Andrew W. Kuhn

Depression as a Modifying Factor in Sport-Related Concussion: A Critical Review of the Literature

Abstract Since its third iteration in 2008, the international Concussion in Sport Group (CISG) has delineated several ‘modifying factors’ that have the potential to influence the management of sport-related concussions (SRC). One of these factors is co- and pre-morbidities, which includes migraines, mental health disorders, attention-deficit hyperactive disorder (ADHD), learning disability, and sleep disorders. Mental health disorders, and in particular, depression, have received some attention in the management of SRC and in this review we summarize the empirical evidence for its inclusion as a modifying factor. This review is divided into three main bodies of findings: (1) the incidence and prevalence of depression and depressive symptoms in non-concussed and concussed athletes, with comparison made to the general population; (2) managing the post-concussion athlete and accounting for premorbid depressive symptoms; and (3) depression as a long-term effect of repetitive head trauma. Overall, it has been reported that certain subpopulations of athletes have similar or even higher rates of depressive symptoms when compared to the general population. The challenge of accounting for these baseline-depressive symptoms while managing the post-concussive athlete is stressed. And lastly, the prevalence of depression and its relationship to concussion in later-life is discussed.

Participation in Pre–High School Football and Neurological, Neuroradiological, and Neuropsychological Findings in Later Life A Study of 45 Retired National Football League Players

Background: A recent study found that an earlier age of first exposure (AFE) to tackle football was associated with long-term neurocognitive impairment in retired National Football League (NFL) players. Purpose: To assess the association between years of exposure to pre–high school football (PreYOE) and neuroradiological, neurological, and neuropsychological outcome measures in a different sample of retired NFL players. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Forty-five former NFL players were included in this study. All participants prospectively completed extensive history taking, a neurological examination, brain magnetic resonance imaging, and a comprehensive battery of neuropsychological tests. To measure the associations between PreYOE and these outcome measures, multiple regression models were utilized while controlling for several covariates. Results: After applying a Bonferroni correction for multiple comparisons, none of the neurological, neuroradiological, or neuropsychological outcome measures yielded a significant relationship with PreYOE. A second Bonferroni-corrected analysis of a subset of these athletes with self-reported learning disability yielded no significant relationships on paper-and-pencil neurocognitive tests but did result in a significant association between learning disability and computerized indices of visual motor speed and reaction time. Conclusion: The current study failed to replicate the results of a prior study, which concluded that an earlier AFE to tackle football might result in long-term neurocognitive deficits. In 45 retired NFL athletes, there were no associations between PreYOE and neuroradiological, neurological, and neuropsychological outcome measures.

Three-dimensional Imaging and Computer Navigation in Planning for Hip Preservation Surgery.

Hip preservation surgery is performed to address femoroacetabular impingement, alleviate any associated pain, and reduce the risk of early onset of osteoarthritis. In the last decade, arthroscopy has become more popular in addressing femoroacetabular impingement, due to its minimally invasive approach. However, poor visualization and limited spatial awareness of the joint make arthroscopy of the hip difficult, resulting in a steep learning curve. This paper reviews the utility and benefits of 3-dimensional imaging and computer navigation and what these tools may add to the preoperative planning stages of hip preservation surgery.

Post-operative medical and surgical complications after primary total joint arthroplasty in solid organ transplant recipients: a case series

PurposeIn 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.MethodsThe 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.ResultsThe 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).ConclusionsA 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 designLevel IV, Prognostic Case-Series.

Return to Play Following Hip Arthroscopy.

Femoroacetabular impingement may be particularly disabling to the high-demand athlete, especially those with significant cutting and pivoting requirements. If nonoperative treatment fails to adequately alleviate symptoms or sufficiently restore function in the athlete, hip arthroscopy can lead to improved pain, improved range of motion, and high rates of return to play with proper postoperative rehabilitation. The rate of return to previous level of competition is also high with accurate diagnosis and well-executed correction of deformity. A clear understanding of the etiology, diagnosis, management, and outcomes is essential for clinicians to optimally help patients to return to play.

