Multiple Ankle Injuries Are Associated With an Increased Risk of Subsequent Concussion in National Football League Players.

Background: There is a gap in the literature regarding musculoskeletal risk factors for concussion within the National Football League (NFL), which is an avenue that must be explored to promote player safety given the high incidence of both injury types. This study aims to observe if ankle injuries are associated with an increased risk of subsequent concussion in NFL players. Methods: The public online database ProFootballReference.com was used to identify ankle injuries and concussions in NFL players from the 2009-2010 to 2019-2020 seasons. Multivariable logistic regression for subsequent concussion and ankle injury was performed, adjusting for body mass index (BMI), age, and player position. For descriptive statistics, unpaired t tests with unequal variance were performed for continuous variables, including BMI and age. χ2 testing was performed for categorical variables, including player position, and whether the position was offensive, defensive, or on special teams. Results: Of the 5538 NFL players included in the study, 941 had an ankle injury, 633 had a concussion, and 240 had both an ankle injury and a subsequent concussion. The adjusted odds ratio (aOR) for concussion following a single ankle injury was 0.90 (95% CI 0.72-1.14, P = .387); however, the aOR for concussion following multiple ankle injuries was 2.87 (95% CI 1.23-6.75, P = .015). Special teams players had the lowest risk for concussion (aOR 0.17, 95% CI 0.069-0.36, P < .001) following ankle injury, and there was no significant difference in risk between offense and defense (aOR 0.91, 95% CI 0.77-1.08, P = .295). Conclusion: Multiple ankle injuries were associated with an increased risk of a subsequent concussion after adjusting for BMI; player position; and offense, defense, or special teams designation. These findings can inform injury prevention practices in the National Football League. Level of Evidence: Level III, retrospective comparative study.

Surgical Setting in Achilles Tendon Repair: How Does It Relate to Costs and Complications?

Background: Primary Achilles tendon repair (ATR) can be performed in ambulatory surgery centers (ASCs) or hospitals. We compared costs and complication rates of ATR performed in these settings. Methods: We retrospectively queried the electronic medical record of our academic health system and identified 97 adults who underwent primary ATR from 2015 to 2021. Variables were compared between patients treated at ASCs vs those treated in hospitals. We compared continuous variables with Wilcoxon rank-sum tests and categorical variables with χ2 tests. We used an α of 0.05. Multivariable logistic regression was performed to determine associations between surgical setting and costs. Linear regression was performed between each charge subtype and total cost to identify which charge subtypes were most associated with total cost. Results: Patients who underwent ATR in hospitals had a higher rate of unanticipated postoperative hospital admission (13%) than those treated in ASCs (0%) (P = .01). We found no differences with regard to postoperative complications, emergency department visits, readmission, rerupture, reoperation/revision, or death. Patients treated in hospitals had a higher mean (±SD) implant cost ($664 ± $810) than those treated in ASCs ($175 ± $585) (P < .01). We found no differences between settings with regard to total cost, supply costs, operating room charges, or anesthesia charges. Higher implant cost was associated with hospital setting (odds ratio = 16 [95% CI: 1.7-157]) and body mass index > 25 (odds ratio = 1.2 [95% CI: 1.0-1.5]). Operating room costs were strongly correlated with total costs (R2 = .94). Conclusion: The overall cost and complication rate of ATRs were not significantly different between ASCs and hospitals. ATRs performed in hospitals had higher implant costs and higher rates of postoperative admission than those performed in ASCs. Level of Evidence: Level III, retrospective comparative study.

What Factors Are Associated With Arterial Line-Related Limb Ischemia in Patients on Extracorporeal Membrane Oxygenation? A Single-Center Retrospective Cohort Study.

