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Objective Several clinical practice guidelines have been produced and disseminated for the evaluation of a neck mass. However, to date, the quality and methodologic rigor of these clinical practice guidelines have not been appraised. Therefore, this study set out to identify and assess the methodologic quality of national and international guidelines for the evaluation and management of neck masses in adults. Methods We conducted a comprehensive search of EMBASE, MEDLINE/PubMed, SCOPUS and grey literature sources until September 2020. The quality of these guidelines was assessed by four reviewers using the Appraisal of Guidelines for Research and Evaluation, 2nd edition (AGREE II). Domain scores were considered acceptable quality if they scored >60%, and Intraclass Correlation Coefficients (ICC) were calculated to assess agreement among the appraisers. Results Seven guidelines were assessed for evaluation. Among these, only the American Academy of Otolaryngology (AAO), Cancer Care Manitoba (CCMB), and the American Society of Clinical Oncology (ASCO) achieved an overall rating of “high”. The remaining four guidelines achieved ratings of either “average” or “low”. The “Scope and Purpose” domain achieved the highest mean score (94.4% ± 5.0%), and lowest was “Applicability” (51.5% ± 29.2%). ICC analysis showed substantial to very good agreement across all domains (0.75–0.98). Conclusion These findings highlight the variability in methodologic quality of guidelines for the evaluation and management of adult neck mass. The results from this analysis highlight the need to improve guidelines development process for this topic and may guide the selection and use of these guidelines in clinical practice.

Introduction: Although advances in surgical technique and medical management have drastically improved outcomes of free flap reconstructive surgery in head and neck patients, there is no clear cons...

Postoperative pain after head and neck cancer surgery is commonly treated with opioids, which are associated with considerable side effects. The objective of this study is to analyze the safety and efficacy of using multimodal analgesia (MMA) for patients undergoing head and neck cancer surgery with free flap reconstruction.A systematic search was conducted in PubMed, Cochrane, Embase, Scopus, and clinicaltrials.gov.All studies comparing patients receiving MMA (gabapentin, corticosteroids, local anesthetic, acetaminophen, nonsteroidal anti-inflammatory drugs [NSAIDs]) vs patients receiving opioids for head and neck cancer surgery with free flap reconstruction were screened. The primary outcome was postoperative opioid usage. Secondary outcomes included length of stay, subjective pain scores, surgical/medical complications, adverse effects, and 30-day outcomes.A total of 10 studies representing 1253 patients (MMA, n = 594; non-MMA, n = 659) met inclusion criteria. Gabapentinoids were the most commonly used intervention (72.9%) followed by NSAIDs (44.6%), acetaminophen (44.3%), corticosteroids (25.1%), ketamine (7.2%), and nerve block (3.4%). Eight studies reported a significant decrease in postoperative opioid usage in the MMA groups. Subjective pain had wider variation, with most studies citing significant pain improvement. There were no differences in surgical outcomes, medical complications, adverse effects, or 30-day mortality and readmission rates.With the rise of the opioid epidemic, MMA may play an important role in the treatment of postoperative pain after head and neck cancer surgery. A growing body of literature demonstrates a variety of effective perioperative regimens.

Orbital hypertelorism (OHT) represents a congenital condition defined by lateralization of the bony orbit, unlike soft tissue telecanthus in which there is an increase in intercanthal distance without true bony lateralization. Existing literature remains very limited in its postoperative assessment of bony versus soft tissue relapse, which may both clinically present as telecanthus. We performed a critical appraisal of the literature to determine the postoperative incidence of bony versus soft tissue relapse following OHT repair. The PubMed, MEDLINE, EMBASE, Scopus, Cochrane Central Register of Controlled Trials, and clinicaltrials.org were searched systematically for all English studies published in any time frame reporting relapse rates following primary OHT repair. The primary outcome was incidence of bony and soft tissue relapse defined as orbital lateralization and medial canthal drift, respectively. The secondary outcome measures include postoperative complications, predictors of postoperative complications, timing and type of surgery, and revision rates. Eleven articles were included. A total of 84 (35.3%) patients experienced bony relapse while 43 (27.2%) patients experienced soft tissue relapse. Age at time of intervention (p < 0.92), severity at presentation (p < 0.90), and surgical technique (p < 0.09) were not found be significantly associated with relapse rate. Methods for long-term follow-up were not standardized, and there was no consistent measure to objectively assess telecanthus. There is no general consensus on predictive factors of long-term relapse following OHT repair in the form of box osteotomy or facial bipartition. These findings call for cross-sectional outcome standardization to better understand long-term outcomes across institutional, provider, and patient differences.

