball. Beach volleyball players needed longer time to recover after injuries to the knee, low back, and shoulder.

Five-Year Surveillance of Vitamin D Levels in NCAA Division I Football Players: Risk Factors for Failed Supplementation

Background

Monitoring vitamin D levels in athletes and determining their response to supplementation in cases of deficiency is thought to be necessary to modulate the risks associated with vitamin D deficiency.

Hypothesis/Purpose

To report the results of a 5-year-long surveillance program of vitamin D in the serum of football players on a National Collegiate Athletic Association (NCAA) Division I team and to examine whether factors including age, body mass index (BMI), race, position played, and supplement type would affect the response to 12-month oral vitamin D replacement therapy in athletes with deficiency. We hypothesized that yearly measurements would decrease the proportion of athletes with vitamin D insufficiency over the years and that the aforementioned factors would affect the response to the supplementation therapy.

Study Design

Cohort study; Level of evidence, 3.

Methods

We measured serum 25(OH)D levels (25-hydroxyvitamin D) in 272 NCAA Division I football players from our institution annually between 2012 and 2017. Athletes with insufficient vitamin D levels (<32 ng/mL) received supplementation with vitamin D3 alone or combined vitamin D3/D2. The percentage of insufficient cases between the first 2 years and last 2 years of the program was compared, and yearly team averages of vitamin D levels were calculated. Associations between player parameters (age, BMI, race, team position, supplement type) and failed supplementation were evaluated.

Results

The prevalence of vitamin D insufficiency decreased significantly during the study period, from 55.5% in 2012-2013 to 30.7% in 2016-2017 (P = .033). The mean 25(OH)D level in 2012 was 36.3 ng/mL, and this increased to 40.5 ng/mL in 2017 (P < .001); however, this increase was not steady over the study period. Non-Hispanic athletes and quarterbacks had the highest average 25(OH)D levels, and Black players and running backs had the lowest overall levels. There were no significant differences in age, BMI, race, or playing position between athletes with and without failed vitamin D supplementation. Athletes receiving vitamin D3 alone had a more successful rate of conversion (48.15%) than those receiving combined vitamin D3/D2 (22.22%; P = .034).

Conclusion

To decrease the prevalence of vitamin D deficiency in football players, serum vitamin D measurements should be performed at least once a year, and oral supplementation therapy should be provided in cases of deficiency. Black players might be at increased risk of vitamin D insufficiency. Oral vitamin D3 may be more effective in restoring vitamin D levels than combined vitamin D3/D2 therapy.

Epidemiology of Anterior Cruciate Ligament Injury on Natural Grass Versus Artificial Turf in Soccer: 10-Year Data From the National Collegiate Athletic Association Injury Surveillance System

Background:

Anterior cruciate ligament (ACL) injury is prevalent among National Collegiate Athletic Association (NCAA) soccer players. Controversy remains regarding the effect of the surface type on the rate of ACL injury in soccer players, considering differences in sex, type of athletic exposure, and level of competition.

Hypothesis:

Natural grass surfaces would be associated with decreased ACL injury rate in NCAA soccer players. Sex, type of athletic exposure (match vs practice), and level of competition (Division I-III) would affect the relationship between playing surface and ACL injury rates.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Using the NCAA Injury Surveillance System (ISS) database, we calculated the incidence rate of ACL injury in men and women from 2004-2005 through 2013-2014 seasons. The incidence was normalized against athletic exposure (AE). Additional data collected were sex, athletic activity at time of injury (match vs practice), and level of competition (NCAA division) to stratify the analysis. Statistical comparisons were made by calculating incidence rate ratios (IRR). Statistical significance was set at an alpha of .05.

Results:

There were 30,831,779 weighted AEs during the study period. The overall injury rate was 1.12 ACL injuries per 10,000 AEs (95% CI, 1.08-1.16). Women comprised 57% of the match data (10,261 games) and 55% of practice data (26,664 practices). The overall injury rate was significantly higher on natural grass (1.16/10,000 AEs; 95% CI, 1.12-1.20) compared with artificial turf (0.92/10,000 AEs [95% CI, 0.84-1.01]; IRR, 1.26 [95% CI, 1.14-1.38]) (P < .0001). This relationship was demonstrated consistently across all subanalyses, including stratification by NCAA division and sex. The injury rate on natural grass (0.52/10,000 AEs; 95% CI, 1.11-1.26) was significantly greater than the injury incidence during practice on artificial turf (0.06/10,000 AEs; 95% CI, 0.043-0.096). Players were 8.67 times more likely to sustain an ACL injury during practice on natural grass compared with practice on artificial turf (95% CI, 5.43-12.13; P < .0001). No significant difference was found in injury rates between matches played on grass versus turf (IRR, 0.93; 95% CI, 0.84-1.03; P = .15).

Conclusion:

NCAA soccer players who practice on natural grass have increased risk of ACL injury compared with the risk of those practicing on an artificial surface, regardless of sex or NCAA division of play. No difference in risk of ACL injury between playing surfaces was detected during matches. Further research is necessary to examine the effect of multiple factors when evaluating the effect of the surface type on the risk of ACL injury in soccer players.

National Trends in Use of Regional Anesthesia and Postoperative Patterns of Opioid Prescription Filling in Shoulder Arthroscopy: A Procedure-Specific Analysis in Patients With or Without Recent Opioid Exposure

Background

There are few large database studies on national trends in regional anesthesia for various arthroscopic shoulder procedures and the effect of nerve blocks on the postoperative rate of opioid prescription filling.

Hypothesis

The use of regional nerve block will decrease the rate of opioid prescription filling after various shoulder arthroscopic procedures. Also, the postoperative pattern of opioid prescription filling will be affected by the preoperative opioid prescription-filling history.

Study Design

Cohort study; Level of evidence, 3.

Methods

Patient data from Humana, a large national private insurer, were queried via PearlDiver software, and a retrospective review was conducted from 2007 through 2015. Patients undergoing arthroscopic shoulder procedures were identified through Current Procedural Terminology codes. Nerve blocks were identified by relevant codes for single-shot and indwelling catheter blocks. The blocked and unblocked cases were age and sex matched to compare the pain medication prescription-filling pattern. Postoperative opioid trends (up to 6 months) were compared by regression analysis.

Results

We identified 82,561 cases, of which 54,578 (66.1%) included a peripheral nerve block. Of the patients who received a block, 508 underwent diagnostic shoulder arthroscopy; 2449 had labral repair; 4746 had subacromial decompression procedure; and 12,616 underwent rotator cuff repair. The percentage of patients undergoing a nerve block increased linearly over the 9-year study period (R ² = 0.77; P = .002). After matching across the 2 cohorts, there was an identical trend in opioid prescription filling between blocked and unblocked cases (P = .95). When subdivided by procedure, there was no difference in the trends between blocked and unblocked cases (P = .52 for diagnostic arthroscopies; P = .24 for labral procedures; P = .71 for subacromial decompressions; P = .34 for rotator cuff repairs). However, when preoperative opioid users were isolated, postoperative opioid prescription filling was found to be less common in the first 2 weeks after surgery when a nerve block was given versus not given (P < .001).

