Disparities in concussion diagnoses compared to ankle injuries.

BACKGROUND: Health disparities related to concussions have been reported in the literature for certain minority populations. Given the significant impact of concussions on long- and short-term function, the mitigation of barriers to accessing care is an important public health objective. OBJECTIVE: To determine if racial and ethnic disparities exist in patients who seek care for concussions compared to a control group with orthopedic ankle injuries (sprains and fractures) to minimize confounding factors that predispose to injury. DESIGN: Cohort study. SETTING: Single institution between February 2016 and December 2020. PATIENTS: A retrospective review of electronic medical records was completed for patients with International Classification of Diseases, Tenth Revision (ICD-10) diagnosis codes for concussion, ankle sprain, and ankle fracture. A total of 10,312 patients were identified: 1568 (15.2%) with concussion, 4871 (47.3%) with ankle sprain, and 3863 (37.5%) with ankle fracture. INTERVENTIONS: Patients were stratified by demographic factors, including sex, ethnicity, race, and insurance type. MAIN OUTCOME MEASURES: Diagnosis of concussion. RESULTS: The concussion group was the youngest (28.3 years ± 18.0) and had the fewest females (53.1%) compared to the ankle sprain (35.1 years ± 19.7; 58.7%) and fracture groups (44.1 years ± 21.3; 57.3%). The concussion group had a smaller proportion of Hispanic patients than the ankle sprain group (odds ratio [OR] 0.71, 95% confidence interval [CI] 0.55-0.92, p = .010) and fracture group (OR 0.58, 95% CI 0.44-0.75, p = <.001). In addition, the concussion group was less likely to be Asian (OR 0.70, CI 0.52-0.95, p = .023) than the sprain group and less likely to be Black/African American than both sprain (OR 0.65, 95% CI 0.46-0.93, p = .017) and fracture groups (OR 0.62, 95% CI 0.43-0.89, p = .010). There were no differences across racial groups between ankle sprains and fractures. Patients with Medicaid/Medicare and self-pay had a higher likelihood of being in the concussion group than those with private insurance. CONCLUSION: Differences in concussion diagnosis may exist between certain demographic groups compared to those with ankle injuries. Efforts to mitigate disparities in concussion care are worthwhile with a focus on patient and caregiver education.

The Relationship between Bacterial Load and Initial Run Time of a Surgical Helmet.

Background: Periprosthetic joint infection (PJI) is a complication of arthroplasty surgery with significant morbidity and mortality. Surgical helmets are a possible source of infection. Pre-existing dust and microorganisms on its surface may be blown into the surgical field by the helmet ventilation system. Methods: Twenty surgical helmets at our institution were assessed through microscopy and polymerase chain reaction testing. Helmets were arranged with agar plates under the front and rear outflow vents. Helmets ran while plates were exchanged at different time points. Bacterial growth was assessed via colony counts and correlated with fan operating time. Gram staining and 16S sequencing were performed to identify bacterial species. Results: The primary microbiological contaminate identified was Burkholderia. There was an inverse relationship between colony formation and fan operating time. The highest number of colonies was found within the first minute of fan operating time. There was a significant decrease in the number of colonies formed from the zero-minute to the three (27 vs 5; P = <.01), four (27 vs 3; P = <.01), and five-minute (27 vs 4; P = <.01) time points for the front outflow plates. A significant difference was also observed between the one-minute and four-minute time points (P = .046). Conclusion: We observed an inverse relationship between bacterial spread helmet fan operation time, which may correlate with dispersion of pre-existing contaminates. To decrease contamination risk, we recommend that helmets are run for at least 3 min prior to entering the operating room.

Particulated Juvenile Articular Cartilage and Matrix-Induced Autologous Chondrocyte Implantation Are Cost-Effective for Patellar Chondral Lesions.