The emergence of SARS-CoV-2/2019 novel coronavirus (COVID-19) has created a global pandemic with no approved treatments or vaccines. Many treatments have already been administered to COVID-19 patients but have not been systematically evaluated. We performed a systematic literature review to identify all treatments reported to be administered to COVID-19 patients and to assess time to clinically meaningful response for treatments with sufficient data. We searched PubMed, BioRxiv, MedRxiv, and ChinaXiv for articles reporting treatments for COVID-19 patients published between 1 December 2019 and 27 March 2020. Data were analyzed descriptively. Of the 2706 articles identified, 155 studies met the inclusion criteria, comprising 9152 patients. The cohort was 45.4% female and 98.3% hospitalized, and mean (SD) age was 44.4 years (SD 21.0). The most frequently administered drug classes were antivirals, antibiotics, and corticosteroids, and of the 115 reported drugs, the most frequently administered was combination lopinavir/ritonavir, which was associated with a time to clinically meaningful response (complete symptom resolution or hospital discharge) of 11.7 (1.09) days. There were insufficient data to compare across treatments. Many treatments have been administered to the first 9152 reported cases of COVID-19. These data serve as the basis for an open-source registry of all reported treatments given to COVID-19 patients at www.CDCN.org/CORONA. Further work is needed to prioritize drugs for investigation in well-controlled clinical trials and treatment protocols. Electronic supplementary material The online version of this article (10.1007/s40121-020-00303-8) contains supplementary material, which is available to authorized users.

BACKGROUND Fusion of cranial-base sutures/synchondroses presents a clinical conundrum, given their often unclear "normal" timing of closure. This study investigates the physiologic fusion timelines of cranial-base sutures/synchondroses. METHODS Twenty-three age intervals were analyzed in subjects aged 0 to 18 years. For each age interval, 10 head computed tomographic scans of healthy subjects were assessed. Thirteen cranial-base sutures/synchondroses were evaluated for patency. Partial closure in greater than or equal to 50 percent of subjects and complete bilateral closure in less than 50 percent of subjects defined the fusion "midpoint." Factor analysis identified clusters of related fusion patterns. RESULTS Two hundred thirty scans met inclusion criteria. The sutures' fusion midpoints and completion ages, respectively, were as follows: frontoethmoidal, 0 to 2 months and 4 years; frontosphenoidal, 6 to 8 months and 12 years; and sphenoparietal, 6 to 8 months and 4 years. Sphenosquamosal, sphenopetrosal, parietosquamosal, and parietomastoid sutures reached the midpoint at 6 to 8 months, 8 years, 9 to 11 months, and 12 years, respectively, but rarely completed fusion. The occipitomastoid suture partially closed in less than or equal to 30 percent of subjects. The synchondroses' fusion midpoints and completion ages, respectively, were as follows: sphenoethmoidal, 3 to 5 months and 5 years; spheno-occipital, 9 years and 17 years; anterior intraoccipital, 4 years and 10 years; and posterior intraoccipital, 18 to 23 months and 4 years. The petro-occipital synchondrosis reached the midpoint at 11 years and completely fused in less than 50 percent of subjects. Order of fusion of the sutures, but not the synchondroses, followed the anterior-to-posterior direction. Factor analysis suggested three separate fusion patterns. CONCLUSIONS The fusion timelines of cranial-base sutures/synchondroses may help providers interpret computed tomographic data of patients with head-shape abnormalities. Future work should elucidate the mechanisms and sequelae of cranial-base suture fusion that deviates from normal timelines.

Objective The aim of this study is to identify and analyze the gender breakdown of first authorship contributing to the most cited papers in the field of otolaryngology, with a goal towards identifying trends in gender representation in publishing. Methods The top fifty most-cited papers were identified using Science Citation Index of the Institute for Scientific Information. Institution, journal, date of publication, research nature, and subspecialty were extracted for each article. Among the first authors, gender, h-index, percentage of first, last, and corresponding authorship positions, total publications, and citations were analyzed. Results The majority of papers were in the English language, from the United States, of clinical nature, and on otologic topics. Eighty-four percent of papers had men who were first authors although there was no difference in h-index score, authorship position, and number of publications between men and women first authors. Women first authors had significantly more citations (p = 0.02) and average citations/year (p= 0.04) compared to their colleagues. There was no difference in the number of articles with women first authors (p = 0.17) or the total percentage of women authors (p = 0.44) in papers published earlier compared to those published later. Conclusion While a promising number of women otolaryngologists are publishing high-powered articles, future initiatives to promote academic productivity and inclusivity should be considered.

