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Objective: To evaluate the role of parental influence on youth SSS and to characterize parental perceptions of SSS., Data Sources: Embase.com, Ovid-Medline All, CINAHL Plus, APA PsycInfo, Scopus, Web of Science, and PubMed Central (PMC) since database inception., Study Selection: Primary studies that assessed reasons for youth SSS that included parental influence as a factor and/or studies that investigated the nature or extent of parental influence on SSS were included., Data Extraction: A single author extracted data, focusing on definitions and measures of SSS and parental influence, findings concerning primary reasons for SSS, any quantitative or qualitative findings on the extent of parental influence on SSS, and findings concerning various associations between parental influence, SSS, and other themes., Data Synthesis: 61 articles were assessed in total, with 23 meeting criteria for inclusion. Parental influence plays a limited direct role in SSS, accounting for approximately 10.6% of the overall influence. Athlete self-influence or self-enjoyment of sport was found to be the predominant reason to pursue SSS, accounting for 82.3% of the overall influence. However, parents indirectly influence SSS by modulating athlete motivation and providing financial, practical, and emotional support., Conclusions: Athlete self-motivation primarily drives SSS directly, while parents indirectly influence SSS by modulating athlete self-motivation and offering financial, practical, and emotional support. Misconceptions persist regarding parental perceptions of SSS-related injury risks, scholarship attainment, and athletic development. Communication with parents regarding the risks associated with SSS and their role in monitoring their children's sports participation is crucial for mitigating adverse outcomes in youth athletes.

Soccer is considered the most popular sport in the world. The game involves frequent agile maneuvers, such as rapid accelerations/decelerations and pivoting, and carries an inherent risk of high-speed collisions, which can lead to lower extremity injury. Knee and meniscus injuries can cause significant pain and disability, precluding participation in the sport. Understanding the diagnosis and management of meniscal injuries in soccer players is essential to the care of these athletes. This paper reviews meniscal anatomy, biomechanics, and mechanisms of injury; discusses the work-up, diagnosis, and management of meniscus injuries; and reports on rehabilitation, return to sport, and outcomes after meniscal injuries in soccer players., Competing Interests: Disclosure: R.H.B. is the chief medical officer for St. Louis City SC of Major League Soccer (MLS). The remaining author declares no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Studies routinely evaluate high ankle sprains in isolation, but recent data suggest that these injuries are often associated with concomitant pathology, potentially influencing return to full participation., Hypothesis: In National Football League (NFL) players, isolated high ankle sprains are rare and syndesmosis injuries with concomitant pathology will result in increased time to return to full participation., Study Design: Cross-sectional study., Level of Evidence: Level 3., Methods: Distal tibiofibular syndesmosis injuries sustained by NFL players between 2017 and 2019 were identified through NFL Injury Surveillance Database queries and verified with video analysis. Each injury underwent a comprehensive magnetic resonance imaging (MRI) review. Regression modeling was utilized to explore the influence of numerous imaging findings on time to return to full participation., Results: There were 83 external rotation ankle injuries involving the syndesmosis. Isolated distal tibiofibular syndesmosis injuries were rare (n = 11; 13%) and more often associated with other ligamentous injury (deltoid ligament and lateral ligamentous complex) and/or fractures. Regression modeling resulted in clustering of 3 injury pattern groups for time to return to full participation across numerous imaging findings: syndesmosis injury-fracture combinations (250 days [interquartile range [IQR,] 142-266 days]), syndesmosis injury with complete deep deltoid tear or acute diastasis (175 days [IQR, 20-248 days]), and all other syndesmosis injuries (27 days [IQR, 18-46 days])., Conclusion: In NFL athletes with external rotation ankle injuries, isolated distal tibiofibular syndesmosis injuries were rare and more often associated with concomitant pathology. Time to return to full participation was affected by an associated fracture and complete deep deltoid ligament tear or diastasis but no other relevant MRI variables such as lateral ligament complex involvement or the presence of osteochondral lesions or bone contusions., Competing Interests: The following authors declared potential conflicts of interest: M.J.C. has received royalties or licenses from Arthrex, Stryker, and Smith & Nephew, consulting fees from Donjoy, and patents from Tenova Tenodesis Screw. M.M.H. has received consulting fees from the National Football League (NFL) and is a full-time employee of IQVIA. N.W. has received consulting fees from the NFL and is a full-time employee of the Green Bay Packers. E.M.S. has received consulting fees from the NFL and is a full-time employee of Biocore. C.M.O. has received consulting fees from the NFL and is a full-time employee of Biocore. R.B.A. has received royalties or licenses from Stryker and Artelon, and consulting fees from Stryker, Envois, Arthrex, Artelon, OsteoRemedies, and Nuvasive.

Background: Publicly obtained data (POD) have recently been utilized frequently by sports medicine researchers to describe injury patterns, risk factors, and outcomes in elite athletes. The relative ease of this type of research that is based solely on internet and media sources has resulted in a near exponential increase in the number of these POD studies., Purpose: To systematically review the sports medicine literature for studies based solely on POD., Study Design: Systematic review and bibliometric analysis; Level of evidence, 4., Methods: A systematic review of POD studies published since 2000 was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Studies of interest were those relying on publicly available injury reports or online media for data acquisition in collegiate, semiprofessional, and professional athletes., Results: There were 209 POD studies published between 2000 and 2022, with 173 (82.8%) of these studies published after 2016. Studies were published most frequently on athletes participating in North American professional leagues: National Football League (n = 69 [28.4%]), Major League Baseball (n = 56 [23.0%]), National Basketball Association (n = 37 [15.2%]), and National Hockey League (n = 33 [13.6%]). The most common injuries assessed were head injuries/concussions (n = 43 [21.1%]), anterior cruciate ligament injuries (n = 33 [16.2%]), and ulnar collateral ligament injuries (n = 23 [11.3%]). One-quarter of the studies (n = 53 [25.4%]) reported only 1 POD source, and 1 study (0.5%) reported no source. Additionally, 65 studies (31.1%) listed nonspecific POD resources or solely cited previous literature to describe the POD search methodology and data acquisition., Conclusion: POD studies are exponentially increasing in number, particularly across major North American professional sports leagues, with significant variability in the injury of interest, search methodology, and number of data sources. The accuracy of the conclusions reached based on the POD methodology appears highly variable. Given the potential impact of these publications as both contributors to current knowledge and drivers of future research, the sports medicine community should be aware of the inherent biases and limitations of POD injury studies., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: P.M.I. and A.W.K. have received support for education from Elite Orthopaedics. G.S.S. is a paid consultant for the National Football League. M.J.M. has received consulting fees from Arthrex and support for education from Elite Orthopaedics. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Background: Gluteus maximus tendon transfer has recently been described as a treatment option for irreparable abductor tendon tears. The purpose of this study was to systematically review outcomes following gluteus maximus tendon transfer for hip abductor deficiency., Methods: The published literature was queried for outcomes following gluteus maximus transfer in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Outcomes of interest included preoperative and postoperative functional scores, resolution of pain and gait abnormalities, postoperative rehabilitation protocols, surgical complications, reoperation rates, and postoperative magnetic resonance imaging. In total, 10 studies with a total of 125 patients (76% women) with a mean age of 67 years (range, 30 to 87) were identified for inclusion., Results: Modified Harris Hip Score (+30.1 ± 6.6 [95% confidence interval: +15.5 to +46.5]) and Visual Analog Scale for pain (-4.1 ± 1.1 [95% confidence interval: -7.1 to -1.0]) were improved following gluteus maximus transfer, compared to preoperative levels. No significant improvement was noted in abduction strength and 33% of patients demonstrated a residual Trendelenburg gait postoperatively. The overall complication rate was 5.6% (7 of 125), with a reoperation rate of 1.6% (2 of 125)., Conclusions: Gluteus maximus tendon transfer for abductor insufficiency has demonstrated reliable outcomes at 3 years, with improvement in hip function and pain. However, patients demonstrate modest improvements in abduction strength, and a significant subset will continue to demonstrate a Trendelenburg gait postoperatively., (Copyright © 2023 Elsevier Inc. All rights reserved.)

