Hyperhaemolysis caused by anti-HI antibodies in a patient with myelodysplastic syndrome following a first ever red cell transfusion.

BACKGROUND: Hyperhaemolysis is a rare and life-threatening delayed haemolytic transfusion reaction characterised by complement-mediated destruction of both host and transfused red cells. It is well recognised as a complication of transfusion in patients with haemoglobinopathies and has occasionally been described in haematological malignancy and anaemia of chronic disease. Anti-HI antibodies are usually clinically insignificant but have rarely been associated with haemolytic transfusion reactions, including cases of hyperhaemolysis in sickle cell disease. METHODS AND MATERIALS: Here, we describe a novel case of a patient with myelodysplastic syndrome developing hyperhaemolysis as a result of an anti-HI alloantibody following their first-ever transfusion. The patient required multiple lines of treatment, including erythropoietin, haematinic supplementation, corticosteroids, intravenous immunoglobulin and rituximab. RESULTS: Following treatment, steady-state haemoglobin was achieved with quiescent haemolysis, and complement inhibition with eculizumab was considered but ultimately not required. CONCLUSION: This is the first known report of hyperhaemolysis with an anti-HI antibody in a non-haemoglobinopathy patient. The treatment of hyperhaemolysis is evolving, and future commissioning needs to consider the role of complement inhibition in non-haemoglobinopathy patients.

Validity of Research Based on Public Data in Sports Medicine: A Quantitative Assessment of Anterior Cruciate Ligament Injuries in the National Football League.

BACKGROUND: Numerous researchers have leveraged publicly available Internet sources to publish publicly obtained data (POD) studies concerning various orthopaedic injuries in National Football League (NFL) players. PURPOSE: To provide a comprehensive systematic review of all POD studies regarding musculoskeletal injuries in NFL athletes and to use anterior cruciate ligament (ACL) injuries in NFL players to quantify the percentage of injuries identified by these studies. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: A systematic review was conducted to identify all published studies utilizing POD regarding ACL injury in NFL athletes from 2000 to 2019. Data regarding player demographics were extracted from each publication. These results were compared with prospectively collected data reported by the teams' medical staff to the NFL Injury Surveillance System database linked to the League's electronic health record. An ACL "capture rate" for each article was calculated by dividing the number of ACL injuries in the POD study by the total number of ACL injuries in the NFL injury database occurring in the study period of interest. RESULTS: A total of 42 studies were extracted that met the definition of a POD study: 28 evaluated a variety of injuries and 14 dealt specifically with ACL injuries, with 35 (83%) of the 42 studies published during or since 2015. POD studies captured a mean of 66% (range, 31%-90%) of ACL injuries reported by the teams' medical staff. This inability to capture all injury rates varied by position, with 86% capture of ACL injuries in skill athletes, 72% in midskill athletes, and 61% in linemen. POD studies captured 35% of injuries occurring during special teams play. CONCLUSION: The frequency of studies leveraging publicly obtained injury data in NFL players has rapidly increased since 2000. There is significant heterogeneity in the degree to which POD studies correctly identify ACL injuries from public reports. Sports medicine research relying solely on publicly obtained sources should be interpreted with an understanding of their inherent limitations and biases. These studies underreport the true incidence of injuries, with a bias toward capturing injuries in more popular players.

Postoperative Rehabilitation of Anterior Cruciate Ligament Reconstruction: A Systematic Review.

Recent studies have investigated the various components of postoperative rehabilitation protocols following anterior cruciate ligament reconstruction (ACLR). The objective of this article was to access and summarize the latest evidence for postoperative rehabilitation protocols following ACLR to evaluate common timeframes, number of phases, exercises, as well as the length of rehabilitation protocol. Common interventions include vibration training, open-chain and closed-chain exercises, electrical stimulation, postoperative bracing, and aquatic therapy. The eligibility criteria included English-language articles published from 2000 to 2019 pertaining to rehabilitation following ACLR, excluding addresses, commentaries, and editorials. Two blinded reviewers screened, graded, and extracted data from articles. Recommendations on various aspects of rehabilitation were summarized. A total of 3651 articles were retrieved from the database search, and 62 level 1 to 2 studies were available for extraction. On the basis of the evidence, vibration training can be safely incorporated into the postoperative rehabilitation protocol following ACLR. Accelerated rehabilitation may give patients short-term functional benefits. Open kinetic chain exercises may have additional strength and endurance benefits. Postoperative bracing does not confer additional benefits. Long-term use of neuromuscular electrical stimulation seems to be more beneficial than short-term use. Aquatic rehabilitation may be beneficial in the early phases of anterior cruciate ligament rehabilitation.

