Head Injury Assessment in the Elite Level Rugby Union in Japan: Review of 3 Seasons.

Head Injury Assessment (HIA) is the screening tool for head injury during a rugby game. The purpose of this study was to investigate the epidemiology of HIA in the Japan Rugby Top League (JRTL). The incidences of HIA, defined concussion (per 1,000 player-hours) and repeated concussions were evaluated in three seasons (2016-17, 2017-18, 2018-19; total 360 games). The HIA incidence rates were 12.7 (95% confidence interval 9.5-15.9), 20.8 (16.8-24.9), and 25.0 (20.5-29.5) in each season. HIA-1 criteria 2, which is applied for suspected concussion cases, was performed for 46 cases in the 2016-17 season, 81 cases in the 2017-18 season, and 88 cases in the 2018-19 season. The concussion incidence rates were significantly greater in the 2017-18 season (9.6/1000 player-hours, 95% confidence interval 6.8-12.4) and the 2018-19 season (14.4, 11-17.8) compared to the 2016-17 season (4.8, 2.8-6.8). The number of repeated concussion cases in the same season was 1 in the 2016-17 season and 4 in both the 2017-18 and 2018-19 seasons. This study confirmed significantly higher HIA and concussion incidence rates over time. Although the HIA system might have been established in the three seasons in JRTL, comprehensive management needs to be improved to prevent repeated concussions.

Reproducibility, responsiveness and validation of the Tampa Scale for Kinesiophobia in patients with ACL injuries.

BACKGROUND AND PURPOSE: Psychological factors including fear of pain, re-injury during movement (kinesiophbia) affect return-to-sport rates after anterior cruciate ligament (ACL) reconstructive surgery. Clinicians often encounter in the daily practice that athletes explain lack of self-confidence or psychological readiness during the sports activity. The Tampa Scale for Kinesiophobia (TSK) has been used to evaluate psychological outcomes in patients with ACL injuries in many countries and translated into Japanese version in 2013. However, no researchers validated its reliability, validity, and responsiveness of TSK for patients with ACL injury up to now. The purpose of this study was to evaluate the measurement properties of the Japanese version of the TSK (TSK-J) in patients with ACL injuries. STUDY DESIGN: Cohort study (Diagnostic); Level of evidence, 2. METHODS: This prospective study was performed in the department of orthopaedic surgery at the university hospital of Juntendo from Sep 2016 and Apr 2017. Patients who diagnosed with ACL injury with or without reconstruction surgery completed several patient-reported outcome measures (PROMs) were included in this study. The COnsensus-based Standards for the selection of health status Measurement INstruments (COSMIN) guidelines were used to evaluate reliability, validity, responsiveness, and interpretability of the TSK-J. RESULTS: 222 patients were included in this study. The TSK-J for ACL injured patients showed good internal consistency (Cronbach's alpha = 0.79) and excellent test-retest reliability (intra-class correlation coefficient, ICC2,1 = 0.90, 95% CI = 0.81 to 0.95). In addtion, the TSK-J was significantly but moderately correlated with the IKDC-SKF (r = - 0.49, P <0.001), VAS-Sports (r = - 0.48, P <0.001), and JACL-25 (r = 0.48, P <0.001). The effect size (ES) was small with the Cohen's d = - 0.2. The minimal important difference (MID) was - 1.3 points. No significant TSK-J score change was observed over 1-year after ACL reconstruction (r = - 0.12, P <0.001). There were no floor or ceiling effects. CONCLUSIONS: Our study demonstrated that the Japanese version of TSK has good reliability. However, its low validity and responsiveness indicate that it may not the best way to assess psychological factors for patients with ACL injury.

Accelerated Return to Play for Professional Rugby Players After Facial Fractures.

BACKGROUND: Facial fractures may result in a significant time away from competition for professional rugby players. An understanding of the return-to-play times is an integral part of clinical decision making when treating professional athletes. A period of 8 to 12 weeks has been conventionally recommended for returning to collision sports after facial fractures. The conventional time to return to sports of 8 to 12 weeks is usually too long for professional players. However, the time of return to play after such facial fractures in elite athletes has not been well described. PURPOSE: To investigate the return to play after facial fractures in professional rugby players with an accelerated rehabilitation protocol. METHODS: Ten professional rugby players with facial fractures were identified and analyzed. The authors investigated the number of days required to return to training and full-contact play according to the trauma type. The authors also determined the presence or absence of refractures and sequelae. RESULTS: The average age of the patients was 26.9 years. Medial orbital wall fractures were the most represented pattern, followed by orbital floor fractures and zygomatic arch fractures. The players returned to jogging after 9.9 days, to sports-specific training after a mean of 10.8 days, and to full-contact training after 18.3 days. There were no cases of refractures and sequelae. CONCLUSION: Players were able to return to their regular rugby activities, earlier than the time commonly allowed to return to full activity.