The purpose of this study was to assess the prevalence of multicenter studies in the orthopedic literature compared to general medicine and other surgical subspecialty studies as an update to a previous study. The number of multicenter research studies across three orthopedic surgery journals was higher in 2021 compared to 2009 (7.2% [95% CI: 5.1%-9.4%, χ 2  [df = 1 = 43.8]], p < 0.0001), as was the number of authors and institutions listed on clinical research studies. While these trends in multicenter research publishing are encouraging, orthopedic surgery still lags behind the general medicine and other surgical subspecialty literature bases. Of the 934 orthopedic surgery studies published, 92 (9.9%) were multicenter studies compared to 64.4% of the general medicine and 26.9% of the other surgical subspecialty studies (χ 2  [df = 2] = 472.6, p < 0.001). Multicenter trials conducted in orthopedics have fundamentally changed musculoskeletal care, affecting the lives of millions of patients. Participation in multicenter research should be encouraged and prioritized through continued advocacy, funding, support, and direction from orthopedic governing bodies, journals, and subspecialty groups., (© 2023 Orthopaedic Research Society.)

Background: The demonstrated benefits of virtual reality (VR) in orthopaedic surgical training are numerous. However, it is relatively unknown how best to implement VR into an already established orthopaedic resident education curriculum and how trainees will engage and use these technologies longitudinally., Methods: This was an exploratory, qualitative research study performed in accordance with Consolidated Criteria for Reporting Qualitative Research guidelines. Orthopaedic surgery residents at a single institution were recruited during the 2022 to 2023 academic year. Semistructured interviews were conducted. Data were analyzed through grounded theory methodology, beginning with open coding, followed by axial coding, and concluding with selective coding that describes orthopaedic surgery residents' current perceptions of VR as a training tool., Results: Six residents participated in interviews before thematic saturation was achieved. Average interview length was 13:27 (±2:59) minutes. Residents felt that currently, VR is most useful for interns and junior residents as an educational adjunct for learning anatomy, surgical exposures, and the steps of a procedure in a risk- and judgment-free arena. There seems to be a "ceiling effect" with VR given current technological limitations, and residents remarked that there is an associated "opportunity cost" with using VR technology. Some residents may find it more time-efficient to study texts, videos, or surgical guides rather than use VR. Cost (limited number of headsets) and technological barriers (i.e., hardware, software, and Wi-Fi issues) were some of the described barriers to VR utilization. Residents felt that there needs to be dedicated technological support to help with these issues. At this time, given these limitations of VR, many preferred VR as an optional educational adjunct rather than as a required curricular tool or assessment of surgical competency., Conclusions: There is current utility for VR in orthopaedic surgical training. Future technological advances may make VR more central to resident education. This study describes resident perceptions about the technology and best use practices for the technology., Level of Evidence: Qualitative Study, Level V Evidence., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSOA/A607)., (Copyright © 2024 The Authors. Published by The Journal of Bone and Joint Surgery, Incorporated. All rights reserved.)

Objectives: To compile the existing literature on bilateral anterior shoulder dislocation (BASD) and analyze patient demographics, mechanisms of injury, injury characteristics, management, and outcome., Methods: This systematic review was conducted in accordance with Preferred Reporting Items for Systematic review and Meta-Analyses (PRISMA) guidelines. Online databases, including Ovid Medline 1946-, Embase.com 1947-, Scopus 1960-, Cochrane Central, and Clinicaltrials.gov were systematically queried. Studies eligible for inclusion were case reports or case-series, documenting BASD. Two reviewers independently screened and applied a set of a priori exclusion criteria to each returned study. Data were extracted, compiled, and synthesized from each reported case of BASD. Contingency tables/Chi-Square Analyses, T-tests, and univariate regression analyses were conducted to assess relationships between different variables., Results: Eighty-one studies (87 cases of BASD) were included. Patients were 41.1 (SD± 19.5) years old and most were male (n=63; 72.4%). Around a quarter of patients (28.7%) had a history of epilepsy/seizures or were being worked-up for such. Younger males were more likely to have BASD due to a seizure or electrocution (P<0.05). Close to a third of cases (n=27; 31.0%) were delayed in presentation. Those sustaining seizures or electrocutions were more likely to be delayed in presentation (P=0.013). Most events resulted in simple dislocations that were closed reduced successfully. BASD resulting from seizures or electrocutions were more likely to be fracture-dislocations (P=0.018); and in younger patients with fracture-dislocations, closed reduction was more often to fail or not be attempted (P<0.05). Median follow-up was 6 months (IQR: 3 months - 12 months). Seven patients (10.6%) had complications and 4 (2.3%) demonstrated recurrent instability., Conclusion: In young males presenting with BASD without known trauma, suspicion should be high for a convulsant event. In patients with a known seizure disorder who present with chronic bilateral shoulder or arm pain, BASD should be considered and work-up should be expedited to avoid misdiagnosis., Competing Interests: None, (2024 © BY THE ARCHIVES OF BONE AND JOINT SURGERY.)

Objectives: (1) Determine effects of computed tomography (CT) on reproducibility of olecranon fracture classification. (2) Determine effects of CT utilization on interobserver agreement regarding management of olecranon fractures. (3) Evaluate factors associated with articular impaction., Methods: Seven surgeons retrospectively evaluated radiographs of 46 olecranon fractures. Each fracture was classified according to Colton, Mayo, Orthopaedic Trauma Association/AO Foundation (OTA/AO) systems. Observers determined whether articular impaction was present and provided treatment plans. This was repeated at minimum 6 weeks with addition of CT. Descriptive and comparative statistics were performed and intraclass correlation coefficients (ICCs) were calculated., Results: Interrater agreement was near-perfect for all classifications using radiographs (ICC 0.91, 0.93, 0.89 for Colton, Mayo, OTA/AO) and did not substantially change with CT (ICC 0.91, 0.91, 0.93). Agreement was moderate regarding articular impaction using radiographs (ICC 0.44); this improved significantly with CT (ICC 0.82). Articular impaction was significantly associated with OTA/AO classification, with high prevalence of impaction in OTA/AO 2U1B1e ( P < 0.03). Agreement was substantial for chosen fixation construct using radiographs (ICC 0.71); this improved with CT (ICC 0.79). Utilization of CT changed fixation plans in 25% of cases. Agreement regarding need for void filler was fair using radiographs (ICC 0.37); this notably improved with CT (ICC 0.64)., Conclusions: Utilization of CT for evaluating olecranon fractures led to significant improvements in interobserver agreement for presence of articular impaction. Impaction was significantly associated with fracture pattern, but not with patient-related factors. Addition of CT improved agreement regarding fixation construct and led to notable improvement in agreement regarding need for void filler., Competing Interests: A. W. Aleem is a paid consultant for Stryker. M. B. Berkes is a paid consultant for Arthrex, Smith and Nephew, and Mediflix and receives teaching honoraria from AO Trauma North America. B. M. Zmistowski is a paid consultant for Zimmer-Biomet. The remaining authors report no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

