Overhead athletes have comparable intraoperative injury patterns and clinical outcomes to non-overhead athletes following surgical stabilization for first-time anterior shoulder instability at average 6-year follow-up

BACKGROUND AND HYPOTHESIS

Anterior shoulder instability is a common problem affecting young, athletic populations that results in potential career-altering functional limitations. However, little is known regarding the differences in clinical outcomes after operative management of overhead vs. non-overhead athletes presenting with first-time anterior shoulder instability. We hypothesized that overhead athletes would have milder clinical presentations, similar surgical characteristics, and diminished postoperative outcomes when compared with non-overhead athletes after surgical stabilization following first-time anterior shoulder instability episodes.

METHODS

Patients with first-time anterior shoulder instability events (subluxations and dislocations) undergoing operative management between 2013 and 2020 were included. The exclusion criteria included multiple dislocations and multidirectional shoulder instability. Baseline demographic characteristics, imaging data, examination findings, and intraoperative findings were retrospectively collected. Patients were contacted to collect postoperative patient-reported outcomes including American Shoulder and Elbow Surgeons score, Western Ontario Shoulder Instability Index score, Brophy activity index score, and Subjective Shoulder Value, in addition to return-to-work and -sport, recurrent dislocation, and revision rates.

RESULTS

A total of 256 patients met the inclusion criteria, of whom 178 (70%) were non-overhead athletes. The mean age of the entire population was 23.1 years. There was no significant difference in concomitant shoulder pathology, preoperative range of motion, or preoperative strength between cohorts. A greater proportion of overhead athletes presented with instability events not requiring manual reduction (defined as subluxations; 64.1% vs. 50.6%; P < .001) and underwent arthroscopic surgery (97% vs. 76%, P < .001) compared with non-overhead athletes. A smaller proportion of overhead athletes underwent open soft-tissue stabilization compared with non-overhead athletes (1% vs. 19%, P < .001). Outcome data were available for 60 patients with an average follow-up period of 6.7 years. No significant differences were found between groups with respect to recurrent postoperative instability event rate (13.0% for overhead athletes vs. 16.8% for non-overhead athletes), revision rate (13.0% for overhead athletes vs. 11.1% for non-overhead athletes), American Shoulder and Elbow Surgeons score, Western Ontario Shoulder Instability Index score, Brophy score, Subjective Shoulder Value, or rates of return to work or sport.

CONCLUSION

Overhead athletes who underwent surgery after an initial instability event were more likely to present with subluxations compared with non-overhead athletes. With limited follow-up subject to biases, this study found no differences in recurrence or revision rates, postoperative patient-reported outcomes, or return-to-work or -sport rates between overhead and non-overhead athletes undergoing shoulder stabilization surgery following first-time instability events. Although larger prospective studies are necessary to draw firmer conclusions, the findings of this study suggest that overhead athletes can be considered in the same treatment pathway for first-time dislocation as non-overhead athletes.

Patient Characteristics Associated with Hospital Admission or Antiarrhythmic Medication Changes After Emergency Department Evaluation of Supraventricular Tachycardia

BACKGROUND

Supraventricular tachycardia (SVT) is a relatively frequent diagnosis in the pediatric emergency department (ED). However, there are no consensus guidelines for ED disposition, and there are limited data on ED outcomes. Better understanding of those who are admitted or have antiarrhythmic medication changes may avoid potentially unnecessary transfers or admissions. Our objective was to identify patient factors associated with discharge from the emergency department without medication initiation or modification after management of SVT in the pediatric ED.

DESIGN/METHODS

A retrospective review of children aged 0-18 years seen in the emergency department for SVT was conducted using electronic medical record data over a ten-year period at a single academic tertiary children's hospital. Patients with congenital cardiac disease or prior cardiac surgeries were excluded. Multivariable logistic regression analysis was used to determine association between patient factors of interest and the primary outcome of admission and secondary outcome of change to antiarrhythmic medications.

