Manipulation Under Anesthesia and/or Lysis of Adhesions After Anterior Cruciate Ligament Reconstruction in Female Basketball Players: Does Race Play a Role?

BACKGROUND: Arthrofibrosis can limit function and return to sport after anterior cruciate ligament (ACL) reconstruction. Previously reported risk factors for developing arthrofibrosis after ACL reconstruction include female sex, age <18 years, time from injury to surgery <28 days, concomitant meniscal repair, prolonged immobilization, and genetic factors. There is a lack of evidence regarding whether race plays a significant role. HYPOTHESIS: The risk of undergoing manipulation under anesthesia (MUA) and/or lysis of adhesions (LOA) after primary ACL reconstruction with bone-patellar tendon-bone (BTB) autograft in female basketball players is higher in African American players than in White players. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: Using a computerized relational database, the authors identified competitive female basketball players who underwent primary ACL reconstruction with BTB autograft by the senior author over a 13-year period. Data previously entered from examinations and surgical findings were reviewed retrospectively. Univariate statistics and multivariable logistic regression were used to assess the relationship between undergoing subsequent MUA and/or LOA and study predictors. RESULTS: A total of 186 knees (114 African American knees and 72 White knees) met inclusion criteria. The overall rate of MUA and/or LOA was 8.6%. Thirteen African American knees (11.4%) and 3 White knees (4.2%) underwent MUA and/or LOA for treatment of arthrofibrosis. No study predictor was found to have a statistically significant relationship with the rate of MUA and/or LOA on univariate analysis. However, when controlling for body mass index and previously described risk factors (age <18 years, time from injury to surgery ≤28 days, and concomitant meniscal repair) in the logistic regression model, the authors found that MUA and/or LOA was more likely in African American (odds ratio, 4.01 [95% CI, 1.01-15.92]; P = .049) than in White female players and in patients who underwent ACL reconstruction within 28 days of injury (odds ratio, 4.01 [95% CI, 1.18-13.57]; P = .026) compared with those with surgery delayed beyond 28 days. CONCLUSION: In female basketball players, the present study found a statistically significantly increased risk for undergoing MUA and/or LOA after primary ACL reconstruction with BTB autograft in African American females compared with White females and in patients who underwent ACL reconstruction within 28 days of injury.

The value-added benefit of utilizing two attending surgeons for patients with scoliosis secondary to cerebral palsy.

PURPOSE: The use of two attending surgeons during posterior spinal fusion (PSF) for cerebral palsy (CP) patients has been shown to improve perioperative outcomes. This study aims to determine if the use of two surgeons is associated with an increase in the number of subsequent surgeries that can be performed in the same operating room (OR) during business hours. METHODS: Patients with scoliosis and CP treated with PSF with minimum 90-day follow-up were included. Patients were grouped based on whether one or two attending surgeons performed the case. The primary outcome was the number of surgeries that followed in the same OR before 5 PM. Secondary outcomes included operative time, estimated blood loss (EBL), length of stay, rate of surgical site infection, and rate of unplanned return to the operating room. RESULTS: Thirty-six patients were included (10 with 1 surgeon and 26 with 2 surgeons). The two surgeon group had a significant increase in the average number of surgeries subsequently performed in the same OR during business hours (1.1 vs. 0.3, p = 0.01), as well as shorter mean operative time (159 vs. 307 min, p = 0.007) and EBL (554 vs. 840 cc, p = 0.01; 26 vs. 39%EBV, p = 0.03). CONCLUSION: The use of two attending surgeons was associated with a significant increase in the number of cases subsequently performed in the same OR during business hours, and significant decreases in operative time and EBL. Hospitals should consider the patient care and potential system-level improvements when considering implementation of two surgeon teams for PSF in CP patients. LEVEL OF EVIDENCE: Therapeutic Level III.

An Analysis of Symptomatic Meniscal Re-Tear Incidence in Two Age Populations: Differences in Older versus Younger Adults.

