After 40 days intra-articular injury, risk profile increases linearly with time to surgery in adolescent patients undergoing primary anterior cruciate ligament reconstruction.

PURPOSE: Anterior cruciate ligament (ACL) injuries are becoming more common in youth athletes. Time-to-surgery has been shown to significantly affect the rates of concurrent injuries at the time of ACL reconstruction (ACLR). The purpose of this study was to evaluate if time-to-surgery in ACLR impacts observances of intra-articular injuries and to categorize injury profile in relation to time. METHODS: An Institutional Review Board-approved retrospective cohort study was conducted. Included subjects were aged 21 and below and underwent primary ACLR within 6 months of injury between January 2012 and April 2020. Skeletal maturity was determined via imaging. Laterality, location and severity/pattern of meniscal and chondral injuries were recorded. Multivariate logistic regression was utilized to identify risk factors for intra-articular pathology. Cut-off analyses were added to regression models to identify trends of concurrent injuries. RESULTS: Eight hundred and fifty patients met the inclusion criteria. Patients with observed articular cartilage injuries had a significantly longer time-to-surgery of 66 days (p = 0.01). Risk factors for chondral injury were time-to-surgery (p = 0.01) and skeletal maturity (p = 0.01), while medial meniscal tears were prognosticated by time-to-surgery (p = 0.03), skeletal maturity (p = 0.01) and body mass index (p = 0.00). Cut-off analysis showed that after 40 days the proportion of patients with observed chondral injury increased with time to surgery and that there were significantly different observances of chondral (p = 0.00) and medial meniscal (p = 0.03) injuries in the 6-week model, as compared to the continuous time model. CONCLUSION: Longer time-to-surgery in ACLR is associated with higher rates of concomitant intra-articular pathology, especially chondral injuries. After 40 days, the observed rates of intra-articular injury increase proportionately with time from injury. A 6-week categorical model best stratifies intra-articular injury risk profile. Risk factor analysis identified skeletally mature patients with delayed surgery of >12 weeks to be at the highest risk for both chondral and medial meniscal injuries after an ACLR. LEVEL OF EVIDENCE: Level III.

Lateral extra-articular tenodesis at primary ACL reconstruction increases career length in professional rugby players.

PURPOSE: To assess the effect of preoperative and surgical factors on return to play (RTP) rates and career longevity of professional rugby athletes after primary anterior cruciate ligament (ACL) reconstruction (ACL-R). METHODS: A retrospective review of a consecutive cohort of professional rugby players undergoing primary ACL-R by the senior author between 2005 and 2019 was undertaken. Athletes were included if they were under contract with a professional rugby team at the time of injury and had a minimum of 2-year follow-up. Univariate and multivariate analyses were performed to determine significant predictors of RTP rate, time and career longevity. RESULTS: One hundred and eighteen rugby players with 125 ACL-Rs were identified. Return to professional rugby was achieved in 115/125 (92%) of cases at an average of 9.6 months and those athletes participated at the professional level for 5.9 ± 3.4 years after ACL-R. Younger age (p = 0.006) and ACL-R with a concomitant lateral extra-articular tenodesis (LET) (p = 0.013) were predictors of a longer career. A Cox proportional hazards model that controlled for age revealed that athletes who underwent ACL-R with an LET had increased career longevity compared to those with an ACL-R without LET (hazard ratio = 2.74, p = 0.021). No factors were significantly associated with RTP rate or RTP time. CONCLUSION: In professional rugby players undergoing primary ACL-R, those having ACL-R with a concomitant LET and younger age predicted increased career longevity. Rugby players who underwent LET at the time of ACL-R had an 18% greater chance of still playing professionally at 5 years compared to those who underwent ACL-R alone. LEVEL OF EVIDENCE: Level III.

Skeletal Maturity Is Associated With Increased Meniscal and Chondral Pathology in Patients Under 21 Years of Age Undergoing Primary Anterior Cruciate Ligament Reconstruction Within 6 Months of Injury.

