Male Youth Ice Hockey Concussion Incidence in a USA Hockey Membership-Adjusted Population: A Peak in 2011 and the Impact of Major Rule Changes.

OBJECTIVE: To investigate the incidence of youth ice hockey-related concussions preceding and following the implementation of new body-checking and head contact rules by USA hockey in 2011. We hypothesized a decrease in concussions after the rule change. DESIGN: Retrospective analysis. SETTING: United States emergency department (ED) data queried in the National Electronic InjurySurveillance System (NEISS). PATIENTS: National Electronic Injury Surveillance System reported male youth (≤18 years) ice hockey concussion cases from January 1, 2002, to December 31, 2016. In total, 848 players were diagnosed with concussion, representing a national estimate of 17 374 cases. INDEPENDENT VARIABLES: Time, specifically years. MAIN OUTCOME MEASURES: Incidences and incidence rates (measured per 10 000 person-years) of male youth ice hockey concussions. Annual trends were analyzed using descriptive and linear or polynomial regression analysis. RESULTS: The national estimate of youth ice hockey-related concussions seen in US emergency departments (EDs) increased significantly from 656 in 2007 to 2042 in 2011 (P < 0.01). During the same period, their respective incidence increased significantly from 21.8 to 66.8 per 10 000, before dropping through 2016 (P < 0.05). After 2011, concussions decreased from 1965 in 2012 to 1292 in 2016 (P = 0.055). The gap in concussion incidence between the 11 to 12 and 13 to 14 divisions widened after 2011 (before 2011: 41 vs 49 per 10 000 person-years [P = 0.80]; after 2011: 45 and 89, respectively [P < 0.01]). CONCLUSIONS: US EDs experienced a significant increase in youth ice hockey concussion visits from 2007 to 2011. After the 2011 rule changes, concussion visits decreased significantly from 2012 to 2016.

Trends and epidemiology of radial head subluxation in the United States from 2004 to 2018.

BACKGROUND: Increased body mass may predispose children to a greater risk for radial head subluxation (RHS). Recent studies in the literature have reported a plateau in obesity prevalence among infants and toddlers. This study sought to examine recent epidemiological trends in RHS incidence from 2004 to 2018 using the National Electronic Injury Surveillance System database to determine how obesity patterns may affect RHS incidence. METHODS: The National Electronic Injury Surveillance System (NEISS) database was queried for patients 6 years of age or younger presenting with radial head subluxation between January 1, 2004 and December 31, 2018. Patient demographics, mechanisms of injury, and location of injury were recorded. RESULTS: An estimated total 253,578 children 6 years or younger were treated for RHS with 14,204 (95% CI = 8124-20,284) in 2004 to 21,408 (95% CI = 12,882-29,934) in 2018. The overall annual rate of RHS per 10,000 children ≤ 6 years was 6.03 (95% CI = 4.85-7.58). The annual rate of RHS per 10,000 children ≤ 6 years increased (m = 0.200, ß = 0.802, p < 0.001) from 5.18 (95% CI 2.96-7.39) in 2004 to 7.69 (95% CI = 4.63-10.75) in 2018. The most common mechanism associated with RHS was falls (39.4%) with 103,466 (95% CI 74,806-132,125) cases. Pulls accounted for the second most common mechanism of injury, accounting for 90,146 (95% CI 68,274-112,018) cases or 36.2%. Yearly RHS incidence was compared to obesity prevalence for ages 2-5 children provided by the National Health and Nutritional Examination Survey (NHANES) surveys. Changes in obesity prevalence may visually reflect RHS incidence trends, but no causality between obesity prevalence and RHS incidence could be confirmed. CONCLUSION: This study corroborated previous findings that falls and arm pulling contribute to the vast majority of RHS cases. The nonsignificant rise in RHS cases may reflect a possible plateau in obesity prevalence of children aged 2-5 years in recent years. LEVEL OF EVIDENCE: III.

Financial Analysis of Closed Femur Fractures in 3- to 6-Year-Olds Treated With Immediate Spica Casting Versus Intramedullary Fixation.