A symptomatic meniscal tear is one of the most common problems treated by an orthopaedic surgeon. Treatment ranges from observation to complete meniscectomy. Prior research has shown that contact stresses increase within the joint compartment after partial meniscectomy, thus leading to arthritis of the compartment. The purpose of the current study was to determine the incidence of meniscal re-tears in two populations of patients and identify potential factors predisposing to re-tear. A retrospective review of our relational database identified 1,930 arthroscopic partial meniscectomies from 1993 to 2003. Meniscectomies were divided into two groups, 430 patients < 45 years of age (YOUNG) and 712 patients ≥ 45 (OLD). Age, onset date, Lysholm, Tegner, tear type, radial and circumferential location, as well as degree and location of chondromalacia, were analyzed. Of the YOUNG group, 1.16% experienced re-tears, versus 0.42% of the OLD group. From the younger re-tear group, 80% were chronic and 20% had grade 2 chondromalacia in one compartment. The YOUNG re-tear group was slightly more active with higher Tegner (5.6 vs. 4.3) and Lysholm (66.2 vs. 60) scores than the rest of the YOUNG group. The OLD re-tear group was less active with a lower Tegner (2.5 vs. 4.1) and Lysholm (62 vs. 66) score compared with the rest of the older group. In this study, patients under 45 years and with chronic tears had slightly higher incidence of re-tears. Results indicated that the lateral meniscus is more likely to re-tear.

Barriers to Increasing Diversity in Orthopaedics: The Residency Program Perspective.

BACKGROUND: There are little data to explain why the surgical subspecialty of orthopaedic surgery struggles with improving the racial/ethnic composition of its workforce. The current work sought to determine what orthopaedic residency program directors and coordinators believe are the barriers to improving diversity at their own programs. METHODS: Between November 17, 2018, and April 1, 2019, a 17-question survey was electronically distributed to the program directors and coordinators of 155 allopathic orthopaedic surgery residency programs. Seventy-five of 155 programs (48.4%) responded to the survey. A p-value of < 0.05 was used to determine statistical significance. RESULTS: The most commonly stated barriers to increasing diversity within the orthopaedic surgery programs were the following: "We do not have enough minority faculty, which may deter the applicants" (69.3%), "We consistently rank minority applicants high but can never seem to match them" (56%), and "Not enough minorities are applying to our program" (54.7%). Programs with higher percentages of underrepresented minority (URM) faculty had higher percentages of URM residents (p = 0.001). Programs participating in the Nth Dimensions and/or Perry Initiative programs had a higher percentage of URM faculty as compared to the residency programs that did not participate in these programs (p = 0.004). URM residents represented 17.5% of all residents who resigned and/or were dismissed in the 10 years preceding the survey while also only representing 6% of all orthopaedic residents during the same time period. CONCLUSIONS: From the orthopaedic residency program perspective, the greatest perceived barrier to increasing the racial/ethnic diversity of residents in their program is their lack of URM faculty. Surveyed programs with more URM faculty had more URM residents, and programs participating in Nth Dimensions and/or Perry Initiative programs had a higher percentage of URM faculty.

Mississippi Diabetes Telehealth Network: A Collaborative Approach to Chronic Care Management.

Background/Introduction: Ineffective management of chronic illness and lack of referral sources in underserved areas has contributed to increased health care spending and a decline in quality of life for the affected. In 2016, 15.4% of the adult population of Mississippi had diabetes. Telehealth in the home is a viable way to bring a care team to patients to assist them as they manage their illnesses. The purpose of the study was to determine the relationship between the Mississippi Diabetes Telehealth Network clinical care model and selected diabetes outcomes over time. Methods: A prospective, longitudinal cohort study design evaluated the relationship between using telehealth for chronic care management and diabetes outcomes over a 12-month period. Eligible participants were patients over 18 years old diagnosed with diabetes at a rural health clinic with an hemoglobin A1c (HbA1c) ≥7.0%. Rolling enrollment continued until the pool of eligible participants was depleted. A total of 171 were enrolled. Results: There was a significant difference in HbA1c values from baseline to 3-, 6-, 9-, and 12-month values. A significant difference was found between baseline and 12-month measures for total cholesterol, low density lipoproteins (LDL), high density lipoproteins (HDL), triglycerides, creatinine clearance, glomerular filtration rate, and potassium. There were no differences in baseline and 12-month measures for weight, blood pressure, blood urea nitrogen (BUN), and microalbumin. Discussion/Conclusions: Even with the limited sample size and design, remote patient monitoring and telehealth may be an effective tool for assisting home-based patients in the self-management of diabetes in rural areas. The maximum benefit was achieved after 3-4 months on the program and maintained over the 12-month period.