PURPOSE: To compare the cost-effectiveness of nonoperative management, particulated juvenile allograft cartilage (PJAC), and matrix-induced autologous chondrocyte implantation (MACI) in the management of patellar chondral lesions. METHODS: A Markov model was used to evaluate the cost-effectiveness of three strategies for symptomatic patellar chondral lesions: 1) nonoperative management, 2) PJAC, and 3) MACI. Model inputs (transition probabilities, utilities, and costs) were derived from literature review and an institutional cohort of 67 patients treated with PJAC for patellar chondral defects (mean age 26 years, mean lesion size 2.7 cm2). Societal and payer perspectives over a 15-year time horizon were evaluated. The principal outcome measure was the incremental cost-effectiveness ratio (ICER) using a $100,000/quality-adjusted life year (QALY) willingness-to-pay threshold. Sensitivity analyses were performed to assess the robustness of the model and the relative effects of variable estimates on base case conclusions. RESULTS: From a societal perspective, nonoperative management, PJAC, and MACI cost $4,140, $52,683, and $83,073 and were associated with 5.28, 7.22, and 6.92 QALYs gained, respectively. PJAC and MACI were cost-effective relative to nonoperative management (ICERs $25,010/QALY and $48,344/QALY, respectively). PJAC dominated MACI in the base case analysis by being cheaper and more effective, but this was sensitive to the estimated effectiveness of both strategies. PJAC remained cost-effective if PJAC and MACI were considered equally effective. CONCLUSIONS: In the management of symptomatic patellar cartilage defects, PJAC and MACI were both cost-effective compared to nonoperative management. Because of the need for one surgery instead of two, and less costly graft material, PJAC was cheaper than MACI. Consequently, when PJAC and MACI were considered equally effective, PJAC was more cost-effective than MACI. Sensitivity analyses accounting for the lack of robust long-term data for PJAC or MACI demonstrated that the cost-effectiveness of PJAC versus MACI depended heavily on the relative probabilities of yielding similar clinical results. LEVEL OF EVIDENCE: III, economic and decision analysis.

Combined MPFL Reconstruction with Tibial Tubercle Osteotomy and Repair of Patellar Cartilage Defect with Particulated Juvenile Articular Cartilage.

Medial patellofemoral ligament (MPFL) reconstruction with tibial tubercle osteotomy (TTO) and particulated juvenile articular cartilage (PJAC) grafting can be performed in combination for the treatment of recurrent patellar instability with associated patellar cartilaginous defects. Description: Preoperative planning is an essential component for this procedure. Measurement of the tibial tubercle to trochlear groove (TT-TG) distance and the Caton-Deschamps index (CDI) allows for determination of the degree of medial and anterior translation and helps to identify whether distalization is necessary. The procedure begins with a thorough examination under anesthesia to determine range of motion, patellar tracking, translation, and tilt. A diagnostic arthroscopy is performed, at which time patellar tracking is again assessed and the patellar and trochlear cartilage are evaluated. A medial parapatellar incision is made, and the layer between the capsule and retinaculum is identified. This layer will serve as the location for the MPFL graft passage. The medial patella is decorticated to prepare for graft fixation. The patella is then everted, and the cartilaginous defect is prepared and sized. The PJAC graft is prepared on the back table based on these measurements. The MPFL graft is then anchored to the decorticated medial patella. Attention is then turned to performing the TTO. The patellar tendon is isolated and protected. The osteotomy shingle is created with a combination of sagittal saw and osteotomes, followed by shingle translation and fixation. Attention is then turned to performing the MPFL graft fixation on the femur. An incision is made, the area of the sulcus between the medial epicondyle and adductor tubercle is identified, and a pin is placed. Graft isometry is assessed, pin placement is confirmed, and a socket is created. After thorough irrigation, the patella is then everted and the PJAC graft is implanted and set with fibrin glue. Finally, the MPFL graft is passed through the previously identified layer and docked into the medial femur at its isometric point. Alternatives: Nonoperative treatment of first-time patellar instability can often include physical therapy, bracing, and activity modification. However, recurrence rates can be high, especially in a subset of high-risk patients with characteristics such as age of <25 years, trochlear dysplasia, patella alta, and coronal plane malalignment. For patients with recurrent patellar instability, a well-executed MPFL reconstruction restores stability while the TTO serves to unload the lateral and/or inferior patellar cartilage and correct osseous malalignment. Additional techniques, such as a distal femoral osteotomy and trochleoplasty, have been suggested to address patellar tracking and trochlear dysplasia. For patients who have sustained cartilaginous injury from their previous dislocations, PJAC can be utilized to restore the patellofemoral cartilage. Alternative operative treatments of cartilaginous defects include matrix-induced autologous chondrocyte implantation (MACI), mosaicplasty, osteochondral allograft, microfracture, and-in later stages of disease-patellofemoral arthroplasty. Rationale: The MPFL is an important medial stabilizer in the knee, with high rates of injury in patients who have experienced patellar instability. When an MPFL reconstruction is combined with a TTO, it can stabilize the patella while simultaneously correcting osseous malalignment and unloading the patellofemoral joint. Additionally, use of PJAC is advantageous for patients with patellar chondral defects because it is a single-stage technique, has low technical difficulty, and can be customized to accommodate large lesions. Expected Outcomes: MPFL in combination with TTO and PJAC provides patellar stabilization and overall improvements in pain and function, with low rates of recurrent instability. A recent study by Franciozi et al. showed significant improvement in functional outcome scores at a minimum of 2 years with no recurrent subluxations or dislocations1. Another study by Krych et al. showed an 83% rate of return to sport in patients who underwent MPFL reconstruction combined with TTO2. With respect to PJAC grafts, a study by Grawe et al. assessed the maturation of PJAC implanted into patellar chondral defects, demonstrating that the matured grafts paralleled the characteristics of the surrounding native cartilage. In addition, the authors reported that 73% of patients who completed follow-up magnetic resonance imaging at 2 years postoperatively had good defect fill, defined as >66%3. Important Tips: A lateral release may be necessary if the patella is unable to be everted parallel with the table. Typically, 80% of patients with instability do not need a lateral release, whereas 80% of patients with malalignment and isolated patellar osteoarthritis do need a release.MPFL graft isometry should be assessed by manually placing the patella in the center of the trochlea and flexing the knee to roughly 70°. The graft should slacken in subsequent deeper flexion and should never tighten.When customizing the TTO to obtain the necessary anatomic alignment, the surgeon can achieve additional medialization by dropping their hand to create a flatter cut, while additional anteriorization can be created with a steeper cut.Once the cartilage defect has been prepared and measured, a mold can be created to allow for concomitant PJAC preparation on the back table earlier in the procedure. Acronyms and Abbreviations: TT-TG = tibial tubercle to trochlear groove distanceMPFL = medial patellofemoral ligamentTTO = tibial tubercle osteotomyPJAC = particulated juvenile articular cartilageMACI = matrix-induced autologous chondrocyte implantationOR = operating roomIV = intravenousK-wires = Kirschner wiresCPM = continuous passive motionMRI = magnetic resonance imagingOA = osteoarthritisASA = acetylsalicylic acid (aspirin)DVT = deep vein thrombosisPPX = prophylaxisNWB = non-weight-bearingFWB = full weight-bearingPOD = postoperative day.