BACKGROUND: Health care in America continues to place more importance on providing value-based medicine. Medicare reimbursements are increasingly being tied to this and future policy changes are expected to reinforce these trends. Recent literature has shown pediatric femur fractures in preschool-age children have equivalent clinical and radiographic outcomes when treated with spica casting or flexible intramedullary nails (IMN). We compared hospital care statistics including charges for nonoperative versus operative treatment for closed femur fractures in 3- to 6-year-olds. METHODS: An IRB-approved retrospective chart review was performed of 73 consecutive 3- to 6-year-olds treated at a regional level 1 pediatric hospital from January 1, 2009 to December 31, 2013 with an isolated, closed femoral shaft fracture. Exclusion criteria included open fractures, bilateral injury, and polytrauma. Immediate spica casting was performed in the Emergency Department or Anesthesia Procedure Unit versus IMN in the operating room. RESULTS: A total of 41 patients were treated with spica casting and 32 patients were treated operatively with flexible IMNs; 3 patients failed nonoperative care. After analysis of final treatment groups, significant differences included age at injury: 3.7 years for cast versus 5.3 years for IMN (P<0.001), time to discharge 21 versus 41 hours (P<0.001), 3.2 versus 4.4 clinic visits (P<0.001), follow-up 3.5 versus 9.4 months (P<0.001). Orthopedic surgeon charges were $1500 for casted patients versus $5500 for IMN (P<0.001). Total hospital charges were $19,200 for cast versus $59,700 for IMN (P<0.001). No difference was found between clinic charges or number of radiographs between groups. In total, 76% of cast group were discharged <24 hours from admission versus 8.6% in operative group. In the operative group, 83% had implant removal with no statistically significant charge difference between those who had implant removal versus retention. CONCLUSIONS: Treatment of pediatric femur fractures in 3- to 6-year-olds with IMN is associated with longer hospital stays, significantly greater hospital charges, longer follow-up and more clinic visits compared with spica casting. These findings are at odds with previous literature showing shorter hospital stays and decreased cost with nailing compared to traction and casting. This shows a clear difference between 2 treatments that yield similar clinical and radiographic outcomes. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Intimomedial mucoid degeneration resulting in a dissecting infrarenal abdominal aortic aneurysm in a young Middle Eastern male: a case report.

Introduction and importance: Intimomedial mucoid degeneration is a rare vascular disorder first depicted in 1977. It involves mucin deposition in arterial layers. This will cause elastic tissue degeneration and aneurysm formation. This pathology predominantly affects the aorta. However, it could involve other smaller vessels. Surgical treatment could become complicated by a bleeding diathesis. Therefore, a precise surgical technique is necessary to avoid the ensuing complications. Case presentation: We present the case of a previously healthy 27-year-old Middle Eastern male who presented to our surgical clinic following the incidental discovery of an infrarenal abdominal aortic aneurysm following a blunt trauma to the left flank incurred during a fall. Preoperative radiology unveiled a dissecting an infrarenal aortic aneurysm with a concurrent dissection flap at the left renal artery level. Furthermore, an additional dissection flap was observed at the abdominal aortic bifurcation devoid of thrombosis. Clinical discussion: We planned to perform a bilateral aortoiliac bypass. However, due to the fragility of the artery wall, bleeding diathesis, and the tearing that occurred due to the anastomotic suture, the irreparable tear in the anastomosis complicated the situation, we decided to ligate the aorta and perform an axillary-bi-femoral bypass. Conclusion: Intimomedial mucoid degeneration presenting as a dissecting infrarenal abdominal aortic aneurysm is an exceptionally rare pathology. This underscores the crucial need for extensive epidemiological research to document and raise awareness about these cases. Our literature review confirms that our case is the first documented instance in our country, and this emphasizes the significance of our findings.

Multiple Hereditary Exostoses instigating a popliteal pseudoaneurysm in a young Middle Eastern male: A case report and literature review.

