Team Approach: Neuromuscular Training for Primary and Secondary Prevention of Anterior Cruciate Ligament Injury.

Neuromuscular training is a method of performance optimization-typically combining plyometrics, balancing training, agility, and dynamic stabilization-predicated on improving the efficiency of fundamental movement patterns. Neuromuscular training has consistently been shown to reduce the risk of anterior cruciate ligament injury, particularly for athletes engaged in activities associated with noncontact knee injuries (i.e., women's soccer). Successful implementation of neuromuscular training programs requires input from coaches, physical therapists, athletic trainers, and physicians to generate efficacious programs with high rates of adherence.

Orthopaedic Surgery Residency: Perspective of Applicants and Program Directors on Medical Student Virtual Experiences.

INTRODUCTION: Orthopaedic Residency Directors advised against visiting subinternship rotations in the peak of the pandemic. To adapt, programs offered multiple virtual experiences. The purpose of this study was to evaluate programs and applicants perceptions regarding the value of virtual experiences during the 2020 to 2021 application cycle and their utility in future application cycles. METHODS: A survey was disseminated to 31 residency programs gathering data about virtual experiences offered in this cycle. A second survey was disseminated to interns who have successfully matched at those programs to identify how interns think to have benefited from the experiences. RESULTS: Twenty-eight programs completed the survey (90% response rate). One hundred eight new interns completed the survey (70% response rate). Virtual information sessions and resident socials were the highest attended (94% and 92%, respectively). Interns and leadership agreed that virtual rotations provided students with a good understanding of program culture and what the programs offer educationally. Neither the leadership nor the interns would recommend replacing in-person aways with virtual experiences. CONCLUSION: Virtual experiences helped bridge the gap after away rotations were canceled. Alongside in-person aways, virtual experiences are likely to play a role in future cycles. However, virtual experiences remain incomparable to in-person away rotations and are not recommended as a replacement.

Effect of Postoperative Immobilization Time on PROMIS Scores and Clinical outcomes in Ankle Fracture Patients.

Background: Ankle fractures are among the most common injuries treated by orthopaedic surgeons, yet little guidance exists in postoperative protocols for ankle fractures concerning time of immobilization. Here, we aim to investigate the association between early mobilization and patient-reported outcomes. Our null hypothesis was that no difference in Patient-Reported Outcomes Measurement Information System (PROMIS) scores would be identified in patients when comparing the effect of time of immobilization. Methods: A retrospective review identified ankle fractures that underwent surgical fixation between 2015 and 2020 at a level 1 trauma center and its associated facilities. One hundred nineteen patients from 9 providers met inclusion criteria for our final analysis. Forty-seven patients were immobilized for <6 weeks (early) and 68 patients were immobilized for ≥6 weeks (late). Our primary outcome measures included the PROMIS questionnaire, time of immobilization, and time to full weightbearing. Our secondary outcome measures included time to return to work, wound complications (infection, delayed healing), and complications associated with fracture fixation (loss of reduction, delayed union, reoperation, hardware failure). Repeated measures analysis of variance as well as linear mixed outcome regression were used to predict each of the PROMIS outcomes of anxiety, depression, physical function, and pain interference. Each model included the predictors of age, sex, race, body mass index (BMI), diabetes, rheumatoid arthritis, smoking status, payor, provider, time to radiographic union, time to return to work, time to full weightbearing, and early vs late immobilized groups. Results: We found no differences in PROMIS scores between mobilization groups even when controlling for possible confounders such as age, BMI, rheumatoid arthritis, smoking status, and diabetes mellitus (P > .05). Furthermore, we found no differences in complications associated with fracture fixation (P > .05). Across our cohort, lower physical function scores were associated with higher BMI, increasing age, and longer time to return to work/play (P < .05). Our analysis further showed that depression, anxiety, pain interference, and physical function levels improve as a function of time (P < .05). Higher BMI was also noted to have a significant impact on PROMIS depression and anxiety when controlling for other variables. African Americans had greater pain interference scores (P < .05). Conclusion: Our study suggests that early mobilization in a walker boot after operative treatment of ankle fractures is a safe alternative to casting in non-neuropathic patients. When considering operative treatment of ankle fractures, factors such as increasing age and BMI are likely to negatively affect postoperative anxiety, physical function, and depression PROMIS scores regardless of immobilization time. Level of Evidence: Level III, retrospective cohort study.

