Selected issues in sport-related concussion (SRC|mild traumatic brain injury) for the team physician: a consensus statement.

Selected Issues in Sport-Related Concussion (SRC|Mild Traumatic Brain Injury) for the Team Physician: A Consensus Statement is title 22 in a series of annual consensus documents written for the practicing team physician. This document provides an overview of selected medical issues important to team physicians who are responsible for athletes with sports-related concussion (SRC). This statement was developed by the Team Physician Consensus Conference (TPCC), an annual project-based alliance of six major professional associations. The goal of this TPCC statement is to assist the team physician in providing optimal medical care for the athlete with SRC.

Selected Issues in Sport-Related Concussion (SRC | Mild Traumatic Brain Injury) for the Team Physician: A Consensus Statement.

ABSTRACT: Selected Issues in Sport-Related Concussion (SRC | Mild Traumatic Brain Injury) for the Team Physician: A Consensus Statement is title 22 in a series of annual consensus articles written for the practicing team physician. This document provides an overview of select medical issues important to team physicians who are responsible for athletes with sports-related concussion (SRC). This statement was developed by the Team Physician Consensus Conference (TPCC), an annual project-based alliance of six major professional associations. The goal of this TPCC statement is to assist the team physician in providing optimal medical care for the athlete with SRC.

Prospective Evaluation of Cognitive Outcomes After Anesthesia for Patients in the Beach Chair Position.

The beach chair position has been popularized for shoulder surgeries, particularly those involving arthroscopy. Several published case reports and studies have raised concerns for neurologic complications related to anesthesia for surgery performed with patients in the beach chair position. The question has been raised whether cerebral perfusion monitoring should be used routinely to minimize these potential complications. This prospective study evaluated cognitive outcomes in patients who underwent anesthesia in the beach chair position. Patients were randomized to 2 groups. In group 1, the anesthesiologist was blinded to the cerebral monitoring and could treat based only on mean arterial pressure (MAP). In group 2, the anesthesiologist was aware of the results of the cerebral monitoring and could treat any desaturation events. All patients were evaluated pre- and postoperatively with a cognitive assessment tool. A total of 80 patients were enrolled in the study, with 40 patients in each group. There were no significant differences regarding age, body mass index, or American Society of Anesthesiologists score. Only 3 desaturation events occurred with no significant change in cognitive function. The findings indicate no advantage to cerebral perfusion monitoring during anesthesia for surgery performed with patients in the beach chair position as long as MAP is maintained within strict limits. Although little is known about the level of cerebral desaturation that will result in cognitive dysfunction, it may likely be related to MAP and cerebral perfusion. The findings of this study reinforce the need for careful monitoring of MAP during surgery and dispute the need for additional expensive monitoring devices. [Orthopedics. 2020; 43(1):e27-e30.].

Complications after medial opening wedge high tibial osteotomy.

PURPOSE: The purpose of this study was to investigate complications of the medial opening wedge high tibial osteotomy (HTO) procedure at our institution. METHODS: All cases of medial opening wedge HTO performed between 2001 and 2004 at our institution were identified. Medical records, operative reports, and radiographs were retrospectively reviewed for all patients who experienced a complication within 12 months postsurgery. All complications were identified for analysis. RESULTS: Forty-six patients were included in this study; 17 (36.9%) patients had a documented complication. There were 7 patients (15.2%) with loss of correction, 2 (4.3%) with intraoperative lateral cortex fractures, 2 (4.3%) with postoperative lateral cortex fractures, 2 (4.3%) with deep venous thrombosis, 2 (4.3%) with delayed unions, and 2 (4.3%) with symptomatic hardware. Patients with a loss of angular correction had a greater body mass index (BMI) than those without a loss of correction (mean BMI, 32.5 v 28.8; P = .0416). Of the 7 patients with loss of angular correction, 6 had a first-generation fixation device and 1 had a second-generation device. There was no apparent association between delayed union and graft type (allograft v autograft). CONCLUSIONS: The medial opening wedge HTO is associated with a moderate frequency of complications. The frequency and type of complications seem to be similar to those reported for the lateral closing technique. Although there are technical advantages offered by the medial opening wedge HTO, their influence on the frequency and type of complications experienced by patients in our series was not apparent. LEVEL OF EVIDENCE: Level IV, case series.

