Cervical misalignment in motorcyclists in relation to new helmet removal recommendations shown with augmented reality resources: A biomechanical analysis.

Objective: The aim of this study is to determine the best technique and position for helmet removal in injured motorcyclists by comparing cervical misalignment produced in the supine position and prone position. Method: Comparative cross-sectional clinical simulation study to quantify CM using biomechanical analysis with the use of inertial systems. The main variable was determined for the flexion-extension motion. The extraction was tested for both positions (prone position and supine position), which were repeated 3 times for each of the 30 volunteers included, and the movement from the initial neutral position was also determined, resulting in a total of 270 biomechanical studies. Results: A flexion was observed when moving the patient from the neutral position to the SP, due to the size of the helmet, of 1.29° ± 5.12°. Helmet removal in the supine position resulted in an average flexion-extension range of 17.51° ± 6.49°, while the same extraction in prone position recorded an average range of 10.82° ± 8.05°. For the main variable, statistically significant differences were found when comparing prone position and supine position (p = 0.0087). Conclusions: The main conclusion of the study is that the helmet removal should be done in the position in which we find the patient, whether in prone position or supine position. Additionally, the new technique described for the prone position causes less movement of the cervical spine than the usual supine position.

UCL Throwing Injuries in Nonprofessional Baseball Players: A 14-Year Retrospective Study.

BACKGROUND: This study evaluated treatment modality (surgical vs nonoperative) of medial ulnar collateral ligament (UCL) injuries in nonprofessional throwing baseball athletes by comparing type, severity, and location of UCL injury. HYPOTHESIS: Baseball players with closed medial epicondyle physes and concomitant throwing-related UCL injury will be more likely to undergo surgical intervention than players with open medial epicondyle physes. STUDY DESIGN: Retrospective. LEVEL OF EVIDENCE: Level 5. METHODS: A total of 119 baseball players with a mean age of 16.9 ± 2.5 years (range, 11-25 years) were included in the study. Datapoints included sex, age at time of injury, severity, and location of UCL injury, growth plate status, operative versus conservative management, and concomitant flexor forearm injury. RESULTS: A total of 75 players were treated conservatively; 43 underwent UCL reconstruction (UCL-R), and 1 had an unknown treatment outcome. No significant difference was found for age related to treatment type, UCL-R (17.2 ± 2.2) versus conservative treatment (16.8 ± 2.6). Athletes with closed medial epicondylar growth plates were more likely to undergo UCL-R than athletes with open medial epicondylar growth plates (P = 0.02). There were no significant differences between UCL injury location (42 distal, 37 proximal, 18 combined tear locations, 11 complete tears, and 11 intact UCLs with inflammation) by treatment type (P = 0.09). There was a significant difference for UCL severity (11 complete tears, 96 partial tears) by treatment type (P = 0.03). CONCLUSION: Nonprofessional athletes with closed medial epicondylar growth plates and throwing-related UCL injuries were more likely to be treated surgically. Baseball athletes with partial tears, if skeletally immature, require further long-term evaluation. CLINICAL RELEVANCE: Continued knowledge gains in this area of throwing medicine will further improve our treatment algorithms in nonprofessional baseball players.

Opioid Utilization After Primary Total Hip and Knee Arthroplasty Following Sequential Implementation of Statewide Legislation.