OBJECTIVES: The primary purpose of this study was to identify factors associated with the development of arterial line-related limb ischemia in patients on extracorporeal membrane oxygenation (ECMO). The authors also sought to characterize and report the outcomes of patients who developed arterial line-related limb ischemia. DESIGN: Retrospective cohort study. SETTING: A single academic tertiary referral ECMO center. PARTICIPANTS: Consecutive patients who were treated with ECMO over 6 years. INTERVENTIONS: Use of arterial line. MEASUREMENTS AND MAIN RESULTS: A total of 278 consecutive ECMO patients were included, with 19 (7%) patients developing arterial line-related limb ischemia during the ECMO run. Postcannulation Sequential Organ Failure Assessment (SOFA) (adjusted odds ratio [aOR] 1.20, 95% CI 1.08-1.32), Acute Physiology and Chronic Health Evaluation-II (aOR 0.84, 95% CI 0.74-0.95), and adjusted Vasopressor Dose Equivalence (aOR 1.03, 95% CI 1.01-1.05) scores were independently associated with the development of arterial line-associated limb ischemia. A SOFA score of ≥17 at the time of ECMO cannulation had an 80% sensitivity and 87% specificity for predicting arterial line-related limb ischemia. CONCLUSIONS: Arterial line-related limb ischemia is much more common in ECMO patients than in the typical intensive care unit setting. The SOFA score may be useful in identifying which patients may be at risk for arterial line-related limb ischemia. As this was a single-center retrospective study, these results are inherently exploratory, and prospective multicenter studies are necessary to validate these results.

Is Fasciotomy Associated With Increased Mortality in Extracorporeal Cardiopulmonary Resuscitation?

Our primary objective was to identify if fasciotomy was associated with increased mortality in patients who developed acute compartment syndrome (ACS) on extracorporeal cardiopulmonary resuscitation (ECPR). Additionally, we sought to identify any additional risk factors for mortality in these patients and report the amputation-free survival following fasciotomy. We retrospectively reviewed adult ECPR patients from the Extracorporeal Life Support Organization registry who were diagnosed with ACS between 2013 and 2021. Of 764 ECPR patients with limb complications, 127 patients (17%) with ACS were identified, of which 78 (63%) had fasciotomies, and 14 (11%) had amputations. Fasciotomy was associated with a 23% rate of amputation-free survival. There were no significant differences in demographics or baseline laboratory values between those with and without fasciotomy. Overall, 88 of 127 (69%) patients with ACS died. With or without fasciotomy, the mortality of ACS patients was similar, 68% vs. 71%. Multivariable logistic regression demonstrated that body mass index (BMI; adjusted odds ratio [aOR] = 1.22, 95% confidence interval [CI] = 1.01-1.48) and 24 hour mean blood pressure (BP; aOR = 0.93, 95% CI = 0.88-0.99) were independently associated with mortality. Fasciotomy was not an independent risk factor for mortality (aOR = 0.24, 95% CI = 0.03-1.88). The results of this study may help guide surgical decision-making for patients who develop ACS after ECPR. However, the retrospective nature of this study does not preclude selection bias in patients who have received fasciotomy. Thus, prospective studies are necessary to confirm these findings.

What Factors Are Associated With Delayed Wound Closure in Open Reduction and Internal Fixation of Adult Both-bone Forearm Fractures?

