The Delayed Presentation and Diagnosis of Youth Wrestling Injuries: A 20-Year Analysis of National Injury Data.

INTRODUCTION: The nature of wrestling may lead athletes to mask injuries with the delayed presentations of youth wrestling-related injuries not being well characterized. METHODS: This descriptive epidemiological study queried the National Electronic Injury Surveillance System database to characterize delayed presentations of wrestling-related injuries in middle and high-school athletes. Data collection consisted of national estimates, demographics, and injury characteristics of patients with delayed (D) presentations (≥1 day) and same-day (S) presentations to US emergency departments after sustaining a wrestling-related injury during the scholastic wrestling season (December to February, 2000 to 2019). RESULTS: Of middle and high-school wrestlers presenting to US emergency departments, 5.6% (95% confidence interval [CI] 4.3% to 7.1%) reported delayed presentations for a total of 1,110 patients (CI, 591 to 1,630) annually. Most commonly (P < 0.001), injuries were sustained on Saturdays in both cohorts (D, 28.2%; CI, 22.4% to 34.8%; S, 29.6%; CI, 24.3% to 35.5%). Patients reporting delayed presentations were less likely to sustain fractures (D, 11.5%; CI, 8.3% to 15.6%; S, 18.9%; CI, 15.0% to 23.5%; P = 0.019) and injuries of the head/neck (D, 20.0%; CI, 16.5 to 24.1%; S, 26.2%; CI, 21.4% to 31.7%; P = 0.011). DISCUSSION: A substantial proportion of adolescent wrestlers report delayed presentations of injuries. This emphasizes the need for vigilance in detecting subtle signs of injury.

Acute Vertebral Fractures in Skiing and Snowboarding: A 20-Year Sex-Specific Analysis of National Injury Data.

Background: The epidemiology of acute vertebral fractures (AVFs) sustained while skiing and snowboarding remains poorly defined in the United States. Hypothesis: It was hypothesized that there would be no significant differences across sex and a greater number of AVFs in younger age groups associated with skiing and snowboarding. Study Design: Descriptive epidemiological study. Methods: The authors utilized the National Electronic Injury Surveillance System to identify patients who were reported in emergency departments in the United States from 2000 to 2019. All patients were noted to have sustained AVFs during skiing or snowboarding. National estimates and demographic analysis were performed. Results: A total of 466 AVFs were identified, or roughly 23.3 AVFs per year. Compared with women, men accounted for the majority of AVFs sustained in both skiing and snowboarding: 67.8% (95% CI, 62.6%-73.0%) during skiing and 82.1% (95% CI, 76.3%-87.8%) during snowboarding. This represented a significantly larger percentage of AVFs while snowboarding compared with skiing (P = .002). Women accounted for 32.2% (95% CI, 27.0%-37.4%) of AVFs while skiing and 17.9% (95% CI, 12.2%-23.7%) while snowboarding, which indicated a significantly larger percentage of AVFs sustained during skiing compared with snowboarding (P = .002). Snowboarders were more likely than skiers to sustain an AVF in the region of the coccyx (21.5% [95% CI, 14.3%-28.7%] vs 11.5% [95% CI, 3.5%-16.9%], respectively; P = .003) and as a result of a fall at ground level (69.2% [95% CI, 62.1%-76.4%] vs 52.8% [95% CI, 43.2%-62.4%], respectively; P = .009). A significant decrease in the number of snowboarding-related AVFs was identified over the 20-year study period: 899 in 2000-2003 versus 283 in 2016-2019 (P < .01). The change in skiing-related AVFs over the study period was not statistically significant (694 vs 462; P = .5). Conclusion: This national study of AVFs sustained while skiing and snowboarding identified critical sex- and age-specific differences in the population at risk, anatomic location of injury, and mechanism of injury. The national data generated from this study over a 20-year period may be utilized to better inform public health injury awareness and prevention initiatives in the rapidly growing sports of skiing and snowboarding.

Does a 2-Stage Debridement Result in Higher Rates of Implant Retention Compared With Single Debridement Alone?

