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Overuse injuries are well described for both upper and lower extremities among skeletally immature athletes. To our knowledge, there is no description in the literature of an overuse injury affecting the medial tibial physis that is different from the typical Osgood-Schlatter disease or tibial tubercle apophysitis. In this article we present a 13-year-old athlete with medial proximal tibial widening or epiphysiolysis from overuse playing soccer. We need to be aware that with increased early sports specialization we may see injuries we have not seen before. [ Orthopedics . 2022;46(6):e345-e347.].

Objective: The novel severe acute respiratory coronavirus virus 2 (SARS-CoV-2) was first reported in Wuhan, China, in December 2019 and is notable for being highly contagious and potentially lethal; and SARS-CoV-2 is mainly spread by droplet transmission. The US healthcare system's response to the COVID-19 pandemic has been challenged by a shortage of personal protective equipment (PPE), especially N95 respirators. Restricted use, reuse, and sanitation of PPE have been widely adopted to provide protection for frontline healthcare workers caring for often critically ill and highly contagious patients. Here, we describe our validated process for N95 respirator sanitation., Design: Process development, validation, and implementation., Setting: Level 1, urban, academic, medical center., Methods: A multidisciplinary team developed a novel evidence-based process for N95 respirator reprocessing and sanitation using ultraviolet (UV) light. Dose measurement, structural integrity, moisture content, particle filtration, fit testing, and environmental testing were performed for both quality control and validation of the process., Results: The process achieved UV light dosing for sanitation while maintaining the functional and structural integrity of the N95 respirators, with a daily potential throughput capacity of ∼12,000 masks. This process has supported our health system to provide respiratory PPE to all frontline team members., Conclusions: This novel method of N95 respirator sanitation can safely enable reuse of the N95 respirators essential for healthcare workers caring for patients with COVID-19. Our high-throughput process can extend local supplies of this critical PPE until the national supply is replenished.

Background: The novel coronavirus disease (COVID-19) has afflicted millions of people worldwide since its first case was reported in December 2019. Personal protective equipment (PPE) has been tailored accordingly, but as of April 2020, close to 10 000 health care workers in the United States have contracted COVID-19 despite wearing recommended PPE. As such, standard guidelines for PPE may be inadequate for the health care worker performing high-risk aerosolizing procedures such as endotracheal intubation. In this brief technical report, we describe the integration of an orthopedic hood cover as an item for full barrier protection against COVID-19 transmission., Technical Description: The Coronavirus Airway Task Force at Virginia Commonwealth University Medical Center approved this initiative and went live with the full barrier suit during the last week of March 2020. The PPE described in this report includes a Stryker T4 Hood, normally used in conjunction with the Stryker Steri-Shield T4 Helmet. Instead of the helmet, the hood is secured to the head via a baseball cap and binder clip. This head covering apparatus is to be used as an accessory to other PPE items that include an N95 mask, waterproof gown, and disposable gloves. The motor ventilation system is not used in order to prevent airborne viral entry into the hood., Discussion: An advantage of the full barrier suit is an additional layer of droplet protection during intubation. The most notable disadvantage is the absence of a ventilation system within the hood covering., Conclusion: Modification of existing PPE may provide protection for health care workers during high-risk aerosolizing procedures such as endotracheal intubation. Although the integration of this medical equipment meets the immediate needs of an escalating crisis, further innovation is on the horizon. More research is needed to confirm the safety of modified PPE., Competing Interests: Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: B.W.T. is a member of the editorial board for the Geriatric Orthopaedic Surgery and Rehabilitation journal., (© The Author(s) 2020.)

Anterior cervical spine surgery (ACSS) is a common procedure, but not without its own risks and complications. Complications that can cause airway compromise occur infrequently, but can rapidly lead to respiratory arrest, leading to severe morbidity or death. Knowing emergent post-operative airway management including surgical airway placement is critical. We aim to review the different etiologies of post-operative airway compromise following ACSS, the predictable timeline in which they occur, and the most appropriate treatment and management for each. We place special emphasis on the timing and proper surgical technique for an emergent cricothyrotomy. Angioedema is seen the earliest as a cause of post-operative airway compromise, typically within 6-12 hours. Retropharyngeal hematomas can be seen between 6-24 hours, most commonly within 12 hours. Pharyngolaryngeal edema is seen within 24-72 hours. After 72 hours, retropharyngeal abscess is the most likely etiology. Several studies have utilized delayed extubation protocols following ACSS based on patient risk factors and found reduced postoperative airway complications and reintubation rates. The administration of perioperative corticosteroids continues to be controversial with high-level studies recommending both for and against their use. Animal studies showed that after cardiac arrest, the brain can recover if oxygenation is restored within 5 minutes, but this time is likely shorter with asphyxia prior to cardiac arrest. Experience and training are essential to reduce the time for successful cricothyrotomy placement. Physicians must be prepared to diagnose and treat acute postoperative airway complications following ACSS to prevent anoxic brain injury or death. If emergent intubation cannot be accomplished on the first attempt, physicians should not delay placement of a surgical airway such as cricothyrotomy., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Background and Purpose: Prompt identification of outpatients who may have proximal lower-extremity deep vein thrombosis (PDVT) is important, in part, because of the risk of pulmonary embolism. The purposes of our study were to determine the degree of accuracy of physical therapists' estimates of the probability of PDVT in hypothetical patient vignettes and to determine whether physical therapists would contact the referring physician about the hypothetical patients' condition as recommended in published evidence., Subjects and Methods: A survey instrument consisting of 6 vignettes was sent to a nationally representative random sample of 1,500 physical therapists. The clinical decision rule developed by Wells and colleagues served as the gold standard for PDVT probability., Results: A total of 969 (65% response rate) physical therapists completed the survey. We found no evidence of nonresponse bias. For the 2 high-probability vignettes, 87% and 64% of the physical therapists underestimated the probability of PDVT. For the 2 high-probability cases, 32% and 27% of the physical therapists reported that they would not have contacted the referring physician. For the 2 moderate-probability cases, 15% and 30% of the physical therapists would not have contacted the referring physician. Therapist experience, certification status, place of practice, and region of the country did not explain the findings., Discussion and Conclusion: The care of outpatients who are at risk for PDVT could potentially be improved by use of the clinical decision rule developed by Wells and colleagues, although more study is warranted.