Conclusion

An increasing percentage of shoulder arthroscopies are being performed with regional nerve blocks. However, there was no difference in patterns of filled postoperative opioid prescriptions between blocked and unblocked cases, except for the subgroup of patients who had filled an opioid prescription within 1 to 3 months prior to shoulder arthroscopy. Future research should focus on recording the amount of prescribed opioids consumed in national databases to reinforce our strategy against the opioid epidemic.

Epidemiologic Assessment of Concussions in an NCAA Division I Women's Soccer Team

Background:

Among collegiate sports, ice hockey and wrestling have been reported to have the highest rates of concussion injury. Recent literature has shown that among all sports, female soccer players had the highest rate of concussion injury at the high school level. Sport-specific analysis will increase our knowledge of epidemiologic characteristics of this serious injury in young soccer players, where “heading” is commonly involved during participation.

Hypothesis:

Heading during soccer will be associated with increased frequency of concussion injury in collegiate female players compared with other mechanisms of injury, and concussion injury mechanism and rates will differ by setting of injury (practice or match) and player position.

Study Design:

Descriptive epidemiologic study.

Methods:

This was a retrospective review and epidemiologic analysis of all concussions documented from a single National Collegiate Athletic Association (NCAA) Division I female collegiate soccer team between 2004 and 2017. A total of 381 participants were reviewed, and concussion injury mechanism, setting (practice or match), player position, and number of games and practices missed due to injury were analyzed.

Results:

Overall, 25 concussions in 22 players from the 2004 to 2017 seasons were identified, for an annual rate of 1.79 concussions per year. Collisions (36%) followed by headers (20%) were the most common mechanisms. Forwards sustained the most concussions (32%). Injuries were more common in games (56%) than practice (40%). Of note, the most common cause of concussion during practice was headers (40%). Of the concussions documented, 20 (91%) were the player’s first concussion. On average, each concussion resulted in a player missing 3.96 games and 12.46 practices.

Conclusion:

Our results demonstrate that concussion rates in female NCAA soccer players vary by position and occur with different frequencies and mechanisms in practice and games. Interventions for concussion avoidance should aim to limit exposure to high-risk activity, including player-to-player contact in games and headers in practice. Although gameplay and collisions can be unpredictable and difficult to control, practice settings can be modified in an attempt to decrease risk.

Return to Sport After Hip Arthroscopy for Femoroacetabular Impingement Syndrome in NCAA Division I Athletes: Experience at a Single Institution

Background:

The rate of return to sport after surgical treatment of femoroacetabular impingement (FAI) syndrome (FAIS) has been studied in high-level athletes. However, few studies examining this rate have focused exclusively on National Collegiate Athletic Association (NCAA) Division I athletes.

Purpose:

To evaluate the return-to-sport rate after hip arthroscopy for FAIS and to examine the influence of sport type on the clinical presentation of FAIS in collegiate athletes.

Study Design:

Case series; Level of evidence, 4.

Methods:

Included in this study were NCAA Division I student-athletes who underwent hip arthroscopy for FAIS at our institution between 2010 and 2017. Exclusion criteria were history of previous hip pathology, pediatric hip disease, radiographic evidence of osteoarthritis (Tönnis grade >0), prior lower extremity procedure, history of chronic pain, osteoporosis, or history of systemic inflammatory disease. Athletes were categorized into 6 subgroups based on the type of sport (cutting, contact, endurance, impingement, asymmetric/overhead, and flexibility) by using a previously reported classification system. Patient characteristics and preoperative, intraoperative, and return-to-sport variables were compared among sport types.

Results:

A total of 49 hip arthroscopies for FAIS were performed in 39 collegiate athletes (10 females, 29 males; mean age, 19.5 ± 1.3 years). A total of 1 (2.6%) cutting athlete, 15 (38.5%) contact athletes, 8 (20.5%) impingement athletes, 6 (15.4%) asymmetric/overhead athletes, and 9 (23.1%) endurance athletes were included in the study. There were no differences among sports groups with respect to the FAI type. Endurance athletes had lower rates of femoral osteochondroplasty (45.5%) and labral debridement (0.0%) (P < .0001). Contact sport athletes had higher rates of labral debridement (50.0%; P < .0001). Patients were evaluated for return to sport at an average of 1.96 ± 0.94 years. Overall, the return-to-sport rate was 89.7%. There were no differences in return-to-sport rates based on the sport type except for endurance athletes, who returned at a lower rate (66.6%; P < .001). No differences in return-to-sport rate (P = .411), duration after return (P = .265), or highest attempted level of sport resumed (P = .625) were found between patients who underwent labral repair versus debridement.

Conclusion:

Collegiate-level athletes who underwent hip arthroscopy for FAIS returned to sport at high and predictable rates, with endurance athletes possibly returning to sport at lower rates than all other sport types. Surgical procedures may be influenced by sport type, but the rate of return to sport between athletes who underwent labral debridement versus labral repair was similar.

Injections Prior to Rotator Cuff Repair Are Associated With Increased Rotator Cuff Revision Rates

PURPOSE

To determine whether shoulder injections prior to rotator cuff repair (RCR) are associated with deleterious surgical outcomes.

METHODS

Two large national insurance databases were used to identify a total of 22,156 patients who received ipsilateral shoulder injections prior to RCR. They were age, sex, obesity, smoking status, and comorbidity matched to a control group of patients who underwent RCR without prior injections. The 2 groups were compared regarding RCR revision rates.

RESULTS

Patients who received injections prior to RCR were more likely to undergo RCR revision than matched controls (odds ratio [OR], 1.52; 95% confidence interval [CI], 1.38-1.68; P < .0001). Patients who received injections closer to the time of index RCR were more likely to undergo revision (P < .0001). Patients who received a single injection prior to RCR had a higher likelihood of revision (OR, 1.25; 95% CI, 1.10-1.43; P = .001). Patients who received 2 or more injections prior to RCR had a greater than 2-fold odds of revision (combined OR, 2.12; 95% CI, 1.82-2.47; P < .0001) versus the control group.

CONCLUSIONS

This study strongly suggests a correlation between preoperative shoulder injections and revision RCR. There is also a frequency dependence and time dependence to this finding, with more frequent injections and with administration of injections closer to the time of surgery both independently associated with higher revision RCR rates. Presently, on the basis of this retrospective database study, orthopaedic surgeons should exercise due caution regarding shoulder injections in patients whom they are considering to be surgical candidates for RCR.

LEVEL OF EVIDENCE

Level III, therapeutic study.