INTRODUCTION AND IMPORTANCE: Multiple Hereditary Exostoses is a rare autosomal dominant bone disorder that predominantly affects males at an incidence of (1:50,000 to 1:100,000) in Western populations. The etiology is owed to mutations in the EXT gene group, specifically EXT1 and EXT2 which cause the formation of Osteochondromas. Diagnosis is typically established in childhood. Nevertheless, vascular complications are extremely rare while being potentially fatal. Therefore, timely diagnosis and treatment are vital for such patients. CASE PRESENTATION: We present the case of a 37-year-old Middle Eastern male with Multiple Hereditary Exostoses who experienced sudden-onset left lower limb pain persisting for a month prior to admission. It was associated with coldness and paresthesia of the ipsilateral lower limb. The presurgical radiological workup uncovered a popliteal pseudoaneurysm subsequent to Multiple Hereditary Exostoses. CLINICAL DISCUSSION: Through open surgery, the vascular perfusion was successfully restored, and a subsequent supra- to infra-geniculate popliteal artery anastomosis via saphenous vein grafting was done. Furthermore, the Osteochondroma was utterly resected to limit recurrence of another vascular injury. The following histopathological analysis confirmed the diagnosis of an Osteochondroma as a result of MHE. CONCLUSION: Multiple Hereditary Exostoses is a rare occurrence leading to pseudoaneurysms. This event underscores the need for further documentation to aid in establishing a prompt diagnosis and carrying out suitable interventions. Considering this pathology in a multidisciplinary approach ensures proper treatment. Following a comprehensive literature review, our case stands as the first case in the published literature from our country which emphasizes its value and rarity.

Chronic contained ruptured abdominal aortic aneurysm with a rare presentation of lower limb neuropathic claudication: a report of two cases.

A vertebral body erosion that takes place due to a chronic contained rupture of an abdominal aortic aneurysm is an especially rare vascular pathology that comprises less than 5% of all causes of vertebral body erosion. Chronic contained rupture of an abdominal aortic aneurysms are primarily observed in hemodynamically stable patients whose chief complaint is lower limb neuropathic pain. This entity is extremely misleading and this results in delayed management of those patients increasing the morbidity and mortality rates. Case presentation: We present the two cases of 62-year-old and 65-year-old males. Preoperative radiology for each patient showed an infrarenal aortic aneurysm with a retroperitoneal hematoma in contact with the lumbar vertebral bodies and psoas muscle. The draped aorta sign was evident in both cases. Clinical discussion: A curative surgical intervention was accomplished for both patients, respectively. This was achieved through the removal of the existing hematomas that were compressing the vertebrae in addition to the complete isolation and resection of the respective abdominal aortic aneurysms along with thorough reconstruction of the aortoiliac spindles with patent synthetic grafts to ensure the patency of the preexisting vascular axis. Conclusion: A contained rupture of an abdominal aortic aneurysm is a rare occurring vascular pathology that manifests with nonspecific symptoms, such as femoral neuropathy and lower back pain proportionate to the degree of the level of erosion of the affected lumbar vertebrae. This will increase the possibility of misdiagnosis and delays in treatment. Such a life-threatening vascular emergency should be timely detected and treated to avoid its complications and patient mortality.

A distinguished case of a spontaneously dissecting Left Common Iliac Artery Aneurysm, associated with an Elastinopathy, in a healthy 36-year-old male, successfully treated with open surgical repair - A Case Report.

INTRODUCTION AND IMPORTANCE: Elastin is a major protein of the Extracellular Matrix (ECM), essential in providing elasticity to the vascular wall, which enables blood vessels to reversibly expand and contract. Several inherited or acquired etiologies, such as elastinopathies and fibrillinopathies negatively impact the objective of the Extracellular Matrix via compromising the Elastin fibers in the Cardiovascular System (CVS) and the skin. Such compromises will have devastating ramifications through the increase in vascular wall stiffness and the inability to properly dissipate energy. This impact on the vascular wall will contribute to the development of arterial aneurysms and dissections. CASE PRESENTATION: Our case is of a 36-year-old previously healthy male patient who presented with an acute onset of left lower limb pain associated with cold sensation two days prior to admission. Radiology demonstrated a dissecting aneurysm in the left Common Iliac Artery. CLINICAL DISCUSSION: The patient was surgically treated with an Aorto-bi-Femoral Bypass (ABFB). Histopathological analysis of the excised aortic and iliac specimens revealed no Elastin fibers in the vessel walls. CONCLUSION: Isolated Iliac aneurysms are a rare entity and are challenging to diagnose preoperatively. In our case, there were no risk factors whatsoever and the patient's history - including family history - was negative. It is vital to establish preoperative diagnostic approaches in such cases and keep them in mind so that we can diminish the morbidity and mortality resultants from the complications.

A rare incidence of primary Synovial Spindle Cell Sarcoma in a 46-year-old male, successfully managed by surgical intervention-A Case Report.