BACKGROUND: Delayed wound closure is often used after open reduction and internal fixation (ORIF) of both-bone forearm fractures to reduce the risk of skin necrosis and subsequent infection caused by excessive swelling. However, no studies we are aware of have evaluated factors associated with the use of delayed wound closure after ORIF. QUESTIONS/PURPOSES: (1) What proportion of patients undergo delayed wound closure after ORIF of adult both-bone forearm fractures? (2) What factors are associated with delayed wound closure? METHODS: The medical records of all patients who underwent ORIF with plate fixation for both-bone fractures by the adult orthopaedic trauma service at our institution were considered potentially eligible for analysis. Between January 2010 and April 2022, we treated 74 patients with ORIF for both-bone forearm fractures. Patients were excluded if they had fractures that were fixed more than 2 weeks from injury (six patients), if their fracture was treated with an intramedullary nail (one patient), or if the patient experienced compartment syndrome preoperatively (one patient). No patients with Gustilo-Anderson Type IIIB and C open fractures were included. Based on these criteria, 89% (66 of 74) of the patients were eligible. No further patients were excluded for loss of follow-up because the primary endpoint was the use of delayed wound closure, which was performed at the time of ORIF. However, one further patient was excluded for having bilateral forearm fractures to ensure that each patient had a single fracture for statistical analysis. Thus, 88% (65 of 74) of patients were included in the analysis. These patients were captured by an electronic medical record search of CPT code 25575. The mean ± SD age was 34 ± 15 years and mean BMI was 28 ± 7 kg/m 2 . The mean follow-up duration was 4 ± 5 months. The primary endpoint was the use of delayed wound closure, which was determined at the time of definitive fixation if tension-free closure could not be achieved. All surgeons used a volar Henry or modified Henry approach and a dorsal subcutaneous approach to the ulna for ORIF. Univariate logistic regression was used to identify which factors might be associated with delayed wound closure. A multivariable logistic regression analysis was then performed for male gender, open fractures, age, and BMI. RESULTS: Twenty percent (13 of 65) of patients underwent delayed wound closure, 18% (12 of 65) of which occurred in patients who had high-energy injuries and 14% (nine of 65) in patients who had open fractures. Being a man (adjusted odds ratio 9.9 [95% confidence interval 1 to 87]; p = 0.04) was independently associated with delayed wound closure, after adjusting for open fractures, age, and BMI. CONCLUSION: One of five patients had delayed wound closure after ORIF of both-bone forearm fractures. Being a man was independently associated with greater odds of delayed wound closure. Surgeons should counsel all patients with these fractures about the possibility of delayed wound closure, with particular attention to men with high-energy and open fractures. Future larger-scale studies are necessary to confirm which factors are associated with the use of delayed wound closure in ORIF of both-bone fractures and its effects on fracture healing. LEVEL OF EVIDENCE: Level III, therapeutic study.

Recurrence of Hamstring Injuries and Risk Factors for Partial and Complete Tears in the National Football League: An Analysis From 2009-2020.

PURPOSE: To (1) characterize hamstring injury (HSI) recurrence rates across the 2009-2010 to 2019-2020 NFL seasons and (2) to identify HSI recurrence risk factors among positions and determine the weekly return to play (RTP) recurrence risk. We hypothesized that older players, skill position players, and players returning to play faster were most at risk. METHODS: Public data from the 2009-2010 to 2019-2020 seasons were reviewed to identify HSIs. Player characteristics were collected before and two seasons following injury. A week-by-week analysis of recurrence risk was evaluated with linear and logarithmic trendlines of the best fit. RESULTS: A total of 2075 HSI were identified with a mean age of 26.2 years (20.0-43.0), BMI of 29.6 (22.7-43.5), and 3.4 seasons of experience (0-17), with 1826 strains (88.0%), 236 partial tears (11.3%), and 13 complete tears (0.63%). Of the 2075 injuries, 796 (38.4%) were recurrent, with 247 (11.9%) being a same-season reinjury. Logistic regression found that fewer weeks before RTP, in-game injury, and lower BMI were risk factors for same-season recurrence. For any recurrence, logistic regression identified more recent year of injury, lower BMI, and longer playing experience as significant risk factors. Wide receivers were found to be at risk for same-season recurrence. For any-season recurrence, defensive backs, linebackers, running backs, tight ends, and wide receivers were at risk. Week-by-week recurrence analysis determined the greatest risk to be when players returned within 2 weeks (13.4%). CONCLUSIONS: There is a high rate of HSI recurrence in the NFL. Risk factors for same-season injury include shorter time to RTP, in-game injury, lower BMI, and playing wide receiver. Risk factors for any-season recurrence were more recent year of injury, lower BMI, longer playing experience, and playing defensive back, linebacker, running back, tight end, or wide receiver. The greatest risk factor for HSI recurrence was RTP within 2 weeks.

Intramedullary Canal Injection of Vancomycin- and Tobramycin-loaded Calcium Sulfate: A Novel Technique for the Treatment of Chronic Intramedullary Osteomyelitis.

