Charles A. Popkin

Early use of recombinant factor VIIa improves mean arterial pressure and may potentially decrease mortality in experimental hemorrhagic shock: a pilot study.

BACKGROUND Recombinant factor VIIa (rFVIIa) is used for treatment of bleeding episodes in hemophilia patients who develop inhibitors to factors VIII and IX. We tested the hypothesis that administration of rFVIIa early after injury would decrease bleeding and improve survival after experimental hepatic trauma. METHODS Anesthetized swine were cannulated for blood sampling and hemodynamic monitoring. Avulsion of left median lobe of the liver induced uncontrolled hemorrhage. After a 10% reduction of mean arterial pressure, animals were blindly randomized to receive intravenous rFVIIa (180 microg/kg) (n = 6) or placebo (n = 7). RESULTS Mortality was 43% (three of seven) in controls versus 0% with rFVIIa (p = 0.08, chi2). Significantly shorter prothrombin time and higher mean arterial pressures were observed in the rFVIIa group. CONCLUSION Intravenous administration of rFVIIa early after induction of hemorrhage shortens prothrombin time and improves mean arterial pressure. A trend toward improved survival was observed.

A Minimally Disruptive Surgical Technique for the Treatment of Osteitis Pubis in Athletes

Background: Multiple surgical procedures exist for the treatment of osteitis pubis: curettage of the symphysis joint, wedge resection, complete resection of the joint, placement of extraperitoneal retropubic synthetic mesh, and arthrodesis of the joint. However, a paucity of literature has reported long-term successful outcomes with the aforementioned approaches. Patients treated operatively have reported recalcitrant pain resulting from iatrogenic instability. The article presents the results of a conservative operative technique that avoids disruption of adjacent ligaments. Hypothesis: Preserving the adjacent ligamentous structures will allow competitive athletes to return to competition and activities of daily living free of iatrogenic pelvic instability and pain. Study Design: Case series. Methods: Four competitive athletes (2 professional and 2 collegiate football players) diagnosed with osteitis pubis were treated conservatively for a minimum of 6 months. Patients underwent surgical intervention upon failure to respond to nonoperative management. The degenerative tissue was resected, allowing only bleeding cancellous bone to remain while preserving the adjacent ligaments. An arthroscope was used to assist in curettage, allowing the debridement to be performed through a small incision in the anterior capsule. Results: The symptoms of all 4 patients resolved, and they returned to competitive athletics. This ligament-sparing technique provided a solid, stable repair and pain relief. Conclusion: This surgical technique preserves the adjacent ligamentous structures and allows competitive athletes to return to competition and activities of daily living free of pain and void of pelvic instability. Clinical Relevance: This technique is a surgical treatment option for athletes with osteitis pubis who fail conservative treatment.

The incision of choice for pregnant women with appendicitis is through McBurney’s point

BACKGROUND There is uncertainty over the optimal incision for gravid patients with appendicitis. METHODS Data were collected retrospectively from January 1, 1995, through December 31, 2000, on 374 women of childbearing age who underwent appendectomies. Of these, 23 gravid patients were evaluated. RESULTS Eighteen incisions were made over McBurneys point and five were created superior to McBurneys point. Patients in the third trimester of pregnancy all received incisions over McBurneys point. The appendix was located without difficulty in all 4 of the third trimester patients. The appendix was easily located in 94% of the incisions made through McBurneys point and 80% of the incisions made above McBurneys point. CONCLUSIONS Our clinical experience indicates that the incision for the removal of the appendix in pregnant patients in all trimesters can be successfully made over McBurneys point.

Evaluation and management of pediatric proximal humerus fractures.

In the pediatric population, sports participation, falls, and motor vehicle accidents can result in proximal humerus fractures. Because the proximal humeral growth plate is responsible for up to 80% of the growth of the humerus, the remodeling of these fractures in children is tremendous. Most of these injuries can be treated with a sling or hanging arm cast, although older children with decreased remodeling capacity may require surgery. Special considerations should be taken for management of proximal humerus fractures that occur in the context of Little League shoulder, lesser tuerosity avulsion fractures, fracture-dislocations, birth fractures, and fractures associated with cysts. Most pediatric patients with proximal humerus fractures have favorable results, and complications are infrequent.

