The Impact of the Instigator Rule on Fighting in the National Hockey League.

Background: Fighting is often considered an essential part of professional hockey. Increased ticket sales, a means to self-regulate other dangerous gameplay, and helping teams win are a few of the reasons that fighting advocates provide for retaining fighting in the NHL. However, fighting trends have changed over the past 50 years. Given the recent data on concussions and player safety, an in-depth analysis of fighting is required to understand if fighting has a place in the future of the NHL. Methods: Seasonal statistical team data on NHL teams from the 1967 to 2019 seasons were collected and analyzed using publicly available databases. Specific outcome variables of interest related to fighting, penalties, the final team record for a given season, and final standing were recorded. The data were divided into subgroups according to "era of play" and before/after the implementation of the instigator rule. The trends in fighting, seasonal outcomes, and other minor penalties were assessed to determine the trends in fighting over the past 50 years, the relationship between fighting and winning, and the impact of the instigator rule. Results: Fights per game decreased significantly after the implementation of the instigator rule (0.71 to 0.51 fights per game, p < 0.0001). There was no significant difference in fights per game when comparing Stanley Cup champions to nonplayoff teams in either the modern era (0.36 vs. 0.42, p = 0.43) or the expansion era (0.45 vs. 0.51, p = 0.49). Only two Stanley Cup champions (the Flyers 1974-1975 and the Ducks 2006-2007) led the league in fighting. A multivariate regression analysis comparing fights per game and points earned per season divided by the number of games played revealed a statistically significant inverse relationship (coefficient = -0.16, p < 0.001). Conclusion: Our analysis demonstrates that the Instigator rule achieved its intended effect to decrease the number of fights per game. In the current era of professional hockey, there is no compelling evidence that a team with more fights per game will achieve greater seasonal success. These results continue to cast doubt on the belief that fighting is a necessary strategy for winning games at the NHL level.

Huygens' Principle geometric derivation and elimination of the wake and backward wave.

Huygens' Principle (1678) implies that every point on a wave front serves as a source of secondary wavelets, and the new wave front is the tangential surface to all the secondary wavelets. But two problems arise: portions of wavelets that exist outside of the new wave front combine to form a wake. Also there are two tangential surfaces so wave fronts are propagated in both the forward and backward directions. These problems have not previously been resolved by using a geometrical theory with impulsive wavelets that are in harmony with Huygens' geometrical description. Doing so would provide deeper understanding of and greater intuition into wave propagation, in addition to providing a new model for wave propagation analysis. The interpretation, developed here, of Huygens' geometrical construction shows Huygens' Principle to be correct: as for the wake, the Huygens' wavelets disappear when combined except where they contact their common tangent surfaces, the new propagating wave fronts. As for the backward wave, a source propagates both a forward wave and a backward wave when it is stationary, but it propagates only the forward wave front when it is advancing with a speed equal to the propagation speed of the wave fronts.

Debate Update: Surgery After 48 Hours of Admission for Geriatric Hip Fracture Patients Is Associated With Increase in Mortality and Complication Rate: A Study of 27,058 Patients Using the National Trauma Data Bank.

OBJECTIVE: To determine the association between surgical timing and short-term morbidity and mortality in elderly patients who sustain hip fractures using a national trauma database (OTA/AO 31A1-3, 31B1-3). DESIGN: Retrospective cohort study. SETTING: Level I-IV trauma centers in the United States. PATIENTS/PARTICIPANTS: All patients ≥65 years of age who underwent surgery for hip fracture from 2011 to 2013. INTERVENTION: Time to surgery of <24, 24-48, and >48 hours from admission. MAIN OUTCOME MEASUREMENTS: Primary outcome was mortality by hospital discharge. Secondary outcomes were complications of myocardial infarction, cardiac arrest, acute respiratory distress syndrome (ARDS), unplanned reintubation, pneumonia, stroke, severe sepsis, and intensive care unit length of stay. RESULTS: Twenty-seven thousand fifty-eight patients were included in the study. Relative to the <24 hours cohort, patients in the >48 hours cohort were at increased risk for mortality (OR 1.89, 95% CI 1.52-2.33, P < 0.001), ARDS (OR 2.57, 95% CI 1.94-3.39, P < 0.001 for ARDS), myocardial infarction (OR 2.19, 95% CI 1.64-2.94, P < 0.0001), pneumonia (OR 2.04, 95% CI 1.71-2.44, P < 0.001), severe sepsis (OR 2.34, 95% CI 1.52-3.58, P = 0.003), and intensive care unit stay (OR 2.48, 95% CI 2.25-2.74, P < 0.0001). A subgroup analysis showed that healthier patients (modified Charlson Comorbidity Index less than 5) who had surgery >48 hours were not at increased risk of mortality. CONCLUSIONS: For elderly patients with hip fractures, delaying surgery for more than 48 hours may be associated with increased short-term morbidity and mortality. This association may be pronounced for patients with more medical comorbidities. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Inter- and Intraobserver Reliability Between Orthopaedic Surgeons for Reparability of the Anterior Cruciate Ligament Using MRI.

