Describing the women of orthopaedic surgery

Aims

The purpose of this survey study was to examine the demographic and lifestyle factors of women currently in orthopaedic surgery.

Methods

An electronic survey was conducted of practising female orthopaedic surgeons based in the USA through both the Ruth Jackson Society and the online Facebook group "Women of Orthopaedics".

Results

The majority of surveyed female orthopaedic surgeons reported being married (76.4%; 285/373) and having children (67.6%; 252/373). In all, 66.5% (247/373) were collegiate athletes; 82.0% (306/373) reported having no female orthopaedic surgeon mentors in undergraduate and medical school. Their mean height is 65.8 inches and average weight is 147.3 lbs.

Conclusion

The majority of female orthopaedic surgeons did not have female mentorship during their training. Additionally, biometrically, their build is similar to that of the average American woman.

Engineering a human P2X2 receptor with altered ligand selectivity in yeast

P2X receptors are a family of ligand gated ion channels found in a range of eukaryotic species including humans but are not naturally present in the yeast Saccharomyces cerevisiae. We demonstrate the first recombinant expression and functional gating of the P2X2 receptor in baker's yeast. We leverage the yeast host for facile genetic screens of mutant P2X2 by performing site saturation mutagenesis at residues of interest, including SNPs implicated in deafness and at residues involved in native binding. Deep mutational analysis and rounds of genetic engineering yield mutant P2X2 F303Y A304W, which has altered ligand selectivity toward the ATP analog AMP-PNP. The F303Y A304W variant shows over 100-fold increased intracellular calcium amplitudes with AMP-PNP compared to the WT receptor and has a much lower desensitization rate. Since AMP-PNP does not naturally activate P2X receptors, the F303Y A304W P2X2 may be a starting point for downstream applications in chemogenetic cellular control. Interestingly, the A304W mutation selectively destabilizes the desensitized state, which may provide a mechanistic basis for receptor opening with suboptimal agonists. The yeast system represents an inexpensive, scalable platform for ion channel characterization and engineering by circumventing the more expensive and time-consuming methodologies involving mammalian hosts.

Telerehabilitation to Address the Rehabilitation Gap in Anterior Cruciate Ligament Care: Survey of Physical Therapists/Care Providers

Background

While the importance of structured rehabilitation following anterior cruciate ligament reconstruction (ACLR), particularly in the return-to-sport phase, is known, for most patients, supervised physical therapy is often completed before this time point. The recent emergence of telerehabilitation and other digital health interventions has the potential to address this "rehabilitation gap."

Methods

The study was conducted as a cross-section, online survey collecting qualitative and quantitative data from open and closed questions. Inclusion criteria included local qualified physical therapists or other professionals working with ACLR patients.

Results

Eighty-three percent of respondents experienced a "rehabilitation gap" with their ACLR patients. Few reported currently utilizing apps or websites (9.74%). The majority (41/58) reported experience with telerehabilitation, and 84% felt that there was a role for digital rehabilitation strategies to address the "rehabilitation gap." The vast majority (94.74%) of participants felt that standard commercial insurance did not permit sufficient rehabilitation.

Discussion

While the majority of our respondents acknowledged the existence of a "rehabilitation gap," as well as familiarity with and confidence in telerehabilitation, few were using this technique at the time of our survey. This suggests an opportunity for development in this space.

Changes in Body Composition and Athletic Performance in National Collegiate Athletic Association Division I Female Field Hockey Athletes Throughout a Competitive Season

ABSTRACT

Summer, LC, Cheng, R, Moran, JT, Lee, M, Belanger, AJ, TaylorIV, WL, and Gardner, EC. Changes in body composition and athletic performance in National Collegiate Athletic Association Division I female field hockey athletes throughout a competitive season. J Strength Cond Res 38(1): 146-152, 2024-The purposes of this study were (a) to analyze the changes in total and regional body composition measurements in a National Collegiate Athletic Association (NCAA) Division I female field hockey team throughout a 17-game competitive season using dual X-ray absorptiometry (DXA); (b) to examine improvements, if any, in athletic performance measures after a season; and (c) to report on the relationship between these body composition changes and changes in athletic performance. Preseason and postseason dual-energy DXA and performance data from the 2019-2020 season were retrospectively identified for 20 field players (forwards, midfielders, and defenders). Body composition data included total and regional fat mass, lean mass, and body fat percentage, whereas athletic performance measures included the vertical jump, 10-yard dash, and pro-agility (5-10-5) shuttle run. All variables were quantitative and analyzed using paired t -tests or its nonparametric equivalent and an alpha level of p < 0.05 was used to determine significance. After a competitive season, athletes had significant decreases in fat mass and increases in lean mass in their arms, legs, trunks, gynoids, and total body measurements. Android fat mass and body fat percentage also decreased. Athletes performed significantly better on the pro-agility shuttle run at the end of the season, but no significant differences were observed in other performance metrics. Moderate correlations were observed between changes in body composition (total fat mass and total lean mass) and changes in athletic performance. Our study provides a novel, longitudinal assessment of body composition and athletic performance for elite female field hockey athletes that will help trainers and coaches better understand how these variables change throughout a season and allow them to better prepare their players for competitive success.

SARS-COV-2 Omicron variants conformationally escape a rare quaternary antibody binding mode

The ongoing evolution of SARS-CoV-2 into more easily transmissible and infectious variants has provided unprecedented insight into mutations enabling immune escape. Understanding how these mutations affect the dynamics of antibody-antigen interactions is crucial to the development of broadly protective antibodies and vaccines. Here we report the characterization of a potent neutralizing antibody (N3-1) identified from a COVID-19 patient during the first disease wave. Cryogenic electron microscopy revealed a quaternary binding mode that enables direct interactions with all three receptor-binding domains of the spike protein trimer, resulting in extraordinary avidity and potent neutralization of all major variants of concern until the emergence of Omicron. Structure-based rational design of N3-1 mutants improved binding to all Omicron variants but only partially restored neutralization of the conformationally distinct Omicron BA.1. This study provides new insights into immune evasion through changes in spike protein dynamics and highlights considerations for future conformationally biased multivalent vaccine designs.