Factors That Drive Youth Specialization

Background: Specialization in young athletes has been linked to overuse injuries, burnout, and decreased satisfaction. Despite continued opposition from the medical community, epidemiological studies suggest the frequency is increasing. Hypothesis: Extrinsic pressures in addition to individual aspirations drive this national trend in sports specialization. Study Design: Descriptive epidemiology study. Level of Evidence: Level 3. Methods: A novel instrument assessing the driving factors behind youth specialization was generated by an interdisciplinary team of medical professionals. Surveys were administered to patients and athletes in the department’s sports medicine clinic. Results: The survey was completed by 235 athletes between 7 and 18 years of age, with a mean age of 13.8 ± 3.0 years. Athletes specialized at a mean age of 8.1 years, and 31% of athletes played a single sport while 58% played multiple sports but had a preferred sport. More than 70% of athletes had collegiate or professional ambitions, and 60% played their primary sport for 9 or more months per year, with players who had an injury history more likely to play year-round (P < 0.01). Approximately one-third of players reported being told by a coach not to participate in other sports, with specialized athletes reporting this significantly more often (P = 0.04). Half of the athletes reported that sports interfered with their academic performance, with older players stating this more frequently (P < 0.01). Conclusion: Young athletes are increasingly specializing in a single sport before starting high school. While intrinsic drive may identify healthy aspirations, extrinsic influences are prevalent in specialized athletes. Clinical Relevance: Extrinsic factors contributing to youth specialization were identified and compounded the deleterious sequelae of youth athlete specialization.

Quantifying Parental Influence on Youth Athlete Specialization: A Survey of Athletes’ Parents:

Background: Youth athlete specialization has been linked to decreased enjoyment, burnout, and increased injury risk, although the impact of specialization on athletic success is unknown. The extent to which parents exert extrinsic influence on this phenomenon remains unclear. Purpose/Hypothesis: The goal of this study was to assess parental influences placed on young athletes to specialize. It was hypothesized that parents generate both direct and indirect pressures on specialized athletes. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A survey tool was designed by an interdisciplinary medical team to evaluate parental influence on youth specialization. Surveys were administered to parents of the senior author’s orthopaedic pediatric patients. Results: Of the 211 parents approached, 201 (95.3%) completed the assessment tool. One-third of parents stated that their children played a single sport only, 53.2% had children who played multiple sports but had a favorite sport, and 13.4% had children who balanced their multiple sports equally. Overall, 115 (57.2%) parents hoped for their children to play collegiately or professionally, and 100 (49.7%) parents encouraged their children to specialize in a single sport. Parents of highly specialized and moderately specialized athletes were more likely to report directly influencing their children’s specialization (P = .038) and to expect their children to play collegiately or professionally (P = .014). Finally, parents who hired personal trainers for their children were more likely to believe that their children held collegiate or professional aspirations (P = .009). Conclusion: Parents influence youth athlete specialization both directly and by investment in elite coaching and personal instruction. Parents of more specialized athletes exert more influence than parents of unspecialized athletes.

Visualization of the Capitellum During Elbow Arthroscopy: A Comparison of 3 Portal Techniques

Background: Capitellar osteochondritis dissecans (OCD) is a debilitating condition of unknown etiology for which various arthroscopic treatments are available. Prior data suggest that greater than 75% of the capitellum can be visualized arthroscopically through a dual lateral portal approach. However, there is no literature assessing arthroscopic visualization of the capitellum via alternative portals. Purpose: To determine the percentage of capitellum visualized using the dual lateral, distal ulnar and soft spot, and posterolateral and soft spot portal configurations in a cadaver model. Study Design: Descriptive laboratory study. Methods: Arthroscopy was performed on 12 fresh-frozen cadaver elbows, 4 for each of the following approaches: dual lateral, distal ulna, and posterolateral. Electrocautery was used to mark the most anterior, posterior, medial, and lateral points seen on the capitellum. The radiocapitellar joint was subsequently exposed through an extensile posterior dissection, and the surface anatomy was reconstructed using the Microscribe 3D digitizing system. Using Rhinoceros software, the percentage of capitellum surface area visualized by each approach was determined. Results: The mean percentage of capitellum visualized for the dual lateral, distal ulna, and posterolateral approaches was approximately 68.8%, 66.3%, and 63.5%, respectively. There was no significant difference between the percentage of capitellum seen among approaches (P = .68). On average, 66.5% of the capitellum was visible through these 3 arthroscopic approaches to the elbow. Conclusion: Approximately 66.5% of the capitellum is visualized through the popularized posterior arthroscopic portals, with no significant differences found between the 3 investigated approaches. Clinical Relevance: As determined in this cadaveric model investigation, each portal technique provides equivalent visualization for capitellar OCD pathology.

