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Background: Basketball-related fractures involving the lower extremities frequently present to emergency departments (ED) in the United States (US). This study aimed to identify the primary mechanisms, distribution, and trends of these injuries., Hypothesis: We hypothesize that (1) lower extremity fracture frequency will decrease from 2013 to 2022, (2) the ankle will be the most common fracture site, and (3) noncontact twisting will be the most common injury mechanism., Study Design: Descriptive epidemiological., Level of Evidence: Level 3., Methods: The National Electronic Injury Surveillance System (NEISS) was queried for lower extremity fractures from basketball presenting to US EDs from January 1, 2013 to December 31, 2022. Patient demographics, injury location, and disposition were recorded. The injury mechanism was characterized using the provided narrative. National estimates (NEs) were calculated using the NEISS statistical sample weight. Injury trends were evaluated by linear regression., Results: There were 6259 cases (NE: 185,836) of basketball-related lower extremity fractures. Linear regression analysis of annual trends demonstrated a significant decrease in lower extremity fractures over the study period (2013-2022: P = 0.01; R 2 = 0.64). The most common injury mechanism was a noncontact twisting motion (NE: 49,897, 26.9%) followed by jumping (NE: 39,613, 21.3%). The ankle was the most common fracture site (NE: 69,936, 37.6%) followed by the foot (NE: 49,229, 26.49%). While ankle and foot fractures decreased significantly ( P < 0.05), fractures of the lower leg, knee, toe, and upper leg showed no significant trends ( P = 0.09, 0.75, 0.07, and 0.85, respectively)., Conclusion: Basketball-related lower extremity fractures decreased from 2013 to 2022, with the ankle being the most common fracture site and most fractures arising from a noncontact twist. Increasing utilization of outpatient clinics may have contributed to the decline, particularly for ankle and foot fractures. The prevalence of ankle fractures and twisting-related injuries reinforces the importance of protective footwear and targeted strengthening protocols., Competing Interests: The following authors report potential conflicts of interest: R.L.P has received educational support from Gotham Surgical Solutions and Devices. J.D.K. has received educational support from Paladin Technology Solutions and hospitality from Baxter Healthcare. D.P.T. has received educational support from Gotham Surgical Solutions and Devices and Arthrex.

Objectives: Nearly 3 million children participate in youth soccer annually in the United States. Popularity of youth soccer within recent years has prompted investigation describing youth-soccer concussion trends presenting to United States emergency departments (EDs)., Methods: Data from National Electronic Injury Surveillance System were analyzed for soccer players 2-18 years old sustaining concussions from January 2013 to December 2022. Patient data included age, sex, mechanism of injury, setting (practice vs. game), diagnosis, loss of consciousness, and disposition. Raw data were used to calculate national estimates based on assigned statistical sample weight of each hospital., Results: A total of 80,582 youth soccer concussions were diagnosed in US EDs (51.0% female, 49.0% male). The most common mechanism of injury was head to ball (31.0%). On average, overall concussions decreased by 572 per year ( p  = 0.02). Head to body concussions decreased by 169 per year ( p < 0.01) and head to ground concussions decreased by 155 per year ( p  < 0.01). No changes per year in concussion trends for head to ball, head to head, not specified, and other mechanisms. Exclusion of years 2020 and 2021 (COVID), demonstrated decreases in concussions for head to body by 125 ( p = 0.01) and head to ground mechanisms by 135 per year ( p  = 0.01)., Conclusion: There is a decreasing trend in youth soccer head injuries and concussions presenting to US emergency departments from 2013 to 2022. The trends from this study indicate that heading may be the most important aspect of soccer-related concussions presenting to US emergency departments. This study contributes to the growing literature regarding concussions in youth soccer athletes.

Surfer's neurapraxia is a rare surfing injury of the saphenous nerve secondary to persistent compression of the saphenous nerve along the medial thigh by the surfboard when paddling prone and while sitting upright on the board waiting for a wave. Symptoms may be nonspecific and consist of pain in the medial thigh with or without radiation along the saphenous nerve distribution (medial leg, medial ankle, medial arch of the foot). The saphenous nerve tension test can be utilized to reproduce the symptoms of surfer's neurapraxia. Treatment consists of conservative management while refractory cases may benefit from injection with local anesthetic. The authors propose the Obana Plan (WATER) for prevention of surfer's neurapraxia, consisting of Wetsuits, Abduction, Timing, Exercise, and Rest. Overall, surfer's neurapraxia is a benign condition that can be prevented and managed conservatively.

Background: While prevention protocols have been implemented, skiing-related musculoskeletal injuries and concussions continue to present to emergency departments in the United States. Previous literature has suggested the pediatric population may constitute up to 40% of skiing-related injuries., Purpose: To assess injury trends and the underlying mechanisms of skiing injuries in pediatric patients seen at emergency departments in the United States., Study Design: Descriptive epidemiology study., Methods: The National Electronic Injury Surveillance System (NEISS) was queried for pediatric (age ≤18 years) skiing injuries between January 1, 2012, and December 31, 2022. Injury mechanism, location, disposition, and diagnosis were recorded, and the statistical sample weight assigned by NEISS by hospital was used to calculate national estimates (NEs). Injury trends were evaluated with linear regression analysis., Results: Overall, 2951 pediatric skiing injuries were included (NE = 123,386). The mean age of the patients was 12.4 ± 3.5 years, with 61.3% of the injuries occurring in male patients. Impact with the ground was the most common injury mechanism (NE = 87,407; 70.8%). Fractures were the most common diagnosis (NE = 38,527, 31.2%), followed by strains/sprains (NE = 22,562, 18.3%), contusions/abrasions (NE = 16,257, 13.2%), and concussions (NE = 12,449, 10.1%). The lower leg was the most common fracture site (NE = 9509, 24.7%), followed by the shoulder (NE = 7131, 18.5%) and lower arm (NE = 5876, 15.3%). Analysis of annual injuries revealed no significant trend between 2012 and 2022 ( P  = .17), with fluctuations apparent throughout the study period. Significant decreases were seen in strains/sprains ( P  < .01) and contusions/abrasions ( P  < .01), but not in concussions ( P  = .57) or fractures ( P  = .70)., Conclusion: Impacts with the snow/ground made up 70.8% of all injuries. Fractures were the most common injury diagnosis, followed by strains/sprains, with the lower leg being most frequently fractured. While strains/sprains and contusions/abrasions showed a significant decline, there were no significant trends in fractures and concussions between 2012 and 2022., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: E.I.H. has received nonconsulting payments from Bioventus and hospitality payments from AbbVie, AstraZeneca Pharmaceuticals, and Aesculap. K.D.P. has received education payments from Gotham Surgical; nonconsulting fees from Bioventus and Linvatec; consulting fees from Anika Therapeutics, Flexion Therapeutics, Heron Therapeutics, and Smith+Nephew; and hospitality payments from Aesculap Biologics. D.P.T. has received grant support from Arthrex and education payments from Arthrex and Smith+Nephew. R.L.P. has received grant support and education payments from Arthrex. 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) 2024.)