Background We tracked endocrine surgery patients with treatment delays due to COVID-19 to investigate the relationship between physician assigned priority scoring (PAPS), the Medically Necessary, Time Sensitive (MeNTS) scoring system and delay to surgery. Material & Methods Patients scheduled for endocrine surgery or clinically evaluated during COVID-19-related elective surgery hold at our institution (2/26/20–5/1/20) were prospectively enrolled. PAPS was assigned based on categories of high, moderate, or low risk, consistent with the American College of Surgeons’ priority system. MeNTS scores were calculated. The primary outcome was delay to surgery. Descriptive statistics were performed, and receiver operator characteristic (ROC) curves and area under the curve (AUC) values were calculated for PAPS and MeNTS. Results Of 146 patients included, 68% (n=100) were female; the median age was 60 years (IQR:43,67). Mean delay to surgery was significantly shorter (p=0.01) in patients with high PAPS (35 days), compared with moderate (61 days) and low (79 days) PAPS groups. MeNTS scores were provided for 105 patients and were analyzed by diagnosis. Patients with benign thyroid disease (n=17) had a significantly higher MeNTS score than patients with thyroid disease which was malignant/suspicious for malignancy (n=44) patients (51.5 vs. 47.6, p=0.034). Higher PAPS correlated well with a delay to surgery of

Enhanced recovery after surgery (ERAS) protocols are evidenced-based multidisciplinary programs implemented in the perioperative setting to improve postoperative recovery and attenuate the surgical stress response. However, evidence on their effectiveness in thyroid and parathyroid surgery remains sparse. Therefore, our goal was to investigate the clinical benefits and cost-effectiveness of ERAS protocols for the perioperative management of thyroidectomy and parathyroidectomy.A systematic review of Medline, Scopus, Embase, and gray literature was performed to identify studies of ERAS or clinical care protocols for thyroidectomy and parathyroidectomy.Two reviewers screened studies using predetermined inclusion criteria. Our primary outcomes included hospital length of stay and hospital costs. Readmission and postoperative complication rates composed our secondary outcomes. Meta-analysis was performed to compare outcomes for patients enrolled in the ERAS protocol versus standard of care.A total of 450 articles were identified; 7 (1.6%) met inclusion criteria with a total of 3082 patients. Perioperative components in ERAS protocols varied across the studies. Nevertheless, patients enrolled in ERAS protocols had reduced hospital length of stay (mean difference, -0.64 days [95% CI, -0.92 to -0.37]) and hospital costs (in US dollars; mean difference, -307.70 [95% CI, -346.49 to -268.90]), without an increase in readmission (odds ratio, 0.75 [95% CI, 0.29-1.94]) or complication rates (odds ratio, 1.14 [95% CI, 0.82-1.57]).There is growing literature supporting the role of ERAS protocols for the perioperative management of thyroidectomy and parathyroidectomy. These protocols significantly reduce hospital length of stay and costs without increasing complications or readmission rates.

Enhanced recovery after surgery (ERAS) protocols have been developed in numerous surgical specialties as a means of systematically improving patient recovery, functional outcomes, cost savings, and resource utilization. Such multidisciplinary initiatives seek to minimize variability in several aspects of perioperative patient care, helping to reduce inpatient length of hospital stay, complications, and the overall resource and financial burden of surgical care. Head and neck oncology patients stand to benefit from the implementation of comprehensive ERAS protocols, as these patients have complex medical needs that may dramatically impact multiple aspects of their recovery, including breathing, eating, nutrition, pain, speech, swallowing, and communication. Implementing ERAS protocols for head and neck cancer patients may present unique challenges, and require significant interdisciplinary coordination and collaboration. We therefore sought to provide a comprehensive guide to the planning and institution of such ERAS systems at institutions undertaking care of head and neck cancer patients. Key elements to consider in the implementation of successful ERAS protocols for this population include organizing a team consisting of frontline leaders such as nursing staff, medical specialists, and associated health professionals; designing interventions based on systematically evaluated, high-quality literature; and instituting a clear methodology for regularly updating protocols and auditing the success or potential limitations of a given intervention. Potential obstacles to the success of ERAS interventions for head and neck cancer patients include challenges in systematically tracking progress of the protocol, as well as resource limitations in a given health system.