BACKGROUND/METHODS: We retrospectively reviewed 89 patients with acute prosthetic joint infection treated with debridement, antibiotics, and implant retention (DAIR) or 2-DAIR. Patients had <3 weeks of symptoms and met Musculoskeletal Infection Society criteria for infection. Sixty-three patients were treated with DAIR, whereas 26 patients were managed using a 2-DAIR protocol where patients underwent initial debridement, antibiotic bead placement, and subsequent return to the operating room at an average of 16.3 days for repeat debridement and modular component exchange. Patients received a 6-week course of intravenous antibiotics and 3 months of oral antibiotics for suppression. Demographics, comorbidities, implant retention rates, and complications were compared between the groups. The McPherson host type and infection type classification system were used to categorize patients in both the DAIR and 2-DAIR groups. Regression analysis was performed to control postoperative vs acute hematogenous infection, procedure, and comorbidities. The McPherson host types and infection types were not different between DAIR and 2-DAIR patients, P = .728 and P = .061, respectively. RESULTS: There was no difference in the overall implant retention rate between DAIR and 2-DAIR (63.49% vs 69.23%, P = .605). The average days to reinfection was significantly longer for the 2-DAIR cohort compared with DAIR (271.3 vs 165.3, P = .024) in patients who failed treatment. However, when controlling for infection, microorganism, index procedure, and comorbidities, there was no difference in days to reinfection (P = .679). There were no differences in complications, 90-day readmission, or revision rates between the groups. CONCLUSIONS: A staged debridement for acute prosthetic joint infection did not improve the rates of infection control. Randomized trials are needed to define indications and potential benefits of 2-DAIR.

Rock climbing confers distinct injury risk in pediatric versus adult populations: an analysis of twenty-year national trends.

OBJECTIVES: The sport of rock climbing has recently gained in popularity due in part to its adoption by noncompetitive athletes as a physical activity with a level of intensity that can be self-regulated. However, the epidemiology of rock climbing injuries is poorly described at the national level. METHODS: We report demographic and injury characteristics from 85,235 national weighted estimates of rock climbing injuries presenting to United States (US) emergency departments (EDs) between 2000 and 2019 in the National Electronic Injury Surveillance System, stratifying by whether patients were ≤18 years of age (A) or ≥19 years of age (B). RESULTS: The national weighted estimate of patients presenting to US EDs with injuries associated with rock climbing rose significantly (p < 0.001) from 2000 (2,667, CI 1,777-3,557) to 2019 (7,087, CI 4,544-9,630). Patients ≤18 years of age were significantly less likely to be male (A: 56.3%, CI 52.0-60.6%; B: 64.7%; CI 60.4-69.0%; p = 0.003), sustain injuries on weekends (A: 29.8%, 24.5-35.1%; B: 64.7%, CI 60.4-69.0%; p = 0.002), or sustain injuries during summer seasons (A: 26.6%, CI 22.1-31.1%; B: 33.2%, CI 28.1-38.3%; p = 0.049). Multivariate logistic regression demonstrated that patients ≤18 years of age were significantly more likely to present to EDs with head and neck (OR: 1.52, CI 1.04-2.21; p = 0.032) or upper extremity (OR: 1.55; CI 1.24-1.93; p < 0.001) injuries associated with rock climbing. CONCLUSION: We identified a significant increase in the annual estimated number of patients presenting to US EDs with rock climbing injuries compared to what has previously been reported. As the number of climbers continues to grow, standardized safety policies may be implemented that specifically target injury mechanisms and patterns unique to both adult and pediatric populations.

Comparison of in-season and off-season wrestling injuries presenting to United States emergency departments: 2000-2018.