The evaluation and treatment of adolescents and young adults with hip pain has seen tremendous growth over the past 20 years. Labral tears are well established as a common cause of hip pain but often occur because of underlying bony abnormalities. Femoroacetabular impingement (FAI) and acetabular dysplasia are now well-established causes of hip osteoarthritis and are increasingly treated in the prearthritic stage in hopes of improving symptoms and prolonging the longevity of the native hip. Beyond FAI and acetabular dysplasia, this patient population can present with a complex and variable group of underlying conditions that need to be taken into account. Expertise in the conservative management of this population, including physical therapy, is valuable to maximize the success. Preoperative, surgical, and postoperative decision-making and care in this population is complex and evolving. A comprehensive, multidisciplinary approach to the care of this patient population has been used for over 20 years by our institution with great success. The purpose of this article is to review the "team-based approach" necessary for successful management of the spectrum of adolescent and young adult hip disorders., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSREV/B12)., (Copyright © 2023 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Anterior shoulder instability is a common problem around the world, with a high risk for recurrence following the index dislocation. Surgical stabilization is commonly indicated for persistent instability, particularly in patients at high risk for recurrence, to minimize the risk of further labral injury and glenoid bone loss. However, there is little known about global geographic differences in the surgical management of anterior shoulder instability. As such, the purpose of this study was to evaluate and systematically review regional differences in the surgical treatment of anterior shoulder instability, particularly the indications for and outcomes from bony stabilization procedures compared to soft tissue procedures., Methods: A systematic review, in accordance with the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, was performed. Inclusion criteria consisted of level I and II evidence studies evaluating indications, techniques, and outcomes following operative management of anterior shoulder instability published from January 2000 to September 2021. Studies meeting inclusion criteria were grouped into four global regions (Asia, Europe, North America, South America) based on primary study location. Patient demographics, procedural details, patient reported outcomes, and complications (recurrence and reoperation rates) were compared between regions., Results: Sixty (n = 60) studies (5480 patients) were identified. Eighty-six percent of all patients were male, with a mean age of 26.7 years. There was no difference in mean patient age, though patients undergoing bony stabilization procedures were older than those undergoing soft-tissue stabilization procedures ( P  = .0002) in all regions. The proportion of bony versus soft-tissue procedure groups did not differ significantly among regions. The indications for bony stabilization procedures varied significantly. Mean final follow-up was 3.5 years. Recurrent instability was 5.0% and did not vary across regions. However, recurrent instability occurred more frequently following soft-tissue compared to bony stabilization procedures ( P  = .017). South American studies utilized fewer anchors during soft tissue stabilization ( P < .0001) and reported a higher reoperation rate compared to other regions ( P  = .009)., Conclusion: There is global variation in the reporting of outcomes following surgery for anterior shoulder instability. The proportion of bony and soft-tissue procedures is similar, irrespective of geographic region. Recurrent instability does not vary by region but occurs more frequently following soft-tissue compared to bony stabilization procedures. There are a number of potential medical and nonmedical factors that may affect global variation in the surgical treatment of anterior shoulder instability., (© 2023 The Author(s).)

COVID-19 forced surgical resident training programs to adapt to meet educational requirements within the constraints of various guidelines. Some of the changes implemented during the pandemic have imparted a lasting effect on orthopaedic education. As such, the purpose of this article was to review how orthopaedic training and education were affected during the COVID-19 pandemic., Methods: The published literature was queried using search strategies devised by a medical librarian, according to the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. Studies eligible for inclusion were studies related to COVID-19, orthopaedic surgical training, and medical education. Studies were excluded if they (1) were abstracts, conference proceedings, letters, perspective pieces, reviews, or editorials; (2) evaluated medical student education; (3) included other specialties; or (4) were unrelated to COVID-19 and/or orthopaedic training., Results: Eighty-three (n = 83) studies were included. Five themes emerged including (I) Fellowship Application, Interview, and Match Processes; (II) Social Media and Websites for Program Information; (III) Changes in Trainee Surgical Volume; (IV) Trainee Mental Health and Well-being; and (V) Innovations in Education. The pandemic decreased opportunities for medical students to gain exposure to orthopaedic surgery. Social media use, particularly Instagram, among orthopaedic residencies increased during the pandemic. Between the cancellation of away rotations and in-person interviews, applicants saved over $6,000; however, both residency applicants and interviewers preferred in-person interviews. The pandemic led to decreased surgical volume and in-person didactics for trainees, thus relying more on virtual learning. Orthopaedic trainees had mixed feelings regarding online virtual education. Although some respondents reported that they preferred the convenience of online learning, others expressed dissatisfaction with the quality of virtual education., Conclusions: The shift to virtual learning affected how applicants learned about residency programs, with many relying on virtual away rotations and social media to compare different programs. The pandemic also highlighted issues of diversity and accessibility within orthopaedic surgery, with cost savings from virtual interviews and canceled away rotations potentially benefiting applicants from lower socioeconomic backgrounds. Although some innovative approaches and adaptations to orthopaedic education and training have shown promise and may continue to be used in the future after the COVID-19 pandemic, the role of others, such as virtual interviews, is less clear., (Copyright © 2023 The Authors. Published by The Journal of Bone and Joint Surgery, Incorporated. All rights reserved.)

Background: Because of the rarity of dysplasia epiphysealis hemimelica (DEH), little is known about the relationship between disease classification and clinical symptoms or patient outcomes. This studies therefore aims to characterize DEH of the lower extremity and correlate radiographic classification to presenting symptomatology and need for surgical intervention., Methods: A multi-center, retrospective review of all patients with DEH of the lower extremity over a 47-year period was conducted. Demographic data, presenting complaints, treatments, and symptoms at final follow-up were recorded. Radiographs were reviewed to classify lesions using the Universal Classification System for Osteochondromas (UCSO) and document the presence of solitary or multiple lesions within the involved joint. Correlative statistics were used to determine whether presenting complaints, lesion location or radiographic classification predicted the need for surgery or a pain-free outcome., Results: Twenty-eight patients met inclusion criteria with an average age at presentation of 7.8 years. The ankle was the most commonly affected joint with 20/28 patients (71%) having lesions of the talus, distal tibia, or distal fibula. Patients with chief complaints of pain were more likely to undergo surgery than those with complaints of a mass or deformity ( P =0.03). Ankle lesions were more likely to be managed operatively than those of the hip or knee ( P =0.018) and all 12 patients with talar lesions underwent surgery. Neither the number of lesions nor lesion classification was predictive of surgical intervention or a pain-free outcome after surgery. Patients presenting with pain were more likely to have a pain-free outcome (11/14 patients) after surgery ( P =0.023) whereas all patients presenting with deformity who underwent surgery had pain at final follow-up., Conclusions: Although no single radiographic characteristic of DEH was predictive of surgical intervention or outcome, painful lesions of the ankle, and lesions of the talus were more likely to be managed operatively. Although surgery does not always result in a pain-free outcome, the operative management of painful lesions was more likely to provide a pain-free outcome than surgery for deformity or a mass., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Context: Numerous researchers have leveraged publicly available internet sources to publish clinical research concerning incidence and recovery from injuries in National Football League (NFL) players., Objective: This study aims to (1) provide a comprehensive systematic review of all publicly obtained data studies (PODS) regarding concussions in NFL athletes and (2) quantify the percentage of injuries identified by these studies in comparison with published concussion data from the NFL injury database., Study Selection: A systematic review was conducted in accordance with PRISMA guidelines to identify all published studies utilizing publicly obtained data regarding concussions in NFL athletes., Study Design: Systematic review., Level of Evidence: Level 4., Data Extraction: Manuscript details, factors related to the athletes of interest (eg, study period, positions included), and results (eg, concussion rate, number of total concussions, return-to-play data) were extracted independently by 2 authors. Results were compared with incident concussions reported from 2015 to 2019 by each medical staff member to the NFL database linked to the League's electronic health record (EHR)., Results: A total of 20 concussion-focused manuscripts based on PODS were identified from 2014 to 2020. PODS captured between 20% and 90% of concussions (mean, 70%) reported by medical staff to the injury database. PODS reported that 55% of concussions occurred on offensive plays, 45% on defensive plays and <1% occurred during special teams plays, compared with 44%, 37%, and 18%, respectively, as indicated by published data from the NFL injury database. When analyzed by position groups, running backs and quarterbacks comprised the most over-represented positions concussed in PODS, while offensive linemen, defensive backs, and linebackers comprised the most under-represented positions., Conclusion: PODS captured approximately 70% of concussions reported by NFL medical staff to the NFL injury database. There is heterogeneity in the degree to which PODS were able to identify concussions, with a bias toward concussions among players at higher profile positions.