Objectives: This study investigates the most common online patient questions pertaining to posterior cruciate ligament (PCL) injuries and the quality of the websites providing information., Methods: Four PCL search queries were entered into the Google Web Search. Questions under the 'People also ask' tab were expanded in order and 100 results for each query were included (400 total). Questions were categorized based on Rothwell's Classification of Questions (Fact, Policy, Value). Websites were categorized by source (Academic, Commercial, Government, Medical Practice, Single Surgeon Personal, Social Media). Website quality was evaluated based on the Journal of the American Medical Association (JAMA) Benchmark Criteria. Pearson's chi-squared was used to assess categorical data. Cohen's kappa was used to assess inter-rater reliability., Results: Most questions fell into the Rothwell Fact category (54.3%). The most common question topics were Diagnosis/Evaluation (18.0%), Indications/Management (15.5%), and Timeline of Recovery (15.3%). The least common question topics were Technical Details of Procedure (1.5%), Cost (0.5%), and Longevity (0.5%). The most common websites were Medical Practice (31.8%) and Commercial (24.3%), while the least common were Government (8.5%) and Social Media (1.5%). The average JAMA score for websites was 1.49 ± 1.36. Government websites had the highest JAMA score (3.00 ± 1.26) and constituted 42.5% of all websites with a score of 4/4. Comparatively, Single Surgeon Personal websites had the lowest JAMA score (0.76 ± 0.87, range [0-2]). PubMed articles constituted 70.6% (24/34) of Government websites, 70.8% (17/24) had a JAMA score of 4 and 20.8% (5/24) had a score of 3., Conclusion: Patients search the internet for information regarding diagnosis, treatment, and recovery of PCL injuries and are less interested in the details of the procedure, cost, and longevity of treatment. The low JAMA score reflects the heterogenous quality and transparency of online information. Physicians can use this information to help guide patient expectations pre- and post-operatively.

Background: Surfing is an increasingly popular sport with a high propensity for both traumatic and atraumatic injuries., Purpose: To analyze the trends, etiologies, and diagnoses of lower extremity orthopaedic-related surfing injuries presenting to United States (US) emergency departments (EDs) within a 21-year study period., Study Design: Descriptive epidemiology study., Methods: The National Electronic Injury Surveillance System database was queried for data on lower extremity surfing injuries presenting to US EDs from January 1 to December 31, 2022. Data collected included year, injury mechanism, injury location, diagnosis, and disposition. The raw data were used to calculate national estimates (NEs) based on each hospital's assigned statistical sample weight. Linear regressions were performed to analyze annual trends., Results: A total of 776 lower extremity surfing injuries were included (NE = 49,218 injuries). The mean age of the patients was 29.4 ± 13.6 years. The most common injured areas were the foot (NE = 17,411; 35.4%), lower leg (NE = 8673, 17.6%), and knee (NE = 8139; 16.5%). The most common mechanism of injury was impact with board (NE = 17,144; 34.8%), and the most common fracture locations were the lower leg (NE = 1195; 29.5%), ankle (NE = 1594; 24.5%), and foot (NE = 1495; 23.0%). There were statistically significant decreases in weighted estimates for lower extremity surfing injuries by 108 per year ( P < .001), for lacerations by 76 per year ( P < .001), and for sprains by 18 per year ( P = .01). Impact-with-board injuries decreased by 59 injuries per year ( P < .001) and constituted 63.5% of lacerations and 12.1% of fractures. Only 3.9% of patients were admitted for hospitalization., Conclusion: There was a decreasing trend in lower extremity surfing injuries presenting to US EDs during the 21-year study period., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: B.M.S. has received a grant from Arthrex, education payments from Arthrex and Smith & Nephew, and consulting fees from Bioventus. R.L.P. has received grant support and education payments from Arthrex. D.P.T. has received grant support from Arthrex and education payments from Arthrex and Smith & Nephew. 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) 2024.)

Objective: Evaluate injury trends in Brazilian Jiu Jitsu (BJJ) participation by presenting to U.S. emergency departments over a 10-year period and formulate an injury profile., Methods: The U.S. Consumer Product Safety Commission's (CPSC) National Electronic Injury Surveillance System (NEISS) database was queried for martial arts related injuries from 1 January 2012 to 31 December 2021. Codes and narratives were examined to compile data for patients sustaining BJJ-related injuries., Results: From 1 January 2012 to 31 December 2021 there were 7,722 (NE = 282,315) ED-diagnosed martial arts related injuries with 911 (NE = 36,023) BJJ-related injuries identified. Regression analysis demonstrated an increasing trend in the annual incidence of Brazilian Jiu Jitsu injuries presenting to the ED (R2 = 0.934; SE = 2.069: p  < .0001). Average age was 25.68 years of age (range 4-83). The most common injury diagnoses were sprains/strains and other/not listed at 27.68% and 26.39%. The most commonly injured body parts were the upper trunk, and the shoulder comprising 13.66% and 12.14% of injured body parts, respectively. The most commonly fractured region was toes, at 14.15% of all fractures. The most common dislocations occurred at the shoulder and knee, at 32.49% and 28.45% of dislocations, respectively. The most common mechanisms of injury specifically identified were indeterminate contact between players, fall onto ground, or fall onto another player comprising 18.62% and 17.17%, of injuries, respectively., Conclusion: There was an increasing trend of BJJ-related injuries presenting to U.S. Emergency Departments. The most common diagnoses and body parts injured were sprains/strains and upper trunk and shoulder, respectively. The most commonly fractured and dislocated regions were toes and shoulder, respectively. The most common mechanisms of injury were indeterminate contact or falling. This study provides novel information concerning trends in injury and injury profiles for Brazilian Jiu Jitsu related injuries.

Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/H924).

Background: Management of acromioclavicular (AC) joint injuries has been an ongoing source of debate, with over 150 variations of surgery described in the literature. Without a consensus on surgical technique, patients are seeking answers to common questions through internet resources. This study investigates the most common online patient questions pertaining to AC joint injuries and the quality of the websites providing information., Hypothesis: 1) Question topics will pertain to surgical indications, pain management, and success of surgery and 2) the quality and transparency of online information are largely heterogenous., Methods: Three AC joint search queries were entered into the Google Web Search. Questions under the "People also ask" tab were expanded in order and 100 results for each query were included (300 total). Questions were categorized based on Rothwell's classification. Websites were categorized by source. Website quality was evaluated by the Journal of the American Medical Association (JAMA) Benchmark Criteria., Results: Most questions fell into the Rothwell Fact category (48.0%). The most common question topics were surgical indications (28.0%), timeline of recovery (13.0%), and diagnosis/evaluation (12.0%). The least common question topics were anatomy/function (3.3%), evaluation of surgery (3.3%), injury comparison (1.0%), and cost (1.0%). The most common websites were medical practice (44.0%), academic (22.3%), and single surgeon personal (12.3%). The average JAMA score for all websites was 1.0 ± 1.3. Government websites had the highest JAMA score (4.0 ± 0.0) and constituted 45.8% of all websites with a score of 4/4. PubMed articles constituted 63.6% (7/11) of government website. Comparatively, medical practice websites had the lowest JAMA score (0.3 ± 0.7, range [0-3])., Conclusion: Online patient AC joint injury questions pertain to surgical indications, timeline of recovery, and diagnosis/evaluation. Government websites and PubMed articles provide the highest-quality sources of reliable, up-to-date information but constitute the smallest proportion of resources. In contrast, medical practice represents the most visited websites, however, recorded the lowest quality score. Physicians should utilize this information to answer frequently asked questions, guide patient expectations, and help provide and identify reliable online resources., (© 2024 The Author(s).)

Purpose: To analyze epidemiology, mechanisms, and diagnoses of upper extremity volleyball injuries in youth who present to United States emergency departments., Methods: Data from the National Electronic Injury Surveillance System were analyzed for upper extremity volleyball injuries in patients ≤18 years old from January 1, 2012, to December 31, 2022. Data were collected for body part, diagnosis, mechanism of injury, and disposition. Weighted national estimates were calculated using the hospitals' corresponding statistical sample weights. Linear regressions were used to analyze annual trends. χ 2 tests were used to analyze categorical variables., Results: A weighted national estimate of 131,624 upper extremity volleyball-related injuries occurred in the study period. Average age was 13.9 ± 2.3 years. Female patients constituted 77.6% of patients; 99.3% of patients did not require admission. The most common body parts injured were fingers (43.0%), wrists (22.8%), and shoulders (12.2%). The most common identifiable mechanisms of injury were impacts with the floor (19.4%), impacts with the ball (14.7%), and spikes/serves (5.7%). Most common diagnoses were strains/sprains (42.6%) and fractures (19.5%). Most common locations of fracture were fingers (57.4% of all fractures), wrists (16.6%), and lower arms (12.4%). There was a decrease of 544 overall injuries per year ( P  = .03, 95% confidence interval [CI] -1031 to -58). Female players experienced more contusions/abrasions (16.0% vs 9.9%, P < .001) and strains/sprains (46.1% vs 30.4%, P < .001) compared with male players. Female patients had decreases of 513 overall injuries ( P  = .01, 95% CI -881 to -144), 349 strains/sprains ( P  = .002, 95% CI -530 to -168), 102 contusions/abrasions ( P  = .008, 95% CI 170 to -34), and 92 fractures per year ( P  = .03, 95% CI -175 to -10)., Conclusions: Youth volleyball players are at risk of upper extremity injury, particularly involving the fingers, wrist, and shoulder. Despite increasing national participation in youth volleyball, there is a decreasing incidence of upper extremity injuries., Level of Evidence: Level IV, prognostic case series., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: W.N.L. reports a relationship with Zimmer Biomet Holdings that includes: consulting or advisory. R.L.P. reports a relationship with American Orthopaedic Society for Sports Medicine that includes: board membership; a relationship with Arthrex that includes: consulting or advisory; a relationship with Arthroscopy Association of North America that includes: board membership; a relationship with Eastern Orthopaedic Association that includes: board membership; a relationship with Journal of Cartilage and Joint Preservation that includes: board membership; a relationship with Journal of Sport Rehabilitation that includes: board membership; a relationship with New England Orthopaedic Society that includes: board membership; a relationship with The Society of Military Orthopaedic Surgeons that includes: board membership; a relationship with Arthroscopy that includes: board membership. R.L.P. (co-author) was appointed to editorial board for Arthroscopy (after initial manuscript submission). B.O.P. reports a relationship with American Academy of Orthopaedic Surgeons that includes: board membership; a relationship with Arthrex that includes: consulting or advisory and speaking and lecture fees; and a relationship with Journal of Bone and Joint Surgery that includes: board membership and consulting or advisory. D.P.T. reports a relationship with Gotham Surgical Solutions that includes: funding grants. All other authors (K.K.O., P.S., N.K.N.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Full ICMJE author disclosure forms are available for this article online, as supplementary material., (© 2024 The Authors.)

Anterior cruciate ligament tears or ruptures are common orthopedic injuries. Anterior cruciate ligament reconstruction (ACLR) is an orthopedic procedure allowing for earlier return to sports, improved maintenance of lifestyle demands, and restored knee stability and kinematics. A perioperative rehabilitative adjunct recently gaining interest is blood flow restriction (BFR), a method in which temporary restriction of blood flow to a chosen extremity is introduced and can be used as early as a few days postoperative. There has been increasing investigation and recent literature regarding BFR. This review synthesizes current concepts of BFR use in the ACLR perioperative period. [ Orthopedics . 2023;46(6):e333-e340.].

