Playing Surface and Sport Contact Status Modulate Time to Lower Extremity Musculoskeletal Injury at a Greater Level than Concussion History Among Collegiate Student-Athletes.

OBJECTIVES: While previous investigations have demonstrated a positive correlation between previous concussion and risk of subsequent lower extremity musculoskeletal injury (LEMSKI), the effect of sport- and patient-specific factors on time to injury has not been thoroughly described. This study's main objective was to evaluate the relationship between prior concussion and time to LEMSKI among a population of collegiate student-athletes. Secondary objectives were to evaluate the relationship between playing surface, sport contact status, and biologic sex on time to LEMSKI. We hypothesized that those with previous concussion, those competing on synthetic surfaces, and those competing in collision sports would experience decreased latency to LEMSKI overall. METHODS: A retrospective observational analysis of National Collegiate Athletic Association (NCAA) Division I student-athletes was conducted utilizing a mixed linear model analysis with contrasts. Inclusion criteria included participation in the Pac-12 Health Analytics Program with a documented LEMSKI between 2017 and 2020. Exclusion criteria included concurrent concussion and LEMSKI, injury resulting in serious morbidity or mortality, and incomplete medical record. Participants were classified by whether they sustained a concussion prior to LEMSKI in each athletic season. RESULTS: Of 1179 athletes included, 1140 had no previous concussion and 37 had a previous concussion. There was no observed effect of previous concussion (F=0.038; p=0.846) on time to LEMSKI overall. Student-athletes competing on constructed surfaces sustained a subsequent LEMSKI 14.5 days sooner (SE=5.255; p=0.045), and those competing on organic surfaces sustained a subsequent LEMSKI 23.5 days sooner (SE=4.018; p<0.001) in the season than those competing on synthetic surfaces. Contact sport student-athletes sustained a subsequent LEMSKI 52.1 days sooner than collision sport student-athletes (SE=5.248; p<0.001), and limited contact sport student-athletes sustained a subsequent LEMSKI 42.29 days sooner than collision sport student-athletes (SE=4.463; p<0.001). There was no observed effect of biologic sex (F=0.602; p=0.438) on time to LEMSKI overall. CONCLUSION: There was no observed impact of concussion on time to LEMSKI overall in this collegiate athletic population. Contact sports were associated with decreased time to LEMSK, while synthetic surfaces were associated with increased time to LEMSKI in this population. There was no observed impact of biologic sex on time to LEMSKI. LEVEL OF EVIDENCE: Case-control, level of evidence III.

Noninvasive Soft Tissue Expansion Strips and Wound Complications After Total Ankle Arthroplasty.

BACKGROUND: Total ankle arthroplasty through the anterior approach (TAR-AA) is an increasingly popular treatment for ankle arthritis, but it carries a known risk for wound complications. Several products have been investigated to mitigate this risk; however, most are either costly or invasive. Noninvasive skin expansion strips (NSESs) were designed to transfer tension away from the incision and induce new skin growth at the edges of the strips. We hypothesize that postoperative application of NSESs will decrease unplanned clinic visits and wound complications after TAR-AA. METHODS: This is a prospective cohort study of 41 patients at a single institution (3 surgeons) treated with NSESs after undergoing TAR-AA. An additional 41 consecutive historical patients treated without NSESs were retrospectively included as a control group. Patients received application of NSESs in the operating room after routine wound closure and again 2 weeks postoperatively. No other changes were made to the surgeons' wound closure technique, immobilization, follow-up timing, or rehabilitation protocols. Primary outcomes included (1) additional clinic visit required for wound assessment or suture removal, (2) superficial wound complication, and (3) deep infection. RESULTS: Baseline demographics did not differ significantly from our 41 consecutively treated historical controls. Additional clinic visits for suture removal or wound evaluation were significantly lower for patients treated with NSESs (15%, 6 of 41) compared to the control group (49%, 20 of 41) (P = .001). There was also a significant difference in the superficial wound complication rate in the treatment group vs control group, 2% and 12%, respectively (P = .04). There were no deep infections in either group. CONCLUSION: Noninvasive skin expansion strips placed after TAR-AA with an anterior approach have the potential to decrease wound complications and unplanned clinic visits. Further high-volume or randomized studies are needed to clarify their cost effectiveness and effect on long-term outcomes. LEVEL OF EVIDENCE: Level II, prospective cohort study.