OBJECTIVE Nimodipine has emerged as a promising strategy for protection of cranial nerves following vestibular schwannoma (VS) resections. Our goal was to conduct a comprehensive analysis of clinical studies to determine the therapeutic efficacy of nimodipine in improving facial nerve and cochlear nerve function. DATABASE REVIEWED We searched PubMed, Scopus, Cochrane Clinical Trial Registry, Clinicaltrials.gov, World Health Organization's International Clinical Trials Registry Platform, and EU Clinical Trials Registry to identify clinical studies up to May 11, 2020. METHODS We included studies evaluating perioperative administration of nimodipine as a strategy to prevent or treat facial nerve or cochlear nerve dysfunction following VS resections. Primary outcomes included preservation or recovery of House-Brackman scale for facial nerve function and Hearing and Equilibrium Guidelines for cochlear nerve function at the latest follow-up visit. Secondary outcomes included adverse events and administration strategies of nimodipine. RESULTS Nine studies (603 patients) met inclusion, of which seven studies (559 patients) were included in the quantitative analysis. Overall, nimodipine significantly increased the odds of cranial nerve recovery compared with controls (odds ratio [OR] 2.87, 95% confidence intervals [CI] [2.08, 3.95]; I2 = 0%). Subgroup analysis demonstrated that nimodipine was only effective for cochlear nerve preservation (OR 2.78, 95% CI [1.74, 4.45]; I2 = 0%), but not for facial nerve function (OR 4.54, 95% CI [0.25, 82.42]; I2 = 33%). CONCLUSION Although there is evidence supporting the perioperative role of nimodipine for VS resections, more studies are warranted to help clarify the effects of nimodipine therapy on cranial nerve preservation.

To examine prognostic factors for survival in patients with melanoma of the eyelid.Retrospective cohort study.This population-based study reviewed patients with primary melanoma of the eyelid diagnosed in the Surveillance, Epidemiology and End Results database between 1975 and 2016. The primary outcomes included survival rates estimated by Kaplan-Meier analysis and mortality hazard ratios (HRs) for overall survival and disease-specific survival (DSS).The cohort consisted of 2257 patients with cutaneous melanoma of the eyelid, representing 1380 cases of melanoma in situ and 877 cases of invasive melanoma. For melanoma in situ and invasive melanoma respectively, at 5 years, the overall survival rates were 88.6% and 77.1%, while DSS rates were 99.4% and 91.0%. Cox regression analysis for eyelid melanoma indicated that for invasive melanoma, age at diagnosis ≥75 years (HR 2.17 [95% confidence interval {CI} 1.02-4.60]; P = .04), T4 staging (HR 8.45 [95% CI 2.96-25.31]; P.001), lymph node involvement (HR 3.61 [95% CI 1.12-11.60]; P = .03), and nodular melanoma (HR 3.31 [95% CI 1.50-7.32]; P = .003) histologic subtype were associated with decreased rates of survival. Sex and tumor ulceration did not impact survival.This study is the largest analysis to date that focuses on DSS for cutaneous melanoma of the eyelid. The most significant predictors for invasive melanoma survival are age ≥75 years at diagnosis, T4 staging, lymph node involvement, and the nodular melanoma histologic subtype. Patients with these attributes are at higher risk and should be counseled regarding prognosis.

Introduction Head and neck free flap reconstruction requires multidisciplinary and coordinated care in the perioperative setting to ensure safe recovery and success. Several institutions have introduced enhanced recovery after surgery (ERAS) protocols to attenuate the surgical stress response and improve postoperative recovery. With multiple studies demonstrating mixed results, the success of these interventions on clinical outcomes has yet to be determined. Objective To evaluate the impact of ERAS protocols and clinical care pathways for head and neck free flap reconstruction. Methods We searched PubMed, SCOPUS, EMBASE, and grey literature up to September 1st, 2020 to identify studies comparing patients enrolled in an ERAS protocol and control group. Our primary outcomes included hospital length of stay (LOS) and readmission. Mortality, reoperations, wound complication and ICU (intensive care unit) LOS comprised our secondary outcomes. Results 18 studies met inclusion criteria, representing a total of 2630 patients. The specific components of ERAS protocols used by institutions varied. Nevertheless, patients enrolled in ERAS protocols had reduced hospital LOS (MD −4.36 days [−7.54, −1.18]), readmission rates (OR 0.64 [0.45;0.92]), and wound complications (RR 0.41 [0.21, 0.83]), without an increase in reoperations (RR 0.65 [0.41, 1.02]), mortality (RR 0.38 [0.05, 2.88]), or ICU LOS (MD −2.55 days [−5.84, 0.74]). Conclusion There is growing body of evidence supporting the role of ERAS protocols for the perioperative management of head and neck free flap patients. Our findings reveal that structured clinical algorithms for perioperative interventions improve clinically-meaningful outcomes in patients undergoing complex ablation and microvascular reconstruction procedures.

