Augmented Stress Weight-bearing CT for Evaluation of Subtle Lisfranc Injuries in the Elite Athlete.

BACKGROUND: Lisfranc injuries refer to a disruption or displacement of the tarsometatarsal joint of the foot. Subtle Lisfranc injuries can go undiagnosed on conventional imaging leading to devastating consequences and poor functional outcomes for elite athletes. Objective. The objective of this case study is to present a novel imaging technique using weight-bearing computed tomography (CT) with enhanced stress to identify subtle, dynamically unstable Lisfranc injuries. We illustrate this with a case presentation of an elite athlete who ultimately required surgical fixation for a subtle Lisfranc injury. MATERIALS AND METHODS: To perform an augmented stress weight-bearing CT, the patient was positioned standing, with their feet facing forward, and weight equally distributed. The patient was then coached to symmetrically raise both heels from the scanner platform. This plantarflexion provided augmented stress on the midfoot, allowing for more sensitive imaging of the Lisfranc injury. The weight-bearing CT and augmented stress images undergo 3D reconstruction and postprocessing to render coronal and sagittal images, allowing for comparison of the standard weight-bearing and augmented stress images. RESULTS: We present the case of a 22-year-old collegiate football lineman sustaining a Lisfranc injury. The injury diagnosis was made by magnetic resonance imaging (MRI) and clinical examination, without evidence of injury on weight-bearing XR or standard weight-bearing CT. With augmented stress CT imaging, the Lisfranc instability was noted, leading to surgical fixation, and return to sport the next season. CONCLUSION: We propose this technique for diagnosing subtle, unstable Lisfranc injuries where clinical suspicion persists despite inconclusive imaging, particularly in elite athletes. Further research is needed with larger sample sizes to investigate the sensitivity of this novel imaging technique for the detection of Lisfranc injury. LEVELS OF EVIDENCE: Level 4: Case Report.

Different methods of 3D QRS area calculation from vectorcardiographic X, Y, and Z Leads.

3DQRSarea is a strong marker for cardiac resynchronization therapy and can be obtained by taking the (i) summation or the (ii) difference of the areas subtended by positive and negative deflections in X, Y, Z vectorcardiographic electrocardiogram (ECG) leads. We correlated both methods with the instantaneous-absolute-3D-voltage-time-integral (VTIQRS-3D). 3DQRSarea consistently underestimated the VTIQRS -3D, but the summation method was a closer and more reliable approximation. The dissimilarity was less apparent in left bundle branch block (r2 summation .996 vs. difference .972) and biventricular paced ECGs (r2 .996 vs. .957) but was more apparent in normal ECGs (r2 .988 vs. .653).

Suture Tape Augmentation of Posterior Cruciate Ligament Reconstruction Shows Improved Biomechanical Stability With Equivalent Outcome and Complication Rates: A Scoping Review.

PURPOSE: To assess the current literature surrounding suture tape augmentation (STA) of posterior cruciate ligament reconstruction (PCLR) with additional evaluation of PCLR+STA in clinical practice. METHODS: A systematic search of 3 databases (PubMed, EMBASE, and Web of Science Core Collection) was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and was completed in April 2023 to identify studies related to PCLR+STA. Surgical technique, animal, biomechanical, and clinical studies were included for review with quality appraisal conducted according to study design. RESULTS: A total of 380 articles were identified in the search, 6 of which met inclusion criteria. Biomechanical studies showed a significant reduction in posterior tibial translation with STA of PCLR in multiple studies. STA was found to decrease total elongation by 45% to 58% in multiple studies; increased load to failure was seen with STA as well in 1 study. Clinical studies showed equivalent or improved patient-reported outcomes with STA of PCLR compared with PCLR alone. CONCLUSIONS: Biomechanical studies offer evidence showing the beneficial load-sharing properties of STA such as increased strength and ultimate load with decreased elongation of the graft, especially with larger forces. Clinical evidence illustrates improved or equivalent patient-reported outcomes to standard PCLR with no difference in complication rate. CLINICAL RELEVANCE: STA of PCLR offers an opportunity to improve initial graft stability during the early healing phase through load sharing between the augmentation and the graft.