Background: Following total hip arthroplasty (THA) and total knee arthroplasty (TKA), increased opioid use is associated with poor clinical outcomes. This study investigates implications of Florida legislative mandates on prescribing practices and opioid utilization following primary THA and TKA. Methods: We retrospectively reviewed patients undergoing primary TKA or THA between January 1, 2018, to December 31, 2020 at our academic medical center. Three groups were identified: procedures performed prior to mandates, after seven-day prescription limit, and after mandated electronic prescribing. A multivariate analyses of variance evaluated length of stay, morphine milligram equivalents (MMEs), age, body mass index and number of prescription refills. Chi-square tests compared preoperative opioid use, readmissions, and discharge disposition. Results: There were 198 patients in group one, 238 patients in group two, and 215 patients in group three (N = 651). Prior to any mandates, patients were prescribed 822.3 + 626.7 MMEs. Following a seven-day prescription limit this decreased to 465.0 + 296.0 MMEs (P < .001), which further decreased after mandated electronic prescribing (228.0 + 284.4 MMEs [P < 0.001]). Patients undergoing THA were prescribed less MME than those undergoing TKA. There was a 2.6% 90-day readmission rate, with no pain-related readmissions. Conclusions: Florida legislative mandates for opioid prescription quantities and electronic prescribing have effectively reduced average MMEs prescribed following primary arthroplasty. Despite a shift towards ambulatory surgery, opioid utilization decreased without compromising patient outcomes. These findings underscore the significance of both legislative and surgical practices influencing opioid prescribing habits among orthopaedic surgeons.

A Physician-led Care Redesign Blunts Predictors of Length of Stay after Total Hip and Knee Arthroplasty.

We questioned to what extent traditional predictors of care team burden (via increased length of stay [LOS] after total joint arthroplasty [TJA]) were able to be mitigated through alteration of the care pathway. The impact on LOS of traditional patient risk factors, as well as encounter variables, were analyzed for a consecutive set of patients undergoing surgery before and after a physician-initiated arthroplasty care pathway redesign. We analyzed the impact of these variables on LOS, discharge disposition, and 90-day readmission; separate analyses were performed pre- and post-redesign for LOS. Several patient factors (Risk Assessment and Prediction Tool, body mass index, age, insurance type, smoking) predicted longer LOS in the pre-redesign cohort; post-redesign, only ambulation on the day of surgery and anticoagulation type were predictive. The redesign also lessened the aggregate impact of the patient-specific risk factors, resulting in reduced variation in LOS. Physician leadership of care pathways can reduce the impact of factors that have portended longer LOS, thereby reducing variability in LOS and costs for disparate patient populations while driving improvements in value-based care indices. (Journal of Surgical Orthopaedic Advances 32(2):097-101, 2023).

Radiographic parameters of pelvic and proximal femoral morphology do not predict outcomes for direct anterior total hip arthroplasty.

BACKGROUND: Radiographic predictors of outcomes associated with direct anterior approach (DAA) total hip arthroplasty (THA) are largely unknown. Anecdotally, some surgeons limit surgery to patients with low body mass index (BMI) or "favorable" bony morphology. Objective data on the impact of these factors is limited. We sought to determine radiographic and demographic predictors of outcomes after DAA arthroplasty. METHODS: A consecutive series of patients undergoing unilateral, elective DAA THA, who had linked pre- and post-operative patient reported outcome scores, from January 1, 2017 to March 30, 2019 were included. Radiographic measurements, including proxies for pelvic overhang, femoral canal access, acetabular morphologic changes, and markers of disease severity, were performed on calibrated radiographs. Intra-observer consistency was also evaluated. Outcome measures included disease specific and general health patient-reported outcomes scores, while surgical difficulty was approximated by estimated blood loss and surgical time. Multivariate analyses were performed to determine statistically significant correlations. RESULTS: 168 patients were included. Overall, patients experienced significant improvement in outcome scores (mean ∆ HOOS-JR 39.4, PROMIS-physical 12.3). There were two reoperations (1.2%), for recurrent dislocation. Female sex (p = 0.015) and increasing age (p == 0.019) were associated with shorter surgical times. No statistically significant correlations were found between the radiographic parameters and outcome measures. Intraclass correlation coefficients of the radiographic measurements were overall strong (0.73-1.0). CONCLUSION: We demonstrated consistent results in this series of patients despite variation in bony morphology. Our findings suggest that DAA THA can be safely performed on a broader patient population.

