Increased electrode impedance as an indicator for early detection of deep brain stimulation (DBS) hardware Infection: Clinical experience and in vitro study.

BACKGROUND: When deep brain stimulation (DBS) infections are identified, they are often too advanced to treat without complete hardware removal. New objective markers to promptly identify DBS infections are needed. We present a patient with GPi (globus pallidus interna) DBS for dystonia, where the electrode impedance unexpectedly increased 3-months post-operatively, followed by serologic and hematologic markers of inflammation at 6-months, prompting explantation surgery. We recreated these conditions in a laboratory environment to analyze the pattern of changing of electrical impedance across the contacts of a DBS lead following Staphylococcus biofilm formation. METHODS: A stainless-steel culture chamber containing 1 % brain heart infusion agar was used. A DBS electrode was dipped in peptone water containing a strain of S. aureus and subsequently introduced into the chamber. The apparatus was incubated at 37 °C for 6 days. Impedance was measured at 24hr intervals. A control experiment without S. Aureus inoculation was used to determine changes in impedance over a period of 6-days. RESULTS: The mean monopolar impedance on day-1 was 751.8 ± 23.8 Ω and on day-3 was 1004.8 ± 68.7 Ω, a 33.7 % rise (p = 0.007). A faint biofilm formation could be seen around the DBS lead by day-2 and florid growth by day-3. After addition of the linezolid solution, a 15.9 % decrease in monopolar impedance was observed from day 3-6 (p = 0.003). CONCLUSION: This study gives insight into impedance trends following a hardware infection in DBS. Increased impedance outside expected norms may be valuable for early prediction of infection. Furthermore, timely management using antibiotics might reduce the frequency of infection-related explant surgeries.

Hip Range of Motion During Passive and 1-Leg Exercises Is Greater in Women: A Meta-analysis and Systematic Review.

PURPOSE: To summarize sex-related differences in hip range of motion (ROM), including flexion, extension, abduction, adduction, internal rotation, and external rotation. METHODS: We performed a systematic search of 3 databases (PubMed, CINAHL [Cumulative Index to Nursing and Allied Health Literature], and Embase). The search terms were as follows: hip, pelvis, range of motion, kinematic, men, and women. Included studies reported sex-specific data on hip ROM in healthy, uninjured adults. To generate hip ROM mean differences, a DerSimonian-Laird random-effects model was used. Effect sizes were pooled for each exercise. Subgroup analyses compared hip ROM by physical activity group: passive ROM, 1-leg hop or jump, 2-leg hop or jump, 2-leg drop or landing, 1-leg squat, 2-leg squat, walking, and jogging/running. Positive effect sizes represent greater ROM in women. RESULTS: Thirty-eight studies with 3,234 total subjects were included; of these subjects, 1,639 were women (50.1%). The mean age was 25.3 years. An effect difference was considered statistically significant if P < .05 and clinically significant if the mean difference was greater than 4.0°. Women showed statistically and clinically significantly greater hip flexion in passive ROM (mean difference, 6.4°) and during the 1-leg hop or jump exercise (mean difference, 6.5°). Women also showed statistically and clinically significantly greater hip adduction during the 1-leg hop or jump (mean difference, 4.5°) and 1-leg squat (mean difference, 4.4°) exercises, as well as statistically and clinically significantly greater hip internal rotation in passive ROM (mean difference, 8.2°). In contrast, men showed statistically and clinically significantly greater flexion during the 2-leg hop or jump exercise (mean difference, -9.1°). No clinically significant differences in extension, abduction, or external rotation were found between women and men. CONCLUSIONS: On average, women showed statistically and clinically significantly greater flexion, adduction, and internal rotation during passive and 1-leg exercises whereas men showed statistically and clinically significantly greater flexion during the 2-leg hop or jump exercise. LEVEL OF EVIDENCE: Level IV, meta-analysis and systematic review of Level II-IV studies.

Diversity in Orthopaedic Sports Medicine Societies.