Return to Play of Rugby Players After Anterior Cruciate Ligament Reconstruction Using Hamstring Autograft: Return to Sports and Graft Failure According to Age.

PURPOSE: To assess return to play and the frequencies of graft failure in rugby players after anterior cruciate ligament (ACL) reconstruction using a hamstring autograft augmented with an artificial ligament and to compare outcomes between rugby players aged <20 and ≥20 years over the long term. METHODS: A consecutive series of 146 rugby players who underwent ACL reconstruction with a hamstring autograft augmented with an artificial ligament were retrospectively reviewed. The study population was further divided into 2 groups aged <20 years and >20 years and compared. RESULTS: Twenty-five patients could not be followed up, and 121 (83%) were evaluated. Most patients (90%, <20 years; 92%, ≥20 years) returned to play after ACL reconstruction. At an average follow-up period of 56.5 months, 16% of the patients sustained an ACL graft rupture. Regarding age, <20 years (n = 58, 48%) and ≥20 years (n = 63, 52%), younger players had a significantly higher failure rate (23% vs 5%, respectively; P = .006) and a shorter time to failure (22.8 ± 13.2 vs 35.4 ± 15.4 months, respectively; P = .006) than older players. CONCLUSIONS: Rugby players were likely to return to play after ACL reconstruction with a hamstring autograft. However, there was a higher risk of graft failure in younger players than in older players. On the basis of this study, we conclude that the hamstring autograft may not be an appropriate graft source to use in a younger active population, including rugby players. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Effect of hemoperfusion using polymyxin B-immobilized fibers on acute lung injury in a rat sepsis model.

Direct hemoperfusion using polymyxin B-immobilized column (PMX-DHP) is recognized as an effective treatment for septic shock. However, whether its efficacy is limited to cardiovascular dysfunction remains unknown. Therefore, we planned to examine the effects of PMX-DHP in an acute lung injury model. [Materials and methods] Rats were assigned to either PMX-DHP group or control group (n= 7 in each). A lung injury was created by the intratracheal instillation of LPS. In PMX-DHP group, an arteriovenous extracorporeal circuit using PMX column was applied for three hours. The same procedure using a dummy column was applied in control group. The lung microcirculation was observed, and adherent leukocytes, RBC velocity, and the arterial PaO2 were calculated. Pathological changes and the wet/dry weight ratio of the lungs were examined. [Results] Adherent leukocytes and platelets to the lung venules were recognized at 3 hours, and their numbers increased over time. Treatment with PMX-DHP significantly suppressed these events and helped maintenance of the blood flow and PaO2 levels. The lung edema and the histologic damages were also suppressed. [Conclusions] PMX-DHP improved the microcirculation by suppressing leukocyte and platelet adhesion. PMX-DHP had beneficial effects in a model for acute lung injury.

Incidence of and risk factors for traumatic anterior shoulder dislocation: an epidemiologic study in high-school rugby players.

BACKGROUND: The incidence of reinjuries due to glenohumeral instability and the major risk factors for primary anterior shoulder dislocation in youth rugby players have been unclear. PURPOSE: The purpose of this study was to investigate the incidence, mechanisms, and intrinsic risk factors of shoulder dislocation in elite high-school rugby union teams during the 2012 season. METHODS: A total of 378 male rugby players from 7 high-school teams were investigated by use of self-administered preseason and postseason questionnaires. RESULTS: The prevalence of a history of shoulder dislocation was 14.8%, and there were 21 events of primary shoulder dislocation of the 74 overall shoulder injuries that were sustained during the season (3.2 events per 1000 player-hours of match exposure). During the season, 54.3% of the shoulders with at least one episode of shoulder dislocation had reinjury. This study also indicated that the persistence of glenohumeral instability might affect the player's self-assessed condition, regardless of the incidence during the current season. By a multivariate logistic regression method, a history of shoulder dislocation on the opposite side before the season was found to be a risk factor for contralateral primary shoulder dislocation (odds ratio, 3.56; 95% confidence interval, 1.27-9.97; P = .02). CONCLUSIONS: High-school rugby players with a history of shoulder dislocation are not playing at full capacity and also have a significant rate of reinjury as well as a high risk of dislocating the other shoulder. These findings may be helpful in deciding on the proper treatment of primary anterior shoulder dislocation in young rugby players.