RESULTS

We analyzed 197 patients encounters. The mean age was 7 years. Of these 104 (52.8%) were admitted to the hospital or discharged with antiarrhythmic medication changes. This primary outcome was associated with younger age (aOR 0.77, 95% CI 0.67-0.86), history of pre-excitation (aOR 5.82, 95% CI 2.01-18.8), intercurrent illness (aOR 3.75, 95% CI 1.27-12.1), number of adenosine doses prior to arrival (aOR 5.45, 95% CI 1.55-22.3), and in-person cardiology consultation (aOR 6.42, 95% CI 2.43-19.4).

CONCLUSIONS

Nearly half of children treated in a pediatric ED for SVT are discharged without changes in medications. We identified patient factors associated with hospital admission or antiarrhythmic medication changes. These factors represent high value care and can be assessed when considering transfer from a referring facility. Risk stratification using these patient characteristics may reduce potentially avoidable transfers and admissions.

Open Ischiofemoral Impingement Decompression

Ischiofemoral impingement is a relatively rare cause of posterior hip pain associated with narrowing of the space between the lateral aspect of the ischium and the lesser trochanter. Symptoms typically consist of lower buttock, groin, and/or medial thigh pain, which is commonly exacerbated by adduction, extension, and external rotation of the hip. This condition can be treated nonoperatively in many circumstances; however, recalcitrant cases may require surgical intervention. Whereas described operative treatment options for this pathology range from endoscopic to open procedures, this Technical Note describes a safe and reliable technique for open ischiofemoral decompression with sciatic nerve neurolysis through a posterior approach for treatment of ischiofemoral impingement refractory to conservative treatment.

Thread Delamination in 4.5 mm AO Cannulated Screws: A Small Case Series in the Pediatric Trauma Population

BACKGROUND

Thread delamination associated with cannulated screws have been reported but likely represent an under-recognized complication in the orthopaedic literature. The purpose of this study is to report the occurrence of repeated hardware failures through thread delamination in the setting of a commonly used orthopaedic cannulated screw implant in a small cohort involving pediatric fracture care at a single academic level I trauma center.

METHODS

Between August 2015 and December 2020, 9 cases of hardware failure associated with 4.5 mm arbeitsgemeinschaft für osteosynthesefragen cannulated stainless-steel screws were identified within a pediatric orthopaedic division at a single academic level I trauma center. Three cases were excluded, and 6 cases of thread delamination were retrospectively reviewed.

RESULTS

Six cases of thread delamination comprised a cohort of patients with a mean age of 13.7 years (range: 12 to 15 y). All cases involved 4.5 mm arbeitsgemeinschaft für osteosynthesefragen cannulated screws, including 5 partially threaded and 1 fully threaded screw. Five cases involved open reduction and internal fixation of incarcerated medial humeral epicondylar fragments and the other case was an open reduction and internal fixation of a displaced medial malleolar fracture. Five of these occurred within a recent 18-month period of time. There were 4 cases of partial, distal thread delamination, 1 case of partial proximal thread delamination and another case of complete thread delamination which had unwound into the tibiotalar joint and required an anterior ankle arthrotomy to retrieve the thread. None of the 5 patients in this series who currently harbor a retained thread have experienced symptoms because of this issue.

CONCLUSIONS

Thread delamination associated with cannulated screw implantation likely represents an under-reported phenomenon in orthopaedic surgery. In cases where retained, delaminated threads exist, these do not appear to cause short-term concern.

LEVEL OF EVIDENCE

Level IV-case series.

Continuous-Loop Tape Technique Has Greater Stiffness and Less Elongation Compared With Tied-Suture Fixation of Full-Thickness All-Soft Tissue Quadriceps Tendon Autografts

Background

Many graft fixation techniques are utilized for full-thickness soft tissue quadriceps tendon autografts during anterior cruciate ligament reconstruction (ACLR).

Purpose

To determine the tensile properties of all-soft tissue quadriceps tendon graft fixation using a tied-suture versus continuous-loop tape technique. It was hypothesized that the continuous-loop tape technique would have less cyclic elongation and greater ultimate load to failure and stiffness compared with a commonly used tied-suture technique.

Study Design

Controlled laboratory study.