Interference Screw Versus Suture Anchors for Femoral Fixation in Medial Patellofemoral Ligament Reconstruction: A Biomechanical Study.

BACKGROUND: Femoral-sided graft fixation in medial patellofemoral ligament (MPFL) reconstruction is commonly performed using an interference screw (IS). However, the IS method is associated with several clinical disadvantages that may be ameliorated by the use of suture anchors (SAs) for femoral fixation. PURPOSE: To compare the load to failure and stiffness of SAs versus an IS for the femoral fixation of a semitendinosus autograft in MPFL reconstruction. STUDY DESIGN: Controlled laboratory study. METHODS: Based on a priori power analysis, a total of 6 matched pairs of cadaveric knees were included. Specimens in each pair were randomly assigned to receive either SA or IS fixation. After an appropriate reconstruction procedure, the looped end of the MPFL graft was pulled laterally at a rate of 6 mm/s until construct failure. The best-fit slope of the load-displacement curve was then used to calculate the stiffness (N/mm) in a post hoc fashion. A paired t test was used to compare the mean load to failure and the mean stiffness between groups. RESULTS: No significant difference in load to failure was observed between the IS and the SA fixation groups (294.0 ± 61.1 vs 250.0 ± 55.9; P = .352), although the mean stiffness was significantly higher in IS specimens (34.5 ± 9.6 vs 14.7 ± 1.2; P = .004). All IS reconstructions failed by graft pullout from the femoral tunnel, whereas 5 of the 6 SA reconstructions failed by anchor pullout. CONCLUSION: In this biomechanical study using a cadaveric model of MPFL reconstruction, SA femoral fixation was not significantly different from IS fixation in terms of load to failure. The mean load-to-failure values for both reconstruction techniques were greater than the literature-reported values for the native MPFL. CLINICAL RELEVANCE: These results suggest that SAs are a biomechanically viable alternative for femoral-sided graft fixation in MPFL reconstruction.

Incidence of Knee Injuries on Artificial Turf Versus Natural Grass in National Collegiate Athletic Association American Football: 2004-2005 Through 2013-2014 Seasons.