Manipulation Under Anesthesia and Lysis of Adhesions Are the Most Commonly Reported Treatments for Arthrofibrosis of the Knee After Arthroscopy or Anterior Cruciate Ligament Reconstruction in Both Pediatric and Adult Patients.

Purpose: To systematically review the literature and provide a detailed summary of the current treatments and outcomes for arthrofibrosis following knee arthroscopy and anterior cruciate ligament reconstruction (ACLR) and to compare the treatment strategies in pediatric and adult populations. Methods: A systematic review was performed in March 2022 using PubMed, EMBASE, and Cochrane Library Databases per Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Search terms consisted of variations of the following: ("arthrofibrosis" OR "stiffness" OR "stiff" OR "complications") AND ("arthroscopy" OR "arthroscop" OR "ACL" OR "anterior cruciate") AND ("treat" OR "care" OR "management" AND "knee"). The inclusion criteria were studies that were written in English, were published since 2000, and that reported outcomes of knee arthroscopy or ACLR for treatment of arthrofibrosis of the knee. The study quality was assessed, and data about the patients and treatments were recorded. Treatments were compared between pediatric and adult patients. Results: A total of 1,208 articles were identified in the initial search, 42 (3.48%) of which met eligibility criteria, involving treatment regimens for arthrofibrosis following knee arthroscopy or ACLR. Of the 42 studies included, 29 (69.0%) were reported data for adults and 13 (31.0%) reported data for pediatric patients. Thirty-nine studies (92.8%) discussed manipulation under anesthesia and/or lysis of adhesions (LOA) as treatment for arthrofibrosis of the knee, whereas 2 (4.8%) described the use of medications. Conclusions: Within orthopaedic sports medicine literature, there is variability in the reported treatment options for arthrofibrosis of the knee. Most studies identified manipulation under anesthesia and/or LOA as the treatment among both adult and pediatric patients. Other variants include notchplasty, open posterior arthrolysis, total graft resection, removal of hardware with LOA, dynamic splinting, casting in extension, bracing, and medications. Level of Evidence: Level IV, systematic review of Level I-IV studies.

Review of Intra-Articular Use of Antibiotics and Antiseptic Irrigation and Their Systematic Association with Chondrolysis.

Introduction: Intra-articular antibiotics have been proposed as a treatment for septic arthritis to allow for high local concentrations without subjecting a patient to the toxicity/side effects of systemic therapy. However, there is concern for chondrotoxicity with intra-articular use of these solutions in high concentrations. The purpose of this systematic review was to evaluate the intra-articular use of antibiotics and antiseptic solutions, and to determine their association with chondrolysis following in vitro or in vivo administration. Methods: A systematic review was conducted following PRISMA guidelines through PubMed, Clinical Key, OVID, and Google Scholar. Studies in English were included if they evaluated for chondrotoxicity following antibiotic exposure. Results: The initial search resulted in 228 studies, with 36 studies meeting criteria. These 36 studies included manuscripts that studied 24 different agents. Overall, 7 of the 24 (29%) agents were non-chondrotoxic: minocycline, tetracycline, chloramphenicol, teicoplanin, pefloxacin, linezolid, polymyxin-bacitracin. Eight (33%) agents had inconsistent results: doxycycline, ceftriaxone, gentamicin, vancomycin, ciprofloxacin, ofloxacin, chlorhexidine, and povidone iodine. Chondrotoxicity was evident with 9 (38%) agents, all of which were also dose-dependent chondrotoxic based on reported estimated half maximal inhibitory concentrations (est. IC50): amikacin (est. IC50 = 0.31-2.74 mg/mL), neomycin (0.82), cefazolin (1.67-3.95), ceftazidime (3.16-3.59), ampicillin-sulbactam (8.64 - >25), penicillin (11.61), amoxicillin (14.01), imipenem (>25), and tobramycin (>25). Additionally, chondroprotective effects of doxycycline and minocycline were reported. Conclusions: This systematic review identified agents that may be used in the treatment of septic arthritis. Nine agents should be avoided due to their dose-dependent chondrotoxic effects. Further studies are needed to clarify the safety of these medications for human intra-articular use.

A Brief Review of the Literature for Published Dual-Energy X-Ray Absorptiometry Protocols for Athletes.