Bilateral Medial and Lateral Patellofemoral Ligament Reconstruction in a Patient with Hypermobility Type Ehlers-Danlos Syndrome: A Case Report.

CASE: Medial patellar instability (MPI) is a known sequela of previous lateral retinacular release. Literature on surgical intervention is scarce. We present a case of a 35-year-old woman with hypermobility type Ehlers-Danlos syndrome, with bilateral iatrogenic MPI (IMPI) and lateral patellar instability. This condition led to a marked decrease in quality of life, 10/10 persistent pain, and frequent dislocation events. She was successfully treated surgically, and at 2 years had 0/10 pain and no further dislocations. CONCLUSIONS: Our technique for medial and lateral patellofemoral ligament reconstruction is a viable intervention for patients with IMPI, even in the setting of underlying collagen disorder.

Operative Cost Comparison: Plating Versus Intramedullary Fixation for Clavicle Fractures.

Although clavicle fractures often heal well with nonoperative management, current literature has shown improved outcomes with operative intervention for specific fracture patterns in specific patient types. The 2 most common methods of midshaft clavicle fracture fixation are intramedullary and plate devices. Through retrospective analysis, this study performed a direct cost comparison of these 2 types of fixation at a single institution over a 5-year period. Outcome measures included operative costs for initial surgery and any hardware removal surgeries. This study reviewed 154 patients (157 fractures), and of these, 99 had intramedullary fixation and 58 had plate fixation. A total of 80% (79 of 99) of intramedullary devices and 3% (2 of 58) of plates were removed. Average cost for initial intramedullary placement was $2955 (US dollars) less than that for initial plate placement (P<.001); average cost for removal was $1874 less than that for plate removal surgery (P=.2). Average total cost for all intramedullary surgeries was $1392 less than the average cost for all plating surgeries (P<.001). Average cost for all intramedullary surgeries requiring plate placement and removal was $653 less than the average cost for all plating surgeries that involved only placement (P=.04). Intramedullary fixation of clavicle fractures resulted in a statistically significant cost reduction compared with plate fixation, despite the incidence of more frequent removal surgeries. [Orthopedics.2016; 39(5):e877-e882.].

Concurrent treatment of a middle-third clavicle fracture and type IV acromioclavicular dislocation.

Acromioclavicular (AC) dislocation with an associated displaced fracture of the middle third of the clavicle is a rare injury with no established standard treatment. Previous AC fixation techniques described have not included simultaneous internal fixation of the clavicle. We present the case of a 19-year-old man who sustained this combined injury pattern with a type IV AC dislocation. He underwent open reduction and internal fixation of the clavicle fracture with open reduction of the AC joint and coracoclavicular (CC) screw fixation through the plate to stabilize the AC dislocation. The CC screw was removed 3 months after surgery. By 1-year follow-up, the patient had returned to manual labor and normal activities of daily living. In comparison with previously described treatment, his case highlights a unique approach to this rare shoulder entity.

Repair of large animal partial-thickness cartilage defects through intraarticular injection of matrix-rejuvenated synovium-derived stem cells.