Aim: In this study, we present a detailed surgical technique for treating chronic osteomyelitis (COM) of the intramedullary canal with injectable tobramycin and vancomycin-loaded calcium sulfate (CS). Background: Chronic osteomyelitis of the long bones has been treated using antibiotic-impregnated polymethyl methacrylate (PMMA), which typically requires a second procedure for removal. Technique: Removal of the infected intramedullary nail (if any), copious irrigation, canal reaming, and intramedullary canal injection of vancomycin- and tobramycin-loaded calcium sulfate as a single-stage procedure for the treatment of COM of long bones. Conclusion: Intramedullary injection of vancomycin- and tobramycin-loaded CS can be used as a single-stage procedure for the treatment of long bone intramedullary COM. Further studies are necessary to compare the long-term outcomes of antibiotic-coated CS vs other antibiotic carriers for infection eradication. Clinical significance: The authors have endeavored to explain the best surgical technique to eradicate long bones COM with injectable tobramycin and vancomycin-loaded CS. How to cite this article: Elhessy AH, Rivera JC, Shu HT, et al. Intramedullary Canal Injection of Vancomycin- and Tobramycin-loaded Calcium Sulfate: A Novel Technique for the Treatment of Chronic Intramedullary Osteomyelitis. Strategies Trauma Limb Reconstr 2022;17(2):123-130.

Elevated exposures to persistent endocrine disrupting compounds impact the sperm methylome in regions associated with autism spectrum disorder.

Environmental exposures to endocrine disrupting compounds (EDCs) such as the organochlorines have been linked with various diseases including neurodevelopmental disorders. Autism spectrum disorder (ASD) is a highly complex neurodevelopmental disorder that is considered strongly genetic in origin due to its high heritability. However, the rapidly rising prevalence of ASD suggests that environmental factors may also influence risk for ASD. In the present study, whole genome bisulfite sequencing was used to identify genome-wide differentially methylated regions (DMRs) in a total of 52 sperm samples from a cohort of men from the Faroe Islands (Denmark) who were equally divided into high and low exposure groups based on their serum levels of the long-lived organochlorine 1,1-dichloro-2,2-bis(p-chlorophenyl)ethylene (DDE), a primary breakdown product of the now banned insecticide dichlorodiphenyltrichloroethane (DDT). Aside from being considered a genetic isolate, inhabitants of the Faroe Islands have a native diet that potentially exposes them to a wide range of seafood neurotoxicants in the form of persistent organic pollutants (POPs). The DMRs were mapped to the human genome using Bismark, a 3-letter aligner used for methyl-seq analyses. Gene ontology, functional, and pathway analyses of the DMR-associated genes showed significant enrichment for genes involved in neurological functions and neurodevelopmental processes frequently impacted by ASD. Notably, these genes also significantly overlap with autism risk genes as well as those previously identified in sperm from fathers of children with ASD in comparison to that of fathers of neurotypical children. These results collectively suggest a possible mechanism involving altered methylation of a significant number of neurologically relevant ASD risk genes for introducing epigenetic changes associated with environmental exposures into the sperm methylome. Such changes may provide the potential for transgenerational inheritance of ASD as well as other disorders.

Is there an increased risk for subtrochanteric stress fracture with the Femoral Neck System versus multiple cannulated screws fixation?

Purpose: This study sought to compare the risk of subtrochanteric stress-riser fractures and biomechanical stability of the Femoral Neck System (FNS) versus multiple screw fixation (MSF). Methods: Eight paired cadaveric femurs were randomly assigned to FNS or MSF. Physiologic load mimicking single leg stance at the subtrochanteric region was applied to the constructs. Results: No constructs failed in the subtrochanteric region during loading. There was no significant difference in force (P = 0.364) or loading cycles (P = 0.348) between groups. Conclusion: FNS constructs were not associated with an increased incidence of iatrogenic subtrochanteric fractures or biomechanical stability versus MSF.

Chemoprophylaxis for venous thromboembolism in pelvic and/or acetabular fractures: A systematic review.