Orthopaedic Injury Patterns Related to Ice Skating, Inline Skating, and Roller Skating: A 20-Year Epidemiologic Analysis

Background

Ice skating, inline skating, and roller skating are popular sports in the United States (US). Although they are similar, injuries incurred may be distinct and may have evolved over time.

Purpose

To characterize injuries related to ice skating, inline skating, and roller skating and track injury patterns over a 20-year period.

Study Design

Descriptive epidemiology study.

Methods

The current study utilized the National Electronic Injury Surveillance System, a database reporting consumer product-related injuries seen at emergency departments in the US. All ice skating, inline skating, and roller skating injuries between 2002 and 2021 were identified, and patient demographics, types of injury, and year of injury were compared between skating types.

Results

A total of 1,656,746 skating-related injuries were estimated nationally: 24% (403,791) for ice skating, 24% (400,172) for inline skating, and 52% (852,783) for roller skating. While the incidence of ice-skating- and roller-skating-related injuries decreased by 34.4% (from 22,490 in 2002-2004 to 14,758 in 2019-2021) and 29.6% (from 42,452 in 2002-2004 to 31,980 in 2019-2021), respectively, injuries related to inline skating decreased comparatively more, by 75.8% over the study period (from 48,097 in 2002-2004 to 11,662 in 2019-2021). Injuries occurred predominantly to the head/face/neck for ice skating (n = 139,501; 34.5% of injuries), whereas injuries occurred predominantly in the shoulder/arm/elbow/wrist for inline skating (n = 212,088, 53.0% of injuries) and roller skating (n = 425,216, 49.9% of injuries). Fracture was the most common injury type for all 3 skating types (n = 614,853, 37.1% of injuries), and the majority of fractures occurred in the upper extremity (shoulder/arm/elbow/wrist) for all 3 skating types (n = 59,624, 60.0% [ice skating]; n = 69,197, 41.2% [inline skating], and n = 237,099, 68.2% [roller skating]). Lower extremity (leg/knee/ankle) fractures were more common among ice skating (n = 28,019, 28.2%) and roller skating (n = 82,094, 23.6%) injuries compared with inline skating (n = 21,391, 12.7%).

Conclusion

In the current study, we found that fractures were the most common type of injury regardless of skating type but that the location of the injury/fracture varied by skating type.

Previous Isolated Medial Bucket-Handle Meniscus Repair Significantly Increases Risk of Subsequent Ipsilateral Anterior Cruciate Ligament Reconstruction

Purpose

(1) To define the incidence of surgically treated isolated bucket-handle meniscus tears (BHMTs); (2) to investigate risk of subsequent ipsilateral anterior cruciate ligament reconstruction (ACLR) in patients who underwent previous isolated bucket handle (BH) meniscus repair; and (3) to investigate the risk of subsequent ACLR for various types of surgically treated meniscal tears.

Methods

A retrospective review of a national database was conducted to identify patients, aged 10 to 40 years, who underwent primary isolated BH meniscus surgery from 2015 to 2020. Patients were stratified by operative method. A control group of 500,000 age-matched patients was randomly selected to establish a benchmark rate of ACLR. Kaplan-Meier analysis was performed to compare the timing and incidence of subsequent ipsilateral ACLR after primary isolated BH meniscus surgery to the control group within 2 and 5 years.

Results

In total, 1,767 patients with isolated BHMTs treated with surgery were identified and met inclusion criteria. The incidence of isolated BHMTs among all surgically treated (repair or meniscectomy) meniscal injuries was 1.67%. Isolated BH repairs had significantly greater odds of ACLR within 5 years compared to the control group (odds ratio [OR] 6.09; 95% confidence interval [CI] 2.86-12.99; P < .001). Medial BH repairs had the greatest odds of ACLR within 5 years (OR 9.15; 95% CI 4.27-19.57; P < .001). Lateral BH repair was not associated with subsequent ipsilateral ACLR within 5 years (OR 2.63; CI 0.37-18.90; P = .340).

Conclusions

Isolated BHMTs comprised 1.67% of all surgically treated meniscal injuries. Patients who underwent prior surgery for isolated BHMT were at increased risk of undergoing subsequent ipsilateral ACLR compared with the general population. Isolated medial BHMTs treated with repair had the highest risk for subsequent ACLR.

Level of Evidence

Level III, retrospective cohort study.

An Epidemiological Study of Cell Phone–Related Injuries of the Hand and Wrist Reported in United States Emergency Departments From 2011 to 2020

Purpose

Increasing ownership and use of mobile phones has been recently linked to reports of hand and wrist pain from overuse, as well as more serious injuries related to distracted behaviors, such as falls and texting while driving. We describe the epidemiology of hand and wrist injuries presenting to US emergency departments from 2011 to 2020, which were associated with cell phone use using the Consumer Product Safety Commission's National Electronic Injury Surveillance System.

Methods

The National Electronic Injury Surveillance System database was queried for treatment records from 2011 through to 2020 for all cell phone-related injuries of the lower arm, wrist, hand, and fingers. Using parameters provided by the National Electronic Injury Surveillance System database, there were 1,213 unique cases, yielding a total weighted estimate of 50,487 national cases presenting to emergency departments in the United States.

Results

Between 2011 and 2020, the weighted estimate of annual cell phone-related injuries ranged from 3,389 to 7,320 cases. Falls were the most common cause of injury, accounting for 29.8% of estimated cases. The most common types of injuries were lacerations (22.3%). The national estimate of cell phone-related injury was the highest in the age range of 11-20 years (26.4%), followed by 21-30 years (22.2%). Women were affected more frequently than men (59.6% vs 40.4%).

Conclusions

Upper extremity injuries related to cell phone use represent an increasing burden of disease to the US healthcare system. Raising awareness regarding cell phone-related injuries and in-home fall-prevention strategies, especially among elderly individuals, should be considered as means of decreasing the number of such injuries. Strategies for decreasing the burden of cell phone-related injuries occurring as a result of falls among teenagers and young adults should focus on minimizing distractions while using a cell phone. Limitations of the study include inaccuracies related to probability-weighted case estimation and limitations in reporting injuries.

Clinical relevance

Knowledge of the burden of upper extremities injuries associated with this common handheld device can help to both raise awareness of this issue, as well as to potentially inform injury-prevention strategies.