INTRODUCTION AND IMPORTANCE: Synovial sarcoma (SS) is a rare form of Soft Tissue Sarcoma (STS) which results from the malignant proliferation of mesenchymal cells. Specific etiologies are not yet known, and its incidence rate ranges between 0.81 and 1.42 per 1 million individuals. Its gender-specific prevalence is almost the same between males and females and it is unique from other subtypes of STS in that it's slow growing and in almost half the cases, patients present with distant metastasis at the time of diagnosis. CASE PRESENTATION: We present the case of a 46-year-old previously healthy male patient, who complained from a right lower extremity painless bulge, which began to be visibly noticeable by the patient 2 months prior to admission. There were no signs of allocated inflammation nor lower limb ischemia. Radiology revealed an irregular mass formation conformant with neoplasia. CLINICAL DISCUSSION: Surgical resection of the mass along with synthetic graft replacement of the concomitant vascular bundle. Histopathological analysis of the resected mass revealed a monophasic synovial spindle cell sarcoma. CONCLUSION: SS is a rare neoplasm poses a grave risk for patients due to its malignant pathophysiology and the wide margin of misdiagnoses. It is pivotal to set-up proper preoperative diagnostic guidelines for it and maintain high clinical suspicion so that we can bring down the high rates of the morbidity and mortality which ensue from this malignancy.

A remarkably rare case of Adventitial Cystic Disease of the Popliteal Artery in a 51-year-old Middle Eastern female - A Case Report.

INTRODUCTION AND IMPORTANCE: Adventitial Cystic Disease (ACD) is a vastly rare non-atherosclerotic vascular pathology that is principally manifested as intermittent claudication because of peripheral vascular ischemia. Precise etiological factors are not yet concretely identified, and it represents 0.1 % of all lower limb claudication causes. Middle-aged males are the most affected gender age group. Misdiagnosis of Popliteal Artery ACD could delay proper management and hence risk the loss of the affected limb due to critical limb ischemia. CASE PRESENTATION: We hereby explore the rare case of a 51-year-old female patient, who complained of vague left lower extremity pain accompanied by paresthesia for 1 month prior to admission without signs of local inflammation. The preoperative radiological assessment suggested the presence of thrombosis within the left Popliteal Artery which caused an occlusion in it and hence the proper blood flow was compromised. CLINICAL DISCUSSION: Surgical intervention and the complete removal of the lesion along with establishing a patent synthetic anastomotic graft to maintain the preexisting vascular bundle was the key to treating our patient. Microscopic analysis of the excised specimen revealed an Adventitial Cystic Disease of the Popliteal Artery. CONCLUSION: Adventitial Cystic Disease represents an extremely rare vascular pathology with a vast margin of non-specific symptoms that could lead to misdiagnoses. It is fundamental to establish suitable preoperative screening protocols for it and sustain adequate levels of clinical awareness so that we can timely diagnose and in turn, achieve proper therapeutic interventions to plummet the potential disastrous complications that could ensue.

Comparing Relative Value Units among Shoulder Arthroplasty, Hemiarthroplasty, and ORIF for Proximal Humerus Fractures in the Elderly: Which is Most Worth Your Time?

BACKGROUND: Relative value units (RVUs) are assigned to Current Procedural Technology (CPT) codes and give relative economic values to the services physicians provide. This study compared the RVU reimbursements for the surgical options of proximal humerus fractures in the elderly, which include arthroplasty (reverse [RSA] and total [TSA]), hemiarthroplasty (HA), and open reduction and internal fixation (ORIF). METHODS: Using the National Surgical Quality Improvement Program, a total of 1,437 patients of at least 65 years of age with proximal humerus fractures between 2008 and 2016 were identified. Of those, 259 underwent RSA/TSA (CPT code 23472), 418 underwent HA (CPT codes 23470 and 23616), and 760 underwent ORIF (CPT code 23615). Univariate analysis compared RVU per minute, reimbursement rate, and the average annual revenue across cohorts based on respective operative times. RESULTS: RSA/TSA generated a mean RVU per minute of 0.197 (SD 0.078; 95%CI [0.188, 0.207]), which was significantly greater than the mean RVU per minute for 23470 HA (0.156; SD 0.057; 95%CI [0.148, 0.163]), 23616 HA (0.166; SD 0.065; 95%CI [0.005, 0.156]), and ORIF (0.135; SD 0.048; 95%CI [0.132, 0.138]; P<0.001). This converted to respective reimbursement rates of $6.97/min (SD 2.78; 95%CI [6.63, 7.31]), $5.48/min (SD 2.05; 95%CI [5.22, 5.74]), $5.83/min (SD 2.28; 95%CI [5.49, 6.16]) and $4.74/min (SD 1.69; 95%CI [4.62, 4.87]). After extrapolation, respective average annual revenues were $580,386, $456,633, $475,077, and $395,608. CONCLUSION: RSA/TSA provides significantly greater reimbursement rates compared to HA and ORIF. Orthopaedic surgeons can use this information to optimize daily procedural cost-effectiveness in their practices.