BACKGROUND: The use of artificial turf in American football continues to grow in popularity, and the effect of these playing surfaces on athletic injuries remains controversial. Knee injuries account for a significant portion of injuries in the National Collegiate Athletic Association (NCAA) football league; however, the effect of artificial surfaces on knee injuries remains ill-defined. HYPOTHESIS: There is no difference in the rate or mechanism of knee ligament and meniscal injuries during NCAA football events on natural grass and artificial turf playing surfaces. STUDY DESIGN: Descriptive epidemiology study. METHODS: The NCAA Injury Surveillance System Men's Football Injury and Exposure Data Sets for the 2004-2005 through 2013-2014 seasons were analyzed to determine the incidence of anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (MCL), medial meniscus, and lateral meniscal tear injuries. Injury rates were calculated per 10,000 athlete exposures, and rate ratios (RRs) were used to compare injury rates during practices and competitions on natural grass and artificial turf in NCAA football as a whole and by competition level (Divisions I, Divisions II and III). Mechanisms of injury were calculated for each injury on natural grass and artificial turf surfaces. RESULTS: A total of 3,009,205 athlete exposures and 2460 knee injuries were reported from 2004 to 2014: 1389 MCL, 522 ACL, 269 lateral meniscal, 164 medial meniscal, and 116 PCL. Athletes experienced all knee injuries at a significantly higher rate when participating in competitions as compared with practices. Athletes participating in competitions on artificial turf experienced PCL injuries at 2.94 times the rate as those playing on grass (RR = 2.94; 95% CI, 1.61-5.68). When stratified by competition level, Division I athletes participating in competitions on artificial turf experienced PCL injuries at 2.99 times the rate as those playing on grass (RR = 2.99; 95% CI, 1.39-6.99), and athletes in lower NCAA divisions (II and III) experienced ACL injuries at 1.63 times the rate (RR = 1.63; 95% CI, 1.10-2.45) and PCL injuries at 3.13 times the rate (RR = 3.13; 95% CI, 1.14-10.69) on artificial turf as compared with grass. There was no statistically significant difference in the rate of MCL, medial meniscal, or lateral meniscal injuries on artificial turf versus grass when stratified by event type or level of NCAA competition. No difference was found in the mechanisms of knee injuries on natural grass and artificial turf. CONCLUSION: Artificial turf is an important risk factor for specific knee ligament injuries in NCAA football. Injury rates for PCL tears were significantly increased during competitions played on artificial turf as compared with natural grass. Lower NCAA divisions (II and III) also showed higher rates of ACL injuries during competitions on artificial turf versus natural grass.

Epidemiology of Injuries in Women's Lacrosse: Implications for Sport-, Level-, and Sex-Specific Injury Prevention Strategies.

OBJECTIVE: By the end of 2013, the United States had an estimated 278 000 female lacrosse players, with half of those participating at the youth level. The effects of the sport's rapid growth on injury rates have yet to be determined. The purpose of this clinical review is to synthesize the available published data on injuries that have occurred in the sport of women's lacrosse. Of particular interest was the risk of injury based on the level of play and position. DATA SOURCES: A comprehensive literature search was performed in PubMed, High Wire Press, SPORTDiscus, Google Scholar, and Ovid using the keywords "Lacrosse Injuries," "Epidemiology Lacrosse Injuries," "Lacrosse Injury," "Lacrosse," and "Injury." STUDY SELECTION: The electronic search included material published during or after 1950. In addition, all bibliographies of electronically found sources were cross-referenced to identify any additional publications that were not produced in the electronic searches. DATA EXTRACTION: All articles with data on women's injury rates were categorized by overall injury rates, rates by session (competition vs practice), nature of injury, location, type, severity, and player position. DATA SYNTHESIS: Injury rates increase with age: from youth leagues to high school and finally to the collegiate level. Rates of injury varied from 0.03 to 3.9 injuries/100 athletes. Women's game injury rates are consistently higher than practice injury rates (ranging from 0.2 to 7.1 vs 0.01 to 3.3). Injuries occur most frequently from stick-to-player or player-to-ball contact, rather than player-to-player contact. Women sustain a higher percentage of head and facial injuries relative to male lacrosse players. The most common types of injuries for women are concussions, sprains, contusions, and lacerations. More than half of all injuries are in the mild category resulting in players missing practice and games for 1 to 7 days. Offensive players had the most injuries, followed by defensive players and then midfielders, with goalies having the fewest number of injuries. CONCLUSIONS: In women's lacrosse, the rules and equipment used are substantially different than for the men's game. Face and hand injuries are more prevalent for women when compared with men, and ankle injuries are most prevalent in female youth. Medical professionals who treat lacrosse players can benefit from an improved understanding of the types and rates of the injuries they are likely to encounter. Improved awareness of lacrosse-specific injuries can assist these professionals to be more prepared to treat these athletes, which may lead to improved care and outcomes.

Epidemiology of injuries in men's lacrosse: injury prevention implications for competition level, type of play, and player position.