Open hand fractures: a prospective analysis of functional outcomes and risk factors for infection after initial management in the emergency department.

PURPOSE: Open hand fractures are common orthopaedic injuries, historically managed with early debridement in the operating room. Recent studies suggest immediate operative treatment may not be necessary but have been limited by poor follow-up and lack of functional outcomes. This study sought to prospectively evaluate these injuries treated initially in the emergency department (ED), without immediate operative intervention, to determine long-term infectious and functional outcomes using the Michigan Hand Outcomes Questionnaire (MHQ). METHODS: Adult patients with open hand fractures managed initially in the ED at a Level-I trauma center were considered for inclusion (2012-2016). Follow-up and MHQ administration occurred at 6 weeks, 12 weeks, 6 months, and 1 year. Logistic regression and Kruskal-Wallis testing were used for analysis. RESULTS: Eighty-one patients (110 fractures) were included. Most had Gustilo Type III injuries (65%). Injury mechanisms most commonly included saw/cut (40%) and crush (28%). Nearly half of all patients (46%) had additional injuries involving a nailbed or tendon. Fifteen percent of patients had surgery within 30 days. The average follow-up was 8.9 months, with 68% of patients completing at least 12 months. Eleven patients (14%) developed an infection, of which 4 (5%) required surgery. Subsequent surgery and laceration size were associated with increased odds of infection, and at one-year, functional outcomes were not significantly different regardless of fracture classification, injury mechanism, or surgery. CONCLUSIONS: Initial ED management of open hand fractures results in reasonable infection rates compared to similar literature and functional recovery demonstrated by MHQ score improvements over time.

Caregiver Awareness of Safe Pitching Recommendations in Youth Fastpitch Softball Pitchers.

Background: Although fastpitch softball participation continues to rise, there is a lack of established pitch count guidelines, potentially putting young female athletes at risk of overuse injuries. In addition to coaches, caregivers' ability to recognize and employ safe pitching guidelines plays an important role in athlete safety. Purpose/Hypothesis: The purpose of this study was to assess caregivers' knowledge of their child's pitching practices and their familiarity with softball pitching recommendations. We hypothesized that caregivers would be unaware of safe pitching recommendations in youth fastpitch softball. Study Design: Cross-sectional study. Methods: A 30-question survey was distributed to caregivers of youth fastpitch softball pitchers in age groups 10U (ie, ≤10 years), 12U, 14U, 16U, and 18U. The survey included questions on the demographic characteristics of caregivers and athletes, caregivers' knowledge of safe pitching recommendations, and athletes' pitching background and throwing habits. Comparisons of responses between the age groups were conducted using the chi-square test, Fisher exact test, or 1-way analysis of variance, as appropriate. Results: A total of 115 caregivers completed the survey. Of the respondents, 84% were between 31 and 50 years, and 81.7% had a degree beyond high school. Only 28.1% of caregivers reported participating in youth sports. When asked to estimate the number of pitches they considered a safe amount during a single outing, 28.7% of caregivers (n = 33) did not provide a limit, 4.3% (n = 5) stated no limit was needed, 32.2% (n = 37) suggested 25 to 80 pitches, 21.7% (n = 25) suggested 81 to 100 pitches, 12.2% (n = 14) suggested 100 to 150 pitches, and 0.9% (n = 1) suggested that >150 pitches were acceptable. These data emphasized that only 14.8% of the caregivers were aware of any pitching guidelines. However, 93% of caregivers acknowledged that they would adhere to recommendations if guidelines were made available. Conclusion: The study findings demonstrated that a majority of caregivers are unaware of current youth fastpitch softball pitching recommendations.

Evaluation of Sleep Quality and Its Relationship With Pain, Mood, and Physical Function After Orthopaedic Trauma Surgery: A Prospective Cohort Study.