Evaluating success rate and comparing complications of operative techniques used to treat chronic syndesmosis injuries.

PURPOSE: To assess the success rate and complications of the surgical interventions used to manage chronic syndesmosis injuries. METHODS: Multiple online databases were queried to identify studies reporting operative intervention for chronic syndesmosis injuries. RESULTS: Modalities of operative fixation include suture-button fixation, arthroscopy and debridement, as well as arthrodesis. The use of operative treatment is effective; however, more direct comparison studies are necessary to evaluate the efficacy of each treatment. CONCLUSION: Various operative procedures have been used for the management of chronic syndesmotic injuries but further prospective studies are necessary to determine the type of treatment that should be indicated.

Are the anatomy textbooks wrong? A clinical patho-anatomic study of foveal vessels in the round ligament of the hip.

BACKGROUND: The foveal vessels of the ligamentum teres are an anterior branch of the posterior division of the obturator artery, providing blood to the capitis of the femoral head. However, the basic anatomic description of foveal vasculature in the ligamentum teres of the hip is widely variable, with some studies reporting that the vessels are not patent in roughly one third of all adults. Therefore, the purpose of this study was to evaluate the status of foveal vessels in primary total hip arthroplasty (THA) patients. Specifically, we evaluated: (I) if the foveal vessels were intact; and we (II) correlated foveal vessel status with (i) patient demographics, including gender and age; as well as (ii) perioperative data, such as operative time and blood loss. METHODS: The macroscopic status of the foveal vessels in the ligamentum teres femoris was documented in 266 patients at the time of primary unilateral THA performed between August 2015 and April 2017. The vessels were considered to be intact if active bleeding was directly visible from the acetabular stump of the severed ligamentum teres femoris. Demographics including age, gender, and preoperative diagnosis were collected. The perioperative outcome variables included estimated blood loss (EBL) and operative time. Foveal vessel status defined as intact or not intact, was also correlated with patient demographics and perioperative data. A student's t-test was used to compare the continuous variables and a chi square test was used for categorical variables. RESULTS: The foveal vessels were intact in 161 patients (61%) and not intact in 105 patients (39%). The mean age for patients with intact foveal vessels was found to be 64 years (range, 18 to 94 years) vs. 65 years (range, 29 to 94 years) (P>0.05) for not intact. No correlation was found between preoperative diagnosis, gender, operative time, and EBL and foveal vessel status. CONCLUSIONS: The results of this clinical patho-anatomic study of the foveal vessels in the ligamentum teres femoris of the hip refutes the polarized claims of prior anatomy texts that document the vessels as either "absent in adults" or "always intact." Rather, the results of this study reveal an alternate option: that foveal vessels can be present and either be intact (61%) or not intact (39%). No correlation was found between age, gender, operative time, and EBL and foveal vessel status.

A low concentration of ethanol impairs learning but not motor and sensory behavior in Drosophila larvae.

Drosophila melanogaster has proven to be a useful model system for the genetic analysis of ethanol-associated behaviors. However, past studies have focused on the response of the adult fly to large, and often sedating, doses of ethanol. The pharmacological effects of low and moderate quantities of ethanol have remained understudied. In this study, we tested the acute effects of low doses of ethanol (∼7 mM internal concentration) on Drosophila larvae. While ethanol did not affect locomotion or the response to an odorant, we observed that ethanol impaired associative olfactory learning when the heat shock unconditioned stimulus (US) intensity was low but not when the heat shock US intensity was high. We determined that the reduction in learning at low US intensity was not a result of ethanol anesthesia since ethanol-treated larvae responded to the heat shock in the same manner as untreated animals. Instead, low doses of ethanol likely impair the neuronal plasticity that underlies olfactory associative learning. This impairment in learning was reversible indicating that exposure to low doses of ethanol does not leave any long lasting behavioral or physiological effects.