OBJECTIVES: Wrestling is a physically demanding sport with an inherently high risk of injury relative to other sports. Injury risk factors may change dramatically for athletes participating in off-season wrestling, given exposure to new opponents, training methods, and wrestling styles compared with in-season months; however, this has never been elucidated in the literature. This study seeks to characterize the injuries sustained while participating in off-season wrestling and compare them to injuries sustained during the in-season months for middle and high school age athletes. METHODS: The National Electronic Injury Surveillance System (NEISS) database was queried (2000-2018) to directly compare national estimates and injury characteristics of middle and high school age patients (11-18 years of age) presenting to US emergency departments (EDs) with wrestling-associated injuries, stratified by in-season and off-season months. RESULTS: The average annual number of patients 11 to 18 years of age presenting to US EDs with wrestling-associated injuries was 20,157 (95% Confidence Interval [C.I.] 16,622-23,691) during in-season months and 5,321 (C.I. 3,954-6,688) during off-season months between 2000 and 2018. Those sustaining in-season injuries were significantly (p < 0.001) more and less likely to injure their upper trunk (8.0%; C.I. 7.1% - 8.8%) and wrists (3.7%; C.I. 3.2% - 4.2%), respectively, than those presenting with off-season injuries (upper trunk: 5.3%; C.I. 4.2% - 6.5%; wrists: 6.6%; C.I. 5.1% - 8.1%). There were no significant differences with respect to the overall prevalence of injury diagnoses between in-season and off-season patient cohorts, including for fractures and dislocations (p > 0.05). CONCLUSION: These findings may alleviate concerns that off-season wrestling is inherently more dangerous than in-season wrestling due to changes in wrestling styles or opponent skill levels as the prevalence of specific injury diagnoses between the two seasons is similar.

Epidemiology of Pediatric Nonballistic Firearm Injuries to the Upper Extremity in the United States From 2000 to 2017.

Background: This study aimed to describe the epidemiology of pediatric upper extremity injury secondary to nonballistic firearms in the United States. Methods: The National Electronic Injury Surveillance Survey (NEISS) database was queried between 2000 and 2017 for injuries to the upper extremity from nonballistic firearms in patients aged ≤18 years. In total, 1502 unique cases were identified. Using input parameters intrinsic to the NEISS database, national weighted estimates were derived using Stata/IC 15.1 statistical software (StataCorp LLC, College Station, Texas), which yielded an estimate of 52 118 cases of nonballistic firearm trauma to the upper extremity who presented to US emergency departments over the study period. Descriptive statistics were performed using NEISS parameters. Results: An average of 2895 annual pediatric upper extremity nonballistic firearm injuries were identified between 2000 and 2017. Over 91% were sustained by men, and adolescents aged 12 to 18 were the most commonly injured (69.8%). Only 3.5% of all injuries required inpatient admission, and the most common sites of injury were the hand (41.1%), followed by fingers (35.9%). Conclusions: We conclude that nonballistic firearm injuries represent a significant burden of disease to adolescent men in the United States.

Superior Pubic Ramus Screw Placement During Complex Acetabular Revision: Acetabular Distraction for Treatment of Pelvic Discontinuity.

Insertion of a superior pubic ramus screw may be indicated for the treatment of a chronic pelvic discontinuity when utilizing acetabular distraction in revision total hip arthroplasty (THA), especially in the setting of severe bone loss in the ischium. The aim of this procedure is to stabilize and prevent abduction failure of the acetabular component when utilizing acetabular distraction. Description: With the patient in the lateral decubitus position, the acetabulum is exposed from a standard posterior approach for a revision THA. The location of the superior pubic root is identified after making a recess within the anteroinferior capsule. In order to ensure that the appropriate trajectory is obtained, C-arm imaging (inlet view and orthogonal obturator outlet views) is utilized to safely predrill the screw trajectory into the superior pubic ramus. A Kirschner wire (K-wire) is then placed into the hole. With use of a metal-cutting burr on the back table, customized peripheral screw holes are placed and then the acetabular component is slid and impacted into place over the K-wire. After cup insertion, the K-wire is removed and the superior pubic ramus screw can be placed and confirmed on fluoroscopy. Alternatives: In general, chronic pelvic discontinuity requires surgical management with revision THA and has historically employed the use of a cup-cage construct, custom triflange implants, and/or jumbo acetabular cups with modular porous metal augments1-5. With these treatment options, it is typically necessary to insert "kickstand" screws, which function to prevent abduction failure of the acetabular cup4,5. However, in many cases of discontinuity, there may be severe ischial osteolysis, making ischial screw placement difficult or impossible. The superior pubic ramus, however, remains a reliable option that can be utilized for inferior screw fixation, even in cases of severe acetabular bone loss, and thus is especially beneficial in these difficult cases. Rationale: The technique of acetabular distraction was developed because of limitations with alternative techniques. This procedure achieves cementless biologic fixation and eventual discontinuity healing as a result of lateral or peripheral acetabular distraction and resultant medial or central compression across the pelvic discontinuity. Acetabular distraction allows for intraoperative customization and cement unitization of the acetabular construct. This procedure requires the use of a "kickstand" screw or of inferior screw fixation in order to prevent abduction failure of the cup. These screws may be placed into either the ischium or superior pubic ramus. If the patient has substantial ischial osteolysis, ischial screw fixation may not be possible. If not placed in a systematic manner, pubic ramus screws can be technically challenging, and incorrect placement can result in neurovascular injury. The present video article demonstrates a reproducible technical method for safely placing a screw in the superior ramus to aid in optimal fixation of the acetabular component in cases of pelvic discontinuity. Expected Outcomes: Thus far, short-term survivorship of acetabular distraction with use of a jumbo cup and kickstand screws has been about 95%. In the largest study to date assessing patients with chronic pelvic discontinuity who underwent revision THA with use of the acetabular distraction technique, only 1 of 32 patients required revision for aseptic loosening6. An additional 2 patients had evidence of radiographic loosening but did not undergo revision, and 3 had migration of the acetabular component into a more stable configuration. Radiographically, 22 of 32 patients in the study demonstrated healing of the discontinuity6. In another study assessing the survivorship of porous tantalum acetabular shells in revision THA to treat severe acetabular defects, patients with inferior screw fixation with superior pubic ramus or ischial screws had a significantly lower incidence of proximal translation of components compared with those without inferior screw fixation7. Important Tips: For reproducible, successful execution of this technique, it is important to confirm correct placement of the acetabular retractors at the correct anatomical locations to ensure adequate surgical visualization of the acetabulum for easy identification of the superior pubic root.It is also critical to check placement of the drill via fluoroscopy with an inlet and obturator outlet views prior to drilling.The drill should be advanced on the oscillate setting to avoid inadvertently perforating the cortical bone and damaging surrounding neurovascular structures. Acronyms and Abbreviations: OR = operating roomf/u = follow-upvac = vacuum-assisted closureRSA = radiostereometric analysis.