Patient Demographic and Socioeconomic Factors Associated With Physical Therapy Utilization After Uncomplicated Meniscectomy

INTRODUCTION

The extent to which physical therapy (PT) is used after meniscectomy is unknown. The objective of this study was to estimate the extent to which PT is implemented after meniscectomy and to identify factors associated with its utilization.

METHODS

The Mariner PearlDiver database was queried to identify patients who underwent uncomplicated meniscectomy. The number of PT visits for each patient was tabulated. Logistic regressions were used to compare demographic factors associated with no use of PT and use of nine or more PT visits.

RESULTS

In total, 92,291 patients met inclusion criteria. Of these patients, 72.21% did not use PT and 27.8% used 1 or more PT visits. Of the patients who used PT, 19.76% had 1 to 8 PT visits and 8.03% had 9 or more PT visits. Older age and noncommercial insurance types were associated with no PT use. Male sex, Medicaid, and Medicare were associated with markedly lower odds of increased PT utilization.

CONCLUSION

PT is used in the minority of the time after meniscectomy. Among patients who do use PT, however, notable variation exists in the amount of PT visits used. Patient age, sex, insurance status, and geographic variables were independently associated with PT utilization.

Functional expression of opioid receptors and other human GPCRs in yeast engineered to produce human sterols

The yeast Saccharomyces cerevisiae is powerful for studying human G protein-coupled receptors as they can be coupled to its mating pathway. However, some receptors, including the mu opioid receptor, are non-functional, which may be due to the presence of the fungal sterol ergosterol instead of cholesterol. Here we engineer yeast to produce cholesterol and introduce diverse mu, delta, and kappa opioid receptors to create sensitive opioid biosensors that recapitulate agonist binding profiles and antagonist inhibition. Additionally, human mu opioid receptor variants, including those with clinical relevance, largely display expected phenotypes. By testing mu opioid receptor-based biosensors with systematically adjusted cholesterol biosynthetic intermediates, we relate sterol profiles to biosensor sensitivity. Finally, we apply sterol-modified backgrounds to other human receptors revealing sterol influence in SSTR5, 5-HTR4, FPR1, and NPY1R signaling. This work provides a platform for generating human G protein-coupled receptor-based biosensors, facilitating receptor deorphanization and high-throughput screening of receptors and effectors.

Epidemiology of Sports-Related Traumatic Hip Dislocations Reported in United States Emergency Departments, 2010-2019

Background:

Traumatic hip dislocations are rare injuries that most commonly occur in motor vehicle accidents. There is a paucity of literature that describes sports-related hip dislocations.

Purpose:

To estimate the incidence of sports-related hip dislocations and determine any sport- or sex-related epidemiological trends using the National Electronic Injury Surveillance System (NEISS) database.

Study Design:

Descriptive epidemiology study.

Methods:

Data regarding sports-related hip dislocations from 2010 to 2019 were retrieved from the NEISS, a database that catalogs injury information during emergency department visits from 100 hospitals across the United States to produce nationwide estimates of the injury burden. The estimated number of injuries was calculated using weights assigned by the NEISS database. The injuries were then stratified by sport and sex to determine any epidemiological patterns.

Results:

A total of 102 hip dislocation injuries were identified over the surveyed 10 years, indicating 2941 estimated injuries nationwide. Overall, 10 (9.8%) of 102 sports-related hip dislocations presented with concomitant acetabular fractures, representing an estimated 288 injuries nationally over 10 years. Male athletes sustained more sports-related hip dislocations than female athletes, with a relative incidence of 12.51 (P < .001). Adolescents aged 15 to 19 years recorded the highest number of hip dislocations. There were 17 sports identified as having caused at least 1 hip dislocation over the 10-year period. More hip dislocation injuries were sustained from contact sports (91.2%) than noncontact sports (8.8%) (P < .001). Football (estimated 164 injuries per year; 55.6%), snowboarding (28 per year; 9.5%), skiing (26 per year; 8.8%), and basketball (21 per year; 7.1%) had the highest rates of hip dislocation. Additionally, 43 (82.7%) football-related injuries were caused by tackling mechanisms, and 9 (17.3%) were caused by nontackling mechanisms (P < .001).

Conclusion:

The incidence of traumatic sports-related hip dislocations was extremely low in the United States during the study period. Male adolescents, aged 15 to 19 years, sustained the greatest number of injuries during football. Significantly more hip dislocations occurred in contact sports, most commonly football, snowboarding, skiing, and basketball, compared with noncontact sports. As adolescent athletes may have limited treatment options if osteonecrosis occurs, these data serve to increase the clinical awareness of these injuries.

Orthogonal control of gene expression in plants using synthetic promoters and CRISPR-based transcription factors

BACKGROUND

The construction and application of synthetic genetic circuits is frequently improved if gene expression can be orthogonally controlled, relative to the host. In plants, orthogonality can be achieved via the use of CRISPR-based transcription factors that are programmed to act on natural or synthetic promoters. The construction of complex gene circuits can require multiple, orthogonal regulatory interactions, and this in turn requires that the full programmability of CRISPR elements be adapted to non-natural and non-standard promoters that have few constraints on their design. Therefore, we have developed synthetic promoter elements in which regions upstream of the minimal 35S CaMV promoter are designed from scratch to interact via programmed gRNAs with dCas9 fusions that allow activation of gene expression.

RESULTS

A panel of three, mutually orthogonal promoters that can be acted on by artificial gRNAs bound by CRISPR regulators were designed. Guide RNA expression targeting these promoters was in turn controlled by either Pol III (U6) or ethylene-inducible Pol II promoters, implementing for the first time a fully artificial Orthogonal Control System (OCS). Following demonstration of the complete orthogonality of the designs, the OCS was tied to cellular metabolism by putting gRNA expression under the control of an endogenous plant signaling molecule, ethylene. The ability to form complex circuitry was demonstrated via the ethylene-driven, ratiometric expression of fluorescent proteins in single plants.

CONCLUSIONS

The design of synthetic promoters is highly generalizable to large tracts of sequence space, allowing Orthogonal Control Systems of increasing complexity to potentially be generated at will. The ability to tie in several different basal features of plant molecular biology (Pol II and Pol III promoters, ethylene regulation) to the OCS demonstrates multiple opportunities for engineering at the system level. Moreover, given the fungibility of the core 35S CaMV promoter elements, the derived synthetic promoters can potentially be utilized across a variety of plant species.