Purpose: The purpose of this study was to report demographic trends in terms of ethnicity/race and gender among the membership and leadership positions of the Arthroscopy Association of North America (AANA) and the American Orthopaedic Society of Sports Medicine (AOSSM). Over the years both AANA and AOSSM will increase in diversity through their committee membership and leadership positions. Methods: AANA and AOSSM membership and leadership were reviewed for the years 2010, 2015, and 2020. Race/ethnicity was divided into Caucasian, Asian, African American (AA), Hispanic/Latin/South American (HLSA), and Middle Eastern (ME). Gender was limited to male or female, based on name and photographic depiction. Results: Diversity in AANA and AOSSM committee and leadership positions is summarized in Table 1 and Table 2, respectively. In 2010, 166/191 (87%) AANA committee members were Caucasian, as compared with 125/186 (67%) in 2020. Asian committee members were similar in 2010 (13/191, 7%) and 2015 (13/216, 6%) but increased to 17/186 (10%) in 2020. HLSA committee members increased from 5/191 (3%) 2010 to 11/186 (6%) in 2020. AA committee membership increased from 2/191 (1%) in 2010 to 5/186 (3%) in 2020. The diversity of AANA Board of Director leadership positions increased, with Caucasian representation decreasing from 14/14 (100%) 2010 to 11/12 (92%) in 2020 and Asian representation increasing from 0% in 2010 to 1/12 (8%) in 2020, with HLSA, AA and ME remaining the same with 0/12 (0%). In AANA, men comprised 181/191 (95%) committee members in 2010 and 166/186 (89%) in 2020. The percentage of female committee members increased from 10/191 (5%) in 2010 to 20/186 (11%) in 2020. In 2010, 73/79 (92%) AOSSM committee members were Caucasian compared to 62/81 (77%) in 2020 with AA having the largest increase in committee members from 0% in 2010 to 6/81 (7%) in 2020 (Table 2). Within AOSSM, men comprised 73/79 (92%) committee members in 2010 and 70/81 (86%) in 2020. The percentage of female committee members in AOSSM increased from 6/79 (8%) in 2010 to 11/81 (14%) in 2020. Conclusion: There has been a progressive trend toward increasing diversity in both committee membership and leadership positions in AANA and AOSSM from 2010 to 2020. Within AANA, there has been a decrease in the Caucasian representation from 87% in 2010 to 67% in 2020 and an increase in the female representation from 5% in 2010 to 11% in 2020. AOSSM demonstrated a similar trend, with Caucasian representation decreasing from 92% in 2010 to 77% in 2020, in addition to female percentage increasing from 8% in 2010 to 14% in 2020. Although there has been an increase in representation of minority and female orthopaedic surgeons within both societies, there is still room for more diversity and inclusion within committee membership and leadership. It is important to progress toward the understanding of the changes that need to be made and work to implement opening the field of orthopaedic sports medicine.

Females Are More Likely Than Males to Fill an Opioid Prescription in the Year After Anterior Cruciate Ligament Reconstruction.

Purpose: To report rates of preoperative and postoperative opioid use between male and female patients and to identify risk factors for extended opioid use following anterior cruciate ligament reconstruction (ACLR). Methods: Patients undergoing ACLR between 2011 and 2018 were identified from the PearlDiver database. The opioid refill rates for males vs females were compared at monthly intervals for 1 year after ACLR. Patients who filled an opioid prescription <3 months before surgery were classified as opioid users, while those who had never filled one were classified as nonopioid users. Results: Of 106,995 ACLR patients, 37,890 (35.4%) were opioid users <3 months before surgery, and 37,554 (35.1%) had never filled an opioid prescription. Of the preoperative opioid users, 20,413 (53.9%) were female and 17,477 (46.1%) were male (P < .001). Postoperatively, females were at higher risk of filling an opioid prescription at each monthly interval, except for the first month after surgery. The refill rate for opioid users was also higher than that for nonopioid users at each monthly interval after ACLR. In addition to patient sex, a preoperative diagnosis of anxiety/depression, low back pain, myalgia, a history of drug dependence, alcohol abuse, and tobacco use increased a patient's risk of filling an opioid prescription postoperatively. Conclusions: This study demonstrated that females are significantly more likely to be opioid users than males prior to ACLR and are more likely to continue to refill an opioid prescription in the year following surgery. Multiple risk factors were associated with prolonged postoperative opioid utilization, including female sex, anxiety/depression, low back pain, myalgia, a history of drug dependence, alcohol abuse, and tobacco use. Level of Evidence: Level III, retrospective cohort study.

Persistent Lack of Female Orthopaedic Sports Medicine Fellows.

