The Association of Vitamin D Status in Lower Extremity Muscle Strains and Core Muscle Injuries at the National Football League Combine.

PURPOSE: To evaluate the association between serum vitamin D level and the prevalence of lower extremity muscle strains and core muscle injuries in elite level athletes at the National Football League (NFL) combine. METHODS: During the 2015 NFL combine, all athletes with available serum vitamin D levels were included for study. Baseline data were collected, including age, race, body mass index, position, injury history specific to lower extremity muscle strain or core muscle injury, and Functional Movement Screen scores. Serum 25-hydroxyvitamin D was collected and defined as normal (≥32 ng/mL), insufficient (20-31 ng/mL), and deficient (<20 ng/mL). Univariate regression analysis was used to examine the association of vitamin D level and injury history. Subsequent multivariate regression analysis was used to examine this relation with adjustment for collected baseline data variables. RESULTS: The study population included 214 athletes, including 78% African American athletes and 51% skilled position players. Inadequate vitamin D was present in 59%, including 10% with deficient levels. Lower extremity muscle strain or core muscle injury was present in 50% of athletes, which was associated with lower vitamin D levels (P = .03). Athletes with a positive injury history also showed significantly lower vitamin D levels as compared with uninjured athletes (P = .03). African American/black race (P < .001) and injury history (P < .001) was associated with lower vitamin D. Vitamin D groups showed no differences in age (P = .9), body mass index (P = .9), or Functional Movement Screen testing (P = .2). Univariate analysis of inadequate vitamin D levels showed a 1.86 higher odds of lower extremity strain or core muscle injury (P = .03), and 3.61 higher odds of hamstring injury (P < .001). Multivariate analysis did not reach an independent association of low vitamin D with injury history (P = .07). CONCLUSIONS: Inadequate vitamin D levels are a widespread finding in athletes at the NFL combine. Players with a history of lower extremity muscle strain and core muscle injury had a higher prevalence of inadequate vitamin D. LEVEL OF EVIDENCE: Level IV, retrospective study-case series.

Autologous distal clavicle versus autologous coracoid bone grafts for restoration of anterior-inferior glenoid bone loss: a biomechanical comparison.

BACKGROUND: Treating anterior glenoid bone loss in patients with recurrent shoulder instability is challenging. Coracoid transfer techniques are associated with neurologic complications and neuroanatomic alterations. The purpose of our study was to compare the contact area and pressures of a distal clavicle autograft with a coracoid bone graft for the restoration of anterior glenoid bone loss. We hypothesized that a distal clavicle autograft would be as effective as a coracoid graft. METHODS: In 13 fresh-frozen cadaveric shoulder specimens, we harvested the distal 1.0 cm of each clavicle and the coracoid bone resection required for a Latarjet procedure. A compressive load of 440 N was applied across the glenohumeral joint at 30° and 60° of abduction, as well as 60° of abduction with 90° of external rotation. Pressure-sensitive film was used to determine normal glenohumeral contact area and pressures. In each specimen, we created a vertical, 25% anterior bone defect, reconstructed with distal clavicle (articular surface and undersurface) and coracoid bone grafts, and determined the glenohumeral contact area and pressures. We used analysis of variance for group comparisons and a Tukey post hoc test for individual comparisons (with P <.05 indicating a significant difference). RESULTS: The articular distal clavicle bone graft provided the lowest mean pressure in all testing positions. The coracoid bone graft provided the greatest contact area in all humeral positions, but the difference was not significant. CONCLUSION: An articular distal clavicle bone graft is comparable in glenohumeral contact area and pressures to an optimally placed coracoid bone graft for restoring glenoid bone loss. LEVEL OF EVIDENCE: Basic Science Study; Biomechanics.

Sterile pretibial cyst formation following anterior cruciate ligament reconstruction with a bioabsorbable screw.

Sterile pretibial cysts are a complication after anterior cruciate ligament (ACL) reconstruction with bioabsorbable screws. We present a case series of sterile pretibial abscesses following ACL reconstruction with bioabsorbable poly-L-lactide (PLLA) screws, including a patient that developed a saphenous neuroma and a patient who underwent ACL reconstruction with tibialis anterior (TA) allograft. Neither of these circumstances has been previously reported in the literature.