Hip abductor deficiency resulting from gluteus medius and minimus pathology is increasingly recognized as a generator of lateral-sided hip pain. In the setting of a failed gluteus medius repair or in patients with irreparable tears, transfer of the anterior portion of the gluteus maximus muscle can be performed to treat gluteal abductor deficiency. The classic description of the gluteus maximus transfer technique relies solely on bone tunnel fixation. This article describes a reproducible technique that incorporates the addition of a distal row to the tendon transfer, which may improve fixation by both compressing the tendon transfer to the greater trochanter and providing improved biomechanical strength to the transfer., (© 2023 The Authors.)

Scholarship and research are important aspects of orthopaedic surgery training. Many orthopaedic surgery residency programs have developed dedicated research curricula, often culminating in a capstone thesis project with the intended goal of peer-reviewed publication. However, data on the success of these programs are scarce. The purpose of the current study was to determine the success rate and time to publication of resident research thesis projects at our own institution while evaluating factors associated with these outcomes., Methods: Resident research thesis projects performed over the past 15 years were aggregated and reviewed. Additional data regarding the projects and former trainees who performed them were collected using public resources which included measures of current academic aptitude (i.e., H-index and number of publications) as well as project and publication characteristics. Cox and linear regression analyses were conducted to assess the relation between numerous predictor variables and the success and time to publication. All analyses were conducted at the 95% confidence interval (CI) level., Results: Sixty-eight (n = 68; 83%) resident research thesis projects were published an average of 2,582.8 days, or roughly 7 years from the start of their residency training. Graduate adjusted H-index was associated with increased success and decreased time to publication (hazard ratio 1.183 [95% CI: 1.059-1.322], p = 0.003). A lower journal impact factor was associated with taking significantly shorter time to reach publication ( F (1,66) = 7.839, p = 0.007; Β 1 = 146.45, p = 0.007). Study type (clinical vs. laboratory), posttraining practice setting (academic vs. private), and whether the research topic was within the same area of the trainee's matched fellowship(s) did not predict publication success., Discussion/conclusion: Over the past 15 years, 83% of orthopaedic resident research thesis projects at our institution were published. A higher adjusted H-index was associated with greater completion and faster timing to publication. A lower journal impact factor was also associated with quicker publication. These data highlight the publication metrics of a formalized resident research program and identify factors associated with success and timing of publication., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSOA/A457)., (Copyright © 2023 The Authors. Published by The Journal of Bone and Joint Surgery, Incorporated. All rights reserved.)

Background: The Vanderbilt Community Circle (VC2) was designed to provide all faculty, staff, and students within the entire Vanderbilt University Medical Center community a dedicated venue to discuss current events and ongoing societal issues., Approach: During the 2017-18 academic year, four VC2 events were held on: "Race, identity, and conflict in America," "Gun violence in America," "Gender in the workplace," and "Immigration in America." Facilitators guided participants to share their views and perspectives on these matters with pre-developed open-ended questions. Attendees started discussions in small groups and then eventually combined into a large one. Pre- and post-event surveys were administered to measure the program's effectiveness., Evaluation: One-hundred and twenty-four participants were included, 75 of whom completed both the pre- and post-event surveys. Sixty-four of the 75 (85%) agreed or strongly agreed that "multiple perspectives and opinions were represented" and 73% felt that their "own perspective was broadened on the issue." Most (89%) believed that the format and setting of the event was conducive to dialogue and discussion, and almost all (91%) reported that they would attend a similar event in the future. Groningen Reflection Ability Scale scores were high before (94 [25th-75th: 88-99]) and remained high after the events (93 [25th-75th: 88-93.3], p > 0.05)., Reflection: We successfully implemented a medical center-wide, recurring current events and dialogue forum in hopes of increasing reflection, unity, and understanding across our own community., (© 2021. The Author(s).)

The purpose of the current study was to identify risk factors for deep infection after an open long-bone fracture in pediatric patients. Systematic billing queries were utilized to identify pediatric patients who presented to a level I trauma center from 1998 to 2019 with open long-bone fractures. There were 303 open long-bone fractures, and 24 (7.9%) of these became infected. Fractures of the tibia/fibula ( p = 0.022), higher revised Gustilo-Anderson type ( p = 0.017), and a longer duration of time between the injury and hospital presentation ( p = 0.008) were all associated with the presence of deep infection. Those who went on to have a deep infection also required more operative debridements ( p = 0.022) and a total number of operative procedures ( p = 0.026). The only factor that remained significant in multivariable regression was the duration between the injury and hospital presentation (OR 1.01 [95%CI 1.003-1.017]; p = 0.009), where the odds of deep infection increased by 1% for every minute of delayed presentation.

Introduction: Compared with hemiarthroplasty (HA), reverse total shoulder arthroplasty (RTSA) may provide greater cost and health-related benefits for patients with complex three- and four-part proximal humeral fractures. This study set out to compare RTSA versus HA for the incremental cost per incremental improvement in quality adjusted life years (QALYs) for a hypothetical cohort of patients with proximal humerus fractures., Methods: Parameters and characteristics for a hypothetical cohort of elderly patients with proximal humerus fractures were collected through the literature. A cohort-level Markov decision model was constructed. Incremental cost-effectiveness ratios representing the difference in cost divided by the difference in QALYs were calculated, and scenario, one-way, and probabilistic analysis were conducted., Results: RTSA was associated with lower cost and greater effectiveness compared with HA. The predicted cost difference corresponded to a saving of $99,626 per 100 individuals treated, and the predicted difference in QALY was 16.8 per 100 individuals treated. Results were sensitive to the discount rate, the health-related quality of life assigned to health states, and the cost of the surgical procedures. In probabilistic analysis, 77.1% of iterations were cost-effective at a threshold willingness-to-pay for a QALY of $100,000 US dollars., Discussion: Findings suggest that RTSA may be a cost-effective alternative to HA for treating elderly patients requiring surgery for proximal humerus fractures., Data Availability: The model and corresponding code are available on request to the corresponding author., Level of Evidence Using the Journal of the American Academy of Orthopedic Surgeons Guidance: Level III., (Copyright © 2021 by the American Academy of Orthopaedic Surgeons.)

Objectives : To assess the association between team sport participation and behavioral, psychological, and social health outcomes in young athletes. Methods : A systematic review and meta-analysis were undertaken to identify studies published between 01/01/1950-05/01/2020 investigating the association between team sport participation and health outcomes in young athletes (<25 years). Included studies compared team sport participants to controls or themselves, assessed health outcomes, and had a sample size >50. Prospective and retrospective studies were included; non-primary literature was excluded. Health outcomes were categorized as: 1) behavioral, 2) psychological, or 3) social. Data were extracted to form 2 × 2 tables for each study to calculate odds ratios (OR) and 95% confidence intervals (CI). Results : Of 371 queried articles, 34 studies from 10 countries across 4 continents were included, with 9 reporting homogenous outcomes for meta-analysis.Behavioral: Fifteen studies evaluated behavioral health outcomes of alcohol and/or drug use, fitness, and diet. Quantitatively, team sport participation was found to decrease rates of cigarette/tobacco use across 5 studies (OR 0.72, 95% CI 0.69-0.76) and alcohol/drug use across 7 studies (OR 0.73, 95% CI 0.69-0.77). Qualitatively, 12/15 (80%) of studies confirmed improved behavioral health outcomes with team sport participation.Psychological: Nineteen studies evaluated psychological health outcomes including anorexia, anxiety, depression, self-esteem, and suicidal ideation. Quantitatively, team sport participation was associated with decreased depression/anxiety rates across 5 studies (OR 0.59, 95%CI 0.54-0.64). Qualitatively, 14/19 (74%) of studies confirmed improved psychological health.Social: Ten studies evaluated social health outcomes including academic performance, commitment, psychosocial health, social behavior/identity, and delinquency/high-risk activity. Qualitatively, 7/10 (70%) of studies confirmed improved social health outcomes with team sport participation. Conclusion : Team sport participation was associated with decreased odds of smoking/tobacco use, alcohol/drug use, and depression/anxiety. Though few studies mentioned potential negative effects of team sport participation, the majority reported improved behavioral, psychological, and social health outcomes in youth athletes worldwide.