Purpose: To evaluate the gender composition of fellows, faculty, and leaders within orthopaedic sports medicine fellowship programs to provide a more complete description of gender diversity within this subspecialty. Methods: Official program websites of orthopaedic sports medicine fellowships listed on the Arthroscopy Association of North America fellowship directory were examined. Data collected for analysis included the gender of program directors, fellowship faculty, orthopaedic surgery department faculty, current sports medicine fellows, and fellows who graduated within the last 5 years. Results: Of the 132 orthopaedic sports medicine fellows in training in the United States in the 2021 to 2022 academic year, 113 (85.6%) were men and 19 (14.4%) were women (P < .001). Within the past 5 years, 419 fellows were listed as completing a sports medicine fellowship, with 375 (89.5%) being men, and 44 (10.5%) being women (P < .001). There was no significant difference in the gender composition of current fellows compared with the composition of fellows within the last 5 years (P = .74). When we examined gender trends in sports medicine faculty, 639 (86.6%) were men and 99 (13.4%) were women (P < .001). There were 14 women (14.4%) orthopaedic sports medicine faculty in leadership positions (i.e., program director or assistant program director) compared with 83 men in such positions (85.6%) (P < .001). Conclusions: Orthopaedic sports medicine fellowships remain heavily male-dominated on all levels, including fellows, faculty, and leadership. There were no differences in the gender composition of current fellows when compared with those who graduated in the last 5 years, suggesting persistent gender disparity and the need for novel initiatives to enhance gender diversity in sports medicine. Level of Evidence: IV, descriptive study.

Examining the Healthcare and Economic Burden of Gun Violence in a Major US Metropolitan City.

INTRODUCTION: The highest rates of fatal and nonfatal injury due to firearms occur in the Southern United States. This study examined the epidemiology of gunshot wound (GSW) injuries and the association of injury severity with mortality. METHODS: This is a retrospective cross-sectional analysis of 2016 to 2019 data from a mandatory reporting system for all licensed hospitals in Louisiana. Patients aged 18 years and older at the time of hospitalization for GSW were included. Injury severity was measured by the New Injury Severity Score (NISS). Primary outcomes assessed included mortality, length of stay, and total hospital charges. RESULTS: There were 1,709 firearm injuries identified. The patient sample was 83.2% Black and 87.4% male, with a mean age of 34 years. Orthopaedics was the most frequently consulted surgical service. Total hospital visit charges for all GSW-associated care were $262.4 million. The multivariable adjusted odds ratio and 95% confidence interval for mortality associated with a high NISS was 16.32 (8.96, 29.72). CONCLUSION: This study demonstrated the utility of NISS as a predictor of total hospital charges and length of stay, in addition to its well-established role as a predictor of mortality. Epidemiologic trends in GSW pathologies and associated procedures at a major urban trauma center were also reported. LEVEL OF EVIDENCE: Level III, prognostic study.

Bullying in Orthopaedic Surgery: A Survey of US Orthopaedic Trainees and Attending Surgeons.

INTRODUCTION: Bullying is a notable problem in surgery, creating a hostile environment for surgeons and trainees, and may negatively affect patient care. However, specific details regarding bullying in orthopaedic surgery are lacking. The primary aim of this study was to determine the prevalence and nature of bullying within orthopaedic surgery in the United States. METHODS: A deidentified survey was developed using the survey created by the Royal College of Australasian Surgeons and the validated Negative Acts Questionnaire-Revised survey tool. This survey was distributed to orthopaedic trainees and attending surgeons in April 2021. RESULTS: Of the 105 survey respondents, 60 (60.6%) were trainees and 39 (39.4%) were attending surgeons. Although 21 respondents (24.7%) stated they had been bullied, 16 victims (28.1%) did not seek to address this behavior. Perpetrators of bullying were most commonly male (49/71, 67.2%) and the victims' superior (36/82, 43.9%). Five bullying victims (8.8%) reported the behavior, despite 46 respondents (92.0%) stating that their institution has a specific policy against bullying. CONCLUSION: Bullying behavior occurs in orthopaedic surgery, with perpetrators being most commonly male and the victims' superiors. Despite the fact that an overwhelming majority of institutions have policies against bullying, the reporting of such behavior is lacking.

Evaluating Risk Factors for Biceps Tendon Injuries in Softball Players: A Systematic Review.