Sports-related concussions in high school females: an epidemiologic analysis of twenty-year national trends.

The epidemiology of sports-related concussions (SRCs) and closed head injuries (CHIs) in high school females remains undefined at the national level, especially for unorganized sports and recreational activities. This study examines 1,176,092 national weighted estimates of SRCs or CHIs in female patients 14-18 years of age presenting to United States (US) emergency departments (EDs) between 2000 and 2019 in the National Electronic Injury Surveillance System (NEISS). The national weighted estimate of female patients in our study increased significantly (p < 0.001) between 2000 (9,835; 95% Confidence Interval [CI] 7,105-12,566) and 2019 (31,751; CI 26,392-37,110). The top five ranked sports and recreational activities most commonly associated with concussions and CHIs in female patients 14-18 years of age were: soccer (20.6%; CI 17.6%-23.6%); basketball (18.5%; CI 16.9%-20.1%); cheerleading (10.4%; CI 8.9%-11.9%); softball (10.1%; CI 9.0%-11.3%); volleyball (6.5%; CI 5.7%-7.2%). Simple univariate regression models showed that an increase of 10,000 annual female participants across all high school sports and recreational activities was associated with 308.7 (SE = 20.8, p < 0.001, R2 = 0.92) additional annual SRCs and CHIs presenting to US EDs. The promotion of concussion awareness and educational programs may help minimize SRCs and CHIs.

Association of Graduate Medical Education With Hospital Performance and Patient Outcomes.