OBJECTIVE: The growth in participation in men's lacrosse has increased the likelihood of sport-specific injuries, yet there continues to be a need for specific epidemiological data concerning lacrosse injuries. The purpose of this literature review is to aggregate available published data on injuries that occur in the sport of men's lacrosse at the youth, high school, collegiate, and professional levels. METHODS: A comprehensive literature search was performed in PubMed, High Wire Press, SPORTDiscus, Google Scholar, and Ovid, using the keywords Lacrosse Injuries, Epidemiology Lacrosse Injuries, Lacrosse Injury, Lacrosse AND Injury and limited to 1990-2016. All bibliographies were cross-referenced to identify any additional publications. Sources were categorized based on data provided and were aggregated into groups based on reported overall injury rates, rates by setting (competition vs. practice), nature of injury, location, type, severity, and player position. RESULTS: The game and practice injury rates in college are greater than the rates in high school, similarly rates greater for high school players than in youth leagues. Rates of injury varied from 0.095-12.98 per 1000 athlete exposures. Game injury rates were higher across all studies. Injuries in men's lacrosse occur most often from player-to-player contact, which result in immediate injuries, such as concussions, contusions, and lacerations. Overall concussion incidence was reported to range from 0.11-0.84 per 1000 AE. The most common types of injuries were sprain, strain, concussion, and contusions and the most common area of injury was hand (23%), with a significant proportion of these (59.4%) being to the thumb. Limited evidence of different injuries among the player positions suggests there might be a pattern that midfield players had the most injuries, followed by offensive players and then defensive players. CONCLUSIONS: The potential for sports-related injury is of relative concern; especially considering rising participation and total number of injuries. Further development and proper enforcement of safety rules on player contact and protective equipment are recommended to decrease the rate of lacrosse-related injury. Additional longitudinal research is needed to better classify and to ultimately predict lacrosse injury factors and mechanisms across all levels of play.

Five-Strand versus Four-Strand Hamstring Tendon Graft Technique for Anterior Cruciate Ligament Reconstruction: A Biomechanical Comparison.

The aim of this article is to compare diameter and stiffness, displacement, and strain in a five-strand versus four-strand hamstring graft for anterior cruciate ligament reconstruction. Eight matched pairs of lower extremities underwent four-strand or five-strand hamstring graft reconstruction. Diameter was significantly higher in the five-strand versus the four-strand construct (p = 0.002). No significant difference was found between the groups in construct displacement or stiffness. Significantly higher strain was observed in the inner limb versus the outer limb in the four-strand construct (p = 0.001) and in the inner limb versus the fifth limb in the 5-strand construct (p = 0.004). A fifth limb added to a four-strand hamstring graft significantly increased graft diameter but did not significantly change stiffness or displacement, suggesting that attachment of additional graft material via suture did not provide for full incorporation of the added limb into the graft at time zero. The inner limb in both constructs absorbed significantly greater load than did other limbs. The use of suture to attach additional material to a four-strand hamstring graft may not contribute to improved biomechanical qualities of the graft at time zero.

Putting an end to Black Wednesday: improving patient safety by achieving comprehensive trust induction and mandatory training by day 1.

The term 'Black Wednesday' has been used to describe the August national changeover day, a day when a new cohort of inexperienced doctors start work, many of whom are absent from patient care to attend organisational induction and mandatory training. In this paper, we report on the development and implementation of a novel, interactive e-learning programme for induction and mandatory training for junior doctors in a district general hospital in south-west England from August 2013. This comprehensive mandatory-training programme with summative assessment saved 19.5 hours of trust time per trainee. Since the programme's inception, the completion rate has been 100% (n = 370). Subgroup analysis of starters from August 2013 (n = 141) showed that 85.7% completed by day 1 (mean time of completion 3.0 days before day 1, standard deviation 14.2 days). Importantly, 90 minutes of induction was freed on Black Wednesday, enabling earlier, ward-based clinical orientation, thereby enhancing patient safety. We believe that this is the first programme to combine induction with fully assessed, comprehensive mandatory training in a single package. Such an approach is suitable for widespread application and is to be implemented regionally.

Biceps tenodesis versus allograft reconstruction for varus instability.