OBJECTIVE: Softball players commonly suffer overuse injuries due to the demands of repetitive throwing. The biceps tendon plays an important role in stabilizing the shoulder during the windmill pitch. The purpose of this study was to evaluate the measures used to identify and study biceps tendon pathology in softball players. DESIGN: This was a systematic review. SETTING: PubMed MEDLINE, Ovid MEDLINE, and EMBASE were searched. PARTICIPANTS: Studies that investigated biceps tendon injuries in softball players. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Range of motion (ROM), strength, and visual analog scale data were collected. RESULTS: Of 152 search results, 18 were included. A total of 536 of 705 athletes (76%) were softball players (average age 14-25 years). Five of 18 articles (27.7%) studied changes in external rotation with the shoulder at 90 degrees of abduction, and 4 of 18 (22.2%) studied internal rotation. Two of 18 studies (11.1%) examined ROM or strength changes in forward flexion. CONCLUSIONS: While researchers agree that the windmill pitch places significant stress on the biceps tendon, our study finds that the metrics used to evaluate shoulder pathology in these players primarily evaluate the rotator cuff without isolating the biceps tendon. Future studies should include clinical tests and biomechanical metrics more specific to identifying biceps and labral pathology (eg, strength, fatigue, and ROM in glenohumeral forward flexion, elbow flexion, and forearm supination) and attempt to clarify differences in pathology between pitchers and position players to better characterize the frequency and severity of biceps tendon pathology in softball players.

WITHDRAWN:Persistent Lack of Female Orthopaedic Sports Medicine Fellows

PURPOSE: The purpose of this study was to evaluate the gender composition of fellows, faculty, and leaders within orthopaedic sports medicine fellowship programs to provide a more complete analysis of gender diversity within this subspecialty. METHODS: Official program websites of orthopaedic sports medicine fellowships listed on the Arthroscopy Association of North America (AANA) fellowship directory were examined. Data collected for analysis included the gender of program directors, fellowship faculty, orthopaedic surgery department faculty, current sports medicine fellows, and fellows who graduated within the last five years. RESULTS: Of the 132 orthopaedic sports medicine fellows in training in the United States in the 2021-2022 academic year, 113 (85.6%) were men and 19 (14.4%) were women (p<0.001). Within the past five years, 419 fellows were listed as completing a sports medicine fellowship, with 375 (89.5%) being men, and 44 (10.5%) being women (p<0.001). There was no significant difference in the gender composition of current fellows compared to the composition of fellows within the last 5 years (p=0.74). When examining gender trends in sports medicine faculty, 639 (86.6%) were men and 99 (13.4%) were women (p<0.001). There were 14 women (14.4%) orthopaedic sports medicine faculty in leadership positions (i.e., program director or assistant program director) compared to 83 men in such positions (85.6%) (p<0.001) CONCLUSIONS: Orthopaedic sports medicine fellowships remain heavily male-dominated on all levels, including fellows, faculty, and leadership. There were no differences in the gender composition of current fellows when compared to those who graduated in the last five years, suggesting persistent gender disparity and the need for novel initiatives to enhance gender diversity in sports medicine.

Mentoring on Orthopedic Surgery Clinical Rotations: A Survey of Mentor Effectiveness on Student Mentees Compared to an Unmentored Control Group.

INTRODUCTION: Mentorship is an important aspect of medical education in providing students guidance and connections to new opportunities, ultimately leading to increased productivity and career satisfaction. The purpose of this study was to design and implement a formal mentoring program between medical students participating in their orthopedic surgery rotation and orthopedic residents to determine if this relationship improved students' experiences during their rotation compared to students who were not mentored. DESIGN: Third- and fourth-year medical students rotating in orthopedic surgery and PGY2-PGY5 orthopedic residents at one institution were eligible to participate in a voluntary mentoring program between the months of July and February during 2016 to 2019. Students were either randomly paired with a resident mentor (experimental group) or not (unmentored control group). Anonymous surveys were distributed to participants at weeks 1 and 4 of their rotation. There were no minimum number of meetings required between mentors and mentees. RESULTS: Twenty-seven students (18 mentored, 9 unmentored) and 12 residents completed surveys during week 1. Fifteen students (11 mentored, 4 unmentored) and 8 residents completed surveys during week 4. While both mentored and unmentored students experienced an increase in enjoyment, satisfaction, and level of comfort at week 4 compared to week 1, the unmentored group demonstrated a greater overall increase. However, from the perspective of the residents, excitement for the mentoring program and the perceived value of mentoring decreased and 1 (12.5%) resident felt that it detracted from their clinical responsibilities. CONCLUSION: While formal mentoring enhanced the experience of medical students on orthopedic surgery rotations, it did not substantially improve medical student perceptions when compared to students who did not receive formal mentoring. The greater satisfaction and enjoyment observed in the unmentored group may be explained by informal mentoring that naturally occurs among students and residents with similar interests and goals.