Importance: Graduate medical education (GME) funding consists of more than $10 billion annual subsidies awarded to academic hospitals to offset the cost of resident training. Critics have questioned the utility of these subsidies and accountability of recipient hospitals. Objective: To determine the association of GME funding with hospital performance by examining 3 domains of hospital operations: financial standing, clinical outcomes, and resident academic performance. Design, Setting, and Participants: This study is an economic evaluation of all academic centers that received GME funding in 2017. GME funding data were acquired from the Hospital Compare Database. Statistical analysis was performed from May 2016 to April 2020. Exposures: GME funding. Main Outcomes and Measures: This study assessed the association between GME funding and each aspect of hospital operations. Publicly available hospital financial data were used to calculate a financial performance score from 0 to 100 for each hospital. Clinical outcomes were defined as 30-day mortality, readmission, and complication rates for a set of predefined conditions. Resident academic performance was determined by Board Certification Examination (BCE) pass rates at 0, 2, and 5 years after GME funding was awarded. Confounder-adjusted linear regression models were used to test association between GME funding data and a hospital's financial standing, clinical outcomes, and resident academic performance. Results: The sample consisted of 1298 GME-funded hospitals, with a median (IQR) of 265 (168-415) beds and 32 (10-101) residents per training site. GME funding was negatively correlated with hospitals' financial scores (ß = -7.9; 95% CI, -10.9 to -4.8, P = .001). Each additional $1 million in GME funding was associated with lower 30-day mortality from myocardial infarction (-2.34%; 95% CI, -3.59% to -1.08%, P < .001), heart failure (-2.59%; 95% CI, -3.93% to -1.24%, P < .001), pneumonia (-2.20%; 95% CI, -3.99% to -0.40%, P = .02), chronic obstructive pulmonary disease ( -1.20%; 95% CI, -2.35% to -0.05%, P = .04), and stroke (-3.40%; 95% CI, -5.46% to -1.33%, P = .001). There was no association between GME funding and readmission rates. There was an association between higher GME funding and higher internal medicine BCE pass rates (0.066% [95% CI, 0.033% to 0.099%] per $1 million in GME funding; P < .001). Conclusions and Relevance: This study found a negative linear correlation between GME funding and patient mortality and a positive correlation between GME funding and resident BCE pass rates in adjusted regression models. The findings also suggest that hospitals that receive more GME funding are not more financially stable.

American football is the youth sporting activity most commonly associated with acute vertebral fractures.

OBJECTIVES: Athletics confer cardiovascular fitness and improved cognitive processing in pediatric populations. However, one risk of sports participation is acute vertebral fracture, an injury with significant morbidity. It is currently unknown which sports represent the highest risk of acute vertebral fracture in pediatric populations. This study seeks to identify the youth sporting activities most commonly associated with acute vertebral fractures presenting to United States (U.S.) emergency departments (EDs). METHODS: This cross-sectional, retrospective study queries the National Electronic Injury Surveillance System database to report national weighted estimates and demographic characteristics of pediatric patients with acute vertebral fractures presenting to U.S. EDs. RESULTS: The mean annual incidence of estimated acute vertebral fractures over the study period was 1,672 (C.I. 1,217-2,126). From 2000-2001 (N = 4,030; C.I. 2,934-5,125) to 2016-2017 (N = 2,559; C.I. 1,681-3,438), there was no significant change in the estimated rate of sports-related acute vertebral fractures in pediatric patients (p = 0.09). American football was identified as the sport most frequently associated with acute vertebral fractures (23.4%; C.I. 17.6-29.3%). We found no appreciable change in the rate of football-related acute vertebral fractures over time, with 48.2% (C.I. 37.3-59.0%) occurring from 2000 to 2008 and 51.8% (C.I. 41.0-62.7%) from 2009 to 2017. CONCLUSIONS: While sports-related acute vertebral fractures remain rare injuries in pediatric populations, we identify youth football as the sport associated with the highest risk of such injuries. Despite decreasing football participation rates over our study period, the annual incidence of football-associated acute vertebral fractures has not exhibited a proportional decline. Our findings raise concern that the relative risk of acute vertebral fracture associated with youth football has not significantly decreased over time. Elimination of dangerous tackling technique, improvement in helmet fit and technology, and availability of on-site medical care may contribute to decreased estimates in the future.

Wrestling-related concussions and closed head injuries predominantly occur in high school age athletes.

BACKGROUND: Sports-related concussions (SRC) and closed head injuries (CHI) have recently garnered national attention given mounting concern for long-term neurological sequelae resulting from repetitive head trauma. Despite historically dangerous techniques in wrestling that involve impacts to the head, there is a paucity of epidemiologic data in regard to wrestling-related concussions (WRCs) in the United States (USA). METHODS: The National Electronic Injury Surveillance System (NEISS) database was queried (2000-2018) to report national estimates and demographic characteristics of patients 6-25 years of age presenting to US emergency departments (EDs) with WRCs and CHIs. RESULTS: The average annual number of patients presenting to US EDs with WRCs or CHIs was 3465 (95% confidence interval [CI]: 2489-4441). Over one-third of patients were between 15 (17.7%; 95% CI: 15.8%-19.7%) and 16 (17.0%; 95% CI: 14.9%-19.1%) years of age, which comprised the peak age groups during which such head injuries were sustained. The vast majority of patients were male (96.3%; 95% CI: 94.8%-97.7%). Lastly, 6.2% (95% CI: 4.3-8.2%) of patients did not present to the ED on the same day that the injury was sustained. CONCLUSIONS: Due to the unique nature and culture of the sport, wrestlers may be more likely to attribute SRC or CHI symptoms to normal training-related fatigue, which can lead to underreporting or delayed diagnosis. It is therefore imperative that appropriate safety initiatives and concussion awareness campaigns be implemented in youth wrestling to decrease the incidence of SRCs at local and national levels.