Evaluation and management of patellar instability.

Patellar instability is a common clinical problem that primarily affects the adolescent and young adult population. The demographic and anatomic risk factors that predispose patients to patellar instability are multifactorial and include young age, female sex, trochlear dysplasia, elevated tibial tubercle to trochlear groove distance (TT-TG), patella alta, femoral and tibial malalignment, ligamentous laxity, and lack of neuromuscular control. There have been substantial efforts to predict which patients who sustain a first-time dislocation will go on to incur additional dislocations. This is particularly important because with each dislocation event, there is a significant risk of injury to the patellofemoral joint including both medial patellofemoral ligament (MPFL) stretch or rupture and damage to the cartilage which can range from simple fissures to full-thickness cartilage defects and osteochondral fractures. Prediction models have demonstrated that amongst first time dislocators, young patients with trochlear dysplasia are at the highest risk for redislocation. The current standard of care for treatment of first-time dislocators without a loose body or osteochondral fracture is nonoperative management. However, recently there has been a focus on implementing a risk-stratified approach to the surgical indications for a first-time dislocator as the high-risk population might be better treated with early surgical stabilization to prevent or reduce their risk of recurrent dislocation and its associated morbidity. Likewise, for patients with recurrent dislocations, it remains to be determined whether an isolated MPFL reconstruction is sufficient for high-risk patients with several poor prognostic risk factors or if bony realignment procedures should be implemented concurrently.

Clinical Outcomes After Hematoma Development: A Study of 627 Tissue Expander Breast Reconstructions.