Concomitant Tibial Tubercle Osteotomy Reduces the Risk of Revision Surgery After Medial Patellofemoral Ligament Reconstruction for the Treatment of Patellar Instability.

PURPOSE: To compare postoperative complication rates between patients who underwent medial patellofemoral ligament reconstruction (MPFLR) and those who underwent MPFLR with tibial tubercle osteotomy (TTO) in a large-scale study. A secondary goal was to investigate demographic associations with outcomes. METHODS: Patients who underwent MPFLR (n = 3,480) or MPFLR-TTO (n = 615) for patellar instability were identified in the PearlDiver database. Rates of surgery for infection, procedures for knee stiffness, patellar fracture, and revision MPFLR within 2 years postoperatively were compared using multivariable logistic regression. Demographic associations with outcomes were also investigated. RESULTS: The MPFLR-TTO cohort exhibited a significantly lower rate of revision surgery at 2 years (0.8% vs 1.9%; odds ratio [OR], 0.33; 95% confidence interval [CI], 0.10-0.80; P = .036) when compared with the MPFLR group. Independent of index procedure, patients younger than 21 years had significantly lower rates of requiring procedures for knee stiffness (OR, 0.35; 95% CI, 0.22-0.54; P < .001) and any complication at 2 years (OR, 0.59; 95% CI, 0.45-0.78; P < .001) when compared with older patients. Male patients displayed a significantly lower rate of requiring procedures for knee stiffness at 2 years than female patients (OR, 0.46; 95% CI, 0.25-0.78; P = .007). Tobacco use was associated with a significantly higher rate of postoperative infection at 2 years (OR, 2.35; 95% CI, 1.00-5.38; P = .046). CONCLUSIONS: The MPFLR cohort exhibited higher rates of revision surgery at 2 years compared with the MPFLR-TTO cohort. Patient age under 21 years was associated with lower rates of any complication and requiring procedures for knee stiffness, male sex was associated with a lower rate of requiring procedures for knee stiffness, and tobacco use was associated with a higher rate of surgery for postoperative infection. This information can assist surgeons when counseling patients before these procedures are performed. LEVEL OF EVIDENCE: Level III, retrospective, comparative prognostic trial.

Return to Play After Shoulder Arthroscopy in Major League Baseball Pitchers vs Position Players.

Background: Recovery from shoulder arthroscopy may vary between professional pitchers and position players in Major League Baseball (MLB). The time that it takes to return to play (RTP) and the level of skills to be regained after surgery are important factors for an athlete to consider when making career decisions. Purpose: To identify MLB players who had arthroscopic shoulder surgery and observe their rates of RTP to MLB and the minor league, as well as to compare pre- and postinjury performance statistics and career metrics. Study Design: Descriptive epidemiology study. Methods: Public records (press releases, http://www.prosportstransactions.com, http://www.baseball-reference.com) were searched and analyzed to determine the number of days from shoulder arthroscopy to RTP and pre- and postinjury statistics for pitchers and position players in the MLB and minor league from 1998 to 2018. To meet inclusion criteria, a player must have undergone shoulder arthroscopy after having played at least 1 game in the MLB and had no identifiable concomitant injuries. Results: Of 134 players, 89 (66.4%) returned to MLB. Fifty-four of 89 pitchers (60.7%) and 35 of 45 position players (77.8%) returned to MLB (P = .048). Forty-nine of 54 pitchers (90.7%) and 23 of 35 position players (65.7%) who returned to MLB returned to the minor league first. The mean time to RTP was 469.6 days (range, 100-1079 days) for pitchers and 301.6 days (range, 94-1488) for position players (P = .002). The WAR statistic (wins above replacement) for the pitchers decreased significantly (P = .004) after shoulder arthroscopy. Conclusion: MLB position players returned to play at higher rates and more quickly than did pitchers. The WAR statistic declined in pitchers during the first season of RTP. Players undergoing arthroscopic shoulder surgery should be aware of these possible outcomes in time to RTP and postoperative performance.