Do Self-Reported Drug Allergies Influence Clinically Significant Outcome Improvement Following Osteochondral Allograft Transplantation? A Nested Cohort Study.

OBJECTIVE: To compare clinical outcomes for patients who underwent osteochondral allograft transplantation (OCA) based on the presence or absence of one or more self-reported drug allergies. DESIGN: Prospective data were collected from 245 consecutive patients after OCA of the knee from one large academic institution. Patient-reported allergies were obtained via chart review. Patient-reported outcome measures, including activities of daily living of the Knee Outcome Survey (KOS-ADL), Marx Activity Scale, International Knee Documentation Committee (IKDC), and visual analogue scale (VAS) pain were all collected. The minimal clinically important difference (MCID) for each outcome was quantified using a distribution-based method. Independent t tests were used to compare patient-reported outcome measures between those with and without self-reported allergies, while chi-square analysis of association was used to compare rates of MCID achievement. RESULTS: Of 245 patients included, 83 (33.9%) reported having at least one drug allergy at the time of OCA. There were no statistically significant differences with regard to patient demographics, including age, body mass index, gender, or sports participation between those with and without a reported allergy. Similarly, there were no significant differences found between baseline preoperative patient-reported outcomes. Overall, both cohorts demonstrated a significant improvement from baseline scores at 2 years postoperatively. There were no differences found between any patient-reported outcome at 2 years postoperatively. The presence of at least one self-reported drug allergy was not a significant risk factor for failing to achieve the MCID in any specific outcome measure. CONCLUSIONS: The presence of one or more drug allergy was not associated with worse patient-reported outcomes or lower rates of clinically significant outcome improvement after OCA.

Biologic Adjuvants for the Management of Osteochondral Lesions of the Talus.

Surgical techniques for the management of recalcitrant osteochondral lesions of the talus have improved; however, the poor healing potential of cartilage may impede long-term outcomes. Repair (microfracture) or replacement (osteochondral transplants) is the standard of care. Reparative strategies lead to production of fibrocartilage, which, compared with the native type II articular cartilage, has decreased mechanical and wear properties. The success of osteochondral transplants may be hindered by poor integration between grafts and host that results in peripheral cell death and cyst formation. These challenges have led to the investigation of biologic adjuvants to augment treatment. In vitro and in vivo models have demonstrated promise for cartilage regeneration by decreasing inflammatory damage and increasing the amount of type II articular cartilage. Further research is needed to investigate optimal formulations and time points of administration. In addition, clinical trials are needed to investigate the long-term effects of augmentation.

Customized platelet-rich plasma with transforming growth factor ß1 neutralization antibody to reduce fibrosis in skeletal muscle.

UNLABELLED: The formation of fibrous tissue during the healing of skeletal muscle injuries leads to incomplete recovery of the injured muscle. Platelet-rich-plasma (PRP) contains beneficial growth factors for skeletal muscle repair; however, it also contains deleterious cytokines and growth factors, such as TGF-ß1, that can cause fibrosis and inhibit optimal muscle healing. OBJECTIVE: To test if neutralizing TGF-ß1's action within PRP, through neutralization antibodies, could improve PRP's beneficial effect on skeletal muscle repair. METHODS: PRP was isolated from in-bred Fisher rats. TGF-ß1 neutralization antibody (Ab) was used to block the TGF-ß1 within the PRP prior to injection. The effects of customized PRP (TGF-ß1 neutralized PRP) on muscle healing was tested on a cardiotoxin (CTX) induced muscle injury model. RESULTS: A significant increase in the numbers of regenerative myofibers was observed in the PRP and customized PRP groups compared to the untreated control. A significant decrease in collagen deposition was observed in customized PRP groups when compared to the control and PRP groups. Significantly enhanced angiogenesis and more Pax-7 positive satellite cells were found in the PRP and customized PRP groups compared to the control group. Macrophage infiltration was increased in the customized PRP groups when compared with the PRP group. More M2 macrophages were recruited to the injury site in the customized PRP groups when compared with the PRP and control groups. CONCLUSION: Neutralizing TGF-ß1 within PRP significantly promotes muscle regeneration while significantly reducing fibrosis. Not only did the neutralization reduce fibrosis, it enhanced angiogenesis, prolonged satellite cell activation, and recruited a greater number of M2 macrophages to the injury site which also contributed to the efficacy that the customized PRP had on muscle healing.