The Effect of Obesity on Operative Times and 30-Day Readmissions After Anterior Cruciate Ligament Reconstruction

PURPOSE

To understand the effect of obesity on operative times and 30-day readmission rates after arthroscopic anterior cruciate ligament reconstruction (ACLR).

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was queried using Current Procedural Terminology billing codes to identify all patients aged 18 years and older who underwent ACLR between 2007 and 2014. The Student t test was used for continuous variables, and the χ-square or Fisher exact test was used for categorical variables. Multivariate analysis was conducted to identify factors associated with 30-day readmission.

RESULTS

We identified 9,000 patients who underwent ACLR. In the readmission analysis, the total readmission rate was 0.70%. After multivariate analysis, a body mass index (BMI) of 40 or greater was associated with a significantly increased risk of 30-day readmission (odds ratio, 3.06; 95% confidence interval, 1.09-8.57). An operative time of less than 80 minutes was associated with a decreased risk of readmission (odds ratio, 0.40, 95% confidence interval, 0.18-0.92). In the operative-time analysis, the mean operative time was 100.7 minutes. Older age was predictive of decreasing operative time, with the operative time being 32.75 minutes shorter in patients aged 65 years or older than in those younger than 25 years. After multivariate analysis, class II obesity (BMI of 35-39.9) predicted an increase of 7.11 minutes and class III obesity (BMI ≥ 40) predicted an increase of 8.70 minutes compared with normal weight (BMI of 18.5-24.9).

CONCLUSIONS

Obesity is associated with longer operative times and increased 30-day readmissions after ACLR, with patients with a BMI of 40 or greater having over 3 times the risk of readmission compared with patients with a normal weight. Male sex, black race, and younger age are all also associated with increased operative times.

LEVEL OF EVIDENCE

Level III, observational, retrospective cohort study.

NONOPERATIVE TREATMENT FOR INJURIES TO THE IN-SEASON THROWING SHOULDER: A CURRENT CONCEPTS REVIEW WITH CLINICAL COMMENTARY

Repetitive overhead throwing generates tremendous demands on the shoulder joint of the overhead athlete. Clinicians, therapists, and medical staff are charged with optimizing a throwing athlete's shoulder mobility and stability to maximize performance and prevent injury. Modifiable risk factors such as strength asymmetry, glenohumeral range of motion deficits, and scapulothoracic joint abnormalities contribute to the overhead athlete's predisposition to shoulder injury. Most shoulder injuries in the overhead thrower can be successfully treated nonoperatively to allow in-season return to sport. The optimal rehabilitation program must be based on an accurate evaluation of historical and physical information as well as diagnostic imaging. Return to play decisions should be individualized and should weigh subjective assessments along with objective measurements of range of motion, strength, and function. The purpose of this clinical commentary is to summarize the current literature regarding the nonoperative treatment options for these common injuries, and to present a treatment plan to safely return these athletes to the field of play.

Level of evidence

5.

Return to Play After Shoulder Instability Surgery in National Collegiate Athletic Association Division I Intercollegiate Football Athletes

BACKGROUND

Recent attention has focused on the optimal surgical treatment for recurrent shoulder instability in young athletes. Collision athletes are at a higher risk for recurrent instability after surgery.

PURPOSE

To evaluate variables affecting return-to-play (RTP) rates in Division I intercollegiate football athletes after shoulder instability surgery.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Invitations to participate were made to select sports medicine programs that care for athletes in Division I football conferences (Pac-12 Conference, Southeastern Conference [SEC], Atlantic Coast Conference [ACC]). After gaining institutional review board approval, 7 programs qualified and participated. Data on direction of instability, type of surgery, time to resume participation, and quality and level of play before and after surgery were collected.

RESULTS

There were 168 of 177 procedures that were arthroscopic surgery, with a mean 3.3-year follow-up. Overall, 85.4% of players who underwent arthroscopic surgery without concomitant procedures returned to play. Moreover, 15.6% of athletes who returned to play sustained subsequent shoulder injuries, and 10.3% sustained recurrent instability, resulting in reduction/revision surgery. No differences were noted in RTP rates in athletes who underwent anterior labral repair (82.4%), posterior labral repair (92.9%), combined anterior-posterior repair (84.8%; P = .2945), or open repair (88.9%; P = .9362). Also, 93.3% of starters, 95.4% of utilized players, and 75.7% of rarely used players returned to play. The percentage of games played before the injury was 49.9% and rose to 71.5% after surgery ( P < .0001). Athletes who played in a higher percentage of games before the injury were more likely to return to play; 91% of athletes who were starters before the injury returned as starters after surgery. Scholarship status significantly correlated with RTP after surgery ( P = .0003).

CONCLUSION

The majority of surgical interventions were isolated arthroscopic stabilization procedures, with no statistically significant difference in RTP rates when concomitant arthroscopic procedures or open stabilization procedures were performed. Athletes who returned to play often played in a higher percentage of games after surgery than before the injury, and many played at the same or a higher level after surgery.

Direct Cost Analysis of Outpatient Arthroscopic Rotator Cuff Repair in Medicare and Non-Medicare Populations

Background:

Providing high-quality care while also containing cost is a paramount goal in orthopaedic surgery. Increasingly, insurance providers in the United States, including government payers, are requiring financial and performance accountability for episodes of care, including a push toward bundled payments.

Hypothesis:

The direct cost of outpatient arthroscopic rotator cuff repair was assessed to determine whether, due to an older population, rotator cuff surgery was more costly in Medicare-insured patients than in patients covered by other insurers. We hypothesized that operative time, implant cost, and overall higher cost would be observed in Medicare patients.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Billing and operative reports from 184 outpatient arthroscopic rotator cuff repairs performed by 5 fellowship-trained arthroscopic surgeons were reviewed. Operative time, number and cost of implants, hospital reimbursement, surgeon reimbursement, and insurance type were determined from billing records and operative reports. Patients were stratified by payer (Medicare vs non-Medicare), and these variables were compared.

Results:

There were no statistically significant differences in the number of suture anchors used, implant cost, surgical duration, or overall cost of arthroscopic rotator cuff repair between Medicare and other insurers. Reimbursement was significantly higher for other payers when compared with Medicare, resulting in a mean per case deficit of $263.54 between billing and reimbursement for Medicare patients.

Conclusion:

Operating room time, implant cost, and total procedural cost was the same for Medicare patients as for patients with private payers. Further research needs to be conducted to understand the patient-specific factors that affect the cost of an episode of care for rotator cuff surgery.

Epidemiology of Operative Procedures in an NCAA Division I Football Team Over 10 Seasons

Background:

Injury rates are high for collegiate football players. Few studies have evaluated the epidemiology of surgical procedures in National Collegiate Athletic Association (NCAA) Division I collegiate football players.

Purpose:

To determine the most common surgical procedures performed in collegiate football players over a 10-year period.

Study Design:

Descriptive epidemiological study.