BACKGROUND: It is unclear which pharmacological agents, and at what dosage and timing, are most effective for venous thromboembolism (VTE) prophylaxis in patients with pelvic/acetabular fractures. METHODS: We searched the Cochrane Database of Systematic Reviews, Embase, Web of Science, EBSCO, and PubMed on October 3, 2020, for English-language studies of VTE prophylaxis in patients with pelvic/acetabular fractures. We applied no date limits. We included studies that compared efficacy of pharmacological agents for VTE prophylaxis, timing of administration of such agents, and/or dosage of such agents. We recorded interventions, sample sizes, and VTE incidence, including deep vein thrombosis (DVT) and pulmonary embolism. RESULTS: Two studies (3604 patients) compared pharmacological agents, reporting that patients who received direct oral anticoagulants (DOACs) were less likely to develop DVT than those who received low molecular weight heparin (LMWH) (p < 0.01). Compared with unfractionated heparin (UH), LMWH was associated with lower odds of VTE (odds ratio [OR] = 0.37, 95% confidence interval [CI]: 0.22-0.63) and death (OR = 0.27, 95% CI: 0.10-0.72). Three studies (3107 patients) compared timing of VTE prophylaxis, reporting that late prophylaxis was associated with higher odds of VTE (OR = 1.9, 95% CI: 1.2-3.2) and death (OR = 4.0, 95% CI: 1.5-11) and higher rates of symptomatic DVT (9.2% vs. 2.5%, p = 0.03; and 22% vs. 3.1%, p = 0.01). One study (31 patients) investigated dosage of VTE prophylaxis, reporting that a higher proportion of patients with acetabular fractures were underdosed (23% of patients below range of anti-Factor Xa [aFXa] had acetabular fractures vs. 4.8% of patients within adequate range of aFXa, p<0.01). CONCLUSIONS: Early VTE chemoprophylaxis (within 24 or 48 h after injury) was better than late administration in terms of VTE and death. Many patients with acetabular fractures are underdosed with LMWH, with inadequate aFXa levels. Compared with UH, LMWH was associated with lower odds of VTE and death. DOACs were associated with lower risk of DVT compared with LMWH. LEVEL OF EVIDENCE: III, systematic review of retrospective cohort studies.

Tranexamic acid use in pelvic and/or acetabular fracture surgery: A systematic review and meta-analysis.

PURPOSE: The purpose of this study is to determine whether tranexamic acid (TXA) use was associated with lower rates of blood transfusion in patients undergoing pelvic and/or acetabular fracture surgery. METHODS: Four studies were included, 3 of which were included in the pooled data analysis for a total of 308 patients. RESULTS: The transfusion rate was significantly lower in the TXA group (44%) compared with the non-TXA group (57%) (P = 0.02). CONCLUSION: TXA use was associated with a significantly lower transfusion rate in patients who underwent pelvic and/or acetabular fracture surgery. LEVEL OF EVIDENCE: Level 3. Systematic review of retrospective cohort studies and prospective randomized controlled trials.

Performance and Survivorship of National Football League Players with Pectoralis Major Injuries.

PURPOSE: The purpose of this study was to determine return-to-play (RTP), performance and career survivorship for National Football League (NFL) athletes sustaining pectoralis major (PM) injuries with comparison among grades of injury and between nonoperative and operative management. METHODS: Publicly available data from the 1998-2020 NFL seasons were reviewed to identify athletes with PM injuries. Athlete characteristics were collected 1 season before and 2 seasons after injury. Percent of total games played in a season, player efficiency rating (PER), and Pro Football Focus (PFF) grades were compared for the preinjury season and 2 postinjury seasons. Kaplan-Meier survivorship plots were computed for RTP and postinjury career length, whereas a log-rank test was used to compare survivorship differences. RESULTS: In total, 258 PM injuries were reported at a mean age of 27.1 ± 3.3 years. A total of 126 surgical repairs occurred in 48.8% (n = 126) of injuries, with athletes undergoing repair possessing a lower RTP rate and longer time to RTP compared to athletes treated conservatively (P < .001). Survival analysis revealed shorter career length for athletes sustaining PM tears compared to strains (P < .001), although no difference in career length was appreciated on the basis of injury management (P = .980). Defensive linemen and wide receivers had lower PER during their second postinjury seasons (P = .019 and .030, respectively), whereas defensive linemen had lower PFF grades during their second post-injury seasons (P = .044). CONCLUSION: NFL athletes requiring PM repair may experience a lower likelihood of RTP, and longer RTP timing, likely because of higher-grade injuries. Defensive linemen and wide receivers experiencing PM injuries are at risk for diminished performance post-injury. Career length does not appear to be affected based on injury management. LEVEL OF EVIDENCE: Level III, cohort study.