This study measured the amount of immature collagen type III present in tendon rafts obtained from anterior cruciate ligament (ACL) reconstructions. These values were compared with those obtained from control grafts typically used for reconstruction--Achilles, patellar, and fascia lata--and also to the normal ACL. Analyses were performed using a commercially available radioimmunoassay (RIA). The RIA made use of a rabbit polyclonal antibody specific to the amino terminus of procollagen type III. The specificity of the Ab was confirmed by a western blot. Fibril diameter of each of the above samples was measured by transmission electron microscopy (TEM). We thus were able to determine if there was a relationship between pN collagen III content and fibril diameter. The mean amount of pN collagen type III in the normal tendon control group was 0.8 +/- 0.3 ng/microg total protein (range 0.0-2.5 ng/microg). There was significantly greater pN collagen III (16 +/- 3.7 ng/microg total protein) in the grafts containing an average fibril diameter <55 nm than in the normal tendons or ACL (P < 0.05). Grafts with an average fibril diameter >55 nm had similar levels of pN collagen III (1.0 +/- 0.79 ng/microg) as the controls. There was also significantly less pN-collagen III within the functional grafts (5.3 +/- 1.9 ng/microg) as compared to failed grafts, (21.6 +/- 5.1 ng/microg, P < 0.05). These results indicate that incomplete processing of procollagen III may be responsible for some of the ultrastructural alterations seen in tendon grafts. Since ultrastructural organization is believed to influence mechanical properties of these tissues. pN collagen III levels may be a possible indicator of ligament or tendon weakness.

The patellar tendon is the most commonly used graft source in reconstruction of the anterior cruciate ligament. The performance of a patellar tendon graft in such a reconstruction is largely related to the structural and functional differences between patellar tendons and anterior cruciate ligaments. From a genetic point of view, the structural and functional differences are ultimately decided by the differential patterns of gene expression between the two tissues. In the present study, the genetic differences between normal patellar tendons and normal anterior cruciate ligaments were explored by screening a large number of mRNA species to detect the species unique to each tissue. Of the approximately 1,000 mRNAs screened, 20 differentially expressed mRNA species were detected. Eight were unique to patellar tendons, and 12 were unique to anterior cruciate ligaments. Of these 20 unique mRNA species, 12 did not match any of the known sequences in gene databases and were probably novel genes. Transcriptional control is a major step in the genetic pathway; therefore, the variations found between patellar tendons and anterior cruciate ligaments at this level of gene expression indicate that the differences between the two tissues are likely more extensive than previously thought. These differences probably influence the survival of patellar tendon autografts and should be explored further.

Patellar tendon is widely used for reconstruction of the anterior cruciate ligament. However, few studies have investigated the tendon's homogeneity, a characteristic often assumed of it in experiments. In this study, the assumption that the patellar tendon is homogeneous was tested by dividing the central half of the tendon into six sections along its length and width and comparing commonly measured biochemical parameters and patterns of gene expression among these sections. No significant differences were found between the sections for any of the studied parameters: water content (p > 0.5), DNA content (p > 0.9), total collagen content (p > 0.8), amount of type I collagen (p > 0.7) or type-III collagen (p > 0.7), or expression of mRNA (p > 0.9). For all parameters, the minimum power value for statistical analyses was greater than 0.80. It was concluded that the central half of the tendon is homogeneous in terms of all of the measured parameters. The results provide important information for the many experiments that sample part of the patellar tendon to infer the characteristics of the whole tendon, e.g., biopsy studies.