Two Orthogonal Nitinol Staples and Combined Nitinol Staple-Screw Constructs for a First Metatarsophalangeal Joint Arthrodesis: A Biomechanical Cadaver Study.

BACKGROUND: End-stage hallux metatarsophalangeal (MTP) joint arthritis is commonly treated with arthrodesis using stainless steel or titanium implants. These implants provide static compression that is maximal at the time of implant insertion. Alternatively, nitinol staples are capable of dynamic compression. They have most frequently been used for midfoot arthrodesis procedures. However, their biomechanical performance during hallux MTP arthrodesis has not been described. METHODS: 8 matched pairs of cadaveric feet (4 female, 4 male) were prepared for hallux MTP arthrodesis using cup and cone reamers. Cadaveric pairs were then instrumented with either (1) a transarticular lag screw and dorsal nitinol staple or (2) orthogonal nitinol staples placed dorsally and medially. Walking in a short leg cast for 6 weeks was simulated by applying 90-N forces at 3 Hz to the plantar proximal phalanx for up to 250 000 cycles. Failure was defined as catastrophic implant failure or plantar gapping beyond 7 mm. RESULTS: 15 of 16 specimens failed cyclic loading. All 8 specimens fixed with orthogonal staples failed at an average of 37 ± 81 cycles. 7 of 8 specimens fixed with a dorsal staple and crossed screw failed at 14 900 ± 39 000 cycles. Collectively, 5 specimens failed because of bone fracture (1 in orthogonal staples, 4 in staple-screw group) and 10 failed because of excessive gap formation (7 in orthogonal staples, 3 in staple-screw group). The number of cycles to failure was significantly lower (P = .0469) in the orthogonal staple constructs compared with the dorsal staple and crossed screw constructs. CONCLUSION: The tested constructs permit significant motion at the first MTP fusion surface during simulated protected weightbearing. Although multiple in vivo factors should be considered when extrapolating results from this cadaveric study, this motion may result in clinical failure with early postoperative weightbearing protocols. CLINICAL RELEVANCE: We report the first biomechanical evaluation of hallux MTP arthrodesis using modern nitinol staples in 2 separate constructs.

Diagnostic Accuracy of the Progressive Collapsing Foot Deformity (PCFD) Classification.

BACKGROUND: A consensus group recently proposed the term progressive collapsing foot deformity (PCFD) and a new classification with 2 stages plus 5 classes to describe the complex array of flatfoot deformities. This study aimed to validate different diagnostic accuracy rates of the PCFD classification. METHODS: This was a survey-based study distributed among 13 foot and ankle fellowship programs for 3 groups of participants with varied experience in practice (group 1: fellows in training, group 2: surgeons in practice for 1-4 years, and group 3: surgeons in practice for ≥5 years). Each participant was asked to assign 20 different cases of flatfoot deformity to the appropriate classes and stages using the PCFD classification. The overall diagnostic accuracy, class, and stage diagnostic accuracy rates for the 20 cases were calculated first for the entire cohort and then compared among the 3 groups. The misdiagnosis rate for each class of deformity (the sum of overdiagnosis and underdiagnosis rates) of the entire cohort was calculated and compared with the other classes. Mean and standard evidence were used to describe numerical data. One-way analysis of variance was used to compare values among the 3 groups and the 5 classes. P <.05 was considered statistically significant. RESULTS: For the whole cohort, the overall diagnostic accuracy, class diagnostic accuracy, and stage diagnostic accuracy rates were 71.0%, 78.3%, and 81.7%, respectively There was a statistically significant difference between group 1 and 2, and group 1 and 3, in overall diagnostic accuracy and class diagnostic accuracy, with no significant difference among the 3 groups regarding stage diagnostic accuracy. Class B had a significantly higher overdiagnosis rate than the rest of the classes, whereas class D was significantly underdiagnosed than others. The misdiagnosis rates for classes A to E were 3.3%, 17.5%, 11.1%, 26.0%, and 3.7%, respectively. CONCLUSION: The PCFD classification showed overall fair diagnostic accuracy rates. The highest diagnostic accuracy was for "hindfoot valgus deformity" and "ankle instability." Further content validation of the PCFD classification is needed to examine the terminology and interpretation of those classes with low diagnostic accuracy including "midfoot/forefoot abduction deformity," "forefoot varus deformity/medial column instability," and "peritalar subluxation/dislocation."Level of Evidence: Level II, prospective comparative study.