Operating Room Virtual Reality Immersion Improves Self-Efficacy Amongst Preclinical Physician Assistant Students.

OBJECTIVE: To assess the impact on self-efficacy for preclinical physician assistant (PA) students through immersive virtual reality (VR) operating room simulation. DESIGN: Randomized double-blinded controlled experiment measuring self-efficacy using Schwarzer and Jerusalem's general self-efficacy scale. An entirely novel operating room was created, casted, and filmed using VR software. Fifty-two preclinical PA students were randomly assigned to VR (n = 26) or traditional lecture (n = 26) and self-efficacy was measured in both conditions using a general self-efficacy scale given before and after the virtual experience. A mixed ANOVA, independent sample t tests, and paired samples t tests were performed. SETTING: Shenandoah University Physician Assistant program, Winchester, Virginia. RESULTS: Exposure to VR training after the traditional lecture improves self-efficacy amongst PA students (p < 0.05). Exposure to VR improved self-efficacy compared to traditional methods (p < 0.05). There was no difference in self-efficacy amongst PA students with the traditional model (p < 0.05). CONCLUSIONS: The introduction of VR simulation improved preclinical PA student self-efficacy in the operating room setting.

Basic Science Research Trends in Orthopedic Surgery: An Analysis of the Top 100 Cited Articles.

BACKGROUND: Much of current clinical orthopedics traces its origin to basic science investigation of cellular and biochemical pathways, tissue engineering, and biomechanics of bone and joint physiology in animal and cadaveric models. QUESTIONS/PURPOSES: We sought to describe research trends in highly cited basic science studies in orthopedics. METHODS: By searching Web of Science, we identified the 100 most cited basic science orthopedics articles and focused on author position and degree (PhD, MD, or MD/PhD), topic, type of study, country, institution, and citation trends. RESULTS: These articles were published from 1970 to 2008 (citation range, 330 to 2111), with the majority from the USA (78). While there was no correlation between years since publication and total citations, more recent articles had higher citation rates. There were 38 unique first authors represented, with Caplan, Harris, Mankin, Noyes, and Warren as primary authors or co-authors of four articles each. Twelve journals published these 100 articles, with the majority in Journal of Bone and Joint Surgery (46) and Clinical Orthopaedics and Related Research (18). Frequent topics included biomechanics (31), healing/regeneration (21), and cellular/molecular biology (13). The Hospital for Special Surgery/Cornell University (10) published the most, followed by the Hospital for Joint Diseases/New York University (6), and University of Pittsburgh (6). No difference was observed in total citations and average citation rate by author degree. Eight articles were contributed from privately owned institutions or industry, with the rest from academic hospitals. CONCLUSION: This review may aid those seeking insight into landmark studies and future direction of basic science research in orthopedics.

Resection of a Giant-Cell Tumor of the Proximal Aspect of the Radius with Osteoarticular Allograft Reconstruction: A Case Report.

CASE: Giant-cell tumors are locally aggressive osteolytic benign tumors that are characterized by multinucleated giant cells. Recurrence rates are ≤30% after curettage and <5% after resection, but reconstruction can be difficult. We describe an osteoarticular allograft reconstruction of the proximal aspect of the radius in a 23-year-old man after resection of a giant-cell tumor. CONCLUSION: Five months after surgery, the patient had satisfactory joint articulation, range of motion, and strength, with no signs of hardware or graft failure. By 17 months, there was complete osseous union. The joint remained stable at 54 months. We describe our surgical approach, which restores joint stability and minimizes recurrence.

Commercial Separation Systems Designed for Preparation of Platelet-Rich Plasma Yield Differences in Cellular Composition.