Methods:

From the 2004-2005 season through the 2013-2014 season, all surgical procedures performed on athletes from a single NCAA Division I college football team during athletic participation were reviewed. Surgeries were categorized by anatomic location, and operative reports were used to obtain further surgical details. Data collected over this 10-season span included type of injury, primary procedures, reoperations, and cause of reoperation, all categorized by specific anatomic locations and position played.

Results:

From the 2004-2005 through the 2013-2014 seasons, 254 operations were performed on 207 players, averaging 25.4 surgical procedures per year. The majority of surgeries performed were orthopaedic procedures (92.1%, n = 234). However, there were multiple nonorthopaedic procedures (7.9%, n = 20). The most common procedure performed was arthroscopic shoulder labral repair (12.2%, n = 31). Partial meniscectomy (11.8%, n = 30), arthroscopic anterior cruciate ligament (ACL) reconstruction (9.4% n = 24), and arthroscopic hip labral repair (5.9% n = 15) were the other commonly performed procedures. There were a total of 29 reoperations performed; thus, 12.9% of primary procedures had a reoperation. The most common revision procedure was a revision open reduction internal fixation of stress fractures in the foot as a result of a symptomatic nonunion (33.33%, n = 4) and revision ACL reconstruction (12.5%, n = 3). By position, relative to the number of athletes at each position, linebackers (30.5%) and defensive linemen (29.1%) were the most likely to undergo surgery while kickers (6%) were the least likely.

Conclusion:

In NCAA Division I college football players, the most commonly performed surgeries conducted for injuries were orthopaedic in nature. Of these, arthroscopic shoulder labral repair was the most common, followed closely by partial meniscectomy. Nonorthopaedic procedures nonetheless accounted for a sizable portion of surgical volume. Familiarity with this injury and surgical spectrum is of utmost importance for the team physician treating these high-level contact athletes.

Factors predicting complication and reoperation rates following surgical fixation of proximal humeral fractures

BACKGROUND

The purpose of this study was to report complication and reoperation rates following non-arthroplasty fixation of shoulder fractures determined on the basis of observational, population-based data from all inpatient admissions in California over an eleven-year period.

METHODS

Records from all inpatient hospital discharges and subsequent readmissions related to operative non-arthroplasty treatment of proximal humeral fractures were obtained for patients in California from December 1994 through December 2005. These admissions were evaluated to identify patient and hospital characteristics associated with short and intermediate-term complications (within and after ninety days, respectively) as well as reoperation rates. Procedures performed included open reduction and internal fixation in 9254 patients, closed reduction and internal fixation in 1903 patients, and internal fixation without reduction in 302 patients.

RESULTS

The short-term complications included mortality in 401 patients (3.5%), which was associated with a higher Charlson comorbidity index (odds ratio [OR] = 1.5, p < 0.001) and male sex (OR = 1.7, p < 0.001); and pulmonary embolism in sixty patients (0.5%), which was associated with male sex (OR = 2.2, p = 0.007) and patient age of seventy-five years or older (OR = 3.6, p = 0.001). Intermediate-term reoperations included conversion to hemiarthroplasty in 174 patients (1.5%); and conversion to total shoulder arthroplasty in eight patients (0.07%), which was associated with an age of fifty to sixty-four years (hazard ratio = 2.8, p = 0.007). Overall, an age of sixty-five years or older, male sex, residence in an area with an income in the lowest two quintiles, and the presence of preexisting comorbidities were associated with elevated risks of short-term complications but not of intermediate-term conversion to arthroplasty. The ninety-day revision rate was 5.3%.

CONCLUSIONS

Surgical fixation of proximal humeral fractures has a low complication and mortality profile. The data provided in this study can serve in counseling patients about risks associated with operative fixation of displaced proximal humeral fractures.

Prevalence of Abnormal Vitamin D Levels Among Division I NCAA Athletes

Background:

Up to 1 billion people have insufficient or deficient vitamin D levels. Despite the well-documented, widespread prevalence of low vitamin D levels and the importance of vitamin D for athletes, there is a paucity of research investigating the prevalence of vitamin D deficiency in athletes.

Hypothesis:

We investigated the prevalence of abnormal vitamin D levels in National Collegiate Athletic Association (NCAA) Division I college athletes at a single institution. We hypothesized that vitamin D insufficiency is prevalent among our cohort.

Study Design:

Cohort study.

Level of Evidence:

Level 1.

Methods:

We measured serum 25-hydroxyvitamin D (25(OH)D) levels of 223 NCAA Division I athletes between June 2012 and August 2012. The prevalence of normal (≥32 ng/mL), insufficient (20 to <32 ng/mL), and deficient (<20 ng/mL) vitamin D levels was determined. Logistic regression was utilized to analyze risk factors for abnormal vitamin D levels.

Results:

The mean serum 25(OH)D level for the 223 members of this study was 40.1 ± 14.9 ng/mL. Overall, 148 (66.4%) participants had sufficient 25(OH)D levels, and 75 (33.6%) had abnormal levels. Univariate analysis revealed the following significant predictors of abnormal vitamin D levels: male sex (odds ratio [OR] = 2.83; P = 0.0006), Hispanic race (OR = 6.07; P = 0.0063), black race (OR = 19.1; P < 0.0001), and dark skin tone (OR = 15.2; P < 0.0001). Only dark skin tone remained a significant predictor of abnormal vitamin D levels after multivariate analysis (adjusted OR = 15.2; P < 0.0001).

Conclusion:

In a large cohort of NCAA athletes, more than one third had abnormal vitamin D levels. Races with dark skin tones are at much higher risk than white athletes. Male athletes are more likely than female athletes to be vitamin D deficient. Our study demonstrates a high prevalence of vitamin D deficiency among healthy NCAA athletes.

Clinical Relevance:

Many studies indicate a significant prevalence of vitamin-D insufficiency across various populations. Recent studies have demonstrated a direct relationship between serum 25(OH)D levels and muscle power, force, velocity, and optimal bone mass. In fact, studies examining muscle biopsies from patients with low vitamin D levels have demonstrated atrophic changes in type II muscle fibers, which are crucial to most athletes. Furthermore, insufficient 25(OH)D levels can result in secondary hyperparathyroidism, increased bone turnover, bone loss, and increased risk of low trauma fractures and muscle injuries. Despite this well-documented relationship between vitamin D and athletic performance, the prevalence of vitamin D deficiency in NCAA athletes has not been well studied.

Arthroscopic versus open shoulder stabilization: current practice patterns in the United States

PURPOSE

The purpose of this study was to investigate current trends in arthroscopic and open shoulder stabilization in the United States.

METHODS

Patients who underwent arthroscopic shoulder stabilization (Current Procedural Terminology code 29806) or open stabilization (Current Procedural Terminology codes 23455 [open Bankart repair], 23460 [anterior bone block], and 23462 [coracoid transfer]) were identified using a national database of insurance billing records during the years 2004 through 2009. Demographic data were recorded for each patient.