BACKGROUND: Anterior cruciate ligament (ACL) reconstruction is the standard of care for patients after an ACL tear, as poor historical outcomes were observed after primary ACL repair. Certain subgroups of patients, however, have been shown to have outcomes equivalent to reconstruction after undergoing ACL repair and therefore may benefit from the potential advantages offered by avoiding reconstruction. It is important to accurately and consistently identify and indicate these candidates for ACL repair. PURPOSE/HYPOTHESIS: The purpose of this study was to determine the inter- and intraobserver reliability of magnetic resonance imaging (MRI) evaluation for the reparability of ACL tears and to identify imaging factors that may lead to surgeon uncertainty or disagreement in decision making. Our hypothesis was that the orthopaedic surgeons surveyed would not be able to reliably agree on the reparability of an ACL using MRI scans alone. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 3. METHODS: We administered 2 surveys to 6 fellowship-trained orthopaedic sports medicine surgeons. Each surgeon reviewed preoperative MRI scans for 20 patients and answered a series of questions, ultimately determining whether they would choose an ACL reconstruction or repair for the patient based on the imaging alone. The same survey was repeated 6 weeks later. Kappa values for inter- and intraobserver reliability of their decision making were then calculated. RESULTS: The average kappa for interobserver reliability in the 2 surveys was 0.22, and the average kappa for intraobserver reliability was 0.34. Interobserver reliability among the surgeons in this group was poor to moderate; intraobserver reliability was slightly better. The choice for ACL repair was significantly correlated with proximal tear locations (r = 0.854; P < .001), good-quality ACL tissue remnant (r = 0.929; P < .001), and how many surgeons believed that the tear only involved a single bundle (r = 0.590; P = .006). CONCLUSION: The surgeons surveyed in this study did not consistently agree on candidates for ACL repair using MRI alone.

Current Trends and Impact of Early Sports Specialization in the Throwing Athlete.

Early sports specialization (ESS) is a relatively new trend that has led to many youth athletes to focus on only 1 sport at an increasingly young age. Although parents and coaches perceive that this will improve their athlete's chances of success at the collegiate and professional levels, studies have shown the opposite. ESS leads to increased injury risk, higher rates of burnout, and lower lifelong sports participation without increasing elite achievement. Throwing athletes are particularly vulnerable to these overuse injuries of the shoulder and elbow, which have been shown to correlate directly to the number of throws and innings played.

Lessons Learned for Orthopaedic Care Within the NYC COVID Epicenter Using the United States Naval Ship Comfort.

Although elective surgeries and in-person office visits were greatly reduced during the COVID-19 crisis, orthopaedic surgeons continue to play a critical role in caring for both orthopaedic and nonorthopaedic problems during this pandemic. Orthopaedic departments provide the ability to off-load emergency departments of orthopaedic issues, redeploy staff to areas of need across the hospital system, and provide direct care to COVID-19 patients. The following will discuss the experience of a large academic orthopaedic surgery department within the epicenter of the COVID-19 pandemic with respect to redeployment of human capital and unique resources such as the United States Naval Ship Comfort as well as our recommended strategy for handling future disaster situations.

Polyester Mesh Dressings Reduce Delayed Wound Healing and Reoperations Compared with Silver-Impregnated Occlusive Dressings after Knee Arthroplasty.