Risk Factors for Kidney Dysfunction With the Use of Gentamicin in Open Fracture Antibiotic Treatment.

OBJECTIVES: To evaluate all patients who received gentamicin for open fracture treatment and determine the incidence of, and risk factors for, kidney injury in this population. DESIGN: Retrospective, case control. SETTING: Single institution; Level 1 trauma center. PATIENTS/PARTICIPANTS: A retrospective chart review identified patients who received gentamicin for open fracture antibiotic treatment from January 2008 to December 2012. Overall, 371 patients met the inclusion criteria and were categorized into 2 groups using risk, injury, failure, loss of kidney function, and end-stage kidney disease criteria: normal kidney function (74.9%) versus abnormal kidney function (25.1%). INTERVENTION: Use of gentamicin in open fracture antibiotic treatment. MAIN OUTCOME MEASUREMENTS: Kidney function; injury and treatment characteristics (eg, mechanism of injury; Gustilo-Anderson classification; number of surgical debridements, timing of definitive wound coverage, and type of wound coverage); and patient information (eg, age, height, weight, and body mass index, tobacco use, diabetes mellitus, human immunodeficiency virus, hepatitis, and current chemotherapy treatment). RESULTS: Those with abnormal kidney function had lower baseline creatinine (P < 0.001) and higher injury severity scores (16.5 vs. 11.8, P < 0.001) and were more likely to require intensive care unit admission (P < 0.001) than the normal group. Female sex (P = 0.015), and higher weight (P = 0.004), ICU admission (P < 0.001), and use of CT contrasted imaging (P < 0.001) were independently associated with abnormal kidney function. Abnormal kidney function incidence also sharply increased with age. CONCLUSIONS: Females and heavier individuals are at-risk of kidney injury while receiving gentamicin. ICU admission and concurent CT contrasted imaging are strongly associated with kidney injury in patients receiving gentamicin for open fracture treatment, and gentamicin should be avoided in those >60 years of age. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Intraoperative Evaluation of the Anatomic Lateral Distal Femoral Angle and Its Variation due to Positioning.

BACKGROUND/PURPOSE: Preoperative evaluation of the contralateral anatomic lateral distal femoral angle (aLDFA) at our institution is used to judge coronal plane alignment. In our study, we investigated 4 different techniques for obtaining an anteroposterior intraoperative fluoroscopic image of the distal femur to determine which technique provides (1) the greatest interobserver reliability; (2) the lowest variability from the previously published population mean; and (3) the lowest side-to-side variability. METHODS: Inclusion criteria included lower extremity injuries needing fixation that required intraoperative fluoroscopy with an intact femur and an intact extensor mechanism (N = 100). Fluoroscopic images were obtained of the distal femur in 4 positions differentiated by the position of the limb and the orientation of the C-arm beam to the femoral shaft. RESULTS: All measurement techniques resulted in mean measurements within one degree of 81 degrees. Variance between measurements was small among patients with all views, but images that involved a true anteroposterior with the beam perpendicular to the femur had the lowest rate of measurements that were <78 or >84 degrees. CONCLUSION: Side-to-side differences in patients were <2 degrees on average with every image used. With the best-performing images, 20% of patients had an aLDFA > 3 degrees different from the population mean of 81 degrees and 3% of patients were >5 degrees different. Although restoring aLDFA to 81 degrees will be within 3 degrees of the contralateral side the vast majority of the time, matching the aLDFA to the injured side will be the most accurate reconstruction.