BACKGROUND: The role of platelet-rich plasma (PRP) in the treatment of sport-related injuries is unclear, largely due to the heterogeneity of clinical results. This may relate to compositional differences in PRP from different separation systems. QUESTIONS/PURPOSES: This study aims to compare the composition of PRP produced with five different commercially available systems, focusing on cellular concentrations and pH. METHODS: Seven donors (41 ± 12 years) provided blood for PRP preparation using five systems (Arthrex Angel, Emcyte Genesis CS, Arteriocyte Magellan, Harvest SmartPrep, and Biomet GPS III). Post processing, cellular composition was measured including platelets (PLT), white blood cells (WBC), neutrophils (NE), and red blood cells (RBC), as well as pH. RESULTS: Platelet concentration and capture efficiency were similar between systems, except the Angel 7% preparation had a greater concentration than Genesis CS (2310 ± 524 vs. 1129 ± 264 k/µL). WBC concentration was variable between systems; however, significant differences were only found between the Angel 2% and GPS III preparations (11.0 ± 4.5, 27.3 ± 7.1 k/µL). NE concentration was significantly lower in the Angel 2% and 7% preparations compared with GPS III (0.6 ± 0.6 and 1.8 ± 1.3 k/µL vs. 9.4 ± 7.0 k/µL). RBC concentration was highest in SmartPrep (3.2 ± 0.6 M/µL) and Genesis CS systems (3.1 ± 0.6 M/µL) compared with all other systems (≤1.1 ± 1.2 M/µL). Finally, pH was significantly lower with the SmartPrep system (6.95 ± 0.06) compared with all others (≥7.26 ± 0.06). CONCLUSION: Aside from platelet concentration and capture efficiency, significant compositional differences were identified between preparation systems. Caution should be employed when interpreting clinical results of studies utilizing PRP, as the role of compositional differences and their effect on outcome are unknown. Further study is necessary to determine the clinical significance of these differences.

Current Trends in Ulnar Collateral Ligament Reconstruction Surgery Among Newly Trained Orthopaedic Surgeons.

INTRODUCTION: Ulnar collateral ligament (UCL) reconstructions are being performed with an increasing annual incidence. The purpose of this study was to evaluate trends in UCL surgery among recently trained orthopaedic surgeons. METHODS: The American Board of Orthopaedic Surgeons (ABOS) database was used to identify all UCL reconstructions from 2004 to 2013. Procedures were identified by Current Procedural Terminology (CPT) codes and verified by International Classification of Disease, Ninth Revision (ICD-9) codes. Data on surgeon fellowship, practice location, concomitant surgical procedures, and complications were collected. RESULTS: One hundred sixty-four UCL reconstructions were performed by 133 ABOS Part II candidates. The annual incidence increased from 1.52 to 3.46 cases per 10,000 (P = 0.042). Reconstructions were most commonly performed by surgeons with fellowship training in sports medicine (65.9%), hand and upper extremity (18.9%), and shoulder and elbow (9.1%). Most reconstructions were performed in isolation (57.3%), or with ulnar nerve transposition (32.9%) or elbow arthroscopy (9.8%). Concomitant elbow arthroscopy rates decreased significantly (P = 0.022). Complications occurred in 9.8% of cases, although the rates did not significantly change (P = 0.466). CONCLUSIONS: UCL reconstructions are being performed with increasing frequency. Concomitant procedure rates remained the same, although arthroscopy was less commonly performed. Complication rates did not change considerably over the observed period. Further study of the surgical trends and associated long-term outcomes is warranted. LEVEL OF EVIDENCE: Level IV.

Hip arthroscopy utilization and associated complications: a population-based analysis.