Objective: To determine the outcomes of patients undergoing tracheostomy for COVID-19 and of healthcare workers performing these procedures. Background: Tracheostomy is often performed for prolonged endotracheal intubation in critically ill patients. However, in the context of COVID-19, tracheostomy placement pathways have been altered due to the poor prognosis of intubated patients and the risk of transmission to providers through this highly aerosolizing procedure. Methods: A prospective single-system multi-center observational cohort study was performed on patients who underwent tracheostomy after acute respiratory failure secondary to COVID-19. Results: Of the 53 patients who underwent tracheostomy, the average time from endotracheal intubation to tracheostomy was 19.7 days ± 6.9 days. The most common indication for tracheostomy was acute respiratory distress syndrome, followed by failure to wean ventilation and post-extracorporeal membrane oxygenation decannulation. Thirty patients (56.6%) were liberated from the ventilator, 16 (30.2%) have been discharged alive, 7 (13.2%) have been decannulated, and 6 (11.3%) died. The average time from tracheostomy to ventilator liberation was 11.8 days ± 6.9 days (range 2–32 days). Both open surgical and percutaneous dilational tracheostomy techniques were performed utilizing methods to mitigate aerosols. No healthcare worker transmissions resulted from performing the procedure. Conclusions: Alterations to tracheostomy practices and processes were successfully instituted. Following these steps, tracheostomy in COVID-19 intubated patients seems safe for both patients and healthcare workers performing the procedure.

Background The emergence of SARS-CoV-2/2019 novel coronavirus (COVID19) has created a global pandemic with no approved treatments or vaccines. Repurposing existing drugs and rapidly launching clinical trials present the greatest near-term opportunities for mitigating COVID19s impact. Many treatments have already been administered to COVID19 patients but have not been systematically evaluated. We performed a systematic literature review to identify and assess all treatments reported to be administered to COVID19 patients. Methods We searched PubMed, BioRxiv, MedRxiv, and ChinaXiv for articles reporting treatments for COVID19 patients published between Dec 1, 2019 and Mar 27, 2020. All studies reporting treatments were included. Data for each paper were manually extracted by two independent extractors. Outcomes included the duration from drug administration to clinically-meaningful response (complete symptom resolution or hospital discharge). Data were analysed descriptively. Results We identified 2,706 articles from single patient case reports to single-centre interventional studies. Of these, 155 studies met inclusion criteria, comprising 9,152 patients from 14 different countries. The cohort was 45.4% female and 98.3% hospitalised, and mean (SD) age was 44.4 years (SD 21.0). The most frequently administered drug classes were antivirals, antibiotics, and corticosteroids, and of the 115 reported drugs, the most frequently administered was combination lopinavir/ritonavir, which was associated with a response time of 11.7 (1.09) days. Discussion A large number of treatments have been administered to the first 9,152 reported cases of COVID19. Further work is needed to prioritise drugs for investigation in well-controlled clinical trials and treatment protocols. Funding None.

Coronavirus disease 2019 has undoubtedly impacted the health care system while causing lasting and profound implications for medical education. Senior medical students seeking exposure to the field of otolaryngology now find themselves in the challenging position of obtaining the experiences to make an informed decision on a future specialty. Virtual electives using comprehensive online material, discussion, and videos as well as the advent of telemedicine may be potential solutions to increase exposure to otolaryngology. While incorporating opportunities for authentic patient interactions is still a challenge, it is crucial that the academic otolaryngology community prioritize seeking solutions for interested medical students.

Objective Measures to decrease hospital length of stay and outpatient visits are crucial during the coronavirus disease 2019 (COVID-19) pandemic. Physician-guided home drain removal presents a potential opportunity for mitigating viral spread and transmission. Methods A prospective case series on patients undergoing major head and neck surgery with Jackson-Pratt drain placement was conducted. Patients were shown an infographic detailing drain care and removal at preoperative assessment and prior to discharge. At a 1-week follow-up telemedicine visit, patients were instructed to remove the drain under physician guidance. Patients were assessed 7 days after to determine complication rate and satisfaction. Results Twenty-five patients were enrolled with 100% patients undergoing successful drain removal at home with caregiver support. There were no complications reported at the 7-day postdrain removal time point, and overall patient satisfaction was high. Discussion Infographics and telemedicine are 2 synergistic strategies to guide safe and effective home drain removal. Implications for Practice This study demonstrates how telemedicine and an infographic can be effectively used in physician-guided home drain removal. During a time like the COVID-19 pandemic, innovative measures are necessary to curb transmission and infection rates. We propose a unique and replicable yet safe solution to limit unnecessary exposure and encourage other surgical providers to adopt a similar strategy.