INTRODUCTION: Sleep disturbances are associated with pain and mental health. We prospectively compared a cohort of patients with orthopaedic trauma with a control group to establish the prevalence and duration of sleep disturbance and associations between sleep disturbance and pain, mood scores, and functional outcome scores. METHODS: Subjects were patients with orthopaedic trauma undergoing in-patient surgical procedures and healthy control subjects from the community. Questionnaires completed by all subjects included the VAS numerical pain rating scale, the abbreviated profile of mood states, Patient-Reported Outcomes Measurement Information System Physical Function, and Patient-Reported Outcomes Measurement Information System Sleep Disturbance. Control subjects completed the surveys once, and subjects with trauma completed them at 2, 6, and 24 weeks postoperatively. RESULTS: Healthy control subjects (28.6 ± 13.2) were significantly younger than patients with trauma (41.8 ± 18.9) ( P < 0.001). Compared with control subjects, at 2-week follow-up visit, patients with trauma had worse sleep ( P < 0.001) and worse mood ( P = 0.006). Across the study period, patients with trauma showed improvements in physical function ( P < 0.001) and pain (at rest [ P = 0.02], during activity [ P = 0.02], and at night [ P = 0.002]). In patients with trauma, better sleep disturbance scores were associated with better mood and less pain for all pain metrics ( P < 0.001). DISCUSSION: Patients with orthopaedic trauma have worse sleep disturbance scores at 2 weeks postoperatively compared with normal control subjects; this difference attenuated at 6 weeks. Sleep disturbance was found to markedly correlate with pain and mood, with worse sleep quality associated with higher pain and worse mood. Improvement in sleep quality across 24 weeks postoperatively was associated with improvement in mood scores. CONCLUSION: Patients should be counseled about the likely development of sleep disturbance and the possible association with worse emotional/mental health with worse sleep. Physicians should consider incorporating a multidisciplinary approach to the management of these select patients.

Early reduction in postoperative pain is associated with improved long-term function after shoulder arthroplasty: a retrospective case series.

PURPOSE: Mixed modalities are frequently utilized in total shoulder arthroplasty (TSA) to control pain, improve patient satisfaction, reduce narcotics use and facilitate earlier discharge. We investigate the relationship between early postoperative pain control and long-term functional outcomes after shoulder arthroplasty. METHODS: A retrospective review identified 294 patients (314 shoulders) who underwent anatomic or reverse TSA and received a continuous cervical paravertebral nerve block perioperatively. Opioid and non-opioid analgesics were also available to the patients in an "as needed" capacity to augment perioperative pain control. In addition to demographic and surgical characteristics, the impact on functional outcomes of relative pain (i.e., a patient's subjective pain relative to the entire cohort), pain gradient (i.e., the slope of a patient's subjective pain), and opioid consumption during the first 24 h postoperatively were assessed. Shoulder function was assessed using validated outcome measures collected at 2 year follow-up. Outcomes were measured using American Shoulder and Elbow Surgeons questionnaire (ASES), Shoulder Pain and Disability Index (SPADI), SPADI-130, Raw and Normalized Constant Score, SST-12 and UCLA score. RESULTS: Patients younger than 65, females, reverse TSA, revisions, and preoperative opioid users had worse functional outcomes. On univariate analysis, increased pain perioperatively (> 50% percentile relative pain) was associated with decreased function at 2 years when analyzed with all seven outcome scores (P < .001 for all), reaching minimal clinically important difference (MCID) using the Constant Score. On multivariate analysis, increased pain in the first 24 h postoperatively (assessed on a continuous scale) was independently associated with worse ASES, SPADI, and SPADI-130 scores. Intraoperative ketamine administration and opioid consumption in the 24 h postoperative period did not influence long-term shoulder function. CONCLUSION: Patients reporting reduced pain after TSA demonstrated improved shoulder function with the Constant score at 2 years postoperatively in both univariate and multivariate analysis. Larger-scale investigation may be warranted to see if this is true for other functional outcome measures. LEVEL OF EVIDENCE: III, treatment study.