Comparison of prothrombin time tests used in the monitoring of edoxaban and their evaluation as indicators of the reversal effect.

Clinical demand for the prompt assessment of the activity of direct-acting factor Xa inhibitors in the emergency care setting is increasing. In the present study, we examined whether prothrombin time (PT) tests can serve as a clinically useful indicator of anti-factor Xa activity. In the first series, the in vitro effect of edoxaban on PT was evaluated by spiking human plasma with edoxaban and measuring PT using three different commercial PT tests. In the second series, the reversal effect of prothrombin complex concentrates (PCC) and activated PCC (aPCC) in edoxaban-spiked plasma was evaluated. In the third series, PT of plasma samples from patients administered either 15 or 30 mg/day of edoxaban was assessed, and the results were compared with edoxaban concentrations determined by a calibrated anti-factor Xa activity assay. The spike test revealed that all PT reagents positively correlated with edoxaban. The sensitivity to edoxaban varied among the three reagents and Triniclot(®) Excel S showed the best performance. Prolonged PT by edoxaban was reversed by PCC and aPCC in a dose-dependent manner; however, complete reversal was not achieved. Positive correlation between anti-factor Xa activity and PT was shown in the clinical samples at the edoxaban range from 0 to >300 ng/mL.

Anterior cruciate ligament injuries in elite and high school rugby players: a 11-year review.

OBJECTIVES: Over a 11-year period, we investigated the incidence of anterior cruciate ligament (ACL) injuries and the clinical outcomes after ACL reconstruction with hamstring autografts in two homogenous cohorts of rugby players. METHODS: Two teams, including those in elite (94 players) and high school (290 players) clubs, were followed. RESULTS: Isolated ACL injuries occurred in 28 players (12 elite, 16 high school). The incidence during match play was 1.26 per 1000 player-hours (95% confidence interval [95% CI]: 0.48-2.05) among elite players and 0.97 per 1000 player-hours (95% CI: 0.30-1.64) among high school players. After ACL reconstruction, 26 players (12 elite, 14 high school) were successfully contacted for follow-up at a mean of 71.9 months. None (0%) of the elite and 4 (29%) of the high school players experienced graft ruptures. Seven (58%) elite and 10 (91%) high school players were fearful of reinjury; the mean time to overcome this fear was 6.1 ± 4.9 months among elite players and 17.5 ± 26.0 months among high school players. CONCLUSION: In conclusion, young rugby players experienced inferior outcomes after ACL reconstruction with hamstring autografts compared with their older counterparts.

Incidence of Stingers in Young Rugby Players.

BACKGROUND: A stinger is a type of neurapraxia of the cervical roots or brachial plexus and represents a reversible peripheral nerve injury. The incidence of and major risk factors for stingers among young rugby players remain uninvestigated. PURPOSE: To investigate the incidence, symptoms, and intrinsic risk factors for stingers in elite rugby union teams of young players. STUDY DESIGN: Descriptive epidemiology study. METHODS: A total of 569 male rugby players, including 358 players from 7 high school teams and 211 players from 2 university teams, were investigated using self-administered preseason and postseason questionnaires. RESULTS: The prevalence of a history of stingers was 33.9% (95% CI, 30.3-37.9), and 20.9% (119/569) of players experienced at least 1 episode of a stinger during the season (34.2 [95% CI, 26.2-42.1] events per 1000 player-hours of match exposure). The reinjury rate for stingers per season was 37.3% (95% CI, 30.4-44.2). Using the multivariate Poisson regression method, a history of stingers in the previous season and the grade and position of the player were found to be risk factors for stingers during the current season. The mean severity of injury was 2.9 days, with 79.3% (191/241) of the players not losing any time from playing after sustaining a stinger injury and 5.8% (14/241) of the players recovering within more than 14 days. The most frequent symptom was numbness in the unilateral upper extremity, and the most severe symptom was weakness of grasping (mean severity, 6 days). A logistic regression analysis indicated that a history of stingers in the previous season and an injury with more than 3 symptoms, especially motor weakness, were correlated with the severity of injury. CONCLUSION: Young rugby players with a history of stingers have a significantly high rate of repeat injuries. Although nearly 80% of the players experienced only minimal (0-1 day) time loss injuries, neurological deficits sometimes last beyond 1 month. A history of stingers was identified to be the strongest risk factor for injuries and for lasting symptoms. This information may be useful for planning the proper treatment for stingers in young rugby players.

Case series: Revision anterior cruciate ligament reconstructions using patellar tendon autografts.