RESULTS

From 2004 through 2009, there were 23,096 cases of shoulder stabilization, of which 84% (19,337) were arthroscopic and 16% (3,759) were open procedures. There were 17,241 male patients (75%) and 5,855 female patients (25%). The incidence of arthroscopic shoulder stabilization nearly doubled during the period studied, increasing from 11.8 cases for every 10,000 patients in 2004 to 22.9 cases for every 10,000 patients in 2009. The percentage of arthroscopic stabilizations increased from 71% of stabilization procedures in 2004 to 89% in 2009, whereas the percentage of open stabilizations decreased from 29% in 2004 to 11% in 2009 (P < .0001). Among open procedures, a significant decline in the incidence of open Bankart repair was observed, from 4.5 cases for every 10,000 patients in 2004 to 2.2 cases for every 10,000 patients in 2009 (P < .0001), whereas the performance of open coracoid transfer increased from 0.17 cases per 10,000 patients in 2004 to 0.40 cases per 10,000 patients in 2009 (P < .0001). For both arthroscopic and open stabilization, the group aged 10 to 19 years had the highest rate of surgery (29%), followed by the group aged 20 to 29 years (25%).

CONCLUSIONS

The current data indicate that arthroscopic stabilization is performed in nearly 90% of shoulder stabilization surgeries and nearly doubled in incidence from 2004 to 2009 in the United States. Additional research is needed to further investigate the long-term clinical outcomes of this practice pattern.

LEVEL OF EVIDENCE

Level IV, retrospective database review.

Analysis of rotator cuff repair trends in a large private insurance population

PURPOSE

The purpose of this study was to identify current trends in open and arthroscopic surgical treatment of rotator cuff tears across sex, age, and region in the United States.

METHODS

Using the PearlDiver Patient Record Database (PearlDiver, Fort Wayne, IN), a publicly available national database of insurance records, patients who underwent rotator cuff repair from 2004 through 2009 were identified. The number of open (CPT codes 23410, 23412, 23420) and arthroscopic (CPT code 29827) rotator cuff repairs were quantified in isolation and in combination with acromioplasty (CPT codes 23415, 29826). The type of procedure, date, sex, and region of the country was identified for each patient. Trend tests (χ(2) and Cochran-Armitage) were used to determine statistical significance.

RESULTS

There were 151,866 rotator cuff repair procedures identified in the database from 2004 through 2009, which represented an incidence of 13.6 for every 1,000 patients assigned an orthopaedic International Classification of Diseases, Ninth Revision (ICD-9) or Current Procedural Terminology (CPT) code. Male patients accounted for 60% of the repairs and female patients for 40%. There were 98,174 arthroscopic cuff repairs (65%) and 53,692 open repairs (35%). The annual percentage of arthroscopic cases increased from 48.8% in 2004 to 74.3% in 2009, whereas the percentage of open cases decreased from 51.2% in 2004 to 25.7% in 2009 (P < .0001). Acromioplasty was also performed in 47.3% of cases, and the rate showed only a slight increase (from 46.6% to 47.8%) between 2004 and 2009 (P < .01). All regions of the United States showed similar surgical trends and trends for sex and age distributions.

CONCLUSIONS

Our analysis shows that the majority of rotator cuff repairs in the United States are now performed arthroscopically (>74%) and there has been a recent steady decline in performance of open rotator cuff repair. Concomitant acromioplasty is performed approximately half the time, and this trend is increasing slightly. These findings were consistent across age, sex, and region in the United States.

LEVEL OF EVIDENCE

IV, cross-sectional study.

Shoulder function and pain level after revision of failed reverse shoulder replacement to hemiarthroplasty

BACKGROUND

The reverse total shoulder replacement has become a popular treatment option for cuff tear arthropathy and other shoulder conditions requiring arthroplasty in the setting of a deficient rotator cuff. Despite a revision rate of as much as 10%, to date, there are few reports of reverse replacement conversion to hemiarthroplasty, and none specifically examining shoulder function.

MATERIALS AND METHODS

Six patients with a reverse replacement that was dislocated, infected or loose were revised an average of 9.2 months after the reverse replacement. Two of the three patients that were dislocated also had a known deep infection. Patients with known infection were treated with explant of the reverse prosthesis and conversion to a preformed antibiotic spacer hemiarthroplasty. In three cases with gross loosening of the glenosphere without infection, treatment was performed with removal of glenosphere only, bone grafting of glenoid with allograft and conversion of humeral stem to hemiarthroplasty. Patients were evaluated with outcome scores and physical examination an average of 26.5 months after removal of the reverse prosthesis.

RESULTS

The average range of motion postoperatively was forward elevation 42.5 degrees and external rotation 1.7 degrees. The VAS pain score was 2.42 (range 0-6); simple shoulder test was 3.17 (range 1-5); and ASES score was 52.1 ± 8.5. There were no reoperations to date, and five patients had anterosuperior escape.

CONCLUSIONS

Safe removal of a reverse replacement and conversion to hemicement spacer or hemiarthroplasty can provide pain relief in those patients with a dislocated or infected reverse replacement. However, the shoulder will likely have very poor function and anterosuperior escape postoperatively. Further studies are needed to determine the optimal treatment for the failed reverse shoulder replacement.

LEVEL OF EVIDENCE

Therapeutic Level IV.

Complications of arthroscopic meniscectomy in the older population

BACKGROUND

Complications of arthroscopic meniscectomy in the older population have not been established.

PURPOSE

To determine the risk and relative risk of developing pyogenic arthritis (PA), a deep vein thrombosis (DVT), and pulmonary embolism (PE) in an older population of patients who have undergone arthroscopic meniscectomy.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Men and women ≥65 years old who underwent procedures coded as CPT-29880 (medial and lateral meniscectomy) and CPT-29881 (medial or lateral meniscectomy) were identified in the Medicare Standard Analytic Files database from 2005 to 2008. Identified patients were analyzed for gender and postoperative complications, including PA, DVT, and PE, occurring within 90 days of the index operation.

RESULTS

Overall, 314,578 patients (119,814 men and 194,764 women) were identified. With respect to the Current Procedural Terminology codes, 131,420 patients were coded 29880 and 183,158 patients were coded 29881. In the study population, 0.4% (1107 patients) developed PA, 0.8% (2507 patients) developed a DVT, and 0.3% (982 patients) developed a PE. Among male patients, 0.4% developed PA, 0.7% developed a DVT, and 0.2% developed a PE. Among female patients, 0.3% developed PA, 0.8% developed a DVT, and 0.3% developed a PE. Overall, men had a statistically significant higher relative risk of PA and women had a statistically significant higher relative risk of DVT and PE.

CONCLUSION

Postoperative complications, including PA, DVTs, and PEs, are rare in patients ≥65 years old. However, gender-specific differences in the rate and type of postoperative complications may exist. Further studies in this population are warranted.