Long-term Analysis of Lip Augmentation With Superficial Musculoaponeurotic System (SMAS) Tissue Transfer Following Biplanar Extended SMAS Rhytidectomy.

IMPORTANCE: To our knowledge, long-term, objective results of lip augmentation using superficial musculoaponeurotic system (SMAS) tissue transfer beyond 1 year have not been previously described. OBJECTIVE: To evaluate the efficacy, longevity, and safety of lip augmentation using SMAS tissue transfer. DESIGN, SETTING, AND PARTICIPANTS: A retrospective single-blind cohort study was designed to evaluate all patients who underwent surgical lip augmentation using SMAS following rhytidectomy between January 1, 2000, and November, 16, 2015, at a private facial plastic surgery practice in Birmingham, Alabama. Preoperative photographs of each patient served as controls and were compared with postoperative photographs at 3 months, 1 year, and 5 years after lip augmentation. A total of 104 images (from 26 individual patients) were reviewed by 12 blinded observers using a validated lip augmentation grading scale. EXPOSURES: Lip augmentation using SMAS. MAIN OUTCOMES AND MEASURES: Median lip volumes of all patients at each postoperative interval (3 months, 1 year, and 5 years) compared with preoperative lip volumes. Secondary outcome measures included postoperative complications. RESULTS: A total of 423 patients were identified who underwent surgical lip augmentation using SMAS. Sixty patients with approximately 5 years or more of postoperative photographs were reviewed for complications. Twenty-six patients had 3-month, 1-year, and 5-year postoperative follow-up photographs and were included in the photographic evaluation. The mean age of these patients at the time of surgery was 54.6 years (range, 41.2-80.6 years. Fifty-nine of the 60 patients (98.3%) were female. Two of 60 patients (3.3%) with 5 years or more of postoperative follow-up developed complications requiring intervention. Both the superior lip and the inferior lip showed statistically significant increases in volume at 3 months, 1 year, and 5 years (P ≤ .004 for the superior lip after 5 years; P ≤ .001 for all other comparisons) after SMAS lip augmentation. The greatest median increase was observed in the superior lip at 3 months, while the smallest median increase was observed for the inferior lip at 5 years. The degree of increase in median volume seemed to weaken slightly over time, but remained statistically significant even at 5 years. CONCLUSIONS AND RELEVANCE: SMAS lip augmentation is an effective and safe method for lip augmentation that can yield natural, long-lasting results with minimal risk. The degree of augmentation tends to fade slightly over time, but remains significant for at least 5 years postoperatively. LEVEL OF EVIDENCE: 3.

Relationship Between Posterior-Inferior Tibial Slope and Bilateral Noncontact ACL Injury.

Is there a correlation between increased posterior-inferior tibial slope angle and noncontact anterior cruciate ligament (ACL) injury? Does increasing the posterior-inferior tibial slope angle increase the risk of bilateral ACL injury? A computerized relational database (Access 2007; Microsoft Inc, Redmond, Washington) was used to conduct a retrospective review of patients undergoing bilateral or unilateral ACL reconstruction surgery or treatment by a single surgeon between 1995 and 2013. Included in the study were patients with bilateral and unilateral ACL injuries and patellofemoral pain syndrome with no associated ACL deficiency. Exclusion criteria included concomitant ligament injury, previous ACL reconstruction, and previous knee surgery. Also excluded were patients who did not have plain lateral radiographs. Fifty patients were randomly selected from each group. After controlling for age and Tegner activity level, the authors found that the posterior-inferior tibial slope angle was a significant predictor (P=.002) of noncontact ACL injury. Mean posterior-inferior tibial slope angle for the bilateral, unilateral, and control groups was 11.8°±2.3°, 9.3°±2.4°, and 7.5°±2.3°, respectively. In the group with unilateral ACL injury vs the group without ACL deficiency, a 1° increase in posterior-inferior tibial slope angle (P=.03) was associated with a 20% increase in unilateral ACL injury. In those with bilateral ACL injury vs those without ACL deficiency, a 1° increase in posterior-inferior tibial slope angle (P=.001) increased bilateral knee injury by 34%. The difference between the mean angles of the control group without ACL deficiency and both the bilateral injury and unilateral injury cohorts was statistically significant (P=.003). Increased posterior-inferior tibial slope angle is associated with an increased risk of noncontact bilateral and unilateral ACL injury. [Orthopedics. 2017; 40(1):e136-e140.].