CONTEXT: Dual-energy x-ray absorptiometry (DXA) is widely known for its utility in diagnosing a patient with osteopenia or osteoporosis; however, its utility in evaluation of body composition and potential athletic performance was previously routinely overlooked. In recent years, athletic programs have begun employing this equipment during athlete screening. However, it is currently unknown how athletic programs are utilizing this information to guide an athlete's training and health. OBJECTIVE: To explore the literature to identify what is known regarding sports performance and athlete health based on body composition recordings. DATA SOURCES: PubMed and Google Scholar databases were searched for this brief review. STUDY SELECTION: A focus was placed on articles within the past 10 years that discussed DXA protocols within athletic populations; 14 articles were included in this brief literature review. STUDY DESIGN: Brief literature review. LEVEL OF EVIDENCE: Level 5. DATA EXTRACTION: One member of the research team searched the literature and retrieved articles with the purpose of analyzing and/or explaining DXA imaging in body composition analysis of active persons (primarily athletes). RESULTS: Quality assurance scans with a phantom calibration block as well as athlete prescreening condition and activity standardization was routinely recommended. However, only 1 study reported a specific DXA protocol for athletes, and only 1 study described guidelines for how to report DXA results in athletic populations, suggesting it is plausible yet difficult due to the small changes detectable. CONCLUSION: Due to the limited literature as well as a lack of reference values for specific athletic populations, the authors of this review recommend using the current Nana et al (Int J Sport Nutr Exerc Metab 2015;25:198-215) DXA protocol for performing DXA scans in the athletic population as well as current Hind et al (J Clin Densitom 2018;21:429-443) guidelines for distributing the information.

A Scoping Review to Assess Risk of Fracture Associated with Anxiolytic Medications.

Introduction: Recent research has focused on evaluating the impact of pharmalogical sources on fracture risk. The purpose of this study was to review the literature on anxiolytic medications that may be associated with an increased risk of fracture. Methods: A search was conducted in MEDLINE and Embase databases to identify primary clinical studies of patients who sustained a fracture while prescribed anxiolytic medications and were published prior to July 2021. Anxiolytics defined by ATC Class N05B, beta blockers, and zolpidem were included. The search terms consisted of variations of the following: ("Psychotropic Drugs" or MeSH terms) AND ("Fracture" or MeSH terms). Results: Of 3,213 studies, 13 (0.4%) met inclusion criteria and were evaluated. Fractures associated with benzodiazepine were reported in 12 of 13 studies; the highest risk occurred in patients aged 60 years and older (RR=2.29, 95% CI (1.48-4.40)). The ATC Class N05B showed an increased fracture risk for those ≤ 55 years of age that differed by sex: for men (RR=5.42, 95% CI(4.86-6.05)) and for women (RR=3.33, 95% CI (3.03-3.66)). Zolpidem also showed an increase fracture risk (RR=2.29, 95% CI(1.48-3.56)), but only during the first four weeks of treatment. A relative risk of 0.77, 95% CI(0.72-0.83) was observed for beta blockers. Conclusions: Fractures are a mainstay of traumatic injuries and are accompanied by economical, physiological, and psychological hardship. With proper assessment and prophylactic measures, fracture risk can be reduced dramatically. Anxiolytic medications have been described widely to increase fracture risk, such as benzodiazepines in 60+ year old patients, and ATC Class N05B anxiolytics increased fracture risk in 55+ year old men and in 55+ year old women. Yet, some studies showed that at low doses, nitrazepam lowered fracture risk. Other anxiolytic medications, such as zolpidem and beta blockers, also showed a decrease in fracture risk. Ultimately, this scoping review helped to illuminate the inconsistency of anxiolytic fracture risk assessment while simultaneously illustrating the necessary steps to guide future research.

Rib Stress Fractures and a Novel Muscle-Sparing Rib Fixation Plating in an Elite Tennis Player: A Systematic Review of the Literature and Case Report.

A nationally ranked Division One female collegiate tennis player presented with pain in the chest and right posterior rib region after feeling a popping sensation during a routine overhead movement. The patient was eventually diagnosed with 2 lower rib stress fractures. After unsuccessful conservative management, the player underwent an open reduction and internal fixation and autologous bone grafting of the sixth and seventh ribs with a muscle-sparing approach and was able to return to full competition. We present this case along with a systematic review of the literature regarding rib stress fractures, which included 6 separate online data sources (PubMed, EMBASE, Cochrane, CINAHL, SportDiscus, and Medline). The successful surgical intervention demonstrates a significant option for elite athletes who wish to return to competition but have been unable to with standard of care conservative management of rib stress fractures.