The Impact of Body Checking on Youth Ice Hockey Injuries

Background: Body checking is a common cause of youth ice hockey injuries. Consequently, USA Hockey raised the minimum age at which body checking is permitted from the Pee Wee level (11-12 years old) to the Bantam level (13-14 years old) in 2011. Purpose/Hypothesis: The purpose of this investigation was to determine the impact of body checking on the distribution of injuries reported in youth ice hockey players. We hypothesized that the elimination of body checking at the Pee Wee level would lower the frequency of serious injuries, particularly concussions. Study Design: Descriptive epidemiology study. Methods: Injury data from the National Electronic Injury Surveillance System (NEISS), a United States Consumer Product Safety Commission database, were analyzed for Pee Wee and Bantam players between January 1, 2008 and December 31, 2010 and again between January 1, 2013 and December 31, 2015. Data on the location of injury, diagnosis, and mechanism of injury were collected. The location of injury was categorized into 4 groups: head and neck, upper extremity, lower extremity, and core. Diagnoses investigated included concussions, fractures, lacerations, strains or sprains, internal organ injuries, and other. The mechanism of injury was broken down into 2 categories: checking and other. Results: Between the 2008-2010 and 2013-2015 seasons, overall injuries decreased by 16.6% among Pee Wee players, with injuries caused by body checking decreasing by 38.2% (P = .012). There was a significant change in the distribution of diagnoses in the Pee Wee age group during this time frame (P = .007): strains or sprains, internal organ injuries, and fractures decreased in frequency, while the number of concussions increased by 50.0%. In the Bantam age group, recorded injuries decreased by 6.8%, and there was no change in the distribution of the location of injury, diagnosis, or mechanism of injury (P > .05). Conclusion: There was an observed reduction in the total number, mechanism, and type of injuries when body checking was eliminated from the Pee Wee level. There was, however, an unexpected increase in the number of concussions.

Evaluation, management and prevention of lower extremity youth ice hockey injuries

Ice hockey is a fast-paced sport played by increasing numbers of children and adolescents in North America and around the world. Requiring a unique blend of skill, finesse, power and teamwork, ice hockey can become a lifelong recreational activity. Despite the rising popularity of the sport, there is ongoing concern about the high frequency of musculoskeletal injury associated with participation in ice hockey. Injury rates in ice hockey are among the highest in all competitive sports. Numerous research studies have been implemented to better understand the risks of injury. As a result, rule changes were adopted by the USA Hockey and Hockey Canada to raise the minimum age at which body checking is permitted to 13–14 years (Bantam level) from 11–12 years (Pee Wee). Continuing the education of coaches, parents and players on rules of safe play, and emphasizing the standards for proper equipment use are other strategies being implemented to make the game safer to play. The objective of this article was to review the evaluation, management and prevention of common lower extremity youth hockey injuries.

Trends in Management and Complications of Anterior Cruciate Ligament Injuries in Pediatric Patients: A Survey of the Prism Society

Background:Anterior cruciate ligament (ACL) injuries have been recognized and treated with increasing frequency in children and adolescents. ACL reconstruction (ACLR) in skeletally immature patients has unique considerations and there is a large practice variation in the management of these injuries. The purpose of this study was to survey the members of the Pediatric Research in Sports Medicine (PRiSM) Society regarding their experience with the management and complications of pediatric ACL injuries. Methods:A 15-question survey was distributed to 71 orthopaedic members of the Pediatric Research in Sports Medicine study group. Results:Regarding treatment of an 8-year-old child with a complete ACL tear, 53% of respondents recommended iliotibial band reconstruction, 33% recommended all-epiphyseal reconstruction, and only 3% would treat nonoperatively in a brace. In adolescent patients with 2 years of growth remaining, 47% of respondents recommended a physeal “respecting” technique, 31% recommended a physeal-sparing technique, and 19% would perform an adult-style ACLR. There were 29 new cases of growth arrest reported. Conclusions:This study demonstrates that there have been major changes in the trends in pediatric ACLR over the past 15 years, and the most treatment variability is found among adolescent patients with about 2 years of growth remaining. The study also demonstrates that while the overall incidence of growth disturbance after ACLR remains low, new cases of growth disturbance continue to be identified. Level of Evidence:Level V—survey of expert opinion and experience.