Incidence of Pectoralis Major Injuries Has Increased 40% Over the Last 22 National Football League Seasons.

PURPOSE: To examine trends in the incidence of pectoralis major (PM) injuries over the last 22 National Football League (NFL) seasons and identify risk factors for injuries requiring operative management. METHODS: Publicly available data from the 1998-1999 through 2019-2020 NFL seasons were reviewed to identify PM injuries, demographics, injury mechanisms, and management. Injury incidence was calculated using linear regression per 10,000 athlete-exposures, while risk factors for operative management were identified through multivariate logistic regression. RESULTS: There were 258 PM injuries. Mean athlete age at the time of injury was 27.1 years (range: 21-37) with a mean body mass index of 32.6 (range: 24.8-43.1). Overall incidence was 0.603 per 10,000 athlete-exposures, which was found to significantly increase with time by 0.039 per athlete-exposures per year (R 2 = .787, P < .001). Defensive athletes accounted for 64.7% of PM injuries. Repair was performed in 48.8% of athletes, with defensive linemen (odds ratio [OR] 3.78, CI 1.42-10.60, P = .009), defensive backs (OR 12.20, CI 2.13-76.60, P = .006), linebackers (OR 8.98, CI 2.58-33.60, P < .001), more recent time of injury (OR 1.11, CI 1.05-1.17, P < .001), and shorter NFL experience (OR .77 for older athletes, CI .59-.99), P = .047) at significant risk for operative treatment. CONCLUSION: A total of 258 PM injuries were identified over 22 NFL seasons, with an overall incidence of 0.603 per 10,000 athlete-exposures, which was found to increase by 0.039 injuries per 10,000 athlete-exposures per year. Repair was performed in 48.8% of athletes, with more recent time of injury, shorter NFL experience, defensive linemen, defensive backs and linebackers at significantly higher risk for operative treatment. STUDY DESIGN: Cohort study; Level of evidence, 3.

Orthopedic management of pubic symphysis osteomyelitis: a case series.

Objectives: The purpose of this case series is to describe the orthopedic management of pubic symphysis osteomyelitis with an emphasis on the key principles of treating bony infection. Furthermore, we sought to identify whether debridement of the pubic symphysis without subsequent internal fixation would result in pelvic instability. Methods: A retrospective chart review was performed to identify all cases of pubic symphysis osteomyelitis treated at both institutions from 2011 to 2020. Objective outcomes collected included infection recurrence, change in pubic symphysis diastasis, sacroiliac (SI) joint diastasis, and ambulatory status. Subjective outcome measures collected included the numeric pain rating scale (NPRS) and the 36-Item Short Form Survey (SF-36). Pubic symphysis diastasis was measured as the distance between the two superior tips of the pubis on a standard anterior-posterior (AP) view of the pelvis. SI joint diastasis was measured bilaterally as the joint space between the ileum and sacrum approximately at the level of the sacral promontory on the inlet view of the pelvis. A paired t test was utilized to compare the differences in outcome measures. An α value of 0.05 was utilized. Results: Six patients were identified, of which five were males and one was female (16.7 %), with a mean ± standard deviation (SD) follow-up of 19  ±  12 months (range 6-37 months). Mean  ±  SD age was 76.2  ±  9.6 years (range 61.0-88.0 years) and body mass index (BMI) was 28.0  ±  2.9 kg/m 2 (range 23.0-30.8 kg/m 2 ). When postoperative radiographs were compared to final follow-up radiographs, there were no significant differences in pubic symphysis diastasis ( P   =  0.221) or SI joint diastasis (right, P   =  0.529 and left, P   =  0.186). All patients were ambulatory without infection recurrence at final follow-up. Mean improvement for NPRS was 5.6  ±  3.4 ( P   =  0.020) and mean improvement for SF-36 physical functioning was 53.0  ±  36.8 ( P   =  0.032). Conclusion: This case series highlights our treatment strategy for pubic symphysis osteomyelitis of aggressive local debridement with local antibiotic therapy. Additionally, debridement of the pubic symphysis without subsequent internal fixation did not result in pelvic instability, as determined by pelvic radiographs and ability to fully weight bear postoperatively.