Although effective to restore stability in varus laxity, a fibula-based procedure such as figure-of-8 reconstruction can be technically demanding and requires use of allograft or autograft. Biceps rerouting offers an alternative without the potential complications of allograft or autograft procedures. It is not known whether biceps tenodesis is effective in addressing isolated varus laxity with lateral collateral ligament (LCL) rupture. We compared biceps tenodesis and figure-of-8 allograft reconstruction for restoration of varus stability. Nine knees were loaded at 10 N-m at 0- and 30-degree knee flexion in intact, LCL sectioned, and reconstructed state. Both biceps tenodesis and figure-of-8 reconstruction restored varus stability to at least baseline stability. Normalized displacement with biceps tenodesis measured at time zero was significantly lower than with allograft reconstruction at 0 degrees (0.75 ± 0.26 vs. 1.09 ± 0.31 degrees; p = 0.04) and 30 degrees (0.66 ± 0.14 vs. 0.91 ± 0.27 degrees; p = 0.04). Biceps tenodesis was effective at restoring baseline varus stability in isolated varus laxity.

Rate of injury among youth lacrosse players.

OBJECTIVE: This study describes the rate of injury and the types and mechanisms of injuries incurred by girls and boys during youth recreational lacrosse. DESIGN: Prospective cohort study. SETTING: Games were played at a large turf community athletic complex. PARTICIPANTS: Participants included male and female lacrosse players aged 9-15 years. A total of 143 games were played, resulting in 4603 athlete-exposures (AEs). ASSESSMENT OF RISK FACTORS: Youth players were grouped based on sex and 3 age categories: under 11 (U11; 9-10 years), under 13 (U13; 11-12 years), and under 15 (U15; 13-14 years). MAIN OUTCOME MEASURES: Certified athletic trainers collected data on type of injury and injury mechanism. RESULTS: There were 6.3 injuries per 1000 AEs for boys and girls combined. Girls had 7 injuries (3.4 per 1000 AEs) and boys had 22 injuries (8.7 per 1000 AEs). Contusions and lacerations were the most frequent injury (n = 13), and body-to-body contact (n = 10) was the most common injury mechanism. There were 4 concussions among boys (U13 and U15) and none among girls. CONCLUSIONS: Most injuries evaluated in youth lacrosse were contusions/lacerations; however, serious injuries were observed, including concussions in boys in the age group where body contact is allowed.

Biomechanical analysis of distal clavicle excision with acromioclavicular joint reconstruction.

BACKGROUND: Acromioclavicular (AC) joint separation is a common injury, usually affecting young adults. Controversy exists regarding whether to excise the distal clavicle when surgical intervention is required. PURPOSE: To evaluate the biomechanical strength of AC and coracoclavicular (CC) ligament reconstruction with and without concurrent distal clavicle excision. STUDY DESIGN: Controlled laboratory study. METHODS: Nine matched pairs of cadaver shoulders were used. All shoulders were tested with intact CC and AC ligaments, and the ligaments were sectioned. For 1 shoulder in each pair, a 7-mm distal clavicle excision was performed. The contralateral distal clavicle was left intact. Single-tunnel CC ligament reconstruction was performed, and excess graft length was extended and secured across the AC joint to reconstruct the superior AC joint ligaments in all specimens. Specimens were then potted and cyclically loaded for 500 cycles in the anterior-posterior and superior-inferior planes using an MTS Minibionix load frame to evaluate displacement across the AC joint. RESULTS: Regarding the clavicle-intact reconstructed versus the intact state, there was significantly greater AC joint translation in the reconstructed state in the anterior-posterior (20.2 ± 7.0 mm vs 6.0 ± 1.5 mm; P < .001) and superior-inferior directions (12.3 ± 3.3 mm vs 4.2 ± 1.2 mm; P < .001). In the clavicle-excised reconstructed versus the intact state, there was also significantly greater translation in the reconstructed state in the anterior-posterior (21.7 ± 5.1 mm vs 8.9 ± 4.3 mm; P < .001) and superior-inferior directions (12.3 ± 6.1 mm vs 5.8 ± 3.1 mm; P < .001). When the difference in translation between the reconstructed and intact groups in the clavicle-intact versus the clavicle-excised group was compared, no statistically significant difference was noted in anterior-posterior (14.2 ± 7.8 mm vs 12.8 ± 5.0 mm; P = .67) or superior-inferior translation (8.1 ± 2.9 mm vs 6.6 ± 3.9 mm; P = .39). CONCLUSION: Excision of the distal clavicle did not have a significant effect on anterior-posterior or superior-inferior motion at the AC joint following single-tunnel CC and AC ligament reconstruction. CLINICAL RELEVANCE: The study suggests that excision of the distal clavicle in this procedure is not associated with increased anterior-posterior or superior-inferior instability in this model.