Abstract: Participation in youth sports can have a positive, lasting impact on a child's general health and physical well-being. Unfortunately, some youth populations are unable to participate and/or reap the benefits of sports because of existing inequities. Youth from lower socioeconomic status and ethnic minority children have been found to participate in sports less. These disparities are unfortunately pervasive and likely the result of multiple barriers, including financial and time constraints, limited resources and the inability to access facilities both in and out of school, and lack of familial support. There also exist inequities with regard to sports injury management, including knowledge, access to athletic trainers, and care. This article provides a review of the numerous disparities and inequities in youth sports. Compiling and understanding these data may help develop a framework to make youth sports more equitable and beneficial for all., (Copyright © 2021 by the American College of Sports Medicine.)

While risk factors for postoperative urinary retention (POUR) after total joint arthroplasty (TJA) have been identified, its association with type of spinal anesthetic has not yet been thoroughly investigated. Patients undergoing primary TJA between 2013-2018 were reviewed. From August 2013 to March 2016 bupivacaine was primarily given and from March 2016 through August 2018, most, although not all, received mepivacaine. Patient demographics as well as intraoperative data were recorded. One-thousand and fifty-four patients were included. POUR rates were not significantly different between groups (5.5% vs 6.1%, p = 0.675). Those who received mepivacaine had a significantly shorter length of stay (LOS) (1 vs. 2 days, p < 0.001). However, spinal anesthetic type was not significantly associated with either POUR or LOS after controlling for between-group differences. Older age (odds ratio [OR] 1.024 [95% confidence interval {CI}:1.000-1.049]; p = 0.049) and a history of benign prostatic hyperplasia or urinary incontinence/retention (OR 2.155 [95% CI:1.114-4.168]; p = 0.023) were confirmed as independent risk factors for POUR. (Journal of Surgical Orthopaedic Advances 29(4):225-229, 2020).

Aim: The potential financial burden of American football-related concussions (FRC) is unknown. Our objective was to describe the healthcare costs associated with an FRC and determine factors associated with increased costs., Methodology/results: A retrospective cohort study of concussed high school football players presenting between November 2017 and March 2020 was undertaken; 144 male high school football players were included. Total costs were about $115,000, for an average direct healthcare cost of $800.10/concussion. Visiting the emergency department (β = 502.29, 95% CI: 105.79-898.61; p = 0.01), the initial post-concussion symptom scale score (β = 0.39, 95% CI: 0.11-0.66; p = 0.01) and a post-concussion syndrome diagnosis (β = 670.37, 95% CI: 98.96-1241.79; p = 0.02) were each independently associated with total costs., Conclusion: A granular understanding of cost-driving factors associated with FRC is the first step in understanding the cost-effectiveness of prevention and treatment methods., Competing Interests: Financial & competing interests disclosure The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties. No writing assistance was utilized in the production of this manuscript., (© 2020 Aaron Yengo-Kahn.)

Background: Fly-fishing requires rhythmic, coordinated movements to successfully cast a fly line. Previous studies have shown that the biomechanical demands of fly-casting may cause some individuals to develop upper extremity pain or injuries., Purpose: To report the rates, trends, and contributing factors of upper extremity pain and overuse injuries in a sample of North American recreational fly-fishers., Study Design: Descriptive epidemiology study., Methods: Participants were reached via 3 popular online fly-fishing forums in April 2019. Each consenting North American participant over 18 years of age was given a link to a unique survey that recorded his or her demographic and orthopaedic histories, fly-fishing experience, equipment, casting techniques, upper extremity pain after fly-fishing, and chronic outcomes., Results: The 162 fly-fishers included were 63.3 (± 11.5) years of age, and 95.1% were men. In total, 59 (36.4%) reported experiencing upper extremity pain immediately after fly-fishing. Pain was rated a 4.0 (interquartile range, 3.0-6.0) on a 10-point Likert scale, commonly lasting less than 1 day (45.0%) or between 1 day and 1 week (45.0%). The majority (62.7%) reported not needing to see a medical provider for their pain/soreness. Those who did most commonly received diagnoses of elbow or rotator cuff tendinitis. Pain/soreness was associated with casting in an elliptical/sidearm fashion, compared with overhead or 2-handed casting ( P = .006) using a weighted line or added weight (split-shot, weighted heads, etc) ( P = .034) and with grip styles where the hand was pronated compared with being in a more neutral position ( P = .046). The mean shortened version of the Disabilities of the Arm, Shoulder and Hand score was 10.8 (± 11.5). Higher scores were associated with a history of self-reported upper extremity orthopaedic injuries (B = 6.059 [95% CI, 2.476-9.642]; SE, 1.814; P = .001) and having had surgery for these injuries (B = 8.484 [95% CI, 4.454-12.513]; SE, 0.314; P < .001)., Conclusion: In this sample of recreational fly-fishers, no aspects of fly-fishing were associated with long-term upper extremity disability, and only a little more than a third reported having transient pain immediately after fishing. Casting style, using weighted lines or added weight, and grip style were all associated with pain. These are modifiable risk factors that can be adjusted to reduce the risk of upper extremity pain immediately after fly-fishing., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: J.E.K. receives compensation for his role as an associate editor of the Journal of Shoulder and Elbow Surgery. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2020.)

As incoming orthopaedic surgery interns, we enter the workforce amidst a global pandemic-a pivotal moment in history. We do not know what the landscape will look like later this summer, but it will most likely be different for each of us and from those of our predecessors. Regardless whether COVID-19 will still be rampant or under better control, we know that we can start our internship and orthopaedic residency embracing a set of principles to "heed the call" no matter the circumstance., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSOA/A182)., (Copyright © 2020 The Authors. Published by The Journal of Bone and Joint Surgery, Incorporated. All rights reserved.)

Little is known about the epidemiology of orthopaedic conditions among the uninsured. This is a descriptive study of 107 patients presenting with 140 orthopaedic conditions for care at the student-run free clinic, the Shade Tree Clinic. Patients were 50.0 (± 13.0) years old with a BMI of 32.9 (± 8.60). About half were female (58.9%), of Spanish origin/Hispanic or Latino descent (50.9%), immigrants (48.3%), and non-English speaking (44.9%). Most presented with chronic (75.5%) conditions of the knee (24.3%), hand (16.4%) and spine (13.6%). While knee osteoarthritis was the most common diagnosis made (18.7%), there were 38 (35.5%) unique diagnoses with only a single occurrence. Most conditions were initially treated nonoperatively (82.9%). There was an average of 1.92 (± 1.44) visits per condition, and 74.0% of conditions had reported improvement or resolution. Though further study is needed, providing free comprehensive patient-centered orthopaedic care to uninsured individuals in a low-cost setting may prove cost-effective. (Journal of Surgical Orthopaedic Advances 29(2):112-116, 2020).

Objective : To determine chronic traumatic encephalopathy (CTE)-related publication characteristics associated with higher Altmetric scores. Methods : A systematic review of the CTE literature was conducted using PubMed. Publications were coded for: journal impact factor (JIF); publication type (primary versus non-primary data collection); discussion of American football; contact sport-CTE association conclusion (yes versus no/neutral); and Altmetric score. Multivariable ordinal logistic regression identified predictors of higher Altmetric scores. Results : Most of the 270 CTE-related publications did not include primary data collection (60%). The median Altmetric score was 12 (range = 0-3745). Higher Altmetric scores were associated with primary data collection [Odds ratio (OR) Adjusted  = 2.29; 95% confidence interval (CI) = 1.35-3.89] and discussing American football (OR Adjusted  = 2.11; 95%CI = 1.24-3.59). Among publications concluding contact sport-CTE associations, higher Altmetric scores were associated with higher JIF (3-point-JIF-increase OR Adjusted = 2.11; 95%CI = 1.24-3.59); however, the association of higher Altmetric scores with higher JIF was not found among neutral publications or those concluding no contact sport-CTE associations (3-point-JIF-increase OR Adjusted  = 1.07; 95%CI = 0.94-1.22). Conclusions : Most CTE-related publications (60%) did not involve primary data collection. Publication characteristics such as higher JIF and concluding contact sport-CTE associations were associated with higher Altmetric scores. It is important for the academic community to consider strategies to counter publication and promotion bias in the presentation of CTE literature.