Background & Objective The COVID-19 pandemic and resulting cancellation of medical student clinical rotations pose unique challenges to students’ educations, the impact of which has not yet been explored. Design This cross-sectional survey study collected responses from 13 April 2020 until 30 April 2020. Students at US allopathic medical schools completed the survey online. Results 1,668 responses were analyzed. A total of 337 (20.2%) respondents thought the pandemic would affect their choice of specialty, with differences across class years: 15.2% (53) of first-years (MS1s), 26.4% (92) of second-years (MS2s), 23.7% (162) of third-years (MS3s), and 9.7% (22) of fourth-years (MS4s) (p

INTRODUCTION Sternoclavicular joint (SCJ) dislocations, although uncommon, are observed in patients with ligamentous laxity as well as those who experience traumatic injuries. The incidence and epidemiology of this costly and debilitating injury to our relatively young and active military population have not previously been reported. The purpose of this study is to consider and quantify the non-modifiable risk factors associated with this injury. METHODS Using Defense Medical Epidemiological Database, first-time occurrences, from 2006 to 2015 for the ICD-9-CM code 839.61 (closed dislocation of the SCJ), were obtained and further categorized by gender, race, age, rank, and branch of service. Race was classified based on self-reporting of patients into White, Black, or other categories. Age was divided into the categories of less than 20 yr, 20–24 yr, 25–29 yr, 30–34 yr, 35–39 yr, and greater than 40 yr. Rank was categorized as junior enlisted (E-1 to E-4), senior enlisted (E-5 to E-9), junior officer (O-1 to O-3), and senior officer (O-4 to O-10). Branch of service includes Army, Navy, Air Force, and Marines. Multivariate data analysis was performed to obtain rate per 1,000 person-years as well as adjusted rate (adjusted for age group, gender, race, rank, and service) to isolate risk factors. RESULTS Between 2006 and 2015, 427 cases of closed SCJ dislocations occurred among an at-risk population of 13,772,342 person-years for an unadjusted incidence rate (IR) of 0.031 per 1,000 person-years. The annual unadjusted IR ranged from 0.017 in 2006 to 0.059 in 2014 with the greatest increase occurring between 2006 and 2007 representing 61% increase in the rate of injuries. Males were almost twice as likely to sustain these injuries compared with females (adjusted rate ratio 1.73; 95% confidence interval [CI] 1.23, 2.43). Age was not found to be a risk factor for the development of these injuries with IRs for each age group overlapping with 95% CI for all other age groups. Similarly, the other category for race was also not found to be a statistically significant risk factor. Junior Officers (adjusted rate 0.017; 95% CI 0.011, 0.025) were found least likely to suffer from these injuries with Junior Enlisted (0.034; 95% CI 0.030, 0.040) and Senior Enlisted (0.032; 95% CI 0.028, 0.037) most at risk. Being in the Navy (0.019; 95% CI 0.015, 0.025) was found to be most protective compared with Air Force (0.032; 95% CI 0.026, 0.039), Army (0.036; 95% CI 0.031, 0.041), and Marines (0.036; 95% CI 0.028, 0.045). DISCUSSION and CONCLUSION Annual unadjusted IR of SCJ dislocations readily increased from 2006 to 2014. Statistically significant risk factors, for suffering a closed SCJ dislocation, identified by our study, were male sex, enlisted rank, and branch of service other than Navy. Age and race were not found to have a statistically significant risk. These results can shed light on non-modifiable risk factors for dislocations of the SCJ and can be used in other studies to aid in reducing injury burden on the U.S. Military.

Background The aims of the study were as follows: to perform a systematic review of meta-analyses comparing “early motion” and “delayed motion” after arthroscopic rotator cuff repair; to provide a framework to analyze the best available evidence to develop recommendations; and to identify gaps where suggestions could be made for future investigations. Methods Literature searches were performed to identify meta-analyses examining arthroscopic rotator cuff repair with early-motion vs. delayed-motion rehabilitation protocols. Clinical data were extracted, and meta-analysis quality was assessed using the Quality of Reporting of Meta-analyses and Oxman-Guyatt scales. Results Nine meta-analyses met inclusion criteria. No clear superiority was noted in clinical outcome scores for early-motion or delayed-motion rehabilitation. Results of tendon healing were found to be either no different or in favor of delayed motion, but no differences were noted in rotator cuff tear recurrence rates postoperatively. The majority of meta-analyses found significantly better range of motion with early motion up to a year postoperatively for forward elevation and up to 6 months for external rotation, but significant differences were not reported for functional improvements and strength at 12 months postoperatively. Subgroup analyses suggested that larger preoperative tear sizes have significantly greater retear rates with early-motion rehabilitation. Conclusions The current highest level of evidence suggests that early-motion rehabilitation after rotator cuff repair results in superior postoperative range of motion up to 1 year. Whereas early motion and delayed motion after cuff repair may lead to comparable functional outcomes and retear rates, concern exists that early motion may result in greater retear rates, particularly with larger tear sizes.