Rapid characterization of spike variants via mammalian cell surface display

The SARS-CoV-2 spike protein is a critical component of vaccines and a target for neutralizing monoclonal antibodies (nAbs). Spike is also undergoing immunogenic selection with variants that increase infectivity and partially escape convalescent plasma. Here, we describe Spike Display, a high-throughput platform to rapidly characterize glycosylated spike ectodomains across multiple coronavirus-family proteins. We assayed ∼200 variant SARS-CoV-2 spikes for their expression, ACE2 binding, and recognition by 13 nAbs. An alanine scan of all five N-terminal domain (NTD) loops highlights a public epitope in the N1, N3, and N5 loops recognized by most NTD-binding nAbs. NTD mutations in variants of concern B.1.1.7 (alpha), B.1.351 (beta), B.1.1.28 (gamma), B.1.427/B.1.429 (epsilon), and B.1.617.2 (delta) impact spike expression and escape most NTD-targeting nAbs. Finally, B.1.351 and B.1.1.28 completely escape a potent ACE2 mimic. We anticipate that Spike Display will accelerate antigen design, deep scanning mutagenesis, and antibody epitope mapping for SARS-CoV-2 and other emerging viral threats.

Resistance Training as Treatment for Sarcopenia: Examining Sex-Related Differences in Physiology and Response

Sarcopenia or muscle mass atrophy reportedly occurs in up to 50% of those aged >80 years and is a significant risk factor for functional disability and poor physical performance. Over time, the deterioration in both skeletal muscle quality and composition may compromise functional independence and has been shown to independently increase the risk for falls, fractures, and overall poor health in the elderly population. These are seen most obviously in older women. Given these serious consequences, much effort has been directed toward promoting increased activity and resistance training for muscle maintenance or even muscle regeneration in older adults. The Centers for Disease Control and Prevention states that for all adults ≥65 years of age, weekly aerobic and strength training are vital to healthy aging. Older patients who have not previously participated in strength training may be hesitant about starting a resistance training program and resort to simple and familiar aerobic exercise options such as walking, jogging, or cycling. However, the benefits of strength training are too important to miss: it can improve skeletal muscle metabolic capacity, mitigate effects of aging on functional capacity, maintain bone density, and, most importantly, help individuals maintain a higher quality of life and independence. Due to their increased risk of disability and injury, this opportunity for "exercise as medicine" is particularly important to women and must be encouraged by clinicians. As such, the purpose of this commentary was to highlight known sex-related differences in muscle metabolism and potential benefits of resistance training for elderly patients. A comprehensive understanding of the issues and prevention measures presented here may allow clinicians to better serve their patients, especially older female patients, and, ultimately, alleviate the burden placed on our society by our rapidly aging population.

Coronal Malalignment-When and How to Perform a Tibial Tubercle Osteotomy

Coronal malalignment of the patellofemoral joint may contribute to both instability as well as pain and joint overload. The use of distal realignment procedures has evolved to include uniplanar and multiplanar osteotomies, which allows patient-specific treatment. With a careful understanding of the complex pathoanatomy, including osseous, soft tissue, and dynamic muscular factors, an appropriately designed tibial tubercle osteotomy (TTO) is an invaluable tool for the orthopedic surgeon to improve joint biomechanics and off-load articular injuries. Current techniques have improved TTO surgery to limit complications and produce reliably good results.

Synthetic repertoires derived from convalescent COVID-19 patients enable discovery of SARS-CoV-2 neutralizing antibodies and a novel quaternary binding modality

The ongoing evolution of SARS-CoV-2 into more easily transmissible and infectious variants has sparked concern over the continued effectiveness of existing therapeutic antibodies and vaccines. Hence, together with increased genomic surveillance, methods to rapidly develop and assess effective interventions are critically needed. Here we report the discovery of SARS-CoV-2 neutralizing antibodies isolated from COVID-19 patients using a high-throughput platform. Antibodies were identified from unpaired donor B-cell and serum repertoires using yeast surface display, proteomics, and public light chain screening. Cryo-EM and functional characterization of the antibodies identified N3-1, an antibody that binds avidly (Kd,app = 68 pM) to the receptor binding domain (RBD) of the spike protein and robustly neutralizes the virus in vitro. This antibody likely binds all three RBDs of the trimeric spike protein with a single IgG. Importantly, N3-1 equivalently binds spike proteins from emerging SARS-CoV-2 variants of concern, neutralizes UK variant B.1.1.7, and binds SARS-CoV spike with nanomolar affinity. Taken together, the strategies described herein will prove broadly applicable in interrogating adaptive immunity and developing rapid response biological countermeasures to emerging pathogens.

Temporal Utilization of Physical Therapy Visits After Anterior Cruciate Ligament Reconstruction

Background:

Physical therapy (PT) rehabilitation is critical to successful outcomes after anterior cruciate ligament reconstruction (ACLR). Later-stage rehabilitation, including sport-specific exercises, is increasingly recognized for restoring high-level knee function. However, supervised PT visits have historically been concentrated during the early stages of recovery after ACLR.

Purpose/Hypothesis:

To assess the number and temporal utilization of PT visits after ACLR in a national cohort. We hypothesized that PT visits would be concentrated early in the postoperative period.

Study Design:

Descriptive epidemiological study.

Methods:

The Humana PearlDiver database was searched to identify patients who underwent ACLR between 2007 and 2017. Patients with additional structures treated were excluded. The mean ± SD, median and interquartile range (IQR), and range of number of PT visits for each patient were determined for the 52 weeks after ACLR. PT visits over time were also assessed in relation to patient age and sex.

Results:

In total, 11,518 patients who underwent ACLR met the inclusion criteria; the mean age was 32.62 ± 13.70 years, and 42.7% were female patients. Of this study cohort, 10,381 (90.4%) had documented PT postoperatively; the range of PT visits was 0 to 121. On average, patients had 16.90 ± 10.60 PT visits (median [IQR], 16 [9-22]) after ACLR. Patients completed a mean of 52% of their PT visits in the first 6 weeks, 75% in the first 10 weeks, and 90% in the first 16 weeks after surgery. Patients aged 10 to 19 years had the highest number of PT visits (mean ± SD, 19.67 ± 12.09; median [IQR], 18 [12-25]), significantly greater than other age groups (P < .001).