Performance and Style of Play After Returning From Concussion in the National Hockey League

Background: Few studies have empirically examined outcomes of concussion in the National Hockey League (NHL) and whether these athletes return to games after concussion at a performance level comparable to preconcussion play. Hypothesis: NHL players would not demonstrate changes in performance or style of play after returning from a concussion when compared with a group of control athletes. Study Design: Cohort study; Level of evidence, 3. Methods: NHL players with a reported hockey-related concussion during the 2008-2009 through 2014-2015 seasons were identified utilizing secondary media sources. Players who missed games for non–injury related causes were selected as the control group. “Performance” was operationally defined as the statistics for goals, assists, points, plus-minus, and shots, and “style of play” was operationally defined as the statistics for penalty minutes, blocked shots, hits, giveaways, and time on ice. Each gameplay statistic was recorded and totaled for the 5 games before and after each player′s injury or absence. After meeting strict inclusion criteria, the 2 groups were compared across each postconcussion/absence statistic by generalized linear models while incorporating the particular preconcussion/absence statistic, position played, games missed, and concussion history as covariates to control for intraplayer and between-group differences. Results: A total of 287 players sustained a concussion; 130 missed time for non–injury related reasons and were identified as controls. After the exclusion criteria were applied, 94 concussed players were compared with 58 controls. None of the models reached statistical significance, indicating that the concussion and control groups did not differ across performance or style of play after returning from a concussion or non–injury related absence. Conclusions: When compared with a control group, players who returned to consistent play after concussion did not demonstrate changes in performance or style of play.

Radiographic Hip Anatomy Correlates with Range of Motion and Symptoms in National Hockey League Players

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.

Outcomes Following Nonoperative Treatment of Isolated Posterior Malleolar Ankle Fractures

Category: Ankle, Trauma Introduction/Purpose: Ankle fractures are common injuries, however isolated posterior malleolar fractures are rare. Axial loading of the foot in hyper-plantarflexion is thought to be the most likely mechanism of injury for this fracture pattern. Management of isolated posterior malleolar fractures presents challenges for clinicians, and controversy exists over surgical indications. The literature to-date examining isolated posterior malleolar fractures is scarce and confined to case reports and small clinical series. Recommendations for surgical treatment are based largely on biomechanical studies and not clinical evidence. The purpose of this study was to assess outcomes in a series of patients, who were consecutively treated nonoperatively for isolated posterior malleolus ankle fractures. Methods: Outcomes of patients with isolated posterior malleolus fractures who were all treated nonoperatively at two academic teaching hospitals were retrospectively reviewed. The size of the posterior malleolar fracture fragment was measured on lateral ankle radiographs, and clinical outcomes were evaluated using the American Academy of Orthopaedic Surgeons (AAOS) Foot and Ankle Survey. These scores were then compared to published normative data from the general population via independent t-tests. These same outcome measures were then correlated with the size of the posterior malleolar fragment via Spearman Rank Correlations. Results: A total of 28 patients (17 male, 11 female) were retrospectively reviewed. The average size of the posterior malleolus fragment was 16.0% (Range: 2.0-59.5%) of the tibial plafond articular surface. The average follow-up duration was 2 years and 7 months. At follow-up, the average “Foot and Ankle Core Score” and “Shoe Comfort Scale Score” were 90 (±11.2) and 80.0 (±28.9), respectively. When these scores were compared to normative data from the general population, no significant differences were found (Foot and Ankle Core Score: p=0.234, Shoe Comfort Scale: p=0.276). There was also no significant association between these scores and the size of fracture fragment. At follow-up, no patients demonstrated signs of instability, dermatological complications, malalignment of the mortise or post-traumatic arthritis. Conclusion: This is the largest study to date evaluating outcomes of isolated posterior malleolus fractures in patients treated nonoperatively. This series of 28 patients with isolated posterior malleolar fractures managed nonoperatively demonstrates short- to mid-term functional outcomes that are no different than reported normative data for the general population. These findings are consistent with previously reported clinical outcomes and suggest that nonoperative management is a viable treatment option for isolated posterior malleolar fractures.