Doximity Orthopaedic Surgery Program Rankings Are Associated with Academic Productivity.

Doximity residency rankings are used to compare training programs. Reputation is a component of Doximity rankings and is based on physician surveys. Outcomes-based measures allow for objective program comparison and may be more appropriate when assessing programs. This study evaluated how Doximity rankings of orthopaedic surgery residency programs compare with an outcomes-based ranking of programs based on academic productivity. This study also evaluated whether program size and type were associated with academic productivity. Methods: Orthopaedic program rankings, size, type, and research productivity were recorded from Doximity. An academic productivity score was calculated by averaging the mean percentage of alumni clinical trials and alumni publications. Analysis of variance and post hoc analyses were performed to determine whether academic productivity was associated with program reputation, size, and type. Results: One hundred seventy-five orthopaedic residency programs were included. Program rankings, size, and type had a statistically significant association with academic productivity (p < 0.0001). The 44 orthopaedic programs in the top quartile had an academic productivity score of 79.1 ± 13 in comparison with programs in the bottom quartile, who had a score of 38.3 ± 12.1 (p < 0.0001). Of the programs in the top quartile of reputation rankings, 32 (73%) were also in the top quartile for academic productivity. Programs with more residents demonstrated greater academic productivity than smaller programs. Twenty-three programs (13%) had more than 30 residents and a mean academic productivity of 76.2 ± 14.8. In comparison, 13 programs (7.5%) had 10 or fewer residents with an academic productivity score of 40.6 ± 16.3 (p < 0.0001). An academic productivity score differed significantly based on program type: university (63.9 ± 14.8), military (54.7 ± 16.9), university/community (46.3 ± 15.6), and community (38.7 ± 15) (p < 0.0001). Conclusions: Academic productivity among orthopaedic residency programs is associated with Doximity ranking, program size, and type. This information can be used by medical students, residents, and physicians to understand the Doximity rankings and how they correlate with this objective measure. Level of Evidence: III.

Part II: Risk Factors for Stress Fractures in Female Military Recruits.

INTRODUCTION: Stress fractures (SFx) represent a significant proportion of injuries in military recruits internationally. Stress fractures disproportionately affect female recruits, a disparity that has similarly been consistently demonstrated in female athletes. Stress fractures result in medical morbidity, financial burden, and medical discharge from military service. This review presents current literature regarding SFx risk factors to identify and/or mitigate in this high-risk population. METHODS: A literature review was conducted using PubMed to find relevant articles. We utilized keywords stress fracture, military, recruits, female, risk factors, modifiable, non-modifiable, overuse, nutrition, and/or prevention. Articles older than 10 years (published before 2010) were not considered. Review articles were considered, but if a research article was cited by a review, the research was included directly. Articles with primary military data, members of the military as subjects, especially when female recruits were included, were strongly considered for inclusion in this review. RESULTS: Modifiable risk factors for SFx include nutritional deficiency, especially of iron, vitamin D, and possibly calcium, poor physical fitness, suboptimal training programming for injury development and recovery, load carriage, and military footwear. Non-modifiable risk factors include female sex, greater height, lower weight and body mass index in females but lower or higher weight and body mass index in males, lower body fat percentage, and lower bone mineral density. In addition, menstrual dysfunction, low energy availability, later age at menarche, and iron deficiency pose unique risks to female recruits. Preventive measures include leadership education, programs with recovery considerations, and risk factor screening. CONCLUSION: This review, Part II of a two-part series, guides multidisciplinary management of military recruits, especially females, who are at risk for developing SFx. Unique nuances of the military recruit require specific knowledge to reduce high incidence rates of injury internationally.

Part I: Background and Clinical Considerations for Stress Fractures in Female Military Recruits.