Contrast-enhanced ultrasound characterization of the vascularity of the repaired rotator cuff tendon: short-term and intermediate-term follow-up

BACKGROUND

The objectives of this study were to characterize and compare the vascularity of arthroscopically repaired rotator cuff tendons at short-term and intermediate-term follow-up.

MATERIALS AND METHODS

Nineteen patients who underwent arthroscopic rotator cuff repair were prospectively monitored for an average of 21.2 months. Initial baseline, grayscale ultrasound images of the operated-on shoulder were obtained on all patients at 3 months and at a minimum of 10 months postoperatively. Perflutren-lipid microsphere contrast (DEFINITY, Lantheus Medical Imaging, North Billerica, MA, USA) was injected after baseline grayscale images and after exercise to obtain contrast-enhanced images of the repair. Three regions of interest--supraspinatus tendon, peribursal tissue, and bone anchor site--were evaluated before and after rotator cuff-specific exercises.

RESULTS

The peribursal tissue demonstrated the greatest blood flow, followed by the bone anchor site and tendon, in pre-exercise and postexercise states. Significantly less blood flow was observed in all regions of interest before exercise (P < .05) and only at the bone anchor site after exercise (P < .001) at latest follow-up compared with the 3-month values. Intratendinous blood flow remained relatively low at both evaluation points after surgical repair.

CONCLUSION

Preliminary findings suggest that the peribursal tissue and bone anchor site are the main conduits of blood flow for the rotator cuff tendon after arthroscopic repair, with the supraspinatus tendon being relatively avascular. Blood flow of the repaired rotator cuff tendon decreases with time. Furthermore, exercise significantly enhances blood flow to the repaired rotator cuff.

Demographic trends in arthroscopic SLAP repair in the United States

BACKGROUND

Treatment of superior labral anterior posterior (SLAP) tears remains controversial, particularly in older age groups. Repair, debridement, biceps tenodesis, tenotomy, and observation have been recommended depending on patient characteristics, but there have not been any large epidemiologic studies investigating treatment trends.

PURPOSE

To investigate current trends in SLAP repair across time, gender, age, and regions in the United States.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

Patients who underwent arthroscopic SLAP repair (Current Procedural Terminology [CPT] code 29807) were identified using a publicly available national database of insurance records (PearlDiver Patient Records Database) during years 2004 through 2009. Factors identified for each patient included gender, age group, and region in the United States. Logistic regression analysis and the chi-square test were used for statistical measures.

RESULTS

From 2004 to 2009 there were 25,574 cases of arthroscopic SLAP repair identified, of which 75% were male patients and 25% were female patients. There was a significant rise in cases of SLAP repair from 2004 to 2009 as the incidence of SLAP repair increased from 17.0 for every 10,000 patients with an orthopaedic International Classification of Diseases, Ninth Revision (ICD-9) or CPT code in 2004 to 28.1 in 2009 (P < .0001). Age analysis revealed the highest incidence in the 20-29-year (29.1 per 10,000) and 40-49-year (27.8 per 10,000) age groups. Men (37.3 per 10,000) had a significantly higher incidence of repairs than did women (10.7 per 10,000). The West (24.6 per 10,000) and South (24.4 per 10,000) regions also demonstrated a higher incidence than the Midwest (20.5 per 10,000) and Northeast (20.1 per 10,000) regions (P < .0001).

CONCLUSION

Our analysis illustrates that surgeons are performing significantly more arthroscopic SLAP repairs each year. The highest incidence of repair is in the 20-29- and 40-49-year age groups, and a significant gender difference exists, with men having a threefold higher incidence of repair.

Biologic augmentation of rotator cuff repair

Rotator cuff repair is a common orthopedic procedure. Despite advances in surgical technique, the rotator cuff tendons often fail to heal after surgery. In recent years, a number of biologic strategies have been developed and tested to augment healing after rotator cuff repair. These strategies include allograft, extracellular matrices (ECMs), platelet rich plasma (PRP), growth factors, stem cells, and gene therapy. This chapter reviews the most current research on biologic augmentation of rotator cuff repair using these methods.

Contrast-enhanced sonographic characterization of the vascularity of the repaired rotator cuff: utility of maximum intensity projection imaging

OBJECTIVES

To characterize the distribution of vascularity of the postoperative rotator cuff tendon using a maximum intensity projection technique after contrast-enhanced sonography.

METHODS

We retrospectively evaluated image data on 23 patients (11 male and 12 female) with intact rotator cuff repairs who had previously undergone contrast-enhanced sonography of their shoulders using lipid microspheres before and after a standardized exercise protocol. The patients were on average 3 months out from their surgery. Using offline image analysis software, a maximum intensity projection image was obtained for each patient, reflecting the regional vascular distribution within the repair and adjacent soft tissue. Subjective analysis was performed in 4 regions of interest: peribursal, articular medial, articular lateral, and suture anchor, independently by 2 musculoskeletal radiologists using a semiquantitative scale ranging from 0 to 4 for each region (0, no enhancement; 1, 1%-25% enhancement; 2, 26%-50%; 3, 51%-75%; and 4, 76%-100%). A combined vascularity score (0-8) was produced for each region and formed the basis for the subjective analysis.

RESULTS

Using a Mann-Whitney nonparametric test, the data showed significantly higher regional enhancement in the peribursal and suture anchor regions compared to the tendon (P < .001). Exercise resulted in a statistically significant increase in the extent of enhancement in all regions (P < .002). Inter-rater reliability analysis using a weighted κ statistic showed strong agreement (0.63-0.64) for the suture anchor site and moderate agreement for the others (peribursal, 0.35-0.39; articular medial, 0.45-0.55; and articular lateral 0.32-0.33).

CONCLUSIONS

The maximum intensity projection technique after contrast-enhanced sonography provides a topographic map of rotator cuff vascularity; the latter has been implicated as an important factor in promoting bone-tendon healing. Approximately 3 months after rotator cuff repair, the suture anchor and peribursal regions showed the most robust vascularity. Maximum intensity projection imaging further establishes that there is a global increase in vascular response at the repair site after exercise.

Vascularity of the supraspinatus tendon three months after repair: characterization using contrast-enhanced ultrasound

BACKGROUND

There has been limited in-vivo assessment of rotator cuff vascularity following repair. This study aims to characterize the vascularity of the shoulder 3 months following supraspinatus tendon repair.

METHODS

Twenty-nine patients (average age, 61.4 years) underwent Perflutren lipid microsphere contrast-enhanced shoulder ultrasound examinations 3 months after arthroscopic rotator cuff repair. Each shoulder was scanned at rest and following exercise using linear phased array 9-MHz transducer optimized to detect the contrast agent. Blood flow was quantified off-line using ultrasound imaging quantification and analysis software (QLAB, Philips, Andover, MA). Peak enhancement (vascular volume) and rate of rise (perfusion) were determined for 3 regions of interest: peribursal area, supraspinatus tendon, and anchor site.