Video incident analysis of concussions in boys' high school lacrosse.

BACKGROUND: Boys' lacrosse has one of the highest rates of concussion among boys' high school sports. A thorough understanding of injury mechanisms and game situations associated with concussions in boys' high school lacrosse is necessary to target injury prevention efforts. PURPOSE: To characterize common game-play scenarios and mechanisms of injury associated with concussions in boys' high school lacrosse using game video. STUDY DESIGN: Descriptive epidemiological study. METHODS: In 25 public high schools of a single school system, 518 boys' lacrosse games were videotaped by trained videographers during the 2008 and 2009 seasons. Video of concussion incidents was examined to identify game characteristics and injury mechanisms using a lacrosse-specific coding instrument. RESULTS: A total of 34 concussions were captured on video. All concussions resulted from player-to-player bodily contact. Players were most often injured when contact was unanticipated or players were defenseless (n = 19; 56%), attempting to pick up a loose ball (n = 16; 47%), and/or ball handling (n = 14; 41%). Most frequently, the striking player's head (n = 27; 79%) was involved in the collision, and the struck player's head was the initial point of impact in 20 incidents (59%). In 68% (n = 23) of cases, a subsequent impact with the playing surface occurred immediately after the initial impact. A penalty was called in 26% (n = 9) of collisions. CONCLUSION: Player-to-player contact was the mechanism for all concussions. Most commonly, injured players were unaware of the pending contact, and the striking player used his head to initiate contact. Further investigation of preventive measures such as education of coaches and officials and enforcement of rules designed to prevent intentional head-to-head contact is warranted to reduce the incidence of concussions in boys' lacrosse.

Video incident analysis of head injuries in high school girls' lacrosse.

BACKGROUND: Knowledge of injury mechanisms and game situations associated with head injuries in girls' high school lacrosse is necessary to target prevention efforts. PURPOSE: To use video analysis and injury data to provide an objective and comprehensive visual record to identify mechanisms of injury, game characteristics, and penalties associated with head injury in girls' high school lacrosse. STUDY DESIGN: Descriptive epidemiology study. METHODS: In the 25 public high schools of 1 school system, 529 varsity and junior varsity girls' lacrosse games were videotaped by trained videographers during the 2008 and 2009 seasons. Video of head injury incidents was examined to identify associated mechanisms and game characteristics using a lacrosse-specific coding instrument. RESULTS: Of the 25 head injuries (21 concussions and 4 contusions) recorded as game-related incidents by athletic trainers during the 2 seasons, 20 head injuries were captured on video, and 14 incidents had sufficient image quality for analysis. All 14 incidents of head injury (11 concussions, 3 contusions) involved varsity-level athletes. Most head injuries resulted from stick-to-head contact (n = 8), followed by body-to-head contact (n = 4). The most frequent player activities were defending a shot (n = 4) and competing for a loose ball (n = 4). Ten of the 14 head injuries occurred inside the 12-m arc and in front of the goal, and no penalty was called in 12 injury incidents. All injuries involved 2 players, and most resulted from unintentional actions. Turf versus grass did not appear to influence number of head injuries. CONCLUSION: Comprehensive video analysis suggests that play near the goal at the varsity high school level is associated with head injuries. Absence of penalty calls on most of these plays suggests an area for exploration, such as the extent to which current rules are enforced and the effectiveness of existing rules for the prevention of head injury.