INTRODUCTION: Stress fractures (SFx) represent a significant proportion of musculoskeletal injuries in military recruits internationally. Incidence rates as high as 40% have been reported, varying by country and branch of military cohorts. Tibial SFx are the most common, followed by other lower extremity sites, and are related to the emphasis on running during training. SFx disproportionately affect female recruits, similarly to a disparity demonstrated in female athletes. METHODS: A literature review of articles relevant to our review was conducted using PubMed, utilizing keywords stress fracture, military, recruits, diagnosis, management, treatment, prevention, epidemiology, background, and/or female. Articles older than 10 years old (prior to 2010) were not considered. Review articles were considered, but if a research article was cited by a review, the research was included directly. Articles with primary military data, members of the military as subjects, especially when female recruits were included, were strongly considered for inclusion in this review. RESULTS: SFx can cause medical morbidity and financial burden and can require discharge from military service. SFx management in the military has cost the United States approximately $100 million annually, which may be underestimated due to lost duty hours or medical discharge with resulting compensation. However, SFx incidence rates have been demonstrated to be reducible with concerted efforts in military cohorts. CONCLUSION: This review, Part I of a two-part series, provides updated information for multidisciplinary management of SFx in female military recruits. There are many similarities to management in athletes, but unique nuances of the military recruit require specific knowledge to reduce the high incidence rates of injury.

Closure of the Quadriceps Tendon Autograft Harvest Site for Anterior Cruciate Ligament Reconstruction: A Systematic Review.

BACKGROUND: The quadriceps tendon (QT) autograft is a commonly used and effective graft option for anterior cruciate ligament reconstruction (ACLR). Surgical techniques vary, and there is no current standard of care for management of the QT autograft harvest site. PURPOSE: To examine the literature on patient-reported outcomes and complications after ACLR with a QT autograft and to further clarify the frequency with which the harvest site is closed and potential biomechanical implications. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: A systematic review according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was performed using multiple medical databases. Level 1 to 4 studies on patients undergoing ACLR with a QT autograft were included. There were 2 independent reviewers who analyzed all studies. Study quality was analyzed using the methodological index for non-randomized studies checklist. RESULTS: Overall, 13 studies with a total of 650 patients were included. The mean patient age for all studies was 31 years (range, 14-59 years) with a mean follow-up of 21.2 months (range, 6-84 months). Of the 13 studies, 12 studies (92%) documented patient sex, comprising 331 female patients (55%) and 274 male patients (45%). There were 8 studies (62%) that reported the use of a bony QT autograft in 273 patients, and 5 studies (38%) reported the use of a soft tissue QT autograft in 377 patients. The graft length harvested was most commonly 7 to 8 cm, while the tendon width harvested was 10 mm. Moreover, 5 studies (38%) did not discuss closure of the harvest site, while 2 studies (15%) only closed the harvest site if a capsular rent was present. The surgical technique for harvest-site closure varied when reported in 7 studies (54%). Good to excellent clinical outcomes were reported in 80% of patients when the harvest site was closed. CONCLUSION: Based on the results of this study, there is no consensus on whether the QT defect should be closed after harvesting the graft for ACLR. It has been reported that closure of the harvest site is performed if there is a capsular rent present. Several techniques are utilized to close the QT autograft harvest site; however, it is unclear if there is a difference in outcomes based on the technique used. Future studies should further clarify whether there are any biomechanical and clinical advantages to closing the QT autograft harvest site.

Quality Assessment of YouTube Content on SLAP Tears.

OBJECTIVES: Superior labrum anterior posterior (SLAP) tears can cause shoulder pain, disability, instability, and humeral head translation. YouTube has become an increasingly popular source of medical information, but little is currently known in terms of quality control of the uploaded content. The purpose of this study was to assess the quality of YouTube videos related to the diagnosis and treatment of Superior Labrum Anterior Posterior (SLAP) tears. METHODS: YouTube was queried in August 2021 using the two predetermined keywords: 'SLAP tear' and 'superior labral tear.' The first 50 videos were analyzed by two independent reviewers and scored using 3 scoring systems: Global Quality Scale (GQS), the Journal of the American Medical Association (JAMA), and the Shoulder-Specific Score (SSS) to determine video accuracy and reliability. Title, number of views, video duration, video source, content type, views/day, number of likes, number of dislikes, days since upload, like ratio (Like × 100/ [Like + Dislike]) and Video Power Index (VPI) (Like ratio × View ratio/100) were all recorded and analyzed. RESULTS: The scores of most videos were low, with a mean JAMA score of 2.5 (1-4, SD 0.73), a mean GQS of 2.66 (0.5-4.5, SD 0.99) and a mean SSS of 7.13 (0-18, SD 4.39). There were significantly higher mean scores for JAMA, GQS, and SSS in the academic and independent physician categories, with a mean JAMA score of 3.11, GQS score of 3.39, and SSS score of 11 for academic sources and a mean JAMA score of 2.83, GQS score of 3.23, and SSS score of 9.23 for independent physician sources. JAMA score was significantly and positively correlated with video duration (r = 0.405, p = 0.006). Views, likes, dislikes, publication dates, and VPI were not significantly correlated with any scoring scale. CONCLUSION: YouTube videos on the diagnosis and management of SLAP tears have low overall quality and reliability scores. Independent physician and academic institution sources received higher mean scores for JAMA, GQS, and SSS. Video quality was not correlated with number of views.