Surfing is a globally popular recreational sport with limited epidemiologic data. Currently, there is a paucity of literature regarding injury profiles and mechanisms of orthopaedic-related injuries. This study analyzed trends, etiologies, and diagnoses of upper extremity orthopaedic-related surfing injuries presenting to United States (US) emergency departments. The National Electronic Injury Surveillance System database was accessed to query upper extremity surfing-related injuries presenting to US emergency departments from January 1, 2002 to December 31, 2021. Data were analyzed for year, body part, mechanism of injury, diagnosis, and disposition. National estimates were calculated based on the assigned statistical sample weight of each hospital. A total of 33 323 surfing-related injuries were included. The most common upper extremity body parts involved 15 169 shoulders (45.5%), 4220 fingers (12.7%), and 3753 hands (11.3%). The most common identifiable mechanisms of injuries were 7474 board-to-body (22.4%), 4188 impact with sand (12.6%), and 2639 impact with water (7.9%). Overuse constituted 7.2% of overall upper extremity injuries but 40% of strains. Only 2.2% of injuries required hospital admission. Between 2002 and 2021, there was a decreasing annual trend in upper extremity surfing-related injuries (P=.01). The decreasing trend in emergency department visits may be due to urgent care utilization and training for surfers and lifeguards to manage these injuries on-site, as the majority were minor given the small proportion requiring hospital admission. Chronic stress on rotator cuff and peri-scapular musculature while paddling in the prone position likely contributed to the large proportion of overuse injury., Competing Interests: None of the authors identify a conflict of interest., (©Copyright 2023 by University Health Partners of Hawai‘i (UHP Hawai‘i).)

Objective: Posterior cruciate-stabilized (PS) and ultracongruent (UC) inserts are used during total knee arthroplasty (TKA), but superiority in gaining postoperative knee flexion and functionality remains contested. Therefore, this study compared postoperative outcomes between PS and UC inserts., Methods: A retrospective review evaluated unilateral or bilateral TKAs with PS or UC inserts from August 2011 to March 2020. Nonparametric statistics were performed to evaluate differences in patient demographics, pre- and postknee flexion and Knee Society Knee (KSS-K) and Function Score (KSS-F). Univariate and multivariable regressions were performed to evaluate the influence on postoperative knee flexion ≥ 120°, presented as odds ratios (OR) and 95% confidence intervals (CI)., Results: Patient demographics were not significantly different between the 577 PS and 399 UC knees evaluated. Postoperatively, a larger proportion of UC knees demonstrated knee flexion < 120° (36.0% vs. 18.6%, p < 0.001) and lower KSS-K (91.0 ± 8.7 vs. 91.6 ± 10.3, p < 0.001) and KSS-F (76.8 ± 21.6 vs. 79.9 ± 21.6, p = 0.007) than the PS group. The PS group had greater improvement in flexion angle (4.9° ± 14.9° vs. 1.0° ± 15.6°, p < 0.001) and KSS-F (27.3 ± 23.3 vs. 23.1 ± 25.3, p = 0.007) as compared to that of UC patients. Patients with preoperative flexion < 120° (OR 2.787, CI 2.066-3.761; p < 0.001), higher body mass index (OR 1.033, CI 1.006-1.061; p = 0.017) and UC insert (OR 2.461, CI 1.832-3.307; p < 0.001) were less likely to achieve flexion ≥ 120°., Conclusion: Favorable clinical and functional outcomes were noted in the PS group as compared to UC inserts in TKA. The greater improvement in overall knee flexion may suggest the PS insert may be especially appropriate for patients with lower preoperative range of motion., Level of Evidence: III, retrospective comparative study., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Treatment of acute pediatric Monteggia fractures requires ulnar length stability to maintain reduction of the radiocapitellar joint. When operative care is indicated, intramedullary ulna fixation can be buried or left temporarily exposed through the skin while under a cast. The authors hypothesized that treatment with exposed fixation yields equivalent results to buried fixation for Monteggia fractures while avoiding secondary surgery for hardware removal., Methods: A retrospective review of children with acute Monteggia fractures at our Level 1 pediatric trauma center was performed. Patient charts and radiographs were evaluated for age, fracture type, fracture location, Bado classification, type of treatment, complications, cast duration, time to fracture union, time to hardware removal, and range of motion., Results: Out of 59 acute Monteggia fractures surgically treated (average age 6 y, range 2 to 14), 15 (25%) patients were fixed with buried intramedullary fixation and 44 (75%) with exposed intramedullary fixation under a cast. There were no significant differences between buried and exposed intramedullary fixation in cast time after surgery (39 vs. 37 d; P =0.55), time to fracture union (37 vs. 35 d; P =0.67), pronation/supination (137 vs. 134 degrees; P =0.68) or flexion/extension (115 vs. 114 degrees; P =0.81) range of motion. The exposed fixation had a return to OR of 4.5% (2 out of 44), and the buried fixation returned to the OR for removal on all patients., Conclusion: Exposed intramedullary fixation yielded equivalent clinical outcomes to buried devices in the treatment of acute pediatric Monteggia fractures while eliminating the need for a second surgery to remove hardware, reducing the associated risks and costs of surgery and anesthesia, but had a higher complication rate. Open Monteggia fractures or patterns with a known risk of delayed union may benefit from buried instead of exposed intramedullary fixation for earlier mobilization., Level of Evidence: III., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The use of "orthobiologics" or regenerative therapies in orthopaedic surgery has grown in recent years. Particular interest has been raised with regard to platelet-rich plasma, bone marrow aspirate, adipose-derived cells, and amniotic cells. Although studies have analyzed outcomes after orthobiologic treatment, no study has analyzed how the literature as a whole has evolved., Purpose: To evaluate trends in platelet-rich plasma, bone marrow aspirate, adipose-derived cells, and amniotic cell publications and to assess how these might inform efforts to establish minimum reporting standards and forecast future use., Study Design: Systematic review; Level of evidence, 4., Methods: A database was compiled systematically using PubMed to identify articles published between 2009 and 2019 within 9 prominent orthopaedic journals and pertaining to the use of platelet-rich plasma, bone marrow aspirate, adipose-derived cells, and amniotic cells in the treatment of musculoskeletal conditions. Included articles were classified as clinical, nonclinical (translational or basic science), or review, and a variety of study parameters were recorded for each. Additional queries were performed to identify articles that utilized minimum reporting standards., Results: A total of 474 articles (132 clinical, 271 nonclinical, 71 review) were included, consisting of 244 (51.5%) platelet-rich plasma, 146 (30.8%) bone marrow aspirate, 72 (15.2%) adipose-derived cells, and 12 (2.5%) amniotic cells. The greatest annual increase in publications for each orthobiologic topic was from 2018 to 2019. The American Journal of Sports Medicine demonstrated the highest number of overall (34.2%) and clinical (50.0%) publications, and accounted for 44.3% of all platelet-rich plasma publications. The Journal of Orthopaedic Research accounted for the second highest overall number of publications (24.9%) and highest nonclinical publications (41.0%). Platelet-rich plasma accounted for 91.5% of all level 1 clinical studies, while much greater than half of bone marrow aspirate, adipose-derived cells, and amniotic cell publications were level 3 or lower. Out of the 207 articles that used some form of reporting protocol, 59 (28.5%) used an established algorithm and 125 (60.4%) used their own., Conclusion: Interest in orthobiologics continues to grow, as evidenced by an increasing trend in publications over an 11-year period. However, current reporting on orthobiologic formulations is largely heterogeneous, emphasizing the need for minimum reporting standards and higher-quality studies.