Mild Quadriceps and Hamstring Strength Deficits Do Not Persist After Sport-Related Concussion.

BACKGROUND: Risk for lower extremity musculoskeletal injury increases after sport-related concussion (SRC) and may result from unresolved motor control deficits. Muscle weakness is a deficit that could contribute to musculoskeletal injury risk. HYPOTHESIS: Athletes with SRC will demonstrate quadriceps and hamstring muscle weakness at the time of return to sport and 30 days later compared with controls. STUDY DESIGN: Prospective matched cohort. LEVEL OF EVIDENCE: Level 3. METHODS: A total of 31 athletes with SRC (CONCUSSION) were matched by sex, age, and activity level to controls (CONTROL). Testing was conducted at initial assessment and 30 days later; initial assessment in CONCUSSION occurred when cleared for return to play. Isokinetic testing assessed quadriceps and hamstring strength of the dominant and nondominant legs at 60 and 180 deg/s. Peak torque values were normalized to body mass (N-m/kg). Data were analyzed with repeated measures general linear models (group × time), and effect sizes were calculated. RESULTS: Analysis at 60 deg/s included 26 matched pairs (15 male per group) and at 180 deg/s included 30 matched pairs (17 males per group). Time from concussion to initial assessment was 21.3 (7.8) mean (standard deviation) days. No significant interactions or main effects were detected (P > 0.05). Across muscle groups, legs, and testing speeds, effect sizes at initial assessment were small (d = 0.117 to 0.353), equating to a strength deficit in CONCUSSION of 0.04 to 0.18 N-m/kg, and effect sizes were further reduced at 30-day follow-up (d = -0.191 to 0.252). CONCLUSION: In athletes with SRC, quadriceps and hamstring strength were decreased only minimally at return to play compared with controls and the difference lessened over 30 days. CLINICAL RELEVANCE: Strength deficits may not be a major contributor to increased lower extremity musculoskeletal injury risk after SRC. Strength training could be implemented before return to play after SRC to mitigate any strength deficits.

Biomechanical Analysis of Cervical Motion With a Pediatric Immobilization and Extrication Device.

OBJECTIVE: To determine the motions produced during pediatric extrication when using a system of motion estriction and extrication. METHODS: Simulation-based biomechanical analysis study conducted with inertial sensors to measure motion produced in the cervical spine of a pediatric simulator during extrication from a vehicle. RESULTS: The mean of the movements was 3.5° (SD ±1.35°). The mean time was 4 minutes 1 second (SD, ±45.09 seconds). The mean rotation toward the right was 3.34° (SD ±3.52°) and toward the left 2.62° (SD ±2.26°). The mean for lateralization was 6.24° (SD ±3.20°) toward the right and 2.50° (DE ±2.76°) toward the left. The mean for flexion was 2.36° (SD ±2.10°) and for extension 4.21° (SD ±2.15°). CONCLUSIONS: The device analyzed allows for the extrication of the pediatric patient with high levels of motion restriction of the spinal column with the Pediatric Immobilization and Extrication System.

Survival and NF1 Analysis in a Cohort of Orthopedics Patients with Malignant Peripheral Nerve Sheath Tumors.

Neurofibromatosis type 1 (NF1) is an autosomal dominant tumor syndrome in which benign plexiform neurofibromas are at risk of transforming into malignant peripheral nerve sheath tumors (MPNSTs), a very rare soft-tissue sarcoma. The prognosis of patients with MPNSTs is poor, with most studies reporting <50% survival at five years. However, studies evaluating MPNSTs are limited and report heterogeneous results. Because no MPNST-specific evidence-based treatment guideline exists, individual institutional experiences are very informative to the field. The main objective of this study was to investigate and report MPNST prognostic clinical and genetic biomarkers from our institution's Orthopedics service experience treating 20 cases from 1992 to 2017. Most patients were treated with resection and adjuvant radiation. Extended follow-up, averaging 11.4 years (ranging 1.1 to 25.1), revealed excellent five-year survival rates: 70% for overall and 60% for metastatic disease. An S100 B immunonegative tumor phenotype was associated with a significantly worse outcome than MPNSTs with positive S100 B stain. In addition, NF1 gene mutation analysis was performed on 27 families with NF1 in which at least one affected family member developed MPNSTs. Of the 27 NF1 germline mutations, five were large deletions spanning (or nearly spanning) the gene (18.5%), substantially more than such deletions in NF1 in general, consistent with increased risk of MPNSTs in such cases.