Accuracy of magnetic resonance imaging in predicting anterior cruciate ligament tear location and tear degree.

PURPOSE: The purpose of this study is to evaluate the reliability of magnetic resonance imaging (MRI) in predicting the location of ACL tears in preoperative planning for anterior cruciate ligament (ACL) repair. METHODS: Thirty-four patients who underwent ACL repair were retrospectively analyzed to compare intraoperative arthroscopic findings with preoperative MRIs. RESULTS: For identifying type I tears, the sensitivity of MRI was 9.0% and the accuracy of MRI was 8.8%. There was moderate interrater agreement between MRI findings for tear location and tear degree. CONCLUSION: MRI alone may not necessarily be accurate in identifying which ACL tears are amenable to repair. STUDY DESIGN: Retrospective case series; Level of Evidence: IV.

Primary Anterior Cruciate Ligament Repair Using Suture Tape Augmentation: A Case Series of 29 Patients With Minimum 2-Year Follow-Up.

PURPOSE: To evaluate clinical outcomes and patient-reported outcomes of patients who underwent primary anterior cruciate ligament (ACL) repair using suture tape augmentation. METHODS: Patients with a proximal tear of the ACL who underwent primary ACL repair with a minimum 2-year follow-up were included. The exclusion criteria included multiligamentous knee injuries, midsubstance tears, tibial avulsion fractures, and distal tears. Demographic characteristics, injury pattern, concomitant injury pattern, and patient-reported outcome measures were recorded. Patients were evaluated at a minimum 2-year follow-up for clinical success, defined as stability not requiring revision ACL reconstruction, and for patient-reported outcome measurements. Failure was defined as the need for revision surgery. RESULTS: The mean follow-up period was 2.8 ± 0.9 years. Thirty-five patients met the inclusion criteria, with an average age of 32.2 ± 7.2 years, and 2-year follow-up was obtained for 29 of these patients. Revision surgery was required in 2 of the 29 patients (6.9%); successful treatment was achieved in the remaining 93.1%. The Single Assessment Numeric Evaluation score and Knee Injury and Osteoarthritis Outcome Score for the 27 successfully treated patients were recorded, with 70.4% having Single Assessment Numeric Evaluation scores of 80 or greater. CONCLUSIONS: This case series shows that primary surgical repair of proximal ACL tears using suture tape augmentation results in a low rate of revision surgery. LEVEL OF EVIDENCE: Level IV, prospective case series.

Posterior Cruciate Ligament Repair With Suture Augmentation: A Report of Two Cases With Two-Year Follow-Up.

We present two cases of posterior cruciate ligament (PCL) repair with suture augmentation (SA) in the setting of multiligamentous knee injury (MLKI). Excellent clinical outcomes were obtained at two-year follow-up with both patients returning to sport following injury. Both patients demonstrated improvements in Knee Injury and Osteoarthritis Outcome Score (KOOS) that exceeded the minimal clinically important difference (MCID) as reported in the literature for ligamentous knee injuries. One patient developed arthrofibrosis, which was successfully treated with manipulation under anesthesia and arthroscopic lysis of adhesions two months postoperatively. Both patients had full knee range of motion (ROM) by a one-year follow-up. One patient returned to full preinjury level of sport at six months postoperatively while the other patient returned to 50% of preinjury intensity at two-year follow-up. This series of two cases of PCL repair with SA in MLKIs demonstrates that PCL repair with SA is a viable procedure that can result in excellent short-term outcomes and restore knee stability.

Reduced Opioid Use Among Patients Who Received Liposomal Bupivacaine for ACL Reconstruction.