Objectives: Neck injuries in football are attributed to helmet-to-helmet contact with youth players being at greatest risk. In 2014, the National Federation of State High School Associations (NFHS) implemented rules defining illegal contact against a defenseless player above the shoulders to reduce head and neck injuries in football players. This study evaluates whether rule implementation decreased rates of high school football neck injuries presenting to the emergency department (ED) pre-rule implementation (2009-2013) to post-rule implementation (2015-2019)., Methods: Data were queried from the National Electronic Injury Surveillance System for high school football players 14 to 18 years old diagnosed with a neck injury from 1 January 2009 to 31 December 2019. Narratives in the data were reviewed for mechanism of injury, setting, loss of consciousness (LOC), and type of injury., Results: Between 2009 and 2019, an estimated 47,577 high school football neck injuries were diagnosed in EDs across the United States. 52.0% of neck injuries were sustained during competition compared to 48.0% during practice. A statistically significant ( P = 0.004) decrease in neck injuries was realized from pre-rule implementation to post-rule implementation with averages of 5,278 and 3,481 injuries per year, respectively. Helmet-to-helmet neck injuries significantly ( P = 0.04) decreased from pre- to post-rule implementation with averages of 851 and 508 injuries per year, respectively. Neck injuries sustained via other mechanisms were not affected by the 2014 rule implementation., Conclusion: This study is the first to identify a decrease in overall and helmet-to-helmet related neck injuries diagnosed in the ED following the 2014 NFHS targeting rule implementation. These findings add to the growing literature regarding the importance and efficacy of rule implementation in reducing sports-related neck injuries.

Abstract: Pre-operative nutritional assessments have been used as a "cornerstone" to help optimize nutritional status and weight in children with cerebral palsy (CP) to lower the risk of postoperative complications. However, the potential value of nutritional assessments on surgical outcomes in patients with CP undergoing major orthopedic surgery remains unproven.Do pre-operative nutritional assessments reduce complication rates of varus derotational osteotomy surgery in children with CP? Are complication rates higher in patients with a gastrostomy tube (G-tube) and can they be decreased by pre-operative nutritional assessment?One-hundred fifty-five patients with CP who underwent varus derotational osteotomy from January 1, 2012 through December 31, 2017 at a tertiary pediatric hospital with minimum 6 months follow-up were retrospectively identified. One-hundred-ten (71%) were categorized as "non-ambulatory" (Gross Motor Function Classification System [GMFCS] IV-V), and 45 (29%) as "ambulatory" (GMFCS I-III). Variables assessed included age, GMFCS level, G-tube, body mass index (BMI) percentile, complications, and if patients underwent pre-operative nutritional assessment.One-hundred-eleven patients (71.6%) underwent pre-operative nutritional assessment. Sixty-two of 155 patients (40.0%) had G-tubes. In non-ambulatory patients with G-tubes, BMI percentile changes were not significantly different between patients with a pre-operative nutritional assessment compared to those without at 1 (P = .58), 3 (P = .61), 6 (P = .28), and 12 months (P = .21) postoperatively. In non-ambulatory patients who underwent pre-operative nutritional assessment, BMI percentile changes were not significantly different between those with and without G-tubes at 1 (P = .61), 3 (P = .71), 6 (P = .19), and 12 months (P = .10). Pulmonary complication rates were significantly higher in non-ambulatory patients with G-tubes than in non-ambulatory patients without G-tubes (20% vs 4%, P = .03). Pre-operative nutritional assessments did not influence postoperative complication rates for non-ambulatory patients with or without a G-tube (P = .12 and P = .16, respectively). No differences were found in postoperative complications between ambulatory patients with and without G-tubes (P = .45) or between ambulatory patients with or without nutritional assessments (P = .99).Nutritional assessments, which may improve long term patient nutrition, should not delay hip surgery in patients with CP and progressive lower extremity deformity. Patients and their families are unlikely to derive any short-term nutritional improvement using routine pre-operative evaluation and surgical outcomes are unlikely to be improved.Level of Evidence: III, retrospective comparative., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Concussions occur at higher rates in high school football as compared with all other high school sports. In 2014, the National Federation of State High School Associations implemented rules defining illegal contact against a defenseless player above the shoulders to reduce concussions in football players in the United States. To the best of our knowledge, rates of emergency department (ED)-diagnosed concussions of high school football players before and after the 2014 rule implementation have not been compared., Hypothesis: It was hypothesized that (1) there would be lower rates of helmet-to-helmet and helmet-to-body-part concussions after rule implementation and (2) alternative mechanisms of concussion would not differ, as these would be less influenced by rule implementation., Study Design: Cohort study; Level of evidence, 3., Methods: Data from the National Electronic Injury Surveillance System (NEISS) were analyzed for high school football players 14 to 18 years old sustaining a concussion from January 1, 2009, to December 31, 2019. Data were collected on mechanism of injury, setting, and loss of consciousness. Raw data were used to calculate national estimates based on the assigned statistical sample weight of each hospital by the NEISS., Results: A total of 4983 (national estimate = 154,221) high school football concussions were diagnosed in US EDs; 58.8% of concussions occurred during competition and 41.2% during practice. Between 2009 and 2013 the rate of concussions diagnosed in EDs rose 10.7% as compared with a 6.2% decrease between 2015 and 2019 ( P = .04). Between 2009 and 2013, the rate of helmet-to-helmet concussions rose 17.6% as compared with a 5.6% decrease between 2015 and 2019 ( P = .03). There were no significant changes between other mechanisms of concussion before and after the 2014 rule implementation., Conclusion: We identified a decreased trend in overall and helmet-to-helmet high school football concussions diagnosed in the ED after implementation of the targeting rule. This study adds to the growing literature regarding the importance and efficacy of rule implementation in reducing sports-related concussions., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: B.M.S. has received grant support from Arthrex and education payments from Arthrex and Smith & Nephew. T.S.B. has received education payments from Arthrex and honoraria from Fidia Pharma. C.S.A. has received consulting fees, nonconsulting fees, and royalties from Arthrex. R.L.P. has received grant support from Arthrex and hospitality payments from Smith & Nephew. D.P.T. has received grant support from Arthrex and education payments from Arthrex and Smith & Nephew. 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) 2021.)