BACKGROUND: New dressings aimed at reducing surgical wound complications after knee arthroplasty continue to evolve. We compared wound complications and reoperations between 2 dressings: 2-octyl cyanoacrylate adhesive and polyester mesh (Dermabond® Prineo®, "mesh") and silver-impregnated occlusive dressings and n-butyl-2-cyancacrylate adhesive (AQUACEL® Ag SURGICAL cover dressing with SwiftSet™, "standard"). METHODS: This retrospective cohort study reviewed 353 consecutive partial and total knee arthroplasties performed by a single surgeon; 6 were excluded for not using either dressing type. Thus, 347 cases were separated into 2 cohorts: mesh (n = 176) and standard dressing (n = 171). Demographics and risk factors were similar, except for age. Surgical and closure techniques were consistent in all patients. Delayed wound healing was assessed by the surgeon at the 2-week office visit for drainage, suture abscess, or wound edge separation. Secondary outcome measures include infection, office-based closure, and return to the operating room for reclosure. RESULTS: There were 2 instances of delayed wound healing in the mesh group and 16 in the standard dressing group (1.14% vs 9.36%, P ≤ .0001). There were significantly fewer reoperations in the mesh group than in the standard group (0 vs 2.33%, P = .04). There were no infections or office-based closures. CONCLUSION: Mesh dressings were associated with fewer episodes of delayed wound healing and reoperations than the standard dressing. A possible mechanism may be that this brand of mesh distributes wound tension more evenly. In addition, because it remains in place longer during the immediate postoperative period, it may work via prolonged wound edge support.

Evaluation and Management of Hand, Wrist and Elbow Injuries in Ice Hockey.

Ice hockey continues to be a popular, fast-paced, contact sport enjoyed internationally. Due to the physicality of the game, players are at a higher risk of injury. In the 2010 Winter Olympics, men's ice hockey had the highest injury rate compared to any other sport. In this review, we present a comprehensive analysis of evaluation and management strategies of common hand, wrist, and elbow injuries in ice hockey players. Future reseach focusing on the incidence and outcomes of these hand, wrist and elbow injuries in ice hockey players is warranted.

Post-Traumatic Epilepsy after Sports-Related Concussion: A Case Report.

Sports-related concussions (SRCs) are a public health concern across the United States, and they lead to neurological sequelae that can last long after the event itself. Concussive convulsions at the time of injury are common and rarely require additional workup or treatment. Post-traumatic epilepsy (PTE), however, is a rare phenomenon that can develop after traumatic brain injury and must be managed with adequate medical therapy. Herein we present the case of a 15-year-old football player who developed PTE after an SRC. This condition must be identified through proper education of sports clinicians and those involved in care and management of athletes.

Change in Heart Rate Variability after Concussion in a Collegiate Soccer Player.

Athletes are known to under-report concussion symptoms due to competitive disincentives to report and conflation of concussion symptoms with other conditions associated with rigorous participation in sports. A quantitative biomarker for concussion has the potential to decrease the reliance on inconsistent patient-reported symptoms for the diagnosis of concussion. The objective of this project was to monitor heart rate variability (HRV) patterns of in-season athletes as a potential biomarker for concussion. Twenty in-season National Collegiate Athletic Association (NCAA) Division 2 collegiate soccer players were given a wristband heart rate sensor with instructions to wear the band full time (24/7) for the entire fall season (approximately 3 months). The athletes were prompted by email to complete a weekly survey on the severity and frequency of any concussion symptoms. The survey and HRV data were de-identified for confidentiality, and to increase the likelihood of accurate reporting the athletes were told their responses would not be used to disqualify them from athletics. Our hypothesis was that HRV would be diminished in those with recent concussion. One athlete (5% of the cohort) sustained a concussion during the study period. A marked decrease in HRV was identified 7 days following the concussion, which eventually returned to baseline. This normalization of HRV followed the timing of resolution of concussion symptoms. Participants who did not sustain a concussion exhibited minimal variance in HRV over time. This preliminary study shows that HRV has potential as a biomarker for symptom resolution after clinically apparent concussion. HRV is unlikely to serve as a concussion diagnostic due to the 7-day lag in HRV change after concussion.