Various Definitions of Failure Are Used in Studies of Patients Who Underwent Anterior Cruciate Ligament Reconstruction.

Purpose: To conduct a literature review to assess the definitions of anterior cruciate ligament reconstruction (ACLR) failure used throughout the orthopaedic literature. Methods: A systematic search of Embase, Ovid Medline, SPORTDiscus, and Web of Science was conducted by a university librarian to identity level I-IV clinical studies on ACLR failure. Inclusion criteria consisted of patients who underwent ACLR and included a definition of failure of ACLR. Patients who underwent anterior cruciate ligament (ACL) repairs, animal/cadaver studies, review studies, non-English language articles, and non-full text articles were excluded. Failure data were extracted from each study and categorized. Other data that were extracted included follow-up time after ACLR, failure reoperation rate, and failure reoperation procedure. Descriptive statistics was used to analyze the data. Results: Out of 2,775 studies, 104 (3.75%) met inclusion criteria and were analyzed in this review. The most common definition of ACLR failure included the use of a physical examination, specifically Lachman's test (21/104 [20.2%]), anterior laxity assessment, or a Pivot-Shift test (24/104 [35.2%]) or undergoing or requiring revision ACLR (39/104 [37.5%]). Although some studies used quantitative tests or imaging to help define "failure," others simply defined it as graft rerupture that was otherwise not defined (22/104 [22.5%]). Other common definitions included: the use of imaging (magnetic resonance imaging/radiographs) to confirm graft re-rupture (37/104 [35.6%]), patient-reported outcomes (recurrent instability)/patient reported outcomes measures (International Knee Documentation Committee [IKDC], Knee injury and Osteoarthritis Outcome Score [KOOS], Tegner) (18/104 [17.3%]), and the use of an arthrometer (KT-1000/2000, Rollimeter, or Kneelax) (17/104 [16.3%]). The least common definitions included graft failure or rerupture confirmed by arthroscopy (13/104 [12.5%]) and nonrevision surgery (2/104 [1.0%]). The failure rate of this procedure ranged from 0% to 100% depending on the definition of "failure." Conclusion: In this study, we found that a variety of definitions of failure are used among studies published in the orthopaedic literature. The most common criteria for failure of ACLR were the results of physical examination tests (35%), the need for undergoing a revision ACLR (36%), and the use of imaging to diagnose the failure (34%). About 17% of studies included in this review used patient-reported outcomes, specifically recurrent instability, or PROMs (IKDC, KOOS, Tegner) in their assessment of failure of ACLR. The least used definitions of "failure" of ACLR included nonrevision ACLR surgery (2%). Although some studies used similar tests or categories in their definition of failure, there were a variety of score and grade cutoff points between them. Level of Evidence: Level IV, systematic review of Level II-IV studies.

Eco-Friendly and High Performance Supercapacitors for Elevated Temperature Applications Using Recycled Tea Leaves.

Used tea leaves are utilized for preparation of carbon with high surface area and electrochemical properties. Surface area and pore size of tea leaves derived carbon are controlled by varying the amount of KOH as activating agent. The maximum surface area of 2532 m2 g-1 is observed, which is much higher than unactivated tea leaves (3.6 m2 g-1). It is observed that the size of the electrolyte ions has a profound effect on the energy storage capacity. The maximum specific capacitance of 292 F g-1 is observed in 3 m KOH electrolyte with outstanding cyclic stability, while the lowest specific capacitance of 246 F g-1 is obtained in 3 m LiOH electrolyte at 2 mV s-1. The tea leaves derived electrode shows almost 100% capacitance retention up to 5000 cycles of study. The symmetrical supercapacitor device shows a maximum specific capacitance of 0.64 F cm-2 at 1 mA cm-2 and about 95% of specific capacitance is retained after increasing current density to 12 mA cm-2, confirming the high rate stability of the device. An improvement over 35% in the charge storage capacity is seen when increasing device temperature from 10 to 80 °C. The study suggests that used tea leaves can be used for the fabrication of environment friendly high performance supercapacitor devices at a low cost.