Study Design: Retrospective comparative study OBJECTIVES: The goal of this study was to investigate fluoroscopy time and radiation exposure during pediatric spine surgery using a dedicated radiology technologist with extensive experience in spine operating rooms. Repetitive use of intraoperative fluoroscopy during posterior spinal fusion (PSF) exposes the patient, surgeon, and staff to radiation., Methods: Retrospective review was conducted on patients with posterior spinal fusion (PSF) of ≥ 7 levels for adolescent idiopathic scoliosis (AIS) at a pediatric hospital from 2015 to 2019. Cases covered by the dedicated radiology technologist (dedicated group) were compared to all other cases (non-dedicated group). Surgical and radiologic variables were compared between groups., Results: 230 patients were included. 112/230 (49%) were in the dedicated group and 118/230 (51%) were in the non-dedicated group. Total fluoroscopy time was significantly reduced in cases with the dedicated technologist (46 s) compared to those without (69 s) (p = 0.001). Radiation dose area product (DAP) and air kerma (AK) were reduced by 43% (p < 0.001) and 42% (p < 0.001) in the dedicated group, respectively. The dedicated group also had reduced total surgical time (4.1 vs. 3.5 h; p < 0.001) and estimated blood loss (447 vs. 378 cc (; p = 0.02). Multivariate regression revealed that using a dedicated radiology technologist was independently associated with decreased fluoroscopy time (p = 0.001), DAP (p < 0.001), AK (p < 0.001), surgical time (p < 0.001), and EBL (p = 0.02)., Conclusions: In AIS patients undergoing PSF, using a dedicated radiology technologist was independently associated with significant reductions in fluoroscopy time, radiation exposure, surgical time, and EBL. This adds to the growing body of research demonstrating that the experience level of the team-not just that of the surgeon-is necessary for optimal outcomes., Level of Evidence: III.

Background: Due to the rare incidence of tibial plateau nonunions, current studies are limited to small sample sizes and patient demographics. The aim of this systematic review is to quantify and report patient and fracture traits, possible risk factors, and treatment outcomes of tibial plateau nonunions ., Methods: PubMed, Clinical Key, and MEDLINE were searched for articles published prior to August 2020 in accordance to the preferred reporting items for systematic reviews and meta-analyses (PRISMA). The authors used varying combinations of the following terms to identify relevant articles: "tibial," "plateau," "nonunion," "non-union." Studies were assessed for patient demographics, pre-revision nonunion characteristics, treatment, and post-revision outcomes., Results: Eight studies were included, yielding 31 tibial plateau nonunions (21 males, 10 females). The majority of nonunions were associated with high energy trauma (52.2%) and were Schatzker class VI (54.8%). Schatzker class I and II nonunions were not attributed to neglect, contradicting previous suggestions. Time to union was 4.0 months, the most common treatments being autologous bone grafting (76.7%) and revision plating (63.3%)., Conclusion: This study demonstrates the effectiveness of autologous bone grafts and revision plating for tibial plateau nonunions. Physicians may use these findings to guide decision making in the event of high energy plateau nonunions. Lastly, various limitations exist within the current literature, emphasizing the need for standardized reporting measures., Competing Interests: None., (© 2020 Delhi Orthopedic Association. All rights reserved.)

Background: Forearm deformity occurs in one third of patients with multiple hereditary exostoses (MHE). Conservative and surgical treatment are aimed at preventing radial head subluxation and/or dislocation. Dislocation has been associated with isolated distal ulnar lesions, radial bowing, and ulnar shortening. Risk factors for radial head subluxation have not been clearly elucidated. This study aimed to identify risk factors for all radial head instability in MHE, to optimize early detection and prevent frank dislocation., Methods: This multicenter retrospective case-control investigation included MHE patients with forearm lesions seen between 2000 and 2017 at 2 tertiary care children's hospitals. Demographic, clinical factors, radiographic measures, and surgical history were quantified. Comparisons were made between forearms that developed radial head instability versus those that remained stable and between those that progressed to radial head subluxation versus those that progressed to dislocation., Results: This study included 171 forearms in 113 patients with MHE, who presented at a mean age of 8.0 years with a median follow-up time of 6.0 years. Nine forearms progressed to radial head subluxation (mean age: 10.2 y), and 24 forearms had radial head dislocation (mean age: 9.9 y). Five subluxations and 3 dislocations occurred despite preventative surgery. Initial radial bowing (7.2% vs. 8.5%, P=0.04), ulnar variance (-5.8% vs. 11.0%, P<0.001), and ulnar shortening (-2.5 vs. 9.1 mm, P=0.04) were predictive of radial head instability. Distal ulnar lesions and more severe ulnar variance (-5.8 vs. -10.6, P<0.001) and shortening (-2.5 vs. 13.2 mm, P=0.02) were associated with an increased risk of radial head subluxation. No significant differences were identified between forearms that progressed to subluxation versus those that progressed to dislocation., Conclusions: Distal ulnar lesions and radiographic measures can be used to determine the risk of radial head instability in MHE. Ulnar variance and shortening are early identifiable risk factors for radial head subluxation that can help guide monitoring and treatment. Radial bowing may be a late predictor of instability., Level of Evidence: Level III-prognostic.