Given the prevalence of anterior cruciate ligament (ACL) tears in young athletes, it is essential to elucidate and illustrate surgical interventions that return the most favorable outcomes. Although most ACL injuries are full-thickness tears, occasionally either the anteromedial (AM) or posterolateral (PL) bundle is torn in isolation, allowing consideration of an ACL reconstruction or augmentation. Because the ACL-deficient knee has been shown to exhibit less proprioceptive feedback, the preservation of the intact bundle may offer an inherent component of stability. After arthroscopy has confirmed a partial ACL tear, the decision to augment the intact bundle can be made. The technique is adapted from principles of the double-bundle reconstruction such that the graft follows the path of either the native AM bundle or the native PL bundle, depending on the location of the partial tear. We present our surgical technique for ACL AM bundle augmentation with PL bundle reconstruction using a semitendinosus tendon autograft.

Vascular malformations presenting in the nasal cavity and paranasal sinuses are rare. Differentiating benign vascular malformations of the sinonasal cavity from other pathologic entities can be challenging and the role of preoperative angiography and embolization is not well defined. We present two unique cases of large pediatric sinonasal vascular malformations and describe their presentation, diagnosis and subsequent management. Both patients underwent embolization of the ipsilateral arterial supply followed by successful and complete endonasal surgical excision. This report provides description of management of the very rare occurrence of sinonasal vascular malformation in two adolescents.

Background There is increasing interest in outpatient shoulder arthroplasty (SA); however, the clinical evidence behind this practice is sparse. The purpose of this study was to assess the safety of outpatient SA performed in an ambulatory surgery center and to determine patient factors that are associated with increased risk for perioperative complications or dissatisfaction. Methods Patient demographics and operative variables were collected retrospectively for patients undergoing outpatient SA at 2 ambulatory surgery centers with a minimum follow-up of 90 days. Patients completed a postsurgery questionnaire about their experience, satisfaction, pain control, and health care use. Results Forty-one anatomic total SAs (n = 32) and reverse SAs (n = 9) with a mean follow-up of 60 weeks (16.4 weeks-3 years) were included. The mean age, body mass index, Charlson Comorbidity Index, and American Society of Anesthesiologists class were 60.6 ± 4.8 years, 31.8 ± 6.6, 2.9 ± 1.9, and 2.3 ± 0.6, respectively. Three (7.3%) minor complications occurred within 90 days of the SA, none before first follow-up. Two patients stayed in the ambulatory surgery center 23-hour observation unit. Thirty-five patients (85.4%) completed the questionnaire, of whom 97.0% (n = 32) were satisfied with the outpatient procedure. Two patients had difficulties with postoperative pain control and were taking chronic narcotic medication before surgery. Conclusion Outpatient SA in an ambulatory surgery center is safe with high patient satisfaction and low rates of perioperative complications. Although larger cohorts are required to adequately determine which patients will be appropriate candidates for an outpatient SA, our findings do suggest that patients with a history of preoperative narcotic use may have difficulties or dissatisfaction with outpatient SA.

Sport-specific, performance-based outcomes are increasingly used to improve evaluation of treatment efficacy in elite athletes; however, its usage in elite soccer may be limited. The purpose of this investigation is to (1) assess current outcome reporting in elite soccer; (2) identify any variability in reporting of outcomes; and (3) determine how sport-specific performance-based outcomes are utilized to assess treatment efficacy in elite soccer. A systematic review of the Pubmed, MEDLINE, and Embase, Scopus, SportDiscus, CINAHL and HealthSource: Nursing databases was performed without limitation on publication year. Inclusion criteria were (1) reporting of outcomes after a (2) lower extremity injury in (3) elite soccer players. The study’s population, type of injury, return to play, as well as functional, objective, and sport-specific performance-based outcomes were extracted from each article. The methodological index for nonrandomized studies was used for quality assessment. Twenty-one studies were selected after application of the inclusion and exclusion criteria. Objective outcomes were reported by 6 (29%) studies, and 6 (29%) employed patient-reported outcomes. The visual analog scale, Lysholm, and Tegner scores were the most common patient-reported outcomes (PROs). Return to play was reported by 18 (86%) studies, and only 2 (10%) utilized sport-specific performance-based outcomes. Despite the majority of studies reporting return to play, variation was seen in the definitions, and 15 (71%) studies reported the activity level of the players at final follow-up. Assessment of treatment efficacy is limited in elite athletes, and PROs lack the sensitivity to identify residual performance deficits after an injury. Although performance-based measures are available at the elite level, these outcomes were seldom used for evaluation of treatment efficacy. When treating elite soccer players, patient-reported outcome measures lack the sensitivity to detect changes in patient function, thus performance-based metrics may be more efficacious in assessing return from injury in these patients. IV.