The burden of prosthetic hip dislocations in the United States is projected to significantly increase by 2035.

INTRODUCTION: Prosthetic hip dislocation is a common, costly complication of total hip arthroplasty (THA). Despite this, the national burden of prosthetic hip dislocations remains uncharacterised in the United States, especially pertaining to injuries occurring years after the index procedure. This study examines historical and projected national estimates of prosthetic hip dislocations presenting to U.S. emergency departments between 2000 and 2035. METHODS: We conducted a cross-sectional, retrospective epidemiological study using narratives in the National Electronic Injury Surveillance System (NEISS) database (2000-2017) to identify an estimated 64,671 prosthetic hip implant dislocations presenting to U.S. emergency departments. Estimates for the prevalence of individuals living with a total hip implant were derived from the literature. RESULTS: The national estimate of prosthetic hip dislocations presenting to U.S. emergency departments rose significantly (p < 0.001) between 2000 (n = 2395; 95% CI, 1264-3526) and 2017 (n = 8094; 95% CI, 4276-11,912). These increases are likely driven by increased numbers of people living with THA overall, since between 2000 and 2017, the average incidence of prosthetic hip dislocation (0.14%; CI 0.08-0.21%) in patients living with hip implants has not changed significantly. Linear regression modeling (R2 = 0.7, p < 0.01) projected an increasing number of dislocations through 2035, predicting 10,446 national cases per year by this date. CONCLUSIONS: Driven by increases in THA, the annual volume of prosthetic hip dislocations presenting to U.S. emergency departments has increased significantly since 2000 and is projected to continue to rise sharply. Future advances in surgical technique, prosthesis design, and injury prevention policies aimed at decreasing the rate of THA dislocation would help alleviate this mounting national health burden.

Shoulder injuries associated with handling luggage presenting to U.S. emergency departments: 2003-2017.

BACKGROUND: Demand for travel for both work and leisure continues to rise in the U.S. However, handling luggage subjects the shoulder to excessive physical loads. OBJECTIVE: To report national estimates, demographic characteristics, and injury mechanisms of patients presenting to U.S. emergency departments with luggage-associated shoulder injuries. METHODS: This cross-sectional, retrospective study analyzes the National Electronic Injury Surveillance System (NEISS) database (2003-2017) to identify annual cases of luggage-associated shoulder injuries presenting to U.S. emergency departments. RESULTS: On average, 1,811 luggage-associated shoulder injuries presented to U.S. emergency departments annually (95% Confidence Interval: [C.I.] 1,123-2,499). Patients were commonly females (62.3%; 57.9%-66.8%) sustaining sprains, strains, or muscle tears (60.1%; 52.6%-67.7%). The majority of patients sustained shoulder injuries while lifting their luggage (70.1%; C.I. 64.9%-75.2%). Injuries were most often observed in patients 40-49 (21.5%; C.I. 16.5%-26.5%) and 50-59 (24.9%; C.I. 20.2%-29.6%) years of age. However, those sustaining shoulder injuries due to falls to the ground were significantly older (p < 0.001) on average than those with injuries from lifting or pulling their luggage. CONCLUSIONS: We recommend that at-risk individuals for luggage-associated shoulder injuries take certain precautions when handling heavy baggage to reduce said chances of injury.

Do Year-Out Programs Make Medical Students More Competitive Candidates for Orthopedic Surgery Residencies?