Standard multimodal pain management for anterior cruciate ligament reconstruction typically includes a combination of local anesthetics, nonsteroidal anti-inflammatory drugs, and opioids. Opioids present a substantial risk, and there is a rising number of prescription opioid-related overdoses in the United States. The goal of this study was to evaluate the quantity of opioids prescribed to patients who received liposomal bupivacaine as a component of their multi-modal pain regimen. The electronic medical records of patients who underwent anterior cruciate ligament reconstruction by a single surgeon at an urban hospital during a 2-year period were evaluated. Patients in the case group received liposomal bupivacaine and those in the control group did not. Statistical analysis of the number of pills prescribed and numeric pain rating scale scores was performed with a 2-tailed unequal variance t test. Statistical analysis of opioid prescription refills was performed with a chi-square test. A total of 67 patients were included. The mean number of 5-mg oxycodone tablets prescribed to the case group (9.29±10.29 tablets) was significantly lower (P<.01) compared with the number prescribed to the control group (66.26±37.13 tablets). Patients in the case group also were less likely to require an opioid prescription refill at the first follow-up appointment (P<.01; absolute risk reduction, 50%; number needed to treat, 2). Mean numeric pain rating scale score at 2 weeks was 2.8±2.1 in the case group and 3.8±2.4 in the control group (P=.09). Patients who received liposomal bupivacaine as part of multimodal pain management had significantly fewer opioid prescriptions. Despite the reduction in opioids prescribed, patients in the case group only showed a trend toward a reduction in pain at 2-week follow-up. [Orthopedics. 2021;44(2):e229-e235.].

Altered DNA methylation in a severe subtype of idiopathic autism: Evidence for sex differences in affected metabolic pathways.

LAY ABSTRACT: This study investigates altered DNA methylation that may contribute to autism spectrum disorders. DNA methylation is an epigenetic mechanism for regulating the level at which genes are expressed, and is thus complementary to genetics and gene expression analyses which look at the variations in gene structure and gene products in cells. Here, we identify DNA methylation differences between autistic and sex-matched non-autistic siblings, focusing on a subgroup of severely affected individuals with language impairment to reduce the clinical heterogeneity among the cases. Our results show significant differentially methylated genes between the sibling groups that are enriched in autism risk genes as well as in signaling and biochemical pathways previously associated with the pathobiology of autism spectrum disorders. Moreover, we show for the first time that these differences are in part sex dependent, with differentially methylated genes in females associated with pathways that implicate mitochondrial dysfunction and metabolic disorders that may offer some protection to females against autism spectrum disorders. Further investigations of sex differences are required to develop a fuller understanding of the pathobiology, gene regulatory mechanisms, and differential susceptibility of males and females toward autism spectrum disorders.

The effect of silicone ankle sleeves and lace-up ankle braces on neuromuscular control, joint torque, and cutting agility.

OBJECTIVE: To evaluate the effects of silicone ankle sleeves (SASs) and lace-up ankle braces (LABs) on neuromuscular control, net joint torques, and cutting agility in healthy, active individuals. DESIGN: Markerless motion-capture technology tracked subjects fitted with SASs, LABs, or no brace while they performed the movements: Y-excursion, left cutting, right cutting, single-leg drop vertical jump (SLDVJ), 45-degree bound, and single-leg squat (SLS). SETTING: University Laboratory. PARTICIPANTS: Ten healthy, active individuals (5 males and 5 females, mean ± SD 23.60 ± 1.43 years of age). MAIN OUTCOME MEASURES: Degrees of joint range of motion (ROM), Newton-meters of joint torque, time to perform a cutting maneuver. RESULTS: SASs and LABs resulted in significantly different knee and ankle ROM and hip internal rotation in the SLDVJ, SLS, Y-excursion, cutting maneuver, and 45-degree bound when compared to control (p < .05). Both ankle and knee torque were significantly reduced in the 45-degree bound and cutting movements with both types of PABs (p < .05). There were minimal differences between the SASs and LABs for all conditions. There were no statistically significant differences in cutting times for any of the 3 conditions. CONCLUSION: Both SAS and LAB positively impacted neuromuscular control, reduced net joint torque, and neither impaired cutting agility when compared to control.