Conclusion:

PT after ACLR is concentrated in the early postoperative period. Physicians, therapists, and patients may consider adjusting the limited access to PT to optimize patient recovery.

Clinical Relevance:

As supervised PT visits may be limited, the appropriate temporal utilization of supervised PT visits must be maximized. Strategies to ensure sessions for later neuromuscular and activity-specific rehabilitation are needed.

Sex- and Sports-Specific Epidemiology of Traumatic Lumbar Spine Injuries Sustained During Sporting Activities: Male Snowboarders and Female Horseback Riders at Greatest Risk

Purpose

To generate national estimates of sports-related traumatic lumbar spine injury incidence rates using the National Electronic Injury Surveillance System (NEISS) database and determine any sports- and sex-specific epidemiologic patterns of these traumatic injuries.

Methods

Data regarding traumatic lumbar spine injuries sustained through sporting activities from 2009 to 2018 were extracted from the NEISS, a database generating nationwide estimates through patient information collected during emergency department visits from 100 NEISS hospitals across the United States. The estimated number of injuries was calculated using weights assigned by the NEISS database depending on the geographic location of the injury.

Results

A total of 497 traumatic lumbar spine injuries were identified over the course of 10 years, suggesting 19,208 estimated injuries. The estimated average injury rate was 6.1 injuries per million persons per year. When analyzed by sex, the incidence rate of traumatic lumbar spine injury was 3.6 injuries per million persons per year for male patients and 2.5 injuries per million persons per year for female patients (P = .663). In male patients, 47% of the injuries occurred in individuals aged between 10 and 29 years, whereas injuries in female patients were more equally distributed across different age groups. Horseback riding (27%), skiing (5%), and roller skating (4%) were the leading causes of traumatic lumbar injuries in female patients. In male patients, most injuries were experienced as a result of snowboarding (13%), weightlifting (10%), and football (6%).

Conclusions

From 2009 to 2018, the estimated incidence of sports-associated traumatic lumbar spine injuries was approximately 6.1 injuries per million persons per year. Male patients experienced a greater number of traumatic lumbar injuries (3.60) than female patients (2.46), with a relative incidence rate of 1.46. The most common source of injury was snowboarding in male patients and horseback riding in female patients.

Level of Evidence

Level III, retrospective comparative study.

Telerehabilitation to Address the Rehabilitation Gap in Anterior Cruciate Ligament Care: Survey of Patients

BACKGROUND

Evidence shows that after anterior cruciate ligament (ACL) reconstruction, patients may have varied access to physical therapy. In particular, physical therapy input may end many months before patients reach full recovery. Telerehabilitation may provide an opportunity to address this rehabilitation gap and improve access to evidence-based rehabilitation alongside physical therapy at all stages of care.

OBJECTIVE

This study aims to understand the opinions of patients who have undergone ACL surgery and rehabilitation on the use of telerehabilitation as part of ACL care and define the population and explore their experiences and views on the acceptability of telerehabilitation after ACL reconstruction.

METHODS

This study was a cross-sectional, voluntary, web-based survey combining both closed and open questions. Ethical approval was obtained from the Yale School of Medicine Institutional Review Board. Participants were aged 16 years or older at the time of recruitment and had undergone ACL reconstruction within the past 5 years. A 26-item survey was developed using the Qualtrics survey platform. No items were mandatory. Responses were multiple choice, binary, and qualitative. The CHERRIES (Checklist for Reporting Results of Internet E-Surveys) was used to ensure the quality of reporting of surveys in the medical literature. Data were analyzed using Stata version 15. Qualitative data were analyzed using NVivo 11. The theoretical framework for this analysis is based on the Capability, Opportunity, and Motivation-Behavior model of behavior change.

RESULTS

A total of 100 participants opened the survey. All completers were unique. The participation and completion rates were each 96% (96/100). Patients reported their physical therapy care ended at an average of 6.4 months and that they felt fully recovered at an average of 13.2 months. Only 26% (25/96) of patients felt fully recovered at the end of physical therapy. Of these 96 patients, 54 (60%) were younger than 30 years, 71 (74%) were recreational athletes, 24 (24%) were competitive athletes, 72 (75%) had private insurance, 74 (77%) were not familiar at all with telerehabilitation, and 89% (85/96) felt capable. They preferred to use telerehabilitation at different stages of care. Reported benefits included resource saving, improved access to care, improved learning, and greater engagement. Concerns included incorrect performance of exercises or unmanaged pain being missed and less access to manual therapy, motivation, and opportunities to ask questions. Participants' priorities for a future telerehabilitation intervention included its use as an adjunct to physical therapy rather than a replacement, with content available for each stage of care, especially return to sports. Participants stressed that the intervention should be personalized to them and include measures of progress.

CONCLUSIONS

These findings helped understand and define the ACL reconstruction population. Participants found telerehabilitation acceptable in principle and highlighted the key user requirements and scope of future interventions.

Erratum: Correction Notice: Single-step Precision Genome Editing in Yeast Using CRISPR-Cas9

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The First Decade of Web-Based Sports Injury Surveillance: Descriptive Epidemiology of Injuries in US High School Girls' Field Hockey (2008-2009 Through 2013-2014) and National Collegiate Athletic Association Women's Field Hockey (2004-2005 Through 2013-2014)

CONTEXT: 

The advent of Web-based sports injury surveillance via programs such as the High School Reporting Information Online system and the National Collegiate Athletic Association Injury Surveillance Program has aided the acquisition of data for girls' and women's field hockey injuries.

OBJECTIVE: 

To describe the epidemiology of injuries sustained in high school girls' field hockey in the 2008-2009 through 2013-2014 academic years and collegiate women's field hockey in the 2004-2005 through 2013-2014 academic years using Web-based sports injury surveillance.

DESIGN: 

Descriptive epidemiology study.

SETTING: 

Online injury surveillance from field hockey teams in high school girls (annual average = 61) and collegiate women (annual average = 14).