Age and sport are associated with higher odds of playing through a concussion and delayed removal from play

Objective To elucidate situational factors and individual characteristics related to playing through a sport-related concussion (SRC) and delayed removal from play. Design Retrospective cross-sectional analysis. Setting A single comprehensive sports-concussion centre. Participants 250 middle school, high school, and collegiate athletes who sustained an SRC and presented to a regional concussion center between 2011 and 2015. Intervention Standardised in-depth phone interviews. Outcome measures Gender, race, age, competition level, sport, concussion history, practice/game, and collision awareness, among other variables, were incorporated into a multivariate regression model to determine if any of these variable could significantly predict the likelihood of playing through a sport-related concussion versus immediate removal from play. Main results Age (p=0.047) and sport (p=0.006) were both significantly associated with playing through a concussion. For every additional year of age, the odds of playing through an SRC decreased by 1.32 [95% CI: 1.00–1.72]. Football players were much more likely to attempt to “play through” a concussion when compared to baseball/softball, basketball, cheerleading, lacrosse, rugby and volleyball athletes (OR 5.41 [95% CI: 1.62–18.2] to 71.4 [95% CI: 4.93–1,000] times the odds of playing through an SRC for various sports, with all differences reaching statistical significance). Conclusions Younger age and certain sports (football) were significantly associated with delayed removal from play after a SRC in middle school, high school, and collegiate athletes. Given these results, sports medicine practitioners may be better able to identify situational and individual characteristics of athletes who may be more likely play through a SRC. Competing interests GS Solomon receives consulting fees from the Tennessee Titans (NFL), the Nashville Predators (NHL), and the athletic departments of several universities, all fees paid to institution. In addition he is a member of the ImPACT Scientific Advisory Board, and receives reimbursement for expenses to board meetings. AK Sills is a consulting physician to the Nashville Predators (uncompensated) and also serves as an unaffiliated neurotrauma consultant for the NFL. SL Zuckerman, AW Kuhn, AM Yengo-Kahn, ZY Kerr, DJ Totten, report no conflicts of interest.

Outcomes after sport-related concussion: does socioeconomic status matter?

Objective To determine the impact of socioeconomic status (SES) on outcomes after sport-related concussion (SRC) in a regional sports concussion centre. Design Retrospective cohort study. Setting Comprehensive sports concussion centre. Participants 282 youth, high school, and collegiate student-athletes. Intervention All patients seen at a comprehensive sports concussion centre were contacted after their injury for in-depth telephone interviews. Subsequent demographic data was also collected. Outcome measures SES was defined based on six variables: cost of living percentile, median income percentile, % college graduates, % homeowners, county type, and insurance. Outcomes after SRC were defined as the following three variables: days of symptom duration, days of missed school, and days of missed practice. Main results A total of 282 student-athletes were studied. The median age was 15.8 years (range 11.6–22.2). American football was the most common sport (32.2%). After multivariate cox-regression analysis, no relationship between SES and symptom duration or missed practice was seen. For the outcome of missed school, insurance status had a significant relationship, where those with private insurance had fewer missed days of school than those with public insurance (HR 0.46, 95% CI: 0.26–0.83, p=0.009). Conclusions In a regional cohort of youth, high school and collegiate student-athletes, SES had largely no impact on the outcomes of symptom duration, missed school, and missed practice. The only significant relationship was that those with private insurance returned to school quicker than those with public insurance, which may represent increased access to rehabilitation resources after SRC. Competing interests None. GS Solomon receives consulting fees from the Tennessee Titans (NFL), the Nashville Predators (NHL), and the athletic departments of several universities, all fees paid to institution. In addition he is a member of the ImPACT Scientific Advisory Board and receives reimbursement for expenses to board meetings. AK Sills is a consulting physician to the Nashville Predators (uncompensated) and also serves as an unaffiliated neurotrauma consultant for the NFL.