OBJECTIVE: As orthopedic surgery residency programs are becoming more competitive, medical students interested in orthopedics are increasingly completing "year-out" programs. This study sought to evaluate student and faculty perceptions of these programs. DESIGN: A survey evaluating baseline characteristics was disseminated to directors of year-out programs identified through postings on the orthopedics forum, Orthogate.org. A second survey was sent to all program directors (PDs) of accredited US orthopedic residencies, while a final survey was distributed to participants identified by year-out PDs. SETTING: Ninety-six orthopedic year-out programs at 56 institutions were contacted. PARTICIPANTS: Twenty-six year-out programs, 72 PDs of ACGME-accredited orthopedic residencies, and 34 year-out participants from 6 programs completed our questionnaires. RESULTS: 73.1% (19) year-out program provided funding to participants, averaging $30,368. 84.6% (22) reported >75% match rates into orthopedics for participants. 65.4% (17) of programs selected students between their MS3/MS4 school years. 4.2% (3) of residency PDs agreed or strongly agreed that year-out programs were important factors for consideration in residency programs, compared with 82.4% (28) of year-out participants and 69.2% (18) of year-out PDs (p < 0.001). 58.8% (2) of year-out participants cited completion of a year-out for improving the chance of matching into any orthopedic residency, while 85.3% (29) wanted to be more competitive for top programs. The average Step 1 score was 248, which was insignificantly different from the national average for matched orthopedic applicants. CONCLUSIONS: Orthopedic year-out programs have dramatically increased in number over the last 20 years. Most of these programs are funded, 1-year clinical research fellowships with relative match success for participants pursuing orthopedic residencies. While year-out PDs and students consider participation in such programs to be an important factor for residency applications, and often participate in them in order to improve their competitiveness for matching at desired programs, residency PDs overall hold different views.

Safely Implementing the Direct Anterior Total Hip Arthroplasty: A Methodological Approach to Minimizing the Learning Curve.

INTRODUCTION: Orthopaedic surgeons often cite concern for a learning curve as a barrier to adopting the direct anterior approach (DAA) for total hip arthroplasty (THA) while transitioning from other approaches. Studies both assessing and describing a practical approach and strategy to safely accomplish this transition, as well as the effect on clinical outcomes, are not well described. METHODS: This prospective study compares a single surgeon's operative results and complications for the first consecutive 100 direct anterior THA to the last 100 consecutive posterior THA after 7 years in practice. The regimented and disciplined learning strategy used to implement the DAA is detailed in this study. The data were analyzed using univariate and multivariate regression models. RESULTS: Univariate analyses identified significant differences in sex, age, Asian race, and diagnostic cause for THA between the two cohorts. Multivariate analyses controlled for these differences and showed that relative to posterior THA, direct anterior THA cases were associated with 7-minute longer procedures (P = 0.002) and lengths of stay that were 0.7 days fewer (P = 0.013). No significant differences were present in the estimated blood loss, and importantly, no significant differences in death or surgical complication rates between cohorts. DISCUSSION: This study suggests that the DAA for THA can be safely implemented without the increased and adverse risk to the patient when a structured learning process is maintained and meticulously performed.

Rising Trends in Wrestling-associated Injuries in Females Presenting to US Emergency Departments.

INTRODUCTION: Wrestling is one of the fastest-growing sports among females in the United States (US). However, female wrestling injuries remain poorly characterized. In this study we describe historical and projected national estimates of female wrestling injuries, and compare injury characteristics with those of male wrestlers. METHODS: We queried the National Electronic Injury Surveillance System (NEISS) database (2005-2019) to compare national weighted estimates and injury characteristics of male vs female wrestlers presenting to US emergency departments (ED) and projected annual female wrestling injuries expected by 2030. RESULTS: Our analyses demonstrated a significant (P < 0.001) increase in female wrestling injuries between 2005 (N = 1500; confidence interval [CI], 923 - 2,078) and 2019 (N = 3,404; CI 2,296 - 4,513). Linear regression (R2 = 0.69; P < 0.001) projected 4,558 (CI, 3104 - 6033) such injuries in 2030. Of female wrestling injuries 50.1% (CI, 44.1 - 56.2) occurred in patients 14-18 years of age. Compared with age-matched males, female wrestlers were significantly less likely to present with fractures (Female [F]: 10.6%; CI 7.5% - 13.7%; Male [M]: 15.7%; CI 14.7% - 16.7%; P = 0.003) or head/neck injuries (F: 18.5%; CI 13.2% - 23.9%; M: 24.6%; CI 23.2% - 26.0%; P = 0.018), and significantly more likely to present with strains/sprains (F: 48.8%; CI, 41.2% - 56.3%; M: 34.4%; CI 31.6% - 37.1%; P < 0.001). CONCLUSION: Males and females possess distinctly unique physiology and anatomy, such as variances in ligamentous and muscular strength, which may help to explain differences in wrestling injury characteristics. Prompt management of injuries and specific training strategies aimed at prevention may help to reduce the projected increase of female wrestling-associated injuries as the popularity of the sport continues to rise.