The purpose of this study is to review the trends in hip arthroscopy using data from a statewide database, focusing on utilization rates, patient demographics and complication rates. The Statewide Planning and Research Cooperative System (SPARCS) database for New York State was queried for cases of hip arthroscopy from 1998 to 2012. Patient demographics and procedural details were collected. Patients were subsequently reviewed for complications and readmissions within 30 and 90 days. In total, 12 194 hip arthroscopy procedures were performed by 295 surgeons in 137 centers between 1998 and 2012. There was a 95-fold increase in the annual frequency of hip arthroscopy procedures between 1998 (n = 24) and 2012 (n = 2296). Thirty-day complication rates were 0.2% (n = 19), whereas the 90-day complication rate was 0.3% (n = 30). The all-cause 30-day readmission rate was 0.5% (n = 66), whereas the 90-day rate was 1.6% (n = 200). The number of surgeons performing hip arthroscopy increased 7-fold over the observation period. However, only 14.9% (n = 44) of surgeons performed more than 30 procedures annually. Lower volume surgeons (<102 cases/year) demonstrated significantly higher 90-day readmission rates, compared with higher volume surgeons (>163 cases/year, P < 0.0060); however, complication rates and readmission rates did not differ based on surgeon volume. Our findings confirm our hypothesis, demonstrating a significant increase in utilization of hip arthroscopy in the State of New York. We did not identify an associated increase in annual complication rates as hypothesized with increasing utilization, although there was an association of higher readmission rates among lower volume surgeons. Further study is needed to define rates of failure requiring revision hip arthroscopy or conversion to arthroplasty, and to clarify the relationship between complication rates and surgeon volume and case complexity. Level of Evidence: III, retrospective cohort series.

Reliability and Validity of 3 Methods of Assessing Orthopedic Resident Skill in Shoulder Surgery.

OBJECTIVE: Traditional measures for evaluating resident surgical technical skills (e.g., case logs) assess operative volume but not level of surgical proficiency. Our goal was to compare the reliability and validity of 3 tools for measuring surgical skill among orthopedic residents when performing 3 open surgical approaches to the shoulder. METHODS: A total of 23 residents at different stages of their surgical training were tested for technical skill pertaining to 3 shoulder surgical approaches using the following measures: Objective Structured Assessment of Technical Skills (OSATS) checklists, the Global Rating Scale (GRS), and a final pass/fail assessment determined by 3 upper extremity surgeons. Adverse events were recorded. The Cronbach α coefficient was used to assess reliability of the OSATS checklists and GRS scores. Interrater reliability was calculated with intraclass correlation coefficients. Correlations among OSATS checklist scores, GRS scores, and pass/fail assessment were calculated with Spearman ρ. Validity of OSATS checklists was determined using analysis of variance with postgraduate year (PGY) as a between-subjects factor. Significance was set at p < 0.05 for all tests. RESULTS: Criterion validity was shown between the OSATS checklists and GRS for the 3 open shoulder approaches. Checklist scores showed superior interrater reliability compared with GRS and subjective pass/fail measurements. GRS scores were positively correlated across training years. The incidence of adverse events was significantly higher among PGY-1 and PGY-2 residents compared with more experienced residents. CONCLUSION: OSATS checklists are a valid and reliable assessment of technical skills across 3 surgical shoulder approaches. However, checklist scores do not measure quality of technique. Documenting adverse events is necessary to assess quality of technique and ultimate pass/fail status. Multiple methods of assessing surgical skill should be considered when evaluating orthopedic resident surgical performance.

The Top 100 Cited Articles in Clinical Orthopedic Sports Medicine.

Orthopedic sports medicine continues to evolve, owing much of its clinical management and practice to rigorous academic research. In this review, we identify and describe the top 100 cited articles in clinical sports medicine and recognize the authors and institutions driving the research. We collected articles (excluding basic science, animal, and cadaveric studies) from the 25 highest-impact sports medicine journals and analyzed them by number of citations, journal, publication date, institution, country, topic, and author. Mean number of citations was 408 (range, 229-1629). The articles were published in 7 journals, most in the 1980s to 2000s, and represented 15 countries. Thirty topics were addressed, with a heavy emphasis on anterior cruciate ligament injury and reconstruction, knee rating systems, rotator cuff reconstruction, and chondrocyte transplantation. The 3 most cited articles, by Insall and colleagues, Constant and Murley, and Tegner and Lysholm, addressed a knee, a shoulder, and another knee rating system, respectively. Several authors contributed multiple articles. The Hospital for Special Surgery and the University of Bern contributed the most articles (5 each). This study provides a comprehensive list of the past century's major academic contributions to sports medicine. Residents and fellows may use this list to guide their scholarly investigations.