PATIENTS OR OTHER PARTICIPANTS: 

Girls' and women's field hockey players who participated in practices and competitions during the 2008-2009 through 2013-2014 high school academic years and the 2004-2005 through 2013-2014 collegiate academic years.

MAIN OUTCOME MEASURE(S): 

Athletic trainers collected time-loss (≥24 hours) injury and exposure data. Injury rates per 1000 athlete-exposures (AEs), injury rate ratios (IRRs) with 95% confidence intervals (CIs), and injury proportions by body site and diagnosis were calculated.

RESULTS: 

The High School Reporting Information Online system documented 983 time-loss injuries during 569 551 AEs; the National Collegiate Athletic Association Injury Surveillance Program documented 996 time-loss injuries during 185 984 AEs. The injury rate from 2008-2009 through 2013-2014 was higher in college than in high school (3.25 versus 1.73/1000 AEs; IRR = 1.89; 95% CI = 1.63, 2.18). Most injuries occurred during practices in high school (52.0%) and college (60.7%). Injury rates were higher during competitions than practices in high school (IRR = 2.00; 95% CI = 1.76, 2.26) and college (IRR = 1.96; 95% CI = 1.73, 2.23). At both levels, injuries most commonly occurred to the lower extremity and head/face and resulted in muscle/tendon strains and contusions. However, injury patterns varied between practices and competitions.

CONCLUSIONS: 

Injury rates and patterns varied across age groups and between practices and competitions, highlighting the need for development of targeted injury-prevention strategies at both levels of play.

Single-step Precision Genome Editing in Yeast Using CRISPR-Cas9

Genome modification in budding yeast has been extremely successful largely due to its highly efficient homology-directed DNA repair machinery. Several methods for modifying the yeast genome have previously been described, many of them involving at least two-steps: insertion of a selectable marker and substitution of that marker for the intended modification. Here, we describe a CRISPR-Cas9 mediated genome editing protocol for modifying any yeast gene of interest (either essential or nonessential) in a single-step transformation without any selectable marker. In this system, the Cas9 nuclease creates a double-stranded break at the locus of choice, which is typically lethal in yeast cells regardless of the essentiality of the targeted locus due to inefficient non-homologous end-joining repair. This lethality results in efficient repair via homologous recombination using a repair template derived from PCR. In cases involving essential genes, the necessity of editing the genomic lesion with a functional allele serves as an additional layer of selection. As a motivating example, we describe the use of this strategy in the replacement of HEM2, an essential yeast gene, with its corresponding human ortholog ALAD.

The epidemiology of back/neck/spine injuries in National Collegiate Athletic Association men's and women's ice hockey, 2009/2010 to 2014/2015

This study describes the epidemiology of back/neck/spine injuries in National Collegiate Athletic Association (NCAA) men's and women's ice hockey. Data from 66 NCAA men's and 29 women's ice hockey programmes (total of 147 and 67 team-seasons, respectively) were analysed from the NCAA Injury Surveillance Program during the 2009/2010-2014/2015 academic years. In the study period, 226 and 97 back/neck/spine injuries were reported in men and women, respectively, for injury rates of 0.56 and 0.65/1000 athlete exposures. Injury rates were higher in competitions than practices in men (injury rate ratio [IRR] = 4.22; 95% confidence interval [CI]: 3.24-5.49) and women (IRR = 2.49; 95% CI: 1.67-3.70). Most injuries occurred in the lower back/lumbar spine (men: 52.2%; women: 48.5%). There were notably low rates of fractures and severe spinal injuries for both sexes. This study enhances our understanding of the incidence, mechanisms and factors influencing these injuries and can ultimately lead to more effective injury prevention.

Patient-Centered Perioperative Care for a Victim of Military Sexual Trauma

INTRODUCTION

The patient population seen in our nation's Veterans Affairs Healthcare system is increasingly female and an alarming percentage of our veterans, male and female alike, report a history of military sexual trauma (MST), which is associated with an increased burden of morbidities including post-traumatic stress disorder (PTSD) and substance abuse. The experience of surgery can produce symptoms of PTSD in a clinically significant percentage of patients. This article describes the challenges of achieving a patient-centered perioperative care plan in the case of a female veteran who suffers from PTSD as a result of MST.

METHODS

We provide a brief background on the changing demographics of our nation's veterans, a review of MST and patient-centered care, and a description of the interdisciplinary care plan created and implemented for our patient. We note how this care model employs key elements of the Perioperative Surgical Home Model as developed by the American Society of Anesthesiologists. Finally, we propose an agenda for improving perioperative care for this group of veterans. No institutional review board was required for this case report-based discussion.

RESULTS

The patient-centered care plan developed and implemented by an interdisciplinary team was well received by the patient and enabled her to comply with her postsurgical physical therapy. This recent interdisciplinary experience was in stark contrast to her experience of former surgical procedures, and produced much higher patient satisfaction.

CONCLUSION

Improvements are needed in patient-centered perioperative care for victims of MST, both within the Veterans Affairs system and in the larger health care system. We suggest an agenda to improve care for these patients including: (1) increasing provider awareness and education about MST and about the potential psychological trauma of surgery per se, (2) employing elements of the Perioperative Surgical Home to encourage patient-centered care involving collaboration within an interdisciplinary team, (3) and measurement of patient centered outcomes. Perioperative care for the victim of MST is heretofore not addressed in the literature. We hope this case report and review will stimulate further research into optimizing care for these vulnerable patients.

Shoulder Injuries in Men's Collegiate Lacrosse, 2004-2009

BACKGROUND

Men's lacrosse has been one of the fastest growing team sports in the United States, at both the collegiate and high school levels. Uniquely, it combines both continuous overhead and contact activity. Thus, an understanding of its injury epidemiology and mechanisms is vital. Shoulder injuries have been shown to be common in the sport, but thus far there has been no dedicated analysis of these injuries with which to better inform injury prevention strategies.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

All athlete exposures (AEs) and shoulder injuries reported to the National Collegiate Athletic Association (NCAA) Injury Surveillance System for intercollegiate men's lacrosse athletes from 2004-2005 through 2008-2009 were collected. Type of injury was documented and the injury incidence per 1000 AEs was calculated. Event type, injury mechanism, specific injury, outcome, and time lost were recorded. Statistical analysis was performed using 95% CIs, calculated based on a normal approximation to Poisson distribution.