Cartilage defects have a limited ability to self-heal. Stem cell treatment is a promising approach; however, replicative senescence is a challenge to acquiring large-quantity and high-quality stem cells for cartilage regeneration. Synovium-derived stem cells (SDSCs) are a tissue-specific stem cell for cartilage regeneration. Our recent findings suggest that decellularized stem cell matrix (DSCM) can rejuvenate expanded SDSCs in cell proliferation and chondrogenic potential. In this study, we were investigating (1) whether transforming growth factor (TGF)-ß1 and TGF-ß3 played a similar role in chondrogenic induction of SDSCs after expansion on either DSCM or plastic flasks (plastic), and (2) whether DSCM-expanded SDSCs had an enhanced capacity in repairing partial-thickness cartilage defects in a minipig model. SDSCs were isolated from synovium in two 3-month-old pigs and DSCM was prepared using SDSCs. Passage 2 SDSCs were expanded on either DSCM or plastic for one passage. The expanded cells were evaluated for cell morphology, chondrogenic capacity, and related mechanisms. TGF-ß1 and TGF-ß3 were compared for their role in chondrogenesis of SDSCs after expansion on either DSCM or plastic. The chondrogenic induction medium without TGF-ß served as a control. In 13 minipigs, we intraarticularly injected DSCM- or plastic-expanded SDSCs or saline into knee partial-thickness cartilage defects and assessed their repair using histology and immunohistochemistry. We found DSCM-expanded SDSCs were small, had a fibroblast-like shape, and grew quickly in a three-dimensional format with concomitant up-regulation of phosphocyclin D1 and TGF-ß receptor II. Plastic-expanded SDSCs exhibited higher mRNA levels of chondrogenic markers when incubated with TGF-ß3, while DSCM-expanded SDSCs displayed comparable chondrogenic potential when treated with either TGF-ß isotype. In the minipig model, DSCM-expanded SDSCs were better than plastic-expanded SDSCs in enhancing collagen II and sulfated glycosaminoglycan expression in repair of partial-thickness cartilage defects, but both groups were superior to the saline control group. Our observations suggested that DSCM is a promising cell expansion system that can promote cell proliferation and enhance expanded cell chondrogenic potential in vitro and in vivo. Our approach could lead to a tissue-specific cell expansion system providing large-quantity and high-quality stem cells for the treatment of cartilage defects.

Pseudoseptic arthritis of the shoulder following pneumococcal vaccination.

Pseudoseptic arthritis is primarily described in rheumatoid arthritis and other systemic inflammatory conditions. To our knowledge, only 1 case report of pseudoseptic arthritis associated with intra-articular injection of a pneumococcal polyvalent vaccine (PPV) has been published. Here, a second case is presented in which a patient presented with swelling, pain, and erythema of the affected shoulder. A 59-year-old woman presented to the emergency department with a 3-day history of severe pain and decreased mobility of her left shoulder after receiving a PPV vaccination. Her clinical and laboratory workup was suspicious for septic arthritis; however, magnetic resonance imaging of the affected shoulder with and without contrast showed only a partial thickness tear of the rotator cuff, fluid in the subacromial/subdeltoid bursa, and subcutaneous edema without evidence of an abscess. Based on the clinical and laboratory data, she underwent arthroscopic debridement. There was inflammatory tissue throughout the shoulder but no obvious purulent material. She did well postoperatively with a supervised range of motion rehabilitation protocol. Her cultures remained negative. At 12 weeks, she was discharged from follow-up. We suspect that the vaccination was inadvertently injected into the glenohumeral joint directly through the rotator cuff given the lack of a full-thickness tear and the patient's thin body habitus, which could explain her aseptic inflammatory arthritis.

Multiligamentous injuries of the knee and associated vascular injuries.

BACKGROUND: Recently published studies have raised the question of whether arteriography is warranted in the evaluation of multiligamentous injuries of the knee. PURPOSE: The objective is to report the frequency of associated vascular injuries in the multiligament-injured knee and examine the role arteriography plays in the treatment protocol. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A retrospective analysis was performed on 71 patients over a 12-year period who had a diagnosis of multiligamentous injury of the knee with a tibial-femoral dislocation documented based on physical examination and magnetic resonance imaging findings. RESULTS: Of 72 knee injuries involving multiple ligaments, 12 vascular injuries were identified. Four knees were found to have a vascular injury at initial presentation based on abnormal physical examination and confirmed with arteriography. Eight patients with a vascular injury had normal pulses. Routine arteriography discovered an intimal injury of the popliteal artery in 5 of these patients. Arteriography in the remaining 3 patients was interpreted as normal. CONCLUSION: These findings suggest that physical examination alone is not sufficient in detecting the majority of vascular injuries after a suspected knee dislocation.