A comparison of functional outcomes in patients undergoing revision arthroscopic repair of massive rotator cuff tears with and without arthroscopic suprascapular nerve release.

PURPOSE: This study was designed to compare functional outcomes in patients undergoing revision repair of massive rotator cuff tears (retracted medial to the glenoid) with Goutallier Grade 4 atrophy and concomitant release of the suprascapular nerve to a similar group of patients with Grade 3 atrophy undergoing revision rotator cuff repair (RTCR) without nerve release. We hypothesized that patients undergoing nerve release would have more favorable functional outcomes as measured by the Modified University of California at Los Angeles shoulder rating scale (UCLA). PATIENTS AND METHODS: Twenty-two patients underwent revision repair of massive rotator cuff tears with release of the suprascapular nerve at the suprascapular notch. We compared total preoperative, postoperative, and change in UCLA score in these patients to a similar group of 22 patients undergoing revision RTCR without suprascapular nerve release. Additionally, UCLA subscores between the two groups were compared preoperatively and at final follow-up. RESULTS: The average preoperative UCLA score in the nerve-release group was 7.91, and final follow-up average was 27.86; average 3.05 grades of strength were recovered. In the comparison group, average preoperative UCLA score was 11.77, and final follow-up average was 29.09; average 1.32 grades of strength were recovered. The average preoperative UCLA score was significantly worse in the nerve-release group (P=0.007). The average postoperative UCLA score was not significantly different (P=0.590) between the groups, indicating a better improvement in the nerve-release group with significantly greater improvement in active forward flexion, strength, and pain relief. CONCLUSION: Patients who underwent concomitant release of the suprascapular nerve during revision RTCR had greater overall improvement as noted in pain relief, active forward flexion, and strength, than a comparable group without nerve release.

Tracheotomy Outcomes in Super Obese Patients.

IMPORTANCE: Surgeons need to understand the expected outcomes for super obese patients undergoing tracheotomy to appropriately counsel patients and families about likely risks and benefits. OBJECTIVE: To determine the outcomes, complications, and mortality after tracheotomy in super obese patients (those with a body mass index [BMI] greater than 50). DESIGN, SETTING, AND PARTICIPANTS: A retrospective review was conducted of billing records from a tertiary care academic medical center from November 1, 2010, through June 30, 2013, to identify patients undergoing tracheotomy. Medical records were reviewed to identify patients with a BMI (calculated as weight in kilograms divided by height in meters squared) greater than 50 and a control group with a BMI of 30 to 50. Patient characteristics, including BMI, age, race/ethnicity, primary diagnosis for hospitalization, medical comorbidities, and surgical technique, were measured. MAIN OUTCOMES AND MEASURES: The primary outcome measure was dependence on tracheostomy at discharge. Secondary outcomes included rates of ventilator dependence, mortality, postoperative complications, and discharge disposition. RESULTS: The super obese population included 31 patients and was predominantly African American (20 patients [65%]) and female (21 patients [68%]). Mean BMI of super obese patients was 64.0 (range, 50.2-95.5). The obese patient population was mainly African American (25 patients [74%]) and female (17 patients [50%]). Twenty-five of 31 super obese patients (81%) were discharged with a tracheotomy tube in place, compared with 16 of 34 obese patients (52%). Seven patients (23%) in the super obese group were ventilator dependent at discharge, compared with 4 patients (13%) in the obese group. Only 2 of the super obese patients (3%) were decannulated before discharge, compared with 15 (44%) in the obese group. In-hospital mortality was similar for the 2 groups (super obese, 4 patients [13%] and obese, 3 patients [9%]). The overall complication rate was 19% in the super obese group (6 patients) compared with 6% in the obese group (2 patients). Super obese patients were less likely to be discharged to a health care facility (17 patients [55%]) compared with patients in the obese group (22 patients [65%]). CONCLUSIONS AND RELEVANCE: Tracheotomy in super obese patients is a safe and effective strategy for airway management. Critically ill, super obese patients have a high likelihood of remaining dependent on a tracheotomy or ventilator at the time of discharge.