A positive relationship between sport-related concussion (SRC) history and depressive symptoms in retired National Football League (NFL) athletes has been observed, with self-rated physical functioning identified as a confounding factor. The authors examined the influence of somatic symptom endorsement on the relationship between SRC history and self-reported depressive symptom severity in retired NFL athletes. Forty-three former NFL athletes completed self-report inventories of depression (with the Beck Depression Inventory II) and somatic symptoms (with the adjusted Patient Health Questionnaire-15). A moderation analysis examined the influence of somatic symptoms on the relationship between SRC history and depressive symptom severity. SRC history and somatic symptoms accounted for a significant amount of depressive symptomology. SRC history was not significantly associated with depressive symptom severity at low levels of somatic symptoms but was significant at the mean and high levels. The effect of somatic symptoms on depressive symptoms was nearly twice that of SRC history. The relationship between SRC and depression is complex, and treatment of depression in retired athletes should address comorbid somatic symptoms.

Vanderbilt University School of Medicine recently changed from 2 pre-clerkship years (Traditional curriculum) to a 1.5-year pre-clerkship phase for one class (Hybrid curriculum) to a 1-year pre-clerkship phase (Curriculum 2.0). This study investigated the relationship between shortened pre-clerkship training and stress associated with selecting a residency field. The surveyed graduating medical student population included one cohort from the Traditional and Hybrid curricula, and the first two cohorts from Curriculum 2.0. The authors modeled recollected stress levels using a Zero-Inflated Linear Mixed Model with additional covariate and random effects adjustments. Specialty decision-related stress levels increased in the Hybrid curriculum by 10.208 points [ p  = 0.0115, 95% CI 2.293, 18.122] on a 0-100 point scale. Curriculum 2.0 students had an insignificant increase in stress of 4.062 points [ p  = 0.304, 95% CI - 3.690, 11.814] relative to the Traditional curriculum. Time since starting medical school and time when a specialty was chosen were the largest factors associated with stress. While this study only evaluated a single facet of the potential downstream effects of curricular change, these data should inspire confidence for reform efforts as a significant increase in specialty decision-related stress present in Hybrid curriculum resolved in both cohorts of Curriculum 2.0., Competing Interests: Conflict of InterestThe authors report no conflicts of interest or disclosures., (© International Association of Medical Science Educators 2019.)

Objectives: To provide students at our own institution with more accurate and granular data regarding the costs associated with applying for residency., Methods: We created an electronic survey with >28 different fields delineating the costs associated with applying for residency. Demographic data, costs broken down by type of expenditure, and how these costs were financed were measured. Each year, graduating students at our institution took the survey in 2015, 2016, 2017, and 2018 before The Match. We then created a dynamic, user-friendly, and interactive Web-based application to display these data numerically and graphically for students to use while planning and preparing for The Match., Results: There was a response rate of 48.9% (194/397). Overall, students completed an away rotation at a median of 1.0 (interquartile range [IQR] 0-2.0) programs and spent $1000 (IQR $292-$1606) per away rotation. They applied to a median of 30.0 (IQR 20.0-47.8) categorical programs and attended 12.0 (IQR 10.0-16.0) interviews. The cost per interview was $282 (IQR $192-$407). The total expenditures for preparing for residency were $4992 (IQR $3034-$8,274). These numbers varied significantly by intended specialty. Differences were noted between our data and those from both a regional and recent national cohort., Conclusions: The costs associated with applying for residency are relatively unknown and can be significant for some. Institutionally led efforts may allow students to more appropriately plan and budget for The Match. Other institutions may benefit from a similar program.

Context: Postconcussion deficits in neurocognitive performance and postural control may persist at the time of return to sport participation. How these deficits, if present, affect athletic performance is largely unknown, with prior studies showing mixed results., Objective: To evaluate postconcussion National Hockey League player performance using advanced hockey metrics over short- (5 games), medium- (10 games), and long-term (remainder of the season) seasonal performance., Design: Retrospective cohort study., Patients or Other Participants: National Hockey League players who sustained a sport-related concussion (SRC; n = 93) and returned during the same season and players (n = 51) who missed time for non-injury-related reasons., Main Outcome Measure(s): Six performance metrics were used: (1) points per 60 minutes, (2) Corsi percentage, (3) personal Fenwick shooting percentage, (4) scoring chances per 60 minutes, (5) penalty difference, and (6) PDO (not an acronym but sometimes referred to as SVSP% [save percentage shooting percentage]). Performance was compared using 2 (group) × 2 (time) repeated-measures analyses of variance for 3 time windows: (1) ±5 games, (2) ±10 games, and (3) the remainder of the season postconcussion. Alpha values were set at a conservative .01 to account for the lack of independence among dependent variables., Results: No significant interactions were present for any of the 6 dependent variables at any of the 3 time windows. Overall, none of the secondary variables differed., Conclusions: Using advanced, sport-specific metrics, we found that National Hockey League players did not display worse seasonal performance during 3 postinjury time frames after they sustained an SRC. Whereas laboratory studies have identified lingering neurologic deficits after concussion, our results suggest that these deficits, if present, either do not translate to worse athletic performance or were not captured by these 44 metrics. Further, prospective efforts are needed to accurately quantify performance after SRC among professional hockey players.

Youth athletics can provide numerous benefits to children. Until recently, athletics have been relatively free from scrutiny over the ways they put participants at risk. While it was often disregarded in early childhood research, athletics emerged as an avenue of child abuse in the 1980s. Individual cases reporting maltreatment of children participating in sports certainly existed, but these were felt to be single instances, not sentinel events. By the 1990s a small body of research had been established showing a pattern of abuse, spurring sporting organizations and governing bodies to assess their own policies and produce rough standards for safeguarding children against abuse. While multiple strides have been taken, there still exist gaps in knowledge surrounding abuse of child and adolescent athletes. This article reviews the scope and prevalence of abuse in youth athletics, definitions and what ultimately constitutes "abuse," the unique aspects of abuse in sport, and recognition and preventative efforts.

Objective: The empirical identification of risk factors associated with sport-related concussion (SRC) may improve the management of student-athletes. The current study attempted to identify and quantify bio-cognitive risk factors associated with sustaining a SRC., Methods: Cross-sectional ambispective study; level of evidence, 3. Neurocognitive testing of 12,320 middle school, high school and collegiate athletes was completed at preseason baseline and post-SRC. Univariate and multivariable logistic regressions were used to determine which pre-injury variables accurately predicted the occurrence of SRC. A quantitative risk score for each variable was developed., Results: Five of 13 variables maintained significance in the multivariable model with the associated weighted point scores: SRC history (21), prior headache treatment (6), contact sport (5), youth level of play (7), and history of ADHD/LD (2). Six stratified groups were formed based on probability of SRC, which produced an area under the curve (AUC) of 0.71 (95% CI 0.69-0.72, p < .001). Though the model was a significant predictor of SRC (X2 = 1,112.75, p < .001), the effect size was small and accounted for only 16% of the overall variance., Conclusions: An initial aggregate model of weighted bio-cognitive factors associated with increased odds of sustaining a SRC was developed. Previously validated factors were confirmed, yet a large source of variance remained unexplained. These findings emphasize the need to expand the host factors studied when assessing SRC risk, and that the existing, empirically based bio-cognitive factors do not adequately quantify the risk of SRC.