Quadriceps tendon rupture is an uncommon injury that usually occurs in middle-aged and elderly men with a history of chronic illnesses. We report the case of a 17-year-old healthy adolescent male baseball player who sustained this injury as a result of sudden deceleration in his left knee. He initially reported to the emergency department and then presented to our practice, where he was diagnosed with a quadriceps tendon tear. Preoperatively, he was unable to perform a single straight-leg raise. During surgical repair, the free edge of the quadriceps tendon was mobilized and anchored into the superior pole of the patella, followed by sutures to ensure reinforcement of the quadriceps footprint. His postoperative course progressed normally, demonstrating full range of motion at 3 months and return to team training at 5 months. Unlike previously reported quadriceps tendon ruptures in adolescents, to our knowledge, this is the first report of a patient who sustained such an injury without previous trauma to his knee or quadriceps mechanism. It is possible that weakened tendon integrity from repeated microtrauma during training combined with the sudden weight change distribution may have resulted in the injury. As urgent surgical intervention is necessary to ensure efficient recovery and return to sport, the sports medicine practitioner must remain educated and vigilant on caring for these patients.

Objectives: Biceps pathology typically includes pain in the anterior shoulder that is reproduced with provocative maneuvers. However, optimal treatment of patient with this diagnosis is not clear and can include tenotomy or various forms of tenodesis. As tenotomy can lead to cosmetic deformity and anterior humeral discomfort from spasms, many surgeons perform tenodesis. Technique for tenodesis includes intra-articular soft tissue fixation or osseous fixation, suprapectoral osseous fixation, and subpectoral osseous fixation. Focusing on the later two, it is unclear if there is a clinical or surgical benefit of performing an open subpectoral biceps tenodesis (OBT) versus arthroscopic suprapectoral biceps tenodesis (ABT). We therefore designed this randomized clinical trial to assess these two techniques. Methods: Patients diagnosed with biceps tendinopathy meeting the inclusion and exclusion criteria were randomized into the arthroscopic and mini-open biceps tenodesis groups. Prior to surgery, patients were asked a series of questions regarding their anterior shoulder pain and underwent a subsequent shoulder exam. Follow-up was d at 3 months, 6 months, and 1 year time points, during which the shoulder exam and patient questionnaires were also d. Results: A total of 38 patients were enrolled with a mean age of 43.5 ± 10.5 years and a mean BMI of 28.3 ± 5.4. All patients had arthroscopic evidence of biceps pathology and underwent either an ABT (18) or an OBT (20). All patients underwent a concomitant arthroscopic subacromial decompression. The surgical time for the ABT group, 17.2 ± 3.7 minutes, was significantly greater than the OBT group, 11.7 ± 6.1 (p 0.05) was found in strength or anterior shoulder pain at 3 months, 6 months, and 1 year. Additionally, no significant difference (p > 0.05) was found in clinical outcome scores (ASES, Constant subjective, WORC, KJOC) between the two groups. Conclusion: This randomized clinical trial suggests there is no clinical difference between the two techniques. Additionally, while the arthroscopic procedure requires more surgical time, the revision rates are not different. Besides the cosmetic concern for an additional scar, we recommend decisions to be made based on surgeon preference and experience.

Preservation of the meniscus has been shown to influence the progression of degenerative changes of the knee. As more meniscus is preserved, the propensity for development of osteoarthritis is lessened. Surgical treatment of a torn discoid meniscus has typically been a subtotal meniscectomy or partial meniscectomy. Similar to tears of a normal meniscus, partial meniscectomy compared with subtotal meniscectomy of the discoid meniscus confers better long-term results. With the abnormal morphology predisposing the discoid meniscus to tearing, several characteristic tear patterns can be observed—the horizontal tear being commonly encountered. We present a technique that not only creates a more normal morphology of a discoid meniscus but also preserves the tissue by using an all-inside, intrameniscal repair technique. This technique restores the central rim of the meniscus in the setting of a horizontal cleavage plane, thus restoring a more normal meniscus morphology.