Body Mass Index as an Indicator of Associated Intra-articular Injuries in Patients With Anterior Cruciate Ligament Tears.

This study assessed the relationship between body mass index (BMI), anterior cruciate ligament (ACL) injury, and associated meniscal and cartilage injury. Age, ACL classification, and Tegner activity score were considered. A total of 1968 ACL reconstruction patients (2/1/1996 to 5/1/2012) were analyzed. All graft types, age groups, and activity levels were included. A BMI ≥30 correlated with a significant likelihood of medial meniscus tears (p = .022). Patients with a BMI ≥30 were 21.6% more likely to have a medial meniscus tear with an ACL injury. Grade III and IV chondral lesions correlated with a BMI ≥30 (p = .029). Patient's age predicted medial meniscus outcome (p = .013). Patients whose age was >25 had a 25.7% higher risk of medial meniscus tear. Chronic ACL patients were 52.6% more likely to have a meniscus injury. BMI, age, Tegner activity score, and ACL classification are good predictors of medial meniscus injury. Patients with a BMI ≥30 exhibit a greater risk of medial meniscus tear with ACL instability; however, BMI does not significantly contribute to increased chondral damage in ACL-deficient patients.

Standard Dosing of Enoxaparin for Venous Thromboembolism Prophylaxis Is Not Sufficient for Most Patients Within a Trauma Intensive Care Unit.

Recent reports confirm that the standard dose of enoxaparin in obese patients is often subtherapeutic, leading to a higher incidence of venous thromboembolism. All patients receiving subcutaneous enoxaparin 30 mg twice a day (b.i.d.) for venous thromboembolism prophylaxis were prospectively enrolled in this study. Trough antiXa levels were obtained and any level less than 0.1 IU/mL was considered subtherapeutic and the final dosage requirement was recorded. Body mass index (BMI), abdominal wall thickness, and fluid balance were collected. Thirty-four patients were prospectively enrolled in the study, 14 (50%) of which had a BMI >30. Sixty-five per cent of obese patients were initially nontherapeutic, compared with 53 per cent of the nonobese (P = 0.73). However, elevated BMI (P < 0.05) and abdominal wall thickness (P < 0.05) correlated to an increased final dose required to attain an anti Xa ≥0.1 when not initially therapeutic, whereas fluid balance demonstrated no correlation (P = 0.232). Subcutaneous enoxaparin dosing of 30 mg b.i.d. is not sufficient for the majority adult trauma patients in the intensive care unit, regardless of BMI. When enoxaparin 30 mg b.i.d. is initially subtherapeutic, obese patients may require a larger dose necessary to achieve necessary anticoagulation.

Opening-Wedge High Tibial Osteotomy: Review of 100 Consecutive Cases.