PURPOSE: To compare injury profiles of meniscal and/or chondral injury in skeletally mature (SM) with immature (SI) patients undergoing primary anterior cruciate ligament reconstruction (ACLR). METHODS: Current Procedural Terminology code 29888 was queried from January 2012 to April 2020. Patients younger than 22 years who underwent primary ACLR within 6 months of injury were included. Exclusion criteria included age older than 22 years, treatment after 6 months, revision ACLR, concurrent osteotomy, or multiligamentous injury. All patients required a minimum 1-year follow-up. Demographics and intraoperative pathology were recorded. Data were analyzed for factors affecting intra-articular injury and stratified by sport. RESULTS: Of 927 patients (739 SM, 188 SI), the mean age was 16.63 and 14.00 years for the SM and SI cohorts, respectively (P < .001). There were more SM males (51.4%) compared to SI males (81.9%) (P < .001); however, in univariate analysis, sex did not significantly affect the rates of meniscal (P = .519) or chondral injury (P = .961). In total, 887 meniscal injuries were recorded (344 medial, 543 lateral) in 659 patients. SM sustained greater rates of medial meniscal tear (MMT) (P < .001) and underwent higher rates of partial meniscectomy (P = .022). Male sex conferred meniscal injury (95% confidence interval [CI], 0.43-0.81; P = .001). Body mass index prognosticated medial meniscal (95% CI, 1.01-1.06; P = .002) and medial chondral injuries (95% CI, 1.02-1.09; P < .001). Skeletal maturity was a superior predictor of intra-articular pathology than age for all outcomes: MMT (95% CI, 0.00-0.06; P = .002), lateral meniscal tear (95% CI, 0.00-0.75; P = .034), and chondral injury (95% CI, 0.00-0.49; P = .049). In sport subanalysis, soccer anterior cruciate ligament (ACL) injuries were most common (32.6%). Soccer and basketball athletes were more likely SM (P = .016, P = .003 respectively) with increased medial compartment pathology. Football ACL injuries occurred significantly in SI athletes (P = .001) via contact mechanisms (P = .025). CONCLUSIONS: Skeletal maturity affects the meniscal and chondral injury profile in ACL-injured patients. SM patients have greater risk of sustaining concomitant meniscal injury, while chondral injury profile depends more on the mechanism of injury. Mechanism of injury and skeletal maturity status affect risk of sports-related ACL rupture and ACL-concurrent pathology in young patients. Patient-specific variables influence injury profiles within each sport. Skeletal maturity rather than age predicts concomitant intra-articular injury risk. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

A Survey of Neurosurgery Residency Program Coordinators: Their Roles, Responsibilities, and Perceived Value.

Objective Residency program coordinators play an important role behind the scenes, in the function of residency and fellowship programs. In addition, coordinators have significantly heterogeneous job roles among institutions. The aim of this study was to evaluate the training, responsibilities, and contribution of residency program coordinators within the field of neurosurgery. Methods A 24-question survey was submitted to 133 program coordinators, and 78 responses (59% response rate) were received. Results The survey results showed that >80% of coordinators have been in their current position for ≥3 years. Coordinators identified at least 24 unique departmental responsibilities with an average of 85% of the time devoted to residency program management. Among coordinators, 82% reported no formal training, with 60% and 55% reporting inadequate training from their department and institution, respectively. Interestingly, 84% completely or partially agreed that their work is valued by residents, 91% by the program director(s), 78% by the department chair, 62% by other faculty, and 56% by other departmental staff. Lastly, 50% of coordinators reported that their department has not been receptive to receiving feedback on how to improve the roles of the position, with 80% reporting no career advancement track. Conclusion Residency program coordinators reported a wide range of experience and responsibilities within their respective departments. The majority reported limited training for their current position, and a significant number reported not feeling valued by members of their department, suggesting two areas for improvement. As coordinators continue to play a larger role in the management and accreditation of their departments, strategies to optimize their role may be important.

The Role of Elbow Tender Point Examination in the Diagnosis of Lateral Epicondylitis.

OBJECTIVE: To quantify sensitivity and specificity of the tender points and demonstrate how variability in case definition impacts prevalence of lateral epicondylitis (LE). METHODS: Baseline data analyzed from 1216 workers from the WISTAH study, a multicenter prospective cohort study of upper extremity musculoskeletal disorders. All workers completed computerized questionnaires, structured interviews, and two independent physical examinations in accordance with an established protocol. RESULTS: The prevalence of LE differed based on case definition ranging from 4.7% to 12.1%. Sensitivity was low for tender points 1 to 4 ranging from 6.8% to 34.6%. Specificity was high for tender points 1 to 4 ranging from 95.2% to 97.9%. CONCLUSIONS: The prevalence of lateral epicondylitis differs markedly based on case definition used, ranging more than two-fold. Standardization of a case definition is essential to allow for comparisons across studies.

Opioid use: Case-control analyses of worker's compensation data.