Age, female sex, and oral contraceptive use are risk factors for anterior cruciate ligament reconstruction: A nationwide database study.

BACKGROUND: The purpose of this study was to investigate risk factors affecting anterior cruciate ligament (ACL) tears and outcomes following ACL reconstruction in males versus females. This study also analyzed oral contraceptive pill (OCP) use, demographics (e.g., body mass index [BMI], age group), comorbidities (e.g., diabetes, hypertension), and post-operative systemic complications (e.g., anemia, malignant hyperthermia) in patients undergoing ACL reconstruction. METHODS: Medical records of patients undergoing ACL reconstruction from 2010-2018 were queried from the PearlDiver administrative claims database current procedural terminology (CPT) and international classification of disease (ICD) codes. The following information was collected using ICD-9/ICD-10 codes: concurrent use of OCPs, concomitant meniscus repair, demographics, age, comorbidities, and systemic complications. The number of ACL reconstructions in females and males were analyzed using multivariate regressions. RESULTS: Of 11,498 ACL reconstructions, 5,967 (51.9%) were in females and 5,531 (48.1%) were in males. The majority of patients were ages 15-19 (24.1%) and were not obese (BMI < 30 kg/m2) (35.9%). A greater proportion of female patients undergoing ACL reconstruction were between 15-19 years old (P < 0.001) and obese (BMI > 40 kg/m2) (P < 0.001). A larger proportion of females aged 15-39 taking OCPs underwent ACL reconstruction compared to those not taking OCPs within the same age group (P < 0.001). CONCLUSION: ACL tears are more common in female patients compared to males and are more commonly treated with ACL reconstruction. This study identified several factors that may be associated with the increased risk of ACL tears in females, including young age (age 15-39), obesity (BMI > 40 kg/m2), and the use of OCPs prior to ACL reconstruction, which warrant further investigation and attention from surgeons.

Sport Specialization Classification and Injury Risk in Female Athletes.

BACKGROUND: Description of possible detrimental effects of sport specialization specific to adolescent female athletes is limited in current literature with no consensus on sport specialization classification. HYPOTHESIS: Specialized female athletes will have higher rates of injury, body image issues, and menstrual dysfunction, regardless of the specialization classification utilized. STUDY DESIGN: Cross-sectional. LEVEL OF EVIDENCE: Level 3. METHODS: Retrospective data was obtained from questionnaires from female athletes in local high schools (n = 229; 13-18 years of age). The 3-point specialization scale was used to analyze differences in injury rates, body image issues, and menstrual dysfunction within low, moderate, and highly specialized athletes. When comparing accuracy of specialization scales in identifying high risk athletes, three peer-reviewed specialization classification scales were utilized-a 3-point scale, a 6-point scale, and a binary self-selection scale. Odds ratios (OR) and 95% confidence intervals (CI) were calculated for studied variables (a priori p ≤ 0.05). RESULTS: Of 229 athletes surveyed, 219 (95.6%) completed the 3-point specialization classification questions and were included in the study. 91 athletes (41.6%) were categorized as low specialization (LS), 59 (26.9%) were moderately specialized (ModS), and 69 (31.5%) were highly specialized (HS). ModS athletes were more likely to have a history of stress fractures (SFx) compared to LS athletes (p = 0.02; OR 3.62; 95% CI 1.27-10.26). Compared to LS athletes, HS athletes were more likely to have injury history (p = 0.01; OR 2.93; 95% CI 1.38-6.24) and a history of concussion (p < 0.01; OR 5.00; 95% CI 1.86-13.42). CONCLUSION: Among female high school athletes, higher levels of specialization are associated with greater risk of injuries overall, and greater risk of concussions and SFx. This study did not demonstrate significant associations between specialization and body image issues or menstrual dysfunction. CLINICAL RELEVANCE: This study further strengthens the association between injury and sport specialization and suggests that combining specialization scales better improves risk stratification which overall aids in preventing athlete injury.