RESULTS

Peak enhancement and rate of rise were greatest in the peribursal soft tissue and anchor site. Resting peak enhancement and rate of rise were significantly lower within the tendon compared to the other 2 regions (P < .001). Exercise resulted in increased enhancement and rate-of-rise to all 3 regions, but had a significant predilection towards increasing vascular volume within the peri-bursal region (P = .026).

CONCLUSION

At 3 months following repair, the majority of blood flow to the repair is derived from the peribursal soft tissues and the anchor site. The tendon, particularly those with a defect at 3 months, is relatively avascular. Though limited by inclusion of only a single time point, this study introduces a new technique to quantify vascularity following supraspinatus repairs and suggests that the surrounding vascular milieu may play a role in tendon healing.

LEVEL OF EVIDENCE

Basic Science.

Nonoperative treatment for proximal avulsion of the rectus femoris in professional American football

BACKGROUND

Avulsion of the rectus femoris origin is a rare injury. The only previous report of this injury in professional American football has been limited to the kicking athlete.

PURPOSE

To describe the incidence and treatment of proximal rectus femoris avulsion in the National Football League (NFL).

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

The NFL Injury Surveillance System (NFLISS) was reviewed for any proximal rectus femoris avulsion injuries from 1986 to 2006, including the type and mechanism of injury, player demographics, method of treatment, and time to return to play. The NFL team physicians and trainers were surveyed as to their experience with these injuries as well.

RESULTS

A total of 11 cases of proximal rectus femoris avulsion were identified starting in 1997. These injuries occurred in athletes in a variety of positions. All of these were treated nonoperatively, and the mean return to play was 69.2 days.

CONCLUSION

Rectus femoris avulsions are uncommon injuries in the NFL, occurring about once a year in the entire league (once magnetic resonance imaging facilitated correct diagnosis of these injuries). Conservative treatment of these injuries usually results in return to play after 6 to 12 weeks.

CLINICAL RELEVANCE

Proximal avulsions of the rectus femoris can be treated nonoperatively with a high degree of predictability for return to full, unrestricted participation in professional American football.

Effect of turf toe on foot contact pressures in professional American football players

BACKGROUND

The relationship between turf toe and plantar foot pressures has not been extensively studied. Two hypotheses were tested in a cohort of professional American football players: first, that a history of turf toe is associated with increased peak hallucal and first metatarsophalangeal (MTP) plantar pressures; second, that decreased range of motion (ROM) of the first MTP correlates with increased peak hallucal and first MTP plantar pressures.

MATERIALS AND METHODS

Forty-four athletes from one National Football League (NFL) team were screened for a history of turf toe during preseason training. Dorsal passive MTP ROM and dynamic plantar pressures were measured in both feet of each player. Anatomical masking was used to assess peak pressure at the first MTP and hallux.

RESULTS

First MTP dorsiflexion was significantly lower in halluces with a history of turf toe (40.6 +/- 15.1 degrees versus 48.4 +/- 12.8 degrees, p = 0.04). Peak hallucal pressures were higher in athletes with turf toe (535 +/- 288 kPa versus 414 +/- 202 kPa, p = 0.05) even after normalizing for athlete body mass index (p = 0.0003). Peak MTP pressure was not significantly different between the two groups tested. First MTP dorsiflexion did not correlate with peak hallucal or first MTP pressures.

CONCLUSION

This study showed that turf toe is associated with decreased MTP motion. In addition, increased peak hallucal pressures were found. Further study is warranted to determine whether these pressures correlate with the severity of symptoms or progression of turf toe to first MTP arthritis.

Articular cartilage repair using a resorbable matrix scaffold

The creation of cartilage repair tissue relies on the implantation or neosynthesis of cartilage matrix elements. One cartilage repair strategy involves the implantation of bioabsorbable matrices that immediately fill a chondral or osteochondral defect. Such matrices support the local migration of chondrogenic or osteogenic cells that ultimately synthesize new ground substance. One such matrix scaffold, a synthetic resorbable biphasic implant (TruFit Plug; Smith & Nephew, San Antonio, TX), is a promising device for the treatment of osteochondral voids. The implant is intended to serve as a scaffold for native marrow elements and matrix ingrowth in chondral defect repair. The device is a resorbable tissue regeneration scaffold made predominantly from polylactide-coglycolide copolymer, calcium sulfate, and polyglycolide. It is approved in Europe for the treatment of acute focal articular cartilage or osteochondral defects but is approved by the US Food and Drug Administration only for backfill of osteochondral autograft sites. Preclinical studies demonstrated restoration of hyaline-like cartilage in a goat model with subchondral bony incorporation at 12 months. Early clinical results of patients enrolled in the Hospital for Special Surgery Cartilage Registry have been favorable, with a good safety profile.

Kidney injuries in professional American football: implications for management of an athlete with 1 functioning kidney

BACKGROUND

The frequency and severity of kidney injuries and their impact on return to play in American football has not been described in the literature.

PURPOSE

Our objective is to identify the number of kidney injuries in the National Football League (NFL) and the effect of these injuries.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

All kidney injuries in the NFL from 1986 to 2004 were reviewed, including the type and mechanism of injury, treatment, and time to return to play. In addition, NFL physicians and athletic trainers were asked if they were aware of any football player at the professional, collegiate, or high school levels who had lost a kidney and how they would advise a football player with only 1 functioning kidney.

RESULTS

A total of 52 cases of renal injuries were identified, an average of 2.7 cases per season. The rate of kidney injury was 10 times greater during games (0.000055 per exposure) than practices (0.000005 per exposure) (P < .0001). The most common injury was kidney contusion (42), followed by kidney laceration (6) and kidney stones and dysfunction (2 each). Almost all the injuries were contact related (49). More than a third of the players required hospitalization for their injury (18), although none required surgery. All the athletes returned to play. The most days missed were after a kidney laceration (mean, 59.8), followed by kidney contusion (15.1) and dysfunction (14.0). While 61% of respondents would allow a professional athlete with only 1 kidney to play, approximately 50% would advise a college athlete with only 1 functioning kidney not to play football, and 60% would advise a similar high school athlete not to play.

CONCLUSION

Renal trauma is a rare but potentially debilitating injury in the NFL, with players at greater risk during games. Most players recover to play, but it may take some time, especially with a kidney laceration. It may be safe for players with only 1 functioning kidney to play in the NFL.

Health-related quality of life outcomes improve after multilevel surgery in ambulatory children with cerebral palsy

BACKGROUND

Studies evaluating multilevel surgery to treat spastic deformity and functional deficits in cerebral palsy (CP) usually focus on data from instrumented gait analysis and clinical examination without examining functional and health-related quality of life (HRQOL) outcomes. Recently, outcome measures for well-being in children with a variety of musculoskeletal disorders have also been validated specifically for CP. Therefore, this study aimed to investigate the impact of multilevel surgery on the function and HRQOL in a group of ambulatory children with CP.