PURPOSE: We report intermediate-term outcomes of a large consecutive series of medial opening-wedge tibial osteotomies. METHODS: One hundred consecutive patients who underwent medial high tibial osteotomy from 2004-2013 were retrospectively reviewed. Charts were reviewed for patient age and gender, knee pain and range of motion, smoking status, and body mass index. Operative reports were reviewed for bone graft type, degree of correction, and osteotomy fixation method. Radiographs were evaluated for lateral cortical or intra-articular fracture, osteotomy healing, and preoperative and postoperative tibiofemoral angles. RESULTS: Eighty-nine osteotomies (89%) in 83 patients were included in the study. Most procedures were performed for medial knee arthritis. The mean age at surgery was 48.1 years, and the mean follow-up period was 4.0 years. The mean tibiofemoral alignment was 3.2° of varus preoperatively and 6.4° of valgus postoperatively. Plate and screw fixation was used in all cases. Bone grafting methods included autograft, allograft, iliac crest aspirate, platelet-rich plasma, and demineralized bone matrix. Of the osteotomies, 83 (93%) healed uneventfully. Five nonunions and 1 delayed union occurred. Allograft combined with demineralized bone matrix and/or platelet-rich plasma was associated with nonunion (P = .02). Lateral cortical fracture was associated with repeat surgery for nonunion or alignment loss (P = .02). Pain was minimal or mild in 65% of patients, moderate in 16%, and severe in 19%. Osteotomy fixation with a small 4-screw plate was associated with increased postoperative pain (P = .01). Seven patients underwent arthroplasty an average of 5 years after osteotomy. The need for arthroplasty was associated with longer follow-up (P = .02) and use of a smaller plate (P = .04). CONCLUSIONS: Uncomplicated osteotomy union occurred in 93% of medial opening-wedge high tibial osteotomies. Allograft mixed with demineralized bone matrix and/or platelet-rich plasma was associated with nonunion. At intermediate follow-up, 65% of patients had minimal or mild pain. Seven patients had undergone arthroplasty. Fixation with a smaller plate was associated with increased postoperative pain and the need for subsequent arthroplasty. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Helmet use is associated with a decrease in intracranial hemorrhage following all-terrain vehicle crashes.

BACKGROUND: With the recent increase in size and horsepower of all-terrain vehicles (ATVs), it is imperative that preventable injuries be identified to protect the large population using ATVs. Currently, many states have no laws regulating ATV or helmet use. By identifying preventable injuries, the legislature can design appropriate laws to protect both children and adults. METHODS: A retrospective review of all patients with ATV injuries presenting between the years 2005 and 2010 was conducted. The data were grouped in several ways for analysis. This included age less than 9 years, weight less than 30 kg, crash at night, substance abuse, and presence of a helmet. RESULTS: There were 481 patients included in the study. Only 28 (8%) were using a helmet at the time of the crash. Helmet use was associated with less intracranial hemorrhage (3% vs. 22%, p = 0.01) and a decreased incidence of loss of consciousness (14% vs. 35%, p = 0.01). Patients testing positive for alcohol intoxication with or without drugs were significantly more likely to have intracranial hemorrhage, to crash at night, to have facial fracture, to have rib fracture, to arrive intubated, and to have a higher Injury Severity Score (ISS) (p < 0.01 for all). CONCLUSION: With the recent increase in size and horsepower of ATVs, it is imperative that preventable injuries be identified to help protect a growing population of ATV operators. This study reveals a high rate of intracranial hemorrhage following an ATV crash in operators who do not use a helmet. Legislative efforts to implement strict helmet laws for ATV operators may be warranted. LEVEL OF EVIDENCE: Prognostic study, level III.

Age, graft size, and Tegner activity level as predictors of failure in anterior cruciate ligament reconstruction with hamstring autograft.

BACKGROUND: Patient age, Tegner activity level, and graft size could be factors that influence the outcome of anterior cruciate ligament reconstruction (ACLR) with hamstring autografts. HYPOTHESIS: Decreased graft size, higher Tegner activity score, and younger age are associated with an increased failure rate of ACLR, represented by continued knee laxity and revision surgery. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A total of 98 patients who had undergone ACLR with hamstring tendon autografts between 2000 and 2007 were identified from a computerized relational database. Inclusion criteria consisted of a minimum of 2 years of follow-up, all age groups, and all activity levels. Exclusion criteria consisted of treatment with other grafts or previous ligament surgery, previous ACL repairs, bilateral ACL injuries, and associated ligament tears. Failure was defined as a 2+ Lachman result, positive pivot shift, and 5-mm difference or more on KT-1000 arthrometer measurement. RESULTS: Fifteen of the 98 ACLRs (15.3%) were defined as failures. Of the failures, 12 of 48 (25%) occurred in patients aged 25 years and younger, whereas 3 of 50 (6%) occurred in patients older than 25 years. There was a statistically significant association when comparing failure rate and age groups (P = .009); however, a significant association was not found between graft size and failure rate in the entire study population (P = .135) or within the different age groups (age ≤25 years vs. >25 years) based on failure rate (P = .390 and P = .165, respectively). No statistical significance was found when Tegner activity level and failure rate were compared in the overall study population (P = .463) or within age groups (≤25 years, P = .707; >25 years, P = .174). CONCLUSION: In this study population, younger patients (≤25 years) demonstrated a higher failure rate compared with the over-25 age group. A statistically significant difference was not found in terms of graft size and activity level correlating with failure rate in ACL reconstruction with hamstring autograft.