Magnetic resonance (MR) imaging is a significant advance in musculoskeletal noninvasive visualization, especially for the soft tissues including the menisci. The purpose of this article is to give the radiologist a surgeon's perspective on the role of this technology in clinical practice. For MR imaging to be cost effective, it must accurately define anatomy, and reveal changes that have an impact on patient care--i.e., be clinically relevant. For MR imaging to be accurate, optimum software, hardware, and an experienced radiologist are essential. However, even if an MR examination has high accuracy, the abnormal findings of this evaluation may not be related to the clinical problem that the patient presents with. This is supported by the demonstration that asymptomatic patients may have grade 3 meniscal tears, herniated discs, and rotator cuff changes. The MR examination may not change patient management even if it demonstrates pathologies such as a meniscal tear. The patient may tolerate the dysfunction and pain. The most cost-effective method of providing musculoskeletal care is still a careful history and competent physical examination.

A long-term radiographic follow-up study was conducted on 24 patients (34 hips) who underwent core decompression of the femoral head for avascular necrosis (AVN). The purpose of the study was to assess the potential correlation between the extent of AVN, as determined with preoperative magnetic resonance (MR) imaging, and development of collapse. The preoperative MR results were classified into four categories: group A, no AVN; group B, less than 25% involvement of the weight-bearing portion of the femoral head; group C, 25%-50% involvement; and group D, more than 50% involvement. Histologic evidence of AVN was found in all 34 hips. Collapse occurred in none of the hips in groups A and B (n = 12), in three of seven hips (43%) in group C, and in 13 of 15 hips (87%) in group D. It is concluded that MR estimation of the extent of femoral head involvement with AVN may help in predicting which femoral heads will collapse shortly after core decompression, so that this invasive procedure can be avoided in patients at risk.

An 18-year-old man sought treatment for a pulsatile mass in the medial distal thigh four years after he had sustained blunt trauma during a wrestling match. Investigation, which included magnetic resonance imaging and arteriography, showed the mass to be a pseudoaneurysm, which should be considered in the differential diagnosis of masses resulting from direct, blunt trauma. At exploration, a pseudoaneurysmic thrombus in the superficial femoral artery was evacuated and the vessel was repaired with an interposition graft of reversed saphenous vein, followed by complete recovery of the patient.

High-field surface coil magnetic resonance (MR) images were obtained of 12 ankles: two from healthy volunteers, seven from patients, and three from fresh cadavers. The cadaver ankles were sectioned in the coronal, sagittal, and axial planes for direct comparison with the MR images. Plain film confirmation of pathologic conditions was obtained in all patients, and five underwent arthroscopy or surgery, or both. MR imaging provided excellent delineation of ligaments and cartilaginous structures in all cases.

Either an anomalous extensor indicis proprius muscle or an extensor digitorum brevis manus may coexist with a dorsal wrist ganglion. To assure relief of symptoms, treatment must include division of the fourth dorsal extensor compartment in the case of the former muscle, and excision in the case of the latter.

Magnetic Resonance Imaging (MRI) and conventional radiographs were compared in 49 hips with Avascular Necrosis (AVN). MRI detected AVN in 25% of the hips during the preradiological stage of the disease. Both MRI and conventional radiographs accurately detected AVN in the remaining 75% of hips. Correlation between the patterns observed with the two techniques reflected the underlying histopathologic events. The reactive interface between infarcted bone and viable bone could be identified on MRI as a low signal intensity (SI) band. On conventional radiographs the reactive interface appeared as a sclerotic band. The adjacent hyperemic zone was seen on MRI as a high SI band and as a lucent zone on the plain films. Variations of this pattern occurred as related to the extend and duration of AVN and to the individual's ability to mount a healing response. Minor degrees of collapse of the femoral head were better identified with plain radiographs but MRI demonstrated small areas of hyperintensity probably corresponding to early subchondral fractures.

Arthroscopy can be a difficult technique for the resident and staff physician to master. Various models have been constructed to allow the training arthroscopist time to perfect the technique. Aside from cadaver knees, there has been only one report of a successful in vivo training model. Sectioned pig knee joints for teaching and practicing arthroscopy satisfy many of the points suggested by others: they are cost effective, easy to use, mount and store, provide a realistic approach, and have comparable structural anatomy to the human knee.

A retrospective evaluation of magnetic resonance (MR) imaging for the detection of avascular necrosis (AVN) of the femoral head was performed in 49 patients (85 hips) with clinical suspicion of AVN. Positive findings at bone biopsy or evidence on plain radiographs was considered proof of AVN. Absence of clinical symptoms and of radiographic findings for a minimum of 18 months after MR imaging was considered evidence of the absence of AVN. All patients were studied with plain radiography and technetium-99m methylene diphosphonate bone scintigraphy. Five hips had negative MR images, positive findings at bone marrow biopsy, positive bone pressure measurement (BMP), and positive bone scans. A comparison between MR images and bone scans showed MR imaging to be superior, with a sensitivity of 88.8% (vs. 77.5%) and a specificity of 100% (vs. 75%). BMP was the most sensitive (92%) but least specific test (57%).