METHODS

In a multicenter prospective trial, 57 ambulatory children with CP, mean age 9.5 years, underwent multilevel soft tissue surgery to correct sagittal imbalance. Validated clinical outcome measures for HRQOL were administered preoperatively and postoperatively with an average follow-up time of 15.2 months. The functional and psychosocial components of the Pediatric Outcomes Data Collection Instrument (PODCI), Pediatric Quality of Life Questionnaire (PedsQL), and the Functional Assessment Questionnaire Walking Score were used.

RESULTS

Significant improvements in outcome scores occurred postoperatively in the following: PedsQL parent-total (17.6%; P < 0.001) and parent-physical sections (25.0%; P < 0.001), the Functional Assessment Questionnaire Walking Score (15.3%; P < 0.001), and the PODCI sections for transfers and basic mobility (15.8%; P < 0.001), sports and physical function (23.9%; P = 0.012), and global (12.9%; P < 0.001). Improvements also occurred in the PedsQL child-total (8.4%; P = 0.104) and child-physical sections (8.6%; P = 0.189), but these were not statistically significant. There were no significant changes in the PODCI parent-derived pain (-3.2%; P = 0.504) and happiness sections (1.9%; P = 0.645).

CONCLUSIONS

Multilevel surgery in ambulatory patients with CP improves function and HRQOL. However, improved functional well-being does not imply improved psychosocial well-being, and patients and their families should be counseled accordingly.

Tracking expression of virally mediated BMP-2 in gene therapy for bone repair

Ex vivo gene therapy using stem cells transduced with viral vectors is a useful method for delivering a therapeutic protein to augment bone repair in animal models. However, the duration of cell-mediated protein production and the fate of the transduced cells are unknown. We constructed an adenoviral vector encoding Myc epitope tagged bone morphogenetic protein (BMP)-2 gene (AdBMP-2). Rat bone marrow cells transduced with this vector produced biologically active BMP-2 protein, which was confirmed by Western blot analysis and alkaline phosphatase assay. Implantation of bone marrow cells infected ex vivo with AdBMP-2 caused orthotopic bone formation in mouse hindlimbs and bony union of critical-sized mouse radial defects. Immunohistochemical analysis revealed that rBMCs expressed Myc epitope-tagged BMP-2 protein for 14 days in vivo and became incorporated in the endochondral fracture callus. This novel adenovirus encoding for epitope-tagged BMP-2 can be used for immunohistochemical tracking of transduced cells in ex vivo gene therapy for bone repair.

Overexpression of noggin inhibits BMP-mediated growth of osteolytic prostate cancer lesions

INTRODUCTION

Although a majority of metastatic prostate cancer lesions are osteoblastic in nature, some are mixed or lytic; and, osteoblastic lesions require osteolytic activity in order to progress. The role of BMPs in the formation of prostate cancer metastases to bone remains unknown. We hypothesized that BMPs influence the development and progression of osteolytic prostate cancer lesions.

METHODS

RT-PCR and Western blot analysis were used to determine BMP receptor expression on the osteolytic prostate cancer cell line PC-3. Migration, invasion, and cellular proliferation assays were performed on PC-3 cells to quantify the effects of BMP-2, -4, and -7. In vivo, PC-3 cells were injected alone, with an empty retroviral vector, or with a retroviral vector overexpressing noggin, into the tibias of SCID mice. The animals were followed for 8 weeks, and histologic and radiographic analysis were performed at 2, 4, 6, and 8 weeks.

RESULTS

BMP receptors are expressed on PC-3 cells, suggesting that they would be responsive to host BMP secretion. BMP-2, and to a lesser extent, BMP-4, stimulated PC-3 cell migration and invasion in a dose-dependent fashion. Noggin inhibited cellular migration and invasion of BMP-2 and -4 stimulated PC-3 cells. BMP-2 alone stimulated PC-3 cell proliferation, but BMP-4 had no effect. BMP-7 had no effect on proliferation, migration, or invasion. PC-3 cells implanted into SCID mouse tibias formed osteolytic lesions as early as 2 weeks and completely destroyed the proximal tibia by 8 weeks. Overexpression of noggin in PC-3 cells inhibited the expansion of the lesion in vivo.

CONCLUSIONS

BMPs influence the formation of the osteolytic prostate cancer metastases, and treatment modalities that inhibit BMP activity may limit the progression of the lytic component of prostate cancer metastases.

Influence of BMPs on the formation of osteoblastic lesions in metastatic prostate cancer

The purpose of this study was to evaluate the role of BMPs on the formation of metastatic prostate cancer lesions to bone. Our results show that BMPs influence the development and progression of osteoblastic lesions and suggest that therapies that inhibit BMP activity may reduce the formation and progression of osteoblastic lesions.

INTRODUCTION

Prostate adenocarcinoma is the leading cause of cancer in North American men. The formation of skeletal metastases affects approximately 70% of patients with advanced disease, and a majority of these patients have osteoblastic lesions. Although BMPs have been found to be expressed in multiple oncogenic cell lines, their role in the formation of metastatic osteoblastic lesions remains uncharacterized. We hypothesized that BMPs influence the development of metastatic osteoblastic lesions associated with prostate cancer.

MATERIALS AND METHODS

Western blot analysis and RT-PCR was used to determine BMP receptor expression on osteoblastic prostate cancer cell lines LAPC-4 and LAPC-9. Migration, invasion, and cellular proliferation assays were used to quantify the effects of BMP-2, -4, and -7 on LAPC-4 cells in vitro. LAPC-9 cells alone or transfected with a retrovirus overexpressing noggin were injected into the tibias of SCID mice, and the animals were followed for 8 weeks. Tumor size was determined by radiographs and direct measurement. Histology was performed at the time of death.

RESULTS

We determined that BMP receptor mRNA and protein was expressed on osteoblastic prostate cancer cell lines LAPC-4 and LAPC-9. In vitro studies showed that BMP-2 and -7 stimulated cellular migration and invasion of prostate cancer cells in a dose-dependent fashion, although BMP-4 had no effect. Noggin inhibited cellular migration and invasion of BMP-2- and -7-stimulated LAPC-4 cells. LAPC-9 cells implanted into immunodeficient mouse tibias formed an osteoblastic lesion with sclerotic bone at 8 weeks. Formation of osteoblastic lesions was inhibited by overexpression of noggin by prostate cancer cells transduced with a retrovirus containing the cDNA for noggin.

CONCLUSIONS

BMPs are critical in the formation of the osteoblastic lesions associated with prostate cancer metastases, and future treatment strategies that inhibit local BMP activity may reduce the formation and progression of osteoblastic lesions.