Objective: To evaluate rates and characteristics of slipped capital femoral epiphysis (SCFE) in children who are not obese to prevent missed diagnoses and subsequent complications., Study Design: A multicenter, retrospective review identified all patients with SCFE from January 1, 2003 to December 31, 2012. Patients were excluded if they received previous surgery at an outside institution, had no recorded height and weight, or had medical co-morbidity associated with increased risk of SCFE. Body mass index (BMI) percentile for age was calculated and categorized for each patient (patients without obesity vs with obesity)., Results: In total, 275 patients met inclusion criteria. Average BMI was 91.2 percentile (range: 8.4-99.7). Thirteen percent (34 patients) were considered "normal weight" (BMI 5%-85%), 17% (48 patients) were considered "overweight" (BMI 85%- 95%), and 70% (193 patients) were considered "obese" (BMI >95%). Average BMI percentile was higher in male than female patients (93.2 ± 12.7 vs 88.5 ± 21.4, P = .034). Patients without obesity were older compared with patients with obesity (12.2 ± 1.7 vs 11.7 ± 1.6 years, P = .015). Fewer patients without obesity were seen at the hospital in the southwest. The southwest had fewer patients without obesity than the northeast (18.3% vs 36.1%, P = .002). Patients without obesity were more likely to present with a severe slip as graded by Wilson percent displacement (27.2% vs 11.4%, P = .007) and an unstable slip (32.9% vs 14.7%, P = .001)., Conclusion: Rates of nonobese SCFE in this study are higher than reported in the previous literature. Normal weight patients with SCFE are more likely to be older, female, and present with a severe and unstable SCFE., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: There are a number of nonsurgical modalities used by athletes in attempts to improve performance or prevent, treat, and rehabilitate musculoskeletal injuries. A concise review of available evidence on common nonsurgical modalities used today is necessary so that practitioners may appropriately counsel patients., Methods: A comprehensive review of relevant publications regarding Kinesio taping, sports massage therapy, and acupuncture from 2006 through 2019 was completed using PubMed and Google Scholar., Results: There have been numerous investigations evaluating the efficacy of nonsurgical modalities for a myriad of musculoskeletal conditions. There is some low level evidence to suggest the use of Kinesio tape for athletes with acute shoulder symptoms and acupuncture for carpal tunnel syndrome and as an adjunct treatment for low back pain. There is a need for higher quality research to better elucidate the effect of sports massage therapy on sports performance, recovery, and musculoskeletal conditions in general., Conclusions: Nonsurgical modalities are low-cost treatment strategies with very few reported adverse outcomes that will likely continue to increase in popularity. High-quality studies are needed to effectively evaluate these treatments, so that care providers can provide appropriate guidance based on evidence-based medicine.

Postoperative fever in pediatric patients following reconstructive hip surgery is of unknown significance. This study identifies the prevalence of postoperative fever after corrective hip surgery, its relationship to infection, and whether preventative use of anti-pyretics affects patient outcomes.Overall, 222 patients who underwent a varus derotational osteotomy (VDRO) between 11/1/2004 to 8/1/2014 with minimum 6 months follow up were retrospectively identified. Variables included diagnosis, inpatient stay, daily maximum temperature, duration of fever, fever workup, and administration of scheduled anti-pyretics. Fever was defined as temperature ≥38°C.In total, 123/222 (55.4%) and 70/222 (31.5%) had postoperative fevers of ≥38°C and ≥38.5°C, respectively. Average inpatient stay was 2.7 days postoperatively. Temperature (mean = 38.0°C) was greatest on postoperative day 1 (POD1), and 43.7% of patients had T ≥38°C on POD1. Anti-pyretics did not influence the duration of fever. Anti-pyretics on the day of surgery (POD0) did not influence the incidence of fever. Acetaminophen on POD0 significantly reduced likelihood of fever on POD1 (P = .02). Average length of fevers ≥38°C and 38.5°C were 8.4 and 4.2 hours, respectively. 3/18 (16.7%) fever workups administered were positive. Postoperative fever did not predict infection. 9/222 (4/1%) patients had postoperative infection - 5/123 (4.1%) with fever ≥38°C and 4/70 (5.7%) with fever ≥38.5°C. Rates of infection in patients with and without fevers were not significantly different (P = .97 for T ≥38°C and P = .38, for T ≥38.5°C).Though common, postoperative fever does not increase risk of infection. The low prevalence of positive cultures indicates routine fever workups can safely be avoided in most patients.Level of Evidence: III, retrospective comparative study.

Objective: There are a number of nonsurgical modalities used by athletes in attempts to improve performance or prevent, treat, and rehabilitate musculoskeletal injuries. A concise review of available evidence on common nonsurgical modalities used today is necessary, so that practitioners may appropriately counsel patients., Methods: A comprehensive review of relevant publications regarding cupping and blood flow restriction (BFR) from 2006 through 2019 was completed using PubMed and Google Scholar., Results: There have been numerous investigations evaluating the efficacy of nonsurgical modalities for a myriad of musculoskeletal conditions. Cupping may be an effective option with low risk in treating nonspecific, musculoskeletal pain. Studies comparing BFR with non-BFR controls suggest that it may increase muscle strength and endurance for individuals undergoing rehabilitation or sport-specific training by mimicking the low oxygen environment during exercise., Conclusions: Nonsurgical modalities are low-cost treatment strategies with rates of adverse outcomes as low as 0.008% that will likely continue to increase in popularity. Despite the paucity of recent research in cupping and BFR, evidence suggests benefits with use. High-quality studies are needed to effectively evaluate these treatments, so that care providers can provide appropriate guidance based on evidence-based medicine.

Purpose: Clinical presentation of paediatric septic arthritis (SA) can be similar to other joint pathologies. Despite potential for infection in all major joints, most diagnostic criteria are based on values from the hip. This study identifies the best joint aspirate values in diagnosing SA in all joints., Methods: In all, 166 patients who underwent 172 joint aspirations at the authors' institution between 01 September 2004 and 01 September 2014 were retrospectively identified. Recorded measures included age, sex, duration of symptoms, fever history, weight-bearing status, aspiration results, serum results and antibiotic administration. Patients were placed in the following four categories: 'culture confirmed SA' (C-SA), 'suspected SA' (S-SA), 'Other' and 'Other-rheumatologic' (Other-R), a subcategory of 'Other'., Results: Most common sites of aspiration were the knee (55%) and hip (29%). Diagnostic grouping was as follows: C-SA = 44, S-SA = 45, Other = 83 (Other-R = 21). Fever and non-weight-bearing prior to admission were useful predictors of SA, though in C-SA patients, 21% did not have a fever and 23% could weight bear at the time of admission. Aspirate white blood cell (WBC) count was significantly greater in both C-SA (92 000 cells/hpf) and S-SA (54 000) than in Other (10 000) and Other-R (18 000) patients. The percentage of polymorphonuclear (%PMN) was also significantly greater in C-SA (81.1%) and S-SA (80.9%) than in Other (57.9%) and Other-R (63.3%)., Conclusion: Joint aspirate values, especially %PMN, are valuable in diagnosing SA. Additionally, antibiotics pre-aspiration did not affect %PMN, facilitating subsequent diagnosis of infection. Lastly, while aspirate WBC count was a valuable indicator of SA, this finding is not as definitive as previous research suggests., Level of Evidence: IV Case Series.