Section for residents and fellows-in-training survey results.

OBJECTIVES: (1) To present data from the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) Section for Residents and Fellows-in-Training (SRF) annual survey from 2002 to 2011. (2) To compare and analyze trends in resident demographics, residency experiences, and post-training career choices. STUDY DESIGN: Review of cross-sectional survey data. SETTING: Residents and Fellows registered as Members-in-Training through AAO-HNS. METHODS: A review of data from surveys distributed between 2002 and 2011 was conducted. Respondent demographic data including age, postgraduate year, gender, and geographic distribution were analyzed. Responses about training experiences, fellowship selection, debt burden, and post-training practice choice were studied in order to elicit trends. RESULTS: Respondents have consistently rated otolaryngology, anesthesia, and trauma/critical care as the most important intern rotations for otolaryngology residents. Each year, approximately 70% of respondents have reported interest in pursuing a fellowship. Pediatric otolaryngology fellowship is now the most popular fellowship among respondents. There has been a recent increase in the percentage of respondents who are interested in pursuing a career in academics. Location, family, and lifestyle have consistently been the most important factors in determining choice of practice. Respondents have reported increasing levels of educational debt. CONCLUSION: The AAO-HNS SRF survey collects important data regarding resident/fellow training. Several factors limit the generalizability of these results. Despite its limitations, these unique data provide valuable information for continual evaluation and improvement of physician training in the specialty.

Dietary recommendations in ambulatory care: evaluation of the Southern Remedy Healthy Eating Plate.

There are few useful tools to provide dietary health education including calorie and portion control to patients, particularly in a busy ambulatory health care setting. In this report, we provide results of the evaluation of an adaptation of the recent US Department of Agriculture dietary recommendations modified for the southern diet and individuals with limited knowledge of healthy eating. Using standardized methods, we found that the "Southern Remedy Healthy Eating Plate" was well accepted by patients and can be used quickly and effectively in the outpatient setting. Moreover, the review of this placemat with easy to understand instructions for meals and snacks was associated with acceptable levels of data retention after a single visit averaging 5 minutes. Although the need for some modification of instruction techniques was identified, the Southern Remedy Healthy Eating Plate appears to be a practical and useful format for providing structured dietary counseling and education in this setting and others.

The effect of prayer on depression and anxiety: maintenance of positive influence one year after prayer intervention.

OBJECTIVE: To investigate whether the effect of direct contact person-to-person prayer on depression, anxiety, and positive emotions is maintained after 1 year. DESIGN, SETTING, AND PARTICIPANTS: One-year follow-up of subjects with depression and anxiety who had undergone prayer intervention consisting of six weekly 1-hour prayer sessions conducted in an office setting. Subjects (44 women) completed Hamilton Rating Scales for Depression and Anxiety, Life Orientation Test, and Daily Spiritual Experiences Scale after finishing a series of six prayer sessions and then again a month later in an initial study. The current study reassessed those subjects with the same measures 1 year later. One-way repeated measures ANOVAs were used to compare findings pre-prayer, immediately following the six prayer sessions, and 1 month and again 1 year following prayer interventions. RESULTS: Evaluations post-prayer at 1 month and 1 year showed significantly less depression and anxiety, more optimism, and greater levels of spiritual experience than did the baseline (pre-prayer) measures (p < 0.01 in all cases). CONCLUSIONS: Subjects maintained significant improvements for a duration of at least 1 year after the final prayer session. Direct person-to-person prayer may be useful as an adjunct to standard medical care for patients with depression and anxiety. Further research in this area is indicated.