This study aimed to determine if gameplay performance in the National Football League (NFL) is adversely affected after returning to play from a sport-related concussion (SRC). Players who sustained a SRC between the 2007-2008 and 2013-2014 seasons were identified. Concussed players were matched to nonconcussed control players in a 2:1 (control-case) fashion by position, season, experience, age, body mass index, and time missed. Gameplay statistics were recorded for the three games before and after returning from SRC. When compared with the control group, the majority of NFL players did not demonstrate any performance-based deficits on returning to play after SRC. However, concussed quarterbacks (QBs) displayed a reduced QB rating compared with controls. These results indicate that performance immediately following return from SRC may be adversely affected in certain populations and circumstances, though the overwhelming majority of players showed no decline in performance. (Journal of Surgical Orthopaedic Advances 27(3):187-197, 2018).

Objective: Amid the public health controversy surrounding American football, a helmet that can reduce linear and rotational acceleration has the potential to decrease forces transmitted to the brain. The authors hypothesized that a football helmet with an outer shell would reduce both linear and rotational acceleration. The authors' objectives were to 1) determine an optimal material for a shock-absorbing outer shell and 2) examine the ability of an outer shell to reduce linear and/or rotational acceleration., Methods: A laboratory-based investigation was undertaken using an extra-large Riddell Revolution football helmet. Two materials (Dow Corning Dilatant Compound and Sorbothane) were selected for their non-Newtonian properties (changes in viscosity with shear stress) to develop an outer shell. External pads were attached securely to the helmet at 3 locations: the front boss, the side, and the back. The helmet was impacted 5 times per location at 6 m/sec with pneumatic ram testing. Two-sample t-tests were used to evaluate linear/rotational acceleration differences between a helmet with and a helmet without the outer shell., Results: Sorbothane was superior to the Dow Corning compound in force reduction and recovered from impact without permanent deformation. Of 5 different grades, 70-duro (a unit of hardness measured with a durometer) Sorbothane was found to have the greatest energy dissipation and stiffness, and it was chosen as the optimal outer-shell material. The helmet prototype with the outer shell reduced linear acceleration by 5.8% (from 75.4g to 71.1g; p < 0.001) and 10.8% (from 89.5g to 79.8g; p = 0.033) at the side and front boss locations, respectively, and reduced rotational acceleration by 49.8% (from 9312.8 rad/sec2 to 4671.7 rad/sed2; p < 0.001) at the front boss location., Conclusions: Sorbothane (70 duro) was chosen as the optimal outer-shell material. In the outer-shell prototype helmet, the results demonstrated a 5%-10% reduction in linear acceleration at the side and front boss locations, and a 50% reduction in rotational acceleration at the front boss location. Given the paucity of publicly reported helmet-design literature and the importance of rotational acceleration in head injuries, the substantial reduction seen in rotational acceleration with this outer-shell prototype holds the potential for future helmet-design improvements.

Objectives: This study investigated the relationship between on-field, objective signs immediately following sport-related concussion and self-reported symptom endorsement within 1 day post injury., Methods: A retrospective case series of 237 concussed high school athletes was performed. On-field signs were evaluated immediately post injury. Self-reported symptoms (2 clusters) were collected within 1 day post injury. A two-step structural equation model and follow-up bivariate regression analyses of significant on-field signs and symptom clusters were performed., Results: Signs of immediate memory, β=0.20, p=.04, and postural instability, β=0.19, p < .01, significantly predicted a greater likelihood of endorsing the cognitive-migraine-fatigue symptom cluster within 1 day post injury. Regarding signs correlated with specific symptoms, immediate memory was associated with symptoms of trouble remembering, χ 2 =37.92, p < .001, odds ratio (OR)=3.89 (95% confidence interval (CI) [2.47, 6.13]), and concentration difficulties, χ 2 =10.84, p=.001, OR=2.13 (95% CI [1.37, 3.30]). Postural instability was associated with symptom endorsement of trouble remembering, χ 2 =12.08, p < .001, OR=1.76 (95% CI [1.29, 2.40])., Conclusions: Certain post-concussion on-field signs exhibited after injury were associated with specific symptom endorsement within 1 day post injury. Based on these associations, individualized education-based interventions and academic accommodations may help reduce unanticipated worry from parents, students, and teachers following a student-athlete's sport-related concussion, especially in cases of delayed onset symptoms. (JINS, 2018, 24, 476-485).

Background: Schedule-based and in-season factors (e.g., competition type) have been shown to be associated with symptom reporting patterns and injury severity in sport-related concussion (SRC). To determine if acute neurocognitive and symptom presentation following SRC differ by time point within a high school football season., Methods: Multicenter ambispective cohort of high school football players who sustained a SRC (N = 2594). Timing (early, mid, and late season) of SRC was based on median dates for the start of the pre-season, regular season, and playoffs of each states' football schedules. Analysis of covariance (ANCOVA) investigated differences across season period groups for: (1) neurocognitive test scores, (2) total symptom scores (TSS), and (3) individual symptom increases from baseline within 1-week post-injury., Results: Significant group differences were observed in TSS, F(2, 2589) = 15.40, p <  0.001, η p 2  = 0.01, and individual symptom increases from baseline, F(2, 2591) = 16.40, p <  0.001, η p 2  = 0.01. Significant increases were seen from baseline to both midseason and late season in both TSS, χ 2  = 24.40, p <  0.001, Φ = 0.10 and individual symptoms, χ 2  = 10.32, p = 0.006, Φ = 0.10. Post hoc tests indicated a linear trend, with late-season injured athletes reporting approximately twice the TSS (13.10 vs. 6.77) and new symptoms (5.70 vs. 2.68) as those with early-season injuries., Conclusion: In a cohort of American high school football student-athletes, those suffering SRC in the late-season time period had increased acute symptom burden. SRC sustained later in-season may require more conservative management.

Background: The risk of sport-related concussion (SRC) has emerged as a major public health concern. In rare instances, sport-related head injuries can be even more severe, such as subdural hemorrhage, epidural hemorrhage, or malignant cerebral edema. Unlike SRCs, sport-related structural brain injury (SRSBI) is rare, may require neurosurgical intervention, and can lead to permanent neurologic deficit or death. Data characterizing SRSBI are limited, and many have recognized the need to better understand these catastrophic brain injuries. The goal of the current series is to describe, in detail, the presentation, management, and outcomes of examples of these rare injuries., Case Description: During the fall of 2015, three high school football players presented with acute subdural hemorrhages following in-game collisions and were treated at our institution within a span of 2 months. For the 2 athletes who required surgical intervention, a previous SRC was sustained within 4 weeks before the catastrophic event. One year after injury, 2 players have returned to school, though with persistent deficits. One patient remains nonverbal and wheelchair bound. None of the athletes has returned to sports., Conclusions: Acute subdural hemorrhage resultant from an in-game football collision is rare. The temporal proximity of the reported SRSBIs to recent SRCs emphasizes the importance of return-to-play protocols and raises questions regarding the possibility of second impact syndrome. Although epidemiologic conclusions cannot be drawn from this small sample, these cases provide a unique opportunity to demonstrate the presentation, management, and long-term outcomes of SRSBI in American high school football., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Hip disorders in athletes have been increasingly recognized., Purpose: To characterize radiographic hip anatomy for National Hockey League (NHL) players and correlate it with hip range of motion and hip symptoms and/or surgery., Study Design: Cross-sectional study; Level of evidence, 3., Methods: Fifty-nine professional hockey players (118 hips) with 1 NHL organization (mean age, 24.2 years; range, 18-36) prospectively underwent history and physician examination by 2 independent orthopaedic surgeons. Current or previous groin and/or hip pain or surgery was noted. Anteroposterior (AP) pelvis and bilateral Dunn lateral radiographs were obtained for all players with assessment of hip morphology by 2 blinded independent orthopaedic surgeons., Results: Good to very good reliability of radiographic assessments was noted (intraclass correlation coefficients = 0.749-0.958). Sixty-four percent of athletes had a positive crossover sign, while 86% and 60% had a positive posterior wall sign and a prominent ischial spine sign, respectively. Twenty-one percent of hips demonstrated dysplastic acetabular features (lateral center edge angle <25°). Eighty-five percent and 89% of hips demonstrated cam-type morphology based on alpha angle (>50° Dunn lateral) and head-neck offset, respectively. Good to very good reliability was noted for ROM assessments (intraclass correlation coefficient >0.69). Mean hip flexion was 107.4º ± 6.7º, and mean hip internal rotation was 26.1º ± 6.6º. Thirty-one percent of hips had a history of hip-related pain and/or surgery. Higher AP, Dunn lateral, and maximal alpha angles correlated with decreased hip internal rotation ( P = .004). Greater AP alpha angle correlated with decreased hip extension/abduction ( P = .025), and greater Dunn lateral and maximal alpha angle correlated with decreased hip flexion/abduction ( P = .001). A positive posterior wall sign correlated with increased straight hip abduction, while other radiographic acetabular parameters were not predictive of range of motion. Only decreased hip external rotation and total arc of motion correlated with an increased risk for current or prior hip symptoms or surgery ( P < .001)., Conclusion: Hip anatomy in NHL players is characterized by highly prevalent cam-type morphology (>85%) and acetabular retroversion (>60%). In addition, acetabular dysplasia (21%) was relatively common. Greater cam-type morphology correlated with decreased hip range of motion, and a positive crossover sign correlated with increased hip abduction. Decreased hip external rotation and total arc of motion were predictive of hip-related pain and/or surgery.