BACKGROUND: Using intra-operative findings and clinical results, including return to play (RTP) at the pre-injury level, this study investigated the causes of primary graft failure after revision anterior cruciate ligament (ACL) reconstruction with bone-patellar-tendon-bone (BPTB) autografts. METHODS: A total of 54 patients were followed for a mean of 38.2 ± 10.2 months post-surgery. Subjective and objective results were evaluated using single assessment numeric evaluation (SANE) scores, Lachman tests, KT-2000 arthrometer results, and pivot-shift tests. The change in each patient's Tegner activity scale and RTP at the pre-injury level were also evaluated. RESULTS: Inappropriate positioning of the tunnels was the most important reason (54%) for primary graft failure. After revision surgery, anterior knee stability was significantly improved (1.2 (mean) ± 1.2 (SD)mm vs 4.5(mean) ± 1.9 (SD)mm; P < 0.01). Two (4%) patients sustained revision graft ruptures while two (4%) sustained contralateral knee ACL tears. The rate of RTP at the pre-injury level was 67% (36 patients), and mean SANE scores at the time of RTP were higher than before surgery (74.8 ± 13.8 points vs 24.1 ± 16.4; P<0.001). The average time from primary graft failure to revision surgery was shorter (12.2 (mean) ± 4.0 (SD) vs 37.6 (mean) ± 8.8 (SD)months; P < 0.01) and the ratio of major cartilage injury was lower (39% vs 83%; P < 0.05) in the RTP group than that in the non-RTP group. CONCLUSIONS: The time from primary graft failure to revision surgery and the extent of the cartilage injury are major factors in RTP after revision ACL reconstructions.

A case of paraparesis with thoracic ossification of the posterior longitudinal ligament and the ligamentum flavum induced by falling down on the abdomen.

AIM: To describe an educational case. METHODS: Case report. RESULTS: A 71-year-old female was transported to our emergency department with complaints of lower abdominal pain and gate disturbance after falling down on her abdomen. She had lower abdominal painful paresthesia in the dermatome from the twelfth thoracic to the first lumbar level without signs of peritoneal stimulation. Paraparesis and dysesthesia of the lower extremities was predominant on the left side. Abdominal computed tomography revealed severe thoracic ossification of the posterior longitudinal ligament and the ligamentum flavum at the thoracic level 10/11. Laminectomy and spinal fusion with rods resulted in recovery of the patient's symptoms. CONCLUSION: Physician should pay attention to thoracic spinal cord injury induced by hyperextensive stress on the spine, even in cases of minor trauma, among patients with preexisting bony pathologies at the thoracolumbar level.

Rivaroxaban attenuates leukocyte adhesion in the microvasculature and thrombus formation in an experimental mouse model of type 2 diabetes mellitus.

INTRODUCTION: Thrombosis is a major complication in diabetes mellitus. Since Factor Xa inhibitors are not only inhibit the coagulation system but also attenuate the leukocyte-endothelial interaction in acute inflammation models, the purpose of this study is to confirm the similar effects of rivaroxaban in a mouse model of type 2 diabetes mellitus. MATERIALS AND METHODS: In the treatment groups, either 5 or 10mg/kg of rivaroxaban dissolved in DMSO was orally given to KK-A(y) mice for 7 weeks (n=6 in each group). KK-A(y) mice fed by chow containing DMSO without rivaroxaban for 7 weeks were served for the control group (n=6). Following clamping of the mesenteric vein for 20 minutes, intravital microscopic observation of the intestinal microcirculation and the measurement of bleeding time after the needle puncture were carried-out. In another series, the calculation for blood cell counts and the measurement of blood fluidity using micro channel array flow analyzer (MC-FAN) were performed. RESULTS: The initial event in the microvasculature is the leukocyte adhesion on endothelium. Then, the leukocytes make clusters and the platelets are involved in. These leukocyte-platelet conjugates aggregate and form thrombus. The leukocyte adherence and the microthrombus formation was significantly suppressed with the treatment of 10 mg/kg of rivaroxaban compared to the control group (P<0.05). While, the bleeding time was significantly extended with the treatment with 10mg/kg of rivaroxaban (P<0.01). The blood fluidity was maintained best with the treatment of 10 mg/kg rivaroxaban. CONCLUSIONS: Rivaroxaban attenuates the leukocyte-platelet-endothelial interaction, which leads to the attenuation of microthrombus formation in a mouse model of diabetes mellitus.

Analysis of non-traumatic truncal back pain in patients who visited an emergency room.