Background: Youth athletes are starting sports earlier and training harder. Intense, year-round demands are encouraging early sports specialization under the perception that it will improve the odds of future elite performance. Unfortunately, there is growing evidence that early specialization is associated with increased risk of injury and burnout. This is especially true of pediatric and adolescent baseball players., Purpose/hypothesis: The purpose of this investigation was to analyze national injury trends of youth baseball players. We hypothesized that while the total number of baseball injuries diagnosed over the past decade would decrease, there would be an increase in adolescent elbow injuries seen nationally. A further hypothesis was that this trend would be significantly greater than other injuries to the upper extremity and major joints., Study Design: Descriptive epidemiology study., Methods: Injury data from the National Electronic Injury Surveillance System, a United States Consumer Product Safety Commission database, were analyzed between January 1, 2006, and December 31, 2016, for baseball players aged ≤18 years. Data were collected on the location of injury, diagnosis, and mechanism of injury., Results: Between 2006 and 2016, an estimated 665,133 baseball injuries occurred nationally. The mean age of the injured players was 11.5 years. The most common injuries diagnosed included contusions (26.8%), fractures (23.6%), and strains and sprains (18.7%). Among major joints, the ankle (25.6%) was most commonly injured, followed by the knee (21.3%), wrist (19.2%), elbow (17.7%), and shoulder (16.2%). The incidence of the ankle, knee, wrist, and shoulder injuries decreased over time, while only the incidence of elbow injuries increased. A linear regression analysis demonstrated that the increasing incidence of elbow injuries was statistically significant against the decreasing trend for all baseball injury diagnoses, as well as ankle, knee, wrist, hand, and finger injuries ( P < .05). Additionally, the only elbow injury mechanism that increased substantially over time was throwing., Conclusion: The current investigation found that while the incidence of baseball injuries sustained by youth players is decreasing, elbow pathology is becoming more prevalent and is more commonly being caused by throwing. Given that the majority of elbow injuries among adolescent baseball players are overuse injuries, these findings underscore the importance of developing strategies to continue to ensure the safety of these youth athletes., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: B.S. has received educational support from Smith & Nephew and Arthrex. M.S.N. has received grant support from Arthrex. C.A.P. has received hospitality payments from Smith & Nephew and educational support from Arthrex. C.S.A. has received consulting fees from Acumed and Arthrex; research support from Arthrex, Stryker, and Major League Baseball; and hospitality payments from DePuy. 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 health disparities of Native Hawaiians and Pacific Islanders (NHPI) are well established for diabetes and cardiovascular disease, but less is known about disparities in arthritis. This study examined possible disparities in the prevalence of arthritis by age, sex, and severity comparing NHPI, Whites, and Asians. The study population included adult Hawai'i participants in the 2013 Behavioral Risk Factor Surveillance Survey. NHPI males had a significantly higher prevalence of arthritis, which peaked twenty years earlier, than White and Asian males (P<.001). The prevalence of arthritis peaked at 65-79 years in males and females in all racial groups, except in NHPI males where it peaked at 45-54 years. The mean ages (years) for males with arthritis were 46.2 for NHPI, 59.1 for Whites, and 60.5 for Asians; the respective ages for females were 54.2, 60.5, and 58.8. NHPI males body mass index averaged 2.4 kg/m(2) greater than White males (P<.001), and obese NHPI males had twice the age-adjusted odds of arthritis than obese White males. Although NHPI females had a greater body mass index than White females (P=.05), the prevalence of arthritis was only slightly and not significantly higher. NHPI males and females reported high pain scores more frequently than Whites did, but the differences did not reach statistical significance. Diabetes was a comorbidity more than twice as often in NHPI and Asians of both sexes than among Whites. This study demonstrated racial disparities in the prevalence of arthritis among NHPI, Whites, and Asians.

Traumatic brain injury (TBI) is a major public health problem that significantly impacts young adults. Since severe TBI patients lack decision-making capacity, the providers and patient surrogates are often faced with the challenging task of deciding whether to continue with aggressive life-prolonging care or to transition to comfort-focused care with an expected outcome of natural death. The assumption is often made that aggressive care is appropriate for young patients who suffer severe TBI despite the high likelihood of a poor outcome. However, the young community's attitude towards goals of care after severe TBI has not been studied. A questionnaire-based survey study on young healthy adults was conducted to assess their attitude towards aggressive care after a hypothetical case of severe TBI. Logistic regression analysis was performed to determine the factors associated with the decision to favor aggressive care. Among a total of 120 community-dwelling young adults (mean age: 19 ± 1 years) who were surveyed, 79 (66%) were willing to live with severe motor disability, 78 (65%) were willing to live with expressive aphasia, and 53 (44%) were willing to live with receptive aphasia. Despite being presented with a high likelihood of long-term moderately severe-to-severe disability, 65 of the 115 respondents (57%) favored aggressive care. A willingness to live with receptive aphasia was the only independent factor that predicted aggressive care (OR 2.50, 95% CI: 1.15 to 5.46). Even among the young adults, preference of care was divided between aggressive and conservative approaches when presented with a hypothetical case of severe TBI.

A 58-year-old man was evaluated for a 42-year complaint of a pharyngeal foreign body sensation whenever he ate. Examination revealed normal anatomy at rest but diffuse hypopharyngeal distension with Valsalva's maneuver. His past history was remarkable for an infectious illness, possibly diphtheria. We speculate that this unusual case most likely represents a postdiphtheritic selective pharyngeal paralysis and present his case, radiographic findings, and a discussion of the differential diagnosis.