The Effect of a Brief, Web-Based Animated Video for Improving Comprehension and Implementation Feasibility for Reducing Anterior Cruciate Ligament Injury: A Three-Arm Randomized Controlled Trial.

Neuromuscular injury prevention training (IPT) has been shown to reduce anterior cruciate ligament (ACL) injury risk by approximately 50%, but the implementation rate is low. One of the most important modifiable barriers for implementation is coaches' comprehension of risk and intervention strategies. This study aimed to evaluate the effect of a brief, web-based, animated video on ACL injury prevention comprehension and IPT implementation feasibility. Coaches in landing and cutting sports were recruited and randomized into three groups. (1) Intervention: brief multimedia animated video about ACL injury and prevention. (2) Active control: commonly accessed, text-based web resource about ACL injury and prevention. (3) Placebo control: brief multimedia video about concussions. Overall ACL comprehension-composed of basic ACL knowledge, risk knowledge, prevention knowledge, and severity knowledge-as well as implementation feasibility were all measured prior to and immediately following the interventions. Overall ACL comprehension improved the most in the animated video group (Cohen's d = 0.86) and, to a lesser degree, in the active control web-based article group (Cohen's d = 0.39). Both video and web-based article groups had greater implementation feasibility compared to the control group (p = 0.01). Overall, these initial results suggest that a brief, web-based, animated video has the potential to be a superior method for informing stakeholders in order to reduce traumatic injuries in sport.

A Comprehensive Primer for Quality Assessment in Orthopaedic Surgery: Quality Measures, Payment Programs, and Registries.

Practicing orthopaedic surgeons are subject to both the requirement and the opportunity to participate in individual or group quality assessment, quality-based payment programs, and clinical data registries. An important limitation to participating in and receiving the benefits of quality measuring activities and programs is the lack of a current resource outlining quality assessment models, current quality metrics, and the presence and function of current quality programs, payment models, and active orthopaedic registries. This article is intended as a primer for the practicing orthopaedic surgeon and orthopaedic groups. We provide a detailed overview of current quality metric databases, their categorization and use, and orthopaedic surgeon's role in creating and shaping the definition of quality care and outcomes assessment in the future.

Increasing educational attainment and mortality reduction: a systematic review and taxonomy.

BACKGROUND: Understanding the relationship between increasing educational attainment and mortality reduction has important policy and public health implications. This systematic review of the literature establishes a taxonomy to facilitate evaluation of the association between educational attainment and early mortality. METHODS: Following PRISMA guidelines, we searched Ovid Medline, Embase, PubMed and hand searches of references for English-language primary data analyses using education as an independent variable and mortality as a dependent variable. Initial searches were undertaken in February 2015 and updated in April 2016. RESULTS: One thousand, seven hundred and eleven unique articles were identified, 418 manuscripts were screened and 262 eligible studies were included in the review. After an iterative review process, the literature was divided into four study domains: (1) all-cause mortality (n = 68, 26.0%), (2) outcome-specific mortality (n = 89, 34.0%), (3) explanatory pathways (n = 51, 19.5%), and (4) trends over time (n = 54, 20.6%). These four domains comprise a novel taxonomy that can be implemented to better quantify the relationship between education and mortality. CONCLUSIONS: We propose an organizational taxonomy for the education-mortality literature based upon study characteristics that will allow for a more in-depth understanding of this association. Our review suggests that studies that include mediators or subgroups can explain part, but not all, of the relationship between education and early mortality. TRIAL REGISTRATION: PROSPERO registration # CRD42015017182 .