AIM: To investigate epidemiology of acute non-traumatic back pain using modern diagnostic methods in patients who visited an emergency room. METHODS: The medical charts were retrospectively reviewed for all patients with back pain who were treated in our hospital. In addition, the patients were divided into two groups based on whether they were treated at the hospital or as outpatients. RESULTS: There were 95 patients with non-traumatic acute back pain. Leading cause of back pain was ureterolithiasis (53 cases), followed by pyelonephritis (10), orthopedic disease including two cases of purulent spondylitis (24), aortic disease (3), pancreatitis (1), renal bleeding (1), adrenal bleeding (1), psoas abscess (1), and torsion of an ovarian tumor (1). All cases of pyelonephritis, aortic disease, purulent spondylitis, renal bleeding, adrenal bleeding, psoas abscess, and torsion of an ovarian tumor were treated in admission. Using a multiple logistic regression analysis, blood pressure, age, and body temperature were the only factors that were independently associated with whether the patient was admitted or treated as an outpatient. CONCLUSION: This study showed that urological diseases are the most common cause of back pain in patients who visit the emergency room, followed by orthopedic disease. Older age, low blood pressure, and high body temperature were independently associated with the decision to admit the patient who might have lethal disease.

Late recurrence of giant cell tumour of bone after curettage and adjuvant treatment: a case report.

We report a rare case of late recurrence of a giant cell tumour (GCT) of bone 16 years after curettage and cryosurgery treatment. A 46-year-old man presented with swelling and progressively worsening pain in the lateral aspect of his right distal femur. He had undergone 4 procedures elsewhere to manage a GCT of bone and its recurrence 16 to 23 years previously. He underwent en bloc resection with an adequate wide margin and reconstruction with prosthesis. At the one-year follow-up, there was no evidence of recurrence or metastasis.

Subcapital femoral neck fracture after fixation of an intertrochanteric fracture with a proximal femoral nail: a report of two cases.

Subcapital femoral neck fractures are a rare complication after fixation of an intertrochanteric fracture with a proximal femoral nail. We report 2 such cases where the patients had severe osteoporosis, based on Singh's index and pathological findings. In one case there was a technical error leading to a tip-apex distance of more than 20 mm, but osteoporosis appeared to be a more significant cause than any technical problems.

Combined preoperative autologous blood donation and intra-operative cell salvage for hip surgery.

PURPOSE: To review records of 161 consecutive hip surgery patients for whom preoperative autologous blood donation (PABD) was used in combination with intra-operative cell salvage (ICS). METHODS: 114 women and 14 men aged 41 to 86 (mean, 64) years underwent 135 primary total hip arthroplasties (THAs), whereas 19 women and 7 men aged 16 to 52 (mean, 35) years underwent 26 rotational acetabular osteotomies (RAOs). Two or 3 weeks before the operation, patients deposited one unit (400 ml) of blood weekly, so long as their haemoglobin levels exceeded 110 g/l (if they had osteoarthritis) or 100 g/l (if they had rheumatoid arthritis). Patients were given oral ferrous sulphate, lactated Ringer's solution, and recombinant human erythropoietin. 800 and 1200 ml of blood were deposited for patients undergoing THA and RAO, respectively. Intra-operatively, ICS was carried out using a continuous autotransfusion system. The blood from ICS was transfused first, and then the blood from PABD was transfused during the latter half of the operation. RESULTS: By combining PABD and ICS, homologous blood transfusion was avoided in all patients, even in those with unexpected massive bleeding during surgery. In 3 patients, one unit of deposited autologous blood was discarded, because they showed no sign of anaemia. The mean total blood loss was almost 1.5 times higher in RAO than in THA patients (1095 vs 1550 ml). In the THA and RAO patients respectively, the mean amount of ICS was 181 and 210 ml, whereas the mean total blood transfusion volume was 975 and 1394 ml. No complications (including infection) related to autologous blood transfusion were observed during PABD, the surgery or the postoperative period. CONCLUSION: Homologous blood transfusion was avoided with the use of PABD and ICS. Preoperative donation of 800 and 1200 ml of blood (combined with ICS) seemed optimal, as only 3 units of blood were discarded.

Rapid resolution of femoral head osteonecrosis after rotational acetabular osteotomy.

The natural history of osteonecrosis of the femoral head is generally thought to be one of progressive deterioration if no intervention is undertaken. However, it is unknown whether surgical intervention is beneficial for patients with a small region of osteonecrosis. We observed rapid improvement of MRI findings after rotational acetabular osteotomy (RAO) was performed in a young patient with osteonecrosis of the femoral head. The band-like low signal area on T2-weighted images almost resolved by six months after surgery. He returned to work as an electrician by six months after surgery. Early surgical intervention such as RAO that alters the mechanical force acting on the necrotic region of the femoral head may accelerate the recovery of osteonecrosis and the improvement of symptoms.