RESULTS

There were a total of 124 observed shoulder injuries during 229,591 monitored AEs. With weights, this estimates 1707 shoulder injuries over 2,873,973 AEs, for an incidence of 0.59 per 1000 AEs (95% CI, 0.56-0.62). The incidence of shoulder injury during competition was 1.89 per 1000 AEs (95% CI, 1.76-2.02), compared with 0.35 per 1000 AEs (95% CI, 0.33-0.38) during practice. Acromioclavicular joint injuries were most common (0.29 per 1000 AEs; 95% CI, 0.27-0.31). Labral injuries and instability events were also frequent (0.11 per 1000 AEs; 95% CI, 0.10-0.13). Player-to-player contact caused 57% of all shoulder injuries, with 25% due to contact with the playing surface. The average time lost was 11.0 days, with 41.9% of all shoulder injuries requiring ≥10 days. Clavicle fractures and posterior shoulder dislocation were particularly severe, with no athletes returning to play during the same season.

CONCLUSION

Shoulder injuries are common in NCAA men's lacrosse and are an important source of lost playing time. Acromioclavicular injuries were the most frequent injury in this series, but labral and instability injuries were also common. In this increasingly popular contact sport, an understanding of the epidemiology and mechanism of shoulder injuries may be used to improve protective equipment and develop injury prevention.

The Epidemiology of Hip/Groin Injuries in National Collegiate Athletic Association Men's and Women's Ice Hockey: 2009-2010 Through 2014-2015 Academic Years

Background:

There is limited research regarding the epidemiology of hip/groin injuries in ice hockey, the majority of which is restricted to time-loss injuries only.

Purpose:

To describe the epidemiology of hip/groin injuries in collegiate men’s and women’s ice hockey from 2009-2010 through 2014-2015.

Study Design:

Descriptive epidemiology study.

Methods:

Hip/groin injury data from the National Collegiate Athletic Association Injury Surveillance Program (NCAA-ISP) during the 2009-2010 through 2014-2015 seasons were analyzed. Injury rates, rate ratios (RRs), and injury proportion ratios (IPRs) were reported with 95% confidence intervals (CIs).

Results:

During the 2009-2010 through 2014-2015 seasons, 421 and 114 hip/groin injuries were reported in men’s and women’s ice hockey, respectively, leading to injury rates of 1.03 and 0.78 per 1000 athlete-exposures (AEs), respectively. The hip/groin injury rate was greater in men than in women (RR, 1.32; 95% CI, 1.08-1.63). In addition, 55.6% and 71.1% of hip/groin injuries in men’s and women’s ice hockey, respectively, were non–time loss (NTL) injuries (ie, resulted in participation restriction time <24 hours); 7.6% and 0.9%, respectively, were severe (ie, resulted in participation restriction time >3 weeks). The proportion of hip/groin injuries that were NTL injuries was greater in women than in men (IPR, 1.28; 95% CI, 1.11-1.48). Conversely, the proportion of hip/groin injuries that were severe was greater in men than in women (IPR, 8.67; 95% CI, 1.20-62.73). The most common hip/groin injury diagnosis was strain (men, 67.2%; women, 76.3%). Also, 12 (2.9%) and 3 (2.6%) cases of hip impingement were noted in men’s and women’s ice hockey, respectively.

Conclusion:

Hip/groin injury rates were greater in men’s than in women’s ice hockey. Time loss varied between sexes, with men sustaining more injuries with time loss over 3 weeks. Despite increasing concerns of femoroacetabular impingement in ice hockey players, few cases of hip impingement were reported in this dataset.

Head, Face, and Eye Injuries in Collegiate Women's Field Hockey

BACKGROUND

While there is concern regarding head, face, and eye injuries in field hockey, prompting some to recommend the use of protective equipment such as goggles and helmets, little has been written about their incidence and mechanism of injury in the modern game of field hockey. The elucidation of this information will better inform the development of maximally effective injury prevention schemes to protect the athlete while maintaining the integrity of the game.

PURPOSE

To determine the incidence and epidemiology of head, face, and eye injuries in United States collegiate women's field hockey players from 2004-2005 to 2008-2009.

STUDY DESIGN

Descriptive epidemiological study.

METHODS

All head, face, and eye injuries reported to the National Collegiate Athletic Association Injury Surveillance System for collegiate women's field hockey athletes from the 2004-2005 through 2008-2009 seasons were analyzed. Data regarding the event type, injury mechanism, body part injured, type of injury, outcome, and time lost were reviewed. The weighted injury incidence per 1000 athlete-exposures (AEs) was calculated using the exposure data set for the same years; 95% CIs were calculated based on a normal approximation to the Poisson distribution.

RESULTS

There were 150 reported traumatic injuries during this time period, with a weighted occurrence of 1587.3 injuries. The overall incidence of head, face, and eye injuries in collegiate women's field hockey was 0.94 per 1000 AEs (95% CI, 0.86-1.19). Injuries to the head or face, other than the mouth, nose, and eye, accounted for 75.3% of these injuries. The incidence of eye injuries was 0.07 per 1000 AEs (95% CI, 0.03-0.12); nose injuries occurred at a rate of 0.10 per 1000 AEs (95% CI, 0.05-0.15). The rate of traumatic dental injuries was 0.06 per 1000 AEs (95% CI, 0.04-0.14). Contact with an apparatus caused 72.9% of all injuries; specifically, contact with an elevated ball accounted for 47.9% of all injuries, and contact with an elevated stick caused 21.7% of all injuries. While the majority of players suffering a head, face, or eye injury were able to return to sport that season (90.0%), the remaining athletes suffered season-ending injuries (10%). Concussions accounted for 42.8% of all head, face, and eye injuries reported (0.40 per 1000 AEs; 95% CI, 0.32-0.53).

CONCLUSION

Head, face, and eye injuries occur regularly in women's field hockey. This description of the injury profile and mechanisms of injury may be used to design appropriate injury prevention schemes for the sport.