Brief Mindfulness Practices for Healthcare Providers - A Systematic Literature Review.

Mindfulness practice, where an individual maintains openness, patience, and acceptance while focusing attention on a situation in a nonjudgmental way, can improve symptoms of anxiety, burnout, and depression. The practice is relevant for health care providers; however, the time commitment is a barrier to practice. For this reason, brief mindfulness interventions (eg, ≤ 4 hours) are being introduced. We systematically reviewed the literature from inception to January 2017 about the effects of brief mindfulness interventions on provider well-being and behavior. Studies that tested a brief mindfulness intervention with hospital providers and measured change in well-being (eg, stress) or behavior (eg, tasks of attention or reduction of clinical or diagnostic errors) were selected for narrative synthesis. Fourteen studies met inclusion criteria; 7 were randomized controlled trials. Nine of 14 studies reported positive changes in levels of stress, anxiety, mindfulness, resiliency, and burnout symptoms. No studies found an effect on provider behavior. Brief mindfulness interventions may be effective in improving provider well-being; however, larger studies are needed to assess an impact on clinical care.

Screening for Social Determinants of Health in Michigan Health Centers.

OBJECTIVE: Through an academic-community partnership with a statewide consortium of health centers (HCs) in Michigan, we characterize the current scope of screening for social determinants of health (SDH). METHODS: We requested copies of forms used to screen for SDH at the 39 HC organizations in Michigan. Using content analysis, we examined variation in screening domains and processes. We present descriptive analyses of HC characteristics and patient demographics. RESULTS: We received screening documentation from 23 of the 39 HCs (59%), representing 167 delivery sites. We found broad empiric consensus regarding a core set of 13 SDH screening domains that align with nationally recommended screening guidelines. Two additional domains, Culture and Functional Status, were screened for by <40% of HCs. While patient self-report is the most frequent mode of SDH screening (41%), many HCs use staff members to administer the screening documents. CONCLUSIONS: HCs across a large and diverse state are screening for SDH and largely agree on core SDH screening domains. Using existing empiric data from frontline providers can inform potential best practices in SDH screening.

Culturally Targeted Strategies for Diabetes Prevention in Minority Population.

Purpose The purpose of this study is to (a) assess the effectiveness of culturally tailored diabetes prevention interventions in minority populations and (b) develop a novel framework to characterize 4 key domains of culturally tailored interventions. Prevention strategies specifically tailored to the culture of ethnic minority patients may help reduce the incidence of diabetes. Methods We searched PubMed, EMBASE, and CINAHL for English-language, randomized controlled trials (RCTs) or quasi-experimental (QE) trials testing culturally tailored interventions to prevent diabetes in minority populations. Two reviewers independently extracted data and assessed risk of bias. Inductive thematic analysis was used to develop a framework with 4 domains (FiLLM: Facilitating [ie, delivering] Interventions Through Language, Location, and Message). The framework was used to assess the overall effectiveness of culturally tailored interventions. Results Thirty-four trials met eligibility criteria. Twelve studies were RCTs, and 22 were QE trials. Twenty-five out of 34 studies (74%) that used cultural tailoring demonstrated significantly improved A1C, fasting glucose, and/or weight loss. Of the 25 successful interventions, 21 (84%) incorporated at least 3 culturally targeted domains. Seven studies used all 4 domains and were all successful. The least utilized domain was delivery (4/34) of the intervention's key educational message. Conclusions Culturally tailoring interventions across the 4 domains of facilitators, language, location, and messaging can be effective in improving risk factors for progression to diabetes among ethnic minority groups. Future studies should evaluate how specific tailoring approaches work compared to usual care as well as comparative effectiveness of each tailoring domain.