The incidence and reporting of sharps exposure among medical students, orthopedic residents, and faculty at one institution.

OBJECTIVE: To compare the incidence of sharps injuries among medical students, orthopedic residents/fellows, and orthopedic faculty at one institution and to determine the rate of reporting exposures. DESIGN: Cross-sectional survey. Surveys were completed by 44% (53/120) of medical students, 76% (23/30) of residents/fellows, and 56% (17/30) of full-time faculty. SETTING: Academic medical center. PARTICIPANTS: Medical students, orthopedic surgery residents/fellows, full-time academic orthopedic surgery faculty. RESULTS: Twenty-eight percent of medical students, 83% of residents/fellows, and 100% of faculty had been exposed to a sharps injury at some point in their career; 42% of residents/fellows had experienced a sharps exposure within the past year. The most common single instrument responsible for sharps injuries among all groups was the solid-bore needle; students and residents were significantly more likely than faculty to have a sharps injury from a solid-bore needle than all other devices combined (p = 0.04). Medical students were more likely to ignore the exposure than residents/fellows (p = 0.004) or faculty (p = 0.036). Only 12.5% of medical students followed all the steps of the postexposure protocol. CONCLUSION: Sharps exposures occur among orthopedic surgeons and their trainees. Interventions are needed to increase safety among residents and medical students. Further research should evaluate factors suppressing medical student reporting of sharps exposures.

Dorsal radiocarpal dislocation in a patient with Goldenhar syndrome: case report.

BACKGROUND: Fracture-dislocations of the carpus are rare, generally occurring after high-energy trauma. Goldenhar syndrome is among a group of genetic abnormalities associated with radial limb defects. We present a case of a dorsal radiocarpal dislocation in a patient with Goldenhar syndrome after a low-energy fall. To our knowledge, there has been no previous report of radiocarpal dislocation in the setting of Goldenhar syndrome. METHODS: This patient with Goldenhar syndrome had a dorsal radiocarpal dislocation in the setting of an absent scaphoid and dysplastic distal radius. A computed tomography scan, recognized as a useful modality to evaluate the wrist and scaphoid, was used to rule out any other osseous trauma or avulsion fractures. RESULTS: Closed reduction and 6 weeks of immobilization resulted in a successful treatment. CONCLUSIONS: The incidence of radiocarpal dislocations in patients with Goldenhar syndrome and the appropriate long-term treatment for patients with Goldenhar syndrome with radiocarpal dislocations require further investigation.

Role of hematologic laboratory studies in the postoperative management of patients undergoing anterior cervical diskectomy and fusion.

Anterior cervical diskectomy and fusion is a common spinal procedure. Over time, complications and hospital stay have decreased. However, to the authors' knowledge, no study has examined the necessity of routine postoperative hematologic laboratory studies for patients undergoing this procedure.From January 2005 through July 2010, four hundred thirty-four consecutive patients with cervical radioculopathy or myelopathy underwent anterior cervical diskectomy and fusion at 1 institution. Patients who had a concomitant second spinal procedure, revision anterior cervical diskectomy and fusion, history of anemia or a hematologic condition, or intraoperative complications were excluded, leaving 372 patients for the study group. Data were collected on postoperative hematologic laboratory studies ordered (complete blood count, coagulation studies, type, screen), postoperative blood transfusions, and readmissions within 1 month for anemia or transfusion. Patients were divided into those with and those without postoperative hematologic studies: 290 patients (119 one-level, 133 two-level, 38 three-level anterior cervical diskectomy and fusion) and 82 patients (41 one-level and 41 two-level anterior cervical diskectomy and fusion), respectively. No patient in either group required postoperative blood transfusion or readmission within 1 month for hematologic issues or surgery-related complications.For patients undergoing 1-, 2-, or 3-level anterior cervical diskectomy and fusion with no history of hematologic issues, routine postoperative hematologic laboratory studies may be deferred without affecting the incidence of postoperative blood transfusions or hematologic-related readmissions. The elimination of unnecessary routine studies may result in substantial health care cost savings.