Length of Stay and Readmission After Total Shoulder Arthroplasty: An Analysis of 1505 Cases

We conducted a study to characterize the risk factors for extended length of stay (LOS) and readmission after primary total shoulder arthroplasty (TSA). Patients who were 60 years or older and underwent TSA between 2011 and 2012 were identified from the American College of Surgeons National Surgical Quality Improvement Program database. Bivariate and multivariate analyses were used to test patient characteristics for association with extended LOS and readmission within 30 days. Extended LOS was defined as LOS of more than 3 days (90th percentile LOS). Of the 1505 TSA patients identified, 49 (3.3%) were readmitted. Multivariate analysis revealed that extended LOS was independently associated with age 70 years or older and history of diabetes. Readmission was independently associated with history of heart disease and history of hypertension. The identified risk factors may be useful for preoperative discussions, surgical decision-making, and postoperative planning for THA patients.

Risk factors for short-term adverse events and readmission after arthroscopic meniscectomy: does age matter?

BACKGROUND

Recent studies have questioned the efficacy of meniscectomy in older patients with and without evidence of osteoarthritis; however, it continues to be frequently performed. There is limited information about age and other risk factors for adverse events and readmission after the procedure. This knowledge is vital to understand the true risk profile of this common surgery.

PURPOSE

To investigate if age and medical comorbidities were risk factors for postoperative adverse events and readmission after meniscectomy.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Patients who underwent arthroscopic meniscectomy between 2005 and 2012 were identified from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. Age≥65 years and medical comorbidities were evaluated as risk factors for any adverse event (AAE), severe adverse events (SAEs), and readmission after meniscectomy using univariate and multivariate analyses.

RESULTS

A total of 17,774 patients who underwent meniscectomy were identified. The mean age was 53.0±13.6 years. A total of 3420 patients (19.2%) were ≥65 years. Overall, 208 patients (1.17%) had AAE, 203 patients (1.14%) had an SAE, and 102 patients were readmitted (0.97%). Multivariate logistic regression analyses demonstrated no significant differences between age groups for the occurrence of AAE, SAEs, and readmission. Patients with American Society of Anesthesiologists classification≥3 had increased odds of AAE (odds ratio [OR], 1.58), SAEs (OR, 1.59), and readmission (OR, 1.99). Patients with diabetes had increased odds of AAE (OR, 1.57) and SAEs (OR, 1.51). Smokers had increased odds of readmission (OR, 1.67). Patients with pulmonary disease had increased odds of AAE (OR, 1.76) and SAEs (OR, 1.70).

CONCLUSION

Meniscectomy is a safe procedure in older patients, as age over 65 years did not increase the odds of any of the adverse events studied. However, regardless of age, patients with an increased comorbidity burden and those with a history of smoking are at increased risk of adverse events and/or readmission after the procedure.

CLINICAL RELEVANCE

Knowledge of these risk factors for adverse events and readmission provides essential information for patient selection and preoperative counseling.

Limitations of administrative databases in spine research: a study in obesity

BACKGROUND CONTEXT

The use of national inpatient databases for spine surgery research has been increasing. Unfortunately, without firsthand knowledge of each specific database, it can be difficult to judge the validity of such studies. Large databases that rely on administrative data, such as International Classification of Diseases, Ninth Revision (ICD-9) codes, may misrepresent patient information and could thus affect the results of studies that use these data.

PURPOSE

The present study uses obesity, an easily quantified and objective variable, as an example comorbidity to assess the accuracy of ICD-9 codes in the setting of their continued use in spine database studies.

STUDY DESIGN/SETTING

A cross-sectional study at a large academic medical center.

PATIENT SAMPLE

All patients spending at least one night in the hospital as an inpatient between April 1, 2013 and April 16, 2013. Obstetrics and gynecology, psychiatry, and pediatric patients were excluded.

OUTCOME MEASURES

Proportion of patients for whom ICD-9 obesity diagnosis codes assigned at hospital discharge match chart-documented body mass index (BMI).

METHODS

The medical record was reviewed for each patient, and obesity ICD-9 codes were directly compared with documented BMI.

RESULTS

The study included 2,075 patients. Of 573 "obese" patients (calculated BMI 30-39.9), only 109 received the correct code (278.00), giving this ICD-9 code a sensitivity of 0.19. Of 174 "morbidly obese" patients (calculated BMI >40), only 84 received the correct code (278.01), giving this ICD-9 code a sensitivity of 0.48.

CONCLUSIONS

Using obesity as an example, this study highlights the potential errors inherent to using ICD-9-coded databases for spine surgery research. Should a study based on such data use "obesity" as a variable in any analyses, the reader should interpret these results with caution. We further suggest that obesity is likely not the only comorbidity to which these results apply. As database research continues to represent an increasing proportion of publications in the field of spine surgery, it is important to realize that study outcomes can be skewed by data accuracy, and, thus, should not be blindly accepted simply by virtue of large sample sizes.

Absence of disseminated intravascular coagulation with endoscopic sclerosis of esophageal varices

Esophageal varices were injected with 5% sodium morrhuate and a solution containing thrombin, concentrated dextrose, and cephalothin sodium using the flexible gastroscope with balloon cuff modification. Hematologic and coagulating parameters were checked before and after the procedure to look for evidence of disseminated intravascular coagulation. No effect was noted on hematocrit, hemoglobin, platelet count, haptoglobin, prothrombin time, partial thromboplastin time, fibrinogen, fibrin split products, factor V, or factor VIII. Injection sclerotherapy with currently available solutions appears to have no effect on the systemic coagulation system.

Primary hyperparathyroidism and the gastrointestinal tract

To determine the frequency of gastrointestinal symptoms in primary hyperparathyroidism, we retrospectively analyzed 100 consecutive patients seen at Emory University Hospital from Jan 1, 1977 through March 1, 1979. At the time of diagnosis, 28 patients complained of nausea, 19 of vomiting, 29 of abdominal pain, and 33 of constipation. One patient presented with acute pancreatitis and 14 had ulcer disease (two gastric and 12 duodenal ulcers). Hypercalcemia increases gastric acid secretion and may account for associated ulcer disease and the ulcer-like pain in primary hyperparathyroidism. The mechanisms causing the other gastrointestinal symptoms in hypercalcemia remain to be elucidated. These symptoms abate on correction of hyperparathyroidism.