Methods

Sixteen fresh-frozen human knee specimens were used to harvest a full-thickness all-soft tissue quadriceps tendon graft; half were secured using a Krackow suture technique with 2 braided sutures, and half were secured using a continuous-loop tape suspensory fixation button with a rip-stop stitch. Cyclic and permanent elongation, toe- and linear-region stiffness, and ultimate load were determined. Statistical analysis was performed at P <.05.

Results

The tied-suture fixation group demonstrated significantly higher permanent elongation (11.7 ± 3.6 vs 4.2 ± 1.0 mm, P < .001) and cyclic elongation (5.9 ± 1.3 vs 2.0 ± 0.4 mm, P < .001) compared with the continuous-loop tape fixation group. There was a significantly higher linear-region stiffness with continuous-loop tape fixation compared with tied-suture fixation (98.8 ± 12.7 vs 85.5 ± 7.5 N/mm, P = .022). No significant difference in ultimate load between groups (517.1 ± 149.2 vs 465.6 ± 64.6 N) was found. The mode of failure was tendon pull-through for the continuous-loop tape group and suture breakage in the tied-suture group (P < .001).

Conclusion

Continuous-loop tape fixation is superior to tied-suture fixation in regard to elongation and stiffness for all-soft tissue quadriceps tendon grafts, but there was no significant difference in ultimate load.

Clinical Relevance

Continuous-loop tape fixation of all-soft tissue quadriceps tendon grafts for ACLR is a valid technique with superior tensile properties.

Conflict of interest disclosure in orthopaedic and general surgical trauma literature

SIGNIFICANCE

Financial relationships between industry and physicians are a key aspect for the advancement of surgical practice and training, but these relationships also result in a conflict of interest with respect to research. Financial payments to physicians are public within the United States in the Open Payments Database, but the rate of accurate financial disclosure of payments has not previously been studied in trauma surgery publications.

OBJECTIVE

To determine the rate of accurate financial disclosure in major surgical trauma journals compared with the Open Payments Database.

MATERIALS AND METHODS

The names of all authors publishing in The Journal of Orthopaedic Trauma, Injury, and The Journal of Trauma and Acute Care Surgery between 2015 and 2018 were obtained from MEDLINE. Non-physicians, physicians outside of the United States, physicians without payments in the Open Payments Database, and physicians with payments types of only "Food and Drink" were excluded. Financial disclosure statements were obtained from the journal websites and manually compared against Open Payments Database entries the year prior to submission and during the year of submission up until 3 months prior to publication for each individual physician. Main outcomes were accuracy of disclosure published with each article, total amount of payments received (disclosure or undisclosed), surgical subspecialty of the reporting physician. Statistical comparisons were made using Chi-square testing with significance defined as p<0.05.

RESULTS

Between 2015 and 2018, 5070 articles were published involving 28,948 authors. 2945 authors met inclusion criteria. 490 authors accurately disclosed their financial relationships with industry (16.6%). The median value of undisclosed payments was $22,140 [IQR $6465, $77,221] which was significantly less than the medial value of disclosed payment of $66,433 [IQR $24,624, $161,886], p<0.001 Orthopaedic surgeons disclosed at a higher rate (26.3%, 479/1818) than general surgeons (4.8%, 47/971), p<0.001.

CONCLUSIONS

Physician-industry relationships are key for advancing surgical practice and providing training to physicians. These relationships are not inherently unethical, but there is consistently high inaccuracy of financial disclosure across multiple trauma surgery journals which may indicate the need for further education on financial disclosures during surgical training or active obtainment of publicly available financial disclosures by journals.

Association of Bacteremia with Vaccination Status in Children Aged 2 to 36 Months

OBJECTIVE

To determine the association between bacteremia and vaccination status in children aged 2-36 months presenting to a pediatric emergency department.

STUDY DESIGN

Retrospective cohort study of children aged 2-36 months with blood cultures obtained in the pediatric emergency department between January 2013 and December 2017. The exposure of interest was immunization status, defined as number of Haemophilus influenzae type B (Hib) and Streptococcus pneumoniae vaccinations, and the main outcome positive blood culture. Subjects with high-risk medical conditions were excluded.