OBJECTIVES: Working-age adults are disproportionately impacted by opioid misuse. Factors associated with opioid misuse in people with workers compensation (WC) claims are not well studied. WC in some states is a "captured" market making it a more efficient site for researching the opioids epidemic. A pilot study was conducted to identify factors associated with opioid use using a large WC insurer's claims in Utah. METHODS: This was a case-control study using a large WC insurer's database. We conducted secondary data analyses of a de-identified dataset originally obtained from the WC insurer. Cases were defined as claims with a morphine equivalent dose (MED)≥50 mg/d in the 30 days after the claim was filed while controls = 0 mg/d. RESULTS: A total of 76 patient's claims (28 cases and 48 controls) were included in the final data analyses. The majority of claimants were male (N = 50, 65.8 percent), worked full time (N = 58, 76.3 percent) and had a mean age of 37.0±11.4 years. The majority of controls filed medical only claims (N = 40, 83.3 percent) while the majority of cases filed indemnity claims (N = 19, 67.9 percent). Cases were prescribed a mean MED of 126.4 (SD = 93.3) within the first month after filing the claim. Most cases visited>3 medical providers (N = 13, 46.4 percent) in the first month after filing the claim while the majority of controls only visited one provider (N = 28, 58.3 percent). Remarkably, the mean number of providers visited within the first month for the cases was 3.8, which was 2-fold greater than the control group. Exploratory multivariate analyses showed that cases were 4.6 times more likely to have visited 2-3 medical providers (p = 0.025), and 41.8 times more likely to have visited more than three medical providers (p < 0.001). Cases had 3.6 higher odds of having been prescribed nonsteroidal anti-inflammatory prescription within the first month as compared to controls (p = 0.014). CONCLUSION: This pilot study found risk factors, some of which may be modifiable. We aim to conduct a large study using existing WC data to create a scoring system that identifies those claimants at higher risk of adverse opioid-related events that may have preventive applications at a systems-level.

Giant Cell Tumor of the Lateral Skull Base: Diagnostic and Management Options.

Giant cell tumor of bone (GCTB) is a rare, benign, osteolytic neoplasm that most commonly occurs in early adulthood and often involves the long bones of the body. Although GCTB largely affects the epiphyses of long bones, several reports of GCTB involvement of the cranial and facial bones exist in the literature. In addition to reviewing other reported cases of GCTBs of the lateral skull base in the literature, the authors report here on the clinical presentation, radiographic findings, and neurosurgical management of a patient found to have a GCTB of the middle and infratemporal fossae, which was treated by aggressive en bloc resection of the lateral skull base.

A retrospective analysis of cardiometabolic health in a large cohort of truck drivers compared to the American working population.

BACKGROUND: Truck drivers face many health challenges, including lifestyle, diet, inactivity, stressors, and social support. METHODS: A repeated cross-sectional analysis compared 88,246 truck drivers with data from (n = 11 918) the National Health and Nutrition Examination Survey (NHANES). Trends over time for body mass index (BMI), high blood pressure, diabetes mellitus, heart disease, and sleep disorders were analyzed, adjusting for potential confounders. RESULTS: Truck drivers had significantly worsening health metrics between 2005 and 2012 compared to NHANES participants. Truck drivers were significantly more likely to be obese and morbidly obese with prevalence odds ratios (POR) and 95% confidence intervals (95%CI) of 1.99 (1.87, 2.13) and 2.34 (2.16, 2.54), respectively. Measured blood pressure, self-reported high blood pressure, diabetes mellitus, and heart disease all significantly increased. Also, sleep disorders increased among truck drivers from 2005 to 2012 (POR = 6.55, 95%CI 5.68, 7.55). CONCLUSION: These data suggest disproportionate increases in poor health among truck drivers from 2005 to 2012.

P value interpretations and considerations.

Application and interpretation of statistical evaluation of relationships is a necessary element in biomedical research. Statistical analyses rely on P value to demonstrate relationships. The traditional level of significance, P<0.05, can be negatively impacted by small sample size, bias, and random error, and has evolved to include interpretation of statistical trends, correction factors for multiple analyses, and acceptance of statistical significance for P>0.05 for complex relationships such as effect modification.

Misuse of statistics in surgical literature.

Statistical analyses are a key part of biomedical research. Traditionally surgical research has relied upon a few statistical methods for evaluation and interpretation of data to improve clinical practice. As research methods have increased in both rigor and complexity, statistical analyses and interpretation have fallen behind. Some evidence suggests that surgical research studies are being designed and analyzed improperly given the specific study question. The goal of this article is to discuss the complexities of surgical research analyses and interpretation, and provide some resources to aid in these processes.

The Association Between Cardiovascular Disease Risk Factors and Motor Vehicle Crashes Among Professional Truck Drivers.

OBJECTIVE: This study assesses relationships between the Framingham cardiovascular disease risk (CVD risk) score and prevalence of US Department of Transportation (DOT)-reportable crashes in commercial motor vehicle (CMV) drivers, after controlling for potential confounders. METHODS: Data were analyzed from CMV drivers (N = 797) in a large cross-sectional study. CVD risk was calculated for each driver. Adjusted odds ratios (ORs) and 95% confidence intervals (95% CIs) between CVD risk and DOT-reportable crashes were calculated. RESULTS: Drivers in the two highest CVD risk groups had significantly higher likelihood of crash (OR = 2.08, 95% CI = 1.20 to 3.63 and OR = 1.99, 95% CI = 1.05 to 3.77, respectively) after adjusting for confounders. There was a significant trend of increasing prevalence of crashes with an increasing CVD risk score (P = 0.0298). CONCLUSION: Drivers with a high CVD risk had a higher likelihood of a crash after controlling for confounders.