OBJECTIVE A significant proportion of patients experience long-term symptoms after sport-related concussion (SRC), and several factors have been associated with this protracted recovery. Limited data exist on the role of socioeconomic status (SES) on SRC outcomes. The objective in this study was to conduct a preliminary investigation to determine the effect of SES on outcomes after SRC in student-athletes treated at a regional sports concussion center. METHODS A retrospective cohort study of 282 middle school, high school, and collegiate student-athletes was conducted. An attempt was made to contact all patients seen at a comprehensive SRC center between January 2012 and May 2015 for in-depth interviews. Subsequent demographic data were collected. The SES was defined as follows: cost of living percentile, median income percentile, percentage of college graduates, percentage of homeowners, county type, and insurance status. Outcomes after SRC were defined as follows: days of symptom duration, days of missed school, and days of missed practice. Statistically controlled covariates included sex, race, age, body mass index, concussion history, neuropsychiatric history, and type of sport. RESULTS A total of 282 student-athletes consented and were studied. The median age was 15.8 years (range 11.6-22.2 years) and 61.4% of student-athletes were male. A previous concussion was incurred by 34.0% of student-athletes. Football was the most common sport (32.3%), followed by soccer (16.3%), and basketball (15.6%). The median symptom duration was 21 days (range 1-365 days); the median missed school days was 2 (range 0-90 days); and median for days of missed practice was 10 (range 0-150 days). After multivariate Cox regression analysis, no relationship between any of the 6 SES variables and symptom duration or missed practice was seen. However, individuals with private insurance had more missed days of school than those with public insurance (hazard ratio 0.46, 95% CI 0.26-0.83, p = 0.009). CONCLUSIONS In a preliminary study of middle school, high school, and collegiate student-athletes, SES had no impact on the outcomes of symptom duration and missed practice. However, for individuals with private insurance, the return to school was slower than for those with public insurance. This pilot study reveals the complex relationship between SES and SRC recovery, which demands further study with more accurate and validated assessments of SES.

Background: Structural brain changes, potentially resulting from repetitive brain trauma (RBT), have been correlated with neurocognitive decline and increased symptom reporting in retired athletes., Hypothesis: In a cohort of retired National Football League (NFL) players, the relationships between 3 neuroimaging parameters, neuropsychological testing, and symptom scores will be significantly correlated., Study Design: Cross-sectional study., Level of Evidence: Level 3., Methods: Comprehensive magnetic resonance imaging was performed in 45 retired NFL players. Three neuroanatomical parameters were assessed by board-certified radiologists blinded to the purpose of the study: (1) the absence or presence of small or large cavum septum pellucidum, (2) a global mean score of fractional anisotropy (FA), and (3) the presence or absence of microhemorrhages. The subjects underwent a battery of 9 paper-and-pencil neuropsychological tests, a computerized neurocognitive test, and multiple symptom and depression scales. The associations among the neuroimaging results with these outcome measures were assessed utilizing Pearson, Spearman rank, and point-biserial correlations., Results: The 45 subjects (mean age, 46.7 ± 9.1 years) reported a mean 6.9 (±6.2) concussions and 13.0 (±7.9) "dings" in the NFL. Ten (22%) did not have a cavum septum pellucidum, while 32 (71%) had a small and 3 (7%) had a large one. Four (9%) had microhemorrhages. Global FA mean was 0.459 (±0.035). The majority (50.8%) of correlations among the neuroimaging parameters and neurocognitive/symptom scores fell below the threshold of "small" effect size ( r < 0.10). The remaining (49.2%) correlations were between "small" and "medium" effect sizes (0.1 < r < 0.3). However, all correlations were statistically nonsignificant., Conclusion: There were minimal and statistically nonsignificant correlations among the neuroimaging, neurocognitive, and symptom scores examined in this cohort of NFL retirees., Clinical Relevance: Associating the severity of structural brain changes to neurocognitive performance and symptom burden after RBT is complex may involve other moderating variables or biomarkers, and demands further study.

Purpose: In a series of solid organ transplant (SOT) recipients who underwent a subsequent primary total joint arthroplasty (TJA) procedure, this study aimed to determine: (1) 90-day morbidity and mortality after primary total knee or hip arthroplasty (TKA and THA), (2) overall post-operative infection rates, and (3) how complication and infection rates compared across primary TJA procedure and type of transplant organ., Methods: The University of Michigan Health System database was retrospectively searched using current procedural terminology codes for any primary TKA or THA performed at the institution in years 2000-2012 in a patient who previously received a successful SOT at any hospital., Results: The search yielded 44 arthroplasties performed in 29 SOT recipients (average age 54.8 years, average follow-up about 30 months for both groups). No deaths were reported, but 13/27 (48.1%) THA patients and 2/6 (33.3%) TKA patients experienced a total of 29 complications within 90 days of surgery. One patient (3.7%) [1/27 patients, 1/37 joints] underwent revision hip arthroplasty to correct limb length. One THA patient and two TKA patients developed infection requiring revision surgery (3.7% and 33%, respectively). Type of transplant did not affect complication rates (P=0.65), and infection was more common after TKA (P=0.01)., Conclusions: A series of SOT recipients demonstrated increased rates of infection and other complications following TJA. Surgical and medical teams should work closely to optimize this population for TJA surgery and minimize peri-operative complications., Level of Evidence & Study Design: Level IV, Prognostic Case-Series.

The purpose of this study was to evaluate the antiproliferative and antigenotoxic activity of Sambucus australis Cham. & Schltdl. aqueous extracts on the cell cycle of Allium cepa L. as well as determine the phenolic compounds in such extracts. S. australis inflorescences and leaves of two accessions were used for aqueous extract preparation at concentrations: 0.003 g/ml and 0.012 g/ml. A. cepa bulbs were rooted in distilled water and, subsequently, placed in treatments for 24 hours. Rootlets were collected and fixed in modified Carnoy's solution for 24 hours and kept. The squash technique was performed for slide preparation. Root tips were smashed and stained with 2% acetic orcein, and a total of 4000 cells per treatment were analyzed. The phenolic compounds were determined using high-performance liquid chromatography and data was analyzed using the Scott-Knott test. The results show that S. australis aqueous extracts have antiproliferative potential. Besides, the extracts prepared from S. australis leaves of both accessions at a concentration of 0.012 g/ml have shown antigenotoxic activity. The phytochemical analysis allowed us to determine the presence of flavonoids and phenolic acids, of which kaempferol and chrologenic acid were the most predominant compounds in the extracts from the inflorescences and leaves, respectively.