Epidemiology of Fireworks-Related Injuries to the Upper Extremity in the United States From 2011 to 2017.

Purpose: Fireworks may result in a wide spectrum of injury to the upper extremity ranging from mild burns to amputation. In this cross-sectional study, we describe the epidemiology of upper-extremity injuries in the United States associated with fireworks using the Consumer Product Safety Commission's National Electronic Injury Surveillance System (NEISS). Methods: The NEISS database was queried between 2011 and 2017 for all injuries of the upper extremity (from shoulder to fingertip) associated with fireworks. There were 806 unique cases, yielding a total weighted estimate of 31,430 national cases presenting to emergency departments in the United States during this time frame. National estimates, standard errors, and 95% confidence intervals were calculated using parameters provided by the NEISS database. Significance of trends was determined using adjusted Wald tests, for which P values less than .05 were considered significant. Results: The weighted estimate was 4,490 yearly cases from 2011 until 2017. Trend analysis did not show a significant change in the number of yearly cases during that time frame. Most injuries (62%) occurred around June 27 until July 11. Nearly 50% of those injured were aged 10 to 29 years and were male. Fireworks with low pyrotechnic content such as sparklers, snakes, and poppers resulted in 26% of injuries. Although 83% of patients were treated and released from the emergency department, other injuries were more severe, with a 4.5% rate of amputation, 7% rate of hospital admission, and 8% rate of transfer to another hospital. Conclusions: Fireworks injuries to the hand and upper extremity continue to represent a serious burden of disease to the United States population and the health care system. Increased awareness, legislation, and targeted public education about the dangers of fireworks should be considered ways to reduce the incidence of these injuries. Type of study/level of evidence: Prognostic III.

The Association Between Newly Accredited Orthopedic Residency Programs and Teaching Hospital Complication Rates in Lower Extremity Total Joint Arthroplasty.

OBJECTIVE: The influence of residency programs on teaching hospital outcomes in total joint arthroplasty (TJA) has recently been debated. This study investigates how complication and readmission rates for primary elective total hip (THA) and total knee arthroplasty (TKA) changed before and after new orthopedic surgery residency programs meeting ACGME accreditation requirements were introduced at hospitals. DESIGN: We conducted a retrospective cohort study using the CMS Hospital Compare database, which contains hospital-level data on risk-standardized complication and readmission rates (2013-2018) for primary elective THA and TKA in Medicare beneficiaries. Orthopedic surgery residency programs that were newly accredited during this time were identified using ACGME publicly available data. SETTING: Eight primary adult teaching hospitals with complication and readmission data in the CMS database available prior to the first full year its affiliated residency program was implemented, and with subsequent program data also available. PARTICIPANTS: Six ACGME accredited orthopedic surgery residency programs. RESULTS: Even after controlling for annual variation in surrounding hospital rates, the at-risk patient volume, and variation in starting rates for a given hospital in the first available year, multivariate linear regression demonstrated that complication rates for lower extremity TJA in Medicare beneficiaries decreased by 0.20 per year (R2 = 0.78, p = 0.005) after hospitals introduced new orthopedic surgery residency programs meeting ACGME accreditation requirements. There were no significant differences in readmission rates after the addition of newly accredited programs to these same hospitals (R2 = 0.51; p = 0.706). CONCLUSIONS: Starting an orthopedic surgery residency program meeting ACGME accreditation requirements was associated with significantly reduced complication rates for primary elective lower extremity TJA in Medicare beneficiaries at teaching hospitals where these programs began rotating residents. These findings raise awareness regarding the potential for residency programs to contribute to improved patient care outside of the operating room as well as through direct resident involvement in procedures.