A Biomechanical Comparison Shows No Difference Between Two Knee Braces used for Medial Collateral Ligament Injuries.

PURPOSE: The purpose of this study was to assess the ability of 2 commonly used knee braces to control knee valgus motion and subsequent strain on the medial collateral ligament (MCL) in a laboratory-controlled environment. METHODS: Twenty healthy individuals (6 male, 14 female; mean age, 23 ± 3 years) with no history of knee injury or brace use performed a jump landing task while wearing either no brace or 1 of 2 braces: the Playmaker and Total Range of Motion . Three-dimensional joint kinematics and kinetics were measured in our biomechanics laboratory. RESULTS: Significantly less knee dynamic valgus angulation was noted when using either brace (-0.51° ± 3.9° and -1.3° ± 3.2°) compared no brace (4.8° ± 3.0°). Dynamic valgus angulation did not differ significantly between the 2 braces tested, which were both not statistically different from baseline alignment. There were significant differences seen in peak knee flexion angle between each brace (77.9° ± 8.8°and 83.1° ± 8.4°), as well as between both braces and no brace (90.6° ± 11.1°). There was no significant difference in knee frontal plane moment or peak vertical ground reaction force loading among all 3 testing conditions. CONCLUSIONS: Compared to no brace, both braces allowed significantly less dynamic valgus angulation of the knee under physiological vertical loads but were not significantly different from one another. CLINICAL RELEVANCE: Knee braces are commonly used to protect the MCL when placed under physiological loads. It is important to know which braces effectively reduce valgus stress to provide the best outcomes.

Youth Baseball Caregiver Understanding of Safe Pitching Guidelines and Player Injury.

BACKGROUND: As more athletes participate in youth baseball, there has been an associated increase in upper extremity injuries. Knowledge of baseball injury prevention guidelines continues to be developed and defined as throwing-related injuries rise. The purpose of this study was to evaluate how knowledgeable youth baseball caregivers were about safe pitching guidelines and secondarily determine pitching practices which may be associated with increased risk of player injury. METHODS: A twenty-two question survey comprised of demographic data, knowledge of overhead throwing guidelines, pitching history, presence of risk factors associated with overhead throwing and pitching habits was distributed to the caregivers of youth baseball pitchers in North Central Florida. RESULTS: Eighty-three percent (81/98) of those polled were unaware of the existence of safe pitching guidelines, regardless of the pitcher's playing experience (p > 0.05). Those who pitched more than six months out of the year were significantly more prone to experience throwing arm pain after a performance (p < 0.05). Fifty-two percent (51/98) of the caregivers recalled their child having throwing arm pain as a direct result of pitching, with twenty-six percent (25/98) of pitchers having to miss either a game or a pitching appearance. Twenty-seven percent (26/98) of all players went on to seek medical evaluation for arm discomfort due to pitching. Pitchers 13 years of age and older were more likely to throw curveballs and miss games because of throwing arm pain (p < 0.05). CONCLUSION: Despite implementation and accessibility of safe pitching guidelines, a large portion of those surveyed were unaware or noncompliant with these established recommendations. Given the results of this study, further measures need to be taken to improve caregivers' understanding of current guidelines to help increase compliance and protect youth pitchers. LEVEL OF EVIDENCE: Cross-sectional survey study, 3b.