BACKGROUND: Hematomas after tissue expander immediate breast reconstruction (TE-IBR) pose a significant challenge during the recovery period. In this study, we aim to evaluate whether hematoma formation leads to subsequent complications and how management can impact final reconstructive goals. METHODS: A single-institution retrospective review of TE-IBRs from 2001 to 2018 was performed using an established breast reconstruction database. Demographics, medications, comorbidities, and complications were identified. Implant loss was defined as removal of the tissue expander/implant without immediate reimplantation during that operation. Hematoma size, management, transfusion requirement, reoperations, and final outcome were recorded. Reconstructive failure was defined as an implant loss that was not replaced with another implant or required secondary autologous reconstruction. RESULTS: Six hundred twenty-seven TE-IBR patients were analyzed. Postoperative hematoma (group 1) occurred in 4.1% (n = 26) of TE-IBRs and did not develop in 95.9% (group 2: n = 601). Group 2 had a higher mean body mass index (24.5 vs 27.3 kg/m, P = 0.018); however, there were no significant differences in smoking status, preoperative/postoperative radiation/chemotherapy, or other comorbidities. Group 1 was found to have increased rates of implant loss (15.4% vs 3.7%, P = 0.0033) and reconstructive failure (11.5% vs 2.8%, P = 0.0133) compared with group 2.Eighteen hematomas (69.2%) underwent surgical intervention (group 1a) compared with 30.8% (n = 8) that were clinically managed (group 1b). Group 1a had statistically significant lower rates of subsequent complications (22.2% vs 62.5%, P = 0.046) and reoperations (5.6% vs 27.5%, P = 0.037) than did group 1b, respectively.Lastly, 23.1% (n = 6) of patients who developed a hematoma were on home antithrombotics (group 1c) compared with 76.9% (n = 20) of patients with no antithrombotics (group 1d). There were statistically significant differences in transfusion rates (50% vs 0%, P = 0.001) between groups 1c and 1d, respectively. Differences in hematoma volume (330 vs 169.3 mL, P = 0.078) and reconstructive failure (33.3% vs 5%, P = 0.057) approached significance between both groups. CONCLUSIONS: Hematoma after TE-IBR should be monitored closely, as it may play a role in jeopardizing reconstruction success. Patients on home antithrombotic medication may be at increased risk of larger-volume hematomas and reconstruction failure. Plastic surgeons should consider aggressive surgical evacuation of postoperative TE-IBR hematomas to reduce subsequent complications and reoperations, thus optimizing reconstructive outcomes.

Do Postoperative Prophylactic Antibiotics Reduce Highly Virulent Infections?: An Analysis of 660 Tissue Expander Breast Reconstructions.

BACKGROUND: Many surgeons are reluctant to discontinue prophylactic antibiotics after 24 hours in tissue expander breast reconstruction (TEBR) because of fear of increased risk of surgical site infection (SSI). Currently, there is no consensus regarding antibiotic prophylaxis duration in TEBR. In addition, there remains a lack of research investigating microorganisms involved in SSI across various perioperative antibiotic protocols. The purpose of this study was to examine how 2 different prophylactic antibiotic regimens impacted the bacterial profiles of SSI and rate of implant loss after TEBR. METHODS: A single-institution retrospective review of immediate TEBRs between 2001 and 2018 was performed. Surgical site infections requiring hospitalization before stage 2 were included. Highly virulent organisms were defined as ESKAPE pathogens (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, Enterobacter species). Implant loss was defined as removal of tissue expander without immediate replacement. RESULTS: Of 660 TEBRs, 85 (12.9%) developed an SSI requiring hospitalization before stage 2. Fifty-six (65.9%) received less than 24 hours of perioperative intravenous antibiotics and oral antibiotics after discharge (group 1), and 29 (34.1%) received less than 24 hours of intravenous antibiotics only (group 2). There was no significant difference in demographics, preoperative chemotherapy/radiation, acellular dermal matrix usage, or treatment of SSI between groups. In group 1, 64% (n = 36) developed culture positive SSIs, compared with 83% (n = 24) in group 2 (P = 0.076). Staphylococcus aureus was the most common bacteria in both groups. Group 2 demonstrated a significantly increased incidence of gram-positive organisms (46.4% vs 72.4%, P = 0.022) and S. aureus (21.4% vs 55.2%, P = 0.002). However, there was no significant difference in overall highly virulent (P = 0.168), gram-negative (P = 0.416), or total isolated organisms (P = 0.192). Implant loss between groups 1 and 2 (62.5% vs 62.1%, P = 0.969) respectively, was nearly identical. CONCLUSIONS: Our study demonstrates that, despite differences in bacterial profiles between 2 antibiotic protocols, prolonged postoperative antibiotic use did not protect against overall highly virulent infections or implant loss. Antibiotic stewardship guidelines against the overuse of prolonged prophylactic regimens should be considered. Further analysis regarding timing of SSIs and antibiotic treatment is warranted.