RESULTS

Of 5534 encounters, 4742 met inclusion criteria. The incidence of bacteremia was 1.5%. The incidence of contaminated blood culture was 5.0%. The relative risk of bacteremia was 0.79 (95% CI 0.39-1.59) for unvaccinated and 1.20 (95% CI 0.52-2.75) for undervaccinated children relative to those who had received age-appropriate vaccines. Five children were found to have S pneumoniae bacteremia and 1 child had Hib bacteremia; all of these subjects had at least 3 sets of vaccinations. No vaccine preventable pathogens were isolated from blood cultures of unvaccinated children. We found no S pneumoniae or Hib in children 2-6 months of age who were not fully vaccinated due to age (95% CI 0-0.13%) and the contamination rate in this group was high compared with children 7-36 months (6.6% vs 3.7%).

CONCLUSIONS

Bacteremia in young children is an uncommon event. Contaminated blood cultures were more common than pathogens. Bacteremia from S pneumoniae or Hib is uncommon and, in this cohort, was independent of vaccine status.

Distal locking of short cephalomedullary nails decreases varus collapse in unstable intertrochanteric fractures - a biomechanical analysis

INTRODUCTION

Peritrochanteric fractures are a growing problem and complications relating to operative fixation of these fracture, including varus collapse and screw cutout, are common in elderly osteoporotic patients. We hypothesize that unlocked nails will demonstrate increased varus collapse and inferior construct stiffness in specimens with increased diaphyseal medullary diameter.

MATERIALS AND METHODS

Sixteen non-cadaveric osteoporotic biomechanical femur specimens were utilized in this study, with eight specimens having an artificially large femoral canal to represent Dorr C femurs. All femurs were instrumented with a short cephalomedullary nail with and without distal cross-lock screw fixation and had an unstable intertrochanteric fracture created in a repeatable pattern. Specimens underwent cyclic compression to a maximal load of 1000N with segmental motion quantified through the use of visual tracking markers. Statistical comparisons were performed using one-way ANOVA with Tukey post-hoc analysis to determine differences between specific groups. Significance was defined as p<0.05.

RESULTS

Unlocked short cephalomedullary nails showed increased varus collapse due to motion of the nail within the femoral canal in capacious femoral canals compared with narrow femoral canals and distally cross-locked nails. The coronal deformation of the wide canal unlocked group (17.9 ^o±2.6^o) was significantly greater in the varus direction than any other fixation under compressive load of 1000N. There was no significant difference in varus angulation between the wide canal or narrow canal locked groups (11.1^o±8.7^o vs. 8.2^o±1.7^o respectively, p=0.267). The narrow canal unlocked group (13.7^o±2.4^o) showed significantly greater varus angulation than the narrow canal locked (p=0.015). The wide canal unlocked group showed significantly greater varus angulation than the wide canal locked group (p=0.003). Motion between the femoral shaft and the cephalomedullary nail (toggling of the nail within the shaft) was significantly greater in narrow or wide canal unlocked specimens, 7.94^o±2.13^o and 10.2^o±1.7^o respectively, than in the narrow or wide canal locked specimens, 2.4^o±0.2^o and 4.2^o±0.5^o respectively (p<0.05) CONCLUSION: Unlocked short intramedullary fixation for unstable peritrochanteric fractures results in increased varus collapse under axial compression. This study supports the use of distal cross-locking of short intramedullary fixation for unstable peritrochanteric fractures in patients with capacious femoral canals secondary to osteoporosis who might otherwise be as risk for varus collapse, device failure, and malunion.

Anterior Cruciate Ligament Reconstruction With a Partial-Thickness Quadriceps Tendon Graft Secured With a Continuous-Loop Fixation Device

Anterior cruciate ligament reconstruction using quadriceps tendon (QT) autograft has recently gained popularity because newer techniques allow harvest of a robust graft with little soft-tissue dissection or donor-site morbidity. The QT graft can provide a safe, reproducible, and versatile option for primary and revision anterior cruciate ligament reconstruction with equivalent outcomes and failure rates to those of bone-patellar tendon-bone and hamstring tendon grafts. Therefore, continued improvement in surgical technique may help to further improve patient outcomes. This study introduces a modification of current QT techniques using a partial-thickness graft with continuous-loop EndoButton fixation (Smith & Nephew, Andover, MA).